Clinical outcomes of endoscopic management of pancreatic fluid collections in cirrhotics vs non-cirrhotics: A comparative study.

BACKGROUND: Endoscopic management of symptomatic pancreatic fluid collections (PFCs) using self-expandable metal stents (SEMS) placement has emerged as an innovative therapeutic approach with excellent efficacy, safety, and relatively few adverse outcomes. However, their use has not been studied in patients with cirrhosis. Cirrhotics tend to be considered less than optimal candidates due to concern for portal hypertension and coagulopathy related complications. AIM: To compare the efficacy and safety of using SEMS for drainage of symptomatic PFCs in cirrhotic vs non-cirrhotic patients. METHODS: We conducted a retrospective comparative analysis of patients with symptomatic PFCs [pancreatic pseudocyst (PP) or walled-off necrosis (WON)] who underwent endoscopic ultrasound (EUS)-guided placement of fully covered self-expandable metals stents or lumen-apposing self-expandable metal stents. All patients were followed clinically until resolution of PFCs or death. Definition: (1) Technical success was defined as successful placement of SEMS; and (2) Clinical success was defined as complete resolution of the PFCs without additional interventions including interventional radiology or surgery. Number of procedures performed per patient, number of patients who achieved complete resolution of the PFCs without additional interventions and procedure related adverse events were recorded. RESULTS: From January 2012 to December 2017, a total of 88 patients underwent EUS-guided drainage of symptomatic PFCs. Of these, 58 non cirrhotic patients underwent plastic stent insertion for management of PFC and 30 patients, 5 with cirrhosis and 25 without cirrhosis, underwent EUS-guided transmural drainage with SEMS, including 18 (60%) PP and 12 (40%) WON. Technical success was achieved in all 30 patients. Clinical success was achieved in 60% cirrhotic patients and 92% non-cirrhotics (P = 0.12). Procedure-related adverse events were 60% in cirrhotic and 28% non-cirrhotic (P = 0.62). Moreover, fatal adverse events were statistically more common in cirrhotics compared with non-cirrhotics (0 vs 40%; P = 0.023). Successful stent removal following resolution of the PFC, was 60% in cirrhotics and 80% in non-cirrhotics (P = 0.57). Post-procedure length of hospitalization was 18.6 ± 20.3 d in cirrhotics and 5.6 ± 13.7 d in non-cirrhotics (P = 0.084). CONCLUSION: EUS-guided management of PFC using SEMS placement has a high technical and clinical success rate in non-cirrhotics. However, in cirrhotics caution must be exercised given the high morbidity and mortality as evidenced by our cohort, particularly for the endoscopic debridement of WONs. Larger, multicenter studies are warranted to further characterize the risk profile and outcomes in these patients.

Lumen apposing metal stents are superior to plastic stents in pancreatic walled-off necrosis: a large international multicenter study.

Background and study aims The use of lumen apposing metal stents (LAMS) during EUS-guided transmural drainage (EUS-TD) of pancreatic walled-off necrosis (WON) has gained popularity. Data supporting their use in WON over plastic stents (PS), however, remain scarce. The aim of this study was to compare the clinical efficacy of LAMS (Axios, Boston Scientific) with PS in WON. Patients and methods This was a multicenter, retrospective study involving 14 centers. Consecutive patients who underwent EUS-TD of WON (2012 - 2016) were included. The primary end point was clinical success defined as WON size ≤ 3 cm within a 6-month period without need for percutaneous drainage (PCD) or surgery. Results A total of 189 patients (mean age 55.2 ±â€Š15.6 years, 34.9 % female) were included (102 LAMS and 87 PS). Technical success rates were similar: 100 % in LAMS and 98.9 % in PS ( P  = 0.28). Clinical success was attained in 80.4 % of LAMS and 57.5 % of PS ( P  = 0.001). Rate of PCD was similar (13.7 % LAMS vs. 16.3 % PS, P  = 0.62), while PS was associated with a greater need for surgery (16.1 % PS vs. 5.6 % LAMS, P  = 0.02). Adverse events (AEs) were observed in 9.8 % of LAMS and 10.3 % of PS ( P  = 0.90) and were rated as severe in 2.0 % and 6.9 %, respectively ( P  = 0.93). After excluding patients with < 6 months follow-up, the rate of WON recurrence following initial clinical success was greater with PS (22.9 % PS vs. 5.6 % LAMS, P  = 0.04). Conclusions When compared to PS, LAMS in WON is associated with higher clinical success, shorter procedure time, lower need for surgery, and lower rate of recurrence.

Role of Magnification Chromoendoscopy in the Management of Colorectal Neoplastic Lesions Suspicious for Submucosal Invasion.

BACKGROUND: Correctly predicting the depth of tumor invasion in the colorectal wall is crucial for successful endoscopic resection of superficial colorectal neoplasms. OBJECTIVE: The aim of this study was to assess the accuracy of magnifying chromoendoscopy in a Western medical center to predict the depth of invasion by the pit pattern classification in patients with colorectal neoplasms with a high risk of submucosal invasion. DESIGN: This single-center retrospective study, from a prospectively collected database, was conducted between April 2009 and June 2015. SETTINGS: The study was conducted at a single academic center. PATIENTS: Consecutive patients with colorectal neoplasms with high risk of submucosal invasion were included. These tumors were defined by large (≥20 mm) sessile polyps (nonpedunculated), laterally spreading tumors, or depressed lesions of any size. INTERVENTIONS: Patients underwent magnifying chromoendoscopy and were classified according to the Kudo pit pattern. The therapeutic decision, endoscopic or surgery, was defined by the magnification assessment. MAIN OUTCOME MEASURES: Sensitivity, specificity, and positive and negative predictive values of magnifying chromoendoscopy for assessment of these lesions were determined. RESULTS: A total of 123 lesions were included, with a mean size of 54.0 ± 37.1 mm. Preoperative magnifying chromoendoscopy with pit pattern classification had 73.3% sensitivity, 100% specificity, 100% positive predictive value, 96.4% negative predictive value, and 96.7% accuracy to predict depth of invasion and consequently to guide the appropriate treatment. Thirty-three rectal lesions were also examined by MRI, and 31 were diagnosed as T2 lesions. Twenty two (70.1%) of these lesions were diagnosed as noninvasive by magnifying colonoscopy, were treated by endoscopic resection, and met the curative criteria. LIMITATIONS: This was a single-center retrospective study with a single expert endoscopist experience. CONCLUSIONS: Magnifying chromoendoscopy is highly accurate for assessing colorectal neoplasms suspicious for submucosal invasion and can help to select the most appropriate treatment. See Video Abstract at http://links.lww.com/DCR/A920.