Disconnected Pancreatic Duct in Children With Walled OFF Necrosis: Impact on Outcomes of Endoscopic Drainage.

OBJECTIVES: Disconnected pancreatic duct syndrome (DPDS) is frequently encountered in cases with walled off necrosis (WON). The impact of DPDS on the outcomes of pancreatic fluid collections (PFCs) is not well known. In this study, we aim to evaluate the incidence of DPDS and its clinical impact on the outcomes of endoscopic ultrasound (EUS)-guided drainage of PFC in children. METHODS: All children with symptomatic WON who underwent EUS-guided drainage using metal stents were included in the study. At 4 weeks, pancreatic ductal anatomy was evaluated, and metal stents removed. All the children were followed at regular intervals and evaluated for the recurrence of PFC and the development of new-onset diabetes. RESULTS: A total of 32 children (28 boys, median age 15 years) underwent EUS-guided drainage of WON. Resolution of WON was documented in all children at 4 weeks. Pancreatic ductal anatomy using magnetic resonance retrograde cholangiopancreatography and endoscopic retrograde pancreatography was available in 30 (93.7%) children. Of these, DPDS was documented in 25 (83.3%) children including proximal disconnection in 12 and distal disconnection in 13 children. Recurrent PFC and new-onset diabetes were found in 5 (20%) and 2 (8%) children with DPDS, respectively. Of the 5 recurrences of PFC, endoscopic reintervention was required in 3 children. CONCLUSIONS: Majority of the children with DPDS do not develop a symptomatic recurrence of PFC after the removal of cystogastric stents. DPDS may be a risk factor for the development of new-onset diabetes. However, future prospective studies are needed.

Peroral Endoscopic Myotomy in Children: First Experience With a New Triangular Knife.

OBJECTIVES: Peroral endoscopic myotomy (POEM) is a novel treatment modality for achalasia cardia. The procedure is technically challenging and time consuming. Recently, a new triangle tip knife (TTJ) has been introduced, which is equipped with water jet facility. In the present study, we analyzed the feasibility, safety, and efficacy of POEM in children with new triangle tip knife. METHODS: We retrospectively evaluated the data of children (18 years or younger) who underwent POEM using TTJ knife at our institution. All POEM procedures were performed under general anesthesia in an endoscopy suite. Technical feasibility, safety, efficacy, and procedure duration were assessed. RESULTS: Ten children (4 boys, 6 girls) with mean age of 14.2 ±â€Š2.74 (9-18) years, underwent POEM with TTJ knife. The subtypes of achalasia cardia were type I (4), type II (5), and type III (1). Two children had prior treatment with pneumatic balloon dilatation. POEM was performed via anterior route in majority of children (70%). Mean operating time was 47.6 ±â€Š19.74 (30-98) minutes with no significant difference between anterior and posterior approaches to POEM (48.57 ±â€Š24.01 vs 45.3 ±â€Š3.51; P < 0.05). Four gas-related adverse events were encountered including capnoperitoneum and retroperitoneal carbon dioxide in 2 children each. Clinical success was noticed in 9 children with significant reduction in Eckardt score at 1 month after POEM (6.7 ±â€Š1.49 vs 0.3 ±â€Š0.48; P = 0.0001). CONCLUSIONS: POEM can be efficiently performed with new triangle knife equipped with water jet technique. Integration of water jet reduces procedure duration and technical difficulty with POEM.

Endoscopic Ultrasound-guided Drainage of Walled-off Necrosis in Children With Fully Covered Self-expanding Metal Stents.

OBJECTIVES: Endoscopic ultrasound (EUS)-guided drainage with fully covered self-expanding metallic stents (FCSEMS) has been successfully used in adult patients. The utility of FCSEMS in children with walled-off necrosis (WON) is, however, unknown. The aim of present study was to evaluate the feasibility, safety, and efficacy of EUS drainage of WON using FCSEMS in children. METHODS: We retrospectively evaluated the data of children (18 years or younger) who underwent EUS drainage of WON using FCSEMS at our institution. All FCSEMS were removed between 1 and 3 months. Feasibility, safety, and efficacy were analysed. RESULTS: Twenty-one children (20 boys, mean age 14.9 ±â€Š2.34 years, range 9-18 years) underwent EUS-guided drainage of WON with FCSEMS. The median size of WON was 88 mm (55-148 mm). The median interval between onset of acute pancreatitis and EUS guided drainage was 58 days (range 30-288 days). The technical and clinical success rates were 100% and 95%, respectively. Nasocystic tube was placed in 3 children for lavage. Endoscopic necrosectomy was not required in any of the children. There were no major complications. Minor complications included bleeding (2), stent migration (1), and difficulty in removal of stent (1). After a median follow-up of 360 days (range: 30-1020 days), there was 1 recurrence of WON. CONCLUSIONS: EUS drainage of WON using specially designed FCSEMS is safe and efficacious in children. The utility of FCSEMS in children should be further explored and compared with plastic stents.