Endoscopic Ultrasound-Guided Drainage and Treatment of Symptomatic Pancreatic Fluid Collection following Acute or Acute-on-Chronic Pancreatitis – A Single Center Case Series

Abstracts

Introduction Pancreatic fluid collection (PFC) is a common complication of acute pancreatitis. Endoscopic ultrasound (EUS)-guided drainage, which is often followed by direct endoscopic necrosectomy (DEN), has become the primary approach to treat PFC, including pancreatic pseudocysts (PP) and walled-off necrosis (WON). We aimed to determine retrospectively the short- and long-term results of patients treated in our endoscopy unit and to identify parameters that are associated with treatment efficacy and outcome.

Methods The data of 41 consecutive patients with post-pancreatitic PFC, who underwent endoscopic transmural intervention between 2014 and 2016, were analyzed retrospectively. After an initial EUS-guided puncture, one or more plastic stents were placed and DEN was performed if necrotic tissue remained.

Results The mean diameter of the PFC was 74.0 ± 4.8 mm. Of the PFCs, 29.3% were classified as PP and 70.7% as WON. Altogether, 196 transmural endoscopic procedures were performed, including 73 endoscopic necrosectomies in a subgroup of 21 patients (20 WON, 1 PP). Initial technical success was achieved in 97.6% of patients and the short-term clinical success rate was 90.2%. The long-term clinical success rate was 82.9%, since four patients died from septic shock and/or multiple organ failure and three patients developed recurrent PFC some months after the initial discharge from endoscopic treatment. Procedural complications were registered in 9 patients during 10 of 196 endoscopic procedures (5.1%): bleeding (6), cardiorespiratory insufficiency (2), perforation with pneumoperitoneum (1), aspiration with respiratory insufficiency (1), and non-perforating superficial damage of the gastric wall (1). Neither the size of the PFC nor the initial value of C-reactive protein (CRP) or other biochemical markers were correlated with efficacy or outcome of treatment. Only the cumulative number of days with CRP > 50 mg/L significantly correlated with the number of follow-up endoscopic sessions and DEN. Fungal colonization of PFC correlated significantly (p < 0.05) with the risk of mortality (44% vs. 0%), need for intensive care treatment (66.7% vs. 25%), and sepsis (55.6% vs. 12.5%).

Conclusions We confirm that EUS-guided drainage followed by DEN in patients with solid necrotic material is an effective and relatively safe therapeutic approach. Prolonged elevation of CRP and fungal colonisation of the PFC are associated with a worse course of the disease.

Zusammenfassung

Hintergrund Peripankreatische Flüssigkeitsansammlungen (PFC) sind eine häufige Komplikation der akuten Pankreatitis. Die endosonografisch (EUS) gesteuerte Drainage, oft gefolgt von der direkten endoskopischen Nekrosektomie (DEN), stellt mittlerweile den primären Therapieansatz von PFC einschließlich Pankreaspseudozysten (PP) und ummauerten Nekrosen (WON) dar. Ziel war es, retrospektiv die Kurz- und Langzeitergebnisse der in unserer Endoskopie behandelten Patienten zu ermitteln und Parameter zur Verlaufseinschätzung zu identifizieren.

Methoden Daten von 41 konsekutiven Patienten mit postpankreatitischer PFC, die zwischen 2014 und 2016 eine endoskopische transmurale Intervention erhielten, wurden retrospektiv analysiert. Zunächst wurden nach einer EUS-gesteuerten Punktion ein oder mehrere Kunststoff-Stents platziert und im Falle verbleibenden nekrotischen Materials erfolgte eine DEN.

Ergebnisse Der mittlere Durchmesser der PFC betrug 74,0 ± 4,8 mm. 29,3% wurden als PP und 70,7% als WON eingestuft. Insgesamt erfolgten 196 transmurale Endoskopien, darunter 73 DEN in einer Subgruppe von 21 Patienten (20 WON, 1 PP). Die initiale technische Erfolgsrate betrug 97,6% und die kurzfristige klinische Erfolgsrate 90,2%. Die langfristige klinische Erfolgsrate betrug 82,9%, da 4 Patienten an septischem Schock/multiplem Organversagen starben und 3 Patienten einige Monate nach Beendigung der endoskopischen Therapie rezidivierende PFC entwickelten. Prozedurale Komplikationen wurden bei 10 von 196 endoskopischen Eingriffen (5,1%) bei 9 Patienten registriert: Blutung (6), kardiorespiratorische Insuffizienz (2), Perforation mit Pneumoperitoneum (1), Aspiration (1) und nichtperforierender oberflächlicher Magenwandriss (1). Weder die Größe der PFC noch der Anfangswert des C-reaktiven Proteins (CRP) oder andere biochemische Marker korrelierten mit Effizienz oder Behandlungsergebnis. Nur die kumulative Anzahl an Tagen mit einem CRP > 50 mg/l korrelierte signifikant mit der Anzahl der Verlaufsendoskopien und der DEN. Eine Pilzbesiedelung der PFC korrelierte signifikant (p < 0,05) mit dem Mortalitätsrisiko (44% vs. 0%), mit Intensivpflichtigkeit (66,7% vs. 25%) und Sepsis (55,6% vs. 12,5%).

Schlussfolgerung Unsere Daten bestätigen, dass die EUS-gesteuerte Drainage gefolgt von DEN bei Vorhandensein festen nekrotischen Materials ein effektiver und relativ sicherer Therapieansatz ist. Anhaltende CRP-Erhöhung und Pilzbesiedlung der PFC sind mit einem schlechteren Erkrankungsverlauf assoziiert.

Key words

interventional endoscopy - risk factor - microbiology - pancreatitis - pancreatic fluid collection - endoscopic necrosectomy

Schlüsselwörter

Interventionelle Endoskopie - Risikofaktor - Mikrobiologie - Pankreatitis - Pankreasnekrose - endoskopische Nekrosektomie

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