A Case Series of Late Gastrointestinal Fistulization in 16 Patients with Walled-Off Necrosis.

BACKGROUND: Gastrointestinal fistulization (GIF) is a rare and potentially fatal complication of acute necrotizing pancreatitis (ANP). There is paucity of data on clinical course and outcome of GIF in walled of necrosis (WON). OBJECTIVE: To evaluate frequency, clinical as well as imaging findings and outcome of spontaneous symptomatic GIF in patients with WON. METHODS: Retrospective analysis of database of patients with asymptomatic WON on regular follow-up over last six years to identify patients with symptomatic GIF. RESULTS: Out of 138 patients with asymptomatic WON seen during the study period, 16 (11.5%) patients (all males; mean age 41.7 ± 9.9 years) developed symptomatic GIF. The mean size of WON in patients who developed GIF was 9.5 ± 2.4 cm, and fistulization occurred after 65.1 ± 17.8 days of the onset of ANP. The site of fistulization was stomach, duodenum, jejunum, colon, and esophagus in seven (43.7%), five (31.2%), one (6.2%), two (12.5%), and one (6.2%) patients, respectively. GIF resulted in spontaneous resolution in two patients (stomach 1 and esophagus 1). The remaining patients with gastric (six patients) and duodenal (five patients) fistulization were successfully treated endoscopically by placing multiple plastic stents in the necrotic cavity after balloon dilatation of the fistulous tract. Patients with colonic fistulization required surgery. None of the patients succumbed to the illness. CONCLUSION: Symptomatic GIF of WON usually occurs within the first three months of onset of ANP. It commonly occurs in either stomach or duodenum and can be successfully managed endoscopically.

Endoscopic ultrasound-guided transmural drainage of post-traumatic pancreatic fluid collections.

BACKGROUND: Pancreatic injury is an uncommon consequence of abdominal trauma, and surgery has been the conventional treatment. The role and timing of endoscopic ultrasound (EUS)-guided treatment of the consequences of traumatic pancreatic injury is unclear. Our study evaluated the safety and efficacy of EUS-guided transmural drainage of post-traumatic pancreatic fluid collections (PFC). METHODS: A retrospective analysis of 13 patients (mean age 20.2±4.4 years; 12 males) with post-traumatic PFC treated with EUS-guided transmural drainage over the last 10 years was performed. Patient demographics, imaging findings, size of PFC, details of endoscopic transmural drainage procedure, outcome details, as well complications were retrieved from our database. RESULTS: The patients underwent drainage at 26.8±7.4 days after abdominal trauma, and the mean size of PFC was 11.8±3.2 cm with 2 patients having multiple fluid collections. Ten patients had PFC with a well-formed wall and 3 patients had an incompletely formed wall. Endoscopic drainage was technically successful in all 13 patients and 11 patients underwent transmural drainage with multiple plastic stents whereas 2 patients were treated with lumen apposing metal stents. The PFC resolved in all patients over a mean period of 2.7±0.4 weeks. One patient developed gastrointestinal bleeding 6 days after the procedure, successfully treated with angio-embolization. CONCLUSION: EUS-guided transmural drainage of post-traumatic PFC is safe and effective and can be safely performed at an early phase (<4 weeks) after pancreatic trauma.

Safety and Efficacy of Early (<4 Weeks of Illness) Endoscopic Transmural Drainage of Post-acute Pancreatic Necrosis Predominantly Located in the Body of the Pancreas.

BACKGROUND: Endoscopic transmural drainage is usually not performed for pancreatic necrotic collection (PNC) < 4 weeks after onset of acute necrotizing pancreatitis (ANP) because of lack of encapsulating wall and increased risk of complications. OBJECTIVE: Study safety and efficacy of early (<4 weeks) endoscopic transluminal drainage in patients with symptomatic PNC. METHODS: Retrospective analysis of data base of patients with PNC treated with endoscopic transmural drainage within 4 weeks of onset of ANP (early drainage) was done. The outcomes and complications were compared with patients with PNC who underwent delayed endoscopic drainage (≥4 weeks of onset of ANP). RESULTS: Thirty-four patients (26 males; mean age: 35.9 ± 8.6 years) underwent early and 136 patients (115 males; mean age: 37.9 ± 9.4 years) underwent delayed endoscopic drainage. The PNC was significantly larger (12.3 ± 2.1 cm vs 10.5 ± 2.7 cm, p <0.001) with increased solid component (47.7 ± 8.9% vs 28.3 ± 11.7%, p <0.001) in the early group. Clinical success was achieved in 94% patients in the early group and all patients in the delayed group. Direct endoscopic necrosectomy was performed more frequently in the early group (50% vs 7.4%; p<0.001). There was increased mortality (5.7% vs 0%), need for rescue surgical necrosectomy (5.7% vs 0%), and clinically significant bleeding (20% vs 1.5%, p<0.001) in the early group as compared to the delayed group. CONCLUSION: Early endoscopic drainage of PNC is feasible and seems to be safe as well as effective but is associated with increased risk of complications as compared to delayed drainage.

Efficacy and safety of plastic versus lumen-apposing metal stents for transmural drainage of walled-off necrosis: a retrospective single-center study.

BACKGROUND: Lumen-apposing metal stents (LAMS) were considered a breakthrough in the endoscopic management of walled-off necrosis (WON), as their larger drainage diameter was expected to provide effective drainage of necrotic material. However, various studies and meta-analyses that have compared plastic and metal stents for the treatment of WON have shown conflicting results. We retrospectively compared the efficacy and safety of endoscopic transmural drainage between multiple plastic stents and LAMS. METHODS: Endoscopic data were retrospectively retrieved for patients who had undergone endoscopic ultrasound (EUS)-guided drainage/debridement of WON. Patients were divided into 2 groups according to whether multiple plastic stents or LAMS were deployed during initial drainage. The resolution and complication rates were compared between the 2 groups. RESULTS: One hundred sixty-six patients (83% male, mean age 37.5 years) with symptomatic WON were treated with EUS-guided drainage using either multiple plastic stents (n=138) or LAMS (n=28). Patients in the LAMS group had significantly larger WON and a significantly higher proportion of solid content. WON resolution rates did not differ between plastic stents and LAMS (98.5% vs. 96.4% respectively, P=0.42). However, the time taken to resolution was significantly shorter in the LAMS group than in the plastic stents group (26.7 vs. 29.8 days, P=0.03). There was no significant difference between the groups in either mortality or complication rates. CONCLUSIONS: The technical success, rates of WON resolution and complications were similar in patients treated with multiple plastic stents and LAMS. However, LAMS were associated with a significantly shorter time to resolution.