Transluminal retroperitoneal endoscopic necrosectomy with the use of hydrogen peroxide and without external irrigation: a novel approach for the treatment of walled-off pancreatic necrosis.

BACKGROUND: Transluminal retroperitoneal endoscopic necrosectomy (TREN) is an attractive NOTES technique alternative to surgery for treatment of walled-off pancreatic necrosis (WOPN). The main limitations to this technique are the need for repeated sessions, prolonged external irrigation, and EUS availability. In our study, we introduced new modifications, including the use of hydrogen peroxide, and abandoning the use of EUS and external irrigation. METHODS: This is a retrospective study of outcome of consecutive patients who underwent TREN for WOPN between April 2011 and August 2012. The technique included (1) non-EUS-guided transluminal drainage, and (2) direct endoscopic debridement using hydrogen peroxide and different accessories. No external irrigation was used. RESULTS: Ten patients were included. Initial clinical and technical success was achieved in all patients. Complete radiological success and long-term clinical efficacy was achieved in nine patients (1 patient had an inaccessible left paracolic gutter collection and died 62 days after endotherapy). Mean number of sessions was 1.4 (range 1-2). Complications included bleeding, which was self-limited in three patients and endoscopically controlled in one. All patients avoided surgery, and no recurrence was reported during median follow-up of 289 (range 133-429) days. CONCLUSIONS: TREN is a safe and effective treatment for WOPN and could be performed safely without EUS guidance in selected cases. Hydrogen peroxide played a major role in reduction of number of sessions and timing. External irrigation of WOPN is not necessary, if adequate debridement could be achieved.

Percutaneous ultrasound-guided bowel wall core biopsy: a nonconventional way of diagnosis of gastrointestinal lesions.

BACKGROUND: Patients with gastrointestinal lesions; unsuccessfully diagnosed by endoscopy are challenging to gastroenterologists. We aimed to study the role and safety of ultrasound, its guided biopsy in visualizing and diagnosing these bowel lesions. PATIENTS AND METHODS: Sixty-three patients with endoscopically and/or imaging documented gastrointestinal lesions were prospectively enrolled. All had detailed high-frequency (5-8 MHz) transabdominal bowel ultrasound examination to identify, localize and characterize the lesions, which were further biopsied using ultrasound guidance. RESULTS: Lesions were histo-pathologically diagnosed; 57 (90.5%) were malignant and 6 (9.5%) were benign. Ultrasound was able to localize all the lesions. They were characterized as focal in 12 (19.1%) and diffuse bowel wall involvement in 51 (80.9%) patients. Ultrasound was capable of suggesting the nature of diffuse bowel involvement whether benign or malignant in 94.1%. Comparing malignant diffuse bowel lesions and benign ones; the former had greater mean wall thickness (2.2 vs. 1.1 cm), loss of layering pattern (87.2 vs. 50%), asymmetrical pattern of involvement (78.7 vs. 0%), short length of affected segment (87.2 vs. 50%) and paucity of perilesional findings. Ultrasound-guided core biopsy was diagnostic in 60 (95.2%) patients with no reported complications. Diagnostic laparotomy was resorted to in 3 (4.8%). Ultrasound-guided bowel wall core biopsy had sensitivity of 98.2% in diagnosing malignant lesions and specificity of 66.6% in benign lesions. CONCLUSION: High-frequency transabdominal ultrasound and ultrasound-guided core biopsy of bowel lesions are potentially safe and effective diagnostic methods in select gastrointestinal lesions whenever conventional endoscopic diagnosis was unsuccessful, thus avoiding unnecessary diagnostic surgical procedures.