Relationship between stent characteristics and treatment outcomes in endoscopic transmural drainage of uncomplicated pancreatic pseudocysts.

BACKGROUND: Transmural stents are placed at endoscopy to drain pancreatic fluid collections. This study evaluated the relationship between stent placement and treatment outcomes in patients undergoing endoscopic transmural drainage of uncomplicated pancreatic pseudocysts. METHODS: This is a retrospective study of all patients who underwent endoscopic drainage of uncomplicated pancreatic pseudocysts over a 10-year period. After dilating the transmural tracts in the range of 8-15 mm, single or multiple, 7 or 10Fr double-pigtail plastic stents were deployed. The main outcome measure was to evaluate the relationship between stent characteristics and the number of endoscopic interventions required to achieve resolution of the pancreatic pseudocyst (treatment success). RESULTS: Of 122 patients, 45 (36.9%) had 10Fr stents of which 30 patients (66.7%) had more than one stent; the remaining 77 (63.1%) patients had 7Fr stents of which 56 (72.7%) had more than one stent. The overall treatment success was 94.3%. Treatment was successful in 102 patients (83.6%) with one intervention; 13 patients (10.7%) required re-intervention for successful drainage and 7 patients (5.7%) failed endoscopic treatment. There was no significant difference in the number of interventions required for treatment success between patients with 7 or 10Fr stents (one intervention required in 87.7 vs. 90.5%, respectively; p = 0.766) and between patients with 1 or >1 stent (one intervention required in 88.9 vs. 88.6%, respectively; p = 0.999). On multiple logistic regression analysis, the stent size (OR 1.54; 95% CI 0.23-10.4) and number (OR 1.15; 95% CI 0.25-5.25) were not associated with the number of interventions required for treatment success when adjusted for pseudocyst size, location, drainage modality, the presence or absence of pancreatic duct stent and luminal compression. CONCLUSIONS: There appears to be no relationship between the number of interventions required for treatment success and stent characteristics in patients undergoing endoscopic transmural drainage of uncomplicated pancreatic pseudocysts.

Equal efficacy of endoscopic and surgical cystogastrostomy for pancreatic pseudocyst drainage in a randomized trial.

BACKGROUND & AIMS: Although surgery is the standard technique for drainage of pancreatic pseudocysts, use of endoscopic methods is increasing. We performed a single-center, open-label, randomized trial to compare endoscopic and surgical cystogastrostomy for pancreatic pseudocyst drainage. METHODS: Patients with pancreatic pseudocysts underwent endoscopic (n = 20) or surgical cystogastrostomy (n = 20). The primary end point was pseudocyst recurrence after a 24-month follow-up period. Secondary end points were treatment success or failure, complications, re-interventions, length of hospital stay, physical and mental health scores, and total costs. RESULTS: At the end of the follow-up period, none of the patients who received endoscopic therapy had a pseudocyst recurrence, compared with 1 patient treated surgically. There were no differences in treatment successes, complications, or re-interventions between the groups. However, the length of hospital stay was shorter for patients who underwent endoscopic cystogastrostomy (median, 2 days, vs 6 days in the surgery group; P < .001). Although there were no differences in physical component scores and mental health component scores (MCS) between groups at baseline on the Medical Outcomes Study 36-Item Short-Form General Survey questionnaire, longitudinal analysis showed significantly better physical component scores (P = .019) and mental health component scores (P = .025) for the endoscopy treatment group. The total mean cost was lower for patients managed by endoscopy than surgery ($7011 vs $15,052; P = .003). CONCLUSIONS: In a randomized trial comparing endoscopic and surgical cystogastrostomy for pancreatic pseudocyst drainage, none of the patients in the endoscopy group had pseudocyst recurrence during the follow-up period, therefore there is no evidence that surgical cystogastrostomy is superior. However, endoscopic treatment was associated with shorter hospital stays, better physical and mental health of patients, and lower cost. TRIAL REGISTRATION: ClinicalTrials.gov: NCT00826501.

Habitat type influences endocrine stress response in the degu (Octodon degus).

While many studies have examined whether the stress response differs between habitats, few studies have examined this within a single population. This study tested whether habitat differences, both within-populations and between-populations, relate to differences in the endocrine stress response in wild, free-living degus (Octodon degus). Baseline cortisol (CORT), stress-induced CORT, and negative feedback efficacy were measured in male and female degus from two sites and three habitats within one site during the mating/early gestation period. Higher quality cover and lower ectoparasite loads were associated with lower baseline CORT concentrations. In contrast, higher stress-induced CORT but stronger negative feedback efficacy were associated with areas containing higher quality forage. Stress-induced CORT and body mass were positively correlated in female but not male degus across all habitats. Female degus had significantly higher stress-induced CORT levels compared to males. Baseline CORT was not correlated with temperature at time of capture and only weakly correlated with rainfall. Results suggest that degus in habitats with good cover quality, low ectoparasite loads, and increased food availability have decreased endocrine stress responses.

Endoscopic ultrasonography-guided ablation therapy.

Endoscopic ultrasonography (EUS) imaging has undergone extensive technological advancement since its development in the 1980s, including improvement of echoendoscopes with larger channels and accessories.These advancements enable not only tissue procurement for diagnosis but also therapeutic interventions that hitherto would have required surgery, with its attendant risks. A wide array of interventional procedures are performed under EUS guidance, including celiac plexus neurolysis, drainage of pancreatic and pelvic fluid collections, drainage of obstructive pancreatic-biliary ducts, ablation of cyst neoplasms in the pancreas, and implantation of fiducial markers and radioactive seeds into gastrointestinal tumors. Various experimental procedures are also underway to evaluate the role of EUS in radiofrequency ablation, vascular therapy, and natural orifice transluminal endoscopic surgery. In this review, we examine the various EUS-guided ablation therapies currently undertaken in humans.

Successful stenting in ductal disruption favorably impacts treatment outcomes in patients undergoing transmural drainage of peripancreatic fluid collections.

BACKGROUND AND AIM: The role of pancreatic duct (PD) stenting in patients undergoing endoscopic transmural drainage of peripancreatic fluid collection (PFC) remains unclear. The objective of this study is to evaluate the effect of PD stenting on treatment success in patients undergoing endoscopic transmural drainage of PFC. METHODS: This is a retrospective follow-up study of all patients who underwent endoscopic and endoscopic ultrasonography-guided transmural drainage of PFC during a 5-year period. Double-pigtail stents were deployed in all patients; in addition, nasocystic catheters were deployed in those with abscess/necrosis. An endoscopic retrograde cholangiopancreatogram was attempted whenever feasible in all patients, and pancreatic stents were placed when the duct disruption could be bridged. Success was defined as an improvement in symptoms and resolution of PFC upon follow-up computed tomography at 8 weeks. RESULTS: Of the 110 patients who underwent PFC drainage, 40 (36%) underwent simultaneous PD stenting. Treatment was successful in 95 of the 110 patients (86%). The PFC types were: pseudocyst (62%), necrosis (20%), and abscess (18%). The median duration of follow up was 9.9 months. Those who underwent PD stenting were significantly more likely to have treatment success than those who did not undergo PD stenting (97.5% vs 80%; risk ratio [RR](crude) = 1.48, P = 0.01). In the multivariable analysis, this association remained significant (RR(adjusted) = 1.14, 95% confidence interval: 1.01-1.29, P = 0.036), even after adjusting for the etiology of pancreatitis, type and location of PFC, luminal compression at endoscopy, enteral nutrition, white blood cell count, and number of endoscopic interventions. CONCLUSIONS: Transpapillary PD stenting improves treatment outcomes in patients undergoing endoscopic transmural drainage of PFC.

EUS for the management of peripancreatic fluid collections after distal pancreatectomy.

BACKGROUND: Peripancreatic fluid collections (PFCs) are a common complication after distal pancreatectomy and are usually managed by percutaneous drainage. The role of EUS in the management of postoperative PFCs has not been previously reported. OBJECTIVE: To evaluate the role of EUS in the management of PFCs after distal pancreatectomy. STUDY DESIGN: Case series. SETTING: Academic tertiary referral center. PATIENTS: Symptomatic patients with PFCs after a distal pancreatectomy. INTERVENTIONS: At EUS, the PFCs were accessed transgastrically by using a 19-gauge FNA needle and after passage of a 0.035-inch guidewire; sequential dilation of the transgastric tract was performed up to 8 mm and multiple 7F or 10F double-pigtail stents were deployed. Nasocystic drainage catheters were deployed in those with poor drainage at the time of endoscopy. MAIN OUTCOME MEASUREMENTS: To evaluate the technical and treatment success and safety profile of the EUS-based approach for management of PFCs after distal pancreatectomy. RESULTS: Ten patients (6 men, 4 women; mean age, 56.8 years [range 20-76 years]) underwent EUS-guided drainage of PFCs after distal pancreatectomy over a 30-month period. Indications for distal pancreatectomy were neuroendocrine tumor in 5 patients, focal chronic pancreatitis in 2, cyst neoplasm in 1, adenocarcinoma in 1, and trauma in 1. The mean size of the PFCs (largest dimension) was 91.4 mm (range 45-140 mm). EUS-guided drainage was technically successful in all 10 patients; 1 patient underwent EUS-guided drainage of 2 large noncommunicating PFCs in the same endoscopy session. Treatment was successful in 9 (90%) of 10 patients; 1 patient had persistent symptoms requiring reoperation. No procedural complications were encountered. At a mean follow-up of 151 days (range 96-280 days), all 9 patients were doing well without any evidence of symptom recurrence. LIMITATIONS: Small number of patients and lack of a comparative treatment group. CONCLUSIONS: EUS-guided drainage is a minimally invasive, safe, and highly effective technique for the management of symptomatic PFC after distal pancreatectomy.

EUS-guided transesophageal drainage of peripancreatic fluid collections.

BACKGROUND: Although several large series have reported on EUS-guided transgastric and transduodenal drainage of peripancreatic fluid collections (PFCs), only commentary on individual cases has been presented on EUS-guided transesophageal drainage of PFCs. OBJECTIVE: To evaluate the technical success and safety of EUS-guided transesophageal drainage of PFCs. DESIGN: Observational study. SETTING: Tertiary academic referral center. PATIENTS: This study involved 3 consecutive patients referred for EUS-guided transesophageal drainage of PFCs over a 3-year period. INTERVENTIONS: The PFCs were accessed via the transesophageal route under EUS-guidance by using a 19-gauge needle. After a 0.035-inch guidewire was passed into the PFC, and the transmural tract was dilated to 6 mm, a transmural stent and/or drainage catheter was deployed. MAIN OUTCOME MEASUREMENTS: Evaluation of the technical and treatment success and safety profile of EUS-guided transesophageal drainage of PFCs. RESULTS: Three male patients (mean age 57.8 years [range 49-75 years]) underwent EUS-guided transesophageal drainage of PFCs (2 pseudocyst, 1 abscess) over a 3-year period. The etiology of the PFC was alcohol abuse in 2 patients and postsurgical in 1. The mean size of the PFCs was 7 cm (range 6-8 cm) in its largest dimension. The procedures were technically successful in all 3 patients, and no complications were encountered. All 3 patients had a successful treatment outcome. At a mean follow-up period of 24 months (range 12-36 months), all patients were doing well, without any evidence of PFC recurrence. LIMITATION: Small number of patients. CONCLUSIONS: In experienced hands, EUS-guided transesophageal drainage of PFCs is technically feasible and safe and is associated with favorable clinical outcomes. A long-term follow-up with larger numbers of patients is required to determine whether the procedure could be an effective alternative to surgical cyst-enterostomy or percutaneous drainage techniques.

Initial experience with the prototype forward-viewing echoendoscope for therapeutic interventions other than pancreatic pseudocyst drainage (with videos).

BACKGROUND: The current oblique-viewing echoendoscope can occasionally be limited in its ability to perform therapeutic interventions because of the acute angle at which endoscopic accessories passed via the biopsy channel make contact with the gut wall. In an effort to overcome this limitation, a prototype forward-viewing echoendoscope was developed and successfully tested for performing transgastric drainage of pancreatic pseudocysts. OBJECTIVE: Evaluation of an initial experience with the prototype forward-viewing echoendoscope for performing interventions such as bile-duct drainage, pelvic-abscess drainage, and fiducial marker placement via the transduodenal and transrectal approaches. DESIGN: A retrospective study. SETTING: An academic tertiary-referral center. PATIENTS: Three patients. INTERVENTIONS: By using the prototype forward-viewing echoendoscope, transduodenal drainage of an obstructed bile duct, transrectal drainage of a pelvic abscess, and placement of fiducial markers in a rectal cancer were undertaken in 3 patients. MAIN OUTCOME MEASUREMENTS: To evaluate the feasibility of performing interventions via the transduodenal and transrectal approaches by using the prototype forward-viewing echoendoscope. OBSERVATIONS: The procedures were technically successful in all 3 patients, and no procedural complications were encountered. The passage of accessories and the deployment of stents were technically easy with the forward-viewing echoendoscope. In addition, there was no need to reorient the position of the echoendoscope when switching from a sonographic to endoscopic view while performing therapeutic interventions. LIMITATION: Small number of patients. CONCLUSIONS: It was feasible to perform interventions such as drainage of an obstructive bile duct and a pelvic abscess, and placement of fiducial markers via the transduodenal and transrectal approaches by using the prototype forward-viewing echoendoscope. Further studies that include larger numbers of patients are needed to evaluate the role of the forward-viewing echoendoscope for performing EUS-guided therapeutic interventions.

Modified technique for EUS-guided drainage of pelvic abscess (with video).

BACKGROUND: We previously described a technique for EUS-guided drainage of pelvic abscess by means of transrectal catheter placement. However, drainage catheters are prone to accidental dislodgement, and their management has mandated a prolonged inpatient hospital stay. OBJECTIVE: To evaluate the effectiveness of a combined technique by using EUS-guided transrectal drainage catheter and stent placement for management of patients with pelvic abscesses. DESIGN: An observational study. SETTING: Academic tertiary-referral center. PATIENTS: Four patients underwent EUS-guided drainage of pelvic abscesses that were not amenable for drainage by US and/or CT guidance. INTERVENTIONS: A 10F drainage catheter and one or two 7F double-pigtail stents were deployed in the abscess cavity under EUS guidance. Subsequently, the drainage catheter was periodically flushed and aspirated for 36 hours until improvement in size of the abscess was confirmed by CT imaging. The drainage catheter was then discontinued, and the patients were discharged from the hospital. If resolution of the abscess was noted on outpatient CT at 2 weeks, then the stents were retrieved by sigmoidoscopy. MAIN OUTCOMES MEASUREMENTS: Short-term treatment success was defined as improvement in clinical symptoms and a decrease in size of the pelvic abscess on postprocedure CT obtained at 36 hours. Medium-term treatment success was defined as resolution of clinical symptoms and pelvic abscess on follow-up CT at 2 weeks. RESULTS: The procedure was technically successful in all 4 patients. The mean size of the abscess was 93 x 61 mm. No procedural complications were encountered. Treatment was successful both in the short and medium term in all 4 patients, and the mean duration of the postprocedure hospital stay was 2 days. At a mean follow-up of 221 days (range, 65-416 days), all 4 patients were doing well, without any symptoms of pelvic-abscess recurrence. LIMITATIONS: The small number of patients and the absence of a comparative treatment group. CONCLUSIONS: The combined placement of a transrectal drainage catheter and a stent under EUS guidance was a technically feasible, safe, and effective technique for management of patients with pelvic abscess. This technique minimized the possibility of accidental dislodgement of the drainage catheter and facilitated earlier patient discharge from the hospital.

Endoscopic resection of minor papilla adenomas (with video).

BACKGROUND: Although there are several large series on endoscopic resection of the major duodenal papilla, only commentary on individual cases has been presented on endoscopic minor papilla resection. OBJECTIVE: To evaluate the technical success and safety of endoscopy for resection of minor papilla adenomas. DESIGN: Observational study. SETTING: Academic tertiary-referral center. PATIENTS: Consecutive patients referred for endoscopic resection of minor papilla adenomas over a 12-month period. INTERVENTIONS: All patients underwent an EUS before an ERCP to exclude ductal involvement by the tumor and for evaluation of pancreatic-ductal anatomy. The minor papilla was removed by snare electrocautery in all patients. A pancreatic stent was placed in the dorsal duct in patients with pancreas divisum as a prophylaxis for post-ERCP pancreatitis. Complications were assessed per consensus criteria. MAIN OUTCOME MEASUREMENTS: To evaluate the technical success and safety of endoscopy for resection of minor papilla adenomas. OBSERVATIONS: Three patients underwent endoscopic resection of minor papilla adenomas over a 12-month period. The first patient had minor papilla adenoma, the second had coexisting pancreas divisum anatomy, and the third had adenomatous involvement of both the major and minor papillas. Minor papilla resection was technically successful in all 3 patients, with dual major and minor papilla resection in 1 patient who had adenomatous changes at both sites. Although 2 patients experienced no complications, the patient with pancreas divisum developed mild post-ERCP pancreatitis. At a 12-month follow-up, there was no evidence of tumor recurrence in any of the 3 patients. LIMITATION: Small number of patients. CONCLUSIONS: In experienced hands, endoscopic resection of the minor papilla is technically feasible, safe, and is associated with favorable clinical outcomes.