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EUS Versus Surgical Cyst-Gastrostomy for Management of Pancreatic Pseudocysts
Abstracts
36, abscess 15, necrosis 9). Technical success was 95% (57/60): failures were due to inability to drain thick necrotic PFC in 2 and inability to visualize PFC in 1. Treatment success was 93% (53/57): 3 abscesses and 1 necrosis required surgery. No complications were encountered. There were no significant differences in patient/ clinical characteristics between group A and B patients. While there was no difference in technical or clinical outcomes, median procedural duration was significantly shorter for group B than group A patients (25 vs.70 min; p ! 0.001). After 25 procedures, procedural duration for performing EUS-D of PFC was more likely to be ! 30 minutes (adj. OR Z 11.6; p Z 0.01) even after adjusting for patient age, serum albumin, type/location/size of PFC, drainage modality (stent vs. stent plus drainage catheter) and site of endoscopic access in GI tract for establishing drainage. Conclusions: In this study, the largest reported to-date, EUSguided drainage of PFC was performed safely using the graded dilation technique with a successful outcome in a majority of patients. Learning curve, with regard to procedural duration, improved significantly after the first 25 cases.
[range, 5-16]) who underwent surgical cyst-gastrostomy were matched with 20 patients who underwent EUS-guided cyst-gastrostomy. There were no significant differences in demographic data, comorbidity, and clinical characteristics between both groups. While there were no significant differences in rates of treatment success (100% vs. 95%; p Z 0.36), procedural complications (none in both groups) or reinterventions (10% vs. 0%; p Z 0.13) between surgery vs. EUS-guided cystgastrostomy, the mean length of hospital stay for EUS-guided cyst-gastrostomy was significantly shorter than for surgical cyst-gastrostomy (2.6 vs. 6.5 days; p Z 0.008). The average total cost per case for the EUS-guided cyst-gastrostomy approach was significantly less when compared to surgical cyst-gastrostomy ($7943 vs. $14,815, p Z 0.01) with the total cost savings being $6872 per patient. Conclusions: When available, EUS-guided cyst-gastrostomy should be the first-line treatment approach for patients with uncomplicated pancreatic pseudocysts as the procedure is less costly and is associated with shorter length of hospital stay than surgical cyst-gastrostomy. There was no significant difference in clinical outcomes between both treatment modalities.
M1494 EUS-Guided Drainage: An Alternative to Surgical and Percutaneous Approaches for Management of Multiple, Non-Communicating Peripancreatic Fluid Collections Shyam Varadarajulu, Jeanetta Blakely
M1496 One-Step, EUS-Guided Drainage of Pancreatic Pseudocysts: Experience in 52 Patients Colin Mckay, Simon Denley, Ross Carter
Background: Management of multiple peripancreatic fluid collections (PFC) is a therapeutic challenge, particularly in patients with disrupted main pancreatic duct as pancreatic stenting is not feasible. Also, endoscopic trans-mural drainage may not be feasible as none or only few of the PFC may cause definitive luminal compression (LC). Under such circumstances, management is relegated to percutaneous/surgical drainage. Although the role of EUS for drainage of PFC without LC is well known, there are no published reports on use of this modality for drainage of multiple PFC. Aim: Evaluate the role of EUS in drainage of multiple, non-communicating PFC. Methods: Prospective study of all patients who underwent EUS-guided drainage of PFC over a 42-month period. Prior to EUS, all patients underwent contrast enhanced abdomen CT and ERCP was attempted for pancreatic stenting. In symptomatic patients with multiple PFC that were noncommunicating, not causing LC, and large (O 6 cm), EUS-guided drainage of PFC in all locations was undertaken. At EUS, the PFC were accessed using a 19-gauge needle and after passage of a 0. 035 inch guidewire, sequential dilation of the tract was performed and 7 Fr/10 Fr stents or drainage catheters were deployed. Clinical follow-up and CT was undertaken at 6-weeks to assess treatment response. Results: Multiple, large, non-communicating PFC was encountered in 6 (3 pseudocyst, 2 abscess, 1 necrosis) of 60 patients (10%; 95% CI [4.3%, 20.4%]) who underwent EUS-guided drainage. Etiology of pancreatitis in the 6 patients (3 female, mean age 60.5yrs [range, 41-70]) were idiopathic in 4, gallstone 1 and ETOH 1. ERCP revealed complete duct disruption in all 6 patients. Three patients with pseudocyst had PFC at 3 locations and others at 2 locations. The procedure was technically successful in all patients (100%). A total of 15 PFC sites were drained under EUS-guidance in these 6 patients. Sites of access were GE junction in 1, gastric cardia/fundus (6), greater curvature (2), antrum (2), duodenum (3), and Roux-en-Y loop in (1). The mean procedural duration was 60 minutes (range, 47-76). No complications were encountered. At follow-up, 4 (3 pseudocyst, 1 abscess) of 6 patients (66%) had complete symptom relief and resolution of PFC; others experienced persistent symptoms with residual fluid collection requiring surgical drainage. Conclusions: EUS-guided drainage of multiple, non-communicating peripancreatic fluid collections is technically feasible, safe, obviates the need for surgery or placement of multiple percutaneous drainage catheters, and leads to a successful clinical outcome in two-thirds of patients.
M1495 EUS Versus Surgical Cyst-Gastrostomy for Management of Pancreatic Pseudocysts Shyam Varadarajulu, Tercio Lopes, Charles M. Wilcox, Ernesto R. Drelichman, Meredith L. Kilgore, John D. Christein Background: Although EUS-guided cyst-gastrostomy is increasingly performed, there are no studies comparing the clinical outcomes and cost-effectiveness of this approach with ‘gold standard’ surgical cyst-gastrostomy. Aim: Compare the clinical outcomes of EUS-guided cyst-gastrostomy with surgical cyst-gastrostomy for management of patients with pancreatic pseudocysts and perform a cost analysis of each treatment modality. Methods: This is a retrospective case-control study of consecutive patients with uncomplicated pancreatic pseudocysts who underwent either surgical or endoscopic cyst-gastrostomy over a 3-yr period at a tertiary referral center. Individual patients who underwent surgical cyst-gastrostomy were matched with two patients who underwent EUS-guided cyst-gastrostomy during the same time period for age, etiology of pancreatitis, and size of the pseudocyst. All procedures were performed by one experienced pancreaticobiliary surgeon and one experienced endosonographer. Patients with pancreatic abscess or necrosis were excluded. Main outcome measures were rates of treatment success, complications and reinterventions, length of hospital stay (post-procedure), and cost associated with each treatment modality. Treatment success was defined as resolution of clinical symptoms and pseudocyst on follow-up imaging at 6-weeks. Results: Ten patients (6 male, median age 41yrs, mean pseudocyst size 6.2 cm
AB226 GASTROINTESTINAL ENDOSCOPY Volume 67, No. 5 : 2008
Introduction: In the treatment of pancreatic pseudocysts endoscopic treatment is now standard. Increasingly, trans-gastric drainage is being used in patients with acute pancreatitis and patients with more complex cysts containing debris. We report our experience in 52 patients using a one-step, two stent procedure under EUS guidance. Methods: All patients had persistent, symptomatic cysts. Aetiology was acute pancreatitis in 34 and chronic pancreatitis in 18 patients. 17 cysts were infected. ERCP or duct stent placement was either unsuccessful (8 cases) or demonstrated no communication (31 cases). In 10 cases ERCP was not attempted. In the remaining 3 cases, cysts persisted despite pancreatic duct stenting. Cyst drainage was carried out under EUS control using a therapeutic echoendoscope (Pentax EG-3830UT) with a 3.8 mm working channel and bridge. Two or more pigtail stents were inserted after entering the cyst with a Wilson-Cook CystotomeTM and performing balloon dilatation (oesophageal balloon) of the cystgastrostomy to 12-15 mm. Results: Cysts resolved at the first procedure in 37 cases, with one patient undergoing 24h of lavage via a naso-cyst catheter. A further 5 patients underwent a second procedure, 3 for placement of a naso-cyst catheter and lavage, 2 for further dilatation of the cyst-gastrostomy. All 5 resolved after a second procedure. One patient underwent 4 procedures, a naso-cyst catheter at the first followed by 3 further dilatations. In 3 patients formal open surgery was required, one 2 months later for incomplete drainage, the other two for procedure related complications. Two patients died following surgery for persistent, infected cysts. A third death occurred due to liver failure following successful cyst drainage and a fourth died approximately 1 year after successful cyst drainage from a pancreatic tumour. Conclusions: One-step EUS-guided drainage with the deployment of two or more stents is an effective treatment with 43 of 52 patients having complete cyst resolution by endoscopic means only. Complications all occurred early in this study indicating a learning curve, but these can be minimised by appreciating the need for further intervention and the use of naso-cyst lavage in more complex cysts.
M1497 Effectiveness and Safety of EUS Guided Pancreatic Pseudocyst/ Abscess Drainage: A Systematic Review of Prospective Studies Priyanka Tiwari, Nadim S. Jafri, Praveen K. Roy, Mainor R. Antillon Background: EUS guided pseudocyst and abscess drainage has been reported since it was first described in 1992. Overall success rates and complications of this procedure are however not known and it is unclear if this treatment is definitive. We conducted a systematic review to evaluate the effectiveness and safety of EUS guided drainage of pancreatic pseudocysts and abscesses. Method: We performed a systematic search of Medline, EMBASE, and Cochrane Central Register of Controlled Trials without language restriction for prospective studies evaluating the role of EUS guided drainage of pancreatic pseudocysts/abscess. We also hand searched grey literature from major gastrointestinal meetings. Standard forms were used to extract data regarding study design, cyst/abscess size, success rates, recurrence, surgical intervention, mortality and complications by two independent reviewers. Result: Six studies (156 patients) met our predefined eligibility criteria. The sample size of the studies ranged from 8 to 46 patients. Patient age ranged from 9-81 years. Time of intervention from time of diagnosis was less than 4 weeks. The length of follow-up period after the therapeutic intervention ranged from 3-468 weeks among the studies. The etiology of cyst/abscess formation reported in the studies were: alcohol, acute pancreatitis, gallstones and other causes. The size of the pseudocysts/abscess ranged from 4-14 cm in all the studies. The pancreatic body was the most common location (22-76% of patients), followed by the head of the pancreas (12-52%) and pancreatic tail (8-34%). In two prospective studies, 3-8% patients were also found to have gastric varices at the time of endoscopy. An endoscopic bulge was seen in 3-12% patients (3 studies). Overall, the success rate for EUS guided drainage of pancreatic pseudocysts and abscesses varied from 82%-100% among the studies. The most common complications from the endoscopic intervention were bleeding, perforation, stent migration and stent occlusion. The rate of recurrence of the pesudocyst/abscess
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36, abscess 15, necrosis 9). Technical success was 95% (57/60): failures were due to inability to drain thick necrotic PFC in 2 and inability to visualize PFC in 1. Treatment success was 93% (53/57): 3 abscesses and 1 necrosis required surgery. No complications were encountered. There were no significant differences in patient/ clinical characteristics between group A and B patients. While there was no difference in technical or clinical outcomes, median procedural duration was significantly shorter for group B than group A patients (25 vs.70 min; p ! 0.001). After 25 procedures, procedural duration for performing EUS-D of PFC was more likely to be ! 30 minutes (adj. OR Z 11.6; p Z 0.01) even after adjusting for patient age, serum albumin, type/location/size of PFC, drainage modality (stent vs. stent plus drainage catheter) and site of endoscopic access in GI tract for establishing drainage. Conclusions: In this study, the largest reported to-date, EUSguided drainage of PFC was performed safely using the graded dilation technique with a successful outcome in a majority of patients. Learning curve, with regard to procedural duration, improved significantly after the first 25 cases.
[range, 5-16]) who underwent surgical cyst-gastrostomy were matched with 20 patients who underwent EUS-guided cyst-gastrostomy. There were no significant differences in demographic data, comorbidity, and clinical characteristics between both groups. While there were no significant differences in rates of treatment success (100% vs. 95%; p Z 0.36), procedural complications (none in both groups) or reinterventions (10% vs. 0%; p Z 0.13) between surgery vs. EUS-guided cystgastrostomy, the mean length of hospital stay for EUS-guided cyst-gastrostomy was significantly shorter than for surgical cyst-gastrostomy (2.6 vs. 6.5 days; p Z 0.008). The average total cost per case for the EUS-guided cyst-gastrostomy approach was significantly less when compared to surgical cyst-gastrostomy ($7943 vs. $14,815, p Z 0.01) with the total cost savings being $6872 per patient. Conclusions: When available, EUS-guided cyst-gastrostomy should be the first-line treatment approach for patients with uncomplicated pancreatic pseudocysts as the procedure is less costly and is associated with shorter length of hospital stay than surgical cyst-gastrostomy. There was no significant difference in clinical outcomes between both treatment modalities.
M1494 EUS-Guided Drainage: An Alternative to Surgical and Percutaneous Approaches for Management of Multiple, Non-Communicating Peripancreatic Fluid Collections Shyam Varadarajulu, Jeanetta Blakely
M1496 One-Step, EUS-Guided Drainage of Pancreatic Pseudocysts: Experience in 52 Patients Colin Mckay, Simon Denley, Ross Carter
Background: Management of multiple peripancreatic fluid collections (PFC) is a therapeutic challenge, particularly in patients with disrupted main pancreatic duct as pancreatic stenting is not feasible. Also, endoscopic trans-mural drainage may not be feasible as none or only few of the PFC may cause definitive luminal compression (LC). Under such circumstances, management is relegated to percutaneous/surgical drainage. Although the role of EUS for drainage of PFC without LC is well known, there are no published reports on use of this modality for drainage of multiple PFC. Aim: Evaluate the role of EUS in drainage of multiple, non-communicating PFC. Methods: Prospective study of all patients who underwent EUS-guided drainage of PFC over a 42-month period. Prior to EUS, all patients underwent contrast enhanced abdomen CT and ERCP was attempted for pancreatic stenting. In symptomatic patients with multiple PFC that were noncommunicating, not causing LC, and large (O 6 cm), EUS-guided drainage of PFC in all locations was undertaken. At EUS, the PFC were accessed using a 19-gauge needle and after passage of a 0. 035 inch guidewire, sequential dilation of the tract was performed and 7 Fr/10 Fr stents or drainage catheters were deployed. Clinical follow-up and CT was undertaken at 6-weeks to assess treatment response. Results: Multiple, large, non-communicating PFC was encountered in 6 (3 pseudocyst, 2 abscess, 1 necrosis) of 60 patients (10%; 95% CI [4.3%, 20.4%]) who underwent EUS-guided drainage. Etiology of pancreatitis in the 6 patients (3 female, mean age 60.5yrs [range, 41-70]) were idiopathic in 4, gallstone 1 and ETOH 1. ERCP revealed complete duct disruption in all 6 patients. Three patients with pseudocyst had PFC at 3 locations and others at 2 locations. The procedure was technically successful in all patients (100%). A total of 15 PFC sites were drained under EUS-guidance in these 6 patients. Sites of access were GE junction in 1, gastric cardia/fundus (6), greater curvature (2), antrum (2), duodenum (3), and Roux-en-Y loop in (1). The mean procedural duration was 60 minutes (range, 47-76). No complications were encountered. At follow-up, 4 (3 pseudocyst, 1 abscess) of 6 patients (66%) had complete symptom relief and resolution of PFC; others experienced persistent symptoms with residual fluid collection requiring surgical drainage. Conclusions: EUS-guided drainage of multiple, non-communicating peripancreatic fluid collections is technically feasible, safe, obviates the need for surgery or placement of multiple percutaneous drainage catheters, and leads to a successful clinical outcome in two-thirds of patients.
M1495 EUS Versus Surgical Cyst-Gastrostomy for Management of Pancreatic Pseudocysts Shyam Varadarajulu, Tercio Lopes, Charles M. Wilcox, Ernesto R. Drelichman, Meredith L. Kilgore, John D. Christein Background: Although EUS-guided cyst-gastrostomy is increasingly performed, there are no studies comparing the clinical outcomes and cost-effectiveness of this approach with ‘gold standard’ surgical cyst-gastrostomy. Aim: Compare the clinical outcomes of EUS-guided cyst-gastrostomy with surgical cyst-gastrostomy for management of patients with pancreatic pseudocysts and perform a cost analysis of each treatment modality. Methods: This is a retrospective case-control study of consecutive patients with uncomplicated pancreatic pseudocysts who underwent either surgical or endoscopic cyst-gastrostomy over a 3-yr period at a tertiary referral center. Individual patients who underwent surgical cyst-gastrostomy were matched with two patients who underwent EUS-guided cyst-gastrostomy during the same time period for age, etiology of pancreatitis, and size of the pseudocyst. All procedures were performed by one experienced pancreaticobiliary surgeon and one experienced endosonographer. Patients with pancreatic abscess or necrosis were excluded. Main outcome measures were rates of treatment success, complications and reinterventions, length of hospital stay (post-procedure), and cost associated with each treatment modality. Treatment success was defined as resolution of clinical symptoms and pseudocyst on follow-up imaging at 6-weeks. Results: Ten patients (6 male, median age 41yrs, mean pseudocyst size 6.2 cm
AB226 GASTROINTESTINAL ENDOSCOPY Volume 67, No. 5 : 2008
Introduction: In the treatment of pancreatic pseudocysts endoscopic treatment is now standard. Increasingly, trans-gastric drainage is being used in patients with acute pancreatitis and patients with more complex cysts containing debris. We report our experience in 52 patients using a one-step, two stent procedure under EUS guidance. Methods: All patients had persistent, symptomatic cysts. Aetiology was acute pancreatitis in 34 and chronic pancreatitis in 18 patients. 17 cysts were infected. ERCP or duct stent placement was either unsuccessful (8 cases) or demonstrated no communication (31 cases). In 10 cases ERCP was not attempted. In the remaining 3 cases, cysts persisted despite pancreatic duct stenting. Cyst drainage was carried out under EUS control using a therapeutic echoendoscope (Pentax EG-3830UT) with a 3.8 mm working channel and bridge. Two or more pigtail stents were inserted after entering the cyst with a Wilson-Cook CystotomeTM and performing balloon dilatation (oesophageal balloon) of the cystgastrostomy to 12-15 mm. Results: Cysts resolved at the first procedure in 37 cases, with one patient undergoing 24h of lavage via a naso-cyst catheter. A further 5 patients underwent a second procedure, 3 for placement of a naso-cyst catheter and lavage, 2 for further dilatation of the cyst-gastrostomy. All 5 resolved after a second procedure. One patient underwent 4 procedures, a naso-cyst catheter at the first followed by 3 further dilatations. In 3 patients formal open surgery was required, one 2 months later for incomplete drainage, the other two for procedure related complications. Two patients died following surgery for persistent, infected cysts. A third death occurred due to liver failure following successful cyst drainage and a fourth died approximately 1 year after successful cyst drainage from a pancreatic tumour. Conclusions: One-step EUS-guided drainage with the deployment of two or more stents is an effective treatment with 43 of 52 patients having complete cyst resolution by endoscopic means only. Complications all occurred early in this study indicating a learning curve, but these can be minimised by appreciating the need for further intervention and the use of naso-cyst lavage in more complex cysts.
M1497 Effectiveness and Safety of EUS Guided Pancreatic Pseudocyst/ Abscess Drainage: A Systematic Review of Prospective Studies Priyanka Tiwari, Nadim S. Jafri, Praveen K. Roy, Mainor R. Antillon Background: EUS guided pseudocyst and abscess drainage has been reported since it was first described in 1992. Overall success rates and complications of this procedure are however not known and it is unclear if this treatment is definitive. We conducted a systematic review to evaluate the effectiveness and safety of EUS guided drainage of pancreatic pseudocysts and abscesses. Method: We performed a systematic search of Medline, EMBASE, and Cochrane Central Register of Controlled Trials without language restriction for prospective studies evaluating the role of EUS guided drainage of pancreatic pseudocysts/abscess. We also hand searched grey literature from major gastrointestinal meetings. Standard forms were used to extract data regarding study design, cyst/abscess size, success rates, recurrence, surgical intervention, mortality and complications by two independent reviewers. Result: Six studies (156 patients) met our predefined eligibility criteria. The sample size of the studies ranged from 8 to 46 patients. Patient age ranged from 9-81 years. Time of intervention from time of diagnosis was less than 4 weeks. The length of follow-up period after the therapeutic intervention ranged from 3-468 weeks among the studies. The etiology of cyst/abscess formation reported in the studies were: alcohol, acute pancreatitis, gallstones and other causes. The size of the pseudocysts/abscess ranged from 4-14 cm in all the studies. The pancreatic body was the most common location (22-76% of patients), followed by the head of the pancreas (12-52%) and pancreatic tail (8-34%). In two prospective studies, 3-8% patients were also found to have gastric varices at the time of endoscopy. An endoscopic bulge was seen in 3-12% patients (3 studies). Overall, the success rate for EUS guided drainage of pancreatic pseudocysts and abscesses varied from 82%-100% among the studies. The most common complications from the endoscopic intervention were bleeding, perforation, stent migration and stent occlusion. The rate of recurrence of the pesudocyst/abscess
www.giejournal.org