Endoscopic management of walled of pancreatic necrosis

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ENDOSCOPIC MANAGEMENT OF NECROTIZING

PANCREATITIS

MODERATOR – DR.MANDHIRSENIOR CONSULTANT GASTROENTEROLOGY AND HEPATOLOGY

AGENDA

ACUTE PANCREATITIS – DIAGNOSIS AND TYPES CLASSIFICATION OF FLUID COLLECTIONS WHEN TO INTERVENE IN NECROTISING

PANCREATITIS METHODS FOR INTERVENTIONS IN WOPN ENDOSCOPIC TECHNIQUES OF

DRAINAGE/NECROSECTOMY RISKS AND COMPLICATIONS IN EUS-GUIDED

DRAINAGE REVIEW OF LITERATURE

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Classification of acute pancreatitis—2012:revision of the Atlanta classification and definitions by international consensus

Banks PA et al. Gut 2013;62:102-111.

DIAGNOSIS (ANY OF THE TWO)

Abdominal pain consistent with acute pancreatitis

Serum lipase activity (or amylase activity) at least three times greater than the upper limit of normal

Characteristic findings of acute pancreatitis on contrast-enhanced computed tomography (CECT) and less commonly magnetic resonance imaging (MRI) or transabdominal ultrasonography

Banks PA et al. Gut 2013;62:102-111.

Banks PA et al. Am J Gastroenterol 2006;101:2379; Tsiotos GG et al. Br J Surg 1998;85:1650;Fagenholz PJ et al. Ann Epidemiol 2007;17:491; Martinez J et al. Pancreatology 2006;6:206;Chauhan S et al. Am J Gastroenterol 2010;105:443.

Acute Pancreatitis

(AP)

15% Necrotising AP

Mortality 15% Organ failure 54% Organ failure with

infected necrosis (mortality 30%)

85% Interstitial AP

Mortality 3% Organ failure 10% Recovery within 5-7

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GRADES OF SEVERITY

Mild acute pancreatitis▸ No organ failure▸ No local or systemic complications

Moderately severe acute pancreatitis▸ Organ failure that resolves within 48 h (transient organ failure) and/or▸ Local or systemic complications without persistent organ failure

Severe acute pancreatitis Persistent organ failure (>48 h) –Single organ failure–Multiple organ failure

Type of pancreatitis

Collections < 4 weeks(Acute collections)

Collections > 4 weeks

Interstitial(85%)

APFC (acute pancreatic fluid collection)- sterile- infected

Pseudozyste - sterile - infected

Necrotising(15%)

ANC (acute necrotic collection) - containing solid and fluid material - intra and/or extrapancreatic - sterile/infected

WON (walled off pancreatic necrosis) - sterile - infected

Banks PA et al. Gut 2013;62:102-111.

Pancreatic fluid collections According to the revised Atlanta classification

Key points Acute fluid collections:

Lack a well-defined wall

> 1 week distinction between APFC vs. ANC

Usually NO treatment

Acute peripancreatic fluid collection

Occurs in the setting of interstitial oedematous pancreatitis

Homogeneous collection with fluid density

Confined by normal peripancreatic fascial planes

No definable wall encapsulating the collection

Adjacent to pancreas (no intrapancreatic extension)

ACUTE PERIPANCREATIC COLLECTION

AT 1st week and 3rd week

ACUTE NECROTIC COLLECTION

Occurs only in the setting of acute necrotising pancreatitis

Heterogeneous and non-liquid density of varying degrees in different locations (some appear homogeneous early in their course)

No definable wall encapsulating the collection

Location—intrapancreatic and/or extrapancreatic

Acute necrotic collection (ANC)

Banks PA et al. Gut 2012;62:102-111.

Stars: necrosis; arrows: borders of the ANC

Pancreatic and peripancreatic collections should be described on the basis of…….

Location (pancreatic, peripancreatic, other)

Nature of the content (liquid, solid, gas)

Thickness of any wall (thin, thick).

Pancreatic fluid collections According to the revised Atlanta classification

Type of pancreatitis

Collections < 4 weeks Collections > 4 weeks

Interstitial(85%)

APFC (acute pancreatic fluid collection)- sterile- infected

Pseudocyst - sterile - infected - no solid material

Necrotising(15%)

ANC (acute necrotic collection) - solid material - parenchymal and/or peripancreatic tissue - sterile/infected

WON (walled-off pancreatic necrosis) - mature, encapsulated necrotic collection with well defined wall - sterile/infected - parenchymal/peripancreatic/distant from pancreas

Banks PA et al. Gut 2013;62:102-111.

PANCREATIC PSEUDOCYST

Well circumscribed, usually round or oval

Homogeneous fluid density

No non-liquid component

Well defined wall; that is, completely encapsulated

Maturation usually requires >4 weeks after onset of acute pancreatitis

PANCREATIC PSEUDOCYSTNote the round to oval, low-attenuated, homogeneous fluid collections with a well defined enhancing rim, but absence of areas of greater attenuation indicative of non-liquid components.

WALLED OF NECROSIS (WON)

Heterogeneous with liquid and non-liquid density with varying degrees of loculations (some may appear homogeneous)

Well defined wall, that is, completely encapsulated

Location—intrapancreatic and/or extrapancreatic

Maturation usually requires 4 weeks after onset of acute necrotising pancreatitis

WALLED OF NECROSIS (WON)

Heterogeneous, fully encapsulated collection is noted in the pancreatic and peripancreatic area

Non-liquid components of high attenuation (black arrowheads) in the collection are noted

Natural history of pancreatic necrosisis variable

May remain solid or liquefy

May remain sterile or become infected

May persist or disappear over time

Banks PA et al. Gut 2013;62:102-111.

Available methods for intervention in pancreatic necrosis

Freeman ML et al. Pancreas 2012;41:1176-1194.

Endoscopic

Image-guided

percutaneous

Minimally-invasive surgery

Open surgical

necrosectomy

Available methods for intervention in pancreatic necrosis


Endoscopic

Image-guided

percutaneous

Minimally-invasive surgery

Open surgical

necrosectomy

Last choice!

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When is intervention indicated for

Necrosis?

Besselink MG et al. Arch Sur 2007;142:1194-1201.

It’ s all about timing...!

WAITat least 3-4 weeks

Direct endoscopic necrosectomy for the treatment of walled-off pancreatic necrosis: results from a multicenter

U.S. series

The median number of days from acute pancreatitis to first endoscopic intervention was 46 days.

Clearly waiting for encapsulation or “walling off” is critical to the success of primary endoscopic therapy, and the success of necrosectomy often directly correlates with the degree to which the collection is encapsulated.

Gardner TB, Direct endoscopic necrosectomy for the treatment of walled-off pancreatic necrosis: results from a multicenter U.S. series. Gastrointest Endosc. 2011 Apr;73(4):718-26

Freeman ML et al. Pancreas 2012;41:1176-1194; Baron TH et al. Clin Gastroenterol Hepatol 2012;10:1202-1207.

High suspicion for or known infected WOPN Early intervention should be avoided whenever possible (wait >4weeks)

Infected necrosis (WOPN)

Symptomatic sterile necrosis (WOPN) Intractable pain Obstructive symptoms (gastric outlet / biliary

obstruction) Inability to eat

When is intervention indicated for necrosis?

Endoscopic techniques of drainage/necrosectomy


Peroral flexible endoscopic drainage

transpapillary transmural

Direct endoscopic

necrosectomy

Nasocystic catheter

FIRST EXPERIENCE

In 1996, Baron and colleagues reported the first experience with endoscopic management of WON in 11 patients by performing a standard cystgastrotomy with nasoscystic tube irrigation.

Complete resolution occurred in 9 patients.

Gastroenterology 1996;111:755–64.

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ENDOSCOPIC INTERVENTIONS

PREPARATIONS

Define whether the procedure is being performed for source control or removal of the collection

Timing of intervention is appropriate

Patient does not have any obvious medical contraindications to the procedure—coagulopathy

Procedure is within the realm of the endoscopist’s.

Gastrointest Endoscopy Clin N Am 23 (2013) 787–802

PREPARATIONS

Make sure the collection is an inflammatory collection and not a premalignant condition, such as a mucinous cystic neoplasm or intraductal papillary mucinous neoplasm.

Anesthesia team- managing the patients with appropriate airway protection because there is the potential for extensive reflux and subsequent aspiration of fluid following initial cavity puncture.

Be certain to have availability of appropriate endoscopic expertise following the procedure


PATIENT POSITION

Prone positioning may allow for better gravitational drainage from posteriorly located collections and decrease the incidence of fluid reflux and aspiration.


TECHNIQUE

Initial endoscopy is performed using a therapeutic, side- viewing video duodenoscope, gastroscope, or echoendoscope.

There is evidence that EUS-guided drainage of PFCs is substantially more effective and less prone to complications than “conventional” techniques.

Varadarajulu S et al Gastrointest Endosc 2008;68:1102–11.

Prospective randomized trial comparing EUS and EGD for

transmural drainage of pancreatic pseudocysts

Technical success was defined as the ability to access and drain a pseudocyst by placement of transmural stents.

Complications were assessed at 24 hours and at day 30.

Treatment success was defined as the complete resolution or decrease in size of the pseudocyst to <2 cm on CT

GASTROINTESTINAL ENDOSCOPY Volume 68, No. 6 : 2008

30 patients randomized to undergo pseudocyst drainage by EGD or the EUS-guided approach.

All patients who had an EUS underwent successful drainage.

EGD was technically successful in only 33%; all who failed underwent successful drainage on crossover to EUS.

Major procedure related bleeding was encountered in 2 patients in whom drainage by EGD was attempted


PREPARATION

Routine antibiotic use is recommended for those not already receiving broad- spectrum antibiotics for presumed or documented infection.

If possible, CO2 insufflation should be used to help minimize the risk of air embolism, a rare but potentially catastrophic complication

IDENTIFICATION OF FISTULA SITE

With EUS: Endosonography is used to identify the appropriate site of transmural puncture.

It is important to ensure that the cyst lumen is well approximated against the luminal gastroinestinal tract.

The most appropriate site of transmural puncture should ideally be through a combined wall of 10 mm or less in thickness, although in some circumstances up to 20 mm may be acceptable.

Without EUS: External compression of the gastric or duodenal wall is determined endoscopically while referencing the most recent cross-sectional imaging


PUNCTURE

Most endoscopists use a 19-gauge fine-needle aspiration needle for puncture, and subsequently the needle sheath for initial dilation.

Aspiration of cavity contents and/or demonstration of contrast injection into the cavity under fluoroscopic guidance confirms cavity access and allows collection of liquid for microbial culture.

Puncture of the cavity by using the sheath of an EUS needle.

Validation of the guidewire within the cavity by using fluoroscopic guidance.

Multiple transluminal gateway technique for EUS-guided drainage

of symptomatic walled-off pancreatic necrosis

Comparison between patients with walled-off pancreatic necrosis managed endoscopically by a multiple transluminal gateway technique (MTGT) or a conventional drainage technique (CDT).

In MTGT, 2 or 3 transmural tracts were created by using EUS guidance between the necrotic cavity and the GI lumen.

One tract was used to flush normal saline solution via a nasocystic catheter, multiple stents were deployed in others to facilitate drainage of necrotic contents

In the CDT, two stents with a nasocystic catheter were deployed via 1 transmural tract.


Of 60 patients with symptomatic walled-off pancreatic necrosis, 12 were managed by MTGT and 48 by CDT.

Treatment was successful in 11 of 12 (91.7%) patients managed by MTGT versus 25 of 48 (52.1%) managed by CDT (P < .01)

In the CDT cohort, 17 required surgery, 3 underwent endoscopic necrosectomy, and 3 died of multiple-organ failure.


EUS versus surgical cystgastrostomy for management of pancreatic

pseudocysts.

Matched 10 patients who underwent surgical cystgastrostomy with 20 patients who underwent an EUS-guided cystgastrostomy

No significant differences in rates of treatment success (100% vs 95%), procedural complications (none in either cohort), or reinterventions (10% vs 0%) was found.

Mean length of a post procedure hospital stay for an EUS-guided cystgastrostomy was significantly shorter than for surgical cystgastrostomy (2.65 vs 6.5 days, P 5 .008).

Direct cost per case for EUS-guided cystgastrostomy was significantly less.

Gastrointest Endosc 2008;68:649–55.

FISTULA TRACT CREATION AND DILATATION

Standard-sized guidewire (as small as 0.018 inch) is advanced into the collection under fluoroscopic guidance.

Pseudocyst drainage - the tract is dilated to at least 10 mm in size using sequentially larger hydrostatic balloons.

Endoscopic debridement - the goal is to dilate the fistula tract fully to 20 mm at the time of the first endoscopy.

Dilation of the fistula tract by using a through-the-scope balloon.

The cystduodenostomy after balloon deflation

Stent placement for drainage

Pseudocyst - place stents to maintain the patency of the fistula tract and not necessarily act as a conduit for drainage.

Recommend 10-F double-pigtail stents of 2 to 4 cm length, preferably of soft material to minimize trauma to the back wall of the cavity or intestinal obstruction if the stents migrate spontaneously.

Alternatives are placement of a fully covered biliary type metallic stent, or even various forms of larger enteral or esophageal metallic stents to create a larger fistula.


Insertion of pigtail & nasocystic catheter

10 F double pigtail

7 F nasocystic catheter

Irrigation with 1500 ml saline/24hvia nasocystic catheter

Debridement of WON

Necrosis will often not resolve with the simple creation of a fistula tract.

Drive an endoscope through the dilated fistula tract into the necrotic cavity.

Devitalized pancreatic tissue can be removed via a combination of several accessories including balloons, snares, waterjets, baskets, and cap-suction techniques.

Goal is to remove as much of the devitalized necrotic tissue as possible from the cavity, but without disrupting a major vessel or the wall of the cavity, potentially leading to perforation, bleeding, or air embolus.

Endoscopic necrosectomy ( Dilate up to 18-20 mmInsert a therapeutic gastroscope, generous lavage,

Instruments: Dormia basket Retrieval nets Soft snares

Nasocystic catheter

Remove debris

Debridement of the cavity by using a snare.

At conclusion of each debridement session, stents must be left in place to allow the fistula tract to remain patent.

Preferably to use pigtail stents as with the pseudocyst drainage.

Fully covered metal stents can be used which may allow for dissolution of solid necrosis by gastric and bile acids over several weeks to months ??


Stent placement after cavitary debridement

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COMPLICATIONS

TRANSPAPILLARY STENT PLACEMENT

Whether to perform direct pancreatography using ERCP at the time of initial drainage is subject to variable opinion.

Transpapillary stenting of the duct is required if the duct is found to have a persistent leak.

In ill patients with infected necrosis, ERCP should generally be avoided at the initial intervention and postponed until after the infection is controlled.

Disconnected pancreatic duct

Creating a cystenterotomy fistula tract will usually allow for adequate pancreatic drainage and general current practice it to leave the stents across the fistula tract permanently to allow for adequate pancreatic drainage proximal to the site of disruption.


Direct endoscopic necrosectomy for the treatment of walled-off pancreatic necrosis:

results from a multicenter U.S. series

Largest published multicenter series to date

Six U.S. tertiary medical centers.

104 patients with a history of acute pancreatitis and symptomatic WOPN since 2003

Gardner et al.Gastrointest Endosc 2011;73:718–26

14 % patients had complications

19 patients had bleeding requiring endoscopic intervention

2 patients had a retrogastric perforation

3 patients had pneumoperitoneum

One death occurred during the initial debridement procedure

STEP UP APPROACH

Minimally invasive technique is initially used for drainage of WON such as percutaneous drainage.

Progress to minimally invasive necrosectomy (by endoscopic, sinus tract endoscopy, VARD, or open surgery) as needed.

Minimally invasive surgical necrosectomy

SINUS TRACT ENDOSCOPY

VIDEO-ASSISTED RETROPERITONEAL DEBRIDEMENT (VARD)

Access to the necrotic pancreas is achieved by following the tract of a radiologically placed drainage catheter.

Sinus tract endoscopy

A nephroscope is inserted into the infected collection after dilatation of the drain tract to 30 Fr under fluoroscopic guidance.

Debridement is carried out using a long forceps, and the necrotic cavity is flushed using jet irrigation and suction devices.

Three to five procedures is needed for adequate necrosectomy.

A large retrospective cohort series indicated that survival rates are potentially better with sinus tract endoscopy compared with open necrosectomy (mortality rate: 19 per cent of 137 patients versus 38 per cent of 52 patients)

Minimal access retroperitoneal pancreatic necrosectomy: improvement in morbidity and mortality with a less invasive approach. Ann Surg 2010; 251: 787 – 793

VIDEO-ASSISTED RETROPERITONEAL DEBRIDEMENT

(VARD)

Uses a 5-cm subcostal incision in the left flank near the exit point of the percutaneous drain

First solid debris that is encountered can be removed bluntly using a long grasping forceps.

Subsequently a laparoscope is introduced into the necrotic cavity and more central necrotic debris can be removed

A Step-up Approach or Open Necrosectomy for Necrotizing

Pancreatitis (NEJM 2010)

88 patients with necrotizing pancreatitis and suspected or confirmed infected necrotic tissue were randomized to undergo primary open necrosectomy or a step-up approach to treatment.

Step-up approach consisted of percutaneous drainage followed, if necessary, by minimally invasive retroperitoneal necrosectomy

Primary end point was a composite of major complications (new-onset multiple-organ failure or multiple systemic complications, perforation of a visceral organ or enterocutaneous fistula, or bleeding) or death

31 of 45 patients (69%) assigned to open necrosectomy and in 17 of 43 patients (40%) assigned to the step-up approach

35% were treated with percutaneous drainage only (step up group).

Endoscopic Transgastric vs Surgical Necrosectomy for Infected Necrotizing

Pancreatitis A Randomized Trial

First and the only trial comparing endoscopic v/s surgical necrosectomy.

Objective To compare the proinflammatory response and clinical outcome of endoscopic transgastric and surgical necrosectomy.

3 academic hospitals and 1 regional teaching hospital in the Netherlands between August 20, 2008, and March 3, 2010.

Bakker OJ et al. JAMA 2012,307:1053-1061.

The primary end point was the postprocedural proinflammatory response as measured by serum interleukin 6 (IL-6) levels.

Secondary clinical end points included a predefined composite end point of major complications (new- onset multiple organ failure, intra-abdominal bleeding, enterocutaneous fistula, or pancreatic fistula) or death.

ENDOSCOPIC NECROSECTOMY

Significant reduction of proinflammatory response (IL-6)

Significant reduction of major complications (20% vs. 80%; P=0.03)

Reduction of pancreatic fistula (10% vs.70%; P=0.02)

Comparative evaluation of structural and functional changes in pancreas after endoscopic and

surgical management

of pancreatic necrosis Records of patients who underwent endoscopic transmural

drainage of walled off pancreatic necrosis (WOPN) over the last 3 years and who completed at least 6 months of follow up were analyzed.

Structural and functional changes in these patients were compared with 25 historical surgical controls (operated in 2005-2006)

Surinder Singh Ranaa, Deepak Kumar Bhasin Annals of Gastroenterology (2014) 27, 162-166

KEY MESSAGES

Define the pancreatic fluid collection (Revised Atlanta classification) Acute fluid collection: Usually no treatment Collections > 4 weeks: Distinct between pseudocyst / WOPN WOPN with solid material

Intervention in WOPN: Timing! Wait >3-4 weeks

Endoscopic interventions in WOPN: effective and safe

THANKS

Endoscopic management of walled of pancreatic necrosis

Health & Medicine

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