Published online Jun 16, 2019. doi: 10.4253/wjge.v11.i6.403
Peer-review started: March 3, 2019
First decision: March 20, 2019
Revised: May 16, 2019
Accepted: May 23, 2019
Article in press: May 23, 2019
Published online: June 16, 2019
Processing time: 104 Days and 13.8 Hours
Endoscopic ultrasound (EUS) guided drainage of symptomatic pancreatic fluid collections (PFCs), using self-expandable metal stents (SEMS) has a high technical and clinical success rate. However, their use in cirrhotics has not yet been studied. These patients are less than optimal surgical candidates given the underlying coagulopathy and portal hypertension related complications increasing their risk of adverse events.
Over the past decade, EUS guided drainage of symptomatic PFCs via placement of transmural stents has largely replaced the more traditional approaches of surgery or percutaneous drainage mainly been due to its high success rate (87%-97%) coupled with low adverse event (6%-34%) and mortality (0%-1%) rates. Thus, we wanted to study if this would be a viable option for cirrhotic patients.
Our study aimed to compare the technical success rate and clinical outcomes of EUS guided drainage of symptomatic PFCs using SEMS in cirrhotics vs non-cirrhotics.
We conducted a retrospective comparative analysis of patients with symptomatic PFCs [pancreatic pseudocyst (PP) or walled-off necrosis (WON)] who underwent EUS-guided placement of fully covered self-expandable metals stents (FCSEMS) or lumen-apposing self-expandable metal stents (LASEMS). All patients were followed clinically until resolution of PFCs or death. Definition: (1) Technical success was defined as successful placement of SEMS; and (2) Clinical success was defined as complete resolution of the PFCs without additional interventions including interventional radiology or surgery. Number of procedures performed per patient, number of patients who achieved complete resolution of the PFCs without additional interventions and procedure related adverse events were recorded.
From January 2012 to December 2017, a total of 88 patients underwent EUS-guided drainage of symptomatic PFCs. Of these, 58 non cirrhotic patients underwent plastic stent insertion for management of PFC and 30 patients, 5 with cirrhosis and 25 without cirrhosis, underwent EUS-guided transmural drainage with SEMS, including 18 (60%) PP and 12 (40%) WON. Technical success was achieved in all 30 patients. Clinical success was achieved in 60% cirrhotic patients and 92% non-cirrhotics (P = 0.12). Procedure-related adverse events were 60% in cirrhotic and 28% non-cirrhotic (P = 0.62). Moreover, fatal adverse events were statistically more common in cirrhotics compared with non-cirrhotics (0% vs 40%; P = 0.023). Successful stent removal following resolution was 60% in cirrhotics and 80% in non-cirrhotics (P = 0.57). Post-procedure length of hospitalization was 18.6 ± 20.3 d in cirrhotics and 5.6 ± 13.7 d in non-cirrhotics (P = 0.084).
Despite a 100% technical success rate (endoscopist technique), clinically success was attained in only 60% cirrhotics, with two of the five cirrhotic patients having expired (p: 0.023) compared to 92% clinical success in non-cirrhotic and no fatalities. The rate of adverse events also tended to be higher in the cirrhotic patients (60% cirrhotics vs 28% non-cirrhotics). Although the EUS guided transmural drainage of symptomatic PFCs is considered a less invasive procedure, when compared with the traditional surgical approach, it still seems to pose cirrhotic patients to clinical decompensation. Our study even though the first of its kind, was limited by its retrospective nature and small sample size and so these results must be interpreted as such.
In cirrhotic patients caution must be exercised when performing EUS guided drainage of symptomatic PFCs given the high morbidity and mortality as evidenced by our cohort, particularly for the endoscopic debridement of WONs. Larger, prospective, multicenter studies are warranted to further characterize the risk profile and outcomes in these patients.