Role of EUS in drainage of peripancreatic fluid collections not amenable for endoscopic transmural drainage

• Published in: Gastrointestinal endoscopy 2007-12, Vol.66 (6), p.1107-1119
• Main Authors: Varadarajulu, Shyam, MD, Wilcox, C. Mel, MD, Tamhane, Ashutosh, MD, MSPH, Eloubeidi, Mohamad A., MD, MHS, Blakely, Jeanetta, RN, Canon, Cheri L., MD
• Format: Article
• Language: English
• Subjects: Biological and medical sciences; Digestive system; Digestive system. Abdomen; Drainage - methods; Endoscopy; Endoscopy, Digestive System - methods; Gastroenterology and Hepatology; Gastroenterology. Liver. Pancreas. Abdomen; Humans; Investigative techniques, diagnostic techniques (general aspects); Liver. Biliary tract. Portal circulation. Exocrine pancreas; Medical sciences; Necrosis; Other diseases. Semiology; Pancreas - pathology; Pancreatic Diseases - therapy; Pancreatic Function Tests; Prospective Studies; Radiodiagnosis. Nmr imagery. Nmr spectrometry
• ISSN: 0016-5107; 1097-6779
• DOI: 10.1016/j.gie.2007.03.1027

Background Increasingly, peripancreatic fluid collections (PFCs) are managed endoscopically with conventional transmural drainage (CTD). The role of interventional EUS in drainage of PFCs requires further clarification, because the procedure is technically challenging, with limited availability. Objective Identify characteristics that determine the need for drainage of PFC by CTD versus EUS. Patients Consecutive patients with symptomatic PFCs (types: pseudocyst, abscess, and necrosis) referred for endoscopic drainage. Study Design Prospective study. Setting Tertiary-referral center. Methods After ERCP, transmural drainage was attempted by CTD. If unsuccessful, drainage by EUS was then attempted. Findings on contrast-enhanced CT and endoscopy were collected to identify characteristics that predict the need for CTD versus EUS drainage. Main Outcome Measurements Identify characteristics to determine whether CTD or EUS is best suited for drainage of a particular PFC. Technical outcomes and safety of both techniques were also compared. Results Of 53 patients with PFCs, CTD was technically successful in 30 (57%) and failed in 23 (43%). PFC regional location was the pancreatic head in 16, the body in 20, and the tail in 17; in these locations, CTD was successful in 13 (81%), 17 (85%), and 0, respectively. The causes of failed CTD were absence of luminal compression (LC) in 20, difficulty with scope positioning in 2, and bleeding with attempted drainage (portal hypertension) in 1. One PFC drained by CTD was later diagnosed as necrotic sarcoma. Of the 23 patients who failed CTD and underwent EUS, an alternate diagnosis of mucinous neoplasm was made in 2 patients, and EUS-guided drainage was successful in the other 21 patients (100%). Although CTD failed in all PFCs in the tail, all were successfully drained by EUS. In the pancreatic-head region, only those PFCs superior to pancreas and extending into porta hepatis (n = 3) required drainage by EUS. In the pancreatic body, only PFCs that developed bleeding from a transmural puncture or without definitive LC because of gastric mural edema (albumin