Lumenapposing stents versus plastic stents in the management

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Lumen-apposing stents versus plastic stents in the management of pancreatic pseudocysts: a large, comparative,

Lumen-apposing stents versus plastic stents in the management of pancreatic pseudocysts: a large, comparative, international, multicenter study Yang J. et al. Endoscopy. 2019 Nov; 51(11): 1035 -1043. Dr. Federico Cravero Tutor: Dr. Mauro Bruno

Acute pancreatitis subtypes Acute pancreatitis 10 -20% 80 -90% Edematous pancreatitis Fluid collection 10

Acute pancreatitis subtypes Acute pancreatitis 10 -20% 80 -90% Edematous pancreatitis Fluid collection 10 -40 % Necrotizing pancreatitis

Atlanta classification

Atlanta classification

When drainage is indicated? Infected collection Symptomatic collection • • Abdominal pain Inability to

When drainage is indicated? Infected collection Symptomatic collection • • Abdominal pain Inability to eat Biliary obstruction Gastric obstruction 4 weeks

Drainage techniques Percutaneous ENDOSCOPY Surgery 70 -80 % resolution 10 -15% morbidity 4 -10%

Drainage techniques Percutaneous ENDOSCOPY Surgery 70 -80 % resolution 10 -15% morbidity 4 -10% mortality Severe disease only

Endoscopic drainage Double pigtail plastic stents (DPPS) Fully covered self-expanding metal stent LAMS

Endoscopic drainage Double pigtail plastic stents (DPPS) Fully covered self-expanding metal stent LAMS

Choosing stent Pseudocysts Plastic stent are a valid solution: Multiple stents for optimal drainage

Choosing stent Pseudocysts Plastic stent are a valid solution: Multiple stents for optimal drainage WON Data on LAMS are lacking, but in recent studies they show excellent results: Low price Greater clinical success Complex insertion procedure Lower insertion time Infectious and occlusion risk Lower occlusion rate Access to cavity (e. g. necrosectomy) Greater cost LAMS role? ? Greater bleeding risk

Today topic

Today topic

Background

Background

Background e scopo dello studio LAMS are mostly studied for WON drainage or in

Background e scopo dello studio LAMS are mostly studied for WON drainage or in mixed WON/pseudocyst cohort Large direct comparative studies of LAMSs with DPPSs in pancreatic pseudocyst management are lacking Objective: to compare the clinical outcomes of transmural guided EUS drainage of pancreatic pseudocysts performed with DPPSs vs LAMS

Methods Retrospective international multicentric study. 14 tertiary hospitals: 12 USA, 2 UE Inclusion criteria:

Methods Retrospective international multicentric study. 14 tertiary hospitals: 12 USA, 2 UE Inclusion criteria: Patients who underwent EUS-guided pancreatic pseudocyts drainage Used stent: LAMS or DPPSs Enrolling time: January 2012 – August 2016 Exclusion criteria: WON Less than 30 days follow-up inferiore ai 30 giorni Atlanta classification

End points Primary end point clinical success • Pseudocyst reduction < 3 cm •

End points Primary end point clinical success • Pseudocyst reduction < 3 cm • Symptoms resolution • No need of percutaneous drainage or surgery

End points Secondary end points: • • • Rate of technical success Adverse events

End points Secondary end points: • • • Rate of technical success Adverse events (severity graded) Stent migration Pseudocyst recurrence (symptoms, diameter > 3 cm) Need for surgery

Patients - demographics

Patients - demographics

Patients – PC characteristics

Patients – PC characteristics

Procedure technique LAMS DPPS Linear array echoendoscopes PC size and position evaluation Access to

Procedure technique LAMS DPPS Linear array echoendoscopes PC size and position evaluation Access to cavity with 19 gauge needle from stomach or duodenum Probe – PC distance < 1 cm Color-doppler to exclude vessel interposition Cautery assisted LAMS insertion (60%) Non cautery assisted: needle, wire, tract dilation, insertion 0. 025 or 0. 035 guidewire insertion in cyst cavity under fluoroscopic guidance Tract dilation with baloon or cystotome DPPS insertion over guidewire under fluoroscopic guidance

Procedure characteristics

Procedure characteristics

Clinical outcomes

Clinical outcomes

Adverse events

Adverse events

Predictors of clinical success POSITIVE NEGATIVE LAMS placement Paracolic gutter extension Lower procedure times

Predictors of clinical success POSITIVE NEGATIVE LAMS placement Paracolic gutter extension Lower procedure times Younger age Lower use of pancreatic duct stent Increased number of endoscopic procedures prior to stent removal

Conclusions LAMS usage is associated with: • • Higher clinical success (p=0. 03) Shorter

Conclusions LAMS usage is associated with: • • Higher clinical success (p=0. 03) Shorter procedure time (p<0. 001) Lower rate of percutaneous drainage (p=0. 03) Lower rate of adverse events (p=0, 04)

Bibliography Arvanitakis M, et al. Endoscopic management of acute necrotizing pancreatitis: European Society of

Bibliography Arvanitakis M, et al. Endoscopic management of acute necrotizing pancreatitis: European Society of Gastrointestinal Endoscopy (ESGE) evidence-based multidisciplinary guidelines. Endoscopy. 2018 May; 50(5): 524 -546. Banks PA et al. Classification of acute pancreatitis--2012: revision of the Atlanta classification and definitions by international consensus. Gut. 2013; 62(1): 102. ASGE Standards of Practice Committee, The role of endoscopy in the diagnosis and treatment of inflammatory pancreatic fluid collections. Gastrointest Endosc. 2016; 83(3): 481. Hookey LC et al. Endoscopic drainage of pancreatic-fluid collections in 116 patients: a comparison of etiologies, drainage techniques, and outcomes. Gastrointest Endosc. 2006; 63(4): 635. Antillon MR et al. Single-step EUS-guided transmural drainage of simple and complicated pancreatic pseudocysts. Gastrointest Endosc. 2006; 63(6): 797 B. Joseph Elmunzer. Endoscopic Drainage of Pancreatic Fluid Collections. Clinical Gastroenterology and Hepatology 2018; 16: 1851– 1863