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Endoscopia

versión On-line ISSN 2444-6483versión impresa ISSN 0188-9893

Endoscopia vol.31 no.1 Ciudad de México ene./mar. 2019  Epub 25-Oct-2021

https://doi.org/10.24875/end.m19000001 

Original articles

Questionable benefit of being in hospital after procedure for patients without immediate adverse events in EUS-guided drainage of pancreatic pseudocysts

Beneficio cuestionable de estar en el hospital después del procedimiento para pacientes sin eventos adversos inmediatos en el drenaje guiado por USE de pseudoquistes pancreáticos

Félix I. Téllez-Ávila1  2  * 

Luis Eduardo Casasola-Sánchez1 

Angela Saul1  2 

Carlos Chan1  3 

Jorge Hernández-Calleros1  4 

Miguel Ángel Ramírez-Luna1  2 

Luis Uscanga-Domínguez1  4 

1Pancreas Clinic. Instituto Nacional de Ciencias Médicas y Nutrición Dr. Salvador Zubirán, Mexico City, México

2Department of Gastrointestinal Endoscopy. Instituto Nacional de Ciencias Médicas y Nutrición Dr. Salvador Zubirán, Mexico City, México

3Surgery. Instituto Nacional de Ciencias Médicas y Nutrición Dr. Salvador Zubirán, Mexico City, México

4Department of Gastroenterology. Instituto Nacional de Ciencias Médicas y Nutrición Dr. Salvador Zubirán, Mexico City, México


Abstract

Introduction:

There is no consensus about if patients with EUS-guided drainage (EUS-GD) of pancreatic pseudocyst (PPC) could be discharged the same day or if the patient must stay at least one night in hospital. The aim was to report adverse events rate in the first 24 h after the procedure of patients with PPC treated by EUS-GD.

Materials and Methods:

A retrospective analysis of data obtained prospectively was conducted. Patients with PPC were included in the study. EUS-GD was using two double pigtail plastic stents (7F and 4 cm).

Results:

A total of 31 procedures in 29 patients with PPC were analyzed. There were 16 (55.2%) men with a mean ± SD age of 42.5 ± 14.5 years. The endoscopic drainage was performed through transgastric in 23/29 (79.3%) patients and transduodenal in 6/29 (17.2%) patients. Technical success was 100%, clinical success was 27/29 (93.1%), and three (10.3%) patients had recurrence. In total, 5/31 (16.1%) procedures have adverse events. One patient had stent migration after 24-month follow-up, two patients had infection of PPC after the punctuation (at day 4 and 5 after procedure), and two patients who bled during endoscopic drainage (one of them was successfully treated endoscopically with clips and the second required surgery).

Conclusion:

There is not a clear reason because patients with PPC and EUS-GD need for staying one night in hospital if was not any adverse event during the procedure.

Key words México; EUS-guided drainage; Pancreatic pseudocyst

Resumen

Introducción:

No hay consenso acerca de si los pacientes con pseudoquiste pancreático (PQP) con drenaje guiado por EUS (EUS-GD) podrían ser dados de alta el mismo día o si el paciente debe permanecer al menos una noche en el hospital. El objetivo fue informar la tasa de eventos adversos en las primeras 24 horas después del procedimiento.

Material y métodos:

Se realizó un análisis retrospectivo de datos obtenidos prospectivamente. Se incluyeron pacientes con PQP. Los EUS-GD utilizaron dos endoprótesis de plástico de doble cola de cochino (7F X 4 cm).

Resultados:

se analizaron un total de 31 procedimientos en 29 pacientes con PQP. Se incluyeron 16 (55.2%) hombres con una media ± DE de edad 42.5 ± 14.5 años. El drenaje se realizó por vía transgástrica en 23/29 pacientes (79,3%) y transduodenal en 6/29 pacientes (17,2%). El éxito técnico fue del 100%, el éxito clínico fue de 27/29 (93,1%) y 3 (10,3%) pacientes tuvieron recurrencia. En total, 5/31 (16.1%) procedimientos tuvieron eventos adversos. Un paciente tuvo una migración del stent después de 24 meses de seguimiento, dos pacientes tuvieron una infección del PQP después de la punción (en los días 4 y 5 después del procedimiento) y dos pacientes con hemorragia durante el drenaje endoscópico (uno de ellos se trató con éxito con endoscopia con clips y el segundo requirió cirugía). En

conclusión:

no hay una razón clara por la cual los pacientes con EUS-GD de PQP necesitan quedarse hospitalizados si no hubo ningún evento adverso durante el procedimiento.

Palabras clave México; Drenaje guiado por ultrasonido endoscópico; Pseudoquiste pancreático

Introduction

Endoscopic ultrasound-guided drainage (EUS-GD) is replacing surgical treatment of pancreatic pseudocysts (PPC)1 regardless that now there is agreement that endoscopic treatment must be the first line therapy for PPC2-5, there are some unanswered questions. There is no consensus about if patients with EUS-GD of PPC could be discharged the same day or if the patient must stay at least one night in hospital. Many endosonographers leave patients in hospital, regardless, they are asymptomatic after procedure and others prefer to discharge the patient the same day of the procedure. In an email survey made by one of the authors (free-trade agreements [FTA]) with six top endosonographers around the world (France, the United States, Canada, and Brazil), four of six endosonographers prefer to discharge the patient to home the day after the procedure, regardless, they are asymptomatic. Two of the endosonographers consulted also recommend that antibiotics should be given up to 7 days after drainage. This is an important topic because space in the third level hospitals and costs. The aim was to report adverse events rate in the first 24 h after procedure of patients with PPC treated by EUS-GD with focus in the question about if to stay for one night in hospital could represent some benefit to patients.

Materials and methods

A retrospective analysis of data obtained prospectively was conducted. Patients were seen from 2008 to 2014 at the National Institute of Medical Sciences and Nutrition Salvador Zubirán at Mexico City, Mexico. PPC was defined as a fluid collection in the pancreatic/peripancreatic area that had a well-defined wall and contained no solid debris or recognizable parenchymal necrosis6. All patients gave their written informed consent before the procedure and all were evaluated routinely with a contrast-enhanced computed tomography (CT) scan before the procedure. Patients were intubated and received prophylactic antibiotics before the procedure (1 g I.V. of ceftazidime 30 min before). A convex linear array echoendoscope was used and once the PPC was identified, it was accessed using a 19-gauge needle (Echo-Tip, Wilson-Cook Medical, Inc., Winston Salem, North Carolina, USA) and a 0.035-inch guidewire was inserted through the needle into the pseudocyst with fluoroscopic guidance. After removal of the needle, we used a needle knife inserted over the guidewire to create a bigger fistula. Finally, the gastric wall was dilated up to 12-15 mm and two double pigtail plastic stents (7F and 4 cm) were deployed for drainage. The procedure was performed in both inpatients and outpatients. In those outpatients, they were observed at least every 4 h and discharged once they were awake and asymptomatic. Decision about if one particular patient was discharged the same day of procedure or if the patient stayed one night in hospital was based on criteria of the treating physician.

We consider complications as follows: perforation was diagnosed when pneumoperitoneum was evident on imaging studies associated with peritoneal signs. Bleeding was defined as any hemorrhagic event that required endotherapy, blood product transfusion, or inpatient observation. Infection was considered if any septic event occurred after the initial endoscopic drainage and was caused by contamination of PPC, proven by new-onset fever, positive blood cultures, or by positive fluid cultures obtained at endoscopic revision5,7. Stent migration was defined as the need to retrieve a stent from within the pseudocyst or the enteral lumen8. 8 weeks after the drainage, an endoscopic retrograde pancreatography or magnetic resonance cholangiopancreatography was performed. Partial ductal disruption was defined as extravasation of contrast from the main pancreatic duct (MPD) with opacification of PD proximal to the disruption9,10. An abrupt cutoff of MPD with or without contrast extravasation, or an inability to traverse this disconnection with a guidewire, was diagnostic of disconnected pancreatic duct syndrome11.

Clinical success was defined as complete resolution or a decrease in size of the PPC to 2 cm or smaller on CT associated with the resolution of symptoms at the 8-week outpatient follow-up evaluation2. Recurrence was defined as PPC found on CT associated with symptoms after an initial resolution2. Reintervention was defined as the need for repeat surgery or endoscopy due to persistent symptoms in association with a residual pseudocyst that was not <50% of the original size on follow-up imaging2.

Statistical analysis

Continuous variables were expressed as means and SD. Categorical data were expressed as absolute numbers and percentages. Differences between groups were analyzed for categorical variables with the Chi-square test, except where the frequency was <5, in which Fisher's exact test was used. For continuous variables, analysis with Mann-Whitney U-test was done. We considered p < 0.05 as statistically significant. Statistical analysis was performed with SPSS version 20.0 for Mac (SPSS Inc., Chicago, EEUU).

Results

A total of 31 procedures in 29 patients with PPC were analyzed. There were 16 (55.2%) men and 13 (44.8%) women with a mean ± SD age of 42.5 ± 14.5 years. Gallstones were the most common etiology of pancreatitis with 15/29 (51.7%) cases. The average diameter of PPC was 9.6 cm (range 4.5-33 cm). Table 1 summarizes the baseline clinical characteristics of patients.

Table 1 Baseline clinical characteristics of patients included in the study 

Characteristic n = 29 (%)
Male 16 (55.2)
Age, years 42.5 ± 14.5
BMI 24.2 ± 4.1
Comorbidities 16 (55.2)
Cause of pancreatitis
Gallstones 15 (51.7)
Alcohol 6 (20.7)
Hypertriglyceridemia 2 (6.9)
Idiopathic 1 (3.4)
Unspecified 5 (17.2)

BMI: body mass index calculated by dividing the patient's body weight by the square of their height expressed as kg/m2, PPC: pancreatic pseudocyst.

The endoscopic drainage with EUS guidance was performed through transgastric in 23/29 (79.3%) patients and transduodenal in 6/29 (17.2%) patients. The mean number of stents used was 2 (1-4). 12 (41.3%) patients required a nasocystic catheter because of infected PPC. In one patient, a metallic stent was used. The location of PPC in the 29 patients was the pancreatic body in 9 (31%), body-tail in 8 (27.6%), head in 5 (17.2%), tail in 2 (6.9%), uncinate region in 2 (6.9%), and head-body in 2 (6.9%). In one patient, PPC location was not specified. Technical success was 100%, clinical success was 27/29 (93.1%), and three (10.3%) patients had recurrence. In total, 5/31 (16.1%) procedures have adverse events (Table 2).

Table 2 Patients with adverse events related to EUS-GD of PPC 

Patient Sex/age Complication Size of PPC, cm Time from procedure Need for hospitalization Need for surgery Days of follow-up Outcome Reintervention
1 F/46 Bleed 13 During procedure Yes Yes 760 Alive No
2 F/74 Migration of stent 8 2 years No No 730 Alive Yes*
3 M/44 Infection 15 Yes No 1825 Alive Yes**
4 F/33 Bleed 16 During procedure Yes No 720 Alive No
5 M/36 Infection 15 5 days Yes No 670 Alive Yes**

*Need for enteroscopy for to get the prosthesis.

**Need for new EUS procedure.

Patient was discharged the next day without another adverse event.

Stent migration

One patient had stent migration after 24-month follow-up; in this case, PPC resolved, and in CT, one stent was detected in the small bowel at ileum. Due to intermittent abdominal pain, a double-balloon enteroscopy was performed; this found the stent 30 cm from the ileocecal valve and enabled retrieval of them with a polypectomy loop, with improvement on follow-up.

Infection

The first patient was a male of 36 years old with PPC of 15 cm in the head of the pancreas who back to the emergency department because chills and fever at day 4 after procedure. The second patient was a male of 44 years old with PPC of 15 cm who presented with abdominal pain and fever after 5 days of the drainage. The two patients with infectious adverse events were treated with a second EUS-GD using a nasocystic catheter with irrigation of 1000 mL/day of saline solution for 5 days with clinical and radiological resolution. The infection presented after the first procedure, regardless, both patients received prophylactic antibiotics.

Bleeding

About the two patients who bled during endoscopic drainage, one of them was successfully treated endoscopically with clips and the second required surgery. No deaths related to endoscopic treatment were documented.

Discussion

According to our data staying one night in hospital, if were not any adverse events during the procedure, does not make a difference. If there is an adverse event, it happens immediately (bleeding and perforation) or days later (infection).

According to our results, in a previous retrospective analysis, only 32% of patients with EUS-GD required hospitalization12. Another study with 30 patients did not found any immediate adverse event procedure related, but four secondary infections were reported13. Siddiqui et al. reported a complication rate of 10.3% (n = 9), they had 5 intraprocedural bleeding, three post-procedure pain, and one patient fever of uncertain etiology14. One RCT (2) with 20 patients with EUS-GD of PPC reported none adverse events in concordance to another study that compares EUS versus EGD7. In Table 3, complications reported in previous studies of EUS-GD of PPC are shown, as it can be seen in that table, of 15 studies reported, 2-23% of the total of complications are during the procedure or < 24 h later and the rest appears after more than 3 days.

Table 3 Complications reported in previous studies of EUS-guided drainage of pancreatic pseudocysts 

Author/year N Complications n, (%) Type complication Time after procedure Treatment
Krüger 2006 35 11 (31) Cyst infection (4)
Stent occlusion (4)
Limited stent drainage (3)
- Endoscopy
Varadarajulu 2008 20 0 - - -
Itoi 200815 13 0 - - -
Yasuda 2009 26 0 - - -
Varadarajulu 2011 20 0 - - -
Sadik 201116 16 1 (6) Perforation 2 days Surgery
Varadarajulu 2011 148 8 (5.4) Perforation (2)
Bleeding (1)
Stent migration (1)
Infection (4)
<24 h (3)
not specified (4)
1 week (1)
Surgery (5)
Endoscopy (3)
Puri 201217 40 3 (7.5) Bleeding (1)
Infection (1)
Perforation (1)
Inmediatly (2)
40 h (1)
Surgery (1)
Conservative (2)
Seewald 2012*18 80 21 (26) Bleeding (12)
Perforation (7)
Portal air-embolis (1)
Ogilvie Syndrome (1)
Inmediatly (19)
Not specified (2)
Surgery (4)
Conservative (5)
Self-limited (11)
Endoscopy (1)
Wen 2014 118 23 (19.5) Bleeding Infection Migration - -
Siddiqui 2013 87 11 (12) Bleeding (5)
Pain (3)
Fever (1)
Stent migration (2)
Inmediatly (5) (bleeding)
48-72 h (4)
1 month (2)
Embolization by radiology (1)
Self-limited (8)
Endoscopically (2)
Kwon 201319 12 5 (41) Fever (3)
Stent migration (2)
2 months (1 stent)
8 months (1 stent)
4-6 weeks (2 fever)
Pancreatic stent (2)
Stent replacemente (1)
Nothing (2 stent migration)
Shah 2015 33 5 (15) Pain (3)
Stent migration (1)
Infection (1)
- -
Kokosis 2015 65 11 (17) Infection (4)
Perforation (5)
Stent migration (1)
Bleeding (1)
24 h (1)
Inmediatly (5)
Not specifed (5)
Surgery (3)
Self-limited (1)
Conservative (6)
Radiology (1)
Kokosis 2015 65 11 (17) Infection (4)
Perforation (5)
Stent migration (1)
Bleeding (1)
24 h (1)
Inmediatly (5)
Not specifed (5)
Surgery (3)
Self-limited (1)
Conservative (6)
Radiology (1)
Krüger 2006 35 11 (31) Cyst infection (4)
Stent occlusion (4)
Limited stent drainage (3)
- Endoscopy
Varadarajulu 2008 20 0 - - -
Itoi 200815 13 0 - - -
Yasuda 2009 26 0 - - -
Varadarajulu 2011 20 0 - - -
Sadik 201116 16 1 (6) Perforation 2 days Surgery
Varadarajulu 2011 148 8 (5.4) Perforation (2)
Bleeding (1)
Stent migration (1)
Infection (4)
<24 h (3)
not specified (4)
1 week (1)
Surgery (5)
Endoscopy (3)
Puri 201217 40 3 (7.5) Bleeding (1)
Infection (1)
Perforation (1)
Inmediatly (2)
40 h (1)
Surgery (1)
Conservative (2)
Seewald 2012*18 80 21 (26) Bleeding (12)
Perforation (7)
Portal air-embolis (1)
Ogilvie Syndrome (1)
Inmediatly (19)
Not specified (2)
Surgery (4)
Conservative (5)
Self-limited (11)
Endoscopy (1)
Wen 2014 118 23 (19.5) Bleeding Infection Migration - -
Siddiqui 2013 87 11 (12) Bleeding (5)
Pain (3)
Fever (1)
Stent migration (2)
Inmediatly (5)
(bleeding)
48-72 h (4)
1 month (2)
Embolization by radiology (1)
Self-limited (8)
Endoscopically (2)
Kwon 201319 12 5 (41) Fever (3)
Stent migration (2)
2 months (1 stent)
8 months (1 stent)
4-6 weeks (2 fever)
Pancreatic stent (2)
Stent replacemente (1)
Nothing (2 stent migration)
Shah 2015 33 5 (15) Pain (3)
Stent migration (1)
Infection (1)
- -
Kokosis 2015 65 11 (17) Infection (4)
Perforation (5)
Stent migration (1)
Bleeding (1)
24 h (1)
Inmediatly (5)
Not specifed (5)
Surgery (3)
Self-limited (1)
Conservative (6)
Radiology (1)
Kokosis 2015 65 11 (17) Infection (4)
Perforation (5)
Stent migration (1)
Bleeding (1)
24 h (1)
Inmediatly (5)
Not specifed (5)
Surgery (3)
Self-limited (1)
Conservative (6)
Radiology (1)

WEN ◊ in chinese, only abstract is available in English

*WON and PQP

The complication rate in our study was 16.1% and is according with previous reports2,7,15-21. For us, bleeding was the more important complication and we think that the use of needle knife to create a bigger fistula could explain this. Other authors recommend the use of a cystostome 6F after initial puncture; however, unfortunately, this is not widely available in our country. We have two patients with infection of PPC after the initial drainage. The occurrence of post-puncture infections has been attempted to prevent with the use of prophylactic antibiotics; however, these are not 100% effective. It is currently recommended that patients with pseudocysts with viscous debris-laden fluid the use of a nasocystic drain for the purpose of performing either “in bolus” or continuous lavage14. At this moment, there is no information on how long after drainage, the nasocystic drain must be in place or if there is any difference between doing them continuously or “in bolus.” According to our experience, when PPCs are large (> 15 cm) and the contents are clearly purulent, it is more appropriate to perform the washing through the nasoabscess catheter “in bolus” and not continuously, because at least in our experience, it causes a higher frequency of patients with systemic inflammatory response.

There are some limitations of our study; first, the retrospective design. However, for our knowledge, there is a lack of studies specifically focus on complications of EUS-guided PPC drainage21. Our data could be important for future study designs and reviews.

Conclusion

There is not a clear reason because patients with PPC and EUS-GD need for staying one night in hospital if was not any adverse event during the procedure.

Disclosure: All authors disclosed no financial relationship relevant to this publication.

Authors' Contributions

Félix I. Téllez-Ávila design the study; Félix I. Téllez-Ávila and Miguel A. Ramírez-Luna were attending doctors and performed endoscopies; Félix I. Téllez-Ávila, Luis Eduardo Casasola-Sánchez, Angela Saul, Carlos Chan, Jorge Hernández-Calleros and Luis Uscanga-Domínguez organized the report; and Félix I. Téllez-Ávila, Luis Eduardo Casasola-Sánchez, Angela Saul, Carlos Chan, Jorge Hernández-Calleros and Luis Uscanga-Domínguez wrote the paper.

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Received: September 01, 2018; Accepted: November 20, 2018

* Correspondence: Félix I. Téllez-Ávila Department of Endoscopy Instituto Nacional de Ciencias Médicas y Nutrición Salvador Zubirán Vasco de Quiroga,15 Col. Belisario Domínguez, Sección XVI, Del. Tlalpan C.P. 14080, Mexico City, Mexico E-mail: felixtelleza@gmail.com

Creative Commons License Instituto Nacional de Cardiología Ignacio Chávez. Published by Permanyer. This is an open ccess article under the CC BY-NC-ND license