Clinical Endoscopy

Systematic Review and Meta-analysis

Coaxial plastic stent placement within lumen-apposing metal stents for the management of pancreatic fluid collections: a systemic review and meta-analysis: Jad AbiMansour, Veeravich Jaruvongvanich, Saran Velaga, Ryan Law, Andrew C. Storm, Mark Topazian, Michael J. Levy, Ryan Alexander, Eric J. Vargas, Aliana Bofill-Garica, John A. Martin, Bret T. Petersen, Barham K. Abu Dayyeh, Vinay Chandrasekhara; Clin Endosc 2024;57(5):595-603. Published online July 24, 2024; DOI: https://doi.org/10.5946/ce.2023.297

Graphical Abstract Abstract PDF Supplementary Material PubReader ePub: Background
/Aims: Coaxial placement of double pigtail plastic stents (DPPS) through lumen-apposing metal stents (LAMSs) is commonly performed to reduce the risk of LAMS obstruction, bleeding, and stent migration when used for the drainage of pancreatic fluid collections (PFCs). A systematic review and meta-analysis were performed to compare the outcomes of LAMS alone and LAMS with coaxial DPPS placement in the management of PFCs.
Methods
A systematic review was conducted to identify studies comparing LAMS and LAMS/DPPS for PFC drainage. Primary outcomes included the rate of clinical success, overall adverse events (AEs), bleeding, infection, occlusion, and stent migration. The pooled effect size was summarized using a random-effects model and compared between LAMS and LAMS/DPPS by calculating odds ratios (ORs).
Results
Nine studies involving 709 patients were identified (338 on LAMS and 371 on LAMS/DPPS). LAMS/DPPS was associated with a reduced risk of stent obstruction (OR, 0.59; p=0.004) and infection (OR, 0.55; p=0.001). No significant differences were observed in clinical success (OR, 0.96; p=0.440), overall AEs (OR, 0.57; p=0.060), bleeding (OR, 0.61; p=0.120), or stent migration (OR, 1.03; p=0.480).
Conclusions
Coaxial DPPS for LAMS drainage of PFCs is associated with a reduced risk of stent occlusion and infection; however, no difference was observed in the overall AE rates or bleeding.

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Case Report

Bronchoesophageal fistula in a patient with Crohn’s disease receiving anti-tumor necrosis factor therapy: Kyunghwan Oh, Kee Don Choi, Hyeong Ryul Kim, Tae Sun Shim, Byong Duk Ye, Suk-Kyun Yang, Sang Hyoung Park; Clin Endosc 2023;56(2):239-244. Published online December 21, 2021; DOI: https://doi.org/10.5946/ce.2021.215

Abstract PDF PubReader ePub

Tuberculosis is an adverse event in patients with Crohn’s disease receiving anti-tumor necrosis factor (TNF) therapy. However, tuberculosis presenting as a bronchoesophageal fistula (BEF) is rare. We report a case of tuberculosis and BEF in a patient with Crohn’s disease who received anti-TNF therapy. A 33-year-old Korean woman developed fever and cough 2 months after initiation of anti-TNF therapy. And the symptoms persisted for 1 months, so she visited the emergency room. Chest computed tomography was performed upon visiting the emergency room, which showed BEF with aspiration pneumonia. Esophagogastroduodenoscopy with biopsy and endobronchial ultrasound with transbronchial needle aspiration confirmed that the cause of BEF was tuberculosis. Anti-tuberculosis medications were administered, and esophageal stent insertion through endoscopy was performed to manage the BEF. However, the patient’s condition did not improve; therefore, fistulectomy with primary closure was performed. After fistulectomy, the anastomosis site healing was delayed due to severe inflammation, a second esophageal stent and gastrostomy tube were inserted. Nine months after the diagnosis, the fistula disappeared without recurrence, and the esophageal stent and gastrostomy tube were removed.

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(Re-)introduction of TNF antagonists and JAK inhibitors in patients with previous tuberculosis: a systematic review
Thomas Theo Brehm, Maja Reimann, Niklas Köhler, Christoph Lange
Clinical Microbiology and Infection.2024; 30(8): 989. CrossRef
Azathioprine/infliximab/methylprednisolone

Reactions Weekly.2023; 1963(1): 114. CrossRef

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Original Article

RWON Study: The Real-World Walled-off Necrosis Study: Ankush Pawar, Ujjwal Sonika, Manish Kumar, Sundeep Saluja, Siddharth Srivastava; Clin Endosc 2021;54(6):909-915. Published online February 23, 2021; DOI: https://doi.org/10.5946/ce.2020.175

Abstract PDF PubReader ePub

Background
/Aims: The management of walled-off necrosis (WON) has undergone a paradigm shift from surgical to nonsurgical modalities. Real-world data on the management of symptomatic WON are scarce.
Methods
Prospectively collected data of symptomatic WON cases were retrospectively evaluated. The treatment modalities used were medical management alone, percutaneous catheter drainage (PCD) or endoscopic drainage (ED), or a combination of PCD and ED. We compared clinical outcome among these modalities.
Results
A total of 264 patients were evaluated. The most common indications for drainage were pain and fever. Of the patients, 28% was treated with medical therapy alone, 31% with ED, 37% with PCD, and 4% with a combined approach. Technical success and clinical success were achieved in 93% and 91% of patients in the endoscopic arm and in 90% and 81% patients in the PCD arm, respectively (p=0.0004 for clinical success). Lower rates of complications (7% vs. 22%, p=0.005), readmission (20% vs. 34%, p=0.04), and mortality (4% vs. 19%, p=0.0012), and shorter hospital stay (13 days vs. 19 days, p=0.0018) were observed in the endoscopic group than in the PCD group.
Conclusions
ED of WON is better than PCD and is associated with lower mortality, fewer complications, and shorter hospitalization.

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Endoscopic ultrasound drainage of pancreatic fluid collections: do we know enough about the best approach?
Andrada Seicean, Cristina Pojoga, Voicu Rednic, Claudia Hagiu, Radu Seicean
Therapeutic Advances in Gastroenterology.2023;[Epub] CrossRef
Treatment of Walled-off Necrosis – Outcomes are Best When Endoscopy and Percutaneous Interventions are Complimentary, Not Exclusive
Ji Young Bang, Shyam Varadarajulu
Clinical Endoscopy.2021; 54(6): 785. CrossRef

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2 Crossref

Review

Endoscopic Transmural Necrosectomy: Timing, Indications, and Methods: Rungsun Rerknimitr; Clin Endosc 2020;53(1):49-53. Published online September 18, 2019; DOI: https://doi.org/10.5946/ce.2019.131

Abstract PDF PubReader ePub

Walled-off necrosis is considered one of the most severe complications after an episode of severe acute pancreatitis. Traditionally, percutaneous drainage is selected as the first treatment step, while open surgery can be planned as a secondary option if necrosectomy is required. In recent years, endoscopic necrosectomy has evolved as a more favorable approach. To date, a step-up treatment strategy is recommended, particularly when a plastic stent is selected as the drainage device. Multi-gateway endoscopic therapy may be used in a step-up fashion if only one stent fails to clear debris. Over many years, there has been an evolution in stent selection, from plastic to metallic stents. Within a few years of its clinical usage, lumen-apposing stents are gaining more popularity as they offer direct endoscopic necrosectomy and only require a few sessions.

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Daryl Ramai, Zohaib Ahmed, Saurabh Chandan, Antonio Facciorusso, Smit S. Deliwala, Yaseen Alastal, Ali Nawras, Marcello Maida, Monique T. Barakat, Andrea Anderloni, Douglas G. Adler
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Postponed endoscopic necrosectomy results in a lower rate of additional intervention for infected walled-off necrosis
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Cirugía Española (English Edition).2022; 100(1): 52. CrossRef
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Rungsun Rerknimitr
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Ning Xu, Ya-Qi Zhai, Long-Song Li, Ning-Li Chai
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Original Article

Pancreatic Necrosectomy through Sinus Tract Endoscopy: Mahesh Kumar Goenka, Usha Goenka, Md.Yasin Mujoo, Indrajit Kumar Tiwary, Sanjay Mahawar, Vijay Kumar Rai; Clin Endosc 2018;51(3):279-284. Published online January 4, 2018; DOI: https://doi.org/10.5946/ce.2017.066

Abstract PDF PubReader ePub

Background
/Aims: Direct endoscopic pancreatic necrosectomy is increasingly being utilized to treat infected or symptomatic walled-off necrosis (WON) located close to the stomach or duodenum. Laterally-placed WON has traditionally been treated surgically. We evaluated a less utilized technique of sinus tract endoscopy (STE) for symptomatic laterally-placed WON.
Methods
Two hundred seventy-six patients with acute pancreatitis admitted in our hospital, 32 had symptomatic or infected WON requiring intervention. Of the 12 patients with laterally placed WON, 10 were treated by STE. STE was performed with a standard adult gastroscope passed through a percutaneous tract created by the placement of a 32-Fr drain.
Results
Ten patients (7 males; mean age, 43.8 years) underwent STE. Mean number of sessions was 2.3 (range, 1–4), with mean time of 70 minutes for each session (range, 15–70 minutes). While 9 patients had complete success, 1 patient had fever and chose to undergo surgery. Two patients developed pneumoperitoneum, which was treated conservatively. There was no mortality, cutaneous fistula, or recurrence during follow-up.
Conclusions
Laterally placed WON can be successfully managed by STE performed through a percutaneously placed drain. Details of the technique and end-points of STE require further evaluation.

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Santi Mangiafico, Helga Bertani, Flavia Pigò, Salvatore Russo, Marinella Lupo, Silvia Cocca, Giuseppe Grande, Ugo Germani, Raffaele Manta, Rita Conigliaro
Surgical Laparoscopy, Endoscopy & Percutaneous Techniques.2024; 34(2): 156. CrossRef
Metal stent and percutaneous endoscopic necrosectomy as dual approach for the management of complex walled-off pancreatic necrosis
Cecilia BINDA, Barbara PERINI, Chiara COLUCCIO, Paolo GIUFFRIDA, Stefano FABBRI, Giulia GIBIINO, Antonio VIZZUSO, Emanuela GIAMPALMA, Carlo FABBRI
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Daniela Giraldo Campillo, Juliana Lucía Molina Valencia, Juan Camilo Ricaurte Ciro, Carlos Andrés Delgado López
Revista colombiana de Gastroenterología.2024; 39(2): 194. CrossRef
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Sohini Sameera, Tayyaba Mohammad, Kelvin Liao, Haroon Shahid, Avik Sarkar, Amy Tyberg, Michel Kahaleh
Journal of Clinical Gastroenterology.2023; 57(4): 346. CrossRef
Placement of Plastic Stents after Direct Endoscopic Necrosectomy through a Novel Lumen-Apposing Metal Stent for Effective Treatment of Laterally Extended Walled-Off Necrosis: A Pilot Study
Kyong Joo Lee, Se Woo Park, Da Hae Park, Jung Hee Kim, Jang Han Jung, Dong Hee Koh, Jin Lee, Mi Gang Kim
Journal of Clinical Medicine.2023; 12(3): 1125. CrossRef
Percutaneous endoscopic necrosectomy (PEN) for treatment of necrotizing pancreatitis: a systematic review and meta-analysis
Mihajlo Gjeorgjievski, Abishek Bhurwal, Abhishek A. Chouthai, Abdelhai Abdelqader, Monica Gaidhane, Haroon Shahid, Amy Tyberg, Avik Sarkar, Michel Kahaleh
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Case Report

Tranexamic Acid-Induced Acute Renal Cortical Necrosis in Post-Endoscopic Papillectomy Bleeding: Doo Hyun Ko, Tae Hyung Kim, Jong Wook Kim, Ja Joong Gu, Baek Hyun Yoon, Ji Hong Oh, Seung Goun Hong; Clin Endosc 2017;50(6):609-613. Published online August 9, 2017; DOI: https://doi.org/10.5946/ce.2017.021

Abstract PDF PubReader ePub

Acute renal failure can be the result of acute renal cortical necrosis (RCN), which commonly occurs from complications occurring during pregnancy. RCN is rarely caused by medications, although tranexamic acid, which is used in patients with acute bleeding for its antifibrinolytic effects, reportedly causes acute RCN in rare cases. An 82-year-old woman experienced gastrointestinal bleeding after endoscopic papillectomy of an ampullary adenoma. The bleeding was controlled with tranexamic acid administration; however, 4 days later, her urine volume decreased and she developed pulmonary edema and dyspnea. Serum creatinine levels increased from 0.8 to 3.9 mg/dL and dialysis was performed. Abdominal pelvic computed tomography with contrast enhancement revealed bilateral RCN with no renal cortex enhancement. Renal dysfunction and oliguria persisted and hemodialysis was continued. Clinicians must be aware that acute RCN can occur after tranexamic acid administration to control bleeding.

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Review

Necrotizing Pancreatitis: Current Management and Therapies: Christine Boumitri, Elizabeth Brown, Michel Kahaleh; Clin Endosc 2017;50(4):357-365. Published online May 16, 2017; DOI: https://doi.org/10.5946/ce.2016.152

Abstract PDF PubReader ePub

Acute necrotizing pancreatitis accounts for 10% of acute pancreatitis (AP) cases and is associated with a higher mortality and morbidity. Necrosis within the first 4 weeks of disease onset is defined as an acute necrotic collection (ANC), while walled off pancreatic necrosis (WOPN) develops after 4 weeks of disease onset. An infected or symptomatic WOPN requires drainage. The management of pancreatic necrosis has shifted away from open necrosectomy, as it is associated with a high morbidity, to less invasive techniques. In this review, we summarize the current management and therapies for acute necrotizing pancreatitis.

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Focused Review Series: EUS-Guided Therapeutic Interventions

Endoscopic Ultrasound-Guided Management of Pancreatic Fluid Collections: Update and Review of the Literature: Ali Alali, Jeffrey Mosko, Gary May, Christopher Teshima; Clin Endosc 2017;50(2):117-125. Published online March 30, 2017; DOI: https://doi.org/10.5946/ce.2017.045

Abstract PDF PubReader ePub

Severe acute pancreatitis is often complicated by the development of pancreatic fluid collections (PFCs), which may be associated with significant morbidity and mortality. It is crucial to accurately classify these collections as a pseudocyst or walled-off necrosis (WON) given significant differences in outcomes and management. Interventions for PFCs have increasingly shifted to less invasive strategies, with endoscopic ultrasound (EUS)-guided methods being shown to be safer and equally effective as more invasive surgical techniques. In recent years, many new developments have improved the safety and efficacy of EUS-guided interventions, such as the introduction of lumen-apposing metal stents (LAMS), direct endoscopic necrosectomy (DEN) and multiple other adjunctive techniques. Despite these developments, treatment of PFCs, and infected WON in particular, continues to be associated with significant morbidity and mortality. In this article, we discuss the EUS-guided management of PFCs while reviewing the latest developments and controversies in the field. We end by summarizing our own approach to managing PFCs.

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Minimal-access video-assisted retroperitoneal and/or transperitoneal debridement (VARTD) in the management of infected walled-off pancreatic necrosis with deep extension: initial experience from a prospective single-arm study
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Case Report

Eosinophilic Gastritis Presenting as Tissue Necrosis: Yong Min Jo, Jin Seok Jang, Seung Hee Han, Sang Hyun Kang, Woo Jae Kim, Jin Sook Jeong; Clin Endosc 2015;48(6):558-562. Published online November 30, 2015; DOI: https://doi.org/10.5946/ce.2015.48.6.558

Abstract PDF PubReader ePub: Eosinophilic gastroenteritis is very rare disorder that is characterized by eosinophilic infiltration of the gastrointestinal tract in the absence of any definite causes of eosinophilia. It is associated with various clinical gastrointestinal manifestations, and depends on the involved layer and site. We report a case of eosinophilic gastritis presenting with severe necrosis. The symptoms disappeared immediately after beginning steroid treatment, and the eosinophil count decreased to the reference range. The patient showed eosinophilic gastritis characterized by necrotic change such as necrotizing gastritis. It is a unique presentation of eosinophilic gastritis. To the best of our knowledge, no case of eosinophilic gastritis characterized by necrotic change such as necrotizing gastritis has been previously reported in Korea.

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Review

Endoscopic Ultrasound-Guided Management of Pancreatic Pseudocysts and Walled-Off Necrosis: Ji Young Bang, Shyam Varadarajulu; Clin Endosc 2014;47(5):429-431. Published online September 30, 2014; DOI: https://doi.org/10.5946/ce.2014.47.5.429

Abstract PDF PubReader ePub

The outcome of endoscopic management of pancreatic fluid collections is dependent on the type of collection being treated. While pseudocysts have an excellent treatment response, the outcomes are modest for walled-off pancreatic necrosis. Recent advances in cross-sectional body imaging have enabled a more accurate distinction of pancreatic fluid collections, which, in turn, facilitates the correct triage of patients to receive the appropriate treatment. Newly described endoscopic techniques and the development of dedicated accessories have improved the clinical outcomes in walled-off pancreatic necrosis, with treatment success rates comparable to that of minimally invasive surgery. This review summarizes the key concepts and provides a concise update on the endoscopic management of pancreatic fluid collections.

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Special Issue Articleses of IDEN 2012

Endoscopic Ultrasound-Guided Drainage of Pancreatic Fluid Collections (with Video): Mark Topazian; Clin Endosc 2012;45(3):337-340. Published online August 22, 2012; DOI: https://doi.org/10.5946/ce.2012.45.3.337

Abstract PDF PubReader ePub

Endoscopic ultrasound (EUS) is often used to guide drainage of pancreatic fluid collections (PFCs). EUS enhances the diagnosis of cystic pancreatic lesions and enables real-time image-guided control of PFC drainage. EUS may facilitate the endoscopic treatment of patients with pancreatic necrosis and patients with disconnected pancreatic duct syndrome.

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Endoscopic Necrosectomy for Walled-Off Pancreatic Necrosis: Michel Kahaleh; Clin Endosc 2012;45(3):313-315. Published online August 22, 2012; DOI: https://doi.org/10.5946/ce.2012.45.3.313

Abstract PDF PubReader ePub

Approximately 20% of patients with acute pancreatitis develop pancreatic necrosis with significant mortality. Surgical debridement is the traditional management of necrotizing pancreatitis, but it is associated with significant morbidity and mortality. Endoscopic necrosectomy using repeats session of debridement and stent insertion has been more frequently used within the last decade and half. This technique continues to evolve as we attempt to optimize the post-procedural outcomes.

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A Case of Simple Ulcer of the Terminal Ileum Successfully Treated by Monoclonal Antibody to Tumor Necrosis Factor-Ձ (Infliximab): Seok Jong Lee, M.D., Woo Chul Chung, M.D., Kang Moon Lee, M.D., You Suk Oh, M.D., Eun Jung Kim, M.D., Kang Hyun Choi, M.D. and Chang Nyol Paik, M.D.; Korean J Gastrointest Endosc 2010;41(1):56-60. Published online July 31, 2010

Abstract PDF: Nonspecific and idiopathic ulcer of the small bowel or colon is a rare condition, and it is the so called "simple ulcer" when the patients do not have systemic symptoms of Behcet's syndrome. Differentiation of simple ulcer from intestinal Behcet's disease according to the endoscopic and pathologic findings is often impossible and the clinical course of the 2 maladies is similar. A 51-year-old man presented with low abdominal pain, and colonoscopy revealed a huge deep ulceration with an entero-enteric fistula in the terminal ileum. He was diagnosed with simple ulcer without the constitutional symptoms of Behcet's syndrome. He was refractory to conventional therapy with corticosteroids and antibiotics, and so he required surgical resection. Monoclonal antibody against tumor necrosis factor-Ձ (Infliximab) was administered at 0, 2 and 6 weeks. His symptoms were relieved after the therapy and the ulceration had completely resolved after 1 year. He was entirely asymptomatic at the 36 month follow up. (Korean J Gastrointest Endosc 2010;41:56-60)

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A Case of Extensive Necrosis of the Gastric Mucosa Following Ethanol Injection Therapy: Su Min Jang, M.D., Jung Sik Choi, M.D., Hyun Seok Ryu, M.D., Jae Nam Lee, M.D., Sung Hoo Park, M.D., Sang Yong Lee, M.D. and Sang Ho Lee, M.D.; Korean J Gastrointest Endosc 2008;36(3):154-158. Published online March 30, 2008

Abstract PDF: A bleeding peptic ulcer is the most common cause of upper gastrointestinal bleeding as well as for hospitalization and death. Many endoscopic methods of treating bleeding peptic ulcers are currently being studied and developed. Among them, the endoscopic pure ethanol injection therapy is favored because of its high efficacy, low cost, and rapid administration. Pure ethanol is an excellent agent to stop bleeding and manifests itslef by inducing tissue dehydration, fixation and vessel compression, which in turn causes arterial coagulation and tissue necrosis. However, an excessive injection volume may bring about extensive mucosal necrosis; hence, caution should be taken when deciding upon the injection volume and depth. We report a case of extensive necrosis of the gastric mucosa following endoscopic ethanol injection therapy of a bleeding peptic ulcer along with a review of the relevant literature. (Korean J Gastrointest Endosc 2008;36:154-158)

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Definitive Treatment of Infected Pancreatic Fluid Collection by Endoscopic Transmural Drainage: Jeong Han Kim, M.D., Jong-Jae Park, M.D., Sang Kyun Yu, M.D., Young Kul Jung, M.D., Ji Yeon Lee, M.D., Ik Yoon, M.D., Kyung Oh Kim, M.D., Hyung Joon Yim, M.D., Jin Yong Kim, M.D, Jong Eun Yeon, M.D., Jae Seon Kim, M.D., Kwan Soo Byun, M.D., Young-Tae Bak,; Korean J Gastrointest Endosc 2004;28(1):9-17. Published online January 30, 2004

Abstract PDF: Background
/Aims: Recent experience with endoscopic transmural drainage of pancreatic pseudocysts prompted the use of a similar technique for the primary treatment of infected pancreatic fluid collection (PFC) such as pancreatic abscess and infected pancreatic necrosis (IPN). The aim of this study was to determine the safety and effectiveness of endoscopic transmural drainage for the primary treatment of infected PFC complicating acute pancreatitis. Methods: In 11 patients, a total of 13 infected PFC (11 pancreatic abscesses and 2 IPNs) compressing the stomach, duodenum, or both were drained endoscopically by means of an endoscopic fistulization followed by stent (s) placement alone or additional nasopancreatic catheter insertion. Complete resolution of PFC was defined as the absence of symptoms and no residual collection on the follow-up computed tomography. Results: Complete resolution was achieved in 12 infected PFC (92%) (10 pancreatic abscesses and 2 IPNs) after stent placement for a mean duration of 31 days. For IPN and 2 pancreatic abscess, insertion of a nasopancreatic catheter was required to irrigate thick pus or necrotic debris. There was 1 case of bleeding (8%) but no mortality. Conclusions: Endoscopic transmural drainage is an effective therapy with minimal morbidity for infected pancreatic fluid collection compressing the gut lumen and is a valuable alternative to surgical drainage. (Korean J Gastrointest Endosc 2004;28:9⁣17)

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혈액투석 중인 만성 신부전 환자의 위궤양 출혈에서 HS - E 용액 국소주입법 후 발생한 위점막 괴사 1 예: Korean J Gastrointest Endosc 2001;23(5):369-369. Published online November 30, 2000

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위 악성 평활근 육종: Korean J Gastrointest Endosc 2000;20(5):387-387. Published online November 30, 1999

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증례 : 식도 위장관 ; 점막하 종양으로 표현된 원발성 위결핵 1예 ( Case Reports : Esophagus , Stomach & Intestine ; A Case of Primary Gastric Tuberculosis Diagnosed as a Submucosal Tumor ): Korean J Gastrointest Endosc 1998;18(4):567-572. Published online November 30, 1997

Abstract PDF: Gastric tuberculosis is a rare disease and is usually secondary to pulmonary or intestinal tuberculosis. Only a few cases of gastric tuberculosis have been reported in the literature. In most cases, gastric tuberculosis exists as an ulcerating lesion, whereby the clinical symptom is non-specific and similar to that of a peptic ulcer. The diagnosis af gastric tuberculosis is based on either positive histological or bacteriological study. Submucasal tumors resembling gastric tuberculosis has been reported extremely rare in incidence. In this study we report a case of a young woman admitted with intermittent abdominal pain due to gastric tuberculosis presenting as submucosal tumor in the greater curvature of the lower body. After gastric resection, a histological examination revealed chronic granulomatous inflammation with caseation necrosis which is consistent with tuberculosis. There was no evidence of the tuberculous lesion anywhere else. The patient was put on antituberculosis medications. The patient's follow-up observation in the clinic was uneventful. (Korean J Gastrointest Endosc 18: 567-572, 1998)

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