Algorithm for the multidisciplinary management of hemorrhage in EUS-guided drainage for pancreatic fluid collections

Abstract

Pancreatic fluid collections (PFCs), common sequelae of acute or chronic pancreatitis, are broadly classified as pancreatic pseudocysts or walled-off necrosis according to the revised Atlanta classification. Endoscopic ultrasound (EUS)-guided drainage is often considered a standard first-line therapy preferable to surgical or interventional radiology approaches for patients with symptomatic PFC. EUS-guided drainage is effective and successful; it has a technical success rate of 90%-100% and a clinical success rate of 85%-98%. Recent studies have shown a 5%-30% adverse events (AEs) rate for the procedure. The most common AEs include infection, hemorrhage, perforation and stent migration. Hemorrhage, a severe and sometimes deadly outcome, requires a well-organized and appropriate treatment strategy. However, few studies have reported the integrated management of hemorrhage during EUS-guided drainage of PFC. Establishing a practical therapeutic strategy is an essential and significant step in standardized management. The aim of this review is to describe the current situation of EUS-guided drainage of PFCs, including the etiology and treatment of procedure-related bleeding as well as current problems and future perspectives. We propose a novel and meaningful algorithm for systematically managing hemorrhage events. To our limited knowledge, a multidisciplinary algorithm for managing EUS-guided drainage for PFC-related bleeding has not been previously reported.

Endoscopic Management of Giant Walled-Off Pancreatic Necrosis With a High Risk of Bleeding

“…5 The bleeding rate in EUS-guided cystogastrostomy ranges between 0% and 20% based on randomized trials and observational studies. 10 Contrast-enhanced CT imaging studies and EUS are essential to localize the blood vessels surrounding and/or intervening the cyst. 11–13 The utilization of EUS helps endoscopists to avoid damaging the blood vessels during the drainage and allows direct visualization of blood vessels crossing over the cyst.…”

S3-Leitlinie Pankreatitis – Leitlinie der Deutschen Gesellschaft für Gastroenterologie, Verdauungs- und Stoffwechselkrankheiten (DGVS) – September 2021 – AWMF Registernummer 021-003

“…Die endoskopisch interventionelle Therapie der eingebluteten Pseudozyste ist mit einem hohen Blutungsrisiko verbunden 547 . Sie sollten daher chirurgisch oder angiografisch therapiert werden.…”

“…Eine prospektive Untersuchung zeigt einen deutlich schlechteren Langzeiteffekt der Stentversorgung von distalen Gallengangsstenosen mit Kunststoffprothesen, wenn Kalzifikationen bei chronischer Pankreatitis vorliegen, daher wird eine operative Therapie empfohlen [537]. Die endoskopisch interventionelle Therapie der eingebluteten Pseudozyste ist mit einem hohen Blutungsrisiko verbunden [547]. Sie sollten daher chirurgisch oder angiografisch therapiert werden.…”

Quality in pancreatic endoscopic ultrasound: what’s new in 2020?

“…Moreover, providing the patient with fundamental postprocedural information is mandatory, including the avoidance of driving and/or intense physical activity, given their potentially fatal consequences. The vast majority of medications can usually be resumed safely in most cases of EUS or EUS-FNA after the examination, although when bleeding is suspected, following an individualized approach seems to be a sound practice [ 50 , 51 ]. As well as informing the patient about the procedure’s findings, as mentioned above, the endoscopist also has the responsibility for receiving and interpreting the pathology/cytology results.…”