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Computed tomography imaging-based predictors of the need for a step-up approach after initial endoscopic ultrasound-guided transmural drainage for pancreatic fluid collections

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Abstract

Background

A step-up approach is recommended as a new treatment algorithm for pancreatic fluid collections (PFCs). However, determining which patients with PFCs require a step-up approach after endoscopic ultrasound-guided transmural drainage (EUS-TD) is unclear. If the need for a step-up approach could be predicted, it could be performed early for relevant patients. We aimed to identify PFC-related predictive factors for a step-up approach after EUS-TD.

Methods

This retrospective cohort study included consecutive patients who had undergone EUS-TD for PFCs from January 2008 to May 2020. Multivariable logistic regression analyses were performed to investigate PFC factors related to requiring a step-up approach. A step-up approach was performed for patients who did not respond clinically to EUS-TD.

Results

We enrolled 81 patients, of whom 25 (30.9%) required a step-up approach. In multivariate logistic regression analysis, the pre-EUS-TD number of PFC-occupied regions ≥ 3 (multivariate odds ratio [OR] 16.2, 95% confidence interval [CI] 2.68–97.6, P = 0.002), the post-EUS-TD PFC-remaining percentage ≥ 35% (multivariate OR 19.9, 95% CI 2.91–136.1, P = 0.002), and a positive sponge sign, which is a distinctive computed tomography finding in the early stage after EUS-TD (multivariate OR 6.26, 95% CI 1.33–29.3, P = 0.020), were independent predictive factors associated with requiring a step-up approach for PFCs.

Conclusion

Pre-EUS-TD PFC-occupied regions, post-EUS-TD PFC-remaining percentage, and a positive sponge sign were predictors of the need for a step-up approach. Patients with PFC with these findings should be offered a step-up approach whereas conservative treatment is recommended for patients without these findings.

Clinical registration number

UMIN 000030898.

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Acknowledgements

This work was supported by JSPS KAKENHI (Grants-in-Aid for Scientific Research), Grant no. 21K07913 (H.S.).

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  1. Masahiro Tsujimae and Hideyuki Shiomi shares co-first authorship.

Authors and Affiliations

  1. Division of Gastroenterology, Department of Internal Medicine, Kobe University Graduate School of Medicine, Kobe, Japan

    Masahiro Tsujimae, Hideyuki Shiomi, Arata Sakai, Atsuhiro Masuda, Noriko Inomata, Shinya Kohashi, Kae Nagao, Hisahiro Uemura, Shigeto Masuda, Masanori Gonda, Shohei Abe, Shigeto Ashina, Kohei Yamakawa, Takeshi Tanaka, Ryota Nakano, Takashi Kobayashi & Yuzo Kodama

  2. Division of Gastroenterology and Hepatobiliary and Pancreatic Diseases, Department of Internal Medicine, Hyogo Medical University, 1-1, Mukogawa-Cho, Nishinomiya, Hyogo, 663-8501, Japan

    Hideyuki Shiomi & Ryota Nakano

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Contributions

HS designed the study concept. MT and HS wrote the manuscript. SA, MT, and HS reviewed all the CT findings in the study. AM, NI, SK, KN, HU, SM, MG, SA, SA, KY, TT, RN, TK, and YK supervised the study. All authors revised the manuscript critically for important intellectual content and gave final approval of the version to be published.

Corresponding author

Correspondence to Hideyuki Shiomi.

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Hideyuki Shiomi, Masahiro Tsujimae, Arata Sakai, Atsuhiro Masuda, Noriko Inomata, Shinya Kohashi, Kae Nagao, Hisahiro Uemura, Shigeto Masuda, Masanori Gonda, Shohei Abe, Shigeto Ashina, Kohei Yamakawa, Takeshi Tanaka, Ryota Nakano, Takashi Kobayashi, and Yuzo Kodama have no conflicts of interest or financial ties to disclose.

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Supplementary file1 (DOCX 53 KB)

464_2022_9610_MOESM2_ESM.tif

Supplementary file2 (TIF 5376 KB) Supplemental Figure 1. EUS-TD procedures. (a) The PFC was punctured with a 19 G needle under EUS guidance. (b) Two 0.025-inch guidewires were inserted and coiled within the PFC. (c) After dilatation of the needle tract, a 7 Fr double pigtail stent and a 7 Fr nasocystic drainage catheter were placed into the PFC. A LAMS was placed transmurally between the PFC and the gastric wall. (d) EUS image, (e) endoscopic image, and (f) fluoroscopy image. EUS endoscopic ultrasound, EUS-TD endoscopic ultrasound transmural drainage, LAMS lumen-apposing metal stent, PFC pancreatic fluid collection

464_2022_9610_MOESM3_ESM.tif

Supplementary file3 (TIF 3289 KB) Supplemental Figure 2. Endoscopic necrosectomy. (a) The fistula was dilated using a 15 mm dilating balloon. (b) An endoscope was inserted into the WON, and necrotic tissue was removed using grasping forceps. (c) The endoscopic necrosectomy was continued periodically until necrotic tissue was mostly removed in the cavity. WON walled-off necrosis

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Tsujimae, M., Shiomi, H., Sakai, A. et al. Computed tomography imaging-based predictors of the need for a step-up approach after initial endoscopic ultrasound-guided transmural drainage for pancreatic fluid collections. Surg Endosc 37, 1096–1106 (2023). https://doi.org/10.1007/s00464-022-09610-2

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