Christopher J. DiMaio, MD, from the Icahn School of Medicine at Mount Sinai in New York, New York discusses this Original Article, “Transpapillary drainage has no added benefit on treatment outcomes in patients undergoing EUS-guided transmural drainage of pancreatic pseudocysts: a large multicenter study.”

Over the past 15 years, there has been a marked paradigm shift in the management of pancreatic fluid collections (PFCs). Once the domain of surgeons and interventional radiologists, PFCs are now largely managed primarily by endoscopy. In particular, the use of EUS-guided transmural drainage (TMD) has become the first-line therapeutic intervention for symptomatic PFCs.

In this study, our aim was to compare clinical outcomes between patients who underwent TMD alone versus those who underwent combined drainage (CD) with both TMD and transpapillary pancreatic stent placement (TP). It has largely been our experience that the vast majority of patients with symptomatic PFCs have excellent clinical outcomes with TMD alone. In discussing this topic with colleagues around the country, we found that there were various approaches to the management of PFCs and clearly there was no one consensus approach. Furthermore, published studies examining this question provided conflicting results. We felt that it was important to conduct this study and determine the utility and impact of whether to perform endoscopic retrograde pancreatography (ERP) and TP as the addition of these modalities  to TMD will add time, cost, and risk of adverse events to the management of this condition.

A total of 174 patients who underwent TMD of a pancreatic pseudocyst underwent analysis.  TMD alone was performed in 95 (55%) and CD in 79 (45%). Technical success was significantly greater in the TMD  group (97%) compared to that of the CD group (44%).  There was no significant difference in adverse events between both groups, with adverse events being encountered in 15% of the TMD group, and 14% in the CD groups.

Figure 4. Treatment outcomes (symptomatic and radiologic resolution) and follow-up. TMD, transmural drainage; CD, combined drainage; IQR, interquartile range.

There was no significant difference in long term symptomatic resolution between the two groups, 69% in the TMD group, compared to 62% in the CD group. Similarly, there was no significant difference in long term radiologic resolution between the two groups.

In a subgroup analysis of patients undergoing CD who did have successful pancreatic duct stent placed across a duct leak or disruption, there was still no significant difference in treatment outcomes when compared to those who underwent TMD alone.

Multivariate logistic regression analysis showed the absence of any statistically significant predictors of adverse events, or of short term or long term symptomatic resolution, or short term radiologic resolution. Attempt at transpapillary drainage was the only clinical variable negatively associated with long-term radiologic resolution.

In conclusion, this study demonstrated that TP drainage may have no added benefit on treatment outcomes in patients who underwent TMD of pancreatic pseudocysts. Ideally, future studies would be prospective, randomized, and involve a larger number of subjects, and in particular, control for the presence of a pancreatic duct leak or disruption.

Find the abstract for this article online.

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