Aug. 15, 2020
Patients undergoing surgery for pancreatic cancer and other conditions of the pancreas and liver are at risk of developing a postoperative abdominal fluid collection, usually due to a small leak from the cut surface of the pancreas or liver. These fluid collections can cause significant symptoms, including pain, nausea and the inability to eat, or signs of infection including fever and abnormally low blood pressure.
Traditionally, patients with postoperative fluid collections either have required an additional surgery to drain the collection or have had tubes placed through the skin (percutaneous drains) until the collection was resolved.
Endoscopic tools that can be guided through the mouth – including endoscopic ultrasound and specialized stents – have become increasingly available. Mayo Clinic researchers have published their experience providing patients with minimally invasive internal drainage of postoperative fluid collections, whereby the collection is drained with one or more stents into the stomach or small intestine, rather than through the skin.
Study methods
In a retrospective review published in Gastrointestinal Endoscopy, researchers identified 75 individuals diagnosed with a postoperative fluid collection that caused signs and symptoms ranging from abdominal pain or difficulty eating to fever and infection of the collection, and who were referred to Mayo Clinic's endoscopy practice in Rochester, Minnesota, for internal, endoscopic ultrasound-guided drainage of their collections.
Researchers analyzed patient data to determine the timing of the drainage procedure after surgery as well as patient outcomes to determine the safety of the procedure, especially in patients with symptomatic postoperative fluid collections requiring treatment within 30 days of surgery.
Results
Of the 75 study participants who underwent endoscopic ultrasound-guided stent placement, 42 (56%) were drained within 30 days of surgery, and 20 of those drainage procedures were performed within two weeks of surgery.
- Internal drains were able to be placed successfully in all 75 patients (100%).
- Clinical success, defined as resolution of the fluid collection without recurrence on follow-up imaging, was achieved in 70 patients (93%), with five patients who had a recurrence of their collection again treated with endoscopic ultrasound-guided internal drainage with ultimate resolution of their fluid collection.
- Thirteen patients who were successfully treated with endoscopic internal drainage had previously failed to resolve their collections with a percutaneous drain.
- Adverse events associated with endoscopic ultrasound drainage were all mild or moderate in severity, including post-procedure vomiting, one stent maldeployment that was simply replaced, and the aforementioned fluid re-accumulation after stent removal in five patients who then underwent a repeat endoscopic drainage procedure.
- There was no difference in success or risk of adverse outcome between patients undergoing drainage within 30 days from surgery compared with those undergoing drainage more than 30 days from surgery.
Conclusions
According to Mayo Clinic researchers, these study results suggest endoscopic ultrasound-guided drainage of postoperative fluid collections is a highly effective and acceptably safe alternative to percutaneous drain placement regardless of timing of the development of symptoms after surgery.
"We are excited to offer this minimally invasive procedure to our patients who have just undergone some of the biggest and most difficult surgeries that are performed in our specialty, including Whipple and partial pancreatectomy, to help them recover without the need for external drains or bags," said Andrew C. Storm, M.D., lead author and member of the Mayo Clinic advanced endoscopy team in Rochester, Minnesota.
Co-author, Michael J. Levy, M.D., also noted, "An important finding of this study was the fact that these collections can be drained even within the week after surgery, something that was traditionally thought to be either difficult or less safe than percutaneous — through-the-skin — options."
"A prospective study evaluating endoscopic ultrasound-guided drainage of postoperative fluid collections as compared with percutaneous, or draining through the skin, would potentially be the next step in validating this retrospective study," said Dr. Storm. "What is clear is that our multidisciplinary group of surgical oncologists, interventional radiologists and gastroenterologists are fully invested in working together to improve outcomes and comfort of our patients."
For more information
Storm AC, et al. Acute and early EUS-guided transmural drainage of symptomatic postoperative fluid collections. Gastrointestinal Endoscopy. 2020;91:1085.e1.