SNFGE SNFGE
 
Thématique :
- Endoscopie/Imagerie
Originalité :
Intermédiaire
Solidité :
Très solide
Doit faire évoluer notre pratique :
Immédiatement
 
 
Nom du veilleur :
Docteur Vincent VALANTIN
Coup de coeur :
 
 
Endoscopy
  2018/06  
 
  2018 Jun;50(6):597-605.  
  doi: 10.1055/s-0043-123575.  
 
  Early removal of biflanged metal stents in the management of pancreatic walled-off necrosis: a prospective study.  
 
  Dhir V, Adler DG, Dalal A, Aherrao N, Shah R, Maydeo A  
  https://www.ncbi.nlm.nih.gov/pubmed/29272904  
 
 

Abstract

BACKGROUND AND STUDY AIMS:

 Dedicated stents placed under endoscopic ultrasound (EUS) guidance have shown promise for the management of pancreatic walled-off necrosis (WON). A long duration of stent placement may increase the risk of adverse events. We prospectively evaluated the effects of (i) early removal of biflanged metal stents (BFMSs) and (ii) additional stenting of the pancreatic duct with plastic stents in patients with ductal leaks, on the risk of WON recurrence.

PATIENTS AND METHODS:

 Symptomatic patients with pancreatic WON underwent EUS-guided BFMS placement, followed by necrosectomy, when required, from Day 3. A 5 Fr plastic stent was placed in patients with ductal leak. BFMS was removed when the WON cavity had collapsed completely. Patients were followed up at 3-month intervals.

RESULTS:

 BFMS placement was successful in all 88 patients. A total of 64 patients (72.7 %) underwent necrosectomy (median 3 sessions). All BFMSs were removed at a median of 3.5 weeks (range 3 - 17 weeks). Ductal disconnection and leak occurred in 53/87 (60.9 %) and 61/87 (70.1 %) patients, respectively. A 5 Fr stent was placed in 56/61 patients (91.8 %) with ductal leak. Overall, 22 patients (25.0 %) had adverse events (17 mild, 1 moderate, 3 severe, 1 fatal). Recurrence was noted in 8/88 (9.1 %) at a median follow-up of 22 months. The recurrence rate was higher in patients with ductal disconnection than in those without (13.2 % vs. 2.9 %; P = 0.08), and was similar in patients with vs. without pancreatic duct stenting (7.1 % vs. 12.9 %; P = 0.44). Seven recurrences (87.5 %) partially regressed on follow-up and did not require therapy; in one case, drainage with a plastic stent was performed.

CONCLUSIONS:

 Short-term BFMS placement is an effective therapy for pancreatic WON. The majority of recurrences developed in patients with ductal disconnection and did not require therapy. Additional pancreatic duct stents probably do not influence the recurrence rate.

 

 
Question posée
 
Combien de temps laisser en place les prothèses d’apposition luminale ou diabolo dans les WON ? Faut-il y associer une intubation du canal pancréatique en cas de fuite ou de rupture de ce dernier ?
 
Question posée
 
Un délai moyen de 3,5 semaines était suffisant pour obtenir une guérison du kyste. L’ablation précoce de la prothèse réduit les effets secondaires (hémorragie notamment). La fuite ou la rupture du canal pancréatique, si elles sont des facteurs de récidive du kyste, ne semblent pas bénéficier de pose de prothèse pancréatique.
 
Commentaires

L’absence d’efficacité en cas d’intubation du canal pancréatique reste à démontrer sur une plus grande étude.

Néanmoins une prise charge précoce et courte par prothèse diabolo ou d’apposition luminale permet de guérir les WON et de diminuer les évènements indésirables liés à cette même prothèse.

 
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