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• W4247278085 abstract "I thank Drs Hookey and Deviere for their interest in our study evaluating the role of EUS in drainage of peripancreatic fluid collections (PFC) not amenable for drainage by conventional endoscopy.1Varadarajulu S. Wilcox C.M. Tamhane A. et al.Role of EUS in drainage of peripancreatic fluid collections not amenable for endoscopic transmural drainage.Gastrointest Endosc. 2007; 66: 1107-1119Abstract Full Text Full Text PDF PubMed Scopus (122) Google Scholar The authors raise issue with the conclusion of our study, which is that EUS is most useful for drainage of PFC located in the pancreatic tail region. They cite successful outcomes with EUS even for drainage of PFC located at other regions of the pancreas. As stated in the study title and explained clearly in the methods section,1Varadarajulu S. Wilcox C.M. Tamhane A. et al.Role of EUS in drainage of peripancreatic fluid collections not amenable for endoscopic transmural drainage.Gastrointest Endosc. 2007; 66: 1107-1119Abstract Full Text Full Text PDF PubMed Scopus (122) Google Scholar this prospective investigation was designed to identify specific circumstances in which EUS is mandatory for drainage of PFC, ie, to identify those PFC that are not amenable for drainage by gastroscopy but are amenable for drainage only by EUS. Eighty-one percent of PFC located in the pancreatic head and 85% of PFC in the pancreatic body were amenable for drainage by gastroscopy; failures were due to lack of a luminal compression or to local bleeding from varices. PFC located in the head (19%) and body (15%) of the pancreas that could not be drained by gastroscopy were subsequently drained successfully under EUS-guidance. On the other hand, all 17 PFC located in the pancreatic tail region could not be drained by gastroscopy due to the lack of a luminal compression or secondary to difficult scope position; EUS was successful in drainage of all (100%) of these failed cases. In our study, using EUS, we were able to drain 100% of PFC (irrespective of their location) that were not amenable for drainage by gastroscopy. A majority of PFC (>80%) located in the head or body of pancreas cause a luminal compression and can be drained easily by gastroscopy. EUS may be required only in challenging patients when a luminal compression is absent, or in high-risk cases (varices). On the other hand, PFC located at the pancreatic tail region tend to extend to the subphrenic, splenic, pararenal space, or left upper quadrant. These areas typically do not extrinsically compress the GI tract, and hence are difficult to access by gastroscopy. Even if PFC at this location cause luminal compression, they are localized to the fundus or cardia of the stomach; these are areas that are hard to access due to difficulty in positioning the endoscope at these locations. In such cases, EUS would be the modality of choice because the PFC can be visualized easily and drained safely. While we conclude that EUS is most useful for drainage of PFC located at the pancreatic tail region, we do not intend or imply or state that EUS is not useful for drainage of PFC located at other regions of the pancreas. As stated above, EUS can access PFC in most instances, irrespective of their location in the pancreatic bed. However, EUS is a technology that is still not widely available outside the academic and tertiary setting. On the other hand, increasingly, PFC are being drained by endoscopists using gastroscopy.2Yusuf T.E. Baron T.H. Endoscopic transmural drainage of pancreatic pseudocysts: results of a national and an international survey of ASGE members.Gastrointest Endosc. 2006; 63: 223-227Abstract Full Text Full Text PDF PubMed Scopus (94) Google Scholar The aim of our study was to provide physicians and surgeons with a roadmap for endoscopic management of PFC. It would enable referral of appropriate cases (PFC at pancreatic tail regions) to centers that have access to EUS. In a recently concluded randomized trial, we have shown that, compared to gastroscopy, the technical success rate of EUS for drainage of PFC is close to 100% (33% for gastroscopy), and the complication rate is much lower.3Varadarajulu S. Christein J.C. Tamhane A. et al.Prospective randomized trial comparing endoscopic ultrasound and gastroscopy for transmural drainage of pancreatic pseudocysts.Gastrointest Endosc. 2008; 68: 1102-1111Abstract Full Text Full Text PDF PubMed Scopus (335) Google Scholar In centers that have access to the technology, I strongly believe that EUS should be the first-line modality for drainage of all PFC. This is particularly relevant because close to 5% of pancreatic cyst neoplasm can mimic a pseudocyst on CT.1Varadarajulu S. Wilcox C.M. Tamhane A. et al.Role of EUS in drainage of peripancreatic fluid collections not amenable for endoscopic transmural drainage.Gastrointest Endosc. 2007; 66: 1107-1119Abstract Full Text Full Text PDF PubMed Scopus (122) Google Scholar EUS can establish a definitive diagnosis in these patients and thereby alter subsequent management. With regards to differences in outcome between transmural versus transpapillary drainage approaches, all patients enrolled in our study underwent transmural drainage. In all patients, an ERCP was attempted to evaluate for ductal integrity, and for placement of a bridging stent whenever possible. Therefore, the study methodology prohibits analysis of this outcome." @default.
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• W4247278085 doi "https://doi.org/10.1016/j.gie.2008.04.047" @default.
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