Introduction Wide flange fully covered self-expandable metallic stents (FCSEMS) have recently been developed for EUS-guided transmural drainage of pancreatic fluid collections. We used these wide calibre stents for transgastric access for endoscopic necrosectomy in patients requiring necrotic debridement.
Method Patients referred with large, symptomatic walled off-necrosis for endoscopic therapy were included. Under EUS guidance, the necrotic cavity was accessed using the needle knife of a cystotome. After securing the access with a guidewire the new tract was enlarged to 10 F using the ring diathermy of the cystotome. This allowed a 2 or 3 cm long 14 mm diameter FCSEMS to be placed transmurally. If clinically required, endoscopic necrosectomy sessions were performed through the FCSEMS in weekly intervals.
Results Six patients (5 men, median age 50 years) had a walled off-necrosis with a median size of 16 cm (range 12–17 cm) causing gastric outlet obstruction (5) or biliary compression (1). One patient with an endosonographically visible artery transversing the necrotic cavity was declined due to bleeding risk. In the other five patients, the insertion of a transgastric FCSEMS under EUS guidance was successful without immediate complications. In all five patients, the cavity reduced to <3 cm after a mean of 3 (range 2–5) endoscopic necrosectomy sessions. There were no major complications. One stent migration occurred after the cavity had reduced to less than 3 cm.
Conclusion EUS-guided insertion of FCSEMS into walled-off necrosis appears safe and results in effective drainage. Endoscopic necrosectomy can be performed through the transmural FCSEMS which provides endoscopic access for repeated debridement and flushing of the necrotic cavity.
Disclosure of interest None Declared.
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