Introduction Transgastric placement of specially designed fully covered self-expandable metal stent (FCSMS) has improved the management and the outcome of walled-off necrosis (WON) after severe pancreatitis. Reduction of radiation exposure is of increasing importance. Therefore, we investigated whether transgastric insertion of FCMS for drainage of WON is possible only by EUS-guidance.
Methods Patients with symptomatic pancreatic walled-off necrosis referred for endoscopic drainage were included. EUS-guided stent insertion was performed under concious sedation or endotracheal intubation. The pancreatic collection was accessed from the stomach using a linear echoendoscope with a 19 G access needle, a cystotome or directly using the hot Axios® device. After insertion of a guidewire and enlargement of the transgastric access by diathermy a fully covered self-expandable metal stent was inserted under EUS guidance without fluoroscopy. As clinically indicated, endoscopic necrosectomy was performed through the large diameter metal stent. When the collection had shrunk to less than 4 cm, symptoms and inflammatory parametrs had improved, the stent was endoscopically removed.
Results 18 patients (median age: 55 years; range 48–63 years) with symptomatic WON (median diameter: 14 cm; range 8–18 cm) were referred for EUS-guided drainage. In 2 patients large traversing arteries within the cavity were detected by colour Doppler imaging during EUS, therefore the insertion of FCSMS was not attempted to avoid possible erosion of the vessels by the stent edges with reducing collection size. In all other patients (88.9%) the completely EUS-guided transgastric stent insertion without fluoroscopy was technically successful (6 AXIOS® and 10 Nagi® stents were inserted). The stent insertion into the cavity and the opening of the distal flange could be clearly visualised by EUS in all cases. After correct positioning of the FCSMS by EUS the proximal stent flange was deployed under endoscopic guidance. Two patients were readmitted with fever when the stent was blocked with debris. Seven patients required endoscopic necrosectomy through the FCSMS. One patient developed self-limiting bleeding. WON resolved in all patients within 8 weeks.
Conclusion The good sonographic visibility of the FCSMS throughout the procedure allows safe and easy insertion of transgastric drainage under EUS-guidance without fluoroscopy.
Reference 1 Seifert H, Wehrmann T, Schmitt T, Zeuzem S, Caspary WF. Retroperito-neal endoscopic debridement for infected peripancreatic necrosis. Lancet 2000; 356:653–5.
Disclosure of Interest None Declared