Endoscopic "step-up approach" using a dedicated biflanged metal stent reduces the need for direct necrosectomy in walled-off necrosis (with videos)

Gastrointest Endosc. 2017 Jun;85(6):1243-1252. doi: 10.1016/j.gie.2016.10.037. Epub 2016 Nov 11.

Abstract

Background and aims: EUS-guided drainage using plastic stents may be inadequate for treatment of walled-off necrosis (WON). Recent studies report variable outcomes even when using covered metal stents. The aim of this study was to evaluate the efficacy of a dedicated covered biflanged metal stent (BFMS) when adopting an endoscopic "step-up approach" for drainage of symptomatic WON.

Methods: We retrospectively evaluated consecutive patients with symptomatic WON who underwent EUS-guided drainage using BFMSs over a 3-year period. Reassessment was done between 48 and 72 hours for resolution. Endoscopic reinterventions were tailored in nonresponders in a stepwise manner. Step 1 encompassed declogging the blocked lumen of the BFMS. In step 2, a nasocystic tube was placed via BFMSs with intermittent irrigation. Step 3 involved direct endoscopic necrosectomy (DEN). BFMSs were removed between 4 and 8 weeks of follow-up. The main outcome measures were technical success, clinical success, adverse events, and need for DEN.

Results: Two hundred five WON patients underwent EUS-guided drainage using BFMSs. Technical success was achieved in 203 patients (99%). Periprocedure adverse events occurred in 8 patients (bleeding in 6, perforation in 2). Clinical success with BFMSs alone was seen in 153 patients (74.6%). Reintervention adopting the step-up approach was required in 49 patients (23.9%). Incremental success was achieved in 10 patients with step 1, 16 patients with step 2, and 19 patients with step 3. Overall clinical success was achieved in 198 patients (96.5%), with DEN required in 9.2%. Four patients failed treatment and required surgery (2) or percutaneous drainage (2).

Conclusions: The endoscopic step-up approach using BFMSs was safe, effective, and yielded successful outcomes in most patients, reducing the need for DEN.

Publication types

  • Video-Audio Media

MeSH terms

  • Adolescent
  • Adult
  • Aged
  • Child
  • Drainage / methods*
  • Endoscopy, Digestive System / methods*
  • Endosonography
  • Female
  • Humans
  • Male
  • Middle Aged
  • Necrosis / etiology
  • Necrosis / surgery*
  • Pancreatic Diseases / etiology
  • Pancreatic Diseases / surgery*
  • Pancreatitis / complications
  • Retrospective Studies
  • Self Expandable Metallic Stents
  • Stents*
  • Surgery, Computer-Assisted
  • Young Adult