Original article
Clinical endoscopy
Multiple transluminal gateway technique for EUS-guided drainage of symptomatic walled-off pancreatic necrosis

https://doi.org/10.1016/j.gie.2011.03.1122Get rights and content

Background

Walled-off pancreatic necrosis often leads to severe clinical deterioration necessitating open debridement or endoscopic necrosectomy. A new EUS-based approach was devised to manage this condition by creating multiple transluminal gateways to facilitate effective drainage of the necrotic contents.

Objective

To compare treatment outcomes between patients with walled-off pancreatic necrosis managed endoscopically by a multiple transluminal gateway technique (MTGT) or a conventional drainage technique (CDT).

Design

Retrospective study.

Setting

Tertiary-care referral center.

Patients

This study involved patients with severe acute pancreatitis complicated by walled-off pancreatic necrosis managed endoscopically.

Intervention

In MTGT, 2 or 3 transmural tracts were created by using EUS guidance between the necrotic cavity and the GI lumen. While one tract was used to flush normal saline solution via a nasocystic catheter, multiple stents were deployed in others to facilitate drainage of necrotic contents. In the CDT, two stents with a nasocystic catheter were deployed via 1 transmural tract.

Main Outcome Measurements

Resolution of symptoms, radiological findings on follow-up CT, and the need for subsequent surgery or endoscopic necrosectomy.

Results

Of 60 patients with symptomatic walled-off pancreatic necrosis, 12 (3 women, mean age 55.1 years) were managed by MTGT and 48 (12 women, mean age 55.2 years) by CDT. Treatment was successful in 11 of 12 (91.7%) patients managed by MTGT versus 25 of 48 (52.1%) managed by CDT (P = .01). Although 1 patient in the MTGT cohort required endoscopic necrosectomy, in the CDT cohort, 17 required surgery, 3 underwent endoscopic necrosectomy, and 3 died of multiple-organ failure. Treatment success was more likely for patients treated by MTGT than by CDT (adjusted odds ratio = 9.24; 95% confidence interval, 1.08-79.02; P = .04) when we adjusted for the size of the walled-off pancreatic necrosis and pancreatic duct stent placement.

Limitations

Selective patient population.

Conclusion

The EUS-guided MTGT is an effective treatment option for the management of symptomatic walled-off pancreatic necrosis because it obviates the need for surgery and endoscopic necrosectomy and its attendant procedure-related morbidity. Prospective studies are required to confirm these preliminary but promising data.

Section snippets

Patients

The study cohort comprised all patients with symptomatic walled-off pancreatic necrosis who underwent endoscopic transmural drainage over a 6-year period from 2004 to 2010. Indications for endoscopic drainage were the following: (1) CT-confirmed walled-off pancreatic necrosis measuring >6 cm in size and located adjacent to the stomach or duodenum, (2) evidence of ongoing infection (abdominal pain and fever) despite administration of intravenous antibiotics, (3) continued clinical deterioration

Results

Of the 60 patients who underwent endoscopic drainage of walled-off pancreatic necrosis over a 6-year period, 48 were treated by CDT and 12 by MTGT. There was no difference in patient demographics, laboratory indices, and CT severity index between both cohorts (Table 1). With the exception of lesions in 8 patients (16.6%) in the CDT cohort, all other walled-off pancreatic necrosis lesions in both groups measured more than 80 mm in diameter, a majority of which were drained via the transgastric

Discussion

This study describes a new EUS-based approach to the management of symptomatic walled-off pancreatic necrosis. In a select group of patients, the MTGT is a minimally invasive treatment option that precludes the need for surgery or endoscopic necrosectomy. Despite several recent developments, the management of walled-off pancreatic necrosis remains a challenge. To offset the morbidity and mortality associated with surgical debridement,4, 5 other minimally invasive approaches such as percutaneous

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DISCLOSURE: All authors disclosed no financial relationships relevant to this publication.

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