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

• Published in: Gastrointestinal endoscopy 2017-06, Vol.85 (6), p.1243-1252
• Main Authors: Lakhtakia, Sundeep, DM, Basha, Jahangeer, DM, Talukdar, Rupjyoti, MD, Gupta, Rajesh, DM, Nabi, Zaheer, DNB, Ramchandani, Mohan, DM, Kumar, B.V.N., MD, Pal, Partha, MD, Kalpala, Rakesh, DNB, Reddy, P. Manohar, DNB, Pradeep, R., MCh, Singh, Jagadish R., MD, Rao, G.V., MS, Reddy, D. Nageshwar, DM
• Format: Article
• Language: English
• Subjects: Adolescent; Adult; Aged; Child; Drainage - methods; Endoscopy, Digestive System - methods; Endosonography; Female; Gastroenterology and Hepatology; 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
• ISSN: 0016-5107; 1097-6779
• DOI: 10.1016/j.gie.2016.10.037

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.