title: Graded dilation technique for EUS-guided drainage of peripancreatic fluid collections: an assessment of outcomes and complications and technical proficiency (with video).
abstract: BACKGROUND
  Although the utility and safety of EUS and EUS-guided FNA is well known, there is a need for more data on outcomes and complications of EUS-guided drainage procedures.
  
  
  OBJECTIVE
  To evaluate the rates of technical success, treatment success, and complications of the graded dilation technique for performing EUS-guided drainage of peripancreatic fluid collections (PFCs) in a large cohort of patients. Also, the technical proficiency for performing EUS-guided drainage of PFCs was evaluated.
  
  
  METHODS
  A prospective study of all patients undergoing EUS-guided drainage of PFC.
  
  
  METHODS
  A tertiary-referral center.
  
  
  METHODS
  After passage of a 0.035-inch guidewire into the PFC by using a 19-gauge needle, graded dilation of the tract was sequentially performed by using a 4.5F ERCP cannula, a 10F ERCP inner guiding catheter, and an 8-mm balloon dilator. A transmural stent and/or drainage catheter was then deployed.
  
  
  METHODS
  To evaluate the technical success, treatment success, and complications of the graded dilation technique. Technical proficiency was evaluated by comparing the procedural duration between the first 25 cases (group A), with a later cohort of patients (group B, n = 29) who underwent EUS-guided drainage of a single PFC.
  
  
  RESULTS
  Sixty patients (41 men; mean age 51 years [range 20-79 years], 6 multiple PFCs) underwent EUS-guided drainage of a PFC (types included 36 pseudocyst, 15 abscess, and 9 necrosis) over a 42-month period. The rates of technical and treatment success were 95% and 93%, respectively. A minor complication of stent migration was encountered in 1 of 60 patients (1.7%). There was no significant difference in patient or clinical characteristics between group A and B patients who were undergoing drainage of a single PFC. Although there was no significant difference in technical or treatment outcome, median procedural duration was significantly shorter for group B than for group A patients (25 vs 70 minutes; P < .001). Procedural duration for performing EUS-guided drainage of a single PFC was more likely to be <30 minutes in group B than in group A patients (crude odds ratio [OR] 18.8; P < .001), which remained significant (adjusted OR 11.8; P = .01), even after adjusting for patient age; serum albumin; type, location, and size of PFCs; drainage modality (stent vs stent plus drainage catheter); and site of endoscopic access for establishing drainage.
  
  
  CONCLUSIONS
  In this study, EUS-guided drainage of a PFC could be performed safely by using the graded dilation technique, with a successful outcome in a majority of patients. Technical proficiency, with regard to procedural duration, improved significantly after the first 25 cases.
authors.affiliation: Division of Gastroenterology-Hepatology, University of Alabama at Birmingham School of Medicine, Birmingham, Alabama 35294, USA.
authors.forename: Shyam
authors.initials: S
authors.lastname: Varadarajulu
authors.forename: Ashutosh
authors.initials: A
authors.lastname: Tamhane
authors.forename: Jeanetta
authors.initials: J
authors.lastname: Blakely
mesh_terms: D000038:Abscess / Q000628:therapy; D000328:Adult; D000368:Aged; D004106:Dilatation / Q000009:adverse effects / Q000379:methods*; D004322:Drainage / Q000009:adverse effects / Q000379:methods*; D019160:Endosonography; D005260:Female; D006801:Humans; D008297:Male; D008875:Middle Aged; D009336:Necrosis; D010179:Pancreas; D010182:Pancreatic Diseases / Q000628:therapy*; D010192:Pancreatic Pseudocyst / Q000628:therapy; D011446:Prospective Studies; D016896:Treatment Outcome