title: Multiple transluminal gateway technique for EUS-guided drainage of symptomatic walled-off pancreatic necrosis.
abstract: 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).
  
  
  METHODS
  Retrospective study.
  
  
  METHODS
  Tertiary-care referral center.
  
  
  METHODS
  This study involved patients with severe acute pancreatitis complicated by walled-off pancreatic necrosis managed endoscopically.
  
  
  METHODS
  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.
  
  
  METHODS
  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.
  
  
  CONCLUSIONS
  Selective patient population.
  
  
  CONCLUSIONS
  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.
authors: Division of Gastroenterology-Hepatology, University of Alabama at Birmingham School of Medicine, Birmingham, AL, USA.
authors: Shyam
authors: S
authors: Varadarajulu
authors: Milind A
authors: MA
authors: Phadnis
authors: John D
authors: JD
authors: Christein
authors: C Mel
authors: CM
authors: Wilcox