title: Endoscopic "step-up approach" using a dedicated biflanged metal stent reduces the need for direct necrosectomy in walled-off necrosis (with videos).
abstract: OBJECTIVE
  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.
authors.affiliation: Asian Institute of Gastroenterology, Hyderabad, India.
authors.forename: Sundeep
authors.initials: S
authors.lastname: Lakhtakia
authors.affiliation: Asian Institute of Gastroenterology, Hyderabad, India.
authors.forename: Jahangeer
authors.initials: J
authors.lastname: Basha
authors.affiliation: Asian Institute of Gastroenterology, Hyderabad, India.
authors.forename: Rupjyoti
authors.initials: R
authors.lastname: Talukdar
authors.affiliation: Asian Institute of Gastroenterology, Hyderabad, India.
authors.forename: Rajesh
authors.initials: R
authors.lastname: Gupta
authors.affiliation: Asian Institute of Gastroenterology, Hyderabad, India.
authors.forename: Zaheer
authors.initials: Z
authors.lastname: Nabi
authors.affiliation: Asian Institute of Gastroenterology, Hyderabad, India.
authors.forename: Mohan
authors.initials: M
authors.lastname: Ramchandani
authors.affiliation: Asian Institute of Gastroenterology, Hyderabad, India.
authors.forename: B V N
authors.initials: BVN
authors.lastname: Kumar
authors.affiliation: Asian Institute of Gastroenterology, Hyderabad, India.
authors.forename: Partha
authors.initials: P
authors.lastname: Pal
authors.affiliation: Asian Institute of Gastroenterology, Hyderabad, India.
authors.forename: Rakesh
authors.initials: R
authors.lastname: Kalpala
authors.affiliation: Asian Institute of Gastroenterology, Hyderabad, India.
authors.forename: P Manohar
authors.initials: PM
authors.lastname: Reddy
authors.affiliation: Asian Institute of Gastroenterology, Hyderabad, India.
authors.forename: R
authors.initials: R
authors.lastname: Pradeep
authors.affiliation: Asian Institute of Gastroenterology, Hyderabad, India.
authors.forename: Jagadish R
authors.initials: JR
authors.lastname: Singh
authors.affiliation: Asian Institute of Gastroenterology, Hyderabad, India.
authors.forename: G V
authors.initials: GV
authors.lastname: Rao
authors.affiliation: Asian Institute of Gastroenterology, Hyderabad, India.
authors.forename: D Nageshwar
authors.initials: DN
authors.lastname: Reddy
mesh_terms: D000293:Adolescent; D000328:Adult; D000368:Aged; D002648:Child; D004322:Drainage / Q000379:methods*; D016145:Endoscopy, Digestive System / Q000379:methods*; D019160:Endosonography; D005260:Female; D006801:Humans; D008297:Male; D008875:Middle Aged; D009336:Necrosis / Q000209:etiology / Q000601:surgery*; D010182:Pancreatic Diseases / Q000209:etiology / Q000601:surgery*; D010195:Pancreatitis / Q000150:complications; D012189:Retrospective Studies; D000069322:Self Expandable Metallic Stents; D015607:Stents; D025321:Surgery, Computer-Assisted; D055815:Young Adult