title: Endoscopic ultrasound guided transmural drainage of walled off pancreatic necrosis using a "step - up" approach: A single centre experience.
abstract: BACKGROUND
  Walled off necrosis (WON) can be treated endoscopically using multiple transmural plastic stents or fully covered self-expandable metallic stent (FCSEMS) and direct endoscopic necrosectomy (DEN). We evaluated the efficacy of "step-up" endoscopic transmural approach for treatment of WON.
  
  
  METHODS
  Retrospective analysis of data of 86 patients with WON who were treated with attempted endoscopic ultrasound (EUS) guided "step up" transmural drainage during last 5 years was done. Initially multiple plastic stents were placed and patients not responding underwent FCSEMS placement and/or DEN.
  
  
  RESULTS
  Patients presented 10.8 ± 2.8 weeks after an acute attack of acute pancreatitis and mean size of WON was 10.7 ± 2.9 cm. EUS guided transmural drainage was technically successful in 85/86 (98.8%) patients and 70 (82.4%) were drained with multiple 7/10Fr plastic stents alone while DEN was needed in 9 (10.6%) and FCSEMS was inserted in 6 (7%) patients. All patients had successful outcome with none requiring surgery. The patients who needed DEN/FCSEMS presented earlier and had large size collection with more solid necrotic debris as compared to patients treated with multiple plastic stents alone. The complications were pneumoperitoneum (n = 1), bile leak following cholecystecomy (n = 1), development of external pancreatic fistula following percutaneous drainage (n = 1) and gastrointestinal bleed (n = 1).
  
  
  CONCLUSIONS
  "Step up" endoscopic transmural drainage using multiple plastic stents as an initial therapy is safe and effective treatment of WON and avoids more aggressive DEN in majority of patients. Large size WON with more necrotic debris may require DEN.
authors.affiliation: Department of Gastroenterology, Post Graduate Institute of Medical Education and Research (PGIMER), Sector 12, Chandigarh 160012, India. Electronic address: drsurinderrana@gmail.com.
authors.forename: Surinder S
authors.initials: SS
authors.lastname: Rana
authors.affiliation: Department of Gastroenterology, Post Graduate Institute of Medical Education and Research (PGIMER), Sector 12, Chandigarh 160012, India.
authors.forename: Vishal
authors.initials: V
authors.lastname: Sharma
authors.affiliation: Department of Gastroenterology, Post Graduate Institute of Medical Education and Research (PGIMER), Sector 12, Chandigarh 160012, India.
authors.forename: Ravi
authors.initials: R
authors.lastname: Sharma
authors.affiliation: Department of Surgery, Post Graduate Institute of Medical Education and Research (PGIMER), Sector 12, Chandigarh 160012, India.
authors.forename: Rajesh
authors.initials: R
authors.lastname: Gupta
authors.affiliation: Department of Gastroenterology, Post Graduate Institute of Medical Education and Research (PGIMER), Sector 12, Chandigarh 160012, India.
authors.forename: Deepak K
authors.initials: DK
authors.lastname: Bhasin
mesh_terms: D000328:Adult; D016099:Endoscopy, Gastrointestinal / Q000379:methods*; D019160:Endosonography / Q000379:methods*; D005260:Female; D006801:Humans; D008297:Male; D008875:Middle Aged; D019283:Pancreatitis, Acute Necrotizing / Q000601:surgery; D019152:Paracentesis / Q000379:methods*; D012189:Retrospective Studies; D015607:Stents; D016896:Treatment Outcome
keywords: Acute pancreatitis; Gall stones; Self-expanding metallic stents; Transmural drainage; Walled off necrosis