Endoscopic Transmural Drainage of Walled-off Necrosis in Difficult Situations Using a Forward-Viewing Echoendoscope

Endoscopic transmural drainage (ETD) using a therapeutic oblique-viewing echoendoscope is procedure of choice for symptomatic walled-off necrosis (WON). However, occasionally the procedure fails because of poor visualization, non-negotiation of proximal luminal narrowing, presence of intervening venous collaterals or difficult puncture because of oblique angle. In such situations, a forward-viewing echoendoscope (FVE) may offer technical advantages.

To evaluate safety and efficacy of EUS-guided ETD of WON using a FVE in patients in whom drainage could not be completed using oblique-viewing echoendoscope.

The endoscopic database of a tertiary-care center was retrospectively reviewed and patients who underwent ETD of WON using a FVE following failure with a conventional oblique-viewing echoendoscope were identified. Demographic data, characteristics of WON, procedural details, technical success, and procedure-related adverse events were analyzed.

Twenty-one patients (18 males; age range 12-54 years) underwent ETD using a FVE. The size of the WON ranged from 9 to 18 cm. Collections were located in the head (n = 2), body (n = 5), tail (n = 2), and body and tail (n = 12) of the pancreas. ETD was performed 5-24 weeks after an episode of acute necrotizing pancreatitis. Technical success was achieved in all patients (100%). Lumen-apposing metal stents were placed in 12 patients, multiple plastic stents in 7 patients, and a nasocystic drain in 2 patients. No immediate or early procedure-related complications or stent maldeployment were observed.

ETD of WON using an FVE is safe and effective in patients in whom drainage using a conventional oblique-viewing echoendoscope is technically challenging or unsuccessful.