Endoscopic ultrasound-guided drainage of pancreatic walled-off necrosis using self-expanding metal stents without fluoroscopy

AIM To investigate whether endoscopic ultrasound (EUS)guided insertion of fully covered self-expandable metal stents in walled-off pancreatic necrosis (WOPN) is feasible without fluoroscopy. METHODS Patients with symptomatic pancreatic WOPN undergoing EUS-guided transmural drainage using self-expandable and fully covered self expanding metal stents (FCSEMS) were included. The EUS visibility of each step involved in the transmural stent insertion was assessed by the operators as "visible" or "not visible": (1) Access to the cyst by needle or cystotome; (2) insertion of a guide wire; (3) introducing of the diathermy and delivery system; (4) opening of the distal flange; and (5) slow withdrawal of the delivery system until contact of distal flange to cavity wall. Technical success was defined as correct positioning of the FCSEMS without the need of fluoroscopy. RESULTS In total, 27 consecutive patients with symptomatic WOPN referred for EUS-guided drainage were included. In 2 patients large traversing arteries within the cavity were detected by color Doppler, therefore the insertion of FCSEMS was not attempted. In all other patients (92.6%) EUS-guided transgastric stent insertion was technically successful without fluoroscopy. All steps of the procedure could be clearly visualized by EUS. Nine patients required endoscopic necrosectomy through the FCSEMS. Adverse events were two readmissions with fever and one self-limiting bleeding; there was no procedure-related mortality. CONCLUSION The good endosonographic visibility of the FCSEMS delivery system throughout the procedure allows safe EUS-guided insertion without fluoroscopy making it available as bedside intervention for critically ill patients.