Endoscopic transluminal drainage and necrosectomy by using a novel, through-the-scope, fully covered, large-bore esophageal metal stent: Preliminary experience in 10 patients

Background Interventions for necrotizing pancreatitis have undergone a recent paradigm shift toward minimally invasive techniques, including endoscopic transluminal necrosectomy (ETN). The optimal stent for endoscopic transmural drainage remains unsettled. Objective To evaluate a novel large-bore, fully covered metal through-the-scope (TTS) esophageal stent for cystenterostomy in large walled-off necrosis (WON). Design Retrospective case series. Setting Single tertiary care academic center. Patients Ten patients with large (>10 cm) WON collections who underwent endoscopic transmural drainage and ETN. Intervention Initial cystenterostomy was performed by using EUS, and in the same session, a TTS (18 × 60 mm), fully covered esophageal stent was placed to create a wide-bore fistula into the cavity. In 1 or more later sessions, the stent was removed, and ETN was performed as needed. Main Outcome Measurements Technical and clinical success rates and adverse events. Results The TTS stent was successfully deployed at the initial cystogastrostomy in all 10 patients. All patients had large WON (median size 17 cm, range 11-30 cm) and underwent intervention at a median of 30 days (range 12-117 days) after onset of acute pancreatitis. Resolution of WON was achieved in 9 of the 10 patients (90%) after a median of 3 endoscopic sessions. There were no early adverse events. Late adverse events occurred in 3 patients (30%); worsening of infection from stent migration and occlusion of cystogastrostomy (2 patients), and fatal pseudoaneurysmal bleeding from erosion of infected necrosis into a major artery distant from the stent (1 patient). The stent was easily removed in all the cases after resolution or improvement of the necrotic cavity. Limitations Retrospective, single-center evaluation of a small number of cases. No comparative arm to determine the relative efficacy or cost-effectiveness of these stents compared with conventional plastic stents. Conclusions Endoscopic therapy using a large-bore TTS, fully covered esophageal stent is feasible for use in the treatment of large WON. Further studies are needed to validate these findings.