Published online May 25, 2016. doi: 10.4253/wjge.v8.i10.402
Peer-review started: February 9, 2016
First decision: March 9, 2016
Revised: March 16, 2016
Accepted: April 5, 2016
Article in press: April 6, 2016
Published online: May 25, 2016
AIM: To determine the feasibility and safety of transgastric direct endoscopic necrosectomy (DEN) in patients with walled-off necrosis (WON) and gastric varices.
METHODS: A single center retrospective study of consecutive DEN for WON was performed from 2012 to 2015. All DEN cases with gastric fundal varices noted on endoscopy, computed tomography (CT) or magnetic resonance imaging (MRI) during the admission for DEN were collected for analysis. In all cases, external urethral sphincter (EUS) with doppler was used to exclude the presence of intervening gastric varices or other vascular structures prior to 19 gauge fine-needle aspiration (FNA) needle access into the cavity. The tract was serially dilated to 20 mm and was entered with an endoscope for DEN. Pigtail stents were placed to facilitate drainage of the cavity. Procedure details were recorded. Comprehensive chart review was performed to evaluate for complications and WON recurrence.
RESULTS: Fifteen patients who underwent DEN for WON had gastric varices at the time of their procedure. All patients had an INR < 1.5 and platelets > 50. Of these patients, 11 had splenic vein thrombosis and 2 had portal vein thrombosis. Two patients had isolated gastric varices, type 1 and the remaining 13 had > 5 mm gastric submucosal varices on imaging by CT, MRI or EUS. No procedures were terminated without completing the DEN for any reason. One patient had self-limited intraprocedural bleeding related to balloon dilation of the tract. Two patients experienced delayed bleeding at 2 and 5 d post-op respectively. One required no therapy or intervention and the other received 1 unit transfusion and had an EGD which revealed no active bleeding. Resolution rate of WON was 100% (after up to 2 additional DEN in one patient) and no patients required interventional radiology or surgical interventions.
CONCLUSION: In patients with WON and gastric varices, DEN using EUS and doppler guidance may be performed safely. Successful resolution of WON does not appear to be compromised by the presence of gastric varices, with similar rates of resolution and only minor bleeding events. Experienced centers should not consider gastric varices a contraindication to DEN.
Core tip: In this retrospective cohort, 15 out of 90 patients (16.7%) presenting for endoscopic necrosectomy had gastric varices. When performed with best practice technique, direct endoscopic necrosectomy may be safely performed in patients with gastric varices. The best practice technique, from Thompson et al. Pancreatology, 2015 includes: (1) EUS evaluation with doppler to confirm absence of intervening vessels; (2) injection of contrast to distend collection and create wall tension for access; (3) stiff guidewire looped in cavity to mark access site for duration of the case; (4) entry into the cavity with stiff balloon catheter dilated to 4-8 mm, then 20 mm; (5) exchange for a large-channel endoscope for lavage and debridement of necrosis; (6) placement of pigtail catheters for ongoing drainage of the cavity; and (7) avoid proton pump inhibitor to encourage ongoing digestion of necrotic material.