Observational Study
Copyright ©The Author(s) 2018. Published by Baishideng Publishing Group Inc. All rights reserved.
World J Gastrointest Endosc. May 16, 2018; 10(5): 93-98
Published online May 16, 2018. doi: 10.4253/wjge.v10.i5.93
Endoscopic ultrasound-guided drainage of pancreatic walled-off necrosis using self-expanding metal stents without fluoroscopy
Barbara Braden, Andreas Koutsoumpas, Michael A Silva, Zahir Soonawalla, Christoph F Dietrich
Barbara Braden, Andreas Koutsoumpas, Translational Gastroenterology Unit, Oxford University Hospitals, Oxford OX3 9DU, United Kingdom
Michael A Silva, Zahir Soonawalla, Hepatobiliary Surgery, Oxford University Hospitals, Oxford OX3 9DU, United Kingdom
Christoph F Dietrich, Caritas Krankenhaus, Bad Mergentheim 97980, Germany
Author contributions: Braden B and Dietrich CF contributed to study conception and design, performed the interventions and data acquisition; Braden B, Koutsoumpas A, Silva MA, Soonawalla Z and Dietrich CF contributed to data acquisition, data analysis and interpretation, editing, reviewing and final approval of article.
Institutional review board statement: After discussion with the local Ethics Service, they considered this observational project to be an audit rather than a research project, therefore ethical approval was not required.
Informed consent statement: Informed consent was obtained from all patients.
Conflict-of-interest statement: No potential conflicts of interest relevant to this article were reported.
Data sharing statement: Data set available from corresponding author braden@em.uni-frankfurt.de. Consent has not been obtained for sharing of this data but all data have been anonymised and the risk of identification is therefore low.
STROBE statement: Guidelines of the STROBE Statement have been adopted.
Open-Access: This article is an open-access article which was selected by an in-house editor and fully peer-reviewed by external reviewers. It is distributed in accordance with the Creative Commons Attribution Non Commercial (CC BY-NC 4.0) license, which permits others to distribute, remix, adapt, build upon this work non-commercially, and license their derivative works on different terms, provided the original work is properly cited and the use is non-commercial. See: http://creativecommons.org/licenses/by-nc/4.0/
Correspondence to: Barbara Braden, BSc, FEBG, MD, PhD, Professor, Translational Gastroenterology Unit, Oxford University Hospitals, NHS Foundation Trust, Headley Way, Oxford OX3 9DU, United Kingdom. braden@em.uni-frankfurt.de
Telephone: +44-186-5228760 Fax: +44-186-5228763
Received: January 3, 2018
Peer-review started: January 4, 2018
First decision: January 22, 2018
Revised: February 20, 2018
Accepted: March 14, 2018
Article in press: March 15, 2018
Published online: May 16, 2018

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.


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.


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.


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.

Keywords: Necrotizing pancreatitis, Peripancreatic fluid collection, Therapeutic endoscopic ultrasound, Transmural drainage, Acute pancreatitis

Core tip: The use of self-expanding and lumen-apposing metal stents for the drainage of walled-off necrosis has revolutionised the treatment options and outcome of this disease. Conventionally, these stents are placed by endoscopic ultrasound-guidance but under fluoroscopic control. We could demonstrate that all steps of the stent insertion are visible endosonographically which allows safe and controlled stent placement. Without the need for fluoroscopy and consequent radiation protection regulations, this procedure becomes available in the endoscopy unit and at the bedside of critically ill patients.