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Endoscopic Ultrasound Guided Transmural Drainage of Walled off Pancreatic Necrosis in Patients With Portal Hypertension and Intra Abdominal Collaterals
Surinder S. Rana^*, Vishal Sharma, Puneet Chhabra, Ravi Sharma, Rajesh Gupta, Deepak K. Bhasin
Post Graduate Institute of Medical Education & Research, Chandigarh, India

Background: Acute necrotising pancreatitis (ANP) is often complicated with segmental portal hypertension (PHT) and formation of intra abdominal venous collaterals. Presence of collaterals in vicinity of transmural tract pathway can lead on to potentially catastrophic situation. Endoscopic ultrasound (EUS), by avoiding these vessels, can decrease risk of bleeding during endoscopic drainage. Aim: To assess the safety and outcome of EUS guided transmural drainage of walled off pancreatic necrosis (WOPN) in patients with portal hypertension and intra abdominal collaterals. Methods: Retrospective analysis of collected database of patients who underwent EUS guided transmural drainage of WOPN was searched to retrieve data about patients who had evidence of portal hypertension as evidenced by presence of portal or splenic thrombosis and collaterals. The WOPN was punctured under EUS guidance using 19G needle avoiding intra abdominal collaterals and multiple stents placed after balloon dilatation of the tract. This procedure was repeated till resolution of WOPN. In patients with persisting WOPN with symptoms, a decision for direct endoscopic necrosectomy or SEMS or surgery was taken after interdisciplinary consultation with pancreatic surgeons. Results: Of the 18 patients who were noted to have portal hypertension the etiology for acute pancreatitis was alcohol in 14, gall stones in 3 and others in 1 patient. The mean age was 40.94 ± 8.43 years and 17 of the patients were males. All patients had acute necrotizing pancreatitis and mean duration of presentation after acute episode was 11.28 ± 2.67 weeks. The symptoms at presentation were: pain (18), fever (3) and gastric variceal bleeding (1). The mean size of collection was 10.67 ± 3.45 cm and all 18 patients had splenic vein thrombosis with one patient also having portal vein thrombosis. Of these 18 patients, drainage was not feasible in 1 patient as no echo window free of collaterals could be found and in patient with variceal bleeding endoscopic drainage was attempted after successful obliteration of gastric varix with glue injection. Endoscopic drainage was done in 17 patients and of these 15 underwent transmural drainage with multiple 7/10 Fr plastic stents, one patients underwent SEMS insertion and 1 patient needed direct endoscopic necrosectomy (DEN). The mean numbers of procedures needed were 3 ± 0.79 and the time to resolution of collection was 4.35 ± 1.32 weeks. One patient developed bleeding 10 hours after drainage and was successfully managed with blood transfusion, intra venous terlipressin and intermittent irrigation of WOPN cavity via nasocystic catheter. he successfully treated patients have been asymptomatic over a follow-up period of 15.65 ± 12.2 weeks. Conclusion: EUS guided drainage of WOPN is safe and effective in patients with portal hypertension and intra abdominal collaterals

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