Mo1440 Pancreatic Necrosectomy Using a Fully Covered Esophageal Metallic Stent: a New Platform

techniques may be insufficient for very extensive infected WON. Theoretical advantages of combining DEN and STE include ability to reach much deeper into the abdomen and to allow high volume PCD lavage with one-way flow through internal cystenterostomy between interventions. Combined DEN and STE has not been reported. Methods: We reviewed 54 patients (pts) who required intervention for necrotizing pancreatitis between Jul 2009 and Nov 2012 at one center. A step up approach was used for all pts starting with drainage, then minimally invasive debridement as needed, with open surgery reserved only for failures. Interventions included DEN alone (n 35), DEN PCD (n 7), DEN STE (n 5), PCD alone (n 6), PCD STE (n 1). 4/54 pts failed step up approach and required surgery. All cause mortality was 7.4%. The results of only the 5 pts treated with DEN STE are reported. Selection for DEN STE was based on extensive and/or nonresolving WON despite DEN PCD approach. DEN was performed serially by EUS guided cystenterostomy or via spontaneous internal fistula with dilation/stenting, followed by DEN at later sessions as needed. STE was performed with standard gastroscope after dilating a PCD tract. All procedures were done under general anesthesia and with CO2 insufflation. High volume lavage was performed via the PCD catheter between sessions. Results: All 5 pts had infected WON (4 culture proven, 1 suspected). 2 pts had acute renal failure and 1 multiorgan failure. Extension of WON was deep into left pelvis (3 pts), right pelvis (1 pt), and around spleen and to the anterior abdominal wall (1 pt). Mean 3 sessions of DEN and 2.2 sessions of STE per pt. In all cases necrotic cavities could be completely traversed to the other stoma via DEN, STE or both. Complications after DEN and STE consisted of 1 internal fistula to small bowel. No pt developed external fistula or new organ failure following DEN or STE. 4 pts had complete resolution of WON, and 1 underwent open necrosectomy because of failure to respond and died due to multiorgan failure. Conclusion: Combined DEN STE is an effective approach to necrosectomy in pts with infected WON that extends deeply into the flank or that fails to resolve with other techniques.