Endoscopic Ultrasound Guided Transmural Drainage (Eutmd) for Walled off Pancreatic Necrosis (WOPN) a Single Center Experience of 65 Patients Advay Aher*, Amol Bapaye Dept. of Digestive Diseases & Endoscopy, Deenanath Mangeshkar Hospital & Research Center, Pune, India Introduction & Aim: WOPN defined as a walled off collection of pus, necrotic debris & enzyme rich fluid in the lesser sac, is a frequent sequel of acute severe pancreatitis. WOPN may be infected or sterile. Infected WOPN is the commonest cause of sepsis & intervention in these patients. Intervention may be percutaneous, surgical or endoscopic with or without EUS guidance. Controversy exists regarding the best approach. We present a retrospective analysis of outcomes of 66 consecutive patients of WOPN treated by EUTMD over 7 years (2005-11). Patients & Methods: Median age was 38 years (Range 19 62); 57 (86%) males. Etiology of pancreatitis was gall stones 42 (64%), alcohol 17 (26%) & others 7 (10%). Sepsis (42, 64%) was the commonest indication for intervention; followed by failure to tolerate enteral feeds & severe abdominal pain. Contrast enhanced spiral CT scan confirmed suitability of endoscopic drainage based on location, wall thickness & contents. Visual quantification of necrosis by EUS excluded 5 patients (8%, 50% solid debris). EUTMD was performed in the rest. After EUS guided puncture using 19G FNA needle, tract was dilated to 18mm over a guide wire & multiple stents were placed. Same session endoscopic necrosectomy was performed when EUS showed 25% solid debris, additional nasocystic drain (NCD) was placed & cavity irrigated. Procedure was repeated till debris was cleared; NCD was removed & multiple stents left in place. Intravenous antibiotics were prescribed throughout hospitalization. Follow up was at 1, 2, 4 & 6 weeks using appropriate imaging. ERP & pancreatic sphincterotomy was performed between 2 to 4 weeks, duct stents were placed to bridge leak or into the cavity in case of disconnection. Observations & Results: 61/66 (92%) patients underwent EUTMD. Balloon dilation (18mm) was performed in all. Median 4 (2-5) stents placed. Necrosectomy was performed in 29/61 (48%), NCD & irrigation in 29/29 (100%), median 2 (1-4) sessions. Median hospital stay was 8 (4-65) days. Complications were seen in 23/61 (37.7%) patients aggravation of infection in 11 (18%), hemorrhage in 5 (8.1%, 2 surgery, 1 endoclips, 2 self limiting), residual intra abdominal (IA) fluid collections in 7 (11.4%). Subsequent surgery was required in 20/61 (32.7%). 4(6.5%) patients died of ongoing post-operative sepsis. ERP & sphincterotomy was performed in 38/61 (62.3%). Stents were placed in 26/38 (68.4%), 20 (84.3%) in cavity, 6 (15.7%) bridging the leak. Conclusions: EUTMD is an effective treatment for most WOPN patients. Aggressive approach of large balloon dilation, necrosectomy (for 25% solid debris), multiple stent placement & ERP with pancreatic duct stenting may avoid surgery in two thirds patients. Complications can occur in one third patients & nearly always demand surgery.