三長 孝輔, 北野 雅之, 今井 元, 山雄 健太郎, 鎌田 研, 宮田 剛, 松田 友彦, 大本 俊介, 門阪 薫平, 工藤 正俊

Kosuke MINAGA, Masayuki KITANO, Hajime IMAI, Kentaro YAMAO, Ken KAMATA, Takeshi MIYATA, Tomohiko MATSUDA, Shunsuke OMOTO, Kumpei KADOSAKA, Masatoshi KUDO

近畿大学医学部消化器内科

Department of Gastroenterology and Hepatology, Kindai University Faculty of Medicine

キーワード :

Background and objectives: Walled-off necrosis（WON）remains difficult to manage endoscopically due to insufficient drainage of solid necrotic tissue. This study aimed to evaluate the technical/clinical success, and safety of EUS-guided treatment of WON and to ascertain factors associated with failed endoscopic treatments.
Patients and methods: This retrospective study involved 70 consecutive patients who had undergone a step-up approach based on EUS-guided drainage for WON. Our treatment strategy is shown in Figure 1. Multivariable logistic regression analysis was performed to ascertain factors associated with failed endoscopic treatments.
【Results】
Seventy patients（57 men and 13 women; mean age 57.1 years）underwent EUS-guided drainage. Forty-one cases（59％）had a multilocular lesion and 13 cases（19％）had WON cavity extending to the pelvis. The mean number of stents placed was 3.7; metal stents were deployed in 32 cases（46％）. The technical success rate（successful stent deployment）of EUS-guided drainage was 97％．The clinical success rates（resolution of symptoms or inflammation）up to STEP 1, 2, 3, and 4 were 40％, 69％, 76％, and 89％, respectively. Eight（11％）cases experienced adverse events related to endoscopic interventions and 10（14％）required surgical necrosectomy; 8（11％）patients died. The multivariable analysis to examine factors associated with failure to manage the procedure successfully up to STEP 2 showed the significant risk factors were patients with serious comorbidities（Charlson comorbidity index≧3）and with WON cavity extending to the pelvis（odds ratio 5.3 and 4.7, P = 0.021 and 0.026，respectively）.
【Conclusions】
A step-up approach based on EUS-guided drainage is an effective strategy for the management of WON, particularly in patients with serious comorbid conditions or in those with WON cavity extending to the pelvis, who are difficult to manage with endoscopy alone. In those patients, more options, such as surgical necrosectomy should be considered.