INTRO: Complications during endoscopic transmural drainage (TMD) of pancreatic collections (PC) are primarily related to entry thorough the gastric or duodenal wall using needle-knife electrocautery (NKE). We describe TMD using the Seldinger technique without electrocautery and compare complications to entry using NKE. METHODS: The first 10 TMDs using NKE were excluded from analysis because of complications/potential learning curve bias. From 1/95-12/96, 68 consecutive pts. underwent attempted endoscopic drainage of symptomatic PCs; 17 underwent transpapillary drainage, and in 51 endoscopic TMD was attempted without EUS guidance. From 1/95-3/96, PCs were entered using NKE (HPC-2, Wilson-Cook). From 4/96-12/96, localization, entry and TMD were performed through a single entry site using a 19G needle (GAN-1-19, Wilson-Cook). After aspiration and contrast injection confirmed needle placement, a 0.018″ guidewire was placed directly through the needle into the collection. The needle was withdrawn, exchanged for a 5Fr catheter, and a 0.035″ wire inserted. In both techniques, the tract was then dilated with an 8mm balloon followed by placement of 10Fr stents. Successful entry and complications specifically related to transmural entry (bleeding and perforation) were noted. RESULTS 1 p ≤ 0.05 significant SELDINGER (N=18) NKE (N=33) p SUCCESSFUL ENTRY 17 (94%) 31 (94%) NS TRANSGASTRIC 7 (41%) 19 (61%) NS TRANSDUODENAL 10 (59%) 12 (39%) NS MAX. DIAMETER (cm) Mean ± SEM 7.9 ± 0.9 9.9 ± 1.0 RANGE (cm) (3-19 cm) (4-21 cm) NS BLEEDING/PERFORATION 0 (0%)/0(0%) 4 (12%)/2 (6%) NS TOTAL COMPLICATIONS 0 (0%) 6 (18%) 0.05 1 No entry complications occurred in the seldinger group. Of the 6 complications in the NKE group, 4 were severe (3 bleeds, 1 perforation), and 2 were moderate (1 bleed, 1 perforation) [as defined by Cotton et al. 1991]. CONCLUSIONS: 1) The Seldinger technique of transmural entry into and drainage of pancreatic collections without the use of electrocautery is safer than entry using needle-knife electrocautery with a significantly lower incidence of bleeding and perforation. 2) Collections as small as 3cm can be safely entered using the Seldinger technique without the need for EUS guidance. 3) The Seldinger technique of entry into and drainage of pancreatic collections without the use of electrocautery should be used as the primary technique for transmural drainage of pancreatic collections.
