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Gel immersion EUS-guided drainage for walled-off necrosis with poor visibility using a lumen-apposing metal stent (with video)

 2nd Department of Internal Medicine, Osaka Medical College, Osaka, Japan

Date of Submission06-Dec-2021
Date of Acceptance27-Feb-2022
Date of Web Publication08-Jun-2022

Correspondence Address:
Takeshi Ogura,
2nd Department of Internal Medicine, Osaka Medical College, 2-7 Daigakuchou, Takatsukishi, Osaka 569-8686
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/EUS-D-21-00255

How to cite this URL:
Ogura T, Okuda A, Nishioka N, Yamada M, Higuchi K. Gel immersion EUS-guided drainage for walled-off necrosis with poor visibility using a lumen-apposing metal stent (with video). Endosc Ultrasound [Epub ahead of print] [cited 2022 Nov 28]. Available from: http://www.eusjournal.com/preprintarticle.asp?id=346867

EUS-guided drainage is widely performed for walled-off necrosis (WON). Currently, the lumen-apposing metal stent (LAMS) plays an important role as an effective drainage device for this condition.[1] However, LAMS deployment may be challenging if the visibility of a pancreatic pseudocyst is poor on EUS imaging due to debris or necrotic tissue, because the distal flange of the LAMS may not be sufficiently open. To obtain technical success, a two-step puncture technique using saline solution has been reported.[2] However, the saline solution can flow into nonpuncture sites because of its low viscosity, thus limiting the available space for opening of the distal flange. The use of gel immersion endoscopy using a transparent gel (Viscoclear; Otsuka Pharmaceutical Factory, Tokushima, Japan), which is more viscous than saline [Figure 1], has recently been reported for securing the visual field.[3],[4],[5] The retention of Viscoclear injected around the puncture site increases the available space for flange opening, enabling LAMS deployment if the contents of WON are mainly necrotic tissue. Here, we present technical tips for gel immersion EUS-guided drainage for WON using a LAMS.
Figure 1: Experimental comparison images between saline (left side) and Viscoclear (right side). When blood is injected, visibility is better with Viscoclear than with saline

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An 88-year-old man was referred to our hospital to undergo drainage for WON. EUS revealed a large amount of debris or necrotic tissue [Figure 2]. Therefore, to avoid mis-deployment of a LAMS, gel immersion EUS-guided drainage was performed. The area of WON was punctured using a 19-G needle and injected with contrast medium. Viscoclear was injected into the lumen of the WON (200 ml), which obtained good visibility of the lumen of the WON [Figure 3]. The stent delivery system was then inserted into the WON and deployed into the distal lumen with good visibility on EUS [Figure 4]. Finally, a LAMS was successfully deployed without any adverse events [[Figure 5] and Video [Additional file 1]].
Figure 2: The lumen of the walled-off necrosis is not clearly visualized due to debris and necrotic tissue

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Figure 3: The lumen of the walled-off necrosis is visualized following injection of Viscoclear

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Figure 4: The distal flange of the lumen-apposing metal stent is sufficiently opened

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Figure 5: Successful deployment of the lumen-apposing metal stent

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In conclusion, in deployment of a LAMS for WON, gel immersion EUS-guided drainage appears to be a useful technique for increasing visibility and enlarging the available space to facilitate opening of the distal flange of the LAMS. Further study is necessary to evaluate the safety and efficacy of this method.

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Conflicts of interest

Takeshi Ogura is an Editorial Board Member of the journal. This article was subject to the journal's standard procedures, with peer review handled independently of this editor and his research group.

  References Top

Angadi S, Mahapatra SJ, Sethia R, et al. Endoscopic transmural drainage tailored to quantity of necrotic debris versus laparoscopic transmural internal drainage for walled-off necrosis in acute pancreatitis: A randomized controlled trial. Pancreatology 2021;21:1291-8.  Back to cited text no. 1
Mukai S, Itoi T, Tsuchiya T, et al. New deployment techniques of the lumen-apposing metal stent in walled-off necrosis filled with necrotic tissue: Chick opening its mouth (with video). Dig Endosc 2021;33:985-9.  Back to cited text no. 2
Yano T, Nemoto D, Ono K, et al. Gel immersion endoscopy: A novel method to secure the visual field during endoscopy in bleeding patients (with videos). Gastrointest Endosc 2016;83:809-11.  Back to cited text no. 3
Miura Y, Yano T, Takezawa T, et al. Gel immersion endoscopy simplifies hemostasis during endoscopic submucosal dissection using the pocket-creation method. Endoscopy 2018;50:E294-5.  Back to cited text no. 4
Yano T, Ohata A, Hiraki Y, et al. Development of a gel dedicated to gel immersion endoscopy. Endosc Int Open 2021;9:E918-24.  Back to cited text no. 5


  [Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5]


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