Endoscopic ultrasound guided cystogastrostomy of walled-off pancreatic necrosis avoids the need for any necrosectomy in severe necrotising pancreatitis.

Introduction: Necrotising pancreatitis is often complicated by walled-off pancreatic necrosis (WOPN), causing either infection or obstructive symptoms. Minimally invasive necrosectomy, either percutaneously or endoscopically, is the favoured treatment, though this is not without complication and some patients still ultimately require open necrosectomy1. Our experience suggests that endoscopic ultrasound (EUS) guided drainage of necrotic collections via cystogastrostomy is a sufficient enough intervention, without the need for any modality of necrosectomy. Method(s): Data from consecutive patients admitted to Monash Health, a quaternary pancreaticobiliary referral centre, with necrotising pancreatitis that underwent EUS guided cystogastrostomy of WOPN was prospectively collected and analysed. Patient demographics, procedural details and complications, length of stay and morbidity and mortality data were collected. Result(s): Eighteen patients with a median age of 67 (range 31-81 years) were analysed. The predominant aetiology of pancreatitis was gallstone (41.2%). The median bedside index for severity in acute pancreatitis (BISAP) and computer tomography severity index (CTSI) scores were 3 and 7, respectively. Initial EUS guided cystogastrostomy was performed at a median of 31 days post-admission (range 12 to 131 days). The majority of procedures were performed for infected necrotic collections. The median number of EUS procedures was 2 and the length of stay post-initial EUS intervention was 17 days. There was one peritoneal perforation from cystogastrostomy and two deaths, though none related to the EUS procedure. At a median follow-up of 12.1 months, no patients required minimally invasive or open necrosectomy. Conclusion(s): Patients with WOPN, a life-threatening complication of necrotisting pancreatitis, were able to be effectively and safely managed with EUS guided cystogastrostomy, without the need for necrosectomy. A prospective randomised controlled trial is