In Search of Nodular Gastric Antral Vascular Ectasia: A Distinct Entity or Simply Hyperplastic Polyps Arising in Gastric Antral Vascular Ectasia?

CONTEXT.­: Nodular gastric antral vascular ectasia (GAVE) is a reported phenotype of GAVE that has histologic features overlapping with gastric hyperplastic polyps (GHPs), with additional features often seen in flat mucosa of GAVE. OBJECTIVE.­: To determine if nodular GAVE and GHPs are distinct lesions by evaluating the prevalence of features reported in nodular GAVE in GHPs with or without associated GAVE. DESIGN.­: A review of all lesions diagnosed as GHPs between 2014 and 2017 was performed. Slides were analyzed for a number of features including established histologic features of GAVE without knowledge of clinical or endoscopic features. RESULTS.­: A total of 90 polyps were analyzed including 18 from patients with GAVE (20%). GAVE polyps were larger than non-GAVE polyps (average size, 1.3 cm versus 0.68 cm; P < .001), with more common extensive ulceration and associated granulation tissue (61.11% [n = 11] versus 4.17% [n = 3]; P = .004), fibrin thrombi (50% [n = 9] versus 15% [n = 11]; P = .003), moderate to marked vascular ectasia (83% [n = 15] versus 35% [n = 11]; P = .001), and fibrohyalinosis (72% [n = 13] versus 28% [n = 20]; P = .001). All polyps showed foveolar hyperplasia and smooth muscle proliferation. There were no features that were exclusively found in GAVE or non-GAVE cases. CONCLUSIONS.­: Nodular GAVE appears to represent GHPs arising in a background of GAVE, with superimposed features found in flat mucosa of GAVE stomachs. The presence of fibrin thrombi, marked vascular ectasia, fibrohyalinosis, and/or ulceration in a GHP is suggestive but not diagnostic of GAVE, and the absence of these features does not rule out GAVE.

Primary Pancreatic Liposarcoma: An Unexpected Cause of a Pancreatic Mass.

Liposarcoma is the most common type of soft-tissue sarcoma and typically occurs in the extremities or retroperitoneum. Primary liposarcoma of the pancreas is exceedingly rare, with only 10 cases reported since 1979. We present a patient who was incidentally discovered to have a pancreatic mass on imaging, which was ultimately diagnosed as dedifferentiated pancreatic liposarcoma. We review the clinical and histologic features of pancreatic liposarcoma in this case and in the 10 previously reported cases to increase awareness and knowledge of this rare disease.

Visceral artery pseudoaneurysms in necrotizing pancreatitis: risk of early bleeding with lumen-apposing metal stents.

BACKGROUND AND AIMS: Visceral artery pseudoaneurysm (PSA) in necrotizing pancreatitis (NP) is associated with significant morbidity and mortality. This study aimed to evaluate the incidence, clinical presentation, management, and outcomes of PSA in NP. METHODS: All NP patients managed at our institution between 2010 and 2020 were retrospectively reviewed from a prospectively maintained database for PSA. Demographics, clinical presentation, method of diagnosis, management, and outcomes were collected. RESULTS: Thirty-nine of 607 patients (6.4%) with NP had a confirmed diagnosis of PSA. Demographics, presence of infected necrosis, development of organ failure(s), and severity of disease were similar between PSA and no PSA. Endoscopic and percutaneous drainages for walled-off necrosis (WON) were more common in the PSA group. Seven patients developed PSA without requiring any intervention for WON, and 17 patients (43.6%) had lumen-apposing metal stents (LAMSs) placed before PSA diagnosis. The time from NP diagnosis to PSA diagnosis was shorter in these patients (n = 17) compared with the remaining patients (n=22; 47 days [interquartile range {IQR}: 17-85] vs 109 days [IQR: 61-180.5, P=0.009]). In addition, 7 of 11 patients (63.6%) with early PSA (defined by <3 weeks from index cystgastrostomy/cystduodenostomy) had an indwelling LAMS at the time of the PSA diagnosis. Seventy-seven percent of patients presented with anemia, 74.3% with GI bleeding, and 30% with hemorrhagic shock. CT was diagnostic for PSA in 83.9% with a false-negative rate of 16.1%. Splenic (50%) and gastroduodenal (28%) arteries were the most common arteries involved by PSA. Angiography and embolization for PSA were successful in 33 of 35 patients. In-hospital mortality was observed in 9 patients (23.1%). CONCLUSIONS: Although visceral artery PSA affects a small percentage of NP patients, it is associated with significant morbidity and mortality. In addition, bleeding from PSA induced by erosion of LAMSs may occur in the first 2 weeks, prompting individualization of removal intervals.

Single-Session Endoscopic Ultrasound-Directed Transgastric ERCP ("EDGE") in a Bariatric Patient with Pancreatic Mass and Biliary Obstruction.

This video case report presents a patient with an invasive pancreatic mass and a history of Roux-en-Y gastric bypass surgery who underwent single-session endoscopic ultrasound-directed transgastric ERCP for tissue sampling and biliary stenting with subsequent maintenance of the newly established gastrogastrostomy. The demonstrated technique enables spectrum of endoscopic interventions in gastric bypass patients by facilitating a direct endoscopic passage through the reconnected stomach. Importantly, the method carries a risk of weight regain by essentially reversing the bypass. However, this can be an actual desire in selected cases, e.g., oncologic patients, making it a favorable choice over other alternatives.

Mediastinal ganglioneuroma diagnosed by transesophageal endoscopic ultrasound guided fine needle aspiration (EUS-FNA).

Ganglioneuromas are rare benign tumors that arise from the sympathetic nerve fibers and represent the final maturation stage of neuroblast tumors. The most common sites of involvement in the body include posterior mediastinum, followed by retroperitoneum, adrenal gland, and soft tissues of the head and neck. In the mediastinum, this tumor is most frequently located in posterior compartment, together with other neurogenic tumors. The reports of mediastinal ganglioneuroma diagnosed by fine needle aspiration (FNA), especially endoscopic ultrasound-guided FNA (EUS-FNA) are very sparse. We describe the clinical, radiologic, cytologic, gross and histologic features of mediastinal ganglioneuroma diagnosed by transesophageal endoscopic ultrasound-guided fine needle aspiration.

Current Concepts in Severe Acute and Necrotizing Pancreatitis: An Evidence-Based Approach.

The incidence of acute pancreatitis continues to rise, inducing substantial medical and social burden, with annual costs exceeding $2 billion in the United States alone. Although most patients develop mild pancreatitis, 20% develop severe and/or necrotizing pancreatitis, requiring advanced medical and interventional care. Morbidity resulting from local and systemic complications as well as invasive interventions result in mortality rates historically as high as 30%. There has been substantial evolution of strategies for interventions in recent years, from open surgery to minimally invasive surgical and endoscopic step-up approaches. In contrast to the advances in invasive procedures for complications, early management still lacks curative options and consists of adequate fluid resuscitation, analgesics, and monitoring. Many challenges remain, including comprehensive management of the entire spectrum of the disease, which requires close involvement of multiple disciplines at specialized centers.

Three-way comparative study of endoscopic ultrasound-guided transmural gallbladder drainage using lumen-apposing metal stents versus endoscopic transpapillary drainage versus percutaneous cholecystostomy for gallbladder drainage in high-risk surgical patients with acute cholecystitis: clinical outcomes and success in an International, Multicenter Study.

BACKGROUND: Percutaneous cholecystostomy tube (PTGBD), endoscopic retrograde cholangiopancreatography with transpapillary gallbladder drainage (TP), and endoscopic ultrasound-guided transmural gallbladder drainage (EGBD) using lumen-apposing metal stents (LAMS) have been offered for gallbladder decompression for acute cholecystitis in high-risk surgical patients. Yet, there are limited data comparing these therapies. Our aim was to compare the safety and efficacy of EGBD to TP and PTGBD for gallbladder drainage. METHODS: We retrospectively collected high-risk surgical patients from six centers with acute cholecystitis who underwent gallbladder drainage by EGBD, TP, or PTGBD. Data included technical success (gallbladder drainage), clinical success (acute cholecystitis resolution), adverse events (AE), and follow-up. RESULTS: From 2010 to 2016, 372 patients underwent gallbladder drainage, with 146 by PTGBD, 124 by TP, and 102 drained by EGBD. Technical (98% vs. 88% vs. 94%; p = 0.004) and Clinical (97% vs. 90% vs. 80%; p < 0.001) success rates were significantly higher with PTGBD and EGBD compared to TP. PTGBD group had statistically significantly higher number of complications as compared to EGBD and TP groups (2 0% vs. 2% vs. 5%; p = 0.01). Mean hospital stay in the EGBD group was significantly less than TP and PTGBD (16 vs. 18 vs. 19 days; p = 0.01), while additional surgical intervention was significantly higher in the PTGBD group compared to the EGBD and TP groups (49% vs. 4% vs. 11%; p < 0.0001). CONCLUSIONS: EGBD with LAMS is an effective and safer alternative to TP and PTGBD for treatment of patients with acute cholecystitis who cannot undergo surgery. EGBD with LAMS has significantly lower overall AEs, hospital stay, and unplanned admissions compared to PTGBD. TRIAL REGISTRATION: ClinicalTrials.gov Identifier: NCT01522573.

Early (<4 Weeks) Versus Standard (≥ 4 Weeks) Endoscopically Centered Step-Up Interventions for Necrotizing Pancreatitis.

OBJECTIVES: Current guidelines for necrotizing pancreatitis (NP) recommend delay in drainage ± necrosectomy until 4 or more weeks after initial presentation to allow collections to wall off. However, evidence of infection with clinical deterioration despite maximum support may mandate earlier (<4 weeks) intervention. There are concerns, but scant data regarding risk of complications and outcomes with early endoscopic intervention. Our aim was to compare the results of an endoscopic centered step-up approach to NP when initiated before versus 4 or more weeks. METHODS: All patients undergoing intervention for NP were managed using an endoscopically centered step-up approach, with transluminal drainage whenever feasible, ±necrosectomy, and/or percutaneous catheter drainage as needed, with surgery only for failures. Interventions were categorized as early or standard based on timing of intervention (<4 weeks or ≥ 4 weeks from onset of pancreatitis). Demographic data, indications and timing for interventions, number and type of intervention, mortality and morbidity (length of stay in hospital and ICU) and complications were compared. RESULTS: Of 305 patients with collections associated with NP, 193 (63%) (median age-52 years) required intervention, performed by a step-up approach. Of the 193 patients, 76 patients underwent early and 117 patients standard intervention. 144 (75%) interventions included endoscopic drainage ± necrosectomy. As compared with standard intervention, early intervention was more often performed for infection (91% vs. 39%, p < 0.05), more associated with acute kidney injury (43% vs. 32%, p = 0.09), respiratory failure (41% vs. 22%, p = 0.005), and shock (13% vs. 4%, p < 0.05). Organ failure improved significantly after intervention in both groups. There was a significant difference in mortality (13% vs. 4%, p = 0.02) and need for rescue open necrosectomy (7% vs. 1%, p = 0.03) between groups. Patients undergoing early intervention had increased median hospital (37 days vs. 26 days, p = 0.01) and ICU stay (median 2.5 days vs. 0 days, p = 0.001). There was no difference in complications. CONCLUSIONS: When using an endoscopically centered step-up strategy in necrotizing pancreatitis, early (<4 weeks) interventions were more often performed for infection and organ failure, with no increase in complications, similar improvement in organ failure, slightly increased need for surgery, and relatively low mortality. Early endoscopic drainage ± necrosectomy should be considered when there is a strong indication for intervention.

Efficacy of endoscopic-guided fine-needle aspiration in the diagnosis of gastrointestinal spindle cell tumors.

BACKGROUND: Spindle cell neoplasms of the gastrointestinal (GI) tract constitute a wide group of lesions that may raise diagnostic difficulties on hematoxylin-eosin-stained slides. Appropriate endoscopic ultrasound-guided fine-needle aspiration (EUS-FNA) technique with sufficient cell block material for immunohistochemistry (IHC) can lead to accurate diagnosis. METHODS: This is a retrospective study of 29 cases obtained from our institution's records over a five-year period (2011-2015). Cytomorphology, histology (when available), IHC, FNA procedure details, imaging characteristics, and clinical history were reviewed. Rapid onsite evaluation (ROSE) was used in all cases. Cytologic samples were correlated with surgical pathology resection specimens when available. RESULTS: Eighteen GI stromal tumors, six leiomyomas, two schwannomas, and one granular cell tumor were analyzed; two cases were not amenable for a definitive diagnosis: one showed fragments of smooth muscle not otherwise specified (smooth muscle vs. leiomyoma) and the other one was insufficient for diagnosis. Locations included stomach, esophagus, duodenum, and colon. EUS-FNA was performed with different gauge needles. Total number of passes ranged between two and nine. We found no evidence that larger-sized needles are superior in procuring adequate lesional tissue. Cell block material was stained with various antibodies. Fourteen surgical resection specimens available showed 100% correlation between cytology and histology. None of the neoplasms recurred until now; one patient succumbed to known esophageal squamous cell carcinoma. CONCLUSION: FNA is a pivotal and inexpensive method for rapid evaluation of GI spindle cell tumors and should be used widely in the attempt to avoid unnecessary surgery. Size of needle used for EUS-FNA does not seem to influence the yield of lesional tissue; rather, ROSE can guide the number of passes and subsequently lead to an adequate cell block.

Interventions for walled off necrosis using an algorithm based endoscopic step-up approach: Outcomes in a large cohort of patients.

OBJECTIVES: The minimally invasive step-up approach for treatment of walled off necrosis (WON) involves drainage followed by later necrosectomy as needed, and is superior to primary surgical necrosectomy. Reported series of endoscopic transluminal necrosectomy include highly selected patients. We report outcomes of a large series of patients with WON managed by an algorithm based on an endoscopically centered step-up approach. METHODS: Consecutive patients with necrotizing pancreatitis from 2009 to 2014, with intervention only for infected or persistently symptomatic WON. The primary approach involved endoscopic transluminal drainage plus minus necrosectomy whenever feasible, with percutaneous catheter drainage (PCD) plus minus sinus tract endoscopy if not feasible or sufficient. Surgery was reserved for failures of the step up approach. RESULTS: Of 109 consecutive patients with necrotizing pancreatitis, intervention was required in 83, including endoscopic transluminal drainage in 73 (88%) (alone in 49 and combined with PCD in 24), and PCD alone in 10 (12%). 64 (77%) of the 83 patients required endoscopic transluminal and/or sinus tract necrosectomy. Adverse events occurred in 11 (13%). Three patients (4%) failed step up approach and required open surgical necrosectomy. All-cause mortality occurred in 6 (7%) of 83 patients after intervention, including 2 of 3 requiring surgery. CONCLUSIONS: An algorithm based step-up approach for interventions in necrotizing pancreatitis using primarily endoscopic techniques with adjunctive percutaneous approaches as needed resulted in favorable outcomes with small numbers proceeding to open surgery, and with acceptable rates of major complications and mortality. A purely endoscopic transluminal approach was feasible in approximately 60% of patients requiring intervention in this series.

Pancreatic involvement by metastasizing neoplasms as determined by endoscopic ultrasound-guided fine needle aspiration: A clinicopathologic characterization.

BACKGROUND: Pancreatic tumors often represent primary neoplasms, however organ involvement with metastatic disease can occur. The use of endoscopic ultrasound-guided fine needle aspiration (EUS-FNA) to determine the underlying pathology provides guidance of clinical management. METHODS: 25 cases were identified in a retrospective review of our institution's records from 2006 to 2016. Clinical parameters and prognosis are described. RESULTS: Metastatic lesions to the pancreas diagnosed by EUS-FNA accounted for 4.2% of all pancreatic neoplastic diagnoses, each lesion had a median greatest dimension of 1.5 cm, were most often located in the head of the pancreas, and by EUS were typically hypoechoic masses with variably defined borders. Patients were of a median age of 64 years old at diagnosis of the metastatic lesion(s) and the mean interval from primary diagnosis to the diagnosis of metastasis to the pancreas was 58.7 months (95% confidence interval, CI, 35.4 to 82.0 months). The rates of 24-month overall survival after diagnoses of metastatic renal cell carcinoma or all other neoplasms to the pancreas were 90% and 7% respectively. The origin of the neoplasms included the kidney (n = 10), colon (n = 4), ovary (n = 3), lung (n = 2), et al. Smear-based cytomorphology, and a combination of histomorphology and immunohistochemical studies from cell block preparations showed features consistent with the neoplasm of derivation. CONCLUSION: Metastases to the pancreas can be diagnosed via EUS-FNA, with enough specimen to conduct immunohistochemical studies if necessary to delineate origin. The determination of metastatic disease to the pancreas alters management and prognosis of the patient. Diagn. Cytopathol. 2017;45:418-425. © 2017 Wiley Periodicals, Inc.

Evaluation of Rosemont criteria for non-calcific chronic pancreatitis (NCCP) based on histopathology - A retrospective study.

BACKGROUND: Rosemont classification for chronic pancreatitis has not been evaluated specifically in non-calcific chronic pancreatitis (NCCP) patients and to this date, it has not been correlated with the gold standard namely histopathology. OBJECTIVE: To assess the correlation of EUS Rosemont criteria for NCCP with histopathology from surgical specimens and evaluate the impact of age, sex, BMI, smoking and alcohol on Rosemont classification. METHODS: Adult patients undergoing TPIAT for NCCP between July 2009 and January 2013 were identified from our institutional database. The presence or absence of standard and Rosemont (major and minor) criteria were determined by expert endosonographers using linear endosonography. Patients were categorized into normal, indeterminate and suggestive with CP based on Rosemont classification. Histology was obtained at time of TPIAT from the resected pancreas by wedge biopsy of head, body and tail. All histopathology were re-reviewed by a GI pathologist blinded to endosonographic features and clinical outcomes. Available pancreatic tissue was graded for severity of intralobular and perilobular pancreatic fibrosis by the Ammann classification system. RESULTS: 50 patients with NCCP (42 females, mean age± SD = 37.9 ± 10.8) underwent TPIAT with preoperative EUS during the study period. Univariate analysis of features such as age, sex, BMI, smoking and alcohol history showed no significant difference between patients identified as normal and those identified as indeterminate/suggestive (p > 0.05). Rosemont "Normal" was poor in excluding CP as 5/9 patients (55.5%) had CP on histopathology. 25/26 patients (96.2%) with features "suggestive" of CP had evidence of CP on histopathology. 12/15 patients (80.0%) with "indeterminate" features had CP on histopathology. CONCLUSIONS: Rosemont classification can be used independent of patient characteristics (age, sex and BMI) and environmental factors (smoking and alcohol exposure). In our cohort, Rosemont classification was strongly predictive of CP in patients with features "suggestive" of CP. However, "normal" Rosemont classification had poor correlation in this study. This is maybe due to lack of true comparator "normal" pancreas which cannot be obtained reasonably. The strength of agreement for diagnosis of CP was substantial between the standard and Rosemont criteria.

Successful Endoscopic Ultrasound-Guided Alcohol Ablation of Sporadic Insulinoma Using Three-Dimensional Targeting (with Video).

Surgical resection is considered the standard of care in the management of symptomatic insulinoma. In this video, we describe the successful management of a symptomatic insulinoma by using linear array endoscopic ultrasound (EUS)-guided ethanol ablation in a poor surgical candidate. EUS-guided ethanol ablation of insulinoma offers a safer, effective, and less invasive alternative to surgery.

Diagnostic Performance of Endoscopic Ultrasound (EUS) for Non-Calcific Chronic Pancreatitis (NCCP) Based on Histopathology.

OBJECTIVES: Studies correlating endoscopic ultrasound (EUS) with histopathology for chronic pancreatitis (CP) are limited by small sample size, and/or inclusion of many patients without CP, limiting applicability to patients with painful CP. The aim of this study was to assess correlation of standard EUS features for CP with surgical histopathology in a large cohort of patients with non-calcific CP (NCCP). METHODS: Adult patients undergoing total pancreatectomy and islet autotransplantation (TPIAT) for NCCP, between 2008 and 2013, with EUS <1 year before surgery. Histology from resected pancreas at the time of TPIAT (from head, body, and tail) was graded by a GI pathologist blinded to the EUS features. A fibrosis score (FS) ≥2 was abnormal, and FS≥6 was considered severe fibrosis. A multivariate regression analysis for the EUS features predicting fibrosis, after taking age, sex, smoking, and body mass index into consideration, was performed. A quantitative receiver operating characteristic (ROC) curve analysis was performed and Spearman rank correlation co-efficient (r) was calculated. RESULTS: 68 patients (56 females, mean±s.d. age-38.77±10.92) underwent TPIAT for NCCP with pre-operative EUS. ROC curve showed that four or more EUS features provided the best balance of sensitivity (61%), specificity (75%), and accuracy (63%). Although significant, correlation between standard EUS features and degree of fibrosis was poor (r=0.24, P<0.05). Multivariate regression analysis showed that main pancreatic duct irregularity was the only independent EUS feature (P=0.02) which predicted CP. CONCLUSIONS: Correlation between standard EUS features and histopathology is poor in NCCP. MPD irregularity is an independent predictor for NCCP.

Diagnostic Performance of Contrast-Enhanced MRI With Secretin-Stimulated MRCP for Non-Calcific Chronic Pancreatitis: A Comparison With Histopathology.

OBJECTIVES: Diagnosis of non-calcific chronic pancreatitis (NCCP) in patients presenting with chronic abdominal pain is challenging and controversial. Contrast-enhanced magnetic resonance imaging (MRI) with secretin-stimulated MRCP (sMRCP) offers a safe and noninvasive modality to diagnose mild CP, but its findings have not been correlated with histopathology. We aimed to assess the correlation of a spectrum of MRI/sMRCP findings with surgical histopathology in a cohort of NCCP patients undergoing total pancreatectomy with islet autotransplantation (TPIAT). METHODS: Adult patients undergoing TPIAT for NCCP between 2008 and 2013 were identified from our institution's surgery database and were included if they had MRI/sMRCP within a year before surgery. Histology was obtained from resected pancreas at the time of TPIAT by wedge biopsy of head, body, and tail, and was graded by a gastrointestinal pathologist who was blinded to the imaging features. A fibrosis score (FS) of 2 or more was considered as abnormal, with FS ≥6 as severe fibrosis. A multivariate regression analysis was performed for MRI features predicting fibrosis, after taking age, sex, smoking, alcohol, and body mass index (BMI) into consideration. A quantitative receiver operating characteristic (ROC) curve analysis was performed and Spearman rank correlation coefficient (r) was calculated. RESULTS: Fifty-seven patients (females=49, males=8) with NCCP and MRI/sMRCP were identified. ROC curve analysis showed that two or more MRI/sMRCP features provided the best balance of sensitivity (65%), specificity (89%), and accuracy (68%) to differentiate abnormal (FS≥2) from normal pancreatic tissue. Two or more features provided the best cutoff (sensitivity 88%, specificity 78%) for predicting severe fibrosis (FS≥6). There was a significant correlation between the number of features and severity of fibrosis (r=0.6, P<0.0001). A linear regression after taking age, smoking, and BMI into consideration showed that main pancreatic duct irregularity, T1-weighted signal intensity ratio between pancreas and paraspinal muscle, and duodenal filling after secretin injection to be significant independent predictors of fibrosis. CONCLUSIONS: A strong correlation exists between MRI/sMRCP findings and histopathology of NCCP.

Endoscopic interventions for necrotizing pancreatitis.

Interventions for necrotizing pancreatitis have undergone a paradigm shift away from open surgical necrosectomy and toward minimally invasive techniques, with endoscopic transmural drainage (ETD) and necrosectomy emerging as principle forms of treatment. Recent multicenter studies, randomized trials, evidence-based guidelines, and consensus statements have endorsed the safety and efficacy of endoscopic and other minimally invasive techniques for the treatment of walled-off necrosis. A comprehensive review of indications, standard and novel approaches, outcomes, complications, and controversies regarding ETD and necrosectomy is presented. Given the inherent challenges and associated risks, endoscopic techniques for the management of necrotizing pancreatitis should be performed at specialized multidisciplinary centers by expert endoscopists well versed in the management of necrotizing pancreatitis.

Endoscopic necrosectomy in children.

Acute pancreatitis in children is rarely complicated by the development of necrosis. Although endoscopic transluminal necrosectomy is evolving as the standard of care in adults, its feasibility in the pediatric population has not been established. We hereby report the first case series of children with necrotizing pancreatitis successfully treated with endoscopic therapy. We believe the use of fully covered self-expanding metallic stents in the cystgastrostomy may reduce the number of transluminal necrosectomy sessions for large necrotic collections in children.

Endoscopic transluminal drainage and necrosectomy by using a novel, through-the-scope, fully covered, large-bore esophageal metal stent: preliminary experience in 10 patients.

BACKGROUND: Interventions for necrotizing pancreatitis have undergone a recent paradigm shift toward minimally invasive techniques, including endoscopic transluminal necrosectomy (ETN). The optimal stent for endoscopic transmural drainage remains unsettled. OBJECTIVE: To evaluate a novel large-bore, fully covered metal through-the-scope (TTS) esophageal stent for cystenterostomy in large walled-off necrosis (WON). DESIGN: Retrospective case series. SETTING: Single tertiary care academic center. PATIENTS: Ten patients with large (>10 cm) WON collections who underwent endoscopic transmural drainage and ETN. INTERVENTION: Initial cystenterostomy was performed by using EUS, and in the same session, a TTS (18 × 60 mm), fully covered esophageal stent was placed to create a wide-bore fistula into the cavity. In 1 or more later sessions, the stent was removed, and ETN was performed as needed. MAIN OUTCOME MEASUREMENTS: Technical and clinical success rates and adverse events. RESULTS: The TTS stent was successfully deployed at the initial cystogastrostomy in all 10 patients. All patients had large WON (median size 17 cm, range 11-30 cm) and underwent intervention at a median of 30 days (range 12-117 days) after onset of acute pancreatitis. Resolution of WON was achieved in 9 of the 10 patients (90%) after a median of 3 endoscopic sessions. There were no early adverse events. Late adverse events occurred in 3 patients (30%); worsening of infection from stent migration and occlusion of cystogastrostomy (2 patients), and fatal pseudoaneurysmal bleeding from erosion of infected necrosis into a major artery distant from the stent (1 patient). The stent was easily removed in all the cases after resolution or improvement of the necrotic cavity. LIMITATIONS: Retrospective, single-center evaluation of a small number of cases. No comparative arm to determine the relative efficacy or cost-effectiveness of these stents compared with conventional plastic stents. CONCLUSIONS: Endoscopic therapy using a large-bore TTS, fully covered esophageal stent is feasible for use in the treatment of large WON. Further studies are needed to validate these findings.