Early endoscopic treatment of symptomatic pancreatic necrotic collections

Abstract

EUS-guided transmural endoscopic drainage is commonly used in the treatment of WOPN in the late phase of ANP. The role of endoscopic intervention remains unclear in the early phase of ANP. This study aimed to prospectively evaluate early endoscopic treatment of ANCs compared with endoscopic drainage of WOPN. Overall, 71 patients with ANP who underwent transmural endoscopic drainage for necrotic collections were included. Endoscopic intervention was performed within the first four weeks of ANP in 25 (35.21%) patients with ANC (Group 1) and in 46 (64.79%) patients after four weeks since the onset of ANP with WOPN (Group 2). The overall mean age of patients was 49.9 (22–79) years and 59 of them were males. The mean time of active drainage and duration of total endoscopic treatment was 26.8 and 16.9 days (P = 0.0001) and 270.8 and 164.2 days (P = 0.0001) in Groups 1 and 2, respectively. The average total number of endoscopic interventions was 9.5 and 4.5 in Groups 1 and 2, respectively (P = 0.0001). The clinical success rate, frequency of complications of endoscopic interventions, long-term success rate, and recurrence rate were not significantly different between the groups (P > 0.05 for each). Transmural endoscopic drainage is effective method of treatment of early ANCs within the first four weeks of ANP. However, compared with endoscopic intervention in WOPN, more interventions and longer duration of drainage are required.

Early versus delayed interventions for necrotizing pancreatitis: A systematic review and meta‐analysis

“…25,26,28 Patients in the early intervention group were likely to have more organ failure 25,27,35 as well as less encapsulation 28,29 and larger collections. 28,29,[32][33][34] The summary of pooled ORs according to the treatment approach is shown in Table 4. Based on eight studies, 25,[27][28][29][32][33][34][35] the rate of adverse events was comparable, with a pooled OR of 1.41 (95% CI 0.66-3.01; p = 0.38; Figure 2) for early interventions compared to delayed interventions, though the data were heterogeneous between the studies (p heterogeneity < 0.01 and I 2 = 82%).…”

Percutaneous Endoscopic Necrosectomy—A Review of the Literature

“…Since the first reports on the dual-modality drainage technique [56], the methods for endoscopic and percutaneous treatment of pancreatic necrosis have evolved toward a more aggressive [1][2][3][4][5][6][7][8][9][10][11][12][13][14]16,[19][20][21][22][23][24][25][26][27][28][29][30][31][32][33][34][35]35,36,[38][39][40][41]59], necrosectomy-based approach, which is also reflected in the aforementioned PEN approach, as well as in the multiple-access strategy in which PEN is combined with transmural endoscopic access techniques [37,[42][43][44][45][46][47][48][49]…”

“…Since the first reports on the dual-modality drainage technique [ 56 ], the methods for endoscopic and percutaneous treatment of pancreatic necrosis have evolved toward a more aggressive [ 1 , 2 , 3 , 4 , 5 , 6 , 7 , 8 , 9 , 10 , 11 , 12 , 13 , 14 , 16 , 19 , 20 , 21 , 22 , 23 , 24 , 25 , 26 , 27 , 28 , 29 , 30 , 31 , 32 , 33 , 34 , 35 , 35 , 36 , 38 , 39 , 40 , 41 , 59 ], necrosectomy-based approach, which is also reflected in the aforementioned PEN approach, as well as in the multiple-access strategy in which PEN is combined with transmural endoscopic access techniques [ 37 , 42 , 43 , 44 , 45 , 46 , 47 , 48 , 49 , 50 , 51 , 52 , 53 , 54 , 55 ]. In more than one-third of patients who underwent PEN, percutaneous access was combined ...…”

“…Percutaneous drainage consists of the insertion of a drainage tube (10)(11)(12)(13)(14)(15)(16)(17)(18)(19)(20)(21)(22)(23)(24)(25)(26)(27)(28) into the necrotic collection from a transperitoneal or retroperitoneal access, under ultrasound or computed tomography guidance, with the flushing of the necrotic cavity using physiological saline at intervals of approximately 8 h [12][13][14]. Retroperitoneal access to the necrotic collection is preferred [14].…”

“…The main limitation of endoscopic techniques that utilize transmural access in the treatment of pancreatic necrosis is the distance between the gastrointestinal lumen and the necrotic collection, which should not exceed 40 mm, as visualized on endosonographic scans [ 6 , 7 , 8 ]. If the distance is longer than 40 mm, it is technically impossible to access the necrotic collection through the transmural route [ 6 , 7 , 8 , 9 , 10 ]. In these cases, the surgical step-up approach involving percutaneous drainage from the retroperitoneal access remains the treatment of choice [ 3 , 4 , 5 , 11 ].…”