Endoscopic Pancreatic Necrosectomy

Abstract

Traditionally, patients with symptomatic sterile pancreatic necrosis or infected necrosis have been managed by open surgical debridement and removal of necrotic tissue. Within the last decade, however, reports of endoscopic pancreatic necrosectomy, an alternative minimally invasive approach, have demonstrated high success rates and low mortality rates. This report describes the indications, technique, and study outcome data of the procedure. While our experience with this technique has recently increased, better selection criteria are needed to identify patients who are most suitable for endoscopic therapy.

Endoscopic ultrasonography‐guided transmural drainage of walled‐off pancreatic necrosis: Comparison between a specially designed fully covered bi‐flanged metal stent and multiple plastic stents

“…Endoscopic ultrasonography‐guided transmural drainage for PFC including WON has shown comparable outcomes to surgical or laparoscopic drainage . MPS have been the traditional choice, but drainage is often suboptimal in WON because of small‐diameter stents . Conventional self‐expandable metal stents (biliary or esophageal) have been used with some success but have shown significant adverse events .…”

“…Although MPS placement is adequate for PPC drainage with clear contents, WON often requires aggressive drainage using large balloon tract dilation and one or more sessions of direct endoscopic necrosectomy (DEN). Outcomes are suboptimal, despite aggressive measures, possibly as a result of poor‐quality drainage provided by small‐caliber MPS . Repeat DEN sessions necessitate repeated tract dilation with increased risk of hemorrhage, intraperitoneal leak and/or infection …”

“…Outcomes are suboptimal, despite aggressive measures, possibly as a result of poorquality drainage provided by small-caliber MPS. 3,[6][7][8][9][10] Repeat DEN sessions necessitate repeated tract dilation with increased risk of hemorrhage, intraperitoneal leak and/or infection. 6,7,9,10 A specially designed removable BFMS (Nagi stent ™ ; Taewoong Medical Co. Ltd, Gyeonggi-do, South Korea) has been recently described for PFC drainage.…”

Acute Pancreatitis

“…There is an increasing strong evidence that endoscopic drainage and necrosectomy using a transgastric or transduodenal approach ensures good results, but these data still require validation [61,[67][68][69][70] (LE3). Endoscopic necrosectomy is a form of natural orifice trans-luminal endoscopic surgery (NOTES) and is theoretically the less invasive intervention: it can be performed under conscious sedation without the need for general anesthesia and it can be repeated, but it can only be used when stomach or duodenum is apposed to the area of necrosis, while retroperitoneoscopic approach is effective to access fluid collections close to the lateral abdominal wall, usually in the pancreatic tail or the left paracolic gutter and less frequently for fluid collections of the right paracolic gutter [62] (LE3).…”

Necrotizing Pancreatitis: Update and When to Operate

“…As previously described, at least five alternative modalities have been established: percutaneous debridement, which involves the assistance of imaging methods and allows a limited instrumentation of the pancreatic tissue; "traditional" endoscopic approach through the trans-gastric or trans-duodenal route, which carries the advantage of being less invasive, but has very limited indications, such as liquefied collections located at very favorable sites [60]; Natural Orifice Surgery (NOTES), using the trans-gastric route, which involves a greater incision on the posterior wall of the stomach, allowing a wider debridement of the pancreatic tissue than the one provided by the earlier endoscopic approaches [61]; laparoscopic debridement, clearly efficacious for necrosis located at sites such as para-colic gutter and the omental bursa, but only applicable in situations in which the patient is stable enough to tolerate the pneumoperitoneum [46]; and finally, retroperitoneal technique, which allows a wide access to areas not contemplated by the other techniques described above, but has the disadvantage of being more invasive [62]. These techniques are being increasingly used by many centers, which now reserve the most traditional surgical approach, that is, through laparotomy, for the cases in which these techniques fail or do not apply [5].…”