Endotherapy for pancreatic necrosis: An update

Abstract

Approximately 20% of patients with acute pancreatitis develop pancreatic necrosis. The presence of necrosis in a pancreatic collection significantly worsens the prognosis. Pancreatic necrosis is associated with high mortality and morbidity. In the last few decades, there has been a significant revolution in the treatment of infected pancreatic necrosis. A step‐up approach has been proposed, from less invasive procedures to the operative intervention. Minimally invasive treatment modalities such as endoscopic drainage and necrosectomy, percutaneous drainage, and minimally invasive surgery have recently replaced open surgical necrosectomy as the first‐line treatment option. Endoscopic intervention for pancreatic necrosis is being increasingly performed with good success and a lower complication rate. However, techniques of endotherapy are still not uniform and vary as per local expertise, and there are still many unresolved questions with regard to the interventions in patients with pancreatic necrosis. The objective of this paper is to critically review the literature and update the concepts of endoscopic interventional therapy of pancreatic necrosis.

Open necrosectomy is feasible as a last resort in selected cases with infected pancreatic necrosis: a case series and systematic literature review

“…Infection of such pancreatic fluid or necrotic collection is an unusual circumstance reported in literature, occurring in approximately 30% of patients with necrotizing pancreatitis but is related to a high mortality rate (20%) [8][9][10][11][12][13][14]. The common clinical manifestations of IPN are persistent fever, abdominal discomfort, or back pain accompanied to early satiety, anorexia, weight loss, abdominal distention, vomiting, or worsening reflux due to partial or complete gastric or duodenal outlet obstruction [46,47]. The presence of a systemic inflammatory response syndrome, with modification of inflammatory markers (elevation of C-reactive protein, progressive leucocytosis or positive blood cultures) and the onset of clinical deterioration in a stable patient on adequate support, with new or prolonged organ failure, are suggestive for IPN in 80% of cases [46,47].…”

“…The common clinical manifestations of IPN are persistent fever, abdominal discomfort, or back pain accompanied to early satiety, anorexia, weight loss, abdominal distention, vomiting, or worsening reflux due to partial or complete gastric or duodenal outlet obstruction [46,47]. The presence of a systemic inflammatory response syndrome, with modification of inflammatory markers (elevation of C-reactive protein, progressive leucocytosis or positive blood cultures) and the onset of clinical deterioration in a stable patient on adequate support, with new or prolonged organ failure, are suggestive for IPN in 80% of cases [46,47]. Jaundice may also occur secondary to biliary obstruction while symptoms related to hemorrhage into WON and gastroduodenal and/or splenic arterial erosions are more critic with hemodynamic instability.…”

The over-the-scope grasper (OTSG)

“…of them has been designed for such an indication [3][4][5][6]. The limitations of a snare are that, in soft tissue, the snare often cuts through the tissue instead of grabbing it.…”

Surgical Management of Necrotizing Pancreatitis

“…[21] On average, 3-6 endoscopic interventions are necessary prior to resolution of necrosis. [22] DEN was first compared to surgical necrosectomy in the Pancreatitis, Endoscopic Transgastric vs. Primary Necrosectomy in Patients with Infected Necrosis (PENQUIN) Trial. In this trial, patients in the surgery group underwent a number of different operations, including 6 video-assisted retroperitoneal debridement (VARD) surgeries, 4 open necrosectomies, and 2 percutaneous drainage placements without need for more invasive therapy.…”