inShare Direct endoscopic necrosectomy: a minimally invasive endoscopic technique for the treatment of infected walled-off pancreatic necrosis and infected pseudocysts with solid debris

Kwek, Andrew; Tan, Siong San; Ibrahim, Salleh; Fock, Kwong Ming; Teo, Eng Kiong

doi:10.11622/smedj.2013074

Cited by 21 publications

(18 citation statements)

References 31 publications

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“…There is no clarity in literature about the patients selected for this intervention. Current literature suggests that DEN is a less invasive and less risky alternative to open surgical necrosectomy for managing infected WON and infected pseudocyst with solid debris[ 31 ]. Two randomized trials have resulted in a high success rate at the beginning[ 32 , 33 ].…”

Section: Discussionmentioning

confidence: 99%

Mortality and morbidity in necrotizing pancreatitis managed on principles of step-up approach: 7 years experience from a single surgical unit

Aparna¹,

Kumar²,

Kamalkumar³

2017

WJGS

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AIMTo determine percentage of patients of necrotizing pancreatitis (NP) requiring intervention and the types of interventions performed. Outcomes of patients of step up necrosectomy to those of direct necrosectomy were compared. Operative mortality, overall mortality, morbidity and overall length of stay were determined.METHODSAfter institutional ethics committee clearance and waiver of consent, records of patients of pancreatitis were reviewed. After excluding patients as per criteria, epidemiologic and clinical data of patients of NP was noted. Treatment protocol was reviewed. Data of patients in whom step-up approach was used was compared to those in whom it was not used.RESULTSA total of 41 interventions were required in 39% patients. About 60% interventions targeted the pancreatic necrosis while the rest were required to deal with the complications of the necrosis. Image guided percutaneous catheter drainage was done in 9 patients for infected necrosis all of whom required further necrosectomy and in 3 patients with sterile necrosis. Direct retroperitoneal or anterior necrosectomy was performed in 15 patients. The average time to first intervention was 19.6 d in the non step-up group (range 11-36) vs 18.22 d in the Step-up group (range 13-25). The average hospital stay in non step-up group was 33.3 d vs 38 d in step up group. The mortality in the step-up group was 0% (0/9) vs 13% (2/15) in the non step up group. Overall mortality was 10.3% while post-operative mortality was 8.3%. Average hospital stay was 22.25 d.CONCLUSIONEarly conservative management plays an important role in management of NP. In patients who require intervention, the approach used and the timing of intervention should be based upon the clinical condition and local expertise available. Delaying intervention and use of minimal invasive means when intervention is necessary is desirable. The step-up approach should be used whenever possible. Even when the classical retroperitoneal catheter drainage is not feasible, there should be an attempt to follow principles of step-up technique to buy time. The outcome of patients in the step-up group compared to the non step-up group is comparable in our series. Interventions for bowel diversion, bypass and hemorrhage control should be done at the appropriate times.

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Section: Discussionmentioning

confidence: 99%

Mortality and morbidity in necrotizing pancreatitis managed on principles of step-up approach: 7 years experience from a single surgical unit

Aparna¹,

Kumar²,

Kamalkumar³

2017

WJGS

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“…41,46,50,53,57,58,61,72,73 Data on complications were collected retrospectively. Finally, we analyzed a total of 37 articles 7,[15][16][17]19,23,28,29,31,[42][43][44][45]48,49,51,52,[54][55][56]59,60,[62][63][64][65][66][67][68][69][70][71]74,75,[78][79][80] and 633 patients after excluding unclear data on complication rates. The rates of morbidity and mortality associated with endoscopic necrosectomy were 27.3% (173/633) and 4.4% (28/633), respectively.…”

Section: Complications Of Endoscopic Necrosectomymentioning

confidence: 99%

“…We reviewed 38 published articles that reported treatment success, and a total of 697 patients treated with endoscopic necrosectomy were analyzed. 7,[15][16][17]19,23,28,29,31,36,42,43,45,[47][48][49]51,52,[54][55][56]59,60,[63][64][65][66][67][68][69][70][71][74][75][76][77][78][79] When we define the resolution of the WON cavity as "treatment success," the success rate was 82.6% (576/697). In addition, the recurrence rate after endoscopic necrosectomy was retrospectively studied.…”

Section: Complications Of Endoscopic Necrosectomymentioning

confidence: 99%

Asian consensus statements on endoscopic management of walled‐off necrosis. Part 2: Endoscopic management

Isayama

Nakai

Rerknimitr

et al. 2016

J of Gastro and Hepatol

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Walled‐off necrosis (WON) is a new term for encapsulated necrotic tissue after severe acute pancreatitis. Various terminologies such as pseudocyst, necroma, pancreatic abscess, and infected necrosis were previously used in the literature, resulting in confusion. The current and past terminologies must be reconciled to meaningfully interpret past data. Recently, endoscopic necrosectomy was introduced as a treatment option and is now preferred over surgical necrosectomy when the expertise is available. However, high‐quality evidence is still lacking, and there is no standard management strategy for WON. The consensus meeting aimed to clarify the diagnostic criteria for WON and the role of endoscopic interventions in its management. In the Consensus Conference, 27 experts from eight Asian countries took an active role and examined key clinical aspects of WON diagnosis and endoscopic management. Statements were crafted based on literature review and expert opinion, employing the modified Delphi method. All statements were substantiated by the level of evidence and the strength of the recommendation. We created 27 consensus statements for WON diagnosis and management, including details of endoscopic procedures. When there was not enough solid evidence to support the statements, this was clearly acknowledged to facilitate future research. Proposed management strategies were formulated and are illustrated using flow charts. These recommendations, which are based on the best current scientific evidence and expert opinion, will be useful for guiding endoscopic management of WON. Part 2 of this statement focused on the endoscopic management of WON.

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“…This is in keeping with other studies which show a low complication rate with DEN in addition to a high clinical and technical success rate. 37…”

Section: Clinical Outcomementioning

confidence: 99%

Is endoscopic necrosectomy the way to go?

2016

Int J Gastrointest Interv

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Pancreatic necrosis with the formation of walled-off collections is a known complication of severe acute pancreatitis. Infected necrotic pancreatic collections are associated with a high mortality rate. Open necrosectomy and debridement with closed drainage has traditionally been the gold standard for treatment of infected pancreatic necrosis, but carries a high risk of perioperative complications. Direct endoscopic necrosectomy has emerged as a safe and effective modality of treatment for this condition. Careful patient selection and gentle meticulous debridement is important to optimize clinical success. Bleeding is the commonest associated complication with the procedure but most cases can be managed conservatively. Air embolism, although rare, is potentially fatal. The use of fully covered large diameter lumen apposing self-expandable metal stents has further simplified the procedure. These stents optimize drainage, and facilitate endoscopic necrosectomy because repeat insertion of the endoscope into the necrotic cavity can be easily achieved.

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inShare Direct endoscopic necrosectomy: a minimally invasive endoscopic technique for the treatment of infected walled-off pancreatic necrosis and infected pseudocysts with solid debris

Cited by 21 publications

References 31 publications

Mortality and morbidity in necrotizing pancreatitis managed on principles of step-up approach: 7 years experience from a single surgical unit

Mortality and morbidity in necrotizing pancreatitis managed on principles of step-up approach: 7 years experience from a single surgical unit

Asian consensus statements on endoscopic management of walled‐off necrosis. Part 2: Endoscopic management

Is endoscopic necrosectomy the way to go?

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