Management of Infected and Sterile Pancreatic Necrosis by Programmed Endoscopic Necrosectomy

Abstract

Introduction: Necrosectomy is the gold standard treatment for infected pancreatic necrosis (IPN). A percutaneous and endoscopic approach has been accepted in selected cases. Endoscopic drainage (ED) of IPN can be performed by using transpapillary or transmural procedures, or a combination of both with or without endoscopic ultrasound. Aims: The aim of this study was to determine the indications, complications, success rate, and the importance of assessment of main pancreatic duct integrity by endoscopic retrograde pancreatography (ERP) in patients with IPN. Methods: Records of all patients who underwent endoscopic necrosectomy from January 2002 to December 2007 at Rio de Janeiro Federal University Hospital were reviewed. A total of 56 patients were included. ED was performed using daily transmural and transpapillary drainage. A diagnostic pancreatogram (ERP) to search for communications between the pancreatic duct and the collection were performed in all cases and in cases where communication existed. A pre-cut needle knife was used to puncture the cyst wall, aspirate the content and then enter at the cyst cavity (contrast was injected to ensure opacification of the cyst and subsequent drainage). Sphincterotomy catheter or balloons were used to enlarge and ensure a wide cystoenterostomy. All patients were followed with computerized tomography scans or ultrasound to ensure clinical resolution. Mean follow-up was 21 months. Results: 49/56 patients could be successfully treated. ED was successful in 49 patients (87%) and in 3 (13%) it failed. Mean follow-up was 21 months. During this period, there were 2 (10.5%) pseudocyst recurrences and only 1 (5.2%) recurrence of new episodes of pancreatic necrosis, and all were managed clinically and/or endoscopically. No mortality was related to the procedure. Conclusion: ED with daily necrosectomy is a useful method to remove infected and sterile pancreatic necrosis.

Combined endoscopic and percutaneous drainage of organized pancreatic necrosis

“…Aside from drain manipulation, endoscopy subsequent to initial drainage was performed for ERCP, feeding tube placement, or manipulation, as well as for the investigation of GI bleeding. Patients underwent a median of 8 CT scans (range, [6][7][8][9][10][11][12][13][14][15][16][17][18][19] and 5 percutaneous drain manipulations (range, [3][4][5][6][7][8][9][10][11][12][13] subsequent to the initial drainage (Table 1).…”

Endoscopic ultrasound-guided endoscopic necrosectomy of the pancreas: is irrigation necessary?

“…Endoscopic necrosectomy has been established as a treatment method for symptomatic pancreatic necroses [4][5][6][7][8][9][10][11][12][13][14]. However, it was presumed, that subsequent repeat endoscopic irrigation or external nasocystic or percutaneous drainages were necessary ( Table 1).…”

“…In 2000, Seifert et al [4] introduced an alternative endoscopic method using transgastric access and debridement of the necrotic material in three patients. Subsequently, endoscopic necrosectomy using endoscopic ultrasound guidance (EUS-G) was performed in single-center series of up to 54 patients [5][6][7][8][9][10][11][12][13]. Compared with surgery, EUS-G was associated with a relatively low complication rate and a significantly lower mortality rate.…”

Acute and Chronic Pancreatitis — Complications

“…The important point is that the therapeutic principles can be attained through careful assessment and actions by professionals with experienced of the various types of treatment available. [14,15] …”