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

Abstract

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.

Duration of antibiotic treatment after endoscopic ultrasound‐guided drainage of walled‐off pancreatic necrosis not affecting outcomes

“…These recommendations are primarily based on two retrospective studies showing post‐procedural infections to be very rare when a prophylactic antibiotic therapy was given . The same guidelines and the Asian consensus statements both suggest prophylactic antibiotic therapy for endoscopic drainage of WON, which is commonly performed with EUS guidance, yet evidence to support this is lacking …”

“…10,11 The same guidelines and the Asian consensus statements both suggest prophylactic antibiotic therapy for endoscopic drainage of WON, which is commonly performed with EUS guidance, yet evidence to support this is lacking. 3 Recent publications of endoscopic treatment of WON either do not elaborate on antibiotic use 12,13 or mention antibiotics were given pre-procedure and post-procedure without further detail. 14 In fact, in a large European study, the choice of prophylaxis was left to the discretion of the performing endoscopist.…”

“…Most recent Asian consensus guidelines for the treatment of WON state that prophylactic antibiotics should be given prior to endoscopic interventions; however, the appropriate type of antibiotic or duration for endoscopic treatment of WON has not been clearly outlined yet. 3 The 2015 American Society for Gastrointestinal Endoscopy guidelines for antibiotic prophylaxis for endoscopic procedures highlight that studies where peri-procedural antibiotics were administered followed by a short course of post-procedural antibiotic therapy, resulted in minimal post-procedural infections. 4 Therefore, antibiotic prophylaxis is considered standard of care both prior to and after endoscopic procedures to prevent post-drainage infections in WON.…”

Endoscopic ultrasonography‐guided drainage of pancreatic fluid collections

“…W HEN THERE IS a lack of clinical response to antibiotics and transmural drainage, additional DEN is indicated. 23,24 This is the so-called step-up approach. The concept and success of DEN was first reported in 2000 in three patients.…”

Endoscopic Transmural Necrosectomy: Timing, Indications, and Methods

“…Due to the aggressiveness of open surgery and risk of pancreatico-cutaneous fistula from the percutaneous approach (unless internal drainage or pancreatic duct bridging by an internal stent is provided), 2 these two techniques are not recommended as the first line in current practice. 3 Over the last decade, new minimally invasive techniques, including video-assisted retroperitoneal debridement (VARD) and endoscopic necrosectomy (EN), have emerged as more favorable approaches. In this review, we will mainly address EN and the selection of patients with WON for this procedure based on the appropriate timing and indications.…”