Efficacy of Conservative Treatment, Without Necrosectomy, for Infected Pancreatic Necrosis: A Systematic Review and Meta-analysis

�Step Up� Approach in the Management of Pancreatic Necrosis. Is it A Step in the Right Direction?

“…Off late, several studies on the step up approach in the management of infected pancreatic necrosis have been reported [4][5][6][7][8][9][10][11][12][13][14][15][16][17][18][19][20]. The enthusiasm in the step up management was raised by the results of the Dutch multicenter-randomized trial (PANTER) in patients with infected pancreatic necrosis who were either subjected to step up approach or open necrosectomy [4].…”

“…Minimally invasive necrosectomy is performed by different techniques. This could involve endoscopic transluminal necrosectomy (ETN) [17][18][19][20], or percutaneous minimally invasive retroperitoneal necrosectomy using scopes (nephroscope or laparoscope) [4,6,9].…”

“…Endoscopic transluminal necroscetomy is appealing as it is the least invasive of all the minimal invasive approaches [17][18][19][20]. The infected walled off pancreatic necrotic tissue is accessed transluminally, usually puncturing the stomach wall or duodenal wall.…”

“…The infected walled off pancreatic necrotic tissue is accessed transluminally, usually puncturing the stomach wall or duodenal wall. Under direct vision or endoscopic ultrasound guidance, the gastric wall is punctured to reach the walled off necrosis [17][18][19][20]. The transluminal tract is dilated sequentially using a balloon.…”

“…In order to avoid additional interventions, multiple transluminal gateways have been suggested to improve drainage of infected material and in a small cohort of selected patients, success has been achieved in 90% of these patients [25]. Patients in whom endoscopic drainage proves insufficient, may benefit from endoscopic necrosectomy [8,17,19]. The necrotic material is removed using various instruments including endoscopic baskets, snares, jet irrigation and forceps [8,17,20].…”