Endoscopic management of walled‐off pancreatic necrosis

Abstract

Walled‐off pancreatic necrosis (WON) can develop in the late phase of necrotizing pancreatitis. When the WON is accompanied by an infection in the necrotic bed, it becomes a life‐threatening complication. Open necrosectomy with drainage has been the standard treatment; however, it is associated with a significant morbidity and high mortality. Therefore, minimally invasive therapeutic alternatives are in demand. Recently, a new treatment algorithm for necrotizing pancreatitis, known as the step‐up approach, has been proposed. The initial report on it consisted of percutaneous drainage followed by, if necessary, a minimally invasive retroperitoneal necrosectomy. However, the endoscopic step‐up approach, which consists of EUS‐guided transluminal drainage followed by, if necessary, endoscopic necrosectomy, was later introduced. Recent studies have suggested that an endoscopic step‐up approach might be more advantageous than a minimally invasive surgical step‐up approach. A lumen apposing metal stent (LAMS) with a cautery‐enhanced delivery system is currently preferred over the conventional plastic stents for endoscopic interventions, because it decreases the technical difficulty of the procedure and may obviate the need for an adjunctive debridement procedure. However, some recent findings suggest that LAMS could be associated with a higher risk of stent‐related complications than conventional plastic stents, especially in patients with long‐term placement. Therefore, early removal of LAMS at 3 weeks post‐intervention is proposed if the WON is resolved on CT examination. Thus, endoscopic interventions have emerged as a key player in the management of WON. However, multidisciplinary treatment approaches should be considered because the endoscopic approach has limitations in treating complicated WON.

Multiple transluminal gateway technique with transplantation of lumen‐apposing metal stent for direct endoscopic necrosectomy in a patient with infected walled‐off pancreatic necrosis

“…Lumen‐apposing metal stent (LAMS) is the preferred treatment modality for direct endoscopic necrosectomy (DEN) of walled‐off pancreatic necrosis (WON), since LAMS allows maintaining a large opening for repeated endoscopic insertion 1 . We present a case of a 72‐year‐old man referred to our hospital for the management of infected WON.…”

Overtube‐assisted necrosectomy for a large walled‐off pancreatic necrosis using a short‐type single‐balloon enteroscope

“…2C, Video S1). 1 The treatment of a large WON may require multiple rounds of DEN 2 . This case suggests that overtube‐assisted DEN may be useful in removing more necrotic tissue in a single session, due to the large diameter of the suction and ease of repeated insertion of the endoscope.…”

New deployment techniques of the lumen‐apposing metal stent in walled‐off necrosis filled with necrotic tissue: Chick opening its mouth (with video)

“…The lumen‐apposing metal stent (LAMS), developed for its use in endoscopic ultrasound‐guided transluminal drainage (EUS‐TD), has been widely used for the treatment of walled‐off necrosis (WON), which occurs after acute necrotizing pancreatitis 1,2 . The LAMS is remarkably useful, as once it is placed, an endoscope can be easily inserted into the WON, and additional procedures, such as endoscopic necrosectomy, can be performed efficiently 3 .…”