Endoscopic Necrosectomy Through Percutaneous Self-Expanding Metal Stents May Be a Promising Additive in Treatment of Necrotizing Pancreatitis

Thorsen, Andreas; Borch, Anders; Novovic, Srdan; Schmidt, Palle Nordblad; Gluud, Lise Lotte

doi:10.1007/s10620-018-5131-3

Cited by 24 publications

(39 citation statements)

References 31 publications

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“…We have performed such procedure in one patient. Intra-abdominal hypertension, which is relatively common in severe acute pancreatitis, may lead to abdominal ACS (33). ACS is a life-threatening event that has to be addressed to prevent deleterious effects (34).…”

Section: Discussionmentioning

confidence: 99%

Multidisciplinary Approach to Treating Severe Acute Pancreatitis in a Low‐Volume Hospital

Robin-Lersundi

et al. 2019

World j. surg.

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Acute pancreatitis is one of the most frequent reasons for hospital admittance due to bilio-pancreatic diseases (1-2). The main etiologies of acute pancreatitis are biliary and alcohol consumption although in other cases the origin of the disease is unknown (3). Most of the patients have an uneventful course but up to 25 % of all patients with acute pancreatitis develop severe complications and are classified as severe pancreatitis with an associated death rate up to 30-50% (2-4). Treatment of acute pancreatitis and in particular severe acute pancreatitis (SAP) has progressively evolved and improved. Probably one of the reasons for this improvement is the fact that step by step algorithms have been incorporated to the decision-making process (5-6). Similarly, a step-up approach has been proposed for pancreatic necrosis (7). In order to offer treatment in accordance to the severity of the disease, we need to obtain an accurate view of the expected evolution and prognosis. For that purpose, patients have to be stratified on the bases of standard classifications. One of the first classifications is the Ranson criteria that includes several laboratory and clinical data to obtain an estimated mortality (8-9). Radiological features observed on CT-scan that consider pancreatic necrosis and the appearance of the pancreas point out an estimated mortality rate (10). Simplified acute physiology score version 3 (SAPS 3) is a mathematical model that provides predicted mortality and is widely used in ICUs. It is a useful index for severely ill patients (11). The revised Atlanta classification of acute pancreatitis provides a graduation of two phases of the disease: early and late phases and severity is classified as mild, moderate or severe by using clinical and radiologic features (5-12). As mortality of severe pancreatitis is usually high, patients are expected to undergo long intensive care unit (ICU) and hospital stay. Beside medical treatment for single or multiple organ failure, various complications may require percutaneous, endoscopic or surgical procedures. In some circumstances, major complications have to be addressed in order to improve outcomes in terms of morbid-mortality. Although surgical procedures are unlikely, surgery is required for abdominal sepsis due to hollow viscera necrosis/perforation or persistent abdominal sepsis spite medical treatment and percutaneous procedures (13). Compartment abdominal syndrome is associated to high complication and mortality rates. Failure of aggressive medical and nonoperative treatment is expected to lead to surgery after multidisciplinary evaluation (6, 14, 15). Necrotizing pancreatitis with infected pancreatic necrosis is associated to high mortality rates. If a "Step-up" approach does not solve the pancreatic focus of sepsis by the means of percutaneous drainage among others, this approach may require to be completed by retroperitoneal access to pancreatic necrosis (6, 7). However early open access to the pancreatic necrosis has also been advocated (16). Considering tha...

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Section: Discussionmentioning

confidence: 99%

Multidisciplinary Approach to Treating Severe Acute Pancreatitis in a Low‐Volume Hospital

Robin-Lersundi

et al. 2019

World j. surg.

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“…Together with the need of multiple PEN sessions to achieve the complete debridement of necrotic tissue, these limitations flowed into the use of covered esophageal SEMS as firstly described in 2011 by Navarrete et al [ 5 ], allowing to easily achieve and maintain a stable access to the cavity. Several other case reports and studies [ 6 – 8 , 19 – 26 ] describing PEN through SEMS for the management of complex WOPN were published thereafter, summarized in Table 1 .…”

Section: From Sinus Tract Endoscopy To Sems-assisted Percutaneous Necrosectomy For the Treatment Of Wopn: A Literature Overviewmentioning

confidence: 99%

“…Although some differences regarding the definition of clinical success has emerged, the referred rates ranged from 65 to 89% [ 6 , 8 , 25 ]. The number of PEN sessions needed for WOPN resolution varied widely, from 1 to 7, and the mean time for stent removal ranged between 7 and 37 days (range 3–65) [ 5 – 8 , 19 – 26 ].…”

Section: From Sinus Tract Endoscopy To Sems-assisted Percutaneous Necrosectomy For the Treatment Of Wopn: A Literature Overviewmentioning

confidence: 99%

“…Indeed, no severe, procedure-related adverse events were observed, and the rate of pancreatic fistula was significantly lower compared to the surgical approach, as emerged in the TENSION trial [ 4 – 8 , 19 – 26 ]. However, this translates into a lengthening of hospitalization as emerged in Thorsen et al study [ 6 ]. Patients included in this series were discharged after a mean of 61 days after percutaneous SEMS removal, although the length of the hospital stay varied among patients and were strongly influenced by the several complications occurred (i.e., stomach and colon perforation after ETDN attempt, aspiration pneumonia, critical illness neuropathy etc.).…”

Section: From Sinus Tract Endoscopy To Sems-assisted Percutaneous Necrosectomy For the Treatment Of Wopn: A Literature Overviewmentioning

confidence: 99%

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EUS-guided drainage using lumen apposing metal stent and percutaneous endoscopic necrosectomy as dual approach for the management of complex walled-off necrosis: a case report and a review of the literature

et al. 2021

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Background Endoscopic ultrasound-guided drainage is suggested as the first approach in the management of symptomatic and complex walled-off pancreatic necrosis. Dual approach with percutaneous drainage could be the best choice when the necrosis is deep extended till the pelvic paracolic gutter; however, the available catheter could not be large enough to drain solid necrosis neither to perform necrosectomy, entailing a higher need for surgery. Therefore, percutaneous endoscopic necrosectomy through a large bore percutaneous self-expandable metal stent has been proposed. Case presentation In this study, we present the case of a 61-year-old man admitted to our hospital with a history of sepsis and persistent multiorgan failure secondary to walled-off pancreatic necrosis due to acute necrotizing pancreatitis. Firstly, the patient underwent transgastric endoscopic ultrasound-guided drainage using a lumen-apposing metal stent and three sessions of direct endoscopic necrosectomy. Because of recurrence of multiorgan failure and the presence of the necrosis deeper to the pelvic paracolic gutter at computed tomography scan, we decided to perform percutaneous endoscopic necrosectomy using an esophageal self-expandable metal stent. After four sessions of necrosectomy, the collection was resolved without complications. Therefore, we perform a revision of the literature, in order to provide the state-of-art on this technique. The available data are, to date, derived by case reports and case series, which showed high rates both of technical and clinical success. However, a not negligible rate of adverse events has been reported, mainly represented by fistulas and abdominal pain. Conclusion Dual approach, using lumen apposing metal stent and percutaneous self-expandable metal stent, is a compelling option of treatment for patients affected by symptomatic, complex walled-off pancreatic necrosis, allowing to directly remove large amounts of necrosis avoiding surgery. Percutaneous endoscopic necrosectomy seems a promising technique that could be part of the step-up-approach, before emergency surgery. However, to date, it should be reserved in referral centers, where a multidisciplinary team is disposable.

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“…Based on the results of relevant studies, the success rate of PEN was 67-93% and procedure-related complication rate was no more than 20%, [64][65][66][67][68][69][70][71][72][73][74][75] with minor complications such as bleeding and pancreatico-cutaneous fistulae. Because of the small operating space, even minor bleeding during PEN operation can be problematic and should be avoided as much as possible.…”

Section: Percutaneous Endoscopic Necrosectomymentioning

confidence: 99%

Endoscopic transmural drainage and necrosectomy in acute necrotizing pancreatitis: A review

Feng

Guo

Wang

et al. 2021

Journal of Translational Internal Medicine

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Acute necrotizing pancreatitis occurs in 10%–20% of patients with acute pancreatitis (AP) which is one of the most important acute abdominal diseases that require hospital admission. Pancreatic necrosis is also associated with high mortality and morbidity. In the past 20 years, the treatment of pancreatic necrosis has shifted from open necrosectomy to minimally invasive techniques, such as endoscopic interventions. With the development of endoscopic techniques, the safety and effectiveness of endoscopic interventions have improved, but there exist several unresolved problems. Currently, there is no unified standard approach for endoscopic treatment of pancreatic necrosis that takes into account local expertise, anatomical features of necrosis, patients’ preferences, and comorbidity profile. We reviewed the current status of endoscopic therapy for acute necrotizing pancreatitis, focusing on the new endoscopic drainage technique and necrosectomy protocol.

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Endoscopic Necrosectomy Through Percutaneous Self-Expanding Metal Stents May Be a Promising Additive in Treatment of Necrotizing Pancreatitis

Abstract: In our small case series, endoscopic necrosectomy through a percutaneous SEMS seemed beneficial and safe in the treatment of infected WON.

Cited by 24 publications

References 31 publications

Multidisciplinary Approach to Treating Severe Acute Pancreatitis in a Low‐Volume Hospital

Multidisciplinary Approach to Treating Severe Acute Pancreatitis in a Low‐Volume Hospital

EUS-guided drainage using lumen apposing metal stent and percutaneous endoscopic necrosectomy as dual approach for the management of complex walled-off necrosis: a case report and a review of the literature

Endoscopic transmural drainage and necrosectomy in acute necrotizing pancreatitis: A review

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