Endoscopic step up: When and how

Endoscopic treatment of pancreatic necrosis: Still searching for perfection!

“…The endoscopic step-up approach includes the initial step of ETD by either plastic or metal stents followed, if necessary, by the next step of ETN in patients not responding to drainage alone and finally stepping up to surgical necrosectomy in patients failing to endoscopic therapy or developing complications. 7 Studies have shown that 30-75% patients with pancreatic necrotic collections respond to ETD alone and do not require ETN. 14,15 This is because of the heterogenous nature of the PFC's with predominantly liquefied collections responding to drainage with LAMS alone and collections with significant solid necrotic content requiring stepping up of therapy form drainage alone to ETN.…”

“…The endoscopic step‐up approach includes the initial step of ETD by either plastic or metal stents followed, if necessary, by the next step of ETN in patients not responding to drainage alone and finally stepping up to surgical necrosectomy in patients failing to endoscopic therapy or developing complications 7 . Studies have shown that 30–75% patients with pancreatic necrotic collections respond to ETD alone and do not require ETN 14,15 .…”

“…5,6 The "step-up" approach is a staged management approach that involves either an endoscopic transluminal drainage (ETD) or image-guided percutaneous drainage (PCD) as the initial intervention step based on the location of the necrosis and the availability of expertise followed by, if required, to "stepping up" to additional and more aggressive interventions including endoscopic transluminal necrosectomy (ETN) or minimally invasive surgical necrosectomy. 7 Studies including randomized controlled trials (RCTs) as well as systematic reviews/meta-analysis comparing the two minimally invasive management options have reported that endoscopic "stepup" management approach is associated with reduced occurrence of new onset multi-organ failure as well as external pancreatic fistulae along with shorter hospital stay, lower costs, and better quality of life compared with minimally invasive surgical approach. [8][9][10] Superiority of endoscopic "step-up" approach has resulted in experts/guidelines recommending it to be preferred intervention for management of endoscopically accessible pancreatic necrotic collections at expert centers with endoscopic expertise with minimally invasive surgical interventions reserved for collections that are not accessible endoscopically or when endoscopic expertise is unavailable or has failed.…”

“…The results of PANTER trial laid the foundation for the current “step‐up” management approach for NP 5,6 . The “step‐up” approach is a staged management approach that involves either an endoscopic transluminal drainage (ETD) or image‐guided percutaneous drainage (PCD) as the initial intervention step based on the location of the necrosis and the availability of expertise followed by, if required, to “stepping up” to additional and more aggressive interventions including endoscopic transluminal necrosectomy (ETN) or minimally invasive surgical necrosectomy 7 …”

Risk Factors for Bleeding during Endoscopic Necrosectomy: Are We Wiser Now?

“…Over the last decade, there has been a paradigm shift in the management of infected/symptomatic pancreatic necrosis with endoscopic and minimally invasive "step up" management approach like endoscopic necrosectomy (EN) or video-assisted retroperitoneal debridement replacing open surgical necrosectomy. [1][2][3] Despite advances in EN including the development of larger diameter lumen apposing metal stents (LAMS), bleeding continues to be a common and serious adverse event noted with EN. 4,5 Use of adjunct techniques for EN like hydrogen peroxide as well as streptokinase irrigation has also been associated with increased risk of bleeding.…”