Endoscopic Transmural Necrosectomy: Timing, Indications, and Methods

Abstract

Walled-off necrosis is considered one of the most severe complications after an episode of severe acute pancreatitis. Traditionally, percutaneous drainage is selected as the first treatment step, while open surgery can be planned as a secondary option if necrosectomy is required. In recent years, endoscopic necrosectomy has evolved as a more favorable approach. To date, a step-up treatment strategy is recommended, particularly when a plastic stent is selected as the drainage device. Multi-gateway endoscopic therapy may be used in a step-up fashion if only one stent fails to clear debris. Over many years, there has been an evolution in stent selection, from plastic to metallic stents. Within a few years of its clinical usage, lumen-apposing stents are gaining more popularity as they offer direct endoscopic necrosectomy and only require a few sessions.

Management of pancreatic fluid collections

“…DEN is mechanical debridement performed by passing an endoscope directly into the cavity to facilitate the removal of necrotic debris. DEN may be necessary in collections with large amounts of solid debris and in those that fail drainage with stent placement alone (55). A "step up approach" can be utilized in that DEN is performed only after standard drainage with stents alone or after adjunctive irrigation techniques fail to completely resolve the necrotic collection (56) (57).…”

“…When first described, a combination of nasocystic irrigation and placement of double pigtail placement stents was used. Now with the advent of LAMS, this technique is not as frequently utilized but MTGT could be considered if LAMS with DEN fails (55).…”

GRUPUGE Perspective: Endoscopic Ultrasound-Guided Drainage of Peripancreatic Collections

“…This modality consists of the creation of 2–3 fistulous tracts (rather than a single one) between the WON and the gastric or duodenal lumen in order to facilitate better drainage of necrotic material and fluid [41]. One tract may serve for irrigation through a nasocystic tube and the others for drainage through deployed stents [6, 41].…”

“…This modality consists of the creation of 2–3 fistulous tracts (rather than a single one) between the WON and the gastric or duodenal lumen in order to facilitate better drainage of necrotic material and fluid [41]. One tract may serve for irrigation through a nasocystic tube and the others for drainage through deployed stents [6, 41]. The multiple transluminal gateway technique can be considered for patients with multiple or large (>12-cm) WON, with a suboptimal response to single transluminal gateway drainage, or when the position of first access hampers the introduction of the endoscope into the cavity for necrosectomy [9].…”

“…Again, no criteria for WON resolution have been defined, but some have been proposed: more than 40% necrotic tissue disappearance within 1 month; the combination of clinical response with complete resolution of fluid collection on CT scans; the combination of granulation pink tissue in almost all walls of the cavity with significant cavity reduction on CT scans; or the combination of clinical response with pink granulation tissue on the cavity wall [41].…”