Percutaneous direct endoscopic pancreatic necrosectomy

Abstract

Approximately 10%-20% of the cases of acute pancreatitis have acute necrotizing pancreatitis. The infection of pancreatic necrosis is typically associated with a prolonged course and poor prognosis. The multidisciplinary, minimally invasive “step-up” approach is the cornerstone of the management of infected pancreatic necrosis (IPN). Endosonography-guided transmural drainage and debridement is the preferred and minimally invasive technique for those with IPN. However, it is technically not feasible in patients with early pancreatic/peripancreatic fluid collections (PFC) (< 2-4 wk) where the wall has not formed; in PFC in paracolic gutters/pelvis; or in walled off pancreatic necrosis (WOPN) distant from the stomach/duodenum. Percutaneous drainage of these infected PFC or WOPN provides rapid infection control and patient stabilization. In a subset of patients where sepsis persists and necrosectomy is needed, the sinus drain tract between WOPN and skin-established after percutaneous drainage or surgical necrosectomy drain, can be used for percutaneous direct endoscopic necrosectomy (PDEN). There have been technical advances in PDEN over the last two decades. An esophageal fully covered self-expandable metal stent, like the lumen-apposing metal stent used in transmural direct endoscopic necrosectomy, keeps the drainage tract patent and allows easy and multiple passes of the flexible endoscope while performing PDEN. There are several advantages to the PDEN procedure. In expert hands, PDEN appears to be an effective, safe, and minimally invasive adjunct to the management of IPN and may particularly be considered when a conventional drain is in situ by virtue of previous percutaneous or surgical intervention. In this current review, we summarize the indications, techniques, advantages, and disadvantages of PDEN. In addition, we describe two cases of PDEN in distinct clinical situations, followed by a review of the most recent literature.

Management of infected acute necrotizing pancreatitis

“…The necrotizing form represents approximately 10%-20% of patients with acute pancreatitis, with an overall mortality of up to 15%[ 3 , 4 ]. However, 30%-40% of patients with acute necrotizing pancreatitis (ANP) will develop debris infection through translocation of intestinal microbial flora.…”

“…The escalated step-by-step management consists of endoscopic management, interventional methods and surgical approaches. The timing of interventional application is still under debate[ 1 , 3 , 4 , 6 ]. However, early recognition and timely debridement are crucial.…”

“…Transgastric debridement and drainage are not technically applicable early within the first 2-4 wk before the cyst wall matures, in lesser sac locations or in walled-off cysts at distant sites from the stomach. Transabdominal drainage is an alternative option for sepsis control[ 4 ]. For fluid removal and debridement, adequate drain placement is needed.…”

“…For fluid removal and debridement, adequate drain placement is needed. Double pig-tail plastic stents or esophageal fully covered self-expandable metal stents have been used[ 4 , 11 , 15 - 17 ]. Percutaneous direct endoscopic necrosectomy is feasible despite technical difficulties, but the technique requires relevant experience[ 4 ].…”

“…Double pig-tail plastic stents or esophageal fully covered self-expandable metal stents have been used[ 4 , 11 , 15 - 17 ]. Percutaneous direct endoscopic necrosectomy is feasible despite technical difficulties, but the technique requires relevant experience[ 4 ]. Failure of the procedure ultimately requires surgical necrosectomy[ 3 , 18 ].…”