The management of pancreatic necrosis has evolved. Sterile necrosis is now managed conservatively. Intervention is generally required for infected necrosis but is now deferred until four weeks after disease onset in order to permit encapsulation and demarcation of the necrotic collection. Demarcation facilitates necrosectomy and reduces complications related to the drainage and debridement procedures. The approach to pancreatic necrosectomy has evolved from primary open necrosectomy to minimally-invasive radiologic, surgical and endoscopic procedures. Direct endoscopic necrosectomy is a minimally-invasive technique that was introduced in recent years for the treatment of infected walled-off necrosis. A stoma is created endoscopically between the gastric lumen and the walled-off collection. An endoscope is then inserted directly into the cavity to perform endoscopic necrosectomy. This is followed by short-term placement of double pigtail transgastric stents and nasocystic catheter for post-procedural irrigation and drainage. This review will summarise the current status of direct endoscopic necrosectomy.
ForsmarkCEBaillieJ, AGA Institute Clinical Practice and Economics Committee, AGA Institute Governing Board. AGA Institute technical review on acute pancreatitis. Gastroenterology2007;132(5):2022–44.
2.
BollenTLBesselinkMGvan SantvoortHCGooszenHGvan LeeuwenMS. Toward an update of the Atlanta classification on acute pancreatitis: Review of new and abandoned terms. Pancreas2007;35(2):107–13.
3.
BesselinkMGvan SantvoortHCBakkerOJBollenTLGooszenHG. Draining sterile fluid collections in acute pancreatitis?Primum non nocere! Surg Endosc2011;25(1):331–2.
4.
RodriguezJRRazoAOTargaronaJThayerSPRattnerDWWarshawAL. Debridement and closed packing for sterile or infected necrotizing pancreatitis. Ann Surg2008;247(2):294–9.
5.
BesselinkMGVerwerTJSchoenmaeckersEJBuskensERidwanBUVisserMR. Timing of surgical intervention in necrotizing pancreatitis. Arch Surg2007;142(12): 1194–1201.
6.
RaratyMGHalloranCMDoddSGhanehPConnorSEvansJ. Minimal access retroperitoneal pancreatic necrosectomy: Improvement in morbidity and mortality with a less invasive approach. Ann Surg2010; 251(5):787–93.
7.
BuchlerMWGloorBMullerCAFriessHSeilerCAUhlW. Acute necrotizing pancreatitis: Treatment strategy according to the status of infection. Ann Surg2000;232(5):619–26.
8.
AshleySWPerezAPierceEABrooksDCMooreFDJrWhangEE. Necrotizing pancreatitis: Contemporary analysis of 99 consecutive cases. Ann Surg2001;234(4):572–9.
9.
BabuBISheenAJLeeSHO'SheaSEddlestonJMSiriwardenaAK. Open pancreatic necrosectomy in the multidisciplinary management of postinflammatory necrosis. Ann Surg2010;251(5):783–6.
10.
ConnorSAlexakisNRaratyMGGhanehPEvansJHughesM. Early and late complications after pancreatic necrosectomy. Surgery2005;137(5):499–505.
11.
HowardTJPatelJBZyromskiNSandrasegaranKYuJNakeebA. Declining morbidity and mortality rates in the surgical management of pancreatic necrosis. J Gastrointest Surg2007;11(1):43–9.
12.
RauBBotheABegerHG. Surgical treatment of necrotizing pancreatitis by necrosectomy and closed lavage: Changing patient characteristics and outcome in a 19-year, single-center series. Surgery2005; 138(1):28–39.
13.
TsiotosGGLeonE Luque-DeSarrMG. Long-term outcome of necrotizing pancreatitis treated by necrosectomy. Br J Surg1998;85(12):1650–3.
14.
van SantvoortHCBesselinkMGBakkerOJHofkerHSBoermeesterMADejongCH. A step-up approach or open necrosectomy for necrotizing pancreatitis. N Engl J Med2010;362(16):1491–502.
15.
BabuBISiriwardenaAK. Current status of minimally invasive necrosectomy for post-inflammatory pancreatic necrosis. HPB (Oxford). 2009;11(2):96–102.
16.
SeewaldSAngTLTengKYKSoehendraN. EUS-guided drainage of pancreatic pseudocysts, abscesses and infected necrosis. Dig Endosc2009;21(Suppl 1):S61–5.
17.
SeewaldSAngTLKidaMTengKYSoehendraN, EUS 2008 Working Group. EUS 2008 Working Group document: Evaluation of EUS-guided drainage of pancreatic-fluid collections (with video). Gastrointest Endosc2009; 69 (2 Suppl):S13–21.
18.
VaradarajuluSLopesTLWilcoxCMDrelichmanERKilgoreMLChristeinJD. EUS versus surgical cystgastrostomy for management of pancreatic pseudocysts. Gastrointest Endosc2008;68(4):649–55.
19.
HookeyLCDebrouxSDelhayeMArvanitakisMLe MoineODevièreJ. Endoscopic drainage of pancreatic-fluid collections in 116 patients: A comparison of etiologies, drainage techniques, and outcomes. Gastrointest Endosc2006;63(4):635–43.
20.
GardnerTBChahalPPapachristouGIVegeSSPetersenBTGostoutCJ. A comparison of direct endoscopic necrosectomy with transmural endoscopic drainage for the treatment of walled-off pancreatic necrosis. Gastrointest Endosc2009;69(6):1085–94.
21.
AngTLTeoEKFockKM. EUS-guided drainage of infected pancreatic pseudocyst: Use of a 10F Soehendra dilator to facilitate a double-wire technique for initial transgastric access (with videos). Gastrointest Endosc2008; 68(1):192–4.
22.
SeifertHBiermerMSchmittWJürgensenCWillUGerlachR. Transluminal endoscopic necrosectomy after acute pancreatitis: A multicentre study with long-term follow-up (the GEPARD Study). Gut2009; 58(9):1260–6.
23.
GardnerTBCoelho-PrabhuNGordonSRGelrudAMapleJTPapachristouGI. Direct endoscopic necrosectomy for the treatment of walled-off pancreatic necrosis: Results from a multi-centre U.S. series. Gastrointest Endosc2011;73(4):718–26.
24.
SeewaldSAngTLRichterHTengKYZhongYGrothS. Long-term results after endoscopic drainage and necrosectomy of symptomatic pancreatic fluid collections. Dig Endosc2012;24(1):36–41.
25.
AngTLKwekABETanSSIbrahimSFockKMTeoEK. Direct endoscopic necrosectomy — a minimally invasive endoscopic technique for the treatment of infected walled-off pancreatic necrosis and infected pseudocysts with solid debris. Singapore Med J2012 (in press).
26.
BakkerOVan SanvoortHvan BrunschotSGeskusRBBesselinkMGBollenTL. Endoscopic transgastric vs surgical necrosectomy for infected necrotizing pancreatitis: A randomized trial. JAMA2012; 307(10):1053–61.
27.
BauschDWellnerUKahlSKuestersSRichter-SchragHUtzolinoS. Minimally invasive operations for acute necrotizing pancreatitis: Comparison of minimally invasive retroperitoneal necrosectomy with endoscopic transgastric necrosectomy. Surgery2012;152 (3Suppl 1): S128–34.
28.
FinkDSoaresRMatthewsJBAlverdyJC. History, goals, and technique of laparoscopic pancreatic necrosectomy. J Gastrointest Surg2011;15(7):1092–7.
29.
CastellanosGPiñeroADoigLASerranoAFusterMBixquertV. Management of infected pancreatic necrosis using retroperitoneal necrosectomy with flexible endoscope: 10 years of experience. Surg Endosc2012 Jul 18. [Epub ahead of print].
30.
van BrunschotSvan SantvoortHCGooszenHGFockensP. [Endoscopic versus surgical treatment of infected necrotising pancreatitis: The TENSION study]. Ned Tijdschr Geneeskd. 2012;156(4):A4329.
31.
GluckMRossAIraniSLinOHauptmannESiegalJ. Endoscopic and percutaneous drainage of symptomatic walled-off pancreatic necrosis reduces hospital stay and radiographic resources. Clin Gastroenterol Hepatol2010;8(12):1083–8.
32.
NealonWHBhutaniMRiallTSRajuGOzkanONeilanR. A unifying concept: Pancreatic ductal anatomy both predicts and determines the major complications resulting from pancreatitis. J Am Coll Surg2009;208(5):790–9.
33.
TelfordJJFarrellJJSaltzmanJRShieldsSJBanksPALichtensteinDR. Pancreatic stent placement for duct disruption. Gastrointest Endosc2002;56(1):18–24.
34.
SeewaldSBrandBGrothSOmarSMendozaGSeitzU. Endoscopic sealing of pancreatic fistula by using N-butyl-2-cyanoacrylate. Gastrointest Endosc2004;59(4):463–70.
35.
AngTLTeoEKFockKM. Endoscopic drainage and endoscopic necrosectomy in the management of symptomatic pancreatic collections. J Dig Dis2009;10(3):213–24.
36.
ArvanitakisMDelhayeMBaliMAMatosCDe MaertelaerVLe MoineO. Pancreatic fluid collections: A randomized controlled trial regarding stent removal after endoscopic transmural drainage. Gastrointest Endosc2007;65(4):609–19.
