Introduction

Acute pancreatitis in 10%–20% of cases can be associated with necrosis of the pancreatic gland, peripancreatic tissue, or both. Expert multidisciplinary care by gastroenterologists, surgeons, interventional radiologists, and specialists in critical care medicine, infectious disease, and nutrition is required to successfully manage these patients.
The current accepted invasive treatment for patients with necrotizing pancreatitis is the so-called "step-up" approach, which includes an initial percutaneous catheter drainage (PCD) followed by endoscopic, surgical, or laparoscopic necrosectomy, if necessary.
We report a case series of a new endoscopic approach to treat infected pancreatic necrosis (IPN).

Aims & Methods

Consecutive patients with IPN, extended from perigastric area up to the paracolic gutters or into the pelvis, were prospectively studied from January 2017 and June 2022.
Treatment protocol was radiological percutaneous drainage as first step followed by fully covered metal stent placement (FC-SEMS) in the track of the catheter. Percutaneous endoscopic necrosectomy (PEN) was performed 2-4 days later using a flexible endoscope through the percutaneous tract.
About 2-4 weeks later when, a matured sac was visible, EUS-guided endoscopic transluminal drainage (ETD) with lumen-apposing metal stents (LAMS) was performed.
Control of sepsis with resolution of collection(s) was primary outcome measure.

Results

We included 18 patients, males in 50% of cases with age 60 ± 12 years old. The most frequent cause of pancreatitis was biliary (7 cases) followed by alcoholic in 6 cases; in 3 cases pancreatitis was caused by hyperlipemia and in 2 cases was idiopathic. The mean size of WON was 18 ± 2 cm. For PEN, the SEMSs used were oesophageal FC-SEMS. LAMS used for ETD were Hot Axios, Hot Spaxus, and Nagistent. The mean time of endoscopic intervention for PEN and ETD was 18 ± 3 days and 37 ± 4 days respectively. In 5 cases adverse events occurred: 3 cases of overinflations resolved with the introduction of Verres needles in the abdomen. In 2 cases post procedural GI bleeding required endoscopic intervention.
The median time of resolution of WON was 3.5 weeks (minimum 2, maximum 6 weeks), with a median of 2 sessions for PEN (minimum 2, maximum 3) and 2 sessions for ETD (minimum 2, maximum 4) at an interval of 7 days (range: 4-9 days) were needed to achieve resolution of fluid collection. In all cases control of sepsis was reached together with resolution of collections. No cases of deaths were observed.

Conclusion

The combined step-up dual approach of initial PCD after 2-3 weeks of illness followed by early PEN and delayed ETD is a safe and effective alternative treatment for patients with large size IPN, extended from the pancreatic lodge into paracolic gutters or the pelvis.

References

1. Arvanitakis M, Dumonceau J-M, Albert J, et al. Endoscopic management of acute necrotizing pancreatitis: European Society of Gastrointestinal Endoscopy (ESGE) evidence-based multidisciplinary guidelines. Endoscopy. 2018;50:524–546.
2. Carter CR, McKay CJ, Imrie CW. Percutaneous necrosectomy and sinus tract endoscopy in the management of infected pancreatic necrosis: An initial experience. Ann Surg 2000;232:175‑80.
3. van Brunschot S, van Grinsven J, van Santvoort HC, et al. Endoscopic or surgical step-up approach for infected necrotising pancreatitis: a multicentre randomised trial. Lancet 2018;391:51–5
4. Mathers B, Moyer M, Mathew A et al. Percutaneous debridement and washout of walled-off abdominal abscess and necrosis using flexible endoscopy: a large single-center experience. Endosc Int Open 2016; 4: E102 – E106
5. Goenka MK, Goenka U, Mujoo MY, et al. Pancreatic necrosectomy through sinus tract endoscopy. Clin Endosc. 2018;51(3):279– 84
6. Pérez-Cuadrado-Robles E, Berger A, Perrod G, et al. Endoscopic treatment of walled-off pancreatic necrosis by simultaneous transgastric and retroperitoneal approaches. Endoscopy. 2020; 52(3):E88–9
7. Moyer MT, Walsh LT, Manzo CE, et al. Percutaneous debridement and washout of walled-off abdominal abscess and necrosis by the use of flexible endoscopy: an attractive clinical option when transluminal approaches are unsafe or not possible. VideoGIE Off Video J Am Soc Gastrointest Endosc. 2019;4(8):389–93.

Clinical Case Summary

Walled-off necrosis following acute pancreatitis poses a considerable challenge for successful management. In selected cases, percutaneous endoscopic necrosectomy emerges as a viable alternative for collections unsuitable for transmural drainage.
We report the case of an 80-year-old woman who presented with a month-long history of food intolerance following an episode of intense abdominal pain. Abdominal CT revealed an extensive peripancreatic collection extending from the left parietocolic gutter to the left iliac fossa (27 cm), leading to a gastric outlet obstruction syndrome due to compression from walled-off necrosis following acute pancreatitis.
A broad-spectrum antibiotic regimen was initiated and adjusted based on microbiologic results.
The collection was initially drained transgastrically using a lumen-apposing metal stent, achieving partial resolution without reducing the left parietocolic gutter portion.
Following two unsuccessful percutaneous drainage attempts, a multidisciplinary decision led to percutaneous drainage using an esophageal self-expanding metallic stent (120x25 mm) and subsequent necrosectomy. Two sessions of percutaneous necrosectomy were performed after stent dilation, contributing to the overall management of the patient. There was clinical, endoscopic and imaging improvement, so the stent was removed fourteen days later. For the closure of the cutaneous fistula, a vacuum assisted closure therapy was applied, and the wound showed good progress. There were no local complications from the procedure, and the percutaneous stent placement and necrosectomy sessions were well tolerated by the patient, who was subsequently discharged.
This is a case where the performance of dual endoscopic drainage (transgastric and percutaneous) proved essential for controlling peripancreatic collection, using an unconventional method of endoscopic necrosectomy without complications associated with this procedure.

References

We present detailed iconography of the procedure of insertion of percutaneous self-expanding metallic stent, dilation of the stent and percutaneous endoscopic necrosectomy in both image and video formats. Additionally, we present abdominal CT images before and after endoscopic and percutanous procedures showing collection evolution.

Disclosure

Nothing to declare

Introduction

Pancreatic necrosis is a devastating disease that leads to a high mortality and morbidity rates. Necrosectomy is the golf standart treatment for infected pancreatic necrosis. Percutaneous and endoscopic approaches has been widely accepted in selected cases. Endoscopic necrosectomy in early complicated pancreatic necrosis were performed as a first intent to treat and retrospectively evaluated regarding to morbidity, efficacy, recurrence and length of hospital stay.

Aims & Methods

Report our experience on endoscopic manage of pancreatic necrosis using a daily transmural and transpapillary drainage in 25 patients.
Records of all patients who underwent EN from January 2023 to January 2025 Endoscopic manage of acute pancreatic necrosis using a daily transmural and transpapillary drainage in 25 patients. The Apache classification and CCT score is used. Diagnostic ERP to search communications between pancreatic duct and the collection were performed in selective cases and in cases that communication exists; prothesis can be inserted through the minor or major papilla to plug it. The transmural drainage was performed in 25 patients (05 Duodenal and 20 gastric) and transpapillary and transmural in 07 patients, after identification of the most proeminent or bulging part of the stomach or duodenum. All patients were followed with CT scans, IRM to ensure clinical resolution.

Results

25 patients (14 women, 09 men) could be treated. The Apache classification is used 0 a 9 score in 14 patients (56,%) and 11 (44%), CT severity index was 30-50% in 05, > 50% in 20. Pancreatic necrosis were located in the pancreatic head in 03 patients, the head/body in 02, body in 6, body/tail 04, head/body/tail 10. ERP demonstrated the ductal communication of the colection with the main pancreatic duct in 07 patients, rupture in 03, disconnect syndrome in 03 and normal in 02. Drainage was successful in 25 (100%). 07 (28%) combined treatment (transpapillary and transmural), 18 (72%) transmural. The median number of endoscopic session for each patients was 4 (range 2 to 8). The median hospital stay for in the all patients was only endoscopic therapy was 9. The range follow –up was 18 months (range 6 to 24) with mean number of ERCPs was 4 (range 2 to 8). Two patients required concurrent radiology procedure, recurrence of fluid collection (n=1), flank abscess (n=1). There were 2 (16,6%) pseudocyst recurrences during this period, and were managed clinically and/or endoscopically. There was no mortality related to the procedure.

Conclusion

The early and aggressive endoscopic treatment with daily necrosectomy can be performed and show promising results same in early complications of pancreatic necrosis. Combined approaches with radiology and conventional surgery can also be applied in selected cases.

Disclosure

No Conflict of Interest

Introduction

Endoscopic step-up approach comprising EUS-guided (endoscopic ultrasound) transmural drainage with or without direct endoscopic necrosectomy (DEN) is the standard of care for centrally placed necrotic collections in patients with ANP (acute necrotising pancreatitis). However, after initial EUS-guided drainage, the timing and frequency of endoscopic necrosectomy are still evolving.

Aims & Methods

To compare the outcomes of a top-down vs. step-up approach after EUS-guided drainage of the infected pancreatic necrotic collection.
We performed a single-centre, open-label, randomised trial. We included patients with ANP who had a proven or clinically suspected infected WON (walled--off necrosis) greater than 10 cm in size and more than 30% solid debris, which should be suitable for EUS-guided drainage. In the top-down arm, the patient received an up-front DEN in the same session of initial EUS-guided drainage. The necrosectomy was performed using conventional accessories in both arms. The DEN was continued till complete removal of all debris or 60 minutes of the procedure, whichever is earlier. In case of incomplete clearance, the patient was again taken up for the endoscopic necrosectomy after 24 hours of the initial procedure. This process continued until complete clearance of the necrotic debris, along with visualization of the healthy granulation tissue in most of the cavity. In the step-up approach, after initial EUS-guided drainage, necrosectomy was performed only in the presence of pre-defined clinical criteria (non-response or worsening of SIRS and/or organ failure at 72 hours). The primary endpoint was the number of re-interventions per patient required after the index drainage procedure to achieve clinical success till 3 months of follow-up. Secondary endpoints were the time for resolution of SIRS, new onset organ failure, procedure-related complications, the requirement of re-hospitalisation, total hospitalisation days and all-cause mortality. An intention-to-treat analysis on all randomly assigned patients was performed for the primary and secondary endpoints.

Results

Out of 208 patients screened during the study period, 54 were enrolled (27 in each group). The mean age was 38.70 ± 12.58, and gallstone pancreatitis was the most common aetiology (48.1%). Half the patients had severe disease with a median APACHE II Score of 8 (IQR 7-10). 42 patients (77.8%) had culture-positive infected necrotic collections, and 12 patients (22.2%) had clinically suspected infection. All enrolled patients achieved technical success. The median number of re-interventions required in the top-down arm was lower (1 (0-2) vs 2 (1-3); p=0.02). All patients in the top-down arm underwent DEN, and 77.8% of patients (n=21) in the step-up arm required DEN for clinical success. Patients in the step-up arm had higher re-admissions (44.4% vs 18.5%; p=0.04) and prolonged hospitalization (12 (8.5-20.5) vs 4 (2-10.5) ; p<0.01) compared to the other arm. Time for resolution SIRS (2 (1-8.25) vs 3.5 (2-18); vs; p=0.051), procedure-related complications (7.4% vs 7.4%; p=1.0), new onset organ failure (11.1 % vs 14.8%; p=0.68), and mortality (11.1% vs 18.5%; p=0.44) were equivalent across both arms.

Conclusion

In patients with large infected WON with significant solid debris (>30%), the top-down approach comprising an upfront and complete necrosectomy reduces the requirement of re-interventions, re-admissions and total hospitalisation days.
Trial Registration: ctri.nic.in (CTRI/2024/01/061515)

References

1.Bang JY, Arnoletti JP, Holt BA, Sutton B, Hasan MK, Navaneethan U, Feranec N, Wilcox CM, Tharian B, Hawes RH, Varadarajulu S. An Endoscopic Transluminal Approach, Compared With Minimally Invasive Surgery, Reduces Complications and Costs for Patients With Necrotizing Pancreatitis. Gastroenterology. 2019 Mar;156(4):1027-1040.e3. doi: 10.1053/j.gastro.2018.11.031.
2. Bang JY, Lakhtakia S, Thakkar S, Buxbaum JL, Waxman I, Sutton B, Memon SF, Singh S, Basha J, Singh A, Navaneethan U, Hawes RH, Wilcox CM, Varadarajulu S; United States Pancreatic Disease Study Group. Upfront endoscopic necrosectomy or step-up endoscopic approach for infected necrotising pancreatitis (DESTIN): a single-blinded, multicentre, randomised trial. Lancet Gastroenterol Hepatol. 2024 Jan;9(1):22-33. doi: 10.1016/S2468-1253(23)00331-X.
3. Yan L, Dargan A, Nieto J, Shariaha RZ, Binmoeller KF, Adler DG, DeSimone M, Berzin T, Swahney M, Draganov PV, Yang DJ, Diehl DL, Wang L, Ghulab A, Butt N, Siddiqui AA. Direct endoscopic necrosectomy at the time of transmural stent placement results in earlier resolution of complex walled-off pancreatic necrosis: Results from a large multicenter United States trial. Endosc Ultrasound. 2019 May-Jun;8(3):172-179.

Introduction

Pancreatic walled-off necrosis (WON) presents a significant challenge in acute pancreatitis management, often necessitating endoscopic intervention for drainage and necrosectomy. However, the optimal selection of stent type for endoscopic drainage remains debatable. This study aimed to evaluate the utility of the QNI classification in guiding stent selection for WON drainage.

Aims & Methods

We conducted a retrospective analysis of patients who underwent endoscopic drainage and necrosectomy for symptomatic pancreatic WON at a tertiary referral center between January 2022 and September 2023. Patients were divided into two groups based on the QNI classification: Group 1 consisted of patients who had WON affecting 1 quadrant or 2 quadrants with a necrosis of less than 30%. Group 2 consisted of patients whose WON had affected 3 quadrants, 2 quadrants with 30% necrosis, or 1 quadrant with more than 60% necrosis at the time of the index procedure. A WON-based decision was made by the endoscopist regarding the use of LAMS or plastic stents. Necrosectomy was performed in cases of infection following WON drainage. Resolution was considered in clinically asymptomatic patients with WON < 30 mm at the 3-month imaging follow-up.

Results

Forty-eight patients were included in the study, with a mean age of 55.7 (±12.28) and a male-to-female ratio of 2.4:1, 20 patients in Group 1 and 28 patients in Group 2. Except for infection, which occurred more frequently in Group 2, the indications for drainage (pain, weight loss) were similar between the two groups (28% vs 5%, p=0.03). LAMS were used more frequently in group 2 than in group 1 (64% vs 40%, p=0.001). The mean number of endoscopic procedures in Group 1 was 1.7 and in Group 2 it was 3. The interval between endoscopic procedures in Group 1 and Group 2 was 20.3 days and 12.4 days, respectively (p=0.05). Clinical resolution at 3 months showed no significant difference between groups, with rates of 90% vs 85% (p=0.87), and the complication rates was 10% vs 14.2% (p=NS). Percutaneous drainage was done in 0% vs 7.14% cases, and surgery was required in 0% vs 7.1% of cases.

Conclusion

As a result of the newly proposed QNI classification system, patients can be guided in the selection of LAMS placement as well as for multidisciplinary management. Severe QNI scores may need more aggressive interventions, yet outcomes are comparable to those with milder disease.

References

Baroud, S., Chandrasekhara, V., Storm, A. C., Law, R. J., Vargas, E. J., Levy, M. J., Mahmoud, T., Bazerbachi, F., Bofill-Garcia, A., Ghazi, R., Maselli, D. B., Martin, J. A., Vege, S. S., Takahashi, N., Petersen, B. T., Topazian, M. D., & Abu Dayyeh, B. K. (2023). Novel classification system for walled-off necrosis: a step toward standardized nomenclature and risk-stratification framework. Gastrointestinal endoscopy, 97(2), 300–308.

Introduction

The need for endoscopic necrosectomy (EN) has increased dramatically, as endoscopic EUS-guided drainage has become gold standard for treatment of pancreatic walled-off-necrosis (WON)[1,2]. Although snares and baskets are commonly used in EN procedures, they can be ineffective and dedicated instruments specifically designed for EN are scarce. Recently, an innovative powered endoscopic debridement system (EndoRotor, Interscope Inc., Northbridge, MA, USA) designed to excise and remove necrotic tissue within the WON was introduced specifically for EN with promising results[3,4]. While the first generation EndoRotor catheter was limited to 3.2 mm diameter, a larger catheter that fits into a large-channel gastroscope with a working channel of 6.0 mm has now been introduced. This study evaluates the clinical outcomes, safety, and feasibility of the novel 6.0 catheter for EN of WON.

Aims & Methods

This retrospective study was performed using prospectively collected data from all patients who underwent EN with the 6.0 catheter between December 2021 and March 2023 at Gastro Unit, Copenhagen University Hospital Hvidovre, a tertiary referral center in Denmark. All patients with symptomatic WON and need for necrosectomy were considered eligible for this study. Technical feasibility, safety, and clinical outcomes were evaluated.

Results

Sixteen patients underwent a total of 25 EN procedures with the 6.0 catheter. The mean age of the patients was 51.8 years (SD 17.7 years) and 11 (68.8%) were male. The etiology of the acute necrotizing pancreatitis was alcohol in 4 patients (25.0%), gall stones in 7 patients (43.8%), post-endoscopic retrograde cholangiopancreatography (ERCP) in 3 patients (18.8%), and idiopathic in 2 patients (12.5%). The mean size of the WON was 27.5 cm (SD 10.5 cm). The median computed tomography severity index (CTSI) was 8.5 (P25-P75: 6.0-9.0) and median modified CTSI (mCTSI) was 9.0 (P25-P75: 8.0-10). Two patients did not achieve clinical resolution (12.5%), as they died from multisystem organ failure before resolution of the WON was achieved. The median length of stay in hospital for the patients who achieved clinical resolution was 56.0 days (P25-P75: 36.5-96.0 days) and the median number of necrosectomy procedures performed to achieve clinical resolution was 5.0 (P25-P75: 2.0-8.5). All patients had EN procedures performed with snares in addition to the procedures with the powered debridement system. Five patients had necrosectomy performed with the 3.2 catheter (31.0%) as well as the 6.0 catheter. The median duration of EN with the 6.0 catheter was 60.0 minutes (P25-P75: 45.0-100 minutes) per procedure.
A device-related adverse event was noted in one instance (4.0%). The patient exhibited symptoms of peritoneal reaction in the hours following the procedure, which may have been caused by perforation of the WON into the peritoneal cavity. The patient was treated with laparoscopic peritoneal lavage and drainage and recovered without further interventions. No other procedure-related adverse events were identified. Malfunction of the catheter was observed in 7 procedures (28.0%).

Conclusion

To perform necrosectomy procedures optimally, dedicated endoscopic instruments designed for debridement of pancreatic WON are required. This study suggests that EN with the novel EndoRotor 6.0 catheter is safe and feasible with promising clinical results for EN of pancreatic WON. To assess the efficacy relative to standard techniques, comparative studies are warranted.

References

[1] Karstensen JG, Novovic S, Hansen EF, et al. EUS-guided drainage of large walled-off pancreatic necroses using plastic versus lumen-apposing metal stents: A single-centre randomised controlled trial. Gut 2022; 0: 1–7. doi:10.1136/gutjnl-2022-328225
[2] Ebrahim M, Werge MP, Hadi A, et al. Clinical outcomes following endoscopic or video-assisted retroperitoneal management of acute pancreatitis with large (>15 cm) walled-off pancreatic necrosis: Retrospective, single tertiary center cohort study. Dig Endosc 2022; 34: 1245–1252. doi:10.1111/den.14295
[3] Stassen PMC, de Jonge PJF, Bruno MJ, et al. Safety and efficacy of a novel resection system for direct endoscopic necrosectomy of walled-off pancreas necrosis: a prospective, international, multicenter trial. Gastrointest Endosc 2022; 95: 471–479. doi:10.1016/J.GIE.2021.09.025
[4] Wiel SE van der, May A, Poley JW, et al. Preliminary report on the safety and utility of a novel automated mechanical endoscopic tissue resection tool for endoscopic necrosectomy: a case series. Endosc Int Open 2020; 08: E274–E280. doi:10.1055/A-1079-5015