Percutaneous direct endoscopic pancreatic necrosectomy

Metal stent and percutaneous endoscopic necrosectomy as dual approach for the management of complex walled-off pancreatic necrosis

Pancreatic fluid collections (PFCs) are one of the local complications of acute pancreatitis and include walled-off pancreatic necrosis (WOPN), which are complex entities with challenging management. The infection of pancreatic necrosis leads to a poorer prognosis, with a growth of the mortality rate up to 30%. The primary strategy for managing PFCs is a minimally invasive step-up approach, with endosonography-guided transmural drainage and debridement as the preferred and less invasive method. Percutaneous drainage (PCD) can be the technique of choice when endoscopic drainage is not feasible, for example for early PFCs without a mature wall or for the anatomic location and extension to the paracolic gutter of the collection. As PCD alone may be ineffective, especially when a great amount of necrosis is present, a percutaneous endoscopic necrosectomy (PEN) has been proposed, showing interesting results. The technique consists of the placement of an esophageal fully or partially covered self-expandable metal stent (SEMS) percutaneously into the collection and a direct debridement can be performed using a flexible endoscope through the SEMS. In this review, we will discuss about the role of metal stent and PEN for the management of complex walled-off pancreatic necrosis.

Management of infected acute necrotizing pancreatitis

Necrotizing or severe pancreatitis represents approximately 10%-20% of acute pancreatitis. 30%-40% of patients with acute necrotizing pancreatitis (ANP) will develop debris infection through translocation of intestinal microbial flora. Infected ANP constitutes a serious clinical condition and is complicated by severe sepsis with high mortality rates of up to 40% despite progress in current intensive care. The timely detection of sepsis is crucial. The Quick Sequential Organ Failure Assessment score, procalcitonin levels > 1.8 ng/mL and increased lactates > 2 mmol/L (> 18 mg/dL), indicate the need for urgent management. The escalated step-by-step management protocol starts with broad-spectrum antibiotics, percutaneous drainage or endoscopic management, and ends with surgical management if needed. The latter includes necrosectomy (either laparoscopic or traditional open surgery), peritoneal lavage and extensive drainage. This management protocol increases the chance of survival to approximately 60% in patients with otherwise fatal cases. Any treatment choice must be individualized, and the timing is critical.