Endoscopic transmural debridement of symptomatic organized pancreatic necrosis (with videos)

Background

Surgical management of pancreatic necrosis is associated with significant morbidity and mortality. Several weeks after an episode of a necrotizing pancreatitis, necrosis can become organized. By the time necrosis becomes organized, endoscopic therapy has the potential to offer an alternative treatment to surgery.

Objective

To evaluate the safety and efficacy of endoscopic debridement of organized pancreatic necrosis and to identify procedural aspects that may improve outcome.

Design

Retrospective cohort study.

Setting

Tertiary referral center.

Patients

All consecutive patients who underwent this novel endoscopic approach were included.

Interventions

Treatment started with a cystoenterostomy or a cystogastrostomy. The next steps consisted of balloon dilation, up to 18 mm; advancement of an endoscope into the retroperitoneal cavity; and endoscopic debridement of the collection under direct endoscopic vision. Debridement was repeated every 2 days until most necrotic material was evacuated. In addition, nasocystic catheter irrigation was performed manually with saline solution 6 to 8 times a day.

Main Outcome Measurements

Clinical success, number of endoscopic procedures, and complications.

Results

Twenty-five patients were identified, who had undergone debridement of 27 collections. In 11, 13, 2, and 1 collections, 1, 2, 3, and 4 endoscopic debridement procedures, respectively, were performed. There was no mortality. Severe complications that required surgery occurred in 2 patients: hemorrhage in 1 case and perforation of cyst wall in the other. During a median follow-up of 16 months (range 3-38 months), the overall clinical success rate with resolution of the collection and related symptoms was 93%.

Limitations

Retrospective study.

Conclusions

In this study, we showed that endoscopic debridement is an effective and relatively safe minimally invasive therapy in patients with symptomatic organized pancreatic necrosis. Further comparative studies are warranted to define its definitive role in the management of these patients.

Abbreviations: CECT, contrast-enhanced CT, ERP, endoscopic retrograde pancreatogram, MRI, magnetic resonance imaging, NCC, nasocystic catheter