A comparison of direct endoscopic necrosectomy with transmural endoscopic drainage for the treatment of walled-off pancreatic necrosis

Gardner, Timothy B.; Chahal, Prabhleen; Papachristou, Georgios I.; Vege, Santhi Swaroop; Petersen, Bret T.; Gostout, Christopher J.; Topazian, Mark D.; Takahashi, Naoki; Sarr, Michael G.; Baron, Todd H.

doi:10.1016/j.gie.2008.06.061

« Previous Next »Gastrointestinal Endoscopy
Volume 69, Issue 6 , Pages 1085-1094, May 2009

A comparison of direct endoscopic necrosectomy with transmural endoscopic drainage for the treatment of walled-off pancreatic necrosis

Current affiliations: Miles and Shirley Fiterman Center for Digestive Diseases (P.C., S.S.V., B.T.P., C.J.G., M.D.T., T.H.B.), Department of Radiology (N.T.), Department of Surgery (M.G.S.), Mayo Clinic, Rochester, Minnesota, Section of Gastroenterology and Hepatology (T.B.G.), Dartmouth-Hitchcock Medical Center, Lebanon, New Hampshire, Department of Medicine (G.I.P.), Division of Gastroenterology, Hepatology and Nutrition, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, USA

Received 17 March 2008; accepted 30 June 2008. published online 25 February 2009.

Rochester, Minnesota, USA

Background

Endoscopic therapy of walled-off pancreatic necrosis (WOPN) via direct intracavitary debridement is described.

Objective

To compare direct endoscopic necrosectomy with conventional transmural endoscopic drainage for the treatment of WOPN.

Design

Retrospective, comparative study.

Setting

Academic tertiary-care center.

Patients

Patients referred to Mayo Clinic, Rochester, Minnesota, since April 1998 for endoscopic drainage of WOPN.

Interventions

Each patient underwent standard endoscopic drainage that consisted of transmural cavity puncture, dilation of the fistula tract, and placement of a large-bore stent(s). Patients were classified into the direct endoscopic necrosectomy group if, during any of their procedures, adjunctive direct endoscopic necrosectomy was performed; all others were in the standard drainage group.

Main Outcome Measurements

Success was defined as resolution of the necrotic cavity without the need for operative or percutaneous intervention.

Results

Forty-five patients were identified who met study criteria: 25 underwent direct endoscopic necrosectomy, and 20 underwent standard endoscopic drainage. There were no differences in baseline patient or cavity characteristics. Successful resolution was accomplished in 88% who underwent direct endoscopic necrosectomy versus 45% who received standard drainage (P < .01), without a change in the total number of procedures. The maximum size of tract dilation was larger in the direct endoscopic necrosectomy group (17 mm vs 14 mm, P < .02). Complications were limited to mild periprocedural bleeding with equivalent rates between groups.

Limitations

Retrospective, referral bias, single center.

Conclusions

Direct endoscopic necrosectomy achieves higher rates of resolution, without a concomitant change in the number of endoscopic procedures, complication rate, or time to resolution compared with standard endoscopic drainage for WOPN. The need for fewer postprocedural inpatient hospital days and a decrease in the rate of cavity recurrence are also likely benefits of this technique.

Abbreviations: BMI, body mass index, NOTES, natural orifice transluminal endoscopic surgery, OR, odds ratio, PFC, pancreatic-fluid collection, TTS, through-the-scope, WOPN, walled-off pancreatic necrosis