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- 1.Fear not to do good. Patients with pancreatic necrosis are quite ill. Many, although not all, are hospitalized, and these individuals frequently warrant intensive care unit admission. Once you agree to drain and debride a pancreatic necrosis in a patient, recognize that other caregivers will look to you to answer a plethora of questions regarding management. Most physicians are uncomfortable managing these patients, so you need to be willing to take on a significant role in their care. If you believe you have the skill and perseverance to take these patients on, you should do so. If not, send them to someone who does these procedures frequently.
- 2.Understand your equipment. LAMSs typically have a more complex delivery system than standard self-expanding metal stents, especially if the device is equipped with a diathermic tip. In my experience, although anything can happen at any time, most LAMS placement failures are secondary to the operator not understanding how the LAMS deployment system works and/or poor visualization of the LAMS during implantation (Videos 1a-d, available online at www.giejournal.org).
- 3.Consider placing the patient under general anesthesia when creating the cystgastrostomy or cystenterostomy. Most pancreatic fluid collections (PFCs) are large, and these can easily contain over 1 L of turbid fluid in addition to solid debris. When the cystgastrostomy or cystenterostomy is created, there is often a torrent of fluid that drains to the stomach or small bowel, respectively, and the patient is at risk for aspiration in this setting. General anesthesia will lower the risk of aspiration and provide an added margin of safety overall (Video 1e, available online at www.giejournal.org).
- 4.When selecting a site for cystgastrostomy or cystenterostomy, take your time and choose carefully. In my practice, the average PFC of walled-off necrosis (WON) that I manage is 15 cm in diameter. Before the initial LAMS placement, I almost always make a point of looking at the collection from multiple angles and orientations to find what I believe is the best place for stent implantation. Many of these patients have splenic vein thrombosis and perigastric varices, so a careful interrogation of the fluid collection, its wall, and a thorough search for surrounding vessels often results in a better clinical outcome. Remember, you can do everything right and bleeding can still occur, but in general a careful evaluation of the PFC or WON will pay long-term dividends to you and the patient.
- 5.It is up to you whether or not to perform necrosectomy at the time of stent placement. Some interventional endoscopists like to perform the initial direct endoscopic necrosectomy (DEN) at the time of stent placement. This can potentially save the patient 1 procedure down the road, and patients often like it, but it may create other problems as well. There is a potential increased risk of stent dislodgement if DEN is performed right away. In addition, I often wait a few days to perform the initial DEN so the PFC or WON can “dry out” and become a somewhat less hostile environment to work in. A “dry” PFC or WON often provides better endoscopic visualization than one that contains copious fluid. Neither approach is wrong, but you should have a plan so you can let the patient know what to expect.
- 6.Be familiar with the tools you want to use to perform DEN. I perform a very large number of DEN procedures per year. In my practice, I often use snares, rat-tooth forceps, retrieval nets, a motorized debridement system, and biliary stone baskets to break up, dislodge, and remove necrotic tissue from a PFC or WON. When people ask what tool works best, I often reply “all of them.” Each of these devices can play a different role in grasping, dissecting, mobilizing, and removing necrotic debris, and they often work synergistically with each other (Figure 1, Figure 2, Figure 3, Figure 4, Videos 2a-c, available online at www.giejournal.org).
- 7.Individualize DEN intervals. Every patient is different. Some patients may only desire DEN every few weeks given their distance from the hospital and their ability to tolerate sedation. Others make rapid clinical progress with closely spaced DEN procedures. I often choose the timing of subsequent DEN procedures after discussing these issues with the patient and their family directly so they are fully on board with the care plan.
- 8.Leave stents in as long as clinically required. Some endoscopists feel pressure to remove stents at certain time points. In general, I leave stents (metal, plastic, or both) in place for as long as clinically indicated. The disease does not read the textbook, so you have to do what is best for the patient. Some patients with very severe or complex PFCs or WONs require stent indwell times of many months, and that is okay. Some patients require long-term stenting.
- 9.Interval CTs can often guide therapy. It can be extremely helpful to obtain a CT of the abdomen and pelvis in patients with PFC or WON at around the 4-week mark, especially if there are questions about the ongoing size and configuration of the collection. I have been fooled on a few occasions into thinking a patient was doing better than they actually were, only to discover that the CT revealed a pocket of pancreatic necrosis that had been missed during my DEN procedures. On subsequent procedures I was able to access these pockets and placed double-pigtail stents directly into them. Not every patient needs a CT, and sometimes your endoscopic visualization during DEN may be fully descriptive of the current state of affairs, but in many patients they are very helpful.
- 10.Be patient, but be persistent. Some patients with a PFC or WON take a very long time to heal. If you can fully debride a patient’s necrosis in 2 sessions you will both be very happy. Some patients make very slow progress over months, and you may believe your DEN procedures are yielding little clinical benefit. Be patient and rest assured that your efforts are very likely bearing fruit. You and the patient have to understand that treating pancreatic necrosis can be a marathon and not a sprint. With time and effort, you will get there (Video 3, available online at www.giejournal.org).
Abbreviations:DEN (direct endoscopic necrosectomy), LAMS (lumen-apposing metal stent), PFC (pancreatic fluid collection), WON (walled-off necrosis)
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- Surgery versus endoscopy for patients with infected pancreatic necrosis.Lancet. 2018; 391: 6-8
- EUS-guided drainage of peripancreatic fluid collections and necrosis by using a novel lumen-apposing stent: a large retrospective, multicenter U.S. experience (with videos).Gastrointest Endosc. 2016; 83: 699-707
- A multi-institutional consensus on how to perform endoscopic ultrasound-guided peri-pancreatic fluid collection drainage and endoscopic necrosectomy.Endosc Ultrasound. 2017; 6: 285-291
- Lumen apposing metal stents in drainage of pancreatic walled-off necrosis: Are they any better than plastic stents? A systematic review and meta-analysis of studies published since the revised Atlanta classification of pancreatic fluid collections.Endosc Ultrasound. 2019; 8: 82-90
DISCLOSURE: The following author disclosed financial relationships: D. G. Adler: Consultant for BSC and Endorotor.