To the Editor:
The recently published meta-analysis on H2O2-assisted endoscopic necrosectomy of pancreatic walled-off necrosis (WON) showed that it facilitated debridement without significant adverse events.
1
Debridement is often inefficient, requiring multiple procedures and the retention of drains or stents for prolonged periods.2
Many solutions have been investigated, including collagenases,3
tissue plasminogen activator,4
and gastric acid.5
An in vitro study by us also showed that fluid obtained from a nasogastric tube (patient taking a proton pump inhibitor) was an effective liquefaction solution.6
We conducted an in vitro study to evaluate the liquefying effects of 4 different chemical solutions on human pancreatic necrosis: 0.9% normal saline (group I), 5% sodium bicarbonate (group II), 3% H2O2 (group III), and artificial gastric juice (Coolaber Corporation, Beijing: 3.5 mg/mL pepsin, hydrochloric acid diluted to pH 2.0, group IV). Approval from the Institutional Review Board and informed consent were obtained for the collection of human pancreatic necrosis samples from patients who underwent necrosectomy procedures. Pancreatic necrosis tissue (weight A) was incubated with individual test solutions for 2 hours at 37°C, and then the remaining tissues were weighed (weight B). The liquefaction efficiency (%) was calculated by (1-B/A) ∗ 100%. The liquefaction results (median and interquartile range) in groups I to IV (each n = 12) were 28.4% (5.1), 31.8% (26.2), 40.5% (22.8), and 56.7% (36.1), respectively. Artificial gastric juice was significantly more effective than H2O2 in liquefying pancreatic necrosis (P < .01). As a safety study, normal healthy aortic tissue from rats was also incubated (for 2 hours at 37°C) with each solution (each n = 6), and no histologic evidence of injury was identified for any of the solutions.
In this pilot study, artificial gastric juice exposure for at least 2 hours was more effective than H2O2 in accelerating liquefaction of pancreatic necrosis without damaging normal vascular tissue. This approach should be further investigated as an adjunct to percutaneous drainage and debridement procedures.
Disclosure
All authors disclosed no financial relationships.
References
- Hydrogen peroxide-assisted endoscopic necrosectomy of pancreatic walled-off necrosis: a systematic review and meta-analysis.Gastrointest Endosc. 2022; 95: 1060-1066.e7
- American Gastroenterological Association Clinical Practice Update: management of pancreatic necrosis.Gastroenterology. 2020; 158: 67-75.e1
- Different digestion enzymes used for human pancreatic islet isolation: a mixed treatment comparison (MTC) meta-analysis.Islets. 2014; 6e977118
- Complex abdominal and pelvic abscesses: efficacy of adjunctive tissue-type plasminogen activator for drainage.Radiology. 2008; 247: 567-573
- Can endogenous gastric acid and bile facilitate chemical debridement of walled off necrosis?.Pancreatology. 2019; 19: 398-399
- The use of gastric juice to aid in liquefaction and drainage of pancreatic ecrosis.HPB. 2016; 18: 327-328
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Footnotes
This work was supported by National Natural Science Foundation of China (No. 82070665).
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© 2022 by the American Society for Gastrointestinal Endoscopy
