Endoscopic necrosectomy of organized pancreatic necrosis: a currently practiced NOTES procedure

Background

Endoscopic necrosectomy is now an established minimally invasive method for treatment of organized pancreatic necrosis.

Methods

Review of methods and results of endoscopic treatment of pancreatic necrosis.

Results

Reports by multiple groups have demonstrated favorable results of endoscopic necrosectomy. The mortality of critically ill patients undergoing endoscopic treatment in several series is approximately 10%. Some patients will eventually also require surgery for situations such as complete pancreatic duct disruption, but even in these cases endoscopic necrosectomy is useful because pancreatic surgery can often be delayed until the patient is stable.

Conclusions

Endoscopic necrosectomy will likely assume an increasing role in the treatment of pancreatic necrosis. This should result in reduced morbidity and mortality in these critically ill patients.     

Endoscopic fibrin glue injection for closure of pancreatocutaneous fistula following transgastric endoscopic necrosectomy

Transgastric endoscopic necrosectomy has been recently introduced as the effective and alternative management of infected pancreatic necrosis and pancreatic abscess. However, up to 40% of patients who undergo endoscopic necrosectomy may need an additional percutaneous approach for subsequent peripancreatic fluid collection or non-resolution of pancreatic necrosis. This percutaneous approach may lead to persistent pancreatocutaneous fistula, which remains a serious problem and usually requires prolonged hospitalization, or even open-abdominal surgery. We describe the first case of pancreatocutaneous fistula and concomitant abdominal wall defect following transgastric endoscopic necrosectomy and percutaneous drainage, which were endoscopically closed with fibrin glue injection via the necrotic cavity.     

Management of pancreatic ductal leaks and fistulae

Pancreatic duct leaks can occur as a result of both acute and chronic pancreatitis or in the setting of pancreatic trauma. Manifestations of leaks include pseudocysts, pancreatic ascites, high amylase pleural effusions, disconnected duct syndrome, and internal and external pancreatic fistulas. Patient presentations are highly variable and range from asymptomatic pancreatic cysts to patients with severe abdominal pain and sepsis from infected fluid collections. The diagnosis can often be made by high‐quality cross‐sectional imaging or during endoscopic retrograde cholangiopancreatography (ERCP). Because of their complexity, pancreatic leak patients are best managed by a multidisciplinary team comprised of therapeutic endoscopists, interventional radiologists, and surgeons in the field of pancreatic interventions. Minor leaks will often resolve with conservative management while severe leaks will frequently require interventions. Endoscopic treatments for pancreatic duct leaks have replaced surgical interventions in many situations. Interventional radiologists also have the ability to offer therapeutic interventions for many leak patients. The mainstay of endotherapy for pancreatic leaks is transpapillary pancreatic duct stenting with a stent that bridges the leak if possible, but varies based on the manifestation and clinical presentation. Fluid collections that result from leaks, such as pseudocysts, can often be treated by endoscopic transluminal drainage with or without endoscopic ultrasound or by percutaneous drainage. Endoscopic interventions have been shown to be effective and have an acceptable complication rate.     

Management of pancreatic fluid collections: A comprehensive review of the literature

Pancreatic fluid collections(PFCs) are a frequent complication of pancreatitis. It is important to classify PFCs to guide management. The revised Atlanta criteria classifies PFCs as acute or chronic, with chronic fluid collections subdivided into pseudocysts and walled-off pancreatic necrosis(WOPN). Establishing adequate nutritional support is an essential step in the management of PFCs. Early attempts at oral feeding can be trialed in patients with mild pancreatitis. Enteral feeding should be implemented in patients with moderate to severe pancreatitis. Jejunal feeding remains the preferred route of enteral nutrition. Symptomatic PFCs require drainage; options include surgical, percutaneous, or endoscopic approaches. With the advent of newer and more advanced endoscopic tools and expertise, and an associated reduction in health care costs, minimally invasive endoscopic drainage has become the preferable approach. An endoscopic ultrasonography-guided approach using a seldinger technique is the preferred endoscopic approach. Both plastic stents and metal stents are efficacious and safe; however, metal stents may offer an advantage, especially in infected pseudocysts and in WOPN. Direct endoscopic necrosectomy is often required in WOPN. Lumen apposing metal stents that allow for direct endoscopic necrosectomy and debridement through the stent lumen are preferred in these patients. Endoscopic retrograde cholangio pancreatography with pancreatic duct(PD) exploration should be performed concurrent to PFC drainage. PD disruption is associated with an increased severity of pancreatitis, an increased risk of recurrent attacks of pancreatitis and long-term complications, and a decreased rate of PFC resolution after drainage. Any pancreatic ductal disruption should be bridged with endoscopic stenting.     

Endoskopisches retroperitoneales Débridement – sinnvolle Interventionen?

There is a general consensus that infected peripancreatic necrosis following acute pancreatitis requires interventional therapy. Endoscopic transgastric retroperitoneal debridement is a less traumatic alternative to open surgical procedures. Sufficiently wide fenestrations of the posterior gastric wall to the retroperitoneal space are created under endosonographic control. Using this access, even extended necrotic and putrid lesions can be cleaned and flushed. The first results are encouraging. In 150 patients treated in five German hospitals, the mortality rate was 8%. It must be emphasized that endoscopic retroperitoneal necrosectomy should always be combined with the transpapillary reconstruction of the pancreatic duct ensuring the physiological flow of pancreatic secretion. “Endoscopic surgery” by gaining access through adequately wide gastric wall fenestrations seems possible with minimal tissue trauma and few intervention-related complications.     

Endoscopic ultrasonography-guided drainage combined with trans-duodenoscope cyclic irrigation technique for walled-off pancreatic necrosis

BackgroundEndoscopic ultrasonography-guided drainage has been established as a good treatment modality in the management of walled-off pancreatic necrosis, but the unmanageable infection of postoperation is still a thorny problem due to the poor drainage ability for solid necrotic debris only through transmural stent and nasocystic catheter.AimsIntroduce a novel therapeutic method, namely endoscopic ultrasonography-guided drainage combined with cyclic irrigation technique in managing patients with walled-off pancreatic necrosis.Methods18 patients with severe acute pancreatitis complicated with walled-off pancreatic necrosis received treatment with endoscopic ultrasonography-guided drainage combined with cyclic irrigation were involved in this retrospective study.Results17 of 18 patients with walled-off pancreatic necrosis were treated by this new therapeutic method. Subsequent surgery was performed in 1 case due to uncontrolled infection, complications such as perforation, bleeding or multiple organ failure were not observed. Treatment success rate was high (16 in 17, 94.12%).ConclusionEndoscopic ultrasonography-guided drainage combined with cyclic irrigation is an effective treatment option for symptomatic walled-off pancreatic necrosis to facilitate drainage and obviate the need for subsequent surgery or endoscopic necrosectomy.     

Evaluation of hydrogen peroxide-assisted endoscopic ultrasonography-guided necrosectomy in walled-off pancreatic necrosis: A single-center experience

Hydrogen peroxide is a liquid that functions in mechanical removal of the necrotic tissue via the elimination of tissue debris.In this study, we aimed to evaluate the effectiveness of the use of hydrogen peroxide in necrosectomy treatment of walled-off pancreatic necrosis.Records of 24 patients who were diagnosed with pancreatic necrosis or walled-off pancreatic necrosis and underwent endoscopic necrosectomy (EN) were retrospectively assessed. Patients were divided into 2 groups; hydrogen peroxide used for treatment or not used, and these 2 groups were compared.A total of 24 patients underwent endoscopic intervention for walled-off pancreatic necrosis. Procedural success was comparable between the 2 groups. During the post-procedural follow-up, the duration of the hospital stay, recurrence, and complication rates were found to be similar in both groups. The mean number of the endoscopic interventions was significantly lower in the hydrogen peroxide group (4.2 ± 1.4 vs 6.1 ± 4.2; P = .01).The use of hydrogen peroxide for EN in walled-off pancreatic necrosis patients seems to have similar efficiency and safety. However, it can be said that the use of hydrogen peroxide could reduce the number of endoscopic procedures.     

NOTES spin-off for the therapeutic gastroenterologist: natural orifice surgery

Natural orifice transluminal endoscopic surgery (NOTES) has ushered in a new era in flexible endoscopy. Over the past decade, modest advances have been made in addressing the fundamental challenges of NOTES surgery including transluminal access and closure techniques, and advancement of NOTES-specific technology. Despite these encouraging initial efforts significant obstacles to widespread acceptance of NOTES as a surgical option persist. Moreover, due to the well-documented safety and efficacy of laparoscopic techniques, the question remains as to the best candidate NOTES procedure. Presently, interest has shifted from true NOTES to hybrid procedures and single incision laparoscopic surgery, due to the lure of more immediate success. Additionally, there is also a growing awareness of the potential applications of natural orifice surgery techniques to the present field of therapeutic endoscopy. Research into transluminal access and closure has born several techniques and devices that are now being explored in endoscopic procedures such as full-thickness resection, endoscopic myotomy, direct endoscopic pancreatic necrosectomy and bariatric endoscopy. Such NOTES "spin-off" procedures are expanding the armamentarium of today's therapeutic endoscopists, and a growing body of literature suggests that they will play a significant role in the evolution of therapeutic endoscopy in the future.     

Long-term results after endoscopic drainage and necrosectomy of symptomatic pancreatic fluid collections

Aims: To determine the immediate and long‐term results of endoscopic drainage and necrosectomy for symptomatic pancreatic fluid collections. Methods: The data of 80 patients with symptomatic pancreatic fluid collections (mean diameter: 11.7 cm, range 3–20; pseudocysts: 24/80, abscess: 20/80, infected walled‐off necrosis: 36/80) referred for endoscopic management from October 1997 to March 2008 were analyzed retrospectively. Results: Endoscopic drainage techniques included endoscopic ultrasound (EUS)‐guided aspiration (2/80), EUS‐guided transenteric drainage (70/80) and non‐EUS‐guided drainage across a spontaneous transenteric fistula (8/80). Endoscopic necrosectomy was carried out in 49/80 (abscesses: 14/20; infected necrosis: 35/36). Procedural complications were bleeding (12/80), perforation (7/80), portal air embolism (1/80) and Ogilvie Syndrome (1/80). Initial technical success was achieved in 78/80 (97.5%) and clinical resolution of the collections was achieved endoscopically in 67/80 (83.8%), with surgery required in 13/80 (perforation: four; endoscopically inaccessible areas: two; inadequate drainage: seven). Within 6 months five patients required surgery due to recurrent fluid collections; over a mean follow up of 31 months, surgery was required in four more patients due to recurrent collections as a consequence of underlying pancreatic duct abnormalities that could not be treated endoscopically. The long‐term success of endoscopic treatment was 58/80 (72.5%). Conclusions: Endoscopic drainage of symptomatic pancreatic fluid collections is safe and effective, with excellent immediate and long‐term results. Endoscopic necrosectomy has a risk of serious complications. The underlying pancreatic duct abnormalities must be addressed to prevent recurrence of fluid collections.     

Endoscopic transluminal pancreatic necrosectomy using a self-expanding metal stent and high-flow water-jet system

Walled-off pancreatic necrosis and a pancreatic abscess are the most severe complications of acute pancreatitis. Surgery in such critically ill patients is often associated with significant morbidity and mortality within the first few weeks after the onset of symptoms. Minimal invasive approaches with high success and low mortality rates are therefore of considerable interest. Endoscopic therapy has the potential to offer safe and effective alternative treatment. We report here on 3 consecutive patients with infected walled-off pancreatic necrosis and 1 patient with a pancreatic abscess who underwent direct endoscopic necrosectomy 19-21 d after the onset of acute pancreatitis. The infected pancreatic necrosis or abscess was punctured transluminally with a cystostome and, after balloon dilatation, a non-covered self-expanding biliary metal stent was placed into the necrotic cavity. Following stent deployment, a nasobiliary pigtail catheter was placed into the cavity to ensure continuous irrigation. After 5-7 d, the metal stent was removed endoscopically and the necrotic cavity was entered with a therapeutic gastroscope. Endoscopic debridement was performed via the simultaneous application of a high-flow water-jet system; using a flush knife, a Dormia basket, and hot biopsy forceps. The transluminal endotherapy was repeated 2-5 times daily during the next 10 d. Supportive care included parenteral antibiotics and jejunal feeding. All patients improved dramatically and with resolution of their septic conditions; 3 patients were completely cured without any further complications or the need for surgery. One patient died from a complication of prolonged ventilation severe bilateral pneumonia, not related to the endoscopic procedure. No procedure related complications were observed. Transluminal endoscopic necrosectomy with temporary application of a self-expanding metal stent and a high-flow water-jet system shows promise for enhancing the potential of this endoscopic approach in patients with walled-off pancreatic ne     

Flexible percutaneous endoscopic retroperitoneal necrosectomy as rescue therapy for pancreatic necroses beyond the reach of endoscopic ultrasonography: A case series

Minimally invasive or endoscopic transluminal drainage and necrosectomy are the standard of care for infected pancreatic fluid collections and necroses after pancreatitis. In an endoscopic treatment algorithm, necroses beyond the reach of safe endoscopic access are typically treated by percutaneous drainage. We aimed to evaluate percutaneous minimally invasive necrosectomy using a purely endoscopic technique in patients with extensive necrosis. In patients with necroses beyond safe transluminal reach, the percutaneous drainage canal was used for flexible endoscopic access and dilatation of the tract to 20 mm. Percutaneous endoscopic necrosectomy was carried out through this canal. We present a case series of 14 patients in whom between one and four necrosectomy (median two) sessions were done to remove solid necroses successfully in 13 out of 14 patients. There were no major complications apart from one patient with abdominal compartment syndrome secondary to delayed erosion of the splenic artery. Percutaneous flexible necrosectomy might evolve into an alternative to surgical minimally invasive necrosectomy in anatomical sites beyond transluminal endoscopic reach.     

JPN Guidelines for the management of acute pancreatitis:surgical management

Acute pancreatitis represents a spectrum of disease ranging from a mild, self-limited course to a rapidly progressive, severe illness. The mortality rate of severe acute pancreatitis exceeds 20%, and some patients diagnosed as mild to moderate acute pancreatitis at the onset of the disease may progress to a severe, life-threatening illness within 2–3 days. The Japanese (JPN) guidelines were designed to provide recommendations regarding the management of acute pancreatitis in patients having a diversity of clinical characteristics. This article sets forth the JPN guidelines for the surgical management of acute pancreatitis, excluding gallstone pancreatitis, by incorporating the latest evidence for the surgical management of severe pancreatitis in the Japanese-language version of the evidence-based Guidelines for the Management of Acute Pancreatitis published in 2003. Ten guidelines are proposed: (1) computed tomography-guided or ultrasound-guided fine-needle aspiration for bacteriology should be performed in patients suspected of having infected pancreatic necrosis; (2) infected pancreatic necrosis accompanied by signs of sepsis is an indication for surgical intervention; (3) patients with sterile pancreatic necrosis should be managed conservatively, and surgical intervention should be performed only in selected cases, such as those with persistent organ complications or severe clinical deterioration despite maximum intensive care; (4) early surgical intervention is not recommended for necrotizing pancreatitis; (5) necrosectomy is recommended as the surgical procedure for infected pancreatic necrosis; (6) simple drainage should be avoided after necrosectomy, and either continuous closed lavage or open drainage should be performed; (7) surgical or percutaneous drainage should be performed for pancreatic abscess; (8) pancreatic abscesses for which clinical findings are not improved by percutaneous drainage should be subjected to surgical drainage immediately; (9) pancreatic pseudocysts that produce symptoms and complications or the diameter of which increases should be drained percutaneously or endoscopically; and (10) pancreatic pseudocysts that do not tend to improve in response to percutaneous drainage or endoscopic drainage should be managed surgically.     

Therapeutic intervention and surgery of acute pancreatitis

The clinical course of acute pancreatitis varies from mild to severe. Assessment of severity and etiology of acute pancreatitis is important to determine the strategy of management for acute pancreatitis. Acute pancreatitis is classified according to its morphology into edematous pancreatitis and necrotizing pancreatitis. Edematous pancreatitis accounts for 80–90% of acute pancreatitis and remission can be achieved in most of the patients without receiving any special treatment. Necrotizing pancreatitis occupies 10–20% of acute pancreatitis and the mortality rate is reported to be 14–25%. The mortality rate is particularly high (34–40%) for infected pancreatic necrosis that is accompanied by bacterial infection in the necrotic tissue of the pancreas (Widdison and Karanjia in Br J Surg 80:148–154, 1993; Ogawa et al. in Research of the actual situations of acute pancreatitis. Research Group for Specific Retractable Diseases, Specific Disease Measure Research Work Sponsored by Ministry of Health, Labour, and Welfare. Heisei 12 Research Report, pp 17–33, 2001). On the other hand, the mortality rate is reported to be 0–11% for sterile pancreatic necrosis which is not accompanied by bacterial infection (Ogawa et al. 2001; Bradely and Allen in Am J Surg 161:19–24, 1991; Rattner et al. in Am J Surg 163:105–109, 1992). The Japanese (JPN) Guidelines were designed to provide recommendations regarding the management of acute pancreatitis in patients having a variety of clinical characteristics. This article describes the guidelines for the surgical management and interventional therapy of acute pancreatitis by incorporating the latest evidence for the management of acute pancreatitis in the Japanese-language version of JPN guidelines 2010. Eleven clinical questions (CQ) are proposed: (1) worsening clinical manifestations and hematological data, positive blood bacteria culture test, positive blood endotoxin test, and the presence of gas bubbles in and around the pancreas on CT scan are indirect findings of infected pancreatic necrosis; (2) bacteriological examination by fine needle aspiration is useful for making a definitive diagnosis of infected pancreatic necrosis; (3) conservative treatment should be performed in sterile pancreatic necrosis; (4) infected pancreatic necrosis is an indication for interventional therapy. However, conservative treatment by antibiotic administration is also available in patients who are in stable general condition; (5) early surgery for necrotizing pancreatitis is not recommended, and it should be delayed as long as possible; (6) necrosectomy is recommended as a surgical procedure for infected necrosis; (7) after necrosectomy, a long-term follow-up paying attention to pancreatic function and complications including the stricture of the bile duct and the pancreatic duct is necessary; (8) drainage including percutaneous, endoscopic and surgical procedure should be performed for pancreatic abscess; (9) if the clinical findings of pancreatic abscess are not improved by percutaneous or endoscopic drainage, surgical drainage should be performed; (10) interventional treatment should be performed for pancreatic pseudocysts that give rise to symptoms, accompany complications or increase the diameter of cysts and (11) percutaneous drainage, endoscopic drainage or surgical procedures are selected in accordance with the conditions of individual cases.     

Endoscopic management of complications of acute pancreatitis: an update on the field

ABSTRACT

Introduction: Acute pancreatitis is a frequent, nonmalignant gastrointestinal disorder leading to hospital admission. For its severe form and subsequent complications, minimally invasive and endoscopic procedures are being used increasingly, and are subject to rapid technical advances.

Areas covered: Based on a systematic literature search in PubMed, medline, and Web-of-Science, we discuss the currently available treatment strategies for endoscopic therapy of pancreatic pseudocysts, walled-off pancreatic necrosis (WON), and disconnected pancreatic duct syndrome (DPDS), and compare the efficacy and safety of plastic and metal stents. A special focus is placed on studies directly comparing different stent types, including lumen-apposing metal stents (LAMS) and clinical outcomes when draining pseudocysts or WONs. The clinical significance and endoscopic treatment options for DPDS are also discussed.

Expert commentary: Endoscopic therapy has become the treatment of choice for different types of pancreatic and peripancreatic collections, the majority of which, however, require no intervention. The use of LAMS has facilitated drainage and necrosectomy in patients with WON or pseudocysts. Serious complications remain a problem in spite of high technical and clinical success rates. DPDS is an increasingly recognized problem in the presence of pseudocysts or WONs but evidence for endoscopic stent placement in this situation remains insufficient.     

Complications of diagnostic and therapeutic Endoscopic Ultrasound

Endoscopic Ultrasound (EUS) provides the unique opportunity to visualize, interrogate and intervene gastrointestinal (GI) luminal, mural or peri-luminal structures and pathology with negligible adverse effects. Diagnostic, upper GI and rectal EUS is feasible, extremely safe, and efficacious. Most EUS guided interventions are safe, effective and minimally invasive, compared to peers in the percutaneous radiological or surgical procedures.As with any endoscopic procedure, EUS and its guided interventions may be accompanied by adverse events. EUS related complications are generally infrequent in expert hands, and mainly include bleeding and perforation. However, the nature and severity of adverse events associated with each EUS guided procedure are unique. Hence, it is paramount for endosonographer to have sufficient knowledge of the indications, techniques, and potential risks involved before contemplating any given procedure.Most common intervention with EUS is transmural fine needle aspiration (FNA), which is an extremely safe procedure. EUS guided drainage procedures are rapidly evolving with newer devices and methods being employed. Among them, EUS guided drainage of pancreatic fluid collection-pseudocyst or walled off necrosis (WON), has largely replaced other methods (surgical, percutaneous or non-EUS endoscopic) with acceptable complications. Currently, dedicated metal stents are more widely used compared to plastic stents for drainage of PFC, especially WON. EUS has made a definite impact in biliary access and drainage of obstructed biliary system, in patients where ERCP has failed or is technically not possible, closely competing with percutaneous biliary drainage. In spite of some complications, recent improvement in devices for bilio-enteric fistula creation and stent designs, has added to its safety and efficacy. EUS guided pancreatic duct drainage remains the most challenging of EUS guided interventions where in-roads are being made.     

New fully-covered self-expandable metal stent for endoscopic ultrasonography-guided intervention in infectious walled-off pancreatic necrosis (with video)

Endoscopic ultrasonography (EUS)-guided pancreatic pseudocyst drainage using a self-expandable metal stent (SEMS) has been reported for satisfactory drainage and endoscopic necrosectomy. Here, we described an interesting case in which successful endoscopic therapy was performed using a new SEMS in infectious walled-off pancreatic necrosis.     

Combined endoscopic trangastric drainage and video assisted retroperitoneal pancreatic debridement – The best of both worlds for extensive pancreatic necrosis with enteric fistulae

Enteric fistula is a serious complication of necrotizing pancreatitis. Endoscopic transluminal drainage and necrosectomy can significantly reduce the incidence of enterocutaneous fistula after pancreatic debridement. However, endoscopic necrosectomy may not be well-suited to debridement of necrosis that tracks laterally to the paracolic gutters, which is often more efficiently addressed by video-assisted retroperitoneal debridement (VARD). We report the combined use of endoscopic transgastric drainage and VARD for treatment of a 76 year old man with severe necrotizing acute pancreatitis complicated by infected, walled-off pancreatic necrosis. Computed tomography showed laterally tracking pancreatic necrosis and flouroscopic drain injection after percutaneous drainage demonstrated with fistulas to the stomach, duodenum, and colon. The infection and fistulas resolved completely. This approach combined the major advantage of VARD with the major advantage of endoscopic transluminal drainage. We are not aware of any reports of combining these techniques and believe the combination offers a minimally invasive approach for patients with extensive necrosis and a high likelihood of enteric or pancreatic fistulas.     

Interventional applications of endoscopic ultrasound

Endoscopic ultrasound, which was developed more than 20 years ago, is currently a valuable investigative tool for endoscopists. It began as a diagnostic instrument and in the short span of a decade made a clinical impact as a therapeutic tool with a promising potential for various interventional applications. The introduction of the curved linear array echoendoscope in the 1990s enabled a whole range of interventional applications of endoscopic ultrasound ranging from fine needle aspiration of lesions surrounding the gastrointestinal tract to celiac plexus block and drainage of pancreatic pseudocyst. This review article outlines the current interventional applications of endoscopic ultrasound and discusses potential future procedures. These procedures include endoscopic ultrasound guided creation of communication between the gastrointestinal tract and adjacent organs, such as hepaticogastrostomy and choledochoduodenostomy.     

Endoskopisch geführte Gastroenteroanastomose – bald Realität?

Endoscopic procedures have become more invasive over the recent years. This tendency has resulted in a transgastric approach involving, for example, necrosectomy. Recently transgastric gastrojejunostomy has been developed as an entirely endoscopic procedure. This has resulted in a new endoscopic surgical approach into the peritoneal cavity, where an iatrogenic opening has to be cut into the gastrointestinal wall with the necessity of endoscopically closing this incision. The techniques and challenges, but also the advantages and disadvantages of this new approach are discussed in this review.