Operative vs. Nonoperative therapy in necrotizing pancreatitis

Anecdotal and uncontrolled recommendations for programmatic surgical intervention in necrotizing pancreatitis are gradually being replaced by nonoperative approaches as prospective natural history information becomes available. In patients with sterile pancreatic necrosis, nonoperative managements has now been shown to result in a mortality rate equal or better to surgical debridement. Moreover, since surgical debridement of sterile pancreatic necrosis has not been shown to prevent or ameliorate co-existing organ failure, and given that secondary infection of sterile necrosis occurs as a result of operative debridement in 25% of cases and results in a trebling of mortality risk, it is becoming increasingly clear that surgical debridement in sterile necrotizing pancreatitis will become the exception rather than the rule. However, surgical debridement and drainage remains the preferred approach for infected pancreatic necrosis despite occasional anecdotal reports of successful management by transcutaneous or endoscopic means. While the optimal post-surgical technique of drainage remains controversial, a selective approach is reasonable, with the choice between closed drainage, lesser sac lavage, or schedule re-explorations being based upon extent of the necrotic process.     

Necrosectomy in acute pancreatitis

Indications for surgical intervention in necrotizing pancreatitis, and the specific technique to be employed, have been controversial. Accumulating data suggest that pancreatic debridement is not beneficial in patients with sterile pancreatic necrosis. Infected pancreatic necrosis, on the other hand, is widely accepted as an absolute indication for surgical intervention. The choice of a specific technique (conventional closed drainage, lesser sac lavage, or open packing) depends upon the extent and the location of the infected process. Open packing is superior for patients with extensive infected necrosis.     

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.     

Management of complicated acute pancreatitis: Impact of computed tomography

The usefulness of computed tomography (CT) in guiding the management of 43 patients who had a complicated clinical course of acute pancreatitis was retrospectively studied. The CT scans were performed when patients had persistent fever, leucocytosis, hyperamylasaemia, palpable abdominal masses or when there was organ failure. The CT scans showed normal findings in six patients, features of pancreatic abscess in three patients, pseudocysts in three patients and inflammatory masses (a mixture of sterile inflammation and necrosis) in 31 patients. Patients with pancreatic abscesses underwent emergency laparotomy, drainage and debridement; patients with pseudocysts had delayed drainage unless complication occurred; patients with normal CT scan or findings of inflammatory masses were managed conservatively. For patients undergoing conservative management, repeated CT scanning and percutaneous aspiration of the inflammatory mass was performed when pancreatic sepsis was strongly suspected. By this approach, basing on careful clinical and CT scan surveillance, five patients with pancreatic sepsis (pancreatic abscess and localized abscess collection in pseudocyst) underwent emergency surgery and four survived, while 25 patients with inflammatory masses were successfully managed conservatively and some who may have been operated on clinical grounds were spared unnecessary early debridement surgery.     

Pseudocyst Drainage Predisposes to Infection When Pancreatic Necrosis is Unrecognized

Objective: The objective of this report was to determine the clinical outcome of intervention among patients with a pancreatic pseudocyst associated with sterile pancreatic necrosis. Methods: We reviewed records of all patients with sterile pancreatic necrosis who required intervention during the past 10 yr. Results: A total of 17 patients required intervention. Twelve with sterile necrosis unassociated with a pancreatic pseudocyst underwent surgical debridement. An additional five patients with sterile necrosis associated with a pancreatic pseudocyst underwent drainage of the pseudocyst (two by pigtail catheter drainage, one by endoscopic cyst gastrostomy, and two by surgical cyst gastrostomy). After drainage, four of these five patients developed pancreatic infection that required surgical debridement Pancreatic infection occurred because the drainage procedures in these four patients failed to remove the underlying necrotic material. Conclusions: When a pancreatic pseudocyst occurs in association with pancreatic necrosis, radiological and endoscopic decompression should not be attempted.     

Acute pancreatitis: when and how to operate.

Patients with proved necrotizing pancreatitis should be treated in an intensive care unit. Surgical management of necrotizing pancreatitis is indicated if an acute abdomen or persistent or increasing signs of organ complications develop, such as pulmonary or renal insufficiency, cardiocirculatory dysfunction or metabolic disorders, and these do not respond to maximum intensive care treatment over at least 72 h. Besides these so-called non-responders to ICU treatment, operative management is clearly indicated in patients who develop signs of sepsis on the basis of a bacteriologically positive fine-needle aspiration of pancreatic necroses. In patients with minor necroses without any bacterial contamination and without extensive retroperitoneal fatty tissue necroses intensive care therapy can be successful without the necessity of a surgical intervention. The gold standard of surgical management of necrotizing pancreatitis is careful removal of necrotic tissue, drainage of bacterially infected area, elimination of the pancreatogenic ascites in order to prevent systemic spread of vasoactive and toxic substances and interruption of the inflammatory process. For the treatment of pancreatic necrosis we strongly support surgical debridement (necrosectomy), supplemented by postoperative closed continuous lavage of the lesser sac and the adjacent necrotic cavities. In 152 patients suffering from severe necrotizing pancreatitis the hospital mortality was 12.5% (19/152) by this surgical approach.     

Surgical treatment of acute pancreatitis

Opinion statement Patients with predicted severe necrotizing pancreatitis as diagnosed by C-reactive protein (>150 mg/L) and/or contrast-enhanced computed tomography should be managed in the intensive care unit. Prophylactic broad-spectrum antibiotics reduce infection rates and survival in severe necrotizing pancreatitis. Endoscopic retrograde cholangiopancreatography and endoscopic sphincterotomy is a causative therapy for gallstone pancreatitis with impacted stones, biliary sepsis, or obstructive jaundice. Fine needle aspiration for bacteriology should be performed to differentiate between sterile and infected pancreatic necrosis in patients with sepsis syndrome. Infected pancreatic necrosis in patients with clinical signs and symptoms of sepsis is an indication for surgery. Patients with sterile pancreatic necrosis should be managed conservatively. Surgery in patients with sterile necrosis may be indicated in cases of persistent necrotizing pancreatitis and in the rare cases of “fulminant acute pancreatitis.” Early surgery, within 14 days after onset of the disease, is not recommended in patients with necrotizing pancreatitis. The surgical approach should be organ-preserving (debridement/necrosectomy) and combined with a postoperative management concept that maximizes postoperative evacuation of retroperitoneal debris and exudate. Minimally invasive surgical procedures have to be regarded as an experimental approach and should be restricted to controlled trials. Cholecystectomy should be performed to avoid recurrence of gallstone-associated acute pancreatitis.     

Operative management of necrotizing pancreatitis--necrosectomy and continuous closed postoperative lavage of the lesser sac.

In patients with severe acute pancreatitis, the most important diagnostic goal is differentiation between the interstitial-edematous and the necrotizing type of acute pancreatitis. Surgical management in patients with proven necrotizing pancreatitis is indicated in patients who develop surgical acute abdomen, sepsis, shock syndrome, multisystemic organ failure syndrome, persistent or progressive despite maximum intensive care. The most appropriate procedure for surgical management of pancreatic necrosis is the careful removal of necrosis and preservation of vital pancreatic tissue. Necrosectomy supplemented by postoperative closed continuous lavage of the lesser sac is a procedure that offers the advantages of debridement of devitalized tissue only, and the non-surgical removal of necrotic tissue and bacterially and biologically active compounds. In comparison with a reoperation protocol, necrosectomy and continuous lavage reduce the reoperation rate as well as the need for tracheostomy. In a prospectively treated series of patients suffering from necrotizing pancreatitis, hospital mortality was 8.4% and the reoperation rate 27%. Any tissue becoming necrotic in the postoperative course of disease is rinsed with lavage fluid, thus obviating the need for repeated surgical reoperation in most patients. Local lavage is achieved by the insertion of two, in some cases five, large double-lumen tubus and the use of 8 liters (median) of lavage fluid per day.     

Infected necrosis: morbidity and therapeutic consequences.

Some 20% of cases of acute pancreatitis are associated with pancreatic and/or peripancreatic necrosis. Mortality of necrotizing pancreatitis is higher than that of acute interstitial pancreatitis, especially if there is secondary pancreatic infection. Despite the fact that patients with infected necrosis are in general more seriously ill than those with sterile necrosis, it is not possible at present by any individual laboratory test or constellation of tests to determine precisely which patients are infected or will develop pancreatic infection. CT-guided percutaneous aspiration with bacteriological sampling continues to be a very safe, reliable method of distinguishing severe sterile pancreatitis from pancreatic infection. Improved survival for infected necrosis depends on earlier recognition and prompt effective surgical debridement. Necrosectomy and post-operative local lavage appear to improve survival in infected necrosis.     

Changing concepts in the surgical management of acute pancreatitis.

Most episodes of acute pancreatitis are mild and self-limiting, but severe disease complicated by multiple system organ failure develops in up to 20% of cases. Early detection of those patients who subsequently develop necrotizing pancreatitis allows the start of supportive treatment in the intensive care unit before organ failure occurs. Conservative treatment in the intensive care unit, including the administration of intravenous antibiotics, is the gold standard. Surgery is indicated in patients with infected pancreatic necrosis but not in patients with sterile necrosis in the absence of deteriorating multi-organ failure despite maximal intensive care unit treatment, or other specific surgical complications. At our institution, out of 44 patients with necrotizing pancreatitis 29 (66%) had sterile necrosis and were managed conservatively while 15 (34%) had infected pancreatic necrosis and were treated by necrosectomy and continuous closed retroperitoneal lavage. There were two deaths resulting in an overall mortality of 5% in patients with severe acute pancreatitis.     

Management of infection in acute pancreatitis

The clinical course of acute pancreatitis varies from a mild, transitory illness to a severe, rapidly fatal disease. In about 80% to 90% of cases pancreatitis presents as a mild, self‐limiting disease with low morbidity and mortality. Unlike mild pancreatitis, necrotizing pancreatitis develops in about 15% of patients, with infection of pancreatic and peripancreatic necrosis representing the single most important risk factor for a fatal outcome. Infection of pancreatic necrosis in the natural course develops in the second and third week after onset of the disease and is reported in 40% to 70% of patients with necrotizing pancreatitis. Just recently, prevention of infection by prophylactic antibiotic treatment and assessment of the infection status of pancreatic necrosis by fine‐needle aspiration have been established in the management of severe pancreatitis. Because medical treatment alone will result in a mortality rate of almost 100% in patients with signs of local and systemic septic complications, patients with infected necrosis must undergo surgical intervention, which consists of an organ‐preserving necrosectomy combined with a postoperative closed lavage concept that maximizes further evacuation of infected debris and exudate. However, intensive care treatment, including prophylactic antibiotics, reduces the infection rate and delays the need for surgery in most patients until the third or fourth week after the onset of symptoms. At that time, debridement of necrosis is technically easier to perform, due to better demarcation between viable and necrotic tissue compared with necrosectomy earlier in the disease. In contrast, surgery is rarely needed in the presence of sterile pancreatic necrosis. In those patients the conservative approach is supported by the present data.     

The surgical approach to severe acute pancreatitis

The indications for surgery in severe acute pancreatitis include circumstances in which the diagnosis is uncertain, persistent biliary pancreatitis, infected pancreatic necrosis, and some patients with pancreatic abscess. The controversy surrounding surgical treatment for sterile pancreatic necrosis, and situations in which the disease persists in spite of intensive medical management are also addressed. Surgical principles and the merits of open versus closed drainage are reviewed.     

Infections complicating severe pancreatitis.

Infections accompanying severe pancreatitis are secondary and of three types: infected pancreatic necrosis, infected pseudocyst (including peripancreatic fluid collection), and pancreatic abscess. The first is an earlier, more morbid process, with antibiotics supportive and surgical debridement necessary. The latter two processes occur later in the course of pancreatitis and are less morbid. Antibiotics are supportive and invasive-nonsurgical drainage methods are possible. The decision for intervention is based first on clinical toxicity as determined by an overall assessment by the clinician. The presence of parenchymal necrosis is best determined by the dynamic bolus CT scan. The presence of infection is best determined by percutaneous CT-guided aspiration. Infected necrosis is fatal unless treated with operative intervention. A peripancreatic fluid collection, pseudocyst, or pancreatic abscess needs to be treated if symptomatic. If infected, as determined by CT-guided needle aspiration, then they should be drained. Radiologic or endoscopic invasive-nonsurgical methods are tried initially and then surgery is attempted if they fail. The nonsurgical methods are most successful with pancreatitis of a nonbiliary or a nonalcohol etiology.     

Necrotizing pancreatitis: a surgical approach independent of documented infection

BackgroundStrategies for the management of patients with necrotizing pancreatitis remain controversial. While consensus opinion supports operative necrosectomy for the treatment of infected pancreatic necrosis, the timing for surgical intervention is not completely resolved. Further, the indication for the surgical management of sterile pancreatic necrosis is also subject to debate.MethodsThe objective of this study was to evaluate outcome measures for the surgical management of necrotizing pancreatitis, independent of documented infection. A retrospective review was undertaken between 1994 and 2002 at a single county hospital.ResultsTwenty-one patients with CT-documented necrotizing pancreatitis underwent operative pancreatic necrosectomy with laparostomy within 21 days of initial diagnosis and had an average of three reoperations. Average length of stay (LOS) in the ICU was 36 days and in the hospital 67 days. Ten patients had documented infected necrosis based on initial intra-operative cultures, while I I had sterile necrosis. Overall, 95% (20/21) of the patients had a complication, with an average of three complications per patient. Common complications included ARDS (71%), sepsis (33%), renal failure (24%), and pneumonia (24%). The overall mortality rate was 14% (3/21), with a mean follow-up of 469 days.DiscussionThe surgical management of acute necrotizing pancreatitis, independent of documented infection, can be undertaken within 3 weeks of diagnosis with an acceptable morbidity and a low mortality rate. Creation of a laparostomy to enable ready, atraumatic debridement of the retroperitoneum is a safe alternative to standard repeat laparotomies and thus represents a useful adjunct to the surgical management of necrotizing pancreatitis.     

Surgery in acute pancreatitis.

The most important diagnostic step in the management of patients with severe acute pancreatitis is discrimination between interstitial-edematous pancreatitis and necrotizing pancreatitis. In this respect, laboratory measures like CRP, LDH, and antiproteases, and the application of contrast-enhanced CT are highly sensitive methods. Surgical decision-making should be based on clinical, bacteriological and contrast-enhanced CT data. Persistent or progressive systemic or local organ complications occurring despite ICU treatment for a minimum of three days are indicators for surgical management of necrotizing pancreatitis. Patients suffering from sepsis syndrome, cardiovascular shock, multisystemic organ failure syndrome, or surgical acute abdomen should be treated surgically early in the course of the disease. The use of a major pancreatic resection for the surgical management of necrotizing pancreatitis should be excluded from treatment protocols. Carefully performed necrosectomy or debridement, in combination with continuous or repeatedly applied surgical evacuation techniques for necrotic tissue, bacteria, and biologically active compounds, has proved to be very effective in experienced treatment centers. Necrosectomy and postoperative continuous local lavage is a well-adapted, safe, and atraumatic procedure. It results in a hospital mortality of less than 10% in patients with necrotizing pancreatitis.     

Modern phase-specific management of acute pancreatitis

The management of acute necrotizing pancreatitis has changed significantly over the past years. In contrast to the early surgical intervention of the past, there is now a strong tendency towards a more conservative approach. Initially, severe acute pancreatitis is characterized by the systemic inflammatory response syndrome. Early management is non-surgically and solely supportive. A specific treatment still does not exist. In cases of necrotizing disease, prophylactic antibiotics should be applied to reduce late septic complications. Today, more patients survive the first phase of severe pancreatitis due to improvements of intensive care medicine, thus increasing the risk of later sepsis. Pancreatic infection is the major risk factor with regard to morbidity and mortality in the second phase of severe acute pancreatitis. Whereas early surgery and surgery for sterile necrosis can only be recommended in selected cases, pancreatic infection is a well-accepted indication for surgical treatment in the second phase of the disease. Surgery should ideally be postponed until 4 weeks after the onset of symptoms, as necrosis is well demarcated at that time. Three surgical techniques can be performed with comparable results regarding mortality: necrosectomy combined with the (1) open packing technique, (2) planned staged relaparotomies with repeated lavage, or (3) closed continuous lavage of the retroperitoneum. However, the latter method seems to be associated with the lowest morbidity compared to the other approaches.     

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.     

Severe acute pancreatitis： Clinical course and management

Severe acute pancreatitis (SAP) develops in about 25% of patients with acute pancreatitis (AP). Severity of AP is linked to the presence of systemic organ dysfunctions and/or necrotizing pancreatitis pathomorphologically. Risk factors determining independently the outcome of SAP are early multi-organ failure, infection of necrosis and extended necrosis (> 50%). Up to one third of patients with necrotizing pancreatitis develop in the late course infection of necroses. Morbidity of SAP is biphasic, in the first week strongly related to early and persistence of organ or multi-organ dysfunction. Clinical sepsis caused by infected necrosis leading to multi-organ failure syndrome (MOFS) occurs in the later course after the first week. To predict sepsis, MOFS or deaths in the first 48-72 h, the highest predictive accuracy has been objectified for procalcitonin and IL-8; the Sepsis- Related Organ Failure Assessment (SOFA)-score predicts the outcome in the first 48 h, and provides a daily assessment of treatment response with a high positive predictive value. Contrast-enhanced CT provides the highest diagnostic accuracy for necrotizing pancreatitis when performed after the first week of disease. Patients who suffer early organ dysfunctions or at risk of developing a severe disease require early intensive care treatment. Early vigorous intravenous fluid replacement is of foremost importance. The goal is to decrease the hematocrit or restore normal cardiocirculatory functions. Antibiotic prophylaxis has not been shown as an effective preventive treatment. Early enteral feeding is based on a high level of evidence, resulting in a reduction of local and systemic infection. Patients suffering infected necrosis causing clinical sepsis, pancreatic abscess or surgical acute abdomen are candidates for early intervention. Hospital mortality of SAP after interventional or surgical debridement has decreased in high volume centers to below 20%.     

Gallstone Pancreatitis

Opinion statement The majority of patients with acute gallstone pancreatitis have a mild attack and recover without additional treatment. In about 20% of patients, the attack is severe and is associated with a mortality rate of about 20%. Patients with severe pancreatitis require management in a high-dependency or intensive care setting. These patients are best managed in a specialized unit. Antibiotic prophylaxis is advised in patients with necrosis, and imipenem and cefuroxime are recommended. In severe pancreatitis, early enteral nutrition is recommended through a nasojejunal tube. In patients with severe pancreatitis or with cholangitis, urgent endoscopic retrograde cholangiopancreatography within 72 hours is indicated, and when appropriate, a sphincterotomy and clearance of the bile duct is performed. In sterile necrosis, conservative treatment is indicated unless the patient fails to improve or deteriorates, whereupon surgery is considered. If there is infection of pancreatic necrosis or abscess (pancreatic or peripancreatic), surgery is indicated. A symptomatic and persistent pancreatic pseudocyst requires intervention with either endoscopic drainage (transpapillary pancreatic stent, cystgastrostomy, or cystduodenostomy), percutaneous drainage, or surgery. Before discharge, patients should undergo cholecystectomy, or if they are unfit for surgery, endoscopic sphincterotomy and bile duct clearance.     

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.