Endoscopic pancreatic necrosectomy: Why to scuff when you can flush the muck-make it an easy row to hoe

Abstract

Background and Objectives:Endoscopic ultrasound (EUS)-guided drainage of symptomatic walled-off pancreatic necrosis (WON) followed by fully covered self-expanding metal stent (FCSEMS) placement offers several advantages such as higher technical success and option of necrosectomy. The aim was to evaluate the safety and efficacy of EUS-guided drainage of patients with WON using FCSEMS and intracavitary lavage with solution containing hydrogen peroxide by adopting a step-up approach.Methods:A prospective open-label study was done at a single tertiary care center from January 2014 to January 2016. Patients with symptomatic WON who underwent EUS-guided drainage followed by FCSEMS placement were included in the study. Primary endpoints were complete drainage with improvement in symptoms or major adverse events. Secondary endpoints were minor adverse events related to procedures.Results:A total of 64 patients (mean age 36 years; 52 males) were included. Technical success was achieved in 100% and clinical success was achieved in 90.6%. Complete drainage was achieved with FCSEMS alone in 18 (28.1%), FCSEMS with necrosectomy using lavage in 40 (62.5%), FCSEMS with percutaneous drainage in 5 (7.8%), and 1 (1.5%) patient required salvage surgery. Major adverse events were life-threatening bleeding in 3 (4.6%). Minor adverse events were nonlife-threatening bleeding in 2 (3.1%) patients and stent migration in 3 (4.6%) patients.Conclusion:EUS-guided WON drainage with FCSEMS followed by necrosectomy with lavage using solution containing hydrogen peroxide as a step-up approach is a minimally invasive and effective method with high technical and clinical success. Patients with solid debris >40% need aggressive management.