EUS-Guided Interventions for Walled-off Pancreatic Necrosis

Abstract

In recent years, evidence suggests that a minimally invasive step-up approach is superior to conventional open necrosectomy, with decreased rates of the composite end point of major complications or death among patients with necrotizing pancreatitis and walled-off necrosis (WON). Since first described in 1992, EUS-guided transluminal drainage for pancreatic fluid collection has played a pivotal role and spread worldwide as a minimally invasive alternative to surgical and percutaneous drainage with reportedly high technical and clinical success rates. However, the clinical response rate of the conventional single transluminal gateway technique with single stenting for treating WON is not satisfactory (described as 45%–63%). Recently, various techniques, such as the use of wide-caliber lumen-apposing metal stents, multiple transluminal gateway technique and direct endoscopic necrosectomy have improved the clinical success rate of endoscopic management of WON. When conventional EUS fails to depict the WON reflecting solid necrotic components, contrast-enhanced EUS may be useful to clearly visualize target lesions and to decisively puncture them. We evaluated the clinical outcomes of the algorithmic step-up approach based on EUS-guided drainage for WON. The result shows the step-up approach based on EUS-guided drainage is an effective strategy for the management of WON, particularly in patients with serious comorbid conditions or in those with WON cavity extending to the pelvis, who are difficult to manage with endoscopy alone. More options, such as surgical necrosectomy should be considered. In conclusion, EUS-guided intervention has become an essential treatment method of WON. The development of new dedicated devices for EUS-guided drainage would help make it a more sophisticated and promising procedure.