Direct Endoscopic Necrosectomy Research Articles

Retrieval and reuse of a dislodged lumen-apposing metal stent during endoscopic necrosectomy for pancreatic necrosis

A 53-year-old man with gallstone pancreatitis complicated by infected walled-off pancreatic necrosis (WOPN) was admitted to our institution. EUS-guided cystgastrostomy was performed with insertion of a 15-mm diameter lumen-apposing metal stent (LAMS). Two weeks later, during direct endoscopic necrosectomy (DEN), a therapeutic gastroscope (10-mm diameter, 3.7-mm working channel) was inserted through the LAMS into the cavity. Hydrogen peroxide lavage and debridement of the necrotic tissue was performed. Upon withdrawal of the gastroscope from the cavity, the LAMS was noted endoscopically and fluoroscopically to have dislodged (Fig. 1A). Necrosectomy was continued through the fistulous tract, and upon completion, the LAMS was retrieved from the stomach using biopsy forceps and was removed through the mouth. The retrieved LAMS was then backloaded into the gastroscope channel using biopsy forceps to grasp one flange of the stent while elongating the stent in a cylindrical fashion and simultaneously applying gentle traction on the biopsy forceps (Video 1, available online at www.giejournal.org). Once the LAMS was backloaded into the channel, the gastroscope was advanced into the cavity, and the biopsy forceps were advanced to deploy the LAMS with the distal flange in the cavity and the proximal flange within the stomach (Fig. 1B). Dilation of the LAMS to 15 mm was then performed with a controlled radial expansion balloon. Two more sessions of DEN were performed without further dislodgment of the LAMS with complete resolution of the WOPN.

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.

Safety of direct endoscopic necrosectomy in patients with gastric varices.

To determine the feasibility and safety of transgastric direct endoscopic necrosectomy (DEN) in patients with walled-off necrosis (WON) and gastric varices. A single center retrospective study of consecutive DEN for WON was performed from 2012 to 2015. All DEN cases with gastric fundal varices noted on endoscopy, computed tomography (CT) or magnetic resonance imaging (MRI) during the admission for DEN were collected for analysis. In all cases, external urethral sphincter (EUS) with doppler was used to exclude the presence of intervening gastric varices or other vascular structures prior to 19 gauge fine-needle aspiration (FNA) needle access into the cavity. The tract was serially dilated to 20 mm and was entered with an endoscope for DEN. Pigtail stents were placed to facilitate drainage of the cavity. Procedure details were recorded. Comprehensive chart review was performed to evaluate for complications and WON recurrence. Fifteen patients who underwent DEN for WON had gastric varices at the time of their procedure. All patients had an INR < 1.5 and platelets > 50. Of these patients, 11 had splenic vein thrombosis and 2 had portal vein thrombosis. Two patients had isolated gastric varices, type 1 and the remaining 13 had > 5 mm gastric submucosal varices on imaging by CT, MRI or EUS. No procedures were terminated without completing the DEN for any reason. One patient had self-limited intraprocedural bleeding related to balloon dilation of the tract. Two patients experienced delayed bleeding at 2 and 5 d post-op respectively. One required no therapy or intervention and the other received 1 unit transfusion and had an EGD which revealed no active bleeding. Resolution rate of WON was 100% (after up to 2 additional DEN in one patient) and no patients required interventional radiology or surgical interventions. In patients with WON and gastric varices, DEN using EUS and doppler guidance may be performed safely. Successful resolution of WON does not appear to be compromised by the presence of gastric varices, with similar rates of resolution and only minor bleeding events. Experienced centers should not consider gastric varices a contraindication to DEN.

A two-center comparative study of plastic and lumen-apposing large diameter self-expandable metallic stents in endoscopic ultrasound-guided drainage of pancreatic fluid collections.

Background and Objectives:Endoscopic ultrasound-guided drainage of walled-off pancreatic fluid collections (PFCs) (pseudocyst [PC]; walled-off necrosis [WON]) utilizes double pigtail plastic stents (PS) and the newer large diameter fully covered self-expandable stents (FCSEMS) customized for PFC drainage. This study examined the impact of type of stent on clinical outcomes and costs.Patients and Methods:Retrospective two-center study. Outcome variables were technical and clinical success, need for repeat procedures, need for direct endoscopic necrosectomy (DEN), and procedure-related costs.Results:A total of 49 (PC: 31, WON: 18) patients were analyzed. Initially, PS was used in 37 and FCSEMS in 12. Repeat transmural drainage was required in 14 (PS: 13 [9 treated with PS, 4 treated with FCSEMS]; FCSEMS: 1 [treated with PS]) due to stent migration (PS: 3; FCSEMS: 1) or inadequate drainage (PS: 10). Technical success was 100%. Initial clinical success was 64.9% (25/38) for PS versus 91.7% (11/12) for FCSEMS (P = 0.074). With repeat transmural stenting, final clinical success was achieved in 94.6% and 100%, respectively (P = 0.411). Compared to FCSEMS, PS was associated with greater need for repeat drainage (34.2% vs. 6.3%, P = 0.032). The need for and frequency of DEN was similar between both groups, but PS required more frequent balloon dilatation. PS was significantly cheaper for noninfected PC. Costs were similar for infected PC and WON.Conclusion:PS was associated with a higher need for a second drainage procedure to achieve clinical success. The use of FCSEMS did not increase procedural costs for infected PC and WON.

Percutaneous debridement and washout of walled-off abdominal abscess and necrosis using flexible endoscopy: a large single-center experience.

Background and study aims: Direct percutaneous endoscopic necrosectomy has been described as a minimally invasive intervention for the debridement of walled-off pancreatic necrosis (WOPN). In this retrospective cohort study, we aimed to confirm these findings in a US referral center and evaluate the clinical value of this modality in the treatment of pancreatic necrosis as well as other types of intra-abdominal fluid collections and necrosis. Patients and methods: Twelve consecutive patients with WOPN or other abdominal abscess requiring debridement and washout underwent computed tomography (CT)-guided drainage catheter placement. Each patient then underwent direct percutaneous endoscopic necrosectomy and washout with repeat debridement performed until complete. Drains were then removed once output fell below 30 mL/day and imaging confirmed resolution. The primary endpoints were time to clinical resolution and sustained resolution at 1-year follow up. Results: Ten patients were treated for WOPN, one for necrotic hepatic abscesses, and one for omental necrosis. The median time to intervention was 85 days with an average of 2.3 necrosectomies performed. Complete removal of drains was accomplished in 11 patients (92 %). The median time to resolution was 57 days. No serious adverse events occurred; however, one patient developed pancreaticocutaneous fistulas. Ten patients completed 1-year surveillance of which none required drain replacement. No patients required surgery or repeat endoscopy. Conclusions: This series supports the premise that direct percutaneous endoscopic necrosectomy is a safe and effective intervention for intra-abdominal fluid collections and necrosis in appropriately selected patients. Our study demonstrates a high clinical success rate with minimal adverse events. This modality offers several potential advantages over surgical and transgastric approaches including use of improved accessibility, an excellent safety profile, and requirement for only deep or moderate sedation.

Direct endoscopic necrosectomy in retroflexion when using a lumen-apposing transmural covered metal stent

Direct endoscopic necrosectomy (DEN) is an effective method for the nonsurgical treatment of walled-off necrotic collections by means of debridement and drainage. Some aspects of the DEN technique are areas of ongoing debate, such as size or type of stent, need for simultaneous percutaneous drainage, specific approach to debridement, and number of repeated procedures. However, common to all approaches to DEN is the need for a stable, durable stomach-to-collection transmural tract for drainage and access. This is particularly important when a difficult endoscopic position is required, such as retroflexion. In this video, we demonstrate DEN while using a lumen-apposing transmural covered metal stent (Video 1, available online at www.giejournal.org). The stent has a dumbbell-like shape because both ends have a flared contour, facilitating endoscope passage and debridement in the retroflexed position (Fig. 1). DISCLOSURE

EUS-guided drainage of pancreatic fluid collections using a novel lumen-apposing metal stent on an electrocautery-enhanced delivery system: a large retrospective study (with video)

A lumen-apposing, self-expanding metal stent incorporated in an electrocautery-enhanced delivery system for EUS-guided drainage of pancreatic fluid collections (PFCs) recently has become available. The aim of this study was to analyze the safety and clinical effectiveness of this newly developed device in this clinical setting. This was a retrospective analysis of all consecutive patients with PFCs who underwent EUS-guided drainage using the study device in 13 European centers. Ninety-three patients with PFCs (80% with complex collections) underwent drainage using the study device. Penetration of the PFC was accomplished directly with the study device in 74.2% of patients, and successful stent placement was accomplished in all but 1 patient, mostly without fluoroscopic assistance. Direct endoscopic necrosectomy (DEN) was carried out in 31 of 52 cases (59.6%) of walled-off necrosis and in 2 of 4 cases (50%) of acute peripancreatic fluid collection. Complete resolution of the PFC was obtained in 86 cases (92.5%), with no recurrence during follow-up. Treatment failure occurred in 6 patients because of persistent infection requiring surgery (n = 3), perforation and massive bleeding caused by the nasocystic drainage catheter (NCDC) (n = 2), and the need for a larger opening to extract large necrotic tissue pieces (n = 1). Major adverse events occurred in 5 patients (perforation and massive bleeding caused by the NCDC in 2 patients, 1 pneumoperitoneum and 1 stent dislodgement during DEN, and 1 postdrainage infection) and were mostly not related to the drainage procedure. EUS-guided drainage with the electrocautery-enhanced delivery system is a safe, easy to perform, and a highly effective minimally invasive treatment modality for PFCs.

Mo1420 Multiple Plastic Pigtail Stent Method for the Endoscopic Treatment of Walled Off Pancreatic Necrosis

Walled off pancreatic necrosis (WOPN) is increasingly being treated via direct endoscopic necrosectomy; however the number and type of stents to place following cystenterostomy is controversial. We compared the “one and done” technique of placing multiple plastic pigtail stents at the time of first endoscopy vs. the standard multiple debridement technique for important clinical outcomes.

EUS-guided drainage of hepatic abscess and infected biloma using short and long metal stents (with videos)

Currently, few reports exist on EUS-guided hepatic abscess drainage (EUS-HAD) and EUS-guided biloma drainage (EUS-BLD) using a metal stent. We evaluated the technical success rate and efficacy of EUS-HAD and EUS-BLD for patients with hepatic abscess (HA) and infected biloma. Retrospective case series. Single tertiary referral medical center. We evaluated 7 HA and 6 infected biloma patients who were treated between August 2013 and August 2014 at Tokyo Medical University Hospital. EUS-HAD or EUS-BLD using a short (length, 2 or 3 cm) or long (length, 6 or 8 cm) self-expandable fully covered metal stent. Technical success, clinical success, and adverse event. The overall technical success rate was 100% in both EUS-HAD and EUS-BLD. The clinical success ratesofEUS-HAD and EUS-BLD at the first session were 71.4% and 83.3%, respectively. Direct endoscopic necrosectomy was required in 1 case each of HA and infected biloma. The final clinical success rate was 100%. There were no procedure-related adverse events or cases of recurrence during the follow-up period (median, 83.5 days; range, 24-396 days). Small sample size and no control group. EUS-HAD and EUS-BLD using a metal stent can be performed safely and effectively for HA and infected biloma.

Pancreatic endotherapy and necrosectomy.

There has been a paradigm shift in the management of pancreatic necrosis from open surgical debridement of infected necrosis to minimally invasive interventional radiologic, laparoscopic, and endoscopic drainage/debridement techniques. A step-up approach from less invasive to the more invasive modalities is recommended. An important distinction to make is between pseudocysts and walled-off necrosis (WON), as the interventions for each are different. Endoscopic or other interventions should be delayed for at least 4weeks for collections to encapsulate. Direct endoscopic necrosectomy (DEN) is an effective, minimally invasive option. Several variations in the technique, including the use of esophageal fully covered self-expanding metal stents (SEMS) and lumen-apposing SEMS have recently been described. The incremental effectiveness of these stents over conventional techniques needs to be studied. Dual-modality drainage with endoscopic transmural stent placement and lavage through percutaneous drains is also an effective option with low mortality and morbidity. Several minimally invasive surgical options, including video-assisted retroperitoneal debridement and sinus tract endoscopy are available and may be preferable to open surgical necrosectomy. An algorithmic, multidisciplinary management is warranted for successful outcomes. Disconnected pancreatic duct syndrome in the setting of necrotizing pancreatitis is challenging; long-term endoscopic transmural stent placement and/or distal pancreatectomy are potential treatment options.

Endoscopic ultrasound-guided drainage and necrosectomy of walled-off pancreatic necrosis using a metal stent with an electrocautery-enhanced delivery system and hydrogen peroxide.

Direct endoscopic necrosectomy of walled-off pancreatic necrosis (WOPN) has recently been reported to have comparable success rates to surgery, but with lower morbidity and mortality [1] [2]. The procedure is, however, time consuming and requires multiple device exchanges [3], which may increase the risk of complications.

Necrotizing Pancreatitis: New Definitions and a New Era in Surgical Management

Necrotizing pancreatitis is a challenging condition that requires surgical treatment commonly and is associated with substantial morbidity and mortality. Over the past decade, new definitions have been developed for standardization of severity of acute and necrotizing pancreatitis, and new management techniques have emerged based on prospective, randomized clinical trials. Review of English-language literature. A new international classification of acute pancreatitis has been developed by PANCREA (Pancreatitis Across Nations Clinical Research and Education Alliance) to replace the Atlanta Classification. It is based on the actual local (whether pancreatic necrosis is present or not, whether it is sterile or infected) and systemic determinants (whether organ failure is present or not, whether it is transient or persistent) of severity. Early management requires goal-directed fluid resuscitation (with avoidance of over-resuscitation and abdominal compartment syndrome), assessment of severity of pancreatitis, diagnostic computed tomography (CT) imaging to assess for necrotizing pancreatitis, consideration of endoscopic retrograde cholangiopancreatography (ERCP) for biliary pancreatitis and early enteral nutrition support. Antibiotic prophylaxis is not recommended. Therapeutic antibiotics are required for treatment of documented infected pancreatic necrosis. The initial treatment of infected pancreatic necrosis is percutaneous catheter or endoscopic (transgastric/transduodenal) drainage with a second drain placement as required. Lack of clinical improvement after these initial procedures warrants consideration of minimally invasive techniques for pancreatic necrosectomy including video-assisted retroperitoneal debridement (VARD), minimally invasive retroperitoneal pancreatectomy (MIRP), or transluminal direct endoscopic necrosectomy (DEN). Open necrosectomy is associated with substantial morbidity, but to date no randomized trial has documented superiority of either minimally invasive or open surgical technique. Additional trials are underway to address this. Severe acute and necrotizing pancreatitis requires a multi-disciplinary treatment strategy that must be individualized for each patient. Optimal treatment of necrotizing pancreatitis now requires a staged, multi-disciplinary, minimally invasive "step-up" approach that includes a team of interventional radiologists, therapeutic endoscopists, and surgeons.

Clinical evaluation of endoscopic ultrasonography-guided drainage using a novel flared-type biflanged metal stent for pancreatic fluid collection.

Background and Objectives:Endoscopic ultrasonography (EUS)-guided transluminal drainage for pancreatic fluid collections (PFCs) has become the standard therapy worldwide as a minimally invasive therapy compared with surgical drainage. Recently, a novel flared-type biflanged metal stent (BFMS) designed specifically for the treatment of PFCs has been developed. The aim of this study was to retrospectively assess the feasibility and safety of EUS-guided drainage and direct endoscopic necrosectomy (DEN) for PFCs using the novel flared-type BFMS.Patients and Methods:Twenty-one patients were treated by EUS-guided drainage using a flared-type BFMS for PFCs (pancreatic pseudocyst, 2 patients; walled-off necrosis, 19 patients).Results:The present study showed a technical success rate of 100%, a final clinical success rate of 100%, a procedure-related adverse event (AE) rate of 0%, an early AE rate of 28.6% (moderate and severe AE rate of 9.5%), a mortality rate of 0%, and a recurrence rate of 9.5%. DEN (mean, 2.3 sessions) was required in 38% of the patients.Conclusion:The present study clarified that the EUS-guided drainage using the flared-type BFMS is an effective and safe treatment approach for PFCs. Further studies using randomized controlled multicenter trials are warranted.

Pulsating pseudoaneurysm in a walled-off necrosis

Bleeding from the cavity caused by the rupture of a pseudoaneurysm is a fatal adverse event in patients with walled-off necrosis (WON). Thus, the management of bleeding is mandatory for treatment success. Herein, we describe a pulsating pseudoaneurysm in the cavity of a WON diagnosed by endoscopy through a fully covered biflanged metal stent (BFMS). Subsequently, the pseudoaneurysm was successfully treated. A 38-year-old man experienced an infected WON after a severe necrotizing pancreatitis. A novel BFMS (16 mm in diameter and 20 mm in length) was placed under EUS guidance. Then, direct endoscopic necrosectomy was performed through the BFMS. Seven days afterward, the patient vomited blood; we suspected bleeding from the cavity. Emergency angiography was not able to detect any obvious bleeding point. After 7 days of conservative

Management of pancreatic collections with a novel endoscopically placed fully covered self-expandable metal stent: a national experience (with videos)

Recent medical literature on novel lumen-apposing stents for the treatment of pancreatic fluid collections (PFCs) is limited by small numbers, solo operators, and single-center experience. To evaluate a recently developed lumen-apposing, fully covered self-expandable metal stent (FCSEMS) in the management of PFCs. Retrospective case series. Thirteen tertiary and private health care centers across Australia. Forty-seven patients (median age 51 years) who underwent endoscopic management of PFCs. Insertion of FCSEMS after PFC puncture under EUS guidance. A subgroup of 9 patients underwent direct endoscopic necrosectomy. Technical and clinical success rate, adverse event rate. The technical success rate was 53 of 54 patients (98.1%), and the initial clinical success rate was 36 of 47 (76.6%), which was sustained for more than 6 months in 34 of 36 (94.4%). Early adverse events included 4 cases (7.4%) of stent migration during direct endoscopic necrosectomy, 4 cases (7.4%) of sepsis, 1 case (1.9%) of bleeding, and 1 case (1.9%) of stent migration into the fistula tract. Late adverse events were6 (11.1%) spontaneous stent migrations, 3 (5.6%) recurrent stent occlusions, 3 (5.6%) tissue ingrowth/overgrowth, and 2 (3.7%) bleeding into PFC. The majority of stents inserted (48 of 54, 88.9%) and removed (31 of 35, 88.6%) in our study were described by the operator as superior to pigtail stents with regard to ease of use. Retrospective study. Although FCSEMSs are technically easier to insert and remove compared with traditional pigtail stents, there are significant limitations to the widespread use of FCSEMSs in the management of PFCs. These include cost, adverse events, and lower-than-expected resolution rates.

Resolution of walled-off pancreatic necrosis by EUS-guided drainage when using a fully covered through-the-scope self-expandable metal stent in a single procedure (with video)

Walled-off pancreatic necrosis (WOPN) is effectively managed with percutaneous and endoscopic techniques such as direct endoscopic necrosectomy. However, they require repeat interventions and lengthy hospital stays. To evaluate a new platform to manage WOPNs by using a large-bore, through-the-scope, fully covered, self-expandable metal stent (FCSEMS) to overcome the need for repeat interventions and extended hospital stays. Retrospective, single-center study. Academic tertiary care center. Five consecutive patients with symptomatic WOPN underwent EUS-guided drainage of WOPN by using a large-bore FCSEMSs. EUS-guided transgastric drainage of WOPN by using a large-bore FCSEMS. Cross-sectional imaging was repeated at 6- to 8-week intervals. The FCSEMS was removed after WOPN resolution. Clinical success, number of repeat interventions, and length of hospital stay. Five patients (mean age 60 years) with WOPN (mean diameter, 12.3 cm; range 9.8-14.3 cm) underwent drainage with the described technique. Technical and clinical success was achieved in 100% of patients. Direct endoscopic necrosectomy was not required in any patient. The median number of endoscopic procedures was 1. The median length of hospital stay was 1 day. There were no adverse events. Small, retrospective study. The described novel platform facilitates resolution of WOPN with a single procedure, avoiding the need for repeat interventions and lengthy hospital stays.

Mo1389 Plastic Stent Versus Biflanged Metal Stent Placement Under EUS Guidance for the Treatment of Pancreatic Pseudocysts and Walled-off Necrosis

Endoscopic ultrasonography (EUS)-guided drainage of pancreatic fluid collections (PFCs) using single or multiple plastic stents (PS) with or without nasocystic catheter is common. Recently, EUS-guided drainage using a novel self-expandable biflanged metal stent (BFMS) has been reported for satisfactory drainage and sequential direct endoscopic necrosectomy. However, its safety and efficacy is still controversial. In the present study, we retrospectively assessed its safety, efficacy and cost-effectiveness of EUS-guided drainage for PCFs using BFMS compared to PS.

A Diagnosis That’s Up in the Air

Question: A 61-year-old man presented with severe upper abdominal pain. He had a history of moderate alcohol intake, but no prior pancreatic disease. On physical examination he was afebrile with upper abdominal tenderness and voluntary guarding. Laboratory studies were notable for: aspartate aminotransferase, 118 U/L (normal, <48); alanine aminotransferase, 114 U/L (normal, <55); creatinine 3.8 mg/dL (normal, <1.3); and lipase, 3,843 U/L (normal, <73). A computed tomographic (CT) scan of the abdomen without contrast was obtained (Figure A). Urgent endoscopic retrograde cholangiopancreatography was performed and biliary sludge and 1 stone were removed. He developed progressive multiorgan failure over the next week, including septic shock requiring vasopressor support, acute renal failure requiring dialysis, and hypoxemic respiratory failure necessitating mechanical ventilation. Subsequently, a CT-guided fine-needle aspiration of a peripancreatic fluid collection revealed polymicrobial growth of Escherichia coli, Klebsiella pneumoniae, Enterococcus casseliflavus, and Candida albicans. What is the diagnosis? Look on page 1429 for the answer and see the Gastroenterology web site (www.gastrojournal.org) for more information on submitting your favorite image to Clinical Challenges and Images in GI. The CT image obtained at initial presentation demonstrates air within the pancreatic parenchyma and an acute peripancreatic fluid collection abutting the tail of the pancreas. A large gallstone was also noted. Emphysematous pancreatitis is a rare variant of severe acute pancreatitis. The phrase has been used ambiguously for many years, but in the purest form describes air located within the pancreatic parenchyma. This is analogous to other entities such as emphysematous cholecystitis and gastritis. Semantically, this is distinguished from infected walled off pancreatic necrosis, in which air is seen within a defined collection.1Banks P.A. Bollen T.L. Dervenis C. et al.Classification of acute pancreatitis–2012: revision of the Atlanta classification and definitions by international consensus.Gut. 2013; 62: 102-111Crossref PubMed Scopus (3608) Google Scholar The origin of the air seen within the pancreatic parenchyma at the onset of pancreatitis is not understood. In well-formed collections, microbial isolation of a gas-forming organism is uncommon, leading some authors to believe such air is the consequence of a fistulous communication to the gastrointestinal lumen (stomach, duodenum, or colon). Because the terminology of emphysematous pancreatitis is used loosely, existing series generally do not discriminate between those with air in the parenchyma or within a defined pancreatic fluid collection. It may be the case that these 2 entities represent the same disease process at different points in time; however, we believe that patients with intraparenchymal air have a worse outcome. Historically, intraparenchymal air was an indication for surgical debridement. However, there are emerging data, including the current report, in which patients can be successfully managed nonsurgically with a combination of antibiotics, percutaneous drainage, and/or endoscopic treatment.2Kvinlaug K. Kriegler S. Moser M. Emphysematous pancreatitis: a less aggressive form of infected pancreatic necrosis?.Pancreas. 2009; 38: 667-671Crossref PubMed Scopus (19) Google Scholar, 3Nadkarni N. D'Cruz S. Kaur R. et al.Successful outcome with conservative management of emphysematous pancreatitis.Indian J Gastroenterol. 2013; 32: 242-245Crossref PubMed Scopus (11) Google Scholar Despite the use of broad-spectrum antibiotics and maximal medical support, this patient progressively deteriorated clinically. He underwent direct endoscopic necrosectomy on hospital days 14 and 16 (approximately 3 weeks after onset of symptoms). A temporary percutaneous drain was placed into a left paracolic gutter extension. He was discharged 1 month later, and was tolerating an oral diet without the need for supplemental oxygen or dialysis. As an outpatient, 2 additional endoscopic débridements were performed and all stents were removed 3 months after discharge (Figure B). This case illustrates an uncommon variant of pancreatitis in which gas was present in the parenchyma at the time of initial presentation. Previously, emphysematous pancreatitis was felt to be an absolute indication for surgical debridement, but this case, amongst others, illustrates the possibility for successful nonoperative management. Dr Baron is currently affiliated with University of North Carolina Chapel Hill.

Extended Open Transgastric Necrosectomy (EOTN) as a Safer Procedure for Necrotizing Pancreatitis.

The treatment of infected necrotizing pancreatitis has evolved from time to time and the success of surgical intervention depends on the timing of necrosectomy. Bacterial infection occurs in 40-70% of patients with necrotizing pancreatitis. Infection is the main risk factor for mortality among patients with pancreatic necrosis. Timely intervention is generally required for pancreatic necrosis but is now deferred until four weeks after disease onset in order to permit encapsulation and demarcation of the necrotic material. Demarcation facilitates necrosectomy and reduces complications related to the drainage and debridement procedures. The approach to pancreatic necrosectomy has evolved from primary open necrosectomy to minimally-invasive radiologic, surgical and endoscopic procedures. Direct endoscopic necrosectomy is a minimally-invasive technique that was introduced in recent years for the treatment of walled-off necrosis. The pancreas is approached through the posterior wall of stomach and debridement is done.

Hydrogen Peroxide-Assisted Endoscopic Necrosectomy for Walled-Off Pancreatic Necrosis: A Dual Center Pilot Experience

Pancreatic necrosis (PNec) is a serious local complication occurring in 10–15 % of patients with acute pancreatitis (AP). Necrotizing pancreatitis can organize into necrotic collections, termed walled-off necrosis (WON) [1, 2]. Symptomatic WON has traditionally been treated operatively [3]. In several recent trials, successful resolution of WON was achieved using endoscopic therapy, termed direct endoscopic necrosectomy (DEN) [4, 5]. A challenge to DEN is removal of all necrotic material from within the collection [6, 7]. Hydrogen peroxide (H2O2) is acknowledged as an effective means to achieve mechanical debridement of wounds [8–11]. In this case series, we describe a dual center experience with the use of H2O2 to facilitate removal of necrotic debris in patients undergoing DEN as the preliminary measure for management of WON.