Endoscopic Necrosectomy Research Articles

Percutaneous endoscopic necrosectomy (PEN) for treatment of necrotizing pancreatitis: a systematic review and meta-analysis.

Background and study aims Endoscopic necrosectomy is limited by the proximity of necrosis to the gastrointestinal tract. Percutaneous endoscopic necrosectomy (PEN) is a minimally invasive endoscopic method of percutaneous debridement. Studies regarding its efficacy and safety are lacking. The purpose of this study was to assess the efficacy and safety of PEN in necrotizing pancreatitis. Methods Pubmed, Ovid, Cochrane, Scopus and Web of Science Database were searched from inception through February 2021. Dual extraction and quality assessment of studies using Cochrane risk of bias tool were performed independently by two authors. The primary outcome was defined as clinical success of PEN. Secondary outcomes included periprocedural morbidity, mortality, and long-term morbidity and mortality. Results Sixteen observational studies including 282 subjects were analyzed. The average reported age of the participants was 50.3 years. Patients with reported gender included 39 % females and 61 % males. The success rate as defined by complete resolution of necrosis and removal of drainage catheters/stents was 82 % (95 % confidence interval 77-87). The mean size of pancreatic necrosis was 14.86 cm (5-54 cm). The periprocedural morbidity rate was 10 %, while there was no reported periprocedural mortality. The long-term morbidity rate was reported as 23 % and mortality at follow-up was 16 %. Conclusions PEN is a novel method of endoscopic management of pancreatic necrosis. Based on our meta-analysis of retrospective studies, it represents a safe treatment modality with high rates of clinical success and low rates of perioperative morbidity and mortality. This study supports the use of PEN when conventional endoscopic therapy is not feasible.

Endoscopic drainage and necrosectomy for inoperable gangrenous cholecystitis.

A 56-year-old man with liver, peritoneal, and lymph node metastases after previous transthoracic esophagectomy was diagnosed with acute calculous cholecystitis. Transduodenal endoscopic ultrasound-guided gallbladder drainage (EUS-GBD) was performed using a 10 × 10 mm cautery-enhanced lumen-apposing metal stent (LAMS). Purulent fluid was aspirated and submitted for culture, which identified Enterococcus faecium.

Spray coagulation as an alternative to argon plasma coagulation for bleeding portal hypertensive gastropathy

Spray coagulation as an alternative to argon plasma coagulation for bleeding portal hypertensive gastropathy

Placement of Plastic Stents after Direct Endoscopic Necrosectomy through a Novel Lumen-Apposing Metal Stent for Effective Treatment of Laterally Extended Walled-Off Necrosis: A Pilot Study.

Direct endoscopic necrosectomy (DEN) using a lumen-apposing metal stent (LAMS) is a standard therapy for the management of symptomatic walled-off necrosis (WON). Here, we demonstrated the efficacy of the routine placement of long plastic stents after a DEN session to treat laterally extended WON. Patients (n = 6) with symptomatic laterally extended WON who underwent DEN after long plastic stent placement were included. The primary endpoint was clinical efficacy of the procedure. The technical and clinical success rates were 100% without major adverse events. The WON extended to the pelvic cavity or pericolic area, and the WON size was between 18.6 and 35.8 cm in length. The median number of DEN sessions was 10 (range 6-16), and two or three long plastic stents were placed after every DEN session. Only one patient suffered from pneumoperitoneum during DEN, which spontaneously resolved within 20 min. Placement of a long plastic stent after DEN using LAMS is a minimally invasive and effective treatment for symptomatic laterally extended WON. Further studies are needed to define the indications and most suitable patients.

Direct endoscopic necrosectomy with the newly developed 6-mm powered rotating resection catheter: When size matters.

Direct endoscopic necrosectomy with the newly developed 6-mm powered rotating resection catheter: When size matters.

Percutaneous Endoscopic Necrosectomy of Walled-Off Necrosis in Post-ERCP Pancreatitis

Introduction: Acute pancreatitis is the most frequent complication in patients who undergo endoscopic retrograde cholangiopancreatography (ERCP), with an incidence rate of 3.5-9.7% [1]. 5-10% of these develop acute necrotizing pancreatitis, which may have a pancreatic or peripancreatic localization in 75-80% [2]. We describe a case report of post-ERCP acute necrotizing pancreatitis with walled-off necrosis (WON) treated with percutaneous endoscopic necrosectomy (PEN) [3]. Case Report: A 60-year-old man with obstructive jaundice and common bile duct stones at abdominal CT scan underwent ERCP to clear the biliary tract. In the following days, due to the onset of severe acute pancreatitis and sepsis, he repeated the abdominal CT scan where multiple necrotic collections were found around the pancreas with extension to the pelvic paracolic gutters. Following a step-up approach, targeted antibiotic therapy was started. After four weeks, it was not possible to perform Endoscopic Ultrasound-Guided drainage because of the distance from the stomach or the duodenum to the WON. Then percutaneous drainage was radiologically inserted into the collections through the left side of the abdomen of the patient to flush with hydrogen peroxide every day. Due to the persistent infection and necrosis in the collections, an esophageal fully covered self-expanding metal stent was temporarily inserted through the percutaneous fistula in order to increase the caliber of the fistula and to perform PEN. Discussion: The step-up approach suggests endoscopic or percutaneous drainage of infected WON as the first interventional method, depending on the location of the WON and the local expertise [1]. PEN is a safe and effective alternative to surgical treatment with a technical success rate of 47-93% and a complication rate of no more than 20% [4]. Conclusion: PEN is an advanced endoscopic technique that is showing promising results but still needs randomized controlled trials to establish safety and efficacy.

Response to "The second shot to walled-off necrosis: The sooner the better versus sooner or later".

We appreciate Sato et al's interest in our study. There has been conflicting evidence on the optimal timing of direct endoscopic necrosectomy (DEN).1 In a study by Yan et al., the number of necrosectomies required to achieve resolution was fewer in patients undergoing immediate DEN. In addition, in multivariable analysis, DEN at the time of initial lumen apposing metal stent placement was the only positive predictor for decreasing time to clinical success.2 One concern raised by Sato et al. was using the length of stay as a surrogate marker of treatment success. In our study, systemic inflammatory response syndrome was present in almost all patients at some point in the disease course (95% immediate DEN group and 100% delayed DEN group). However, patients with systemic inflammatory response syndrome within 1 week of drainage underwent dDEN. This group of patients not only had a shorter length of stay in the hospital after initial stent placement but also required fewer overall necrosectomies. The authors requested additional markers of treatment success including time to clinical success and avoidance of DEN altogether. Clinical success was defined as a lack of symptoms and a decrease in collection size to less than 2 cm at which time the lumen apposing metal stent was promptly removed. The average time to clinical success was not statistically significant in the two groups (immediate DEN 40.0 days [SD 24.7] vs. delayed DEN 44.3 days [SD 24.0], p = 0.45). In addition, all patients in our study had necrosis greater than 10% and underwent at least one necrosectomy. A randomized controlled trial would further validate these results and eliminate biases innate to its retrospective design. Dr Rishi Pawa is a consultant for Boston Scientific.

Supportive treatment during the periprocedural period of endoscopic treatment for pancreatic fluid collections: a critical review of current knowledge and future perspectives.

Pancreatic fluid collections (PFCs) commonly develop as complications of acute pancreatitis and ductal disruption due to chronic pancreatitis. In the revised Atlanta classification, PFCs were classified based on the presence of necrosis and duration following the onset of acute pancreatitis. Interventions are required in cases of symptomatic pancreatic pseudocysts or walled-off necrosis (WON). In the management of these PFCs, endoscopic ultrasound-guided transluminal drainage and subsequent direct endoscopic necrosectomy for WON are increasingly utilized as less invasive treatment modalities compared to surgical debridement. To date, researchers have focused predominantly on the technical aspects of endoscopic therapy for symptomatic PFCs. Given the poor physical condition of patients receiving endoscopic treatment for PFCs, systemic support may have a substantial impact on the short- and long-term outcomes of these patients. A multidisciplinary approach is required to improve the clinical outcomes of patients with infected PFCs and their associated comorbidities. However, non-interventional support during the periprocedural period of endoscopic treatment of PFCs has not been fully discussed, and there have been considerable variations in the selection of treatment options between endoscopists and centers. To address these unmet needs in the clinical management of PFCs and promote future research to improve the clinical outcomes, we conducted a review of the literature within a multicenter consortium of expert endoscopists with specific expertise in the endoscopic treatment of PFCs. In this review, we summarize the current evidence on non-interventional supportive care (e.g., continuous lavage, medications, nutritional support, and antimicrobials) and propose potential topics for future research.

The second shot to walled‐off necrosis: The sooner the better versus sooner or later

To the Editor, We read with great interest the article by Pawa et al.,1 reporting a retrospective study comparing immediate and delayed direct endoscopic necrosectomy (DEN) after lumen-apposing metal stent placement for walled-off necrosis. The authors reported preferable outcomes of the delayed DEN in terms of length of stay and the number of DEN sessions as well as comparable rates of clinical success and adverse events. There has been a debate about the optimal timing of DEN during the treatment course of walled-off necrosis.2 The rationale of delaying interventions has been supported by a randomized trial by the Dutch pancreatitis group, which demonstrated the potential of delayed catheter drainage in avoiding a part of adjunctive interventions.3 However, other groups reported conflicting results that a reduction in an interval until the second intervention might be translated into that in the overall treatment duration.4 In the current study, the delayed DEN group consisted of patients presenting with systemic inflammatory response syndrome for whom DEN was postponed for at least 7 days. Since patients with systemic inflammatory response syndrome were generally associated with worse clinical outcomes, we believe that the study results in favor of delayed DEN were promising. Nonetheless, given the time to DEN of more than 7 days in the delayed DEN group, length of stay (reported to be 3 days in this group) might not be a good surrogate of treatment effectiveness. We therefore ask the authors to provide other metrics such as time to clinical success and the rate of avoiding DEN in the delayed group, which would increase the clinical relevance of their findings. In summary, along with upcoming results of randomized trials by our group (NCT05451901) and others, the current study would help us to address clinical unmet needs in endoscopic treatment of symptomatic walled-off necrosis and optimize treatment strategies. The authors would like to appreciate the following members of the WONDERFUL study group for their valuable comments on the manuscript: Tomotaka Saito, Department of Gastroenterology, Graduate School of Medicine, The University of Tokyo, Tokyo, Japan; Mamoru Takenaka, Department of Gastroenterology and Hepatology, Faculty of Medicine, Kindai University, Osaka, Japan; Hideyuki Shiomi, Division of Gastroenterology and Hepatobiliary and Pancreatic Diseases, Department of Internal Medicine, Hyogo Medical University, Hyogo, Japan; Hiroyuki Isayama, Department of Gastroenterology, Graduate School of Medicine, Juntendo University, Tokyo, Japan; Takuji Iwashita, First Department of Internal Medicine, Gifu University Hospital, Gifu, Japan. This work was supported in part by a grant from the Japanese Foundation for Research and Promotion of Endoscopy (#1015 to T. Saito). The funder had no role in study design, data collection and analysis, decision to publish, or preparation of the manuscript. The authors declare that they have no conflicts of interest. Ichiro Yasuda serves as an Associate Editor of DEN Open, and Yousuke Nakai serves as an Associate Editor of Digestive Endoscopy. Japanese Foundation for Research and Promotion of Endoscopy (#1015).

Endoscopic necrosectomy in patients with necrotizing pancreatitis Ц a single center experience

Endoscopic necrosectomy in patients with necrotizing pancreatitis Ц a single center experience

Endoscopic drainage and necrosectomy for inoperable gangrenous cholecystitis.

A 56-year-old man with liver, peritoneal, and lymph node metastases after previous transthoracic esophagectomy was diagnosed with acute calculous cholecystitis. Transduodenal endoscopic ultrasound-guided gallbladder drainage (EUS-GBD) was performed using a 10 × 10 mm cautery-enhanced lumen-apposing metal stent (LAMS). Purulent fluid was aspirated and submitted for culture, which identified Enterococcus faecium.

Timing, approach, and treatment strategies for infected pancreatic necrosis: a narrative review

Timing, approach, and treatment strategies for infected pancreatic necrosis: a narrative review

"Foul-smelling sign" during endoscopic necrosectomy indicates the presence of pancreatico-colonic fistula.

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S1072 Safety of Endoscopic Pancreatic Necrosectomy Compared With Radiologic or Surgical Necrosectomy: A Nationwide Inpatient Analysis

Introduction: Pancreatic necrosis is an independent predictor of morbidity and mortality among patients with acute pancreatitis. Patients with pancreatic necrosis often undergo direct endoscopic necrosectomy, surgical and interventional radiology approaches exist. We compared the safety and outcomes of 3 techniques including endoscopic necrosectomy, fluoroscopy-guided necrosectomy by an interventional radiologist (IR-necrosectomy), and open necrosectomy performed by a surgeon (surgical necrosectomy). Methods: Using the Nationwide Readmissions Database, we identified hospitalised patients who underwent pancreatic necrosectomy from 2016 to 2019. They were identified using the International Classification of Diseases, 10th Revision, Procedure Coding System. Categorical variables were described using proportions and compared with Chi-Squared Test. Continuous variables were presented as means and compared using the adjusted Wald test. Adjusted odds ratios for adverse events associated with each technique were calculated using multivariable logistic regression analysis. Adjusted hazard ratios were calculated to compare mortality rates. Results: Of the 2,281 patients meeting the selection criteria, the method of pancreatic necrosectomy was as follows: endoscopy, 672 (52.1 ± 1.00 years); IR, 1,338 (53.2 ± 0.56 years); and open surgery, 271 (52.0 ± 1.36 years). The rate of mortality was lowest for endoscopy (hazard ratio (HR) 0.27; 95% CI 0.08-0.90; P = 0.033) followed by IR (HR 0.44; 95% CI, 0.20-0.98; P =0.045), compared to surgery. Endoscopy was associated with less post procedure bleeding compared to IR and surgical necrosectomy, respectively (n=74 vs n=195 vs n=102; P< 0.001); as well as lower rates of post procedure end organ damage including renal failure (n=134, vs n=449, vs n= 133; P< 0.001) and respiratory failure (n=0, vs n=18, vs n= 13; P=0.002). Endoscopy was associated with average shorter lengths of stay and total hospital costs when compared with IR and surgery, respectively (20.1 vs 25.8 vs 38.3 days; P < 0.001) and ($57K vs $76K vs $123K; P< 0.001). Conclusion: Endoscopic necrosectomy is associated with significantly lower risk of inpatient mortality, adverse events, length of stay, and cost when compared to IR and surgical approaches.Figure 1.: Kaplan-Meier survival curve comparing endoscopic, radiologic, and surgical pancreatic necrosectomy

S2848 Massive Pseudo-Pneumoperitoneum After Endoscopic Necrosectomy

Introduction: Encapsulated peripancreatic fluid collection and walled-off necrosis are some of the complications of acute pancreatitis. Most resolve spontaneously but symptomatic pseudocysts or walled-off necrosis require drainage. The preferred therapeutic management is endoscopic ultrasound (EUS) guided drainage with stent placement. Known iatrogenic complications of the procedure include bleeding and perforation. Case Description/Methods: A 39-year-old woman with history of ulcerative colitis, in remission on certrolizumab presented with symptomatic walled-off necrosis after idiopathic necrotizing pancreatitis. EUS-guided drainage and stent placement was successfully performed. On subsequent upper endoscopy for necrosectomy, post-procedure large pneumoperitoneum was noted on imaging leading to emergent surgical evaluation with laparoscopy. However, no perforation or pancreatic fluid contamination was seen. On post-operative day 1, patient was asymptomatic and tolerating diet. She was discharged on post-operative day 2. At 3-month follow-up, patient remained asymptomatic and plastic stents were removed. Discussion: Pneumoperitoneum is an uncommon but dreaded complication of EUS guided cystogastrostomy. This occurs when there is separation of the gastric wall and the wall of the pancreatic cyst or walled-off necrosis. If perforation is detected during cystgastrostomy, it may be possible to use a LAMS to close the defect by bridging the walls or close the gastric defect endoscopically with clips or sutures. Immediate surgery (such as cyst-enterotomy with closure of the wall defect) should be performed if there is generalized contamination of the peritoneum with cyst fluid content and subsequent signs of peritonitis. (Figure) Our case, to our knowledge, is the only one that describes pneumoperitoneum after endoscopic necrosectomy, two weeks after placement of LAMS. Our hypothesis is that the walled-off necrosis moved away from the gastric wall after removal of LAMS, which had aided apposition of the gastric wall and cyst wall due to its flanges and short saddle length. Pneumoperitoneum, in the absence of peritoneal findings, is referred to as benign peritoneum. Our case describes massive benign pneumoperitoneum after endoscopic necrosectomy without perforation. There is a paucity of literature on non-surgical management of post-endoscopic pneumoperitoneum and we hope that our case, will help endoscopists carefully select patients who will benefit from surgical management of pneumoperitoneum.Figure 1.: Figure A. CT abdomen showing pancreatic walled off necrosis containing turbid fluid and debris. Figure B. Massive pneumoperitoneum seen on CT abdomen after EUS-guided drainage and double pig-tailed stent placement for continued drainage.

S1093 Assessment of Physical and Mental Health Before and After Protocolized Endoscopic Necrosectomy for Walled-Off Pancreatic Necrosis in a Prospective Multi-Center Trial

Introduction: A regulatory FDA IDE prospective multi-center clinical trial (G170261-NCT03525808) was performed to evaluate rigorous protocolized management of walled off necrosis (WON) ≥ 6 cm in size with > 30% necrotic material using endoscopic ultrasound (EUS) guided lumen apposing metal stent (LAMS) placement with/without endoscopic necrosectomy. Few studies have examined changes in health related quality of life (HRQOL) before and after endoscopic management for WON. The SF-12 is a validated measure of HRQOL containing 12 items which yield a Mental Components Score (MCS) and a Physical Components Score (PCS). Higher scores correspond to a greater perceived quality of life. Methods: The pre-specified target sample of 40 consecutive eligible patients was enrolled by multiple centers from September 2018 to March 2020. Patients with radiographic WON resolution (as demonstrated by size ≤ 3 cm on CT or MRI) and/or 60 days LAMS indwell time had stent removal followed by an end of study visit 6 months later. SF-12 quality of life questionnaires were completed by patients at baseline, stent removal and at the end of study visit. Results: Mean SF-12 Physical Components Score (PCS) was 27.5±21.1 at baseline, 54.4±19.5 at the time of LAMS removal, and 77.9±22.3 at end of study. Mean SF-12 Mental Components Score (MCS) was 44.9±20.1 at baseline, 64.7±16.5 at the time of LAMS removal, and 79.0±17.2 at end of study. The mean improvement in PCS score from baseline to LAMS removal was 26.0±24.8 (p< 0.0001), with the mean improvement in score from baseline to end of the study being 49.1±29.6 (p< 0.0001). The mean improvement in MCS was 19.6±20.1 from baseline to LAMS removal (p< 0.0001) and 32.0±22.3 from baseline to the end of study (p< 0.0001). The mean improvement from the time of stent removal to the end of study was 25.2±18.0 (PCS, p< 0.0001) and 15.5±18.5 (MCS, p=0.0002) (Figure). Conclusion: These data suggest that patients undergoing protocolized endoscopic necrosectomy for walled-off pancreatic necrosis experience significant improvement in both physical and mental HRQOL. Improvement in the physical score domain appeared to be greater than for the mental score domain. HRQOL indicators continued to improve over a mean follow-up of 180 days.Figure 1.: SF-12 Physical and Mental Components Score.

S100 Predictors of Need of Surgery in Patients With Acute Necrotic Collections Treated With Percutaneous Drainage

Introduction: Percutaneous drainage (PCD) is an important initial component of the “step-up” treatment strategy for the management of infected acute necrotic collections consequent to acute necrotizing pancreatitis (ANP). However, PCD alone has a high failure rate and these patients require additional necrosectomy. Delaying necrosectomy can increase morbidity and mortality and therefore, timely intervention is important. Identifying predictors of failure of percutaneous therapy can help in making timely management decisions. In this prospective single-center study, we attempted to identify predictors of failure of PCD in patients with infected ANC. Methods: Twenty-one patients (males:13, mean age:36.05years) (etiology: ethanol-related 47.6% (10/21), GSD related 28.6% (6/21) unknown19% (4/21) PEP 4.8% (1/21)) admitted with infected ANC who were treated with step-up strategy of initial PCD followed by endoscopic or surgical necrosectomy in non-responders were enrolled and studied prospectively. We studied the association between the success of PCD (survival without necrosectomy) & baseline clinical and investigational parameters including etiology, severity scores, C-reactive protein (CRP), computed tomography severity indices (CTSI), and PCD parameters (size of catheter & timing). Results: Nine (42.8%) patients with infected ANC were successfully treated with PCD alone whereas 12 (57.2%) patients either underwent necrosectomy or succumbed to the illness. The frequency of males was significantly higher (83.3% vs 33.33%) in the PCD failure group(p=0.03). The PCD was inserted later in the failure group as compared to the successful group (mean day of insertion of PCD being 20.5 days vs 15.1 days respectively; p=0.023). The mean SIRS score at admission (2.92 vs 2.33; p=0.102) & at 48 hours (3.5 vs 2.89; p=0.12), mean APACHE-II score (7.8 vs 7.0; p=0.508), mean ferritin levels (2916.9 vs 1033.4ng/mL; p= 0.394), and mean CRP levels (249.5 vs 209.6ng/mL; p=0.508.) were higher in the PCD failure group but did not reach statistical significance. The corrected calcium levels were lower(8.3 vs 9.0gm/dL p=0.069) in the PCD failure group. Also, the mean diameter of PCD catheters was more in the success group but the difference was not statistically significant (16.2 vs 14.7F; p=0.277). (Table) Conclusion: Male gender & delayed insertion of PCD seem to be associated with failure of PCD alone in patients with infected necrotic collections. Table 1. - Comparison of parameters between PCD Success and PCD Failure Group Parameter PCD Success group n=9 PCD failure group n=12 P Value Age 37.3±7.5yrs 36.8±13.4yrs 0.65 Males 3(33.33%) 10(83.33%) 0.03 BMI 24.5±4.3Kg/m2 22.4±3.8kg/m2 0.22 TLC 13871±6616.1/mm3 15014.2±7818.6/mm3 0.862 Platelet Count 321666.7±187813.7/mm3 304350.0±155671.1/mm 0.972 Ferritin Level 1033.4±628.2ng/mL 2916.9±2961.8ng/mL 0.394 Corrected Calcium 9.0±0.3gm/dL 8.3±1.2gm/dL 0.069 qCRP Levels 209.6±95.9mg/L 249±107.1mg/L 0.508 SIRS At admission 2.33±0.5 2.92±1.0 0.10 At 48hrs 2.89±0.93 3.50±0.52 0.12 APACHE-II 7.0±3.0 7.8±8.0 0.51 MMS 1.4±0.9 1.7±1.8 0.70 BISAP 2.1±0.3 2.3±0.8 0.55 Size of largest collection on CT 10.3±4.34cm 11.15±3.42cm 0.81 CTSI Score 7.3±2.5 7.8±2.5 0.65 mCTSI Score 8.7±1.7 9.2±1.3 0.60 Day of PCD placement 15.1±4.9 20.5±3.9 0.02 Size of largest PCD in the French scale 16.2±3.1 14.7±4.2 0.28

S1118 Safety and Efficacy of the Novel EndoRotor Device for the Treatment of Walled-Off Pancreatic Necrosis (WOPN): A Systematic Review and Meta-Analysis

Introduction: Debridement of infected walled-off pancreatic necrosis (WOPN) is indicated to treat and prevent sepsis-related multi-organ failure. The lack of dedicated and effective accessories for WOPN debridement results in the need for time-consuming repetitive procedures. The aim of this study was to evaluate the efficacy and safety of the EndoRotor® powered endoscopic debridement system to remove solid debris under direct endoscopic visualization. Methods: Search strategies were developed for PubMed, EMBASE, and Cochrane Library databases from inception through June 2022, in accordance with PRISMA and MOOSE guidelines. Outcomes of interest included technical success defined as successful use of device for debridement, clinical success defined as complete debridement and cyst resolution, and procedure-related adverse events. A random effects model was used for analysis and results were expressed as Odds ratio (OR) along with 95% confidence interval (CI). Results: A total of 8 studies (n = 91 patients) were included. The most common etiology of WOPN was biliary (30%). Mean WOPN size was 154.6 ± 34.0 mm, while mean procedure time was 71.4 minutes. LAMS were used to create a cystgastrostomy for 73.6% of cases with the remaining cases relying upon a placement of plastic stents (24.2%) and self-expanding metal stents (SEMS) (2.2%). The mean number of necrosectomy sessions required was 2.2 (range 1 to 7). The pooled rate of clinical success was 97% (95% CI 93-100%, I2 = 0%) with a pooled technical success rate of 97% (93-100%, I2 Z54%). The pooled procedure-related adverse event rate was 7% (2-12%, I2 = 0%), which included procedure-associated bleeding, pneumoperitoneum, peritonitis, pleural effusion, and dislodgement of LAMS. Overall publication bias was considered low. (Figure) Conclusion: Our study illustrates that the novel EndoRotor device appears to be safe and effective for treating pancreatic necrosis. Patients undergoing endoscopic necrosectomy with the EndoRotor appear to require less debridement sessions when compared with studies using conventional instruments.Figure 1.: Forrest plot of pooled rates of clinical success.

Transluminal and retroperitoneal minimally invasive necrosectomy in acute pancreatitis

The research review presents literature data on the possibilities of performing minimally invasive necrosectomy for infected forms of acute necrotizing pancreatitis. The paper provides detailed information concerning the terminology, indications for, and technical features of implementing the principal methods of minimally invasive surgical debridement of necrotic accumulations. The techniques include endoscopic transluminal necrosectomy, videoassisted retroperitoneal debridement, and minimally invasive retroperitoneal necrosectomy. The review describes results of numerous studies on the evaluation of their effectiveness and possible options for their combined use. Additionally, we present the materials of relevant international clinical guidelines which indicate the viability of performing minimally invasive necrosectomy as part of a phased strategy for the treatment of patients with acute necrotizing pancreatitis.

Endoscopic step up: When and how

The management of (peri)pancreatic collections has undergone a paradigm shift from open surgical drainage to minimally invasive endoscopic, percutaneous, or surgical interventions. Minimally invasive interventions are associated with less morbidity and mortality compared to open necrosectomy. The (peri)pancreatic collections are currently treated with a “step-up approach” of an initial drainage procedure followed, if necessary, by a more invasive debridement. The step-up approach for management of (peri)pancreatic collections is mainly of two types, namely, surgical and endoscopic. Surgical step up includes initial image-guided percutaneous catheter drainage followed, if necessary, by minimally invasive video-assisted retroperitoneal debridement. Endoscopic step-up approach includes endoscopic transluminal drainage followed, if necessary by direct endoscopic necrosectomy. The development of endoscopic ultrasound and lumen apposing metal stents (LAMSs) has revolutionized the endoscopic management of (peri)pancreatic collections. Compared to surgical step-up approach, endoscopic step-up treatment approach has been reported to be associated with less new-onset organ failure, pancreatic fistula, enterocutaneous fistula, or perforation of visceral organ and shorter hospital/intensive care unit stay. This review will mainly focus on indications, techniques, timing, and recent advances related to endoscopic step-up approach in management of symptomatic(peri)pancreatic collections.