Endoscopic Transluminal Necrosectomy Research Articles

Endoscopic transluminal necrosectomy in the complex treatment of a patient with acute infected necrotizing pancreatitis. Clinical case

This study presents a clinical case of acute pancreatitis treatment, which manifested as infected walled‑off necrosis in a 49‑year‑old obese woman. Diagnosis and treatment were provided by a multidisciplinary team comprising surgeons, anesthesiologists, interventional radiologists, and endoscopists. The treatment strategy followed a «step‑up approach,» a modern technique involving gradual progression from less to more invasive methods, thereby reducing the physiological stress on the patient. This approach has demonstrated efficacy in numerous studies. In Western countries, endoscopic transluminal necrosectomy is gaining popularity, and our clinic has been implementing it successfully since 2021. Despite its effectiveness, clinicians still encounter challenges when opting for endoscopic transluminal interventions over other minimally invasive methods. Key issues include determining the timing and frequency of interventions, choosing debridement techniques and antiseptics for walled‑off necrosis, and establishing criteria for transitioning to more invasive procedures. Today, researchers handle these nuances on a case‑by‑case basis, relying on the expertise and proficiency of a specific specialized department, which necessitates further research. In this case the patient achieved complete debridement of a localized fluid/necrosis collection through a stepwise approach. Initial management involved ultrasound‑guided percutaneous drainage and lavage, followed by four sessions of endoscopic transluminal necrosectomy as the final minimally invasive intervention. We assess the unfavorable long‑term outcomes, 2.5 years post‑treatment, as negligible.

Role of Necrosectomy in Necrotizing Pancreatitis: A Narrative Review.

Necrotizing pancreatitis (NP) is a severe complication of acute pancreatitis, characterized by necrosis of pancreatic and peripancreatic tissues, leading to significant morbidity and mortality. The role of necrosectomy, the surgical removal of necrotic tissue, in the management of NP has evolved over the past few decades, moving from early aggressive surgical intervention to a more conservative and stepwise approach. This narrative review explores the historical perspectives, current practices, and future trends in the role of necrosectomy in NP. Early studies favored open surgical debridement; however, high mortality rates associated with early intervention prompted a shift towards minimally invasive techniques, delayed interventions, and the "step-up approach,"combining percutaneous drainage with minimally invasive surgery. We also review the indications for surgery, optimal timing, and various techniques, including video-assisted retroperitoneal debridement and endoscopic transluminal necrosectomy. The review highlights the benefits of these strategies in reducing complications, improving patient outcomes, and minimizing hospital stays. Ongoing research into patient selection, timing, and procedural refinement will continue to shape the role of necrosectomy in NP management. Understanding the evolving role of necrosectomy is crucial for optimizing care and reducing the burden of this life-threatening condition.

Efficacy and Safety of Anhydrous Ethanol-Assisted Endoscopic Ultrasound-Guided Transluminal Necrosectomy in Infected Necrotizing Pancreatitis.

Endoscopic necrosectomy has become the first-line treatment option for infectious necrotizing pancreatitis (INP), especially walled-off necrosis. However, the problems, including operation-related adverse events (AEs) and the need for multiple endoscopic procedures, have not been effectively addressed. We sought to evaluate the clinical safety and efficacy of anhydrous ethanol-assisted endoscopic ultrasound (EUS)-guided transluminal necrosectomy in INP. A single-center observational cohortstudy of INP patients was conducted in a tertiaryendoscopic center. Anhydrous ethanol-assisted EUS-guided transluminal necrosectomy (modified group) and conventional endoscopic necrosectomy (conventional group) were retrospectively compared in INP patients. The technical and clinical success rates, operation time, perioperative AEs, postoperative hospital stay, and recurrent INP rates were analyzed, respectively. Atotalof55patientswereenrolled. No statistically significant differences were observed between the two groups regarding baseline characteristics. Compared to patients in the conventional group, patients in the modified group demonstrated significantly reduced times of endoscopic transluminal necrosectomies (1.96 ± 0.89 vs. 2.73 ± 0.98; P = 0.004) and comparable perioperative AEs (P = 0.35). Meanwhile, no statistically significant differences were observed in the technical and clinical success rates (P = 0.92), operation time (P = 0.59), postoperative hospital stay (P = 0.36), and recurrent INP rates (P = 1.00) between the two groups. Anhydrous ethanol-assisted EUS-guided transluminal necrosectomy seemed safe and effective in treating INP. Compared with conventional endoscopic transluminal necrosectomy, its advantage was mainlyin reducing the number of endoscopic necrosectomies without increasing perioperative AEs.

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.

Current Controversies and Challenges in Endoscopic Management of Necrotizing Pancreatitis

The current paradigm for intervention in necrotizing pancreatitis involves a staged multidisciplinary step-up approach with endoscopic transluminal drainage (ETD) or percutaneous drainage as the initial step based on the location of the collection and the availability of localized expertise (Figure 1). 1 Trikudanathan G. Wolbrink D.R.J. Santvoort HC van et al. Current concepts in severe acute and necrotizing pancreatitis: an evidence-based approach. Gastroenterology. 2019; 156: 1994-2007 Abstract Full Text Full Text PDF PubMed Scopus (116) Google Scholar Endoscopic step-up approach is associated with reduced occurrence of new-onset multiorgan failure and physiological stress, reduced risk of external fistulae, shorter hospital stay, lower costs, and better quality of life with no significant difference in mortality when compared with surgical approach as shown in 3 randomized trials. 1 Trikudanathan G. Wolbrink D.R.J. Santvoort HC van et al. Current concepts in severe acute and necrotizing pancreatitis: an evidence-based approach. Gastroenterology. 2019; 156: 1994-2007 Abstract Full Text Full Text PDF PubMed Scopus (116) Google Scholar The endoscopic approach involves ETD (cystenterostomy) followed by endoscopic transluminal necrosectomy (ETN) as needed, and has significantly evolved with new innovations. However, there are controversies in the timing and choice of stents for ETD, with challenges and need for further refinement and standardization of technique of ETN, which is addressed in this focused review.

Comparison of lumen-apposing metal stents versus double-pigtail plastic stents for infected necrotising pancreatitis

ObjectiveLumen-apposing metal stents (LAMS) are believed to clinically improve endoscopic transluminal drainage of infected necrosis when compared with double-pigtail plastic stents. However, comparative data from prospective studies are very limited.DesignPatients...

Clinical outcome of endoscopic treatment for symptomatic sterile walled-off necrosis.

The majority of patients with symptomatic sterile walled-off necrosis (WON) can be treated conservatively. Although endoscopic transluminal drainage (ETD) is often performed in cases of persistent symptoms, post-procedural iatrogenic infection may occur. This study aimed to evaluate clinical outcomes after ETD of symptomatic sterile WON. This was a retrospective, multicenter, open-label case series of 56 patients with necrotizing pancreatitis who underwent ETD for symptomatic sterile WON between July 2001 and August 2018 at two tertiary referral hospitals. Primary end point was clinically relevant post-procedural iatrogenic infection, defined as need for endoscopic transluminal necrosectomy. Secondary end points included mortality, total number of interventions, hospital stay, and resolution of symptoms at 1-year follow-up. RESULTS : ETD of sterile WON was performed in 56 patients (median age 55 years, 57 % male), who presented with abdominal pain (71 %), gastric outlet obstruction (45 %), jaundice (20 %), and failure to thrive (27 %). A total of 41 patients (73 %) developed clinically relevant post-procedural iatrogenic infection, resulting in a median of 3 (interquartile range [IQR] 2 - 4) endoscopic, radiological, and/or surgical interventions. Mortality rate was 2 %. Median total hospital stay was 12 days (IQR 6 - 17). Resolution of symptoms was reported in 40 of 46 patients (87 %) for whom long-term follow-up data were available (median follow-up 13 months, IQR 6 - 29). ETD of symptomatic sterile WON resulted in high clinical success. Nonetheless, the majority of patients required additional reinterventions for clinically relevant post-procedural iatrogenic infection.

Managing Acute Severe Necrotising Pancreatitis

Background: Severe necrotising pancreatitis (SNP) is characterised by high mortality, severe complications and bad prognosis despite progress in understanding of aetiology and progression of the disease. Traditionally, necrotic changes were removed by open necrosectomy but the paradigm has shifted towards more conservative management and minimally-invasive surgical procedures. However, there is still no consensus on the best management pathway. Minimally-invasive procedures percutaneous drainage, endoscopic transluminal necrosectomy, video-assisted retroperitoneal debridement (VARD) and other minimally-invasive surgical variants including percutaneous necrosectomy, as well as step-up protocols (less invasive procedure followed by a more invasive procedure if needed). Methods: A literature search was conducted in PubMed database to look for comparative studies (RCTs, case series and pooled analyses) between two or more surgical techniques utilised for SNP management. Studies were limited to the last 10 years; retrospective studies were restricted by the number of cases (min. 50). Only management of necrotic collections was taken intro considerations. Results: Evidence indicate that all minimally invasive surgical options present a viable, non-inferior alternative to open necrosectomy, allowing for reduction in major complications and reduced length of hospital stay. There is no consensus on which minimally-invasive method results in better patient outcomes. Conclusions: Management of SNP is still dependent on preference and skill of the clinicians and while the evidence basis supports introduction of step-up protocols and less-invasive methods, more high-quality randomised control trails have to be undertaken to identify groups of patients, who will benefit from a certain type of intervention.

Interventions for walled off necrosis using an algorithm based endoscopic step-up approach: Outcomes in a large cohort of patients

ObjectivesThe minimally invasive step-up approach for treatment of walled off necrosis (WON) involves drainage followed by later necrosectomy as needed, and is superior to primary surgical necrosectomy. Reported series of endoscopic transluminal necrosectomy include highly selected patients. We report outcomes of a large series of patients with WON managed by an algorithm based on an endoscopically centered step-up approach. MethodsConsecutive patients with necrotizing pancreatitis from 2009 to 2014, with intervention only for infected or persistently symptomatic WON. The primary approach involved endoscopic transluminal drainage plus minus necrosectomy whenever feasible, with percutaneous catheter drainage (PCD) plus minus sinus tract endoscopy if not feasible or sufficient. Surgery was reserved for failures of the step up approach. ResultsOf 109 consecutive patients with necrotizing pancreatitis, intervention was required in 83, including endoscopic transluminal drainage in 73 (88%) (alone in 49 and combined with PCD in 24), and PCD alone in 10 (12%). 64 (77%) of the 83 patients required endoscopic transluminal and/or sinus tract necrosectomy. Adverse events occurred in 11 (13%). Three patients (4%) failed step up approach and required open surgical necrosectomy. All-cause mortality occurred in 6 (7%) of 83 patients after intervention, including 2 of 3 requiring surgery. ConclusionsAn algorithm based step-up approach for interventions in necrotizing pancreatitis using primarily endoscopic techniques with adjunctive percutaneous approaches as needed resulted in favorable outcomes with small numbers proceeding to open surgery, and with acceptable rates of major complications and mortality. A purely endoscopic transluminal approach was feasible in approximately 60% of patients requiring intervention in this series.

The clinical practice and related reflections of staged step-up approach in the treatment of patients with severe acute pancreatitis

Both new insights in the pathophysiology of severe acute pancreatitis (SAP) and upspringing related evidence-based supports prompt the staged step-up approach, which stress emphasis on minimal invasiveness and damage control, to be accepted and advocated by the majority of guidelines. For documented or suspected patients with infected pancreatic necrosis, an imaging-guided percutaneous catheter drainage or an endoscopic transluminal drainage should be initially performed followed by, if necessary, a minimal access retroperitoneal necrosectomy, or a video-assisted retroperitoneal debridement, or an endoscopic transluminal necrosectomy, or an even an open access necrosectomy. The outstanding performance of staged step-up approach in patients with SAP has been justified from both a clinical and a health economic point of view, meanwhile, there are some issues remained to be further elucidated and optimized.

Erratum to: Endoscopic transluminal necrosectomy in necrotising pancreatitis: a systematic review

Erratum to: Endoscopic transluminal necrosectomy in necrotising pancreatitis: a systematic review

Endoscopic transluminal drainage and necrosectomy by using a novel, through-the-scope, fully covered, large-bore esophageal metal stent: preliminary experience in 10 patients

Interventions for necrotizing pancreatitis have undergone a recent paradigm shift toward minimally invasive techniques, including endoscopic transluminal necrosectomy (ETN). The optimal stent for endoscopic transmural drainage remains unsettled. To evaluate a novel large-bore, fully covered metal through-the-scope (TTS) esophageal stent for cystenterostomy in large walled-off necrosis (WON). Retrospective case series. Single tertiary care academic center. Ten patients with large (>10 cm) WON collections who underwent endoscopic transmural drainage and ETN. Initial cystenterostomy was performed by using EUS, and in the same session, a TTS (18 × 60 mm), fully covered esophageal stent was placed to create a wide-bore fistula into the cavity. In 1 or more later sessions, the stent was removed, and ETN was performed as needed. Technical and clinical success rates and adverse events. The TTS stent was successfully deployed at the initial cystogastrostomy in all 10 patients. All patients had large WON (median size 17 cm, range 11-30 cm) and underwent intervention at a median of 30 days (range 12-117 days) after onset of acute pancreatitis. Resolution of WON was achieved in 9 of the 10 patients (90%) after a median of 3 endoscopic sessions. There were no early adverse events. Late adverse events occurred in 3 patients (30%); worsening of infection from stent migration and occlusion of cystogastrostomy (2 patients), and fatal pseudoaneurysmal bleeding from erosion of infected necrosis into a major artery distant from the stent (1 patient). The stent was easily removed in all the cases after resolution or improvement of the necrotic cavity. Retrospective, single-center evaluation of a small number of cases. No comparative arm to determine the relative efficacy or cost-effectiveness of these stents compared with conventional plastic stents. Endoscopic therapy using a large-bore TTS, fully covered esophageal stent is feasible for use in the treatment of large WON. Further studies are needed to validate these findings.

Endoscopic transluminal necrosectomy in necrotising pancreatitis: a systematic review

We performed a systematic review to assess the outcome of endoscopic transluminal necrosectomy in necrotising pancreatitis with additional focus on indication, disease severity, and methodological quality of studies. We searched the literature published between January 2005 and June 2013. Cohorts, including patients with (infected) necrotising pancreatitis, undergoing endoscopic necrosectomy were included. Indication, disease severity, and methodological quality were described. The main outcomes were mortality, major complications, number of endoscopic sessions, and definitive successful treatment with endoscopic necrosectomy alone. After screening 581 papers, 14 studies, including 455 patients, fulfilled the eligibility criteria. All included studies were retrospective analyses except for one randomized, controlled trial. Overall methodological quality was moderate to low (mean 5, range 2-9). Less than 50 % of studies reported on pre-procedural severity of disease: mean APACHE-II score before intervention was 8; organ failure was present in 23 % of patients; and infected necrosis in 57 % of patients. On average, four (range 1-23) endoscopic interventions were performed per patient. With endoscopic necrosectomy alone, definitive successful treatment was achieved in 81 % of patients. Mortality was 6 % (28/460 patients) and complications occurred in 36 % of patients. Bleeding was the most common complication. Endoscopic transluminal necrosectomy is an effective treatment for the majority of patients with necrotising pancreatitis with acceptable mortality and complication rates. It should be noted that methodological quality of the available studies is limited and that the combined patient population of endoscopically treated patients is only moderately ill.

Transluminal endoscopic step-up approach versus minimally invasive surgical step-up approach in patients with infected necrotising pancreatitis (TENSION trial): design and rationale of a randomised controlled multicenter trial [ISRCTN09186711

BackgroundInfected necrotising pancreatitis is a potentially lethal disease that nearly always requires intervention. Traditionally, primary open necrosectomy has been the treatment of choice. In recent years, the surgical step-up approach, consisting of percutaneous catheter drainage followed, if necessary, by (minimally invasive) surgical necrosectomy has become the standard of care. A promising minimally invasive alternative is the endoscopic transluminal step-up approach. This approach consists of endoscopic transluminal drainage followed, if necessary, by endoscopic transluminal necrosectomy. We hypothesise that the less invasive endoscopic step-up approach is superior to the surgical step-up approach in terms of clinical and economic outcomes.Methods/DesignThe TENSION trial is a randomised controlled, parallel-group superiority multicenter trial. Patients with (suspected) infected necrotising pancreatitis with an indication for intervention and in whom both treatment modalities are deemed possible, will be randomised to either an endoscopic transluminal or a surgical step-up approach. During a 4 year study period, 98 patients will be enrolled from 24 hospitals of the Dutch Pancreatitis Study Group. The primary endpoint is a composite of death and major complications within 6 months following randomisation. Secondary endpoints include complications such as pancreaticocutaneous fistula, exocrine or endocrine pancreatic insufficiency, need for additional radiological, endoscopic or surgical intervention, the need for necrosectomy after drainage, the number of (re-)interventions, quality of life, and total direct and indirect costs.DiscussionThe TENSION trial will answer the question whether an endoscopic step-up approach reduces the combined primary endpoint of death and major complications, as well as hospital stay and related costs compared with a surgical step-up approach in patients with infected necrotising pancreatitis.

Endoscopic transluminal necrosectomy in infected necrotizing pancreatitis: A systematic review

Endoscopic transluminal necrosectomy in infected necrotizing pancreatitis: A systematic review

Endoscopic transluminal necrosectomy in infected necrotizing pancreatitis: A systematic review

From 1983 to 1995, 72 patients with necrotizing pancreatitis were treated with a general approach involving planned reoperative necrosectomies and interval abdominal wound closure using a zipper.Hospital mortality was 25%. Multiple organ failure without sepsis caused early mortality in 3 of 4 patients and sepsis caused late mortality in 11 of the remaining 14. The mean number of reoperative necrosectomies/debridements was 2 (0 to 7). Fistulae developed in 25 patients (35%); 64% were treated conservatively. Recurrent intraabdominal abscesses developed in 9 patients (13%) but were drained percutaneously in 5. Hemorrhage required intervention in 13 patients (18%). Prognostic factors included APACHE-II score on admission <13 (P = 0.005), absence of postoperative hemorrhage (P = 0.01), and peripancreatic tissue necrosis alone (P <0.05).The zipper approach effectively maximizes the necrosectomy and decreases the incidence of recurrent intraabdominal infection requiring reoperation. APACHE-II score ≥13, extensive parenchymal necrosis, and postoperative hemorrhage signify worse outcome.

Endoscopic transluminal step-up approach versus surgical step-up approach in patients with infected necrotizing pancreatitis (TENSION): Design and rationale of a randomized controlled multicenter trial

s / Pancreatology 12 (2012) 502–597 575 showed that endoscopic necrosectomy significantly reduced the proinflammatory response as well as complications and death compared to surgical necrosectomy. These preliminary outcomes require confirmation in a larger trial. We describe the design and rationale of a nationwide study called TENSION: “Endoscopic transluminal step-up approach versus surgical step-up approach in patients with infected necrotizing pancreatitis” (Trial registration: ISRCTN09186711). Methods: The TENSION trial is a randomized controlled parallel-group, superiority multicenter trial. Patients with infected necrotizing pancreatitis will be randomized to an endoscopic or surgical step-up approach. The endoscopic step-up approach consists of endoscopic transluminal drainage followed, if necessary, by endoscopic transluminal necrosectomy. The surgical step-up approach consists of percutaneous catheter drainage, if necessary, followed by video-assisted retroperitoneal debridement (VARD). The primary endpoint is a composite of major complications (i.e., new onset organ failure, bleeding requiring intervention, perforation of a visceral organ requiring intervention, enterocutaneous fistula requiring intervention and incisional hernia) or death within 6 months following randomization. Secondary endpoints include other complications such as pancreatic fistula, pancreatic insufficiency, length of intensive careand hospital stay, quality of life, and costs. 98 patients will be enrolled in 25 hospitals of the Dutch Pancreatitis Study Group in a 3-year period. Conclusion: The TENSION trial is designed to evaluate if an endoscopic step-up approach is superior to a surgical step-up approach in terms of clinical outcomes and cost-effectiveness in patients with infected necrotizing pancreatitis.

Tu1728 Endoscopic Transluminal Necrosectomy in Necrotizing Pancreatitis: A Systematic Review

Infected necrotizing pancreatitis almost always requires intervention. The historical reference standard is surgical necrosectomy. A promising minimal invasive alternative is endoscopic transluminal necrosectomy (ETN). Various new cohort-studies on ETN have been reported in recent years. We performed a systematic review of the literature on ETN in (infected) necrotizing pancreatitis.