Walled-off Pancreatic Necrosis Research Articles

Pancreatic Walled-Off Necrosis: Cross-Sectional Imaging Depiction of Debris Predicts the Success of Endoscopic Drainage Using Lumen Apposing Metal Stents.

The use of endoscopic ultrasound-guided (EUS) transmural stent placement for pancreatic walled-off-necrosis (WON) drainage is widespread. This study retrospectively analyzes imaging parameters predicting the outcomes of WON endoscopic drainage using lumen apposing metal stents (LAMS). The study analyzed data of 115 patients who underwent EUS-guided debridement using LAMS from 2011 to 2015. Pre-intervention CT or MRI were used to analyze WON total volume, percentage of debris, multilocularity, and density. Success measures included technical success, the number of endoscopic sessions, requirement of percutaneous drainage, long-term success, and recurrence. The primary cause of pancreatitis was gallstones (50.4%), followed by alcohol (27.8%), hypertriglyceridemia (11.3%), idiopathic (8.7%), and autoimmune (1.7%). The mean WON size was 674 mL. All patients underwent endoscopic necrosectomies, averaging 3.1 sessions. Stent placement was successful in 96.5% of cases. Procedural complications were observed in 13 patients (11.3%) and six patients (5.2%) needed additional percutaneous drainage. No patients reported recurrent WON post-treatment. Univariate analysis indicated a significant correlation between debris percentage and the need for additional drainage and long-term success (p <0.001). The number of endoscopic sessions correlated significantly with debris percentage (p < 0.001). Preprocedural imaging, particularly debris percentage within WON, significantly predicts the number of endoscopic sessions, the need for further percutaneous drainage, and overall long-term success.

Impact of long-term transmural plastic stents on recurrence after endoscopic treatment of walled-off pancreatic necrosis

Background and study aims: Endoscopic transmural drainage (ETD) using double pigtail stents (DPS) is a well-established treatment for walled-off pancreatic necrosis (WON). This study aimed to compare outcomes in patients undergoing ETD with DPS left indwelling versus those where stents were removed or migrated. Patients and methods: This retrospective, multicenter cohort study included patients with WON who underwent ETD using DPS between July 2001 and December 2019. The primary outcome was recurrence of a pancreatic fluid collection (PFC). Secondary outcomes were long term complications and recurrence-associated factors. Competing risk regression analysis considered DPS removal or migration as time-varying covariate. Results: Among 320 patients (median age 58, 36% female), DPS were removed in 153 (47.8%), migrated spontaneously in 27 (8.4%), and remained indwelling in 140 (43.8%). PFC recurrence was observed in 57 patients (17.8%): after removal in 39 (25.5%), after migration in 4 (14.8%) and in patients with indwelling DPS in 14 patients (10%). In 25 patients (7.8%) drainage of recurrent PFC was indicated. Risk factors for recurrence were DPS removal or migration (HR: 3.45, 95%CI: 1.37–8.70) and presence of a disconnected pancreatic duct (HR: 3.45, 95%CI: 1.84–14.0). Conclusions: Among patients who undergo ETD of WON, leaving DPS in situ seems to lower the risk on recurrent fluid collections, without any long term DPS-related complications. These results suggest that DPS should not be routinely removed and can be safely left indwelling indefinitely.

Acidic solution irrigation as a novel approach for treating infected walled-off pancreatic necrosis

Walled-off pancreatic necrosis (WOPN) is a severe complication of acute pancreatitis arising from pancreatic or peripancreatic necrosis complicated by infection, leading to elevated mortality rates. Extravasation of pancreatic juice creates a weakly alkaline microenvironment favorable for the survivial of translocated intestinal bacteria and activated pancreatic enzyme-mediated autodigestion of pancreatic and peripancreatic tissues. Conventional treatments for WOPN involve invasive procedures with irrigation to mitigate postoperative infections. However, there remains a lack of a unified standard for lavage fluid. Herein, we raise the hypothesis that the utilization of acidic solution irrigation may serve as a promising strategy for preventing and treating infected WOPN. Acidic solutions create an unfavorable environment for translocated intestinal bacteria in WOPN cases. Additionally, the acidic microenvironment may alleviate self-digestion of pancreatic and peripancreatic tissues by inhibiting pancreatic enzyme activity. This innovative approach holds potential for enhancing the management and outcomes of infected WOPN.

Metal versus plastic stents for walled-off pancreatic necrosis: much alike, then which?

Metal versus plastic stents for walled-off pancreatic necrosis: much alike, then which?

Laparoscopic necrosectomy for acute necrotising pancreatitis: Retrospective analysis of a decade-long experience from a tertiary centre.

The objective of this study is to evaluate the role of minimally invasive surgery for the management of necrotising pancreatitis in acute settings and to propose tailor-made approaches to deal with various locations of pancreatic necrosis. Three hundred and thirteen patients underwent laparoscopic management of necrotising pancreatitis in this study period from January 2010 to June 2021, out of which 122 patients underwent minimally invasive necrosectomy for acute necrotising pancreatitis. The remaining 191 patients underwent laparoscopic internal drainage in the form of cystogastrostomy/cystojejunostomy for walled-off pancreatic necrosis. Mean body mass index was 26.45 ± 3.78 kg/sqm. Mean operating time was 56.40 ± 20.48 min and mean blood loss was 120 ± 31.45 mL. Ten patients required reoperation (6 underwent open procedure and 4 underwent laparoscopic redo necrosectomy). Six patients died of multi-organ failure. The mean duration of return of bowel function was 5 ± 1.8 days. The mean length of hospital stay after surgery was 10.19 ± 7.09 days. There were no major wound-related complications. A minimally invasive approach to pancreatic necrosectomy is safe and feasible with good outcomes in centres with advanced laparoscopic expertise. It requires not only careful case selection but also proper timing and the ideal route of access to achieve optimal outcomes.

Current Utility of Transgastric Percutaneous Drainage for the Management of Pancreatitis-Related Retrogastric Walled-Off Necrotic Collections: A Prospective Observational Study.

Introduction Pancreatic fluid collection (PFC) is one of the most frequent complications associated with acute pancreatitis. The route of drainage is guided by the size and site of collection. The present study aims to assess the clinical and technical success of transgastric percutaneous drainage (PCD) for managing retrogastric walled-off pancreatic necrosis (WOPN). Materials and methods A total of 44 patients with acute pancreatitis diagnosed with WOPN who underwent transgastric PCD with ultrasound or CT guidance as part of standard clinical management were included in the study. Patients were observed for improvement in clinical parameters, and treatment outcomes were noted in terms of technical success, clinical success, adverse events, need for additional procedures, hospital stay, and duration of placement of all drains. Data for the internalization of transgastric PCD was also observed in the study. Results Technical success during the drain placement was observed in 93% (n=41) of patients.Internalization of the transgastric drain was attempted in 12 patients and successful in 11 (91%). The median duration of hospital stay from the time of placement of the first PCD until discharge and the median duration of all PCDs placed were higher in patients where the transgastric drain was not internalized as compared to patients where the transgastric drain was internalized. Conclusion In WOPN, transgastric drain placement and successful internalization in any form help in the early resolution of peripancreatic and abdominal collections. It also reduces the time to percutaneous catheter removal, which in turn reduces the morbidity and decreases the need for additional interventions or surgery.

Prediction of Admission to Intensive Care Unit and 1-Year Mortality After Acute Pancreatitis With Walled-Off Pancreatic Necrosis: A Retrospective, Single-Center Cohort Study.

Pancreatic walled-off necrosis (WON) carries significant mortality and morbidity risks, often necessitating intensive care unit (ICU) admission. This retrospective study aimed to evaluate whether routine biochemical parameters at the time of the index endoscopic procedure could predict ICU admission and 1-year mortality following endoscopic treatment of WON. We retrospectively identified 201 consecutive patients who underwent endoscopic drainage for WON between January 1, 2010, and December 31, 2020. Associations between routine biochemical blood tests and outcomes were assessed using logistic regression models. Within 1 year of the index endoscopy, 31 patients (15.4%) died, and 40 (19.9%) were admitted to the ICU due to sepsis. Preoperative electrolyte disturbances were more prevalent among ICU-admitted patients and nonsurvivors. Hyperkalemia, hypoalbuminemia, and elevated urea were significant predictors of 1-year mortality, while hypernatremia, elevated serum creatinine, and hypoalbuminemia predicted ICU admission. Predictive models exhibited good discriminative ability, with an AUC of 0.84 (95% CI,0,75-0.93) for 1-year mortality and 0.86 (95%CI, 0.79-0.92) for ICU admission. Preoperative imbalances in routine blood tests effectively predict adverse outcomes in endoscopically treated WON patients.

A location-based anatomic classification system for acute pancreatic fluid collections: Roadmap for optimal intervention in the step-up era

Walled-off pancreatic necrosis (WOPN) is a local complication of acute necrotizing pancreatitis frequently requiring intervention. Treatment is typically through the coordinated efforts of a multidisciplinary team. Current management guidelines recommend a step-up approach beginning with minimally invasive techniques (percutaneous or transmural endoscopic drainage) followed by escalation to more invasive procedures if needed. Although the step-up approach is an evidence-based treatment paradigm for management of pancreatic fluid collections, it lacks guidance regarding optimal invasive technique selection based on the anatomic characteristics of pancreatic fluid collections. Similarly, existing cross-sectional imaging-based classification systems of pancreatic fluid collections have been used to predict disease severity and prognosis; however, none of these systems are designed to guide intervention. We propose a novel classification system which incorporates anatomic characteristics of pancreatic fluid collections (location and presence of disconnected pancreatic duct) to guide intervention selection and clinical decision making. We believe adoption of this simple classification system will help streamline treatment algorithms and facilitate cross-study comparisons for pancreatic fluid collections.

Repetitive endoscopic drainage as initial intervention is safe and effective for early treatment of pancreatic necrotic collections.

While endoscopic step-up approach with delayed drainage (more than 28 days from diagnosis) was shown to produce the best outcomes in the treatment of pancreatic walled-off necrosis (WON), we assessed our single centre experience of early versus delayed endoscopic drainage of pancreatic necrotic collections. Patients who underwent endoscopic drainage of pancreatic necrotic collections between 2011 and 2022 under Monash Health were identified. They were excluded if below 18 years old or their follow up data were missing. The included patients' medical records, pathology results, and imaging findings were retrospectively reviewed. A total of 60 patients were included. 31.58% required percutaneous drainage and 15% received either endoscopic or surgical necrosectomy. The disease related mortality was 8.47% and the average length of stay (LOS) was 70.92 days. No significant difference was shown in disease-related mortality (10.5% vs. 7.5%, P = 0.697) or LOS (75.35 vs. 68.7, P = 0.644) between early and delayed drainage cohorts, but patients who received early drainage have higher qSOFA score on the day of drainage (2 vs. 0, P = 0.004). Repetitive endoscopic drainage with selective percutaneous drainage is effective in the management of pancreatic necrotic collections. Early drainage should be considered in patients who developed severe sepsis.

Safety and efficacy of the EndoRotor device for the treatment of walled-off pancreatic necrosis after EUS-guided cystenterostomy: A systematic review and meta-analysis

ABSTRACT Debridement of infected walled-off pancreatic necrosis is indicated to treat and prevent sepsis-related multiorgan failure. 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. Search strategies were developed for PubMed, EMBASE, and Cochrane Library databases from inception to June 2022, in accordance with Preferred Reporting items for Systematic Reviews and Meta-Analyses and Meta-Analysis of Observational Studies in Epidemiology 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 along with 95% confidence interval. A total of 7 studies (n = 79 patients) were included. The mean walled-off pancreatic necrosis size was 154.6 ± 34.0 mm, whereas the mean procedure time was 71.4 minutes. The mean number of necrosectomy sessions required was 2.2 (range, 1–7). The pooled rate of clinical success was 96% (95% confidence interval, 91%–100%; I 2 = 0%) with a pooled technical success rate of 96% (91%–100%; I 2 = 0%). The pooled procedure-related adverse event rate was 8% (2%–14%; I 2 = 6%), which included procedure-associated bleeding, pneumoperitoneum, peritonitis, pleural effusion, and dislodgement of lumen-apposing metal stents. Our study shows that the novel EndoRotor device seems to be safe and effective for treating pancreatic necrosis. Patients undergoing endoscopic necrosectomy with the EndoRotor seem to require less debridement sessions when compared with studies using conventional instruments.

A Retrospective Study on Comparison Between Surgical and Endoscopic Management of Pancreatic Pseudocyst and Walled-off Pancreatic Necrosis

BACKGROUND: Surgical management is the standard approach for pancreatic pseudocyst and walled off pancreatic necrosis. With newly evolving procedures and a comprehensive approach, management of walled off pancreatic necrosis and pancreatic pseudocyst is taking a new turn. A multi-centric study comparing surgical and endoscopic management of pancreatic pseudocyst and walled off pancreatic necrosis was performed. METHODS: Data was collected retrospectively from multiple centers and patients were followed up till date since the time of intervention. The outcomes were therapeutic success, post-operative complications, recurrence rate, mortality and duration of hospitalization. RESULTS: At the end of the follow-up period, none of the patients who received endoscopic intervention had a recurrence, compared to 2 patients in the surgical group. There was 16.67% mortality in the surgical group and only 3.33% mortality in the endoscopic group. Significantly high mortality was seen in the patients with Walled-Off Pancreatic Necrosis treated surgically, compared to no mortality in the patients treated endoscopically. 86 % of the patients in the endoscopic group had resolution of the disease following intervention compared to 70% in the other group. There were no statistically significant differences in mortality, resolution or recurrence of disease following intervention between the two groups. However, the length of hospital stay was significantly shorter for patients who underwent endoscopic intervention than open surgery. CONCLUSION: Endoscopic drainage of Pancreatic Pseudocysts and Walled off Pancreatic necrosis have demonstrated a therapeutic success rate, mortality and recurrence statistically comparable to that seen in surgical treatment, but with reduced time of hospitalization, supporting its use as the preferred initial modality for drainage.

Metal stent and percutaneous endoscopic necrosectomy as dual approach for the management of complex walled-off pancreatic necrosis.

Pancreatic fluid collections (PFCs) are one of the local complications of acute pancreatitis and include walled-off pancreatic necrosis (WOPN), which are complex entities with challenging management. The infection of pancreatic necrosis leads to a poorer prognosis, with a growth of the mortality rate up to 30%. The primary strategy for managing PFCs is a minimally invasive step-up approach, with endosonography-guided transmural drainage and debridement as the preferred and less invasive method. Percutaneous drainage (PCD) can be the technique of choice when endoscopic drainage is not feasible, for example for early PFCs without a mature wall or for the anatomic location and extension to the paracolic gutter of the collection. As PCD alone may be ineffective, especially when a great amount of necrosis is present, a percutaneous endoscopic necrosectomy (PEN) has been proposed, showing interesting results. The technique consists of the placement of an esophageal fully or partially covered self-expandable metal stent (SEMS) percutaneously into the collection and a direct debridement can be performed using a flexible endoscope through the SEMS. In this review, we will discuss about the role of metal stent and PEN for the management of complex walled-off pancreatic necrosis.

Diagnosis and treatment of a biliary fistula to walled-off pancreatic necrosis

Video 1Visualization and treatment of a biliary fistula into a walled-off pancreatic necrosis collection.

Novel powered 5.0-mm endoscopic debridement catheter for endoscopic transmural necrosectomy of pancreatic walled-off necrosis: a case series of consecutive patients from a tertiary referral center (with video)

Background and AimsEUS-guided drainage and, if required, endoscopic necrosectomy (EN) has become gold standard for treatment of pancreatic walled-off necrosis (WON). A dedicated powered endoscopic debridement system, EndoRotor (Interscope Inc., Northbridge, MA, USA), has been introduced as an alternative to snare necrosectomy. This study evaluates the novel EndoRotor catheter, NecroMax 6.0, for EN in patients with WON. MethodsThis single-center retrospective case series included consecutive WON patients treated with the NecroMax 6.0 catheter. Safety, ability to perform EN, and clinical resolution were evaluated. ResultsTwenty patients underwent a total of 30 EN procedures with the NecroMax 6.0 catheter. One suspected device-related adverse event was observed (3.3%). In one procedure EN could not be performed due to excessive bending of the endoscope. Eighteen (90.0%) patients achieved clinical resolution. ConclusionEndoscopic necrosectomy with the NecroMax 6.0 catheter was technically feasible in 96.7% with a low rate of adverse events.

The use of a novel haemostatic peptide gel in the management of walled-off pancreatic necrosis (WOPN) drained using lumen apposing metal stents (LAMSs): a case series

The use of a novel haemostatic peptide gel in the management of walled-off pancreatic necrosis (WOPN) drained using lumen apposing metal stents (LAMSs): a case series

The clinical and procedure-related outcomes of endoscopic management of walled-off pancreatic necrosis

The clinical and procedure-related outcomes of endoscopic management of walled-off pancreatic necrosis

Real-life Indications and Outcome of Electrocautery-enhanced Lumen-apposing Metal Stents in a Tertiary Center.

Electrocautery-enhanced lumen-apposing stents (EC-LAMS) were originally designed for the drainage of the gallbladder, bile duct, and pancreas pseudocysts. Throughout the years, several off-label indications were established. This study aims to evaluate the indication, safety, efficacy, and outcome of all LAMS implanted in a single tertiary referral center. From April 2016 to April 2022, all patients undergoing LAMS placement in a single tertiary center were included. We present a detailed analysis of indications, success rates, and complications based on a retrospective analysis of our prospectively maintained database. A total of 86 stents were placed in 77 patients between April 2016 and April 2022. Indications were walled-off pancreatic necrosis (25.6%), bile duct obstructions (16.3%), acute cholecystitis (15.1%), pancreas pseudocysts (15.1%), postoperative collections (10.5%), postoperative pancreatic fistulas (9.3%), and gastro-gastrostomy/jejunostomy (8.1%) to enable to perform an endoscopic retrograde cholangiopancreatography in patients with gastric bypass. Technical success was 97.7% (84 out of 86). A total of 10 (11.7%) adverse events were observed. In 3 patients (3.5%), severe complications occurred, which required acute surgery; one displacement was closed through clips. In 7 patients (8.2%), bleedings occurred during necrosectomy or from mucosal erosions at the stent side, respectively, that were treated with endoclips. EC-LAMS are safe and show a high technical success rate in all indications. In everyday clinical practice, the main indications are hepato-pancreato-biliary, and therefore an hepato-pancreato-biliary-surgical department should have EC-LAMS in their armamentarium.

Endoscopic transvaginal drainage and necrosectomy of presacral walled-off pancreatic necrosis.

Endoscopic transvaginal drainage and necrosectomy of presacral walled-off pancreatic necrosis.

COVID-19 Associated Multisystem Inflammatory Syndrome in Children Presenting as Acute Necrotizing Pancreatitis with Walled-off Pancreatic Necrosis (WOPN)

COVID-19 Associated Multisystem Inflammatory Syndrome in Children Presenting as Acute Necrotizing Pancreatitis with Walled-off Pancreatic Necrosis (WOPN)

Hemostatic matrix for treating intracollection bleeding after endoscopic ultrasound-guided drainage and endoscopic necrosectomy of walled-off pancreatic necrosis in a patient with cirrhosis.

A 45-year-old man with alcoholic liver cirrhosis was referred to our institute for treatment of infected walled-off pancreatic necrosis (WOPN) 6 months after an episode of acute pancreatitis. Computed tomography confirmed cirrhotic liver disease with collateral vessels and a pancreatic fluid collection at the body-tail (9 × 3 cm). Laboratory tests showed low platelets (55 000/mm3) and international normalized ratio of 1.5. Endoscopic ultrasound (EUS) evaluation showed perigastric collateral circulation and a WOPN with necrotic material accounting for 90 % of the total volume ([Fig. 1]).