Published online May 16, 2020. doi: 10.4253/wjge.v12.i5.149
Peer-review started: March 27, 2020
First decision: April 29, 2020
Revised: May 6, 2020
Accepted: May 12, 2020
Article in press: May 12, 2020
Published online: May 16, 2020
Currently, no official practice guidelines exist for direct endoscopic necrosectomy (DEN). A recent international expert panel issued recommendations about some of its technical aspects, but they are not universally applied by endoscopists worldwide.
To demonstrate that in DEN, flexibility within acceptable limits does not compromise outcomes.
To describe how our DEN technique differs from recent expert panel recommendations and other previously published studies. To provide an in-depth overview of our DEN technique with detailed description of endoscopes and devices used, as well as of its clinical outcomes and adverse events.
Retrospective review of medical records of patients with walled-off necrosis (WON) who underwent DEN. Technical success was defined as adequate lumen apposing metal stent (LAMS) deployment plus removal of ≥ 90% of necrosum. Clinical success was defined as complete resolution of WON cavity by imaging and of symptoms at ≤ 3 mo after last DEN. Data analysis was performed using mean and standard deviation for continuous variables, frequency and proportion for categorical variables, and median and range for interval data.
Data was collected on 21 patients. The mean age was 51 ± 17 years. The majority of patients were Hispanic and most of the collections were located in the body of the pancreas. Antibiotics were administered only in cases of infected necrosis. All LAMS were placed without radiological guidance, dilated the same day of deployment and removed after a mean of 27 ± 11 d. Routine cross-sectional imaging immediately after drainage was not performed. The mean number of DEN/patient was 3 ± 2. Technical and clinical success rates were both 95%. Two patients were lost to follow-up. Five patients experienced adverse events, but none were fatal.
This study showed that endoscopic management of pancreatic WON is a procedure in which technical diversity within acceptable limits does not compromise clinical outcomes. It suggests that antibiotic prophylaxis and complete debridement are not necessary; and that stent occlusion is not unequivocally associated to sepsis.
Prospective multicenter randomized trials addressing topics such as the optimal interval for LAMS removal, the role of prophylactic antibiotics, cross-sectional imaging and complete debridement of the cavity are needed.