Clin Endosc.  2020 Jan;53(1):49-53. 10.5946/ce.2019.131.

Endoscopic Transmural Necrosectomy: Timing, Indications, and Methods

• Rerknimitr R

• KMID: 2500904
• DOI: http://doi.org/10.5946/ce.2019.131

Abstract

Walled-off necrosis is considered one of the most severe complications after an episode of severe acute pancreatitis. Traditionally, percutaneous drainage is selected as the first treatment step, while open surgery can be planned as a secondary option if necrosectomy is required. In recent years, endoscopic necrosectomy has evolved as a more favorable approach. To date, a step-up treatment strategy is recommended, particularly when a plastic stent is selected as the drainage device. Multi-gateway endoscopic therapy may be used in a step-up fashion if only one stent fails to clear debris. Over many years, there has been an evolution in stent selection, from plastic to metallic stents. Within a few years of its clinical usage, lumen-apposing stents are gaining more popularity as they offer direct endoscopic necrosectomy and only require a few sessions.

Keyword

Walled-off necrosis; Endoscopic necrosectomy; Lumen-apposing metallic stent

Figure

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  Fig. 1. Algorithm to approach for walled-off necrosis (WON). EN, endoscopic necrosectomy; LAMS, lumen-apposing metallic stent; MTGT, multiple transluminal gateway technique; PS, plastic stent; VARD, video-assisted retroperitoneal debridement.

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  Fig. 2. (A) A computed tomography (CT) scan of the upper abdomen demonstrated an infected walled-off necrosis (WON) by showing air bubbles inside the cavity (yellow arrow). (B) Necrotic debris occluding the first lumen-apposing stent that was placed transduodenally. (C) Endoscopic debridement via the second lumen-apposing metallic stent (LAMS) that was placed transgastrically. Notably, the first LAMS (blue arrow) could be seen from a far distance. (D) Plain radiography of the abdomen demonstrated two LAMS (red arrows) in place at the WON site. (E) The final CT scan of the upper abdomen showed a resolution of the WON with a transmural plastic stent in place.

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