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. 2016 Jan-Feb;16(1):66-72.
doi: 10.1016/j.pan.2015.12.001. Epub 2015 Dec 22.

A standardized method for endoscopic necrosectomy improves complication and mortality rates

Christopher C Thompson  1 , Nitin Kumar  2 , James Slattery  3 , Thomas E Clancy  4 , Michele B Ryan  5 , Marvin Ryou  6 , Richard S Swanson  7 , Peter A Banks  8 , Darwin L Conwell  9
Affiliations

A standardized method for endoscopic necrosectomy improves complication and mortality rates

Christopher C Thompson et al. Pancreatology. 2016 Jan-Feb.

Abstract

Objectives: Endoscopic necrosectomy is effective in the treatment of walled-off necrosis (WON), and is preferred to surgical approaches, however complication and mortality rates remain high with few centers regularly employing the technique. Lack of a standardized approach may also contribute to these limitations.

Methods: Prior to the study, a multidisciplinary team applied standardized care assessment and management plan principles to develop and optimize a systematic approach for the management of WON. Preoperative, postoperative, and endoscopic management were standardized. Patient preparation, room set-up, technical features (EUS-guidance, cold-access with balloon dilation, fragmentation of necrosis on the initial procedure, antibiotic lavage, double pigtail stents), and discontinuation of PPIs to encourage auto-digestion of necrosis were included. This study employed a consecutive prospective clinical registry to assess the clinical outcomes of this standardized approach.

Results: 60 consecutive patients underwent 1.58 ± 0.1 necrosectomies, with debridement accomplished on the initial procedure in 98.3%. 39 patients (65%) required only one session. Clinical resolution occurred in 86.7%, with radiologic confirmation. Percutaneous drainage was required in 8 patients during follow-up, and 4 of these later required surgery. Serious adverse events occurred in 3.3% of patients, and there was no mortality.

Conclusions: The standardized technique employed in this series was associated with lower rates of adverse events, morbidity, and mortality than prior large series. Use of a systematic approach, and integrating elements of this method may improve the risk profile of endoscopic necrosectomy and allow broader adoption.

Keywords: Direct endoscopic necrosectomy (DEN); Necrosectomy; Pancreatitis; Pseudocyst; Walled-off necrosis (WON); Walled-off pancreatic necrosis (WOPN).

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Figures

Figure 1
Figure 1. Charlson Comorbidity Index Scoring System
Reprinted from American Journal of Kidney Diseases, 32(2), Fried L, Bernardini J, Piraino B, Charlson Comorbidity Index as a Predictor of Outcomes in Incident Peritoneal Dialysis Patients, 338, 2001, with permission from Elsevier.
Figure 2
Figure 2. CT Scan showing WOPN
See this image and copyright information in PMC

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