Endoscopic step up: When and how

Abstract

The management of (peri)pancreatic collections has undergone a paradigm shift from open surgical drainage to minimally invasive endoscopic, percutaneous, or surgical interventions. Minimally invasive interventions are associated with less morbidity and mortality compared to open necrosectomy. The (peri)pancreatic collections are currently treated with a "step-up approach" of an initial drainage procedure followed, if necessary, by a more invasive debridement. The step-up approach for management of (peri)pancreatic collections is mainly of two types, namely, surgical and endoscopic. Surgical step up includes initial image-guided percutaneous catheter drainage followed, if necessary, by minimally invasive video-assisted retroperitoneal debridement. Endoscopic step-up approach includes endoscopic transluminal drainage followed, if necessary by direct endoscopic necrosectomy. The development of endoscopic ultrasound and lumen apposing metal stents (LAMSs) has revolutionized the endoscopic management of (peri)pancreatic collections. Compared to surgical step-up approach, endoscopic step-up treatment approach has been reported to be associated with less new-onset organ failure, pancreatic fistula, enterocutaneous fistula, or perforation of visceral organ and shorter hospital/intensive care unit stay. This review will mainly focus on indications, techniques, timing, and recent advances related to endoscopic step-up approach in management of symptomatic(peri)pancreatic collections.

Fig 1

EUS-guided transmural drainage with multiple plastic stents. (A) EUS: WON with predominantly liquid content. (B) Transmural tract dilatation with balloon. (C) Placement of multiple plastic stents by placing multiple guide wires in WON. (D) Multiple plastic stents placed in WON.

Fig 2

EUS-guided transmural drainage with cautery enhanced LAMS. (A) Puncture of WON with cautery enhanced LAMS. (B) Deployment of LAMS. Guide wire negotiated into WON cavity through the deployed LAMS for dilatation of deployed LAMS. (C) Balloon dilatation of the deployed LAMS. (D) DEN being performed through the deployed LAMS.

Fig 3

Hydrogen peroxide assisted DEN.

Fig 4

Dual-modality drainage for WON with multiple plastic stents and large bore percutaneous catheter. (A) X-ray. (B) Computed tomography.