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Review
. 2024 Feb 9;14(4):381.
doi: 10.3390/diagnostics14040381.

Indications, Techniques and Future Perspectives of Walled-off Necrosis Management

Edoardo Troncone  1 , Rosa Amendola  1 , Fabio Gadaleta  1 , Elena De Cristofaro  1 , Benedetto Neri  1 , Pasquale De Vico  2 , Omero Alessandro Paoluzi  1 , Giovanni Monteleone  1 , Andrea Anderloni  3 , Giovanna Del Vecchio Blanco  1
Affiliations
Review

Indications, Techniques and Future Perspectives of Walled-off Necrosis Management

Edoardo Troncone et al. Diagnostics (Basel). .

Abstract

Necrotizing pancreatitis is a complex clinical condition burdened with significant morbidity and mortality. In recent years, the huge progress of interventional endoscopic ultrasound (EUS) has allowed a shift in the management of pancreatic necrotic collections from surgical/percutaneous approaches to mini-invasive endoscopic internal drainage and debridement procedures. The development of lumen-apposing metal stents (LAMSs), devices specifically dedicated to transmural EUS interventions, further prompted the diffusion of such techniques. Several studies have reported excellent outcomes of endoscopic interventions, in terms of technical success, clinical efficacy and safety compared to surgical interventions, and thus endoscopic drainage of walled-off necrosis (WON) has become a fundamental tool for the management of such conditions. Despite these advancements, some critical unresolved issues remain. Endoscopic therapeutic approaches to WON are still heterogeneous among different centers and experts. A standardized protocol on indication, timing and technique of endoscopic necrosectomy is still lacking, and experts often adopt a strategy based on personal experience more than robust data from well-conducted studies. In this review, we will summarize the available evidence on endoscopic management of WON and will discuss some unanswered questions in this rapidly evolving field.

Keywords: EUS drainage; necrotizing pancreatitis; walled-off necrosis.

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Conflict of interest statement

All authors declare no conflicts of interest.

Figures

Figure 1
Figure 1
CT scan image of a necrotizing pancreatitis, with hypoenhancing areas of pancreatic parenchyma. CT, computed tomography.
Figure 2
Figure 2
CT scan image of a large collection determining symptomatic gastric compression. CT, computed tomography.
Figure 3
Figure 3
(A) CT scan and (B) EUS image of a large WON with large amount of solid necrotic material; (C) EUS image of the distal flange of a 20 mm LAMS (white arrow) deployed into the WON; (D) endoscopic image through the LAMS of the necrotic cavity completely filled with necrotic debris; (E) endoscopic image of the clean cavity after drainage and repeated necrosectomy sessions; (F) CT scan image of the collapsed cavity with indwelling LAMS and a 10 French/4 cm coaxial DPS. CT: computed tomography; EUS: endoscopic ultrasound; WON: walled-off necrosis; LAMS: lumen-apposing metal stent; DPS: double-pigtail stent.
Figure 4
Figure 4
CT scan image of WON drained endoscopically with multiple transluminal gateway technique, with a transgastric 20 mm and a transduodenal 15 mm LAMS. CT: computed tomography; WON: walled-off necrosis; LAMS: lumen-apposing metal stent.
Figure 5
Figure 5
Endoscopic view of direct necrosectomy through a 20 mm LAMS with a polypectomy snare. LAMS: lumen-apposing metal stent.
Figure 6
Figure 6
(A) Endoscopic view of a naso-cystic catheter within a necrotic collection; (B) endoscopic view of a retroperitoneal cavity after lavage with peroxide hydrogen.
Figure 7
Figure 7
The Necrolit device is composed of a snare (1) and a nitinol basket (2). Image reproduced with authorization of Meditalia s.a.s.
See this image and copyright information in PMC

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