Peroral Endoscopic Drainage/Debridement of Walled-off Pancreatic Necrosis (original) (raw)

Background: Experience with minimal access, transoral/transmural endoscopic drainage/debridement of walled-off pancreatic necrosis (WOPN) after necrotizing pancreatitis is limited. We sought to determine outcome using this technique. Methods: Retrospective analysis. Results: From 1998 to 2006, 53 patients underwent transoral/ transmural endoscopic drainage/debridement of sterile (27, 51%) and infected (26, 49%) WOPN. Intervention was performed a median of 49 days (range, 20 -300 days) after onset of acute necrotizing pancreatitis. A median of 3 endoscopic procedures/ patient (range, 1-12) were performed. Twenty-one patients (40%) required concurrent radiologic-guided catheter drainage of associated or subsequent areas of peripancreatic fluid and/or WOPN. Twelve patients (23%) required open operative intervention a median of 47 days (range, 5-540) after initial endoscopic drainage/ debridement, due to persistence of WOPN (n ϭ 3), recurrence of a fluid collection (n ϭ 2), cutaneous fistula formation (n ϭ 2), or technical failure, persistence of pancreatic pain, colonic obstruction, perforation, and flank abscess (n ϭ 1 each). Final outcome after initial endoscopic intervention (median, 178 days) revealed successful endoscopic therapy in 43 (81%) and persistence of WOPN in 10 (19%). Preexistent diabetes mellitus, size of WOPN, and extension of WOPN into paracolic gutter were significant predictive factors for need of subsequent open operative therapy. Conclusions: Successful resolution of symptomatic, sterile, and infected WOPN can be achieved using a minimal access endoscopic approach. Adjuvant percutaneous drainage is necessary in up to 40% of patients, especially when WOPN extends to paracolic gutters or pelvis. Operative intervention for failed endoscopic treatment is required in about 20% of patients. (Ann Surg 2007;245: 943-951) FIGURE 2. Endoscopic debridement/necrosectomy of WOPN. A, Dilatation of transmural tract; necrotic debris within WOPN can be seen. B, Upper endoscope advanced through gastric wall into WOPN to allow direct endoscopic debridement/necrosectomy. C, Devitalized pancreatic tissue removed with a tripod grasper.