Various Endoscopic Techniques for Treatment of Consequences of Acute Necrotizing Pancreatitis: Practical Updates for the Endoscopist

Mateusz Jagielski, Marian Smoczyński, Jacek Szeliga, Krystian Adrych, Marek Jackowski, Mateusz Jagielski, Marian Smoczyński, Jacek Szeliga, Krystian Adrych, Marek Jackowski

Abstract

Despite great progress in acute pancreatitis (AP) treatment over the last 30 years, treatment of the consequences of acute necrotizing pancreatitis (ANP) remains controversial. While numerous reports on minimally invasive treatment of the consequences of ANP have been published, several aspects of interventional treatment, particularly endoscopy, are still unclear. In this article, we attempt to discuss these aspects and summarize the current knowledge on endoscopic therapy for pancreatic necrosis. Endotherapy has been shown to be a safe and effective minimally invasive treatment modality in patients with consequences of ANP. The evolution of endoscopic techniques has made endoscopic drainage more effective and reduced the use of other minimally invasive therapies for pancreatic necrosis.

Keywords: acute necrotizing pancreatitis; endotherapy; minimally invasive; pancreatic necrosis; therapeutic EUS; therapeutic endoscopy.

Conflict of interest statement

The authors declare no conflict of interest.

Figures

Figure 1
Figure 1
(a,b) Abdominal CECT was obtained in a 24-year-old male with ANP on day 9. In the pancreatic area, an ANC can be seen. ANC, acute necrotic collection; ANP, acute necrotizing pancreatitis; CECT, contrast-enhanced computed tomography.
Figure 2
Figure 2
(a,b) Abdominal CECT was obtained in the same patient (Figure 1a,b) five weeks after the episode of ANP. A WOPN is visible, indenting the gastrointestinal wall. ANP, acute necrotizing pancreatitis; CECT, contrast-enhanced computed tomography; WOPN, walled-off pancreatic necrosis.
Figure 3
Figure 3
In the patient with symptomatic WOPN (Figure 2a,b), endoscopic transmural drainage was performed. Under EUS guidance, a cystogastrostomy was created. (a) The fistula was widened with a high-pressure 12-mm balloon. (b,c) Two stents and a nasocystic catheter were inserted into the necrotic collection. (d) Contrast agent was administered through the catheter and filled up the necrotic collection, which then drained freely into the stomach. EUS, endoscopic ultrasonography; WOPN, walled-off pancreatic necrosis.
Figure 3
Figure 3
In the patient with symptomatic WOPN (Figure 2a,b), endoscopic transmural drainage was performed. Under EUS guidance, a cystogastrostomy was created. (a) The fistula was widened with a high-pressure 12-mm balloon. (b,c) Two stents and a nasocystic catheter were inserted into the necrotic collection. (d) Contrast agent was administered through the catheter and filled up the necrotic collection, which then drained freely into the stomach. EUS, endoscopic ultrasonography; WOPN, walled-off pancreatic necrosis.
Figure 4
Figure 4
(a,b), Abdominal CECT was obtained during endoscopic transmural drainage (Figure 3a–d) of the WOPN. Transmural stents were inserted through the cystogastrostomy into the necrotic collection. CECT, contrast-enhanced computed tomography; WOPN, walled-off pancreatic necrosis.
Figure 5
Figure 5
(a,b), Abdominal CECT was obtained after 36 days of active transmural drainage (Figure 4a,b). Complete regression of the necrotic collection can be appreciated. In the pancreatic area, transmural stents are visible. CECT, contrast-enhanced computed tomography.
Figure 6
Figure 6
(a,b), SEMS in endoscopic transmural drainage of pancreatic necrosis. Two plastic stents and a nasocystic catheter were inserted into the WOPN through the metallic stent. Thick necrotic content is draining through the metal stent. SEMS, self-expanding metallic stent; WOPN, walled-off pancreatic necrosis.
Figure 7
Figure 7
(a–e), Endoscopic treatment of WOPN with use of the Hot AXIOS lumen-apposing stents. During the first endoscopic procedure the cystogastrostomy was performed (a–c). The outflow of necrotic content through the transmural stent is visible. During the next endoscopic procedure, the endoscopic necrosectomy was performed. Through the lumen of stent, the gastroscope was inserted to the lumen of necrotic cavity and necrotic tissues were removed with the use of a Dormia basket.
Figure 8
Figure 8
ERP during endoscopic treatment of pancreatic necrosis. (a) Complete disruption of the pancreatic duct can be seen within the tail at the level of transmural stent. (b) The stent bridging the pancreatic duct disruption. ERP, endoscopic retrograde pancreatography.
Figure 9
Figure 9
ERP was performed during transmural drainage of the WOPN. Complete disruption of the pancreatic duct within the tail can be seen, which causes contrast dye to spill outside the duct. ERP, endoscopic retrograde pancreatography; WOPN, walled-off pancreatic necrosis.
Figure 10
Figure 10
Endoscopic transpapillary drainage of symptomatic WOPN. (a,b) During ERP, the guide wire is introduced through the complete pancreatic duct disruption within the tail and looped within the central necrotic collection; the high-pressure 8-mm balloon is visible, which was used to dilate the pancreatic duct. (c,d) Transpapillary nasocystic catheter and stent insertion into the pancreatic duct, with the distal ends within the necrotic collection; contrast agent was administered through the catheter, filled up the collection, and drained freely into the duodenum.
Figure 11
Figure 11
ERP was performed during endoscopic treatment for pancreatic necrosis. (a) Contrast dye is spilling out through the complete pancreatic duct disruption at the isthmus. (b,c) The guide wire was introduced through the complete pancreatic duct disruption and looped within the necrotic collection. (d) The stent was inserted through the duodenal papilla (red arrow) with the distal end within the collection, where the transmural stent is also visible ERP, endoscopic retrograde pancreatography.

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Source: PubMed

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