Endoscopic transmural debridement of symptomatic organized pancreatic necrosis (with videos)

Background: Surgical management of pancreatic necrosis is associated with significant morbidity and mortality. Several weeks after an episode of a necrotizing pancreatitis, necrosis can become organized. By the time necrosis becomes organized, endoscopic therapy has the potential to offer an alternative treatment to surgery. Objective: To evaluate the safety and efficacy of endoscopic debridement of organized pancreatic necrosis and to identify procedural aspects that may improve outcome. Design: Retrospective cohort study. Setting: Tertiary referral center. Patients: All consecutive patients who under-went this novel endoscopic approach were included. Interventions: Treatment started with a cystoenterostomy or a cystogastrostomy. The next steps consisted of balloon dilation, up to 18 mm; advancement of an endoscope into the retroperitoneal cavity; and endoscopic debridement of the collection under direct endoscopic vision. Debridement was repeated every 2 days until most necrotic material was evacuated. in addition, nasocystic catheter irrigation was performed manually with saline solution 6 to 8 times a day. Main Outcome Measurements: Clinical success, number of endoscopic procedures, and complications. Results: Twenty-five patients were identified, who had undergone debridement of 27 collections. In 11, 13, 2, and 1 collections, 1, 2, 3, and 4 endoscopic debridement procedures, respectively, were performed. There was no mortality. Severe complications that required surgery occurred in 2 patients: hemorrhage in 1 case and perforation of cyst wall in the other. During a median follow-up of 16 months (range 3-38 months), the overall clinical success rate with resolution of the collection and related symptoms was 93%. Limitations: Retrospective study. Conclusions: In this study, we showed that endoscopic debridement is an effective and relatively safe minimally invasive therapy in patients with symptomatic organized pancreatic necrosis. Further comparative studies are warranted to define its definitive role in the management of these patients.