Aggressive endoscopic therapy for pancreatic necrosis and pancreatic abscess: a new safe and effective treatment algorithm (videos).
BACKGROUND
Pancreatic necrosis and pancreatic abscess are severe complications of acute pancreatitis. Surgery is associated with significant morbidity and mortality in these critically ill patients. Endoscopic therapy has the potential to offer a safer and more effective alternative treatment modality. However, its role needs to be further investigated.


METHODS
This is a retrospective study of the outcome of consecutive patients with pancreatic necrosis and pancreatic abscess, all unfit to undergo surgery, who underwent a new aggressive endoscopic approach. The treatment includes (1) synchronous EUS-guided multiple transmural and/or transpapillary drainage procedures followed by balloon dilation of the cystogastrostoma or cystoduodenostoma, (2) daily endoscopic necrosectomy and saline solution lavage, and (3) sealing of pancreatic fistula by N-butyl-2-cyanoacrylate.


RESULTS
Pancreatic necrosis and pancreatic abscesses were successfully drained in 13 patients, thus avoiding emergency surgery as an initial treatment. Surgery was completely avoided in 9 patients over a median follow-up of 8.3 months (range 3-81 months). Surgery was combined with endoscopic therapy in one patient because of abscess extension into the right paracolic gutter, which was not manageable by endoscopic drainage. Because of the "disconnected-duct syndrome," two patients later developed recurrent pseudocysts and underwent elective surgery. Complications included minor bleeding after balloon dilation and necrosectomy in 4 cases, which were self limiting or controlled endoscopically.


CONCLUSIONS
This aggressive endoscopic approach shows promising results. It expands the potential for endoscopic treatment in patients with pancreatic necrosis and/or pancreatic abscess.
Department of Interdisciplinary Endoscopy, University Hospital Hamburg-Eppendorf, 20246 Hamburg, Germay.
Stefan
S
Seewald
Stefan
S
Groth
Salem
S
Omar
Hiroo
H
Imazu
Uwe
U
Seitz
Andreas
A
de Weerth
Roy
R
Soetikno
Yan
Y
Zhong
Parupudi V J
PV
Sriram
Ryan
R
Ponnudurai
Sanjay
S
Sikka
Frank
F
Thonke
Nib
N
Soehendra
D000038:Abscess / Q000175:diagnosis / Q000628:therapy*; D000328:Adult; D000368:Aged; D000369:Aged, 80 and over; D000465:Algorithms; D001706:Biopsy; D002404:Catheterization; D004322:Drainage / Q000379:methods; D016099:Endoscopy, Gastrointestinal / Q000379:methods*; D019160:Endosonography; D005260:Female; D006801:Humans; D008297:Male; D008875:Middle Aged; D010179:Pancreas / Q000000981:diagnostic imaging / Q000473:pathology; D010180:Pancreatectomy / Q000379:methods; D019283:Pancreatitis, Acute Necrotizing / Q000175:diagnosis / Q000628:therapy*; D012189:Retrospective Studies; D014057:Tomography, X-Ray Computed; D016896:Treatment Outcome; D014741:Video Recording