title: A comparison of direct endoscopic necrosectomy with transmural endoscopic drainage for the treatment of walled-off pancreatic necrosis.
abstract: BACKGROUND
  Endoscopic therapy of walled-off pancreatic necrosis (WOPN) via direct intracavitary debridement is described.
  
  
  OBJECTIVE
  To compare direct endoscopic necrosectomy with conventional transmural endoscopic drainage for the treatment of WOPN.
  
  
  METHODS
  Retrospective, comparative study.
  
  
  METHODS
  Academic tertiary-care center.
  
  
  METHODS
  Patients referred to Mayo Clinic, Rochester, Minnesota, since April 1998 for endoscopic drainage of WOPN.
  
  
  METHODS
  Each patient underwent standard endoscopic drainage that consisted of transmural cavity puncture, dilation of the fistula tract, and placement of a large-bore stent(s). Patients were classified into the direct endoscopic necrosectomy group if, during any of their procedures, adjunctive direct endoscopic necrosectomy was performed; all others were in the standard drainage group.
  
  
  METHODS
  Success was defined as resolution of the necrotic cavity without the need for operative or percutaneous intervention.
  
  
  RESULTS
  Forty-five patients were identified who met study criteria: 25 underwent direct endoscopic necrosectomy, and 20 underwent standard endoscopic drainage. There were no differences in baseline patient or cavity characteristics. Successful resolution was accomplished in 88% who underwent direct endoscopic necrosectomy versus 45% who received standard drainage (P < .01), without a change in the total number of procedures. The maximum size of tract dilation was larger in the direct endoscopic necrosectomy group (17 mm vs 14 mm, P < .02). Complications were limited to mild periprocedural bleeding with equivalent rates between groups.
  
  
  CONCLUSIONS
  Retrospective, referral bias, single center.
  
  
  CONCLUSIONS
  Direct endoscopic necrosectomy achieves higher rates of resolution, without a concomitant change in the number of endoscopic procedures, complication rate, or time to resolution compared with standard endoscopic drainage for WOPN. The need for fewer postprocedural inpatient hospital days and a decrease in the rate of cavity recurrence are also likely benefits of this technique.
authors.affiliation: Section of Gastroenterology and Hepatology, Dartmouth-Hitchcock Medical Center, Lebanon, New Hampshire, USA.
authors.forename: Timothy B
authors.initials: TB
authors.lastname: Gardner
authors.forename: Prabhleen
authors.initials: P
authors.lastname: Chahal
authors.forename: Georgios I
authors.initials: GI
authors.lastname: Papachristou
authors.forename: Santhi Swaroop
authors.initials: SS
authors.lastname: Vege
authors.forename: Bret T
authors.initials: BT
authors.lastname: Petersen
authors.forename: Christopher J
authors.initials: CJ
authors.lastname: Gostout
authors.forename: Mark D
authors.initials: MD
authors.lastname: Topazian
authors.forename: Naoki
authors.initials: N
authors.lastname: Takahashi
authors.forename: Michael G
authors.initials: MG
authors.lastname: Sarr
authors.forename: Todd H
authors.initials: TH
authors.lastname: Baron
mesh_terms: D000368:Aged; D003646:Debridement / Q000379:methods*; D004322:Drainage / Q000379:methods*; D004384:Duodenoscopy / Q000379:methods*; D019160:Endosonography; D005260:Female; D005773:Gastroscopy / Q000379:methods*; D006801:Humans; D008297:Male; D008875:Middle Aged; D010181:Pancreatic Cyst / Q000601:surgery*; D019283:Pancreatitis, Acute Necrotizing / Q000601:surgery*; D011183:Postoperative Complications / Q000209:etiology; D012189:Retrospective Studies; D015607:Stents; D013525:Surgical Instruments; D018084:Ultrasonography, Interventional