title: A standardized method for endoscopic necrosectomy improves complication and mortality rates.
abstract: OBJECTIVE
  Endoscopic necrosectomy is effective in the treatment of walled-off necrosis (WON), and is preferred to surgical approaches, however complication and mortality rates remain high with few centers regularly employing the technique. Lack of a standardized approach may also contribute to these limitations.
  
  
  METHODS
  Prior to the study, a multidisciplinary team applied standardized care assessment and management plan principles to develop and optimize a systematic approach for the management of WON. Preoperative, postoperative, and endoscopic management were standardized. Patient preparation, room set-up, technical features (EUS-guidance, cold-access with balloon dilation, fragmentation of necrosis on the initial procedure, antibiotic lavage, double pigtail stents), and discontinuation of PPIs to encourage auto-digestion of necrosis were included. This study employed a consecutive prospective clinical registry to assess the clinical outcomes of this standardized approach.
  
  
  RESULTS
  60 consecutive patients underwent 1.58 ± 0.1 necrosectomies, with debridement accomplished on the initial procedure in 98.3%. 39 patients (65%) required only one session. Clinical resolution occurred in 86.7%, with radiologic confirmation. Percutaneous drainage was required in 8 patients during follow-up, and 4 of these later required surgery. Serious adverse events occurred in 3.3% of patients, and there was no mortality.
  
  
  CONCLUSIONS
  The standardized technique employed in this series was associated with lower rates of adverse events, morbidity, and mortality than prior large series. Use of a systematic approach, and integrating elements of this method may improve the risk profile of endoscopic necrosectomy and allow broader adoption.
authors.affiliation: Division of Gastroenterology, Hepatology and Endoscopy, Brigham and Women's Hospital, 75 Francis St., ASB II, Boston, MA 02115, USA. Electronic address: cthompson@hms.harvard.edu.
authors.forename: Christopher C
authors.initials: CC
authors.lastname: Thompson
authors.affiliation: Division of Gastroenterology, Hepatology and Endoscopy, Brigham and Women's Hospital, 75 Francis St., ASB II, Boston, MA 02115, USA. Electronic address: nitinkumar.101@gmail.com.
authors.forename: Nitin
authors.initials: N
authors.lastname: Kumar
authors.affiliation: Division of Gastroenterology, Hepatology and Endoscopy, Brigham and Women's Hospital, 75 Francis St., ASB II, Boston, MA 02115, USA. Electronic address: Jslattery2@partners.org.
authors.forename: James
authors.initials: J
authors.lastname: Slattery
authors.affiliation: Department of Surgery, Brigham and Women's Hospital, 75 Francis St, Boston, MA 02115, USA. Electronic address: tclancy@partners.org.
authors.forename: Thomas E
authors.initials: TE
authors.lastname: Clancy
authors.affiliation: Division of Gastroenterology, Hepatology and Endoscopy, Brigham and Women's Hospital, 75 Francis St., ASB II, Boston, MA 02115, USA. Electronic address: mryan15@partners.org.
authors.forename: Michele B
authors.initials: MB
authors.lastname: Ryan
authors.affiliation: Division of Gastroenterology, Hepatology and Endoscopy, Brigham and Women's Hospital, 75 Francis St., ASB II, Boston, MA 02115, USA. Electronic address: mryou@partners.org.
authors.forename: Marvin
authors.initials: M
authors.lastname: Ryou
authors.affiliation: Department of Surgery, Brigham and Women's Hospital, 75 Francis St, Boston, MA 02115, USA. Electronic address: rswanson@partners.org.
authors.forename: Richard S
authors.initials: RS
authors.lastname: Swanson
authors.affiliation: Division of Gastroenterology, Hepatology and Endoscopy, Brigham and Women's Hospital, 75 Francis St., ASB II, Boston, MA 02115, USA. Electronic address: pabanks@partners.org.
authors.forename: Peter A
authors.initials: PA
authors.lastname: Banks
authors.affiliation: Division of Gastroenterology, Hepatology, and Nutrition, Ohio State University Medical Center, 288 Office Tower, 395 W. 12th Avenue, Columbus, OH 43210, USA. Electronic address: darwin.conwell@osumc.edu.
authors.forename: Darwin L
authors.initials: DL
authors.lastname: Conwell
mesh_terms: D016145:Endoscopy, Digestive System; D016099:Endoscopy, Gastrointestinal / Q000379:methods* / Q000592:standards*; D005260:Female; D006801:Humans; D008297:Male; D008875:Middle Aged; D009336:Necrosis; D010195:Pancreatitis / Q000473:pathology* / Q000601:surgery*
keywords: Direct endoscopic necrosectomy (DEN); Necrosectomy; Pancreatitis; Pseudocyst; Walled-off necrosis (WON); Walled-off pancreatic necrosis (WOPN)