Endoscopic Step-Up Approach Of Symptomatic Pancreatic Necrotic Collections. A Need For Fine-Tuning Of The Guidelines?

Aims Multidisciplinary step-up approach is recommended in the management of symptomatic pancreatic necrotic collections (PNC). Application of lumen-apposing metal stents (LAMS) facilitates the transmural endoscopic ultrasound (EUS)-guided drainage. Subsequent debridement of necrotic material can be performed in a form of irrigation by naso-cavital drain and/or direct endoscopic necrosectomy (DEN). Whether to apply irrigation or DEN is unclear. Furthermore, when and “on-demand” or scheduled DEN should be carried out is also unknown. Delayed removal of the LAMS has been associated with increased risk of complications, accordingly timing of removal is also in evolution. Our aim was to fine-tune the recommendations in a form of a local protocol to improve safety and clinical efficacy of the step-up approach using LAMS.

Methods 12 patients with symptomatic PNC who underwent EUS-guided drainage with LAMS followed by debridement were assessed. First group of patients (n = 8) after LAMS placement were treated routinely only with irrigation drain and released when clinically improved; DEN was performed only if septic complications occurred. In a second group of patients (n = 4) irrigation and subsequent scheduled DEN (2-4 times) was accomplished. Clinical outcome was compared and evaluated.

Results In the first group in 62.5 % (5/8) of patients PNC resolved with no need for DEN or other intervention and the LAMS were removed after 5-6 weeks. In 37.5 % (3/8) of patients after discharge septic complications occurred and required readmission and series of DEN for debridement. In the second group where LAMS placement was routinely followed by scheduled DEN all PNCs resolved without septic complications and LAMS were removed within 4-5 weeks, except one patient who died few hours after successful scheduled DEN session of an unpredicted fatal hemorrhage.

Conclusions Fine-tuning of the guidelines may improve safety and clinical efficacy of the step-up approach in the management of symptomatic pancreatic necrotic collections.

Citation Keczer B, Miheller P, Horváth M et al. eP420 ENDOSCOPIC STEP-UP APPROACH OF SYMPTOMATIC PANCREATIC NECROTIC COLLECTIONS. A NEED FOR FINE-TUNING OF THE GUIDELINES? Endoscopy 2021; 53: S233.

Publication History

Article published online:
19 March 2021