Single-center experience with endoscopic management of demarcated pancreatic walled-off pancreatic necrosis (WOPN)

Aims The revised Atlanta Classification delineates the local complications of acute pancreatitis, categorizing them as acute (peri)pancreatic fluid collections (PFCs), acute necrotic collections, pancreatic pseudocysts, and walled-off pancreatic necrosis (WOPN). Various endoscopic interventions are employed for the management of WOPN, notably including direct transluminal endoscopic necrosectomy (DEN) following the placement of an endoscopic ultrasound-guided (EUS) lumen-apposing metal stent (LAMS). This study aims to assess the clinical outcomes and safety profile of DEN in patients diagnosed with pancreatic WOPN.

Methods This single-center retrospective analysis encompasses patients with pancreatic WOPN who underwent DEN at Semmelweis University between October 1, 2021, and October 1, 2024. The procedures were performed by three seasoned specialists in EUS and endoscopic retrograde cholangiopancreatography (ERCP). Comprehensive data on patient demographics, procedural specifics, and follow-up outcomes were collected, with adverse events classified according to the AGREE criteria [1] [2].

Results We successfully placed LAMS in 31 patients (61% female, mean age 66.3 years, SD 9.4). The primary indications for intervention included the dimensions of WOPN, exacerbation of gastric outlet obstruction, and signs of infection. The mean dimensions of WOPN were recorded as 98 mm in the anteroposterior direction (SD 35.6), 90 mm laterolateral (SD 44), and 88 mm craniocaudal (SD 27.4), with a predominant occurrence in the head of the pancreas (60%). Alcohol consumption emerged as the leading etiological factor for WOPN in 92% of male patients, whereas biliary causes were identified in 67% of female patients. In total, we conducted 83 DEN procedures across the 31 patients (51 males and 32 females). The average number of DEN sessions was three for both male and female groups (range: 2-6). The technical success rate achieved was 100%, accompanied by a clinical success rate of 97%. One patient succumbed to the condition; however, three of the surviving 30 required intensive care due to multiorgan failure. To enhance the resolution of infection between DEN sessions, we employed 7 Fr/250 cm nasocystic tubes for irrigation of the WOPN with a saline solution in all patients, with no adverse events reported as a result of this intervention.

Conclusions DEN can be performed safely in experienced medical centers and demonstrates a high success rate in the treatment of infected WOPN, effectively alleviating symptoms and decreasing enzyme levels. The predominant etiology of WOPN formation in male patients is attributed to alcohol consumption, while biliary factors are more prevalent in female patients.

Publikationsverlauf

Artikel online veröffentlicht:
27. März 2025

• References

• 1 Upfront endoscopic necrosectomy or step-up endoscopic approach for infected necrotising pancreatitis (DESTIN): a single-blinded, multicentre, randomised trial
• 2 Endoscopic management of acute necrotizing pancreatitis: European Society of Gastrointestinal Endoscopy (ESGE) evidence-based multidisciplinary guidelines