Early endoscopic drainage (< 4 weeks) for necrotic pancreatic collections: recklessness or advisable

Aims A necrotising pancreatitis may develop to Walled-Off Necrosis (WON) or acute necrosis collection (ANC)) depending on the on-set time after pancreatitis (< o>4-weeks). Current guidelines recommend that endoscopic drainage should be delayed at least 4 weeks after the onset of pancreatitis whenever possible to allow encapsulation of necrotic tissue. Nevertheless, in daily-clinical practice, some acute pancreatic collections causing a critical life-threating scenario are considered in multidisciplinary team for an early-endoscopic drainage. But there is a lack of scientific-evidence and clinical results for recommending this approach. The aim was to assess the efficacy and safety of an early-endoscopic drainage for a necrotizing pancreatitis management [1] [2].

Methods This is a retrospective observational study of a prospective database for all patients who underwent an early endoscopic intervention for pancreatic collection. Study period carried out between January 2010 to September 2024 at 3 centres. Primary outcome: adverse events (AEs) related to the endoscopic approach; secondary outcomes: success/failure, surgical rescue and mortality.

Results Among 549 endoscopic drainages for collections, 39 (7%) were identified as early-drainage on pancreatic collections, and were selected (59% men; median age 62 years, range: 33-81; Charlson 3 [1-8]; SIRS 59%). Main ethiology: biliary acute pancreatitis (44%). Most of them (73%) including moderate-severe necrosis content, and only 9 patients<30%-necrosis; infection was present in 92% (suspicious 42%, diagnosed 58%), and non-encapsulated (64%) or partially-encapsulated (36%). Technical success: 92% (34/37; 3 not performed due a poor safety windows/optimal distance). Stent type: 14 double-plastic pigtail; 10 lumen-apposing-metal-stent (LAMS) plus coaxial pigtail; 7 single LAMS; 7 simple-aspiration until collapse; 1 conservative management. Endoscopic necrosectomy performed on 11 patients. Requeriment for percutaneous drainage after endoscopic drainage in 8 patients (20%); and surgery needing after-endoscopy therapy in 5 patients (13%). Intensive-care unit stay in 24 pacients (62%). Global hospital stay length, 67 days (range, 9-228). AEs reported in 5 patients (13%), (2 bleedings, 1 sepsis, 1 stent migration, 1 respiratory failure). Mortality in 5 patients (2 multiorganic failure, 2 respiratory failure, 1 post-surgery).

Conclusions The early-endoscopic drainage (< 4 weeks) for immature pancreatic collections seems to be feasible and safe, in experienced centres. Maybe, patients requiring endoscopic drainage might not be delayed for 4 weeks.

Publication History

Article published online:
27 March 2025

• References

• 1 Ramai D, Enofe I, Deliwala SS, Mozell D, Facciorusso A, Gkolfakis P. et al. Early (< 4 weeks) versus standard (≥ 4 weeks) endoscopic drainage of pancreatic walled-off fluid collections: a systematic review and meta-analysis. Gastrointest Endosc 2023; 97: 415-421
• 2 Oblizajek N, Takahashi N, Agayeva S, Bazerbachi F, Chandrasekhara V, Levy M. et al. Outcomes of early endoscopic intervention for pancreatic necrotic collections: a matched case-control study. Gastrointest Endosc 2020; 91: 1303-1309