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.
