Download PDF
Digestive Disease Interventions 2023; 07(04): 228-239
DOI: 10.1055/s-0043-1771306
Review Article

Walled-off Pancreatic Necrosis: Multidisciplinary Perspective

Keith B. Quencer
1   Charles Dotter Department of Interventional Radiology, Oregon Health and Science University, Portland, Oregon
,
Erin W. Gilbert
2   Division of Gastrointestinal and General Surgery, Department of Surgery, Oregon Health and Science University, Portland, Oregon
,
Leonardo Campos
1   Charles Dotter Department of Interventional Radiology, Oregon Health and Science University, Portland, Oregon
,
Emily R. Jonica
3   Division of Gastroenterology and Hepatology, Department of Medicine, Oregon Health and Science University, Portland, Oregon
› Author Affiliations
› Further Information
Also available at
    Permissions and Reprints

Abstract

Walled-off pancreatic necrosis is a potential sequela of necrotizing pancreatitis. When drainage is indicated, such as in the setting of local complications (biliary or bowel obstruction), superinfection, or the collection causing abdominal pain, endoscopic, percutaneous, and surgical approaches are possible. Endoscopic drainage with or without placement of a luminal apposing metal stent and possible direct endoscopic necrosectomy is the preferred approach for drainage given good outcomes and patient comfort. In some cases, due to location and/or lack of a mature wall, endoscopic drainage is not possible or may be ineffective. In such cases, percutaneous and/or surgical drainage may be necessary.

Keywords

necrotizing pancreatitis - walled-off pancreatic necrosis - luminal apposing metal stent - percutaneous drainage - video-assisted retroperitoneal debridement


Publication History

Received: 31 March 2023

Accepted: 12 June 2023

Article published online:
09 August 2023

© 2023. Thieme. All rights reserved.

Thieme Medical Publishers, Inc.
333 Seventh Avenue, 18th Floor, New York, NY 10001, USA

 

  • References

  • 1 Gapp J, Hall AG, Walters RW, Jahann D, Kassim T, Reddymasu S. Trends and outcomes of hospitalizations related to acute pancreatitis: epidemiology from 2001 to 2014 in the United States. Pancreas 2019; 48 (04) 548-554
    CrossrefPubMedGoogle Scholar
  • 2 Banks PA, Bollen TL, Dervenis C. et al; Acute Pancreatitis Classification Working Group. Classification of acute pancreatitis--2012: revision of the Atlanta classification and definitions by international consensus. Gut 2013; 62 (01) 102-111
    CrossrefPubMedGoogle Scholar
  • 3 Forsmark CE, Vege SS, Wilcox CM. Acute pancreatitis. N Engl J Med 2016; 375 (20) 1972-1981
    CrossrefPubMedGoogle Scholar
  • 4 Bruennler T, Hamer OW, Lang S. et al. Outcome in a large unselected series of patients with acute pancreatitis. Hepatogastroenterology 2009; 56 (91-92): 871-876
    PubMedGoogle Scholar
  • 5 Werge M, Novovic S, Schmidt PN, Gluud LL. Infection increases mortality in necrotizing pancreatitis: a systematic review and meta-analysis. Pancreatology 2016; 16 (05) 698-707
    CrossrefPubMedGoogle Scholar
  • 6 Le Mée J, Paye F, Sauvanet A. et al. Incidence and reversibility of organ failure in the course of sterile or infected necrotizing pancreatitis. Arch Surg 2001; 136 (12) 1386-1390
    CrossrefPubMedGoogle Scholar
  • 7 Chatila AT, Bilal M, Guturu P. Evaluation and management of acute pancreatitis. World J Clin Cases 2019; 7 (09) 1006-1020
    CrossrefPubMedGoogle Scholar
  • 8 Dellinger EP, Forsmark CE, Layer P. et al; Pancreatitis Across Nations Clinical Research and Education Alliance (PANCREA). Determinant-based classification of acute pancreatitis severity: an international multidisciplinary consultation. Ann Surg 2012; 256 (06) 875-880
    CrossrefPubMedGoogle Scholar
  • 9 Diculescu M, Ciocîrlan M, Ciocîrlan M, Stănescu D, Ciprut T, Marinescu T. Predictive factors for pseudocysts and peripancreatic collections in acute pancreatitis. Rom J Gastroenterol 2005; 14 (02) 129-134
    PubMedGoogle Scholar
  • 10 Cui ML, Kim KH, Kim HG. et al. Incidence, risk factors and clinical course of pancreatic fluid collections in acute pancreatitis. Dig Dis Sci 2014; 59 (05) 1055-1062
    CrossrefPubMedGoogle Scholar
  • 11 Türkvatan A, Erden A, Seçil M, Türkoğlu MA. Fluid collections associated with acute pancreatitis: a pictorial essay. Can Assoc Radiol J 2014; 65 (03) 260-266
    CrossrefPubMedGoogle Scholar
  • 12 Bezmarević M, van Dijk SM, Voermans RP, van Santvoort HC, Besselink MG. Management of (peri)pancreatic collections in acute pancreatitis. Visc Med 2019; 35 (02) 91-96
    CrossrefPubMedGoogle Scholar
  • 13 Mier J, León EL, Castillo A, Robledo F, Blanco R. Early versus late necrosectomy in severe necrotizing pancreatitis. Am J Surg 1997; 173 (02) 71-75
    CrossrefPubMedGoogle Scholar
  • 14 Howard TJ, Patel JB, Zyromski N. et al. Declining morbidity and mortality rates in the surgical management of pancreatic necrosis. J Gastrointest Surg 2007; 11 (01) 43-49
    CrossrefPubMedGoogle Scholar
  • 15 van Santvoort HC, Besselink MG, Bakker OJ. et al; Dutch Pancreatitis Study Group. A step-up approach or open necrosectomy for necrotizing pancreatitis. N Engl J Med 2010; 362 (16) 1491-1502
    CrossrefPubMedGoogle Scholar
  • 16 Singhal D, Kakodkar R, Sud R, Chaudhary A. Issues in management of pancreatic pseudocysts. JOP 2006; 7 (05) 502-507
    PubMedGoogle Scholar
  • 17 Working Group IAP/APA Acute Pancreatitis Guidelines. IAP/APA evidence-based guidelines for the management of acute pancreatitis. Pancreatology 2013; 13 (4, Suppl 2): e1-e15
    CrossrefPubMedGoogle Scholar
  • 18 Tyberg A, Karia K, Gabr M. et al. Management of pancreatic fluid collections: a comprehensive review of the literature. World J Gastroenterol 2016; 22 (07) 2256-2270
    CrossrefPubMedGoogle Scholar
  • 19 Baron TH, DiMaio CJ, Wang AY, Morgan KA. American Gastroenterological Association Clinical Practice Update: management of pancreatic necrosis. Gastroenterology 2020; 158 (01) 67-75.e1
    CrossrefPubMedGoogle Scholar
  • 20 Petrov MS, Shanbhag S, Chakraborty M, Phillips AR, Windsor JA. Organ failure and infection of pancreatic necrosis as determinants of mortality in patients with acute pancreatitis. Gastroenterology 2010; 139 (03) 813-820
    CrossrefPubMedGoogle Scholar
  • 21 Stamatakos M, Stefanaki C, Kontzoglou K, Stergiopoulos S, Giannopoulos G, Safioleas M. Walled-off pancreatic necrosis. World J Gastroenterol 2010; 16 (14) 1707-1712
    CrossrefPubMedGoogle Scholar
  • 22 Wysocki AP, McKay CJ, Carter CR. Infected pancreatic necrosis: minimizing the cut. ANZ J Surg 2010; 80 (1-2) 58-70
    CrossrefPubMedGoogle Scholar
  • 23 Maatman TK, Heimberger MA, Lewellen KA. et al. Visceral artery pseudoaneurysm in necrotizing pancreatitis: incidence and outcomes. Can J Surg 2020; 63 (03) E272-E277
    CrossrefPubMedGoogle Scholar
  • 24 Nadkarni NA, Khanna S, Vege SS. Splanchnic venous thrombosis and pancreatitis. Pancreas 2013; 42 (06) 924-931
    CrossrefPubMedGoogle Scholar
  • 25 Siddiqui AA, Adler DG, Nieto J. et al. EUS-guided drainage of peripancreatic fluid collections and necrosis by using a novel lumen-apposing stent: a large retrospective, multicenter U.S. experience (with videos). Gastrointest Endosc 2016; 83 (04) 699-707
    CrossrefPubMedGoogle Scholar
  • 26 Gkolfakis P, Chiara Petrone M, Tadic M. et al. Efficacy and safety of endoscopic drainage of peripancreatic fluid collections: a retrospective multicenter European study. Ann Gastroenterol 2022; 35 (06) 654-662
    PubMedGoogle Scholar
  • 27 van Baal MC, van Santvoort HC, Bollen TL, Bakker OJ, Besselink MG, Gooszen HG. Dutch Pancreatitis Study Group. Systematic review of percutaneous catheter drainage as primary treatment for necrotizing pancreatitis. Br J Surg 2011; 98 (01) 18-27
    CrossrefPubMedGoogle Scholar
  • 28 Ke L, Li J, Hu P, Wang L, Chen H, Zhu Y. Percutaneous catheter drainage in infected pancreatitis necrosis: a systematic review. Indian J Surg 2016; 78 (03) 221-228
    CrossrefPubMedGoogle Scholar
  • 29 van Brunschot S, van Grinsven J, van Santvoort HC. et al; Dutch Pancreatitis Study Group. Endoscopic or surgical step-up approach for infected necrotising pancreatitis: a multicentre randomised trial. Lancet 2018; 391 (10115): 51-58
    CrossrefPubMedGoogle Scholar
  • 30 Horvath K, Freeny P, Escallon J. et al. Safety and efficacy of video-assisted retroperitoneal debridement for infected pancreatic collections: a multicenter, prospective, single-arm phase 2 study. Arch Surg 2010; 145 (09) 817-825
    CrossrefPubMedGoogle Scholar
  • 31 Varadarajulu S, Bang JY, Sutton BS, Trevino JM, Christein JD, Wilcox CM. Equal efficacy of endoscopic and surgical cystogastrostomy for pancreatic pseudocyst drainage in a randomized trial. Gastroenterology 2013; 145 (03) 583-90.e1
    CrossrefPubMedGoogle Scholar
  • 32 Garg PK, Meena D, Babu D. et al. Endoscopic versus laparoscopic drainage of pseudocyst and walled-off necrosis following acute pancreatitis: a randomized trial. Surg Endosc 2020; 34 (03) 1157-1166
    CrossrefPubMedGoogle Scholar
  • 33 Angadi S, Mahapatra SJ, Sethia R. et al. Endoscopic transmural drainage tailored to quantity of necrotic debris versus laparoscopic transmural internal drainage for walled-off necrosis in acute pancreatitis: a randomized controlled trial. Pancreatology 2021; 21 (07) 1291-1298
    CrossrefPubMedGoogle Scholar
  • 34 Bang JY, Arnoletti JP, Holt BA. et al. An endoscopic transluminal approach, compared with minimally invasive surgery, reduces complications and costs for patients with necrotizing pancreatitis. Gastroenterology 2019; 156 (04) 1027-1040.e3
    CrossrefPubMedGoogle Scholar
  • 35 Boxhoorn L, van Dijk SM, van Grinsven J. et al; Dutch Pancreatitis Study Group. Immediate versus postponed intervention for infected necrotizing pancreatitis. N Engl J Med 2021; 385 (15) 1372-1381
    CrossrefPubMedGoogle Scholar
  • 36 Park DH, Lee SS, Moon SH. et al. Endoscopic ultrasound-guided versus conventional transmural drainage for pancreatic pseudocysts: a prospective randomized trial. Endoscopy 2009; 41 (10) 842-848
    Article in Thieme ConnectPubMedGoogle Scholar
  • 37 Varadarajulu S, Christein JD, Tamhane A, Drelichman ER, Wilcox CM. Prospective randomized trial comparing EUS and EGD for transmural drainage of pancreatic pseudocysts (with videos). Gastrointest Endosc 2008; 68 (06) 1102-1111
    CrossrefPubMedGoogle Scholar
  • 38 Bang JY, Navaneethan U, Hasan MK, Sutton B, Hawes R, Varadarajulu S. Non-superiority of lumen-apposing metal stents over plastic stents for drainage of walled-off necrosis in a randomised trial. Gut 2019; 68 (07) 1200-1209
    CrossrefPubMedGoogle Scholar
  • 39 Maharshi S, Sharma SS, Ratra S, Sapra B, Sharma D. Management of walled-off necrosis with nasocystic irrigation with hydrogen peroxide versus biflanged metal stent: randomized controlled trial. Endosc Int Open 2021; 9 (07) E1108-E1115
    Article in Thieme ConnectPubMedGoogle Scholar
  • 40 Elmunzer BJ. Endoscopic drainage of pancreatic fluid collections. Clin Gastroenterol Hepatol 2018; 16 (12) 1851-1863.e3
    CrossrefPubMedGoogle Scholar
  • 41 Sharaiha RZ, Tyberg A, Khashab MA. et al. Endoscopic therapy with lumen-apposing metal stents is safe and effective for patients with pancreatic walled-off necrosis. Clin Gastroenterol Hepatol 2016; 14 (12) 1797-1803
    CrossrefPubMedGoogle Scholar
  • 42 Saunders R, Ramesh J, Cicconi S. et al. A systematic review and meta-analysis of metal versus plastic stents for drainage of pancreatic fluid collections: metal stents are advantageous. Surg Endosc 2019; 33 (05) 1412-1425
    CrossrefPubMedGoogle Scholar
  • 43 Patil R, Ona MA, Papafragkakis C, Anand S, Duddempudi S. Endoscopic ultrasound-guided placement of AXIOS stent for drainage of pancreatic fluid collections. Ann Gastroenterol 2016; 29 (02) 168-173
    CrossrefPubMedGoogle Scholar
  • 44 Yi H, Liu Q, He S. et al. Current uses of electro-cautery lumen apposing metal stents in endoscopic ultrasound guided interventions. Front Med (Lausanne) 2022; 9: 1002031
    CrossrefPubMedGoogle Scholar
  • 45 Brimhall B, Han S, Tatman PD. et al. Increased incidence of pseudoaneurysm bleeding with lumen-apposing metal stents compared to double-pigtail plastic stents in patients with peripancreatic fluid collections. Clin Gastroenterol Hepatol 2018; 16 (09) 1521-1528
    CrossrefPubMedGoogle Scholar
  • 46 Gardner TB, Coelho-Prabhu N, Gordon SR. et al. Direct endoscopic necrosectomy for the treatment of walled-off pancreatic necrosis: results from a multicenter U.S. series. Gastrointest Endosc 2011; 73 (04) 718-726
    CrossrefPubMedGoogle Scholar
  • 47 van Brunschot S, Fockens P, Bakker OJ. et al. Endoscopic transluminal necrosectomy in necrotising pancreatitis: a systematic review. Surg Endosc 2014; 28 (05) 1425-1438
    CrossrefPubMedGoogle Scholar
  • 48 Bakker OJ, van Santvoort HC, van Brunschot S. et al; Dutch Pancreatitis Study Group. Endoscopic transgastric vs surgical necrosectomy for infected necrotizing pancreatitis: a randomized trial. JAMA 2012; 307 (10) 1053-1061
    CrossrefPubMedGoogle Scholar
  • 49 Siddiqui AA, Easler J, Strongin A. et al. Hydrogen peroxide-assisted endoscopic necrosectomy for walled-off pancreatic necrosis: a dual center pilot experience. Dig Dis Sci 2014; 59 (03) 687-690
    CrossrefPubMedGoogle Scholar
  • 50 Messallam AA, Adler DG, Shah RJ. et al. Direct endoscopic necrosectomy with and without hydrogen peroxide for walled-off pancreatic necrosis: a multicenter comparative study. Am J Gastroenterol 2021; 116 (04) 700-709
    CrossrefPubMedGoogle Scholar
  • 51 Varadarajulu S, Phadnis MA, Christein JD, Wilcox CM. Multiple transluminal gateway technique for EUS-guided drainage of symptomatic walled-off pancreatic necrosis. Gastrointest Endosc 2011; 74 (01) 74-80
    CrossrefPubMedGoogle Scholar
  • 52 Jagielski M, Smoczyński M, Adrych K. Endoscopic treatment of multilocular walled-off pancreatic necrosis with the multiple transluminal gateway technique. Wideochir Inne Tech Malo Inwazyjne 2017; 12 (02) 199-205
    PubMedGoogle Scholar
  • 53 Szakó L, Mátrai P, Hegyi P. et al. Endoscopic and surgical drainage for pancreatic fluid collections are better than percutaneous drainage: meta-analysis. Pancreatology 2020; 20 (01) 132-141
    CrossrefPubMedGoogle Scholar
  • 54 Voermans RP, Besselink MG, Fockens P. Endoscopic management of walled-off pancreatic necrosis. J Hepatobiliary Pancreat Sci 2015; 22 (01) 20-26
    CrossrefPubMedGoogle Scholar
  • 55 van Grinsven J, Timmerman P, van Lienden KP. et al; Dutch Pancreatitis Study Group. Proactive versus standard percutaneous catheter drainage for infected necrotizing pancreatitis. Pancreas 2017; 46 (04) 518-523
    CrossrefPubMedGoogle Scholar
  • 56 Oblizajek N, Takahashi N, Agayeva S. et al. Outcomes of early endoscopic intervention for pancreatic necrotic collections: a matched case-control study. Gastrointest Endosc 2020; 91 (06) 1303-1309
    CrossrefPubMedGoogle Scholar
  • 57 Rana SS, Sharma R, Gupta R. Endoscopic treatment of refractory external pancreatic fistulae with disconnected pancreatic duct syndrome. Pancreatology 2019; 19 (04) 608-613
    CrossrefPubMedGoogle Scholar
  • 58 Gupta P, Bansal A, Samanta J. et al. Larger bore percutaneous catheter in necrotic pancreatic fluid collection is associated with better outcomes. Eur Radiol 2021; 31 (05) 3439-3446
    CrossrefPubMedGoogle Scholar
  • 59 van Santvoort HC, Bakker OJ, Bollen TL. et al; Dutch Pancreatitis Study Group. A conservative and minimally invasive approach to necrotizing pancreatitis improves outcome. Gastroenterology 2011; 141 (04) 1254-1263
    CrossrefPubMedGoogle Scholar
  • 60 Ghabili K, Shaikh J, Pollak J, Elwood D, Majdalany BS, Nezami N. Percutaneous chemical and mechanical necrosectomy for walled-off pancreatic necrosis. J Vasc Interv Radiol 2023; 34 (03) 454-459.e2
    CrossrefPubMedGoogle Scholar
  • 61 Nealon WH, Walser E. Main pancreatic ductal anatomy can direct choice of modality for treating pancreatic pseudocysts (surgery versus percutaneous drainage). Ann Surg 2002; 235 (06) 751-758
    CrossrefPubMedGoogle Scholar
  • 62 Ross AS, Irani S, Gan SI. et al. Dual-modality drainage of infected and symptomatic walled-off pancreatic necrosis: long-term clinical outcomes. Gastrointest Endosc 2014; 79 (06) 929-935
    CrossrefPubMedGoogle Scholar
  • 63 Panick CEP, Schenning RC, Huber TC, Kaufman J. Rendezvous technique for advanced pancreatic duct interventions. J Vasc Interv Radiol 2022; 33 (10) 1208-1212.e2
    CrossrefPubMedGoogle Scholar
  • 64 Irani S, Gluck M, Ross A. et al. Resolving external pancreatic fistulas in patients with disconnected pancreatic duct syndrome: using rendezvous techniques to avoid surgery (with video). Gastrointest Endosc 2012; 76 (03) 586-93.e1, 3
    CrossrefPubMedGoogle Scholar
  • 65 Husu HL, Kuronen JA, Leppäniemi AK, Mentula PJ. Open necrosectomy in acute pancreatitis-obsolete or still useful?. World J Emerg Surg 2020; 15 (01) 21
    CrossrefPubMedGoogle Scholar
  • 66 Trikudanathan G, Wolbrink DRJ, van Santvoort HC, Mallery S, Freeman M, Besselink MG. Current concepts in severe acute and necrotizing pancreatitis: an evidence-based approach. Gastroenterology 2019; 156 (07) 1994-2007.e3
    CrossrefPubMedGoogle Scholar
  • 67 Maatman TK, Flick KF, Roch AM, Zyromski NJ. Operative pancreatic debridement: contemporary outcomes in changing times. Pancreatology 2020; 20 (05) 968-975
    CrossrefPubMedGoogle Scholar
  • 68 Mathew MJ, Parmar AK, Sahu D, Reddy PK. Laparoscopic necrosectomy in acute necrotizing pancreatitis: our experience. J Minim Access Surg 2014; 10 (03) 126-131
    CrossrefPubMedGoogle Scholar
  • 69 van Santvoort HC, Besselink MG, Horvath KD. et al; Dutch Acute Pancreatis Study Group. Videoscopic assisted retroperitoneal debridement in infected necrotizing pancreatitis. HPB (Oxford) 2007; 9 (02) 156-159
    CrossrefPubMedGoogle Scholar
  • 70 Connor S, Ghaneh P, Raraty M. et al. Minimally invasive retroperitoneal pancreatic necrosectomy. Dig Surg 2003; 20 (04) 270-277
    CrossrefPubMedGoogle Scholar
  • 71 Yang Y, Zhang Y, Wen S, Cui Y. The optimal timing and intervention to reduce mortality for necrotizing pancreatitis: a systematic review and network meta-analysis. World J Emerg Surg 2023; 18 (01) 9
    CrossrefPubMedGoogle Scholar
  • 72 Nemoto Y, Attam R, Arain MA. et al. Interventions for walled off necrosis using an algorithm based endoscopic step-up approach: outcomes in a large cohort of patients. Pancreatology 2017; 17 (05) 663-668
    CrossrefPubMedGoogle Scholar
  • 73 Ross A, Gluck M, Irani S. et al. Combined endoscopic and percutaneous drainage of organized pancreatic necrosis. Gastrointest Endosc 2010; 71 (01) 79-84
    CrossrefPubMedGoogle Scholar