Endoscopic ultrasound-guided transluminal drainage and direct endoscopic necrosectomy in patients with walled-off necrosis

Year 2025, Volume: 42 Issue: 3, 242 - 246, 30.09.2025

Omer Kucukdemırcı , Ufuk Avcıoğlu , Ahmet Bektaş

Abstract

Management of Walled-Off Necrosis (WON) poses a high mortality risk with a non-interventional approach. Minimally invasive techniques, including endoscopic ultrasound-guided cystogastrostomy with a step-up approach, have gained prominence. This study retrospectively analyzed data from 18 patients (2016–2018) who underwent endoscopic ultrasound-guided cystogastrostomy, with 13 subsequently undergoing direct endoscopic necrosectomy (DEN) using lumen apposing metal stents (LAMS). The insertion of cystogastrostomy stents was technically successful in all patients. Two patients experienced perforation following LAMS placement. Cyst size positively correlated with hospital stay duration. Between LAMS with pigtail (n=7) and without pigtail (n=6) groups, session numbers, stent duration, and hospital stay did not significantly differ, though numerical reductions were observed in pigtail cases. A moderate correlation existed between stent duration and amylase levels (r=-0.575, p=0.040). Percutaneous drainage catheters (PDC) were necessary in two patients without endoscopic access, and PDC patients had prolonged hospital stays. LAMS-supported EUS-DEN was a low-complication, high-success approach for symptomatic or infected WON. Perforation was identified as a severe complication. The addition of pigtail catheters within SEMS may positively impact session numbers, hospitalization duration, and stent residence time. Prospective cohorts are warranted for further validation.

Keywords

Pancreatitis , Walled off necrosis , Full covered self-expandable stents , pig tail stent , direct endoscopic necrosectomy

References

• van Brunschot S, Bakker OJ, Besselink MG, et al. Treatment of necrotizing pancreatitis. Clinical Gastroenterology and Hepatology. 2012;10(11):1190-1201.
• Dupuis CS, Baptista V, Whalen G, et al. Diagnosis and management of acute pancreatitis and its complications. Gastrointestinal Intervention. 2013;2(1):36-46.
• Besselink MG, van Santvoort HC, Nieuwenhuijs VB, et al. Minimally invasive'step-up approach'versus maximal necrosectomy in patients with acute necrotising pancreatitis (PANTER trial): design and rationale of a randomised controlled multicenter trial [ISRCTN13975868]. BMC surgery. 2006;6(1):1-10.
• Lakhtakia S, Basha J, Talukdar R, et al. Endoscopic “step-up approach” using a dedicated biflanged metal stent reduces the need for direct necrosectomy in walled-off necrosis (with videos). Gastrointestinal endoscopy. 2017;85(6):1243-1252.
• Gardner TB, Coelho-Prabhu N, Gordon SR, et al. Direct endoscopic necrosectomy for the treatment of walled-off pancreatic necrosis: results from a multicenter US series. Gastrointestinal endoscopy. 2011;73(4):718-726.
• Gulati R, Rustagi T. Endoscopic removal and replacement of the same lumen-apposing metal stent for multiple endoscopic necrosectomy sessions. Endoscopy. 2021;53(01):71-74.
• Van Santvoort HC, Besselink MG, Bakker OJ, et al. A step-up approach or open necrosectomy for necrotizing pancreatitis. New England journal of medicine. 2010;362(16):1491-1502.
• Van Brunschot S, Hollemans RA, Bakker OJ, et al. Minimally invasive and endoscopic versus open necrosectomy for necrotising pancreatitis: a pooled analysis of individual data for 1980 patients. Gut. 2018;67(4):697-706.
• Gardner TB, Coelho-Prabhu N, Gordon SR, et al. Direct endoscopic necrosectomy for the treatment of walled-off pancreatic necrosis: results from a multicenter US series. Gastrointestinal endoscopy. 2011;73(4):718-726.
• Garg R, Gupta S, Singh A, Simonson MT, Rustagi T, Chahal P. Hydrogen peroxide assisted endoscopic necrosectomy for walled-off pancreatic necrosis: A systematic review and meta-analysis. Pancreatology. 2021;21(8):1540-1547.
• Rinninella E, Kunda R, Dollhopf M, et al. EUS-guided drainage of pancreatic fluid collections using a novel lumen- apposing metal stent on an electrocautery-enhanced delivery system: a large retrospective study (with video). Gastrointestinal endoscopy. 2015;82(6):1039-1046.
• Bansal RK, Puri R, Choudhary NS, et al. Endoscopic pancreatic necrosectomy: why scuff when you can flush the muck–make it an easy row to hoe. Endoscopy International Open. 2017;5(09):E847-E853.
• Waddingham W, Kamran U, Kumar B, et al. Complications of diagnostic upper Gastrointestinal endoscopy: common and rare recognition, assessment and management BMJ Open Gastroenterology 2022;9:e000688. doi: 10.1136/bmjgast-2021-000688
• Johnson KD, Perisetti A, Tharian B, Thandassery R, Jamidar P, Goyal H, Inamdar S (2020) Endoscopic retrograde cholangiopancreatography-related complications and their management strategies: a “scoping” literature review. Digestive diseases and sciences 65:361-375
• Akbas A, Bakir H, Dasiran M, et al. Significance of gastric wall thickening detected in abdominal ct scan to predict gastric malignancy. Journal of Oncology. 2019;2019
• Dayyeh BKA, Mukewar S, Majumder S, et al. Large-caliber metal stents versus plastic stents for the management of pancreatic walled-off necrosis. Gastrointestinal endoscopy. 2018;87(1):141-149.
• Bang JY, Wilcox CM, Hawes R, Varadarajulu S (2021) Outcomes of a structured, stepwise approach to endoscopic necrosectomy. Journal of Clinical Gastroenterology 55:631-637
• Vyawahare MA, Gulghane S, Titarmare R, et al. Percutaneous direct endoscopic pancreatic necrosectomy. World Journal of Gastrointestinal Surgery. 2022;14(8):731.
• Samanta J, Dhar J, Muktesh G, et al. Endoscopic drainage versus percutaneous drainage for the management of infected walled-off necrosis: a comparative analysis. Expert Review of Gastroenterology & Hepatology. 2022;16(3):297-305.
• Pawa R, Dorrell R, Clark C, Russell G, Gilliam J, Pawa S. Delayed endoscopic necrosectomy improves hospital length of stay and reduces endoscopic interventions in patients with symptomatic walled‐off necrosis. DEN open. 2022;3(1):e162.
• 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. Clinical Gastroenterology and Hepatology. 2016;14(12):1797-1803.
• Abdelhafez M, Elnegouly M, Allah H, Elshazli M, Mikhail H, Yosry A. Transluminal retroperitoneal endoscopic necrosectomy with the use of hydrogen peroxide and without external irrigation: a novel approach for the treatment of walled-off pancreatic necrosis. Surgical endoscopy. 2013;27(10):3911-3920.