Endoscopic Therapy for Infected Pancreatic Necrosis Using Fully Covered Self-expandable Metal Stents: Combination of Transluminal Necrosectomy, Transluminal and Percutaneous Drainage

Background/aims: Endoscopic transluminal therapy has become the standard of care as a less invasive alternative to surgery. In a retrospective case series of two tertiary referral centers we report on an individualized concept combining EUS-guided drainage with self-expanding metal stents, direct transluminal debridement und percutaneous drainage.

Methods: We treated 13 patients with infected pancreatic necrosis. Initially in all patients an EUS-guided drainage with plastic stents was performed under antibiotic protection (transduodenal: 2, transgastral: 11). After clinical consolidation (after 9.6 ± 9.4 days) a covered self-expanding metal stent (Niti-S, Taewoong medical Co., Seoul, Korea) was inserted by performing direct endoscopic necrosectomy in 2.9 ± 1.7 sessions through the stent. In cases of disrupted duct syndromes a pancreatic plastic stent was inserted (5 of 13 patients). In 5 of 13 cases additional percutaneous drainage was applied because of extended necrosis. In one patient percutaneous endoscopic drainage using the percutaneous access was needed.

Results: A sustained clinical success was achieved in 12 of 13 cases (CRP before therapy 23.5 ± 14.4 mg/L, after 3.1 ± 2.6 mg/lL). Discharge occurred after 2.5 ± 22.4 days. The self-expanding metal stent was extracted after 82.5 ± 56.6 days. Mean follow up was 8.5 ± 5.9 months.

Conclusion: Our concept of combining transluminal drainage, direct endoscopic necrosectomy and percutaneuos drainage offers a safe and reliable alternative to surgery, even in case of extended necrosis.