Endoscopic necrosectomy as primary treatment for infected peripancreatic fluid collections (with video)

Background: The success of endoscopic intervention in the management of uncomplicated pancreatic pseudocysts has allowed endoscopists to be more aggressive in managing complicated pancreatic fluid collections. Surgery is considered the mainstay of therapy once pancreatic abscesses develop. As a second-line treatment, endoscopic drainage of pancreatic abcess has been performed in those who are not candidates for surgery. Objective: Our purpose was to report our experience with single-session endoscopic necrosectomy and drainage as the primary mode of treatment of infected pancreatic necrosis or abscesses. Design: This was a case series. Setting: A single endoscopy unit based at a university medical center. Patients: Six consecutive patients who underwent endoscopic necrosectomy as the primary treatment modality for pancreatic abscess or necrosis between May 2006 and February 2007. Main Outcome Measurements: Resolution of the infected pancreatic fluid collection and avoidance of surgery. Results: Successful single-session endoscopic necrosectomy was performed in all 6 patients with impressive and immediate symptom relief. None needed surgery or other endoscopic or percutaneous interventions. Patients were discharged from the hospital in a median of 8.5 days. Complete resolution of pancreatic lesions were noted in 5 of 6 patients (1 patient had a small residual cyst) in median follow-up of 3.5 months (range 3-11 months). Conclusions: Endoscopic necrosectomy can be performed safely and efficiently for the primary treatment of pancreatic necrosis and abcess. Our data suggest that aggressive single-session necrosectomy can be adequate for the complete removal of infected and necrotic debris.