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August 13, 2019/Digestive/Q&A

What You Need to Know About Endoscopic Pancreatic Necrosectomy

Minimally invasive technique is highly successful for managing pancreatic necrosis

Acute pancreatitis is associated with a significant morbidity rate of 1 to 5% and is among the most common gastrointestinal causes of inpatient hospitalization. Complications of pancreatic necrosis may be treated using several minimally-invasive surgical techniques.

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In this Q&A with Consult QD, Prabhleen Chahal, MD, therapeutic endoscopist and Program Director of Advanced Endoscopy Fellowship in Cleveland Clinic’s Department of Gastroenterology, discusses her experience managing pancreatic necrosis using endoscopic pancreatic necrosectomy (EPN).

What complications are associated with acute pancreatitis?

Dr. Chahal: Acute pancreatitis can lead to formation of a pseudocyst or walled-off necrosis. A pseudocyst is an encapsulated homogenous fluid collection, whereas a walled-off necrosis has both fluid and non-fluid solid components that represent dead pancreatic or fat tissue.

In which cases is surgical treatment of pancreatic necrosis considered?

Dr. Chahal: We intervene upon a pseudocyst or walled-off necrosis only when there are significant symptoms present, such as persistent abdominal pain, infection or extrinsic compression of the stomach or small intestine. Fluid collections can cause a narrowing of the lumen, leading to the inability to eat, nausea and vomiting.

What types of surgical techniques are available?

Dr. Chahal: There are several different types of minimally-invasive techniques to drain and debride the pseudocyst or infected pancreatic necrosis, including interventional radiology-guided percutaneous drainage, surgeon-led laparoscopy and retroperitoneal debridement.

Endoscopic pancreatic necrosectomy refers to the endoscopic drainage and debridement of pancreatic necrosis. The procedure has been performed for close to three decades but has evolved over time due to the availability of newer and larger-sized stents that facilitate access to the necrotic cavity from the stomach or duodenum for drainage and direct endoscopy-guided debridement of dead tissue.

This image shows a stent extending from the stomach into an infected, walled-off pancreatic necrotic region. A snare is used to remove necrotic tissue.

This image shows a stent extending from the stomach into an infected, walled-off pancreatic necrotic region. A snare is used to remove necrotic tissue.

How is a patient evaluated before EPN?

Dr. Chahal: Prior to endoscopic management, it is crucial to classify pancreatic fluid collections as either pseudocyst or walled-off pancreatic necrosis because of the differences in prognosis and treatment. Magnetic resonance imaging (MRI) and endoscopic ultrasound are the preferred tests for evaluating the necrotic debris, as computed tomography (CT) imaging can underestimate the presence of necrosis. The management has changed from what was historically a surgical intervention to less invasive approaches.

What are some potential complications of EPN?

Dr. Chahal: Patients with walled-off pancreatic necrosis are sicker, with a higher risk of death from the underlying disease. If the necrosis is infected, the risk of death is as much as 20%, or 1 in 5. Endoscopic management of walled-off necrosis carries the risk of bleeding, perforation, stent migration and infection. The reported complication rate can be as high as 15 to 18%. Usually, patients with walled-off necrosis in close proximity to the stomach or duodenum are best suited for the endoscopic approach. Typically, these patients require one to three endoscopic procedures for complete debridement of necrosis, followed by a CT scan or MRI to confirm the resolution of the collection, then endoscopic stent removal.

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Describe your experience and outcomes with EPN. What are the advantages of this procedure?

Dr. Chahal: At Cleveland Clinic, we have been successfully managing walled-off pancreatic necrosis endoscopically, with a success rate of more than 85 percent. The remainder of our patients required either additional drainage in the form of percutaneous drainage tubes or minimally invasive surgery.

As described in the medical literature, some of the advantages of EPN over other techniques include shorter hospital length of stay and greater cost-effectiveness, with comparable safety and efficacy.

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