Outcomes of a Structured, Stepwise Approach to Endoscopic Necrosectomy

Despite the increasing number of procedures being performed, there is no consensus on the optimal approach to performing direct endoscopic necrosectomy (DEN), which is a labor-intensive, nonstandardized intervention. We prospectively validated the usefulness of a predefined, structured, stepwise approach to DEN with the objective of improving procedural efficiency and resource use.

A prospective study of patients with necrotizing pancreatitis who after endoscopic transluminal drainage did not have clinical improvement and required DEN. The study was undertaken in 2 phases. Phase I was a retrospective analysis of interventions performed using an unstructured, conventional approach. Median of 3 necrosectomy sessions (range, 2 to 3) were required to achieve 80% treatment success in 20 patients. On the basis of these observations, a structured approach that included 3 steps (debridement, necrosis extraction, and irrigation) was developed and validated prospectively in phase II in 39 patients. The main outcome was to compare procedural efficiency defined as a number of necrosectomy sessions to achieve treatment success.

Although there was no significant difference in treatment success (phase I=80.0 vs. phase II=94.9%, P=0.17), the procedure was more efficient in phase II [median session, 2 (interquartile range=1 to 3) vs. 3 (interquartile range=2 to 3); P=0.003]. Multiple logistic regression analysis revealed that a structured, stepwise approach was associated with fewer necrosectomy sessions to achieve treatment success (odds ratio=4.7; 95% confidence interval=1.5-15.0; P=0.008) when adjusted for patient demographics, lab parameters, and disease characteristics.

By decreasing the number of necrosectomy sessions, a structured, stepwise approach to endoscopic necrosectomy seems to improve procedural efficiency.