Endoscopic therapies for walled-off necrosis

Area of Science:

• Gastroenterology
• Interventional Endoscopy
• Pancreatic Diseases

Background:

• Walled-off necrosis (WON) management traditionally uses a step-up approach.
• Minimally invasive drainage and debridement are key techniques.
• Endoscopic interventions are increasingly utilized for WON.

Purpose of the Study:

• Review technical aspects of endoscopic WON management.
• Evaluate technical and clinical success rates of endoscopic drainage.
• Assess adverse event rates and dedicated devices for direct endoscopic necrosectomy (DEN).

Main Methods:

• MEDLINE database search (up to April 2022).
• Keywords: walled-off necrosis, endoscopic necrosectomy, interventional EUS, severe acute pancreatitis, necrotizing pancreatitis, lumen-apposing metal stent.
• Manuscript drafted and edited by ASGE Technology Committee and Governing Board.

Main Results:

• Primary cystenterostomy with stents (plastic or metal, including lumen-apposing metal stents) shows acceptable drainage outcomes.
• Necrotic debris clearance is facilitated by lavage, catheters, transluminal gateway technique, dual-modality therapy, and novel DEN devices.
• Novel DEN devices (e.g., EndoRotor, waterjet, over-the-scope grasper) aim to reduce procedural time and sessions compared to traditional tools.

Conclusions:

• EUS-guided endoscopic drainage and debridement is a well-established WON treatment.
• Further evaluation of adjunctive technologies is needed to optimize WON treatment.
• Improvements in DEN devices are expected to enhance outcomes and endoscopic treatment utilization.