The Use of Direct Endoscopic Necrosectomy During Endoscopic Drainage of Walled-Off Pancreatic Necrosis

Introduction: Endotherapy is an established minimally invasive treatment for pancreatic necrosis. Aim: This study aims to evaluate the efficacy and safety of direct endoscopic necrosectomy (DEN) performed during transmural drainage in patients with symptomatic walled-off pancreatic necrosis (WOPN). Materials and Methods: A retrospective analysis was conducted of 512 patients with symptomatic WOPN treated endoscopically between 2018 and 2025 at the Department of General, Gastroenterological and Oncological Surgery, Collegium Medicum, Nicolaus Copernicus University in Toruń. In patients qualified for endoscopic necrosectomy, an endoscope was introduced into the necrotic cavity through a previously created transmural (transgastric or transduodenal) fistula, and necrotic tissue was removed using various endoscopic tools. Results: All 512 patients underwent transmural endoscopic drainage. Of these, 226/512 (44.14%) patients (61 women, 165 men; mean age 51.8 [20-78] years) were qualified for endoscopic necrosectomy. The mean size of the necrotic collection was 22.9 (10.6-36.6) cm. A transgastric approach was used in 219/226 (96.9%) patients, and a transduodenal approach in 7/226 (3.1%). Active drainage was maintained for a mean of 16 (7-82) days. The mean number of endoscopic procedures was 4.84 (1-24). Complications occurred in 24/226 (10.61%) patients. Mortality was 5.75% (13/226). Clinical success was achieved in 203/226 (89.82%) patients and long-term success in 197/226 (87.17%). Conclusions: Direct endoscopic necrosectomy performed during transmural drainage achieved high clinical and long-term success with acceptable morbidity in patients with symptomatic WOPN.