Peroral Transgastric/Transduodenal Necrosectomy Success in the Treatment of Infected Pancreatic Necrosis

Objective: To assess the results and complications of an endoscopic transgastric/transduodenal approach as a possible alternative to conventional surgery. Summary Background Data: Infected organized pancreatic necrosis carries a high mortality despite antibiotic therapy and numerous conventional and laparoscopic surgical techniques of debridement. The advent of natural orifice transluminal endoscopic surgery (NOTES) provides a possible alternative approach. Methods: Between 2004 and 2007, patients with infected organized pancreatic necrosis were referred for endoscopic necrosectomy as their initial treatment of choice. Accessibility was confirmed by CT and endoscopic ultrasound. Access to the cavities was transgastric or transduodenal, after passing the endoscope inside the retroperitoneal cavity all necrotic and purulent material was evacuated under direct endoscopic vision. Results: Thirteen patients (12 men, mean age: 55 years, range: 38-66 years) underwent endoscopic necrosectomy. Two patients had complementary percutaneous drainage for endoscopically inaccessible cavities. Resolution infection was the rule in all cases. Infection recur-red in 4 patients and a necrotic cavity persisted in 1 patient; all were managed by further endoscopic necrosectomies (total = 23 necrosectomy sessions; mean, 1.8 per patient; range, 1-3). Mean duration of each session was 3.5 hours (range, 2.5-4 hours). Endoscopic treatment was eventually successful in all patients with gradual diminution of the necrotic cavities on CT images. Average duration of follow-up was 19.5 months (range, 2-56 months) with no recurrence of the infectious process and no surgery was required for any patient. Complications included bleeding (n = 3) and transient aggravation of sepsis (n = 3). No mortality occurred. Conclusions: This technique is highly effective and safe in the treatment of infected organized pancreatic necrosis. Results are achievable and sustainable with a limited number of sessions.