Portal de Periódicos da CAPES

Endoscopic management of pancreatic necrosis: not for the uncommitted

2005; Elsevier BV; Volume: 62; Issue: 1 Linguagem: Inglês

10.1016/s0016-5107(05)01638-x

1097-6779

Richard A. Kozarek,

Gastrointestinal disorders and treatments

Acute necrotizing pancreatitis, defined as local or diffuse areas of nonviable pancreatic parenchyma, has been reported to be associated with mortality ranging from 27% to 45%, contingent upon the extent and the location of necrosis, the development of superinfection from gut translocation, the presence or the absence of multisystem organ failure (MSOF), and the baseline medical status of the patient.1Wyncoll D.L. The management of severe acute necrotising pancreatitis: an evidence-based review of the literature.Intensive Care Med. 1999; 25: 146-156Crossref PubMed Scopus (109) Google Scholar, 2Forsmark C.E. The clinical problem of biliary acute necrotizing pancreatitis: epidemiology, pathophysiology, and diagnosis of biliary necrotizing pancreatitis.J Gastrointest Surg. 2001; 5: 235-239Crossref PubMed Scopus (18) Google ScholarTraditionally diagnosed by pancreas protocol abdominal CT, necrosis is defined by the lack of parenchymal contrast enhancement, a consequence of disruption of the organ's microcirculation.3Balthazar E.J. Freeny P.C. van Sonnenberg E. Imaging and intervention in acute pancreatitis.Radiology. 1994; 193: 297-306PubMed Google Scholar Treatment consists of supportive care with perenteral or enteral nutrition, prophylactic antibiotics in many centers, and ventilatory and dialysis support in acute pulmonary and renal failure.4Slavin J. Ghaneh P. Sutton R. Hartley M. Rowlands P. Garvey C. et al.Management of necrotizing pancreatitis.World J Gastroenterol. 2001; 7: 476-481PubMed Google Scholar Drainage of the necrotic material traditionally has been done surgically. Initially undertaken in most patients with MSOF, this practice, particularly early debridement, has been abandoned because of mortality rates in excess of 50% and the frequent need for additional debridement procedures.5Mier J. Leon E.L. Castillo A. Robledo F. Blanco R. Early versus late necrosectomy in severe necrotizing pancreatitis.Am J Surg. 1997; 173: 71-75Abstract Full Text PDF PubMed Scopus (414) Google Scholar Nor is surgery necessarily undertaken for patients with necrosis of >50% of their gland, or for those with stable clinical status but persistent glandular necrosis.1Wyncoll D.L. The management of severe acute necrotising pancreatitis: an evidence-based review of the literature.Intensive Care Med. 1999; 25: 146-156Crossref PubMed Scopus (109) Google Scholar Instead, many investigators define infected pancreatic necrosis as the major reason to surgically debride patients.6Büchler M.W. Gloor B. Muller C.A. Friess H. Seiler C.A. Uhl W. Acute necrotizing pancreatitis: treatment strategy according to the status of infection.Ann Surg. 2000; 232: 619-626Crossref PubMed Scopus (669) Google Scholar This has led to a cottage industry in which patients with pancreatic necrosis undergo multiple percutaneous FNA of the pancreatic bed, with the end result of surgery if either gram stain or culture of the aspirate is positive. Although there has been some debate within the surgical literature about laparoscopic or retroperitoneal drainage techniques with either a nephroscope or a laparoscope, large anterior incisions, surgical scoop, and multiple Jackson-Pratt drain placements at time of operation are the norm and not the exception.5Mier J. Leon E.L. Castillo A. Robledo F. Blanco R. Early versus late necrosectomy in severe necrotizing pancreatitis.Am J Surg. 1997; 173: 71-75Abstract Full Text PDF PubMed Scopus (414) Google Scholar, 7Zhou Z.G. Zheng Y.C. Shu Y. Hu W.M. Tian B.L. Li Q.S. et al.Laparoscopic management of severe acute pancreatitis.Pancreas. 2003; 27: e46-e50Crossref PubMed Scopus (44) Google Scholar, 8Tzovaras G. Parks R.W. Diamond T. Rowlands B.J. Early and long-term results of surgery for severe necrotising pancreatitis.Dig Surg. 2004; 21: 41-46Crossref PubMed Scopus (50) Google ScholarSeveral heresies have begun to creep into the standard treatment of pancreatic necrosis over the last few years. On the one hand, a subset of patients with a significant fluid component to their necrosis could be drained percutaneously.9Freeny P.C. Hauptmann E. Althaus S.J. Traverso L.W. Sinanan M. Percutaneous CT-guided catheter drainage of infected acute necrotizing pancreatitis: techniques and results.AJR Am J Roentgenol. 1998; 170: 969-975Crossref PubMed Scopus (405) Google Scholar, 10Memis A. Parildar M. Interventional radiological treatment in complications of pancreatitis.Eur J Radiol. 2002; 43: 219-228Abstract Full Text Full Text PDF PubMed Scopus (30) Google Scholar This led to the discovery that multiple, large-bore catheters could be used to drain extensive areas of necrosis, although catheter occlusions necessitated frequent changes and a committed interventional radiologist. Catheter placement, however, was invariably associated with bacterial colonization, and, while it can cure the necrosis, it also can leave the patient with a disconnected gland, particularly in the setting of central pancreatic necrosis. Percutaneous drainage also taught us something else: most necrotic areas are bathed in high amylase fluid, not necessarily from glandular destruction but from a ductal leak.11Lau S.T. Simchuk E.J. Kozarek R.A. Traverso L.W. A pancreatic ductal leak should be sought to direct treatment in patients with acute pancreatitis.Am J Surg. 2001; 181: 411-415Abstract Full Text Full Text PDF PubMed Scopus (100) Google Scholar Our group, as well as others, has noted ductal disruptions in up to three quarters of patients with severe pancreatic necrosis,12Kozarek R.A. Attia F.M. Traverso L.W. Pancreatic duct leak in necrotizing pancreatitis. Role of diagnostic and therapeutic ERCP as part of a multi-disciplinary approach.Gastrointest Endosc. 2000; 51 ([abstract]): AB138Google Scholar, 13Uomo G. Molino D. Visconti M. Ragozzino A. Manes G. Rabitti P.G. The incidence of main pancreatic duct disruption in severe biliary pancreatitis.Am J Surg. 1998; 176: 49-52Abstract Full Text Full Text PDF PubMed Scopus (81) Google Scholar and this fact has changed our practice patterns. Accordingly, we now study patients who are not improving with ERCP and place transpapillary stents, if feasible, across the level of duct disruption.11Lau S.T. Simchuk E.J. Kozarek R.A. Traverso L.W. A pancreatic ductal leak should be sought to direct treatment in patients with acute pancreatitis.Am J Surg. 2001; 181: 411-415Abstract Full Text Full Text PDF PubMed Scopus (100) Google Scholar, 12Kozarek R.A. Attia F.M. Traverso L.W. Pancreatic duct leak in necrotizing pancreatitis. Role of diagnostic and therapeutic ERCP as part of a multi-disciplinary approach.Gastrointest Endosc. 2000; 51 ([abstract]): AB138Google Scholar, 14Kozarek R.A. Endoscopic therapy of complete and partial pancreatic duct disruptions.Gastrointest Endosc Clin N Am. 1998; 8: 39-53PubMed Google Scholar While it is uncertain whether ductal disruptions are a primary or a secondary event in this setting, it seems reasonable that limiting enzyme exposure to the necrotic area may improve the patient's clinical course comparable with results reported when this technique is used to treat pseudocysts, pancreaticoenteric fistulas, pancreatic ascites, high amylase pleural effusions, and amenable pancreaticocutaneous fistulas.15Kozarek R.A. Traverso L.W. Pancreatic fistulas and ascites.in: Brandt J. Textbook of clinical gastroenterology. Current Medicine, Philadelphia1998: 1175-1181Google Scholar In our institution, we drain some necrotic fluid collections transgastrically or through the duodenum but generally believe that large collections with considerable debris are better handled percutaneously with large-bore catheters. Surgery is used as salvage or to electively resect a disconnected portion of the pancreas. Endoscopic therapy of pancreatic necrosis is not for the time-challenged, not for endoscopists without EUS or surgical and interventional radiologic support, and not for patients with slow resolution of uninfected pancreatic necrosis.There have been additional heresies about the treatment of pancreatic necrosis. For instance, Baron et al,16Baron T.H. Thaggard W.G. Morgan D.E. Stanley R.J. Endoscopic therapy for organized pancreatic necrosis.Gastroenterology. 1996; 111: 755-764Abstract Full Text Full Text PDF PubMed Scopus (347) Google Scholar have popularized transgastric or transduodenal puncture into the necrotic cavity, subsequently placing a 7F nasal drain in addition to one or two 10F double-pigtail stents into the cavity. By using high-volume irrigation through the nasopancreatic drain for a mean of 3 weeks, 8 of the original 11 reported patients had improvement in their condition with endotherapy alone, whereas two patients required surgery and one additional percutaneous drainage. Not for the faint of heart, a mean of 2.7 endoscopy sessions were required and 5 patients (45%) experienced significant complications. This group went on to expand its experience of draining necrosis and demonstrated statistically significant, lower rates of successful resolution, higher complications, a greater recurrence rate, and longer hospitalization times when compared with patients who underwent endoscopic drainage of chronic pancreatic pseudocysts.17Baron T.H. Harewood G.C. Morgan D.E. Yates M.R. Outcome differences after endoscopic drainage of pancreatic necrosis, acute pancreatic pseudocysts, and chronic pancreatic pseudocysts.Gastrointest Endosc. 2002; 56: 7-17Abstract Full Text Full Text PDF PubMed Scopus (389) Google ScholarSince these first steps, additional series have been published, demonstrating the efficacy of endoscopic treatment of pancreatic abscess. For instance, Park et al,18Park J.J. Kim S.S. Koo Y.S. Choi D.J. Park H.C. Kim J.H. et al.Definitive treatment of pancreatic abscess by endoscopic transmural drainage.Gastrointest Endosc. 2002; 55: 256-262Abstract Full Text Full Text PDF PubMed Scopus (50) Google Scholar attempted transmural access and placement of stents and a transnasal irrigation drain in 9 patients with a total of 11 pancreatic abscesses.18Park J.J. Kim S.S. Koo Y.S. Choi D.J. Park H.C. Kim J.H. et al.Definitive treatment of pancreatic abscess by endoscopic transmural drainage.Gastrointest Endosc. 2002; 55: 256-262Abstract Full Text Full Text PDF PubMed Scopus (50) Google Scholar Ten (91%) resolved completely, and stents were left in place for a mean of 32 days. The relapse rate was 13% over a mean follow-up of 18 months. Venu et al,19Venu R.P. Brown R.D. Marrero J.A. Pastika B.J. Frakes J.T. Endoscopic transpapillary drainage of pancreatic abscess: technique and results.Gastrointest Endosc. 2000; 51: 391-395Abstract Full Text Full Text PDF PubMed Scopus (36) Google Scholar demonstrated comparable results by using a transpapillary approach. Finally, Seifert et al,20Seifert H. Wehrmann T. Schmitt T. Zeuzem S. Caspary W.F. Retroperitoneal endoscopic debridement for infected peripancreatic necrosis.Lancet. 2000; 356: 653-655Abstract Full Text Full Text PDF PubMed Scopus (296) Google Scholar were the first to describe the combination of EUS-directed, transmural puncture into necrotizing pancreatitis or abscess followed by tract dilation and repeated, direct endoscopic debridements of the lesser sac.In this issue of Gastrointestinal Endoscopy, Seewald and his colleagues from Hamburg use all of the above mentioned techniques, and more, in 13 consecutive patients, 5 with infected pancreatic necrosis and 8 with abscess, over a 7-year period.21Seewald S. Groth S. Omar S. Imazu H. Seitz U. de Weerth A. et al.Aggressive endoscopic therapy for pancreatic necrosis and pancreatic abscess: a new safe and effective treatment algorithm (videos).Gastrointest Endosc. 2005; 62: 92-100Abstract Full Text Full Text PDF PubMed Scopus (274) Google Scholar That abscess and necrotic cavities can be safely punctured and balloon dilated under EUS control is not news.22Fuchs M. Reimann F.M. Gaebel C. Ludwig D. Stange E.F. Treatment of infected pancreatic pseudocysts by endoscopic ultrasonography-guided cystogastrostomy.Endoscopy. 2000; 32: 654-657Crossref PubMed Scopus (34) Google Scholar, 23Giovannini M. Pesenti C. Rolland A.L. Moutardier V. Delpero J.R. Endoscopic ultrasound-guided drainage of pancreatic pseudocysts or pancreatic abscesses using a therapeutic echo endoscope.Endoscopy. 2001; 33: 473-477Crossref PubMed Scopus (267) Google Scholar Nor is it unique to do pancreatography to define either the site of ductal disruption or a downstream stricture that may be amenable to endoscopic stent placement.24Kozarek R.A. Ball T.J. Patterson D.J. Freeny P.C. Ryan J.A. Traverso L.W. Endoscopic transpapillary therapy for disrupted pancreatic duct and peripancreatic fluid collections.Gastroenterology. 1991; 100: 1362-1370PubMed Google Scholar, 25Kozarek R.A. Patterson D.J. Ball T.J. Traverso L.W. Endoscopic placement of pancreatic stents and drains in the management of pancreatitis.Ann Surg. 1989; 209: 261-266Crossref PubMed Scopus (136) Google Scholar Finally, it is not unique to undertake high volume lavage through nasopancreatic drains16Baron T.H. Thaggard W.G. Morgan D.E. Stanley R.J. Endoscopic therapy for organized pancreatic necrosis.Gastroenterology. 1996; 111: 755-764Abstract Full Text Full Text PDF PubMed Scopus (347) Google Scholar, 20Seifert H. Wehrmann T. Schmitt T. Zeuzem S. Caspary W.F. Retroperitoneal endoscopic debridement for infected peripancreatic necrosis.Lancet. 2000; 356: 653-655Abstract Full Text Full Text PDF PubMed Scopus (296) Google Scholar or even to debride an infected cavity with direct endoscope visualization.20Seifert H. Wehrmann T. Schmitt T. Zeuzem S. Caspary W.F. Retroperitoneal endoscopic debridement for infected peripancreatic necrosis.Lancet. 2000; 356: 653-655Abstract Full Text Full Text PDF PubMed Scopus (296) Google Scholar What is unique, however, is the intensity of treatment in this acutely ill group of patients, all of whom historically would have gone to surgery.The endoscopic treatment algorithm described by Seewald et al,21Seewald S. Groth S. Omar S. Imazu H. Seitz U. de Weerth A. et al.Aggressive endoscopic therapy for pancreatic necrosis and pancreatic abscess: a new safe and effective treatment algorithm (videos).Gastrointest Endosc. 2005; 62: 92-100Abstract Full Text Full Text PDF PubMed Scopus (274) Google Scholar includes control of the internal pancreatic-duct leak with stent placement, if feasible; access into the infected area with EUS-guided puncture, and placement of pigtail stents and nasocyst drains either through the gastric or the duodenal wall; repeated balloon dilation of the fistulous tracts with daily, direct endoscopic necrosectomy and lavage; and, when necessary, sealing of a persistent ductal disruption with N-butyl-2-cyanoacrylate. How well did they do, and how did the patients fare? To answer the first question, I direct the readers to Figures 3 to 5 in the Seewald article.21Seewald S. Groth S. Omar S. Imazu H. Seitz U. de Weerth A. et al.Aggressive endoscopic therapy for pancreatic necrosis and pancreatic abscess: a new safe and effective treatment algorithm (videos).Gastrointest Endosc. 2005; 62: 92-100Abstract Full Text Full Text PDF PubMed Scopus (274) Google Scholar However, these are static representations of the wonderful video clips that can be reviewed by logging onto the electronic version of this issue of Gastrointestinal Endoscopy. If a picture is, at times, worth a thousand words, the video segments are a veritable lexicon of technique and the requisite skill set required to reproduce the investigators' results.How did the patients do, and should I try this on my next patient with pancreatic necrosis? From a technical standpoint, endoscopic therapy was successful in resolving the infected necrosis or the abscess in 12 of 13 patients, although one patient required additional surgery to evacuate necrosis extending into the paracolic gutter. Moreover, two patients with a disconnected duct gland syndrome developed recurrent fluid collections after 2 and 4 months, a consequence of an undrained body and tail after initial endotherapy was complete. Both of these patients ultimately required pancreatic head resections, as did a third patient who was found to have a malignant head stricture but whose abscess was posttraumatic and located in the pancreatic tail. Two patients had persistent duct leaks glued, a process previously described by the investigators and a few others but not used in most endoscopic practices.26Seewald S. Brand B. Groth S. Omar S. Mendoza G. Seitz U. et al.Endoscopic sealing of pancreatic fistula by using N-butyl-2-cyanoacrylate.Gastrointest Endosc. 2004; 59: 463-470Abstract Full Text Full Text PDF PubMed Scopus (84) Google Scholar, 27Findeiss L.K. Brandabur J. Traverso L.W. Robinson D.H. Percutaneous embolization of the pancreatic duct with cyanoacrylate tissue adhesive in disconnected duct syndrome.J Vasc Interv Radiol. 2003; 14: 107-111Abstract Full Text Full Text PDF PubMed Scopus (16) Google ScholarThe investigators were able to undertake these techniques without free perforation occurring, although there is no comment whether high-volume nasocavity irrigation was associated either with septic complications or possibly spreading infections into the paracolic gutters and more distant tissue planes. They did have 3 episodes of minor, procedurally related bleeding that stopped with dilute epinephrine injection, although erosion into the major splenic vasculature that required urgent surgery also has been previously reported with this technique (Thomas Rösch, ASGE Plenary Session 2003). Of particular note is that the median number of daily necrosectomies was 7, with a range between two and 12, and the number of high volume irrigations ranged between two and 41. There is no description of the average or the cumulative time required to do these procedures, but suffice it to say that none of these techniques are likely to be effective if scheduled between colonoscopies in an already full endoscopic schedule.Which brings me back to the question: Who should do this? It also suggests a corollary: Is this the best way to approach this problem? The “who” should be obvious. Not for the time challenged. Not for endoscopists without EUS access unless there is absolute assurance of abscess/necrosis proximity and the absence of interposed vessels. Not for endoscopists without expert surgical and interventional radiologic support to treat bleeding and infectious complications not amenable to the endoscopic approach (see Fig. 1 in Seewald et al21Seewald S. Groth S. Omar S. Imazu H. Seitz U. de Weerth A. et al.Aggressive endoscopic therapy for pancreatic necrosis and pancreatic abscess: a new safe and effective treatment algorithm (videos).Gastrointest Endosc. 2005; 62: 92-100Abstract Full Text Full Text PDF PubMed Scopus (274) Google Scholar), and, currently, not for patients simply because they have mild symptoms and slow resolution of uninfected necrosis. In other words, this procedure should only be undertaken by expert pancreaticobiliary endoscopists who have a support system in place, and the clinical judgment regarding the appropriate patient in whom this may prove to be effective therapy.Which brings me back to the corollary: Is this the best way to approach this problem? (See Algorithm for Potential Approaches to Pancreatic Necrosis; Fig. 1) As a clinician who has treated many of these patients over the past 20 years with a combination of endotherapy and percutaneous drainage,11Lau S.T. Simchuk E.J. Kozarek R.A. Traverso L.W. A pancreatic ductal leak should be sought to direct treatment in patients with acute pancreatitis.Am J Surg. 2001; 181: 411-415Abstract Full Text Full Text PDF PubMed Scopus (100) Google Scholar, 12Kozarek R.A. Attia F.M. Traverso L.W. Pancreatic duct leak in necrotizing pancreatitis. Role of diagnostic and therapeutic ERCP as part of a multi-disciplinary approach.Gastrointest Endosc. 2000; 51 ([abstract]): AB138Google Scholar several issues remain important:1.Small tubes (holes) are less likely to be effective drainage conduits than large tubes when dealing with adherent, particulate debris.2.Patients with pancreatic necrosis are unlikely to become infected within the first week, and previous data suggest that early surgery is associated with a significantly higher mortality.5Mier J. Leon E.L. Castillo A. Robledo F. Blanco R. Early versus late necrosectomy in severe necrotizing pancreatitis.Am J Surg. 1997; 173: 71-75Abstract Full Text PDF PubMed Scopus (414) Google Scholar In a similar vein, there are no data to suggest that the techniques described by Seewald et al,21Seewald S. Groth S. Omar S. Imazu H. Seitz U. de Weerth A. et al.Aggressive endoscopic therapy for pancreatic necrosis and pancreatic abscess: a new safe and effective treatment algorithm (videos).Gastrointest Endosc. 2005; 62: 92-100Abstract Full Text Full Text PDF PubMed Scopus (274) Google Scholar are necessary or safe early in the course of pancreatic necrosis.3.Finally, the cross-fertilization of disciplines with input from pancreatic surgeons, interventional radiologists, and gastroenterologists has been crucial in the development of a treatment plan in our institution for this extremely ill group of patients. As such, the ability to apply therapy exclusively endoscopically should not preclude the need for interdisciplinary interaction. Until additional series have been published that define the true risk-benefit and relative resource utilization of this technique when compared with surgical or interventional radiologic drainage, the team approach should remain central to the care of patients with severe pancreatic necrosis. Acute necrotizing pancreatitis, defined as local or diffuse areas of nonviable pancreatic parenchyma, has been reported to be associated with mortality ranging from 27% to 45%, contingent upon the extent and the location of necrosis, the development of superinfection from gut translocation, the presence or the absence of multisystem organ failure (MSOF), and the baseline medical status of the patient.1Wyncoll D.L. The management of severe acute necrotising pancreatitis: an evidence-based review of the literature.Intensive Care Med. 1999; 25: 146-156Crossref PubMed Scopus (109) Google Scholar, 2Forsmark C.E. The clinical problem of biliary acute necrotizing pancreatitis: epidemiology, pathophysiology, and diagnosis of biliary necrotizing pancreatitis.J Gastrointest Surg. 2001; 5: 235-239Crossref PubMed Scopus (18) Google Scholar Traditionally diagnosed by pancreas protocol abdominal CT, necrosis is defined by the lack of parenchymal contrast enhancement, a consequence of disruption of the organ's microcirculation.3Balthazar E.J. Freeny P.C. van Sonnenberg E. Imaging and intervention in acute pancreatitis.Radiology. 1994; 193: 297-306PubMed Google Scholar Treatment consists of supportive care with perenteral or enteral nutrition, prophylactic antibiotics in many centers, and ventilatory and dialysis support in acute pulmonary and renal failure.4Slavin J. Ghaneh P. Sutton R. Hartley M. Rowlands P. Garvey C. et al.Management of necrotizing pancreatitis.World J Gastroenterol. 2001; 7: 476-481PubMed Google Scholar Drainage of the necrotic material traditionally has been done surgically. Initially undertaken in most patients with MSOF, this practice, particularly early debridement, has been abandoned because of mortality rates in excess of 50% and the frequent need for additional debridement procedures.5Mier J. Leon E.L. Castillo A. Robledo F. Blanco R. Early versus late necrosectomy in severe necrotizing pancreatitis.Am J Surg. 1997; 173: 71-75Abstract Full Text PDF PubMed Scopus (414) Google Scholar Nor is surgery necessarily undertaken for patients with necrosis of >50% of their gland, or for those with stable clinical status but persistent glandular necrosis.1Wyncoll D.L. The management of severe acute necrotising pancreatitis: an evidence-based review of the literature.Intensive Care Med. 1999; 25: 146-156Crossref PubMed Scopus (109) Google Scholar Instead, many investigators define infected pancreatic necrosis as the major reason to surgically debride patients.6Büchler M.W. Gloor B. Muller C.A. Friess H. Seiler C.A. Uhl W. Acute necrotizing pancreatitis: treatment strategy according to the status of infection.Ann Surg. 2000; 232: 619-626Crossref PubMed Scopus (669) Google Scholar This has led to a cottage industry in which patients with pancreatic necrosis undergo multiple percutaneous FNA of the pancreatic bed, with the end result of surgery if either gram stain or culture of the aspirate is positive. Although there has been some debate within the surgical literature about laparoscopic or retroperitoneal drainage techniques with either a nephroscope or a laparoscope, large anterior incisions, surgical scoop, and multiple Jackson-Pratt drain placements at time of operation are the norm and not the exception.5Mier J. Leon E.L. Castillo A. Robledo F. Blanco R. Early versus late necrosectomy in severe necrotizing pancreatitis.Am J Surg. 1997; 173: 71-75Abstract Full Text PDF PubMed Scopus (414) Google Scholar, 7Zhou Z.G. Zheng Y.C. Shu Y. Hu W.M. Tian B.L. Li Q.S. et al.Laparoscopic management of severe acute pancreatitis.Pancreas. 2003; 27: e46-e50Crossref PubMed Scopus (44) Google Scholar, 8Tzovaras G. Parks R.W. Diamond T. Rowlands B.J. Early and long-term results of surgery for severe necrotising pancreatitis.Dig Surg. 2004; 21: 41-46Crossref PubMed Scopus (50) Google Scholar Several heresies have begun to creep into the standard treatment of pancreatic necrosis over the last few years. On the one hand, a subset of patients with a significant fluid component to their necrosis could be drained percutaneously.9Freeny P.C. Hauptmann E. Althaus S.J. Traverso L.W. Sinanan M. Percutaneous CT-guided catheter drainage of infected acute necrotizing pancreatitis: techniques and results.AJR Am J Roentgenol. 1998; 170: 969-975Crossref PubMed Scopus (405) Google Scholar, 10Memis A. Parildar M. Interventional radiological treatment in complications of pancreatitis.Eur J Radiol. 2002; 43: 219-228Abstract Full Text Full Text PDF PubMed Scopus (30) Google Scholar This led to the discovery that multiple, large-bore catheters could be used to drain extensive areas of necrosis, although catheter occlusions necessitated frequent changes and a committed interventional radiologist. Catheter placement, however, was invariably associated with bacterial colonization, and, while it can cure the necrosis, it also can leave the patient with a disconnected gland, particularly in the setting of central pancreatic necrosis. Percutaneous drainage also taught us something else: most necrotic areas are bathed in high amylase fluid, not necessarily from glandular destruction but from a ductal leak.11Lau S.T. Simchuk E.J. Kozarek R.A. Traverso L.W. A pancreatic ductal leak should be sought to direct treatment in patients with acute pancreatitis.Am J Surg. 2001; 181: 411-415Abstract Full Text Full Text PDF PubMed Scopus (100) Google Scholar Our group, as well as others, has noted ductal disruptions in up to three quarters of patients with severe pancreatic necrosis,12Kozarek R.A. Attia F.M. Traverso L.W. Pancreatic duct leak in necrotizing pancreatitis. Role of diagnostic and therapeutic ERCP as part of a multi-disciplinary approach.Gastrointest Endosc. 2000; 51 ([abstract]): AB138Google Scholar, 13Uomo G. Molino D. Visconti M. Ragozzino A. Manes G. Rabitti P.G. The incidence of main pancreatic duct disruption in severe biliary pancreatitis.Am J Surg. 1998; 176: 49-52Abstract Full Text Full Text PDF PubMed Scopus (81) Google Scholar and this fact has changed our practice patterns. Accordingly, we now study patients who are not improving with ERCP and place transpapillary stents, if feasible, across the level of duct disruption.11Lau S.T. Simchuk E.J. Kozarek R.A. Traverso L.W. A pancreatic ductal leak should be sought to direct treatment in patients with acute pancreatitis.Am J Surg. 2001; 181: 411-415Abstract Full Text Full Text PDF PubMed Scopus (100) Google Scholar, 12Kozarek R.A. Attia F.M. Traverso L.W. Pancreatic duct leak in necrotizing pancreatitis. Role of diagnostic and therapeutic ERCP as part of a multi-disciplinary approach.Gastrointest Endosc. 2000; 51 ([abstract]): AB138Google Scholar, 14Kozarek R.A. Endoscopic therapy of complete and partial pancreatic duct disruptions.Gastrointest Endosc Clin N Am. 1998; 8: 39-53PubMed Google Scholar While it is uncertain whether ductal disruptions are a primary or a secondary event in this setting, it seems reasonable that limiting enzyme exposure to the necrotic area may improve the patient's clinical course comparable with results reported when this technique is used to treat pseudocysts, pancreaticoenteric fistulas, pancreatic ascites, high amylase pleural effusions, and amenable pancreaticocutaneous fistulas.15Kozarek R.A. Traverso L.W. Pancreatic fistulas and ascites.in: Brandt J. Textbook of clinical gastroenterology. Current Medicine, Philadelphia1998: 1175-1181Google Scholar In our institution, we drain some necrotic fluid collections transgastrically or through the duodenum but generally believe that large collections with considerable debris are better handled percutaneously with large-bore catheters. Surgery is used as salvage or to electively resect a disconnected portion of the pancreas. Endoscopic therapy of pancreatic necrosis is not for the time-challenged, not for endoscopists without EUS or surgical and interventional radiologic support, and not for patients with slow resolution of uninfected pancreatic necrosis. Endoscopic therapy of pancreatic necrosis is not for the time-challenged, not for endoscopists without EUS or surgical and interventional radiologic support, and not for patients with slow resolution of uninfected pancreatic necrosis. Endoscopic therapy of pancreatic necrosis is not for the time-challenged, not for endoscopists without EUS or surgical and interventional radiologic support, and not for patients with slow resolution of uninfected pancreatic necrosis. There have been additional heresies about the treatment of pancreatic necrosis. For instance, Baron et al,16Baron T.H. Thaggard W.G. Morgan D.E. Stanley R.J. Endoscopic therapy for organized pancreatic necrosis.Gastroenterology. 1996; 111: 755-764Abstract Full Text Full Text PDF PubMed Scopus (347) Google Scholar have popularized transgastric or transduodenal puncture into the necrotic cavity, subsequently placing a 7F nasal drain in addition to one or two 10F double-pigtail stents into the cavity. By using high-volume irrigation through the nasopancreatic drain for a mean of 3 weeks, 8 of the original 11 reported patients had improvement in their condition with endotherapy alone, whereas two patients required surgery and one additional percutaneous drainage. Not for the faint of heart, a mean of 2.7 endoscopy sessions were required and 5 patients (45%) experienced significant complications. This group went on to expand its experience of draining necrosis and demonstrated statistically significant, lower rates of successful resolution, higher complications, a greater recurrence rate, and longer hospitalization times when compared with patients who underwent endoscopic drainage of chronic pancreatic pseudocysts.17Baron T.H. Harewood G.C. Morgan D.E. Yates M.R. Outcome differences after endoscopic drainage of pancreatic necrosis, acute pancreatic pseudocysts, and chronic pancreatic pseudocysts.Gastrointest Endosc. 2002; 56: 7-17Abstract Full Text Full Text PDF PubMed Scopus (389) Google Scholar Since these first steps, additional series have been published, demonstrating the efficacy of endoscopic treatment of pancreatic abscess. For instance, Park et al,18Park J.J. Kim S.S. Koo Y.S. Choi D.J. Park H.C. Kim J.H. et al.Definitive treatment of pancreatic abscess by endoscopic transmural drainage.Gastrointest Endosc. 2002; 55: 256-262Abstract Full Text Full Text PDF PubMed Scopus (50) Google Scholar attempted transmural access and placement of stents and a transnasal irrigation drain in 9 patients with a total of 11 pancreatic abscesses.18Park J.J. Kim S.S. Koo Y.S. Choi D.J. Park H.C. Kim J.H. et al.Definitive treatment of pancreatic abscess by endoscopic transmural drainage.Gastrointest Endosc. 2002; 55: 256-262Abstract Full Text Full Text PDF PubMed Scopus (50) Google Scholar Ten (91%) resolved completely, and stents were left in place for a mean of 32 days. The relapse rate was 13% over a mean follow-up of 18 months. Venu et al,19Venu R.P. Brown R.D. Marrero J.A. Pastika B.J. Frakes J.T. Endoscopic transpapillary drainage of pancreatic abscess: technique and results.Gastrointest Endosc. 2000; 51: 391-395Abstract Full Text Full Text PDF PubMed Scopus (36) Google Scholar demonstrated comparable results by using a transpapillary approach. Finally, Seifert et al,20Seifert H. Wehrmann T. Schmitt T. Zeuzem S. Caspary W.F. Retroperitoneal endoscopic debridement for infected peripancreatic necrosis.Lancet. 2000; 356: 653-655Abstract Full Text Full Text PDF PubMed Scopus (296) Google Scholar were the first to describe the combination of EUS-directed, transmural puncture into necrotizing pancreatitis or abscess followed by tract dilation and repeated, direct endoscopic debridements of the lesser sac. In this issue of Gastrointestinal Endoscopy, Seewald and his colleagues from Hamburg use all of the above mentioned techniques, and more, in 13 consecutive patients, 5 with infected pancreatic necrosis and 8 with abscess, over a 7-year period.21Seewald S. Groth S. Omar S. Imazu H. Seitz U. de Weerth A. et al.Aggressive endoscopic therapy for pancreatic necrosis and pancreatic abscess: a new safe and effective treatment algorithm (videos).Gastrointest Endosc. 2005; 62: 92-100Abstract Full Text Full Text PDF PubMed Scopus (274) Google Scholar That abscess and necrotic cavities can be safely punctured and balloon dilated under EUS control is not news.22Fuchs M. Reimann F.M. Gaebel C. Ludwig D. Stange E.F. Treatment of infected pancreatic pseudocysts by endoscopic ultrasonography-guided cystogastrostomy.Endoscopy. 2000; 32: 654-657Crossref PubMed Scopus (34) Google Scholar, 23Giovannini M. Pesenti C. Rolland A.L. Moutardier V. Delpero J.R. Endoscopic ultrasound-guided drainage of pancreatic pseudocysts or pancreatic abscesses using a therapeutic echo endoscope.Endoscopy. 2001; 33: 473-477Crossref PubMed Scopus (267) Google Scholar Nor is it unique to do pancreatography to define either the site of ductal disruption or a downstream stricture that may be amenable to endoscopic stent placement.24Kozarek R.A. Ball T.J. Patterson D.J. Freeny P.C. Ryan J.A. Traverso L.W. Endoscopic transpapillary therapy for disrupted pancreatic duct and peripancreatic fluid collections.Gastroenterology. 1991; 100: 1362-1370PubMed Google Scholar, 25Kozarek R.A. Patterson D.J. Ball T.J. Traverso L.W. Endoscopic placement of pancreatic stents and drains in the management of pancreatitis.Ann Surg. 1989; 209: 261-266Crossref PubMed Scopus (136) Google Scholar Finally, it is not unique to undertake high volume lavage through nasopancreatic drains16Baron T.H. Thaggard W.G. Morgan D.E. Stanley R.J. Endoscopic therapy for organized pancreatic necrosis.Gastroenterology. 1996; 111: 755-764Abstract Full Text Full Text PDF PubMed Scopus (347) Google Scholar, 20Seifert H. Wehrmann T. Schmitt T. Zeuzem S. Caspary W.F. Retroperitoneal endoscopic debridement for infected peripancreatic necrosis.Lancet. 2000; 356: 653-655Abstract Full Text Full Text PDF PubMed Scopus (296) Google Scholar or even to debride an infected cavity with direct endoscope visualization.20Seifert H. Wehrmann T. Schmitt T. Zeuzem S. Caspary W.F. Retroperitoneal endoscopic debridement for infected peripancreatic necrosis.Lancet. 2000; 356: 653-655Abstract Full Text Full Text PDF PubMed Scopus (296) Google Scholar What is unique, however, is the intensity of treatment in this acutely ill group of patients, all of whom historically would have gone to surgery. The endoscopic treatment algorithm described by Seewald et al,21Seewald S. Groth S. Omar S. Imazu H. Seitz U. de Weerth A. et al.Aggressive endoscopic therapy for pancreatic necrosis and pancreatic abscess: a new safe and effective treatment algorithm (videos).Gastrointest Endosc. 2005; 62: 92-100Abstract Full Text Full Text PDF PubMed Scopus (274) Google Scholar includes control of the internal pancreatic-duct leak with stent placement, if feasible; access into the infected area with EUS-guided puncture, and placement of pigtail stents and nasocyst drains either through the gastric or the duodenal wall; repeated balloon dilation of the fistulous tracts with daily, direct endoscopic necrosectomy and lavage; and, when necessary, sealing of a persistent ductal disruption with N-butyl-2-cyanoacrylate. How well did they do, and how did the patients fare? To answer the first question, I direct the readers to Figures 3 to 5 in the Seewald article.21Seewald S. Groth S. Omar S. Imazu H. Seitz U. de Weerth A. et al.Aggressive endoscopic therapy for pancreatic necrosis and pancreatic abscess: a new safe and effective treatment algorithm (videos).Gastrointest Endosc. 2005; 62: 92-100Abstract Full Text Full Text PDF PubMed Scopus (274) Google Scholar However, these are static representations of the wonderful video clips that can be reviewed by logging onto the electronic version of this issue of Gastrointestinal Endoscopy. If a picture is, at times, worth a thousand words, the video segments are a veritable lexicon of technique and the requisite skill set required to reproduce the investigators' results. How did the patients do, and should I try this on my next patient with pancreatic necrosis? From a technical standpoint, endoscopic therapy was successful in resolving the infected necrosis or the abscess in 12 of 13 patients, although one patient required additional surgery to evacuate necrosis extending into the paracolic gutter. Moreover, two patients with a disconnected duct gland syndrome developed recurrent fluid collections after 2 and 4 months, a consequence of an undrained body and tail after initial endotherapy was complete. Both of these patients ultimately required pancreatic head resections, as did a third patient who was found to have a malignant head stricture but whose abscess was posttraumatic and located in the pancreatic tail. Two patients had persistent duct leaks glued, a process previously described by the investigators and a few others but not used in most endoscopic practices.26Seewald S. Brand B. Groth S. Omar S. Mendoza G. Seitz U. et al.Endoscopic sealing of pancreatic fistula by using N-butyl-2-cyanoacrylate.Gastrointest Endosc. 2004; 59: 463-470Abstract Full Text Full Text PDF PubMed Scopus (84) Google Scholar, 27Findeiss L.K. Brandabur J. Traverso L.W. Robinson D.H. Percutaneous embolization of the pancreatic duct with cyanoacrylate tissue adhesive in disconnected duct syndrome.J Vasc Interv Radiol. 2003; 14: 107-111Abstract Full Text Full Text PDF PubMed Scopus (16) Google Scholar The investigators were able to undertake these techniques without free perforation occurring, although there is no comment whether high-volume nasocavity irrigation was associated either with septic complications or possibly spreading infections into the paracolic gutters and more distant tissue planes. They did have 3 episodes of minor, procedurally related bleeding that stopped with dilute epinephrine injection, although erosion into the major splenic vasculature that required urgent surgery also has been previously reported with this technique (Thomas Rösch, ASGE Plenary Session 2003). Of particular note is that the median number of daily necrosectomies was 7, with a range between two and 12, and the number of high volume irrigations ranged between two and 41. There is no description of the average or the cumulative time required to do these procedures, but suffice it to say that none of these techniques are likely to be effective if scheduled between colonoscopies in an already full endoscopic schedule. Which brings me back to the question: Who should do this? It also suggests a corollary: Is this the best way to approach this problem? The “who” should be obvious. Not for the time challenged. Not for endoscopists without EUS access unless there is absolute assurance of abscess/necrosis proximity and the absence of interposed vessels. Not for endoscopists without expert surgical and interventional radiologic support to treat bleeding and infectious complications not amenable to the endoscopic approach (see Fig. 1 in Seewald et al21Seewald S. Groth S. Omar S. Imazu H. Seitz U. de Weerth A. et al.Aggressive endoscopic therapy for pancreatic necrosis and pancreatic abscess: a new safe and effective treatment algorithm (videos).Gastrointest Endosc. 2005; 62: 92-100Abstract Full Text Full Text PDF PubMed Scopus (274) Google Scholar), and, currently, not for patients simply because they have mild symptoms and slow resolution of uninfected necrosis. In other words, this procedure should only be undertaken by expert pancreaticobiliary endoscopists who have a support system in place, and the clinical judgment regarding the appropriate patient in whom this may prove to be effective therapy. Which brings me back to the corollary: Is this the best way to approach this problem? (See Algorithm for Potential Approaches to Pancreatic Necrosis; Fig. 1) As a clinician who has treated many of these patients over the past 20 years with a combination of endotherapy and percutaneous drainage,11Lau S.T. Simchuk E.J. Kozarek R.A. Traverso L.W. A pancreatic ductal leak should be sought to direct treatment in patients with acute pancreatitis.Am J Surg. 2001; 181: 411-415Abstract Full Text Full Text PDF PubMed Scopus (100) Google Scholar, 12Kozarek R.A. Attia F.M. Traverso L.W. Pancreatic duct leak in necrotizing pancreatitis. Role of diagnostic and therapeutic ERCP as part of a multi-disciplinary approach.Gastrointest Endosc. 2000; 51 ([abstract]): AB138Google Scholar several issues remain important:1.Small tubes (holes) are less likely to be effective drainage conduits than large tubes when dealing with adherent, particulate debris.2.Patients with pancreatic necrosis are unlikely to become infected within the first week, and previous data suggest that early surgery is associated with a significantly higher mortality.5Mier J. Leon E.L. Castillo A. Robledo F. Blanco R. Early versus late necrosectomy in severe necrotizing pancreatitis.Am J Surg. 1997; 173: 71-75Abstract Full Text PDF PubMed Scopus (414) Google Scholar In a similar vein, there are no data to suggest that the techniques described by Seewald et al,21Seewald S. Groth S. Omar S. Imazu H. Seitz U. de Weerth A. et al.Aggressive endoscopic therapy for pancreatic necrosis and pancreatic abscess: a new safe and effective treatment algorithm (videos).Gastrointest Endosc. 2005; 62: 92-100Abstract Full Text Full Text PDF PubMed Scopus (274) Google Scholar are necessary or safe early in the course of pancreatic necrosis.3.Finally, the cross-fertilization of disciplines with input from pancreatic surgeons, interventional radiologists, and gastroenterologists has been crucial in the development of a treatment plan in our institution for this extremely ill group of patients. As such, the ability to apply therapy exclusively endoscopically should not preclude the need for interdisciplinary interaction. Until additional series have been published that define the true risk-benefit and relative resource utilization of this technique when compared with surgical or interventional radiologic drainage, the team approach should remain central to the care of patients with severe pancreatic necrosis.