Endoscopic management of walled-off pancreatic necrosis

Pancreatic necrosis, which can be associated with organ failure and infection, occurs in approximately 15% of patients with acute pancreatitis (AP). Indications for endoscopic or other interventions include infected necrosis or symptomatic sterile necrosis. Delayed intervention leads to improved outcomes, and it is generally recommended that interventions are performed at least 4 to 6 weeks after the onset of AP. It is also critical to accurately characterize the anatomical extent and level of organization of the necrosis and to preoperatively differentiate walled-off necrosis from pancreatic pseudocysts. Options for debridement include endoscopic transmural (transgastric or transduodenal) necrosectomy, percutaneous drainage alone, combined percutaneous and endoscopic drainage, and retroperitoneal, laparoscopic, or open surgical debridement. Most available data now support a “step-up” approach to the management of patients with severe AP complicated by infected or symptomatic walled-off pancreatic necrosis with more invasive options reserved for patients who do not respond to initial conservative management. Regardless of the approach to debridement used, patients with pancreatic necrosis, particularly those with infected necrosis, are best treated by an experienced multidisciplinary clinical team.