• Cirugía pancreática
• Drenaje percutáneo
• Infected necrosis
• Necrosis infectada
• Pancreatic surgery
• Pancreatitis
• Percutaneous drainage
• Pseudocyst
• Seudoquiste

• Humans
• Aged
• Middle Aged
• Female
• Male
• Adult
• Aged, 80 and over
• Gastrostomy/methods
• Drainage/methods
• Pancreatitis/surgery
• Retrospective Studies
• Pancreatic Pseudocyst/surgery
• Anastomosis, Surgical

• acute pancreatitis
• percutaneous retroperitoneal necrectomy

• Pancreatitis, Acute Necrotizing/surgery
• Humans
• Debridement/methods
• Retroperitoneal Space/surgery
• Pancreas/surgery
• Video-Assisted Surgery/methods
• Treatment Outcome

• Humans
• Endoscopy
• Stents
• Necrosis/etiology
• Necrosis/surgery
• Pancreatitis, Acute Necrotizing/surgery
• Drainage

• acute necrotic collection
• open necrosectomy
• pancreatic necrosis
• walled-off necrosis

• Humans
• Pancreatitis, Acute Necrotizing/surgery
• Pancreatitis, Acute Necrotizing/mortality
• Male
• Female
• Middle Aged
• Adult
• Length of Stay
• Treatment Outcome
• Pancreatectomy/methods
• Pancreatectomy/adverse effects
• Aged
• Pancreas/surgery
• Pancreas/pathology
• Postoperative Complications/etiology
• Intensive Care Units
• Pancreatic Fistula/etiology
• Pancreatic Fistula/surgery
• Retrospective Studies

• laparoscopic pancreatic necrosectomy
• laparoscopic surgery
• necrosectomy
• pancreas
• pancreatic necrosis

• Male
• Humans
• Middle Aged
• Aged
• Pancreatitis, Acute Necrotizing/surgery
• Acute Disease
• Treatment Outcome
• Stents/adverse effects
• Drainage/methods
• Sepsis
• Intraabdominal Infections
• Necrosis
• Retrospective Studies

• Humans
• Pancreatitis, Acute Necrotizing/diagnostic imaging
• Pancreatitis, Acute Necrotizing/surgery
• Acute Disease
• Endoscopy/methods
• Stents

• acute care surgery
• pancreas

• Male
• Humans
• Middle Aged
• Female
• Debridement/methods
• Pancreas/surgery
• Laparoscopy/methods
• Pancreatitis, Acute Necrotizing/surgery
• Retroperitoneal Space/surgery
• Drainage/methods
• Treatment Outcome

• Necrosectomy
• Necrotizing pancreatitis
• PEN
• Sinus tract endoscopy

• Humans
• Acute Disease
• Pancreatitis
• Endoscopy
• Anti-Bacterial Agents
• Catheters
• Necrosis

• EUS-guided drainage
• EndoRotor
• direct endoscopic necrosectomy
• necrotizing pancreatitis
• walled-off pancreatic necrosis

This review summarized the current controversies in the management of acute pancreatitis (AP). The controversies in management range from issues involving fluid resuscitation, nutrition, the role of antibiotics and antifungals, which analgesic to use, role of anticoagulation and intervention for complications in AP. The interventions vary from percutaneous drainage, endoscopy or surgery. Active research and emerging data are helping to formulate better guidelines. The available evidence favors crystalloids, although the choice and type of fluid resuscitation is an area of dynamic research. The nutrition aspect does not have controversy as of now as early enteral feeding is preferred most often than not. The empirical use of antibiotics and antifungals are gray zones, and more data is needed for conclusive guidelines. The choice of analgesic is being studied, and the recommendations are still evolving. The position of using anticoagulation is still awaiting consensus. The role of intervention is well established, although the modality is constantly changing and favoring endoscopy or percutaneous drainage rather than surgery. It is evident that more multicenter randomized controlled trials are required for establishing the standard of care in these crucial management issues of AP to improve the morbidity and mortality worldwide.

• Acute pancreatitis
• Fluid resuscitation
• Antibiotics
• Analgesia
• Anti coagulation
• Intervention

• Humans
• Pancreatic Diseases/surgery
• Endoscopy
• Drainage/methods

Background and study aims  Endoscopic necrosectomy is limited by the proximity of necrosis to the gastrointestinal tract. Percutaneous endoscopic necrosectomy (PEN) is a minimally invasive endoscopic method of percutaneous debridement. Studies regarding its efficacy and safety are lacking. The purpose of this study was to assess the efficacy and safety of PEN in necrotizing pancreatitis.

Methods  Pubmed, Ovid, Cochrane, Scopus and Web of Science Database were searched from inception through February 2021. Dual extraction and quality assessment of studies using Cochrane risk of bias tool were performed independently by two authors. The primary outcome was defined as clinical success of PEN. Secondary outcomes included periprocedural morbidity, mortality, and long-term morbidity and mortality.

Results  Sixteen observational studies including 282 subjects were analyzed. The average reported age of the participants was 50.3 years. Patients with reported gender included 39 % females and 61 % males. The success rate as defined by complete resolution of necrosis and removal of drainage catheters/stents was 82 % (95 % confidence interval 77–87). The mean size of pancreatic necrosis was 14.86 cm (5–54 cm). The periprocedural morbidity rate was 10 %, while there was no reported periprocedural mortality. The long-term morbidity rate was reported as 23 % and mortality at follow-up was 16 %.

Conclusions  PEN is a novel method of endoscopic management of pancreatic necrosis. Based on our meta-analysis of retrospective studies, it represents a safe treatment modality with high rates of clinical success and low rates of perioperative morbidity and mortality. This study supports the use of PEN when conventional endoscopic therapy is not feasible.

• acute pancreatitis
• necrosectomy
• necrotizing pancreatitis

• infected pancreatic necrosis
• minimally invasive methods of surgical treatment
• open methods of surgical treatment

• complication
• intervention
• pancreatitis
• ultrasound

Approximately 10%-20% of the cases of acute pancreatitis have acute necrotizing pancreatitis. The infection of pancreatic necrosis is typically associated with a prolonged course and poor prognosis. The multidisciplinary, minimally invasive “step-up” approach is the cornerstone of the management of infected pancreatic necrosis (IPN). Endosonography-guided transmural drainage and debridement is the preferred and minimally invasive technique for those with IPN. However, it is technically not feasible in patients with early pancreatic/peripancreatic fluid collections (PFC) (< 2-4 wk) where the wall has not formed; in PFC in paracolic gutters/pelvis; or in walled off pancreatic necrosis (WOPN) distant from the stomach/duodenum. Percutaneous drainage of these infected PFC or WOPN provides rapid infection control and patient stabilization. In a subset of patients where sepsis persists and necrosectomy is needed, the sinus drain tract between WOPN and skin-established after percutaneous drainage or surgical necrosectomy drain, can be used for percutaneous direct endoscopic necrosectomy (PDEN). There have been technical advances in PDEN over the last two decades. An esophageal fully covered self-expandable metal stent, like the lumen-apposing metal stent used in transmural direct endoscopic necrosectomy, keeps the drainage tract patent and allows easy and multiple passes of the flexible endoscope while performing PDEN. There are several advantages to the PDEN procedure. In expert hands, PDEN appears to be an effective, safe, and minimally invasive adjunct to the management of IPN and may particularly be considered when a conventional drain is in situ by virtue of previous percutaneous or surgical intervention. In this current review, we summarize the indications, techniques, advantages, and disadvantages of PDEN. In addition, we describe two cases of PDEN in distinct clinical situations, followed by a review of the most recent literature.

• Infected pancreatic necrosis
• Direct endoscopic necrosectomy
• Percutaneous endoscopic necrosectomy
• Sinus tract endoscopy
• Stent-assisted percutaneous direct endoscopic necrosectomy

• necrosis
• preferred
• retroperitoneal access
• transmural access

• infected pancreatic necrosis
• minimally invasive interventions
• pancreas
• transfistulous sequestrectomy

• Humans
• Pancreatitis, Acute Necrotizing/complications
• Pancreatitis, Acute Necrotizing/diagnosis
• Pancreatitis, Acute Necrotizing/surgery
• Intraabdominal Infections/etiology
• Endoscopy/adverse effects
• Drainage/adverse effects
• Drainage/methods
• Orthopedic Procedures/adverse effects

Acute necrotizing pancreatitis occurs in 10%–20% of patients with acute pancreatitis (AP) which is one of the most important acute abdominal diseases that require hospital admission. Pancreatic necrosis is also associated with high mortality and morbidity. In the past 20 years, the treatment of pancreatic necrosis has shifted from open necrosectomy to minimally invasive techniques, such as endoscopic interventions. With the development of endoscopic techniques, the safety and effectiveness of endoscopic interventions have improved, but there exist several unresolved problems. Currently, there is no unified standard approach for endoscopic treatment of pancreatic necrosis that takes into account local expertise, anatomical features of necrosis, patients’ preferences, and comorbidity profile. We reviewed the current status of endoscopic therapy for acute necrotizing pancreatitis, focusing on the new endoscopic drainage technique and necrosectomy protocol.

• acute necrotizing pancreatitis
• direct endoscopic necrosectomy
• endoscopic ultrasound
• percutaneous endoscopic necrosectomy

• acute necrotizing pancreatitis
• endoscopic sequestrectomy

• Minimally invasive retroperitoneal pancreatectomy (MIRP)
• Necrosectomy
• Necrotizing pancreatitis
• Pancreatic debridement
• Step-up approach
• Transgastric necrosectomy (TGN)
• Video assisted retroperitoneal debridement (VARD)
• Walled-off pancreatic necrosis

• Drainage
• Humans
• Pancreatitis, Acute Necrotizing/surgery
• Treatment Outcome

Endoscopic ultrasound-guided drainage is suggested as the first approach in the management of symptomatic and complex walled-off pancreatic necrosis. Dual approach with percutaneous drainage could be the best choice when the necrosis is deep extended till the pelvic paracolic gutter; however, the available catheter could not be large enough to drain solid necrosis neither to perform necrosectomy, entailing a higher need for surgery. Therefore, percutaneous endoscopic necrosectomy through a large bore percutaneous self-expandable metal stent has been proposed.

In this study, we present the case of a 61-year-old man admitted to our hospital with a history of sepsis and persistent multiorgan failure secondary to walled-off pancreatic necrosis due to acute necrotizing pancreatitis. Firstly, the patient underwent transgastric endoscopic ultrasound-guided drainage using a lumen-apposing metal stent and three sessions of direct endoscopic necrosectomy. Because of recurrence of multiorgan failure and the presence of the necrosis deeper to the pelvic paracolic gutter at computed tomography scan, we decided to perform percutaneous endoscopic necrosectomy using an esophageal self-expandable metal stent. After four sessions of necrosectomy, the collection was resolved without complications. Therefore, we perform a revision of the literature, in order to provide the state-of-art on this technique. The available data are, to date, derived by case reports and case series, which showed high rates both of technical and clinical success. However, a not negligible rate of adverse events has been reported, mainly represented by fistulas and abdominal pain.

Dual approach, using lumen apposing metal stent and percutaneous self-expandable metal stent, is a compelling option of treatment for patients affected by symptomatic, complex walled-off pancreatic necrosis, allowing to directly remove large amounts of necrosis avoiding surgery. Percutaneous endoscopic necrosectomy seems a promising technique that could be part of the step-up-approach, before emergency surgery. However, to date, it should be reserved in referral centers, where a multidisciplinary team is disposable.

• Endoscopic necrosectomy
• Lumen-apposing metal stent
• Necrotizing pancreatitis
• Percutaneous endoscopic necrosectomy
• Walled-off pancreatic necrosis

• Arterial bleeding
• Computed tomography
• Drainage
• Necrotizing pancreatitis
• Pseudoaneurysm

• acute pancreatitis
• infected pancreatic necrosis
• late complications
• nephroscopic necrosectomy
• organ failure

The present study aimed to determine whether a difference in pancreatic function and quality of life (QoL) is present between patients with infected pancreatitis necrosis (IPN) undergoing open necrosectomy (ON) and minimally invasive drainage (MID). The medical records of patients with IPN discharged from Jinling Hospital were retrospectively analyzed. Pancreatic function and QoL were compared between patients treated with ON and MID. Pancreatic endocrine and exocrine function were assessed using the oral glucose tolerance test and fecal elastase-1 (FE-1) test, respectively. The standard Short Form 36 health questionnaire was used to evaluate the QoL of patients. The analysis included 101 patients who underwent either ON (n=40, 39.6%) or MID (n=61, 60.4%). There were no significant differences in exocrine and endocrine pancreatic function between the two groups evaluated based on FE-1, fasting blood glucose, glycated hemoglobin and 2-h plasma glucose (P<0.05). The scores of the QoL questionnaire were significantly higher in patients treated with MID than in patients treated with ON, including the scores of general health perception (19.39±3.07 vs. 17.37±3.63, P=0.003), vitality (18.93±2.88 vs. 17.57±3.47, P=0.035), social role functioning (8.85±1.43 vs. 8.15±1.98, P=0.042), emotional role functioning (5.33±1.07 vs. 4.82±1.25, P=0.034), mental health (24.21±3.31 vs. 22.57±3.91, P=0.026) and the total QoL score (125.12±13.16 vs. 116.50±16.94, P=0.005). In conclusion, although the initial health of the patient may have influenced the treatment provided, patients with IPN who received MID achieved a better post-treatment QoL than those treated with ON. No significant differences between the two groups were observed regarding the endocrine and exocrine functions of the pancreas.

• infected pancreatitis necrosis
• minimally invasive drainage
• open necrosectomy
• pancreatic function
• quality of life

Acute pancreatitis (AP) is defined as an acute inflammatory attack of the pancreas of sudden onset. Around 25% of patients have either moderately severe or severe disease with a mortality rate of 15–20%.

The aim of this article was to summarize the advances being made in the understanding of this disease and the important role of surgery.

An accurate diagnosis should be made a soon as possible, initiating resuscitation with large volume intravenous fluids and oxygen by mask. Predicted severe disease will require intensive monitoring. Most deaths within the first week are due to multi-organ failure; thus, these patients will require intensive therapy unit management. During the second phase of the disease, death is due to local complications arising from the pancreatic inflammation, requiring accurate identification to determine the correct form of treatment. Acute peripancreatic fluid collections arise < 4 weeks after onset of interstitial edematous pancreatitis, not requiring any treatment. Most pancreatic pseudocysts arise > 4 weeks and largely resolve on conservative management. Necrotizing pancreatitis causing acute necrotic collections and later walled-off necrosis will require treatment if symptomatic or infected. Initial endoscopic transgastric or percutaneous drainage will resolve less serious collections but necrosectomy using minimally invasive approaches will be needed for more serious collections. To prevent recurrent attacks of AP, causative factors need to be removed where possible such as cholecystectomy and cessation of alcohol. Future progress requires improved management of multi-organ failure and more effective minimally invasive techniques for the removal of necrosis.

• Endoscopic
• Infection
• Minimally invasive surgery
• Necrosectomy
• Pancreatic necrosis
• Percutaneous

• Videoscopic assisted retroperitoneal debridement
• acute necrotising pancreatitis
• infected pancreatic necrosis
• step up approach

• Bleeding complications
• CT scan guidance
• Infected pancreatic necrosis, Sterile pancreatic necrosis
• Intestinal fistula
• Necrotizing pancreatitis
• Percutaneous catheter drainage
• Pseudoaneurysms
• Ultrasound guidance

• Acute pancreatitis
• Infected pancreatic necrosis
• Percutaneous endoscopic necrosectomy
• Walled-off necrosis

• Endoscopy
• Humans
• Pancreatitis, Acute Necrotizing

• acute pancreatitis
• drainage
• haemorrhage
• infection
• necrosectomy

• intra-abdominal collection
• step-up approach
• video-assisted retroperitoneal debridement

• Acute Pancreatitis
• Necrotizing Pancreatitis
• Severe Acute Pancreatitis

Incidence of acute pancreatitis seems to be increasing in the Western countries and has been associated with significantly increased morbidity. Nearly 80% of the patients with acute pancreatitis undergo resolution; some develop complications including pancreatic necrosis. Infection of pancreatic necrosis is the leading cause of death in these patients. A significant portion of these patients needs surgical interventions. Traditionally, the “gold standard” procedure has been the open surgical necrosectomy, which is now being completed by the relatively lesser invasive interventions. Minimally invasive surgical (MIS) procedures include endoscopic drainage, percutaneous image-guided catheter drainage, and retroperitoneal drainage. This review article discusses the open and MIS interventions for pancreatic necrosis with each having its own respective benefits and disadvantages are covered.

• Pancreatic necrosis
• Necrosectomy
• Open surgery
• Minimally invasive surgery
• Complications
• Treatment
• Review article