Percutaneous direct endoscopic pancreatic necrosectomy

Table 1 Case series of percutaneous direct endoscopic necrosectomy for infected pancreatic necrosis

Ref.	Number of patients	Initial intervention	PDEN/stent assisted PDEN	Anaesthesia	Median PDEN sessions	Additional intervention-number of patients	Clinical success rate (%)	Procedure related complications-number of patients	Mortality (%)
Carter et al[11], 2000	14	ON-4, PD-10	PDEN	GA	2	Surgery-1	85.7	Bleeding-1	14.3
Mui et al[12], 2005	13	ON-4, PD-10	PDEN	TIVA	3	ERCP-9, Surgery-1	76.9	Colonic perforation-1; catheter dislodgement-1	7.7
Dhingra et al[14], 2015	15	PD-15	PDEN	TIVA	4	Surgery-1	93.3	Bleeding-1; pancreatico-cutaneous Fistula-1	6.7
Mathers et al[15], 2016	10	PD-10	PDEN	TIVA; GA if clinically warranted	1.5	None	100	Pancreatico-cutaneous Fistula-1	0
Goenka et al[18], 2018	10	PD-10	PDEN	TIVA	2.3	Transmural, DEN-2, Surgery-1	90	Pneumo-peritoneum-2	0
Saumoy et al[19], 2018	9	PD-9	Stent-assisted PDEN	GA	3	None	88.9	None	11.1
Thorsen et al[20], 2018	5	PD-3; transmural; DEN-2	Stent-assisted PDEN	TIVA or GA	6	Transmural DEN-1	80	Abdominal Pain-5; pancreatico-cutaneous fistula-2	20
Tringali et al[21], 2018	3	PD-3	Stent-assisted PDEN	TIVA	3	0	100	None	0
Jain et al[5], 2020	53	PD-53	PDEN	TIVA	4	Surgery-8	79.2	Pancreatico-cutaneous fistula-4; bleeding-1; aspiration pneumonia-2; peritonitis-2; paralytic ileus-1; subcutaneous emphysema-1	20.8
Ke et al[25], 2021	37	PD-37	Stent-assisted PDEN	NA	4	Surgery-8	86.5	Bleeding-6; pancreatico-cutanoeus fistula-7; colonic fistula-4; gastro-duodenal fistula-4	13.5

ON: Open necrosectomy; PD: Percutaneous drainage; DEN: Direct endoscopic necrosectomy; PDEN: Percutaneous direct endoscopic necrosectomy; GA: General anaesthesia; TIVA: Total intravenous anaesthesia without endotracheal intubation; PFC: Pancreatic/peripancreatic collection; NA: Not available.

Table 2 Indications of percutaneous direct endoscopic necrosectomy

Indications
< 2-4 wk-Infected acute pancreatic/peripancreatic collection in which percutaneous drainage is required early and infection persists even after percutaneous drainage alone
> 2-4 wk-Infected walled off pancreatic necrosis unsuitable for transmural drainage: (1) Location (Paracolic/pelvic extension); (2) Distance > 1 cm; (3) Coagulopathy; (4) Multiple collaterals-Endosonography guided can be done

Table 3 Advantages and disadvantages of percutaneous direct endoscopic necrosectomy

No.	Advantages	Disadvantages
1	It can be done in critically ill patients where laparoscopy access is not possible- bed side	More invasive (compared to transmural necrosectomy) (Multiple interventions-percutaneous drainage followed by multiple tract dilation/drainage catheter exchanges, if not stent-assisted percutaneous direct endoscopic necrosectomy)
2	Subsequent liquefied necrosis drained by gravity	Small endoscopic accessories for necrosectomy-hence, time-consuming and labour-intensive procedure (compared to VARD/surgical necrosectomy)
3	No intraperitoneal transmission (retroperitoneal approach); a fully covered self-expandable metal stent may help to prevent intraperitoneal transmission in transperitoneal approach	The need for repeated procedures for effective drainage (compared to VARD/surgical necrosectomy)
4	Access various extensions deep within the abdomen using the flexible endoscope’s angulation and versatility (Figures 3C and 6C)	Pancreatico-cutaneous fistula (compared to transmural necrosectomy)
5	Usually carried out under deep sedation; general anaesthesia avoided	-

VARD: Video-assisted retroperitoneal drainage.