Per Oral Transluminal Route: A New Approach for the Management of Serious Infected Necrotic Pancreatitis

Severe necrotizing pancreatitis remains a difficult condition to manage with infection of pancreatic necrosis being the most serious complication and is the single most important risk factor of a fatal outcome. Severe pancreatic necrosis affects 15% of all cases of pancreatitis, 40-70% of these cases are later infected with a mortality of up to 50%. Current management is mainly surgical debridement and drainage, yet despite the development of numerous surgical techniques and approaches the outcome of this treatment modality remains rather disappointing with a morbidity of up to 92% and a mortality of 20-40% in most case series. Radiological procedures have been described with some success yet their failure to remove extensive necrosis leaves them largely a method to postpone surgery rather than a definite treatment. Recently, the advent of natural orifice transluminal endoscopic surgery (NOTES) has opened a new area for intra-abdominal surgery, endoscopy debridement of necrotic pancreatic tissue has been described with encouraging results. ln this lecture we present our experience with an aggressive endoscopy technique with deep retroperitoneal access as a primary treatment of infected pancreatic necrosis.The objective has been to assess the results and complications of an endoscopy transgastric/transduodenal approach as a possible alternative to conventional surgery.Infected organized pancreatic necrosis carries a high mortality despite antibiotic therapy and numerous conventional and laparoscopic surgical techniques of debridement.2004-2015 patients with infected organized pancreatic necrosis were referred for endoscopy 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. Among 27 patients, (21 men, mean age: 55 years) endoscopic necrosectomy was possible in 26. 2 patients had extra percutaneous drainage for endoscopically inaccessible cavities. Resolution of infection was the rule in all cases.Endoscopic treatment was eventually successful in all patients with gradual diminution of the necrotic cavities on CT-images. Average duration of follow up was 30 months (range 2- 60 months) with no recurrence of the infectious process and no surgery was required for any patient. Complications included bleeding n=5 and transient aggravation of sepsis n=5 mortality 1(12%) due to multiple organ failure.This technique is higly effective and safe in the treatment of infected organized pancreatic necrosis. Results are achievable and sustainable in a few numbers of sessions.With further larger prospective series confirming our results, this technique could well be an alternative to current surgical approaches. Yet this enthusiasm should be slightly hampered by the complexity of the technique and the need of profound expertise in endoscopic therapy by the operator. This technique should be limited to specialized equipped centers allowing swift and adequate cooperation among a team of endoscopists, surgeons, radiologists and intensive care specialists. As other "Natural Orifice Transluminal Endoscopy Surgery" (NOTES) this technique is still at its infancy and is expected to develop greatly with the advent of more specialized equipment and more importantly practical experience.