Management of walled-off necrosis (WON) : Percutaneous step-up approach

INTRODUCTION : Walled-off necrosis (WON) is a potentially life-threatening complication in acute necrotising pancreatitis (ANP) . In recent times, minimally invasive therapy has been recommended for patients with symptomatic WON. Here we report the efficacy and complications seen in cases of ANP with symptomatic WON managed using percutaneous drainage, with or without endoscopic necrosectomy.<br> AIMS & METHODS : We retrospectively searchedadmission records at our hospital of patients with ANP and symptomatic WON.<br>Treatment firstly involved puncturing of the WON using US-guidance, and then placement of a 7Fr drainage catheter into the cavity of the lesion. Lavage of the cavity was performed daily using 500-1000 ml saline. If the patientʼs symptoms were not stable, the percutaneous tract was dilated up to 10 mm in diameter and a larger sized catheter placed. Endoscopic necrosectomy was then performed once or twice weekly via the tract. The procedure was ceased when necrotic tissues had almost been eradicated. After necrosectomy, a pancreatic stent was placed endoscopically into the WON cavity.<br> RESULTS : Seven patients with WON were treated at our hospital using the percutaneous approach during the period from May 2009 to May 2013 : six patients were treated via the transperitoneal approach and one via the transperitoneal-transgastric approach. Four were treated using drainage only and three by endoscopic necrosectomy.<br> Timing of intervention after the onset of pancreatitis ranged from 24 to 131 days. The mean number of necrosectomy sessions was 3.6 (2-7) . After drainage was successfully completed, a pancreatic stent was placed via the duodenal papilla (five cases) or transgastrically (two cases) . Symptoms resolved in six patients ; one patient died of sepsis.<br>CONCLUSION : Percutaneous drainage with or without endoscopic necrosectomy is one option for minimally invasive treatment of ANP with symptomatic WON. Compared with the EUS-guided approach, the percutaneous approach has several merits. Firstly, a larger sized catheter can be placed, so lavage of WON can be more effectively performed. Secondly, in a hospital where EUS-guided drainage is not available, the percutaneous approach can be the treatment of choice.