Endoscopic pancreatic necrosectomy

Acute pancreatitis can be complicated by necrosis of the pancreas, peripancreatic tissue, or both in 10-20% of cases, with a risk of developing infection up to 30%. Necrosis can involve any part of the pancreas, and it could be endoscopically reachable from both the stomach or duodenum, allowing to perform a EUS-guided drainage of the collection if a mature wall of the collection is present. After the creation of transmural drainage, the amount of solid necrosis within the collection could affect the need for a debridement and therefore for a direct endoscopic necrosectomy (DEN). DEN is performed directly introducing an endoscope into the cavity of the cyst, and the debridement could be performed using a combination of different techniques. However, to date, no specifically dedicated devices were designed for DEN, but several endoscopic accessories have been used. DEN is a challenging procedure which may be complicated by several adverse events, with an overall complication rate that could rank 36%. For all these reasons, it is still debating whether DEN should be done up-front, namely just following stent placement, or delayed to another session, and whether to perform it scheduled or "on-demand."