Current Controversies and Challenges in Endoscopic Management of Necrotizing Pancreatitis

The current paradigm for intervention in necrotizing pancreatitis involves a staged multidisciplinary step-up approach with endoscopic transluminal drainage (ETD) or percutaneous drainage as the initial step based on the location of the collection and the availability of localized expertise (Figure 1). 1 Trikudanathan G. Wolbrink D.R.J. Santvoort HC van et al. Current concepts in severe acute and necrotizing pancreatitis: an evidence-based approach. Gastroenterology. 2019; 156: 1994-2007 Abstract Full Text Full Text PDF PubMed Scopus (116) Google Scholar Endoscopic step-up approach is associated with reduced occurrence of new-onset multiorgan failure and physiological stress, reduced risk of external fistulae, shorter hospital stay, lower costs, and better quality of life with no significant difference in mortality when compared with surgical approach as shown in 3 randomized trials. 1 Trikudanathan G. Wolbrink D.R.J. Santvoort HC van et al. Current concepts in severe acute and necrotizing pancreatitis: an evidence-based approach. Gastroenterology. 2019; 156: 1994-2007 Abstract Full Text Full Text PDF PubMed Scopus (116) Google Scholar The endoscopic approach involves ETD (cystenterostomy) followed by endoscopic transluminal necrosectomy (ETN) as needed, and has significantly evolved with new innovations. However, there are controversies in the timing and choice of stents for ETD, with challenges and need for further refinement and standardization of technique of ETN, which is addressed in this focused review.