Transgastric Endoscopic Interventions at the Pancreas

Abstract

Infected pancreatic or peripancreatic necrosis is traditionally an indication for a therapeutic intervention. Since the first description of EUS-guided lavage (Baron et al. Gastroenterology 111:755–764, 1996) and open retroperitoneal endoscopic debridement (Seifert et al. Lancet 356:653–655, 2000) for complicated necrotizing pancreatitis more than 20 years ago, minimally invasive therapy has become standard worldwide. After open surgery was defended by expert groups still in 2005 (Werner et al. Scand J Surg 94(2):130–134, 2005; Gut 54(3):426–436, 2005), minimally invasive surgery nowadays is the only acceptable surgical approach to infected necroses that can be reasonably compared to transmural endoscopic therapy (Hollemans et al. Gastroenterology 156:1016–1026, 2019). Several studies (van Brunschot et al. Gut 67(4):697–706, 2018; Bakker et al. JAMA 307(10):1053–1061, 2012; Khreiss, J Gastrointest Surg 19(8):1441–1448, 2015; van Brunschot et al. Lancet 391(10115):51–58, 2018; Kumar et al. Pancreas 43(8):1334–1339, 2014; Bang et al. Gastroenterology 156(4):1027–1040, 2019) and meta-analyses (Hu et al. Rev Esp Enferm Dig 111(6):471–480, 2019; Khan et al. J Clin Gastroenterol 53(2):81–88, 2019; Bang et al. Dig Endosc 32(3):298–308, 2020) have proved that the endoscopic transluminal approach is superior to minimally invasive surgery. While there was no benefit in mortality, endoscopic therapy was associated with less organ failure and fistula formation as well as shorter hospital stay. In recent years, self-expanding metal stents (SEMS) in various forms specially adapted to the transmural procedure as “lumen-apposing metal stents” (LAMS) have facilitated endoscopic retroperitoneal access for repeated interventions (Binmoeller and Shah. Endoscopy. 44(5):499–503, 2012; Itoi et al. Gastrointest Endosc 75(4):870–876, 2012). In addition, the dilated pancreatic duct is now accessible for transgastromural endoscopic diagnosis and therapy.