Christopher C Thompson1, Nitin Kumar2, James Slattery3, Thomas E Clancy4, Michele B Ryan5, Marvin Ryou6, Richard S Swanson7, Peter A Banks8, Darwin L Conwell9. 1. Division of Gastroenterology, Hepatology and Endoscopy, Brigham and Women's Hospital, 75 Francis St., ASB II, Boston, MA 02115, USA. Electronic address: cthompson@hms.harvard.edu. 2. Division of Gastroenterology, Hepatology and Endoscopy, Brigham and Women's Hospital, 75 Francis St., ASB II, Boston, MA 02115, USA. Electronic address: nitinkumar.101@gmail.com. 3. Division of Gastroenterology, Hepatology and Endoscopy, Brigham and Women's Hospital, 75 Francis St., ASB II, Boston, MA 02115, USA. Electronic address: Jslattery2@partners.org. 4. Department of Surgery, Brigham and Women's Hospital, 75 Francis St, Boston, MA 02115, USA. Electronic address: tclancy@partners.org. 5. Division of Gastroenterology, Hepatology and Endoscopy, Brigham and Women's Hospital, 75 Francis St., ASB II, Boston, MA 02115, USA. Electronic address: mryan15@partners.org. 6. Division of Gastroenterology, Hepatology and Endoscopy, Brigham and Women's Hospital, 75 Francis St., ASB II, Boston, MA 02115, USA. Electronic address: mryou@partners.org. 7. Department of Surgery, Brigham and Women's Hospital, 75 Francis St, Boston, MA 02115, USA. Electronic address: rswanson@partners.org. 8. Division of Gastroenterology, Hepatology and Endoscopy, Brigham and Women's Hospital, 75 Francis St., ASB II, Boston, MA 02115, USA. Electronic address: pabanks@partners.org. 9. Division of Gastroenterology, Hepatology, and Nutrition, Ohio State University Medical Center, 288 Office Tower, 395 W. 12th Avenue, Columbus, OH 43210, USA. Electronic address: darwin.conwell@osumc.edu.
Abstract
OBJECTIVES: Endoscopic necrosectomy is effective in the treatment of walled-off necrosis (WON), and is preferred to surgical approaches, however complication and mortality rates remain high with few centers regularly employing the technique. Lack of a standardized approach may also contribute to these limitations. METHODS: Prior to the study, a multidisciplinary team applied standardized care assessment and management plan principles to develop and optimize a systematic approach for the management of WON. Preoperative, postoperative, and endoscopic management were standardized. Patient preparation, room set-up, technical features (EUS-guidance, cold-access with balloon dilation, fragmentation of necrosis on the initial procedure, antibiotic lavage, double pigtail stents), and discontinuation of PPIs to encourage auto-digestion of necrosis were included. This study employed a consecutive prospective clinical registry to assess the clinical outcomes of this standardized approach. RESULTS: 60 consecutive patients underwent 1.58 ± 0.1 necrosectomies, with debridement accomplished on the initial procedure in 98.3%. 39 patients (65%) required only one session. Clinical resolution occurred in 86.7%, with radiologic confirmation. Percutaneous drainage was required in 8 patients during follow-up, and 4 of these later required surgery. Serious adverse events occurred in 3.3% of patients, and there was no mortality. CONCLUSIONS: The standardized technique employed in this series was associated with lower rates of adverse events, morbidity, and mortality than prior large series. Use of a systematic approach, and integrating elements of this method may improve the risk profile of endoscopic necrosectomy and allow broader adoption.
OBJECTIVES: Endoscopic necrosectomy is effective in the treatment of walled-off necrosis (WON), and is preferred to surgical approaches, however complication and mortality rates remain high with few centers regularly employing the technique. Lack of a standardized approach may also contribute to these limitations. METHODS: Prior to the study, a multidisciplinary team applied standardized care assessment and management plan principles to develop and optimize a systematic approach for the management of WON. Preoperative, postoperative, and endoscopic management were standardized. Patient preparation, room set-up, technical features (EUS-guidance, cold-access with balloon dilation, fragmentation of necrosis on the initial procedure, antibiotic lavage, double pigtail stents), and discontinuation of PPIs to encourage auto-digestion of necrosis were included. This study employed a consecutive prospective clinical registry to assess the clinical outcomes of this standardized approach. RESULTS: 60 consecutive patients underwent 1.58 ± 0.1 necrosectomies, with debridement accomplished on the initial procedure in 98.3%. 39 patients (65%) required only one session. Clinical resolution occurred in 86.7%, with radiologic confirmation. Percutaneous drainage was required in 8 patients during follow-up, and 4 of these later required surgery. Serious adverse events occurred in 3.3% of patients, and there was no mortality. CONCLUSIONS: The standardized technique employed in this series was associated with lower rates of adverse events, morbidity, and mortality than prior large series. Use of a systematic approach, and integrating elements of this method may improve the risk profile of endoscopic necrosectomy and allow broader adoption.
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