Endoscopic transluminal drainage and necrosectomy for infected necrotizing pancreatitis: Progress and challenges

Table 1 Characteristics of endoscopic transluminal drainage and stents

	Recommendations and benefits	Areas of concern	Ref.
Recommending EUS guidance	Effective and minimally invasive; lower morbidity; reduced reinterventions; decreased follow-up imaging; shorter hospital stay	-	[18-21,24,25,66]
Indications for drainage	INP-associated symptoms and complications	Patients' general conditions and symptoms; PFC characteristics; endoscopic experience	[27-28]
Timing of intervention
Early intervention (< 2 wk)	Not recommended; no superiority in complications	Increased mortality and invasive interventions	[5,45]
Early intervention (3–4 wk)	Safe and effective when identifying a partial collection	Increased mortality, endoscopic necrosectomy, and rescue surgery	[14,50,51]
Delayed intervention (> 4 wk)	Generally recommended; after INP encapsulation; excellent clinical success; reduced reinterventions and mortality	-	[17,45-49]
Stents
DPPS	Affordable, safe, and easily accessible; recommended for little debris (≤ 10 %) or pure PPC	Stent occlusion; possible leakage; limited endoscopic access to the necrotic cavity	[18,28-30,54,57]
SEMS	Feasible; deployed when LAMS is unavailable	-	[32]
LAMS	Simpler procedure; higher technical and long-term success rates; less AD than DPPS; recommended for significant debris (≥ 30 %)	Higher cost; increased risks of pseudoaneurysm bleeding, delayed bleeding, perforation, and buried stent syndrome	[12,29,33,34,52-55,60-63]
Negative predictors for drainage effect	Male; MOF; extensive necrosis (≥ 150 mm); heterogeneity (necrosis ≥ 50%)	-	[35-37]
Improving drainage	Additional nasocystic drainage; multiple transluminal gateway technique; hybrid techniques	-	[28,31,38,39,42,43]
Technical aspects	Not always requiring fluoroscopy and LAMS dilation; novel techniques for complicated deployments; timely stent removal; endoscopic closure for patients with a poor situation or early needs for transoral feeding	Lack of standardized protocol	[11,12,17,61,62,68,69]

EUS: Endoscopic ultrasound; INP: Infected necrotizing pancreatitis; PPC: Pancreatic pseudocyst; PFC: Pancreatic fluid collection; DPPS: Double-pigtail plastic stents; SEMS: Self-expanding metal stents; LAMS: Lumen-apposing metal stents; AD: Adverse events; MOF: Multiple organ failure.