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

Table 2 Characteristics of endoscopic transluminal necrosectomy

	Recommendations and benefits	Areas of concern	Ref.
Indications for necrosectomy	Unsolved INP-associated symptoms	Conservative management or endoscopic drainage alone is sufficient in selected patients	[77-80]
Endoscopic transluminal necrosectomy	First-line therapy; recommended endoscopic step-up approach; increased life quality; reduced proinflammatory response, complications, hospitalization time, costs, and new-onset multiple organ failure	One single treatment may not suit all INP patients; no superiority in reducing major complications or mortality when compared with the surgical step-up procedure	[6,8-10,71,83-85]
Improve necrosectomy efficiency	A solid component is better assessed by EUS than by CT scanning	Lack of unified assessment protocol for necrosis proportion	[54]
Irrigation techniques	A three-step structured approach; saline, streptokinase, antibiotics, and hydrogen peroxide; reduced mortality and debridements	Lack of optimal procedure and concentration; prolonged stent retrieval; perforation caused by forced irrigation	[79,86-97]
Dedicated instruments	OTSG; PED; WAND; safe and effective; reduced interventions and hospital duration	Efficacy and indispensable safety; further research and popularization	[98-100]
Predictors for complications	Small size (≤ 7 cm) and delayed stent removal (≥ 4 w); PD disruption, abnormal vessels, and requirements of percutaneous drainage or hybrid techniques; elevated intracavitary amylase; exocrine insufficiency	Lack of prospective multicenter large-scale RCT	[37,106-109]
Managing complications	A novel algorithm for systematically managing hemorrhage events; LAMS with a larger diameter; mouthwash with chlorhexidine; suspension of PPI; timely follow-up and endoscopic management		[60,62,63,74,79,101-104]
MDT strategy	Individualized treatment; reduced mortality; improved clinical outcomes; optimal strategy for patients with high risks of potential complications	Lack of standardized endoscopic protocol; considerable variations among endoscopists	[11,79,110-112]

EUS: Endoscopic ultrasound; INP: Infected necrotizing pancreatitis; OTSG: Over-the-scope grasper; PED: Powered endoscopic debridement system; WAND: Waterjet necrosectomy device; PD: Pancreatic duct; RCT: Randomized controlled trials; LAMS: Lumen-apposing metal stents; MDT: Multi-disciplinary treatment.