Endoscopic pancreatic necrosectomy in the United States-Mexico border: A cross sectional study

Table 1 Patient demographics

Characteristics	n = 21
Gender, n (%)
Male	15 (71.4)
Female	6 (28.6)
Age, mean ± SD, yr	51 ± 16.9
Race, n (%)
Hispanic	16 (76.2)
Non-Hispanic White	5 (23.8)
Etiology of pancreatitis, n (%)
Biliary	17 (81.0)
Alcohol	3 (14.3)
Idiopathic	1 (4.7)
Location of WON, n (%)
Body	17 (81.0)
Entire pancreas	2 (9.5)
Head	1 (4.7)
Tail	1 (4.7)
WON dimension, mean ± SD, cm	13.4 ± 5.0
Indication for DEN, n (%)1
Persistent vomiting	14 (66.7)
Abdominal pain	13 (61.9)
Infection/sepsis	6 (28.6)

¹Indications may overlap. WON: Walled-off necrosis; DEN: Direct endoscopic necrosectomy.

Table 2 Procedure details

LAMS	n = 24
Trans-gastric, n (%)	23 (96)
Body, n (%)	17 (74)
Antrum, n (%)	3 (13)
Cardia, n (%)	1 (4.3)
Incisura, n (%)	1 (4.3)
Pre-pyloric, n (%)	1 (4.3)
Trans-duodenal	1 (4)
Dilated same day, n (%)	24 (100)
Placement to retrieval, mean ± SD, d	27.2 (10.6)
DEN	n = 66
DEN/patient, mean ± SD	3.1 ± 2.2
LAMS placement to first DEN, mean ± SD, d	5.4 ± 4.4
DEN duration, mean ± SD, min	49.9 ± 28.9
DEN interval, mean ± SD, d	6.9 ± 4.1
Endoscope n (%)1
EVIS EXERA III (GIF-HQ190)	66 (100)
EVIS EXERA II (GIF-2TH180)	11 (16.7)
Endoscpic device n (%)2
27 mm Captiflex Snare	62 (93.9)
Trapezoid RX Wireguided Retrieval Basket	9 (13.6)
Raptor Forceps	4 (6.1)
Roth Net Platinum Retriever	4 (6.1)
Extractor Pro Balloon	3 (4.5)
Single-Use Radial Jaw 4 Forceps	2 (3.0)
Talon Grasping Device	1 (1.5)

¹Combination used in some cases.

²Combination used in some cases.

Table 3 Adverse events

Subject	Complication	Severity grade1	Treatment
3	Stent misplaced inside the collection	Mild	New stent placed through the same tract. Both stents removed after 4 wk.
4	Sepsis and entanglement of grasping device with the stent	Mild, Moderate	IV antibiotics and emergent DEN. Stent removed, and 2 more stents placed.
5	Cavity wall rupture	Severe	Exploratory laparotomy and IV antibiotics.
11	Stent migration	Mild	No treatment. Stent could not be found.
15	Sepsis	Mild	IV antibiotics and emergent DEN.

¹According to the American Society for Gastrointestinal Endoscopy lexicon severity grading system.

Table 4 DEN protocol

Perform all procedures under general anesthesia to protect the patient’s airway. Do not administer routine antibiotic prophylaxis except in patients undergoing treatment of infected necrosis.

Access the cavity with the AXIOS™ Stent and Electrocautery Enhanced Delivery System either through a GF-UCT180 curvilinear array ultrasound gastrovideoscope, or the TGF-UC180J forward-viewing curvilinear array ultrasound gastrovideoscope. Trans-gastric access is preferred, but if no safe window is found, trans-duodenal access is acceptable.

Deploy and dilate the LAMS on the same session. Dilation should be made with the distal 2 cm of the 12-13.5-15 mm CRE balloon dilation catheters in a sequential manner holding each diameter for 1 min until the maximum of 15 mm is achieved.

Perform the first DEN ≥ 1 wk after initial drainage and repeat weekly until the cavity is free of necrosum. Infuse 60 cc of 3% H2O2 into the cavity at the end of each DEN. Extending each DEN for > 1 h is not recommended.

Perform DEN with the EVIS EXERA III GIF-HQ190 or the II GIF-2TH180 video gastroscopes. If the 2TH180 is used, caution needs to be exercised as passing this endoscope through the LAMS may increase the risk of dislodgement.

Perform debridement with metal snares such as the CaptiflexTM or the HistolockTM. Avoid using other devices, especially those with open prongs as these may get entangled with the LAMS and force stent removal.

Obtain cross-sectional imaging once the cavity is free of necrosum and preparations are being made for stent removal (unless any acute adverse events are suspected before that).

Once the cavity is clean, remove the LAMS with a rat tooth forceps.

LAMS: Lumen apposing metal stent; DEN: Direct endoscopic necrosectomy.