Hybrid percutaneous-endoscopic necrosectomy for large walled-off pancreatic necrosis: an observational feasibility study.

Abstract

Background and aim: Although direct endoscopic necrosectomy (DEN) by transgastric approach is accurate and enough in most patients presenting with infected walled-off necrosis (WON), some of them with very large and/or distal collections may need further therapies such as percutaneous endoscopic necrosectomy. Percutaneous hybrid necrosectomy (PHN) represents a new approach in these cases, combining the use of surgical clamps through the percutaneous fistula and a transgastric or percutaneous endoscopic guidance. The aim was to analyze the impact of this innovative multidisciplinary technique on selected patients with WON.

Methods: This is an observational single-center study. All consecutive patients presenting with large WON who underwent PHN in 2019-2023 were included. A classification in early (<3 previous DEN) or late PHN (≥3) was defined. The primary outcome was the clinical success, defined as symptom relief with WON complete resolution. The secondary aims were the time to WON resolution and the adverse event (AE) rate.

Results: Of 51 patients presenting with WON, 15 (mean age: 59±12.7, 80% male) underwent DEN combined with PHN and were included. The median number DEN sessions were two. Overall, most patients required only one single PHN procedure (n=9, 60%) during an interval time of 8 days (range: 2-14). Clinical success was obtained in 14 cases (93.3%). The time to WON resolution was lower in patients with an early PHN strategy (13 vs. 30 days, p=0.024). The overall per-procedure AE rate was 10.5% during a median follow-up of 6.5 months (range: 3-49), with no procedure-related mortality.

Conclusions: PHN under transgastric or percutaneous guidance represents a new minimally invasive and collaborative approach for selected patients with large WON. A low number of procedures is needed to achieve clinical success in a shorter time.