Optimal Therapeutic Options for Complex Walled-Off Necrosis: Endoscopic and Percutaneous Drainage

Up to 15% of acute pancreatitis can develop to acute necrotizing pancreatitis characterized by necrosis of the pancreas parenchyma and/or the peripancreatic tissue. It is associated with high rates of morbidity and mortality compared to interstitial edematous pancreatitis. A collection of fluid and necrotic tissue is called acute necrotic collections (ANC) and may form an enhancing wall consisting of reactive tissue after 4 weeks, which is called walled-off necrosis (WON). ANC and WON could be either sterile or infected. WON is often complex and septated, and when it gets infected or causes other serious complications, drainage or resection is indicated. The traditional approach is to surgically remove all the infected necrotic tissue, but this invasive approach carries high rates of complications and death. The recent advance of percutaneous and/or endoscopic approaches has enabled a stepup method for the management of necrotizing pancreatitis. Herein, the authors focused on the endoscopic and percutaneous approaches for the care of patients with necrotizing pancreatitis.