Thompson Christopher C, Kumar Nitin, Slattery James, Clancy Thomas E, Ryan Michele B, Ryou Marvin, Swanson Richard S, Banks Peter A, Conwell Darwin L
Division of Gastroenterology, Hepatology and Endoscopy, Brigham and Women's Hospital, 75 Francis St., ASB II, Boston, MA 02115, USA.
Department of Surgery, Brigham and Women's Hospital, 75 Francis St, Boston, MA 02115, USA.
Pancreatology. 2016 Jan-Feb;16(1):66-72. doi: 10.1016/j.pan.2015.12.001. Epub 2015 Dec 22.
Endoscopic necrosectomy is effective in the treatment of walled-off necrosis (WON), and is preferred to surgical approaches, however complication and mortality rates remain high with few centers regularly employing the technique. Lack of a standardized approach may also contribute to these limitations.
Prior to the study, a multidisciplinary team applied standardized care assessment and management plan principles to develop and optimize a systematic approach for the management of WON. Preoperative, postoperative, and endoscopic management were standardized. Patient preparation, room set-up, technical features (EUS-guidance, cold-access with balloon dilation, fragmentation of necrosis on the initial procedure, antibiotic lavage, double pigtail stents), and discontinuation of PPIs to encourage auto-digestion of necrosis were included. This study employed a consecutive prospective clinical registry to assess the clinical outcomes of this standardized approach.
60 consecutive patients underwent 1.58 ± 0.1 necrosectomies, with debridement accomplished on the initial procedure in 98.3%. 39 patients (65%) required only one session. Clinical resolution occurred in 86.7%, with radiologic confirmation. Percutaneous drainage was required in 8 patients during follow-up, and 4 of these later required surgery. Serious adverse events occurred in 3.3% of patients, and there was no mortality.
The standardized technique employed in this series was associated with lower rates of adverse events, morbidity, and mortality than prior large series. Use of a systematic approach, and integrating elements of this method may improve the risk profile of endoscopic necrosectomy and allow broader adoption.
内镜坏死组织清除术在治疗包裹性坏死（WON）方面有效，且优于外科手术方法，然而并发症和死亡率仍然很高，很少有中心经常采用该技术。缺乏标准化方法也可能导致这些局限性。
在研究之前，一个多学科团队应用标准化护理评估和管理计划原则，以制定和优化WON管理的系统方法。术前、术后和内镜管理均实现标准化。包括患者准备、房间设置、技术特点（超声内镜引导、球囊扩张冷通路、初次手术时坏死组织破碎、抗生素灌洗、双猪尾支架）以及停用质子泵抑制剂以促进坏死组织的自身消化。本研究采用连续前瞻性临床登记来评估这种标准化方法的临床结果。
60例连续患者接受了1.58±0.1次坏死组织清除术，98.3%的患者在初次手术时完成清创。39例患者（65%）仅需一次手术。86.7%的患者实现临床缓解，并经影像学证实。随访期间8例患者需要经皮引流，其中4例后来需要手术。3.3%的患者发生严重不良事件，无死亡病例。
本系列中采用的标准化技术与之前的大型系列研究相比，不良事件、发病率和死亡率较低。使用系统方法并整合该方法的要素可能会改善内镜坏死组织清除术的风险状况，并使其得到更广泛的应用。
