Third Department of Internal Medicine, University of Toyama, Toyama, Japan.
Dig Endosc. 2021 Mar;33(3):335-341. doi: 10.1111/den.13699. Epub 2020 Jun 7.
Walled-off pancreatic necrosis (WON) can develop in the late phase of necrotizing pancreatitis. When the WON is accompanied by an infection in the necrotic bed, it becomes a life-threatening complication. Open necrosectomy with drainage has been the standard treatment; however, it is associated with a significant morbidity and high mortality. Therefore, minimally invasive therapeutic alternatives are in demand. Recently, a new treatment algorithm for necrotizing pancreatitis, known as the step-up approach, has been proposed. The initial report on it consisted of percutaneous drainage followed by, if necessary, a minimally invasive retroperitoneal necrosectomy. However, the endoscopic step-up approach, which consists of EUS-guided transluminal drainage followed by, if necessary, endoscopic necrosectomy, was later introduced. Recent studies have suggested that an endoscopic step-up approach might be more advantageous than a minimally invasive surgical step-up approach. A lumen apposing metal stent (LAMS) with a cautery-enhanced delivery system is currently preferred over the conventional plastic stents for endoscopic interventions, because it decreases the technical difficulty of the procedure and may obviate the need for an adjunctive debridement procedure. However, some recent findings suggest that LAMS could be associated with a higher risk of stent-related complications than conventional plastic stents, especially in patients with long-term placement. Therefore, early removal of LAMS at 3 weeks post-intervention is proposed if the WON is resolved on CT examination. Thus, endoscopic interventions have emerged as a key player in the management of WON. However, multidisciplinary treatment approaches should be considered because the endoscopic approach has limitations in treating complicated WON.
胰腺包裹性坏死（WON）可在坏死性胰腺炎的晚期发展。当 WON 伴有坏死床感染时，它会成为危及生命的并发症。开放性坏死切除术加引流一直是标准治疗方法；然而，它与显著的发病率和高死亡率相关。因此，需要微创治疗的替代方法。最近，提出了一种新的坏死性胰腺炎治疗算法，称为逐步升级方法。最初的报告包括经皮引流，如果需要，然后进行微创腹膜后坏死切除术。然而，后来引入了内镜逐步升级方法，包括 EUS 引导的经腔引流，如果需要，然后进行内镜坏死切除术。最近的研究表明，内镜逐步升级方法可能比微创外科逐步升级方法更有优势。与传统的塑料支架相比，带有电凝增强输送系统的 lumen apposing 金属支架（LAMS）目前更常用于内镜介入，因为它降低了手术的技术难度，并可能避免需要辅助清创术。然而，一些最近的发现表明，与传统的塑料支架相比，LAMS 可能与更高的支架相关并发症风险相关，尤其是在长期放置的患者中。因此，如果 CT 检查显示 WON 已解决，则建议在介入后 3 周内早期取出 LAMS。因此，内镜介入已成为 WON 管理的关键手段。然而，应考虑多学科治疗方法，因为内镜方法在治疗复杂的 WON 方面存在局限性。
