Percutaneous endoscopic necrosectomy for infected necrotizing pancreatitis with retroperitoneal extension: a retrospective single-center cohort

Background Infected necrotizing pancreatitis (INP) is managed using a step-up approach combining antibiotics, interventional drainage and minimally invasive necrosectomy. Although transluminal endoscopic necrosectomy is well established, extensive retroperitoneal necrosis may remain difficult to access. We evaluated the feasibility of percutaneous endoscopic necrosectomies (PEN) via percutaneous drainage tracts as an escalation step within the step-up strategy. Methods We retrospectively analyzed consecutive patients with severe INP treated at a tertiary referral center in whom transluminal necrosectomy was technically infeasible or insufficient. Previously placed radiologically guided drains provided retroperitoneal access to necrotic collections. After tract dilation, a flexible endoscope enabled direct endoscopic debridement. Timing and sequence of interventions, number of procedures and clinical outcomes were assessed. Results Twelve patients (mean age 47.3 years, range 18–87) were treated with a total of 74 PEN. Etiology was alcohol-related in 7, hypertriglyceridemia-related in 4, biliary in 2 and drug-induced in 2 patients (not mutually exclusive). In accordance with the step-up strategy, percutaneous drainage and transluminal necrosectomy via lumen-apposing metal stent were initiated earlier, at a mean of 24.9 and 35.4 days after diagnosis, respectively. PEN via percutaneous drainage tracts was introduced later for persistent retroperitoneal necrosis, at a mean of 70.2 days from diagnosis (range 24–133). A mean of 6.2 PEN were required per patient. Technical success rate was 100.0% and clinical success rate was 75.0%, with a 90-day mortality of 16.7%. One patient required rescue surgical necrosectomy. Mean hospital stay was 127.9 days (range 79–218). Conclusion PEN was feasible as an anatomy-directed escalation modality within multidisciplinary step-up management and may complement transluminal treatment in patients with persistent peripheral retroperitoneal necrosis.