Endotherapy for organized pancreatic necrosis.

G&H What is organized pancreatic necrosis, and how does it differ from a pseudocyst? RK There are over 200,000 hospitalizations for pancre-atitis in the United States yearly, and 20–25% of these cases involve severe acute pancreatitis. Most severe acute pancreatitis cases are associated with the loss of perfusion, or death, of part of the pancreas, a marker of and a prerequisite for pancreatic BLOCKINnecrosis. This BLOCKINcondition is usually diagnosed 1–2 weeks after a patient presents to the hospital in BLOCKINthis BLOCKINsetting. BLOCKINComputed tomography (CT) shows the failure to perfuse part of the pancreas. Pathologically, there may be significant dead tissue with or without a concomitant fluid collection. Organized BLOCKINpancreatic BLOCKINnecrosis, BLOCKINwhich BLOCKINis BLOCKINalso BLOCKINknown as walled-off pancreatic necrosis, usually occurs after 4–6 weeks of severe pancreatitis, in which the body forms a rim or shell around a collection of necrotic tissue containing a variable amount of enzyme-rich fluid. This condition differs from a pseudocyst, which has a fibrous capsule or wall and primarily fluid internal contents. The internal contents of organized pancreatic necrosis have a liquid component but also contain a lot of dead tissue; thus, the 2 conditions cannot be treated the same way. Pseudocysts can be poked percutaneously, transgas-trically, or transduodenally in order to insert a tube that will allow collapse and disappearance of the pseudocyst. With organized pancreatic necrosis, the fluid component can be drained, but the solid component has the potential for infection if it does not drain. G&H How can endotherapy be used to manage organized pancreatic necrosis? RK Endotherapy is just one tool in our armamentarium. Other tools are used before drainage of the necrosis; just because there is necrosis does not mean that it has to be drained. However, it may be relatively asymptomatic and resolve spontaneously. If a patient is quite ill, several endoscopic interventions are available. If the pancreatitis is caused by common bile duct stones, an endoscopic ret-rograde cholangiopancreatography (ERCP) could be performed to remove choledocholithiasis. If the endoscopic necrosis is associated with a partial ductal disruption, a transpapillary pancreatic duct stent could be endoscopi-cally placed in order to reduce the ongoing pancreatic duct leak feeding the necrotic area and limiting pancreatic enzyme egress outside the pancreas and progressive necro-sis of pancreatic and intrapancreatic tissues. If the necrosis itself has to be approached, most endoscopists and surgeons now support waiting as long as possible to drain the necrotic tissue. Thus, …