• infected pancreatic necrosis
• necrosi pancreatica infetta
• acute pancreatitis
• pancreatite acuta
• walled-off pancreatic necrosis
• necrosectomia endoscopica percutanea
• percutaneous endoscopic necrosectomy
• drenaggio endoscopico transluminale
• step-up approach
• endoscopic transluminal necrosectomy
• necrosectomia endoscopica transluminale
• endoscopic transluminal drainage

Infected pancreatic necrosis (IPN) is a major complication of acute pancreatitis with associated mortality of up to 20%–30% if infection develops in the necrotic collection. The current paradigm for intervention in IPN involves a staged multi-disciplinary algorithmic step-up approach with endoscopic transluminal drainage (ETD) or percutaneous drainage (PCD) as the initial step based on the location of the necrotic collection and the availability of localized expertise. We report a case series of step up percutaneous endoscopic necrosectomy for treatment of large size infected pancreatic necrosis.
Consecutive patients with large size IPN, where necrosis was extended from stomach into on paracolic gutters or the pelvis, hospitalized to Baggiovara Hospital (MO) were studied prospectively. The treatment protocol for IPN was first step PCD followed by fully covered metal stent (FC-SEMS) placement in the track of the percutaneous catheter under fluoroscopic guidance to dilate the track. Percutaneous endoscopic necrosectomy (PEN) was performed 2-4 days later using a flexible endoscope through the
percutaneous tract under conscious sedation. About 2-4 weeks late EUS-guided ETD with LAMS was performed under general anesthesia when a matured sac was visible. Control of sepsis with resolution of collection(s) was the primary outcome measure. A total of 14 patients (median age 56) with large size IPN (median maximum diameter 18 cm) were included. SEMSs in PEN were 8 cm (8 cases) or 12 cm in lenght (6 cases) and LAMS in ETD were Hot Axios (8 cases), Hot Spaxus (3 cases) and Nagi Stent (3 cases). PEN was performed by 1-3 session debridement of the cavity which subsequently resulted in significant clinical improvement. No persistent fistula in the percutaneous sinus tract were observed. In 1 case surgical necrosectomy needed. EUS-guided transluminal necresectomy was performed in 1-4 sessions and the lumen-apposing stent was successfully removed 2-4 weeks after placement. During ETD in 1 case we observed overinflation and in 2 cases we had hemorrhage, endoscopically treated. The mean time for the resolution was 4±2 weeks.
Step up percutaneous and transluminal endoscopic necrosectomy therapy is an effective strategy for large size IPN with combined central and peripheral necrosis. It requires not only a specialist in interventional endoscopy but also a multidisciplinary approach that involves skillful interventional radiologists and pancreatic surgeons as backup to prepare for potential fatal adverse events.