Endoscopic ultrasound-guided drainage is suggested as the first approach in the management of symptomatic and complex walled-off pancreatic necrosis. Dual approach with percutaneous drainage could be the best choice when the necrosis is deep extended till the pelvic paracolic gutter; however, the available catheter could not be large enough to drain solid necrosis neither to perform necrosectomy, entailing a higher need for surgery. Therefore, percutaneous endoscopic necrosectomy through a large bore percutaneous self-expandable metal stent has been proposed. In this study, we present the case of a 61-year-old man admitted to our hospital with a history of sepsis and persistent multiorgan failure secondary to walled-off pancreatic necrosis due to acute necrotizing pancreatitis. Firstly, the patient underwent transgastric endoscopic ultrasound-guided drainage using a lumen-apposing metal stent and three sessions of direct endoscopic necrosectomy. Because of recurrence of multiorgan failure and the presence of the necrosis deeper to the pelvic paracolic gutter at computed tomography scan, we decided to perform percutaneous endoscopic necrosectomy using an esophageal self-expandable metal stent. After four sessions of necrosectomy, the collection was resolved without complications. Therefore, we perform a revision of the literature, in order to provide the state-of-art on this technique. The available data are, to date, derived by case reports and case series, which showed high rates both of technical and clinical success. However, a not negligible rate of adverse events has been reported, mainly represented by fistulas and abdominal pain. Dual approach, using lumen apposing metal stent and percutaneous self-expandable metal stent, is a compelling option of treatment for patients affected by symptomatic, complex walled-off pancreatic necrosis, allowing to directly remove large amounts of necrosis avoiding surgery. Percutaneous endoscopic necrosectomy seems a promising technique that could be part of the step-up-approach, before emergency surgery. However, to date, it should be reserved in referral centers, where a multidisciplinary team is disposable.

中文翻译：

---

EUS引导下管腔对置金属支架引流和经皮内镜下坏死切除术双重治疗复杂壁坏死：病例报告及文献复习

内镜超声引导引流被建议作为治疗有症状和复杂的胰壁坏死的首选方法。当坏死深至盆腔旁沟时，经皮引流双重入路是最佳选择；然而，可用的导管不能大到足以引流实体坏死，也不能进行坏死切除术，因此需要更高的手术量。因此，提出了通过大口径经皮自膨式金属支架进行经皮内窥镜坏死切除术。在这项研究中，我们介绍了一名 61 岁男性入院，他有败血症和持续性多器官衰竭病史，继发于急性坏死性胰腺炎导致的胰壁坏死。首先，该患者接受了使用腔对置金属支架的经胃内镜超声引导引流术和三个疗程的直接内镜下坏死切除术。由于多器官功能衰竭的复发和在计算机断层扫描中存在更深的骨盆旁结肠沟坏死，我们决定使用食管自膨式金属支架进行经皮内镜下坏死切除术。经过四次坏死切除术，收集物得到解决，没有出现并发症。因此，我们对文献进行了修订，以提供该技术的最新技术。迄今为止，可用数据来自病例报告和病例系列，显示技术和临床成功率都很高。然而，已经报告了不可忽视的不良事件发生率，主要表现为瘘管和腹痛。使用腔对置金属支架和经皮自膨式金属支架的双重方法是治疗有症状的复杂胰腺坏死患者的一种引人注目的选择，可以直接去除大量坏死，避免手术。经皮内窥镜坏死切除术似乎是一种很有前途的技术，可以在急诊手术之前作为升级方法的一部分。然而，迄今为止，它应该保留在转诊中心，那里有一个多学科团队是一次性的。经皮内窥镜坏死切除术似乎是一种很有前途的技术，可以作为急诊手术前的升级方法的一部分。然而，迄今为止，它应该保留在转诊中心，在那里多学科团队是一次性的。经皮内窥镜坏死切除术似乎是一种很有前途的技术，可以作为急诊手术前的升级方法的一部分。然而，迄今为止，它应该保留在转诊中心，在那里多学科团队是一次性的。