In this article, an attempt was made to clarify the role of percutaneous endoscopic necrosectomy (PEN) in the interventional treatment of pancreatic necrosis. A comprehensive review of the current literature was performed to identify publications on the role of PEN in patients with consequences of acute necrotizng pancreatitis. The aim of the study was to review the literature on minimal invasive necrosectomy, with emphasis on PEN using esophageal self-expanding metal stents (SEMS). The described results come from 15 studies after a review of the current literature. The study group comprised 52 patients (36 men and 16 women; mean age, 50.87 (13–75) years) with walled-off pancreatic necrosis, in whom PEN using a self-expandable esophageal stent had been performed. PEN was successfully completed in all 52 patients (100%). PEN complications were observed in 18/52 (34.62%) patients. Clinical success was achieved in 42/52 (80.77%) patients, with follow-up continuing for an average of 136 (14–557) days. In conclusion, the PEN technique is potentially effective, with an acceptable rate of complications and may be implemented with good clinical results in patients with pancreatic necrosis.

Thoracic complications, such as biliopleural fistula and bile leaking into the right pleural cavity, are serious adverse events of transmural endoscopic ultrasound- (EUS-) guided biliary drainage involving EUS-guided hepaticoesophagostomy (EUS-HES). In this article, the authors present endoscopic treatment of biliopleural fistula as a serious thoracic complication of EUS-HES. The authors highlight key components of EUS-guided transmural biliary drainage and their experience with particular emphasis on endoscopic treatment of thoracic complications.

Background: Transpapillary biliary drainage in endoscopic retrograde cholangiopancreatography (ERCP) is an established method for treatment of patients with benign and malignant biliary obstruction. However, attempts to gain access to the biliary tract through the major duodenal papilla during ERCP have been unsuccessful in some patients. This study aims to determine the role of endoscopic ultrasonography (EUS)-guided transmural approach in biliary endotherapy in case of failed ERCP. Materials and Methods: A prospective analysis of the treatment outcomes of all 896 patients with obstructive jaundice secondary to biliary obstruction, who underwent endoscopic treatment in the years 2016-2021 at our institution. Results: Effective drainage of bile ducts through the major duodenal papilla during ERCP was achieved in 772/896 (86.16%) patients with biliary obstruction. In 124/896 (13.84%) patients [92 males, 32 females; mean age 63.52 (46 to 89) y] ERCP failed and EUS-guided transmural approach was performed. Benign biliary obstruction was identified in 17/124 (13.71%) patients; the remaining 107/124 (86.29%) were diagnosed with malignant biliary obstruction. EUS-guided endoscopic transpapillary biliary tract stenting with transmural access was performed in 21/124 (16.94%) patients; the remaining 103/124 (83.06%) required extra-anatomic transmural anastomosis of the bile ducts to the gastrointestinal tract. Technical success was achieved in 121/124 (97.58%) patients, while clinical success was achieved in 112/124 (90.32%). Complications were reported in 15/124 (12.1%) patients; with early complications in 12 and late complications in 3. Conclusions: Various methods of EUS-guided transmural access to bile ducts improves endotherapy outcomes of patients with biliary obstruction. Endoscopic transmural access is highly effective and associated with an acceptable number of complications.

Background: Minimally invasive approaches for managing complications of acute necrotizing pancreatitis have advanced significantly in recent decades. When extensive walled-off pancreatic or peripancreatic necrosis is present, a single transluminal access may be insufficient. This study aimed to prospectively evaluate the effectiveness and safety of a novel percutaneous endoscopic necrosectomy technique used as an adjunct to transmural drainage in patients with symptomatic walled-off necrosis. Methods: A total of 513 consecutive patients with symptomatic walled-off pancreatic or peripancreatic necrosis treated between 2018 and 2025 at a single tertiary center in Poland were included. All patients underwent minimally invasive endoscopic management. Among them, a subgroup required additional percutaneous drainage. The innovative technique involved creating retroperitoneal percutaneous access to the necrotic cavity, enlarging the tract, and placing a self-expanding metal stent to allow passage of the endoscope for percutaneous endoscopic necrosectomy. Results: Additional percutaneous drainage was necessary in 39/513 patients (7.6%). Of these, 9/39 (23.1%) patients (2 women, 7 men; mean age 46.7 years) underwent percuaneous endoscopic necrosectomy. The mean size of the necrotic collection was 25.96 cm. Active percutaneous drainage during ongoing transmural endotherapy lasted a median of 15 days. Patients underwent an average of 3.12 necrosectomy sessions. Treatment-related complications occurred in 2/9 patients (22.22%). Clinical and long-term success were each achieved in 8/9 patients (88.89%). Conclusions: Percutaneous endoscopic necrosectomy is a promising minimally invasive therapeutic option for extensive walled-off pancreatic and peripancreatic necrosis, particularly when necrosis extends into the pelvic region. However, clinical evidence remains limited and further studies are needed.

Introduction: Endotherapy is an established minimally invasive treatment for pancreatic necrosis. Aim: This study aims to evaluate the efficacy and safety of direct endoscopic necrosectomy (DEN) performed during transmural drainage in patients with symptomatic walled-off pancreatic necrosis (WOPN). Materials and Methods: A retrospective analysis was conducted of 512 patients with symptomatic WOPN treated endoscopically between 2018 and 2025 at the Department of General, Gastroenterological and Oncological Surgery, Collegium Medicum, Nicolaus Copernicus University in Toruń. In patients qualified for endoscopic necrosectomy, an endoscope was introduced into the necrotic cavity through a previously created transmural (transgastric or transduodenal) fistula, and necrotic tissue was removed using various endoscopic tools. Results: All 512 patients underwent transmural endoscopic drainage. Of these, 226/512 (44.14%) patients (61 women, 165 men; mean age 51.8 [20–78] years) were qualified for endoscopic necrosectomy. The mean size of the necrotic collection was 22.9 (10.6–36.6) cm. A transgastric approach was used in 219/226 (96.9%) patients, and a transduodenal approach in 7/226 (3.1%). Active drainage was maintained for a mean of 16 (7–82) days. The mean number of endoscopic procedures was 4.84 (1–24). Complications occurred in 24/226 (10.61%) patients. Mortality was 5.75% (13/226). Clinical success was achieved in 203/226 (89.82%) patients and long-term success in 197/226 (87.17%). Conclusions: Direct endoscopic necrosectomy performed during transmural drainage achieved high clinical and long-term success with acceptable morbidity in patients with symptomatic WOPN.