Step-up strategy for the treatment of infected pseudocysts and infected walled-off necrosis: a prospective observational study

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Abstract

Background. Infected pseudocysts and infected walled-off necrosis (WON) are severe complications of acute pancreatitis associated with high mortality rates (up to 35%) following open surgery. The use of lumen-apposing metal stents (LAMS) enables minimally invasive endoscopic drainage; however, data on the dynamics of laboratory inflammatory markers and cavity regression during staged endoscopic debridement remain insufficient.

Aims — to evaluate the efficacy and safety of transmural drainage using LAMS followed by staged endoscopic debridement and necrosectomy in patients with infected pseudocysts and infected walled-off necrosis.

Methods. A prospective observational single-center study was conducted from January 2019 to March 2025. A total of 43 patients with infected pseudocysts or infected walled-off necrosis were enrolled. All patients underwent endoscopic ultrasound-guided transmural drainage with a 10-mm LAMS, followed by staged debridement for infected pseudocysts and staged necrosectomy for infected walled-off necrosis. The primary outcomes were the dynamics of C-reactive protein (CRP) levels and cavity volume. Statistical analysis was performed using the Wilcoxon signed-rank test.

Results. Median CRP decreased from 132.7 (53.1; 190.2) mg/L at admission to 43.6 (14.8; 76.1) at discharge (p < 0.001). Cavity volume decreased from 344.8 (88.9; 830.2) to 11.2 (5.3; 16.4) cm³ (p < 0.001), representing a regression of 94.2%. A total of 30 adverse events were recorded, with hyperthermia being the most common (20 cases, 66.7% of all complications). Life-threatening complications (cyst perforation, erosive bleeding) required laparotomy in 5 patients (11.6%). Mortality was 2.3%. In patients with ineffective endoscopic treatment, the initial cavity volume exceeded 1000 mL and sequestrum size exceeded 5 cm.

Conclusions. Endoscopic transmural drainage with LAMS and staged debridement effectively controls inflammation and achieves almost complete cavity regression in patients with infected pseudocysts and infected walled-off necrosis. In cases with cavity volume > 1000 mL and large sequestra (> 5 cm), combined drainage techniques (percutaneous drainage, video-assisted retroperitoneal debridement) should be considered.

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About the authors

Igor G. Noskov

Professor V.F. Voino-Yasenetsky Krasnoyarsk State Medical University; Krasnoyarsk Regional Clinical Hospital

Email: igornoskov@mail.ru
ORCID iD: 0000-0002-1221-030X
SPIN-code: 5808-9047

PhD, Assistant Professor

Russian Federation, Krasnoyarsk; Krasnoyarsk

Dmitrij V. Cherdantsev

Professor V.F. Voino-Yasenetsky Krasnoyarsk State Medical University; Krasnoyarsk Regional Clinical Hospital

Email: gs7@mail.ru
ORCID iD: 0000-0002-4743-4565
SPIN-code: 6760-3354

MD, PhD, Professor

Russian Federation, Krasnoyarsk; Krasnoyarsk

Evgenij G. Takhtobin

Professor V.F. Voino-Yasenetsky Krasnoyarsk State Medical University; Krasnoyarsk Regional Clinical Hospital

Email: teg294@mail.ru
ORCID iD: 0009-0006-4507-1525
SPIN-code: 3602-4191
Russian Federation, Krasnoyarsk; Krasnoyarsk

Vyacheslav Y. Dyatlov

Krasnoyarsk Regional Clinical Hospital

Email: gnsurdger@gmail.com
Russian Federation, Krasnoyarsk

Pavel S. Zhegalov

Krasnoyarsk Regional Clinical Hospital

Email: poul24@mail.ru
Russian Federation, Krasnoyarsk

Dmitrij V. Shindyakin

Professor V.F. Voino-Yasenetsky Krasnoyarsk State Medical University

Email: shindyakin.d@gmail.com
ORCID iD: 0009-0007-4322-3385
Russian Federation, Krasnoyarsk

Anastasiya V. Mayorova

Professor V.F. Voino-Yasenetsky Krasnoyarsk State Medical University

Email: maiorova_nastasia00@mail.ru
ORCID iD: 0009-0008-8962-0041
Russian Federation, Krasnoyarsk

Kseniya S. Chernyavskaya

Professor V.F. Voino-Yasenetsky Krasnoyarsk State Medical University

Author for correspondence.
Email: ksushagrant@icloud.com
ORCID iD: 0009-0004-4199-7609
Russian Federation, Krasnoyarsk

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2. Fig. 1. Stages of endoscopic drainage and cavity debridement: A — pre-intervention multislice computed tomography (a large infected pseudocyst is identified); B — CT scan after placement of a LAMS-type stent (the stent is visualized, fixed between the cyst cavity and the gastric lumen); C — endoscopic view during the first debridement (purulent exudate with fibrin and necrotic debris is observed within the cyst cavity); D — endoscopic view after the third staged debridement (the cyst cavity is clean; sparse fibrin deposits and the appearance of granulation tissue are observed).

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3. Fig. 2. Dynamics of C-reactive protein levels in patients with infected pseudocysts and infected walled-off pancreatic necrosis following staged endoscopic debridement and necrosectomy.

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4. Fig. 3. Dynamics of cavity volume reduction in infected pseudocysts and infected walled-off pancreatic necrosis following staged endoscopic debridement and necrosectomy.

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5. Fig. 4. Distribution of adverse events in patients in the study group, abs. (%)

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