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Endoscopic Necrosectomy — RACP Adult Medicine MCQ

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HardGastroenterologyEndoscopic NecrosectomyRACP Adult Medicine

A 60-year-old man with severe acute pancreatitis develops walled-off pancreatic necrosis at week 5. He has persistent low-grade fever and rising WCC. CT shows a 12 cm walled-off collection with internal debris abutting the stomach. FNA grows Klebsiella. He is on appropriate antibiotics. What is the most appropriate interventional approach?

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Correct answer: C — Endoscopic (transgastric) necrosectomy

Walled-off necrosis (>4 weeks) abutting the stomach is amenable to endoscopic transgastric necrosectomy (EUS-guided). The TENSION trial showed endoscopic step-up is non-inferior to surgical step-up with lower rates of pancreatic fistula and shorter hospital stay. Lumen-apposing metal stents (LAMS) facilitate access for direct endoscopic necrosectomy.

Reference: GESA – 2024 – Pancreatic Necrosis; TENSION Trial; ESGE 2024