Walled-off necrosis (WON) is a collection of necrotic (dead) pancreatic and peripancreatic tissue that develops weeks after severe acute pancreatitis. It is encapsulated by a wall and can cause infection, pain, or failure to improve. Traditionally, treatment required open or laparoscopic surgery. Endoscopic drainage and direct endoscopic necrosectomy now offer a minimally invasive alternative for many patients.
Dr. Kalpit Devani, an interventional gastroenterologist in Greenville, South Carolina, specializes in diagnostic and therapeutic EUS, including the management of walled-off necrosis. This guide explains the endoscopic approach and when it is appropriate.
What Is Walled-Off Necrosis?
Walled-off necrosis forms when pancreatic tissue dies during severe acute pancreatitis. Over 4-6 weeks, a wall develops around the collection. The cavity may contain fluid and solid debris. If it becomes infected or causes persistent symptoms, treatment is needed. WON is distinct from pancreatic pseudocyst, which contains only fluid and has a different wall structure.
When Does It Need Treatment?
Not all walled-off necrosis requires intervention. Treatment is considered when there is infection, persistent pain, gastric outlet obstruction, or failure to improve over time. Size alone does not always dictate treatment; symptoms and clinical course matter. A multidisciplinary team, including an interventional gastroenterologist, helps decide the best approach.
Endoscopic Approach: EUS-Guided LAMS Placement
EUS-guided drainage allows access to the necrotic collection through the stomach or duodenum. A lumen-apposing metal stent (LAMS) is placed under EUS guidance, creating a channel from the GI lumen into the cavity. This allows fluid to drain and provides a passage for debridement. The procedure is performed under sedation and avoids external drains or open incisions.
Direct Endoscopic Necrosectomy: Debridement Through the Stent
After LAMS placement, an endoscope can be passed through the stent into the necrotic cavity. Solid debris is removed with forceps, snares, or irrigation (direct endoscopic necrosectomy). This may require multiple sessions. The goal is to clear the cavity and allow it to collapse and heal. Many patients avoid surgery entirely.
Comparison to Surgical and Percutaneous Approaches
Surgical debridement (open or laparoscopic) has been the traditional option. It is more invasive and carries higher morbidity. Percutaneous drainage (tube through the skin) can drain fluid but does not remove solid debris effectively. Endoscopic necrosectomy combines drainage with debridement through a natural orifice (no external tube, no abdominal incision). Outcomes in experienced hands are comparable to surgery with faster recovery.
Recovery Timeline
Recovery depends on the extent of disease and number of sessions. Many patients are hospitalized briefly and can go home within days. Follow-up endoscopy may be needed to remove the LAMS or perform additional debridement. Long-term follow-up monitors for recurrence or complications.
Why This Should Be Done at a High-Volume Center
Endoscopic necrosectomy is technically demanding and carries risks (bleeding, perforation, infection). Outcomes improve when performed by interventional endoscopists with significant experience. Dr. Devani offers comprehensive EUS and coordinates with complex ERCP and surgical colleagues when needed.
If you or a loved one have walled-off necrosis and are considering endoscopic treatment, or for referrals and consultations, Dr. Devani welcomes inquiries from patients and referring physicians in Greenville, South Carolina and beyond.
Frequently Asked Questions
What is walled-off necrosis?
Walled-off necrosis is a collection of dead pancreatic tissue that forms weeks after severe acute pancreatitis. It can become infected or cause symptoms and may require drainage and debridement.
Can walled-off necrosis be treated without surgery?
Yes. Endoscopic drainage with LAMS placement and direct endoscopic necrosectomy can clear the cavity in many patients, avoiding open or laparoscopic surgery.
How long does endoscopic necrosectomy take?
Treatment may require multiple sessions over weeks. Each procedure typically lasts 1-2 hours. The number of sessions depends on the size and content of the cavity.
Where is endoscopic necrosectomy performed?
High-volume interventional endoscopy centers, such as those where Dr. Kalpit Devani practices in Greenville, South Carolina. Experience matters for safety and outcomes.
Dr. Kalpit Devani, MD, FACP, FACG, FASGE is a board-certified interventional gastroenterologist based in Greenville, South Carolina, specializing in diagnostic and therapeutic EUS, complex ERCP, and endoscopic suturing.
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Read more →This article is for educational purposes only and does not constitute medical advice. Please consult your physician for individualized care.