Guidance
3 The procedure
3 The procedure
3.1 Endoscopic transluminal pancreatic necrosectomy is done with the patient under sedation or general anaesthesia, using upper gastrointestinal endoscopy and endosonographic or fluoroscopic guidance or both. The stomach is distended with carbon dioxide. The area where the necrotic tissue has collected is usually identified as a bulge in the stomach wall. An opening is made in the posterior wall of the stomach. The opening is dilated with a balloon over a guide wire to allow the endoscope to pass through into the area of necrotic tissue. Any fluid that has collected is drained. Necrotic tissue is removed through the endoscope using suction, forceps and irrigation. One or more self-expanding stents or irrigation catheters may be left in place in the stomach wall to help further drainage from the retroperitoneal space into the stomach. Repeated sessions may be needed over many days until the cavity is clean and lined with granulation tissue. The procedure aims to avoid the need for open or laparoscopic necrosectomy and its associated morbidity.