1, 2, 4, 5, 6, 7, 8 and 9 Some authors initially argued that endoscopic ultrasound (EUS) should be used to assist draining procedures, but recent series do not report different outcomes in terms of efficiency or adverse events without the use of EUS given that a clearly visible gastric or duodenal bulge exists.1, 2 and 6 We did not use EUS in our patients because an evident luminal compression was seen in both. It is prudent to postpone endoscopic drainage and debridement for some weeks after onset of pancreatitis because this enhances a better demarcation of necrotic tissue from the viable pancreas, thus avoiding unnecessary risks.5 and 8 This was our attitude in both cases and it is unanimously supported from

published experiences.4, 6 and 7 We had no significant complications but multiple sessions were needed to definitively achieve complete evacuation of necrotic material. In the first case, there was not much solid material and therefore mTOR inhibitor our strategy was to maintain stents

and a nasobiliary catheter with intense saline lavage rather than doing necrosectomy. Conversely, the second patient had significant amount of thick solid material thus demanding aggressive debridement. Limitations of endoscopic necrosectomy are the need for multiple sessions, endoscopic complications (e.g. perforation, bleeding, air embolism) STA-9090 ic50 and the lack of efficacy in large collections extending far away from the transluminal access point into the pelvis.1, 4, 5, 6 and 8 Furthermore the experience of the endoscopist is of paramount

importance. Moreover, the lack of available specific endoscopic devices to retrieve necrotized material from a cavity is a relative restraint. Endoscopists have been improvising with ERCP and EUS equipment to overtake this problem.1 Manufacturers are expected to design novel tools which may possibly reduce the number of endoscopic sessions Dimethyl sulfoxide per patient whilst making the procedure simpler. An eventually useful tool might be a removable metallic stent placed in the gastro/enterocystostomy to allow easier drainage.1 Advantages of endoscopic intervention are considered to be its less invasiveness, fewer days of hospitalizations, faster recovery, less organ failure and secondary infections and better aesthetic outcomes.1, 4, 6 and 8 All these arguments are still certainly a matter of debate however, taking into account the lack of prospective randomized trials. Considering our experience, we believe that a turning point in the management of peripancreatic infected and/or symptomatic necrotic collections has arrived. Endoscopic transluminal necrosectomy will probably expand as an alternative method to classic surgery. Nevertheless, this presumption is expected to occur in large tertiary hospitals since only these health-structures can more easily gather a multidisciplinary task force and high number of patients to bear large experience.