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Background The interventional management of necrotizing pancreatitis has evolved from early open surgery to delayed endoscopic or percutaneous intervention. However, few studies have directly compared the three treatment modalities. We aim to compare the outcomes of patients who had endoscopic, percutaneous or surgical interventions for necrotizing pancreatitis at our institution. Methods This is a retrospective cohort study of patients who had interventions for necrotizing pancreatitis at our institution from 2005 to 2014. Primary outcome was length of stay ( LOS); secondary outcomes were complication rate and number of procedures required for resolution of necrosis. Results Thirty patients were included. Mortality rate was 13% (four patients). Median LOS and time to intervention was 88 and 28 days, respectively. There were no significant differences in the computed tomography severity indices and 48-h C-reactive protein levels among the three groups. Initial endoscopic intervention was associated with a median LOS of 62 days compared with 101 days in the percutaneous group and 91 days in the surgical group ( P = 0.04). There were higher rates of pancreatic fistulae (40%) ( P = 0.012) and new onset diabetes (30%) ( P = 0.046) in the surgical group. Median number of procedures was similar among the three groups. Median LOS for patients with delayed intervention (fourth to sixth week of pancreatitis) was 66 days, compared with 137 days in patients with early intervention (first to third week) and 104 days in patients with late intervention (seventh week onwards) ( P ≤ 0.001). Conclusion A delayed, endoscopy first approach appears to be a reasonable strategy as it is associated with decreased LOS and low complication rate. [ABSTRACT FROM AUTHOR]

The article present a case study of an 83-year-old man with cholangitis having had a simple cholecystectomy many years previously. It mentions an endoscopic retrograde changiopancreatography (ERCP) was attempted but biliary cannulation failed due to difficulty accessing the ampulla in a large diverticulum; and also mentions a wire was inserted into the biliary tree and the tract was enlarged with a needle knife to allow decompression of the biliary tree with a fully covered metal stent.

Background and Objectives: At the time of endoscopic retrograde cholangiopancreatography, deep cannulation of the bile duct is a prerequisite to be able to provide endoscopic therapy. We describe a simple technique to assist in difficult bile duct cannulation., Methods: If the pancreatic duct is easily entered but the bile duct cannot be accessed, a guidewire is advanced into the pancreatic duct, and the cannulating catheter is removed leaving the tip of the wire in the mid pancreatic duct. Alongside the pancreatic wire, a catheter, preloaded with a second wire, is advanced via the channel of the endoscope. With the first wire in the pancreatic duct, the second wire is advanced above it in the anticipated bile duct axis., Results: We have used this technique in 12 cases and succeeded in 10. No complications occurred., Discussion: Inserting a pancreatic wire can assist in bile duct cannulation, by straightening and stabilizing the papilla. The use of this new technique can reduce the need for precut sphincterotomy, with its inherent increased risks of pancreatitis, bleeding, and perforation. The approach proposed by us can assist in any difficult bile duct cannulation, but it can be particularly useful when dealing with a papilla that is very prominent with a tortuous intraduodenal segment or a papilla located in a duodenal diverticulum.