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Sinus tract endoscopy is a special variant of percutaneous treatment and forms part of the “step‐up” approach. This technique was first described by Carter et al. [22], who hypothesized that complications and multiorgan failure could be reduced by minimizing the massive inflammatory “hit” of open pancreatic necrosectomy. In fact, sinus tract endoscopy was described as a procedure that followed open necrosectomy in order to preclude further reoperations, although the initial indication was extended to the primary management of retroperitoneal peripancreatic sepsis, as patients developed fewer organ dysfunctions and postsurgical recovery was faster.

This approach would be ideal for treating laterally placed WON (i.e. at more than 1–2 cm from the stomach and duodenal wall [23]), whereas it is not appropriate for necrotic collections in and around the pancreatic head, which are more suitable for transmural drainage (see next section).

The procedure takes place under general anesthesia and fluoroscopic guidance with the patient in the right lateral decubitus position, using the previous drain as the point of entry. The drain tract is dilated by a 30‐Fr balloon to allow the insertion of Amplatz dilators and sheaths (Figure 15.1a).

A 5‐mm working channel nephroscope (Figure 15.1b) is normally employed to clean the residual cavity [24]. Abundant normal saline serum together with a grasper and a Dormia basket can be used to evacuate the abundant, fluffy, cloud‐like pus and loose necrotic material. A 32‐Fr Nelaton drain is reintroduced along the sinus track to permit subsequent postoperative cleaning. The drainage tube is kept in place until the output is less than 10 ml/day and is then withdrawn, the main advantage being that necrotic tissue can be removed as many times as necessary without the need for formal reoperation. Antibiotics are usually administered while the drain is in place.