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The endoscopic approach is a less invasive approach consisting of extracting the necrosis by natural orifices and has now become a promising option for the management of IPN patients. The technique was initially defined in 1996 by Baron et al. [25] and since then the results reported on different series in the literature show that mortality has been reduced to 5.6% with an overall complication rate of 28%. More recently, a randomized controlled trial comparing the endoscopic and surgical approaches revealed significantly fewer complications and rate of pancreatic fistula in the endoscopic arm [24]. As with all other techniques, serious specific complications have been reported, such as bleeding, perforation of the abdominal cavity, and peritonitis [18]. Although the endoscopic approach via the duodenum has been described, in practice the transgastric route is usually preferred as it can also be used to assess the integrity of the duct and has the further advantage of providing a diagnostic and therapeutic option for associated pancreatic and biliary pathologies.

The endoscopic approach is normally performed under general anesthesia but can also be carried out under sedation with midazolam and fentanyl. The post‐inflammatory pancreatic necrosis behind the posterior stomach wall is located and punctured. With successive balloon dilatations, a window of up to 2 cm in length is obtained for direct lavage, through which a gastroscope is passed to enable manipulation of the necrosis with forceps. Optionally, additional transgastric pigtails may also be inserted to facilitate drainage and ensure the reproducibility of the procedure [26].

Figure 15.1 (a, b) Amplatz and dilatators used to dilate the drainage tract and facilitate nephroscope insertion. (c) The previous drain is used as a guide to introduce the wire under fluoroscopic guidance. (d) Necrotic tissue and debris are extracted with the Dormia basket under direct visualization.

Source: courtesy of Patricia Sánchez‐Velázquez.

One of the technique’s drawbacks is that at least three procedures are usually required due to the small size of the window in the gastric wall and the poor capacity of the devices used to grasp the necrosis. Also, since it is quite a complex operation, it is performed at only a few centers, including tertiary referral centers, and is heavily reliant on the endoscopist’s experience. Although the published results seem to be satisfactory and mortality is very low, up to 40% of patients require additional placement of percutaneous drains to eliminate new areas of necrosis or collections, and between 20 and 28% require further surgical treatment. However, it has the great advantage of being less invasive and of providing further endoscopic therapy options. Moreover, the pancreatic juice drains directly into the gastric/duodenal lumen, so the rate of pancreatic fistula is reduced to less than 10%, as has been shown by the only randomized controlled trial published on this topic [27].