Direct endoscopic necrosectomy using the novel 5 millimeter powered endoscopic debridement device. The larger winner? The authors include Shruti Mouni, Michael Bejjani, Bashir Ghandour, and Professor Mohin Kashyap. The following are author disclosures. Endoscopic drainage of Waldorf necrosis and subsequent direct endoscopic necrosectomy, or DEN, has been shown to be an effective step-up management strategy in patients with symptomatic Waldorf necrosis, or WAN. Conventional accessories used for DEN include forceps, snares, baskets, and rotmuts. These make the procedure cumbersome and time-consuming, as these instruments are not designed for DEN and can limit the effectiveness of necrosectomy. Further, they result in prolonged hospital stays, increased costs, and require multiple endoscopic interventions to clear the cavity. The concept of powered endoscopic debridement, or PED, has now come into play, where a single device performs multiple functions of debridement, including high-performance suction, irrigation, and tissue dissection for symptomatic WAN. PED device components consist of a motorized catheter and a system console. The motorized catheter has been upgraded to a larger 5 millimeter catheter diameter that was previously 3 millimeter, and the catheter goes through a 6 millimeter working channel therapeutic gastroscope. The system console allows the endoscopist to control the catheter via fit pedals for suction and cutting, and has containers for continuous purge and vacuum function. This video shows the previous version using the 3 millimeter PED in a patient who has undergone prior necrosectomy with the same device. The catheter's rotator blade is seen through a small opening window, which limits its ability to resect large pieces of necrotic tissue. That's resulting in suboptimal necrosectomy. We present two cases of direct endoscopic necrosectomy performed in patients with Waldorf necrosis using the novel larger 5 millimeter PED device. All patients had undergone prior endoscopic cyst gastrostomy with a lumen-opposing metal stent, or LAMS. The first case is that of a 71-year-old female with a history of prior gallstone pancreatitis, whose postcholestectomy and presenter would say that the endoscopic severe sepsis due to necrotizing pancreatitis and Waldorf necrosis. This was seen on her CT on day one, and the collection measured 13 by 7 centimeters in maximum dimension, replacing more than 50 percent of her pancreas. The patient underwent multigated cyst gastrostomy using 20 millimeters lumen-opposing metal stent. Despite this, there was very minimal clinical improvement following LAMS placement, showing a partially occluded LAMS with only 70 percent necrotic debris. We thus decided to use the novel 5 millimeter PED device. After insertion through a 6 millimeter channel therapeutic gastroscope, the device is purged. The catheter has a fixed outer and hollow inner cannula with a rotating blade at its distal end. The necrotic cavity is then entered, and debridement is only initiated when the aspiration pedal is activated, which guarantees its safety. The catheter is placed within the necrotic cavity, and necrotic tissue is sucked into the catheter using negative pressure, cut by the rotating blade, which is the inner cannula, and the resected tissue is immediately aspirated away and collected in a standard vacuum container. For optimal removal of tissue, the angle of the device relative to the necrotic tissue plane is important. The cutter opening should be directed to face the necrosis with direct contact. The larger opening diameter of the 5 millimeter catheter allows for debridement of large pieces of necrotic tissue. The catheter rotation speed is set at 1750 revolutions per minute, which is at the discretion of the endoscopist. Suction is set at a negative pressure of 620 millimeters of mercury. The necrotic tissue is trapped between the cavity wall and the cutter opening of the catheter, with the tip of the cutter visible at all times, making it a controlled debridement. The catheter shaft is flexible and can tolerate endoscope bending and manipulation up to greater than 160 degrees. This aids in avoiding contact not only with the cyst wall, but also with blood vessels, thus further reducing the risk of bleeding. At the end of the necrosectomy session, healthy granulation tissue is noted within the cavity. Seven French double pigtail stems were then deployed within the cavity to further allow optimal drainage. The series of CT scans show the reduction in size of the walled-off necrotic cavity from day one, where it measured 13 centimeters, to day 14, where we see near complete resolution of the cavity following one session of necrosectomy with the novel 5 millimeter PED device. Our second case is that of a 31-year-old male with a history of autism who presents with necrotizing pancreatitis due to biliary etiology. He's hemodynamically stable and his imaging showed 11 centimeter walled-off necrotic fluid collection. Despite undergoing cyst gastrostomy, necrotic debris remained up to 50 percent within the cavity, and thus we decided to use the novel 5 millimeter PED device. In this video, we demonstrate the motorized cutting tool carefully manipulating the cyst cavity, avoiding direct contact and damage to the cyst wall. Again noted is the positioning of the cutter opening placed in direct contact to the center of the necrosis. The larger opening diameter and cutting window has eight times greater throughput focus for optimal debridement of large necrotic tissue pieces, both solid as well as liquid debris. As shown, the catheter remains within the cavity during this cycle of debridement, suction, and aspiration of tissue away from the working field, which avoids multiple passages through the lens, reducing the risk of stent displacement as well as procedure time. The 360 degree rotatable distal aperture also allows maneuvering through narrow spaces under direct visualization. This process is repeated till most of the cavity is free of necrotic material and healthy granulation tissue is noted. In comparison to the old 3 millimeter PED device, the novel 5 millimeter device achieved near complete reduction in necrosis at the end of necrosectomy with a median of 2 DEN sessions and a mean procedure time of 33 minutes. At follow-up imaging at four weeks, there was near complete resolution of necrosis. In comparison, the 3 millimeter device achieved suboptimal necrosectomy despite 3 DEN sessions over a mean procedure time of 55 minutes with follow-up imaging showing persistent necrosis. Key features of the novel 5 millimeter PED device include its large catheter outer diameter of 5 millimeters, which passes through a 6 millimeter working channel therapeutic gastroscope. This large catheter diameter opening window allows three times larger cutting for debridement of tissue and an eight times greater volume of tissue debrided. In addition to the technical advantages highlighted in our video, the clinical advantages of the novel 5 millimeter PED include a shortened procedure time, lower risk of stent related complications, reduced risk of bleeding, and the reduced need for multiple necrosectomy sessions. In conclusion, the novel 5 millimeter PED device is a unique tool that overcomes some of the inherent problems associated with conventional instruments currently used for DEN. Prospective comparative evaluation of this device in a large series of patients is required to confirm these favorable observations and further evaluates its safety and clinical efficacy.

endoscopic debridement device

direct endoscopic necrosectomy

symptomatic Waldorf necrosis

novel device

necrotic tissue removal