In this issue of Gut, Seifert et al1 (see page 1260), in a multicentre study from Germany, have investigated the results of endoscopic treatment of pancreatic necrosis. The paper highlights the long-term results of this endoscopic management, considered from an endoscopic point of view as an aggressive treatment but from a surgical point of view as a minimally invasive treatment. The endoscopic management of pancreatic necrosis is moving to the frontier between surgery and endoscopy. Transluminal endoscopic necrosectomy is probably the first step of NOTES (natural orifice trans-endoscopic surgery) procedures in humans.

The first limitation of transluminal endoscopic necrosectomy after acute pancreatitis (TENAP) series is the definition of pancreatic necrosis. Transmural endoscopic drainage of pancreatic pseudocysts or abscesses has been performed since the 1980s and is becoming a standardised procedure.2 Recently, endoscopic ultrasound (EUS) guidance of such complications of acute pancreatitis has expanded the field of the endoscopic treatment of pancreatic pseudocysts and made it safer. More than half of the pseudocysts do not bulge through the digestive wall and are not amenable to conventional endoscopic drainage.2 In addition, portal hypertension due to thrombosis or compression of the splenic vein by the pseudocysts increases the risk of bleeding. It has been demonstrated that EUS guidance is required in about half of the patients to achieve drainage of pancreatic pseudocysts or abscesses.2 However, according to the Atlanta classification, pseudocysts or abscesses are fluid collections originating from the pancreas, not only due to acute pancreatitis but also to ductal obstruction in cases of chronic pancreatitis. These lesions are fluid collections without necrotic debris or a solid component, which can be drained by stenting through the digestive wall, with or without associated nasocatheter drainage for a few days at the beginning of the drainage. Pancreatic necrosis …