Abstract

Introduction: Acute pancreatitis is the most frequent complication in patients who undergo endoscopic retrograde cholangiopancreatography (ERCP), with an incidence rate of 3.5-9.7% [1]. 5-10% of these develop acute necrotizing pancreatitis, which may have a pancreatic or peripancreatic localization in 75-80% [2]. We describe a case report of post-ERCP acute necrotizing pancreatitis with walled-off necrosis (WON) treated with percutaneous endoscopic necrosectomy (PEN) [3]. Case Report: A 60-year-old man with obstructive jaundice and common bile duct stones at abdominal CT scan underwent ERCP to clear the biliary tract. In the following days, due to the onset of severe acute pancreatitis and sepsis, he repeated the abdominal CT scan where multiple necrotic collections were found around the pancreas with extension to the pelvic paracolic gutters. Following a step-up approach, targeted antibiotic therapy was started. After four weeks, it was not possible to perform Endoscopic Ultrasound-Guided drainage because of the distance from the stomach or the duodenum to the WON. Then percutaneous drainage was radiologically inserted into the collections through the left side of the abdomen of the patient to flush with hydrogen peroxide every day. Due to the persistent infection and necrosis in the collections, an esophageal fully covered self-expanding metal stent was temporarily inserted through the percutaneous fistula in order to increase the caliber of the fistula and to perform PEN. Discussion: The step-up approach suggests endoscopic or percutaneous drainage of infected WON as the first interventional method, depending on the location of the WON and the local expertise [1]. PEN is a safe and effective alternative to surgical treatment with a technical success rate of 47-93% and a complication rate of no more than 20% [4]. Conclusion: PEN is an advanced endoscopic technique that is showing promising results but still needs randomized controlled trials to establish safety and efficacy.

Keywords

percutaneous endoscopic necrosectomy, walled-off necrosis, post-ERCP pancreatitis, step-up approach, hybrid technique

1. Case Presentation

A 60-year-old man with obstructive jaundice and common bile duct stones at abdominal CT scan underwent ERCP to clear the biliary tract. In the following days, due to the onset of severe acute pancreatitis and sepsis, the patient repeated the abdominal CT scan, where multiple necrotic collections were found around the pancreas with extension to the pelvic paracolic gutters. After a multidisciplinary discussion, a step-up approach was chosen. The patient started targeted antibiotic therapy, but after four weeks, it was not possible to perform an Endoscopic Ultrasound-Guided drainage because of the distance from the stomach or the duodenum to the WON.

Then a 20 Fr percutaneous drainage and a 7 Fr naso-digiunal catheter were radiologically inserted through the left side of his abdomen. Normal saline solution was constantly instilled via the 7 Fr catheter at a daily volume of 1000 mL. The patient was discharged when he was clinically improved, and the collections decreased. After one month because of persistent infection and necrosis in the collections, the percutaneous drainage was inserted again and once removed, progressive over the guidewire Savary dilations were performed. Then a 20 mm × 10 cm esophageal fully covered self-expanding metal stent was temporarily placed in the percutaneous fistula to keep the lumen open and increase the caliber. After about four days, when the fistula was consolidated, the stent was removed, leaving in place two 30 Fr drainages. The original idea to perform a video-assisted retroperitoneal debridement through the fistula was not possible because the collections were too narrow and angled. Therefore, a hybrid technique was performed: a gastroscope was introduced into the percutaneous fistula, and thanks to its flexibility, laparoscopic devices were used under the endoscopic vision for the initial debridement of necrotic tissue. We weekly performed PEN clearing all the collections and allowing their closure, gradually shortening the drainage.

REFERENCES

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[3]  Linlin Feng, Jintao Guo, Sheng Wang, et al. “Endoscopic Transmural Drainage and Necrosectomy in Acute Necrotizing Pancreatitis: A Review.” J Transl Int Med, vol. 9, no. 3, pp. 168-176, 2021. View at: Publisher Site | PubMed