Case report: Endorotor based necrosectomy via multigate approach using gastric LAMS and duodenal fistula as a “natural orifice”

A 57y old male patient presented with acute pancreatitis. Index CT scan after 1 week revealed a significant pancreatic necrosis extended to the duodenum.With increasing CRP levels, next CT scan in week 4 confirmed an infected WON. Under EUS guidance, in week 5 a transgastric LAMS (Hot Axios 15x10mm) was placed and a first endoscopic necrosectomy with cold snare and irrigation+suction was performed. A duodenal fistula was confirmed being connected to the same necrotic space in fluoroscopy.

Due to the dimensions of the necrosis, an Endorotor based necrosectomy via LAMS was performed in week 6 and 7. As a „natural“ orifice – a duodenal fistula occured giving an additional retroperitoneal access. Even with angulation, transduodenal application of the Endorotor device was effective. Control CT scan showed a decreasing size of the necrosis, we removed the LAMS in week 9. Further course of pancreatitis was prolonged, requiring repeated antibiotic treatment, parenteral nutrition and drainage of symptomatic pleural and abdominal fluid collections, but no more pancreatic interventions or surgery. CT scan in week 17 showed a decreasing size of the necrotic mass [1] [2] [3].

The patient was dismissed with home nursing, receiving combined parenteral and enteral nutrition. 6 months after his first presentation, he was able to compensate his weight loss and to recover completely.

Conclusion: Endorotor based necrosectomy can effectively and safely be performed via multigate approach – using LAMS and a „natural“ duodenal fistula. Repeated endoscopic treatment sessions can be crucial supporting a prolonged healing process.

Publikationsverlauf

Artikel online veröffentlicht:
27. März 2025

• References

• 1 Arvanitakis M. et al. Endoscopic management of acute necrotizing pancreatitis: European Society of Gastrointestinal Endoscopy (ESGE) evidence-based multidisciplinary guidelines. Endoscopy 2018; 50: 524-546
• 2 van Brunschot S, Hollemans RA, Bakker OJ. et al. Minimally invasive and endoscopic versus open necrosectomy for necrotising pancreatitis: a pooled analysis of individual data for 1980 patients. Gut 2018; 67: 697-706
• 3 Rizzatti G, Rimbas M, Impagnatiello M, Gasbarrini A, Costamagna G, Larghi A.. Endorotor-Based Endoscopic Necrosectomy as a Rescue or Primary Treatment of Complicated Walled-off Pancreatic Necrosis. A Case Series. J Gastrointestin Liver Dis 2020; 29 (4): 681-684