Endoscopy 2021; 53(05): E199-E200
DOI: 10.1055/a-1220-5926
E-Videos

Endoscopy-guided percutaneous stapled pancreatic cystgastrostomy and necrosectomy

Harshit S. Khara
1  Division of Gastroenterology and Hepatology, Geisinger Medical Center, Danville, Pennsylvania, United States
,
Jon D. Gabrielsen
2  Division of Foregut and Bariatric Surgery, Geisinger Medical Center, Danville, Pennsylvania, United States
,
David L. Diehl
1  Division of Gastroenterology and Hepatology, Geisinger Medical Center, Danville, Pennsylvania, United States
,
Ryan D. Horsley
2  Division of Foregut and Bariatric Surgery, Geisinger Medical Center, Danville, Pennsylvania, United States
› Author Affiliations
 

Endoscopic ultrasound (EUS)-guided transmural drainage of symptomatic pancreatic fluid collections using plastic or metal stents has become first-line therapy [1] [2]. However, stents can become occluded despite direct endoscopic necrosectomy (DEN) of the walled-off necrosis (WON), and an alternative management plan is required.

A 57-year-old man with necrotizing pancreatitis developed an 18-cm WON ([Fig. 1]), producing significant mass effect on the stomach and surrounding bowel. EUS-guided cystgastrostomy was performed with placement of two lumen-apposing metal stents (LAMS) in the body and the antrum of the stomach. Despite undergoing seven sessions of extensive DEN, the massive cavity could not be completely cleared of necrotic material, and the patient repeatedly presented with infection due to recurrent clogging of the LAMS ([Fig. 2]). We therefore reviewed the case with our minimally invasive surgical colleagues and devised an innovative approach utilizing endoscopic and laparoscopic tools for definitive therapy.

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Fig. 1 Large pancreatic walled-off necrosis collection causing gastric outlet obstruction.
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Fig. 2 Persistent infection due to recurrent stent occlusion despite multiple endoscopic necrosectomy sessions.

Under endoscopic guidance, we created an anchored percutaneous gastrostomy site on the anterior gastric wall, through which we placed a 12-mm port directly into the stomach. The distal LAMS was removed, and the stapler was placed via the port into the existing cystgastrostomy site. The stapler was aimed towards the proximal LAMS ([Fig. 3]). Several applications of the stapler were used to create a wide opening of the cavity into the gastric lumen. This allowed extensive debridement of the cavity using laparoscopic tools under endoscopic guidance, which could not be performed with purely endoscopic techniques ([Video 1]). Large pieces of necrotic material were retrieved ([Fig. 4]). A percutaneous endoscopic gastrostomy tube was placed at the newly created gastrostomy site.

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Fig. 3 Percutaneous stapler used via the anterior abdominal wall gastrostomy port to extend the existing cystgastrostomy site on the posterior abdominal wall under endoscopic guidance.

Video 1 Endoscopically guided percutaneous stapled cystgastrostomy and necrosectomy of a large walled-off pancreatic necrosis collection refractory to endoscopic debridement.


Quality:
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Fig. 4 Percutaneous necrosectomy using laparoscopic tools under endoscopic guidance.

Follow-up endoscopy and computed tomography scan 3 months later showed complete resolution of the WON cavity ([Fig. 5]). The combined laparoscopic and endoscopic approach created a wide cystgastrostomy and allowed for one-step debridement after repeated endoscopic necrosectomies failed.

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Fig. 5 Complete resolution of the walled-off necrosis cavity at 3-month follow-up.

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Competing interests

The authors declare that they have no conflict of interest.


Corresponding author

Harshit S. Khara, MD, FACG, FASGE
Center for Advanced Therapeutic Endoscopy
Division of Gastroenterology and Nutrition
Geisinger Medical Center
100 N. Academy Avenue
21-11, Danville
PA 17822
United States   
Fax: +1-570-271-6852   

Publication History

Publication Date:
02 September 2020 (online)

© 2020. Thieme. All rights reserved.

Georg Thieme Verlag KG
Rüdigerstraße 14, 70469 Stuttgart, Germany


Zoom Image
Fig. 1 Large pancreatic walled-off necrosis collection causing gastric outlet obstruction.
Zoom Image
Fig. 2 Persistent infection due to recurrent stent occlusion despite multiple endoscopic necrosectomy sessions.
Zoom Image
Fig. 3 Percutaneous stapler used via the anterior abdominal wall gastrostomy port to extend the existing cystgastrostomy site on the posterior abdominal wall under endoscopic guidance.
Zoom Image
Fig. 4 Percutaneous necrosectomy using laparoscopic tools under endoscopic guidance.
Zoom Image
Fig. 5 Complete resolution of the walled-off necrosis cavity at 3-month follow-up.