Direct retroperitoneal necrosectomy through an insufficient jejunal blind stump after gastrectomy for necrotizing pancreatitis

A 53-year-old patient with a history of alcohol abuse presented with acute severe epigastric pain. Computed tomography (CT) showed signs of acute pancreatitis with a 9-cm measuring walled-off pancreatic necrosis (WOPN) in the pancreatic tail, with broad-based contact to the greater curvature of the stomach. Initial gastroscopy revealed severe ischemic gastric wall necrosis without signs of perforation ([Fig. 1]). An electrocautery-enhanced lumen-apposing metal stent (LAMS; 15 × 10 mm) was implanted transgastrically under endoscopic ultrasound guidance, to enable direct necrosectomy ([Fig. 2]). Because of a suspicion of splenic infarction, another CT scan was performed; this showed free air collections in the upper abdomen, with urgent suspicion of gastric wall perforation in the area of the ischemic gastric wall. A gastrectomy was done, with reconstruction by esophagojejunostomy and Roux-en-Y anastomosis.

Fig. 1 Gastroscopy after transgastric implantation of a lumen-apposing metal stent (LAMS), with the intention of draining a walled-off pancreatic necrosis collection. White arrow, distal flange of the LAMS; black arrow, severe gastric wall necrosis.

Fig. 2 Endosonographic ultrasound showing a 10.4 × 6.6-cm walled-off pancreatic necrosis (WOPN) cavity with inhomogeneous content.

Gastroscopy 6 days postoperatively revealed an anastomotic leak at the esophagojejunostomy. Endoscopic vacuum therapy was started with changes every 3–4 days. At 16 days postoperatively, a second endoscopic vacuum sponge was inserted into a newly occurring insufficiency in the jejunal blind stump that accessed the 5-cm necrotic pancreatic cavity. At 3 weeks later, after complete healing of the esophagojejunostomy anastomosis, vacuum therapy was ended, and a LAMS (20 × 16 mm) was implanted in the jejunal blind stump providing access for necrosectomy of the WOPN ([Video 1]). After five extensive endoscopic necrosectomies, the stent was removed. The patient was free of infection up to that time and was discharged from the hospital. At follow-up gastroscopy 1 week later, the jejunal blind stump had healed except for a 6-mm blind-ending fistula without secretion.

Video 1 Direct retroperitoneal necrosectomy through an insufficient jejunal blind stump, after gastrectomy for necrotizing pancreatitis.

Acute pancreatitis is a common disease with an unpredictable course and a wide range of severity [1] [2]. This case highlights the difficulty in managing the potential complications and describes how a secondary post-surgical complication enabled an unusual approach for endoscopic treatment.

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• References

• 1 Boxhoorn L, Voermans RP, Bouwense SA. et al. Acute pancreatitis. Lancet 2020; 396: 726-734
• 2 Zerem E. Treatment of severe acute pancreatitis and its complications. World J Gastroenterol 2014; 20: 13879-13892