Acute pancreatic necrotic collections (APNCs) complicating necrotic pancreatitis are
managed conservatively. Upon onset of complications, percutaneous, endoscopic ultrasound
(EUS)-guided or surgical drainage can be applied [1]
[2].
A 40-year-old with severe necrotic pancreatitis became critically ill on week 3 due
to an infected APNC, diagnosed via computed tomography (CT). Percutaneous and EUS-drainage
failed while surgery carried a high risk of fatal outcomes. During gastroscopy, no
visible “bulge” corresponding to a compression or indentation from the collection
was identified. Based on anatomy and CT, the left lateral–posterior wall of the corpus–antrum
junction below the incisura exhibited optimal APNC-gastric wall contact ([Fig. 1]). A novel endoscopic technique conforming to the principles of NOTES, termed per-oral
endoscopic tunneling transgastric drainage (POET-D), was applied as a rescue therapy
([Video 1]).
Fig. 1 Computed tomography image showing the site of optimal contact (blue arrow) between
the pancreatic collection and the gastric wall.
Per-oral endoscopic tunneling transgastric drainage (POET-D) of an acute pancreatic
necrotic collection.Video 1
First, submucosal injection of 10 cc indigo carmine-solution was performed at the
left lateral–posterior wall of the corpus–antrum junction. A mucosal incision was
made using an endoscopic knife. A short submucosal tunnel was created. Muscle fibers
and serosa were gradually dissected near the distal end of the tunnel to allow for
the preservation of a mucosal flap above the distal defect. The endoscope entered
the omental bursa. The omentum, spleen and splenic ligament could be visualized. 560
cc of Klebsiella spp-infected APNCs were aspirated and the cavity was lavaged with
saline and gentamycin. A nasobiliary tube was placed inside the omental bursa for
further drainage and lavage. Within 48 hours the patient improved. The tube was removed
and the defect was closed with clips.
POET-D allows for preservation of a mucosal flap over the sero-muscular defect and
continuous visualization of adjacent structures during dissection. It can provide
rapid, large-volume drainage of viscous contents and lavage of infected cavities.
POET-D can treat complicated cases of APNCs, potentially filling a therapeutic gap
in-between percutaneous, EUS and surgical procedures.
Endoscopy_UCTN_Code_TTT_1AO_2AG_3AZ
E-Videos is an open access online section of the journal Endoscopy, reporting on interesting cases and new techniques in gastroenterological endoscopy.
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