Keywords walled-off pancreatic necrosis - WON - WOPN - percutaneous direct endoscopic necrosectomy
- direct endoscopic necrosectomy - DEN - DEN - p-DEN
Introduction
Management of infected walled-off pancreatic necrosis (WOPN) is technically challenging.
Optimal endoscopic or surgical drainage with or without necrosectomy has been recommended.
Endoscopic ultrasound (EUS)-guided transgastric or transduodenal placement of a lumen-apposing
metal stent (LAMS) has been shown to be effective for drainage of WOPN in the lesser
sac. Additional direct endoscopic necrosectomy (DEN) has been recommended whenever
indicated for effective removal of solid necrotic debris from the collection. A “step-up”
approach (drainage as the first step and additional DEN whenever required) has been
recommended as the standard of care.[1 ] WOPN extending into the left paracolic gutter are difficult to effectively drain
endoscopically, especially because the paracolic extension is beyond the reach of
the transgastric endoscope. Additional measures like percutaneous catheter drainage
(PCD), video-assisted retroperitoneal drainage (VARD), or surgery may therefore be
required. However, VARD or surgery is associated with high morbidity and PCD is frequently
inadequate for drainage. This video case demonstrates a combined EUS-LAMS and percutaneous
self-expandable metal stent (SEMS)-guided DEN (e-DEN + p-DEN) approach for successful
management of an infected lesser sac WOPN with paracolic extension.
Case Discussion
An 18-year-old male patient presented with acute necrotizing pancreatitis and WOPN.
Duration of illness was 6 weeks. Presenting symptoms were abdominal pain, fever, and
failure to thrive. Laboratory investigations revealed total leucocyte count (TLC)
21,000/mm2 . Contrast-enhanced computed tomography (CECT) scan of the abdomen revealed a large
lesser sac peripancreatic fluid collection (size 95 × 85 × 270mm) with significant
paracolic extension ([Fig. 1A ]). EUS revealed a multiloculated poorly defined collection in the lesser sac with
solid debris extending caudally into the left paracolic gutter ([Fig. 1B ]). A 24Fr PCD catheter was placed under USG guidance for the paracolic extension
and EUS-guided transgastric drainage of the lesser sac collection was performed using
a LAMS (Plumber stent 30 mm × 16 mm; MI Tech, South Korea) ([Video 1 ]). Patient's fever persisted, and therefore two DEN sessions (e-DEN) were performed
using mixture of hydrogen peroxide, betadine, and saline. Interval CECT at 3 weeks
revealed persistent residual lesser sac and significant paracolic collection with
solid debris.
Video 1 Video demonstrating step-by-step technique of e-DEN and p-DEN for treatment of WOPN
with paracolic extension.
Interdisciplinary consultation was sought from interventional radiology and surgery
teams. The consensus was that the paracolic gutter collection was contributing to
the persistent symptoms and required effective drainage. Due to the irregular paracolic
cavity with multiple side extensions, VARD was unlikely to be effective and open surgery
was considered too morbid. A decision for p-DEN was therefore agreed upon.
The PCD track was dilated to 12 mm using Hegar's dilators ([Fig. 2 ]) and an esophageal fully covered SEMS (FCSEMS) (Wallflex 18 × 100 mm; Boston Scientific
Corporation, USA) was placed over the guidewire into the cavity to create an access
port ([Video 1 ]). A standard gastroscope was introduced through the stent into the cavity and DEN
was performed (p-DEN) ([Fig. 3A ]–[C ]). Additional e-DEN was performed through the transgastric route. Nasocystic drains
were placed in both the collections for continuous saline irrigation of the cavities.
A total of five DEN sessions (3 e-DEN, 2 p-DEN) were required. LAMS was exchanged
to multiple double pigtail plastic stents (7 Fr × 3 cm) 3 weeks after its placement
([Fig. 4 ]) and FCSEMS was exchanged to a 16 Fr PCD catheter after 5 days once paracolic cavity
had collapsed. Interval CECT revealed near total resolution of WOPN ([Fig. 5 ]). PCD was removed after 4 weeks. During the entire course of management, patient
was maintained on intravenous antibiotics as per sensitivity patterns. Nutrition was
maintained initially using a nasojejunal feeding tube and later by oral diet, and
appropriate supportive care was prescribed as required. Total length of hospital stay
was 39 days. At 8-week follow-up, patient was asymptomatic, was eating well, and had
gained weight.
Fig. 1 (A ) Contrast-enhanced computed tomography (CECT) abdomen coronal view demonstrating
lesser sac and paracolic collection (red arrow). (B ) Linear endoscopic ultrasound (EUS) showing multiloculated ill-defined necrotic collection
with solid debris.
Fig. 2 Fluoroscopy images. (A ) Percutaneous catheter drain (PCD) in situ for drainage of paracolic collection.
(B ) Contrast examination of paracolic cavity through PCD. (C ) Guidewire passed into paracolic cavity through PCD. (D ) Dilatation of percutaneous tract using 12 mm Hegar's dilator.
Fig. 3 (A ) Deployed percutaneous esophageal fully covered self-expandable metal stent (FCSEMS)
seen on fluoroscopy image (red arrow). (B ) Endoscopic view through the percutaneous esophageal FCSEMS. (C ) Solid debris seen in paracolic gutter collection.
Fig. 4 Endoscopic view of multiple 7 Fr double pigtail plastic stents placed via the transgastric
cystogastrostomy after removal of the lumen-apposing metal stent (LAMS).
Fig. 5 Interval contrast-enhanced computed tomography (CECT) abdomen coronal section showing
near complete resolution of walled-off pancreatic necrosis (WOPN) (B , green arrows) as compared with the index CECT (A , red arrows).
Discussion
This case presented a peculiar clinical dilemma. Our patient had persistent sepsis
despite drainage of the lesser sac WOPN due to a paracolic gutter collection which
defied PCD drainage. Given the ongoing sepsis, surgical necrosectomy could be considered
as the next logical step of management. However, due to the issues mentioned earlier,
VARD or surgical drainage was not considered optimal in our patient. A combined e-DEN
and p-DEN approach has been infrequently described, although high technical and clinical
success rates of 100 and 80 to 89%, respectively, have been reported.[2 ]
[3 ] We employed this combined approach in our patient with successful outcome. The advantage
of such an approach is that the esophageal FCSEMS acts as an access port for passing
the scope into the paracolic collection so that an effective DEN can be performed.
This may obviate the need for formal VARD or surgical necrosectomy. By using a flexible
endoscope, all side extensions and sinuses within the cavity can be effectively accessed.
The FCSEMS can be easily removed once the cavity has collapsed. In our patient, a
total of five DEN sessions (3 e-DEN, 2 p-DEN) were required.
In conclusion, this video case demonstrates successful management of a complex WOPN
with paracolic extension using a combined e-DEN and p-DEN approach. Such an approach
may help minimize or avoid surgical morbidity in appropriately selected patients.
