Definitive treatment of walled off necrosis – case report

Abstract

Background: Walled off necrosis (WON) is defined as a mature collection of pancreatic or peripancreatic necrosis with a well defined wall. Diagnosis is made after 4 weeks to the onset of necrotising pancreatitis. Minimally invasive approaches currently are reported to be associated with less morbidity and mortality with similar success rates than surgery alone. We report a case of a walled of necrosis which was treated through an endoscopic approach. Methods: We report the case of a 48 year old woman, admitted on May 2017 with severe acute pancreatitis (respiratory and renal disfunction). Admission computed tomography (CT) - pancreatic and peri pancreatic necrosis compromising pancreatic body and tail (Figure 1). Patient had a good response to initial intensive care treatment. On first month of follow up patient begun with epigastric pain and fullness postprandial sensation. Magnetic resonance (MRI) - pancreatic collection of approximately 5 inches occupying body and tail with a thin wall. Interior is liquid and has detritus. (Figure 2) Medical treatment is proposed and patient is discharged. Symptoms do not decrease and 3 months after onset of pancreatitis, a trans gastric endoscopic approach of the WON is performed. (Figure 3). Results: Endoscopic cystogastrostomy was performed to manage WON. A yo-yo stent to maintain its lumen for programmed endoscopic drainages. Endoscopic trans gastric necrosectomy was done in three opportunities. Symptoms decreased and a new CT scan was made 2 months after treatment, this showed no elements of WON nor pancreatic tissue alterations. (Figure 4) Laparoscopic cholecystectomy was done 2 months after to complete integral treatment of this pathology. No complications were registered during or after both procedures. Conclusion: WON is an evolutive complication of necrotising pancreatitis. Minimally invasive approaches, particularly endoscopic access has shown to be the procedure with less morbidity and mortality than other procedures. Laparoscopic cholecystectomy completes treatment, avoiding new complications.