Hydrogen Peroxide-Assisted Endoscopic Necrosectomy

Abstract

Pancreatic inflammation can result in varying degrees of transient and permanent pancreatic parenchymal or ductal injury. Pancreatic necrosis and pseudocyst formation may occur and can require endoscopic or surgical intervention. Hydrogen peroxide-assisted necrosectomy is an endoscopic technique for irrigation of walled off pancreatic collections to chemically debride solid components. An 84-year-old male with a medical history of gallstone pancreatitis post cholecystectomy complicated by sepsis, pseudocyst (17.2 cm x 9 cm) and end organ damage, experienced gram negative bacteremia from pseudocyst infection 4 weeks after his bout of pancreatitis. The patient underwent cystgastrostomy with endoscopic ultrasound, aspiration of purulent material, and lumen opposing (Axios) stent placement. Several necrosectomies were required due to the presence of solid necrotic material within the pseudocyst. The initial necrosectomy successfully cleared the stent of solid material and aspirated purulent fluid. Upon re-inspection at a 2 week interval, solid material was visualized and lavage of the pseudocyst with 2 weeks of enterally ingested “coca-cola” was attempted. A third inspection of the stent revealed re-occlusion with solid debris. Intra-procedurally, 120mL of 1.5% hydrogen peroxide solution lavage with mechanical debridement resulted in near complete evacuation of the pseudocyst cavity. The stent was removed and a 10 French x 7 cm pigtail was left to enable further drainage of the cavity. Patient's symptomatology resolved and repeat imaging confirmed collapse of the pseudocyst to 2.3 by 1.2 cm. The pigtail stent was removed and the patient remains asymptomatic. The use of hydrogen peroxide during pancreatic pseudocyst necrosectomy appears to aid in the chemical dissolution of solid necrotic material and facilitate resolution of pancreatic collections. We encourage scrupulous utilization of this technique as an aide during necrosectomies to collect further data on its absolute utility during endoscopic management of pancreatic pseudocycts.2112_A Figure 1. Endoscopic view of pancreatic pseudocyst through the lumen opposing stent visualizing extensive necrotic debris prior to lavage with a 1.5% solution of hydrogen peroxide.2112_B Figure 2. Endoscopic view of cystgastrostomy with solid necrotic debris extruding through the lumen opposing stent prior to debridement with a 1.5% solution of hydrogen peroxide.2112_C Figure 3. Endoscopic view of pancreatic pseudocyst through the lumen opposing stent visualizing successful debridement of solid necrotic material using a 1.5% solution of hydrogen peroxide.