Minimally invasive treatment of walled-off pancreatic necrosis complicated by colonic fistula

Abstract

Objective: Walled-off pancreatic necrosis (WOPN) is a life-threatening complication of acute pancreatitis, occurring more than 4–6 weeks after the initial attack. WOPN can lead to serious additional complications such as sepsis, hemorrhage, or gastrointestinal and pancreatic fistula formation. Our video presents a case of WOPN complicated by colonic fistula managed surgically via laparoscopic cyst-gastrostomy followed by video-assisted percutaneous pancreatic necrosectomy. A 54 year old man was admitted to an outside hospital with alcohol-induced acute pancreatitis and subsequently developed a peri-pancreatic fluid collection. His symptoms resolved without additional intervention and he was able to resume a regular diet. Two months later the patient was admitted to our institution with sudden onset of severe abdominal pain and sepsis. Imaging studies revealed a 25 cm area of gas-containing WOPN suggestive of infected contents. A laparoscopic cyst-gastrostomy was performed evacuating a large amount of stool and solid necrotic debris confirming fistulization to the left colon. Seven days later, residual necrosis was removed via video-assisted percutaneous retroperitoneal approach utilizing a 12 mm trocar. The patient had a favorable clinical evolution and was discharged home 15 days later on enteral nutrition, having resumed normal bowel function, and with scant output from an indwelling drain. Follow-up imaging confirmed near-complete resolution of the WOPN. Our case report illustrates the effectiveness and safety of minimally invasive approaches in the management of WOPN complicated by colonic fistula, without the need for stool diversion and open procedures.