Percutaneous Endoscopic Necrosectomy of Complex Walled-Off Lateral Necrosis of the Pancreas with the Aid of Laparoscopic Babcock Forceps: A Case Report of an Endoscopic and Radiologic Team Approach.

Abstract

The initial therapeutic intervention for infected necrotizing pancreatitis usually begins with endoscopic cystogastrostomy for drainage, followed by endoscopic necrosectomy. Endoscopic pancreatic necrosectomy is commonly performed transluminally through transgastric or transduodenal routes. This case describes necrosectomy via a transcutaneous route for laterally located walled-off pancreatic necrosis and the novel use of Babcock forceps for an obstructed fully covered metal stent. A 62-year-old woman presented with abdominal pain, nausea, and vomiting. After multiple admissions and repeated abdominal imaging, she was found to have laterally located, infected, walled-off pancreatic necrosis. Initially, a drainage catheter was placed by an interventional radiologist and was eventually upsized to a 28F catheter. Subsequently, a fully covered metal stent was placed in the gastroenterology suite under fluoroscopic guidance and was used to gain access for percutaneous sessions of necrosectomy. A percutaneous sinus tract endoscopic necrosectomy was performed under direct endoscopic view. However, difficulties occurred with removing necrotic debris even through this large covered stent. Thus, laparoscopic Babcock forceps were used under fluoroscopy to remove lodged debris from the midstent. Repeat abdominal computed tomography scan 3 days after necrosectomy showed near resolution of the walled-off pancreatic necrosis. This Babcock technique with endoscopic necrosectomy has not been previously described in the literature, to our knowledge. Babcock forceps were an ideal tool in our case because they were able to gain access to the obstruction in the stent, but the "teeth" are small and dull enough to prevent from catching onto the metal stent mesh.