Percutaneous Endoscopic Necrosectomy of Walled-Off Necrosis in Post-ERCP Pancreatitis

Abstract

Introduction: Acute pancreatitis is the most frequent complication in patients who undergo endoscopic retrograde cholangiopancreatography (ERCP), with an incidence rate of 3.5-9.7% [1]. 5-10% of these develop acute necrotizing pancreatitis, which may have a pancreatic or peripancreatic localization in 75-80% [2]. We describe a case report of post-ERCP acute necrotizing pancreatitis with walled-off necrosis (WON) treated with percutaneous endoscopic necrosectomy (PEN) [3]. Case Report: A 60-year-old man with obstructive jaundice and common bile duct stones at abdominal CT scan underwent ERCP to clear the biliary tract. In the following days, due to the onset of severe acute pancreatitis and sepsis, he repeated the abdominal CT scan where multiple necrotic collections were found around the pancreas with extension to the pelvic paracolic gutters. Following a step-up approach, targeted antibiotic therapy was started. After four weeks, it was not possible to perform Endoscopic Ultrasound-Guided drainage because of the distance from the stomach or the duodenum to the WON. Then percutaneous drainage was radiologically inserted into the collections through the left side of the abdomen of the patient to flush with hydrogen peroxide every day. Due to the persistent infection and necrosis in the collections, an esophageal fully covered self-expanding metal stent was temporarily inserted through the percutaneous fistula in order to increase the caliber of the fistula and to perform PEN. Discussion: The step-up approach suggests endoscopic or percutaneous drainage of infected WON as the first interventional method, depending on the location of the WON and the local expertise [1]. PEN is a safe and effective alternative to surgical treatment with a technical success rate of 47-93% and a complication rate of no more than 20% [4]. Conclusion: PEN is an advanced endoscopic technique that is showing promising results but still needs randomized controlled trials to establish safety and efficacy.