Sp614 Endoscopic Necrosectomy via a Fully Covered Esophageal Metal Stent: A New Efficacious Platform

Abstract

A 34 year old man with type V hyperlipidemia was initially admitted with severe acute pancreatitis requiring a prolonged MICU stay due to sepsis. He underwent an ERCP with pancreatic duct stent placement due to duct disruption and endoscopic cystgastrostomy. Two weeks later, he was sent to the emergency department with fever and abdominal pain. His WBC was 17,000 and the CT showed a large enhancing multi-loculated collection surrounding the pancreatic tail, concerning for infected pancreatic necrosis. Endoscopic necrosectomy with PEG-J placement was performed. A traditional 24 F PEG tube is placed using the pull through technique. A bronchoscope is advanced through the PEG tube deep into the duodenum. A long guidewire is then advanced through the scope and beyond the Ligament of Treitz under fluoroscopic guidance. The scope is exchanged for a12 F jejunal tube. Contrast injection confirms location. An echoendoscope is used to locate the area of necrosis. Color flow Doppler is used to evaluate for local vasculature. A 19 gauge FNA needle is used to puncture the cavity in a transgastric fashion. Fluid is aspirated and is sent for microbiology analysis. A guidewire is advanced through the needle into the cyst cavity. Over the guidewire, a 15 mm dilating balloon is used to create a fistula. An 18 mm x 60 mm fully covered esophageal self expanding metal stent with flanged ends is deployed across the fistula under both endoscopic and fluoroscopic guidance yielding pus and debris. Surgical necrosectomy with post-operative irrigation was the standard method of treatment in the past. Alternative approaches of minimally invasive treatments emerged, including percutaneous and endoscopic techniques. Endoscopic necrosectomy has become the mainstay of treatment for infected pancreatic necrosis, and this technique continues to evolve in order to optimize outcomes. Initially, double pigtail plastic stents were used for drainage of necrotic cavities. More recently, dilation had been performed to permit advancement of the endoscope within the cavity for debridement. We propose utilizing fully covered self expanding metal esophageal stents in order to facilitate better drainage with a larger diameter stent and to provide a safer platform for active endoscopic irrigation and debridement with a standard gastroscope.