Successful Endoscopic Pancreatic Necrosectomy in 5-Year-Old Child

Abstract

Introduction: Endoscopic necrosectomy (EN) for treatment of Walled off Pancreatic Necrosis (WOPN) has been performed as an alternative to operative or percutaneous therapy. All available reports now in adult population, we report here the role of this approach in the pediatric population. Patient is a 5-year-old boy with a history of pre-B cell acute lymphoblastic leukemia diagnosed 11/2013 treated with protocol COG -AALL0932 consisting of cytarabine, methotrexate, vincristine, peg-asparaginase, and dexamethasone. He was admitted on 12/12/2013 with acute pancreatitis thought to be secondary to PEG asparaginase, his case was complicated by large peripancreatic fluid collection. On 12/20, CT abdomen was done due to high fever and worsening abdominal pain and showed organized collection in the left upper quadrant between the pancreas and the stomach measured 7.5X9 cm. Patient underwent US guided drainage with 8F pigtail catheter placement, and was treated with antibiotics, antibiotics regimen changed based on the bacteria sensitivity; After 3 weeks, the drain was removed after ultrasound showed improvement of the collection. Ten days later, CT of the abdomen revealed reaccumulation of large walled fluid collection adjacent to pancreas measured 5x5 cm. US aspiration of the collection showed thick green fluid positive for Enterococcus faecium. Patient was referred to the GI service for endoscopic drainage of the collection; patient underwent endoscopy ultrasound which revealed peripancreatic collection measured 45 X 50 mm. There was internal debris within the cavity. Cystgastrostomy was performed by passing a 19-gauge needle using a transgastric approach. A wire was inserted into the collection under fluoroscopic guidance. The cystotomy was dilated with a 10-12mm then 12-15 balloons and 5-7-10 Fr catheter dilators. One 7Fr x 4 cm and three 10Fr x 1cm plastic double pigtail stents were placed over the wire. Four weeks post cystgastrostomy, patient underwenten via EUS approach; the cystotomy was dilated with a 12-13.5-15 mm balloon dilator, then entered. The cyst was partially filled with fluid and necrotic tissue. EN was performed with a forceps. Follow-up images showed resolution of the collection and 3 weeks post necrosectomy, the cystgastrostomy stents were removed. EN offers the advantage of minimally invasive endoscopic treatment without transabdominal surgery. In the last several years, endoscopic management of WOPN has come to serve as an important primary interventional technique in adult population. Recently, Trikudanathan et al. reported 3 cases with children between 11 and 17 years of age. To our knowledge, this is the youngest patient who underwent successful endoscopic necrosectomy.