Treatment of Walled-off Pancreatic Necrosis by Percutaneous Endoscopic Necrosectomy

Abstract

Walled-off pancreatic necrosis (WOPN) consists of a mature collection of pancreatic necrotic tissue within a well-defined inflammatory wall. Treatment involves drainage and debridement of the necrotic material. Modalities such as laparoscopic, endoscopic, and video-assisted retroperitoneal debridement are effective, and have less morbidity than open surgery. Percutaneous endoscopic necrosectomy (PEN) is a novel technique that allows the operator to use conventional endoscopes to perform necrosectomy via a percutaneous tract in patients with WOPN that is difficult to access via the stomach or duodenum. A 44-year old male with newly diagnosed diabetes mellitus presented with severe abdominal pain and sepsis secondary to a peripancreatic fluid collection that developed after an episode of acute pancreatitis. On arrival, his vitals were: Temp 100.4 F, BP 100/63 mm Hg, HR 129 beats/min, RR 20 breaths/min, and SPO2 96% room air. Abdominal examination revealed mild distension and severe epigastric tenderness. A percutaneous drain was placed via the left flank into the fluid collection at another facility. However, the collection persisted and grew E. Coli and K. Pneumoniae. Endoscopic ultrasound showed a debris-filled cavity abutting the pancreatic tail without close approximation to the gastric wall. Following upsizing of the percutaneous drain, three sessions of PEN were performed via the drain tract. Ongoing drainage was found to originate from a colonic fistula and pancreatic duct leak, which were treated with a diverting loop colostomy and endoscopic retrograde cholangiopancreatogram (ERCP) with pancreatic duct stent placement, respectively. The patient's condition improved with and resolution of the duct leak, confirmed on repeat ERCP performed two months later. His percutaneous drainage eventually stopped and the external drain was removed. PEN is a safe and effective minimally invasive technique that can be used to treat WOPN. It may be the procedure of choice in instances where necrosis cannot be accessed through the stomach or duodenum. Recent studies have shown that PEN has superior safety profile compared to the existing endoscopic (e.g. transgastric endoscopic necrosectomy) or surgical interventions. Additionally, percutaneous access along a predefined tract avoids inherent complexities of the transluminal approach. This novel technique may also be utilized for other intra-abdominal fluid collection accessible to interventional radiologists.