In this video, we will show the minimally invasive endoscopic and retroperitoneoscopic management of a morbidly obese woman with severe pancreatitis after a failed ERCP at an outside hospital. While in the ICU, she developed increasing tachycardia, confusion, and an expanding complex acute necrotic collection. She was transferred to our center for further care. CT showed very extensive peri-pancreatic necrosis containing gas and extending deep into the retroperitoneum and pelvis.
Emergency endoscopic drainage was performed using EUS. After endosonographic visualization of the necrotic collection was achieved, a 19 gauge needle was passed through the posterior wall of the stomach into the collection, a catheter passed over the guidewire into the collection, and fluid aspirated for culture. The cystgastrostomy tract was dilated to 16mm and two double pigtail 10F stents placed. Pus and debris were drained.
The patient defervesced, became more alert and less tachycardic. Because of the extent of the infected peripancreatic necrosis into the pelvis, a percutaneous drain was placed under CT guidance by interventional radiology using a retroperitoneal approach through the left flank. Lavage of the retroperitoneum was initiated on the floor.
Over the next few weeks, the patient underwent a series of procedures by a combined team of GI and critical care surgery in the OR under general anesthesia. These included direct endoscopic necrosectomy via a transgastric approach, video assisted retroperitoneal debridement (VARD), and drainage tube placement via a left flank retroperitoneal percutaneous approach. All endoscopic procedures were done using carbon dioxide insufflation.
First we performed endoscopic peroral balloon dilation of the cystgastrostomy to 20mm, leaving the double pigtail stents to act as a pressure relief valve and also guide passage of the endoscope. There was an enormous burden of infected peripancreatic necrosis in the retroperitoneum, so that removal solely endoscopically with a Roth net or other techniques would be tedious and likely futile. Therefore we also performed video assisted retroperitoneal debridement (VARD), done here by our surgical service. The percutaneous catheter tract was serially dilated with step-dilators in order to allow placement of a large trochar which can permit passage of a forward viewing endoscope. That allows exploration of the retroperitoneum down into the pelvis as well as upwards into the lesser sac. Just as endoscopic debridment from above would be futile for this volume of necrosis, we need a combination of different techniques. The cap suction technique utilizes a band ligator cap on the tip of the endoscope pushed up into the necrosis and suctioned in plugs out through the large left flank trochar, which is in a dependent position with the patient in the supine position. Lavage will be an essential adjunct, with one large multisidehole chest tube placed into the pelvis, and a second tube placed through this tract up into the lesser sac. These tubes allow high volume lavage at the bedside.
After 10 days of beside lavage the patient was ready for the final combined procedure by GI and surgery. First, the peroral transgastric approach was used for direct endoscopic necrosectomy of the final remaining adherent solid necrosis using the cap suction technique. Note that as fluid was irrigated through the transgastric endoscope, fluid and debris were flushed out of the dependent percutaneous flank drain. Then the remaining adherent solid necrosis was removed using the cap suction technique. We believe that the cap suction technique may be safer than direct mechanical devices such as baskets and grasping forceps because of less propensity to disrupt vessels or vital organs. After the necrotic material was removed, you can see in this endoscopic transgastric view the chest tube coming up from the left flank into the lesser sac, and a clean cavity. Final CT scan showed the tubes entering the left flank, one heading downwards into the pelvis and other heading upwards towards the lesser sac. The cavity had completely resolved. You can also see the cystgastrostomy double pigtail stents in place. All drains and stents were eventually removed and the patient was discharged.
At clinic follow up, the patient was doing very well, showing us the only scars: one from a removed percutaneous endoscopic gastrostomy, and the other from the left flank tube. She has no surgical incision or risk of hernia. She has lost a substantial amount of weight, is back at work, and is feeling well
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Gardner TB, Coelho-Prabhu N, Gordon SR, et al. Direct endoscopic necrosectomy for the treatment of walled-off pancreatic necrosis: results from a multicenter U.S. series. Gastrointest Endosc 2011;73:718-26.
Gluck M, Ross A, Irani S, et al. Endoscopic and percutaneous drainage of symptomatic walled-off pancreatic necrosis reduces hospital stay and radiographic resources. Clin Gastroenterol Hepatol 2010;8:1083-8
Castellanos G, Pinero A, Serrano A, et al. Infected pancreatic necrosis: translumbar approach and management with retroperitoneoscopy. Archives of Surgery 2002;137:1060-3
van Santvoort HC, Besselink MG, Bakker OJ, et al. A step-up approach or open necrosectomy for necrotizing pancreatitis. N Engl J Med 2010;362:1491-502
Mustafa Arain, MD, University of Minnesota
Rajeev Attam, MD, University of Minnesota
Gregory Beilman, MD, University of Minnesota
Martin L. Freeman, M.D., University of Minnesota