Our video aims to review the combined interventional radiographic and endoscopic techniques used to perform a percutaneous retroperitoneal necrosectomy in a patient with severe necrotizing pancreatitis. The five minimally invasive tenants of the procedure will be demonstrated:
? Using interventional techniques to establish a retroperitoneal access site that will allow repeated endoscopic access.
? Inspect and lavage infected tissue under direct endoscopic guidance to soften the site for debridement.
? Demonstrate debridement of necrotic tissue using a combination of snare polypectomy, rat-tooth forceps, and Roth net extraction.
? Once adequate debridement has been completed, Malencott drains are left in place in the access tract to allow residual fluid and tissue collection.
? And finally, demonstrate radiographic and clinical improvement following necrosectomy.
This preoperative CT scan demonstrates extensive multiloculated cystic fluid collections within the left retroperitoneum with small pockets of air, as indicated by the red arrows. The location of these retroperitoneal cystic collections made it difficult for conventional transgastric endoscopic access.
After the patient is placed in the right lateral position, a previously placed percutaneous drainage tube is removed over wire, and the tract is dilated over a balloon stent. A nine millimeter Pentax endoscope is passed through the overtube into the perinephric area with almost immediate expulsion of purulent material, as shown in the video in the upper left corner.
On the fluoroscopic view, the proximity of the endoscope can be seen between the previously placed transgastric stent is visible. Using standard snare polypectomy technique, large sections of necrotic debris are removed through the access tract.
In between snare removals, the tissue is irrigated with multiple flushes of sterile saline and aspirated to expose the underlying adherent debris.
Here we demonstrate the utility of the rat-tooth forceps in breaking up large sections of necrotic debris. The device is carefully thrust back and forth to break sections that do not readily break free following snare polypectomy or saline flush.
A readily available Roth net is shown here removing sections of tissue that are too large or too adherent to come through the access catheter. Roth net extraction allowed for larger sections of tissue removal.
As evidenced here, visibility is often compromised, requiring delicacy and skill to be practiced while performing the separate techniques of the endoscopic necrosectomy.
At the completion of the necrosectomy, a Malencott drain is left in place to allow residual drainage of the necrotic debris over time.
The five week post-operative CT scan demonstrates interval decrease of the peripancreatic and the left retroperitoneal fluid collection, as shown here.
The red arrow designates placement of the Malencott drainage catheter.
In summary endoscopic intervention is effective in resolving collections of pancreatic necrosis that cannot be readily accessed by a transluminal approach.
Percutaneous access sites can be adequately dilated to achieve sufficient access for percutaneous endoscopy. Percutaneous endoscopy can be performed either directly or as demonstrated in this case, via a nephrostomy tube.
The goal of therapy should always be complete removal of necrosum for best outcome. All three patients who underwent percutaneous necrosectomy at our institution have done well.
In conclusion, percutaneous endoscopic necrosectomy can be complementary to standard transluminal therapy in the management of complicated peri-pancreatic necrotic collections.
Matthew T. Moyer, MD, MS, Penn State Milton S. Hershey Medical Center
Arnab Biswas, DO, Penn State Milton S. Hershey Medical Center
Abraham Mathew, MD, Penn State Milton S. Hershey Medical Center
Frank C. Lynch, MD, Penn State Milton S. Hershey Medical Center
Leslie B. Scorza, MD, Penn State Milton S. Hershey Medical Center