Transgastric Endoscopic Necrosectomy for Walled-Off Pancreatic Necrosis
Comments: The patient is a 61 year-old gentleman with multiple medical problems, including end stage renal disease requiring a deceased donor kidney transplant, who developed walled-off pancreatic necrosis four months after an episode of severe gallstone pancreatitis.
He developed progressive anorexia, early satiety, and post-prandial nausea, leading to profound weight loss despite nutritional supplementation and pancreatic enzyme replacement.
Abdominal computed tomography (CT) scan revealed a 15 cm x 5 cm collection of necrotic debris and gas replacing the majority of the pancreatic parenchyma.
A prolonged trial of percutaneous drainage failed to resolve the collection and resulted in a pancreatic-percutaneous fistula. Because of the patient's multiple comorbidities, compromised nutritional state, and suboptimal functional status, a formal surgical necrosectomy was deferred. After discussion of the risks, benefits, and alternatives, he elected to proceed with a transgastric endoscopic necrosectomy.
The steps involved in performing a transgastric necrosectomy are:
1) EUS-guided transgastric puncture into the necrosis followed by passage of a guidewire into the cavity.
2) Over the guidewire, electrosurgical current is delivered through a needle-knife cannula to establish a tract.
3) Pneumatic dilators are used to sequentially dilate the tract over the guidewire.
4) The necrosis cavity is entered with a standard gastroscope.
5) Flexible endoscopic instruments are used to debride necrotic tissue.
6) In the event multiple sessions are necessary, the tract is maintained for future debridement by placing multiple double pigtail stents.
With the curved-linear array echoendoscope in the antrum of the stomach, the necrosis cavity was identified endosonographically. After using Doppler to exclude an intervening blood vessel, a 19-gauge fine needle aspiration (FNA) needle was advanced into the cavity under endoscopic ulrasound (EUS) guidance. Through the needle, a hydrophilic guidewire was then passed into the cavity and coiled. Over this guidewire, a needle knife cannula was used to establish a tract between the lumen of the stomach and the necrosis cavity.
After withdrawing the needle knife, the echoendoscope was exchanged for a standard upper endoscope over the wire. Subsequently, wire-guided, through-the-scope pneumatic dilators were used to sequentially dilate the tract. In this particular case, the tract was dilated to a maximum diameter of 15 mm. The final dilation was performed alongside the wire.
The necrosis cavity was then entered with the standard gastroscope. After briefly exploring the cavity, mechanical debridement is initiated. Multiple endoscopic devices, including jumbo forceps, foreign body graspers, and an endoscopic net were used to grasp necrotic tissue and remove it from the cavity into the stomach lumen. In this case, resecting morsels of necrotic tissue with a hot snare and transferring these pieces into the stomach with a two-pronged grasper was most effective.
The quantity of necrosis within the cavity was such that multiple prolonged sessions were necessary for complete debridement. In between sessions, the tract connecting the gastric lumen to the necrosis cavity was maintained by placing three 10 french double pigtail plastic stents. The necrosectomies were performed at 3-4 week intervals. The patient was given five days of oral fluoroquinolones after each procedure.
After the second session, the patient's symptoms improved substantially and his oral intake increased, leading to weight gain. After four sessions, a very small amount of necrotic tissue remained and all further intervention resulted in oozing from the cavity wall, suggesting viability. A repeat CT scan confirmed the near-complete resolution of pancreatic necrosis and the double pigtail stents were removed.
He remains asymptomatic 3 months after completion of the necrosectomy.
| Contributed by: |
B. Joseph Elmunzer, MD University of Michigan Amaar Ghazale, MD University of Michigan Akbar K. Waljee, MD University of Michigan Craig M. Womeldorph MD University of Michigan |
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Citation: Elmunzer, BJ & Ghazale, A. & Waljee, AK & Womeldorph MD, CM (Oct 28 2009). Transgastric Endoscopic Necrosectomy for Walled-Off Pancreatic Necrosis. The DAVE Project. Retrieved Feb, 8, 2010, from http://daveproject.org/viewfilms.cfm?film_id=883 Times viewed since Feb 2006: 1494 |
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