Transpapillary drainage of walled-off pancreatic necrosis - a single center experience

Abstract

Introduction: Walled-off pancreatic necrosis (WOPN) often coexists with disruption of the main pancreatic duct that manifests as a leak of contrast medium into the necrotic collection during endoscopic retrograde pancreatography.

Aim: To assess the efficacy and safety of treatment of patients with symptomatic WOPN and disruption of the main pancreatic duct, who underwent endoscopic transpapillary drainage as the only access to the necrosis cavity.

Material and methods: In 22 patients with symptomatic WOPN, active endoscopic transpapillary drainage was performed. During endoscopic retrograde pancreatography (ERP), partial disruption of the main pancreatic duct was observed in 14 patients and complete disruption in 8 patients. After the active drainage was finished, a transpapillary pancreatic stent was inserted into the main pancreatic duct, which was later exchanged after 6, 12 and 24 months or when no extravasation of contrast from the pancreatic duct was observed. The results of treatment and complications were compared retrospectively.

Results: The mean duration of active drainage was 22 (range: 7-94) days. Complications of endotherapy occurred in 3/22 patients. The mean time of the main pancreatic duct stenting was 304 (range: 85-519) days. Success of endoscopic treatment of WOPN and pancreatic duct disruption was achieved in 20/22 patients. During a 1-year follow-up, recurrence of the collection was noted in 4/20 patients. Long-term success was achieved in 16/22 patients.

Conclusions: In patients with WOPN who cannot undergo transmural drainage when there is a communication between the necrotic collection and the main pancreatic duct, transpapillary access may be an effective and safe method of treatment.

Keywords: acute pancreatitis; disconnected pancreatic duct syndrome; endoscopic drainage/debridement; transpapillary drainage/debridement; walled-off pancreatic necrosis.

Photo 1

A – Abdominal contrast-enhanced computed tomography (CECT) of a 40-year-old woman performed 20 weeks after an acute bout of pancreatitis. Walled-off pancreatic necrosis (WOPN) is visible in the pancreatic tail. B – Endoscopic retrograde pancreatography (ERP) reveals contrast leak to the necrosis collection in the region of the pancreatic tail. In the stomach a “double pigtail” stent, which was removed from the bile ducts, is visible. C – A guide-wire introduced into the main pancreatic duct loops in the cavity of the necrosis collection. D – A nasal drain was inserted into the main pancreatic duct. Its distal tip is placed in the collection's cavity. E – Abdominal contrast-enhanced computed tomography performed 12 months after the end of active drainage. In the main pancreatic duct a transpapillary pancreatic stent is visible

Photo 2

A – A 64-year-old woman with central walled-off pancreatic necrosis (WOPN). A nasal drain and a pancreatic stent that were introduced transpapillarly into the main pancreatic duct are visible. The distal tip of the drain and stent are in the collection's cavity. B, C – Contrast medium injected via nasal drain fills the necrosis collection's cavity and then flows freely to the duodenum

Figure 1

The scheme presents the results of treatment in patients with walled-off pancreatic necrosis (WOPN) who underwent transpapillary endoscopic drainage