Percutaneous direct endoscopic pancreatic necrosectomy

Abstract

Approximately 10%-20% of the cases of acute pancreatitis have acute necrotizing pancreatitis. The infection of pancreatic necrosis is typically associated with a prolonged course and poor prognosis. The multidisciplinary, minimally invasive "step-up" approach is the cornerstone of the management of infected pancreatic necrosis (IPN). Endosonography-guided transmural drainage and debridement is the preferred and minimally invasive technique for those with IPN. However, it is technically not feasible in patients with early pancreatic/peripancreatic fluid collections (PFC) (< 2-4 wk) where the wall has not formed; in PFC in paracolic gutters/pelvis; or in walled off pancreatic necrosis (WOPN) distant from the stomach/duodenum. Percutaneous drainage of these infected PFC or WOPN provides rapid infection control and patient stabilization. In a subset of patients where sepsis persists and necrosectomy is needed, the sinus drain tract between WOPN and skin-established after percutaneous drainage or surgical necrosectomy drain, can be used for percutaneous direct endoscopic necrosectomy (PDEN). There have been technical advances in PDEN over the last two decades. An esophageal fully covered self-expandable metal stent, like the lumen-apposing metal stent used in transmural direct endoscopic necrosectomy, keeps the drainage tract patent and allows easy and multiple passes of the flexible endoscope while performing PDEN. There are several advantages to the PDEN procedure. In expert hands, PDEN appears to be an effective, safe, and minimally invasive adjunct to the management of IPN and may particularly be considered when a conventional drain is in situ by virtue of previous percutaneous or surgical intervention. In this current review, we summarize the indications, techniques, advantages, and disadvantages of PDEN. In addition, we describe two cases of PDEN in distinct clinical situations, followed by a review of the most recent literature.

Keywords: Direct endoscopic necrosectomy; Infected pancreatic necrosis; Percutaneous endoscopic necrosectomy; Sinus tract endoscopy; Stent-assisted percutaneous direct endoscopic necrosectomy.

Figure 1

Schematic representation of steps involved in percutaneous direct endoscopic necrosectomy. A: Image-guided pigtail drainage of infected pancreatic/peripancreatic collection; B: Partial resolution of infected walled off pancreatic necrosis (WOPN) with maturation of drainage tract between the skin and WOPN (usually 7-10 d approximately); C and D: Drainage tract dilation with (C) wire-guided controlled radial expansion balloon or (D) an esophageal fully covered self-expandable metal stent (SEMS); E and F: Percutaneous direct endoscopic necrosectomy with flexible endoscope through (E) the dilated tract or (F) a fully covered SEMS; G: Placement of large bore abdominal drain and irrigation catheter for drainage and irrigation of WOPN cavity, respectively.

Figure 2

Abdominal contrast enhanced computerized tomography. A and B: Large, irregular infected pancreatic/peripancreatic collection (PFC) (arrows) in upper abdomen in coronal and transverse sections; C: Partial resolution of PFC (arrow) with a 14 F pigtail (arrow head) in situ; D-F: A 26 F drain (arrows) and a 7 F pigtail irrigation catheter (red arrow head) in walled off pancreatic necrosis (WOPN), and nasojejunal tube (white arrow heads); G and H: A 32 F drain (arrow) in situ with complete resolution of WOPN after (G) 2 wk and (H) 4 wk of percutaneous direct endoscopic necrosectomy.

Figure 3

Percutaneous direct endoscopic necrosectomy. A and B: Infected necrotic debris in walled off pancreatic necrosis (WOPN); C: A flexible upper gastrointestinal scope deep within the WOPN cavity for percutaneous direct endoscopic necrosectomy (PDEN); D and E: Clean WOPN cavity after PDEN.

Figure 4

Abdominal contrast enhanced computerized tomography. A and B: Residual walled off pancreatic necrosis (WOPN) (arrow heads) with post open necrosectomy drain (arrows) in situ; C: An esophageal fully covered self-expandable stent (red arrow) in WOPN with a 7 F irrigation catheter (yellow arrow). The asterisk (*) indicates injected contrast within WOPN cavity; D: Complete resolution of WOPN with the drain in situ (arrow).

Figure 5

Drainage tract dilation and placement of a self-expandable metal stent. A: Coiling of the guide-wire along with contrast in walled off pancreatic necrosis (WOPN); B: Dilation of the drainage tract with Amplatz dilators over the guide-wire; C: An esophageal fully covered self- expandable metal stent (SEMS) secured to the skin with sutures; D: A 7 F irrigation catheter in WOPN through a fully covered SEMS; E: A stoma bag secured in place over fully covered SEMS with a 7 F irrigation catheter in place.

Figure 6

Percutaneous direct endoscopic necrosectomy. A and B: Infected necrotic debris in walled off pancreatic necrosis (WOPN); C: A flexible endoscope through a fully covered self-expandable metal stent with ability to angulate to reach deep within the cavity; D and E: Clean WOPN cavity after percutaneous direct endoscopic necrosectomy.