Current Utility of Transgastric Percutaneous Drainage for the Management of Pancreatitis-Related Retrogastric Walled-Off Necrotic Collections: A Prospective Observational Study

Abstract

Introduction Pancreatic fluid collection (PFC) is one of the most frequent complications associated with acute pancreatitis. The route of drainage is guided by the size and site of collection. The present study aims to assess the clinical and technical success of transgastric percutaneous drainage (PCD) for managing retrogastric walled-off pancreatic necrosis (WOPN). Materials and methods A total of 44 patients with acute pancreatitis diagnosed with WOPN who underwent transgastric PCD with ultrasound or CT guidance as part of standard clinical management were included in the study. Patients were observed for improvement in clinical parameters, and treatment outcomes were noted in terms of technical success, clinical success, adverse events, need for additional procedures, hospital stay, and duration of placement of all drains. Data for the internalization of transgastric PCD was also observed in the study. Results Technical success during the drain placement was observed in 93% (n=41) of patients.Internalization of the transgastric drain was attempted in 12 patients and successful in 11 (91%). The median duration of hospital stay from the time of placement of the first PCD until discharge and the median duration of all PCDs placed were higher in patients where the transgastric drain was not internalized as compared to patients where the transgastric drain was internalized. Conclusion In WOPN, transgastric drain placement and successful internalization in any form help in the early resolution of peripancreatic and abdominal collections. It also reduces the time to percutaneous catheter removal, which in turn reduces the morbidity and decreases the need for additional interventions or surgery.

Keywords: acute necrotizing pancreatitis; internalization; percutaneous drainage; transgastric drainage; walled-off pancreatic necrosis.

Figure 1. Steps of CT-guided transgastric drain placement

(a) An ill-defined, walled-off pancreatic necrosis in the lesser sac. (b) Placement of an 18-G needle across the anterior wall of the stomach. (c) Puncturing both the anterior and posterior walls of the stomach. (d) Passage of 0.038-inch stiff wire through the needle. (e) Dilatation of the tract using 10 Fr Coon’s dilator (f) Placement of 10 Fr locking loop pigtail catheter

Figure 2. Steps of internalization of transgastric drain

The stomach is inflated with air before the procedure. (a) Terumo guidewire was inserted through the drain into the collection. (b) One end of the drain and its two wires are cut, while the Terumo guidewire is still in place and the cut end is removed. (c) One end of Coon’s dilator is cut. (d) The cut end of Coon’s dilator is used to push the drain inside the stomach. (e and f) CT images showing the final position of the internalized drain within the stomach after the removal of the guidewire and dilator