Gastroscopic pancreatic necrosectomy : reporting the first two cases performed at Mater Dei Hospital

Abstract

Background: Severe acute pancreatitis is associated with significant pancreatic and peri-pancreatic necrosis. Infection of this necrotic tissue is associated with a mortality in the region of 30%. Infected pancreatic necrosis was conventionally treated with open surgical techniques, but this approach was associated with a very high morbidity and mortality. Over the past two decades minimally invasive techniques have proved to be both effective and safe. Methods: A 54-year-old male presented with biliary severe acute pancreatitis. He was admitted to the ITU on the second day post-admission where he required ventilatory support, dialysis and parenteral nutrition. Regular pancreatic CT’s showed evolving walled-off pancreatic necrosis. The patient’s septic markers indices deteriorated requiring intervention for infected necrosis. A cyst-gastrostomy was fashioned, which was then dilated with a CRE oesophageal balloon. The necrosis was then debrided, washed out, and three pig-tail stents left in-situ. During week 8, the patient required endoscopic retrograde cholangio-pancreatography and bile duct stenting as he developed jaundice and worsening septic markers. A final necrosectomy was performed during week 10. Following this, he was discharged home and an elective laparoscopic cholecystectomy was organised. Results: Aggressive ITU care was required to help this patient with severe acute pancreatitis to survive. Three sessions were required to achieve resolution after the walled-off pancreatic necrosis was judged mature. As opposed to percutaneous, laparoscopic or retroperitoneoscopic techniques, this approach obviates the development of pancreatic fistula and the need for cumbersome constant irrigation. Conclusion: Pancreatic necrosectomy can be performed safely and effectively with readily available ERCP and gastroscopic equipment, with the help of EUS localisation. This procedure should be considered as treatment of choice for patients developing walled-off pancreatic necrosis.