EUS-guided drainage using lumen apposing metal stent and percutaneous endoscopic necrosectomy as dual approach for the management of complex walled-off necrosis: a case report and a review of the literature

Choledochoscope-Guided Necrosectomy for Retroperitoneal and Posterior Rectal Post-Pancreatitis Necrosis

BACKGROUND Severe acute pancreatitis is a severe acute abdominal disease. Signs and symptoms classically vary from abdominal pain to fever, vomiting, and abdominal distension. Severe complications, such as infected pancreatic necrosis and multiple organ dysfunction syndrome, can occur. The various treatment strategies in acute necrotizing pancreatitis include percutaneous drainage, laparoscopic necrosectomy, endoscopic necrosectomy, and minimally invasive or more hazardous open surgery. In the presently described case, the effect of puncture drainage was not significant, and then choledochoscope-assisted pancreatic necrosectomy was performed. CASE REPORT In this case, a 41-year-old Chinese man developed extensive retroperitoneal necrosis extending into the posterior rectum following severe acute pancreatitis. The treatment of secondary infection of pancreatic necrotic tissue remains a major challenge. The drainage catheter for the abdominal puncture was inserted, but it was not effective enough. On the 45th day of admission, choledochoscope-assisted pancreatic necrosectomy was performed. After the operation, the patient was given continuous saline flushing through the drain and low continuous suction was applied to the lumen sump drain. We consider this to be a valuable case in which a patient improved in response to placement of a drain intraoperatively in the posterior rectum. CONCLUSIONS We report a patient who developed extensive retroperitoneal necrosis extending into the posterior rectum following severe acute pancreatitis. We decided to perform choledochoscope-assisted pancreatic necrosectomy; the necrotic tissue around the posterior rectum was removed and a triple lumen sump drain was placed in the posterior rectum. This is the first case of infection of the posterior rectal space after severe acute pancreatitis treated by choledochoscope-assisted pancreatic necrosectomy.

[Percutaneous retroperitoneal necrectomy for infected forms of acute necrotizing pancreatitis]

The review is devoted to percutaneous retroperitoneal necrectomy in the treatment of infected forms of acute pancreatitis. The indications for retroperitoneal necrectomy are given, and technical features are described for open retroperitoneal necrectomy, percutaneous endoscopic retroperitoneal necrectomy, video-assisted retroperitoneal debridement and transfistular endoscopic retroperitoneal necrectomy. Available data on results of percutaneous retroperitoneal necrectomy indicate expediency of wider application of this treatment option for infected forms of acute necrotizing pancreatitis in large multidisciplinary centers.

Efficacy and Safety of Anhydrous Ethanol-Assisted Endoscopic Ultrasound-Guided Transluminal Necrosectomy in Infected Necrotizing Pancreatitis

AIM

Endoscopic necrosectomy has become the first-line treatment option for infectious necrotizing pancreatitis (INP), especially walled-off necrosis. However, the problems, including operation-related adverse events (AEs) and the need for multiple endoscopic procedures, have not been effectively addressed. We sought to evaluate the clinical safety and efficacy of anhydrous ethanol-assisted endoscopic ultrasound (EUS)-guided transluminal necrosectomy in INP.

METHODS

A single-center observational cohort study of INP patients was conducted in a tertiary endoscopic center. Anhydrous ethanol-assisted EUS-guided transluminal necrosectomy (modified group) and conventional endoscopic necrosectomy (conventional group) were retrospectively compared in INP patients. The technical and clinical success rates, operation time, perioperative AEs, postoperative hospital stay, and recurrent INP rates were analyzed, respectively.

RESULTS

A total of 55 patients were enrolled. No statistically significant differences were observed between the two groups regarding baseline characteristics. Compared to patients in the conventional group, patients in the modified group demonstrated significantly reduced times of endoscopic transluminal necrosectomies (1.96 ± 0.89 vs. 2.73 ± 0.98; P = 0.004) and comparable perioperative AEs (P = 0.35). Meanwhile, no statistically significant differences were observed in the technical and clinical success rates (P = 0.92), operation time (P = 0.59), postoperative hospital stay (P = 0.36), and recurrent INP rates (P = 1.00) between the two groups.

CONCLUSION

Anhydrous ethanol-assisted EUS-guided transluminal necrosectomy seemed safe and effective in treating INP. Compared with conventional endoscopic transluminal necrosectomy, its advantage was mainly in reducing the number of endoscopic necrosectomies without increasing perioperative AEs.

Efficacy and Safety of Anhydrous Ethanol-Assisted Endoscopic Ultrasound-Guided Transluminal Necrosectomy in Infected Necrotizing Pancreatitis

AIM

Endoscopic necrosectomy has become the first-line treatment option for infectious necrotizing pancreatitis (INP), especially walled-off necrosis. However, the problems, including operation-related adverse events (AEs) and the need for multiple endoscopic procedures, have not been effectively addressed. We sought to evaluate the clinical safety and efficacy of anhydrous ethanol-assisted endoscopic ultrasound (EUS)-guided transluminal necrosectomy in INP.

METHODS

A single-center observational cohort study of INP patients was conducted in a tertiary endoscopic center. Anhydrous ethanol-assisted EUS-guided transluminal necrosectomy (modified group) and conventional endoscopic necrosectomy (conventional group) were retrospectively compared in INP patients. The technical and clinical success rates, operation time, perioperative AEs, postoperative hospital stay, and recurrent INP rates were analyzed, respectively.

RESULTS

A total of 55 patients were enrolled. No statistically significant differences were observed between the two groups regarding baseline characteristics. Compared to patients in the conventional group, patients in the modified group demonstrated significantly reduced times of endoscopic transluminal necrosectomies (1.96 ± 0.89 vs. 2.73 ± 0.98; P = 0.004) and comparable perioperative AEs (P = 0.35). Meanwhile, no statistically significant differences were observed in the technical and clinical success rates (P = 0.92), operation time (P = 0.59), postoperative hospital stay (P = 0.36), and recurrent INP rates (P = 1.00) between the two groups.

CONCLUSION

Anhydrous ethanol-assisted EUS-guided transluminal necrosectomy seemed safe and effective in treating INP. Compared with conventional endoscopic transluminal necrosectomy, its advantage was mainly in reducing the number of endoscopic necrosectomies without increasing perioperative AEs.

Metal stent and percutaneous endoscopic necrosectomy as dual approach for the management of complex walled-off pancreatic necrosis

Pancreatic fluid collections (PFCs) are one of the local complications of acute pancreatitis and include walled-off pancreatic necrosis (WOPN), which are complex entities with challenging management. The infection of pancreatic necrosis leads to a poorer prognosis, with a growth of the mortality rate up to 30%. The primary strategy for managing PFCs is a minimally invasive step-up approach, with endosonography-guided transmural drainage and debridement as the preferred and less invasive method. Percutaneous drainage (PCD) can be the technique of choice when endoscopic drainage is not feasible, for example for early PFCs without a mature wall or for the anatomic location and extension to the paracolic gutter of the collection. As PCD alone may be ineffective, especially when a great amount of necrosis is present, a percutaneous endoscopic necrosectomy (PEN) has been proposed, showing interesting results. The technique consists of the placement of an esophageal fully or partially covered self-expandable metal stent (SEMS) percutaneously into the collection and a direct debridement can be performed using a flexible endoscope through the SEMS. In this review, we will discuss about the role of metal stent and PEN for the management of complex walled-off pancreatic necrosis.

[Transgastric necrectomy for acute pancreatitis]

The review is devoted to transgastric necrectomy in the treatment of infected forms of acute pancreatitis. The authors discuss the indications for transgastric necrectomy and technical features of these interventions (direct endoscopic necrectomy, laparoscopic and open transgastric necrectomy). Numerous studies devoted to results of transgastric necrectomy indicate advisability of this procedure in carefully selected patients and interdisciplinary interaction of various specialists before and after surgery. Regional specialized centers for the treatment of severe acute pancreatitis are necessary for wider introduction of minimally invasive surgical technologies and their personalization.

Renal Abscess Drainage Using a Novel Transgastric Endoscopic Approach: A Case Report

Renal and perinephric abscesses are rare purulent infections within or around renal parenchyma, typically treated with antibiotics or various procedural approaches depending on abscess size. In this case report, we describe the novel use of a transgastric endoscopic ultrasound (EUS)-guided technique with placement of a stent for drainage between a renal abscess and the stomach in a patient who had failed attempted percutaneous drainage twice and where an open surgical approach was deemed inappropriate. The patient presented with a chief complaint of left flank pain, with CT revealing a ~4 x 4 cm renal abscess in the upper pole of the left kidney. Urology, Infectious Disease, and Interventional Radiology were consulted. Following two failed attempts at percutaneous drain placement, the patient elected for EUS-guided transgastric stent placement for drainage. The stent was removed by postoperative day two after significant decompression of the abscess. He was advised to follow up outpatient with Urology to confirm full renal abscess resolution.

Endoscopic versus minimally invasive surgical approach for infected necrotizing pancreatitis: a systematic review and meta-analysis of randomized controlled trials

BACKGROUND/AIMS

Acute pancreatitis is a common condition of the digestive system, but sometimes it develops into severe cases. In about 10-20% of patients, necrosis of the pancreas or its periphery occurs. Although most have aseptic necrosis, 30% of cases will develop infectious necrotizing pancreatitis. Infected necrotizing pancreatitis (INP) requires a critical treatment approach. Minimally invasive surgical approach (MIS) and endoscopy are the management methods. This meta-analysis compares the outcomes of MIS and endoscopic treatments.

METHODS

We searched a medical database until December 2022 to compare the results of endoscopic and MIS procedures for INP. We selected eligible randomized controlled trials (RCTs) that reported treatment complications for the meta-analysis.

RESULTS

Five RCTs comparing a total of 284 patients were included in the meta-analysis. Among them, 139 patients underwent MIS, while 145 underwent endoscopic procedures. The results showed significant differences (p < 0.05) in the risk ratios (RRs) for major complications (RR: 0.69, 95% confidence interval (CI): 0.49-0.97), new onset of organ failure (RR: 0.29, 95% CI: 0.11-0.82), surgical site infection (RR: 0.26, 95% CI: 0.07-0.92), fistula or perforation (RR: 0.27, 95% CI: 0.12-0.64), and pancreatic fistula (RR: 0.14, 95% CI: 0.05-0.45). The hospital stay was significantly shorter for the endoscopic group compared to the MIS group, with a mean difference of 6.74 days (95% CI: -12.94 to -0.54). There were no significant differences (p > 0.05) in the RR for death, bleeding, incisional hernia, percutaneous drainage, pancreatic endocrine deficiency, pancreatic exocrine deficiency, or the need for enzyme use.

CONCLUSIONS

Endoscopic management of INP performs better compared to surgical treatment due to its lower complication rate and higher patient life quality.

Percutaneous endoscopic necrosectomy for walled-off necrosis in the retroperitoneal space of the elderly: A case report

BACKGROUND

Walled-off necrosis (WON) is a late complication of acute pancreatitis possibly with a fatal outcome. Even for WON spreading to the retroperitoneal space, percutaneous endoscopic necrosectomy (PEN) can be an alternate approach to surgical necrosectomy, particularly for the older individuals or patients with poor condition because of WON.

CASE SUMMARY

An 88-year-old man was admitted to our hospital with a jaundice. Endoscopic retrograde cholangiopancreatography (ERCP) was performed to improve jaundice; however, post-ERCP pancreatitis developed. The inflammation of pancreatitis spread widely from the right retroperitoneal cavity to the pelvis, and WON was formed 4 wk later. A percutaneous drainage tube was placed into the WON under computed tomography guidance. However, the drainage did not ameliorate clinical symptoms including fever, which assured less invasive necrosectomy. A metallic stent for the upper gastrointestinal (GI) tract was placed from the percutaneous drainage route. An upper GI endoscope was inserted into the inside of the WON through the metallic stent, and the necrotic tissues were bluntly removed with a snare forceps. Ten times of these necrosectomies resulted in the near-complete removal of necrotic tissues. These procedures consequently abated his fever and remarkable improvement in blood tests.

CONCLUSION

PEN for WON occurring in the retroperitoneal space was safe and effective for very old individuals.

Percutaneous direct endoscopic pancreatic necrosectomy

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.

Percutaneous Endoscopic Necrosectomy-A Review of the Literature

In this article, an attempt was made to clarify the role of percutaneous endoscopic necrosectomy (PEN) in the interventional treatment of pancreatic necrosis. A comprehensive review of the current literature was performed to identify publications on the role of PEN in patients with consequences of acute necrotizng pancreatitis. The aim of the study was to review the literature on minimal invasive necrosectomy, with emphasis on PEN using esophageal self-expanding metal stents (SEMS). The described results come from 15 studies after a review of the current literature. The study group comprised 52 patients (36 men and 16 women; mean age, 50.87 (13-75) years) with walled-off pancreatic necrosis, in whom PEN using a self-expandable esophageal stent had been performed. PEN was successfully completed in all 52 patients (100%). PEN complications were observed in 18/52 (34.62%) patients. Clinical success was achieved in 42/52 (80.77%) patients, with follow-up continuing for an average of 136 (14-557) days. In conclusion, the PEN technique is potentially effective, with an acceptable rate of complications and may be implemented with good clinical results in patients with pancreatic necrosis.