Geoffrey A. Bader, MD, Kimberly Zibert, DO, Charles B. Miller, MD
Brooke Army Medical Center, San Antonio, TX
Introduction: Pancreatic fluid collections are one of the most common complications of acute pancreatitis. While the majority of pancreatic fluid collections are self-limited, acute necrotic collections have a high likelihood of evolving into walled off pancreatic necrosis, with nearly two-thirds of cases requiring intervention. Endoscopic debridement of centrally located walled off pancreatic necrosis via transmural stents and direct necrosectomy is becoming increasingly popular due to its high success rate and low associated morbidity and mortality.
Management of lateral walled off pancreatic necrosis has traditionally been managed surgically. New innovations in multidisciplinary, minimally invasive procedures are becoming increasingly utilized, though case reports are rare. We present a case of sinus tract endoscopy via a surgically placed trocar to debride an extensive collection of walled off necrosis in the left retroperitoneal space.
Case Description/Methods: Our patient is a 65 year old female with a history of alcohol induced, necrotizing pancreatitis with infected walled off necrotic collections extending along the infrarenal spaces bilaterally. She initially underwent computed tomography guided percutaneous catheter placement, which failed to provide source control. Given the large size and technically difficult location of the infrarenal necrosis, a multidisciplinary approach was pursued. In the operating room, the general surgery service placed a 15mm surgical trocar into the left retroperitoneal space to successfully access the lesion. The therapeutic gastroenterology team then advanced a pediatric colonoscope via the trocar into the retroperitoneal space. Following the previously placed percutaneous drains, and utilizing various sized snares, 3-prong grasper, and Rat tooth forceps, all necrotic tissue was successfully debrided and retrieved. A wire was left in place and used to successfully place a surgical drain. The patient tolerated the procedure well without acute complications. Repeat cross sectional imaging demonstrated significant interval decrease in size of the necrotic collections. The patient recovered without further intervention and was doing well at 6 month follow up.
Discussion: Sinus tract endoscopy via surgically or CT guided placement of trocars is an efficacious and safe procedure for lateral walled off pancreatic necrosis. Our case illustrates the evolving role for minimally invasive procedures for pancreatic fluid collections inaccessible to transmural approaches.
Citation: Geoffrey A. Bader, MD, Kimberly Zibert, DO, Charles B. Miller, MD. P0044 - A CASE OF DIRECT NECROSECTOMY VIA SINUS TRACT ENDOSCOPY IN THE RETROPERITONEUM: A UNIQUE APPROACH TO A DIFFICULT PROBLEM. Program No. P0044. ACG 2019 Annual Scientific Meeting Abstracts. San Antonio, Texas: American College of Gastroenterology.