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A 76-year-old man underwent EUS for the evaluation of intermittent elevation of liver enzymes; EUS revealed cholelithiasis with choledocholithiasis. Successful stone extraction was accomplished with biliary sphincterotomy and balloon extraction. A pancreatic duct stent was placed for post-ERCP prophylaxis of pancreatitis. The procedures were performed with the patient under propofol anesthesia without an esophageal overtube.
The patient subsequently experienced postprocedure pancreatitis, later complicated by an infected walled-off pancreatic necrosis (WOPN) measuring 17 × 12 × 8 cm (Figs. 1A-C). An interventional radiologist placed a 12F pigtail catheter for drainage. After 4 weeks, the patient underwent the creation of cyst-gastrostomy with a plan for necrosectomy (Video 1, available online at www.VideoGIE.org).
Figure 1A, B, C, Initial CT scan showing large walled-off pancreatic necrosis (transverse, coronal, and sagittal views). D, EUS-guided lumen-apposing metal stent placement. E, Large tissue pieces removed with cap-assisted snare. F, Large tissue pieces removed with cap-assisted forceps. G, Cyst cavity after second session of necrosectomy. H, Follow-up CT view at 3 weeks showing complete resolution. LAMS, lumen-apposing metal stent; WOPN, walled-off pancreatic necrosis.
EUS-guided cyst-gastrostomy (Fig. 1D) was performed with a cautery-enhanced lumen-apposing metal stent (LAMS), 15 mm × 10 mm (Axios, Boston Scientific, Natick, Mass). Three days later, the patient underwent endoscopic necrosectomy. Multiple passes with a combination of snare and raptor forceps were performed, with only a small amount of necrotic material removed each time from within the blocked lumen of the stent. Afterward, a sterilized banding cap (6 shooter multiband ligator, Cook Medical, Bloomington, Ind) was attached and was used to suction necrotic material from the stent lumen, which helped remove larger amounts of debris. While the cap was kept within the lumen of the stent, a snare was opened, necrotic tissue was suctioned, and the snare was used to either cut or pull away the necrotic debris. Similarly, the raptor forceps was opened within the cap and suction was applied. These techniques resulted in significantly larger pieces of tissue being easily removed (Figs. 1E and F). The external pigtail catheter was removed during the second endoscopic necrosectomy 1 week later (Fig. 1G). Subsequent CT 3 weeks later showed complete resolution of the WOPN (Fig. 1H).
The major advantage of this technique is that staying within the lumen of the LAMS and initiating suction pulls up just the necrotic material, not viable tissue, into the cap, which significantly increases safety. Additionally, significant time is saved because much larger amounts of tissue are removed, and clearance of the necrotic material can be accomplished in fewer and shorter endoscopy sessions. In addition, forceps cannot catch the lattice of the stent. In our patient, complete necrosectomy was achieved easily in just 2 upper-endoscopy appointments.
In conclusion, cap-assisted necrosectomy increases the safety and efficiency of the procedure, is likely more cost effective, and can be instituted easily.
Disclosure
All authors disclosed no financial relationships relevant to this publication.
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