Advertisement

Percutaneous debridement and washout of walled-off abdominal abscess and necrosis by the use of flexible endoscopy: an attractive clinical option when transluminal approaches are unsafe or not possible

Open AccessPublished:May 30, 2019DOI:https://doi.org/10.1016/j.vgie.2019.04.005

      Background and Aims

      Walled-off pancreatic necrosis is a well-known serious adverse event of severe acute pancreatitis. EUS-guided transluminal access followed by direct endoscopic necrosectomy is increasingly used to remove necrosis, with good efficacy and a superior safety profile when compared with surgery. However, a percentage of patients is too critically ill to undergo this procedure or lack an appropriate transluminal window for access. Here we describe the use of percutaneous flexible endoscopic necrosectomy (PEN) with use of standard-sized upper endoscopes and accessories in a retrospective single-institution experience with a video demonstration of 1 patient in the series.

      Methods

      The authors present a 23-patient retrospective case series of PEN with standard-sized endoscopes. The series includes 12 patients from a previously published analysis in 2016 and 11 additional patients from 2013 to 2018. A representative case illustrates the described technique in a patient with severe acute pancreatitis complicated by multisystem organ failure who required immediate drainage of a pancreatic fluid collection and placement of a percutaneous drain into the collection for decompression. The drain was serially upsized to 28F, and its tract was used for PEN.

      Results

      A total of 23 patients have undergone PEN at our institution. On average, the size of the pancreatic fluid collection was 11.6 cm in cross-sectional diameter. Of those 23 patients, 11 presented with symptoms of severe disease. The median time from onset of symptoms to PEN was 84 days. The median number of procedures per patient was 2.1. The median time to complete resolution of symptoms and fluid collections was 67 days. In total, resolution was reached in 22 of 23 patients. Two patients died of unrelated causes.

      Conclusion

      PEN is a minimally invasive and effective treatment approach to walled-off pancreatic necrosis in patients who are not amenable to transluminal drainage and in whom percutaneous drains have been successfully placed. This case series demonstrates the efficacy and safety of this approach. A randomized prospective trial would be warranted to validate these results.

      Abbreviations:

      PEN (percutaneous flexible endoscopic necrosectomy), WOPN (walled-off pancreatic necrosis)

      Introduction

      Walled-off pancreatic necrosis (WOPN) is a well-known serious adverse event of severe acute pancreatitis. In many referral centers, EUS-guided transluminal drainage followed by direct endoscopic necrosectomy is increasingly used to remove the necrosis, with good clinical efficacy and a superior safety profile when compared with surgery (mortality rate of 2%-6% vs up to 50%, respectively).
      • Bello B.
      • Matthews J.
      Minimally invasive treatment of pancreatic necrosis.
      However, a percentage of patients is too critically ill to undergo the deep sedation or general anesthesia that is required for this procedure, and others lack an appropriate transluminal window for access, with both situations typically resulting in percutaneous drainage by radiology. Percutaneous drainage typically provides immediate relief with regard to decompressing the fluid aspect of the collection and stabilizing the patient’s condition; however, percutaneous catheters rarely result in adequate removal of significant necrosis.
      Direct percutaneous flexible endoscopic necrosectomy (PEN) through the established tract with both small and standard-sized endoscopes with CRE™ balloon dilation of the tract has been described, but with limited success. We demonstrate the safety and utility of serial percutaneous drain upsizing to 28F (typically 2-4 exchanges over 2-3 weeks) that allow the use of a standard 8.8-mm upper video endoscope with a 2.8-mm working channel and standard-sized accessories (such as a snare) for mechanical debridement through the established tract. After a clean cavity is achieved, a smaller, more compliant drain is replaced by the endoscopist under fluoroscopy, which is left to gravity drainage until follow-up clinic evaluation with repeated cross-sectional imaging.
      The authors propose that this minimally invasive approach offers a safe and effective treatment modality for WOPN and other intra-abdominal fluid collections in appropriately selected patients. Here we review a 23-patient retrospective case series from our institution (Table 1). The video (Video 1, available online at www.VideoGIE.org) highlights 1 patient in the case series.
      Table 1Summary of cases
      SexAgeEtiology of necrosisSize of necrosis (cm)Severity/adverse eventsDays from symptoms to first interventionNumber of PENNumber of percutaneous drainsTime to resolution (all drains removed) (days)Postprocedure adverse events1-year sustained resolution
      M63Pancreatic10.5 x 3.7 cmNone992157FistulaYes
      M46Hepatic11.9 x 9.7 cm, 12.7 x 6.4 cmSepsis214374NoneYes
      F51Pancreatic23.8 x 15.5 cmSepsis6121171NoneYes
      F34Pancreatic21.2 x 14.9 cm, 13.5 x 7.6 cm, 12.3 x 5.5 cmMultiorgan failure, sepsis6853123NoneYes
      F65Pancreatic14.7 x 3.8 cmMultiorgan failure, sepsis8742n/aNone (death 3 months after procedure)n/a
      F73Omental9.8 x 3.5 cmNone861131NoneYes
      F45Pancreatic14.1 x 12.9 cmNone791110NoneYes
      F26Pancreatic6.4 x 2.5 cmNone2481119NoneYes
      F53Pancreatic11.6 x 5.2 cmNone1241157NoneYes
      M41Pancreatic7.0 x 3.2 cmSepsis531159NoneYes
      F61Pancreatic12.4 x 2.5 cmNone15911210FistulaYes
      F54Pancreatic10.6 x 9.6 cmSepsis845240Nonen/a
      M60Pancreatic11.7 cm x 2.2 cmNone771127NoneYes
      M55Pancreatic15.7 x 9.2 cmMultiorgan failure, sepsis743189NoneYes
      F65Hepatic11.4 x 9.3 x 10.3 cmPersistent leukocytosis12211n/aNone (death 1 month after procedure)n/a
      M42Pancreas9 x 5 x 11 cmNone9511203Fistula/pancreatic duct leakYes
      M31Pancreas6.0 x 7.8 cmNone6822140PD leakYes
      M31Pancreas16.4 x 5.7 cmSepsis7311184PD leakYes, but persistent pseudocyst
      F36Pancreas22 x 10 x 5 cmSepsis18512100NoneYes, persistent fluid
      M51Pancreas22 x 11 cmNone1212135NoneYes
      F85Pancreas10.8 x 5.1 cmTenuous resp status421153PD leakYes
      M79Omental/post-surg bed10 x 5.5 cmNone22421Drains remainNonen/a
      M37Pancreas10 cm x 6.2 cmNone6062116NoneYes

      Patient Case

      A 55-year-old man with a significant cardiac history presented to the emergency department with severe acute pancreatitis and systemic inflammatory response syndrome. He further decompensated, and his case was complicated by acute respiratory distress syndrome, septic shock, and a non-ST-segment elevation myocardial infarction. He was intubated, given vasopressors, and transferred to the intensive care unit. CT showed pancreatic inflammation and colonic wall pneumatosis; he therefore required an urgent exploratory laparotomy and left hemicolectomy. The patient remained in critically ill condition for the following 3 weeks, and CT imaging showed progression of a peripancreatic fluid collection (Fig. 1). On hospital day 27, because of worsening fevers, tachycardia, tachypnea, and abdominal pain, it was thought that the WOPN was likely infected and treatment was indicated.
      Figure thumbnail gr1
      Figure 1Axial CT image showing progression of a peripancreatic fluid collection.
      The patient’s condition was not stable enough to permit endoscopy with deep sedation, and the fluid collection did not appear mature enough for transgastric access and debridement. Consequently, after a multidisciplinary discussion, an interventional radiologist placed a percutaneous drain into the peripancreatic collection, and we planned for serial catheter upsizing for eventual PEN after stabilization. The patient was discharged at week 4 and underwent serial upsizing as an outpatient, concluding with a 28F catheter (Thal-Quick Abscess Drainage Set, Cook Medical, Bloomington, IN, USA).
      He was seen for follow-up in clinic 4 weeks after hospital discharge and was found to be febrile, tachycardic, and tachypneic. He was directly admitted to the hospital and underwent PEN the following day.
      The 28F percutaneous drainage catheter was removed, and a standard 8.8-mm upper flexible endoscope with a 2.8-mm working channel was introduced through the established tract (Fig. 2) into the necrotic cavity. The cavity was lavaged with normal saline, and necrotic debris was progressively removed with a 2-cm stiff polypectomy snare (Fig. 3). When all necrotic debris was removed, the cavity was lavaged with high-volume normal saline solution, and the 28F catheter was replaced. The patient was instructed to flush the drain with 20 to 50 mL of normal saline solution every 4 hours. A total of 3 procedures were performed, and upon completion of the third debridement and washout, no further necrosis was noted (Fig. 4). A smaller, more compliant, 14F pigtail drainage catheter (Skater All-Purpose Drainage Catheter, Argon Medical Devices, Frisco, Tex, USA) (Fig. 5) was placed until outpatient follow-up.
      Figure thumbnail gr2
      Figure 2Endoscopic view of the percutaneous tract leading to the necrotic cavity.
      Figure thumbnail gr3
      Figure 3Endoscopic view of the cavity showing necrotic debris being removed with a stiff polypectomy snare.
      Figure thumbnail gr4
      Figure 4Endoscopic view of the cavity and guidewire after completion of the third percutaneous flexible endoscopic necrosectomy with no further necrosis noted.
      Figure thumbnail gr5
      Figure 514F Skater percutaneous drainage catheter placed by the endoscopist at the completion of the debridement and washout.
      At 12 weeks after necrosectomy, the percutaneous drainage catheter was removed because the output was less than 20 mL per day for 3 days, and follow-up cross-sectional imaging showed complete resolution of the WOPN (Fig. 6). No recurrent fluid collections were noted.
      Figure thumbnail gr6
      Figure 6Coronal CT image 12 weeks after necrosectomy showing complete resolution of the walled-off pancreatic necrosis.

      Conclusion

      PEN is a minimally invasive and effective treatment approach to WOPN in patients who are not amenable to transluminal drainage and in whom percutaneous drains have been successfully placed. A brief overview of the 23 patients treated with the PEN techniques described using standard-sized upper endoscopes and accessories at our institution is summarized in Table 1. This approach demonstrates the effectiveness and safety of direct PEN in the treatment of intra-abdominal fluid collections and necrosis in appropriately selected patients. PEN appears to have equivalent efficacy and improved safety when compared with EUS-guided transluminal access, which carries a known serious adverse event rate to upward of 25% and a postoperative mortality rate of 2% to 6%.
      • Bello B.
      • Matthews J.
      Minimally invasive treatment of pancreatic necrosis.
      • Thompson C.C.
      • Kumar N.
      • Slattery J.
      • et al.
      A standardized method for endoscopic necrosectomy improves complication and mortality rates.
      More experience and more robust clinical trials will be required to confirm these results and further develop this approach.

      Disclosure

      Dr Moyer and Dr Mathew are consultants for Boston Scientific. All other authors disclosed no financial relationships relevant to this publication.

      Supplementary data

      • Loading ...

      References

        • Bello B.
        • Matthews J.
        Minimally invasive treatment of pancreatic necrosis.
        World J Gastroenterol. 2012; 18: 6829-6835
        • Thompson C.C.
        • Kumar N.
        • Slattery J.
        • et al.
        A standardized method for endoscopic necrosectomy improves complication and mortality rates.
        Pancreatology. 2015; 16: 66-72