Combined minimally invasive management of infected pancreatic necrosis: a case report.

IntroductionSevere acute pancreatitis (SAP) has a high mortality rate of 20% to 30%, with death often resulting from hemorrhage.AimTo investigate the role of digital subtraction angiography (DSA) and endovascular embolization in the management of arterial bleeding in SAP patients.Material and methodsSeventy-six patients with SAP admitted to our hospital between January 2010 and May 2016 underwent DSA. DSA revealed arterial bleeding in 22 of these patients, who were treated with transcatheter endovascular embolization with coils and/or gelfoam particles. Patient demographics, angiographic features of vascular abnormalities, and outcomes of embolization were assessed.ResultsArterial bleeding was the most common vascular abnormality (22/76 patients; 28.9%). DSA enabled the identification of 27 bleeding arteries in 22 patients. The splenic artery was the most commonly affected vessel (11/27; 40.7%). Among the 27 arteries treated with endovascular embolization, successful hemostasis was achieved in 96.3% (26/27). Two patients developed major complications (hepatic and splenic abscess). These patients were treated with abdominal catheter drainage and anti-infection measures and ultimately recovered. The mean interval between initial onset of SAP and angiographic diagnosis of arterial bleeding was 56 days. Rebleeding was diagnosed in 5 patients (5/22; 22.7%) during repeat angiography, with bleeding from new sites in four of these patients. The mean interval between successive angiography treatments was 38 days.ConclusionsEndovascular embolization is a safe and effective method to localize bleeding arteries and achieve complete hemostasis in patients with SAP-related arterial bleeding.

Section: Discussionmentioning

confidence: 99%

Endovascular embolization of arterial bleeding in patients with severe acute pancreatitis.

Ai¹,

Lu²,

Xu³

2019

“…Moreover, such methods result in better outcomes as well as in higher safety in comparison to classical surgical treatment [ 12 , 13 ]. The dilation of an access to necrosis by use of a few techniques at the same time makes the drainage conditions better (“step-up approach”) [ 6 , 9 ]. Endoscopic treatment of WOPN is based on transpapillary or transmural (through the stomach or duodenal wall) drainage, or a combination of both access methods.…”

Section: Introductionmentioning

confidence: 99%

Transpapillary drainage of walled-off pancreatic necrosis - a single center experience.

Smoczyński¹,

Jagielski²,

Jabłońska³

et al. 2015

IntroductionWalled-off pancreatic necrosis (WOPN) often coexists with disruption of the main pancreatic duct that manifests as a leak of contrast medium into the necrotic collection during endoscopic retrograde pancreatography.AimTo assess the efficacy and safety of treatment of patients with symptomatic WOPN and disruption of the main pancreatic duct, who underwent endoscopic transpapillary drainage as the only access to the necrosis cavity.Material and methodsIn 22 patients with symptomatic WOPN, active endoscopic transpapillary drainage was performed. During endoscopic retrograde pancreatography (ERP), partial disruption of the main pancreatic duct was observed in 14 patients and complete disruption in 8 patients. After the active drainage was finished, a transpapillary pancreatic stent was inserted into the main pancreatic duct, which was later exchanged after 6, 12 and 24 months or when no extravasation of contrast from the pancreatic duct was observed. The results of treatment and complications were compared retrospectively.ResultsThe mean duration of active drainage was 22 (range: 7–94) days. Complications of endotherapy occurred in 3/22 patients. The mean time of the main pancreatic duct stenting was 304 (range: 85–519) days. Success of endoscopic treatment of WOPN and pancreatic duct disruption was achieved in 20/22 patients. During a 1-year follow-up, recurrence of the collection was noted in 4/20 patients. Long-term success was achieved in 16/22 patients.ConclusionsIn patients with WOPN who cannot undergo transmural drainage when there is a communication between the necrotic collection and the main pancreatic duct, transpapillary access may be an effective and safe method of treatment.

Endoscopic treatment of multilocular walled-off pancreatic necrosis with the multiple transluminal gateway technique.

Jagielski¹,

Smoczyński²,

Adrych³

2017

The development of minimally invasive techniques allowed access to the necrotic cavity through transperitoneal, retroperitoneal, transmural and transpapillary routes. The choice of access to walled-off pancreatic necrosis (WOPN) should depend not only on the spread of necrosis, but also on the experience of the clinical center. Herein we describe treatment of a patient with multilocular symptomatic walled-off pancreatic necrosis using minimally invasive techniques. The single transmural access (single transluminal gateway technique – SGT) to the necrotic collection of the patient was ineffective. The second gastrocystostomy was performed using the same minimally invasive technique as an extra way of access to the necrosis (multiple transluminal gateway technique – MTGT). In the described case the performance of the new technique consisting in endoscopic multiplexing transmural access (MTGT) was effective enough and led to complete recovery of the patient.