Endoscopic transluminal pancreatic necrosectomy using a self-expanding metal stent and high-flow water-jet system

Abstract

Walled-off pancreatic necrosis and a pancreatic abscess are the most severe complications of acute pancreatitis. Surgery in such critically ill patients is often associated with significant morbidity and mortality within the first few weeks after the onset of symptoms. Minimal invasive approaches with high success and low mortality rates are therefore of considerable interest. Endoscopic therapy has the potential to offer safe and effective alternative treatment. We report here on 3 consecutive patients with infected walled-off pancreatic necrosis and 1 patient with a pancreatic abscess who underwent direct endoscopic necrosectomy 19-21 d after the onset of acute pancreatitis. The infected pancreatic necrosis or abscess was punctured transluminally with a cystostome and, after balloon dilatation, a non-covered self-expanding biliary metal stent was placed into the necrotic cavity. Following stent deployment, a nasobiliary pigtail catheter was placed into the cavity to ensure continuous irrigation. After 5-7 d, the metal stent was removed endoscopically and the necrotic cavity was entered with a therapeutic gastroscope. Endoscopic debridement was performed via the simultaneous application of a high-flow water-jet system; using a flush knife, a Dormia basket, and hot biopsy forceps. The transluminal endotherapy was repeated 2-5 times daily during the next 10 d. Supportive care included parenteral antibiotics and jejunal feeding. All patients improved dramatically and with resolution of their septic conditions; 3 patients were completely cured without any further complications or the need for surgery. One patient died from a complication of prolonged ventilation severe bilateral pneumonia, not related to the endoscopic procedure. No procedure related complications were observed. Transluminal endoscopic necrosectomy with temporary application of a self-expanding metal stent and a high-flow water-jet system shows promise for enhancing the potential of this endoscopic approach in patients with walled-off pancreatic necrosis and/or a pancreatic abscess.

A demarkált pancreasnecrosis kezelése. Irodalmi áttekintés

“…A sebészi gyakorlatban számos lehetőség nyílik a kezelésre attól füg-gően, hogy a necrosis hol helyezkedik el és milyen úton közelíthető meg és távolítható el. Ismeretesek olyan módszerek is, ahol endoszkóppal behelyezett, öntáguló fémstenten keresztül végzik a necrectomiát [8,9,20,39,44,45,49,50,[55][56][57]. A kezelést egyesek hidrogén-hiperoxid alkalmazásával egészítik ki, amellyel tökéletesebb necrectomiát tudnak kivitelezni [15,32,42,49].…”

Waterjet Dissection for Partial Nephrectomy Without Hilar Clamping in a Porcine Model

“…[5][6][7] The kinetic energy of the waterjet carefully separates the layers of tissue. [5][6][7] The ERBEJET 2 (ERBE Elektromedizin GmbH, Tübingen, Germany) is a waterjet surgical device for the preparation and separation of tissue, suitable for preserving layering. The selective separation property of water supports the surgeon in the dissection of parenchymal tissue (e.g., liver, spleen, kidney, brain) while sparing blood vessels and nerves.…”

“…Waterjet dissection has been used for selective dissection of the parenchyma of liver, 4-6 pancreatic necrosectomy, 7 and endoscopic submucosal dissection for gastrointestinal tumors. [8][9][10] In this study, we investigated whether waterjet resection is applicable or feasible for partial nephrectomy without temporary ischemia in a porcine model.…”

Endoscopic ultrasound-guided extraluminal drainage: Novel concepts, challenges and future directions

“…63 EUS-guided transmural gallbladder drainage (EUS-GBD) can be performed as an effective alternative therapy. Recent studies proved that EUS-guided gallbladder transmural drainage is as ef- 50 fective as percutaneous drainage of the gallbladder for patients with acute cholecystitis who are unfit for emergency surgery. 11,64,65 However, potential complications of EUS-GBD are air or bile leakage into the peritoneal cavity and related peritonitis, since plastic stents cannot isolate the fistulous tract and prevent leakage alongside the prosthesis.…”

“…Our group published a series of 4 patients treated with this novel approach combined with irrigation with a high-flow water jet system. 50 Briefly, the infected pancreatic necrosis or abscess was punctured with a cystostome and after balloon dilatation of the tract, a biliary FC-SEMS was placed into the cavity. Following stent deployment, a nasobiliary pigtail catheter was placed into the cavity to ensure continuous irrigation.…”