EUS-guided drainage using lumen apposing metal stent and percutaneous endoscopic necrosectomy as dual approach for the management of complex walled-off necrosis: a case report and a review of the literature

Abstract

Background Endoscopic ultrasound-guided drainage is suggested as the first approach in the management of symptomatic and complex walled-off pancreatic necrosis. Dual approach with percutaneous drainage could be the best choice when the necrosis is deep extended till the pelvic paracolic gutter; however, the available catheter could not be large enough to drain solid necrosis neither to perform necrosectomy, entailing a higher need for surgery. Therefore, percutaneous endoscopic necrosectomy through a large bore percutaneous self-expandable metal stent has been proposed. Case presentation In this study, we present the case of a 61-year-old man admitted to our hospital with a history of sepsis and persistent multiorgan failure secondary to walled-off pancreatic necrosis due to acute necrotizing pancreatitis. Firstly, the patient underwent transgastric endoscopic ultrasound-guided drainage using a lumen-apposing metal stent and three sessions of direct endoscopic necrosectomy. Because of recurrence of multiorgan failure and the presence of the necrosis deeper to the pelvic paracolic gutter at computed tomography scan, we decided to perform percutaneous endoscopic necrosectomy using an esophageal self-expandable metal stent. After four sessions of necrosectomy, the collection was resolved without complications. Therefore, we perform a revision of the literature, in order to provide the state-of-art on this technique. The available data are, to date, derived by case reports and case series, which showed high rates both of technical and clinical success. However, a not negligible rate of adverse events has been reported, mainly represented by fistulas and abdominal pain. Conclusion Dual approach, using lumen apposing metal stent and percutaneous self-expandable metal stent, is a compelling option of treatment for patients affected by symptomatic, complex walled-off pancreatic necrosis, allowing to directly remove large amounts of necrosis avoiding surgery. Percutaneous endoscopic necrosectomy seems a promising technique that could be part of the step-up-approach, before emergency surgery. However, to date, it should be reserved in referral centers, where a multidisciplinary team is disposable.

Percutaneous Endoscopic Necrosectomy—A Review of the Literature

“…Since the first reports on the dual-modality drainage technique [56], the methods for endoscopic and percutaneous treatment of pancreatic necrosis have evolved toward a more aggressive [1][2][3][4][5][6][7][8][9][10][11][12][13][14]16,[19][20][21][22][23][24][25][26][27][28][29][30][31][32][33][34][35]35,36,[38][39][40][41]59], necrosectomy-based approach, which is also reflected in the aforementioned PEN approach, as well as in the multiple-access strategy in which PEN is combined with transmural endoscopic access techniques [37,[42][43][44][45][46][47][48][49]…”

“…In these cases, percutaneous drainage of the necrotic collection, with potential escalation to surgical necrosectomy, remains the treatment of choice [3,[19][20][21][22][23][24][25][26][27][28][29][30]. However, isolated cases of an alternative approach that combines the elements of the endoscopic step-up approach with those of the surgical step-up approach and is referred to as PEN have been published recently [42][43][44][45][46][47][48]. acute necrotizing pancreatitis has limitations [1,[4][5][6][7][8].…”

“…The quality assessment was limited by small amount of data and small number of available articles on this issue (Table 1). In total, 52 patients from 15 studies were included in this review [37,[42][43][44][45][46][47][48][49][50][51][52][53][54][55] (Table 1).…”

“…This method involves endoscopic techniques and percutaneous retroperitoneal access. PEN [ 42 , 43 , 44 , 45 , 46 , 47 , 48 ] consists of the gaining of access to the necrotic collection via percutaneous drainage, followed by broadening of the access and percutaneous placement of a large-diameter self-expandable esophageal stent to facilitate percutaneous insertion of an endoscope into the necrotic collection for endoscopic necrosectomy. Only a few papers [ 37 , 44 , 45 , 46 , 47 , 48 , 49 , 50 , 51 , 52 , 53 , 54 , 55 ] have presented the treatment outcomes of patients with pancreatic necrosis who underwent PEN since the first published description [ 42 , 43 ] of the technique.…”

“…PEN [ 42 , 43 , 44 , 45 , 46 , 47 , 48 ] consists of the gaining of access to the necrotic collection via percutaneous drainage, followed by broadening of the access and percutaneous placement of a large-diameter self-expandable esophageal stent to facilitate percutaneous insertion of an endoscope into the necrotic collection for endoscopic necrosectomy. Only a few papers [ 37 , 44 , 45 , 46 , 47 , 48 , 49 , 50 , 51 , 52 , 53 , 54 , 55 ] have presented the treatment outcomes of patients with pancreatic necrosis who underwent PEN since the first published description [ 42 , 43 ] of the technique. This paper reviews the available literature to evaluate the efficacy and safety of PEN for the treatment of patients with acute necrotizing pancreatitis.…”