Gastroscopic Pancreatic Necrosectomy - reporting the first case performed at Mater Dei Hospital
Abstract
Background: Severe acute pancreatitis is associated with significant pancreatic and peri-pancreatic necrosis. Infection of this necrotic tissue is associated with a mortality in the region of 30%. Infected pancreatic necrosis was conventionally treated with open surgical techniques, but this approach was associated with a very high morbidity and mortality. Over the past two decades minimally invasive techniques have proved to be both effective and safe.
Methods: A 54-year-old male presented with biliary severe acute pancreatitis. He was admitted to the ITU on the second day post-admission where he required ventilatory support, dialysis and parenteral nutrition. Regular pancreatic CT’s showed evolving walled-off pancreatic necrosis. The patient’s septic markers indices deteriorated requiring intervention for infected necrosis. A cyst-gastrostomy was fashioned, which was then dilated with a CRE oesophageal balloon. The necrosis was then debrided, washed out, and three pig-tail stents left in-situ. During week 8, the patient required endoscopic retrograde cholangio-pancreatography and bile duct stenting as he developed jaundice and worsening septic markers. A final necrosectomy was performed during week 10. Following this, he was discharged home and an elective laparoscopic cholecystectomy was organised.
Results: Aggressive ITU care was required to help this patient with severe acute pancreatitis to survive. Three sessions were required to achieve resolution after the walled-off pancreatic necrosis was judged mature. As opposed to percutaneous, laparoscopic or retroperitoneoscopic techniques, this approach obviates the development of pancreatic fistula and the need for cumbersome constant irrigation.
Conclusion: Pancreatic necrosectomy can be performed safely and effectively with readily available ERCP and gastroscopic equipment, with the help of EUS localisation. This procedure should be considered as treatment of choice for patients developing walled-off pancreatic necrosis.
Case Presentation
The two male patients in their fifties presented to the emergency department with severe, generalised abdominal pain associated with vomiting and pyrexia. Patient A was a previously fit and healthy individual with a normal body habitus. Patient B was a morbidly obese non-insulin dependent diabetic gentleman with a history of sleep apnoea and depression. Their admission serum levels were more than 2000U/l. Liver function tests were deranged with a cholestatic picture. CT confirmed the diagnosis of severe necrotising acute pancreatitis in both patients, with ultrasound scan confirming gall bladder stones. The patients were admitted for supplemental oxygen, intravenous fluids and analgesia.
Two days post-admission, with a serum lactate level of 6.2mmol/L and a C-reactive protein of 442mh/L, patient A was transferred to the intensive care unit with multi-organ failure. He was suffering from hypoxia, hypotension, uncontrolled hyperglycaemia and renal failure. Total parenteral nutrition was instituted as there was failure of naso-gastric and naso-jejunal feeding.
Repeat serial CT scans performed during his 6 weeks of ITU admission confirmed that the pancreatitis was necrotising in nature with no enhancing parenchyma and revealed an evolving WOPN. (Figure 1)
At 6 weeks, despite making a remarkable recovery in terms of his ventilatory and cardiovascular status, his septic markers deteriorated rapidly indicating the need for intervention.
Patient B had a more benign course and did not require intensive support until the 4thweek post-admission. At this time his 20cm diameter WOPN caused gastric outlet obstruction, worsening jaundice with a bilirubin level peaking at 250mg/l, hypoxia, hypotension and renal failure. An intervention was performed at this time.
The procedures were performed under general anaesthesia, with antibiotic cover. With a linear EUS probe, the WOPN was delineated, punctured and a guide-wire passed into it. A side-viewing endoscope was passed, and the posterior gastric wall was punctured with a precut knife and the tip of a diathermy snare. A sphincterotome was then passed into the WOPN and the cyst-gastrostomy widened to 1cm. A forward viewing gastroscope was then exchanged and the cyst-gastrostomy was dilated to 20mm with an oesophageal balloon. The gastroscope was then inserted into the necrosis and debridement performed with biopsy forceps and a polyp-retrieval net. The cavity was washed out and pig-tail stents left in-situ. (Figures 2 and 3)
Both patients were observed in ITU for 48 hours. Their parameters improved steadily. Patient A developed insulin-dependent diabetes and was started on an insulin regimen. He required a further two necrosectomies and ERCP with stenting for biliary inflammatory stricture before his WOPN resolved (Figure 4)and an elective laparoscopic cholecystectomy and stent retrieval was then performed as definitive management. Patient B remained well and is due to have a cholecystectomy.
Discussion
Acute pancreatitis has a reported annual incidence of 13-45 cases per 100,000, making it one of the most common gastrointestinal disorders requiring acute hospitalisation4. The incidence is increasing globally and is a major burden on health care worldwide. Pancreatic fluid collections occur in about 10% of patients with acute pancreatitis2.
Within the first 4 weeks of presentation, fluid and necrotic material may collect within the lesser sac and retroperitoneum creating an acute necrotic collection (ANC). WOPN develops after 4 weeks have elapsed from presentation of acute NP and the collection persists by becoming encapsulated (Atlanta Classification, revised in 2012 and 2016).WOPN can remain sterile but infection rapidly causes organ dysfunction. In the cases we present, the patients developed this complication in addition to causing gastric outlet obstruction and obstructive jaundice.
The International Association of Pancreatology and American Pancreatic Association (IAP and APA respectively) guidelines for the management of acute pancreatitis were published in 2013 and described indications for intervention in NP. These include; suspicion of, or documented, infected pancreatic necrosis with clinical deterioration, gastric outlet obstruction, biliary obstruction, organ failure, persistent pain and disconnected duct syndrome. Intervention in infected NP is generally delayed until it has become WOPN.4
Conventionally, techniques including open necrosectomy were performed for WOPN and other pancreatic collections. However, in the past two decades, there has been a move towards minimally invasive techniques and step-up techniques. Step up techniques involve first the drainage of the collection, followed by necrosectomy. Minimally invasive techniques involve percutaneous (retroperitoneal or transabdominal) or endoscopic approaches.5,7
In the case of endoscopic interventions, an endoscopic ultrasound or conventional endoscope is used and a cystgastrostomy tract is formed and dilated with large diameter (10–20 mm) balloon. Multiple double-pigtails stents or metallic biliary stents are then inserted, allowing drainage into the gastrointestinal tract. This is generally followed by entering the collection using a forward viewing endoscope, performing a washout of the WOPN cavity with saline or/and hydrogen peroxide and followed by a necrosectomy using endoscopic equipment such as large forceps, baskets, Roth nets and balloons.1-7
There have been various studies carried out showing the benefits of endoscopic techniques as compared to open surgical techniques. A few benefits include decreased new onset diabetes, decreased pancreatic fistula formation, decreased pro-inflammatory response, and essentially, decreased morbidity and mortality.5
Pancreatic necrosectomy can be performed safely and effectively with readily available ERCP and gastroscopic equipment, under EUS localisation. This procedure should be considered as treatment of choice for patients developing WOPN.
List of Abbreviations
A&E Accident and Emergency
ANC Acute necrotic collection
CT Computed tomography
ERCP Endoscopic retrograde cholangio-pancreatography
ITU Intensive therapy unit
NP Necrotising pancreatitis
NIV Non-invasive ventilation
SAP Severe acute pancreatitis
TPN Total parenteral nutrition
WOPN Walled-off pancreatic necrosis
References
- Abela JE and Carter CR. Acute pancreatitis -a review. Surgery (Oxford)2010;28(5):205-211
- Banks PA, Bollen TL, Dervenis C et-al. Classification of acute pancreatitis-2012: revision of the Atlanta classification and definitions by international consensus. Gut 2012;62 (1): 102-11
- Bryan R. Foster, Kyle K. Jensen, Gene Bakis, Akram M. Shaaban, Fergus V. Coakley. Revised Atlanta Classification for Acute Pancreatitis: A Pictorial Essay. RadioGraphics2016;36(3):675-87
- Working Group IAP/APA Acute Pancreatitis Guidelines. IAP/APA evidence-based guidelines for the management of acute pancreatitis. Pancreatology2013;13(4 Suppl 2):e1–15
- Bakker O.J., van Santvoort H.C., van Brunschot S. et al. Endoscopic transgastric vs surgicalnecrosectomy for infected necrotizing pancreatitis: a randomized trial. JAMA2012;307: 1053–1061
- Trikudanathan G, Attam R, Arain MA, et al. Endoscopic interventions for necrotizing pancreatitis. Am J Gastroenterol2014;109: 969–81.
- van Santvoort HC, Besselink MG, Bakker OJ et al.; Dutch Pancreatitis Study Group. A step-up approach or open necrosectomy for necrotizing pancreatitis. Engl. J. Med2010;362(16),1491–1502
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