Case study
Endoscopic necrosectomy as primary treatment for infected peripancreatic fluid collections (with video)

https://doi.org/10.1016/j.gie.2008.05.010Get rights and content

Background

The success of endoscopic intervention in the management of uncomplicated pancreatic pseudocysts has allowed endoscopists to be more aggressive in managing complicated pancreatic fluid collections. Surgery is considered the mainstay of therapy once pancreatic abscesses develop. As a second-line treatment, endoscopic drainage of pancreatic abscess has been performed in those who are not candidates for surgery.

Objective

Our purpose was to report our experience with single-session endoscopic necrosectomy and drainage as the primary mode of treatment of infected pancreatic necrosis or abscesses.

Design

This was a case series.

Setting

A single endoscopy unit based at a university medical center.

Patients

Six consecutive patients who underwent endoscopic necrosectomy as the primary treatment modality for pancreatic abscess or necrosis between May 2006 and February 2007.

Main Outcome Measurements

Resolution of the infected pancreatic fluid collection and avoidance of surgery.

Results

Successful single-session endoscopic necrosectomy was performed in all 6 patients with impressive and immediate symptom relief. None needed surgery or other endoscopic or percutaneous interventions. Patients were discharged from the hospital in a median of 8.5 days. Complete resolution of pancreatic lesions were noted in 5 of 6 patients (1 patient had a small residual cyst) in median follow-up of 3.5 months (range 3-11 months).

Conclusions

Endoscopic necrosectomy can be performed safely and efficiently for the primary treatment of pancreatic necrosis and abscess. Our data suggest that aggressive single-session necrosectomy can be adequate for the complete removal of infected and necrotic debris.

Section snippets

Patients

Six consecutive patients (4 female, 2 male) underwent endoscopic necrosectomy between May 2006 and February 2007 as the primary treatment for pancreatic abscess or necrosis. The median age was 48 years (range 16-77 years). Infection was suspected if significant fever, abdominal pain, or leukocytosis were present in the right clinical setting or if CT imaging revealed a fluid collection with the presence of air without a spontaneous fistula. Contrast-enhanced abdominal CT was obtained in all

Results

Patient demographics and outcomes are detailed in Table 1. Four of the 5 patients had biliary pancreatitis. Endoscopic treatment was sought 4 to 6 weeks after the episode of pancreatitis because of enlarging fluid collections. Three patients had EUS drainage, and 1 had CT-guided tube placement before the development of pancreatic abscess. The median follow-up was 3.5 months (range 3-11 months).

All procedures were done by the transgastric approach. The fluid collections were entered at a site

Discussion

Pancreatic abscess can be defined as a contained collection of purulent material in proximity to the pancreas.18 Infected pseudocyst and infected pancreatic necrosis are included in this definition.19 Characteristically, a pancreatic abscess develops 3 to 4 weeks after the initial episode of pancreatitis. The basic tenet of treating any abscess is complete removal of necrotic material, pus and lavage of the cavity in addition to antibiotics. Management of pancreatic abscesses has traditionally

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