Use of a vacuum sponge to expedite healing of a large peripancreatic collection.

Abstract

Infected pancreatic necrosis carries a poor prognosis, with high rates of morbidity and mortality [1]. Open surgical necrosectomy is associated with higher rates of major complications and death compared with minimally invasive approaches [2] such as transgastric endoscopic necrosectomy. When a transgastric approach does not provide complete access or drainage, the percutaneous endoscopic route offers an additional modality for larger collections [3]; however, treatment duration may be prolonged given the extent of necrosis, with patients requiring multiple imaging and necrosectomy sessions. A 56-year-old woman presented with fever and epigastric pain 2 months after an episode of severe necrotizing pancreatitis. Repeat abdominal computed tomography revealed a 22-cm infected walledoff pancreatic necrotic collection containing gas and fluid and tracking into the left paracolic gutter. Broad-spectrum antibiotics were started and a percutaneous catheter was placed by interventional radiology to provide subsequent access for percutaneous endoscopic necrosectomy. An endoscopic ultrasoundguided cyst-gastrostomy with a 15-mm lumen-apposing metal stent (LAMS) was successfully performed (▶Video1). The percutaneous drain was exchanged for a fully covered esophageal metal stent of sufficient length to extend from the skin to the cavity. The patient underwent simultaneous transgastric and percutaneous necrosectomies, eventually allowing for both endoscopes to meet within the necrotic cavity. To expedite healing, a vacuum sponge mounted on a flexible plastic tube was placed deep within the collection cavity from the percutaneous access point and was connected to suction to accelerate drainage and promote formation of healthy granulation tissue. Two plastic stents were also placed across the LAMS cyst-gastrostomy. Serial endoscopic necrosectomies were repeated in the same manner over a 3-week period. The patient’s symptoms resolved after completion of the necrosectomies and repeat imaging revealed resolution of necrosis. A complex infected peripancreatic collection in the setting of necrotizing pancreatitis can be successfully managed by a combination of transgastric and transcutaneous endoscopic necrosectomy, thereby avoiding surgery [3]. Use of endoscopic vacuum-assisted drainage can serve as an adjunct to facilitate and expedite healing by reducing the number of endoscopic sessions [4].