Dataset Information

Percutaneous debridement and washout of walled-off abdominal abscess and necrosis by the use of flexible endoscopy: an attractive clinical option when transluminal approaches are unsafe or not possible.

ABSTRACT:

Background and aims

Walled-off pancreatic necrosis is a well-known serious adverse event of severe acute pancreatitis. EUS-guided transluminal access followed by direct endoscopic necrosectomy is increasingly used to remove necrosis, with good efficacy and a superior safety profile when compared with surgery. However, a percentage of patients is too critically ill to undergo this procedure or lack an appropriate transluminal window for access. Here we describe the use of percutaneous flexible endoscopic necrosectomy (PEN) with use of standard-sized upper endoscopes and accessories in a retrospective single-institution experience with a video demonstration of 1 patient in the series.

Methods

The authors present a 23-patient retrospective case series of PEN with standard-sized endoscopes. The series includes 12 patients from a previously published analysis in 2016 and 11 additional patients from 2013 to 2018. A representative case illustrates the described technique in a patient with severe acute pancreatitis complicated by multisystem organ failure who required immediate drainage of a pancreatic fluid collection and placement of a percutaneous drain into the collection for decompression. The drain was serially upsized to 28F, and its tract was used for PEN.

Results

A total of 23 patients have undergone PEN at our institution. On average, the size of the pancreatic fluid collection was 11.6 cm in cross-sectional diameter. Of those 23 patients, 11 presented with symptoms of severe disease. The median time from onset of symptoms to PEN was 84 days. The median number of procedures per patient was 2.1. The median time to complete resolution of symptoms and fluid collections was 67 days. In total, resolution was reached in 22 of 23 patients. Two patients died of unrelated causes.

Conclusion

PEN is a minimally invasive and effective treatment approach to walled-off pancreatic necrosis in patients who are not amenable to transluminal drainage and in whom percutaneous drains have been successfully placed. This case series demonstrates the efficacy and safety of this approach. A randomized prospective trial would be warranted to validate these results.

SUBMITTER: Moyer MT

PROVIDER: S-EPMC6675874 | biostudies-literature | 2019 Aug

REPOSITORIES: biostudies-literature

ACCESS DATA

Publications

Percutaneous debridement and washout of walled-off abdominal abscess and necrosis by the use of flexible endoscopy: an attractive clinical option when transluminal approaches are unsafe or not possible.

Moyer Matthew T MT Walsh Leonard T LT Manzo Carl E CE Loloi Justin J Burdette Allene A Mathew Abraham A

VideoGIE : an official video journal of the American Society for Gastrointestinal Endoscopy 20190530 8

<h4>Background and aims</h4>Walled-off pancreatic necrosis is a well-known serious adverse event of severe acute pancreatitis. EUS-guided transluminal access followed by direct endoscopic necrosectomy is increasingly used to remove necrosis, with good efficacy and a superior safety profile when compared with surgery. However, a percentage of patients is too critically ill to undergo this procedure or lack an appropriate transluminal window for access. Here we describe the use of percutaneous fle ...[more]

PMID: 31388621

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Project description:Background and aimsGI tract perforations and anastomotic dehiscence are increasingly effectively being repaired endoscopically; however, well-known and long-held surgical principles must still be honored. One important principle is that significant extraluminal contamination must be washed out, debrided, and drained in conjunction with repair of the defect if the wound is to effectively heal and resolve. Here we describe the use of endoscopic washout and debridement of extraluminal contamination at the time of luminal defect closure in a 7-patient series at our institution, with video demonstration of 2 patients in the series.MethodsWe reviewed a series of 7 patients at our institution and provide a video demonstration of the described technique in 2 patients. A 50-year-old man with decompensated liver cirrhosis presented with a large distal esophageal disruption secondary to a severe Minnesota tube injury. Extensive thoracic and mediastinal contamination of solid and liquid debris was removed and washed out endoscopically, followed by esophageal defect repair. Closure of the defect with overlapping, fully covered, esophageal stents sutured in place was successful after attempts at repairing the primary disruption with suturing alone failed. A 49-year-old man with multiple endocrine neoplasia type 1 and multiple prior surgeries presented with an acute abdomen and sepsis secondary to a fully perforated duodenal ulcer. Extensive endoscopic washout and lavage of the purulent liquid and semiliquid debris covering the liver, stomach, and adjacent structures was performed, followed by closure of the perforation by endoscopic suturing. A percutaneous pigtailed drainage catheter was placed in the extraluminal cavity to facilitate postoperative drainage, followed by placement of a PEG with jejunal extension for enteric exclusion and nutrition.ResultsThe results for all 7 patients were reviewed. The overall rate of technical success, defined as effective repair of the luminal defect and drainage of extraluminal contamination, was 100%. The overall rate of clinical success, defined as clinical recovery and return to the patient's previous state of health, was 86% because 1 patient died because of severe concomitant disease. The length of time from the described procedure to hospital discharge ranged from 8 to 52 days (mean, 27 days).ConclusionEndoscopic washout and debridement can effectively and immediately address extraluminal contamination at the time of endoscopic luminal defect repair in appropriately selected patients. Therefore, it may represent a valuable option to address this clinical situation when a more conventional surgical approach is problematic. A more structured study should be considered for the development and validation of this approach.

Dataset Information

Percutaneous debridement and washout of walled-off abdominal abscess and necrosis by the use of flexible endoscopy: an attractive clinical option when transluminal approaches are unsafe or not possible.

Background and aims

Methods

Results

Conclusion

Publications

Percutaneous debridement and washout of walled-off abdominal abscess and necrosis by the use of flexible endoscopy: an attractive clinical option when transluminal approaches are unsafe or not possible.

Similar Datasets

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