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Endoscopic transgastric pancreatic necrosectomy using a fully covered self expanding metal stent (FCSEMS)

Authors

Scott RD, Mulholland K, Kirk SJ, Caddy G

Departments / Institutions

Ulster Hospital Dundonald, South Eastern Health and Social Care Trust

Publication Date

Spring 2014

Introduction

Walled off pancreatic necrosis (WOPN) is one of the most severe complications of acute pancreatitis. Surgical intervention is associated with significant morbidity, mortality and prolonged hospital stay. Recently there has been a shift towards minimally invasive techniques for necrosectomy, obviating the need for open necrosectomy in most cases. We present the case of a 53 year old man who was admitted with severe upper abdominal pain, pyrexia, hyperamylasaemia and elevated inflammatory markers. CT revealed extensive peripancreatic inflammatory stranding with features of developing necrosis in the pancreatic head. Follow up CT imaging demonstrated a large pancreatic fluid collection (PFC) measuring 20 x 11 x 12 cm, with evidence of pancreatic necrosis. He had ongoing pyrexia despite broad spectrum antibiotics and a decision was made to proceed with endoscopic treatment using a FCSEMS (Nagi stent, Taewoong- Medical Co, Korea) on day 47 following the onset of acute necrotising pancreatitis. A cyst gastrostomy using the FCSEMS was performed successfully with a duodenoscope under fluoroscopic guidance. Direct endoscopic necrosectomy via the stent was performed in 3 sessions using the standard gastroscope. The cyst debris cultured a glycopeptide resistant enterococcus and antibiotic therapy was changed accordingly. His symptoms improved with normalisation of inflammatory markers and a marked reduction in the size of the pseudocyst on CT. He was discharged and readmitted electively for an uncomplicated laparoscopic cholecystectomy. The FCSEMS was removed endoscopically 6 weeks after insertion without complications. The patient remains well, with no evidence of cyst recurrence, 6 months after his initial presentation. We believe that this is the first reported use of a FCSEMS for this purpose in Northern Ireland. This case highlights the advantages of this method compared to standard cyst gastrostomy using multiple 10F plastic stents.


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