EUS-guided transgastric pancreatic necrosectomy in a patient with sleeve gastrectomy (with video).

We hereby report a patient with sleeve gastrectomy who underwent EUS-guided transgastric pancreatic necrosectomy (EUS-TPN) for walled-off pancreatic necrosis (WOPN).

A 31-year-old male patient whose informed consent was obtained presented with severe abdominal pain persisting for the past month. The patient had a history of a sleeve gastrectomy performed 3 years before his application. The laboratory results showed leukocytosis (17 × 103/μL), elevated C-reactive protein (170 mg/dL), and lipase (1700 IU/L). A computed tomography (CT) revealed acute necrotizing pancreatitis. A 4-week long combination antibiotherapy was initiated. On a lack of improvement during the antibiotherapy, the diagnosis was considered as WOPN. EUS-TPN was performed using a self-expendable metallic stent from the incisura angularis to the necrotic area for drainage following balloon dilation. Two 16-Fr–sized drains were placed bilaterally in the retroperitoneal abdomen by an interventional radiologist in the same session. After the second necrosectomy session, CT of the abdomen revealed a disconnection of the pancreatic duct syndrome, and a plastic stent was placed into the pancreatic duct via endoscopic retrograde cholangiopancreatography. The left retroperitoneal drain was removed for the fourth necrosectomy session, and a pediatric gastroscope was directed percutaneously through the tract of the removed drain to remove the solid necrotic components [Figure 1 and Video 1].

Figure 1

EUS-guided image of the entrance to the pancreatic necrotic area via a 19-gauge needle.

EUS-guided pancreatic necrosectomy is a minimally invasive approach that offers a safe alternative to surgery.[12] Similar results have been reported previously in the literature.[234] The narrowed lumen of the stomach after sleeve gastrectomy constitutes a challenge through the available range of motion of the echoendoscope, and altered arterial supply might result in the defective closure of the artificial lumen which is created by the EUS-guided necrosectomy procedure. In addition, plastic drains facilitate only the liquid drainage; however, solid necrotic segments remain in the necrotic cavity and might occlude the drain. Directing a thin endoscope through the removed drain tract to remove the solid necrotic components using endoscopic tools facilitates the healing process. To our knowledge, this is the first case in the literature where EUS-TPN was performed in a patient with sleeve gastrectomy.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form the patient has given his consent for his images and other clinical information to be reported in the journal. The patient understands that his name and initials will not be published and due efforts will be made to conceal his identity, but anonymity cannot be guaranteed.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.