Combined endoscopic and percutaneous drainage of organized pancreatic necrosis

Abstract

Background: Severe acute pancreatitis is often complicated by organized necrosis, which can lead to abscess formation and clinical deterioration. We sought to devise a combined endoscopic and percutaneous approach to drainage of organized pancreatic necrosis, with the primary goal of preventing the formation of chronic pancreaticocutaneous fistulae, and secondary goals of avoiding the need for surgical necrosectomy and reducing endoscopic resource utilization.

Design: Retrospective review of an institutional review board-approved database.

Setting: Single North American tertiary referral center.

Patients: Patients with severe acute pancreatitis complicated by organized necrosis requiring drainage.

Interventions: CT-guided percutaneous drain, followed immediately by endoscopic transenteric drainage.

Main outcome measurements: Development of chronic pancreaticocutaneous fistulae, number of endoscopic procedures requiring follow-up drainage, need for surgical necrosectomy, procedure-related morbidity, and mortality.

Results: Fifteen patients (12 males, 3 females; mean age, 58 years) underwent combined modality drainage. All procedures were technically successful. Immediate complications included fever and hypotension (n = 2); late complications included parenchymal infection after drain removal (n = 1). Twenty-five total endoscopies (4 for drain manipulation) were performed in the cohort subsequent to the initial drainage. After a median duration of follow-up of 189 days, percutaneous drains were removed in all 13 patients in whom this was attempted; no patients had development of chronic pancreaticocutaneous fistulae. There were no deaths, and no patients required surgery.

Limitations: Highly selected patient population, lack of comparison group, single-center experience.

Conclusions: In some highly selected patients with infected or symptomatic organized pancreatic necrosis, combined modality drainage results in favorable clinical outcomes with low associated, procedure-related morbidity. Pancreaticocutaneous fistulae and surgical necrosectomy were avoided with minimal endoscopic resource utilization.