Department of Gastroenterology and Endoscopy, Fejér Megyei Szent György Teaching Hospital, H-8000 Székesfehérvár, Hungary.
World J Gastroenterol. 2013 Jun 21;19(23):3685-92. doi: 10.3748/wjg.v19.i23.3685.
Walled-off pancreatic necrosis and a pancreatic abscess are the most severe complications of acute pancreatitis. Surgery in such critically ill patients is often associated with significant morbidity and mortality within the first few weeks after the onset of symptoms. Minimal invasive approaches with high success and low mortality rates are therefore of considerable interest. Endoscopic therapy has the potential to offer safe and effective alternative treatment. We report here on 3 consecutive patients with infected walled-off pancreatic necrosis and 1 patient with a pancreatic abscess who underwent direct endoscopic necrosectomy 19-21 d after the onset of acute pancreatitis. The infected pancreatic necrosis or abscess was punctured transluminally with a cystostome and, after balloon dilatation, a non-covered self-expanding biliary metal stent was placed into the necrotic cavity. Following stent deployment, a nasobiliary pigtail catheter was placed into the cavity to ensure continuous irrigation. After 5-7 d, the metal stent was removed endoscopically and the necrotic cavity was entered with a therapeutic gastroscope. Endoscopic debridement was performed via the simultaneous application of a high-flow water-jet system; using a flush knife, a Dormia basket, and hot biopsy forceps. The transluminal endotherapy was repeated 2-5 times daily during the next 10 d. Supportive care included parenteral antibiotics and jejunal feeding. All patients improved dramatically and with resolution of their septic conditions; 3 patients were completely cured without any further complications or the need for surgery. One patient died from a complication of prolonged ventilation severe bilateral pneumonia, not related to the endoscopic procedure. No procedure related complications were observed. Transluminal endoscopic necrosectomy with temporary application of a self-expanding metal stent and a high-flow water-jet system shows promise for enhancing the potential of this endoscopic approach in patients with walled-off pancreatic necrosis and/or a pancreatic abscess.
胰腺脓肿和胰腺包裹性坏死是急性胰腺炎最严重的并发症。对于此类重症患者，手术往往会在症状出现后的数周内导致较高的发病率和死亡率。因此，微创方法具有较高的成功率和较低的死亡率，引起了广泛的关注。内镜治疗有可能提供安全有效的替代治疗方法。我们报告了 3 例患有感染性胰腺包裹性坏死和 1 例胰腺脓肿的连续患者，他们在急性胰腺炎发病后 19-21 天接受了直接内镜下坏死组织清除术。通过经皮穿刺将感染性胰腺坏死或脓肿用囊肿切开刀穿刺进入，然后进行球囊扩张，将非覆膜自膨式胆道金属支架置入坏死腔内。支架置入后，将鼻胆引流管置入腔内以确保持续冲洗。在 5-7 天后，经内镜取出金属支架，并通过治疗性胃镜进入坏死腔。通过同时应用高流量水刀系统进行内镜清创术；使用冲洗刀、Dormia 篮和热活检钳。在接下来的 10 天内，每天进行 2-5 次经皮内镜下腔内治疗。支持性治疗包括静脉注射抗生素和空肠喂养。所有患者均明显改善，感染情况得到缓解；3 例患者完全治愈，无任何进一步并发症或需要手术。1 例患者因长时间通气导致严重双侧肺炎而死亡，与内镜手术无关。未观察到与操作相关的并发症。经皮内镜下坏死组织清除术联合临时应用自膨式金属支架和高流量水刀系统，有望增强这种内镜方法在胰腺包裹性坏死和/或胰腺脓肿患者中的应用潜力。
