Saumoy Monica, Kumta Nikhil A, Tyberg Amy, Brown Elizabeth, Lieberman Micheal D, Eachempati Soumitra R, Winokur Ronald S, Gaidhane Monica, Sharaiha Reem Z, Kahaleh Michel
Division of Gastroenterology and Hepatology.
Division of Surgery.
J Clin Gastroenterol. 2018 May/Jun;52(5):458-463. doi: 10.1097/MCG.0000000000000895.
Walled-off pancreatic necrosis (WON) is a sequelae of acute pancreatitis that requires debridement, once infected. Recently, endoscopic necrosectomy has become the mainstay for management. However, peripancreatic collections that extend to the paracolic gutter or lesser sac, are more challenging to treat endoscopically. We report an endoscopic method for management of necrotic collections that extend into the paracolic gutter.
Consecutive patients, with symptomatic WON extending into the retroperitoneum, were included in a prospective registry. Each patient underwent transcutaneous endoscopic necrosectomy (TEN) through a fully covered self-expanding esophageal metal stent. After resolution of the collection, the external stent was removed, and the cutaneous fistula was allowed to close by secondary intention. Clinical success was defined as resolution of the WON, and successful removal of all percutaneous drains. Patient demographics, procedural/periprocedural adverse events, and follow-up data, were collected.
Nine patients underwent direct TEN. Patients initially underwent CT-guided percutaneous drainage, with an average of 31 days between initial drainage and endoscopic necrosectomy. All patients had a technically successful placement of a fully covered esophageal metal stent through the cutaneous fistula. After a median of 3 endoscopic debridement sessions, 8 of 9 (89%) patients had successful removal of all percutaneous drains, and resolution of necrotic collections. One patient died of multisystem organ failure from severe acute pancreatitis.
TEN for infected WON is a safe and efficacious technique for patients with endoscopically inaccessible collections.
包裹性胰腺坏死（WON）是急性胰腺炎的一种后遗症，一旦感染则需要清创。近来，内镜下坏死组织清除术已成为主要的治疗手段。然而，延伸至结肠旁沟或小网膜囊的胰周积液在内镜治疗上更具挑战性。我们报告一种内镜治疗延伸至结肠旁沟坏死积液的方法。
有症状的WON延伸至腹膜后的连续患者被纳入一项前瞻性登记研究。每位患者通过一个全覆膜自膨式食管金属支架接受经皮内镜坏死组织清除术（TEN）。在积液消退后，移除外部支架，让皮肤瘘口通过二期愈合自行闭合。临床成功定义为WON消退且所有经皮引流管成功拔除。收集患者的人口统计学资料、手术/围手术期不良事件及随访数据。
9例患者接受了直接TEN。患者最初接受CT引导下经皮引流，从初始引流至内镜坏死组织清除术的平均间隔时间为31天。所有患者通过皮肤瘘口在技术上成功置入了全覆膜食管金属支架。经过中位3次内镜清创术后，9例患者中有8例（89%）成功拔除了所有经皮引流管，坏死积液消退。1例患者死于严重急性胰腺炎导致的多系统器官衰竭。
对于内镜无法到达的感染性WON患者，TEN是一种安全有效的技术。
