Nguyen Andrew K, Song Andrew J, Swopes Tanya, Ko Albert, Lim Brian S
University of California, Riverside, School of Medicine.
Department of Internal Medicine, Riverside Medical Center, CA.
Perm J. 2019;23. doi: 10.7812/TPP/18-230. Epub 2019 Jun 21.
The initial therapeutic intervention for infected necrotizing pancreatitis usually begins with endoscopic cystogastrostomy for drainage, followed by endoscopic necrosectomy. Endoscopic pancreatic necrosectomy is commonly performed transluminally through transgastric or transduodenal routes. This case describes necrosectomy via a transcutaneous route for laterally located walled-off pancreatic necrosis and the novel use of Babcock forceps for an obstructed fully covered metal stent.
A 62-year-old woman presented with abdominal pain, nausea, and vomiting. After multiple admissions and repeated abdominal imaging, she was found to have laterally located, infected, walled-off pancreatic necrosis. Initially, a drainage catheter was placed by an interventional radiologist and was eventually upsized to a 28F catheter. Subsequently, a fully covered metal stent was placed in the gastroenterology suite under fluoroscopic guidance and was used to gain access for percutaneous sessions of necrosectomy. A percutaneous sinus tract endoscopic necrosectomy was performed under direct endoscopic view. However, difficulties occurred with removing necrotic debris even through this large covered stent. Thus, laparoscopic Babcock forceps were used under fluoroscopy to remove lodged debris from the midstent. Repeat abdominal computed tomography scan 3 days after necrosectomy showed near resolution of the walled-off pancreatic necrosis.
This Babcock technique with endoscopic necrosectomy has not been previously described in the literature, to our knowledge. Babcock forceps were an ideal tool in our case because they were able to gain access to the obstruction in the stent, but the "teeth" are small and dull enough to prevent from catching onto the metal stent mesh.
感染性坏死性胰腺炎的初始治疗干预通常始于内镜下囊肿胃造口术引流，随后进行内镜下坏死组织清除术。内镜下胰腺坏死组织清除术通常经胃或十二指肠经腔进行。本病例描述了经皮途径对位于外侧的包裹性胰腺坏死进行坏死组织清除术，以及使用巴布科克钳处理阻塞的全覆膜金属支架的新方法。
一名62岁女性出现腹痛、恶心和呕吐。经过多次入院和反复腹部影像学检查，发现她有位于外侧的感染性包裹性胰腺坏死。最初，介入放射科医生放置了一根引流导管，最终将其扩大到28F导管。随后，在透视引导下于胃肠病科放置了一个全覆膜金属支架，并用于经皮坏死组织清除术。在直接内镜观察下进行了经皮窦道内镜坏死组织清除术。然而，即使通过这个大的覆膜支架，清除坏死碎片也遇到了困难。因此，在透视下使用腹腔镜巴布科克钳从支架中部清除堵塞的碎片。坏死组织清除术后3天重复腹部计算机断层扫描显示包裹性胰腺坏死几乎消退。
据我们所知，这种使用巴布科克钳进行内镜坏死组织清除术的技术此前在文献中尚未有描述。在我们的病例中，巴布科克钳是一种理想的工具，因为它们能够接近支架内的阻塞物，但其“齿”小且钝，足以防止卡在金属支架网眼上。
