salvage therapy for severe necro - tizing pancreatitis

A 68-year-old patient with severe biliary pancreatitis developed extensive retroperitoneal necroses, with air collections, extending from the pancreatic compartment to the pelvis (●" Fig.1a,b). Percutaneous and transgastric drainage (twice each) did not resolve the solid calcified infected material (vancomycin-resistant enterococci, Staphylococcus epidermidis, Neisseria subflava, Haemophilus influenzae, Candida albicans), which could not be adequately accessed transluminally [1]. Laparotomy was deemed too risky for this moribund patient (30-kg loss of body weight), who had persistent sepsis 9 weeks after presentation. A guidewire (Jagwire, 0.035 inch, 460mm; Boston-Scientific, Ratingen,Germany)was inserted through thedrainage access in the left lower quadrant, and a thin endoscope (outer diameter 6.3mm; Pentax, Tokyo, Japan) was percutaneously advanced into the retroperitoneal spaceunder fluoroscopy. A 10-mm laparoscopic trocar (Kii Fios First Entry; AppliedMedical, Rancho Santa Margarita, California, USA), which was loaded onto the endoscope, was inserted under optical guidance to secure the retroperitoneal access (●" Fig.2). Debridement was then performed with a standard gastroscope (9.8mm; Pentax) through the trocar (●" Video 1), with the patient in the supine position under propofol sedation. Debridementwasperformed from thepelvic space, through the retrosplenic and retrorenal areas andup tothepancreatic area. Craniocaudal trocarmovements facilitated the maneuverability of the endoscope. A large bore drainage catheter (Thal-Quick 28Fr; Cook Medical, Limerick, Ireland) was then placed to secure the access. Clinical, radiological, and serological improvement were observed, and the procedure was repeated 8 days later. Lavage with sterile saline was then continued in an outpatient setting. A third percutaneous endoscopy (without trocar) after 4 months demonstrated vital retroperitoneal tissue and closure of most of the pelvic and retrosplenic access routes (●" Fig.3). These findings were confirmed by computed tomography (●" Fig.1c,d). One year later, the patient was well, although still suffering from pancreatic insufficiency. In trocar-assisted endoscopic retroperitoneal debridement, a stiff trocar stabilizes and guides the endoscope and allows repeated extraction of debris through the abdominal wall, similar to videoscopicassisted retroperitoneal debridement [2]. At the same time, flexible endoscopic maneuverability and instrumentation is maintained in the retroperitoneal space, similar to transmural procedures, but with more direct access. Such a procedure (with re-interventions “on demand”) may be adequate in an interdisciplinary step-up approach [3] for infected pancreatic necroses.