Transgastral retroperitoneal endoscopy in septic patients with pancreatic necrosis or infected pancreatic pseudocysts

Peripancreatic fluid collections are common complications of acute pancreatitis or acute exacerbations of chronic pancreatitis. Surgery is required when these fluid collections become infected or cause obstruction or pain. However, morbidity and mortality after surgery in these cases are still too high, therefore minimally invasive approaches have been encouraged. The aim of this study was to evaluate the feasibility of endoscopic ultrasound-guided transmural drainage with intracystic endoscopy and necrosectomy.

From 2000 to 2006 30 patients (age: 57 +/- 10 years, range: 34 - 74 years) with an infected pancreatic pseudocyst or infected pancreatic necrosis were included in the study. The diagnosis of infection in patients who had fever despite an adequate antibiotic regime was confirmed by endoscopic fine needle aspiration with a positive bacterial or mycological result. The mean C-reactive protein value before treatment was 202 +/- 58 mg/L and the mean leukocyte count was 13.25 +/- 4.75 GPt/L. Transgastric cyst drainage was performed using a therapeutic endoscopic ultrasound probe (Pentax 38 UX or Olympus GF UCT 140) with insertion of an 8-Fr double pigtail prosthesis. After balloon dilatation (12 mm) a normal gastroscope was inserted into the cavity and all the fluid and easy removable necrosis were removed. The prosthesis was removed 4 weeks after the end of the endoscopic treatment. Clinical and ultrasound follow-up were carried out 3 and 6 months after removal of the prosthesis. The mean follow-up was 60 weeks.

The technical success of the procedure was 96.7 %, the long-term success was 83.4 %. On average 2.7 (range: 1 - 16) procedures were necessary for complete removal of necrosis and the remaining fluid. Major complications (bleeding, perforation, fistulation) occurred in 10 %. In 10 % a secondary operation was necessary. The overall mortality rate was 6.6 %.

Endoscopic treatment of infected pseudocysts and infected postacute pancreatic necrosis using transgastral retroperitoneal endoscopy with fluid and necrosis removal is a minimally invasive and effective procedure in patients with acute pancreatitis or acute exacerbation of chronic pancreatitis. However, the mortality rate of 6.6 % has to be taken into account.