Dual access endoscopic necrosectomy of infected pancreatic necrosis: a case report

A 73-year-old male developed fever and jaundice 6 months after an episode of acute necrotizing pancreatitis. During endoscopic retrograde cholangiography, a distal bile duct compression was documented and stent insertion led to resolution of jaundice, however, the febrile condition persisted. A pancreatic necrosis measuring 11x7 cm was shown by computed tomography (CT) and the patient was referred for necrosectomy. During the first endoscopic session, spontaneous drainage of pus was observed in the duodenal bulb. Therefore, the pancreatic necrosis was first punctured under endoscopic ultrasound-guidance transduodenally. The pancreatic necrosis was then additionally punctured transgastrically and the necrotic cavity was entered with a standard upper gastrointestinal scope. Despite extensive irrigation and necrosectomy we felt the transgastric approach was not sufficient enough to treat the large necrotic cavity and decided to perform the further treatment by using both accesses. Endoscopic debridement was repeated daily through the transgastric as well as the transduodenal approach over 5 days. The clinical condition of the patient dramatically improved and he became afebrile. Two months after the initial endoscopic necrosectomy, a CT scan showed nearly complete resolution of the pancreatic necrosis and the bile duct stenosis resolved. Six months later, CT scans showed no residual necrosis and an atrophic but otherwise normal pancreas.