Endoscopic necrosectomy - when the gastroenterologist faces his greatest nightmare

Area of Science:

• Gastroenterology
• Interventional Endoscopy
• Pancreatic Diseases

Background:

• Severe acute necrotizing pancreatitis can lead to infected walled-off-pancreatic-necrosis (WOPN).
• Transgastric endoscopic drainage is a common treatment for WOPN.
• Persistent sepsis may necessitate further endoscopic interventions like necrosectomy.

Observation:

• A patient with infected WOPN undergoing endoscopic necrosectomy.
• A large, pulsatile vessel was identified on the posterior wall of the pancreatic collection.
• The vessel's location and appearance suggested it was the splenic artery.

Findings:

• The presence of a large pulsatile vessel, presumed to be the splenic artery, posed a significant risk during necrosectomy.
• The endoscopic necrosectomy procedure was suspended due to the potential for catastrophic hemorrhage.

Implications:

• Vascular anomalies near WOPN collections require careful pre-procedural evaluation.
• Endoscopic interventions for WOPN carry inherent risks, including vascular injury.
• Enhanced imaging or alternative approaches may be necessary when major vessels are closely associated with pancreatic necrosis.