Efficacy of chymotrypsin irrigation for endoscopically non-accessible walled-off necrosis in necrotizing pancreatitis

In necrotizing pancreatitis, incomplete debridement of necrotic tissue can result in persistent infection. This case series describes use of an innovative chymotrypsin irrigation technique for treatment of walled-off necrosis (WON).

Six patients with endoscopically non-accessible WON were treated with percutaneous catheter drainage (PCD) combined with chymotrypsin irrigation. In each session, 50 to 200 mL of a 120 U/mL chymotrypsin solution was instilled via the drainage catheter, retained for 30 minutes, and then gently flushed with 0.9% sodium chloride. The procedure was repeated once daily until radiologic resolution of the necrotic cavity was achieved.

WON was located in the pancreatic body/tail (n = 4), involved the entire pancreas (n = 1), or was subphrenic (n = 1). All lesions measured ≥ 6 cm in maximum diameter (largest: 21×10×23 cm). Complete radiologic resolution of the necrotic cavity was achieved in all patients after a median irrigation duration of 7 days (range 4-21 days). In two cases where endoscopic debridement was also performed, the necrotic tissue was notably softened, facilitating the procedure. No severe complications occurred and all patients completed the treatment course.

Chymotrypsin irrigation effectively liquefies fibrotic necrotic tissue and promotes WON clearance via PCD, representing a promising adjunctive therapy for managing endoscopically non accessible WON.