All right. Thank you. Dr. Sethi? Actually, so these are my disclosures. Actually, Ryan's patient came back with pancreatitis. No, I'm just kidding. It so happened to be that this case is a case of a 48-year-old woman with FAP who underwent a subtotal colectomy and an ampulectomy over 10 years ago at another institution and now is admitted with necrotizing pancreatitis. Initially, the CT that you see here, it demonstrated a very large peripancreatic collection extending into the pelvis, very ill-defined margins, and there were some foci of air suggesting infection. Patient also developed fevers, leukocytosis, and was actually sent to IR for drainage, as also found to have a DVT and was started on anticoagulation. I'll actually stop right there. What does everybody think of the fact that the patient was sent for IR with this imaging? Greg, you can speak now. My mic's turned on. Well, it depends on what point. I think that IR is a very good option for early on in the course of the acute necrotizing pancreatitis. I think if you have a more well-defined collection, it's if you're beyond four weeks, I would probably favor endoscopic transgastric drainage. Okay. Right. This was actually prior to GI being consulted, but it was within two weeks, actually, of presentation, so I think it was appropriate. But then the patient continued to have fevers despite the drain being in place and also intermittently was not having great drainage, and so they were sent to interventional GI to consider endoscopic drainage. So just a word on that. Again, the indications for drainage are infection, biliary gastric obstructive symptoms, failure to thrive. Diagnosis, you obviously want to do cross-sectional imaging to confirm that there is some degree of a wall or organization, and indications for drainage are really only if there's a pseudocyst or walled-off necrosis, not just necrotizing pancreatitis. Endoscopic transluminal drainage is considered the first-line therapy. This has been demonstrated through multiple, large multicenter trials, including the PANTERA tension and MISER trials that demonstrate that with endoscopic drainage, you have fewer major complications, such as fistulas and multi-organ failure and a shorter length of stay. And then the preferred endoscopic drainage is EUS-guided, either using luminoposing metal stents or double pigtail stents. I was going to say, Amrita, so if you decide you're going to do the EUS-guided drainage, just some of your logistics for doing the procedure, intubated, antibiotics, hydrogen peroxide? Yeah, so we intubate all of our patients if we're anticipating a large volume of drainage, or if you anticipate going in and performing necrosectomy on the index procedure. All patients are given antibiotics, although this patient was already on antibiotics, so that was taken care of. And, you know, one has to consider whether we're just going to get access and then bring the patient back later for necrosectomy versus is the patient really infected and should we continue to treat them all in one step? Or, for example, place a nasocystic tube. And adjunctive techniques, which we'll talk about, do include multi-gateway placement of multiple transluminal stents, as well as nasocystic irrigation. So, okay. So this is the CT. You can see it's a little bit more organized now. There's a nice wall adjacent to the stomach. It does look like it's continuous across the abdomen and extending down into the pelvis. This is the placement of the LAMs. And full disclosure, this is not this patient's LAMs placement, but you can see insertion using electrocautery access, catheter into the collection, deployment of the first flange, and then creating apposition by pulling back on the deployed stent. Create apposition between the cyst wall and the gastric wall. And then finally, deployment of the proximal flange within the channel of the scope so you don't see anything actually happening. And then finally, looking endoscopically, you can confirm that your flange is on the gastric side and you should see a big rush of fluid. And then it's very variable whether you place dilate or place double pigtail stents, but in most cases where there's a lot of necrotic material and you're not going to do necrosectomy, I think that's fair to place them. Now, in her case, she did not have a gush of fluid and our confirmation was more based on seeing that our wire was going in towards her IR drain. And we were concerned because she was having fevers and signs of sepsis despite having this IR drain. And so just gaining access didn't seem like it would necessarily fix the problem. So instead, we looked for another potential site. Okay. Sorry, I'm having little mouse difficulties now. Okay. So we looked for a second potential site and found that there was another, what appeared like another collection closer to the duodenum or the distal antrum. And when we did an FNA, we did come back with pus. And so we decided that we wanted to drain this site as well in order to maximize drainage. So we placed a second LAMS that was actually transduodenal and placed double pigtail stents through both of them. One could argue that we try to place a mesocystic drain in, but she already had the IR drain here and the access to this, it was just a small pocket that we could really see at the time. So we did not do that. Her symptoms resolved quickly and she actually was able to have her percutaneous drain removed once the transgastric access had been obtained. And then, and she did quite well, but the decision was to go ahead and pursue further necrosectomy. And so, and I'll just try to show you this. There we go. So this is her drain with the two stents in. You can see it's already partially resolving, but there's quite a bit of material left. So in thinking about the necrosectomy, we wanna think about what tools we're gonna use. These can be sort of everything that you have on your shelf from snares and baskets to a new dedicated necrosectomy tool that is powered. Okay, here you go. So this is a 6.0 millimeter channel, millimeter catheter that has a rotor or a blade, rotating blade that is in the window there. You are applying suction at about 400 millimeters of mercury and as well as irrigation. And you can see how quickly this is actually suctioning in the necrotic material into the collection. And this allows you to actually stay, keep your scope in the collection as opposed to coming in and out of the catheter and in and out of the collection with the scope. Here, we're infusing hydrogen peroxide to try to help break up the material a little bit. It does obscure your view for a little while, and you wanna make sure that you debride everything, you suction out everything so the patient doesn't have aspiration of it. But here you can see, again, just applying the catheter inside, that it's excellent debridement. This does require a large channel, 6.0 millimeter channel scope, and these can be hard to obtain. In our case, we had to obtain it beforehand and knowing that we wanted to use this device. And here you can see afterwards, we placed double pigtail stents, and now we were able to get actually a stent going from this collection, from this stent all the way to the other side of the collection, confirming that there was communication. Two days later, she actually developed hematemesis and hemorrhagic shock, and an angiogram was performed that confirmed that she had active bleeding from her proximal splenic artery pseudoaneurysm, and she had coils placed and was placed, IVC filter was placed. So just to comment that the adverse events include bleeding from pseudoaneurysms, occlusion of the lambs, infection, and stent migration. And after she settled down and stabilized, we came back and repeated her necrosectomy. You can actually see the coils from within the collection, but you see nicely that it's fairly well debrided. So she was discharged home and will come back. All right, great presentation. If you think we had differences on how we do ampulectomy, wait till you hear about how we handle necrosectomies. For the panel, again, quickly, if you can just tell me, do you like to say you're going to do a necrosectomy, you put your lambs in? A, do you bring that patient on a schedule, like every two days, or do you kind of see how they do? If the patient requires inpatient admission for another reason, scheduled every few days. If they're an outpatient, generally one to two weeks. Same here, we do every two days. We check for the clinics. As from the data, I think it's known by now that some patients just do not need additional procedures. So we are especially keen on, do they develop fever? How are they clinically going? So it's not a fixed schedule. Yeah, I think it's also size of the collection. So something like this, you want to stay on top of it every two days. If it's a smaller collection, like Janine said, not everybody needs a true necrosectomy. So I don't schedule, but I think the clinical status of the patient is what determines it. If you don't have adequate source control, then you have to bring them back sooner. You can also use the IR drains in this scenario to do copious irrigation as well. Yeah, nothing more to talk about interval. The only thing I would say is I think it's very, very important to have a good CT angio before you do any intervention, because you want to know if there are pseudoaneurysms there. And when you're doing necrosectomy, you have to replace the, well, you could either leave plastic stents and dilate or replace the axios. Most of us replace the axios for convenience, but then you're getting prolonged axios with a contracting pseudocyst. So it's critically important to know what the vasculature is before you undertake that. And especially with the endorotor, of course, and the risk of abrading a vessel. So the pseudoaneurysm wasn't seen on her prior imaging, or there were no concerns, and she was on anticoagulation, which I think contributed. But the one thing I would say that's important about a case like this is you want to make sure you understand the underlying cause of pancreatitis. Remember, she had had an ampulectomy well over 10 years ago. It's very possible that she has a restenosis of her pancreatic duct. And so at some point, we would probably want to do an ERCP, make sure that that is open so she doesn't have recurrence. And lastly, on follow-up imaging, you want to confirm that there's complete resolution. There could very well, in this case, be a disrupted duct, given how extensive her necrosis is. And if that's the case, then I would leave a double pigtail stent in the distal collection to make sure permanently, to make sure she continues to drain. The other important thing to mention is once that pseudoaneurysm is treated, there's no reason you can't go back in the cavity for necrosectomy. So once you have control of the pseudoaneurysm necrosectomy, even if it's hematoma contents, can commence as normal. All right. Thank you, guys. Take-home points from those cases are, you know, have a plan of care and then, you know, go with what you're comfortable with.

FAP

necrotizing pancreatitis

endoscopic drainage

EUS-guided drainage

necrosectomy