Endoscopic management of walled-off necrosis. Primary author, Mateus Pereira Funari. Authors, Mateus Funari, Vitórias Catimburgo, Igor Proença, Marcos Leira, Eduardo Moura. These are our disclosures. Case presentation, 40-year-old woman presented with mild acute biliary pancreatitis. Laparoscopic cholecystectomy was performed on the same hospitalization. Two months later, she presented fever, epigastric pain and postprandial bundling. CT scan of the abdomen revealed a well-defined heterogeneous peripancreatic collection measuring 10 for 12 centimeters compatible with walled-off necrosis. The proposed treatment was an endoscopic ultrasound-guided transgastric drainage. Endoscopic ultrasound-guided drainage was performed with a 10 for 60 millimeters sense. One week after drainage, ERCP with viscography was performed. The PD was completely disrupted without contrast esterilization. On CT scan, we can see the stomach compressed by the pancreatic collection. Endoscopic assessment revealed bulging in the posterior gastric wall. As we can see in the ultrasound, the collection is heterogeneous, characterizing walled-off necrosis. The dimensions are 116 by 129 millimeters. The distance between the gastric and collection lumens was less than 3.2 millimeters. The next step is to puncture with a 19-gauge needle and confirm the guide wire position on fluoroscopy. Then, we access the collection with a sysotome using pure current 100 volts. The next step was to dilate the tract with a 10 French dilation catheter, which was controlled by x-ray and ultrasound. We passed the SAMS catheter over the guide wire and the distal SAMS end was deployed under ultrasound and x-ray control. The proximal stent deployment was controlled by endoscopy view. After the deployment, satisfactory drainage was observed and the stent's position was confirmed on fluoroscopy, as we can see in the final aspect. After one week, the patient returned to access the pancreatic duct. The VIRSungraphy reviewed a complete stop in the pancreatic head, with no contrast leak into the pancreatic collection. We performed PD drainage with a 5 French stent. Three weeks after drainage, the patient developed fever. The obstructed SAMS was removed and a large amount of necrotic purulent content was observed through the gastric fistula orifice. Direct washing of the collection with saline and hydrogen peroxide, followed by direct endoscopic necrosectomy, and placement of two double pigtail plastic stents of 10 French stents. Two double pigtail plastic stents of 10 French by 6 centimeters was performed. After one week, the collection was washed with saline and the stents were left in place. After the stent removal, we note pus coming from the collection. We placed a guide wire and proceeded with balloon dilation up to 15 millimeters. Accessing the collection, we observe infected necrotic content, which was washed with saline and hydrogen peroxide. This helps to release the necrosis from the collection wall. Now we can see the final aspect after saline and hydrogen peroxide application. We then proceeded with necrosectomy with a polypectomy snare. Endoscopic scissors were also needed to release the necrosis from the collection wall. Due to the great amount of necrotic material, the same maneuvers have to be repeated several times. Now we observe the final aspect after the endoscopic necrosectomy. The procedure ended with the placement of two double pigtail French by 6 centimeters plastic stents to ensure collection drainage. Abdominal CT scans three months after drainage show resolution of the collection and the transgastric plastic stents were removed. In the follow-up, abdominal CT scans 6 and 12 months after used drainage showed completed resolution of the collection, confirming clinical and radiological success of the treatment. One year follow-up, the patient remained asymptomatic without late sequela or recurrence. This is the controlled CT scan with complete collection resolution. Conclusions Pancreatic fluid collections can be treated effectively in a minimally invasive endoscopic approach. One presents significant higher incidence of complications than pseudocysts, such as infection, which can be treated with endoscopic necrosectomy and antibiotics. In the multidisciplinary management of such patients, it is essential to include an experienced pancreatobiliary endoscopist.

40-year-old woman

acute biliary pancreatitis

walled-off necrosis

endoscopic ultrasound-guided drainage

ERCP with viscography