Endoscopic transgastric cholecystectomy during direct endoscopic necrosectomy for wallet of necrosis. Primary author, Marcos Eduardo Leira dos Santos. All authors have nothing to disclosure. A 54-year-old man was admitted with acute biliary pancreatitis with good response to clinical treatment, being discharged 4 days after admission. One month later, he returned with delayed gastric emptying, abdominal pain and fever. Abdominal CT showed a delayed common bile duct and gallbladder and a pancreatic heterogeneous collection with gas bubbles. Despite intravenous antibiotic therapy and nasoenterial tube feeding, he presented clinical worsening with fever, weight loss, increased abdominal volume and pain. One month later, a second CT showed an encapsulated heterogeneous pancreatic collection measuring 11 x 18 cm, compatible with wallet of necrosis. Endoscopic ultrasound guided drainage was performed with a 10 mm x 10 cm transgastric SEMS. After release, necrotic purulent content was observed. Saline and hydrogen peroxide wash was performed. He maintained intermittent fever and clinical worsening. The following weeks, he underwent two sessions of direct endoscopic necrosectomy, on day 7 and 14, and a nasocytic drain was placed for continuous irrigation. He presented partial clinical and laboratory improvement. It was necessary to remove SEMS in order to perform endoscopic necrosectomy, which was replaced by double pigtail plastic stents. MRCP was performed and showed an enteropatic biliary duct dilation and common bioduct filling defect. A third endoscopic necrosectomy and ERCP were performed on day 21. Esophageal varices were noted. Transgastric plastic pigtail stents were well located. We noted a deformed duodenal boob. The papilla was cannulated, a small stone, the distal collaticus, was observed, biliary sphincterotomy was performed, and the biliary stone came out during the procedure. Extraction balloon did not remove any other stone, cholangiography looks then apparently unremarkable, but under pressure we could identify cyst duct infundibulum biliary fistula. The main pancreatic duct was then cannulated, endoscopic pancreatography showed main pancreatic duct complete resorption with contrast extravasation, type 4a lera proensa classification, pancreatic sphincterotomy was performed, we placed a 10 french by 10 centimeter biliary plastic stent to treat biliary fistula. With a gastroscope the transgastric fistula was dilated up to 20 millimeters using a hydrostatic balloon. A large amount of purulent necrotic content was found. We observed bio output coming through necrosis, saline and hydrogen peroxide were used to extensive wash. Extensive endoscope necrosectomy with snare was performed. During necrosectomy, the gallbladder was captured and removed through the mouth, probably due to necrosis and cystic artery ischemia. On the gallbladder evaluation, we could see the entire gallbladder, sectioned by the cystic duct. We opened it and observed bio-mud and three biliary stones inside. On the final endoscopic aspect, we observed a granulation tissue and was possible to identify the former location of the pancreatic body and tail, pancreatic neck, pancreatic head. and the location of the Berry Pankrat collection without any bleeding. We performed the insertion of four transgastric plastic double PQT stents with distal end covering gallbladder bed and the other locations of former collections. Fluoroscopy final aspect showed a blocked area in the gallbladder bed with no signs of nail peritoneum and well located stents. The patient evolved well, showing clinical and laboratorial improvement. He started oral feeding on the first day after cholecystectomy with good acceptance and was discharged seven days after endoscopic cholecystectomy. Clinical implications. Through an extensive endoscopic direct necrosectomy for wallowed-off necrosis, an unintentional transgastric cholecystectomy was performed without complications. Clinical success was achieved and the patient was discharged seven days later. In conclusion, endoscopic ultrasound guided drainage is the gold standard treatment for symptomatic wallowed-off necrosis. Direct endoscopic necrosectomy may be necessary in select cases when drainage is not enough to achieve clinical success. In this very specific case, it was possible to perform an unintentional transgastric cholecystectomy during endoscopic necrosectomy with clinical success and without complications.

case study

54-year-old man

acute biliary pancreatitis

complications

endoscopic interventions