Endoscopic necrosectomy using novel rotational microdebridement. These are our disclosures. In this case, a 43-year-old male with history of acute cholecystitis, status post cholecystectomy, presented with severe abdominal pain, nausea, and vomiting. MRI, with and without contrast, revealed necrotizing pancreatitis complicated by walled-off necrosis. The pancreatic parenchyma can be seen almost completely replaced by a large complex pancreatic collection, measuring 21.2 by 9 by 11.9 centimeters. The collection was not felt to be completely mature, and the patient was doing relatively well. The decision was made to allow additional time for maturation and liquefaction. The patient was treated with conservative management and nutritional support. Within two months, the patient developed severe abdominal pain. The pancreatic collection showed maturation on CT scan, and the patient underwent cyskestrosomy, with placement of a luminoposing metal coaxial stent. A copious amount of fluid can be seen here, draining from the stent. This was followed by three standard endoscopic necrosectomy procedures. The patient's presentation was atypical in that he had a large amount of densely adherent necrosome within the pancreatic cavity. He was also found to have a hydrogen peroxide hypersensitivity, which limited its use as an agent for microdebridement. The patient continued to have persistent symptoms, and the collection was refractory to standard mechanical approaches. The case was reviewed in a multidisciplinary manner, and the decision was made to offer an off-label approach to necrosectomy using a rotational microdebridement device. In this procedure, black necrosome was found to be clogging the luminoposing coaxial metal stent. Once cleared, there was copious flow of purulent material from the cavity, which contained approximately 40% necrosis. Excessive suctioning and saline lavage was completed. The rotational microdebridement device was then used to extensively debride the necrosome. A larger two-channel therapeutic gastroscope accommodates the microdebrider, which can be seen here. Rotation is controlled using a foot switch. The device uses auto-irrigation to allow necrosome to mobilize, thereby becoming easier to remove with vacuum suction through the small hole near the tip of the microdebrider. The device has a steerable cutting window and inner rotating blade, which revolve 360 degrees to reach difficult areas during a procedure. The device simultaneously dissects, resects, and collects tissue. Here, the device can be seen suctioning necrosome into the device tip, where it encounters the rotational cutting element. This blade breaks the necrosome into smaller fragments. Once the solid component is debrided, the necrosome can be easily liberated from the wall of the cavity. The device's vacuum then suctions the morselized necrosome into the channel and out of the cavity. Care must be taken to avoid contact between the debrider and metal stent mesh of the coaxial lumen opposing stent. Large volumes of purulence were suctioned throughout the procedure. Once necrosome was mobilized with the rotational microdebrider, large pieces were removed using an endoscopic net. This sequence shows the removal of visible necrosome from the cavity. A massive piece of necrosome can be seen getting extracted from the patient's cavity with the endoscopic net. This was just one of many pieces removed from the cavity throughout the procedure. A zoomed-in view of the removed piece of necrosome is shown here. The cavity then underwent repeat saline lavage, and healthy granulation tissue was visualized throughout. A double pigtail stent was placed into the cavity, with proximal end terminating in the gastric body. On follow-up at one month, the patient had full resolution of symptoms and was able to return to his baseline activity level. He was no longer diabetic, was off pain medications, and could tolerate intake by mouth without any difficulty. CT scan confirmed resolution of the Waldorf necrosis with essentially complete evacuation of the cavity. The pancreas remained atrophied with mild edematous changes, but there were no new fluid collections on his scan. Following the necrosectomy with rotational microdebridement, complete resolution was confirmed endoscopically. The cavity can be seen completely cleared of necrosome with viable granulation tissue throughout. Both stents were removed from the cavity. First, the double pigtail stent was retrieved, followed subsequently by the luminoposing coaxial metal stent. In summary, this video outlines a case of a patient with severe necrotizing pancreatitis complicated by massive Waldorf necrosis. Due to hydrogen peroxide hypersensitivity and densely adherent necrosome, the collection could not be treated with standard mechanical approaches. Utilizing a novel rotational microdebridement approach, the collection was ultimately cleared and the patient had a complete recovery.

abdominal pain

nausea

vomiting

necrotizing pancreatitis

pancreatic collection