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Endoscopic transmural necrosectomy through spontaneous pancreaticoduodenal fistula

Published:August 27, 2015DOI:https://doi.org/10.1016/j.gie.2015.07.025
      A 32-year-old man with no relevant medical history initially presented to the emergency department with 24 hours of severe abdominal pain and received a diagnosis of acute interstitial pancreatitis. He was given supportive treatment and discharged home; however, 6 weeks after discharge he returned with abdominal pain, fever, and gram-negative rod bacteremia. Repeated imaging at that time demonstrated walled-off necrosis (WON) involving the pancreas and extrapancreatic tissues and a possible cystduodenal fistula. Upper endoscopy with an adult endoscope revealed a spontaneous cystduodenal fistula, which was used for necrosectomy. He underwent complete necrosectomy in only one session by use of a snare and tripod, and his fever resolved within 24 hours (Fig. 1; Video 1, available online at www.giejournal.org). Six weeks after discharge, at his follow-up appointment, he underwent repeated imaging, which showed resolution of the WON. Spontaneous cystduodenal or gastric fistulas are rare adverse events of WON or pseudocysts. The solid or adherent debris within WON is unlikely to drain spontaneously through these fistulas; however, endoscopic transmural necrosectomy through a well-formed fistulous tract is safe and efficacious in obtaining control of the source.
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      Figure 1Endoscopic transmural necrosectomy through spontaneous cystduodenal fistula. A, Endoscopic view of necrotic material during debridement. B, Cavity marked by healthy granulation tissue after debridement.
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