Novel treatment for walled-off necrosis (WON)

WON in necrotising pancreatitis is estabilished by a thickened wall without epithelial living between the necrosis and the adjecent surviving tissue. For decompression of this fluid collection it is recomended to implant at least two 10F drains with nasocysticus drain for continuous lavage. The most common complication is occlusion of the drains with debris.

Case I.: a 75 years old female was admitted to the hospital for acute necrotising pancreatitis some weeks earlier. WON occurred at the tail of pancreas with sepsis, and an EUS guided cystogastrostomy was performed. The irregularly shaped pancreatic collection was punctured at the fundus of the stomach with a needle knife. Using a stiff guidwire we have dilated the opening with a 8mm ballondilator, and we have placed a 10mm diameter covered metal stent into the anastomosis. We have fixed the stent to the gastric wall with a clip, then placed a 5F nasocystic drain into the lumen for lavage. At the same time we have introduced another guidewire into the jejunum through the working channel of the scope for jejunal feeding tube placement. The patient become feverless, and ameliorated gradually. Later on gastric perforation occured and the old lady died from surgical complications.

Case II.: a 44 years old male presented with acute necrotising pancreatitis. Despite of long lasting jejunal feeding a 10cm diameter WON developed. It was not bulging into the stomach and the thinkness of the wall was more than 2 centimeters, thus EUS guided drainage was choosen. After implantation of two 10F pigtail stents with a nasocystic drain, high fever occurred, so we have implanted further 2 stents. Inspite of tailored antibacterial treatment the fever continued, so we decided to change the 4 pigtail stents for a 2,2cm wide uncovered intestinal metal stent with nasocystic drain. After 8 weeks with continuous lavage the WON regressed and we have removed the stent without complications.

Conclusion: Selfexpandable metal stents give a large outlet of WON for successful lavage of debris and infected materials. However, thorough supplementery treatment with tailored antibiotics and jejunal feeding is mandatory.