E-mail:madacsy.laszlo@endo-kapszula.hu

1. TRANSGASTRIC ENDOSCOPIC NECROSECTOMY FOR AN INFECTED WALLED-OFF PANCREATIC NECROSIS WITH A HIGH FLOW WATERJET SYSTEM AND A TEMPORARILY PLACEMENT OF A SELF EXPANDING METAL STENT TO MAINTAIN ADEQUATE DRAINAGE– CASE SERIES Madácsy L., Balogh G., Fejes R., Székely A., Luka F., Altorjay Á, 1st Dept. of Internal Medicine and Gastroenterology, Department of Endoscopy and Surgery, SzentGyörgy County Hospital, Székesfehérvár, Hungary Our new method for endoscopic necrosectomy (ENT) I. ABSTRACT INTRODUCTION/OBJECTIVES: Walled-off pancreatic necrosis and pancreatic abscess are the most severe complications of acute necrotizing pancreatitis (ANP). Surgery is associated with a significant morbidity and mortality in these critically ill patients within the first 30 days of the onset of ANP. Endoscopic therapy has the potential to offer a safer and more effective alternative treatment modality. AIMS & Methods: Three consecutive patients with infected walled off pancreatic necrosis, multi organ failure and sepsis were treated with endoscopic necrosectomy after 19-21 days of the onset of acute necrotizing pancreatitis. The pancreatic necrosis was punctured transgastrically with a cystostome (Wilson-Cook) and after balloon dilatation we placed a covered self expanding metal stent (SEMS) into the necrosis. A large volume of necrotic debris and purulent fluid collection was then spontaneously emptied into the stomach. After 5 days of continuous nasocystic irrigation we removed the SEMS endoscopically, and then the necrotic cavity was entered with an operative double channel upper GI endoscope (Fujinon EG-250D5). Further endoscopic debridement was performed with a high flow waterjet system of the Fujinon Flush Knife (1 L/session, isotonic saline with Betadine), Dormia basket and hot biopsy forceps, and thereafter repeated 3-5 times through the transgastric approach over the next 10 days. All patients were treated with antibioticts and jejunal feeding. RESULTS: All of the patients dramatically improved with a resolution of the septic condition and two patients were uneventfully cured without further complication or the need for surgery. No procedure related complications, such as bleeding or perforation was observed. The average in-hospital time was 42 days.   CONCLUSION: Transgatric endoscopic necrosectomy with the temporarily application of SEMS and high flow waterjet system shows promising results, which might expand the potential for this aggressive endoscopic approach in patients with walled-off pancreatic necrosis and/or pancreatic abscess. Results: effect of ENT on CRP levels • Linear echoendoscope and jumbo duodenoscope (Fujinone). • Sterile sampling for bacteriological examination during the transgastric punction of the infected wall (Acinetobacter and Pseudomonas vs. Acinetobacter, Enterobacter, Enterococcus, Pseudomonas) . • The gastric wall was perforated with a cystostome (Wilson-Cook). • Guide-wire was placed into the cavity. • The hole was dilated with a 1 cm of diameter balloon. • A 6 cm’s long 10 mm wide, uncovered, self expanding metallic biliary stent was implanted into the necrotic cavity (figure 2-3). A naso-cystic lavage drain was also inserted through the stent. • 5 days continuous physiological saline rinses in 100 ml / hr rate • Further jejunal nutrition. • Targeted antibiotic therapy Results Endoscopic treatment: ERCP, EST, stone extraction (Figure 1) After the ENT, the SOFA (Sequential Organ Failure Assessment) score and the sepsis improved, a decreased level of consciousness has ceased, the CRP was halved, and the CT scan showed no further improvement of fluid, necrosis or abscess. All but one patient completely cured after ENT and medical treatment. After 6 weeks of further treatment and jejunal nutrition they could leave the hospital. The artificial gastric fistula spontaneously closed during 2 months. Following a temporary improvement, FJ had died after 3 weeks of the endoscopic intervention on the 35th day of the intensive care treatment. The autopsy confirmed multifocal pulmonary abscess and severe bilateral pneumonia, which was an obvious complication of prolonged ventilation. There was no retroperitoneal abscess, and only a moderate inflammatory signs were observed at autopsy on the site of ENT. Endoscopic treatment: punction, dilatation and metallic stent implantation (Figure 2-3) Introduction • The metal stent was successfully removed on average 7 days later in all patients with gastroscopy and foreign body forceps • A 11 mm of diameter FUJINON operative gastroscope with two working channel was introduced into the retroperitoneal space through the gastric fistula. • A retroperitoneal debridement was carried out under continuous suction with a high pressure (Flush knife) water jet system applying 1000 ml’s of Betadine and H2O2 saline solution (figure 4). • The remaining necrotic tissue parts were removed with Hotbiopsy clamp and Dormia basket (figure5). • The procedure was repeated four times per patient applying naso-cystic lavage drain and jejunal nutrition in between the necroscetomy proceduresfor 4 weeks. Acute necrotizing pancreatitis (ANP) complicates nearly 20%–30% of all patients with acute pancreatitis, and in patients in whom infected necrosis develops the mortality could be as high as 25-70%. Walled off pancreatic necrosis (WOPN), defined as poorly circumscribed infected areas of pancreatic and peri-pancreatic necrosis, which is the most feared and severe complication from acute necrotizing pancreatitis. Conventional treatment of infected WOPN and PA necessitates surgical debridement along with sump drainage and continuous lavage. The key objectives of surgical approach are to remove all necrotic pancreatic and peripancreatic tissue, to evacuate all purulent materials, and to provide continuous and adequate drainage to aid resolution of the inflammatory process.Unfortunately, the recommended surgical procedure of open necrosectomy associated with a high operative morbidity (13%-53%) and mortality (6.2%-36%). Transluminal retroperitoneal endoscopy applied for the debridement of infected WOPN can be considered as the first clinical application of NOTES interventions. Different endoscopic techniques have been described, such as transmural EUS-guided drainage with balloon dilation of the cystogastrostoma or cystoduodenostoma, daily endoscopic necrosectomy with a polypectomy snare or a Dormia basket, continuous lavage with saline, and, if required a repeated balloon dilation of the fistulous tract. Nevertheless, all of the current endoscopic techniques have obvious inherent limitations, such as risk of air embolism or endoscopically uncontrollable bleeding, and inadequate drainage through the multiple plastic stents together with an early occlusion of the fistulous tract. Conclusions • The necrotic tissue and purulent secretions can be removed without complications by washing with the high pressure water jet system of the Flush Knife. • The temporary placement of the self expanding metallic stent facilitates the ENT, because: • Large particles of the necrotic tissue can be removed with andoscopic suction and continuous irrigation through the uncovered metallic stent. • The metal stent can be easily removed endoscopically after 5-7 days without complication. • Temporarily placement of the metal stent results in a sustained, open fistulous tract with a wide orifice between the stomach and pancreatic necrosis, through which the ENT can easily be traced and re-performed, without additional plastic stent insertion. Endoscopic treatment: removal of the metal stent, NOTES, endoscopic necrosectomy with high pressure Flush knife water jet system (FJ) (Figure 4) AIM To overcome these difficulties, in the present case series we demonstrate a new and highly efficient method of transgastric endoscopic necrosectomy as a combination of temporary placement of a self expanding metal stent into the fistulous tract and daily irrigation of the necrotic cavity with a high flow waterjet system of the Fujinone flush knife through a therapeutic gastroscope. Endoscopic treatment (NF): NOTES, necroscetomy with Flush knife and Hotbiopsy clamp (figure 5) Case series - Patients 4 female patients Mean age: 63 years All patients had acute biliary pancreatitis (ABP) Ranson score (mean): 8,5 (predictive mortality=100%) Urgent ERCP and stone extraction within 24 hours (figure 1) Early ICU care, CT scan, jejunal nutrition The indication of endoscopic necrosectomy (ENT): Septic shock, walled off, infecting necrosis. The mean time from the onset of ABP till the endoscopic necrosectomy procedure was: 21 days. E-mail:madacsy.laszlo@endo-kapszula.hu