C0195 - Management of Huge Walled-Off Necrosis Using Sequential Percutaneous and Endoscopic Drainage: The First Experience from Qatar

Khaled Elfert, MD, MRCP¹, Bulent Baran, MD², Azizullah A. Beran, MD³, Esraa Elromisy, MD⁴, Saad Al Kaabi, MD^2
1SBH Health System, New York, NY; ²Hamad Medical Corporation, Doha, Ad Dawhah, Qatar; ³The University of Toledo, Toledo, OH; ⁴Tanta University Faculty of Medicine, Ridgefield, NJ

Introduction: Acute pancreatitis can be categorized into acute interstitial edematous pancreatitis and acute necrotizing pancreatitis. Acute necrotizing pancreatitis is associated with an acute necrotic collection that can progress into walled-off necrosis once a well-defined inflammatory wall has developed. Here we present a challenging case of huge acute necrotic collection that progressed into walled-off necrosis and was managed with percutaneous and endoscopic drainage.

Case Description/Methods: We present a 48-year-old patient with a past medical history of hypertension, alcohol use disorder, and acute pancreatitis who presented to our hospital with fever and generalized abdominal pain. Computed tomography of the abdomen revealed a large complex multi-loculated pancreatic collection with fluid and multiple air locules measuring16 x 17 x 33 cm. It also revealed a small distal CBD stone. The patient underwent percutaneous drainage with catheter insertion. Repeated CT scan showed interval reduction in the size of the collection. Three weeks later, the patient underwent second percutaneous drainage with catheter insertion. A repeated CT scan of the abdomen showed further reduction of the collection with the development of thick organized wall (Walled-off necrosis). After EUS confirmed the presence of the small distal CBD stone, ERCP was performed with the insertion of double-pigtail plastic biliary stent and a pancreatic stent. A third transcutaneous drainage procedure was performed with the removal of two catheters and deployment of a new one. It was followed by an EUS-guided cystogastrostomy with the insertion of a 10F 5 cm long double pigtail plastic stent. The patient underwent cystogastrostomy tract dilatation with placement of a second double-pigtail plastic stent through the cystogastrostomy tract. Repeated endoscopy after a week showed migration of one of the double-pigtail stents, so another stent was inserted into the cystogastrostomy tract. 5 weeks later, CT scan of the abdomen revealed a significant reduction in the size of the WON, and the patient finally underwent removal of the two transluminal cystogastrostomy stents and the biliary stent two weeks after the CT scan (8 weeks from the initial cystogastrostomy).

Discussion: Our presentation highlights a case of severe acute necrotizing pancreatitis complicated by an acute necrotic collection that progressed into walled-off pancreatic necrosis requiring multiple transcutaneous and endoscopic drainage procedures.


Disclosures:


Khaled Elfert, MD, MRCP¹, Bulent Baran, MD², Azizullah A. Beran, MD³, Esraa Elromisy, MD⁴, Saad Al Kaabi, MD². C0195 - Management of Huge Walled-Off Necrosis Using Sequential Percutaneous and Endoscopic Drainage: The First Experience from Qatar, ACG 2022 Annual Scientific Meeting Abstracts. Charlotte, NC: American College of Gastroenterology.