Infected Walled-Off Pancreatic Necrosis following EUS-Guided Drainage Successfully Treated Using Multiple Stents in Different Sites Technique
We experienced the case of a 40-year-old female who was referred and diagnosed with a WOPN sized 13 × 9 × 7.4 cm that developed 2 weeks after an episode of acute severe pancreatitis. She was initially admitted due to acute severe epigastric pain. Her blood workup showed leukocytosis 2.73 × 103/µl (reference range 4.0–11.0 × 103/µl) with 91% neutrophils (reference range 40–74%) and serum amylase 1,309 U/l (reference range 0–220 U/l); liver chemistry showed total bilirubin 1.9 mg/dl (reference range 0.3–1.2 mg/dl), direct bilirubin 0.5 mg/dl (reference range 0.0–0.5 mg/dl), AST 126 U/l (reference range 0–40 U/l), ALT 343 U/l (reference range 0–40 U/l) and alkaline phosphatase 104 U/l (reference range 32–92 U/l). She underwent endoscopic retrograde cholangiopancreatography which showed only common bile duct sludge. She did not need intensive care but developed high-grade fever with abdominal pain 14 days after admission. A CT scan showed pancreatic necrosis with fluid collection at the pancreatic body. She had high-grade fever even after intravenous antibiotics for another 7 days. She underwent EUS-guided drainage with a 10 Fr × 7 cm double pigtail stent, and prophylactic antibiotics were prescribed for 7 days.\nHowever, she was re-admitted 1 week later because of severe abdominal pain and sepsis. A CT scan of the upper abdomen showed enlargement of the pancreatic collection to 15 × 7 × 14.5 cm with increased enhancement of the rim, septation and some air inside (fig. ). She was scheduled for repeat EUS-guided drainage of the infected WOPN. The procedure was performed with the patient in the left lateral decubitus position using a curvilinear echoscope (GF UC-140P, Olympus, Tokyo, Japan). Endoview showed a partially clogged stent (fig. ) and echoview showed a large collection with turbid content and some air inside (fig. ). We punctured the abscess using a 19-gauge needle (EchoTip® Ultra, Cook Ireland, Limerick, Ireland) at a different site under EUS guidance. The aspirated fluid was noted grossly to be purulent and was sent for culture. After contrast injection, 8.5 and 10 Fr tapered tip Teflon catheters were used for dilatation, and a 10 Fr × 7 cm double pigtail stent was subsequently inserted. Since the collection was multiseptated with thick and turbid pus, we decided to place two additional stents into the abscess for better drainage via a different puncture site using the same technique (fig. ). The patient received an extended course of intravenous antibiotics and was discharged after 33 days of hospitalization without complications. A follow-up MRI 6 weeks later showed only a small pancreatic fluid collection (fig. ).