Ryan Law, DO from the Division of Gastroenterology and Hepatology at the Mayo Clinic in Rochester, Minnesota, USA presents this video case “Simultaneous transgastric and transcolonic debridement of walled-off pancreatic necrosis.”

Our video demonstrates concomitant transgastric and transcolonic debridement of pancreatic necrosis in a patient 4 weeks after an episode of severe acute pancreatitis with multisystem organ failure. Cross sectional imaging obtained 2 weeks into his hospitalization demonstrated a large, gas-containing, area of walled-off necrosis extending into the lesser sac along the posterior gastric wall, in addition to a pancreaticocolic fistula at the splenic flexure. Transgastric direct endoscopic necrosectomy was initially performed; however, the patient failed to clinically improve. Direct endoscopic necrosectomy was then repeated using a rendezvous approach with simultaneous debridement via the prior cystgastrostomy site and the pancreaticocolic fistula at the splenic flexure.

This video highlights a unique scenario where endoscopic debridement was successful in the left paracolic gutter preventing the need for surgical necrosectomy, the traditional therapy for this clinical scenario. Additionally, this case showcases the autofistulization that frequently occurs with with walled off necrosis.

Endoscopists treating walled off necrosis should recognize that autofistulization occurs commonly with walled off pancreatic necrosis resulting in air within the collection and can be used to access the cavity for endoscopic debridement. Frequently, non-gastroenterologists associate air within a collection with an infection involving gas-producing organisms, though this is rarely accurate.

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