Post written by C. Roberto Simons-Linares, MD, and Prabhleen Chahal, MD, from the Department of Gastroenterology and Hepatology, Cleveland Clinic Foundation, Cleveland, Ohio.
We describe a case a 57-year-old man with a history of neuroendocrine tumor of the pancreas status post-laparoscopic distal pancreatectomy and splenectomy that presented to us with severe abdominal pain and found with new post-surgical acute peripancreatic collection not amenable to percutaneous drainage. Initially, he was managed conservatively and the plan was for a follow-up abdominal computed tomography (CT) scan in 6 weeks to reassess the collection. However, the patient presented back to the hospital due to severe persistent abdominal pain and low-grade fever. Abdominal CT scan was repeated, and he was diagnosed with symptomatic walled-off omental fat necrosis (WOFN). He underwent endoscopic ultrasound (EUS)-guided placement of lumen-apposing metal stent (LAMS) and was managed endoscopically with direct debridement through LAMS. The patient reported resolution of the symptoms within 24 hours of LAMS placement and was discharged home with outpatient follow-up for further endoscopic debridement. He underwent a total of 2 direct endoscopic debridement sessions. Four weeks later, follow-up abdominal CT scan showed complete resolution of WOFN. Finally, the LAMS was removed uneventfully, and there were no immediate or delayed post-procedure adverse events. The patient completely recovered and is asymptomatic at 12 months follow-up.
Post-surgical fluid collections after abdominal surgeries are not uncommon and percutaneous drainage is the most common less-invasive approach, but recovery periods are often lengthy and occasionally require surgical intervention if symptoms persist, infection occurs, or if debridement is needed. This video illustrates a case of an uncommon post-operative adverse event of symptomatic walled-off omental fat necrosis (WOFN) after distal pancreatectomy that was successfully managed endoscopically with direct debridement of omental fat necrosis through a lumen-apposing metal stent (LAMS), avoiding external percutaneous drains and re-operation of the patient for surgical debridement of the infected necrotic tissue.
EUS-guided drainage of abdominal collections through LAMS have successfully been used for management of multiple entities (pancreatic fluid collections, gallbladder drainage, abdominal abscesses)–and with our case we demonstrate a very rare post-surgical adverse event of symptomatic omental fat necrosis which was successfully managed via EUS-guided drainage and debridement through LAMS thus avoiding percutaneous or surgical interventions which have been historically used to manage this entity.
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