Choledochoscope-Guided Necrosectomy for Retroperitoneal and Posterior Rectal Post-Pancreatitis Necrosis

BACKGROUND Severe acute pancreatitis is a severe acute abdominal disease. Signs and symptoms classically vary from abdominal pain to fever, vomiting, and abdominal distension. Severe complications, such as infected pancreatic necrosis and multiple organ dysfunction syndrome, can occur. The various treatment strategies in acute necrotizing pancreatitis include percutaneous drainage, laparoscopic necrosectomy, endoscopic necrosectomy, and minimally invasive or more hazardous open surgery. In the presently described case, the effect of puncture drainage was not significant, and then choledochoscope-assisted pancreatic necrosectomy was performed. CASE REPORT In this case, a 41-year-old Chinese man developed extensive retroperitoneal necrosis extending into the posterior rectum following severe acute pancreatitis. The treatment of secondary infection of pancreatic necrotic tissue remains a major challenge. The drainage catheter for the abdominal puncture was inserted, but it was not effective enough. On the 45th day of admission, choledochoscope-assisted pancreatic necrosectomy was performed. After the operation, the patient was given continuous saline flushing through the drain and low continuous suction was applied to the lumen sump drain. We consider this to be a valuable case in which a patient improved in response to placement of a drain intraoperatively in the posterior rectum. CONCLUSIONS We report a patient who developed extensive retroperitoneal necrosis extending into the posterior rectum following severe acute pancreatitis. We decided to perform choledochoscope-assisted pancreatic necrosectomy; the necrotic tissue around the posterior rectum was removed and a triple lumen sump drain was placed in the posterior rectum. This is the first case of infection of the posterior rectal space after severe acute pancreatitis treated by choledochoscope-assisted pancreatic necrosectomy.