PMC5356234_01
First CT scans at admission. Acute pancreatic necrosis and edema of pancreatic tail and surrounding adipose tissue are visible (arrows)
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Fig1
The patient underwent CT scan which showed acute necrosis of the cephalic portion of the pancreas, with reduced enhancement in pancreatic tail and a 11 x 5.5 cm fluid collection in the right retroperitoneal space (Fig. 1).
CT scans after 4 weeks. Acute pancreatic necrosis is replaced by a central walled-off pancreatic necrosis (a, arrow) and lateral retroperitoneal fluid collections (b, arrows)
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Fig2
Also, the necrotic collection cranial to the pancreatic head connected with the left hepatic lobe collection augmented, with a diameter of 15 x cm, and acquired features of walled-off pancreatic necrosis (WOPN) (Fig. 2).
a-d Transgastric necrosectomy and percutaneous drainage. The central necrotic collection has been almost completely solved after transgastric necrosectomy (a, arrow), and a percutaneous drainage was performed on the left retroperitoneal collection (d, arrow)
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Fig3
A 1.6 x 2 cm metallic stent (Niti-S yo-yo stent, Taewoong, South Korea) was positioned, draining abundant necrotic and purulent material, and a 6-Fr naso-cystic tube was then positioned to guarantee continuous irrigation of the drained WOPN with 2 L saline/die (Fig. 3a). Subsequently, the patient repeated abdominal CT scan which confirmed a significant reduction of the WOPN, being 5.6 x 4.3 cm, while the large right and left retroperitoneal collections increased in size (Fig. 3b, c). Then, an ultrasound-guided PD was performed of the left retroperitoneal collection, positioning a 10-Fr drainage tube (Fig. 3d).
ERCP and biliary stenting. Cholangiography confirmed an intrapancreatic biliary leak (arrow), and a 18 Fr x 4 cm biliary stent was positioned (a). ERCP after patient discharge demonstrated a common bile duct post-inflammatory stenosis (arrow), and a 24 Fr x 6 cm biliary stent was positioned (b)
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Fig4
ERCP confirmed a biliary fistula from the distal third of the common bile duct to the WOPN cavity; therefore, sphincterotomy of papilla was performed and a 6 mm x 4 cm fully covered metallic biliary stent (Wallflex, Boston Scientific, Boston, MA, USA) was positioned (Fig. 4a). Endoscopic second-look documented almost complete debridement of the WOPN.  A subsequent ERCP was performed to remove the biliary stent but a common bile duct post-inflammatory stenosis was detected; therefore, a new 8 mm x 6 cm fully covered metallic biliary stent (Wallflex, Boston Scientific, Boston, MA, USA) was positioned (Fig. 4b).
Video-assisted retroperitoneal debridement. VARD was performed on the right retroperitoneal necrotic collection (a). Two large bore drains were left for lavage and drainage of the necrotic cavity (b)
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Fig5
When the descending part of the duodenum was visualized frontally, with the inferior vena cava being visible inferiorly and the right mesocolon superiorly, the VARD was considered completed (Fig. 5a). The retroperitoneal space was then flushed with 4 L saline solution, and two 32-Fr drainages were positioned superiorly and inferiorly; the fascia and skin were closed (Fig. 5b).
a-d CT scans after VARD. After transgastric necrosectomy, VARD, and percutaneous drainage, all the retroperitoneal necrotic collections dramatically reduced (arrows)
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Fig6
The following CT scan demonstrated a significant reduction of all abdominal collections, being the right retroperitoneal collection sized 7.5 x 4 cm (Fig. 6).