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Pancreatic Debridement via Sinus Tract Endoscopy

Peter Fagenholz, MD
Massachusetts General Hospital

1. Introduction

2. Surgical Approach

  1. Patient Positioning: A partial lateral decubitus position is often required to allow the percutaneous drain to be prepped into the field.
  2. Patient Preparation: Use a draping system that can catch the continuous irrigation. We use a neurosurgical head drape with attached collection bag.

3. Exchange Superior Drain for 30 French Sheath

  1. Set up and align fluoroscopy.
  2. Insert Super Stiff Amplatz guidewire into drain.
  3. Remove drain over the wire. Use fluoroscopy to be sure the wire stays in position.
  4. Enlarge incision to 1 cm.
  5. Insert dilating balloon over guidewire and inflate.
  6. Advance 30 French sheath over balloon.
  7. Deflate and remove balloon, keeping the wire in place.
  8. Insert the nephroscope to confirm placement in necrotic cavity, and remove the guidewire.

4. Debridement of Necrotic Pancreatic Tissue

  1. Take care to avoid viable tissue on cavity borders.
  2. Remove entire scope and grasper—do not try to pull necrosis through the scope.
  3. Can work with or without continuous irrigation. Use whichever technique provides better visibility.

5. Remove Sheath and Replace Drain

6. Suture Drain

7. Drain Study to Examine Fistula

  1. Optional depending on cavity.

8. Exchange Inferior Drain for 30 French Sheath

  1. Same as step 3.

9. Examination of Cavity for Necrotic Tissue

  1. Same as step 4.

10. Remove Sheath and Replace Drain

  1. Same as step 5.

11. Drain Study

  1. Same as step 7.

12. Suture Drain

  1. Same as step 6.

13. Post-op Remarks