Combined Laparoscopic and Choledochoscopic Necrosectomy for Infected Pancreatic Necrosis: A Case Report

Summary

We report a single case of infected pancreatic necrosis after failed percutaneous drainage. A combined laparoscopic and choledochoscopic necrosectomy was performed, following which the patient was successfully discharged with improved imaging findings.

Abstract

Infected pancreatic necrosis often necessitates intervention when initial step-up management fails. We present the case of a 63-year-old female with severe acute necrotizing pancreatitis complicated by extensive, multiloculated infected collections that persisted despite prolonged percutaneous catheter drainage and antibiotic therapy. Imaging demonstrated necrosis involving both the pancreatic head and tail regions, a distribution that limited the effectiveness of unilateral retroperitoneal or purely endoscopic approaches. Given the failure of drainage and the complex anatomical extent of disease, a combined laparoscopic and choledochoscopic necrosectomy was performed to achieve comprehensive debridement within a single procedure.

Laparoscopy provided panoramic access to the lesser sac and retroperitoneum, enabling adhesiolysis and controlled entry into the necrotic cavities, while the flexible choledochoscope facilitated targeted irrigation and removal of debris within deep and anatomically complex regions, particularly in the pancreatic head. Double-lumen irrigation drains were placed to support postoperative lavage and cavity management. The procedure was completed without conversion to open surgery, with an operative time of 7 h and 11 min and an estimated blood loss of 800 mL.

Postoperatively, the patient recovered with normalization of inflammatory markers and was discharged on postoperative day 50. Follow-up imaging demonstrated marked resolution of the necrotic collections, and no additional invasive interventions were required. This case illustrates that a combined laparoscopic and choledochoscopic approach may represent a feasible minimally invasive option for complex, pan-pancreatic necrosis refractory to drainage.

Introduction

Severe acute pancreatitis (SAP) continues to pose a significant challenge in clinical practice, with infected pancreatic necrosis (IPN) representing a critical and often lethal complication. The management paradigm has evolved from early open surgery to a minimally invasive step-up approach, which prioritizes delayed intervention and begins with Percutaneous Drainage (PD) as a first-line procedure^1,2,3,4. This strategy has been widely adopted for its success in reducing the procedural morbidity and mortality associated with traditional necrosectomy⁵.

However, a significant clinical dilemma arises when PD fails, particularly in cases of extensive, multiloculated necrosis that spans multiple anatomical compartments. In such scenarios, the logical next step in the step-up algorithm is surgical debridement. While video-assisted retroperitoneal debridement (VARD) and endoscopic transluminal techniques are established options⁶. Both are constrained by their anatomical access: VARD by its unilateral retroperitoneal approach, and endoscopy by its transluminal route. Unilateral access in VARD often results in a restricted visual field and a narrow working corridor, which can hamper complete debridement of necrosis extending beyond a single compartment. Conversely, the transluminal nature of endoscopic techniques limits their reach to collections immediately adjacent to the gastrointestinal lumen and may not provide sufficient force to evacuate solid debris from multiple locales. In contrast, the transluminal nature of endoscopic techniques limits their reach to collections immediately adjacent to the gastrointestinal lumen and may not provide sufficient force to evacuate solid debris.

This case report presents the management of a patient with precisely such a complex scenario: extensive, multiloculated IPN refractory to percutaneous drainage. In this specific instance, the necrosis involved both the pancreatic head and tail regions, a distribution that challenged optimal access with either a standalone VARD (limited to the head) or a purely endoscopic approach⁷. Therefore, a combined laparoscopic and choledochoscopic necrosectomy was employed. While both laparoscopy and choledochoscopy have been described individually for pancreatic necrosectomy^8,9,10, reports on their synergistic / combined use are scarce. The purpose of presenting this case is to detail the application and immediate perioperative outcomes of this combined approach in a specific anatomical context where standard step-up options were considered suboptimal, thereby illustrating a potential alternative surgical pathway for similar complex presentations.

Case Presentation:

Clinical history and initial management

A 63-year-old female was admitted to the hospital due to a one-week history of epigastric pain and vomiting without an obvious precipitating factor. Past medical history was significant for coronary artery disease, for which she had undergone percutaneous coronary intervention (PCI) at our hospital 4 years prior. Her long-term medications included aspirin (discontinued one week prior to admission due to gastrointestinal symptoms), fenofibrate, and metoprolol succinate. On admission, physical examination revealed tachypnea, absence of fever, epigastric muscle guarding, and mild generalized abdominal tenderness without rebound. Laboratory investigations demonstrated a marked elevation of pancreatic enzymes (amylase 27547 IU/L, lipase 9832.0 IU/L), leukocytosis (17.37×10⁹/L), and significantly elevated inflammatory markers (C-reactive protein 184.48 mg/L, procalcitonin >1.0 ng/mL). Contrast-enhanced abdominal computed tomography (CT) revealed diffuse pancreatic enlargement with heterogeneous density, accompanied by extensive peripancreatic and retroperitoneal exudation and fluid collections, findings consistent with acute necrotizing pancreatitis (Figure 1). Follow-up imaging after surgical intervention is shown in Figure 2.

Following admission, the patient was managed as critically ill. Treatment included fasting, aggressive fluid resuscitation, gastrointestinal decompression, omeprazole, octreotide, ulinastatin, and empirical antibiotic therapy with imipenem-cilastatin sodium. The first ultrasound-guided percutaneous catheter drainage (PCD) of abdominal fluid was performed the next day. Post-procedure, the patient developed acute respiratory failure with a respiratory rate of 35 breaths/min and oxygen saturation declining to 86.5% (on 40% FiO₂), suggestive of acute respiratory distress syndrome (ARDS). She was subsequently transferred to the Intensive Care Unit (ICU) for endotracheal intubation and ventilatory support. After approximately two weeks of comprehensive management in the ICU, with initial control of infection (return to normothermia) and improvement in respiratory function (oxygen saturation 96.3% on 37% FiO₂), she was transferred back to the general ward.

Diagnosis, Assessment, and Plan

Diagnosis of infected pancreatic necrosis and failure of percutaneous drainage

After returning to the general ward, anti-infective therapy (de-escalated to piperacillin-tazobactam) and supportive care were continued. Over the following month, despite multiple ultrasound-guided PCD procedures, follow-up imaging showed persistent peripancreatic, encapsulated, necrotic collections. Drainage fluid cultures were repeatedly negative, and the patient experienced recurrent infection symptoms. Approximately one month after admission, culture of brown, turbid fluid obtained during one such drainage procedure finally yielded Burkholderia cepacia, confirming the diagnosis of infected pancreatic necrosis (IPN). The antibiotic regimen was subsequently adjusted to cefoperazone-sulbactam sodium based on antimicrobial susceptibility testing.

The persistence of systemic symptoms and imaging findings of multiloculated, solid necrotic tissue despite prolonged, multi-site PCD indicated that drainage alone was insufficient. This clinical dilemma necessitated progression to the next stage of the step-up approach: surgical necrosectomy.

Surgical intervention: combined laparoscopic and choledochoscopic necrosectomy

After nearly 2 months of persistent infection, the patient underwent the definitive procedure on March 7, 2025. The rationale for selecting a combined approach was the need for both panoramic access (laparoscopy) and precise intraluminal debridement (choledochoscopy) to address extensive, multiloculated necrosis involving both the pancreatic head and tail.

Protocol

Anesthesia and intraoperative support

Anesthesia was induced approximately 20 min before skin incision with midazolam (2 mg), atropine (0.5 mg), sufentanil (15 µg), etomidate (12 mg), and rocuronium (40 mg). It was maintained with sevoflurane (1.5-2.5 MAC) and target-controlled infusion of propofol (1,500 mg) and remifentanil (3 mg). Sustained intraoperative management included neuromuscular blockade with additional rocuronium (cumulative ~90 mg), hemodynamic support with norepinephrine infusion (total 2 mg) and a single dose of esmolol (5 mg), adjunctive therapy with ulinastatin (300,000 units), and comprehensive fluid/component therapy.

Surgical procedure

Access and Initial Debridement: After establishing laparoscopic ports, extensive adhesiolysis was performed (Figure 3A). The gastrocolic ligament was divided along the prior drainage tract to enter the lesser sac (Figure 3B). The tract was incised to expose the indwelling drain catheter (Figure 3C), which guided dissection toward the pancreatic head for initial debridement (Figure 3D).

Choledochoscopic debridement (Technical Note: No dedicated intraoperative video was captured; the following is based on the operative record): A flexible endoscope was used as a choledochoscope. It was advanced into the pancreatic head cavity (Figure 4A), revealing an irregular space with grayish, semi-solid debris. Under direct vision, targeted saline irrigation and mechanical disruption were used to mobilize necrotic tissue. Debris was either suctioned or retrieved under laparoscopic guidance. The endpoint was visual identification of viable tissue. An attempt to explore the pancreatic tail (Figure 4B) was limited by anatomic constraints. A protocol for managing significant hemorrhage (>100 mL) with epinephrine-saline irrigation was in place.

Concluding Steps: Double-lumen irrigation drains were placed in the pancreatic head and tail regions (Figure 5A,B). A vascular clip was applied to the jejunum 20 cm distal to the ligament of Treitz (Figure 6) to landmark the site for a subsequent needle-catheter feeding jejunostomy via a separate mini-laparotomy.

The procedure was completed in 7 h and 11 min with an estimated blood loss of 800 mL without conversion to open surgery.

Results

Postoperative course and outcome

The patient was transferred to the ICU postoperatively. She remained hemodynamically stable with no significant postoperative bleeding or pancreatic fistula (drain amylase normal). Serum amylase on postoperative day 1 was 33.4 IU/L, and inflammatory markers normalized within 48 h.

In-hospital recovery: ...

Discussion

The minimally invasive step-up approach, including procedures such as video-assisted retroperitoneal debridement (VARD) and endoscopic necrosectomy, is the established standard for managing infected pancreatic necrosis (IPN)^6,10. Laparoscopic and choledochoscopic techniques have also been individually described for necrosectomy with reported success^8,9. However, reports on their combined, simultaneous app...

Materials

List of materials used in this article

Name	Company	Catalog Number	Comments
Double-lumen irrigation drain	Not specified	Used for postoperative lavage and cavity management
Flexible endoscope (used as choledochoscope)	Zhuhai Pusen	PC515	Advanced into pancreatic head cavity for targeted debridement
Laparoscopic ports/trocars	Not specified	Used for abdominal access
Needle-catheter jejunostomy tube	Not specified	Used for postoperative enteral nutrition
Ultrasonic scalpel	Not specified	Used for adhesiolysis and division of gastrocolic ligament
Vascular clip	Not specified	Used to landmark jejunum for feeding jejunostomy