Endorotor-based endoscopic necrosectomy avoiding the superior mesenteric artery

A 67-year-old man with a 15-cm pancreatic necrotic collection was transferred to our unit after 2 months’ hospitalization for necrotizing pancreatitis. His conditions was poor, with decreased mental status, high fever, neutrophilic leukocytosis (white blood cells 27.6 × 10⁹/L, neutrophils 93.1 %), and signs of sepsis (C-reactive protein 150.5 mg/L, procalcitonin 9.83 ng/mL).

Emergency endosonography-guided drainage using a 15 × 10 mm Axios stent (Boston Scientific, Marlborough, Massachusetts, USA) mounted onto a cautery device was successfully performed. During the procedure a major vessel was observed inside the collection. He was sent for embolization but angio-computed tomography revealed the vessel to be the superior mesenteric artery (SMA) and embolization prior to direct endoscopic necrosectomy (DEN) was aborted. A decision to pursue DEN was made and the Endorotor system (Interscope, Inc., Whitinsville, Massachusetts, USA) ([Fig. 1]), which allows constant endoscopic visualization during necrosectomy ([Fig. 2]), was utilized. The procedure was performed using a dedicated Endorotor XT catheter, high rotating speed (1700 rpm), and progressive increase of suction up to 60 L/min ([Fig. 3]), with careful visualization of the site at which the catheter was active ([Video 1]).

Fig. 1 The catheter tip emerging from a therapeutic endoscope. The fixed outer cannula and the hollow inner cannula can be seen.

Fig. 2 The catheter inside the endoscope passing through a previously placed Axios stent (Boston Scientific, Marlborough, Massachusetts, USA) to start direct endoscopic necrosectomy.

Fig. 3 Endorotor system console (Interscope, Inc., Whitinsville, Massachusetts, USA). Connections to the catheter and vacuum system can be seen.

Video 1 Endoscopic necrosectomy with Endorotor (Interscope, Inc., Whitinsville, Massachusetts, USA), avoiding the superior mesenteric artery.

After two DEN sessions (40 and 120 minutes’ duration, respectively), without any complications, only minimal debris remained in the area proximal to the SMA. A double-pigtail stent was placed through the Axios stent and the patient was discharged home.

At 3 weeks’ follow-up, both stents were removed, and the patient remained in good clinical condition thereafter.

Endorotor is a new endoscopic rotating morcellator device, which reported successful accomplishment of DEN in two patients in whom conventional necrosectomy failed [1], and in another patient [2] with a collection containing 70 % necrotic content. In our case, the Endorotor catheter performed DEN under constant endoscopic visualization, allowing successful treatment despite the presence of the SMA inside the collection.

Endoscopy_UCTN_Code_TTT_1AR_2AI

Competing interests

Dr. Larghi has received fees for lecture and training from Pentax Medical and Boston Scientific. He has also received research grant from Medtronic.
Prof. Costamagna is a consultant for Olympus Medical, Boston Scientific Corp., Cook Medical.

• References

• 1 van der Wiel SE, Poley JW, Grubben MJAL. et al. The EndoRotor, a novel tool for the endoscopic management of pancreatic necrosis. Endoscopy 2018; 50: E240-E241
• 2 Bazarbashi AN, Ge PS, de Moura DTH. et al. A novel endoscopic morcellator device to facilitate direct necrosectomy of solid walled-off necrosis. Endoscopy 2019; 51: E396-E397

Publication History

Article published online:
24 April 2020