How to Do It: Dual Irrigation‐Drainage System for Drainage and Debridement of Pancreatic Necrosis Collections

ABSTRACT

This article describes a MIRP irrigation drainage system that facilitates saline or H₂O₂ debridement of pancreatic necrosis using readily available equipment.

This article describes a MIRP irrigation drainage system that facilitates saline or H₂O₂ debridement of pancreatic necrosis using cost‐effective, readily available equipment.

1. Background

Pancreatic necrosis occurs due to inflammatory injury in severe acute pancreatitis [1]. Complications include sepsis, haemorrhage, gastrointestinal and/or biliary tract obstruction. Strong evidence recognises that early aggressive intervention increases morbidity and mortality [2, 3]. If patients remain stable, intervention should be delayed beyond 4 weeks and initial treatment should focus on supportive care with organ support, nutrition and analgesia. Antibiotics can temporise infection, allowing necrotic collections to mature [3, 4]. A step‐up approach is used for symptomatic necrosis, escalating drainage and minimally invasive debridement procedures to resolve necrosis [5]. Here, Endoscopic transluminal drainage is the first choice for centrally located walled‐off collections [6, 7, 8].

When patients develop organ dysfunction and sepsis in the early phase, retroperitoneal percutaneous catheter drainage (PCD) remains crucial in treating necrosis. Benefits include accessing difficult‐to‐reach collections, treating drain blockage at the bedside and facilitating minimally invasive surgical retroperitoneal pancreatic necrosectomy/debridement (MIRP).

Drainage and debridement of necrosis can be tedious, often requiring multiple procedures. The addition of retroperitoneal drain irrigation provides mechanical and/or chemical debridement if hydrogen peroxide (H₂O₂) is added. This may improve the efficiency of debridement [9].

Technical considerations for PCD with irrigation include ease of use for patients and medical staff, skin protection with a secure seal to handle high‐volume irrigation, and careful monitoring of output to recognise complications early. This article describes a MIRP irrigation drainage system that facilitates saline or H₂O₂ debridement of pancreatic necrosis using readily available equipment with over 15 years of experience [10, 11]. During this period no complications directly related to H₂O₂ have been observed.

The dressing includes a stoma bag with a bespoke waterproof seal. The irrigating catheter is accessed outside of the bag for additional flushes. The bag can be emptied using an in‐built release valve. This allows weight to be removed from the drain bag, improves patient comfort and reduces drain migration by preventing stitch extrusion. This reduces leakage without compromising the waterproof seal. 0.9% Sodium Chloride or H₂O₂ (diluted to 0.3%) at 50–100 mL/h is used for irrigation. Drain input/output are monitored hourly, allowing early detection of drain blockage or sentinel pseudoaneurysm bleed. Minimally invasive debridement is performed regularly until clearance of necrosis. Drains can be downsized and gradually withdrawn, or the tract embolised if a pancreatic cutaneous fistula persists.

2. Method

2.1. Equipment

• Hollister Drain Bag Faecal Collector 500 mL (Stoma bag) (Figure 1.A1)

• Eakin Cohesive Seal Slims 48 mm (Stoma leak protection) (Figure 1.A2)

• 3M Cavilon Advanced Skin Protectant

• Comfeel Plus Dressing.

• Elastrator Tailing Ring Applicator (‘The Original’ Elastrator) (Figure 1.A3).

• Docking rings (‘The Original’ Elastrator Latex Rings) (Figure 1.A4)

• Urinary Hourly Measure/Urinary Drainage bag

FIGURE 1.

Step‐by‐step—creating a Dual‐irrigation drainage system. (A) Equipment for procedure. A1: Hollister Drain Bag Faecal Collector 500 mL. A2: Eakin Cohesive Seal Slims 48 mm. A3: Elastrator Tailing Ring Applicator (‘The Original’ Elastrator). A4: Docking rings (‘The Original’ Elastrator Latex Rings). (B) Drain system using 28Fr intercostal drain and Nasogastric tube. (C) Irrigating drain fed through the cut hole in the collection bag. (D) Eakin Cohesive Seal Slim is warmed and moulded around the irrigating drain. (E) Ring Applicator used to place 2–3 docking rings over the moulded Eakin ring. (G) A Comfeel Plus Dressing is placed around the entry site, protecting skin and securing the drain bag [12].

2.2. Procedure

After radiological PCD placement, upsizing and insertion of a dual irrigating drain catheter are performed. The drain is formed using a 28Fr intercostal catheter and a nasogastric tube. The nasogastric tube is threaded through the most distal draining hole of the 28 Fr drain, and the two are sutured together and to the skin. The drain entry site is cleaned of debris and Cavilon Advanced Skin Protectant is applied. A hole is cut through the stoma bag opposite the skin entry site. The stoma bag is applied over the drains and the irrigating drain is fed through the cut hole (Figure 1C). One‐half of an Eakin Cohesive Seal Slim is warmed and moulded around the irrigating drain, creating a seal. (Figure 1D) The Ring Applicator is used to place 2–3 docking rings over the moulded Eakin ring. (Figure 1E,F) A Comfeel Plus Dressing is placed around the entry site, protecting the skin and securing the drain bag. (Figure 1G) An hourly urine bag is attached to accurately measure output.

3. Conclusion

This drainage system is efficient for managing continuous irrigation of peri‐pancreatic collections. This article has described the procedure and equipment required to create and monitor this system.

Conflicts of Interest

The authors declare no conflicts of interest.

Data Availability Statement

The data that support the findings of this study are available from the corresponding author upon reasonable request.