Severe necrotizing pancreatitis after endoscopic papillectomy in a patient with ampullary adenoma

Summary of Event: A 38-year-old man diagnosed with ampullary adenoma was referred for further treatment, and initially treated with the endoscopic papillectomy without complications. Recurred lesions were found during follow-up and second procedure was planned. However, severe necrotizing pancreatitis with small bowel ileus occurred following the second endoscopic papillectomy for the recurred lesion. He had to undergo bypass surgery (gastrojejunostomy) for persistent small bowel ileus, and repetitive percutaneous radiologic interventions for necrotic fluid collections in the abdominal cavity during a 6-month period of hospitalization. Teaching Point: During endoscopic papillectomy for ampullary adenoma, every effort to prevent pancreatitis including the decision of appropriate resection extent, prophylactic pancreatic duct stenting, and rectal indomethacin should be made. If severe necrotizing pancreatitis with small bowel ileus occurs, and oral feeding is difficult, early bypass surgery should be considered. In addition, removal of necrotic material in the abdominal cavity requires continuous collaboration among endoscopists, intervention radiologists, and surgeons.