Initial minimally invasive retroperitoneal necrosectomy for acute necrotizing pancreatitis
Main Article Content
Abstract
Introduction: Minimally invasive approches in treatment of acute necrotizing pancreatitis and/or infected pancreatic necrosis gain a notable advantage compared with open surgery.
Aim: We present our experience in treatment of acute necrotizing pancreatitis by an original minimally invasive retroperitoneal necrosectomy technique, evaluate feasibility and safety of this method, compare our results to other studies.
Patients and methods: A retrospective analysis of 22 patients with acute necrotizing pancreatitis and large fluid collections in retroperitoneal space was performed. All patients underwent retroperitoneal necrosectomy as an initial interventional procedure in treatment of infected pancreatic necrosis.
Results: Sixteen males and six females aged between 24 and 60 with an average age of 42.59 ±7.3 years were included. Alcohol abuse was an etiologic factor of acute necrotizing pancreatitis for 18 patients (81.8%). Average time between diagnosis and performance of necrosectomy was 28.6 ±13.2 days. Ten patients (45.5%) did not undergo any additional intervention after initial retroperitoneal necrosectomy. Other 12 patients (54.5%) required additional procedures. 3 patients (13.6%) needed 5 or more reinterventions: 4 sonoscopically-guided drainages, 4 retroperitoneal renecrosectomies and 11 laparotomies. 9 patients (40.9%) required less than 5 reinterventions: 2 sonoscopically-guided drainages, 12 retroperitoneal renecrosectomies and 3 laparotomies. Most of reinterventions were performed due to insufficient drainage and bleeding. 63.6% of our patients did not require more than one reintervention. Postoperative hospitalisation ranged from 9 to 148 days with an average of 52.2 ±35.2 days. The mortality rate in our study was 0%.
Conclusions: Minimally invasive techniques should be considered as a first-choice surgical option in treating patients with acute necrotizing pancreatitis whenever possible. Pancreatic necrosis occupying less than 30% and with massive fluid collections can be safely managed by an initial minimally invasive retroperitoneoscopic necrosectomy when an appropriate gap in the left retroperitoneum between the colon and the kidney exist.
Article Details
The Medical Research Archives grants authors the right to publish and reproduce the unrevised contribution in whole or in part at any time and in any form for any scholarly non-commercial purpose with the condition that all publications of the contribution include a full citation to the journal as published by the Medical Research Archives.
References
2. Bausch D, Wellner U, Kahl S, et al. Minimally invasive operations for acute necrotizing pancreatitis: comparison of minimally invasive retroperitoneal necrosectomy with endoscopic transgastric necrosectomy. Surgery 2012; 152:S128–S134
3. Bello B, Matthews JB. Minimally invasive treatment of pancreatic necrosis. World J Gastroenterol 2012; 18(46): 6829-6835
4. Bucher P, Pugin F, Morel P. Minimally invasive necrosectomy for infected necrotizing pancreatitis. Pancreas 2008; 36:113-9
5. Cacopardo B, Pinzone MR, Berretta S, et al. Localized and systemic bacterial infections in necrotizing pancreatitis submitted to surgical necrosectomy or percutaneous drainage of necrotic secretions. BMC Surgery 2013, 13(Suppl 2):S50
6. Carter CR, McKay CJ, Imrie CW. Percutaneous necrosectomy and sinus tract endoscopy in the management of infected pancreatic necrosis: an initial experience. Ann Surg 2000; 232:175–80
7. Castellanos G, Piñero A, Doig LA, et al. Management of infected pancreatic necrosis using retroperitoneal necrosectomy with flexible endoscope: 10 years of experience. Surg Endosc (2013) 27:443–453
8. Castellanos G, Piñero A, Serrano A, et al. Translumbar retroperitoneal endoscopy: an alternative in the follow-up and management of drained infected pancreatic necrosis. Arch Surg 2005; 140:952-5
9. Chang YC, Tsai HM, Lin XZ, et al. No debridement is necessary for symptomatic or infected acute necrotizing pancreatitis: delayed, mini-retroperitoneal drainage for acute necrotizing pancreatitis without debridement and irrigation. Dig Dis Sci 2006; 51:1388–95
10. Cirocchi R, Trastulli S, Desiderio J, et al. Minimally invasive necrosectomy versus conventional surgery in the treatment of infected pancreatic necrosis: a systematic review and a meta-analysis of comparative studies. Surg Laparosc Endosc Percutan Tech 2013;23:8–20
11. Connor S, Alexakis N, Raraty MG, et al. Early and late complications after pancreatic necrosectomy. Surgery 2005; 137:499–505
12. Dellinger EP, Forsmark CE, Layer P, et al. Determinant based classification of acute pancreatitis severity: an international multidisciplinary consultation. Ann Surg 2012;256:875–880
13. Freeman M, Werner J, van Santvoort H, et al. Interventions for necrotizing pancreatitis. Pancreas 2012;41: 1176-1194
14. Kokosis G, Perez A, Pappas TN. Surgical management of necrotizing pancreatitis: an overview. World J Gastroenterol 2014; 20(43): 16106-16112
15. Lakshmanan R, Iyer SG, Lee VT, et al. Minimally invasive retroperitoneal pancreatic necrosectomy in the management of infected pancreatitis. Surg Laparosc Endosc Percutan Tech 2010; 20:e11–5
16. Mui LM, Wong SK, Ng EK, et al. Combined sinus tract endoscopy and endoscopic retrograde cholangiopancreatography in management of pancreatic necrosis and abscess. Surg Endosc 2005; 19:393–7
17. Navaneethan U, Vege SS, Chari ST, Baron TH. Minimally invasive techniques in pancreatic necrosis. Pancreas 2009; 38:867-75
18. Raraty MG, Halloran CM, Dodd S, et al. Minimal access retroperitoneal pancreatic necrosectomy: improvement in morbidity and mortality with a less invasive approach. Ann Surg 2010; 251:787–93
19. Ross AS, Irani S, Gan SI, et al. Dual-modality drainage of infected and symptomatic walled-off pancreatic necrosis: long-term clinical outcomes. Gastrointest Endosc 2014; 79:929-935
20. Shelat VG, Diddapur RK. Minimally invasive retroperitoneal pancreatic necrosectomy in necrotising pancreatitis. Singapore Med J 2007; 48:e220-3
21. Šileikis A, Beiša V, Beiša A, et al. Minimally invasive retroperitoneal necrosectomy in management of acute necrotizing pancreatitis. Videosurgery Miniinv 2013; 8 (1): 29-35
22. Šileikis A, Beiša V, Simutis G, et al. Three-port retroperitoneoscopic necrosectomy in management of acute necrotic pancreatitis. Medicina (Kaunas) 2010; 46:176-9
23. van Santvoort HC, Bakker OJ, Bollen TL, et al. A conservative and minimally invasive approach to necrotizing pancreatitis improves outcome. Gastroenterology 2011; 141:1254-63
24. van Santvoort HC, Besselink MG, Bakker OJ, et al. A step-up approach or open necrosectomy for necrotizing pancreatitis. N Engl J Med 2010; 362:1491-502
25. van Santvoort HC, Besselink MG, Bollen TL, et al. Case-matched comparison of the retroperitoneal approach with laparotomy for necrotizing pancreatitis. World J Surg 2007; 31:1635–42
26. Werner J, Feuerbach S, Uhl W, et al. Management of acute pancreatitis: from surgery to interventional intensive care. Gut 2005;54:426–436
27. Werner J, Hartwig W, Hackert T, et al. The role of minimally invasive techniques for necrosectomy in acute pancreatitis. The American Journal of Surgery 194 (Suppl to October 2007) S24–S27
28. Working Group IAP/APA Acute Pancreatitis Guidelines. IAP/APA evidence-based guidelines for the management of acute pancreatitis. Pancreatology 2013; 13:e1-e15
29. Zhao G, Hu M, Liu R, et al. Retroperitoneoscopic anatomical necrosectomy: a modified single-stage video-assisted retroperitoneal approach for treatment of infected necrotizing pancreatitis. Surg Innov 2015, Vol. 22(4) 360–365