Interventions for Necrotizing Pancreatitis
Interventions for Necrotizing Pancreatitis
Laparoscopic-assisted pancreatic debridement is performed with laparoscopic visualization followed by hand-assisted or laparoscopic necrosectomy through a separate port, or alternatively by creation of a cyst-enterostomy via a transgastric or retrogastric approach. Laparoscopic debridement, although conceptually appealing, has gained little acceptance, especially in ill patients with infected necrosis, because it usually involves a transperitoneal route and thus risk of disseminating retroperitoneal infection into the peritoneal cavity. It may be most suitable for patients with well-organized necrosis who are scheduled to undergo simultaneous cholecystectomy late in the course of the disease.
Gagner and colleagues pioneered the treatment of pancreatic necrosis using three different minimally invasive approaches: transgastric, retrogastric retrocolic and a full retroperitoneoscopic technique in eight patients. Bucher et al. demonstrated the successful use of single-port laparoscopic necrosectomy in eight patients, with infected WON patients not responding to radiological drainage. The authors reported that the use of a single large-port laparoscopic trochar enabled good visualization for debridement and extraction. Only one patient needed a repeat minimally invasive necrosectomy. No peri-operative complications or postoperative morbidity was reported. Parekh and colleagues reported on a series of 19 patients undergoing laparoscopic hand-assisted necrosectomy through a transperitoneal infracolic approach. Only 1 of the 19 patients needed conversion to open necrosectomy. The authors demonstrated a significantly reduced local peritoneal and systemic immune response following laparoscopic approach compared to open necrosectomy, as well as no postoperative complications such as wound dehiscence or external or bowel fistulae and a shorter hospital stay. Fischer et al. described a novel laparoendoscopic rendezvous maneuver, which was successful in five out of six cases of symptomaticWON. Overall, laparoscopic necrosectomy has a clinical success rate of 70–95%, morbidity of approximately 20% and mortality of 0–18%.
There are theoretical advantages to each of the laparoscopic approaches. Laparoscopic debridement through a transgastric route via cyst enterostomy is less likely to injure major vessels and thus may avoid the associated risk of visceral ischemia and bleeding. A transperitoneal approach enables access to areas inaccessible through endoscope to the lesser sac, right and left paracolic gutters, perinephric space, retroduodenal space and root of the mesentery. Single large-port laparoscopic necrosectomy permits resection of a large amount of necrotic debris and may obviate the need for repeated interventions. It also permits simultaneous laparoscopic cholecystectomy in patients with biliary pancreatitis. However, it is unclear if the pneumoperitoneum created during laparoscopy has deleterious effects in hemodynamically unstable patients. The laparoscopic approach to WON should be undertaken by highly experienced minimally invasive surgeons and the transgastric approach only in cases in which the collection closely abuts the stomach lumen. Laparoscopic debridement appears to be a valid therapeutic option that definitely warrants further refinement and investigation.
Laparoscopic Debridement
Laparoscopic-assisted pancreatic debridement is performed with laparoscopic visualization followed by hand-assisted or laparoscopic necrosectomy through a separate port, or alternatively by creation of a cyst-enterostomy via a transgastric or retrogastric approach. Laparoscopic debridement, although conceptually appealing, has gained little acceptance, especially in ill patients with infected necrosis, because it usually involves a transperitoneal route and thus risk of disseminating retroperitoneal infection into the peritoneal cavity. It may be most suitable for patients with well-organized necrosis who are scheduled to undergo simultaneous cholecystectomy late in the course of the disease.
Gagner and colleagues pioneered the treatment of pancreatic necrosis using three different minimally invasive approaches: transgastric, retrogastric retrocolic and a full retroperitoneoscopic technique in eight patients. Bucher et al. demonstrated the successful use of single-port laparoscopic necrosectomy in eight patients, with infected WON patients not responding to radiological drainage. The authors reported that the use of a single large-port laparoscopic trochar enabled good visualization for debridement and extraction. Only one patient needed a repeat minimally invasive necrosectomy. No peri-operative complications or postoperative morbidity was reported. Parekh and colleagues reported on a series of 19 patients undergoing laparoscopic hand-assisted necrosectomy through a transperitoneal infracolic approach. Only 1 of the 19 patients needed conversion to open necrosectomy. The authors demonstrated a significantly reduced local peritoneal and systemic immune response following laparoscopic approach compared to open necrosectomy, as well as no postoperative complications such as wound dehiscence or external or bowel fistulae and a shorter hospital stay. Fischer et al. described a novel laparoendoscopic rendezvous maneuver, which was successful in five out of six cases of symptomaticWON. Overall, laparoscopic necrosectomy has a clinical success rate of 70–95%, morbidity of approximately 20% and mortality of 0–18%.
There are theoretical advantages to each of the laparoscopic approaches. Laparoscopic debridement through a transgastric route via cyst enterostomy is less likely to injure major vessels and thus may avoid the associated risk of visceral ischemia and bleeding. A transperitoneal approach enables access to areas inaccessible through endoscope to the lesser sac, right and left paracolic gutters, perinephric space, retroduodenal space and root of the mesentery. Single large-port laparoscopic necrosectomy permits resection of a large amount of necrotic debris and may obviate the need for repeated interventions. It also permits simultaneous laparoscopic cholecystectomy in patients with biliary pancreatitis. However, it is unclear if the pneumoperitoneum created during laparoscopy has deleterious effects in hemodynamically unstable patients. The laparoscopic approach to WON should be undertaken by highly experienced minimally invasive surgeons and the transgastric approach only in cases in which the collection closely abuts the stomach lumen. Laparoscopic debridement appears to be a valid therapeutic option that definitely warrants further refinement and investigation.
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