Hellenic Journal of Surgery

, Volume 90, Issue 1, pp 9–15 | Cite as

Minimally Invasive Retroperitoneal Approach for Pancreatic Necrosectomy via a Percutaneous Drainage Tract

  • AA Polydorou
  • EV Pantiora
  • A Vezakis
  • P-T Arkoumanis
  • CJ Psichogios
  • EA Kontis
  • Georgios P Fragulidis
  • G Polymeneas
Original Article
  • 7 Downloads

Abstract

Aim-Background

Infected pancreatic necrosis (IPN) develops in approximately one third of patients with necrotizing pancreatitis (NP). In the past, open necrosectomy (ON) was the standard treatment for this condition, but it carried significant morbidity and mortality. Currently, minimally invasive procedures (MIPs) have been established for the management of IPN, decreasing the risk of complications compared with ON.

Methods

A prospective study was made of patients with IPN treated by a MIP for necrosectomy via a percutaneous drainage catheter, followed by video-assisted retroperitoneal debridement (VARD).

Results

Between 2013 and 2016, 3 consecutive patients, with a mean age of 58 years, underwent a MIP for the management of IPN. All 3 patients had left lateral retroperitoneal pockets of necrosis, and the first-line procedure consisted of placement of a pigtail catheter. The drain tract was subsequently used to carry out VARD. None of the patients presented major postoperative complications or required re-intervention.

Conclusion

The management of IPN has shifted away from ON, which was associated with high morbidity, towards less invasive techniques. MIPs should be used initially as the surgical treatment of choice in most cases. When this is not feasible, or when the MIP is not successful, ON should be implemented.

Keywords

Walled-off pancreatic necrosis minimally invasive necrosectomy infected pancreatic necrosis step-up approach 

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References

  1. 1.
    Working Group IAP/APA Acute Pancreatitis Guidelines. IAP/APA evidence-based guidelines for the management of acute pancreatitis. Pancreatology 2013; 13(4 Suppl 2):e1-e15.Google Scholar
  2. 2.
    van Grinsven J, van Santvoort HC, Boermeester MA, et al. Dutch Pancreatitis Study Group. Timing of catheter drainage in infected necrotizing pancreatitis. Nat Rev Gastroenterol Hepatol 2016;13:306–12.CrossRefPubMedGoogle Scholar
  3. 3.
    Boumitri C, Brown E, Kahaleh M. Necrotizing Pancreatitis: Current Management and Therapies. Clin Endosc 2017; 50:357–65.CrossRefPubMedPubMedCentralGoogle Scholar
  4. 4.
    Werge M, Novovic S, Schmidt PN, et al. Infection increases mortality in necrotizing pancreatitis: a systematic review and meta-analysis. Pancreatology 2016; 16:698–707.CrossRefPubMedGoogle Scholar
  5. 5.
    Bruennler T, Hamer OW, Lang S, et al. Outcome in a large unselected series of patients with acute pancreatitis. Hepatogastroenterology 2009; 56:871–6.PubMedGoogle Scholar
  6. 6.
    Rodriguez JR, Razo AO, Targarona J, et al. Debridement and closed packing for sterile or infected necrotizing pancreatitis: insights into indications and outcomes in 167 patients. Ann Surg 2008; 247:294–9.CrossRefPubMedPubMedCentralGoogle Scholar
  7. 7.
    Ashley SW, Perez A, Pierce EA, et al. Necrotizing pancreatitis: contemporary analysis of 99 consecutive cases. Ann Surg 2001;234:572–9.CrossRefPubMedPubMedCentralGoogle Scholar
  8. 8.
    Connor S, Alexakis N, Raraty MG, et al. Early and late complications after pancreatic necrosectomy. Surgery 2005;137:499–505.CrossRefPubMedGoogle Scholar
  9. 9.
    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;232:175–180.CrossRefPubMedPubMedCentralGoogle Scholar
  10. 10.
    Connor S, Ghaneh P, Raraty M, et al. Minimally invasive retroperitoneal pancreatic necrosectomy. Dig Surg 2003;20:270–7.CrossRefPubMedGoogle Scholar
  11. 11.
    Logue JA, Carter CR. Minimally Invasive Necrosectomy Techniques in Severe Acute Pancreatitis: Role of Percutaneous necrosectomy and video-assisted retroperitoneal debridement. Gastroenterol Res Pract 2015. doi: 10.1155/2015/693040Google Scholar
  12. 12.
    Sorrentino L, Chiara O, Mutignani M, et al. Combined totally mini-invasive approach in necrotizing pancreatitis: A case report and systematic literature review. World J Emerg Surg 2017;12:16.CrossRefPubMedPubMedCentralGoogle Scholar
  13. 13.
    Velagapudi A, McKay M, Barry T, et al. A low impact approach to infected pancreatic necrosis: Review of a Case Series. Surg Infect 2016;17:749–54.CrossRefGoogle Scholar
  14. 14.
    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.CrossRefPubMedGoogle Scholar
  15. 15.
    Besselink MG. The “step-up approach” to infected necrotizing pancreatitis: delay, drain, debride. Dig Liver Dis 2011;43:421–2.CrossRefPubMedGoogle Scholar
  16. 16.
    Wronski M, Cebulski W, Witkowski B, et al. Comparison between minimally invasive and open surgical treatment in necrotizing pancreatitis. J Surg Res 2017;210:22–31.CrossRefPubMedGoogle Scholar
  17. 17.
    He WH, Zhu Y, Zhu Y, et al. The outcomes of initial endoscopic transluminal drainage are superior to percutaneous drainagefor patients with infected pancreatic necrosis: A prospective cohort study. Surg Endosc 2017;31:3004–13.CrossRefPubMedGoogle Scholar
  18. 18.
    Guo Q, Li A, Xia Q, et al. Timing of intervention in necrotizing pancreatitis. J Gastrointest Surg 2014;18:1770–6.CrossRefPubMedGoogle Scholar
  19. 19.
    Poves I, Burdío F, Dorcaratto D, et al. Minimally invasive techniques in the treatment of severe acute pancreatitis. Cent Eur J Med 2014;9:580–7.Google Scholar
  20. 20.
    Windsor JA. Minimally invasive pancreatic necrosectomy. Br J Surg 2007;94:132–3.CrossRefPubMedGoogle Scholar
  21. 21.
    Gomatos IP, Halloran CM, Ghaneh P, et al. Outcomes From Minimal Access Retroperitoneal and Open Pancreatic Necrosectomy in 394 Patients With Necrotizing Pancreatitis. Ann Surg 2016;263:992–1001.CrossRefPubMedGoogle Scholar
  22. 22.
    Beck WC, Bhutani MS, Raju GS, et al. Surgical management of late sequelae in survivors of an episode of acute necrotizing pancreatitis. J Am CollSurg 2012;214: 682–8.Google Scholar
  23. 23.
    van Santvoort HC, Besselink MG, Bakker OJ, et al. Dutch Pancreatitis Study Group. A step-up approach or open necrosectomy for necrotizing pancreatitis. N Eng J Med 2010; 362:1491–502.PubMedGoogle Scholar
  24. 24.
    Sharaiha RZ, Tyberg A, Khashab MA, et al. Endoscopic therapy with lumen-apposing metal stents is safe and effective for patients with pancreatic walled-off necrosis. Clin Gastroenterol Hepatol 2016;14:1797–803.CrossRefPubMedGoogle Scholar
  25. 25.
    Siddiqui AA, Kowalski TE, Loren DE, et al. Fully covered self-expanding metal stents versus lumen-apposing fully covered self-expanding metal stent versus plastic stents for endoscopic drainage of pancreatic walled-off necrosis: clinical outcomes and success. Gastrointest Endosc 2017;85:758–65.CrossRefPubMedGoogle Scholar
  26. 26.
    Adler DG, Siddiqui AA. Nobody really knows how to perform endoscopic necrosectomy. Endosc Ultrasound 2017; 6:147–8.CrossRefPubMedPubMedCentralGoogle Scholar
  27. 27.
    Mathew MJ, Parmar AK, Sahu D, et al. Laparoscopic necrosectomy in acute necrotizing pancreatitis: Our experience. J Minim Access Surg 2014;10:126–31.CrossRefPubMedPubMedCentralGoogle Scholar
  28. 28.
    Mowery NT, Bruns BR, MacNew HG, et al. Surgical management of pancreatic necrosis: A practice management guideline from the Eastern Association for the Surgery of Trauma. J Trauma Acute Care Surg 2017;83:316–27.CrossRefPubMedGoogle Scholar

Copyright information

© Hellenic Surgical Society and Springer-Verlag GmbH Austria, part of Springer Nature 2018

Authors and Affiliations

  • AA Polydorou
    • 1
  • EV Pantiora
    • 1
  • A Vezakis
    • 1
  • P-T Arkoumanis
    • 1
  • CJ Psichogios
    • 2
  • EA Kontis
    • 1
    • 3
  • Georgios P Fragulidis
    • 1
  • G Polymeneas
    • 1
  1. 1.2nd Department of Surgery, “Aretaieio” Hospital, School of MedicineNational and Kapodistrian University of AthensAthensGreece
  2. 2.1st Department of Radiology, “Aretaieio” Hospital, School of MedicineNational and Kapodistrian University of AthensAthensGreece
  3. 3.Institute of Liver StudiesKing’s College HospitalLondonUK

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