Laparoscopic Transgastric Pancreatic Débridement
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Open operative debridement has been the traditional approach to patients with pancreatic necrosis. Recently, improved understanding of the disease natural history coupled with significant advances in minimally invasive interventional techniques (both endoscopic and laparoscopic) have led clinicians to apply these minimally invasive interventions to pancreatic debridement. This report details one such minimally invasive approach—laparoscopic transgastric pancreatic necrosectomy. A thorough understanding of this complex and heterogeneous disease process is necessary to select patients properly for the most appropriate therapeutic approach.
KeywordsAcute pancreatitis Necrotizing pancreatitis Pancreatic debridement Transgastric Laparoscopic Postoperative care Patient selection
Débridement of as much necrotic material is safely possible
Wide external drainage of the pancreas
Access to the alimentary tract
Cholecystectomy (if indicated in biliary acute pancreatitis)
Recently, minimally invasive approaches to treatment of necrotizing pancreatitis have generated a great deal of enthusiasm. These minimally invasive approaches include percutaneous , endoscopic [12, 13•], retroperitoneal [14, 15, 16••], and transabdominal [17, 18].
The purpose of this report is to describe our approach to patients with pancreatic and peripancreatic necrosis predominantly isolated within the lesser sac: laparoscopic transgastric pancreatic débridement. Clinical experience with transgastric debridement is scant; therefore, after a brief review, the main focus will be on our approach to patient selection and operative conduct.
History of Transgastric Débridement
The concept of pancreatic débridement through the posterior stomach wall dates to the first endoscopic intervention in 1996 . In 2002 Ammori reported the first case of laparoscopic transgastric débridement , and in 2008 the Freiburg pancreatic surgery group reported a small series of 6 patients approached by a novel laparoendoscopic rendezvous approach .
Two groups have reported small series of transgastric débridement via conventional open operative approach. A Danish report of 7 patients treated by this strategy documents zero mortality, two repeat operations, and a mean hospital stay of 18 days . Follow up of these patients was quite short: 3 months. More recently, the Calgary group reported 10 patients (of 51 total necrotizing pancreatitis patients managed surgically) treated by open transgastric débridement. These patients had a longer delay from initial pancreatitis insult to surgery (100 days); one required re-operation and none died [22•]. The longer-term follow up of 18 months documented two late complications—recurrent retroperitoneal abscess and recurrent pseudocyst (the latter ascribed to continued alcohol misuse and chronic pancreatitis.
Two points are notable in this limited experience: first, the potential for major hemorrhage exists when transecting the gastric wall, especially with splenic vein thrombosis and sinistral portal hypertension. The single mortality in the German experience was related to massive hemorrhage—after removing a gastrostomy tube 46 days following initial treatment. Secondly, while the transgastric approach is intuitively attractive particularly in hopes of avoiding pancreatic fistula, long term follow up will be required to support early positive experience with the transgastric technique.
Early infection (<4 weeks into the disease course) is managed with a percutaneous drain to temporize the immediate situation, allowing time for clinical improvement prior to definitive intervention to treat the (peri) pancreatic collections. As many as 30 % of patients may be treated definitively by percutaneous drainage; [11, 14, 16••] however, the majority of patients will need further definitive intervention to completely débride the retroperitoneum. While percutaneous drainage is not an absolute contraindication to transgastric débridement, the drain tract does provide a route of egress for pancreatic fistula. Infection in and of itself is also not a definite contraindication to the transgastric approach; however, we have seen the best outcomes in patients taken to operation for the indication of symptomatic sterile necrosis (see below). Necrosis tracking down either paracolic gutter represents a relative contraindication to the transgastric approach as this space potentiated in the retroperitoneum permits reaccumulation of pancreatic juice leading to uncontrolled pancreatic fistula.
Advantages and Limitations of the Transgastric Approach
The major disadvantage of this laparoscopic transgastric débridement lies in the fact that no long-term follow up of these patients exist. In our practice we have seen two patients return more than 1-year following transgastric débridement with recurrent (left sided) pancreatitis related to pancreatic duct stricture in the disconnected left pancreatic remnant (Fig. 3). Data from patients with pancreatic pseudocysts suggest that cystogastrostomy may provide less durable drainage then Roux-en-Y cyst-jejunostomy, though mapping the underlying pancreatic duct anatomy to direct proper drainage is clearly of paramount importance . Time will tell whether this finding is borne out in the setting of pancreatic necrosis.
The transgastric approach is not ideal for all patients with necrotizing pancreatitis: specifically, those with necrosis tracking down the right or left pericolic gutters or down the small bowel mesenteric root may be less than ideally suited for this treatment approach. Once evacuated, these areas become potential spaces, which allow collection of pancreatic secretions that ultimately result in an uncontrolled pancreatic fistula or retroperitoneal abscess. Indeed, we have treated two patients who required early reoperation for reaccumulation of pancreatic necrosis in the pericolic space. Leaving a closed suction drain in the potential space adjacent to the pericolic gutter or small bowel mesenteric root may avoid this problem.
Finally, it is unclear whether preoperative percutaneous drainage to temporize patients with infected pancreatic necrosis is a contraindication to definitive débridement through the stomach. The drain tract offers a site of potential egress for pancreatic secretion and as such at the very least a closed suction drain should be placed adjacent to the drain tract in this clinical setting.
One note regarding patients with pancreatic head parenchymal involvement: this clinical situation portends biliary and possible duodenal involvement (stricture/fistula) in the late term, and commonly causes superior mesenteric vein/portal vein thrombosis with cavernous venous transformation around the pancreatic head and in the porta hepatis. Experienced pancreatic surgeons approach these patients with great caution, expecting protracted clinical involvement.
The patient is placed in a supine position. External compression cuffs are activated for deep vein thrombosis prophylaxis. Given the extremely high incidence of venous thromboembolism in necrotizing pancreatitis patients, it is reasonable to provide preoperative chemical prophylaxis if the operator is comfortable with this strategy.
Adequate intravascular access is also mandatory should the situation of brisk hemorrhage arise. Intravenous antibiotic prophylaxis is administered; if the patient is suspected to have sterile necrosis antibiotics with a good coverage of the general GI flora such as a second generation cephalosporin are a reasonable choice.
Trocars are positioned similar to a laparoscopic distal pancreatectomy. We generally start with a 10/12 mm trocar either at or just cranial to the umbilicus for the camera port. Additional working ports are based on the view of the intra abdominal anatomy. Occasionally a 5-mm subxyphoid port is useful for retraction of a bulky left lateral liver segment.
Once the necrosis cavity is satisfactory cleared, communication between the cavity and posterior of the wall of the stomach is secured. If this opening has not been created with an endovascular stapler, running suture is performed at this point. We also biopsy the cystic cavity wall to prove that necrotizing pancreatitis was not caused by a cystic pancreatic neoplasm.
Depending on the patient’s nutritional status, access to the alimentary tract is often advised. Based on the operator’s preference an enteral feeding tube is placed at this time. Our general preference is to place a gastrostomy tube with jejunal extension, which provides the ability to decompress the stomach through the gastric ports while feeding the alimentary tract downstream (in the jejunum).
Postoperative recuperation is dictated largely by the extent of preoperative debilitation. Many patients have “gastric ileus” in addition to mechanical impingement of the stomach; therefore, tolerance of pure oral intake may take up to several weeks (gastrojejunostomy feeding tubes prove quite valuable in this population). On the other hand, some patients (the “walking wounded” with just “persistent unwellness”) may recuperate with remarkable alacrity.
Transgastric pancreatic débridement appears to be an excellent therapeutic option for select patients with (peri) pancreatic necrosis confined to the lesser sac. Patients treated by this technique must be followed to determine long-term outcomes.
Nicholas J. Zyromski declares that he has no conflict of interest.