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Minimally Invasive Strategies for the Treatment of Necrotizing Infected Pancreatitis: Video-Assisted Retroperitoneal Debridement (VARD)

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Minimally Invasive Acute Care Surgery
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Abstract

Infected pancreatic necrosis is a complex disease process associated with significant morbidity and mortality. For years, management relied on extensive open operations to remove the necrotic tissue. The operations, themselves, also had high mortality rates. Over the past 15 years, however, improvements in laparoscopy and other “minimally invasive” techniques have led to newer approaches to manage this disease. In particular, the advent of the “step-up” approach and the concurrent development of video-assisted retroperitoneal debridement (VARD) have resulted in reduced incidence of major complications, long-term morbidity, and mortality.

The “step-up” method is a graded approach toward infected pancreatic necrosis, starting with percutaneous drainage and then using increasingly interventional techniques if the previous methods fail. VARD is one of the “minimally invasive” techniques and allows the surgeon to approach the necrotic pancreatic or peripancreatic collection through the retroperitoneum without violating the peritoneal cavity. Using a percutaneous drain as a road map to the collection, an incision is made in the retroperitoneum, and blunt dissection is taken down toward the necrosectum. Placement of a laparoscopic port allows enhanced access to the retroperitoneal space and can then be utilized for visualization, irrigation, and removal of necrotic tissue with a laparoscopic grasper. Complications can still occur and include hemorrhage, fistulae, and bowel injury. Overall, however, the incidence of complications is significantly less than open necrosectomy.

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Key References

  1. Peery AF, Dellon ES, Lund J, Crockett SD, McGowan CE, Bulsiewicz WJ, et al. Burden of gastrointestinal disease in the United States: 2012 update. Gastroenterology. 2012;143(5):1179–87. e1-3.

    Article  PubMed  PubMed Central  Google Scholar 

  2. Petrov MS, Shanbhag S, Chakraborty M, Phillips AR, Windsor JA. Organ failure and infection of pancreatic necrosis as determinants of mortality in patients with acute pancreatitis. Gastroenterology. 2010;139(3):813–20.

    Article  PubMed  Google Scholar 

  3. Bradley EL 3rd. A clinically based classification system for acute pancreatitis. Summary of the International Symposium on Acute Pancreatitis, Atlanta, Ga, September 11 through 13, 1992. Arch Surg. 1993;128(5):586–90.

    Article  PubMed  Google Scholar 

  4. Banks PA, Bollen TL, Dervenis C, Gooszen HG, Johnson CD, Sarr MG, et al. Classification of acute pancreatitis–2012: revision of the Atlanta classification and definitions by international consensus. Gut. 2013;62(1):102–11.

    Article  PubMed  Google Scholar 

  5. 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;2015:693040.

    Article  PubMed  PubMed Central  Google Scholar 

  6. Working Group IAPAPAAPG. IAP/APA evidence-based guidelines for the management of acute pancreatitis. Pancreatology. 2013;13(4 Suppl 2):e1–15.

    Google Scholar 

  7. Mier J, Leon EL, Castillo A, Robledo F, Blanco R. Early versus late necrosectomy in severe necrotizing pancreatitis. Am J Surg. 1997;173(2):71–5.

    Article  CAS  PubMed  Google Scholar 

  8. Wronski M, Cebulski W, Slodkowski M, Krasnodebski IW. Minimally invasive treatment of infected pancreatic necrosis. Prz Gastroenterol. 2014;9(6):317–24.

    PubMed  PubMed Central  Google Scholar 

  9. van Santvoort HC, Besselink MG, Bakker OJ, Hofker HS, Boermeester MA, Dejong CH, et al. A step-up approach or open necrosectomy for necrotizing pancreatitis. N Engl J Med. 2010;362(16):1491–502.

    Article  PubMed  Google Scholar 

  10. Beger HG, Buchler M, Bittner R, Oettinger W, Block S, Nevalainen T. Necrosectomy and postoperative local lavage in patients with necrotizing pancreatitis: results of a prospective clinical trial. World J Surg. 1988;12(2):255–62.

    Article  CAS  PubMed  Google Scholar 

  11. Fagniez PL, Rotman N, Kracht M. Direct retroperitoneal approach to necrosis in severe acute pancreatitis. Br J Surg. 1989;76(3):264–7.

    Article  CAS  PubMed  Google Scholar 

  12. Nieuwenhuijs VB, Besselink MG, van Minnen LP, Gooszen HG. Surgical management of acute necrotizing pancreatitis: a 13-year experience and a systematic review. Scand J Gastroenterol Suppl. 2003;239:111–6.

    Article  Google Scholar 

  13. Gagner M. Laparoscopic treatment of acute necrotizing pancreatitis. Semin Laparosc Surg. 1996;3(1):21–8.

    CAS  PubMed  Google Scholar 

  14. Connor S, Ghaneh P, Raraty M, Sutton R, Rosso E, Garvey CJ, et al. Minimally invasive retroperitoneal pancreatic necrosectomy. Dig Surg. 2003;20(4):270–7.

    Article  CAS  PubMed  Google Scholar 

  15. Gambiez LP, Denimal FA, Porte HL, Saudemont A, Chambon JP, Quandalle PA. Retroperitoneal approach and endoscopic management of peripancreatic necrosis collections. Arch Surg. 1998;133(1):66–72.

    Article  CAS  PubMed  Google Scholar 

  16. 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(2):175–80.

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  17. Besselink MG, van Santvoort HC, Nieuwenhuijs VB, Boermeester MA, Bollen TL, Buskens E, et al. Minimally invasive ‘step-up approach’ versus maximal necrosectomy in patients with acute necrotising pancreatitis (PANTER trial): design and rationale of a randomised controlled multicenter trial [ISRCTN13975868]. BMC Surg. 2006;6:6.

    Article  PubMed  PubMed Central  Google Scholar 

  18. Garcia-Urena MA, Lopez-Monclus J, Melero-Montes D, Blazquez-Hernando LA, Castellon-Pavon C, Calvo-Duran E, et al. Video-assisted laparoscopic debridement for retroperitoneal pancreatic collections: a reliable step-up approach. Am Surg. 2013;79(4):429–33.

    PubMed  Google Scholar 

  19. Ulagendra Perumal S, Pillai SA, Perumal S, Sathyanesan J, Palaniappan R. Outcome of video-assisted translumbar retroperitoneal necrosectomy and closed lavage for severe necrotizing pancreatitis. ANZ J Surg. 2014;84(4):270–4.

    Article  PubMed  Google Scholar 

  20. Sileikis A, Beisa V, Beisa A, Samuilis A, Serpytis M, Strupas K. Minimally invasive retroperitoneal necrosectomy in management of acute necrotizing pancreatitis. Wideochir Inne Tech Maloinwazyjne. 2013;8(1):29–35.

    PubMed  Google Scholar 

  21. Freeny PC, Hauptmann E, Althaus SJ, Traverso LW, Sinanan M. Percutaneous CT-guided catheter drainage of infected acute necrotizing pancreatitis: techniques and results. AJR Am J Roentgenol. 1998;170(4):969–75.

    Article  CAS  PubMed  Google Scholar 

  22. Horvath KD, Kao LS, Ali A, Wherry KL, Pellegrini CA, Sinanan MN. Laparoscopic assisted percutaneous drainage of infected pancreatic necrosis. Surg Endosc. 2001;15(7):677–82.

    Article  CAS  PubMed  Google Scholar 

  23. van Santvoort HC, Besselink MG, Bollen TL, Buskens E, van Ramshorst B, Gooszen HG, et al. Case-matched comparison of the retroperitoneal approach with laparotomy for necrotizing pancreatitis. World J Surg. 2007;31(8):1635–42.

    Article  PubMed  Google Scholar 

  24. Horvath K, Freeny P, Escallon J, Heagerty P, Comstock B, Glickerman DJ, et al. Safety and efficacy of video-assisted retroperitoneal debridement for infected pancreatic collections: a multicenter, prospective, single-arm phase 2 study. Arch Surg. 2010;145(9):817–25.

    Article  PubMed  Google Scholar 

  25. Horvath KD, Kao LS, Wherry KL, Pellegrini CA, Sinanan MN. A technique for laparoscopic-assisted percutaneous drainage of infected pancreatic necrosis and pancreatic abscess. Surg Endosc. 2001;15(10):1221–5.

    Article  CAS  PubMed  Google Scholar 

  26. van Santvoort HC, Besselink MG, Horvath KD, Sinanan MN, Bollen TL, van Ramshorst B, et al. Videoscopic assisted retroperitoneal debridement in infected necrotizing pancreatitis. HPB (Oxford). 2007;9(2):156–9.

    Article  Google Scholar 

  27. Zhao G, Hu M, Liu R, Xu Y. Retroperitoneoscopic anatomical Necrosectomy: a modified single-stage video-assisted retroperitoneal approach for treatment of infected necrotizing pancreatitis. Surg Innov. 2015;22(4):360–5.

    Article  PubMed  Google Scholar 

  28. Sileikis A, Beisa V, Simutis G, Tamosiunas A, Strupas K. Three-port retroperitoneoscopic necrosectomy in management of acute necrotic pancreatitis. Medicina (Kaunas). 2010;46(3):176–9.

    Google Scholar 

  29. Wronski M, Cebulski W, Slodkowski M, Karkocha D, Krasnodebski IW. Retroperitoneal minimally invasive pancreatic necrosectomy using single-port access. Surg Laparosc Endosc Percutan Tech. 2012;22(1):e8–11.

    Article  PubMed  Google Scholar 

  30. Lim E, Sundaraamoorthy RS, Tan D, Teh HS, Tan TJ, Cheng A. Step-up approach and video assisted retroperitoneal debridement in infected necrotizing pancreatitis: a case complicated by retroperitoneal bleeding and colonic fistula. Ann Med Surg (Lond). 2015;4(3):225–9.

    Article  Google Scholar 

  31. Connor S, Alexakis N, Raraty MG, Ghaneh P, Evans J, Hughes M, et al. Early and late complications after pancreatic necrosectomy. Surgery. 2005;137(5):499–505.

    Article  CAS  PubMed  Google Scholar 

  32. Weltz AS, Harris DG, O’Neill NA, O’Meara LB, Brenner ML, Diaz JJ. The use of resuscitative endovascular balloon occlusion of the aorta to control hemorrhagic shock during video-assisted retroperitoneal debridement or infected necrotizing pancreatitis. Int J Surg Case Rep. 2015;13:15–8.

    Article  PubMed  PubMed Central  Google Scholar 

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Correspondence to Jacques Mather .

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Mather, J., Diaz, J.J. (2018). Minimally Invasive Strategies for the Treatment of Necrotizing Infected Pancreatitis: Video-Assisted Retroperitoneal Debridement (VARD). In: Khwaja, K., Diaz, J. (eds) Minimally Invasive Acute Care Surgery. Springer, Cham. https://doi.org/10.1007/978-3-319-64723-4_9

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  • DOI: https://doi.org/10.1007/978-3-319-64723-4_9

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