Video-Assisted Retroperitoneal Debridement (VARD) of Infected Necrotizing Pancreatitis: An Update

Percutaneous Interventions and Necrosectomy in the Management of Peripancreatic Collections

Acute pancreatitis (AP) is a severe inflammatory condition of the pancreas with significant morbidity and mortality, particularly in its necrotizing form. This review explores the management of peripancreatic collections and in particular necrotizing pancreatitis, focusing on the evolution from traditional open surgical methods to contemporary minimally invasive image-guided techniques. AP can lead to various local complications, including pancreatic pseudocysts, acute necrotic collections, and walled-off necrosis. Imaging plays a crucial role in diagnosing complications of AP, while treatment approaches have shifted toward a step-up strategy involving percutaneous, endoscopic, and minimally invasive methods. Percutaneous necrosectomy, combining mechanical and chemical debridement, has shown promising results. Mechanical necrosectomy uses devices like baskets and retrieval nets, while chemical necrosectomy adds agents like hydrogen peroxide and streptokinase. Current evidence suggests that the step-up approach, starting with percutaneous drainage or necrosectomy and escalating to endoscopic or surgical interventions, if necessary, improves patient outcomes. The review underscores the need for a multidisciplinary approach in managing complicated AP and highlights ongoing advancements in minimally invasive techniques.

Laparoscopic-Assisted Pancreatic Necrosectomy: Technique and Initial Outcomes

BACKGROUND

Necrotizing pancreatitis (NP) may result de novo or following procedures such as ERCP or partial pancreatectomy (post-procedural), and may require surgical debridement. Video-assisted retroperitoneal debridement (VARD) is a standard approach for NP that employs a 5 cm incision with varying degrees of blind and open debridement. We describe our technique and outcomes of a modified VARD called laparoscopic-assisted pancreatic necrosectomy (LAPN) performed through a single 12 mm incision that uses direct laparoscopic visualization during debridement.

METHODS

At one medical center, all LAPN patients (2012-2020) were assessed for demographics, disease factors, and outcomes. Bivariate logistic regression analyses were performed to identify factors independently associated with recovery after LAPN for patients with de novo vs post-procedural necrosum.

RESULTS

Over 9 years, 60 patients underwent LAPN for NP. Median age was 57 years (IQR: 47-66) and 43 (69%) were men. Pancreas necrosum was de novo in 39 (63%) patients and post-procedural in 23 (37%). NP resolved with a median of 1 LAPN procedure and median hospitalization was 33 days. The LAPN major morbidity rate and in-hospital mortality rate were 47% and 5%. No significant differences were seen between NP etiology cohorts, although post-procedure NP patients trended towards a faster clinical recovery to baseline compared to de novo patients (193 vs 394 days; p-value = .07).

CONCLUSIONS

LAPN offers a smaller incision with excellent visualization and non-inferior outcomes, regardless of etiology, with likely faster recovery for patients with post-procedural vs de novo necrotizing pancreatitis.

Management of Pancreatic Fluid Collections: An Evidence-based Approach

Managing pancreatic fluid collections (PFCs) remains a challenge for many clinicians. Recently, significant progress has been made in the therapy of PFCs, including improvements in technology and devices, as well as in the development of minimally invasive endoscopic techniques, many of which are proven less traumatic when compared with surgical options and more efficacious when compared with percutaneous techniques. This review will explore latest developments in the management of PFCs and how they incorporate into the current treatment algorithm.

Video-assisted retroperitoneal debridement for infected pancreatic necrosis: A single center series

Introduction and importance

Case presentation

Clinical discussion

Conclusion

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VARD is a first option when surgery is required for infected necrotizing pancreatic necrosis.

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The VARD procedure requires placement of percutaneous CT guided retroperitoneal flank drains.

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Complications of the VARD procedure include bleeding, bowel injury, and pancreatic fistula.

Cost-effectiveness analysis of infected necrotizing pancreatitis management in an academic setting

BACKGROUND AND AIMS

Traditional management for infected necrotizing pancreatitis (INP) often utilizes open necrosectomy, which carries high morbidity and complication rates. Thus, minimally invasive strategies have gained favor, specifically step-up approaches utilizing endoscopic or minimally-invasive surgery (MIS); however, the ideal management modality for INP has not been identified.

METHODS

A decision tree model was designed to analyze costs and survival associated with open necrosectomy, endoscopic step-up, and MIS step-up protocols for management of INP after 4 weeks of necrosis development with adequate retroperitoneal access. Costs were based on a third-party payer perspective using Medicare reimbursement rates. The model's effectiveness was represented by quality-adjusted life-years (QALYs). Sensitivity analyses were performed to validate results.

RESULTS

Endoscopic step-up was the dominant economic strategy with 7.92 QALYs for $90,864.09. Surgical step-up resulted in a decrease of 0.09 QALYs and a cost increase of $10,067.89 while open necrosectomy resulted in a decrease of 0.4 QALYs and an increased cost of $18,407.52 over endoscopic step-up. In 100,000 random-sampling simulations, 65.5% of simulations favored endoscopic step-up. MIS step-up was favored when MIS acute mortality rates fell and when MIS drainage success rates rose.

CONCLUSIONS

In our simulated patients with INP, the most cost-effective management strategy is endoscopic step-up. Cost-effectiveness varies with changes in acute mortality and drainage success, which will depend on local expertise.

Simultaneous endoscopic and video-assisted retroperitoneal debridement in walled-off pancreatic necrosis using a laparoscopic access platform: Two case reports

BACKGROUND

Infected walled-off necrosis is a potentially life-threatening complication of necrotizing pancreatitis. While some patients can be treated by drainage alone, many patients also need evacuation of the infected debris. Central necroses in relation to the pancreatic bed are easily reached via an endoscopic transluminal approach, whereas necroses that involve the paracolic gutters and the pelvis are most efficiently treated via a percutaneous approach. Large and complex necroses may need a combination of the two methods.

CASE SUMMARY

Transluminal and percutaneous drainage followed by simultaneous endoscopic and modified video-assisted retroperitoneal debridement was carried out in two patients with very large (32-38 cm), infected walled-off necroses using a laparoscopic access platform. After 34 d and 86 d and a total of 9 and 14 procedures, respectively, complete regression of the walled-off necroses was achieved. The laparoscopic access platform improved both access to the cavities as well as the overview. Simultaneous transluminal and percutaneous necrosectomy are feasible with the laparoscopic access platform serving as a useful adjunctive.

CONCLUSION

This approach may be necessary to control infection and achieve regression in some patients with complex collections.

Laparoscopy in Emergency: Why Not? Advantages of Laparoscopy in Major Emergency: A Review

A laparoscopic approach is suggested with the highest grade of recommendation for acute cholecystitis, perforated gastroduodenal ulcers, acute appendicitis, gynaecological disorders, and non-specific abdominal pain (NSAP). To date, the main qualities of laparoscopy for these acute surgical scenarios are clearly stated: quicker surgery, faster recovery and shorter hospital stay. For the remaining surgical emergencies, as well as for abdominal trauma, the role of laparoscopy is still a matter of debate. Patients might benefit from a laparoscopic approach only if performed by experienced teams and surgeons which guarantee a high standard of care. More precisely, laparoscopy can limit damage to the tissue and could be effective for the reduction of the overall amount of cell debris, which is a result of the intensity with which the immune system reacts to the injury and the following symptomatology. In fact, these fragments act as damage-associated molecular patterns (DAMPs). DAMPs, as well as pathogen associated molecular patterns (PAMPs), are recognised by both surface and intracellular receptors of the immune cells and activate the cascade which, in critically ill surgical patients, is responsible for a deranged response. This may result in the development of progressive and multiple organ dysfunctions, manifesting with acute respiratory distress syndrome (ARDS), coagulopathy, liver dysfunction and renal failure. In conclusion, none of the emergency surgical scenarios preclude laparoscopy, provided that the surgical tactic could ensure sufficient cleaning of the abdomen in addition to resolving the initial tissue damage caused by the “trauma”.

Adherence to the evidence-based guidelines in the management of acute biliary pancreatitis: A case series

BACKGROUND

Acute pancreatitis (AP) is considered one of the most common gastrointestinal disorders; the annual worldwide incidence for AP is 4.9-73.4 cases / 100,000 people and the total mortality rate is 4-8%, increasing to 33% in patients with infected necrosis. This study aims to assess the outcome of providing standardized evidence-based care to patients with acute biliary pancreatitis.

METHODS

Thirty patients diagnosed with acute biliary pancreatitis, were enrolled in this study and managed according to the Japanese guidelines, 2015 with a complementary scope on other recent guidelines.

RESULTS

Out of 30 patients in the study, 60% were females. Twenty-five cases were presented in the early phase of the disease while the rest presented in the late phase. Gallstones were the commonest cause (80%). The complications encountered were a systemic complication in one case, organ failure in three cases, and the local complications in the form of fluid collections in (43.3%) of cases.Out of 30 patients, 6 patients had an intervention. The main approach was minimally invasive techniques (4 cases), Open approach was performed in 2 cases. The total mortality rate was 10%. Most mild cases were discharged within one week from admission. Cases readmitted with recurrent attacks of acute pancreatitis were 3 cases, one male and 2 females.

CONCLUSION

By applying guidelines in the management of acute biliary pancreatitis, we can reduce disease-related morbidity and mortality. Besides, we can reduce the costs of medical services with the proper investment of healthcare resources.

Walled-off pancreatic necrosis: a staged multidisciplinary step-up approach

Walled-off pancreatic necrosis (WOPN) is a rare complication of pancreatitis. We present the case of a woman in her eighties admitted for diffuse abdominal pain. She had a palpable abdominal mass and the CT scan showed necrosis throughout the tail of the pancreas, a peripancreatic and retrogastric hydroaerial collection (19 cm of diameter) and a calculus in the main biliary duct, thus establishing a diagnosis of emphysematous necrotising obstructive pancreatitis. A step-up approach was decided, first with removal of the biliary calculus, followed by a waiting period of 4 weeks in which the patient was under intravenous antibiotics. At re-evaluation, the CT scan showed a smaller and more organised collection, bounded by a wall, defining WOPN. At this stage, transgastric drainage via echoendoscopy was attempted, without success, followed by percutaneous CT-guided drainage, also with little effect. Surgical necrosectomy was then executed, as a final step, with a successful outcome.

Open necrosectomy in acute pancreatitis-obsolete or still useful?

BACKGROUND

Multiple organ failure and early surgery are associated with high morbimortality after open necrosectomy. Data are mostly derived from historical cohorts with early necrosectomy bereft of step-up treatment algorithm implementation. Thus, mostly circumstantial evidence suggests a better clinical course following mini-invasive surgical and endoscopic necrosectomy. We studied the results of open necrosectomy in a contemporary cohort of patients with complicated pancreatic necrosis treated at a tertiary center.

METHODS

A retrospective cohort study from a university teaching hospital. Results of 109 consecutive patients treated with open necrosectomy during a 12-year period are reported.

RESULTS

The overall 90-day mortality rate was 22.9%. The 90-day mortality rate was 10.6% if necrosectomy could be delayed until 4 weeks from symptom onset and the necrosis had become walled off on preoperative imaging. The risk factors for 90-day mortality were age over 60 years (OR 19.4), pre-existing co-morbidities (OR 16.9), necrosectomy within 4 weeks (OR 6.5), multiple organ failure (OR 12.2), white blood cell count over 23 × 10⁹ (OR 21.4), and deterioration or prolonged organ failure as an indication for necrosectomy (OR 10.4). None or one of these risk factors was present in 52 patients (47.7% of all patients), and these patients had no mortality.

CONCLUSION

Late open necrosectomy for walled-off necrosis has a low mortality risk. Open necrosectomy can be done without mortality in the absence of multiple risk factors for surgery.

Endoscopic transluminal necrosectomy in necrotising pancreatitis: a systematic review

OBJECTIVE

We performed a systematic review to assess the outcome of endoscopic transluminal necrosectomy in necrotising pancreatitis with additional focus on indication, disease severity, and methodological quality of studies.

DESIGN

We searched the literature published between January 2005 and June 2013. Cohorts, including patients with (infected) necrotising pancreatitis, undergoing endoscopic necrosectomy were included. Indication, disease severity, and methodological quality were described. The main outcomes were mortality, major complications, number of endoscopic sessions, and definitive successful treatment with endoscopic necrosectomy alone.

RESULTS

After screening 581 papers, 14 studies, including 455 patients, fulfilled the eligibility criteria. All included studies were retrospective analyses except for one randomized, controlled trial. Overall methodological quality was moderate to low (mean 5, range 2-9). Less than 50 % of studies reported on pre-procedural severity of disease: mean APACHE-II score before intervention was 8; organ failure was present in 23 % of patients; and infected necrosis in 57 % of patients. On average, four (range 1-23) endoscopic interventions were performed per patient. With endoscopic necrosectomy alone, definitive successful treatment was achieved in 81 % of patients. Mortality was 6 % (28/460 patients) and complications occurred in 36 % of patients. Bleeding was the most common complication.

CONCLUSIONS

Endoscopic transluminal necrosectomy is an effective treatment for the majority of patients with necrotising pancreatitis with acceptable mortality and complication rates. It should be noted that methodological quality of the available studies is limited and that the combined patient population of endoscopically treated patients is only moderately ill.