Minimally invasive necrosectomy for infected necrotizing pancreatitis

The Potential Clinical Benefits of Direct Surgical Transgastric Pancreatic Necrosectomy for Patients With Infected Necrotizing Pancreatitis

OBJECTIVE

Surgical transgastric pancreatic necrosectomy (STGN) has the potential to overcome the shortcomings (ie, repeat interventions, prolonged hospitalization) of the step-up approach for infected necrotizing pancreatitis. We aimed to determine the outcomes of STGN for infected necrotizing pancreatitis.

MATERIALS AND METHODS

This observational cohort study included adult patients who underwent STGN for infected necrosis at two centers from 2008 to 2022. Patients with a procedure for pancreatic necrosis before STGN were excluded. Primary outcomes included mortality, length of hospital and intensive care unit (ICU) stay, new-onset organ failure, repeat interventions, pancreatic fistulas, readmissions, and time to episode closure.

RESULTS

Forty-three patients underwent STGN at a median of 48 days (interquartile range [IQR] 32-70) after disease onset. Mortality rate was 7% (n = 3). After STGN, the median length of hospital was 8 days (IQR 6-17), 23 patients (53.5%) required ICU admission (2 days [IQR 1-7]), and new-onset organ failure occurred in 8 patients (18.6%). Three patients (7%) required a reintervention, 1 (2.3%) developed a pancreatic fistula, and 11 (25.6%) were readmitted. The median time to episode closure was 11 days (IQR 6-22).

CONCLUSIONS

STGN allows for treatment of retrogastric infected necrosis in one procedure and with rapid episode resolution. With these advantages and few pancreatic fistulas, direct STGN challenges the step-up approach.

Epidemiology and risk factors for mortality in critically ill patients with pancreatic infection

Background

The AbSeS-classification defines specific phenotypes of patients with intra-abdominal infection based on the (1) setting of infection onset (community-acquired, early onset, or late-onset hospital-acquired), (2) presence or absence of either localized or diffuse peritonitis, and (3) severity of disease expression (infection, sepsis, or septic shock). This classification system demonstrated reliable risk stratification in intensive care unit (ICU) patients with intra-abdominal infection. This study aimed to describe the epidemiology of ICU patients with pancreatic infection and assess the relationship between the components of the AbSeS-classification and mortality.

Methods

This was a secondary analysis of an international observational study ("AbSeS") investigating ICU patients with intra-abdominal infection. Only patients with pancreatic infection were included in this analysis (n=165). Mortality was defined as ICU mortality within 28 days of observation for patients discharged earlier from the ICU. Relationships with mortality were assessed using logistic regression analysis and reported as odds ratio (OR) and 95% confidence interval (CI).

Results

The overall mortality was 35.2% (n=58). The independent risk factors for mortality included older age (OR=1.03, 95% CI: 1.0 to 1.1 P=0.023), localized peritonitis (OR=4.4, 95% CI: 1.4 to 13.9 P=0.011), and persistent signs of inflammation at day 7 (OR=9.5, 95% CI: 3.8 to 23.9, P<0.001) or after the implementation of additional source control interventions within the first week (OR=4.0, 95% CI: 1.3 to 12.2, P=0.013). Gram-negative bacteria were most frequently isolated (n=58, 49.2%) without clinically relevant differences in microbial etiology between survivors and non-survivors.

Conclusions

In pancreatic infection, a challenging source/damage control and ongoing pancreatic inflammation appear to be the strongest contributors to an unfavorable short-term outcome. In this limited series, essentials of the AbSeS-classification, such as the setting of infection onset, diffuse peritonitis, and severity of disease expression, were not associated with an increased mortality risk.ClinicalTrials.gov number: NCT03270345.

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.

Small Incision Combined with Nephroscope Operation in the Treatment of Infectious Pancreatic Necrosis: A Single-Center Experience of 37 Patients

Objective

To explore the safety and efficacy of small incision combined with nephroscope surgery in the treatment of infectious pancreatic necrosis.

Methods

A retrospective analysis of the clinical data of 37 patients with infectious pancreatic necrosis who underwent small incision combined with nephroscopy in the Department of Hepatobiliary Surgery of Hunan Provincial People's Hospital from January 2018 to December 2019.

Results

All 37 patients successfully completed small incision combined nephroscope surgery. The median time from the onset to the operation of all patients was 38 days (range: 29-80 days), and the hospital stay was 19 days (range: 3-95 days). The median number of drainage tubes placed during the operation was 4 (range: 2-8). According to the different surgical approaches, 13 cases were through the retroperitoneal approach, 11 cases were through the omental sac approach, 2 cases were through the intercostal approach, and 11 cases were combined approach. The operation time was 85.3 ± 31.6 min, and intraoperative bleeding was 63.1 ± 40.0 ml. The incidence of complications (Clavien-Dindo grade 3 and above) was 5.4%. Among them, 2 patients were admitted to the intensive care unit due to postoperative bleeding, 1 case was cured by conservative treatment, and 1 case was cured by interventional treatment. During the follow-up period, 2 patients developed colonic fistula at 2 weeks after operation, and 2 patients developed gastric fistula at 1 week and 3 weeks after operation; all were cured by conservative treatment.

Conclusion

Small incision combined with nephroscope surgery is an effective treatment for patients with infectious pancreatic necrosis by removing necrotic tissue, unobstructed drainage, and reducing complications.

[Surgical strategy for suppurative complications of pancreatic necrosis]

Severe acute pancreatitis is one of the most difficult problems in emergency abdominal surgery. Mortality among patients with this disease ranges from 20 to 80 percent. The use of staged surgical intervention in the treatment of purulent complications of acute severe pancreatitis may affect not only the risk of open surgery, but also the number of post-operative complications.

OBJECTIVE

Improving the results of treatment of patients with infected pancreatic necrosis by applying a step by step surgical approach and comprehensive correction of endotoxicosis.

MATERIAL AND METHODS

The study was retrospectively prospective. All patients were divided into two clinical groups. The control group for the period from 2018 to 2019 included 31 patients for whom the standard surgical tactics of treating pancreatic necrosis were used: laparotomy, necrsecestrectomy and drainage of parapancreatic fluid accumulations, and, if necessary, repeated sanation. The main group included 26 patients, treated from 2019 to 2020. According to the developed step-by-step approach with the application of the correction of endogenous intoxication and enteral insufficiency syndrome. The choice of surgery for the patients of the main group depended on the type of parapancreatic fluid accumulation and included minimally invasive interventions in the first stage and, if necessary, the expansion of the amount of interventions (puncture and drainage under ultrasound control + video assisted retroperitoneal debridement, or ultrasound-controlled puncture and drainage + laparotomy).

RESULTS

The effectiveness of the treatment in both groups was determined by changes in blood leukocyte and C-reactive protein values on the day of the operation, as well as on the 2nd, 4th, 6th day of the post-operative period. By the fourth day after the surgery, the main group patients' white blood cell and CRP blood levels were positively lower than in the control group: p=0.0001, t=9.65 and p=0.0001, t=9.02, respectively. Forty-eight hours after the operation, the dynamics of the EIS were determined. In the control group, where standard methods of treating enteral insufficiency were used, there was an increase in the number of patients with II and III degrees of severity, in comparison with patients of the main group (p<0.05). The number of complications of pancreonecrosis of IIIb and IVb of degrees on the Clavien-Dindo scale in patients of the major group was lower than in the control group: χ²=0.00021, p<0.05 and χ²=0.01553, p<0.05, respectively. 10 (32.3%) died in the control group, 2 (7.7%), χ²=0.04739, p<0.05.

CONCLUSIONS

The choice of surgical intervention for pancreonecrosis should be determined taking into account the development phase of the disease, the type of location of the purulent-necrotic sinuses, and its delimitation from surrounding tissues. Phased surgical treatment with the initial application of minimally invasive technologies affects the number and severity of post-operative complications as well as the early start of correction of enteric insufficiency syndrome - the early relief of endogenous intoxication.

Ultrasonic Pressure Ballistic System-Assisted Minimally Invasive Pancreatic Necrosectomy for Necrotizing Pancreatitis

Background: Although minimally invasive pancreatic necrosectomy (MIPN) is a new invasive technique for necrotizing pancreatitis, it has some disadvantages. This study aimed to improve the debridement technique with an ultrasonic pressure ballistic system. We hypothesized that this system would facilitate debridement and improve the safety of the procedure. Materials and Methods: Between October 2016 and January 2019, 5 patients diagnosed with necrotizing pancreatitis were enrolled in the clinical cohort. All patients underwent debridement due to infective necrosis. Access for debridement was typically established with percutaneous puncture. Then MIPN was performed. During the procedure, ultrasonic pressure was applied to liquefy the necrotic material and make it absorbable. The effect of debridement was assessed by analyzing the average bleeding volume, operation time, and complications. Postoperative clinical parameters were evaluated. Results: Debridement was performed successfully for all patients. Semisolid necrotic tissue was dissolved with ultrasonic pressure. Viscous pus was rapidly aspirated with the suction applied with negative pressure, which greatly enhanced efficiency. This approach enhanced the visibility of blood vessels, which improved safety. No major complications were encountered. Two patients (40%) developed puncture site infections. The average blood loss during the operation was 13 ± 6 mL. The average operation time was 78 ± 31 minutes. Postoperative APACHE II scores were significantly lower than preoperative scores (P < .05). White blood cells, C-reactive protein, and procalcitonin levels declined postoperatively. Conclusions: The ultrasonic pressure ballistic system could potentially enhance MIPN and make it safer.

Pancreatic Necrosectomy through Sinus Tract Endoscopy

BACKGROUND/AIMS

Direct endoscopic pancreatic necrosectomy is increasingly being utilized to treat infected or symptomatic walled-off necrosis (WON) located close to the stomach or duodenum. Laterally-placed WON has traditionally been treated surgically. We evaluated a less utilized technique of sinus tract endoscopy (STE) for symptomatic laterally-placed WON.

METHODS

Two hundred seventy-six patients with acute pancreatitis admitted in our hospital, 32 had symptomatic or infected WON requiring intervention. Of the 12 patients with laterally placed WON, 10 were treated by STE. STE was performed with a standard adult gastroscope passed through a percutaneous tract created by the placement of a 32-Fr drain.

RESULTS

Ten patients (7 males; mean age, 43.8 years) underwent STE. Mean number of sessions was 2.3 (range, 1-4), with mean time of 70 minutes for each session (range, 15-70 minutes). While 9 patients had complete success, 1 patient had fever and chose to undergo surgery. Two patients developed pneumoperitoneum, which was treated conservatively. There was no mortality, cutaneous fistula, or recurrence during follow-up.

CONCLUSIONS

Laterally placed WON can be successfully managed by STE performed through a percutaneously placed drain. Details of the technique and end-points of STE require further evaluation.

Incisional hernia after robotic single-site cholecystectomy: a pilot study

PURPOSE

Robotic LaparoEndoscopic Single-Site Surgery Cholecystectomy has been performed for 5 years using a dedicated platform (da Vinci^® Single-Site^®) with the da Vinci^® Surgical System (Intuitive Surgical Inc., Sunnyvale, CA, USA). While short-term feasibility has been described, long-term assessment of this method is currently outstanding. The aim of this study was to assess long-term parietal complications of this technique.

METHODS

In this retrospective study, patients operated between 2011 and 2013 were evaluated. Parietal incision was assessed with ultrasonography and patients screened for residual pain from scar tissue. Demographic and perioperative data were also collected.

RESULTS

We evaluated 48 patients [38 female, 79.2%; median age 49 years (range: 24-81 years)]; mean BMI 25.9 kg/m² [±SD 4.1 kg/m²]. After a median follow-up of 39 months (range: 25-46 months), six incisional hernias (two patients had a positive echography but a negative clinical examination) were found (12.5%, 95% CI 7.5-30.2), and two patients had a surgical repair. The overall rate of incisional hernia was 16.7% (95% CI 7.5-30.2). Residual pain was observed in 5 of 48 patients.

CONCLUSION

This preliminary study suggests that a clinically significant rate of incisional hernias can occur after R-LESS-C. Larger studies comparing R-LESS-C to alternative methods with long-term follow-up are necessary.

Severe acute pancreatitis: pathogenesis, diagnosis and surgical management

BACKGROUND

Severe acute pancreatitis is a subtype of acute pancreatitis, associated with multiple organ failure and systemic inflammatory response syndrome. In this qualitative review we looked at the principles of pathogenesis, classification and surgical management of severe acute pancreatitis. We also looked at the current shift in paradigm in the management of severe acute pancreatitis since the guideline developed by the British Society of Gastroenterology.

DATA SOURCES

Studies published between 1st January 1991 and 31st December 2015 were identified with PubMed, MEDLINE, EMBASE and Google Scholar online search engines using the following Medical Subject Headings: "acute pancreatitis, necrosis, mortality, pathogenesis, incidence" and the terms "open necrosectomy and minimally invasive necrosectomy". The National Institute of Clinical Excellence (NICE) Guidelines were also included in our study. Inclusion criteria for our clinical review included established guidelines, randomized controlled trials and non-randomized controlled trials with a follow-up duration of more than 6 weeks.

RESULTS

The incidence of severe acute pancreatitis within the UK is significantly rising and pathogenetic theories are still controversial. In developed countries, the most common cause is biliary calculi. The British Society of Gastroenterology, acknowledges the Revised Atlanta criteria for prediction of severity. A newer Determinant-based system has been developed. The principle of surgical management of acute necrotizing pancreatitis requires intensive care management, identifying infection and if indicated, debridement of any infected necrotic area. The current procedures opted for include standard surgical open necrosectomy, endoscopic necrosectomy and minimally invasive necrosectomy. The current paradigm is shifting towards a step-up approach.

CONCLUSIONS

Severe acute pancreatitis is still a subject of grey areas in its surgical management even though new studies have been recorded since the origin of the latest UK guidelines for management of severe acute pancreatitis.

Outcomes From Minimal Access Retroperitoneal and Open Pancreatic Necrosectomy in 394 Patients With Necrotizing Pancreatitis

OBJECTIVE

To examine the outcomes from minimal access retroperitoneal pancreatic necrosectomy (MARPN) and open pancreatic necrosectomy (OPN) for severe necrotizing pancreatitis in a single center.

BACKGROUND

The optimal management of severe pancreatic necrosis is evolving with a few large center single series.

METHODS

Between 1997 and 2013, patients with necrotizing pancreatitis at the Liverpool Pancreas Center were reviewed. Outcome measures were retrospectively analyzed by intention to treat.

RESULTS

There were 394 patients who had either MARPN (274, 69.5%) or OPN (120, 30.5%). Complications occurred in 174 MARPN patients (63.5%) and 98 (81.7%) OPN patients (P < 0.001). OPN was associated with increased postoperative multiorgan failure [42 (35%) vs 56 (20.4%), P = 0.001] and median (inter-quartile range) Acute Physiology and Chronic Health Evaluation II score 9 (6-11.5) vs 8 (5-11), P < 0.001] with intensive care required less frequently in MARPN patients [40.9% (112) vs 75% (90), P < 0.001]. The mortality rate was 42 (15.3%) in MARPNs and 28 (23.3%) in OPNs (P = 0.064). Both the mortality and the overall complication rates decreased between 1997-2008 and 2008-2013 [49 (23.8%) vs 21 (11.2%) P = 0.001, respectively; and 151 (73.3%) vs 121 (64.4%), P = 0.080, respectively). Increased mortality was independently associated with age (P < 0.001), preoperative intensive care stay (P = 0.014), and multiple organ failure (P < 0.001); operation before 2008 (P < 0.001) and conversion to OPN (P = 0.035). MARPN independently reduced mortality odds risk (odds ratio = 0.27; 95% confidence interval = 0.12-0.57; P < 0.001).

CONCLUSIONS

Increasing experience and advances in perioperative care have led to improvement in outcomes. The role of MARPN in reducing complications and deaths within a multimodality approach remains substantial and should be used initially if feasible.

Percutaneous catheter drainage in severe acute pancreatitis: Application and problems

Severe acute pancreatitis (SAP) is an acute abdominal disease which has a number of complications and a high mortality rate. The prognosis had improved much since the use of multidisciplinary comprehensive therapy and minimally invasive treatment in this disease. Percutaneous catheter drainage (PCD) can be used as a step-up minimally invasive treatment for SAP, and as a bridge between internal conservative therapy and open surgery for removal of necrotic tissue. PCD has a therapeutic effect on the local complications of SAP, such as abdominal free effusion, retroperitoneal necrosis infection and pancreatic pseudocyst, and can help to choose the operation timing when the necrotic tissue encapsulation is confirmed in patients with SAP. Clinical therapy should be slected based on the lesion location, quantity and consistency of effusion. When the effusion is located in shallow location, PCD shuold be guided by ultrasound; if the effusion is located in location deep, CT guidance should be adopted. After PCD is finished, the catheter should be cared carefully by keeping the drainage tube patent, rinsing the tube and adjusting its position in time. All of these are the necessary measures to maintain the PCD effectively. When the drainage fluid is less than 10 mL/d and imaging shows that the lesions disappear, it is the best time to remove the tube.

Routine use of U-tube drainage for necrotizing pancreatitis: a step toward less morbidity and resource utilization

BACKGROUND

A U-tube drainage catheter (UTDC) is a novel intervention for necrotizing pancreatitis, with multiple benefits: bidirectional flushing, greater interface with large fluid collections, less risk of dislodgement, and creation of a large-diameter fistula tract for potential fistulojejunostomy. We report the first clinical experience with UTDC for necrotizing pancreatitis.

METHODS

From 2011 to 2014, all patients undergoing UTDC for necrotizing pancreatitis at our institution were identified. Clinical variables including patient, disease, and intervention-specific characteristics as well as long-term outcomes populated our dataset.

RESULTS

Twenty-two patients underwent UTDC for necrotizing pancreatitis; the median follow-up was 10.2 months. Necrotizing pancreatitis was most commonly owing to gallstones (n = 9; 41%), idiopathic disease (n = 5; 23%), and alcohol abuse (n = 4; 18%). During the course of UTDC and definitive operative therapy (when required), patients had median hospital stays of 31 days, 6 interventional radiology procedures, and 6 CT scans. Operative intervention was not necessary in 9 patients (41%). Among the other 13 patients, 4 patients underwent distal pancreatectomy/splenectomy, 8 had a fistulojejunostomy performed, and 1 underwent both procedures.

CONCLUSION

UTDC for necrotizing pancreatitis patients is associated with effective drainage and low morbidity/hospital resource utilization. With skilled interventional radiologists and multidisciplinary coordination, this technique is a valuable means of minimizing morbidity for patients with necrotizing pancreatitis.

Single or multiport percutaneous endoscopic necrosectomy performed with the patient under conscious sedation is a safe and effective treatment for infected pancreatic necrosis (with video)

BACKGROUND

Infected pancreatic necrosis (IPN) is a dreaded adverse event of acute pancreatitis (AP). Most patients with IPN require drainage and necrosectomy, preferably by a minimally invasive method.

OBJECTIVE

To study the success and safety of an alternative form of minimally invasive necrosectomy for IPN.

DESIGN

Observational study.

SETTING

Tertiary care academic center.

PATIENTS

Consecutive patients with IPN formed the study group.

INTERVENTION

Patients with IPN were initially treated conservatively including percutaneous drainage. Those who failed to improve underwent percutaneous endoscopic necrosectomy (PEN). Single- or multiport PEN was performed by using a flexible endoscope through the percutaneous tract. PEN involved vigorous lavage and suction followed by necrosectomy. Multiple sessions were undertaken depending on the size and number of collections and the amount of necrotic debris.

MAIN OUTCOME MEASUREMENTS

Control of sepsis and resolution of collection(s) without the need for surgical necrosectomy.

RESULTS

During the period from October 2012 to July 2013, 165 patients (mean age, 38.82 ± 14.99 years; 119 male patients) were studied. Of them, 103 patients had necrotizing pancreatitis and IPN had developed in 74. Of these 74 patients with IPN, 15 underwent PEN after a mean interval of 39.2 days. Fourteen of the 15 patients improved after a mean of 5 sessions of PEN. Two of 15 patients had minor adverse events: self-limiting bleeding and pancreatic fistula in 1 patient each. One patient required surgery but died of organ failure.

LIMITATIONS

Lack of a control arm.

CONCLUSION

PEN is a safe and effective minimally invasive technique for necrosectomy for IPN.

Minimally invasive treatment of infected pancreatic necrosis

Infected pancreatic necrosis is a challenging complication that worsens prognosis in acute pancreatitis. For years, open necrosectomy has been the mainstay treatment option in infected pancreatic necrosis, although surgical debridement still results in high morbidity and mortality rates. Recently, many reports on minimally invasive treatment in infected pancreatic necrosis have been published. This paper presents a review of minimally invasive techniques and attempts to define their role in the management of infected pancreatic necrosis.

Surgical management of necrotizing pancreatitis: An overview

Necrotizing pancreatitis is an uncommon yet serious complication of acute pancreatitis with mortality rates reported up to 15% that reach 30% in case of infection. Traditionally open surgical debridement was the only tool in our disposal to manage this serious clinical entity. This approach is however associated with poor outcomes. Management has now shifted away from open surgical debridement to a more conservative management and minimally invasive approaches. Contemporary approach to patients with necrotizing pancreatitis and/or infectious pancreatitis is summarized in the 3Ds: Delay, Drain and Debride. Patients can be managed in the intensive care unit and any intervention should be delayed. Percutaneous drainage can be utilized first and early in the course of the disease, followed by endoscopic drainage or video assisted retroperitoneoscopic drainage if necrosectomy is deemed necessary. Open surgery is now less frequently performed and should be reserved for cases refractory to any other approach. The management of necrotizing pancreatitis therefore requires a multidisciplinary dynamic model of approach rather than being a surgical disease.

Laparoscopic transgastric endolumenal cystogastrostomy and pancreatic debridement

BACKGROUND

Cystogastrostomy is commonly performed for internal drainage of pancreatic pseudocysts (PP) and concomitant debridement of walled-off pancreatic necrosis (WOPN). While an open approach to cystogastrostomy is well established, an optimal minimally invasive technique continues to evolve. This laparoscopic transgastric endolumenal cystogastrostomy presented here allows for a large cystogastrostomy with complete debridement of necrosis and internal drainage through a minimally invasive approach.

METHODS

We performed a retrospective review of 22 patients with symptomatic PP/WOPN treated with attempted laparoscopic transgastric endolumenal cystogastrostomy (Lap-TEC) and pancreatic debridement. Short- and long-term outcomes were assessed.

RESULTS

From November 2006 to March 2013, a total of 22 Lap-TEC/pancreatic debridement procedures were attempted; 15 were completed laparoscopically. The median age of the cohort was 49.5 ± 12 years (range = 18-71), average body mass index = 29.1 kg/m(2), 77 % had an ASA score ≥ 3, and 10 were female. Gallstones were the most common etiology (50 %), and median time between initial presentation and surgery was 86 days (range = 0-360). Median operative time and estimated blood loss were 213 min and 100 cc, respectively. Forty-one percent of the patients were admitted to the ICU postoperatively and the average length of stay was 14 days (range = 4-50). Median follow-up was 2 months (range = 0-62.5), with one patient having a procedure-related complication. No other reoperations, late complications, or mortalities occurred. All patients had resolution of their symptoms and fluid collections.

CONCLUSION

This technique of internal drainage via Lap-TEC and pancreatic debridement has been successful in achieving primary drainage and relieving symptoms of PP/WOPN with no mortality and minimal morbidity.

Pancreatic necrosectomy using covered esophageal stents: a novel approach

BACKGROUND

Endoscopic necrosectomy for necrotizing pancreatitis has been increasingly used as an alternative to surgical or percutaneous interventions. The use of fully covered esophageal self-expandable metallic stents may provide a safer and more efficient route for internal drainage. The aim of this study was to evaluate the safety and efficacy of endoscopic treatment of pancreatic necrosis with these stents.

METHODS

A retrospective study at 2 US academic hospitals included patients with infected pancreatic necrosis from July 2009 to November 2012. These patients underwent transgastric placement of fully covered esophageal metallic stents draining the necrosis. After necrosectomy, patients underwent regular sessions of endoscopic irrigation and debridement of cystic contents. The efficacy endpoint was successful resolution of infected pancreatic necrosis without the need for surgical or percutaneous interventions.

RESULTS

Seventeen patients were included with the mean age of 41±12 years. A mean of 5.3±3.4 sessions were required for complete drainage and the follow-up period was 237.6±165 days. Etiology included gallstone pancreatitis (6), alcohol abuse (6), s/p distal pancreatectomy (2), postendoscopic retrograde cholangiopancreatography pancreatitis (1), medication-induced pancreatitis (1), and hyperlipidemia (1). Mean size of the necrosis was 14.8 cm (SD 5.6 cm), ranging from 8 to 19 cm. Two patients failed endoscopic intervention and required surgery. The only complication was a perforation during tract dilation, which was managed conservatively. Fifteen patients (88%) achieved complete resolution.

CONCLUSIONS

Endoscopic necrosectomy with covered esophageal metal stents is a safe and successful treatment option for infected pancreatic necrosis.

Minimally invasive necrosectomy versus conventional surgery in the treatment of infected pancreatic necrosis: a systematic review and a meta-analysis of comparative studies

AIM

The purpose of this meta-analysis and systematic review is to compare minimally invasive necrosectomy (MIN) versus open necrosectomy (ON) surgery for infected necrosis of acute pancreatitis.

METHODS

One randomized controlled trial and 3 clinical controlled trials were selected, with a total of 336 patients (215 patients who underwent MIN and 121 patients underwent ON) included after searching in the following databases: Medline, Embase, Cochrane Central Register of Controlled Trials, BioMed Central, Science Citation Index (from inception to August 2011), Greynet, SIGLE (System for Information on Grey Literature in Europe), National Technological Information Service, British Library Integrated catalogue, and the Current Controlled Trials. Statistical analysis is performed using the odds ratio (OR) and weighted mean difference with 95% confidence interval (CI).

RESULTS

After the analysis of the data amenable to polling, significant advantages were found in favor of the MIN in terms of: incidence of multiple organ failure (OR, 0.16; 95% CI, 0.06-0.39) (P < 0.0001), incisional hernias (OR, 0.23; 95% CI, 0.06-0.90) (P = 0.03), new-onset diabetes (OR, 0.32; 95% CI, 0.12-0.88) (P = 0.03), and for the use of pancreatic enzymes (OR, 0.005; 95% CI, 0.04-0.57) (P = 0.005). No differences were found in terms of mortality rate (OR, 0.43; 95% CI, 0.18-1.05) (P = 0.06), multiple systemic complications (OR, 0.34; 95% CI, 0.01-8.60) (P = 0.51), surgical reintervention for further necrosectomy (OR, 0.16; 95% CI, 0.00-3.07) (P = 0.19), intra-abdominal bleeding (OR, 0.79; 95% CI, 0.41-1.50) (P = 0.46), enterocutaneous fistula or perforation of visceral organs (OR, 0.52; 95% CI, 0.27-1.00) (P = 0.05), pancreatic fistula (OR, 0.66; 95% CI, 0.30-1.46) (P = 0.30), and surgical reintervention for postoperative complications (OR, 0.50; 95% CI, 0.23-1.08) (P = 0.08).

CONCLUSIONS

The lack of comparative studies and high heterogeneity of the data present in the literature did not permit to draw a definitive conclusion on this topic. The results of the present meta-analysis might be helpful to design future high-powered randomized studies that compare MIN with ON for acute necrotizing pancreatitis.

Interventions for necrotizing pancreatitis: an overview of current approaches

The management of necrotizing pancreatitis has undergone a paradigm shift toward minimally invasive techniques for necrosectomy, obviating the need for open necrosectomy in most cases. There is increasing evidence that minimally invasive approaches including a step-up approach that incorporates percutaneous catheter or endoscopic transluminal drainage, followed by video-assisted retroperitoneal or endoscopic debridement are associated with improved outcomes over traditional open necrosectomy for patients with infected necrosis. A recent international multidisciplinary consensus conference emphasized the superiority of minimally invasive approaches over standard surgical approaches. The success of these techniques depends on concerted efforts of a multidisciplinary team of interventional endoscopists, radiologists, intensivists and surgeons dedicated to the management of severe acute pancreatitis and its complications. This review provides an overview of minimally invasive techniques for management of necrotizing pancreatitis, including indications, timing, advantages and disadvantages.

Surgical indications in acute pancreatitis

PURPOSE OF REVIEW

This review provides an update on the surgical management of acute pancreatitis, with a focus on evidence accumulated over the past year regarding the optimal approach to pancreatic debridement in the critically ill patient.

RECENT FINDINGS

Infected pancreatic necrosis remains the primary indication for surgery in patients with acute pancreatitis. Up to a quarter of patients with acute pancreatitis develop early bacteremia and pneumonia, and assessment of patients for surgery should include a thorough search for nonpancreatic sources of infection. Retroperitoneal, percutaneous and endoscopic approaches to pancreatic debridement can be used with success in appropriately selected critically ill patients. All minimally invasive approaches to necrosectomy are evolving, and there is currently insufficient evidence to advocate one approach over another. Management of patients with acute pancreatitis at high-volume centers appears to be associated with a survival benefit.

SUMMARY

The existing evidence demonstrates that control of infected pancreatic necrosis without laparotomy is possible with appropriate patient selection. Evidence regarding minimally invasive approaches to pancreatic debridement remains of limited quality.

Interventions for necrotizing pancreatitis: summary of a multidisciplinary consensus conference

Pancreatic and peripancreatic necrosis may result in significant morbidity and mortality in patients with acute pancreatitis. Many recommendations have been made for management of necrotizing pancreatitis, but no published guidelines have incorporated the many recent developments in minimally invasive techniques for necrosectomy. Hence, a multidisciplinary conference was convened to develop a consensus on interventions for necrotizing pancreatitis. Participants included most international experts from multiple disciplines. The evidence for efficacy of interventions was reviewed, presentations were given by experts, and a consensus was reached on each topic. In summary, intervention is primarily indicated for infected necrosis, less often for symptomatic sterile necrosis, and should ideally be delayed as long as possible, preferably 4 weeks or longer after the onset of disease, for better demarcation and liquefaction of the necrosis. Both the step-up approach using percutaneous drainage followed by minimally invasive video-assisted retroperitoneal debridement and per-oral endoscopic necrosectomy have been shown to have superior outcomes to traditional open necrosectomy with respect to short-term and long-term morbidity and are emerging as treatments of choice. Applicability of these techniques depends on the availability of specialized expertise and a multidisciplinary team dedicated to the management of severe acute pancreatitis and its complications.

Minimally invasive retroperitoneal necrosectomy in management of acute necrotizing pancreatitis

INTRODUCTION

One of the most important requirements in treatment of acute necrotizing pancreatitis is minimized invasion.

AIM

We are presenting experience in treatment of acute necrotizing pancreatitis by an original minimally invasive retroperitoneal necrosectomy technique, comparing our results to other studies, evaluating feasibility and safety, discussing advantages and disadvantages of this method.

MATERIAL AND METHODS

We performed a retrospective analysis of 13 patients who had acute necrotizing pancreatitis with large fluid collections in retroperitoneal space and underwent retroperitoneal necrosectomy.

RESULTS

There were eight males and three females aged between 24 and 60 years, average age was 42.8 ±9.2 years. The most common cause of pancreatitis was alcohol, 10 patients (76.9%). Average time between diagnosis and performance of operation was 25.7 ±11.3 days. One patient underwent eight repeated interventions: two retroperitoneal necrosectomies; five laparotomies; ultrasound-guided drainage. One patient underwent four reinterventions: lumbotomy; revision; two lavages. Three patients had two reinterventions: one had laparotomy and tamponation; one had two repeated retroperitoneal necrosectomies; third had one repeated retroperitoneal necrosectomy and one had ultrasound-guided drainage. Three patients needed one additional retroperitoneal necrosectomy. Five patients did not required additional interventions. 61.5% of our patients did not require more than one reintervention. Postoperative stay varied from 9 to 94 days, average 50.8 ±32.6 days.

CONCLUSIONS

Minimally invasive techniques should be considered as first-choice surgical option in treating patients with acute necrotizing pancreatitis. Pancreatic necrosis occupying less than 30% and with massive fluid collections in the left retroperitoneal space can be safely managed by minimally invasive retroperitoneal necrosectomy.

Management of infected pancreatic necrosis using retroperitoneal necrosectomy with flexible endoscope: 10 years of experience

BACKGROUND

This study was designed to provide our experience in the management of infected and drained pancreatic necrosis using the retroperitoneal approach.

METHODS

This was a prospective observational study in a tertiary care university hospital. Thirty-two patients with confirmed infected pancreatic necrosis were studied. Superficial necrosectomy was performed with lavage and aspiration of debris. This was achieved though a retroperitoneal approach of the pancreatic area and under the direct vision of a flexible endoscope. The follow-up procedure using retroperitoneal endoscopy did not require taking the patient to the operating room. The main outcome measures were infection control, morbidity, and mortality related to technique, reintervention, and long-term follow-up.

RESULTS

No significant morbidity or mortality related to the technique was observed in all of the patients with infected pancreatic necrosis treated with this retroperitoneal approach compared with published data using other approaches. Reinterventions were not required and patients are currently asymptomatic.

CONCLUSIONS

Retroperitoneal access of the pancreatic area is a good approach for drainage and debridement of infected pancreatic necrosis. Translumbar retroperitoneal endoscopy allows exploration under direct visual guidance avoiding open transabdominal reintervention and the risk of contamination of the abdominal cavity. This technique does not increase morbidity and mortality, can be performed at the patients' bedside as many times as necessary, and has advantages over other retroperitoneal approaches.

The revised Atlanta classification of acute pancreatitis: its importance for the radiologist and its effect on treatment

An international working group has modified the Atlanta classification for acute pancreatitis to update the terminology and provide simple functional clinical and morphologic classifications. The modifications (a) address the clinical course and severity of disease, (b) divide acute pancreatitis into interstitial edematous pancreatitis and necrotizing pancreatitis, (c) distinguish an early phase (1st week) and a late phase (after the 1st week), and (d) emphasize systemic inflammatory response syndrome and multisystem organ failure. In the 1st week, only clinical parameters are important for treatment planning. After the 1st week, morphologic criteria defined on the basis of computed tomographic findings are combined with clinical parameters to help determine care. This revised classification introduces new terminology for pancreatic fluid collections. Depending on presence or absence of necrosis, acute collections in the first 4 weeks are called acute necrotic collections or acute peripancreatic fluid collections. Once an enhancing capsule develops, persistent acute peripancreatic fluid collections are referred to as pseudocysts; and acute necrotic collections, as walled-off necroses. All can be sterile or infected. Terms such as pancreatic abscess and intrapancreatic pseudocyst have been abandoned. The goal is for radiologists, gastroenterologists, surgeons, and pathologists to use the revised classifications to standardize imaging terminology to facilitate treatment planning and enable precise comparison of results among different departments and institutions.

Minimally invasive treatment of pancreatic disease

Minimally invasive surgery has been widely accepted as an alternative to conventional open surgery in many gastrointestinal fields and is now considered the standard of care in bariatric surgery as well as oncologic surgery of the colon and stomach. Despite the advancements in laparoscopic surgery instrumentation and technique, the anatomic relationships of the pancreas and the need for complex reconstructions have slowed similar progress in management of pancreatic disease. However, numerous recent studies show promising results in laparoscopic management of pancreatic pseudocyst, necrosis, and benign and malignant pancreatic neoplasms. We present the current status of clinical application of minimally invasive techniques for the treatment of complicated pancreatitis, chronic pancreatitis, and pancreatic neoplasms, and provide a review of the relevant literature. Present day and probable future developments, such as the use of robotics, natural orifice techniques, and major vascular reconstruction are also presented.

The minimally invasive approach to surgical management of pancreatic diseases

Laparoscopic pancreas surgery has undergone rapid development over the past decade. Although acceptability among traditional surgeons has been low, emerging specialty centers are reporting excellent outcomes for advanced and complex operations, such as pancreaticoduodenectomy. A note of caution is necessary: These outstanding results are from skilled surgeons, many of whom are pioneers in the field, who have overcome the learning curve over many years of innovation. As the procedures gain wider practice, outcomes need to be carefully watched because many of these procedures are extremely demanding technically. Although many have suggested that controlled, randomized studies comparing laparoscopic pancreatic resections with open resections are necessary to establish the efficacy of laparoscopic procedure, the cumulative data on the safety and efficacy of the laparoscopic procedure argues against such an approach. The logistic difficulties of conducting such studies will be considerable given patient preferences, the need for multicenter studies, and the rapid adoption of the laparoscopic procedure among experienced pancreatic surgeons. A more reasonable approach to truly evaluate the safety of these procedures is the establishment of a national registry that can measure progress of the field and record outcomes in the wider, nonspecialty community. Hepatobiliary training programs should also establish a minimal standard of training for many of the advanced procedures, such as the pancreaticoduodenectomy, so that the benefit of laparoscopic surgery can be made available outside of just a few specialty centers.

Multivariate analysis of factors influencing medical costs of acute pancreatitis hospitalizations based on a national administrative database

BACKGROUND

Little information is available on the analysis of medical costs of acute pancreatitis hospitalizations.

AIM

This study aimed to determine the factors affecting medical costs of patients with acute pancreatitis during hospitalization using a Japanese administrative database.

METHODS

A total of 7193 patients with acute pancreatitis were referred to 776 hospitals. We defined "patients with high medical costs" as patients whose medical costs exceeded the 90th percentile in medical costs during hospitalization and identified the independent factors for patients with high medical costs with and without controlling for length of stay.

RESULTS

Multiple logistic regression analysis demonstrated that necrosectomy was the most significant factor for medical costs of acute pancreatitis during hospitalization. The odds ratio of necrosectomy was 33.64 (95% confidence interval, 14.14-80.03; p<0.001). Use of an intensive care unit was the most significant factor for medical costs after controlling for LOS. The OR of an ICU was 6.44 (95% CI, 4.72-8.81; p<0.001).

CONCLUSION

This study demonstrated that necrosectomy and use of an ICU significantly affected the medical costs of acute pancreatitis hospitalization. These results highlight the need for health care implementations to reduce medical costs whilst maintaining the quality of patient care, and targeting patients with severe acute pancreatitis.

Short-term outcomes from a multicenter retrospective study in China comparing laparoscopic and open surgery for the treatment of infected pancreatic necrosis

BACKGROUND

Laparoscopic surgery for confirmed infected pancreatic necrosis (IPN) represents a relatively new solution. There are no studies comparing the outcomes of laparoscopic and open surgery for patients with IPN. The aims of this study were to investigate the feasibility of laparoscopic management for patients with IPN and to compare the outcomes of laparoscopic and open surgery.

METHODS

Seventy-six patients with IPN who underwent open surgery (Open-group) or laparoscopic surgery (Lap-group) were retrospectively reviewed. Demographic data, white blood cell count, and APACHE II score upon admission, operative findings, major complications, and mortality were compared between the Open-group and the Lap-group. The Lap-group was further divided into two subgroups (early and late), and the operative difficulty was compared between the two subgroups.

RESULTS

There were no significant differences between the Open-group and the Lap-group with respect to demographic data, white blood cell count, and APACHE II score. Although the mean operative time was significantly shorter in the Open-group than in the Lap-group, the estimated blood loss was significantly greater in the Open-group than in the Lap-group, as was the rate of complications. The mean postoperative hospital stay in the Open-group was significant longer than in the Lap-group, too. In the Lap-group, the mean operating time, estimated blood loss, and conversion rate in the early subgroup were significantly lower than in the late subgroup.

CONCLUSION

Laparoscopic necrosectomy and the placement of an intermittent irrigation and continuous suction drainage system for IPN is feasible, effective, and of minimal invasiveness. The late laparoscopic necrosectomy is relatively difficult.

Management of severe acute pancreatitis

Severe acute pancreatitis (SAP) develops in about 25% of patients with acute pancreatitis. Severity of acute pancreatitis is linked to the presence of systemic organ dysfunctions and/or necrotizing pancreatitis. Risk factors independently determining the outcome of SAP are early multiorgan failure (MOF), infection of necrosis, and extended necrosis (>50%). Morbidity of SAP is biphasic, in the first week it is strongly related to systemic inflammatory response syndrome while, sepsis due to infected pancreatic necrosis leading to MOF syndrome occurs in the later course after the first week. Contrast-enhanced computed tomography provides the highest diagnostic accuracy for necrotizing pancreatitis when performed after the first week of disease. Patients who suffer early organ dysfunctions or are at risk for developing a severe disease require early intensive care treatment. Antibiotic prophylaxis has not been shown as an effective preventive treatment. Early enteral feeding is based on a high level of evidence, resulting in a reduction of local and systemic infection. Patients suffering infected necrosis causing clinical sepsis are candidates for intervention. Hospital mortality of SAP after interventional or surgical debridement has decreased to below 20% in high-volume centers.

Management of severe acute pancreatitis

Severe acute pancreatitis (SAP) develops in about 25% of patients with acute pancreatitis. Severity of acute pancreatitis is linked to the presence of systemic organ dysfunctions and/or necrotizing pancreatitis. Risk factors independently determining the outcome of SAP are early multiorgan failure (MOF), infection of necrosis, and extended necrosis (>50%). Morbidity of SAP is biphasic, in the first week it is strongly related to systemic inflammatory response syndrome while, sepsis due to infected pancreatic necrosis leading to MOF syndrome occurs in the later course after the first week. Contrast-enhanced computed tomography provides the highest diagnostic accuracy for necrotizing pancreatitis when performed after the first week of disease. Patients who suffer early organ dysfunctions or are at risk for developing a severe disease require early intensive care treatment. Antibiotic prophylaxis has not been shown as an effective preventive treatment. Early enteral feeding is based on a high level of evidence, resulting in a reduction of local and systemic infection. Patients suffering infected necrosis causing clinical sepsis are candidates for intervention. Hospital mortality of SAP after interventional or surgical debridement has decreased to below 20% in high-volume centers.

Laparoscopic pancreatic necrosectomy in a child with severe acute pancreatitis

Acute pancreatitis (AP) in children usually follows a mild course but occasionally may be severally problematic. We report the case of a 12-year-old boy with severe AP who was managed with repeated laparoscopic pancreatic necrosectomy. Three weeks later he represented with a pancreatic pseudocyst that was treated with endoscopic gastrocystotomy. His abdominal pain persisted and a subsequent magnetic resonance cholangiopancreatogram showed multiple gallbladder and common bile duct (CBD) stones that were missed on previous imaging investigations. He underwent laparoscopic cholecystectomy with transcystic exploration of the CBD. The patient is currently well, more than 2 years following the definitive corrective surgery. To the best of our knowledge, this is the first case of laparoscopic pancreatic necrosectomy in a child.

Total abdominal colectomy for refractory ulcerative colitis. Surgical treatment in evolution

INTRODUCTION

Total abdominal colectomy is the procedure of choice for debilitated patients with acute, medical refractory ulcerative colitis in our practice. A laparoscopic approach has been previously shown to be safe and effective, and has become our preferred strategy. This study illustrates the laparoscopic evolution towards a truly minimally invasive approach comparing three phases of a single colorectal surgeon experience.

MATERIAL AND METHODS

In May 2010 single incision laparoscopy was introduced in our practice and has become our preferred approach. Ten consecutive ulcerative colitis patients were case matched and compared with 10 previous laparoscopic-assisted (Feb 2003-Jan 2007) and 10 hand-assisted (Feb 2006-Apr 2010) total abdominal colectomies. Patient, disease and surgery-related factors were analyzed and short-term outcomes were compared.

RESULTS

Given the study design, there were no differences in demographics, smoking history, disease duration and severity, nutritional and inflammatory parameters, and indication for surgery between groups. Single incision patients were more likely to have received immunosuppressive therapy within 30 days of the surgery (p = 0.016). In the single incision group we noticed significantly shorter duration of surgery (p < 0.001) and faster resumption of solid diet (p = 0.019) compared to the other groups. Other short-term outcomes did not differ between groups.

CONCLUSION

Single incision laparoscopy offers a safe alternative to other laparoscopic approaches. Despite the higher technical complexity, the duration of surgery is shorter with faster resumption of oral intake. Studies with larger sample size and longer follow-up will be required to confirm the benefits of this approach.

Single-incision laparoscopic total abdominal colectomy for refractory ulcerative colitis

BACKGROUND

A three-stage restorative proctocolectomy with ileal pouch-anal anastomosis is the treatment of choice for the particularly debilitated patient with medically refractory ulcerative colitis (UC). Laparoscopic surgery has been shown to offer several advantages over the open approach in this setting. Single-incision laparoscopic surgery is an emerging minimally invasive strategy representing a truly scarless procedure for the first surgical step, namely, the total abdominal colectomy (TAC).

METHODS

Nine consecutive patients with medically refractory UC underwent a single-incision laparoscopic TAC between May and October 2010. All patients were on aggressive medical therapy with corticosteroids or immunosuppressors and were selected for this approach on the basis of their body habitus and the absence of relevant comorbidities. The whole operation was performed through a single access to the abdominal cavity, placed at the ostomy site marked preoperatively.

RESULTS

Mean operating time was 142 ± 23 min, with an estimate blood loss of 108 ± 125 ml. No intraoperative complications or conversions to conventional laparoscopy or open surgery occurred. In all cases the postoperative course was uneventful. The return of bowel function was observed on postoperative day 1.7 ± 0.7, and patients could tolerate a solid diet on postoperative day 3 ± 0.5. The mean postoperative length of stay was 5.2 ± 1.3 days.

CONCLUSIONS

In our experience, a single-incision laparoscopic approach to total abdominal colectomy for refractory ulcerative colitis has been shown to be safe and feasible. Initial results suggest that this technique can lead to improvements in short-term outcomes in selected patients.

History, goals, and technique of laparoscopic pancreatic necrosectomy

The surgical treatment of severe acute pancreatitis has significantly changed in the last several years with the advent of enhanced imaging techniques and minimally invasive surgery. Criteria for surgical intervention have been influenced by the use of step-up approaches that provide incremental multimodality interventions with repeat imaging. Here, we provide a brief introduction to the history, goals, indications, and technique of laparoscopic pancreatic necrosectomy. The technique requires a fundamental understanding of the natural history of pancreatitis and its complication. Laparoscopic approaches can be useful as primary and adjunctive therapy for the treatment of infected pancreatitic necrosis.

Acute pancreatitis with an emphasis on infection

Acute pancreatitis is an inflammatory disease that is mild and self-limiting in about 80% of cases. However, severe necrotizing disease still has a mortality of up to 30%. Differentiated multimodal treatment concepts are needed for these patients, including a multidisciplinary team (intensivists, gastroenterologists, interventional radiologists, and surgeons). The primary therapy is supportive. Patients with infected pancreatic necrosis who are septic undergo interventional or surgical treatment, ideally not before the fourth week after onset of symptoms. This article reviews the pathophysiologic mechanisms of acute pancreatitis and describes clinical pathways for diagnosis and management based on the current literature and guidelines.

Single-incision Laparoscopic Surgery (SILS) in general surgery: a review of current practice

Single-incision laparoscopic surgery (SILS) aims to eliminate multiple port incisions. Although general operative principles of SILS are similar to conventional laparoscopic surgery, operative techniques are not standardized. This review aims to evaluate the current use of SILS published in the literature by examining the types of operations performed, techniques employed, and relevant complications and morbidity. This review considered a total of 94 studies reporting 1889 patients evaluating 17 different general surgical operations. There were 8 different access techniques reported using conventional laparoscopic instruments and specifically designed SILS ports. There is extensive heterogeneity associated with operating methods and in particular ways of overcoming problems with retraction and instrumentation. Published complications, morbidity, and hospital length of stay are comparable to conventional laparoscopy. Although SILS provides excellent cosmetic results and morbidity seems similar to conventional laparoscopy, larger randomized controlled trials are needed to assess the safety and efficacy of this novel technique.

Systematic review of percutaneous catheter drainage as primary treatment for necrotizing pancreatitis

BACKGROUND

The role of percutaneous catheter drainage (PCD) in patients with (infected) necrotizing pancreatitis was evaluated.

METHODS

A systematic literature search was performed. Inclusion criteria were: consecutive cohort of patients with necrotizing pancreatitis undergoing PCD as primary treatment for peripancreatic collections; indication for PCD either (suspected) infected necrosis or symptomatic sterile pancreatic necrosis; and outcomes reported to include percentage of infected peripancreatic collections, need for additional surgical necrosectomy, complications and deaths. Exclusion criteria were: cohort of fewer than five patients; cohort included patients with chronic pancreatitis; selected subgroup of patients with acute pancreatitis studied, such as those with pseudocysts, pancreatic abscesses and/or exclusively sterile pancreatic necrosis; and cohort in which PCD was combined with another minimally invasive strategy and results for PCD alone not reported separately.

RESULTS

Eleven studies, including 384 patients, fulfilled the inclusion criteria. Only one study was a randomized controlled trial; most others were retrospective case series. Four studies reported on the presence of organ failure before PCD; this occurred in 67·2 per cent of 116 patients. Infected necrosis was proven in 271 (70·6 per cent) of 384 patients. No additional surgical necrosectomy was required after PCD in 214 (55·7 per cent) of 384 patients. Complications consisted mostly of internal and external pancreatic fistulas. The overall mortality rate was 17·4 per cent (67 of 384 patients). Nine of 11 studies reported mortality separately for patients with infected necrosis undergoing PCD; the mortality rate in this group was 15·4 per cent (27 of 175).

CONCLUSION

A considerable number of patients can be treated with PCD without the need for surgical necrosectomy.

Analysis of the delayed approach to the management of infected pancreatic necrosis

AIM

To analyze outcomes of delayed single-stage necrosectomy after early conservative management of patients with infected pancreatic necrosis (IPN) associated with severe acute pancreatitis (SAP).

METHODS

Between January 1998 and December 2009, data from patients with SAP who developed IPN and were managed by pancreatic necrosectomy were analyzed.

RESULTS

Fifty-nine of 61 pancreatic necrosectomies were performed by open surgery and 2 laparoscopically. In 55 patients, single-stage necrosectomy could be performed (90.2%). Patients underwent surgery at a median of 29 d (range 13-46 d) after diagnosis of acute pancreatitis. Sepsis and multiple organ failure accounted for the 9.8% mortality rate. Pancreatic fistulae (50.8%) predominantly accounted for the morbidity. The median hospital stay was 23 d, and the median interval for return to regular activities was 110 d.

CONCLUSION

This series supports the concept of delayed single-stage open pancreatic necrosectomy for IPN. Advances in critical care, antibiotics and interventional radiology have played complementary role in improving the outcomes.

Progress in the management of necrotizing pancreatitis

Pancreatic necrosis, a complication of severe pancreatitis, may become infected, resulting in significant morbidity and potential mortality. Infected necrosis was heretofore considered a surgical condition, and despite aggressive operative management, the mortality remained high. With a better understanding of the natural history of necrosis, established methods to diagnose infection and the increasing use of minimally invasive techniques, less aggressive therapies have been utilized with some success. The present study evaluated a step-up approach for the treatment of infected pancreatic necrosis, utilizing endoscopic and percutaneous techniques, and if ineffective, necrosectomy with a minimally invasive retroperitoneal approach. They compared this step-up approach to the standard open necrosectomy. They demonstrated that when using such an approach compared with open necrosectomy, the frequency of major complications such as organ failure, perforation, fistula or even death was significantly less than in those who received conventional open necrosectomy. Indeed, for those randomized to the step-up approach, roughly a third of the patients were successfully treated with percutaneous drainage alone. In the long-term, development of diabetes was also less frequent in those receiving less aggressive therapy. These findings, in combination with other reports, suggest that the dogma that open necrosectomy is mandatory for all patients with infected necrosis should be re-evaluated, and that less aggressive treatments as part of a multidisciplinary approach can reduce morbidity and mortality.

Surgical treatment of acute pancreatitis today

Az enyhe akut pancreatitis kezelése alapvetően konzervatív, míg súlyos esetekben a sebészi kezelésnek jelentős szerepe van. Módszer: A szerzők az utóbbi 10 évben megjelent, a műtét kérdéseit taglaló közlemények alapján elemzik a sebészi kezelés indikációit, időzítését és a műtét technikai kérdéseit. Eredmények/következtetések: A steril pancreasnecrosis csak ritkán, a szeptikus necrosis azonban műtéti indikációt képez, ha a konzervatív kezelés eredménytelen. A terápiarezisztens sokszervi elégtelenség, a súlyos hasi kompartmentszindróma és egyéb sebészi szövődmény, mint a vérzés, perforáció is műtéti beavatkozást tesz szükségessé. Pancreatitist okozó epekövesség talaján kialakult cholestasis esetén sürgős endoszkópos sphincterotomia és később cholecystectomia javasolt. Pancreasnecrosis esetén a műtét ideális időpontja a betegség kezdetétől számított 21. nap utánra tehető, mivel a „korai” műtétek szövődmény- és halálozási aránya magas. Fontos a gondos necrectomia, amelynek a retrocolicus és retroduodenalis terekre is ki kell terjednie. A nyitott has kezelésének több a szövődménye, ezért csak válogatott esetekben javasolják. A műtétet posztoperatív bursa omentalis lavage-zsal érdemes kiegészíteni. Orv. Hetil., 2010, 41, 1697–1701.

Transumbilical single incision laparoscopic sigmoidectomy for benign disease

BACKGROUND

Transumbilical single incision laparoscopic surgery (SILS) has made its initial forays into clinical minimally invasive surgery. SILS combines in part the cosmetic advantage and decrease parietal trauma of natural orifice surgery, but allow operative realization with standard and validated laparoscopic instruments. We report here the first clinical transumbilical SILS sigmoidectomy for benign disease.

METHOD

Preliminary experience with transumbilical single incision laparoscopic surgery (or embryonic natural orifice transluminal endoscopic surgery) sigmoidectomy in a female patient (34 years, BMI 22 kg/m(2)) with sigmoid stenosis caused by nodular endometriosis was reported. Transumbilical SILS treatment of pelvic endometriosis was performed during the same operation through cauterization.

RESULTS

Transumbilical single incision laparoscopic sigmoidectomy was feasible with conventional laparoscopic instruments. The combined uses of straight and articulated laparoscopic instruments allow the avoidance of transparietal sling suture for exposition. Operative time for sigmoidectomy and endometriosis therapy was 125 min. No intra-operative or postoperative complications were recorded. SILS achieved excellent cosmetic results and may be associated with accelerated recovery.

CONCLUSION

Transumbilical single incision laparoscopic sigmoidectomy is feasible by experienced laparoscopic surgeons using conventional laparoscopic instruments and staplers. The combined uses of strait and articulated instruments allow transumbilical SILS sigmoidectomy without the need for additional incision or transparietal sling suture. SILS sigmoidectomy may have the clinical advantage over NOTES of offering the safety of laparoscopic colectomy and the avoidance of vaginal access. It has to be determined if SILS offers benefit to the patient, except in cosmesis, compared with standard laparoscopic sigmoidectomy.