Infected Pancreatic Necrosis: Our Management Approach

Abstract

Management of infected Pancreatic necrosis caries a significant morbidity and mortality. With percutaneous and endoscopic modalities reducing the need for operative intervention, a surgeon is still called when the liquid component is drained while solid component causes ongoing sepsis (despite upsizing). Here we present our management approach to this vexing problem. We divide the abdominal cavity containing necrotic material into (CECT scan based), Type 1 Central collection with or without gas Type 2 Paracolic gutter collectiona)Rightb)Left Type 3 Central collection witha)Right Paracolic gutter collectionb)Left Paracolic gutter collection Type 4 Central collection with both Paracolic gutter involvement. (Butterfly pattern) Type 5 Generalized peritonitis. Central collection is drained using Laparoscopic Transmesocolic approach while Paracolic gutter collection are dealt with Extra Peritoneal approach ( Modified VARD). Laparoscopic transmesocolic approach involves removal of solid and liquid necrotic material and placement of large bore drainage tubes for irrigation under direct vision. Extra peritoneal approach is using 5 cm incision in either flank and removal of necrotic material under vision using laparoscope. After the material is removed a drain is placed. Type 1(laparoscopic only) type 2(modified vard) has the best prognosis while type 3 is done using both techniques in a staged or simultaneous manner, type 4 and 5 has high morbidity and mortality. If a previous percutaneous drain is placed we use it as irrigation drain. This strategy simplifies the management in a minimally invasive way with good results.