Miniinvasive Step-up Strategy of Surgical Treatment in Different Phases of Acute Necrotizing Pancreatitis

Abstract

Background: Surgical management of acute necrotizing pancreatitis (ANP) has evolved from primary laparotomic operation to wide application of minimal invasive interventions during last decades. Objective of our research was to establish strategy of application of miniinvasive interventional treatment during different phases of ANP. Material & Methods: We performed a prospective observational cohort study of 373 patients with ANP during 2013-2018. The following parameters were collected for each case: length of hospital stay, in-hospital mortality, presence of organ failure and local complications. Result(s): Surgical treatment was applied in 210 (57.8%) patients. We used the step-up approach of surgical treatment and started from either transcutaneous ultrasound-guided (TUG) in 102 (48.2%) or endoscopic ultrasound-guided (EUS) puncture/drainage in 97 (46.2%) observations. During shock phase only decompression fascitomy was performed in 6 (2.9%) cases with non-controlled intra-abdominal compartment syndrome. Necessary for interventional treatment occurred in 55 (26.2%) patients with infected acute necrotic collections (ANC) and 149 (73.8%) - with walled-off pancreatic necrosis (WOPN). Proactive TUG procedures and video-assisted retroperitoneal debridement (VARD) through nephroscope were followed by less complication rate in ANC cases whereas EUS and endoscopic necrosectomies – in WOPN observations. Wide laparotomic necrosectomies was applied in 46 (21.9%) of surgically operated patients after 4th week of disease. Pancreatic fistula occurred in 6.5%, hemorrhagic complications - 8.7%, new organ failures cases – 15.2%. Overall mortality rate was 3.3%, after interventional treatment – 6.5%. Conclusions: Surgical treatment in patients with ANP based on step-up approach is followed by acceptable complication and mortality level. Interventional treatment should be postponed on terms after 4th week whenever is possible with exception of patients with intra-abdominal compartment syndrome. In patients with ANC transcutaneous approach is followed by less complications rate whereas in WOPN cases endoscopic route is preferable.