Necrosectomía endoscópica asistida por laparoscopia: un enfoque efectivo en la necrosis pancreática infectada

Abstract

Acute pancreatitis is a disease characterized by intense inflammation caused by the degradation of the parenchyma and adjacent tissue, through activation and consequent protease output. Approximately 15% of patients with the disease progress to necrotizing form and subsequent infection of this necrotic tissue is a complex process and associated with significant morbidity and mortality. Interventional treatment is mandatory in the management of infected necrosis and open surgery has perpetuated for decades as a first-line treatment to remove infected necrotic tissue. In recent years, with the improvement in laparoscopy and other techniques, new approaches for the management of this condition have been advocated to the detriment of open surgery, in particular, the advent of the Step-up approach. This new approach allowed the management of infected necrosis in a gradual way. Percutaneous drainage is the first step, and is effective by itself in up to 35% of cases, then, if there is no clinical remission or if the collection drainage is not satisfactory, the invasiveness of the process increases. Techniques such as video-assisted retroperitoneal debridement (VARD) and endoscopic transgastric necrosectomy (ETN) are examples of minimally invasive procedures widely used and applied in these cases, as they allow access to the necrotic collection with minimal aggression, in addition to inducing low physiological stress, resulting in a lower incidence of unfavorable outcomes. We describe a case of a patient, male, 64 years old, hypertensive, with infected necrotizing pancreatitis, with 6 weeks of evolution. Following the parameters of the Step-up approach, treatment started with percutaneous drainage to resolve the acute condition and, sub- sequently, an alternative technique was used, employing endoscopic necrosectomy assisted by laparoscopy. The management of this case demonstrates an effective and fully feasible technique, which can be replicated in other hospital centers.