Serial endoscopic debridement via the VARD entrance as new treatment approach for necrotizing pancreatitis

Abstract

Introduction: Necrotizing pancreatitis develops in approx. 15% of all patients with acute pancreatitis leading to mortality rates of up to 20%. Today, the gold standard of therapy is the so called step-up-approach. First, necrosis is drained by a CT-drainage and only if unsuccessful, therapy is being escalated towards endoscopic or surgically minimal invasive (VARD, video assisted retroperitoneal debridement) necrosectomy. The Tension trial of the Dutch Pancreatitis Study group demonstrated that both therapies are of equal use. We describe our experiences with a serial endoscopic debridement following VARD, thereby combining both techniques. Material and Methods: All patients who received serial endoscopic debridement following VARD at the Aachen University Hospital between 2016 and 2018 were included. After providing a sufficient drainage channel by VARD, endoscopic necrosectomies were performed on regular basis through this channel. This can be done in analgosedation, intubation anesthesia is not necessary. Results were compared with a VARD only cohort already described by us. Results: 8 patients (6 male, 2 female) received a VARD followed by serial endoscopic debridement. The average age was 51.8 ± 14.1 years, average BMI was 28.8 ± 7.1 and average ASA Score was 3.3 ± 0.5. In all patients, bacteria could be identified as sign of a superinfected necrosis. Endoscopic debridement took place 5 times (mean, [2-15]) in a time frame of 17 days (mean, [5-88] days). The 30-day-mortality was 0%. The time in the ICU was reduced significantly from 29 ± 41 days to 17 ± 23 days compared with VARD alone. The average postoperative stay was 68 ± 30 days. Conclusion: Serial endoscopic debridement via the VARD entrance is a further step of escalation in treating necrotizing pancreatitis. It seems to hold the advantage of combining both minimal invasive necrosectomy forms, endoscopic and VARD. Future prospective studies must investigate this advantage further.