Invasive Pancreatic Necrosectomy Research Articles

Two-Port Minimally Invasive Nephro-Laparoscopic Retroperitoneal Debridement for Pancreatic Necrosis.

Walled-off necrosis (WON) occurs in approximately 20% of patients with necrotizing pancreatitis. Infection occurs in approximately 30% of necrosis patients, and despite advances in management, infected necrosis still confers a high mortality between 30 and 40%. While sterile necrosis requires drainage only for cases of symptom relief or "persistent unwellness," prompt intervention is critical for infected necrosis. Several management strategies exist depending on the location and anatomy of the necrosum. In particular, retroperitoneal collections away from the stomach are typically managed with a step-up approach that begins with percutaneous drain placement. While a minority of patients skirt further intervention, the majority require formal debridement at some point via the existing drain tract. These debridement techniques include video-assisted retroperitoneal debridement (VARD) through a flank incision or minimally invasive retroperitoneal pancreatic (MIRP) necrosectomy under continuous irrigation with a nephroscope. While effective, both debridement strategies have drawbacks: for VARD, the flank incision is prone to infections and hernia while MIRP debridements are tedious and often require repeat operative trips. To overcome these pitfalls, we describe a novel two-trocar minimally invasive hybrid nephro-laparoscopic retroperitoneal debridement technique for an efficient retroperitoneal pancreatic necrosectomy.

Correlative factor of death in patients with infected pancreatic necrosis after surgical intervention

Background: Acute pancreatitis (AP) was a potentially fatal disease with a variation in severity. Infected pancreatic necrosis was a common complication in AP which needed surgical intervention. The present study was to study the correlative factors of death in patients with infected pancreatic necrosis after surgical intervention. Methods: From January 2016 to October 2019, a total of 186 patients with infected pancreatic necrosis after surgical intervention in the First Medical Center, Chinese PLA General Hospital were retrospectively enrolled in this study. Of the 186 patients, 22 who died in the hospital were defined as a mortality group and the others as a survival group. The clinical characteristic of the 2 groups was compared and the relative risk of mortality in patients with infected pancreatic necrosis after the surgical intervention was studied. Results: Acute fluid collection, acute kidney injury, acute lung injury, acute liver injury, multiple organ dysfunction syndromes, abdominal bleeding, abdominal Acinetobacter baumannii infection, pulmonary infection, pulmonary A baumannii infection, positive blood culture, A baumannii of blood culture, severe acute pancreatitis according to Atlanta 2012, the use of continuous renal replacement therapy, mechanical ventilation and minimally invasive retroperitoneal pancreatic necrosectomy was associated with death in hospital. Older age, longer acute kidney injury lasting time, longer acute lung injury lasting time, longer acute liver injury lasting time, and longer multiple organ dysfunction syndromes lasting time in predicting mortality in patients with infected pancreatic necrosis after surgical intervention were (0.635 [95% confidence interval (CI): 0.512–0.758], P = .040), (0.877 [95% CI: 0.788–0.965], P = .000], (0.932 [95% CI: 0.897–0.968], P = .000), (0.822 [95% CI: 0.708–0.935], P = .000), and (0.943 [95% CI: 0.887–0.998], P = .000). Due to the small number of death cases, the results of the multivariate analyses were not available. Conclusion: In this single-center retrospective study of 186 cases of infected pancreas necrosis, the correlative factors of death are identified. The results warranted further strategies are needed especially focusing on elder patients to prevent blood infection and to protect the functions of vital organs.

Patient-reported outcomes after minimally invasive retroperitoneal pancreatic necrosectomy to treat acute pancreatitis: An exploratory study.

The aim of this study (abbreviated as QUANTUM) was to assess the quality of life (QoL) of patients who underwent minimally invasive retroperitoneal pancreatic necrosectomy (MIRPN) for acute pancreatic necrosis with or without infection of necrotic tissue collections after discharge and to compare the patient-reported outcomes (PRO) in these patients with published data in normative population. Patients with acute pancreatitis who underwent MIRPN between January 2010 and December 2016 were identified and invited to complete the European Organisation for Research and Treatment of Cancer (EORTC) QLQ-C30 and EORTC PAN28(CP) questionnaires. PRO were compared using Pearson correlation coefficient and ANOVA (significance P < 0.01) with an age- and sex-matched normative population of western Europe, stratified by age, and also the time duration after MIRPN (<3 y and >3 y). A change >15 points in the PRO score was taken as clinically important. Among 52 eligible patients identified, 46 (88%) agreed to participate, 74% returned questionnaires. After the MIRPN all patients had worse physical and social functioning scores with a clinically important (>15 points) reduction in those ≤50 years; while fatigue, pain and insomnia symptom scales had the highest scores (42, 26 and 30 points, respectively). Patients <3 years after MIRPN had similar scores for all functional scales and global health-related quality of life (HRQoL) compared to the normative population. However, over time their global HRQoL deteriorated and after 3 years their scores for functioning and symptoms were statistically (P < 0.0001) and clinically (>15 points) worse than those in age-matched controls. During the first 3 years after the MIRPN patients have a relatively high QoL but report worse fatigue than the normative population. However, patients should be informed that their HRQoL deteriorates with time, often due to chronic pancreatitis and pancreatic insufficiency. This study supports the use of MIRPN and prospective studies of HRQoL in this setting are indicated.

Two port laparoscopic retroperitoneal pancreatic necrosectomy: improvement in morbidity and mortality with a less invasive approach

Background: Severe pancreatitis is associated with a high rate of mortality even with advanced surgical care and practices worldwide. Morbidity and mortality rates are much higher in the presence of infected pancreatic necrosis. From open necrosectomy, simple percutaneous drainage or one of several minimal access approaches, the question of optimal or best treatment is yet debatable. Step-up approach is currently practised by many physicians. We describe our technique of early drainage by minimal invasive two-port laparoscopic retroperitoneal pancreatic necrosectomy in our centre.Methods: Thirteen consecutive patients with proven infected pancreatic necrosis were treated by 2P-LRPN over a two-year period in the setting of a teaching hospital. The median patient age was 44 years (range: 28-66 years) and 10 of the patients were male.Results: The median time to discharge following the procedure of 14 days (range: 08-21 days). There was no mortality and the morbidity rate was 37%, consisting mainly of pancreatic fistula (37%).Conclusions: Two-port laparoscopic retroperitoneal pancreatic necrosectomy is an effective and minimally invasive procedure which had better outcomes with improved patient morbidity, shorter hospital stay and lesser complication rate. Early intervention with necrosectomy has better patient compliance.

Analysis of risk factors for minimally invasive pancreatic necrosectomy combined with bleeding and endoscopic hemostasis in acute necrotizing pancreatitis: a real-world study

Analysis of risk factors for minimally invasive pancreatic necrosectomy combined with bleeding and endoscopic hemostasis in acute necrotizing pancreatitis: a real-world study

A Rare Complication of Sudden Cerebral Embolism After a Series of Beneficial Surgical Minimally Invasive Pancreatic Necrosectomy: a Case Report

Patients with acute pancreatitis can benefit more from step-up management. The minimally invasive approaches (MIA) could reduce complications, mortality, days, and expenses in hospitals. Even in these cases, they would still suffer fatal complications during the treatment. We present here a case of infected pancreatic necrosis (IPN) in a 51-year-old Chinese woman who developed a fatal cerebral embolism and died after a beneficial step-up procedure. The minimally invasive approach included surgical dual-scope necrosectomy and sequential non-narcotic nephroscopic pancreatic necrosectomy; a great improvement was made both in clinical condition and images after the advanced technique. Our case attempts to show that a dual-scope necrosectomy is a superior approach for patients with IPN. Cerebral embolism is a rare but life-threatening complication of severe acute pancreatitis (SAP). Patients with SAP may be at risk of cerebral embolism. If clinically suspected, necessary investigations should be arranged to look for causes. Once diagnosed, early treatment should be considered on a case-by-case basis.

Minimally Invasive Pancreatic Necrosectomy: A step-up approach towards ultra-low mortality in 103 consecutive procedures

Background: Infected pancreatic necrosis carries up to 70% risk of mortality. Open necrosectomy, previously regarded as standard treatment, carries very high risk of morbidity and mortality. Step-up management with percutaneous drainage followed by minimally invasive pancreatic necrosectomy (MIPN) has shown improved outcomes. We report the outcomes of the protocol developed at Cambridge of ‘early’ percutaneous drainage followed by ‘delayed’ MIPN. Materials and Methods: Cambridge University Hospital is a tertiary referral centre for pancreatic surgery including complicated pancreatitis. Retrospective analysis of all MIPNs between December 2009 and October 2018. Demographics, morbidity and mortality outcomes were reported. Results: During the 9-year period, 103 MIPNs were performed in 86 patients, with 12 (13.9%) needing multiple procedures. The mean age was 58 ±15 years, with 74.4% (n=64) being male gender and 50.0% (n=43) with BMI >30 Kg/m2.Thirty patients (34.9%) had required preoperative ITU admission for multi-organ support due to infected necrosis. The median time for insertion of percutaneous drain was 28 days (range 1-99). The median time of the MIPN from acute episode was 45 days (range 4-307). Thirteen patients (15.1%) required admission to ITU after MIPN with a median stay of 22 days (range 1-104). Complications of MIPN (n=29, 33.7%) included bleeding requiring intervention (n=5), pancreatic fistula (n=5) and multi-organ failure (n=19), which was considered as the morbidity rate. 30-day and 90-day mortality following MIPN was 2.3% (n=2) and 5.8% (n=5). All deaths were due to sepsis and multi-organ failure. Conclusions: This is the lowest reported mortality rate for patients with infected pancreatic necrosis. Minimally invasive management with early percutaneous drain insertion followed by delayed MIPN is associated with ultra-low mortality. Management of complicated necrotizing pancreatitis almost invariably requires tertiary referral expertise as it involves multimodal approaches, complex medical and ITU care, multiple procedures, prolonged admissions and long-term follow-up.

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.

Minimally Invasive Pancreatic Necrosectomy: A step-up approach towards ultra-low mortality in 103 consecutive procedures

Introduction: Infected pancreatic necrosis carries up to 70% risk of mortality. Open necrosectomy, previously regarded as standard treatment, carries very high risk of morbidity and mortality. Step-up management with percutaneous drainage followed by minimally invasive pancreatic necrosectomy (MIPN) has shown improved outcomes. We report the outcomes of the protocol developed at Cambridge of ‘early’ percutaneous drainage followed by ‘delayed’ MIPN. Method: Cambridge University Hospital is a tertiary referral centre for pancreatic surgery including complicated pancreatitis. Retrospective analysis of all MIPNs between December 2009 and October 2018. Demographics, morbidity and mortality outcomes are reported. Result: During the 9-year period, 103 MIPNs were performed in 86 patients, with 12 (13.9%) needing multiple procedures. The mean age was 58 ±15 years, with 74.4% (n=64) being male gender and 50.0% (n=43) with BMI more than 30 Kg/m2.Thirty (34.9%) patients had required preoperative ITU admission for multi-organ support related to infected necrosis. The mean time for insertion of percutaneous drain was 28 days (range 1-99). The mean time of the MIPN from acute episode was 45 days (range 4-307). Thirteen patients (15.1%) required admission to ITU after MIPN with a mean stay of 22 days (range 1-104). Composite endpoint for complications including bleeding needing intervention (n=5), multi-organ failure (19) and fistula (5) were 29 (33.7%), which was considered as the morbidity rate. 30-day and 90-day mortality following MIPN was 2.3% (n=2) and 5.8% (n=5), all deaths were due to sepsis and multi-organ failure. Conclusion: This is the lowest reported mortality rate for patients with infected pancreatic necrosis. Minimally invasive management with early percutaneous drain insertion followed by delayed MIPN is associated with ultra-low mortality. Management of complicated necrotizing pancreatitis almost invariably requires tertiary referral expertise as multimodal approaches, complex medical and ITU involvement, multiple procedures, prolonged admissions and long-term follow-up.

Clinical analysis of small incision minimally invasive approach in treatment of infected pancreatic necrosis

Objective: To investigate the safety and efficiency of small incision minimally invasive approach pancreatic necrosectomy in the treatment of infected pancreatic necrosis. Methods: The data of 164 patients who underwent small incision minimally invasive approach pancreatic necrosectomy for infected pancreatic necrosis at Department of Pancreatic and Biliary Surgery, the First Affiliated Hospital of Harbin Medical University from January 2012 to December 2016 were analyzed retrospectively.Among 164 patients, there were 102 male and 62 female patients.The median age was 46 years(ranging from 19 to 79 years). One hundred and one patients(61.6%) suffered from severe acute pancreatitis and 63 patients(38.4%) suffered from moderately severe acute pancreatitis.Following step-up approach principle, the surgical procedures were performed for 131 patients(79.9%) who suffered from sepsis which could not be alleviated via percutaneous catheter drainage(PCD). The other 33 patients(20.1%) who did not undergo PCD directly took small incision minimally invasive approach pancreatic necrosectomy.Preoperative CT images were used to determine the location of the lesion.The PCD puncture points or the points where the abscess was closest to the skin were chosen as the incision.Gradually, the small incision minimally invasive approach pancreatic necrosectomy were performed via cutting all layers into the abscess. Results: The median time from the onset of symptom to first operation was 32 days(ranging from 23 to 45 days). The average hospital stay was 46 days(ranging from 29 to 103 days). The average number of drainage tubes placed was 4 pieces(ranging from 2 to 8 pieces). Ninety-two patients(56.0%) underwent minimal access retroperitoneal pancreatic necrosectomy. Thirty-six patients(22.0%) underwent minimal invasive approach lesser omentum sac pancreatic necrosectomy.Thirty-six patients(22.0%) underwent minimal invasive approach lesser omentum sac pancreatic necrosectomy combined with minimal access retroperitoneal pancreatic necrosectomy.A total of 148 cases(90.2%) were cured via minimally invasive approach pancreatic necrosectomy, 8 cases(4.9%) were cured after transfering to open pancreatic necrosectomy.The cure rate was 95.1%(156/164). The mainly postoperative complications included pancreatic fistula(25 cases), intra-abdominal hemorrhage(10 cases), gastric fistula (2 cases), duodenal fistula(4 cases) and colonic fistula(3 cases). The overall incidence rate of complications was 26.8%(44/164). Eight cases were dead after surgery and the in-hospital mortality was 4.9%(8/164). Conclusion: In summary, small incision minimally invasive approach pancreatic necrosectomy is an effective way to clean up necrotic tissue, improve the drainage, reduce complications in dealing with infected pancreatic necrosis.

Minimally invasive pancreatic necrosectomy; a technical pictorial review.

Necrotizing pancreatitis is the most severe form of acute pancreatitis, which is associated with significant mortality and morbidity. Open necrosectomy has been one of the treatment modalities; however, it has been associated with high mortality rates and alternative minimally invasive procedures such as minimal invasive pancreatic necrosectomy (MIPN) were developed to improve on the outcomes. While current clinical evidence on MIPN showed significant advantages in terms of incidence of multiple organ failure, incisional hernias and new-onset diabetes there were no differences in terms of mortality rate. In this pictorial review we are presenting the technical details of MIPN as a minimally invasive procedure for the debridement of the necrotic pancreatic tissue and we will discuss the current evidence around the use of this procedure for the management of pancreatic necrosis.

Access to small collections in minimally invasive pancreatic necrosectomy

Access to small collections in minimally invasive pancreatic necrosectomy

Novel use of a single port laparoscopic surgery device for minimally invasive pancreatic necrosectomy.

Novel use of a single port laparoscopic surgery device for minimally invasive pancreatic necrosectomy.

Novel use of a single port laparoscopic surgery device for minimally invasive pancreatic necrosectomy

Novel use of a single port laparoscopic surgery device for minimally invasive pancreatic necrosectomy

Novel use of a single port laparoscopic surgery device for minimally invasive pancreatic necrosectomy

Novel use of a single port laparoscopic surgery device for minimally invasive pancreatic necrosectomy

PMO-100 Outcome of minimally invasive pancreatic necrosectomy without irrigation

IntroductionNecrotizing Pancreatitis with secondary infection of the pancreatic tissue is associated with significant morbidity and mortality. Current evidence suggests that a minimally invasive retroperitoneal necrosectomy (MIRP) is feasible, well tolerated...

Outcome of minimally invasive pancreatic necrosectomy without irrigation

Outcome of minimally invasive pancreatic necrosectomy without irrigation

Novel use of a single port laparoscopic surgery device for minimally invasive pancreatic necrosectomy

Novel use of a single port laparoscopic surgery device for minimally invasive pancreatic necrosectomy

Is Minimally Invasive Retroperitoneal Pancreatic Necrosectomy Too Aggressive in Treating Infected Pancreatic Necrosis?

their poor general condition and because it would be difficult to discriminate between necrotic and normal tissue during the sur-gery. Besides, the risk of uncontrolled hem-orrhage during or immediately after the surgery would be very high. Open necrosectomy results in signifi-cant deterioration of organ dysfunction scores after the procedure [2]. M IPN is less aggressive compared to open surgery but it is a much more aggressive method com-pared to percutaneous catheter drainage (PCD) using 8- or 10-Fr catheters under ultrasound or CT control (general anes-thesia, progressive dilatation of the drain tract to 30 Fr allowing insertion of a trocar, using grasping forceps for removal of ne-crotic tissue) [1, 3]. P CD seems technically feasible in the vast majority of patients with necrotizing pancreatitis [4, 5] . B-esides, with this method a few catheters can be simultaneously introduced into liquid areas of necroses (into different pancreatic and peripancreatic regions) without gen-eral anesthesia and with fewer traumas, performing vigorous irrigation with simi-lar or better effects than by MIPN. On the basis of our long-term experi-ence [4, 6] , we believe that necrosecto-my (including MIPN) as a primary treat-ment may represent overtreatment of IPN. Therefore, we consider that sole conserva-tive treatment with proper intravenous hy-dration and administration of proper an-tibiotics should be performed at the begin-ning of the disease. PCD with vigorous D e a rE d itor, We read with great interest the article by Ahmad et al. [1] published in issue 1 of Pancreatology 2 011, volume 11. The article describes a case series outlining the expe-rience and results of retroperitoneal mini-mally invasive pancreatic necrosectomy (MIPN) and demonstrates that MIPN can be performed with acceptable morbidity and mortality and with good end results. The authors note that multiple MIPNs may be needed to eradicate the necrosis satisfactorily [1] . However, we wish to highlight certain issues regarding the statement that multiple MIPNs represent the optimal treatment for infected pancre-atic necroses (IPN). In the beginning of acute necrotizing pancreatitis, pancreatic and peripancreatic necroses are solid and the discrimination between necrotic tissue and normal tissue is very difficult. However, during the course of IPN, after the transition from solid ne-crotic tissue to more liquid contents takes place, there is a chance of a higher success rate in evacuating the necrotic tissue from the cavities, regardless of the method that is used. The presence of infection and vigor-ous irrigation can accelerate the process of transition from solid necrotic tissue to more liquid content. In those conditions, patients with necrotizing pancreatitis are not good candidates for surgery because of

Minimally Invasive Retroperitoneal Pancreatic Necrosectomy

Introduction: This article describes a case series outlining the experience and results of the retroperitoneal minimally invasive pancreatic necrosectomy (MIPN) procedure performed by, or done under the supervision of, a single surgeon. Methods: All data of the patients who underwent MIPN from 2006 to 2008 were entered into a prospectively maintained, computerized database. Results: A total of 93 MIPN procedures were performed on 32 patients. All patients had severe acute pancreatitis. The median number of MIPN procedures per patient was 3. Only 6 patients needed intensive care unit (ICU) admission after MIPN. There were 15 complications, which included bleeding requiring transfusion (n = 3), bowel fistulae (n = 7), thromboembolic events (n = 2) and acute myocardial infarction (n = 3). Four patients died after the procedure (13%); 1 died of ongoing multiorgan failure in spite of the MIPN. Four patients developed pancreatic pseudocysts within the follow-up period of 2 years. Three of these patients required intervention. Conclusion: This case series demonstrates that MIPN can be performed with acceptable morbidity and mortality and with good end results. The ICU dependency after the procedure is minimal. As seen in this series, multiple MIPNs may be needed to eradicate the necrosis satisfactorily.