Retroperitoneal Necrosectomy Research Articles

Evaluating the role of the Minimal Incision Retroperitoneal Necrosectomy (MIRN) in the management of infected pancreatic necrosis: Experience from a tertiary care center

BackgroundThe conventional open necrosectomy was associated with high mortality and morbidities like secondary organ failure, incisional hernia, enterocutaneous fistula, and external pancreatic fistula. In acute pancreatitis, collections are primarily confined to the retroperitoneal space. Hence, the retroperitoneal approach can be used to drain the collection and necrotic material. It benefits smaller incisions and better outcomes in terms of morbidity and mortality than the conventional open necrosectomy. This study primarily aims to describe the effects of minimal incision retroperitoneal necrosectomy versus conventional open necrosectomy for treating INP. Moreover, it provides evidence supporting the efficacy and safety of this method. MethodsA single-center retrospective study of the prospectively maintained database from April 2008 to December 2021. ResultsA total of 122 patients were included in the study. Seventy-eight patients had an open necrosectomy, 30 had a MIRN, and 14 had a VARD procedure. These three groups were comparable in demographic variables. Preoperative variables like APACHE II at presentation, Modified CTSI, percentage of necrosis, multi-organ failure, time to surgery, and need for preoperative ICU stay were comparable among the three groups. Postoperative mortality was low in the MIRN group{open 35.8 % vs. MIRN 20.5 % vs. VARD 35.7 %, p = 0.066}. The postoperative stay was also significantly low in the MIRN and VARD group {open 23.62 ± 16.61 vs. MIRN 11.77 ± 7.73, VARD 8.86 ± 2.98, p = 0.00}. No significant difference in re-intervention rate, postoperative bleeding, and enterocutaneous fistula. ConclusionMIRN is a simple and easy-to-adapt procedure for infected pancreatic necrosis in the appropriately selected patient group.

Minimally invasive retroperitoneal necrosectomy: how do we do it?

: Acute pancreatitis (AP) is an inflammatory condition that includes local and systemic manifestations, showing a mild behavior in most patients. Infected pancreatic necrosis is the most aggressive scenario with a high mortality rate. According to the PANTER trial, the “step-up approach” has shown a lower rate of new-onset organ failure compared with open necrosectomy. Whenever possible, major surgical interventions in infected pancreatitis should be delayed as long as possible, ideally until the fourth week since the onset of symptoms. The selection and timing of the procedure are key points, taking into account the clinical condition of the patient, the location, the availability of equipment, and the experience of the surgical team. The technical description of the laparoscopic retroperitoneal necrosectomy is presented focused on the path to the retroperitoneum, anatomical aspects, and tips and tricks. Furthermore, the step-up approach flowchart, indications, contraindications, patient’s workup, post-operative management, advantages, complications, and technique video are included. Although laparoscopic necrosectomy requires mastery of retroperitoneal anatomy and good laparoscopic skills, it is an exceptional tool for the surgeon within the arsenal for this difficult and serious condition. The authors have adopted the laparoscopic retroperitoneal necrosectomy as part of the step-up approach and have found it very replicable and ergonomic.

Transluminal and retroperitoneal minimally invasive necrosectomy in acute pancreatitis

The research review presents literature data on the possibilities of performing minimally invasive necrosectomy for infected forms of acute necrotizing pancreatitis. The paper provides detailed information concerning the terminology, indications for, and technical features of implementing the principal methods of minimally invasive surgical debridement of necrotic accumulations. The techniques include endoscopic transluminal necrosectomy, videoassisted retroperitoneal debridement, and minimally invasive retroperitoneal necrosectomy. The review describes results of numerous studies on the evaluation of their effectiveness and possible options for their combined use. Additionally, we present the materials of relevant international clinical guidelines which indicate the viability of performing minimally invasive necrosectomy as part of a phased strategy for the treatment of patients with acute necrotizing pancreatitis.

Direct retroperitoneal necrosectomy through an insufficient jejunal blind stump after gastrectomy for necrotizing pancreatitis.

Direct retroperitoneal necrosectomy through an insufficient jejunal blind stump after gastrectomy for necrotizing pancreatitis.

Strategic approach to minimally invasive necrosectomy for necrotizing pancreatitis: technique, complications and predictors of outcome.

Minimally invasive retroperitoneal necrosectomy has been an integral component of 'step-up' approach for infected pancreatic necrosis. Even though the clinical outcome of nephroscopic necrosectomy has been studied earlier, its predictor and morbidities following surgery have not been extensively evaluated. We aimed to evaluate the clinical outcome and early and late complications after percutaneous nephroscopic necrosectomy (PCNN). The pre- and intra-operative as well as post-operative and follow-up data of severe pancreatitis patients undergoing PCNN were collected prospectively. Out of 115 patients requiring intervention, 40 patients (34.78%) improved with percutaneous drain alone and another 40 proceeded for PCNN. After exclusion, 37 patients successfully underwent 48 sessions of PCNN. Median number of PCNN session was 1 (1-4). Early complications were seen in 21 (56.75%) patients and mortality was experienced in eight (21.62%) patients. On median follow-up of 36 months, 12 (32.43%) patients experienced late complications. Persistent post-operative pancreatic fistula was observed in six (16.21%) patients. Of these, three developed late-onset pseudocyst, whereas one patient had disconnected duct syndrome. Seven patients experienced new-onset diabetes. Age, severity of pancreatitis, preoperative organ failure and multiorgan failure were significant predictors of mortality on univariate analysis (P ≤ 0.05 for each). The logistic regression analysis revealed presence of multiorgan failure before surgery as the sole predictor (P = 0.007; odds ratio 10.417; 95% confidence interval 1.759-61.672). Preoperative multiorgan failure was the most important predictor of mortality following PCNN. Late complications were seen in nearly one-third of patients emphasizing the need for long-term follow-up.

Outcome of open necrosectomy versus minimally invasive retroperitoneal necrosectomy following percutaneous drainage in infected necrotising pancreatitis

Introduction: Percutaneous drainage is the first step in the well established “step - up” approach in management of infected necrotising pancreatitis. This study intended to compare the outcome of open necrosectomy and minimally invasive retroperitoneal necrosectomy (MIRP) following percutaneous drainage. Method: Single centre, retrospective analysis of 32 patients between 2016-2019 who underwent further necrosectomy procedure following percutaneous drainage for infected necrosis, were included in this study. Result: Among 32 patients, 21(65.63%) patients underwent open necrosectomy. The most common etiology was due to alcohol intake (71.88%). Mean interval of necrosectomy following acute episode was 25.31±12.72 day. Overall procedure mortality was 31.25%, while 33.33% (p- 0.705) following open necrosectomy. 46.88% patients developed major complications other than organ failure (n=5). Pancreatic fistula was the most common complication (15.63%). Open necrosectomy causes more blood loss (216.66±184.88 ml, p-0.463) and takes more time (161.90±58.61 mins) than MIRP. Conclusion: Initial percutaneous drainage decreases the infective and others pro-inflammatory mediators load, resulting in decrease inflammatory cascade and delaying the need for further surgical necrosectomy. In this study there was no significant difference in morbidity or mortality between open necrosectomy and MIRP in patients of infective necrosis following initial percutaneous drainage.

Endoscopic management of walled-off pancreatic necrosis.

Walled-off pancreatic necrosis (WON) can develop in the late phase of necrotizing pancreatitis. When the WON is accompanied by an infection in the necrotic bed, it becomes a life-threatening complication. Open necrosectomy with drainage has been the standard treatment; however, it is associated with a significant morbidity and high mortality. Therefore, minimally invasive therapeutic alternatives are in demand. Recently, a new treatment algorithm for necrotizing pancreatitis, known as the step-up approach, has been proposed. The initial report on it consisted of percutaneous drainage followed by, if necessary, a minimally invasive retroperitoneal necrosectomy. However, the endoscopic step-up approach, which consists of EUS-guided transluminal drainage followed by, if necessary, endoscopic necrosectomy, was later introduced. Recent studies have suggested that an endoscopic step-up approach might be more advantageous than a minimally invasive surgical step-up approach. A lumen apposing metal stent (LAMS) with a cautery-enhanced delivery system is currently preferred over the conventional plastic stents for endoscopic interventions, because it decreases the technical difficulty of the procedure and may obviate the need for an adjunctive debridement procedure. However, some recent findings suggest that LAMS could be associated with a higher risk of stent-related complications than conventional plastic stents, especially in patients with long-term placement. Therefore, early removal of LAMS at 3weeks post-intervention is proposed if the WON is resolved on CT examination. Thus, endoscopic interventions have emerged as a key player in the management of WON. However, multidisciplinary treatment approaches should be considered because the endoscopic approach has limitations in treating complicated WON.

Clinical efficacy of minimal access retroperitoneal pancreatic necrosectomy for infected pancreatic necrosis

Objective To investigate the clinical efficacy of minimal access retroperitoneal pancreatic necrosectomy (MARPN) for infected pancreatic necrosis (IPN). Methods The retrospective cohort study was conducted. The clinical data of 61 patients with IPN who were admitted to Union Hospital Affiliated to Tongji Medical College of Huazhong University of Science and Technology between January 2014 and December 2017 were collected. There were 39 males and 22 females, aged 36-67 years, with a median age of 49 years. Of 61 patients, 40 undergoing open surgery were allocated into open group, and 21 undergoing MARPN were allocated into MARPN group. All the patients underwent surgical treatments after standard non-surgical treatments according to the Guidelines for the diagnosis and treatment of severe acute pancreatitis (2014 edition). Observation indicators: (1) intraoperative and postoperative situations; (2) follow-up. Follow-up using telephone interview or outpatient examination was performed to detect weight loss, pathoglycemia, steatorrhea, intestinal obstruction, and pancreatic portal hypertension for one year after surgery up to December 2017. Measurement data with normal distribution were represented as Mean±SD, and comparison between groups was analyzed using the t test. Count data were represented as absolute numbers or percentages, and comparison between groups was done using the chi-square test. Results (1) Intraoperative and postoperative situations: operation time, time to out-of-bed activity, time to initial food intake, cases with reoperation, cases with postoperative multiple organ dysfunction syndrome (MODS), incidence rate of postoperative complications, mortality, time to drainage-tube removal, duration of hospital stay, and hospital expenses were (77±20)minutes, (13.0±3.6)days, (9.0±2.7)days, 8, 9, 45.0%(18/40), 7.5%(3/40), (37.0±6.3)days, (49±8)days, (84 321±8 872)yuan in the open group, and (59±20)minutes, (2.7±0.9)days, (1.9±0.4)days, 6, 2, 19.0%(4/21), 0, (21.0±2.7)days, (39±6)days, (58 594±3 576)yuan in the MARPN group, respectively, showing no significant difference in the cases with reoperation (χ2=0.69, P>0.05) but significant differences in the other indices between the two groups (t=4.24, 9.61, 15.34, χ2=23.76, 4.02, 36.03, t=11.07, 5.93, 8.43, P 0.05). Conclusion MARPN for IPN is safe and reliable, with certain efficacy, which can effectively reduce incidence of postoperative complication, motality and shorten hospital stay. Key words: Pancreatitis; Infection; Retroperitoneal approach; Pancreatic necrosectomy

The trends in surgical treatment and the outcomes of critical acute pancreatitis

Objective To study the trends in surgical treatment and the outcomes of critical acute pancreatitis (CAP). Methods The clinical data of 76 patients with CAP who were treated in the Department of Biliopancreatic Surgery of the Xiangya Hospital, Central South University from January 2010 to December 2017 were retrospectively reviewed. Data which included demographics, micro-organisms, surgical interventions and mortality were compared between the time periods of 2010 to 2013 and 2014 to 2017. Results Before 2014, 19 patients with CAP were treated in the Department of Biliopancreatic Surgery of the Xiangya Hospital, Central South University. The percentage of multidrug resistant organisms (MDRO) in pancreatic drainage was 5.3% (1/19). In the latter 4 years, 57 patients with CAP were treated. The percentage of MDRO was 50.9% (29/57), which was significantly higher than the initial 4 years (P<0.001). For surgical treatment, the proportion of minimally invasive surgery in the latter 4 years was significantly higher than that in the initial 4 years. The percentage of percutaneous catheter drainage (PCD) increased from 63.2% in the initial 4 years to 86.0% in the latter 4 years. The proportion of minimal access retroperitoneal pancreatic necrosectomy (MARPN) increased from zero in the initial 4 years to 59.6%, while the proportion of open pancreatic necrosectomy (OPN) decreased from 68.4% in the initial 4 years to 24.6%. The mortality rate of patients with CAP dropped from 52.6% (10/19) in the initial 4 years to 24.6% (14/57) in the latter four years. Conclusions In the center which specializes in treating pancreatitis, although the problem of bacterial resistance had become increasingly prominent, the mortality rate of CAP had shown a significant downward trend due to the development of various minimally invasive techniques. Key words: Critical acute pancreatitis; Infected pancreatic necrosis; Minimally invasive techniques

Comparing efficacy of lumen-apposing stents to plastic stents in the endoscopic management of mature peripancreatic fluid collections: a single-center experience.

IntroductionMature peripancreatic fluid collection (MPFC) is a known and often challenging consequence of acute pancreatitis and often requires intervention. The most common method accepted is the “step-up approach,” which consists of percutaneous drainage followed, if necessary, by minimally invasive retroperitoneal necrosectomy. Our paper aims to distinguish between plastic stents and lumen-apposing stents in the endoscopic management of MPFC in terms of morbidity, mortality, and haste of fluid collection resolution.MethodsA retrospective analysis was performed at UMass Memorial Medical Center in patients with a diagnosis of MPFC. Utilizing medical records, clinical data, radiology, as well as endoscopic evidence, patients were differentiated by stent type used (plastic versus lumen-apposing) for the management of the MPFC. The primary outcome of the study was to assess the time to MPFC resolution following the placement of either plastic or lumen-apposing stents (on endoscopic ultrasound or computerized tomography scan) using a multivariate analysis with a logistic regression model.ResultsA total of 54 patients were included in this study from UMass Memorial Medical Center between 2012 and 2015. Twelve (22%) of these patients received lumen-apposing stents and 42 (78%) of these patients received plastic pigtail stents. For the lumen-apposing stent group, the mean interval between stent placement and resolution of MPFC was 57 days as compared to 102 days for plastic pigtail stents (p=0.02). The mean interval for placement/removal of lumen-apposing stents was 48 days as compared to 81 days for plastic pigtail stents (p=0.01). Stent migration was seen in 5 patients (11%) who received a plastic pigtail stent compared to 0 (0%) patients who received a lumen-apposing stent.DiscussionOur study demonstrates that lumen-apposing stents result in a significant reduction in the interval between stent placement and MPFC resolution as well as the time from stent placement to removal, when compared to plastic pigtail stents, the prior standard-of-care. Our study reached similar conclusions regarding the number of stents placed. However, we did not find a significant difference between the complication rates, specifically peri- and postprocedural bleeding or perforation, between the 2 study groups, as demonstrated in prior papers.

Initial minimally invasive retroperitoneal necrosectomy for acute necrotizing pancreatitis

Introduction: Minimally invasive approches in treatment of acute necrotizing pancreatitis and/or infected pancreatic necrosis gain a notable advantage compared with open surgery.Aim: We present our experience in treatment of acute necrotizing pancreatitis by an original minimally invasive retroperitoneal necrosectomy technique, evaluate feasibility and safety of this method, compare our results to other studies.Patients and methods: A retrospective analysis of 22 patients with acute necrotizing pancreatitis and large fluid collections in retroperitoneal space was performed. All patients underwent retroperitoneal necrosectomy as an initial interventional procedure in treatment of infected pancreatic necrosis.Results: Sixteen males and six females aged between 24 and 60 with an average age of 42.59 ±7.3 years were included. Alcohol abuse was an etiologic factor of acute necrotizing pancreatitis for 18 patients (81.8%). Average time between diagnosis and performance of necrosectomy was 28.6 ±13.2 days. Ten patients (45.5%) did not undergo any additional intervention after initial retroperitoneal necrosectomy. Other 12 patients (54.5%) required additional procedures. 3 patients (13.6%) needed 5 or more reinterventions: 4 sonoscopically-guided drainages, 4 retroperitoneal renecrosectomies and 11 laparotomies. 9 patients (40.9%) required less than 5 reinterventions: 2 sonoscopically-guided drainages, 12 retroperitoneal renecrosectomies and 3 laparotomies. Most of reinterventions were performed due to insufficient drainage and bleeding. 63.6% of our patients did not require more than one reintervention. Postoperative hospitalisation ranged from 9 to 148 days with an average of 52.2 ±35.2 days. The mortality rate in our study was 0%.Conclusions: Minimally invasive techniques should be considered as a first-choice surgical option in treating patients with acute necrotizing pancreatitis whenever possible. Pancreatic necrosis occupying less than 30% and with massive fluid collections can be safely managed by an initial minimally invasive retroperitoneoscopic necrosectomy when an appropriate gap in the left retroperitoneum between the colon and the kidney exist.

The clinical practice and related reflections of staged step-up approach in the treatment of patients with severe acute pancreatitis

Both new insights in the pathophysiology of severe acute pancreatitis (SAP) and upspringing related evidence-based supports prompt the staged step-up approach, which stress emphasis on minimal invasiveness and damage control, to be accepted and advocated by the majority of guidelines. For documented or suspected patients with infected pancreatic necrosis, an imaging-guided percutaneous catheter drainage or an endoscopic transluminal drainage should be initially performed followed by, if necessary, a minimal access retroperitoneal necrosectomy, or a video-assisted retroperitoneal debridement, or an endoscopic transluminal necrosectomy, or an even an open access necrosectomy. The outstanding performance of staged step-up approach in patients with SAP has been justified from both a clinical and a health economic point of view, meanwhile, there are some issues remained to be further elucidated and optimized.

The two-port laparoscopic retroperitoneal approach for minimal access pancreatic necrosectomy.

Despite advances in surgery and critical care, severe pancreatitis continues to be associated with a high rate of mortality, which is increased significantly in the presence of infected pancreatic necrosis. Controversy persists around the optimal treatment for such cases, with specialist units variously advocating open necrosectomy, simple percutaneous drainage or one of several minimal access approaches. We describe our technique and outcomes with a two-port laparoscopic retroperitoneal necrosectomy (2P-LRN). Thirteen consecutive patients with proven infected pancreatic necrosis were treated by 2P-LRN over a three-year period in the setting of a specialist hepatopancreatobiliary unit. The median patient age was 46 years (range: 28-87 years) and 10 of the patients were male. The median number of procedures required to clear the necrosis was 2 (range: 1-5), with a median time to discharge following the procedure of 44 days (range: 10-135 days). There was no 90-day mortality and the morbidity rate was 38%, consisting of pancreatic fistula (31%) and bleeding (23%). Two-port laparoscopic retroperitoneal necrosectomy has been demonstrated to confer similar or better outcomes to other techniques for necrosectomy. It carries the additional advantages of better visualisation, leading to fewer procedures and the opportunity to deploy simple laparoscopic instruments such as diathermy or haemostatic clips.

Video assisted retroperitoneal debridement in huge infected pancreatic pseudocyst

In recent years the incidence of acute pancreatitis has increased worldwide. Some of 85% of all patients with acute pancreatitis will recover fast, but in 15% a necrosis of the pancreatic or extra pancreatic tissue will be developed. Two minimally invasive surgical techniques have gained wide spread acceptance: minimal access retroperitoneal necrosectomy( MARPN) and video assisted retroperitoneal debridement(VARD) We present a case of a patient with a huge infected pancreatic pseudo cyst occupying almost the entire abdominal cavity in which a video assisted retroperitoneal debridement was performed. MARPN and VARD are relatively simple and costless procedures which can be performed by a gastrointestinal surgeon with basic laparoscopic or endoscopic skills.

Retroperitoneoscopic Anatomical Necrosectomy: A Modified Single-Stage Video-Assisted Retroperitoneal Approach for Treatment of Infected Necrotizing Pancreatitis.

Video-assisted retroperitoneal necrosectomy is a minimally invasive surgical technique for the treatment of severe acute pancreatitis. This study evaluated the safety and feasibility of a modified single-stage video-assisted retroperitoneal necrosectomy, retroperitoneoscopic anatomical necrosectomy (REAN). Between September 2010 and May 2012, a total of 17 patients with infected necrotizing pancreatitis underwent REAN. The surgical procedures were similar to retroperitoneoscopic pancreatectomy, in which 3 trocars are utilized. Briefly, the perirenal space was entered through the posterior pararenal space. Dissection proceeded from posterior to anterior direction to expose the dorsal side of the perirenal fascia. This was opened to reach the anterior perirenal space, where the peripancreatic abscess was located. Necrotic tissue was then debrided and catheter drainage was performed in a single stage. Operating time ranged from 45 to 100 minutes with minimal blood loss. All patients recovered except for one who died. Major perisurgical complications included peritoneal injury (1 patient), splenic vein injury (1 patient), retroperitoneal infection with paralytic ileus (1 patient), hydrothorax and atelectasis (2 patients), and subcutaneous cellulitis beneath the incision (3 patients). Two patients required additional percutaneous catheter drainage, and 1 patient required a laparotomy to debride the remaining necrotic tissue. Postoperative hospital stay ranged from 21 to 64 days. This study demonstrates that REAN, a modified single-stage video-assisted retroperitoneal approach, was safe and feasible for the treatment of infected necrotizing pancreatitis. The advantages of this procedure include direct access with shorter operating time, complete necrotic tissue debridement, easy hemostasis, simple manipulation, and easy drainage.

The impact of minimally invasive retroperitoneal necrosectomy on organ dysfunction in patients with infected pancreatic necrosis.

The impact of minimally invasive retroperitoneal necrosectomy on organ dysfunction in patients with infected pancreatic necrosis.

Is necrosectomy obsolete for infected necrotizing pancreatitis? Is a paradigm shift needed?

In 1886, Senn stated that removing necrotic pancreatic and peripancreatic tissue would benefit patients with severe acute pancreatitis. Since then, necrosectomy has been a mainstay of surgical procedures for infected necrotizing pancreatitis (NP). No published report has successfully questioned the role of necrosectomy. Recently, however, increasing evidence shows good outcomes when treating walled-off necrotizing pancreatitis without a necrosectomy. The literature concerning NP published primarily after 2000 was reviewed; it demonstrates the feasibility of a paradigm shift. The majority (75%) of minimally invasive necrosectomies show higher completion rates: between 80% and 100%. Transluminal endoscopic necrosectomy has shown remarkable results when combined with percutaneous drainage or a metallic stent. Related morbidities range from 40% to 92%. Single-digit mortality rates have been achieved with transluminal endoscopic necrosectomy, but not with video-assisted retroperitoneal necrosectomy series. Drainage procedures without necrosectomy have evolved from percutaneous drainage to transluminal endoscopic drainage with or without percutaneous endoscopic gastrostomy access for laparoscopic instruments. Most series have reached higher success rates of 79%-93%, and even 100%, using transcystic multiple drainage methods. It is becoming evident that transluminal endoscopic drainage treatment of walled-off NP without a necrosectomy is feasible. With further refinement of the drainage procedures, a paradigm shift from necrosectomy to drainage is inevitable.

Ultrasound-guided percutaneous drainage of infected pancreatic necrosis

The role of percutaneous drainage in the management of infected pancreatic necrosis remains controversial, and ultrasound-guided technique is rarely used for this indication. The purpose of this study was to evaluate the safety and efficacy of sonographically guided percutaneous catheter drainage for infected pancreatic necrosis.The patient group consisted of 16 men and 2 women. The mean age of the patients was 47 years. The median computed tomography severity index of acute pancreatitis was 10 points. Percutaneous catheter drainage was performed under sonographic guidance using preferably retroperitoneal approach, and transperitoneal access in selected cases. The medical records and imaging scans were reviewed retrospectively for each patient.Percutaneous catheter drainage resulted in a complete resolution of infected pancreatic necrosis in 6 of 18 patients (33 %). Twelve of 18 patients who were initially managed with PCD required eventually necrosectomy (67 %). The most common reason for crossover to surgical intervention was persistent sepsis (n = 7). Open necrosectomy was performed in 4 of these patients, and 3 patients underwent successful minimally invasive retroperitoneal necrosectomy. Five patients required conversion to open surgery because of procedure-related complications. In 3 cases, there was leakage of the necrotic material into the peritoneal cavity. Two other patients experienced hemorrhagic complications. Overall mortality rate was 17 %. The size of the largest necrotic collection in patients who were successfully treated with percutaneous drainage decreased by a median of 76 % shortly after the procedure, whereas it decreased only by a median of 16 % in cases of failure of percutaneous drainage.Ultrasound-guided percutaneous catheter drainage used in infected pancreatic necrosis is a technique with acceptably low morbidity and mortality that may be the definitive treatment or a bridge management to necrosectomy. A negligible decrease in size of the necrotic collection predicts failure of percutaneous drainage.

Video-Assisted Retroperitoneal Debridement (VARD) of Infected Necrotizing Pancreatitis: An Update

The treatment of necrotizing pancreatitis has changed considerably over the last decades. Intervention is now primarily performed in case of infected necrosis, is preferably delayed to approximately 4 weeks after onset of disease and minimally invasive techniques have gained popularity. Percutaneous catheter drainage obviates the need for additional necrosectomy in around 30 % of patients and should, therefore, be the first step of treatment. Minimally invasive necrosectomy can be performed as a next step in those patients who do not improve after drainage. This review discusses the background, technique, and results of the literature of a form of minimally invasive retroperitoneal necrosectomy: video-assisted retroperitoneal debridement.

Outcome of video‐assisted translumbar retroperitoneal necrosectomy and closed lavage for severe necrotizing pancreatitis

Surgery for necrotizing pancreatitis is associated with a high rate of morbidity and mortality. We present a series of 26 patients who underwent video-assisted translumbar retroperitoneal necrosectomy and analyse their outcomes. Records of 26 patients who underwent video-assisted translumbar retroperitoneal necrosectomy and closed drainage for infected pancreatitic necrosis between January 2008 and March 2012 were reviewed, retrospectively. Twenty-three out of 26 patients were males, with a mean age of 38.6 (±9.9) years. Alcohol was the aetiology in 18 patients, gall stones in 7, and in 1 it was idiopathic. The mean duration of symptoms before patients were taken up for surgery was 47.2 (±34.8) days. The mean computed tomography severity index was 7.7 (±1.2). All patients had undergone video-assisted retroperitoneal necrosectomy through a limited left lumbar incision. Post-operative lavage was given through drains placed in the retroperitoneum. Three patients required re-exploration. Eleven patients developed complications and there were two mortalities. The median intensive care unit (ICU) stay was 4 days (range 2-14 days). The mean post-operative hospital stay was 22.5 (±6.6) days. Video-assisted translumbar retroperitoneal necrosectomy followed by closed lavage of infected pancreatic necrosis in select cases of infected pancreatic necrosis was associated with a low rate of ICU stay, hospital stay and need for re-entry.