Video-assisted Retroperitoneal Debridement Research Articles

Laparoscopic necrosectomy for acute necrotizing pancreatitis: mesocolon-preserving approach and outcomes.

The surgical treatment of acute necrotizing pancreatitis has significantly evolved in recent years with the advent of enhanced imaging techniques and minimally invasive surgery. Various minimally invasive techniques, such as video-assisted retroperitoneal debridement (VARD) and endoscopic transmural necrosectomy (ETN), have been employed in the management of acute necrotizing pancreatitis and are often part of step-up approaches. However, almost all reported step-up approaches only employ a fixed minimally invasive technique prior to open surgery. In contrast, we implemented different minimally invasive techniques during the treatment of acute pancreatitis based on the extent of pancreatic necrosis. For acute necrotizing pancreatitis of the pancreatic bed with or without extension into the left retroperitoneum, we performed mesocolon-preserving laparoscopic necrosectomy for debridment. The quantitative indication for pancreatic debridment in our institute has been described previously. For acute necrotizing pancreatitis of the pancreatic bed with or without extension into the left retroperitoneum, mesocolon-preserving laparoscopic necrosectomy was performed for debridment. To safeguard the mesocolon, the pancreatic bed was entered via the gastrocolic ligament, and the left retroperitoneum was accessed via the lateral peritoneal attachments of the descending colon. Of the 77 patients requiring pancreatic debridment, 41 patients were deemed suitable for mesocolon-preserving laparoscopic necrosectomy by multiple disciplinary team and informed consent was acquired. Of these 41 patients, 27 underwent percutaneous drainage, 10 underwent transluminal drainage, and 2 underwent transluminal necrosectomy prior to laparoscopic necrosectomy. Two patients (4.88%) died of sepsis, three patients (7.32%) required further laparotomic necrosectomy, and five patients (12.20%) required additional percutaneous drainage for residual infection. Three patients (7.32%) experienced duodenal fistula, all of which were cured through non-surgical treatments. Nineteen patients (46.34%) developed pancreatic fistula that persisted for over 3weeks, with 17 being successfully treated non-surgically. The remaining two patients had pancreatic fistulas that lasted over 3months; an internal drainage procedure has been planned for them. No patient developed colonic fistula. Mesocolon-preserving laparoscopic necrosectomy proved to be safe and effective in selected patients. It can serve as a supplementary procedure for step-up approaches or as an alternative to other debridment procedures such as VARD, ETN, and laparotomic necrosectomy.

Pancreatitis sepsis: Evolution and principles in the management of necrotizing pancreatitis

Outcomes from some recent clinical trials have helped to improve the management of necrotizing pancreatitis over the last 2 decades. The location of the retroperitoneal collection, previous gastric surgery, patient preference, and medical expertise dictates a minimally invasive surgical step-up versus endoscopic approach. Endoscopic drainage is facilitated by either a plastic or metallic stent. Direct endoscopic necrosectomy is performed for lack of improvement after endoscopic drainage. The surgical approach is accomplished by minimally invasive surgery with either video-assisted retroperitoneal debridement or laparoscopic drainage. A multidisciplinary team with appropriate expertise should care for patients with necrotizing pancreatitis. This brief review summarizes the landmark clinical trials, compares the benefits and roles of endoscopic, surgical, and percutaneous interventions, and discusses treatment algorithms for necrotizing pancreatitis in the modern era.

Predictive Risk Factors of Pancreatic Exocrine Insufficiency Developed After Acute Pancreatitis: A Retrospective Cohort Study.

The aim of this study was to compare the clinical characteristics of acute pancreatitis (AP) patients between those who developed pancreatic exocrine insufficiency (PEI) and those who did not, and to investigate the predictive factors of PEI. From October 1st 2019 to July 30th 2021, AP patients admitted at our center were included. The fecal elastase-1 assay was adopted for PEI diagnosis. The clinical characteristics, treatments, and outcomes between the patients with and without PEI were analyzed. In total, 63 males and 42 females were included. There were 27 patients with mild AP, 54 with moderately severe AP, and 24 with severe AP. The median modified computed tomography severity index (MCTSI) was 6.000(4.000, 8.000). During the follow-up, 38 patients developed PEI after AP. The univariate analysis showed that higher ASA grade (P = 0.006), more severe AP (P = 0.000), the presence of multiple organ dysfunction syndrome (P = 0.030), higher MCTSI (P = 0.000), the development of infected pancreatic necrosis (P = 0.002) and local complications (P = 0.000), higher levels of triacylglycerol (P = 0.022), video-assisted retroperitoneal debridement intervention (P = 0.015), and longer intensive care unit stay (P = 0.044) were correlated with PEI development. Furthermore, the logistic regression analyses showed that MCTSI during hospitalization is an independent risk factor for PEI development during the AP recovery period. ASA grade, severity of AP, multiple organ dysfunction syndrome, MCTSI, infected pancreatic necrosis, local complications, higher levels of triacylglycerol, video-assisted retroperitoneal debridement intervention, and longer intensive care unit stay were potentially associated with PEI development during the AP recovery period. High MCTSI was independently associated with the development of PEI during the AP recovery period, which may help alert to the possibility of PEI to help with its early detection and treatment.

Minimal-access video-assisted retroperitoneal and/or transperitoneal debridement (VARTD) in the management of infected walled-off pancreatic necrosis with deep extension: initial experience from a prospective single-arm study

BackgroundThe currently preferred minimally invasive approaches have substantially improved outcomes of infected walled-off pancreatic necrosis (iWON). However, iWON with deep extension (iWONde) still poses a tricky challenge for sufficient necrosis evacuation by one stand-alone approach, often requiring repeated interventions. The aim of this study was to assess the effectiveness and safety of a minimal-access video-assisted retroperitoneal and/or transperitoneal debridement (hereafter called VARTD) in the management of iWONde.MethodsPatients who had developed an iWONde were recruited to receive the VARTD in this prospective single-arm study. The primary efficacy endpoint was clinical improvement up to day 28 after the VARTD, defined as a ≥ 75% reduction in size of necrotic collection (in any axis) on CT and clinical resolution of sepsis or organ dysfunction. The primary safety endpoint was a composite of major complications or death during follow-up. Six-month postdischarge follow-up was available.ResultsBetween July 18, 2018, and November 12, 2020, we screened 95 patients with necrotizing pancreatitis; of these, 21 iWONde patients (mean [SD] age, 42.9 [11.7] years; 10 [48%] women) were finally enrolled. The primary efficacy endpoint was achieved by most participants (14/21, 67%). No participants required repeated interventions. The primary safety endpoint occurred in six patients (29%). Except one in-hospital death attributable to repeated intra-abdominal hemorrhage, others were discharged without any major complication.ConclusionsThe VARTD approach appears to have a reasonable efficacy with acceptable complication rates and thus might be an option for improving clinical management of iWONde.Trial registrationThis study is registered with Chinese Clinical Trial Registry (chictr.org.cn number, ChiCTR1800016950).

Decreasing use of pancreatic necrosectomy and NSQIP predictors of complications and mortality

BackgroundSurgical pancreatic necrosectomy (SPN) is an option for the management of infected pancreatic necrosis. The literature indicates that an escalating, combined endoscopic, interventional radiology and minimally invasive surgery “step-up” approach, such as video-assisted retroperitoneal debridement, may reduce the number of required SPNs and ICU complications, such as multiple organ failure. We hypothesized that complications for surgically treated severe necrotizing pancreatitis patients decreased during the period of adoption of the “step-up” approach.MethodsThe American college of surgeons national surgery quality improvement program database (ACS-NSQIP) was used to find SPN cases from 2007 to 2019 in ACS-NSQIP submitting hospitals. Mortality and Clavien-Dindo class 4 (CD4) ICU complications were collected. Predictors of outcomes were identified by univariate and multivariate analyses.ResultsThere were 2457 SPN cases. SPN cases decreased from 0.09% in 2007 to 0.01% in 2019 of NSQIP operative cases (p < 0.001). Overall mortality was 8.5% and did not decrease with time. CD4 complications decreased from 40 to 27% (p < 0.001). There was a 65% reduction in SPN cases requiring a return to the operating room. Multivariate predictors of complications were emergency general surgery (EGS, p < 0.001), serum albumin (p < 0.0001) and modified frailty index (mFI) (p < 0.0001). Multivariate predictors of mortality were EGS (p < 0.0001), serum albumin (p < 0.0001), and mFI (p < 0.04). The mFI decreased after 2010 (p < 0.001).ConclusionSPNs decreased after 2010, with decreasing CD4 complications, decreasing reoperation rates and stable mortality rates, likely indicating broad adoption of a “step-up” approach. Larger, prospective studies to compare indications and outcomes for “step up” versus open SPN are warranted.

Video-Assisted Retroperitoneal Debridement for Recurrent Pancreatic Necrosis After Previous Open Necrosectomy.

Video-Assisted Retroperitoneal Debridement for Recurrent Pancreatic Necrosis After Previous Open Necrosectomy.

Endoscopic step up: When and how

The management of (peri)pancreatic collections has undergone a paradigm shift from open surgical drainage to minimally invasive endoscopic, percutaneous, or surgical interventions. Minimally invasive interventions are associated with less morbidity and mortality compared to open necrosectomy. The (peri)pancreatic collections are currently treated with a “step-up approach” of an initial drainage procedure followed, if necessary, by a more invasive debridement. The step-up approach for management of (peri)pancreatic collections is mainly of two types, namely, surgical and endoscopic. Surgical step up includes initial image-guided percutaneous catheter drainage followed, if necessary, by minimally invasive video-assisted retroperitoneal debridement. Endoscopic step-up approach includes endoscopic transluminal drainage followed, if necessary by direct endoscopic necrosectomy. The development of endoscopic ultrasound and lumen apposing metal stents (LAMSs) has revolutionized the endoscopic management of (peri)pancreatic collections. Compared to surgical step-up approach, endoscopic step-up treatment approach has been reported to be associated with less new-onset organ failure, pancreatic fistula, enterocutaneous fistula, or perforation of visceral organ and shorter hospital/intensive care unit stay. This review will mainly focus on indications, techniques, timing, and recent advances related to endoscopic step-up approach in management of symptomatic(peri)pancreatic collections.

Indocyanine Green-Guided Intraoperative Imaging to Facilitate Video-Assisted Retroperitoneal Debridement for Treating Acute Necrotizing Pancreatitis.

Video-assisted retroperitoneal debridement (VARD) is a feasible, minimally invasive necrosectomy method for treating severe acute necrotizing pancreatitis, if it does not resolve or is accompanied with infected necrosis in the retroperitoneum. As there are rarely any visually clear separating surface in white light image between necrotic debris and adjacent inflammatory normal tissues due to extensive retroperitoneal adhesions, VARD is accompanied with the risk of vascular injury, external pancreatico-cutaneous or enterocutaneous fistulae. In view of the above disadvantages, we apply real-time intraoperative near-infrared fluorescence imaging with indocyanine green (ICG) during VARD, which enables visualization of the well-perfused adjacent normal tissues. This modified technique (ICG-guided VARD) can provide a clear separating surface during debridement and reduce the risk of vascular or enteric injury. ICG-guided VARD may facilitate surgeons to perform safer debridement in treating severe acute necrotizing pancreatitis.

Indocyanine Green-Guided Intraoperative Imaging to Facilitate Video-Assisted Retroperitoneal Debridement for Treating Acute Necrotizing Pancreatitis

Indocyanine Green-Guided Intraoperative Imaging to Facilitate Video-Assisted Retroperitoneal Debridement for Treating Acute Necrotizing Pancreatitis

Transabdominal self-expandable metal stent placement as a rescue therapy for drainage of walled-off necrosis.

Video 1CT scan of a walled-off necrosis in the right pararenal space extended to the iliac area.

Video-assisted retroperitoneal debridement for infected pancreatic necrosis: A single center series

Introduction and importanceOpen anterior necrosectomy is no longer considered the first approach for the up to 20% of patients with acute pancreatitis who develop infected necrosis. When endoscopic debridement and percutaneous drains fail, video assisted retroperitoneal debridement (VARD) is now the favored surgical approach.Case presentationWe report a current patient who underwent the VARD procedure and provide a seven-year follow-up on ten additional patients who underwent the VARD procedure for infected pancreatic necrosis between 2010 and 2015. We analyzed patient demographics, APACHE II scores, length of hospital stay, number of VARD procedures, and surgical complications.Clinical discussionDuring this study period, we cared for 320 patients, 59 women, and 261 men, with acute necrotizing pancreatitis. Ten of our patients ultimately underwent the VARD procedure. We report a 50% overall complication rate and a 20% mortality rate. Two of the patients who underwent the VARD procedure had already undergone open necrosectomy; two additional patients in the VARD group required open necrosectomy after the VARD procedure.ConclusionOur current case report demonstrates the effectiveness of the VARD procedure for patients with infected pancreatic necrosis. Our case series provides additional details regarding the significant morbidity and mortality associated with infected pancreatic necrosis. We acknowledge that despite following the step-up protocol, both VARD procedures and open necrosectomy may still be required.

Laparoscopic-Assisted Pancreatic Necrosectomy: Technique and Initial Outcomes.

Necrotizing pancreatitis (NP) may result de novo or following procedures such as ERCP or partial pancreatectomy (post-procedural), and may require surgical debridement. Video-assisted retroperitoneal debridement (VARD) is a standard approach for NP that employs a 5cm incision with varying degrees of blind and open debridement. We describe our technique and outcomes of a modified VARD called laparoscopic-assisted pancreatic necrosectomy (LAPN) performed through a single 12mm incision that uses direct laparoscopic visualization during debridement. At one medical center, all LAPN patients (2012-2020) were assessed for demographics, disease factors, and outcomes. Bivariate logistic regression analyses were performed to identify factors independently associated with recovery after LAPN for patients with de novo vs post-procedural necrosum. Over 9years, 60 patients underwent LAPN for NP. Median age was 57years (IQR: 47-66) and 43 (69%) were men. Pancreas necrosum was de novo in 39 (63%) patients and post-procedural in 23 (37%). NP resolved with a median of 1 LAPN procedure and median hospitalization was 33 days. The LAPN major morbidity rate and in-hospital mortality rate were 47% and 5%. No significant differences were seen between NP etiology cohorts, although post-procedure NP patients trended towards a faster clinical recovery to baseline compared to de novo patients (193 vs 394days; p-value = .07). LAPN offers a smaller incision with excellent visualization and non-inferior outcomes, regardless of etiology, with likely faster recovery for patients with post-procedural vs de novo necrotizing pancreatitis.

A Hybrid VARD Approach to Infected Acute Necrotic Collections

Infected acute necrotic collections (ANC) are a complication of acute pancreatitis that routinely require early drainage procedures. The “step up” approach has gained acceptance as the preferred paradigm for infected ANC. With this approach, open necrosectomy is avoided in favor of percutaneous drainage followed by video assisted retroperitoneal debridement (VARD). We describe a novel hybrid VARD technique. For patients meeting criteria for step-up procedure, a percutaneous drain is placed into the collection using a left retroperitoneal approach. If serially upsizing this drain does not resolve the infection, a VARD is performed. Traditionally this is done by cutting down along the drain tract with a small incision until the necrotic cavity is reached, allowing VARD. However, a majority of patients at our institution have a high BMI, making approaching the collection via a minimally invasive cutdown difficult. We made 2 modifications to the existing technique. First, we use a 12 mm optiview® trocar loaded with a 0-degree camera inserted alongside the drain track through an small incision. The camera is advanced into the collection using the drain as a horizon. Pneumoperitoneum is insufflated, additional trocars placed, and necrosectomy completed. Second, for complex geographic collections we upsize to a 15 mm trocar and use a flexible endoscope to delineate the edges of the necrosis and remove free necrosum using a Roth net device. Closure is accomplished with drains and occasionally vacuum assisted devices. Using these techniques, we have been able to manage complex infected necrosis in morbidly obese patients with good results.

Operative Pancreas Debridement in 2021: Who and When?

Introduction: Treatment of necrotizing pancreatitis (NP) has shifted in favor of a minimally invasive step-up approach rather than primary operative pancreatic debridement (OPD). We evaluated the contemporary role of OPD in NP treatment. Methods: Single institution retrospective review of 468 NP patients treated between 2011-2019. Operative pancreatic debridement included video-assisted retroperitoneal debridement (VARD), open and minimally invasive transgastric debridement, and open debridement with external drainage. NP patients whose treatment included OPD were compared with patients treated definitively without OPD. Results: Since 2011, 256/468 (55%) of patients were treated with OPD. Gender and comorbidity profile were similar between groups. Necrotizing pancreatitis etiology was more likely biliary (52% vs 32%) and less likely secondary to alcohol (19% vs 35%) in patients treated with OPD (p<0.001). Computed tomography severity index (CTSI) of pancreatic necrosis was similar between groups; however, infected necrosis was more common in patients who underwent OPD (68% versus 33%, p <0.001). Patients treated with OPD were more likely to have disconnected pancreatic duct syndrome (DPDS) (53% vs 29%, p <0.001). Among patients who underwent OPD during their treatment, 73% underwent OPD as their initial intervention at 73 ± 6 days after disease onset while 27% underwent OPD as salvage therapy at 95 ± 16 days after disease onset, p=0.1. Conclusions: Operative pancreatic debridement remains an important treatment modality in patients with pancreatic necrosis. OPD is employed as either primary or salvage therapy most frequently in patients with NP of biliary etiology, infected necrosis, and patients with disconnected pancreatic duct.

Modified Two-Trocar Minimally Invasive Retroperitoneal Debridement for Walled-Off Pancreatic Necrosis

Retroperitoneal walled-off pancreatic necrosis (WOPN) that is not amenable to transgastric drainage is typically approached with percutaneous drains, then “stepping up” to video-assisted retroperitoneal debridement (VARD) through a flank incision or minimally invasive retroperitoneal pancreatectomy (MIRP) with a nephroscope. We present a two-trocar hybrid minimally invasive approach, combining “step-up” from percutaneous drains to nephroscope to laparoscope for a more efficient debridement. Preoperatively planning with interventional radiology is essential to plan careful drain placement, i.e.

Acute Complicated Necrotising Pancreatitis Treated with Video-Assisted Retroperitoneal Debridement

Abstract Acute necrotising pancreatitis is a complex disease with high morbidity and mortality rates. In cases of infected necrosis, treatment consists of a step-up approach involving endoscopic or mini-invasive surgical methods. In some cases, there are extremely rare complications. In addition, the underlying comorbidities worsen the course of the disease. We report a case of a 32-year-old male with acute necrotising pancreatitis complicated with recurrent retroperitoneal abscesses, sepsis, iatrogenic pylephlebitis, exacerbation of underlying Crohn’s disease, and the outcome of the treatment was successful. During the period of hospitalisation, one ultrasound-guided percutaneous drainage, two computed tomography-guided punctures of the retroperito-neal space (percutaneous and transhepatic) and five video-assisted retroperitoneal debridement procedures were carried out. The patient was discharged after 185 days of hospitalisation.

Step-up mini invasive surgical treatment of patients with different morphological forms of acute necrotizing pancreatitis

Introduction: Despite significant progress in the treatment strategy of acute necrotizing pancreatitis (ANP), mortality in cases of its severe form remains high. There is no single point of view concerning the indications for the use of mini invasive interventions depending on the nature, extension and localization of the pathological foci of ANP. Material: We performed a prospective observational cohort study of efficacy of elaborated algorithmic mini invasive step-up approach of surgical treatment of 317 patients with different morphological forms of ANP. The following parameters were collected for each episode: length of hospital stay, mortality, occurrence of organ failure and local complications. Results: Transcutaneous punction/drainages were applied as the first step in 37 patients with acute necrotic collections (ANC). In the presence of walled-off pancreatic necrosis (WOPN) EUS procedures were preferred in case their close localization to the stomach or duodenum in 65 observations. Initial surgical treatment wasn't effective in 18.8% and video-assisted retroperitoneal debridement (VARD) in patients with ANC or necrosectomies under EUS control in cases of WOPN were applied. Necessary for laparotomic necrosectomies occurred in 14.5% of patients and was the final step of proposed algorithmic approach. During postoperative period complications occurred in 28.3% of patients. They included 7 new episodes of organ failure, 4 cases of arosive hemorrhage, and 5 observations of pancreatic and duodenal fistulas. Overall mortality rate was 3.3%, after interventional treatment - 6.5%. Conclusion: Surgical treatment in patients with ANP based on elaborated algorithmic step-up approach is followed by acceptable complication and mortality level.

Combination of minimally invasive approaches of the debridement in treatment of the patient with infected necrotizing pancreatitis

This article presents the clinical case of using combination of minimally invasive approaches of debridement in patient with infected necrotizing pancreatitis. The decision of using minimally invasive approaches: endoscopic transluminal pancreatic necrosectomy combined with percutaneous catheter drainage under US-navigation and video-assisted retroperitoneal debridement was made, due to the giant necrotic cavity, containing huge amount of necrotized tissues (diagnosed by instrumental methods—CT, US).Discussion: Acute necrotizing pancreatitis is still the important surgical problem, because of the great number of different complications and high level of mortality, despite achievements in the treatment of this group of patients. Many articles, focused on the use of modern minimally invasive approaches in case of infected necrotizing pancreatitis, have been published. Moreover, the combination of minimally invasive approaches is using in managing of some patients for better debridement (including minimally invasive methods of debridement).Conclusion: The combination of minimally invasive ways of debridement in patients with necrotizing pancreatitis is an effective surgical tactic, which leads to better results in treatment.

Comparison between video-assisted retroperitoneal debridement and small incision pancreatic necrosectomy in infected pancreatic necrosis.

Debridement and drainage have always been mainstream treatment for infected pancreatic necrosis (IPN), and the application of minimally invasive necrosectomy is becoming increasingly widespread. However, few studies have compared video-assisted retroperitoneal debridement (VARD) and small incision pancreatic necrosectomy (SIPN) individually. Our aim was to compare VARD and SIPN by evaluating outcomes. We retrospectively reviewed patients with IPN who underwent either VARD or SIPN between 2010 and 2019 in China. Data relative to patient demographics, major complications, health care resource utilization and mortality were collected. Statistical analyses used were the two-tailed Student's t-test and the chi-squared test. Of 59 patients, 31 patients underwent SIPN and 28 patients were treated with VARD. SIPN and VARD had similar treatment success and mortality rates. The rate of reintervention due to lack of clinical improvement was significantly lower in the SIPN group (32% versus 61%; P = 0.028). In addition, the length of total hospital stay was 60 days in the SIPN group and 72 days in the VARD group (P < 0.0001) and mean total costs was significantly less in the SIPN group than in the VARD group (P = 0.008). Given the shorter hospitalization period, lower total cost and lower rate of reinterventions, SIPN may be superior to the step-up approach for patients with IPN than for those with VARD.

Combined Surgical Tactics with Step-up Approach in the Treatment of Infected Acute Pancreatitis

Objective. To evaluate the results of treatment using minimally invasive interventions and open necrectomy in patients with infected acute pancreatitis.&#x0D; Materials and methods. A retrospective cohort two-centered analysis was performed in 211 patients with infected acute pancreatitis who divided into two groups: the first included 101 patients, in the treatment of which used open surgery; the second included 110 patients, in the treatment of which used treatment tactic step-up approach.&#x0D; Results. In the first group used open necrosectomy with drainage for postoperative lavage (75 patients, 74.3%), including open packing with planned re-laparotomy (8 patients, 7.9%), and omentobursostomy for necrosectomy after surgery (18 patients, 17.8%). Postoperative complications occurred in 58 (57.4%), after the surgery 34 (33.7%) patients was died: 30 had a thirty-day mortality, and 4 had a ninety-day mortality. In the second group group, 72 (65.5%) patients were treated by percutaneous catheter drainage, 6 (5.5%) by video-assisted retroperitoneal debridement and drainage, 5 (4.5%) by through the wall of the stomach or duodenum in the infected pseudocyst and open necrosectomy was performed on 27 (24.5%) patients. Postoperative complications occurred in 37 (33.6%) patients, after the surgery 19 (17.3%) was died: 15 had a thirty -day mortality and 4 had a ninety-day mortality. In the regression analysis, only the presence of multiple organ dysfunction before (AUC = 0.867) and after surgery (AUC = 0.930) significantly affected postoperative mortality, but the effect of the prevalence of pancreatic necrosis (AUC = 0.693) on mortality was limited. Differences were likely between groups (χ2=7.282, p=0.026).&#x0D; Conclusion. The surgical treatment should be initiated with a minimally invasive procedures and combination these operations with open surgery was able to reduce complications and mortality in the patients with infected acute pancreatitis.