Video-assisted Retroperitoneal Debridement Research Articles

Evolving Techniques in Pancreatic Surgery.

Evolving Techniques in Pancreatic Surgery.

感染性壊死性膵炎に対してvideo-assisted retroperitoneal debridementが有効であった1例

感染性壊死性膵炎に対してvideo-assisted retroperitoneal debridementが有効であった1例

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.

Step-up approach and video assisted retroperitoneal debridement in infected necrotizing pancreatitis: A case complicated by retroperitoneal bleeding and colonic fistula

IntroductionInfected Necrotizing Pancreatitis carries a high mortality and necessitates intervention to achieve sepsis control. The surgical strategy for proven infected necrosis has evolved, with abandonment of open necrosectomy to a step-up approach consisting of percutaneous drains and Video-assisted retroperitoneal debridement (VARD). We present a case that underwent VARD complicated by bleeding and colonic perforation and describe its management.Presentation of caseA 38 year-old male with acute pancreatitis developed infected necrotizing pancreatitis. Initial treatment was by percutaneous drainage under radiological guidance and intravenous antibiotics. The infected retroperitoneal necrosis was then debrided using gasless laparoscopy through a mini-incision. Post-operatively, he developed peripancreatic bleeding which was controlled with angioembolisation. He also developed a descending colon fistula which was treated with laparotomy and defunctioning loop ileostomy. He recovered and subsequently had his ileostomy closed twelve months later. The colonic fistula recurred and was treated with endoscopic clips and histoacryl glue injection and finally closed.DiscussionStep-up approach consists of the 3 D's: Delay, drain and debride. VARD is recommended as it is replicable in general surgical units using standard laparoscopic instruments. Bleeding and colon perforation are potential complications which must have multi-disciplinary input, aggressive resuscitation and timely radiologic intervention. Defunctioning ileostomy is recommended to control sepsis in colonic fistulation. Novel fistula closing methods using endoscopic clips and histoacryl glue are potential treatment options.ConclusionStep-up approach and VARD is the new paradigm to treat necrotizing pancreatitis. Complications of bleeding and colon fistula are uncommon and require multi-disciplinary management.

Pancreatic endotherapy and necrosectomy.

There has been a paradigm shift in the management of pancreatic necrosis from open surgical debridement of infected necrosis to minimally invasive interventional radiologic, laparoscopic, and endoscopic drainage/debridement techniques. A step-up approach from less invasive to the more invasive modalities is recommended. An important distinction to make is between pseudocysts and walled-off necrosis (WON), as the interventions for each are different. Endoscopic or other interventions should be delayed for at least 4weeks for collections to encapsulate. Direct endoscopic necrosectomy (DEN) is an effective, minimally invasive option. Several variations in the technique, including the use of esophageal fully covered self-expanding metal stents (SEMS) and lumen-apposing SEMS have recently been described. The incremental effectiveness of these stents over conventional techniques needs to be studied. Dual-modality drainage with endoscopic transmural stent placement and lavage through percutaneous drains is also an effective option with low mortality and morbidity. Several minimally invasive surgical options, including video-assisted retroperitoneal debridement and sinus tract endoscopy are available and may be preferable to open surgical necrosectomy. An algorithmic, multidisciplinary management is warranted for successful outcomes. Disconnected pancreatic duct syndrome in the setting of necrotizing pancreatitis is challenging; long-term endoscopic transmural stent placement and/or distal pancreatectomy are potential treatment options.

Necrotizing Pancreatitis: New Definitions and a New Era in Surgical Management

Necrotizing pancreatitis is a challenging condition that requires surgical treatment commonly and is associated with substantial morbidity and mortality. Over the past decade, new definitions have been developed for standardization of severity of acute and necrotizing pancreatitis, and new management techniques have emerged based on prospective, randomized clinical trials. Review of English-language literature. A new international classification of acute pancreatitis has been developed by PANCREA (Pancreatitis Across Nations Clinical Research and Education Alliance) to replace the Atlanta Classification. It is based on the actual local (whether pancreatic necrosis is present or not, whether it is sterile or infected) and systemic determinants (whether organ failure is present or not, whether it is transient or persistent) of severity. Early management requires goal-directed fluid resuscitation (with avoidance of over-resuscitation and abdominal compartment syndrome), assessment of severity of pancreatitis, diagnostic computed tomography (CT) imaging to assess for necrotizing pancreatitis, consideration of endoscopic retrograde cholangiopancreatography (ERCP) for biliary pancreatitis and early enteral nutrition support. Antibiotic prophylaxis is not recommended. Therapeutic antibiotics are required for treatment of documented infected pancreatic necrosis. The initial treatment of infected pancreatic necrosis is percutaneous catheter or endoscopic (transgastric/transduodenal) drainage with a second drain placement as required. Lack of clinical improvement after these initial procedures warrants consideration of minimally invasive techniques for pancreatic necrosectomy including video-assisted retroperitoneal debridement (VARD), minimally invasive retroperitoneal pancreatectomy (MIRP), or transluminal direct endoscopic necrosectomy (DEN). Open necrosectomy is associated with substantial morbidity, but to date no randomized trial has documented superiority of either minimally invasive or open surgical technique. Additional trials are underway to address this. Severe acute and necrotizing pancreatitis requires a multi-disciplinary treatment strategy that must be individualized for each patient. Optimal treatment of necrotizing pancreatitis now requires a staged, multi-disciplinary, minimally invasive "step-up" approach that includes a team of interventional radiologists, therapeutic endoscopists, and surgeons.

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.

Minimally Invasive Necrosectomy Techniques in Severe Acute Pancreatitis: Role of Percutaneous Necrosectomy and Video-Assisted Retroperitoneal Debridement.

Consensus advocating a principle of early organ support, nutritional optimisation, followed ideally by delayed minimally invasive intervention within a “step-up” framework where possible has radically changed the surgical approach to complications of acute pancreatitis in the last 20 years. The 2012 revision of the Atlanta Classification incorporates these changes, and provides a background which underpins the complexities of individual patient management decisions. This paper discusses the place for delayed minimally invasive surgical intervention (percutaneous necrosectomy, video-assisted retroperitoneal debridement (VARD)), and the rationale for opting to adopt a percutaneous approach over endoscopic or laparoscopic approaches in different clinical situations.

Peer review report 1 on “Step-up approach and video-assisted retroperitoneal debridement in infected necrotizing pancreatitis: A case complicated by retroperitoneal bleeding and colonic fistula”

Peer review report 1 on “Step-up approach and video-assisted retroperitoneal debridement in infected necrotizing pancreatitis: A case complicated by retroperitoneal bleeding and colonic fistula”

Synchronous ovarian carcinoma detected on staging 18F-FDG PET/CT in a patient of esophageal carcinoma: A rare association

Enteric fistula is a serious complication of necrotizing pancreatitis. Endoscopic transluminal drainage and necrosectomy can significantly reduce the incidence of enterocutaneous fistula after pancreatic debridement. However, endoscopic necrosectomy may not be well-suited to debridement of necrosis that tracks laterally to the paracolic gutters, which is often more efficiently addressed by video-assisted retroperitoneal debridement (VARD). We report the combined use of endoscopic transgastric drainage and VARD for treatment of a 76 year old man with severe necrotizing acute pancreatitis complicated by infected, walled-off pancreatic necrosis. Computed tomography showed laterally tracking pancreatic necrosis and flouroscopic drain injection after percutaneous drainage demonstrated with fistulas to the stomach, duodenum, and colon. The infection and fistulas resolved completely. This approach combined the major advantage of VARD with the major advantage of endoscopic transluminal drainage. We are not aware of any reports of combining these techniques and believe the combination offers a minimally invasive approach for patients with extensive necrosis and a high likelihood of enteric or pancreatic fistulas.

Minimally invasive procedures in severe acute pancreatitis treatment - assessment of benefits and possibilities of use.

IntroductionAcute pancreatitis (AP) consists of an extremely varied complex of pathological symptoms and clinical conditions, ranging from mild gastric complaints to multi-organ failure resulting in death.AimTo present the authors’ own experience regarding surgical treatment for pancreatic necrosis complicated by infection using different methods, including classic and laparoscopic methods as well as those combined with percutaneous techniques.Material and methodsIn the period 2007–2010, 34 patients with the diagnosis of severe AP were treated at the Department of General, Gastroenterological and Oncological Surgery, Collegium Medicum, Nicolaus Copernicus University. In 7 patients classic necrosectomy with repeated peritoneal flushing was performed (type 1), in 5 patients laparotomy with active drainage (type 2), in 12 video-assisted retroperitoneal debridement (type 3), and in 10 only percutaneous drainage methods (type 4).ResultsTotal duration of hospitalisation was from 10 to 192 days. The highest death rate was observed for type 1 procedures. Significant differences with regard to the absolute number of postoperative complications between different groups were not observed; however, their quality varied. Classic methods were used in patients whose general and local condition was more severe.ConclusionsWhen AP and its complications are diagnosed, a suitable method of surgical treatment has to be selected extremely precisely and in an individualised way. Minimally invasive methods used in selected patients provide better outcomes and higher safety superseding classic, open techniques of surgical treatment.

Interventions for necrotizing pancreatitis: an overview of current approaches

The management of necrotizing pancreatitis has undergone a paradigm shift toward minimally invasive techniques for necrosectomy, obviating the need for open necrosectomy in most cases. There is increasing evidence that minimally invasive approaches including a step-up approach that incorporates percutaneous catheter or endoscopic transluminal drainage, followed by video-assisted retroperitoneal or endoscopic debridement are associated with improved outcomes over traditional open necrosectomy for patients with infected necrosis. A recent international multidisciplinary consensus conference emphasized the superiority of minimally invasive approaches over standard surgical approaches. The success of these techniques depends on concerted efforts of a multidisciplinary team of interventional endoscopists, radiologists, intensivists and surgeons dedicated to the management of severe acute pancreatitis and its complications. This review provides an overview of minimally invasive techniques for management of necrotizing pancreatitis, including indications, timing, advantages and disadvantages.

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.

Endoscopic transluminal step-up approach versus surgical step-up approach in patients with infected necrotizing pancreatitis (TENSION): Design and rationale of a randomized controlled multicenter trial

s / Pancreatology 12 (2012) 502–597 575 showed that endoscopic necrosectomy significantly reduced the proinflammatory response as well as complications and death compared to surgical necrosectomy. These preliminary outcomes require confirmation in a larger trial. We describe the design and rationale of a nationwide study called TENSION: “Endoscopic transluminal step-up approach versus surgical step-up approach in patients with infected necrotizing pancreatitis” (Trial registration: ISRCTN09186711). Methods: The TENSION trial is a randomized controlled parallel-group, superiority multicenter trial. Patients with infected necrotizing pancreatitis will be randomized to an endoscopic or surgical step-up approach. The endoscopic step-up approach consists of endoscopic transluminal drainage followed, if necessary, by endoscopic transluminal necrosectomy. The surgical step-up approach consists of percutaneous catheter drainage, if necessary, followed by video-assisted retroperitoneal debridement (VARD). The primary endpoint is a composite of major complications (i.e., new onset organ failure, bleeding requiring intervention, perforation of a visceral organ requiring intervention, enterocutaneous fistula requiring intervention and incisional hernia) or death within 6 months following randomization. Secondary endpoints include other complications such as pancreatic fistula, pancreatic insufficiency, length of intensive careand hospital stay, quality of life, and costs. 98 patients will be enrolled in 25 hospitals of the Dutch Pancreatitis Study Group in a 3-year period. Conclusion: The TENSION trial is designed to evaluate if an endoscopic step-up approach is superior to a surgical step-up approach in terms of clinical outcomes and cost-effectiveness in patients with infected necrotizing pancreatitis.

Interventions for Necrotizing Pancreatitis

Pancreatic and peripancreatic necrosis may result in significant morbidity and mortality in patients with acute pancreatitis. Many recommendations have been made for management of necrotizing pancreatitis, but no published guidelines have incorporated the many recent developments in minimally invasive techniques for necrosectomy. Hence, a multidisciplinary conference was convened to develop a consensus on interventions for necrotizing pancreatitis. Participants included most international experts from multiple disciplines. The evidence for efficacy of interventions was reviewed, presentations were given by experts, and a consensus was reached on each topic. In summary, intervention is primarily indicated for infected necrosis, less often for symptomatic sterile necrosis, and should ideally be delayed as long as possible, preferably 4 weeks or longer after the onset of disease, for better demarcation and liquefaction of the necrosis. Both the step-up approach using percutaneous drainage followed by minimally invasive video-assisted retroperitoneal debridement and per-oral endoscopic necrosectomy have been shown to have superior outcomes to traditional open necrosectomy with respect to short-term and long-term morbidity and are emerging as treatments of choice. Applicability of these techniques depends on the availability of specialized expertise and a multidisciplinary team dedicated to the management of severe acute pancreatitis and its complications.

A Case of Video-assisted Retroperitoneal Debridement in a Patient With HELLP Syndrome

Hemolysis, elevated liver enzymes, low platelet count (HELLP) syndrome describes a cohort of disease processes that may have devastating consequences for the peripartum patient. Although the hemopoetic and hepatic systems are classically involved, we illustrate a case of walled-off pancreatic necrosis occurring in a woman with HELLP syndrome. Initially managed with resuscitation, steroids, and plasmapheresis, the patient developed necrotizing pancreatitis that overtime became walled-off. Despite attempts at percutaneous drainage, the patient ultimately had a video-assisted retroperitoneal debridement. As there are no descriptions in the literature of walled-off pancreatic necrosis stemming from HELLP syndrome, this case provides a new avenue from which to study the pathophysiology and provides a management strategy for this problem.

Endoscopic Transgastric Necrosectomy for Infected Necrotizing Pancreatitis

Endoscopic Transgastric Necrosectomy for Infected Necrotizing Pancreatitis

Endoscopic Transgastric vs Surgical Necrosectomy for Infected Necrotizing Pancreatitis

Most patients with infected necrotizing pancreatitis require necrosectomy. Surgical necrosectomy induces a proinflammatory response and is associated with a high complication rate. Endoscopic transgastric necrosectomy, a form of natural orifice transluminal endoscopic surgery, may reduce the proinflammatory response and reduce complications. To compare the proinflammatory response and clinical outcome of endoscopic transgastric and surgical necrosectomy. Randomized controlled assessor-blinded clinical trial in 3 academic hospitals and 1 regional teaching hospital in The Netherlands between August 20, 2008, and March 3, 2010. Patients had signs of infected necrotizing pancreatitis and an indication for intervention. Random allocation to endoscopic transgastric or surgical necrosectomy. Endoscopic necrosectomy consisted of transgastric puncture, balloon dilatation, retroperitoneal drainage, and necrosectomy. Surgical necrosectomy consisted of video-assisted retroperitoneal debridement or, if not feasible, laparotomy. The primary end point was the postprocedural proinflammatory response as measured by serum interleukin 6 (IL-6) levels. Secondary clinical end points included a predefined composite end point of major complications (new-onset multiple organ failure, intra-abdominal bleeding, enterocutaneous fistula, or pancreatic fistula) or death. We randomized 22 patients, 2 of whom did not undergo necrosectomy following percutaneous catheter drainage and could not be analyzed for the primary end point. Endoscopic transgastric necrosectomy reduced the postprocedural IL-6 levels compared with surgical necrosectomy (P = .004). The composite clinical end point occurred less often after endoscopic necrosectomy (20% vs 80%; risk difference [RD], 0.60; 95% CI, 0.16-0.80; P = .03). Endoscopic necrosectomy did not cause new-onset multiple organ failure (0% vs 50%, RD, 0.50; 95% CI, 0.12-0.76; P = .03) and reduced the number of pancreatic fistulas (10% vs 70%; RD, 0.60; 95% CI, 0.17-0.81; P = .02). In patients with infected necrotizing pancreatitis, endoscopic necrosectomy reduced the proinflammatory response as well as the composite clinical end point compared with surgical necrosectomy. isrctn.org Identifier: ISRCTN07091918.

Covering the Cover

Covering the Cover

Pancreatitis aguda

The present review discusses eight studies, selected for their clinical importance in the field of acute pancreatitis (AP). A multicenter clinical trial demonstrated that treatment of infected pancreatic necrosis through drainage, followed by video-assisted retroperitoneal debridement in patients with poor clinical course, was superior to classical open surgery in terms of costs and complications. A retrospective study analyzed the radiation from computed tomography received by patients with necrotizing AP and warned of the high dose administered, which could have significant carcinogenic effects. A multicenter retrospective study confirmed the utility of measuring blood urea nitrogen at admission and at 24 hours in predicting mortality due to AP. A prospective study of fluid therapy reported that inadequate or excess fluid administration in the first 24 hours of admission were related to poor outcome. Two studies analyzed the bedside index for severity in AP (BISAP) score at admission; this scoring system was useful in AP in general but not in the subgroup of patients requiring admission to the intensive care unit. Lastly, two studies showed the highly promising prognostic value of determining serum concentrations of angiogenic factors in AP.