Minimally Invasive Retroperitoneal Pancreatic Necrosectomy

Abstract

Introduction: Open surgery for pancreatic necrosis is associated with considerable morbidity and mortality. We report the results of a recently developed minimally invasive technique that we adopted in 1998. Methods: A descriptive explanation of the approach is given together with the results of a retrospective analysis of patients who underwent a minimally invasive retroperitoneal pancreatic necrosectomy (MIRP) between August 1998 and April 2002. Patients: There were 24 patients with a median (range) age of 61 (29–75) years. The initial median (range) APACHE II score was 8 (2–21). All patients had infected pancreatic necrosis with at least 50% pancreatic necrosis. In three patients it was not possible to complete the first MIRP because of technical reasons. Results: A total of 88 procedures were performed with a median (range) of 4 (0–8) per patient. Twenty-one (88%) patients developed 36 complications during the course of their illness. Five patients required an additional open procedure: 2 for subsequent distant collections, 2 for bleeding and 1 for persisting sepsis and a distant abscess. Six (25%) patients who had MIRP died. The median (range) post-operative hospital stay was 51 (5–200) days. Conclusions: MIRP is a new technique that has shown promising results, and could be preferable to open pancreatic necrosectomy in selected patients. However, unresolved issues remain to be overcome and the exact role of MIRP in the management of pancreatic necrosis has yet to be defined.

Practice Guidelines in Acute Pancreatitis

“…These techniques have generally been reserved for patients with infected pancreatic necrosis who are too ill to undergo prompt surgical debridement (such as those with organ failure and/or serious comorbid disease). The first technique is minimally invasive retroperitoneal necrosectomy (55,101,102,116,156), which uses a percutaneous technique to gain access to the necrotic area, dilatation of the tract to a 30-French size, an operating nephroscope for piecemeal retrieval of solid material, irrigation with high volume lavage, and placement of catheters for long-term continuous irrigation. This technique requires general anesthesia and has not been compared in a prospective fashion to more traditional surgical debridement.…”

“…Such a technique is minimally invasive retroperitoneal surgery, which has been used in sterile necrosis as well as infected necrosis (55,102,156). Minimally invasive surgery within the first 2-3 wk of severe sterile necrosis has not been compared prospectively with the continuation of medical therapy and thus far is an evolving technology that has been restricted to research centers.…”

Necrotizing Pancreatitis: Update and When to Operate

“…The need for specialized personnel and equipment is also a limitation to the widespread adoption of these techniques. More frequently, such approaches have been reserved for smaller and well delineated necrosis, located at favourable sites, such as the pancreatic tail, in stable patients [46,54].…”

�Step Up� Approach in the Management of Pancreatic Necrosis. Is it A Step in the Right Direction?

“…These approaches include sinus tract endoscopy (STN) also referred to as minimal access retroperitoneal necrosectomy, (MARPN), using scopes like nephroscope or laparoscope [8,27,28]. The other approach is Video Assisted Retroperitoneal Debridement (VARD) [6].…”