Retroperitoneal Approach and Endoscopic Management of Peripancreatic Necrosis Collections

Abstract

To review the results of the different modalities of treatment of acute necrotizing pancreatitis that have been used by a single team during a 6-year period to assess the technique and indications of an endoscopic method of retroperitoneal drainage that is routinely performed for the management of peripancreatic necrosis.Design and Setting: Retrospective study of 53 patients in a tertiary care center.Results: All patients had signs of peripancreatic necrosis on initial computed tomography scan, 20 patients experienced organ failure during the first 7 days of the disease, and bacterial contamination was proved in 22 (56%) of 39 samples of peripancreatic necrosis. Methods of treatment included supportive therapy alone (group 1), percutaneous drainage (group 2), endoscopic retroperitoneal drainage (group 3), and laparotomy and transperitoneal drainage (group 4). Mortality and mean hospital stay were as follows: group 1, 0% and 23 days; group 2, 20% and 89 days; group 3, 10% and 62 days; and group 4, 33% and 86 days. Percutaneous drainage was beneficial in only 3 cases of sterile collection. Two local complications were related to the method of endoscopic drainage. Primary laparotomy was not routinely performed except in patients with an intraperitoneal complication. Overall mortality was 13.2%; mortality was significantly higher in patients with an infected necrosis (32%). Conclusions:The use of endoscopic retroperitoneal drainage seemed to be a significant factor in the observed improvement by providing a reliable drainage of the peripancreatic areas and avoiding the opening of the peritoneal cavity. This surgical approach is not exclusive and may be combined with a secondary laparotomy when needed. The preferred indications of this method are heterogeneous collections of necrosis with bacterial contamination.

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

“…Indeed, Gambiez et al reported that 2 out of 20 patients developed late hernias through the lumbotomy wound following endoscopic retroperitoneal drainage and both needed reoperation. 16 Minimising the number and length of incisions may therefore prevent this complication, and we have not had any issues with hernias at the laparoscopic port sites.…”

The Role of Percutaneous Drainage in the Treatment of Severe Acute Pancreatitis on the Basis of the Modified Atlanta Classification

“…Air bubbles can be seen in it on CT examination. In its cavity pseudoaneurysm can develop which can cause fatal bleeding [2,6,11,14,28,33,37]. In those cases where compressive or respiratory complications or pain develop, surgery or less burdensome percutaneous drainage gives an opportunity for treatment, allowing for the descent of the fluid as well as its bacterological examination [3,4,6,8,11,18,24,33,35].…”

“…The authors do not recommend surgical treatment in the early phase of the illness because of the high morbidity and mortality rates. With the development of interventional radiology and manipulative laparo-endoscopy there are other possibilities to evacuate these fluid collections without operation [1, 6,11,14,21,25,35,40,44]. For the treatment of sterile fluid collection percutaneous puncture and drainage are widely applied.…”

“…However, this is succesful only in a few cases and drainage or surgical intervention follows [6,28,40,44]. According to those who are pro drainage in the treatment of sterile acute peripancreatic fluid collections, drainage can be applied effectively [1, 3,4,14,21,25,34,35,40,44]. Acute compartment syndrome caused by massive acute peripancreatic fliud collection can be treated effectively with PD [9].…”

What is New in Acute Pancreatitis?

“…Recently Gambiez et al in 1998 have reported their experience of endoscopic retroperitoneal approach in 20 patients via a 6-cm lumbotomy centered on 12 th rib with mean number of 5 lumboscopic procedures required [37].…”