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

Abstract

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.

Retroperitoneoscopic Approaches for Infected Necrotizing Pancreatitis

“…The VARD procedure [ 25 ] is performed under general anesthesia and the patient is in supine position and 30° tilted towards the contralateral side. A VARD can be performed via a left-sided or right-sided approach, the latter being more challenging.…”

“…In most patients (81 %) one VARD was suffi cient, and no patient required more than two VARD procedures. The overall mortality of VARD reported in literature is 13 %, with a range of 0-33 % [ 25 ].…”

Endoscopic treatment of infected necrosis

“…However, reports on endoscopic treatment for necrotizing pancreatitis included patients that are generally less ill than patients treated in studies reporting on surgical procedures. This is indicated by lower APACHE-II scores, less organ failure and less infected necrosis in the endoscopic studies (26,28). These differences may in part explain the more favorable outcomes of endoscopy.…”

“…The endoscopic approach of necrotizing pancreatitis appears to measure up to surgical techniques in terms of choice of primary and definitive treatment, number of complications, health care utilization and costs (10,11,26,28). Available studies even suggest lower mortality rates and lower incidence of new onset endocrine insufficiency (5,9,11,16,22,28,35).…”

“…This, combined with the fact that necrotizing pancreatitis is relatively rare and invasive interventions are not performed frequently, means that the endoscopic approach is reserved for specialist centers only. Finally, for treatment success with endoscopic necrosectomy, an average of four procedures per patient are necessary as opposed to 1 -3 for the minimally invasive surgical and open necrosectomy (26,28,31). Although not necessarily associated with higher costs, this can be a significant burden on the patient and its relatives, as well as on health care resources.…”