Current status of minimally invasive necrosectomy for post-inflammatory pancreatic necrosis^-www.drkeyurbhatt.in*

REVIEW ARTICLE

Hepatobiliary Surgical Unit, Manchester Royal Infirmary, Manchester, UK

Abstract
Objective: This paper reviews current knowledge on minimally invasive pancreatic necrosectomy.
Background: Blunt (non-anatomical) debridement of necrotic tissue at laparotomy is the standard
method of treatment of infected post-inflammatory pancreatic necrosis. Recognition that laparotomy may
add to morbidity by increasing postoperative organ dysfunction has led to the development of alternative,
minimally invasive methods for debridement. This study reports the status of minimally invasive necrosectomy
by different approaches.

Methods: Searches of MEDLINE and EMBASE for the period 1996–2008 were undertaken. Only studies
with original data and information on outcome were included. This produced a final population of 28
studies reporting on 344 patients undergoing minimally invasive necrosectomy, with a median (range)
number of patients per study of nine (1–53). Procedures were categorized as retroperitoneal, endoscopic
or laparoscopic.

Results: A total of 141 patients underwent retroperitoneal necrosectomy, of whom 58 (41%) had
complications and 18 (13%) required laparotomy. There were 22 (16%) deaths. Overall, 157 patients
underwent endoscopic necrosectomy; major complications were reported in 31 (20%) and death in seven
(5%). Laparoscopic necrosectomy was carried out in 46 patients, of whom five (11%) required laparotomy
and three (7%) died.


Conclusions: Minimally invasive necrosectomy is technically feasible and a body of evidence now
suggests that acceptable outcomes can be achieved. There are no comparisons of results, either with
open surgery or among different minimally invasive techniques.

Received 31 October 2008; accepted 27 January 2009

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Recent advances in the surgical management of necrotizing pancreatitis^-www.drkeyurbhatt.in*

Department of Surgery, Meilahti Hospital, University of Helsinki, Helsinki, Finland

2005 Lippincott Williams & Wilkins.

1070-5295

Underdiagnosed and untreated, abdominal compartment syndrome is a potential contributing factor to the

development of early organ failure in patients with severe acute pancreatitis and warrants routine measurement of intra-abdominal pressure in patients treated for severe pancreatitis. The current estimate of the prevalence of intra-abdominal hypertension in severe acute pancreatitis is about 40%, with about 10% overall developing abdominal compartment syndrome, associated with increased hospital mortality rates. Early surgical decompression without exploring the pancreas further seems to be the most effective treatment. Primary fascial closure of the abdominal wall following abdominal decompression can be attempted, but in most cases the prolonged inflammatory process in the abdomen and the risk of recurrent abdominal compartment syndrome favors use of gradual closure or delayed reconstruction of the abdominal wall.

Summary

Recent studies confirm the overall validity of the established surgical principles for necrotizing pancreatitis:

delayed necrosectomy in patients with infected peripancreatic necrosis, mostly nonoperative management

of sterile necrosis, and delayed cholecystectomy in severe gallstone-associated pancreatitis. The role of abdominal compartment syndrome as an important contributing factor to early development of multiple organ failure and the potential benefit of surgical decompression are gaining support from recent reports and should be carefully assessed in future studies.

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CASE: Chronic pancreatitis - LPJ^-www.drkeyurbhatt.in*

26YRS female with pain in abdomen for 2 yrs
diagnosed as chronic pancreatitis

X RAY:

CECT;

Surgery: LPJ.

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CASE: Infected liver cyst^-www.drkeyurbhatt.in*

55 yrs female with pain in abdomen
for 2 yrs..h/o aspiration from liver cyst in last 1 yr for 8 times

presented with severe pain in abdomen and fever with chills, nauesa vomiting,.

CECT: S/O infected huge simple cyst in liver

SURGERY: De roofing of cyst and drainage..

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CASE: Chronic alcoholic pancreatitis with huge sigmoid shaped pseudocyst of pancreas -- cysto gastrostomy^-www.drkeyurbhatt.in*

44 yrs male, chronic alcoholic pancreaitis..with huge pseudocyst of pancreas..

Initially considered for endoscopic management...but considering vascular colaterals and size of cyst...and discussion with GE physician taken up for cysto gastrostomy...

CECT:

SURGERY:

Pt discharged on POD 4.

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CASE: Necrotizing pancreatitis-- lap assisted R/P approach NECROSECTOMY^-www.drkeyurbhatt.in*

55 yrs male with episodes of pancreatitis with last episode being necrotizing pancreatitis
treated conservatively initially..
later developed sepsis and infected necrosis...
Treated with : lap assisted retroperitoneal approach necrosectomy
ICU stay : 2 day
Discharged on POD 6. With one drain insitu.
CECT:

SURGERY:

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CASE: Internal hernia with gangrene of bowel^-www.drkeyurbhatt.in*

24 yrs male with sever abdominal pain for 2 days
nausea , vomiting, distension

Xray s/o multiple air fluid levels.

USG: s/o mesenteric twist p/o internal hernia and edematous dilated bowels.

SURGERY: exploratory laparotomy and resection of terminal ileum and ileo ascending anastomosis
pt discharged on POD 7.

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CASE: Distal pancreatectomy with splenectomy^-www.drkeyurbhatt.in*

24 yrs female with blunt trauma abdomen
and headinjury
2 days old presentation with severe abdominal pain and distension, respiratory distress and hypotension

CECT: S/O pancreatic fracture near tail

surgery: exploration after 36 hrs of trauma...so changes of pancreatitis was evident..

 Distal pancreatectomy and splenectomy.

pt on oral diet POD 5 , on the line of discharge...

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