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Yang Y, Liu Y, Liu Z, Peng T, Wang C, Wu H, Gou S. Laparoscopic necrosectomy for acute necrotizing pancreatitis: mesocolon-preserving approach and outcomes. Updates Surg 2024; 76:487-493. [PMID: 38429596 DOI: 10.1007/s13304-024-01773-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/27/2023] [Accepted: 01/29/2024] [Indexed: 03/03/2024]
Abstract
The surgical treatment of acute necrotizing pancreatitis has significantly evolved in recent years with the advent of enhanced imaging techniques and minimally invasive surgery. Various minimally invasive techniques, such as video-assisted retroperitoneal debridement (VARD) and endoscopic transmural necrosectomy (ETN), have been employed in the management of acute necrotizing pancreatitis and are often part of step-up approaches. However, almost all reported step-up approaches only employ a fixed minimally invasive technique prior to open surgery. In contrast, we implemented different minimally invasive techniques during the treatment of acute pancreatitis based on the extent of pancreatic necrosis. For acute necrotizing pancreatitis of the pancreatic bed with or without extension into the left retroperitoneum, we performed mesocolon-preserving laparoscopic necrosectomy for debridment. The quantitative indication for pancreatic debridment in our institute has been described previously. For acute necrotizing pancreatitis of the pancreatic bed with or without extension into the left retroperitoneum, mesocolon-preserving laparoscopic necrosectomy was performed for debridment. To safeguard the mesocolon, the pancreatic bed was entered via the gastrocolic ligament, and the left retroperitoneum was accessed via the lateral peritoneal attachments of the descending colon. Of the 77 patients requiring pancreatic debridment, 41 patients were deemed suitable for mesocolon-preserving laparoscopic necrosectomy by multiple disciplinary team and informed consent was acquired. Of these 41 patients, 27 underwent percutaneous drainage, 10 underwent transluminal drainage, and 2 underwent transluminal necrosectomy prior to laparoscopic necrosectomy. Two patients (4.88%) died of sepsis, three patients (7.32%) required further laparotomic necrosectomy, and five patients (12.20%) required additional percutaneous drainage for residual infection. Three patients (7.32%) experienced duodenal fistula, all of which were cured through non-surgical treatments. Nineteen patients (46.34%) developed pancreatic fistula that persisted for over 3 weeks, with 17 being successfully treated non-surgically. The remaining two patients had pancreatic fistulas that lasted over 3 months; an internal drainage procedure has been planned for them. No patient developed colonic fistula. Mesocolon-preserving laparoscopic necrosectomy proved to be safe and effective in selected patients. It can serve as a supplementary procedure for step-up approaches or as an alternative to other debridment procedures such as VARD, ETN, and laparotomic necrosectomy.
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Affiliation(s)
- Yuxin Yang
- Department of Pancreatic Surgery, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, 1277 Jifang Avenue, Wuhan, 430022, China
- Sino-German Laboratory of Personalized Medicine for Pancreatic Cancer, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Yang Liu
- Sino-German Laboratory of Personalized Medicine for Pancreatic Cancer, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
- Department of Gastrointestinal Surgery, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Zhiqiang Liu
- Department of Pancreatic Surgery, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, 1277 Jifang Avenue, Wuhan, 430022, China
- Sino-German Laboratory of Personalized Medicine for Pancreatic Cancer, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Tao Peng
- Department of Pancreatic Surgery, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, 1277 Jifang Avenue, Wuhan, 430022, China
- Sino-German Laboratory of Personalized Medicine for Pancreatic Cancer, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Chunyou Wang
- Department of Pancreatic Surgery, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, 1277 Jifang Avenue, Wuhan, 430022, China
- Sino-German Laboratory of Personalized Medicine for Pancreatic Cancer, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Heshui Wu
- Department of Pancreatic Surgery, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, 1277 Jifang Avenue, Wuhan, 430022, China
- Sino-German Laboratory of Personalized Medicine for Pancreatic Cancer, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Shanmiao Gou
- Department of Pancreatic Surgery, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, 1277 Jifang Avenue, Wuhan, 430022, China.
- Sino-German Laboratory of Personalized Medicine for Pancreatic Cancer, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China.
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Latif J, Creedon L, Mistry P, Thurley P, Bhatti I, Awan A. Complicated Severe Acute Pancreatitis: Open and Laparoscopic Infracolic Approach. J Gastrointest Surg 2022; 26:1686-1696. [PMID: 35581460 DOI: 10.1007/s11605-022-05350-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/18/2022] [Accepted: 04/30/2022] [Indexed: 01/31/2023]
Abstract
INTRODUCTION The heterogeneous nature of severe acute pancreatitis (SAP) renders decisions related to complications challenging. Central solid collections at the root of the mesentery are difficult to access with traditional techniques. Here we describe a case series of laparoscopic infracolic necrosectomy (ICN) and open or laparoscopic infracolic necrosectomy with Roux-en Y cystjejunostomy (ICN-RYCJ) for the management of complicated SAP. MATERIALS AND METHODS A retrospective analysis of a prospectively maintained database identified all patients treated with infracolic necrosectomy or drainage of pancreatic collections for complicated SAP between 2012 and 2021 inclusive at a single institution. RESULTS Forty patients were identified (median age 53 years)-ICN group 9 patients (median time to intervention-22 days) and ICN-RYCJ group 31 patients (median time to intervention-99 days). Two patients in ICN group underwent interval fistula-tract jejunostomy. Thirty-one patients had laparoscopic surgery and 9 patients underwent an open approach. Four patients required intervention post-operatively. Nineteen patients were discharged from follow-up at two years. CONCLUSION Infracolic approach with selective Roux-en Y cystjejunostomy, as a single or staged intervention, is an effective and safe operative option to add to the armamentarium of the pancreatic surgeon when dealing with complicated SAP not amenable to drainage/debridement by traditional techniques.
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Affiliation(s)
- Javed Latif
- Department of Pancreaticobiliary, Advanced Laparoscopic and Robotic Surgery, University Hospitals of Derby & Burton, Uttoxeter Road, Derby, DE22 3NE, UK.
| | - Lee Creedon
- Department of Pancreaticobiliary, Advanced Laparoscopic and Robotic Surgery, University Hospitals of Derby & Burton, Uttoxeter Road, Derby, DE22 3NE, UK
| | - Pritesh Mistry
- Department of Upper Gastro-Intestinal Surgery, Countess of Chester Hospital, Liverpool Road, Liverpool Road, Chester, CH2 1UL, UK
| | - Peter Thurley
- Department of Interventional & Clinical Radiology, University Hospitals of Derby & Burton, Uttoxeter Road, Derby, DE22 3NE, UK
| | - Imran Bhatti
- Department of Pancreaticobiliary, Advanced Laparoscopic and Robotic Surgery, University Hospitals of Derby & Burton, Uttoxeter Road, Derby, DE22 3NE, UK
| | - Altaf Awan
- Department of Pancreaticobiliary, Advanced Laparoscopic and Robotic Surgery, University Hospitals of Derby & Burton, Uttoxeter Road, Derby, DE22 3NE, UK
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Laparoscopy in Emergency: Why Not? Advantages of Laparoscopy in Major Emergency: A Review. Life (Basel) 2021; 11:life11090917. [PMID: 34575066 PMCID: PMC8470929 DOI: 10.3390/life11090917] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/26/2021] [Revised: 08/24/2021] [Accepted: 08/30/2021] [Indexed: 01/09/2023] Open
Abstract
A laparoscopic approach is suggested with the highest grade of recommendation for acute cholecystitis, perforated gastroduodenal ulcers, acute appendicitis, gynaecological disorders, and non-specific abdominal pain (NSAP). To date, the main qualities of laparoscopy for these acute surgical scenarios are clearly stated: quicker surgery, faster recovery and shorter hospital stay. For the remaining surgical emergencies, as well as for abdominal trauma, the role of laparoscopy is still a matter of debate. Patients might benefit from a laparoscopic approach only if performed by experienced teams and surgeons which guarantee a high standard of care. More precisely, laparoscopy can limit damage to the tissue and could be effective for the reduction of the overall amount of cell debris, which is a result of the intensity with which the immune system reacts to the injury and the following symptomatology. In fact, these fragments act as damage-associated molecular patterns (DAMPs). DAMPs, as well as pathogen associated molecular patterns (PAMPs), are recognised by both surface and intracellular receptors of the immune cells and activate the cascade which, in critically ill surgical patients, is responsible for a deranged response. This may result in the development of progressive and multiple organ dysfunctions, manifesting with acute respiratory distress syndrome (ARDS), coagulopathy, liver dysfunction and renal failure. In conclusion, none of the emergency surgical scenarios preclude laparoscopy, provided that the surgical tactic could ensure sufficient cleaning of the abdomen in addition to resolving the initial tissue damage caused by the “trauma”.
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Affiliation(s)
- Amy Y Li
- Department of Surgery, Section of Surgical Oncology, Stanford University School of Medicine, 300 Pasteur Drive, Room H3591, Stanford, CA 94305, USA
| | - John R Bergquist
- Department of Surgery, Section of Surgical Oncology, Stanford University School of Medicine, 300 Pasteur Drive, Room H3591, Stanford, CA 94305, USA
| | - Brendan C Visser
- Department of Surgery, Section of Surgical Oncology, Stanford University School of Medicine, 300 Pasteur Drive, H3680, Stanford, CA 94305-5655, USA.
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Historical review of our knowledge of acute pancreatitis. GASTROENTEROLOGIA Y HEPATOLOGIA 2017; 41:143.e1-143.e10. [PMID: 29249269 DOI: 10.1016/j.gastrohep.2017.11.004] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/08/2017] [Revised: 10/27/2017] [Accepted: 11/09/2017] [Indexed: 12/29/2022]
Abstract
Acute pancreatitis is one of most common causes of consultation due to abdominal pain in medical emergency units and it requires hospital admission. Although the majority of cases are mild and patients tend to recover quickly, a small percentage of cases is severe, with mortality in the region of 5-10%. This historical review considers how our understanding of this disease has changed since it was first described in 1579 thanks to the contributions of renowned experts such as Nicolaes Tulp, Reginald Fitz, Nicholas Senn and many others who, through their expertise and dedication, have improved the survival of patients with this disease.
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Navarro S. The art of pancreatic surgery. Past, present and future. The history of pancreatic surgery. GASTROENTEROLOGIA Y HEPATOLOGIA 2017; 40:648.e1-648.e11. [PMID: 28533021 DOI: 10.1016/j.gastrohep.2017.03.010] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/11/2017] [Revised: 03/23/2017] [Accepted: 03/29/2017] [Indexed: 01/10/2023]
Affiliation(s)
- Salvador Navarro
- Servicio de Gastroenterología, Institut de Malalties Digestives i Metabòliques, Hospital Clínic, Barcelona, España.
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Alsfasser G, Hermeneit S, Rau BM, Klar E. Minimally Invasive Surgery for Pancreatic Disease - Current Status. Dig Surg 2016; 33:276-83. [PMID: 27216738 DOI: 10.1159/000445007] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/10/2022]
Abstract
Laparoscopic procedures have advanced to represent the new gold standard in many surgical fields. Although application in pancreatic surgery is hampered by the friable nature of the gland and the difficulty of its exposure, advanced technology and surgeons' experience are leading to an expansion of minimally invasive pancreatic surgery. Addressing the whole range of main operative procedures, this review analyzes the literature data so far to give an overview about the current status of minimally invasive pancreatic surgery, its indications and limitations. In acute pancreatitis, a step-up approach from percutaneous drainage to retroperitoneoscopic necrosectomy seems beneficial. Transgastric necrosectomy also preserves the retroperitoneal compartment in contrast to the laparoscopic approach, which has widely been abandoned. In tumor pathology, laparoscopic access is adequate for small benign lesions in the pancreatic tail and body. Oncological outcome shows to be at least equal to the open procedure. Concerning laparoscopic pancreaticoduodenectomy, there is no evidence for a patients' benefit currently although several studies prove that it can be done.
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Affiliation(s)
- G Alsfasser
- Department of General, Thoracic, Vascular and Transplantation Surgery, University of Rostock, Rostock, Germany
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8
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Abstract
BACKGROUND Perforated peptic ulcer is a common abdominal disease that is treated by surgery. The development of laparoscopic surgery has changed the way to treat such abdominal surgical emergencies. The results of some clinical trials suggest that laparoscopic surgery could be a better strategy than open surgery in the correction of perforated peptic ulcer but the evidence is not strongly in favour for or against this intervention. OBJECTIVES To measure the effect of laparoscopic surgical treatment versus open surgical treatment in patients with a diagnosis of perforated peptic ulcer in relation to abdominal septic complications, surgical wound infection, extra-abdominal complications, hospital length of stay and direct costs. SEARCH METHODS We searched the Cochrane Central Register of Controlled Trials (CENTRAL) on The Cochrane Library (2004, Issue 2), PubMed/MEDLINE (1966 to July 2004), EMBASE (1985 to November 2004) and LILACS (1988 to November 2004) as well as the reference lists of relevant articles. Searches in all databases were updated in December 2009 and January 2012. We did not confine our search to English language publications. SELECTION CRITERIA Randomized clinical trials comparing laparoscopic surgery versus open surgery for the repair of perforated peptic ulcer using any mechanical method of closure (suture, omental patch or fibrin sealant). DATA COLLECTION AND ANALYSIS Primary outcome measures included proportion of septic and other abdominal complications (surgical site infection, suture leakage, intra-abdominal abscess, postoperative ileus) and extra-abdominal complications (pulmonary). Secondary outcomes included mortality, time to return to normal diet, time of nasogastric aspiration, hospital length-of-stay and costs. Outcomes were summarized by reporting odds ratios (ORs) and 95% confidence intervals (CIs), using the fixed-effect model. MAIN RESULTS We included three randomized clinical trials of acceptable quality. We found no statistically significant differences between laparoscopic and open surgery in the proportion of abdominal septic complications (OR 0.66; 95% CI 0.30 to 1.47), pulmonary complications (OR 0.43; 95% CI 0.17 to 1.12) or number of septic abdominal complications (OR 0.60; 95% CI 0.32 to 1.15). Heterogeneity was significant for pulmonary complications and operating time. AUTHORS' CONCLUSIONS This review suggests that a decrease in septic abdominal complications may exist when laparoscopic surgery is used to correct perforated peptic ulcer. However, it is necessary to perform more randomized controlled trials with a greater number of patients to confirm such an assumption, guaranteeing a long learning curve for participating surgeons. With the information provided it could be said that laparoscopic surgery results are not clinically different from those of open surgery.
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Affiliation(s)
- Alvaro Sanabria
- Oncology Unit, Hospital Pablo Tobon Uribe, School ofMedicine,Medellin, Colombia.
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Iacobone M, Citton M, Nitti D. Laparoscopic distal pancreatectomy: Up-to-date and literature review. World J Gastroenterol 2012; 18:5329-37. [PMID: 23082049 PMCID: PMC3471101 DOI: 10.3748/wjg.v18.i38.5329] [Citation(s) in RCA: 35] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/24/2012] [Revised: 04/19/2012] [Accepted: 05/13/2012] [Indexed: 02/06/2023] Open
Abstract
Pancreatic surgery represents one of the most challenging areas in digestive surgery. In recent years, an increasing number of laparoscopic pancreatic procedures have been performed and laparoscopic distal pancreatectomy (LDP) has gained world-wide acceptance because it does not require anastomosis or other reconstruction. To date, English literature reports more than 300 papers focusing on LDP, but only 6% included more than 30 patients. Literature review confirms that LDP is a feasible and safe procedure in patients with benign or low grade malignancies. Decreased blood loss and morbidity, early recovery and shorter hospital stay may be the main advantages. Several concerns still exist for laparoscopic pancreatic adenocarcinoma excision. The individual surgeon determines the technical conduction of LDP, with or without spleen preservation; currently robotic pancreatic surgery has gained diffusion. Additional researches are necessary to determine the best technique to improve the procedure results.
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Zhao L, Qin MF, Li N, Gou CY, Zheng MW, Dai QL. Laparoscopy combined with cholangioscopy for the treatment of pancreatic abscess after severe acute pancreatitis. Shijie Huaren Xiaohua Zazhi 2012; 20:2101-2105. [DOI: 10.11569/wcjd.v20.i22.2101] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023] Open
Abstract
AIM: To evaluate the value of laparoscopy combined with cholangioscopy in the treatment of pancreatic abscess after severe acute pancreatitis.
METHODS: The clinical data for 38 patients with pancreatic abscess after severe acute pancreatitis who underwent laparoscopy and cholangioscopy co-therapy or open surgery in Nankai Hospital from June 2000 to June 2011 were retrospectively analyzed, including general information, operative time, intraoperative blood loss, postoperative intestinal recovery time, WBC and liver function changes, postoperative complications, mortality, hospital stay, and hospitalization costs.
RESULTS: The laparoscopy and cholangioscopy co-therapy group had no significant differences with the open group in general information, patient composition, operative time, hospital stay, and mortality. However, significant differences were noted in intraoperative blood loss (108 mL ± 18 mL vs 137 mL ± 25 mL), postoperative intestinal recovery time (26.8 h ± 9.7 h vs 31 h ± 10.1 h), liver function changes at 2 weeks postoperatively (ALP: 76.7 U/L ± 12.6 U/L vs 83.2 U/L ± 13.6 U/L; GGT: 60.3 U/L±14.1 U/L vs 67.1 U/L±13.8 U/L), incidence of postoperative complications (19.0% vs 41.2%), hospitalization costs (49.3 ± 0.9 thousand Yuan vs 43.2 ± 0.6 thousand Yuan) between the two groups (all P < 0.05).
CONCLUSION: Laparoscopy and cholangioscopy co-therapy is a safe, effective, and minimally invasive treatment for pancreatic abscess after severe acute pancreatitis but is associated with higher cost and longer operation time and hospital stay.
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11
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Management of infected pancreatic necrosis using retroperitoneal necrosectomy with flexible endoscope: 10 years of experience. Surg Endosc 2012; 27:443-53. [PMID: 22806520 DOI: 10.1007/s00464-012-2455-5] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/20/2012] [Accepted: 06/12/2012] [Indexed: 12/16/2022]
Abstract
BACKGROUND This study was designed to provide our experience in the management of infected and drained pancreatic necrosis using the retroperitoneal approach. METHODS This was a prospective observational study in a tertiary care university hospital. Thirty-two patients with confirmed infected pancreatic necrosis were studied. Superficial necrosectomy was performed with lavage and aspiration of debris. This was achieved though a retroperitoneal approach of the pancreatic area and under the direct vision of a flexible endoscope. The follow-up procedure using retroperitoneal endoscopy did not require taking the patient to the operating room. The main outcome measures were infection control, morbidity, and mortality related to technique, reintervention, and long-term follow-up. RESULTS No significant morbidity or mortality related to the technique was observed in all of the patients with infected pancreatic necrosis treated with this retroperitoneal approach compared with published data using other approaches. Reinterventions were not required and patients are currently asymptomatic. CONCLUSIONS Retroperitoneal access of the pancreatic area is a good approach for drainage and debridement of infected pancreatic necrosis. Translumbar retroperitoneal endoscopy allows exploration under direct visual guidance avoiding open transabdominal reintervention and the risk of contamination of the abdominal cavity. This technique does not increase morbidity and mortality, can be performed at the patients' bedside as many times as necessary, and has advantages over other retroperitoneal approaches.
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12
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Pattillo JC, Funke R. Laparoscopic pancreatic necrosectomy in a child with severe acute pancreatitis. J Laparoendosc Adv Surg Tech A 2011; 22:123-6. [PMID: 22044514 DOI: 10.1089/lap.2011.0260] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
Acute pancreatitis (AP) in children usually follows a mild course but occasionally may be severally problematic. We report the case of a 12-year-old boy with severe AP who was managed with repeated laparoscopic pancreatic necrosectomy. Three weeks later he represented with a pancreatic pseudocyst that was treated with endoscopic gastrocystotomy. His abdominal pain persisted and a subsequent magnetic resonance cholangiopancreatogram showed multiple gallbladder and common bile duct (CBD) stones that were missed on previous imaging investigations. He underwent laparoscopic cholecystectomy with transcystic exploration of the CBD. The patient is currently well, more than 2 years following the definitive corrective surgery. To the best of our knowledge, this is the first case of laparoscopic pancreatic necrosectomy in a child.
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Affiliation(s)
- Juan-Carlos Pattillo
- Sección Cirugía Pediátrica, División de Cirugía, Facultad de Medicina, Pontificia Universidad Católica de Chile, Santiago, Chile.
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Brisinda G, Vanella S, Crocco A, Mazzari A, Tomaiuolo P, Santullo F, Grossi U, Crucitti A. Severe acute pancreatitis: advances and insights in assessment of severity and management. Eur J Gastroenterol Hepatol 2011; 23:541-551. [PMID: 21659951 DOI: 10.1097/meg.0b013e328346e21e] [Citation(s) in RCA: 35] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/05/2023]
Abstract
The patients with acute pancreatitis are at risk to develop different complications from ongoing pancreatic inflammation. Often, there is no correlation between the degree of structural damage to pancreas and clinical manifestation of the disease. The effectiveness of any treatment is related to the ability to predict severity accurately, but there is no ideal predictive system or biochemical marker. Severity assessment is indispensable to the selection of proper initial treatment in the management of acute pancreatitis. The use of multiparametric criteria and the evaluation of severity index permit us to select high-risk patients. Furthermore, contrast-enhanced computed tomographic scanning and contrast-enhanced MRI play an important role in severity assessment. The adoption of multiparametric criteria proposed together with morphological evaluation consents the formulation of a discreetly reliable prognosis on the evolution of the disease a few days from onset.
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Affiliation(s)
- Giuseppe Brisinda
- Department of Surgery, Catholic School of Medicine, University Hospital Agostino Gemelli, Largo Agostino Gemelli 8, Rome, Italy.
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14
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Abstract
The challenge for the pancreatologist managing patients with infected pancreatic necrosis is to devise a treatment algorithm that enables recovery but at the same time limits the morbidity and mortality. The current gold standard remains open necrosectomy. Recent literature contains scattered reports of endoscopic, radiologic, laparoscopic, percutaneous and lumbotomy approaches to managing patients with this condition. This literature review addresses the role of techniques that aim to minimize the physiological insult to the patient with infected pancreatic necrosis.
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Affiliation(s)
- A Peter Wysocki
- Department of Surgery, Logan Hospital, Meadowbrook, Queensland, Australia.
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Cheung MT, Li WH, Kwok PCH, Hong JKF. Surgical management of pancreatic necrosis: towards lesser and later. JOURNAL OF HEPATO-BILIARY-PANCREATIC SCIENCES 2010; 17:338-44. [PMID: 20464564 DOI: 10.1007/s00534-009-0251-y] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/03/2009] [Accepted: 11/24/2009] [Indexed: 01/03/2023]
Abstract
BACKGROUND/PURPOSE Our aim was to determine the overall success rate and survival rate with respect to the timing of intervention in the management of pancreatic necrosis. The use of minimally invasive pancreatic necrosectomy was also examined. METHODS This was a retrospective study carried out in a tertiary referral hospital. The subjects were all patients who suffered from acute pancreatic necrosis with emergency interventions from January 2001 to December 2007. For outcome measures, special emphasis was placed on the overall success rate and survival rate with respect to the timing of intervention. The success rate of percutaneous pancreatic necrosectomy (PCPN) was examined. RESULTS A total of 26 patients with pancreatic necrosis were studied. The overall mortality rate was 26.9% and the rate was significantly higher in those patients who had earlier intervention (before 6 weeks). Eleven patients had PCPN. There were 2 failures due to PCPN in the early phase; 2 had partial success, while the procedure was completely successful to remove all the necrotic tissues in the other 7 patients. CONCLUSIONS With a multidisciplinary approach, particularly with sophisticated intensive care, most patients with pancreatic necrosis can survive the initial phase. Open surgery should be limited to simple drainage and laparostomy to relieve the abdominal tension. Active intervention preferably should be delayed until the necrosis has become walled off, when a variety of minimally invasive maneuvers, notably percutaneous necrosectomy, can be offered to remove the debris. The surgical management of pancreatic necrosis should change towards a strategy of "lesser and later".
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Affiliation(s)
- Moon-Tong Cheung
- Department of Surgery, Block H10, Queen Elizabeth Hospital, 33, Gascoigne Road, Kowloon, Hong Kong.
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Amano H, Takada T, Isaji S, Takeyama Y, Hirata K, Yoshida M, Mayumi T, Yamanouchi E, Gabata T, Kadoya M, Hattori T, Hirota M, Kimura Y, Takeda K, Wada K, Sekimoto M, Kiriyama S, Yokoe M, Hirota M, Arata S. Therapeutic intervention and surgery of acute pancreatitis. JOURNAL OF HEPATO-BILIARY-PANCREATIC SCIENCES 2010; 17:53-59. [PMID: 20012651 DOI: 10.1007/s00534-009-0211-6] [Citation(s) in RCA: 35] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/01/2009] [Accepted: 09/01/2009] [Indexed: 02/08/2023]
Abstract
The clinical course of acute pancreatitis varies from mild to severe. Assessment of severity and etiology of acute pancreatitis is important to determine the strategy of management for acute pancreatitis. Acute pancreatitis is classified according to its morphology into edematous pancreatitis and necrotizing pancreatitis. Edematous pancreatitis accounts for 80-90% of acute pancreatitis and remission can be achieved in most of the patients without receiving any special treatment. Necrotizing pancreatitis occupies 10-20% of acute pancreatitis and the mortality rate is reported to be 14-25%. The mortality rate is particularly high (34-40%) for infected pancreatic necrosis that is accompanied by bacterial infection in the necrotic tissue of the pancreas (Widdison and Karanjia in Br J Surg 80:148-154, 1993; Ogawa et al. in Research of the actual situations of acute pancreatitis. Research Group for Specific Retractable Diseases, Specific Disease Measure Research Work Sponsored by Ministry of Health, Labour, and Welfare. Heisei 12 Research Report, pp 17-33, 2001). On the other hand, the mortality rate is reported to be 0-11% for sterile pancreatic necrosis which is not accompanied by bacterial infection (Ogawa et al. 2001; Bradely and Allen in Am J Surg 161:19-24, 1991; Rattner et al. in Am J Surg 163:105-109, 1992). The Japanese (JPN) Guidelines were designed to provide recommendations regarding the management of acute pancreatitis in patients having a variety of clinical characteristics. This article describes the guidelines for the surgical management and interventional therapy of acute pancreatitis by incorporating the latest evidence for the management of acute pancreatitis in the Japanese-language version of JPN guidelines 2010. Eleven clinical questions (CQ) are proposed: (1) worsening clinical manifestations and hematological data, positive blood bacteria culture test, positive blood endotoxin test, and the presence of gas bubbles in and around the pancreas on CT scan are indirect findings of infected pancreatic necrosis; (2) bacteriological examination by fine needle aspiration is useful for making a definitive diagnosis of infected pancreatic necrosis; (3) conservative treatment should be performed in sterile pancreatic necrosis; (4) infected pancreatic necrosis is an indication for interventional therapy. However, conservative treatment by antibiotic administration is also available in patients who are in stable general condition; (5) early surgery for necrotizing pancreatitis is not recommended, and it should be delayed as long as possible; (6) necrosectomy is recommended as a surgical procedure for infected necrosis; (7) after necrosectomy, a long-term follow-up paying attention to pancreatic function and complications including the stricture of the bile duct and the pancreatic duct is necessary; (8) drainage including percutaneous, endoscopic and surgical procedure should be performed for pancreatic abscess; (9) if the clinical findings of pancreatic abscess are not improved by percutaneous or endoscopic drainage, surgical drainage should be performed; (10) interventional treatment should be performed for pancreatic pseudocysts that give rise to symptoms, accompany complications or increase the diameter of cysts and (11) percutaneous drainage, endoscopic drainage or surgical procedures are selected in accordance with the conditions of individual cases.
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Affiliation(s)
- Hodaka Amano
- Department of Surgery, Teikyo University School of Medicine, 2-11-1, Kaga-cho, Itabashi, Tokyo, 173-8605, Japan.
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17
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Acidification Enhances Peritoneal Macrophage Phagocytic Activity. J Surg Res 2008; 147:206-11. [DOI: 10.1016/j.jss.2008.02.049] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/07/2008] [Revised: 02/21/2008] [Accepted: 02/23/2008] [Indexed: 11/17/2022]
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Takaori K, Tanigawa N. Laparoscopic pancreatic resection: the past, present, and future. Surg Today 2007; 37:535-45. [PMID: 17593471 DOI: 10.1007/s00595-007-3472-1] [Citation(s) in RCA: 68] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/09/2006] [Accepted: 01/11/2007] [Indexed: 02/06/2023]
Abstract
Since the early 1990s, laparoscopic techniques have been applied to a growing number of pancreatic surgeries. Laparoscopic pancreatic resections have been performed in patients with a variety of diseases including chronic pancreatitis, pancreatic trauma, congenital hyperinsulinism, and neoplasms of the pancreas; e.g., insulinoma, mucinous cystic neoplasm, intraductal papillary mucinous neoplasm, etc. Laparoscopic pancreatic resections with an en bloc lymph node dissection have also been performed for invasive carcinomas. The long-term results after laparoscopic resections for invasive pancreatic cancer, however, are still not well defined. Laparoscopic distal pancreatectomies with or without spleen preservation may benefit patients with reduced postoperative pain, shorter hospital stay, a quicker recovery to normal activity, and better cosmetic appearances based on retrospective analyses of collective series and case reports. Prospective randomized controlled trials are needed to validate these benefits. In contrast, laparoscopic proximal pancreatectomies with or without duodenum preservation remain controversial. Although a laparoscopic pancreaticoduodenectomy and laparoscopic duodenum-preserving pancreatic head resection are technically feasible, laparoscopic reconstruction after proximal pancreatectomies is not yet generally practicable but limited to personal experiences by highly skilled endoscopic surgeons. To justify the performance of laparoscopic proximal pancreatectomies, it is mandatory to demonstrate the potential clinical benefits and safety of these complicated procedures.
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Affiliation(s)
- Kyoichi Takaori
- Department of General and Gastroenterological Surgery, Osaka Medical College, 2-7 Daigakumachi, Takatsuki, Osaka, 569-8686, Japan
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19
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Abstract
BACKGROUND Laparoscopy has been practiced in the management of emergencies resulting from inflammatory conditions, lumenal obstruction, perforation, vascular occlusion, and trauma. This article identifies and discusses controversial areas in the field, in particular surrounding the efficacy, cost effectiveness, and perceived advantages of laparoscopy in the evaluation and treatment of patients with acute abdominal conditions. MATERIALS AND METHODS Review and commentary on pertinent articles in the English language literature are presented. RESULTS Prospective randomized trials have been reported in the treatment of some disorders, but a lack of recommendations that are evidence-based has hindered more widespread usage of laparoscopy in an emergency setting. In addition, concerns have been raised that the creation of capnoperitoneum in the patient with established peritonitis may be detrimental with respect to potentiation of bacteremia and severe sepsis, and experimental studies have yielded conflicting data in this regard. CONCLUSION As such issues are resolved, utilization of laparoscopy is likely to increase substantially as expertise is acquired. A minimal-access approach carries less morbidity and may offer other practical advantages in terms of surgical technique and application. When surgical intervention is appropriate, laparoscopy is now preferred for acute biliary disease. Female patients of reproductive age with acute appendicitis may benefit, particularly if there is preoperative diagnostic uncertainty. Selected cases of intestinal obstruction and visceral perforation presenting soon after symptom onset and in whom shock is absent may also be amenable to laparoscopic repair. Its use in the treatment of most trauma patients and patients with generalized peritonitis or hemodynamic instability is not recommended at present.
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Affiliation(s)
- Frank J Branicki
- Department of Surgery, United Arab Emirates University, Al Ain, United Arab Emirates.
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20
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Warren O, Kinross J, Paraskeva P, Darzi A. Emergency laparoscopy--current best practice. World J Emerg Surg 2006; 1:24. [PMID: 16945124 PMCID: PMC1564132 DOI: 10.1186/1749-7922-1-24] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/21/2006] [Accepted: 08/31/2006] [Indexed: 12/18/2022] Open
Abstract
Emergency laparoscopic surgery allows both the evaluation of acute abdominal pain and the treatment of many common acute abdominal disorders. This review critically evaluates the current evidence base for the use of laparoscopy, both diagnostic and interventional, in the emergency abdomen, and provides guidance for surgeons as to current best practise. Laparoscopic surgery is firmly established as the best intervention in acute appendicitis, acute cholecystitis and most gynaecological emergencies but requires further randomised controlled trials to definitively establish its role in other conditions.
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Affiliation(s)
- Oliver Warren
- Department of BioSurgery and Surgical Technology, Imperial College of Science, Technology and Medicine, St. Mary's Hospital, London, UK
| | - James Kinross
- Department of BioSurgery and Surgical Technology, Imperial College of Science, Technology and Medicine, St. Mary's Hospital, London, UK
| | - Paraskevas Paraskeva
- Department of BioSurgery and Surgical Technology, Imperial College of Science, Technology and Medicine, St. Mary's Hospital, London, UK
| | - Ara Darzi
- Department of BioSurgery and Surgical Technology, Imperial College of Science, Technology and Medicine, St. Mary's Hospital, London, UK
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Fernández-Cruz L, Lozano-Salazar RR, Olvera C, Higueras O, López-Boado MA, Astudillo E, Navarro S. Pancreatitis aguda grave: alternativas terapéuticas. Cir Esp 2006; 80:64-71. [PMID: 16945302 DOI: 10.1016/s0009-739x(06)70925-3] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
The management of acute necrotizing pancreatitis has changed significantly over the last few years. Currently, most patients survive the early phases of the disease due to improvements in intensive care unit management. The most important risk factor for morbidity and mortality is infection of the pancreatic necrosis. Ideally, surgery should be delayed until 4 weeks after the onset of symptoms of pancreatitis, as it is at this time that the necrosis is most clearly demarcated. Advances in diagnostic imaging and minimally invasive techniques in surgery and radiology have revolutionized the surgical management of this disease. However, minimally invasive techniques should be limited to critically-ill patients unfit for conventional surgery.
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Affiliation(s)
- Laureano Fernández-Cruz
- Institut Clínic de Malalties Digestives, Departamento de Cirugía, Hospital Clínic i Provincial de Barcelona, Universidad de Barcelona, Barcelona, España.
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22
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Mori T, Abe N, Sugiyama M, Atomi Y. Laparoscopic pancreatic surgery. ACTA ACUST UNITED AC 2006; 12:451-5. [PMID: 16365817 DOI: 10.1007/s00534-005-1031-y] [Citation(s) in RCA: 35] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/27/2005] [Accepted: 02/28/2005] [Indexed: 12/28/2022]
Abstract
In the past, in the pancreas, a minimally invasive technique was only used for diagnostic laparoscopy in evaluating periampullary malignancy. Recent advances in operative techniques and instrumentation have empowered surgeons to perform virtually all procedures in the pancreas, including the Whipple procedure. Some of these procedures represent the most sophisticated application of minimally invasive surgery, and their outcomes are reportedly better than those of conventional open approaches. In addition to the evaluation of resectability in periampullary malignancy, palliative procedures, including biliary bypasses and gastrojejunostomy, can be performed laparoscopically. Although it is reportedly feasible to perform a Whipple procedure laparescopically, no benefit of the laparoscopic approach over the conventional open approach has been documented. Laparoscopic distal pancreatectomy, with or without preserving the spleen, is technically easier than the Whipple procedure, and is more widely accepted. Indications for laparoscopic distal pancreatectomy include cystic neoplasms and islet-cell tumors located in the pancreatic body or tail. Complications of acute and chronic pancreatitis may be treated with the use of surgical laparoscopy. When infected necrotizing pancreatitis is identified, surgical intervention for drainage and debridement is required. According to the type and location of infected necrotizing pancreatitis, three laparoscopic operative approaches have been reported: infracolic debridement, retroperitoneal debridement, and laparoscopic transgastric pancreatic necrosectomy. When internal drainage is indicated for a pseudocyst, a minimally invasive technique is a promising option. Laparoscopic pseudocyst gastrostomy, cyst jejunostomy, or cyst duodenostomy can be performed, depending on the size and location of the pseudocyst. Especially when a pseudocyst is located in close contact with the posterior wall of the stomach, it is best drained by a pseudocyst gastrostomy, which can also be done with the use of an intragastric operative technique.
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Affiliation(s)
- Toshiyuki Mori
- Department of Surgery, Kyorin University, 6-20-2 Shinkawa, Mitaka, Tokyo, 181-8611, Japan
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23
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The laparoscopic approach for inflammatory pancreatic diseases. Eur Surg 2006. [DOI: 10.1007/s10353-006-0245-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/24/2022]
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Isaji S, Takada T, Kawarada Y, Hirata K, Mayumi T, Yoshida M, Sekimoto M, Hirota M, Kimura Y, Takeda K, Koizumi M, Otsuki M, Matsuno S. JPN Guidelines for the management of acute pancreatitis: surgical management. JOURNAL OF HEPATO-BILIARY-PANCREATIC SURGERY 2006; 13:48-55. [PMID: 16463211 PMCID: PMC2779397 DOI: 10.1007/s00534-005-1051-7] [Citation(s) in RCA: 56] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
Acute pancreatitis represents a spectrum of disease ranging from a mild, self-limited course to a rapidly progressive, severe illness. The mortality rate of severe acute pancreatitis exceeds 20%, and some patients diagnosed as mild to moderate acute pancreatitis at the onset of the disease may progress to a severe, life-threatening illness within 2-3 days. The Japanese (JPN) guidelines were designed to provide recommendations regarding the management of acute pancreatitis in patients having a diversity of clinical characteristics. This article sets forth the JPN guidelines for the surgical management of acute pancreatitis, excluding gallstone pancreatitis, by incorporating the latest evidence for the surgical management of severe pancreatitis in the Japanese-language version of the evidence-based Guidelines for the Management of Acute Pancreatitis published in 2003. Ten guidelines are proposed: (1) computed tomography-guided or ultrasound-guided fine-needle aspiration for bacteriology should be performed in patients suspected of having infected pancreatic necrosis; (2) infected pancreatic necrosis accompanied by signs of sepsis is an indication for surgical intervention; (3) patients with sterile pancreatic necrosis should be managed conservatively, and surgical intervention should be performed only in selected cases, such as those with persistent organ complications or severe clinical deterioration despite maximum intensive care; (4) early surgical intervention is not recommended for necrotizing pancreatitis; (5) necrosectomy is recommended as the surgical procedure for infected pancreatic necrosis; (6) simple drainage should be avoided after necrosectomy, and either continuous closed lavage or open drainage should be performed; (7) surgical or percutaneous drainage should be performed for pancreatic abscess; (8) pancreatic abscesses for which clinical findings are not improved by percutaneous drainage should be subjected to surgical drainage immediately; (9) pancreatic pseudocysts that produce symptoms and complications or the diameter of which increases should be drained percutaneously or endoscopically; and (10) pancreatic pseudocysts that do not tend to improve in response to percutaneous drainage or endoscopic drainage should be managed surgically.
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Affiliation(s)
- Shuji Isaji
- Department of Hepatobiliary Pancreatic Surgery and Breast Surgery, Mie University Graduate School of Medicine, Tsu, Mie 514-8507, Japan
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25
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Sauerland S, Agresta F, Bergamaschi R, Borzellino G, Budzynski A, Champault G, Fingerhut A, Isla A, Johansson M, Lundorff P, Navez B, Saad S, Neugebauer EAM. Laparoscopy for abdominal emergencies. Surg Endosc 2005; 20:14-29. [PMID: 16247571 DOI: 10.1007/s00464-005-0564-0] [Citation(s) in RCA: 232] [Impact Index Per Article: 11.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/01/2005] [Accepted: 07/12/2005] [Indexed: 01/10/2023]
Abstract
BACKGROUND Emergency laparoscopic exploration can be used to identify the causative pathology of acute abdominal pain. Laparoscopic surgery also allows treatment of many intraabdominal disorders. This report was prepared to describe the effectiveness of laparoscopic surgery compared to laparotomy or nonoperative treatment. METHODS A panel of European experts in abdominal and gynecological surgery was assembled and participated in a consensus conference using Delphi methods. The aim was to develop evidence-based recommendations for the most common diseases that may cause acute abdominal pain. RECOMMENDATIONS Laparoscopic surgery was found to be clearly superior for patients with a presumable diagnosis of perforated peptic ulcer, acute cholecystitis, appendicitis, or pelvic inflammatory disease. In the emergency setting, laparoscopy is of unclear or limited value if adhesive bowel obstruction, acute diverticulitis, nonbiliary pancreatitis, hernia incarceration, or mesenteric ischemia are suspected. In stable patients with acute abdominal pain, noninvasive diagnostics should be fully exhausted before considering explorative surgery. However, diagnostic laparoscopy may be useful if no diagnosis can be found by conventional diagnostics. More clinical data are needed on the use of laparoscopy after blunt or penetrating trauma of the abdomen. CONCLUSIONS Due to diagnostic and therapeutic advantages, laparoscopic surgery is useful for the majority of conditions underlying acute abdominal pain, but noninvasive diagnostic aids should be exhausted first. Depending on symptom severity, laparoscopy should be advocated if routine diagnostic procedures have failed to yield results.
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Affiliation(s)
- S Sauerland
- Institute for Research in Operative Medicine, University of Witten/Herdecke, Ostmerheimer Strasse 200, D 51109, Cologne, Germany
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Abstract
BACKGROUND Perforated peptic ulcer is a common abdominal disease that is treated by surgery. The development of laparoscopic surgery has changed the way to treat such abdominal surgical emergencies. The results of some clinical trials suggest that laparoscopic surgery could be a better strategy than open surgery in the correction of perforated peptic ulcer but the evidence is not strongly in favour or against this intervention. OBJECTIVES To measure the effect of laparoscopic surgical treatment versus open surgical treatment in patients with a diagnosis of perforated peptic ulcer in relation to abdominal septic complications, surgical wound infection, extra-abdominal complications, hospital length of stay and direct costs. SEARCH STRATEGY We searched the Cochrane Central Register of Controlled Trials (CENTRAL) on The Cochrane Library (Issue 2, 2004), PubMed/MEDLINE (1966 to July 2004), EMBASE (1985 to November 2004) and LILACS (1988 to November 2004) as well as reference lists of relevant articles. SELECTION CRITERIA Randomised clinical trials comparing laparoscopic surgery versus open surgery for the repair of perforated peptic ulcer using any mechanical method of closure (suture, omental patch or fibrin sealant). DATA COLLECTION AND ANALYSIS Primary outcome measures included proportion of septic and other abdominal complications (surgical site infection, suture leakage, intra-abdominal abscess, postoperative ileus) and extra-abdominal complications (pulmonary). Secondary outcomes included mortality, time to return to normal diet, time of nasogastric aspiration, hospital length of stay and costs. Outcomes were summarized by reporting odds ratios and 95% confidence intervals, using the fixed-effect model. MAIN RESULTS We included two randomised clinical trials, which were of acceptable quality. We found no statistically significant differences between laparoscopic and open surgery in the proportion of abdominal septic complications (OR 0.66, 95% CI 0.30 to 1.47), pulmonary complications (OR 0.37, 95% CI 0.11 to 1.31) or actual number of septic abdominal complications (OR 0.72, 95% CI 0.33 to 1.58). Heterogeneity was significant only for pulmonary complications. AUTHORS' CONCLUSIONS This systematic review suggests that a decrease in septic abdominal complications may exist when laparoscopic surgery is used to correct perforated peptic ulcer. However, it is necessary to develop more randomised controlled trials that include a greater number of patients to confirm such an assumption, guaranteeing a long learning curve for participating surgeons. With the information provided by the available clinical trials it could be said that laparoscopic surgery results are not clinically different from those of open surgery.
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Affiliation(s)
- A E Sanabria
- Pontificia Universidad Javeriana-Hospital Universitario San Ignacio, Department of Surgery, Carrera 7 No 40-62, Hospital Universitario de San Ignacio, 7 piso, Bogota, Colombia.
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27
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Fernández-Cruz L, Cesar-Borges G, López-Boado MA, Orduña D, Navarro S. Minimally invasive surgery of the pancreas in progress. Langenbecks Arch Surg 2005; 390:342-54. [PMID: 15999286 DOI: 10.1007/s00423-005-0556-5] [Citation(s) in RCA: 16] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/07/2004] [Accepted: 03/15/2005] [Indexed: 02/06/2023]
Abstract
BACKGROUND Laparoscopic pancreatic surgery should be considered as an advanced laparoscopic procedure and should be performed only in institutions with experience in pancreatic surgery by a team with advanced laparoscopic skills. AIM This review discusses the current status of the laparoscopic approach for inflammatory pancreatic diseases and for benign-appearing pancreatic tumors. RESULTS Laparoscopic surgery has been shown to be beneficial in patients with inflammatory tumors located in the body-tail of the pancreas for chronic pancreatitis. Furthermore, patients with pancreatic pseudocysts may be managed with laparoscopic internal drainage (to the stomach, duodenum, or jejunum). Also, laparoscopic or retroperitoneoscopic necrosectomy has been used with success in patients with necrotizing pancreatitis. At present, laparoscopic surgery has proven to be beneficial in patients with cystic pancreatic neoplasms and neuroendocrine pancreatic tumors. CONCLUSIONS The laparoscopic pancreatic approach was recently shown to be feasible and safe. Laparoscopy may contribute to reduced operation time and perioperative blood loss, and reduces surgical stress because of developments in devices, improvements in procedures, and advanced techniques.
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Affiliation(s)
- Laureano Fernández-Cruz
- Department of Surgery, IMD, Biliary and Pancreatic Unit, Hospital Clinic i Provincial de Barcelona, University of Barcelona, C/Villarroel 170, 08036 Barcelona, Spain.
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Renzulli P, Jakob SM, Täuber M, Candinas D, Gloor B. Severe acute pancreatitis: case-oriented discussion of interdisciplinary management. Pancreatology 2005; 5:145-56. [PMID: 15849485 DOI: 10.1159/000085266] [Citation(s) in RCA: 38] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
The clinical course of an episode of acute pancreatitis varies from a mild, transitory illness to a severe often necrotizing form with distant organ failure and a mortality rate of 20-40%. Patients with severe pancreatitis, representing about 15-20% of all patients with acute pancreatitis, need to be identified as early as possible after onset of symptoms allowing starting intensive care treatment early in the disease process. An episode of severe acute pancreatitis progresses in two phases. The first 10-14 days are characterized by a systemic inflammatory response syndrome maintained by the release of various inflammatory mediators. The second phase, beginning about 10-14 days after the onset of the disease is dominated by sepsis-related morbidity due to infected peripancreatic and pancreatic necrosis. This state is associated with septic multiple organ systemic failure. The importance of infection on the outcome of necrotizing pancreatitis has been clearly delineated and the pre-emptive use of broad-spectrum antibiotics that achieve effective tissue concentrations is considered standard management of patients with severe necrotizing pancreatitis, especially if associated with organ failure or extended necrosis. Patients with infected necrosis should undergo a surgical intervention. The standard open technique consisting of an organ preserving necrosectomy followed by a postoperative concept of lavage and/or drainage to evacuate necrotic debris occurring during the further course has recently been challenged by various minimally invasive approaches.
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Affiliation(s)
- Pietro Renzulli
- Department of Visceral and Transplant Surgery, Inselspital, University of Berne, Berne, Switzerland
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Risse O, Auguste T, Delannoy P, Cardin N, Bricault I, Létoublon C. Percutaneous video-assisted necrosectomy for infected pancreatic necrosis. ACTA ACUST UNITED AC 2004; 28:868-71. [PMID: 15523223 DOI: 10.1016/s0399-8320(04)95150-0] [Citation(s) in RCA: 38] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/17/2023]
Abstract
AIMS OF THE STUDY Percutaneous drainage of infected pancreatic necrosis is not always efficient and morbidity is high with open necrosectomy techniques. Minimally-invasive procedures have been developed to reduce this morbidity. We report our early experience with percutaneous video-assisted necrosectomy. METHODS Among 61 patients with acute pancreatitis treated between January 2001 and February 2003, seven developed infected pancreatic necrosis. Six of these seven patients underwent percutaneous video-assisted necrosectomy after failure of radio-guided percutaneous drainage. RESULTS One to four sessions of percutaneous video-assisted necrosectomy were required. There was no death. Sepsis control was achieved in all patients. One patient developed postoperative peritonitis due to intraoperative contamination of the peritoneal cavity. Eighteen months after the last necrosectomy, one patient developed a pseudocyst which was successfully cured by percutaneous drainage. One patient developed diabetes mellitus. CONCLUSION Early experience in six patients has shown that percutaneous video-assisted necrosectomy is feasible, safe and efficient, in accordance with reports in the literature. Further evaluation is necessary.
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Affiliation(s)
- Olivier Risse
- Département de Chirurgie Digestive et de l'Urgence, Hôpital Michallon, BP 217, 38043 Grenoble Cedex 9.
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Marshall JC, Maier RV, Jimenez M, Dellinger EP. Source control in the management of severe sepsis and septic shock: An evidence-based review. Crit Care Med 2004; 32:S513-26. [PMID: 15542959 DOI: 10.1097/01.ccm.0000143119.41916.5d] [Citation(s) in RCA: 159] [Impact Index Per Article: 7.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/26/2022]
Abstract
OBJECTIVE In 2003, critical care and infectious disease experts representing 11 international organizations developed management guidelines for source control in the management of severe sepsis and septic shock that would be of practical use for the bedside clinician, under the auspices of the Surviving Sepsis Campaign, an international effort to increase awareness and to improve outcome in severe sepsis. DESIGN The process included a modified Delphi method, a consensus conference, several subsequent smaller meetings of subgroups and key individuals, teleconferences, and electronic-based discussion among subgroups and among the entire committee. METHODS The modified Delphi methodology used for grading recommendations built on a 2001 publication sponsored by the International Sepsis Forum. We undertook a systematic review of the literature graded along five levels to create recommendation grades from A to E, with A being the highest grade. Pediatric considerations to contrast adult and pediatric management are in the article by Parker et al. on p. S591. CONCLUSION Source control represents a key component of success in therapy of sepsis. It includes drainage of infected fluids, debridement of infected soft tissues, removal of infected devices or foreign bodies, and finally, definite measures to correct anatomic derangement resulting in ongoing microbial contamination and to restore optimal function. Although highly logical, since source control is the best way to reduce quickly the bacterial inoculum, most recommendations are, however, graded as D or E due to the difficulty to perform appropriate randomized clinical trials in this respect. Appropriate source control should be part of the systematic checklist we have to keep in mind in setting up the therapeutic strategy in sepsis.
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Affiliation(s)
- John C Marshall
- From the Toronto General Hospital, University Health Network, Toronto, Ontario, Canada
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Abstract
Intra-abdominal infections in the hospitalized patient differ from those arising in the community in their clinical presentation, sites of involvement, and characteristic microbiology. They are also associated with greater morbidity and mortality. New onset organ dysfunction, more than acute abdominal pain and tenderness, is the predominant clinical manifestation. Successful management depends on aggressive resuscitation and hemodynamic support, administration of adequate antimicrobial therapy, and the timely use of source control measures appropriate to the clinical situation.
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Affiliation(s)
- John C Marshall
- Department of Surgery and the Interdepartmental Division of Critical Care Medicine, University of Toronto and the Toronto General Hospital, University Health Network, Toronto, Ont., Canada M5G 2C4.
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Abstract
INTRODUCTION Severe acute pancreatitis (SAP) remains a serious disease state difficult to manage. Laparoscopic surgery represents a relatively new solution to this problem. This study was aimed to investigate the feasibility of laparoscopic treatment of SAP and the selection of laparoscopic procedures in various stages of SAP according to different pathologic alterations. METHODS Thirteen patients, 9 men and 4 women with an average age of 46 years old, were diagnosed with SAP. Laparoscopic necrosectomy followed by external drainage were performed on 7 patients with massive fluid collections and/or infected necrosis in acute reaction phase of SAP. For 2 cases in subacute phase characterized by fresh-formed adhesions and encapsulation, laparoscopic intracavitary debridement experienced difficulty. For the other 4 patients in late phase with well-defined pancreatic or peripancreatic pseudocyst/abscess, ultrasound-guided, directly visualized laparoscopic intracavitary debridement, and external drainage were carried out with ease and efficiency. RESULTS Laparoscopic procedures were accomplished successfully on 12 patients (92.3%), except for 1 conversion (7.7%) to open laparotomy owing to poor exposure and hard maneuvers in subacute phase. There was no mortality in this group. Patients were witnessed to have accelerated recovery following laparoscopic surgery. CONCLUSION Laparoscopic technique offers new hope for the treatment of SAP. It is recommended as a feasible, effective, and less traumatic therapeutic means on condition that the strategy of individualization is followed.
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Affiliation(s)
- Zong-Guang Zhou
- Department of General Surgery & Institute of Digestive Surgery, West China Hospital, Sichuan University, Chengdu, 610041, Sichuan, Peoples Republic of China
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