Pancreatic Necrosectomy - Pancreas Center Italy - Treatment Of Cancer Pancreatic In Italy

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PANCREATIC NECROSECTOMY

Necrosectomy procedures are performed in patients with severe acute  pancreatitis and infected necrosis. To date, necrosectomy is used a last  resort, after failure of less invasive techniques (such as percutaneous  drainage of pancreatic necrosis). This “step-up” approach has proven to  be superior to the “step-down” approach in which open necrosectomy  plays a primary role, with less invasive methods used for residual or  subsequent collections.

OPEN NECROSECTOMY

The principle of necrosectomy is minimization of injury to viable  tissues and maximization of postoperative removal of exudative fluid  and extravasated pancreatic exocrine secretions from the operative bed.  It may be a very difficult procedure, associated with an increased risk  of bleeding.
Open necrosectomy is traditionally performed via a midline or a  subcostal laparotomy. Once the focus of necrosis is exposed, debridement  is carried out bluntly. After all loose debris has been removed, the  retroperitoneal cavity is irrigated with normal saline solution. After  necrosectomy, four different techniques are used to provide exit  channels for further slough and infected debris:

  • Open packing (The abdomen is left open, continuous reoperations with open lavage of necrotic areas are performed)
  • Planned staged relaparotomies with repeated lavage (The abdomen is closed, continuous relaparotomies with open lavage of necrotic areas are performed)
  • Closed continuous lavage of the lesser sac and retroperitoneum (the abdomen is closed over drains for contained postoperative lavage of the lesser sac and involved retroperitoneum)
  • Closed packing (the abdomen is closed, reabsorbable sponges are used for packing)

Prof. Perderzoli and Prof. Bassi from Verona were  among the first to describe in 1990 the procedure of open necrosectomy  with continuous lavage of the lesser sac and retroperitoneum (Figure 1).   


Figure 1. Open necrosectomy and continuous lavage of the lesser sac and  retroperitoneum,
as described by Pederzoli and Bassi in 1990.


MINIMALLY INVASIVE NECROSECTOMY

Minimally invasive necrosectomy encompasses radiological,  endoscopic and percutaneous techniques. Minimally invasive necrosectomy  techniques had been initially proposed as an alternative to open  necrosectomy, with the aim of reducing the surgical trauma. However, a  number of studies showed that open necrosectomy often makes patients  sicker and that outcome may be improved when necrosectomy is delayed or  when it is used a last resort, after failure of  minimally invasive  techniques.

However, these results may be influenced by variation in expertise  with minimally invasive techniques, and in the definitions of  target lesions. Variations in the target lesions (location of necrosis,  fluid/mixed/solid nature, early/late procedure, sterile/infected  necrosis, single/multiple areas, wall thickness) and in the patients  (co-morbidity, degree of organ dysfunction) require an individually  tailored  approach to the treatment of pancreatic necrosis.

As reported by Windsor, minimally invasive techniques can be  classified by the type of scope used (flexible endoscope, laparoscope,  nephroscope) and the route of access (transperitoneal,  transgastric, retroperitoneal).

The two approaches that have risen to favour are the endoscopic transgastric and nephroscopic retroperitoneal routes.

Endoscopic transgastric necrosectomy  involves include endoluminal ultrasonographically guided transgastric  puncture of the necrotic area, balloon dilatation of the track,  insertion of multiple stents, direct basket extraction of necrosum,  and transpapillary stenting of the pancreatic duct. The endoscopic  transgastric procedure avoids peritoneal contamination and external  pancreatic fistula formation, but it may not be possible if there is no  abutment of the lesion against the stomach or duodenal wall.

The nephroscopic retroperitoneal procedure has been  advocated by the Glasgow group and appears now to be the most popular  minimally invasive necrosectomy approach. The various techniques  described may use a small retroperitoneal incision or rely on dilatation  of a drain-track. The majority utilize contrast-computed tomography  (CT) or image itensifier to guide the placement of small-calibre  percutaneous drains into retroperitoneal collections. The drain-track is  then dilated using the Seldinger technique and a nephroscope is placed  into the cavity and semi-solid necrotic tissue removed piecemeal. This  is achieved using various accessories, including biopsy forceps and  baskets.
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