VIDEO-ASSITED RETROPERITONEAL NECROSECTOMY: THE STEP-UP APPROACH FOR SEVERE ACUTE NECROTIZING PANCREATITIS
EAES Online Library. Poves Prim I. Jan 10, 2012; 20010
Dr. Ignasi Poves Prim
Dr. Ignasi Poves Prim
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Abstract
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Introduction: Severe acute necrotizing pancreatitis (SANP) is a challenging disease for surgeons. Although the indication of surgical débridement can be performed when pancreatic infection is demonstrated, there is enough evidence that the more we can postpone surgical treatment, more definitive is the treatment. Antibiotherapy and percutaneous drains have lead to delay, in some cases, the definitive surgical necrosectomy. The step-up approach is based in these principles. Retroperitoneal approach is a lesser aggressive operative technique than the classical laparotomy, above all if it can be done by video-assited retroperitoneal approach as it has been described by van Santvoort HC et al. Video presentation: An 82-years old man was referred to our centre with the diagnosis of severe acute biliary pancreatitis. On enhanced-CT it was seen extended pancreatic necrosis (>50%) affecting the body and tail of the pancreas. Antibiobitic treatment with Imipenem was administered. On 37th day infected necrosis was diagnosed on CT. A retroperitoneal percutaneous drainage was inserted obtaining purulent liquid. He improved clinically, but 20 days before he presented again abdominal sepsis. At this moment (58th day of admission) it was decided to perform surgical débridement and necrosectomy. It was done a video-assited retroperitoneal necrosectomy by a 5 cm incision. The previously placed drainage was used as a guide for entering in the correct retroperitoneal space. A great amount of infected necrosis was removed. A huge drain was left in the pancreatic space. The patient was discharged on 45th day after surgical treatment. Total lenght of stay was 103 days. Conclusions: The step-up approach is a useful strategy for management of patients suffering from severe acute necrotizing pancreatitis. Video-assited retroperitoneal necrosectomy is a well described technique that can be performed in some patients with well delimited, consistent, localized and evolved infected pancreatic necrosis.
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