Retroperitoneal endoscopic necrosectomy


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  • Parenchymal necrosis, as a complication of acute pancreatitis, occurs in 10% to 25% of patients requiring hospital admission, and continues to be associated with mortality rate of approximately 25%.
  • -Delayed intervention (>2 weeks) is associated with reduced mortality -With later surgical intervention leading to better demarcation of extent of necrosis and maturation of the local inflammatory ressponce
  • Practically if pt has more than 50 % necrosis it indicates 80 % infection rates.
  • In our institution, necrosectomy is usually
  • Endoscopic ultrasound was used to define the optimal puncture position and to exclude vessel interposition. However the use of EUS did not prevent bleeding complications
  • In pancreatitis thanks got we do not have that kind of tecnique
  • Castellanos et al concluded that
  • There are various surgical approaches for removing the necrosum. Minimally invasive retroperitoneal pancreatic necrosectomy (MIRP) is a relatively novel approach with early encouraging results and is safe in the surgical management of well-selected cases of necrotising pancreatitis.
  • A large fragment of necrosis extruding from the cavity posterior to stomach
  • Retroperitoneal endoscopic necrosectomy

    1. 1. Retroperitoneal Endoscopic Necrosectomy & “NOTES Pancreatic Necrosectomy” Hakan Yanar MD İstanbul Faculty of Medicine General Surgery Service İstanbul, Turkey 12 th European Congress of Trauma and Emergency Surgery April, 27-30, 2011, Milan
    2. 2. Acute Pancreatitis <ul><li>Parenchymal necrosis: 10-25% </li></ul><ul><li>Mild: Non-necrotizing – edematous (80-85%) </li></ul><ul><ul><li>Mortality 0-3% </li></ul></ul><ul><li>Severe: Necrotizing pancreatitis (15-20%) </li></ul><ul><ul><li>Steril necrosis: 0-11% </li></ul></ul><ul><ul><li>Infected necrosis: 40 % on average, up to 70% </li></ul></ul>Hughes SJ, et al. Clin N Am, 2007 Isaji S, J Hepatobiliary Pancreat surg, 2006
    3. 4. Management of the severe pancreatitis <ul><li>Early Phase Interventions </li></ul><ul><li>- Diagnosis of pancreatic necrosis: Role of Imaging, CT </li></ul><ul><li>The use of prophylactic Ab </li></ul><ul><li>Nutrition </li></ul><ul><li>Renal insufficiency and medical management considerations </li></ul><ul><li>Indications for early operative intervention </li></ul>
    4. 5. Management of the severe pancreatitis <ul><li>Late Phase Interventions </li></ul><ul><li>Surgical approaches, timing, and complications -> </li></ul><ul><li>Delayed intervention (>2 weeks) -> decreased mortality </li></ul><ul><li>The standart of care for operative management is not well estabilished!! </li></ul>
    5. 6. Infected necrosis diagnosis <ul><li>Infection of the necrotic tissue should be considered in case of fever > 38.5 ° C, leukocytosis, increasing plasma C-reactive protein (CRP) and procalcitonine (PCT) or rapid clinical deterioration. </li></ul><ul><li>Signs of gas inclusion in pancreatic or extrapancreatic necrosis are highly suspicious for infection . </li></ul><ul><li>Whitcomb DC: N Engl J Med 2006; 354: 2142–215 </li></ul>
    6. 7. Hughes SJ, et al. Gastroenterol Clin N Am, 2007
    7. 8. When? <ul><li>T iming of surgery to debride non-viable pancreas (necrosectomy) after acute pancreatitis is clearly changing, </li></ul><ul><li>N ecrosectomy is usually reserved for persistently febrile patients who fail to respond to broad spectrum a b’s with or without percutaneous drainage of fluid collections over 72 h or more. </li></ul>
    8. 9. CT Diagnosis <ul><li>As classified in Atlanta Symposium , on contrast-enhanced CT, the necrotic pancreatic tissue presents as diffuse or focal area with decreased or missing contrast enhancement compared to normal pancreatic parenchyma . </li></ul>
    9. 10. <ul><li>CT Early Phase </li></ul><ul><li>CT Late Phase </li></ul>
    10. 11. Endo US Endoscopic ultrasound: - to define the optimal puncture position - to exclude vessel interposition.
    11. 12. Conventional management <ul><li>Open necrosectomy and po irrigation </li></ul><ul><li>With MOF mortality 40-60% </li></ul>Charnley RM. Endoscopy, 2006, Slavin J, et al. World J Gastroenterol . 2001 Rau B, et al. Gut. 1997
    12. 14. OPEN SURGERY IS
    13. 15. Why open surgery is <ul><li>D ue to the operative stress in critically ill pts, surgery associated with high M&M (20–30%). </li></ul><ul><li>T wo thirds of pts develope s long-term complications, making repeated laparotomies necessary (17–71%) </li></ul><ul><li>T reatment of infected pancreatic necrosis has progressively been shifted from surgical to nonsurgical strategies </li></ul>Becker V, Pancreatology 2009;9:280–286 ?
    14. 16. Which management technique of infected necroses
    15. 17. Which management technique of infected necroses <ul><li>Percutaneous interventional drainage </li></ul><ul><li>Endoscopic approach (transgastric , transduodenal, transpapillary), </li></ul><ul><li>Retroperitoneal approach </li></ul><ul><li>Minimally invasive, Laparoscopic debridement </li></ul>
    16. 18. Severe Acute Pancreatitis Fine needle aspiration of necrosis (+) (-) Aggresive ICU care Conservative management Necrosis endoscopically accesible Posterior gastric / medical duodenal wall Necrosis in Paracolic gutters Perinephric and Retroduodenal space Endoscopic necrosectomy Laparoscopic necrosectomy or Endoscopic necrosectomy No improvement Surgical drainage
    17. 19. “ Laparoscopic debridement” <ul><li>Advantages: </li></ul><ul><li>-Complete removal of sequestrum possible </li></ul><ul><li>-Access to the lesser sac, paracolic gutters, perinephric space, retro duodenal space for drainage possible </li></ul><ul><li>Disadvantage: </li></ul><ul><li>-More invasive compared to other endoscopic techni q ues </li></ul><ul><li>-Safety of pneumoperitoneum in critically il l patients questionable </li></ul><ul><li>-Risk of intraperitoneal infection transmission rate (36%) </li></ul>
    18. 20. “ Percutaneous interventional drainage” <ul><li>Advantages: </li></ul><ul><li>-Avoids the need for surgery in criticaly ill patients </li></ul><ul><li>-Drainage of infected fluid under pressure aids healing </li></ul><ul><li>Disadvantage: </li></ul><ul><li>-Need for repeated drainage with high morbidity </li></ul><ul><li>-Central gland necrosis not amenable to curative treatment </li></ul><ul><li>-Increased risk of fistula </li></ul><ul><li>-Failure rate of 31-87% </li></ul><ul><li>-Adjunctive treatment often required. </li></ul>Freeny PC, AJR Am J Roentgenol.1998
    19. 21. “ Endoscopic approach” <ul><li>Advantages: </li></ul><ul><li>- Risk of fistula formation less </li></ul><ul><li>- Less invasive and lesser morbidity and mortality </li></ul><ul><li>- Can be used in poor risk surgical candidates </li></ul><ul><li>Disadvantage: </li></ul><ul><li>Necrosis needs to w alled off for effective drainage </li></ul><ul><li>Local bleeding risk (0-32%) </li></ul><ul><li>Single endoscopic procedures are often insufficient in treatment of huge necrotic areas containing large amounts of solid or purulent necrotic material. </li></ul>
    20. 23. Equipment <ul><li>Duodenoscope </li></ul><ul><li>EUS </li></ul><ul><li>Pig tail </li></ul><ul><li>Balloon dilatation </li></ul><ul><li>Basket catheter </li></ul><ul><li>Double J stent </li></ul><ul><li>Guide wire </li></ul><ul><li>Needle knife </li></ul><ul><li>Electrocautery </li></ul>
    21. 24. Case 1/ Percutaneous drainage plus endoscopic trans-gastric necrosectomy <ul><li>53 yo, F </li></ul><ul><li>Referred necrotizing pancreatitis, vomiting, abdominal distantion, </li></ul><ul><li>WBC: 18300, temperature: 39 º C, CRP: 254 mg/L, </li></ul><ul><li>CT: huge pseudocyst </li></ul><ul><li>Percutaneous drainage was unsuccesfull </li></ul>
    22. 26. Gas inclusion in pancreatic necrosis
    23. 27. NOTES Transmural Necrosectomy
    24. 30. Vaka 4
    25. 31. Retroperitoneal approach <ul><li>Advantages: </li></ul><ul><li>-Can be used in critically ill patients w here laparoscopic access not possible </li></ul><ul><li>-Subsequent liquefied necrosis drained by g ravity </li></ul><ul><li>-No intraperitoneal infection transmission </li></ul><ul><li>-Lesser bleeding risk </li></ul><ul><li>Disadvantage: </li></ul><ul><li>-More invasive compared to other endoscopic techniques </li></ul><ul><li>-Need for repeated procedures for effective drainage </li></ul><ul><li>(May not be required if liquefied) </li></ul>
    26. 32. <ul><li>The endoscope introduced through the mature drainage tube sinus tract after formal open necrosectomy. </li></ul><ul><li>“ S inus tract endoscopy” can remove both the residual necrosum and the ongoing developing necrosis. </li></ul><ul><li>In a series of 11 consecutive patients this procedure had no added morbidity/mortality, facilitated lavage, minimised the need for subsequent surgeries . </li></ul>
    27. 33. Minimally Invasive Technique Retroperitoneal Necrosectomy
    28. 34. Case 2/ Minimally Invasive Technique Retroperitoneal Necrosectomy <ul><li>57,M </li></ul><ul><li>Temp: 38,9 º C </li></ul><ul><li>CRP: 215 </li></ul><ul><li>WBC: 16700 </li></ul><ul><li>Percutaneous drainage was ineffective (2 times) </li></ul>
    29. 37. Before After
    30. 38. Case 3/ Endoscopic cystogastrostomy- stending <ul><li>62 yo M </li></ul><ul><li>Abdominal pain, vomiting </li></ul><ul><li>Acute biliary pancreatitis, </li></ul>
    31. 39. August 18
    32. 40. September 15 Before endoscopic cystogastrostomy
    33. 42. October 3 After endoscopic cystogastrostomy
    34. 43. October 18, re-cyctogastrostomy /2nd seance
    35. 44. December, 13
    36. 46. <ul><ul><li>THANK YOU! </li></ul></ul>
    37. 49. <ul><li>46, M </li></ul><ul><li>Ranson 3, biliary pancreatitis </li></ul><ul><li>Vomiting in 3th week, abdominal distantion </li></ul><ul><li>BT: </li></ul>