1) Retroperitoneal endoscopic necrosectomy and NOTES pancreatic necrosectomy are minimally invasive techniques for treating infected pancreatic necrosis as an alternative to open necrosectomy. 2) The document describes various management techniques for infected pancreatic necrosis including percutaneous drainage, endoscopic approaches, laparoscopic debridement, and retroperitoneal approaches. 3) Case studies demonstrate the use of techniques like transgastric endoscopic necrosectomy, retroperitoneal necrosectomy, and endoscopic cystogastrostomy to treat infected pancreatic necrosis.

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. Acute Pancreatitis Parenchymal necrosis: 10-25% Mild: Non-necrotizing – edematous (80-85%) Mortality 0-3% Severe: Necrotizing pancreatitis (15-20%) Steril necrosis: 0-11% Infected necrosis: 40 % on average, up to 70% Hughes SJ, et al. Clin N Am, 2007 Isaji S, J Hepatobiliary Pancreat surg, 2006

4. Management of the severe pancreatitis Early Phase Interventions - Diagnosis of pancreatic necrosis: Role of Imaging, CT The use of prophylactic Ab Nutrition Renal insufficiency and medical management considerations Indications for early operative intervention

5. Management of the severe pancreatitis Late Phase Interventions Surgical approaches, timing, and complications -> Delayed intervention (>2 weeks) -> decreased mortality The standart of care for operative management is not well estabilished!!

6. Infected necrosis diagnosis 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. Signs of gas inclusion in pancreatic or extrapancreatic necrosis are highly suspicious for infection . Whitcomb DC: N Engl J Med 2006; 354: 2142–215

7. Hughes SJ, et al. Gastroenterol Clin N Am, 2007

8. When? T iming of surgery to debride non-viable pancreas (necrosectomy) after acute pancreatitis is clearly changing, 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.

9. CT Diagnosis 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 .

10. CT Early Phase CT Late Phase

11. Endo US Endoscopic ultrasound: - to define the optimal puncture position - to exclude vessel interposition.

12. Conventional management Open necrosectomy and po irrigation With MOF mortality 40-60% Charnley RM. Endoscopy, 2006, Slavin J, et al. World J Gastroenterol . 2001 Rau B, et al. Gut. 1997

14. OPEN SURGERY IS

15. Why open surgery is D ue to the operative stress in critically ill pts, surgery associated with high M&M (20–30%). T wo thirds of pts develope s long-term complications, making repeated laparotomies necessary (17–71%) T reatment of infected pancreatic necrosis has progressively been shifted from surgical to nonsurgical strategies Becker V, Pancreatology 2009;9:280–286 ?

16. Which management technique of infected necroses

17. Which management technique of infected necroses Percutaneous interventional drainage Endoscopic approach (transgastric , transduodenal, transpapillary), Retroperitoneal approach Minimally invasive, Laparoscopic debridement

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

19. “ Laparoscopic debridement” Advantages: -Complete removal of sequestrum possible -Access to the lesser sac, paracolic gutters, perinephric space, retro duodenal space for drainage possible Disadvantage: -More invasive compared to other endoscopic techni q ues -Safety of pneumoperitoneum in critically il l patients questionable -Risk of intraperitoneal infection transmission rate (36%)

20. “ Percutaneous interventional drainage” Advantages: -Avoids the need for surgery in criticaly ill patients -Drainage of infected fluid under pressure aids healing Disadvantage: -Need for repeated drainage with high morbidity -Central gland necrosis not amenable to curative treatment -Increased risk of fistula -Failure rate of 31-87% -Adjunctive treatment often required. Freeny PC, AJR Am J Roentgenol.1998

21. “ Endoscopic approach” Advantages: - Risk of fistula formation less - Less invasive and lesser morbidity and mortality - Can be used in poor risk surgical candidates Disadvantage: Necrosis needs to w alled off for effective drainage Local bleeding risk (0-32%) Single endoscopic procedures are often insufficient in treatment of huge necrotic areas containing large amounts of solid or purulent necrotic material.

23. Equipment Duodenoscope EUS Pig tail Balloon dilatation Basket catheter Double J stent Guide wire Needle knife Electrocautery

24. Case 1/ Percutaneous drainage plus endoscopic trans-gastric necrosectomy 53 yo, F Referred necrotizing pancreatitis, vomiting, abdominal distantion, WBC: 18300, temperature: 39 º C, CRP: 254 mg/L, CT: huge pseudocyst Percutaneous drainage was unsuccesfull

26. Gas inclusion in pancreatic necrosis

27. NOTES Transmural Necrosectomy

30. Vaka 4

31. Retroperitoneal approach Advantages: -Can be used in critically ill patients w here laparoscopic access not possible -Subsequent liquefied necrosis drained by g ravity -No intraperitoneal infection transmission -Lesser bleeding risk Disadvantage: -More invasive compared to other endoscopic techniques -Need for repeated procedures for effective drainage (May not be required if liquefied)

32. The endoscope introduced through the mature drainage tube sinus tract after formal open necrosectomy. “ S inus tract endoscopy” can remove both the residual necrosum and the ongoing developing necrosis. In a series of 11 consecutive patients this procedure had no added morbidity/mortality, facilitated lavage, minimised the need for subsequent surgeries .

33. Minimally Invasive Technique Retroperitoneal Necrosectomy

34. Case 2/ Minimally Invasive Technique Retroperitoneal Necrosectomy 57,M Temp: 38,9 º C CRP: 215 WBC: 16700 Percutaneous drainage was ineffective (2 times)

37. Before After

38. Case 3/ Endoscopic cystogastrostomy- stending 62 yo M Abdominal pain, vomiting Acute biliary pancreatitis,

39. August 18

40. September 15 Before endoscopic cystogastrostomy

42. October 3 After endoscopic cystogastrostomy

43. October 18, re-cyctogastrostomy /2nd seance

44. December, 13

46. THANK YOU!

49. 46, M Ranson 3, biliary pancreatitis Vomiting in 3th week, abdominal distantion BT: