review of literature on clinical pancreatology - The Pancreapedia

to be successful to treat pancreatic necrosis. The anatomic location <strong>of</strong> the necrosis, clinicalcomorbidities, and operator experience determine the best approach for a particular patient.Tertiary care centers with sufficient expertise are increasingly using minimally invasiveprocedures to manage pancreatic necrosis [231].Minimal invasive methodsInfection <strong>of</strong> pancreatic necrosis is a life-threatening complication during the course <strong>of</strong> acutepancreatitis. In critically ill patients, surgical or extended endoscopic interventions areassociated with high morbidity and mortality. Minimally invasive procedures on the otherhand are <strong>of</strong>ten insufficient in patients suffering from large necrotic areas containing solid orpurulent material. It was presented a strategy combining percutaneous and transgastricdrainage with continuous high-volume lavage for treatment <strong>of</strong> extended necroses and liquidcollections in a series <strong>of</strong> patients with severe acute pancreatitis. Seven consecutive patientswith severe acute pancreatitis and large confluent infected pancreatic necrosis were enrolled.In all cases, the first therapeutic procedure was placement <strong>of</strong> a CT-guided drainage catheterinto the fluid collection surrounding peripancreatic necrosis. Thereafter, a secondendosonographically guided drainage was inserted via the gastric or the duodenal wall. Aftercommunication between the separate drains had been proven, an external to internaldirected high-volume lavage with a daily volume <strong>of</strong> 500 ml up to 2,000 ml was started. In allpatients, pancreatic necrosis/liquid collections could be resolved completely by the presentedregime. No patient died in the course <strong>of</strong> the study. After initiation <strong>of</strong> the directed high-volumelavage, there was a significant clinical improvement in all patients. Double drainage wasperformed for a median <strong>of</strong> 101 days, high-volume lavage for a median <strong>of</strong> 41 days. Severalendoscopic interventions for stent replacement were required (median 8). Complicationssuch as bleeding or perforation could be managed endoscopically, and no subsequentsurgical therapy was necessary. All patients could be dismissed from the hospital after amedian duration <strong>of</strong> 78 days. This approach <strong>of</strong> combined percutaneous or endoscopicdrainage with high-volume lavage shows promising results in critically ill patients withextended infected pancreatic necrosis and high risk <strong>of</strong> surgical intervention. Neither surgicalnor endoscopic necrosectomy was necessary in any <strong>of</strong> our patients [232].Minimally invasive necrosectomy is an umbrella term encapsulating the retroperitoneal,endoscopic and laparoscopic approaches which all share the common goal <strong>of</strong> avoidance <strong>of</strong>the physiological insult <strong>of</strong> the traditional “open” laparotomy approach to necrosectomy.However, there is no randomised trial evidence comparing these techniques meaning thatcurrent evidence is unclear in terms <strong>of</strong> which approach to select in any particular setting.Patients with pancreatic necrosis represent individuals at high risk for adverse outcome andshould be managed by a multidisciplinary team in a specialist unit. At a minimum, thereshould be input from surgical, radiological, and gastroenterological experts. Procedures mustnot be selected simply on the expertise <strong>of</strong> a single discipline. Specialist care should reflectevidence from the open necrosectomy era that is likely to translate to minimally invasiveinterventions. In contemporary pancreatic surgical practice, magnetic resonance (MR)scanning provides additional diagnostic information (in addition to computed tomography andendoscopic ultrasonography) in the critical later stages <strong>of</strong> pancreatic sepsis and in particularin relation to the fluid/solid components <strong>of</strong> necrosis. Although it could be argued that MR isnot widely available and that CT remains the gold-standard test, an equally validcounterargument is that complex, novel approaches to pancreatic necrosis should not beadopted in units that are not comprehensively equipped. With staging information to hand, abroad categorization can be made into individuals with predominantly solid necrosis andthose with fluid-predominant collection. In the former category, collections tracking to the leftparacolic gutter and retroperitoneum are in the category wherein good outcomes have beenreported from image-guided placement <strong>of</strong> guidewires, the Seldinger technique for placement<strong>of</strong> drains followed by retroperitoneal necrosectomy. The retroperitoneal approach seems far