Читать книгу Clinical Pancreatology for Practising Gastroenterologists and Surgeons - Группа авторов - Страница 179

Acute necrotizing pancreatitis (ANP) is still a life‐threatening disease associated with high morbidity and up to 60% mortality [1]. It was classically accepted that infected pancreatic necrosis (IPN), confirmed by a positive culture of the necrosis after fine‐needle aspiration (FNA) [2], was an absolute indication for emergent surgical debridement [3], especially in the presence of multiorgan failure [4]. However, it seems that the diagnosis of IPN alone is no longer an absolute indication for direct surgical intervention, or at least that it is extremely challenging to determine the best timing for intervention, or even to decide whether surgery is the best option. In this regard, in a few years we have moved from highly proactive management [5] to a conservative approach. The first randomized controlled trial on this topic in the late 1990s showed that postponing surgery by at least 12 days from onset of symptoms significantly reduced complications [6]. Indeed, it seems that delaying the intervention to the third or fourth week of symptoms tends to reduce mortality compared with the first 14 days after onset of symptoms [7]. The rationale for this delay is based on the fact that a new “hit” in these already critical patients would have a negative impact on outcomes. The international guidelines now advise this cutoff and do not recommend operations on ANP in the first two weeks from onset, as long as the patient responds favorably to medical management [8,9].

The surgical treatment of IPN has evolved rapidly in recent years. When open necrosectomy and debridement were traditionally considered the gold standard [10,11], most patients were subjected to surgical explorations, removal of necrotic debris through the gastrocolic route, and multiple drain placements. This hazardous approach was classically associated with a high rate of postoperative complications, reoperations and mortality, as well as being frequently associated with postoperative diabetes and exocrine pancreas insufficiency [1,12]. However, the new alternative minimally invasive techniques have been shown to reduce morbidity and mortality [13]. In a landmark study published in 2010, van Santvoort et al. [14] established the so‐called “step‐up” approach as the new ANP gold‐standard surgical procedure. This consists of a stepwise rise in the use of invasive techniques, since the success of surgery in this setting depends on controlling the source of infection rather than completely removing the infected necrosis [15]. In fact, severe pancreatitis is more likely to be related to extrapancreatic organ failure than to local complications [16].

The goal of this chapter is thus to describe the different minimally invasive approaches, which can be classified into four broad groups: percutaneous, retroperitoneal, laparoscopic (transperitoneal), and endoscopic (endoluminal).