Читать книгу Clinical Pancreatology for Practising Gastroenterologists and Surgeons - Группа авторов - Страница 183

With the rise of minimally invasive techniques, retroperitoneal pancreatic necrosectomy has become more widespread than open necrosectomy and the transperitoneal laparoscopic approach. Ideally, it should be applied to pancreatic or peripancreatic necrosis in the left pancreas, lesser sac, and left paracolic gutter (Figure 15.2a,b).

The technique was initially described in 1998 by Gambiez et al. [28], was later defined by Horvath et al. [29] as video‐assisted retroperitoneal debridement (VARD), and then popularized by van Santvoort et al. [14]. This approach is accepted as a secondary therapeutic procedure after failure of percutaneous drainage, which indeed is crucial for reaching the pancreatic lodge. It should be noted that the purpose of this procedure is to facilitate percutaneous drainage rather than to completely evacuate necrotic fluid from the cavity. The surgeon will find it easier to locate the necrosis within the cavity if a second anterior or caudal drain has been placed, although this is not essential.

The patient is placed in a modified lateral decubitus position (Figure 15.2c). The entire abdomen and flank are prepared and draped within the sterile field to allow adequate access to the retroperitoneum. A small incision is performed below the 12th rib following the previously inserted drainage. The pancreatic cell is reached via the left retroperitoneal access without opening the peritoneum, passing behind the splenic flexure of the colon and spleen. This dissection is performed bluntly under digital control. Once lodged in the pancreatic area, a laparoscopic camera is inserted through the small incision to view the area. Care must be taken to avoid injuring the blood vessels, so that adherent or necrotic tissue that cannot be freed easily should be left in place. The necrotic tissue is grasped and removed by suction and forceps. At the end of the procedure a large drain should be inserted to allow postoperative washes (Figure 15.2d).

Although this approach has been claimed to be the standard for WON in the left pancreas, real data on patient outcomes is scarce and limited to case series [14,30,31], which still report a mortality of up to 40%. The technique is also not exempt from complications, such as colonic fistula, gastric and duodenal perforation, enteric fistula, pancreatic fistula, and retroperitoneal hemorrhage, and therefore should be confined to centers with an appropriately experienced multidisciplinary team.

Figure 15.2 (a) Infected pancreatic necrosis by abdominal tomography. (b) Placement of a retroperitoneal percutaneous catheter in pancreatic lodge. (c) Position of the patient for video‐assisted retroperitoneal debridement (VARD). (d) After VARD, a 32‐Fr drain is placed in the pancreatic lodge to enable continuous flushes.

Source: courtesy of Patricia Sánchez‐Velázquez.