Page 31 - Journal of Laparoscopic Surgery

WJOLS

Role of Minimal Access Surgery in Management of Infective Pancreatic Necrosis

been documented. The spectrum of bacteria cultured from infection with a secondary deterioration, often during the third
infected necrosis has altered with the more widespread use of and fourth weeks of admission. This is often heralded by a
prophylactic antibiotics, with a shift toward Gram-positive significant rise in CRP.
bacteria and fungal infections. 5 A CT scan often will confirm the presence of a tense
The necrotizing process can extend widely to involve collection with rim enhancement arising from a region of
retroperitoneal fat, small and large bowel mesentery and the pancreatic necrosis. The presence of gas within the tissues
retrocolic and perinephric compartments. confirms infection, with an ‘air bubble’ appearance, but this is
present in the minority of cases. Infected necrosis usually is
DIAGNOSING OF IPN confirmed by fine-needle aspiration (FNA) for Gram’s stain and

The clinical symptoms and signs of pancreatic necrosis are bacterial culture. This can be guided by US or CT scan and is
indistinguishable from those of other patients presenting with considered safe and reliable.
acute pancreatitis. Abdominal pain, distension and guarding
are associated with a low-grade fever and tachycardia. The MANAGEMENT OF IPN
severity of pain and the extent of hyperamylasemia do not The goals of surgical management are to remove necrotic and
correspond with the severity of acute pancreatitis. Patients infected tissue, drain pus, lavage the peritoneal cavity and avoid
presenting late with severe disease often will have established blood loss and injury to other organs. Few advocate only
multiorgan dysfunction. observational nonoperative intensive approach to manage IPN. 7
The classic skin signs of retroperitoneal necrosis are Preservation of vital intact pancreatic tissue is important. The
discoloration at umbilicus (Cullen’s sign), the flanks (Grey- choice of operation is determined by the location, extent and
Turner’s sign) and the inguinal region (Fox’s sign), are rare and maturity of the necrotic material; status of the infection; the
often not seen until the second or third week. The diagnosis of patient’s condition, the degree of organ dysfunction and the
pancreatic necrosis requires more than clinical acumen. preference and experience of the surgeon.
The gold standard for the diagnosis of pancreatic necrosis A number of different approaches have been described some
is contrast-enhanced CT scanning demonstrating hypo- of which are only of historical interest. Necrosectomy is complex,
perfusion in the arterial phase. In the absence of a specific fraught with potentially life-threatening complications and
marker of pancreatic necrosis, many serum predictors have been should be left to the experienced surgeon. None of these surgical
proposed C-reactive protein (CRP) as the most widely used methods have been subjected to a randomized, controlled trial,

predictor of pancreatic necrosis and is useful as a daily monitor and the minimal access approaches are still evolving.The latter
of disease progress. The accuracy in detecting necrosis is about are best suited to treatment of well-demarcated and localized
85%, but it requires 3 to 4 days to reach this level. The threshold necrosis in the later stage of the disease.
values depend on the assay and the study used. The most One possible benefit of this approach is a reduction in the

commonly used threshold is greater than 120 mg/l. number of patients who need intensive-care support. The
Other prognostic markers, none of which has been minimal access surgical approaches to pancreatic necrosectomy
proven to outperform CRP, include interleukin-6 (threshold can be classified according to the type of optical system (flexible
> 14 pg/ml) which peaks a day earlier than polymorphonuclear endoscope, laparoscope or operating nephroscope) and the
elastase (threshold > 120 gm/l), which peaks early and reflects route used (via the stomach, peritoneum or retroperitoneum).
neutrophil activation and degranulation; and phospholipase
A type II (threshold > 15 units/l). Urinary trypsinogen- Open and Minimal Access Approaches to the
2
activating peptide and serum amyloid-A have also been studied Treatment of Pancreatic Necrosis
as early marker for severity prediction. 4 As per review of literature,
In practice, the indications for a CT scan to diagnose and • Open approaches:
determine the extent of pancreatic necrosis are the prediction of – Pancreatic resection
severe pancreatitis (usually during the second week), when a – Necrosectomy + wide tube drainage 8
patient fails to improve with initial resuscitation and/or when – Necrosectomy + staged laparotomy (reexploration)
the CRP has crossed the diagnostic threshold (see above). The – Necrosectomy + drainage + relaparotomy
CT scan can be used to grade the severity of acute pancreatitis – Necrosectomy + laparotomy + open packing 10
[CT Severity Index (CTSI)] based on the extent of extrapancreatic – Necrosectomy + drainage + closed continuous lavage 9
changes and pancreatic necrosis. – Retroperitoneal routed necrosectomy 11,12
The importance of the diagnosis of pancreatic necrosis is • Minimal access approaches:
to initiate intensive-care management, which may necessitate – Laparoscopic necrosectomy
transfer of the patient to a tertiary unit. The diagnosis of infected – Laparoscopic intracavitary necrosectomy
necrosis is imperative because it is an absolute indication for – Laparoscopic-assisted percutaneous drainage
surgical intervention. It is more usual to suspect pancreatic – Laparoscopic transgastric necrosectomy

World Journal of Laparoscopic Surgery, September-December 2011;4(3):160-165 161