Page 34 - Journal of Laparoscopic Surgery

Kiran Somani, Dnyanesh M Belekar

For flexible endoscopy, each tract is dilated to 45 French net basket to achieve cyst resolution. Three large bore 10 French
using a balloon dilator. A twin-channel endoscope is then double pigtail stents are now inserted into the cyst under direct
passed through the skin opening. Further endoscopic antegrade endoscopic guidance. The first stent is delivered over a guide
dilatation of the tract is then performed until the entire length of catheter then the second stent and lastly the third stent. All
the drain tract can be visualized. Jet irrigation using a heater three stents are deployed. Finally, a nasocystic catheter is
probe and suction allows fluid collections to be cleared, and inserted for maintenance of irrigation.
residual solid necrotic tissue or adherent slough can be teased
away using a variety of endoscopic instruments (e.g. snares, DISCUSSION
stent retrieval forceps). A guidewire is then passed through the If acute pancreatitis is a model of sepsis, then conventional
endoscope and an 8 French umbilical catheter sutured to a surgery with its high complication rates is the second hit 14
28 French tube drain is placed in the cavity, after which lavage which could in part accountable for high mortality.
begins again. In IPN, maximal optimal intensive care may not be able to
halt/reverse disease progression in some patients. Most of the
Method of EUS-Guided Endoscopic Transgastric deaths occurring earlier in the course of the disease are due to
Pancreatic Necrosectomy 18
multiple organ dysfunction syndromes (MODS). Infection is
Pancreatic pseudocyst drainage was the first therapeutic the superadded compounding insult for the survivors.
application of EUS. The cyst is punctured under ultrasound Prediction of severity is core to the management.
guidance, contrast injected and a guidewire inserted. Initial The Ranson and Imrie scoring systems have sensitivity of
dilation to 8 mm is performed over the wire. The EUS scope is about 80% at 48 hours, and acute physiology and chronic health
then exchanged over the wire for a forward viewing endoscope. evaluation (APACHE) II system has a sensitivity of around
A second dilation to 18 mm is performed. This enables entry of 85% for score > 9 on admission. Serum biomarkers, such as
the endoscope into the cyst perform cystoscopy, debridement C-reactive protein (> 150 mg/l at 48 hr), IL-8, IL-6, procalcitonin,
if necessary and insertion of multiple large bore double pigtail IL-10 and IL-1 beta-receptor antagonist are predictors of
stents. severity.
We report on the use of the prototype forward viewing Infection in the pancreatic necrosis is not a clinical
echoendoscope in six consecutive patients who were referred diagnosis, due to overlap of features with systematic
for pancreatic cyst drainage. Here, you see endoscopic view inflammatory response syndrome; the latter would be evident.
indistinguishable from that of a gastroscope showing a bulge Acute infective pancreatic necrosis is an objective diagnosis
where the cyst impinges against the posterior gastric wall. Power following positive culture or contrast-enhanced CT showing
Doppler is switched on and highlights multiple vessels gas pockets in/around the necrosum. Serum procalcitonin is a
interposed in the wall. This allows selection of a safe vessel- biomarker of infection and is a valuable tool.
free window for a cyst puncture. A 19 G needle is advanced into Sterile necrosis can either resolve from peripancreatic fluid
the cyst lumen. A sample of contents is aspirated for fluid collections, pseudocyst or can become infected. Patients with
analysis. necrotising pancreatitis should be managed intensively as they
A guidewire under ultrasound guidance is inserted into the have a potential for developing MODS. The demarcation of
cyst. An 18 mm balloon is coaxially thread over the wire and necrotic tissue takes at least one week after the acute attack,
advanced across the cyst wall. Note that resistance is and hence, surgery should be delayed until at least the second
encountered, but the forward transfer of force overcome this. week of the attack, when possible.
The dilation is performed under forward viewing endoscopic Removing the necrotic tissue removes the toxic inflammatory
and ultrasound guidance. As the balloon is maximally inflated mediators that can gain systemic access via portal circulation
we see the cystogastrostomy open up. The balloon is then or retroperitoneal lymphatics. The current consensus is for the
deflated while simultaneously advancing the scope into the removal of necrosum and preservation of viable pancreas along
cyst cavity. with maximal physiological support. In the past, surgical
Cystoscopy is now performed showing the cyst contents management consisted of tissue sparing procedures to total
to be filled with pasty wall-adherent necroses. Pulsed power pancreatectomy.
Doppler is switched on, we can see and hear arterial flow vessels Minimal access pancreatic necrosectomy has its own
within the wall of the cyst. This identifies sensitive areas at limitations. Each of the scopes and access routes has its
bleeding risk when performing debridement. In this case, advantages and disadvantages. The scopes can be compared
vigorous water jet irrigation is performed through an accessory for field of view, working channel for instruments and irrigation,
water irrigation channel built into the echoendoscope. external diameter, length, flexibility and angulation.
This issued to clear nonadherent debris. Our experience The routes can be compared for ease of access, risk of
has shown that it is not necessary to actively remove wall- collateral injury and unnecessary contamination, and the ability
adherent debris using extraction tools as such Dormia or Roth to deal with multiple and complex collections. The two

164
JAYPEE