Laparoscopic Transgastric Pancreatic Necrosectomy and Cystgastrostomy

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Author: Bestoun Ahmed
Published:
Specialties: General Surgery
Schools: University of Florida-Jacksonville
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Basic Info

Contributors: Michael Nussbaum

Pancreatic necrosectomy is a necessary operation for necrotizing pancreatitis. The traditional open approach has been associated with difficult access and significant negative outcomes including wound complications, pancreatic fistula and prolonged hospital stay. A 57-y-old female patient presented with mild abdominal pain and epigastric fullness.She had a history of multiple episodes of acute pancreatitis and pseudocyst formation. Abdominal computed tomography (CT )scan showed a large pseudocyst of 12x15 cm size compressing the posterior wall of the stomach. Following cystgastrostomy, a large amount of necrotic pancreatic tissue is found and so necrosectomty step was added to the operation.This video demonstrates the technical details during a minimally invasive necrosectomy of the pancreas with an expedited recovery. 

DOI: http://dx.doi.org/10.17797/1ms9xzjz24

Editor Recruited By: Jeffrey B. Matthews, MD

Advanced

Procedure

Diagnostic laparoscopy is performed and confirmed the pancreatitis. It shows saponification of the pancreas. Laparoscopic intraoperative ultrasonography confirmed CT scan findings and determined the most accessible pathway to the cyst. An anterior wall gastrotomy is then performed and extended to 5 cm length. The cyst is then aspirated through the posterior stomach wall followed by posterior wall gastrotomy. A linear 60 mm stapler is used to staple posterior stomach wall to the anterior cyst wall. Extensive pancreatic necrosectomy is done and the area is irrigated with normal saline. Closure of the anterior gastrotomy is then achieved and the necrotic tissue is placed in a pouch and extracted. Operative time: 125 minutes, EBL: 50 ml. The patient was out of bed the evening of surgery. She also tolerated oral intake on postoperative day 3 after removing the nasogastric tube. She was then discharged on postoperative day 5. Pathology: Necrotic pancreatic tissue.

Indications

Indications for pancreatic necrosectomy:
1.Infected pancreatic necrosis
2.Severe acute pancreatitis and necrosis associated with hemodynamic changes with no response to resuscitative measures
3.Significant symptoms like persistent abdominal pain
4.¢Walled off¢ necrosis preferably at least 4 weeks following an acute pancreatitis episode.
5.Compression on the surrounding structures: gastric outlet or biliary obstruction, bleeding or fistulizing into the surrounding organs
6.Abdominal compartment syndrome

Indications for Laparoscopic Approach:
1.Stable patients with well-organized necrosis
2.Simultaneous Laparoscopic cholecystectomy in patients with biliary pancreatitis

Contraindications

Contraindications for Laparoscopic Approach:
1.Unstable patients
2.Early cyst formation (less than 4 weeks from pancreatitis episode)
3.Previous multiple abdominal incisions (a relative contraindication)
4.Absence of good abutment of cyst wall to the posterior stomach wall (transgastric approach)

Instrumentation

Setup

The patient is placed in a supine position. The surgeon stands on the patient¢s right side and two assistants on the left side. A Veress needle is placed in the upper abdomen and CO2 pneumoperitoneum is obtained. Four trocars are placed in a crescent fashion along the left costal margin. A 5mm trocar in the epigastric area, a 10 mm trocar midway between xiphisternum and umbilicus, a10 mm trocar at the left midclavicular area and a 5 mm trocar at the left anterior axillary line.

Preoperative Workup

1.CT scan of the abdomen, pancreas protocol
2.Endoscopic ultrasonography (EUS) may facilitate endoscopic drainage in the absence of extensive necrosis.
3.General labs including complete blood count, serum electrolytes, creatinine, glucose, albumin and prealbumin.

Anatomy and Landmarks

1.Percutaneous retroperitoneal drainage with or without endoscopic assistance is an option which could be used before a more extensive procedures
2.Trans-oral (NOTES) approach is a useful approach for patients with limited necrosis
3. Laparoscopic access is performed with hand-assisted or totally laparoscopic approach, or alternatively by creation of a cyst-enterostomy via a transgastric or retrogastric approach.
4.Complete necrosectomy is possible with laparoscopic approach. This may need good exposure of the cyst contents. The approach should give access to the head of pancreas if needed.
5.Caution should be taken to avoid injuring splenic vessels especially in patients who need extensive and deep debridement.
6.The necrotic material should always be extracted through an endopouch. Ample saline irrigation of the pancreatic bed is always needed.
7.Conversion to open approach is vital in case of uncontrollable bleeding, unstable patient and failure of laparoscopic approach.

Advantages/Disadvantages

Advantages of Laparoscopic Approach:
1.Laparoscopic approach has specific benefits over open approach:
-Less intraoperative blood loss
-Less pain
-Cosmetic benefit (smaller incisions)
-Less incidence of incisional hernia
-Less incidence of wound infection
-Earlier return to normal activities of daily living
2.Laparoscopic transgastric necrosectomy approach via cyst enterostomy has less incidence of major vessels injury. Therefore it is associated with less chance of bleeding and visceral ischemia.
3.Pancreatic fistula is less likely with this approach.
4.Laparoscopic approach can access areas which is not amenable through endoscopic or retroperitoneal access.
5.This approach can give a success rate of up to 95%, but with morbidity of 20% and mortality of 0.18%.

Disadvantages:
1.Laparoscopic approach has longer operative time.
2.Laparoscopic approach is not advisable in patients with borderline intraoperative stability.
3.Peritoneal contamination by necrotic and possibly infected material in comparison to endoscopic and retroperitoneal approach.

Complications/Risks

Complications/Risks of pancreatic necrosectomy:
Intraoperative:
-Bleeding which necessitates conversion from laparoscopic to open approach.
-Inability to obtain complete debridement by laparoscopic approach.
Early postoperative:
-Bleeding which requires blood transfusion, angioembolization or operative hemostasis.
-Multiorgan failure is a common reason for prolonged ICU stay.
-Both bleeding and multiorgan failure can lead to a postoperative mortality which can reach 25%.
Late postoperative (Endoscopic or Radiologic approaches could be used to manage most):
-Biliary stricture in (6%).
-Persistent/recurrent pseudocyst in (8%),
-Pancreatic fistula in (13%),
-Gastrointestinal fistula in (2%),
-Delayed collections in (5%)
-Incisional hernia in (2%)
-Exocrine insufficiency in (25%).
-Endocrine insufficiency in (33%)
-Long hospital or ICU and hospital stay

Disclosure of Conflicts

Complications/Risks of pancreatic necrosectomy:
Intraoperative:
-Bleeding which necessitates conversion from laparoscopic to open approach.
-Inability to obtain complete debridement by laparoscopic approach.
Early postoperative:
-Bleeding which requires blood transfusion, angioembolization or operative hemostasis.
-Multiorgan failure is a common reason for prolonged ICU stay.
-Both bleeding and multiorgan failure can lead to a postoperative mortality which can reach 25%.
Late postoperative (Endoscopic or Radiologic approaches could be used to manage most):
-Biliary stricture in (6%).
-Persistent/recurrent pseudocyst in (8%),
-Pancreatic fistula in (13%),
-Gastrointestinal fistula in (2%),
-Delayed collections in (5%)
-Incisional hernia in (2%)
-Exocrine insufficiency in (25%).
-Endocrine insufficiency in (33%)
-Long hospital or ICU and hospital stay

Acknowledgements

References

1.Connor S, Alexakis N, Raraty MG, et al. Early and late complications after pancreatic necrosectomy. Surgery. 2005 May;137(5):499-505.

2.Van Santvoort HC, Besselink MG, Bakker OJ et al.; Dutch Pancreatitis Study Group. A step-up approach or open necrosectomy for necrotizing pancreatitis. N. Engl. J. Med. 2010;362(16):1491¢1502. Multicenter randomized control trial that demonstrated the superiority of minimally invasive necrosectomy over open necrosectomy.

3.Seifert H, Biermer M, Schmitt W et al. Transluminal endoscopic necrosectomy after acute pancreatitis: a multicentre study with long-term follow-up (the GEPARD Study). Gut. 2009;58(9):1260¢1266. First multicentric study with long-term follow-up on direct endoscopic necrosectomy.

4.Bakker OJ, van Santvoort HC, van Brunschot S et al.; Dutch Pancreatitis Study Group. Endoscopic transgastric vs surgical necrosectomy for infected necrotizing pancreatitis: a randomized trial. JAMA. 2012;307(10):1053¢1061. A randomized trial comparing open necrosectomy with minimally invasive necrosectomy in patients with infected necrosis.

5.Besselink MG, van Santvoort HC, Nieuwenhuijs VB et al.; Dutch Acute Pancreatitis Study Group. Minimally invasive 'step-up approach' versus maximal necrosectomy in patients with acute necrotising pancreatitis (PANTER trial): design and rationale of a randomised controlled multicenter trial [ISRCTN13975868]. BMC Surg.2006;6,6.

6.Tan JW, Tan H, Hu B, et al. Short-Term Outcomes from a Multicenter Retrospective Study in China Comparing Laparoscopic and Open Surgery for the Treatment of Infected Pancreatic Necrosis. Journal of Laparoendoscopic & Advanced Surgical Techniques. 2012;22(1):27-33.

7.Parekh D. Laparoscopic-Assisted Pancreatic Necrosectomy. Arch Surg. 2006;141:895-903.

8.Fink D, Soares R, Matthews JB, et al. History, Goals, and Technique of Laparoscopic Pancreatic Necrosectomy. J Gastrointest Surg . 2011;15:1092¢1097.

9.Navaneethan U, Vege SS, Chari ST, et al. Minimally Invasive Techniques in Pancreatic Necrosis. Pancreas. 2009 November; 38(8):867-75.

10.Pamoukian VN, Gagner M. Laparoscopic necrosectomy for acute necrotizing pancreatitis. J Hepatobiliary Pancreat Surg. 2001;8:221¢223.

11.Wysocki AP, McKay KJ, Carter CR, et al. Infected pancreatic necrosis: minimizing the cut. ANZ J Surg .2010;80:58¢70.

12.Schmidt CM. Introduction: SSAT/AGA/ASGE State-of-the-Art Conference: Necrotizing Pancreatitis: Novel Minimally Invasive Strategies. J Gastrointest Surg. 2011;15:1086¢1088.

13.De Rai P, Zerbi A, Castoldi L, et al (Italian Association for the Study of the Pancreas). Surgical management of acute pancreatitis in Italy: lessons from a prospective multicenter study. HPB. 2010;12:597¢604.

14.Owera AM, Ammori BJ. Laparoscopic endogastric and transgastric cystgastrostomy and pancreatic necrosectomy. Hepatogastroenterology. 2008 Jan-Feb;55(81):262-5.

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