Abstract
Introduction:
The management of pancreatic necrosis has evolved rapidly over the past decade. The paradigm has shifted toward minimal procedures rather than upfront open necrosectomy, with subsequent invasive procedures deployed, as needed. This step-up approach has been well accepted around the world and has led to better operative outcomes in terms of complications and survival. 1 The timing and algorithm for an endoscopic step-up approach versus a surgical step-up approach favor an endoscopic approach based on randomized controlled trials. 2 , 3 The endoscopic approach is associated with a reduced rate of pancreatic fistula. However, the endoscopic approach may not be suitable for large pancreatic pseudocyst with thick necrotic material. A surgical procedure may be employed as salvage procedure when endoscopic attempts fail. The use of stents and endoscopic procedures can make subsequent necrosectomy more technically challenging.
Methods:
A 72-year-old male patient developed a large walled off necrosis after an episode of gallstone pancreatitis. The patient had undergone an endoscopic cystogastrostomy, metallic stent placement, and endoscopic necrosectomy earlier. However, his symptoms did not subside, he was referred to the surgical gastroenterology department. A laparoscopic necrosectomy was performed through the gastrocolic omentum route. The metallic stent was removed and the defect in the posterior stomach wall was sutured. A cholecystectomy was also performed. Wide bore drains were placed, along with a small feeding tube to provide postoperative lavage.
Results:
The operating time was 145 minutes and blood loss was 112 mL. One liter saline lavage for the initial 5 postoperative days was implemented. A computed tomography of the abdomen with oral contrast was obtained on postoperative day 5 that did not show a gastric leak from the suture line along the posterior wall. The patient was started on an oral diet. The patient was discharged on postoperative day 8 on a regular diet with no major complications. He was discharged with only one drain in situ, which was removed on first follow-up visit on postoperative day 15. During the 6 months follow-up period, there were no further collections in lesser sac or fever episodes. His appetite improved and he gained weight.
Conclusion:
Laparoscopic necrosectomy is challenging in patients with failed endoscopic procedure. Depending on patient and pseudocyst characteristics, laparoscopic necrosectomy may offer better resolution of symptoms in a single sitting, compared with endoscopy that often needs multiple sessions.
No competing financial interests exist.
Authors have received and archived patient consent for video recording/publication in advance of video recording of procedure.
Source of Video:
Aster Medcity Hospital, Kochi, India
Runtime of video: 8 mins 02 secs
Keywords
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