Step-up Approach and Video Assisted Retroperitoneal Debridement in Infected Necrotizing Pancreatitis: A Case Complicated by Retroperitoneal Bleeding and Colonic Fistula

Overview

Journal Ann Med Surg (Lond)

Publisher Wolters Kluwer

Specialty Medical Education

Date 2015 Nov 21

PMID 26587229

Citations 3

Authors

Eugene Lim

R S Sundaraamoorthy

David Tan

Hui-Seong Teh

Tzu-Jen Tan

Anton Cheng

Affiliations

Soon will be listed here.

Abstract

Introduction: Infected Necrotizing Pancreatitis carries a high mortality and necessitates intervention to achieve sepsis control. The surgical strategy for proven infected necrosis has evolved, with abandonment of open necrosectomy to a step-up approach consisting of percutaneous drains and Video-assisted retroperitoneal debridement (VARD). We present a case that underwent VARD complicated by bleeding and colonic perforation and describe its management.

Presentation Of Case: A 38 year-old male with acute pancreatitis developed infected necrotizing pancreatitis. Initial treatment was by percutaneous drainage under radiological guidance and intravenous antibiotics. The infected retroperitoneal necrosis was then debrided using gasless laparoscopy through a mini-incision. Post-operatively, he developed peripancreatic bleeding which was controlled with angioembolisation. He also developed a descending colon fistula which was treated with laparotomy and defunctioning loop ileostomy. He recovered and subsequently had his ileostomy closed twelve months later. The colonic fistula recurred and was treated with endoscopic clips and histoacryl glue injection and finally closed.

Discussion: Step-up approach consists of the 3 D's: Delay, drain and debride. VARD is recommended as it is replicable in general surgical units using standard laparoscopic instruments. Bleeding and colon perforation are potential complications which must have multi-disciplinary input, aggressive resuscitation and timely radiologic intervention. Defunctioning ileostomy is recommended to control sepsis in colonic fistulation. Novel fistula closing methods using endoscopic clips and histoacryl glue are potential treatment options.

Conclusion: Step-up approach and VARD is the new paradigm to treat necrotizing pancreatitis. Complications of bleeding and colon fistula are uncommon and require multi-disciplinary management.

Citing Articles

An outcome analysis of videoscopic assisted retroperitoneal debridement in infected pancreatic necrosis: a single centre experience.

Budkule D, Desai G, Pande P, Narkhede R, Wagle P, Varty P Turk J Surg. 2020; 35(3):214-222.

PMID: 32550331 PMC: 6795228. DOI: 10.5578/turkjsurg.4289.

Successful treatment for severe pancreatitis with colonic perforation using video-assisted retroperitoneal debridement: A case report.

Hozaka Y, Kurahara H, Mataki Y, Kawasaki Y, Iino S, Sakoda M Int J Surg Case Rep. 2018; 52:23-27.

PMID: 30308424 PMC: 6176850. DOI: 10.1016/j.ijscr.2018.09.046.

Comparison of contrast-enhanced CT with diffusion -weighted MRI in the Evaluation of patients with acute biliary pancreatitis.

Ilhan M, Ucuncu M, Gok A, Oner G, Agolli E, Canbay B Turk J Surg. 2017; 33(3):153-157.

PMID: 28944325 PMC: 5602304. DOI: 10.5152/UCD.2016.3573.

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