Retroperitoneal Approach and Debridement of Peripancreatic Necrosis.
Abstracts
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Aim : In the last ten years, our strategy of management of infected pancreatic necrosis has favored direct retroperitoneal approach (RA), thus avoiding the drawbacks of extensive laparotomies. Performing such lumbotomies has been eased by routine usage of endoscopic equipment which facilitates debridement through a limited operative field and repeat procedures. The indications and results of this strategy are reported. Patients and methods : Between 1990 and 2000, we managed 101 cases of ANP (65 M, 36 F, mean age : 51). Severity of the disease was assessed by Ranson score (average : 3.6) and Balthazar grading system (33 D, 68 E). . Etiologies were : gallstones (n = 42), alcohol (n = 41), miscellaneous (n = 17). RA was performed in 41 patients. Criteria were : clinical and / or bacteriological signs of infection in association to the worsening of the clinical state. Among these, 10 patients already had a percutaneous drainage in another institution with no improvement. Other patients : A laparotomy (L) was performed in 14 other patients because intraperitoneal complications were suspected. The remaining patients underwent only supportive therapy (ST, n = 36) or ST + percutaneous drainage (PD, n = 10) of a collection. Broad spectrum prophylactic antibiotherapy was undertaken in all patients. Results : In the RA group, infection was proved in 32 cases (78 %). The average number of RA repeat procedures was 4 per patient. A small, targeted laparotomy was performed in 4 patients to drain a collection of the mesentery root. Postoperative hemorrhage occurred in 6 patients and was treated by embolization in 3 cases and splenopancreatectomy in the others. A left colonic fistula occurred in 7 patients and always healed after loop ileostomy. None of these local complications caused death. Four patients (10%) died of multiorgan failure which was present and extreme from the beginning, upon admission. All their collections had been drained at the moment they died. Late complications occurred in 13 patients (8 pseudocysts, 5 wound hernias). Average hospital stay was 60 day for the population of RA. Other patients : There were 1 death in the ST group 3 %, 1 in the PD group (10 %) and 3 in the L group (21 %, 2 complete necrosis of the gland). Overall mortality was 9 %. Conclusions : The quality and safety of debridement provided by RA compares with what can be achieved via wide laparotomies. RA does not fully prevent usual local complications of ANP but avoids serious complications of transperitoneal drainage such as small bowel fistulas and large abdominal wall dehiscences. |
