VIDEOSCOPIC ASSISTED RETROPERITONEAL DEBRIDEMENT IN INFECTED NECROTIZING PANCREATITIS

Abstract

Background: Surgical intervention in patients with infected necrotising pancreatitis (INP) generally consists of necrosectomy by laparotomy. Mortality and morbidity remain high. In recent years, we have treated INP with a minimally invasive technique: videoscopic assisted retroperitoneal debridement (VARD). No randomized controlled trial (RCT) has yet been performed to compare a minimally invasive technique with laparotomy in INP. Methods: In case of (suspected) INP a retroperitoneal percutaneous drain is placed in the pancreatic collection, preferably at least 30 days after onset of disease. If surgery cannot be obviated after a maximum of two percutaneous drainage procedures, the collection is approached via a 5 cm subcostal incision using the drain as guidance and videoscopic assisted debridement is performed. Patients in whom retroperitoneal access is not possible undergo laparotomy. In preparation for a nationwide RCT we analyzed the first patients treated with VARD in the period April 2001 to April 2005. Results: A total of 15/24 consecutive patients with INP underwent VARD. Nine complications requiring reintervention occurred in 6/15 patients (40%). An additional laparotomy was needed in 4/15 patients (27%). One patient (7%) died. Median preoperative hospital stay was 50 days (range 1-149), total hospital stay 106 days (range 41-240). PANTER (pancreatitis, necrosectomy vs. minimally invasive step-up approach) is a RCT in which patients with (suspected) INP are randomly allocated to (A) maximal necrosectomy by laparotomy (B) drainage, if necessary followed by VARD. Primary endpoint is the total of major morbidity and mortality. Patients will be allocated from 20 hospitals of the Dutch Acute Pancreatitis Study Group in a 3-year period. Conclusion: In our initial experience VARD is a feasible technique and preliminary results are promising. PANTER is the fist RCT to compare a minimally invasive treatment strategy with conventional necrosectomy by laparotomy.