Laparoscopic transgastric necrosectomy in treatment of walled-off pancreatic necrosis with sinistral portal hypertension

Abstract

Background Laparoscopic transgastric necrosectomy (LTGN) has been used in treatment of walled-off pancreatic necrosis (WON) for more than a decade. However, the safety and effectiveness of LTGN for WON with sinistral portal hypertension was still unclear. Methods WON patients with sinistral portal hypertension treated in our department between January 2011 and December 2018 were included and retrospectively analyzed in this study. Patients were divided into two groups according to different surgical approaches, LTNG or laparoscopic assisted trans-lesser sac necrosectomy (LATLSN). Perioperative and long-term outcomes were compared between two groups. Results 312 cases diagnosed with WON were screened and 53 were finally included in this study. Of the included patients, 21 and 32 cases were received LTGN and LATLSN, respectively. LTGN was associated with significantly lower morbidity than LATLSN (19.0% vs 46.9%, p = 0.04) and similar severe complication (Clavien–Dindo ≥ III) rate (12.5% vs 19.0%, p = 0.70). LTGN did not increase the rate of postoperative hemorrhage (9.5% vs 6.3%, p = 1.00) and mortality (9.5% vs 9.4%, p = 1.00). After 39 (11–108) months follow-up, the recurrence rate of WON and long-term complications were also comparable between groups. Conclusion From current data, LTGN was safe and effective in treatment of WON patients with sinistral portal hypertension in terms of short- and long-term outcomes.

Percutaneous Endoscopic Necrosectomy—A Review of the Literature

“…Since the first reports on the dual-modality drainage technique [56], the methods for endoscopic and percutaneous treatment of pancreatic necrosis have evolved toward a more aggressive [1][2][3][4][5][6][7][8][9][10][11][12][13][14]16,[19][20][21][22][23][24][25][26][27][28][29][30][31][32][33][34][35]35,36,[38][39][40][41]59], necrosectomy-based approach, which is also reflected in the aforementioned PEN approach, as well as in the multiple-access strategy in which PEN is combined with transmural endoscopic access techniques [37,[42][43][44][45][46][47][48][49]…”

“…Since the first reports on the dual-modality drainage technique [ 56 ], the methods for endoscopic and percutaneous treatment of pancreatic necrosis have evolved toward a more aggressive [ 1 , 2 , 3 , 4 , 5 , 6 , 7 , 8 , 9 , 10 , 11 , 12 , 13 , 14 , 16 , 19 , 20 , 21 , 22 , 23 , 24 , 25 , 26 , 27 , 28 , 29 , 30 , 31 , 32 , 33 , 34 , 35 , 35 , 36 , 38 , 39 , 40 , 41 , 59 ], necrosectomy-based approach, which is also reflected in the aforementioned PEN approach, as well as in the multiple-access strategy in which PEN is combined with transmural endoscopic access techniques [ 37 , 42 , 43 , 44 , 45 , 46 , 47 , 48 , 49 , 50 , 51 , 52 , 53 , 54 , 55 ]. In more than one-third of patients who underwent PEN, percutaneous access was combined ...…”

“…However, morbidity and mortality rates were as high as 28% and 20%, respectively. In a meta-analysis of 11 studies involving 384 patients, percutaneous drainage was an effective method of treatment in more than half (55.7%) of the patients, with the requirement of no other interventional treatment [ 16 , 17 ].…”

“…Percutaneous drainage consists of the insertion of a drainage tube (10)(11)(12)(13)(14)(15)(16)(17)(18)(19)(20)(21)(22)(23)(24)(25)(26)(27)(28) into the necrotic collection from a transperitoneal or retroperitoneal access, under ultrasound or computed tomography guidance, with the flushing of the necrotic cavity using physiological saline at intervals of approximately 8 h [12][13][14]. Retroperitoneal access to the necrotic collection is preferred [14].…”

Timing, approach, and treatment strategies for infected pancreatic necrosis: a narrative review

“…[27] Laparoscopic transgastric necrosectomy (LTGN) was used to treat wall-off necrosis (WON) cases with sinistral portal hypertension, and it is confirmed to be a safe and effective way to deal with WON compared to laparoscopic-assisted trans-lesser sac necrosectomy. [28] According to the specific conditions of pancreatic necrosis and the systemic status of patients, the selection of appropriate minimally invasive methods and surgical approaches can safely and effectively treat IPN.…”