Percutaneous “Stepped” Drainage Technique for Infected Pancreatic Necrosis

Abstract

Surgeons and interventional radiologists should be familiar with this evolving technique which is less invasive then surgery, but may prolong the time necessary for complete resolution.

Pancreatite necro-hemorrágica: atualização e momento de operar

“…Da mesma forma, nessa etapa, os desafios terapêuticos se entrelaçam com os de inúmeras outras doenças, caracterizadas por uma cascata de eventos iniciais comuns, como a sepse grave. Mais tardiamente, a partir da segunda ou terceira semanas, prevalece a disfunção multiorgânica como consequência da infecção da necrose pancreática 4 . Desta forma, várias classificações foram historicamente utilizadas, dando origem a uma terminologia muito ampla e que não raro gera confusões (Sarles 1965 -Marselha I, Singer 1984 -Marselha II,1985 -Cambridge).…”

“…De forma ainda mais recente, abordagens percutâneas envolvendo a punção guiada por tomografia computadorizada, seguida de dilatação progressiva e instrumentação do trato também tem se mostrado eficazes em número limitado de pacientes 4 . Na mesma linha, Escorrou e colaboradores 15 , adotaram como modalidade terapêutica de primeira escolha a necrosectomia por via transgástrica.…”

Necrotizing Pancreatitis: Update and When to Operate

“…Recent literature is flourishing with case reports and small series describing the successful results of endoscopic and natural orifices surgical approaches [40,47,48,49]. Also noteworthy is the approach described by Bala and cols., in which a percutaneous drainage tract is constructed initially by CT-guided puncture of the necrosis, followed by the placement of a catheter and dilation of the tract, allowing subsequent percutaneous debridement of the necrosis [5]. Regarding endoscopic/natural orifices approach, Escorrou and cols.…”

“…As previously described, at least five alternative modalities have been established: percutaneous debridement, which involves the assistance of imaging methods and allows a limited instrumentation of the pancreatic tissue; "traditional" endoscopic approach through the trans-gastric or trans-duodenal route, which carries the advantage of being less invasive, but has very limited indications, such as liquefied collections located at very favorable sites [60]; Natural Orifice Surgery (NOTES), using the trans-gastric route, which involves a greater incision on the posterior wall of the stomach, allowing a wider debridement of the pancreatic tissue than the one provided by the earlier endoscopic approaches [61]; laparoscopic debridement, clearly efficacious for necrosis located at sites such as para-colic gutter and the omental bursa, but only applicable in situations in which the patient is stable enough to tolerate the pneumoperitoneum [46]; and finally, retroperitoneal technique, which allows a wide access to areas not contemplated by the other techniques described above, but has the disadvantage of being more invasive [62]. These techniques are being increasingly used by many centers, which now reserve the most traditional surgical approach, that is, through laparotomy, for the cases in which these techniques fail or do not apply [5]. As a general rule, there is now a growing body of evidence favoring the treatment of infected necrosis by a "step-up" approach, in which, according to the patients response, less invasive methods are initially favored, and more invasive techniques are reserved for the non-responders [44,63].…”

“…Later, after the second or third weeks, multi-organic dysfunction is mostly secondary to an incontrollable infected pancreatic necrosis [5].…”