RESUMO
Resumen El tratamiento escalonado de la pancreatitis aguda necrotizante infectada consiste en el uso de antibióticos de amplio espectro, drenaje y necrosectomía mínimamente invasiva, si fuese necesaria. Esto ha reemplazado a la cirugía abierta como el estándar de tratamiento. El desbridamiento retroperitoneal video asistido (VARD), es una forma de necrosectomía quirúrgica mínimamente invasiva. Presentamos una serie de 5 casos (2 mujeres y 3 varones) con pancreatitis aguda grave y necrosis pancreática infectada tratados de forma escalonada y VARD. El rango de edad fue de 27 a 60 años. Todos los pacientes tuvieron pancreatitis de etiología biliar. El rango del APACHE II fue de 16 a 20. El rango del tiempo para el drenaje percutáneo lumbar fue de 4 a 7 semanas. Hubo una complicación del drenaje percutáneo (fistula duodenal) que se resolvió con tratamiento médico. Los cultivos de todas las necrosis fueron positivos. El tiempo para la realización del VARD tuvo un rango de 6 a 10 semanas. Un paciente requirió dos procedimientos. Hubo dos fístulas pancreáticas tipo B asociadas al VARD, que se trataron conservadoramente. No hubo mortalidad. A largo plazo, dos pacientes fueron diagnosticados de insuficiencia pancreática exocrina y endocrina. Concluimos que en los pacientes con necrosis pancreática infectada que requieran desbridamiento, el VARD es una alternativa segura, efectiva y con buenos resultados a largo plazo.
Abstract The step-up approach for infected necrotizing pancreatitis, consisting of broad-spectrum antibiotics, drainage followed, if necessary, by minimally invasive necrosectomy, has replaced open surgery as the standard of management. Video-assisted retroperitoneal debridement (VARD) is a surgical minimally invasive necrosectomy. This is a 5 cases series (2 female and 3 males) with severe acute pancreatitis and infected pancreatic necrosis who underwent step up approach and VARD. The age ranged from 27 to 60 years old. Al patients had biliary pancreatitis. APACHE II ranged from 16 to 20. The time to percutaneous lumbar drainage ranged from 4 to 7 weeks. There was one complication associated with percutaneous drainage (duodenal fistula) with nonoperative management. All necrotizing pancreatitis had positive cultures. The time to perform VARD ranged from 6 to 10 weeks. One patient required two procedures. There were two type B pancreatic fistulas associated with VARD, managed nonoperatively. There was no mortality. During long-term follow-up two patients were diagnosed with exocrine and endocrine pancreatic insufficiency. We conclude that VARD is a safe and effective procedure in patients with infected necrotizing pancreatitis requiring debridement, and with good long-term outcomes.
Assuntos
Humanos , Masculino , Feminino , Adulto , Pessoa de Meia-Idade , Pancreatite Necrosante Aguda/cirurgia , Espaço Retroperitoneal , Doença Aguda , Resultado do Tratamento , DesbridamentoRESUMO
The step-up approach for infected necrotizing pancreatitis, consisting of broad-spectrum antibiotics, drainage followed, if necessary, by minimally invasive necrosectomy, has replaced open surgery as the standard of management. Video-assisted retroperitoneal debridement (VARD) is a surgical minimally invasive necrosectomy. This is a 5 cases series (2 female and 3 males) with severe acute pancreatitis and infected pancreatic necrosis who underwent step up approach and VARD. The age ranged from 27 to 60 years old. Al patients had biliary pancreatitis. APACHE II ranged from 16 to 20. The time to percutaneous lumbar drainage ranged from 4 to 7 weeks. There was one complication associated with percutaneous drainage (duodenal fistula) with nonoperative management. All necrotizing pancreatitis had positive cultures. The time to perform VARD ranged from 6 to 10 weeks. One patient required two procedures. There were two type B pancreatic fistulas associated with VARD, managed nonoperatively. There was no mortality. During long-term follow-up two patients were diagnosed with exocrine and endocrine pancreatic insufficiency. We conclude that VARD is a safe and effective procedure in patients with infected necrotizing pancreatitis requiring debridement, and with good long-term outcomes.
El tratamiento escalonado de la pancreatitis aguda necrotizante infectada consiste en el uso de antibióticos de amplio espectro, drenaje y necrosectomía mínimamente invasiva, si fuese necesaria. Esto ha reemplazado a la cirugía abierta como el estándar de tratamiento. El desbridamiento retroperitoneal video asistido (VARD), es una forma de necrosectomía quirúrgica mínimamente invasiva. Presentamos una serie de 5 casos (2 mujeres y 3 varones) con pancreatitis aguda grave y necrosis pancreática infectada tratados de forma escalonada y VARD. El rango de edad fue de 27 a 60 años. Todos los pacientes tuvieron pancreatitis de etiología biliar. El rango del APACHE II fue de 16 a 20. El rango del tiempo para el drenaje percutáneo lumbar fue de 4 a 7 semanas. Hubo una complicación del drenaje percutáneo (fistula duodenal) que se resolvió con tratamiento médico. Los cultivos de todas las necrosis fueron positivos. El tiempo para la realización del VARD tuvo un rango de 6 a 10 semanas. Un paciente requirió dos procedimientos. Hubo dos fístulas pancreáticas tipo B asociadas al VARD, que se trataron conservadoramente. No hubo mortalidad. A largo plazo, dos pacientes fueron diagnosticados de insuficiencia pancreática exocrina y endocrina. Concluimos que en los pacientes con necrosis pancreática infectada que requieran desbridamiento, el VARD es una alternativa segura, efectiva y con buenos resultados a largo plazo.
Assuntos
Pancreatite Necrosante Aguda , Doença Aguda , Adulto , Desbridamento , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Pancreatite Necrosante Aguda/cirurgia , Espaço Retroperitoneal , Resultado do TratamentoRESUMO
ABSTRACT Background : Acute pancreatitis is the third most common gastrointestinal disorder requiring hospitalization in the United States, with annual costs exceeding $2 billions. Severe necrotizing pancreatitis is a life-threatening complication developed in approximately 20% of patients. Its mortality rate range from 15% in patients with sterile necrosis to up 30% in case of infected one associated with multi-organ failure. Less invasive treatment techniques are increasingly being used. These techniques can be performed in a so-called step-up approach. Aim: To present the technique for videoscopic assisted retroperitoneal debridement (Vard technique) with covered metallic stent in necrotizing pancreatitis. Method: A guide wire was inserted through the previous catheter that was removed in the next step. Afterwards, the tract was dilated over the guide wire. Then, a partially covered metallic stent was deployed. A 30 degrees laparoscopic camera was inserted and the necrosis removed with forceps through the expanded stent under direct vision. Finally, the stent was removed and a new catheter left in place. Result : This technique was used in a 31-year-old man with acute pain in the upper abdomen and diagnosed as acute biliary pancreatitis with infected necrosis. He was treated with percutaneous drains at weeks 3, 6 and 8. Due to partial recovery, a left lateral VARD was performed (incomplete by fixed and adherent tissue) at 8th week. As the patient´s inflammatory response was reactivated, a second VARD attempt was performed in three weeks later. Afterwards, patient showed complete clinical and imaging resolution. Conclusions : Videoassisted retroperitoneal necrosectomy using partially covered metallic stent is a feasible technique for necrotizing pancreatitis.
RESUMO Racional: A pancreatite aguda é a terceira doença gastrointestinal mais comum que requer hospitalização nos Estados Unidos, com custos anuais superiores a $ 2 bilhões. A pancreatite necrosante grave é uma complicação potencialmente fatal, desenvolvida em aproximadamente 20% dos pacientes. A taxa de mortalidade varia de 15% em pacientes com necrose estéril para 30% no caso de uma infecção infectada com falência multiorgânica. As técnicas de tratamento menos invasivas são cada vez mais utilizadas. Elas podem ser realizadas em uma abordagem chamada "step-up". Objetivo: Apresentar a técnica de desbridamento retroperitoneal assistido com videografia (técnica VARD) com stent metálico coberto em pancreatite necrosante. Método: Um fio guia é inserido através do cateter anterior que foi removido no próximo passo. Depois, o trajeto é dilatado sobre o fio guia. Em seguida, um stent metálico parcialmente coberto é implantado. Uma câmera laparoscópica de 30º é inserida e a necrose removida com fórceps através do stent expandido sob visão direta. Finalmente, o stent é removido e um novo cateter deixado no lugar. Resultado: Esta técnica foi utilizada em um homem de 31 anos com dor aguda na parte superior do abdome e diagnosticado como pancreatite biliar aguda com necrose infectada. Ele foi tratado com drenos percutâneos nas semanas 3, 6 e 8. Devido à recuperação parcial, realizou-se um VARD lateral esquerdo (incompleto por tecido fixo e aderente) na 8ª semana. À medida que a resposta inflamatória do paciente foi reativada, uma segunda tentativa VARD foi realizada em três semanas mais tarde. Posteriormente, o paciente apresentou resolução clínica e de imagem completa. Conclusão: A necrosectomia retroperitoneal assistida em vídeo com stent metálico parcialmente coberto é uma técnica viável para pancreatite necrosante.