VARD in infected necrotizing pancreatitis - Dutch Pancreatitis Study Group

Surgical technique used in the PANTER trial (New Engl J Med 2010) of the Dutch Pancreatitis Study Group.

Marc Besselink, Hjalmar van Santvoort, Bert van Ramshorst. Utrecht/Nieuwegein, the Netherlands.

In the Step-Up approach the VARD procedure is used only after catheter drainag has failed. If the patients improves with catheter drainage only (percutaneous retroperitoneal, transabdominal or endoscopic transluminal) no necrosectomy is performed.

Case description:
This is the CT of a 43 year old male patiënt with infected necrotizing pancreatitis that will undergo a VARD procedure; Video-Assisted Retroperitoneal Debridment. Two weeks before this procedure two large bore percutaneous drains were placed in the peripancreatic collection. The patient i...s placed in supine position with the left side 30 degrees elevated. A 5-7 cm subcostal incision is made in the left flank. With help of CT images and by following the percutaneous drain, the subcutaneous tissue and the fascia are dissected and we enter the retroperitoneal peripancreatic collection. First, with a regular suction device any pus encountered is removed. Two long sympathectomy hooks are inserted in order to keep in the incision open. We than insert the zero degree laparoscope. The first necrosis encountered is removed under direct sight with the use of long grasping forceps. Following the percutaneous drain deeper into the cavity, parts of loosely adherent necrotic material are removed. Gently pulling we remove the necrotic tissue. The suction device is helpful in removing any fluid obstructing the view. Complete necrosectomy is not the ultimate aim of this procedure. Only loosely adherent pieces of necrosis are removed thereby keeping the risk of tearing underlying blood vessels to a minimum. In the rare case of extensive bleeding, the retroperitoneal cavity can be easily packed, either awaiting the bleeding to definitely stop or to act as a bridge to angiographic coiling. This patient is now 6 weeks after onset of disease. We always try to postpone surgical intervention, if possible up to 30 days. On the left side of the collection is the percutaneous drain. In this patient the drain had worked well for 2 weeks. When the patient deteriorated again it was decided to perform the VARD procedure. Large pieces of necrotic pancreas can be removed with VARD. This is a big advantage ov VARD over pure endosopic or percutaneous techniques. When all the necrotic tissue is removed we clean the cavity. Two drains are left in situ as a postoperative lavage system. The VARD procedure is performed via a 6 cm incision, which is closed and continuous postoperative lavage started immediately.

Category:

Science & Technology

Tags:

• VARD
• minimally
• invasive
• necrosectomy
• in
• infected
• necrotizing
• pancreatitis
• pancreas
• surgery
• Dutch
• PANTER
• Marc
• Besselink
• Hjalmar
• van
• Santvoort
• Bert
• Ramshorst
• Antonius
• St.Antonius
• Nieuwegein
• Hein
• Gooszen
• Pancreatitis
• Study
• Group
• video-assisted
• retroperitoneal
• debridement
• step-up
• approach
• step
• up
• operatie
• behandeling
• werkgroep
• experts
• intensive
• care
• chirurgie
• videoscopic
• necrotiserende
• alvleesklierontsteking
• alvleesklier
• buik
• abdominaal
• abdominal
• trial
• laparoscopic
• laparoscopie
• keyhole

[catski666]

@AlexHeezen I just have a pain in my neck right now. I believe its fairly obvious that I was trying to suggest that this condition is "best avoided" if at all possible. I think you are treating my good humoured comment with deliberately innappropriate "seriousness"

[AnimalGuardian71]

@AlexHeezen - LOL, I was only teasing :)

[AlexHeezen]

@catski666 Do you have a severe necrotic pancreatitis then?

[AlexHeezen]

@AnimalGuardian71 No its just a Dutch study group :)

[AnimalGuardian71]

Hmmm, is Dutch Pancreatitis much more virulent than say, Canadian Pancreatitis?

[catski666]

I want to clean my pancreas, right now.

[KrautGoesWild]

To me, this looked like the entire pancreas was removed.