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Step-up approach in severe necrotizing pancreatitis: Combination of video-assisted retroperitoneal debridement and endoscopic necrosectomy
Step-up approach en pancreatitis necrosante grave: combinación de desbridamiento retroperitoneal videoasistido y necrosectomía endoscópica
Sergio Cerrato Delgadoa,
Corresponding author
sergio_0892@hotmail.com

Corresponding author.
, Amparo Valverde Martinezb, Tatiana Gómez Sánchezb, Alberto Fierro Aguilara, Jose Manuel Pacheco Garcíac
a Médico Residente de Cirugía General y Digestiva, Servicio de Cirugía General y Digestiva, Hospital Universitario Puerta del Mar, Cádiz, Spain
b FEA de Cirugía General y Digestiva, Servicio de Cirugía General y Digestiva, Hospital Universitario Puerta del Mar, Cádiz, Spain
c Jefe de Servicio, Servicio de Cirugía General y Digestiva, Hospital Universitario Puerta del Mar, Cádiz, Spain
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    "textoCompleto" => "<span class="elsevierStyleSections"><p id="par0005" class="elsevierStylePara elsevierViewall">Walled-off pancreatic necrosis is one of the most feared complications of severe acute pancreatitis&#46; Although most cases evolve favorably with conservative management&#44; up to one-quarter of patients will require interventional techniques<a class="elsevierStyleCrossRefs" href="#bib0005"><span class="elsevierStyleSup">1&#44;2</span></a>&#46; The management of peripancreatic collections has evolved in recent years&#44; and the benefits of the step-up approach have been widely demonstrated<a class="elsevierStyleCrossRefs" href="#bib0015"><span class="elsevierStyleSup">3&#8211;5</span></a>&#46; The current debate in this field focuses on demonstrating the superiority of endoscopic necrosectomy &#40;EN&#41; over video-assisted retroperitoneal debridement &#40;VARD&#41;&#44; or vice versa<a class="elsevierStyleCrossRef" href="#bib0030"><span class="elsevierStyleSup">6</span></a>&#46; We present the case of a patient with severe acute pancreatitis and large walled-off necrosis that required the combined use of EN and VARD for its resolution&#46;</p><p id="par0010" class="elsevierStylePara elsevierViewall">The patient is a 69-year-old man with arterial hypertension and hyperuricemia&#44; who came to the emergency room due to sudden and intense abdominal pain in the epigastrium&#46; We observed notable impairment of his general condition and signs of peripheral hypoperfusion&#46; Blood pressure was 153&#47;95&#8201;mmHg&#59; heart rate 86 bpm&#46; He maintained an oxygen saturation of 89&#37;&#8211;92&#37;&#44; with an inspired oxygen fraction of 21&#37;&#46; Intra-abdominal pressure was 27&#8201;mmHg&#44; measured indirectly&#46; His abdomen was very distended&#44; with generalized tenderness and muscle guarding&#46; Lab work-up showed normal renal function and ions&#44; alanine aminotransferase 256&#8201;U&#47;L&#44; aspartate aminotransferase 518&#8201;U&#47;L&#44; total bilirubin 1&#46;63&#8201;mg&#47;dL &#40;direct 0&#46;96&#8201;mg&#47;dL&#41;&#44; amylase 6&#46;396&#8201;U&#47;L&#44; lipase 21&#8201;200&#8201;U&#47;L&#44; C-reactive protein 51&#8201;mg&#47;dL&#44; leukocytes 262 900&#8201;&#956;L &#40;80&#37; neutrophils&#41; and coagulation in normal ranges&#46; Abdominal computed tomography &#40;CT&#41; scan was performed 48&#8201;h after admission&#44; showing images compatible with pancreatitis&#44; with focal areas of necrosis and gallstones &#40;<a class="elsevierStyleCrossRef" href="#fig0005">Fig&#46; 1</a>A&#41;&#46; During the first month of hospitalization in the Intensive Care Unit&#44; he presented multiple organ failure and required non-invasive mechanical ventilation&#44; hemofiltration&#44; and high doses of vasoactive drugs&#46; Due to suspected superinfection of the collection&#44; empirical antibiotic therapy was started with piperacillin&#47;tazobactam 4&#47;0&#46;5 every 8&#8201;h&#46; The patient then presented an episode of upper gastrointestinal bleeding and endoscopy was performed&#44; during which a large clot was observed with no other observable findings&#46; An abdominal CT scan showed hemorrhage from the left gastric artery&#44; which was embolized&#46; The CT scan 22 days after admission also revealed a necrosis of more than 80&#37; of the pancreatic parenchyma and a peripancreatic necrotic collection &#40;<a class="elsevierStyleCrossRef" href="#fig0005">Fig&#46; 1</a>B&#41;&#46; We then decided to insert a percutaneous pigtail catheter under CT guidance&#46; <span class="elsevierStyleItalic">Klebsiella pneumoniae</span> was isolated in the fluid culture&#44; which was treated with 1&#8201;g ceftriaxone every 24&#8201;h according to the antibiogram&#46; During the next 30 days of hospitalization&#44; the patient continued to present a torpid evolution &#40;improvement after the placement of the drain tube and progressive worsening afterwards&#41;&#46; The drains were changed twice for others with a larger diameter&#44; but the evolution was similar &#40;<a class="elsevierStyleCrossRef" href="#fig0005">Fig&#46; 1</a>C and D&#41;&#46; Orotracheal intubation was required as a consequence of nosocomial pneumonia&#46;</p><elsevierMultimedia ident="fig0005"></elsevierMultimedia><p id="par0015" class="elsevierStylePara elsevierViewall">After 62 days&#44; the follow-up CT scan showed an increase in the peripancreatic collection&#46; We decided to carry out EN&#46; A metallic diabolo stent was placed&#44; and a double pigtail catheter was inserted through it&#46; Two successive sessions of EN were carried out with an infusion of 0&#46;3&#37; hydrogen peroxide&#46; In the 3rd session&#44; a 7 Fr nasocystic catheter was inserted&#44; through which saline lavages were carried out&#46; During the 4th session&#44; the stent was accidentally moved&#44; which required replacement&#46; Evolution continued to be torpid&#46; Radiologically&#44; the part of the collection located around the head of the pancreas continued to grow&#44; extending to the right paracolic gutter&#46; We decided to perform VARD &#40;<a class="elsevierStyleCrossRef" href="#fig0010">Fig&#46; 2</a>&#41;&#46; The collection was accessed by following the pigtail catheter in place&#46; Through a 12&#8201;mmHg trocar&#44; 6&#8722;8&#8201;mmHg retro-pneumoperitoneum was created&#44; and an auxiliary 5&#8201;mmHg trocar was inserted&#46; The purulent contents were aspirated&#44; and the necrotic material was removed&#46; Aspiration lavage of the cavity was done with saline and povidone iodine&#46; A grooved 19 Fr Blake silicone drain was placed inside the cavity&#44; which was washed out with saline and urokinase every 12&#8201;h&#46;</p><elsevierMultimedia ident="fig0010"></elsevierMultimedia><p id="par0020" class="elsevierStylePara elsevierViewall">The patient progressed favorably&#46; The pigtail catheter was removed on the 10th day and the Blake drain on the 16th day&#46; On the 20th postoperative day&#44; the patient was transferred to the hospital ward&#44; and after 190 days of total hospital stay&#44; he was discharged&#46; The gastric prosthesis was removed 9 months later&#44; after having verified that the collections had resolved correctly &#40;<a class="elsevierStyleCrossRef" href="#fig0015">Fig&#46; 3</a>&#41;&#46; The patient is currently asymptomatic and under treatment for pancreatic insufficiency&#46;</p><elsevierMultimedia ident="fig0015"></elsevierMultimedia><p id="par0025" class="elsevierStylePara elsevierViewall">An important factor in the management of patients with severe acute pancreatitis is the correct characterization of pancreatic collections&#46; It is recommended to wait until the definitive conformation of the wall &#40;generally 4 weeks&#41; before attempting any invasive technique<a class="elsevierStyleCrossRefs" href="#bib0035"><span class="elsevierStyleSup">7&#44;8</span></a> &#40;<a class="elsevierStyleCrossRef" href="#fig0005">Fig&#46; 1</a>A&#8211;C&#41;&#46; Within the step-up approach&#44; there are different accepted routes to perform necrosectomy&#46; One of them is the VARD technique&#46; This involves stepwise management&#44; since radioguided placement of a catheter inside the collection is necessary beforehand&#46; There are many studies that have demonstrated a reduction in complications and mortality compared to open surgery<a class="elsevierStyleCrossRefs" href="#bib0025"><span class="elsevierStyleSup">5&#44;9</span></a>&#46; In addition&#44; EN is also evolving as a safe technique within stepwise management&#46; The advent of lumen-apposing metal stents seems to reduce the number of complications&#44; especially migration&#44; as in our patient<a class="elsevierStyleCrossRef" href="#bib0050"><span class="elsevierStyleSup">10</span></a>&#46; The TENSION study &#40;multicenter&#44; controlled and randomized&#41; found no differences in terms of morbidity and mortality between the two techniques&#44; although it did demonstrate superiority of the endoscopic technique in terms of reducing pancreatic fistula and hospital stay compared to VARD<a class="elsevierStyleCrossRef" href="#bib0050"><span class="elsevierStyleSup">10</span></a>&#46; In our case&#44; however&#44; both techniques used in conjunction for the correct resolution of the symptoms&#46; Thus&#44; EN was more suitable for retrogastric collections&#44; and VARD was more useful in the paracolic gutters&#46;</p><p id="par0030" class="elsevierStylePara elsevierViewall">In conclusion&#44; the combination of different necrosectomy techniques should be considered a tool for the management of severe pancreatitis and should be considered part of the multidisciplinary management of patients in hospitals with extensive experience&#46;</p></span>"
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