INTRODUCTION

One of the most frequent pancreatic diseases in the world is acute pancreatitis (AP). It has an incidence from 5 to 80 cases for every 100,000 people, which variates according to different geographical regions, depending on alcohol consumption and the prevalence of gallstones^1). AP is characterized by the activation of pancreatic enzymes and release of cytokines. The 20% of them evolves to become more severe, bringing forth complications such as pancreatic necrosis and sepsis, and finally multi-organ failure².

Currently, the necrosis-infected AP is handled in a minimally invasive manner through the “step-up approach”. This methodology consists in the percutaneous or endoscopic drainage with antibiotics, followed by retroperitoneal debridement in case of the former’s failure, leaving open surgical drainage as the last resort³.

In AP, the main cause of death is infection of the necrotic tissue, which is associated with an improper diagnosis: mortality is approximately up 30 to 39% in those with infected necrosis (which occurs at some point during the clinical process in approximately a third of the necrosis patients). An intervention in the case of an infected pancreatic necrosis is generally required and, with less frequency, in patients with sterile necrosis that are symptomatic (especially in the case of biliary obstruction or gastric or duodenal outlet). Additional treatment has been open surgical necrosectomy: provides ample access to the infected necrosis, but it’s highly invasive and associated with reported morbidity rates of 34% to 95% and mortality rate of 11% to 39%, due to the physiological stress of the laparotomic debridement⁴.

The present study is dedicated to evaluating the characteristics of the procedure known as VARD (video-assisted retroperitoneal debridement) on the Itauguá National Hospital during the years 2015 to 2021.

MATERIALS AND METHODS

An observational, descriptive, retrospective, crosscut study was performed.

The sample were patients with a complicated AP diagnosis with infected necrosis intervened through VARD in the Itauguá National Hospital during the years 2015 to 2021.

As for the inclusion criteria, patients intervened through the VARD technique, that have had or not a previous drainage (percutaneous or endoscopic) were selected. As for exclusion criteria, patients intervened through other methods were not selected.

For the case selection, the surgical procedures’ register book of the General Surgery Services was accessed, to classify the AP patients on which VARD was performed, requesting clinical files to the Itauguá National Hospital’s statistical service afterwards for the recollection of variables of interest.

RESULTS

35 AP and infected necrosis patients were included, on which a VARD was performed. The average age was 57 years old, with a minimal age of 24 and a maximum of 78 years old. The 60% were of the feminine sex, while the 40% were masculine.

Regarding comorbidities, 77.1% reported high blood pressure, 45% obesity and Mellitus diabetes (see Table 1).

*VARD: video-assisted retroperitoneal debridement; HBP: high blood pressure; COPD: chronic obstructive pulmonary disease; CRK: chronic kidney disease

Regarding the admission diagnosis, 57.1% were severe AP and 42.9% moderate AP. As for etiology, 31 patients were of lithiasis cause, 2 alcoholic, and 2 hyperlipidemic.

Of the cited 35 patients on which a VARD was performed, 29 of them (82.9%) followed a “step-up approach” scheme with first a percutaneous drainage placement, and in 6 cases (17.1%) the patients were directly intervened through VARD (see Graphic 1).

Graphic 1.  Handling considering the “step-up approach” on patients with complicated acute pancreatitis with pancreatic necrosis. n=35. Itauguá National Hospital. 

Time within the drainage’s placement and the VARD’s execution was 65.5% between the first and third post drainage weeks, 27.5% between the fourth and sixth weeks, and 7% between the seventh and nine weeks. (see Table 2).

After the first intervention through VARD, another surgical intervention was performed on 24 of the 35 patients (68.6%): second VARD on 12 patients (50%), cholecystectomy on 7 (29.1%), and open necrosectomy on 5 (20.8%) (see Table 3).

DISCUSSION

AP yet constitutes a severe problem for current-day surgery, despite registered advances in its proper clinical identification, causes, production mechanisms, imagery diagnosis elements, and treatment guidelines. According to statistics, 80% of the total patients will present a tame form of the disease, associated to an interstitial edematous pancreatic tissue or around the gland, and generally resolved in a week of medical treatment. However, the necrotizing variant of the condition, present on the resulting 20%, constitutes the most severe outcome, being characterized by pancreatic or peri-pancreatic necrosis, and becoming infected in a third of the cases, associating as well to sepsis statuses, severe sepsis, or simple or multiple organ failure, assessing an estimated mortality of 50% of the operated patient total and almost 100% of the non-operated ones⁵.

On the Itauguá National Hospital between January 2015 and November 2021, 35 patients with infected necrosis AP were intervened through the VARD technique. The average age was 57 years old, with a female predominance of 60%. These findings coincide with the study performed by Bang et al. where a female predominance of 75% was found. The cited study reports an age predominance between 18 to 35 years old reaching the 50%. This age range differs from the range found in our study, in which the patients presented an older age average⁶.

This study is based on patients who received VARD as treatment. The van Santvoort at al. study of the year 2010 showed that close to 35% of “step-up approach” patients did not require a subsequent necrosectomy⁷. The minimally invasive handling looks to reduce the surgical stress and associated complications to conventional interventions. Video-assisted handling of pancreatic necrosis improved the morbidity rates of patients submitted to surgical necrosectomy⁸.

It is crucial to find a proper window for performing a VARD. The point of entry must be comfortable for the patient, the trajectory must be as direct as possible and not compromise any organs or vital structures⁹.

Open necrosectomy is associated to a high mortality (approx. 40%) and morbidity (more than 95%) including bleeding, gastrointestinal fistulas, and pancreatic insufficiency. In the Wrońsky et al. study, the “step-up approach”, including the VARD was the superior approach in terms of results when compared to open necrosectomy. The number of patients with complications was significantly greater in patients submitted to a laparotomy compared to those who received VARD¹⁰.

The dilemma with the percutaneous approach is to define the moment in which the method fails and if the patient requires a necrosectomy, whether video-assisted or through conventional surgery. Early surgery, without a doubt has a higher morbimortality, but a great delay in the surgical indication is also accompanied by an important mortality. Exclusive percutaneous drainage treatment doesn’t always achieve a sepsis control on these patients, making the video-assisted surgical handling through retroperitoneal way necessary¹¹.

CONCLUSION

The average age of AP patients in this work was 57 years old, predominately of the female sex. In 88.5% of cases the etiology was lithiasic.

In this study, 82.9% of patients followed the “step-up approach” scheme, percutaneous drainage and then VARD. Inn 17.1% a VARD was performed as a first procedure. The time between the percutaneous drainage’ performance and the VARD’s was of 1-3 weeks (65.5%).

Approximately two thirds of the patients (68.6%) submitted to VARD required an additional surgical procedure: 50% of patients needed a second debridement (VARD) and 20.8% an open necrosectomy. Mortality was of 11.4%.