Department of Pancreatic Surgery, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, 1277 Jifang Avenue, Wuhan, 430022, China.
Sino-German Laboratory of Personalized Medicine for Pancreatic Cancer, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China.
Updates Surg. 2024 Apr;76(2):487-493. doi: 10.1007/s13304-024-01773-y. Epub 2024 Mar 1.
The surgical treatment of acute necrotizing pancreatitis has significantly evolved in recent years with the advent of enhanced imaging techniques and minimally invasive surgery. Various minimally invasive techniques, such as video-assisted retroperitoneal debridement (VARD) and endoscopic transmural necrosectomy (ETN), have been employed in the management of acute necrotizing pancreatitis and are often part of step-up approaches. However, almost all reported step-up approaches only employ a fixed minimally invasive technique prior to open surgery. In contrast, we implemented different minimally invasive techniques during the treatment of acute pancreatitis based on the extent of pancreatic necrosis. For acute necrotizing pancreatitis of the pancreatic bed with or without extension into the left retroperitoneum, we performed mesocolon-preserving laparoscopic necrosectomy for debridment. The quantitative indication for pancreatic debridment in our institute has been described previously. For acute necrotizing pancreatitis of the pancreatic bed with or without extension into the left retroperitoneum, mesocolon-preserving laparoscopic necrosectomy was performed for debridment. To safeguard the mesocolon, the pancreatic bed was entered via the gastrocolic ligament, and the left retroperitoneum was accessed via the lateral peritoneal attachments of the descending colon. Of the 77 patients requiring pancreatic debridment, 41 patients were deemed suitable for mesocolon-preserving laparoscopic necrosectomy by multiple disciplinary team and informed consent was acquired. Of these 41 patients, 27 underwent percutaneous drainage, 10 underwent transluminal drainage, and 2 underwent transluminal necrosectomy prior to laparoscopic necrosectomy. Two patients (4.88%) died of sepsis, three patients (7.32%) required further laparotomic necrosectomy, and five patients (12.20%) required additional percutaneous drainage for residual infection. Three patients (7.32%) experienced duodenal fistula, all of which were cured through non-surgical treatments. Nineteen patients (46.34%) developed pancreatic fistula that persisted for over 3 weeks, with 17 being successfully treated non-surgically. The remaining two patients had pancreatic fistulas that lasted over 3 months; an internal drainage procedure has been planned for them. No patient developed colonic fistula. Mesocolon-preserving laparoscopic necrosectomy proved to be safe and effective in selected patients. It can serve as a supplementary procedure for step-up approaches or as an alternative to other debridment procedures such as VARD, ETN, and laparotomic necrosectomy.
近年来，随着增强成像技术和微创技术的出现，急性坏死性胰腺炎的手术治疗有了显著的发展。各种微创技术，如视频辅助腹膜后清创术（VARD）和内镜经壁坏死组织切除术（ETN），已被应用于急性坏死性胰腺炎的治疗中，并且通常是逐步治疗方法的一部分。然而，几乎所有报道的逐步治疗方法仅在开放手术前采用固定的微创技术。相比之下，我们根据胰腺坏死的程度，在治疗急性胰腺炎时采用了不同的微创技术。对于伴有或不伴有左侧腹膜后延伸的胰床急性坏死性胰腺炎，我们采用保留横结肠的腹腔镜清创术进行清创。我院已对胰腺清创的定量指标进行了描述。对于伴有或不伴有左侧腹膜后延伸的胰床急性坏死性胰腺炎，采用保留横结肠的腹腔镜清创术进行清创。为了保护横结肠，通过胃结肠韧带进入胰床，通过降结肠外侧腹膜附着处进入左侧腹膜后。在需要胰腺清创的 77 例患者中，经多学科团队评估，有 41 例患者适合行保留横结肠的腹腔镜清创术，并获得知情同意。在这 41 例患者中，27 例行经皮引流，10 例行经内镜引流，2 例行经内镜坏死组织切除术，然后行腹腔镜清创术。2 例患者（4.88%）死于脓毒症，3 例患者（7.32%）需要进一步剖腹坏死组织切除术，5 例患者（12.20%）需要额外的经皮引流以治疗残留感染。3 例患者（7.32%）发生十二指肠瘘，均通过非手术治疗治愈。19 例患者（46.34%）发生持续时间超过 3 周的胰瘘，17 例患者经非手术治疗成功。其余 2 例患者的胰瘘持续时间超过 3 个月；计划为他们进行内引流手术。无患者发生结肠瘘。保留横结肠的腹腔镜清创术在选择的患者中是安全有效的。它可以作为逐步治疗方法的补充，也可以作为 VARD、ETN 和剖腹坏死组织切除术等其他清创术的替代方法。
