Internal drainage of giant acute pseudocysts: the role of video-assisted pancreatic necrosectomy

Abstract

Background: Internal drainage of giant pancreatic pseudocysts secondary to acute pancreatitis is frequently complicated with postoperative retroperitoneal infection and hemorrhage. Recent data suggest that the risk factor is unrecognized pancreatic necrosis; presumably, pancreatic necrosis becomes infected with bacteria introduced by the cystoenteric anastomosis.

Hypothesis: Video-assisted pancreatic necrosectomy, performed at the time of internal drainage, may prevent postoperative retroperitoneal complications in patients with giant acute pseudocysts.

Design: A consecutive case-series.

Setting: An urban, university-affiliated, tertiary referral center.

Patients: Ten consecutive patients with acute pseudocysts measuring 10 cm or more in major diameter. The mean extent of pancreatic necrosis, as shown by contrast-enhanced computed tomography, was 50%. All patients were operated on electively, at an average time of 7.7 weeks from onset of the attack to surgical treatment.

Intervention: Through a midline incision, a 4-cm opening is made at the base of the pseudocyst. Standard laparoscopic instruments are introduced into the pseudocyst and video-assisted pancreatic necrosectomy is performed. The opening is then anastomosed to a Roux-en-Y limb of the jejunum.

Main outcome measures: Feasibility and safety of video-assisted pancreatic necrosectomy, postoperative morbidity and mortality, hospital stay, and resolution of pseudocysts.

Results: Complete necrosectomy was safely performed throughout. There were neither postoperative retroperitoneal complications nor mortality. Mean hospital stay was 8.2 days and all pseudocysts resolved at a mean follow-up of 6.9 months.

Conclusions: Video-assisted pancreatic necrosectomy at the time of internal drainage seems to prevent postoperative retroperitoneal complications in patients with giant acute pseudocysts. Depending on appropriate surgical timing, video-assisted necrosectomy is a feasible and safe procedure.