Necrotic pancreatitis (NP) is a critical condition mainly due to its peripancreatic abscess as well as its uncertainty of outcome. Theoretically, SIRS in its initial onset and late peripancreatic abscess are two malor causes to reach peak of mortality rate. Peritoneal dialysis or hemo-dialysis was previously applied to reduce cytokines in its early sudden onset. More importantly, the key to successful management is to set up pipeline chanells to promise sufficient drainage of necrotic tissue alone with accumulated fluid. Besides, what time to perform surgical drainage and cholecystectomy as well is still worthy of further study despite majority of specialists think later laparoscopic cholecystectomy had better be performed after necrosectomy in first therapeutic period for biliary pancreatitis. But why not perform them together in a single surgery to avoid second surgical hit? Sowe for the first time, combined dual-scopy in a single surgery to challenge previous expertise . It is deemed to be instructive and educational. We believe that our practice would open new vision for strategic management of NP.Case Report
A 57-year-old woman who frequently suffered from abdominal pain 13 days ago becomes worse just 12 hours before admission to our hospital. B type ultrasound examination found cholelithiasis. Blood amylase 1309 U/L. Based on these initial data, she was diagnosed as biliary pancreatitis. Physical examination: temperature 37.2 degree C, blood pressure 121/81mmHg; the upper abdomen tenderness was obvious; rebound pain was suspicious; Morphy sign is positive. CT scan further confirmed the diagnosis of acute pancreatitis, in addition, abdominal effusion and cholecystitis were also unveiled. ERCP showed choledocholithiasis too. At first, ultrasound-guided catheter drainage via multiple prpeline chandelles were immediately conducted. But when the drainage appeared to be lossing its power due to insufficient value, combination of laparoscopic cholecystectomy with nephroscopic necrosectomy via retroperitoneal approach was taken into consideration.And about 4 weeks later, the patient was performed surgery as expected. She was discharged uneventfully about 2 month later after admission. Up to date, she was followed up for about 14 months at out patients' doctor office and there were no surgery-related complications or discomfortable complaint found. Infected necrotizing pancreatitis is one of the most serious complications of acute necrotizing pancreatitis.It often leads to multiple organ failure (MOF). The fatality rate will be nearly 100% if no surgical interventions applied . But even if
various therapies were effectively conducted, its complications and mortality are up to 20-25% and 43% respectively . Only reoperation, aiming to eliminate the residual infected focus, is recommendable . However, at this moment, the abdominal cavity is just like frozen stage due to extensive inflammation, tissue adhesion each other and tissue of edema, etc., which make a big challenge for reoperation particullarlly by endoscopy route. Postoperative intestinal fistula, bleeding of tiny vessels and superinfection were significantly increased.
Recently, minimally invasive procedures become major prevalence worldwidely, such as percutaneous catheter drainage (PCD), laparoscopic debridement, endoscopic surgery through sinus tract . Minimally invasive surgery has the advantages of less trauma, more preservation of internal and external secretory function of pancreas, easy nursing and little postoperative pain, etc. The surgical complications and mortality were less compared to open surgery . Generally, the cure rate of PCD is only about 40% because pancreatic necrosis and peripancreatic fat necrosis tissue is not easy to be liquefied . As a result, it fails to drain normally, potential risk of refractory infection and long-term stay in hospital.
We often conduct naso tube drainage through ERCP, aiming to reduce the pressure ofbiliary tract for patients with critical pancreatitis. If not to do so, biliary-origin pancreatitis may be excavated unprovisionally. But it's not essential to place naso tube drainage for selected cases with stable condition. In addition, MRCP is better as a non invasive maneuver for the purpose of diagnosis when compared to ERCP. To best knowledge, the findings of retroperitoneal gas and fluid co-existing in pseudocyst of pancreas more likely mean an important indicator of definitive infection. Therefore, step-up approach, aiming to allow sufficient drainage was adopted as usual. Generally, the size of the catheter had better be bigger enough such as 28F-36F and the interval duration between the catheter insertion and the combined procedure is addressed around 2-3 weeks according to patients' condition. However, when we obtained written informed consent from the patient and approval of ethic comittee in our hospital, cholecystectomy through laparoscopy approach, retroperitoneal necrosectomy through percutaneous nephroscopy together in a single surgery were performed as plan. During surgery, a large amount of pus, necrous pancreatic tissue and retroperitoneal fasiatitis were in visionable field, while the retroperitoneal abscess and massive necrosis were also in vision via nephroscope.
After surgery, two separated surgery were fulfilled in one time, and as usual, dual-catheters were placed in appropriate position of peripancreas retroperitoneal space respectively. Re-evaluation of enhancement CT of pancreas two weeks after surgery significantly revealed a better improvement compared to last findings. About 1 month after surgery, the second-look operation through her sinus tract with nephroscopy approach was performed successfully, aiming to eliminate the residual necrosis. Meanwhile, pus and pancreatic necrosis along with debridement were all re-drained and dual-catheters was readjusted. After that, the similar work was conducted per 2-3 week until a small amount of necrosis was found in the retroperitoneal space. Accordingly, the dual-catheters should be retracted step by step until it was removed entirely. About 1 month later, enhancement CT of abdomen Showed pancreas close to normal as expected. Based on our experience, the drainage tube is placed in the pancreatic bed along with the omental encraped, while the peritoneal dialysis tube is placed at the lowest position of the pelvis. After the operation, peritoneal lavage was performed to delute pus and drain easily.Laparoscopic technique is recogoized as the priority . But it may also cause iatrogenic infection spreading, aggravate the symptoms . Laparoscopic resection of pancreatic necrosis has not been widely applied in practice and has not been supported by bulk or randomized trials. It has been reported that the success rate is about 77% and the mortality is about 11%. The main complications include pancreatic fistula, abdominal infection and retroperitoneal infection . What time for surgery? If possible, the right time had better be beyond 4 weeks after the onset of pancreatitis. It's imperitable to continue remove necrous tissue via catheter sinus under local anesthesia per 2-3 weeks to accelerate patients' recovery. And the repeated surgery was performed 4 weeks after the combined procedure.
At this moment, the patients' general condition is improved and stablized. Furthermore, the corder line between necrotic tissue and normal tissue have may be easy to identify. Fibrous band or septum begin to be built. Surgery should be conducted if the retroperitoneal space contains gas exclude the potential of colon pereration. If any, ultrasound or CT guided paracentasis be carried out timely.
We realize that any undesired violation of procedure may result in potential of bleeding. If you feel somewhat of resistance when you grap the necrotic tissue, you had better free it. The target of first operation is to drain the pus through loosing the necrotic tissue. The necrotic tissue after loosing could bewashed out by normal saline. According to the way from the proximal to the distant, the procedure will be effective and safety. Minor fresh bleeding means the edge of necrosis. In order to reduce the potential of the bleeding, the necrotic tissue should let issues go unless it has influenced ongoing procedure. It is not necessary to
remove the necrotic tissue within a single operation. In addition, the timing of surgery had better be beyond 1 month after the onset of pancreatitis. At this time, the abscess will be nature enough.
The patient was given endoscopic drainage and PCD after admission. 11 weeks after the onset of the disease, the patient was given a combination of laparoscope and nephroscope removal of pancreatic necrosis and cholecystectomy. At the same time, several double catheterization cannulas were placed. And the patient was given a continuous irrigation after operation. The patient then conducted three times of retroperitoneal pancreatic necrosectomy by percutaneous nephroscope. The last operation wasperformed under local anesthesia. New double catheterization cannulas were readjusted and replaced in each operation. Finally, the drainage tube was removed 22 weeks after the onset of the disease. No bleeding, pancreatic fistula and other complications occurred during therapeutic course. There were no abdominal pain, fever and other symptoms have been found after postoperative 5-month follow-up.
Combination of laparoscope and nephroscope can overlap the advantages of laparoscope and nephroscope within one surgery. It may be a practical alternative choice for necrosectomy of necrotizing pancreatitis due to its accessible and flexible properties.