RETROPERITONEAL APPROACH AND ENDOSCOPIC MANAGEMENT OF PERIPANCREATIC NECROSIS COLLECTIONS

Objective: To review the results of the different modalities of treatm ent of acute necrotizing pancreatitis that have been used by a single team during a 6-year period to assess the technique and indications of an endoscopic method of retroperitoneal drainage that is routinely pe rformed for the management of peripancreatic necrosis. Design and Sett ing: Retrospective study of 53 patients in a tertiary care center. Res ults: All patients had signs of peripancreatic necrosis on initial com puted tomography scan, 20 patients experienced organ failure during th e first 7 days of the disease, and bacterial contamination was proved in 22 (56%) of 39 samples of peripancreatic necrosis. Methods of treat ment included supportive therapy alone (group 1), percutaneous drainag e (group 2), endoscopic retroperitoneal drainage (group 3), and laparo tomy and transperitoneal drainage (group 4). Mortality and mean hospit al stay were as follows: group 1, 0% and 23 days; group 2, 20% and 89 days; group 3, 10% and 62 days; and group 4, 33% and 86 days. Percutan eous drainage was beneficial in only 3 cases of sterile collection. Tw o local complications were related to the method of endoscopic drainag e. Primary laparotomy was not routinely performed except in patients w ith an intraperitoneal complication. Overall mortality was 13.2%; mort ality was significantly higher in patients with an infected necrosis ( 32%). Conclusions: The use of endoscopic retroperitoneal drainage seem ed to be a significant factor in the observed improvement by providing a reliable drainage of the peripancreatic areas and avoiding the open ing of the peritoneal cavity. This surgical approach is not exclusive and may be combined with a secondary laparotomy when needed. The prefe rred indications of this method are heterogeneous collections of necro sis with bacterial contamination.