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

Background: Internal drainage of giant pancreatic pseudocysts secondary to acute pancreatitis is frequently complicated with postoperative retroperito neal infection and hemorrhage. Recent data suggest that the risk factor is unrecognized pancreatic necrosis; presumably, pancreatic necrosis becomes i nfected with bacteria introduced by the cystoenteric anastomosis. Hypothesis: Video-assisted pancreatic necrosectomy, performed at the time o f internal drainage, may prevent postoperative retroperitoneal complication s in patients with giant acute pseudocysts. Design: A consecutive case-series. Settings: An urban, university-affiliated, tertiary referral center. Patients: Ten consecutive patients with acute pseudocysts measuring 10 cm o r more in major diameter. The mean extent of pancreatic necrosis, as shown by contrast-enhanced computed tomography, was 50% All patients were operate d on electively, at an average time of 7.7 weeks from onset of the attack t o surgical treatment. Intervention: Through a midline incision, a 4-cm opening is made at the bas e 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 Rouxen-Y limb of the jejunum. Main Outcome Measures: Feasibility and safety of video-assisted pancreatic necrosectomy, postoperative morbidity and mortality, hospital stay, and res olution of pseudocysts. Results: Complete necrosectomy was safely performed throughout. There were neither postoperative retroperitoneal complications nor mortality. Mean hos pital 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 patie nts pseudocysts. Depending on appropriate surgical timing, video-assisted n ecrosectomy is a feasible and safe procedure.