Ординатура / Хирургия / Библиотека им академика М.И. Перельмана / Книга_683_Библиотеки_им_академика_М_И_Перельмана

Percutaneous catheter drainage (PCD) can be performed either as a “step- up” toward endoscopic or surgical necrosectomy once WON has developed, or in some cases as definitive therapy[31]. PCD may be further con­sidered when endoscopic drainage is unfeasible due to the anatomic distribution of the pancreatic necrosis. For example, in patients with necrotic extension into the pel­vis or the paracolic gutters, PCD may be necessary to access these dependent collections, which are inaccessi­ble from the gastric or duodenal lumen[7].

aspiration was used for early diagnosis of infected necro­sis[19,20]. At the beginning of the twenty- first century, the first study was published on laparoscopic necrosec­tomy followed by a study involving endoscopic necro­sectomy in 2009 [21,22]. The necessity of surgical debridement for infected necrosis was subsequently questioned when Runzi etal. showed that initial conserv­ative therapy, including antibiotic therapy, could be insti­tuted [23]. Mortality in patients managed with surgery was identical to those managed conservatively [23]. Surgical therapy, when required, was often delayed to a later stage of disease, when the systemic inflammatory response has been stabilized and necrotic pancreas had become demarcated. In other patients, surgical therapy was avoided altogether. Subsequent studies have con­firmed this strategy, Garg etal. describe a 10- year series of 80 patients with infected pancreatic necrosis in whom 47were treated with antibiotics alone[24]. The urge for surgical debridement for all patients with infected pan­creatic necrosis is therefore no longer considered valid [25]. Although laparoscopic direct necrosectomy was already described in the 1990s, it failed to gain popu­larity due to technical difficulty. Therefore, until publica­tion of the PANTER trial in 2010, necrosectomy by laparotomy was the standard intervention [26]. In the PANTER trial, 88 patients were randomly assigned to the “step- up” approach or to immediate open necrosectomy. A step- up approach consisted of percutaneous catheter drainage, followed, if needed, by minimally invasive necrosectomy. Major short- term complications such as new onset multiorgan failure and long- term complica­tions such as endocrine insufficiency, and costs, were decreased in the patients who were assigned to the “step­ up” approach. The effect of the step- up approach was beneficial in patients with and without organ failure[26]. In addition, necrosectomy was avoided in 23–50% of the patients treated with percutaneous catheter drain­age[26–29]. Since then, the step- up approach is consid­ered to be the standard treatment. Several new minimally invasive strategies have been introduced and compared in randomized controlled trials with the goal of improv­ing survival and decreasing complications and comor­bidities. In the most recent study, 19 out of the 49 (39%) patients with infected necrosis did not require interven­tion at all and could be treated with antibiotics alone[30].