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48 Case on Pancreatic Pseudocyst Far from the Stomach
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So far, no prospective controlled studies have been reported contrasting the
different drainage approaches. Several retrospective studies compared these
approaches and showed slightly higher morbidity and mortality in the surgical
group as compared with endoscopic intervention. Because of the heterogeneity in
the groups, these results are not comparable. In addition, there is also an enormous
difference in morbidity between emergency operations versus elective procedures.
Most important is that the preferred intervention varies particularly on the localization and the surrounding anatomy of the pseudocyst and may also depend on personal expertise. In this case, based on the location and the large size of the
pseudocyst, an open cystojejunostomy was the preferred option. Aljarabah et al.
published a review study about successful laparoscopic approaches [ 3 ]. Again, as
there have been no prospective randomized trials, it is very diffi cult to compare the
short- and long- term outcome of laparoscopic versus open procedures.
References
1. Behrns K. Surgical therapy of pancreatic pseudocysts. J Gastrointest Surg. 2008;12:2231–9.
2. Aghdassi A, Mayerle J, Kraft M, et al. Diagnosis and treatment of pancreatic pseudocysts in
chronic pancreatitis. Pancreas. 2008;36:105–12.
3. Aljarabah M, Ammori BJ. Laparoscopic and endoscopic approaches for drainage of pancreatic
pseudocysts: a systematic review of published series. Surg Endosc. 2007;21:1936–44.
Chapter 49
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Case on Intra-abdominal Bleeding with Shock
as Consequence of Necrotizing Pancreatitis
Miguel A. Cuesta
Keywords Acute Necrotizing pancreatitis • Intra-abdominal bleeding • Hypovolemic
Shock • Gallstones
Diagnosis and Indication for Surgery
A 55-year-old man was presented to the First Aid department because of abdominal
pain and shock.
Patient was resuscitated by intubation and ventilation, and abundant fl uid reposition. His amylase in serum was high (2,500 U/ml), and the possibility of his having
an acute pancreatitis rose. A CT scan confi rmed acute pancreatitis, Balthazar type C
with gallstones, and no aneurysm of the abdominal aorta (Fig. 49.1a ). He was
admitted to the Intensive Care department and the following day he developed a
hypovolemic shock with low hemoglobin rate. An angiography showed no blush
and no aneurysms in the visceral arteries (Fig. 49.1b ). Because of hemodynamic
instability, the surgeon decided to operate him.
Operation
At laparotomy, an acute necrotizing pancreatitis was found with abundant blood and
clots in the lesser sac. A central bleeding was observed possibly coming from the
left of the celiac trunk, possibly a pseudoaneurysm of the splenic artery, and different stitches were done to fi x the bleeding.
M. A. Cuesta , M.D.
Department of Surgery , VU University Medical Center , Amsterdam , The Netherlands
e-mail: ma.cuesta@vumc.nl
M.A. Cuesta, H.J. Bonjer (eds.), Case Studies of Postoperative Complications
after Digestive Surgery, DOI 10.1007/978-3-319-01613-9_49,
© Springer International Publishing Switzerland 2014
263
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Fig. 49.1 ( a ) CT scan on
admission acute pancreatitis
and cholelithiasis. No aorta
aneurysm. ( b ) Angiography
of celiac trunk and SMA, no
blush
M.A. Cuesta
a
b
Postoperative Course and Identifi cation of the Complication
The patient was mechanically ventilated and the sepsis treated by iv broad spectrum
antibiotics, iv noradrenaline and total parenteral nutrition. His wound became
infected and dehiscent and abundant pus drained spontaneously. Vacuum system
therapy was considered but because of the presence of bowels on the surface of the
wound was not performed. Wound cleansing was performed. During the course of
6 weeks, because of the low-grade septic situation, various CT scans were performed in which different intra-abdominal abscesses were percutaneously drained
49 Case on Intra-abdominal Bleeding with Shock as Consequence of Necrotizing Pancreatitis
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Fig. 49.2 Central abscess in
pancreas, percutaneously
drained
Fig. 49.3 Abscesses are
becoming quite. Open
abdomen approach
265
(Fig. 49.2 ). After a long period of 4 months during which he developed psychosis
with deliriums, he was admitted to the psychiatric unit at the hospital. He recovered
completely (Fig. 49.3 ) and 3 months later a cholecystectomy and repair of the cica-
tricial hernia by means of polypropylene mesh were performed.
Discussion
The lesson of this case is that at presentation, a differential diagnosis was made
between rupture of aorta aneurysm or necrotizing acute pancreatitis. After resuscitation, a CT scan established the proper diagnosis. Because of intra-abdominal
bleeding, an angiography was done without visualization of a blush. Intervention
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M.A. Cuesta
was considered necessary because of no blush and hemodynamic instability. At
emergency laparotomy, it was a diffi cult procedure to fi x the bleeding. Consequently
infection of the necrosis, multiple abscesses, open wound approach, and psychosis
were adequately treated during a very long hospital stay. Mortality may be very
high with this approach.
Chapter 50
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Case on Recurrence of Infection After
Video-Assisted Retroperitoneal
Debridement
Marc Besselink
Keywords Retroperitoneal debridement • Infection • Dutch PANTER trial •
Step-up approach • Drainage • Necrosectomy
After the publication of the Dutch PANTER trial [ 1 ], the “step-up approach” is
now considered the reference standard for treating infected necrotizing pancreatitis. When infection is diagnosed or suspected, antibiotic treatment is started with
the aim to postpone intervention up to 4 weeks, as most collections have become
“walled-off” by that time. The fi rst step is percutaneous catheter drainage, preferably retroperitoneal. In the PANTER trial, 35 % of patients could be treated with
only percutaneous drainage. Additionally, a recent systematic review suggested
that half of all patients with infected necrotizing pancreatitis can be treated with
percutaneous drainage only [ 2 ]. In patients in whom percutaneous drainage fails,
either because they do not improve or because their condition deteriorates after
initial improvement, the next step is drain-guided video-assisted retroperitoneal
debridement (VARD). In this technique, a 5 cm retroperitoneal incision is made
and the drain is followed into the collection with infected necrosis and pus [ 3 ].
The debridement is performed under videoscopic assistance. It is not the goal to
remove all necrosis; some necrosis may be left for the patient to deal with. In this
way the risk of bleeding is minimized. We describe a case in which the step-up
approach was used.
M. Besselink , M.D., Ph.D.
Department of Surgery , Academic Medical Center , Amsterdam , The Netherlands
e-mail: m.besselink@amc.uva.nl
M.A. Cuesta, H.J. Bonjer (eds.), Case Studies of Postoperative Complications
after Digestive Surgery, DOI 10.1007/978-3-319-01613-9_50,
© Springer International Publishing Switzerland 2014
267
268
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Fig. 50.1 CECT 4 weeks
after onset of disease,
demonstrating a large
peri-pancreatic collection
with necrosis and fl uid
M. Besselink
Patient
Diagnosis and Indication for Surgery
A 50-year-old male with alcoholic pancreatitis was treated conservatively on the surgical
ward with enteral nutrition. After 4 weeks, his clinical condition deteriorated with clinical and laboratory signs of infection. A contrast-enhanced computed tomography
(CECT) revealed a large peri-pancreatic collection with necrosis and fl uid (Fig. 50.1 ).
Because of the clinical suspicion of infected necrotizing pancreatitis and the fact
that the majority of the collection had become “walled off,” percutaneous retroperitoneal catheter drainage was performed. Immediately after drainage, some 500 ml
of pus and small necrotic particles drained and in a few days the clinical condition
of the patient clearly improved. One week after drainage a repeat CECT was performed according to protocol of a CECT (Fig. 50.2 ).
One week after the drainage procedure, the clinical condition of the patient deteriorated again with new clinical and laboratory signs of acute infection. A repeat
CECT was performed and is shown in Fig. 50.3 .
It was decided to perform a VARD procedure as initial percutaneous drainage
had clinically failed and the remaining collection seemed to contain almost no
drainable fl uid. Figure 50.4 shows the removal of the fi rst necrosis encountered dur-
ing the VARD procedure.
Again, the patient’s condition improved. One week after the VARD procedure,
the patient again demonstrated clinical signs of infection. A new CECT was performed (Fig. 50.5 ).
As there was necrosis remaining in the collection and the patient experienced
symptoms of infection it was decided to perform a second VARD procedure. During
this procedure, several large pieces of infected necrosis were removed under videoscopic assistance. Figure
After this second VARD procedure, the patient’s condition improved rapidly and
3 weeks later he left the hospital in a good clinical condition.
50.6 shows the necrosis that was removed.
50 Case on Recurrence of Infection After Video-Assisted Retroperitoneal Debridement
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Fig. 50.2 CECT 5 weeks
after onset of disease and 1
week after percutaneous
retroperitoneal catheter
drainage of infected
necrotizing pancreatitis, the
collection has clearly
diminished in size
Fig. 50.3 CECT 6 weeks
after onset of disease and 2
weeks after percutaneous
retroperitoneal catheter
drainage of infected
necrotizing pancreatitis
269
Fig. 50.4 VARD procedure:
a small incision is made in
the left fl ank next to the
retroperitoneal drain. The
drain is followed into the
infected collection and the
fi rst necrosis encountered is
removed. Later, videoassistance is used to clear the
collection of necrosis and two
surgical drains are placed for
continuous postoperative
lavage
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Fig. 50.5 CECT 7 weeks
after onset of disease,
demonstrating the surgical
drain in the collection and
residual necrosis
Fig. 50.6 Necrosis removed
during the second VARD
procedure, 7 weeks after
onset of disease
M. Besselink
Discussion
Several drainage and necrosectomy procedures may be required to remove all infected
necrosis and pus. Some argue that a formal primary laparotomy, without drainage or
minimally invasive necrosectomy, would have been a better option as all necrosis would
have been removed in one procedure. This may seem as a valuable argument, but,
according to the PANTER trial, such a strategy is not in the best interest of the patient.
The PANTER trial demonstrated that a primary laparotomy leads to more new onset
organ failure after intervention than the “step-up approach” [ 1 ]. The reason for this may
be the larger “hit” to the immune system caused by laparotomy as compared to (multiple) minimally invasive procedures. Patients undergoing interventions for infected necrotizing pancreatitis are usually quite ill and have already been hospitalized for several
weeks, weakening their condition. Thus, the least invasive approach is likely to be benefi cial, or rather less harmful. Apparently, the fact that with these minimally invasive
approaches more procedures are required is not detrimental to the patient’s condition.
50 Case on Recurrence of Infection After Video-Assisted Retroperitoneal Debridement
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271
This case also clearly describes the use of repeat CECT for optimal planning of
the optimal treatment strategy. When performing CECT in necrotizing pancreatitis,
one should be very aware of the fact that CECT is not capable of detecting necrosis
in fl uid-predominant collections. Imaging modalities that are capable of doing so
are magnetic resonance imaging and ultrasound.
References
1. Van Santvoort HC, Besselink MG, Bakker OJ, et al. A step-up approach or open necrosectomy
for necrotizing pancreatitis. N Engl J Med. 2010;362:1491–502.
2. Van Baal MC, Van Santvoort HC, Bollen TL, et al. Systematic review of percutaneous catheter
drainage as primary treatment for necrotizing pancreatitis. Br J Surg. 2011;98:18–27.
3. Van Santvoort HC, Besselink MG, Horvath KD, et al. Videoscopic assisted retroperitoneal
debridement in infected necrotizing pancreatitis. HPB (Oxford). 2007;9:156–9.
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