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ISSN: 1734-1922
Archives of Medical Science
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2/2018
vol. 14
 
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abstract:
Letter to the Editor

Endoscopic necrosectomy through the major duodenal papilla under fluoroscopy imaging

Marian Smoczyński, Mateusz Jagielski, Magdalena Siepsiak, Krystian Adrych

Arch Med Sci 2018; 14, 2: 470–474
Online publish date: 2016/08/22
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In the last twenty years we have observed development of minimally invasive techniques of treatment of pancreatic necrosis [1, 2]. Those methods include procedures handled with the use of an endoscope, laparoscope or nephroscope, enabling a transperitoneal, retroperitoneal, transmural or transpapillary approach to necrotic collection [1, 2]. The choice of access to the necrosis depends on its location and spread.
A meta-analysis of 8 studies revealed that in 286 patients with infected pancreatic necrosis, percutaneous drainage, being the only way of access to the necrosis, was efficient in 44% of patients [3]. The average rates of complications and mortality related to treatment were respectively 28% and 20% [3]. The next meta-analysis of 11 studies involving 384 patients revealed that in over half of them percutaneous drainage was an efficient method of treatment [4].
In minimally invasive techniques of treatment of walled-off pancreatic necrosis (WOPN) by a retroperitoneal approach, an inflexible nephroscope or flexible endoscope is inserted into the cavity of the necrosis, and then necrotic tissues can be removed by different endoscopic instruments [5, 6]. The desired effect of treatment by a minimally invasive retroperitoneal approach was achieved in 75–93% of patients [5–11]. Complication were reported in 24–88% of patients and mortality in 0–25% of them [5–11].
Transmural endoscopic drainage of pancreatic necrosis is based on the removal of necrotic content through a stoma formed between the lumen of the gastrointestinal tract and the cavity of the necrotic collection [12]. It is possible to take advantage of transpapillary drainage in treatment of pancreatic necrosis when the main pancreatic duct is damaged [13]. Patients without clinical improvement despite applied endoscopic drainage require necrosectomy. Endoscopic treatment of WOPN is efficient in 81–91% of patients. Complications were observed in 14–26% of patients [14–17].
Laparoscopy is found to be the next technique of pancreatic necrosis treatment consisting in access to the necrosis by a transperitoneal approach. It is said to be the least commonly applied method of minimally invasive WOPN treatment and also the least described in the literature. Successful treatment of pancreatic necrosis by laparoscopic techniques was reported in 74–90% of patients with a complication rate of 13–48% and mortality of 0–11% [18–21].
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