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Hobart W. Harris, MD, MPH
San Francisco, Calif

Arch Surg. 2002;137:1063.

Castellanos and colleagues report their experience using a translumbar approach to treat infected pancreatic necrosis in 15 patients. The authors conclude that this approach, combined with continuous lavage, is safe, facilitates subsequent debridements, and is generally less morbid than a transperitoneal approach. In the last 2 patients presented, the authors added retroperitoneoscopy using a flexible endoscope to the treatment regimen. This addition purportedly facilitated control of the evolving peripancreatic necrosis.

The need for surgical intervention in patients with infected pancreatic necrosis is universally accepted. However, controversy exists regarding the timing of surgery and the recommended surgical procedure. There are no class 1 data (randomized controlled trials) to quiet the debate. Thus, clinicians, often with religious fervor, promote various surgical procedures and therapeutic regimens. In the final analysis, the goals of any intervention should include safe decompression of the infected collections, removal of necrotic debris, and provision for the future evacuation of the evolving necrosis.

A translumbar approach to debride the pancreas is not new. However, there are several recent studies in which minimally invasive techniques have been used to either supplement¹ or supplant^2-6 open surgical approaches. Therein surgeons have successfully used standard laparoscopic instruments, flexible endoscopes, and rigid nephroscopes in their efforts to avoid the standard open, transabdominal approach to pancreatic necrosectomy. Proponents of using minimally invasive technologies in this clinical setting cite a desire to minimize the physiological insult of surgery in patients who are already critically ill. There are no data, including those presented by Castellanos and colleagues, to clearly demonstrate that minimally invasive approaches are less morbid than open surgery in these patients, let alone that they result in improved outcomes. In the absence of well-designed clinical trials, we must be cautious in the application of new technologies. Technical feasibility does not obviate the need for scientific rigor and sound clinical judgment.

REFERENCES
1. Horvath KD, Kao LS, Wherry KL, Pellegrini CA, Sinanan MN. A technique for laparoscopic-assisted percutaneous drainage of infected pancreatic necrosis and pancreatic abscess. Surg Endosc. 2001;15:1221-1225. FULL TEXT | ISI | PUBMED 2. Gagner M. Laparoscopic treatment of acute necrotizing pancreatitis. Semin Laparosc Surg. 1996;3:21-28. PUBMED 3. Carter CR, McKay CJ, Imrie CW. Percutaneous necrosectomy and sinus tract endoscopy in the management of infected pancreatic necrosis: an initial experience. Ann Surg. 2000;232:175-180. FULL TEXT | ISI | PUBMED 4. Hamad GG, Broderick TJ. Laparoscopic pancreatic necrosectomy. J Laparoendosc Adv Surg Tech A. 2000;10:115-118. ISI | PUBMED 5. Alverdy J, Vargish T, Desai T, Frawley B, Rosen B. Laparoscopic intracavitary debridement of peripancreatic necrosis: preliminary report and description of the technique. Surgery. 2000;127:112-114. FULL TEXT | ISI | PUBMED 6. Pamoukian VN, Gagner M. Laparoscopic necrosectomy for acute necrotizing pancreatitis. J Hepatobiliary Pancreat Surg. 2001;8:221-223. FULL TEXT | PUBMED

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Infected Pancreatic Necrosis: Translumbar Approach and Management With Retroperitoneoscopy
Gregorio Castellanos, Antonio Piñero, Andrés Serrano, and Pascual Parrilla
Arch Surg. 2002;137(9):1060-1063.
ABSTRACT | FULL TEXT