PANCREATITE ACUTA:
C’E’ SPAZIO PER TRATTAMENTI
LAPAROSCOPICI ?
M.FILAURO
S.C. CHIRURGIA GENERALE ED
EPATOBILIOPANCREATICA
E.O.OSPEDALE GALLIERA
GENOVA
Sestri Levante, 20 gennaio 2007
INDICAZIONI ALLA VDL NELLA P.A.
STADIAZIONE
NO!! ( TAC)
TRATTAMENTO DELLE COMPLICANZE
TRATTAMENTO DELLE CAUSE
SI
SI
TRATTAMENTO VDL NELLE
COMPLICANZE DELLA P.A. SEVERA
NECROSI INFETTA
SI
PSEUDOCISTI
EMORRAGIE
NO
PERFORAZIONI VISCERALI
TRATTAMENTO VDL DELLE CAUSE DELLA P.A.
LITIASI BILIARE
LITIASI PANCREATICA
SI ( VLC + ERC INTRAOP + PST)
NO
MALFORMAZIONI BILIOPANCREATICHE
TRAUMI PANCREATICI
NO
SI ( SOLO DRENAGGIO)
APPROCCIO VDL NEL TRATTAMENTO
DELLE NECROSI INFETTE
TRANSPERITONEALE
RETROPERITONEALE
TRANSGASTRICO
TRANS- FISTOLA DA DRENAGGIO
( PERCUTANEO/CHIRURGICO)
APPROCCIO VDL TRANSPERITONEALE
OTTICA 30°
4/5 ACCESSI
PINZE ATRAUMATICHE
SISTEMA PER LAVAGGIO/ASPIRAZIONE ADEGUATO
LA TATTICA VDL RIPRODUCE L’APPROCCIO OPEN:
ESPLORAZIONE PERITONEALE
LAVAGGIO DELLE RACCOLTE PARACOLICHE E SUBFRENICHE
APERTURA DELLA RETROCAVITA’ TRAMITE IL LEG.GASTROCOLICO
ASPIRAZIONE/ ASPORTAZIONE DEL MATERIALE NECROTICO INFETTO
LAVAGGI DELLA RETROCAVITA’
DRENAGGI MULTIPLI
Laparoscopic assisted pancreatic necrosectomy: a new surgical
option for treatment of severe necrotizing pancreatitis.
Parekh D.
Arch Surg 2006, 141 (9):895-902
19 pazienti con PA severa sottoposti a necrosectomia transperitoneale
con HALS ( hand assisted laparoscopic surgery)
18/19 pazienti con procedura completata
2 HALS
4 reinterventi
2 open
“ Pancreatic debridment with HALS may provide a new option for the
Surgical treatment of selected patients with severe necrotizing
Pancreatitis.”
Retroperitoneal endoscopic debridement for
infected peripancreatic necrosis.
Seifert H, et al.
Lancet. 2000 Aug 19;356(9230):653-5
Standard management of infected peripancreatic necrosis
consists of open surgical debridement and lavage--a traumatic
intervention with substantial morbidity and mortality. As an
alternative and novel approach with minimum invasiveness, we
present fenestration of the gastric wall and debridement of
infected necrosis by direct retroperitoneal endoscopy. In three
patients, this strategy led to rapid clinical improvement and no
serious complications. Transgastric endoscopic therapy may be a
less traumatic alternative to surgery and should be further
assessed in prospective studies.
LE INDICAZIONI, IL TIMING E LA TATTICA IN CASO DI P.A.
NON SONO MODIFICATE DALLA VDL.
LA VDL COSTITUISCE UNA METODICA DI ACCESSO ALLA
CAVITA’PERITONEALE ED AL RETROPERITONEO
MINIINVASIVA , CON I VANTAGGI PROPRI DI
TALI APPROCCI.
LA RETROPERITONEOSCOPIA AVREBBE IL VANTAGGIO
DI CONSENTIRE UNA TOILETTE PIU’ MIRATA E
RISPETTOSA DELLE STRUTTURE VISCERALI, E DI POTERE
ESSERE RIPETUTA ( ANCHE SULLA GUIDA DI DRENAGGI
LASCIATI IN SITU).
Direct retroperitoneal approach to necrosis in severe acute
pancreatitis.
Fagniez PL Br J Surg. 1989 Mar;76(3):264-7
From 1981 to 1987, 40 patients with severe acute pancreatitis were
operated on using a direct retroperitoneal approach, 22 primarily and
18 after a first operation performed through another incision. The
retroperitoneal approach consisted of a left lateral incision, just
anterior to the 12th rib, allowing direct access to the pancreas and a
complete manual exploration of the gland and peripancreatic spaces.
The direct retroperitoneal approach permits the removal of necrosis
and several reoperations without the risk of large wound dehiscence
and does not preclude the extension of the incision to a subcostal
incision when necessary.
APPROCCIO VDL AL TRATTAMENTO DELLE RACCOLTE
PERIPANCREATICHE E DELLE PSEUDOCISTI.
RACCOLTA LIQUIDA PERIPANCREATICA SINTOMATICA:
EVACUAZIONE E DRENAGGIO
PSEUDOCISTI :
DRENAGGIO
DERIVAZIONE INTERNA
( PSEUDOCISTODIGIUNOANASTOMOSI)
“Minimally invasive procedures, including percutaneous
drainage, endoscopic drainage or minimally invasive surgery
( i.e, retroperitoneo-scopy) for infected pancreatic necrosis
may play a role as a temporary measure to bridge the critical
early time after onset of acute pancreatitis to a later optimal
time point for definitive intervention.
Otherwise, they should be limited to specific indications in
patients who are critically ill and unfit for conventional
surgery or clinical trials”
J Werner, S Feurbach,W Uhl and M Buchler
GUT, 2005;54:426-436
“Newer approach such as laparoscopic, endoscopic or
retroperitoneal procedures might decrease morbidity and
mortality in patients with severe AP”.
S.Heinrich,M Schafer,V. Rousson, PA Clavien
Evidence-based treatment of acute pancreatitis: a look to
established paradigms.
Annals Surg 2006; 243(2):154-168.