Step-up to VARD vs laparoscopic transgastric necrosectomy vs endoscopic necrosectomy

Introduction

The speaker introduces himself and the topic of discussion, which is comparing different procedures for treating necrosis in pancreatitis.

• The speaker acknowledges that there may not be a clear winner among the different procedures.

• Pancreatitis is a significant disease with increasing incidence and mortality.

• Necrosis occurs in about 15% of cases and infected pancreatic rows are the most important determinants of fatal outcome.

• Surgery used to be considered an absolute indication for urgent surgical debridement but it's no longer an absolute indication for surgery at this point in time.

Open Debridement Surgery

The speaker discusses open debridement surgery as a treatment option for necrosis in pancreatitis.

• Open debridement surgery has significant morbidity, bleeding complications, and mortality.

• Studies show that MIS techniques are beneficial from a mortality standpoint and should be considered standard of care.

• Other techniques have been developed including percutaneous drainage, laparoscopic transcranial laparoscopic approach, video-assisted retroperitoneal necrosectomy, laparoscopic transgastric endoscopic approach.

Step Up VARD Procedure

The speaker explains what the step up VARD procedure entails.

• A pertains drain is placed first with the left retroperitoneal approach preferred.

• Then subsequently do a VARD procedure (video-assisted retro-cradle debridement).

• Built into their protocol is a waiting period of 72 hours before doing definitive matters.

Introduction to Pancreatitis Treatment

The speaker discusses the step-up approach for treating pancreatitis and emphasizes the importance of delaying surgery as much as possible.

Step-Up Approach

• The step-up approach involves making a small incision and using a video device to aid in debridement.

• This approach has been found to reduce complications such as diabetes and multiple organ failure.

• Control of sepsis is more important than removal of necrosis.

• Delaying surgery is crucial, as early surgical intervention is an independent prognostic factor for severe acute pancreatitis.

Timing of Surgery

• Independent prognostic factors for severe acute pancreatitis include multi organ failure, high fat score, and early surgical intervention.

• Delaying surgery leads to better long-term endocrine and exocrine function and reduces post-operative adverse events.

• A systematic review from 2017 found that delayed surgery was always beneficial in terms of mortality.

Trans Gastric Necrosectomy

• Endoscopic trans gastric necrosectomy has lower complication rates than open surgery groups.

• Evidence suggests that the MIS step-up approach improves severe outcomes and mortality versus the open group.

Laparoscopic Transgastric Necrosectomy

In this section, the speaker discusses laparoscopic transgastric necrosectomy as a treatment option for walled-off necrosis with a major capsule in a retro gastric position. The laparoscopic approach is used more frequently due to local expertise and availability at the center.

Laparoscopic Transgastric Necrosectomy

• There is not a lot of evidence for laparoscopic transgastric necrosectomy, but it is the approach that the speaker has used more frequently.

• Laparoscopic transgastric necrosectomy was performed on a 53-year-old patient who presented with severe acute pancreatitis and had a two or three-day course in ICU before being transferred to their hospital.

• Percutaneous approach was not accessible due to left retro panel approach, so laparoscopic approach was used instead.

• A triangular stapled necker's connection was made between the pancreatic collection and the posterior wall of the stomach during surgery.

• The collection almost completely disappeared after one month, and after another month it was gone altogether.

Multimodal Approach

• No single therapeutic intervention is definitely better for all patients, so it's best to be multimodal and adaptable.

• The step-up approach is designed to push surgery past 30 days, which may postpone or indefinitely delay the need for surgery.

• No single surgical approach is optimal for all patients, so it's important to be aware of other approaches to better treat them.