title: Laparoscopic transgastric necrosectomy for the management of pancreatic necrosis.
abstract: BACKGROUND
  Traditional open necrosectomy for pancreatic necrosis is associated with significant morbidity and mortality. Although minimally invasive techniques have been described and offer some promise, each has considerable limitations. This study assesses the safety and effectiveness of laparoscopic transgastric necrosectomy (LTN), a novel technique for the management of necrotizing pancreatitis.
  
  
  METHODS
  Between 2009 and 2013, patients with retrogastric pancreatic necrosis requiring debridement were evaluated for LTN. Debridement was performed via a laparoscopic transgastric approach using 2 to 3 ports and the wide cystgastrostomy left open. Patient demographics, disease severity, operative characteristics, and outcomes were collected and analyzed.
  
  
  RESULTS
  Twenty-one patients (13 men, median age 54 years; interquartile range [IQR] 46 to 62 years) underwent LTN during the study period. The duration between pancreatitis onset and debridement was 65 days (IQR 53 to 124 years). Indications for operation included infection (7 patients) and persistent unwellness (14 patients). Median duration of LTN was 170 minutes (IQR 136 to 199 minutes); there were no conversions. Control of the necrosis was achieved via the single procedure in 19 of 21 patients. Median postoperative hospital stay was 5 days (IQR 3 to 14 days) and the majority (71%) of patients experienced no (n = 9) or only minor postoperative complications (n = 6) by Clavien-Dindo grade. Complications of Clavien-Dindo grade 3 or higher developed in 6 patients, including 1 death (5%). With a median follow-up of 11 months (IQR 7 to 22 months), none of the patients required additional operative debridement or had pancreatic/enteric fistulae or wound complications develop.
  
  
  CONCLUSIONS
  Laparoscopic transgastric necrosectomy is a novel, minimally invasive technique for the management of pancreatic necrosis that allows for debridement in a single operation. When feasible, LTN can reduce the morbidity associated with traditional open necrosectomy and avoid the limitations of other minimally invasive approaches.
authors.affiliation: Department of Surgery, Stanford University Medical Center, Stanford, CA.
authors.forename: David J
authors.initials: DJ
authors.lastname: Worhunsky
authors.affiliation: Department of Surgery, Stanford University Medical Center, Stanford, CA.
authors.forename: Motaz
authors.initials: M
authors.lastname: Qadan
authors.affiliation: Department of Surgery, Stanford University Medical Center, Stanford, CA.
authors.forename: Monica M
authors.initials: MM
authors.lastname: Dua
authors.affiliation: Department of Gastroenterology and Hepatology, Stanford University Medical Center, Stanford, CA.
authors.forename: Walter G
authors.initials: WG
authors.lastname: Park
authors.affiliation: Department of Surgery, Stanford University Medical Center, Stanford, CA.
authors.forename: George A
authors.initials: GA
authors.lastname: Poultsides
authors.affiliation: Department of Surgery, Stanford University Medical Center, Stanford, CA.
authors.forename: Jeffrey A
authors.initials: JA
authors.lastname: Norton
authors.affiliation: Department of Surgery, Stanford University Medical Center, Stanford, CA. Electronic address: bvisser@stanford.edu.
authors.forename: Brendan C
authors.initials: BC
authors.lastname: Visser
mesh_terms: D003646:Debridement / Q000379:methods*; D004867:Equipment Design; D005260:Female; D005500:Follow-Up Studies; D006801:Humans; D020706:Laparoscopes; D010535:Laparoscopy / Q000379:methods*; D007902:Length of Stay / Q000639:trends; D008297:Male; D008875:Middle Aged; D010180:Pancreatectomy / Q000379:methods*; D019283:Pancreatitis, Acute Necrotizing / Q000175:diagnosis / Q000601:surgery*; D012189:Retrospective Studies; D013270:Stomach; D014057:Tomography, X-Ray Computed; D016896:Treatment Outcome