title: Step-up approach and video assisted retroperitoneal debridement in infected necrotizing pancreatitis: A case complicated by retroperitoneal bleeding and colonic fistula.
abstract: BACKGROUND
  Infected Necrotizing Pancreatitis carries a high mortality and necessitates intervention to achieve sepsis control. The surgical strategy for proven infected necrosis has evolved, with abandonment of open necrosectomy to a step-up approach consisting of percutaneous drains and Video-assisted retroperitoneal debridement (VARD). We present a case that underwent VARD complicated by bleeding and colonic perforation and describe its management.
  
  
  METHODS
  A 38 year-old male with acute pancreatitis developed infected necrotizing pancreatitis. Initial treatment was by percutaneous drainage under radiological guidance and intravenous antibiotics. The infected retroperitoneal necrosis was then debrided using gasless laparoscopy through a mini-incision. Post-operatively, he developed peripancreatic bleeding which was controlled with angioembolisation. He also developed a descending colon fistula which was treated with laparotomy and defunctioning loop ileostomy. He recovered and subsequently had his ileostomy closed twelve months later. The colonic fistula recurred and was treated with endoscopic clips and histoacryl glue injection and finally closed.
  
  
  CONCLUSIONS
  Step-up approach consists of the 3 D's: Delay, drain and debride. VARD is recommended as it is replicable in general surgical units using standard laparoscopic instruments. Bleeding and colon perforation are potential complications which must have multi-disciplinary input, aggressive resuscitation and timely radiologic intervention. Defunctioning ileostomy is recommended to control sepsis in colonic fistulation. Novel fistula closing methods using endoscopic clips and histoacryl glue are potential treatment options.
  
  
  CONCLUSIONS
  Step-up approach and VARD is the new paradigm to treat necrotizing pancreatitis. Complications of bleeding and colon fistula are uncommon and require multi-disciplinary management.
authors.affiliation: Department of Surgery, Khoo Teck Puat Hospital, 90 Yishun Central, Singapore 768828, Singapore.
authors.forename: Eugene
authors.initials: E
authors.lastname: Lim
authors.affiliation: Department of Surgery, Khoo Teck Puat Hospital, 90 Yishun Central, Singapore 768828, Singapore.
authors.forename: R S
authors.initials: RS
authors.lastname: Sundaraamoorthy
authors.affiliation: Department of Anaesthesia, Khoo Teck Puat Hospital, 90 Yishun Central, Singapore 768828, Singapore.
authors.forename: David
authors.initials: D
authors.lastname: Tan
authors.affiliation: Department of Radiology, Khoo Teck Puat Hospital, 90 Yishun Central, Singapore 768828, Singapore.
authors.forename: Hui-Seong
authors.initials: HS
authors.lastname: Teh
authors.affiliation: Department of Surgery, Khoo Teck Puat Hospital, 90 Yishun Central, Singapore 768828, Singapore.
authors.forename: Tzu-Jen
authors.initials: TJ
authors.lastname: Tan
authors.affiliation: Department of Surgery, Khoo Teck Puat Hospital, 90 Yishun Central, Singapore 768828, Singapore.
authors.forename: Anton
authors.initials: A
authors.lastname: Cheng
keywords: Colonic fistula; Endoscopy; Minimally invasive necrosectomy; Step-up approach; Video assisted retroperitoneal debridement