ORIGINAL ARTICLE pissn 2234-778X eissn 2234-5248 J Minim Invasive Surg 2016;19(3):102-107 Journal of Minimally Invasive Surgery 괴사성췌장염의최소침습치료시대에서복강경괴사제거술의역할 노철규, 윤유석, 한호성, 조재영, 최영록, 장재성, 권성욱, 김성호, 최장규 서울대학교의과대학분당병원외과학교실 The Role of Laparoscopic Necrosectomy in the Era of Minimally Invasive Treatment for Necrotizing Pancreatitis: A Case Series and Review of the Literature Chul Kyu Roh, M.D., Yoo-Seok Yoon, M.D., Ho-Seong Han, M.D, Jai Young Cho, M.D., Young Rok Choi, M.D., Jae Seong Jang, M.D., Seonguk Kwon, M.D., Sung Ho Kim, M.D., Jang Kyu Choi, M.D. Department of Surgery, Seoul National University Bundang Hospital, Seoul National University College of Medicine, Seongnam, Korea Purpose: Despite the recent increasing application of minimally invasive techniques to treat necrotizing pancreatitis, few reports on laparoscopic necrosectomy have appeared. The aim of the present study was to evaluate the role played by laparoscopic necrosectomy in treatment of necrotizing pancreatitis. We review our own experience and the relevant literature. Methods: All patients undergoing laparoscopic necrosectomy at Seoul National University Bundang Hospital from March 2005 to January 2016 were included in the study. Data on patient demographics, CT severity index score, American Society of Anesthesiologists score, preoperative procedures, operative methods, operation time, estimated blood loss, postoperative complications, and length of hospital stay were retrospectively analyzed. We also performed an up-to-date review of the relevant literature. Results: Laparoscopic necrosectomy was performed on four patients with infective pancreatic necrosis that was inadequately treated by percutaneous drainage. A transgastrocolic, transmesocolic, or retrocolic approach was used. The median time from diagnosis to operation was 57 days (range, 34~109 days) and the median operation time 203 min (range, 180~255 min). There was no operative mortality. The necrotic tissue was successfully removed in a single operation in three of the four patients. Three patients experienced postoperative complications, including pleural effusion and recurrence of necrosis. The median postoperative hospital stay was 39 days (range, 16~99 days). Conclusion: Laparoscopic necrosectomy is safe and effective when used to treat necrotizing pancreatitis. Such treatment is especially useful for patients with solid, necrotic pancreatic components that are not removed by percutaneous or endoscopic drainage. Received July 4, 2016 Revised August 18, 2016 Accepted August 22, 2016 Corresponding author Yoo-Seok Yoon Department of Surgery, Seoul National University Bundang Hospital, 82, Gumi-ro, 173 Beongil, Bundang-gu, Seongnam 13620, Korea Tel: +82-31-787-7099 Fax: +82-31-787-4078 E-mail: yoonys@snubh.org Keywords: Laparoscopy, Necrosectomy, Pancreatitis, Acute necrotizing This is an Open Access article distributed under the terms of the Creative Commons Attribution Non-Commercial License (http:// creativecommons.org/licenses/by-nc/4.0/) which permits unrestricted non-commercial use, distribution, and reproduction in any medium, provided the original work is properly cited. Copyright 2016 The Journal of Minimally Invasive Surgery. All rights reserved. Journal of Minimally Invasive Surgery Vol.19, No.3, 2016 http://dx.doi.org/10.7602/jmis.2016.19.3.102
Laparoscopic Necrosectomy for Necrotizing Pancreatitis 103 서론 급성췌장염은대부분저절로호전되지만 10~20% 환자에서는중증으로진행하게되고이는췌장실질이나주변조직의괴사로인한치명적인합병증의발생과관련이있다. 1 괴사성췌장염 (necrotizing pancreatitis) 의 20~30% 에서이차적으로괴사감염이발생하고치료하지않을경우대부분사망에이르게된다. 2 이런이유로감염성췌장괴사 (infected pancreatic necrosis, IPN) 의표준치료로괴사조직제거및배액술이권장되고있다. 3 지난 20여년동안이에대한치료는개복수술의높은합병증및사망률로인해경피적배액술, 내시경적배액술그리고복강경괴사제거술등최소침습치료로발전하였다. 4-6 최근 PANTER (PAncreatitis, Necrosectomy versus a minimally invasive step up approach) 연구에서는감염성췌장괴사환자에대해초기단계에서내과적치료및경피적배액술등을시행한후임상경과의호전이없을경우최소침습후복막괴사제거술 (minimally invasive retroperitoneal necrosectomy) 을시행하는단계적최소침습접근법 (minimally invasive step-up approach) 을하였을때, 개복괴사제거술에비해단기간및장기간주요합병증이감소하였다고보고하였다. 7 그러나이연구는대상환자들의수가적고치료성적을좌우할수있는괴사조직의크기, 액화 (liquefaction) 정도, 위치가두치료군간에차이가있는지에대해명시되어있지않고, 최소침습치료간의비교는없다는제한점이있다. 감염성췌장괴사에대한일차적인최소침습치료로서경피적배액술과내시경적배액술은선택적환자에있어서유용한방법이지만반복적인시술이필요하고완전한괴사제거가어려운경우가많다. 괴사조직이남아있을경우전신염증반응이지속되면서환자의상태가악화될수있기때문에적절한시기에수술적치료를통해완벽한괴사제거를하는것이중요하다. 최근에는개복수술에서발생할수있는상처와관련된합병증을피하고, 수술적손상에의한국소적, 전신적염증반응의유발을최소하여다발성장기부전의가능성을줄이고자하는노력으로최소침습수술이시도되고있다. 8 지금까지보고된최소침습수술은접근방식에따라경복막 (transperitoneal) 접근법과후복막 (retroperitoneal) 접근법이있는데, 지금까지후복막접근법에대한보고들이대부분이고, 경복막접근법에대한보고는드문실정이다. 이에저자들은감염성췌장괴사환자들에서시행된경복막복강경괴사제거술 (laparoscopic transperitoneal necrosectomy) 에대한저자들의임상경험을분석하고, 이에대한문헌고찰을통하여감염성췌장괴사에대한최소침습수술법으로 복강경괴사제거술의역할에대해알아보고자한다. 대상및방법 2005 년 3월부터 2016 년 1월까지분당서울대학교병원에서괴사성췌장염으로복강경괴사제거술을시행받은 4명의환자를대상으로환자특성, 수술전후경과, 수술시기, 수술방법및합병증등에대해환자의의무기록을이용하여후향적으로조사하였다. 이연구는병원연구윤리심의위원회의승인 (B- 1607-354-109) 을받았다. 문헌검색을위한데이터베이스는 PubMed 를이용하였다. 검색용어는 [acute] AND [pancreatitis] AND [laparoscopy] 을이용하였고, 키워드로검색된 727 편의논문중제목과초록을확인하여현재진행중인연구, 동물연구, 다른주제의연구및다른치료를시행한연구등은제외하였다. 이중괴사성췌장염의주치료로경복막괴사제거술을시행한 9편의논문에대해문헌고찰을시행하였다. 수술방법환자는기관삽관후전신마취하에앙아위자세를취하였고, 집도의와카메라조수는환자의우측에, 제1 보조의는좌측에위치하였다. 2개의모니터는각각환자어깨양쪽에위치하였다. 배꼽하방에 12 mm 투관침을넣고, 기복을만든후먼저복강내를확인하였다. 4개혹은 5개의투관침을추가적으로사용하였고, 삽입부위는병변의위치에따라집도의가결정하였다. 구체적인수술방법은이전의보고에기술되었다. 9 병변이췌장의체부부터미부일경우결장간막접근법 (transmesocolic approach) 을이용하였다. 트레이츠인대 (ligament of Treitz) 근처에서대장을상방으로들고좌결장동맥과중결장동맥사이의대장장간막에절개창을내어접근하는방법이다. 병변이췌장경부일경우위대장인대를통한접근법 (transgastrocolic approach) 을이용하였다. 위대장인대를절개하여위를상방으로들고소낭 (lesser sac) 으로접근하여괴사제거를하는방법이다. 병변이결장의후방및신장주변일경우결장측방홈 (paracolic gutter) 을통한결장후방접근법 (retrocolic approach) 을이용하였다. 췌장주변의괴사에대해서는직접접근하여괴사제거를하였다. 집도의는괴사조직의완벽한제거를위해괴사및체액저류의위치에따라한가지이상의접근법을이용하여복강경괴사제거술을시행하였다. 괴사조직제거및지혈후생리식염수를이용하여세척을하였고, 2개의배액관은투관침부위를이용하여복강내에거치하였다. www.e-jmis.org
104 Chul Kyu Roh et al. 결과 복강경괴사제거술을시행받은환자는모두남자였고, 연령의중간값은 43 세 (30~61 세 ) 였다. 괴사성췌장염의원인은모두음주로인한것이었고, 내원당시관련증상은발열이 2명, 복 부통증이 2명이었다. 입원초기시행한조영증강복부전산화단층촬영 (contrast-enhanced computed tomography, CECT) 을이용하여췌장염의중증도를평가하였고, 모두 modified computed tomography severity index (CTSI) 10 8점이상인중증 (severe) 췌장염소견을보였다. 수술전패혈증에의한호 Table 1. Cases of laparoscopic necrosectomy Case 1 Case 2 Case 3 Case 4 Sex M M M M Age 42 61 44 30 Etiology Alcoholic Alcoholic Alcoholic Alcoholic Symptom Fever Abdominal pain Abdominal pain Fever ASA* class 2 2 2 1 Modified CTSI,10 8 (severe) 8 (severe) 9 (severe) 9 (severe) Preoperative percutaneous drainage Yes Yes Yes Yes Microorganism Acinetobacter baumannii Citrobacter braakii Methicillin-resistant Staphylococcus aureus ESBL -producing E coli Vancomycin-sensitive Enterococcus Preoperative organ failure No Yes (respiratory failure, renal failure) Location of necrosis Peripancreatic area Left subphrenic space Pelvic cavity Yes (respiratory failure, renal failure) Peripancreatic area Transverse mesocolon and lesser omentum Enterococcus faecium Klebsiella pneumoniae No Peripancreatic area Transverse mesocolon Time to operation (day) 34 109 60 53 Method of approach Transmesocolic & Retrocolic Retrocolic Transgastrocolic Transmesocolic & Transgastrocolic Operation time (min) 215 180 255 190 Estimated blood loss (cc) 400 750 700 250 Transfusion (intraoperative) No 1 RBC unit 4 RBC units 2 RBC units Hospital stay (day) 50 (POD 16) 131 (POD 23) 158 (POD 99) 71 (POD 54) Duration of drainage (day) 57 (POD 23) 118 (POD 10) 172 (POD 113) 142 (POD 125) Complication Left pleural effusion & Pseudocyst None Recollection Left pleural effusion Treatment for complication Chest PCD Endoscopic cystogastrostomy None Reoperation at POD 70 Laparoscopic necrosectomy and drainage (Retrocolic approach) Chest PCD Duration of follow-up (month) 4 10 6 72 *American Society of Anesthesiologists, postoperative day, extended-spectrum beta-lactamases, percutaneous drainage. Modified computed tomography severity index: pancreatic inflammation (0~4 points)+pancreatic necrosis (0~4)+extrapancreatic complication (0~2); mild (0~2), moderate (4~6), severe (8~10). Journal of Minimally Invasive Surgery Vol. 19. No. 3, 2016
Laparoscopic Necrosectomy for Necrotizing Pancreatitis 105 흡부전및급성신부전으로중환자실집중치료를받은환자는 2명이었다. 모든환자에서수술전중재적시술로평균 11 회 (8~16 회 ) 경피적배액술을시행하였다. 배양검사결과모두감염균이동정되어감염성췌장괴사로진단되었고, 배양된균주로는그람양성구균 (Gram positive cocci) 으로포도상구균 (Staphylococcus aureus), 장구균 (Enterococcus faecium) 이었고, 그람음성간균 (Gram negative rod) 으로대장균 (E coli), 폐렴간균 (Klebsiella pneumoniae), 아시네토박터바우마니 (Acinetobacter baumannii) 등이었다. 진단후수술까지기간의중간값은 57일 (34~109일) 로모든환자에서진단후 4주이후지연수술을시행하였다. 수술시간의중간값은 203 분 (180~255 분 ) 이었고, 수술중적혈구제제수혈은 3명의환자에서시행하였다. 수술후사망은없었고, 수술후합병증은 3명의환자에서발생하였는데 2명에서수술후좌측늑막삼출로경피적배액관을이용하여배액을하였고, 1명에서수술후췌장주변괴사는소실되었으나좌측후복막강에체액저류가지속되고, 발열이동반되어결장후방접근법을이용하여복강경괴사제거술및배액술을다시시행하였다. 수술후재원기간의중간값은 39 일 (16~99 일 ) 이었다. 퇴원후평균추적관찰기간은 23개월 (4~72 개월 ) 이었고, 1명의환자에서수술 4개월후췌장가성낭종 (pseudocyst) 의크기가점점증가하여내시경적위낭종루형성 (endoscopic cystogastrostomy) 및내배액술 (internal drainage) 을시행하였다. 나머지환자들은특별한문제없이지내고있다 (Table 1). 고찰 괴사성췌장염의고전적수술은개복수술로조기에괴사조직을제거하였으나여러연구들에서조기개복수술의높은사망률보고하면서발병초기에내과적보존적치료를하고이후지연수술을고려하는방향으로변화하고있다. 11 세계췌장학회 (IAP) 진료지침에따르면다발성장기부전으로진행하지않는다면첫 2주동안은내과적보존적치료를시행하고수술적치료를지양할것을권고한다. 진단후 3~4 주이후로수술을미루는것은이기간동안정상조직과괴사조직간의충분한경계를확보하여, 수술중출혈을줄이고수술후패혈증및전신염증반응을줄임으로사망률및이환률을감소시킬수있기때문이다. 12 개복괴사제거술은감염성괴사에대해광범위접근이가능하지만그로인한물리적스트레스가심하고매우침습적인방법으로출혈, 장누공, 상처감염등의합병증이 34~95%, 사망률이 11~39% 에이른다. 8 최근개복수술의성공적인결과도보고하고있지만, 11 개복과관련된합병증을피하고자최소침습치료가많이보고되고있다. 괴사성췌장염에대한복강경수술로경복막접근법을보고 한 9편의문헌과본연구의환자들을분석하였다 (Table 2). 총 125 명의환자중 98명 (78%) 에서감염성췌장괴사로진단되었다. 3편의문헌에서진단후수술까지의기간이명시되어있지않았지만, 본연구를포함한나머지문헌에서는모두진단후 4 주이후지연수술을시행하였다. 122 명의환자에서경복막복강경괴사절제술을시행하였고, 3명의환자에서후복막접근법으로괴사제거술을시행하였다. 이중 101 명 (81%) 에서성공적인결과를보였다. 66명 (53%) 이상의환자에서위대장인대를통한접근법을이용하였고, 결장간막접근법은 19 명 (15%), 직접접근법은 9명 (7%), 위벽을통한접근법은 8명 (6%) 의환자에서이용하였다. 수술시간은평균 137 분 (120~270 분 ) 이었다. 수술후합병증은 65명 (52%) 의환자에서발생하였다. 가장많은합병증은췌장루 (pancreatic fistula) 로 30명에서발생하였고, 잔존괴사로인한임상경과의악화로 11 명에서재수술을시행하였고, 재저류 (recollection) 로인해 7명에서경피적배액술등의중재적시술을시행하였다. 수술후평균재원기간은 24일 (7~51 일 ) 이었고, 수술후 5명 (4%) 에서사망환자가발생하였다. 최소침습치료로서경피적배액술및내시경적배액술은국소적인액화괴사가있는선택적환자에대해시행가능하나췌장괴사의액화가덜형성되어주로고형 (solid) 괴사및광범위한괴사일경우에는완벽한제거가어려운제한점이있다. 이로인해반복적인시술을필요로하고, 영양상태의악화, 괴사의감염, 장누공등의합병증이발생할수있다. 13 이경우에는최소침습치료로서복강경괴사제거술이더유용하다. Gagner 은 1996 년처음으로복강경괴사제거술로후위접근법 (retrogastric approach), 위벽을통한접근법 (transgastric approach), 후복막강경접근법 (retroperitoneoscopic approach) 을제시하였고, 성공적인결과를보고하였다. 14 이후 Cuschieri 는복강경괴사제거술의제한점인복강내감염의파급을줄이기위해결장간막접근법에대해처음으로보고하였고, 11 명의환자들에게시행하여 9명의성공, 1명의사망이있었다. 15 Parekh는수부보조복강경괴사제거술 (hand-assisted laparoscopic necrosectomy) 을시행하여성공적인결과를보고하였다. 이는 Cuschieri 가보고한결장간막접근법에수부보조법을추가하여괴사절제, 조직의견인및지혈이용이하여수술시간이단축되고학습곡선 (learning curve) 도단축될수있다고하였다. 게다가후복막접근법과비교한경복막접근법의장점으로후복막으로접근불가능한결장측방홈, 신장주변 (perinephric space), 십이지장후강 (retroduodenal space) 과같은곳을복강경으로접근하여괴사의완전한제거가가능하다는것을보고하였다. 16 2014 년 Mathew 등도복강경괴사제거술로 28명의환자중 22명에서성공하였다고보고하였고, 후복막접근법의주된제한점인한정된시야및불완전한괴사제거를경 www.e-jmis.org
106 Chul Kyu Roh et al. Table 2. Literature review for laparoscopic necrosectomy Studies Patients, n Time to operation, day (mean or median) Operation time, min (mean) Surgical approach, n (%) Infected, n (%) Mortality, n (%) Success, n (%) Hospital stay, day (mean) Complication, n (%) Gagner 1996 14 8 NA* NA Transgastrocolic 4 (50) Transgastric 3 (38) Retroperitoneoscopic 1 (12) 8 (100) 0 6 (75) 51 Recollection 2 (25) Hamad et al 2000 20 1 35 180 Transgastrocolic 1 (100) 1 (100) 0 1 (100) 7 Pancreatic fistula 1 (100) Cuschieri 2002 15 11 NA NA Transmesocolic 11 (100) 11 (100) 1 (9) 9 (82) NA Bleeding 1 (9) Ammori 2002 21 1 42 270 Transgastric 1 (100) 1 (100) 0 1 (100) 14 0 Zhou et al 2003 22 13 NA NA Transgastrocolic 7 (54) Intracavitary 6 (46) Parekh 2006 16 19 65 (median) 153 Transmesocolic Transgastrocolic Wani et al 2011 23 15 34 (mean) 120 Transgastrocolic 6 (40) Transmesocolic 4 (27) Gastrohepatic omenetum 2 (13) Retroperitoneal 2 (13) Intracavitary 1 (7) 4 (31) 0 12 (92) NA Pseudocyst 1 (8) 19 (100) 2 (11) 14 (74) 16 Pancreatic fistula 11 (58) Reoperation-open 2 (11) Reoperation-laparoscopy 2 (11) 15 (100) 0 10 (67) 14 Reoperation-laparoscopy 5 (33) Pancreatic fistula 2 (13) Tan et al 2012 24 25 30 (median) 157 Transgastrocolic 25 (100) 25 (100) 1 (4) 23 (92) 34 Pancreatic fistula 8 (32) Pneumonia 6 (24) Fungal infection 3 (12) Recollection 2 (8) Bleeding 1 (4) Reoperation 1 (4) Enteric fistula 1 (4) Mathew et al 2014 17 28 28 (mean) 101 Transgastrocolic 21 (75) Transmesocolic 1 (4) Transgastric 4 (14) Intracavitary 2 (7) Our series 4 57 (median) 210 Transgastrocolic+transmesocolic 1 (25) Transgastrocolic 1 (25) Transmesocolic 1 (25) Retrocolic 1 (25) Total 125 137 Transgastrocolic 66 (53) Transmesocolic 19 (15) Intracavitary 9 (7) Transgastric 8 (6) Continuous variable are expressed as mean or median value. *Not applicable. 10 (36) 1 (4) 22 (79) 15 Pancreatic fistula 8 (29) Recollection 3 (11) Wound 3 (11) 4 (100) 0 3 (75) 48 Pleural effusion 2 (50) Reoperation 1 (25) Pseudocyst 1 (25) 98 (78) 5 (4) 101 (81) 24 65 (52) Journal of Minimally Invasive Surgery Vol. 19. No. 3, 2016
Laparoscopic Necrosectomy for Necrotizing Pancreatitis 107 복막접근법으로극복할수있다고하였다. 17 괴사성췌장염에대한최소침습수술중후복막접근법은복강내접근을하지않기때문에복강내로의염증의파급을막을수있는장점이있지만제한된시야로인해괴사부위전반에대한접근에어려움이있고, 이로인한주변혈관및장기손상가능성이있다. 반면복강경괴사제거술은소낭, 결장측방홈, 신장주변, 췌장두부 (head of pancreas) 등복강내전반에접근이가능해후복막접근법의제한점을극복할수있다. 18 복강경괴사제거술은최소침습치료의장점은가지면서넓은시야로복강내전반에접근하여괴사의완전한제거가가능하며담낭제거술이나공장루등추가적인처치도가능하다. 하지만감염의파종, 혈역학적으로불안정한환자에서의기복 (pneumoperitoneum), 의인성장천공등에대한우려가있고아직대규모로시행된연구는없어앞으로이에대해전향적다기관연구가필요하다. 19 결론적으로복강경괴사제거술은괴사성췌장염의치료에있어서안전한접근법이고주요합병증과사망률을감소시킨다. 특히고형괴사나광범위괴사인경우에복강경괴사제거술이유용한최소침습치료가될것이다. REFERENCES 1) de Beaux AC, Palmer KR, Carter DC. Factors influencing morbidity and mortality in acute pancreatitis; an analysis of 279 cases. Gut 1995;37:121-126. 2) Gooszen HG, Besselink MG, van Santvoort HC, Bollen TL. Surgical treatment of acute pancreatitis. Langenbecks Arch Surg 2013;398:799-806. 3) IAP/APA evidence-based guidelines for the management of acute pancreatitis. Pancreatology 2013;13:e1-15. 4) Szeliga J, Jackowski M. Minimally invasive procedures in severe acute pancreatitis treatment - assessment of benefits and possibilities of use. Wideochir Inne Tech Maloinwazyjne 2014;9:170-178. 5) Bugiantella W, Rondelli F, Boni M, et al. Necrotizing pancreatitis: A review of the interventions. Int J Surg 2016;28 Suppl 1:S163-171. 6) Bucher P, Pugin F, Morel P. Minimally invasive necrosectomy for infected necrotizing pancreatitis. Pancreas 2008;36:113-119. 7) van Santvoort HC, Besselink MG, Bakker OJ, et al. A step-up approach or open necrosectomy for necrotizing pancreatitis. N Engl J Med 2010;362:1491-1502. 8) Raraty MG, Halloran CM, Dodd S, et al. Minimal access retroperitoneal pancreatic necrosectomy: improvement in morbidity and mortality with a less invasive approach. Ann Surg 2010;251:787-793. 9) Yoon YS, Han HS, Shin SH, et al. Laparoscopic Necrosectomy for Treating Infected Necrotizing Pancreatitis. J Korean Surg Soc 2008;74:387-391. 10) Mortele KJ, Wiesner W, Intriere L, et al. A modified CT severity index for evaluating acute pancreatitis: improved correlation with patient outcome. AJR Am J Roentgenol 2004;183:1261-1265. 11) Mier J, Leon EL, Castillo A, Robledo F, Blanco R. Early versus late necrosectomy in severe necrotizing pancreatitis. Am J Surg 1997;173:71-75. 12) Uhl W, Warshaw A, Imrie C, et al. IAP Guidelines for the Surgical Management of Acute Pancreatitis. Pancreatology 2002;2:565-573. 13) Rana SS, Bhasin DK, Sharma RK, Kathiresan J, Gupta R. Do the morphological features of walled off pancreatic necrosis on endoscopic ultrasound determine the outcome of endoscopic transmural drainage? Endosc Ultrasound 2014;3:118-122. 14) Gagner M. Laparoscopic Treatment of Acute Necrotizing Pancreatitis. Semin Laparosc Surg 1996;3:21-28. 15) Cuschieri A. Pancreatic necrosis: pathogenesis and endoscopic management. Semin Laparosc Surg 2002;9:54-63. 16) Parekh D. Laparoscopic-assisted pancreatic necrosectomy: A new surgical option for treatment of severe necrotizing pancreatitis. Arch Surg 2006;141:895-902; discussion 902-893. 17) Mathew MJ, Parmar AK, Sahu D, Reddy PK. Laparoscopic necrosectomy in acute necrotizing pancreatitis: Our experience. J Minim Access Surg 2014;10:126-131. 18) Tonsi AF, Bacchion M, Crippa S, Malleo G, Bassi C. Acute pancreatitis at the beginning of the 21st century: the state of the art. World J Gastroenterol 2009;15:2945-2959. 19) Martin RF, Hein AR. Operative management of acute pancreatitis. Surg Clin North Am 2013;93:595-610. 20) Hamad GG, Broderick TJ. Laparoscopic pancreatic necrosectomy. J Laparoendosc Adv Surg Tech A 2000;10:115-118. 21) Ammori BJ. Laparoscopic transgastric pancreatic necrosectomy for infected pancreatic necrosis. Surg Endosc 2002;16:1362. 22) Zhou ZG, Zheng YC, Shu Y, et al. Laparoscopic management of severe acute pancreatitis. Pancreas 2003;27:e46-50. 23) Wani SV, Patankar RV, Mathur SK. Minimally invasive approach to pancreatic necrosectomy. J Laparoendosc Adv Surg Tech A 2011;21:131-136. 24) Tan J, Tan H, Hu B, et al. Short-term outcomes from a multicenter retrospective study in China comparing laparoscopic and open surgery for the treatment of infected pancreatic necrosis. J Laparoendosc Adv Surg Tech A 2012;22:27-33. www.e-jmis.org