Feasibility of minimally invasive approaches in patients with infected necrotizing pancreatitis

Minimal-access retroperitoneal pancreatic necrosectomy for infected necrotizing pancreatitis: a multicentre study of a step-up approach

BACKGROUND

Various minimally invasive approaches have been described for infected necrotizing pancreatitis. This article describes a modified minimal-access retroperitoneal pancreatic necrosectomy (MARPN) procedure assisted by gas insufflation.

METHODS

This retrospective, observational study documented patients who had undergone a step-up MARPN between 1 January 2010 and 31 December 2016. A minimum follow-up of 1 year was required for inclusion. The step-up approach involved percutaneous catheter drainage followed by the modified MARPN and necrosectomy. If more than one access site was needed it was categorized as complex MARPN.

RESULTS

Of 212 patients with infected necrotizing pancreatitis, 164 (77·4 per cent) underwent a step-up approach. The median number of percutaneous catheter drains and MARPN procedures was 3 (range 1-7) and 1 (1-6) respectively. Ninety patients (54·9 per cent) underwent complex MARPN. For residual necrosis after MARPN, three patients (1·8 per cent) underwent sinus tract gastroscopy, and 11 (6·7 per cent) had sinography combined with a tube change. However, operations in 13 patients (7·9 per cent) required conversion to open surgery. Postoperative complications developed in 103 patients (62·8 per cent). The mortality rate was 6·1 per cent (10 deaths).

CONCLUSION

A step-up approach using a modified MARPN for infected necrotizing pancreatitis is a reasonable option.

[Surgical resolutions determining outcomes of infected pancreatic necrosis]

AIM

To evaluate technology, indications and time of minimally invasive semi-closed and laparotomic sanations for infected pancreatic necrosis (IP).

MATERIAL AND METHODS

Initially it was used sonography-assisted minimally invasive semi-closed drainage of IP with gradual augmentation of catheters' diameter. In 462 patients with IP liquid pus prevailed over sequesters in epigastric localized pancreatonecrotic phlegmon (ELPF) and pancreatonecrotic abscesses. So, minimally invasive approach may be definitive. Epigastric advanced pancreatonecrotic phlegmon with predominant sequesters is often followed by conversion to transverse omentobursopancreatostomy (OBPS) to open all purulent accumulations.

RESULTS

Surgical treatment immediately after parapancreatic infiltrate suppuration (i.e. within 3-4 weeks after onset of the disease) is associated with reduced mortality. Absent result of minimally invasive drainage is followed by mortality from the 11^th day and maximum in 14 days after treatment onset. Therefore, focal IP resistant to minimally invasive drainage requires conversion to transverse OBPS or video-assisted sequestrectomy after 10-13 days. The lowest mortality (14.8±2.5%) was observed in patients who underwent minimally invasive drainage or transverse OBPS within 10-13 days. Ineffective prolonged minimally invasive drainage was accompanied by high mortality rate (60.7±3.2%, p<0.001).

CONCLUSION

Conversion to transverse OBPS or video-assisted sequestrectomy are required if minimally invasive drainage of IP is ineffective after 10-13 days. Clear understanding of indications for closed and open drainage of PI helps to avoid tactical and technological errors.

Percutaneous Catheter Drainage in Infected Pancreatitis Necrosis: a Systematic Review

The primary aim of this study was to present the outcomes of percutaneous catheter drainage (PCD) in patients with infected pancreatitis necrosis. A second aim was to focus on disease severity, catheter size, and additional surgical intervention. A literature search of the PubMed/MEDLINE/Cochrane Library (January 1998 to February 2015) databases was conducted. All randomized, non-randomized, and retrospective studies with data on PCD techniques and outcomes in patients with infected pancreatitis necrosis were included. Studies that reported data on PCD along with other interventions without the possibility to discriminate results specific to PCD were excluded. The main outcomes were mortality, major complications, and definitive successful treatment with percutaneous catheter drainage alone. Fifteen studies of 577 patients were included. There was only one randomized, controlled trial, and most others were retrospective case series. Organ failure before PCD occurred in 55.3 % of patients. With PCD alone, definitive successful treatment was 56.2 % of patients. Additional surgical intervention was required after PCD in 38.5 % of patients. The overall mortality rate was 18 % (104 of 577 patients). Complications occurred in 25.1 % of patients, and fistula was the most common complication. PCD is an efficient tool for treatment in the majority of patients with infected pancreatitis necrosis as the only intervention. Multiple organ failures before PCD are negative parameters for the outcome of the disease. Large catheters fail to prove to be more effective for draining necrotic tissue. However, in the extent of multi-morbid patients, to determine one single prognostic factor seems to be difficult.

Minimally invasive percutaneous catheter drainage versus open laparotomy with temporary closure for treatment of abdominal compartment syndrome in patients with early-stage severe acute pancreatitis

This study aimed to examine the clinical efficacy of minimally invasive percutaneous catheter drainage (PCD) versus open laparotomy with temporary closure in the treatment of abdominal compartment syndrome (ACS) in patients with early-stage severe acute pancreatitis (SAP). Clinical data of 212 patients who underwent PCD and 61 patients who were given open laparotomy with temporary closure in our hospital over the last 10-year period were retrospectively analyzed, and outcomes were compared, including total and post-decompression intensive care unit (ICU) and hospital stays, physiological data, organ dysfunction, complications, and mortality. The results showed that the organ dysfunction scores were similar between the PCD and open laparotomy groups 72 h after decompression. In the PCD group, 134 of 212 (63.2%) patients required postoperative ICU support versus 60 of 61 (98.4%) in the open laparotomy group (P<0.001). Additionally, 87 (41.0%) PCD patients experienced complications as compared to 49 of 61 (80.3%) in the open laparotomy group (P<0.001). There were 40 (18.9%) and 32 (52.5%) deaths, respectively, in the PCD and open laparotomy groups (P<0.001). In conclusion, minimally invasive PCD is superior to open laparotomy with temporary closure, with fewer complications and deaths occurring in PCD group.

Video-assisted Laparoscopic Débridement for Retroperitoneal Pancreatic Collections: A Reliable Step-up Approach

Several minimal access routes have been implemented as a step-up approach to treat infected pancreatic necrosis. We evaluate our experience with a series of consecutive patients with pancreatic collections treated with video-assisted retroperitoneal débridement (VARD). Seven patients were consecutively treated with VARD: five patients after acute necrotizing pancreatitis, one chronic pancreatitis, and one patient with perforation after endoscopic sphincterotomy. The indication for VARD was: development of sepsis, positive direct culture of the necrosis, and compartment syndrome. The procedure was performed under general anesthesia and modified lateral decubitus. There were four left, two right, and one bilateral VARD. Mean hospital stay since admission to VARD procedure was 30 days (range, 12 to 72 days). Mean operative time was 63 minutes. There were no intraoperative complications. Two patients needed a second procedure to control sepsis. Most patients had a long intensive care unit (ICU) stay with 6.1 days (range, 2 to 22 days) mean postoperative ICU stay. One patient had a hypernatremia as a consequence of saline lavage and three patients presented pancreatic fistula that were managed with conservative treatment. There was no mortality. VARD approach is a recommended step-up approach to treat infected pancreatic necrosis, and its indication may be extended to treat other retroperitoneal collections.

Interventions for necrotizing pancreatitis: summary of a multidisciplinary consensus conference

Pancreatic and peripancreatic necrosis may result in significant morbidity and mortality in patients with acute pancreatitis. Many recommendations have been made for management of necrotizing pancreatitis, but no published guidelines have incorporated the many recent developments in minimally invasive techniques for necrosectomy. Hence, a multidisciplinary conference was convened to develop a consensus on interventions for necrotizing pancreatitis. Participants included most international experts from multiple disciplines. The evidence for efficacy of interventions was reviewed, presentations were given by experts, and a consensus was reached on each topic. In summary, intervention is primarily indicated for infected necrosis, less often for symptomatic sterile necrosis, and should ideally be delayed as long as possible, preferably 4 weeks or longer after the onset of disease, for better demarcation and liquefaction of the necrosis. Both the step-up approach using percutaneous drainage followed by minimally invasive video-assisted retroperitoneal debridement and per-oral endoscopic necrosectomy have been shown to have superior outcomes to traditional open necrosectomy with respect to short-term and long-term morbidity and are emerging as treatments of choice. Applicability of these techniques depends on the availability of specialized expertise and a multidisciplinary team dedicated to the management of severe acute pancreatitis and its complications.

Laparoscopic approach to acute abdomen from the Consensus Development Conference of the Società Italiana di Chirurgia Endoscopica e nuove tecnologie (SICE), Associazione Chirurghi Ospedalieri Italiani (ACOI), Società Italiana di Chirurgia (SIC), Società Italiana di Chirurgia d'Urgenza e del Trauma (SICUT), Società Italiana di Chirurgia nell'Ospedalità Privata (SICOP), and the European Association for Endoscopic Surgery (EAES)

BACKGROUND

In January 2010, the SICE (Italian Society of Endoscopic Surgery), under the auspices of the EAES, decided to revisit the clinical recommendations for the role of laparoscopy in abdominal emergencies in adults, with the primary intent being to update the 2006 EAES indications and supplement the existing guidelines on specific diseases.

METHODS

Other Italian surgical societies were invited into the Consensus to form a panel of 12 expert surgeons. In order to get a multidisciplinary panel, other stakeholders involved in abdominal emergencies were invited along with a patient's association. In November 2010, the panel met in Rome to discuss each chapter according to the Delphi method, producing key statements with a grade of recommendations followed by commentary to explain the rationale and the level of evidence behind the statements. Thereafter, the statements were presented to the Annual Congress of the EAES in June 2011.

RESULTS

A thorough literature review was necessary to assess whether the recommendations issued in 2006 are still current. In many cases new studies allowed us to better clarify some issues (such as for diverticulitis, small bowel obstruction, pancreatitis, hernias, trauma), to confirm the key role of laparoscopy (such as for cholecystitis, gynecological disorders, nonspecific abdominal pain, appendicitis), but occasionally previous strong recommendations have to be challenged after review of recent research (such as for perforated peptic ulcer).

CONCLUSIONS

Every surgeon has to develop his or her own approach, taking into account the clinical situation, her/his proficiency (and the experience of the team) with the various techniques, and the specific organizational setting in which she/he is working. This guideline has been developed bearing in mind that every surgeon could use the data reported to support her/his judgment.

Percutaneous catheter drainage for infective pancreatic necrosis: is it always the first choice for all patients?

OBJECTIVE

To learn the clinical outcome of percutaneous catheter drainage (PCD) for patients with infective pancreatic necrosis and the possible influencing factors.

METHODS

A retrospective review of medical records of patients with infective pancreatic necrosis who received PCD as the first choice for treatment in the recent 2 years. The patients were divided into 2 groups: (1) PCD success group and (2) PCD alteration group. Characteristics, complications, and PCD process were compared.

RESULTS

In this study, 19 of 34 patients were cured by PCD alone (55.9%), whereas open necrosectomy were needed for 15 patients (44.1%). Between these 2 groups, most baseline and clinical characteristics did not show any statistical difference, including the number and size of catheter used and the bacterial culture result. The PCD alteration group had higher mean computed tomographic density (P = 0.012) and larger distribution range of infected pancreatic necrosis (4.53 ± 1.35 vs 5.93 ± 1.62; P = 0.009) than the PCD success group (P < 0.01). The logistic regression analysis revealed the same facts.

CONCLUSION

The mean computed tomographic density and distribution range of infective pancreatic necrosis could significantly influence the success rate of PCD; higher values of them indicate less appropriate for PCD; thus, it should be considered seriously before the treatment decision.

Systematic review of percutaneous catheter drainage as primary treatment for necrotizing pancreatitis

BACKGROUND

The role of percutaneous catheter drainage (PCD) in patients with (infected) necrotizing pancreatitis was evaluated.

METHODS

A systematic literature search was performed. Inclusion criteria were: consecutive cohort of patients with necrotizing pancreatitis undergoing PCD as primary treatment for peripancreatic collections; indication for PCD either (suspected) infected necrosis or symptomatic sterile pancreatic necrosis; and outcomes reported to include percentage of infected peripancreatic collections, need for additional surgical necrosectomy, complications and deaths. Exclusion criteria were: cohort of fewer than five patients; cohort included patients with chronic pancreatitis; selected subgroup of patients with acute pancreatitis studied, such as those with pseudocysts, pancreatic abscesses and/or exclusively sterile pancreatic necrosis; and cohort in which PCD was combined with another minimally invasive strategy and results for PCD alone not reported separately.

RESULTS

Eleven studies, including 384 patients, fulfilled the inclusion criteria. Only one study was a randomized controlled trial; most others were retrospective case series. Four studies reported on the presence of organ failure before PCD; this occurred in 67·2 per cent of 116 patients. Infected necrosis was proven in 271 (70·6 per cent) of 384 patients. No additional surgical necrosectomy was required after PCD in 214 (55·7 per cent) of 384 patients. Complications consisted mostly of internal and external pancreatic fistulas. The overall mortality rate was 17·4 per cent (67 of 384 patients). Nine of 11 studies reported mortality separately for patients with infected necrosis undergoing PCD; the mortality rate in this group was 15·4 per cent (27 of 175).

CONCLUSION

A considerable number of patients can be treated with PCD without the need for surgical necrosectomy.

Infected pancreatic necrosis: minimizing the cut

The challenge for the pancreatologist managing patients with infected pancreatic necrosis is to devise a treatment algorithm that enables recovery but at the same time limits the morbidity and mortality. The current gold standard remains open necrosectomy. Recent literature contains scattered reports of endoscopic, radiologic, laparoscopic, percutaneous and lumbotomy approaches to managing patients with this condition. This literature review addresses the role of techniques that aim to minimize the physiological insult to the patient with infected pancreatic necrosis.

A step-up approach or open necrosectomy for necrotizing pancreatitis

BACKGROUND

Necrotizing pancreatitis with infected necrotic tissue is associated with a high rate of complications and death. Standard treatment is open necrosectomy. The outcome may be improved by a minimally invasive step-up approach.

METHODS

In this multicenter study, we randomly assigned 88 patients with necrotizing pancreatitis and suspected or confirmed infected necrotic tissue to undergo primary open necrosectomy or a step-up approach to treatment. The step-up approach consisted of percutaneous drainage followed, if necessary, by minimally invasive retroperitoneal necrosectomy. The primary end point was a composite of major complications (new-onset multiple-organ failure or multiple systemic complications, perforation of a visceral organ or enterocutaneous fistula, or bleeding) or death.

RESULTS

The primary end point occurred in 31 of 45 patients (69%) assigned to open necrosectomy and in 17 of 43 patients (40%) assigned to the step-up approach (risk ratio with the step-up approach, 0.57; 95% confidence interval, 0.38 to 0.87; P=0.006). Of the patients assigned to the step-up approach, 35% were treated with percutaneous drainage only. New-onset multiple-organ failure occurred less often in patients assigned to the step-up approach than in those assigned to open necrosectomy (12% vs. 40%, P=0.002). The rate of death did not differ significantly between groups (19% vs. 16%, P=0.70). Patients assigned to the step-up approach had a lower rate of incisional hernias (7% vs. 24%, P=0.03) and new-onset diabetes (16% vs. 38%, P=0.02).

CONCLUSIONS

A minimally invasive step-up approach, as compared with open necrosectomy, reduced the rate of the composite end point of major complications or death among patients with necrotizing pancreatitis and infected necrotic tissue. (Current Controlled Trials number, ISRCTN13975868.)

Percutaneous "stepped" drainage technique for infected pancreatic necrosis

INTRODUCTION

Aggressive surgical pancreatic debridement remains the standard of care, may require multiple abdominal explorations and is associated with high mortality. We have introduced the stepped technique of percutaneous treatment of infected peripancreatic fluid collections.

METHODS

We performed a retrospective review of patients with severe infected necrotizing pancreatitis who were managed percutaneously. Culture results, number of radiological interventions, length of stay, and complications were recorded.

RESULTS

There were 8 patients with a median number of Ranson's criteria of 4.5. Sixty invasive procedures were performed. A median number of two separate catheter sites per patient were necessary for the removal of necrotic material. Median duration of percutaneous intervention was 71.5 days with complete removal of necrotic material and resolution of infected collections in all patients.

CONCLUSIONS

Surgeons and interventional radiologists should be familiar with this evolving technique which is less invasive then surgery, but may prolong the time necessary for complete resolution.

Minimally invasive techniques in pancreatic necrosis

Traditional open surgical necrosectomy for treatment of infected pancreatic necrosis is associated with high morbidity and mortality, leading to a shift toward minimally invasive endoscopic, radiologic, and laparoscopic approaches. Percutaneous drainage is useful as a temporizing method to control sepsis and as an adjunctive treatment to surgical intervention. It is limited because of the requirement for frequent catheter care and the need for repeated procedures. Endoscopic transgastric or transduodenal therapies with endoscopic debridement/necrosectomy have recently been described and are highly successful in carefully selected patients. It avoids the need for open necrosectomy and can be used in poor operative candidates. Laparoscopic necrosectomy is also promising for treatment of pancreatic necrosis. However, the need for inducing a pneumoperitoneum and the potential risk of infection limit its usefulness in patients with critical illness. Retroperitoneal access with a nephroscope is used to directly approach the necrosis with complete removal of a sequestrum. Retroperitoneal drainage using the delay-until-liquefaction strategy also appears to be successful to treat pancreatic necrosis. The anatomic location of the necrosis, clinical comorbidities, and operator experience determine the best approach for a particular patient. Tertiary care centers with sufficient expertise are increasingly using minimally invasive procedures to manage pancreatic necrosis.

Current status of minimally invasive necrosectomy for post-inflammatory pancreatic necrosis

OBJECTIVE

This paper reviews current knowledge on minimally invasive pancreatic necrosectomy.

BACKGROUND

Blunt (non-anatomical) debridement of necrotic tissue at laparotomy is the standard method of treatment of infected post-inflammatory pancreatic necrosis. Recognition that laparotomy may add to morbidity by increasing postoperative organ dysfunction has led to the development of alternative, minimally invasive methods for debridement. This study reports the status of minimally invasive necrosectomy by different approaches.

METHODS

Searches of MEDLINE and EMBASE for the period 1996-2008 were undertaken. Only studies with original data and information on outcome were included. This produced a final population of 28 studies reporting on 344 patients undergoing minimally invasive necrosectomy, with a median (range) number of patients per study of nine (1-53). Procedures were categorized as retroperitoneal, endoscopic or laparoscopic.

RESULTS

A total of 141 patients underwent retroperitoneal necrosectomy, of whom 58 (41%) had complications and 18 (13%) required laparotomy. There were 22 (16%) deaths. Overall, 157 patients underwent endoscopic necrosectomy; major complications were reported in 31 (20%) and death in seven (5%). Laparoscopic necrosectomy was carried out in 46 patients, of whom five (11%) required laparotomy and three (7%) died.

CONCLUSIONS

Minimally invasive necrosectomy is technically feasible and a body of evidence now suggests that acceptable outcomes can be achieved. There are no comparisons of results, either with open surgery or among different minimally invasive techniques.

EUS-guided endoscopic transgastric necrosectomy in patients with infected necrosis in acute pancreatitis

BACKGROUND

Infected pancreatic and peripancreatic necrosis in acute pancreatitis is potentially lethal, with mortality rates up to 35%. Therefore, there is growing interest in minimally invasive treatment options, such as (EUS-guided) endoscopic transgastric necrosectomy.

METHODS

Retrospective cohort study on EUS-guided endoscopic transgastric necrosectomy in patients with infected necrosis in acute pancreatitis.

RESULTS

8 patients (age 38-75, mean 50 years) with documented infected peripancreatic or pancreatic necrosis were included. Median time to first intervention was 33 days (range 17-62) after onset of symptoms. At the time of first intervention 2 patients had organ failure. All patients were managed on the patient ward. Initial endoscopic drainage was successful in all patients, a median of 4 (range 2-6) subsequent endoscopic necrosectomies were needed to remove all necrotic tissue. Two patients needed additional surgical intervention because of pneumoperitoneum (n = 1) and insufficient endoscopic drainage (n = 1). Six patients recovered, with 1 mild relapse during follow-up (median 12, range 8-60 months). One patient died.

CONCLUSION

EUS-guided endoscopic transgastric necrosectomy of infected necrosis in acute pancreatitis appears to be a feasible and relatively safe treatment option in patients who are not critically ill. Further randomized comparison with the current 'gold standard' is warranted to determine the place of this treatment modality.

Management of severe pancreatic necrosis

Pancreatic necrosis is a form of severe pancreatitis associated with high morbidity and mortality. In this condition there is necrosis of pancreatic tissue with pancreatic duct disruption leading to release and activation of pancreatic enzymes. This in turn causes peripancreatic necrosis and formation of fluid collections. The diagnosis of pancreatic necrosis is made by contrast-enhanced CT scan of the abdomen. The management of pancreatic necrosis is controversial. No randomized clinical trials are available for guidance in treatment of pancreatic necrosis. Experience, collaboration, and knowledge of the managing teams play a major role in successful treatment. Early percutaneous drainage with frequent monitoring of the catheters is the hallmark of our approach. Using this approach, it is possible to significantly decrease the rate of morbidity and mortality associated with this disease and its treatment.

Case-matched comparison of the retroperitoneal approach with laparotomy for necrotizing pancreatitis

BACKGROUND

Minimally invasive necrosectomy through a retroperitoneal approach is gaining popularity for the treatment of necrotizing pancreatitis. There is, however, no substantial evidence from comparative studies in favor of this technique over laparotomy. The aim of this case-matched study was to perform the first head-to-head comparison of necrosectomy by the retroperitoneal approach with laparotomy in patients with necrotizing pancreatitis.

METHODS

Between 2001 and 2005, there were 15 of 841 consecutive acute pancreatitis patients who underwent necrosectomy by the retroperitoneal approach using a small flank incision. These patients were matched for the presence of preoperative organ failure, status of infection, timing of surgery, age, and computed tomography severity index score with 15 of 46 patients treated with necrosectomy by laparotomy and continuous postoperative lavage (CPL).

RESULTS

In addition to all matched preoperative characteristics, there were no significant differences in sex, preoperative intensive care unit (ICU) admission, preoperative ICU stay, preoperative APACHE-II scores, and preoperative multiple organ failure (MOF). Postoperative complications requiring reintervention occurred in six patients in each group (p = 1.000). Postoperative new-onset MOF occurred in 10 patients in the laparotomy/CPL group versus 2 patients in the retroperitoneal approach group (p = 0.008). Six patients died in the laparotomy/CPL group versus 1 patient in the retroperitoneal approach group (p = 0.080).

CONCLUSIONS

The less postoperative organ failure and the trend toward lower mortality may point to a benefit of the retroperitoneal approach over laparotomy. A randomized controlled design is, however, still required to answer definitively the question of which operative technique is preferably for patients with (infected) necrotizing pancreatitis.