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Makris GC, See T, Winterbottom A, Jah A, Shaida N. Minimally invasive pancreatic necrosectomy; a technical pictorial review. THE BRITISH JOURNAL OF RADIOLOGY 2017; 91:20170435. [PMID: 29099617 DOI: 10.1259/bjr.20170435] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
Necrotizing pancreatitis is the most severe form of acute pancreatitis, which is associated with significant mortality and morbidity. Open necrosectomy has been one of the treatment modalities; however, it has been associated with high mortality rates and alternative minimally invasive procedures such as minimal invasive pancreatic necrosectomy (MIPN) were developed to improve on the outcomes. While current clinical evidence on MIPN showed significant advantages in terms of incidence of multiple organ failure, incisional hernias and new-onset diabetes there were no differences in terms of mortality rate. In this pictorial review we are presenting the technical details of MIPN as a minimally invasive procedure for the debridement of the necrotic pancreatic tissue and we will discuss the current evidence around the use of this procedure for the management of pancreatic necrosis.
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Affiliation(s)
- Gregory C Makris
- 1 Department of Interventional Radiology, Oxford University Hospitals , Oxford , UK.,2 Department of Infectious diseases, Alfa Institute of Biomedical Sciences , Athens , Greece
| | - Teikchoon See
- 3 Department of Interventional Radiology, Cambridge University Hospitals , Cambridge , UK
| | - Andrew Winterbottom
- 3 Department of Interventional Radiology, Cambridge University Hospitals , Cambridge , UK
| | - Asif Jah
- 4 Surgical Division, Cambridge University Hospital , Cambridge , UK
| | - Nadeem Shaida
- 3 Department of Interventional Radiology, Cambridge University Hospitals , Cambridge , UK
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2
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Surgical management of pancreatic necrosis: A practice management guideline from the Eastern Association for the Surgery of Trauma. J Trauma Acute Care Surg 2017; 83:316-327. [PMID: 28452889 DOI: 10.1097/ta.0000000000001510] [Citation(s) in RCA: 24] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
BACKGROUND Pancreatic or peripancreatic tissue necrosis confers substantial morbidity and mortality. New modalities have created a wide variation in approaches and timing of interventions for necrotizing pancreatitis. As acute care surgery evolves, its practitioners are increasingly being called upon to manage these complex patients. METHODS A systematic review of the MEDLINE database using PubMed was performed. English language articles regarding pancreatic necrosis from 1980 to 2014 were included. Letters to the editor, case reports, book chapters, and review articles were excluded. Topics of investigation included operative timing, the use of adjuvant therapy and the type of operative repair. Grading of Recommendations, Assessment, Development and Evaluations methodology was applied to question development, outcome prioritization, evidence quality assessments, and recommendation creation. RESULTS Eighty-eight studies were included and underwent full review. Increasing the time to surgical intervention had an improved outcome in each of the periods evaluated (72 hours, 12-14 days, 30 days) with a significant improvement in outcomes if surgery was delayed 30 days. The use of percutaneous and endoscopic procedures was shown to postpone surgery and potentially be definitive. The use of minimally invasive surgery for debridement and drainage has been shown to be safe and associated with reduced morbidity and mortality. CONCLUSION Acute Care Surgeons are uniquely trained to care for those with pancreatic necrosis due their training in critical care and complex surgery with ongoing shock. In adult patients with pancreatic necrosis, we recommend that pancreatic necrosectomy be delayed until at least day 12. During the first 30 days of symptoms with infected necrotic collections, we conditionally recommend surgical debridement only if the patients fail to improve after radiologic or endoscopic drainage. Finally, even with documented infected necrosis, we recommend that patients undergo a step-up approach to surgical intervention as the preferred surgical approach. LEVEL OF EVIDENCE Systematic review/guideline, level III.
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Nemoto Y, Attam R, Arain MA, Trikudanathan G, Mallery S, Beilman GJ, Freeman ML. Interventions for walled off necrosis using an algorithm based endoscopic step-up approach: Outcomes in a large cohort of patients. Pancreatology 2017; 17:663-668. [PMID: 28803859 DOI: 10.1016/j.pan.2017.07.195] [Citation(s) in RCA: 29] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/06/2016] [Revised: 07/05/2017] [Accepted: 07/30/2017] [Indexed: 12/11/2022]
Abstract
OBJECTIVES The minimally invasive step-up approach for treatment of walled off necrosis (WON) involves drainage followed by later necrosectomy as needed, and is superior to primary surgical necrosectomy. Reported series of endoscopic transluminal necrosectomy include highly selected patients. We report outcomes of a large series of patients with WON managed by an algorithm based on an endoscopically centered step-up approach. METHODS Consecutive patients with necrotizing pancreatitis from 2009 to 2014, with intervention only for infected or persistently symptomatic WON. The primary approach involved endoscopic transluminal drainage plus minus necrosectomy whenever feasible, with percutaneous catheter drainage (PCD) plus minus sinus tract endoscopy if not feasible or sufficient. Surgery was reserved for failures of the step up approach. RESULTS Of 109 consecutive patients with necrotizing pancreatitis, intervention was required in 83, including endoscopic transluminal drainage in 73 (88%) (alone in 49 and combined with PCD in 24), and PCD alone in 10 (12%). 64 (77%) of the 83 patients required endoscopic transluminal and/or sinus tract necrosectomy. Adverse events occurred in 11 (13%). Three patients (4%) failed step up approach and required open surgical necrosectomy. All-cause mortality occurred in 6 (7%) of 83 patients after intervention, including 2 of 3 requiring surgery. CONCLUSIONS An algorithm based step-up approach for interventions in necrotizing pancreatitis using primarily endoscopic techniques with adjunctive percutaneous approaches as needed resulted in favorable outcomes with small numbers proceeding to open surgery, and with acceptable rates of major complications and mortality. A purely endoscopic transluminal approach was feasible in approximately 60% of patients requiring intervention in this series.
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Affiliation(s)
- Yukako Nemoto
- Division of Gastroenterology, Hepatology and Nutrition, University of Minnesota, United States; Division of Gastroenterology and Hepatology, Department of Internal Medicine, Toho University Ohashi Medical Center, Japan; Department of Gastroenterology, Kohsei Chuo General Hospital, Japan
| | - Rajeev Attam
- Division of Gastroenterology, Hepatology and Nutrition, University of Minnesota, United States; Advanced Endoscopy, Southern California Permanente Medical Group, Kaiser Permanente Downey, United States
| | - Mustafa A Arain
- Division of Gastroenterology, Hepatology and Nutrition, University of Minnesota, United States
| | - Guru Trikudanathan
- Division of Gastroenterology, Hepatology and Nutrition, University of Minnesota, United States
| | - Shawn Mallery
- Division of Gastroenterology, Hepatology and Nutrition, University of Minnesota, United States
| | | | - Martin L Freeman
- Division of Gastroenterology, Hepatology and Nutrition, University of Minnesota, United States.
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Gomatos IP, Halloran CM, Ghaneh P, Raraty MGT, Polydoros F, Evans JC, Smart HL, Yagati-Satchidanand R, Garry JM, Whelan PA, Hughes FE, Sutton R, Neoptolemos JP. Outcomes From Minimal Access Retroperitoneal and Open Pancreatic Necrosectomy in 394 Patients With Necrotizing Pancreatitis. Ann Surg 2016; 263:992-1001. [PMID: 26501713 DOI: 10.1097/sla.0000000000001407] [Citation(s) in RCA: 66] [Impact Index Per Article: 8.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
OBJECTIVE To examine the outcomes from minimal access retroperitoneal pancreatic necrosectomy (MARPN) and open pancreatic necrosectomy (OPN) for severe necrotizing pancreatitis in a single center. BACKGROUND The optimal management of severe pancreatic necrosis is evolving with a few large center single series. METHODS Between 1997 and 2013, patients with necrotizing pancreatitis at the Liverpool Pancreas Center were reviewed. Outcome measures were retrospectively analyzed by intention to treat. RESULTS There were 394 patients who had either MARPN (274, 69.5%) or OPN (120, 30.5%). Complications occurred in 174 MARPN patients (63.5%) and 98 (81.7%) OPN patients (P < 0.001). OPN was associated with increased postoperative multiorgan failure [42 (35%) vs 56 (20.4%), P = 0.001] and median (inter-quartile range) Acute Physiology and Chronic Health Evaluation II score 9 (6-11.5) vs 8 (5-11), P < 0.001] with intensive care required less frequently in MARPN patients [40.9% (112) vs 75% (90), P < 0.001]. The mortality rate was 42 (15.3%) in MARPNs and 28 (23.3%) in OPNs (P = 0.064). Both the mortality and the overall complication rates decreased between 1997-2008 and 2008-2013 [49 (23.8%) vs 21 (11.2%) P = 0.001, respectively; and 151 (73.3%) vs 121 (64.4%), P = 0.080, respectively). Increased mortality was independently associated with age (P < 0.001), preoperative intensive care stay (P = 0.014), and multiple organ failure (P < 0.001); operation before 2008 (P < 0.001) and conversion to OPN (P = 0.035). MARPN independently reduced mortality odds risk (odds ratio = 0.27; 95% confidence interval = 0.12-0.57; P < 0.001). CONCLUSIONS Increasing experience and advances in perioperative care have led to improvement in outcomes. The role of MARPN in reducing complications and deaths within a multimodality approach remains substantial and should be used initially if feasible.
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Affiliation(s)
- Ilias P Gomatos
- *Clinical Directorate of General Surgery, National Institutes of Health Research Liverpool Pancreas Biomedical Research Unit, Royal Liverpool and Broadgreen University Hospitals NHS Trust, Liverpool, UK †Liverpool Clinical Trials Unit, University of Liverpool, Liverpool, UK ‡Clinical Directorate of Radiology, National Institutes of Health Research Liverpool Pancreas Biomedical Research Unit, Royal Liverpool and Broadgreen University Hospitals NHS Trust, Liverpool, UK §Clinical Directorate of Gastroenterology, National Institutes of Health Research Liverpool Pancreas Biomedical Research Unit, Royal Liverpool University Hospital NHS Trust, Liverpool, UK
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Bugiantella W, Rondelli F, Boni M, Stella P, Polistena A, Sanguinetti A, Avenia N. Necrotizing pancreatitis: A review of the interventions. Int J Surg 2015; 28 Suppl 1:S163-71. [PMID: 26708848 DOI: 10.1016/j.ijsu.2015.12.038] [Citation(s) in RCA: 51] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/30/2015] [Revised: 04/11/2015] [Accepted: 05/10/2015] [Indexed: 02/06/2023]
Abstract
Acute pancreatitis may have a wide range of severity, from a clinically self-limiting to a quickly fatal course. Necrotizing pancreatitis (NP) is the most dreadful evolution associated to a poor prognosis: mortality is approximately 15% and up to 30-39% in case of infected necrosis, which is the major cause of death. Intervention is generally required for infected pancreatic necrosis and less commonly in patients with sterile necrosis who are symptomatic (gastric or duodenal outlet or biliary obstruction). Traditionally the most widely used approach to infected necrosis has been open surgical necrosectomy, but it is burdened by high morbidity (34-95%) and mortality (11-39%) rates. In the last two decades the treatment of NP has significantly evolved from open surgery towards minimally invasive techniques (percutaneous catheter drainage, per-oral endoscopic, laparoscopy and rigid retroperitoneal videoscopy). The objective of this review is to summarize the current state of the art of the management of NP and to clarify some aspects about its diagnosis and treatment.
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Affiliation(s)
- Walter Bugiantella
- General Surgery, "San Giovanni Battista Hospital", AUSL Umbria 2, Via M. Arcamone, 06034, Foligno, Perugia, Italy; University of Perugia, PhD School in Biotechnologies, Italy.
| | - Fabio Rondelli
- General Surgery, "San Giovanni Battista Hospital", AUSL Umbria 2, Via M. Arcamone, 06034, Foligno, Perugia, Italy; University of Perugia, Department of Surgical and Biomedical Sciences, Via G. Dottori, 06100, Perugia, Italy.
| | - Marcello Boni
- General Surgery, "San Giovanni Battista Hospital", AUSL Umbria 2, Via M. Arcamone, 06034, Foligno, Perugia, Italy.
| | - Paolo Stella
- General Surgery, "San Giovanni Battista Hospital", AUSL Umbria 2, Via M. Arcamone, 06034, Foligno, Perugia, Italy.
| | - Andrea Polistena
- General and Specialized Surgery, "Santa Maria" Hospital, Via T. Di Joannuccio, 05100, Terni, Italy.
| | - Alessandro Sanguinetti
- General and Specialized Surgery, "Santa Maria" Hospital, Via T. Di Joannuccio, 05100, Terni, Italy.
| | - Nicola Avenia
- General and Specialized Surgery, "Santa Maria" Hospital, Via T. Di Joannuccio, 05100, Terni, Italy.
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Kokosis G, Perez A, Pappas TN. Surgical management of necrotizing pancreatitis: An overview. World J Gastroenterol 2014; 20:16106-16112. [PMID: 25473162 PMCID: PMC4239496 DOI: 10.3748/wjg.v20.i43.16106] [Citation(s) in RCA: 41] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/27/2014] [Revised: 04/23/2014] [Accepted: 05/26/2014] [Indexed: 02/06/2023] Open
Abstract
Necrotizing pancreatitis is an uncommon yet serious complication of acute pancreatitis with mortality rates reported up to 15% that reach 30% in case of infection. Traditionally open surgical debridement was the only tool in our disposal to manage this serious clinical entity. This approach is however associated with poor outcomes. Management has now shifted away from open surgical debridement to a more conservative management and minimally invasive approaches. Contemporary approach to patients with necrotizing pancreatitis and/or infectious pancreatitis is summarized in the 3Ds: Delay, Drain and Debride. Patients can be managed in the intensive care unit and any intervention should be delayed. Percutaneous drainage can be utilized first and early in the course of the disease, followed by endoscopic drainage or video assisted retroperitoneoscopic drainage if necrosectomy is deemed necessary. Open surgery is now less frequently performed and should be reserved for cases refractory to any other approach. The management of necrotizing pancreatitis therefore requires a multidisciplinary dynamic model of approach rather than being a surgical disease.
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Abstract
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.
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