Open transgastric debridement and internal drainage of symptomatic non-infected walled-off pancreatic necrosis

The Potential Clinical Benefits of Direct Surgical Transgastric Pancreatic Necrosectomy for Patients With Infected Necrotizing Pancreatitis

OBJECTIVE

Surgical transgastric pancreatic necrosectomy (STGN) has the potential to overcome the shortcomings (ie, repeat interventions, prolonged hospitalization) of the step-up approach for infected necrotizing pancreatitis. We aimed to determine the outcomes of STGN for infected necrotizing pancreatitis.

MATERIALS AND METHODS

This observational cohort study included adult patients who underwent STGN for infected necrosis at two centers from 2008 to 2022. Patients with a procedure for pancreatic necrosis before STGN were excluded. Primary outcomes included mortality, length of hospital and intensive care unit (ICU) stay, new-onset organ failure, repeat interventions, pancreatic fistulas, readmissions, and time to episode closure.

RESULTS

Forty-three patients underwent STGN at a median of 48 days (interquartile range [IQR] 32-70) after disease onset. Mortality rate was 7% (n = 3). After STGN, the median length of hospital was 8 days (IQR 6-17), 23 patients (53.5%) required ICU admission (2 days [IQR 1-7]), and new-onset organ failure occurred in 8 patients (18.6%). Three patients (7%) required a reintervention, 1 (2.3%) developed a pancreatic fistula, and 11 (25.6%) were readmitted. The median time to episode closure was 11 days (IQR 6-22).

CONCLUSIONS

STGN allows for treatment of retrogastric infected necrosis in one procedure and with rapid episode resolution. With these advantages and few pancreatic fistulas, direct STGN challenges the step-up approach.

[Transgastric necrectomy for acute pancreatitis]

The review is devoted to transgastric necrectomy in the treatment of infected forms of acute pancreatitis. The authors discuss the indications for transgastric necrectomy and technical features of these interventions (direct endoscopic necrectomy, laparoscopic and open transgastric necrectomy). Numerous studies devoted to results of transgastric necrectomy indicate advisability of this procedure in carefully selected patients and interdisciplinary interaction of various specialists before and after surgery. Regional specialized centers for the treatment of severe acute pancreatitis are necessary for wider introduction of minimally invasive surgical technologies and their personalization.

Robotic pancreatic necrosectomy and internal drainage for walled-off pancreatic necrosis

BACKGROUND

Pancreatic necrosectomy with concomitant internal drainage is a single-stage treatment option for walled-off pancreatic necrosis (WOPN). However, an optimal minimally invasive technique has not been established. We evaluated the safety and single-intervention success rate of robotic pancreatic necrosectomy and internal drainage.

METHODS

Patients with WOPN undergoing robotic pancreatic necrosectomy and internal drainage at a single institution from 2011-2022 were identified. The primary outcome was the rate of clinical symptom resolution following the index surgical intervention.

RESULTS

57 patients underwent robotic pancreatic necrosectomy and internal drainage, consisting of robotic cystgastrostomy (RCG, n = 37), robotic cystjejunostomy (RCJ, n = 13) and robotic fistulojejunostomy (RFJ, n = 7). Surgery was performed a median of 102 (range 28-1153) days following the onset of necrotizing pancreatitis. The median operative time was 187 (91-344) minutes and there were 2 (3.5%) conversions. The median length of hospital stay was 4 (2-38) days. Postoperative morbidity was 11%, and there was one (1.8%) 90-day mortality. At a median follow-up of 5.5 months, 53 (93%) patients had clinical symptom resolution after their index procedure and did not require any reintervention.

CONCLUSION

In select patients, robotic pancreatic necrosectomy and internal drainage is safe and achieves a high single-intervention success rate.

Multidisciplinary Management of Complicated Pancreatitis: What Every Interventional Radiologist Should Know

Management of acute pancreatitis is challenging in the presence of local complications that include pancreatic and peripancreatic collections and vascular complications. This review, targeted for interventional radiologists, describes minimally invasive endoscopic, image-guided percutaneous, and surgical procedures for management of complicated pancreatitis and provides insight into the procedures' algorithmic application. Local complications are optimally managed in a multidisciplinary team setting that includes advanced endoscopists; pancreatic surgeons; diagnostic and interventional radiologists; and specialists in infectious disease, nutrition, and critical care medicine. Large symptomatic or complicated sterile collections and secondary infected collections warrant drainage or débridement. The drainage is usually delayed for 4-6 weeks unless clinical deterioration warrants early intervention. If collections are accessible by endoscopy, endoscopic procedures are preferred to avoid pancreaticocutaneous fistulas. Image-guided percutaneous drainage is indicated for symptomatic collections that are not accessible for endoscopic drainage or that present in the acute setting before developing a mature wall. Peripancreatic arterial pseudoaneurysms should be embolized before necrosectomy procedures to prevent potentially life-threatening hemorrhage. Surgical procedures are reserved for symptomatic collections that persist despite endoscopic or interventional drainage attempts. Understanding these procedures facilitates their integration by interventional radiologists into the complex longitudinal care of patients with complicated pancreatitis.

Outcomes in Endoscopic and Operative Transgastric Pancreatic Debridement

OBJECTIVES

Select patients with anatomically favorable walled off pancreatic necrosis may be treated by endoscopic (Endo-TGD) or operative (OR-TGD) transgastric debridement (TGD). We compared our experience with these 2 approaches.

SUMMARY BACKGROUND DATA

Select necrotizing pancreatitis (NP) patients are suitable for TGD which may be accomplished endoscopically or surgically. Limited experience exists contrasting these techniques exists.

METHODS

Patients undergoing Endo-TGD and OR-TGD at a single, high-volume pancreatic center between 2008 and 2019 were identified from a prospective database. Patient characteristics, procedural details, and outcomes of these 2 groups were compared.

RESULTS

Among 498 NP patients undergoing necrosis intervention, 160 (32%) had TGD: 59 Endo-TGD and 101 OR-TGD. The groups were statistically similar in age, comorbidity, pancreatitis etiology, necrosis anatomy, pancreatitis severity, and timing of TGD from pancreatitis insult. OR-TGD required 1.1 ± 0.5 and Endo-TGD 3.0 ± 2.0 debridements/patient. Fewer hospital readmissions and repeat necrosis interventions, and shorter total inpatient length of stay were observed in OR-TGD patients. New-onset organ failure [Endo-TGD (13%); OR-TGD (13%); P = 1.0] was similar between groups. Hospital length of stay after TGD was significantly longer in patients undergoing Endo-TGD (13.8 ± 20.8 days) compared to OR-TGD (9.4 ± 6.1 days; P = 0.047). Mortality was 7% in Endo-TGD and 1% in OR-TGD (P = 0.04).

CONCLUSIONS

Operative and endoscopic transgastric debridement achieve necrosis resolution with different temporal and procedural profiles. Clear multidisciplinary communication is essential to determine appropriate approach to individual necrotizing pancreatitis patients.

Surgical Transgastric Necrosectomy for Necrotizing Pancreatitis: A Single-stage Procedure for Walled-off Pancreatic Necrosis

OBJECTIVE

The aim of this study was to evaluate the role of surgical transgastric necrosectomy (TGN) for walled-off pancreatic necrosis (WON) in selected patients.

BACKGROUND

WON is a common consequence of severe pancreatitis and typically occurs 3 to 5 weeks after the onset of acute pancreatitis. When symptomatic, it can require intervention.

METHODS

A retrospective review of patients with WON undergoing surgical management at 3 high-volume pancreatic institutions was performed. Surgical indications, intervention timing, technical methodology, and patient outcomes were evaluated. Patients undergoing intervention <30 days were excluded. Differences across centers were evaluated using a P value of <0.05 as significant.

RESULTS

One hundred seventy-eight total patients were analyzed (mean WON diameter = 14 cm, 64% male, mean age = 51 years) across 3 centers. The majority required inpatient admission with a median preoperative length of hospital stay of 29 days (25% required preoperative critical care support). Most (96%) patients underwent a TGN. The median duration of time between the onset of pancreatitis symptoms and operative intervention was 60 days. Thirty-nine percent of the necrosum was infected. Postoperative morbidity and mortality were 38% and 2%, respectively. The median postoperative length of hospital length of stay was 8 days, with the majority of patients discharged home. The median length of follow-up was 21 months, with 91% of patients having complete clinical resolution of symptoms at a median of 6 weeks. Readmission to hospital and/or a repeat intervention was also not infrequent (20%).

CONCLUSION

Surgical TGN is an excellent 1-stage surgical option for symptomatic WON in a highly selected group of patients. Precise surgical technique and long-term outpatient follow-up are mandatory for optimal patient outcomes.

Pancreatic fluid collections: Clinical manifestations, diagnostic evaluation and management

Pancreatic fluid collections (PFC), including pancreatic pseudocysts and walled-off pancreatic necrosis, are a known complication of severe acute pancreatitis. A majority of the PFCs remain asymptomatic and resolve spontaneously. However, some PFCs persist and can become symptomatic. Persistent PFCs can also cause further complications such as the gastric outlet, intestinal, or biliary obstruction and infection. Surgical interventions are indicated for the drainage of symptomatic sterile and infected PFCs. Management of PFCs has evolved from a primarily surgical or percutaneous approach to a less invasive endoscopic approach. Endoscopic interventions are associated with improved outcomes with lesser chances of complications, faster recovery time, and lower healthcare utilization. Endoscopic ultrasound-guided drainage of PFCs using lumen-apposing metal stents has become the preferred approach for the management of symptomatic and complicated PFCs.

American Gastroenterological Association Clinical Practice Update: Management of Pancreatic Necrosis

DESCRIPTION

The purpose of this American Gastroenterological Association (AGA) Institute Clinical Practice Update is to review the available evidence and expert recommendations regarding the clinical care of patients with pancreatic necrosis and to offer concise best practice advice for the optimal management of patients with this highly morbid condition.

METHODS

This expert review was commissioned and approved by the AGA Institute Clinical Practice Updates Committee and the AGA Governing Board to provide timely guidance on a topic of high clinical importance to the AGA membership, and underwent internal peer review by the Clinical Practice Updates Committee and external peer review through standard procedures of Gastroenterology. This review is framed around the 15 best practice advice points agreed upon by the authors, which reflect landmark and recent published articles in this field. This expert review also reflects the experiences of the authors, who are advanced endoscopists or hepatopancreatobiliary surgeons with extensive experience in managing and teaching others to care for patients with pancreatic necrosis. BEST PRACTICE ADVICE 1: Pancreatic necrosis is associated with substantial morbidity and mortality and optimal management requires a multidisciplinary approach, including gastroenterologists, surgeons, interventional radiologists, and specialists in critical care medicine, infectious disease, and nutrition. In situations where clinical expertise may be limited, consideration should be given to transferring patients with significant pancreatic necrosis to an appropriate tertiary-care center. BEST PRACTICE ADVICE 2: Antimicrobial therapy is best indicated for culture-proven infection in pancreatic necrosis or when infection is strongly suspected (ie, gas in the collection, bacteremia, sepsis, or clinical deterioration). Routine use of prophylactic antibiotics to prevent infection of sterile necrosis is not recommended. BEST PRACTICE ADVICE 3: When infected necrosis is suspected, broad-spectrum intravenous antibiotics with ability to penetrate pancreatic necrosis should be favored (eg, carbapenems, quinolones, and metronidazole). Routine use of antifungal agents is not recommended. Computed tomography-guided fine-needle aspiration for Gram stain and cultures is unnecessary in the majority of cases. BEST PRACTICE ADVICE 4: In patients with pancreatic necrosis, enteral feeding should be initiated early to decrease the risk of infected necrosis. A trial of oral nutrition is recommended immediately in patients in whom there is absence of nausea and vomiting and no signs of severe ileus or gastrointestinal luminal obstruction. When oral nutrition is not feasible, enteral nutrition by either nasogastric/duodenal or nasojejunal tube should be initiated as soon as possible. Total parenteral nutrition should be considered only in cases where oral or enteral feeds are not feasible or tolerated. BEST PRACTICE ADVICE 5: Drainage and/or debridement of pancreatic necrosis is indicated in patients with infected necrosis. Drainage and/or debridement may be required in patients with sterile pancreatic necrosis and persistent unwellness marked by abdominal pain, nausea, vomiting, and nutritional failure or with associated complications, including gastrointestinal luminal obstruction; biliary obstruction; recurrent acute pancreatitis; fistulas; or persistent systemic inflammatory response syndrome. BEST PRACTICE ADVICE 6: Pancreatic debridement should be avoided in the early, acute period (first 2 weeks), as it has been associated with increased morbidity and mortality. Debridement should be optimally delayed for 4 weeks and performed earlier only when there is an organized collection and a strong indication. BEST PRACTICE ADVICE 7: Percutaneous drainage and transmural endoscopic drainage are both appropriate first-line, nonsurgical approaches in managing patients with walled-off pancreatic necrosis (WON). Endoscopic therapy through transmural drainage of WON may be preferred, as it avoids the risk of forming a pancreatocutaneous fistula. BEST PRACTICE ADVICE 8: Percutaneous drainage of pancreatic necrosis should be considered in patients with infected or symptomatic necrotic collections in the early, acute period (<2 weeks), and in those with WON who are too ill to undergo endoscopic or surgical intervention. Percutaneous drainage should be strongly considered as an adjunct to endoscopic drainage for WON with deep extension into the paracolic gutters and pelvis or for salvage therapy after endoscopic or surgical debridement with residual necrosis burden. BEST PRACTICE ADVICE 9: Self-expanding metal stents in the form of lumen-apposing metal stents appear to be superior to plastic stents for endoscopic transmural drainage of necrosis. BEST PRACTICE ADVICE 10: The use of direct endoscopic necrosectomy should be reserved for those patients with limited necrosis who do not adequately respond to endoscopic transmural drainage using large-bore, self-expanding metal stents/lumen-apposing metal stents alone or plastic stents combined with irrigation. Direct endoscopic necrosectomy is a therapeutic option in patients with large amounts of infected necrosis, but should be performed at referral centers with the necessary endoscopic expertise and interventional radiology and surgical backup. BEST PRACTICE ADVICE 11: Minimally invasive operative approaches to the debridement of acute necrotizing pancreatitis are preferred to open surgical necrosectomy when possible, given lower morbidity. BEST PRACTICE ADVICE 12: Multiple minimally invasive surgical techniques are feasible and effective, including videoscopic-assisted retroperitoneal debridement, laparoscopic transgastric debridement, and open transgastric debridement. Selection of approach is best determined by pattern of disease, physiology of the patient, experience and expertise of the multidisciplinary team, and available resources. BEST PRACTICE ADVICE 13: Open operative debridement maintains a role in the modern management of acute necrotizing pancreatitis in cases not amenable to less invasive endoscopic and/or surgical procedures. BEST PRACTICE ADVICE 14: For patients with disconnected left pancreatic remnant after acute necrotizing mid-body necrosis, definitive surgical management with distal pancreatectomy should be undertaken in patients with reasonable operative candidacy. Insufficient evidence exists to support the management of the disconnected left pancreatic remnant with long-term transenteric endoscopic stenting. BEST PRACTICE ADVICE 15: A step-up approach consisting of percutaneous drainage or endoscopic transmural drainage using either plastic stents and irrigation or self-expanding metal stents/lumen-apposing metal stents alone, followed by direct endoscopic necrosectomy, and then surgical debridement is reasonable, although approaches may vary based on the available clinical expertise.

Transgastric Pancreatic Necrosectomy: How I Do It

Necrotizing pancreatitis is a serious medical problem that often requires intervention to debride necrotic pancreatic and peripancreatic tissue. Recently, minimally invasive approaches have been applied to pancreatic necrosectomy. The purpose of this report is to review the history of transgastric pancreatic debridement, identify appropriate patient selection criteria, and highlight technical "pearls." We present this subject matter in the context of our own clinical experience, with a primary focus on a "How I Do It" type of technical description.

Acute Pancreatitis: Revised Atlanta Classification and the Role of Cross-Sectional Imaging

OBJECTIVE

The 2012 revision of the Atlanta Classification emphasizes accurate characterization of collections that complicate acute pancreatitis: acute peripancreatic fluid collections, pseudocysts, acute necrotic collections, and walled-off necroses. As a result, the role of imaging in the management of acute pancreatitis has substantially increased.

CONCLUSION

This article reviews the imaging findings associated with acute pancreatitis and its complications on cross-sectional imaging and discusses the role of imaging in light of this revision.

Cyst Gastrostomy and Necrosectomy for the Management of Sterile Walled-Off Pancreatic Necrosis: a Comparison of Minimally Invasive Surgical and Endoscopic Outcomes at a High-Volume Pancreatic Center

INTRODUCTION

Walled-off pancreatic necrosis (WON) is a sequela of acute necrotizing pancreatitis in 15-40% of cases. We sought to compare the outcomes of minimally invasive surgical and endoscopic cyst gastrostomy (CG) and necrosectomy for the management for sterile WON at a tertiary care high-volume pancreas center.

METHOD

This is a retrospective review of patients who underwent minimally invasive surgical or endoscopic CG and necrosectomy for clinically sterile WON between 2008 and 2013. Peri-procedural outcomes including costs were analyzed and compared.

RESULTS

Twenty patients underwent minimally invasive surgical (robotic = 14, laparoscopic = 6) CG and necrosectomy, and 20 patients underwent endoscopic treatment. The surgical cohort had a larger median cyst size and higher CCI score. For the surgical cohort, median OR time was 167.5 min, estimated blood loss was 30 ml, and 65% underwent concomitant cholecystectomy. There was no mortality in either group and no difference in complication rates (20%). The failure rate was similar (15 versus 10%, P = 0.66). Although surgery was associated with a lower re-intervention rate (0 versus 1, P = 0.008), the endotherapy group was associated with shorter total LOS (inclusive of re-interventions) (7 versus 3 days, P = 0.032). The cost of the index procedure was significantly higher for the surgery group (P = 0.014); however, when considering all readmissions and re-interventions until resolution of the WON, the total cost was similar for both groups.

CONCLUSION

Minimally invasive surgical and endoscopic CG and necrosectomy are comparable treatments for sterile WON in terms of outcomes and overall cost. The surgical approach may be considered advantageous when a concomitant cholecystectomy is required.

Laparoscopic transgastric endolumenal cystogastrostomy and pancreatic debridement

BACKGROUND

Cystogastrostomy is commonly performed for internal drainage of pancreatic pseudocysts (PP) and concomitant debridement of walled-off pancreatic necrosis (WOPN). While an open approach to cystogastrostomy is well established, an optimal minimally invasive technique continues to evolve. This laparoscopic transgastric endolumenal cystogastrostomy presented here allows for a large cystogastrostomy with complete debridement of necrosis and internal drainage through a minimally invasive approach.

METHODS

We performed a retrospective review of 22 patients with symptomatic PP/WOPN treated with attempted laparoscopic transgastric endolumenal cystogastrostomy (Lap-TEC) and pancreatic debridement. Short- and long-term outcomes were assessed.

RESULTS

From November 2006 to March 2013, a total of 22 Lap-TEC/pancreatic debridement procedures were attempted; 15 were completed laparoscopically. The median age of the cohort was 49.5 ± 12 years (range = 18-71), average body mass index = 29.1 kg/m(2), 77 % had an ASA score ≥ 3, and 10 were female. Gallstones were the most common etiology (50 %), and median time between initial presentation and surgery was 86 days (range = 0-360). Median operative time and estimated blood loss were 213 min and 100 cc, respectively. Forty-one percent of the patients were admitted to the ICU postoperatively and the average length of stay was 14 days (range = 4-50). Median follow-up was 2 months (range = 0-62.5), with one patient having a procedure-related complication. No other reoperations, late complications, or mortalities occurred. All patients had resolution of their symptoms and fluid collections.

CONCLUSION

This technique of internal drainage via Lap-TEC and pancreatic debridement has been successful in achieving primary drainage and relieving symptoms of PP/WOPN with no mortality and minimal morbidity.