Surgery in the treatment of acute pancreatitis--open pancreatic necrosectomy

Clinical characteristics and risk factors of organ failure and death in necrotizing pancreatitis

BACKGROUND

Organ failure (OF) and death are considered the most significant adverse outcomes in necrotizing pancreatitis (NP). However, there are few NP-related studies describing the clinical traits of OF and aggravated outcomes.

PURPOSE

An improved insight into the details of OF and death will be helpful to the management of NP. Thus, in our research, we addressed the risk factors of OF and death in NP patients.

METHODS

We performed a study of 432 NP patients from May 2017 to December 2021. All patients with NP were followed up for 36 months. The primary end-points were risk factors of OF and death in NP patients. The risk factors were evaluated by logistic regression analysis.

RESULTS

NP patients with OF or death patients were generally older, had a higher APACHE II score, longer hospital stay, longer ICU stay, as well as a higher incidence of severe acute pancreatitis (SAP), shock and pancreatic necrosis. Independent risk factors related to OF included BMI, APACHE II score and SAP (P < 0.05). Age, shock and APACHE II score (P < 0.05) were the most significant factors correlated with the risk of death in NP patients. Notably, increased mortality was linked to the number of failed organs.

CONCLUSIONS

NP is a potentially fatal disease with a long hospital or ICU stay. Our study indicated that the incidence of OF and death in NP patients was 69.9% and 10.2%, respectively. BMI, SAP, APACHE II score, age and shock are potential risk factors of OF and death in NP patients. Clinicians should focus on these factors for early diagnosis and appropriate therapy.

Interventional strategies in infected necrotizing pancreatitis: Indications, timing, and outcomes

Acute pancreatitis (AP) is one of the most common gastrointestinal diseases and remains a life-threatening condition. Although AP resolves to restitutio ad integrum in approximately 80% of patients, it can progress to necrotizing pancreatitis (NP). NP is associated with superinfection in a third of patients, leading to an increase in mortality rate of up to 40%. Accurate and early diagnosis of NP and associated complications, as well as state-of-the-art therapy are essential to improve patient prognoses. The emerging role of endoscopy and recent trials on multidisciplinary management of NP established the “step-up approach”. This approach starts with endoscopic interventions and can be escalated to other interventional and ultimately surgical procedures if required. Studies showed that this approach decreases the incidence of new multiple-organ failure as well as the risk of interventional complications. However, the optimal interventional sequence and timing of interventional procedures remain controversial. This review aims to summarize the indications, timing, and treatment outcomes for infected NP and to provide guidance on multidisciplinary decision-making.

[Endoscopic transluminal drainage for infected pancreatic necrosis]

OBJECTIVE

To evaluate the effectiveness of intraluminal drainage of acute fluid accumulations for infected pancreatic necrosis.

MATERIAL AND METHODS

There were 848 patients with acute pancreatitis between January 2018 and December 2020 at the Sklifosovsky Research Institute for Emergency Care. Necrotizing pancreatitis was detected in 232 (27.4%) patients. Among necrotic forms, pancreatic parenchymal necrosis was detected in 56 (24.1%) patients, its combination with peripancreatic necrosis - in 176 (75.9%) patients. All patients underwent transabdominal ultrasound, CT of the abdomen and retroperitoneal space, esophagogastroduodenoscopy, endo-ultrasonography of pancreatobiliary zone. Dimensions and localization of acute necrotic accumulations were established using ultrasound and CT data. Endoscopic transluminal drainage was performed in 22 patients with necrotizing pancreatitis and fluid accumulations attached to the stomach or duodenum. There were 12 men (55%) and 10 women (45%) aged 48.5 [39; 56] (35; 88) years. Effectiveness of endoscopic treatment was assessed considering clinical, endoscopic data and reduction of fluid accumulations confirmed by ultrasound and CT data.

RESULTS

Among 22 patients, connection with pancreatic ductal system was detected in 3 patients (13.6%) that required pancreaticoduodenal stenting. Early postoperative period was complicated by bleeding from the area of pancreatogenic destruction in 4 patients (18.1%). Therefore, angiography and endovascular embolization of a. gastroduodenalis were required in 2 (9.1%) cases. In 1 (4.5%) case, we performed endoscopic hemostasis using Hemoblock hemostatic solution (4 ml). Combination of both methods was used in 1 (4.5%) patient. In 11 (50%) patients, endoscopic drainage was the final method of surgical treatment of necrotizing pancreatitis. Four patients (18.1%) died. Multiple organ failure caused mortality in 3 patients (13.6%). One (4.5%) patient died from severe nosocomial pneumonia developed in 32 days after drainage. Spurs not drained into the stomach with US-confirmed suspension and sequestration were observed in 11 (50%) out of 22 patients. These accumulations required additional ultrasound-assisted percutaneous drainage.

CONCLUSION

Endoscopic transluminal drainage is a perspective minimally invasive method for necrotizing pancreatitis.

A Comparison of Endoscopic Versus Surgical Creation of a Cystogastrostomy to Drain Pancreatic Pseudocysts and Walled-Off Pancreatic Necrosis in 5500 Patients

Objective

To determine the success, morbidity, and mortality rates of endoscopic and surgical creation of pancreatic cystenterostomies for the drainage of peripancreatic fluid collections, pseudocysts with necrotic debris, and walled-off pancreatic necrosis.

Summary Background Data

Endoscopic methods of cystenterostomy creation to drain pancreatic pseudocysts (with and without necrotic debris) and infected peripancreatic fluid collections are perceived to be less morbid than surgery. Contemporary reports document a very high complication rate with endoscopic methods.

Methods

A meta-analysis of 5500 patients.

Results

Open and laparoscopic surgical techniques to drain chronic pancreatic pseudocysts, infected pancreatic fluid collections, and walled-off pancreatic necrosis are more successful with less morbidity and mortality than endoscopic methods.

Conclusions

In regards to a surgical step-up approach to treat chronic infected pancreatic fluid collections or walled-off pancreatic necrosis, surgical creation of a cystenterostomy is more successful with fewer complications than endoscopic methods and should be given priority if less invasive or conservative methods fail.

[Indications for Surgical and Interventional Therapy of Acute Pancreatitis]

BACKGROUND

15 to 20% of patients with acute pancreatitis develop necrosis of the pancreatic parenchyma or extrapancreatic tissue. The disease is associated with a mortality rate of up to 20%. The mainstays of treatment consist of intensive medical care and surgical and interventional therapy.

METHODS

A systematic literature search focused on indications for surgical and interventional therapy of necrotising pancreatitis. 85 articles were analysed for this review. By using the Delphi method, the results were presented to the quality committee for pancreas diseases of the German Society for General and Visceral Surgery and to expert pancreatologists in an interactive conference using plenary voting during the visceral medicine congress 2019 in Wiesbaden. For the finalised recommendations, an agreement of 84% of participants was achieved.

RESULTS

Documented or clinical suspicion of infected, necrotising pancreatitis are indications for surgical and interventional therapy (recommendation grade: strong; evidence grade; low). Sterile necrosis is a less common indication for intervention due to late complications or persistent severe pancreatitis. Invasive interventions should be delayed when possible until four weeks after onset of pancreatitis. Optimal treatment strategy consists of a "step-up approach" (evidence grade: high; recommendation grade: strong). The first step is catheter drainage, followed, if necessary, by minimally invasive surgical or interventional necrosectomy. If minimally invasive techniques do not result in clinical improvement, open necrosectomy is necessary. 35 to 50% of patients are successfully treated with drainage alone. Indications for emergency intervention are bowel perforation, bowel ischemia and bleeding. Surgical decompression of abdominal compartment syndrome is indicated if the patient is refractory to medical treatment and percutaneous drainage. Abscesses and symptomatic pseudocysts are indications for interventional drainage. Early cholecystectomy during index admission is recommended for patients with mild biliary pancreatitis. Cholecystectomy should be delayed after severe, biliary pancreatitis.

CONCLUSION

The recommendations for surgical an interventional therapy of necrotising pancreatitis address the basis of current indications in literature. They should serve in daily practice as a reference standard for decision making in multidisciplinary teams.

Ultrasonic Pressure Ballistic System-Assisted Minimally Invasive Pancreatic Necrosectomy for Necrotizing Pancreatitis

Background: Although minimally invasive pancreatic necrosectomy (MIPN) is a new invasive technique for necrotizing pancreatitis, it has some disadvantages. This study aimed to improve the debridement technique with an ultrasonic pressure ballistic system. We hypothesized that this system would facilitate debridement and improve the safety of the procedure. Materials and Methods: Between October 2016 and January 2019, 5 patients diagnosed with necrotizing pancreatitis were enrolled in the clinical cohort. All patients underwent debridement due to infective necrosis. Access for debridement was typically established with percutaneous puncture. Then MIPN was performed. During the procedure, ultrasonic pressure was applied to liquefy the necrotic material and make it absorbable. The effect of debridement was assessed by analyzing the average bleeding volume, operation time, and complications. Postoperative clinical parameters were evaluated. Results: Debridement was performed successfully for all patients. Semisolid necrotic tissue was dissolved with ultrasonic pressure. Viscous pus was rapidly aspirated with the suction applied with negative pressure, which greatly enhanced efficiency. This approach enhanced the visibility of blood vessels, which improved safety. No major complications were encountered. Two patients (40%) developed puncture site infections. The average blood loss during the operation was 13 ± 6 mL. The average operation time was 78 ± 31 minutes. Postoperative APACHE II scores were significantly lower than preoperative scores (P < .05). White blood cells, C-reactive protein, and procalcitonin levels declined postoperatively. Conclusions: The ultrasonic pressure ballistic system could potentially enhance MIPN and make it safer.

Lavage through percutaneous catheter drains in severe acute pancreatitis: Does it help?A randomized control trial

AIMS

There is no study comparing large volume lavage through image guided percutaneously placed drains in severe acute pancreatitis.

METHODS

Of the 114 randomized patients, 60 eligible candidates were randomly allocated to - Lavage Treatment (LT) group (28 patients) and Dependent Drainage (DD) group (32 patients). Primary end point was reversal of pre-existing organ failure, development of new onset organ failure, need for surgery, mortality and hospital stay.

RESULTS

Both the groups were comparable in terms of demographic data, onset and severity of pancreatitis. LT group had higher infected pancreatic necrosis (75% vs 50%,p = 0.047). On intention to treat analysis, lavage treatment group showed a significant reversal of persistent organ failure (84% vs 50%, p = 0.23), reduction in APACHEII scores (3.5 ± 3.405 vs 1.16 ± 3.811 p = 0.012), as measured at the time of placement of PCD to cessation of intervention. There was no difference in development of new onset organ failure in the two groups (25% vs37.5% p=.290). 75% in LT group and 69% in DD group improved with PCD alone. There was no difference in the catheter related complications and number of catheters used. The need for surgical intervention was comparable in two groups (18.8% vs 14.3% p=.737). There was a trend toward decreased mortality in group A (18.8% vs 28.8% p=.370).

CONCLUSION

Large volume lavage trough PCD improves organ failure and this translates into trend towards reduced mortality.

Atraumatic Splenic Hemorrhage as a Rare Complication of Pancreatitis: Case Report and Literature Review

Splenic hemorrhage (hematoma and rupture) is a rare complication of pancreatitis. In this article, we present a rare case of spontaneous splenic rupture as a complication of acute pancreatitis. A literature review was also completed to describe the patient characteristics, associated pancreatitis etiology, clinical presentations, risk factors, diagnostic and treatment modalities, and outcomes.

Current Concepts in Severe Acute and Necrotizing Pancreatitis: An Evidence-Based Approach

The incidence of acute pancreatitis continues to rise, inducing substantial medical and social burden, with annual costs exceeding $2 billion in the United States alone. Although most patients develop mild pancreatitis, 20% develop severe and/or necrotizing pancreatitis, requiring advanced medical and interventional care. Morbidity resulting from local and systemic complications as well as invasive interventions result in mortality rates historically as high as 30%. There has been substantial evolution of strategies for interventions in recent years, from open surgery to minimally invasive surgical and endoscopic step-up approaches. In contrast to the advances in invasive procedures for complications, early management still lacks curative options and consists of adequate fluid resuscitation, analgesics, and monitoring. Many challenges remain, including comprehensive management of the entire spectrum of the disease, which requires close involvement of multiple disciplines at specialized centers.

Pancreatic Necrosectomy through Sinus Tract Endoscopy

Background/Aims

Direct endoscopic pancreatic necrosectomy is increasingly being utilized to treat infected or symptomatic walled-off necrosis (WON) located close to the stomach or duodenum. Laterally-placed WON has traditionally been treated surgically. We evaluated a less utilized technique of sinus tract endoscopy (STE) for symptomatic laterally-placed WON.

Methods

Two hundred seventy-six patients with acute pancreatitis admitted in our hospital, 32 had symptomatic or infected WON requiring intervention. Of the 12 patients with laterally placed WON, 10 were treated by STE. STE was performed with a standard adult gastroscope passed through a percutaneous tract created by the placement of a 32-Fr drain.

Results

Ten patients (7 males; mean age, 43.8 years) underwent STE. Mean number of sessions was 2.3 (range, 1–4), with mean time of 70 minutes for each session (range, 15–70 minutes). While 9 patients had complete success, 1 patient had fever and chose to undergo surgery. Two patients developed pneumoperitoneum, which was treated conservatively. There was no mortality, cutaneous fistula, or recurrence during follow-up.

Conclusions

Laterally placed WON can be successfully managed by STE performed through a percutaneously placed drain. Details of the technique and end-points of STE require further evaluation.

Surgery in Pancreatic Necrosis-Challenges and Outcomes in an Industrial Hospital

Twenty-seven cases of pancreatic necrosis were admitted and treated at our hospital from Jan 2010 till Jan 2015. Eight of these patients (29 %) underwent pancreatic necrosectomy. Of a total number of 957 patients admitted for acute pancreatitis, 27 patients (3 %) were diagnosed to have necrotizing pancreatitis. Of the 8 patients operated on, 5 patients (62.5 %) were treated successfully. The 3 patients who died had 3 organ (renal, respiratory and cardiovascular) failures. Nineteen patients of pancreatic necrosis responded to medical management and were successfully treated.

A Low Impact Approach to Infected Pancreatic Necrosis: Review of a Case Series

BACKGROUND

Infected pancreatic necrosis develops in approximately one third of patients with necrotizing pancreatitis and can lead to significant morbidity and mortality rates. Historically, open necrosectomy has been the mainstay of management for these patients but is in itself a morbid procedure. In recent times, minimally invasive techniques have evolved to allow a less invasive approach to these patients. Percutaneous catheter drainage of infected pancreatic necrosis is a technique that has been demonstrated to be potentially useful in the treatment of this group of patients.

PATIENTS AND METHODS

The aim of this study was to review outcomes and define the technique of percutaneous catheter drainage in patients with infected pancreatic necrosis. All patients with infected pancreatic necrosis were exclusively treated with percutaneous drainage over the study period. Acute Physiology and Chronic Health Evaluation (APACHE) II score, number and size of drains, drainage technique and drain management, hospital and intensive care unit (ICU) stay, nutritional requirements, and morbidity and mortality data were evaluated for the patient group. Computed tomography (CT) scans were used to assess the progression of the disease process and the effectiveness of the treatment.

RESULTS

There were nine patients with infected pancreatic necrosis in this case series between 2007 and 2012, all of whom were treated with percutaneous catheter drainage alone. The median APACHE II score in the patient group was 11, with a median stay in the ICU of 3 d and median hospital stay of 41 d. On average, nine CT scans were performed per patient during the hospital admission. A median of three drains were inserted per patient, and in the course of the study, it was evident that the larger drain size was the most effective. In eight of the nine patients in the group, complications developed that were both directly and indirectly related to the pancreatitis, but were effectively managed. There were no deaths.

CONCLUSION

Percutaneous catheter drainage as a stand-alone intervention is an alternative strategy for infected pancreatic necrosis and can be used with acceptable morbidity and mortality rates in this challenging group of patients.

Necrotizing pancreatitis: diagnosis, imaging, and intervention

Acute necrotizing pancreatitis is a severe form of acute pancreatitis characterized by necrosis in and around the pancreas and is associated with high rates of morbidity and mortality. Although acute interstitial edematous pancreatitis is diagnosed primarily on the basis of signs, symptoms, and laboratory test findings, the diagnosis and severity assessment of acute necrotizing pancreatitis are based in large part on imaging findings. On the basis of the revised Atlanta classification system of 2012, necrotizing pancreatitis is subdivided anatomically into parenchymal, peripancreatic, and combined subtypes, and temporally into clinical early (within 1 week of onset) and late (>1 week after onset) phases. Associated collections are categorized as "acute necrotic" or "walled off" and can be sterile or infected. Imaging, primarily computed tomography and magnetic resonance imaging, plays an essential role in the diagnosis of necrotizing pancreatitis and the identification of complications, including infection, bowel and biliary obstruction, hemorrhage, pseudoaneurysm formation, and venous thrombosis. Imaging is also used to help triage patients and guide both temporizing and definitive management. A "step-up" method for the management of necrotizing pancreatitis that makes use of imaging-guided percutaneous catheter drainage of fluid collections prior to endoscopic or surgical necrosectomy has been shown to improve clinical outcomes. The authors present an algorithmic approach to the care of patients with necrotizing pancreatitis and review the use of imaging and interventional techniques in the diagnosis and management of this pathologic condition.

The open abdomen, indications, management and definitive closure

The indications for Open Abdomen (OA) are generally all those situations in which is ongoing the development an intra-abdominal hypertension condition (IAH), in order to prevent the development of abdominal compartmental syndrome (ACS). In fact all those involved in care of a critically ill patient should in the first instance think how to prevent IAH and ACS. In case of ACS goal directed therapy to achieve early opening and early closure is the key: paradigm of closure shifts to combination of therapies including negative pressure wound therapy and dynamic closure, in order to reduce complications and avoid incisional hernia. There have been huge studies and progress in survival of critically ill trauma and septic surgical patients: this in part has been through the great work of pioneers, scientific societies and their guidelines; however future studies and continued innovation are needed to better understand optimal treatment strategies and to define more clearly the indications, because OA by itself is still a morbid procedure.

Timing of intervention in necrotizing pancreatitis

BACKGROUND

The best available evidence suggests that surgical intervention should be delayed where possible until four weeks after the onset of pancreatitis. Subgroups that may benefit from early or delayed intervention have not been identified.

METHODS

This study reviewed a prospective database with 223 patients of necrotizing pancreatitis who received intervention. A subgroup analysis was performed to compare the results of different surgical timing.

RESULTS

The median timing of intervention was 32 days. The mortality rates in the early (≤30 days) intervention and delayed intervention (>30 days) groups were 21% (28/136) and 10% (9/87), respectively (P = 0.04). In patients with persistent early organ failure, mortality and re-intervention rates were higher in the early group compared with the delayed group (23/61 vs. 3/21, P = 0.04; 17/61 vs. 2/21, P = 0.01). In patients without persistent early organ failure who underwent treatment, mortality rates, and re-intervention rates were similar between the early group and delayed group (5/75 vs. 6/66, P = 0.59; 7/75 vs. 3/66, P = 0.27). In patients with infected necrosis, mortality rate was similar with the early group and delayed group (17/77 vs. 7/57, P = 0.14).

CONCLUSION

Early intervention in patients without persistent organ failure showed similar outcomes with patients who received delayed intervention.

Endoscopic interventions for necrotizing pancreatitis

Interventions for necrotizing pancreatitis have undergone a paradigm shift away from open surgical necrosectomy and toward minimally invasive techniques, with endoscopic transmural drainage (ETD) and necrosectomy emerging as principle forms of treatment. Recent multicenter studies, randomized trials, evidence-based guidelines, and consensus statements have endorsed the safety and efficacy of endoscopic and other minimally invasive techniques for the treatment of walled-off necrosis. A comprehensive review of indications, standard and novel approaches, outcomes, complications, and controversies regarding ETD and necrosectomy is presented. Given the inherent challenges and associated risks, endoscopic techniques for the management of necrotizing pancreatitis should be performed at specialized multidisciplinary centers by expert endoscopists well versed in the management of necrotizing pancreatitis.

Staged multidisciplinary step-up management for necrotizing pancreatitis

Background

Some 15 per cent of all patients with acute pancreatitis develop necrotizing pancreatitis, with potentially significant consequences for both patients and healthcare services.

Methods

This review summarizes the latest insights into the surgical and medical management of necrotizing pancreatitis. General management strategies for the treatment of complications are discussed in relation to the stage of the disease.

Results

Frequent clinical evaluation of the patient's condition remains paramount in the first 24–72 h of the disease. Liberal goal-directed fluid resuscitation and early enteral nutrition should be provided. Urgent endoscopic retrograde cholangiopancreatography is indicated when cholangitis is suspected, but it is unclear whether this is appropriate in patients with predicted severe biliary pancreatitis without cholangitis. Antibiotic prophylaxis does not prevent infection of necrosis and antibiotics are not indicated as part of initial management. Bacteriologically confirmed infections should receive targeted antibiotics. With the more conservative approach to necrotizing pancreatitis currently advocated, fine-needle aspiration culture of pancreatic or extrapancreatic necrosis will less often lead to a change in management and is therefore indicated less frequently. Optimal treatment of infected necrotizing pancreatitis consists of a staged multidisciplinary ‘step-up’ approach. The initial step is drainage, either percutaneous or transluminal, followed by surgical or endoscopic transluminal debridement only if needed. Debridement is delayed until the acute necrotic collection has become ‘walled-off’.

Conclusion

Outcome following necrotizing pancreatitis has improved substantially in recent years as a result of a shift from early surgical debridement to a staged, minimally invasive, multidisciplinary, step-up approach.

Laparoscopic pancreatic resections

PURPOSE

Pancreatic surgery is technically complex and requires considerable expertise. Laparoscopic pancreatic surgery adds the need for considerable experience with advanced laparoscopic techniques. Despite the technical difficulties, an increasing number of centers propagate the use of laparoscopy in pancreatic surgery over the last decade.

METHODS

In this review, we provide an overview of the literature regarding the advantages and disadvantages of laparoscopic pancreatic surgery. Larger prospective randomized studies have emerged in the subset of laparoscopic or retroperitoneoscopic surgery for acute pancreatitis, considerable single center experience has been reported for laparoscopic pancreatic tail resection, and laparoscopic pancreatic head resection, however, is still restricted to a few experienced centers worldwide.

RESULTS AND CONCLUSIONS

Laparoscopic pancreatic surgery is becoming more and more established, in particular for the treatment of benign and premalignant lesions of the pancreatic body and tail. It has been shown to decrease postoperative pain, narcotic use, and length of hospital stay in larger single center experience. However, prospective trials are needed in laparoscopic resective pancreatic surgery to evaluate its advantages, safety, and efficacy in the treatment of pancreatic neoplasms and in particular in malignant pancreatic tumors.

Five-year cohort study of open pancreatic necrosectomy for necotizing pancreatitis suggests it is a safe and effective operation

INTRODUCTION

Despite advances in the management of necrotizing pancreatitis, open necrosectomy remains an important management option for necrotizing pancreatitis, and patients undergoing necrosectomy suffer significant morbidity and mortality. The aim of this study was to report the outcomes of open necrosectomy from a recent large cohort of patients with necrotizing pancreatitis.

METHODS

Data are reported from a cohort of 276 consecutive patients with necrotizing pancreatitis who underwent open surgical debridement. Nutritional status, nutritional methods, bleeding, infection, demarcation of necrotic tissues, and time from onset of disease were scored. Scores ≥ 10 were considered as an indication for debridement.

RESULTS

One hundred sixty-two (58.7%) and 52 (18.8%) patients underwent minimally invasive peritoneal and retroperitoneal drainage, respectively, before necrosectomy. Median delay from disease onset to debridement was 48 days. Fifty-five patients (19.9%) underwent more than one operation; 352 operations were performed in total. There were 17 deaths (6.2%) postoperatively.

CONCLUSION

This study demonstrated the results for open debridement in a recent large cohort of patients. Although minimally invasive necrosectomy has been developed in recent years, open necrosectomy remains an important approach for the debridement of necrotizing pancreatitis effectively and safely.

Interventions for necrotizing pancreatitis: an overview of current approaches

The management of necrotizing pancreatitis has undergone a paradigm shift toward minimally invasive techniques for necrosectomy, obviating the need for open necrosectomy in most cases. There is increasing evidence that minimally invasive approaches including a step-up approach that incorporates percutaneous catheter or endoscopic transluminal drainage, followed by video-assisted retroperitoneal or endoscopic debridement are associated with improved outcomes over traditional open necrosectomy for patients with infected necrosis. A recent international multidisciplinary consensus conference emphasized the superiority of minimally invasive approaches over standard surgical approaches. The success of these techniques depends on concerted efforts of a multidisciplinary team of interventional endoscopists, radiologists, intensivists and surgeons dedicated to the management of severe acute pancreatitis and its complications. This review provides an overview of minimally invasive techniques for management of necrotizing pancreatitis, including indications, timing, advantages and disadvantages.

Endoscopic approach to pancreatic pseudocyst, abscess and necrosis: review on recent progress

AIM

The aim of this study is to introduce recent progress in the treatment of pancreatic pseudocyst, abscess and necrosis using the endoscopic approach.

METHODS

Studies on PubMed and MEDLINE from the last 30 years on progress in the management of the complications from severe pancreatitis were researched and reviewed. Herein, the indication for intervention, definition of fluid collection associated with acute pancreatitis and treatment modalities of these complications are summarized.

RESULTS

Three types of management are employed for complications of severe pancreatitis: the endoscopic, surgical and percutaneous approaches.

CONCLUSIONS

Over the years, as technical expertise has increased and instruments for endoscopy have improved, patients who had endoscopic surgery to address the complications of severe pancreatitis have had higher survival rates, lower mortality rates and lower complication rates than those having open debridement. However, traditional open abdominal surgery should be advocated when minimally invasive management fails or necrosis is extensive and extends diffusely to areas such as the paracolic gutter and the groin (i.e. locations not accessible by endoscopy).

Minimally invasive operations for acute necrotizing pancreatitis: comparison of minimally invasive retroperitoneal necrosectomy with endoscopic transgastric necrosectomy

BACKGROUND

A "step-up" approach is currently the treatment of choice for acute necrotizing pancreatitis. Our aim was to evaluate the outcome of minimally invasive retroperitoneal necrosectomy (MINE) and endoscopic transgastric necrosectomy (ETG) and to compare it to open necrosectomy (ONE).

METHODS

Patients with acute pancreatitis admitted to our institution from 1998 to 2010 (n = 334) were identified. From these, patients who underwent either ONE, MINE, or ETG were selected for further analysis. Statistical analysis employed 2-sided Fisher's exact test and Mann-Whitney U-test.

RESULTS

From 2002 to 2010, 32 patients with acute necrotizing pancreatitis were treated by minimally invasive procedures including MINE (n = 14) and ETG (n = 18) or with the classic technique of ONE (n = 30). Time from onset of symptoms to intervention was less for ONE than for MINE or ETG (median, 11 vs 39 vs 54 days; P < .05). The rate of critically ill patients with sepsis or septic shock was greatest in ONE (93%) and MINE (71%) compared with ETG (17%; P < .05). Problems after ONE and MINE were ongoing sepsis (ONE 73% vs MINE 29% vs ETG 11%) and bleeding requiring intervention (ONE 26% vs MINE 21% vs ETG 17%). A specific complication of ETG was gastric perforation into the peritoneal cavity during the procedure (28%), requiring immediate open pseudocystogastrostomy. Laparotomy was necessary in 21% after MINE and 28% after ETG owing to specific complications or persistent infected necrosis. Overall mortality was greatest after ONE (ONE 63% vs MINE 21% vs ETG 6%; P < .05).

CONCLUSION

Morbidity and mortality remains high in acute necrotizing pancreatitis. Operative procedures should be delayed as long as possible to decrease morbidity and mortality. Minimally invasive procedures can avoid laparotomy, but also introduce specific complications requiring immediate or secondary open operative treatment. Minimally invasive procedures require unique expertise and therefore should only be performed at specialized centers.

[Pancreatic necrosis: pro surgical therapy]

Currently, patients with severe necrotizing pancreatitis rarely need interventional or surgical treatment. However, in case of pancreatic infection and septic complications they should be treated with the step up approach, primarily with an interventional or endoscopic drainage. If further clinical deterioration occurs necrosectomy is indicated. This should ideally be postponed until the third or fourth week after onset of pancreatitis to optimize surgical conditions including demarcation of the necrosis. Open necrosectomy with postoperative continuous lavage is a valid treatment option with low mortality, low morbidity and good long-term outcome. In recent years, several minimally invasive techniques for necrosectomy have been developed and are alternative approaches in about 70% of cases. In most cases, the retroperitoneoscopic approach is used, although the endoscopic transgastric route is also being used more and more frequently. While the reduced operative trauma should theoretically also reduce the onset of postoperative organ failure, no study has actually proven this.

Severe acute pancreatitis: advances and insights in assessment of severity and management

The patients with acute pancreatitis are at risk to develop different complications from ongoing pancreatic inflammation. Often, there is no correlation between the degree of structural damage to pancreas and clinical manifestation of the disease. The effectiveness of any treatment is related to the ability to predict severity accurately, but there is no ideal predictive system or biochemical marker. Severity assessment is indispensable to the selection of proper initial treatment in the management of acute pancreatitis. The use of multiparametric criteria and the evaluation of severity index permit us to select high-risk patients. Furthermore, contrast-enhanced computed tomographic scanning and contrast-enhanced MRI play an important role in severity assessment. The adoption of multiparametric criteria proposed together with morphological evaluation consents the formulation of a discreetly reliable prognosis on the evolution of the disease a few days from onset.

Subcutaneous Linea Alba Fasciotorny, Does it Really Work?

Subcutaneous linea alba fasciotorny (SLAF) is a minimally invasive treatment method for abdominal compartment syndrome initially used in severe acute pancreatitis (SAP). A retrospective analysis of the first 10 patients with SAP undergoing SLAF was performed to analyze the effect and outcome of this decompressive procedure. The mean age of the patients was 46 (range 33-61) years. SLAF was performed 1 to 17 days postadmission, in six cases within 48 hours. The mean (range) preoperative intra-abdominal pressure was 31 (23-45) mm Hg and immediate postoperative intra-abdominal pressure was 20 (10-33) mm Hg. The mean decrease was 10 (2-17) mm Hg and the decompressive effect was considered sufficient in six cases. A completion laparostomy within 24 hours was required in four cases. The mean preoperative Sequential Organ Failure Assessment score was 12 (4-17) and 11 (1-20) 1 to 5 days postoperatively. The decrease was five or more score points in three patients with successful SLAF. The overall mortality and morbidity rates were 4/10 and 2/10; no complications were attributed to the SLAF itself. It is concluded that SLAF is a safe decompressive technique in SAP-related abdominal compartment syndrome. The initial effect is sufficient in about half of the patients. A completion midline laparostomy is required in the nonresponders.

Progress in the management of necrotizing pancreatitis

Pancreatic necrosis, a complication of severe pancreatitis, may become infected, resulting in significant morbidity and potential mortality. Infected necrosis was heretofore considered a surgical condition, and despite aggressive operative management, the mortality remained high. With a better understanding of the natural history of necrosis, established methods to diagnose infection and the increasing use of minimally invasive techniques, less aggressive therapies have been utilized with some success. The present study evaluated a step-up approach for the treatment of infected pancreatic necrosis, utilizing endoscopic and percutaneous techniques, and if ineffective, necrosectomy with a minimally invasive retroperitoneal approach. They compared this step-up approach to the standard open necrosectomy. They demonstrated that when using such an approach compared with open necrosectomy, the frequency of major complications such as organ failure, perforation, fistula or even death was significantly less than in those who received conventional open necrosectomy. Indeed, for those randomized to the step-up approach, roughly a third of the patients were successfully treated with percutaneous drainage alone. In the long-term, development of diabetes was also less frequent in those receiving less aggressive therapy. These findings, in combination with other reports, suggest that the dogma that open necrosectomy is mandatory for all patients with infected necrosis should be re-evaluated, and that less aggressive treatments as part of a multidisciplinary approach can reduce morbidity and mortality.

Laparostomy: why and when?

This article is one of ten reviews selected from the Yearbook of Intensive Care and Emergency Medicine 2010 (Springer Verlag) and co-published as a series in Critical Care. Other articles in the series can be found online at http://ccforum.com/series/yearbook. Further information about the Yearbook of Intensive Care and Emergency Medicine is available from http://www.springer.com/series/2855.

Percutaneous catheter drainage in combination with choledochoscope-guided debridement in treatment of peripancreatic infection

AIM: To introduce and evaluate the new method used in treatment of pancreatic and peripancreatic infections secondary to severe acute pancreatitis (SAP).

METHODS: A total of 42 SAP patients initially underwent ultrasound-guided percutaneous puncture and catheterization. An 8-Fr drainage catheter was used to drain the infected peripancreatic necrotic foci for 3-5 d. The sinus tract of the drainage catheter was expanded gradually with a skin expander, and the 8-Fr drainage catheter was replaced with a 22-Fr drainage tube after 7-10 d. Choledochoscope-guided debridement was performed repeatedly until the infected peripancreatic tissue was effectively removed through the drainage sinus tract.

RESULTS: Among the 42 patients, the infected peripancreatic tissue or abscess was completely removed from 38 patients and elective cyst-jejunum anastomosis was performed in 4 patients due to formation of pancreatic pseudocysts. No death and complication occurred during the procedure.

CONCLUSION: Percutaneous catheter drainage in combination with choledochoscope-guided debridement is a simple, safe and reliable treatment procedure for peripancreatic infections secondary to SAP.

Acute pancreatitis at the beginning of the 21st century: the state of the art

Acute pancreatitis is an acute inflammatory disease of the pancreas which can lead to a systemic inflammatory response syndrome with significant morbidity and mortality in 20% of patients. Gallstones and alcohol consumption are the most frequent causes of pancreatitis in adults. The treatment of mild acute pancreatitis is conservative and supportive; however severe episodes characterized by necrosis of the pancreatic tissue may require surgical intervention. Advanced understanding of the pathology, and increased interest in assessment of disease severity are the cornerstones of future management strategies of this complex and heterogeneous disease in the 21st century.

Acute pancreatitis at the beginning of the 21st century: The state of the art

Acute pancreatitis is an acute inflammatory disease of the pancreas which can lead to a systemic inflammatory response syndrome with significant morbidity and mortality in 20% of patients. Gallstones and alcohol consumption are the most frequent causes of pancreatitis in adults. The treatment of mild acute pancreatitis is conservative and supportive; however severe episodes characterized by necrosis of the pancreatic tissue may require surgical intervention. Advanced understanding of the pathology, and increased interest in assessment of disease severity are the cornerstones of future management strategies of this complex and heterogeneous disease in the 21st century.

Infected necrosis in severe pancreatitis--combined nonsurgical multi-drainage with directed transabdominal high-volume lavage in critically ill patients

BACKGROUND

Infection of pancreatic necrosis is a life-threatening complication during the course of acute pancreatitis. In critically ill patients, surgical or extended endoscopic interventions are associated with high morbidity and mortality. Minimally invasive procedures on the other hand are often insufficient in patients suffering from large necrotic areas containing solid or purulent material. We present a strategy combining percutaneous and transgastric drainage with continuous high-volume lavage for treatment of extended necroses and liquid collections in a series of patients with severe acute pancreatitis.

PATIENTS AND METHODS

Seven consecutive patients with severe acute pancreatitis and large confluent infected pancreatic necrosis were enrolled. In all cases, the first therapeutic procedure was placement of a CT-guided drainage catheter into the fluid collection surrounding peripancreatic necrosis. Thereafter, a second endosonographically guided drainage was inserted via the gastric or the duodenal wall. After communication between the separate drains had been proven, an external to internal directed high-volume lavage with a daily volume of 500 ml up to 2,000 ml was started.

RESULTS

In all patients, pancreatic necrosis/liquid collections could be resolved completely by the presented regime. No patient died in the course of our study. After initiation of the directed high-volume lavage, there was a significant clinical improvement in all patients. Double drainage was performed for a median of 101 days, high-volume lavage for a median of 41 days. Several endoscopic interventions for stent replacement were required (median 8). Complications such as bleeding or perforation could be managed endoscopically, and no subsequent surgical therapy was necessary. All patients could be dismissed from the hospital after a median duration of 78 days.

CONCLUSION

This approach of combined percutaneous/endoscopic drainage with high-volume lavage shows promising results in critically ill patients with extended infected pancreatic necrosis and high risk of surgical intervention. Neither surgical nor endoscopic necrosectomy was necessary in any of our patients.

Ischemic acute pancreatitis: clinical features of 11 patients and review of the literature

BACKGROUND

Besides alcohol and gallstones, pancreatic ischemia can cause acute pancreatitis (AP). This entity should be considered when no other reasons can be defined. The aim of the current study was to define ischemic AP with its pathophysiologic, radiologic, and clinical conditions.

METHODS

Eleven patients with ischemic AP of different origin were analyzed regarding course, severity, and outcome, as well as diagnostic and therapeutic measures.

RESULTS

Ischemic AP was caused by hemorrhage and hypotension (7 patients) or mesenteric macrovessel occlusion (4 patients). Therapy was conservative (4 patients) or operative with hemostasis, necrosectomy, and drainage (7 patients). Seven patients died within 38 days, and 4 patients recovered.

CONCLUSION

Pancreatic hypoperfusion is an important etiology of AP. Severity of the disease ranges from moderate reversible changes to severe courses with fatal outcome. The indication for surgical intervention in ischemic AP is more aggressive; diagnostic and conservative therapeutic procedures are similar to AP of other etiologies.

Minimally invasive necrosectomy for infected necrotizing pancreatitis

OBJECTIVES

Infected necrotizing pancreatitis represents a serious and therapeutically challenging complication. Percutaneous drainage of infected pancreatic necrosis is often unsuccessful. Alternatively, open necrosectomies are associated with high morbidity. Recently, minimally invasive necrosectomy techniques have been tried with satisfying results; however, they frequently necessitate multiple sessions for definitive necrosectomy. To evaluate results of single large-port laparoscopic necrosectomy for proven infected necrotizing pancreatitis.

METHODS

Eight patients presenting proven infected pancreatic necrosis during course of acute pancreatitis and not responding to radiological drainage were prospectively offered minimally invasive necrosectomy. Laparoscopic necrosectomy were performed using a single large port placed along the drain tract directly into the infected necrosis. In all patients, drainage was placed during laparoscopic necrosectomy for continuous postoperative lavage.

RESULTS

No perioperative complications were recorded with a median operative time of 87 +/- 42 minutes. No blood transfusions were needed. No surgical postoperative morbidity and mortality were recorded. In all cases, except for one patient with multiple abscesses, only one session of necrosectomy was sufficient to completely clear the necrotic abscess. Laparoscopic necrosectomy was successful in all patients, and none required complementary surgical or radiological treatment.

CONCLUSIONS

Minimally invasive necrosectomy has been safe and highly efficient through single large-port laparoscopy for infected pancreatic necrosis in our series of patients. Minimally invasive necrosectomy is a promising technique for infected necrotizing pancreatitis and should be regarded as a valid therapeutic option for necrotizing pancreatitis.

Taurocholate-induced pancreatitis: a model of severe necrotizing pancreatitis in mice

OBJECTIVES

The outcome from acute pancreatitis depends on the severity of systemic complications. To be able to investigate mechanisms underlying the development of these systemic complications in acute pancreatitis in both wild-type and genetically engineered animal models, a mouse model of severe necrotizing pancreatitis was developed and characterized.

METHODS

Pancreatitis was induced by retrograde infusion of sodium taurocholate into the common bile duct in mice. After determining the optimum volume and concentration of taurocholate, the pancreatic damage and systemic inflammatory response were compared with those in cerulein-induced pancreatitis.

RESULTS

Pancreatic damage was higher in taurocholate pancreatitis than hyperstimulation-induced pancreatitis (24 hours: cerulein, 5.8 +/- 0.2 points; taurocholate, 14.8 +/- 0.8 points; P < 0.001) and mortality reached up to 60% within the first 24 hours after taurocholate administration. Pulmonary damage was detected, as measured by an increase in albumin in bronchoalveolar lavage fluid only in taurocholate-induced pancreatitis (12 hours: cerulein, 97.1 +/- 22.83 mg/g of protein; taurocholate, 234.0 +/- 32.7 mg/g of protein; P < 0.001). Furthermore, plasma interleukin 6 concentration was significantly elevated in mice with taurocholate-induced pancreatitis (12 hours: cerulein, 2.6 +/- 6.1 pg/mL; taurocholate, 2168.8 +/- 941.7 microg/mL; P < 0.001) as compared with all other groups.

CONCLUSIONS

Taurocholate pancreatitis is a reliable model for severe necrotizing pancreatitis in mice with significantly greater pancreatic damage and systemic inflammatory response in comparison with cerulein-induced pancreatitis.

Open Abdomen after Severe Acute Pancreatitis

The need for surgical decompression for abdominal compartment syndrome is becoming more frequent in patients with severe acute pancreatitis, especially in association with massive fluid resuscitation at the early stages of the disease. Decompression can be achieved with either a full-thickness laparostomy that can be performed through a vertical midline or transverse subcostal incision, or by performing a subcutaneous linea alba fasciotomy. Following a fullthickness laparostomy the open abdomen can be best managed with some form of negative abdominal pressure dressing. During dressing changes every 2-3 days, every attempt should be made to gradually close the fascial incision starting from edges, but avoiding recurrent abdominal compartment syndrome. Gradual closure is more likely to succeed in association with a negative fluid balance. Peripancreatic exploration or necrosectomy is seldom required at the initial laparostomy, unless performed for late onset abdominal compartment syndrome associated with infected peripancreatic necrosis. Primary fascial closure should always be attempted. If impossible and there is no need for subsequent abdominal re-exploration, the open wound should be covered with split-thickness skin grafting directly over the bowel loops. After a maturation period of 9-12 months definitive repair of the abdominal wall defect is performed utilizing the components separation technique, mesh repair, or a pedicular or microvascular tensor facia lata flap. Knowledge of the available decompression and reconstruction options is essential for individualized management of patients with severe acute pancreatitis and abdominal compartment syndrome. More research and comparative studies are needed to determine the most successful methods to be used.

Transverse laparostomy is feasible and effective in the treatment of abdominal compartment syndrome in severe acute pancreatitis

BACKGROUND

Only recently has the important role of abdominal compartment syndrome (ACS) been recognized as a contributing factor to the multiple organ failure commonly seen in severe acute pancreatitis (SAP). Decompressive laparostomy for ACS is a life-saving procedure usually performed through a midline incision followed by a negative pressure wound dressing. High risk of intestinal fistulas and frequent inability to close the fascia with ensuing planned ventral hernia has prompted the search for alternative techniques. Subcutaneous fasciotomy may be effective in early and less severe cases of ACS but it is always accompanied with a ventral hernia.

CASE REPORT

A patient with SAP developed manifest ACS and was treated with bilateral subcostal laparostomy. Immediately after decompression, the intra-abdominal pressure dropped from 23 mmHg to 10 mmHg, and the respiratory, cardiovascular and renal functions improved markedly leading to full recovery. The abdominal incision including the fascia and the skin was closed gradually over 4 relaparotomies, and during the 6 months' follow up there are no signs of ventral hernia or other wound complications.

DISCUSSION

Transverse subcostal laparostomy is a promising alternative decompression technique for ACS in SAP. It is feasible, effective and might provide a chance of early fascial closure. Comparative studies are needed to define its role as a decompressive technique for ACS.

The efficacy of nonsurgical treatment of infected pancreatic necrosis

OBJECTIVES

We conducted this study to evaluate the efficacy of nonsurgical treatment for patients with infected pancreatic necrosis (IPN).

METHODS

Among 224 patients with acute pancreatitis from 2000 to 2004, there were 31 patients diagnosed as having IPN complication. The diagnostic criteria for IPN were either a positive culture or free gas in the pancreas of patients with acute pancreatic necrosis. Nonsurgical management including percutaneous drainage or endoscopic drainage (ED) followed by vigorous irrigation was initially attempted in all patients. Surgery was planned only when there was no clinical improvement after the initial nonsurgical treatment.

RESULTS

Percutaneous drainage or ED was performed in 18 and 5 patients, respectively. Eight patients received antibiotics only. Four patients (12.9%) (3 from percutaneous drainage group and 1 from ED group) required surgery. Sepsis or fistula developed in 32% and 6% of patients, respectively, and was managed successfully. One patient (3.2%) died as a result of rapidly progressing multiorgan failure. The mean duration of hospitalization was 37 days. During the follow-up period, 7 patients were readmitted because of fever; they were managed by reposition of the drainage tube.

CONCLUSIONS

Intensive nonsurgical treatment is very effective and safe and should be considered as an initial treatment modality for patients with IPN.

Treatment of Abdominal Compartment Syndrome with Subcutaneous Anterior Abdominal Fasciotomy in Severe Acute Pancreatitis

BACKGROUND

Managing the abdominal compartment syndrome associated with severe acute pancreatitis by the open abdomen method is associated with considerable morbidity and resource utilization.

METHODS

A technique of subcutaneous anterior abdominal fasciotomy is described for the first time in two patients with severe acute pancreatitis.

RESULTS

Following the procedure, the intra-abdominal pressure decreased from 30 mmHg immediately to 23 mmHg and to a sustained level of 12-14 mmHg in the first patient, and from 35 mmHg immediately to 23 mmHg and to a sustained level of 14-19 mmHg in the second patient.

CONCLUSIONS

The subcutaneous anterior abdominal fasciotomy is a promising method for safe and effective abdominal decompression with sustained effect and avoiding the morbidity associated with the alternative open abdomen techniques.