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Management of Acute Necrotizing Pancreatitis

Management of Acute Necrotizing Pancreatitis. Dr Joyce WT Ng Tseung Kwan O Hospital. Prophylactic antibiotics ERCP Nutritional support Inhibition of pancreatic secretion Surgical intervention Indication Timing Modalities. Introduction. Severe pancreatitis

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Management of Acute Necrotizing Pancreatitis

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  1. Management of Acute Necrotizing Pancreatitis Dr Joyce WT Ng Tseung Kwan O Hospital

  2. Prophylactic antibiotics • ERCP • Nutritional support • Inhibition of pancreatic secretion • Surgical intervention • Indication • Timing • Modalities

  3. Introduction • Severe pancreatitis • Acute pancreatitis associated with the presence of organ failure or pancreatic/peri-pancreatic complications, or both • Pancreatic necrosis • Diffuse or focal areas of non-viable pancreatic parenchyma, typically associated with peri-pancreatic fat necrosis A clinically based classification system for acute pancreatitis. Summary of the International Symposium on Acute Pancreatitis, Atlanta, 1992. Bradley EL et al. Arch Surg 1993

  4. Surgical Intervention- Indications- Timing- Modalities

  5. Surgical Intervention- Indications- Timing- Modalities

  6. Indications: Infected Necrosis • Infected pancreatic necrosis is a uniformly accepted indication for surgical intervention Acute Pancreatitis: Who Needs an Operation? Beger HG et la. J Hepatobiliary Pancreat Surg 2002 UK Guidelines for the Management of Acute Pancreatitis UK Working party on Acute Pancreatitis. Gut 2005 Acute Necrotizing Pancreatitis: Treatment Strategy According to the Status of Infection Buchler MW et la. Ann Surg 2000

  7. Indications: Sterile Necrosis • Over 90% of patients with sterile necrosis can be successfully treated without surgical intervention Acute Necrotiziing Pancreatitis: Treatment Strategy According to the Status of Infection. Buchler MW et la. Ann Surg 2000 • Surgical treatment of sterile necrosis appears to have a higher mortality rates (11.9%, CI: 5.3-22.2) than the conservative treatment (2.3%, CI: 0.3-8.2) in patients with sterile necrosis Evidence-Based Treatment of Acute Pancreatitis. A look at Established Paradigms. Heinrich S et la. Ann Surg 2006

  8. Indications: Sterile Necrosis • Small group of sterile necrosis still warrants surgical interventions • Deteriorating condition despite maximal support Evidence-Based Treatment of Acute Pancreatitis. A look at Established Paradigms. Heinrich S et la. Ann Surg 2006 JPN Guidelines for the Management of Acute Pancreatitis: Surgical Management Isaji S et la. J Hepatobiliary Pancreat Surg, 2006

  9. Surgical Intervention- Indications- Timing- Modalities

  10. Timing Early versus Late Necrosectomy in Severe Necrotizing Pancreatitis. The American Journal of Surgery 1997 Feb;173(2):71-5. J Mier, E. Leon, A. Castillo, F Robledo, R Blanco • First RCT • Early (<72hrs, n=25) Vs Late (>12 days, n=15) • Indication: MOF with clinical deterioration despite maximal intensive care • Intervention: open packing with staged necrosectomy • Mortality: 56% (early) Vs 27% (Late) • Prematurely terminated because of very high mortality for early surgery group (odd ratio: 3.4)

  11. Timing • Timing of Surgical Intervention in Necrotizing Pancreatitis • Besselink MG et al. Arch Surg 2007 • Systemic review of 11 series • Review of 1136 patients • Only 1 RCT .

  12. Timing • Not recommended early surgical intervention • Late intervention • Separation of viable from non-viable tissue • Reduced bleeding • Removal of less normal pancreas • Operate on a more hemodynamically stable patient Analysis of the delayed approach to the management of infected pancreatic necrosis. Nilesh D et al. Word J Gastro 2011

  13. Timing • However, there was no consensus about the length of time that conservative treatment should be applied before surgical intervention should be considered • It is generalized accepted that at least 3-4 weeks of conservative management is desirable JPN Guideline for the Management of Acute Pancreatitis: surgical Management. Isaji S. et al. J Hepatobiliary Pancreat Surg 2006

  14. Surgical Intervention- Indications- Timing- Modalities

  15. Modalities • Open necrosectomy • Minimally invasive necrosectomy • Percutaneous • Endoscopic • Laparoscopic assisted

  16. Open necrosectomy • Classical modality over the past decades • Principles: control septic foci • Debridement of the necrotic tissue • Post-operative lavage: removal of retroperitoneal debris and exudates • Mortality rate: 13-43% Surgery in the Treatment of Acute Pancreatitis – Open Pancreatic Necrosectomy. Werner J et la. Scand J Surg 2005

  17. Open necrosectomy • 4 principle techniques: • Opening packing • Planned, staged relaparotomies with repeated lavage • Necrosectomy with continuous lavage of the lesser sac and retroperitoneum • Necrosectomy with closed packing

  18. Open necrosectomy • Single necrosectomy with post-operative lavage without planned relaparotomies seems to be less harmful • More complications (e.g. fistula, incisional hernia, local bleeding) were seen in repeated laparotomies Surgery in the Treatment of Acute Pancreatitis – Open Pancreatic Necrosectomy. Werner J et la. Scand J Surg 2005 Acute Pancreatitis at the beginning of the 21st century: The state of the art. Tonsi AF et al. World J Gastroenterol 2009

  19. Minimally Invasive Necrosectomy • Developed in recent 2 decades • It is generally accepted to have comparable results with open necrosectomy • No randomized studies for comparison • Approaches: • Percutanoeus • Endoscopic • Laparoscopic-assisted

  20. 1. Percutaneous Necrosectomy • An endoscope is inserted into the retroperitoneal space under GA • Utilize CT guided placement of small calibre percutanous drain into retroperitoneum • Mainly over left flank • The tract is then dilated for passage of the scope • Remove debris by lavage and piecemeal extraction of necrotic debris • Post operative continuous lavage NICE Guideline for Percutaneous Pancreatic Necrosectomy

  21. 1. Percutaneous Necrosectomy • Potential advantages: • Less postoperative physiological disturbance • Reduced need for intensive care • Fewer complications • Limitations: • May not have feasible route for necrosis in head or uncinate region • May require multiple sessions (subsequent session can be done under LA) Minimal Access Retroperitoneal Pancreatic Necrosectomy Improvement in Morbidity and Mortality With a Less Invasive Approach. Raraty MGT et la. Ann Surg 2010

  22. 2. Endoscopic Necrosectomy • Usually under LA with sedation • Localize the collection with EUS • Transgastric/ transduodenal puncture • Tract is dilatedand scope enter cavity • Necrosectomy under direct vision with irrigation, use of forceps or snares • Placement of multiple nasocystic drains for post-operative drainage Peroral Transgastric/ Transduodneal Necrosectomy. Success in the Treatment of Infected Pancreatic Necrosis. Escourrou J et al. Ann Surg 2008

  23. 2. Endoscopic Necrosectomy • Potential advantages • Comparable results with open necrosectomy • Less postoperative physiological disturbance • Reduced need for intensive care • Providing diagnostic and therapeutic option for biliary pathologies at the same session • Limitations • Highly skilled experienced interventional endoscopist • Transient aggravation of sepsis and hemorrhage • Cannot deal with extended necrosis to paracolic gutter • Limited ability to evacuate large cavities • Multiple sessions were required Peroral Endoscopic Drainage/ Debridement of Walled-off Pancreatic Necrosis. Papachristou GI. Ann Surg 2007

  24. 3. Laparoscopic-assisted Necrosectomy • 2-5 ports • +/- hand ports • Mainly with infra colic approach

  25. 3. Laparoscopic- assisted Necrosectomy • Potential advantages • Decrease the trigger of systemic cytokine-mediated immune response • Better exposure • Possible complications • Spreading of infection to infracolic compartments • Similar morbidity rate compared with open surgery Laparoscopic-Assisted Pancreatic Necrosectomy. A new Surgical Option for Treatment of Severe Necrotizing Pancreatitis. Parekh D. Arch Surg 2006

  26. A Step-up Approach or Open Necrosectomy for Necrotizing Pancreatitis (PANTER trial: Pancreatitis, Necrosectomy versus sTEp up appRoach) Santvoot HC et la. N Engl J Med 2010 Apr 22. 362(16): 1491-502 • First RCT • Multi-centre (20 hospitals in Holland) • Step-up Approach (45) Vs Open necrosectomy (43) • Primary end-point: major complications/ death

  27. Major complication: 12% (step-up) Vs 40% (open), p= 0.002 • Mortality: 19% (step-up) Vs 16% (open), p= 0.7 • Primary end-point: 40% (step-up) Vs 69% (open), p= 0.006 • Conclusion: The minimally invasive step-up approach reduced the rate of the composite end point of major complications or death

  28. Intensive Care MOF Conservative treatment Intensive Care Sterile Necrosis Infected Necrosis 3-4weeks Failed Surgery • Favourable condition • Available experts MIS approach Open necrosectomy

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