Update: Role of surgery in acute necrotizing pancreatitis

Successful resolution of gastric perforation caused by a severe complication of pancreatic walled-off necrosis: A case report

BACKGROUND

Pancreatic walled-off necrosis (WON) rarely causes critical gastric necrosis and perforation, which may develop when pancreatic WON squashes against the stomach. The Atlanta 2012 guidelines were introduced for acute pancreatitis and its related clinical entities. However, there are few reported cases describing the clinical course and resolution of pancreatic WON.

CASE SUMMARY

We report the case of a 45-year-old man who presented to the urgent emergency department with gastric perforation caused by a severe complication of pancreatic WON on computed tomography. The patient underwent an emergency distal pancreatectomy, splenectomy, and gastric wedge resection. Postoperative findings showed re-perforation of the gastric wall at a previously resected margin. Furthermore, endoscopic examination revealed an ulcerative area with a defect in the fundus. After diagnostic endoscopy, endoscopic vacuum-assisted closure was performed, and continuous suction was transferred over all tissues in contact with the sponge surface. The patient recovered without any further complications and was discharged in good condition at postoperative week 8. No recurrence occurred during the 6-mo follow-up period.

CONCLUSION

When managing a patient with serious gastric perforation complicated by pancreatic WON, a multidisciplinary treatment approach should be considered.

Effectiveness of digestive endoscopy and surgery in the treatment of necrotizing pancreatitis: a meta-analysis and systematic review

Background

Digestive endoscopy and surgery are the primary invasive methods for the clinical treatment of necrotizing pancreatitis. However, there are relatively few studies evaluating the effectiveness and safety of these two methods.

Methods

Randomized controlled trials (RCTs) on endoscopic and surgical treatment of necrotizing pancreatitis published from January 2000 to December 2020 were searched in the PubMed, Medline, Embase, China Biology Medicine Disc (CBM), and WanFang databases. The Cochrane System Review Manual was adopted to evaluate the quality of the included literature, and Review Manager 5.3 was used for data analysis.

Results

Ten articles were included in this meta-analysis, involving a total of 401 patients, including 188 in the endoscopy group and 213 in the surgery group. Meta-analysis results revealed that the clinical remission rate (CRR) [odds ratio (OR) =1.30, 95% confidence interval (CI): 0.58-2.92, P=0.52], new organ failure rate (OFR) (OR =0.53, 95% CI: 0.26-1.09, P=0.08), abdominal bleeding rate (ABR) (OR =0.62, 95% CI: 0.33-1.15, P=0.13), and intensive care unit (ICU) stay time (IST) [mean deviation (MD) =-7.33, 95% CI: -16.76 to 2.11, P=0.13] were not significantly different between the endoscopy and surgery groups. In the endoscopy group, the mortality rate (OR =0.56, 95% CI: 0.31-1.02, P=0.05), intestinal fistula rate (IFR) or gastrointestinal perforation rate (GPR) (OR =0.50, 95% CI: 0.26-0.99, P=0.05), and pancreatic fistula rate (PFR) (OR =0.09, 95% CI: 0.04-0.23, P<0.00001) were markedly lower compared to the surgery group.

Discussion

There was no obvious difference in the clinical efficacy of endoscopic and surgical treatment of necrotizing pancreatitis. However, endoscopy can greatly reduce the incidence of postoperative death and major complications in patients.

Acute necrotizing pancreatitis: Has conservative management replaced surgery? Perspective from a tertiary care centre in Pakistan: A cross-sectional study

Background

The main purpose of this study was to review the trends in management of patients presenting with acute necrotizing pancreatitis (ANP) over the last seven years and its effect on morbidity and mortality.

Methods

A cross-sectional study was conducted on all patients presenting with the diagnosis of acute necrotizing pancreatitis to the Aga Khan University Hospital in between the year 2008-2015. The study population was broadly categorized in to two groups based on the way these were managed. The first group consisted of patient who underwent surgery for acute necrotizing pancreatitis while the second group was composed of those patients with necrotizing pancreatitis who were conservatively managed. Patient outcomes were assessed in terms of hospital stay, complication rates and in-hospital mortality. Data was analyzed using SPSS version 20. Comparison of outcomes between two groups was done using chi-square test, Fischer exact test or t-test wherever applicable. A p-value of less than 0.05 was considered statistically significant.

Results

A total of n = 110 patients were included in the study with 68% (n = 75) males and 32% (n = 35) females. Nasojejunal route was found to be the most commonly utilized route of feeding in these patients consisting of around 49% (n = 54) patients with forty percent (n = 44) tolerating direct oral diet. The outcomes in both these groups in terms of hospital stay, complication rate, and in hospital mortality were not found to be statistically significant. The conservative group however was significant in terms of cost-effectiveness which was shown by a p value of (0.035). The management of this clinically important disease over the years showed an increased trend towards conservative approach in our institute.

Conclusion

Our study further substantiates the recent global trend of conservative approach towards managing patients with acute necrotizing pancreatitis as reflected in the recent available literature. Therefore surgeons of the developing world need to evolve and adapt to these new measures for better outcomes in patient management.

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.

Management of infected pancreatic necrosis in the setting of concomitant rectal cancer: A case report and review of literature

BACKGROUND

Pancreatitis with infected necrosis is a severe complication of acute pancreatitis and carries with it high rates of morbidity and mortality. The management of infected pancreatic necrosis alongside concomitant colorectal cancer has never been described in literature.

CASE SUMMARY

A 77 years old gentleman presented to the Emergency Department of our hospital complaining of ongoing abdominal pain for 8 h. The patient had clinical features of pancreatitis with a raised lipase of 3810 U/L, A computed tomography (CT) abdomen confirmed pancreatitis with extensive peri-pancreatic edema. During the course of his admission, the patient had persistent high fevers and delirium thought secondary to infected necrosis, prompting the commencement of broad-spectrum antibiotic therapy with Piperacillin/Tazobactam. Subsequent CT abdomen confirmed extensive pancreatic necrosis (over 70%). Patient was managed with supportive therapy, nutritional support and gut rest initially and improved over the course of his admission and was discharged 42 d post admission. He represented 24 d following his discharge with fever and chills and a repeat CT abdomen scan noted gas bubbles within the necrotic pancreatic tissue thereby confirming infected necrotic pancreatitis. This CT scan also revealed asymmetric thickening of the rectal wall suspicious for malignancy. A rectal cancer was confirmed on flexible sigmoidoscopy. The patient underwent two endoscopic necrosectomies and was treated with intravenous antibiotics and was discharged after 28 d. Within 1 wk post discharge, the patient commenced a course of neoadjuvant radiotherapy and subsequently underwent concomitant chemotherapy prior to undergoing a successful Hartmann’s procedure for treatment of his colorectal cancer.

CONCLUSION

This case highlights the efficacy of endoscopic necrosectomy, early enteral feeding and targeted antibiotic therapy for timely management of infected necrotic pancreatitis. The prompt resolution of pancreatitis permitted the patient to undergo neoadjuvant treatment and resection for his concomitant colorectal cancer.