Minimally invasive techniques in pancreatic necrosis

Waterjet pulse lavage as a safe adjunct to video assisted retroperitoneal debridement in necrotising pancreatitis

BACKGROUND

Minimally invasive surgical necrosectomy plays an important role in the management of infected pancreatic necrosis, with a goal of removing debris and debriding necrotic tissue. Pulse lavage is designed to simultaneously hydrostatically debride and remove the infected necrotic tissue with suction. It is also able to remove significant amounts of debris without traumatic manipulation of the necrotic tissue which may be adherent to surrounding tissue and can result in injury.

METHODS AND RESULTS

The surgical technique of utilising a waterjet pulse lavage device during the minimally invasive necrosectomy is detailed. Sixteen patients being managed via a step-up approach underwent endoscopic necrosectomy via a radiologically placed drain tract. All sixteen patients were successfully managed endoscopically without conversion to open necrosectomy, and survived their admission. There were no complications associated with the use of the waterjet pulse lavage.

CONCLUSION

Waterjet pulse lavage is a useful adjunct in minimally invasive necrosectomy, which reduces the length of the necrosectomy procedure, and facilitates removal of necrotic tissue while minimising the risk of traumatising healthy tissue.

Evaluating the role of the Minimal Incision Retroperitoneal Necrosectomy (MIRN) in the management of infected pancreatic necrosis: Experience from a tertiary care center

Background

The conventional open necrosectomy was associated with high mortality and morbidities like secondary organ failure, incisional hernia, enterocutaneous fistula, and external pancreatic fistula. In acute pancreatitis, collections are primarily confined to the retroperitoneal space. Hence, the retroperitoneal approach can be used to drain the collection and necrotic material. It benefits smaller incisions and better outcomes in terms of morbidity and mortality than the conventional open necrosectomy. This study primarily aims to describe the effects of minimal incision retroperitoneal necrosectomy versus conventional open necrosectomy for treating INP. Moreover, it provides evidence supporting the efficacy and safety of this method.

Methods

A single-center retrospective study of the prospectively maintained database from April 2008 to December 2021.

Results

A total of 122 patients were included in the study. Seventy-eight patients had an open necrosectomy, 30 had a MIRN, and 14 had a VARD procedure. These three groups were comparable in demographic variables. Preoperative variables like APACHE II at presentation, Modified CTSI, percentage of necrosis, multi-organ failure, time to surgery, and need for preoperative ICU stay were comparable among the three groups. Postoperative mortality was low in the MIRN group{open 35.8 % vs. MIRN 20.5 % vs. VARD 35.7 %, p = 0.066}. The postoperative stay was also significantly low in the MIRN and VARD group {open 23.62 ± 16.61 vs. MIRN 11.77 ± 7.73, VARD 8.86 ± 2.98, p = 0.00}. No significant difference in re-intervention rate, postoperative bleeding, and enterocutaneous fistula.

Conclusion

MIRN is a simple and easy-to-adapt procedure for infected pancreatic necrosis in the appropriately selected patient group.

Factors Associated With Serial Lipase Measurement in Hospitalized Patients With Acute Pancreatitis

OBJECTIVES

To determine the factors associated with serial lipase measurement in patients with acute pancreatitis (AP).

METHODS

Patients admitted to Johns Hopkins Health System between September 2019 and August 2020 with lipase ≥3 times upper limit normal were prospectively identified. Acute pancreatitis was defined using revised Atlanta criteria. Serial lipase measurement was defined as >2 lipase measurements on consecutive days within 7 days of presentation.

RESULTS

There were 294 patients with AP with mean age 52.4 ± 16 years (SD), and 155 (52.7%) were male. A total of 227 (77.2%) were admitted to a medical service. There were 111 (37.7%) who underwent serial lipase measurements. There were 89 (30.8%), 36 (12.2%), 6 (1%), and 40 (13.6%) patients with systemic inflammatory response syndrome at time of initial lipase measurement, persistent organ failure, necrosis on admission, and intensive care unit admission. Serial lipase measurements were more likely to be obtained in patients admitted to surgical services (odds ratio, 4.3; 95% confidence interval, 1.4-13.2; P = 0.01) and nontertiary hospitals (odds ratio, 1.8; 95% confidence interval, 1.0-2.9; P = 0.04).

CONCLUSION

More than one-third of AP patients undergo serial lipase measurements. This practice is more likely to occur on surgical services and in nontertiary hospitals.

[Surgical strategy for suppurative complications of pancreatic necrosis]

Severe acute pancreatitis is one of the most difficult problems in emergency abdominal surgery. Mortality among patients with this disease ranges from 20 to 80 percent. The use of staged surgical intervention in the treatment of purulent complications of acute severe pancreatitis may affect not only the risk of open surgery, but also the number of post-operative complications.

OBJECTIVE

Improving the results of treatment of patients with infected pancreatic necrosis by applying a step by step surgical approach and comprehensive correction of endotoxicosis.

MATERIAL AND METHODS

The study was retrospectively prospective. All patients were divided into two clinical groups. The control group for the period from 2018 to 2019 included 31 patients for whom the standard surgical tactics of treating pancreatic necrosis were used: laparotomy, necrsecestrectomy and drainage of parapancreatic fluid accumulations, and, if necessary, repeated sanation. The main group included 26 patients, treated from 2019 to 2020. According to the developed step-by-step approach with the application of the correction of endogenous intoxication and enteral insufficiency syndrome. The choice of surgery for the patients of the main group depended on the type of parapancreatic fluid accumulation and included minimally invasive interventions in the first stage and, if necessary, the expansion of the amount of interventions (puncture and drainage under ultrasound control + video assisted retroperitoneal debridement, or ultrasound-controlled puncture and drainage + laparotomy).

RESULTS

The effectiveness of the treatment in both groups was determined by changes in blood leukocyte and C-reactive protein values on the day of the operation, as well as on the 2nd, 4th, 6th day of the post-operative period. By the fourth day after the surgery, the main group patients' white blood cell and CRP blood levels were positively lower than in the control group: p=0.0001, t=9.65 and p=0.0001, t=9.02, respectively. Forty-eight hours after the operation, the dynamics of the EIS were determined. In the control group, where standard methods of treating enteral insufficiency were used, there was an increase in the number of patients with II and III degrees of severity, in comparison with patients of the main group (p<0.05). The number of complications of pancreonecrosis of IIIb and IVb of degrees on the Clavien-Dindo scale in patients of the major group was lower than in the control group: χ²=0.00021, p<0.05 and χ²=0.01553, p<0.05, respectively. 10 (32.3%) died in the control group, 2 (7.7%), χ²=0.04739, p<0.05.

CONCLUSIONS

The choice of surgical intervention for pancreonecrosis should be determined taking into account the development phase of the disease, the type of location of the purulent-necrotic sinuses, and its delimitation from surrounding tissues. Phased surgical treatment with the initial application of minimally invasive technologies affects the number and severity of post-operative complications as well as the early start of correction of enteric insufficiency syndrome - the early relief of endogenous intoxication.

A PMN-PT Composite-Based Circular Array for Endoscopic Ultrasonic Imaging

Endoscopic ultrasound (EUS), an interventional imaging technology, utilizes a circular array to delineate the cross-sectional morphology of internal organs through the gastrointestinal (GI) track. However, the performance of conventional EUS transducers has scope for improvement because of the ordinary piezoelectric parameters of Pb(Zr, Ti) [Formula: see text] (PZT) bulk ceramic as well as its inferior mechanical flexibility which can cause material cracks during the circular shaping process. To achieve both prominent imaging capabilities and high device reliability, a 128-element 6.8-MHz circular array transducer is developed using a Pb(Mg [Formula: see text]Nb [Formula: see text]) [Formula: see text]-PbTiO₃ (PMN-PT) 1-3 composite with a coefficient of high electromechanical coupling ( [Formula: see text]) and good mechanical flexibility. The characterization results exhibit a large average bandwidth of 58%, a high average sensitivity of 100 mV_pp, and a crosstalk of less than -37 dB near the center frequency. Imaging performance of the PMN-PT composite-based array transducer is evaluated by a wire phantom, an anechoic cyst phantom, and an ex-vivo swine intestine. This work demonstrates the superior performance of the crucial ultrasonic device based on an advanced PMN-PT composite material and may lead to the development of next-generation biomedical ultrasonic devices for clinical diagnosis and treatment.

Retrospective Validation of an Algorithmic Treatment Pathway for Necrotizing Pancreatitis

The role of surgical intervention for necrotizing pancreatitis has evolved; however, no widely accepted algorithm has been established to guide timing and optimal modality in the minimally invasive era. This study aimed to retrospectively validate an established institutional timing- and physiologic-based algorithm constructed from evidence-based guidelines in a high-volume hepatopancreatobiliary center. Patients with necrotizing pancreatitis requiring early (≤six weeks from symptom onset) or delayed (>six weeks) surgical intervention were reviewed over a four-year period (n = 100). Early intervention was provided through laparoscopic drain-guided retroperitoneal debridement (n = 15) after failed percutaneous drainage unless they required an emergent laparotomy (due to abdominal compartment syndrome, bowel necrosis/perforation, or hemorrhage) after which conservative, sequential open necrosectomy was performed (n = 47). Robot-assisted (n = 16) versus laparoscopic (n = 22) transgastric cystgastrostomy for the delayed management of walled-off pancreatic necrosis was compared, including patient factors, operative characteristics, and 90-day clinical outcomes. Major complications after early debridement were similarly high (open 25% and drain-guided 27%), yet 90-day mortality was low (open 8.5% and drain-guided 7.1%). Patient and operative characteristics and 90-day outcomes were statistically similar for robotic versus laparoscopic transgastric cystogastrostomy. Our evidence-based algorithm provides a stepwise approach for the management of necrotizing pancreatitis, emphasizing minimally invasive early and late interventions when feasible with low morbidity and mortality. Robot-assisted transgastric cystogastrostomy is an acceptable alternative to a laparoscopic approach for the delayed treatment of walled-off pancreatic necrosis.

Percutaneous Endoscopic Step-Up Therapy Is an Effective Minimally Invasive Approach for Infected Necrotizing Pancreatitis

BACKGROUND

Infected pancreatic necrosis (IPN) is a major complication of acute pancreatitis (AP), which may require necrosectomy. Minimally invasive surgical step-up therapy is preferred for IPN.

AIM

To assess the effectiveness of percutaneous endoscopic step-up therapy in patients with IPN and identify predictors of its success.

METHODS

Consecutive patients with AP hospitalized to our tertiary care academic center were studied prospectively. Patients with IPN formed the study group. The treatment protocol for IPN was percutaneous endoscopic step-up approach starting with antibiotics and percutaneous catheter drainage, and if required necrosectomy. Percutaneous endoscopic necrosectomy (PEN) was performed using a flexible endoscope through the percutaneous tract under conscious sedation. Control of sepsis with resolution of collection(s) was the primary outcome measure.

RESULTS

A total of 415 patients with AP were included. Of them, 272 patients had necrotizing pancreatitis and 177 (65%) developed IPN. Of these 177 patients, 27 were treated conservatively with antibiotics alone, 56 underwent percutaneous drainage alone, 53 required underwent PEN as a step-up therapy, 1 per-oral endoscopic necrosectomy, and 52 required surgery. Of the 53 patients in the PEN group, 42 (79.2%) were treated successfully-34 after PEN alone and 8 after additional surgery. Eleven of 53 patients died due to organ failure-7 after PEN and 4 after surgery. Independent predictors of mortality were > 50% necrosis and early organ failure.

CONCLUSION

Percutaneous endoscopic step-up therapy is an effective strategy for IPN. Organ failure and extensive pancreatic necrosis predicted a suboptimal outcome in patients with infected necrotizing pancreatitis.

Role of percutaneous catheter drainage as primary treatment of necrotizing pancreatitis

BACKGROUND/AIMS

Necrotizing pancreatitis has morbidity and mortality rates exceeding most of the other acute medical emergencies despite the best possible medical and surgical care. Early surgical intervention has a high operative risk.

MATERIALS AND METHODS

This prospective open-label study was designed to evaluate the role of percutaneous catheter drainage (PCD) of pancreatic necrosis as primary treatment of acute necrotizing pancreatitis. An ultrasound/computed tomography-guided drainage was performed with 10 or 12 Fr catheters using a 0.35 mm guide wire, irrespective of whether necrosis was infected or not. Patients were followed up for organ dysfunction, need for surgical intervention, and survival at week 8.

RESULTS

A total of 20 (65% males) patients who had acute necrotizing pancreatitis with varied etiology were enrolled in the present study. Of these patients, 9 (45%) did not need surgery after PCD. The remaining 11 (55%) patients showed significant reversal of organ failure after PCD insertion (p<0.05 for improvement in serum creatinine, need for mechanical ventilation, and decline in C-reactive protein). Survival at week 8 was 95%. PCD was well tolerated with only two catheter-related complications being observed.

CONCLUSION

Percutaneous catheter drainage can be a primary treatment option for necrotizing pancreatitis. In addition, it helps to stabilize critically ill patients and delay the surgical procedure to beyond 4 weeks to improve the surgical outcomes.

Double-catheter lavage combined with percutaneous flexible endoscopic debridement for infected pancreatic necrosis failed to percutaneous catheter drainage

Background

Infected pancreatic necrosis (IPN) is a serious local complication of acute pancreatitis, with high mortality. Minimally invasive therapy including percutaneous catheter drainage (PCD) has become the preferred method for IPN instead of traditional open necrosectomy. However, the efficacy of double-catheter lavage in combination with percutaneous flexible endoscopic debridement after PCD failure is unknown compared with surgical necrosectomy.

Methods

A total of 27 cases of IPN patients with failure PCD between Jan 2014 and Dec 2015 were enrolled in this retrospective cohort study. Fifteen patients received double-catheter lavage in combination with percutaneous flexible endoscopic debridement, and 12 patients underwent open necrosectomy. The primary endpoint was the composite end point of major complications or death. The secondary endpoint included mortality, major complication rate, ICU admission length of stay, and overall length of stay.

Results

The primary endpoint occurrence rate in double-catheter lavage in combination with percutaneous flexible endoscopic debridement group (8/15, 53%) was significantly lower than that in open necrosectomy group (11/12, 92%) (RR = 1.71, 95% CI = 1.04 – 2.84, P < 0.05). Though the mortality between two groups showed no statistical significance (0% vs. 17%, P = 0.19), the rate of new-onset multiple organ failure and ICU admission length of stay in the experimental group was significantly lower than that in open necrosectomy group (13% vs. 58%, P = 0.04; 0 vs. 17, P = 0.02, respectively). Only 40% of patients required ICU admission after percutaneous debridement, which was markedly lower than the patients who underwent surgery (83%; P < 0.05).

Conclusions

Double-catheter lavage in combination with percutaneous flexible endoscopic debridement showed superior effectiveness, safety, and convenience in patients with IPN after PCD failure as compared to open necrosectomy.

Electronic supplementary material

The online version of this article (10.1186/s12876-017-0717-3) contains supplementary material, which is available to authorized users.

Transgastric pancreatic necrosectomy-expedited return to prepancreatitis health

BACKGROUND

The best operative strategy for necrotizing pancreatitis remains controversial. Traditional surgical necrosectomy is associated with significant morbidity; endoscopic and percutaneous strategies require repeated interventions with prolonged hospitalizations. We have developed a transgastric approach to pancreatic necrosectomy to overcome the shortcomings of the other techniques described.

MATERIALS AND METHODS

Patients with necrotizing pancreatitis treated from 2009 to 2016 at an academic center were retrospectively reviewed. Open or laparoscopic transgastric necrosectomy was performed if the area of necrosis was walled-off and in a retrogastric position on cross-sectional imaging. Study endpoints included postoperative complications and mortality.

RESULTS

Forty-six patients underwent transgastric necrosectomy (nine open and 37 laparoscopic). Median (interquartile range) preoperative Acute Physiologic and Chronic Health Evaluation II score was 6 (3-12). Seventy percent of patients had >30% necrosis on preoperative imaging; infected necrosis was present in 35%. Median total length of stay (LOS) was 6 (3-12) d. No patient required a second operative debridement; four patients (9%) had short-term postoperative percutaneous drainage for residual fluid collections. Median follow-up was 1 y; there were no fistula or wound complications. Six patients (13%) had postoperative bleeding; five patients received treatment by image-guided embolization. There was one death in the cohort.

CONCLUSIONS

Transgastric pancreatic necrosectomy allows for effective debridement with a single definitive operation. When anatomically suitable, this operative strategy offers expedited recovery and avoids long-term morbidity associated with fistulas and prolonged drainage.

Asian consensus statements on endoscopic management of walled-off necrosis. Part 2: Endoscopic management

Walled-off necrosis (WON) is a new term for encapsulated necrotic tissue after severe acute pancreatitis. Various terminologies such as pseudocyst, necroma, pancreatic abscess, and infected necrosis were previously used in the literature, resulting in confusion. The current and past terminologies must be reconciled to meaningfully interpret past data. Recently, endoscopic necrosectomy was introduced as a treatment option and is now preferred over surgical necrosectomy when the expertise is available. However, high-quality evidence is still lacking, and there is no standard management strategy for WON. The consensus meeting aimed to clarify the diagnostic criteria for WON and the role of endoscopic interventions in its management. In the Consensus Conference, 27 experts from eight Asian countries took an active role and examined key clinical aspects of WON diagnosis and endoscopic management. Statements were crafted based on literature review and expert opinion, employing the modified Delphi method. All statements were substantiated by the level of evidence and the strength of the recommendation. We created 27 consensus statements for WON diagnosis and management, including details of endoscopic procedures. When there was not enough solid evidence to support the statements, this was clearly acknowledged to facilitate future research. Proposed management strategies were formulated and are illustrated using flow charts. These recommendations, which are based on the best current scientific evidence and expert opinion, will be useful for guiding endoscopic management of WON. Part 2 of this statement focused on the endoscopic management of WON.

Step-up mini-invasive surgery for infected pancreatic necrosis: Results from prospective cohort study

OBJECTIVES

To investigate the clinical efficacy and success predictors of mini-invasive techniques in the treatment of infected pancreatic necrosis (IPN).

METHODS

IPN patients admitted to our clinic for treatment by mini-invasive techniques were included in this study prospectively. Treatment was divided into four sequential phases: percutaneous catheter drainage (PCD), mini-incision drainage (MID), video assisted debridement (VAD) and open surgery. Patients progressed to next phase if the infection cannot be controlled. The frequency of surgery, treatment duration, cure rate, incidence of complication and overall mortality were recorded. Risk factors for failure of PCD and MID procedures were detected by logistic regression including demographics, disease severity and morphologic characteristics.

RESULTS

From January 2012 to March 2015, a total of 54 consecutive IPN patients were treated, with an average age of 51.2 ± 3.1 years. Of the 54 cases, 18 (33.3%) were cured after PCD; 13 (24.1%) with uncontrolled infection were cured after MID; and the remaining 19 cases (35.2%) were cured after VAD. No open surgery was performed. Overall mortality was 7.4% (4/54), and the incidence of complications was 12.9% (7/54). In multivariable regression, the following factors were associated with high failure rate for both PCD and MID: heterogeneous fluid collection (odds ratio (OR) = 3.14; 95% confidence interval (CI): 1.32 ～ 4.25, P = 0.001 for PCD; OR = 2.99; 95% CI: 1.52 ～ 5.10, P = 0.006 for MID), multiple infected collections (OR = 4.51; 95% CI: 2.94 ～ 8.63; P = 0.000 for PCD; OR = 4.17; 95% CI: 2.77 ～ 8.12, P = 0.000 for MID), CT severity index (0 ～ 3/4 ～ 6/7 ～ 10: OR = 2.16; 95% CI: 1.83 ～ 3.62, P = 0.031 for PCD; OR = 2.72; 95% CI: 1.78 ～ 4.10, P = 0.005 for MID).

CONCLUSIONS

Step-up mini-invasive techniques can be considered a first choice in the treatment of IPN. CT is effective to predict success of PCD and MID.

[Prevention and treatment of post-traumatic pancreatic necrosis in patients with blunt abdominal trauma]

INTRODUCTION

High incidence of necrotic and suppurative complications is feature of acute post-traumatic pancreatitis. Severe trauma of the pancreas and post-traumatic pancreatitis lead to depressurization of ductal system that requires adequate drainage of damaged area and retroperitoneal fat.

MATERIAL AND METHODS

95 patients in group 1 received standardized treatment. The victims of the 2nd group (44 patients) were treated using immunoreactive therapy (roncoleukin) and octreotide (the dose depended on the severity of pancreatitis) at early stages. The efficacy of treatment was assessed based on clinical, laboratory and instrumental parameters.

RESULTS

Regardless severity of pancreatic injury overall mortality in groups 1 and 2 was 41% and 20.5% respectively. The main causes of adverse outcomes are severe destructive pancreatitis, postnecrotic suppurative complications.

CONCLUSION

Adequacy rather radicalism of surgery should be preferred for blunt pancreatic trauma management. Minimally invasive surgical techniques and new methods of biological hemostasis may be applied. Timely use of anti-enzymatic and immunoactive therapy reduces the risk of severe post-traumatic pancreatitis, suppurative complications and improves outcomes in patients with blunt pancreatic trauma.

Laparoscopic approach in gastrointestinal emergencies

This review focuses on the laparoscopic approach to gastrointestinal emergencies and its more recent indications. Laparoscopic surgery has a specific place in elective procedures, but that does not apply in emergency situations. In specific emergencies, there is a huge range of indications and different techniques to apply, and not all of them are equally settle. We consider that the most controversial points in minimally invasive procedures are indications in emergency situations due to technical difficulties. Some pathologies, such as oesophageal emergencies, obstruction due to colon cancer, abdominal hernias or incarcerated postsurgical hernias, are nearly always resolved by conventional surgery, that is, an open approach due to limited intraabdominal cavity space or due to the vulnerability of the bowel. These technical problems have been solved in many diseases, such as for perforated peptic ulcer or acute appendectomy for which a laparoscopic approach has become a well-known and globally supported procedure. On the other hand, endoscopic procedures have acquired further indications, relegating surgical solutions to a second place; this happens in cholangitis or pancreatic abscess drainage. This endoluminal approach avoids the need for laparoscopic development in these diseases. Nevertheless, new instruments and new technologies could extend the laparoscopic approach to a broader array of potentials procedures. There remains, however, a long way to go.

Minimally invasive percutaneous catheter drainage versus open laparotomy with temporary closure for treatment of abdominal compartment syndrome in patients with early-stage severe acute pancreatitis

This study aimed to examine the clinical efficacy of minimally invasive percutaneous catheter drainage (PCD) versus open laparotomy with temporary closure in the treatment of abdominal compartment syndrome (ACS) in patients with early-stage severe acute pancreatitis (SAP). Clinical data of 212 patients who underwent PCD and 61 patients who were given open laparotomy with temporary closure in our hospital over the last 10-year period were retrospectively analyzed, and outcomes were compared, including total and post-decompression intensive care unit (ICU) and hospital stays, physiological data, organ dysfunction, complications, and mortality. The results showed that the organ dysfunction scores were similar between the PCD and open laparotomy groups 72 h after decompression. In the PCD group, 134 of 212 (63.2%) patients required postoperative ICU support versus 60 of 61 (98.4%) in the open laparotomy group (P<0.001). Additionally, 87 (41.0%) PCD patients experienced complications as compared to 49 of 61 (80.3%) in the open laparotomy group (P<0.001). There were 40 (18.9%) and 32 (52.5%) deaths, respectively, in the PCD and open laparotomy groups (P<0.001). In conclusion, minimally invasive PCD is superior to open laparotomy with temporary closure, with fewer complications and deaths occurring in PCD group.

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.

Predictive factors for successful ultrasound-guided percutaneous drainage in necrotizing pancreatitis

BACKGROUND

Percutaneous catheter drainage (PCD) is now regarded as an initial minimal access technique of step-up approach for necrotizing pancreatitis. Factors that led to surgical intervention after initial management with PCD have rarely been reported. This study was to evaluate the safety and efficacy of ultrasound-guided PCD in patients with necrotizing pancreatitis and identify a subgroup of patients where PCD alone would be effective.

METHODS

We performed a retrospective review of patients with necrotizing pancreatitis who underwent intervention in West China Hospital from January 1, 2009, to March 31, 2013.

RESULTS

Patients who underwent initial PCD therapy had lower intra-abdominal bleeding rate (41/235 vs. 1/51, P = 0.002), lower enterocutaneous fistula rate (28/235 vs. 0/51, P = 0.004), and lower mortality rate (46/235 vs. 3/51, P = 0.001) when compared with the patients who underwent operative intervention. The successful PCD group had lower computed tomography (CT) mean density of necrotic fluid collection (18 HU vs. 25 HU, P = 0.01) and higher prevalence of walled-off necrosis (20/35 vs. 5/16, P = 0.04) when compared with failed PCD group. Multivariate analysis of the predictors of surgery showed that only CT mean density of necrotic fluid collection [odd ratio (OR) 1.63, 95 % confidence interval (CI) 1.04-2.94, P = 0.006] was identified as significant factor.

CONCLUSION

CT mean density of necrotic fluid collection and the existence of acute necrotic collection could influence the success rate of PCD.

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.

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.

Laparoscopic pancreatic surgery: An overview of the literature and experiences of a single center

Pancreatic surgery was reported as early as 1898. Since then significant developments have been made in the field of pancreatic resections. In addition, advances in laparoscopic surgery in general have seen the description of this approach in pancreatic surgery with increasing frequency. Although there are no randomized controlled trials, several large series and comparative studies have reported on the short and long term outcome of laparoscopic pancreatic surgery. Furthermore, in the last decade published systematic reviews and meta-analyses have reported on cost effectiveness and outcomes of these procedures.

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.

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.

Retroperitoneal laparoscopic debridement and drainage of infected retroperitoneal necrosis in severe acute pancreatitis

OBJECTIVE

To explore the effect of retroperitoneal laparoscopic debridement and drainage on infected necrosis in severe acute pancreatitis.

MATERIALS AND METHODS

This retrospective study included 18 patients with severe acute pancreatitis (SAP) undergoing retroperitoneal laparoscopic debridement and drainage from May 2006 to April 2012 in our hospital. All patients had infected retroperitoneal necrosis and single or multiple peritoneal abscesses. Eleven patients transferred to our hospital were treated with the retroperitoneal laparoscopic debridement and drainage within 24-72 hours after admission. Conservative treatments were given to eight patients. Retroperitoneal laparoscopic debridement and drainage were applied 3-11 days after admission.

RESULTS

All patients had infection of necrotic pancreas or peripancreatic tissues. Twelve patients had organ failure. Three patients underwent secondary surgery. Laparotomy with debridement and drainage were applied to one patient who had a huge lesser sac abscess 7 days after first surgery. The other two patients were given secondary retroperitoneal laparoscopic debridement and drainage. One case was complicated by retroperitoneal hemorrhage, four cases had pancreatic leakage, and no intestinal fistula was found. The patients' heart rate, respiration, temperature, and white blood cell count were significantly improved 48 hours after surgery compared with those prior to surgery (p<0.05). The average length of stay in hospitals was 40.8 days (range, 6-121 days), and the drainage tube indwelling time was 44.4 days (range, 2-182 days).

CONCLUSION

Retroperitoneal laparoscopic debridement and drainage is an SAP surgical treatment with a minimally invasive procedure and a good effect, and can be applied for infected retroperitoneal necrosis in early SAP.

A retroperitoneal approach for infected pancreatic necrosis

BACKGROUND

Acute pancreatitis remains associated with a high rate of complication and death. The surgery strategy for proven or suspected infected necrosis is controversial.

METHODS

The present study reviews the medical records of 9,421 patients admitted with the diagnosis of acute pancreatitis from 2002 to 2009.

RESULTS

The medical records of 9,421 admitted patients diagnosed with acute pancreatitis were reviewed. Among the patients, 412 received necrosectomy. Of the 412 that were identified, 108 patients underwent retroperitoneal necrosectomy, whereas the remaining 304 patients received open necrosectomy. The mortality rates were 20.4% (62/304) and 8.3% (9/108), respectively (p = 0.004). The rates of complications in the retroperitoneal group were lower than that in the open group (p < 0.05). The mean lengths of hospital stay and ICU stay after surgery were longer in the open group than those in the retroperitoneal group (48 vs. 30 days; 6 vs. 2 days, p < 0.05). Furthermore, the postoperational days in the hospital and surgical time were also significantly different (30 vs. 12 days; 167 vs. 93 min, p < 0.05).

CONCLUSIONS

A retroperitoneal pancreatic necrosectomy approach reduced the rate of complications and death among patients with infected necrosis, compared with open necrosectomy.

An update on minimally invasive therapies for pancreatic necrosis

Pancreatic necrosis is a local complication of severe acute pancreatitis associated with multiple organ dysfunction, infection and increased mortality. While surgery is the mainstay for invasive management, studies have demonstrated that delaying necrosectomy translates to improved patient outcomes. Minimally invasive therapies have been described both for early and late management of necrotic pancreatic collections and fall into three broad categories: endoscopic, radiology assisted percutaneous drainage and laparoscopic or retroperitoneal surgical techniques. Such interventions may serve as temporizing measures delaying necrosectomy, but more importantly, as best demonstrated in recent randomized controlled trials, can serve as alternative approaches resulting in improved patient outcomes. Access to these techniques is based on their availability at expert centers. Minimally invasive therapies have increased in popularity, with a general consensus among experts being that reduced complications and mortality rates are realized by approaches other than open necrosectomy. However, additional well-designed, randomized trials are needed.

Percutaneous minimally invasive necrosectomy following endoscopic transgastric drainage in acute necrotising pancreatitis

A patient who had undergone failed transgastric placement of two cystgastrostomy stents referred to the regional pancreatic unit with ongoing sepsis for further management. Following stabilisation, percutaneous minimally invasive necrosectomy (MIN) was performed. MIN resulted in sustained clinical resolution of the sepsis and normalisation of serum C reactive protein levels. The transgastric drains were removed by MIN and, importantly, the patient did not develop a gastric fistula. To our knowledge, this is the first report of MIN following endoscopic cystgastrostomy stent placement. Pancreatic necrosis progresses from solid to semisolid to liquid states over a period of several months. Transgastric drainage should be reserved for subjects with either a pancreatic abscess or predominantly liquid necrosis reserving MIN for patients with systemic sepsis and those with semisolid necrosis. As increasing strategies to treat pancreatic necrosis become available clinicians must be alert to the development of new complications of these treatments.

Minimally invasive retroperitoneal necrosectomy in management of acute necrotizing pancreatitis

INTRODUCTION

One of the most important requirements in treatment of acute necrotizing pancreatitis is minimized invasion.

AIM

We are presenting experience in treatment of acute necrotizing pancreatitis by an original minimally invasive retroperitoneal necrosectomy technique, comparing our results to other studies, evaluating feasibility and safety, discussing advantages and disadvantages of this method.

MATERIAL AND METHODS

We performed a retrospective analysis of 13 patients who had acute necrotizing pancreatitis with large fluid collections in retroperitoneal space and underwent retroperitoneal necrosectomy.

RESULTS

There were eight males and three females aged between 24 and 60 years, average age was 42.8 ±9.2 years. The most common cause of pancreatitis was alcohol, 10 patients (76.9%). Average time between diagnosis and performance of operation was 25.7 ±11.3 days. One patient underwent eight repeated interventions: two retroperitoneal necrosectomies; five laparotomies; ultrasound-guided drainage. One patient underwent four reinterventions: lumbotomy; revision; two lavages. Three patients had two reinterventions: one had laparotomy and tamponation; one had two repeated retroperitoneal necrosectomies; third had one repeated retroperitoneal necrosectomy and one had ultrasound-guided drainage. Three patients needed one additional retroperitoneal necrosectomy. Five patients did not required additional interventions. 61.5% of our patients did not require more than one reintervention. Postoperative stay varied from 9 to 94 days, average 50.8 ±32.6 days.

CONCLUSIONS

Minimally invasive techniques should be considered as first-choice surgical option in treating patients with acute necrotizing pancreatitis. Pancreatic necrosis occupying less than 30% and with massive fluid collections in the left retroperitoneal space can be safely managed by minimally invasive retroperitoneal necrosectomy.

Management of infected pancreatic necrosis using retroperitoneal necrosectomy with flexible endoscope: 10 years of experience

BACKGROUND

This study was designed to provide our experience in the management of infected and drained pancreatic necrosis using the retroperitoneal approach.

METHODS

This was a prospective observational study in a tertiary care university hospital. Thirty-two patients with confirmed infected pancreatic necrosis were studied. Superficial necrosectomy was performed with lavage and aspiration of debris. This was achieved though a retroperitoneal approach of the pancreatic area and under the direct vision of a flexible endoscope. The follow-up procedure using retroperitoneal endoscopy did not require taking the patient to the operating room. The main outcome measures were infection control, morbidity, and mortality related to technique, reintervention, and long-term follow-up.

RESULTS

No significant morbidity or mortality related to the technique was observed in all of the patients with infected pancreatic necrosis treated with this retroperitoneal approach compared with published data using other approaches. Reinterventions were not required and patients are currently asymptomatic.

CONCLUSIONS

Retroperitoneal access of the pancreatic area is a good approach for drainage and debridement of infected pancreatic necrosis. Translumbar retroperitoneal endoscopy allows exploration under direct visual guidance avoiding open transabdominal reintervention and the risk of contamination of the abdominal cavity. This technique does not increase morbidity and mortality, can be performed at the patients' bedside as many times as necessary, and has advantages over other retroperitoneal approaches.

The minimally invasive approach to surgical management of pancreatic diseases

Laparoscopic pancreas surgery has undergone rapid development over the past decade. Although acceptability among traditional surgeons has been low, emerging specialty centers are reporting excellent outcomes for advanced and complex operations, such as pancreaticoduodenectomy. A note of caution is necessary: These outstanding results are from skilled surgeons, many of whom are pioneers in the field, who have overcome the learning curve over many years of innovation. As the procedures gain wider practice, outcomes need to be carefully watched because many of these procedures are extremely demanding technically. Although many have suggested that controlled, randomized studies comparing laparoscopic pancreatic resections with open resections are necessary to establish the efficacy of laparoscopic procedure, the cumulative data on the safety and efficacy of the laparoscopic procedure argues against such an approach. The logistic difficulties of conducting such studies will be considerable given patient preferences, the need for multicenter studies, and the rapid adoption of the laparoscopic procedure among experienced pancreatic surgeons. A more reasonable approach to truly evaluate the safety of these procedures is the establishment of a national registry that can measure progress of the field and record outcomes in the wider, nonspecialty community. Hepatobiliary training programs should also establish a minimal standard of training for many of the advanced procedures, such as the pancreaticoduodenectomy, so that the benefit of laparoscopic surgery can be made available outside of just a few specialty centers.

Retroperitoneal laparoscopic hepatectomy: a novel approach

PURPOSE

Retroperitoneal laparoscopic surgery has been widely used for kidney and adrenal gland resection. However, there have not been any reports of laparoscopic hepatectomy performed using a retroperitoneal approach. Herein, we report on a successful case of laparoscopic hepatectomy using a retroperitoneal approach. Further, we discuss the key technical points, feasibility, and indications of this method.

METHODS

A 48-year-old male patient with multiple hepatic metastases of the left lateral and right posterior segments of the liver following radical colon carcinoma resection underwent laparoscopic partial hepatectomy of the right posterior segment using a retroperitoneal approach, followed by laparoscopic hepatic left-lateral segmentectomy using a transabdominal approach.

RESULTS

The operation time was 120 minutes and the blood loss volume was 150 mL. The patient was discharged at nine days post-surgery. There were no complications, including hemorrhage and bile leakage.

CONCLUSIONS

The results of this case study provide evidence that a retroperitoneal approach is a novel, rapid, and safe method for laparoscopic hepatectomy that can be applied to the partial resection of small and superficial tumors of the right posterior segment of the liver.

Fulminant type of emphysematous pancreatitis has risk of massive hemorrhage

Emphysematous pancreatitis (air in the parenchyma) was previously considered an indication for surgery, but some recent studies have reported good clinical outcomes with non-operative management. As a step toward establishing a better treatment strategy, we report a case of fulminant pancreatitis with massive hemorrhage into the emphysematous space. A 75-year-old man was admitted with worsening abdominal pain with obstructive jaundice and renal failure 28 h after the onset. He was diagnosed as having emphysematous pancreatitis with slight pancreatic necrosis. Despite conservative treatment with intensive care, sudden cardiac and respiratory failure occurred, and he died 53 h after onset. The autopsy findings revealed biliary sludge and massive bleeding in the retroperitoneal space around the pancreas, suggesting that temporary obstruction of the bile duct with sludge induced emphysema and the hemorrhage rapidly spread into the broadened emphysematous space. Whereas conservative management has been thought to be appropriate in selected cases of emphysematous pancreatitis, when there is pancreatic emphysema in the early phase, a fulminant course tends to develop. Since there is a risk of massive bleeding into the emphysematous space, endoscopic or invasive drainage performed to collapse the emphysematous space could benefit the outcome.

Endoscopic pancreatic necrosectomy

Traditionally, patients with symptomatic sterile pancreatic necrosis or infected necrosis have been managed by open surgical debridement and removal of necrotic tissue. Within the last decade, however, reports of endoscopic pancreatic necrosectomy, an alternative minimally invasive approach, have demonstrated high success rates and low mortality rates. This report describes the indications, technique, and study outcome data of the procedure. While our experience with this technique has recently increased, better selection criteria are needed to identify patients who are most suitable for endoscopic therapy.

Intra-abdominal fungal infections complicating acute pancreatitis: a review

Intra-abdominal infections of pancreatic or peripancreatic necrotic tissue complicate the clinical course of severe acute pancreatitis (SAP) and are associated with significant morbidity. Fungal infection of necrotic pancreatic tissue is increasingly being reported. The incidence of intra-abdominal pancreatic fungal infection (PFI) varies from 5% to 68.5%. Candida albicans is the most frequently isolated fungus in patients with necrotizing pancreatitis. Prolonged use of prophylactic antibiotics, prolonged placement of chronic indwelling devices, and minimally invasive or surgical interventions for pancreatic fluid collections further increase the risk of PFI. Computed tomography- or ultrasound-guided fine-needle aspiration of pancreatic necrosis is a safe, reliable method for establishing pancreatic infection. Amphotericin B appears to be the most effective antifungal treatment. Drainage and debridement of infected necrosis are also critical for eradication of fungi from the poorly perfused pancreatic or peripancreatic tissues where the antifungal agents may not reach to achieve therapeutic levels. Fungal infection adversely affects the outcome of patients with SAP and is associated with increased morbidity, although the mortality rate is not increased specifically because of PFI. Although antifungal prophylaxis has been suggested for patients on broad-spectrum antibiotics, no randomized controlled trials have yet studied its efficacy in preventing PFI.

History, goals, and technique of laparoscopic pancreatic necrosectomy

The surgical treatment of severe acute pancreatitis has significantly changed in the last several years with the advent of enhanced imaging techniques and minimally invasive surgery. Criteria for surgical intervention have been influenced by the use of step-up approaches that provide incremental multimodality interventions with repeat imaging. Here, we provide a brief introduction to the history, goals, indications, and technique of laparoscopic pancreatic necrosectomy. The technique requires a fundamental understanding of the natural history of pancreatitis and its complication. Laparoscopic approaches can be useful as primary and adjunctive therapy for the treatment of infected pancreatitic necrosis.

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

BACKGROUND

The best treatment options for walled-off pancreatic necrosis (WOPN) are not well defined. A retrospective study of patients treated for WOPN with transgastric debridement and internal drainage was undertaken.

METHODS

Patients with symptomatic non-infected WOPN treated with open transgastric debridement and internal drainage were evaluated.

RESULTS

In all, 51 patients underwent surgical management of necrotizing pancreatitis during the study period. Ten patients (19%) were treated with open transgastric debridement and internal drainage for symptomatic non-infected WOPN. The median patient age was 40 years, the most common aetiology for pancreatitis was biliary, the mean American Society of Anesthesiologists (ASA) score was 2 and the delay to surgery was 100 days. The operating time was 118 min, with a blood loss of 50cc. One patient required reoperation, three patients had morbidity and there were no mortalities. The only factor associated with post-operative morbidity was the presence of positive cultures (P < 0.05). The length of stay (LOS) after surgery was 8 days, at a median follow-up of 18 months, one patient had late complications related to the surgery and the procedure was successful in 90% of the patients.

DISCUSSION

Open transgastric debridement with internal drainage of WOPN is safe and efficacious. Patients were clinically stable (no organ failure) and had a long delay in surgical intervention (100 days). In this select group of patients, the success, morbidity and mortality is similar to all reported minimally invasive techniques.

Early management of severe acute pancreatitis

Significant literature on the management of acute severe acute pancreatitis has emerged in recent years. The new information ranges from data on newer single or multiparameter severity assessment tools and classification systems to therapeutic modalities. However, a few basic issues-the ideal severity assessment modality, volume of intravenous fluids required in the first 48 to 72 h, and the role of prophylactic antibiotics-are still not clear and are subject to controversy. The International Working Group has devised the Revised Atlanta Classification, which will be published soon. This new classification is eagerly awaited worldwide, and hopefully clarifies many of the problems of the original Atlanta Classification. In this article, we discuss the developments that have arisen in the past 2 to 3 years concerning the classification, prognostication, and early management of severe acute pancreatitis.

Natural orifice transluminal endoscopic surgery in pancreatic diseases

Natural orifice transluminal endoscopic surgery (NOTES) is a surgical technique that has received considerable interest in recent years. Although minimal access surgery has increasingly replaced traditional open abdominal surgical approaches for a wide spectrum of indications, in pancreatic diseases its widespread use is limited to few indications because of the challenging and demanding nature of major pancreatic operations. Nonetheless, there have been attempts in animal models as well as in the clinical setting to perform diagnostic and resectional NOTES for pancreatic diseases. Here, we review and comment upon the available data regarding currently analyzed and performed pancreatic NOTES procedures. Potential indications for NOTES include peritoneoscopy, cyst drainage, and necrosectomy, palliative procedures such as gastroenterostomy, as well as resections such as distal pancreatectomy or enucleation. These procedures have already been shown to be technically feasible in several studies in animal models and a few clinical trials. In conclusion, NOTES is a rapidly developing concept/technique that could potentially become an integral part of the armamentarium dealing with surgical approaches to pancreatic diseases.