Open Necrosectomy Research Articles

Evolution of Transluminal Necrosectomy for Acute Pancreatitis to Stent in Stent Therapy: Step-Up Approach Leads to Low Mortality and Morbidity Rates in 302 Consecutive Cases of Acute Pancreatitis.

Background: The step-up approach, using either flexible endoscopy or a minimal invasive retroperitoneal access, has reduced mortality and morbidity in patients with acute pancreatitis. The use of fully covered self-expanding metal stents (FCSEMS) or lumen apposing metal stents (LAMS) facilitates endoscopic necrosectomy and drainage of walled-off necrosis (WON). The aim of our analysis was to investigate the 30/90/365-day mortality and morbidity rates of the subtypes of the revised Atlanta classification for acute pancreatitis. Materials and Methods: We conducted a retrospective analysis of all patients (n = 302) treated with acute pancreatitis in our institution from January 2014 to July 2017. Mortality, morbidity, management of fluid collections, interventions, complications, and new onset of diabetes were recorded. Results: In 30.8% (n = 93/302) of patients, pancreatic fluid collection developed. Out of these, 58.1% (54/93) required intervention, consisting of endoscopic treatment in 63% (34/54) or multidisciplinary approach in 37% (20/54). Overall, 90-day mortality rate according to Kaplan-Meier Estimator was 3.7%. Overall, 1-year mortality rate was 6.2%. One-year mortality for uncomplicated acute pancreatic fluid collection, pseudocyst, and WON were 5.4%, 2.6%, and 13.5%, respectively. Hemorrhage in case of metal stent treatment (FCSEMS/LAMS) occurred in 14.3%. If LAMS was combined with double pigtail stent-in-stent, bleeding was seen in 5.3%. No transperitoneal necrosectomy was needed. Conclusions: Treating acute pancreatitis with a step-up approach, including stent-in-stent procedures, leads to low mortality rates and few stent-associated bleeding complications and minimizes necessity for open transperitoneal surgical necrosectomy.

Necrotizing pancreatitis : Long-term outcomes show superiority of the step-up approach versus open necrosectomy

Necrotizing pancreatitis : Long-term outcomes show superiority of the step-up approach versus open necrosectomy

Open necrosectomy or a step-up approach for infected necrotizing pancreatitis

Open necrosectomy or a step-up approach for infected necrotizing pancreatitis

Minimally Invasive Pancreatic Necrosectomy: A step-up approach towards ultra-low mortality in 103 consecutive procedures

Introduction: Infected pancreatic necrosis carries up to 70% risk of mortality. Open necrosectomy, previously regarded as standard treatment, carries very high risk of morbidity and mortality. Step-up management with percutaneous drainage followed by minimally invasive pancreatic necrosectomy (MIPN) has shown improved outcomes. We report the outcomes of the protocol developed at Cambridge of ‘early’ percutaneous drainage followed by ‘delayed’ MIPN. Method: Cambridge University Hospital is a tertiary referral centre for pancreatic surgery including complicated pancreatitis. Retrospective analysis of all MIPNs between December 2009 and October 2018. Demographics, morbidity and mortality outcomes are reported. Result: During the 9-year period, 103 MIPNs were performed in 86 patients, with 12 (13.9%) needing multiple procedures. The mean age was 58 ±15 years, with 74.4% (n=64) being male gender and 50.0% (n=43) with BMI more than 30 Kg/m2.Thirty (34.9%) patients had required preoperative ITU admission for multi-organ support related to infected necrosis. The mean time for insertion of percutaneous drain was 28 days (range 1-99). The mean time of the MIPN from acute episode was 45 days (range 4-307). Thirteen patients (15.1%) required admission to ITU after MIPN with a mean stay of 22 days (range 1-104). Composite endpoint for complications including bleeding needing intervention (n=5), multi-organ failure (19) and fistula (5) were 29 (33.7%), which was considered as the morbidity rate. 30-day and 90-day mortality following MIPN was 2.3% (n=2) and 5.8% (n=5), all deaths were due to sepsis and multi-organ failure. Conclusion: This is the lowest reported mortality rate for patients with infected pancreatic necrosis. Minimally invasive management with early percutaneous drain insertion followed by delayed MIPN is associated with ultra-low mortality. Management of complicated necrotizing pancreatitis almost invariably requires tertiary referral expertise as multimodal approaches, complex medical and ITU involvement, multiple procedures, prolonged admissions and long-term follow-up.

Open necrosectomy or a step-up approach for infected necrotizing pancreatitis

Open necrosectomy or a step-up approach for infected necrotizing pancreatitis

Combined ultrasound assisted drainage and focused open necrosectomy in the management of sepsis in patients with necrotizing pancreatitis

Background: Minimally invasive approaches considerably changed the surgical management of necrotizing pancreatitis and sepsis. The aim of the study was an evaluation of the efficiency of the combined ultrasound percutaneous drainage (USPD) and focused open necrosectomy (FON) compared to conventional open necrosectomy (CON) in the management of necrotizing pancreatitis and sepsis. Methods: Patients were prospectively included in FON and CON groups between 2004 and 2016. Sepsis-3 definition and C-reactive protein (CRP) level > 150 mg/ml, Procalcitonin (PCT) level> 2.0 ng/ml and SOFA score > 2 proved the development of sepsis. Results: From 182 patients, 84 underwent FON and 98 – CON strategies. The most frequent etiology was alcohol (56%–65%), and gallstones (21%–23%). More than half suffered > 50% of pancreatic and peripancreatic necrosis. Sepsis developed in 79% in the acute necrotic collection phase, but decreased to 37% after USPD in the walled-off necrosis phase. The median CRP dropped from 257 mg/L before the definitive surgery to 46 mg/L on postoperative day 7, being markedly lower in FON group 46 mg/L vs. 108 mg/L in CON group, p=0.001. Similarly, the median PCT was 3.2 ng/ml–3.96 ng/ml, plummeting on postoperative day 7 in FON group 0.15 ng/mL vs. 0,61 ng/mL, p < 0.001. The mortality rate reached 6% in FON group vs. 9.3%. in CON group. Conclusion: Combined USPD and FON is an effective strategy for the management of sepsis in patients with necrotizing pancreatitis.

Combined ultrasound assisted drainage and focused open necrosectomy in the management of sepsis in patients with necrotizing pancreatitis

Combined ultrasound assisted drainage and focused open necrosectomy in the management of sepsis in patients with necrotizing pancreatitis

Severe Acute Pancreatitis due to Gallstones Controlled by Multimodal Therapy Including Open Necrosectomy

Severe Acute Pancreatitis due to Gallstones Controlled by Multimodal Therapy Including Open Necrosectomy

Endotherapy for pancreatic necrosis: An update.

Approximately 20% of patients with acute pancreatitis develop pancreatic necrosis. The presence of necrosis in a pancreatic collection significantly worsens the prognosis. Pancreatic necrosis is associated with high mortality and morbidity. In the last few decades, there has been a significant revolution in the treatment of infected pancreatic necrosis. A step‐up approach has been proposed, from less invasive procedures to the operative intervention. Minimally invasive treatment modalities such as endoscopic drainage and necrosectomy, percutaneous drainage, and minimally invasive surgery have recently replaced open surgical necrosectomy as the first‐line treatment option. Endoscopic intervention for pancreatic necrosis is being increasingly performed with good success and a lower complication rate. However, techniques of endotherapy are still not uniform and vary as per local expertise, and there are still many unresolved questions with regard to the interventions in patients with pancreatic necrosis. The objective of this paper is to critically review the literature and update the concepts of endoscopic interventional therapy of pancreatic necrosis.

Influence of age, body mass index and comorbidity on major outcomes in acute pancreatitis, a prospective nation-wide multicentre study.

There are few large prospective cohort studies evaluating predictors of outcomes in acute pancreatitis. The purpose of this study was to determine the role of age and co-morbid disease in predicting major outcomes in acute pancreatitis. Data points were collected according to a predefined electronic data collection form. Acute pancreatitis and its complications were defined according to the revised Atlanta classification. Univariable and multivariable analyses were conducted using Cox proportional hazard regression and multiple logistic regression. From June 2013-February 2015, 1655 adult patients were recruited from 23 centres across Spain. Co-morbid disease, obesity, open surgical necrosectomy within 30 days, and pancreatic necrosis were independently associated with both 30-day mortality and persistent organ failure (p < 0.05 for all). Age was not associated with persistent organ failure, however the extreme of age (>85 years) was associated with mortality (p < 0.05). Co-morbid disease and obesity were not independently associated with a prolonged length of stay or other markers of morbidity on adjusted analysis (p > 0.05). Comorbidity and obesity are important determinates of mortality and persistent organ failure in acute pancreatitis, but in the absence of organ failure they do not appear to independently contribute to morbidity. This has important implications for severity classification and predictive models of severity in acute pancreatitis.

Minimally invasive drainage in critically ill patients with severe necrotizing pancreatitis is associated with better outcomes: an observational study

BackgroundInfected pancreatic necrosis, which occurs in about 40% of patients admitted for acute necrotizing pancreatitis, requires combined antibiotic therapy and local drainage. Since 2010, drainage by open surgical necrosectomy has been increasingly replaced by less invasive methods such as percutaneous radiological drainage, endoscopic necrosectomy, and laparoscopic surgery, which proved effective in small randomized controlled trials in highly selected patients. Few studies have evaluated minimally invasive drainage methods used under the conditions of everyday hospital practice. The aim of this study was to determine whether, compared with conventional open surgery, minimally invasive drainage was associated with improved outcomes of critically ill patients with infection complicating acute necrotizing pancreatitis.MethodsA single-center observational study was conducted in patients admitted to the intensive care unit for severe acute necrotizing pancreatitis to compare the characteristics, drainage techniques, and outcomes of the 62 patients managed between September 2006 and December 2010, chiefly with conventional open surgery, and of the 81 patients managed between January 2011 and August 2015 after the introduction of a minimally invasive drainage protocol.ResultsSurgical necrosectomy was more common in the early period (74% versus 41%; P <0.001), and use of minimally invasive drainage increased between the early and late periods (19% and 52%, respectively; P <0.001). The numbers of ventilator-free days and catecholamine-free days by day 30 were higher during the later period. The proportions of patients discharged from intensive care within the first 30 days and from the hospital within the first 90 days were higher during the second period. Hospital mortality was not significantly different between the early and late periods (19% and 22%, respectively).ConclusionIn our study, the implementation of a minimally invasive drainage protocol in patients with infected pancreatic necrosis was associated with shorter times spent with organ dysfunction, in the intensive care unit, and in the hospital. Mortality was not significantly different. These results should be interpreted bearing in mind the limitations inherent in the before-after study design.

An Endoscopic Transluminal Approach, Compared With Minimally Invasive Surgery, Reduces Complications and Costs for Patients With Necrotizing Pancreatitis

Infected necrotizing pancreatitis is a highly morbid disease with poor outcomes. Intervention strategies have progressed from open necrosectomy to minimally invasive approaches. We compared outcomes of minimally invasive surgery vs endoscopic approaches for patients with infected necrotizing pancreatitis. We performed a single-center, randomized trial of 66 patients with confirmed or suspected infected necrotizing pancreatitis who required intervention from May 12, 2014, through March 24, 2017. Patients were randomly assigned to groups that received minimally invasive surgery (laparoscopic or video-assisted retroperitoneal debridement, depending on location of collection, n= 32) or an endoscopic step-up approach (transluminal drainage with or without necrosectomy, n= 34). The primary endpoint was a composite of major complications (new-onset multiple organ failure, new-onset systemic dysfunction, enteral or pancreatic-cutaneous fistula, bleeding and perforation of a visceral organ) or death during 6 months of follow-up. The primary endpoint occurred in 11.8% of patients who received the endoscopic procedure and 40.6% of patients who received the minimally invasive surgery (risk ratio 0.29; 95% confidence interval 0.11-0.80; P= .007). Although there was no significant difference in mortality (endoscopy 8.8% vs surgery 6.3%; P=.999), none of the patients assigned to the endoscopic approach developed enteral or pancreatic-cutaneous fistulae compared with 28.1% of the patients who underwent surgery (P= .001). The mean number of major complications per patient was significantly higher in the surgery group (0.69 ± 1.03) compared with the endoscopy group (0.15 ± 0.44) (P= .007). The physical health scores for quality of life at 3 months was better with the endoscopic approach (P= .039) and mean total cost was lower ($75,830) compared with $117,492 for surgery (P= .039). In a randomized trial of 66 patients, an endoscopic transluminal approach for infected necrotizing pancreatitis, compared with minimally invasive surgery, significantly reduced major complications, lowered costs, and increased quality of life. Clinicaltrials.gov no: NCT02084537.

Superiority of Step-up Approach vs Open Necrosectomy in Long-term Follow-up of Patients With Necrotizing Pancreatitis

In a 2010 randomized trial (the PANTER trial), a surgical step-up approach for infected necrotizing pancreatitis was found to reduce the composite endpoint of death or major complications compared with open necrosectomy; 35% of patients were successfully treated with simple catheter drainage only. There is concern, however, that minimally invasive treatment increases the need for reinterventions for residual peripancreatic necrotic collections and other complications during the long term. We therefore performed a long-term follow-up study. We reevaluated all the 73 patients (of the 88 patients randomly assigned to groups) who were still alive after the index admission, at a mean 86 months (±11 months) of follow-up. We collected data on all clinical and health care resource utilization endpoints through this follow-up period. The primary endpoint was death or major complications (the same as for the PANTER trial). We also measured exocrine insufficiency, quality of life (using the Short Form-36 and EuroQol 5 dimensions forms), and Izbicki pain scores. From index admission to long-term follow-up, 19 patients (44%) died or had major complications in the step-up group compared with 33 patients (73%) in the open-necrosectomy group (P= .005). Significantly lower proportions of patients in the step-up group had incisional hernias (23% vs 53%; P= .004), pancreatic exocrine insufficiency (29% vs 56%; P= .03), or endocrine insufficiency (40% vs 64%; P= .05). There were no significant differences between groups in proportions of patients requiring additional drainage procedures (11% vs 13%; P= .99) or pancreatic surgery (11% vs 5%; P= .43), or in recurrent acute pancreatitis, chronic pancreatitis, Izbicki pain scores, or medical costs. Quality of life increased during follow-up without a significant difference between groups. In an analysis of long-term outcomes of trial participants, we found the step-up approach for necrotizing pancreatitis to be superior to open necrosectomy, without increased risk of reinterventions.

The trends in surgical treatment and the outcomes of critical acute pancreatitis

Objective To study the trends in surgical treatment and the outcomes of critical acute pancreatitis (CAP). Methods The clinical data of 76 patients with CAP who were treated in the Department of Biliopancreatic Surgery of the Xiangya Hospital, Central South University from January 2010 to December 2017 were retrospectively reviewed. Data which included demographics, micro-organisms, surgical interventions and mortality were compared between the time periods of 2010 to 2013 and 2014 to 2017. Results Before 2014, 19 patients with CAP were treated in the Department of Biliopancreatic Surgery of the Xiangya Hospital, Central South University. The percentage of multidrug resistant organisms (MDRO) in pancreatic drainage was 5.3% (1/19). In the latter 4 years, 57 patients with CAP were treated. The percentage of MDRO was 50.9% (29/57), which was significantly higher than the initial 4 years (P<0.001). For surgical treatment, the proportion of minimally invasive surgery in the latter 4 years was significantly higher than that in the initial 4 years. The percentage of percutaneous catheter drainage (PCD) increased from 63.2% in the initial 4 years to 86.0% in the latter 4 years. The proportion of minimal access retroperitoneal pancreatic necrosectomy (MARPN) increased from zero in the initial 4 years to 59.6%, while the proportion of open pancreatic necrosectomy (OPN) decreased from 68.4% in the initial 4 years to 24.6%. The mortality rate of patients with CAP dropped from 52.6% (10/19) in the initial 4 years to 24.6% (14/57) in the latter four years. Conclusions In the center which specializes in treating pancreatitis, although the problem of bacterial resistance had become increasingly prominent, the mortality rate of CAP had shown a significant downward trend due to the development of various minimally invasive techniques. Key words: Critical acute pancreatitis; Infected pancreatic necrosis; Minimally invasive techniques

Multimodal video-endoscopic and transcutaneous interventions in surgical treatment of infected acute necrotizing pancreatitis

Background: Recent researches improves understanding of natural course of acute necrotizing pancreatitis (ANP). Today there are no disagreements on timing and indications for surgical treatment, but different approaches still exist. Our aim was to establish the efficacy of multimodal video-endoscopic (VE) and transcutaneous interventions (TI) in surgical treatment of infected ANP. Methods: We performed retrospective study of step-up surgical ttreatment of 173 patients with ANP. As a first step VE were used in 69, TI - 99 cases. In 31 patients with extended necrosis their multimodal application were performed. Duration of in-hospital treatment, complications, amount of procedures and necessarily for open necrosectomy were studied. Results: From 52 patients with acute necrotizing collections (ANC) separate application of VE or TI was final method of treatment in 74.0% patients, video-assisted retroperitoneal debridement (VARD) we performed in 13.5%, mini-laparotomic necrosectomies - 5.8%, open necrosectomies -19.2% observations. Their application in 102 patients with walled off pancreatic necrosis (WOPN) was followed by VARD in 10.8%, mini-laparotomic necrosectomies - 3.9%, open necrosectomies - 16.8% cases. Total number of invasive procedures reached 2.5±0.24, complication rate - 12.3% (pancreatic fistula -7.2%), overall mortality - 2%. Multimodal VE and PTI approach was applied in 9 ANC and 32 WOPN observations with no mortality cases. Necessary of additional intervention occurred in 12.9% (p<0.05), open necrosectomies - 6.4% (p<0.05), there were no procedure-related immediate and long-term complications. Conclusions: Multimodal application of video-endoscopic and transcutaneous interventions is effective approach as first step for surgical treatment of patients with extended infected ANP.

Hepatic necrosectomy: an important procedure to manage massive hepatic necrosis

Just like pancreatic necrosectomy for infected pancreatic necrosis, here we describe a new term “hepatic necrosectomy” for infected hepatic necrosis. Infected hepatic necrosis is a rare but devastating complication after high grade liver injury and rarely post hepatic artery chemoembolization. Smaller areas of necrosis can be managed with antibiotics, but patients with sepsis and bacteremia needs percutaneous drainage. If both of these fails, then open or laparoscopic technique needs to be considered for hepatic necrosectomy. We present five patients whom we have managed with hepatic necrosectomy. First patient had post hepatic artery embolization left lobe necrosis and required open necrosectomy. Second patient had high grade liver trauma with right lobe hepatic necrosis. He developed sepsis and did not respond to antibiotics and percutaneous drainage. Finally, he required open debridement. Third and forth patients were post traumatic and had left portal vein branch and left hepatic artery -post traumatic thrombosis with devitalized segment II and III. Their triphasic CT Scans showed non-enhancing segment II and III. Subsequently both of them needed early curative debridement in form of left lateral segmentectomy. Fifth patient had blunt injury abdomen and presented late with sepsis. He had devitalised segment II and III with pancreatic neck transection and transverse colon crush injury. He required segment II-III resection with distal pancreatectomy and colectomy. Hepatic necrosis is common after high grade liver trauma and hepatic artery embolization. This complication can be safely managed with operative hepatic necrosectomy in conjunction with interventional procedures or with hepatic lobectomy.

Videoscope-assisted necrosectomy of left-sided infected pancreatic walled-off necrosis (WON): report of four patients

Videoscope-assisted debridement of infected pancreatic walled-off necrosis (WON) is a minimally invasive technique. We report four patients successfully treated with intraperitoneal or retroperitoneal videoscope-assisted debridement for left-sided infected WON. This is an original gasless technique, in contradistinction to videoscopic assisted retroperitoneal debridement (VARD). We defined predominant infected WON as right or left-sided according to the location on CT scan. In patients with predominantly left-sided WON consisting mostly of fluid, we perform endoscopic drainage up to three times. If there is mainly necrotic tissue, we perform videoscope-assisted necrosectomy as the first step. While planning the approach, we consider the distance from the skin to the WON and interposed organs. If expansion of the WON spreads to the omental bursa ventrally, we select an intraabdominal approach. If the necrosis spreads from the retroperitoneum anteriorly to the pararenal extraperitoneal space, debridement is performed retroperitoneally. In patients with predominately right-sided infected WON, we perform conventional open necrosectomy for safety. This new videoscope-assisted debridement is performed with a 5cm skin incision. A metallic tube (Ootsuki fukukyo tube (TKZ-F1338), Takasago Medical Industry, Tokyo, Japan) is initially placed from the skin to inside the WON. A flexible videoscope, suction, or laparoscopic forceps are easily inserted and removed through this tube under direct vision. This new technique allows adequate debridement in a safe manner without using CO2 insufflation. The postoperative course in all four patients was favorable after a single procedure.

Focused open necrosectomy in the treatment of necrotizing pancreatitis: a 12-year experience in a single institution

Focused open necrosectomy in the treatment of necrotizing pancreatitis: a 12-year experience in a single institution

Step-up minimally invasive approach for surgical treatment of infected walled-off pancreatic necrosis

In a 2010 randomized trial (the PANTER trial), a surgical step-up approach for infected necrotizing pancreatitis was found to reduce the composite endpoint of death or major complications compared with open necrosectomy; 35% of patients were successfully treated with simple catheter drainage only. There is concern, however, that minimally invasive treatment increases the need for reinterventions for residual peripancreatic necrotic collections and other complications during the long term. We therefore performed a long-term follow-up study.We reevaluated all the 73 patients (of the 88 patients randomly assigned to groups) who were still alive after the index admission, at a mean 86 months (±11 months) of follow-up. We collected data on all clinical and health care resource utilization endpoints through this follow-up period. The primary endpoint was death or major complications (the same as for the PANTER trial). We also measured exocrine insufficiency, quality of life (using the Short Form-36 and EuroQol 5 dimensions forms), and Izbicki pain scores.From index admission to long-term follow-up, 19 patients (44%) died or had major complications in the step-up group compared with 33 patients (73%) in the open-necrosectomy group (P = .005). Significantly lower proportions of patients in the step-up group had incisional hernias (23% vs 53%; P = .004), pancreatic exocrine insufficiency (29% vs 56%; P = .03), or endocrine insufficiency (40% vs 64%; P = .05). There were no significant differences between groups in proportions of patients requiring additional drainage procedures (11% vs 13%; P = .99) or pancreatic surgery (11% vs 5%; P = .43), or in recurrent acute pancreatitis, chronic pancreatitis, Izbicki pain scores, or medical costs. Quality of life increased during follow-up without a significant difference between groups.In an analysis of long-term outcomes of trial participants, we found the step-up approach for necrotizing pancreatitis to be superior to open necrosectomy, without increased risk of reinterventions.

Laparoscopic transgastric necrosectomy reduces re-intervention and morbidity compared to open necrosectomy

Background: Operative intervention for persistent or infected pancreatic necrosis is highly morbid. Recently, laparoscopic trans-gastric necrosectomy (LTGN) has emerged as an alternative to open necrosectomy (ON) in select patients. We sought to compare the two techniques in well-matched instances. Methods: Using an institutional database of 403 cases of pancreatitis requiring procedural intervention, we abstracted 30 cases of LTGN and matched them to 22 cases of open debridement. Cases were matched on the basis of age, gender, indication, confirmed pre-op infection, presence of SIRS at operation, multiple organ dysfunction score, and overall percent necrosis. We compared the groups for operative characteristics, number of procedures, and pancreatic fistula following debridement. Results: Fifty-two cases were included (LTGN = 30, ON = 22). There were no differences in the matched categories selected. Open drainage was associated with greater operative blood loss (median 500 cc [IQR: 212–1000] vs 25 cc [20–81] p < 0.001), transfusions (83% vs 17% p < 0.001), length of stay (15.5 d [8.5–28.5] vs 4.0 d [3.0–8.4] p < 0.001). No difference in hospital, 30 d or 90 d mortality were seen. Major complications were seen in 82% of ON vs 29% of LTGN (p = 0.001). ON was associated with increased number of total postoperative drainage interventions (1.5 [1.0–2.3] vs 1.0 [1.0–1.0] p = 0.003), increased rates of pancreatic fistula (36.4% vs 0%, p = 0.001), and total operations [1.8 [1.0–2.0] vs 1.0 [1.0–1.0] p = 0.001). There were no differences in rates of endocrine insufficiency, or development of hernia. Conclusion: Pancreatic necrosis remains a challenging clinical entity with a range of interventions available. Laparoscopic transgastric necrosectomy is a novel approach allowing for both durable drainage and definitive debridement that limits the morbidity of an open approach.