Open Pancreatic Necrosectomy Research Articles

Iatrogenic transmesenteric defect mimicking a Petersen’s space hernia after open pancreatic necrosectomy

Abstract Complications of acute pancreatitis can be disastrous if appropriate treatment is not initiated. Pancreatic necrosis can occur without the presence of symptoms; however, in some cases, it can be accompanied by organic failure, abscess, pseudocyst, fistulas, and pancreatic exocrine disfunction. The surgical treatment of pancreatic necrosis can be managed with open surgical debridement of necrotic tissue. Hence, complications after surgery can appear even in patients without clinical background; complications mostly appear if the surgical technique is not done properly. We present a case of a 47-year-old woman who appeared with abdominal pain, nausea, vomiting, and oral intake intolerance. Symptoms were present for 1 week; she was admitted to the nearest clinic, and surgical management was offered. The patient went to an open pancreatic necrosectomy; however, she presented purulent exudate from the surgical wound and drains. Was referred to our center; on abdominal contrasted computed tomography, a transmesenteric defect and cutaneous-pancreatic fistula were found.

Pancreatic necrosis: a scoping review.

Acute pancreatitis (AP) is a commonly encountered GI diagnosis, accounting for 275,000 hospital admissions annually in the United States alone. Pancreatic necrosis (PN) is the most common complication of AP, and the development of PN is associated with significant morbidity and increased mortality. This expert review evaluates the evidence-based management of symptomatic PN from the era of maximal open pancreatic necrosectomy in the late 1990s though the modern paradigm of minimally invasive and endoscopic interventions. The authors present the retrospective and controlled data behind the "step-up approach" to PN treatment and discuss the application of current society guidance. Evidence based management of PN is characterized by early supportive care, and treatment by minimally invasive intervention when a patient is critically ill or persistently symptomatic. Appropriate choices when intervention is required include percutaneous drainage, minimally invasive surgery, and/or endoscopic treatment. The transition from open maximal necrosectomy to minimally invasive intervention has resulted in improved outcomes for patients, including gains in mortality, significant morbidity, and cost. The ideal precision management strategy for an individual patient remains an area of increasing understanding.

Is Contemporary Open Pancreatic Necrosectomy Still Useful In The Minimally Invasive Era?

BackgroundPrevious studies have shown that open pancreatic necrosectomy for infected pancreatic necrosis was associated with high morbidity and mortality. However, these results were mostly concluded from historical cohorts with traditional early necrosectomy in the absence of a minimally invasive step-up approach. ObjectiveTo explore the value of contemporary open pancreatic necrosectomy for infected pancreatic necrosis in the minimally invasive era. MethodsA post hoc analysis was performed in a prospective maintained database of 320 patients with infected pancreatic necrosis from January 2011 to December 2022 at a large Chinese tertiary hospital. ResultsA total of 320 patients with infected pancreatic necrosis received either a minimally invasive step-up approach (245, 76.6%) or open pancreatic necrosectomy (75, 23.4%), which included upfront open pancreatic necrosectomy (32, 10.0%) and salvage open pancreatic necrosectomy (43, 13.4%). Upfront open pancreatic necrosectomy was associated with similar morbidity and mortality rates but fewer surgical interventions compared with a minimally invasive step-up approach. However, salvage open pancreatic necrosectomy was associated with significantly higher mortality (48.8% vs 18.8%, P = .007), gastrointestinal fistula (44.2% vs 18.8%, P = .021), hemorrhage (48.8% vs 15.6%, P = .003), and intensive care unit stay (25 vs 7 days, P = .040) compared with upfront open pancreatic necrosectomy. Multivariate analysis suggested that multiple organ failure (hazard ratio = 5.1; 95% confidence interval, 1.4–18.2, P = .013) and synchronous critical acute pancreatitis (hazard ratio = 3.0; 95% confidence interval, 1.1–8.6, P = .040) were 2 independent risk factors of death for patients who received open pancreatic necrosectomy. ConclusionPatients undergoing upfront open pancreatic necrosectomy received fewer surgical interventions with comparable efficacy compared to the minimally invasive step-up approach. Salvage open pancreatic necrosectomy was potentially lifesaving, though it carried high morbidity and mortality. Multiple organ failure and synchronous critical acute pancreatitis were 2 independent risk factors of death for patients who received open pancreatic necrosectomy.

A Risk Score for Predicting the Necessity of Surgical Necrosectomy in the Treatment of Infected Necrotizing Pancreatitis

BackgroundFor infected necrotizing pancreatitis (INP), percutaneous catheter drainage (PCD) is now widely acknowledged as the initial intervention in a step-up approach, followed, if necessary, by minimally invasive necrosectomy or even open pancreatic necrosectomy. However, an overemphasis on PCD may cause a patient’s condition to deteriorate, leading to missed surgical opportunities or even death. This study aimed to develop a simple and convenient scoring tool for assessing the need for surgery in INP patients who received PCD procedures. MethodsIn an observational study conducted between April 2015 and December 2020, PCD was utilized as the initial step to treat 143 consecutive INP patients. A surgical necrosectomy was performed when the patient failed to respond. Risk factors of PCD failure (i.e., need for surgical necrosectomy) were identified by multivariate logistic regression models. An integer-based risk scoring tool was developed using the β coefficients derived from the logistic regression model. ResultsIn 62 (43.4%) patients, PCD was successful, while the remaining 81 (56.6%) individuals required subsequent surgical necrosectomy. In the multivariate model, organ failure, percentage of pancreatic necrosis, extrapancreatic necrosis volume, and mean CT density of extrapancreatic necrosis volume were associated with a need for surgical necrosectomy. A predictive scoring tool based on these four factors demonstrated an area under the receiver operating characteristic curve (AUC) of 0.893. Under the scoring tool, a total score of 4 or more indicates a high possibility of surgical necrosectomy being required (at least 80%). Using the coordinates of the receiver operating characteristic curve (ROC), the sensitivity and specificity at this threshold are 0.802 and 0.903, respectively. ConclusionsA risk score model integrating organ failure, percentage of pancreatic necrosis, extrapancreatic necrosis volume, and mean CT density of extrapancreatic necrosis volume can identify INP patients at high risk for necrosectomy. The straightforward risk assessment tool assists clinicians in stratifying INP patients and making more judicious medical decisions.

Post-Discharge Outcomes After Pancreatic Necrosectomy: A Single Institution Experience Following Endoscopic vs Open Debridement.

Pancreatic necrosectomy outcomes have been studied extensively; however, long-term results of these procedures have not been well characterized. Our study aimed to assess the outcomes at and after discharge for patients following necrosectomy. Data from patients undergoing pancreatic necrosectomy at a single tertiary referral hospital from January 1, 2007, to June 1, 2019 were retrospectively analyzed. Patients were stratified into an open pancreatic necrosectomy (OPN) and an endoscopic pancreatic necrosectomy (EPN) group. Cohorts were composed of an OPN (n = 30) and EPN (n = 31) groups with a mean follow-up of 22 and 13.5months, respectively. There was no statistically significant difference in the demographics or etiology of disease; however, the presence of severe sepsis and elevated BISAP scores was significantly higher in the OPN group (40% vs 13% p = .016, 37% vs 10% p = .012, respectively). There was no significant difference in discharge parameters or disposition other than a higher need for wound care in the OPN group (14% vs 0% p =< .0001). No significant difference in the number of patients who returned to baseline, 12-month ED visits, 12-month readmissions, medical comorbidities, or long-term survival was noted. Previous studies have demonstrated that OPN patients have a higher severity of disease and higher inpatient mortality; however, this does not hold true once the acute phase of the illness has passed. Long-term medical comorbidities and survival of patients with necrotizing pancreatitis who endure the primary insult do not differ in long term, regardless of the debridement modality performed for source control.

Cost analysis and outcomes of endoscopic, minimal access and open pancreatic necrosectomy.

Objectives:To assess both individual patient and institutional costs as well as outcomes in patients with pancreatic necrosis who underwent either endoscopic, minimal access or open pancreatic necrosectomy. These data can be used to evaluate clinical effectiveness with a view to informing local healthcare providers.Background:Intervention for infected pancreatic necrosis is associated with a high morbidity, mortality, and long hospital stays. Minimal access surgical step-up approaches have been the gold standard of care; however, endoscopic approaches are now offered preferentially.Methods:All patients undergoing endoscopic (EN), minimal access retroperitoneal (MARPN), and open (OPN) necrosectomy at a single institution from April 2015 to March 2017 were included. Patients were selected for intervention based on morphology and position of the necrosis and on clinical factors. Patient-level costing systems were used to determine inpatient and outpatient costs.Results:Eighty-six patients were included: 38 underwent EN, 35 MARPN, and 13 OPN. Preoperative APACHEII was 6 versus 9 versus 9 (P = 0.017) and CRP 107 versus 204 versus 278 (P = 0.012), respectively. Postoperative stay was 19 days for EN versus 41 for MARPN versus 42 for OPN (P = 0.007). Complications occurred in 68.4%, 68.6%, and 46.2% (P = 0.298), whereas mortality was 10.5%, 22.9%, and 15.4% (P = 0.379), respectively. Mean total cost was £31,364 for EN, £52,770 for MARPN (P = 0.008), and £60,346 for OPN. Ward and critical care costs for EN were lower than for MARPN (ward: £9430 vs £14,033, P = 0.024; critical care: £5317 vs £16,648, P = 0.056).Conclusions:EN was at least as safe and effective as MARPN and OPN and was associated with markedly reduced hospital stay and cost, although some markers of disease severity were higher in patients undergoing MARPN and OPN. These results support EN as the preferred approach to necrosectomy, but hybrid utilization of all available techniques remains integral to optimal outcomes.

Establishing a new pancreatic surgery program in the community setting (our open and robotic experience)

Presenter: Jane Han MD | St. Elizabeth Youngstown Hospital Background: The hepato-pancreato-biliary (HPB) subspecialty has predominantly been centered around large academic centers. We believe expansion into the community setting is possible with equivalent surgical outcomes. Methods: This is a single institution, single surgeon, ongoing prospective study from February 2017 up to March 2020. The pancreatic program was started in a Level 1 trauma community teaching hospital with 305 acute care beds located 70 miles from four major academic institutions with established HPB programs. Total open and robotic pancreatic cases were assessed with all robotic cases performed on the DaVinci Xi platform. All patients were placed on an enhanced recovery after surgery protocol. Outcomes measured were R1 resections, reoperations, biochemical pancreatic leaks, post operative pancreatic fistulas (POPF), bile leak, surgical site infections (SSI), delayed gastric emptying (DGE), Clavien-Dindo grade III-IV complications, length of stay (LOS), hospital readmissions, and 30 and 90 day mortalities respectively. Results: Prior to February 2017, our institution had low to no volume in pancreatic surgeries. Since the HPB program was started, 64 patients have undergone pancreatic surgery with zero 90-day mortalities. The 38 pancreaticoduodenectomies (PD) were all performed open. Of the 16 distal pancreatectomy with splenectomies (DPS) performed, 5 were open and 11 were robotic. There were 7 robotic transgastric pancreatic necrosectomy with cyst gastrostomies (PNCG), all performed between March 2019 to March 2020, and 1 open pancreatic necrosectomy with Roux-en-Y cyst jejunostomy. Additionally, 1 duodenum-preserving pancreatic head resection and 1 total pancreatectomy were performed. Of our PD patients, 13% had an R1 resection, 5% required reoperation, 11% had a biochemical pancreatic leak with 5% progressing to POPF, none had a bile leak, 5% developed an SSI, 26% had DGE, 13% had a Clavien-Dindo grade III-IV complication, their mean LOS was 8 days, 21% had a readmission, and none had a 30 or 90 day mortality. Positive correlations were found with POPF and SSI (p=0.0036), POPF and DGE (p=0.0346), and DGE and LOS (p=0.0345); however, POPF was not related to LOS (p=0.1653). SSI, biochemical pancreatic leak, POPF, and Clavien-Dindo grade III-IV were associated with readmissions (p=0.0049, 0.0051, 0.0049, and 0.0005, respectively). The mean operative time was 444 minutes with an estimated blood loss (EBL) of 697 ± 546 mL. Our DPS patients had a biochemical leak rate of 31%, a mean LOS of 6 days, and a 13% readmission rate. There were zero instances of R1 resection (all were R0), reoperation, POPF, SSI, DGE, or Clavien-Dindo grade III-IV complication. The mean operative time was 286 minutes with an EBL of 306 mL. Among robotic PNCG patients, there were no accounts of reoperation, biochemical pancreatic leak, POPF, SSI, or DGE. There was one Clavien-Dindo grade III-IV complication which resulted in a readmission. The mean operative time was 190 minutes with an EBL of 40 mL. Conclusion: Establishing a quality pancreatic surgery program in a community teaching hospital is feasible as long as outcomes reflect those seen nationally.

Primary Emphysematous Pancreatitis Caused by Clostridium Perfringens Infection

A 66-year-old male was admitted to a close hospital for acute pancreatitis. 48h hours after developed clinical worsening. Therefore, a CT scan was performed showing signs of Emphysematous Severe Acute Pancreatitis. A transfer to our hospital was granted, being admitted to the ICU. A follow-up CT scan was performed, showing an increase in the size of abdominal collections and pneumoretroperitoneum. For this reason, an open pancreatic necrosectomy was performed. However, the patient showed an overall excellent response allowing for weaning and extubation. 15 days after the surgery, bleeding from the abdominal wall is detected. A CT scan was performed showing epigastric artery bleeding. After infructuous endovascular embolization, a surgery was required. During the stay in the ICU the patient suffered through diverse nosocomial infections by multiresistant bacteria. The patient’s condition worsened. Due to an absence in response to therapy, the patient died 58 days after being admitted to the hospital. Discussion: Clostridium’s perfringens necrotizing acute pancreatitis is a rare condition that can usually be suspected by the presence of gas around the pancreas and characteristically pneumoretroperitoneum. Its origin is usually linked to invasive procedures of the bile duct. It can also appear on collections or necrotic tissue related to previous acute pancreatitis or chronic pancreatitis. Conclusion: The Clostridium perfringens confers a raise in morbidity and mortality in spite of optimal treatment decisions. Therefore, an early diagnosis and admission to ICUs, as well as an early appliance of surgical measures, might lower the chances of adverse outcomes.

Four-steps surgery for infected pancreatic necrosis based on "Step-up" strategy: a retrospective study

Objective: To examine the effect of the "four-steps" treatment on infectious pancreatic necrosis(IPN). Methods: The data of 207 patients who were diagnosed with IPN from January 2013 to December 2017 at Department of Pancreaticobiliary Surgery, the First Affiliated Hospital of Harbin Medical University were analyzed retrospectively. Among 207 patients, 132(63.8%) were males and 75(36.2%) were females. The median age was 45 years old (range: 19 to 80 years old). One hundred and fifty-eight patients(76.3%) suffered severe acute pancreatitis and 49 patients(23.7%) suffered moderately severe acute pancreatitis. Percutaneous catheter drainage(PCD) was performed on all the patients(Step 1). Patients received "four-steps" minimally invasive treatment strategy in step-up group(173 patients). The following steps after PCD were mini-incision access pancreatic necrosectomy(MIAPN) (Step 2), sinus tract endoscopic debridement and(or) PCD for residual infections(Step 3) and finally conventional open pancreatic necrosectomy(OPN) (Step 4). Patients(34 cases) received conventional open pancreatic necrosectomy after invalided PCD in OPN group. The perioperative parameters and prognosis were compared between Step-up group and OPN group. Normally distributed quantitative variables were analyzed by t-test, non-normally distributed quantitative variables were analyzed by Wilcoxon chi-square test and categorical variables were analyzed by χ(2) test or Fisher exact test, respectively. Results: The basic characteristics of the two groups of patients were similar, but the referral rate of patients and the rate of preoperative 3 days organ failure in the OPN group were significantly higher than those of step-up group patients(47.1% vs. 28.9%, χ(2)=4.313, P=0.038; 26.5% vs. 9.2%, χ(2)=2.819, P=0.011). The frequency of PCD and the number of PCD tube (root) were less than those in the step-up group(1(1) vs. 2(1), Z=-3.373, P=0.018; 2(1) vs. 3(2), Z=-2.208, P=0.027). Compared with the OPN group, the interval time from onset to surgery and the MIAPN operation time were significantly shorter in the step-up group(29(15) days vs. 36(17)days, Z=-0.567, P=0.008; 58(27)minutes vs. 90(56)minutes, Z=-3.908, P<0.01); postoperative mortality was lower(5.8% vs.17.6%, χ(2)=4.070, P=0.044); the overall incidence of postoperative complications was reduced(23.1% vs. 55.9%, χ(2)=14.960, P<0.01) and the incidence of new-onset organ failure was decreased after operation in the step-up group(37.5% vs.47.4%, χ(2)=7.133, P=0.007). The incidence of local abdominal complications (pancreatic fistula, intra-abdominal hemorrhage, gastrointestinal fistula) showed no significant difference between the two groups (P>0.05). Fewer patients required ICU treatment after operation in the step-up group compared with OPN group(22.0% vs. 44.1%, χ(2)=6.204, P=0.013). Patients in the Step-up group has shorter hospital stay than patients in OPN group (46(13) days vs. 52(13)days, Z=-1.993, P=0.046). Conclusions: The clinical effects of "four-steps" exhibited the superiority of minimally invasive treatment of IPN.And MIAPN is a simple, safe and effective procedure to remove pancreatic necrotic tissue and decrease complications.

Open Pancreatic Necrosectomy Is Still Safe and Effective Treatment for Pancreatic Necrosis Managed by Step-Up Approach

Open Pancreatic Necrosectomy Is Still Safe and Effective Treatment for Pancreatic Necrosis Managed by Step-Up Approach

Gender Differences in Gastrointestinal, Hepatobiliary and Pancreatic Surgery and Perceived Relevance on Outcomes &amp;lt;br/&amp;gt;—A Single Center 22-Year Observational Study in India (1996-2018)

Introduction: Gender differences are still quite prevalent in the present time. Although there is literature regarding gender differences in healthcare expenditure in India, there is no data regarding gender differences in hospital stay, hospital seeking behaviors and mortality. Aim: To evaluate the Gender differences in a hospital seeking behavior, mortality and hospital stay. Methods: We prospectively analyzed, from a retrospective database, all patients who underwent surgical gastrointestinal, hepato-biliary, pancreatic and splenic surgeries from 1996 to 2018 in our unit. Patients were divided into groups based on gender, admission time period and priority of admission i.e., elective or emergency. Both the gender groups were compared with respect to total procedures done, hospital stay and mortality. Organ specific mortality was calculated as proportions, was analyzed and compared between the groups. Time trends of the same were observed and compared. Results: Of 12,411 patients, 7979 (64.3%) were males and 4432 (35.7%) were females. 9191 (74.1%) patients underwent elective procedures whereas 3220 (25.9%) had emergency procedures (p ≤ 0.001). Overall mortality was higher in males (n = 473, 5.92%) in comparison to females (n = 185, 4.17%) (p ≤ 0.001). Majority of surgeries in males were of small intestine (22.5%) in which small bowel resection was most commonly done (5.4%), whereas, gallbladder and biliary surgeries (27.4%) were the most common in females in which laparoscopic cholecystectomy was most commonly done (5.8%). Median hospital stay was higher in males (10 days vs 9 days), (p ≤ 0.001). Mortality was higher in females in all organ categories except in liver (6.34% vs 2.7%), pancreas (37.3% Vs 18.3%) and spleen (3.38% Vs 1.62%) where mortality was higher for male gender. Highest mortality for females was in small intestinal surgery (34%) and for males, it was pancreatic surgery (37.3%). Highest mortality in males was emergency open pancreatic necrosectomy (21.6%) and that in females was emergency small intestinal surgery (11.9%). Although the number of surgeries in females increased over time (380 in 1996-1999 Vs 951 in 2016-2018), the proportion remained constant (36.3% Vs 38.3% in 1996-1999 and 2016-2018 respectively). Conclusion: We conclude that mortality is found to be higher in males after gastrointestinal surgery, which may be explained by the fact that hospital seeking behavior is more in males though it is fairly increasing in females in the recent years.

Outcomes of Endoscopic and Surgical Pancreatic Necrosectomy: A Single Institution Experience

Pancreatic necrosis can be managed conservatively; however, infection of pancreatic necrosis usually dictates more aggressive management. Our study aimed to assess the outcomes of open pancreatic necrosectomy (OPN) and endoscopic pancreatic necrosectomy (EPN) in a single center. Data from patients undergoing pancreatic necrosectomy at the Geisinger Medical Center from January 1, 2007, to April 25, 2016, were collected and retrospectively analyzed. Cohorts were composed of EPN (n = 22) and OPN (n = 34) groups. The prevalence of preoperative respiratory failure, septic shock, and multiorgan dysfunction syndrome was higher in the OPN group. The OPN group presented with a higher Bedside Index Severity in Acute Pancreatitis score. Postoperative abscess, persistent kidney dysfunction, and death were more frequent in the OPN group. The EPN group had a higher readmission rate. The results of the univariate analysis for complication and mortality demonstrated that higher mortality and persistent kidney dysfunction were associated with the procedure type, specifically OPN and with a higher Bedside Index Severity in Acute Pancreatitis score. Patients who presented with higher severity of disease underwent an OPN, whereas EPN often was performed successfully in a more benign clinical setting. However, patients with infected necrosis are served best in a tertiary medical facility where multiple treatment modalities are available.

Terapia de presión negativa combinada con tracción fascial mediante malla en el tratamiento de la necrosis pancreática infectada. Una nueva opción terapéutica

Acute pancreatitis represents one of the most frequent digestive pathologies worldwide, which can be complicated as an infected necrotizing acute pancreatitis, that may require treatment with necrosectomy and open abdomen with the risk that this leads to the appearance of intestinal fistula and giant incisional hernias difficult to manage. A 35-year-old woman underwent laparoscopic cholecystectomy for acute cholecystitis, which was re-admitted due to jaundice and abdominal pain 3 days after her hospital discharge. Diagnostic laparoscopy is performed, where a 3200 cc biliperitoneum secondary to a cystic duct stump leak is located and drained. Likewise, an endoscopic retrograde cholangiopancreatography (ERCP) is performed, with extraction of an impacted bile gallstone in the distal common bile duct. It presents as a complication of the procedure an acute post-ERCP pancreatitis with infected pancreatic necrosis. Open pancreatic necrosectomy was performed with a negative pressure therapy and mesh-mediated fascial traction, achieving resolution of the infectious condition with definitive closure of the abdominal cavity without incisional hernia or postoperative intestinal fistula. Patients with complicated acute pancreatitis with infected pancreatic necrosis represent a challenge in their treatment due to the serious nature of the condition and the morbidity associated with it. A therapeutic option is presented with the combined use of negative pressure therapy (ABThera™) and mesh-mediated fascial traction. With this report we propose a potential line of research to determine its role in the treatment of these patients, as well as their possible advantages and complications.

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

AB001. 216. Pancreatic necrosectomy: a revised role in clinical practice

: The role of pancreatic necrosectomy has been revised substantially over the last two decades. While previously widely employed in the management of infected pancreatic necrosis, current practice emphasises the use of radiologically placed drains in the ‘Step-up’ approach as outlined in the PANTER trial. Pancreatic necrosectomy is still a viable treatment option in patients who fail to progress in spite of radiological management. We will present the case report of a 56-year-old gentleman admitted with alcohol induced pancreatitis who subsequently developed infected pancreatic necrosis. The patient was initially managed with the ‘step-up’ approach of radiological drainage, with frequent drain upsizing over the course of 3 weeks. In spite of this, adequate source control was not achieved, and the decision was made to progress to pancreatic necrosectomy. A good clinical outcome was achieved. With the aid of intra-operative video, the revised indications and process of open pancreatic necrosectomy will be outlined. The current literature will be discussed. Selective pancreatic necrosectomy remains an effective procedure in a small group of patients with infected pancreatic necrosis, who fail to progress in spite of optimum radiological management.

Comparison of open pancreatic necrosectomy with step-up minimally invasive approach as surgical treatment of patients with acute necrotizing pancreatitis

Background: Recent experimental and clinical researches improves our understanding of natural course of acute necrotizing pancreatitis and mechanisms of its complications development. Today there are no disagreements on the issue of timing and main indications for surgery of ANP, but different surgical approaches still exist.Methods: The analysis of treatment of 226 patients with acute necrotizing pancreatitis has been performed. The study group included 116 patients in whom consequently diapeutic methods, endoscopic and lumbotomic video-controlled pancreatic necrsequesterectomy, minilaparo and lumbotomy, in case of their insufficiency- “open” interventions on pancreas were applied. In 110 persons of the control group traditional surgical tactic with application of laparotomic procedures was used.Results: Sequential (step-up) implementation of mini-invasive surgery allowed to reduce the number of open wide operations by 3.4 times (p &lt;0,05) and to postpone their performance: 85% of operations in the study group were performed after 4 weeks of the disease onset, in the control group only 33% (p &lt;0,05). Compared with the control group the level of the first diagnosed OF after the surgery was significantly lower in patients undergoing preliminary mini-invasive surgery (12.5% versus 28.2%, p &lt;0.05), the number of patients requiring prolonged intensive care after the surgery was significantly lower (17.5% versus. 38.2%, p &lt;0.05). 4 patients of the study group died (versus 26 in the control group р&lt;0,05).Conclusions: Application of step-up individualized approach in patients with acute necrotizing pancreatitis ensures a decrease in the number of laparotomic pancreatic necrosectomies and allows to postpone "open" operations for the period after the 4th week of disease onset which is accompanied by reduction of the incidence of postoperative organ failure and mortality.

Outcomes From Minimal Access Retroperitoneal and Open Pancreatic Necrosectomy in 394 Patients With Necrotizing Pancreatitis.

To examine the outcomes from minimal access retroperitoneal pancreatic necrosectomy (MARPN) and open pancreatic necrosectomy (OPN) for severe necrotizing pancreatitis in a single center. The optimal management of severe pancreatic necrosis is evolving with a few large center single series. Between 1997 and 2013, patients with necrotizing pancreatitis at the Liverpool Pancreas Center were reviewed. Outcome measures were retrospectively analyzed by intention to treat. There were 394 patients who had either MARPN (274, 69.5%) or OPN (120, 30.5%). Complications occurred in 174 MARPN patients (63.5%) and 98 (81.7%) OPN patients (P < 0.001). OPN was associated with increased postoperative multiorgan failure [42 (35%) vs 56 (20.4%), P = 0.001] and median (inter-quartile range) Acute Physiology and Chronic Health Evaluation II score 9 (6-11.5) vs 8 (5-11), P < 0.001] with intensive care required less frequently in MARPN patients [40.9% (112) vs 75% (90), P < 0.001]. The mortality rate was 42 (15.3%) in MARPNs and 28 (23.3%) in OPNs (P = 0.064). Both the mortality and the overall complication rates decreased between 1997-2008 and 2008-2013 [49 (23.8%) vs 21 (11.2%) P = 0.001, respectively; and 151 (73.3%) vs 121 (64.4%), P = 0.080, respectively). Increased mortality was independently associated with age (P < 0.001), preoperative intensive care stay (P = 0.014), and multiple organ failure (P < 0.001); operation before 2008 (P < 0.001) and conversion to OPN (P = 0.035). MARPN independently reduced mortality odds risk (odds ratio = 0.27; 95% confidence interval = 0.12-0.57; P < 0.001). Increasing experience and advances in perioperative care have led to improvement in outcomes. The role of MARPN in reducing complications and deaths within a multimodality approach remains substantial and should be used initially if feasible.

Open pancreatic necrosectomy – A six year experience from a DGH

Open pancreatic necrosectomy – A six year experience from a DGH

Improved outcomes following minimal access vs open pancreatic necrosectomy in 394 patients with severe necrotizing pancreatitis. Comparison of two time periods

s / Pancreatology 15 (2015) S1eS141 S59 Aims: The authors present their results of surgical treatment in patients with extended WOPN. Patients&methods: 17 patients (11 male, 6 female with a mean age of 57 years) were operated with extended WOPN. The intervention was prolonged with conservative treatment and percutaneous drainage. The mean time of surgery was 13,6 weeks after the onset of the disease. Ten open necrosectomy with closed bursa drainage and 7 transgastric necrosectomy were performed. Results: There were no intraoperative complications. After open necrosectomy bile leakage developed in one patient (10%) that didn’t required reoperation. In another patient repeated necrosectomy was necessary two times. Because of pseudocyst Juras operation was performed later in three cases (30%). One 74 years old patient died because of cardiac failure. In patients with transgastric necrosectomy no reoperation and mortality occured. In one patient endoscopic lavage was needed two times after the operation. The mean mortality rate was 5,9%. Conclusion: In case of extended WOPN surgery is safe and effective. Because of the lower rate of early and late complications the transgastric approach is suggested.

Five-Year Cohort Study of Open Pancreatic Necrosectomy for Necotizing Pancreatitis Suggests It Is a Safe and Effective Operation

IntroductionDespite advances in the management of necrotizing pancreatitis, open necrosectomy remains an important management option for necrotizing pancreatitis, and patients undergoing necrosectomy suffer significant morbidity and mortality. The aim of this study was to report the outcomes of open necrosectomy from a recent large cohort of patients with necrotizing pancreatitis. MethodsData are reported from a cohort of 276 consecutive patients with necrotizing pancreatitis who underwent open surgical debridement. Nutritional status, nutritional methods, bleeding, infection, demarcation of necrotic tissues, and time from onset of disease were scored. Scores ≥ 10 were considered as an indication for debridement. ResultsOne hundred sixty-two (58.7 %) and 52 (18.8 %) patients underwent minimally invasive peritoneal and retroperitoneal drainage, respectively, before necrosectomy. Median delay from disease onset to debridement was 48 days. Fifty-five patients (19.9 %) underwent more than one operation; 352 operations were performed in total. There were 17 deaths (6.2 %) postoperatively. ConclusionThis study demonstrated the results for open debridement in a recent large cohort of patients. Although minimally invasive necrosectomy has been developed in recent years, open necrosectomy remains an important approach for the debridement of necrotizing pancreatitis effectively and safely.