Pancreatic Necrosectomy Research Articles

Roux-en-Y drainage of a pancreatic fistula for disconnected pancreatic duct syndrome after acute necrotizing pancreatitis

BackgroundAfter acute necrotizing pancreatitis (ANP), a pancreatic fistula may occur from disconnected pancreatic duct syndrome (DPDS) where a segment of the pancreas is no longer in continuity with the main pancreatic duct. AimTo study the outcome of patients treated using Roux-Y pancreatic fistula tract-jejunostomy for DPDS after ANP. MethodsBetween 2002 and 2011, patients treated for DPDS in the setting of endoscopic retrograde cholangiopancreatography (ERCP) or magnetic resonance cholangiopanreatography (MRCP) documented main pancreatic duct disruption with Roux-Y pancreatic fistula tract-jejunostomy. ResultsIn all, seven patients with DPDS were treated. The median age was 62 years (range 49–78) and five were men. The cause of ANP was gallstones (2), alcohol (1), ERCP (1) and idiopathic (3). Pancreatic necrosectomy was done in six patients. Time from onset of pancreatitis to fistula drainage was 270 days (164–365). Pancreatic fistulae arose from DPDS in the head/neck (4) and body/tail (3). Patients had a median fistula output of 140ml (100–200) per day before surgery. The median operative time was 142min (75–367) and estimated blood loss was 150ml (25 to 500). Patients began an oral diet on post-operative day 4 (3–6) and were hospitalized for a median of 7 days (5–12). The median follow-up was 264 days (29–740). Subsequently, one patient required a distal pancreatectomy. After surgery, three patients required oral hypoglycaemics. No patient developed pancreatic exocrine insufficiency. ConclusionInternal surgical drainage using Roux-en-Y pancreatic fistula tract-jejunostomy is a safe and definitive treatment for patients with DPDS.

Case matched comparison study of the necrosectomy by retroperitoneal approach with transperitoneal approach for necrotizing pancreatitis in patients with CT severity score of 7 and above

BackgroundMinimally invasive necrosectomy through a retroperitoneal approach has shown promising results for the treatment of necrotizing pancreatitis. There is however, little evidence from comparative studies in favor of these techniques over laparotomy. AimTo perform a case matched comparison of patients with necrotizing pancreatitis who underwent necrosectomy by the retroperitoneal approach with transperitoneal approach, thus minimizing the risk of confounding and selection bias. MethodsBetween August 2008 and March 2011, 85 patients were admitted with pancreatic necrosis. Each of the 15 patients who underwent necrosectomy by retroperitoneal approach using a small flank incision (RP group) were compared with 15 of those treated with necrosectomy by transperitoneal approach (TP group). These patients were matched for the age (±10 years), status of infection, CT severity score (±2 points), preoperative organ failure and timing for surgery (±7 days). ResultsPostoperative complications occurred in 4 patients (26.6%) in the RP group and 8 (53.3%) in the TP group (p = 0.248). Reintervention, was required in 4 patients (26.6%) in the RP group and 7 (46.6%) in the TP group (p = 0.366). The median post operative ICU stay was 10 days in the RP group compared to 15 days in the TP group (p = 0.317). Median post operative hospital stay was 26 days in the RP group and 32 days in the TP group (p = 0.431). The total hospital stay among the survivors was 31 days in the RP group and 40 days in the TP group (p = 0.285). ConclusionsThe RP approach for pancreatic necrosectomy through a small flank incision was associated with less post operative morbidity compared to TP approach. The surgical outcomes in terms of post operative new onset organ failure and in hospital mortality were similar in both the groups, but the post op ICU/hospital stay and the total hospital stay was lower in the RP approach group. These results still requires to be confirmed by further randomized studies.

Laparoscopic Pancreatic Necrosectomy in a Child with Severe Acute Pancreatitis

Acute pancreatitis (AP) in children usually follows a mild course but occasionally may be severally problematic. We report the case of a 12-year-old boy with severe AP who was managed with repeated laparoscopic pancreatic necrosectomy. Three weeks later he represented with a pancreatic pseudocyst that was treated with endoscopic gastrocystotomy. His abdominal pain persisted and a subsequent magnetic resonance cholangiopancreatogram showed multiple gallbladder and common bile duct (CBD) stones that were missed on previous imaging investigations. He underwent laparoscopic cholecystectomy with transcystic exploration of the CBD. The patient is currently well, more than 2 years following the definitive corrective surgery. To the best of our knowledge, this is the first case of laparoscopic pancreatic necrosectomy in a child.

重症急性膵炎に対する開腹術後におけるドレナージの問題点 ―壊死性膵炎に対する積極的膵切除, Necrosectomy後のOpen Drainageを中心として―

重症急性膵炎に対する開腹術後におけるドレナージの問題点 ―壊死性膵炎に対する積極的膵切除, Necrosectomy後のOpen Drainageを中心として―

Role of Minimal Access Surgery in Management of Infective Pancreatic Necrosis

Aim: To study various minimal access surgical techniques of pancreatic debridement for infected pancreatic necrosis (IPN).Method: A review of literature is done using various search engines like Google, Yahoo, PubMed, etc. by using keywords: Pancreaticnecrosectomy, laparoscopic, endoscopic pancreatic necrosectomy.This article reviews various methods of minimally access pancreatic necrosectomy (MAN) can be classified by the type of scopeused flexible endoscope, laparoscope, nephroscope and the route of access transperitoneal, transgastric, retroperitoneal. Each of thescopes and access routes has its advantages and disadvantages.Result and conclusion: Only few large series of cases of MAN have been published, rest are limited to case reports. There are nocomparisons of results, either with open surgery or among different minimal access surgeries but a body of evidence now suggeststhat acceptable outcomes can be achieved and minimal access necrosectomy is technically feasible, well tolerated and beneficial forpatients when compared with open surgery.

Minimally Invasive Retroperitoneal Pancreatic Necrosectomy

Introduction: This article describes a case series outlining the experience and results of the retroperitoneal minimally invasive pancreatic necrosectomy (MIPN) procedure performed by, or done under the supervision of, a single surgeon. Methods: All data of the patients who underwent MIPN from 2006 to 2008 were entered into a prospectively maintained, computerized database. Results: A total of 93 MIPN procedures were performed on 32 patients. All patients had severe acute pancreatitis. The median number of MIPN procedures per patient was 3. Only 6 patients needed intensive care unit (ICU) admission after MIPN. There were 15 complications, which included bleeding requiring transfusion (n = 3), bowel fistulae (n = 7), thromboembolic events (n = 2) and acute myocardial infarction (n = 3). Four patients died after the procedure (13%); 1 died of ongoing multiorgan failure in spite of the MIPN. Four patients developed pancreatic pseudocysts within the follow-up period of 2 years. Three of these patients required intervention. Conclusion: This case series demonstrates that MIPN can be performed with acceptable morbidity and mortality and with good end results. The ICU dependency after the procedure is minimal. As seen in this series, multiple MIPNs may be needed to eradicate the necrosis satisfactorily.

Analysis of Residual Pancreatic Bed Necrosis Using Computed Tomography Following Minimally Invasive Necrosectomy

In a unit practicing minimally invasive pancreatic necrosectomy (MIPN), our aim was to assess whether tomographic residual necrotic volume was an objective indicator for repeat necrosectomy. Prospective study of acute pancreatitis admissions. Patients with infected pancreatic necrosis or deteriorating sepsis had MIPN. Outcome parameters included necrotic volumes, conversion rate, morbidity, and mortality. Thirty patients were admitted with acute pancreatitis of which 15 required organ support. Twenty-nine necrosectomy sessions were performed. Average time from admission to necrosectomy was 39.7 days with an internecrosectomy interval of 6 to 14 days. Mean reduction of necrosis volume was 89.5% and postnecrosectomy volumes were variable. Mean length of hospital and intensive care unit stay was 124.3 and 40.2 days, respectively. Complications included bleeding, pancreatic fistula, and gastric outlet obstruction. No in-hospital deaths or conversions occurred. Frequent MIPN achieves substantial pancreatic bed volume reduction with no conversions. Repetitive tomographic scanning is of limited use as an indicator for renecrosectomy.

Open Pancreatic Necrosectomy

Open Pancreatic Necrosectomy

Open Pancreatic Necrosectomy in the Multidisciplinary Management of Postinflammatory Necrosis

Open Pancreatic Necrosectomy in the Multidisciplinary Management of Postinflammatory Necrosis

Open Pancreatic Necrosectomy in the Multidisciplinary Management of Postinflammatory Necrosis

Brisinda, Giuseppe MD; Mazzari, Andrea MD; Crocco, Anna MD; Grossi, Ugo MD; Tomaiuolo, Pasquina MD; Vanella, Serafino MD Author Information

Laparoscopic-assisted management of severe necrotizing pancreatitis with obstructive jaundice: A case report

We report a severely infected necrotizing pancreatitis managed with hand-assisted laparoscopic necrosectomy along with a review of the relevant literature. Minimally invasive necrosectomy has been shown to be efficient and advantageous in managing necrotizing pancreatitis. Multiple techniques have been advocated over the last decade. Laparoscopic pancreatic debridement is a feasible option for some patients with necrotizing pancreatitis. We selected hand-assisted laparoscopic pancreatic necrosectomy, which has gained some favor over open necrosectomy because of the morbidity and mortality associated with laparotomy. We report on an Indian male patient who presented with acute abdomen and severe jaundice. A CT scan of the abdomen showed severe necrotizing pancreatitis. After conservative management failed, a hand-assisted laparoscopic pancreatic necrosectomy was performed. The patient recovered and was discharged 4 weeks after surgery.

Sa1477 Translumenal Access for Endoscopic Pancreatic Necrosectomy: the Safe Entrance for Necrosectomy Sans Electrocautery (SENSE) Technique

Then each slide was processed to be stained at the department of cytopathology and reviewed by cytopathologists to assess the specimen adequacy. Results: Seventy-eight specimens were collected from 33 patients. Aspirated lesions were as follows: 46 pancreas (59.0%), 14 intra-abdominal lymph nodes (17.9%), other intra-abdominal organ (17.9%) and mediastinal lymph node (5.1%). Of these, malignancies were 69.2%, borderline malignancies 3.8% and benign lesions 26.9%. The positive predictive value (PPV) of non-bloody white core for prediction of specimen adequacy was 95.2% and the PPV of bloody core with white spots was 100.0%. Among adequate sample slides, non-bloody white core was observed in 60.6% and bloody core with white spots were observed only in 28.8%. Combined criteria of non-bloody white core and bloody core with white spots, presence of white core/spots showed sufficient value of sensitivity (89.4%), specificity (83.3%) and PPV (96.7%) for predicting sample adequacy. Conclusions: sVisual assessment of specimen adequacy seems to be very useful during EUS-FNA. Presence of white core/spots showed very high PPV. By using morphologic criteria with high PPV, it may be possible to reduce the number of needle pass and procedural time in general fields of practice. In future, studies for decreasing interobserver variability should be followed.

Sp699 Pancreatic Necrosectomy via Percutaneous Self-Expandable Metal Stent Placement

gastric wall to adhere to the abdominal wall before proceeding with ERCP. At our institution we have developed a novel way of EUS guided, fluoroscopic assisted access of gastric remnant followed by sutured gastropexy and subsequent ERCP, all in one session. We describe a series of three such cases. Endoscopic methods: The echo-endoscope was inserted trans-orally and advanced to the gastric pouch or the Roux limb. The remnant stomach was identified using sonographic features and was punctured across the pouch or roux limb wall using a 19G needle pre-loaded with 0.025 guidewire. Radioopaque contrast injection and fluoroscopy were used to confirm needle position. After advancing guidewire the remnant stomach was maximally inflated with air injection through the needle and the best point of percutaneous entry on the abdominal wall was chosen. An 18-gauge introducer needle was inserted into the lumen of the gastric remnant and a 0.035 wire advanced. The wire track was serially dilated and a gastroscope inserted into the remnant. The gastric wall was now secured to the anterior abdominal wall using full thickness sutures. The gastroscope was removed and a 15mm laproscopy port inserted for duodenoscope access. Clinical implications: This novel, one setting minimally invasive approach allows access to remnant stomach and upper GI tract for the purposes of diagnostic and therapeutic endoscopy/ERCP. It allows the use of duodenoscope for difficult cannulation and precise therapeutic ERCP manouvers such as bliary and pancreatic sphioncterotomy. As the gastric wall is secured to anterior abdominal wall with full thickness sutures, one does not run into the risk of dehisence and intra-peritoneal leakage of gastric contents. The use of EUS to access gastric remnant and maximal insufflation alllows for identification of the best point of per cutaneous puncture for gastrostomy tube thus reducing post operative complications and pain. This technique allows the gastrostomy placement and ERCP to be done in the same setting thus reducing health care costs and patient visits.

A comparison of the hospital costs of open vs. minimally invasive surgical management of necrotizing pancreatitis

BackgroundInfected necrotizing pancreatitis is a major burden for both the patient and the health care system. Little is known about how hospital costs break down and how they may have shifted with the increasing use of minimally invasive techniques. The aim of this study was to analyse inpatient hospital costs associated with pancreatic necrosectomy. MethodsA prospective database was used to identify all patients who underwent an intervention for necrotizing pancreatitis. Costs of treatment were calculated using detailed information from the Decision Support Department. Costs for open and minimally invasive surgical modalities were compared. ResultsTwelve open and 13 minimally invasive necrosectomies were performed in a cohort of 577 patients presenting over a 50-month period. One patient in each group died in hospital. Overall median stay was 3.8 days in the intensive care unit (ICU) and 44 days on the ward. The median overall treatment cost was US$56674. The median largest contributors to this total were ward (26.3%), surgical personnel (22.3%) and ICU (17.0%) costs. These did not differ statistically between the two treatment modalities. ConclusionsPancreatic necrosectomy uses considerable health care resources. Minimally invasive techniques have not been shown to reduce costs. Any intervention that can reduce the length of hospital and, in particular, ICU stay by reducing the incidence of organ failure or by preventing secondary infection is likely to be cost-effective.

Minimally Invasive Approach to Pancreatic Necrosectomy

Conventional open surgery for infected pancreatic necrosis is associated with significant surgical morbidity, that is, wound complications, facial dehiscence, and intestinal fistulae. In recent years, there has been interest in attempting to reduce this surgical morbidity by adopting a number of minimally invasive approaches. Fifteen patients with pancreatic necrosis underwent pancreatic necrosectomy by minimally invasive surgery (11 men, 4 women; age group: 25-64 years, mean age: 46 years). Apache II scores ranged from 5 to 14. Pancreatic necrosectomy was performed by laparoscopic transperitoneal approach in 12 patients (transmesocolic, 4 patients; transgastrocolic, 6 patients; and gastrohepatic omentum, 2 patients), by retroperitoneal approach in 2 patients, and by a combination of methods in 1 patient (endoscopic transgastric drainage followed by laparoscopic intracavity necrosectomy). Relook laparoscopy was done in 5 patients to assess for residual necrosis. All the patients tolerated the procedure well, and there was no mortality. Two of them had pancreatic fistula, which eventually responded to conservative treatment. Three patients were converted to open necrosectomy because of bleeding or difficulty to access the area of necrosis. The mean operating time was 120 ± 10 minutes. There were no postoperative complications related to the procedure itself, such as major wound infections, intestinal fistulae, or postoperative hemorrhage. Postoperative computed tomographic scans confirmed adequacy of debridement. The average length of hospital stay after surgery was 14 days. Minimally invasive necrosectomy is technically feasible and a body of evidence now suggests that acceptable outcomes can be achieved. There are no comparisons of results available, either with open surgery or among different minimally invasive techniques.

Analysis of the delayed approach to the management of infected pancreatic necrosis

To analyze outcomes of delayed single-stage necrosectomy after early conservative management of patients with infected pancreatic necrosis (IPN) associated with severe acute pancreatitis (SAP). Between January 1998 and December 2009, data from patients with SAP who developed IPN and were managed by pancreatic necrosectomy were analyzed. Fifty-nine of 61 pancreatic necrosectomies were performed by open surgery and 2 laparoscopically. In 55 patients, single-stage necrosectomy could be performed (90.2%). Patients underwent surgery at a median of 29 d (range 13-46 d) after diagnosis of acute pancreatitis. Sepsis and multiple organ failure accounted for the 9.8% mortality rate. Pancreatic fistulae (50.8%) predominantly accounted for the morbidity. The median hospital stay was 23 d, and the median interval for return to regular activities was 110 d. This series supports the concept of delayed single-stage open pancreatic necrosectomy for IPN. Advances in critical care, antibiotics and interventional radiology have played complementary role in improving the outcomes.

Application of retroperitoneal pancreatic necrosectomy using percutaneous nephroscope

Objective Infected pancreatic necrosis is a serious complication of necrotizing pancreatitis. A method of minimally-invasive retroperitoneal infected pancreatic necrosectomy using percutaneous nephroscope was evaluated. Methods 21 patients with acute pancreatitis were treated in our hospital from June 2008 to August 2009. Among 13 patients who developed infected pancreatic necrosis, 6 underwent percutaneous catheter drainage by CT guidance. Then retroperitoneal infected pancreatic necrostectomy using percutaneous nephroscope along the sinus tract were performed after drainage for 5-36 d. Results In these 6 patients, 3 received percutaneous nephroscopic treatment one time, 2 two times and 1 three times. There were no operative mortality and morbidity except that 1 patient developed pseudocyst 6 months after operation. Conclusion Retroperitoneal pancreatic necrosectomy by percutaneous nephroscope is a safe, feasible, minimally-invasive and efficient method for treating infected pancreatic necrosis when the indication and occasion are suitable. This method would be a valid therapeutic option for treating necrotizing pancreatitis. However, further evaluation is necessary. Key words: Infected pancreatic necrosis; Percutaneous nephroscope; Retroperitoneal pancreatic necrosectomy

Retrospective Study: Surgical intervention in the management of severe acute pancreatitis in cats: 8 cases (2003–2007)

AbstractObjective – To evaluate clinical characteristics and outcomes of cats undergoing surgical intervention in the course of treatment for severe acute pancreatitis.Design – Retrospective observational study from 2003 to 2007 with a median follow‐up period of 2.2 years (range 11 d–5.4 y) postoperatively.Setting – Private referral veterinary center.Animals – Eight cats.Interventions – None.Measurements and Main Results – Quantitative data included preoperative physical and clinicopathologic values. Qualitative parameters included preoperative ultrasonographic interpretation, perioperative and intraoperative feeding tube placement, presence of free abdominal fluid, intraoperative closed suction abdominal drain placement, postoperative complications, microbiological culture, and histopathology. Common presenting clinical signs included lethargy, anorexia, and vomiting. Leukocytosis and hyponatremia were present in 5 of 8 cats. Hypokalemia, increased total bilirubin, and hyperglycemia were present in 6 of 8 cats. Elevated alanine aminotransferase and aspartate transferase were present in all cats. Surgery for extrahepatic biliary obstruction was performed in 6 cats, pancreatic abscess in 3 cats, and pancreatic necrosis in 1 cat. Six of the 8 cats survived. Five of the 6 cats that underwent surgery for extrahepatic biliary obstruction and 1 cat that underwent pancreatic necrosectomy survived. All 5 of the cats with extrahepatic biliary obstruction secondary to pancreatitis survived. The 2 nonsurvivors included a cat with a pancreatic abscess and a cat with severe pancreatitis and extrahepatic biliary obstruction secondary to a mass at the gastroduodenal junction. Postoperative complications included progression of diabetes mellitus, septic peritonitis, local gastrostomy tube stoma inflammation, local gastrostomy tube stoma infection, and mild dermal suture reaction.Conclusion – Cats with severe acute pancreatitis and concomitant extrahepatic biliary obstruction, pancreatic necrosis, or pancreatic abscesses may benefit from surgical intervention. Cats with extrahepatic biliary obstruction secondary to severe acute pancreatitis may have a good prognosis.

Open Pancreatic Necrosectomy in the Multidisciplinary Management of Postinflammatory Necrosis

To examine clinical outcome in a consecutive cohort of patients undergoing open necrosectomy for postinflammatory necrosis. The last decade has witnessed major developments in the surgical management of pancreatic necrosis. Minimally invasive approaches have become established. However, there are limited data from contemporary open necrosectomy, in particular where multidisciplinary care and aggressive interventional radiology are used. This report provides data on outcome from open necrosectomy in a tertiary referral Hepatobiliary unit over the last decade. During the period January 1, 2000 to July 31, 2008, 1535 patients were admitted with a final discharge code of acute pancreatitis. Twenty-eight (1.8%) of all admissions underwent open surgical necrosectomy. Twenty-four (86%) were tertiary referral patients. The median APACHE II score on admission was 10.5 (5-26). Median logistic organ dysfunction score on admission was 3 (0-10). Median LODS score after surgery was 2 (0-8). Twenty patients (71%) underwent radiologically guided drainage of collections before surgery. Thirty-day mortality occurred in 2 (7%), 4 further deaths occurred in patients after discharge from intensive care resulting in a total of 6 (22%) episode-related deaths. Modern open necrosectomy can be performed without the procedure-related deterioration in organ dysfunction associated with major debridement. Multidisciplinary care with an emphasis on aggressive radiologic intervention before and after surgery results in acceptable outcomes in this cohort of critically ill patients. Newer laparoscopic techniques must demonstrate similar outcomes in the setting of stage-matched severity before wider acceptance.

VHM08: Endoscopic Treatment of Acute Arterial Bleeding During Pancreatic Necrosectomy

VHM08: Endoscopic Treatment of Acute Arterial Bleeding During Pancreatic Necrosectomy