The Management of Acute The Management of Acute Necrotizing PancreatitisNecrotizing Pancreatitis

Stephanie Cheung Hay ManStephanie Cheung Hay ManCaritas Medical CentreCaritas Medical Centre

25th July 2009 25th July 2009 Joint Hospital Grand RoundJoint Hospital Grand Round

IntroductionIntroduction

Severe pancreatitis occurs in 15-20% Severe pancreatitis occurs in 15-20% of patients with acute pancreatitisof patients with acute pancreatitis

The degree of necrosis and the The degree of necrosis and the presence of infection are crucial presence of infection are crucial determinants of overall outcome determinants of overall outcome

Patients with predicted severe acute Patients with predicted severe acute pancreatitis should be nursed in high pancreatitis should be nursed in high dependency unit or ICUdependency unit or ICU

Close monitoring and organ supportClose monitoring and organ support

Disease progressionDisease progression

Early Early First 2 weeksFirst 2 weeks Organ failure is Organ failure is

commoncommon As a result of SIRS As a result of SIRS

due to release of due to release of inflammatory inflammatory mediators into the mediators into the circulationcirculation

LateLate Two weeks after Two weeks after

onset of symptomsonset of symptoms Dominated by Dominated by

septic related septic related complications of complications of the infected the infected necrosisnecrosis

UK Guidelines 2003 The UK Guidelines 2003 The Management of Acute Management of Acute

PancreatitisPancreatitisAcute pancreatitis

Diagnosis

Assessment of severity

Mild

Severe

Prevention of complication

Management of gallstone

Management of necrosis

ControversiesControversies Does prophylactic antibiotic help to Does prophylactic antibiotic help to

prevent infection of the pancreatic prevent infection of the pancreatic necrosis?necrosis?

Management of necrosisManagement of necrosis What is the role of surgery in sterile What is the role of surgery in sterile

necrosis?necrosis? Which is the best treatment modality Which is the best treatment modality

for infected necrosis?for infected necrosis?

Meta-analysis of Prophylactic Antibiotic Meta-analysis of Prophylactic Antibiotic Use In Acute Necrotizing Pancreatitis Use In Acute Necrotizing Pancreatitis

(ANP)(ANP)

Prophylactic Antibiotic in Prophylactic Antibiotic in ANPANP

On the contrary, some meta-analyses On the contrary, some meta-analyses have lent support to prophylactic usehave lent support to prophylactic use

Indicating reduction in the incidence Indicating reduction in the incidence of infected necrosis and mortalityof infected necrosis and mortality

Villatoro et al Antibiotic Therapy for Prophylaxis Villatoro et al Antibiotic Therapy for Prophylaxis Againist Againist Infection of Pancreatic necrosis in ANP; Infection of Pancreatic necrosis in ANP; Cochrane Database Cochrane Database Syst Rev 2009Syst Rev 2009

Is Prophylactic Antibiotic Useful Is Prophylactic Antibiotic Useful In ANP?In ANP?

Remains controversialRemains controversial Imipenem is frequently used due to its Imipenem is frequently used due to its

good penetration to the pancreasgood penetration to the pancreas Judicious use of antibioticJudicious use of antibiotic

Change of Gram negative to Gram positive Change of Gram negative to Gram positive infection infection

Promotion of fungal infection Promotion of fungal infection

Buchler et al Acute Necrotizing Pancreatitis: Buchler et al Acute Necrotizing Pancreatitis: Treatment Treatment Strategy According to The Status of Infection; Strategy According to The Status of Infection; Ann of Surg Ann of Surg 20002000

Management of Necrosis Management of Necrosis in ANPin ANP

What is the optimal time for What is the optimal time for necrosectomy?necrosectomy?

What is the role of surgery in sterile What is the role of surgery in sterile necrosis ?necrosis ?

Which surgical modality is best for Which surgical modality is best for treating infected necrosis?treating infected necrosis?

Timing of Surgery in ANP (I)Timing of Surgery in ANP (I)

For predicted severe pancreatitis, CT helps to For predicted severe pancreatitis, CT helps to document the presence and degree of necrosis document the presence and degree of necrosis

Early phase Early phase –– multimodality approach multimodality approach Safe period Safe period –– 4-6 weeks 4-6 weeks Surgical intervention in the early phase carries Surgical intervention in the early phase carries

high mortality when inflammation is spreading high mortality when inflammation is spreading without a clear demarcationwithout a clear demarcation

The unorganised necrosis also leads to The unorganised necrosis also leads to massive intraoperative bleedingmassive intraoperative bleeding

MT Cheung Surgical Intervention in Necrotizing MT Cheung Surgical Intervention in Necrotizing Pancreatitis: Pancreatitis: towards lesser and later, ANZ J Of Surg 2009towards lesser and later, ANZ J Of Surg 2009

Timing Of Surgical Intervention Timing Of Surgical Intervention In ANP (II)In ANP (II)

Retrospective study of 53 infected necrosisRetrospective study of 53 infected necrosis Surgery for persistant organ failure despite Surgery for persistant organ failure despite

maximal ICU support or proven infected maximal ICU support or proven infected necrosisnecrosis

Open necrosectomy and post operative lavageOpen necrosectomy and post operative lavage Post operative mortality rate Post operative mortality rate

within 14 days within 14 days –– 75% 75% 15-29 days 15-29 days –– 45% 45% > 30 days > 30 days –– 8% 8%

Besselink et al Timing of surgical intervention in Besselink et al Timing of surgical intervention in necrotizing pancreatitis, Arch of Surg 2007necrotizing pancreatitis, Arch of Surg 2007

Does Surgery Help in The Does Surgery Help in The Management of Sterile Management of Sterile

Necrosis?Necrosis? Sterile necrosis is not an indication to surgery Sterile necrosis is not an indication to surgery Reports have shown that sterile necrosis can be managed Reports have shown that sterile necrosis can be managed

conservatively with antibioticsconservatively with antibiotics With the exception when persistant or progressive organ With the exception when persistant or progressive organ

complications despite maximal ICU supportcomplications despite maximal ICU support

Heinrich et al, Evidence Based Treatment of Acute Necrotizing Heinrich et al, Evidence Based Treatment of Acute Necrotizing Pancreatitis, Ann of Surg 2006Pancreatitis, Ann of Surg 2006

The decision to surgery is by clinical judgementThe decision to surgery is by clinical judgement FNA has false negative rate FNA has false negative rate

Conservative Management of Conservative Management of Sterile NecrosisSterile Necrosis

86 patients with ANP86 patients with ANP All were given imipenemAll were given imipenem Sterile necrosis Mx with antibiotic regime Sterile necrosis Mx with antibiotic regime

Mortality 1.8% Mortality 1.8% Buchler et al Acute necrotizing pancreatitis: Treatment strategy Buchler et al Acute necrotizing pancreatitis: Treatment strategy according to the status of infection; Ann of Surg 2000according to the status of infection; Ann of Surg 2000

100% survival on conservative Management100% survival on conservative ManagementBradley and Allen A prospective longitudinal study of observation vs Bradley and Allen A prospective longitudinal study of observation vs surgical intervention in the management of ANP; Am J Surg 1991surgical intervention in the management of ANP; Am J Surg 1991

Results Of Surgery In Sterile Results Of Surgery In Sterile NecrosisNecrosis

Mortality rate is significantly higher in the surgical group than conservative treatment

Management Of Infected Management Of Infected Necrosis in ANPNecrosis in ANP

What Treatment Modalities What Treatment Modalities Are Available?Are Available?

Open Necrosectomy Open Necrosectomy

Open necrosectomy + continuous Open necrosectomy + continuous post- operative drainage with post- operative drainage with irrigation is commonly used for irrigation is commonly used for infected necrotizing pancreatitisinfected necrotizing pancreatitis

Considerable mortality 15-43%Considerable mortality 15-43%

Connor et alConnor et al Early and Late Complications After Early and Late Complications After Necrosectomy; Necrosectomy; Surgery 2005Surgery 2005

Werner et al Surgery in The Treatment of Acute Werner et al Surgery in The Treatment of Acute Pancreatitis- open Pancreatitis- open pancreatic necrosectomy; Scand J Surg pancreatic necrosectomy; Scand J Surg 20052005

Minimally Invasive Minimally Invasive Necrosectomy Necrosectomy

MIN

Laparoscopic assisted Percutaneous Endoscopic

Published Series Of MIN Up To Published Series Of MIN Up To 2008 2008

• No perioperative complication• Single/ double sessions• Mortality rate < 20%

Laparoscopic Laparoscopic Assisted Assisted

Necrosectomy Necrosectomy Removal of necrosis Removal of necrosis

under direct visionunder direct vision Operative time ~ 87 Operative time ~ 87

minsmins 75% with complete 75% with complete

clearance of necrosis clearance of necrosis after single sessionafter single session

No peri or post No peri or post operative complication operative complication

Bucher et al Minimally Invasive Bucher et al Minimally Invasive Necrosectomy for Infected Necrosectomy for Infected Necrotizing Pancreatitis; Pancreas Necrotizing Pancreatitis; Pancreas 20082008

Percutaneous Percutaneous Necrosectomy Necrosectomy

8fr nephrostomy catheter 8fr nephrostomy catheter placed into necrosis under placed into necrosis under CT guidanceCT guidance

irrigation, suction and irrigation, suction and piecemeal extraction of piecemeal extraction of necrotic debrisnecrotic debris

No patients required open No patients required open surgery surgery

Mean ~ 2 sessionsMean ~ 2 sessions

Carter et alCarter et al Percutaneous Percutaneous necrosectomy and sinus tract necrosectomy and sinus tract endoscopy in the management of endoscopy in the management of infected pancreatic necrosis; Ann infected pancreatic necrosis; Ann of Surg 2000of Surg 2000

Which Is Better?Which Is Better?

MIN vs open necrosectomy MIN vs open necrosectomy Safe Safe Effective Effective Improved mortality and morbidityImproved mortality and morbidity

The PANTER trial (The Netherlands)The PANTER trial (The Netherlands) Multicentred RCTMulticentred RCT Minimal invasive step up approach vs open Minimal invasive step up approach vs open

necrosectomy in patients with acute necrosectomy in patients with acute necrotizing pancreatitisnecrotizing pancreatitis

Conclusion- Management of Conclusion- Management of ANPANP

Prophylactic antibioticProphylactic antibiotic No definite data supporting use of A/B to No definite data supporting use of A/B to

improve mortality and reduce incidence of improve mortality and reduce incidence of infected necrosisinfected necrosis

Judicious use of antibiotic due to trend of Judicious use of antibiotic due to trend of emerging Gram positive and fungal infectionemerging Gram positive and fungal infection

Conclusion- Management of Conclusion- Management of NecrosisNecrosis

Timing of necrosectomy Timing of necrosectomy –– towards the later the towards the later the betterbetter

Surgery is not indicated in patients with sterile Surgery is not indicated in patients with sterile necrosis except when clinical condition continues necrosis except when clinical condition continues to deteriorate despite maximal ICU careto deteriorate despite maximal ICU care

The efficacy of MIN in ANP is yet to be The efficacy of MIN in ANP is yet to be determined by future randomized controlled trial determined by future randomized controlled trial whether the observed improved mortality and whether the observed improved mortality and morbidity is attributable to this surgical morbidity is attributable to this surgical approachapproach

Thank YouThank You