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MANAGEMENT OF PANCREATIC NECROSIS. Kevin E. Behrns, M. D. Division of Gastrointestinal Surgery. PANCREATIC NECROSIS Definition. Pancreatic necrosis- diffuse or focal areas of non-viable pancreatic parenchyma, which is typically associated with peripancreatic fat necrosis.

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management of pancreatic necrosis

MANAGEMENT OF PANCREATIC NECROSIS

Kevin E. Behrns, M. D.

Division of Gastrointestinal Surgery

pancreatic necrosis definition
PANCREATIC NECROSISDefinition
  • Pancreatic necrosis- diffuse or focal areas of non-viable pancreatic parenchyma, which is typically associated with peripancreatic fat necrosis.

Atlanta International Symposium

Arch Surgery 1993;128:586

pancreatic necrosis surgical indications
PANCREATIC NECROSISSurgical Indications
  • WHAT ARE THE SURGICAL

INDICATIONS FOR DEBRIDEMENT OR NECROSECTOMY?

    • Absolute indications
    • Relative indications
pancreatic necrosis surgical decision making
PANCREATIC NECROSISSurgical Decision-Making

PANCREATIC NECROSIS

INFECTED NECROSIS

STERILE NECROSIS

NON-OPERATIVE MANGEMENT VS. NECROSECTOMY

NECROSECTOMY

pancreatic necrosis infected necrosis
PANCREATIC NECROSISInfected Necrosis
  • Mandates a semi-urgent operation
  • Removal of all necrotic pancreas and peripancreatic tissues
  • May require 1-3 operations
  • Preferred method is to delay initial operation until necrosis demarcated
pancreatic necrosis infected necrosis6
PANCREATIC NECROSISInfected Necrosis
  • Outcomes
    • Mortality 6-24%
    • Morbidity 34-50+%
  • Bacteria
    • Staph
    • E. coli
    • Klebsiella

Ann Surg 1998;228:676

2000;234:619

2001;234:572

pancreatic necrosis sterile necrosis
PANCREATIC NECROSISSterile Necrosis
  • WHAT DISTINGUISHES STERILE NECROSIS FROM INFECTED NECROSIS?
    • Retroperitoneal air within necroma on CT indicates gas-producing organism and infected necrosis.
    • Role of FNA of necrotic pancreatic and peripancreatic tissue.
pancreatic necrosis sterile necrosis9
PANCREATIC NECROSISSterile Necrosis
  • Utility of FNA
    • Good sensitivity and specificity
    • Highly dependent on accurate needle placement in necrotic tissue (not nearby fluid collection)
    • Surgeon’s Perspective- not that useful
      • Timing is everything in pancreatic necrosectomy
      • Early positive FNA forces surgeon’s hand when pancreatic necrosis not demarcated
      • May result in multiple operations and increased risk of morbidity and mortality
      • CONSULT SURGEON PRIOR TO FNA
pancreatic necrosis sterile necrosis10
PANCREATIC NECROSISSterile Necrosis
  • Controversial management
    • Non-operative management
      • Most of the world
    • Operation for all patients with pancreatic necrosis
      • MGH
pancreatic necrosis sterile necrosis12
PANCREATIC NECROSISSterile Necrosis

Which patients are

likely to get

infected necrosis?

pancreatic necrosis sterile necrosis13
PANCREATIC NECROSISSterile Necrosis
  • What are the outcomes with planned operative management of sterile necrosis?
  • Mortality 6.2%

Ann Surg 1998;228:676

pancreatic necrosis sterile necrosis14
PANCREATIC NECROSISSterile Necrosis
  • DO ALL PATIENTS WITH NON-OPERATIVE TREATMENT OF STERILE NECROSIS GET WELL?
    • NO!
    • Subgroup of patients that never develop infection but have persistent nausea, vomiting, abdominal pain. “Fail to thrive”
pancreatic necrosis sterile necrosis15
PANCREATIC NECROSISSterile Necrosis
  • When should patients with sterile necrosis that induces persistent symptoms undergo operation?
    • About one month after diagnosis if no improvement

Ann Surg 1998;228:676

pancreatic necrosis sterile necrosis16
PANCREATIC NECROSISSterile Necrosis
  • What are the outcomes of patients that have delayed operation for sterile pancreatic necrosis?

Ann Surg 2001 234:572

pancreatic necrosis sterile necrosis17
PANCREATIC NECROSISSterile Necrosis
  • What factors predict survival from pancreatic necrosectomy?
    • Age
    • APACHE II score
    • Time to surgery
      • Survivors- 39 days
      • Non-survivors- 23 days

Brit J Surg 2003;90:1542

pancreatic necrosis quality of care
PANCREATIC NECROSISQuality of care

HOW CAN WE PROVIDE HIGHESTQUALITY OF CARE FOR PATIENTS WITH PANCREATITIS?

pancreatic necrosis surgical treatment guidelines
PANCREATIC NECROSISSurgical Treatment Guidelines
  • International Association of Pancreatology (IAP) evidence-based guidelines for surgical management of acute pancreatitis:
    • Mild acute pancreatitis does not require surgery
    • Antibiotics decrease infection rates but not mortality in CT-proven necrotizing pancreatitis
    • Patients with sterile necrosis should undergo operation only in selected cases

Pancreatology 2002;2:565

pancreatic necrosis surgical treatment guidelines20
PANCREATIC NECROSISSurgical Treatment Guidelines
  • IAP recommendations (continued):
    • Patients with infected necrosis and clinical presentation of sepsis should have surgery or radiological drainage
    • Early surgery (<14 days) not recommended unless special circumstances
    • Surgical operations should favor organ-preserving approach
    • Cholecystectomy should be performed at operation

Pancreatology 2002;2:565

pancreatic necrosis surgical treatment guidelines21
PANCREATIC NECROSISSurgical Treatment Guidelines
  • IAP recommendations (continued):
    • In gallstone-induced edematous pancreatitis, cholecystectomy should be performed during initial hospitalization
    • In gallstone-induced necrotizing pancreatitis, cholecystectomy should delayed until inflammatory response subsides
    • Endoscopic sphincterotomy is alternative to cholecystectomy in high-risk patients

Pancreatology 2002;2:565

pancreatic necrosis conclusion
PANCREATIC NECROSISConclusion
  • Necrotizing pancreatitis accounts for 10% of all pancreatitis but is lethal disease
    • Surgical consult should be obtained in the ER
    • Many, if not all, patients should be admitted to surgical service
    • Management relies on team effort of surgeons, endoscopist, intensivist, radiologist, interventional radiologist, primary care physician, etc.
  • Gallstone-induced edematous pancreatitis should have surgical consult prior to discharge
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