Management of pancreatic necrosis
Download
1 / 22

MANAGEMENT OF PANCREATIC NECROSIS - PowerPoint PPT Presentation


  • 566 Views
  • Uploaded on

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.

loader
I am the owner, or an agent authorized to act on behalf of the owner, of the copyrighted work described.
capcha
Download Presentation

PowerPoint Slideshow about 'MANAGEMENT OF PANCREATIC NECROSIS' - KeelyKia


An Image/Link below is provided (as is) to download presentation

Download Policy: Content on the Website is provided to you AS IS for your information and personal use and may not be sold / licensed / shared on other websites without getting consent from its author.While downloading, if for some reason you are not able to download a presentation, the publisher may have deleted the file from their server.


- - - - - - - - - - - - - - - - - - - - - - - - - - E N D - - - - - - - - - - - - - - - - - - - - - - - - - -
Presentation Transcript
Management of pancreatic necrosis l.jpg

MANAGEMENT OF PANCREATIC NECROSIS

Kevin E. Behrns, M. D.

Division of Gastrointestinal Surgery


Pancreatic necrosis definition l.jpg
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 l.jpg
PANCREATIC NECROSISSurgical Indications

  • WHAT ARE THE SURGICAL

    INDICATIONS FOR DEBRIDEMENT OR NECROSECTOMY?

    • Absolute indications

    • Relative indications


Pancreatic necrosis surgical decision making l.jpg
PANCREATIC NECROSISSurgical Decision-Making

PANCREATIC NECROSIS

INFECTED NECROSIS

STERILE NECROSIS

NON-OPERATIVE MANGEMENT VS. NECROSECTOMY

NECROSECTOMY


Pancreatic necrosis infected necrosis l.jpg
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 l.jpg
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 infected necrosis7 l.jpg
PANCREATIC NECROSISInfected Necrosis

Ann Surg 2000;232:619


Pancreatic necrosis sterile necrosis l.jpg
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 l.jpg
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 l.jpg
PANCREATIC NECROSISSterile Necrosis

  • Controversial management

    • Non-operative management

      • Most of the world

    • Operation for all patients with pancreatic necrosis

      • MGH


Pancreatic necrosis sterile necrosis non operative management l.jpg
PANCREATIC NECROSISSterile Necrosis- Non-Operative Management

Ann Surg 2000:232:619


Pancreatic necrosis sterile necrosis12 l.jpg
PANCREATIC NECROSISSterile Necrosis

Which patients are

likely to get

infected necrosis?


Pancreatic necrosis sterile necrosis13 l.jpg
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 l.jpg
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 l.jpg
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 l.jpg
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 l.jpg
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 l.jpg
PANCREATIC NECROSISQuality of care

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


Pancreatic necrosis surgical treatment guidelines l.jpg
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 l.jpg
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 l.jpg
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 l.jpg
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


ad