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The Management of Acute Necrotizing Pancreatitis

The Management of Acute Necrotizing Pancreatitis. Stephanie Cheung Hay Man Caritas Medical Centre 25th July 2009 Joint Hospital Grand Round. Introduction. Severe pancreatitis occurs in 15-20% of patients with acute pancreatitis

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The Management of Acute Necrotizing Pancreatitis

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  1. The Management of Acute Necrotizing Pancreatitis Stephanie Cheung Hay Man Caritas Medical Centre 25th July 2009 Joint Hospital Grand Round

  2. Introduction • Severe pancreatitis occurs in 15-20% of patients with acute pancreatitis • The degree of necrosis and the presence of infection are crucial determinants of overall outcome • Patients with predicted severe acute pancreatitis should be nursed in high dependency unit or ICU • Close monitoring and organ support

  3. Early First 2 weeks Organ failure is common As a result of SIRS due to release of inflammatory mediators into the circulation Late Two weeks after onset of symptoms Dominated by septic related complications of the infected necrosis Disease progression

  4. UK Guidelines 2003 The Management of Acute Pancreatitis

  5. Controversies • Does prophylactic antibiotic help to prevent infection of the pancreatic necrosis? • Management of necrosis • What is the role of surgery in sterile necrosis? • Which is the best treatment modality for infected necrosis?

  6. Meta-analysis of Prophylactic Antibiotic Use In Acute Necrotizing Pancreatitis (ANP)

  7. Prophylactic Antibiotic in ANP • On the contrary, some meta-analyses have lent support to prophylactic use • Indicating reduction in the incidence of infected necrosis and mortality Villatoro et al Antibiotic Therapy for Prophylaxis Againist Infection of Pancreatic necrosis in ANP; Cochrane Database Syst Rev 2009

  8. Is Prophylactic Antibiotic Useful In ANP? • Remains controversial • Imipenem is frequently used due to its good penetration to the pancreas • Judicious use of antibiotic • Change of Gram negative to Gram positive infection • Promotion of fungal infection Buchler et al Acute Necrotizing Pancreatitis: Treatment Strategy According to The Status of Infection; Ann of Surg 2000

  9. Management of Necrosis in ANP What is the optimal time for necrosectomy? What is the role of surgery in sterile necrosis ? Which surgical modality is best for treating infected necrosis?

  10. Timing of Surgery in ANP (I) • For predicted severe pancreatitis, CT helps to document the presence and degree of necrosis • Early phase – multimodality approach • Safe period – 4-6weeks • Surgical intervention in the early phase carries high mortality when inflammation is spreading without a clear demarcation • The unorganised necrosis also leads to massive intraoperative bleeding MT Cheung Surgical Intervention in Necrotizing Pancreatitis: towards lesser and later, ANZ J Of Surg 2009

  11. Timing Of Surgical Intervention In ANP (II) • Retrospective study of 53 infected necrosis • Surgery for persistant organ failure despite maximal ICU support or proven infected necrosis • Open necrosectomy and post operative lavage • Post operative mortality rate • within 14 days – 75% • 15-29 days – 45% • > 30 days – 8% Besselink et al Timing of surgical intervention in necrotizing pancreatitis, Arch of Surg 2007

  12. Does Surgery Help in The Management of Sterile Necrosis? • Sterile necrosis is not an indication to surgery • Reports have shown that sterile necrosis can be managed conservatively with antibiotics • With the exception when persistant or progressive organ complications despite maximal ICU support Heinrich et al, Evidence Based Treatment of Acute Necrotizing Pancreatitis, Ann of Surg 2006 • The decision to surgery is by clinical judgement • FNA has false negative rate

  13. Conservative Management of Sterile Necrosis • 86 patients with ANP • All were given imipenem • Sterile necrosis Mx with antibiotic regimeMortality 1.8% Buchler et al Acute necrotizing pancreatitis: Treatment strategy according to the status of infection; Ann of Surg 2000 • 100% survival on conservative Management Bradley and AllenA prospective longitudinal study of observation vs surgical intervention in the management of ANP; Am J Surg 1991

  14. Results Of Surgery In Sterile Necrosis Mortality rate is significantly higher in the surgical group than conservative treatment

  15. Management Of Infected Necrosis in ANP What Treatment Modalities Are Available?

  16. Open Necrosectomy • Open necrosectomy + continuous post- operative drainage with irrigation is commonly used for infected necrotizing pancreatitis • Considerable mortality 15-43% Connor et alEarly and Late Complications After Necrosectomy; Surgery 2005 Werner et al Surgery in The Treatment of Acute Pancreatitis- open pancreatic necrosectomy; Scand J Surg 2005

  17. Minimally Invasive Necrosectomy

  18. Published Series Of MIN Up To 2008 • No perioperative complication • Single/ double sessions • Mortality rate < 20%

  19. Removal of necrosis under direct vision Operative time ~ 87 mins 75% with complete clearance of necrosis after single session No peri or post operative complication Bucher et al Minimally Invasive Necrosectomy for Infected Necrotizing Pancreatitis; Pancreas 2008 Laparoscopic Assisted Necrosectomy

  20. 8fr nephrostomy catheter placed into necrosis under CT guidance irrigation, suction and piecemeal extraction of necrotic debris No patients required open surgery Mean ~ 2 sessions Carter et alPercutaneous necrosectomy and sinus tract endoscopy in the management of infected pancreatic necrosis; Ann of Surg 2000 Percutaneous Necrosectomy

  21. Which Is Better? • MIN vs open necrosectomy • Safe • Effective • Improved mortality and morbidity • The PANTER trial (The Netherlands) • Multicentred RCT • Minimal invasive step up approach vs open necrosectomy in patients with acute necrotizing pancreatitis

  22. Conclusion- Management of ANP • Prophylactic antibiotic • No definite data supporting use of A/B to improve mortality and reduce incidence of infected necrosis • Judicious use of antibiotic due to trend of emerging Gram positive and fungal infection

  23. Conclusion- Management of Necrosis • Timing of necrosectomy – towards the later the better • Surgery is not indicated in patients with sterile necrosis except when clinical condition continues to deteriorate despite maximal ICU care • The efficacy of MIN in ANP is yet to be determined by future randomized controlled trial whether the observed improved mortality and morbidity is attributable to this surgical approach

  24. Thank You

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