Transcript 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
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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
Disease progression
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Early
First 2 weeks
Organ failure is
common
As a result of SIRS
due to release of
inflammatory
mediators into the
circulation
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Late
Two weeks after
onset of symptoms
Dominated by septic
related complications
of the infected
necrosis
UK Guidelines 2003 The
Management of Acute Pancreatitis
Acute pancreatitis
Diagnosis
Assessment of severity
Mild
Severe
Prevention of complication
Management of gallstone
Management of necrosis
Controversies
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Does prophylactic antibiotic help to
prevent infection of the pancreatic
necrosis?
Management of necrosis
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What is the role of surgery in sterile necrosis?
Which is the best treatment modality for
infected necrosis?
Meta-analysis of Prophylactic Antibiotic Use
In Acute Necrotizing Pancreatitis (ANP)
Prophylactic Antibiotic in ANP
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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
Is Prophylactic Antibiotic Useful In
ANP?
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Remains controversial
Imipenem is frequently used due to its good
penetration to the pancreas
Judicious use of antibiotic
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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
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?
Timing of Surgery in ANP (I)
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For predicted severe pancreatitis, CT helps to
document the presence and degree of necrosis
Early phase – multimodality approach
Safe period – 4-6 weeks
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
Timing Of Surgical Intervention In
ANP (II)
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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
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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
Does Surgery Help in The
Management of Sterile Necrosis?
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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
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The decision to surgery is by clinical judgement
FNA has false negative rate
Conservative Management of
Sterile Necrosis
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86 patients with ANP
All were given imipenem
Sterile necrosis Mx with antibiotic regime
Mortality 1.8%
Buchler et al Acute necrotizing pancreatitis: Treatment strategy according
to the status of infection; Ann of Surg 2000
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100% survival on conservative Management
Bradley and Allen A prospective longitudinal study of observation vs
surgical intervention in the management of ANP; Am J Surg 1991
Results Of Surgery In Sterile
Necrosis
Mortality rate is significantly
higher in the surgical group
than conservative treatment
Management Of Infected
Necrosis in ANP
What Treatment Modalities Are
Available?
Open Necrosectomy
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Open necrosectomy + continuous postoperative drainage with irrigation is
commonly used for infected necrotizing
pancreatitis
Considerable mortality 15-43%
Connor et al Early and Late Complications After Necrosectomy;
Surgery 2005
Werner et al Surgery in The Treatment of Acute Pancreatitis- open
pancreatic necrosectomy; Scand J Surg 2005
Minimally Invasive Necrosectomy
MIN
Laparoscopic assisted
Percutaneous
Endoscopic
Published Series Of MIN Up To
2008
• No perioperative complication
• Single/ double sessions
• Mortality rate < 20%
Laparoscopic
Assisted
Necrosectomy
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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
Percutaneous
Necrosectomy
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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 al Percutaneous
necrosectomy and sinus tract
endoscopy in the management of
infected pancreatic necrosis; Ann of
Surg 2000
Which Is Better?
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MIN vs open necrosectomy
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Safe
Effective
Improved mortality and morbidity
The PANTER trial (The Netherlands)
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Multicentred RCT
Minimal invasive step up approach vs open
necrosectomy in patients with acute necrotizing
pancreatitis
Conclusion- Management of ANP
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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
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Conclusion- Management of
Necrosis
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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
Thank You