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JOINT HOSPITAL SURGICAL GRAND ROUND 19th May 2007
Charing ChongAlice Ho Miu Ling Nethersole Hospital / North District Hospital
Surgery for Severe Pancreatitis: Whom, When and What
JOINT HOSPITAL SURGICAL GRAND ROUND 19th May 2007
Definition
“ Acute pancreatitis with the presence of organ failure (e.g., shock, pulmonary insufficiency, renal failure, or gastrointestinal bleeding) or pancreatic or peri-pancreatic complications (e.g., necrosis, abscess, or pseudocyst), or both, along with unfavorable early prognostic signs (e.g., using the Ranson criteria or
the APACHE II score) “Bradley EL 3rd: A clinically based classification system for acute pancreatitis. Summary of the International Symposium on Acute Pancreatitis, Atl
anta, 1992. Arch Surg 1993
W h a t i s s e v e r e p a n c r e a t i t i s ?
JOINT HOSPITAL SURGICAL GRAND ROUND 19th May 2007
SURGEONPATIENT
JOINT HOSPITAL SURGICAL GRAND ROUND 19th May 2007
Who requires surgery?When to intervene?
What technique should be used?
JOINT HOSPITAL SURGICAL GRAND ROUND 19th May 2007
WHOM?
JOINT HOSPITAL SURGICAL GRAND ROUND 19th May 2007
WhomS h o u l d a l l p a t i e n t s w i t h s e v e r e p a n c r e a t i t i s b e o p e r a t e d ?
DETECTION OF NECROSIS ITSELF IS
NOT AN INDICATION FOR SURGERY
JOINT HOSPITAL SURGICAL GRAND ROUND 19th May 2007
Whom
Over 90% of patients with sterile necrosis can be successfully treated without surgical intervention
Surgical treatment of sterile necrosis appears to have a higher mortality rates (11.9%, C.I. 5.3 – 22.2) than the conservative treatment (2.3%, C.I. 0.3 – 8.2) in patient with sterile necrosis
Ashley SW, et al. Necrotising pancreatitis. Ann Surg 2001
Buchler MW, et al. Acute necrotising pancreatitis: treatment stratergy according to status of infection.
Ann Surg 2000
S h o u l d a l l p a t i e n t s w i t h s e v e r e p a n c r e a t i t i s b e o p e r a t e d ?
Heinrich S, et al. Evidence-based treatment of acute pancreatitis: A look at established paradigms. Ann Surg 2006
JOINT HOSPITAL SURGICAL GRAND ROUND 19th May 2007
Whom
STERILE NECROSIS
Small subset warrants surgery:– Deteriorating organ failure despite maximal
support– Persisting symptoms that preclude hospital
discharge despite several weeks of optimum conservative treatment
S h o u l d a l l p a t i e n t s w i t h s e v e r e p a n c r e a t i t i s b e o p e r a t e d ?
Beger HG, et al. Acute pancreatitis: Who needs anoperation? J Hepatobiliary Pancreat Surg 2002
Fernadez-del Castillo C, et al. Debridement and closed packingfor the treatment of necrotising pancreatitis. Ann Surg 2000
JOINT HOSPITAL SURGICAL GRAND ROUND 19th May 2007
Whom
NECROTIZING PANCREATITIS WITH PROVEN INFECTED NECROSIS IS AN
INDICATION FOR SURGICAL INTERVENTION
Werner J, et al. Management of acute pancreatiits: from surgery to interventional intensive care. Gut 2005.
Uhl W, et al. IAP guidelines for the surgical management ofacute pancreatitis. Pancreatology 2002.
Ranson JHC. The current management of acute pancreatitis. Adv Surg 1995.
McFadden DW, Reber HA. Indications for surgery in severeacute pancreatitis. Int J Pancreatol 1994.
S h o u l d a l l p a t i e n t s w i t h s e v e r e p a n c r e a t i t i s b e o p e r a t e d ?
JOINT HOSPITAL SURGICAL GRAND ROUND 19th May 2007
Whom• Complete blood pictur
e• Positive blood culture• Positive endotoxin test
of blood• Gas in and around the
pancreas on CT scan
Merely indirect evidence of infection in general
CT- or USG - guided fine-
needle aspiration
High accuracy, 89.4% - 100%
Safe and reliable
W h a t i s t h e b e s t d i a g n o s t i c t o o l ?
Banks PA, et al. CT-guided aspiration of suspected pancreatic infection: bacteriology and clinical outcome. Int J Pancreatol 1995.
Rau B, et al. Role of ultrasonographically guided fine-needle aspiration cytology in the diagnosis of infected pancreatic necrosis. Br J Surg 1998.
JOINT HOSPITAL SURGICAL GRAND ROUND 19th May 2007
WHEN?
JOINT HOSPITAL SURGICAL GRAND ROUND 19th May 2007
When
EARLY
• To control sepsis and prevent major organ failure
• High mortality rate
LATE
• Border between normal and necrotic pancreatic tissue becomes more distinct with time
• Minimize intra-operative haemorrhage
• Avoid unnecessary removal of normal pancreas
W h a t i s t h e o p t i m a l t i m i n g f o r s u r g i c a l i n t e r v e n t i o n ?
JOINT HOSPITAL SURGICAL GRAND ROUND 19th May 2007
When
Early versus late necrosectomy in severe necrotizing pancreatitis. J. Mier, E. León, A. Castillo, F. Robledo, R. BlancoThe American Journal of Surgery 1997, Volume 173, Pages 71-75.
W h a t i s t h e o p t i m a l t i m i n g f o r s u r g i c a l i n t e r v e n t i o n ?
• Early (within 72 hours, n = 25) vs Late (more than 12 days, n = 15)
• Indication: MOF with clinical deterioration despite maximal intensive care
• Open packing and staged necrosectomy• Mortality: 56% (Early) vs 27% (Late)• Terminated early because of very high mortality rate
for patients underwent early surgery (Odds ratio 3.4)
JOINT HOSPITAL SURGICAL GRAND ROUND 19th May 2007
When
In case of suspected or proven infection of necrosis, prophylactic antibiotic treatment could be primarily applied
W h a t i s t h e o p t i m a l t i m i n g f o r s u r g i c a l i n t e r v e n t i o n ?
Heinrich S, et al. Evidence-based treatment of acute pancreatitis: A look at established paradigms. Ann Surg 2006
Isaji S, et al. JPN Guidelines for the management of acute pancreatitis: surgical management.
J Hepatobiliary Pancreat Surg.2002.
EARLY SURGERY IS NOT RECOMMENDED FOR SEVERE ACUTE
PANCREATITIS
JOINT HOSPITAL SURGICAL GRAND ROUND 19th May 2007
When
However, reports have different views about the length of time that conservative management should be applied before surgical intervention is considered.(Period ranging from 3 – 5 days to more than 5 weeks)
Werner J, et al. Management of acute pancreatiits: from surgery to interventional intensive care. Gut 2005.
Buchler P, et al. Surgical approach in patients with acute pancreatitis. Is infected or sterile necrosis an indication — in whom should this be done, when, and why? Gastroenterol Clin North A
m 1999.
ALTHOUGH IT IS DIFFICULT TO RECOMMEND AN EXACT DURATION,
AT LEAST 3-4 WEEKS OF CONSERVATIVE MANAGEMENT IS
DESIRABLE
W h a t i s t h e o p t i m a l t i m i n g f o r s u r g i c a l i n t e r v e n t i o n ?
JOINT HOSPITAL SURGICAL GRAND ROUND 19th May 2007
WHAT?
JOINT HOSPITAL SURGICAL GRAND ROUND 19th May 2007
WhatPANCREATIC RESECTION:• Increased perioperative morbidity• Normal pancreatic parenchyma unnecessarily re
moved• Long term outcome of patients is closely related
to the amount of preserved pancreatic tissue
W h i c h s u r g i c a l t e c h n i q u e s h o u l d b e u s e d ?
ORGAN PRESERVING NECROSECTOMY IS THE SURGICAL TECHNIQUE OF CHOICE
FOR TREATMENT OF INFECTED PANCREATIC AND PERIPANCREATIC
NECROSIS
Uhl W, et al. International Association of Pancreatology. IAP Guidelines for the surgical management of acute pancreatitis. Pancreatology 2002.
JOINT HOSPITAL SURGICAL GRAND ROUND 19th May 2007
What
OPEN PACKING +/- PLANNED STAGED RE-LAPAROTOM
IES• Performed in 48-hour intervals• Until all necrosis has resolved and
granulation tissue developed• Lower recurrent intra-abdominal
sepsis• Higher post-operative morbidity li
ke fistulae, bleeding and incisional hernias
W h i c h s u r g i c a l t e c h n i q u e s h o u l d b e u s e d ?
Bradley EL 3rd, Allen K.. A prospective longitudinal study of observation versus surgical intervention in the m
anagement of necrotizing pancreatitis. Am J Surg. 1991
Werner J,et al. Surgical treatment of acute pancreatitis. Curr Treat Options Gastroenterol 2003.
JOINT HOSPITAL SURGICAL GRAND ROUND 19th May 2007
What W h i c h s u r g i c a l t e c h n i q u e s h o u l d b e u s e d ?
Beger HG. Operative management of necrotizing pancreatitis: necrosectomy and continuous closed postoperative lavage of the lesser sac. Hepatogastroenterology. 1991.
Werner J,et al. Surgical treatment of acute pancreatitis. Curr Treat Options Gastroenterol 2003.
CLOSED PACKING +/- CONTINUOUS POST-OPERATIVE LAVAGE
• Necrosectomy and subsequent closed continuous lavage of lesser sac
• 8 – 10 L/day through surgically placed drainages
• To continuously remove residual pancreatic necrosis
• Re-laparotomies are frequently not necessary
• Less post-operative morbidity
JOINT HOSPITAL SURGICAL GRAND ROUND 19th May 2007
WhatW h i c h s u r g i c a l t e c h n i q u e s h o u l d b e u s e d ?
JOINT HOSPITAL SURGICAL GRAND ROUND 19th May 2007
WhatW h i c h s u r g i c a l t e c h n i q u e s h o u l d b e u s e d ?
JOINT HOSPITAL SURGICAL GRAND ROUND 19th May 2007
WhatW h i c h s u r g i c a l t e c h n i q u e s h o u l d b e u s e d ?
Heinrich S, et al. Evidence-based treatment of acute pancreatitis: A look at established paradigms. Ann Surg 2006.
Isaji S, et al. JPN Guidelines for the management of acute pancreatitis: surgical management. J Hepatobiliary Pancreat Surg. 2006.
Werner J, et al. Management of acute pancreatiits: from surgery to interventional intensive care. Gut 2005.
CAREFUL SINGLE NECROSECTOMY AND POST-OPERATIVE LAVAGE
WITHOUT PLANNED RELAPAROTOMIES SEEMS TO BE LESS HARMFUL AND COULD BE
CONSIDERED WHEN APPLICABLE
JOINT HOSPITAL SURGICAL GRAND ROUND 19th May 2007
What
Only a few prospective trials None of them was randomized
Level of evidence is very low
W h i c h s u r g i c a l t e c h n i q u e s h o u l d b e u s e d ?
JOINT HOSPITAL SURGICAL GRAND ROUND 19th May 2007
What
MINIMALLY INVASIVE RETROPERITONEAL PANCREATIC NECROSECTOMY Removal of the solid necrotic material under direct vision through a wide bore tract Use of high volume post-operative lavage Can be performed under local anaesthesia Reduced the need for post-operative intensive care Avoiding escalation of organ dysfunction
Increase in the number of procedures
W h i c h s u r g i c a l t e c h n i q u e s h o u l d b e u s e d ?
Connor S et al. Minimally invasive retroperitoneal pancreatic necrosectomy. Dig Surg 2003.
Carter RC, et al. Percutaneous necrosectomy and sinus tract endoscopy in the management of infected pancreatic necrosis: An initial experience. Ann
Surg 2000.
Not yet been shown to significantly reduce
mortality
JOINT HOSPITAL SURGICAL GRAND ROUND 19th May 2007
What
ENDOSCOPIC THERAPY: First reported by Baron in 1996• Several transgastric o transduodenal drainage catheters in
serted endoscopically• Lavage continued until resolution of the collection• 2-4 procedures were required for resolution• Mean duration of catheter placement was 19 days• Successful removal of necrosis in > 80%• No mortality
• Almost 40% iatrogenic infection• Serious complication in 45% of patient including serious bl
eeding, perforation• Up to 60% developed further collection after two years
W h i c h s u r g i c a l t e c h n i q u e s h o u l d b e u s e d ?
Baron T, et al. Endoscopic therapy for organized
pancreatic necrosis. Gastroenterology 1996.
JOINT HOSPITAL SURGICAL GRAND ROUND 19th May 2007
What
A n y p l a c e f o r e n d o s c o p i c t h e r a p y ?
Series N PathologyStudy design
Mortality
Mean no of procedures
Morbidity
Charnley
Endoscopy 2006
13 11 infectedRetro-spective 15 % 4
Open surgery x 1Additional percutaneous drainage x 2Laparoscopic drainage x 3
Hookey
GIE 2006
116
Necrosis x 8Pancreatic abscess x 9Acute fluid collection + acute and chronic pseudocysts
Retro-spective 5.1% / 11%
Seewald
GIE 200513
Pancreatic necrosis and abscess
Retro-spective N/A /
Open surgery x 1 Recurrent pseudocyst x 2Bleeding x 4
JOINT HOSPITAL SURGICAL GRAND ROUND 19th May 2007
What
W h i c h s u r g i c a l t e c h n i q u e s h o u l d b e u s e d ?
Werner J, et al. Management of acute pancreatiits: from surgery to interventional intensive care. G
ut 2005.
MINIMALLY INVASIVE PROCEDURES FOR INFECTED PANCREATIC NECROSIS ARE
STILL EVOLVING
JOINT HOSPITAL SURGICAL GRAND ROUND 19th May 2007
Conclusion
• Whom– Infected necrosis– Sterile necrosis with MOF despite maximal support
• When– Early surgery not recommended– Desirable to be 3rd to 4th week after the onset
• What– Organ preserving necrosectomy vs pancreatic reseciton– Open vs closed– Packing vs continuous lavage– Convention vs Minimally invasive
W h a t s h a l l w e d o ?
JOINT HOSPITAL SURGICAL GRAND ROUND 19th May 2007
Conclusion
• Low level of evidence• Further studies:
– Refine the indications for surgery– Define the timing for surgery– Find the optimal procedures– Newer approaches: laparoscropic, endoscopic, retr
operitoneal procedures
W h a t s h a l l w e d o ?
JOINT HOSPITAL SURGICAL GRAND ROUND 19th May 2007