MANAGEMENT OF PANCREATIC NECROSIS

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MANAGEMENT OF PANCREATIC NECROSIS

• Kevin E. Behrns, M. D.
• Division of Gastrointestinal Surgery

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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 1993128586

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PANCREATIC NECROSISSurgical Indications

• WHAT ARE THE SURGICAL
• INDICATIONS FOR DEBRIDEMENT OR NECROSECTOMY?
• Absolute indications
• Relative indications

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PANCREATIC NECROSISSurgical Decision-Making
PANCREATIC NECROSIS
INFECTED NECROSIS
STERILE NECROSIS
NON-OPERATIVE MANGEMENT VS. NECROSECTOMY
NECROSECTOMY
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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

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PANCREATIC NECROSISInfected Necrosis

• Outcomes
• Mortality 6-24
• Morbidity 34-50
• Bacteria
• Staph
• E. coli
• Klebsiella
• Ann Surg 1998228676
• 2000234619
• 2001234572

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PANCREATIC NECROSISInfected Necrosis
Ann Surg 2000232619
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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.

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PANCREATIC NECROSISSterile Necrosis

• Utility of FNA
• Good sensitivity and specificity
• Highly dependent on accurate needle placement in
  necrotic tissue (not nearby fluid collection)
• Surgeons Perspective- not that useful
• Timing is everything in pancreatic necrosectomy
• Early positive FNA forces surgeons hand when
  pancreatic necrosis not demarcated
• May result in multiple operations and increased
  risk of morbidity and mortality
• CONSULT SURGEON PRIOR TO FNA

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PANCREATIC NECROSISSterile Necrosis

• Controversial management
• Non-operative management
• Most of the world
• Operation for all patients with pancreatic
  necrosis
• MGH

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PANCREATIC NECROSISSterile Necrosis-
Non-Operative Management
Ann Surg 2000232619
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PANCREATIC NECROSISSterile Necrosis

• Which patients are
• likely to get
• infected necrosis?

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PANCREATIC NECROSISSterile Necrosis

• What are the outcomes with planned operative
  management of sterile necrosis?
• Mortality 6.2
• Ann Surg 1998228676

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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

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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 1998228676

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PANCREATIC NECROSISSterile Necrosis

• What are the outcomes of patients that have
  delayed operation for sterile pancreatic
  necrosis?
• Ann Surg 2001 234572

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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 2003901542

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PANCREATIC NECROSISQuality of care

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

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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 20022565

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PANCREATIC NECROSISSurgical Treatment Guidelines

• IAP recommendations (continued)
• Patients with infected necrosis and clinical
  presentation of sepsis should have surgery or
  radiological drainage
• Early surgery (lt14 days) not recommended unless
  special circumstances
• Surgical operations should favor organ-preserving
  approach
• Cholecystectomy should be performed at operation
• Pancreatology 20022565

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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 20022565

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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