Sepsis in Acute Pancreatitis - UP · –Open necrosectomy is no longer the standard of care...

Sepsis in Acute

Pancreatitis

MD Smith

Department of Surgery

University of the Witwatersrand,

Johannesburg

Chris Hani Baragwanath

Academic Hospital

Introduction

Self limiting disease in 85%

Minority develop severe pancreatitis

characterised by a severe inflammatory

response

These patients develop necrosis

40 - 70% will become infected

This accounts for 80% of mortality

Infected Necrosis

– Incidence of infection increases from

a low of 24% in the first week to a

high of 55% and 71% in the 3rd and

4th weeks respectively

– Poor outcome, mortality >30%

– Non surgical (interventional)

treatment results in 100% mortality

Management of Infected

Necrosis

What is accepted management?

– Open necrosectomy is no longer the

standard of care

– infected necrosis mandates intervention

– little role for organ resection

Results for open Necrosectomy

Werner et.al. Gut 2005

Results for open Necrosectomy

Werner et.al. Gut 2005

Minimally invasive procedures for

debridement of infected necrosis

Percutaneous drainage

– Allows for stabilization of critically ill patients

– Very labor intensive and requires dedicated and

committed interventional radiologists

Endoscopic necrosectomy.

Babu BI, Siriwarden AK. HPB 2009;11:96-102

First Author

& year

n Delay to

necrosectomy in

days

Median (range)

Pre-op

Infected

necrosis

Post-op

irrigation

No of

procedures

per pt

Major

complications

(%)

Laparotomy

required

Inpatient

stay

(days)

Mortality

Voermans R

200717

25 84 (21-385) n/a 25 (100%) 2 (7%) 0 5 (1-45) 0

Papachristou GI

200718

53 49

(20-300)

n/a 53 (100%) 3

(1-12)

11 (21%) 12 (23%) 13

(0-90)

3 (6%)

Will U 200619 5 n/a n/a n/a 2 (average)

2-6 (range)

0 0 n/a n/a

Hookey LC 200620 8 23 (mean)

(10-45)

n/a 6 (75%) nasocystic

1 (median)

(iqr 1-1)

2 (25%) 2 (25%) 18 (10-

35)

1 (13%)

Charnley RM

200621

13 24 (3-180) 11 (85%) 13 (100%)

Naso-

cavity

4 (1-10) n/a 1 (8%) n/a 2(15%)

Raczynski S

200622

2 n/a n/a 2 (100%) 4 0 0 n/a 0

Seewald S 200523 5 14 n/a 5 7 n/a (2) 40% n/a 0

Baron TH 200224 43 n/a n/a n/a 2 (1-6) 16 (37%) n/a 20 (0-75) 1 (2%)

Seifert H 200025 3 n/a 0 n/a n/a 0 0 n/a 0

Selection of patients for

endoscopic necrosectomy

Eradication of solid necrosis

Minimally invasive procedures for

debridement of infected necrosis

Patient selection

Expertize

Percutaneous Necrosectomy in Glasgow

Management of post acute fluid collections Glasgow 1998 -2010

Drainage route N(total) N (tech success) infected Success mortality

Transpapillary 79 73(92%) - 60(82%) 1(1.5%)#

Transmural 88 - - 73(83%) 1(1.1%)#

Perc Necrosectomy 159 148(95%) 142(92%) 124(78%) 30(19%)

Surgical open 38 38(100%)- 34(93%) 28(74%) 10(27%)

laparoscopic cyst gastrostomy

36 6 conversions - 34(94%) 0(0%)

Open cyst gastrostomy 8 8(100%) - 8 (100%) 0(0%)

total 408 337(81%) 41(10.2%)

Consecutive series of 189

Necrosectomies

Raraty et al. Ann Surg 2010 May;251(5):787-93

University of Liverpool

Department of Surgery

Demographics Variable n=189 N % or range

Median age (yrs) 58 18-85

Aetiology (stones or Etoh) 119 63

Infected necrosis 107/162 64

ITU prior to surgery 75 40

Time to Surgery (days)

32 1-181

No significant difference between two groups University of Liverpool

Department of Surgery

Outcome Variable median (range) Open

(n=52)

MARP (n=137)

p

Number of

procedures

1 (1-9) 3 (1-9) <0.001

Hospital stay 85 (8-222) 95 (16-300) 0.011

Morbidity (%) 42 (81) 75 (55) 0.001

Mortality (%) 20 (38) 26 (19) 0.009

University of Liverpool

Department of Surgery Raraty et al. Ann Surg 2010 May;251(5):787-93

MARP associated with reduced

APACHE II scores and post-operative

need for ITU

Pre-operatively Post-operatively

0

20

40

60

80

100

MARP OPN MARP* OPN*

0

2

4

6

8

10

12

14

P<0.001

P<0.001

APACHE II scores

(n=137) (n=52)

APACHE II scores

p=0.038

p=0.773

ITU stay ITU stay

Median,

(range) (n=137) (n=52)

(1-29)

(2-20)

(1-22)

(2-24)

(*Increase in % requiring ICU post op, MARP p=0.544, OPN p<0.001) University of Liverpool

Department of Surgery

Minimal Access

Retroperitoneal Necrosectomy

Liverpool data

– Lower morbidity and mortality and decrease

need for ICU with lower rise in post operative

inflammatory markers and new onset of organ

dysfunction

CHBAH experience up to 2011

28 patients: 16 males; 12 females

Median age: 39 (20 – 75) years

Organ failure: 3 (1 – 5)

Etiology:

– Alcohol: 13

– Gallstones: 8

– ARVs: 5

– ?idiopathic: 2

Number of procedures/pt: 3 (2 – 6)

ICU\HCU stay: 23 (6 – 46) days

Hospital stay: 48 (40 – 80) days

Follow-up: 8 (6 – 15) months

Complications 15

– pancreatic fistula 7

– pneumonia 5

– enterocutaneous fistula 3

Mortality 5 (17.9%):

– pulmonary embolism 1

– multiple organ failure 3

– Mesenteric artery aneurysms 1

Timing of Necrosectomy

Rationale for delaying intervention for as long as

possible and up to 3 weeks

– Maturation of infected necrotic lesions

– Allow demarcation of necrosis

– Aids in debridement and reduces bleeding

– Allow reversal of organ dysfunction

If bowel perforation or massive bleeding or

abdominal compartment syndrome early surgery

must be performed

Percutaneous Catheter

Drainage Experience with this as a secondary

procedure after open necrosectomy

and in delaying necrosectomy

Little evidence to support is use as

a primary therapy

Uncertain of role but its use will

become a permanent part of the

landscape

Placement of external drains may reduce

pressure in the necrosis and “take the

heat out of the fire”

Reduce pressure in the contained area of

pus

56% of patients survived without additional

surgical necrosectomy (214/384 pts in 11 studies)

c.f. 35% in PANTER trial

BJS 2011

How often is PCD effective as

primary treatment ?

How often is PCD feasible ?

PCD deemed „feasible‟ in 84 % (67/80 patients)

– But PCD via left retroperitoneum feasible in only 56 %

Lesion was „drainable‟ in 56 % (43/80 patients)

– But poor interobserver agreement (kappa = 0.289)

BJS 2007

Step up approach

Panter trial

– First RCT comparing minimally invasive with

open approach

– Also gave supporting evidence for the evolving

concepts that there was not a one size fits all

approach

– Supporting evidence for PCD as primary

treatment

A step-up approach or open necrosectomy for necrotizing

pancreatitis. Van Sanvoort HC et al. New Engl J Med 2010;362 1491-1502

Primary open

necrosectomy

n = 45

Minimally

invasive step-up

approach.

N = 43

CTSI 8 (4-10) 8 (4-10)

Retroperitoneal

percutaneous

drainage

43

Number

undergoing

necrosectomy

44

Additional

necrosectomy

19 (42%)

Percutaneous

drainage

15 (33%)

A step-up approach or open necrosectomy for necrotizing

pancreatitis. Van Sanvoort HC et al. New Engl J Med 2010;362 1491-1502

Primary open

necrosectomy

n = 45

Minimally

invasive step-up

approach.

N = 43

Composite

primary endpoint

(major

complications or

death)

31 (69%) 17 (40%)

Percutaneous

drainage only

35%

Mortality

19%

16%

First intervention whenever feasible

Room to improve technique

– Standardization, regular exchange, multiple, and

larger calibre with up-sizing

– Continuous ± pulsatile irrigation

– Future: accelerate liquifaction (dec LOS)

techniques

PCD: no standardization as identified in

systemic review

– Consider bigger drains

– Frequent dilatation and increase in size and

number of drains as required

– Improved technology such as ports for repeated

interventions without anaesthesia

Exciting time as rapid developments in the

treatment of infected pancreatic necrosis.

Much work needs to be done to answer the

evolving questions posed by this minimally

invasive approach

– Primary PCD is not suitable for all patients and

can we begin to predict which patients will

succeed?

– Can we increase the number of patients in

which PCD will succeed?