JOINT HOSPITAL SURGICAL GRAND ROUND 19 th May 2007 Charing Chong Alice Ho Miu Ling Nethersole Hospital / North District Hospital Surgery for Severe Pancreatitis:

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


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 ?


SURGEONPATIENT


Who requires surgery?When to intervene?

What technique should be used?


WHOM?


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


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


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


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


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.



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.


WHEN?


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 ?


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.


• 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)


When

In case of suspected or proven infection of necrosis, prophylactic antibiotic treatment could be primarily applied


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


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)


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



WHAT?


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.


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


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.


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


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.


CAREFUL SINGLE NECROSECTOMY AND POST-OPERATIVE LAVAGE

WITHOUT PLANNED RELAPAROTOMIES SEEMS TO BE LESS HARMFUL AND COULD BE

CONSIDERED WHEN APPLICABLE


What

Only a few prospective trials None of them was randomized

Level of evidence is very low



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


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


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


Baron T, et al. Endoscopic therapy for organized

pancreatic necrosis. Gastroenterology 1996.


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


What


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


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 ?


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 ?


Documents

JOINT HOSPITAL SURGICAL GRAND ROUND 19 th May 2007 Charing Chong Alice Ho Miu Ling Nethersole Hospital / North District Hospital Surgery for Severe Pancreatitis: