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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?