Presentation on theme: "The Management of Acute Necrotizing Pancreatitis"— Presentation transcript:
1 The Management of Acute Necrotizing Pancreatitis Stephanie Cheung Hay ManCaritas Medical Centre25th July 2009Joint Hospital Grand Round
2 IntroductionSevere pancreatitis occurs in 15-20% of patients with acute pancreatitisThe degree of necrosis and the presence of infection are crucial determinants of overall outcomePatients with predicted severe acute pancreatitis should be nursed in high dependency unit or ICUClose monitoring and organ support
3 Disease progression Early First 2 weeks Organ failure is common As a result of SIRS due to release of inflammatory mediators into the circulationLateTwo weeks after onset of symptomsDominated by septic related complications of the infected necrosis
4 UK Guidelines 2003 The Management of Acute Pancreatitis
5 ControversiesDoes prophylactic antibiotic help to prevent infection of the pancreatic necrosis?Management of necrosisWhat is the role of surgery in sterile necrosis?Which is the best treatment modality for infected necrosis?
6 Meta-analysis of Prophylactic Antibiotic Use In Acute Necrotizing Pancreatitis (ANP) In total 6 eligible RCT included, 329 patients in the meta-analysis with 167 received prophylactic AB and 162 in the control group.Infected necrosis reported in all studies. Of total 81 patients with infected necrosis, 34 in prophylactic group and 47 in control, Antibiotic group was not associated with significant reduction in incidence of infected necrosis, p= 0.17344 deaths reported in all studies, 17 in prophylactic group and 27 in control. A/B use showed no significant reduction in reducing mortality p=0.404non pancreatic infection ( Respiratory or UTI), results a/v from 4 RCTs only. Of 61 reported non pancreatic infections, 26 in prophylactic group and 35 in control. Again no significant reduction in reducing non pancreatic infection p= 0.402Results a/v from 5 RCTs for need of surgery. 86 ( total) 39 from prophylactic group and 47 from control. Results not significant p=0.1673 RCTS reported on hospital stay. There is significant reduction p= 0.04
7 Prophylactic Antibiotic in ANP On the contrary, some meta-analyses have lent support to prophylactic useIndicating reduction in the incidence of infected necrosis and mortalityVillatoro et al Antibiotic Therapy for Prophylaxis Againist Infection of Pancreatic necrosis in ANP; Cochrane Database Syst Rev 2009
8 Is Prophylactic Antibiotic Useful In ANP? Remains controversialImipenem is frequently used due to its good penetration to the pancreasJudicious use of antibioticChange of Gram negative to Gram positive infectionPromotion of fungal infectionBuchler et al Acute Necrotizing Pancreatitis: Treatment Strategy According to The Status of Infection; Ann of Surg 2000Whether to use prophylactic antibiotic or not remains controversial. Imipenem is frequently used due to its good penetration to the pancreas, however one should consider it use with caution
9 Management of Necrosis in ANP What is the optimal time for necrosectomy?What is the role of surgery in sterile necrosis ?Which surgical modality is best for treating infected necrosis?
10 Timing of Surgery in ANP (I) For predicted severe pancreatitis, CT helps to document the presence and degree of necrosisEarly phase – multimodality approachSafe period – 4-6 weeksSurgical intervention in the early phase carries high mortality when inflammation is spreading without a clear demarcationThe unorganised necrosis also leads to massive intraoperative bleedingMT Cheung Surgical Intervention in Necrotizing Pancreatitis: towards lesser and later, ANZ J Of Surg 2009With the use of CT in dx the presence and amount of necrosis in the pancreatitis, these patients ought to be management with mutlidisciplinary approach in the early phase. The safe period suggested around 4-6 weeks due to surgery in early phase carries high mortality when inflammation is spreading without demarcation and the unorganised necrosis easily lead to massive bleeding intraoperatively
11 Timing Of Surgical Intervention In ANP (II) Retrospective study of 53 infected necrosisSurgery for persistant organ failure despite maximal ICU support or proven infected necrosisOpen necrosectomy and post operative lavagePost operative mortality ratewithin 14 days – 75%15-29 days – 45%> 30 days – 8%Besselink et al Timing of surgical intervention in necrotizing pancreatitis, Arch of Surg 2007In this study, the authors aimed to find out the optimal timing of surgical intervention. 53 pts reviewed retrospectively, surgery indicated for persistant organ failure and proven infected necrosis. Open necrosectomy with post op larvage used . There is significant reduction in mortality when surgery performed more than 30 days p< 0.01
13 Does Surgery Help in The Management of Sterile Necrosis? Sterile necrosis is not an indication to surgeryReports have shown that sterile necrosis can be managed conservatively with antibioticsWith the exception when persistant or progressive organ complications despite maximal ICU supportHeinrich et al, Evidence Based Treatment of Acute Necrotizing Pancreatitis, Ann of Surg 2006The decision to surgery is by clinical judgementFNA has false negative rate
14 Conservative Management of Sterile Necrosis 86 patients with ANPAll were given imipenemSterile necrosis Mx with antibiotic regime Mortality 1.8%Buchler et al Acute necrotizing pancreatitis: Treatment strategy according to the status of infection; Ann of Surg 2000100% survival on conservative ManagementBradley and Allen A prospective longitudinal study of observation vs surgical intervention in the management of ANP; Am J Surg 1991
15 Results Of Surgery In Sterile Necrosis Mortality rate is significantly higher in the surgical group than conservative treatmentMeta-analysis to justify the role of surgery in sterile necrosis is not possible because these studies are not randomised controlled trials. If we compare the mortality rate of surgery vs conservative with sterile nercosis as the indication to surgery, there is significant increase in mortality in the surgical group
16 Management Of Infected Necrosis in ANP What Treatment Modalities Are Available?
17 Open NecrosectomyOpen necrosectomy + continuous post- operative drainage with irrigation is commonly used for infected necrotizing pancreatitisConsiderable mortality 15-43%Connor et al Early and Late Complications After Necrosectomy; Surgery 2005Werner et al Surgery in The Treatment of Acute Pancreatitis- open pancreatic necrosectomy; Scand J Surg 2005
18 Minimally Invasive Necrosectomy Sometimes radiological guided drainage is used to facilitate post op drainage and to delay open necrosectomy, MIN offers advantage over radiological drainage as it enables infected necrosum debridement and avoid laparotomy
19 Published Series Of MIN Up To 2008 No perioperative complicationSingle/ double sessionsMortality rate < 20%This table shows a list of published series of MIN, the no. of patients is each study is small, MIN used due to open necrosectomy and post op drainage or just radiological drainage not enough to control sepsis
20 Laparoscopic Assisted Necrosectomy Removal of necrosis under direct visionOperative time ~ 87 mins75% with complete clearance of necrosis after single sessionNo peri or post operative complicationBucher et al Minimally Invasive Necrosectomy for Infected Necrotizing Pancreatitis; Pancreas 2008
21 Percutaneous Necrosectomy 8fr nephrostomy catheter placed into necrosis under CT guidanceirrigation, suction and piecemeal extraction of necrotic debrisNo patients required open surgeryMean ~ 2 sessionsCarter et al Percutaneous necrosectomy and sinus tract endoscopy in the management of infected pancreatic necrosis; Ann of Surg 2000
22 Which Is Better? MIN vs open necrosectomy SafeEffectiveImproved mortality and morbidityThe PANTER trial (The Netherlands)Multicentred RCTMinimal invasive step up approach vs open necrosectomy in patients with acute necrotizing pancreatitis
23 Conclusion- Management of ANP Prophylactic antibioticNo definite data supporting use of A/B to improve mortality and reduce incidence of infected necrosisJudicious use of antibiotic due to trend of emerging Gram positive and fungal infection
24 Conclusion- Management of Necrosis Timing of necrosectomy – towards the later the betterSurgery is not indicated in patients with sterile necrosis except when clinical condition continues to deteriorate despite maximal ICU careThe efficacy of MIN in ANP is yet to be determined by future randomized controlled trial whether the observed improved mortality and morbidity is attributable to this surgical approach