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Sepsis in Acute
Pancreatitis
MD Smith
Department of Surgery
University of the Witwatersrand,
Johannesburg
Chris Hani Baragwanath
Academic Hospital
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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
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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
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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
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Results for open Necrosectomy
Werner et.al. Gut 2005
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Results for open Necrosectomy
Werner et.al. Gut 2005
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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
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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
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Selection of patients for
endoscopic necrosectomy
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Eradication of solid necrosis
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Minimally invasive procedures for
debridement of infected necrosis
Patient selection
Expertize
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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%)
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Consecutive series of 189
Necrosectomies
Raraty et al. Ann Surg 2010 May;251(5):787-93
University of Liverpool
Department of Surgery
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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
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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
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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
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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
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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
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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
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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
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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
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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
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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
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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 ?
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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
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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
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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%)
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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%
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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)
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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
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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?