role of surgery in sap in minimally-invasive era
TRANSCRIPT
![Page 1: Role of surgery in SAP in minimally-invasive era](https://reader035.vdocuments.mx/reader035/viewer/2022081615/62ca97338d436a782e4f1816/html5/thumbnails/1.jpg)
Role of Surgery for SAP
in Minimally-invasive Era
Yi MIAO, MD PhD FACS FRCS FICS(Hon)
Pancreas Center
Institute of Pancreas
![Page 2: Role of surgery in SAP in minimally-invasive era](https://reader035.vdocuments.mx/reader035/viewer/2022081615/62ca97338d436a782e4f1816/html5/thumbnails/2.jpg)
The MIS Era of Surgical Treatment for SAP
PancreasFest 2019・Pittsburgh
![Page 3: Role of surgery in SAP in minimally-invasive era](https://reader035.vdocuments.mx/reader035/viewer/2022081615/62ca97338d436a782e4f1816/html5/thumbnails/3.jpg)
20112010 201
32012
2014
1886
-1929
1960
-1970s1990s
1930
-1950
1970
-1980s2000s
Early surgerySimple
drainage
Pancreaticresections
DelayedSurgery
Non-surgicaltreatment
Debridement& Drainage
Debridement& Drainage
with MISapproach
The Journey of Odessey
Surgical treatment pattern in SAP
Bradley EL 3rd, et al. Ann Surg 2010PancreasFest 2019・Pittsburgh
![Page 4: Role of surgery in SAP in minimally-invasive era](https://reader035.vdocuments.mx/reader035/viewer/2022081615/62ca97338d436a782e4f1816/html5/thumbnails/4.jpg)
PancreasFest 2019・Pittsburgh
The value of surgical step-up approach
2010, NEJM
The value of endoscopic step-up approach
2018, Lancet
Surgical treatment pattern in SAP
![Page 5: Role of surgery in SAP in minimally-invasive era](https://reader035.vdocuments.mx/reader035/viewer/2022081615/62ca97338d436a782e4f1816/html5/thumbnails/5.jpg)
The PANTER study Long-term FU w/ 86 ± 11 months FU time
Step-up approach was associated w/
- Less death + major complications (44% vs. 73%, p= 0.005)
- Less incisional hernias (23% vs. 53%, p = 0.004)
- Less PEI (29% vs. 56%, p = 0.03)
- Less endocrine insufficiency (40% vs. 64%, p = 0.05)
Hollemans RA, et al. Gastroenterology 2019
![Page 6: Role of surgery in SAP in minimally-invasive era](https://reader035.vdocuments.mx/reader035/viewer/2022081615/62ca97338d436a782e4f1816/html5/thumbnails/6.jpg)
IPD Meta Analysis
1980 Px w/ necrotizing pancreatitis from 51 hospitals in 8
countries (1991-2011)
1167 open, 467 MIS surgical & 346 MIS endoscopic
necrosectomy
- ↓ Death for surgical MIS (OR=0.53, p=0.006), and ↓ Death for
endoscopic MIS (OR=0.20, p=0.006)
After PSM with risk stratification
- In very high risk group: ↓ Death for surgical MIS (RR=0.70, p=0.02),
and ↓ Death for endoscopic MIS (RR=0.43, p=0.005)
- In high risk group: ↓ Death for endoscopic MIS (RR=0.27, p=0.03)
van Brunschot S, et al. Gut 2018PancreasFest 2019・Pittsburgh
![Page 7: Role of surgery in SAP in minimally-invasive era](https://reader035.vdocuments.mx/reader035/viewer/2022081615/62ca97338d436a782e4f1816/html5/thumbnails/7.jpg)
Surgery for SAP in China
PancreasFest 2019・Pittsburgh
![Page 8: Role of surgery in SAP in minimally-invasive era](https://reader035.vdocuments.mx/reader035/viewer/2022081615/62ca97338d436a782e4f1816/html5/thumbnails/8.jpg)
The Nanjing Pancreas Center A multi-disciplinary center designated for pancreatic diseases (24/7 MDT)
A real high-volume center- 644 pancreatic resections, 371 Whipples, and 455 APs, 32 SAPs, 98 NAPs in 2018
Treatment modalities in our center (All-in-One)- CT guided PCD
- MARPN
- Endoscopic drainage & debridement
- Small-incision retroperitoneal necrosectomy
- Trans-abdominal open necrosectomy ± small-incision Doctors in the Center
![Page 9: Role of surgery in SAP in minimally-invasive era](https://reader035.vdocuments.mx/reader035/viewer/2022081615/62ca97338d436a782e4f1816/html5/thumbnails/9.jpg)
Surgery for SAP in China
What we’ve learnt as surgeons for the SAP treatment
during the past 10 years
Delayed intervention
Minimal-invasion
To avoid trans-abdominal approach
Techniques in necrosectomy
High-volume makes profession and perfection
PancreasFest 2019・Pittsburgh
![Page 10: Role of surgery in SAP in minimally-invasive era](https://reader035.vdocuments.mx/reader035/viewer/2022081615/62ca97338d436a782e4f1816/html5/thumbnails/10.jpg)
“Tomb Raider” techniques in necrosectomy
Historical material + shovel
Right timing (Midnight)
Find safe pathways
Enter vaults along passage
Dig out treasures
Running away
Tomb Raiders Surgeons
Medical history + Imaging
Right timing(after 4w)
Find right approaches
Enter cavities along abscess
Take out debris and pus
Drainage & -ostomies
PancreasFest 2019・Pittsburgh
![Page 11: Role of surgery in SAP in minimally-invasive era](https://reader035.vdocuments.mx/reader035/viewer/2022081615/62ca97338d436a782e4f1816/html5/thumbnails/11.jpg)
Surgery for SAP in China
Our surgical techniques for surgical necrosectomy in SAP
Precise allocation of necrotic cavity: imaging study, route of
PCD
Combined approach: flank retroperitoneal small incision ±
trans-abdominal incision, depends on the location and form
of necrotic cavity
Trans-abdominal: Approach via the greater curvature
Debridement: Iron-heart with soft-hand
Cautions: Signs of GI fistula, bare vessels
Large-bore drainage with irrigation
PancreasFest 2019・Pittsburgh
![Page 12: Role of surgery in SAP in minimally-invasive era](https://reader035.vdocuments.mx/reader035/viewer/2022081615/62ca97338d436a782e4f1816/html5/thumbnails/12.jpg)
Surgical algorithm I
Choosing approach according to necrosis location
Central type: trans-abdominal
Lateral / bilateral type: flank retroperitoneal small incision
Mixed type: combined approach
PancreasFest 2019・Pittsburgh
![Page 13: Role of surgery in SAP in minimally-invasive era](https://reader035.vdocuments.mx/reader035/viewer/2022081615/62ca97338d436a782e4f1816/html5/thumbnails/13.jpg)
Surgical algorithm II
Early surgical intervention (<4 weeks)
Massive hemorrhage, fistulas, sepsis due to large IPN, etc.
43 year-old, Male
Uncontrolled IPN
Referred from another
hospital 300km+ away
Repeated CPR on his
transferring way
PCD was utilized
Massive venous
hemorrhage
Emergent open surgery
Video clip
![Page 14: Role of surgery in SAP in minimally-invasive era](https://reader035.vdocuments.mx/reader035/viewer/2022081615/62ca97338d436a782e4f1816/html5/thumbnails/14.jpg)
Colonic fistula
Video clip
![Page 15: Role of surgery in SAP in minimally-invasive era](https://reader035.vdocuments.mx/reader035/viewer/2022081615/62ca97338d436a782e4f1816/html5/thumbnails/15.jpg)
MARPN
Video clip
![Page 16: Role of surgery in SAP in minimally-invasive era](https://reader035.vdocuments.mx/reader035/viewer/2022081615/62ca97338d436a782e4f1816/html5/thumbnails/16.jpg)
Endoscopic Necrosectomy
Video clip
![Page 17: Role of surgery in SAP in minimally-invasive era](https://reader035.vdocuments.mx/reader035/viewer/2022081615/62ca97338d436a782e4f1816/html5/thumbnails/17.jpg)
Small-incision Retroperitoneal Necrosectomy
Video clip
![Page 18: Role of surgery in SAP in minimally-invasive era](https://reader035.vdocuments.mx/reader035/viewer/2022081615/62ca97338d436a782e4f1816/html5/thumbnails/18.jpg)
Surgical Necrosectomy
Video clip
![Page 19: Role of surgery in SAP in minimally-invasive era](https://reader035.vdocuments.mx/reader035/viewer/2022081615/62ca97338d436a782e4f1816/html5/thumbnails/19.jpg)
Reflections on the Current Treatment Model
PancreasFest 2019・Pittsburgh
![Page 20: Role of surgery in SAP in minimally-invasive era](https://reader035.vdocuments.mx/reader035/viewer/2022081615/62ca97338d436a782e4f1816/html5/thumbnails/20.jpg)
Reflections on current surgical treatment in SAP
ALL patients undergoing same treatment modality,
ignoring the characteristics of the necrosis
ALL patients undergoing step-up approach, ignoring the
personal features of the disease
ALL patients undergoing intervention after 4 weeks
PancreasFest 2019・Pittsburgh
![Page 21: Role of surgery in SAP in minimally-invasive era](https://reader035.vdocuments.mx/reader035/viewer/2022081615/62ca97338d436a782e4f1816/html5/thumbnails/21.jpg)
Surgical Step-up
Interventions from
serosal surface
Endoscopic Step-up
Interventions from
mucosal surface
Approach depends on familiar technique, not on the patient
Doctors tend to not trust techniques from other disciplines
Deeply integrated MDT team is the solution
Trans-mucosal vs. Trans-serosal Surgery
SURGERY vs. NOTES
![Page 22: Role of surgery in SAP in minimally-invasive era](https://reader035.vdocuments.mx/reader035/viewer/2022081615/62ca97338d436a782e4f1816/html5/thumbnails/22.jpg)
Assistant: “Should we remove the lipoma with NOTES?”
Surgeon: “NOTES is NUTS”
From: The little
book of surgical
cartoons,
Evgeniy E. Perelygin
![Page 23: Role of surgery in SAP in minimally-invasive era](https://reader035.vdocuments.mx/reader035/viewer/2022081615/62ca97338d436a782e4f1816/html5/thumbnails/23.jpg)
“Dry” necrosis VS. “Wet” necrosis
“Dry” necrosis
- Mainly solid/semi-solid necrosis
- Debridement is the mainstay of treatment
- More likely need small-incision/open
necrosectomy
“Wet” necrosis
- Mainly liquified necrosis and pus
- Drainage is the mainstay of treatment
- More likely to be cured by MIS approach
PancreasFest 2019・Pittsburgh
![Page 24: Role of surgery in SAP in minimally-invasive era](https://reader035.vdocuments.mx/reader035/viewer/2022081615/62ca97338d436a782e4f1816/html5/thumbnails/24.jpg)
Solid debris evaluation
PancreasFest 2019・Pittsburgh
Accuracy of CT in evaluation of percentage fluid
volume was 65% using T2WI MRI used as standard
Higher interreader agreement for percentage fluid
volume on MRI (κ = 0.55) vs. CT (κ = 0.196)
MRI demonstrates higher reproducibility for fluid
to debris component estimation
Kamal A, et al. Abdom Imaging 2015
![Page 25: Role of surgery in SAP in minimally-invasive era](https://reader035.vdocuments.mx/reader035/viewer/2022081615/62ca97338d436a782e4f1816/html5/thumbnails/25.jpg)
Solid debris evaluation
Rana SS, et al. Gastroenterol Rep (Oxf) 2016
More than 40% debris was better characterized on EUS and MRI
EUS detected collaterals around WOPN that were not detected on
USG or MRI PancreasFest 2019・Pittsburgh
![Page 26: Role of surgery in SAP in minimally-invasive era](https://reader035.vdocuments.mx/reader035/viewer/2022081615/62ca97338d436a782e4f1816/html5/thumbnails/26.jpg)
When not step-up?
Case 1: repeated endoscopic necrosectomy
Endoscopic necrosectomy for 17 times + endoscopic gastrostomy
+ ERC w/ biliary stenting
Hospitalization 4 months+, Px developed mental sickness
Video clip
![Page 27: Role of surgery in SAP in minimally-invasive era](https://reader035.vdocuments.mx/reader035/viewer/2022081615/62ca97338d436a782e4f1816/html5/thumbnails/27.jpg)
Solid debris & clinical outcomes
Rana SS, et al. Endosc Ultrasound 2014
<10% necrotic debris needed only single session of endoscopic
drainage,
10-40% solid debris needed two or more sessions
>40% solid debris either needed direct endoscopic debridement or
surgical necrosectomy
<40% solid debris >40% solid debris
PancreasFest 2019・Pittsburgh
![Page 28: Role of surgery in SAP in minimally-invasive era](https://reader035.vdocuments.mx/reader035/viewer/2022081615/62ca97338d436a782e4f1816/html5/thumbnails/28.jpg)
Prediction of need for surgery after PCD
130 IPN, factors associated with PCD
success (survival w/o necrosectomy)
were analyzed
Risk factors for reduced success- Male sex (OR=0.27, p<0.01)
- Multiple organ failure (OR=0.15, p<0.01)
- Percentage of pancreatic necrosis (<30%/30%–
50%/>50%: OR=0.54, p=0.03)
- Heterogeneous collection (OR=0.21, p<0.01)
Prediction model: AUC-ROC = 0.76Hollemans RA, et al. Ann Surg 2016
PancreasFest 2019・Pittsburgh
![Page 29: Role of surgery in SAP in minimally-invasive era](https://reader035.vdocuments.mx/reader035/viewer/2022081615/62ca97338d436a782e4f1816/html5/thumbnails/29.jpg)
Prediction of need for surgery after PCD
Other reported Risk factors
Alcoholic pancreatitis
Hypocalcaemia at admission; higher APACHE II at admission
Extrapancreatic necrosis in the left anterior and posterior para-renal
spaces
Mean CT density of necrotic fluid collection
Number of failed organ; late-onset organ failure on PCD
Up-rising trend in hsCRP, IL-6, prealbumin during treatment; lower
albumin level
Serum procalcitonin levelShenvi S, et al. Pancreatology 2016
Ji L, et al. Pancreas 2018PancreasFest 2019・Pittsburgh
![Page 30: Role of surgery in SAP in minimally-invasive era](https://reader035.vdocuments.mx/reader035/viewer/2022081615/62ca97338d436a782e4f1816/html5/thumbnails/30.jpg)
Tailored approach for SAP
Clinical situations with predicted failure of non-surgical
treatment (PCD, MARPN, endoscopic…) [Indication >5 points]
- Amount of necrotic debirs (≥200m / ≥400mL in imaging study)
[3 points/5 points]
- Large hematoma after hemorrhage w/ infected necrosis [2
points]
- Early development of clinical deterioration (≥2 persistent organ
failure) despite ideal intensive care [2 points]
- Other risk factors: Male gender, etc. [1 point]
- Presence of sepsis [1 point]
PancreasFest 2019・Pittsburgh
![Page 31: Role of surgery in SAP in minimally-invasive era](https://reader035.vdocuments.mx/reader035/viewer/2022081615/62ca97338d436a782e4f1816/html5/thumbnails/31.jpg)
Take home message
Step-up approach is the currently preferred treatment
modality for necrotizing pancreatitis
Surgery remains to be indispensable in the minimal-
invasion era
Not all patient will benefit from a fixed treatment norm
New risk-stratified treatment strategy warrant further
validation
PancreasFest 2019・Pittsburgh
![Page 32: Role of surgery in SAP in minimally-invasive era](https://reader035.vdocuments.mx/reader035/viewer/2022081615/62ca97338d436a782e4f1816/html5/thumbnails/32.jpg)
PANCREAS CENTER
PANCREAS INSTITUTE
WWW.PANCREAS.ORG.CN
Thank You for Your Attention