Details the current approach to the management of pancreatic necrosis and other local complications of acute pancreatitis.

1. Management of Pancreatic fluid collections and
Necrosis
Dr. Abhishek Yadav
MS MCh
Consultant Liver Transplantation
& GI Surgery
Calicut Gut club
10th Jan 2018

2. ‘With the formation of pus in the omental
cavity comes the opportunity for the surgeon’
Fitz, 1889

3. Approach to acute pancreatitis: has anything
changed?

4. There is much that has not changed in acute
pancreatitis

5. Natural History
Out of every 100 cases:
60-75 mild
25-40 severe
4 to 26
(average 10) die

6. Early surgery in severe acute pancreatitis (1st
3 wks)
• Avoid early surgery
– Initial problems due to SIRS
– No demarcated necrosis
– Early exploration increases the risk of subsequent
infection
– Critical care is the key!

7. The first significant probability cut off point was on day 27
Fernandez-del-Castillo et al, Ann Surg 1998

8. Delay intervention as far as possible
• Hartwig et al, J GI Surg 2002
• De Beaux et al, Gut 1995
• Mier J, Am J Surg 1997 (randomised trial)
• Hungness, JACS 2002

9. • Abdominal compartment syndrome
• Suspicion or proof of bowel perforation or
gangrene
• Pseudoaneurysm on CT (if angiography fails)
3 exceptions to delayed surgery

10. But much has changed too…..

11. Mild
Moderate
Severe
Acute Fluid Collection
Acute Pseudocyst
Pancreatic abscess
Pancreatic Necrosis

13. Well circumscribed
Extra pancreatic
Homogeneous fluid density
No non Liquid content
No internal septa
Heterogenous fluid collection
Walled off
Extra or intra pancreatic

14. Revised Atlanta. Not Perfect!
• AIP and ANP are not always black and white
• Necrosis occurring in fluid collection is dynamic
• 4 Weeks- What transforms overnight?

15. Emergence of newer modalities

16. Options available
• Debride/close/reoperate
• Debride/lesser sac lavage
• Debride/open packing
• lumbotomy
• Open
• Percutaneous
• Percutaneous with sinus tract endoscopy
• Video-assisted retroperitoneal debridement (VARD),
MIRP
• Endoscopic
• laparoscopic
• Minimally
Invasive
• Trans-arterial injection of protease inhibitors
• No operation (supportive therapy, antibiotics, only)
• Non
operative
Gold standard
Emerging treatment?
Is it any good?

18. Conservative treatment of IPN
• Baril Ann Surg 2000 6 cases
• Runzi SCNA 1999 6 cases
• Nordback J GI Surg 2001 3 cases
• Adler Am J GE 2003 3 cases
• Ramesh Dig surg 2003 4 cases
• Whitelaw Br J Surg 2004 8 cases

19. Indications to Intervene
• Only when symptoms can be attributed to the
collection
• Infection
• Persistent abdominal pain
• Nausea
• Anorexia
• Mechanical obstruction

21. . Location
. Size
. Extent (close to pancreas or far
away)
. Necrosis extends to Paracolic gutters
. How close it to parietes?
. Enhancement on CECT?
. How walled off is it?
. How late in the presentation is it?
. More fluid or more necrosis?

22. Percutaneous necrosectomy

23. Big pieces can be removed!

24. Laparoscopic necrosectomy

25. Endoscopic necrosectomy

26. Endoscopic necrosectomy
Pro
• Works well in selected cases,
such as
• Central collections
• WOPN
• Balloon dilatation is safe
Con
• Is EUS needed always?
• Ideal size of balloon yet to be
determined
• Endoscopist needs full
armamentarium of accessories
for necrosectomy
• Optimum use of nasocystic
irrigation catheter not
standardized
• Prolonged procedure – air
embolism risk (? CO2)

27. Endoscopic access

28. Retroperitoneal approaches
Authors Patients MIPN/pt Morbidity Mortality
Carter 14 2 (1-4) 21% 14%
Alverdy 2 2.5 (2-3) 50% 0
Hovarth 6 33% open 33% 0
Risse 6 2 (1-4) 17% 0
Connor 47 3 (1-9) 26% 19%
Cheung 4 NA 75% 0
Haan 3 NA 33% 0
Ahmad 32 3 45% 13%
Selected group of patients and small numbers?

29. Percutaneous catheter drainage
384 patients
66% organ failure
70% had documented infected pancreatic necrosis
55% no need for surgery
17.5% mortality

30. Conclusion: A “considerable” number of patients can be treated with
PCD without the need for surgical
necrosectomy.

31. More than one modality of drainage may be
required!

34. Various approaches, and various thoughts
• Endoscopic approaches in general for central lesions,
and especially for late WOPN, less fistula
• Percutaneous necrosectomy is merely an extension of
PCD, repeat procedures, fistula more
• MIRP also needs access – usually from the left, not so
suitable for central and right sided lesions
• Laparoscopic necrosectomy: seems to have more range
of access, but peritoneal contamination is a problem; a
lap chole can be added, but repeated laparoscopic
surgery…..
• Somewhere, open surgery may be required too
• A combination may be necessary

35. Practical Guide to case selection
Retroperitoneal
approach
Left sided- no
contamination
No use for
cephalic necrosis
Risk of colonic
injury
Difficult biliary
access
Endoscopic
approach
Retrogastric-
unilocular
collection
No use in
multilocular/para
colic extension
Laparoscopy
Retro gastric
uni/multilocular
collection
Biliary access
Difficult for para
colic extension

36. What about step-up versus step-
down?

37. The step-up approach
• percutaneous or transgastric
drainage when necessary
followed by minimally
invasive necrosectomy.
•Step up
• primary maximal
necrosectomy by
laparotomy
•Step
down

38. Order of intervention: step up vs step down
Step down
open
MIS
Percut
Step up
radiology
MIS
Open

39. Really which is better?

40. What about the only randomized trial?
35% of patients who underwent PCD did not undergo
necrosectomy

41. Highlights of the PANTER Study
• APACHE II similar in the two groups: mean 15
• Mortality: 19 vs 16% after Step down
• More major complications with step down
• More functional debility and hernias in the later
stage
• But ICU stay (9 vs 11) and Hospital stay (50 vs
60) not much different
• Remember 290 out of 380 cases excluded

42. Potential benefits of the step-up approach
• Avoids the potential hit of a major abdominal
surgery
• IPN contains infected fluid + necrosis: draining
the infected fluid leaves a sterile necrosis.
Hence 30 % did not need any operation.
• May run the risk of removing parts of the
pancreas which are still viable – hence the
greater functional loss?

43. Open surgery is no slouch either!
J Am Coll Surg 2009;209:712–719
Overall morbidity was 62% and 30-day mortality was 6.8%

45. Salient features
• 68 patients -2006 to 2009 (4 years)
• Debridement – 29 to 73 days (39.5)
• 18% had preoperative percutaneous drainage
• In hospital mortality was 8%
• Percutaneous FNA was false negative for infection in 20%
• Bad outcomes
– Elderly
– High APACHE II
– Preoperative ICU stay
– Postoperative organ failure

46. Pancreatic necrosis

48. Devamatha/PVS/Lakeshore: 1987-
1990-2000 2001-2010 2011-
Total Number of
cases
46 116 75
Operated 37 (80) 56 (48) 43 (56)
Died 7 (16) 14 (12) 8 (11)
Laparoscopy 4 7 19*
Percutaneous
drainage
3 78 75
Retroperitoneal
approach
0 16 42
Endoscopy 1 7 9
Open surgery 29 (63) 48 (41) 11 (15)

49. 1. Location
2. Size
3. Extent (close to pancreas or far
away)
4. Necrosis extends to Paracolic gutters
5. How close it to parietes?
6. Enhancement on CECT?
7. How walled off is it?
8. How late in the presentation is it?
9. More fluid or more necrosis?
1. Central vs lateral
2. Small multiple, versus large single
3. Retrogastric versus paracolic gutter
4. Deep versus superficial
5. Needs angiography / embolization
6. If not well walled off, then no
endoscopic/retroperitoneal
approach
7. Later the better
8. More fluid or more necrosis?
Hounsfield U can determine
whether to do PCD, MIRP , lap or
open necrosectomy

50. Central necrosis
Cephalic necrosis
Multilocular necrosis
Gall stones
Bowel complications
Open necrosectomy

51. Conclusions
• Despite a dramatic increase in Minimally
invasive approaches for acute pancreatitis, and
a step-up approach………………..
• A tailored approach to acute pancreatitis
based on disease and patient characteristics
combined with high-intensity critical care and
multiorgan support will alone produce the best
results

52. Pseudocyst
19 patients mean size 9.5 cm
5 patients (26%) had complete resolution
11 patients (56%) had decrease in size
Indications for intervention
Symptomatic
Infection

53. Pseudocyst Surgery When?
• Non adherence to stomach/duodenum
• Dependent drainage not possible
• Disconnected duct
• Gall stones
• ?Presence of debris

54. The woods are lovely, dark and deep,
And I have promises to keep,
Many more miles to go before I sleep
Miles to go before I sleep
Robert Frost