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 2007 17 25 84 (21-385) n/a 25 (100%) 2 (7%) 0 5 (1-45) 0 Papachristou GI 2007 18 53 49 (20-300) n/a 53 (100%) 3 (1-12) 11 (21%) 12 (23%) 13 (0-90) 3 (6%) Will U 2006 19 5 n/a n/a n/a 2 (average) 2-6 (range) 0 0 n/a n/a Hookey LC 2006 20 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 2006 21 13 24 (3-180) 11 (85%) 13 (100%) Nasocavity 4 (1-10) n/a 1 (8%) n/a 2(15%) Raczynski S 2006 22 2 n/a n/a 2 (100%) 4 0 0 n/a 0 Seewald S 2005 23 5 14 n/a 5 7 n/a (2) 40% n/a 0 Baron TH 2002 24 43 n/a n/a n/a 2 (1-6) 16 (37%) n/a 20 (0-75) 1 (2%) Seifert H 2000 25 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) Number of procedures Open (n=52) MARP (n=137) p 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 100 80 60 40 20 0 University of Liverpool Department of Surgery APACHE II scores (1-29) MARP OPN MARP* OPN* (n=137) p=0.038 ITU stay p=0.773 (2-20) Pre-operatively (n=52) APACHE II scores (1-22) (n=137) P<0.001 ITU stay P<0.001 (2-24) (n=52) Post-operatively (*Increase in % requiring ICU post op, MARP p=0.544, OPN p<0.001) 14 12 10 8 6 4 2 0 Median, (range)
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: Median age: 16 males; 12 females 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: Hospital stay: Follow-up: 23 (6 46) days 48 (40 80) days 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
How often is PCD effective as primary treatment? BJS 2011 56% of patients survived without additional surgical necrosectomy (214/384 pts in 11 studies) c.f. 35% in PANTER trial
How often is PCD feasible? BJS 2007 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)
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 Number undergoing necrosectomy Additional necrosectomy Percutaneous drainage 44 19 (42%) 15 (33%) 43
A step-up approach or open necrosectomy for necrotizing pancreatitis. Van Sanvoort HC et al. New Engl J Med 2010;362 1491-1502 Composite primary endpoint (major complications or death) Percutaneous drainage only Primary open necrosectomy n = 45 Minimally invasive step-up approach. N = 43 31 (69%) 17 (40%) 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?