Acute necrotizing pancreatitis: traditional laparotomy vs. minimally invasive procedures

Česká verzia

Authors: R. Kostka; J. Havlůj
Authors place of work: Chirurgická klinika 3. LF UK v Praze, přednosta: prof. MUDr. R. Gürlich, CSc.
Published in the journal: Rozhl. Chir., 2015, roč. 94, č. 4, s. 160-165.
Category: Original articles

Summary

Introduction:
Treatment of necrotizing pancreatitis continues to evolve. The standard therapeutic method for infected pancreatic necrosis and its subsequent septic complications is open surgical drainage. The advances in radiological imaging and interventional radiology have enabled the development of minimally invasive procedures, i.e. percutaneous drainage (PCD) under CT/USG control, endoscopic transgastric necrosectomy (ENE), laparoscopic transperitoneal necrosectomy (LNE) and retroperitoneal access to pancreatic necrosis (RENE).

Methods:
Patients with acute pancreatitis treated from 2002 to 2013 (n=932) were included in the study. In patients with a severe form of the disease, results obtained in two groups of patients were compared: the first group was treated by classic laparotomy (group A), the second one was treated by means of minimally invasive procedures (group B). Statistical analysis employed the chi-square test.

Results:
During the mentioned period, 677 (72.6%) patients with a mild form and 255 (27.4%) with a severe form of the disease were treated. The male/female ratio was 1.4:1. In the group of patients suffering from a severe form of acute pancreatitis, 171 patients were treated conservatively, mortality rate being at 16.4% (28/171). Surgery was indicated in a total of 84 patients, mortality rate reaching 26.2% (22/84). Fifty-two of the patients underwent laparotomy (group A), minimally invasive procedures were used in a total of 32 patients (group B). Overall mortality in group A was 30.8% (16/52) vs. 18.8% (6/32) in group B, p = 0.224. The average length of hospitalization was longer in group A (65.4 days; median 52.4 vs. 49 days; median 36.5 in group B). PCD was the most frequent procedure performed in 19 patients; 5 of them died due to ongoing sepsis and multiorgan failure and 2 of them underwent revisional laparotomy. RENE was performed in 8 patients; lumbotomy was used in 5 of them. ENE was performed on 2 patients, 1 of them died, and LNE was used once. A less invasive procedure, the linea alba fasciotomy, was performed in 2 patients with intra-abdominal hypertension.

Conclusion:
Open surgical drainage represents the standard treatment for infected pancreatic necrosis. Minimally invasive procedures are suitable alternatives especially in critically ill patients providing lower morbidity and mortality rates.

Key words:
necrotizing pancreatitis – necrosectomy – percutaneous drainage – endoscopy − laparoscopy

Zdroje

1. Yadav D, Lowenfels AB. The epidemiology of pancreatitis and pancreatic cancer. Gastroenterology 2013;144:1252−61.

2. Karakayali FY. Surgical and interventional management of complications caused by acute pancreatitis. World J Gastroenterol 2014; 20:13412−23.

3. Rau B, Uhl W, Büchler MV, et al. Surgical treatment of infected necrosis. World J Surg 1997;21:155−61.

4. Isenmann R, Rau B, Beger HG. Bacterial infection and extent of necrosis are determinants of organ failure in patients with acute necrotizing pancreatitis. Br J Surg 1999;86:1020−4.

5. Gooszen HG, Besselink MG, van Santvoort HC, et al. Surgical treatment of acute pancreatitis. Langenbecks Arch Surg 2013;398:799−806.

6. Amano H, Takada T, Isaji S, et al. Therapeutic intervention and surgery of acute pancreatitis. J Hepatobiliary Pancreat Sci 2010;17:53−9.

7. Nieuwenhuijs VB, Besselink MG, van Minnen LP, et al. Surgical management of acute necrotizing pancreatitis: a 13-year experience and a systematic review. Scand J Gastroenterol Suppl 2003;239:111−6.

8. Rau B, Bothe A, Beger HG. Surgical treatment of necrotizing pancreatitis by necrosectomy and closed lavage: changing patient characteristics and outcome in a 19-year, single-center series. Surgery 2005;138:28−39.

9. Uhl W, Warshaw A, Imrie C, et al. IAP guidelines for the surgical management of acute pancreatitis. Pancreatology 2002; 2:565−73.

10. de Waele JJ, Vogelaers D, Blot S, et al. Fungal infections in patients with severe acute pancreatitis and the use of prophylactic therapy. Clinical Infectious Diseases 2003;37:208−13.

11. Besselink MGH, Verwer TJ, Schoenmaeckers EJP, et al. Timing of surgical intervention in necrotizing pancreatitis. Archives of Surgery 2007;142:1194−1201.

12. van Santvoort HC, Bakker OJ, Bollen TL, et al. A conservative and minimally invasive approach to necrotizing pancreatitis improves outcome. Gastroenterology 2011;141:1254−63.

13. Krška Z, Šváb J. Posuny v chirurgii pankreatu na 1. chirurgické klinice 1. LF UK a VFN. Rozhl Chir 2012;91:262−6.

14. Gerzof S, Robbins A, Johnson W, et al. Percutaneous catheter drainage of abdominal abscesses. N Engl J Med 1981;305:653−7.

15. Gagner M. Laparoscopic treatment of acute necrotizing pancreatitis. Semin Laparosc Surg 1996;3:21−28.

16. Bello B, Matthews JB. Minimally invasive treatment of pancreatic necrosis. World J Gastroenterol 2012;18:6829−35.

17. Freeny P, Hauptmann E, Althaus S, et al. Percutaneous CT-guided catheter drainage of infected acute necrotizing pancreatitis: techniques and results. Am J Roentgenol 1998;170:969−75.

18. Gmeinwieser J, Feuerbach S, Zirngibl H, et al. Percutaneous treatment of infected necrotizing pancreatitis. Eur IHPBA 1997;23:575−8.

19. Echenique A, Sleeman D, Yrizarry J, et al. Percutaneous catheter-directed debridement of infected pancreatic necrosis: results in 20 patients. J Vasc Intervent Radiol 1998;9:565−71.

20. Besselink MG, van Santvoort HC, Nieuwenhuijs VB. Minimally invasive ‚step-up approach‘ versus maximal necrosectomy in patients with acute necrotising pancreatitis (PANTER trial): design and rationale of a randomised controlled multicenter trial. BMC Surg 2006;11:6.

21. van Baal MC, van Santvoort HC, Bollen TL, et al. Systematic review of percutaneous catheter drainage as primary treatment for necrotizing pancreatitis. Br J Surg 2011;98:18−27.

22. van Santvoort HC, Besselink MG, Bakker OJ, et al. A step-up approach or open necrosectomy for necrotizing pancreatitis. N Engl J Med 2010;362:1491−1502.

23. Bausch D, Wellner U, Kahl S, et al. Minimally invasive operations for acute necrotizing pancreatitis comparison of minimally invasive retroperitoneal necrosectomy with endoscopic transgastric necrosectomy. Surgery 2012;152 Suppl. 1:128−34.

24. Seewald S, Groth S, Omar S, et al. Aggressive endoscopic therapy for pancreatic necrosis and pancreatic abscess: a new safe and effective treatment algorithm (videos). Gastrointest Endosc 2005; 62: 92−100.

25. Ang TL, Kwek AB, Tan SS, et al. Direct endoscopic necrosectomy: a minimally invasive endoscopic technique for the treatment of infected walled-off pancreatic necrosis and infected pseudocysts with solid debris. Singapore Med J 2013;54:206−11.

26. Parekh D. Laparoscopic-assisted pancreatic necrosectomy: A new surgical option for treatment of severe necrotizing pancreatitis. Arch Surg 2006;141:895−902; discussion 902−3.

27. Zhu JF, Fan XH, Zhang XH. Laparoscopic treatment of severe acute pancreatitis. Surg Endosc 2001;15:146−8.

28. Gambiez LP, Denimal FA, Porte HL, et al. Retroperitoneal approach and endoscopic management of peripancreatic necrosis collections. Arch Surg 1998;133:66−72.

29. Raraty MG, Halloran CM, Dodd S, et al. Minimal access retroperitoneal pancreatic necrosectomy: improvement in morbidity and mortality with a less invasive approach. Ann Surg 2010;251:787−93.

30. Chang YC, Tsai HM, Lin XZ, et al. No debridement is necessary for symptomatic or infected acute necrotizing pancreatitis: delayed, mini-retroperitoneal drainage for acute necrotizing pancreatitis without debridement and irrigation. Dig Dis Sci 2006;51:1388−95.

31. Castellanos G, Piñero A, Serrano A, et al. Translumbar retroperitoneal endoscopy: an alternative in the follow-up and management of drained infected pancreatic necrosis. Arch Surg 2005;140:952−5.

32. Carter CR, McKay CJ, Imrie CW. Percutaneous necrosectomy and sinus tract endoscopy in the management of infected pancreatic necrosis: an initial experience. Ann Surg 2000;232:175−80.

33. Zhao G, Hu M, Liu R, et al. Retroperitoneoscopic anatomical necrosectomy: A modified single-stage video-assisted retroperitoneal approach for treatment of infected necrotizing pancreatitis. Surg Innov 2014; 14. pii: 1553350614552732. [Epub ahead of print]

34. Guo Q, Lu H, Hu W, Zhang Z. A retroperitoneal approach for infected pancreatic necrosis. Scand J Gastroenterol 2013;48:225−30.

35. Doležalová L, Volšanský P, Neumann F, et al. Těžká akutní pankreatitida – řešení komplikací kombinací miniinvazivních přístupů. Rozhl Chir 2014;93:216−9.

36. De Waele JJ, Leppäniemi AK. Intra-abdominal hypertension in acute pancreatitis. World J Surg 2009;33:1128−33.

37. Leppäniemi A, Hienonen P, Mentula P, et al. Subcutaneous linea alba fasciotomy, does it really work? Am Surg 2011;77:99−102.