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MANAGEMENT OF PANCREATIC NECROSIS

MANAGEMENT OF PANCREATIC NECROSIS. Kevin E. Behrns, M. D. Division of Gastrointestinal Surgery. PANCREATIC NECROSIS Definition. Pancreatic necrosis- diffuse or focal areas of non-viable pancreatic parenchyma, which is typically associated with peripancreatic fat necrosis.

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MANAGEMENT OF PANCREATIC NECROSIS

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  1. MANAGEMENT OF PANCREATIC NECROSIS Kevin E. Behrns, M. D. Division of Gastrointestinal Surgery

  2. PANCREATIC NECROSISDefinition • Pancreatic necrosis- diffuse or focal areas of non-viable pancreatic parenchyma, which is typically associated with peripancreatic fat necrosis. Atlanta International Symposium Arch Surgery 1993;128:586

  3. PANCREATIC NECROSISSurgical Indications • WHAT ARE THE SURGICAL INDICATIONS FOR DEBRIDEMENT OR NECROSECTOMY? • Absolute indications • Relative indications

  4. PANCREATIC NECROSISSurgical Decision-Making PANCREATIC NECROSIS INFECTED NECROSIS STERILE NECROSIS NON-OPERATIVE MANGEMENT VS. NECROSECTOMY NECROSECTOMY

  5. PANCREATIC NECROSISInfected Necrosis • Mandates a semi-urgent operation • Removal of all necrotic pancreas and peripancreatic tissues • May require 1-3 operations • Preferred method is to delay initial operation until necrosis demarcated

  6. PANCREATIC NECROSISInfected Necrosis • Outcomes • Mortality 6-24% • Morbidity 34-50+% • Bacteria • Staph • E. coli • Klebsiella Ann Surg 1998;228:676 2000;234:619 2001;234:572

  7. PANCREATIC NECROSISInfected Necrosis Ann Surg 2000;232:619

  8. PANCREATIC NECROSISSterile Necrosis • WHAT DISTINGUISHES STERILE NECROSIS FROM INFECTED NECROSIS? • Retroperitoneal air within necroma on CT indicates gas-producing organism and infected necrosis. • Role of FNA of necrotic pancreatic and peripancreatic tissue.

  9. PANCREATIC NECROSISSterile Necrosis • Utility of FNA • Good sensitivity and specificity • Highly dependent on accurate needle placement in necrotic tissue (not nearby fluid collection) • Surgeon’s Perspective- not that useful • Timing is everything in pancreatic necrosectomy • Early positive FNA forces surgeon’s hand when pancreatic necrosis not demarcated • May result in multiple operations and increased risk of morbidity and mortality • CONSULT SURGEON PRIOR TO FNA

  10. PANCREATIC NECROSISSterile Necrosis • Controversial management • Non-operative management • Most of the world • Operation for all patients with pancreatic necrosis • MGH

  11. PANCREATIC NECROSISSterile Necrosis- Non-Operative Management Ann Surg 2000:232:619

  12. PANCREATIC NECROSISSterile Necrosis Which patients are likely to get infected necrosis?

  13. PANCREATIC NECROSISSterile Necrosis • What are the outcomes with planned operative management of sterile necrosis? • Mortality 6.2% Ann Surg 1998;228:676

  14. PANCREATIC NECROSISSterile Necrosis • DO ALL PATIENTS WITH NON-OPERATIVE TREATMENT OF STERILE NECROSIS GET WELL? • NO! • Subgroup of patients that never develop infection but have persistent nausea, vomiting, abdominal pain. “Fail to thrive”

  15. PANCREATIC NECROSISSterile Necrosis • When should patients with sterile necrosis that induces persistent symptoms undergo operation? • About one month after diagnosis if no improvement Ann Surg 1998;228:676

  16. PANCREATIC NECROSISSterile Necrosis • What are the outcomes of patients that have delayed operation for sterile pancreatic necrosis? Ann Surg 2001 234:572

  17. PANCREATIC NECROSISSterile Necrosis • What factors predict survival from pancreatic necrosectomy? • Age • APACHE II score • Time to surgery • Survivors- 39 days • Non-survivors- 23 days Brit J Surg 2003;90:1542

  18. PANCREATIC NECROSISQuality of care HOW CAN WE PROVIDE HIGHESTQUALITY OF CARE FOR PATIENTS WITH PANCREATITIS?

  19. PANCREATIC NECROSISSurgical Treatment Guidelines • International Association of Pancreatology (IAP) evidence-based guidelines for surgical management of acute pancreatitis: • Mild acute pancreatitis does not require surgery • Antibiotics decrease infection rates but not mortality in CT-proven necrotizing pancreatitis • Patients with sterile necrosis should undergo operation only in selected cases Pancreatology 2002;2:565

  20. PANCREATIC NECROSISSurgical Treatment Guidelines • IAP recommendations (continued): • Patients with infected necrosis and clinical presentation of sepsis should have surgery or radiological drainage • Early surgery (<14 days) not recommended unless special circumstances • Surgical operations should favor organ-preserving approach • Cholecystectomy should be performed at operation Pancreatology 2002;2:565

  21. PANCREATIC NECROSISSurgical Treatment Guidelines • IAP recommendations (continued): • In gallstone-induced edematous pancreatitis, cholecystectomy should be performed during initial hospitalization • In gallstone-induced necrotizing pancreatitis, cholecystectomy should delayed until inflammatory response subsides • Endoscopic sphincterotomy is alternative to cholecystectomy in high-risk patients Pancreatology 2002;2:565

  22. PANCREATIC NECROSISConclusion • Necrotizing pancreatitis accounts for 10% of all pancreatitis but is lethal disease • Surgical consult should be obtained in the ER • Many, if not all, patients should be admitted to surgical service • Management relies on team effort of surgeons, endoscopist, intensivist, radiologist, interventional radiologist, primary care physician, etc. • Gallstone-induced edematous pancreatitis should have surgical consult prior to discharge

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