Interventions for Necrotizing Pancreatitis

An Overview of Current Approaches

Guru Trikudanathan; Mustafa Arain; Rajeev Attam; Martin L Freeman

Disclosures

Expert Rev Gastroenterol Hepatol. 2013;7(5):463-475. 

In This Article

Abstract and Introduction

Abstract

The management of necrotizing pancreatitis has undergone a paradigm shift toward minimally invasive techniques for necrosectomy, obviating the need for open necrosectomy in most cases. There is increasing evidence that minimally invasive approaches including a step-up approach that incorporates percutaneous catheter or endoscopic transluminal drainage, followed by video-assisted retroperitoneal or endoscopic debridement are associated with improved outcomes over traditional open necrosectomy for patients with infected necrosis. A recent international multidisciplinary consensus conference emphasized the superiority of minimally invasive approaches over standard surgical approaches. The success of these techniques depends on concerted efforts of a multidisciplinary team of interventional endoscopists, radiologists, intensivists and surgeons dedicated to the management of severe acute pancreatitis and its complications. This review provides an overview of minimally invasive techniques for management of necrotizing pancreatitis, including indications, timing, advantages and disadvantages.

Introduction

Acute pancreatitis (AP) is a dynamic inflammatory process involving the pancreas, peri-pancreatic tissues and less commonly remote organ systems. The incidence of acute pancreatitis is increasing globally[1] and the consequent increase in overall hospitalization has posed an enormous burden on healthcare utilization and costs.[2] In a recent study, pancreatitis was estimated to account for nearly 274,000 hospitalizations in the United States annually, making it the leading gastrointestinal discharge diagnosis.[3]

The most widely used definitions for acute pancreatitis are derived from clinically based Atlanta classification.[4] While seminal at the time of publication in 1993, the Atlanta criteria have undergone extensive revision by an international panel of experts from multiple disciplines, a summary of which has been recently published.[5] From a morphological point of view, AP is defined as either interstitial or necrotizing pancreatitis. Necrotizing pancreatitis is typically defined by non-enhancement of pancreatic parenchyma on contrast-enhanced computed tomography (CECT). Necrosis can involve either pancreatic parenchyma alone (less commonly), both the pancreatic parenchyma and the peri-pancreatic tissues (more commonly) or isolated peri-pancreatic tissue alone (least commonly). Isolated peri-pancreatic necrosis may be associated with improved long-term outcomes compared to pancreatic necrosis.[6,7] However, peri-pancreatic necrosis carries a worse prognosis than acute interstitial pancreatitis.[6–8] Both pancreatic and peri-pancreatic necrosis can be either sterile or infected.

From a clinical point of view, approximately 20% of patients with acute pancreatitis are classified as severe, based on presence of sustained organ failure or local complications such as necrosis.[9] Mortality of necrotizing pancreatitis has varied from approximately 15% in patients with sterile necrosis, to as much as 39% in patients with infected necrosis, which occurs in approximately 40–70% of patients.[10,11] In general, sterile necrosis does not require intervention, while infected necrosis usually requires evacuation. The traditional management of infected necrosis has centered on open surgical debridement, with additional percutaneous drainage and peritoneal lavage, all of which usually require multiple operative sessions and interventions.[12,13] Open surgical debridement is accompanied by significant risk of perioperative stress, organ failure, and long-term complications including external fistulas, diabetes, pancreatic exocrine insufficiency, and incisional hernias. Over the past decade, the management of pancreatic necrosis has evolved substantially with introduction and refinement of a variety of minimally invasive approaches to drainage and evacuation of necrosis. The aim of the current review is to give an insight of the various minimally invasive modalities available for necrosectomy. Regardless of approach, to achieve optimal outcomes, emphasis is placed on the necessity for multidisciplinary management in advanced medical centers with specialized expertise in the management of severe acute pancreatitis.

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