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Minimally Invasive Debridement andLavage ofNecrotizing Pancreatitis

Downloaded from https://onlinelibrary.wiley.com/doi/ by Universität Bern, Wiley Online Library on [22/08/2023]. See the Terms and Conditions (https://onlinelibrary.wiley.com/terms-and-conditions) on Wiley Online Library for rules of use; OA articles are governed by the applicable Creative Commons License

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Figure30.3 Debridement of necrotic pancreatic tissue under

direct vision using an operating nephroscope.

Figure30.4 A 12F Ryles nasogastric tube and 28F chest drain are

placed into the cavity at the end of the procedure and used as an irrigating drainage system to continuously flush the necrotic cavity with 0.9% saline solution at a rate of 125 mL/h.

the commonest minimal access technique, though endoscopic approaches have become first line in many institutions as part of a step- up approach strategy. Most data published in the form of comparative studies and trials

compare open surgery with minimally invasive strategies. Hence why the largest cohort study of MARPN remains of 274 patients published from the pancreatic unit in Liverpool in 2016[11]. They describe a procedurespecific complication rate of 20.4% with a conversion rate to open necrosectomy of 13.1% due to technical difficulties in maintaining a tract, bleeding during the procedure, and inaccessible collections.

One of the most important complications is that of bleeding during or after the procedure; the incidence of this is 11–21% [8,10,11]. Primary bleeding during the procedure is from contact with granulating tissue or avulsion of a vessel, with the rare possibility of injury to the splenic artery. If cessation of the procedure and irrigation fails to stem the bleeding then the cavity requires closing by a pack, suture, or drain clamp in order to facilitate tamponade. Secondary bleeding can occur at any time in the postoperative period from an erosion into a vessel or a pseudoaneurysm rupture. If clamping the drain does not prevent cardiovascular instability then an urgent CT angiography investigation needs to be performed with a view to a mesenteric angiogram and embolization of a bleeding vessel.

Subsequent procedures may prove difficult and a period of conservative management is advocated to ensure there is no further bleeding.

Fistulation to the GI tract has been reported but the incidence remains very low. Approximately 1% can occur from erosion of necrosis into the lumen of the bowel or the development of focal ischemia as tributaries of mesenteric vessels become occluded[12]. It may also become apparent from the medial border of the duodenum as necrosectomy of the head of the pancreas reveals thedefect. Management of this is on a case by case basis and may require cessation of intervention, keeping the patient starved and commencing total parenteral nutrition. Fistulation from the pancreas duct occurs in 5–28% of patients from the remnant healthy pancreas and is managed conservatively providing flow proximally is not obstructed[8,11]. An endoscopic retrograde cholangiopancreatography (ERCP) and pancreatic duct stent may treat an established fistula.

Compared to open surgery, MARPN has significantly lower complications (35.4% vs. 51.7%), less incidence of multiorgan failure (12–20% vs. 35–40%) but mortality rates remain similar (23.1% vs. 22.9%), respectively[8,11,13,14]. The difficulty in comparing techniques in the management of necrotizing pancreatitis is that the development of novel drainage strategies has provided multiple options. In previous cohort studies, it has been reported that the use of MARPN is not suitable in 30% of cases in some studies and one quarter of all patients will require additional percutaneous drains[8,11]. This implies that as good as MARPN is as a technique, there will be areas of walled-

off necrosis that may not be accessible.

Modern Management ofNecrotizing Pancreatitis 269

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Thus is the nature of necrotizing pancreatitis and why the development of different drainage techniques has improved management.

Single Port Pancreatic Necrosectomy

There has been a single report published reviewing the use of a single port for necrosectomy in seven patients[15]. It is important to state that this technique is used for extrapancreatic walled- off collections, predominantly those that are accessible using a three- channel SILS port. A percutaneous drain is inserted radiologically into the collection under local anesthetic and then the patient is given a general anesthetic where a 3 cm cut- down incision is made over the drain site to afford the SILS port. A zerodegree nephroscope is then inserted through one channel and an articulating grasper through the other, with a 0.9% saline irrigation channel. A necrosectomy is performed under direct vision and an irrigation nasogastric tube is then placed for further lavage and drainage. The case series is small, a morbidity rate is not possible to accurately calculate and the post- procedural median length of stay was 47days[15]. Though this is a technically feasible technique, it is for a specific, difficult to access, area of necrosis of critically unwell patients. It should become part of an array of minimal access techniques for patients with complex necrotizing pancreatitis.

Laparoscopic Approaches toPancreatic Necrosectomy

Many small volume case series have been reported over the past couple of decades but the technique remains low in popularity and there are no large volume studies published[16]. The peritoneal approach has been commonly reported and the pancreatic cavity is approached from either the mesocolon or through the greater omentum into the lesser sac. It is also possible to enter transgastrically once the collection/necrosis is walled- off and ready to drain through a cystgastrostomy[17]. The major benefit is that only single operation is needed for necrosectomy, though it has been reported that 20% of patients require a further procedure[16]. Other reported benefits include a morbidity rate of 21% and the simultaneous ability to perform a cholecystectomy [16,18]. The only comparative study between laparoscopic and open techniques of necrosectomy was published in 2012, which stated that there was a lower complication rate, less blood loss, and a shorter length of stay[19]. The operation duration was longer, which leads to specific respiratory complications from prolonged abdominal insufflation. There is a further risk of introducing a contained

collection into a previously sterile peritoneal compartment. Many units prefer to approach necrosectomy through the retroperitoneum. There has been a retroperitoneal laparoscopic approach described where two ports are placed into the necrotic cavity over percutaneous drains. This allows insufflation of carbon dioxide and necrosectomy can be performed using laparoscopic instruments and clips and diathermy can be used to control bleeding[20]. The major advantage of this technique is that it requires only two procedures, compared to other retroperitoneal techniques, with a lower median time to discharge of 44days. There remains a complication rate of 38% and the series was of only 13 patients [20]. The retroperitoneal is still an important aspect of pancreatic necrosectomy, though the MARPN technique remains the most commonly used minimally invasive strategy.

Modern Management ofNecrotizing Pancreatitis

In 2016 a Cochrane review was published comparing interventions in necrotizing pancreatitis and summarized that there was low to very low quality evidence to compare minimally invasive step approaches to open necrosectomy [21]. This highlights the difficulties in comparing techniques and establishing the role of MARPN with a solid evidence base. More recent studies have established that minimally invasive step- up approaches have significantly fewer deaths than open surgery (2% vs. 10%), respectively and a risk ratio of

0.7 [22]. Two randomized control trials have been reported from the Dutch Pancreatitis Group. The Panter trial, which compared open necrosectomy with a minimally invasive step- up approach and found the latter to be superior in terms of mortality, postoperative complications, and pancreatitis insufficiency [23]. Van Brunschot etal. published a randomized trial reviewing surgical step- up and endoscopic step- up approaches and determined that there was no difference in mortality or major complications. The only differences reported was a short length of stay and few pancreatic fistulae in the endoscopic step- up group. It was concluded that there should be a shift toward endoscopic approaches[10].

As the evidence bases slowly improves, the primary use of open necrosectomy becomes less recommended and minimally invasive strategies have become first line. The advent of endoscopic therapies has further shifted management from surgically minimally invasive techniques, especially MARPN. Given these advances a modern pancreas unit should be able to provide multiple strategies and afford a multidisciplinary decision- making process, where patient factors, collection distribution and timing can be discussed in order to tailor personalized management.

Minimally Invasive Debridement andLavage ofNecrotizing Pancreatitis

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national burden of pancreatitis in 195 countries and territories, 1990–2017: a systematic analysis for the Global Burden of Disease Study 2017. BMC Med 2020;18(1):388.

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pancreatitis. Lancet 2020;396(10252):726–734.

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Revised Atlanta classification for acute pancreatitis: a pictorial essay. Radiographics 2016;36(3):675–687.

4 Banks PA, Bollen TL, Dervenis C etal. Classification of

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2012: revision of the Atlanta classification and definitions by international consensus. Gut 2013;62(1):102–111.

5 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(5):787–793.

6 Connor S, Ghaneh P, Raraty M etal. Minimally invasive

retroperitoneal pancreatic necrosectomy. Dig Surg 2003;20(4):270–277.

7 Luckhurst CM, El Hechi M, Elsharkawy AE etal.

Improved mortality in necrotizing pancreatitis with a multidisciplinary minimally invasive step- up approach: comparison with a modern open necrosectomy cohort. JAm Coll Surg 2020;230(6):873–883.

8 van Santvoort HC, Besselink MG, Bakker OJ etal. A

up approach or open necrosectomy for necrotizing

steppancreatitis. N Engl J Med 2010;362(16):1491–1502.

9 Horvath KD, Kao LS, Wherry KL, Pellegrini CA, Sinanan

MN. A technique for laparoscopic-

assisted percutaneous drainage of infected pancreatic necrosis and pancreatic abscess. Surg Endosc 2001;15(10):1221–1225.

10 van Brunschot S, van Grinsven J, van Santvoort HC etal.

Endoscopic or surgical step-

up approach for infected necrotising pancreatitis: a multicentre randomised trial. Lancet 2018;391(10115):51–58.

11 Gomatos IP, Halloran CM, Ghaneh P etal. Outcomes from

minimal access retroperitoneal and open pancreatic necrosectomy in 394 patients with necrotizing pancreatitis. Ann Surg 2016;263(5):992–1001.

12 Bakker OJ, van Santvoort HC, van Brunschot S etal.

Endoscopic transgastric vs surgical necrosectomy for infected necrotizing pancreatitis: a randomized trial. JAMA 2012;307(10):1053–1061.

13 Saunders R, Hughes FE, Evans JC etal. Cost analysis and

outcomes of endoscopic, minimal access and open pancreatic necrosectomy. Ann Surg Open 2021;2(2).

14 Darrivere L, Lapidus N, Colignon N etal. Minimally

invasive drainage in critically ill patients with severe necrotizing pancreatitis is associated with better outcomes: an observational study. Crit Care 2018;22(1):321.

15 Saunders R, Neoptolemos JP, Hughes F, Ghaneh P,

Halloran CM. Single port retroperitoneal pancreatic necrosectomy for the treatment of extra-

pancreatic walled

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16 Bugiantella W, Rondelli F, Boni M etal. Necrotizing

pancreatitis: a review of the interventions. Int J Surg 2016;28(Suppl 1):S163–171.

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CR. ’Stepmanagement of organized solid predominant post-

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acute fluid collections after severe acute pancreatitis. HPB 2014;16(2):170–6.

18 Mathew MJ, Parmar AK, Sahu D, Reddy PK. Laparoscopic

necrosectomy in acute necrotizing pancreatitis: our experience. J Minim Access Surg 2014;10(3):126–131.

19 Tan J, Tan H, Hu B etal. Short- term outcomes from a

multicenter retrospective study in China comparing laparoscopic and open surgery for the treatment of infected pancreatic necrosis. J Laparoendosc Adv Surg Tech A 2012;22(1):27–33.

20 Cresswell AB, Nageswaran H, Belgaumkar A etal. The

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twominimal access pancreatic necrosectomy. Ann R Coll Surg Engl 2015;97(5):354–358.

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Davidson BR. Interventions for necrotising pancreatitis. Cochrane Database Syst Rev 2016;4:CD011383.

van Brunschot S, Hollemans RA, Bakker OJ etal.

Minimally invasive and endoscopic versus open necrosectomy for necrotising pancreatitis: a pooled analysis of individual data for 1980 patients. Gut 2018;67(4):697–706.

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Open Surgical Debridement ofNecrotizing Pancreatitis: Late Postoperative Morbidity andOutcome

Dongya Huang1, Zipeng Lu1, and Yi Miao

Pancreas Center, The First Affiliated Hospital of Nanjing Medical University, Nanjing, China

Pancreas Center, The Affiliated BenQ Hospital of Nanjing Medical University, Nanjing, China

1,2

271

Introduction

Open surgical debridement, once considered as the firstline treatment for necrotizing pancreatitis, is now reserved as the final step in contemporary treatment algorithms with the “step- up” approach and is needed in fewer than 20% of cases[1]. However, an open approach may have advantages over minimally invasive debridement techniques in the following conditions: (i) infeasible for minimally invasive approaches, due to solid material constituting majority of the necrosis, or unfavorable anatomic location of the necrosis; (ii) complications including abdominal compartment syndrome, enteric fistula, ileus, and massive intra- abdominal hemorrhage; (iii) additional surgical procedures are needed (e.g., cholecystectomy for biliary etiology); (iv) efficient removal of necrotic tissue and rapid control of systemic infection are warranted, particularly in critically ill patients with severe sepsis. In selected cases, a “stepjump” open surgery first approach, by skipping the precedent treatments in the “step- up” approach including percutaneous catheter drainage and minimally invasive debridement, may be beneficial[2].

Historically, open surgical debridement with large incision and extensive necrosectomy resulted in a high incidence of complications and mortality after surgery[3,4]. A better understanding of the natural course of disease, advances in medical treatment especially in critical care, incorporating a “step- up” strategy, and accumulation of expertise in high- volume centers significantly improved clinical outcomes after open surgical debridement for necrotizing pancreatitis [5–11]. Improvement of surgical techniques also played an important role in continuous optimization of patients’ prognosis in this clinical setting. Traditional open

surgical procedures for necrotizing pancreatitis included debridement and continuous closed lavage[12], debridement and open packing/staged laparotomy[13], debridement and closed packing[14]. Nowadays, the tendency of minimalization in open surgery for necrotizing pancreatitis is remarkable, and reported techniques included open transgastric necrosectomy[5,8] and small incision retroperitoneal debridement[15].

Late complications in necrotizing pancreatitis are common and have a significant impact on patients’ long- term wellness (Table31.1). In a recent report involving 578 consecutive cases of necrotizing pancreatitis with a median follow- up time of 46 months, 85% of the patients developed ≥1 long- term complication, and 59% of them required invasive interventional treatment[16]. In an earlier cohort of patients with necrotizing pancreatitis after surgical debridement with a median follow- up time of

28.9 months, 62% of the patients developed a long- term complication and 26% of them required intervention[17].

The following paragraphs will focus on individual long- term complications closely related to the procedure of open debridement.

Pancreatocutaneous Fistula

Pancreatic leakage develops in necrotizing pancreatitis when the main pancreatic duct or its branches are destructed and subsequent pancreatic juice extravasates to the peripancreatic space. Any transcutaneous interventions including open surgery with postoperative drainage may cause pancreatocutaneous fistula [18]. Another form of pancreatic fistula in necrotizing pancreatitis is internal fistula, which is less associated with necrosectomy, thus is not discussed in this chapter.

The Pancreas: An Integrated Textbook of Basic Science, Medicine, and Surgery, Fourth Edition. Edited by Hans G. Beger, Markus W. Büchler, RalphH. Hruban, Julia Mayerle, John P. Neoptolemos, Tooru Shimosegawa, Andrew L. Warshaw, David C. Whitcomb, and Yupei Zhao. © 2023 John Wiley & Sons Ltd. Published 2023 by John Wiley & Sons Ltd. Companion website: www.wiley.com/go/beger/thepancreas4e

Table31.1 Clinical results andlong- term complications after open surgical debridement fornecrotizing pancreatitis.

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First author

Surgery period

Surgical technique Patient N

Short- term mortality

rate % Follow-

up time

Hemorrhage %Pancreatic

fistula %

Enteric fistula %

Incisional hernia %

Endocrine insufficiency %

Exocrine insufficiency %Supplementary

enzyme use %

Tsiotos[21,41] 1983–1995 OD & SL 44/72 25 mean: 60mo 18.1 19.4 23.6 27.3 36.4 25 25

Tzovaras[22] 1987–1999 mixed 21/44 18.3 median: 48mo NA 9.1 13.6 47.6 47.6 9.5 NA

Rodriguez[10] 1990–2005 OD & CP 167 12 NA 4 41 15 NA 16 20 NA

Cinquepalmi[42] 1990–2005 OD & CL 32/35 22 median: 85mo NA NA NA 91 29 NA NA

Busse[49] 2003–2012 TGOD 50 20 NA NA NA NA NA 35 NA 20

Hollemans[19,34] 2005–2008 OD & CL 38/45 16 mean: 86mo 27 38 22 53 56 56 42

Luckhurst[6] 2006–2019 OD & CL 88 10

12mo 9 73 NA NA 26 NA 14

Chandrasekaran[48] 2009–2010 OD & SL 21 NA >12mo NA NA NA NA 61.9 57.1 80.9

Jones[35] 2010–2015 mixed 33 21.9

12mo 9.1 30.3 9.1 9.1 NA 48.5

Zhang[15] 2010–2019 SIOD 31 16 6mo 6 16 6 6 13 NA 10

Patient number included in long- term follow- up/patient number after necrosectomy; b90- day mortality rate. mo: months; NA: not applicable; OD & CL: open debridement & continuous closed lavage; OD & CP: open debridement & closed packing; OD & SL: open debridement & open packing/staged laparotomy; SIOD:small incision open debridement; TGOD: transgastric open debridement.

Pancreatic fistula rate after surgical debridement in

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necrotizing pancreatitis was 8−73% from different studies[6,7,9–11,15,19–26]. Transgastric necrosectomy has the innate advantage of minimizing risk of external fistula by creating durable internal drainage for potential gland leaks, and the reported pancreatic fistula rate after open transgastric necrosectomy was 2.0−4.7% [5,8]. When postoperative pancreatic fistula persists, underlying anatomical deformity of the pancreatic duct secondary to parenchymal necrosis should be suspected. When duct stricture or disconnected pancreatic duct syndrome (DPDS) presented, persistent pancreatic fistula after pancreatic debridement increased from 27% in cases with normal duct to 54% and 85%, respectively [27]. Disconnected left pancreatic remnant on preoperative CT scan was also found to be a risk factor for the development of pancreatic fistula after necrosectomy[7].

Around two- thirds of the post- necrosectomy pancreatic fistula will close spontaneously after noninterventional treatments at around 4months after surgery[18,28]. Conservative treatments included optimized drainage, somatostatin analogues, antibiotics, and nutritional support. If the fistula is refractory to medical treatment, the choice between different interventional modalities currently lacks strong evidence support. Endoscopic transpapillary duct drainage [29], surgical interventions including fistulojejunostomy, pancreaticojejunostomy, and left pancreatectomy[30] are among the physician’s arsenal and were reported with a satisfactory safety and efficacy profile. Changes in ductal morphology may provide helpful information in clinical decision- making to choose the appropriate treatment[31]. Simultaneous left pancreatectomy resection with the index debridement for cases with DPDS were also recommended[7].

Hemorrhage

Hemorrhage is one of the most fatal complications and contributes to a substantial mortality rate in necrotizing pancreatitis. Late hemorrhage in necrotizing pancreatitis is related to the presence of residual peripancreatic or pancreatic necrosis, long- standing pseudocyst, and gastrointestinal varicosis following thrombosis and obstruction of the portosplenomesenteric vein. Too aggressive or expectant timing for debridement and traumatic manipulation during necrosectomy may also increase the risk of postoperative bleeding. The common sites of hemorrhage in necrotizing pancreatitis include splenic artery, gastroduodenal or pancreaticoduodenal artery, portal vein, spleen, and unspecified peripancreatic vessels[32,33]. Isolated vessels or even vascular stumps in the necrotic cavity are frequently found during necrosectomy; proper ligation or transfixation of the vessel or its

Hemorrhage 273

Figure31.1 Isolated vascular stumps (arrows) in necrotic cavity

during open debridement, which require proper management with ligation or transfixation.

stump is required, and surgical debridement holds technical advantages in this respect (Fig.31.1).

Various studies have reported a rate of postoperative hemorrhage of 2.7−10.1% after open pancreatic necrosectomy[6–10,15,19–21,23–26,34–36]. In the extended observational study of a randomized controlled trial, two more patients (5%) had intra- abdominal bleeding requiring intervention during the long- term follow- up period, making an overall hemorrhage rate of 27% in the open surgery arm[34]. As regards a different but closely related disease entity, the visceral artery pseudoaneurysm was reported to be 4.3% in all patients with necrotizing pancreatitis with a median incidence timing of 63.5days after disease onset and 21% of the patients were diagnosed based on incidental CT findings [37]. Age >50 years, presence of any organ failure, and previous endoscopic transluminal necrosectomy with lumen- opposing metal stent were reported to be risk factors for visceral pseudoaneurysm in necrotizing pancreatitis[37,38].

Recognition of early signs of hemorrhage and/or pseudoaneurysm is critical for prompt intervention and successful treatment; these include blood in drainage, acute onset of abdominal pain, gastrointestinal bleeding, and early presentations of hemorrhagic shock. Visceral angiography is considered as the first step in management of bleeding after necrosectomy if the patient is hemodynamically stable, which could provide detailed information on bleeding sites. And further intravascular embolization with a coil or covered stent would provide definite treatment or a bridging measure for surgery[33,37]. Emergent open laparotomy for hemostasis is a lifesaving procedure for patients with catastrophic intra- abdominal bleeding or failed percutaneous vascular embolization, and has the advantage of eliminating underlying causes of bleeding including residual infected necrosis and direct compression from the drainage tube,

Open Surgical Debridement ofNecrotizing Pancreatitis: Late Postoperative Morbidity andOutcome

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and so on. Extensive blood oozing into the necrotic cavity represents another challenging scenario, in which gauze packing may be the only choice of treatment. Postoperative hemorrhage would have a profoundly detrimental impact on a patient’s outcome with a mortality rate of 34.1%[32].

Enteric Fistula

Multiple factors were involved in the pathogenesis of enteric fistula in necrotizing pancreatitis, which include organ ischemia secondary to vascular thrombosis due to enzyme- rich and inflammatory exudates involvement, colonic ischemia in hypoperfusion status in splanchnic blood supply, direct autodigestion from extravasated pancreatic juice, and iatrogenic causes during interventions[28]. Enteric fistula was reported with an incidence rate of 6−23.6% after surgical debridement from various studies [7,9,10,15,19–23,25]. The incidence of enteric fistula in necrotizing pancreatitis was associated with organ failure, presence of extensive necrosis, and operative intervention[16,39].

Once the diagnosis of enteric fistula is established, timely interventional management is essential to stabilize the patients. Percutaneous catheter drainage, endoscopic stenting, enterostomy, enteric resection, enteric fixation, or proximal diversion of the gastrointestinal tract is indicated for different clinical settings. Although surgery is still the mainstay treatment for enteric fistula, nonsurgical interventions have been increasingly applied in recent years. In one report focused on colonic fistula after necrosectomy for infected pancreatic necrosis, 34.8% of the cases with colonic fistula closed spontaneously[40]. Once colonic ischemia is suspected during surgical debridement, it is recommended that a prophylactic loop ileostomy be constructed [20]. Necrotizing pancreatitis complicated with gastrointestinal fistula represents a treatment challenge, as studies have found out that the disease course is significantly prolonged, and mortality is substantially high in this group of patients[16,40].

Incisional Hernia

Risk factors for the development of incisional hernia including wound infection, repeated laparotomies, obesity, diabetes mellitus, malnutrition are commonly seen in patients after open debridement. Various incidence rates of incisional hernia after traditional transperitoneal surgical debridement were reported with a wide range of 9.1% to 91% [22,25,34–36,41,42]. Patients with incisional hernia increased from 24% to 53% if the follow- up time was extended from 6months to an average of over 7 years after

open necrosectomy[19,34]. In a retrospective study specifically focused on long- term hernia development after laparotomy for necrotizing pancreatitis, elder age was found to be the only risk factor for hernia development[43].

Hernias are more common when marsupialization of thelesser sac is used as a controlled laparostomy[44,45]. Transverse incision resulted in less incisional hernia when compared with midline incision[46,47]. However, a retrospective case- control study in necrotizing pancreatitis did not find a difference in hernia development between various types of incision[43]. Minimalization of the incision in open necrosectomy may help to avoid the risk of incisional hernia[15]. In the authors’ institution, we now use uni- / bilateral flank incision (retroperitoneal) and/or mini transverse incision (transperitoneal) instead of a midline incision for open debridement. The choice of incision is flexible and depends on the location and extension of necrosis (Fig.31.2). A minimally invasive “step- up” approach could significantly reduce the chance of hernia development by avoiding laparotomy in some patients[19,34].

Incisional hernia is a condition that frequently requires surgical reintervention and 52−86.5% of the patients whodeveloped incisional hernia subsequently received hernia repair[16,22,41,43].

New- Onset Endocrine Insufficiency

Acute necrosis of the pancreatic parenchyma, extensive debridement, and subsequent chronic inflammation after acute onset will cause permanent loss of functional unit both in the endocrine and exocrine compartment of the pancreata. Pancreatic functional loss in necrotizing pancreatitis seems to be progressive and irreversible in long- term follow- up[16,34].

Endocrine insufficiency after open necrosectomy was reported with an incidence rate of 9.1−61.9% after various follow- up times [6,10,15,22,34,35,41,42,48,49]. Endocrine insufficiency occurs early in necrotizing pancreatitis, as serum glucose greater than 200 included in Ranson’s score. Worth noting, over one- third of euglycemic patients at the time of acute attack resolution further developed endocrine insufficiency, after follow- up time was extended from 6months to 86months in the PANTER trial[19,34]. And this finding was supported by other observations[16,41].

Studies have suggested that functional loss of the pancreas was more dependent on the severity of the attack rather than on the action of debridement [16,50]. Development of organ failure, infection other than sterile necrosis, higher computed tomography (CT) severity index, and more extensive necrosis during acute onset of necrotizing pancreatitis were associated with the development of endocrine insufficiency afterward[16,41,48].

mg/dL was

References 275

(a) (b)

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Figure31.2 Minimalization of incision in open debridement. (a) Extensive pancreatic necrosis was found in a preoperative computed

tomography (CT) exam of a patient with infected necrotizing pancreatitis. (b) Epigastric 7- cm transverse incision (arrow heads) with bilateral flank incisions (arrows) in open necrosectomy for this patient (drainage tubes were introduced via the flank incisions).

New- Onset Pancreatic Exocrine Insufficiency (PEI)

The incidence of PEI after open debridement for necrotizing pancreatitis varied from 9.5% to 57.1%[10,22,34,41,48], and the percentage of patients who relied on enzyme supplementation was reported to be 10−80.9%[6,15,19,34,35, 41,48,49]. Different diagnostic criteria will lead to different estimations of the burden of exocrine insufficiency. One study used fecal elastase- 1 <200 μg/g and found the incidence rate of long- term PEI after open necrosectomy to be 56% [34], while exocrine insufficiency was diagnosed in 25–57.1% of patients when fecal fat excretion >7 g/24 h was used[41,48].

Direct open debridement was reported to increase the risk of longwith the minimally invasive step- up approach both in functional test and supplementary enzyme dependence[34]. The extent and infection status of the necrosis, and no or incomplete visualization of the main pancreatic duct are associated with the incidence of exocrine insufficiency[41,48]. In another study, renal failure and

term exocrine insufficiency when compared

cardiovascular failure during the acute phase were found to be independent risk factors for long-

term PEI devel-

opment in patients with necrotizing pancreatitis[16].

Summary

Late complications are common in patients with necrotizing pancreatitis and after open surgical debridement. Long- term follow- up in these patients is essential and warranted to identify potential complications and initiate treatment promptly. In a contemporary treatment algorithm, the role of open surgery for necrotizing pancreatitis has fundamentally changed but remains indispensably important, as it seems to be decisive for the fate in a subset of patients with necrotizing pancreatitis, not only as a bail-

out procedure after failed minimally invasive interventions but maybe also as a first choice in selected patients. In future, novel treatment strategy and surgical techniques for necrotizing pancreatitis should be tested in well- designed clinical trials focusing on both shortterm outcomes and long- term morbidities.

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