A Step-up Approach or Open Necrosectomy for Necrotizing Pancreatitis

University Medical Center, Utrecht, The Netherlands.
New England Journal of Medicine (Impact Factor: 55.87). 04/2010; 362(16):1491-502. DOI: 10.1056/NEJMoa0908821
Source: PubMed


Necrotizing pancreatitis with infected necrotic tissue is associated with a high rate of complications and death. Standard treatment is open necrosectomy. The outcome may be improved by a minimally invasive step-up approach.
In this multicenter study, we randomly assigned 88 patients with necrotizing pancreatitis and suspected or confirmed infected necrotic tissue to undergo primary open necrosectomy or a step-up approach to treatment. The step-up approach consisted of percutaneous drainage followed, if necessary, by minimally invasive retroperitoneal necrosectomy. The primary end point was a composite of major complications (new-onset multiple-organ failure or multiple systemic complications, perforation of a visceral organ or enterocutaneous fistula, or bleeding) or death.
The primary end point occurred in 31 of 45 patients (69%) assigned to open necrosectomy and in 17 of 43 patients (40%) assigned to the step-up approach (risk ratio with the step-up approach, 0.57; 95% confidence interval, 0.38 to 0.87; P=0.006). Of the patients assigned to the step-up approach, 35% were treated with percutaneous drainage only. New-onset multiple-organ failure occurred less often in patients assigned to the step-up approach than in those assigned to open necrosectomy (12% vs. 40%, P=0.002). The rate of death did not differ significantly between groups (19% vs. 16%, P=0.70). Patients assigned to the step-up approach had a lower rate of incisional hernias (7% vs. 24%, P=0.03) and new-onset diabetes (16% vs. 38%, P=0.02).
A minimally invasive step-up approach, as compared with open necrosectomy, reduced the rate of the composite end point of major complications or death among patients with necrotizing pancreatitis and infected necrotic tissue. (Current Controlled Trials number, ISRCTN13975868.)

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Available from: Bert van Ramshorst
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    • "It seems that the triad comprising a) control of initial acute inflammatory process, b) control of sepsis and c) delay of definitive surgical treatment are the key factors in the successful management of necrotizing pancreatitis (NP). In this regard, the PANTER study has shown that the key issue is not the resection of the necrosis but the control of the local infection [11]. "
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    ABSTRACT: Open necrosectomy, the standard surgical treatment of infected pancreatic necrosis (IPN), presents a high rate of postoperative complications and an associated mortality of 20–60%. In the last decade various minimally invasive approaches (MIA) have been proposed for the treatment of IPN and the results seem to improve on those reported with open necrosectomy. These MIA include: percutaneous, retroperitoneal, endoscopic (endoluminal) and laparoscopic (transperitoneal). The adoption of the step-up approach in the management of severe acute pancreatitis (SAP) facilitates the implementation of MIA as the surgical treatment of choice in most cases. Since MIA require the expertise of radiologists, endoscopists and surgeons, patients suffering SAP should be treated by multidisciplinary teams in referral centers. We describe the MIA currently available and discuss their advantages, disadvantages, and results.
    Full-text · Article · Aug 2014 · Central European Journal of Medicine
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    • "Also any progression of organ failure to death was classified as grade V complication. Because surgical trauma can cause postoperative organ dysfunctions as shown in patients operated for infected pancreatic necrosis [12], any new organ failure occurring after surgery is a deviation from ideal postoperative course and should be classified as a complication according to the Clavien-Dindo classification. Although in many patients with severe trauma or peritonitis these complications may be inevitable, the classification of complications should be as objective as possible leaving minimal room for subjectivity. "
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    ABSTRACT: Background Patients undergoing emergency surgery have a high risk for surgical complications and death. The Clavien-Dindo classification has been developed and validated in elective general surgical patients, but has not been validated in emergency surgical patients. The aim of the current study was to evaluate the Clavien-Dindo classification of surgical complications in emergency surgical patients and to study preoperative factors for risk stratification that should be included into a database of surgical complications. Methods A cohort of 444 consecutive patients having emergency general surgery during a three-month period was retrospectively analyzed. Surgical complications were classified according to the Clavien-Dindo classification. Preoperative risk factors for complications were studied using logistic regression analysis. Results Preoperatively 37 (8.3%) patients had organ dysfunctions. Emergency surgical patients required a new definition for Grade IV complications (organ dysfunctions). Only new onset organ dysfunctions or complications that significantly contributed to worsening of pre-operative organ dysfunctions were classified as grade IV complications. Postoperative complications developed in 115 (25.9%) patients, and 14 (3.2%) patients developed grade IV complication. Charlson comorbidity index, preoperative organ dysfunction and the type of surgery predicted postoperative complications. Conclusions The Clavien-Dindo classification of surgical complications can be used in emergency surgical patients but preoperative organ dysfunctions should be taken into account when defining postoperative grade IV complications. For risk stratification patients’ comorbidities, preoperative organ dysfunctions and the type of surgery should be taken into consideration.
    Full-text · Article · Jul 2014 · Patient Safety in Surgery
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    • "In 2010, PANTER trial by Dutch Pancreatitis Study Group concluded that minimally invasive step-up approach, as compared with open necrosectomy, reduced the rate of the major complications or death among patients with PN and IPN.[18] With the step-up approach, more than one-third of patients were successfully treated with percutaneous drainage and did not require major abdominal surgery. "
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    ABSTRACT: CONTEXT: Pancreatic necrosis is a local complication of acute pancreatitis. The development of secondary infection in pancreatic necrosis is associated with increased mortality. Pancreatic necrosectomy is the mainstay of invasive management. AIMS: Surgical approach has signifi cantly changed in the last several years with the advent of enhanced imaging techniques and minimally invasive surgery. However, there have been only a few case series related to laparoscopic approach, reported in literature to date. Herein, we present our experience with laparoscopic management of pancreatic necrosis in 28 patients. MATERIALS AND METHODS: A retrospective study of 28 cases [20 men, 8 women] was carried out in our institution. The medical record of these patients including history, clinical examination, investigations, and operative notes were reviewed. The mean age was 47.8 years [range, 23-70 years]. Twenty-one patients were managed by transgastrocolic, four patients by transgastric, two patients by intra-cavitary, and one patient by transmesocolic approach. RESULTS: The mean operating time was 100.8 min [range, 60-120 min]. The duration of hospital stay after the procedure was 10-18 days. Two cases were converted to open (7.1%) because of extensive dense adhesions. Pancreatic fi stula was the most common complication (n = 8; 28.6%) followed by recollection (n = 3; 10.7%) and wound infection (n = 3; 10.7%). One patient [3.6%] died in postoperative period. CONCLUSIONS: Laparoscopic pancreatic necrosectomy is a promising and safe approach with all the benefi ts of minimally invasive surgery and is found to have reduced incidence of major complications and mortality.
    Full-text · Article · Jun 2014 · Journal of Minimal Access Surgery
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