Definition and Overview

Pancreatic necrosectomy is the surgical procedure used in the management of acute necrotising pancreatitis, a condition characterised by the inflammation of the pancreas.

Acute pancreatitis is a serious condition, which often comes with severe and sometimes, fatal complications. While mild cases can be managed with conservative therapies, such as aggressive hydration, antibiotic treatment, and total parenteral nutrition, severe cases typically require intensive care admission, and occasionally, surgical intervention, such as necrosectomy, which is a form of debridement where necrotic tissue is resected or removed.

Who Should Undergo and Expected Results

Necrotising pancreatitis is seen in approximately 20% all acute pancreatitis cases. This is a severe form of pancreatitis, wherein the perfusion to the pancreatic tissues becomes poor, resulting in tissue death. This condition increases the risk of developing organ failure, which subsequently raises the risk for mortality.

The primary indication for performing a pancreatic necrosectomy, whether it be open or laparoscopic, is the presence of infected pancreatic necrosis. It can also be performed in the case of sterile pancreatic necrosis with associated deterioration of the patient’s clinical status.

Although open pancreatic necrosectomy remains to be the gold standard in the surgical management of acute pancreatitis, minimally invasive approaches, including laparoscopic and endoscopic procedures, are increasingly being performed in recent times. Success rates for these procedures range from 70-95% with morbidity of around 20%. Mortality rates, on the other hand, can reach as high as 18%.

Prior to performing the operation, patients must be adequately resuscitated and optimised. Prolonged stay in the intensive care unit may be expected and blood products must be secured beforehand.

How is the Procedure Performed?

Pancreatic necrosectomy is traditionally performed via an open surgery with an abdominal incision. However, concerns regarding additional morbidity, specifically related to organ dysfunction brought about by an abdominal incision, have resulted in the introduction of alternative techniques. These make use of laparoscopic equipment that are inserted in significantly smaller incisions.

After the incisions are made, the surgeon will access the abdominal cavity and the pancreas. This can be done via the transgastric, retrocolic or retroperitoneal routes. The pancreas should be thoroughly exposed, making sure that all necrotic areas and pockets are visualised.

Once the retroperitoneum is accessed, purulent materials are gently suctioned to minimise the contamination of the abdominal cavity. The pus is also collected as specimen and sent for culture studies to determine the proper antibiotic therapy to be used later on.

The ultimate goal of necrosectomy is to remove all the areas of infection and necrosis. Using forceps, the necrotic pancreatic tissues and debris are removed. Dissection should be limited to areas with loose tissues, making sure that normal pancreatic tissue is preserved.

Following the procedure, drains are inserted from the pancreatic area to minimise the exposure of the abdominal contents to the pancreatic juice. A gastric tube is also placed to control secretions coming from the stomach. An appropriate access for feeding must also be inserted, typically a jejunal tube.

Possible Risks and Complications

In and by itself, severe acute pancreatitis is fraught with complications. Patients with this condition requiring surgical intervention are usually at the advanced stages of the disease, with mortality rates as high as 50%.

After the operation, bacteremia or sepsis may occur. Postoperative intensive care unit admission is generally recommended to ensure close monitoring and optimal supportive management. Vasopressor and antibiotic therapies may also be necessary.

One of the most common complications of pancreatic necrosectomy is hemorrhage, which may be related to overaggressive necrosectomy. In these cases, balloon tamponade or embolisation may help, depending on where the bleeding is coming from. In worse cases, re-exploration of the abdomen may be necessary.

Several issues regarding minimally invasive pancreatic necrosectomy have been raised. In particular, there have been reports showing that repeated interventions may be necessary in order to achieve full resolution of the condition, resulting in longer hospital stay. Some experts have also questioned its usefulness in the severely ill, and suggest that it be reserved for patients with already organised necrosis.

Recovery time tend to vary, depending on the patient’s condition and the adequacy of the necrosectomy. Even after recovery, long-term complications can still occur. Although infrequent, one of the more bothersome complications of the procedure is the development of a fistula, which occurs in about 10-15% of cases. Damage to the main pancreatic duct may result in persistent leakage of pancreatic fluid, eventually creating a tract. Some cases of pancreatic fistulae may be managed with endoscopic stenting. In cases where there is extensive necrosis resulting in the separation of the main pancreatic duct from the tail (“disconnected duct”), further surgery may be necessary to remove the residual tail and create a formal connection to the intestines (pancreaticojejunostomy).

References:

  • Bradley EL 3rd. A clinically based classification system for acute pancreatitis. Summary of the International Symposium on Acute Pancreatitis, Atlanta, Ga, September 11 through 13, 1992. Arch. Surg.128(5),586–590(1993)

  • Lenhart DK, Balthazar EJ. MDCT of acute mild (nonnecrotizing) pancreatitis: abdominal complications and fate of fluid collections. AJR Am. J. Roentgenol.190(3),643–649(2008).

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