Percutaneous Necrosectomy and Sinus Tract Endoscopy in the Management of Infected Pancreatic Necrosis: An Initial Experience

Abstract

ObjectiveTo describe the development of a minimally invasive technique aimed at surgical debridement in addition to simple drainage of the abscess cavity. Summary Background DataSurgical intervention for secondary infection of pancreatic necrosis is associated with a death rate of 25% to 40%. Although percutaneous approaches may drain the abscess, they have often failed in the long term as a result of inability to remove the necrotic material adequately. MethodsFourteen consecutive patients with infected necrosis secondary to acute pancreatitis were studied. The initial four patients underwent sinus tract endoscopy along a drainage tract for secondary sepsis after prior open necrosectomy. This technique was then modified to allow primary debridement for proven sepsis to be carried out percutaneously in a further 10 patients. The techniques and initial results are described. ResultsAdditional surgery for sepsis was successfully avoided in the initial four patients managed by sinus tract endoscopy, and none died. Of the following 10 patients managed by percutaneous necrosectomy, 2 died. The median inpatient stay was 42 days. There was one conversion for intraoperative bleeding. Eight patients recovered and were discharged from the hospital after a median of three percutaneous explorations. Only 40% of patients required intensive care management after surgery. ConclusionsThese initial results in an unselected group of patients are encouraging and show that unlike with percutaneous or endoscopic techniques, both resolution of sepsis and adequate necrosectomy can be achieved. The authors' initial impression of a reduction in postoperative organ dysfunction is particularly interesting; however, the technique requires further evaluation in a larger prospective series.

Practice Guidelines in Acute Pancreatitis

“…These techniques have generally been reserved for patients with infected pancreatic necrosis who are too ill to undergo prompt surgical debridement (such as those with organ failure and/or serious comorbid disease). The first technique is minimally invasive retroperitoneal necrosectomy (55,101,102,116,156), which uses a percutaneous technique to gain access to the necrotic area, dilatation of the tract to a 30-French size, an operating nephroscope for piecemeal retrieval of solid material, irrigation with high volume lavage, and placement of catheters for long-term continuous irrigation. This technique requires general anesthesia and has not been compared in a prospective fashion to more traditional surgical debridement.…”

Surgery for Acute Pancreatitis

“…This is an efficient method for debridement. An alternative approach is to use the approach used by urologists for percutaneous nephrolithotomy, with dilation of the drain track, insertion of an Amplatz sheath and high flow operating rigid nephoscope [29]. This less efficient method of debridement is often done as an adjunct to upsizing and placement of wide-bore drains (e.g., 32 Fr).…”

Changes in the Management of Treatment in Acute Pancreatitis Patients

“…The recommendation in International Association of Pancreatology reports that prophylactic application of broad-spectrum antibiotics reduces infection of computer tomography confirmed necrotic acute pancreatitis, but it does not improve survival rate. When choosing the antibiotics, it is pointed at the best results Imipenem or Meropenem (decrease of necrosis, less necessities to surgical treatment, lower mortality) (Carter et al, 2000). Comparing Imipenem and Meropenem, no differences in incidence of the septic complications were observed (Heinrich et al, 2006).…”