Percutaneous necrosectomy in patients with acute, necrotizing pancreatitis

Abstract

The objective of this retrospective study was to evaluate the outcome of patients with acute necrotizing pancreatitis treated by active percutaneous necrosectomy. By searching the radiological, surgical and internal medicine databases, all patients with acute necrotizing pancreatitis treated by active percutaneous necrosectomy between 1992 and 2004 were identified. Demographic, laboratory, and clinical data, and details about invasive procedures were collected by reviewing patient charts, radiological and surgical reports. The computed tomography severity index (CTSI) scores were determined by reviewing CT images. Eighteen patients were identified. Median Ranson score on admission was 2. The Acute Physiology and Chronic Health Evaluation (APACHE) II score was median 22. Median CTSI score was 7. Initially all patients were treated with CT-guided drainage placement. Because passive drainage proved not to be effective, subsequent minimally invasive, percutaneous necrosectomy was performed. Eight out of 18 patients recovered fully without the need for surgery. Ten of 18 patients required additional surgical necrosectomy. For one of ten patients, percutaneous necrosectomy allowed postponing surgery by 39 days. Four of ten surgically treated patients died: three from septic multiorgan failure, one from pulmonary embolism. Percutaneous minimally invasive necrosectomy can be regarded as a safe and effective complementary treatment modality in patients with necrotizing pancreatitis. It is suitable for a subset of patients to avoid or delay surgery.

Imaging acute pancreatitis

“…Using either endoscopic or percutaneous approaches, a flexible endoscope is inserted in to the necrotic tissue cavity (usually requires a sheath of up to 30 Fr). Necrotic tissue may then be removed under direct visualisation using irrigation, snares and dormia baskets [26]. The published literature consists largely of relatively small retrospective case series, but clinical results are consistently being improved and the morbidity of the procedure is relatively low.…”

Severe Acute Pancreatitis Requiring Drainage Therapy: Findings on Computed Tomography as Predictor of Patient Outcome

“…Drainage therapy was performed in this group as well, because the clinical, laboratory and radiological findings strongly suggested infection. In addition to drainage therapy, surgical and percutaneous necrosectomy [18] were performed in 20 and 18 patients, respectively. 65 patients (81%) were referred to the intensive care unit (ICU).…”

Changes in the Management of Treatment in Acute Pancreatitis Patients

“…Also other authors published the report about very positive results with percutaneous necrosectomy (Bruennler et al, 2008;Hartwig et al, 2002a). The benefit of percutaneous necrosectomy is mini invasive approach, which does not require total anesthesia, but the disadvantages are: longer time of hospitalization, higher doses of X-ray because of repetitive computer tomography controls and high percentage of cases, when patients had to perform of laparotomy due to the insufficiency of previous one.…”

“…Percutaneous computer tomography-guided catheter debridement without surgery has been shown to be feasible in selected series in more than 50% of the included patients, with infected and sterile necrosis. Mortality rates of 12-30%, of patients treated by percutaneous drainage only, have been reported, using different access routes and a variety of catheter types (Bruennler et al, 2008;Mortelé et al, 2009). The major reported complications were hemorrhage and injury to adjacent organs.…”