Choose Your Weapon for Postpancreatitis Infection : Some form of debridement or drainage is imperative when peripancreatic infection is present.

LOS ANGELES — Management options for infections following acute pancreatitis have expanded in recent years, with enhancement of percutaneous and endoscopic techniques and improvements in laparoscopic alternatives to open surgery.

But open pancreatic necrosectomy still has a vital and sometimes lifesaving role, Nicholas N. Nissen, M.D., said at the 12th International Symposium on Pancreatic and Biliary Endoscopy sponsored by the Cedars-Sinai Medical Center.

Some form of debridement or drainage is imperative when peripancreatic infection is present, which happens in about 30%-50% of pancreatic necrosis cases, Dr. Nissen emphasized.

“The mortality rate for untreated infected pancreatic necrosis is 100% without drainage or debridement,” he noted.

The best treatment method for an individual patient depends on a number of factors, said Dr. Nissen, who has a special interest in minimally invasive surgery of the liver and pancreas at Cedars-Sinai.

He also serves on the surgical faculty at the University of California, Los Angeles.

Management considerations include:

▸ Duration of disease. During the early inflammatory phase of severe pancreatitis, the risk of infection is low. However, even 2-3 weeks after symptom onset, a CT scan may show evidence of early organization and loculation of peripancreatic fluid that may indicate a gathering infection.

▸ Stability of the patient. “A hemodynamically unstable patient or a patient in septic shock really doesn't belong in an interventional radiology unit having percutaneous drainage. They really belong in the operating room,” Dr. Nissen said.

▸ Local expertise. Some interventional radiologists are comfortable with cases that require aggressive drainage of necrotic peripancreatic fluid, while others really only want to handle pseudocysts. Surgical referral is a better alternative than pushing a radiologist beyond his or her limits.

▸ The likelihood of success. If a case seems likely to require multiple endoscopic treatments, surgery may be a wiser first option, as the extent of debridement can be much more aggressive with surgery and the likelihood of repeated procedures much lower.

▸ The need for other procedures. A patient with an infection who is also likely to need a cholecystectomy or another surgical procedure is best served by having one procedure—surgery.

Debridement may be accomplished via laparotomy, laparoscopy, endoscopic transgastric drainage, or a novel percutaneous technique called sinus tract endoscopy.

Percutaneous and endoscopic approaches work best when the infection is mostly liquid, without organized necrotic tissue, Dr. Nissen said.

Extensive infection and/or a dense necrotic bed without liquefaction, especially in an unstable patient, call for open pancreatic necrosectomy. “This is a fairly impressive procedure—dramatic for the surgeon and for the patient,” he said.

Wound complications, enteric fistulas, and bleeding often complicate the procedure, which carries a reported mortality of 20%-50%.

Most patients require repeated laparotomies; however, the surgery can be lifesaving in grave cases.

A rather large incision permits access for surgical instruments used to physically remove as much necrotic tissue as possible—ideally, up to 90%.

Other cases can be handled laparoscopically, even in the face of complications arising when a percutaneous drain fails to resolve symptoms of infection.

In one 26-year-old woman with mercaptopurine-induced pancreatitis, a CT scan performed 5 weeks after symptom onset appeared to show mostly fluid behind the stomach. The woman was symptomatic and feverish, and a percutaneous drain placed after aspiration of fluid was repeatedly malfunctioning.

Dr. Nissen showed a video demonstrating laparoscopic pancreatic debridement; large amounts of necrotic tissue were removed from behind the stomach using minimally invasive techniques.

The principal objective of surgery was to physically remove “wads” of necrotic tissue that could not be seen on the rather benign-appearing CT scan. A larger-bore drain was placed at the conclusion of surgery; the original drain had been too small to handle the large amount of necrotic tissue.

“Once that necrotic tissue is gone, there is a much better chance of this cavity collapsing around the drain, small leaks or big leaks closing, and of the sepsis resolving,” he said.

“Our ability to laparoscopically manage pancreatic necrosis and pancreatic fluid collections is an important advance in the field of pancreatic surgery.

“Techniques and practices are continuing to evolve and are increasingly reliant on the cooperative efforts of gastroenterologists, surgeons, and radiologists,” Dr. Nissen added.

Necrotic tissue (arrow) is removed from behind the stomach (S). The tube is a previously placed percutaneous drain. Courtesy Dr. Nicholas N. Nissen