1. JOINT HOSPITAL SURGICAL GRAND ROUND 19 th May 2007 Charing Chong Alice Ho Miu Ling Nethersole Hospital / North District Hospital Surgery for Severe Pancreatitis: Whom, When and What

2. JOINT HOSPITAL SURGICAL GRAND ROUND 19 th May 2007 Definition “ Acute pancreatitis with the presence of organ failure (e.g., shock, pulmonary insufficiency, renal failure, or gastrointestinal bleeding) or pancreatic or peri-pancreatic complications (e.g., necrosis, abscess, or pseudocyst), or both, along with unfavorable early prognostic signs (e.g., using the Ranson criteria or the APACHE II score) “ Bradley EL 3rd: A clinically based classification system for acute pancreatitis. Summary of the International Symposium on Acute Pancreatitis, Atlanta, 1992. Arch Surg 1993 W h a t i s s e v e r e p a n c r e a t i t i s ?

3. JOINT HOSPITAL SURGICAL GRAND ROUND 19 th May 2007 Definition 10 – 20 % Generally classified into two stages: 1.Early (within 2 weeks): SIRS Pancreatic necrosis develops in parallel with that within 4 days after onset 2.Late (after 3-4 weeks): Development of infectious pancreatic complications and pancreatic abscess Mortality rate of 20 – 50% W h a t i s s e v e r e p a n c r e a t i t i s ?

4. JOINT HOSPITAL SURGICAL GRAND ROUND 19 th May 2007 SURGEON PATIENT

5. JOINT HOSPITAL SURGICAL GRAND ROUND 19 th May 2007 Who requires surgery? When to intervene? What technique should be used?

6. JOINT HOSPITAL SURGICAL GRAND ROUND 19 th May 2007 WHOM?

7. JOINT HOSPITAL SURGICAL GRAND ROUND 19 th May 2007 Whom S h o u l d a l l p a t i e n t s w i t h s e v e r e p a n c r e a t i t i s b e o p e r a t e d ? DETECTION OF NECROSIS ITSELF IS NOT AN INDICATION FOR SURGERY

8. JOINT HOSPITAL SURGICAL GRAND ROUND 19 th May 2007 Whom Over 90% of patients with sterile necrosis can be successfully treated without surgical intervention Surgical treatment of sterile necrosis appears to have a higher mortality rates (11.9%, C.I. 5.3 – 22.2) than the conservative treatment (2.3%, C.I. 0.3 – 8.2) in patient with sterile necrosis Ashley SW, et al. Necrotising pancreatitis. Ann Surg 2001 Buchler MW, et al. Acute necrotising pancreatitis: treatment stratergy according to status of infection. Ann Surg 2000 S h o u l d a l l p a t i e n t s w i t h s e v e r e p a n c r e a t i t i s b e o p e r a t e d ? Heinrich S, et al. Evidence-based treatment of acute pancreatitis: A look at established paradigms. Ann Surg 2006

9. JOINT HOSPITAL SURGICAL GRAND ROUND 19 th May 2007 Whom STERILE NECROSIS Small subset warrants surgery: –Deteriorating organ failure despite maximal support –Persisting symptoms that preclude hospital discharge despite several weeks of optimum conservative treatment S h o u l d a l l p a t i e n t s w i t h s e v e r e p a n c r e a t i t i s b e o p e r a t e d ? Beger HG, et al. Acute pancreatitis: Who needs an operation? J Hepatobiliary Pancreat Surg 2002 Fernadez-del Castillo C, et al. Debridement and closed packing for the treatment of necrotising pancreatitis. Ann Surg 2000

10. JOINT HOSPITAL SURGICAL GRAND ROUND 19 th May 2007 Whom NECROTIZING PANCREATITIS WITH PROVEN INFECTED NECROSIS IS AN INDICATION FOR SURGICAL INTERVENTION Werner J, et al. Management of acute pancreatiits: from surgery to interventional intensive care. Gut 2005. Uhl W, et al. IAP guidelines for the surgical management of acute pancreatitis. Pancreatology 2002. Ranson JHC. The current management of acute pancreatitis. Adv Surg 1995. McFadden DW, Reber HA. Indications for surgery in severe acute pancreatitis. Int J Pancreatol 1994. S h o u l d a l l p a t i e n t s w i t h s e v e r e p a n c r e a t i t i s b e o p e r a t e d ?

11. JOINT HOSPITAL SURGICAL GRAND ROUND 19 th May 2007 Whom Complete blood picture Positive blood culture Positive endotoxin test of blood Gas in and around the pancreas on CT scan Merely indirect evidence of infection in general CT- or USG - guided fine-needle aspiration High accuracy, 89.4% - 100% Safe and reliable W h a t i s t h e b e s t d i a g n o s t i c t o o l ? Banks PA, et al. CT-guided aspiration of suspected pancreatic infection: bacteriology and clinical outcome. Int J Pancreatol 1995. Rau B, et al. Role of ultrasonographically guided fine-needle aspiration cytology in the diagnosis of infected pancreatic necrosis. Br J Surg 1998.

12. JOINT HOSPITAL SURGICAL GRAND ROUND 19 th May 2007 WHEN?

13. JOINT HOSPITAL SURGICAL GRAND ROUND 19 th May 2007 When EARLY To control sepsis and prevent major organ failure High mortality rate LATE Border between normal and necrotic pancreatic tissue becomes more distinct with time Minimize intra-operative haemorrhage Avoid unnecessary removal of normal pancreas W h a t i s t h e o p t i m a l t i m i n g f o r s u r g i c a l i n t e r v e n t i o n ?

14. JOINT HOSPITAL SURGICAL GRAND ROUND 19 th May 2007 When Early versus late necrosectomy in severe necrotizing pancreatitis. J. Mier, E. León, A. Castillo, F. Robledo, R. Blanco The American Journal of Surgery 1997, Volume 173, Pages 71-75. W h a t i s t h e o p t i m a l t i m i n g f o r s u r g i c a l i n t e r v e n t i o n ? Early (within 72 hours, n = 25) vs Late (more than 12 days, n = 15) Indication: MOF with clinical deterioration despite maximal intensive care Open packing and staged necrosectomy Mortality: 56% (Early) vs 27% (Late) Terminated early because of very high mortality rate for patients underwent early surgery (Odds ratio 3.4)

15. JOINT HOSPITAL SURGICAL GRAND ROUND 19 th May 2007 When In case of suspected or proven infection of necrosis, prophylactic antibiotic treatment could be primarily applied W h a t i s t h e o p t i m a l t i m i n g f o r s u r g i c a l i n t e r v e n t i o n ? Heinrich S, et al. Evidence-based treatment of acute pancreatitis: A look at established paradigms. Ann Surg 2006 Isaji S, et al. JPN Guidelines for the management of acute pancreatitis: surgical management. J Hepatobiliary Pancreat Surg.2002. EARLY SURGERY IS NOT RECOMMENDED FOR SEVERE ACUTE PANCREATITIS

16. JOINT HOSPITAL SURGICAL GRAND ROUND 19 th May 2007 When However, reports have different views about the length of time that conservative management should be applied before surgical intervention is considered. (Period ranging from 3 – 5 days to more than 5 weeks) Werner J, et al. Management of acute pancreatiits: from surgery to interventional intensive care. Gut 2005. Buchler P, et al. Surgical approach in patients with acute pancreatitis. Is infected or sterile necrosis an indication — in whom should this be done, when, and why? Gastroenterol Clin North Am 1999. ALTHOUGH IT IS DIFFICULT TO RECOMMEND AN EXACT DURATION, AT LEAST 3-4 WEEKS OF CONSERVATIVE MANAGEMENT IS DESIRABLE W h a t i s t h e o p t i m a l t i m i n g f o r s u r g i c a l i n t e r v e n t i o n ?

17. JOINT HOSPITAL SURGICAL GRAND ROUND 19 th May 2007 WHAT?

18. JOINT HOSPITAL SURGICAL GRAND ROUND 19 th May 2007 What PANCREATIC RESECTION: Increased perioperative morbidity Normal pancreatic parenchyma unnecessarily removed Long term outcome of patients is closely related to the amount of preserved pancreatic tissue W h i c h s u r g i c a l t e c h n i q u e s h o u l d b e u s e d ? ORGAN PRESERVING NECROSECTOMY IS THE SURGICAL TECHNIQUE OF CHOICE FOR TREATMENT OF INFECTED PANCREATIC AND PERIPANCREATIC NECROSIS Uhl W, et al. International Association of Pancreatology. IAP Guidelines for the surgical management of acute pancreatitis. Pancreatology 2002.

19. JOINT HOSPITAL SURGICAL GRAND ROUND 19 th May 2007 What OPEN PACKING +/- PLANNED STAGED RE- LAPAROTOMIES Performed in 48-hour intervals Until all necrosis has resolved and granulation tissue developed Lower recurrent intra-abdominal sepsis Higher post-operative morbidity like fistulae, bleeding and incisional hernias W h i c h s u r g i c a l t e c h n i q u e s h o u l d b e u s e d ? Bradley EL 3rd, Allen K.. A prospective longitudinal study of observation versus surgical intervention in the management of necrotizing pancreatitis. Am J Surg. 1991 Werner J,et al. Surgical treatment of acute pancreatitis. Curr Treat Options Gastroenterol 2003.

20. JOINT HOSPITAL SURGICAL GRAND ROUND 19 th May 2007 What W h i c h s u r g i c a l t e c h n i q u e s h o u l d b e u s e d ? Beger HG. Operative management of necrotizing pancreatitis: necrosectomy and continuous closed postoperative lavage of the lesser sac. Hepatogastroenterology. 1991. Werner J,et al. Surgical treatment of acute pancreatitis. Curr Treat Options Gastroenterol 2003. CLOSED PACKING +/- CONTINUOUS POST- OPERATIVE LAVAGE Necrosectomy and subsequent closed continuous lavage of lesser sac 8 – 10 L/day through surgically placed drainages To continuously remove residual pancreatic necrosis Re-laparotomies are frequently not necessary Less post-operative morbidity

21. JOINT HOSPITAL SURGICAL GRAND ROUND 19 th May 2007 What W h i c h s u r g i c a l t e c h n i q u e s h o u l d b e u s e d ?

22. JOINT HOSPITAL SURGICAL GRAND ROUND 19 th May 2007 What W h i c h s u r g i c a l t e c h n i q u e s h o u l d b e u s e d ?

23. JOINT HOSPITAL SURGICAL GRAND ROUND 19 th May 2007 What W h i c h s u r g i c a l t e c h n i q u e s h o u l d b e u s e d ? Heinrich S, et al. Evidence-based treatment of acute pancreatitis: A look at established paradigms. Ann Surg 2006. Isaji S, et al. JPN Guidelines for the management of acute pancreatitis: surgical management. J Hepatobiliary Pancreat Surg. 2006. Werner J, et al. Management of acute pancreatiits: from surgery to interventional intensive care. Gut 2005. CAREFUL SINGLE NECROSECTOMY AND POST-OPERATIVE LAVAGE WITHOUT PLANNED RELAPAROTOMIES SEEMS TO BE LESS HARMFUL AND COULD BE CONSIDERED WHEN APPLICABLE

24. JOINT HOSPITAL SURGICAL GRAND ROUND 19 th May 2007 What Only a few prospective trials None of them was randomized Level of evidence is very low W h i c h s u r g i c a l t e c h n i q u e s h o u l d b e u s e d ?

25. JOINT HOSPITAL SURGICAL GRAND ROUND 19 th May 2007 What MINIMALLY INVASIVE RETROPERITONEAL PANCREATIC NECROSECTOMY  Removal of the solid necrotic material under direct vision through a wide bore tract  Use of high volume post-operative lavage  Can be performed under local anaesthesia  Reduced the need for post-operative intensive care  Avoiding escalation of organ dysfunction  Increase in the number of procedures W h i c h s u r g i c a l t e c h n i q u e s h o u l d b e u s e d ? Connor S et al. Minimally invasive retroperitoneal pancreatic necrosectomy. Dig Surg 2003. Carter RC, et al. Percutaneous necrosectomy and sinus tract endoscopy in the management of infected pancreatic necrosis: An initial experience. Ann Surg 2000. Not yet been shown to significantly reduce mortality

26. JOINT HOSPITAL SURGICAL GRAND ROUND 19 th May 2007 What ENDOSCOPIC THERAPY: First reported by Baron in 1996 Several transgastric o transduodenal drainage catheters inserted endoscopically Lavage continued until resolution of the collection 2-4 procedures were required for resolution Mean duration of catheter placement was 19 days Successful removal of necrosis in > 80% No mortality Almost 40% iatrogenic infection Serious complication in 45% of patient including serious bleeding, perforation Up to 60% developed further collection after two years W h i c h s u r g i c a l t e c h n i q u e s h o u l d b e u s e d ? Baron T, et al. Endoscopic therapy for organized pancreatic necrosis. Gastroenterology 1996.

27. JOINT HOSPITAL SURGICAL GRAND ROUND 19 th May 2007 What A n y p l a c e f o r e n d o s c o p i c t h e r a p y ? SeriesNPathology Study design Mortality Mean no of procedures Morbidity Charnley Endoscopy 2006 1311 infected Retro- spective 15 %4 Open surgery x 1 Additional percutaneous drainage x 2 Laparoscopic drainage x 3 Hookey GIE 2006 116 Necrosis x 8 Pancreatic abscess x 9 Acute fluid collection + acute and chronic pseudocysts Retro- spective 5.1%/11% Seewald GIE 2005 13 Pancreatic necrosis and abscess Retro- spective N/A/ Open surgery x 1 Recurrent pseudocyst x 2 Bleeding x 4

28. JOINT HOSPITAL SURGICAL GRAND ROUND 19 th May 2007 What W h i c h s u r g i c a l t e c h n i q u e s h o u l d b e u s e d ? Werner J, et al. Management of acute pancreatiits: from surgery to interventional intensive care. Gut 2005. MINIMALLY INVASIVE PROCEDURES FOR INFECTED PANCREATIC NECROSIS ARE STILL EVOLVING

29. JOINT HOSPITAL SURGICAL GRAND ROUND 19 th May 2007 Summary W h a t s h o u l d w e d o ? Diagnosis of acute pancreatitis Mild / ModerateSevere Basic support Multi-Organs Failure Intensive care CT Scan +/- Image-guided Biopsy Sterile Infected Intensive care At least 3-4 th week after onset Prophylactic antibiotics Persistent deterioration despite maximal intensive care support Surgery

30. JOINT HOSPITAL SURGICAL GRAND ROUND 19 th May 2007 Conclusion Whom –Infected necrosis –Sterile necrosis with MOF despite maximal support When –Early surgery not recommended –Desirable to be 3 rd to 4 th week after the onset What –Organ preserving necrosectomy vs pancreatic reseciton –Open vs closed –Packing vs continuous lavage –Convention vs Minimally invasive W h a t s h a l l w e d o ?

31. JOINT HOSPITAL SURGICAL GRAND ROUND 19 th May 2007 Conclusion Low level of evidence Further studies: –Refine the indications for surgery –Define the timing for surgery –Find the optimal procedures –Newer approaches: laparoscropic, endoscopic, retroperitoneal procedures W h a t s h a l l w e d o ?

32. JOINT HOSPITAL SURGICAL GRAND ROUND 19 th May 2007