Open necrosectomy is feasible as a last resort in selected cases with infected pancreatic necrosis: a case series and systematic literature review

Abstract

Background Acute pancreatitis is a common inflammatory pancreatic disorder, often caused by gallstone disease and frequently requiring hospitalization. In 80% of cases, a rapid and favourable outcome is described, while a necrosis of pancreatic parenchyma or extra-pancreatic tissues is reported in 10–20% of patients. The onset of pancreatic necrosis determines a significant increase of early organ failure rate and death that has higher incidence if infection of pancreatic necrosis (IPN) or extra-pancreatic collections occur. IPN always requires an invasive intervention, and, in the last decade, the advent of minimally invasive techniques has gradually replaced the employment of the open traditional approach. We report a series of three severe cases of IPN managed with primary open necrosectomy (ON) and a systematic review of the literature, in order to understand if emergency surgery still has a role in the current clinical practice. Methods From January 2010 to January 2020, 3 cases of IPN were treated in our Academic Department of General and Emergency Surgery. We performed a PubMed MEDLINE search on the ON of IPN, selecting 20 from 654 articles for review. Results The 3 cases were male patients with a mean age of 61.3 years. All patients referred to our service complaining an evolving severe clinical condition evocating a sepsis due to IPN. CT scan was the main diagnostic tool. Patients were initially conservatively managed. In consideration of clinical worsening conditions, and at the failure of conservative and minimal invasive treatment, they were, finally, managed with emergency ON. Patients reported no complications nor procedure-related sequelae in the follow-up period. Conclusion The ON is confirmed to be the last resort, useful in selected severe cases, with a defined timing and in case of proven non-feasibility and no advantage of other minimally invasive approaches.

Spontaneous Free Peritoneal Perforation of an Infected Pancreatic Fluid Collection Managed with Laparoscopic Drainage and Necrosectomy

“…Percutaneous image-guided drains are initially placed followed by retroperitoneoscopic debridement. If all these minimal invasive methods fail, the last resort would be an open necrosectomy, which carries high morbidity and mortality rates [10,11]. This step-up approach was developed over several decades 2…”

Management of Acute Pancreatitis: Conservative Treatment and Step-Up Invasive Approaches—Evidence-Based Guidance for Clinicians

“…Ongoing organ failure without signs of infected necrosis, ongoing gastric outlet, biliary or intestinal obstruction from a large, walled-off necrotic collection, disconnected duct syndrome, and symptomatic or growing pseudocysts are indications for drainage four weeks after the onset of AP, while ongoing pain or discomfort after eight weeks is also another criterion. [16][17][18][19][20][63][64][65]. Furthermore, strong suspicion of infected necrotizing pancreatitis with clinical deterioration is a sign for intervention after four weeks [16][17][18][19][20][63][64][65].…”

“…[16][17][18][19][20][63][64][65]. Furthermore, strong suspicion of infected necrotizing pancreatitis with clinical deterioration is a sign for intervention after four weeks [16][17][18][19][20][63][64][65].…”

“…Open surgery should be considered when endoscopic or percutaneous methods are not effective or when complications occur while performing minimally invasive techniques [16,19,20,63,64]. Other indications for open surgery are severe complications of the disease, including ACS, bowel ischaemia, or perforation due to necrosis, acute necrotizing cholecystitis, and bowel fistula formation extending into the pancreatic collection [16,19,20,63,64]. Finally, a lack of sufficient experience for minimally invasive techniques is another criterion for open surgery [16,19,20,63,64].…”

“…Other indications for open surgery are severe complications of the disease, including ACS, bowel ischaemia, or perforation due to necrosis, acute necrotizing cholecystitis, and bowel fistula formation extending into the pancreatic collection [16,19,20,63,64]. Finally, a lack of sufficient experience for minimally invasive techniques is another criterion for open surgery [16,19,20,63,64].…”