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Drainage?
Editorial Do all Patients With Documented Infected Necrosis Require Necrosectomy/Drainage?
G
arg and colleagues1 have (again) challenged the once prevalent and at that time (pre-2000) fully accepted surgical DOGMA that infected necrosis complicating necrotizing pancreatitis mandates immediate or (more recently) eventual necrosectomy for a successful outcome based on their incredible experience with acute pancreatitis over the last 13 years. Their recent approach of a primary, nonoperative protocol involving directed antibiotics with percutaneous drainage (when indicated) led to better outcomes when compared with primary operative necrosectomy (via formal laparotomy) in their hospital. These investigators raise several very interesting concepts to the multidisciplinary team treating these patients — gastroenterologist, radiologist, surgeon, and intensivist. The more recent approach to the treatment of infected (and sterile) necrotizing pancreatitis has evolved tremendously since the landmark works by Stone, Bradley, Davidson, and others,2,3 describing the concept of extensive debridement/necrosectomy as opposed to just wide, peripancreatic drainage, and the recognition of the importance of pancreatic parenchymal necrosis as imaged by contrast-enhanced computed tomography promoted and emphasized by Beger and associates in Germany.4,5 The realization that severe acute pancreatitis associated with infected pancreatic parenchyma and peripancreatic necrosis is not an abscess that can be evacuated solely by drainage ushered in the new paradigm of treatment in the 1970s. Since then, the management of sterile and infected necrosis has evolved further over these last 3 decades with several major conceptual advances: (1) the move from a primary operative necrosectomy to one of a primary nonoperative, supportive management of patients with sterile necrosis;6 (2) the shift in treatment paradigm that infected necrosis requires immediate operative necrosectomy to that of an attempt to suppress the systemic effects of infected necrosis by the use of focused, intravenous antibiotics to postpone the timing of the inevitable eventual necrosectomy;7,8 (3) the move from an “open” operative necrosectomy via laparotomy with various forms of peripancreatic drainage9 –12 to 1 of a minimal access necrosectomy (not just “drainage”) by other percutaneous,13 endoscopic,14 –16 laparoscopic,17,18 minimal open access,19 or a combined approach to accomplish a focused necrosectomy without the peripancreatic sequelae related to a full, open laparotomy — but in SELECTED INDIVIDUALS; and finally, (4) the more recent possibility proposed by Garg and colleagues1 in this issue of the journal that some patients with infected necrosis actually may be treated successfully without any formal attempt at either drainage or necrosectomy. This latter concept has not yet been embraced fully in the world of pancreatology, but all pancreatologists recognize that selected patients may respond successfully to this approach — BUT — the real questions are WHO, HOW OFTEN, WHEN, and WHAT is the role of percutaneous drainage, and WHAT CRITERIA should be used to abandon this approach to adopt a more aggressive endoscopic, laparoscopic, or open operative (laparotomy) approach involving some form
of necrosectomy. Open necrosectomy is associated with greater mortality as shown by the authors and associated with greater rates of new onset multiple organ failure as shown in the study of van Santvoort, et al.20 Is open necrosectomy only a rescue therapy in case of minimally invasive failure? It has been shown that endoscopic necrosectomy is safe and effective; however, even minimally invasive endoscopic necrosectomy is associated with potential morbidity and mortality.18,21 In contrast, 35% of patients with pancreatic necrosis can be treated by percutaneous drainage alone.20 Randomized prospective studies including endoscopic necrosectomy are lacking. Garg and colleagues describe a subset of all patients presenting with infected (and sterile) necrotizing pancreatitis in whom an initial treatment plan of nonoperative management proved successful with or without adjuvant percutaneous drainage. We all need to acknowledge this possibility and learn from their extensive experience challenging our now current multidisciplinary “dogma.” But their approach raises several other potentially very important possibilities. One possibility is that only the “sickest patients” were selected for operative therapy, especially if the condition of a patient had worsened when percutaneous or endoscopic drainage was inadequate — a very real possibility. Another concern is that patients treated without any drainage could/would have benefitted by an earlier more aggressive intervention. A second possible concern is the 29% mortality in the patients with infected necrosis who were not treated by operative or other minimal access techniques of necrosectomy but were treated by their primary nonoperative approach — might they have benefitted by a more aggressive intervention (necrosectomy) in an attempt to prevent the local and systemic sequelae of infected necrosis? Are/were there some signs or findings that might have identified these patients earlier as non-responders to this primary nonoperative approach? OR should they not have been treated by a primary nonoperative approach? This latter question is and has always been a very difficult one in this set of patients, ie, those patients with acute, necrotizing pancreatitis who, in the first week or two of the disease, develop progressive, overwhelming deterioration — we really have no proven, effective, pancreas-directed therapy in these patients to minimize the systemic inflammatory response syndrome response and prevent organ failure — all we have in our current armamentarium is supportive care. The concurrent article by Gluck and colleagues22 from the Virginia Mason Medical Center in Seattle, Washington, addresses the use of a combined multidisciplinary therapy for patients who have been treated successfully by an initial nonoperative approach and who have successfully walled off their area(s) of necrosis (ie, walled-off necrosis). We all need to embrace the expertise of our specialty colleagues in dealing with these very ill patients and especially so on a selective, individual basis. Depending on location of the walled-off necrosis, either a percutaneous, radiologic, image-guided endoscopic, laparoscopic, minimal open access, or full laparotomy approach may be needed — OR a combination of these approaches to the evacuation of the necrosis (ie, necrosectomy). The management of the underlying pancreatic disease seems to be important for CLINICAL GASTROENTEROLOGY AND HEPATOLOGY 2010;8:1000 –1001
December 2010
EDITORIAL
the long-term success of the minimally invasive approaches. The placement of long-term transmural drainage is a promising concept to prevent a relapse, especially in patients with the disconnected pancreatic duct syndrome.22,23 What this report by Garg and colleagues should teach us is that not all areas of infected necrosis will need a formal operative or minimal access necrosectomy. But also, many patients do/will require intervention, and identification of these individuals must be the key factor, not only to prevent complications or mortality, but also to decrease duration of hospitalization and cost. The unknown number that remains is the numerator — how many patients can be managed safely and effectively without any form of necrosectomy.
MICHAEL G. SARR, MD Department of Surgery Mayo Clinic Rochester, Minnesota STEFAN SEEWALD, MD Center of Gastroenterology Hirslanden Clinic Group Zurich, Switzerland References 1. Garg PK, Sharma M, Mandank K, et al. Primary conservative treatment results in mortality comparable to surgery in patients with infected necrosis. Clin Gastroenterol Hepatology 2010; in press. 2. Davidson ED, Bradley EL 3rd. Marsupialization in the treatment of pancreatic abscess. Surgery 1981;89:252–256. 3. Stone HH, Strom PR, Mullins RJ. Pancreatic abscess management by subtotal resection and packing. World J Surg 1984;8: 340 –345. 4. Block S, Maier W, Bittner R, et al. Identification of pancreatic necrosis in severe acute pancreatitis: imaging procedures versus clinical staging. Gut 1986;27:1035–1042. 5. Ranson JH, Balthazar E, Caccavale R, et al. Computed tomography and the prediction of pancreatic abscess in acute pancreatitis. Ann Surg 1985;201:656 – 665. 6. Büchler MW, Gloor B, Müller CA, et al. Acute necrotizing pancreatitis: treatment strategy according to the status of infection. Ann Surg 2000;232:619 – 626. 7. Mier J, León EL, Castillo A, et al. Early versus late necrosectomy in severe necrotizing pancreatitis. Am J Surg 1997;173:71–75. 8. Kendrick ML, Sarr MG. Pancreatic necrosis and infections in patients with acute pancreatitis. In: Forsmark CE, Totowa NJ, eds. Pancreatitis and complications. New Jersey: Humana Press, 2005:99 –112. 9. Bradley EL 3rd. Management of infected pancreatic necrosis by open drainage. Ann Surg 1987;206:542–550.
1001
10. Beger HG, Buchler M, Bittner R, et al. Necrosectomy and postoperative local lavage in necrotizing pancreatitis. Br J Surg 1988; 75:207–212. 11. Warshaw AL, Jin GL. Improved survival in 45 patients with pancreatic abscess. Ann Surg 1985;202:408 – 417. 12. Sarr MG, Nagorney DM, Mucha P Jr, et al. Acute necrotizing pancreatitis: management by planned, staged pancreatic necrosectomy/debridement and delayed primary wound closure over drains. Brit J Surg 1991;78:576 –581. 13. Freeny PC, Lewis GP, Traverso LW, et al. Infected pancreatic fluid collections: percutaneous catheter drainage. Radiology 1988; 167:435– 441. 14. Papachristou GI, Takahashi N, Chahal P, et al. Peroral endoscopic drainage/debridement of walled-off pancreatic necrosis. Ann Surg 2007;245:943–951. 15. Seifert H, Wehrmann T, Schmitt T, et al. Retroperitoneal endoscopic debridement for infected peripancreatic necrosis. Lancet 2000;356:653– 655. 16. Seewald S, Groth S, Omar S, et al. Aggressive endoscopic therapy for pancreatic necrosis and pancreatic abscess: a new safe and effective treatment algorithm (videos). Gastrointest Endos 2005;62:92–100. 17. Alverdy J, Vargish T, Desai T, et al. Laparoscopic intracavitary debridement of peripancreatic necrosis: preliminary report and description of the technique. Surgery 2000;127:112–114. 18. Carter CR, McKay CJ, Imrie CW. Percutaneous necrosectomy and sinus tract endoscopy in the management of infected pancreatic necrosis: an initial experience. Ann Surg 2000;232:175–180. 19. Horvath KD, Kao LS, Wherry KL, et al. A technique for laparoscopic-assisted percutaneous drainage of infected pancreatic necrosis and pancreatic abscess. Surg Endosc 2001;15:1221– 1225. 20. van Santvoort HC, Besselink MG, Bakker OJ, et al. Dutch Pancreatitis Study Group. A step-up approach or open necrosectomy for necrotizing pancreatitis. NEJM 2010;362:1491–1502. 21. Seifert H, Biermer M, Schmitt W, et al. Transluminal endoscopic necrosectomy after acute pancreatitis: a multicentre study with long-term follow-up (the GEPARD Study). Gut 2009;58:1260 – 1266. 22. Gluck M, Ross A, Irani S, et al. Combined endoscopic and percutaneous drainage of symptomatic walled-off pancreatic necrosis reduces hospital stay and radiographic resource utilization. Clin Gastroenterol Hepatol 2010, in press. 23. Arvanitakis M, Delhaye M, Bali MA, et al. Pancreatic-fluid collections: a randomized controlled trial regarding stent removal after endoscopic transmural drainage. Gastrointest Endosc 2007;65: 609 – 619.
Conflicts of interest The authors disclose no conflicts. doi:10.1016/j.cgh.2010.08.016
G
arg and colleagues1 have (again) challenged the once prevalent and at that time (pre-2000) fully accepted surgical DOGMA that infected necrosis complicating necrotizing pancreatitis mandates immediate or (more recently) eventual necrosectomy for a successful outcome based on their incredible experience with acute pancreatitis over the last 13 years. Their recent approach of a primary, nonoperative protocol involving directed antibiotics with percutaneous drainage (when indicated) led to better outcomes when compared with primary operative necrosectomy (via formal laparotomy) in their hospital. These investigators raise several very interesting concepts to the multidisciplinary team treating these patients — gastroenterologist, radiologist, surgeon, and intensivist. The more recent approach to the treatment of infected (and sterile) necrotizing pancreatitis has evolved tremendously since the landmark works by Stone, Bradley, Davidson, and others,2,3 describing the concept of extensive debridement/necrosectomy as opposed to just wide, peripancreatic drainage, and the recognition of the importance of pancreatic parenchymal necrosis as imaged by contrast-enhanced computed tomography promoted and emphasized by Beger and associates in Germany.4,5 The realization that severe acute pancreatitis associated with infected pancreatic parenchyma and peripancreatic necrosis is not an abscess that can be evacuated solely by drainage ushered in the new paradigm of treatment in the 1970s. Since then, the management of sterile and infected necrosis has evolved further over these last 3 decades with several major conceptual advances: (1) the move from a primary operative necrosectomy to one of a primary nonoperative, supportive management of patients with sterile necrosis;6 (2) the shift in treatment paradigm that infected necrosis requires immediate operative necrosectomy to that of an attempt to suppress the systemic effects of infected necrosis by the use of focused, intravenous antibiotics to postpone the timing of the inevitable eventual necrosectomy;7,8 (3) the move from an “open” operative necrosectomy via laparotomy with various forms of peripancreatic drainage9 –12 to 1 of a minimal access necrosectomy (not just “drainage”) by other percutaneous,13 endoscopic,14 –16 laparoscopic,17,18 minimal open access,19 or a combined approach to accomplish a focused necrosectomy without the peripancreatic sequelae related to a full, open laparotomy — but in SELECTED INDIVIDUALS; and finally, (4) the more recent possibility proposed by Garg and colleagues1 in this issue of the journal that some patients with infected necrosis actually may be treated successfully without any formal attempt at either drainage or necrosectomy. This latter concept has not yet been embraced fully in the world of pancreatology, but all pancreatologists recognize that selected patients may respond successfully to this approach — BUT — the real questions are WHO, HOW OFTEN, WHEN, and WHAT is the role of percutaneous drainage, and WHAT CRITERIA should be used to abandon this approach to adopt a more aggressive endoscopic, laparoscopic, or open operative (laparotomy) approach involving some form
of necrosectomy. Open necrosectomy is associated with greater mortality as shown by the authors and associated with greater rates of new onset multiple organ failure as shown in the study of van Santvoort, et al.20 Is open necrosectomy only a rescue therapy in case of minimally invasive failure? It has been shown that endoscopic necrosectomy is safe and effective; however, even minimally invasive endoscopic necrosectomy is associated with potential morbidity and mortality.18,21 In contrast, 35% of patients with pancreatic necrosis can be treated by percutaneous drainage alone.20 Randomized prospective studies including endoscopic necrosectomy are lacking. Garg and colleagues describe a subset of all patients presenting with infected (and sterile) necrotizing pancreatitis in whom an initial treatment plan of nonoperative management proved successful with or without adjuvant percutaneous drainage. We all need to acknowledge this possibility and learn from their extensive experience challenging our now current multidisciplinary “dogma.” But their approach raises several other potentially very important possibilities. One possibility is that only the “sickest patients” were selected for operative therapy, especially if the condition of a patient had worsened when percutaneous or endoscopic drainage was inadequate — a very real possibility. Another concern is that patients treated without any drainage could/would have benefitted by an earlier more aggressive intervention. A second possible concern is the 29% mortality in the patients with infected necrosis who were not treated by operative or other minimal access techniques of necrosectomy but were treated by their primary nonoperative approach — might they have benefitted by a more aggressive intervention (necrosectomy) in an attempt to prevent the local and systemic sequelae of infected necrosis? Are/were there some signs or findings that might have identified these patients earlier as non-responders to this primary nonoperative approach? OR should they not have been treated by a primary nonoperative approach? This latter question is and has always been a very difficult one in this set of patients, ie, those patients with acute, necrotizing pancreatitis who, in the first week or two of the disease, develop progressive, overwhelming deterioration — we really have no proven, effective, pancreas-directed therapy in these patients to minimize the systemic inflammatory response syndrome response and prevent organ failure — all we have in our current armamentarium is supportive care. The concurrent article by Gluck and colleagues22 from the Virginia Mason Medical Center in Seattle, Washington, addresses the use of a combined multidisciplinary therapy for patients who have been treated successfully by an initial nonoperative approach and who have successfully walled off their area(s) of necrosis (ie, walled-off necrosis). We all need to embrace the expertise of our specialty colleagues in dealing with these very ill patients and especially so on a selective, individual basis. Depending on location of the walled-off necrosis, either a percutaneous, radiologic, image-guided endoscopic, laparoscopic, minimal open access, or full laparotomy approach may be needed — OR a combination of these approaches to the evacuation of the necrosis (ie, necrosectomy). The management of the underlying pancreatic disease seems to be important for CLINICAL GASTROENTEROLOGY AND HEPATOLOGY 2010;8:1000 –1001
December 2010
EDITORIAL
the long-term success of the minimally invasive approaches. The placement of long-term transmural drainage is a promising concept to prevent a relapse, especially in patients with the disconnected pancreatic duct syndrome.22,23 What this report by Garg and colleagues should teach us is that not all areas of infected necrosis will need a formal operative or minimal access necrosectomy. But also, many patients do/will require intervention, and identification of these individuals must be the key factor, not only to prevent complications or mortality, but also to decrease duration of hospitalization and cost. The unknown number that remains is the numerator — how many patients can be managed safely and effectively without any form of necrosectomy.
MICHAEL G. SARR, MD Department of Surgery Mayo Clinic Rochester, Minnesota STEFAN SEEWALD, MD Center of Gastroenterology Hirslanden Clinic Group Zurich, Switzerland References 1. Garg PK, Sharma M, Mandank K, et al. Primary conservative treatment results in mortality comparable to surgery in patients with infected necrosis. Clin Gastroenterol Hepatology 2010; in press. 2. Davidson ED, Bradley EL 3rd. Marsupialization in the treatment of pancreatic abscess. Surgery 1981;89:252–256. 3. Stone HH, Strom PR, Mullins RJ. Pancreatic abscess management by subtotal resection and packing. World J Surg 1984;8: 340 –345. 4. Block S, Maier W, Bittner R, et al. Identification of pancreatic necrosis in severe acute pancreatitis: imaging procedures versus clinical staging. Gut 1986;27:1035–1042. 5. Ranson JH, Balthazar E, Caccavale R, et al. Computed tomography and the prediction of pancreatic abscess in acute pancreatitis. Ann Surg 1985;201:656 – 665. 6. Büchler MW, Gloor B, Müller CA, et al. Acute necrotizing pancreatitis: treatment strategy according to the status of infection. Ann Surg 2000;232:619 – 626. 7. Mier J, León EL, Castillo A, et al. Early versus late necrosectomy in severe necrotizing pancreatitis. Am J Surg 1997;173:71–75. 8. Kendrick ML, Sarr MG. Pancreatic necrosis and infections in patients with acute pancreatitis. In: Forsmark CE, Totowa NJ, eds. Pancreatitis and complications. New Jersey: Humana Press, 2005:99 –112. 9. Bradley EL 3rd. Management of infected pancreatic necrosis by open drainage. Ann Surg 1987;206:542–550.
1001
10. Beger HG, Buchler M, Bittner R, et al. Necrosectomy and postoperative local lavage in necrotizing pancreatitis. Br J Surg 1988; 75:207–212. 11. Warshaw AL, Jin GL. Improved survival in 45 patients with pancreatic abscess. Ann Surg 1985;202:408 – 417. 12. Sarr MG, Nagorney DM, Mucha P Jr, et al. Acute necrotizing pancreatitis: management by planned, staged pancreatic necrosectomy/debridement and delayed primary wound closure over drains. Brit J Surg 1991;78:576 –581. 13. Freeny PC, Lewis GP, Traverso LW, et al. Infected pancreatic fluid collections: percutaneous catheter drainage. Radiology 1988; 167:435– 441. 14. Papachristou GI, Takahashi N, Chahal P, et al. Peroral endoscopic drainage/debridement of walled-off pancreatic necrosis. Ann Surg 2007;245:943–951. 15. Seifert H, Wehrmann T, Schmitt T, et al. Retroperitoneal endoscopic debridement for infected peripancreatic necrosis. Lancet 2000;356:653– 655. 16. Seewald S, Groth S, Omar S, et al. Aggressive endoscopic therapy for pancreatic necrosis and pancreatic abscess: a new safe and effective treatment algorithm (videos). Gastrointest Endos 2005;62:92–100. 17. Alverdy J, Vargish T, Desai T, et al. Laparoscopic intracavitary debridement of peripancreatic necrosis: preliminary report and description of the technique. Surgery 2000;127:112–114. 18. Carter CR, McKay CJ, Imrie CW. Percutaneous necrosectomy and sinus tract endoscopy in the management of infected pancreatic necrosis: an initial experience. Ann Surg 2000;232:175–180. 19. Horvath KD, Kao LS, Wherry KL, et al. A technique for laparoscopic-assisted percutaneous drainage of infected pancreatic necrosis and pancreatic abscess. Surg Endosc 2001;15:1221– 1225. 20. van Santvoort HC, Besselink MG, Bakker OJ, et al. Dutch Pancreatitis Study Group. A step-up approach or open necrosectomy for necrotizing pancreatitis. NEJM 2010;362:1491–1502. 21. Seifert H, Biermer M, Schmitt W, et al. Transluminal endoscopic necrosectomy after acute pancreatitis: a multicentre study with long-term follow-up (the GEPARD Study). Gut 2009;58:1260 – 1266. 22. Gluck M, Ross A, Irani S, et al. Combined endoscopic and percutaneous drainage of symptomatic walled-off pancreatic necrosis reduces hospital stay and radiographic resource utilization. Clin Gastroenterol Hepatol 2010, in press. 23. Arvanitakis M, Delhaye M, Bali MA, et al. Pancreatic-fluid collections: a randomized controlled trial regarding stent removal after endoscopic transmural drainage. Gastrointest Endosc 2007;65: 609 – 619.
Conflicts of interest The authors disclose no conflicts. doi:10.1016/j.cgh.2010.08.016