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Open pancreatic necrosectomy – A six year experience from a DGH
e786
E-AHPBA: Free Prize Papers
to the onset (first, second week or later) of persistent organ failure (41%, 43% and 32% respectively, P = 0.51). Mortality was not related to the duration of multiple organ failure lasting less than 1 week, 1 to 2 weeks, 2 to 3 weeks or longer than 3 weeks was 43%, 38%, 46% and 52% respectively (P = 0.68). Persistent simultaneous failure of all 3 organ systems occurred in 52 patients with 63% mortality. Overall, patients with organ failure alone had a higher risk for mortality (44% of 108 patients) than patients with organ failure and infected necrosis (29% of 132 patients) (RR2.6; 95% CI:1.7e4.0; P < 0.001). However, when only mortality occurring after 10 days of admission was considered, this difference was no longer significant (28% vs. 30%, respectively, RR1.3, P = 0.4). Conclusions: Organ failure, rather than infected necrosis, determines mortality in necrotizing pancreatitis. However, mortality was not related to onset and duration of organ failure. We believe that these results strongly support intensive and prolonged treatment of these patients.
PANCREATITIS 0588 OPEN PANCREATIC NECROSECTOMY e A SIX YEAR EXPERIENCE FROM A DGH J. George, S. Meghji, A. Shah, J. Stevenson and J. Reed Colchester General Hospital, UK Aims: One in five cases of acute pancreatitis develope local complications +/ organ failure (severe acute pancreatitis). These patients are at risk of developing infected pancreatic necrosis. Mortality in this group may be as high as 50%. We describe a case series of open pancreatic necrosectomies performed at our institution over the last six years. Methods: Ten open pancreatic necrosectomies (transperitoneal approach) were undertaken between August 2008 and August 2014. These cases were retrospectively analysed. Data included age, aetiology, Glasgow score, pre- and postoperative length of stay, morbidity and mortalities. Results: The aetiology underlying seven cases was gallstones, one was due to alcohol, one post-ERCP and the remaining case, idiopathic. The male:female ratio was 4:1. The modal Glasgow score on admission was 4. The mean age of patients operated on was 58.7. Mean preoperative length of stay was 47.5 days. Mean postoperative length of stay was 48.3 days. Significant short-term complications included pancreatic abscess (3), pseudocyst (3), pulmonary embolus (1), perforated viscus (2), iatrogenic bowel injury + formation of ileostomy (1) and colonic bleed (1). The colonic bleed could not be controlled with embolisation and had to proceed to laparotomy. There were 4 deaths; all occurred within 30 days. In the long-term, 4 patients developed incisional hernias and 2 recurrent retroperitoneal collections, following discharge from hospital. Conclusions: In this unselected case series over six years from a DGH, we report outcomes which are comparable to those reported in the literature. Infected pancreatic necrosis with organ failure remains a condition with high morbidity and mortality. Aggressive supportive care combined with timely intervention is required for infected necrosis. Debate reigns over the optimal surgical approach - in experienced hands, the open necrosectomy remains a safe technique.
PANCREATITIS 0636 PROACTIVE PERCUTANEOUS CATHETER DRAINAGE STRATEGY DURING THE STEP-UP APPROACH FOR (SUSPECTED) INFECTED NECROTIZING PANCREATITIS J. van Grinsven1, P. Timmerman2, K. P. van Lienden1, J. W. Haveman2, D. Boerma3, C. H. van Eijck4, P. Fockens1, H. C. van Santvoort1, M. A. Boermeester1 and M. G. Besselink1 1 Academic Medical Center Amsterdam; 2University Medical Center Groningen; 3St. Antonius Hospital Nieuwegein; 4Erasmus Medical Center Rotterdam, Netherlands Aims: Infected necrotizing pancreatitis is nearly always an indication for invasive treatment. Percutaneous catheter drainage (PCD) is now well established as the first intervention in a ‘step-up approach’. It has been suggested that a proactive PCD strategy (including low threshold for drain revising and drain upsizing) might more often obviate the need for additional surgical necrosectomy as compared to standard drainage. Methods: We retrospectively identified patients with necrotizing pancreatitis from in-hospital databases (2004e 2014) in four tertiary referral centers. Patients who underwent PCD as primary treatment for suspected or documented infected necrosis were included. We compared patients’ outcomes of a single center with a proactive PCD strategy with those of patient2s treated in three centers where a standard drainage strategy during the step-up approach was used. Results: Of 1427 consecutive patients with acute pancreatitis, 369 patients (26%) were diagnosed with necrotizing pancreatitis, of whom 117 patients (32%) underwent primary PCD for suspected infected necrosis. Infected necrosis was ultimately proven in 82 of these patients (70%). In total 42 patients (36%) were treated in the proactive PCD center versus 75 patients (64%) in the other centers, with respectively a median of drain 3 PCD procedures (interquartile range (IQR) 2-4) and a median drain size of 16Fr (IQR 14-20) versus a median of 2 PCD procedures (IQR 1-2) and a 14Fr drain (IQR 12-14) P < .001. In the proactive PCD center less patients required additional surgical necrosectomy, 29% vs. 52% P = .045, and less new onset (multi) organ failure after PCD was seen, 5% vs. 20% P = .114. Mortality was comparable in both groups, 17% vs. 19% P = .787. Conclusions: A proactive PCD strategy for patients with (suspected) infected necrotizing pancreatitis appears to reduce the need for surgical necrosectomy. Future studies will have to demonstrate the true clinical value of this strategy.
PANCREATITIS 0718 ACHIEVING ULTRA-LOW MORTALITY IN INFECTED PANCREATIC NECROSIS E. Iaculli1, H. Dev1, K. Dajani1, S. Jamdar2, K. Guttula1 and A. Jah1 1 Addenbrooke’s Hospital, UK; 2Manchester University Hospital, UK
HPB 2016, 18 (S2), e782ee787
E-AHPBA: Free Prize Papers
to the onset (first, second week or later) of persistent organ failure (41%, 43% and 32% respectively, P = 0.51). Mortality was not related to the duration of multiple organ failure lasting less than 1 week, 1 to 2 weeks, 2 to 3 weeks or longer than 3 weeks was 43%, 38%, 46% and 52% respectively (P = 0.68). Persistent simultaneous failure of all 3 organ systems occurred in 52 patients with 63% mortality. Overall, patients with organ failure alone had a higher risk for mortality (44% of 108 patients) than patients with organ failure and infected necrosis (29% of 132 patients) (RR2.6; 95% CI:1.7e4.0; P < 0.001). However, when only mortality occurring after 10 days of admission was considered, this difference was no longer significant (28% vs. 30%, respectively, RR1.3, P = 0.4). Conclusions: Organ failure, rather than infected necrosis, determines mortality in necrotizing pancreatitis. However, mortality was not related to onset and duration of organ failure. We believe that these results strongly support intensive and prolonged treatment of these patients.
PANCREATITIS 0588 OPEN PANCREATIC NECROSECTOMY e A SIX YEAR EXPERIENCE FROM A DGH J. George, S. Meghji, A. Shah, J. Stevenson and J. Reed Colchester General Hospital, UK Aims: One in five cases of acute pancreatitis develope local complications +/ organ failure (severe acute pancreatitis). These patients are at risk of developing infected pancreatic necrosis. Mortality in this group may be as high as 50%. We describe a case series of open pancreatic necrosectomies performed at our institution over the last six years. Methods: Ten open pancreatic necrosectomies (transperitoneal approach) were undertaken between August 2008 and August 2014. These cases were retrospectively analysed. Data included age, aetiology, Glasgow score, pre- and postoperative length of stay, morbidity and mortalities. Results: The aetiology underlying seven cases was gallstones, one was due to alcohol, one post-ERCP and the remaining case, idiopathic. The male:female ratio was 4:1. The modal Glasgow score on admission was 4. The mean age of patients operated on was 58.7. Mean preoperative length of stay was 47.5 days. Mean postoperative length of stay was 48.3 days. Significant short-term complications included pancreatic abscess (3), pseudocyst (3), pulmonary embolus (1), perforated viscus (2), iatrogenic bowel injury + formation of ileostomy (1) and colonic bleed (1). The colonic bleed could not be controlled with embolisation and had to proceed to laparotomy. There were 4 deaths; all occurred within 30 days. In the long-term, 4 patients developed incisional hernias and 2 recurrent retroperitoneal collections, following discharge from hospital. Conclusions: In this unselected case series over six years from a DGH, we report outcomes which are comparable to those reported in the literature. Infected pancreatic necrosis with organ failure remains a condition with high morbidity and mortality. Aggressive supportive care combined with timely intervention is required for infected necrosis. Debate reigns over the optimal surgical approach - in experienced hands, the open necrosectomy remains a safe technique.
PANCREATITIS 0636 PROACTIVE PERCUTANEOUS CATHETER DRAINAGE STRATEGY DURING THE STEP-UP APPROACH FOR (SUSPECTED) INFECTED NECROTIZING PANCREATITIS J. van Grinsven1, P. Timmerman2, K. P. van Lienden1, J. W. Haveman2, D. Boerma3, C. H. van Eijck4, P. Fockens1, H. C. van Santvoort1, M. A. Boermeester1 and M. G. Besselink1 1 Academic Medical Center Amsterdam; 2University Medical Center Groningen; 3St. Antonius Hospital Nieuwegein; 4Erasmus Medical Center Rotterdam, Netherlands Aims: Infected necrotizing pancreatitis is nearly always an indication for invasive treatment. Percutaneous catheter drainage (PCD) is now well established as the first intervention in a ‘step-up approach’. It has been suggested that a proactive PCD strategy (including low threshold for drain revising and drain upsizing) might more often obviate the need for additional surgical necrosectomy as compared to standard drainage. Methods: We retrospectively identified patients with necrotizing pancreatitis from in-hospital databases (2004e 2014) in four tertiary referral centers. Patients who underwent PCD as primary treatment for suspected or documented infected necrosis were included. We compared patients’ outcomes of a single center with a proactive PCD strategy with those of patient2s treated in three centers where a standard drainage strategy during the step-up approach was used. Results: Of 1427 consecutive patients with acute pancreatitis, 369 patients (26%) were diagnosed with necrotizing pancreatitis, of whom 117 patients (32%) underwent primary PCD for suspected infected necrosis. Infected necrosis was ultimately proven in 82 of these patients (70%). In total 42 patients (36%) were treated in the proactive PCD center versus 75 patients (64%) in the other centers, with respectively a median of drain 3 PCD procedures (interquartile range (IQR) 2-4) and a median drain size of 16Fr (IQR 14-20) versus a median of 2 PCD procedures (IQR 1-2) and a 14Fr drain (IQR 12-14) P < .001. In the proactive PCD center less patients required additional surgical necrosectomy, 29% vs. 52% P = .045, and less new onset (multi) organ failure after PCD was seen, 5% vs. 20% P = .114. Mortality was comparable in both groups, 17% vs. 19% P = .787. Conclusions: A proactive PCD strategy for patients with (suspected) infected necrotizing pancreatitis appears to reduce the need for surgical necrosectomy. Future studies will have to demonstrate the true clinical value of this strategy.
PANCREATITIS 0718 ACHIEVING ULTRA-LOW MORTALITY IN INFECTED PANCREATIC NECROSIS E. Iaculli1, H. Dev1, K. Dajani1, S. Jamdar2, K. Guttula1 and A. Jah1 1 Addenbrooke’s Hospital, UK; 2Manchester University Hospital, UK
HPB 2016, 18 (S2), e782ee787