Published online Oct 27, 2017. doi: 10.4240/wjgs.v9.i10.200
Peer-review started: December 28, 2016
First decision: January 14, 2017
Revised: July 31, 2017
Accepted: August 16, 2017
Article in press: August 17, 2017
Published online: October 27, 2017
To determine percentage of patients of necrotizing pancreatitis (NP) requiring intervention and the types of interventions performed. Outcomes of patients of step up necrosectomy to those of direct necrosectomy were compared. Operative mortality, overall mortality, morbidity and overall length of stay were determined.
After institutional ethics committee clearance and waiver of consent, records of patients of pancreatitis were reviewed. After excluding patients as per criteria, epidemiologic and clinical data of patients of NP was noted. Treatment protocol was reviewed. Data of patients in whom step-up approach was used was compared to those in whom it was not used.
A total of 41 interventions were required in 39% patients. About 60% interventions targeted the pancreatic necrosis while the rest were required to deal with the complications of the necrosis. Image guided percutaneous catheter drainage was done in 9 patients for infected necrosis all of whom required further necrosectomy and in 3 patients with sterile necrosis. Direct retroperitoneal or anterior necrosectomy was performed in 15 patients. The average time to first intervention was 19.6 d in the non step-up group (range 11-36) vs 18.22 d in the Step-up group (range 13-25). The average hospital stay in non step-up group was 33.3 d vs 38 d in step up group. The mortality in the step-up group was 0% (0/9) vs 13% (2/15) in the non step up group. Overall mortality was 10.3% while post-operative mortality was 8.3%. Average hospital stay was 22.25 d.
Early conservative management plays an important role in management of NP. In patients who require intervention, the approach used and the timing of intervention should be based upon the clinical condition and local expertise available. Delaying intervention and use of minimal invasive means when intervention is necessary is desirable. The step-up approach should be used whenever possible. Even when the classical retroperitoneal catheter drainage is not feasible, there should be an attempt to follow principles of step-up technique to buy time. The outcome of patients in the step-up group compared to the non step-up group is comparable in our series. Interventions for bowel diversion, bypass and hemorrhage control should be done at the appropriate times.
Core tip: Necrotizing pancreatitis is a clinical challenge which requires aggressive conservative management in the early part of the attack. About 60% patients respond to conservative management. Patients who develop infection in the necrosis may require intervention. Delay, drain and debride if required, are the principles of step-up approach. Percutaneous drainage should be performed to be followed later by a step-up necrosectomy if required. If percutaneous drainage is not available or is technically unfeasible, surgical necrosectomy can yield equally good results when performed after an appropriate delay at least of 2 wk. With advent of minimally invasive modalities, infected as well as symptomatic sterile necrosis can be treated variably with radiological, surgical or endoscopic means. The modality selected depends upon the local morphology of the inflamed pancreas and availability of expertise.