Dig Dis Sci (2006) 51:1388–1395 DOI 10.1007/s10620-006-9112-6
ORIGINAL PAPER
No Debridement Is Necessary for Symptomatic or Infected Acute Necrotizing Pancreatitis: Delayed, Mini-Retroperitoneal Drainage for Acute Necrotizing Pancreatitis Without Debridement and Irrigation Yu-Chung Chang · Hong-Min Tsai · Xi-Zhang Lin · Chia-Hao Chang · Jen Pin Chuang
Received: 16 March 2005 / Accepted: 1 November 2005 / Published online: 20 July 2006 C Springer Science+Business Media, Inc. 2006
Abstract We sought to determine if necrosectomy can be omitted for complicated acute necrotizing pancreatitis (ANP). Since 1996, we prospectively performed retroperitoneal drainage by introducing a sump drain to the pancreatic head area via a small left flank incision without debridement and irrigation on 19 consecutive complicated ANP patients. We purposely delayed surgery until liquefaction of retroperitoneal tissue reached the left flank. Our patients had a mean Ranson’s and APACHE II score of 5.9 (range, 4–8) and 20.1(range, 4–45), respectively. Sixteen available CT showed retroperitoneal liquefaction after 21.3 days (range, 14–26). Operations were delayed for 4.7 weeks (range, 1.3–9.0). No patient succumbed during this period. The indications were infected necrosis in 16 and severe abdominal pain/food intolerance in 3 patients. Average skin incision was 4.0 cm (range, 3–9). Fungi or bacteria were cultured in 15 patients (80.0%). The recovery courses were surprisingly uneventful. Oral intake began within 2.4 days (range, 1–5) and mean hospital stay (16 survivals) was 23.2 days (range, 4–120) after operY.-C. Chang () · J. P. Chuang Department of Surgery, National Cheng Kung University Hospital, College of Medicine, National Cheng Kung University, 138, Sheng Li Road, Tainan, 70428, Taiwan e-mail:
[email protected] H.-M. Tsai Department of Radiology, National Cheng Kung University Hospital, College of Medicine, National Cheng Kung University, 138, Sheng Li Road, Tainan, 70428, Taiwan X.-Z. Lin Department of Medicine, National Cheng Kung University Hospital, College of Medicine, National Cheng Kung University, 138, Sheng Li Road, Tainan, 70428, Taiwan C.-H. Chang Department of Surgery, Chi-Mei Hospital, Liouying county, Tainan prefecture, Taiwan Springer
ation. Drains were completely removed 120.6 days (range, 60–250) later from these outpatients. One gastric perforation and one minor duodenal leak were the only procedurerelated complications (10.5%). Three patients died (15.8%), although one had a healed ANP. In conclusion, this delayuntil-liquefaction strategy without necrosectomy is an easy and effective treatment method. Keywords Acute necrotizing pancreatitis . Debridement . Drainage . Minimal surgical procedure Introduction It has been more than a century since the disputes between Senn [1] and Fitz [2] were settled, yet the disagreement regarding treatment of infected necrotizing pancreatitis (INP), a devastating and lethal complication of acute pancreatitis, still remains. Mortality from INP is as high as 100% if not treated surgically. However, in recent years, the mortality and morbidity of this disease has dramatically decreased owing to earlier and more accurate diagnosis and active surgical intervention. Most surgical interventions are carried out via the transperitoneal approach [1, 3–19], scheduled [1, 3–9] or unscheduled [9–11] reexplorations, widespread debridement [1, 3–18] (either with open [3–9]/close packing [6, 12] or continuous lavage [9, 10, 13–17]), and pancreatectomy [19]. However, these methods usually require multiple debridements of the necrotic tissue with drainage, a labor-intensive and difficult technique that risks intraperitoneal spread of the infection and requires cumbersome postoperative care [3–14]. To resolve this predicament, we treated our patients with complicated acute necrotizing pancreatitis (ANP) using delayed, retroperitoneal drainage via a minimal left flank incision and without debridement of the necrotic tissue. We found our method to be successful.
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Materials and methods In March 1996, we successfully treated our first case of complicated ANP using retroperitoneal drainage with delayed surgery and without debridement. Since then, we prospectively explored this strategy on 19 patients. With the cooperation of our gastrointestinal and radiology departments, complicated ANP patients were treated conservatively and underwent weekly computed tomography (CT) exams to assess the progression of retroperitoneal necrosis to liquefaction in the medical ward or the medical intensive care unit. In most cases, necrosis originated in the peripancreatic area, extended upward to the lesser sac, downward to the mesentery, reached the bilateral pararenal space, and finally extended down to the pelvic cavity. Liquefaction of necrotic tissues predominantly reached the left side first. We closely observed the liquefaction process until left flank involvement (Fig. 1) but prior to any spread into the pelvic cavity. Six patients required peritoneal lavage (PL) during this period in the internal medicine department. This surgically placed PL is not routinely performed by all doctors. The internal medicine doctors managed their patients liberally to relieve the intractable abdominal pain and improve hemodynamic instability. One patient eventually died after the retroperitoneal drainage operation. We looked for any clinical evidence of peripancreatic infection and severe abdominal pain or food intolerance as the indications for surgical intervention; however, if the patient was hemodynamically stable, surgical intervention was purposely delayed until necrotic retroperitoneal tissue liquefied or became an abscess. Only
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four patients received fine-needle aspiration before the operation, two of whom had positive and two negative bacterial culture results. One positive result was different from the culture after the drainage. One negative case showed a positive fungal culture from the drained pus during operation. Those patients already liquefied—mostly referred cases— were drained without delay. One patient was drained before liquefaction because this patient suffered PL-induced peritonitis. This patient was lost to follow-up because he moved to another city. Beside this patient, no other patients succumbed or needed immediate operation while waiting for liquefaction. Patients with primary pancreatic abscess, infection superimposed on chronic pseudocyst, external trauma to the pancreas, postoperative pancreatitis, or pancreatitis resulting from drugs other than alcohol were not included in this study. Retroperitoneal drainage is performed under general anesthesia and in supine position. The flank is slightly elevated by placing a pillow under the back. A 5-cm skin incision below the left costal ridge is made (Fig. 1), then bluntly and cautiously deepened into the retroperitoneal necrotic space with index finger. Care should be made not to enter the peritoneum or injure the colon. Usually the left kidney can be easily approached and palpated first. Then, using the left kidney as an anatomic landmark, along with the CT images, the abscess cavity can be reached and opened bluntly. The abscess wall always feels hard to the finger, and this can guide the operator to reach the abscess cavity easily and confidently. The abscess wall can be very thick and firm, and needle aspiration confirmation may be needed before using an instrument to
Fig. 1 CT showing the typical picture of liquefied retroperitoneal necrotic tissue reaching the left flank, which is the best time to perform retroperitoneal drainage. Inset Site for small flank incision
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Fig. 2 A sump drain is inserted from the left flank with a mini-incision
open it. A preoperative CT-guided wire insertion (subcostal approach; never intercostal) may facilitate this procedure, but wire insertion becomes no longer mandatory with experience. Bacterial culture and smear are performed when the abscess is opened. A Yankauer sucker is an ideal instrument for probing the abscess cavity and removing the purulent discharge. Subsequently, a soft sump drain (Fig. 2), sometimes with a stylet as a stent, is inserted to the pancreatic head area. An x-ray is indispensable for confirming the drain position and to avoid subsequent revision. No irrigation or debridement is needed. Once drainage is complete, hemodynamic parameters gradually improve, and the fever subsides. Total parenteral nutrition and IV antibiotics can be discontinued as soon as possible. The patient is then allowed to start oral food intake and oral antibiotics. Most patients can be discharged within 1–2 weeks. The sump drain can be managed at an outpatient clinic once a week and gradually withdrawn if monthly CT scans demonstrate the disappearance of the retroperitoneal abscess, then completely removed 3–4 months later.
Results Of the 19 complicated ANP patients (Table 1), the etiologies were alcoholic in 9 patients, biliary in 5, and hyperlipidemia in 4. The etiology was unknown in 1 patient. For the 11 patients that came to our institution (as opposed to being referred), the mean Ranson score was 5.9 (range, 4–8) and the available mean peak APACHE II score was 20.1 (range,
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4–45). Operations were performed with an average lapse of 4.7 weeks (range, 1.3–9.0). No patient succumbed within the delayed period. Sixteen available CT data showed liquefaction of the retroperitoneal tissue after an average of 21.3 days (range, 14–26). One patient required emergent operation before liquefaction occurred owing to PL-induced peritonitis. Operation indications were infected necrosis in 13, severe abdominal pain/food intolerance in 3, and both in 3 patients. Average length of skin incision was 4 cm (range, 3–9). In four patients, incisions were made along the previous track of the failed CT-guided drainage. Two cases were aided with a guide wire placed under the CT guidance from 1 day before the operation. Only a single sump drain was used in all cases, but additional Penrose drains were added in four. Except the one unliquefied case, all had considerable pus discharge during the procedure. The results of abscess cultures showed 4 fungal and 13 bacterial infections (2 ORSA, 3 Klebsilla pneumoniae, 3 Escherichia coli, 1 Pseudomonas aeroginosa, 1 Acinetobactor baumanii, 3 Streptococcus viridans, 1 Staphylococcus coagulase(–), 1 Citrobacter freundii, 2 Enterococcus cloacae, 1 Enterobacter aerogenes, 1 Salmonella choeraesuis, 1 Prevotella bucca). Two of these patients had both fugal and bacterial infections, and five had mixed bacterial infections. Of the four patients with negative cultures (21.1%), two presented severe abdominal pain and food intolerance, and the other two presented with a clinical picture of severe infection. The cultures of one patient, who presented food intolerance, grew S viridans and P bucca. Fourteen patients did not require intensive care after the drainage procedure; the other 5 patients stayed in the ICU an average of 39.6 days (range, 7–95).
17 24
1+4 3+4
4 5
Done, Staphylococcus Done, Negative
Done, Candida Done, Negative
FNA, B/C
3 3 3 4.7
4
5
4
4
5 3 8
7 3 6
8
1.3 3
4
6
9
weeks
21 19 21.3
24
26
24
23
17
19 17 26
26
17 23
25
14
19
Streptococcus, Prevotella ORSA Negative Negative 80.0%
Negative
Pseudomonas, A. baumani
E. coli
Staphylococcus Klebsiella, Fungus Klebsiella, E. coli, Enterococcus, Streptococcus Negative Citrobacter Streptococcus, Enterobacter Enterococcus Klebsiella Salmonella
Candida
ORSA, E. coli, Candida Candida
CT (day) Discharge B/C
Elapsed Liquefied
3 4 6 4.0
5
3
3
3
3 3 3
3→9 3 3
3
4 3
5
3
7
(cm)
Incisio n
None None None
Residual abscess None
None
None
None None None
None None None
Duodenal perforation None Gastric perforation None
None
None
complication
Procedure
PL, ileus 1 3 2.4
2
Died
1
5
3 3 1
3 Died 3
2
1 Died
3
2
3
POD
Per-os
7 None None
None
30
None
None
None 95 None
None 52 None
None
None 14
None
None
None
ICU
No
Died
Yes
Yes
No No No
No Died No
No
Lost follow-up Died
No
Yes, ∼ preope
Yes
34 Yes 4 Yes 6 Yes, ∼ preope 23.2 43.8% (n = 16)∗ ∗ (n = 16)
6
106
8
12
47 120 16
15 52 7
13
9 201
11
14
50
Hospital Postope. DM
Post-ope. stay (day)
Healed Healed Healed
Healed
Failed
Healed
Healed
Healed Healed Healed
Healed Failed Healed
Healed
Healed
Healed
Healed
Healed
Outcome
ANP
Note. A/V: average; B/C: bacterial culture; FNA: fine needle aspiration; INP: infected necrotizing pancreatitis; (n = 16)∗ : excluded 3 deaths; Ope.: operative; ORSA: oxacillin resistance Staphylococcus aureus; POD: post-operative day.
8 20.1
INP Food intolerance INP
17 2 + 5 18 19 3 + 5 A/V 5.9
9
Abdominal pain
16
INP INP, MOF INP, food intolerance INP, food intolerance INP, food intolerance
INP
10
?
Food intolerance INP, MOF INP
INP
INP, peritonitis INP, MOF
INP, MOF
INP
INP
15
14 4 + 1
13
10 11 12
7 8 9
20 45 17
23
2+3
3
2+4 2+4 4
24
3+2
2
6
24
1+6
(pre-ope.)
P’t Ranson II score
1
Indication
Clinical profiles and results of 19 treated patients
APACH
Table 1
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Excluding the mortality cases, average oral intake started at 2.4 days (range, 1–5) and average hospital stay was 23.2 days (range, 4–120; median, 11) after operation. Drains were completely removed later in outpatient clinic after an average of 120.6 days (range, 60–250). One major gastric perforation and one minor duodenal leak were the only two procedurerelated complications (10.5%). Three patients died (15.8%), although one had resolved ANP. One died of poor wound healing after a laparotomy for gastric perforation, another died of pneumonia caused by nosocomial infection with an incomplete ANP healing, and the other died of incomplete drainage of the left subphrenic area. Two of these patients were over 80 years old.
Discussion Evolution The mortality rate of infected ANP has been extremely high, but is improving after extensive treatment [3–17]. Our strategy for the surgical treatment of complicated ANP had always been a transperitoneal approach. However, laparotomy with necrosectomy and drainage procedure was performed on the first three patients with very troublesome postoperative courses. The fourth case was referred to us for surgical intervention already with an organized retroperitoneal abscess reaching his left flank. This inspired the author to consider an incision and drainage method using a retroperitoneal approach through a small incision (7 cm) in the left flank area for the next case. The surprisingly uneventful and easy recovery inspired our concept for delayed surgical intervention with minimal flank incision, large-pore tube retroperitoneal drainage, and omission of debridement. Early versus delayed surgical intervention Over the years, the timing of surgical intervention in ANP has been widely debated. Early operation has been advocated for removal of necrotic tissue, in an effort to reduce the enzymes and toxic substance that cause multiorgan failure (MOF) and jeopardize survival [7, 13], and to prevent it from becoming a culture medium for bacteria [20]. In contrast, some surgeons have attained significantly better outcomes in patients undergoing later, rather than earlier [8, 11, 17, 18, 21], intervention. The suitable delay for surgical intervention is unclear and controversial, and delays of more than 72 hours [17], 12 days [8], 4–12 weeks [21], or 1–2 months [11] have been proposed. Howard [11] demonstrated on 36 patients that a delay of 1–2 months was possible without preoperative mortality, where necrotic tissue was always retroperitoneal and clearly demarcated from viable tissue. One of his Springer
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patients died after necrosectomy and external drainage, resulting in a mortality rate that compared favorably to early operation. Funariu et al. [21] divided their severe necrotizing pancreatitis patients into three groups and showed 39.1% (n = 23) mortality for a 1-week delay, 19.2% (n = 11) for a 2-week delay, and 0% (n = 10) for delay of 4–12 weeks. Fernandez-del Casstillo et al. [22] found that although intervention is best deferred until the demarcation of necrosis is complete, delay beyond week 4 confers no additional advantage. Their patients underwent surgery a median of 31 days after diagnosis. The excellent result (6.2% mortality) obtained by Warshaw and Fernandez-del Casstillo group may have been achieved due to delay in surgery. Ashley et al. [23] suggested that “most patients can be treated by debridement and simple closed drainage. It may be that the conservative strategy, by delaying surgical intervention beyond the period of on going necrosis, favored such an approach. The time from presentation to surgery was 27 days (range 0–156).” Our clinical observation reveals that the time required for liquefaction to extend from the retroperitonium to left flank area is crucial to successful treatment in our series. We retrospectively reviewed the CT images of ANP patients treated in our medical ward and found that 3–4 weeks is necessary for liquefaction, which is consistent with the literature [24–27]. Therefore, we began to delay our surgical intervention until liquefaction of the retroperitoneal necrotic tissue occurred. The mean liquefaction interval was 21.3 days (range, 14–26) after the display of symptoms in our series. Early mortality? One may speculate that the patients would succumb during the delay. Mutinga et al. [28] investigated 805 patients (1982–1995) admitted to Brigham and Women’s Hospital, and found that 8 deaths (1%) occurred within the first 14 days of hospitalization (median, 8, range, 1–11). From the same center, Ashley et al. [23] analyzed their mortality cases and commented that few patients, if any, would have been candidates for earlier surgical intervention. In our study, we had no such cases of early mortality. Rather, there were a few spontaneously resolved cases, as evidenced by others’ reports [29, 30], even when gas formation was seen during the delay period. Recent advances in ICU management, antibiotics, and imaging studies may also reduce the risk of early mortality and allow for later intervention [29]. Is debridement necessary? To minimize the surgical insults to ANP, interventional [31], laparoscopic [32, 33] or endoscopic [34–37] debridement by transperitoneal [32, 33], retroperitoneal [32, 34, 35], transgastric [32, 36, 37], transduodenal [37], transpapillary [37], or sinus tract [33, 34] approaches have been implemented.
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Nevertheless, is debridement absolutely necessary for complicated ANP? For sterile necrotizing pancreatitis (SNP), there is strong evidence for supportive treatment without debridement [38, 39], indicating that necrotic pancreatic tissue is not an absolutely lethal factor. For INP, percutaneous drainage [40–46] without debridement has also been proved to be partially successful. In addition, INP has been shown to resolve spontaneously with antibiotic treatment [29, 30]. Therefore, evidence shows that debridement is not absolutely necessary for SNP or INP, and the prevailing surgical procedures for ANP, all of which focus on debridement, should be challenged [18]. With advances in ICU care, the causes of mortality are no longer the toxic effects of necrotic tissue, but rather the infection and the surgical insult caused by the operation itself. Percutaneous and laparoscopic procedures CT-guided percutaneous drainage is a nonsurgical alternative to debridement. Success rates have been reported to be around 31–89.5% with a favorable low mortality rate (7–21.4% [40–46]). On average, 3–10 drain insertions are needed for each patient [43, 44]. The initial catheter caliber is usually not large enough to drain the pasty pancreatic necrotic tissue. Therefore, the cooperation of a radiologist is necessary for the frequent upsizing of the catheter, vigorous manual irrigation, and removal of necrotic tissue [44]. Sometimes failure or secondary infection occur and subsequent laparotomy and drainage becomes inevitable (10.5– 85.7%) [29, 40–46]. Several other studies [40–43] have also shown that percutaneous drainage does not result in improvement, with patients progressing to MOF and death if surgical drainage is not performed. The principal reason for failure of percutaneous drainage is likely to be due to the fact that associated necrotic tissues and solid debris, unlike the pus, cannot egress through the relatively small catheters. In this situation, sepsis can only be relieved temporarily, and “pus under pressure” recurs [43]. Retroperitoneal drainage In the published literature, retroperitoneal drainage was originally performed with a wide, 15–20 cm left lumbar [47] or lateral subcostal incision [48, 49] for thorough debridement. As an alternative to the transperitoneal approach for treatment of ANP, retroperitoneal drainage had mortality rates of 18.2% [48] and 20% [49]. These rates are worse compared to the mortality rates of 3.2–15% [4, 9, 11, 13, 22, 23] using the transperitoneal approach. With increasing experience, we realized that the incision size could be reduced to as small as 3 cm if the necrotic tissue liquefied or became an abscess and reached the left flank with omission of debridement.
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It may be doubtful that a single drain with a small incision, contrary to the wide retroperitoneal exploration [47–49] is adequate for managing a detrimental ANP even without debridement. Howard [11] mentioned that multiple retroperitoneal spaces usually communicated. Mindell et al. [50] showed that the extension of both anterior pararenal spaces crossed the middle line via anterior and posterior margin of the pancreas without communication to the intraperitoneal space. This route may explain the initial retroperitoneal extension of the pancreatic necrosis to both flanks. Conversely, a drain may be introduced from the left flank to reach the pancreatic head area in the liquefied necrotic tissue. A previous incomplete or failed percutaneous drainage may form an isolated space that interrupts the communication through the abscess and compromises the success of the current method. Right flank involvement is less common, but because the right cavity communicates with the left, a single drain from the left side is usually enough. However, if necessary, an additional drain from the right side may also be inserted. Transretroperitoneal laparoscopic [32], nephroscopic [34], and endoscopic [34, 35] debridement have been reported in the literature. But after our second case, we found that debridement and irrigation procedures were unnecessary and stopped performing them. Nevertheless, some of these techniques [32, 34] can also be used as an alternative to placing the Sump drain. Sterile necrosis For SNP, 6.2% [39] to 10% [23, 38] of patients may die of a nonoperative principle, and another subset of patients may need surgical intervention with persistence of symptomatic necrotic tissue [51]. In such cases, the patient may also benefit from this mini-incision retroperitoneal drainage procedure if there is liquefaction of the necrotic tissue. Advantages of current method Our method has the advantages of less catheter replacement and revision, less interventional labor by a radiologist, no need for copious irrigation to maintain catheter patency, and no catheter obstruction by debris when compared to the percutaneous drainage [40–46] method. Some common complications of transabdominal approaches can also be prevented, such as troublesome repeated operations, burst abdomen, ileus, ventral hernia, spreading of secondary intraabdominal infection or abscesses from localized retroperitoneal cavity, and pancreatic fistulas [22]. These latter complications can add an unnecessary burden on an already devastating situation and increase morbidity. Most patients in our series experienced early oral feeding, early discharge from the hospital, recovery at home, and outpatient care. Gastrointestinal perforations such as stomach and duodenum occurred in two Springer
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cases, and may have been the result of long-term compression by the sump tube. We now use a softer drain (1.5 × 38 cm, Davol Inc, Cranston, RI, USA) for prophylaxis and no fistulas have since occurred. We are now more confident in improving our morbidity and mortality rates. In addition, two patients were diabetic prior to the treatment; five other patients (35.7%) became diabetic after the procedure. However, none required pancreatic enzyme.
Conclusion This delay-until-liquefaction or abscess strategy is an easy and effective method for treating infected and sterile ANP. Even without debridement and irrigation, our preliminary study shows a very satisfactory result. The procedure itself and postoperative care are both simple and easy. At-home recovery and outpatient care are possible. Acknowledgment The authors thank Dr Chien-Sheng Liao for his excellent illustration work.
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