Management of infected pancreatic necrosis: state of the art / Necrose pancreática com infecção: estado atual do tratamento

ABSTRACT Pancreatic necrosis occurs in 15% of acute pancreatitis. The presence of infection is the most important factor in the evolution of pancreatitis. The diagnosis of infection is still challenging. Mortality in infected necrosis is 20%; in the presence of organic dysfunction, mortality reaches 60%. In the last three decades, there has been a real revolution in the treatment of infected pancreatic necrosis. However, the challenges persist and there are many unsolved questions: antibiotic treatment alone, tomography-guided percutaneous drainage, endoscopic drainage, video-assisted extraperitoneal debridement, extraperitoneal access, open necrosectomy? A step up approach has been proposed, beginning with less invasive procedures and reserving the operative intervention for patients in which the previous procedure did not solve the problem definitively. Indication and timing of the intervention should be determined by the clinical course. Ideally, the intervention should be done only after the fourth week of evolution, when it is observed a better delimitation of necrosis. Treatment should be individualized. There is no procedure that should be the first and best option for all patients. The objective of this work is to critically review the current state of the art of the treatment of infected pancreatic necrosis.

RESUMO A necrose pancreática ocorre em 15% das pancreatites agudas. A presença de infecção é o fator mais importante na evolução da pancreatite. Confirmar o diagnóstico de infecção ainda é um desafio. A mortalidade na necrose infectada é de 30% e na vigência de disfunção orgânica, chega a 70%. Nas últimas décadas, ocorreu uma verdadeira revolução no tratamento da necrose pancreática infectada. Mesmo assim, persiste o desafio e há múltiplas questões ainda não resolvidas: tratamento exclusivo com antibiótico, drenagem percutânea guiada por tomografia, drenagem por via endoscópica, desbridamento extra-peritoneal vídeo-assistido, acesso extra-peritoneal, necrosectomia por via aberta? Foi proposto o tratamento por etapas, "step up approach", iniciando-se com as medidas menos invasivas e reservando-se a intervenção operatória para os casos em que o procedimento anterior não resolver definitivamente o problema. A indicação e o momento da intervenção devem ser determinados pela evolução clínica. O ideal é que a intervenção seja feita apenas depois da quarta semana de evolução, quando já existe melhor delimitação da necrose. O tratamento deve ser individualizado. Não existe um procedimento que deva ser o primeiro e a melhor opção para todos os doentes. O objetivo deste trabalho é fazer uma análise crítica do estado atual do tratamento da necrose pancreática infectada.

Necrosectomía laparoscópica en pancreatitis aguda / Laparoscopic necrosectomy in severe pancreatitis: retrospective analysis of 11 patients

Background: Laparoscopic surgery can be used in the treatment of severe acute pancreatitis. Aim: To report the experience with laparoscopic necrosectomy and abscess drainage in severe acute pancreatitis. Material and Methods: Retrospective analysis of medical records of 11 patients aged 13 to 78 years (10 males), with severe pancreatitis, subjected to laparoscopic necrosectomy or abscess drainage between 2006 and 2009. Results: Operative time ranged from 110 to 205 min. In all cases, a satisfactory necrosectomy and collection drainage were performed. No complications were recorded and no patient required to be converted to open surgery. Five patients were reoperated. In three of these, the laparoscopic approach was used again. Conclusions: Laparoscopic necrosectomy is safe and useful for patients with severe pancreatitis.

Introducción: La pancreatitis aguda grave, asociada a necrosis pancreática infectada, tiene una elevada mortalidad. En la mayoría de los casos, el tratamiento es quirúrgico, sin embargo, este se asocia a una alta morbilidad. El desarrollo de la cirugía mínimamente invasiva ha permitido incorporar la técnica laparoscópica al tratamiento de esta enfermedad. Objetivo: Presentar nuestra experiencia en necrosectomía y drenaje de abscesos por vía laparoscópica en pacientes con pancreatitis aguda grave. Pacientes y Métodos: Análisis retrospectivo de todos los pacientes con diagnóstico de pancreatitis aguda grave con necrosis infectada y/o abscesos sometidos a necrosectomía y drenaje de abscesos por vía laparoscópica. Se describen los datos demográficos, etiología de la pancreatitis aguda, imágenes pre y post-operatorias, así como los detalles de cada cirugía, la indicación quirúrgica, complicaciones, necesidad de re-operaciones y evolución tardía. Resultados: La serie está compuesta por 11 pacientes, todos con diagnóstico de pancreatitis aguda grave, operados entre abril de 2006 y junio de 2009. El tiempo operatorio promedio fue 138 min (110-205 min). En todos los casos, se realizó una necrosectomía satisfactoria y drenaje de colecciones. No hubo complicaciones derivadas de la técnica laparoscópica ni conversión a cirugía abierta en ningún paciente durante la primera cirugía. Cinco pacientes fueron re-operados, 3 de ellos por vía laparoscópica. Conclusiones: La necrosectomía laparoscópica es una alternativa válida y disponible en nuestro centro, con resultados comparables y probablemente superiores a la cirugía abierta, y con resultados satisfactorios en cuanto a morbilidad, protección de la pared abdominal y mortalidad postoperatoria.

Establishment of an infected necrotizing pancreatitis model by retrograde pancreatic duct injection of sodium taurocholate and E. coli in rats / 华中科技大学学报（医学）（英德文版）

A stable and reliable infected necrotizing pancreatitis (INP) model in rats was established in order to study the pathophysiological mechanism and pathological development rule of INP and explore the new therapeutic methods for the diseases. Forty-six SD rats were randomly divided into 5 groups. The animals in group A received the injection of 5% sodium taurocholate into the pancreatic duct and those in group B underwent that of E. coli into the pancreatic duct. The rats in groups C, D and E were subjected to the injection of 5% sodium taurocholate in combination with different concentrations of E. coli (10(3), 10(4), 10(5)/mL, respectively) into the pancreatic duct. The dose of injection was 0.1 mL/100 g and the velocity of injection was 0.2 mL/min in all the 5 groups. Eight h after the injection, the survival rate of animals was recorded and the surviving rats were killed to determine the serum content of amylase and perform pathological examination and germ cultivation of the pancreatic tissue. The results showed that acute necrotizing pancreatitis model was induced by injection of 5% sodium taurocholate into the pancreatic duct. The positive rate of germ cultivation in group A was 12.5%. The acute necrotizing pancreatitis model was not induced by injection of E. coli into the pancreatic duct and the positive rate of germ cultivation in group B was 0. The INP model was established in groups C to E. The positive rate of germ cultivation was 60%, 100% and 100% and 8-h survival rate 100%, 100% and 70% in groups C, D and E, respectively. It was concluded that a stable and reliable model of INP was established by injection of 5% sodium taurocholate in combination with 10(4)/mL E. coli into the pancreatic duct with a dose of 0.1 mL/100 g and a velocity of 0.2 mL/min. The pathogenesis of INP might be that the hemorrhage and necrosis of pancreatic tissue induced by sodium taurocholate results in weakness of pancreatic tissue in fighting against the germs. Meanwhile, the necrotic pancreatic tissue provides a good proliferative environment for the germs.