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A 10 Year Cross Sectional Multicentre Study of Infected Pancreatic Necrosis

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A 10 Year Cross Sectional Multicentre Study of Infected Pancreatic Necrosis JOP. J Pancreas (Online) 2021 Jan 30; 22(1): 11-20. ORIGINAL PAPER A 10 Year Cross Sectional Multicentre Study of Infected Pancreatic Necrosis. Trends in Management and an Analysis of Factors Predicting Mortality for Interventions in Infected Pancreatic Necrosis Johann Faizal Khan1, Suryati Mokhtar1, Krishnan Raman1, Harjit Singh1, Leow Voon Meng 2,3, Manisekar K Subramaniam1,2 1 2 Department of Hepatopancreatobiliary Surgery and Liver Transplantation, Selayang Hospital, Selangor, Malaysia 3Department of General Surgery, Division of Hepatopancreatobiliary Surgery, Sultanah Bahiyah Hospital, Kedah, Malaysia Malaysia Advanced Medical and Dental Institute (AMDI), Science University of Malaysia (USM), Penang, ABSTRACT Objective To identify trends in management and analyse outcomes of patients undergoing interventions for infected pancreatic necrosis Method A cross sectional study of patients undergoing intervention for IPN with specific reference to factors predictive of mortality. between 2009-2018 were performed at two of the largest hepatopancreatobiliary centres in Malaysia. FinalResults outcome A measuretotal number of complete of 65 resolution was compared against mortality (D). Head to head comparison of percutaneous catheter drainage alone versus Videoscopic Assisted Retroperitoneal Debridement was performed based on final predictive factor on mortality. patients with IPN were identified. Data from 59/65 patients were analysed for final outcome of death (D) versus complete resolution. 6 patients were omitted due to incomplete data precluding proper analysis. Overall mortality rate was 25% (15/59 patients). 8 patients had no interventions performed but were included in the analysis. Percutaneous catheter drainage alone and Videoscopic Assisted Retroperitoneal Debridement were the 2 commonest interventions performed (34/55). Multivariable analysisConclusion predictive of mortality studyincluded shows persistent that both organ persistent failure requiringorgan failure intensive requiring care ICUunit admission(ICU) admission and Percutaneous (OR= 336.425, Catheter CI 95% Drainage =3.722-999.999 alone when p value= compared 0.0113) to and when PCD alone was employed compared to VARD (OR = 48.923, CI 95% = 1.888-999.999, p-value = 0.019). Our present a minimally invasive step up approach (in the form of Video assisted Retroperitoneal Debridement) are predictive factors of mortality in patients undergoing intervention for IPN. A step up approach is necessary to prevent mortality in patients with infected pancreatic necrosis requiring intervention while PCD without debridement results in significant mortality. INTRODUCTION of persistent organ failure results in mortality rates Acute pancreatitis (AP) results in an overall mortality ranging between 6-11% [3, 4]. Risk of mortality doubles pancreatitis may result in the development of pancreatic patientswith persistant with NP andorgan approximately failure [5]. twoUnfortunately thirds of patients organ rate of 7.5% in Malaysia [1]. Moderately severe and severe The pancreatic necrosis failure persisting more than 48 hours is present in 50% of and or peripancreatic necrosis [2]. with INP. The crucial determining factor in management may be sterile or infected. Patients may be relatively well should be whether the necrosis is sterile or infected, the or may have persistent organ failure. INP in the absence In general treatment should be aimed at patients who are Received December 10th th patient symptomatic or not, and the nature of the necrosis. Keywords , 2020 - Accepted January 28 , 2020 Severe Acute Pancreatitis, Infected Pancreatic Necrosis, symptomatic and with suspected or proven infection. 2 AbbreviationsStep-up approach, CR Outcome,complete Videoscopicresolution; IPN assisted infected retroperitoneal pancreatic types of necrotic collections are present, notably Acute debridement, Percutaneous Catheter Drainage Necrotic Collections (ANC) and Walled-Off Necrosis (WON). assisted retroperitoneal debridement In general ANC require drainage while WON may require a Correspondencenecrosis; PCD percutaneous catheter drainage; VARD videoscopic “step-up” to formal debridement. Intervention for NP can Transplantation Johann Faizal Khan be divided broadly into the following: 1. Catheter based Department of Hepatopancreatobiliary Surgery and Liver therapy 2. Endoscopic management 3. Combination of Tel FaxSelayang Hospital, Selangor, Malaysia theboth-dual goal standard modality and and perha 4. Openps the surgical only option debridement of treatment [6]. E-mail+ 60192484472 Historically, open surgical debridement was considered + 0361377097 [email protected] prior to the minimally invasive era of management. JOP. Journal of the Pancreas - http://pancreas.imedpub.com/ - Vol. 22 No. 1 – January 2021. [ISSN 1590-8577] 11 JOP. J Pancreas (Online) 2021 Jan 30; 22(1): 11-20. thereAlthough are manythe landmark studies performedPANTER trial which paved have the questioned way for a days of hospitalization, Balthazar CT severity index more minimally invasive approach towards necrosectomy, score (CTSI) score, size of necrosis from cross sectional review revealed that Percutaneous Catheter Drainage CT scan, C-reactive protein and Albumin levels prior to Secondary objective: Using the variables above our (PCD)the actual alone need was for able a formalto obviate necrosectomy. the need forA systemic further intervention. secondary objective was to compare the outcomes of the 2 depends on appropriate type and timing of intervention therapy in 56.2% of patients [7, 8]. Successful outcome mainInclusion interventions criteria: VARD All patients and PCD diagnosed alone. with Infected [9, 10]. Extent of necrosis correlates with probability of wasinfection, to evaluate organ thefailure, trends the in managementneed for intervention and outcomes and Pancreatic Necrosis between January 2009 till December inoverall patients mortality undergoing and morbidity. intervention The formain infected aim of NPthis in study 2 of 2018 in Hospital Selayang (HS), Selangor and Hospital SultanahExclusion Bahiyah Criteria: (HSB), Patients Alor Setar, with Kedah incomplete were included. data or where outcome measures were not clearly stated were objectivethe largest was HPB to centres compare in 2Malaysia of the commonest and to analyse procedures factors predicting mortality in these patients. Our secondary excluded.Statistical Traumatic Analysis: pancreatitis All statistical was also excluded.analyses were performedMETHODOLOGY in these 2 institutions, PCD alone versus VARD. usingperformed Pearson using Chi-squared SPSS version test 25.0 for (SPSS categorical Inc, Chicago, variables IL) Study Design and SAS version 9.4. Descriptive analysis was performed This is a Cross sectional study of patients undergoing intervention for Infected Pancreatic Necrosis in 2 of the and Fisher exact test when appropriate. Continuous wereindependent performed variables using binarywere analyzedlogistic regressionusing Mann- and Whitney U test. Univariable and multivariable analysis Data Collection largest Hepatobiliary centres in Malaysia. p Data were collected from the institution written penalized logistic regression where appropriate. Using a confidence interval of 95% a value < 0.05 was considered statisticallyRESULTS significant. informationadmission recordssystem databaseand progress for all patientsnotes, outpatientdiagnosed A total number of 65 patients (35 patients from clinic visit notes, operative database and the computer Participating Centres with NP between 2000 to 2018. Hospital Sultanah Bahiyah and 30 patients from Hospital Selayang) were included in the study. From this total only intervention for Infected Pancreatic Necrosis between data from 61 patients were adequate for final analysis. Patients with necrotizing pancreatitis undergoing 17 patients underwent Video Assisted Retroperitoneal Debridement (VARD),16 Percutaneous Catheter Drainage January 2009 till December 2018 in Hospital Selayang endoscopicAlone (PCD drainagealone), 13 while patients 8 patients underwent did not open undergo surgery any (HS), Selangor and Hospital Sultanah Bahiyah(HSB),Alor formal(open debridement, procedure (Table open 1). resection), 5 were subjected to Setar,Primary Kedah Objective were included. The main aim of this study was to evaluate the trends Table 1. in management and outcomes in patients undergoing Type, number and percentage of interventions performed for InfectedProcedure Necrotizing Pancreatitis. N(%) in Malaysia and to analyse factors predicting mortality in intervention for infected NP in 2 of the largest HPB centres PCD alone following VARD 17 (27%) these patients. The factors that were analyzed included the 16(27%) Patient demography Open surgery 13(22%) No intervention Endoscopic drainage 5(8%) : Age, gender, race, presence 8(16%) or absence of comorbidities (Hypertension, Diabetis Table 2. Mellitus, Ischaemic heart disease, Renal impairment, Type, number and percentage of complications from COAD / Asthma, other premorbids), Aetiology (Biliary, interventionsComplication performed for infected N(%)necrotizing pancreatitis. SSI Alcohol, ERCP related, idiopathic, hypertriglyceridaemia), Iatrogenic gastric puncture admission to ICU, type of primary intervention employed 4(23%) 1(5%) (no intervention, PCD alone, VARD, Endoscopic drainage Duodenal Perforation without necrosectomy, Open drainage/ resection), Colocutaneous fistula 2(12%) presence or absence of gas on CT scan, nature of 1(5%) Bleeding 3(17%) necrosis whether
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