- Research article
- Open Access
- Published: 08 July 2020
BMC Gastroenterology volume 20, Article number: 212 [2020] Cite this article
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Abstract
Background
To evaluate an innovative open necrosectomy strategy with continuous positive drainage and prophylactic diverting loop ileostomy for the management of late infected pancreatic necrosis [LIPN].
Methods
Consecutive patients were divided into open necrosectomy [ON] group [n = 23], open necrosectomy with colonic segment resection [ON+CSR] group [n = 8] and open necrosectomy with prophylactic diverting loop ileostomy [ON+PDLI] group [n = 11]. Continuous positive drainage [CPD] via double-lumen irrigation–suction tube [DLIST] was performed in ON+PDLI group. The primary endpoints were duration of organ failure after surgery, postoperative complication, the rate of re-surgery and mortality. The secondary endpoints were duration of hospitalization, cost, time interval between open surgery and total enteral nutrition [TEN].
Results
The recovery time of organ function in ON+PDLI group was shorter than that in other two groups. Colonic complications occurred in 13 patients [56.5%] in the ON group and 3 patients [27.3%] in the ON+PDLI group [p = 0.11]. The length of stay in the ON+PDLI group was shorter than the ON group [p = 0.001]. The hospitalization cost in the ON+PDLI group was less than the ON group [p = 0.0052].
Conclusion
ON+PDLI can avoid the intestinal dysfunction, re-ileostomy, the resection of innocent colon and reduce the intraoperative trauma. Despite being of colonic complications before or during operation, CPD + PDLI may show superior effectiveness, safety, and convenience in LIPN.
Peer Review reports
Background
Severe acute pancreatitis [SAP] is a serious disease involving multiple disciplines and systems. A certain proportion of patients with SAP would develop infected pancreatic necrosis [IPN] in the later course of the disease [1]. IPN is a severe complication of SAP with mortality at about 30% [12–39%] [2,3,4,5]. As the treatment protocols sufficiently addressed the under lining pathophysiological mechanisms of the disease, the step-up approach with minimally invasive techniques is emerging as the main stream in the appropriate IPN patient [6, 7]. However, less than 20% patients with LIPN who have failed in minimally invasive surgery still need to be treated with ON ultimately [8]. The operations used for LIPN are aimed at removing necrosis or devitalized tissue, draining pus, providing a safer avenue for egress of pancreatic secretions and the leakage of gastrointestinal tract and managing the colonic complications. Recurrent post necrosectomy local sepsis, due to inadequate drainage, continues to pose a major drawback [9, 10]. In our central, continuous positive drainage [CPD] via double-lumen irrigation–suction tube [DLIST] is one of the key techniques by insert the DLIST into abscess, focus of necrotic and abdominal cavity during the procedure of ON for postoperative CPD, which could ensure the adequate drainage. For colon complications, resection with proximal ostomy and diverting loop ileostomy [DLI] constitutes the treatment for suspected imminent or overt ischemia/perforation in majority of cases [11, 12]. However, just evaluating the outer aspect of the colon, identification of colon involvement may be difficult due to nonspecific symptoms or be masked by the sepsis. On one hand, 45.4% patients were detected with GI fistula after performing open necrosectomy. DLI, ileostomy or colostomy was performed for 65.3% colonic fistulas [13, 14]. On the other hand, with a low threshold for colonic resection due to unreliable detection of ischemia or imminent perforation by outside inspection during surgery for IPN, histologically examined specimens showed that colonic resection was unnecessary in 20–50% [12, 15, 16]. Postoperative mortality was as high as 50% [17]. However, up to now, comparing the role of DLI and the aggressive form of treatment such as subtotal/segment colectomy in terms of clinic outcome and prognosis, there is no data to suggest that which one is more advantageous in treating IPN patients with the suspected imminent or overt ischemia/perforation before or during operation. Also, there is no report about the merits of PDLI in ON for IPN without colonic complications before or during operation.
Therefore, in current study, we aimed to evaluate the effectiveness, safety, and convenience of CPD + PDLI in LIPN compared to the other two open necrosectomy approaches, no matter with or without colonic complications before or during operation.
Methods
Patients
From January 2012 to February 2017, all the consecutive patients admitted to our center with a diagnosis of IPN were registered in an internal database and screened for potential enrollment. Patients who were performed open pancreatic necrosectomy and diagnosed with IPN during the study period were collected. The data were assembled and analyzed retrospectively. Informed consent was exempted because this retrospective study was harmless to the patients and contained no personal data. The study was approved by the Institutional Review Board of Jinling hospital.
The inclusion criteria for the study were: [1] patients diagnosis with IPN according to the presence of gas bubbles within pancreatic necrosis on contrast-enhanced CT scan or a positive bacterial culture obtained by fine-needle aspiration, first drainage and/or operation [18]; [2] patients performed with open pancreatic necrosectomy and diagnosed with IPN.
The exclusion criteria were: [1] pregnant patients; [2] patients received chemotherapy for malignancy or auto-immune diseases; [3] patients received abdominal surgery before IPN and was present due to abdominal compartment syndrome [ACS], perforation of a visceral organ, bleeding during the current episode of AP; [4] patients received ON for IPN before admitting to our institute during the current episode of AP; [5] IPN was caused due to trauma [6] the treatment strategy was not completed for nonmedical reasons.
Initial medical treatment and minimally invasive step-up approach were carried out for every patient before and after IPN confirmation according to the international recommendations [6, 19].
Endpoints
For each participant, the following variables were collected, including age, sex, etiology, and body mass index [BMI], time interval between AP onset to operation. Baseline characteristics such as acute physiology and chronic health evaluation [APACHE] II score, sequential organ failure assessment [SOFA] score, laboratory data including C-reactive protein [CRP], procalcitonin [PCT], Interleukin-6 [IL-6] and white blood cells [WBC] were also collected and assessed within 24 h before surgery, at the third and seventh day after surgery.
Our primary endpoints were duration of organ failure after surgery, postoperative complication, the rate of re-surgery and mortality. Secondary endpoints were duration of hospitalization, cost, time interval between open surgery to total enteral nutrition [TEN]. The main postoperative complications included colonic complication, hemorrhage, pancreatic fistula. The colonic complications included colonic suspected imminent or overt ischemia/perforation, stenosis, hemorrhage, colonic fistula, pseudo-obstruction.
Organ functions were evaluated in cardiovascular, renal and respiratory systems. The criteria for cardiovascular, renal and respiratory failure were defined based on international consensus [18, 20], cardiovascular [systolic blood pressure