Step-up vs open necrosectomy for necrotizing pancreatitis

Here are recent publications on the management of necrotizing pancreatitis.


BACKGROUND: The 2010 randomized PANTER trial in (infected) necrotizing pancreatitis found a minimally invasive step-up approach to be superior to primary open necrosectomy for the primary combined endpoint of mortality and major complications, but long-term results are unknown.

NEW FINDINGS: With extended follow-up, in the step-up group, patients had fewer incisional hernias, less exocrine insufficiency and a trend towards less endocrine insufficiency. No differences between groups were seen for recurrent or chronic pancreatitis, pancreatic endoscopic or surgical interventions, quality of life or costs.

IMPACT: Considering both short and long-term results, the step-up approach is superior to open necrosectomy for the treatment of infected necrotizing pancreatitis.

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World Health Organization: In the presence of drains, does prolonged antibiotic prophylaxis prevent SSI?

World Health Organization. Summary of a systematic review on antimicrobial prophylaxis in the presence of a drain and wound drain removal. WHO Surgical Site Infection Prevention Guidelines, Web Appendix 27 (30p.).

Summary: In the WHO SSI prevention guidelines, one of the PICO questions addressed is:

In the presence of drains, does prolonged antibiotic prophylaxis prevent SSI?

  • Population: inpatients and outpatients of any age undergoing a surgical
    operation (any type of procedure) with the presence of postoperative drainage
  • Intervention: prolonged antibiotic prophylaxis postoperatively
  • Comparator: single-dose antibiotic prophylaxis (or repeated intraoperatively
    according to the duration of the operation)
  • Outcomes: SSI, SSI-attributable mortality

Their findings are quoted below:

Seven RCTs were identified with an SSI outcome comparing prolonged antibiotic prophylaxis in the presence of a wound drain vs. single-dose perioperative prophylaxis, possibly repeated intraoperatively according to the duration of the procedure. The number of days for antibiotic prophylaxis prolongation in the postoperative period varied among studies. Three studies prolonged antibiotic administration until the wound drain was removed. In the remaining trials, patients continued intravenous administration for 3 or 5 days. Included patients were adults undergoing several types of surgical procedures (general surgery, kidney transplantation, and pilonidal sinus surgery). One trial evaluated whether prolonged antibiotic prophylaxis reduced the risk of infectious complications for patients undergoing elective thoracic surgery with tube thoracostomy. The antibiotic was continued for 48 hours after the procedure or until all thoracostomy tubes were removed, whichever came first.

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Article of interest: Comparison of Adverse Events for Endoscopic vs Percutaneous Biliary Drainage in the Treatment of Malignant Biliary Tract Obstruction in an Inpatient National Cohort.

Inamdar S, et al. Comparison of Adverse Events for Endoscopic vs Percutaneous Biliary Drainage in the Treatment of Malignant Biliary Tract Obstruction in an Inpatient National Cohort. JAMA Oncol. 2016 Jan;2(1):112-7.

Full-text for Emory users.

Results: A total of 7445 patients were included for ERCP and 1690 for PTBD. The overall adverse event rate was 8.6% for endoscopic drainage (640 events) and 12.3% for percutaneous biliary drainage (208 events) (P < .001). When analyzed by type of malignant neoplasm, ERCP was associated with a lower rate of adverse events compared with PTBD for pancreatic cancer (2.9% vs 6.2%; odds ratio [OR], 0.46 [95% CI, 0.35-0.61]; P < .001) and cholangiocarcinoma (2.6% vs 4.2% OR, 0.62 [95% CI, 0.35-1.10]; P = .10). For pancreatic cancer, endoscopic procedures were associated with a lower rate of adverse events regardless of the volume of percutaneous procedures performed by a center. For cholangiocarcinoma, centers that performed a low volume of percutaneous biliary drainage procedures were more likely to have adverse events compared with endoscopic procedures performed at the same center (5.7% vs 2.5%; OR, 2.28 [95% CI, 1.02-5.11]; P = .04). In centers that performed a high volume of percutaneous drainage procedures, rates of adverse events were similar to those of endoscopic adverse events (3.5% vs 3.0%; OR, 1.18 [95% CI, 0.53-2.66]; P = .68).

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Article of interest: Efficacy of harmonic focus scalpel in seroma prevention after axillary clearance.

Selvendran S, Cheluvappa R, Tr Ng VK, Yarrow S, Pang TC, Segara D, Soon P. Efficacy of harmonic focus scalpel in seroma prevention after axillary clearance. Int J Surg. 2016 Jun;30:116-20. doi: 10.1016/j.ijsu.2016.04.041.

Free full-text.

“To summarise the salient findings of this retrospective study; we did not find a lower rate of seroma formation (as previously reported) when HF was used in ALND, instead of CD. Instead, we found increased seroma volume in patients after mastectomy and ALND compared to WLE and ALND or ALND alone. Our study had the second highest number of subjects examining HF and CD with respect to ALND.” (p. 119)

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Pancreaticoduodenectomy with and without routine intraperitoneal drainage

Van Buren G 2nd, Bloomston M, Hughes SJ, et al. A randomized prospective multicenter trial of pancreaticoduodenectomy with and without routine intraperitoneal drainage. Ann Surg. 2014 Apr;259(4):605-12.

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Results: There were no differences between drain and no-drain cohorts in demographics, comorbidities, pathology, pancreatic duct size, pancreas texture, baseline quality of life, or operative technique. PD without intraperitoneal drainage was associated with an increase in the number of complications per patient [1 (0-2) vs 2 (1-4), P = 0.029]; an increase in the number of patients who had at least 1 ≥grade 2 complication [35 (52%) vs 47 (68%), P = 0.047]; and a higher average complication severity [2 (0-2) vs 2 (1-3), P = 0.027]. PD without intraperitoneal drainage was associated with a higher incidence of gastroparesis, intra-abdominal fluid collection, intra-abdominal abscess (10% vs 25%, P = 0.027), severe (≥grade 2) diarrhea, need for a postoperative percutaneous drain, and a prolonged length of stay. The Data Safety Monitoring Board stopped the study early because of an increase in mortality from 3% to 12% in the patients undergoing PD without intraperitoneal drainage.

Conclusions: This study provides level 1 data, suggesting that elimination of intraperitoneal drainage in all cases of PD increases the frequency and severity of complications.

See also: Van Buren G 2nd, Fisher WE. Pancreaticoduodenectomy Without Drains: Interpretation of the Evidence. Ann Surg. 2016 Feb;263(2):e20-1.

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T-Tubes

Dageforde LA, Lillemoe KD. (2020). Management of Acute Cholangitis. In: Cameron JL, Cameron AM (Eds), Current Surgical Therapy, 13th ed. Elsevier: Philadelphia.

“Recent literature advocates for primary closure of the common bile duct after elective CBDE because of complications from T-tube placement. But in patients with cholangitis, placement of a T-tube is necessary for biliary decompression and allows easy access for future cholangiogram if the obstruction does not resolve. T-tube drainage has been associated with bile leak and requires externalization of the tube for several days until postoperative cholangiography demonstrates resolution of obstruction. Primary closure can lead to stricture and bile leak and result in no direct access to the biliary tree for future investigations.”

Fig. 2. Insertion of a T-tube in the common bile duct with subsequent closure using absorbable monofilament suture (4-0 or 5-0). The T-tube is prepared in one of the ways shown. From: Zollinger RM, Jr, Zollinger RM. Atlas of Surgical Operations. 7th ed. New York: McGraw-Hill; 1993.

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The management of breast abscesses

Lam E, Chan T, Wiseman SM. Breast abscess: evidence based management recommendations. Expert Rev Anti Infect Ther. 2014 Jul;12(7):753-62.

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Key issues:

  • All breast abscesses should be treated with abscess drainage and concurrent empiric antibiotic therapy.
  • Needle aspiration either with or without ultrasound guidance should be employed as first-line treatment of breast abscesses. However, multiple aspiration sessions may be required.
  • Ultrasound-guided percutaneous catheter placement may be considered as an alternative approach for drainage of larger (>3 cm) abscesses.
  • Surgical incision and drainage is required if needle aspiration or catheter drainage is unsuccessful and there is progression of infection.
  • Surgical incision and drainage should be considered for first-line therapy of large (>5 cm), multiloculated or long-standing breast abscesses.
  • Cultures should be obtained at the time of abscess drainage and antibiotic management tailored to the infecting organism’s susceptibility profile.
  • Empiric antibiotics targeting methicillin-resistant S. aureus may be required for patients who are known to be colonized or considered to be at high risk.
  • For breastfeeding women, the infant should not nurse from the breast with the abscess but may continue nursing from the contralateral, uninfected breast.
  • Future research should prospectively evaluate the utilization of aspiration or percutaneous catheter drainage techniques in terms of frequency of progression of infection requiring surgical management in order to limit selection biases. The optimal frequency of aspirations, time interval between aspirations and duration of catheter placement also requires further study.

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