Surgical management of pancreatic necrosis: A practice management guideline from the Eastern Association for the Surgery of Trauma

Nathan T. Mowery, Brandon R. Bruns, Heather G. Macnew, Suresh Agarwal, Toby M. Enniss, Mansoor Khan, Weidun Alan Guo, Jeremy W. Cannon, Matthew Lissauer, Therese M. Duane, Amy N. Hildreth, Peter A. Pappas, Lynn M. Gries, Meghann Kaiser, Bryce R.H. Robinson

Research output: Contribution to journalArticle

5 Citations (Scopus)

Abstract

Background: Pancreatic or peripancreatic tissue necrosis confers substantial morbidity and mortality. New modalities have created a wide variation in approaches and timing of interventions for necrotizing pancreatitis. As acute care surgery evolves, its practitioners are increasingly being called upon to manage these complex patients. Methods: A systematic review of the MEDLINE database using PubMed was performed. English language articles regarding pancreatic necrosis from 1980 to 2014 were included. Letters to the editor, case reports, book chapters, and review articles were excluded. Topics of investigation included operative timing, the use of adjuvant therapy and the type of operative repair. Grading of Recommendations, Assessment, Development and Evaluations methodology was applied to question development, outcome prioritization, evidence quality assessments, and recommendation creation. Results: Eighty-eight studies were included and underwent full review. Increasing the time to surgical intervention had an improved outcome in each of the periods evaluated (72 hours, 12-14 days, 30 days) with a significant improvement in outcomes if surgery was delayed 30 days. The use of percutaneous and endoscopic procedures was shown to postpone surgery and potentially be definitive. The use of minimally invasive surgery for debridement and drainage has been shown to be safe and associated with reduced morbidity and mortality. Conclusion: Acute Care Surgeons are uniquely trained to care for those with pancreatic necrosis due their training in critical care and complex surgery with ongoing shock. In adult patients with pancreatic necrosis, we recommend that pancreatic necrosectomy be delayed until at least day 12. During the first 30 days of symptoms with infected necrotic collections, we conditionally recommend surgical debridement only if the patients fail to improve after radiologic or endoscopic drainage. Finally, even with documented infected necrosis, we recommend that patients undergo a step-up approach to surgical intervention as the preferred surgical approach. Level of Evidence Systematic review/guideline, level III.

Original languageEnglish (US)
Pages (from-to)316-327
Number of pages12
JournalJournal of Trauma and Acute Care Surgery
Volume83
Issue number2
DOIs
StatePublished - Aug 1 2017

Fingerprint

Practice Management
Practice Guidelines
Necrosis
Wounds and Injuries
Debridement
Drainage
Morbidity
Minimally Invasive Surgical Procedures
Mortality
Critical Care
PubMed
MEDLINE
Pancreatitis
Shock
Language
Databases
Guidelines

All Science Journal Classification (ASJC) codes

  • Critical Care and Intensive Care Medicine
  • Surgery

Keywords

  • Acute care surgery
  • evidence-based medicine
  • pancreatic necrosectomy
  • pancreatic necrosis
  • practice management guideline

Cite this

Mowery, Nathan T. ; Bruns, Brandon R. ; Macnew, Heather G. ; Agarwal, Suresh ; Enniss, Toby M. ; Khan, Mansoor ; Guo, Weidun Alan ; Cannon, Jeremy W. ; Lissauer, Matthew ; Duane, Therese M. ; Hildreth, Amy N. ; Pappas, Peter A. ; Gries, Lynn M. ; Kaiser, Meghann ; Robinson, Bryce R.H. / Surgical management of pancreatic necrosis : A practice management guideline from the Eastern Association for the Surgery of Trauma. In: Journal of Trauma and Acute Care Surgery. 2017 ; Vol. 83, No. 2. pp. 316-327.
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abstract = "Background: Pancreatic or peripancreatic tissue necrosis confers substantial morbidity and mortality. New modalities have created a wide variation in approaches and timing of interventions for necrotizing pancreatitis. As acute care surgery evolves, its practitioners are increasingly being called upon to manage these complex patients. Methods: A systematic review of the MEDLINE database using PubMed was performed. English language articles regarding pancreatic necrosis from 1980 to 2014 were included. Letters to the editor, case reports, book chapters, and review articles were excluded. Topics of investigation included operative timing, the use of adjuvant therapy and the type of operative repair. Grading of Recommendations, Assessment, Development and Evaluations methodology was applied to question development, outcome prioritization, evidence quality assessments, and recommendation creation. Results: Eighty-eight studies were included and underwent full review. Increasing the time to surgical intervention had an improved outcome in each of the periods evaluated (72 hours, 12-14 days, 30 days) with a significant improvement in outcomes if surgery was delayed 30 days. The use of percutaneous and endoscopic procedures was shown to postpone surgery and potentially be definitive. The use of minimally invasive surgery for debridement and drainage has been shown to be safe and associated with reduced morbidity and mortality. Conclusion: Acute Care Surgeons are uniquely trained to care for those with pancreatic necrosis due their training in critical care and complex surgery with ongoing shock. In adult patients with pancreatic necrosis, we recommend that pancreatic necrosectomy be delayed until at least day 12. During the first 30 days of symptoms with infected necrotic collections, we conditionally recommend surgical debridement only if the patients fail to improve after radiologic or endoscopic drainage. Finally, even with documented infected necrosis, we recommend that patients undergo a step-up approach to surgical intervention as the preferred surgical approach. Level of Evidence Systematic review/guideline, level III.",
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author = "Mowery, {Nathan T.} and Bruns, {Brandon R.} and Macnew, {Heather G.} and Suresh Agarwal and Enniss, {Toby M.} and Mansoor Khan and Guo, {Weidun Alan} and Cannon, {Jeremy W.} and Matthew Lissauer and Duane, {Therese M.} and Hildreth, {Amy N.} and Pappas, {Peter A.} and Gries, {Lynn M.} and Meghann Kaiser and Robinson, {Bryce R.H.}",
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Mowery, NT, Bruns, BR, Macnew, HG, Agarwal, S, Enniss, TM, Khan, M, Guo, WA, Cannon, JW, Lissauer, M, Duane, TM, Hildreth, AN, Pappas, PA, Gries, LM, Kaiser, M & Robinson, BRH 2017, 'Surgical management of pancreatic necrosis: A practice management guideline from the Eastern Association for the Surgery of Trauma', Journal of Trauma and Acute Care Surgery, vol. 83, no. 2, pp. 316-327. https://doi.org/10.1097/TA.0000000000001510

Surgical management of pancreatic necrosis : A practice management guideline from the Eastern Association for the Surgery of Trauma. / Mowery, Nathan T.; Bruns, Brandon R.; Macnew, Heather G.; Agarwal, Suresh; Enniss, Toby M.; Khan, Mansoor; Guo, Weidun Alan; Cannon, Jeremy W.; Lissauer, Matthew; Duane, Therese M.; Hildreth, Amy N.; Pappas, Peter A.; Gries, Lynn M.; Kaiser, Meghann; Robinson, Bryce R.H.

In: Journal of Trauma and Acute Care Surgery, Vol. 83, No. 2, 01.08.2017, p. 316-327.

Research output: Contribution to journalArticle

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T1 - Surgical management of pancreatic necrosis

T2 - A practice management guideline from the Eastern Association for the Surgery of Trauma

AU - Mowery, Nathan T.

AU - Bruns, Brandon R.

AU - Macnew, Heather G.

AU - Agarwal, Suresh

AU - Enniss, Toby M.

AU - Khan, Mansoor

AU - Guo, Weidun Alan

AU - Cannon, Jeremy W.

AU - Lissauer, Matthew

AU - Duane, Therese M.

AU - Hildreth, Amy N.

AU - Pappas, Peter A.

AU - Gries, Lynn M.

AU - Kaiser, Meghann

AU - Robinson, Bryce R.H.

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N2 - Background: Pancreatic or peripancreatic tissue necrosis confers substantial morbidity and mortality. New modalities have created a wide variation in approaches and timing of interventions for necrotizing pancreatitis. As acute care surgery evolves, its practitioners are increasingly being called upon to manage these complex patients. Methods: A systematic review of the MEDLINE database using PubMed was performed. English language articles regarding pancreatic necrosis from 1980 to 2014 were included. Letters to the editor, case reports, book chapters, and review articles were excluded. Topics of investigation included operative timing, the use of adjuvant therapy and the type of operative repair. Grading of Recommendations, Assessment, Development and Evaluations methodology was applied to question development, outcome prioritization, evidence quality assessments, and recommendation creation. Results: Eighty-eight studies were included and underwent full review. Increasing the time to surgical intervention had an improved outcome in each of the periods evaluated (72 hours, 12-14 days, 30 days) with a significant improvement in outcomes if surgery was delayed 30 days. The use of percutaneous and endoscopic procedures was shown to postpone surgery and potentially be definitive. The use of minimally invasive surgery for debridement and drainage has been shown to be safe and associated with reduced morbidity and mortality. Conclusion: Acute Care Surgeons are uniquely trained to care for those with pancreatic necrosis due their training in critical care and complex surgery with ongoing shock. In adult patients with pancreatic necrosis, we recommend that pancreatic necrosectomy be delayed until at least day 12. During the first 30 days of symptoms with infected necrotic collections, we conditionally recommend surgical debridement only if the patients fail to improve after radiologic or endoscopic drainage. Finally, even with documented infected necrosis, we recommend that patients undergo a step-up approach to surgical intervention as the preferred surgical approach. Level of Evidence Systematic review/guideline, level III.

AB - Background: Pancreatic or peripancreatic tissue necrosis confers substantial morbidity and mortality. New modalities have created a wide variation in approaches and timing of interventions for necrotizing pancreatitis. As acute care surgery evolves, its practitioners are increasingly being called upon to manage these complex patients. Methods: A systematic review of the MEDLINE database using PubMed was performed. English language articles regarding pancreatic necrosis from 1980 to 2014 were included. Letters to the editor, case reports, book chapters, and review articles were excluded. Topics of investigation included operative timing, the use of adjuvant therapy and the type of operative repair. Grading of Recommendations, Assessment, Development and Evaluations methodology was applied to question development, outcome prioritization, evidence quality assessments, and recommendation creation. Results: Eighty-eight studies were included and underwent full review. Increasing the time to surgical intervention had an improved outcome in each of the periods evaluated (72 hours, 12-14 days, 30 days) with a significant improvement in outcomes if surgery was delayed 30 days. The use of percutaneous and endoscopic procedures was shown to postpone surgery and potentially be definitive. The use of minimally invasive surgery for debridement and drainage has been shown to be safe and associated with reduced morbidity and mortality. Conclusion: Acute Care Surgeons are uniquely trained to care for those with pancreatic necrosis due their training in critical care and complex surgery with ongoing shock. In adult patients with pancreatic necrosis, we recommend that pancreatic necrosectomy be delayed until at least day 12. During the first 30 days of symptoms with infected necrotic collections, we conditionally recommend surgical debridement only if the patients fail to improve after radiologic or endoscopic drainage. Finally, even with documented infected necrosis, we recommend that patients undergo a step-up approach to surgical intervention as the preferred surgical approach. Level of Evidence Systematic review/guideline, level III.

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KW - pancreatic necrosis

KW - practice management guideline

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