Clinical Challenges in Hepatobiliary Surgery: Necrotizing Pancreatitis, Time to Step Up!

Greetings, everyone. Welcome to another HPV episode on Behind The Knife. This is your HPV team coming to you from Stanford University in California. I'm Anish, a general surgery resident here at Stanford, and a former T 32 fellow at MD Anderson. I'm excited to be joined again by my good friend and mentor, Dr. John Harrison, our second year HVV fellow at Stanford, who's only a few weeks from graduation. Before John leaves us to join the faculty at MGH in Boston, we wanna sit down and talk about one of his favorite topics, necrotizing pancreatitis. So, John, I know you love this and you've told me you can talk hours about this, but could you just briefly break down what exactly is pancreatic necrosis or acute necrotizing pancreatitis? Where does it come from and what, what's the presentation? Well, thank you so much, Anish, for inviting me to do this. And you are right. I, I can talk at length to anybody about this because I think it's a very complex topic. In an underserved population, and it's a very nuanced management. And so to get at your

question, there's a couple things that you kinda have to keep in the back of your mind, and one is that not all choose fit for any given type of necrosis pattern, and so you have to have some flexibility in your management paradigm. But I'd say a good starting point is when you see one of these patients, you have to clarify what caused the pancreatitis. And then it's very important to see how sick they are and establish what the extent of necrosis is with some really high quality axial imaging. And so we kind of start with those three things. And then that triages you into is this patient somebody who needs to be in the ICU, or is this patient somebody who I'm gonna be just watching for a long time with the possibility of them needing an intervention and then optimizing their nutritional status and their physiologic reserve. The coaxial imaging, like you said, is key and not, like you said, it's different, different care for different patients. And one thing I actually wanted to ask you about, and I think it's important clarification, is there are different

types of pancreatic fluid collections. Not everything is pancreatic necrosis. There's the acute peripancreatic fluid, there's pseudocyst, there's an acute necrotic collection, and then there's the waled off pancreatic necrosis. What is it that sets. Pancreatic necrosis apart from these other fluid collections or inflammation around the pancreas. Right. So the Atlanta classification is a little imperfect because like you said, there's this wide spectrum. So any patient who has pancreatitis is going to start out with edema and peripancreatic stranding. And how that organizes is totally dictated by where the patient has the necrosis and sort of how well or unwell they are. So generally necrosis is. A like early late kind of phenomenon. So you're generally thinking about two weeks after the incipient episode, whereas a pseudos is gonna be kind of a late finding where you'll see that more at kind of a six week mark.

But certainly patients can have abscesses, which are a mix of infection and necrosis. They can have a pseudo sys with a little bit of necrosis kind of in the cavity still. And it just depends on if that fluid is sterile or not, whether you have to do something so you can see all these different radiographic findings. It's gonna all depend on the timing from when they were initially seen and diagnosed with pancreatitis. They're all gonna start with. Per pancreatic fluid and edema, and it's about managing those cts at the right time intervals where there's either a clinical change or you think there might be a window for intervention that dictates whether or not you need to do something. So it's less relevant, what they actually look like and what they are. Then sort of how the patient's doing and sort of if it's a ripe target for an intervention. Okay, John, that's like a perfect segue into my next question. You and I had a patient with pancreatic necrosis. They were super sick, sitting in the corner of the ICU multi pressor shock intubated, getting RRT. And I remember asking John,

when should we intervene? I'm getting calls about compartment syndrome. Should we go in now? Do we need a decompressive laparotomy? And you advised me that it was, that it was time to wait, but how did you know we should wait for now? And what are some of the signs that tell you like, okay, now's the time to go in with an intervention or procedural intervention for this patient. Right. So yeah, this patient is kind of the textbook sick patient from acute necrotizing pancreatitis where they're in multi-organ system failure. And so everybody wants to do something to help the patient, right? So a lot of the times sitting tight feels like the wrong thing because we're so geared to doing interventions or starting medications or timing an intervention in the future. But really you have to let these patients catch up from a physiologic standpoint. And so if you jumped a gun and you intervene too early, you take away whatever reserve they have left or whatever reserve they're building back

up and you jeopardize the organ systems that might be coming back online with more time. So I think the key example of this is, is renal failure. So a lot of people will be like. Oh my goodness, this patient is in renal failure. We need to do a decompressive laparotomy when in reality this patient just needs to be intubated and sedated and paralyzed and have a fully catheter and at the most, a drain put in to sort of take a little pressure off the necrosis because it's not the decom, it's not abdominal compartment syndrome that's driving this. Even though you can get some bladder pressures that are elevated, that's just an unreliable surrogate for. Whether or not the abdominal compartment syndrome is really driving their, their renal failure, it's really the inflammatory response and sort of the systemic insult from the pancreatitis that's causing the renal insufficiency. So I, I wrote this paper with our other mentor, Brendan Visser, that was an editorial editorial and pancreas really looking at

like these sort of general surgery type issues that come up in acute necrotizing pancreatitis. And the key is you just have to have your nose to the ground and like be ready for anything. But you really want to not intervene until the patient is truly getting sick from the pancreatitis. And that's something that takes just a lot of reps with to sort of recognize the clinical patterns that might be suggesting that they're manifesting infected necrosis, which is the true hard line indication textbook. That's a great summary on that. So. John historically now the intervention when it's been time was that everyone was gonna get an open surgical necrosectomy. But now we've kind of replaced that with the step up approach. Is this, that something that's key, I think, for surgeons at every level to understand. So could you kind of just describe the step up approach for our listeners? Yeah. So this was a, a practice changing paper out of the Dutch pancreatic group in sort of the late two thousands, early 2000 tens called the Panther trial, which

was looking. At how patients do between getting an open necrosectomy versus drain placement, if they had infected pancreatic necrosis. And so historically, the standard of care was an open necrosectomy. And the problem with that is that even at really experienced centers with surgeons who manage a lot of pancreatitis, the mortality rate was still 10%, which is super high. I mean, that is one of the highest sort of operative mortality rates out there. I mean, that's like. You know, on par with doing huge SMA resections in pancreas cancers, right? Like this is, there's gotta be another way. So the Dutch group decided, okay, instead of just committing all these patients to a good old fashioned open necrosectomy, let's see what happens if we put drains in them. And so these are percutaneous strains that the IR team places, the IR team placed them under sort of the direction of the surgical team. So they were very well thought out, drain placements.

And what they found is that the time to resolution and the ultimate need for procedures in the drainage group alone was faster and often didn't require, and I think up to 35% of patients any type of further intervention beyond drain placement. And so you were taking a cohort of patients that had an operative mortality rate of 10% and getting them through an acute necrotizing pancreatitis episode with necrosis, which drains alone. And so now the step up approach is this thoughtful ladder like treatment algorithm where in certain types of necrosis, you can place a drain to at least control the sepsis and then decide if the patient needs some other form of intervention to get the rest of the necrosis out. And so it's kind of a starting point that is. Practice changing the sense that patients aren't going straight to the or when they have infected necrosis for a washout and necrosectomy. It makes sense, like you said, because these patients can often have really poor physiologic reserve and an intervention, like a big operative

intervention would just tank them. And they may never, right. They never bounce back. They have more hernias, they have higher rates of EEC fistulas, they have more, uh, diabetes, they have more rates of exocrine pancreatic insufficiency, so. You're taking more pancreas and you're doing more physiologic insult with an open necrosectomy than with drain placement alone. Mm-hmm. But the problem with drains alone is that someone has to manage it. Right? You can't just put a drain in and send this person to rehab and expect that they're gonna just like one day walk out of there. And the drain falls out on its own. You, you have to, you have to watch how the necrosis evolves. You have to manage the drain. Sometimes you have to upsize the drain, and a lot of times you need to think about some type of procedure to get the necrosis out. That doesn't necessarily include an open neck ectomy. So there's a sort of a joke within the field that people step, but then they don't step up like you have to have something else after the drains. And, uh, if you kind of look at the panther data in a little more detail, you see that the,

the duration of drains is like months. And so yes, that's better than a necrosectomy, but maybe there's something better than having a percutaneous drain hanging off your side for three months. Okay, so then. What is that next step then after the drain? Right. So it depends on A, how the patient's doing. Mm-hmm. B, what the necrosis looks like, how well organized it is, and C, where the necrosis is. So we wrote a paper that was published in Annals last year called What's Behind It All, and that was a little play on words because our sort of institutional preference is to drain all necrosis and luminal if we can. And so the two routes of endoluminal drainage are transgastric surgically or transgastric endoscopically. And there are other ways to do it, like a cys de ostomy, which is a really uncommon but a, a real sort of intervention. But most necrosis sort of organizes

in the lesser sac in a retro gastric position. So, yeah, when, when the necrosis is in a retro gastric position, it's really a perfect sort of setup to do. Some type of intervention, whether it's an endoscopic or a surgical transgastric, necrosectomy. And then what about the VD or the the video assisted retroperitoneal debridement? When does it play a role? So VD, or it's also known as merp, which is minimally invasive. Retroperitoneal necrosectomy, is when you use one of those drains that the IR team placed in step up to create a larger working channel that you can do a debridement through in sort of a. Hybrid Nephro, laparoscopic or nephro visualization. And so you use that drain track to sort of pluck out the necrosis one by one. And so that's a very effective way when you have small necros some, or you have paracolic sequester or pelvic necros, some where you

don't really have a good endoluminal drainage target. But you've got a drain in it, and you gotta get the necrosis out because the patient is unwell still. So we'll do VD, or we'll do kind of like a hybrid nephro laparoscopic approach where we have a couple drains in and put some trocars in, and that allows you to sort of facilitate that drainage a little bit faster. But ultimately those things are tedious and they require several rounds of guarding or murp or minoring, M-I-N-R-I-N-G. That's kind of this hybrid, laparoscopic approach. So if you can drain something endoluminal, you'll want to, because it's a lot faster in terms of the resolution. It gets rid of the necrosis and the infection quicker, and it gets the patients out of the hospital faster and it, it's just a less tedious procedure. In general, you kind of talked about this in your paper a little bit, the endoscopic transgastric approach versus the open or laparoscopic approach. Is there like a superiority to one versus the other, or

when should you go with one versus the other? So the paper showed a couple of things that were interesting. One is that. Sick patients can get a laparoscopic transgastric necrosectomy. And so I think there is sort of an a practice bias that people are too sick for surgery and so they have to get an endoscopic drainage. And that's not necessarily true Surgical necrosectomy, whether it's done open transgastric or laparoscopic transgastric, gets rid of the necrosis much faster, allows you to take out the gallbladder if this was biliary pancreatitis, and gives you this giant cys gastrostomy. That all that necrosis can be debrided through and then drain out much faster than something done endoscopic. So if something's done endoscopic, they do it through an Axios, which is a tiny working channel through which a scope goes and has an even tiny work tinier working channel. And so there's multiple rounds of debridement that need to get done if you go the endoscopic route. And that's not to say it doesn't have a value, because if somebody has a big pseudocyst, an endoscopic drainage is great because most

of. What's gonna drain through your Axios is just liquid. And so that's something where maybe you don't have or time to book this patient. They're totally fine as an outpatient, but they have a little bit of like postprandial fullness or something. You just get them on the books for an endoscopy and then they, they get an Axios and that's that. But then they have to come back and they have to get the Axios taken out. So there's always more procedures involved, whether you, if you do it endoscopically versus surgically. And the one thing that our paper was most notable for is that. The length of stay for the sickest patients was about a week less if they had a laparoscopic trans gastric necrosectomy rather than a direct endoscopic trans gastric necrosectomy. And so you're saving a ton of resources. You're getting patients outta the hospital faster, you towards recovery quicker with a surgical approach. So the pendulum is swinging back towards more aggressive surgical management of pancreatitis. And less away from the hands of the gastroenterologist. Even though there's papers out there like the

Miser Trying Trial, which tried to show that endoscopic drainage was superior to surgical management, though in their methodology, they had a lot of different surgical approaches rather than us who use kind of this very consistent laparoscopic transgastric approach, which has really good results for very sick patients. This Nephro Laparoscopic retroperitoneal. Debridement. Could you just go into like a little bit more detail about the approach and how it works? I know you recently had Yep. Talked about it in js, but just for just for our listeners so they can understand how it works. Right. So this is gonna be for paracolic necrosis where having one drain is just insufficient. So it's generally kind of like the length of the left paracolic gutter, for example. That's commonly where this occurs, and what you do is you ask the IR team to place two drains about five centimeters apart from each other. And then a couple days later, you go to the OR and you exchange over a wire under fluoroscopic guidance, those drain tracks for laparoscopic trocars. And so that gives you a

camera and a working hand, which then allows you to like scoop out the necrosis with laparoscopic instruments as opposed to just the nephro scope, which is what the true merp is. Mm-hmm. Um, and it, the other thing that you could do in this case, rather than like keeping it sort of quote unquote minimally invasive is a, is a true var where you make a flank incision and you kind of hold the, the laparoscope there to shine some light in and get a little bit of a better projection on the camera, but you're manually using ring forceps to, to scoop everything out. So it's kind of this continuum, like Endoluminal drainage is the most minimally invasive. Step up with drains and merp or minor are kind of more minimally invasive, but they still require drains. And then VD is kind of an open approach, but it's not the big laparotomy that that is at the open necrosectomy. So you have all of these different options for patients with necrosis, and it just depends on where it is, how big it is, and if

they're ready for an intervention. And again, they have to be sort of manifesting signs that this is infected necrosis. Or they have persistent unwellness, which, uh, Andy Warshaw, the former chair at MGH, he kind of coined this phrase. It's, it's that person who's living out in the world. They're a citizen again, but they just feel grungy and they don't eat great and they kind of have been losing weight and they're just not perfect. And, and they get a CAT scan and they're still walled off necrosis that just needs to be intervened on. And so that's kind of the other indication for one of these interventions is persistent on wellness. Mm-hmm. That's a key. Um. For all the listeners to pick up on. And then the other thing I wanted to ask you too about John, is pancreatic enzyme replacement for these patients after Yep. I remember we had a couple guys and they needed to get Creon after. Could you just talk about that? Yep. So in all patients with pancreatitis, I kind of harp on this in addition to like clarifying what the etiology of the pancreatitis is, getting high quality imaging evaluating

their physiologic status, you have to get a social worker to see them. Because pancreatitis is a long journey. It's like a book. It has many chapters. Some chapters are good, some chapters are bad, some chapters are longer than others, and you need resources to help support these patients. 'cause a lot of times their patients of, of kind of lower socioeconomic status or they have substance abuse problems and they're unemployed or they're on disability. And you have to be very cognizant of this. And. Kind of coach them along with the, the sort of duration of their recovery. You also need to get, in some cases, psychiatrist if they have addiction issues, and then you need a nutritionist. And the nutritionist is gonna be most helpful for tube feeding because a lot of patients are just gonna be too unwell to eat on their own or get enough calories to overcome the catabolic needs of the pancreatitis. And. They may also have malabsorption, which is, to your

point, which they're having steatorrhea, which is low loose and floating stools. That Creon is kind of the, the, the brand name of, of enzyme replacement. And so we generally start patients on two tablets of Creon at sort of 24,000 as their lipase starting level. And we try to give two of those tablets with every meal and then one with every snack. And this is for anything that has fat protein. You know, is substantive so that they can digest that they take it right with their meal, and then they can digest that food better and they can absorb it better because the last thing they wanna do is throw tube feeds on, or really try to give them a lot of insurers or meal replacements, and then they don't absorb any of it and, and they don't really gain any weight then, and they have a lot of diarrhea. And that just becomes a lot of work for the nurses and just a really uncomfortable hospitalization for the patient. Yeah, I like that point about it being such a long-term disease. I think lots of times you just hear the word acute and you think like, oh, this is, we'll just take care of it now. But

yeah, it really does kind of follow these patients. That's chapter one. Yeah. Yeah, yeah, yeah. That's the beginning. There's, there's generally like a, a prologue and then five acts and then an epilogue and then, you know, some type of encore. It just, pancreatitis can always come back, you know, even when you think you've treated everything. Patients who have disconnected duct can sort of have that tail or remnant pancreas flare up again. And, you know, cause mischief and, and they need repeat drainage or debridement so they're never fully out of the woods, you know, even if you've gotten them back to civilian life. Yeah. And actually John, I just wanna jump on that. You mentioned the, the disconnected pancreatic duck syndrome. You know, we talk about the acute necrotizing pancreatitis being like your chapter one, your intro. This is kind of one of those things that's like one of the mid chapters or maybe even towards the end. Could you talk about what, like what disconnected pancreatic duct syndrome is and like how we have to treat, because I think this is something that a lot of gen surge residents, especially, you're gonna see this when you're in your inner city

hospital and these patients are coming back with issues. Yep. So these are patients where the thinned out portion of the neck and body of the pancreas is where the pancreatitis happens. So the duct blows out at that point. And so you have a pancreatic head that drains into the duodenum. And you have a pancreatic body and tail that is just leaking fluid into the lesser sac in sort of that retro gastric position. And so generally they get a big pseudocyst back there. And what can happen is even after they get some type of intervention for that, the pancreatic duct in the tail, if it doesn't scar down, can leak again. And so if you're having repeated episodes of pancreatitis or pseudocyst, they probably need a distal pancreatectomy. Where you go in and you actually remove that disconnected body and tail and eliminate the possibility of the pancreatic duct out there leaking anymore. So that's a tough operation because often the mesocolon is pulled in, the

stomach is glued down from prior operations. The remnant pancreas is just this atrophic little kind of rock that's just glued to the retroperitoneum. And so that's generally a hard operation. But you know, that might be sort of what the patient needs. To just keep them from having these repeated flares. Man, that's sounds terrible. It is. When they say Don't mess with the pancreas, I can see why. Yeah. So one, one more like kind of long term thing, and you alluded to this a little bit earlier when we were talking about our, our, like our lap necro necrosectomy is if the origin was gallstone pancreatitis. You know, I've been reading some things about like, when, when is though you say the best time to like take out the gallbladder in those patients. Yeah, it's when it's when the patient is well enough to undergo surgery, and so generally sometime around a month or six weeks, the inflammation is cooled off enough from the pancreatitis that you can go in and take out the gallbladder. The thing about it is you want to address any

necrosis if it's still there at the time you do your Coley. So hopefully everything is sort of sock down and healed up and. You know, a lot of patients don't ever end up needing any type of necrosectomy in any form, and so you can just do their gallbladder. But if you've got a patient who is like in the hospital and getting a necrosectomy and they had biliary pancreatitis and you're planning to intervene on the necrosis, you should just take their gallbladder out if you can safely do that. Mm-hmm. Um, otherwise you can sort of wait a little bit electively for things to calm down, decide if the decision tree has split towards needy and necrosectomy or not, and then just handle the gallbladder. Nick Roski at uh, IU is a big proponent of open surgical transgastric necrosectomies because it's super easy to take the gallbladder out at the same time. If you do a lap, transgastric necrosectomy, your ports are always in kind of a little funny place to take out the gallbladder, so it's a little more clunky of an operation to do. Though we do it all the time, um, and it's

certainly possible, but patient's gotta be well enough to have, you know, their gallbladder taken out. It's gotta be safe to take their gallbladder out. The last thing you wanna do is get in there and, and cause some type of biliary issue or leave or remnant gallbladder behind that's going to still drop stones and, and, and get cholecystitis again or something like, you gotta make sure that that gallbladder is, is totally dealt with and this is off the table altogether. All right, John. Well, I'm glad that we got to sit down and do this before you headed over to Boston. Dr. VoLTE always used, tell me you really wanna be a, a student of a disease and you're very obviously a student of necrotizing pancreatitis. With that being said, you know, this is a complex disease as you outlined for us, but what are, what are some key points that, you know, our listeners should walk away with? Yeah, so I think from all the things that we've talked about, the first thing is that. You need patience and persistence. So you have to not jump the gun and intervene too fast on these patients.

But you also can't just let them go. You have to just be kind of like along for the ride with them. So you, you don't want to sort of flinch the minute something changes. You want to make a very calculated decision about how is this gonna affect my long-term management of that patient? Which gets to the second point, is that. It's infected necrosis or persistent unwellness that are the real indications for operating on patients who have walled off necrosis like that. Those are the two key things, like when you've proven those things, there's air in the necros system, or they've been kind of just sputtering along for a long time. You gotta do something about this because it is now time. Now the pancreatitis is driving the clinical picture more than the systemic inflammatory responses. The third thing is that once you've deemed it to be the right time and the right patient along their trajectory of pancreatitis, one size does not fit all. So you

have to know options. You have to enlist IR providers, gastroenterologists, surgeons, medical pancreat agents like we talked about, social workers, maybe psychiatrists, endocrine, your endocrinologists, your nutritionists. All these people have to be involved to get this patient through the planned intervention, and that can be an open necrosectomy if the patient has dead right colon and you have to take it out. Or it can be a endoscopic necrosectomy if they just have a pseudocyst. It can be a laparoscopic or an open surgical transgastric necrosectomy. If they have retro gastric necrosis, it could be a VD or some type of hybrid type, minimally invasive procedure for. A pair of call collection. So you have to, you gotta know the rules of the game and you gotta know the players. And you gotta sort of see how is this patient gonna be best served by having the fewest number of interventions and where do I fit into that? This is a long-term problem. So

again, this is the persistence piece, and this is not letting these patients just get lost into the hinterlands. You gotta have them come back to clinic. You gotta get CT scans at regular intervals. You gotta make sure that their blood sugars are monitored. You gotta make sure that they're on enzyme replacement therapy. You gotta watch for people who develop chronic pancreatitis. If they've had acute necrotizing pancreatitis and you know, 20 years later that gland just burns out and now it's, you know, um, causing them persistent epigastric pain. You gotta take care of the incipient sort of etiology. So if it's biliary pancreatitis, take care of the gallbladder. If it's high triglycerides, get them on a statin. If it's drinking, counsel them on alcohol cessation. If it's medication related, take care of the meds that they're on. If it's post ERCP. Try to find ways to not have them get ERCPs. I mean, there you have to be cognizant of all those factors. And I think the last thing is that this is becoming an increasingly specialized field, so it's not

wrong to sort of be like. This patient's not getting better. We've stepped, but we need to step up. And so patients who are sitting in skilled nursing facilities or at community centers that don't have IR or advanced GI expertise places that don't have surgeons that, that have experience with pancreatitis operations and management, think about those patients getting triaged to another place to, to really get them the care that they deserve. Well, you're the man. Thanks again for breaking it down for us, brother. Best of luck with everything at MGH and for all our listeners. I hope this was helpful for you. I definitely learned a lot and as always, dominate the day.