Surgical transgastric debridement of walled off pancreaticnecrosis: an option for patients with necrotizing pancreatitis

Sujit Kulkarni • Amanda Bogart • James Buxbaum •

Lea Matsuoka • Rick Selby • Dilipkumar Parekh

Received: 25 February 2014 / Accepted: 22 June 2014

� Springer Science+Business Media New York 2014

Abstract

Background Transgastric debridement of walled off

pancreatic necrosis (WOPN) is a surgical treatment option

for patients requiring pancreatic debridement for necro-

tizing pancreatitis. The reported experience with surgical

transgastric pancreatic debridement is limited, however,

the lower incidence of postoperative pancreatic fistulae

with this procedure compared to other options warrants

further evaluation of this technique.

Method Retrospective chart review.

Results Twenty-two patients underwent transgastric

debridement with a cystogastrostomy for clinically symp-

tomatic WOPN from January 1, 2005 to July 31, 2013.

Eight cases were performed laparoscopically and 14 were

performed by an open approach. The mean patient age was

50.9 (50.9 ± 14.5) and the median American Society of

Anesthesiologist score was 3. The most common etiology

for pancreatitis was gallstones and the median time from

attack of pancreatitis to definitive surgical management

was 60 days (range 22–300 days). Median operative time

was 182 min (range 85–327 min) with 100 cc (range

20–500 cc) of blood loss. In seven patients the necrosis

was infected and in 15 patients the necrosis was sterile as

determined by the intraoperative culture of the necrotic

material. The overall significant morbidity (Clavien type 3

or greater) was 13.6 % and the mortality was 0 %. The

incidence of postoperative pancreatic fistula was 0 %. 20

patients (90 %) were symptom free during a median fol-

low-up of 12 months.

Conclusion In selected patients with clinically symp-

tomatic WOPN, surgical transgastric pancreatic debride-

ment appears to be a safe procedure with a low morbidity

and mortality. The low incidence of postoperative pan-

creatic fistulae warrants further evaluation.

Keywords Pancreatic debridement � Walled off

pancreatic necrosis � Necrotizing pancreatitis � Transgastric

debridement

A significant advance in the treatment of necrotizing pan-

creatitis has been the appreciation that delaying surgical

care for 3–4 weeks to allow the pancreatic and peripan-

creatic necrotic material to organize into an area of ‘‘walled

off pancreatic necrosis (WOPN)’’ leads to a substantial

reduction in mortality from the surgery. WOPN, first

described by Connor et al. [1], appears as a heterogeneous

mass with solid and liquid components in a well-formed

wall of fibrous tissue on contrast-enhanced computed

tomography (CT) (Fig. 1). WOPN may cause significant

and life threatening complications such as infection of the

necrosis leading to sepsis, compression of adjacent organs

leading to obstructive jaundice or gastric outlet obstruction

and fistulization or erosion into adjacent organs or vessels

[2]. WOPN may also cause intractable symptoms requiring

treatment such as food intolerance, pain, weight loss, and a

persistent feeling of being unwell [3–6].

S. Kulkarni (&) � L. Matsuoka � R. Selby � D. Parekh

Department of Surgery, Keck School of Medicine, University of

Southern California, 1510 San Pablo Street, Suite 514,

Los Angeles, CA 90033-4612, USA

e-mail: sujit.kulkarni@med.usc.edu

A. Bogart

Keck School of Medicine, University of Southern California,

Los Angeles, CA, USA

J. Buxbaum

Department of Medicine, Keck School of Medicine,

University of Southern California, Los Angeles, CA, USA

123

Surg Endosc

DOI 10.1007/s00464-014-3700-x

and Other Interventional Techniques

Cystogastrostomy is an established treatment option for

the drainage of lesser sac pancreatic pseudocysts [7].

Endoscopic transgastric debridement of pancreatic necrosis

has been reported to be a safe and feasible treatment option

for WOPN [2, 3]. The literature on surgically accessing

WOPN through a transgastric approach is limited. In this

study, we report the largest surgical experience to date

utilizing transgastric access through a cystogastrostomy for

treating WOPN from necrotizing pancreatitis.

Patients and methods

Twenty-two patients with WOPN associated with compli-

cations or intractable symptoms underwent open or

laparoscopic transgastric pancreatic debridement through a

cystogastrostomy from 1/1/2005 and 7/31/2013 at our

institution. Data collection was approved by the University

Institutional Review Board and confidentiality was main-

tained. The selection of laparoscopic versus an open pro-

cedure was at the discretion of the operating surgeon.

Symptoms recorded include persistent abdominal pain

requiring narcotics, inability to tolerate diet, failure to

thrive, repeated hospital admissions for pancreatitis and

persistent feeling of being unwell as described by Rattner

et al. [8]. Patient information collected included age, gen-

der, American Society of Anesthesia (ASA) class, etiology

of necrosis, comorbidities, and prior interventions. Preop-

erative imaging workup included a CT scan and/or mag-

netic resonance imaging (MRI). Operative data collected

included operative time, blood loss, complications, and

cultures. Postoperative data collected included length of

stay, progression of diet, complications, and symptom

resolution (Fig. 2).

Surgical technique

For an open procedure, a small upper midline incision is

performed. An anterior gastrotomy is made where the

WOPN is distorting the stomach. The WOPN cavity is

localized by aspirating the brown or blackish fluid associ-

ated with pancreatic necrosis with an 18 gage needle

through the posterior wall of the stomach. A posterior

gastrotomy is then made with electrocautery to enter the

WOPN cavity and a gastrointestinal stapling device is

utilized to attach the cyst wall to the stomach thereby

establishing a cystogastrostomy and extending the opening

between the stomach and the WOPN cavity. An opening of

approximately 5–10 cm is established between the stomach

and the WOPN cavity. Debridement is achieved using

gentle finger dissection, irrigation, and suction of the

necrotic material. A 30� scope is used to visualize the

cavity and ensure satisfactory debridement and hemostasis.

In hand sewn technique, the posterior stomach wall and

cyst wall are sutured together using 3–0 polypropylene

suture in a continuous manner. The anterior gastrotomy is

then closed.

In the laparoscopic procedure, the abdominal cavity is

entered through a supraumbilical midline incision using

Hasson technique. Two 12 mm ports are placed in the

upper abdomen along the midclavicular lines on the right

and left side. A 5 mm port is placed in the left upper

quadrant. The anterior stomach wall is opened with a

harmonic scalpel. A laparoscopic ultrasound was used to

localize the necrotic area and a laparoscopic needle is used

to aspirate the WOPN cavity. A small posterior gastrotomy

is then performed using hook electrocautery. An endo-

scopic stapler (blue load) is fired to extend the posterior

Fig. 1 CT scan images of pancreatic necrosis

Fig. 2 MRI appearance of pancreatic necrosis (arrow marks solid

component)

Surg Endosc

123

gastrotomy to establish the cystogastrostomy. A bowel-

grasping forceps and suction-irrigator device are used for

debridement. The WOPN cavity is then visualized with the

laparoscope to ensure complete debridement. Necrotic

pancreatic tissue is removed in a plastic bag (Fig. 3).

Hemostasis in the cyst cavity and along the staple line is

ensured. The anterior gastrotomy is closed with an endo-

scopic stapler or 4–0 PDS suture in running fashion. In the

laparoscopic hand-assisted technique, a 5 cm right sub-

costal incision is used for insertion of a Gelport� (Applied

Medical, Rancho Santa Margarita, CA). Two 12 mm ports

are placed in the upper abdomen along the midclavilcular

lines on the right and left side.

Pancreatic fistula

For the purpose of this manuscript, the definition of a

pancreatic fistula followed classification of the Interna-

tional Study Group on Pancreatic Fistula (ISGPF) [9]. If

there is a drain output of any measurable volume of fluid on

or after postoperative day 3 with an amylase level three

times greater than the serum amylase level, then it is

considered as pancreatic fistula. A routine placement of a

drain was avoided both in open or laparoscopic approach.

Preoperatively placed drains are removed at the time of

surgery.

Results

Patient characteristics

The patient characteristics are summarized in Table 1.

Twenty-two patients with WOPN were treated with trans-

gastric debridement through a cystogastrostomy. There

were 13 males and 9 females. The mean patient age was

50.9 (50.9 ± 14.5) and the median ASA score was 3 (range

2–3). Sixteen patients had comorbidities including diabetes

[13], hypertension [5], cirrhosis [1], coronary artery disease

(CAD) [1], and obesity [3]. The cause of pancreatitis was

gallstones in 12, alcoholic in 3, hypertriglyceridemia in 1,

and idiopathic in 6 patients. Eighteen patients did not have

any prior interventions, while two patients had percutane-

ous drains and one patient had endoscopic transgastric

drain. One patient, who underwent prior open debridement

with splenectomy and cholecystectomy, developed a

recurrent peripancreatic fluid collection with necrosis. All

these interventions were performed at the outside hospitals

prior to transfer.

The indications for surgery were based on a prolonged

symptomatic clinical course, which included repeated

readmissions after the developing necrotizing pancreatitis,

persistent feeling of being unwell, abdominal pain, weight

loss and failure to tolerate oral intake. Patients were sur-

gically debrided using the transgastric route at the discre-

tion of the operating surgeon and only patients who did not

have clinical or radiological evidence of infection were

considered. Three out of 22 patients had preoperative organ

failures. Two patients had acute renal failure and acute

respiratory distress syndrome. One patient had renal fail-

ure, respiratory failure, and myocardial infarction. The

majority of the patients had the primary treatment for the

pancreatitis elsewhere and was referred to us afterward.

The median time from attack of pancreatitis to definitive

surgical management was 60 days (range 22–300 days).

Imaging characteristics

CT scan was the most common imaging modality used

(Fig. 1). Two patients had MRI performed because of

contrast allergy (Fig. 2). Median maximal diameter of

WOPN on imaging was 13 cm. Near total necrosis was

seen in seven patients. Left-sided gutter extension of the

necrosis was noted in three patients. Mesenteric extension

along the superior mesenteric vessels was seen in seven

patients. Eight patients had splenic vein thrombosis. Two

out of those eight patients also had portal vein thrombosis

with varices. We were unable to calculate CT severity

index because of lack of availability of initial imaging

studies performed at the outside hospitals.

Perioperative data and outcomes

The perioperative data and outcomes are summarized in

Table 2. Eight out of 22 patients underwent laparoscopic

transgastric debridement and six out of eight laparoscopic

cases were performed totally laparoscopically. Hand-

assisted technique with Gelport� was used in two cases.

Fig. 3 Laparoscopic pancreatic debridement

Surg Endosc

123

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Surg Endosc

123

Eleven patients had concurrent cholecystectomies and one

patient with gallstone pancreatitis had cholecystectomy at

an outside hospital before transfer.

Median operative time was 182.5 min (range

85–327 min). Median blood loss was 100 ml (range

20–500 ml). Six patients required postsurgery ICU care (1,

1, 1, 1, 2 and 21 days). Median postoperative duration for

the nasogastric tube was 3 days (range 2–13), the median

time for passing flatus was 4 days (range 2–7) and to tol-

erate a liquid diet was 5 days (range 2–17). Median total

length of stay was 12.5 days (range 5–27) and median

postoperative length of stay was 7 days (range 4–27).

Ninety-day mortality was 0 %. Eight patients developed

postoperative complications (overall complication rate of

36 %). Two patients developed minor postoperative wound

infections that required only bedside care and antibiotics.

One of these two patients had infected pancreatic necrosis.

Two patients had delayed gastric emptying which was

treated with bowel rest and total parenteral nutrition. Three

out of eight patients were readmitted. Two had delayed

gastric emptying as listed above and one patient had intra-

abdominal infected fluid collection, which was not acces-

sible to radiological drainage, was treated with intravenous

antibiotics. One patient developed urinary tract infection

requiring treatment with antibiotics. Three patients devel-

oped serious Clavien grade 3 or greater morbidity

(13.6 %). One patient, who had preoperative organ failure,

developed a major wound infection with fascial dehiscence

that did not appear to be from a pancreatic fistula and

required reoperation for abdominal wall closure. A second

patient developed wound infection, peripancreatic fluid

collection and superior mesenteric vein thrombosis which

were treated with local debridement, antibiotics, percuta-

neous drainage, and anticoagulation. It is unclear whether

this patient developed a pancreatic fistula as the initial

drain amylase level was 300 units/l but the output

decreased to minimal after 3 days and repeat amylase level

was 10 units/l. Cultures of the necrotic material taken at

the time of surgery were positive for bacteria in seven

patients. Three out of the seven patients had percutaneous

drains placed at outside hospitals and one patient had

endoscopic transgastric drain. Four patients had multiple

organisms in the cultures such as Enterobacter faecalis,

Enterobacter aerogenes, Proteus, Klebsiella, Streptococ-

cus viridans, Hemophilus parainfluenzae, and Candida.

Three patients had single organism grown from cultures

(Vancomycin resistant enterococcus, Enterobacter faecal-

is, and Enterobacter cloacae).

Patients were followed for a median of 12 months

(range 2–20). One patient presented with a distal common

bile duct (CBD) stricture after 4 months which required a

biliary bypass. Symptoms were completely resolved on

follow-up in 20 patients (90 %). Two patients had persis-

tent symptoms after follow-up for 7 and 16 months,

respectively.

Discussion

A major development in the treatment of pancreatic

necrosis has been the observation that areas of pancreatic

necrosis that initially present as a phlegmon or as diffuse

necrosis undergo organization and localization, a process

of forming a WOPN. The term ‘‘walled off pancreatic

necrosis’’ was officially accepted at the Digestive Disease

Week Meeting in 2006 during the American Gastroenter-

ological Association Clinical Symposium [8]. WOPN is a

heterogeneous fluid filled cavity with pancreatic or peri-

pancreatic tissue necrosis lined by a fibro-collagenous wall

and granulation tissue appearing three or more weeks after

the initial episode of pancreatitis [10]. Mortality rates drop

sharply if surgical intervention for pancreatic necrosis is

delayed until WOPN has formed, since this facilitates the

ease and completeness of the necrosectomy [11]. Present

Table 2 Perioperative data and outcomes

Variables Data (range)

Laparoscopic 8

Open 14

Concurrent cholecystectomy 11

Median operative time (min) 182 (85–327)

Median blood loss (ml) 100 (20–500)

Intra-operative cultures

Positive/negative 6/16

Median length of stay

Post op days 7

Total days 13

Time (days) from operation to Median

ICU stay 0 (1–21)

Nasogastric tube removal 3 (2–13)

Flatus 4 (2–7)

Bowel movement 5 (3–12)

Tolerate liquid diet 5 (2–17)

Morbidity

Total number of patients with complications 8

Reoperation 1

Late complication (CBD stricture) 1

Wound infection 4

Recurrent fluid collection 1

Readmissions 3

Mortality 0

Median follow-up (months) 12 (2–20)

Symptom resolution 20/22

Surg Endosc

123

surgical practice strongly recommends against any inter-

vention until there is evidence of WOPN on imaging

studies.

Surgical transgastric debridement is a novel approach to

treatment of pancreatic necrosis and is feasible only in the

presence of WOPN. The present is the largest study

reported to date of transgastric surgical pancreatic

debridement. Our study suggests that this technique is safe

as our overall mortality was 0 % and significant morbidity

(Clavien grade 3 or higher) was 18 %. Symptoms were

resolved in 90 % of patients with long-term follow-up and

only one patient required a second surgical procedure

(4.5 %). Two small previously reported studies mirror our

outcomes with surgical transgastric approach for pancreatic

debridement. Munene et al. have reported their experience

on open transgastric debridement through a cystogastros-

tomy in 10 symptomatic non-infected WOPN patients with

a morbidity of 30 % and a mortality of 0 % [12] and Bo-

land et al. reported eight patients with 0 % mortality and

12 % morbidity [13]. Surgical transgastric debridement

based on this limited experience warrants further evalua-

tion as the procedure is associated with a low morbidity

and mortality.

Transgastric pancreatic debridement was first pioneered

by gastroenterologists who developed per oral endoscopic

debridement techniques that create an opening between the

posterior gastric wall and the WOPN cavity often with the

assistance of endoscopic ultrasound (EUS) guidance [3, 8,

10]. Endoscopic transgastric debridement requires multiple

endoscopic procedures under prolonged anesthesia with a

median of 3–6 procedures/patient. The reported mortality

of endoscopic transgastric debridement is up to 20 % and

complications occur in 15–26 % of patients, including

perforation, peritonitis, bleeding and air embolism,

requiring additional treatments with angiography or sur-

gery [3, 10, 11]. Endoscopic transgastric necrosectomy

using metal stents have been reported but the experience is

very limited [14]. Endoscopic necrosectomy is time con-

suming and complex procedure that requires specialized

advanced endoscopic expertise in endoscopic retrograde

cholagiopancreatography, EUS, endoscopic devices, and

accessories used for necrosectomy. The feasibility of

endoscopic necrosectomy outside of a few highly special-

ized pioneering pancreatic endoscopic centers is unclear.

Comparatively, surgical transgastric debridement does not

require specialized equipment, appear to be safe in the

hands of an experienced pancreatic surgeon and the sur-

gical technique is well established as it is similar to

approaches for lesser sac pseudocyst. Further studies

comparing endoscopic and surgical transgastric debride-

ment are necessary.

The major advantage of transgastric debridement is the

near absence of a posttreatment pancreatic fistula.

Disconnected pancreatic duct syndrome after severe nec-

rotizing pancreatitis is a known entity where the pancreatic

body or tail is often disconnected from rest of the gland due

to necrosis [15]. The separated pancreatic gland will con-

tinue to secrete pancreatic juices and this leads to the

development of a persistent pancreatic fistula in up to 70 %

of patients that often takes months to resolve following

transabdominal and retroperitoneal debridement [10, 16–

18]. None of our patients developed an external pancreatic

fistula after the surgery. The reported incidence of pan-

creatic fistulae is 3.7 % in endoscopic studies after per oral

transgastric pancreatic necrosectomy [8] and in the two

prior surgical studies an incidence of 12 % [12] and 0 %

[13] of pancreatic fistulae was reported.

The traditional treatment for pancreatic necrosis has

been open surgical debridement; however, a median

mortality rate of 25 % (range of from 6 to 56 %) has been

reported for open surgical debridement [3–6]. In the post

WOPN era, the emphasis has shifted to minimally invasive

treatment approaches such as video-assisted retroperito-

neal debridement (VARD) and laparoscopic trans-abdom-

inal or transgastric debridement. VARD has been the most

widely reported surgical minimally invasive surgical pro-

cedure for pancreatic debridement; however, this proce-

dure is feasible as the primary treatment in only 40–50 %

of eligible patients according to recently reported phase II

single arm multicenter study by Horvath et al. [19]. Forty

patients were evaluated with infected pancreatic necrosis

with the step-up approach and 31 patients required sur-

gery. VARD was initially possible in 25 of the 31 patients;

however, of this group an additional 10 (40 %) required

further open surgery because of the failure to drain cen-

trally located collections that were not accessible by

VARD. Therefore, only 15 (48 %) of the eligible 31 sur-

gical patients were treated primarily by VARD. Van

Santvoort et al. reported the results of a randomized con-

trolled trial comparing open necrosectomy to the step-up

approach with VARD [20]. Twenty-four patients in this

study underwent VARD and in 14 of 24 patients (58 %)

further surgical procedures were necessary to address

residual areas of necrosis or complications associated with

VARD. The overall morbidity of VARD treated patients

was 36 % and 30 days mortality 0 % in Horvath study

[19]. The pancreatic fistula rate was 20 %. The experience

with laparoscopic transabdominal debridement is more

limited. We have reported the largest experience of lapa-

roscopic pancreatic necrosectomy. In 56 consecutive sur-

gically treated patients with pancreatic debridement 49

patients were approached laparoscopically and the proce-

dure was completed laparoscopically in 47 patients. The

overall incidence of serious postoperative complications

was 35 % with the majority of the complications being

non-life threatening (Clavien grade 3 in 27 %, grade 4 in

Surg Endosc

123

4.2 % and grade 5 in 4.2 %) and the mortality rate was

6 % [21, 22]. In this study, eight patients underwent lap-

aroscopic transgastric debridement with 0 % mortality and

18 % morbidity suggesting that it is a safe procedure.

These studies support the trend toward minimally invasive

approaches as the published results suggest that minimally

invasive approaches are safe with low morbidity and

mortality compared to that previously reported for open

surgery. A prolonged close follow-up is necessary for

these patients. These patients are at risk of postoperative

complications such as incisional hernia, infection, reoper-

ation, and bleeding. Other issues such as failure to thrive,

poor oral intake, persistent pain, addiction to pain medi-

cations, repeated hospital admissions, pancreatic insuffi-

ciency (exocrine as well as endocrine), anemia, need for

rehabilitation and feeling of being unwell may prolong for

months after the surgery.

There are important limitations of this study. Our sam-

ple size is small and the patients in this study were highly

selected as shown by the fact that only three patients had

organ failure and none of the patients included in this study

had evidence of clinical sepsis or radiological sign of

infection such as presence of air bubbles at the time of

surgery. We were particularly worried about including

patients with evidence of infected pancreatic necrosis in

this study due to the concern over the effect of persistent

postoperative sepsis the gastric suture line. The cultured

necrosis did showed evidence of infection in seven patients

who did not have any preoperative clinical evidence of

invasive sepsis. In none of these patients any dehiscence of

the gastric suture line was seen. Our study suggests that

transgastric debridement through a cystogastrostomy is a

safe procedure in selected group of patients with clinically

symptomatic but non-infected WOPN with a low morbid-

ity, short length of stay and low incidence of postoperative

pancreaticocutaneous fistulae. The application of this

technique to a wider population of patients requiring pan-

creatic debridement is unclear and further experience is

necessary to assess the feasibility of this technique in

subgroups of patients who were excluded from this study in

particular patients with a large burden of necrotic tissue

extending into the retroperitoneal or periduodenal spaces,

presence of multiple organ failure and critically ill patients

with severe sepsis. The markedly lower incidence of pan-

creatic fistulae after transgastric debridement makes this

approach attractive compared to other surgical treatment

options for pancreatic debridement and warrants further

evaluation.

Acknowledgements Grants/Financial support: none

Disclosure Drs. Kulkarni, Boagart, Matsuoka, Buxbaum, Selby and

Parekh have no conflicts of interests or financial ties to disclose.

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