Combined Surgical Tactics with Step-up Approach in the Treatment of Infected Acute Pancreatitis

Keywords: infected acute pancreatitis, minimally invasive surgery, open surgery, results


Objective. To evaluate the results of treatment using minimally invasive interventions and open necrectomy in patients with infected acute pancreatitis.

Materials and methods. A retrospective cohort two-centered analysis was performed in 211 patients with infected acute pancreatitis who divided into two groups: the first included 101 patients, in the treatment of which used open surgery; the second included 110 patients, in the treatment of which used treatment tactic step-up approach.

Results. In the first group used open necrosectomy with drainage for postoperative lavage (75 patients, 74.3%), including open packing with planned re-laparotomy (8 patients, 7.9%), and omentobursostomy for necrosectomy after surgery (18 patients, 17.8%). Postoperative complications occurred in 58 (57.4%), after the surgery 34 (33.7%) patients was died: 30 had a thirty-day mortality, and 4 had a ninety-day mortality. In the second group group, 72 (65.5%) patients were treated by percutaneous catheter drainage, 6 (5.5%) by video-assisted retroperitoneal debridement and drainage, 5 (4.5%) by through the wall of the stomach or duodenum in the infected pseudocyst and open necrosectomy was performed on 27 (24.5%) patients. Postoperative complications occurred in 37 (33.6%) patients, after the surgery 19 (17.3%) was died: 15 had a thirty -day mortality and 4 had a ninety-day mortality. In the regression analysis, only the presence of multiple organ dysfunction before (AUC = 0.867) and after surgery (AUC = 0.930) significantly affected postoperative mortality, but the effect of the prevalence of pancreatic necrosis (AUC = 0.693) on mortality was limited. Differences were likely between groups (χ2=7.282, p=0.026).

Conclusion. The surgical treatment should be initiated with a minimally invasive procedures and combination these operations with open surgery was able to reduce complications and mortality in the patients with infected acute pancreatitis.

Author Biographies

I. A. Kryvoruchko, Kharkiv National Medical University

Kryvoruchko Igor A., MD, DSci(Med), full professor,
Chief of the Department of Surgery No 2
Kharkiv National Medical University, Ukraine.
4 Nauky Ave., 61022, Kharkiv, Ukraine,

V. V. Boyko, Zaitcev Institute of General and Emergency Surgery, Kharkiv

Boyko Valeriy V., MD, DSci(Med), full professor,
Director of Zaytsev Institute of General and Urgent Surgery
Head of department of surgery No 1
Kharkiv National Medical University
Adress: 1 Balakireva entry, 61103, Kharkiv, Ukraine,
tel.: +38(057)3494125

K. Yu. Parkhomenko, Regional Clinical Hospital, Kharkiv

Parkhomenko Kyril Yuriyovych - MD, PhD, Associate Professor
Kharkiv National Medical University,
Head of Department of Surgery
Kharkiv Regional Clinical Hospital, Kharkiv, Ukraine.

A. G. Drozdova, Kharkiv National Medical University

Drozdova Anastasiya Gennadievna - MD, graduate student
Department of Surgery No. 2
Kharkiv National Medical University, Ukraine.
4 Nauki ave., 61022, Kharkiv, Ukraine

S. A. Andreieshchev, Shupyk National Medical Academy of Postgraduate Education, Kyiv

Andreieshchev Sergii A., MD, PhD, associate professor,
associate professor Department of Surgery and Transplantology,
Shupyk National Medical Academy of Postgraduate Education, Kyiv
30 Heroiv Sevastopolia Str., 03680, Kyiv, Ukraina,
+38 (044) 4081811


Peery AF, Dellon ES, Lund J, Crockett SD, McGowan CE, Bulsiewicz WJ, et al. Burden of gastrointestinal diseases in the United States: 2012 update. Gastroenterology. 2012; 143(5):1179–87. doi: 10.1053/j.gastro.2012.08.002.

Darrivere L, Lapidus N, Colignon N, Chafai N, Chaput U, Verdonk F, et al. Minimally invasive drainage in critically ill patients with severe necrotizing pancreatitis is associated with better outcomes: an observational study. Critical Care. 2018;22(1):321. doi: 10.1186/s13054–018–2256–x

Karakayali FY. Surgical and interventional management of complications caused by acute pancreatitis. World J Gastroenterol. 2014;20(37): 13412–23. doi: 10.3748/wjg.v20.i37.13412

IAP/APA evidence–based guidelines for the management of acute pancreatitis Working Group IAP/APA Acute Pancreatitis Guidelines. Pancreatology. 2013;13(4):1–15. doi: 10.1016/j.pan.2013.07.063.

Van Santvoort HC, Besselink MG, Bakker OJ, Hofker HS, Boermeester MA, Dejong CH, et al. A Step–up Approach or Open Necrosectomy for Necrotizing Pancreatitis. N. Engl J Med. 2010;362(16):1491–502. doi: 10.1056/NEJMoa0908821.

Van Brunschot S, van Grinsven J, van Santvoort HC, Bakker OJ, Besselink MG, Boermeester MA, et al. Endoscopic or surgical step–up approach for infected necrotising pancreatitis: a multicentre randomised trial. Lancet. 2018;391(10115):51–8. doi: 10.1016/S0140–6736(17)32404–2.

Van Grinsven J, van Dijk SM, Dijkgraaf MG, Boermeeste MA, Bollen TL, Bruno MJ, et al. Postponed or immediate drainage of infected necrotizing pancreatitis (POINTER trial): study protocol for a randomized controlled trial. Trials. 2019; 20(1):239. doi: 10.1186/s13063–019–3315–6

Van Santvoort HC, Bakker OJ, Bollen TL, Besselink MG, Ali UA, Schrijver AM, et al. A conservative and minimally invasive approach to necrotizing pancreatitis improves outcome. Gastroenterology. 2011;141(4):1254–63. doi: 10.1053/j.gastro.2011.06.073.

Tenner S, Baillie J, DeWitt J, Vege SS. American College of Gastroenterology guideline: management of acute pancreatitis. Am J Gastroenterol. 2013;108(9):1400–15. doi: 10.1038/ajg.2013.218.

Van Grinsven J, van Brunschot S, Bakker OJ, Bollen TL, Boermeester MA, Bruno MJ, et al. Diagnostic strategy and timing of intervention in infected necrotizing pancreatitis: an international expert survey and case vignette study. HPB (Oxford). 2016;18(1):49–56. doi: 10.1111/hpb.12491.

Darrivere L, Lapidus N, Colignon N, Chafai N, Chaput U, Verdonk F, et al. Minimally invasive drainage in critically ill patients with severe necrotizing pancreatitis is associated with better outcomes: an observational study Critical Care. 2018;22:321. doi: 10.1186/s13054–018–2256–x.

Beger HG, Bittner R, Block S, Büchler M. Bacterial contamination of pancreatic necrosis. A prospective clinical study Gastroenterology. 1986;91(2):433–8. doi: 10.1016/0016–5085(86)90579–2.

Fernández–del Castillo C, Rattner D, Makary MA, Mostafavi A, McGrath D, Warshaw AL. Debridement and closed packing for the treatment of necrotizing pancreatitis. Ann Surg. 1998;228(5):676–84. doi: 10.1097/00000658–199811000–00007

Bradley EL. Management of infected pancreatic necrosis by open drainage. Ann Surg. 1987;206(4):542–50. PMCID: PMC1493219. PMID: 3662663.

Nieuwenhuijs VB, Besselink MG, van Minnen LP, Gooszen HG. Surgical management of acute necrotizing pancreatitis: a 13–year experience and a systematic review. Scand J Gastroenterol Suppl. 2003; (239):111–6. doi: 10.1080/00855920310002799.

Howard TJ, Patel JB, Zyromski N, Sandrasegaran K, Yu J, Nakeeb A, et al. Declining morbidity and mortality rates in the surgical management of pancreatic necrosis. J Gastrointest Surg. 2007;11(1):43–9. doi: 10.1007/s11605–007–0112–4.

Boyko VV, Kryvoruchko IA, Shevchenko RS, Smachilo RM, Pesotskiy ON. Ostryiy pankreatit. Patofiziologiya i lechenie. Kharkov: Tornado; 2002. 288 s.

Banks PA, Bollen TL, Dervenis C, Gooszen HG, Johnson CD, Sarr MG, et al. Classification of acute pancreatitis––2012: revision of the Atlanta classification and definitions by international consensus. Gut. 2013;62 (1):102–11. doi: 10.1136/gutjnl–2012–302779.

Moynihan B. Acute pancreatitis. Ann Surg. 1925;81(1):132–42. PMID: 17865162.

Raraty MG, Halloran CM, Dodd S, et al. Minimal access retroperitoneal pancreatic necrosectomy: improvement in morbidity and mortality with a less invasive approach. Ann Surg.2010; 251(5):787–93. doi: 10.1097/SLA.0b013e3181d96c53.

Horvath K, Freeny P, Escallon J, Heagerty P, Comstock B, Glickerman DJ, et al. Safety and efficacy of video–assisted retroperitoneal debridement for infected pancreatic collections: a multicenter, prospective, single–arm phase 2 study. Arch Surg. 2010;145(9):817–25. doi: 10.1001/archsurg.2010.178.

Kryvoruchko IA, Boyko VV, Drozdova AG. Surgical Treatment of Secondary Pancreatic Infection. Acta Scientific Medical Sciences. 2019;3(4): 68–72.

Parekh D. Laparoscopic–assisted pancreatic necrosectomy: A new surgical option for treatment of severe necrotizing pancreatitis. Arch Surg. 2006;141(9):895–902. doi: 10.1001/archsurg.141.9.895.

Escourrou J, Shehab H, Buscail L, Bournet B, Andrau P, Moreau J, et al. Peroral transgastric/transduodenal necrosectomy: success in the treatment of infected pancreatic necrosis. Ann Surg. 2008;248(6):1074–80. doi: 10.1097/SLA.0b013e31818b728b.

Bakker OJ, van Santvoort HC, van Brunschot S, Geskus RB, Besselink MG, Bollen TL, et al. Endoscopic transgastric vs surgical necrosectomy for infected necrotizing pancreatitis: a randomized trial. JAMA. 2012;307(10:1053–61. doi: 10.1001/jama.2012.276.

Sleeman D, Levi DM, Cheung MC, Rahnemai–Azar A, Parisek S, Casillas V, et al. Percutaneous lavage as primary treatment for infected pancreatic necrosis. J Am Coll Surg. 2011; 212:748–52. doi: 10.1016/j.jamcollsurg.2010.12.019.

Boyko VV, Kryvoruchko IA, Klosova MO. Miniinvazyvni tekhnolohii v kompleksnomu likuvanni ridynnykh kolektoriv pry pankreonekrozi. Shpytalna khirurhiia. 2003;2:15–8. [In Ukranian].

Navalho M, Pires F, Duarte A, Gonçalves A, Alexandrino P, Tavora I. Percutaneous drainage of infected pancreatic fluid collections in critically ill patients: correlation with C–reactive protein values. Clin. Imaging. 2006;30(2):114–9. doi: 10.1016/j.clinimag.2005.09.026.

How to Cite
Kryvoruchko, I. A., Boyko, V. V., Parkhomenko, K. Y., Drozdova, A. G., & Andreieshchev, S. A. (2020). Combined Surgical Tactics with Step-up Approach in the Treatment of Infected Acute Pancreatitis. Klinicheskaia Khirurgiia, 87(3-4), 3-9.
General Problems of Surgery