A 36-year-old male patient was admitted to Aster Hospital, Mankhool 2 months ago with severe pancreatitis. His clinical course was further complicated by development of pancreatic necrosis within the first 2 weeks of hospitalization. He developed severe sepsis leading to renal dysfunction and acute lung injury secondary to MRSA bacteremia. The source of MRSA was localized to the necrotic areas of the pancreas and peri-pancreatic tissues as detected on a positive culture on an aspirate from the necrotic areas. The patient was managed using a multi-disciplinary approach under the specialties of Gastroenterology, Intensive Care, Hepatology and Surgery.
The patient had repeated hospital admissions for recurrent sepsis and had to be treated with multiple courses of antibiotics and empirical antifungal therapy. Despite an ultrasound guided catheter drainage of the infected necrosis, the patient continued to have repeated episodes of bacteremia.
The index patient was a 36-year-old male who presented with severe upper abdominal pain and was diagnosed to have acute pancreatitis. He developed an infected pancreatic necrosis leading to repeated episodes of MRSA bacteremia. The white circles show the necrotic area. In the top two images, the necrotic areas are within the pancreatic parenchyma while in the lower two images, there is a large necrotic area in the retroperitoneum. Despite percutaneous drainage of the retroperitoneal collection, persistent bacteremia persisted. Using a minimally invasive single port technique with a rigid nephroscope, drainage of the retropancreatic collection and debridement of necrotic tissue was done.
Pancreatic necrosis is a local complication of acute pancreatitis. The development of secondary infection in pancreatic necrosis is associated with increased mortality upto 20%. Pancreatic necrosectomy is the mainstay of invasive management. The traditional surgical approach to pancreatic necrosis is open necrosectomy that aims at wide drainage of all infected collections and complete removal of all necrotic tissue with the placement of drains for continuous postoperative closed lavage. Frequently, repeat laparotomy is needed to ensure complete debridement. Open approach is associated with substantial morbidity and high rates of perioperative mortality. The current recommendation is to perform minimally invasive step-up procedures initially starting with placement of percutaneous drainage catheters to drain the infected fluid. Laparoscopic drainage of necrosis and infected collections is then indicated in patients who have ongoing sepsis even after percutaneous drainage of the infected fluid. Minimally invasive necrosectomy provokes less surgical trauma in patients who are already severely ill. There is substantial reduction in the incidence of new-onset multiple organ failure with this approach.
Minimally invasive pancreatic necrosectomy should be undertaken only by surgeons experienced in this procedure. Good critical care is extremely important after the procedure since there is a potential risk of bleeding, persistent infection, and ongoing pancreatitis. The index patient underwent minimally invasive single port pancreatic necrosectomy. The existing drain site was dilated and necrosectomy done using a rigid nephroscope. He had an uneventful post-operative recovery and was discharged on the 8th post-op day.
Consultant in Gastroenterology
HOD of Critical Care Medicine
Specialist General Surgeon
Dr. Mathew Jacob
Senior Consultant in Hepatology and Liver Transplantation
Aster Hospital, Mankhool