Experience in the implementation of a modified step-up approach in the treatment of infected pancreatic necrosis

Aim. Analysis of the results of the application of the modified step-up approach in the treatment of infected pancreatonecrosis in a third-level hospital.

Materials and methods. The study included 52 patients over 18 years of age with acute pancreatitis and suspected or proven infection with pancreatic or peripancreatic necrosis .The control group included 27 patients who underwent primary open necrectomy. The comparison group included 25 patients who underwent surgical treatment within the framework of the modified concept of the stepwise surgical approach (Step-up). In the groups compared mortality rates, early postoperative complications (IIIb-IVb grade Clavien-Dindo), late postoperative complications (ventral hernias, pseudocysts, diabetes mellitus), the duration of inpatient treatment, and the duration of treatment in the intensive care unit. The indicator "Full return to primary social activity after treatment" was also proposed.

Results. In the Step-up approach group, in comparison with the control group, there was a decrease in the overall incidence of postoperative complications of IIIb-IVb grade Clavien-Dindo (24% and 51.9%, respectively, p <0.05), the frequency of arrosive bleeding (0% and 14 , 8%,  respectively, p <0.05), the need for necrsequestrectomy (64 and 100%, respectively, p <0.01), the total average duration of treatment in the intensive care unit (3.2 ± 0.6 and 9.2 ± 1.6 days, respectively, p <0.05), and the average duration of treatment in the intensive care unit after execution of necrosectomy (1,4±0,4 7,2±1,3 days, respectively, p<0.01).  A complete return to social activity in the control group was noted only in 10 (37%) patients compared with 19 (76%) in the Step-up group (p <0.01).  In the Step-up group, in comparison with the control group, a tendency towards a decrease in mortality was revealed (16% and 34.5%, respectively, p> 0.05).

Conclusion. The step-up approach can improve the results of treatment of infected pancreatic necrosis. The most important advantage of this concept is reproducibility - that is, the possibility of using it not only in the leading metropolitan clinics, but also in the regions of the Russian Federation. The step-up approach, however, has not yet acquired a complete form, and there is room for improvement.

1. Mitryakov P .S. Modern methods of treatment of patients with pancreatic necrosis. International journal of experimental education= Mezhdunarodnyy zhurnal eksperimentalnogo obrazovaniya. 2016; 9: 221-224 (In Russian)

2. Peter A .B., Thomas L.B., Christos D., Hein G.G., Colin D. J., Michael G. S., Gregory G. T., Santhi S. V., Acute Pancreatitis Classification Working Group . Classification of acute pancreatitis—2012: revision of the Atlanta classification and definitions by international consensus. Gut 2013;62:102–111. https: //doi:10.1136/gutjnl-2012-302779

3. Trikudanathan G., Tawfik P., Amateau S.K., Munigala S., Arain M., Attam R., Beilman G., Flanagan S., Freeman M.L., Mallery S. Early (<4 Weeks) Versus Standard (≥ 4 Weeks) Endoscopically Centered Step-Up Interventions for Necrotizing Pancreatitis. The American journal of gastroenterology 2018;113(10):1550-1558. https: // doi: 10.1038/s41395-018-0232-3.

4. Aliev S.A., Aliev E.S. Unsolved issues of surgical treatment of infected pancreonecrosis. Surgery=Khirurgiya.2015; 8: 64-69. https: //doi: 10.17116/hirurgia2015864-69 (in Russian)

5. Nemoto Y., Attam R., Arain M.A., Trikudanathan G., Mallery S., Beilman G.J., Freeman M.L. Interventions for walled off necrosis using an algorithm based endoscopic step-up approach: Outcomes in a large cohort of patients. Pancreatology. 2017; 17(5):663-668 https: //doi: 10.1016/j.pan.2017.07.195

6. Freeman L.M., Werner J., van Santvoort H.C., Todd H.B., Besselink M.G.,Windsor J.A., Horvath K.D., Sonnenbeg E., Bollen T.L., Vege S.S. et al. Interventions for Necrotizing Pancreatitis. Summary of a Multidisciplinary Consensus Conference. Pancreas 2012;41(8): 1176-1194. https: // doi: 10.1097/MPA.0b013e318269c660

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

8. Morato O., Poves I., Ilzarbe L., Radosevic A., Vazquez-Sánchez A., Sanchez-Parrilla J., Burdio F., Grande L. Minimally invasive surgery in the era of step-up approach for treatment of severe acute pancreatitis. Int J Surg. 2018. 51:164-169. https: //doi: 10.1016/j.ijsu.2018.01.017

9. Rasch S, Phillip V, Reichel S, Rau B, Zapf C, Rosendahl J, et al. Open Surgical versus Minimal Invasive Necrosectomy of the Pancreas—A Retrospective Multicenter Analysis of the German Pancreatitis Study Group. PLoS ONE 2016; 11(9): e0163651. https://doi.org/10.1371/journal.pone.0163651

10. Bakker O.J., van Santvoort H.C., van Brunschot S., , Geskus R.B., Besselink M.G., Bollen T.L., van Eijck C.H., Fockens P., Hazebroek E.J., Nijmeijer R.M., Poley J.-W., van Ramshorst B., Vleggaar F.P., Boermeester M.A., Gooszen H.G., Weusten B.L., Timmer R. et al. Endoscopic transgastric vs surgical necrosectomy for infected necrotizing pancreatitis: a randomized trial. JAMA. 2012;307(10):1053-1061. https://doi: 10.1001/jama.2012.276

11. van Grinsven, J., van Dijk, S.M., Dijkgraaf, M.G. et al. Postponed or immediate drainage of infected necrotizing pancreatitis (POINTER trial): study protocol for a randomized controlled trial. Trials 20, 239 (2019). https://doi.org/10.1186/s13063-019-3315-6

12. Rakhimov R. R. Аn Integrated approach to the diagnosis and treatment of infected pancreonecrosis.Perm medical journal. 2016; 6: 36-41. (In Russian)

13. Kostanai A. V., Kеrimov E. J., Kerimov E.E. Surgical treatment of infected pancreatic necrosis. Tavrian Medico-biological Bulletin= Tavricheskiy Mediko-Biologicheskiy Vestnik 2015; 3: 37-39. (In Russian)

14. National clinical guidelines “Acute pancreatitis". Website of the Russian society of surgeons. 2015. [quoted 24.09.2020]. Available: http://xn----9sbdbejx7bdduahou3a5d.xn--p1ai/stranica-pravlenija/unkr/urgentnaja-abdominalnaja-hirurgija/nacionalnye-klinicheskie-rekomendaci-po-ostromu-pankreatitu.html.(In Russian)

15. Lukin A. Yu., Shabunin A.V., Shikov D. V. Definition of therapeutic tactics and choice of surgical treatment of patients with pancreatic necrosis. The Moscow surgical journal= Moskovskiy khirurgicheskiy zhurnal. 2013; 3: 17-24. (In Russian)

16. Dindo D, Demartines N, Clavien PA. Classification of surgical complications: a new proposal with evaluation in a cohort of 6336 patients and results of a survey. AnnSurg. 2004;240(2):205-213. doi: 10.1097/01.sla.0000133083.54934.ae

17. Besselink, M.G., van Santvoort, H.C., Nieuwenhuijs, V.B. et al. Minimally invasive 'step-up approach' versus maximal necrosectomy in patients with acute necrotising pancreatitis (PANTER trial): design and rationale of a randomised controlled multicenter trial [ISRCTN13975868]. BMC Surg 6, 6 (2006). https://doi.org/10.1186/1471-2482-6-6

18. van Santvoort H.C, Besselink M.G, Bakker O.J, et al. A step-up approach or open necrosectomy for necrotizing pancreatitis. N Engl J Med. 2010;362(16):1491-1502. doi:10.1056/NEJMoa0908821

19. Besselink M.G., de Bruijn M.T., Rutten J.P., et al. Surgical intervention in patients with necrotizing pancreatitis. Br J Surg. 2006;93(5):593-599. https://doi.org/10.1002/bjs.5287

20. Hollemans R.A., Bakker O.J., Boermeester M.A., et al. Superiority of Step-up Approach vs Open Necrosectomy in Long-term Follow-up of patients with necrotizing pancreatitis. Gastroenterology.2019;156(4):1016-1026. https://doi.org/10.1053/j.gastro.2018.10.045

21. Dyuzheva T.G., Jus E.V., Shefer A.V., Akhaladze G.G., Chevokin A.Yu., Kotovsky A.E., Platonova L.V., Shono N.I., Galperin E .I. Pancreatic necrosis configuration and differentiated management of acute pancreatitis. Annaly khirurgicheskoy gepatologii = Annals of HPB Surgery. 2013; 18 (1): 92-102 . (In Russian)

22. Aliev S.A., Aliev E.S. Minimally invasive methods in surgery of infected pancreatonecrosis: possibilities and prospects. Vestnik khirurgii= Bulletin of surgery. 2017; 6: 106-110 . (In Russian)

23. Demin D. B., Solodov Yu. Yu., Sobolev Yu. A. Combined staged treatment of pancreatic necrosis. Orenburgskiy meditsinskiy vestnik=Orenburg Medical Bulletin. 2019; 2: 19-22. (In Russian)

24. Tseimakh E.A., Bombizo V.A., Buldakov P.N., Averkina A.A., Ustinov D.N., Udovichenko A.V. The choice of surgical treatment in patients with infected pancreonecrosis. Vestnik khirurgii imeni I.I. Grekova= Grekov's Bulletin of Surgery. 2018;177(6):20-26. (In Russ.) https://doi.org/10.24884/0042-4625-2018-177-6-20-26 (In Russian)

25. Krasilnikov D.M., Abduljanov A.V., Zajnullin I.V., et al. Surgical tactics in patients with pancreatic necrosis and its complications. Kazanskiy meditsinskiy zhurnal=Kazan medical journal. 2016; 97(6) 898-903. doi: 10.17750/KMJ2016-898 (In Russian)

26. KuleznyovaYu.V., Moroz O.V., Izrailov R.E., Smirnov E.A., Egorov V.P. Percutaneous Interventions forNecrotic Suppurative Complications of Pancreonecrosis. Annaly khirurgicheskoy gepatologii = Annals of HPB Surgery. 2015;20(2):90-97. https://doi.org/10.16931/1995-5464.2015290-97 (In Russian)

27. van Brunschot S., van Grinsven J., Voermans R.P., et al. Transluminal endoscopic step-up approach versus minimally invasive surgical step-up approach in patients with infected necrotising pancreatitis (TENSION trial): design and rationale of a randomised controlled multicenter trial [ISRCTN09186711]. BMC Gastroenterol. 2013;13:161. https://doi.org/10.1186/1471-230X-13-161

28. van Brunschot S., van Grinsven J., van Santvoort HC, et al. Endoscopic or surgical step-up approach for infected necrotising pancreatitis: a multicentre randomised trial. Lancet. 2018; 391(10115):51-58 https://doi.org/10.1016/S0140-6736(17)32404-2