Pancreatitis Management Evolves with Minimally Invasive, Delayed Interventions

Recent advances in the management of pancreatitis—including minimally invasive surgical approaches and delayed interventions—have helped improve patient outcomes and quality of life. And now, with improved imaging, genetic testing, and artificial intelligence (AI), disease management is poised to advance even further.

Differentiating Acute Versus Chronic Pancreatitis

Pancreatitis can be chronic or acute. Because it presents in many ways, it is easy to mistake for another gastrointestinal disease. In managing pancreatitis, it’s critical to understand the initial insult, proper classification, and prognosis,¹ as acute pancreatitis and chronic pancreatitis are different, with completely different treatments.

Acute Pancreatitis

Acute pancreatitis is the leading cause of gastrointestinal-related hospitalizations in the US, and its frequency continues to rise in the US and worldwide.²

Treatment usually is conservative for mild disease, with mild acute pancreatitis accounting for approximately 75% of cases.₂ Gallstone pancreatitis, the most common cause of mild acute pancreatitis, is typically treated with intravenous fluids and supportive care in the early days after presentation.

One recent advance in treating mild acute pancreatitis is same-admission laparoscopic cholecystectomy, which decreases recurrence and readmissions. Another is the use of robotic-assisted cholecystectomy, which has increased 40-fold in the last decade; however, a large Medicare database study showed a higher rate of bile duct injury with robotic compared with laparoscopic cholecystectomy (0.7% versus 0.2%).³

“This threefold increase will need to be critically followed to ensure the rates decrease,” explained Karen D. Horvath, MD, FACS, a general surgeon at the University of Washington Medical Center–Montlake in Seattle. “I expect that it will decrease. However, if it does not, in my opinion, robotic-assisted cholecystectomy should be thoughtfully reconsidered or even abandoned if necessary.”

In moderate-to-severe acute pancreatitis, which accounts for approximately 10% to 20% of acute pancreatitis patients, the mortality rate ranges from 15% to 30%, with 20% of patients developing necrosis, Dr. Horvath said. The treatment for patients with severe acute biliary pancreatitis is a delayed cholecystectomy.

Severe acute pancreatitis has high morbidity and mortality, and surgical or endoscopic interventions may be necessary for infected necrosis of the pancreas and other complications such as abdominal compartment syndrome, bowel ischemia, and debridement of collections not accessible via transgastric procedures.

Some of the biggest innovations in surgical management of severe acute pancreatitis include ways to debride patients with infected walled-off necrosis, aiming to reduce complications and mortality by minimizing surgical stress in the already critically ill patient. Among these innovations are:

• Video-assisted retroperitoneal debridement procedure, which includes surgical necrosectomy under the direct visualization of a laparoscope (This technique is especially useful in paracolic gutter and pelvic collections.)
• Minimally invasive retroperitoneal pancreatectomy, which is a novel technique developed in the UK where the dead pancreas is surgically removed through the patient’s side using a special operating endoscope
• Transgastric laparoscopic approaches through the lumen of the stomach to remove diseased tissue and connect the stomach to the pancreas, allowing drainage of the pancreas into the stomach (A robotic form of this approach allows for drainage of pancreatic pseudocysts and walled-off pancreatic necrosis.)
• Transgastric endoscopic necrosectomy through a lumen-opposing metal stent

A step-up approach is often applied in which percutaneous drainage is followed, if necessary, by one of these techniques.⁴

“Surgery is reserved for when all else has failed,” said Greg C. Wilson, MD, FACS, an assistant professor of surgery at the University of Cincinnati College of Medicine in Ohio.

Although the trend toward minimally invasive surgery has reduced the operating room role of surgeons for these patients, Dr. Wilson said surgeons should continue to stay engaged in care management decisions.

“We’re surprised all the time. Acute pancreatitis patients can develop catastrophic complications even on the day of discharge,” he said. “We still need to be intimately involved with the decision-making related to these patients, especially when they are inpatients. They can be very complicated.”

Chronic Pancreatitis

Chronic pancreatitis is a longstanding inflammation of the pancreas that leads to irreversible destruction of exocrine and endocrine pancreatic parenchyma and other changes such as strictures, duct stones, and gland atrophy.⁵ Chronic pancreatitis is often confused with recurrent acute pancreatitis, which is a subtype of severe acute pancreatitis.

“Recurrent acute pancreatitis is basically when a patient presents with acute pancreatitis and then has recurrent attacks, like the waves on a seashore,” Dr. Horvath said. “Recurrent acute pancreatitis can eventually lead to chronic pancreatitis.”

In managing chronic pancreatitis, the role of surgery has shifted more to anatomic operations that focus on cancer. While there haven’t been as many major endoscopic innovations in the surgical treatment of chronic pancreatitis, robotic-assisted surgery has helped operations become more minimally invasive.

As a result, relevant surgical training is more focused on anatomic resections, such as the Whipple procedure, which removes the head of the pancreas; distal pancreatectomy, which removes the tail of the pancreas; and some of the duodenal-preserving resections, including the duodenum-preserving pancreatic head resection, a procedure with favorable short-term and long-term outcomes that has become the most common procedure.⁶

There is less emphasis on some of the traditional, less invasive pancreatitis operations, which include draining the pancreatic duct, removing parts of the pancreas, and the Frey procedure, which both drains and removes diseased tissue.

“I routinely do robotic Whipples. That’s probably the biggest kind of breakthrough and emerging technology in the field,” said Dr. Wilson, adding that he also has had exposure to both the traditional and anatomic approaches, offering flexibility for managing patients with chronic pancreatitis.

Another innovation is the total pancreatectomy with islet cell transplantation. This procedure is intended for patients with genetic mutations that put their entire pancreas at risk, or for some patients with recurrent acute pancreatitis.

In the total pancreatectomy with islet cell transplantation procedure, the entire pancreas is removed, then islet cells isolated from the patient’s pancreas are injected into the portal vein and take up residence in the liver. The islet cells help control and secrete hormones that control blood glucose. While less than a third of patients end up truly insulin independent with the operation, it allows most patients to have diabetes that can be controlled with medications. 

Improved Outcomes

The advances and innovations in surgical management of pancreatitis have yielded a dramatic improvement in patient outcomes.

For acute pancreatitis patients, enhancement of critical care techniques, computed tomography (CT) scans, and percutaneous drains and minimally invasive debridement methods such as those described in this article have reduced mortality from 70% to 20%–30% over the last 50 years, according to Dr. Horvath.

“As we move toward later and more minimally invasive interventions, we see that after the patient recovers, pancreatic function is often preserved in a greater way than when we did maximal open surgery,” Dr. Horvath said.

Minimally invasive necrosectomy techniques have improved the long-term endocrine and exocrine functional outcomes as well as wound complications for these patients, which can be quite morbid, she added.

These improvements have not only helped save lives but have brought marked improvements in quality of life.

Surgical management also has improved quality of life and provided pain relief for chronic pancreatitis patients, many of whom are in serious condition at the time of operation.

“These patients will frequently live a life in which they’re just living from one hospitalization to the next,” explained Dr. Wilson “They can’t keep a job because they have too many sick days. An operation or an intervention can improve their quality of life—basically get them back to a life.”

For long-term results, 1 in 3 patients will die within 10 years, according to Dr. Wilson. Among the many causes of death are infections, cardiovascular disease, diabetes, cancer, end-stage liver disease, end-stage renal disease, and suicide. Major causal factors for suicide in this context are psychosocial issues, including narcotic dependence, substance abuse, and mental health. In fact, a key determinant of survival after surgery for chronic pancreatitis is whether or not patients were able to get off their narcotic medications.⁷

Multidisciplinary Care

Multidisciplinary care is important to both types of pancreatitis patients, and this cross-functional approach is especially important to chronic pancreatitis patients before, during, and after surgery.

The medical team may consist of the primary care doctor, gastroenterologist, surgeon, and mental health, pain management, and addiction care specialists.

“There is a plethora of evidence supporting that acute pancreatitis patient outcomes are better with a multidisciplinary team committed to the care of these complex patients,” Dr. Horvath explained.

Chronic pancreatitis patients often have been marginalized by the healthcare system. Even with advanced imaging, it can be difficult to diagnose chronic pancreatitis as compared with a gastrointestinal disorder. The severe abdominal pain experienced by these patients can be difficult to detect by imaging or other diagnostic techniques, so they are often labeled as “narcotics seekers,” Dr. Wilson said.

“They’re suffering, and they’re not getting treatment that’s helping them,” Dr. Wilson said. “They can require a lot of hands-on work—they’re in and out of the hospital, coming back or calling weekly.”

For acute pancreatitis patients, it’s essential to have a multidisciplinary team along the continuum of care, Dr. Horvath said. This team includes surgery, gastroenterology, critical care, internal medicine, and interventional radiology. Numerous studies have shown these multidisciplinary teams produce better morbidity and mortality outcomes and lower patient and health system costs.

“Acute pancreatitis patients are unique in how their disease evolves over time with many unexpected events,” Dr. Horvath said. “They can have catastrophic complications at the drop of a hat, like a pulmonary embolism or a bleeding pseudoaneurysm, as well as complex biliary complications. They benefit from a care team that’s familiar with the disease and all the typical pitfalls.”

Patients with severe acute pancreatitis and some with moderate acute pancreatitis should be transferred to a regional care center for the large-volume experience, she said. In fact, “it’s extremely difficult to understand this disease unless you see a large volume of patients,” explained Dr. Horvath.  

“If we’re going to advance the management of these patients for the benefit of future generations, it will need to happen in large-volume regional centers solely because of the low disease prevalence and extremely unique and nuanced expression of complications,” Dr. Horvath said.

Improved Diagnostics and Preoperative Planning

Advanced imaging, including contrast-enhanced CT scans, magnetic resonance imaging, and endoscopic ultrasound, has been critical in improving the diagnosis of both acute and chronic pancreatitis and in helping to determine the most appropriate surgical procedure for the patient. CT scans, in particular, have completely changed the care of patients with pancreatitis.

Endoscopic ultrasound is an essential and necessary tool of the interventional endoscopist caring for pancreatitis patients, especially for classifying chronic pancreatitis patients.

“You want to make sure that you know the problem you’re dealing with and are not being fooled by something else that’s kind of mimicking it,” said Dr. Wilson.

Genomics also is a valuable diagnostic tool in identifying at-risk patients. For example, for acute pancreatitis patients, genetic testing can determine if the patient has hereditary pancreatitis or familial pancreatitis.

Unlike most forms of pancreatitis, patients with hereditary pancreatitis usually experience symptoms of acute pancreatitis in childhood with recurrent inflammation of the pancreas often progressing to chronic pancreatitis in early adulthood. This cohort has an increased risk (an estimated 40% lifetime risk) of developing pancreatic cancer, so patients with this gene need to be followed with more intensive cancer screening.

Familial pancreatitis is associated with families that have a higher-than-average incidence of pancreatitis and features at least two or more first- or second-degree family members with idiopathic pancreatitis not attributed to obstructive or environmental causes.

In chronic pancreatitis, three genetic mutations can help identify a genetically linked form of the disease. Dr. Wilson said the best approach for these patients is a total pancreatectomy with islet cell transplantation. More research needs to be done to better understand how to use the identification of some common mutations linked to chronic pancreatitis.

Preoperative Risk Stratification and Planning

For moderate-to-several acute pancreatitis patients, a key challenge is to determine when to perform surgery. Although, for most patients, the approach to surgery is to get the patient stronger and healthier before surgery, for severe acute pancreatitis patients, it’s often the weakening patient that is most appropriate for surgery. Although careful attention to nutrition is critical for these patients, often with enteral tube feeds, some patients remain in a catabolic state.

“We often need to go to surgery as the patient is getting weaker and their serum albumin is falling so that we can reverse the tide and get them better,” Dr. Horvath said. “We can’t wait for them to be strong for surgery because they will never be strong.”

For chronic pancreatitis patients, it’s important to optimize the patient’s nutrition before surgery. Often due to their increasing abdominal pain, they have avoided food and lost weight, so their resulting weak nutritional status puts these patients at risk of developing postoperative complications.

In addition, pain management strategies are important for these patients who are already likely to be on pain medicines and narcotics. “This means managing their pain after a big surgery can be quite difficult,” Dr. Wilson said.

Telemedicine Boosts Follow-Up Care

Telemedicine shows promise in helping to follow pancreatitis patients after surgery. For acute pancreatitis patients at the University of Washington in Seattle, Dr. Horvath and her colleagues often use telemedicine, especially for those for whom distance makes an office visit difficult, such as patients who come from rural Washington or surrounding states, including Wyoming, Alaska, Montana, and Idaho.

“Getting them back to their local physicians and their care teams, but still being able to help with next steps in their recovery, is critical to patients and their families,” she said. 

Although Dr. Wilson acknowledges the benefits of telemedicine, including the reduced need for the patient to travel for doctors’ appointments, he worries that some patients might not be willing to speak up on a telemedicine phone call.

“If you’re not seeing them in person, you might not be able to pick up on some of the subtle cues that maybe you need to look into,” he said.

What’s Next?

One of the emerging areas in surgical management of pancreatitis is artificial intelligence and machine learning, which promise to transform preoperative planning.

In acute pancreatitis, using AI to predict the severity of pancreatitis at admission and to indicate when it would be best to intervene and perform surgery rather than wait longer will help save lives and money. Two recent studies indicate that AI can effectively:

• Predict the development of pancreatic necrosis early on, with glucose, C-reactive protein, alkaline phosphatase, gender, and total white blood cell count as important factors in this process (Necrosis was associated with a four-to-eight-fold increased risk of local and systematic complications, severe disease course, and mortality.⁸)
• Plan the timing of the surgical intervention, with interleukin 6, infected necrosis, onset of fever, and C-reactive protein acting as important factors for patients with infected necrotizing pancreatitis⁹

Research using big data will be more effective with tighter classifications, Dr. Wilson explained. In many databases, chronic pancreatitis often is misapplied in patients, he said. Once diagnoses are more refined and accurate, big data will play a key role in future research endeavors.

Other research making strides in managing pancreatitis include the development of biologic agents to potentially treat chronic pancreatitis and optimization of islet cell transplantation so that patients are not insulin-dependent after the operation.

Jim McCartney is a freelance writer.

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