Necrosectomy

What is a necrosectomy?

A necrosectomy is a procedure to remove dead tissue (necrosis) in or around your pancreas. It’s a treatment option for necrotizing pancreatitis. That’s when severe pancreatitis causes tissue death in your pancreas.

Having dead tissue in your body can lead to life-threatening complications. Healthcare providers try to treat necrosis without surgery, if possible. But if you develop complications, you might need surgery.

When is necrosectomy needed?

Your provider might need to remove dead tissue in your body if it causes serious complications, like:

• Infection: Dead tissue attracts roaming bacteria. A local infection inside your body can quickly snowball into a systemic infection (septicemia). That can trigger a life-threatening reaction (sepsis).
• Systemic inflammatory response syndrome (SIRS): Dead tissue also releases chemicals that can trigger a widespread inflammatory reaction (SIRS). This reaction can be life-threatening, as well.

Types of necrosectomy

Healthcare providers take a stepwise approach to necrosectomy. They start with the least invasive methods possible and step up if they need to. Some methods for removing necrotic tissue include:

• Endoscopic transluminal necrosectomy: This method uses an endoscope to access your pancreas from inside your digestive tract. Endoscopic ultrasound helps place a stent between the stomach and pancreatic collection. This can be used to perform necrosectomy one or more times.
• Percutaneous direct endoscopic pancreatic necrosectomy (PDEN): This method uses an existing portal through your skin to access your pancreas with an endoscope and endoscopic tools.
• Video-assisted retroperitoneal debridement (VARD): This method involves placing a laparoscope (video camera) through your flank to access necrotic pancreatic tissues.
• Open necrosectomy: If your condition is severe and you need emergency surgery, a surgeon might need to access your pancreas directly by cutting through your abdomen (laparotomy).

What happens before necrosectomy?

If you don’t respond to noninvasive treatments — like antibiotics or drainage — your provider will plan for a necrosectomy procedure. In some cases, they might want to delay the procedure.

This might be when:

• Inflammation calms down a little: In necrotizing pancreatitis, this typically happens after the first few weeks. It makes it easier to tell healthy tissue from dead tissue.
• Dead tissue separates from healthy tissue: Necrotizing pancreatitis can form distinct fluid collections, separated by thin tissue. These are easier to remove when they’re well-defined.

What happens during a pancreatic necrosectomy?

Your provider will try to complete your necrosectomy in the least invasive way possible. If you’ve already had a drainage procedure, they may use the same portal to do endoscopic drainage.

If this won’t work for you — for example, if your provider can’t access the collection through an endoscope — they’ll “step up” to the next level of surgery. This might mean VARD or open surgery.

Once they’ve accessed the space, your surgeon will carefully remove all the dead tissue they can find. They’ll close your incisions (if you have any). But they might leave a portal in place in case they need it again.

How long does necrosectomy take?

An endoscopic or percutaneous necrosectomy might take one to three hours. If you need VARD or open surgery, it might take two to four hours. It may take longer if your surgeon is managing complications.

It’s important to note that many people will need more than one procedure to remove all the dead tissue. New necrotic fluid collections may continue to develop and mature over the following weeks.

What are the risks of pancreatic necrosectomy?

If you need a pancreatic necrosectomy, you’re already in critical condition. Your body’s resources for recovery are low. In this setting, surgical complications and risks like bleeding and infection can be very dangerous.

Both of these are common. Inflammation from pancreatitis makes it easier for blood vessels to break or get injured in surgery. Low immunity makes it difficult to completely control bacteria during surgery.

If you develop a new bleed or infection from necrosectomy, it can cause further inflammation in your body and further necrosis. In severe cases, it can trigger sepsis or SIRS and multiple organ dysfunction.

This is why healthcare providers are so cautious in their approach to necrosectomy. They only do as much surgery as they have to.

What happens after necrosectomy?

After necrosectomy, you’ll remain under close observation. In cases where a surgical necrosectomy is performed, your provider will leave a drainage tube in place. They’ll use this to flush the site with saline if they need to, or to reoperate.

You may need one or more additional procedures to clear all of the dead tissue out, or to manage complications. For example, a new infection might produce an abscess or fistula that needs treatment.

What is the recovery time?

Your hospital stay after necrosectomy may be one to three weeks. During this time, you’ll have pain medicine and nutrition through a tube. Your care team will continue to monitor you for complications.

Full recovery takes one to three months. During this time, you’ll slowly taper off pain medications and return to your normal eating patterns. Your care team will explain how to care for your surgical drains at home.

When should I call my provider?

Contact your provider if you develop new or red flag symptoms, like:

• Fever and chills
• Nausea or vomiting
• Severe swelling
• Smelly discharge
• Weakness or faintness
• Worsening pain

What is the outlook after pancreatic necrosectomy?

Surgery for necrotizing pancreatitis can be lifesaving, but it isn’t always. About 2 out of 10 people don’t survive. Things like your overall health, how much necrosis you have and complications affect this rate.

After surviving necrotizing pancreatitis, you may have long-term effects from the loss of pancreatic tissue. If you lose a significant portion of your pancreas to necrosis, a partial or total loss of pancreatic function can occur.

This could mean:

• Exocrine pancreatic insufficiency: Your pancreas may have impaired exocrine function. This means it can’t produce the digestive enzymes you need to break down nutrients in your food.
• Diabetes (Type 3c): Your pancreas may have impaired endocrine function. This means it can’t produce the insulin and other hormones you need to keep your blood sugar balanced.

If these conditions develop, you’ll need lifelong care, including insulin or enzyme replacement therapy.