A step-up approach or open necrosectomy for necrotizing pancreatitis

Surgical and interventional management of complications caused by acute pancreatitis

Acute pancreatitis is one of the most common gastrointestinal disorders worldwide. It requires acute hospitalization, with a reported annual incidence of 13 to 45 cases per 100000 persons. In severe cases there is persistent organ failure and a mortality rate of 15% to 30%, whereas mortality of mild pancreatitis is only 0% to 1%. Treatment principles of necrotizing pancreatitis and the role of surgery are still controversial. Despite surgery being effective for infected pancreatic necrosis, it carries the risk of long-term endocrine and exocrine deficiency and a morbidity and mortality rate of between 10% to 40%. Considering high morbidity and mortality rates of operative necrosectomy, minimally invasive strategies are being explored by gastrointestinal surgeons, radiologists, and gastroenterologists. Since 1999, several other minimally invasive surgical, endoscopic, and radiologic approaches to drain and debride pancreatic necrosis have been described. In patients who do not improve after technically adequate drainage, necrosectomy should be performed. When minimal invasive management is unsuccessful or necrosis has spread to locations not accessible by endoscopy, open abdominal surgery is recommended. Additionally, surgery is recognized as a major determinant of outcomes for acute pancreatitis, and there is general agreement that patients should undergo surgery in the late phase of the disease. It is important to consider multidisciplinary management, considering the clinical situation and the comorbidity of the patient, as well as the surgeons experience.

Timing of intervention in necrotizing pancreatitis

BACKGROUND

The best available evidence suggests that surgical intervention should be delayed where possible until four weeks after the onset of pancreatitis. Subgroups that may benefit from early or delayed intervention have not been identified.

METHODS

This study reviewed a prospective database with 223 patients of necrotizing pancreatitis who received intervention. A subgroup analysis was performed to compare the results of different surgical timing.

RESULTS

The median timing of intervention was 32 days. The mortality rates in the early (≤30 days) intervention and delayed intervention (>30 days) groups were 21% (28/136) and 10% (9/87), respectively (P = 0.04). In patients with persistent early organ failure, mortality and re-intervention rates were higher in the early group compared with the delayed group (23/61 vs. 3/21, P = 0.04; 17/61 vs. 2/21, P = 0.01). In patients without persistent early organ failure who underwent treatment, mortality rates, and re-intervention rates were similar between the early group and delayed group (5/75 vs. 6/66, P = 0.59; 7/75 vs. 3/66, P = 0.27). In patients with infected necrosis, mortality rate was similar with the early group and delayed group (17/77 vs. 7/57, P = 0.14).

CONCLUSION

Early intervention in patients without persistent organ failure showed similar outcomes with patients who received delayed intervention.

Endoscopic ultrasound-guided management of pancreatic pseudocysts and walled-off necrosis

The outcome of endoscopic management of pancreatic fluid collections is dependent on the type of collection being treated. While pseudocysts have an excellent treatment response, the outcomes are modest for walled-off pancreatic necrosis. Recent advances in cross-sectional body imaging have enabled a more accurate distinction of pancreatic fluid collections, which, in turn, facilitates the correct triage of patients to receive the appropriate treatment. Newly described endoscopic techniques and the development of dedicated accessories have improved the clinical outcomes in walled-off pancreatic necrosis, with treatment success rates comparable to that of minimally invasive surgery. This review summarizes the key concepts and provides a concise update on the endoscopic management of pancreatic fluid collections.

Endoscopic approach to the diagnosis and treatment of pancreatic disease

PURPOSE OF REVIEW

The purpose of this review is to provide an update on the diagnosis and treatment of pancreatic disorders using endoscopy.

RECENT FINDINGS

The role of endoscopy in the diagnosis and management of pancreatic disorders continues to increase in importance. The use of post-endoscopic retrograde cholangio-pancreatography (ERCP) provides therapy for many pancreatic disorders, including in the treatment of pancreatitis, its complications and pancreatic neoplasia. In recent years, there has been a focus on improving its safety in the prevention of post-ERCP pancreatitis. Pancreatic endotherapy by ERCP for the treatment of biliary strictures and chronic pain in chronic pancreatitis will also be reviewed. Endoscopic ultrasound (EUS) has a vital diagnostic role in pancreatic disorders; however, much of the recent focus has been on its therapeutic role for simple and complex pancreatic fluid collections. As for the role of EUS in pancreatic cancer, recent technical advances in conjunction with on-site cytopathology service continue to improve pancreatic cancer diagnosis. EUS has an increasing role in treatment with fiducial placement for stereotactic body radiation therapy.

SUMMARY

In this review, I will examine the literature over the last year in ERCP and EUS as they apply to specific pancreatic disorders.

Endoscopic ultrasound in the diagnosis and treatment of pancreatic disease

Endoscopic ultrasound (EUS) is an important part of modern gastrointestinal endoscopy and now has an integral role in the diagnostic evaluation of pancreatic diseases. Furthermore, as EUS technology has advanced, it has increasingly become a therapeutic procedure, and the prospect of multiple applications of interventional EUS for the pancreas is truly on the near horizon. However, this review focuses on the established diagnostic and therapeutic roles of EUS that are used in current clinical practice. In particular, the diagnostic evaluation of acute pancreatitis, chronic pancreatitis, cystic pancreatic lesions and solid masses of the pancreas are discussed. The newer enhanced imaging modalities of elastography and contrast enhancement are evaluated in this context. The main therapeutic aspects of pancreatic EUS are then considered, namely celiac plexus block and celiac plexus neurolysis for pain control in chronic pancreatitis and pancreas cancer, and EUS-guided drainage of pancreatic fluid collections.

Treatment options for acute pancreatitis

This Review covers the latest developments in the treatment of acute pancreatitis. The Atlanta Classification of acute pancreatitis has been revised, proposing several new terms and abandoning some of the old and confusing terminology. The 2012 Revised Atlanta Classification and the determinant-based classification aim to universally define the different local and systemic complications and predict outcome. The most important differences between these classifications are discussed. Several promising treatment options for the early management of acute pancreatitis have been tested, including the use of enteral nutrition and antibiotics as well as novel therapies such as haemofiltration and protease inhibitors. The results are summarized and the quality of evidence is discussed. Finally, new developments in the management of patients with infected pancreatic necrosis are addressed, including the use of the 'step-up approach' and results of minimally invasive necrosectomy.

Resolution of walled-off pancreatic necrosis by EUS-guided drainage when using a fully covered through-the-scope self-expandable metal stent in a single procedure (with video)

BACKGROUND

Walled-off pancreatic necrosis (WOPN) is effectively managed with percutaneous and endoscopic techniques such as direct endoscopic necrosectomy. However, they require repeat interventions and lengthy hospital stays.

OBJECTIVE

To evaluate a new platform to manage WOPNs by using a large-bore, through-the-scope, fully covered, self-expandable metal stent (FCSEMS) to overcome the need for repeat interventions and extended hospital stays.

DESIGN

Retrospective, single-center study.

SETTING

Academic tertiary care center.

PATIENTS

Five consecutive patients with symptomatic WOPN underwent EUS-guided drainage of WOPN by using a large-bore FCSEMSs.

INTERVENTIONS

EUS-guided transgastric drainage of WOPN by using a large-bore FCSEMS. Cross-sectional imaging was repeated at 6- to 8-week intervals. The FCSEMS was removed after WOPN resolution.

MAIN OUTCOME MEASUREMENTS

Clinical success, number of repeat interventions, and length of hospital stay.

RESULTS

Five patients (mean age 60 years) with WOPN (mean diameter, 12.3 cm; range 9.8-14.3 cm) underwent drainage with the described technique. Technical and clinical success was achieved in 100% of patients. Direct endoscopic necrosectomy was not required in any patient. The median number of endoscopic procedures was 1. The median length of hospital stay was 1 day. There were no adverse events.

LIMITATIONS

Small, retrospective study.

CONCLUSIONS

The described novel platform facilitates resolution of WOPN with a single procedure, avoiding the need for repeat interventions and lengthy hospital stays.

Applicability of the Clavien-Dindo classification to emergency surgical procedures: a retrospective cohort study on 444 consecutive patients

Background

Patients undergoing emergency surgery have a high risk for surgical complications and death. The Clavien-Dindo classification has been developed and validated in elective general surgical patients, but has not been validated in emergency surgical patients. The aim of the current study was to evaluate the Clavien-Dindo classification of surgical complications in emergency surgical patients and to study preoperative factors for risk stratification that should be included into a database of surgical complications.

Methods

A cohort of 444 consecutive patients having emergency general surgery during a three-month period was retrospectively analyzed. Surgical complications were classified according to the Clavien-Dindo classification. Preoperative risk factors for complications were studied using logistic regression analysis.

Results

Preoperatively 37 (8.3%) patients had organ dysfunctions. Emergency surgical patients required a new definition for Grade IV complications (organ dysfunctions). Only new onset organ dysfunctions or complications that significantly contributed to worsening of pre-operative organ dysfunctions were classified as grade IV complications. Postoperative complications developed in 115 (25.9%) patients, and 14 (3.2%) patients developed grade IV complication. Charlson comorbidity index, preoperative organ dysfunction and the type of surgery predicted postoperative complications.

Conclusions

The Clavien-Dindo classification of surgical complications can be used in emergency surgical patients but preoperative organ dysfunctions should be taken into account when defining postoperative grade IV complications. For risk stratification patients’ comorbidities, preoperative organ dysfunctions and the type of surgery should be taken into consideration.

Laparoscopic necrosectomy in acute necrotizing pancreatitis: Our experience

CONTEXT:

Pancreatic necrosis is a local complication of acute pancreatitis. The development of secondary infection in pancreatic necrosis is associated with increased mortality. Pancreatic necrosectomy is the mainstay of invasive management.

AIMS:

Surgical approach has significantly changed in the last several years with the advent of enhanced imaging techniques and minimally invasive surgery. However, there have been only a few case series related to laparoscopic approach, reported in literature to date. Herein, we present our experience with laparoscopic management of pancreatic necrosis in 28 patients.

MATERIALS AND METHODS:

A retrospective study of 28 cases [20 men, 8 women] was carried out in our institution. The medical record of these patients including history, clinical examination, investigations, and operative notes were reviewed. The mean age was 47.8 years [range, 23-70 years]. Twenty-one patients were managed by transgastrocolic, four patients by transgastric, two patients by intra-cavitary, and one patient by transmesocolic approach.

RESULTS:

The mean operating time was 100.8 min [range, 60-120 min]. The duration of hospital stay after the procedure was 10-18 days. Two cases were converted to open (7.1%) because of extensive dense adhesions. Pancreatic fistula was the most common complication (n = 8; 28.6%) followed by recollection (n = 3; 10.7%) and wound infection (n = 3; 10.7%). One patient [3.6%] died in postoperative period.

CONCLUSIONS:

Laparoscopic pancreatic necrosectomy is a promising and safe approach with all the benefits of minimally invasive surgery and is found to have reduced incidence of major complications and mortality.

Endoscopic interventions for necrotizing pancreatitis

Interventions for necrotizing pancreatitis have undergone a paradigm shift away from open surgical necrosectomy and toward minimally invasive techniques, with endoscopic transmural drainage (ETD) and necrosectomy emerging as principle forms of treatment. Recent multicenter studies, randomized trials, evidence-based guidelines, and consensus statements have endorsed the safety and efficacy of endoscopic and other minimally invasive techniques for the treatment of walled-off necrosis. A comprehensive review of indications, standard and novel approaches, outcomes, complications, and controversies regarding ETD and necrosectomy is presented. Given the inherent challenges and associated risks, endoscopic techniques for the management of necrotizing pancreatitis should be performed at specialized multidisciplinary centers by expert endoscopists well versed in the management of necrotizing pancreatitis.

Systemic Review for The Effectiveness of Current Conservative Treatment in Necrotizing Pancreatitis

The standard treatment of pancreatic necrosis has been surgical necrosectomy. There has been debate on whether early surgical intervention can reduced by infected pancreatic necrosis (IPN). Early emergency laparotomy and multiple organ failure remain associated with high mortality. However, reports have presented during the last 10 years of survival of severe acute pancreatitis with medical management. Large and multicenter study showed that about two thirds of patients with necrotizing pancreatitis can be treated conservatively with relatively low mortality. Patients with IPN benefit from postponding intervention and minimal invasive treatment. We reviewed 4 literatures including 2 Korean institute reseached reports concerning non-surgical, conservative treatments of necrotizing pancreatitis including IPN. Large and multicenter study showed that about two thirds of patients with necrotizing pancreatitis can be treated conservatively with relatively low mortality.

The role of organ failure and infection in necrotizing pancreatitis: a prospective study

OBJECTIVE

To clarify the roles of organ failure and infection in the outcome of necrotizing pancreatitis.

BACKGROUND

Results of previous cohort studies that focused on the roles of infection and organ failure in acute pancreatitis are controversial.

METHODS

In this study, we collected the medical records of 447 patients with necrotizing pancreatitis from January 2009 to June 2012. Data associated with organ failure and infection were analyzed.

RESULTS

The overall mortality rate was 13% (58/447). Intervention was performed in 223 of 447 patients. Among these 223 patients, 134 were confirmed to be with infected necrosis by a positive culture. The mortality rate was 15% (13/89) in the sterile necrosis group and 18% (24/134) in the infected necrosis group (P = 0.52). A multivariate analysis of death predictors indicated that bacteremia (odds ratio [OR] = 2.76, 95% confidence interval [CI], 1.23-5.46, P < 0.001), age (OR = 1.07, 95% CI, 1.03-1.11, P < 0.001), American Society of Anesthesiologists class (OR = 3.56, 95% CI, 1.65-7.18, P = 0.001), persistent organ failure in the first week (OR = 16.72, 95% CI, 7.04-32.56, P < 0.001), and pancreatic necrosis (OR = 1.73, 95% CI, 1.14-2.98, P = 0.008) were significant factors.

CONCLUSIONS

Among patients with necrotizing pancreatitis, the effects of organ failure on mortality are more critical than those of infection. Bacteremia, age, American Society of Anesthesiologists class, persistent organ failure in the first week, and pancreatic necrosis were identified as the predictors of mortality.

Endoscopic transpapillary stenting for pancreatic fistulas after necrosectomy with necrotizing pancreatitis

BACKGROUND

Data concerning the incidence and treatment of pancreatic fistula after necrosectomy in severe acute necrotizing pancreatitis (SAP) are scarce. Our aim was to assess the incidence of pancreatic fistula, and the feasibility and results of endoscopic transpapillary stenting (ETS) in patients with SAP after necrosectomy.

METHODS

From January 2009 to December 2012 twenty-nine consecutive patients with SAP and necrosectomy in Oulu University Hospital were enrolled into this study. Five patients died before ETS because of the rapid progress of the disease and were, therefore, excluded.

RESULTS

ERP was performed for the remaining 24 patients demonstrating fistula in 22/24 patients (92 %). ETS was successful in 23 patients and the fistula closed in all of them after a median of 82 (2-210) days with acceptable morbidity and no procedure-related mortality.

CONCLUSION

All patients after necrosectomy for SAP seem to have internal or external pancreatic fistula. EST aimed at internal drainage of the necrosectomy cavity is a feasible and effective therapy in these patients.

Evolution and results of the surgical management of 143 cases of severe acute pancreatitis in a referral centre

INTRODUCTION

Surgery is the accepted treatment for infected acute pancreatitis, although mortality remains high. As an alternative, a staged management has been proposed to improve results. Initial percutaneous drainage could allow surgery to be postponed, and improve postoperative results. Few centres in Spain have published their results of surgery for acute pancreatitis.

OBJECTIVE

To review the results obtained after surgical treatment of acute pancreatitis during a period of 12 years, focusing on postoperative mortality.

MATERIAL AND METHODS

We have reviewed the experience in the surgical treatment of severe acute pancreatitis (SAP) at Bellvitge University Hospital from 1999 to 2011. To analyse the results, 2 periods were considered, before and after 2005. A descriptive and analytical study of risk factors for postoperative mortality was performed

RESULTS

A total of 143 patients were operated on for SAP, and necrosectomy or debridement of pancreatic and/or peripancreatic necrosis was performed, or exploratory laparotomy in cases of massive intestinal ischemia. Postoperative mortality was 25%. Risk factors were advanced age (over 65 years), the presence of organ failure, sterility of the intraoperative simple, and early surgery (< 7 days). The only risk factor for mortality in the multivariant analysis was the time from the start of symptoms to surgery of<7 days; furthermore, 50% of these patients presented infection in one of the intraoperative cultures.

CONCLUSIONS

Pancreatic infection can appear at any moment in the evolution of the disease, even in early stages. Surgery for SAP has a high mortality rate, and its delay is a factor to be considered in order to improve results.

A comparative evaluation of outcomes of endoscopic versus percutaneous drainage for symptomatic pancreatic pseudocysts

BACKGROUND

Endoscopic drainage (ED) and percutaneous drainage (PD) have largely replaced surgical drainage as the initial approach for symptomatic pseudocysts. However, there are few studies comparing ED and PD.

OBJECTIVE

To compare the outcomes of ED and PD for symptomatic pseudocysts.

DESIGN

Retrospective cohort study.

SETTING

Academic center.

PATIENTS

Adult patients with symptomatic pseudocysts within ≤ 1 cm of the gastric or duodenal wall who underwent ED or PD between 1993 and 2011. Patients with walled-off pancreatic necrosis were excluded.

INTERVENTION

ED or PD.

MAIN OUTCOME MEASUREMENTS

Rates of technical success, procedural adverse events, clinical success, reinterventions, and failure. Other outcomes included the length of hospital stay and number of follow-up abdominal imaging studies.

RESULTS

There were 81 patients, 41 who underwent ED and 40 who underwent PD, with no differences in age, sex, and comorbidity between the 2 groups. There were no differences in the rates of technical success (90.2% vs 97.5%; P = .36), adverse events (14.6% vs 15%; P = .96), and clinical success (70.7% vs 72.5%; P = .86) between ED and PD, respectively. Patients who underwent PD had higher rates of reintervention (42.5% vs 9.8%; P = .001), longer length of hospital stay (14.8 ± 14.4 vs 6.5 ± 6.7 days; P = .001), and median number [quartiles] of follow-up abdominal imaging studies (6 [3.25, 10] vs 4 [2.5, 6]; P = .02) compared with patients who underwent ED.

LIMITATIONS

Single center, retrospective study.

CONCLUSION

ED and PD have similar clinical success rates for symptomatic pseudocysts. However, PD is associated with significantly higher rates of reintervention, longer length of hospital stay, and increased number of follow-up abdominal imaging studies.

Dual-modality drainage of infected and symptomatic walled-off pancreatic necrosis: long-term clinical outcomes

BACKGROUND

Management options for symptomatic and infected walled-off pancreatic necrosis (WOPN) have evolved over the past decade from open surgical necrosectomy to more minimally invasive approaches. We reported the use of a combined percutaneous and endoscopic approach (dual modality drainage [DMD]) for the treatment of symptomatic and infected WOPN, with good short-term outcomes in a small cohort of patients.

OBJECTIVE

To describe the long-term outcomes of 117 patients with symptomatic and infected WOPN treated by DMD.

DESIGN

Review of a prospective, internal review board-approved database.

SETTING

Single, North American, tertiary-care center.

PATIENTS

All patients with symptomatic and infected WOPN treated by DMD at our institution between 2007 and 2012.

INTERVENTION

DMD of symptomatic and infected WOPN.

MAIN OUTCOME MEASUREMENTS

Disease-related mortality, pancreaticocutaneous fistula formation, need for early and late surgical intervention, procedure-related adverse events.

RESULTS

A total of 117 patients underwent DMD for symptomatic and infected WOPN. A total of 103 have completed treatment, with all percutaneous drains removed. Ten patients are still undergoing treatment, and 4 patients died with percutaneous drains in place (3.4% disease-related mortality). For the patients completing therapy, the median duration of follow-up was 749.5 days. No patients required surgical necrosectomy or surgical treatment of DMD-related adverse events; 3 patients required late surgery for pain (n = 2) and gastric outlet obstruction (n = 1). There were no procedure-related deaths. In patients who have completed treatment, percutaneous drains have been removed in 100%; no patients have developed pancreaticocutaneous fistulas.

LIMITATIONS

Single-center design, lack of a comparison group.

CONCLUSION

DMD for symptomatic and infected WOPN results in favorable clinical outcomes; complete avoidance of pancreaticocutaneous fistulae, surgical necrosectomy, and major procedure-related adverse events, while maintaining single-digit disease-related mortality.

Early surgical intervention in severe acute pancreatitis: Central Australian experience

BACKGROUND

Severe acute pancreatitis (SAP) is a disease associated with a high mortality and morbidity; however, many patients survive due to better understanding of the disease and multidisciplinary care. Those who do not respond to intensive care management with persistent multi-organ dysfunction still have a high mortality. There is a role for early surgical intervention in two subsets of critically ill patients: the first, with acute compartment syndrome (ACS) of the abdomen with persisting organ dysfunction despite medical measures to control intra-abdominal pressure; the second, being early infected pancreatic necrosis (IPN) with the presence of gas in the retroperitoneum.

METHODS

The current analysis is an 8-year (2005-2012) study. The data were collected prospectively by the Surgical Department in Alice Springs Hospital. Intensive care data were also sourced from ANZICS CORE (Australia and New Zealand Intensive Care Society and Centre for Outcome and Resource Evaluation) for ICU (intensive care unit) mortality comparison between ICUs of Australia and New Zealand with Alice Springs.

RESULTS

There were 1163 episodes of acute pancreatitis with an annual incidence of 275 per 100 000. Of importance, 114 patients had SAP of whom 42 developed pancreatic necrosis. Eleven patients required surgical intervention. Five patients had decompressive laparotomies for ACS and six patients had laparotomies for IPN. The mortality of patients with SAP was 0%.

CONCLUSIONS

The two subsets of patients with either ACS or early IPN require early surgical intervention either by decompressive laparotomy or open necrosectomy with laparostomy. The authors attribute improved survival in this cohort due to these interventions.

Laparoscopic transgastric necrosectomy for the management of pancreatic necrosis

BACKGROUND

Traditional open necrosectomy for pancreatic necrosis is associated with significant morbidity and mortality. Although minimally invasive techniques have been described and offer some promise, each has considerable limitations. This study assesses the safety and effectiveness of laparoscopic transgastric necrosectomy (LTN), a novel technique for the management of necrotizing pancreatitis.

STUDY DESIGN

Between 2009 and 2013, patients with retrogastric pancreatic necrosis requiring debridement were evaluated for LTN. Debridement was performed via a laparoscopic transgastric approach using 2 to 3 ports and the wide cystgastrostomy left open. Patient demographics, disease severity, operative characteristics, and outcomes were collected and analyzed.

RESULTS

Twenty-one patients (13 men, median age 54 years; interquartile range [IQR] 46 to 62 years) underwent LTN during the study period. The duration between pancreatitis onset and debridement was 65 days (IQR 53 to 124 years). Indications for operation included infection (7 patients) and persistent unwellness (14 patients). Median duration of LTN was 170 minutes (IQR 136 to 199 minutes); there were no conversions. Control of the necrosis was achieved via the single procedure in 19 of 21 patients. Median postoperative hospital stay was 5 days (IQR 3 to 14 days) and the majority (71%) of patients experienced no (n = 9) or only minor postoperative complications (n = 6) by Clavien-Dindo grade. Complications of Clavien-Dindo grade 3 or higher developed in 6 patients, including 1 death (5%). With a median follow-up of 11 months (IQR 7 to 22 months), none of the patients required additional operative debridement or had pancreatic/enteric fistulae or wound complications develop.

CONCLUSIONS

Laparoscopic transgastric necrosectomy is a novel, minimally invasive technique for the management of pancreatic necrosis that allows for debridement in a single operation. When feasible, LTN can reduce the morbidity associated with traditional open necrosectomy and avoid the limitations of other minimally invasive approaches.

Infections and use of antibiotics in patients admitted for severe acute pancreatitis: data from the EPIC II study

BACKGROUND

Infectious complications are frequent in severe acute pancreatitis (SAP) but multinational epidemiologic data are lacking. The aim of the study was to analyze the characteristics of the infectious complications and antimicrobial use in this setting.

METHODS

One-day point prevalence study of infection in critically ill patients (Extended Prevalence of Infection in the ICU-II study), performed in 1,265 ICUs in 75 countries.

RESULTS

Of the 13,796 patients in the study, 159 were admitted with SAP. One-hundred sixteen (73%) had infections: 31% intra-abdominal, 16% extra-abdominal, and 26% both. Gram-negative bacteria were more prevalent than gram-positive organisms, anaerobes, or fungi. Therapeutically, penicillins and other beta-lactams were used most frequently. Prophylactic antibiotics were administered to 24% of the patients with SAP.

CONCLUSIONS

Infections are frequent in patients admitted with SAP; most are intra-abdominal infections. Microbiology is diverse with gram-negative micro-organisms most frequently isolated. Most patients admitted to the ICU for SAP receive antibiotics at some point.

Relationship between stent characteristics and treatment outcomes in endoscopic transmural drainage of uncomplicated pancreatic pseudocysts

BACKGROUND

Transmural stents are placed at endoscopy to drain pancreatic fluid collections. This study evaluated the relationship between stent placement and treatment outcomes in patients undergoing endoscopic transmural drainage of uncomplicated pancreatic pseudocysts.

METHODS

This is a retrospective study of all patients who underwent endoscopic drainage of uncomplicated pancreatic pseudocysts over a 10-year period. After dilating the transmural tracts in the range of 8-15 mm, single or multiple, 7 or 10Fr double-pigtail plastic stents were deployed. The main outcome measure was to evaluate the relationship between stent characteristics and the number of endoscopic interventions required to achieve resolution of the pancreatic pseudocyst (treatment success).

RESULTS

Of 122 patients, 45 (36.9%) had 10Fr stents of which 30 patients (66.7%) had more than one stent; the remaining 77 (63.1%) patients had 7Fr stents of which 56 (72.7%) had more than one stent. The overall treatment success was 94.3%. Treatment was successful in 102 patients (83.6%) with one intervention; 13 patients (10.7%) required re-intervention for successful drainage and 7 patients (5.7%) failed endoscopic treatment. There was no significant difference in the number of interventions required for treatment success between patients with 7 or 10Fr stents (one intervention required in 87.7 vs. 90.5%, respectively; p = 0.766) and between patients with 1 or >1 stent (one intervention required in 88.9 vs. 88.6%, respectively; p = 0.999). On multiple logistic regression analysis, the stent size (OR 1.54; 95% CI 0.23-10.4) and number (OR 1.15; 95% CI 0.25-5.25) were not associated with the number of interventions required for treatment success when adjusted for pseudocyst size, location, drainage modality, the presence or absence of pancreatic duct stent and luminal compression.

CONCLUSIONS

There appears to be no relationship between the number of interventions required for treatment success and stent characteristics in patients undergoing endoscopic transmural drainage of uncomplicated pancreatic pseudocysts.

Prognostic markers in acute pancreatitis

Acute pancreatitis has a mortality rate of 5-10%. Early deaths are mainly due to multiorgan failure and late deaths are due to septic complications from pancreatic necrosis. The recently described 2012 Revised Atlanta Classification and the Determinant Classification both provide a more accurate description of edematous and necrotizing pancreatitis and local complications. The 2012 Revised Atlanta Classification uses the modified Marshall scoring system for assessing organ dysfunction. The Determinant Classification uses the sepsis-related organ failure assessment scoring system for organ dysfunction and, unlike the 2012 Revised Atlanta Classification, includes infected necrosis as a criterion of severity. These scoring systems are used to assess systemic complications requiring intensive therapy unit support and intra-abdominal complications requiring minimally invasive interventions. Numerous prognostic systems and markers have been evaluated but only the Glasgow system and serum CRP levels provide pragmatic prognostic accuracy early on. Novel concepts using genetic, transcriptomic and proteomic profiling and also functional imaging for the identification of specific disease patterns are now required.

Outcomes of pancreatic debridement in acute pancreatitis: analysis of the nationwide inpatient sample from 1998 to 2010

BACKGROUND

The objective of this study was to perform a national review of patients with acute pancreatitis (AP) who undergo pancreatic debridement (PD) to evaluate for risk factors of in-hospital mortality.

METHODS

The Nationwide Inpatient Sample was used to identify patients with AP who underwent PD between 1998 and 2010. Risk factors for in-hospital mortality were assessed with multivariate logistic regression.

RESULTS

From 1998 to 2010, there were 585,978 nonelective admissions with AP, of which 1,783 (.3%) underwent PD. From 1998 to 2010, the incidence of PD decreased from .44% to .25% (P < .01) and PD in-hospital mortality decreased from 29.0% to 15% (P < .05). Of patients undergoing PD, independent factors associated with increased odds of mortality were increased age (odds ratio [OR] 1.04, confidence interval [CI] 1.03 to 1.05; P < .01), sepsis with organ failure (OR 1.76, CI 1.24 to 2.51; P < .01), peptic ulcer disease (OR 1.83, CI 1.02 to 3.30; P < .05), liver disease (OR 2.27, CI 1.36 to 3.78; P < .01), and renal insufficiency (OR 1.78, CI 1.14 to 2.78; P < .05).

CONCLUSIONS

The incidence and operative mortality of PD have decreased significantly over the last decade in the United States with higher odds of dying in patients who are older, with chronic liver, renal, or ulcer disease, and higher rates of sepsis with organ failure.

A contemporary series of patients undergoing open debridement for necrotizing pancreatitis

BACKGROUND

For patients with acute pancreatitis complicated by infected necrosis, minimally invasive techniques have taken hold without substantial comparison with open surgery. We present a contemporary series of open necrosectomies as a benchmark for newer techniques.

METHODS

Using a prospective database, we retrospectively identified consecutive patients undergoing debridement for necrotizing pancreatitis (2006 to 2009). The primary endpoint was in-hospital mortality.

RESULTS

Sixty-eight patients underwent debridement for pancreatic/peripancreatic necrosis. In-hospital mortality was 8.8% (n = 6). Infection (n = 43, 63%) and failure-to-thrive (n = 13, 19%) comprised the most common indications for necrosectomy. The false negative rate (FNR) for infection of percutaneous aspirate was 20.0%. Older age (P = .02), Acute Physiology and Chronic Health Evaluation II score upon admission (P = .03) or preoperatively (P < .01), preoperative intensive care unit admission (P = .01), and postoperative organ failure (P = .03) were associated with mortality.

CONCLUSIONS

Open debridement for necrotizing pancreatitis results in a low mortality, providing a useful comparator for other interventions. Given the high FNR of percutaneous aspirate, debridement should not be predicated on proven infection.

[Acute pancreatitis]

Acute pancreatitis is a potentially fatal disease with individually differing expression of systemic involvement. For this reason early diagnosis with subsequent risk stratification is essential in the clinical management of this frequent gastroenterological disorder. Severe forms of acute pancreatitis occur in approximately 20 % of cases often requiring intensive care monitoring and interdisciplinary therapeutic approaches. In the acute phase adequate fluid replacement and sufficient analgesic therapy is of major therapeutic importance. Concerning the administration of antibiotics and the nutritional support of patients with acute pancreatitis a change in paradigms could be observed in recent years. Furthermore, endoscopic, radiological or surgical interventions can be necessary depending on the severity of the disease and potential complications.

Combined minimally invasive management of infected pancreatic necrosis: a case report

Infected necrosis is a potentially fatal complication of necrotizing pancreatitis. Open surgical debridement is the mainstay management of infected pancreatic necrosis. Over the last decade minimally invasive techniques have been increasingly used for the treatment of infected pancreatic necrosis and their results are encouraging. However, the optimal technique of minimal access necrosectomy and the timing of intervention have not been established yet. Patients with septic complications of acute pancreatitis represent a challenging group which requires individualized management often involving numerous techniques. We report a case of a 52-year-old patient in whom 3 minimally invasive techniques were needed for complete recovery.

Position paper: timely interventions in severe acute pancreatitis are crucial for survival

Severe acute pancreatitis has high mortality, but multiple and timely interventions can improve survival. Early in the course of the disease aggressive fluid resuscitation is needed for the prevention and treatment of shock. In conjunction with leaking capillaries this results in increased tissue edema, which may lead to intra-abdominal hypertension and abdominal compartment syndrome. Invasive hemodynamic monitoring is essential for optimizing fluid therapy while monitoring of intra-abdominal pressure is necessary for identification patients at risk of developing abdominal compartment syndrome. Abdominal compartment syndrome develops usually within the first days after hospitalization. Conservative treatment modalities are useful in prevention but also in the treatment of abdominal compartment syndrome. If conservative management fails surgical decompression of abdomen may be needed. Multiple organ dysfunction syndrome and increased intra-abdominal pressure predispose patients with severe pancreatitis to secondary infections. Extrapancreatic infections predominate during the first week of the disease, whereas infection of pancreatic necrosis usually develops later. Early enteral nutrition reduces the risk of infections whereas advantage of prophylactic antibiotics is lacking evidence. Surgery for infected pancreatic necrosis is associated with high mortality when performed within the first two weeks of the disease. Therefore surgery should be postponed as late as possible, preferably later than four weeks after disease onset.

Laparoscopic pancreatic surgery: An overview of the literature and experiences of a single center

Pancreatic surgery was reported as early as 1898. Since then significant developments have been made in the field of pancreatic resections. In addition, advances in laparoscopic surgery in general have seen the description of this approach in pancreatic surgery with increasing frequency. Although there are no randomized controlled trials, several large series and comparative studies have reported on the short and long term outcome of laparoscopic pancreatic surgery. Furthermore, in the last decade published systematic reviews and meta-analyses have reported on cost effectiveness and outcomes of these procedures.

Acute inflammatory surgical disease

Infectious and inflammatory diseases comprise some of the most common gastrointestinal disorders resulting in hospitalization in the United States. Accordingly, they occupy a significant proportion of the workload of the acute care surgeon. This article discusses the diagnosis, management, and treatment of appendicitis, acute cholecystitis/cholangitis, acute pancreatitis, diverticulitis, and Clostridium difficile colitis.

Endoscopic transluminal necrosectomy in necrotising pancreatitis: a systematic review

OBJECTIVE

We performed a systematic review to assess the outcome of endoscopic transluminal necrosectomy in necrotising pancreatitis with additional focus on indication, disease severity, and methodological quality of studies.

DESIGN

We searched the literature published between January 2005 and June 2013. Cohorts, including patients with (infected) necrotising pancreatitis, undergoing endoscopic necrosectomy were included. Indication, disease severity, and methodological quality were described. The main outcomes were mortality, major complications, number of endoscopic sessions, and definitive successful treatment with endoscopic necrosectomy alone.

RESULTS

After screening 581 papers, 14 studies, including 455 patients, fulfilled the eligibility criteria. All included studies were retrospective analyses except for one randomized, controlled trial. Overall methodological quality was moderate to low (mean 5, range 2-9). Less than 50 % of studies reported on pre-procedural severity of disease: mean APACHE-II score before intervention was 8; organ failure was present in 23 % of patients; and infected necrosis in 57 % of patients. On average, four (range 1-23) endoscopic interventions were performed per patient. With endoscopic necrosectomy alone, definitive successful treatment was achieved in 81 % of patients. Mortality was 6 % (28/460 patients) and complications occurred in 36 % of patients. Bleeding was the most common complication.

CONCLUSIONS

Endoscopic transluminal necrosectomy is an effective treatment for the majority of patients with necrotising pancreatitis with acceptable mortality and complication rates. It should be noted that methodological quality of the available studies is limited and that the combined patient population of endoscopically treated patients is only moderately ill.

A minimally invasive management for abdominal compartment syndrome in severe acute pancreatitis

Three patients with severe acute pancreatitis (SAP) developed into overt abdominal compartment syndrome (ACS) and confirmed or suspected infection of necrotic tissue. We successfully treated these patients by minimally invasive decompression with the assist of laparoscope after the failures of intensive care treatments. This technique we report here may be another safe and effective management for ACS in SAP.

Direct endoscopic necrosectomy: a minimally invasive endoscopic technique for the treatment of infected walled-off pancreatic necrosis and infected pseudocysts with solid debris

INTRODUCTION

Endoscopic transenteric stenting is the standard treatment for pseudocysts, but it may be inadequate for treating infected collections with solid debris. Surgical necrosectomy results in significant morbidity. Direct endoscopic necrosectomy (DEN), a minimally invasive treatment, may be a viable option. This study examined the efficacy and safety of DEN for the treatment of infected walled-off pancreatic necrosis and infected pseudocysts with solid debris.

METHODS

This study was a retrospective analysis of data collected from a prospective database of patients who underwent DEN in the presence of infected walled-off pancreatic necrosis or infected pseudocysts with solid debris from April 2007 to October 2011. DEN was performed as a staged procedure. Endoscopic ultrasonography-guided transgastric stenting was performed during the first session for initial drainage and to establish endoscopic access to the infected collection. In the second session, the drainage tract was dilated endoscopically to allow transgastric passage of an endoscope for endoscopic necrosectomy. Outcome data included technical success, clinical success and complication rates.

RESULTS

Eight patients with infected walled-off pancreatic necrosis or infected pseudocysts with solid debris (mean size 12.5 cm; range 7.8-17.2 cm) underwent DEN. Underlying aetiologies included severe acute pancreatitis (n = 6) and post-pancreatic surgery (n = 2). DEN was technically successful in all patients. Clinical resolution was achieved in seven patients. One patient with recurrent collection opted for surgery instead of repeat endotherapy. No procedural complications were encountered.

CONCLUSION

DEN is a safe and effective minimally invasive treatment for infected walled-off pancreatic necrosis and infected pseudocysts.

Acute pancreatitis--costs for healthcare and loss of production

OBJECTIVE. Severity of acute pancreatitis (AP) can vary from a mild to a fulminant disease with high morbidity and mortality. Cost analysis has, however, hitherto been sparse. The aim of this study was to calculate the cost of acute pancreatitis, both including hospital costs and costs due to loss of production. MATERIAL AND METHODS. All adult patients treated at Skane University Hospital, Lund, during 2009-2010, were included. A severity grading was conducted and cost analysis was performed on an individual basis. RESULTS. Two hundred and fifty-two patients with altogether 307 admissions were identified. Mean age was 60 ± 19 years, and 121 patients (48%) were men. Severe AP (SAP) was diagnosed in 38 patients (12%). Thirteen patients (5%) died. Acute biliary pancreatitis was more costly than alcohol induced AP (p < 0.001). Total costs for treating mild AP (MAP) in patients ≤65 years old was lower (p = 0.001) and costs for SAP was higher (p = 0.024), as compared to older patients. The overall hospital cost and cost for loss of production was per person in mean €5,100 ± 2,400 for MAP and €28,200 ± 38,100 for SAP (p < 0.001). The costs for treating AP during the two-year-long study period were in mean €9,762 ± 19,778 per patient. Extrapolated to a national perspective, the annual financial burden for AP in Sweden would be €38,500,000; corresponding to €4,100,000 per million inhabitants. CONCLUSIONS. The costs of treating AP are high, especially in severe cases with a long ICU stay. These results highlight the need to optimize care and continue the identification and focus on SAP, in order to try to limit organ failure and infectious complications.

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]

Background

Infected necrotising pancreatitis is a potentially lethal disease that nearly always requires intervention. Traditionally, primary open necrosectomy has been the treatment of choice. In recent years, the surgical step-up approach, consisting of percutaneous catheter drainage followed, if necessary, by (minimally invasive) surgical necrosectomy has become the standard of care. A promising minimally invasive alternative is the endoscopic transluminal step-up approach. This approach consists of endoscopic transluminal drainage followed, if necessary, by endoscopic transluminal necrosectomy. We hypothesise that the less invasive endoscopic step-up approach is superior to the surgical step-up approach in terms of clinical and economic outcomes.

Methods/Design

The TENSION trial is a randomised controlled, parallel-group superiority multicenter trial. Patients with (suspected) infected necrotising pancreatitis with an indication for intervention and in whom both treatment modalities are deemed possible, will be randomised to either an endoscopic transluminal or a surgical step-up approach. During a 4 year study period, 98 patients will be enrolled from 24 hospitals of the Dutch Pancreatitis Study Group. The primary endpoint is a composite of death and major complications within 6 months following randomisation. Secondary endpoints include complications such as pancreaticocutaneous fistula, exocrine or endocrine pancreatic insufficiency, need for additional radiological, endoscopic or surgical intervention, the need for necrosectomy after drainage, the number of (re-)interventions, quality of life, and total direct and indirect costs.

Discussion

The TENSION trial will answer the question whether an endoscopic step-up approach reduces the combined primary endpoint of death and major complications, as well as hospital stay and related costs compared with a surgical step-up approach in patients with infected necrotising pancreatitis.

Staged multidisciplinary step-up management for necrotizing pancreatitis

Background

Some 15 per cent of all patients with acute pancreatitis develop necrotizing pancreatitis, with potentially significant consequences for both patients and healthcare services.

Methods

This review summarizes the latest insights into the surgical and medical management of necrotizing pancreatitis. General management strategies for the treatment of complications are discussed in relation to the stage of the disease.

Results

Frequent clinical evaluation of the patient's condition remains paramount in the first 24–72 h of the disease. Liberal goal-directed fluid resuscitation and early enteral nutrition should be provided. Urgent endoscopic retrograde cholangiopancreatography is indicated when cholangitis is suspected, but it is unclear whether this is appropriate in patients with predicted severe biliary pancreatitis without cholangitis. Antibiotic prophylaxis does not prevent infection of necrosis and antibiotics are not indicated as part of initial management. Bacteriologically confirmed infections should receive targeted antibiotics. With the more conservative approach to necrotizing pancreatitis currently advocated, fine-needle aspiration culture of pancreatic or extrapancreatic necrosis will less often lead to a change in management and is therefore indicated less frequently. Optimal treatment of infected necrotizing pancreatitis consists of a staged multidisciplinary ‘step-up’ approach. The initial step is drainage, either percutaneous or transluminal, followed by surgical or endoscopic transluminal debridement only if needed. Debridement is delayed until the acute necrotic collection has become ‘walled-off’.

Conclusion

Outcome following necrotizing pancreatitis has improved substantially in recent years as a result of a shift from early surgical debridement to a staged, minimally invasive, multidisciplinary, step-up approach.

Factors impacting treatment outcomes in the endoscopic management of walled-off pancreatic necrosis

BACKGROUND

Treatment outcomes are suboptimal for patients undergoing endoscopic treatment of walled-off pancreatic necrosis (WOPN). The objective of this study is to identify factors that impact treatment outcomes in this patient subset.

METHODS

This is a retrospective study of patients with WOPN treated endoscopically over 10 years. Patients underwent placement of stents and nasocystic catheters within the necrotic cavity. In select patients, the multiple transluminal gateway technique (MTGT) was adopted to create several openings in the stomach or duodenum to facilitate drainage of necrosis. In patients with disconnected pancreatic duct syndrome (DPDS), the transmural stents were left in place indefinitely to decrease pancreatic fluid collection (PFC) recurrence.

RESULTS

Endoscopic treatment was successful in 53 of 76 (69.7%) patients. Treatment success was higher in patients undergoing MTGT than in those in whom conventional drainage was used (94.4% vs. 62.1%, P = 0.009). On multivariate logistic regression analysis, only MTGT (OR 15.8, 95% CI 1.77-140.8; P = 0.01) and fewer endoscopic sessions being needed (OR 4.0, 95% CI 1.16-14.0; P = 0.03) predicted treatment success. PFC recurrence was significantly lower in patients with indwelling transmural stents than in patients in whom the stents were removed (0 vs. 20.8%; P = 0.02).

CONCLUSIONS

Creating multiple gateways for drainage of necrotic debris improves treatment success, and not removing the transmural stents decreases PFC recurrence in patients undergoing endoscopic drainage of WOPN.

Endoscopic ultrasound-guided transmural drainage of postoperative pancreatic collections

BACKGROUND

Pancreatic leak is a major cause of morbidity after pancreatectomy. Traditionally, peripancreatic fluid collections have been managed by percutaneous or operative drainage. Data for endoscopic ultrasound (EUS)-guided drainage of postoperative fluid collections are limited. Here we report on the safety, efficacy, and timing of EUS-guided drainage of postoperative peripancreatic collections.

STUDY DESIGN

This is a retrospective review of 31 patients who underwent EUS-guided drainage of fluid collections after pancreatic resection. Technical success was defined as successful transgastric deployment of at least one double pigtail plastic stent. Clinical success was defined as resolution of the fluid collection on follow-up CT scan and resolution of symptoms. Early drainage was defined as initial transmural stent placement within 30 days after surgery.

RESULTS

Endoscopic ultrasound-guided drainage was performed effectively with a technical success rate of 100%. Clinical success was achieved in 29 of 31 patients (93%). Nineteen of the 29 patients (65%) had complete resolution of their symptoms and collection with the first endoscopic procedure. Repeat drainage procedures, including some with necrosectomy, were required in the remaining 10 patients, with eventual resolution of collection and symptoms. Two patients who did not achieve durable clinical success required percutaneous drainage by interventional radiology. Seventeen (55%) of 31 patients had successful early drainage completed within 30 days of their operation.

CONCLUSIONS

Endoscopic ultrasound-guided drainage of fluid collections after pancreatic resection is safe and effective. Early drainage (<30 days) of postoperative pancreatic fluid collections was not associated with increased complications in this series.

Extrapancreatic necrosis without pancreatic parenchymal necrosis: a separate entity in necrotising pancreatitis?

OBJECTIVE

In the revised Atlanta classification of acute pancreatitis, the term necrotising pancreatitis also refers to patients with only extrapancreatic fat necrosis without pancreatic parenchymal necrosis (EXPN), as determined on contrast-enhanced CT (CECT). Patients with EXPN are thought to have a better clinical outcome, although robust data are lacking.

METHODS

A post hoc analysis was performed of a prospective multicentre database including 639 patients with necrotising pancreatitis on contrast-enhanced CT. All CECT scans were reviewed by a single radiologist blinded to the clinical outcome. Patients with EXPN were compared with patients with pancreatic parenchymal necrosis (with or without extrapancreatic necrosis). Outcomes were persistent organ failure, need for intervention and mortality. A predefined subgroup analysis was performed on patients who developed infected necrosis.

RESULTS

315 patients with EXPN were compared with 324 patients with pancreatic parenchymal necrosis. Patients with EXPN less often suffered from complications: persistent organ failure (21% vs 45%, p<0.001), persistent multiple organ failure (15% vs 36%, p<0.001), infected necrosis (16% vs 47%, p<0.001), intervention (18% vs 57%, p<0.001) and mortality (9% vs 20%, p<0.001). When infection of extrapancreatic necrosis developed, outcomes between groups were equal (mortality with infected necrosis: EXPN 28% vs pancreatic necrosis 18%, p=0.16).

CONCLUSION

EXPN causes fewer complications than pancreatic parenchymal necrosis. It should therefore be considered a separate entity in acute pancreatitis. Outcome in cases of infected necrosis is similar.

Endoscopic therapy of necrotizing pancreatitis and pseudocysts

Endoscopic therapy has become an essential component in the management of postpancreatitis complications, such as infected and/or symptomatic pancreatic pseudocysts and walled-off necrosis. However, although there have been 2 recent randomized, controlled trials performed, a general lack of comparative effectiveness data regarding the timing, indications, and outcomes of these procedures has been a barrier to the development of practice standards for therapeutic endoscopists managing these issues. This article reviews the available data and expert consensus regarding indications for endoscopic intervention, timing of procedures, endoscopic technique, periprocedural considerations, and complications.