Debridement and closed packing for sterile or infected necrotizing pancreatitis: insights into indications and outcomes in 167 patients. Ann Surg. 2008;247:294-299. [PMID: 18216536 DOI: 10.1097/sla.0b013e31815b6976]

Occurrence and Risk Factors of Infected Pancreatic Necrosis in Intensive Care Unit-Treated Patients with Necrotizing Severe Acute Pancreatitis

BACKGROUND

In patients with severe acute pancreatitis (SAP), infected pancreatic necrosis (IPN) is associated with a worsened outcome. We studied risk factors and consequences of IPN in patients with necrotizing SAP.

METHODS

The study consisted of a retrospective cohort of 163 consecutive patients treated for necrotizing SAP at a university hospital intensive care unit (ICU) between 2010 and 2018.

RESULTS

All patients had experienced at least one persistent organ failure and approximately 60% had multiple organ failure within the first 24 h from admission to the ICU. Forty-seven (28.8%) patients had IPN within 90 days. Independent risk factors for IPN were more extensive anatomical spread of necrotic collections (unilateral paracolic or retromesenteric (OR 5.7, 95% CI 1.5-21.1) and widespread (OR 21.8, 95% CI 6.1-77.8)) compared to local collections around the pancreas, postinterventional pancreatitis (OR 13.5, 95% CI 2.4-76.5), preceding bacteremia (OR 4.8, 95% CI 1.3-17.6), and preceding open abdomen treatment for abdominal compartment syndrome (OR 3.6, 95% CI 1.4-9.3). Patients with IPN had longer ICU and overall hospital lengths of stay, higher risk for necrosectomy, and higher readmission rate to ICU.

CONCLUSIONS

Wide anatomical spread of necrotic collections, postinterventional etiology, preceding bacteremia, and preceding open abdomen treatment were identified as independent risk factors for IPN.

Consensus and controversy among severe pancreatitis surgery guidelines: a guideline evaluation based on the Appraisal of Guidelines for Research and Evaluation II (AGREE II) tool

The purpose of this study was to systematically evaluate guidelines for surgery in patients with severe pancreatitis and to identify gaps limiting evidence-based medicine practice. A systematic search of databases and related websites was conducted to identify surgical guidelines for patients with severe pancreatitis. The quality of the included guidelines was assessed using the Appraisal of Guidelines for Research and Evaluation II (AGREE II) tool. The similarities among key recommendations were compared, and the evidence supporting them was extracted and analysed. Seven surgical guidelines for patients with severe pancreatitis were included. Only two guidelines, those of the World Society of Emergency Surgery (WSES) and the European Society of Gastrointestinal Endoscopy (ESGE), scored more than 60% for overall quality and were worthy of clinical recommendation. We found that the quality of the severe acute pancreatitis surgical guidelines have much room for improvement, especially in the field of application, the participation of stakeholders and editorial independence. The heterogeneity and causes of surgical recommendations were further analysed, and the latest evidence was retrieved. It was found that the surgical guidelines for severe pancreatitis lacked high-quality evidence, some of the recommendations were controversial, and evidence citation was unreasonable. The quality of surgical guidelines for patients with severe pancreatitis varies widely. In the past 5 years, the key recommendations of the surgical guidelines for severe pancreatitis have been somewhat consistent and controversial, and improvement in these existing problems and controversies will be an effective way for developers to upgrade the surgical guidelines for severe pancreatitis.

Severe acute pancreatitis: surgical indications and treatment

Background

Acute pancreatitis (AP) is defined as an acute inflammatory attack of the pancreas of sudden onset. Around 25% of patients have either moderately severe or severe disease with a mortality rate of 15–20%.

Purpose

The aim of this article was to summarize the advances being made in the understanding of this disease and the important role of surgery.

Results and conclusions

An accurate diagnosis should be made a soon as possible, initiating resuscitation with large volume intravenous fluids and oxygen by mask. Predicted severe disease will require intensive monitoring. Most deaths within the first week are due to multi-organ failure; thus, these patients will require intensive therapy unit management. During the second phase of the disease, death is due to local complications arising from the pancreatic inflammation, requiring accurate identification to determine the correct form of treatment. Acute peripancreatic fluid collections arise < 4 weeks after onset of interstitial edematous pancreatitis, not requiring any treatment. Most pancreatic pseudocysts arise > 4 weeks and largely resolve on conservative management. Necrotizing pancreatitis causing acute necrotic collections and later walled-off necrosis will require treatment if symptomatic or infected. Initial endoscopic transgastric or percutaneous drainage will resolve less serious collections but necrosectomy using minimally invasive approaches will be needed for more serious collections. To prevent recurrent attacks of AP, causative factors need to be removed where possible such as cholecystectomy and cessation of alcohol. Future progress requires improved management of multi-organ failure and more effective minimally invasive techniques for the removal of necrosis.

Open necrosectomy is feasible as a last resort in selected cases with infected pancreatic necrosis: a case series and systematic literature review

BACKGROUND

Acute pancreatitis is a common inflammatory pancreatic disorder, often caused by gallstone disease and frequently requiring hospitalization. In 80% of cases, a rapid and favourable outcome is described, while a necrosis of pancreatic parenchyma or extra-pancreatic tissues is reported in 10-20% of patients. The onset of pancreatic necrosis determines a significant increase of early organ failure rate and death that has higher incidence if infection of pancreatic necrosis (IPN) or extra-pancreatic collections occur. IPN always requires an invasive intervention, and, in the last decade, the advent of minimally invasive techniques has gradually replaced the employment of the open traditional approach. We report a series of three severe cases of IPN managed with primary open necrosectomy (ON) and a systematic review of the literature, in order to understand if emergency surgery still has a role in the current clinical practice.

METHODS

From January 2010 to January 2020, 3 cases of IPN were treated in our Academic Department of General and Emergency Surgery. We performed a PubMed MEDLINE search on the ON of IPN, selecting 20 from 654 articles for review.

RESULTS

The 3 cases were male patients with a mean age of 61.3 years. All patients referred to our service complaining an evolving severe clinical condition evocating a sepsis due to IPN. CT scan was the main diagnostic tool. Patients were initially conservatively managed. In consideration of clinical worsening conditions, and at the failure of conservative and minimal invasive treatment, they were, finally, managed with emergency ON. Patients reported no complications nor procedure-related sequelae in the follow-up period.

CONCLUSION

The ON is confirmed to be the last resort, useful in selected severe cases, with a defined timing and in case of proven non-feasibility and no advantage of other minimally invasive approaches.

Step-up approach combined with negative pressure wound therapy for the treatment of severe necrotizing pancreatitis: a case report

A step-up approach and continuous drainage using NPWT was an effective strategy for the treatment of severe necrotizing pancreatitis. A 62-year-old woman developed severe necrotizing pancreatitis after endoscopic retrograde cholangiopancreatography, extending from the left anterior pararenal space to the interior renal pole. Endoscopic transluminal drainage and percutaneous catheter drainage were unsuccessful in controlling the disease. We proceeded with video-assisted retroperitoneal necrosectomy, at the pancreas and splenic hilum, and drainage, with two additional surgical drains located at the left inferior renal pole and, subcutaneously, at the incision wound. NPWT enhanced fluid drainage and facilitated surgical wound closure, which was infected and opened. Four subsequent endoscopic necrosectomy procedures were required, at the site of the draining fistula, to achieve complete resolution of fluid collection and wound closure.

Open necrosectomy combined with continuous positive drainage and prophylactic diverting loop ileostomy for late infected pancreatic necrosis: a retrospective cohort study

Background

To evaluate an innovative open necrosectomy strategy with continuous positive drainage and prophylactic diverting loop ileostomy for the management of late infected pancreatic necrosis (LIPN).

Methods

Consecutive patients were divided into open necrosectomy (ON) group (n = 23), open necrosectomy with colonic segment resection (ON+CSR) group (n = 8) and open necrosectomy with prophylactic diverting loop ileostomy (ON+PDLI) group (n = 11). Continuous positive drainage (CPD) via double-lumen irrigation–suction tube (DLIST) was performed in ON+PDLI group. The primary endpoints were duration of organ failure after surgery, postoperative complication, the rate of re-surgery and mortality. The secondary endpoints were duration of hospitalization, cost, time interval between open surgery and total enteral nutrition (TEN).

Results

The recovery time of organ function in ON+PDLI group was shorter than that in other two groups. Colonic complications occurred in 13 patients (56.5%) in the ON group and 3 patients (27.3%) in the ON+PDLI group (p = 0.11). The length of stay in the ON+PDLI group was shorter than the ON group (p = 0.001). The hospitalization cost in the ON+PDLI group was less than the ON group (p = 0.0052).

Conclusion

ON+PDLI can avoid the intestinal dysfunction, re-ileostomy, the resection of innocent colon and reduce the intraoperative trauma. Despite being of colonic complications before or during operation, CPD + PDLI may show superior effectiveness, safety, and convenience in LIPN.

[Indications for Surgical and Interventional Therapy of Acute Pancreatitis]

BACKGROUND

15 to 20% of patients with acute pancreatitis develop necrosis of the pancreatic parenchyma or extrapancreatic tissue. The disease is associated with a mortality rate of up to 20%. The mainstays of treatment consist of intensive medical care and surgical and interventional therapy.

METHODS

A systematic literature search focused on indications for surgical and interventional therapy of necrotising pancreatitis. 85 articles were analysed for this review. By using the Delphi method, the results were presented to the quality committee for pancreas diseases of the German Society for General and Visceral Surgery and to expert pancreatologists in an interactive conference using plenary voting during the visceral medicine congress 2019 in Wiesbaden. For the finalised recommendations, an agreement of 84% of participants was achieved.

RESULTS

Documented or clinical suspicion of infected, necrotising pancreatitis are indications for surgical and interventional therapy (recommendation grade: strong; evidence grade; low). Sterile necrosis is a less common indication for intervention due to late complications or persistent severe pancreatitis. Invasive interventions should be delayed when possible until four weeks after onset of pancreatitis. Optimal treatment strategy consists of a "step-up approach" (evidence grade: high; recommendation grade: strong). The first step is catheter drainage, followed, if necessary, by minimally invasive surgical or interventional necrosectomy. If minimally invasive techniques do not result in clinical improvement, open necrosectomy is necessary. 35 to 50% of patients are successfully treated with drainage alone. Indications for emergency intervention are bowel perforation, bowel ischemia and bleeding. Surgical decompression of abdominal compartment syndrome is indicated if the patient is refractory to medical treatment and percutaneous drainage. Abscesses and symptomatic pseudocysts are indications for interventional drainage. Early cholecystectomy during index admission is recommended for patients with mild biliary pancreatitis. Cholecystectomy should be delayed after severe, biliary pancreatitis.

CONCLUSION

The recommendations for surgical an interventional therapy of necrotising pancreatitis address the basis of current indications in literature. They should serve in daily practice as a reference standard for decision making in multidisciplinary teams.

Outcomes of Endoscopic and Surgical Pancreatic Necrosectomy: A Single Institution Experience

Pancreatic necrosis can be managed conservatively; however, infection of pancreatic necrosis usually dictates more aggressive management. Our study aimed to assess the outcomes of open pancreatic necrosectomy (OPN) and endoscopic pancreatic necrosectomy (EPN) in a single center. Data from patients undergoing pancreatic necrosectomy at the Geisinger Medical Center from January 1, 2007, to April 25, 2016, were collected and retrospectively analyzed. Cohorts were composed of EPN (n = 22) and OPN (n = 34) groups. The prevalence of preoperative respiratory failure, septic shock, and multiorgan dysfunction syndrome was higher in the OPN group. The OPN group presented with a higher Bedside Index Severity in Acute Pancreatitis score. Postoperative abscess, persistent kidney dysfunction, and death were more frequent in the OPN group. The EPN group had a higher read-mission rate. The results of the univariate analysis for complication and mortality demonstrated that higher mortality and persistent kidney dysfunction were associated with the procedure type, specifically OPN and with a higher Bedside Index Severity in Acute Pancreatitis score. Patients who presented with higher severity of disease underwent an OPN, whereas EPN often was performed successfully in a more benign clinical setting. However, patients with infected necrosis are served best in a tertiary medical facility where multiple treatment modalities are available.

Surgical Transgastric Necrosectomy for Necrotizing Pancreatitis: A Single-stage Procedure for Walled-off Pancreatic Necrosis

OBJECTIVE

The aim of this study was to evaluate the role of surgical transgastric necrosectomy (TGN) for walled-off pancreatic necrosis (WON) in selected patients.

BACKGROUND

WON is a common consequence of severe pancreatitis and typically occurs 3 to 5 weeks after the onset of acute pancreatitis. When symptomatic, it can require intervention.

METHODS

A retrospective review of patients with WON undergoing surgical management at 3 high-volume pancreatic institutions was performed. Surgical indications, intervention timing, technical methodology, and patient outcomes were evaluated. Patients undergoing intervention <30 days were excluded. Differences across centers were evaluated using a P value of <0.05 as significant.

RESULTS

One hundred seventy-eight total patients were analyzed (mean WON diameter = 14 cm, 64% male, mean age = 51 years) across 3 centers. The majority required inpatient admission with a median preoperative length of hospital stay of 29 days (25% required preoperative critical care support). Most (96%) patients underwent a TGN. The median duration of time between the onset of pancreatitis symptoms and operative intervention was 60 days. Thirty-nine percent of the necrosum was infected. Postoperative morbidity and mortality were 38% and 2%, respectively. The median postoperative length of hospital length of stay was 8 days, with the majority of patients discharged home. The median length of follow-up was 21 months, with 91% of patients having complete clinical resolution of symptoms at a median of 6 weeks. Readmission to hospital and/or a repeat intervention was also not infrequent (20%).

CONCLUSION

Surgical TGN is an excellent 1-stage surgical option for symptomatic WON in a highly selected group of patients. Precise surgical technique and long-term outpatient follow-up are mandatory for optimal patient outcomes.

Preoperative endoscopic transpapillary stenting: A solution to preventing and/or treating postsurgical external pancreatic fistula and infection in patients with infected necrotizing pancreatitis

Currently, open surgical necrosectomy is only performed when the step-up approach fails in patients with necrotizing pancreatitis. As a common complication after surgery, external pancreatic fistula often leads to a long hospital stay and increased expenditure. Current therapeutic strategies include conservative management; however, unresponsive patients with pancreatic leaks will frequently require interventions. Existing evidence indicates that endoscopic transpapillary stenting can shorten the duration of external pancreatic fistula; however, the length of conservative treatment in the early stage cannot be avoided. Therefore, endoscopic transpapillary stenting cannot play a decisive role in the treatment and prevention of postsurgical external pancreatic fistula. The authors propose that endoscopic transpapillary stenting before surgery, however, can be used to prevent and treat postsurgical external pancreatic fistula and complications caused by the prolonged maintenance of the drainage tube for abscesses, including retrograde infection, through its physiological drainage effect. This hypothesis has important clinical implications for the accelerated postoperative recovery of patients with necrotizing pancreatitis.

Complications of Percutaneous Drainage in Step-Up Approach for Management of Pancreatic Necrosis: Experience of 10 Years from a Tertiary Care Center

INTRODUCTION

Percutaneous catheter drainage (PCD) as initial intervention in necrotizing pancreatitis has led to improved outcomes and obviated need for surgery in a significant proportion. However, there can be difficulty in accessing deep-seated necrotic collections by percutaneous catheter and complications are likely.

METHODS

The present study involves a retrospective analysis of a prospectively maintained database of patients with necrotizing pancreatitis managed by a step-up approach. All patients who underwent PCD were studied for catheter-related complications.

RESULTS

A total of 707 PCD catheters were used in 314 patients (median 2, interquartile range IQR 1-3). The total number of interventions were 1194 (median 3, IQR 2-5). Enteric communication was seen in 8.9%, of which colonic fistula occurred in 71.4%, duodenal in 17.8%, and jejunal in 10.7% of patients. Majority (78.5%) of the fistulae were managed conservatively by withdrawal of the drain. Operative management was required in 30% of colonic and 40% of duodenal fistulae. Need for surgery, length of hospital stay, and mortality were not significantly different between patients with and without fistulae. Bleeding complications were seen in 7.3% of patients, out of which 34.7% were managed conservatively, 21.7% required angioembolization of pseudo-aneurysms, and 34.7% needed surgery. Patients with bleeding had significantly higher requirement for surgery and mechanical ventilation compared to those with no bleeding. There was no significant increase in hospital stay, ICU stay, and mortality.

CONCLUSION

Hollow viscus and vascular injuries are important complications seen with catheter drainage of necrotic collections. Majority of patients with enteric communication were managed conservatively, with no added morbidity or mortality. Bleeding complications related to PCD had higher requirement for surgical intervention, but mortality rates remained similar to those of patients with no bleeding complications.

American Gastroenterological Association Clinical Practice Update: Management of Pancreatic Necrosis

DESCRIPTION

The purpose of this American Gastroenterological Association (AGA) Institute Clinical Practice Update is to review the available evidence and expert recommendations regarding the clinical care of patients with pancreatic necrosis and to offer concise best practice advice for the optimal management of patients with this highly morbid condition.

METHODS

This expert review was commissioned and approved by the AGA Institute Clinical Practice Updates Committee and the AGA Governing Board to provide timely guidance on a topic of high clinical importance to the AGA membership, and underwent internal peer review by the Clinical Practice Updates Committee and external peer review through standard procedures of Gastroenterology. This review is framed around the 15 best practice advice points agreed upon by the authors, which reflect landmark and recent published articles in this field. This expert review also reflects the experiences of the authors, who are advanced endoscopists or hepatopancreatobiliary surgeons with extensive experience in managing and teaching others to care for patients with pancreatic necrosis. BEST PRACTICE ADVICE 1: Pancreatic necrosis is associated with substantial morbidity and mortality and optimal management requires a multidisciplinary approach, including gastroenterologists, surgeons, interventional radiologists, and specialists in critical care medicine, infectious disease, and nutrition. In situations where clinical expertise may be limited, consideration should be given to transferring patients with significant pancreatic necrosis to an appropriate tertiary-care center. BEST PRACTICE ADVICE 2: Antimicrobial therapy is best indicated for culture-proven infection in pancreatic necrosis or when infection is strongly suspected (ie, gas in the collection, bacteremia, sepsis, or clinical deterioration). Routine use of prophylactic antibiotics to prevent infection of sterile necrosis is not recommended. BEST PRACTICE ADVICE 3: When infected necrosis is suspected, broad-spectrum intravenous antibiotics with ability to penetrate pancreatic necrosis should be favored (eg, carbapenems, quinolones, and metronidazole). Routine use of antifungal agents is not recommended. Computed tomography-guided fine-needle aspiration for Gram stain and cultures is unnecessary in the majority of cases. BEST PRACTICE ADVICE 4: In patients with pancreatic necrosis, enteral feeding should be initiated early to decrease the risk of infected necrosis. A trial of oral nutrition is recommended immediately in patients in whom there is absence of nausea and vomiting and no signs of severe ileus or gastrointestinal luminal obstruction. When oral nutrition is not feasible, enteral nutrition by either nasogastric/duodenal or nasojejunal tube should be initiated as soon as possible. Total parenteral nutrition should be considered only in cases where oral or enteral feeds are not feasible or tolerated. BEST PRACTICE ADVICE 5: Drainage and/or debridement of pancreatic necrosis is indicated in patients with infected necrosis. Drainage and/or debridement may be required in patients with sterile pancreatic necrosis and persistent unwellness marked by abdominal pain, nausea, vomiting, and nutritional failure or with associated complications, including gastrointestinal luminal obstruction; biliary obstruction; recurrent acute pancreatitis; fistulas; or persistent systemic inflammatory response syndrome. BEST PRACTICE ADVICE 6: Pancreatic debridement should be avoided in the early, acute period (first 2 weeks), as it has been associated with increased morbidity and mortality. Debridement should be optimally delayed for 4 weeks and performed earlier only when there is an organized collection and a strong indication. BEST PRACTICE ADVICE 7: Percutaneous drainage and transmural endoscopic drainage are both appropriate first-line, nonsurgical approaches in managing patients with walled-off pancreatic necrosis (WON). Endoscopic therapy through transmural drainage of WON may be preferred, as it avoids the risk of forming a pancreatocutaneous fistula. BEST PRACTICE ADVICE 8: Percutaneous drainage of pancreatic necrosis should be considered in patients with infected or symptomatic necrotic collections in the early, acute period (<2 weeks), and in those with WON who are too ill to undergo endoscopic or surgical intervention. Percutaneous drainage should be strongly considered as an adjunct to endoscopic drainage for WON with deep extension into the paracolic gutters and pelvis or for salvage therapy after endoscopic or surgical debridement with residual necrosis burden. BEST PRACTICE ADVICE 9: Self-expanding metal stents in the form of lumen-apposing metal stents appear to be superior to plastic stents for endoscopic transmural drainage of necrosis. BEST PRACTICE ADVICE 10: The use of direct endoscopic necrosectomy should be reserved for those patients with limited necrosis who do not adequately respond to endoscopic transmural drainage using large-bore, self-expanding metal stents/lumen-apposing metal stents alone or plastic stents combined with irrigation. Direct endoscopic necrosectomy is a therapeutic option in patients with large amounts of infected necrosis, but should be performed at referral centers with the necessary endoscopic expertise and interventional radiology and surgical backup. BEST PRACTICE ADVICE 11: Minimally invasive operative approaches to the debridement of acute necrotizing pancreatitis are preferred to open surgical necrosectomy when possible, given lower morbidity. BEST PRACTICE ADVICE 12: Multiple minimally invasive surgical techniques are feasible and effective, including videoscopic-assisted retroperitoneal debridement, laparoscopic transgastric debridement, and open transgastric debridement. Selection of approach is best determined by pattern of disease, physiology of the patient, experience and expertise of the multidisciplinary team, and available resources. BEST PRACTICE ADVICE 13: Open operative debridement maintains a role in the modern management of acute necrotizing pancreatitis in cases not amenable to less invasive endoscopic and/or surgical procedures. BEST PRACTICE ADVICE 14: For patients with disconnected left pancreatic remnant after acute necrotizing mid-body necrosis, definitive surgical management with distal pancreatectomy should be undertaken in patients with reasonable operative candidacy. Insufficient evidence exists to support the management of the disconnected left pancreatic remnant with long-term transenteric endoscopic stenting. BEST PRACTICE ADVICE 15: A step-up approach consisting of percutaneous drainage or endoscopic transmural drainage using either plastic stents and irrigation or self-expanding metal stents/lumen-apposing metal stents alone, followed by direct endoscopic necrosectomy, and then surgical debridement is reasonable, although approaches may vary based on the available clinical expertise.

Ultrasonic Pressure Ballistic System-Assisted Minimally Invasive Pancreatic Necrosectomy for Necrotizing Pancreatitis

Background: Although minimally invasive pancreatic necrosectomy (MIPN) is a new invasive technique for necrotizing pancreatitis, it has some disadvantages. This study aimed to improve the debridement technique with an ultrasonic pressure ballistic system. We hypothesized that this system would facilitate debridement and improve the safety of the procedure. Materials and Methods: Between October 2016 and January 2019, 5 patients diagnosed with necrotizing pancreatitis were enrolled in the clinical cohort. All patients underwent debridement due to infective necrosis. Access for debridement was typically established with percutaneous puncture. Then MIPN was performed. During the procedure, ultrasonic pressure was applied to liquefy the necrotic material and make it absorbable. The effect of debridement was assessed by analyzing the average bleeding volume, operation time, and complications. Postoperative clinical parameters were evaluated. Results: Debridement was performed successfully for all patients. Semisolid necrotic tissue was dissolved with ultrasonic pressure. Viscous pus was rapidly aspirated with the suction applied with negative pressure, which greatly enhanced efficiency. This approach enhanced the visibility of blood vessels, which improved safety. No major complications were encountered. Two patients (40%) developed puncture site infections. The average blood loss during the operation was 13 ± 6 mL. The average operation time was 78 ± 31 minutes. Postoperative APACHE II scores were significantly lower than preoperative scores (P < .05). White blood cells, C-reactive protein, and procalcitonin levels declined postoperatively. Conclusions: The ultrasonic pressure ballistic system could potentially enhance MIPN and make it safer.

Current status of diagnosis and Mesenchymal stem cells therapy for acute pancreatitis

Acute pancreatitis (AP) is an acute gastrointestinal disorder that is the most common and requiring emergency hospitalization. Its incidence is increasing worldwide, thus increasing the burden of medical services. Approximately 20% of the patients develop moderate to severe necrotizing pancreatitis associated with pancreatic or peri-pancreatic tissue necrosis and multiple organ failure. There are many reports about the anti-inflammatory effect of mesenchymal stem cells (MSCs) on pancreatitis and the repair of tissue damage. MSCs cells come from a wide range of sources, autologous MSCs come from bone marrow and allogeneic MSCs such as umbilical cord blood MSCs, placenta-derived MSCs, etc. The wide source is not only an advantage of MSCs but also a disadvantage of MSCs. Because of different cell sources and different methods of collection and preparation, it is impossible to establish a unified standard method for evaluation of efficacy. The biggest advantage of iMSCs is that it can be prepared by a standardized process, and can be prepared on a large scale, which makes it easier to commercialize. This paper reviews the present status of diagnosis and progress of MSCs therapy for AP.

Together We Stand, Divided We Fall: A Multidisciplinary Approach in Complicated Acute Pancreatitis

Acute pancreatitis (AP) is an inflammatory condition with a mild course in most patients, but 20-30% evolve to single or multiple organ dysfunction and pancreatic/peripancreatic necrosis, with potentially infected collections. In the first weeks of disease, a systemic inflammatory syndrome (SIRS) dominates the clinical setting, and early management decisions in this precocious phase can change the course of the disease. Imaging is crucial in the diagnosis, and since the adoption of the revised Atlanta classification, four different types of pancreatic/peripancreatic collections have been defined. The management of the complicated forms of AP has been defined by several treatment guidelines, and the main indication for intervention is local infection, preferably in walled-off necrosis. Open surgery necrosectomy is associated with a very high rate of morbimortality, giving a place to different multidisciplinary methodologies, emphasizing drainage and necrosectomy techniques in a "step-up" approach starting from mini-invasive endoscopic drainage and moving, if needed, to progressively more invasive techniques, including interventional radiology and mini-invasive surgery. With the advent of several new technologies in the specialties involved, the complicated AP cases which need drainage and necrosectomy benefit from a new era of multidisciplinary cooperation, permitting higher efficacy with lower levels of morbimortality and reducing hospital stay and costs.

Adverse clinical outcomes associated with multidrug-resistant organisms in patients with infected pancreatic necrosis

BACKGROUND

Multidrug-resistant organisms (MDROs) is becoming a serious worldwide threat to public health. However, the impact of MDROs on the outcomes of the patients with infected pancreatic necrosis (IPN) remains unclear. This study aims to evaluate the roles of MDROs in IPN.

METHODS

A prospectively maintained database of 188 patients with IPN between January 2010 and May 2019 was analyzed. The microbiology profile of organisms isolated from wall-off necrosis (WON) was specifically investigated to correlate with the outcomes of the patients.

RESULTS

Of the 188 patients with IPN, 108 patients (57.4%) had MDROs detected in aspirates from WON. Carbapenem-resistant Klebsiella pneumoniae (CRKP) accounted for 43.5% of the MDROs isolated (60/138), followed by Carbapenem-resistant Acinetobacter baumanii (CRAB) (34.8%, 48/138) and Escherichia coli producing an extended-spectrum beta-lactamase (ESBLp) (6.5%, 9/138). MDROs infection was associated with higher mortality (35.2% vs 11.3%, P < 0.001), higher rate of hemorrhage (36.1% vs 11.3%, P < 0.001), longer intensive care unit (ICU) stay (23 vs 12 days, P < 0.001), longer hospital stay (68 vs 51 days, P = 0.001) and more hospitalization expenses (45,190 ± 31,680 vs 26,965 ± 17,167 $, P < 0.001). Multivariate analysis of predictors of mortality indicated that MDROs infection (OR = 2.6; 95% confidence interval [CI], 1.0-6.5; P = 0.042), age ≥ 50 years (OR = 2.6; 95% CI, 1.2-5.8; P = 0.016), severe category (OR = 2.9; 95% CI, 1.1-8.0; P = 0.035), bloodstream infection (OR = 3.4; 95% CI, 1.5-7.6; P = 0.049), step-down surgical approach (OR = 2.7; 95% CI, 1.1-6.2; P = 0.023) were significant factors.

CONCLUSIONS

MDROs infection was prevalent among patients with IPN and associated with adverse clinical outcomes and increased mortality.

Predictors of outcome of percutaneous catheter drainage in patients with acute pancreatitis having acute fluid collection and development of a predictive model

BACKGROUND

Percutaneous catheter drainage (PCD) is effective initial strategy in the step-up approach of management of acute pancreatitis (AP). The objective of this study was to identify factors associated with outcomes after PCD and develop a predictive model.

METHOD AND MATERIALS

In a prospective observational study between July 2016 and Nov 2017, 101 consecutive AP patients were treated using a "step-up approach" in which PCD was used as the first step. We evaluated the association between success of PCD (survival without necrosectomy) and baseline parameters viz. etiology, demography, severity scores, C-reactive protein (CRP), and intra-abdominal pressure (IAP), morphologic characteristics on computed tomography (CT) [percentage of necrosis, CT severity index (CTSI), characteristics of collection prior to PCD (volume, site and solid component of the collection), PCD parameters (initial size, maximum size, number and duration of drainage) and factors after PCD insertion (fall in IAP, reduction in volume of collection).

RESULTS

Among 101 patients, 51 required PCD. The success rate of PCD was 66.66% (34/51). Four patients required additional surgical necrosectomy after PCD. Overall mortality was 29.4% (15/51). Multivariate analysis showed percentage of volume reduction of fluid collection (p = 0.016) and organ failure (OF) resolution (p = 0.023) after one week of PCD to be independent predictors of success of PCD. A predictive model based on these two factors resulted in area under curve (AUROC) of 0.915. Nomogram was developed with these two factors to predict the probability of success of PCD.

CONCLUSION

Organ failure resolution and reduction in volume of collection after one week of PCD are significant predictors of successful PCD outcomes in patients with fluid collection following AP.

Management of infected pancreatic necrosis in the intensive care unit: a narrative review

BACKGROUND

Severe acute pancreatitis is marked by organ failure and (peri)pancreatic necrosis with local complications such as infected necrosis. Infection of these necrotic collections together with organ failure remain the major causes of admission to an intensive care unit (ICU) in acute pancreatitis. Appropriate treatment of infected necrosis is essential to reduce morbidity and mortality. Overall knowledge of the treatment options within a multidisciplinary team-with special attention to the appropriate use of antimicrobial therapy and invasive treatment techniques for source control-is essential in the treatment of this complex disease.

OBJECTIVES

To address the current state of microbiological diagnosis, antimicrobial treatment, and source control for infected pancreatic necrosis in the ICU.

SOURCES

A literature search was performed using the Medline and Cochrane libraries for articles subsequent to 2003 using the keywords: infected necrosis, pancreatitis, intensive care medicine, treatment, diagnosis and antibiotic(s).

CONTENT

This narrative review provides an overview of key elements of diagnosis and treatment of infected pancreatic necrosis in the ICU.

IMPLICATIONS

In pancreatic necrosis it is essential to continuously (re)evaluate the indication for antimicrobial treatment and invasive source control. Invasive diagnostics (e.g. through fine-needle aspiration, FNA), preferably prior to the start of broad-spectrum antimicrobial therapy, is advocated. Antimicrobial stewardship principles apply: paying attention to altered pharmacokinetics in the critically ill, de-escalation of broad-spectrum therapy once cultures become available, and early withdrawal of antibiotics once source control has been established. This is important to prevent the development of antimicrobial resistance, especially in a group of patients who may require repeated courses of antibiotics during the prolonged course of their illness.

2019 WSES guidelines for the management of severe acute pancreatitis

Although most patients with acute pancreatitis have the mild form of the disease, about 20-30% develops a severe form, often associated with single or multiple organ dysfunction requiring intensive care. Identifying the severe form early is one of the major challenges in managing severe acute pancreatitis. Infection of the pancreatic and peripancreatic necrosis occurs in about 20-40% of patients with severe acute pancreatitis, and is associated with worsening organ dysfunctions. While most patients with sterile necrosis can be managed nonoperatively, patients with infected necrosis usually require an intervention that can be percutaneous, endoscopic, or open surgical. These guidelines present evidence-based international consensus statements on the management of severe acute pancreatitis from collaboration of a panel of experts meeting during the World Congress of Emergency Surgery in June 27-30, 2018 in Bertinoro, Italy. The main topics of these guidelines fall under the following topics: Diagnosis, Antibiotic treatment, Management in the Intensive Care Unit, Surgical and operative management, and Open abdomen.

Short- and long-term survival after severe acute pancreatitis: A retrospective 17 years' cohort study from a single center

PURPOSE

To study mortality in severe acute pancreatitis (SAP) and to identify risk factors for mortality.

MATERIALS AND METHODS

A retrospective 17-years' cohort study of 435 consecutive adult patients with SAP treated at intensive care unit of a university hospital.

RESULTS

Overall, 357 (82.1%) patients survived at 90 days follow-up. Three-hundred six (89.5%) patients under 60 years, 38 (60.3%) patients between 60 and 69 years, and 13 (43.3%) patients over 69 years of age survived at 90 days follow-up. Independent risk factors for death within 90-days were: 60 to 69 years of age (odds ratio [OR] 5.1), >69 years of age (OR 10.4), female sex (OR 2.0), heart disease (OR 2.9), chronic liver failure (OR 12.3), open abdomen treatment (OR 4.4) and sterile necrosectomy within 4 weeks (OR 14.7). The 10-year survival estimate was <70% in patients under 60 years and <30% in patients over 60 years. Underlying cause of death after the initial 90-day follow-up period was alcohol-related in 48 (57.1%) patients, and all of them had suffered from alcoholic SAP.

CONCLUSIONS

Although younger patients have excellent short-term survival after SAP, the long-term survival estimate is disappointing mostly due to alcohol abuse.

Outcomes of infected pancreatic necrosis complicated with duodenal fistula in the era of minimally invasive techniques

Background: Duodenal fistula (DF) was reportedly thought to be the second most common type of gastrointestinal fistula secondary to acute necrotizing pancreatitis. However, infected pancreatic necrosis (IPN) associated DF (IPN-DF) was rarely specifically reported in the literature. The outcome of IPN-DF was also less well recognized, especially in the era of minimally invasive techniques. A retrospective cohort study was designed mainly focused on the management and outcomes of IPN-DF in the era of minimally invasive techniques. Methods: One hundred and twenty-one consecutive patients diagnosed with IPN between January 2015 and May 2018 were enrolled retrospectively. Among them, 10 patients developed DF. The step-up minimal invasive techniques were highlighted and outcomes were analyzed. Results: Compared with patients without IPN-DF, patients with IPN-DF had longer hospital stay (95.8 vs. 63.5 days, p < .01), but similar mortality rates (10% vs. 21.6%, p > .05). The median interval between the onset of acute pancreatitis (AP) and detection of DF was 2.4 months (1-4 months). The median duration of DF was 1.5 months (0.5-3 months). Out of the 10 patients with DF, 9 had their fistulas resolve spontaneously over time by means of controlling the source of infection with the use of minimally invasive techniques and providing enteral nutritional support, while one patient died of uncontrolled sepsis. No open surgery was performed. On follow-up, the 9 patients recovered completely and remained free of infection and leakage. Conclusion: IPN-DF could be managed successfully using minimally invasive techniques in specialized acute pancreatitis (AP) center. Patients with IPN-DF suffered from a longer hospital stay, but similar mortality rate compared with patients without DF.

Current Concepts in Severe Acute and Necrotizing Pancreatitis: An Evidence-Based Approach

The incidence of acute pancreatitis continues to rise, inducing substantial medical and social burden, with annual costs exceeding $2 billion in the United States alone. Although most patients develop mild pancreatitis, 20% develop severe and/or necrotizing pancreatitis, requiring advanced medical and interventional care. Morbidity resulting from local and systemic complications as well as invasive interventions result in mortality rates historically as high as 30%. There has been substantial evolution of strategies for interventions in recent years, from open surgery to minimally invasive surgical and endoscopic step-up approaches. In contrast to the advances in invasive procedures for complications, early management still lacks curative options and consists of adequate fluid resuscitation, analgesics, and monitoring. Many challenges remain, including comprehensive management of the entire spectrum of the disease, which requires close involvement of multiple disciplines at specialized centers.

Pancreatic necrosis: Complications and changing trend of treatment

Incidence of acute pancreatitis seems to be increasing in the Western countries and has been associated with significantly increased morbidity. Nearly 80% of the patients with acute pancreatitis undergo resolution; some develop complications including pancreatic necrosis. Infection of pancreatic necrosis is the leading cause of death in these patients. A significant portion of these patients needs surgical interventions. Traditionally, the “gold standard” procedure has been the open surgical necrosectomy, which is now being completed by the relatively lesser invasive interventions. Minimally invasive surgical (MIS) procedures include endoscopic drainage, percutaneous image-guided catheter drainage, and retroperitoneal drainage. This review article discusses the open and MIS interventions for pancreatic necrosis with each having its own respective benefits and disadvantages are covered.

Postponed or immediate drainage of infected necrotizing pancreatitis (POINTER trial): study protocol for a randomized controlled trial

Background

Infected necrosis complicates 10% of all acute pancreatitis episodes and is associated with 15–20% mortality. The current standard treatment for infected necrotizing pancreatitis is the step-up approach (catheter drainage, followed, if necessary, by minimally invasive necrosectomy). Catheter drainage is preferably postponed until the stage of walled-off necrosis, which usually takes 4 weeks. This delay stems from the time when open necrosectomy was the standard. It is unclear whether such delay is needed for catheter drainage or whether earlier intervention could actually be beneficial in the current step-up approach. The POINTER trial investigates if immediate catheter drainage in patients with infected necrotizing pancreatitis is superior to the current practice of postponed intervention.

Methods

POINTER is a randomized controlled multicenter superiority trial. All patients with necrotizing pancreatitis are screened for eligibility. In total, 104 adult patients with (suspected) infected necrotizing pancreatitis will be randomized to immediate (within 24 h) catheter drainage or current standard care involving postponed catheter drainage. Necrosectomy, if necessary, is preferably postponed until the stage of walled-off necrosis, in both treatment arms. The primary outcome is the Comprehensive Complication Index (CCI), which covers all complications between randomization and 6-month follow up. Secondary outcomes include mortality, complications, number of (repeat) interventions, hospital and intensive care unit (ICU) lengths of stay, quality-adjusted life years (QALYs) and direct and indirect costs. Standard follow-up is at 3 and 6 months after randomization.

Discussion

The POINTER trial investigates if immediate catheter drainage in infected necrotizing pancreatitis reduces the composite endpoint of complications, as compared with the current standard treatment strategy involving delay of intervention until the stage of walled-off necrosis.

Trial registration

ISRCTN, 33682933. Registered on 6 August 2015. Retrospectively registered.

Electronic supplementary material

The online version of this article (10.1186/s13063-019-3315-6) contains supplementary material, which is available to authorized users.

Outcomes of Infected versus Symptomatic Sterile Walled-Off Pancreatic Necrosis Treated with a Minimally Invasive Therapy

BACKGROUND/AIMS

Acute pancreatitis complicated by walled-off necrosis (WON) is associated with high morbidity and mortality, and if infected, typically necessitates intervention. Clinical outcomes of infected WON have been described as poorer than those of symptomatic sterile WON. With the evolution of minimally invasive therapy, we sought to compare outcomes of infected to symptomatic sterile WON.

METHODS

We performed a retrospective cohort study examining patients who were undergoing dual-modality drainage as minimally invasive therapy for WON at a high-volume tertiary pancreatic center. The main outcome measures included mortality with a drain in place, length of hospital stay, admission to intensive care unit, and development of pancreatic fistulae.

RESULTS

Of the 211 patients in our analysis, 98 had infected WON. The overall mortality rate was 2.4%. Patients with infected WON trended toward higher mortality although not statistically significant (4.1% vs 0.9%, p=0.19). Patients with infected WON had longer length of hospitalization (29.8 days vs 17.3 days, p<0.01), and developed more spontaneous pancreatic fistulae (23.5% vs 7.8%, p<0.01). Multivariate analysis showed that infected WON was associated with higher odds of spontaneous pancreatic fistula formation (odds ratio, 2.65; 95% confidence interval, 1.20 to 5.85).

CONCLUSIONS

This study confirms that infected WON has worse outcomes than sterile WON but also demonstrates that WON, once considered a significant cause of death, can be treated with good outcomes using minimally invasive therapy.

An Endoscopic Transluminal Approach, Compared With Minimally Invasive Surgery, Reduces Complications and Costs for Patients With Necrotizing Pancreatitis

BACKGROUND & AIMS

Infected necrotizing pancreatitis is a highly morbid disease with poor outcomes. Intervention strategies have progressed from open necrosectomy to minimally invasive approaches. We compared outcomes of minimally invasive surgery vs endoscopic approaches for patients with infected necrotizing pancreatitis.

METHODS

We performed a single-center, randomized trial of 66 patients with confirmed or suspected infected necrotizing pancreatitis who required intervention from May 12, 2014, through March 24, 2017. Patients were randomly assigned to groups that received minimally invasive surgery (laparoscopic or video-assisted retroperitoneal debridement, depending on location of collection, n = 32) or an endoscopic step-up approach (transluminal drainage with or without necrosectomy, n = 34). The primary endpoint was a composite of major complications (new-onset multiple organ failure, new-onset systemic dysfunction, enteral or pancreatic-cutaneous fistula, bleeding and perforation of a visceral organ) or death during 6 months of follow-up.

RESULTS

The primary endpoint occurred in 11.8% of patients who received the endoscopic procedure and 40.6% of patients who received the minimally invasive surgery (risk ratio 0.29; 95% confidence interval 0.11-0.80; P = .007). Although there was no significant difference in mortality (endoscopy 8.8% vs surgery 6.3%; P = .999), none of the patients assigned to the endoscopic approach developed enteral or pancreatic-cutaneous fistulae compared with 28.1% of the patients who underwent surgery (P = .001). The mean number of major complications per patient was significantly higher in the surgery group (0.69 ± 1.03) compared with the endoscopy group (0.15 ± 0.44) (P = .007). The physical health scores for quality of life at 3 months was better with the endoscopic approach (P = .039) and mean total cost was lower ($75,830) compared with $117,492 for surgery (P = .039).

CONCLUSIONS

In a randomized trial of 66 patients, an endoscopic transluminal approach for infected necrotizing pancreatitis, compared with minimally invasive surgery, significantly reduced major complications, lowered costs, and increased quality of life. Clinicaltrials.gov no: NCT02084537.

Time for a Changing of Guard: From Minimally Invasive Surgery to Endoscopic Drainage for Management of Pancreatic Walled-off Necrosis

BACKGROUND AND AIMS

Endoscopic drainage (ED) with or without necrosectomy, and minimally invasive surgical necrosectomy (MISN) have been increasingly utilized for treatment of symptomatic sterile and infected pancreatic walled-off necrosis (WON). We conducted this systematic review to compare the safety of ED with MISN for management of WON.

METHODS

We searched several databases from inception through November 9, 2017 to identify comparative studies evaluating the safety of ED versus MISN for management of WON. MISN could be performed using video-assisted retroperitoneal debridement or laparoscopy. We evaluated difference in mortality, major organ failure, adverse events, and length of hospital stay.

RESULTS

Six studies (2 randomized controlled trials and 4 observational studies) with 641 patients (326 ED and 315 MISN) were included in this meta-analysis. Rates of mortality for ED and MISN were 8.5% and 14.2%, respectively. Pooled odds ratio (OR) with 95% confidence interval was 0.59 (0.35-0.98), I=0% in favor of ED. On subgroup analysis: no difference in mortality was seen based on randomized controlled trials [OR, 0.65 (0.08-5.11)], while ED had improved survival in observational studies [OR, 0.49 (0.27-0.89)]. Development of new major organ failure rates after interventions were 12% and 54% for ED and MISN, respectively. Pooled OR was 0.12 (0.06-0.31), I=25% in favor of ED. For adverse events, pooled OR was 0.25 (0.10-0.67), I=70% in favor of ED. There was no difference in risk of bleeding [OR, 0.68 (0.44-1.05)], while ED was associated with a significantly lower rate of pancreatic fistula formation [OR, 0.20 (0.11-0.37)], I=0%. Length of stay was also lower with ED, pooled mean difference was -21.07 (-36.97 to -5.18) days.

CONCLUSIONS

When expertise is available, ED is the preferred invasive management strategy over MISN for management of WON as it is associated with lower mortality, risk of major organ failure, adverse events, and length of hospital stay.

Endotherapy for pancreatic necrosis: An update

Approximately 20% of patients with acute pancreatitis develop pancreatic necrosis. The presence of necrosis in a pancreatic collection significantly worsens the prognosis. Pancreatic necrosis is associated with high mortality and morbidity. In the last few decades, there has been a significant revolution in the treatment of infected pancreatic necrosis. A step-up approach has been proposed, from less invasive procedures to the operative intervention. Minimally invasive treatment modalities such as endoscopic drainage and necrosectomy, percutaneous drainage, and minimally invasive surgery have recently replaced open surgical necrosectomy as the first-line treatment option. Endoscopic intervention for pancreatic necrosis is being increasingly performed with good success and a lower complication rate. However, techniques of endotherapy are still not uniform and vary as per local expertise, and there are still many unresolved questions with regard to the interventions in patients with pancreatic necrosis. The objective of this paper is to critically review the literature and update the concepts of endoscopic interventional therapy of pancreatic necrosis.

Endoscopic Transgastric Versus Surgical Approach for Infected Necrotizing Pancreatitis: A Systematic Review and Meta-Analysis

Surgical approach (SA) is the standard treatment for infected necrotizing pancreatitis (INP) and endoscopic transgastric approach (ETA) is a promising alternative treatment. This systematic review and meta-analysis aimed to compare the effectiveness and safety of ETA versus SA in INP. Several databases were systematically searched for eligible studies that compared ETA with SA for INP. Predefined criteria were used for study selection. Three reviewers independently assessed the risk of bias. Primary outcomes included clinical resolution rate, short-term mortality, major complications, and hospital stay. Study-specific effect sizes and their 95% confidence interval (CI) were combined to calculate the pooled value using fixed-effects or random-effects model. Six studies were included with 295 patients. Major complication rate [odds ratio (OR), 0.13; 95% CI, 0.06-0.29], new-onset organ failure rate (OR, 0.26; 95% CI, 0.12-0.54), postoperative pancreatic fistula rate (OR, 0.09; 95% CI, 0.03-0.28), and incisional hernia rate (OR, 0.10; 95% CI, 0.01-0.85) were lower in the ETA group. There was a shorter hospital stay (mean difference, -17.72; 95% CI, -21.30 to -14.13) in the ETA group. No differences were found in clinical resolution, short-term mortality, postoperative bleeding, perforation of visceral organ, and endocrine or exocrine insufficiency. Compared with SA, ETA showed comparable effectiveness and safety for the treatment of INP based on current evidence.

Minimally Invasive Debridement for Infected Pancreatic Necrosis

Necrotizing pancreatitis has historically been treated with open necrosectomy, which carries a high morbidity and mortality rate. More recently, there has been a shift towards endoscopic and percutaneous approaches employed as part of a minimally invasive step-up approach. Herein, we describe the technical approaches to video-assisted retroperitoneal debridement and sinus tract endoscopic debridement of pancreatic necrosis. Additionally, we review important patient selection considerations and the strengths and weaknesses of each of the approaches.

Minimally invasive drainage in critically ill patients with severe necrotizing pancreatitis is associated with better outcomes: an observational study

Background

Infected pancreatic necrosis, which occurs in about 40% of patients admitted for acute necrotizing pancreatitis, requires combined antibiotic therapy and local drainage. Since 2010, drainage by open surgical necrosectomy has been increasingly replaced by less invasive methods such as percutaneous radiological drainage, endoscopic necrosectomy, and laparoscopic surgery, which proved effective in small randomized controlled trials in highly selected patients. Few studies have evaluated minimally invasive drainage methods used under the conditions of everyday hospital practice. The aim of this study was to determine whether, compared with conventional open surgery, minimally invasive drainage was associated with improved outcomes of critically ill patients with infection complicating acute necrotizing pancreatitis.

Methods

A single-center observational study was conducted in patients admitted to the intensive care unit for severe acute necrotizing pancreatitis to compare the characteristics, drainage techniques, and outcomes of the 62 patients managed between September 2006 and December 2010, chiefly with conventional open surgery, and of the 81 patients managed between January 2011 and August 2015 after the introduction of a minimally invasive drainage protocol.

Results

Surgical necrosectomy was more common in the early period (74% versus 41%; P <0.001), and use of minimally invasive drainage increased between the early and late periods (19% and 52%, respectively; P <0.001). The numbers of ventilator-free days and catecholamine-free days by day 30 were higher during the later period. The proportions of patients discharged from intensive care within the first 30 days and from the hospital within the first 90 days were higher during the second period. Hospital mortality was not significantly different between the early and late periods (19% and 22%, respectively).

Conclusion

In our study, the implementation of a minimally invasive drainage protocol in patients with infected pancreatic necrosis was associated with shorter times spent with organ dysfunction, in the intensive care unit, and in the hospital. Mortality was not significantly different. These results should be interpreted bearing in mind the limitations inherent in the before-after study design.

Early (<4 Weeks) Versus Standard (≥ 4 Weeks) Endoscopically Centered Step-Up Interventions for Necrotizing Pancreatitis

OBJECTIVES

Current guidelines for necrotizing pancreatitis (NP) recommend delay in drainage ± necrosectomy until 4 or more weeks after initial presentation to allow collections to wall off. However, evidence of infection with clinical deterioration despite maximum support may mandate earlier (<4 weeks) intervention. There are concerns, but scant data regarding risk of complications and outcomes with early endoscopic intervention. Our aim was to compare the results of an endoscopic centered step-up approach to NP when initiated before versus 4 or more weeks.

METHODS

All patients undergoing intervention for NP were managed using an endoscopically centered step-up approach, with transluminal drainage whenever feasible, ±necrosectomy, and/or percutaneous catheter drainage as needed, with surgery only for failures. Interventions were categorized as early or standard based on timing of intervention (<4 weeks or ≥ 4 weeks from onset of pancreatitis). Demographic data, indications and timing for interventions, number and type of intervention, mortality and morbidity (length of stay in hospital and ICU) and complications were compared.

RESULTS

Of 305 patients with collections associated with NP, 193 (63%) (median age-52 years) required intervention, performed by a step-up approach. Of the 193 patients, 76 patients underwent early and 117 patients standard intervention. 144 (75%) interventions included endoscopic drainage ± necrosectomy. As compared with standard intervention, early intervention was more often performed for infection (91% vs. 39%, p < 0.05), more associated with acute kidney injury (43% vs. 32%, p = 0.09), respiratory failure (41% vs. 22%, p = 0.005), and shock (13% vs. 4%, p < 0.05). Organ failure improved significantly after intervention in both groups. There was a significant difference in mortality (13% vs. 4%, p = 0.02) and need for rescue open necrosectomy (7% vs. 1%, p = 0.03) between groups. Patients undergoing early intervention had increased median hospital (37 days vs. 26 days, p = 0.01) and ICU stay (median 2.5 days vs. 0 days, p = 0.001). There was no difference in complications.

CONCLUSIONS

When using an endoscopically centered step-up strategy in necrotizing pancreatitis, early (<4 weeks) interventions were more often performed for infection and organ failure, with no increase in complications, similar improvement in organ failure, slightly increased need for surgery, and relatively low mortality. Early endoscopic drainage ± necrosectomy should be considered when there is a strong indication for intervention.

The Evolution of EUS-Guided Transluminal Drainage for the Treatment of Pancreatic Fluid Collections: A Comparison of Clinical and Cost Outcomes with Double-Pigtail Plastic Stents, Conventional Metal Stents and Lumen-Apposing Metal Stents

Background

While most pancreatic fluid collections (PFCs) resolve spontaneously, endoscopic ultrasound-guided transluminal drainage (EUS-TD) may be necessary. EUS-TD has evolved from multiple double-pigtail plastic stents (DPPS) to fully covered self-expanding metal stents (FCSEMS) and lumen-apposing metal stents (LAMS). This study compares clinical attributes of DPPS, FCSEMS and LAMS.

Methods

This is a single-centre retrospective review of EUS-TD for PFCs. The primary outcome was clinical success. Secondary outcomes were technical success, procedure time, hospital length of stay (HLOS), number of endoscopies, need for necrosectomy, adverse events (AEs) and overall cost.

Results

Fifty-eight patients (37 male, average age 49 years) underwent a total of 60 EUS-TD procedures for PFCs (average size 11.2 cm with 29 pseudocysts and 29 walled-off necrosis). Ten patients (17%) underwent EUS-TD with DPPS and 48 patients (83%) with metal stents (32 FCSEMS, 16 LAMS). Overall technical and clinical success was 100% and 84%, respectively. Lumen-apposing metal stents had shorter procedure times (14.9 versus 63.6 DPPS, 39.1 min FCSEMS, P < 0.001), and no difference in AEs (3 of 16 versus 4 of 10 DPPS, 12 of 34 FCSEMS, ns). Double-pigtail plastic stents required more endoscopies (3.7 versus 2.3 LAMS, 2.3 FCSEMS, P = 0.013) and necrosectomies (4 of 10 [40%]) compared with 5 of 34 [15%] in the FCSEMS group and 3 of 16 [19%] in the LAMS group, respectively, P = 0.001) to achieve clinical resolution. The overall cost and HLOS was not significantly different between groups.

Conclusion

The use of LAMS for PFCs is not associated with any significant increase in cost despite technical (shorter procedure time) and clinical advantages (shorter indwell time, reduced need for necrosectomy and no increase in AEs).

Endoscopic Management of Infected Necrotizing Pancreatitis: an Evidence-Based Approach

PURPOSE OF REVIEW

Endoscopic management of infected necrotizing pancreatitis has evolved rapidly over the past years and there have been interesting innovations in this field. This review provides an update on the most recently published literature regarding endoscopic management of infected necrotizing pancreatitis.

RECENT FINDINGS

A recent randomized trial demonstrated no difference in mortality and major morbidity between endoscopic and surgical step-up treatment of infected necrotizing pancreatitis. However, endoscopic therapy resulted in shorter hospital stay and less pancreatic fistulas. Various innovations have been investigated with the aim to further optimize endoscopic therapy, in particular lumen-apposing metal stents. While major stent-related complications were also reported, findings from recent studies indicated that their use was associated with higher resolution rates of walled-off necrosis compared to double-pigtail stents. Other innovations, such as the multiple gateway technique and dual-modality mode, can be considered for treatment of particular cases. Furthermore, research suggests that irrigation of walled-off necrosis can be performed by using a nasocystic tube and discontinuation of proton-pump inhibitors may be considered. Endoscopic treatment should be the preferred treatment modality in patients with infected necrotizing pancreatitis who are eligible for endoscopic drainage. Although data suggests that lumen-apposing metal stents are superior to double-pigtail stents, prospective multicenter studies focusing on safety as well as long-term follow-up are first needed.

Management of infected pancreatic necrosis: state of the art

Pancreatic necrosis occurs in 15% of acute pancreatitis. The presence of infection is the most important factor in the evolution of pancreatitis. The diagnosis of infection is still challenging. Mortality in infected necrosis is 20%; in the presence of organic dysfunction, mortality reaches 60%. In the last three decades, there has been a real revolution in the treatment of infected pancreatic necrosis. However, the challenges persist and there are many unsolved questions: antibiotic treatment alone, tomography-guided percutaneous drainage, endoscopic drainage, video-assisted extraperitoneal debridement, extraperitoneal access, open necrosectomy? A step up approach has been proposed, beginning with less invasive procedures and reserving the operative intervention for patients in which the previous procedure did not solve the problem definitively. Indication and timing of the intervention should be determined by the clinical course. Ideally, the intervention should be done only after the fourth week of evolution, when it is observed a better delimitation of necrosis. Treatment should be individualized. There is no procedure that should be the first and best option for all patients. The objective of this work is to critically review the current state of the art of the treatment of infected pancreatic necrosis.

Supplemented Use of Pre-, Pro-, and Synbiotics in Severe Acute Pancreatitis: An Updated Systematic Review and Meta-Analysis of 13 Randomized Controlled Trials

Introduction: The role of pre-, pro-, and synbiotics supplemented to standard enteral nutrition in severe acute pancreatitis (SAP) remains unclear. We performed this updated meta-analysis to determine the value of pre-, pro- and synbiotics supplemented to standard enteral nutrition in predicted SAP.

Methods: A systematic search in PubMed, EMBASE and Cochrane Central Register of Controlled Trials (CENTRAL) databases was performed. Eligible studies were randomized controlled trials (RCTs) that compared the effects of pre-, pro-, and synbiotics supplemented to standard enteral nutrition with control regime in predicted SAP patients. Risk ratio (RR) and mean difference (MD) with 95% confidence interval (95% CI) were used to express the estimates of dichotomous and continuous data respectively.

Results: 13 RCTs comprising an aggregate total of 950 patients were eventually enrolled. Pooled results suggested that supplemented use of pre-, pro- and synbiotics effectively shorten the length of hospital stay in Chinese SAP cohorts (6 RCTs, MD = −5.57, 95% CI = −8.21 to −2.93, P < 0.001); however significant differences with regard to remaining clinical outcomes were not detected for all patients. Further analysis based on category of interventions including pre-, pro- and synbiotics also confirmed the findings to be reliable.

Conclusions: Supplemented use of pre-, pro and synbiotics reduced the length of hospital stay in Chinese SAP cohorts. And thus, we concluded that pre-, pro- and synbiotics supplemented to standard enteral nutrition may be a potential option for the treatment of SAP patients. However, we also suggest designing further studies with large-scale and rigorous methods of addressing data to establish the effects and safety of supplemented use of pre-, pro- and synbiotics for SAP patients due to the presence of limitations.

Isolated pancreatic tail remnants after transgastric necrosectomy can be observed

BACKGROUND

Severe necrotizing pancreatitis may result in midbody necrosis and ductal disruption leaving an isolated pancreatic tail. The purpose of this study was to characterize outcomes among patients with an isolated tail remnant who underwent transgastric drainage or necrosectomy (endoscopic or surgical) and determine the need for subsequent operative management.

MATERIALS AND METHODS

Patients with necrotizing pancreatitis and retrogastric walled-off collections treated by surgical transgastric necrosectomy or endoscopic cystgastrostomy ± necrosectomy between 2009 and 2017 were identified by a retrospective chart review. All available preprocedure and postprocedure imaging was reviewed for evidence of isolated distal pancreatic tail remnants.

RESULTS

Seventy-four patients were included (40 surgical and 34 endoscopic). All the patients in the surgical group underwent laparoscopic transgastric necrosectomy; the endoscopic group consisted of 26 patients for pseudocyst drainage and eight patients for necrosectomy. A disconnected pancreatic tail was identified in 22 (29%) patients (13 laparoscopic and nine endoscopic). After the creation of the "cystgastrostomy," there were no external fistulas despite the viable tail. Of the 22 patients, four patients developed symptoms at a median of 23 months (two, recurrent episodic pancreatitis; two, intractable pain). Two patients (both initially in endoscopic group) ultimately required distal pancreatectomy and splenectomy at 24 and 6 months after index procedure.

CONCLUSIONS

Patients with a walled-off retrogastric collection and an isolated viable tail are effectively managed by a transgastric approach. Despite this seemingly "unstable anatomy," the creation of an internal fistula via surgical or endoscopic "cystgastrostomy" avoids external fistulas/drains and the short-term necessity of surgical distal pancreatectomy. A very small subset requires intervention for late symptoms.

Minimally invasive and endoscopic versus open necrosectomy for necrotising pancreatitis: a pooled analysis of individual data for 1980 patients

OBJECTIVE

Minimally invasive surgical necrosectomy and endoscopic necrosectomy, compared with open necrosectomy, might improve outcomes in necrotising pancreatitis, especially in critically ill patients. Evidence from large comparative studies is lacking.

DESIGN

We combined original and newly collected data from 15 published and unpublished patient cohorts (51 hospitals; 8 countries) on pancreatic necrosectomy for necrotising pancreatitis. Death rates were compared in patients undergoing open necrosectomy versus minimally invasive surgical or endoscopic necrosectomy. To adjust for confounding and to study effect modification by clinical severity, we performed two types of analyses: logistic multivariable regression and propensity score matching with stratification according to predicted risk of death at baseline (low: <5%; intermediate: ≥5% to <15%; high: ≥15% to <35%; and very high: ≥35%).

RESULTS

Among 1980 patients with necrotising pancreatitis, 1167 underwent open necrosectomy and 813 underwent minimally invasive surgical (n=467) or endoscopic (n=346) necrosectomy. There was a lower risk of death for minimally invasive surgical necrosectomy (OR, 0.53; 95% CI 0.34 to 0.84; p=0.006) and endoscopic necrosectomy (OR, 0.20; 95% CI 0.06 to 0.63; p=0.006). After propensity score matching with risk stratification, minimally invasive surgical necrosectomy remained associated with a lower risk of death than open necrosectomy in the very high-risk group (42/111 vs 59/111; risk ratio, 0.70; 95% CI 0.52 to 0.95; p=0.02). Endoscopic necrosectomy was associated with a lower risk of death than open necrosectomy in the high-risk group (3/40 vs 12/40; risk ratio, 0.27; 95% CI 0.08 to 0.88; p=0.03) and in the very high-risk group (12/57 vs 28/57; risk ratio, 0.43; 95% CI 0.24 to 0.77; p=0.005).

CONCLUSION

In high-risk patients with necrotising pancreatitis, minimally invasive surgical and endoscopic necrosectomy are associated with reduced death rates compared with open necrosectomy.

Minimally invasive surgery in the era of step-up approach for treatment of severe acute pancreatitis

OBJECTIVES

To assess the minimally invasive surgery into the step-up approach procedures as a standard treatment for severe acute pancreatitis and comparing its results with those obtained by classical management.

METHODS

Retrospective cohort study comparative with two groups treated over two consecutive, equal periods of time were defined: group A, classic management with open necrosectomy from January 2006 to June 2010; and group B, management with the step-up approach with minimally invasive surgery from July 2010 to December 2014.

RESULTS

In group A, 83 patients with severe acute pancreatitis were treated, of whom 19 underwent at least one laparotomy, and in 5 any minimally invasive surgery. In group B, 81 patients were treated: minimally invasive surgery was necessary in 17 cases and laparotomy in 3. Among operated patients, the time from admission to first interventional procedures was significantly longer in group B (9 days vs. 18.5 days; p = 0.042). There were no significant differences in Intensive Care Unit stay or overall stay: 9.5 and 27 days (group A) vs. 8.5 and 21 days (group B). Mortality in operated patients and mortality overall were 50% and 18.1% in group A vs 0% and 6.2% in group B (p < 0.001 and p = 0.030).

CONCLUSIONS

The combination of the step-up approach and minimally invasive surgery algorithm is feasible and could be considered as the standard of treatment for severe acute pancreatitis. The mortality rate deliberately descends when it is used.

Double-catheter lavage combined with percutaneous flexible endoscopic debridement for infected pancreatic necrosis failed to percutaneous catheter drainage

Background

Infected pancreatic necrosis (IPN) is a serious local complication of acute pancreatitis, with high mortality. Minimally invasive therapy including percutaneous catheter drainage (PCD) has become the preferred method for IPN instead of traditional open necrosectomy. However, the efficacy of double-catheter lavage in combination with percutaneous flexible endoscopic debridement after PCD failure is unknown compared with surgical necrosectomy.

Methods

A total of 27 cases of IPN patients with failure PCD between Jan 2014 and Dec 2015 were enrolled in this retrospective cohort study. Fifteen patients received double-catheter lavage in combination with percutaneous flexible endoscopic debridement, and 12 patients underwent open necrosectomy. The primary endpoint was the composite end point of major complications or death. The secondary endpoint included mortality, major complication rate, ICU admission length of stay, and overall length of stay.

Results

The primary endpoint occurrence rate in double-catheter lavage in combination with percutaneous flexible endoscopic debridement group (8/15, 53%) was significantly lower than that in open necrosectomy group (11/12, 92%) (RR = 1.71, 95% CI = 1.04 – 2.84, P < 0.05). Though the mortality between two groups showed no statistical significance (0% vs. 17%, P = 0.19), the rate of new-onset multiple organ failure and ICU admission length of stay in the experimental group was significantly lower than that in open necrosectomy group (13% vs. 58%, P = 0.04; 0 vs. 17, P = 0.02, respectively). Only 40% of patients required ICU admission after percutaneous debridement, which was markedly lower than the patients who underwent surgery (83%; P < 0.05).

Conclusions

Double-catheter lavage in combination with percutaneous flexible endoscopic debridement showed superior effectiveness, safety, and convenience in patients with IPN after PCD failure as compared to open necrosectomy.

Electronic supplementary material

The online version of this article (10.1186/s12876-017-0717-3) contains supplementary material, which is available to authorized users.

Diagnosis and treatment of severe acute pancreatitis: Current status and main problems

Acute pancreatitis (AP) is a disease of various causes, characterized by pancreatic enzyme activation and local pancreatic inflammatory response. Serious cases may develop systemic inflammatory response syndrome and even organ dysfunction. Severe AP (SAP) as a category of AP associated with persistent organ failure (>48 h) has an acute onset and high fatality rate. SAP accounts for about 5%-10% of all AP cases, with 30%-50% mortality rate. In this paper, we discuss the current status and main problems on the diagnosis and treatment of SAP based on the literature and our experience.

Minimally invasive pancreatic necrosectomy; a technical pictorial review

Necrotizing pancreatitis is the most severe form of acute pancreatitis, which is associated with significant mortality and morbidity. Open necrosectomy has been one of the treatment modalities; however, it has been associated with high mortality rates and alternative minimally invasive procedures such as minimal invasive pancreatic necrosectomy (MIPN) were developed to improve on the outcomes. While current clinical evidence on MIPN showed significant advantages in terms of incidence of multiple organ failure, incisional hernias and new-onset diabetes there were no differences in terms of mortality rate. In this pictorial review we are presenting the technical details of MIPN as a minimally invasive procedure for the debridement of the necrotic pancreatic tissue and we will discuss the current evidence around the use of this procedure for the management of pancreatic necrosis.

Update: Role of surgery in acute necrotizing pancreatitis

Acute necrotizing pancreatitis is a prevalent disease with high morbidity and mortality. The development of radiologic and endoscopic techniques to manage pancreatic necrosis commands a multidisciplinary approach, which has considerably decreased the need for laparotomy. The objective of this update is to define the role of surgery in the multidisciplinary approach to management of necrotizing acute pancreatitis.

Early enteral nutrition versus delayed enteral nutrition in acute pancreatitis: A PRISMA-compliant systematic review and meta-analysis

BACKGROUND

Whether early enteral nutrition (EEN) administration is more beneficial than delayed enteral nutrition (DEN) for patients with acute pancreatitis remains controversial.

METHODS

This meta-analysis aimed to pool all relevant articles to evaluate the effects of EEN within 48 hours versus DEN beyond 48 hours on the clinical outcomes of patients with acute pancreatitis. We searched PubMed, Scopus, Embase, and Web of Science for all relevant studies and extracted the data concerning basic characteristics, complications, and mortality. We calculated the pooled risk ratio (RR), weighted mean difference, and the corresponding 95% confidential interval (95% CI) using STATA 12.0.

RESULTS

For complications, the pooled analysis showed that EEN was related to a reduced risk of multiple organ failure (RR = 0.67, 95% CI 0.46-0.99, P = .04), but not for necrotizing pancreatitis (RR = 0.95, 95% CI 0.81-1.12, P = .57). There was a tendency for decreased systemic inflammatory response syndrome in the EEN group, but the trend was not significant (RR = 0.85, 95% CI 0.71-1.02, P = .09). For mortality, no significant difference was found between the EEN and DEN groups (RR = 0.78, 95% CI 0.27-2.24, P = .64).

CONCLUSION

EEN within 48 hours is superior to DEN beyond 48 hours for patients with acute pancreatitis; however, more studies are required to verify this conclusion.

Management of acute pancreatitis in children

PURPOSE OF REVIEW

Pediatric acute pancreatitis has been on the rise in the last decades, with an incidence close to adult pancreatitis. In the majority of cases acute pancreatitis resolves spontaneously, but in a subset of children the disease progresses to severe acute pancreatitis with attendant morbidity and mortality.

RECENT FINDINGS

Pediatric acute pancreatitis in this era is recognized as a separate entity from adult acute pancreatitis given that the causes and disease outcomes are different. There are slow but important advances made in understanding the best management for acute pancreatitis in children from medical, interventional, and surgical aspects.

SUMMARY

Supportive care with fluids, pain medications, and nutrition remain the mainstay for acute pancreatitis management. For complicated or severe pancreatitis, specialized interventions may be required with endoscopic or drainage procedures. Surgery has an important but limited role in pediatric acute pancreatitis.

Clinical impact of EUS treatment of walled-off pancreatic necrosis with dedicated devices

BACKGROUND AND STUDY AIMS

 Walled-off pancreatic necrosis (WOPN) represents the major risk factor for sepsis-related multiple organ failure. Surgical debridement is an invasive approach associated with high rates of adverse events (AEs) and death. As an alternative, endoscopic ultrasound-guided cysto-gastro-anastomosis has emerged as an effective treatment for WOPNs. Recently a new dedicated-lumen apposing metal stent (LAMS) has been used with satisfactory results in treating peri-pancreatic fluid collections, including WOPNs. The primary outcomes of this study were to evaluate survival and clinical success. Secondary outcomes included: technical success, adverse events and recurrence rate.

PATIENTS AND METHODS

 All consecutive patients with infected WOPN between February 2014 and June 2016 were retrospectively reviewed. Patients underwent placement of a new LAMS incorporated in an electrocautery-enhanced delivery system and direct endoscopic necrosectomy (DEN). DEN was performed immediately after stent deployment and repeated every 3 to 7 days until complete resolution.

RESULTS

 In the study period we treated 20 consecutive patients with infected WOPN using the new LAMS. Technical success was achieved in 95 % of patients. Clinical success was achieved in 73 % and 84.2 % of patients at 1 and 3 months, respectively. Survival rate was 84.2 % and 79 %. Mean length of hospital stay was 19 days (range 3 - 43). No AEs occurred. Patients were followed up after stent retrieval for a mean time of 554,7 days (range 70 - 986) and no recurrence was observed.

CONCLUSIONS

 DEN following "1-step, exchange-free" LAMS positioning recorded excellent results. We believe that simplicity of procedure plays a key role in terms of safety.

The role of multidisciplinary meetings for benign pancreatobiliary diseases: a tertiary centre experience

Multidisciplinary meetings are central to the management of chronic and complex diseases and they have become widely established across the modern healthcare. Patients with pancreatobiliary diseases can often present with complex clinical dilemmas, which fall out with the scope of current guidelines. Therefore, these patients require a personalised management approach discussed in a multidisciplinary meeting.

Transgastric pancreatic necrosectomy-expedited return to prepancreatitis health

BACKGROUND

The best operative strategy for necrotizing pancreatitis remains controversial. Traditional surgical necrosectomy is associated with significant morbidity; endoscopic and percutaneous strategies require repeated interventions with prolonged hospitalizations. We have developed a transgastric approach to pancreatic necrosectomy to overcome the shortcomings of the other techniques described.

MATERIALS AND METHODS

Patients with necrotizing pancreatitis treated from 2009 to 2016 at an academic center were retrospectively reviewed. Open or laparoscopic transgastric necrosectomy was performed if the area of necrosis was walled-off and in a retrogastric position on cross-sectional imaging. Study endpoints included postoperative complications and mortality.

RESULTS

Forty-six patients underwent transgastric necrosectomy (nine open and 37 laparoscopic). Median (interquartile range) preoperative Acute Physiologic and Chronic Health Evaluation II score was 6 (3-12). Seventy percent of patients had >30% necrosis on preoperative imaging; infected necrosis was present in 35%. Median total length of stay (LOS) was 6 (3-12) d. No patient required a second operative debridement; four patients (9%) had short-term postoperative percutaneous drainage for residual fluid collections. Median follow-up was 1 y; there were no fistula or wound complications. Six patients (13%) had postoperative bleeding; five patients received treatment by image-guided embolization. There was one death in the cohort.

CONCLUSIONS

Transgastric pancreatic necrosectomy allows for effective debridement with a single definitive operation. When anatomically suitable, this operative strategy offers expedited recovery and avoids long-term morbidity associated with fistulas and prolonged drainage.