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]

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.

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.

Clinical effect of CT-guided percutaneous catheter drainage versus laparotomy in treatment of infective pancreatic necrosis

AIM: To compare the clinical effect of CT-guided percutaneous catheter drainage versus laparotomy in the management of infective pancreatic necrosis.

METHODS: Clinical data for 45 SAP patients with infective pancreatic necrosis who were treated from January 2009 to December 2012 were analyzed retrospectively. These patients were divided into two groups based on the treatment choice. Twenty-one patients in the percutaneous drainage group underwent CT-guided percutaneous catheter drainage, and the efficacy was evaluated after 3 d. If no improvement was achieved, they would receive laparotomy. Twenty-four patients in the laparotomy group received surgical drainage when the diagnosis of infective pancreatic necrosis was confirmed.

RESULTS: Approximately 42.3% of patients in the percutaneous drainage group did not require laparotomy. The percutaneous drainage group had a significantly higher success rate of first laparotomy (91.7% vs 66.7%, P < 0.05), significantly lower rates of postoperative residual abscess (8.3% vs 33.3%, P < 0.05) and new organ dysfunction (9.5% vs 37.5%, P < 0.05), shorter hospital duration (46.71 d ± 10.96 d vs 55.93 d ± 11.54 d, P < 0.05) and less expenditure (181872 yuan ± 42011 yuan vs 2510000 yuan ± 57365 yuan, P < 0.05).

CONCLUSION: CT-guided percutaneous catheter drainage can effectively reduce the use of laparotomy, improve the success rate of first laparotomy, and decrease the rate of postoperative residual abscess and new organ dysfunction as well as the cost of medical resources.

Early management of acute pancreatitis

Acute pancreatitis is the most common gastro-intestinal indication for acute hospitalization and its incidence continues to rise. In severe pancreatitis, morbidity and mortality remains high and is mainly driven by organ failure and infectious complications. Early management strategies should aim to prevent or treat organ failure and to reduce infectious complications. This review addresses the management of acute pancreatitis in the first hours to days after onset of symptoms, including fluid therapy, nutrition and endoscopic retrograde cholangiography. This review also discusses the recently revised Atlanta classification which provides new uniform terminology, thereby facilitating communication regarding severity and complications of pancreatitis.

Five-year cohort study of open pancreatic necrosectomy for necotizing pancreatitis suggests it is a safe and effective operation

INTRODUCTION

Despite advances in the management of necrotizing pancreatitis, open necrosectomy remains an important management option for necrotizing pancreatitis, and patients undergoing necrosectomy suffer significant morbidity and mortality. The aim of this study was to report the outcomes of open necrosectomy from a recent large cohort of patients with necrotizing pancreatitis.

METHODS

Data are reported from a cohort of 276 consecutive patients with necrotizing pancreatitis who underwent open surgical debridement. Nutritional status, nutritional methods, bleeding, infection, demarcation of necrotic tissues, and time from onset of disease were scored. Scores ≥ 10 were considered as an indication for debridement.

RESULTS

One hundred sixty-two (58.7%) and 52 (18.8%) patients underwent minimally invasive peritoneal and retroperitoneal drainage, respectively, before necrosectomy. Median delay from disease onset to debridement was 48 days. Fifty-five patients (19.9%) underwent more than one operation; 352 operations were performed in total. There were 17 deaths (6.2%) postoperatively.

CONCLUSION

This study demonstrated the results for open debridement in a recent large cohort of patients. Although minimally invasive necrosectomy has been developed in recent years, open necrosectomy remains an important approach for the debridement of necrotizing pancreatitis effectively and safely.

Surgical treatment of acute pancreatitis

BACKGROUND

Acute pancreatitis remains an unpredictable, potentially lethal disease with significant morbidity and mortality rates. New insights in the pathophysiology of acute pancreatitis have changed management concepts. In the first phase, characterized by a systemic inflammatory response syndrome, organ failure, not related to infection but rather to severe inflammation, dominates the focus of treatment. In the second phase, secondary infectious complications largely determine the clinical outcome. As infection is associated with increased mortality in acute pancreatitis, numerous prophylactic strategies have been explored in the past two decades.

PURPOSE

This review describes the strategies that have been developed to lower the infection rate, in an attempt to lower mortality. Antibiotic prophylaxis has been the subject of many RCT's without showing convincing evidence of their efficacy. Probiotics, although theoretically capable of lowering the rate of infection, also had no effect on infectious complications, and consequently, no effective strategy to lower the rate of infectious complications is currently available. In the second part of this review, new approaches for necrosectomy that have been designed by different centers around the world are discussed. All the interventional techniques have in common their aim to lower the invasive character, hypothesizing that lowering the surgical trauma will improve survival and lower complication rates. Recent advances include postponing intervention as a strategy to facilitate necrosectomy and improve prognosis and the "step-up approach" in case of infected necrosis. The step-up approach includes percutaneous catheter drainage as the first step, to be followed by necrosectomy, either through a minimally invasive approach or by open necrosectomy, as the next step.

CONCLUSIONS

All attempts to develop treatment strategies to lower the infection rate in acute pancreatitis have failed. Accumulating evidence is emerging to show that the combination of centralization, the use of catheter drainage as the first step of invasive treatment, and the development of minimally invasive techniques, improve the outlook for patients with infected necrosis. It is uncertain at this point in time as to which of the three effects is dominant in the improvement of prognosis.

Surgical treatment of acute pancreatitis

BACKGROUND

Acute pancreatitis remains an unpredictable, potentially lethal disease with significant morbidity and mortality rates. New insights in the pathophysiology of acute pancreatitis have changed management concepts. In the first phase, characterized by a systemic inflammatory response syndrome, organ failure, not related to infection but rather to severe inflammation, dominates the focus of treatment. In the second phase, secondary infectious complications largely determine the clinical outcome. As infection is associated with increased mortality in acute pancreatitis, numerous prophylactic strategies have been explored in the past two decades.

PURPOSE

This review describes the strategies that have been developed to lower the infection rate, in an attempt to lower mortality. Antibiotic prophylaxis has been the subject of many RCT's without showing convincing evidence of their efficacy. Probiotics, although theoretically capable of lowering the rate of infection, also had no effect on infectious complications, and consequently, no effective strategy to lower the rate of infectious complications is currently available. In the second part of this review, new approaches for necrosectomy that have been designed by different centers around the world are discussed. All the interventional techniques have in common their aim to lower the invasive character, hypothesizing that lowering the surgical trauma will improve survival and lower complication rates. Recent advances include postponing intervention as a strategy to facilitate necrosectomy and improve prognosis and the "step-up approach" in case of infected necrosis. The step-up approach includes percutaneous catheter drainage as the first step, to be followed by necrosectomy, either through a minimally invasive approach or by open necrosectomy, as the next step.

CONCLUSIONS

All attempts to develop treatment strategies to lower the infection rate in acute pancreatitis have failed. Accumulating evidence is emerging to show that the combination of centralization, the use of catheter drainage as the first step of invasive treatment, and the development of minimally invasive techniques, improve the outlook for patients with infected necrosis. It is uncertain at this point in time as to which of the three effects is dominant in the improvement of prognosis.

Focused open necrosectomy in necrotizing pancreatitis

BACKGROUND

The control of sepsis is the primary goal of surgical intervention in patients with infected necrosis. Simple surgical approaches that are easy to reproduce may improve outcomes when specialists in endoscopy are not available. The aim of the present study was to describe the experience with a focused open necrosectomy (FON) in patients with infected necrosis.

METHOD

A prospective pilot study conducted to compare a semi-open/closed drainage laparotomy and FON with the assistance of peri-operative ultrasound. The incidence of sepsis, dynamics of C-reactive protein (CRP), intensive care unit (ICU)/hospital stay, complication rate and mortality were compared and analysed.

RESULTS

From a total of 58 patients, 36 patients underwent a conventional open necrosectomy and 22 patients underwent FON. The latter method resulted in a faster resolution of sepsis and a significant decrease in mean CRP on Day 3 after FON, P = 0.001. Post-operative bleeding was in 1 versus 7 patients and the incidence of intestinal and pancreatic fistula was 2 versus 8 patients when comparing FON to the conventional approach. The median ICU stay was 11.6 versus 23 days and the hospital stay was significantly shorter, 57 versus 72 days, P = 0.024 when comparing FON versus the conventional group. One patient died in the FON group and seven patients died in the laparotomy group, P = 0.139.

DISCUSSION

FON can be an alternative method to conventional open necrosectomy in patients with infected necrosis and unresolved sepsis.

IAP/APA evidence-based guidelines for the management of acute pancreatitis

BACKGROUND

There have been substantial improvements in the management of acute pancreatitis since the publication of the International Association of Pancreatology (IAP) treatment guidelines in 2002. A collaboration of the IAP and the American Pancreatic Association (APA) was undertaken to revise these guidelines using an evidence-based approach.

METHODS

Twelve multidisciplinary review groups performed systematic literature reviews to answer 38 predefined clinical questions. Recommendations were graded using the Grading of Recommendations Assessment, Development and Evaluation (GRADE) system. The review groups presented their recommendations during the 2012 joint IAP/APA meeting. At this one-day, interactive conference, relevant remarks were voiced and overall agreement on each recommendation was quantified using plenary voting.

RESULTS

The 38 recommendations covered 12 topics related to the clinical management of acute pancreatitis: A) diagnosis of acute pancreatitis and etiology, B) prognostication/predicting severity, C) imaging, D) fluid therapy, E) intensive care management, F) preventing infectious complications, G) nutritional support, H) biliary tract management, I) indications for intervention in necrotizing pancreatitis, J) timing of intervention in necrotizing pancreatitis, K) intervention strategies in necrotizing pancreatitis, and L) timing of cholecystectomy. Using the GRADE system, 21 of the 38 (55%) recommendations, were rated as 'strong' and plenary voting revealed 'strong agreement' for 34 (89%) recommendations.

CONCLUSIONS

The 2012 IAP/APA guidelines provide recommendations concerning key aspects of medical and surgical management of acute pancreatitis based on the currently available evidence. These recommendations should serve as a reference standard for current management and guide future clinical research on acute pancreatitis.

Predictors of surgery in patients with severe acute pancreatitis managed by the step-up approach

BACKGROUND

Initial management of severe acute pancreatitis (SAP) is conservative. As a step-up approach, percutaneous catheter drainage (PCD) with saline irrigation is reported to be effective. Factors leading to surgery are unclear.

METHODS

In this ongoing prospective study, 70 consecutive patients with SAP were recruited. As a step-up approach, all patients initially received medical management and later underwent PCD and surgery as per the indication.

RESULTS

Of the 70 consecutive patients with SAP, 14 were managed medically, 29 managed with PCD alone, whereas 27 required surgery after initial PCD. Sepsis reversal was achieved with PCD alone in 62.5%. The curative efficacy of PCD alone was in 27 patients (48%). Overall mortality in the whole group was 24%. On univariate analysis, factors significantly affecting surgical intervention included initial acute physiology and chronic health evaluation (APACHE) II score, APACHE II score at first intervention, sepsis reversal by PCD within a week, number of organs failed, organ failure within a week of the onset of disease, number of bacteria isolated per patient, renal failure, respiratory failure, Escherichia coli, computerized tomography severity index score at admission, parenteral nutrition requirement before or after radiological intervention, maximum extent of necrosis of more than 50% of the pancreas, and extrapancreatic necrosis. On multivariate analysis, renal failure (P = -0.03), APACHE II score at first intervention (P = -0.006), and the number of bacteria isolated per patient (P = -0.01) remained independent predictors of surgery. An APACHE II score of more than 7.5 at first intervention (PCD) had the ability to predict surgery with a sensitivity of 88.9% and a specificity of 69%.

CONCLUSIONS

PCD reversed sepsis in 62% and avoided surgery in 48% of the patients. Reversal of sepsis within a week of PCD, APACHE II score at first intervention (PCD), and organ failure within a week of the onset of disease could predict the need for surgery in the early course of disease.

SEMICYUC 2012. Recommendations for intensive care management of acute pancreatitis

OBJECTIVE

Significant changes in the management of acute pancreatitis have taken place since the 2004 Pamplona Consensus Conference. The objective of this conference has been the revision and updating of the Conference recommendations, in order to unify the integral management of potentially severe acute pancreatitis in an ICU.

PARTICIPANTS

Spanish and international intensive medicine physicians, radiologists, surgeons, gastroenterologists, emergency care physicians and other physicians involved in the treatment of acute pancreatitis. LEVELS OF EVIDENCE AND GRADES OF RECOMMENDATION: The GRADE method has been used for drawing them up. DRAWING UP THE RECOMMENDATIONS: The selection of the committee members was performed by means of a public announcement. The bibliography has been revised from 2004 to the present day and 16 blocks of questions on acute pancreatitis in a ICU have been drawn up. Firstly, all the questions according to groups have been drawn up in order to prepare one document. This document has been debated and agreed upon by computer at the SEMICYUC Congress and lastly at the Consensus Conference which was held with the sole objective of drawing up these recommendations.

CONCLUSIONS

Eighty two recommendations for acute pancreatitis management in an ICU have been presented. Of these 84 recommendations, we would emphasize the new determinants-based classification of acute pancreatitis severity, new surgical techniques and nutritional recommendations. Note. This summary only lists the 84 recommendations of the 16 questions blocks except blocks greater relevance and impact of its novelty or because they modify the current management.

A retroperitoneal approach for infected pancreatic necrosis

BACKGROUND

Acute pancreatitis remains associated with a high rate of complication and death. The surgery strategy for proven or suspected infected necrosis is controversial.

METHODS

The present study reviews the medical records of 9,421 patients admitted with the diagnosis of acute pancreatitis from 2002 to 2009.

RESULTS

The medical records of 9,421 admitted patients diagnosed with acute pancreatitis were reviewed. Among the patients, 412 received necrosectomy. Of the 412 that were identified, 108 patients underwent retroperitoneal necrosectomy, whereas the remaining 304 patients received open necrosectomy. The mortality rates were 20.4% (62/304) and 8.3% (9/108), respectively (p = 0.004). The rates of complications in the retroperitoneal group were lower than that in the open group (p < 0.05). The mean lengths of hospital stay and ICU stay after surgery were longer in the open group than those in the retroperitoneal group (48 vs. 30 days; 6 vs. 2 days, p < 0.05). Furthermore, the postoperational days in the hospital and surgical time were also significantly different (30 vs. 12 days; 167 vs. 93 min, p < 0.05).

CONCLUSIONS

A retroperitoneal pancreatic necrosectomy approach reduced the rate of complications and death among patients with infected necrosis, compared with open necrosectomy.

Transmural endoscopic necrosectomy of infected pancreatic necroses and drainage of infected pseudocysts: a tailored approach

OBJECTIVE

Transmural endoscopic drainage and necrosectomy have become favored treatment modes for infected pancreatic pseudocysts and necroses. In this analysis, we summarize the outcome of 40 patients with complicated course of acute pancreatitis after endoscopic treatment.

MATERIAL AND METHODS

From January 2006 through May 2011, 40 patients of our department with complicated pancreatitis were included in this retrospective analysis. All patients underwent endosonographic transgastric puncture followed by wire-guided insertion of one or more double pigtail stents. Patients with extensive necroses were treated repeatedly with transgastric necrosectomy. Treatment success was determined by clinical, laboratory, and radiological parameters.

RESULTS

Nine patients had interstitial pancreatitis (IP) with pancreatic pseudocysts. Thirty-one patients had necrotizing pancreatitis (NP) with acute pancreatic necroses (n = 4) or walled-off pancreatic necrosis (n = 27). All patients with IP and nine patients with NP had pseudocysts without solid material and underwent transgastric drainage only. In this group major complications occurred in 11.1% and no mortality was observed. Twenty-two NP patients were treated with additional repeated necrosectomy. In patients with localized peripancreatic necroses (n = 10) no need of surgery or mortality was observed, major complications occurred in 10%. In patients with extensive necroses reaching the lower abdomen (n = 12), three needed subsequent surgery and three died.

CONCLUSIONS

Transgastric endoscopy is an effective minimally invasive procedure even in patients with advanced pancreatic necroses. Complication rate is low particularly in patients with sole pseudocysts or localized necroses. The extent of the fluid collections and necroses is a new predictive parameter for the outcome of the patients.

Management of peripancreatic fluid collections following partial pancreatectomy: a comparison of percutaneous versus EUS-guided drainage

BACKGROUND

Peripancreatic fluid collections (PFCs) occur in up to 30 % of patients following partial pancreatic resections. Traditionally, postoperative PFCs are managed via percutaneous drainage (PD). EUS-guided transgastric drainage has been shown to be effective for the management of PFCs secondary to acute pancreatitis. However, there are limited data on the use of EUS-guided drainage (EUSD) for the management of postoperative PFCs.

OBJECTIVE

To compare the safety and efficacy of PD versus EUSD of PFCs in patients who have undergone partial pancreatic resections.

DESIGN

Retrospective analysis of patients with symptomatic PFCs following pancreatic enucleation or distal pancreatectomy at MSKCC between January 2008 and December 2010. Patients were identified using an electronic medical records query in addition to a prospectively maintained pancreatic surgery complications database.

SETTING

Single, academic, tertiary referral center.

PATIENTS

Twenty-three patients with symptomatic PFCs following pancreatic enucleation or distal pancreatectomy were retrospectively identified.

INTERVENTIONS

CT-guided PD versus endoscopic ultrasound-guided drainage (EUSD) MAIN OUTCOME MEASURES: Outcomes included technical success, clinical success, number of interventions, and complications. Technical success was defined as successful localization of the PFC by fine-needle aspiration and placement of a drainage catheter or stent. Clinical success was defined as radiographic resolution of the PFC and removal of the drain or stent, without the need for an alternative drainage procedure or surgery.

RESULTS

PD was initially performed in 14 patients and EUSD initially in 9 patients. Three patients with initial PD had recurrence of PFC after removal of the external drain and underwent subsequent EUSD. The mean size of the fluid collections was 10.0 cm in the PD group and 8.9 cm in the EUSD group. Technical success was achieved in all patients in both groups. Clinical success was achieved in 11 of 14 (79 %) patients in the PD group compared with 11 of 11 (100 %) in the EUSD group, with one patient in the EUSD group lost to follow-up. One patient with initial PD required two additional percutaneous procedures before complete PFC resolution. Five EUSD patients required repeat endoscopy for stent revision or necrosectomy. The median number of interventions was two [range 1-5] in the PD group and two [range 1-5] in the EUSD group. The median number of days the drainage catheters were in place was 44.5 [range 2-87] in the PD group versus 57 [range 32-217] in the EUSD group. There were no procedure-related complications in either group. Adverse events in the PD group included splenic artery stump bleeding, pleural effusion, cysto-colonic and cysto-cutaneous fistulae, and persistent catheter site pain. One patient in the EUSD group developed a small-bowel obstruction and bleeding gastric ulcer.

LIMITATIONS

Retrospective, nonrandomized study and small numbers.

CONCLUSIONS

EUSD of postoperative PFCs appears to be safe and technically feasible. This technique appears to be as successful as PD for the management of PFCs with the advantage of not requiring an external drainage apparatus and should be considered as a therapeutic option in this group of patients. Further evaluation, with analysis of cost and quality of life, should be considered in a prospective, randomized trial.

The role of open necrosectomy in the current management of acute necrotizing pancreatitis: a review article

The optimal management of necrotizing pancreatitis continues to evolve. Currently, conservative intensive care treatment represents the primary therapy of acute severe necrotizing pancreatitis, aiming at prevention of organ failure. Following this mode of treatment most patients with sterile necroses can be managed successfully. Surgery might be considered as an option in the late phase of the disease for patients with proven infected pancreatic necroses and organ failure. For these patients surgical debridement is still considered the treatment of choice. However, even for this subgroup of patients, the concept of operative strategy has been recently challenged. Nowadays, it is generally accepted that necrotizing pancreatitis with proven infected necroses as well as septic complications directly caused by pancreatic infection are strong indications for surgical management. However, the question of the most appropriate surgical technique for the treatment of pancreatic necroses remains unsettled. At the same time, recent advances in radiological imaging, new developments in interventional radiology, and other minimal access interventions have revolutionised the management of necrotizing pancreatitis. In light of these controversies, the present paper will focus on the current role of surgery in terms of open necrosectomy in the management of severe acute necrotizing pancreatitis.

Surgical indications in acute pancreatitis

PURPOSE OF REVIEW

This review provides an update on the surgical management of acute pancreatitis, with a focus on evidence accumulated over the past year regarding the optimal approach to pancreatic debridement in the critically ill patient.

RECENT FINDINGS

Infected pancreatic necrosis remains the primary indication for surgery in patients with acute pancreatitis. Up to a quarter of patients with acute pancreatitis develop early bacteremia and pneumonia, and assessment of patients for surgery should include a thorough search for nonpancreatic sources of infection. Retroperitoneal, percutaneous and endoscopic approaches to pancreatic debridement can be used with success in appropriately selected critically ill patients. All minimally invasive approaches to necrosectomy are evolving, and there is currently insufficient evidence to advocate one approach over another. Management of patients with acute pancreatitis at high-volume centers appears to be associated with a survival benefit.

SUMMARY

The existing evidence demonstrates that control of infected pancreatic necrosis without laparotomy is possible with appropriate patient selection. Evidence regarding minimally invasive approaches to pancreatic debridement remains of limited quality.

Minimally invasive treatment of pancreatic necrosis

AIM: To systematically review these minimally invasive approaches to infected pancreatic necrosis.

METHODS: We used the MEDLINE database to investigate studies between 1996 and 2010 with greater than 10 patients that examined these techniques. Using a combination of Boolean operators, reports were retrieved addressing percutaneous therapy (341 studies), endoscopic necrosectomy (574 studies), laparoscopic necrosectomy via a transperitoneal approach (148 studies), and retroperitoneal necrosectomy (194 studies). Only cohorts with at least 10 or more patients were included. Non-English papers, letters, animal studies, duplicate series and reviews without original data were excluded, leaving a total of 27 studies for analysis.

RESULTS: Twenty-seven studies with 947 patients total were examined (eight studies on percutaneous approach; ten studies on endoscopic necrosectomy; two studies on laparoscopic necrosectomy via a transperitoneal approach; five studies on retroperitoneal necrosectomy; and two studies on a combined percutaneous-retroperitoneal approach). Success rate, complications, mortality, and number of procedures were outcomes that were included in the review. We found that most published reports were retrospective in nature, and thus, susceptible to selection and publication bias. Few reports examined these techniques in a comparative, prospective manner.

CONCLUSION: Each minimally invasive approach though was found to be safe and feasible in multiple reports. With these new techniques, treatment of infected pancreatic necrosis remains a challenge. We advocate a multidisciplinary approach to this complex problem with treatment individualized to each patient.

Interventions for necrotizing pancreatitis: summary of a multidisciplinary consensus conference

Pancreatic and peripancreatic necrosis may result in significant morbidity and mortality in patients with acute pancreatitis. Many recommendations have been made for management of necrotizing pancreatitis, but no published guidelines have incorporated the many recent developments in minimally invasive techniques for necrosectomy. Hence, a multidisciplinary conference was convened to develop a consensus on interventions for necrotizing pancreatitis. Participants included most international experts from multiple disciplines. The evidence for efficacy of interventions was reviewed, presentations were given by experts, and a consensus was reached on each topic. In summary, intervention is primarily indicated for infected necrosis, less often for symptomatic sterile necrosis, and should ideally be delayed as long as possible, preferably 4 weeks or longer after the onset of disease, for better demarcation and liquefaction of the necrosis. Both the step-up approach using percutaneous drainage followed by minimally invasive video-assisted retroperitoneal debridement and per-oral endoscopic necrosectomy have been shown to have superior outcomes to traditional open necrosectomy with respect to short-term and long-term morbidity and are emerging as treatments of choice. Applicability of these techniques depends on the availability of specialized expertise and a multidisciplinary team dedicated to the management of severe acute pancreatitis and its complications.

Treatment of necrotizing pancreatitis

Acute pancreatitis is a common and potentially lethal disease. It is associated with significant morbidity and consumes enormous health care resources. Over the last 2 decades, the treatment of acute pancreatitis has undergone fundamental changes based on new conceptual insights and evidence from clinical studies. The majority of patients with necrotizing pancreatitis have sterile necrosis, which can be successfully treated conservatively. Emphasis of conservative treatment is on supportive measures and prevention of infection of necrosis and other complications. Patients with infected necrosis generally need to undergo an intervention, which has shifted from primary open necrosectomy in an early disease stage to a step-up approach, starting with catheter drainage if needed, followed by minimally invasive surgical or endoscopic necrosectomy once peripancreatic collections have sufficiently demarcated. This review provides an overview of current standards for conservative and invasive treatment of necrotizing pancreatitis.

The Evolving Management of Infected Pancreatic Necrosis

Management of infected pancreatic necrosis (IPN) has for decades been based on early operative débridement. This approach is associated with mortality rates as high as 58 per cent. Recently, the care of these patients has evolved and emphasizes delayed operation and early intervention with percutaneous drainage. In 2002, we began to incorporate these new principles for the treatment of IPN and herein characterize the recent UCLA experience with management of IPN. A retrospective review of patients with IPN treated at UCLA between 2002 and 2011 was conducted. Mean patient age was 53.4 years. Mean Ranson's score was 3.3 ± 2.3 and average number of concurrent comorbidities 3.2 ± 2.5. All patients were treated with intravenous antibiotics. Thirteen of 18 patients (72.2%) had percutaneous drainage catheters placed (mean 1.1 drains per patient). Two patients were treated with percutaneous drainage alone. Sixteen of 18 (88.9%) eventually underwent surgical débridement. Of the operative patients, mean time from diagnosis to surgery was 28.4 days. The mortality in this group was 16.7 per cent. In conclusion, antibiotics and percutaneous drainage is an acceptable and possibly preferable initial therapeutic strategy for patients with IPN. Delayed operation and early intervention with percutaneous drainage appears to improve mortality for these patients.

The evolving management of infected pancreatic necrosis

Management of infected pancreatic necrosis (IPN) has for decades been based on early operative débridement. This approach is associated with mortality rates as high as 58 per cent. Recently, the care of these patients has evolved and emphasizes delayed operation and early intervention with percutaneous drainage. In 2002, we began to incorporate these new principles for the treatment of IPN and herein characterize the recent UCLA experience with management of IPN. A retrospective review of patients with IPN treated at UCLA between 2002 and 2011 was conducted. Mean patient age was 53.4 years. Mean Ranson's score was 3.3±2.3 and average number of concurrent comorbidities 3.2±2.5. All patients were treated with intravenous antibiotics. Thirteen of 18 patients (72.2%) had percutaneous drainage catheters placed (mean 1.1 drains per patient). Two patients were treated with percutaneous drainage alone. Sixteen of 18 (88.9%) eventually underwent surgical débridement. Of the operative patients, mean time from diagnosis to surgery was 28.4 days. The mortality in this group was 16.7 per cent. In conclusion, antibiotics and percutaneous drainage is an acceptable and possibly preferable initial therapeutic strategy for patients with IPN. Delayed operation and early intervention with percutaneous drainage appears to improve mortality for these patients.

Current Status of Direct Endoscopic Necrosectomy

The management of pancreatic necrosis has evolved. Sterile necrosis is now managed conservatively. Intervention is generally required for infected necrosis but is now deferred until four weeks after disease onset in order to permit encapsulation and demarcation of the necrotic collection. Demarcation facilitates necrosectomy and reduces complications related to the drainage and debridement procedures. The approach to pancreatic necrosectomy has evolved from primary open necrosectomy to minimally-invasive radiologic, surgical and endoscopic procedures. Direct endoscopic necrosectomy is a minimally-invasive technique that was introduced in recent years for the treatment of infected walled-off necrosis. A stoma is created endoscopically between the gastric lumen and the walled-off collection. An endoscope is then inserted directly into the cavity to perform endoscopic necrosectomy. This is followed by short-term placement of double pigtail transgastric stents and nasocystic catheter for post-procedural irrigation and drainage. This review will summarise the current status of direct endoscopic necrosectomy.

Endoscopic necrosectomy for walled-off pancreatic necrosis

Approximately 20% of patients with acute pancreatitis develop pancreatic necrosis with significant mortality. Surgical debridement is the traditional management of necrotizing pancreatitis, but it is associated with significant morbidity and mortality. Endoscopic necrosectomy using repeats session of debridement and stent insertion has been more frequently used within the last decade and half. This technique continues to evolve as we attempt to optimize the post-procedural outcomes.

Acute and chronic pancreatitis: surgical management

Pancreatitis is becoming increasingly prevalent in children, posing new challenges to pediatric health care providers. Although some general adult treatment paradigms are applicable in the pediatric population, diagnostic workup and surgical management of acute and chronic pancreatitis have to be tailored to anatomic and pathophysiological entities peculiar to children. Nonbiliary causes of acute pancreatitis in children are generally managed nonoperatively with hydration, close biochemical and clinical observation, and early initiation of enteral feeds. Surgical intervention including cholecystectomy or endoscopic retrograde cholangiopancreatography is often required in acute biliary pancreatitis, whereas infected pancreatic necrosis remains a rare absolute indication for pancreatic debridement and drainage via open, laparoscopic, or interventional radiologic procedure. Chronic pancreatitis is characterized by painful irreversible changes of the parenchyma and ducts, which may result in or be caused by inadequate ductal drainage. A variety of surgical procedures providing drainage, denervation, resection, or a combination thereof are well established to relieve pain and preserve pancreatic function.

Management of infected pancreatic necrosis using retroperitoneal necrosectomy with flexible endoscope: 10 years of experience

BACKGROUND

This study was designed to provide our experience in the management of infected and drained pancreatic necrosis using the retroperitoneal approach.

METHODS

This was a prospective observational study in a tertiary care university hospital. Thirty-two patients with confirmed infected pancreatic necrosis were studied. Superficial necrosectomy was performed with lavage and aspiration of debris. This was achieved though a retroperitoneal approach of the pancreatic area and under the direct vision of a flexible endoscope. The follow-up procedure using retroperitoneal endoscopy did not require taking the patient to the operating room. The main outcome measures were infection control, morbidity, and mortality related to technique, reintervention, and long-term follow-up.

RESULTS

No significant morbidity or mortality related to the technique was observed in all of the patients with infected pancreatic necrosis treated with this retroperitoneal approach compared with published data using other approaches. Reinterventions were not required and patients are currently asymptomatic.

CONCLUSIONS

Retroperitoneal access of the pancreatic area is a good approach for drainage and debridement of infected pancreatic necrosis. Translumbar retroperitoneal endoscopy allows exploration under direct visual guidance avoiding open transabdominal reintervention and the risk of contamination of the abdominal cavity. This technique does not increase morbidity and mortality, can be performed at the patients' bedside as many times as necessary, and has advantages over other retroperitoneal approaches.

The revised Atlanta classification of acute pancreatitis: its importance for the radiologist and its effect on treatment

An international working group has modified the Atlanta classification for acute pancreatitis to update the terminology and provide simple functional clinical and morphologic classifications. The modifications (a) address the clinical course and severity of disease, (b) divide acute pancreatitis into interstitial edematous pancreatitis and necrotizing pancreatitis, (c) distinguish an early phase (1st week) and a late phase (after the 1st week), and (d) emphasize systemic inflammatory response syndrome and multisystem organ failure. In the 1st week, only clinical parameters are important for treatment planning. After the 1st week, morphologic criteria defined on the basis of computed tomographic findings are combined with clinical parameters to help determine care. This revised classification introduces new terminology for pancreatic fluid collections. Depending on presence or absence of necrosis, acute collections in the first 4 weeks are called acute necrotic collections or acute peripancreatic fluid collections. Once an enhancing capsule develops, persistent acute peripancreatic fluid collections are referred to as pseudocysts; and acute necrotic collections, as walled-off necroses. All can be sterile or infected. Terms such as pancreatic abscess and intrapancreatic pseudocyst have been abandoned. The goal is for radiologists, gastroenterologists, surgeons, and pathologists to use the revised classifications to standardize imaging terminology to facilitate treatment planning and enable precise comparison of results among different departments and institutions.

Percutaneous catheter drainage for infective pancreatic necrosis: is it always the first choice for all patients?

OBJECTIVE

To learn the clinical outcome of percutaneous catheter drainage (PCD) for patients with infective pancreatic necrosis and the possible influencing factors.

METHODS

A retrospective review of medical records of patients with infective pancreatic necrosis who received PCD as the first choice for treatment in the recent 2 years. The patients were divided into 2 groups: (1) PCD success group and (2) PCD alteration group. Characteristics, complications, and PCD process were compared.

RESULTS

In this study, 19 of 34 patients were cured by PCD alone (55.9%), whereas open necrosectomy were needed for 15 patients (44.1%). Between these 2 groups, most baseline and clinical characteristics did not show any statistical difference, including the number and size of catheter used and the bacterial culture result. The PCD alteration group had higher mean computed tomographic density (P = 0.012) and larger distribution range of infected pancreatic necrosis (4.53 ± 1.35 vs 5.93 ± 1.62; P = 0.009) than the PCD success group (P < 0.01). The logistic regression analysis revealed the same facts.

CONCLUSION

The mean computed tomographic density and distribution range of infective pancreatic necrosis could significantly influence the success rate of PCD; higher values of them indicate less appropriate for PCD; thus, it should be considered seriously before the treatment decision.

Management of severe acute pancreatitis

Severe acute pancreatitis (SAP) develops in about 25% of patients with acute pancreatitis. Severity of acute pancreatitis is linked to the presence of systemic organ dysfunctions and/or necrotizing pancreatitis. Risk factors independently determining the outcome of SAP are early multiorgan failure (MOF), infection of necrosis, and extended necrosis (>50%). Morbidity of SAP is biphasic, in the first week it is strongly related to systemic inflammatory response syndrome while, sepsis due to infected pancreatic necrosis leading to MOF syndrome occurs in the later course after the first week. Contrast-enhanced computed tomography provides the highest diagnostic accuracy for necrotizing pancreatitis when performed after the first week of disease. Patients who suffer early organ dysfunctions or are at risk for developing a severe disease require early intensive care treatment. Antibiotic prophylaxis has not been shown as an effective preventive treatment. Early enteral feeding is based on a high level of evidence, resulting in a reduction of local and systemic infection. Patients suffering infected necrosis causing clinical sepsis are candidates for intervention. Hospital mortality of SAP after interventional or surgical debridement has decreased to below 20% in high-volume centers.

Management of severe acute pancreatitis

Severe acute pancreatitis (SAP) develops in about 25% of patients with acute pancreatitis. Severity of acute pancreatitis is linked to the presence of systemic organ dysfunctions and/or necrotizing pancreatitis. Risk factors independently determining the outcome of SAP are early multiorgan failure (MOF), infection of necrosis, and extended necrosis (>50%). Morbidity of SAP is biphasic, in the first week it is strongly related to systemic inflammatory response syndrome while, sepsis due to infected pancreatic necrosis leading to MOF syndrome occurs in the later course after the first week. Contrast-enhanced computed tomography provides the highest diagnostic accuracy for necrotizing pancreatitis when performed after the first week of disease. Patients who suffer early organ dysfunctions or are at risk for developing a severe disease require early intensive care treatment. Antibiotic prophylaxis has not been shown as an effective preventive treatment. Early enteral feeding is based on a high level of evidence, resulting in a reduction of local and systemic infection. Patients suffering infected necrosis causing clinical sepsis are candidates for intervention. Hospital mortality of SAP after interventional or surgical debridement has decreased to below 20% in high-volume centers.

[Pancreatic necrosis: pro surgical therapy]

Currently, patients with severe necrotizing pancreatitis rarely need interventional or surgical treatment. However, in case of pancreatic infection and septic complications they should be treated with the step up approach, primarily with an interventional or endoscopic drainage. If further clinical deterioration occurs necrosectomy is indicated. This should ideally be postponed until the third or fourth week after onset of pancreatitis to optimize surgical conditions including demarcation of the necrosis. Open necrosectomy with postoperative continuous lavage is a valid treatment option with low mortality, low morbidity and good long-term outcome. In recent years, several minimally invasive techniques for necrosectomy have been developed and are alternative approaches in about 70% of cases. In most cases, the retroperitoneoscopic approach is used, although the endoscopic transgastric route is also being used more and more frequently. While the reduced operative trauma should theoretically also reduce the onset of postoperative organ failure, no study has actually proven this.

A conservative and minimally invasive approach to necrotizing pancreatitis improves outcome

BACKGROUND & AIMS

Treatment of patients with necrotizing pancreatitis has become more conservative and less invasive, but there are few data from prospective studies to support the efficacy of this change. We performed a prospective multicenter study of treatment outcomes among patients with necrotizing pancreatitis.

METHODS

We collected data from 639 consecutive patients with necrotizing pancreatitis, from 2004 to 2008, treated at 21 Dutch hospitals. Data were analyzed for disease severity, interventions (radiologic, endoscopic, surgical), and outcome.

RESULTS

Overall mortality was 15% (n=93). Organ failure occurred in 240 patients (38%), with 35% mortality. Treatment was conservative in 397 patients (62%), with 7% mortality. An intervention was performed in 242 patients (38%), with 27% mortality; this included early emergency laparotomy in 32 patients (5%), with 78% mortality. Patients with longer times between admission and intervention had lower mortality: 0 to 14 days, 56%; 14 to 29 days, 26%; and >29 days, 15% (P<.001). A total of 208 patients (33%) received interventions for infected necrosis, with 19% mortality. Catheter drainage was most often performed as the first intervention (63% of cases), without additional necrosectomy in 35% of patients. Primary catheter drainage had fewer complications than primary necrosectomy (42% vs 64%, P=.003). Patients with pancreatic parenchymal necrosis (n=324), compared with patients with only peripancreatic necrosis (n=315), had a higher risk of organ failure (50% vs 24%, P<.001) and mortality (20% vs 9%, P<.001).

CONCLUSIONS

Approximately 62% of patients with necrotizing pancreatitis can be treated without an intervention and with low mortality. In patients with infected necrosis, delayed intervention and catheter drainage as first treatment improves outcome.

Fluid collections in and around the pancreas in acute pancreatitis

The advent of computed tomographic scan with its wide use in the evaluation of acute pancreatitis has opened up a new topic in pancreatology i.e. fluid collections. Fluid collections in and around the pancreas occur often in acute pancreatitis and were defined by the Atlanta Symposium on Acute Pancreatitis in 1992. Two decades since the Atlanta Conference additional experience has brought to light the inadequacy and poor understanding of the terms used by different specialists involved in the care of patients with acute pancreatitis when interpreting imaging modalities and the need for a uniformly used classification system. The deficiencies of the Atlanta definitions and advances in medicine have led to a proposed revision of the Atlanta classification promulgated by the Acute Pancreatitis Classification Working Group. The newly used terms "acute peripancreatic fluid collections," "pancreatic pseudocyst," "postnecrotic pancreatic/peripancreatic fluid collections," and "walled-off pancreatic necrosis" are to be clearly understood in the interpretation of imaging studies. The current treatment methods for fluid collections are diverse and depend on accurate interpretations of radiologic tests. Management options include conservative treatment, percutaneous catheter drainage, open and laparoscopic surgery, and endoscopic drainage. The choice of treatment depends on a correct diagnosis of the type of fluid collection. In this study we have attempted to clarify the management and clinical features of different types of fluid collections as they have been initially defined under the 1992 Atlanta Classification and revised by the Working Group's proposed categorization.

History, goals, and technique of laparoscopic pancreatic necrosectomy

The surgical treatment of severe acute pancreatitis has significantly changed in the last several years with the advent of enhanced imaging techniques and minimally invasive surgery. Criteria for surgical intervention have been influenced by the use of step-up approaches that provide incremental multimodality interventions with repeat imaging. Here, we provide a brief introduction to the history, goals, indications, and technique of laparoscopic pancreatic necrosectomy. The technique requires a fundamental understanding of the natural history of pancreatitis and its complication. Laparoscopic approaches can be useful as primary and adjunctive therapy for the treatment of infected pancreatitic necrosis.

Endoscopic necrosectomy of pancreatic necrosis: a systematic review

AIM

To review the current status of the novel technique of endoscopic necrosectomy in the management of pancreatic necrosis after acute pancreatitis.

METHODS

Studies were identified by searching Medline, PubMed and Embase databases for articles from January 1990 to December 2009 using the keywords "acute pancreatitis", "pancreatic necrosis" and "endoscopy". Additional papers were identified by a manual search of the references from the key articles. Case series of fewer than five patients and case reports were excluded.

RESULTS

Indications, techniques and outcomes of endoscopic necrosectomy were analysed. There were no randomised controlled trials identified. Ten case series were included in this analysis. There were a total of more than 1,100 endoscopic necrosectomy procedures in 260 patients with pancreatic necrosis. One hundred fifty-five were proven to be infected necrosis on culture. The overall mortality rate was 5%. The mean procedure-related morbidity rate was 27%. The rate of complete resolution of pancreatic necrosis with the endoscopic method alone was 76%.

CONCLUSIONS

Endoscopic necrosectomy is a safe and effective treatment option in selected patients with pancreatic necrosis after acute pancreatitis. Future studies will be required to further define the selection criteria and the techniques for the endoscopic procedure.

[Pancreatic necrosis: pro-endoscopic therapy]

The transmural endoscopic debridement and other minimally invasive therapies of infected postpancreatic necroses have been developed over the last decade as alternatives to open surgery. In several clinical centers the endoscopic approach has become standard therapy. The mortality rate in published series is in the range 0-15% and additional surgery is needed in 0-40%.Out of 73 own patients treated endoscopically between 2006 and 2010, 4 were operated because of bleeding, 2 with an acute abdomen and 3 with sepsis. Of the patients 6 died because of multi-organ failure and in 3 cases despite surgery. Main complications such as bleeding (n=20) and acute abdomen (n=7) were mostly treated conservatively. There was no procedure-related mortality. The endoscopic therapy was successful in 59 patients (80%) of whom 7 required further transmural endoscopic interventions for cystic relapses.At present, finding the best combination of endoscopic-transmural, percutaneous, laparoscopic and sometimes finally open surgical therapy remains an interdisciplinary challenge. The only randomized study published in this context clearly indicates that such a step-up approach is the most favorable.

Open transgastric debridement and internal drainage of symptomatic non-infected walled-off pancreatic necrosis

BACKGROUND

The best treatment options for walled-off pancreatic necrosis (WOPN) are not well defined. A retrospective study of patients treated for WOPN with transgastric debridement and internal drainage was undertaken.

METHODS

Patients with symptomatic non-infected WOPN treated with open transgastric debridement and internal drainage were evaluated.

RESULTS

In all, 51 patients underwent surgical management of necrotizing pancreatitis during the study period. Ten patients (19%) were treated with open transgastric debridement and internal drainage for symptomatic non-infected WOPN. The median patient age was 40 years, the most common aetiology for pancreatitis was biliary, the mean American Society of Anesthesiologists (ASA) score was 2 and the delay to surgery was 100 days. The operating time was 118 min, with a blood loss of 50cc. One patient required reoperation, three patients had morbidity and there were no mortalities. The only factor associated with post-operative morbidity was the presence of positive cultures (P < 0.05). The length of stay (LOS) after surgery was 8 days, at a median follow-up of 18 months, one patient had late complications related to the surgery and the procedure was successful in 90% of the patients.

DISCUSSION

Open transgastric debridement with internal drainage of WOPN is safe and efficacious. Patients were clinically stable (no organ failure) and had a long delay in surgical intervention (100 days). In this select group of patients, the success, morbidity and mortality is similar to all reported minimally invasive techniques.

Pancreatitis, very early compared with normal start of enteral feeding (PYTHON trial): design and rationale of a randomised controlled multicenter trial

BACKGROUND

In predicted severe acute pancreatitis, infections have a negative effect on clinical outcome. A start of enteral nutrition (EN) within 24 hours of onset may reduce the number of infections as compared to the current practice of starting an oral diet and EN if necessary at 3-4 days after admission.

METHODS/DESIGN

The PYTHON trial is a randomised controlled, parallel-group, superiority multicenter trial. Patients with predicted severe acute pancreatitis (Imrie-score ≥ 3 or APACHE-II score ≥ 8 or CRP > 150 mg/L) will be randomised to EN within 24 hours or an oral diet and EN if necessary, after 72 hours after hospital admission.During a 3-year period, 208 patients will be enrolled from 20 hospitals of the Dutch Pancreatitis Study Group. The primary endpoint is a composite of mortality or infections (bacteraemia, infected pancreatic or peripancreatic necrosis, pneumonia) during hospital stay or within 6 months following randomisation. Secondary endpoints include other major morbidity (e.g. new onset organ failure, need for intervention), intolerance of enteral feeding and total costs from a societal perspective.

DISCUSSION

The PYTHON trial is designed to show that a very early (< 24 h) start of EN reduces the combined endpoint of mortality or infections as compared to the current practice of an oral diet and EN if necessary at around 72 hours after admission for predicted severe acute pancreatitis.

TRIAL REGISTRATION

ISRCTN: ISRCTN18170985.

Acute pancreatitis with an emphasis on infection

Acute pancreatitis is an inflammatory disease that is mild and self-limiting in about 80% of cases. However, severe necrotizing disease still has a mortality of up to 30%. Differentiated multimodal treatment concepts are needed for these patients, including a multidisciplinary team (intensivists, gastroenterologists, interventional radiologists, and surgeons). The primary therapy is supportive. Patients with infected pancreatic necrosis who are septic undergo interventional or surgical treatment, ideally not before the fourth week after onset of symptoms. This article reviews the pathophysiologic mechanisms of acute pancreatitis and describes clinical pathways for diagnosis and management based on the current literature and guidelines.