Endoscopic treatment of walled-off pancreatic necrosis complicated with pancreaticocolonic fistula

Selection strategy for endoscopic necrosectomy approaches of infected walled-off pancreatic necrosis: Analysis of 101 patients from a single center with long-term follow-up

OBJECTIVES

Endoscopic necrosectomy (EN) is a promising minimally invasive approach for treating infected walled-off pancreatic necrosis (WOPN). Multiple EN approaches are currently available, though criteria for selecting the optimal approaches are lacking. We aimed to propose a rational selection strategy of EN and to retrospectively evaluate its safety and effectiveness.

METHODS

Altogether 101 patients who underwent EN for infected WOPN at a tertiary hospital between June 2009 and February 2023 were retrospectively included for analysis. Demographic characteristics, details of the EN procedures, procedure-related adverse events, and clinical outcomes were investigated.

RESULTS

Among these 101 patients with WOPN, 56 (55.4%) underwent transluminal EN, 38 (37.6%) underwent percutaneous EN, and seven (6.9%) underwent combined approach, respectively. Clinical success was achieved in 94 (93.1%) patients. Seven (6.9%) experienced procedure-related adverse events, and seven (6.9%) died during the treatment period. During a median follow-up of 50 months, 5 (5.3%) of the 94 patients had disease recurrence, 17.0% (16/94) had new-onset diabetes mellitus, and 6.4% (6/94) needed oral pancreatic enzyme supplementation. The clinical success rate, procedure-related adverse event rate, and long-term follow-up outcomes were not significantly different among the three groups. High APACHE-II scores (≥15) and organ failure were identified as factors related to treatment failure.

CONCLUSIONS

A selection strategy for EN approaches, based on the extent of necrosis and its distance from the gastrointestinal lumen (using a threshold of 15 mm), is safe and effective for treating infected WOPN in both short-term and long-term outcomes.

Characteristics and Incidence of Colon Complication in Necrotizing pancreatitis: A Propensity Score-Matched Study

Objective

To clarify the incidence of colonic complications in patients with NP and their impact on prognosis.

Methods

The clinical data of NP patients admitted to the Department of General Surgery of Xuanwu Hospital, Capital Medical University from January 2014 to December 2020 were retrospectively analyzed. Patients were grouped according to the presence or absence of colonic complications, and the clinical prognosis of the two groups was analyzed after matching using a 1:1 propensity score, The primary study endpoint was patient mortality during hospitalization. Data are reported as median (range) or percentage of patients (%).

Results

A total of 306 patients with NP were included in this study, and the incidence of colonic complications was 12.4%, including 15 cases of colonic obstruction, 17 cases of colonic fistula, and 9 cases of colonic hemorrhage. Before matching, patients in the colonic group had severe admissions and poor clinical outcomes (P<0.05). After matching, the baseline data and clinical characteristics at admission were comparable between the two groups of patients. In terms of clinical outcomes, although the mortality was similar in the two groups (P>0.05), but patients in the colonic group were more likely to have multiorgan failure, length of nutrition support, number of minimally invasive interventions, number of extra-pancreatic infections, length of ICU stay and total length of stay were significantly higher than those of patients in the group without colonic complications (P<0.05). During long-term follow-up, patients in the colonic group were more likely to develop recurrent pancreatitis.

Conclusion

About 12.4% of NP patients developed colonic complications, and after PSM it was found that colonic complications only led to a longer hospital stay and an increased number of clinical interventions in NP patients and did not increase the mortality.

Endoscopic treatment of pancreaticopleural fistulas

INTRODUCTION

Pancreaticopleural fistula (PPF) is a serious complication of acute and chronic pancreatitis.

OBJECTIVE

To evaluate the effectiveness of various endoscopic techniques for the treatment of patients with PPFs.

METHODOLOGY

Prospective analysis of the results of endoscopic treatment of 22 patients with PPF due to pancreatitis was conducted at the Department of General, Gastroenterological, and Oncological Surgery, Ludwik Rydygier Collegium Medicum in Bydgoszcz, Nicolaus Copernicus University in Torun, between 2018 and 2021.

RESULTS

PPF was diagnosed in 22 patients (21 men and 1 woman; mean age 49.52 [30-67] years) with pancreatitis. In 19/22 (86.36%) patients, PPF communicated with the left pleural cavity and in 3/22 (13.64%) patients with the right pleural cavity. Chronic pancreatitis was diagnosed in 14/22 (63.64%) patients. Symptomatic pancreatic fluid collections were found in 15/22 (68.18%) patients with PPF (pancreatic pseudocyst in 11 and walled-off pancreatic necrosis in four patients). Endoscopic retrograde cholangiopancreatography was performed in 21/22 (95.45%) patients, confirming the diagnosis of PPF. All 21 patients underwent endoscopic sphincterotomy with prosthesis implantation in the main pancreatic duct (passive transpapillary drainage). In 1/22 (4.55%) patients, active transmural/transgastric drainage of the PPF was necessary due to inflammatory infiltration of the peripapillary region, precluding endoscopic pancreatography. Endoscopic transmural drainage was performed in all the 15 patients with pancreatic fluid collection. Clinical success was achieved in 21/22 (95.45%) patients. The mean total time of endotherapy was 191 (range 88-712) days. Long-term success of endoscopic treatment of PPFs during one year follow-up period was achieved in 19/22 (86.36%) patients.

CONCLUSIONS

Endoscopic treatment is effective for managing post-inflammatory PPFs. The preferred treatment method is passive transpapillary drainage (prosthesis of the main pancreatic duct). If transpapillary drainage is not feasible, transmural drainage of the PPF remains the preferred method. Endoscopic transmural drainage leads to closure of the fistula canal in patients with pancreatic fluid collection complicated by PPF.

Management of colonic fistulas in patients with infected pancreatic necrosis being treated with a step-up approach

BACKGROUND

Colonic fistula is a potentially fatal complication in acute necrotizing pancreatitis (ANP), especially in patients with infected pancreatic necrosis (IPN). The aim of this study was to evaluate the feasibility of a step-up approach including percutaneous catheter drainage (PCD) and continuous negative pressure irrigation (CNPI) in a group of patients with colonic fistula.

METHODS

A retrospective review of a prospectively collected data was performed. Data were extracted for patients complicated by colonic fistula from January 2010 to January 2017.

RESULTS

A total of 1750 patients were admitted with ANP during the study period. Of these patients, 711 (41%) developed IPN and colonic fistula was present in 132 (19%). A step-up approach was adopted for all patients, with 47% avoiding surgery. The mortality in patients requiring surgery (37%) was higher than that in patients managed non-surgically (19%) constituting an overall mortality rate of 29%. In patients managed conservatively, 92% had spontaneous closure of the fistula.

CONCLUSION

Colonic fistula is not a rare complication in ANP occurring in 19% of patients with IPN in the current study. A step-up approach was effective and safe in managing colonic fistula and surgery could be obviated in nearly half of the patients.

Spontaneous regression of asymptomatic walled-off pancreatic necrosis

INTRODUCTION

Asymptomatic walled-off pancreatic necrosis (WOPN) should be treated conservatively, irrespective of the extent and size of the necrosis. The aim of this study was to evaluate the efficacy and safety of a strategy involving the observation of patients with asymptomatic WOPN over a long period of time.

MATERIAL AND METHODS

This study involved the retrospective analysis of 368 patients hospitalized in our department between 2010 and 2016, due to acute pancreatitis and its consequences in the form of pancreatic and peripancreatic fluid collection.

RESULTS

Walled-off pancreatic necrosis was identified in 168/368 (46%) patients. 124/168 (74%) patients with WOPN required interventional treatment due to clinical symptoms arising from the presence of the WOPN. Asymptomatic WOPN was identified in 44/168 (26%) patients. The mean observation time of patients with asymptomatic WOPN was 417.02 days (range: 47-1149 days). Only 1 out of the 44 patients (2%) failed to complete the follow-up. Complete regression of WOPN occurred in 30/44 (68%) patients. The presence of symptoms related to WOPN were identified in 13/44 (30%) patients during the observation. The most frequent indication for interventional treatment of WOPN was infection of the pancreatic necrosis, which was identified in 6/13 patients (46%). Altogether, 137/168 (82%) patients with WOPN required interventional treatment.

CONCLUSIONS

The majority of patients with WOPN required interventional treatment. This study provided evidence to support the view that careful observation of patients with asymptomatic WOPN is an efficient and safe treatment strategy. Long-term observation of such patients showed that most will experience spontaneous regression of asymptomatic WOPN without any other form of interventional treatment.

The role of endoscopic treatment of pancreatic duct disruption in patients with walled-off pancreatic necrosis

BACKGROUND

The place of endoscopic techniques in the treatment of main pancreatic duct (MPD) disruption arising in the course of acute necrotizing pancreatitis (ANP) remains unclear. The aim of this study was to describe the findings of endoscopic retrograde pancreatography (ERP) in patients with walled-off necrosis (WON). It was attempted to evaluate the role of endoscopic treatment of pancreatic duct disruption in patients with WON.

METHODS

The retrospective analysis of results and complications with particular emphasis to all ERP procedures in the group of 226 patients was conducted, which underwent endoscopic treatment of symptomatic WON between years 2001 and 2016 in the Department of Gastroenterology and Hepatology of Medical University of Gdańsk.

RESULTS

ERP was performed in 204/226 (90.27%) patients. Partial and complete disruption of the MPD were identified in 103 (50.49%) and 63 (30.89%) out of 204 patients, respectively. Endoscopic treatment was used in all 166 patients with MPD disruption. The success of endoscopic treatment of MPD disruption was achieved in 138/161 (85.71%) patients with WON. The therapeutic success of WON endotherapy was achieved in 214/226 (94.69%) patients. The mean follow-up duration was 56 (SD = 37.06) [range 14-158] months. Long-term success of treatment of WON was achieved in 182/226 (80.53%) patients.

CONCLUSIONS

MPD disruption occurs in the majority of patients with WON. Partial disruption of the MPD is more frequent than complete disruption of the duct. This study conducted on a large group of patients demonstrated that prosthesis insertion into the MPD in patients with disruption of the MPD in the course of ANP is one of the key elements in endoscopic treatment of WON. Passive transpapillary drainage is an effective method of treating MPD disruptions, which improves long-term outcomes of endoscopic treatment in patients with WON.