Management of infected pancreatic necrosis

Pancreatic Necrosectomy through Sinus Tract Endoscopy

BACKGROUND/AIMS

Direct endoscopic pancreatic necrosectomy is increasingly being utilized to treat infected or symptomatic walled-off necrosis (WON) located close to the stomach or duodenum. Laterally-placed WON has traditionally been treated surgically. We evaluated a less utilized technique of sinus tract endoscopy (STE) for symptomatic laterally-placed WON.

METHODS

Two hundred seventy-six patients with acute pancreatitis admitted in our hospital, 32 had symptomatic or infected WON requiring intervention. Of the 12 patients with laterally placed WON, 10 were treated by STE. STE was performed with a standard adult gastroscope passed through a percutaneous tract created by the placement of a 32-Fr drain.

RESULTS

Ten patients (7 males; mean age, 43.8 years) underwent STE. Mean number of sessions was 2.3 (range, 1-4), with mean time of 70 minutes for each session (range, 15-70 minutes). While 9 patients had complete success, 1 patient had fever and chose to undergo surgery. Two patients developed pneumoperitoneum, which was treated conservatively. There was no mortality, cutaneous fistula, or recurrence during follow-up.

CONCLUSIONS

Laterally placed WON can be successfully managed by STE performed through a percutaneously placed drain. Details of the technique and end-points of STE require further evaluation.

Nutrition, inflammation, and acute pancreatitis

Acute pancreatitis is acute inflammatory disease of the pancreas. Nutrition has a number of anti-inflammatory effects that could affect outcomes of patients with pancreatitis. Further, it is the most promising nonspecific treatment modality in acute pancreatitis to date. This paper summarizes the best available evidence regarding the use of nutrition with a view of optimising clinical management of patients with acute pancreatitis.

Microbiologic analysis of peri-pancreatic fluid collected during EUS in patients with pancreatitis: impact on antibiotic therapy

BACKGROUND

Pancreatitis is a potentially life-threatening condition frequently accompanied by peri-pancreatic fluid collections (PPFC), such as pseudocysts or pancreatic necrosis. Aspiration of PPFCs during EUS interventions for microbiologic analysis is still rarely performed in clinical routine.

OBJECTIVE

To evaluate the role of routine microbiologic analysis of PPFCs and its impact on antibiotic therapy in patients with pancreatitis.

DESIGN

Prospective, observational, multicenter study.

SETTING

Four treatment centers.

PATIENTS

A total of 44 consecutive patients who presented for endoscopic treatment of PPFCs were included.

INTERVENTION

Concomitantly, PPFC during intervention and concomitant blood cultures were obtained.

MAIN OUTCOME MEASUREMENTS

Microbiologic examination of PPFCs and blood samples.

RESULTS

Colonization of PPFCs was found in 59% of PPFC cultures, whereas all but 2 concomitant blood cultures showed no microbial growth. Risk factors for a colonization were the presence of necrosis (P = .006), acute pancreatitis (P = .033), leukocytosis (P = .001), elevated C-reactive protein levels (P = .003), fever (P = .02), turbid material (P = .031), and longer hospital stay (P = .003). In 23 patients with fluid colonization despite empiric antibiotic therapy, the treatment had to be adjusted in 18 patients (78%) according to the observed antibiotic susceptibility profile.

LIMITATIONS

Contamination cannot be totally excluded.

CONCLUSION

The microbiologic colonization of PPFCs in patients with pancreatitis is common. Only the direct microbiologic analysis of PPFCs, but not of blood cultures, is useful to optimize an effective antibiotic therapy in patients with pancreatitis.

Therapeutic effects of electroacupuncture at ST36 acupoint on sodium-taurocholate-induced severe acute pancreatitis

OBJECTIVE

To explore the protective effects and mechanisms of electroacupuncture (EA) at Zusanli (ST36) acupoint in rats with severe acute pancreatitis (SAP).

METHODS

Sixty-six male Sprague-Dawley rats were randomly assigned to three groups of 22 each: a SAP model group (SAP group), a shamoperated group (sham group) and a EA at ST36 acupoint group (EA group). A rat model of SAP was induced by pancreatic duct injection with 3.5% sodium taurocholate. EA was performed at ST36 acupoint for 30 min after induction of SAP and 30 min before sacrificed. The rats were killed at 3 h (n=7), 6 h (n=7) and 12 h (n=8) after operation, and blood samples were taken for the measurement of tumor necrosis factor-alpha (TNF-α), interleukin-6 (IL-6) and acetylcholine (Ach) by enzyme-linked immunosorbnent assay. The pathological changes of pancreatic tissue, volume of ascites and pancreatic weight/body weight ratio were measured.

RESULTS

The serum concentrations of TNF-α and IL-6 in the EA group were significantly lower than in the SAP group at 3, 6 and 12 h after the operation (p<0.05). Serum Ach in the EA group was significantly higher than in the SAP group at various time points after operation (p<0.05). The other parameters were clearly improved after treatment with EA.

CONCLUSION

EA at ST36 acupoint might have a therapeutic effect in rats with SAP through activating the cholinergic anti-inflammatory pathway.

Interventions for necrotizing pancreatitis: an overview of current approaches

The management of necrotizing pancreatitis has undergone a paradigm shift toward minimally invasive techniques for necrosectomy, obviating the need for open necrosectomy in most cases. There is increasing evidence that minimally invasive approaches including a step-up approach that incorporates percutaneous catheter or endoscopic transluminal drainage, followed by video-assisted retroperitoneal or endoscopic debridement are associated with improved outcomes over traditional open necrosectomy for patients with infected necrosis. A recent international multidisciplinary consensus conference emphasized the superiority of minimally invasive approaches over standard surgical approaches. The success of these techniques depends on concerted efforts of a multidisciplinary team of interventional endoscopists, radiologists, intensivists and surgeons dedicated to the management of severe acute pancreatitis and its complications. This review provides an overview of minimally invasive techniques for management of necrotizing pancreatitis, including indications, timing, advantages and disadvantages.

Magnetic resonance imaging for acute pancreatitis

Acute pancreatitis is characterized by acute chemical injury of the pancreatic parenchyma and peripancreatic tissue. The increased frequency of death in acute pancreatitis is directly correlated with the degree and progress of pancreatic necrosis. Moreover, the occurrence of some local complications in acute pancreatitis, such as pancreatic hemorrhage, peripancreatic abscess or large pseudocyst, and pseudoaneurysm, could influence the choice of treatment for these patients. Magnetic resonance imaging (MRI) can be used to help evaluate the presence and degree of pancreatic necrosis, and is crucial for identifying complications of acute pancreatitis and predicting prognosis. The purpose of this article is to describe MRI techniques for acute pancreatitis, to review the spectrum of pancreatic and peripancreatic patterns, as well as to survey various complications secondary to acute pancreatitis on MRI. The role of MRI in the initial evaluation and staging of acute pancreatitis is emphasized.

Antibiotic therapy for prophylaxis against infection of pancreatic necrosis in acute pancreatitis

BACKGROUND

Pancreatic necrosis may complicate severe acute pancreatitis, and is detectable by computed tomography (CT). If it becomes infected mortality increases, but the use of prophylactic antibiotics raises concerns about antibiotic resistance and fungal infection.

OBJECTIVES

To determine the efficacy and safety of prophylactic antibiotics in acute pancreatitis complicated by CT proven pancreatic necrosis.

SEARCH STRATEGY

Searches were updated in November 2008, in The Cochrane Library (Issue 2, 2008), MEDLINE, EMBASE, and CINAHL. Conference proceedings and references from found articles were also searched.

SELECTION CRITERIA

Randomised controlled trials (RCTs) comparing antibiotics versus placebo in acute pancreatitis with CT proven necrosis.

DATA COLLECTION AND ANALYSIS

Primary outcomes were mortality and pancreatic infection rates. Secondary end-points included non pancreatic infection, all sites infection, operative rates, fungal infections, and antibiotic resistance. Subgroup analyses were performed for antibiotic regimen (beta-lactam, quinolone, and imipenem).

MAIN RESULTS

Seven evaluable studies randomised 404 patients. There was no statistically significant effect on reduction of mortality with therapy: 8.4% versus controls 14.4%, and infected pancreatic necrosis rates: 19.7% versus controls 24.4%. Non-pancreatic infection rates and the incidence of overall infections were not significantly reduced with antibiotics: 23.7% versus 36%; 37.5% versus 51.9% respectively. Operative treatment and fungal infections were not significantly different. Insufficient data were provided concerning antibiotic resistance.With beta-lactam antibiotic prophylaxis there was less mortality (9.4% treatment, 15% controls), and less infected pancreatic necrosis (16.8% treatment group, 24.2% controls) but this was not statistically significant. The incidence of non-pancreatic infections was non-significantly different (21% versus 32.5%), as was the incidence of overall infections (34.4% versus 52.8%), and operative treatment rates. No significant differences were seen with quinolone plus imidazole in any of the end points measured. Imipenem on its own showed no difference in the incidence of mortality, but there was a significant reduction in the rate of pancreatic infection (p=0.02; RR 0.34, 95% CI 0.13 to 0.84).

AUTHORS' CONCLUSIONS

No benefit of antibiotics in preventing infection of pancreatic necrosis or mortality was found, except for when imipenem (a beta-lactam) was considered on its own, where a significantly decrease in pancreatic infection was found. None of the studies included in this review were adequately powered. Further better designed studies are needed if the use of antibiotic prophylaxis is to be recommended.

Recent developments in acute pancreatitis

The incidence of acute pancreatitis (AP) has been increasing worldwide, but the major etiologies remain gallstones and alcohol. Several studies have reported that smoking is an independent risk factor for developing AP. Classification of AP has traditionally used the categories of mild and severe disease. However, a new intermediate category of moderately severe AP has been described with intermediate characteristics including a high incidence of local complications but a low mortality. Assessment criteria that can serve as early predictors of AP severity are often complex and not sufficiently accurate. However, several recently described criteria that rely on criteria such as the body mass index, physical findings, and simple laboratory measurements could prove useful if validated in large prospective studies. Many issues related to the therapy of AP are still unresolved. Although preliminary studies support the importance of early volume expansion for the treatment of acute pancreatitis, optimization of the amount and type of fluids will require further studies. Similarly, preliminary studies suggest that enteral nutrition might benefit patients with AP and could even be useful early in the course of disease. However, the timing and type of fluids as well as the intestinal infusion site require further study. Finally, issues related to the prophylactic use of antibiotics in patients with severe AP have not been resolved. While the process of clinical investigation moves slowly, progress has been made in clinical studies of AP.