A step-up approach or open necrosectomy for necrotizing pancreatitis

Application of deep learning models for accurate classification of fluid collections in acute necrotizing pancreatitis on computed tomography: a multicenter study

PURPOSE

To apply CT-based deep learning (DL) models for accurate solid debris-based classification of pancreatic fluid collections (PFC) in acute pancreatitis (AP).

MATERIAL AND METHODS

This retrospective study comprised four tertiary care hospitals. Consecutive patients with AP and PFCs who had computed tomography (CT) prior to drainage were screened. Those who had magnetic resonance imaging (MRI) or endoscopic ultrasound (EUS) within 20 days of CT were considered for inclusion. Axial CT images were utilized for model training. Images were labelled as those with≤30% solid debris and >30% solid debris based on MRI or EUS. Single center data was used for model training and validation. Data from other three centers comprised the held out external test cohort. We experimented with ResNet 50, Vision transformer (ViT), and MedViT architectures.

RESULTS

Overall, we recruited 152 patients (129 training/validation and 23 testing). There were 1334, 334 and 512 images in the training, validation, and test cohorts, respectively. In the overall training and validation cohorts, ViT and MedVit models had high diagnostic performance (sensitivity 92.4-98.7%, specificity 89.7-98.4%, and AUC 0.908-0.980). The sensitivity (85.3-98.6%), specificity (69.4-99.4%), and AUC (0.779-0.984) of all the models was high in all the subgroups in the training and validation cohorts. In the overall external test cohort, MedViT had the best diagnostic performance (sensitivity 75.2%, specificity 75.3%, and AUC 0.753). MedVit had sensitivity, specificity, and AUC of 75.2%, 74.3%, and 0.748, in walled off necrosis and 79%, 74.2%, 75.3%, and 0.767 for collections >5 cm.

CONCLUSION

DL-models have moderate diagnostic performance for solid-debris based classification of WON and collections greater than 5 cm on CT.

Acute Pancreatitis: Presentation and Outcomes at a Safety Net Hospital

INTRODUCTION

Although acute pancreatitis is common and much is known about its management, further research could lead to targets identified for improvements in care. This study aimed to analyze factors, both medical and socioeconomic, associated with morbidity and mortality at a safety net hospital.

METHODS

This was a retrospective review of patients with acute pancreatitis admitted between 2015 and 2022. Variables were collected from the electronic medical record and primary outcomes of interest were morbidity and mortality. Standard statistics were used for analysis.

RESULTS

Of the 404 patients that met inclusion criteria, the average age was 48 y, 46% were female, the majority were English speaking, most were Black, and the majority had public insurance. Four percent of patients died and 19.6% had a complication within 30 d. Most patients were admitted to medicine. Public insurance or self-pay status was associated with complications, as was presence of comorbidities and interventional radiology consultation. Surgery and interventional radiology consultation, among other factors, were associated with mortality. Thirty-nine percent of patients with gallstone pancreatitis underwent cholecystectomy. Many patients were started on antibiotics, and of those, 44.1% had no clear indication.

CONCLUSIONS

This study reveals novel factors associated with morbidity and mortality in patients with acute pancreatitis, as well as demonstrating that best practices are not uniformly practiced. The study provides further areas of study, including investigations into best pathways for consultations of services and admission service, interventions for at risk patients to improve morbidity and mortality, and how to reduce inappropriate antibiotic use.

The impact of the novel EUS scope and ultrasonographic system for diagnosis and therapy in patients with pancreatobiliary diseases (videos)

PURPOSE

We evaluated the diagnostic and therapeutic capabilities of endoscopic ultrasonography (EUS) in pancreaticobiliary diseases. We aimed to validate the efficiency of detective flow imaging (DFI), shear wave elastography (SWE), and other advanced imaging techniques.

METHODS

We used new EUS scopes (EG-740 UT and G-580UR) and the latest ultrasound equipment (ARIETTA 850) (Fujifilm Healthcare, Kanagawa, Japan). Diagnostic procedures were performed in 16 cases, including pancreatic cancer and intraductal papillary mucinous neoplasms, and therapeutic procedures in eight cases, involving complex biliary and pancreatic interventions. The utility of SWE in assessing tissue stiffness was quantified by measuring the shear wave velocity (SWV) in pancreatic cancer and autoimmune pancreatitis.

RESULTS

We found no significant difference in SWVs among different pancreatic conditions; however, significant variations were observed in the net percentage of effective SWV. Interventional EUS had a 100% technical and clinical success rate, demonstrating the efficacy of new imaging techniques and equipment in enhancing procedural safety and diagnostic accuracy.

CONCLUSIONS

The integration of advanced EUS imaging technologies, particularly DFI, contrast-enhanced EUS, and SWE, significantly enhances the diagnosis and treatment of pancreaticobiliary diseases.

What is the role of parenteral nutrition in the management of the patient with severe acute pancreatitis?

Severe acute pancreatitis often presents as a complex critical illness associated with a high rate of infectious morbidity, multiple organ failure, and in-hospital mortality. Breakdown of gut barrier defenses, dysbiosis of intestinal microbiota, and exaggerated immune responses dictate that early enteral nutrition (EN) is preferred over parenteral nutrition (PN) as the primary route of nutrition therapy. EN, however, is not feasible in all cases because of intolerance, risk of complications, or a direct contraindication to enteral feeding. For these patients, PN can be provided in a manner that is safe, is metabolically appropriate, and follows the principles of modern critical care nutrition. Adherence to goal-directed fluid resuscitation, provision of trophic doses of PN to meet 20%-25% of protein and/or calorie requirements through the acute phases of illness, use of less-inflammatory intravenous lipid emulsions, and close monitoring of electrolytes, triglyceride levels, and signs of refeeding syndrome all serve to optimize the response to this route of nutrition support. For these reasons, prescribing PN remains an important strategy in the management of this difficult population of patients.

Systematic review of peritoneal lavage and dialysis for patients with severe acute pancreatitis

AIMS

Severe acute pancreatitis (SAP) remains a lethal condition with a rising incidence worldwide. Recent randomised trials suggest that peritoneal lavage and/or dialysis (PLD), when administered early in SAP, may be beneficial to improve patient outcomes. This study aimed to review this data systematically.

METHODS

Studies featuring PLD for the treatment of SAP were searched systematically (2012 Atlanta classification to 2023). A traditional approach to reporting data was augmented by a narrative synthesis.

RESULTS

210 articles were reviewed, of which six studies featuring 499 patients were included. The technical approach, duration and type of lavage varied in each study and no safety concerns were reported. In patients undergoing PLD, improvements in inflammatory markers and length of stay were seen in all studies. Where reported, fewer invasive procedures for peri-pancreatic fluid collections were required after PLD. Lower mortality was seen in cohorts receiving laparoscopic lavage alone and combined lavage and dialysis when compared with standard treatment. All studies were rated at moderate or high risk of bias.

CONCLUSIONS

PLD demonstrates potential as an early therapy to improve outcomes for patients with SAP. Further research is required to define intervention delivery, explore acceptability and investigate efficacy through a powered randomised controlled trial.

Metal versus plastic stents for EUS-guided walled-off necrosis drainage: a systematic review and meta-analysis of randomized controlled trials

BACKGROUND & OBJECTIVE

The endoscopic step-up approach is the mainstay of walled-off necrosis management (WON). However, using metal stents versus plastic stents during WON drainage is debatable, with limited high-quality evidence. Therefore, we aim to investigate the comparative safety and efficacy of metal versus plastic stents for endoscopic ultrasound (EUS) guided WON drainage.

METHODS

A systematic review and meta-analysis synthesizing randomized controlled trials (RCTs), retrieved by systematically searching PubMed, EMBASE, WOS, SCOPUS, and Cochrane through July 2024. Continuous and dichotomous outcome variables were pooled using mean difference (MD) and risk ratio (RR), with confidence interval (CI) using Stata MP v. 17. We assessed heterogeneity using the chi-square test and I2 statistic.

PROSPERO ID

CRD42024573859.

RESULTS

Six RCTs with 352 patients were included. There was no difference between both groups regarding clinical success (RR: 1.04 with 95% CI [0.88-1.23], p = 0.61), WON recurrence (RR: 1.46 with 95% CI [0.59-3.61], p = 0.41), the need of necrosectomy (RR: 0.96 with 95% CI [0.65-1.41], p = 0.84), the total number of necrosectomy sessions (MD: 1.03 with 95% CI [- 0.33, 2.40], p = 0.14), total number of interventions (MD: - 0.09 with 95% CI [- 0.72, 0.54], p = 0.79), mortality (RR: 0.87 with 95% CI [0.32-2.37], p = 0.79), bleeding (RR: 1.35 with 95% CI [0.58-3.12], p = 0.48), and stent migration (RR: 0.69 with 95% CI [0.28-1.71], p = 0.42). However, metal stents significantly decreased the procedure duration (MD: - 11.27 with 95% CI [- 17.69, - 4.86], p < 0.001).

CONCLUSION

There was no significant difference between metal and plastic stents in efficacy and safety outcomes during WON EUS-guided drainage, except for a shorter procedural duration with metal stents.

Postoperative pancreatic fistula is higher in patients with necrotizing pancreatitis who develop a colon-transverse fistula

BACKGROUND

This study explores the association between the need for open necrosectomy (ON) during infected necrotizing pancreatitis (INP) treatment and the development of postoperative pancreatic fistula (POPF) following definitive surgery (DS) for transverse colonic fistulas.

MATERIALS AND METHODS

This study was conducted at two tertiary hospitals and included patients who underwent DS for colonic fistula secondary to INP from January 2009 to December 2023. Patients were followed until hospital discharge. The primary outcome was the incidence of POPF.

RESULTS

A total of 135 patients were included. The median age was 38 years (interquartile range [IQR]: 32-44 years), with 85 (62.9%) being male. ON was required in 52 patients (38.5%), with 24 patients developing POPF post-DS. The need for ON (odds ratio [OR] = 2.78, 95% confidence interval [CI]: 1.03-7.58, p = 0.040) and the interval from INP resolution to DS (OR = 0.82, 95% CI: 0.68-0.92, p = 0.011) were associated with POPF.

CONCLUSION

The need for ON during INP treatment is significantly associated with an increased risk of POPF following DS for transverse colonic fistulas.

Practical management of severe acute pancreatitis

Acute pancreatitis (AP) represents one of the most common reasons for hospital admission and intensive care treatment in internal medicine. The incidence of AP is increasing, posing significant financial burden on healthcare systems due to the necessity for frequent medical interventions. Severe acute pancreatitis (SAP) is a potentially life-threatening condition with substantial morbidity and mortality. The management of SAP requires prolonged hospitalization and the expertise of a multidisciplinary team, comprising emergency physicians, intensivists, internists, gastroenterologists, visceral surgeons, and experts in nutrition, infectious disease, endoscopy, as well as diagnostic and interventional radiology. Effective management and beneficial patient outcomes depend on continuous interdisciplinary collaboration. This review synthesizes recent evidence guiding the practical management of SAP, with a particular focus on emergency and intensive care settings. Both established as well as new diagnostic and therapeutic paradigms are highlighted, including workup, risk stratification, fluid management, analgesia, nutrition, organ support, imaging modalities and their timing, along with anti-infective strategies. Furthermore, the review explores interventions for local and vascular complications of SAP, with particular attention to the indications, timing and selection between endoscopic (both endoscopic retrograde cholangiopancreatography (ERCP) and endoscopic ultrasound (EUS)), percutaneous and surgical approaches. Similarly, the management of biliary AP due to obstructive gallstones, including the imaging, timing of ERCP and cholecystectomy, are discussed. By integrating new evidence with relevant guidance for everyday clinical practice, this review aims to enhance the interdisciplinary approach essential for improving outcomes in SAP management.

Endoscopic Step-Up Approach in Management of Necrotizing Pancreatitis

The endoscopic step-up approach in the management of necrotizing pancreatitis involves sequential steps of intervention at different time points in the clinical course of the disease. EUS -guided drainage of walled-off necrosis is the first step of the endoscopic step-up approach. Lumen-apposing metal stents are preferred over plastic stents for safe and effective drainage because of their wide caliber. Successive steps in the endoscopic step-up approach include direct endoscopic necrosectomy and/or irrigation using naso-cystic tube in symptomatic patients, primarily based on necrotic debris characteristics. Minimally invasive percutaneous radiological and/or surgical drainage are considered when endoscopic drainage is not feasible or successful.

Surgical Step-Up Approach in Management of Necrotizing Pancreatitis

Necrotizing pancreatitis often demands intervention; contemporary management is directed by the step-up approach. Timing of intervention and specific approach is best directed by a multi-disciplinary team including advanced endosocpists, interventional radiologists, and surgeons with interest and experience managing this complex problem. The intervention is often a combination of percutaneous drainage, transluminal endoscopic approaches, and surgical debridement (minimally invasive or open). Goals of treatment are to evacuate solid infected necrosis, gain enteral access when needed, and to prevent recurrence-cholecystectomy in the setting of biliary pancreatitis. Experienced clinical judgment leads to optimal patient outcomes.

Pancreatic necrosis: a scoping review

Acute pancreatitis (AP) is a commonly encountered GI diagnosis, accounting for 275,000 hospital admissions annually in the United States alone. Pancreatic necrosis (PN) is the most common complication of AP, and the development of PN is associated with significant morbidity and increased mortality. This expert review evaluates the evidence-based management of symptomatic PN from the era of maximal open pancreatic necrosectomy in the late 1990s though the modern paradigm of minimally invasive and endoscopic interventions. The authors present the retrospective and controlled data behind the "step-up approach" to PN treatment and discuss the application of current society guidance. Evidence based management of PN is characterized by early supportive care, and treatment by minimally invasive intervention when a patient is critically ill or persistently symptomatic. Appropriate choices when intervention is required include percutaneous drainage, minimally invasive surgery, and/or endoscopic treatment. The transition from open maximal necrosectomy to minimally invasive intervention has resulted in improved outcomes for patients, including gains in mortality, significant morbidity, and cost. The ideal precision management strategy for an individual patient remains an area of increasing understanding.

Pancreatitis in children: practical management from the BSPGHAN Pancreatitis Working Group

Pancreatitis, a condition characterised by inflammation of the pancreas, has multiple aetiologies. Improving clinical proficiency in prompt diagnosis and effective management leads to better outcomes for children with acute pancreatitis, acute recurrent pancreatitis and chronic pancreatitis. Establishing consensus guidance via the British Society of Paediatric Gastroenterology Hepatology and Nutrition Pancreatitis Working Group has ensured further focus on these patients who are often cared for in a multidisciplinary framework and may prompt future research in this area. Initial assessment includes serum amylase/lipase, triglyceride levels, full blood count, C reactive protein, renal and liver function profile, glucose, calcium and capillary blood gas. Fasted transabdominal ultrasound for all children and young people with suspected pancreatitis is recommended to identify pancreatic parenchyma and pancreatobiliary ductal changes, and complications. For fluid resuscitation, use crystalloids or Ringer’s lactate: initial bolus of 10 to 20 mL/kg, 1.5–2 times maintenance volume, with hourly monitoring of urine output over the initial 24–48 hours. Initiate oral intake within the first 24 hours after fluid resuscitation; fat restriction is not recommended. For suspected autoimmune pancreatitis, workup includes immunoglobulin levels (IgG, IgM, IgA, IgG subclasses), complement components and autoantibody profile to confirm diagnosis. Significant interventional management for pancreatitis and related complications is performed via endoscopic retrograde cholangiopancreatography or endoscopic ultrasound; referral to a specialised paediatric hepatobiliary surgical team is highly recommended. Close collaboration with a specialist centre can improve diagnostic and management pathways and outcomes for children.

Diffusion weighted MRI and neutrophil lymphocyte ratio non-invasively predict infection in pancreatic necrosis: a pilot study

BACKGROUND

Infected pancreatic necrosis (IPN) is a major determinant of mortality in acute pancreatitis (AP). Non-invasive diagnosis of IPN could guide the intervention in AP. We aimed to investigate the role of non-invasive methods like diffusion weighted magnetic resonance imaging (DW-MRI) and clinico-laboratory parameters as predictors of IPN.

METHODS

Prospective evaluation for predictors of IPN by diffusion restriction (DR) on DW-MRI and clinico-laboratory parameters was performed.

RESULTS

Out of 39 patients included, 31 were analysed after exclusion. Twenty-six (83.8%) patients had moderately severe AP, and the rest had severe disease. They were categorized into Group A: patients with documented infection after intervention (n = 17) and Group B: successfully managed without intervention or negative culture after intervention (n = 14). On univariate analysis, Group A had significantly more incidence of fever (P = 0.020), persistent unwellness (P = 0.003), elevated neutrophil count (P = 0.007), lymphocyte count (P = 0.007), neutrophil lymphocyte ratio (NLR) (P = 0.028), DR on DW-MRI (P = 0.001) and low apparent diffusion coefficient (ADC) (P = 0.086). Multivariate analysis revealed DR on DW-MRI (P = 0.004) and NLR (P = 0.035) as significant predictors of IPN, among other factors. The sensitivity, specificity, positive predictive value (PPV), and negative predictive value (NPV) of DW-MRI were 94.1%, 78.6%, 91.66%, and 84.21%, respectively. The area under curve of NLR on the ROC plot was 0.85 and the best cutoff was >3.5, with sensitivity, specificity, PPV, and NPV of 70.6%, 78.6%, 80%, and 68.7% respectively.

CONCLUSION

DW-MRI and NLR are promising non-invasive tools for accurate prediction of IPN and hence can guide the need for intervention in acute pancreatitis.

Percutaneous cystogastrostomy for treatment of pancreatic collections

OBJECTIVE

Acute pancreatitis (AP) is an inflammatory condition associated with a potential torpid evolution comprising multiple organ failure, pancreatic necrosis, infected collections and high mortality. Current management tends use the step-up approach, with endoscopic collection drainage, followed by percutaneous drainage by an interventional radiologist and video-assisted necrosectomy. We present our experience with a new percutaneous technique of establishing an anastomosis of the pancreatic collection with the closest loop, stomach, duodenum or jejunum that uses balloon dilation and drainage in cases of infection.

MATERIAL AND METHODS

Between 2009 and 2023 we have applied this technique in 30 patients, aged between 32 and 82 years (mean=67 years), 14 with pseudocysts (infected in six cases) and 16 with encapsulated necrosis (all infected). We use dilation balloons of different calibre, to establish the anastomosis between the digestive loop and the collection, as well as different drainages.

RESULTS

The intervention had a primary technical success of 93%. In two patients the cystogastrostomy had to be repeated due to initial technical failure; in both cases a good result was achieved. One patient had a severe postintervention haemorrhage (3%) that required embolisation. Length of follow-up has ranged from between three months and 10 years (mean=4 years), with no recurrence of the anastomosed collection or cutaneous fistula observed in any case.

CONCLUSION

Percutaneous cystogastrostomy is a technique that allows infected collections to be resolved and pancreatic fistulas to be avoided, with few complications, which can be resolved by interventional vascular radiologists.

A Case of Acute Pancreatitis after Pancreatectomy in Grade C Leading to Walled-Off Necrosis Successfully Treated with Necrosectomy by Retroperitoneal Approach

INTRODUCTION

Grade B or C post-pancreatectomy acute pancreatitis (PPAP) is associated with a higher incidence of postoperative complications and mortality. The reason for this is the activation of proteolytic processes that can lead to pancreatic destruction and the activation of systemic reactions that can have adverse consequences such as systemic inflammatory response syndrome, sepsis, and death. We report a case of a patient with Grade C PPAP with walled-off necrosis (WON) who was successfully treated with necrosectomy using a step-up approach.

CASE PRESENTATION

A 73-year-old man was referred to our hospital with elevated biliary enzymes. Results of blood tests, computed tomography (CT), and magnetic resonance imaging led to the diagnosis of distal bile duct cancer. He underwent a pyloric ring-sparing pancreaticoduodenectomy with lymph node dissection. Postoperative P-AMY (pancreatic amylase) was high at 1766 U/L, and contrast-enhanced CT showed increased density of peripancreatic fatty tissue and fluid accumulation on the pancreatic resection surface, leading to the diagnosis of postoperative pancreatitis and pancreatic fistula. On postoperative day (POD) 9, continuous washing with saline solution was started through the drain at the pancreatic anastomosis. Contrast-enhanced CT showed increased fluid retention in the pancreatic body tail. On POD 43, endoscopic ultrasonography drainage was performed for pancreatic necrosis encapsulated in the retroperitoneum; however, the patient self-extracted the drainage tube. On POD 50, CT-guided drainage was performed for a retroperitoneal subcapsular abscess. On POD 69, the patient underwent necrotomy with guided retroperitoneal drainage, a drain was inserted, and continuous flushing was performed. On POD 76, fecal discharge was observed from the drain, and drainage and enterography were performed; a fistula with the colon was confirmed, and an ileal bifurcation colostomy was performed on the same day. On PODs 83, 85, and 100, endoscopic necrotomy was performed through a retroperitoneal incision wound because a contrast-enhanced CT showed a residual abscess on the gastric dorsum. The patient's general condition improved, and his inflammatory response also improved. On POD 139, the patient was transferred for rehabilitation.

CONCLUSION

We describe a case of successful postoperative nutritional management and necrosectomy for Grade C PPAP leading to WON.

Pancreatic Cystic Lesions in Children: A Comprehensive Scoping Review

OBJECTIVE

Pediatric pancreatic cystic lesions (PPCLs) are uncommon and differ from adult pancreatic cystic lesions. Literature is limited on the etiologies, evaluation, and management of PPCL. A multidisciplinary working group formed to provide a comprehensive description of PPCL and recommend best available evidence-based evaluation and management.

MATERIALS AND METHODS

The PPCL working group performed a scoping review by 2 methods: 1) a targeted literature review to describe PPCL and 2) a systematic literature review for management recommendations for PPCL. The systematic review was completed using a 2-stage sifting approach: title and abstract screening followed by a full text review.

RESULTS

One hundred thirty-one studies were included in the systematic review and an additional 20 were included in the targeted search to complete a comprehensive list of PPCL. Five neoplastic PPCL and 10 nonneoplastic PPCL were identified, and prevalence of different cystic lesions differs widely in adults and children. Recommendations on evaluation and management of PPCL are presented based on best available evidence.

CONCLUSIONS

We present a comprehensive review and evidence-based management recommendations with management algorithms for pediatric pancreatic cystic lesions. Given the rarity of many of these entities, this review also highlights many aspects of PPCL, which are not adequately described in the current literature.

Efficacy of Metal Stents Versus Plastic Stents for Treatment of Walled-Off Pancreatic Necrosis: A Systematic Review and Meta-Analysis

Background

Walled-off necrosis (WON) is a potentially fatal condition best treated endoscopically with metal or plastic stents. This study compares the clinical outcomes of these stents.

Methods

PubMed and Cochrane were searched for trials comparing metal and plastic stents for WON. Primary outcomes were clinical and technical success.

Results

Seven studies with 230 metal stent patients and 226 plastic stent patients were included. Metal stents showed significantly shorter procedure times (SMD -0.80, 95% CI: -1.25 to -0.34), better 4-week clinical success (OR 1.94, 95% CI: 1.00 to 3.77), and higher procedure costs (SMD 1.38, 95% CI: 0.56 to 2.20). No significant differences were observed in hospital stay (SMD -0.05, 95% CI: -0.35 to 0.25), technical success (OR 1.45, 95% CI: 0.22 to 9.43), clinical success (OR 1.13, 95% CI: 0.54 to 2.39), interventions (SMD -0.02, 95% CI: -0.34 to 0.29), need for necrosectomy (RR 1.10, 95% CI: 0.59 to 2.04), necrosectomy sessions (SMD 0.35, 95% CI: -0.42 to 1.11), need for percutaneous drainage (RR 0.82, 95% CI: 0.36 to 1.85), stent migration (RR 0.88, 95% CI: 0.29 to 2.66), bleeding (RR 0.97, 95% CI: 0.53 to 1.75), WON recurrence (RR 1.66, 95% CI: 0.70 to 3.92), treatment failure (death) (RR 0.75, 95% CI: 0.37 to 1.53), disconnected pancreatic duct (RR 0.93, 95% CI: 0.79 to 1.11), and total cost (SMD -0.02, 95% CI: -0.29 to 0.26).

Conclusion

Metal stents offer shorter procedure time and better 4-week clinical success, although at a higher cost, with most clinical outcomes showing no significant differences between stent types.

Outcomes of percutaneous endoscopic versus endoscopic transmural necrosectomy for necrotizing pancreatitis: A propensity score-matched study

BACKGROUND

Few published studies exist that compare the outcomes of different endoscopic necrosectomy methods for necrotizing pancreatitis (NP). We compared the safety and efficacy of percutaneous versus transmural endoscopic necrosectomy for NP patients.

METHODS

In this retrospective cohort study, we analyzed adult NP patients who underwent either percutaneous endoscopic necrosectomy (PEN) or endoscopic transmural necrosectomy (ETN), and compared safety and efficacy between the two groups. Propensity score-matched analysis and multivariable logistic regression analysis were conducted.

RESULTS

A total of 280 patients were enrolled, among which 142 underwent PEN and 138 underwent ETN. There were differences in baseline characteristics between the two groups, including body mass index, C-reactive protein, systemic inflammatory response syndrome score. The incidences of sepsis, respiratory failure, and intensive care unit stay were higher among patients who underwent PEN than those who underwent ETN (all P < 0.01). Ninety-one pairs were matched with comparable baseline characteristics and severity. The incidence of postoperative complications, open surgery, clinical success, radiological success, collection recurrence, and reintervention were not significantly different between the ETN group and PEN group (all P > 0.05). Multivariate analysis also showed that the approaches (PEN vs ETN) was not associated with postoperative complications or mortality.

CONCLUSIONS

In real world setting, sicker patients tend to be more effectively managed through PEN compared to ETN. PEN demonstrates comparable efficacy and safety to ETN in the treatment of NP patients.

A systematic review of machine learning-based prognostic models for acute pancreatitis: Towards improving methods and reporting quality

BACKGROUND

An accurate prognostic tool is essential to aid clinical decision-making (e.g., patient triage) and to advance personalized medicine. However, such a prognostic tool is lacking for acute pancreatitis (AP). Increasingly machine learning (ML) techniques are being used to develop high-performing prognostic models in AP. However, methodologic and reporting quality has received little attention. High-quality reporting and study methodology are critical for model validity, reproducibility, and clinical implementation. In collaboration with content experts in ML methodology, we performed a systematic review critically appraising the quality of methodology and reporting of recently published ML AP prognostic models.

METHODS/FINDINGS

Using a validated search strategy, we identified ML AP studies from the databases MEDLINE and EMBASE published between January 2021 and December 2023. We also searched pre-print servers medRxiv, bioRxiv, and arXiv for pre-prints registered between January 2021 and December 2023. Eligibility criteria included all retrospective or prospective studies that developed or validated new or existing ML models in patients with AP that predicted an outcome following an episode of AP. Meta-analysis was considered if there was homogeneity in the study design and in the type of outcome predicted. For risk of bias (ROB) assessment, we used the Prediction Model Risk of Bias Assessment Tool. Quality of reporting was assessed using the Transparent Reporting of a Multivariable Prediction Model of Individual Prognosis or Diagnosis-Artificial Intelligence (TRIPOD+AI) statement that defines standards for 27 items that should be reported in publications using ML prognostic models. The search strategy identified 6,480 publications of which 30 met the eligibility criteria. Studies originated from China (22), the United States (4), and other (4). All 30 studies developed a new ML model and none sought to validate an existing ML model, producing a total of 39 new ML models. AP severity (23/39) or mortality (6/39) were the most common outcomes predicted. The mean area under the curve for all models and endpoints was 0.91 (SD 0.08). The ROB was high for at least one domain in all 39 models, particularly for the analysis domain (37/39 models). Steps were not taken to minimize over-optimistic model performance in 27/39 models. Due to heterogeneity in the study design and in how the outcomes were defined and determined, meta-analysis was not performed. Studies reported on only 15/27 items from TRIPOD+AI standards, with only 7/30 justifying sample size and 13/30 assessing data quality. Other reporting deficiencies included omissions regarding human-AI interaction (28/30), handling low-quality or incomplete data in practice (27/30), sharing analytical codes (25/30), study protocols (25/30), and reporting source data (19/30).

CONCLUSIONS

There are significant deficiencies in the methodology and reporting of recently published ML based prognostic models in AP patients. These undermine the validity, reproducibility, and implementation of these prognostic models despite their promise of superior predictive accuracy.

REGISTRATION

Research Registry (reviewregistry1727).

Case Report: Severe acute pancreatitis accompanied by gastric mucosal exfoliation hemorrhage: clinical alerts and novel insights

Acute pancreatitis (AP), a condition marked by its swift progression, substantial individual discrepancies, and profound concealment, poses a formidable challenge. Within its severe form, known as severe acute pancreatitis (SAP), the disease assumes an even more prevalent status, often entwined with dire complications such as pancreatic abscess, circulatory shock, and the direst of all, multiple organ failure. Regrettably, the conjunction of SAP with gastric mucosal exfoliation culminating in massive hemorrhage remains an exceptionally rare phenomenon within the clinical realm. This study delves into a retrospective analysis of a singular, yet remarkable clinical case, where SAP's therapeutic odyssey unexpectedly led to gastric mucosa stripping and catastrophic gastrointestinal bleeding. This paper endeavors to unravel the diagnostic intricacies, explore the treatment modalities, and prognosticate the outcome, all with the ultimate aim of fostering a heightened clinical vigilance and fostering a novel, nuanced understanding of SAP's exceptional complications within the intensive care arena. Furthermore, this study aspires to serve as a beacon of reference, illuminating the path for clinical practitioners confronted with such elusive yet critical scenarios.

Diagnosis and Management of Acute Pancreatitis

Acute pancreatitis is an inflammatory condition of the exocrine pancreas that is a common indication for hospital admission and has had an increasing incidence in the last few decades. The diagnosis of acute pancreatitis requires the satisfaction of two out of three criteria: (1) abdominal pain radiating to the back, (2) serum lipase or amylase levels three or more times the upper limit of the normal level, and (3) findings indicating pancreatitis obtained via a computed tomography (CT) scan or magnetic resonance imaging (MRI). The different etiologies include gallstones, autoimmune disorders, alcohol abuse, smoking, hypertriglyceridemia, obesity, drugs, and post-endoscope retrograde cholangiopancreatography (ERCP). The initial investigation includes serum amylase and lipase analysis, a lipid panel including triglycerides, analysis of immunoglobulins, a full blood count, electrolyte analysis, a hemoglobin A1c test, a complete metabolic panel, and transabdominal ultrasound. The initial therapy includes oxygen supplementation, the provision of intravenous fluids, pain control, and a nutrition regime. Early oral feeding is encouraged if tolerated; if not, liquid supplement provision or enteral tube feeding within 48 h of admission has shown better outcomes. Some complications of acute pancreatitis are necrosis, infection, insulin resistance leading to diabetes mellitus, and pancreatic exocrine insufficiency requiring enzyme supplementation. Patients need to attend regular follow-ups and abstain from alcohol and smoking (if warranted) to prevent the recurrence of acute pancreatitis. The mortality rate of acute pancreatitis has decreased in the past few decades because of better management skills, but the recent rise in acute pancreatitis episodes is concerning. Sustained endeavors through clinical trials are required to establish a broad variety of drugs that can be used for acute pancreatitis episodes.

Impact of invasive infections on clinical outcomes in acute pancreatitis: early predictive factors and implications for prophylactic anti-infective therapy

BACKGROUND

The use of antibiotic therapy in acute pancreatitis remains controversial and is currently recommended only for confirmed infections of peripancreatic necrosis. However, reliable early predictors of septic complications and unfavorable outcomes are substantially lacking.

METHODS

Patients with acute pancreatitis were retrospectively reviewed and divided into two groups: one with a septic course defined by pathogen detection [GERM(+)] and one without [GERM(-)]. After propensity score matching, both groups were compared regarding clinical outcomes. Early predictors of pathogen detection were evaluated by multivariate analysis.

RESULTS

424 patients with acute pancreatitis were included. After propensity score matching 123 GERM(-) patients were compared to 74 GERM(+) patients. GERM(+) patients demonstrated significantly worse clinical outcomes with higher rate of intensive care treatment (59.5% vs. 35.0%; p = 0.0011) and consecutive longer stay in intensive care unit (11.5 ± 25.2d vs. 3.0 ± 7.9d; p = 0.0007), longer in-hospital stay (26.8 ± 22.0d vs. 14.7 ± 15.0d; p = 0.0003) as well as worse results in the composite outcome length of in-hospital stay > 15d or death (67.6% vs. 31.7%; p < 0.0001). Prescence of ascites and elevated white blood cell count at the onset of acute pancreatitis were identified as significant predictive factors in the early disease associated with invasive infection and pathogen detection. The most frequently detected pathogens were commensals of the gastrointestinal tract, observed in 70.7% of the examined body fluids and 50.7% of the examined blood cultures.

CONCLUSIONS

Detection of pathogens is associated with unfavorable clinical outcomes in acute pancreatitis. The presence of ascites and elevated white blood cell count at onset of acute pancreatitis are significant predictive factors indicating the risk of invasive infection with relevant bacterial load. Thus, an aggressive, early anti-infective strategy against pathogens of intestinal origin should be considered in these cases and may improve patient outcomes.

Successful Treatment of Bilocular Walled-off Necrosis with Transmural Naso-cyst Continuous Irrigation

Recently, transmural naso-cyst continuous irrigation (TNCCI) has been reported as an effective and safe treatment for walled-off necrosis (WON). We herein report a case of bilocular WON that was successfully treated with TNCCI. The patient was a 60-year-old man. The patient underwent endoscopic ultrasound-guided cyst drainage of the main cavity and subcavity using a single transluminal gateway transcystic multiple drainage technique, which was ineffective. Subsequently, a lumen-apposing metal stent (LAMS) was placed in the main cavity and TNCCI was successfully performed in the subcavity. TNCCI with LAMS was effective in treating bilocular WON.

Characterization of Pancreatic Infections in Patients with Severe Acute Pancreatitis: A Retrospective Study from 2019 to 2023

Objective

This study investigated the distribution and changes in pancreatic infections among patients with acute pancreatitis (AP) from 2019 to 2023, while exploring the impact of multidrug-resistant bacterial infections on the prognosis of patients with poor outcomes.

Methods

This study included patients diagnosed with SAP between 2019 and 2023 and collected the demographic and clinical characteristics of all participants. Based on routine clinical microbiological culture results, the distribution and drug resistance of pathogens associated with pancreatic infections were analyzed. Multivariable logistic regression was used to evaluate the association between multidrug-resistant organism (MDRO) infection and poor prognosis.

Results

A total of 1586 pancreatic fluid specimens were analyzed and collected from 843 patients diagnosed with AP. The positive rate of the culture results was 81% (1280/1586), with the predominant pathogens identified as Klebsiella pneumoniae, Pseudomonas aeruginosa, Enterococcus faecium, and Acinetobacter baumannii complex. Of the 843 patients, 756 met the criteria, and the proportion of MDROs in pancreatic infections was 87.57% (662/756). Multivariate logistic regression analysis revealed that septic shock, acute kidney injury, and tracheostomy were associated with a poor prognosis, whereas ICU length of stay, infected pancreatic necrosis, and tracheostomy were associated with multidrug-resistant bacterial infections in patients with severe or critical AP.

Conclusion

The proportion of MDRO infections in patients with severe or critical AP was notably high, primarily involving multidrug-resistant Klebsiella pneumoniae, Pseudomonas aeruginosa, and Acinetobacter baumannii. Septic shock, acute kidney injury, and tracheostomy have been identified as independent risk factors of poor prognosis in patients with severe or critical AP.

Controversies in endoscopic ultrasonography-guided management of walled-off necrosis

Walled-off necrosis (WON) develops as local complications after acute necrotizing pancreatitis. Although less invasive interventions such as endoscopic ultrasonography (EUS)-guided drainage and endoscopic necrosectomy are selected over surgical interventions, delayed and step-up interventions are still preferred to avoid procedure-related adverse events. However, there is a controversy about the appropriate timing of drainage and subsequent necrosectomy. The advent of large-caliber lumen-apposing metal stents has also brought about potential advantages of proactive interventions, which still needs investigation in future trials. When step-up interventions of necrosectomy and additional drainage are necessary, a structured or protocoled approach for WON has been reported to improve safety and effectiveness of endoscopic and/or percutaneous treatment, but has not been standardized yet. Finally, long-term outcomes such as recurrence of WON, pancreatic endocrine, and exocrine function are increasingly investigated in association with disconnected pancreatic duct syndrome. In this review we discuss current evidence and controversy on EUS-guided management of WON.

Efficiency of laparoscopic retroperitoneal pancreatic necrosectomy for treating infected pancreatic necrosis with duodenal fistula: a single-center retrospective cohort study

BACKGROUND

Open surgical debridement was the main treatment option for infected pancreatic necrosis (IPN). However, it was associated with significant trauma, leading to a higher mortality rate. With the development of minimally invasive surgery, the step-up treatment principle centered around minimally invasive intervention, significantly reducing the incidence of complications and mortality rates among IPN patients. However, few studies have reported the efficacy of laparoscopic retroperitoneal pancreatic necrosectomy (LRPN), a new minimally invasive debridement technique, in IPN patients with duodenal fistula (DF)-a severe complication of IPN. Therefore, we analyzed the effectiveness and safety of LRPN for treating IPN with DF and discussed the impact of DF on patient prognosis.

METHODS

We retrospectively examined patients diagnosed with IPN between 2018 and 2023. The patients were divided into two groups based on the presence or absence of DF. Clinical characteristics, treatment strategies, clinical outcomes, and follow-up information were analyzed. A 1:1 propensity score-matching (PSM) method was used to assess differences in outcome indicators more accurately.

RESULTS

A total of 197 patients were examined. After PSM, no significant differences were observed between the two groups in in-hospital mortality rate, incidence of single organ failure, rate of postoperative severe complications (Clavien-Dindo Classification ≥ 3), and intensive care unit stay (P > 0.05). However, the incidence of multiorgan failure, gastrointestinal bleeding, number of percutaneous catheter drainage (PCD) procedures, surgery cases, hospital stay, and hospitalization costs were higher in the DF group (P < 0.05). Of these patients, 71.6% (n = 141) were treated with PCD + LRPN, with a conversion rate of 6.38% to open surgery. A higher proportion of patients in the non-DF group showed improved clinical outcomes solely with PCD (22.6% vs. 2.4%, P < 0.05), whereas a higher proportion of patients in the DF group underwent PCD + LRPN (88.1% vs. 67.1%, P < 0.05). Both groups showed a significant reduction in the Sequential Organ Failure Assessment score 72 h postoperatively.

CONCLUSIONS

For patients with IPN and DF, the LRPN-centered step-up strategy was safe and effective. DF prolongs hospital stay and increases hospitalization costs for patients.

Timing of lumen-apposing metal stents removal in pancreatic fluid collections: Could we go beyond?

BACKGROUND AND AIMS

Lumen-apposing metal stents (LAMS) are the mainstay treatment for pancreatic fluid collections (PFC). A 4-weeks interval for LAMS removal has been suggested to avoid adverse events (AEs). Primary aim is to evaluate the AEs rate in patients with LAMS removal <4 and >4 weeks from placement and possible associated factors.

METHODS

Retrospective study on patients underwent EUS-guided drainage of PFC with LAMS at two Italian centers between January 2017 and November 2023. PFC and LAMS features were collected. AEs were defined as bleeding, obstruction and buried LAMS.

RESULTS

108 patients were enrolled (62.9 % males; mean age 61 ± 14 years old). In 38 % PFC was in pancreatic head. In 64.8 % of patients LAMS ≥15 mm was used. Mean time of LAMS indwelling was 71 ± 87 days and in 73.1 % of patients the LAMS was removed after 4 weeks. AE occurred in 8.3 % of patients and the most common (77.8 %) was bleeding. There was no association between LAMS indwelling >4 weeks (8/9 vs 65/93 p = 0.44) and the rate of AE. A comparable mean time of LAMS persistence (108 ± 96 vs 67 ± 86 p = 0.18) between patients with and without AE was observed. PFC in the head (7/9 vs 33/93 p = 0.02) and LAMS ≥15 mm (9/9 vs 58/93 p = 0.03) were associated with a higher rate of AE.

CONCLUSION

When needed, LAMS removal >4 weeks appears to be as safe as LAMS removal within 4 weeks. LAMS ≥15 mm and Head location were associated with higher rate of AE and thus should arouse more caution.

Biflanged metal stents versus plastic stents for endoscopic ultrasound-guided drainage of walled-off necrosis: a randomized controlled trial

BACKGROUND

Endoscopic ultrasound (EUS)-guided drainage of walled-off necrosis (WON) using either plastic or metal stents is the mainstay of WON management. Our single-center randomized controlled trial aimed to evaluate the efficacy of biflanged metal stents (BFMSs) and plastic stents for WON drainage.

METHODS

Patients with symptomatic WON amenable to EUS-guided drainage were randomized to receive either BFMSs or plastic stents. The primary outcome was reintervention-free clinical success at 4 weeks. Secondary outcomes were: overall clinical success (complete resolution of symptoms and significant reduction in size of WON [<50% of original size and <5 cm in largest diameter at 4-week follow-up]); number of reinterventions; adverse events (AEs); hospital stay for first admission; and medium-term outcomes at 6 months (recurrence, disconnected pancreatic duct, chronic pancreatitis, and new-onset diabetes mellitus).

RESULTS

92 patients were randomized: 46 in each arm. The reintervention-free clinical success rate was significantly higher in the BFMS group on intention-to-treat analysis (67.4% vs. 43.5%; P = 0.02). Overall clinical success at 1 month was similar in both groups. There were significantly fewer reinterventions (median 0 [IQR 0-1] vs. 1 [0-2]; P = 0.03) and shorter hospital stays in the BFMS group (7.0 [SD 3.4] vs. 9.1 [5.5] days; P = 0.04). There were no differences in procedure-related AEs, mortality, or medium-term outcomes.

CONCLUSIONS

BFMSs provide better reintervention-free clinical success at 4 weeks, with shorter hospital stay and without increased risks of AEs, compared with plastic stents for EUS-guided drainage of WON. Medium-term outcomes are however similar for both stent types.

S3-Leitlinie Klinische Ernährung bei Pankreaserkrankungen

Sowohl die akute als auch die chronische Pankreatitis sind häufige Erkrankungen, die ein erhebliches Risiko für eine Mangelernährung mit sich bringen und eine Ernährungstherapie erfordern können. In ca. 20% der akuten Pankreatitiden tritt eine nekrotisierende Pankreatitis auf, die mit einer erhöhten Morbidität und Mortalität verbunden ist. Hier ist oftmals eine Ernährungstherapie mittels einer enteralen oder parenteralen Ernährung notwendig, die neben medikamentösen, endoskopischen, radiologischen oder chirurgischen Maßnahmen eine etablierte Säule der multimodalen Therapie darstellt.

Bei der chronischen Pankreatitis handelt es sich um eine chronische Entzündung der Bauchspeicheldrüse mit Entwicklung einer Fibrose und langfristig Atrophie des Organs. Bauchschmerzen, die zu einer verminderten oralen Aufnahme von Nährstoffen führen, sowie exokrines und endokrines Versagen sind häufige Komplikationen der Krankheit. All diese Faktoren stellen Risikofaktoren für eine Unter- bzw. Mangelernährung dar. Daher sollten Patienten mit chronischer Pankreatitis als ernährungsmedizinische Risikopatienten betrachtet, untersucht und entsprechend behandelt werden. Darüber hinaus sollte bei Patienten mit chronischer Pankreatitis auf Osteoporose und ein erhöhtes Frakturrisiko geachtet werden, und entsprechende Präventivmaßnahmen erwogen werden.

Risk Factors Influencing Mortality in Open Necrosectomy for Acute Pancreatitis: A Comparative Analysis

Background and Objectives: Patients undergoing open necrosectomy (ON) for acute pancreatitis (AP) often face high morbidity and mortality rates. This study aims to identify risk factors associated with adverse outcomes by comparing survivors and non-survivors of ON. Materials and Methods: A retrospective analysis was conducted on 74 patients who underwent ON for AP. Patients were divided into two groups: survivors (n = 52) and non-survivors (n = 22). Preoperative and postoperative variables were compared, and p-values were calculated to identify significant differences. Results: The mortality rate was 29.73%. Significant risk factors for mortality included age over 60 (p = 0.008), multiple organ failure (p = 0.001), early necrosectomy before 28 days (p = 0.001), higher neutrophil-to-lymphocyte ratio (NLR) (p = 0.045), and postoperative complications such as bleeding (p = 0.005) and intestinal fistula (p = 0.038). Delayed ON after 28 days showed a significantly lower mortality rate (12.5%) compared to early ON (50%). Conclusions: Age, severity of AP, timing of ON, and postoperative complications significantly influence mortality rates in patients undergoing ON. Delaying surgery beyond 28 days and optimizing surgical techniques may improve patient outcomes.

Waterjet pulse lavage as a safe adjunct to video assisted retroperitoneal debridement in necrotising pancreatitis

BACKGROUND

Minimally invasive surgical necrosectomy plays an important role in the management of infected pancreatic necrosis, with a goal of removing debris and debriding necrotic tissue. Pulse lavage is designed to simultaneously hydrostatically debride and remove the infected necrotic tissue with suction. It is also able to remove significant amounts of debris without traumatic manipulation of the necrotic tissue which may be adherent to surrounding tissue and can result in injury.

METHODS AND RESULTS

The surgical technique of utilising a waterjet pulse lavage device during the minimally invasive necrosectomy is detailed. Sixteen patients being managed via a step-up approach underwent endoscopic necrosectomy via a radiologically placed drain tract. All sixteen patients were successfully managed endoscopically without conversion to open necrosectomy, and survived their admission. There were no complications associated with the use of the waterjet pulse lavage.

CONCLUSION

Waterjet pulse lavage is a useful adjunct in minimally invasive necrosectomy, which reduces the length of the necrosectomy procedure, and facilitates removal of necrotic tissue while minimising the risk of traumatising healthy tissue.

The 1st i-EUS consensus on the management of pancreatic fluid collections - Part 2

Pancreatic fluid collections (PFCs), including pancreatic pseudocysts (PPs) and walled-off pancreatic necrosis (WON), are common complications of pancreatitis and pancreatic surgery. Historically, the treatment of these conditions has relied on surgical and radiological approaches. The treatment of patients with PFCs has already focused toward an endoscopy-based approach, and with the development of dedicated lumen-apposing metal stents (LAMS), it has almost totally shifted towards interventional Endoscopic Ultrasound (EUS)-guided procedures. However, there is still limited consensus on several aspects of PFCs treatment within the multidisciplinary management. The interventional endoscopy and ultrasound (i-EUS) group is an Italian network of clinicians and scientists with special interest in biliopancreatic interventional endoscopy, especially interventional EUS. This manuscript focuses on the second part of the results of a consensus conference organized by i-EUS, with the aim of providing evidence-based guidance on several intra- and post-procedural aspects of PFCs drainage, such as clinical management and follow-up.

Practical approach to acute pancreatitis: from diagnosis to the management of complications

The purpose of this review is to provide a practical guide for the clinical care of patients with acute pancreatitis (AP) from the management of the early phases of disease to the treatment of local complications. AP is one of the most frequent causes of gastroenterological admission in emergency departments. It is characterized by a dynamic and unpredictable course and in its most severe forms, is associated with organ dysfunction and/or local complications, requiring intensive care with significant morbidity and mortality. Initial therapy includes adequate fluid resuscitation, nutrition, analgesia, and when necessary critical care support. In recent years, the development of minimally invasive tailored treatments for local complications, such as endoscopic drainage, has improved patients' acceptance and outcomes. Despite this, the management of AP remains a challenge for clinicians. The present review was conducted by the authors, who formulated specific questions addressing the most critical and current aspects of the clinical course of AP with the aim of providing key messages.

Video-assisted retroperitoneal debridement for necrotizing pancreatitis: a single center experience in Colombia

INTRODUCTION

Acute pancreatitis (AP) is a common and potentially lethal disease. Approximately 10-20% of the patients progress to necrotizing pancreatitis (NP). The step-up approach is the gold standard approach to managing an infected necrotizing pancreatitis with acceptable morbidity and mortality rates. Video-assisted retroperitoneal debridement (VARD) has been described as a safe and feasible approach with high success rates. Multiple studies in the American, European, and Asian populations evaluating the outcomes of VARD have been published; nevertheless, outcomes in the Latin American population are unknown. This study aims to describe a single-center experience of VARD for necrotizing pancreatitis in Colombia with a long-term follow-up.

METHODS

A prospective cohort study was conducted between 2016 and 2024. All patients over 18 years old who underwent VARD for necrotizing pancreatitis were included. Demographic, clinical variables, and postoperative outcomes at 30-day follow-up were described.

RESULTS

A total of 12 patients were included. The mean age was 55.9 years old (SD 13.73). The median follow-up was 365 days (P25 60; P75 547). Bile origin was the most frequent cause of pancreatitis in 90.1% of the patients. The mean time between diagnosis and surgical management was 78.5 days (SD 22.93). The mean size of the collection was 10.5 cm (SD 3.51). There was no evidence of intraoperative complications. The mean in-hospital length of stay was 65.18 days (SD 26.46). One patient died in a 30-day follow-up. One patient presented an incisional hernia one year after surgery, and there was no evidence of endocrine insufficiency at the follow-up.

CONCLUSION

According to our data, the VARD procedure presents similar outcomes to those reported in the literature; a standardized procedure following the STEP-UP procedure minimizes the requirement of postoperative drainages. Long-term follow-up should be performed to rule out pancreatic insufficiency.

Does the site, size, and number of necrotic collections affect the outcome of necrotizing pancreatitis? - a prospective analysis

PURPOSE

In patients with acute necrotizing pancreatitis (ANP), the site, size, and the number of acute necrotic collections (ANC) may determine the outcome of patients. The current study aimed to correlate the nature of ANC with the adverse outcomes in ANP patients.

METHODS

This was a single-center, prospective study (August 2019-August 2022) recruiting patients with ANP, correlating the site, size, and number of ANC with the length of hospital stay, intensive care unit (ICU) stays, development of organ failure and infection, need for intervention, and mortality.

RESULTS

A total of 114 patients (mean age: 37.3 ± 13.4 years, 85.1% males) with ANP were included in the study. The number and maximum diameter of collections significantly correlated with the length of the hospital and ICU stay and the need for intervention. Taking a cut-off size of 8 cm, the sensitivity and specificity for predicting the need for intervention were 82.7% and 74.2%, respectively. ANCs located in the perinephric, paracolic, subhepatic, and epigastric regions had a significant correlation with two or more adverse outcomes. Additional points were added to the modified CT severity index (mCTSI) based on the present study's findings. The new score had significantly higher AUROC than mCTSI for predicting infection, need for intervention, ICU stay > 1 week, and mortality.

CONCLUSION

The site, size, and number of EPNs have a significant correlation with adverse clinical outcomes in patients with ANP. The inclusion of these parameters, along with present scoring systems, will help further improve the prognostication of patients.

The Strategic Management of Infected Pancreatic Pseudocyst in the Postpartum Period After Cesarean Delivery in a Pregnancy Complicated by Preeclampsia/Hemolysis, Elevated Liver Enzymes, and Low Platelets (HELLP) Syndrome and Shock

Pancreatitis is a rare but serious condition in obstetric patients, associated with significant morbidity and mortality. It can range from mild acute pancreatitis to severe complications such as necrosis, abscesses, pseudocysts, and multi-organ failure. While hypertriglyceridemia is a common cause, pancreatitis has also been linked to preeclampsia and shock. We present the case of a 22-year-old primigravida who developed an infected pancreatic pseudocyst 27 days after a cesarean section performed at 35 + 1 weeks of gestation due to preeclampsia/hemolysis, elevated liver enzymes, and low platelets (HELLP) syndrome, complicated by disseminated intravascular coagulation (DIC) and shock. Initial CT scans revealed a large pseudocyst, which was managed conservatively with antibiotics and ultrasound-guided drainage. On the 46th postoperative day, the patient underwent a retroperitoneal incision and drainage. She was discharged three days after the procedure, and a follow-up two weeks later showed complete recovery and healing of the drainage wound. The current literature lacks established treatment guidelines for managing pancreatitis and its complications in obstetric patients. Based on this case and a review of previous reports, we recommend an approach that starts with conservative management, followed by minimally invasive procedures if necessary, for treating infected pancreatic pseudocysts in the postpartum period. Given that patients are already recovering from the stresses of pregnancy and delivery, avoiding highly invasive techniques that require additional anesthesia or surgery can help minimize stress and improve overall well-being.

When to Intervene in Acute Necrotizing Pancreatitis: A Narrative Review of the Optimal Timing for Intervention Strategies

Introduction: Acute necrotizing pancreatitis (ANP) is the acute inflammation of pancreatic parenchyma, most commonly due to alcohol abuse or cholelithiasis. The treatment can be either conservative or invasive, including a variety of techniques; however, it has not yet been established if the intervention should be early or if it should be delayed. The aim of this review is to investigate the optimal time for intervention in ANP. Methods: A literature search was conducted in PubMed and Scopus from inception until September 2024 for studies reporting the comparison between early and late intervention. Results: Early intervention, within 4 weeks of symptom onset, often involves drainage via percutaneous, endoscopic, or combined methods. Delayed intervention occurs after 4 weeks of symptom onset. This can be conducted either surgically or via minimally invasive means. The results of this review reveal that the time of intervention for ANP plays an important role in the prognosis and the course of the disease. In particular, early intervention is associated with higher mortality, which is also the primary clinical outcome. Delayed intervention is also superior regarding secondary clinical outcomes, specifically the complications associated with the intervention. Thus, it is accompanied by fewer episodes of new-onset organ failure, bleeding, gastrointestinal fistula, pancreatic fistula, wound infection, endocrine pancreatic insufficiency, and other complications. Finally, delayed intervention results in shorter stays, both in hospitals and the ICU. Conclusions: Delayed intervention is clearly more effective than early intervention and should be preferred. However, early intervention appears to be both safe and effective, and it is feasible.

Early versus delayed necrosectomy in pancreatic necrosis: A population-based cohort study on readmission, healthcare utilization, and in-hospital mortality

BACKGROUND

Acute necrotizing pancreatitis is a severe and life-threatening condition. It poses a considerable challenge for clinicians due to its complex nature and the high risk of complications. Several minimally invasive and open necrosectomy procedures have been developed. Despite advancements in treatment modalities, the optimal timing to perform necrosectomy lacks consensus.

AIM

To evaluate the impact of necrosectomy timing on patients with pancreatic necrosis in the United States.

METHODS

A national retrospective cohort study was conducted using the 2016-2019 Nationwide Readmissions Database. Patients with non-elective admissions for pancreatic necrosis were identified. The participants were divided into two groups based on the necrosectomy timing: The early group received intervention within 48 hours, whereas the delayed group underwent the procedure after 48 hours. The various intervention techniques included endoscopic, percutaneous, or surgical necrosectomy. The major outcomes of interest were 30-day readmission rates, healthcare utilization, and inpatient mortality.

RESULTS

A total of 1309 patients with pancreatic necrosis were included. After propensity score matching, 349 cases treated with early necrosectomy were matched to 375 controls who received delayed intervention. The early cohort had a 30-day readmission rate of 8.6% compared to 4.8% in the delayed cohort (P = 0.040). Early necrosectomy had lower rates of mechanical ventilation (2.9% vs 10.9%, P < 0.001), septic shock (8% vs 19.5%, P < 0.001), and in-hospital mortality (1.1% vs 4.3%, P = 0.01). Patients in the early intervention group incurred lower healthcare costs, with median total charges of $52202 compared to $147418 in the delayed group. Participants in the early cohort also had a relatively shorter median length of stay (6 vs 16 days, P < 0.001). The timing of necrosectomy did not significantly influence the risk of 30-day readmission, with a hazard ratio of 0.56 (95% confidence interval: 0.31-1.02, P = 0.06).

CONCLUSION

Our findings show that early necrosectomy is associated with better clinical outcomes and lower healthcare costs. Delayed intervention does not significantly alter the risk of 30-day readmission.

Appropriate Use of Antibiotics in Acute Pancreatitis: A Scoping Review

BACKGROUND

While selective use of antibiotics for infected pancreatic necrosis (IPN) in acute pancreatitis (AP) is recommended, studies indicate a high rate of inadequate treatment.

METHODS

A search of PubMed, Scopus, and Cochrane databases was conducted, focusing on primary research and meta-analyses. Data were categorized based on core concepts, and a narrative synthesis was performed.

RESULTS

The search identified a total of 1016 publications. After evaluating 203 full texts and additional sources from the grey literature, 80 studies were included in the review. The answers obtained were: (1) Preventive treatment does not decrease the incidence of IPN or mortality. Given the risks of bacterial resistance and fungal infections, antibiotics should be reserved for highly suspected or confirmed IPN; (2) The diagnosis of IPN does not always require microbiological samples, as clinical suspicion or computed tomography signs can suffice. Early diagnosis and treatment may be improved by using biomarkers such as procalcitonin and novel microbiological methods; (3) When indicated, early initiation of antibiotics is a key determinant in reducing mortality associated with IPN; (4) Antibiotics with good penetration into pancreatic tissue covering Gram-negative and Gram-positive bacteria should be used. Routine antifungal therapy is not recommended; (5) The step-up approach, including antibiotics, is the standard for IPN management; (6) Antibiotic duration should be kept to a minimum and should be based on the quality of source control and patient condition.

CONCLUSIONS

Early antibiotic therapy is essential for the treatment of IPN, but prophylactic antibiotics are not recommended in AP. High-quality randomized controlled trials are required to better understand the role of antibiotics and antifungals in AP management.

Effect of the Step-Jump Approach in Infected Pancreatic Necrosis: A Propensity Score-Matched Study

Purpose

The effects of the step-jump approach on the survival and prognosis of infected pancreatic necrosis (IPN) patients have not yet been determined.

Patients and Methods

Between November 2018 and June 2023, 188 patients were included in this study. There were 144 patients in the step-up group (the SU group) and 44 in the step-jump group (the SJ group). In the SU group, patients successfully treated with percutaneous catheter drainage (PCD) alone were classified into the SU-1 group (n=101), while those requiring additional surgery after PCD were categorized into the SU-2 group (n=43). In the SJ group, patients who underwent minimally invasive necrosectomy (MIN) without PCD were assigned to the SJ-1 group (n=34), whereas those who initially underwent PCD followed by immediate open surgery were placed in the SJ-2 group (n=10). Propensity score matching (PSM) was used to mitigate bias.

Results

After PSM, a total of 34 pairs were successfully matched. A comparison of the SU group with the SJ-1 group (upfront MIN without PCD) revealed similar mortality rates (P=0.239); however, the incidences of multiple drug-resistant organisms (MDROs) (P=0.029) and surgical complications (P<0.001) were significantly lower in the SJ-1 group. After comparing the SU-2 and SJ-2 groups (patients who underwent direct open necrosectomy without MIN after PCD failure), the incidences of surgical complications and MDRO in the SJ-2 group were significantly lower (P<0.05).

Conclusion

Compared with the step-up approach, the step-jump approach is safer and more effective and can significantly reduce the incidence of MDRO and surgical complications.

Not just a BLiP: early experience with a novel multidisciplinary case conference for benign hepatopancreatobiliary disease at a tertiary Canadian healthcare center

BACKGROUND

Benign Liver and Pancreas (BLiPs) rounds, implemented in 2022 at our Canadian tertiary care center, are a novel concept of a multidisciplinary case conference (MCC) for discussion of benign hepatopancreatobiliary (HPB) disease. BLiPs Rounds are a monthly virtual meeting of surgeons, gastroenterologists, and interventional radiologists experienced in biliary and pancreatic disease.

METHODS

This case series was completed to review the patient cases discussed over the first year of BLiPs rounds, and to evaluate the effect of the multidisciplinary discussion on patient management plans. Meeting minutes were reviewed for BLiPs rounds between May 2022 and July 2023. Data were collected retrospectively on all discussed patients by review of the electronic medical record, and analyzed using frequencies and means with standard deviations.

RESULTS

Between May 2022 and July 2023, 56 cases were discussed at 12 case conferences. 68% of cases concerned pancreatic pathology, 25% concerned biliary pathology, the remainder liver or duodenal pathology. 49 cases (88%) were presented to discuss therapeutic options, and 7 presented as diagnostic challenges. Cases were usually presented once, but 7 patients were discussed at multiple conferences due to complex issues or ongoing symptomatology. 40 patients (71%) had undergone previous endoscopic, percutaneous, or surgical interventions prior to discussion. Endoscopic intervention was recommended in 32% of cases, percutaneous interventional approach in 13%, a combined endoscopic and percutaneous approach in 9%, and surgery in 18%. Repeat imaging or observation was recommended in 29% of cases. Discussion at rounds led to a change or adjustment in the proposed management in 46 cases (82%). The plan recommended by the MCC was carried out in 71% of cases.

CONCLUSION

BLiPs case conference provides a valuable venue to discuss cases, encourage interdisciplinary collaboration, and refine treatment approaches, leading to a change in proposed management plan in over three-quarters of cases presented.

Incisional hernia after major pancreatic resection: long term risk assessment from two distinct sources - A large multi-institutional network and a single high-volume center

BACKGROUND

Post-operative incisional hernia (IH) is a common complication following abdominal surgery. Data regarding IH after major pancreatic surgery are limited. We aim to evaluate the long-term risk of IH following major pancreatic resection.

METHODS

A dual-approach study: a large multi-institutional research network (RN) was investigated for IH incidence and risk factors in propensity-score matched survivors after pancreaticoduodenectomy (PD) and distal pancreatectomy (DP), was complemented by a patient-reported questionnaire.

RESULTS

RN analysis identified 22,113 patients that underwent pancreatic surgery. 11.0% of PD patients and 8.6% of DP patients developed IH (P < 0.0001). IH rates were higher with open surgery compared with minimally invasive approaches in PD (OR = 1.56, P = 0.03) and DP (OR = 1.94, P = 0.003). BMI>35 was found to correlate with increased IH rates for PD and DP (OR = 1.87, and OR = 1.86, respectively, P < 0.0001 each), as did postoperative intraabdominal infections (P < 0.0001). Patient-based survey of 104 patients, revealed that 16 patients (15%) reported post-operative IH during the follow-up period. BMI≥30, SSI and intra-abdominal abscesses were associated with increased IH risk (P < 0.05).

CONCLUSION

Improved survival after pancreatic resection has led to an increased prevalence of long-term surgical sequela. In this study, we demonstrate significant rates of IH among long-term survivors and assess potential risk factors.