Perforation and Fistula of the Gastrointestinal Tract in Patients With Necrotizing Pancreatitis: A Nationwide Prospective Cohort

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.

Transcolonic Necrosectomy: A Rarely-Used Pancreatic Debridement Strategy

Necrotizing pancreatitis represents a life-threatening sequela of acute pancreatitis in which rapid necrotization of pancreatic and abdominal tissue leads to inflammation and sometimes infection. Treatment includes debridement of necrotic tissue to prevent inflammation from spreading and antibiotics if infected. Areas of necrosis are accessed through percutaneous drainage, surgical debridement, or upper endoscopy. In this study, we present a case of walled-off necrosis debrided through a fistulous connection to the transverse colon. Transcolonic necrosectomy is a seldom used approach, which could provide treatment options for necrotizing pancreatitis in anatomically amenable patients.

Comprehensive management of gastrointestinal fistulas in necrotizing pancreatitis: a review of diagnostic and therapeutic approaches

INTRODUCTION

Gastrointestinal fistula (GIF) is a rare but severe complication in patients with necrotizing pancreatitis (NP), significantly prolonging disease course and increasing morbidity and mortality. Its subtle and nonspecific early symptoms often delay diagnosis and intervention. Despite its clinical significance, the low incidence of GIF in NP has resulted in limited research and a lack of consensus on optimal diagnostic and therapeutic strategies.

AREAS COVERED

This review focuses on the epidemiology, pathophysiology, diagnostic approaches, and therapeutic management of GIF in NP patients. Imaging techniques, such as contrast-enhanced computed tomography and endoscopy, have been integral to early diagnosis. Advances in interventional and surgical techniques provide new avenues for treatment, but variability in clinical practice highlights the need for standardized protocols.

EXPERT OPINION

Recent advances in diagnostic imaging have improved the detection of GIF, while innovations in interventional and surgical treatments show promise. Current research is still insufficient and varied. Future research should focus on developing diagnostic methods and treatment measures for such complications. By improving early diagnosis and offering insights into effective management strategies, it is hoped that patient outcomes can be improved.

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.

Emergency pancreaticoduodenectomy for pancreatitis-associated necrotic perforation of the distal stomach and full-length duodenum: A case report

BACKGROUND

Non-ulcerative necrosis of the stomach and duodenum is rare because of the abundant blood supply in the gastrointestinal tract. Duodenal necrosis is a rare complication of severe acute pancreatitis. Emergency pancreaticoduodenectomy (EPD) is a rare procedure, with extensive duodenal necrosis being one of its indications.

CASE SUMMARY

We here report the case of a 57-year-old man who survived EPD for pancreatitis, which resulted in the necrosis of the distal stomach, full-length duodenum, and part of the jejunum.

CONCLUSION

Despite significant surgical risks, an EPD could be a life-saving procedure in severe cases of pancreatitis.

Necrosectomy and its timing in relation to clinical outcomes of EUS-guided treatment of walled-off pancreatic necrosis: a multicenter study

BACKGROUND AND AIMS

EUS-guided transmural drainage with on-demand endoscopic necrosectomy (EN) is increasingly used to manage walled-off necrosis (WON). It has not been fully elucidated how EN and its timing are correlated with treatment outcomes compared with the drainage-based approach.

METHODS

Within a multi-institutional cohort of 423 patients with pancreatic fluid collections, including 227 patients with WON, 153 patients were identified who received the step-up treatment after the initial EUS-guided drainage of symptomatic WON; this included 102 EN patients and 51 non-EN (drainage) patients. Using the competing-risks multivariable proportional hazards regression model with adjustment for potential confounders, we calculated subdistribution hazard ratios (SHRs) for clinical treatment success (WON resolution) according to use of EN and its timing.

RESULTS

Compared with drainage alone, the EN-based treatment was associated with a shorter time to clinical success with a multivariable SHR of 1.66 (95% confidence interval, 1.12-2.46). Despite a higher risk of procedure-related bleeding in the EN group, there were no differences in the rates of severe adverse events (7.8% vs 5.9% in the EN and non-EN groups, respectively) or mortality (6.9% vs 9.8%). In the EN-treated patients, the timing of EN was not statistically significantly associated with the time to clinical success (Ptrend = .34).

CONCLUSIONS

Among patients receiving EUS-guided treatment of symptomatic WON, the use of EN in addition to drainage procedures was associated with earlier disease resolution. Further research is desired to determine the optimal timing of initiating EN considering a risk-benefit balance and cost-effectiveness.

Diagnostic accuracy of abdominal contrast-enhanced multi-slice spiral CT after oral diluted iodide in a time segment for gastrointestinal fistula in patients with severe acute pancreatitis

PURPOSE

To evaluate the diagnostic accuracy of abdominal contrast-enhanced multi-slice spiral CT after oral diluted iodide in a time segment (post-ODI ACE-MSCT) for gastrointestinal fistula (GIF) in severe acute pancreatitis (SAP).

MATERIALS AND METHODS

Patients with SAP who underwent both post-ODI ACE-MSCT and endoscopy/surgery from 2017 to 2023 were continuously retrospectively involved. Their demographic information and clinical features were recorded prospectively in an in-hospital database. Using endoscopy/surgery results as the reference standard, the sensitivity, specificity, positive predictive value, negative predictive value, and accuracy of post-ODI ACE-MSCT for diagnosing GIF in SAP were calculated by a four-cell table. The consistency of the two diagnostic methods was evaluated by the Kappa test and McNemar's test.

RESULTS

Using endoscopy/surgery as the reference standard, a total of 86 cases were divided into the GIF group (N = 52) and the non-GIF group (N = 34). Among the 52 cases of GIF, 88.5% (46/52) cases had a positive result and 11.5% (5/52) cases had a negative result of post-ODI ACE-MSCT for GIF. Among the 34 cases of non-GIF, 2.9% (1/34) case had a positive result and 97.1% (33/34) cases had a negative result of post-ODI ACE-MSCT for GIF. Post-ODI ACE-MSCT had a sensitivity of 88.5% (95% CI 75.9%-95.2%), a specificity of 97.1% (95% CI 82.9%-99.8%), a positive predictive value of 97.9% (95% CI 87.3%-99.9%), a negative predictive value of 84.6% (95% CI 68.8%-93.6%), and an accuracy of 91.9% (83.4%-96.4%). The kappa value was 0.834, and P < 0.001 by McNemar's test. There were no significant differences in diagnostic test characteristics between the two modalities.

CONCLUSION

Post-ODI ACE-MSCT can diagnose GIF in SAP in a simple, noninvasive, and accurate way, and can provide earlier imaging evidence for clinical diagnosis and treatment.

Gastrointestinal Fistulas in Necrotizing Pancreatitis Receiving a Step-Up Approach Incidence, Risk Factors, Outcomes and Treatment

Purpose

Necrotizing pancreatitis (NP) complicated by gastrointestinal fistula is challenging and understudied. As the treatment of necrotizing pancreatitis changed to a step-up strategy, we attempted to evaluate the incidence, risk factors, clinical outcomes and treatment of gastrointestinal fistulas in patients receiving a step-up approach.

Methods

Clinical data from 1274 patients with NP from 2014-2022 were retrospectively analyzed. Multivariable logistic regression analysis was conducted to identify risk factors and propensity score matching (PSM) to explore clinical outcomes in patients with gastrointestinal fistulas.

Results

Gastrointestinal fistulas occurred in 8.01% (102/1274) of patients. Of these, 10 were gastric fistulas, 52 were duodenal fistulas, 14 were jejunal or ileal fistulas and 41 were colonic fistulas. Low albumin on admission (OR, 0.936), higher CTSI (OR, 1.143) and invasive intervention prior to diagnosis of gastrointestinal fistula (OR, 5.84) were independent risk factors for the occurrence of gastrointestinal fistula, and early enteral nutrition (OR, 0.191) was a protective factor. Patients who developed a gastrointestinal fistula were in a worse condition on admission and had a poorer clinical outcome (p<0.05). After PSM, both groups of patients had similar baseline information and clinical characteristics at admission. The development of gastrointestinal fistulas resulted in new-onset persistent organ failure, increased open surgery, prolonged parenteral nutrition and hospitalization, but not increased mortality. The majority of patients received only conservative treatment and minimally invasive interventions, with 7 patients (11.3%) receiving surgery for upper gastrointestinal fistulas and 11 patients (26.9%) for colonic fistulas.

Conclusion

Gastrointestinal fistulas occurred in 8.01% of NP patients. Independent risk factors were low albumin, high CTSI and early intervention, while early enteral nutrition was a protective factor. After PSM, gastrointestinal fistulas resulted in an increased proportion of NP patients receiving open surgery and prolonged hospitalization. The majority of patients with gastrointestinal fistulas treated with step-up therapy could avoid surgery.

Early mean absolute lymphocyte count in acute necrotizing pancreatitis is associated with infected pancreatic necrosis

OBJECTIVES

Peripheral absolute lymphocyte count (ALC) has the potential to predict infected pancreatic necrosis (IPN), but requires verification. This study aimed to assess whether early mean absolute lymphocyte count is associated with the development of IPN in ANP patients using pooled data from a multicenter, randomized controlled trial and a retrospective study.

METHODS

The study subjects are from the TRACE trial and a single-center cohort study. ALC during the first seven days was used to define early mean ALC. The entire cohort was then divided into quartiles of early mean ALC. Multivariable Cox proportional hazards regression (MCPHR) model was used to assess the association between early mean ALC and 90-day IPN.

RESULTS

A total of 660 patients (median age, 44 years; 63.8 % males) were included and 157 (23.8 %) developed IPN within a 90-day period. The median (interquartile range, IQR) of the early mean ALC is 1.07 (0.80-1.36). All the study subjects were evenly divided into 4 groups: quartile-1 (0.33-0.79*10^9/L), quartile-2 (0.80-1.06*10^9/L), quartile-3 (1.07-1.36*10^9/L) and quartile-4 (1.37-4.01*10^9/L). The incidence of 90-day IPN was 38.3 %, 25.7 %, 19.2 % and 12.2 % for each group, respectively. In the MCPHR model, the lowest early mean ALC (quartile-1) was found to be an independent risk factor of 90-day IPN with a hazard ratio (95 %CI) of 2.21 (1.28-3.81) compared to the highest mean ALC(quartile-4) group.

CONCLUSION

Among patients with ANP, early mean ALC was significantly associated with the development of IPN. Preventive strategies should be considered in patients with reduced ALC.