Double-catheter lavage combined with percutaneous flexible endoscopic debridement for infected pancreatic necrosis failed to percutaneous catheter drainage

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.

The severity and infection of acute pancreatitis may increase the risk of bleeding in patients undergoing EUS-guided drainage and endoscopic necrosectomy: a large retrospective cohort

BACKGROUND

There has been great progress in the use of endoscopic ultrasound (EUS)-guided drainage in acute pancreatitis patients using a novel lumen-apposing metal stent (LAMS) in the last decade, but some patients experience bleeding. Our research analyzed the preprocedural risk factors for bleeding.

METHODS

From July 13, 2016 to June 23, 2021, we retrospectively analyzed all patients who received endoscopic drainage by the LAMS in our hospital. Univariate and multivariate statistical analyses were used to identify the independent risk factors. We plotted ROC curves based on the independent risk factors.

RESULTS

A total of 205 patients were analyzed and 5 patients were excluded. A total of 200 patients were included in our research. Thirty (15%) patients presented with bleeding. In the multivariate analysis, computed tomography severity index score (CTSI) score [odds ratio (OR), 2.66; 95% CI: 1.31-5.38; P = 0.007], positive blood cultures [odds ratio (OR), 5.35; 95% CI: 1.31-21.9; P = 0.02], and Acute Physiology and Chronic Health Evaluation II (APACHE II) score [odds ratio (OR), 1.14; 95% CI: 1. 01-1.29; P = 0.045] were associated with bleeding. The area under the ROC curve of the combined predictive indicator was 0.79.

CONCLUSION

Bleeding in endoscopic drainage by the LAMS is significantly associated with the CTSI score, positive blood cultures, and APACHE II score. This result could help clinicians make more appropriate choices.

Percutaneous endoscopic necrosectomy (PEN) for treatment of necrotizing pancreatitis: a systematic review and meta-analysis

Background and study aims  Endoscopic necrosectomy is limited by the proximity of necrosis to the gastrointestinal tract. Percutaneous endoscopic necrosectomy (PEN) is a minimally invasive endoscopic method of percutaneous debridement. Studies regarding its efficacy and safety are lacking. The purpose of this study was to assess the efficacy and safety of PEN in necrotizing pancreatitis.

Methods  Pubmed, Ovid, Cochrane, Scopus and Web of Science Database were searched from inception through February 2021. Dual extraction and quality assessment of studies using Cochrane risk of bias tool were performed independently by two authors. The primary outcome was defined as clinical success of PEN. Secondary outcomes included periprocedural morbidity, mortality, and long-term morbidity and mortality.

Results  Sixteen observational studies including 282 subjects were analyzed. The average reported age of the participants was 50.3 years. Patients with reported gender included 39 % females and 61 % males. The success rate as defined by complete resolution of necrosis and removal of drainage catheters/stents was 82 % (95 % confidence interval 77–87). The mean size of pancreatic necrosis was 14.86 cm (5–54 cm). The periprocedural morbidity rate was 10 %, while there was no reported periprocedural mortality. The long-term morbidity rate was reported as 23 % and mortality at follow-up was 16 %.

Conclusions  PEN is a novel method of endoscopic management of pancreatic necrosis. Based on our meta-analysis of retrospective studies, it represents a safe treatment modality with high rates of clinical success and low rates of perioperative morbidity and mortality. This study supports the use of PEN when conventional endoscopic therapy is not feasible.

A novel mini-invasive step-up approach for the treatment of severe acute pancreatitis with extensive infected necrosis: A single center case series study

RATIONALE

Complete removal of necrosis is critical for treating patients with severe acute pancreatitis (SAP) presenting infection of pancreatic necrosis (IPN). Frequently used mini-invasive methods include the surgical step-up approach suitable for necrosis extending laterally, whereas the endoscopic step-up approach is suitable for medial necrosis. However, in patients with extensive IPN, either approach alone usually has limited treatment effects.

PATIENT CONCERNS

We describe a case series of combined mini-invasive step-up approach for treating extensive IPN.

DIAGNOSES

Patients were diagnosed with SAP and had extensive IPN.

INTERVENTIONS

Seven patients with SAP and extensive IPN were enrolled. All patients underwent a combined step-up approach comprising 4 steps: percutaneous catheter drainage, continuous negative pressure irrigation (CNPI), percutaneous endoscopic necrosectomy (PEN), and transgastric necrosectomy (TN).

OUTCOMES

The median interval from symptom onset to percutaneous catheter drainage and CNPI was 11 days (range, 6-14) and 18 days (range, 14-26), and the median CNPI duration was 84 days (range, 54-116). The median interval from the onset of symptoms to PEN and TN was 36 days (range, 23-42) and 41 days (range, 34-48), respectively, and the median number of procedures was 2 (range, 1-2) for PEN and 3 (range, 2-4) for TN. Only a minor case of abdominal bleeding and a pancreatic-cutaneous fistula were reported, both resolved after conservative treatment. The median length of stay in the intensive care unit was 111 days (range, 73-133); all patients survived.

LESSONS

This mini-invasive step-up approach shows promising clinical effects and is relatively safe in critically ill patients with extensive IPN and high-risk surgical intervention.

Contemporary Surgical Management of Pancreatic Necrosis

Importance

For decades, infected or symptomatic pancreatic necrosis was managed by open surgical necrosectomy, an approach that has now been largely supplanted by an array of techniques referred to as the step-up approach.

Observations

This review describes the evidence base behind the step-up approach, when to use the different techniques, and their technical basics. The most common treatment strategies are included: percutaneous drainage, video-assisted retroperitoneal debridement, sinus tract endoscopy, endoscopic transgastric necrosectomy, and surgical transgastric necrosectomy. Also included is the evidence base around management of common complications that can occur during step-up management, such as hemorrhage, intestinal fistula, and thrombosis, in addition to associated issues that can arise during step-up management, such as the need for cholecystectomy and disconnected pancreatic duct syndrome.

Conclusions and Relevance

The treatment strategies highlighted in this review are those most commonly used during step-up management, and this review is designed as a guide to the evidence base underlying these strategies, as surgeons tailor their therapeutic approach to individual patients.

JPN clinical practice guidelines 2021 with easy-to-understand explanations for the management of acute pancreatitis

BACKGROUND

In preparing the Japanese (JPN) guidelines for the management of acute pancreatitis 2021, the committee focused the issues raised by the results of nationwide epidemiological survey in 2016 in Japan.

METHOD

In addition to a systematic search using the previous JPN guidelines, papers published from January 2014 to September 2019 were searched for the contents to be covered by the guidelines based on the concept of GRADE system.

RESULTS

Thirty-six clinical questions (CQ) were prepared in 15 subject areas. Based on the facts that patients diagnosed with severe disease by both Japanese prognostic factor score and contrast-enhanced computed tomography (CT) grade had a high fatality rate and that little prognosis improvement after 2 weeks of disease onset was not obtained, we emphasized the importance of Pancreatitis Bundles, which were shown to be effective in improving prognosis, and the CQ sections for local pancreatic complications had been expanded to ensure adoption of a step-up approach. Furthermore, on the facts that enteral nutrition for severe acute pancreatitis was not started early within 48 h of admission and that unnecessary prophylactic antibiotics was used in almost all cases, we emphasized early enteral nutrition in small amounts even if gastric feeding is used and no prophylactic antibiotics are administered in mild pancreatitis.

CONCLUSION

All the members of the committee have put a lot of effort into preparing the extensively revised guidelines in the hope that more people will have a common understanding and that better medical care will be spread.

Percutaneous Endoscopic Necrosectomy-A Review of the Literature

In this article, an attempt was made to clarify the role of percutaneous endoscopic necrosectomy (PEN) in the interventional treatment of pancreatic necrosis. A comprehensive review of the current literature was performed to identify publications on the role of PEN in patients with consequences of acute necrotizng pancreatitis. The aim of the study was to review the literature on minimal invasive necrosectomy, with emphasis on PEN using esophageal self-expanding metal stents (SEMS). The described results come from 15 studies after a review of the current literature. The study group comprised 52 patients (36 men and 16 women; mean age, 50.87 (13-75) years) with walled-off pancreatic necrosis, in whom PEN using a self-expandable esophageal stent had been performed. PEN was successfully completed in all 52 patients (100%). PEN complications were observed in 18/52 (34.62%) patients. Clinical success was achieved in 42/52 (80.77%) patients, with follow-up continuing for an average of 136 (14-557) days. In conclusion, the PEN technique is potentially effective, with an acceptable rate of complications and may be implemented with good clinical results in patients with pancreatic necrosis.

Association between morphological features of necrotizing pancreatitis on endoscopic ultrasound and outcomes of the endoscopic transmural step-up approach

OBJECTIVE

To investigate the association between necrotic collections on endoscopic ultrasound (EUS) and outcomes of the endoscopic transmural step-up approach in necrotizing pancreatitis (NP).

METHODS

Adult NP patients who had undergone endoscopic transmural step-up approach, endoscopic transmural drainage or endoscopic transmural necrosectomy, were retrospectively enrolled, and divided into groups 1, 2 and 3 based on the amount of solid necrotic debris (quantified as a percentage of the total collection size of <30%, 30%-50%, and >50%).

RESULTS

A total of 134 patients were included, of whom 52, 59 and 23 patients were categorized into groups 1, 2 and 3. Patients with more solid necrotic debris required more necrosectomy sessions (group 3 vs group 2 vs group 1: 2.0 vs 1.0 vs 1.0, P < 0.001), were more likely to experience stent occlusion (group 3 vs group 2 vs group 1: 34.8% vs 16.9% vs 9.6%, P = 0.011), and had a longer hospitalization (group 3 vs group 2 vs group 1: 40.0 d vs 28.0 d vs 25.5 d, P = 0.015). High procalcitonin level (adjusted odds ratio [aOR] 6.14, 95% confidence interval [CI] 1.40-26.94, P = 0.016) and any organ failure (aOR 11.51, 95% CI 2.42-54.78, P = 0.002) were independently associated with clinical failure of endoscopic transmural step-up approach.

CONCLUSIONS

More solid necrotic debris on EUS is related to more necrosectomy sessions, higher incidence of stent occlusion and longer hospitalization. A nomogram combining procalcitonin and any organ failure performs well in predicting clinical failure of endoscopic transmural step-up approach.

A Novel Strategy for Transmural Stent Removal in Necrotizing Pancreatitis Undergoing Endoscopic Transmural Necrosectomy

BACKGROUND

Although metal stents have been widely used in the endoscopic step-up approach for necrotizing pancreatitis, the exact timing of transmural stent removal has not been well studied. Here, we report a novel strategy for stent removal and compare it with the conventional strategy.

MATERIALS AND METHODS

This retrospective, nested, case-control study analyzed all adult necrotizing pancreatitis patients who underwent endoscopic transmural necrosectomy (ETN). Clinical outcomes were compared between case group (a novel strategy in which the stents were removed during the last necrosectomy when the ETN endpoint was achieved) and 1:1 necrosis extent matched control group (the conventional strategy).

RESULTS

Baseline characteristics was comparable between case group (n=37) and control group (n=37). Three (8.1%) patients in case group and 1 (2.7%) patient in control group needed additional ETN after stent removal (P>0.05). Nearly all patients (case: 97.3%; control: 94.6%) achieved clinical success. There was no difference in disease-related (case: 40.5%; control: 37.8%) or stent-related (case: 27.0%; control: 16.2%) complications. Case group had a trend of shorter length of stent placement (median: 20.0 vs. 29.5 d, P>0.05).

CONCLUSIONS

The novel strategy of transmural stent removal during last necrosectomy might be feasible which needed further validation. Compared with the convention strategy, the novel strategy avoids one endoscopy procedure and should be considered in clinical practice.

Risk factors for bleeding in patients with acute necrotizing pancreatitis undergoing endoscopic necrosectomy

BACKGROUND

This study investigated risk factors for bleeding in patients with acute necrotizing pancreatitis (ANP) undergoing endoscopic necrosectomy (EN) and the effect of endoscopic haemostasis.

METHODS

145 patients with ANP who underwent EN were recruited from January 2014 to December 2018. Patients with and without bleeding were allocated to the bleeding and nonbleeding groups, respectively. Multivariable logistic regression models were used to assess independent risk factors for bleeding.

RESULTS

39 patients (26.9%) experienced bleeding. The body mass index and culture-confirmed infectious pancreatic necrosis (IPN), renal failure and continuous renal replacement therapy rates were significantly higher in the bleeding group (all P < 0.01). In addition, the number of debridement procedures was significantly higher in the bleeding group (P = 0.004), accompanied by a higher mortality rate and greater hospitalization costs (all P < 0.05). Most cases of bleeding during EN were successfully stopped by endoscopic haemostasis (94.1%), but this was difficult to achieve after EN. Multivariate analysis revealed that renal failure (odds ratio [OR]: 3.77, P = 0.02), culture-confirmed IPN (OR: 3.19, P = 0.02), and ≥3 debridement procedures (OR: 12.92, P = 0.001) were associated with an increased bleeding risk.

CONCLUSION

Renal failure, culture-confirmed IPN, and multiple debridement procedures were independent risk factors for bleeding in patients with ANP who underwent EN.

Open necrosectomy combined with continuous positive drainage and prophylactic diverting loop ileostomy for late infected pancreatic necrosis: a retrospective cohort study

Background

To evaluate an innovative open necrosectomy strategy with continuous positive drainage and prophylactic diverting loop ileostomy for the management of late infected pancreatic necrosis (LIPN).

Methods

Consecutive patients were divided into open necrosectomy (ON) group (n = 23), open necrosectomy with colonic segment resection (ON+CSR) group (n = 8) and open necrosectomy with prophylactic diverting loop ileostomy (ON+PDLI) group (n = 11). Continuous positive drainage (CPD) via double-lumen irrigation–suction tube (DLIST) was performed in ON+PDLI group. The primary endpoints were duration of organ failure after surgery, postoperative complication, the rate of re-surgery and mortality. The secondary endpoints were duration of hospitalization, cost, time interval between open surgery and total enteral nutrition (TEN).

Results

The recovery time of organ function in ON+PDLI group was shorter than that in other two groups. Colonic complications occurred in 13 patients (56.5%) in the ON group and 3 patients (27.3%) in the ON+PDLI group (p = 0.11). The length of stay in the ON+PDLI group was shorter than the ON group (p = 0.001). The hospitalization cost in the ON+PDLI group was less than the ON group (p = 0.0052).

Conclusion

ON+PDLI can avoid the intestinal dysfunction, re-ileostomy, the resection of innocent colon and reduce the intraoperative trauma. Despite being of colonic complications before or during operation, CPD + PDLI may show superior effectiveness, safety, and convenience in LIPN.

Lavage through percutaneous catheter drains in severe acute pancreatitis: Does it help?A randomized control trial

AIMS

There is no study comparing large volume lavage through image guided percutaneously placed drains in severe acute pancreatitis.

METHODS

Of the 114 randomized patients, 60 eligible candidates were randomly allocated to - Lavage Treatment (LT) group (28 patients) and Dependent Drainage (DD) group (32 patients). Primary end point was reversal of pre-existing organ failure, development of new onset organ failure, need for surgery, mortality and hospital stay.

RESULTS

Both the groups were comparable in terms of demographic data, onset and severity of pancreatitis. LT group had higher infected pancreatic necrosis (75% vs 50%,p = 0.047). On intention to treat analysis, lavage treatment group showed a significant reversal of persistent organ failure (84% vs 50%, p = 0.23), reduction in APACHEII scores (3.5 ± 3.405 vs 1.16 ± 3.811 p = 0.012), as measured at the time of placement of PCD to cessation of intervention. There was no difference in development of new onset organ failure in the two groups (25% vs37.5% p=.290). 75% in LT group and 69% in DD group improved with PCD alone. There was no difference in the catheter related complications and number of catheters used. The need for surgical intervention was comparable in two groups (18.8% vs 14.3% p=.737). There was a trend toward decreased mortality in group A (18.8% vs 28.8% p=.370).

CONCLUSION

Large volume lavage trough PCD improves organ failure and this translates into trend towards reduced mortality.

Impact of continuous local lavage on pancreatic juice-related postoperative complications: Three case reports

BACKGROUND

Postoperative pancreatic leakage readily results in intractable pancreatic fistula and subsequent intraperitoneal abscess. This refractory complication can be fatal; therefore, intensive treatment is important. Continuous local lavage (CLL) has recently been reevaluated as effective treatment for severe infected pancreatitis, and we report three patients with postoperative intractable pancreatic fistula successfully treated by CLL. We also discuss our institutional protocol for CLL for postoperative pancreatic fistula.

CASE SUMMARY

The first patient underwent subtotal stomach-preserving pancreaticoduodenectomy, and pancreatic leakage was observed postoperatively. Intractable pancreatic fistula led to intraperitoneal abscess, and CLL near the pancreaticojejunostomy site was instituted from postoperative day (POD) 8. The abscess resolved after 7 d of CLL. The second patient underwent distal pancreatectomy. Pancreatic leakage was observed, and intractable pancreatic fistula led to intraperitoneal abscess near the pancreatic stump. CLL was instituted from POD 9, and the abscess resolved after 4 d of CLL. The third patient underwent aneurysmectomy and splenectomy with wide exposure of the pancreatic parenchyma. Endoscopic retrograde pancreatic drainage was performed on POD 15 to treat pancreatic fistula; however, intraperitoneal abscess was detected on POD 59. We performed CLL endoscopically via the transgastric route because the percutaneous approach was difficult. CLL was instituted from POD 63, and the abscess resolved after 1 wk of CLL.

CONCLUSION

CLL has therapeutic potential for postoperative pancreatic fistula.

Severely Calcified True Aneurysm: A Thought-Provoking Case of Solitary Origin and Postoperative Management

BACKGROUND Visceral arterial aneurysms are rare. Most splenic arterial aneurysms (SAAs) are saccular and are in the distal third of the splenic artery. Suggested major causes of SAAs are atherosclerosis, pregnancy, and inflammation. We report the case of a patient who with a SAA extending almost the full length of his splenic artery. CASE REPORT A solitary true aneurysm that extended almost the entire length of the splenic artery was incidentally detected in an asymptomatic 70-year-old male patient with a history of myasthenia gravis and diabetes mellitus. His SAA was severely calcified, but other arteries showed no calcification. The aneurysm had been slightly enlarged toward the celiac artery for 2 years, and aneurysmectomy and splenectomy were performed. Vascular clips were carefully placed at the intact splenic artery without disturbing arterial flows from the celiac artery. Arterial branch from the SAA was ligated at an intact area, and the pancreatic capsule was densely adherent with the calcified aneurysm wall. The pancreas was preserved, although the pancreatic parenchyma was widely exposed during aneurysmectomy. Pathological examination revealed no atherosclerotic changes. Postoperatively, a pancreatic fistula developed, which was treated by placing an intraperitoneal drain and retrograde pancreatic drainage tube. Nevertheless, the intractable pancreatic fistula triggered a bacteriogenic infection, resulting in intraperitoneal abscess. Continuous local lavage via transnasal continuous infusion and endoscopic transgastric drainage was performed, until the fistula closed. He was healthy at 9 months after surgery. CONCLUSIONS A SAA that had the rare form and solitary origin was treated. Continuous local lavage has a therapeutic potential for a pancreatic juice-related bacteriogenic complication.

Percutaneous Endoscopic Necrosectomy (PEN) Combined with Percutaneous Catheter Drainage (PCD) and Irrigation for the Treatment of Clinically Relevant Pancreatic Fistula after Pancreatoduodenectomy

Purpose: This study aimed to evaluate the efficacy of percutaneous endoscopic necrosectomy (PEN) combined with percutaneous catheter drainage (PCD) and irrigation versus PCD for the treatment of clinically relevant postoperative pancreatic fistula (CR-POPF) after pancreatoduodenectomy (PD). Materials and Methods: A total of 34 consecutive patients who suffered from CR-POPF after PD were enrolled in this retrospective cohort study. 12 patients received PEN combined with PCD and irrigation, and 22 patients received PCD. The complications and outcomes of the treatments were compared. Results: No patients suffered from severe PCD- or PEN-related complications. Compared with those treated with PCD, the patients treated with PEN combined with PCD and irrigation had a lower incidence of postoperative delayed severe intraabdominal hemorrhage (31.8% vs. 0%; p = 0.04). During the follow-up period, no patients in either group suffered from collection recurrence or external pancreatic fistula requiring surgical intervention.Conclusions: PEN combined with PCD and irrigation was safe and effective for reducing postoperative delayed severe intraabdominal hemorrhage in patients with CR-POPF after PD.