Predicting the Success of Catheter Drainage in Infected Necrotising Pancreatitis: A Cross-Sectional Observational Study

Background Management of acute necrotising pancreatitis is often challenging for clinicians. Secondary infection of the necrotic collections leads to sepsis and warrants intervention. Minimally invasive techniques like catheter drainage have recently been proposed over more risky and morbid traditional open procedures. Factors that can predict successful catheter drainage of the necrotic pancreatic collection are still unclear and not well established. Materials and methods This study is designed as a retrospective cross-sectional observational study to investigate the association of 21 factors in predicting successful catheter drainage. Data from 30 patients admitted with acute necrotising pancreatitis treated with catheter drainage were collected and analysed. Twenty-one factors, including demographic variables, disease severity factors, drainage criteria, and morphological criteria on imaging, were studied for their predictive association with successful outcomes. Univariate analysis was done for each variable against the outcome. The study was conducted between December 2012 to March 2017. P-value <0.05 was considered statistically significant. Results Patients with no organ involvement responded better to primary catheter drainage. Patients with BMI>25 and multi-organ failure were poor candidates for primary catheter drainage. Clinically unwell patients with a Bedside Index for Severity in Acute Pancreatitis (BISAP) score of ≥4 had a negative outcome on catheter drainage and usually ended up in a surgical procedure or eventually succumbed to the disease. Other variables included in our study did not statistically associate with the success or failure of percutaneous catheter drainage. Conclusion BMI >25, multiple organ failure, and BISAP score ≥ 4 are independent negative predictors for the success of catheter drainage in infected necrotising pancreatitis. No organ failure showed a positive predictor for successful catheter drainage. Further studies are required to explore these predictive factors in a larger sample size to predict the success of catheter drainage in infected pancreatic necrosis.

Controversies in EUS-guided treatment of walled-off necrosis

This review gives an overview of different techniques in the treatment of post-acute complications of acute pancreatitis. The endoscopic treatment of those complications is currently standard of care. EUS opened up the broad implementation of internal drainage methods to make them safe and effective. Due to different endoscopic approaches worldwide, controversies have arisen that are pointed out in this paper. The main focus was placed on weighing up evidence to find the optimal approach. However, if no evidence can be provided, the authors, experienced in the field, give their personal advice.

Patient-reported outcomes after minimally invasive retroperitoneal pancreatic necrosectomy to treat acute pancreatitis: An exploratory study

OBJECTIVE

The aim of this study (abbreviated as QUANTUM) was to assess the quality of life (QoL) of patients who underwent minimally invasive retroperitoneal pancreatic necrosectomy (MIRPN) for acute pancreatic necrosis with or without infection of necrotic tissue collections after discharge and to compare the patient-reported outcomes (PRO) in these patients with published data in normative population.

METHODS

Patients with acute pancreatitis who underwent MIRPN between January 2010 and December 2016 were identified and invited to complete the European Organisation for Research and Treatment of Cancer (EORTC) QLQ-C30 and EORTC PAN28(CP) questionnaires. PRO were compared using Pearson correlation coefficient and ANOVA (significance P < 0.01) with an age- and sex-matched normative population of western Europe, stratified by age, and also the time duration after MIRPN (<3 y and >3 y). A change >15 points in the PRO score was taken as clinically important.

RESULTS

Among 52 eligible patients identified, 46 (88%) agreed to participate, 74% returned questionnaires. After the MIRPN all patients had worse physical and social functioning scores with a clinically important (>15 points) reduction in those ≤50 years; while fatigue, pain and insomnia symptom scales had the highest scores (42, 26 and 30 points, respectively). Patients <3 years after MIRPN had similar scores for all functional scales and global health-related quality of life (HRQoL) compared to the normative population. However, over time their global HRQoL deteriorated and after 3 years their scores for functioning and symptoms were statistically (P < 0.0001) and clinically (>15 points) worse than those in age-matched controls.

CONCLUSIONS

During the first 3 years after the MIRPN patients have a relatively high QoL but report worse fatigue than the normative population. However, patients should be informed that their HRQoL deteriorates with time, often due to chronic pancreatitis and pancreatic insufficiency. This study supports the use of MIRPN and prospective studies of HRQoL in this setting are indicated.

Small Incision Combined with Nephroscope Operation in the Treatment of Infectious Pancreatic Necrosis: A Single-Center Experience of 37 Patients

Objective

To explore the safety and efficacy of small incision combined with nephroscope surgery in the treatment of infectious pancreatic necrosis.

Methods

A retrospective analysis of the clinical data of 37 patients with infectious pancreatic necrosis who underwent small incision combined with nephroscopy in the Department of Hepatobiliary Surgery of Hunan Provincial People's Hospital from January 2018 to December 2019.

Results

All 37 patients successfully completed small incision combined nephroscope surgery. The median time from the onset to the operation of all patients was 38 days (range: 29-80 days), and the hospital stay was 19 days (range: 3-95 days). The median number of drainage tubes placed during the operation was 4 (range: 2-8). According to the different surgical approaches, 13 cases were through the retroperitoneal approach, 11 cases were through the omental sac approach, 2 cases were through the intercostal approach, and 11 cases were combined approach. The operation time was 85.3 ± 31.6 min, and intraoperative bleeding was 63.1 ± 40.0 ml. The incidence of complications (Clavien-Dindo grade 3 and above) was 5.4%. Among them, 2 patients were admitted to the intensive care unit due to postoperative bleeding, 1 case was cured by conservative treatment, and 1 case was cured by interventional treatment. During the follow-up period, 2 patients developed colonic fistula at 2 weeks after operation, and 2 patients developed gastric fistula at 1 week and 3 weeks after operation; all were cured by conservative treatment.

Conclusion

Small incision combined with nephroscope surgery is an effective treatment for patients with infectious pancreatic necrosis by removing necrotic tissue, unobstructed drainage, and reducing complications.

Percutaneous Endoscopic Necrosectomy of Complex Walled-Off Lateral Necrosis of the Pancreas with the Aid of Laparoscopic Babcock Forceps: A Case Report of an Endoscopic and Radiologic Team Approach

INTRODUCTION

The initial therapeutic intervention for infected necrotizing pancreatitis usually begins with endoscopic cystogastrostomy for drainage, followed by endoscopic necrosectomy. Endoscopic pancreatic necrosectomy is commonly performed transluminally through transgastric or transduodenal routes. This case describes necrosectomy via a transcutaneous route for laterally located walled-off pancreatic necrosis and the novel use of Babcock forceps for an obstructed fully covered metal stent.

CASE PRESENTATION

A 62-year-old woman presented with abdominal pain, nausea, and vomiting. After multiple admissions and repeated abdominal imaging, she was found to have laterally located, infected, walled-off pancreatic necrosis. Initially, a drainage catheter was placed by an interventional radiologist and was eventually upsized to a 28F catheter. Subsequently, a fully covered metal stent was placed in the gastroenterology suite under fluoroscopic guidance and was used to gain access for percutaneous sessions of necrosectomy. A percutaneous sinus tract endoscopic necrosectomy was performed under direct endoscopic view. However, difficulties occurred with removing necrotic debris even through this large covered stent. Thus, laparoscopic Babcock forceps were used under fluoroscopy to remove lodged debris from the midstent. Repeat abdominal computed tomography scan 3 days after necrosectomy showed near resolution of the walled-off pancreatic necrosis.

DISCUSSION

This Babcock technique with endoscopic necrosectomy has not been previously described in the literature, to our knowledge. Babcock forceps were an ideal tool in our case because they were able to gain access to the obstruction in the stent, but the "teeth" are small and dull enough to prevent from catching onto the metal stent mesh.

Superiority of Step-up Approach vs Open Necrosectomy in Long-term Follow-up of Patients With Necrotizing Pancreatitis

BACKGROUND & AIMS

In a 2010 randomized trial (the PANTER trial), a surgical step-up approach for infected necrotizing pancreatitis was found to reduce the composite endpoint of death or major complications compared with open necrosectomy; 35% of patients were successfully treated with simple catheter drainage only. There is concern, however, that minimally invasive treatment increases the need for reinterventions for residual peripancreatic necrotic collections and other complications during the long term. We therefore performed a long-term follow-up study.

METHODS

We reevaluated all the 73 patients (of the 88 patients randomly assigned to groups) who were still alive after the index admission, at a mean 86 months (±11 months) of follow-up. We collected data on all clinical and health care resource utilization endpoints through this follow-up period. The primary endpoint was death or major complications (the same as for the PANTER trial). We also measured exocrine insufficiency, quality of life (using the Short Form-36 and EuroQol 5 dimensions forms), and Izbicki pain scores.

RESULTS

From index admission to long-term follow-up, 19 patients (44%) died or had major complications in the step-up group compared with 33 patients (73%) in the open-necrosectomy group (P = .005). Significantly lower proportions of patients in the step-up group had incisional hernias (23% vs 53%; P = .004), pancreatic exocrine insufficiency (29% vs 56%; P = .03), or endocrine insufficiency (40% vs 64%; P = .05). There were no significant differences between groups in proportions of patients requiring additional drainage procedures (11% vs 13%; P = .99) or pancreatic surgery (11% vs 5%; P = .43), or in recurrent acute pancreatitis, chronic pancreatitis, Izbicki pain scores, or medical costs. Quality of life increased during follow-up without a significant difference between groups.

CONCLUSIONS

In an analysis of long-term outcomes of trial participants, we found the step-up approach for necrotizing pancreatitis to be superior to open necrosectomy, without increased risk of reinterventions.

Treatment of severe acute pancreatitis via endoscopic pancreatic stenting and nasopancreatic drainage: Case reports

Severe acute pancreatitis (SAP) is associated with high mortality. SAP is generally treated by conservative management at the early phase, and removal of the pancreatic and peripancreatic necrotic tissue at the late phase. However, studies have suggested that the surgical treatment of SAP should focus on pressure reduction and drainage. In this case report, 3 SAP patients of 44, 30 and 60 years of age were treated at the General Hospital of Ningxia Medical University. They underwent emergency endoscopic pancreatic stenting at the early phase and nasopancreatic drainage at the late phase when peripancreatic encapsulated effusion was observed. All patients were successfully treated and discharged from the hospital. The disease duration of the patients was 71, 58, and 88 days, respectively. Our cases suggested that the surgical strategy of endoscopic pancreatic stenting at the early phase and nasopancreatic drainage at the late phase is promising for the treatment of SAP.

A meta-analysis and systematic review of percutaneous catheter drainage in treating infected pancreatitis necrosis

BACKGROUND

In the current meta-analysis, we focus on the exploration of percutaneous catheter drainage (PCD) in terms of its overall safety as well as efficacy in the treatment of infected pancreatitis necrosis based on qualified studies.

METHODS

The following electronic databases were searched to identify eligible studies through the use of index words updated to May 2018: PubMed, Cochrane, and Embase. Relative risk (RR) or mean difference (MD) along with 95% confidence interval (95% CI) were utilized for the main outcomes.

RESULTS

A total of 622 patients in the PCD group and 650 patients in the control group from 13 studies were included in the present meta-analysis. The aggregated results indicated that the incidence of bleeding was decreased significantly (RR: 0.42, 95% CI: 0.25-0.70) in the PCD group as compared with the control group. In addition, PCD decreased the mortality (RR: 0.76, 95% CI: 0.41-1.42), hospital duration (SMD: -0.22, 95% CI: -0.77 to -0.33), duration in intensive care unit (ICU) (SMD: -0.13, 95% CI: -0.30 to -0.04), pancreatic fistula (RR: 0.73, 95% CI: 0.46-1.17), and organ failure (RR: 0.91, 95% CI: 0.45-1.82) in comparison with the control group, but without statistical significance.

CONCLUSION

Our findings provide evidence for the treatment effect of PCD in the decrease of bleeding, mortality, duration in hospital and ICU, pancreatic fistula, organ failure as compared with the surgical treatment. In conclusion, further studies based on high-quality RCTs with larger sample size and long-term follow-ups are warranted for the confirmation of PCD efficacy in treating infected pancreatitis necrosis.

Percutaneous Catheter Drainage in Infected Pancreatitis Necrosis: a Systematic Review

The primary aim of this study was to present the outcomes of percutaneous catheter drainage (PCD) in patients with infected pancreatitis necrosis. A second aim was to focus on disease severity, catheter size, and additional surgical intervention. A literature search of the PubMed/MEDLINE/Cochrane Library (January 1998 to February 2015) databases was conducted. All randomized, non-randomized, and retrospective studies with data on PCD techniques and outcomes in patients with infected pancreatitis necrosis were included. Studies that reported data on PCD along with other interventions without the possibility to discriminate results specific to PCD were excluded. The main outcomes were mortality, major complications, and definitive successful treatment with percutaneous catheter drainage alone. Fifteen studies of 577 patients were included. There was only one randomized, controlled trial, and most others were retrospective case series. Organ failure before PCD occurred in 55.3 % of patients. With PCD alone, definitive successful treatment was 56.2 % of patients. Additional surgical intervention was required after PCD in 38.5 % of patients. The overall mortality rate was 18 % (104 of 577 patients). Complications occurred in 25.1 % of patients, and fistula was the most common complication. PCD is an efficient tool for treatment in the majority of patients with infected pancreatitis necrosis as the only intervention. Multiple organ failures before PCD are negative parameters for the outcome of the disease. Large catheters fail to prove to be more effective for draining necrotic tissue. However, in the extent of multi-morbid patients, to determine one single prognostic factor seems to be difficult.

Advances in Surgical Management of Pancreatic Diseases

The surgical management of pancreatic diseases is rapidly evolving, encompassing advances in evidence-driven selection of patients amenable for surgical therapy, preoperative risk stratification, refinements in the technical conduct of pancreatic operations, and quantification of postoperative morbidity. These advances have resulted in dramatic reductions in mortality following pancreatic surgery, particularly at high-volume pancreatic centers. Surgical decision making is complex, and requires an intimate understanding of disease pathobiology, host physiology, technical considerations, and evolving trends. This article highlights key developments in the contemporary surgical management of pancreatic diseases.