Interventions for necrotizing pancreatitis: summary of a multidisciplinary consensus conference

Burden of Ionizing Radiation in the Diagnosis and Management of Necrotizing Pancreatitis

INTRODUCTION

A step-up endoscopic or percutaneous approach improves outcomes in necrotizing pancreatitis (NP). However, these require multiple radiographic studies and fluoroscopic procedures, which use low-dose ionizing radiation. The cumulative radiation exposure for treatment of NP has not been well defined.

METHODS

We conducted a retrospective study of consecutive patients with NP admitted to University of California San Francisco Medical Center from January 2011 to June 2019. We calculated effective doses for fluoroscopic procedures using the dose area product and used the National Cancer Institute tool for computed tomography studies. The primary outcome was the cumulative effective dose (CED). Multivariable logistic regression was used to evaluate risk factors of high exposure (CED > 500 mSv).

RESULTS

One hundred seventy-one patients with NP (mean follow-up 40 ± 18 months) underwent a median of 7 (interquartile range [IQR] 5-11) computed tomography scans and 7 (IQR 5-12) fluoroscopic procedures. The median CED was 274 mSv (IQR 177-245) and 30% (51) of patients received high exposure. Risk factors of high exposure include multiorgan failure (aOR 3.47, 95%-CI: 1.53-9.88, P = 0.003), infected necrosis (adjusted odds ratio [aOR] 3.89 95%-CI:1.53-9.88, P = 0.005), and step-up endoscopic approach (aOR 1.86, 95%-CI: 1.41-1.84, P = 0.001) when compared with step-up percutaneous approach.

DISCUSSION

Patients with NP were exposed to a substantial amount of ionizing radiation (257 mSv) as a part of their treatment, and 30% received more than 500 mSv, which corresponds with a 5% increase in lifetime cancer risk. Severity of NP and a step-up endoscopic approach were associated with CED > 500 mSv. Further studies are needed to help develop low-radiation treatment protocols for NP, particularly in patients receiving endoscopic therapy.

The Role of Endoscopic Transpapillary Stenting of the Main Pancreatic Duct during the Endoscopic Treatment of Pancreatic Fluid Collections

Endotherapy is a recognized, widely available, and minimally invasive treatment method for pancreatic fluid collections (PFCs) formed in the course of acute pancreatitis (AP). The use of endoscopic techniques in the treatment of main pancreatic duct (MPD) disruption due to AP remains unclear. In this article, a comprehensive review of current literature referencing our observations was performed to identify publications on the role of MPD stenting in patients undergoing endoscopic drainage of PFCs resulting from AP. In this paper, we attempt to clarify this most controversial aspect of endotherapy for PFCs based on existing knowledge and our own experience regarding the endoscopic treatment of AP sequelae. Endoscopic retrograde pancreatography should be performed in all patients undergoing endoscopic drainage of walled-off pancreatic necrosis to assess the integrity of the main pancreatic duct and to implement endotherapy if pancreatic duct disruption is detected. Passive transpapillary drainage is an effective method for treating MPD disruption in the course of necrotizing AP and is one of the key components of endoscopic therapy for local pancreatic necrosis. Conversely, in patients with pancreatic pseudocysts, passive transpapillary drainage reduces the effectiveness of endoscopic treatment and should not be used even in cases of MPD disruption during transmural drainage of pancreatic pseudocysts. In conclusion, the use of transpapillary drainage should depend on the type of the PFC. This conclusion is of great clinical importance, as it can help improve the results of pancreatic endotherapy for fluid collections resulting from AP.

Outcomes of Open, Laparoscopic, and Percutaneous Drainage of Infected Walled-Off Pancreatic Necrosis: A Nationwide Inpatient Sample Study

Background

Walled-off pancreatic necrosis (WOPN) represents an encapsulated collection of necrotic pancreatic or peripancreatic tissue that tends to develop four weeks after the onset of acute necrotizing pancreatitis. When infected, it is managed initially by antibiotic therapy before drainage by endoscopic, percutaneous, or surgical means. This study aims to describe the morbidity, mortality, length of stay (LOS), and cost of care associated with open surgical, laparoscopic, and radiology-guided percutaneous drainage in adult patients with infected WOPN.

Methods

Using the Nationwide Inpatient Sample (NIS), patients aged 18 years and older discharged with the diagnosis of WOPN between January 1, 2016 and December 31, 2016 who underwent open, laparoscopic, or percutaneous drainage were included. Patients’ characteristics including age, gender, and body mass index were reported. The primary endpoints were the mortality rate as well as length and cost of stay in each group. The secondary endpoint was the rate of procedural complications in each arm. Endpoints were reported and compared with studies assessing similar outcomes. Statistical Analysis System (SAS) statistical software (SAS Institute Inc., Cary, NC, USA) was used to perform the analysis.

Results

A total of 229 patients with the diagnosis of acute pancreatitis with infected necrosis were identified. Of these 229 patients, 27, 15, and 20 underwent open, laparoscopic, and percutaneous drainage, respectively. A total of eight studies were used for comparison of outcome variables. Mortality rate was found to be similar among comparison studies. LOS and costs varied widely among studies. There were significantly fewer pancreatic fistula and significantly more multi-organ failure complications as a result of open necrosectomy in the NIS study sample.

Conclusion

Overall, in analyzing the outcomes of patients undergoing intervention for infected WOPN through the 2016 NIS database, it appears that the database is representative of the majority of outcomes seen in similar clinical trials.

Coating of ferulic acid-loaded silk fibroin nanoparticles with neutrophil membranes: A promising strategy against the acute pancreatitis

Nanotechnology-based approaches have enabled overcoming the challenging issues such as the rapid clearance, poor solubility, and non-specific action or cellular uptake of drugs. In this study, we have evaluated the therapeutic effects of the phenolic compound, ferulic acid (FA), in the acute pancreatitis (AP) as this phenolic compound has demonstrated promising effects against the oxidative stress and inflammatory reactions. In order to overcome the poor solubility and bioavailability of FA, it was entrapped into the nanoparticles (NPs) based on the silk fibroin (SF) as a biomimetic substance. Neutrophil membrane-coated SF-NPs with appropriate capacity of FA loading and physicochemical characteristics, released FA in a controlled fashion, selectively delivered FA into the inflammatory pancreas lesion, and demonstrated protective effects against the detrimental aspects of the disease. The prepared nanoformulation by improving the pharmacological profile of FA and targeted delivery could be of therapeutic importance against the AP via suppressing the inflammation and oxidative stress.

Endoscopic Management of Pancreatic Fluid Collections

Pancreatic fluid collections (PFCs) are a common sequela of pancreatitis. Most PFCs can be managed conservatively, but symptomatic PFCs require either surgical, percutaneous, or endoscopic intervention. Recent advances in the therapeutics of PFCs, including the step-up approach, endoscopic ultrasound-guided transmural drainage with lumen apposing metal stents, and direct endoscopic necrosectomy, have ushered endoscopy to the forefront of PFCs management and have allowed for improved patient outcomes and decreased morbidity. In this review, we explore the progress and future of endoscopic management of PFCs.

French reconnection: A conservative pancreato-enteric reconnection for disconnected pancreatic duct syndrome

BACKGROUND/OBJECTIVES

Disconnectedpancreatic duct syndrome (DPDS), a severe complication of acute necrotizing pancreatitis (ANP), may require surgery, usually by distal splenopancreatectomy, thus increasing the risk of diabetes. We describe a new technique reconnecting the distal pancreas to the digestive tract.

METHODS

This technique was proposed after failure of non-surgical treatment and at least 3 months after the onset of ANP in non-diabetic or non-insulin dependent diabetic patients with a distal pancreas of at least 5 cm. The ruptured zone was identified and the distal side was anastomosed to the stomach or the jejunum.

RESULTS

From 2013 to June 2019, 36 patients (median age = 49 years) with DPDS underwent a "French reconnection" procedure, indicated for chronic pain/recurrent pancreatitis (n = 35; 97%), persistent pancreatic fistula (n = 33; 91%), or digestive compression/fistulisation (n = 9; 25%). Median preoperative weight loss was 10 kg (4-27), the median number of hospitalisations per patient was 5(1-8) and 24(67%) patients had received endoscopic/percutaneous treatment. Surgery was performed in median 279(90-2000) days after ANP, laparoscopically in 9(25%) patients. The remnant pancreas (median length = 70 mm; range = 50-130) was anastomosed to the stomach (n = 30) or the jejunum (n = 6). There were 13(36%) postoperative grade B/C pancreatic fistulas and 3(10%) bleedings including one death (mortality = 3%). The median hospital stay was 18 (7-121) days. After a median follow-up of 24 (4-53) months, all pancreatic fistulas had healed and the clinical success rate was 91%. Median BMI increased from 22 to 25 kg/m². In patients with normal pancreatic function, postoperative de novo endocrine and severe exocrine insufficiencies were observed in 4/27 (15%) and 7/22 (32%), respectively.

CONCLUSIONS

The "French reconnection" procedure, as an alternative to distal splenopancreatectomy for the treatment of DPDS, provides good control of symptoms and decreases the risk of pancreatic insufficiency.

Prospective Analysis of the Mechanisms Underlying Ineffective Deep Vein Thrombosis Prophylaxis in Necrotizing Pancreatitis

BACKGROUND

Patients with necrotizing pancreatitis (NP) have the highest rate of venous thromboembolism (VTE) of any hospitalized patient (57%). We hypothesized that VTE prophylaxis might be inadequate in the setting of this profound inflammatory disease and that early detection of deep vein thrombosis would limit pulmonary embolism.

STUDY DESIGN

All patients with NP treated at a single center between August 2018 and December 2019 were enrolled in prospective, weekly VTE screening, including 4-extremity duplex ultrasound. Routine chemoprophylaxis included low-molecular-weight or unfractionated heparin. Peak serum anti-factor Xa concentration was measured during weekly screening (goal prophylaxis 0.2 to 0.4 IU/mL).

RESULTS

Eighty-five patients with NP underwent a total of 201 screening events (mean 2.4 per patient). VTE developed in 55 patients (65%), including splanchnic vein thrombosis in 41 patients (48%) and extremity deep vein thrombosis (eDVT) in 32 patients (38%). Extremity DVT was diagnosed a mean ± SD of 44 ± 30 days after NP onset. Symptomatic pulmonary embolism was prevented in all patients diagnosed with eDVT and no contraindication to anticoagulation (0 of 29). Prophylactic anti-factor Xa concentration was only achieved in 21% (12 of 57 screening events); no eDVTs developed in patients achieving prophylactic anti-factor Xa concentration.

CONCLUSIONS

In patients with NP, identification of eDVT by screening ultrasound permits early treatment and prevents symptomatic pulmonary embolism. Fixed dosing of chemical prophylaxis is inadequate in most patients with NP and likely contributes to the mechanism of increased VTE in NP.

The impact of pregnancy on the outcome of biliary acute pancreatitis

BACKGROUND AND OBJECTIVE

Acute pancreatitis is one of the most common gastrointestinal conditions requiring hospitalization. Even though its presentation during pregnancy is uncommon, it is a medical challenge. Currently, no studies compare the clinical outcomes between pregnant patients with acute pancreatitis and nonpregnant patients with acute pancreatitis. Our aim was to compare the characteristics and clinical outcomes of pregnant and nonpregnant women with acute pancreatitis.

METHODS

We conducted a retrospective study that included all patients admitted to our hospital with acute pancreatitis over a 10-year period. Demographics, general characteristics, and clinical outcomes were evaluated and compared between pregnant and nonpregnant women with acute pancreatitis, at a ratio of 1:5.

RESULTS

Over 10 years, 27 pregnant patients with acute pancreatitis were treated. Etiology was biliary in 96% and hypertriglyceridemia was the cause in 3.4% (1 patient). The mean patient age was 26.2 years (range 15-36 years). The main cause of acute pancreatitis was biliary disease (96%). Patients in the study group were in their first, second, or third trimester of pregnancy, at 7.4%, 33.3%, and 59.3%, respectively. In the comparison of pregnant versus nonpregnant patients with acute pancreatitis, there were no differences in age, hospital stay (7.37 vs. 10.8, P=.814), severity (severe 3.7% vs. 16.7%, P=.79), local complications (0% vs. 1.9%, P=.476), or mortality (0% vs. 1.9%, P=.476).

CONCLUSIONS

The clinical evolution of both groups with biliary acute pancreatitis was similar, with low morbidity and mortality.

Extrapancreatic infections are common in acute pancreatitis and they are related to organ failure: a population-based study

BACKGROUND

Although the impact of pancreatic infections in acute pancreatitis has been studied extensively, there are no population-based data on extrapancreatic infections and their potential relation to organ failure. We aimed to study the occurrence of pancreatic and extrapancreatic bacterial infections in acute pancreatitis and their relation to patient outcome.

PATIENTS AND METHODS

All patients with first-time acute pancreatitis from 2003 to 2012 in a defined area in Sweden were retrospectively evaluated. Data on acute pancreatitis severity, organ failure, infections, and in-hospital mortality were collected.

RESULTS

Overall, 304 bacterial infections occurred in 248/1457 patients (17%). Fifteen percent had extrapancreatic and 2% had pancreatic infections. The lungs (35%), the urinary tract (24%), and the bile ducts (18%) were the most common sites of extrapancreatic infections. Organ failure, severe acute pancreatitis, and in-hospital mortality were more common in patients with vs those without (pancreatic/extrapancreatic) infections (P < 0.05). Organ failure and severe acute pancreatitis occurred more frequently in pancreatic vs extrapancreatic infections (70% vs 34%, P < 0.001 and 67% vs 28%, P < 0.001), but in-hospital mortality did not differ between the two groups (7.4% vs 6.8%, P = 1.0). Both pancreatic and extrapancreatic infections were independent predictors of organ failure (P < 0.05). Out of culture-positive infections, 18% were due to antibiotic-resistant bacteria, without any significant difference between extrapancreatic vs pancreatic infections (P > 0.05). About two out of five infections were of nosocomial origin.

CONCLUSION

Extrapancreatic infections occurred in 15% and pancreatic infections in 2% of patients with first-time acute pancreatitis. Both pancreatic and extrapancreatic infections were independent predictors of organ failure, leading to increased mortality.

Use of antibiotics in acute pancreatitis: ten major concerns

Acute pancreatitis is one of the most common gastrointestinal causes for hospitalization. In 15-20% it evolves into severe necrotizing pancreatitis. Recent studies have shown no association between the initiation of antibiotic therapy in acute pancreatitis and severe outcomes such as organ failure, infection of pancreatic necrosis, extrapancreatic infections or mortality. Specific subgroups with predicted severe acute pancreatitis or both extensive sterile necrosis and persistent organ failure may benefit from prophylactic antibiotics. Local infection develops in 30% of patients with pancreatic necrosis and results in morbidity and mortality. Contrast enhanced computed tomography should be performed in all patients with acute pancreatitis who develop sepsis, organ failure or fail to improve. C-reactive protein is an independent predictor of severe acute pancreatitis. Procalcitonin is the most sensitive laboratory test for detection of pancreatic infection. Antibiotics do however play a large role in patients with suspected or confirmed infected pancreatic necrosis and extrapancreatic infections. In clinical practice most clinicians prescribe antibiotics in the first 3 days of acute pancreatitis which in turns lead to excessive, unjustified use of antibiotics. Deep knowledge of the recent guidelines combined with an individualized management based on right clinical judgment is a rationale approach of patients with acute pancreatitis.

Consensus and controversy among severe pancreatitis surgery guidelines: a guideline evaluation based on the Appraisal of Guidelines for Research and Evaluation II (AGREE II) tool

The purpose of this study was to systematically evaluate guidelines for surgery in patients with severe pancreatitis and to identify gaps limiting evidence-based medicine practice. A systematic search of databases and related websites was conducted to identify surgical guidelines for patients with severe pancreatitis. The quality of the included guidelines was assessed using the Appraisal of Guidelines for Research and Evaluation II (AGREE II) tool. The similarities among key recommendations were compared, and the evidence supporting them was extracted and analysed. Seven surgical guidelines for patients with severe pancreatitis were included. Only two guidelines, those of the World Society of Emergency Surgery (WSES) and the European Society of Gastrointestinal Endoscopy (ESGE), scored more than 60% for overall quality and were worthy of clinical recommendation. We found that the quality of the severe acute pancreatitis surgical guidelines have much room for improvement, especially in the field of application, the participation of stakeholders and editorial independence. The heterogeneity and causes of surgical recommendations were further analysed, and the latest evidence was retrieved. It was found that the surgical guidelines for severe pancreatitis lacked high-quality evidence, some of the recommendations were controversial, and evidence citation was unreasonable. The quality of surgical guidelines for patients with severe pancreatitis varies widely. In the past 5 years, the key recommendations of the surgical guidelines for severe pancreatitis have been somewhat consistent and controversial, and improvement in these existing problems and controversies will be an effective way for developers to upgrade the surgical guidelines for severe pancreatitis.

Acute pancreatitis

Acute pancreatitis is an unpredictable and potentially lethal disease. The prognosis mainly depends on the development of organ failure and secondary infection of pancreatic or peripancreatic necrosis. In the past 10 years, treatment of acute pancreatitis has moved towards a multidisciplinary, tailored, and minimally invasive approach. Despite improvements in treatment and critical care, severe acute pancreatitis is still associated with high mortality rates. In this Seminar, we outline the latest evidence on diagnostic and therapeutic strategies for acute pancreatitis.

The continuum of complications in survivors of necrotizing pancreatitis

BACKGROUND

Necrotizing pancreatitis survivors develop complications beyond infected necrosis that often require invasive intervention. Remarkably few data have cataloged these late complications after acute necrotizing pancreatitis resolution. We sought to identify the types and incidence of complications after necrotizing pancreatitis.

DESIGN

An observational study was performed evaluating 647 patients with necrotizing pancreatitis captured in a single-institution database between 2005 and 2017 at a tertiary care hospital. Retrospective review and analysis of newly diagnosed conditions attributable to necrotizing pancreatitis was performed. Exclusion criteria included the following: death before disease resolution (n = 57, 9%) and patients lost to follow-up (n = 12, 2%).

RESULTS

A total of 578 patients were followed for a median of 46 months (range, 8 months to 15 y) after necrotizing pancreatitis. In 489 (85%) patients 1 or more complications developed and included symptomatic disconnected pancreatic duct syndrome (285 of 578, 49%), splanchnic vein thrombosis (257 of 572, 45%), new endocrine insufficiency (195 of 549, 35%), new exocrine insufficiency (108 of 571, 19%), symptomatic chronic pancreatitis (93 of 571, 16%), incisional hernia (89 of 420, 21%), biliary stricture (90 of 576, 16%), chronic pain (44 of 575, 8%), gastrointestinal fistula (44 of 578, 8%), pancreatic duct stricture (30 of 578, 5%), and duodenal stricture (28 of 578, 5%). During the follow-up period, a total of 340 (59%) patients required an invasive intervention after necrotizing pancreatitis resolution. Invasive pancreatobiliary intervention was required in 230 (40%) patients.

CONCLUSION

Late complications are common in necrotizing pancreatitis survivors. A broad variety of problems manifest themselves after resolution of the acute disease process and often require invasive intervention. Necrotizing pancreatitis patients should be followed lifelong by experienced clinicians.

Characteristics and Outcomes of Drainage Versus Surgery First in Severe Pancreatitis

BACKGROUND

Percutaneous drainage as the initial procedure for severe pancreatitis (SP) may not always be optimal. Our aim was to identify the characteristics of patients who failed percutaneous drainage and compare their outcomes with patients who underwent surgical intervention as the initial approach.

METHODS

A retrospective review of a prospectively collected emergency general surgery registry of patients admitted to a tertiary-care, academic center with the diagnosis of SP who underwent an intervention was performed (2010-2018). Patients were divided into successful drainage (SD), drainage failure (DF), and surgery first (SF) groups. DF was defined as the need for surgical intervention.

RESULTS

The study included 129 patients. Fifty (38.8%) patients underwent SF as their initial management modality. Among 79 patients who underwent drainage, 34 (43.0%) were in the DF group and progressed to surgical intervention. Within that group, 19 (55.9%) underwent open necrosectomy. The DF group was more likely to have lower rates of peripancreatic fluid collections, a higher rate of necrotizing pancreatitis, and a higher Acute Physiology and Chronic Health Evaluation (APACHE) II score when compared with the DS group. Mortality was higher in the DF and SF groups, and total length of stay and ICU length of stay were highest in the DF group.

DISCUSSION

Patients who experience failure of drainage for SP have high morbidity and mortality rates and fare worse overall than patients who undergo surgery as the primary intervention. Patients with necrotizing pancreatitis and a higher APACHE II score might warrant surgical intervention over a drainage-first approach.

The impacts of infectious complications on outcomes in acute pancreatitis: a retrospective study

BACKGROUND

The occurrence of infectious complications characterizes the more severe forms of acute pancreatitis (AP) and is associated with high mortality. We investigated the effects of infection at different sites in patients with AP, including those with necrotizing pancreatitis (NP).

METHODS

We conducted a retrospective analysis of 285 patients who met the inclusion criteria for AP and were admitted to Tianjin Nankai Hospital between January 2016 and September 2019. According to the source of the culture positivity during hospitalization, patients were divided into four groups: sterile group(n = 148), pancreatic infection group(n = 65), extrapancreatic infection group(n = 22) and combined infection group(n = 50). The source of infection, microbiology, biochemical parameters and prognostic indicators were analyzed.

RESULTS

In terms of baseline characteristics, the four groups were similar in age, sex, aetiology, previous pancreatitis and diabetes. Compared with the severity of the disease in the other groups, the APACHE II scores(9.91 ± 4.65, 9.46 ± 5.05, respectively) and organ failure rate (40.9 and 50%, respectively)were higher in the extrapancreatic infection group and the combined infection group (P < 0.05). The frequency of surgical intervention and hospitalization time in patients with NP complicated with extrapancreatic infection was greatly increased (P < 0.05). Regarding the primary outcome, patients in the combined infection group had longer hospital stays (68.28 ± 51.80 vs 55.58 ± 36.24, P < 0.05) and higher mortality (24.0% vs 9.2%, P < 0.05) than patients in the pancreatic infection group. In addition, patients in the extrapancreatic infection group also showed high intensive care utilization (59.1%) and mortality rates (18.2%). Among the 137 AP patients with infection complications, 89 patients exhibited multidrug-resistant (MDR) microorganisms, and the mortality rate of patients with MDR bacterial infection was higher than that of patients with non-MDR bacterial infection (24.7% vs 3.6%, P = 0.001).

CONCLUSION

Clinicians should be aware that extrapancreatic infection (EPI) significantly aggravates the main outcome in pancreatic infection patients. Infection with MDR bacteria is also associated with AP mortality.

Comparison between video-assisted retroperitoneal debridement and small incision pancreatic necrosectomy in infected pancreatic necrosis

BACKGROUND

Debridement and drainage have always been mainstream treatment for infected pancreatic necrosis (IPN), and the application of minimally invasive necrosectomy is becoming increasingly widespread. However, few studies have compared video-assisted retroperitoneal debridement (VARD) and small incision pancreatic necrosectomy (SIPN) individually. Our aim was to compare VARD and SIPN by evaluating outcomes.

METHODS

We retrospectively reviewed patients with IPN who underwent either VARD or SIPN between 2010 and 2019 in China. Data relative to patient demographics, major complications, health care resource utilization and mortality were collected. Statistical analyses used were the two-tailed Student's t-test and the chi-squared test.

RESULTS

Of 59 patients, 31 patients underwent SIPN and 28 patients were treated with VARD. SIPN and VARD had similar treatment success and mortality rates. The rate of reintervention due to lack of clinical improvement was significantly lower in the SIPN group (32% versus 61%; P = 0.028). In addition, the length of total hospital stay was 60 days in the SIPN group and 72 days in the VARD group (P < 0.0001) and mean total costs was significantly less in the SIPN group than in the VARD group (P = 0.008).

CONCLUSION

Given the shorter hospitalization period, lower total cost and lower rate of reinterventions, SIPN may be superior to the step-up approach for patients with IPN than for those with VARD.

Colon Involvement in Necrotizing Pancreatitis: Incidence, Risk Factors, and Outcomes

OBJECTIVE

To investigate the incidence, risk factors, and outcomes of colon involvement in patients with necrotizing pancreatitis.

SUMMARY/BACKGROUND DATA

Necrotizing pancreatitis is characterized by a profound inflammatory response with local and systemic implications. Mesocolic involvement can compromise colonic blood supply leading to ischemic complications; however, few data exist regarding this problem. We hypothesized that the development of colon involvement in necrotizing pancreatitis (NP) negatively affects morbidity and mortality.

METHODS

Six hundred forty-seven NP patients treated between 2005 and 2017 were retrospectively reviewed to identify patients with colon complications, including ischemia, perforation, fistula, stricture/obstruction, and fulminant Clostridium difficile colitis. Clinical characteristics were analyzed to identify risk factors and effect of colon involvement on morbidity and mortality.

RESULTS

Colon involvement was seen in 11% (69/647) of NP patients. Ischemia was the most common pathology (n = 29) followed by perforation (n = 18), fistula (n = 12), inflammatory stricture (n = 7), and fulminant C difficile colitis (n = 3). Statistically significant risk factors for developing colon pathology include tobacco use (odds ratio (OR), 2.0; 95% confidence interval (CI), 1.2-3.4, P = 0.009), coronary artery disease (OR, 1.9; 95% CI, 1.1-3.7; P = 0.04), and respiratory failure (OR, 4.7; 95% CI, 1.1-26.3; P = 0.049). When compared with patients without colon involvement, NP patients with colon involvement had significantly increased overall morbidity (86% vs 96%, P = 0.03) and mortality (8% vs 19%, P = 0.002).

CONCLUSION

Colon involvement in necrotizing pancreatitis is common; clinical deterioration should prompt its evaluation. Risk factors include tobacco use, coronary artery disease, and respiratory failure. Colon involvement in necrotizing pancreatitis is associated with substantial morbidity and mortality.

A Multimodal Approach for the First-Line Treatment of Infected Pancreatic Necrosis

OBJECTIVES

Because infected pancreatic necrosis (IPN) has multiple presentations, not all patients are likely to benefit from the same first-line treatment. Our objective was to evaluate morbidity and mortality in a series of patients treated with a multimodal therapeutic approach.

METHODS

Between May 2012 and May 2019, 51 patients diagnosed with IPN were treated. The 5 initial treatment alternatives were as follows: percutaneous drainage, minimally invasive necrosectomy, antibiotics alone, transgastric necrosectomy, and temporizing percutaneous/endoscopic drainage. Initial treatment selection depended on evolution, clinical condition, and extension of pancreatic necrosis. Success, morbidity, and mortality rates were determined.

RESULTS

In terms of determinant-based classification, 37 were classified as severe, and 14 as critical. Percutaneous, temporizing drainage, minimally invasive necrosectomy, antibiotics alone and transgastric necrosectomy approaches were used in 21, 10, 11, 4, and 5 patients, respectively. Necrosectomy was not required in 18 patients (35%). There were no significant differences in mortality among the different treatment approaches (P < 0.45). Overall success, morbidity, and mortality rates were 68.6%, 52.9%, and 7.8%, respectively.

CONCLUSIONS

The multimodal approach seems to be a rational and efficient strategy for the initial treatment of IPN.

Operative pancreatic debridement: Contemporary outcomes in changing times

BACKGROUND/OBJECTIVES

Operative pancreatic debridement (OPD) is the historic gold standard for treating necrotizing pancreatitis (NP). Recent success with minimally invasive NP treatment approaches have raised the question of which NP patients require OPD. We therefore sought to define contemporary outcomes of NP patients undergoing OPD.

METHODS

A retrospective analysis was performed of 116 consecutive NP patients undergoing OPD using a prospectively maintained institutional NP database between 2006 and 2018.

RESULTS

86 (74%) patients underwent open pancreatic debridement (OD) and 30 (26%) underwent open transgastric debridement (TGD). Median follow-up was 16 months (interquartile range [IQR], 8-45 months). Median age was 51 years (IQR, 43-65 years); 73 (63%) were male. Pancreatitis etiology included biliary (53%), alcohol (22%), and idiopathic/other (25%). Median time from diagnosis to OPD was 64.5 days (IQR, 32-114.5 days). Mean APACHE-II score was: admission 8.5 (standard deviation [SD], 5.9); worst 12.6 (SD, 7.9); preoperatively 7.2 (SD, 4.6). 40 patients (34%) were initially managed with minimally invasive techniques (percutaneous drain only in 24, endoscopic only in 6, combination in 10). Median postoperative length of stay was 11 days (IQR, 7-19 days). 90-day morbidity and mortality were 70% and 2%, respectively.

CONCLUSIONS

NP patients who require OPD are critically and chronically ill. OPD is associated with substantial morbidity, but acceptable mortality in an experienced center with multidisciplinary support. This large contemporary series demonstrates that in properly selected patients, OPD remains an important treatment for NP.

Minimal-access retroperitoneal pancreatic necrosectomy for infected necrotizing pancreatitis: a multicentre study of a step-up approach

BACKGROUND

Various minimally invasive approaches have been described for infected necrotizing pancreatitis. This article describes a modified minimal-access retroperitoneal pancreatic necrosectomy (MARPN) procedure assisted by gas insufflation.

METHODS

This retrospective, observational study documented patients who had undergone a step-up MARPN between 1 January 2010 and 31 December 2016. A minimum follow-up of 1 year was required for inclusion. The step-up approach involved percutaneous catheter drainage followed by the modified MARPN and necrosectomy. If more than one access site was needed it was categorized as complex MARPN.

RESULTS

Of 212 patients with infected necrotizing pancreatitis, 164 (77·4 per cent) underwent a step-up approach. The median number of percutaneous catheter drains and MARPN procedures was 3 (range 1-7) and 1 (1-6) respectively. Ninety patients (54·9 per cent) underwent complex MARPN. For residual necrosis after MARPN, three patients (1·8 per cent) underwent sinus tract gastroscopy, and 11 (6·7 per cent) had sinography combined with a tube change. However, operations in 13 patients (7·9 per cent) required conversion to open surgery. Postoperative complications developed in 103 patients (62·8 per cent). The mortality rate was 6·1 per cent (10 deaths).

CONCLUSION

A step-up approach using a modified MARPN for infected necrotizing pancreatitis is a reasonable option.

Rendezvous transgastric and percutaneous sinus tract endoscopy (STE) for debridement of necrotic collections with deep retroperitoneal extension: a case series (with video): Meeting presentations: Digestive Disease Week 2018

Background and study aims  Infected necrotic collections extending deep into the retroperitoneum may not be amenable solely to endoscopic necrosectomy. Rendezvous transgastric and percutaneous sinus tract endoscopic necrosectomy was conceived to maximize debridement and obviate the need for open necrosectomy or video-assisted retroperitoneal debridement. Patients and methods  Patients who underwent simultaneous rendezvous transgastric and sinus tract endoscopic transluminal necrosectomy at the same session were identified from a prospectively maintained database. Demographic data, clinical outcomes, immediate and late complications were evaluated. Results  Among 415 patients with necrotizing pancreatitis, four patients (three males, median age 47 years) underwent this intervention after a median 29.5 days following placement of percutaneous drain. Intra-procedural bleeding following dilation of percutaneous tract required placement of esophageal stent for tamponade. No patients required rescue open necrosectomy or video assisted retroperitoneal debridement. Complete removal of percutaneous drains was accomplished in all patients after a median of 78.5 days. Conclusions  Our novel approach is safe and effective and can expand the available armamentarium for management of large necrotic collection with deep retroperitoneal extension.

Endoscopic intervention in pancreatitis: perspectives from a gastroenterologist

The last decade has seen a dramatic paradigm shift for the treatment of pancreatitis and its related complications away from surgery to minimally invasive endoscopic approaches. In this review, we provide an overview of the indications, techniques and outcomes of endoscopic interventions in the management of acute and chronic pancreatitis. Emphasis is placed on drainage of pancreatic pseudocysts and treatment of pain in chronic pancreatitis.

The augmented role of pancreatic imaging in the era of endoscopic necrosectomy: an illustrative and pictorial review

Endoscopic cystogastrostomy for mature pancreatic collections has long been recognized. However, FDA approval of newer lumen-apposing metallic stents in 2014 has now brought pancreatic necrosectomy to the endoscopic realm. Endoscopic drainage of Walled-off necrosis and direct endoscopic necrosectomy are technically challenging procedures with higher rates of complications. Collaborative clinical decision making both pre- and post-procedurally between the radiologist, endoscopist, and the surgeon can greatly improve outcomes in necrotizing pancreatitis. Herein, we review the basic pathophysiology that underlies progressive radiographic findings in NP, value of preprocedural imaging, current management algorithms, newer tools, and techniques as well as potential post-procedure complications on imaging follow-up after endoscopic interventions in necrotizing pancreatitis.

Factors associated with mortality in patients with infected pancreatic necrosis: the "surgery effect"

Severe acute pancreatitis complicated by infection is associated with high mortality. Invasive treatment is indicated in the presence of infected (suspected) pancreatic and/or peripancreatic necrosis (IPN) in the absence of response to intensive medical support. Step-up approach (SUA) has been demonstrated to lower complication rate compared to upfront open surgery. However, this approach has not been associated with lower mortality, and no factors have been studied that could help to identify the high risk patients. In this study, we aimed to analyse those factors associated with mortality following the invasive treatment of IPN, focusing on the role of surgical necrosectomy. A retrospective and observational study based on a multicentre prospective database was conducted. The database was coordinated by the Hospital General Universitario de Alicante, Spain and the Spanish Association of Pancreatology. Demographics, clinical data, and laboratory and imaging findings were collected. Atlanta 2012 criteria were considered to classify acute necrotizing pancreatitis and for the definition of IPN. Step-up approach was used in all centres with the intention of avoiding surgery whenever possible. Surgical necrosectomy was performed by open approach. From January 2013 to October 2014, a total of 1655 patients with the diagnosis of acute pancreatitis were included in our database. 1081 were recruited for the final analysis. Out of them, 205 (19%) were classified into acute necrotizing pancreatitis. 77 (8.3%) patients underwent invasive treatment of INP and were included in our study. Overall mortality was 29.9%. Upfront endoscopic or percutaneous drainage was performed in 60 (77.9%) patients and mortality was 26.6%. Out of 60, 22 (36.6%) patients subsequently received rescue surgery; mortality in rescue surgery group was 18.3%. Upfront surgery was carried out in 17 (22.1%) patients; mortality in this group was 41%. At univariate analysis, surgical necrosectomy, extrapancreatic infection, immunosuppression and de-novo haemodialysis were associated with mortality. At multivariate analysis, only surgical necrosectomy was significantly associated with mortality (p = 0.002 OR 3.89). Surgical approach for IPN is associated with high mortality rate. However, these data should be interpreted with caution, since we are not able to assess whether this occurs due to the need of surgery as the only resort when the other approaches are not feasible or fail.

Preoperative endoscopic transpapillary stenting: A solution to preventing and/or treating postsurgical external pancreatic fistula and infection in patients with infected necrotizing pancreatitis

Currently, open surgical necrosectomy is only performed when the step-up approach fails in patients with necrotizing pancreatitis. As a common complication after surgery, external pancreatic fistula often leads to a long hospital stay and increased expenditure. Current therapeutic strategies include conservative management; however, unresponsive patients with pancreatic leaks will frequently require interventions. Existing evidence indicates that endoscopic transpapillary stenting can shorten the duration of external pancreatic fistula; however, the length of conservative treatment in the early stage cannot be avoided. Therefore, endoscopic transpapillary stenting cannot play a decisive role in the treatment and prevention of postsurgical external pancreatic fistula. The authors propose that endoscopic transpapillary stenting before surgery, however, can be used to prevent and treat postsurgical external pancreatic fistula and complications caused by the prolonged maintenance of the drainage tube for abscesses, including retrograde infection, through its physiological drainage effect. This hypothesis has important clinical implications for the accelerated postoperative recovery of patients with necrotizing pancreatitis.

Disconnected pancreatic duct syndrome predicts failure of percutaneous therapy in necrotizing pancreatitis

BACKGROUND/OBJECTIVES

Minimally invasive approaches, such as percutaneous drainage (PD), are increasingly utilized as initial treatment in necrotizing pancreatitis (NP) requiring intervention. Predictors of success of PD as definitive treatment are lacking. Our aim was to assess the application, predictors of success, and natural history of PD in NP. We hypothesized that necrosis morphology patterns and disconnected pancreatic duct syndrome (DPDS) may predict the ability of PD to provide definitive therapy.

METHODS

714 NP patients were treated from 2005 to 2018. Patients achieving disease resolution with PD alone (PD) were compared to those requiring an escalation in intervention (Step). Outcomes were compared between groups using independent samples t-test, Fisher's exact test, and Pearson's correlation, as appropriate. P < 0.05 was accepted as statistically significant.

RESULTS

115 patients were initially managed with PD (42 PD, 73 Step). No difference in necrosis morphology was seen between the two groups. The PD group underwent significantly more repeat percutaneous interventions (PD, 3.2; Step, 2.0; P = 0.0006) including additional drain placement and drain upsize/reposition procedures. Patients with DPDS were more likely to require an escalation in intervention (odds ratio, 3.4; 95% confidence interval, 1.5-7.6; P = 0.003). The mean number of months to NP resolution was similar (PD, 5.7; Step, 5.8; P = 0.9). Mortality was similar (PD, 7%; Step 14%, P = 0.3).

CONCLUSIONS

Necrosis morphology in and of itself does not reliably predict successful definitive treatment by percutaneous drainage. However, patients with disconnected pancreatic duct syndrome were less likely to have definitive resolution with PD alone.

Percutaneous Endoscopic Step-Up Therapy Is an Effective Minimally Invasive Approach for Infected Necrotizing Pancreatitis

BACKGROUND

Infected pancreatic necrosis (IPN) is a major complication of acute pancreatitis (AP), which may require necrosectomy. Minimally invasive surgical step-up therapy is preferred for IPN.

AIM

To assess the effectiveness of percutaneous endoscopic step-up therapy in patients with IPN and identify predictors of its success.

METHODS

Consecutive patients with AP hospitalized to our tertiary care academic center were studied prospectively. Patients with IPN formed the study group. The treatment protocol for IPN was percutaneous endoscopic step-up approach starting with antibiotics and percutaneous catheter drainage, and if required necrosectomy. Percutaneous endoscopic necrosectomy (PEN) was performed using a flexible endoscope through the percutaneous tract under conscious sedation. Control of sepsis with resolution of collection(s) was the primary outcome measure.

RESULTS

A total of 415 patients with AP were included. Of them, 272 patients had necrotizing pancreatitis and 177 (65%) developed IPN. Of these 177 patients, 27 were treated conservatively with antibiotics alone, 56 underwent percutaneous drainage alone, 53 required underwent PEN as a step-up therapy, 1 per-oral endoscopic necrosectomy, and 52 required surgery. Of the 53 patients in the PEN group, 42 (79.2%) were treated successfully-34 after PEN alone and 8 after additional surgery. Eleven of 53 patients died due to organ failure-7 after PEN and 4 after surgery. Independent predictors of mortality were > 50% necrosis and early organ failure.

CONCLUSION

Percutaneous endoscopic step-up therapy is an effective strategy for IPN. Organ failure and extensive pancreatic necrosis predicted a suboptimal outcome in patients with infected necrotizing pancreatitis.

Hemofiltration in Patients with Severe Acute Pancreatitis (Review)

Questions regarding the application of extracorporeal detoxification to patients with severe acute pancreatitis have been considered. Hemodialysis, the historically first method of extracorporeal detoxification for such patients, has been also described in the review. Appropriateness of using renal replacement therapy methods and among them continued renal replacement therapy has been shown. Hemofiltration and hemodiafiltration technologies are described in detail including different modes of their application and the possibility of using various types of filters. Available data on hemofiltration for patients with severe acute pancreatitis have been analyzed. Great attention is paid to the unsolved aspects of hemofiltration in severe acute pancreatitis such as determining renal and extrarenal indices; time of starting hemofiltration; selection of volume replacement modes and a buffer system; procedure duration; anticoagulation measures, defining criteria to assess the adequacy of hemofiltration, state severity, and organ dysfunction degree. Further multicenter investigations are necessary to be able to assess the efficacy of the hemofiltration procedures on the basis of the thoroughly worked out and pathogenically grounded protocol using adequate control methods taking into consideration endogenic intoxication phases and intensity of the multiple organ failure syndrome.

Various Endoscopic Techniques for Treatment of Consequences of Acute Necrotizing Pancreatitis: Practical Updates for the Endoscopist

Despite great progress in acute pancreatitis (AP) treatment over the last 30 years, treatment of the consequences of acute necrotizing pancreatitis (ANP) remains controversial. While numerous reports on minimally invasive treatment of the consequences of ANP have been published, several aspects of interventional treatment, particularly endoscopy, are still unclear. In this article, we attempt to discuss these aspects and summarize the current knowledge on endoscopic therapy for pancreatic necrosis. Endotherapy has been shown to be a safe and effective minimally invasive treatment modality in patients with consequences of ANP. The evolution of endoscopic techniques has made endoscopic drainage more effective and reduced the use of other minimally invasive therapies for pancreatic necrosis.

Venous Thromboembolism in Necrotizing Pancreatitis: an Underappreciated Risk

BACKGROUND

Necrotizing pancreatitis (NP) is a severe systemic inflammatory process. We have observed a high incidence of venous thromboembolism (VTE) in NP patients. However, remarkably few data exist to document the true incidence of VTE-including splanchnic vein thrombosis (SVT), extremity deep venous thrombosis (eDVT), and pulmonary embolism (PE)-in NP. Therefore, we sought to determine the incidence and risk factors for VTE in NP patients.

METHODS

Retrospective review of all NP patients treated at a single academic center between 2005 and 2015. VTE diagnosis was confirmed by ultrasound (US), computed tomography (CT), magnetic resonance imaging (MRI), and/or ventilation/perfusion (V/Q) scan. Descriptive statistics and univariate analysis were applied where appropriate; p value < 0.05 was considered statistically significant.

RESULTS

Five hundred and forty-five NP patients (median age 53 years; 65% males) were reviewed. VTE was diagnosed in 312 patients (57%). SVT was found in 50%, eDVT in 16%, and PE in 6%. VTE in multiple sites was found in 22% of patients. VTE was diagnosed a median of 37 days following pancreatitis diagnosis. Seventy-nine percent of patients required at least one surgical procedure over the course of their NP. Patients requiring surgery had a DVT incidence of 58%; however, VTE was diagnosed preoperatively in 63%. Male gender, history of previous DVT, infected necrosis, development of organ failure, and development of respiratory failure were identified as risk factors for VTE (p = 0.001-0.04) by univariate analysis.

CONCLUSIONS

Venous thromboembolism is extremely common in necrotizing pancreatitis. Regular ultrasound screening may be considered to facilitate early diagnosis in this extremely high-risk population.

Association of Serum Levels of Silent Information Regulator 1 with Persistent Organ Failure in Acute Pancreatitis

BACKGROUND/AIMS

Early assessment is a key factor for adequate and comprehensive treatment of acute pancreatitis (AP). Silent information regulator 1 (SIRT1) plays an important role in inflammation. The aim was to explore the relationship between serum SIRT1 and persistent organ failure (POF) in patients with AP.

METHODS

Thirty-seven healthy controls (HCs) and 113 patients with AP were recruited for this study. All 113 patients whose blood samples were collected on the first morning after admission were within 48 h of the onset of AP symptoms. The concentration of serum SIRT1 protein was determined by enzyme-linked immunosorbent assay.

RESULTS

The serum SIRT1 protein levels were 1495.7 ± 185.9, 2098.3 ± 153.6, 2498.4 ± 198.2, and 3674.3 ± 170.8 pg/ml in the HCs, mild AP, moderately severe AP, and severe AP groups, respectively. Obvious differences were observed between HCs and patients with AP (P < 0.05). Significant increases were observed in SIRT1 concentrations in patients with POF compared with non-POF patients (P < 0.05). When the cut-off of the SIRT1 concentration was 4065.4 pg/ml, the serum SIRT1 concentration had an area under the curve (AUC) of the receiver operating characteristic curve of 0.825 (95% CI 0.744-0.906) for predicting POF, with a sensitivity of 61.4% and specificity of 92.8%. Combining serum SIRT1 and bedside index for severity acute pancreatitis (BISAP) achieved 0.931 (95% CI 0.882, 0.980) of AUC for the predication of POF.

CONCLUSIONS

High serum SIRT1 levels may serve as an early predictive marker for POF. Combining the serum SIRT1 concentration with BISAP increased the ability to predict outcomes.

Infections of the Hepatobiliary System

Hepatobiliary infections account for a small but clinically important proportion of emergency department presentations. They present a clinical challenge due to the broad range of imaging characteristics on presentation. Recognition of complications is imperative to drive appropriate patient care and resource utilization to avoid diagnostic pitfalls and avert adverse patient outcomes. A thorough understanding of anatomy infectious pathology of hepatobiliary system is essential in the emergency setting to confidently diagnose and guide medical intervention. Many presentations of hepatobiliary infection have characteristic imaging features on individual imaging modalities with others requiring the assimilation of findings of multiple imaging modalities along with incorporating the clinical context and multispecialist consultation. Familiarity with the strengths of individual imaging modalities in the radiologists' arsenal is imperative to guide the appropriate utilization of resources, particularly in the emergent time sensitive setting. Accurate identification and diagnosis of hepatobiliary infections is vital for appropriate patient care and management stratification.

Together We Stand, Divided We Fall: A Multidisciplinary Approach in Complicated Acute Pancreatitis

Acute pancreatitis (AP) is an inflammatory condition with a mild course in most patients, but 20-30% evolve to single or multiple organ dysfunction and pancreatic/peripancreatic necrosis, with potentially infected collections. In the first weeks of disease, a systemic inflammatory syndrome (SIRS) dominates the clinical setting, and early management decisions in this precocious phase can change the course of the disease. Imaging is crucial in the diagnosis, and since the adoption of the revised Atlanta classification, four different types of pancreatic/peripancreatic collections have been defined. The management of the complicated forms of AP has been defined by several treatment guidelines, and the main indication for intervention is local infection, preferably in walled-off necrosis. Open surgery necrosectomy is associated with a very high rate of morbimortality, giving a place to different multidisciplinary methodologies, emphasizing drainage and necrosectomy techniques in a "step-up" approach starting from mini-invasive endoscopic drainage and moving, if needed, to progressively more invasive techniques, including interventional radiology and mini-invasive surgery. With the advent of several new technologies in the specialties involved, the complicated AP cases which need drainage and necrosectomy benefit from a new era of multidisciplinary cooperation, permitting higher efficacy with lower levels of morbimortality and reducing hospital stay and costs.

Laparoscopic surgery in pancreatic diseases: Pushing the boundaries

BACKGROUND

Laparoscopic surgery has expanded exponentially in the last two decades but, somehow it is limited in pancreatic surgery by virtue of the pancreas being a friable, retroperitoneal organ with difficult access and adjacent major vessels risking torrential bleed. It is thought to be unforgiving if not handled well. However, improvements in technology and surgeon's expertise have pushed the boundaries of minimal access surgery (MAS) to include pancreas in its domain. We present our series of laparoscopic pancreatic surgery (LPS) with an aim to look at the feasibility and outcomes.

METHODS

This is a retrospective review of all LPS done at the Gastrointestinal Surgery (GIS) centre of a tertiary care Armed Forces Hospital over a period of 3 years.

RESULTS

A total of 24 LPS were done during this period. The median age of the patients was 46 years (range; 13-81). There were 14 male and 10 female patients. Nine patients had at least one co-morbidity. Three patients underwent laparoscopic lateral pancreaticojejunostomy, 4 distal pancreatectomy, 4 laparoscopic Whipples pancreaticoduodenectomy, 6 laparoscopic pancreatic necrosectomy, 6 laparoscopic cystogastrostomy and 1 roux en y cystojejunostomy.

CONCLUSION

LPS can be performed for almost all open pancreatic surgeries and can be done with reasonable outcomes. However, it has a steep learning curve and therefore, a hybrid approach leading to a totally laparoscopic approach may be the way forward.

High Rates of Readmission in Necrotizing Pancreatitis: Natural History or Opportunity for Improvement?

BACKGROUND

Necrotizing pancreatitis (NP) is a complex and heterogeneous disease with a protracted disease course. Hospital readmission is extremely common; however, few data exist regarding the cause of readmission in NP.

METHODS

A retrospective review of NP patients treated between 2005 and 2017 identified patients readmitted both locally and to our hospital. All patients with unplanned hospital readmissions were evaluated to determine the cause for readmission. Clinical and demographic factors of all patients were recorded. As appropriate, two independent group t tests and Pearson's correlation or Fisher's exact tests were performed to analyze the relationship between index admission clinical factors and readmission. p values of < 0.05 were accepted as statistically significant.

RESULTS

Six hundred one NP patients were reviewed. Median age was 52 years (13-96). Median index admission length of stay was 19 days (2-176). The most common etiology was biliary (49.9%) followed by alcohol (20.0%). Unplanned readmission occurred in 432 patients (72%) accounting for a total of 971 unique readmissions (mean readmissions/patient, 2.3). The most common readmission indications were symptomatic necrosis requiring supportive care and/or intervention (31.2%), infected necrosis requiring antibiotics and/or intervention (26.6%), failure to thrive (9.7%), and non-necrosis infection (6.6%). Patients requiring readmission had increased incidence of index admission renal failure (21.3% vs. 14.2%, p = 0.05) and cardiovascular failure (12.5% vs. 4.7%, p = 0.01).

DISCUSSION

Readmission in NP is extremely common. Significant portions of readmissions are a result of the disease natural history; however, a percentage of readmissions appear to be preventable. Patients with organ failure are at increased risk for unplanned readmission and will benefit from close follow-up.

Spontaneous regression of asymptomatic walled-off pancreatic necrosis

INTRODUCTION

Asymptomatic walled-off pancreatic necrosis (WOPN) should be treated conservatively, irrespective of the extent and size of the necrosis. The aim of this study was to evaluate the efficacy and safety of a strategy involving the observation of patients with asymptomatic WOPN over a long period of time.

MATERIAL AND METHODS

This study involved the retrospective analysis of 368 patients hospitalized in our department between 2010 and 2016, due to acute pancreatitis and its consequences in the form of pancreatic and peripancreatic fluid collection.

RESULTS

Walled-off pancreatic necrosis was identified in 168/368 (46%) patients. 124/168 (74%) patients with WOPN required interventional treatment due to clinical symptoms arising from the presence of the WOPN. Asymptomatic WOPN was identified in 44/168 (26%) patients. The mean observation time of patients with asymptomatic WOPN was 417.02 days (range: 47-1149 days). Only 1 out of the 44 patients (2%) failed to complete the follow-up. Complete regression of WOPN occurred in 30/44 (68%) patients. The presence of symptoms related to WOPN were identified in 13/44 (30%) patients during the observation. The most frequent indication for interventional treatment of WOPN was infection of the pancreatic necrosis, which was identified in 6/13 patients (46%). Altogether, 137/168 (82%) patients with WOPN required interventional treatment.

CONCLUSIONS

The majority of patients with WOPN required interventional treatment. This study provided evidence to support the view that careful observation of patients with asymptomatic WOPN is an efficient and safe treatment strategy. Long-term observation of such patients showed that most will experience spontaneous regression of asymptomatic WOPN without any other form of interventional treatment.

Treatment of walled-off pancreatic necrosis

PURPOSE OF REVIEW

To review the current management of walled-off pancreatic necrosis (WOPN).

RECENT FINDINGS

The management of WOPN has evolved. Many collections do not require intervention and may resolve over time. Nutritional support and treatment of infection are two critical components of medical management. For collections requiring drainage, minimally invasive endoscopic therapies now play a primary role. Endoscopic transmural puncture with stent placement may provide access for drainage and decompression. More complex collections may require transluminal instrumentation with lavage, debridement, and necrosectomy. Concurrent pancreatic duct injuries including strictures, leaks, and disconnections are very common. Addressing the pancreatic ductal injury is a key component in the long-term success of management strategies. Providing high-level care for patients requires a multidisciplinary approach with providers specialized in the management of severe acute pancreatitis and associated complications.

SUMMARY

Minimally invasive management strategies improve the outcomes for patients with WOPN. Close follow-up, medical therapy, and nutritional support are required for most patients. Endoscopic transmural drainage and necrosectomy are the primary approaches for collections requiring intervention. Protocols for endoscopic drainage are being refined to reduce side effects and decrease the number of interventions required for resolution.

Quality of Care Indicators in Patients with Acute Pancreatitis

BACKGROUND

Acute pancreatitis (AP) is a common and expensive condition. Improving quality of care in AP is vital to minimizing cost and improving patient outcomes. However, there has been little work accomplished toward developing and validating explicit quality indicators (QIs) in AP.

AIMS

To define quality of care in patients with AP by developing explicit QIs using standardized techniques.

METHODS

We used the UCLA/RAND Delphi panel approach to combine a comprehensive literature review with the collective judgment of experts to identify a defined set of process measures for AP.

RESULTS

We produced 164 candidate QIs after a comprehensive literature review. After Delphi review, 75 had a median rating ≥ 7. We excluded 11 QIs where the disagreement index exceeded 1.0 and combined indicators overlapping in content to produce a final list of 22 QIs. Overall, 8 QIs related to diagnosis, prevention, or determination of etiology, 2 QIs focused on determination of severity, 3 QIs captured fluid resuscitation, 2 QIs measured nutrition, 1 QI use of antibiotics, and 6 QIs captured endoscopic or surgical management.

CONCLUSIONS

We have developed 22 QIs spanning the spectrum of AP management including diagnosis, risk stratification, and pharmacological and endoscopic therapy. These QIs will facilitate future quality improvement by practitioners and organizations who treat patients with AP and further identify areas that are amenable to improvement to enhance patient care. We anticipate that this QI set will represent the first step in determining a framework for demonstrating value in the care of patients with AP.

Basic Interventional Procedures: Practice Essentials

There has been an increasing demand in image-guided minimally invasive procedures and these have become an integral part of present-day clinical practice. Basic interventional radiology (IR) procedures have greatly reduced the need for invasive procedures for sampling as well as treating conditions like abscess and fluid collections. Owing to their minimally invasive nature, most of these procedures may be performed on the outpatient patients as daycare procedures. Some of these procedures in critically ill patients may be lifesaving. Basic interventional radiology (IR) procedures consist of image-guided fine-needle aspiration cytology and biopsy, tru-cut (core) biopsy, needle aspiration/drainage and percutaneous catheter drainage. This review aims to provide practice requisites for basic IR procedures.

Acute Pancreatitis Task Force on Quality: Development of Quality Indicators for Acute Pancreatitis Management

INTRODUCTION

Detailed recommendations and guidelines for acute pancreatitis (AP) management currently exist. However, quality indicators (QIs) are required to measure performance in health care. The goal of the Acute Pancreatitis Task Force on Quality was to formally develop QIs for the management of patients with known or suspected AP using a modified version of the RAND/UCLA Appropriateness Methodology.

METHODS

A multidisciplinary expert panel composed of physicians (gastroenterologists, hospitalists, and surgeons) who are acknowledged leaders in their specialties and who represent geographic and practice setting diversity was convened. A literature review was conducted, and a list of proposed QIs was developed. In 3 rounds, panelists reviewed literature, modified QIs, and rated them on the basis of scientific evidence, bias, interpretability, validity, necessity, and proposed performance targets.

RESULTS

Supporting literature and a list of 71 proposed QIs across 10 AP domains (Diagnosis, Etiology, Initial Assessment and Risk Stratification, etc.) were sent to the expert panel to review and independently rate in round 1 (95% of panelists participated). Based on a round 2 face-to-face discussion of QIs (75% participation), 41 QIs were classified as valid. During round 3 (90% participation), panelists rated the 41 valid QIs for necessity and proposed performance thresholds. The final classification determined that 40 QIs were both valid and necessary.

DISCUSSION

Hospitals and providers managing patients with known or suspected AP should ensure that patients receive high-quality care and desired outcomes according to current evidence-based best practices. This physician-led initiative formally developed 40 QIs and performance threshold targets for AP management. Validated QIs provide a dependable quantitative framework for health systems to monitor the quality of care provided to patients with known or suspected AP.

Radiology of acute pancreatitis today: the Atlanta classification and the current role of imaging in its diagnosis and treatment

Acute pancreatitis is common and requires multidisciplinary management. The revised Atlanta classification, published in 2012, defines the terminology necessary to enable specialists from different backgrounds to discuss the morphological and clinical types of acute pancreatitis. Radiologists' role depends fundamentally on computed tomography (CT), which makes it possible to classify the morphology of this disease and to predict its clinical severity by applying imaging severity indices. Furthermore, CT- or ultrasound-guided drainage is, together with endoscopy, the current technique of choice in the initial approach to collections that appear as a complication. This paper aims to disseminate the concepts coined in the revised Atlanta classification and to describe the current role of radiologists in the diagnosis and treatment of acute pancreatitis.

Incidence of New Onset Diabetes Mellitus Secondary to Acute Pancreatitis: A Systematic Review and Meta-Analysis

Background and Aims: Patients who have an episode of acute pancreatitis (AP) frequently develop diabetes mellitus (DM) over time. The reported incidence of DM after AP varies depending on the severity, etiology and the extent of pancreatic necrosis during AP. We performed a systematic review to determine the incidence of new-onset DM after AP episode (s), and compared the rate of DM in AP patients based upon different disease characteristics. Methods: A total of 31 relevant studies with 13894 subjects were collected from Medline, Embase, and Web of Science. Stata 15 software was used for data analyses in the meta-analysis. Results: The random-effects pooled incidence was 23.0% for DM (95% CI 16.0-31.0%) and 15.0% (95% CI 9.0-23.0%) for DM treated with insulin. We noted substantial heterogeneity in incidence estimates for DM and DM treated with insulin (I 2 = 95.61 and 71.78%; both p < 0·001). The DM incidence was higher in the populations that had a severe AP (SAP) episode than in those with mild acute pancreatitis (MAP) (39 vs. 14%). Patients that displayed pancreatic necrosis during the AP attack(s) had a higher frequency of DM than those without necrosis (37 vs. 11%). In addition, the pooled incidence of DM was higher after alcoholic compared to biliary AP (28 vs. 12%). The incidence of insulin use after SAP and alcoholic AP was 21 and 18%, respectively, with very low heterogeneities. According to duration of follow-up, the pooled rate of DM and insulin use within 5 years after AP was 20 and 14%, while the rate associated with follow-up duration of more than 5 years was elevated to 37 and 25%, respectively. On meta-regression, year of publication, male proportion, age at DM test, and duration of follow-up were neither positively nor negatively associated with the incidence of DM and DM treated with insulin in patients who had a prior AP attack. Conclusion: Patients with AP developed DM after discharge from hospital with a frequency of about 23%. SAP, alcoholic AP and acute necrotizing pancreatitis (ANP) were associated with increased incidence of DM. Assessments of severity, etiology, and pancreatic necrosis are critical for predicting DM development after AP.

Step-up approach for the management of pancreatic necrosis: a review of the literature

Infected necrotizing pancreatitis is a challenging condition to treat because of the profound inflammatory response these patients undergo which can then be exacerbated by interventions. Treatment of this condition has evolved in timing of intervention as well as method of intervention and includes less invasive options for treatment such as percutaneous drainage and endoscopic drainage, in addition to less invasive endoscopic and video-assisted or laparoscopic debridements. The precise optimal treatment strategy for these patients is an ongoing topic of discussion and may be different for each patient as this is a heterogenous condition.

Evaluation and management of acute pancreatitis

Acute pancreatitis (AP) is one of the most common gastrointestinal causes for hospi-talization in the United States. In 2015, AP accounted for approximately 390000 hospitalizations. The burden of AP is only expected to increase over time. Despite recent advances in medicine, pancreatitis continues to be associated with a substantial morbidity and mortality. The most common cause of AP is gallstones, followed closely by alcohol use. The diagnosis of pancreatitis is established with any two of three following criteria: (1) Abdominal pain consistent with that of AP; (2) Serum amylase and/or lipase greater than three times the upper limit of normal; and (3) Characteristics findings seen in cross-sectional abdominal imaging. Multiple criteria and scoring systems have been established for assessing severity of AP. The cornerstones of management include aggressive intravenous hydration, appropriate nutrition and pain management. Endoscopic retrograde cholangiopancreatography and surgery are important aspects in management of acute gallstone pancreatitis. We provide a comprehensive review of evaluation and management of AP.

Current Concepts in Severe Acute and Necrotizing Pancreatitis: An Evidence-Based Approach

The incidence of acute pancreatitis continues to rise, inducing substantial medical and social burden, with annual costs exceeding $2 billion in the United States alone. Although most patients develop mild pancreatitis, 20% develop severe and/or necrotizing pancreatitis, requiring advanced medical and interventional care. Morbidity resulting from local and systemic complications as well as invasive interventions result in mortality rates historically as high as 30%. There has been substantial evolution of strategies for interventions in recent years, from open surgery to minimally invasive surgical and endoscopic step-up approaches. In contrast to the advances in invasive procedures for complications, early management still lacks curative options and consists of adequate fluid resuscitation, analgesics, and monitoring. Many challenges remain, including comprehensive management of the entire spectrum of the disease, which requires close involvement of multiple disciplines at specialized centers.