Systematic review of percutaneous catheter drainage as primary treatment for necrotizing pancreatitis

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

Pancreatic fluid collections (PFCs), including pancreatic pseudocysts (PPs) and walled-off pancreatic necrosis (WON), are common complications of pancreatitis and pancreatic surgery. Historically, the treatment of these conditions has relied on surgical and radiological approaches; however, it has later shifted toward an endoscopy-based approach. With the development of dedicated lumen-apposing metal stents (LAMS), interventional Endoscopic Ultrasound (EUS)-guided procedures have become the standard approach for PFC drainage. However, there is still limited consensus on several aspects of the multidisciplinary management of PFCs. The interventional endoscopy and ultrasound (i-EUS) group is an Italian network of clinicians and scientists with special interest in biliopancreatic interventional endoscopy, especially interventional EUS. This manuscript describes the first part of the results of a consensus conference organized by i-EUS with the aim of providing evidence-based guidance on aspects such as indications for treating PFCs, the timing of intervention, and different technical strategies for managing patients with PFCs.

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

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

Correlation Between BMI and Severity of Acute Pancreatitis: A Retrospective Study

Background Pancreatitis, marked by sterile inflammation of the pancreas, can present as either acute or chronic. It involves the premature activation of proteolytic enzymes, leading to autodigestion, inflammation, and potential systemic effects. This study investigates the impact of obesity on the severity of acute pancreatitis, given its role in systemic inflammation and its association with severe morbidity and mortality. Methods A retrospective analysis was conducted on patients treated for acute pancreatitis over a five-month period at the Royal Albert Edward Infirmary, Wrightington, Wigan and Leigh (WLL) NHS Foundation Trust, Wigan, United Kingdom. Patients were evaluated using diagnostic criteria such as abdominal pain, elevated serum enzyme levels, and imaging results. The study explored correlations between BMI and pancreatitis severity, hospital length of stay, and complications, applying the Atlanta severity classification. Results The analysis revealed a weak, statistically insignificant correlation between BMI and the severity of acute pancreatitis, hospital stay length, and complications. This was consistent across various statistical methods, including Pearson correlation coefficients and multiple linear regression. These findings suggest that, while obesity may influence the inflammatory response in acute pancreatitis, it does not have a significant impact on clinical outcomes within this cohort. Conclusions The study highlights the complex role of obesity in exacerbating pancreatic inflammation but also emphasizes the need for larger, more definitive studies to explore this relationship further. It underscores the importance of early recognition and intervention in managing acute pancreatitis, regardless of BMI status.

Persisting Cutaneous Pancreatic Fistula in a Patient With Necrotizing Pancreatitis: A Novel Approach of Transfistulous Histoacryl Occlusion

Necrotizing pancreatitis with superinfection of necrotic tissue is associated with a high rate of complications and mortality. The step-up approach is a well-established treatment strategy for necrotizing pancreatitis, emphasizing minimally invasive and endoscopic interventions before considering surgical options. Minimally invasive strategies often involve percutaneous drainage of collections, which carries the risk of persisting cutaneous pancreatic fistulas. Since there is currently no guidance for managing this scenario, we present a novel treatment approach that utilized tissue glue to occlude a persisting and clinically compromising percutaneous fistula. In addition, we summarize the current knowledge in the treatment of percutaneous pancreatic fistulas and provide a potential therapeutic algorithm for further evaluation.

The Potential Clinical Benefits of Direct Surgical Transgastric Pancreatic Necrosectomy for Patients With Infected Necrotizing Pancreatitis

OBJECTIVE

Surgical transgastric pancreatic necrosectomy (STGN) has the potential to overcome the shortcomings (ie, repeat interventions, prolonged hospitalization) of the step-up approach for infected necrotizing pancreatitis. We aimed to determine the outcomes of STGN for infected necrotizing pancreatitis.

MATERIALS AND METHODS

This observational cohort study included adult patients who underwent STGN for infected necrosis at two centers from 2008 to 2022. Patients with a procedure for pancreatic necrosis before STGN were excluded. Primary outcomes included mortality, length of hospital and intensive care unit (ICU) stay, new-onset organ failure, repeat interventions, pancreatic fistulas, readmissions, and time to episode closure.

RESULTS

Forty-three patients underwent STGN at a median of 48 days (interquartile range [IQR] 32-70) after disease onset. Mortality rate was 7% (n = 3). After STGN, the median length of hospital was 8 days (IQR 6-17), 23 patients (53.5%) required ICU admission (2 days [IQR 1-7]), and new-onset organ failure occurred in 8 patients (18.6%). Three patients (7%) required a reintervention, 1 (2.3%) developed a pancreatic fistula, and 11 (25.6%) were readmitted. The median time to episode closure was 11 days (IQR 6-22).

CONCLUSIONS

STGN allows for treatment of retrogastric infected necrosis in one procedure and with rapid episode resolution. With these advantages and few pancreatic fistulas, direct STGN challenges the step-up approach.

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

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

Soluble Fibrinogen-Like Protein 2 Downregulation and Th17/Treg Imbalance in a Taurocholate-Induced Murine Experimental Model of Severe Acute Pancreatitis

BACKGROUND

Severe acute pancreatitis (SAP) is associated with tremendous systemic inflammation, T-helper 17 (Th17) cells, and regulatory T (Treg) cells play an essential role in the inflammatory responses. Meanwhile, soluble fibrinogen-like protein 2 (Sfgl2) is a critical immunosuppressive effector cytokine of Treg cells and modulates immune responses. However, the impact of SAP induction on Sfgl2 expression and the role of Sfgl2 in immunomodulation under SAP conditions are largely unknown.

METHODS

A taurocholate-induced mouse SAP model was established. The ratios of CD4+CD25+Foxp3+ Treg cells or CD4+IL-17+ Th17 cells in blood and pancreatic tissues as well as surface expression of CD80, CD86, and major histocompatibility complex class II (MHC-II) were determined by flow cytometry. Gene mRNA expression was determined by qPCR. Serum amylase and soluble factors were quantitated by commercial kits. Bone marrow-derived dendritic cells (DCs) were generated, and NF-κB/p65 translocation was measured by immunofluorescence staining.

RESULTS

SAP induction in mice decreased the Th17/Treg ratio in the pancreatic tissue and increased the Th17/Treg ratio in the peripheral blood. In addition, SAP was associated with a reduced level of Sfgl2 in the pancreatic tissue and blood: higher levels of serum IL-17, IL-2, IFN-α, and TNF-α, and lower levels of serum IL-4 and IL-10. Furthermore, the SAP-induced reduction in Sfgl2 expression was accompanied by dysregulated maturation of bone marrow-derived DCs.

CONCLUSIONS

SAP causes reduced Sfgl2 expression and Th17/Treg imbalance, thus providing critical insights for the development of Sfgl2- and Th17/Treg balance-targeted immunotherapies for patients with SAP.

Is Contemporary Open Pancreatic Necrosectomy Still Useful In The Minimally Invasive Era?

BACKGROUND

Previous studies have shown that open pancreatic necrosectomy for infected pancreatic necrosis was associated with high morbidity and mortality. However, these results were mostly concluded from historical cohorts with traditional early necrosectomy in the absence of a minimally invasive step-up approach.

OBJECTIVE

To explore the value of contemporary open pancreatic necrosectomy for infected pancreatic necrosis in the minimally invasive era.

METHODS

A post hoc analysis was performed in a prospective maintained database of 320 patients with infected pancreatic necrosis from January 2011 to December 2022 at a large Chinese tertiary hospital.

RESULTS

A total of 320 patients with infected pancreatic necrosis received either a minimally invasive step-up approach (245, 76.6%) or open pancreatic necrosectomy (75, 23.4%), which included upfront open pancreatic necrosectomy (32, 10.0%) and salvage open pancreatic necrosectomy (43, 13.4%). Upfront open pancreatic necrosectomy was associated with similar morbidity and mortality rates but fewer surgical interventions compared with a minimally invasive step-up approach. However, salvage open pancreatic necrosectomy was associated with significantly higher mortality (48.8% vs 18.8%, P = .007), gastrointestinal fistula (44.2% vs 18.8%, P = .021), hemorrhage (48.8% vs 15.6%, P = .003), and intensive care unit stay (25 vs 7 days, P = .040) compared with upfront open pancreatic necrosectomy. Multivariate analysis suggested that multiple organ failure (hazard ratio = 5.1; 95% confidence interval, 1.4-18.2, P = .013) and synchronous critical acute pancreatitis (hazard ratio = 3.0; 95% confidence interval, 1.1-8.6, P = .040) were 2 independent risk factors of death for patients who received open pancreatic necrosectomy.

CONCLUSION

Patients undergoing upfront open pancreatic necrosectomy received fewer surgical interventions with comparable efficacy compared to the minimally invasive step-up approach. Salvage open pancreatic necrosectomy was potentially lifesaving, though it carried high morbidity and mortality. Multiple organ failure and synchronous critical acute pancreatitis were 2 independent risk factors of death for patients who received open pancreatic necrosectomy.

A New Step-Up Dual Endoscopic Approach for Large-Size Infected Pancreatic Necrosis: Percutaneous Endoscopic Necrosectomy Followed by Transluminal Endoscopic Drainage/Necrosectomy

BACKGROUND

Acute pancreatitis in 10% to 20% of cases can be associated with necrosis of the pancreatic gland, peripancreatic tissue, or both. We report a case series of a new endoscopic approach to treat infected pancreatic necrosis (IPN).

PATIENTS AND METHODS

Consecutive patients with IPN, extending from the perigastric area up to the paracolic gutters or into the pelvis, were prospectively studied from January 2017 to June 2022. The treatment protocol was radiologic percutaneous drainage as the first step, followed by fully covered metal stent placement (FC-SEMS) in the track of the catheter. Percutaneous endoscopic necrosectomy (PEN) was performed 2 to 4 days later using a flexible endoscope through the percutaneous tract. About 2 to 4 weeks later, when a matured sac was visible, EUS-guided endoscopic transluminal drainage (ETD) with lumen-apposing metal stents (LAMS) was performed. Control of sepsis with resolution of collection(s) was the primary outcome measure.

RESULTS

We included 18 patients, males in 50% of cases with age 60±12 years old. Most frequent cause of pancreatitis was biliary (7 cases) followed by alcoholic in 6 cases; in 3 cases pancreatitis was caused by hyperlipemia and in 2 cases was idiopathic. Mean size of WON was 18±2 cm. For PEN, SEMSs used were esophageal FC-SEMS. LAMS used for ETD were Hot Axios, Hot Spaxus and Nagistent. Mean time of endoscopic intervention for PEN and ETD was 18±3 and 37±4 days, respectively. In 5 cases adverse events occurred: 3 cases of overinflations resolved with introduction of Verres needles in abdomen. In 2 cases postprocedural GI bleeding required endoscopic intervention. In all cases control of sepsis was reached together with resolution of collections. No cases of deaths were observed.

CONCLUSIONS

Step-up percutaneous and transluminal endoscopic necrosectomy therapy is an effective strategy for large-size IPN with combined central and peripheral necrosis.

Metal stent and percutaneous endoscopic necrosectomy as dual approach for the management of complex walled-off pancreatic necrosis

Pancreatic fluid collections (PFCs) are one of the local complications of acute pancreatitis and include walled-off pancreatic necrosis (WOPN), which are complex entities with challenging management. The infection of pancreatic necrosis leads to a poorer prognosis, with a growth of the mortality rate up to 30%. The primary strategy for managing PFCs is a minimally invasive step-up approach, with endosonography-guided transmural drainage and debridement as the preferred and less invasive method. Percutaneous drainage (PCD) can be the technique of choice when endoscopic drainage is not feasible, for example for early PFCs without a mature wall or for the anatomic location and extension to the paracolic gutter of the collection. As PCD alone may be ineffective, especially when a great amount of necrosis is present, a percutaneous endoscopic necrosectomy (PEN) has been proposed, showing interesting results. The technique consists of the placement of an esophageal fully or partially covered self-expandable metal stent (SEMS) percutaneously into the collection and a direct debridement can be performed using a flexible endoscope through the SEMS. In this review, we will discuss about the role of metal stent and PEN for the management of complex walled-off pancreatic necrosis.

Current Utility of Transgastric Percutaneous Drainage for the Management of Pancreatitis-Related Retrogastric Walled-Off Necrotic Collections: A Prospective Observational Study

Introduction Pancreatic fluid collection (PFC) is one of the most frequent complications associated with acute pancreatitis. The route of drainage is guided by the size and site of collection. The present study aims to assess the clinical and technical success of transgastric percutaneous drainage (PCD) for managing retrogastric walled-off pancreatic necrosis (WOPN). Materials and methods A total of 44 patients with acute pancreatitis diagnosed with WOPN who underwent transgastric PCD with ultrasound or CT guidance as part of standard clinical management were included in the study. Patients were observed for improvement in clinical parameters, and treatment outcomes were noted in terms of technical success, clinical success, adverse events, need for additional procedures, hospital stay, and duration of placement of all drains. Data for the internalization of transgastric PCD was also observed in the study. Results Technical success during the drain placement was observed in 93% (n=41) of patients.Internalization of the transgastric drain was attempted in 12 patients and successful in 11 (91%). The median duration of hospital stay from the time of placement of the first PCD until discharge and the median duration of all PCDs placed were higher in patients where the transgastric drain was not internalized as compared to patients where the transgastric drain was internalized. Conclusion In WOPN, transgastric drain placement and successful internalization in any form help in the early resolution of peripancreatic and abdominal collections. It also reduces the time to percutaneous catheter removal, which in turn reduces the morbidity and decreases the need for additional interventions or surgery.

American College of Gastroenterology Guidelines: Management of Acute Pancreatitis

Acute pancreatitis (AP), defined as acute inflammation of the pancreas, is one of the most common diseases of the gastrointestinal tract leading to hospital admission in the United States. It is important for clinicians to appreciate that AP is heterogenous, progressing differently among patients and is often unpredictable. While most patients experience symptoms lasting a few days, almost one-fifth of patients will go on to experience complications, including pancreatic necrosis and/or organ failure, at times requiring prolonged hospitalization, intensive care, and radiologic, surgical, and/or endoscopic intervention. Early management is essential to identify and treat patients with AP to prevent complications. Patients with biliary pancreatitis typically will require surgery to prevent recurrent disease and may need early endoscopic retrograde cholangiopancreatography if the disease is complicated by cholangitis. Nutrition plays an important role in treating patients with AP. The safety of early refeeding and importance in preventing complications from AP are addressed. This guideline will provide an evidence-based practical approach to the management of patients with AP.

Early endoscopic management of an infected acute necrotic collection misdiagnosed as a pancreatic pseudocyst: A case report

BACKGROUND

Infected acute necrotic collection (ANC) is a fatal complication of acute pancreatitis with substantial morbidity and mortality. Drainage plays an exceedingly important role as the first step in invasive intervention for infected necrosis; however, there is great controversy about the optimal drainage time, and better treatment should be explored.

CASE SUMMARY

We report the case of a 43-year-old man who was admitted to the hospital with severe intake reduction due to early satiety 2 wk after treatment for acute pancreatitis; conservative treatment was ineffective, and a pancreatic pseudocyst was suspected on contrast-enhanced computed tomography (CT). Endoscopic ultrasonography (EUS) suggested hyperechoic necrotic tissue within the cyst cavity. The wall was not completely mature, and the culture of the puncture fluid was positive for A-haemolytic Streptococcus. Thus, the final diagnosis of ANC infection was made. The necrotic collection was not walled off and contained many solid components; therefore, the patient underwent EUS-guided aspiration and lavage. Two weeks after the collection was completely encapsulated, pancreatic duct stent drainage via endoscopic retrograde cholangiopancreatography (ERCP) was performed, and the patient was subsequently successfully discharged. On repeat CT, the pancreatic cysts had almost disappeared during the 6-month follow-up period after surgery.

CONCLUSION

Early EUS-guided aspiration and lavage combined with late ERCP catheter drainage may be effective methods for intervention in infected ANCs.

Endoscopic Ultrasound Guided Walled-off Necrosis Drainage

Walled-off necrosis is a well-recognized complication of necrotizing pancreatitis that can cause sepsis, luminal or ductal obstruction, or persistent unwellness requiring multidisciplinary care. Recent data suggest that minimally invasive endoscopic treatment strategies are preferred over more invasive surgical approaches. Although endoscopic transmural drainage with or without necrosectomy is the primary approach for patients requiring an intervention, for collections not amenable to endoscopic approach, percutaneous drain placement followed by video-assisted retroperitoneal debridement or laparoscopic cystogastrostomy with internal debridement are other alternatives. More studies are required to optimize post-procedure care to shorten the length of stay and minimize resource utilization.

Current trends in acute pancreatitis: Diagnostic and therapeutic challenges

Acute pancreatitis (AP) is an inflammatory disease of the pancreas, which can progress to severe AP, with a high risk of death. It is one of the most complicated and clinically challenging of all disorders affecting the abdomen. The main causes of AP are gallstone migration and alcohol abuse. Other causes are uncommon, controversial and insufficiently explained. The disease is primarily characterized by inappropriate activation of trypsinogen, infiltration of inflammatory cells, and destruction of secretory cells. According to the revised Atlanta classification, severity of the disease is categorized into three levels: Mild, moderately severe and severe, depending upon organ failure and local as well as systemic complications. Various methods have been used for predicting the severity of AP and its outcome, such as clinical evaluation, imaging evaluation and testing of various biochemical markers. However, AP is a very complex disease and despite the fact that there are of several clinical, biochemical and imaging criteria for assessment of severity of AP, it is not an easy task to predict its subsequent course. Therefore, there are existing controversies regarding diagnostic and therapeutic modalities, their effectiveness and complications in the treatment of AP. The main reason being the fact, that the pathophysiologic mechanisms of AP have not been fully elucidated and need to be studied further. In this editorial article, we discuss the efficacy of the existing diagnostic and therapeutic modalities, complications and treatment failure in the management of AP.

Institute-based nurse-led care versus home-based resistance training for patients with acute pancreatitis: Clinical outcomes analysis

Surgeries may have worse clinical outcomes in pancreatitis. In our institute surgical procedure is barely used surgery to treat pancreatitis nowadays. Chinese guidelines recommended regular exercise for severe pancreatitis. The objectives of the current study were to compare nurse-led resistance training at the institute against usual care provided to patients with acute pancreatitis for favorable clinical outcome measures. For acute pancreatitis, patients (≥18 years, of age) received 6 months of resistance training in the garden of the institute under the supervision of registered nurses (NR cohort, n = 102), or received 6 months of resistance training at their home by themselves according to a training manual (HR cohort, n = 120) or received 6 months of usual care only (UC cohort, n = 120). Fewer numbers patients died in the follow-up period in the NR cohort than those of the HR (8 vs 21, P = .0447) and the UC (8 vs 32, P = .0046) cohorts. The frequency of rehospitalization of patients due to any of the reasons in the follow-up period was fewer for patients of the NR cohort than those of the HR and the UC cohorts (P < .05 for both). Hospitalization of patients due to any of the reasons in the follow-up period was fewer for patients of the HR cohort than those of the UC cohort (P < .05). A 52 median score was the quality of life of patients before the start of the non-treatment intervention(s). After 6 months of non-treatment intervention(s), patients of the NR cohort improved their quality of life as compared to their initial quality of life (P < .001), those of HR cohort (P < .05), and those of UC cohort (P < .001). The quality of life of patients with severe pancreatitis after the surgical procedure was worse. Six months of nurse-assisted resistant training at the institute has significant improvement on the quality of life of patients in the follow-up periods of acute pancreatitis. Resistant training at the institute would improve the quality of life of patients with acute pancreatitis (Level of Evidence: IV; Technical Efficacy Stage: 5).

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.

Pancreatic Necrosis Infection as a Determinant of Multiple Organ Failure and Mortality in Acute Pancreatitis

Several recommendations and data on the treatment of acute necrotizing pancreatitis (ANP) are conflicting and different surgical approaches continue to exist. We conducted a study on 148 patients with ANP, who were divided into two groups: the main group (n = 95) when the tactics of the step-up approach were applied with the principles of the concept of Enhanced Recovery After Surgery (ERAS) in order to determine this approach on effectiveness in reducing complications and 30-day mortality (2017-2022); the comparison group (n = 53) when the same tactic of the treatment was used without ERAS principles (2015-2016). Treatment time for the main group in the intensive care unit was minimized (p ≤ 0.004); it has been shown to reduce the frequency of complications in these patients (p < 0.001) requiring conservative or surgical treatment without general anaesthesia (Clavien-Dindo I-IIIa); no statistically significant differences were observed for the total incidence of Clavien-Dindo IIIb-IVb complications (p > 0.05); the median duration of treatment for patients in the primary group was 23 days, and in the reference group-34 days (p ≤ 0.003). Pancreatic infections have been observed in 92 (62.2%) patients and gram-negative bacteria predominated in the overall pathogen structure with 222 (70.7%) strains. The only evidence of multiple organ failure before (AUC = 0.814) and after surgery (AUC = 0.931) was found to be predictive of mortality. Antibiotic sensitivity of all isolated bacteria better understood local epidemiology and identified the most effective antibiotics when treating patients.

The optimal timing and intervention to reduce mortality for necrotizing pancreatitis: a systematic review and network meta-analysis

BACKGROUND

A series of randomized controlled trials have investigated the efficacy and safety of different timings of interventions and methods of intervention. However, the optimal treatment strategy is not yet clear.

METHODS

We searched PubMed, EMBASE, ClinicalTrials.gov and the Cochrane Library until November 30, 2022. A systematic review and Bayesian network meta-analysis were performed following the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. Trials comparing different treatment strategies for necrotizing pancreatitis were included. This study was registered in the Prospective Register of Systematic Reviews (CRD42022364409) to ensure transparency.

RESULTS

We analyzed a total of 10 studies involving 570 patients and 8 treatment strategies. Although no statistically significant differences were identified comparing odds ratios, trends were confirmed by the surface under the cumulative ranking (SUCRA) scores. The interventions with a low rate of mortality were delayed surgery (DS), delayed surgical step-up approach (DSU) and delayed endoscopic step-up approach (DEU), while the interventions with a low rate of major complications were DSU, DEU and DS. According to the clustered ranking plot, DSU performed the best overall in reducing mortality and major complications, while DD performed the worst. Analysis of the secondary endpoints confirmed the superiority of DEU and DSU in terms of individual components of major complications (organ failure, pancreatic fistula, bleeding, and visceral organ or enterocutaneous fistula), exocrine insufficiency, endocrine insufficiency and length of stay. Overall, DSU was superior to other interventions.

CONCLUSION

DSU was the optimal treatment strategy for necrotizing pancreatitis. Drainage alone should be avoided in clinical practice. Any interventions should be postponed for at least 4 weeks if possible. The step-up approach was preferred.

Pancreatitis aguda: puntos clave. Revisión argumentativa de la literatura

Introducción. La pancreatitis aguda es una condición gastrointestinal común que se asocia a una importante morbimortalidad. Se estima que su incidencia es de 34 por cada 100.000 habitantes, afecta principalmente a adultos a partir de la sexta década de la vida y en nuestra región es debida en la mayoría de los casos a cálculos biliares. Métodos. Se hizo una revisión de los aspectos fundamentales de esta patología, común y potencialmente mortal. Resultados. El diagnóstico requiere del hallazgo de manifestaciones clínicas, aumento de las enzimas pancreáticas en suero y, en ocasiones, el uso de imágenes diagnósticas. Se puede clasificar en leve, moderada y severa, lo cual es fundamental para determinar la necesidad de tratamiento y vigilancia en una unidad de cuidados intensivos. Conclusión. En la actualidad los pilares de manejo de la pancreatitis aguda son la terapia temprana con líquidos, tratamiento del dolor, inicio precoz de la vía oral y resolución del factor etiológico desencadenante. En presencia de complicaciones o un curso severo de enfermedad, pueden requerirse manejo antibiótico e intervenciones invasivas.

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.

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.

Minimally invasive management of severe acute pancreatitis: Current status and future perspectives

In the past few years, the diagnosis and treatment of acute pancreatitis have moved towards a multidisciplinary, targeted, and minimally invasive approach. The optimal timing, route, and treatment strategy for intervention for local and systemic complications in patients with severe acute pancreatitis need to be re-evaluated. This review focuses on the development of minimally invasive management of severe acute pancreatitis in recent years and provides an outlook on future directions.

coMpliAnce with evideNce-based cliniCal guidelines in the managemenT of acute biliaRy pancreAtitis): The MANCTRA-1 international audit

BACKGROUND/OBJECTIVES

Reports about the implementation of recommendations from acute pancreatitis guidelines are scant. This study aimed to evaluate, on a patient-data basis, the contemporary practice patterns of management of biliary acute pancreatitis and to compare these practices with the recommendations by the most updated guidelines.

METHODS

All consecutive patients admitted to any of the 150 participating general surgery (GS), hepatopancreatobiliary surgery (HPB), internal medicine (IM) and gastroenterology (GA) departments with a diagnosis of biliary acute pancreatitis between 01/01/2019 and 31/12/2020 were included in the study. Categorical data were reported as percentages representing the proportion of all study patients or different and well-defined cohorts for each variable. Continuous data were expressed as mean and standard deviation. Differences between the compliance obtained in the four different subgroups were compared using the Mann-Whitney U, Student's t, ANOVA or Kruskal-Wallis tests for continuous data, and the Chi-square test or the Fisher's exact test for categorical data.

RESULTS

Complete data were available for 5275 patients. The most commonly discordant gaps between daily clinical practice and recommendations included the optimal timing for the index CT scan (6.1%, χ2 6.71, P = 0.081), use of prophylactic antibiotics (44.2%, χ2 221.05, P < 0.00001), early enteral feeding (33.2%, χ2 11.51, P = 0.009), and the implementation of early cholecystectomy strategies (29%, χ2 354.64, P < 0.00001), with wide variability based on the admitting speciality.

CONCLUSIONS

The results of this study showed an overall poor compliance with evidence-based guidelines in the management of ABP, with wide variability based on the admitting speciality. Study protocol registered in ClinicalTrials.Gov (ID Number NCT04747990).

Application of metagenomic next-generation sequencing for suspected infected pancreatic necrosis

BACKGROUND

Metagenomic next-generation sequencing (mNGS) is increasingly used for the clinical diagnosis of infectious diseases, but there is a paucity of data regarding the application of mNGS in the early diagnosis of infected pancreatic necrosis (IPN).

OBJECTIVE

To investigate the clinical application value of mNGS in the pathogenic diagnosis of IPN.

METHODS

Forty-two patients with suspected IPN were prospectively and consecutively enrolled from August 2019 to August 2021. Blood samples were collected for mNGS and microbial culture simultaneously during fever (T ≥ 38.5 °C). For patients who had indications of surgical interventions, peri-pancreatic specimens were collected for mNGS and microbial culture simultaneously during the first surgical intervention to confirm IPN. The clinical performance of mNGS and microbial culture were compared.

RESULTS

A total of 21 patients (50.0%) were confirmed to have IPN during hospitalization. The sensitivity of blood mNGS was significantly higher than blood culture (95.2% vs. 23.8%, P < 0.001) in diagnosing IPN. The negative predictive value of blood mNGS was 90.0%. The turnaround time of mNGS was significantly shorter than that of microbial culture [(37.70 ± 1.44) vs. (115.23 ± 8.79) h, P < 0.01] and the average costs of mNGS accounted for 1.7% of the average total cost of hospitalization. The survival analysis demonstrates that the positive blood mNGS result was not associated with increased mortality (P = 0.119).

CONCLUSIONS

With more valuable diagnostic performance and shorter turnaround time, clinical mNGS represents a potential step forward in the early diagnosis of IPN.

Percutaneous Catheter Drainage in Acute Infected Necrotizing Pancreatitis: A Real-World Experience at a Tertiary Care Hospital in North India

Introduction

Open necrosectomy in acute infected necrotizing pancreatitis is associated with very high mortality and morbidity. Moreover, if it is performed before four weeks, the benefits are limited. In this study, we evaluated the safety and efficacy of percutaneous catheter drainage (PCD) in patients with acute infected necrotizing pancreatitis.

Methods

It was a single-center, observational study, where all consecutive patients with proven or probable infected acute necrotizing pancreatitis in whom PCD was performed were studied. The patients who failed to respond to PCD underwent open necrosectomy. Baseline characteristics and the outcome of all included patients, including complications of PCD, were studied.

Results

A total of 46 patients (males=36, females=10) underwent PCD over a period of 18 months. Fifteen (32.60%) patients succumbed to their illness. PCD benefitted a total of 31 (67.39%) patients; in 17 (36.95%) patients, it worked as a standalone therapy, while in 14 (30.43%) patients, additional surgery was required where it helped to delay the surgery. Median days at which PCD and surgery were performed were 17.5 days (range: 2-28 days) and 33 days (range: 7-70 days), respectively. Lower mean arterial pressure at presentation, presence of multiorgan failure, more than 50% necrosis, higher baseline creatinine and bilirubin levels, and an early surgery were markers of increased mortality. Three (6.5%) patients had PCD-related complications, out of which only one required active intervention.

Conclusion

PCD in infected acute pancreatic necrosis is safe and effective. In one-third of the patients, it worked as standalone therapy, and in the rest it delayed the surgery beyond four weeks, thereby preventing the complications associated with early aggressive debridement.

Indian College of Radiology and Imaging Consensus Guidelines on Interventions in Pancreatitis

Acute pancreatitis (AP) is one of the common gastrointestinal conditions presenting as medical emergency. Clinically, the severity of AP ranges from mild to severe. Mild AP has a favorable outcome. Patients with moderately severe and severe AP, on the other hand, require hospitalization and considerable utilization of health care resources. These patients require a multidisciplinary management. Pancreatic fluid collections (PFCs) and arterial bleeding are the most important local complications of pancreatitis. PFCs may require drainage when infected or symptomatic. PFCs are drained endoscopically or percutaneously, based on the timing and the location of collection. Both the techniques are complementary, and many patients may undergo dual modality treatment. Percutaneous catheter drainage (PCD) remains the most extensively utilized method for drainage in patients with AP and necrotic PFCs. Besides being effective as a standalone treatment in a significant proportion of these patients, PCD also provides an access for percutaneous endoscopic necrosectomy and minimally invasive necrosectomy. Endovascular embolization is the mainstay of management of arterial complications in patients with AP and chronic pancreatitis. The purpose of the present guideline is to provide evidence-based recommendations for the percutaneous management of complications of pancreatitis.

Drainage of pancreatic fluid collections in acute pancreatitis: A comprehensive overview

Moderately severe and severe acute pancreatitis is characterized by local and systemic complications. Systemic complications predominate the early phase of acute pancreatitis while local complications are important in the late phase of the disease. Necrotic fluid collections represent the most important local complication. Drainage of these collections is indicated in the setting of infection, persistent or new onset organ failure, compressive or pressure symptoms, and intraabdominal hypertension. Percutaneous, endoscopic, and minimally invasive surgical drainage represents the various methods of drainage with each having its own advantages and disadvantages. These methods are often complementary. In this minireview, we discuss the indications, timing, and techniques of drainage of pancreatic fluid collections with focus on percutaneous catheter drainage. We also discuss the novel methods and techniques to improve the outcomes of percutaneous catheter drainage.

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.

Contemporary Intervention in Necrotizing Pancreatitis: Improved Understanding Changing Practice

BACKGROUND

Treatment of necrotizing pancreatitis (NP) has shifted in favor of a minimally invasive step-up approach rather than early open pancreatic debridement. We hypothesized that this paradigm shift would be reflected in the intervention, morbidity, and mortality profile of NP patients.

STUDY DESIGN

Single-institution retrospective review of 767 NP patients treated between 2005 and 2019. Two eras of NP intervention were identified relative to the introduction of a minimally invasive approach to NP. Patients treated between 2005 and 2010 were classified as the "early" group and compared with patients treated between 2011 and 2019, classified as the "late" group.

RESULTS

In total, 299 NP patients comprised the early group and 468 patients comprised the late group. No differences were seen in patient demographics, comorbidity profile, or NP etiology between groups. Necrosis volume, necrosis location, CT severity index (CTSI), and rates of infected necrosis were similar between groups. No difference was seen in mortality. Mechanical intervention for NP was more common in the early than the late group (86% vs. 73%, p < 0.001). Time to first intervention was similar between groups (79 ± 7d vs. 75 ± 6d). The early group had higher rates of open pancreatic debridement (72% vs. 55%, p < 0.001). Endoscopic intervention was less common in the early than the late group (7% vs. 16%, p < 0.001). NP disease duration was longer in the early than the late group (223 ± 12d vs. 179 ± 7d, p = 0.001).

CONCLUSION

Contemporary management of necrotizing pancreatitis is marked by less frequent operative debridement and shorter disease duration.

An Unusual Cause of Biliary Peritonitis on the Background of Acute Pancreatitis: A Case Report

Introduction Acute pancreatitis can cause a wide variety of local complications, sometimes pretty unusual. In the present report, we present a rather unusual cause of biliary peritonitis on the background of acute pancreatitis.

Case Presentation A 41-year-old female patient with biliary acute pancreatitis and concomitant choledocholithiasis required an urgent laparotomy due to signs of sepsis and peritoneal irritation after a trial of conservative management. During laparotomy, the diagnosis of biliary peritonitis was established. Surprisingly, a residual gallstone obstructing the common bile duct at the level of the ampulla was causing bile to reflux, through the common channel, into the main pancreatic duct and subsequently into a partially ruptured acute pancreatic necrotic collection.

Conclusion Dealing with the unexpected is a constant challenge for the surgical team dealing with acute pancreatitis patients. Although deferring surgical intervention during the course of acute pancreatitis, as much as possible, is the ideal strategy, this is not always possible. Deciding the treatment strategy based on the patients' clinical condition represents the most appropriate approach.

A "tailored" interventional and surgical management for moderate to critical acute pancreatitis in late phase: a cohort study

PURPOSE

Several interventional procedures are available to treat moderate-to-critical acute pancreatitis (AP) in its late phase. The ongoing debate on these options, together with the scarcity of reported quality of life (QoL) information in the Literature, prompted us to conduct a review of our experience.

METHODS

All the patients treated at our referral Center for moderate-to-critical AP according to Determinant-Based Classification (DBC) were retrospectively reviewed. Patients treated conservatively or operated within 4 weeks were excluded. The included patients were managed following a "tailored" interventional-surgical approach, which did not exclude the possibility to skip one or more steps of the classic "step-up" approach, based on the patient's clinical course, and divided into four groups, according to the first procedure performed: percutaneous drainage (PD), endoscopic approach (END), internal derivation (INT), and necrosectomy (NE). In-hospital and mid-term follow-up variables were analyzed.

RESULTS

The study sample consisted in 47 patients: 11 patients were treated by PD, 11 by END, 13 by INT, and 12 by NE. A significant distribution of the DBC severity (p = 0.029) was registered among the four groups. Moreover, the NE group had statistically significant reduced SF-36 scores in the domain of social functioning at 3 months (p = 0.011), at 1 year (p = 0.002), and at 2 years (p = 0.001); role limitations due to physical health at 6 months (p = 0.027); and role limitations due to emotional problems at 1 year (p = 0.020).

CONCLUSIONS

In the "late phase" of moderate to critical AP requiring an invasive management, PD, END, INT, and NE are all effective options, depending on patents' status and necrosis location. A "tailored" interventional-surgical management could be pursued, but up-front more invasive approaches are at higher risk of worse QoL.

TRIAL REGISTRATION

The manuscript was registered at clinicaltrials.gov in 04/2021 and identified with NCT04870268.

Retroperitoneal versus transperitoneal percutaneous catheter drainage of necrotic pancreatic collections: a comparative analysis

PURPOSE

To compare the success rate, clinical outcomes, and complications of retroperitoneal (RP) versus transperitoneal (TP) percutaneous catheter drainage (PCD) of the necrotic pancreatic fluid collections.

MATERIALS AND METHODS

This retrospective study comprised consecutive patients with acute pancreatitis who underwent PCD of lesser sac collections amenable to drainage via both TP and RP routes. The patients were divided into two groups based on the route of drainage (group I, RP, and group II, TP). The technical success, clinical success, complications, and clinical outcomes were compared between the groups. Subgroup analysis was performed based on the timing of drainage (acute necrotic collections, ANC vs. walled-off necrosis, WON) and organ failure (OF).

RESULTS

Seventy-nine patients [mean age, 38.7 ± 12.3 years, 54 males] were included in the study. Group I and II comprised 22 (27.8%) and 57 (72.2%) patients, respectively. The procedures were technically successful in all the patients. There was no significant difference in the complication rate between the two groups. The clinical success was higher in group II (75.4%) as compared to group I (54.5%). However, the difference was not statistically significant (p = 0.070). There was no significant difference in the hospital stay (p = 0.298), intensive care unit stay (p = 0.401), need for surgical necrosectomy (p = 0.243), and mortality (p = 0.112) between the two groups. The outcomes in patients with OF and ANC were not affected by the route of PCD. Clinical success rate was significantly higher in WON undergoing TP drainage (p = 0.009).

CONCLUSION

Both RP and TP routes of PCD are safe and effective. Clinical success rate was significantly higher in WON undergoing TP drainage.

Endoscopic or surgical treatment for necrotizing pancreatitis: Comprehensive systematic review and meta-analysis

Background and study aims  Treatment of necrotizing pancreatitis is changed over the past two decades with the availability of endoscopic, and minimally invasive surgical approaches. The aim of this systematic review was to assess outcomes of endoscopic drainage, and different types of surgical drainage approaches in necrotizing pancreatitis. Methods  Medline, Embase, Scopus, and Web of Science were searched from 1998 to 2020 to assess outcomes in endoscopic drainage and various surgical drainage procedures. The assessed variables consisted of mortality, development of pancreatic or enteric fistula, new onset diabetes mellitus, and exocrine pancreatic insufficiency. Results  One hundred seventy studies comprising 11,807 patients were included in the final analysis. The pooled mortality rate was 22 % (95 % confidence interval [CI]: 19%-26 %) in the open surgery (OS), 8 % (95 %CI:5 %-11 %) in minimally invasive surgery (MIS), 13 % (95 %CI: 9 %-18 %) in step-up approach, and 3 % (95 %CI:2 %-4 %) in the endoscopic drainage (ED). The pooled rate of fistula formation was 35 % (95 %CI:28 %-41 %) in the OS, 17 % (95 %CI: 12%-23 %) in MIS, 17 % (95 %CI: 9 %-27 %) in step-up approach, and 2 % (95 %CI: 0 %-4 %) in ED. There were 17 comparative studies comparing various surgical drainage methods with ED. The mortality rate was significantly lower in ED compared to OS (risk ratio [RR]: 30; 95 %CI: 0.20-0.45), and compared to MIS (RR: 0.40; 95 %CI: 0.26-0.6). Also, the rate of fistula formation was lower in ED compared to all other surgical drainage approaches. Conclusions  This systematic review demonstrated lower rate of fistula formation with ED compared to various surgical drainage methods. A lower rate of mortality with ED was also observed in observational studies. PROSPERO Identifier: CRD42020139354.

CCCTC-binding factor-mediated microRNA-340-5p suppression aggravates myocardial injury in rats with severe acute pancreatitis through activation of the HMGB1/TLR4 axis

BACKGROUND

Severe acute pancreatitis (SAP) is a life-threatening disorder associated with multisystem organ failure. This study aimed to investigate the function of high mobility group box 1 (HMGB1) in SAP-induced myocardial injury.

METHODS

A rat model with SAP was induced. The pathological changes in rat pancreatic and cardiac tissues were examined by HE staining. Cardiomyocyte apoptosis in rat cardiac tissues, and the serum levels of myocardial injury markers and pro-inflammatory cytokines were examined. Rat primary cardiomyocytes were treated with H₂O₂ for in vitro experiments. The regulatory molecules of HMGB1 were predicted by bioinformatics analysis. Altered expression of HMGB1, microRNA (miR)-340-5p and CCCTC-binding factor (CTCF) was introduced in rats or cells to investigate their roles in myocardial injury.

RESULTS

CTCF and HMGB1 were highly expressed but miR-340-5p was poorly expressed in cardiac tissues of rats with SAP. HMGB1 silencing reduced toll-like receptor 4 (TLR4) expression to promote proliferation and reduce apoptosis of H₂O₂-treated cardiomyocytes. miR-340-5p targeted HMGB1 mRNA, while CTCF suppressed miR-340-5p transcription. CTCF upregulation or miR-340-5p downregulation blocked the effects of HMGB1 silencing on cardiomyocytes. In vivo, CTCF silencing alleviated injury in rat pancreatic and cardiac tissues and reduced the expression of creatine kinase-MB (CK-MB), lactic dehydrogenase, interleukin (IL)-1β, IL-6 and tumor necrosis factor-α (TNF-α) in rat serum. But further overexpression of HMGB1 or inhibition of miR-340-5p aggravated the symptoms in rats.

CONCLUSION

This study demonstrated that CTCF reduces transcription of miR-340-5p to promote HMGB1 expression, which activates TLR4 expression and promotes myocardial injury in rats with SAP.

Endoscopic drainage versus percutaneous drainage for the management of infected walled-off necrosis: a comparative analysis

BACKGROUND

Comparative data on percutaneous catheter drainage (PCD) vs EUS-guided drainage (EUS-D) for management of symptomatic walled-off-necrosis (WON), specially infected WON with/without organ failure(OF) is limited.

METHODS

Patients with symptomatic WON were divided into two groups of PCD and EUS-D, depending on the modality of drainage. Resolution of OF, adverse events, and other outcome measures were recorded. The two modalities were compared among infected WON sub-cohort and also degree of solid component (SC).

RESULTS

218 patients (175 males; 80.3%) were included who underwent either PCD (n = 102) or EUS-D (n = 116). Clinical success was significantly higher in the EUS-D group (92.1% vs 64.6%; p < 0.0001) and even for infected WON (n = 128) (p = 0.004), with higher (p = 0.007) and faster (p < 0.0001) OF resolution. Other outcome measures including mortality were significantly higher in the PCD group. Among subgroups, PCD with >40% SC had the worst clinical success/OF resolution rates, while EUS-D with <40% SC had the best outcomes.

CONCLUSION

EUS-D should be preferred over PCD in the management of WON, infected or otherwise, for higher clinical success, and higher/faster resolution of OF. PCD should be avoided in WON with>40% SC.

FXYD domain containing ion transport regulator 5 (FXYD5) silencing promotes cell viability and alleviates inflammatory response in cerulein-induced AR42J cells by blocking JAK2/STAT3 signaling pathway

Acute pancreatitis (AP), which causes severe morbidity and mortality, is a heavy burden for people clinically and financially. This study was designed to explore the mechanism of AP and try to find effective therapies against AP. The expression of FXYD5 was interfered by performing transfection. RT-qPCR and Western blot were utilized to measure FXYD5 expression. In addition, the viability, apoptosis and inflammatory response were evaluated using CCK-8, TUNEL and ELISA, respectively. Moreover, Western blot was employed to measure the expressions of apoptosis-, inflammation- and signaling pathway-related proteins. FXYD5 was found to be overexpressed in AP patients and AP cell model. The results showed that in cerulein-induced AR42J cells, cell viability was remarkably increased, and apoptosis was inhibited compared to the normal FXYD5-expressing group because FXYD5 was downregulated. Similarly, in such cells, interference with FXYD5 significantly suppressed the inflammatory response. In addition, Western blot analysis revealed that JAK2/STAT3 signaling was also strongly inhibited by FXYD5 interference. However, the effect of FXYD5 downregulation was reversed upon simultaneous activation of JAK2/STAT3 signaling. In conclusion, downregulation of FXYD5 could promote cell viability and alleviate inflammatory response in cerulein-induced AP via blocking JAK2/STAT3 signaling pathway.

Value of neutrophil-lymphocyte ratio in evaluating response to percutaneous catheter drainage in patients with acute pancreatitis

BACKGROUND

Early prediction of response to percutaneous catheter drainage (PCD) of necrotic collections in acute pancreatitis (AP) using simple and objective tests is critical as it may determine patient prognosis. The role of white blood cell (WBC) count and neutrophil-lymphocyte ratio (NLR) has not been assessed as a tool of early prediction of PCD success and is the focus of this study.

AIM

To assess the value of WBC and NLR in predicting response to PCD in AP.

METHODS

This retrospective study comprised consecutive patients with AP who underwent PCD between June 2018 and December 2019. Severity and fluid collections were classified according to the revised Atlanta classification and organ failure was defined according to the modified Marshall Score. WBC and NLR were monitored 24 h prior PCD (WBC-0/NLR-0) and 24 h (WBC-1/NLR-1), 48 h (WBC-2/NLR-2) and 72 h (WBC-3/NLR-3) after PCD. NLR was calculated by dividing the number of neutrophils by the number of lymphocytes. The association of success of PCD (defined as survival without the need for surgery) with WBC and NLR was assessed. The trend of WBC and NLR was also assessed post PCD.

RESULTS

One hundred fifty-five patients [median age 40 ± 13.6 (SD), 64.5% males, 53.5% severe AP] were included in the final analysis. PCD was done for acute necrotic collection in 99 (63.8%) patients and walled-off necrosis in 56 (36.1%) patients. Median pain to PCD interval was 24 ± 69.89 d. PCD was successful in 109 patients (group 1) and 46 patients (group 2) who failed to respond. There was no significant difference in the baseline characteristics between the two groups except the severity of AP and frequency of organ failure. Both WBC and NLR showed an overall decreasing trend. There was a significant difference between WBC-0 and WBC-1 (P = 0.0001). WBC-1 and NLR-1 were significantly different between the two groups (P = 0.048 and 0.003, respectively). The area under the curve of WBC-1 and NLR-1 for predicting the success of PCD was 0.602 and 0.682, respectively. At a cut-off value of 9.87 for NLR-1, the sensitivity and specificity for predicting the success of PCD were calculated to be 75% and 65.4% respectively.

CONCLUSION

WBC and NLR can be used as simple tests for predicting response to PCD in patients with acute necrotizing pancreatitis.

Treatment of Acute Necrotising Pancreatitis and Its Complications: The Surgeon's Perspective

Acute necrotising pancreatitis (ANP) is associated with high complication and mortality rates. It is still difficult for the surgeon to choose and schedule the most appropriate treatment. Compared to the past, the current minimally invasive "step-up" approach enables better outcomes in terms of morbidity/mortality, notwithstanding long periods of hospitalisation, and above all ensures better levels of residual pancreatic function. We hereby report the case of a patient hospitalised in our division for approximately 4 months with a diagnosis of ANP complicated by infection and late bleeding, handled with a sequential approach.

Efficacy and safety of abdominal paracentesis drainage on patients with acute pancreatitis: a systematic review and meta-analysis

OBJECTIVES

To conduct a systematic review and meta-analysis of the efficacy and safety of abdominal paracentesis drainage (APD) in patients with acute pancreatitis (AP) when compared with conventional 'step-up' strategy based on percutaneous catheter drainage (PCD).

DESIGN

Systematic review and meta-analysis.

METHODS

PubMed, EMBASE, Cochrane Library, MEDLINE (OVID), China National Knowledge Infrastructure and Wanfang Database were electronically searched to collect cohort studies and randomised controlled trials (RCTs) from inception to 25 July 2020. Studies related to comparing APD with conventional 'step-up' strategy based on PCD were included.

OUTCOMES

The primary outcome was all-cause mortality. The secondary outcomes were the rate of organ dysfunction, infectious complications, hospitalisation expenses and length of hospital stay.

RESULTS

Five cohort studies and three RCTs were included in the analysis. Compared with the conventional 'step-up' method, pooled results suggested APD significantly decreased all-cause mortality during hospitalisation (cohort studies: OR 0.48, 95% CI 0.26 to 0.89 and p=0.02), length of hospital stay (cohort studies: standard mean difference (SMD) -0.31, 95% CI -0.53 to -0.10 and p=0.005; RCTs: SMD -0.45, 95% CI -0.64 to -0.26 and p<0.001) and hospitalisation expenses (cohort studies: SMD -2.49, 95% CI -4.46 to -0.51 and p<0.001; RCTs: SMD -0.67, 95% CI -0.89 to -0.44 and p<0.001). There was no evidence to prove that APD was associated with a higher incidence of infectious complications. However, the incidence of organ dysfunction between cohort studies and RCTs subgroup slightly differed (cohort studies: OR 0.66, 95% CI 0.34 to 1.28 and p=0.22; RCTs: OR 0.58, 95% CI 0.35 to 0.98 and p=0.04).

CONCLUSIONS

The findings suggest that early application of APD in patients with AP is associated with reduced all-cause mortality, expenses during hospitalisation and the length of stay compared with the 'step-up' strategy without significantly increasing the risk of infectious complications. These results must be interpreted with caution because of the limited number of included studies as well as a larger dependence on observational trials.

PROSPERO REGISTRATION NUMBER

CRD42020168537.

Current status of treatments of pancreatic and peripancreatic collections of acute pancreatitis

Pancreatic and peripancreatic collections are the main local complications of acute pancreatitis with a high incidence. In the early phase, most acute pancreatic and peripancreatic collections can resolve spontaneously with supportive treatment. However, in some cases, they will develop into pancreatic pseudocyst (PPC) or walled-off necrosis (WON). When causing symptoms or coinfection, both PPC and WON may require invasive intervention. Compared to PPC, which can be effectively treated by endoscopic ultrasound-guided transmural drainage with plastic stents, the treatment of WON is more complicated and challenging, particularly in the presence of infected necrosis. In the past few decades, with the development of minimally invasive interventional technology especially the progression of endoscopic techniques, the standard treatments of those severe complications have undergone tremendous changes. Currently, based on the robust evidence from randomized controlled trials, the step-up minimally invasive approaches have become the standard treatments for WON. However, the pancreatic fistulae during the surgical step-up treatment and the stent-related complications during the endoscopic step-up treatment should not be neglected. In this review article, we will mainly discuss the indications of PPC and WON, the timing for intervention, and minimally invasive treatment, especially endoscopic treatment. We also introduced our preliminary experience in endoscopic gastric fenestration, which may be a promising innovative method for the treatment of WON.

Outcome of percutaneous drainage in patients with pancreatic necrosis having organ failure

BACKGROUND

Percutaneous catheter drainage (PCD) is an effective way of drainage in acute pancreatitis (AP) and its role in persistent organ failure (OF) has not been studied. This study assessed the outcome of severe AP managed with PCD.

METHODS

We retrospectively analysed outcome of AP patients undergoing PCD for persistent OF with respect to success of PCD, etiology, severity scores, OF, imaging features and PCD parameters. Success of PCD was defined as resolution of with PCD and survived without surgical necrosectomy.

RESULTS

Between January 2016 and May 2018, 83 patients underwent PCD for persistent OF at a mean duration of 25.59 ± 21.2 days from pain onset with successful outcome in 47 (56.6%) patients. Among PCD failures, eleven (13.25%) patients underwent surgery. Overall mortality was 31 (37.3%). On multivariate analysis, pancreatic necrosis <50% and absence of extrapancreatic infection (EPI) predicted the success of PCD. Presence of infected necrosis did not affect the outcome of PCD in organ failure.

CONCLUSION

PCD improves the outcome in patients with OF even when done early irrespective of the status of infection of necrosis. Therefore, PCD may be considered early in the course of patients with OF.

The effectiveness of image-guided percutaneous catheter drainage in the management of acute pancreatitis-associated pancreatic collections

Purpose

Acute pancreatitis is commonly complicated by the development of pancreatic collections (PCs). Symptomatic PCs warrant drainage, and the available options include percutaneous, endoscopic, and open surgical approaches. The study aimed to assess the therapeutic effectiveness and safety of image guided percutaneous catheter drainage (PCD) in the management of acute pancreatitis related PCs.

Material and methods

This was a single-centre prospective study covering a 4-year study period. Acute pancreatitisrelated PCs complicated by secondary infection or those producing symptoms due to pressure effect on surrounding structures were enrolled and underwent ultrasound or computed tomography (CT)-guided PCD. The patients were followed to assess the success of PCD (defined as clinical, radiological improvement, and the avoidance of surgery) and any PCD-related complications.

Results

The study included 60 patients (60% males) with a mean age of 43.1 ± 21.2 years. PCD recorded a success rate of 80% (16/20) for acute peripancreatic fluid collections (APFC) and pancreatic pseudocysts (PPs), 75% (12/16) for walled-off necrosis (WON), and 50% (12/24) for acute necrotic collections (ANCs). Post-PCD surgery (necrosectomy ± distal pancreatectomy) was needed in 50% of ANC and 25% of WON. Only 20% of APFCs/PPs patients required surgical/endoscopic treatment post-PCD. Minor procedure-related complications were seen in 4 (6.6%) patients.

Conclusion

PCD is an effective, safe, and minimally invasive therapeutic modality with a good success rate in the management of infected/symptomatic PCs.

Streptokinase irrigation through a percutaneous catheter helps decrease the need for necrosectomy and reduces mortality in necrotizing pancreatitis as part of a step-up approach

BACKGROUND

Percutaneous catheter drainage in pancreatic necrosis with a predominant solid component has a reduced success rate. To improve the efficacy of percutaneous catheter drainage, we used streptokinase in the irrigation fluid in the present study.

METHODS

In this retrospective analysis of 4 prospective randomized studies performed at our center from 2014 to 2019, 108 patients were evaluated. We assessed the safety, feasibility, and efficacy of streptokinase irrigation compared to saline irrigation. Data were also analyzed between 50,000 IU and 150,000 IU streptokinase.

RESULTS

There were 53 patients in the streptokinase irrigation group and 55 in the saline irrigation group, and both groups were comparable in terms of age, sex, etiology, APACHE II score, and percutaneous catheter drainage characteristics. The modified computerised tomography severity index and modified Marshall score at the onset of pain were significantly higher in the streptokinase group. Sepsis reversal was significantly higher in the streptokinase group (75% vs 36%), and the need for necrosectomy (34% vs 54%) was also lower in the streptokinase group. Mortality was lower in the streptokinase group than in the saline group (32% vs 40%). The incidence of bleeding in the streptokinase group was lower than that in the saline group (7% vs 18%). A higher dose of streptokinase (150,000 IU) resulted in lower rates of necrosectomy, bleeding, and mortality compared to those with 50,000 IU streptokinase.

CONCLUSION

Significant reductions in the need for surgery and sepsis reversal were noted in the streptokinase group. The results using 150,000 IU streptokinase were superior to those using 50,000 IU streptokinase.