Endotherapy for pancreatic necrosis and abscess: endoscopic drainage and necrosectomy

Risk factors for walled-off necrosis associated with severe acute pancreatitis: A multicenter retrospective observational study

BACKGROUND

This study aimed to identify the risk factors for walled-off necrosis (WON) associated with severe acute pancreatitis (SAP).

METHODS

This retrospective study was conducted in eight institutions in Japan between 2014 and 2017. We analyzed WON incidence, patient characteristics, and risk factors for WON in patients with SAP who were observed for >28 days.

RESULTS

Of 134 patients with SAP, WON occurred in 40 (29.9%). Male sex (P = .045), body mass index (BMI) ≥25 (P < .001), post-endoscopic retrograde cholangiopancreatography (ERCP) pancreatitis (P = .020), and disseminated intravascular coagulation (DIC) (P = .001) were more frequent in the WON group than in the non-WON group. On admission, the frequency of white blood cell counts ≥ 12 000/µL (P = .037) and hypoenhanced pancreatic lesion on computed tomography (P = .047) were significantly higher in the WON group. In multivariate analysis, BMI ≥ 25 (odds ratio [OR] 5.73, 95% confidence interval [CI] 1.95-16.8; P = .002), post-ERCP (OR 8.08, 95% CI 1.57-41.7; P = .013), and DIC (OR 3.52, 95% CI 1.20-10.4; P = .022) were independent risk factors for WON.

CONCLUSIONS

High BMI, post-ERCP pancreatitis, and DIC are risk factors for the development of WON associated with SAP.

Endoscopic ultrasound-guided drainage of pancreatic fluid collections: The impact of evolving experience and new technologies in diagnosis and treatment over the last two decades

BACKGROUND

Endoscopic ultrasound (EUS)-guided drainage is the preferred approach for drainage of pancreatic fluid collections (PFCs) due to the better experience and significant progress using newer stents and access devices during last decade. This study aimed to evaluate the role of the evolving experience and possible influence of new technological devices on the outcome of patients evaluated for PFCs and submitted to EUS-guided drainage during two different periods: the early period at the beginning of experience when a standardized technique was used and the late period when the increased experience of the operator, combined with different stents quality were introduced in the management of PFCs.

METHODS

We retrospectively analyzed the clinical data of a cohort of 91 consecutive patients, who underwent EUS-guided drainage of symptomatic PFCs from October 2001 to September 2017. Demographic, therapeutic results, complications, and outcomes were compared between early years' group (2001-2008) and late years' group (2009-2017).

RESULTS

Endoscopic treatment was successfully achieved in 55.6% (20/36) of patients in the early years' group, and in 96.4% (53/55) in the late years' group. Eighteen patients (12 in early years' and 6 in the late year's group) required additional open surgery. Procedural complications were observed in 5 patients, 4 in early years' and 1 in late years' group. Mortality was registered in two patients (2.2%), one for each group.

CONCLUSIONS

During our long-term survey using EUS-guided endoscopic drainage of PFCs, significantly better outcomes in term of improved success rate and decrease complications rate were observed during the late period.

Transcutaneous Endoscopic Necrosectomy for Walled-off Pancreatic Necrosis in the Paracolic Gutter

BACKGROUND

Walled-off pancreatic necrosis (WON) is a sequelae of acute pancreatitis that requires debridement, once infected. Recently, endoscopic necrosectomy has become the mainstay for management. However, peripancreatic collections that extend to the paracolic gutter or lesser sac, are more challenging to treat endoscopically. We report an endoscopic method for management of necrotic collections that extend into the paracolic gutter.

METHODS

Consecutive patients, with symptomatic WON extending into the retroperitoneum, were included in a prospective registry. Each patient underwent transcutaneous endoscopic necrosectomy (TEN) through a fully covered self-expanding esophageal metal stent. After resolution of the collection, the external stent was removed, and the cutaneous fistula was allowed to close by secondary intention. Clinical success was defined as resolution of the WON, and successful removal of all percutaneous drains. Patient demographics, procedural/periprocedural adverse events, and follow-up data, were collected.

RESULTS

Nine patients underwent direct TEN. Patients initially underwent CT-guided percutaneous drainage, with an average of 31 days between initial drainage and endoscopic necrosectomy. All patients had a technically successful placement of a fully covered esophageal metal stent through the cutaneous fistula. After a median of 3 endoscopic debridement sessions, 8 of 9 (89%) patients had successful removal of all percutaneous drains, and resolution of necrotic collections. One patient died of multisystem organ failure from severe acute pancreatitis.

CONCLUSIONS

TEN for infected WON is a safe and efficacious technique for patients with endoscopically inaccessible collections.

Predictive Value of Computed Tomography Scans and Clinical Findings for the Need of Endoscopic Necrosectomy in Walled-off Necrosis From Pancreatitis

OBJECTIVES

Choosing the best treatment option at the optimal point of time for patients with walled-off necrosis (WON) is crucial. We aimed to identify imaging parameters and clinical findings predicting the need of necrosectomy in patients with WON.

METHODS

All patients with endoscopically diagnosed WON and pseudocyst were retrospectively identified. Post hoc analysis of pre-interventional contrast-enhanced computed tomography was performed for factors predicting the need of necrosectomy.

RESULTS

Sixty-five patients were included in this study. Forty patients (61.5%) were diagnosed with pseudocyst and 25 patients (38.5%) with WON. Patients with WON mostly had acute pancreatitis with biliary cause compared with more chronic pancreatitis and toxic cause in pseudocyst group (P = 0.002 and P = 0.004, respectively). Logistic regression revealed diabetes as a risk factor for WON. Computed tomography scans revealed 4.62% (n = 3) patients as false positive and 24.6% (n = 16) as false negative findings for WON. Reduced perfusion and detection of solid findings were independent risk factors for WON.

CONCLUSIONS

Computed tomography scans are of low diagnostic yield when needed to predict treatment of patients with pancreatic cysts. Reduced pancreatic perfusion and solid findings seem to be a risk factor for WON, whereas patients with diabetes seem to be at higher risk of developing WON.

Endoscopic necrosectomy under fluoroscopic guidance - a single center experience

INTRODUCTION

Our report presents a technique of necrotic tissue removal during transmural drainage of walled-off pancreatic necrosis (WOPN) that is an alternative to the one that has already been described in the literature.

AIM

To assess the effectiveness and safety of endoscopic necrosectomy performed during transmural drainage of symptomatic WOPN.

MATERIAL AND METHODS

Within the years 2012-2013, 64 patients underwent endoscopic treatment of symptomatic WOPN in our center. Eight patients underwent endoscopic necrosectomy during transmural drainage. Fragments of necrotic tissues were removed from the collection's cavity under fluoroscopic guidance using a Dormia basket. The results and complications of treatment were compared retrospectively.

RESULTS

Sixty-four patients with WOPN underwent transmural drainage under endoscopic ultrasonography (EUS) guidance. Eight patients (12.5%, 5 women and 3 men, mean age 57.25 years) were qualified for endoscopic necrosectomy. Transmural transgastric access was made in 7 patients and transduodenal access in 1 patient. Additional percutaneous drainage was used in 2 patients. Active drainage was continued for 24 days (11-44 days). The mean number of endoscopic procedures was 4.75 (3-9). The average number of necrosectomy procedures during drainage was 1.75 (1-4). Complications of endotherapy occurred in 2/8 (25%) patients, and they were not directly connected with necrosectomy. Therapeutic success after the end of active drainage was achieved in all patients. During a 6-month follow-up no recurrence of the collection was observed.

CONCLUSIONS

Endoscopic necrosectomy under fluoroscopic guidance is an effective and safe method of minimally invasive treatment in a selected group of patients with symptomatic WOPN.

Endoscopic therapy of necrotizing pancreatitis and pseudocysts

Endoscopic therapy has become an essential component in the management of postpancreatitis complications, such as infected and/or symptomatic pancreatic pseudocysts and walled-off necrosis. However, although there have been 2 recent randomized, controlled trials performed, a general lack of comparative effectiveness data regarding the timing, indications, and outcomes of these procedures has been a barrier to the development of practice standards for therapeutic endoscopists managing these issues. This article reviews the available data and expert consensus regarding indications for endoscopic intervention, timing of procedures, endoscopic technique, periprocedural considerations, and complications.

Laparoscopic pancreatic resections

PURPOSE

Pancreatic surgery is technically complex and requires considerable expertise. Laparoscopic pancreatic surgery adds the need for considerable experience with advanced laparoscopic techniques. Despite the technical difficulties, an increasing number of centers propagate the use of laparoscopy in pancreatic surgery over the last decade.

METHODS

In this review, we provide an overview of the literature regarding the advantages and disadvantages of laparoscopic pancreatic surgery. Larger prospective randomized studies have emerged in the subset of laparoscopic or retroperitoneoscopic surgery for acute pancreatitis, considerable single center experience has been reported for laparoscopic pancreatic tail resection, and laparoscopic pancreatic head resection, however, is still restricted to a few experienced centers worldwide.

RESULTS AND CONCLUSIONS

Laparoscopic pancreatic surgery is becoming more and more established, in particular for the treatment of benign and premalignant lesions of the pancreatic body and tail. It has been shown to decrease postoperative pain, narcotic use, and length of hospital stay in larger single center experience. However, prospective trials are needed in laparoscopic resective pancreatic surgery to evaluate its advantages, safety, and efficacy in the treatment of pancreatic neoplasms and in particular in malignant pancreatic tumors.

Endoscopic ultrasonography-guided drainage is an effective and relatively safe treatment for peripancreatic fluid collections in a cohort of 108 symptomatic patients

BACKGROUND AND STUDY AIMS

Endoscopic drainage [i.e. conventional, endoscopic ultrasonography (EUS)-assisted, or EUS-guided] is an accepted treatment modality for symptomatic peripancreatic fluid collections (PFC), but data on the efficacy and safety of EUS-guided drainage performed in a large patient cohort are not widely available. Our aim was to evaluate the clinical success and complication rate of EUS-guided drainage of PFCs and to identify prognostic factors for complications and recurrence of PFCs.

PATIENTS AND METHODS

A retrospective analysis was carried out of consecutive patients undergoing EUS-guided drainage of a symptomatic PFC in the period 2004-2011. Technical success was defined as the ability to enter and drain a PFC by the placement of one or more double-pigtail stents, whereas clinical success was defined as complete resolution of a PFC on follow-up computed tomography.

RESULTS

In total, 108 patients [56% men, mean age 55 (SD 14) years], underwent EUS-guided drainage of a symptomatic PFC. The procedure was technically successful in 105/108 (97%) patients and a median of 2 (range 1-3) pigtail stents were placed. Clinical success was observed in 87/104 (84%) patients after a median follow-up of 53 (interquartile range 21-130) weeks, whereas PFC recurrence was noted in 15/83 (18%) patients. Complications occurred in 21/105 (20%) patients and procedure-related mortality was not observed. Prognostic factors for complications and recurrence of PFCs could not be identified.

CONCLUSION

EUS-guided drainage of PFCs is effective in the majority of patients. Although the complication rate of the procedure is not negligible (20%), they could be managed in almost all patients by conservative and/or endoscopic means and did not result in mortality.

Minimally invasive operations for acute necrotizing pancreatitis: comparison of minimally invasive retroperitoneal necrosectomy with endoscopic transgastric necrosectomy

BACKGROUND

A "step-up" approach is currently the treatment of choice for acute necrotizing pancreatitis. Our aim was to evaluate the outcome of minimally invasive retroperitoneal necrosectomy (MINE) and endoscopic transgastric necrosectomy (ETG) and to compare it to open necrosectomy (ONE).

METHODS

Patients with acute pancreatitis admitted to our institution from 1998 to 2010 (n = 334) were identified. From these, patients who underwent either ONE, MINE, or ETG were selected for further analysis. Statistical analysis employed 2-sided Fisher's exact test and Mann-Whitney U-test.

RESULTS

From 2002 to 2010, 32 patients with acute necrotizing pancreatitis were treated by minimally invasive procedures including MINE (n = 14) and ETG (n = 18) or with the classic technique of ONE (n = 30). Time from onset of symptoms to intervention was less for ONE than for MINE or ETG (median, 11 vs 39 vs 54 days; P < .05). The rate of critically ill patients with sepsis or septic shock was greatest in ONE (93%) and MINE (71%) compared with ETG (17%; P < .05). Problems after ONE and MINE were ongoing sepsis (ONE 73% vs MINE 29% vs ETG 11%) and bleeding requiring intervention (ONE 26% vs MINE 21% vs ETG 17%). A specific complication of ETG was gastric perforation into the peritoneal cavity during the procedure (28%), requiring immediate open pseudocystogastrostomy. Laparotomy was necessary in 21% after MINE and 28% after ETG owing to specific complications or persistent infected necrosis. Overall mortality was greatest after ONE (ONE 63% vs MINE 21% vs ETG 6%; P < .05).

CONCLUSION

Morbidity and mortality remains high in acute necrotizing pancreatitis. Operative procedures should be delayed as long as possible to decrease morbidity and mortality. Minimally invasive procedures can avoid laparotomy, but also introduce specific complications requiring immediate or secondary open operative treatment. Minimally invasive procedures require unique expertise and therefore should only be performed at specialized centers.

Walled-off pancreatic necrosis

Walled-off pancreatic necrosis (WOPN), formerly known as pancreatic abscess is a late complication of acute pancreatitis. It can be lethal, even though it is rare. This critical review provides an overview of the continually expanding knowledge about WOPN, by review of current data from references identified in Medline and PubMed, to September 2009, using key words, such as WOPN, infected pseudocyst, severe pancreatitis, pancreatic abscess, acute necrotizing pancreatitis (ANP), pancreas, inflammation and alcoholism. WOPN comprises a later and local complication of ANP, occurring more than 4 wk after the initial attack, usually following development of pseudocysts and other pancreatic fluid collections. The mortality rate associated with WOPN is generally less than that of infected pancreatic necrosis. Surgical intervention had been the mainstay of treatment for infected peripancreatic fluid collection and abscesses for decades. Increasingly, percutaneous catheter drainage and endoscopic retrograde cholangiopancreatography have been used, and encouraging results have recently been reported in the medical literature, rendering these techniques invaluable in the treatment of WOPN. Applying the recommended therapeutic strategy, which comprises early treatment with antibiotics combined with restricted surgical intervention, fewer patients with ANP undergo surgery and interventions are ideally performed later in the course of the disease, when necrosis has become well demarcated.

[Diagnostic and interventional endoscopy in gastroenterology : from high-resolution chips and procedures for endoscopic resection to NOTES]

In the past 10 years endoscopic diagnostics has benefited from technologies such as big chips, high-definition television (HDTV) and narrow band imaging (NBI). Video capsule endoscopy and double balloon enteroscopy have facilitated visualization of the entire small bowel. A number of studies on mucosal Barrett's and gastric cancers could prove that endoscopic mucosal resection (EMR) is oncologically equivalent to surgical resection when certain criteria are respected. However, EMR is less invasive and carries a substantially lower complication risk and mortality compared to surgery. Endoscopic submucosal dissection (ESD) facilitates en bloc resection with thorough histopathologic evaluation of the specimen, e.g. for mucosal lesions in the stomach and rectum. Endosonography (EUS) guided transgastric necrosectomy using a flexible gastroscope has set a milestone in the treatment of infected pancreatic necroses and has replaced open surgery in many centers. Natural orifice transluminal endoscopic surgery (NOTES) uses natural body openings as minimally invasive access to the abdomen and mediastinum. Interventional GI endoscopists and minimally invasive surgeons have profited from these innovations in micromechanics and microelectronics.