Management of necrotizing pancreatitis by repeated operative necrosectomy using a zipper technique

Management of Necrotizing Pancreatitis

Necrotizing pancreatitis affects 10% to 15% of all patients with acute pancreatitis. Despite improved understanding of this complex disease, it is still attended by up to 15% mortality. Necrotizing pancreatitis provides the clinical challenges of working in a multi-disciplinary group, determining proper timing for intervention, and identifying appropriate intervention approaches. The step-up approach consists of supportive care initially. When there is documented infected necrosis, treatment begins with antibiotics, progressing to minimally invasive mechanical necrosis intervention, and reserving surgery as the final treatment modality. However, treatment must be tailored to the individual patient. This article provides an overview of necrotizing pancreatitis.

Intestinal flora and pancreatitis: Present and future

The role of intestinal flora in human health and diseases has attracted more and more attention. At present, there have been some reports on the relationship between intestinal flora and pancreatitis. These reports reveal that intestinal flora plays some important roles in the occurrence and development of pancreatitis. The specific mechanisms of action are unclear, but there is preliminary consensus that intestinal microbiome dysregulation promotes inflammatory changes in the pancreas. This paper summarizes the correlation between intestinal flora and pancreatitis, in order to provide some references and ideas for further research.

Safety and efficacy of early image-guided percutaneous interventions in acute severe necrotizing pancreatitis: A single-center retrospective study

BACKGROUND

Acute necrotizing pancreatitis is managed conservatively in early phase of the disease. Even minimally invasive procedure is preferred after 21 days of onset and there is a paucity of data on decision and outcomes of early radiological interventions. This study aimed to evaluate efficacy and safety of early image-guided percutaneous interventions in management of acute severe necrotizing pancreatitis.

METHODS

A single-center retrospective study was performed after obtaining Institutional review board approval for analyzing hospital records of patients with acute necrotizing pancreatitis from January 2012 to July 2017. Seventy-eight consecutive patients with necrotizing pancreatitis and acute necrotic collections (ANC) were managed with percutaneous catheter drainage (PCD) and catheter-directed necrosectomy, in early phase of the disease (< 21 days). Clinical data and laboratory parameters of the included patients were evaluated until discharge from hospital, or mortality.

RESULTS

Overall survival rate was 73.1%. Forty-two (53.8%) patients survived with PCD alone, while the remaining 15 (19.2%) survivors needed additional necrosectomy. The timing of intervention from the start of the hospitalization to drainage was 14.3 ± 2.4 days. Significant risk factors for mortality were the presence of organ system failure, need for mechanical ventilation, renal replacement therapy, and the acute physiology and chronic health evaluation II (APACHE II) score. An APACHE II score cutoff value of 15 was a significant discriminant for predicting survival with catheter-directed necrosectomy.

CONCLUSION

An early PCD of ANC in clinically deteriorating patients with acute necrotizing pancreatitis, along with aggressive catheter-directed necrosectomy can avoid surgical interventions, and improve outcome in a significant proportion of patients with acute necrotizing pancreatitis.

Endoscopic Management of Peri-Pancreatic Fluid Collections

In the past decade, there has been a progressive paradigm shift in the management of peri-pancreatic fluid collections after acute pancreatitis. Refinements in the definitions of fluid collections from the updated Atlanta classification have enabled better communication amongst physicians in an effort to formulate optimal treatments. Endoscopic ultrasound (EUS)-guided drainage of pancreatic pseudocysts has emerged as the procedure of choice over surgical cystogastrostomy. The approach provides similar success rates with low complications and better quality of life compared with surgery. However, an endoscopic "step up" approach in the management of pancreatic walled-off necrosis has also been advocated. Both endoscopic and percutaneous drainage routes may be used depending on the anatomical location of the collections. New-generation large diameter EUS-specific stent systems have also recently been described. The device allows precise and effective drainage of the collections and permits endoscopic necrosectomy through the stents.

[The treatment of acute secondary peritonitis : A retrospective analysis of the use of continuous negative pressure therapy]

BACKGROUND

Patients with acute secondary peritonitis often need relaparotomies and open abdominal lavages. Continuous negative pressure therapy seems to be beneficial.

OBJECTIVES

Does the efficacy of the therapy depend on the continuous negative pressure system used?

MATERIALS AND METHODS

A retrospective analysis was performed in the Chirurgische Klinik der Universitätsmedizin Berlin, Charité Campus Mitte, including all patients who underwent abdominal vacuum therapy between December 2013 and February 2015. Two different systems (ABThera®, KCI Medizinprodukte GmbH and Suprasorb® CNP Drainagefolie, Lohmann & Rauscher GmbH) were available for treatment.

RESULTS

During the 14 month study period, 33 patients with acute secondary peritonitis were treated with abdominal negative pressure therapy. Vacuum therapy treatment was applied for a median of 4 days (range 0-22 days). Eight patients (24%) died during hospitalisation. After completion of intraabdominal vacuum therapy, direct fascial closure was feasible in 26 patients (79%). There were no differences concerning patient characteristics, duration of abdominal vacuum therapy, the possibility of direct fascial closure or morbidity and mortality with the two different systems used.

CONCLUSIONS

Acute secondary peritonitis is associated with high morbidity. We achieved a lower mortality rate compared to prospective clinical trials using intraabdominal continuous negative pressure therapy. The effectiveness and cost efficiency of different therapy systems should be the topic of further research.

Role of bedside pancreatic scores and C-reactive protein in predicting pancreatic fluid collections and necrosis

BACKGROUND

Acute pancreatitis is a disease with variable outcome; the course of the disease can be modified by early aggressive management in patients with severe pancreatitis. Easily calculable pancreatic scores and investigations can help to triage these patients. We aimed to determine the role of bedside index for severity in acute pancreatitis (BISAP), harmless acute pancreatitis score (HAPS), and systemic inflammatory response syndrome (SIRS) scores on day of admission and C-reactive protein (CRP) at 48 h for predicting the presence of pancreatic fluid collection (PFC) and necrosis on CT scans done at 72 h.

METHODS

Of a total of 114 consecutively seen patients of pancreatitis, 64 with acute pancreatitis were enrolled in the study. All individuals had the pancreatitis predicting scores calculated at the time of admission, CRP at 48 h, and contrast-enhanced computed tomography (CECT) abdomen at 72 h from admission.

RESULTS

The study population of 64 (55 male) had a mean (+SD) age of 37.7 ± 13 years. Alcohol was the most common (68.8%) etiology in these patients. Based on CECT, patients were divided into 2 groups; group 1 with 41 patients who had mild pancreatitis and group 2 with 23 patients who had pancreatic fluid collection with or without necrosis (PFCN). PFCN were seen in 19 (29.7%) of patients with 2 or more SIRS criteria, 17 (26.6%) of patients with BISAP score ≥3, and 16 patients (25.0%) with HAPS >0 respectively. All three scores were able to predict PFCN significantly. CRP >150 mg/L was noted in 23 patients and was able to predict the presence of fluid collections (p=0.0002) and pancreatic necrosis (p = 0.0004) on CT.

CONCLUSION

BISAP, HAPS, and SIRS scores and CRP of 150 mg/L all correlated significantly with the occurrence of fluid collections and pancreatic necrosis on CT at 72 h. None of the scores was superior to the other in this respect.

Clinical Value of Severity Markers in Acute Pancreatitis

Acute pancreatitis is a common digestive disease of which the severity may vary from mild, edematous to severe, necrotizing disease. An improved outcome in the severe form of the disease is based on early identification of disease severity and subsequent focused management of these high-risk patients. However, the ability of clinicians to predict, upon presentation, which patient will have mild or severe acute pancreatitis is not accurate. Prospective systems using clinical criteria have been used to determine severity in patients with acute pancreatitis, such as the Ranson's prognostic signs, Glasgow score, and the acute physiology and chronic health evaluation II score (APACHE II). Their application in clinical practise has been limited by the time delay of at least 48 h to judge all parameters in the former two and by being cumbersome and time-consuming in the latter. Contrast-enhanced computed tomography is presently the most accurate non-invasive single method to evaluate the severity of acute pancreatitis. It cannot, however, be performed to all patients with acute pancreatitis. Therefore, considerable interest has grown in the development of reliable biochemical markers that reflect the severity of acute pancreatitis. In this article we critically appraise current and new severity markers of acute pancreatitis in their ability to distinguish between mild and severe disease and their clinical utility.

Infection increases mortality in necrotizing pancreatitis: A systematic review and meta-analysis

OBJECTIVES

To assess the influence of infection on mortality in necrotizing pancreatitis.

METHODS

Eligible prospective and retrospective studies were identified through manual and electronic searches (August 2015). The risk of bias was assessed using the Newcastle-Ottawa Scale (NOS). Meta-analyses were performed with subgroup, sensitivity, and meta-regression analyses to evaluate sources of heterogeneity.

RESULTS

We included 71 studies (n = 6970 patients). Thirty-seven (52%) studies used a prospective design and 25 scored ≥5 points on the NOS suggesting a low risk of bias. Forty studies were descriptive and 31 studies evaluated invasive interventions. In total, 801 of 2842 patients (28%) with infected necroses and 537 of 4128 patients (13%) with sterile necroses died with an odds ratio [OR] of 2.57 (95% confidence interval [CI], 2.00-3.31) based on all studies and 2.02 (95%CI, 1.61-2.53) in the studies with the lowest bias risk. The OR for prospective studies was 2.96 (95%CI, 2.51-3.50). In sensitivity analyses excluding studies evaluating invasive interventions, the OR was 3.30 (95%CI, 2.81-3.88). Patients with infected necrosis and organ failure had a mortality of 35.2% while concomitant sterile necrosis and organ failure was associated with a mortality of 19.8%. If the patients had infected necrosis without organ failure the mortality was 1.4%.

CONCLUSIONS

Patients with necrotizing pancreatitis are more than twice as likely to die if the necrosis becomes infected. Both organ failure and infected necrosis increase mortality in necrotizing pancreatitis.

Recognition and Importance of New Definitions of Peripancreatic Fluid Collections in Managing Patients with Acute Pancreatitis

Our understanding of the etiopathogenesis of acute pancreatitis has matured tremendously in the last 3 decades. Advanced cross-sectional imaging with 3-dimensional techniques along with use of intravenous contrast to image the presence or absence of organ tissue perfusion has allowed early recognition of necrotizing pancreatitis. With this knowledge, the old terms to describe what used to be called 'peri-pancreatic fluid collections' we now recognize are no longer accurate nor appropriate. The 2013 revised Atlanta Classification has introduced a new, accurate, objective classification of acute pancreatitis and terminology for the natural history of all forms of acute pancreatitis that is easy to use and will help in both the description of the disease and its appropriate treatment. This review will describe these pancreatic and peri-pancreatic collections with added insight into their natural history.

Role of liver in modulating the release of inflammatory cytokines involved in lung and multiple organ dysfunction in severe acute pancreatitis

The objective of this study was to understand the role of liver in modulating remote organ dysfunction during severe acute pancreatitis (SAP). We used sodium taurocholate and endotoxin to induce SAP in the rats and confirmed the development of this condition by measuring serum and ascite levels of the biomarkers of liver and lung damage. Our results showed that expression of tumor necrosis factor (TNF)-α was up-regulated sequentially, first in the gut, then in the liver, and finally in lung. Moreover, the SAP-induced increase in the expressions of TNF-α and IL-6 occurring in gut, liver, and lung was directly related to the increase in time. However, in liver and lung, the transcriptional activity of NF-κB and expression of TNF-α at 4 and 8 h were not increased. The distribution sequence of the pro-inflammatory cytokines to various organs was determined by their detection in the blood from portal vein and inferior vena cava. Although liver received TNF-α during 0.5-8 h of the SAP induction, the release of this cytokine into vena cava was not increased in this period of time. In conclusion, our results suggest that the aggravation of SAP leading to development of MODS exhibited the gut-liver-lung cytokine axis. Furthermore, this study indicates that liver performs both protective and stimulatory activities in the modulation of pro-inflammatory cytokine generation and their distribution to remote organs, such as lungs.

Laparoscopic necrosectomy in acute necrotizing pancreatitis: Our experience

CONTEXT:

Pancreatic necrosis is a local complication of acute pancreatitis. The development of secondary infection in pancreatic necrosis is associated with increased mortality. Pancreatic necrosectomy is the mainstay of invasive management.

AIMS:

Surgical approach has significantly changed in the last several years with the advent of enhanced imaging techniques and minimally invasive surgery. However, there have been only a few case series related to laparoscopic approach, reported in literature to date. Herein, we present our experience with laparoscopic management of pancreatic necrosis in 28 patients.

MATERIALS AND METHODS:

A retrospective study of 28 cases [20 men, 8 women] was carried out in our institution. The medical record of these patients including history, clinical examination, investigations, and operative notes were reviewed. The mean age was 47.8 years [range, 23-70 years]. Twenty-one patients were managed by transgastrocolic, four patients by transgastric, two patients by intra-cavitary, and one patient by transmesocolic approach.

RESULTS:

The mean operating time was 100.8 min [range, 60-120 min]. The duration of hospital stay after the procedure was 10-18 days. Two cases were converted to open (7.1%) because of extensive dense adhesions. Pancreatic fistula was the most common complication (n = 8; 28.6%) followed by recollection (n = 3; 10.7%) and wound infection (n = 3; 10.7%). One patient [3.6%] died in postoperative period.

CONCLUSIONS:

Laparoscopic pancreatic necrosectomy is a promising and safe approach with all the benefits of minimally invasive surgery and is found to have reduced incidence of major complications and mortality.

Planned re-laparotomy and the need for optimization of physiology and immunology

Planned re-laparotomy or damage control laparotomy (DCL), first described by Dr. Harlan Stone in 1983, has become a widely utilized technique in a broad range of patients and operative situations. Studies have validated the use of DCL by demonstrating decreased mortality and morbidity in trauma, general surgery and abdominal vascular catastrophes. Indications for planned re-laparotomy include severe physiologic derangements, coagulopathy, concern for bowel ischemia, and abdominal compartment syndrome. The immunology of DCL patients is not well described in humans, but promising animal studies suggest a benefit from the open abdomen (OA) and several human trials on this subject are currently underway. Optimal critical care of patients with OA's, including sedation, paralysis, nutrition, antimicrobial and fluid management strategies have been associated with improved closure rates and recovery.

Endoscopic approach to pancreatic pseudocyst, abscess and necrosis: review on recent progress

AIM

The aim of this study is to introduce recent progress in the treatment of pancreatic pseudocyst, abscess and necrosis using the endoscopic approach.

METHODS

Studies on PubMed and MEDLINE from the last 30 years on progress in the management of the complications from severe pancreatitis were researched and reviewed. Herein, the indication for intervention, definition of fluid collection associated with acute pancreatitis and treatment modalities of these complications are summarized.

RESULTS

Three types of management are employed for complications of severe pancreatitis: the endoscopic, surgical and percutaneous approaches.

CONCLUSIONS

Over the years, as technical expertise has increased and instruments for endoscopy have improved, patients who had endoscopic surgery to address the complications of severe pancreatitis have had higher survival rates, lower mortality rates and lower complication rates than those having open debridement. However, traditional open abdominal surgery should be advocated when minimally invasive management fails or necrosis is extensive and extends diffusely to areas such as the paracolic gutter and the groin (i.e. locations not accessible by endoscopy).

Treatment of Pancreatic Abscess with Endoscopic Ultrasound-guided Placement of a Covered Metal Stent Following Failed Balloon Dilation and Endoscopic Necrosectomy

For the management of pancreatic abscess, endoscopic ultrasound (EUS)-guided puncture and drainage has become recognized as a safer and more effective alternative to surgery. Typically, a double-pigtail plastic stent is placed for drainage. When an abscess is complicated by infected necrosis, endoscopic evacuation is essential. However, endoscopic evacuation carries a high risk of hemorrhage and needs to be performed daily to be effective. We describe EUS-guided endoscopic evacuation and placement of a fully covered metal stent following two failed evacuations. Patient recovery time was excellent, and no complications occurred.

Surgical strategies for management of the open abdomen

Since the mid-1990s the surgical community has seen a surge in the prevalence of open abdomens (OAs) reported in the surgical literature and in clinical practice. The OA has proven to be effective in decreasing mortality and immediate postoperative complications; however, it may come at the cost of delayed morbidity and the need for further surgical procedures. Indications for leaving the abdomen open have broadened to include damage control surgery, abdominal compartment syndrome, and abdominal sepsis. The surgical options for management of the OA are now more diverse and sophisticated, but there is a lack of prospective randomized controlled trials demonstrating the superiority of any particular method. Additionally, critical care strategies for optimization of the patient with an OA are still being developed. Review of the literature suggests a bimodal distribution of primary closure rates, with early closure dependent on postoperative intensive care management and delayed closure more affected by the choice of the temporary abdominal closure technique. Invariably, a small fraction of patients requiring OA management fail to have primary fascial closure and require some form of biologic fascial bridge with delayed ventral hernia repair in the future.

Nutrition and the open abdomen

Adequate nutrition support is critical in the management of patients with an open abdomen. Despite the literature supporting its use in trauma patients, provider concerns and clinical controversies remain regarding the early administration and long-term sequelae of enteral nutrition (EN) therapy in these patients. The purpose of this article is to review the clinical concepts behind the use of the open abdomen, as well as examine the altered nutrition requirements associated with the maintenance of a temporary laparostomy. The rationale for early EN is described, as well as the pros and cons surrounding the use of supplemental parenteral nutrition in those patients unable to meet nutrition goals enterally in a reasonable time frame. Finally, an open abdomen nutrition support algorithm is provided as part of the critical care plan in these patients who represent the sickest of surgical patients.

[Pancreatic necrosis: pro surgical therapy]

Currently, patients with severe necrotizing pancreatitis rarely need interventional or surgical treatment. However, in case of pancreatic infection and septic complications they should be treated with the step up approach, primarily with an interventional or endoscopic drainage. If further clinical deterioration occurs necrosectomy is indicated. This should ideally be postponed until the third or fourth week after onset of pancreatitis to optimize surgical conditions including demarcation of the necrosis. Open necrosectomy with postoperative continuous lavage is a valid treatment option with low mortality, low morbidity and good long-term outcome. In recent years, several minimally invasive techniques for necrosectomy have been developed and are alternative approaches in about 70% of cases. In most cases, the retroperitoneoscopic approach is used, although the endoscopic transgastric route is also being used more and more frequently. While the reduced operative trauma should theoretically also reduce the onset of postoperative organ failure, no study has actually proven this.

Minimally invasive retroperitoneal pancreatic necrosectomy

INTRODUCTION

This article describes a case series outlining the experience and results of the retroperitoneal minimally invasive pancreatic necrosectomy (MIPN) procedure performed by, or done under the supervision of, a single surgeon.

METHODS

All data of the patients who underwent MIPN from 2006 to 2008 were entered into a prospectively maintained, computerized database.

RESULTS

A total of 93 MIPN procedures were performed on 32 patients. All patients had severe acute pancreatitis. The median number of MIPN procedures per patient was 3. Only 6 patients needed intensive care unit (ICU) admission after MIPN. There were 15 complications, which included bleeding requiring transfusion (n = 3), bowel fistulae (n = 7), thromboembolic events (n = 2) and acute myocardial infarction (n = 3). Four patients died after the procedure (13%); 1 died of ongoing multiorgan failure in spite of the MIPN. Four patients developed pancreatic pseudocysts within the follow-up period of 2 years. Three of these patients required intervention.

CONCLUSION

This case series demonstrates that MIPN can be performed with acceptable morbidity and mortality and with good end results. The ICU dependency after the procedure is minimal. As seen in this series, multiple MIPNs may be needed to eradicate the necrosis satisfactorily. and IAP.

Analysis of the delayed approach to the management of infected pancreatic necrosis

AIM: To analyze outcomes of delayed single-stage necrosectomy after early conservative management of patients with infected pancreatic necrosis (IPN) associated with severe acute pancreatitis (SAP).

METHODS: Between January 1998 and December 2009, data from patients with SAP who developed IPN and were managed by pancreatic necrosectomy were analyzed.

RESULTS: Fifty-nine of 61 pancreatic necrosectomies were performed by open surgery and 2 laparoscopically. In 55 patients, single-stage necrosectomy could be performed (90.2%). Patients underwent surgery at a median of 29 d (range 13-46 d) after diagnosis of acute pancreatitis. Sepsis and multiple organ failure accounted for the 9.8% mortality rate. Pancreatic fistulae (50.8%) predominantly accounted for the morbidity. The median hospital stay was 23 d, and the median interval for return to regular activities was 110 d.

CONCLUSION: This series supports the concept of delayed single-stage open pancreatic necrosectomy for IPN. Advances in critical care, antibiotics and interventional radiology have played complementary role in improving the outcomes.

The management of the open abdomen in trauma and emergency general surgery: part 1-damage control

BACKGROUND

The open abdomen technique, after both military and civilian trauma, emergency general or vascular surgery, has been used in some form for the past 30 years. There have been several hundred citations on the indications and the management of the open abdomen. Eastern Association for the Surgery of Trauma practice management committee convened a study group to organize the world's literature for the management of the open abdomen. This effort was divided into two parts: damage control and the management of the open abdomen. Only damage control is presented in this study. Part 1 is divided into indications for the open abdomen, temporary abdominal closure, staged abdominal repair, and nutrition support of the open abdomen.

METHODS

A literature review was performed for more than 30 years. Prospective and retrospective studies were included. The reviews and case reports were excluded. Of 1,200 articles, 95 were selected. Seventeen surgeons reviewed the articles with four defined criteria. The Eastern Association for the Surgery of Trauma primer was used to grade the evidence.

RESULTS

There was only one level I recommendation. A patient with documented abdominal compartment syndrome should undergo decompressive laparotomy.

CONCLUSION

The open abdomen technique remains a heroic maneuver in the care of the critically ill trauma or surgical patient. For the best outcomes, a protocol for the indications, temporary abdominal closure, staged abdominal reconstruction, and nutrition support should be in place.

Minimal access retroperitoneal pancreatic necrosectomy: improvement in morbidity and mortality with a less invasive approach

OBJECTIVE

Comparison of minimal access retroperitoneal pancreatic necrosectomy (MARPN) versus open necrosectomy in the treatment of infected or nonresolving pancreatic necrosis.

SUMMARY OF BACKGROUND DATA

Infected pancreatic necrosis may lead to progressive organ failure and death. Minimal access techniques have been developed in an attempt to reduce the high mortality of open necrosectomy.

METHODS

This was a retrospective analysis on a prospective data base comprising 189 consecutive patients undergoing MARPN or open necrosectomy (August 1997 to September 2008). Outcome measures included total and postoperative ICU and hospital stays, organ dysfunction, complications and mortality using an intention to treat analysis.

RESULTS

Overall 137 patients underwent MARPN versus open necrosectomy in 52. Median (range) age of the patients was 57.5 (18-85) years; 118 (62%) were male. A total of 131 (69%) patients were tertiary referrals, with a median time to transfer from index hospital of 19 (2-76) days. Etiology was gallstones or alcohol in 129 cases (68%); 98 of 168 (58%) patients had a positive culture at the first procedure. Of the 137 patients, 34 (31%) had postoperative organ failure in the MARPN group, and 39 of 52 (56%) in the open group (P<0.0001); 59/137 (43%) versus 40/52 (77%), respectively, required postoperative ICU support (P<0.0001). Of the 137 patients 75 (55%) had complications in the MARPN group and 42 of 52 (81%) in the open group (P=0.001). There were 26 (19%) deaths in the MARPN group and 20 (38%) following open procedure (P=0.009). Age (P<0.0001), preoperative multiorgan failure (P<0.0001), and surgical procedure (MARPN, P=0.016) were independent predictors of mortality.

CONCLUSION

This study has shown significant benefits for a minimal access approach including fewer complications and deaths compared with open necrosectomy.

Recent developments in acute pancreatitis

The incidence of acute pancreatitis (AP) has been increasing worldwide, but the major etiologies remain gallstones and alcohol. Several studies have reported that smoking is an independent risk factor for developing AP. Classification of AP has traditionally used the categories of mild and severe disease. However, a new intermediate category of moderately severe AP has been described with intermediate characteristics including a high incidence of local complications but a low mortality. Assessment criteria that can serve as early predictors of AP severity are often complex and not sufficiently accurate. However, several recently described criteria that rely on criteria such as the body mass index, physical findings, and simple laboratory measurements could prove useful if validated in large prospective studies. Many issues related to the therapy of AP are still unresolved. Although preliminary studies support the importance of early volume expansion for the treatment of acute pancreatitis, optimization of the amount and type of fluids will require further studies. Similarly, preliminary studies suggest that enteral nutrition might benefit patients with AP and could even be useful early in the course of disease. However, the timing and type of fluids as well as the intestinal infusion site require further study. Finally, issues related to the prophylactic use of antibiotics in patients with severe AP have not been resolved. While the process of clinical investigation moves slowly, progress has been made in clinical studies of AP.

Acute pancreatitis: risk of recurrence and late consequences of the disease

Research into the clinical management of acute pancreatitis has primarily focused on the immediate complications of the disease, whereas its late consequences have received less attention. These late sequelae of acute pancreatitis refer to complications that arise after the convalescence period, which lasts for 3-6 months after the initial episode. In patients who do not undergo necrosectomy that involves removal of the exocrine gland, pancreatic exocrine function usually improves rather than deteriorates during follow-up. By contrast, glucose intolerance is likely to worsen over time in all patients with acute pancreatitis. Despite the risk of late complications for patients with acute pancreatitis, their long-term quality of life is usually good. The number of pancreatitis episodes a patient has experienced is an important factor that determines the severity of late complications of acute pancreatitis. Risk factors for the recurrence of acute pancreatitis episodes have now been identified. This Review focuses on data from studies that investigated the risk factors for recurrent attacks of acute pancreatitis, and discusses the late consequences of this disease.

Infected necrosis in severe pancreatitis--combined nonsurgical multi-drainage with directed transabdominal high-volume lavage in critically ill patients

BACKGROUND

Infection of pancreatic necrosis is a life-threatening complication during the course of acute pancreatitis. In critically ill patients, surgical or extended endoscopic interventions are associated with high morbidity and mortality. Minimally invasive procedures on the other hand are often insufficient in patients suffering from large necrotic areas containing solid or purulent material. We present a strategy combining percutaneous and transgastric drainage with continuous high-volume lavage for treatment of extended necroses and liquid collections in a series of patients with severe acute pancreatitis.

PATIENTS AND METHODS

Seven consecutive patients with severe acute pancreatitis and large confluent infected pancreatic necrosis were enrolled. In all cases, the first therapeutic procedure was placement of a CT-guided drainage catheter into the fluid collection surrounding peripancreatic necrosis. Thereafter, a second endosonographically guided drainage was inserted via the gastric or the duodenal wall. After communication between the separate drains had been proven, an external to internal directed high-volume lavage with a daily volume of 500 ml up to 2,000 ml was started.

RESULTS

In all patients, pancreatic necrosis/liquid collections could be resolved completely by the presented regime. No patient died in the course of our study. After initiation of the directed high-volume lavage, there was a significant clinical improvement in all patients. Double drainage was performed for a median of 101 days, high-volume lavage for a median of 41 days. Several endoscopic interventions for stent replacement were required (median 8). Complications such as bleeding or perforation could be managed endoscopically, and no subsequent surgical therapy was necessary. All patients could be dismissed from the hospital after a median duration of 78 days.

CONCLUSION

This approach of combined percutaneous/endoscopic drainage with high-volume lavage shows promising results in critically ill patients with extended infected pancreatic necrosis and high risk of surgical intervention. Neither surgical nor endoscopic necrosectomy was necessary in any of our patients.

Endoscopic necrosectomy of organized pancreatic necrosis: a currently practiced NOTES procedure

BACKGROUND

Endoscopic necrosectomy is now an established minimally invasive method for treatment of organized pancreatic necrosis.

METHODS

Review of methods and results of endoscopic treatment of pancreatic necrosis.

RESULTS

Reports by multiple groups have demonstrated favorable results of endoscopic necrosectomy. The mortality of critically ill patients undergoing endoscopic treatment in several series is approximately 10%. Some patients will eventually also require surgery for situations such as complete pancreatic duct disruption, but even in these cases endoscopic necrosectomy is useful because pancreatic surgery can often be delayed until the patient is stable.

CONCLUSIONS

Endoscopic necrosectomy will likely assume an increasing role in the treatment of pancreatic necrosis. This should result in reduced morbidity and mortality in these critically ill patients.

Use of recombinant factor VIIa in the treatment of massive retroperitoneal bleeding due to severe necrotizing pancreatitis

Background. Recently, a growing number of case reports and case series have suggested that the use of recombinant activated factor VII (rFVIIa) may be effective in treatment of patients with non-hemophilic acquired coagulopathy not responding to conventional treatment such as major surgery, major trauma, sepsis, necrotizing pancreatitis and bleeding due to cerebral arteriovenous malformations. Case report. We presented a septic patient with massive, lifethreatening bleeding caused by retroperitoneal necrosis, due to severe acute necrotizing pancreatitis. As conservative treatment (blood, plasma, cryoprecipitates and platelet transfusions) failed to induce cessation of bleeding, the patient was urgently operated on. In spite of usual procedures of surgical hemostasis (ligation, suture, thermocauterisation, fibrin glue, temporary tamponade), hemorrhage could not be stopped. The patient manifested the signs of hypothermia and metabolic acidosis and, therefore, the decision was made to use recombinant activated factor VII (Novo Seven?). The application of rFVIIa resulted in significant discontinuation of hemorrhage, restoration to normal blood count as well as other relevant coagulation parameters. Conclusion. Although application of rFVIIa is still in the initial clinical phase, and the experience is based mainly on uncontrolled series as well as on individual observations, it seems that this drug can be promising, potent and attractive adjunctive prohemostatic agent. This drug may play a beneficial role in the treatment of serious and unresponsive, 'nonsurgical', life-threatening bleeding due to severe acute necrotizing pancreatitis.

Management and Spectrum of Complications in Patients Undergoing Surgical Debridement for Pancreatic Necrosis

Patients who undergo pancreatic necrosectomy frequently develop complications and often have high mortality rates. These patients are best cared for at specialized centers to minimize morbidity, manage complex complications, and reduce mortality. We present a review of our experience and describe the spectrum of complications encountered in managing of these difficult patients. A registry of patients undergoing pancreatic necrosectomy during a 7-year period was analyzed for preoperative clinical scoring systems (Acute Physiology and Chronic Health Evaluation [APACHE] II and APACHE III scores), patient characteristics related to necrosectomy, and morbidity and mortality. Twenty-nine patients underwent necrosectomy. Indications for surgery were consistent with those previously described. There were 27 complications in 22 patients. Sixteen complications were early (less than 3 weeks after surgery) and 14 were late. The mortality rate was 14 per cent. All deaths were in patients transferred from outside institutions, some after extended time periods. Temporary percutaneous catheter drainage of abscesses before transfer and definitive surgery appeared to reduce mortality in transferred patients. There was a statistically significant correlation between mean maximal preoperative APACHE III score, but not APACHE II score, and the number of postoperative intensive care unit days (rho = 0.52, P = 0.004). We describe our experience managing patients with infected pancreatic necrosis that required operative necrosectomy. We found that more severely ill patients (higher APACHE III scores) had longer intensive care unit stays, but the initial severity of their illness did not increase mortality. If patients with infected pancreatic necrosis are referred to specialized centers, preoperative pre-transfer percutaneous drainage may serve to temporarily control sepsis.

Endoscopic necrosectomy as primary treatment for infected peripancreatic fluid collections (with video)

BACKGROUND

The success of endoscopic intervention in the management of uncomplicated pancreatic pseudocysts has allowed endoscopists to be more aggressive in managing complicated pancreatic fluid collections. Surgery is considered the mainstay of therapy once pancreatic abscesses develop. As a second-line treatment, endoscopic drainage of pancreatic abscess has been performed in those who are not candidates for surgery.

OBJECTIVE

Our purpose was to report our experience with single-session endoscopic necrosectomy and drainage as the primary mode of treatment of infected pancreatic necrosis or abscesses.

DESIGN

This was a case series.

SETTING

A single endoscopy unit based at a university medical center.

PATIENTS

Six consecutive patients who underwent endoscopic necrosectomy as the primary treatment modality for pancreatic abscess or necrosis between May 2006 and February 2007.

MAIN OUTCOME MEASUREMENTS

Resolution of the infected pancreatic fluid collection and avoidance of surgery.

RESULTS

Successful single-session endoscopic necrosectomy was performed in all 6 patients with impressive and immediate symptom relief. None needed surgery or other endoscopic or percutaneous interventions. Patients were discharged from the hospital in a median of 8.5 days. Complete resolution of pancreatic lesions were noted in 5 of 6 patients (1 patient had a small residual cyst) in median follow-up of 3.5 months (range 3-11 months).

CONCLUSIONS

Endoscopic necrosectomy can be performed safely and efficiently for the primary treatment of pancreatic necrosis and abscess. Our data suggest that aggressive single-session necrosectomy can be adequate for the complete removal of infected and necrotic debris.

In situ high-volume modified continuous closed and/or open lavage for infected necrotizing pancreatitis

OBJECTIVES

To evaluate the clinical significance of high-volume modified continuous closed and/or open lavage for the treatment of infected necrotizing pancreatitis.

METHODS

From August 1997 to December 2006, 53 patients with infected necrotizing pancreatitis who underwent in situ high-volume (>20 L/d) continuous closed lavage using a single-lumen rubber catheter and/or open lavage were retrospectively studied in our hospital, and the advantages of this new technique were analyzed.

RESULTS

Modified continuous closed lavage was the initial treatment for all patients; in 6 patients with secondary retroperitoneal sepsis or abscess, continuous open lavage was performed. Impaired tube patency and lavage fluid retention did not occur in any of these patients. The overall mortality was 17.0% (9/53). Twelve patients underwent early surgery, and 5 (41.7%) died; 41 patients underwent delayed surgery, and 4 (9.8%) died. Significant local complications occurred in 14 patients (26.4%); the incidence of bleeding, abscess, and fistula was 13.2% (7/53), 9.4% (5/53), and 9.4% (5/53), respectively.

CONCLUSIONS

Our technique of in situ high-volume modified continuous closed and/or open lavage has produced a better control of infected necrotizing pancreatitis.

Characterization of newer subgroups of fulminant and subfulminant pancreatitis associated with a high early mortality

BACKGROUND

Risk stratification of acute pancreatitis (AP) is important.

OBJECTIVE

To characterize patients with early severe pancreatitis, identify risk factors of severity, and assess their outcome.

METHODS

All consecutive patients with AP were included in the study. Severity assessment was done by APACHE II score, and presence and intensity of organ failure (OF). OF was graded from 1 to 4. Patients with severe pancreatitis were divided into early severe and late severe AP. The criterion for early severe AP (ESAP) was severe OF within 7 days of pancreatitis. Patients with ESAP were subdivided into fulminant and subfulminant AP based on timing of OF, i.e., <72 h and between 4 and 7 days of pancreatitis, respectively.

RESULTS

Of 282 patients with AP, 144 (51%) had mild AP, 32 (11.34%) had ESAP, and 106 (37.58%) had late severe AP. Of the ESAP patients (mean age 45.4 yr, 22 men), 10 patients had fulminant AP and 22 had subfulminant AP. Patients with ESAP had higher admission APACHE II compared to patients with late severe AP (14.9 vs 8.8, P<0.001). The proportion of patients with multiorgan failure was significantly higher in ESAP compared with late severe AP (75%vs 26%, P<0.001). The difference in mortality was significant in the fulminant, subfulminant, and late severe AP (90%, 72.7%, and 30%; P<0.001). Patients with ESAP accounted for 44% of all deaths. Predictors of mortality were development and early onset of organ failure.

CONCLUSIONS

We have characterized newer subgroups of patients with fulminant and subfulminant AP with important prognostic and management implications.

Combined anterior and posterior open treatment in infected pancreatic necrosis

OBJECTIVE

To compare the results of combined anterior and posterior open treatments (lesser sac marsupialization (LSM) + lumbostomy, LSM + L) in patients with infected pancreatic necrosis (IPN) with a previous experience of isolated LSM and with data in literature.

MATERIALS AND METHODS

Thirty-four consecutive patients operated on for IPN from 1981 to 2005 were divided into two groups based on the surgical technique used: single LSM (n = 23; period A, 1981-1998) and combined LSM + L (n = 11; period B, 1999-2005).

RESULTS

The postoperative mortality rate was 38.1 (n = 8) and 9% (n = 1) during period A and B, respectively. The most important cause of death was recurrent or persistent sepsis with multiple organ failure. The overall postoperative surgical morbidity was 57 (n = 13) and 27.2% (n = 3) in the two consecutive groups.

CONCLUSIONS

IPN is a challenging condition associated with high mortality mainly because of a persistence of sepsis despite surgery. A comparative analysis of many proposed operative procedures is difficult because of the heterogeneity in the reported series. Open approaches seem to be more effective in controlling local infection and systemic sepsis. Combining open anterior and posterior approaches is in our experience an appropriate surgical treatment in IPN patients.

[Abdominal vacuum device with open abdomen]

BACKGROUND

For the treatment of peritonitis or abdominal compartment syndrome, an open abdomen can be required. Because of the high complication rate associated with this method, different technical modifications were developed that are now being applied. Abdominal vacuum-assisted closure is increasingly favoured. We analyse our experience with this device in a distinct group of patients from gastrointestinal cancer surgery.

PATIENTS AND METHOD

From June 2003 to December 2005, 36 patients were treated with 151 double-layer abdominal vacuum devices. Indications for applying this device were peritonitis (n = 22), abdominal compartment syndrome (n = 11), and necrotising fasciitis (n = 3). Thirty-four patients gave anamneses of malignoma.

RESULTS

Overall, the vacuum therapy treatment lasted a median of 13 days (range 3-48). With it, four enteric fistulas (11%) and four abdominal wall bleedings (11%) occurred. In our patient group, no new intra-abdominal abscesses were observed. Four patients died during treatment with the vacuum-assisted device and four afterward because of multiple organ failure in acute sepsis (in-hospital mortality 22%). Twenty-six patients (72%) underwent direct fascial closure after a median treatment duration of 10 days. Six patients (17%) required synthetic mesh for fascial closure. After a median follow-up of 100 days, two patients developed ventral hernias and two others showed ossification of the scar.

CONCLUSION

Compared with other methods of temporary abdominal closure, our experience with the vacuum-assisted device demonstrates its advantages concerning clinical feasibility and the relatively low complication rate. The high rate of direct fascial closure with an acceptable rate of ventral hernias following vacuum-assisted abdominal closure are further benefits of this technique.

Prevention of infectious complications in severe acute pancreatitis with systemic antibiotics: where are we now?

Infectious complications are the leading cause of death in patients with severe acute pancreatitis. Currently, there is controversy concerning the therapeutic possibilities to reduce the incidence of bacterial infection in this disease. Numerous studies are available which apparently support the prophylactic use of antibiotics in patients with necrotizing pancreatitis. The results, however, are contradicting and interpretation is difficult as these studies have used various antibiotic drugs with different application schemes and heterogeneous study end points. This article gives a critical overview of the background of antibiotic treatment in severe acute pancreatitis, the published data on antibiotic treatment and an outlook on the topics that need to be addressed by future research.

Evidence-based treatment of acute pancreatitis: a look at established paradigms

BACKGROUND

The management of acute pancreatitis (AP) is still based on speculative and unproven paradigms in many centers. Therefore, we performed an evidence-based analysis to assess the best available treatment.

METHODS

A comprehensive Medline and Cochrane Library search was performed evaluating the indication and timing of interventional and surgical approaches, and the value of aprotinin, lexipafant, gabexate mesylate, and octreotide treatment. Each study was ranked according to the evidence-based methodology of Sackett; whenever feasible, we performed new meta-analyses using the random-effects model. Recommendations were based on the available level of evidence (A=large randomized; B=small randomized; C=prospective trial).

RESULTS

None of the evaluated medical treatments is recommended (level A). Patients with AP should receive early enteral nutrition (level B). While mild biliary AP is best treated by primary cholecystectomy (level B), patients with severe biliary AP require emergency endoscopic papillotomy followed by interval cholecystectomy (level A). Patients with necrotizing AP should receive imipenem or meropenem prophylaxis to decrease the risk of infected necrosis and mortality (level A). Sterile necrosis per se is not an indication for surgery (level C), and not all patients with infected necrosis require immediate surgery (level B). In general, early necrosectomy should be avoided (level B), and single necrosectomy with postoperative lavage should be preferred over "open-packing" because of fewer complications with comparable mortality rates (level C).

CONCLUSIONS

While providing new insights into key aspects of AP management, this evidence-based analysis highlights the need for further clinical trials, particularly regarding the indications for antibiotic prophylaxis and surgery.

Planned Staged Reoperative Necrosectomy Using an Abdominal Zipper in the Treatment of Necrotizing Pancreatitis

PURPOSE

The optimal operative treatment for severe necrotizing pancreatitis (SNP) still remains controversial. This article describes the operative approach with a planned staged necrosectomy using the "zipper" technique.

METHODS

Between 1996 and 2000, 35 patients with SNP were treated with this approach. The patient demographics, etiology and severity of SNP, hospital course, and outcome were recorded and comparisons of several parameters were made between the patients who survived and those who died.

RESULTS

Hospital mortality was 34%. A total of 16 fistulae developed in 11 patients (31%), recurrent intra-abdominal abscesses in 4 (11%), and hemorrhaging in 5 (14%). The patients who died compared with those who survived had a higher Acute Physiology and Chronic Health Evaluation (APACHE)-II score on admission (14.5 vs 9, P < 0.001), extrapancreatic extension of necrosis more often (100% vs 65%, P = 0.02), and developed postoperative hemorrhaging more often (33% vs 4%, P = 0.038). A multivariate logistic analysis revealed an APACHE-II score of > 13 on admission (P = 0.018) and an extension of necrosis behind both paracolic gutters (P < 0.001) to both be prognostic factors for mortality.

CONCLUSIONS

Severe necrotizing pancreatitis still carries significant morbidity and mortality. This surgical approach facilitates the removal of all devitalized tissue and seems to decrease the incidence of recurrent intra-abdominal infection requiring reoperation. An APACHE-II score of > or = 13 and an extension of necrosis behind both paracolic gutters was thus found to signify a worse outcome.

Surgical treatment of necrotizing pancreatitis by necrosectomy and closed lavage: changing patient characteristics and outcome in a 19-year, single-center series

BACKGROUND

Surgical treatment of necrotizing pancreatitis (NP) has undergone considerable changes during the past 2 decades. In this study, we report our experience of necrosectomy and continuous closed lavage over the past 19 years in an attempt to define changes in patient characteristics and outcome at an academic referral center.

METHODS

Among 1520 patients admitted with acute pancreatitis, 392 had NP, 285 of whom underwent operative treatment. The total series was evaluated separately for treatment period A (May 1982 until April 1993) and treatment period B (May 1993 until May 2001).

RESULTS

Intraoperative bacteriology revealed sterile necrosis in 145 and infected necrosis in 140 patients. Preoperative disease severity did not differ between the groups; however, the extent of pancreatic parenchymal necrosis was less in patients with sterile necrosis (P < .003). Postoperative complications were more frequent in infected necrosis (78%) than in sterile necrosis (61%) (P < .004), with mortality rates of 27% and 23%, respectively. The analysis of the 2 treatment periods revealed that during period B, there was a decrease in operatively treated patients with sterile necrosis (P < .0005). The preoperative systemic disease severity was significantly higher in these patients than in patients with infected necrosis.

CONCLUSIONS

Surgical treatment of NP by necrosectomy and closed lavage carries an overall mortality of 25%. Patients with sterile necrosis and early onset high disease severity may represent a distinct clinical entity in whom the optimal treatment strategy remains to be defined.

Aggressive endoscopic therapy for pancreatic necrosis and pancreatic abscess: a new safe and effective treatment algorithm (videos)

BACKGROUND

Pancreatic necrosis and pancreatic abscess are severe complications of acute pancreatitis. Surgery is associated with significant morbidity and mortality in these critically ill patients. Endoscopic therapy has the potential to offer a safer and more effective alternative treatment modality. However, its role needs to be further investigated.

METHODS

This is a retrospective study of the outcome of consecutive patients with pancreatic necrosis and pancreatic abscess, all unfit to undergo surgery, who underwent a new aggressive endoscopic approach. The treatment includes (1) synchronous EUS-guided multiple transmural and/or transpapillary drainage procedures followed by balloon dilation of the cystogastrostoma or cystoduodenostoma, (2) daily endoscopic necrosectomy and saline solution lavage, and (3) sealing of pancreatic fistula by N-butyl-2-cyanoacrylate.

RESULTS

Pancreatic necrosis and pancreatic abscesses were successfully drained in 13 patients, thus avoiding emergency surgery as an initial treatment. Surgery was completely avoided in 9 patients over a median follow-up of 8.3 months (range 3-81 months). Surgery was combined with endoscopic therapy in one patient because of abscess extension into the right paracolic gutter, which was not manageable by endoscopic drainage. Because of the "disconnected-duct syndrome," two patients later developed recurrent pseudocysts and underwent elective surgery. Complications included minor bleeding after balloon dilation and necrosectomy in 4 cases, which were self limiting or controlled endoscopically.

CONCLUSIONS

This aggressive endoscopic approach shows promising results. It expands the potential for endoscopic treatment in patients with pancreatic necrosis and/or pancreatic abscess.

Early and late complications after pancreatic necrosectomy

BACKGROUND

Surgery for pancreatic necrosis is associated with a high morbidity and mortality. The aim of this study was to review the incidence of early and late complications after pancreatic necrosectomy in a large contemporary series of patients.

METHODS

The clinical outcomes of 88 patients who underwent pancreatic necrosectomy between 1997 and 2003 were reviewed.

RESULTS

The median age was 55.5 (range, 18-85) years, 54 (61%) were males, 68 (77%) had primary pancreatic infection, 71 (81%) had >50% necrosis, and the median admission Acute Physiology and Chronic Health Evaluation score was 9 (range, 1-21). Median time to surgery was 31 (range, 1-161) days; 47 patients underwent minimally invasive necrosectomy and 41 open necrosectomy; 81 (92%) of patients had complications postoperatively, and 25 (28%) died. Multiorgan failure (odds ratio = 3.4, P = .05) and hemorrhage (odds ratio = 6.1, P = .03) were the only independent predictors of mortality. During a median follow-up of 28.9 months, 39 (62%) of 63 surviving patients had one or more late complications: biliary stricture in 4 (6%), pseudocyst in 5 (8%), pancreatic fistula in 8 (13%), gastrointestinal fistula in 1 (2%), delayed collections in 3 (5%), and incisional hernia in 1 (2%); intervention was required in 10 (16%) patients. Sixteen (25%) of 63 surviving patients developed exocrine insufficiency, and 19 (33%) of 58 without prior diabetes mellitus developed endocrine insufficiency.

CONCLUSIONS

Almost all patients undergoing necrosectomy developed significant early or late complications or both. Multiorgan failure and postoperative hemorrhage were independent predictors of mortality. Long-term follow-up was important because 62% developed complications, and 16% of those with complications required surgical or endoscopic intervention.

Early sequential changes in serum markers of acute pancreatitis induced by endoscopic retrograde cholangiopancreatography

BACKGROUND/AIMS

Trypsinogen activation is thought to play a crucial role in the pathogenesis of acute pancreatitis (AP). Our aim was to characterize the very early sequential changes of trypsinogen-1, trypsinogen-2, the trypsin-2-alpha1-antitrypsin complex (T2-AAT), and pancreatic secretory trypsin inhibitor (PSTI) in serum from patients with pancreatitis induced by endoscopic retrograde cholangiopancreatography (ERCP), a model for studying the early phase of the disease in humans.

PATIENTS AND METHODS

The study population consisted of 659 consecutive patients with 897 ERCP procedures. Blood samples were obtained before and at different time points after the procedure. The serum concentrations of trypsinogen-1 and trypsinogen-2, PSTI and T2-AAT were determined by time-resolved immunofluorometric assays.

RESULTS

ERCP-induced pancreatitis developed after 50 of the 897 ERCP procedures (5.6%). Sixty-one randomly selected ERCP patients without post-ERCP pancreatitis served as controls. Trypsinogen-1 and trypsinogen-2 showed an equally steep increase during the two first hours after ERCP in patients developing AP, but trypsinogen-1 decreased more rapidly than trypsinogen-2, which remained elevated during the 5-day study period. Serum PSTI also increased rapidly whereas T2-AAT increased more slowly peaking at 24 h. In patients developing post-ERCP pancreatitis the median concentration of trypsinogen-1 was markedly higher than in the controls already before the ERCP procedure. In the control group the concentrations of trypsinogen-1, trypsinogen-2, PSTI and T2-AAT did not change significantly.

CONCLUSIONS

The rapid increase of trypsinogen-1 and trypsinogen-2 and PSTI in the early phase of AP suggests that release of pancreatic enzymes is the initial event while the delayed increase of T2-AAT may reflect that the capacity of the intrapancreatic PSTI-based inhibitory mechanism has been exhausted.

Severe acute pancreatitis: case-oriented discussion of interdisciplinary management

The clinical course of an episode of acute pancreatitis varies from a mild, transitory illness to a severe often necrotizing form with distant organ failure and a mortality rate of 20-40%. Patients with severe pancreatitis, representing about 15-20% of all patients with acute pancreatitis, need to be identified as early as possible after onset of symptoms allowing starting intensive care treatment early in the disease process. An episode of severe acute pancreatitis progresses in two phases. The first 10-14 days are characterized by a systemic inflammatory response syndrome maintained by the release of various inflammatory mediators. The second phase, beginning about 10-14 days after the onset of the disease is dominated by sepsis-related morbidity due to infected peripancreatic and pancreatic necrosis. This state is associated with septic multiple organ systemic failure. The importance of infection on the outcome of necrotizing pancreatitis has been clearly delineated and the pre-emptive use of broad-spectrum antibiotics that achieve effective tissue concentrations is considered standard management of patients with severe necrotizing pancreatitis, especially if associated with organ failure or extended necrosis. Patients with infected necrosis should undergo a surgical intervention. The standard open technique consisting of an organ preserving necrosectomy followed by a postoperative concept of lavage and/or drainage to evacuate necrotic debris occurring during the further course has recently been challenged by various minimally invasive approaches.