Clinical outcome of endoscopic treatment for symptomatic sterile walled-off necrosis

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.

Long-term follow-up study of necrotising pancreatitis: interventions, complications and quality of life

OBJECTIVE

To describe the long-term consequences of necrotising pancreatitis, including complications, the need for interventions and the quality of life.

DESIGN

Long-term follow-up of a prospective multicentre cohort of 373 necrotising pancreatitis patients (2005-2008) was performed. Patients were prospectively evaluated and received questionnaires. Readmissions (ie, for recurrent or chronic pancreatitis), interventions, pancreatic insufficiency and quality of life were compared between initial treatment groups: conservative, endoscopic/percutaneous drainage alone and necrosectomy. Associations of patient and disease characteristics during index admission with outcomes during follow-up were assessed.

RESULTS

During a median follow-up of 13.5 years (range 12-15.5 years), 97/373 patients (26%) were readmitted for recurrent pancreatitis. Endoscopic or percutaneous drainage was performed in 47/373 patients (13%), of whom 21/47 patients (45%) were initially treated conservatively. Pancreatic necrosectomy or pancreatic surgery was performed in 31/373 patients (8%), without differences between treatment groups. Endocrine insufficiency (126/373 patients; 34%) and exocrine insufficiency (90/373 patients; 38%), developed less often following conservative treatment (p<0.001 and p=0.016, respectively). Quality of life scores did not differ between groups. Pancreatic gland necrosis >50% during initial admission was associated with percutaneous/endoscopic drainage (OR 4.3 (95% CI 1.5 to 12.2)), pancreatic surgery (OR 3.2 (95% CI 1.1 to 9.5) and development of endocrine insufficiency (OR13.1 (95% CI 5.3 to 32.0) and exocrine insufficiency (OR6.1 (95% CI 2.4 to 15.5) during follow-up.

CONCLUSION

Acute necrotising pancreatitis carries a substantial disease burden during long-term follow-up in terms of recurrent disease, the necessity for interventions and development of pancreatic insufficiency, even when treated conservatively during the index admission. Extensive (>50%) pancreatic parenchymal necrosis seems to be an important predictor of interventions and complications during follow-up.

Long-Term Outcome of Immediate Versus Postponed Intervention in Patients With Infected Necrotizing Pancreatitis (POINTER): Multicenter Randomized Trial

OBJECTIVE

To compare the long-term outcomes of immediate drainage versus the postponed-drainage approach in patients with infected necrotizing pancreatitis.

BACKGROUND

In the randomized POINTER trial, patients assigned to the postponed-drainage approach using antibiotic treatment required fewer interventions, as compared with immediate drainage, and over a third were treated without any intervention.

METHODS

Clinical data of those patients alive after the initial 6-month follow-up were re-evaluated. The primary outcome was a composite of death and major complications.

RESULTS

Out of 104 patients, 88 were re-evaluated with a median follow-up of 51 months. After the initial 6-month follow-up, the primary outcome occurred in 7 of 47 patients (15%) in the immediate-drainage group and 7 of 41 patients (17%) in the postponed-drainage group (RR 0.87, 95% CI 0.33-2.28; P =0.78). Additional drainage procedures were performed in 7 patients (15%) versus 3 patients (7%) (RR 2.03; 95% CI 0.56-7.37; P =0.34). The median number of additional interventions was 0 (IQR 0-0) in both groups ( P =0.028). In the total follow-up, the median number of interventions was higher in the immediate-drainage group than in the postponed-drainage group (4 vs. 1, P =0.001). Eventually, 14 of 15 patients (93%) in the postponed-drainage group who were successfully treated in the initial 6-month follow-up with antibiotics and without any intervention remained without intervention. At the end of follow-up, pancreatic function and quality of life were similar.

CONCLUSIONS

Also, during long-term follow-up, a postponed-drainage approach using antibiotics in patients with infected necrotizing pancreatitis results in fewer interventions as compared with immediate drainage and should therefore be the preferred approach.

TRIAL REGISTRATION

ISRCTN33682933.

Diagnosis and Contemporary Management of Necrotizing Pancreatitis

BACKGROUND

Acute pancreatitis is a common diagnosis which requires a prompt diagnosis and management by a multidisciplinary team with often general surgeons as the initial provider. Morbidity and mortality from an acute pancreatitis can be very high, especially in patients with a progressive worsening acute pancreatitis developing into pancreatic necrosis in the setting of multiple underlying medical comorbidities.

PURPOSE

In this review paper, we discuss all aspects of acute pancreatitis and its potential complications, as well providing updates in the modern management of necrotizing pancreatitis. Practicing general surgeons need to be aware of the evolution in the diagnosis and treatment of this disease.

RESEARCH DESIGN

We conducted a review of literature of evidence and management options for acute pancreatitis, including all published manuscripts from 2012 to 2022.

RESULTS

Diagnosis and management of this disease can vary among specialiaties. The decision to utilize a percutaneous or endoscopic techniques are relevant points of discussion within general surgery and gastroenterology societies. In the past decade, the use of advanced endoscopic interventions has slowly replaced conventional open surgery in managing complications of acute severe pancreatitis.

CONCLUSION

Acute pancreatitis is a disease which requires multidisciplinary approach with evolving treatment options to less invasive nonsurgical methods.

Time to think prime times for treatment of necrotizing pancreatitis: Pendulum conundrum

Pancreatic fluid collections (PFCs) typically develop as local complications of acute pancreatitis and complicate the clinical course of patients with acute pancreatitis and potentially fatal clinical outcomes. Interventions are required in cases of symptomatic walled-off necrosis (WON) (matured PFCs with necrosis) and pancreatic pseudocysts (matured PFCs without necrosis). In the management of necrotizing pancreatitis and WON, endoscopic ultrasound-guided transluminal drainage combined with on-demand endoscopic necrosectomy (i.e. the step-up approach) is increasingly used as a less invasive treatment modality compared with a surgical or percutaneous approach. Through the substantial research efforts and development of specific devices and stents (e.g. lumen-apposing metal stents), endoscopic techniques of PFC management have been standardized to some extent. However, there has been no consensus about timing of carrying out each treatment step; for instance, it is uncertain when direct endoscopic necrosectomy should be initiated and finished and when a plastic or metal stent should be removed following clinical treatment success. Despite emerging evidence for the effectiveness of noninterventional supportive treatment (e.g. antibiotics, nutritional support, irrigation of the cavity), there has been only limited data on the timing of starting and stopping the treatment. Large studies are required to optimize the timing of those treatment options and improve clinical outcomes of patients with PFCs. In this review, we summarize the current available evidence on the indications and timing of interventional and supportive treatment modalities for this patient population and discussed clinical unmet needs that should be addressed in future research.

Update on the management of acute pancreatitis

PURPOSE OF REVIEW

This review provides insight into the recent advancements in the management of acute pancreatitis.

RECENT FINDINGS

Moderate fluid resuscitation and Ringer's lactate has advantages above aggressive fluid resuscitation and normal saline, respectively. A normal "on-demand" diet has a positive effect on recovery from acute pancreatitis and length of hospital stay. A multimodal pain management approach including epidural analgesia might reduce unwarranted effects of opiate use. A more targeted use of antibiotics is starting to emerge. Markers such as procalcitonin may be used to limit unwarranted antibiotic use. Conversely, many patients with infected necrotizing pancreatitis can be treated with only antibiotics, although the optimal choice and duration is unclear. Delay of drainage as much as is possible is advised since it is associated with less procedures. If drainage is required, clinicians have an expanding arsenal of interventional options to their disposal such as the lumen-apposing metal stent for transgastric drainage and (repeated) necrosectomy. Immunomodulation using removal of systemic cytokines or anti-inflammatory drugs is an attractive idea, but up to now the results of clinical trials are disappointing. No additional preventive measures beside non-steroidal anti-inflammatory drugs (NSAIDs) can be recommended for post-endoscopic retrograde cholangiopancreatography (ERCP) pancreatitis.

SUMMARY

More treatment modalities that are less invasive became available and a trend towards less aggressive treatments (fluids, starvation, interventions, opiates) of acute pancreatitis is again emerging. Despite recent advancements, the pathophysiology of specific subgroup phenotypes is still poorly understood which reflects the disappointing results of pharmacological and immunomodulatory trials.

Clinical outcomes following endoscopic or video-assisted retroperitoneal management of acute pancreatitis with large (>15 cm) walled-off pancreatic necrosis: Retrospective, single tertiary center cohort study

OBJECTIVE

Acute pancreatitis with walled-off necrosis (WON) is associated with considerable morbidity and mortality. Previous studies have evaluated outcomes in WON collections of limited size, while data about large WON with long-term follow-up are lacking. We aimed to report our experience in managing large WON.

METHODS

Between 2010 and 2020, consecutive patients with large (>15 cm) WON were identified from a prospectively maintained database. Patients with chronic pancreatitis or an index intervention 90 days or more from the debut of symptoms were excluded. We registered clinical and technical outcomes following minimally invasive treatment in WON >15 cm. Follow-up was a minimum of 1 year.

RESULTS

Overall, 144 patients with WON >15 cm, with a median age of 60 (interquartile range [IQR] 49-69) years, were included. The median WON size was 19.2 cm (IQR 16.8-22.1). Most patients were treated with endoscopic transluminal drainage (93%). The median length of stay was 53 days (IQR 39-76) and 61 (42%) patients needed intensive care support during their hospital stay. As 143 patients (99%) were managed using endoscopic or video-assisted retroperitoneal techniques, only one (0.7%) patient needed an open necrosectomy. Procedure-related adverse events occurred in 10 (7%) patients. Overall, 24 patients (17%) died during admission, all due to multiorgan failure. The median follow-up was 35 months (IQR 15-63.5). Complete resolution was achieved in all remaining patients.

CONCLUSION

Minimally invasive treatment of large WON is feasible, with a minimal need for surgery and acceptable rates of morbidity and mortality.

GIE Editorial Board top 10 topics: advances in GI endoscopy in 2020

The American Society for Gastrointestinal Endoscopy's Gastrointestinal Endoscopy Editorial Board reviewed a systematic literature search of original endoscopy-related articles published during 2020 in Gastrointestinal Endoscopy and 10 other high-impact medical and gastroenterology journals. Votes from each individual board member were tallied to identify a consensus list of the 10 most significant topic areas in GI endoscopy over the calendar year of study using 4 criteria: significance, novelty, impact on national health, and impact on global health. The 10 areas identified were as follows: artificial intelligence in endoscopy, coronavirus disease 2019 and GI practice, third-space endoscopy, lumen-apposing metal stents, single-use duodenoscopes and other disposable equipment, endosonographic needle technology and techniques, endoscopic closure devices, advances in GI bleeding management, improvements in polypectomy techniques, and bariatric endoscopy. Each board member contributed a summary of important articles relevant to 1 to 2 topic areas, leading to a collective summary that is presented in this document of the "top 10" endoscopic advances of 2020.