Predicting Success of Catheter Drainage in Infected Necrotizing Pancreatitis. Ann Surg. 2015;Epub ahead of print. [PMID: 25775071 DOI: 10.1097/sla.0000000000001203]

Risk factors for adverse outcomes at various phases of endoscopic ultrasound-guided treatment of pancreatic fluid collections: Data from a multi-institutional consortium

OBJECTIVES

No comprehensive study has examined short- and long-term adverse outcomes of endoscopic ultrasound (EUS)-guided treatment of pancreatic fluid collections (PFCs) including walled-off necrosis (WON) and pseudocysts.

METHODS

In a multi-institutional cohort of 357 patients receiving EUS-guided treatment of PFCs (228 with WON and 129 with pseudocysts), we examined PFC type-specific risk factors for procedure-related adverse events (AEs), clinical failure, and recurrence. Odds ratios (ORs) and hazard ratios (HRs) with 95% confidence intervals (CIs) were computed using the logistic and Cox regression models, respectively, adjusting for potential confounders.

RESULTS

Adverse events were observed predominantly in WON, and risk factors were WON extension to the pelvis (OR 2.49; 95% CI 1.00-6.19) and endoscopic necrosectomy (OR 5.15; 95% CI 1.61-16.5). Risk factors for clinical failure in WON treatment included higher Charlson Comorbidity Index (OR for ≥3 vs. ≤2, 2.58; 95% CI 1.05-6.35), extension to the pelvis (OR 3.63; 95% CI 1.57-8.43), nonuse of a lumen-apposing metal stent (OR 2.88; 95% CI 1.10-7.54), and percutaneous drainage (OR 3.73; 95% CI 1.27-10.9). Patients with pseudocysts extending to the paracolic gutter and the need for more than two endoscopic/percutaneous procedures had ORs for clinical failure of 5.28 (95% CI 1.10-25.3) and 5.52 (95% CI 1.61-18.9), respectively. Pseudocysts requiring the multigateway approach were associated with a high risk of recurrence (HR 4.00; 95% CI 1.11-11.6).

CONCLUSION

The adverse outcomes at various phases of EUS-guided PFC treatment may be predictable based on clinical parameters. Further research is warranted to optimize treatment strategies for high-risk patients.

Upfront endoscopic necrosectomy or step-up endoscopic approach for infected necrotising pancreatitis (DESTIN): a single-blinded, multicentre, randomised trial

BACKGROUND

Although the preferred management approach for patients with infected necrotising pancreatitis is endoscopic transluminal stenting followed by endoscopic necrosectomy as step-up treatment if there is no clinical improvement, the optimal timing of necrosectomy is unclear. Therefore, we aimed to compare outcomes between performing upfront necrosectomy at the index intervention versus as a step-up measure in patients with infected necrotising pancreatitis.

METHODS

This single-blinded, multicentre, randomised trial (DESTIN) was done at six tertiary care hospitals (five hospitals in the USA and one hospital in India). We enrolled patients (aged ≥18 years) with confirmed or suspected infected necrotising pancreatitis with a necrosis extent of at least 33% who were amenable to endoscopic ultrasound-guided drainage. By use of computer-generated permuted block randomisation (block size four), eligible patients were randomly assigned (1:1) to receive either upfront endoscopic necrosectomy or endoscopic step-up treatment. Endoscopists were not masked to treatment allocation, but participants, research coordinators, and the statistician were. Lumen-apposing metal stents (20 mm diameter; 10 mm saddle length) were used for drainage in both groups. In the upfront group, direct necrosectomy was performed immediately after stenting in the same treatment session. In the step-up group, direct necrosectomy or additional drainage was done at a subsequent treatment session if there was no clinical improvement (resolution of any criteria of systemic inflammatory response syndrome or sepsis or one or more organ failure and at least a 25% percentage decrease in necrotic collection size) 72 h after stenting. The primary outcome was the number of reinterventions per patient to achieve treatment success from index intervention to 6 months' follow-up, which was defined as symptom relief in conjunction with disease resolution on CT. Reinterventions included any endoscopic or radiological procedures performed for necrosectomy or additional drainage after the index intervention, excluding the follow-up procedure at 4 weeks for stent removal. All endpoints and safety were analysed by intention-to-treat. This study is registered with ClinicalTrials.gov, NCT05043415 and NCT04113499, and recruitment and follow-up have been completed.

FINDINGS

Between Nov 27, 2019, and Oct 26, 2022, 183 patients were assessed for eligibility and 70 patients (24 [34%] women and 46 [66%] men) were randomly assigned to receive upfront necrosectomy (n=37) or step-up treatment (n=33) and included in the intention-to-treat population. At the time of index intervention, seven (10%) of 70 patients had organ failure and 64 (91%) patients had walled-off necrosis. The median number of reinterventions was significantly lower for upfront necrosectomy (1 [IQR 0 to 1] than for the step-up approach (2 [1 to 4], difference -1 [95% CI -2 to 0]; p=0·0027). Mortality did not differ between groups (zero patients in the upfront necrosectomy group vs two [6%] in the step-up group, difference -6·1 percentage points [95% CI -16·5 to 4·5]; p=0·22), nor did overall disease-related adverse events (12 [32%] patients in the upfront necrosectomy group vs 16 [48%] patients in the step-up group, difference -16·1 percentage points [-37·4 to 7·0]; p=0·17), nor procedure-related adverse events (four [11%] patients in the upfront necrosectomy group vs eight [24%] patients in the step-up group, difference -13·4 percentage points [-30·8 to 5·0]; p=0·14).

INTERPRETATION

In stabilised patients with infected necrotising pancreatitis and fully encapsulated collections, an approach incorporating upfront necrosectomy at the index intervention rather than as a step-up measure could safely reduce the number of reinterventions required to achieve treatment success.

FUNDING

None.

[Direct transfistulous ultrasound in minimally invasive surgical treatment of infected pancreatic necrosis]

OBJECTIVE

To develop a method for direct transfistulous ultrasound in minimally invasive treatment of infected pancreatic necrosis.

MATERIAL AND METHODS

There were 148 patients with infected pancreatic necrosis between 2015 and 2019 at the Krasnodar City Clinical Hospital No. 2. Drainage with 28-32 Fr tubes was carried out at the first stage, endoscopic transfistulous sequestrectomy - at the second stage (19 (12.8%) patients). In 84 (56.8%) patients, we applied original diagnostic method (transfistulous ultrasonic assessment of inflammatory focus).

RESULTS

There were 3 accesses to omental bursa in 93 (62.8%) patients and 2 in 43 (29.1%) patients. We also performed 2 access to retroperitoneal space in 63 (42.6%) patients and 1 access in 38 (25.8%) cases. Transfistulous ultrasound was used once in 19 (22.6%) patients, twice in 28 (33.3%) and 3 times in 37 (44.1%) patients. Examination was not performed in 18 (12.2%) patients due to the following reasons: migration of drainage catheters - 5, non-rectilinear fistulous tract - 13. No complications were observed.

CONCLUSION

Transfistulous ultrasound makes it possible to diagnose pathological changes in the pancreas and parapancreatic tissue at various stages of surgical treatment.

Endoscopic Necrosectomy

The management of walled-off necrosis has evolved substantially over the past 23 years since its first description. In this article, we review its history and the evidence supporting modern treatment, which is still subject to heterogeneity across centers and among endoscopists. This allows for creativity and customization of what can be an endoscopic marathon. Our typical practice is discussed with image and video guides aimed at improving procedure success.

A Risk Score for Predicting the Necessity of Surgical Necrosectomy in the Treatment of Infected Necrotizing Pancreatitis

BACKGROUND

For infected necrotizing pancreatitis (INP), percutaneous catheter drainage (PCD) is now widely acknowledged as the initial intervention in a step-up approach, followed, if necessary, by minimally invasive necrosectomy or even open pancreatic necrosectomy. However, an overemphasis on PCD may cause a patient's condition to deteriorate, leading to missed surgical opportunities or even death. This study aimed to develop a simple and convenient scoring tool for assessing the need for surgery in INP patients who received PCD procedures.

METHODS

In an observational study conducted between April 2015 and December 2020, PCD was utilized as the initial step to treat 143 consecutive INP patients. A surgical necrosectomy was performed when the patient failed to respond. Risk factors of PCD failure (i.e., need for surgical necrosectomy) were identified by multivariate logistic regression models. An integer-based risk scoring tool was developed using the β coefficients derived from the logistic regression model.

RESULTS

In 62 (43.4%) patients, PCD was successful, while the remaining 81 (56.6%) individuals required subsequent surgical necrosectomy. In the multivariate model, organ failure, percentage of pancreatic necrosis, extrapancreatic necrosis volume, and mean CT density of extrapancreatic necrosis volume were associated with a need for surgical necrosectomy. A predictive scoring tool based on these four factors demonstrated an area under the receiver operating characteristic curve (AUC) of 0.893. Under the scoring tool, a total score of 4 or more indicates a high possibility of surgical necrosectomy being required (at least 80%). Using the coordinates of the receiver operating characteristic curve (ROC), the sensitivity and specificity at this threshold are 0.802 and 0.903, respectively.

CONCLUSIONS

A risk score model integrating organ failure, percentage of pancreatic necrosis, extrapancreatic necrosis volume, and mean CT density of extrapancreatic necrosis volume can identify INP patients at high risk for necrosectomy. The straightforward risk assessment tool assists clinicians in stratifying INP patients and making more judicious medical decisions.

Nomogram development and validation for predicting minimally invasive step-up approach failure in infected necrotizing pancreatitis patients: a retrospective cohort study

BACKGROUND

Previous studies have shown that minimally invasive treatment for infected necrotizing pancreatitis (INP) may be safer and more effective than open necrosectomy (ON), but ON is still irreplaceable in a portion of INP patients. Furthermore, there is a lack of tools to identify INP patients at risk of minimally invasive step-up approach failure (eventually received ON or died), which may enable appropriate treatment for them. Our study aims to identify risk factors that can predict minimally invasive step-up approach failure in INP patients and to develop a nomogram for early prediction.

METHODS

Multivariate logistic regression was performed to evaluate the association between minimally invasive step-up approach failure and factors regarding demographics, disease severity, laboratory index, and the location of extrapancreatic necrotic collections. A novel nomogram was developed, and its performance was validated both internally and externally by its discrimination, calibration, and clinical usefulness.

RESULTS

There were 267, 89, and 107 patients in the training, internal, and external validation cohorts, respectively. Multivariate logistic regression demonstrated that the computed tomography severity index (CTSI) greater than 8 points, Acute Physiology and Chronic Health Evaluation II (APACHE II) score of 16 points or more, early spontaneous bleeding, fungi infection, granulocyte and platelet decrease within 30 days of acute pancreatitis onset, and extrapancreatic necrosis collection located in small bowel mesentery were independent risk factors for minimally invasive step-up approach failure. The area under the curve and coefficient of determination ( R2 ) of the nomogram constructed from the above factors were 0.920 and 0.644, respectively. The Hosmer-Lemeshow test showed that the model had good fitness ( P =0.206). In addition, the nomogram performed well in both the internal and external validation cohorts.

CONCLUSIONS

The nomogram had a good performance in predicting minimally invasive step-up approach failure, which may help clinicians distinguish INP patients at risk of minimally invasive step-up approach failure early.

Endoscopic transluminal drainage and necrosectomy for infected necrotizing pancreatitis: Progress and challenges

Infected necrotizing pancreatitis (INP) represents a severe condition in patients with acute pancreatitis. Invasive interventions are recommended in symptomatic INP. Growing evidence has suggested interventional strategies of INP evolving from traditional surgery to minimally invasive step-up endoscopic procedures. However, there is still no standardized protocol for endoscopic interventions. Recently, various studies have been published about the endoscopic management of INP. This article reviews published articles and guidelines to present the progress and challenges of endoscopic transluminal drainage and necrosectomy in INP.

[A modified method for percutaneous drainage of acute necrotic collections in patients with infected pancreatic necrosis]

OBJECTIVE

To develop a modified method for percutaneous drainage of acute necrotic collections in patients with infected pancreatic necrosis.

MATERIALS AND METHODS

Minimally invasive surgical technologies were used in 74 patients with infected acute necrotic collections at the Krasnodar Regional Clinical Hospital No. 2 between 2017 and 2019. Of these, 59 (79.7%) people underwent percutaneous drainage as a final treatment. In 11 (14.9%) patients, video sequestrectomy through the fistula was additionally used to increase efficiency of percutaneous drainage.

RESULTS

PCD in our modification implies delivery of double-lumen drains 26-32 Fr in the same plane to zones of necrosis, their programmed replacement for prevention of obstruction and flexible endoscopy for control of pathological process. Local purulent-necrotic parapancreatitis occurred in 31 (41.9%) patients, widespread parapancreatitis - in 43 (58.1%) patients. There were 339 minimally invasive interventions. Laparotomy was required in 4 (5.4%) patients. Incidence of perioperative complications was 10.6%, mortality - 16.2%.

CONCLUSION

A modified percutaneous drainage method may be used as final surgical treatment in 79.7% of patients with infected pancreatic necrosis.

[Technological features of open and minimally invasive surgical treatment of local complications of purulent-necrotic pancreatitis]

There are various options for surgical treatment of purulent-necrotic pancreatitis with significant technological differences. Combining surgical methods other than traditional ones into a group of minimally invasive ones based on the principle of the absence of standard laparotomy is not entirely correct. The review presents modern methods of surgical treatment of acute pancreatitis, comparison of their technology regarding classical stages of surgical intervention and their classification.

Predicting the Success of Catheter Drainage in Infected Necrotising Pancreatitis: A Cross-Sectional Observational Study

Background Management of acute necrotising pancreatitis is often challenging for clinicians. Secondary infection of the necrotic collections leads to sepsis and warrants intervention. Minimally invasive techniques like catheter drainage have recently been proposed over more risky and morbid traditional open procedures. Factors that can predict successful catheter drainage of the necrotic pancreatic collection are still unclear and not well established. Materials and methods This study is designed as a retrospective cross-sectional observational study to investigate the association of 21 factors in predicting successful catheter drainage. Data from 30 patients admitted with acute necrotising pancreatitis treated with catheter drainage were collected and analysed. Twenty-one factors, including demographic variables, disease severity factors, drainage criteria, and morphological criteria on imaging, were studied for their predictive association with successful outcomes. Univariate analysis was done for each variable against the outcome. The study was conducted between December 2012 to March 2017. P-value <0.05 was considered statistically significant. Results Patients with no organ involvement responded better to primary catheter drainage. Patients with BMI>25 and multi-organ failure were poor candidates for primary catheter drainage. Clinically unwell patients with a Bedside Index for Severity in Acute Pancreatitis (BISAP) score of ≥4 had a negative outcome on catheter drainage and usually ended up in a surgical procedure or eventually succumbed to the disease. Other variables included in our study did not statistically associate with the success or failure of percutaneous catheter drainage. Conclusion BMI >25, multiple organ failure, and BISAP score ≥ 4 are independent negative predictors for the success of catheter drainage in infected necrotising pancreatitis. No organ failure showed a positive predictor for successful catheter drainage. Further studies are required to explore these predictive factors in a larger sample size to predict the success of catheter drainage in infected pancreatic necrosis.

Predicting persistent organ failure on admission in patients with acute pancreatitis: development and validation of a mobile nomogram

BACKGROUND

Early prediction of persistent organ failure (POF) is important for triage and timely treatment of patients with acute pancreatitis (AP).

METHODS

All AP patients were consecutively admitted within 48 h of symptom onset. A nomogram was developed to predict POF on admission using data from a retrospective training cohort, validated by two prospective cohorts. The clinical utility of the nomogram was defined by concordance index (C-index), decision curve analysis (DCA), and clinical impact curve (CIC), while the performance by post-test probability.

RESULTS

There were 816, 398, and 880 patients in the training, internal and external validation cohorts, respectively. Six independent predictors determined by logistic regression analysis were age, respiratory rate, albumin, lactate dehydrogenase, oxygen support, and pleural effusion and were included in the nomogram (web-based calculator: https://shina.shinyapps.io/DynNomapp/). This nomogram had reasonable predictive ability (C-indexes 0.88/0.91/0.81 for each cohort) and promising clinical utility (DCA and CIC). The nomogram had a positive likelihood ratio and post-test probability of developing POF in the training, internal and external validation cohorts of 4.26/31.7%, 7.89/39.1%, and 2.75/41%, respectively, superior or equal to other prognostic scores.

CONCLUSIONS

This nomogram can predict POF of AP patients and should be considered for clinical practice and trial allocation.

Predicting success of direct endoscopic necrosectomy with lumen-apposing metal stents for pancreatic walled-off necrosis

BACKGROUND AND AIMS

Direct endoscopic necrosectomy (DEN) with lumen-apposing metal stents (LAMSs) is increasingly used in the management of pancreatic walled-off necrosis (WON). However, it still remains unknown which patients will fail to respond to DEN with LAMSs and require additional surgical intervention. Therefore, the aim of our study was to explore predictors of successful DEN with LAMSs for pancreatic WON.

METHODS

This is a retrospective analysis of a prospectively collected database. All consecutive patients who underwent DEN with LAMSs for pancreatic WON were included. Collected data were demographics, disease severity, morphologic features, and procedure characteristics. Potential factors affecting DEN outcome were predefined and analyzed.

RESULTS

One hundred one consecutive patients undergoing DEN with LAMSs for WON were identified, among whom 4 patients were excluded for technical failure (n = 1) and previous debridement without LAMSs (n = 3). In the 97 included patients, clinical success was achieved in 79 patients (81.4%). In logistic multivariable regression, 3 independent factors were negatively associated with success of DEN with LAMSs: increasing Acute Physiology and Chronic Health Evaluation II score (odds ratio [OR], .70; 95% confidence interval [CI], .55-.90; P = .005), >50% pancreatic necrosis (OR, .16; 95% CI, .03-.77; P = .022), and paracolic gutter extension (OR, .08; 95% CI, .02-.42; P = .003). A receiver-operating characteristic curve of the prediction model with these 3 factors demonstrated an area under the curve of .926.

CONCLUSIONS

Paracolic gutter extension, increasing Acute Physiology and Chronic Health Evaluation II score, and >50% gland necrosis are negative predictors for success of DEN with LAMSs in WON. This prediction model with nomogram may be helpful in clinical decision-making and prognostication.

Infected pancreatic necrosis complicating severe acute pancreatitis in critically ill patients: predicting catheter drainage failure and need for necrosectomy

Background

Recent guidelines advocate a step-up approach for managing suspected infected pancreatic necrosis (IPN) during acute pancreatitis. Nearly half the patients require secondary necrosectomy after catheter drainage. Our primary objective was to assess the external validity of a previously reported nomogram for catheter drainage, based on four predictors of failure. Our secondary objectives were to identify other potential predictors of catheter-drainage failure. We retrospectively studied consecutive patients admitted to the intensive care units (ICUs) of three university hospitals in France between 2012 and 2016, for severe acute pancreatitis with suspected IPN requiring catheter drainage. We assessed drainage success and failure rates in 72 patients, with success defined as survival without subsequent necrosectomy and failure as death and/or subsequent necrosectomy required by inadequate improvement. We plotted the receiver operating characteristics (ROC) curve for the nomogram and computed the area under the curve (AUROC).

Results

Catheter drainage alone was successful in 32 (44.4%) patients. The nomogram predicted catheter-drainage failure with an AUROC of 0.71. By multivariate analysis, catheter-drainage failure was independently associated with a higher body mass index [odds ratio (OR), 1.12; 95% confidence interval (95% CI), 1.00–1.24; P = 0.048], heterogeneous collection (OR, 16.7; 95% CI, 1.83–152.46; P = 0.01), and respiratory failure onset within 24 h before catheter drainage (OR, 18.34; 95% CI, 2.18–154.3; P = 0.007).

Conclusion

Over half the patients required necrosectomy after failed catheter drainage. Newly identified predictors of catheter-drainage failure were heterogeneous collection and respiratory failure. Adding these predictors to the nomogram might help to identify patients at high risk of catheter-drainage failure.

ClinicalTrials.gov number: NCT03234166.

Supplementary Information

The online version contains supplementary material available at 10.1186/s13613-022-01039-z.

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

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

Trans-gastric and trans-abdominal percutaneous drainage of acute peripancreatic fluid infected collections: A retrospective analysis

Background

Acute pancreatitis is one of the most common gastrointestinal diseases. Approximately 20% of the patients develop peripancreatic collections. Step-up management it's now the best approach with less rate of morbidity and mortality compared with open or minimally invasive surgery. Percutaneous management could reach a success rate between 50 and 76%. Our study shows the outcomes of trans-gastric versus transabdominal percutaneous drainage in cases of acute peripancreatic fluid infected collections in the absence of interventionist endoscopy.

Methods

A retrospective review of a prospectively collected database was conducted. All the patients older than 18 years old that underwent percutaneous drainage between January 2010–December 2021 were included. Analysis and description of outcomes such as mortality, complications, and avoidance of surgical procedures was performed.

Results

18 patients underwent percutaneous drainage. 66.67% of patients were male. Mean age was 52.55 ± 22.06 years. Mean weight was 74.43 ± 15.25 kg. Mean size of peripancreatic collections 118.4 ± 49.12 mm. Wall-off necrosis was present in 33.33%. Trans-gastric approach was performed in 50% of the cases, the rest was trans-abdominal. No mortality was evidenced after 30 days of follow up. After trans-gastric percutaneous drainage, all patients avoided surgical open or laparoscopic procedure.

Conclusion

Standardized step-up approach shows increased rates of success in percutaneous drainage of peripancreatic collections. Our case series shows a high rate of success in terms of avoidance any surgical procedure with no mortality after trans-abdominal and trans-gastric percutaneous drainage. Nevertheless, further prospective studies with higher sample size are needed.

•

Trans-gastric and trans-abdominal percutaneous drainage of peripancreatic infected collections are safe and feasible procedures.

•

In cases of no access to interventional endoscopy, percutaneous drainage remains to be a safe procedure.

•

Multidisciplinary approach leads to good outcomes with less rate of morbidity and mortality.

Radiologic Predictors of Increased Number of Necrosectomies During Endoscopic Management of Walled-off Pancreatic Necrosis

GOALS

No established methods exist to predict who will require a higher number of endoscopic necrosectomy sessions for walled-off necrosis (WON). We aim to identify radiologic predictors for requiring a greater number of necrosectomy sessions. This may help to identify patients who benefit from aggressive endoscopic management.

MATERIALS AND METHODS

This is a multicenter retrospective study of patients with WON at 3 tertiary care centers. WON characteristics on preintervention computed tomography imaging were evaluated to determine if they were predictive of requiring more endoscopic necrosectomy.

RESULTS

A total of 104 patients were included. Seventy patients (67.3%) underwent endoscopic necrosectomy, with median of 2 necrosectomies. WON largest transverse diameters (P=0.02), largest coronal diameters (P=0.01), necrosis pattern [likelihood ratio (LR)=17.85, P<0.001], spread (LR=11.02, P=0.01), hemorrhage (LR=8.64, P=0.003), and presence of disconnected pancreatic duct (LR=6.80, P=0.01) were associated with undergoing ≥2 necrosectomies. Patients with septations/loculations were significantly less likely to undergo ≥2 necrosectomies (LR=4.86, P=0.03).

CONCLUSIONS

Several computed tomography radiologic features were significantly associated with undergoing ≥2 necrosectomies. These could help identify patients who will undergo a higher number of endoscopic necrosectomy sessions.

Association between morphological features of necrotizing pancreatitis on endoscopic ultrasound and outcomes of the endoscopic transmural step-up approach

OBJECTIVE

To investigate the association between necrotic collections on endoscopic ultrasound (EUS) and outcomes of the endoscopic transmural step-up approach in necrotizing pancreatitis (NP).

METHODS

Adult NP patients who had undergone endoscopic transmural step-up approach, endoscopic transmural drainage or endoscopic transmural necrosectomy, were retrospectively enrolled, and divided into groups 1, 2 and 3 based on the amount of solid necrotic debris (quantified as a percentage of the total collection size of <30%, 30%-50%, and >50%).

RESULTS

A total of 134 patients were included, of whom 52, 59 and 23 patients were categorized into groups 1, 2 and 3. Patients with more solid necrotic debris required more necrosectomy sessions (group 3 vs group 2 vs group 1: 2.0 vs 1.0 vs 1.0, P < 0.001), were more likely to experience stent occlusion (group 3 vs group 2 vs group 1: 34.8% vs 16.9% vs 9.6%, P = 0.011), and had a longer hospitalization (group 3 vs group 2 vs group 1: 40.0 d vs 28.0 d vs 25.5 d, P = 0.015). High procalcitonin level (adjusted odds ratio [aOR] 6.14, 95% confidence interval [CI] 1.40-26.94, P = 0.016) and any organ failure (aOR 11.51, 95% CI 2.42-54.78, P = 0.002) were independently associated with clinical failure of endoscopic transmural step-up approach.

CONCLUSIONS

More solid necrotic debris on EUS is related to more necrosectomy sessions, higher incidence of stent occlusion and longer hospitalization. A nomogram combining procalcitonin and any organ failure performs well in predicting clinical failure of endoscopic transmural step-up approach.

"One-step" approach versus "Step-up" approach minimally invasive treatment for infected pancreatic necrosis: a study protocol for a single-center, prospective, randomized controlled trial

BACKGROUND

Currently, the minimally invasive "Step-up" surgical strategy is still the main treatment for infected pancreatic necrosis (IPN). However, indiscriminate implementation of the "Step-up" strategy can lead to increased numbers of operations and prolonged hospital stay. The "Step-up" approach is not appropriate for some patients due to unavailabilty of a safe puncture path. Therefore, we developed the "One-step" surgical approach to treat IPN, which is safety. However, there is still a lack of comparison of the short and long-term efficacy between the "One-step" and "Step-up" approach. Consequently, we are conducting this clinical trial to provide a reference for IPN treatment.

METHODS

This is an ongoing, single-center, randomized controlled trial of patients with IPN. The total sample size required for the trial (May 2021-December 2023) is approximately 128 patients. Patients will be randomly assigned to either an experimental group (One-step) or a control group (Step-up) at a ratio of 1:1 using the block randomization method. We used the case report forms and electronic data capture systems to obtain demographic information, preoperative laboratory examination, auxiliary examination results, surgery data, postoperative recovery outcomes, and follow-up outcomes. The patients will be followed up for 2 years after surgery. The primary endpoint is a composite endpoint, consisting of mortality and severe complications. The secondary endpoints include the incidence of organ dysfunction, the number of surgical procedures, mortality (the incidence of death in hospital and deaths within 30 days of discharge), hospital stay, intensive care unit stay, hospitalization costs, perioperative inflammatory marker changes, and short-and long-term complications.

DISCUSSION

Compared with the "Step-up," the "One-step" minimally invasive surgery can significantly reduce the number of operations, reduce the length of hospital stay and hospitalization costs without increasing the incidence of composite endpoint events, and has better short- and long-term efficacy and safety. Additionally, there was no statistically significant difference in perioperative complications and mortality between "Step-up" and "One-step". This study will assist with the formulation of an effective and scientific "One-step" minimally invasive treatment strategy for IPN, and an understanding of this technique will facilitate clinical decision-making for IPN. Trial Registration ChiCTR2100044348. Trial status: Ongoing.

One-step laparoscopic pancreatic necrosectomy verse surgical step-up approach for infected pancreatic necrosis: a case-control study

BACKGROUND

The surgical step-up approach often requires multiple debridements and might not be suitable for infected pancreatic necrosis (IPN) patients with various abscesses or no safe route for percutaneous catheter drainage (PCD). This case-control study aimed to investigate the safety and effectiveness of one-step laparoscopic pancreatic necrosectomy (LPN) in treating IPN.

METHODS

This case-control study included IPN patients undergoing one-step LPN or surgical step-up in our center from January 2015 to December 2020. The short-term and long-term complications after surgery, length of hospital stay, and postoperative ICU stays in both groups were analyzed. Univariate and multivariate logistic regression analyses were performed to explore the risk factors of major complications or death.

RESULTS

A total of 53 IPN patients underwent one-step LPN and 37 IPN patients underwent surgical step-up approach in this study. There was no significant difference in the incidence of death, major complications, new-onset diabetes, or new-onset pancreatic exocrine insufficiency between the two groups. However, the length of hospital stay in the one-step LPN group was significantly shorter than that in the surgical step-up group. Univariate regression analysis showed that the surgical approach (one-step/step-up) was not the risk factor for major complications or death. Multivariate logistic regression analysis indicated that computed tomography (CT) severity index, American Society of Anesthesiologists (ASA) class IV, and white blood cell (WBC) were the significant risk factors for major complications or death.

CONCLUSION

One-step LPN is as safe and effective as the surgical step-up approach for treating IPN patients, and reduces total hospital stay.

Comparison of safety, efficacy, and long-term follow-up between “one-step” and “step-up” approaches for infected pancreatic necrosis

BACKGROUND

Although the “Step-up” strategy is the primary surgical treatment for infected pancreatic necrosis, it is not suitable for all such patients. The “One-step” strategy represents a novel treatment, but the safety, efficacy, and long-term follow-up have not yet been compared between these two approaches.

AIM

To compare the safety, efficacy, and long-term follow-up of two surgical approaches to provide a reference for infected pancreatic necrosis treatment.

METHODS

This was a retrospective analysis of infectious pancreatic necrosis patients who underwent “One-step” or “Step-up” necrosectomy at Xuan Wu Hospital, Capital Medical University, from May 2014 to December 2020. The primary outcome was the composite endpoint of severe complications or death. Patients were followed up every 6 mo after discharge until death or June 30, 2021. Statistical analysis was performed using SPSS 21.0 and GraphPad Prism 8.0, and statistical significance was set at P < 0.05.

RESULTS

One-hundred-and-fifty-eight patients were enrolled, of whom 61 patients underwent “One-step” necrosectomy and 97 patients underwent “Step-up” necrosectomy. During the long-term follow-up period, 40 patients in the “One-step” group and 63 patients in the “Step-up” group survived. The time from disease onset to hospital admission (53.69 ± 38.14 vs 32.20 ± 20.75, P < 0.001) and to initial surgical treatment was longer in the “Step-up” than in the “One-step” group (54.38 ± 10.46 vs 76.58 ± 17.03, P < 0.001). Patients who underwent “Step-up” necrosectomy had a longer hospitalization duration (65.41 ± 28.14 vs 52.76 ± 24.71, P = 0.02), and more interventions (4.26 ± 1.71 vs 3.18 ± 1.39, P < 0.001). Postoperative inflammatory indicator levels were significantly lower than preoperative levels in each group. Although the incisional hernia incidence was higher in the “One-step” group, no significant difference was found in the composite outcomes of severe complications or death, new-onset organ failure, postoperative complications, inflammatory indicators, long-term complications, quality of life, and medical costs between the groups (P > 0.05).

CONCLUSION

Compared with the “Step-up” approach, the “One-step” approach is a safe and effective treatment method with better long-term quality of life and prognosis. It also provides an alternative surgical treatment strategy for patients with infected pancreatic necrosis.

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

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSION

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

Development and validation of a computed tomography index for assessing outcomes in patients with acute pancreatitis: "SMART-CT" index

PURPOSE

The existing CT indices do not allow quantitative prediction of clinical outcomes in acute pancreatitis (AP). The aim of this study was to develop and validate a revised CT index using a nomogram-based approach.

METHODS

This retrospective study comprised consecutive patients with AP who underwent contrast-enhanced CT between June 2017 and March 2019. 123 CT scans were randomly divided into training (n = 103) and validation groups (n = 20). Two radiologists analyzed CT scans for findings described in modified CT severity index and additional exploratory items (13 items). Seven items (pancreatic necrosis, number of collections, size of collections, ascites, pleural effusion, celiac artery involvement, and liver steatosis) found to be statistically significant were used for development of index. Synthetic minority oversampling technique (SMOTE) was employed to balance representation of minority classes and hence this index was named "SMOTE Application for Reading CT in AcuTe Pancreatitis (SMART-CT index)". Binomial logistic regression was used for development of prediction algorithm. Nomograms were then created and validated for each outcome.

RESULTS

The new CT index had area under the curve (AUC) of 0.79 [95% CI 0.65-0.93], 0.66 (95% CI 0.54-0.77), 0.75 (95% CI 0.65-0.85), 0.83 (95% CI 0.69-0.96), 0.70 (95% CI 0.60-0.81), and 0.64 (95% CI 0.53-0.75) for mortality, intensive care unit (ICU) stay, length of hospitalization, length of ICU stay, number of admissions, and severity, respectively. The AUC of validation cohort was comparable to the training cohort.

CONCLUSION

The novel nomogram-based index predicts occurrence of clinical outcome with moderate accuracy.

Efficacy of large-volume lavage through a double-lumen drainage tube and continuous negative pressure drainage for infectious pancreatic necrosis

BACKGROUND

Infectious pancreatic necrosis (IPN) is usually treated by surgery. However, the drainage of residual tissues still has problems such as insufficient drainage and easy blockage of the drainage tube. In this study, we compared the efficacy of large-volume lavage through a peripancreatic double-lumen drainage tube and continuous negative pressure drainage vs conventional drainage for IPN.

AIM

To evaluate the clinical efficacy of large-volume lavage through a peripancreatic double-lumen drainage tube and continuous negative pressure drainage for IPN after operation.

METHODS

The clinical data of 57 cases of IPN who received surgical treatment at the Department of Hepatobiliary, Pancreatic and Splenic Surgery, People's Hospital of Tongchuan from June 2015 to June 2019 were retrospectively analyzed. According to the method of postoperative drainage used, the patients were divided into either a double-lumen drainage tube group or a conventional drainage tube group.

RESULTS

The two groups had no significant differences in demographic data, etiology and severity of pancreatitis, operation time, intraoperative blood loss, and duration of intensive care unit stay. There were also no significant differences between the two groups in the number of reversals of postoperative continuous organ failure (84.21% vs 56.25%, P = 0.13) and the incidence of serious complications (16.67% vs 33.33%, P = 0.14). The overall mortality rate was 12.28%. The mortality rate was higher in the conventional drainage tube group, but there was no statistically significant difference between the two groups (P = 0.17). Compared to the conventional drainage tube group, the double-lumen drainage tube group had significantly reduced APACHEⅡ score (8.03 ± 2.13 vs 3.85 ± 1.29, P < 0.01) and reoperation cases (0 vs 22.22%, P = 0.008), shorter hospitalization, more unobstructed drainage tubes, and earlier removal of drainage tubes (P < 0.01).

CONCLUSION

Large volume lavage through a double-lumen drainage tube and continuous negative pressure drainage is an effective method for IPN, which can be used to treat IPN effectively.

Aggressive Percutaneous Catheter Drainage Protocol for Necrotic Pancreatic Collections

BACKGROUND

Percutaneous catheter drainage (PCD) performed pro-actively for collections in acute pancreatitis (AP) is associated with better outcomes. However, there are only a few studies describing this protocol.

AIM

We aimed to evaluate an aggressive PCD protocol.

METHODS

Consecutive patients with AP who underwent PCD with an aggressive protocol between January 2018 and January 2019 were included. This protocol involved catheter upsizing at a pre-specified interval (every 4-6 days) as well as drainage of all the new collections. The indications and technical details of PCD and clinical outcomes were compared with patients who underwent standard PCD.

RESULTS

Out of the 185 patients with AP evaluated during the study period, 110 (59.4%) underwent PCD, all with the aggressive protocol. The historical cohort of standard PCD comprised of 113 patients. There was no significant difference in the indication of PCD and interval from pain onset to PCD between the two groups. The mean number of catheters was significantly higher in the aggressive PCD group (1.86 ± 0.962 vs. 1.44 ± 0.667, p = 0.002). Additional catheters were inserted in 54.2% of patients in aggressive group vs. 36.2% in the standard group (p = 0.006). Length of hospital stay and intensive care unit (ICU) stay were significantly longer in the standard PCD group (34.3 ± 20.14 vs. 27.45 ± 14.2 days, p < 0.001 and 10.46 ± 12.29 vs. 4.12 ± 8.5, p = 0.009, respectively). There was no significant difference in mortality and surgery between the two groups.

CONCLUSION

Aggressive PCD protocol results in reduced length of hospital stay and ICU stay and can reduce hospitalization costs.

[Indications for Surgical and Interventional Therapy of Acute Pancreatitis]

BACKGROUND

15 to 20% of patients with acute pancreatitis develop necrosis of the pancreatic parenchyma or extrapancreatic tissue. The disease is associated with a mortality rate of up to 20%. The mainstays of treatment consist of intensive medical care and surgical and interventional therapy.

METHODS

A systematic literature search focused on indications for surgical and interventional therapy of necrotising pancreatitis. 85 articles were analysed for this review. By using the Delphi method, the results were presented to the quality committee for pancreas diseases of the German Society for General and Visceral Surgery and to expert pancreatologists in an interactive conference using plenary voting during the visceral medicine congress 2019 in Wiesbaden. For the finalised recommendations, an agreement of 84% of participants was achieved.

RESULTS

Documented or clinical suspicion of infected, necrotising pancreatitis are indications for surgical and interventional therapy (recommendation grade: strong; evidence grade; low). Sterile necrosis is a less common indication for intervention due to late complications or persistent severe pancreatitis. Invasive interventions should be delayed when possible until four weeks after onset of pancreatitis. Optimal treatment strategy consists of a "step-up approach" (evidence grade: high; recommendation grade: strong). The first step is catheter drainage, followed, if necessary, by minimally invasive surgical or interventional necrosectomy. If minimally invasive techniques do not result in clinical improvement, open necrosectomy is necessary. 35 to 50% of patients are successfully treated with drainage alone. Indications for emergency intervention are bowel perforation, bowel ischemia and bleeding. Surgical decompression of abdominal compartment syndrome is indicated if the patient is refractory to medical treatment and percutaneous drainage. Abscesses and symptomatic pseudocysts are indications for interventional drainage. Early cholecystectomy during index admission is recommended for patients with mild biliary pancreatitis. Cholecystectomy should be delayed after severe, biliary pancreatitis.

CONCLUSION

The recommendations for surgical an interventional therapy of necrotising pancreatitis address the basis of current indications in literature. They should serve in daily practice as a reference standard for decision making in multidisciplinary teams.

Kissing catheter technique for percutaneous catheter drainage of necrotic pancreatic collections in acute pancreatitis

One of the critical factors for predicting the success of percutaneous catheter drainage (PCD) is the mean CT density of collection. A higher CT density suggests more necrotic solid tissue within the collection. In the present study, a novel technique for PCD of the necrotic pancreatic collection with a higher mean CT density was evaluated. It was a retrospective study of patients with acute pancreatitis (AP) who underwent PCD of pancreatic collections between May 2018 and December 2018. Patients with pancreatic collections having a CT density of >30 Hounsfield Units (HU) were considered for PCD using the kissing catheter technique. This technique involved placing two catheters side-by-side through a single cutaneous entry site, as the conventional technique of PCD may not be effective. The technical details, outcomes and complications of this technique were recorded. A total of 10 patients with a mean age of 30 years underwent PCD using this technique. All patients had severe pancreatitis with a mean CT severity index of 9 (range, 8-10). The mean CT density was 37 HU (range, 32-56). Successful management with PCD alone was achieved in 8 patients. The other 2 patients underwent surgical necrosectomy. One patient who underwent surgical necrosectomy died. Minor complications occurred in 3 patients. The kissing catheter technique allows for a higher success rate of PCD compared with that of the conventional method of PCD, in collections with a higher mean CT density.

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

BACKGROUND/OBJECTIVES

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

Open necrosectomy in acute pancreatitis-obsolete or still useful?

BACKGROUND

Multiple organ failure and early surgery are associated with high morbimortality after open necrosectomy. Data are mostly derived from historical cohorts with early necrosectomy bereft of step-up treatment algorithm implementation. Thus, mostly circumstantial evidence suggests a better clinical course following mini-invasive surgical and endoscopic necrosectomy. We studied the results of open necrosectomy in a contemporary cohort of patients with complicated pancreatic necrosis treated at a tertiary center.

METHODS

A retrospective cohort study from a university teaching hospital. Results of 109 consecutive patients treated with open necrosectomy during a 12-year period are reported.

RESULTS

The overall 90-day mortality rate was 22.9%. The 90-day mortality rate was 10.6% if necrosectomy could be delayed until 4 weeks from symptom onset and the necrosis had become walled off on preoperative imaging. The risk factors for 90-day mortality were age over 60 years (OR 19.4), pre-existing co-morbidities (OR 16.9), necrosectomy within 4 weeks (OR 6.5), multiple organ failure (OR 12.2), white blood cell count over 23 × 10⁹ (OR 21.4), and deterioration or prolonged organ failure as an indication for necrosectomy (OR 10.4). None or one of these risk factors was present in 52 patients (47.7% of all patients), and these patients had no mortality.

CONCLUSION

Late open necrosectomy for walled-off necrosis has a low mortality risk. Open necrosectomy can be done without mortality in the absence of multiple risk factors for surgery.

[Comparison of minimal invasive technologies for treatment of infected pancreatic necrosis]

AIM

the assessment of the role of minimally invasive interventional procedures in the treatment of patients with infected pancreatic necrosis and their safety, as well as comparison of the results of the most common modern minimally invasive techniques among themselves.

METHODS

The results of treatment of 310 patients are presented with infected destructive pancreatitis from 2013 to 2018 on the basis of the city clinical hospital named after I.V. Davydovsky. The patients were divided into three groups: in the first one (n=170) patients underwent puncture followed by drainage of necrotic foci under ultrasound and CT control, in the second (n=98) patients underwent sanation of foci completely by laparoscopic access, in the third (n=42) a series of retroperitoneoscopy was used for the same purpose.

RESULTS

In 114 (67.1%) cases, patients from the first group did not require further surgical intervention. The results of percutaneous drainage were successful. The average length of hospital stay in the first group was 27 days, in the second and third groups - 31 days (the ratio in the 2nd and 3rd groups was 1.03 (95% CI 0.97-1.08; p<0.05)). In the course of treatment, complications were identified in 35 (35.7%) patients in the 2nd and 17 (40.4%) patients in the 3rd group (ratio 0.88 (95% CI 0.82-0.94)). There were 22 (7.1%) deaths. The causes of death were: 1 (0.3%) of the patient had arrosive bleeding, 2 (0.7%) had duodenal fistulas, 19 (6.1%) multiple organ failure against the background of widespread retroperitoneal phlegmon.

CONCLUSION

The efficacy of treatment of infected pancreatic necrosis depends on the possibility of full drainage of the necrotic focus, regardless of approach. Minimally invasive techniques can reduce intraoperative trauma by reducing the wound surface, which contribute to develop systemic inflammatory response syndrome.

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.

Predrainage and Postdrainage Prognostic Nomograms to Predict Outcome of Percutaneous Drainage for Infected Pancreatic and Peripancreatic Necrotic Collections

OBJECTIVES

This study aimed to identify factors affecting outcome of percutaneous catheter drainage (PCD) in management of infected pancreatic necrosis treated with step-up approach.

METHODS

This was a single-center retrospective cohort study that included patients with infected necrosis undergoing PCD as initial intervention. Patients who did not respond underwent necrosectomy. Predictors of PCD failure (ie, mortality or need for necrosectomy) were analyzed. Models were constructed for predrainage and postdrainage use and were internally validated.

RESULTS

Of 304 patients included, catheter drainage was successful in 59.8%, with overall mortality of 22%. Predrainage model consisted of Acute Physiologic and Chronic Health Evaluation II score at admission, early organ failure, and pancreatic necrosis of greater than 50%. Postdrainage model consisted of Acute Physiologic and Chronic Health Evaluation II at first PCD, early organ failure, pancreatic necrosis of greater than 50%, sepsis reversal within 1 week of PCD and Escherichia coli in PCD culture. Both models were internally validated with area under receiver operating characteristics curve of 71.2% for pre-PCD and 81.2% for post-PCD model. Prognostic nomograms were constructed using the models.

CONCLUSIONS

Percutaneous catheter drainage alone was successful in 59.8% with mortality of 22%. The nomograms can help in guiding treatment strategy and referral of high-risk cases.

The effect of technical details of percutaneous catheter drainage on the clinical outcomes of infected necrotizing pancreatitis patients

Background/aim

This study aimed to investigate the effect of technical details of percutaneous catheter drainage (PCD) on the clinical outcomes of patients with infected necrotizing pancreatitis (INP).

Materials and methods

A total of 44 INP patients treated in our hospital from October 2013 to October 2015 were included. The correlations of the first PCD treatment data and the clinical outcomes were analyzed.

Results

The number of catheters was positively correlated with hospital readmission (r = 0.335, P = 0.032). Receiver operating characteristic curve analysis showed that patients with ≥ 3 catheters were more likely to have hospital readmission. Patients with pleural effusion undergoing thoracentesis were more likely to have new intensive care unit admission (P = 0.025) and bleeding in need of intervention (P = 0.032). Patients with more effusion regions had higher incidences of mortality (P = 0.012) and new intensive care unit admissions (2.44 ± 1.03 vs. 1.88 ± 0.80; P = 0.059). Patients with PCD only were less likely to have new intensive care unit admissions (22.22% vs. 54.55%; P = 0.038) than those with PCD + small incision or/and videoscopic assisted retroperitoneal debridement.

Conclusion

Number of catheters greater than three was associated with unfavorable outcomes of PCD treatment in INP patients. Patients that received PCD treatment only had better outcomes.

Predicting Successful Catheter Drainage in Patients With Pancreatic Fistula After Pancreatoduodenectomy

OBJECTIVES

The objective of this study was to identify predictors for successful minimally invasive catheter drainage (ie, survival without relaparotomy) for pancreatic fistula after pancreatoduodenectomy.

METHODS

Included were consecutive patients undergoing catheter drainage as first intervention for pancreatic fistula after pancreatoduodenectomy (2005-2013) in 9 Dutch centers. Possible prognostic factors for successful catheter drainage (ie, survival without relaparotomy) were selected using Akaike information criterion.

RESULTS

Included were 227 patients after 2196 pancreatoduodenectomies. Primary catheter drainage was successful in 175 (77%) of 227 patients. Multivariable logistic regression revealed the following negative prognostic factors for success: male sex (odds ratio [OR], 0.46; 95% confidence interval [CI], 0.21-1.00; P = 0.049), higher age (for every 5 years over 50; OR, 0.69; 95% CI, 0.57-0.84; P < 0.001), and respiratory failure at time of catheter drainage (OR, 0.10; 95% CI, 0.03-0.33; P < 0.001). A prognostic model incorporating these factors yielded an area under the curve of 0.76 and demonstrated a success range of 98% to 14%.

CONCLUSIONS

Male sex, higher age, and respiratory failure are associated with a low success rate of catheter drainage in patients with pancreatic fistula after pancreatoduodenectomy. These patients might benefit from an intensified postoperative monitoring for early detection and management of pancreatic fistula to prevent respiratory failure.

Predictors of outcome of percutaneous catheter drainage in patients with acute pancreatitis having acute fluid collection and development of a predictive model

BACKGROUND

Percutaneous catheter drainage (PCD) is effective initial strategy in the step-up approach of management of acute pancreatitis (AP). The objective of this study was to identify factors associated with outcomes after PCD and develop a predictive model.

METHOD AND MATERIALS

In a prospective observational study between July 2016 and Nov 2017, 101 consecutive AP patients were treated using a "step-up approach" in which PCD was used as the first step. We evaluated the association between success of PCD (survival without necrosectomy) and baseline parameters viz. etiology, demography, severity scores, C-reactive protein (CRP), and intra-abdominal pressure (IAP), morphologic characteristics on computed tomography (CT) [percentage of necrosis, CT severity index (CTSI), characteristics of collection prior to PCD (volume, site and solid component of the collection), PCD parameters (initial size, maximum size, number and duration of drainage) and factors after PCD insertion (fall in IAP, reduction in volume of collection).

RESULTS

Among 101 patients, 51 required PCD. The success rate of PCD was 66.66% (34/51). Four patients required additional surgical necrosectomy after PCD. Overall mortality was 29.4% (15/51). Multivariate analysis showed percentage of volume reduction of fluid collection (p = 0.016) and organ failure (OF) resolution (p = 0.023) after one week of PCD to be independent predictors of success of PCD. A predictive model based on these two factors resulted in area under curve (AUROC) of 0.915. Nomogram was developed with these two factors to predict the probability of success of PCD.

CONCLUSION

Organ failure resolution and reduction in volume of collection after one week of PCD are significant predictors of successful PCD outcomes in patients with fluid collection following AP.

Outcomes of infected pancreatic necrosis complicated with duodenal fistula in the era of minimally invasive techniques

Background: Duodenal fistula (DF) was reportedly thought to be the second most common type of gastrointestinal fistula secondary to acute necrotizing pancreatitis. However, infected pancreatic necrosis (IPN) associated DF (IPN-DF) was rarely specifically reported in the literature. The outcome of IPN-DF was also less well recognized, especially in the era of minimally invasive techniques. A retrospective cohort study was designed mainly focused on the management and outcomes of IPN-DF in the era of minimally invasive techniques. Methods: One hundred and twenty-one consecutive patients diagnosed with IPN between January 2015 and May 2018 were enrolled retrospectively. Among them, 10 patients developed DF. The step-up minimal invasive techniques were highlighted and outcomes were analyzed. Results: Compared with patients without IPN-DF, patients with IPN-DF had longer hospital stay (95.8 vs. 63.5 days, p < .01), but similar mortality rates (10% vs. 21.6%, p > .05). The median interval between the onset of acute pancreatitis (AP) and detection of DF was 2.4 months (1-4 months). The median duration of DF was 1.5 months (0.5-3 months). Out of the 10 patients with DF, 9 had their fistulas resolve spontaneously over time by means of controlling the source of infection with the use of minimally invasive techniques and providing enteral nutritional support, while one patient died of uncontrolled sepsis. No open surgery was performed. On follow-up, the 9 patients recovered completely and remained free of infection and leakage. Conclusion: IPN-DF could be managed successfully using minimally invasive techniques in specialized acute pancreatitis (AP) center. Patients with IPN-DF suffered from a longer hospital stay, but similar mortality rate compared with patients without DF.

Early (<4 Weeks) Versus Standard (≥ 4 Weeks) Endoscopically Centered Step-Up Interventions for Necrotizing Pancreatitis

OBJECTIVES

Current guidelines for necrotizing pancreatitis (NP) recommend delay in drainage ± necrosectomy until 4 or more weeks after initial presentation to allow collections to wall off. However, evidence of infection with clinical deterioration despite maximum support may mandate earlier (<4 weeks) intervention. There are concerns, but scant data regarding risk of complications and outcomes with early endoscopic intervention. Our aim was to compare the results of an endoscopic centered step-up approach to NP when initiated before versus 4 or more weeks.

METHODS

All patients undergoing intervention for NP were managed using an endoscopically centered step-up approach, with transluminal drainage whenever feasible, ±necrosectomy, and/or percutaneous catheter drainage as needed, with surgery only for failures. Interventions were categorized as early or standard based on timing of intervention (<4 weeks or ≥ 4 weeks from onset of pancreatitis). Demographic data, indications and timing for interventions, number and type of intervention, mortality and morbidity (length of stay in hospital and ICU) and complications were compared.

RESULTS

Of 305 patients with collections associated with NP, 193 (63%) (median age-52 years) required intervention, performed by a step-up approach. Of the 193 patients, 76 patients underwent early and 117 patients standard intervention. 144 (75%) interventions included endoscopic drainage ± necrosectomy. As compared with standard intervention, early intervention was more often performed for infection (91% vs. 39%, p < 0.05), more associated with acute kidney injury (43% vs. 32%, p = 0.09), respiratory failure (41% vs. 22%, p = 0.005), and shock (13% vs. 4%, p < 0.05). Organ failure improved significantly after intervention in both groups. There was a significant difference in mortality (13% vs. 4%, p = 0.02) and need for rescue open necrosectomy (7% vs. 1%, p = 0.03) between groups. Patients undergoing early intervention had increased median hospital (37 days vs. 26 days, p = 0.01) and ICU stay (median 2.5 days vs. 0 days, p = 0.001). There was no difference in complications.

CONCLUSIONS

When using an endoscopically centered step-up strategy in necrotizing pancreatitis, early (<4 weeks) interventions were more often performed for infection and organ failure, with no increase in complications, similar improvement in organ failure, slightly increased need for surgery, and relatively low mortality. Early endoscopic drainage ± necrosectomy should be considered when there is a strong indication for intervention.

Natural History of Gas Configurations and Encapsulation in Necrotic Collections During Necrotizing Pancreatitis

BACKGROUND

Decision-making on invasive intervention in patients with clinical signs of infected necrotizing pancreatitis is often related to the presence of gas configurations and the degree of encapsulation in necrotic collections on imaging. Data on the natural history of gas configurations and encapsulation in necrotizing pancreatitis are, however, lacking.

METHODS

A post hoc analysis was performed of a previously described prospective cohort in 21 Dutch hospitals (2004-2008). All computed tomography scans (CTs) performed during hospitalization for necrotizing pancreatitis were categorized per week (1 to 8, and thereafter) and re-assessed by an abdominal radiologist.

RESULTS

A total of 639 patients with necrotizing pancreatitis were included, with median four (IQR 2-7) CTs per patient. The incidence of first onset of gas configurations varied per week without a linear correlation: 2-3-13-11-10-19-12-21-12%, respectively. Overall, gas configurations were found in 113/639 (18%) patients and in 113/202 (56%) patients with infected necrosis. The incidence of walled-off necrosis increased per week: 0-3-12-39-62-76-93-97-100% for weeks 1-8 and thereafter respectively. Clinically relevant walled-off necrosis (largely or fully encapsulated necrotic collections) was seen in 162/379 (43%) patients within the first 3 weeks.

CONCLUSIONS

Gas configurations occur in every phase of the disease and develop in half of the patients with infected necrotizing pancreatitis. Opposed to traditional views, clinically relevant walled-off necrosis occurs frequently within the first 3 weeks.

Management of infected pancreatic necrosis: state of the art

Pancreatic necrosis occurs in 15% of acute pancreatitis. The presence of infection is the most important factor in the evolution of pancreatitis. The diagnosis of infection is still challenging. Mortality in infected necrosis is 20%; in the presence of organic dysfunction, mortality reaches 60%. In the last three decades, there has been a real revolution in the treatment of infected pancreatic necrosis. However, the challenges persist and there are many unsolved questions: antibiotic treatment alone, tomography-guided percutaneous drainage, endoscopic drainage, video-assisted extraperitoneal debridement, extraperitoneal access, open necrosectomy? A step up approach has been proposed, beginning with less invasive procedures and reserving the operative intervention for patients in which the previous procedure did not solve the problem definitively. Indication and timing of the intervention should be determined by the clinical course. Ideally, the intervention should be done only after the fourth week of evolution, when it is observed a better delimitation of necrosis. Treatment should be individualized. There is no procedure that should be the first and best option for all patients. The objective of this work is to critically review the current state of the art of the treatment of infected pancreatic necrosis.

Risk Factors for the Need of Surgical Necrosectomy After Percutaneous Catheter Drainage in the Management of Infection Secondary to Necrotizing Pancreatitis

OBJECTIVES

This study aimed to assess the need of surgical necrosectomy after percutaneous catheter drainage (PCD) for infected necrotizing pancreatitis.

METHODS

The clinical data of documented/suspected patients who were treated with a step-up approach were extracted and analyzed.

RESULTS

Of the 329 patients enrolled, the initial PCD was performed at 12 (interquartile range, 9-15) days since onset and 35.3% were cured by PCD alone. In the pre-PCD model, mean computed tomographic (CT) density of necrotic fluid collection (NFC; P < 0.001), and multiple-organ failure (MOF; P < 0.001) within 24 hours before the initial PCD were independent risk factors, and a combination of the previously mentioned 2 factors produced an area under the curve of 0.775. In the post-PCD model, mean CT density of NFC (P = 0.041), MOF (P = 0.002), and serum procalcitonin level (P = 0.035) 3 days after the initial PCD were independent risk factors, and a combination of these previously mentioned factors produced an area under the curve of 0.642.

CONCLUSIONS

Both mean CT density of NFC and MOF are independent pre- and post-PCD risk factors for the need of necrosectomy after PCD. Post-PCD serum procalcitonin level might be a respondent factor that is correlated with the necessity of necrosectomy.

Risk factors and outcomes of infected pancreatic necrosis: Retrospective cohort of 148 patients admitted to the ICU for acute pancreatitis

Objective

The primary objective of this article is to identify risk factors for infected pancreatic necrosis (IPN) in patients admitted to the intensive care unit (ICU) for severe acute pancreatitis. We also described outcomes of IPN.

Background

Acute pancreatitis is common and associated with multiple, potentially life-threatening complications. Over the last decade, minimally invasive procedures have been developed to treat IPN.

Methods

We retrospectively studied consecutive patients admitted for severe acute pancreatitis to the ICUs of the Nantes University Hospital in France, between 2012 and 2015. Logistic regression was used to evaluate potential associations linking IPN to baseline patient characteristics and outcomes.

Results

Of the 148 included patients, 26 (17.6%) died. IPN developed in 62 (43%) patients and consistently required radiological, endoscopic, and/or surgical intervention. By multivariate analysis, factors associated with IPN were number of organ failure (OF) (for ≥ 3: OR, 28.67 (6.23-131.96), p < 0.001) and portosplenomesenteric venous thrombosis (OR, 8.16 (3.06-21.76)).

Conclusion

IPN occurred in nearly half our ICU patients with acute pancreatitis and consistently required interventional therapy. Number of OFs and portosplenomesenteric venous thrombosis were significantly associated with IPN. Early management of OF may reduce IPN incidence, and management of portosplenomesenteric venous thrombosis should be investigated.

Endoscopic or surgical step-up approach for infected necrotising pancreatitis: a multicentre randomised trial

BACKGROUND

Infected necrotising pancreatitis is a potentially lethal disease and an indication for invasive intervention. The surgical step-up approach is the standard treatment. A promising alternative is the endoscopic step-up approach. We compared both approaches to see whether the endoscopic step-up approach was superior to the surgical step-up approach in terms of clinical and economic outcomes.

METHODS

In this multicentre, randomised, superiority trial, we recruited adult patients with infected necrotising pancreatitis and an indication for invasive intervention from 19 hospitals in the Netherlands. Patients were randomly assigned to either the endoscopic or the surgical step-up approach. The endoscopic approach consisted of endoscopic ultrasound-guided transluminal drainage followed, if necessary, by endoscopic necrosectomy. The surgical approach consisted of percutaneous catheter drainage followed, if necessary, by video-assisted retroperitoneal debridement. The primary endpoint was a composite of major complications or death during 6-month follow-up. Analyses were by intention to treat. This trial is registered with the ISRCTN registry, number ISRCTN09186711.

FINDINGS

Between Sept 20, 2011, and Jan 29, 2015, we screened 418 patients with pancreatic or extrapancreatic necrosis, of which 98 patients were enrolled and randomly assigned to the endoscopic step-up approach (n=51) or the surgical step-up approach (n=47). The primary endpoint occurred in 22 (43%) of 51 patients in the endoscopy group and in 21 (45%) of 47 patients in the surgery group (risk ratio [RR] 0·97, 95% CI 0·62-1·51; p=0·88). Mortality did not differ between groups (nine [18%] patients in the endoscopy group vs six [13%] patients in the surgery group; RR 1·38, 95% CI 0·53-3·59, p=0·50), nor did any of the major complications included in the primary endpoint.

INTERPRETATION

In patients with infected necrotising pancreatitis, the endoscopic step-up approach was not superior to the surgical step-up approach in reducing major complications or death. The rate of pancreatic fistulas and length of hospital stay were lower in the endoscopy group. The outcome of this trial will probably result in a shift to the endoscopic step-up approach as treatment preference.

FUNDING

The Dutch Digestive Disease Foundation, Fonds NutsOhra, and the Netherlands Organization for Health Research and Development.

Novel strategies for the treatment of acute pancreatitis based on the determinants of severity

Acute pancreatitis (AP) is a common disease for which a specific treatment remains elusive. The key determinants of the outcome from AP are persistent organ failure and infected pancreatic necrosis. The prevention and treatment of these determinants provides a framework for the development of specific treatment strategies. The gut-lymph concept provides a common mechanism for systemic inflammation and organ dysfunction. Acute and critical illness, including AP, is associated with intestinal ischemia and drastic changes in the composition of gut lymph, which bypasses the liver to drain into the systemic circulation immediately proximal to the major organ systems which fail. The external diversion of gut lymph and the targeting of treatments to counter the toxic elements in gut lymph offers novel approaches to the prevention and treatment of persistent organ failure. Infected pancreatic necrosis is increasingly treated with less invasive techniques, the mainstay of which is drainage, both endoscopic and percutaneous. Further improvements will occur with the strategies to accelerate liquefaction and through a fundamental re-design of drains, both of which will increase drainage efficacy. The determinants of severity and outcome in patients admitted with AP provide the basis for innovative treatment strategies. The priorities are to translate the gut-lymph concept to clinical practice and to improve the design and active use of drains for infected complications of AP.

Proactive Versus Standard Percutaneous Catheter Drainage for Infected Necrotizing Pancreatitis

OBJECTIVES

Percutaneous catheter drainage (PCD) is often the first invasive treatment step for infected necrotizing pancreatitis. A proactive PCD strategy, including frequent and early drain revising and upsizing, may reduce the need for surgical necrosectomy and could improve outcomes, but data are lacking.

METHODS

Necrotizing pancreatitis patients were identified from in-hospital databases (2004-2014). Patients with primary PCD for infected necrotizing pancreatitis were included. Outcomes of patients from 1 center using a proactive PCD strategy were compared with 3 standard strategy centers.

RESULTS

In total, 369 (25.9%) of 1427 patients received a diagnosis of necrotizing pancreatitis, and 117 (31.7%) of 369 patients underwent primary PCD for infected necrosis: 42 in the proactive group versus 75 in the standard group. Patients in the proactive group had more drain-related procedures (median, 3; interquartile range [IQR], 2-4; versus 2; IQR, 1-2; P < 0.001) and larger final drain sizes (median, 16F; IQR, 14F-20F; versus 14F; IQR, 12F-14F; P < 0.001). Fewer patients underwent additional necrosectomy in the proactive group, 12 (28.6%) versus 39 (52.0%) (adjusted odds ratio, 0.349; 95% confidence interval, 0.137-0.889; P = 0.027), with similar hospital stay and mortality.

CONCLUSIONS

A proactive PCD strategy is associated with reduced need for necrosectomy in infected necrotizing pancreatitis, compared with standard PCD, with similar clinical outcomes.

Pancreatic Necrosis and Gas in the Retroperitoneum: Treatment with Antibiotics Alone

OBJECTIVE:

To present our experience in the management of patients with infected pancreatic necrosis without drainage.

METHODS:

The records of patients with pancreatic necrosis admitted to our facility from 2011 to 2015 were retrospectively reviewed.

RESULTS:

We identified 61 patients with pancreatic necrosis. Six patients with pancreatic necrosis and gas in the retroperitoneum were treated exclusively with clinical support without any type of drainage. Only 2 patients had an APACHE II score >8. The first computed tomography scan revealed the presence of gas in 5 patients. The Balthazar computed tomography severity index score was >9 in 5 of the 6 patients. All patients were treated with antibiotics for at least 3 weeks. Blood cultures were positive in only 2 patients. Parenteral nutrition was not used in these patients. The length of hospital stay exceeded three weeks for 5 patients; 3 patients had to be readmitted. A cholecystectomy was performed after necrosis was completely resolved; pancreatitis recurred in 2 patients before the operation. No patients died.

CONCLUSIONS:

In selected patients, infected pancreatic necrosis (gas in the retroperitoneum) can be treated without percutaneous drainage or any additional surgical intervention. Intervention procedures should be performed for patients who exhibit clinical and laboratory deterioration.

Negative pressure irrigation and endoscopic necrosectomy through man-made sinus tract in infected necrotizing pancreatitis: a technical report

BACKGROUND

In recent years, a step-up approach based on minimally invasive techniques was recommended by latest guidelines as initial invasive treatment for infected pancreatic necrosis (IPN). In this study, we aimed to describe a novel step-up approach for treating IPN consisting of four steps including negative pressure irrigation (NPI) and endoscopic necrosectomy (ED) as a bridge between percutaneous catheter drainage (PCD) and open necrosectomy METHODS: A retrospective review of a prospectively collected internal database of patients with a diagnosis of IPN between Jan, 2012 to Dec, 2012 at a single institution was performed. All patients underwent the same drainage strategy including four steps: PCD, NPI, ED and open necrosectomy. The demographic characteristics and clinical outcomes of study patients were analyzed.

RESULTS

A total of 71 consecutive patients (48 males and 23 females) were included in the analysis. No significant procedure-related complication was observed and the overall mortality was +21.1 % (15 of 71 patients). Seven different strategies like PCD+ NPI, PCD+NPI+ED, PCD+open necrosectomy, etcetera, were applied in study patients and a half of them received PCD alone. In general, each patient underwent a median of 2 drainage procedures and the median total drainage duration was 11 days (interquartile range, 6-21days).

CONCLUSIONS

This four-step approach is effective in treating IPN and adds no extra risk to patients when compared with other latest step-up strategies. The two novel techniques (NPI and ED) could offer distinct clinical benefits without posing unanticipated risks inherent to the procedures.

Comparison between minimally invasive and open surgical treatment in necrotizing pancreatitis

BACKGROUND

Minimal access techniques have gained popularity for the management of necrotizing pancreatitis, but only a few studies compared open necrosectomy with a less invasive treatment. The aim of this study was to evaluate the outcomes of minimally invasive treatment for necrotizing pancreatitis in comparison with open necrosectomy.

MATERIALS AND METHODS

This retrospective study included 70 patients who underwent minimally invasive intervention or open surgical debridement for necrotizing pancreatitis between January 2007 and December 2014. Data were analyzed for postoperative morbidity and outcome.

RESULTS

Of 70 patients, 22 patients underwent primary open necrosectomy and 48 patients were treated with minimally invasive techniques. Percutaneous and endoscopic drainage were successful in 34.9% and 75.0% of patients, respectively. The rates of postoperative new-onset organ failure and intensive care unit stay were significantly lower in the minimally invasive group (25.0% versus 54.5%; P = 0.016, and 29.2% versus 54.5%; P = 0.041, respectively). Gastrointestinal fistulas occurred more frequently after primary open necrosectomy (36.4% versus 10.4%; P = 0.009). Mortality was comparable in both groups (18.6% versus 27.3%; P = 0.420). Mortality for salvage open necrosectomy was similar to that for primary open debridement (28.6% versus 27.3%; P = 0.924). The independent risk factors for major postoperative complications were primary open necrosectomy (P = 0.028) and shorter interval to first intervention (P = 0.020). Mortality was independently associated only with older age (P = 0.009).

CONCLUSIONS

Minimally invasive treatment should be preferred over open necrosectomy for initial management of necrotizing pancreatitis.

Necrotizing pancreatitis: challenges and solutions

Acute pancreatitis is a common disease that can progress to gland necrosis, which imposes significant risk of morbidity and mortality. In general, the treatment for pancreatitis is a supportive therapy. However, there are several reasons to escalate to surgery or another intervention. This review discusses the pathophysiology as well as medical and interventional management of necrotizing pancreatitis. Current evidence suggests that patients are best served by delaying interventions for at least 4 weeks, draining as a first resort, and debriding recalcitrant tissue using minimally invasive techniques to promote or enhance postoperative recovery while reducing wound-related complications.