Percutaneous “stepped” drainage technique for infected pancreatic necrosis. Surg Laparosc Endosc Percutan Tech. 2009;19:e113-e118. [PMID: 19692859 DOI: 10.1097/sle.0b013e3181a9d37d]

Controversies in the management of acute pancreatitis: An update

This review summarized the current controversies in the management of acute pancreatitis (AP). The controversies in management range from issues involving fluid resuscitation, nutrition, the role of antibiotics and antifungals, which analgesic to use, role of anticoagulation and intervention for complications in AP. The interventions vary from percutaneous drainage, endoscopy or surgery. Active research and emerging data are helping to formulate better guidelines. The available evidence favors crystalloids, although the choice and type of fluid resuscitation is an area of dynamic research. The nutrition aspect does not have controversy as of now as early enteral feeding is preferred most often than not. The empirical use of antibiotics and antifungals are gray zones, and more data is needed for conclusive guidelines. The choice of analgesic is being studied, and the recommendations are still evolving. The position of using anticoagulation is still awaiting consensus. The role of intervention is well established, although the modality is constantly changing and favoring endoscopy or percutaneous drainage rather than surgery. It is evident that more multicenter randomized controlled trials are required for establishing the standard of care in these crucial management issues of AP to improve the morbidity and mortality worldwide.

An audit of percutaneous drainage for acute necrotic collections and walled off necrosis in patients with acute pancreatitis

BACKGROUND AND OBJECTIVES

Percutaneous catheter drainage (PCD) is used as a first step in the management of symptomatic fluid collections in patients with acute pancreatitis (AP). We aimed to compare the outcome of patients with acute necrotic collection (ANC) and those with walled-off necrosis (WON), who had undergone PCD as a part of management of AP.

METHODS

Consecutive patients of AP with symptomatic ANC or WON undergoing PCD were evaluated. Primary outcome measures were need for additional surgical necrosectomy and mortality. Secondary outcome measures were need for up-gradation of first PCD, need for additional drain, in-hospital as well as total duration of PCD and length of hospital stay.

RESULTS

Indications of PCD in 375 patients (258 with ANC and 117 with WON) were suspected infected pancreatic necrosis (n = 214), persistent organ failure (n = 117) and pressure symptoms (n = 44). Need for additional surgical necrosectomy was seen in 14% patients with ANC and in 12% of patients with WON (p = 0.364) and mortality was 19% in patients with ANC as compared to 13.7% in those with WON (p = 0.132). There was no significant difference in the secondary outcome parameters between patients who underwent PCD for ANC or WON. Complications of PCD were comparable between patients with ANC and WON except development of external pancreatic fistula which occurred more often in patients with WON than in those with ANC (24.4% versus 34.2% respectively, p = 0.034).

CONCLUSION

Persistent organ failure in more often an indication of PCD in patients with ANC than in WON and suspected infection is more commonly an indication in WON than in ANC. Early PCD is as efficacious and safe as delayed PCD.

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.

Timing of catheter drainage in infected necrotizing pancreatitis

Acute pancreatitis is the most common gastrointestinal indication for hospital admission, and infected pancreatic and/or extrapancreatic necrosis is a potentially lethal complication. Current standard treatment of infected necrosis is a step-up approach, consisting of catheter drainage followed, if necessary, by minimally invasive necrosectomy. International guidelines recommend postponing catheter drainage until the stage of 'walled-off necrosis' has been reached, a process that typically takes 4 weeks after onset of acute pancreatitis. This recommendation stems from the era of primary surgical necrosectomy. However, postponement of catheter drainage might not be necessary, and earlier detection and subsequent earlier drainage of infected necrosis could improve outcome. Strong data and consensus among international expert pancreatologists are lacking. Future clinical, preferably randomized, studies should focus on timing of catheter drainage in patients with infected necrotizing pancreatitis. In this Perspectives, we discuss challenges in the invasive treatment of patients with infected necrotizing pancreatitis, focusing on timing of catheter drainage.

Minimally invasive treatment of infected pancreatic necrosis

Infected pancreatic necrosis is a challenging complication that worsens prognosis in acute pancreatitis. For years, open necrosectomy has been the mainstay treatment option in infected pancreatic necrosis, although surgical debridement still results in high morbidity and mortality rates. Recently, many reports on minimally invasive treatment in infected pancreatic necrosis have been published. This paper presents a review of minimally invasive techniques and attempts to define their role in the management of infected pancreatic necrosis.

Is necrosectomy obsolete for infected necrotizing pancreatitis? Is a paradigm shift needed?

In 1886, Senn stated that removing necrotic pancreatic and peripancreatic tissue would benefit patients with severe acute pancreatitis. Since then, necrosectomy has been a mainstay of surgical procedures for infected necrotizing pancreatitis (NP). No published report has successfully questioned the role of necrosectomy. Recently, however, increasing evidence shows good outcomes when treating walled-off necrotizing pancreatitis without a necrosectomy. The literature concerning NP published primarily after 2000 was reviewed; it demonstrates the feasibility of a paradigm shift. The majority (75%) of minimally invasive necrosectomies show higher completion rates: between 80% and 100%. Transluminal endoscopic necrosectomy has shown remarkable results when combined with percutaneous drainage or a metallic stent. Related morbidities range from 40% to 92%. Single-digit mortality rates have been achieved with transluminal endoscopic necrosectomy, but not with video-assisted retroperitoneal necrosectomy series. Drainage procedures without necrosectomy have evolved from percutaneous drainage to transluminal endoscopic drainage with or without percutaneous endoscopic gastrostomy access for laparoscopic instruments. Most series have reached higher success rates of 79%-93%, and even 100%, using transcystic multiple drainage methods. It is becoming evident that transluminal endoscopic drainage treatment of walled-off NP without a necrosectomy is feasible. With further refinement of the drainage procedures, a paradigm shift from necrosectomy to drainage is inevitable.

Interventions for necrotizing pancreatitis: an overview of current approaches

The management of necrotizing pancreatitis has undergone a paradigm shift toward minimally invasive techniques for necrosectomy, obviating the need for open necrosectomy in most cases. There is increasing evidence that minimally invasive approaches including a step-up approach that incorporates percutaneous catheter or endoscopic transluminal drainage, followed by video-assisted retroperitoneal or endoscopic debridement are associated with improved outcomes over traditional open necrosectomy for patients with infected necrosis. A recent international multidisciplinary consensus conference emphasized the superiority of minimally invasive approaches over standard surgical approaches. The success of these techniques depends on concerted efforts of a multidisciplinary team of interventional endoscopists, radiologists, intensivists and surgeons dedicated to the management of severe acute pancreatitis and its complications. This review provides an overview of minimally invasive techniques for management of necrotizing pancreatitis, including indications, timing, advantages and disadvantages.

Efficacy of conservative treatment, without necrosectomy, for infected pancreatic necrosis: a systematic review and meta-analysis

BACKGROUND & AIMS

Conservative treatment (intensive care, a combination of antimicrobial agents, and nutritional support, with or without drainage of the infected fluid) has recently been shown to be effective for patients with infected pancreatic necrosis (IPN), but the data from individual studies are not robust enough to recommend it as the standard of care. We performed a systematic review and meta-analysis of studies related to primary conservative management for IPN.

METHODS

We performed a literature search of MEDLINE/PubMed from January 1990 to March 2012 for studies of a priori protocols for primary conservative treatment, without necrosectomy, for consecutive patients with IPN. We analyzed data from 8 studies, comprising 324 patients with IPN who received primary conservative management. We then analyzed an additional 4 studies (comprising 157 patients) that reported the efficacy of percutaneous drainage in nonconsecutive patients with IPN. Outcome measures were the success of conservative management strategy, need for necrosectomy, and mortality.

RESULTS

There was significant heterogeneity in results among the studies. Based on a random effects model, conservative management was successful for 64% of patients (95% confidence interval [CI], 51%-78%); mortality was 12% (95% CI, 6%-18%), and 26% of patients required necrosectomy or additional surgery for complications (95% CI, 15%-37%). A separate analysis of 4 studies that reported outcomes of nonconsecutive patients with IPN following percutaneous drainage had comparable results; 50% had successful outcomes (95% CI, 43%-58%), mortality was 18% (95% CI, 6%-30%), and 38% of patients required surgery (95% CI, 20%-56%).

CONCLUSIONS

Conservative management without necrosectomy is a successful approach for 64% of patients with IPN. This approach has low mortality and prevents surgical necrosectomy.

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

AIM

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

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

BACKGROUND

The role of percutaneous catheter drainage (PCD) in patients with (infected) necrotizing pancreatitis was evaluated.

METHODS

A systematic literature search was performed. Inclusion criteria were: consecutive cohort of patients with necrotizing pancreatitis undergoing PCD as primary treatment for peripancreatic collections; indication for PCD either (suspected) infected necrosis or symptomatic sterile pancreatic necrosis; and outcomes reported to include percentage of infected peripancreatic collections, need for additional surgical necrosectomy, complications and deaths. Exclusion criteria were: cohort of fewer than five patients; cohort included patients with chronic pancreatitis; selected subgroup of patients with acute pancreatitis studied, such as those with pseudocysts, pancreatic abscesses and/or exclusively sterile pancreatic necrosis; and cohort in which PCD was combined with another minimally invasive strategy and results for PCD alone not reported separately.

RESULTS

Eleven studies, including 384 patients, fulfilled the inclusion criteria. Only one study was a randomized controlled trial; most others were retrospective case series. Four studies reported on the presence of organ failure before PCD; this occurred in 67·2 per cent of 116 patients. Infected necrosis was proven in 271 (70·6 per cent) of 384 patients. No additional surgical necrosectomy was required after PCD in 214 (55·7 per cent) of 384 patients. Complications consisted mostly of internal and external pancreatic fistulas. The overall mortality rate was 17·4 per cent (67 of 384 patients). Nine of 11 studies reported mortality separately for patients with infected necrosis undergoing PCD; the mortality rate in this group was 15·4 per cent (27 of 175).

CONCLUSION

A considerable number of patients can be treated with PCD without the need for surgical necrosectomy.

Pancreatite necro-hemorrágica: atualização e momento de operar

INTRODUÇÃO: A pancreatite necro-hemorrágica representa a variante mais grave do espectro de apresentações clínicas que podem compor o quadro da pancreatite aguda. Embora já conhecida há muitos séculos, inúmeras questões permanecem em aberto acerca dessa entidade e o número de trabalhos sobre o assunto publicados nos últimos anos tem sido muito expressivo. MÉTODO: Foi realizada ampla pesquisa na literatura, com especial atenção aos artigos publicados nos últimos três anos e indexados ao PubMed. Foram utilizados os seguintes descritores de forma cruzada: pancreatitis, surgical procedures; necrosis. A pesquisa inicial evidenciou cerca de 13.000 artigos, sendo avaliados os mais relevantes dos últimos três anos além de artigos mais antigos, considerados "clássicos" sobre o assunto e que, portanto, não poderiam deixar de ser citados. CONCLUSÃO: O tratamento da pancreatite aguda envolve um grande número de questões, dentre as quais as mais importantes estão relacionadas ao manejo da antibioticoterapia, tipo de dieta empregada e as questões relacionadas ao manejo da necrose infectada. Em especial, mudanças radicais foram implementadas nos últimos anos sobre todos esses tópicos, e uma atualização constante deve ser obrigatoriamente buscada pelos profissionais envolvidos no tratamento dessa doença.

Pseudocyst management: endoscopic drainage and other emerging techniques

Pseudocyst formation is a well known complication of pancreatitis. Not all pancreatic pseudocysts require intervention. Selected patients who are asymptomatic can be subject to expectant management. Spontaneous resolution has been shown to occur in 40% to 50% of patients with no serious complications occurring during the observation period. Intervention is warranted if the patient is symptomatic, there is a progressive increase in size or if the pseudocyst is infected. Surgery was the only available treatment for pseudocysts for a long time. Of late other modalities like percutaneous, endoscopic, and laparoscopic drainage have come to be seen as viable alternatives.