Step-up approach for the management of pancreatic necrosis: a review of the literature

Endoscopic Ultrasonography-Guided Drainage of the Pancreatic Duct (EUS-PD)-Indications and Results with a Literature Review

Background/Objectives: Drawing upon over twenty years of clinical experience in endoscopic and endosonographic procedures, along with comprehensive literature research, we present an overview on EUS-guided pancreatography and pancreatic duct drainage (EUS-PD) as an alternative approach, encompassing indications, procedural methods, and outcomes, including complications and the success rate. Methods: Narrative review. Results: (corner points): EUS-PD is indicated for cases, for which conventional methods are ineffective due to altered abdominal anatomy of the upper gastrointestinal (GI) tract, such as congenital or postoperative conditions that prevent access to the papilla or pancreatoenteric anastomosis. It is also considered if there is symptomatic retention of the pancreatic duct due to pathological changes in the papillary region or stenosis of the pancreatic duct or anastomosis, especially if surgery is not feasible or poses higher risks. EUS-PD has a technical success rate ranging from 25 to 92%, albeit with a complication rate spanning from 14 to 40%, primarily comprising bleeding, perforation, pancreatitis, and pain. Long-term clinical success, measured by pain and symptom relief, falls within a range of 65-85%. Conclusions: The method offers advantages such as minimal invasiveness, enhanced quality of life, the potential for endoscopic revision in the case of complications, and compatibility with most conventional endoscopic instruments requiring extensive expertise in interventional endoscopy and endosonography.

Step-Up versus Open Approach in the Treatment of Acute Necrotizing Pancreatitis: A Case-Matched Analysis of Clinical Outcomes and Long-Term Pancreatic Sufficiency

Background/Objectives: Acute necrotizing pancreatitis (ANP) with secondary infection of necrotic tissue is associated with a high rate of complications and mortality. The optimal approach is still debatable, but the minimally invasive modality has gained great attention in the last decade as it follows the principle of applying minimal surgical trauma to achieve a satisfying therapeutic objective. We compared clinical outcomes between the step-up approach (SUA) and open necrosectomy (ON) in the treatment of acute necrotizing pancreatitis. Methods: A prospective cohort study over the period of 2011-2021 in a university teaching hospital was performed. Results of 99 consecutive patients with ANP who required surgical/radiological intervention were collected. A case match analysis (2:1) was performed, and the final groups comprised 40 patients in the OA group and 20 patients in the SUA group. Demographic, clinicopathologic, and treatment data were reviewed. Results: Baseline characteristics and disease severity were comparable between the two groups. The patients from the SUA group had a significantly lower morbidity rate and rate of pancreatic insufficiency. Death occurred in 4 of 20 patients (20%) in the SUA group and in 11 of 40 patients (27.5%) in the ON group (risk ratio with the step-up approach, 0.72; 95% confidence interval, 0.26 to 1.99; p = 0.53). Conclusions: A minimally invasive step-up approach provides comparable outcomes to open necrosectomy in the treatment of ANP with infected pancreatic necrosis. While mortality and hospital stay were comparable between the groups, morbidity and pancreatic insufficiency were significantly lower in the SUA group. Further studies on a larger number of patients are required to define the place of SUA in the modern treatment of ANP.

Free intraperitoneal air in infected pancreatic necrosis with intraperitoneal rupture: A rare presentation of a complex diseases

Key Clinical Message

Among the multitude of causes for acute abdomen patients presenting with free intraperitoneal air, one almost never finds infected pancreatic necrosis as one of the culprits. In patients with risk factors for acute pancreatitis presenting with generalized peritonitis with free intraperitoneal air, consideration should be given to this often deadly entity.

Abstract

Acute pancreatitis is a morbid acute abdominal pathology that has been increasing in incidence in recent years. Most patients have a mild disease and treated medically, while a few proportion require interventional procedures. We present the case of a 39-year-old male patient who presented with progressive abdominal pain, vomiting, and yellowish discoloration of the eyes. The abdominal condition progressed to the point where clinical signs became consistent with generalized peritonitis and an x-ray finding of free intraperitoneal air. The patient underwent exploratory laparotomy with intraoperative findings of intraperitoneal rupture of infected pancreatic necrosis with intraperitoneal purulent collection. He was managed with necrosectomy and discharged improved after intensive care and general ward stay.

A core outcome set for acute necrotizing pancreatitis: An Eastern Association for the Surgery of Trauma modified Delphi method consensus study

BACKGROUND

The management of acute necrotizing pancreatitis (ANP) has changed dramatically over the past 20 years including the use of less invasive techniques, the timing of interventions, nutritional management, and antimicrobial management. This study sought to create a core outcome set (COS) to help shape future research by establishing a minimal set of essential outcomes that will facilitate future comparisons and pooling of data while minimizing reporting bias.

METHODS

A modified Delphi process was performed through involvement of ANP content experts. Each expert proposed a list of outcomes for consideration, and the panel anonymously scored the outcomes on a 9-point Likert scale. Core outcome consensus defined a priori as >70% of scores receiving 7 to 9 points and <15% of scores receiving 1 to 3 points. Feedback and aggregate data were shared between rounds with interclass correlation trends used to determine the end of the study.

RESULTS

A total of 19 experts agreed to participate in the study with 16 (84%) participating through study completion. Forty-three outcomes were initially considered with 16 reaching consensuses after four rounds of the modified Delphi process. The final COS included outcomes related to mortality, organ failure, complications, interventions/management, and social factors.

CONCLUSION

Through an iterative consensus process, content experts agreed on a COS for the management of ANP. This will help shape future research to generate data suitable for pooling and other statistical analyses that may guide clinical practice.

LEVEL OF EVIDENCE

Therapeutic/Care Management; Level V.

Endoscopic transpapillary stent placement in patients with necrotizing pancreatitis and disconnected main pancreatic duct syndrome

INTRODUCTION

Pancreatic necrosis is one of the most severe acute abdominal conditions, accounting for 15%-20% of all patients with acute pancreatitis and characterized by significant rates of postoperative complications and mortality. Patients with pancreatic necrosis, in which pathological changes are localized in the proximal pancreas and retroperitoneal space, deserve special attention. This form of the disease includes patients with disconnected main pancreatic duct (MPD) syndrome who have a difficult prognosis.

AIM

The aim of the study was an improvement of treatment results in patients with necrotizing pancreatitis and signs of the dissociation of the pancreas duct system using the endoscopic transpapillary stent placement method.

MATERIAL AND METHODS

This study was a retrospective cohort study. There were 32 patients with acute necrotizing pancreatitis who were managed using the endoscopic transpapillary stent placement method between 2019 and 2021. Disconnected MPD syndrome was diagnosed in all 32 patients. In total, 26 patients were admitted to hospital in the first 72 h, while 6 patients were admitted after 72 h. We diagnosed the necrotizing process located in the proximal and central areas of the pancreas and peripancreatic space in all these patients ("model III").

RESULTS

Positive results related to transpapillary stent placement were noted in 24 (75%) patients (first cohort). A total of 20 patients from this group were admitted to hospital in the first 48 h, and 4 patients were admitted later than 72 h from the onset of disease. Moreover, 8 patients (25%; second cohort) failed to succeed in transpapillary stent placement. Complications in the first cohort occurred in 3 (12.5%) patients: dislocation of the stent into the duodenum occurred in 1 patient, and bleeding after papillosphincterotomy took place in 2 patients. Meanwhile, infected necrotized pancreatitis developed in 5 patients, and 1 patient (5%) died. Complications among the second cohort occurred in 2 (25%) patients: erosive bleeding (after debridement). Infected necrotized pancreatitis developed in 4 patients, and 2 patients (25%) died.

CONCLUSIONS

Endoscopic transpapillary stent placement is an effective minimally invasive approach in the management of patients with necrotizing pancreatitis.

Endoscopic necrosectomy of infected WON in acute necrotising pancreatitis - Development of an effective therapeutic algorithm based on a single-center consecutive patient cohort

OBJECTIVE

Development of an effective therapeutic algorithm for interventional (minimally invasive) approach to infected walled-off necrosis (WON) in patients with necrotising pancreatitis reflecting real-word data.

MATERIAL/METHODS

All consecutive patients who underwent endoscopic necrosectomy for necrotising pancreatitis through a defined study period were enclosed in this retrospective observational case study. The therapeutic approach was analysed for clinical success rate, complication spectrum and rate as well as mortality and compared with data from the literature. Finally, a therapeutic algorithm was derived.

RESULTS

From 2004 to 2019, 126 patients with necrotising pancreatitis (median of APACHE II score, 10.5 points) were treated. In 92.9 % of cases (n=117), an infected WON with microbial pathogen detection was found. After a median of 18 days from symptom onset, first intervention was performed (53.2 % as percutaneous drainage with programmed rinsing, 29.4 % as EUS-guided internal drainage). From 2004 to 2010, double pigtail stents were used. Later, lumen-apposing metal stent (LAMS) such as AXIOS^TM stent (Boston Scientific, Ratingen, Germany) was preferred. The combined percutaneous and internal drainage was performed in approximately 50 % of subjects.Endoscopic transluminal necrosectomy was performed in 123 patients (97.6 %) at a median of 33 days from symptom onset. Endoscopic percutaneous necrosectomy was conducted in 11.1 % of the individuals. A median number of two endoscopic necrosectomy sessions per patient was necessary for the therapy. The clinical success rate (discharge without surgical intervention) was 82.5 %. The complication rate (bleeding and perforation) and the need for surgery were both 9.5 %. The overall mortality was 8.7 %.

CONCLUSION

Therapy of necrotising pancreatitis with infected WON consists of early calculated antibiotic therapy with adequate drainage. Combined external and internal drainages with programmed rinsing seem to improve prognosis, as well as minimise I) : the need for forced necrosectomies (mainly via a transluminal access site) and II) : complication rate as well as, thus, improve outcome.

Trends in pancreatic surgery experience in general surgery residency in the US, 1990–2021

BACKGROUND

We hypothesized a decline in resident pancreatic operative experience. The study assesses trends in that experience since 1990.

METHODS

Accreditation Council for Graduate Medical Education (ACGME) national case log data of general surgery residency graduates from 1990 to 2021 were reviewed. Collected and analyzed were the mean and median total number of pancreatic operations per resident, the mean number of specific case types performed, and the annual number of residency graduates. For selected procedures, the mean number of cases by resident role (Surgeon-Chief and Surgeon-Junior) was also analyzed.

RESULTS

Both the mean and median total number of resident pancreatic operations has declined since 2009 as have the mean number of several specific pancreatic case types, including resections. The annual number of residency graduates has significantly increased since 1990, and particularly since 2009.

CONCLUSIONS

Resident volume in pancreatic operations has significantly declined over the last decade.

Decreasing use of pancreatic necrosectomy and NSQIP predictors of complications and mortality

BACKGROUND

Surgical pancreatic necrosectomy (SPN) is an option for the management of infected pancreatic necrosis. The literature indicates that an escalating, combined endoscopic, interventional radiology and minimally invasive surgery "step-up" approach, such as video-assisted retroperitoneal debridement, may reduce the number of required SPNs and ICU complications, such as multiple organ failure. We hypothesized that complications for surgically treated severe necrotizing pancreatitis patients decreased during the period of adoption of the "step-up" approach.

METHODS

The American college of surgeons national surgery quality improvement program database (ACS-NSQIP) was used to find SPN cases from 2007 to 2019 in ACS-NSQIP submitting hospitals. Mortality and Clavien-Dindo class 4 (CD4) ICU complications were collected. Predictors of outcomes were identified by univariate and multivariate analyses.

RESULTS

There were 2457 SPN cases. SPN cases decreased from 0.09% in 2007 to 0.01% in 2019 of NSQIP operative cases (p < 0.001). Overall mortality was 8.5% and did not decrease with time. CD4 complications decreased from 40 to 27% (p < 0.001). There was a 65% reduction in SPN cases requiring a return to the operating room. Multivariate predictors of complications were emergency general surgery (EGS, p < 0.001), serum albumin (p < 0.0001) and modified frailty index (mFI) (p < 0.0001). Multivariate predictors of mortality were EGS (p < 0.0001), serum albumin (p < 0.0001), and mFI (p < 0.04). The mFI decreased after 2010 (p < 0.001).

CONCLUSION

SPNs decreased after 2010, with decreasing CD4 complications, decreasing reoperation rates and stable mortality rates, likely indicating broad adoption of a "step-up" approach. Larger, prospective studies to compare indications and outcomes for "step up" versus open SPN are warranted.

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.

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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.

Splanchnic Vein Thrombosis: A Harbinger of Infection in Peri/Pancreatic Necrotic Collections

OBJECTIVE

Infected pancreatic necrosis (IPN) is associated with poor outcomes. The present study looked at incidence of infection and predictors, if any, in these collections.

METHODS

This prospective observational study was done between July 2019 and October 2020. Symptomatic patients of acute necrotic collections and walled-off necrosis of pancreas requiring drainage were included. Necrotic fluid and blood were analyzed for growth of organisms.

RESULTS

Sixty-two patients were included. The mean age was 36.8 years (standard deviation, 11.5 years). Male-female ratio was 4:1. Alcohol was the most common etiology. Infection was noted in 44 of the 62 patients (70.9%) and bacteremia noted in 23 of the 62 patients (37%). Escherichia coli was the most common organism in necrotic collections and Staphylococcus was the most common organism isolated from blood culture. The patients with Modified Computed Tomography-Severity Index of 8 of higher ( P < 0.001) had significant association with IPN but not with bacteremia. However, splanchnic vein thrombosis ( P = 0.022) was significantly associated with development of IPN as well as bacteremia on both univariate and multivariate analysis.

CONCLUSIONS

Escherichia coli and Staphylococcus were the most common organisms grown from necrotic collections and blood respectively. Presence of splanchnic vein thrombosis was a significant factor for development of IPN and bacteremia on univariate as well as multivariate analysis.

Streptokinase irrigation through a percutaneous catheter helps decrease the need for necrosectomy and reduces mortality in necrotizing pancreatitis as part of a step-up approach

BACKGROUND

Percutaneous catheter drainage in pancreatic necrosis with a predominant solid component has a reduced success rate. To improve the efficacy of percutaneous catheter drainage, we used streptokinase in the irrigation fluid in the present study.

METHODS

In this retrospective analysis of 4 prospective randomized studies performed at our center from 2014 to 2019, 108 patients were evaluated. We assessed the safety, feasibility, and efficacy of streptokinase irrigation compared to saline irrigation. Data were also analyzed between 50,000 IU and 150,000 IU streptokinase.

RESULTS

There were 53 patients in the streptokinase irrigation group and 55 in the saline irrigation group, and both groups were comparable in terms of age, sex, etiology, APACHE II score, and percutaneous catheter drainage characteristics. The modified computerised tomography severity index and modified Marshall score at the onset of pain were significantly higher in the streptokinase group. Sepsis reversal was significantly higher in the streptokinase group (75% vs 36%), and the need for necrosectomy (34% vs 54%) was also lower in the streptokinase group. Mortality was lower in the streptokinase group than in the saline group (32% vs 40%). The incidence of bleeding in the streptokinase group was lower than that in the saline group (7% vs 18%). A higher dose of streptokinase (150,000 IU) resulted in lower rates of necrosectomy, bleeding, and mortality compared to those with 50,000 IU streptokinase.

CONCLUSION

Significant reductions in the need for surgery and sepsis reversal were noted in the streptokinase group. The results using 150,000 IU streptokinase were superior to those using 50,000 IU streptokinase.

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.

Necrotizing pancreatitis: A review for the acute care surgeon

BACKGROUND

Necrotizing pancreatitis is a common condition with high mortality; the acute care surgeon is frequently consulted for management recommendations. Furthermore, there has been substantial change in the timing, approach, and frequency of surgical intervention for this group of patients.

METHODS

In this article we summarize key clinical and research developments regarding necrotizing pancreatitis, including current recommendations for treatment of patients requiring intensive care and those with common complications. Articles from all years were considered to provide proper historical context, and most recent management recommendations are identified.

RESULTS

Epidemiology, diagnosis, treatment in the acute phase, and complications (both short-term and long-term) are discussed. Images of surgical interventions are included from our institutional experience.

CONCLUSION

Necrotizing pancreatitis management remains heavily based on clinical judgement, although technological advances and clinical trials have made decision making more straightforward.