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

Institute-based nurse-led care versus home-based resistance training for patients with acute pancreatitis: Clinical outcomes analysis

Surgeries may have worse clinical outcomes in pancreatitis. In our institute surgical procedure is barely used surgery to treat pancreatitis nowadays. Chinese guidelines recommended regular exercise for severe pancreatitis. The objectives of the current study were to compare nurse-led resistance training at the institute against usual care provided to patients with acute pancreatitis for favorable clinical outcome measures. For acute pancreatitis, patients (≥18 years, of age) received 6 months of resistance training in the garden of the institute under the supervision of registered nurses (NR cohort, n = 102), or received 6 months of resistance training at their home by themselves according to a training manual (HR cohort, n = 120) or received 6 months of usual care only (UC cohort, n = 120). Fewer numbers patients died in the follow-up period in the NR cohort than those of the HR (8 vs 21, P = .0447) and the UC (8 vs 32, P = .0046) cohorts. The frequency of rehospitalization of patients due to any of the reasons in the follow-up period was fewer for patients of the NR cohort than those of the HR and the UC cohorts (P < .05 for both). Hospitalization of patients due to any of the reasons in the follow-up period was fewer for patients of the HR cohort than those of the UC cohort (P < .05). A 52 median score was the quality of life of patients before the start of the non-treatment intervention(s). After 6 months of non-treatment intervention(s), patients of the NR cohort improved their quality of life as compared to their initial quality of life (P < .001), those of HR cohort (P < .05), and those of UC cohort (P < .001). The quality of life of patients with severe pancreatitis after the surgical procedure was worse. Six months of nurse-assisted resistant training at the institute has significant improvement on the quality of life of patients in the follow-up periods of acute pancreatitis. Resistant training at the institute would improve the quality of life of patients with acute pancreatitis (Level of Evidence: IV; Technical Efficacy Stage: 5).

Mortality and costs related to severe acute pancreatitis in the intensive care units of Australia and New Zealand (ANZ), 2003-2020

BACKGROUND AND OBJECTIVE

Comprehensive data on the burden of severe acute pancreatitis (SAP) in global intensive care units (ICUs) and trends over time are lacking. Our objective was to compare trends in hospital and ICU mortality, in-hospital and ICU length of stay, and costs related to ICU admission in Australia and New Zealand (ANZ) for SAP.

METHODS

We performed a retrospective, observational, cohort study of ICU admissions reported to the ANZ Intensive Care Society Adult Patient Database over three consecutive six-year time periods from 2003 to 2020.

RESULTS

12,635 patients with SAP from 189 ICUs in ANZ were analysed. No difference in adjusted hospital mortality (11.4% vs 11.5% vs 11.0%, p = 0.85) and ICU mortality rates (7.5% vs 8.0% vs 8.1%, p = 0.73) were noted over the study period. Median length of hospital admission reduced over time (13.9 days in 2003-08, 13.1 days in 2009-14 and 12.5 days in 2015-20; p < 0.01). No difference in length of ICU stay was noted over the study period (p = 0.13). The cost of managing SAP in ANZ ICUs remained constant over the three time periods.

CONCLUSIONS

In critically-ill SAP patients in ANZ, no change in mortality has been noted over nearly two decades. There was a slight reduction in hospital stay (1 day), while the length of ICU stay remained unchanged. Given the significant costs related to care of patients with SAP in ICU, these findings highlight the need to prioritise resource allocation for healthcare delivery and targeted clinical research to identify treatments aimed at reducing mortality.

Comparison between video-assisted retroperitoneal debridement and small incision pancreatic necrosectomy in infected pancreatic necrosis

BACKGROUND

Debridement and drainage have always been mainstream treatment for infected pancreatic necrosis (IPN), and the application of minimally invasive necrosectomy is becoming increasingly widespread. However, few studies have compared video-assisted retroperitoneal debridement (VARD) and small incision pancreatic necrosectomy (SIPN) individually. Our aim was to compare VARD and SIPN by evaluating outcomes.

METHODS

We retrospectively reviewed patients with IPN who underwent either VARD or SIPN between 2010 and 2019 in China. Data relative to patient demographics, major complications, health care resource utilization and mortality were collected. Statistical analyses used were the two-tailed Student's t-test and the chi-squared test.

RESULTS

Of 59 patients, 31 patients underwent SIPN and 28 patients were treated with VARD. SIPN and VARD had similar treatment success and mortality rates. The rate of reintervention due to lack of clinical improvement was significantly lower in the SIPN group (32% versus 61%; P = 0.028). In addition, the length of total hospital stay was 60 days in the SIPN group and 72 days in the VARD group (P < 0.0001) and mean total costs was significantly less in the SIPN group than in the VARD group (P = 0.008).

CONCLUSION

Given the shorter hospitalization period, lower total cost and lower rate of reinterventions, SIPN may be superior to the step-up approach for patients with IPN than for those with VARD.

Open necrosectomy is feasible as a last resort in selected cases with infected pancreatic necrosis: a case series and systematic literature review

BACKGROUND

Acute pancreatitis is a common inflammatory pancreatic disorder, often caused by gallstone disease and frequently requiring hospitalization. In 80% of cases, a rapid and favourable outcome is described, while a necrosis of pancreatic parenchyma or extra-pancreatic tissues is reported in 10-20% of patients. The onset of pancreatic necrosis determines a significant increase of early organ failure rate and death that has higher incidence if infection of pancreatic necrosis (IPN) or extra-pancreatic collections occur. IPN always requires an invasive intervention, and, in the last decade, the advent of minimally invasive techniques has gradually replaced the employment of the open traditional approach. We report a series of three severe cases of IPN managed with primary open necrosectomy (ON) and a systematic review of the literature, in order to understand if emergency surgery still has a role in the current clinical practice.

METHODS

From January 2010 to January 2020, 3 cases of IPN were treated in our Academic Department of General and Emergency Surgery. We performed a PubMed MEDLINE search on the ON of IPN, selecting 20 from 654 articles for review.

RESULTS

The 3 cases were male patients with a mean age of 61.3 years. All patients referred to our service complaining an evolving severe clinical condition evocating a sepsis due to IPN. CT scan was the main diagnostic tool. Patients were initially conservatively managed. In consideration of clinical worsening conditions, and at the failure of conservative and minimal invasive treatment, they were, finally, managed with emergency ON. Patients reported no complications nor procedure-related sequelae in the follow-up period.

CONCLUSION

The ON is confirmed to be the last resort, useful in selected severe cases, with a defined timing and in case of proven non-feasibility and no advantage of other minimally invasive approaches.

Risk factors for mortality in emphysematous pancreatitis

Objective: To investigate the difference in the characteristics between patients with emphysematous pancreatitis (EP) who survived and those who died. Methods: PubMed search was performed to gather EP cases from March 1959 to February 2019. Forty-two articles with 58 EP cases were identified and met the study's inclusion criteria. The elderly were defined as individuals aged >65 years. Data on patients' demographics, clinical symptoms, laboratory results, treatments, outcomes, and mortality were collected and analyzed by chi-square test and Student's t-test. p-Value <.05 (2-tailed) was set as the significance level. Results: Forty-seven men and eleven women aged 61.3 ± 15.9 (mean ± standard deviation) years were included. The elderly accounted for 43.1% (n = 25) of cases. There were 20 mortality cases, and 38 cases survived, with an overall mortality rate of 34.5%. Sex, underlying diseases, etiologies, and laboratory results were not significantly related to mortality. Older age was significantly related to mortality (p = .001). The shock was more commonly seen in the mortality group (100%) than in the survival group (21%) (p < .001). In contrast, fever was less frequent in the mortality group than in the survival group (25 vs. 71%, p = .002). Conclusions: EP patients have a high mortality rate (34.5%). Older age, afebrile status, and presence of shock are associated with high mortality. To improve the survival of this aggressive group, a further prospective investigation involving a larger sample size is necessary.

Risk factors for mortality in emphysematous pancreatitis

Objective: To investigate the difference in the characteristics between patients with emphysematous pancreatitis (EP) who survived and those who died. Methods: PubMed search was performed to gather EP cases from March 1959 to February 2019. Forty-two articles with 58 EP cases were identified and met the study's inclusion criteria. The elderly were defined as individuals aged >65 years. Data on patients' demographics, clinical symptoms, laboratory results, treatments, outcomes, and mortality were collected and analyzed by chi-square test and Student's t-test. p-Value <.05 (2-tailed) was set as the significance level. Results: Forty-seven men and eleven women aged 61.3 ± 15.9 (mean ± standard deviation) years were included. The elderly accounted for 43.1% (n = 25) of cases. There were 20 mortality cases, and 38 cases survived, with an overall mortality rate of 34.5%. Sex, underlying diseases, etiologies, and laboratory results were not significantly related to mortality. Older age was significantly related to mortality (p = .001). The shock was more commonly seen in the mortality group (100%) than in the survival group (21%) (p < .001). In contrast, fever was less frequent in the mortality group than in the survival group (25 vs. 71%, p = .002). Conclusions: EP patients have a high mortality rate (34.5%). Older age, afebrile status, and presence of shock are associated with high mortality. To improve the survival of this aggressive group, a further prospective investigation involving a larger sample size is necessary.

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.

Minimally invasive and endoscopic versus open necrosectomy for necrotising pancreatitis: a pooled analysis of individual data for 1980 patients

OBJECTIVE

Minimally invasive surgical necrosectomy and endoscopic necrosectomy, compared with open necrosectomy, might improve outcomes in necrotising pancreatitis, especially in critically ill patients. Evidence from large comparative studies is lacking.

DESIGN

We combined original and newly collected data from 15 published and unpublished patient cohorts (51 hospitals; 8 countries) on pancreatic necrosectomy for necrotising pancreatitis. Death rates were compared in patients undergoing open necrosectomy versus minimally invasive surgical or endoscopic necrosectomy. To adjust for confounding and to study effect modification by clinical severity, we performed two types of analyses: logistic multivariable regression and propensity score matching with stratification according to predicted risk of death at baseline (low: <5%; intermediate: ≥5% to <15%; high: ≥15% to <35%; and very high: ≥35%).

RESULTS

Among 1980 patients with necrotising pancreatitis, 1167 underwent open necrosectomy and 813 underwent minimally invasive surgical (n=467) or endoscopic (n=346) necrosectomy. There was a lower risk of death for minimally invasive surgical necrosectomy (OR, 0.53; 95% CI 0.34 to 0.84; p=0.006) and endoscopic necrosectomy (OR, 0.20; 95% CI 0.06 to 0.63; p=0.006). After propensity score matching with risk stratification, minimally invasive surgical necrosectomy remained associated with a lower risk of death than open necrosectomy in the very high-risk group (42/111 vs 59/111; risk ratio, 0.70; 95% CI 0.52 to 0.95; p=0.02). Endoscopic necrosectomy was associated with a lower risk of death than open necrosectomy in the high-risk group (3/40 vs 12/40; risk ratio, 0.27; 95% CI 0.08 to 0.88; p=0.03) and in the very high-risk group (12/57 vs 28/57; risk ratio, 0.43; 95% CI 0.24 to 0.77; p=0.005).

CONCLUSION

In high-risk patients with necrotising pancreatitis, minimally invasive surgical and endoscopic necrosectomy are associated with reduced death rates compared with open necrosectomy.

Severe acute pancreatitis-related renal injury in rats at different altitudes

AIM

To compare severe acute pancreatitis (SAP)-induced renal injury in rats at different altitudes.

METHODS

SAP was induced in rats by injecting 4.5% sodium taurocholate into the pancreas at different time points. Control rats underwent a sham operation (touching the pancreas only after opening the abdominal cavity). Blood samples were collected from the abdominal aorta at different time points to determine serum levels of amylase (AMY), creatinine (Cr), and blood urea nitrogen (BUN). Pancreas tissues were collected and stained with HE to perform histopathological analysis.

RESULTS

The levels of serum AMY, Cr, and BUN were significantly higher in the SAP group than in the control group (P < 0.05). The levels of serum AMY, Cr, and BUN in the SAP group differed significantly at the same time point at different altitudes (P < 0.05) or at different time points at the same altitude (P < 0.05). There was a significant difference in pancreatic histopathological score between the two groups (P < 0.05). The histopathological score in the SAP group differed significantly at the same time point at different altitudes (P < 0.05) or at different time points at the same altitude (P < 0.05).

CONCLUSION

The development and progression of renal injury are aggravated at high altitudes.

Combined totally mini-invasive approach in necrotizing pancreatitis: a case report and systematic literature review

BACKGROUND

Currently, both the step-up approach, combining percutaneous drainage (PD) and video-assisted retroperitoneal debridement (VARD), and endoscopic transgastric necrosectomy (ETN) are mini-invasive techniques for infected necrosis in severe acute pancreatitis. A combination of these approaches could maximize the management of necrotizing pancreatitis, conjugating the benefits from both the experiences. However, reporting of this combined strategy is anecdotal. This is the first reported case of severe necrotizing pancreatitis complicated by biliary fistula treated by a combination of ETN, PD, VARD, and endoscopic biliary stenting. Moreover, a systematic literature review of comparative studies on minimally invasive techniques in necrotizing pancreatitis has been provided.

CASE PRESENTATION

A 59-year-old patient was referred to our center for acute necrotizing pancreatitis associated with multi-organ failure. No invasive procedures were attempted in the first month from the onset: enteral feeding by a naso-duodenal tube was started, and antibiotics were administered to control sepsis. After 4 weeks, CT scans showed a central walled-off pancreatic necrosis (WOPN) of pancreatic head communicating bilateral retroperitoneal collections. ETN was performed, and bile leakage was found at the right margin of the WOPN. Endoscopic retrograde cholangiopancreatography confirmed the presence of a choledocal fistula within the WOPN, and a biliary stent was placed. An ultrasound-guided PD was performed on the left retroperitoneal collection. Due to the subsequent repeated onset of septic shocks and the evidence of size increase of the right retroperitoneal collection, a VARD was decided. The CT scans documented the resolution of all the collections, and the patient promptly recovered from sepsis. After 6 months, the patient is in good clinical condition.

CONCLUSIONS

No mini-invasive technique has demonstrated significantly better outcomes over the others, and each technique has specific indications, advantages, and pitfalls. Indeed, ETN could be suitable for central WOPNs, while VARD or PD could be suggested for lateral collections. A combination of different approaches is feasible and could significantly optimize the clinical management in critically ill patients affected by complicated necrotizing pancreatitis.

Impact of etiology on course and outcomes of severe acute pancreatitis

BACKGROUND AND OBJECTIVE

Since the influence of etiological factors on the course and outcomes of acute pancreatitis (AP) is not fully understood yet, the aim of the study was to compare the outcomes of alcoholic and biliary severe acute pancreatitis (SAP).

MATERIALS AND METHODS

We investigated 81 patients with alcoholic and biliary SAP. Demographic data, etiologic factors, severity scores, intra-abdominal pressure, imaging studies, interventions, and treatment outcomes were prospectively entered into specially maintained database and subsequently analyzed.

RESULTS

No statistically significant difference was observed in the prevalence of SAP in biliary and alcoholic AP groups (P=0.429). Although, in the biliary SAP group patients were predominantly elderly women (P=0.003), the total in-hospital stay was longer in alcoholic SAP patients (P=0.021). The abdominal compartment syndrome developed more frequently (P=0.041) and necrosectomy was more frequently performed in alcoholic SAP group (not statistically significant). Although not statistically significant, a lower mortality rate among biliary SAP patients (25.0% vs. 13.5%) was observed.

CONCLUSIONS

We defined a trend toward decreased incidence of infected necrosis in larger volume (≥30%) pancreatic necrosis, absence of abdominal compartment syndrome, lower rate of necrosectomies, shorter in-hospital stay, and an insignificantly reduced mortality rate in biliary SAP patients, indicating more favorable course of biliary SAP.

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.

Treatment of severe acute pancreatitis and its complications

Severe acute pancreatitis (SAP), which is the most serious type of this disorder, is associated with high morbidity and mortality. SAP runs a biphasic course. During the first 1-2 wk, a pro-inflammatory response results in systemic inflammatory response syndrome (SIRS). If the SIRS is severe, it can lead to early multisystem organ failure (MOF). After the first 1-2 wk, a transition from a pro-inflammatory response to an anti-inflammatory response occurs; during this transition, the patient is at risk for intestinal flora translocation and the development of secondary infection of the necrotic tissue, which can result in sepsis and late MOF. Many recommendations have been made regarding SAP management and its complications. However, despite the reduction in overall mortality in the last decade, SAP is still associated with high mortality. In the majority of cases, sterile necrosis should be managed conservatively, whereas in infected necrotizing pancreatitis, the infected non-vital solid tissue should be removed to control the sepsis. Intervention should be delayed for as long as possible to allow better demarcation and liquefaction of the necrosis. Currently, the step-up approach (delay, drain, and debride) may be considered as the reference standard intervention for this disorder.

Minimally invasive procedures in severe acute pancreatitis treatment - assessment of benefits and possibilities of use

Introduction

Acute pancreatitis (AP) consists of an extremely varied complex of pathological symptoms and clinical conditions, ranging from mild gastric complaints to multi-organ failure resulting in death.

Aim

To present the authors’ own experience regarding surgical treatment for pancreatic necrosis complicated by infection using different methods, including classic and laparoscopic methods as well as those combined with percutaneous techniques.

Material and methods

In the period 2007–2010, 34 patients with the diagnosis of severe AP were treated at the Department of General, Gastroenterological and Oncological Surgery, Collegium Medicum, Nicolaus Copernicus University. In 7 patients classic necrosectomy with repeated peritoneal flushing was performed (type 1), in 5 patients laparotomy with active drainage (type 2), in 12 video-assisted retroperitoneal debridement (type 3), and in 10 only percutaneous drainage methods (type 4).

Results

Total duration of hospitalisation was from 10 to 192 days. The highest death rate was observed for type 1 procedures. Significant differences with regard to the absolute number of postoperative complications between different groups were not observed; however, their quality varied. Classic methods were used in patients whose general and local condition was more severe.

Conclusions

When AP and its complications are diagnosed, a suitable method of surgical treatment has to be selected extremely precisely and in an individualised way. Minimally invasive methods used in selected patients provide better outcomes and higher safety superseding classic, open techniques of surgical treatment.

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.

Update on pathogenesis and clinical management of acute pancreatitis

Acute pancreatitis (AP), defined as the acute nonbacterial inflammatory condition of the pancreas, is derived from the early activation of digestive enzymes found inside the acinar cells, with variable compromise of the gland itself, nearby tissues and other organs. So, it is an event that begins with pancreatic injury, elicits an acute inflammatory response, encompasses a variety of complications and generally resolves over time. Different conditions are known to induce this disorder, although the innermost mechanisms and how they act to develop the disease are still unknown. We summarize some well established aspects. A phase sequence has been proposed: etiology factors generate other conditions inside acinar cells that favor the AP development with some systemic events; genetic factors could be involved as susceptibility and modifying elements. AP is a disease with extremely different clinical expressions. Most patients suffer a mild and limited disease, but about one fifth of cases develop multi organ failure, accompanied by high mortality. This great variability in presentation, clinical course and complications has given rise to the confusion related to AP related terminology. However, consensus meetings have provided uniform definitions, including the severity of the illness. The clinical management is mainly based on the disease´s severity and must be directed to correct the underlying predisposing factors and control the inflammatory process itself. The first step is to determine if it is mild or severe. We review the principal aspects to be considered in this treatment, as reflected in several clinical practice guidelines. For the last 25 years, there has been a global increase in incidence of AP, along with many advances in diagnosis and treatment. However, progress in knowledge of its pathogenesis is scarce.