Diagnosis and Contemporary Management of Necrotizing Pancreatitis

BACKGROUND

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

PURPOSE

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

RESEARCH DESIGN

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

RESULTS

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

CONCLUSION

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

The Usefulness and Reliability of Coagrasper for Artery Bleeding during Endoscopic Necrosectomy

Although endoscopic necrosectomy (EN) is a less invasive therapy for walled-off necrosis (WON), arterial bleeding can occur during EN. A 60-year-old man with infected WON underwent the EN procedure. During EN, the artery in the WON cavity was injured. As the artery was directly visible, we grasped it using a Coagrasper and coagulated the bleeding point. However, the bleeding was aggravated after coagulation owing to an extension of the vessel damage. The entire vessel was grasped, and complete hemostasis was achieved. The Coagrasper is useful for managing arterial bleeding; however, it should be employed only on the basis of its characteristics and in suitable scenarios.

Placement of Plastic Stents after Direct Endoscopic Necrosectomy through a Novel Lumen-Apposing Metal Stent for Effective Treatment of Laterally Extended Walled-Off Necrosis: A Pilot Study

Direct endoscopic necrosectomy (DEN) using a lumen-apposing metal stent (LAMS) is a standard therapy for the management of symptomatic walled-off necrosis (WON). Here, we demonstrated the efficacy of the routine placement of long plastic stents after a DEN session to treat laterally extended WON. Patients (n = 6) with symptomatic laterally extended WON who underwent DEN after long plastic stent placement were included. The primary endpoint was clinical efficacy of the procedure. The technical and clinical success rates were 100% without major adverse events. The WON extended to the pelvic cavity or pericolic area, and the WON size was between 18.6 and 35.8 cm in length. The median number of DEN sessions was 10 (range 6-16), and two or three long plastic stents were placed after every DEN session. Only one patient suffered from pneumoperitoneum during DEN, which spontaneously resolved within 20 min. Placement of a long plastic stent after DEN using LAMS is a minimally invasive and effective treatment for symptomatic laterally extended WON. Further studies are needed to define the indications and most suitable patients.

Endoscopic Treatment of Complex Walled-Off Necrosis in Necrotizing Pancreatitis With Two Simultaneous Lumen-Apposing Metal Stents: A Case Report

Organized pancreatic and peripancreatic collections are complications of pancreatitis and should be treated when symptomatic or complicated. When feasible, the endoscopic ultrasound approach presents high efficacy and low morbidity and mortality, making it the first likely option. Among the available accessories for endoscopic drainage, the lumen-apposing metal stent can be a better option, with a low migration rate; furthermore, it allows endoscopic necrosectomy. Here, we present the case of complex walled-off necrosis treated with two lumen-apposing metal stents in the same procedure. A 41-year-old male patient with walled-off necrosis presented with delayed gastric emptying and obstruction of the main biliary duct. Magnetic resonance imaging and endoscopic ultrasound revealed two non-communicating collections. We opted for endoscopic ultrasound-guided drainage with the deployment of two simultaneous lumen-apposing metal stents: one transduodenal and the other transgastric, with clinical improvement. After three weeks, endoscopic retrograde cholangiopancreatography showed a biliary fistula communicating with the periduodenal collection, which was treated with a biliary plastic stent. An endoscopic necrosectomy was performed, and the metal stents were removed. Control magnetic resonance imaging demonstrated improvement. The patient was asymptomatic at the six-month follow-up. The treatment of symptomatic complex walled-off necrosis remains a challenge and may require multiple endoscopic approaches; moreover, surgical treatment may be necessary in case of failure. In the present report, we demonstrate that the deployment of two lumen-apposing metal stents in the same procedure is feasible when necessary as it was associated with technical success and short-term clinical success.

A case of walled-off necrosis extending into the pelvic cavity successfully treated by endoscopic necrosectomy using a lumen-apposing metal stent

A 31‐year‐old man developed massive walled‐off necrosis extending into the pelvic cavity following severe acute alcoholic pancreatitis. Endoscopic ultrasound‐guided fistula drainage was performed using a lumen‐apposing metal stent, but this was insufficiently effective, and endoscopic necrosectomy was also performed, after which the patient improved. Percutaneous drainage and surgery are other options for the treatment of walled‐off necrosis extending into the pelvic cavity, but a valuable case in which the patient improved with endoscopic treatment alone is presented.

GRUPUGE Perspective: Endoscopic Ultrasound-Guided Drainage of Peripancreatic Collections

Pancreatic and peripancreatic collections (PPC) are a known complication of acute pancreatitis. They are categorized into four types of collection: (1) acute peripancreatic fluid collection, (2) pseudocyst, (3) acute necrotic collection and (4) walled-off necrosis. Most PPC resolve spontaneously or are persistent but asymptomatic. Intervention is needed in a minority of patients with infected or symptomatic collection. Endoscopic ultrasound-guided transmural drainage is currently the first-line treatment option for PPC management. It has shown great technical and clinical success, similar to percutaneous or surgical approaches, but with lower morbidity and costs and better quality of life. In this review article, the GRUPUGE presents an updated perspective on the potential role of endoscopic ultrasound-guided drainage of peripancreatic collections, addressing the selection criteria and the technical issues of different techniques and analysing emerging data on their efficacy and safety.

Endoscopic necrosectomy under fluoroscopic guidance during transmural drainage of walled-off pancreatic necrosis (WOPN)

INTRODUCTION

The endoscopic treatment of walled-off pancreatic necrosis (WOPN) as well as other minimally invasive methods have been evolving since last years.

AIM

The aim of this study is evaluation of efficiency and safety of endoscopic necrosectomy under fluoroscopy done during the transmural drainage in patients with symptomatic WOPN.

MATERIAL AND METHODS

The retrospective analysis 114 consecutive patients with symptomatic WOPN were treated endoscopically in our medical center between 2011 and 2016.

MATERIAL AND METHODS

The retrospective analysis 114 consecutive patients with symptomatic WOPN were treated endoscopically in our medical center between 2011 and 2016.

RESULTS

Endoscopic necrosectomy was performed under fluoroscopic guidance during transmural drainage in 24/114 (21.05%) patients. The mean amount of endoscopic procedures in each patient was 8.88 (3-27). The active drainage was continued averagely for 40.1 (11-96) days. The avarage number of necrosectomy procedures during continued drainage was 6.54 (1-24) per patient. Additional percutaneous drainage was applied in just two patients. The complications of endotherapy were present in 9/24 (37.5%) patients. The therapeutic success was reached in 23/24 (95.83%) patients. The mean time of observation was 35 [18-78] months. The recurrence of pancreatic fluid collection was stated in 4 patients during the observation time. The mean time between the end of endotherapy and recurrence of fluid collection was 19 [16-22] months. In three patients recurrent fluid collections were treated endoscopically and in one patient were treated surgically. Long-term success of endoscopic treatment of WOPN was reached in 22/24 (91.67%) patients.

CONCLUSIONS

Endoscopic necrosectomy under fluoroscopic guidance during transmural drainage is successful and safe method of minimally invasive treatment in selected patients with walled-off pancreatic necrosis.

Radical treatment for walled-off necrosis: Transmural nasocyst continuous irrigation

BACKGROUND AND AIM

Treatment efficiency of walled-off necrosis (WON) using endoscopic ultrasound-guided drainage (EUS-D) with a double pigtail stent (DPS) is limited. Endoscopic necrosectomy is often carried out if EUS-D fails. However, endoscopic necrosectomy is associated with significant morbidity and mortality. Thus, we developed transmural nasocyst continuous irrigation (TNCCI) as an alternative therapeutic option for WON. This study aimed to evaluate the usefulness of TNCCI therapy for WON.

METHODS

Between April 2009 and March 2018, 19 of 39 patients admitted with WON underwent EUS-D. Ten consecutive patients also received TNCCI therapy (TNCCI group) between May 2015 and March 2018. TNCCI was carried out by inserting an external tube from the gastroduodenal lumen into the WON under endoscopic ultrasonography guidance and then continuously irrigating the WON with saline at a rate of 40 ml/h. Nine consecutive patients who underwent EUS-D without TNCCI therapy between April 2009 and April 2015 were used for comparison (control group). Various parameters were compared between the TNCCI and control groups.

RESULTS

Time taken to reduce WON (6 vs 32 days, P = 0.001), implementation rate of endoscopic necrosectomy (0% vs 55.6%, P = 0.01), and number of endoscopic necrosectomy sessions per patient (0 vs 0.8 ± 1.0, P = 0.008) were significantly lower in the TNCCI group than in the control group.

CONCLUSIONS

Walled-off necrosis can be effectively and safely treated by endoscopic drainage with a DPS and TNCCI. This technique can be an alternative therapeutic option before carrying out endoscopic necrosectomy.

Endoscopic treatment of extensive walled-off pancreatic necrosis with the use of single transluminal gateway transcystic multiple drainage (SGTMD)

The paper presents a description of the course of severe acute necrotizing pancreatitis as well as endoscopic treatment of an extensive infected walled-off pancreatic necrosis (WOPN), being the consequence of acute pancreatitis. The basic strategy of interventional treatment was to extend access to necrotic areas with use of single transluminal gateway transcystic multiple drainage (SGTMD). Endoscopic transmural access (transgastric) was applied. Endoscopic necrosectomy under fluoroscopic guidance was repeated nine times during active transluminal drainage. Endotherapy with use of SGTMD, as well as endoscopic necrosectomy became a successful and safe technique of treatment. Moreover, the paper proved the efficiency of endotherapy in the treatment of complete pancreatic duct disruption in the course of acute necrotizing pancreatitis.

Endoscopic ultrasonography-guided drainage of pancreatic fluid collections

Endoscopic ultrasound (EUS)-guided drainage is now firmly established as the best option for drainage of walled-off pancreatic fluid collections (PFC). It has high clinical efficacy, similar to surgical and percutaneous approaches, but with lower morbidity and costs. It is superior to non-EUS-guided approaches because even collections without endoluminal bulging can be successfully drained. Transmural drainage alone is sufficient for pseudocysts, but in the context of walled-off pancreatic necrosis (WON), adjunctive direct endoscopic necrosectomy (DEN) may be required. Traditionally, double pigtail plastic stents (PS) were used for transmural drainage, but, recently, fully covered self-expandable metallic stents (FCSEMS) customized for PFC drainage have become available and are increasingly used, especially in the management of WON, because the larger-diameter stent facilitates drainage and insertion of an endoscope into the WON cavity for DEN. The present review will discuss the evidence for EUS-guided drainage and DEN, the technical problems involved, and the roles of PS and FCSEMS in PFC drainage.

Asian consensus statements on endoscopic management of walled-off necrosis Part 1: Epidemiology, diagnosis, and treatment

Walled-off necrosis (WON) is a relatively new term for encapsulated necrotic tissue after severe acute pancreatitis. Various terminologies such as pseudocyst, necroma, pancreatic abscess, and infected necrosis were previously used in the literature, resulting in confusion. The current and past terminologies must be reconciled to meaningfully interpret past data. Recently, endoscopic necrosectomy was introduced as a treatment option and is now preferred over surgical necrosectomy when the expertise is available. However, high-quality evidence is still lacking, and there is no standard management strategy for WON. The consensus meeting aimed to clarify the diagnostic criteria for WON and the role of endoscopic interventions in its management. In the Consensus Conference, 27 experts from eight Asian countries took an active role and examined key clinical aspects of WON diagnosis and endoscopic management. Statements were crafted based on literature review and expert opinion, employing the modified Delphi method. All statements were substantiated by the level of evidence and the strength of the recommendation. We created 27 consensus statements for WON diagnosis and management, including details of endoscopic procedures. When there was not enough solid evidence to support the statements, this was clearly acknowledged to facilitate future research. Proposed management strategies were formulated and are illustrated using flow charts. These recommendations, which are based on the best current scientific evidence and expert opinion, will be useful for guiding endoscopic management of WON. Part 1 of this statement focused on the epidemiology, diagnosis, and timing of intervention.

Asian consensus statements on endoscopic management of walled-off necrosis. Part 2: Endoscopic management

Walled-off necrosis (WON) is a new term for encapsulated necrotic tissue after severe acute pancreatitis. Various terminologies such as pseudocyst, necroma, pancreatic abscess, and infected necrosis were previously used in the literature, resulting in confusion. The current and past terminologies must be reconciled to meaningfully interpret past data. Recently, endoscopic necrosectomy was introduced as a treatment option and is now preferred over surgical necrosectomy when the expertise is available. However, high-quality evidence is still lacking, and there is no standard management strategy for WON. The consensus meeting aimed to clarify the diagnostic criteria for WON and the role of endoscopic interventions in its management. In the Consensus Conference, 27 experts from eight Asian countries took an active role and examined key clinical aspects of WON diagnosis and endoscopic management. Statements were crafted based on literature review and expert opinion, employing the modified Delphi method. All statements were substantiated by the level of evidence and the strength of the recommendation. We created 27 consensus statements for WON diagnosis and management, including details of endoscopic procedures. When there was not enough solid evidence to support the statements, this was clearly acknowledged to facilitate future research. Proposed management strategies were formulated and are illustrated using flow charts. These recommendations, which are based on the best current scientific evidence and expert opinion, will be useful for guiding endoscopic management of WON. Part 2 of this statement focused on the endoscopic management of WON.

Endoscopic necrosectomy under fluoroscopic guidance - a single center experience

INTRODUCTION

Our report presents a technique of necrotic tissue removal during transmural drainage of walled-off pancreatic necrosis (WOPN) that is an alternative to the one that has already been described in the literature.

AIM

To assess the effectiveness and safety of endoscopic necrosectomy performed during transmural drainage of symptomatic WOPN.

MATERIAL AND METHODS

Within the years 2012-2013, 64 patients underwent endoscopic treatment of symptomatic WOPN in our center. Eight patients underwent endoscopic necrosectomy during transmural drainage. Fragments of necrotic tissues were removed from the collection's cavity under fluoroscopic guidance using a Dormia basket. The results and complications of treatment were compared retrospectively.

RESULTS

Sixty-four patients with WOPN underwent transmural drainage under endoscopic ultrasonography (EUS) guidance. Eight patients (12.5%, 5 women and 3 men, mean age 57.25 years) were qualified for endoscopic necrosectomy. Transmural transgastric access was made in 7 patients and transduodenal access in 1 patient. Additional percutaneous drainage was used in 2 patients. Active drainage was continued for 24 days (11-44 days). The mean number of endoscopic procedures was 4.75 (3-9). The average number of necrosectomy procedures during drainage was 1.75 (1-4). Complications of endotherapy occurred in 2/8 (25%) patients, and they were not directly connected with necrosectomy. Therapeutic success after the end of active drainage was achieved in all patients. During a 6-month follow-up no recurrence of the collection was observed.

CONCLUSIONS

Endoscopic necrosectomy under fluoroscopic guidance is an effective and safe method of minimally invasive treatment in a selected group of patients with symptomatic WOPN.

Endoscopic, transmural drainage and necrosectomy for walled-off pancreatic and peripancreatic necrosis is associated with low mortality--a single-center experience

OBJECTIVE

Endoscopic transmural drainage and necrosectomy (ETDN) is a promising alternative to percutaneous drainage and surgical intervention in the treatment of walled-off pancreatic and peripancreatic necroses (WONs). We assessed the outcome and safety profile of ETDN in a single-center patient cohort.

MATERIALS AND METHODS

In November 2005, ETDN for WON was introduced in our tertiary referral center. During a 6-year period (Nov 2005-Nov 2011), we retrospectively collected data on all patients who underwent ETDN.

RESULTS

Eighty-one patients were treated with ETDN (median age 54, 52 men). Gallstones were the predominant etiology of pancreatitis (41%), followed by alcohol (33%). Median time from debut of symptoms to first endoscopic treatment was 44 (9-246) days. Culture-proven infected necrosis was found in 71% of the cases. Twenty-three patients (28%) required admission in intensive care unit. The technical and clinical success rates were 99% and 89%, respectively. Procedure-related complications occurred in 10 (12%) patients, of which 1 was procedure-related death. In-hospital mortality was 11%.

CONCLUSION

ETDN in patients with necrotizing pancreatitis and infected necrosis performed in a single, high-volume center has an acceptable safety profile and is associated with a low mortality.

Direct endoscopic necrosectomy versus step-up approach for walled-off pancreatic necrosis: comparison of clinical outcome and health care utilization

OBJECTIVES

Infected walled-off pancreatic necrosis (WOPN) is a complication of acute pancreatitis requiring intervention. Surgery is associated with considerable morbidity. Percutaneous catheter drainage (PCD), initial therapy in the step-up approach, minimizes complications. Direct endoscopic necrosectomy (DEN) has demonstrated safety and efficacy. We compared outcome and health care utilization of DEN versus step-up approach.

METHODS

This was a matched cohort study using a prospective registry. Twelve consecutive DEN patients were matched with 12 step-up approach patients. Outcomes were clinical resolution after primary therapeutic modality, new organ failure, mortality, endocrine or exocrine insufficiency, length of stay, and health care utilization.

RESULTS

Clinical resolution in 11 of 12 patients after DEN versus 3 of 12 step-up approach patients after PCD (P < 0.01). Nine step-up approach patients required surgery; 7 of these experienced complications. Direct endoscopic necrosectomy resulted in less new antibiotic use, pulmonary failure, endocrine insufficiency, and shorter length of stay (P < 0.05). Health care utilization was lower after DEN by 5.2:1 (P < 0.01).

CONCLUSIONS

Direct endoscopic necrosectomy may be superior to step-up approach for WOPN with suspected or established infection. Primary PCD generally delayed definitive therapy. Given the higher efficacy, shorter length of stay, and lower health care utilization, DEN could be the first-line therapy for WOPN, with primary PCD for inaccessible or immature collections.

Large area of walled-off pancreatic necrosis successfully treated by endoscopic necrosectomy using a grasping-type scissors forceps

Endoscopic necrosectomy (EN) for walled-off pancreatic necrosis (WOPN) is less invasive than surgical treatment and has become the first choice for pancreatic abscess. EN is usually carried out with several devices including snares, baskets, and grasping forceps. Occasionally, we have encountered cases in which EN has not been satisfactorily carried out, and there is pressure for further innovation in EN. Here, we describe a case of a large area of WOPN that was successfully treated by EN with endoscopic submucosal dissection and associated techniques, which facilitated removal of necrotic tissues. A 60-year-old man was referred to our hospital for WOPN as a complication of necrotizing pancreatitis. As a result of his complicating conditions including ischemic heart disease, uncontrollable arrhythmia, chronic renal failure, and persistent pleural effusion, he was deemed a poor surgical candidate. Although EN with conventional devices was carried out for five sessions, we could not remove the dense and massive necrotic tissues. At the sixth EN session, the Clutch Cutter device (Fujifilm, Tokyo, Japan) was used to remove the necrotic tissues, without major complications. This is believed to be the first report of EN using the Clutch Cutter for successful treatment of WOPN.

Treatment of Pancreatic Abscess with Endoscopic Ultrasound-guided Placement of a Covered Metal Stent Following Failed Balloon Dilation and Endoscopic Necrosectomy

For the management of pancreatic abscess, endoscopic ultrasound (EUS)-guided puncture and drainage has become recognized as a safer and more effective alternative to surgery. Typically, a double-pigtail plastic stent is placed for drainage. When an abscess is complicated by infected necrosis, endoscopic evacuation is essential. However, endoscopic evacuation carries a high risk of hemorrhage and needs to be performed daily to be effective. We describe EUS-guided endoscopic evacuation and placement of a fully covered metal stent following two failed evacuations. Patient recovery time was excellent, and no complications occurred.