Drainage Of Infected Pancreatic Necrosis Research Articles

Infected pancreatic necrosis-Current trends in management.

Acute necrotizing pancreatitis is a common gastrointestinal disease requiring hospitalization and multiple interventions resulting in higher morbidity and mortality. Development of infection in such necrotic tissue is one of the sentinel events in natural history of necrotizing pancreatitis. Infected necrosis develops in around 1/3rd of patients with necrotizing pancreatitis resulting in higher mortality. So, timely diagnosis of infected necrosis using clinical, laboratory and radiological parameters is of utmost importance. Though initial conservative management with antibiotics and organ support system is effective in some patients, amajority of patients still requires drainage of the collection by various modalities. Mode of drainage of infected pancreatic necrosis depends on various factors such as the clinical status of the patient, location and characteristics of collection and availability of the expertise and includes endoscopic, percutaneous and minimally invasive or open surgical approaches. Endoscopic drainage has proved to be a game changer in the management of infected pancreatic necrosis in the last decade with rapid evolution in procedure techniques, development of novel metal stent and dedicated necrosectomy devices for better clinical outcome. Despite widespread adoption of endoscopic transluminal drainage of pancreatic necrosis with excellent clinical outcomes, peripheral collections are still not amenable for endoscopic drainage and in such scenario, the role of percutaneous catheter drainage or minimally invasive surgical necrosectomy cannot be understated. In a nutshell, the management of patients with infected pancreatic necrosis involves a multi-disciplinary team including a gastroenterologist, an intensivist, an interventional radiologist and a surgeon for optimum clinical outcomes.

Immediate Catheter Drainage Versus Delayed Drainage in the Management of Infected Necrotizing Pancreatitis.

Background: Immediate or delayed catheter drainage of infected pancreatic necrosis remains a subject of debate. The present study aimed to evaluate the optimum timing for drainage in patients with infected necrotizing pancreatitis. Methods: A prospective, observational study was undertaken at the Department of Surgery, Liaquat University of Medical & Health Sciences (LUMHS), between 1st March 2018 and 6th July 2020. All patients 18 years or older presenting with acute pancreatitis (AP) in whom necrotizing pancreatitis was confirmed or suspected were enrolled in the study. The exclusion criteria included prior intervention for necrotizing pancreatitis. Those who were diagnosed with infected necrotizing pancreatitis were labeled as Group A and Group B. Group A patients underwent immediate catheter drainage (within 24 h of admission) while Group B patients underwent delayed drainage (after 24 h). Clinical outcome variables including complication rate, mortality, length of hospital, and intensive care unit (ICU) stay were collected in a predefined pro forma.Results: One hundred and thirty patients were enrolled in the study. There were 65 patients in each group. The present study revealed no significant differences in patient outcomes in the immediate drainage group vs. the postponed drainage group. Overall, the mortality rate was 15.38% in Group A while the mortality rate was a little lower in Group B, i.e. 10.77% (p=0.44). The acute onset multiple organ failure was lower in Group A as compared to Group B, however, the difference was statistically insignificant (p=0.08). The rate of wound infection rate was 10.77% and 15.38% in Group A and Group B, respectively (p=0.61).Conclusion: In the present study, we failed to find any significant difference between the immediate and postponed drainage group in terms of patient outcome. As per current findings, the timing of drainage did not impact the prognosis of patients with necrotizing pancreatitis.

Delayed Drainage of Infected Pancreatic Necrosis Is Safe

The current American Gastroenterological Association guidelines recommend strong consideration of catheter drainage of infected necrotic pancreatitis

Endoscopic transluminal drainage of infected pancreatic necrosis

To report initial experience of endoscopic transluminal drainage of infected pancreatic necrosis. There were 8 patients with acute severe pancreatitis and large-focal pancreatic necrosis who underwent transluminal drainage of destruction zones for the period from December 2018 to October 2019. Transluminal drainage of pancreatogenic destruction zones in acute severe pancreatitis can be considered as the only surgical approach in 50% of cases that is comparable with literature data.

Novel techniques for management of portal system hemorrhage in acute pancreatitis

Current management of infected pancreatic necrosis is focused on a minimally invasive step-up approach. The step-up approach consists of initial percutaneous or endoscopic drainage of infected pancreatic necrosis, followed, if necessary, by minimally invasive surgical or endoscopic debridement. While there is reduced morbidity and mortality, vascular complications can be life-threatening. Reported vascular complications have been limited to arterial bleeding. Venous bleeding has not been previously reported. We present two cases of portal venous bleeding in patients who underwent treatment for infected pancreatic necrosis with a step-up approach. We discuss the clinical presentation, diagnosis, and initial management. Moreover, we present two different techniques that can be used to successfully manage venous bleeding in patients who have percutaneous drains in place as part of a step-up approach. These techniques involve tamponading the cavity or drain tract with topical hemostatics and direct embolization of the bleeding vein. These experiences can serve as a guide for managing portal venous bleeding in patients with infected pancreatic necrosis.

Internal Drainage of Infected Pancreatic Necrosis: A Fail-Safe Alternative to Percutaneous Catheter Drainage

Necrosectomy and external drainage has been the traditional surgical treatment for infected pancreatic necrosis (IPN) following acute pancreatitis. It is a highly invasive and high risk procedure in an already compromised individual and demands multiple trips to the operating room for subsequent debridement. Recent evidence suggests that minimally invasive procedures, including surgical video-assisted retroperitoneal debridement and percutaneous catheter drainage (PCD) can often “take the heat out of the fire” and thereby delay or even avoid surgery, but these procedures sometimes fail and surgical intervention needs to be undertaken. In order to avoid multiple surgical procedures we decided to drain the IPN internally into the stomach. To ascertain the efficacy and safety of open necrosectomy and internal drainage into the stomach as a feasible alternative in patients with IPN. We conducted a prospective study of the results of open surgical necrosectomy and internal drainage performed on patients with IPN from March 2012 to February 2019. This was a record based qualitative study. The patients were initially managed in the intensive care unit (ICU) with goal-directed therapy and organ support where indicated. All patients with IPN requiring PCD or surgical intervention were included in this study. A total of 44 patients with acute necrotizing pancreatitis who underwent either PCD or surgical drainage were included in the study. Of the 44 patients, 16 (36.4%) were treated with open transgastric debridement and internal drainage into the stomach for IPN. The mean age of this subgroup of patients was 51.3 ± 11.1 years, the most common etiology of the pancreatitis was alcoholic, the mean acute physiology and chronic health (APACHE II) score of these patients was 15.9 ± 4.72, and the mean bedside index of severity in acute pancreatitis (BISAP) score was 4.92 ± 0.11. On contrast enhanced computed tomography (CECT) scan of the abdomen, 93.8% of the patients had >50% necrosis, with a mean CT severity index (CTSI) of 9.3 ± 0.7. The mean operating time was 137 ± 42.4 minutes, with a mean blood loss of 225.4 ± 50.5 ml. Two patients required reoperation because of persistence of necrosum and signs of collection on repeat CT, and there were two mortalities. None of the patients had any late complications related to the surgery and the procedure was successful in 91%. Internal drainage into the stomach in IPN is a feasible and relatively safe procedure when indicated. It is more effective in avoiding repeated surgical procedures when compared to external drainage.

Minimally Invasive Interventions for Infected Pancreatic Necrosis

Aim. To examine the effectiveness of minimally invasive interventions for infected pancreatic necrosis (purulent necrotic parapancreatitis). Material and Methods. A simple comparative multicenter study included 270 patients with infected pancreatic necrosis who were treated for the period from 2004 to 2013. Paients were divided into three groups: 1 group – 90 patients who underwent only remedial laparotomy. 2 group – 90 patients who had minimally invasive drainage as the first stage followed by subsequent remedial laparotomy. 3 group – 90 patients with only minimally invasive drainage. Patients distribution by age, comorbidities, severity of purulent necrotic parapancreatitis and therapeutic medical complex was homogeneous. Results. There were maximal incidence of complications (digestive fistula, bleeding, RDS, severe sepsis) and mortality rate in group 1. In group 2 there was a tendency to decrease of morbidity and mortality in infected pancreatic necrosis patients although their level remained high. Minimally invasive interventions (3 group) for infected pancreatic necrosis resulted significant reduction of morbidity and mortality. Conclusion. Minimally invasive techniques should be preferred for primary drainage of infected pancreatic necrosis (purulent necrotic parapancreatitis). Laparotomy with necrosectomy is necessary in case of ineffectiveness of minimally invasive drainage or appearance of complications that can not be treated using minimally invasive interventions

Evaluation of a protocol of transmural endoscopic drainage of infected pancreatic necrosis (IPN) with local antibiotherapy through nasocystic catheter

Evaluation of a protocol of transmural endoscopic drainage of infected pancreatic necrosis (IPN) with local antibiotherapy through nasocystic catheter

A Low Impact Approach to Infected Pancreatic Necrosis: Review of a Case Series.

Infected pancreatic necrosis develops in approximately one third of patients with necrotizing pancreatitis and can lead to significant morbidity and mortality rates. Historically, open necrosectomy has been the mainstay of management for these patients but is in itself a morbid procedure. In recent times, minimally invasive techniques have evolved to allow a less invasive approach to these patients. Percutaneous catheter drainage of infected pancreatic necrosis is a technique that has been demonstrated to be potentially useful in the treatment of this group of patients. The aim of this study was to review outcomes and define the technique of percutaneous catheter drainage in patients with infected pancreatic necrosis. All patients with infected pancreatic necrosis were exclusively treated with percutaneous drainage over the study period. Acute Physiology and Chronic Health Evaluation (APACHE) II score, number and size of drains, drainage technique and drain management, hospital and intensive care unit (ICU) stay, nutritional requirements, and morbidity and mortality data were evaluated for the patient group. Computed tomography (CT) scans were used to assess the progression of the disease process and the effectiveness of the treatment. There were nine patients with infected pancreatic necrosis in this case series between 2007 and 2012, all of whom were treated with percutaneous catheter drainage alone. The median APACHE II score in the patient group was 11, with a median stay in the ICU of 3 d and median hospital stay of 41 d. On average, nine CT scans were performed per patient during the hospital admission. A median of three drains were inserted per patient, and in the course of the study, it was evident that the larger drain size was the most effective. In eight of the nine patients in the group, complications developed that were both directly and indirectly related to the pancreatitis, but were effectively managed. There were no deaths. Percutaneous catheter drainage as a stand-alone intervention is an alternative strategy for infected pancreatic necrosis and can be used with acceptable morbidity and mortality rates in this challenging group of patients.

Drainage of infected pancreatic necrosis by using 2 lumen-apposing metal stents, a nasocystic drain, and hydrogen peroxide

A 56-year-old man with a history of pancreatitis and walled-off pancreatic necrosis was seen at our institution with sepsis secondary to an infected pancreatic necrosis after a failed EUS-guided cystogastrostomy. A CT scan revealed a complex fluid collection of 67 x 168 mm. The patient underwent EUS with placement of a 15-mm lumen-apposing metal stent via a transgastric approach. Endoscopic necrosectomy was performed; however, the necrosis showed minimal improvement in size on repeat imaging, and the decision was made to place a second distal stent with a nasocystic drain to provide continuous irrigation.

Ultrasound-guided percutaneous drainage of infected pancreatic necrosis

The role of percutaneous drainage in the management of infected pancreatic necrosis remains controversial, and ultrasound-guided technique is rarely used for this indication. The purpose of this study was to evaluate the safety and efficacy of sonographically guided percutaneous catheter drainage for infected pancreatic necrosis.The patient group consisted of 16 men and 2 women. The mean age of the patients was 47 years. The median computed tomography severity index of acute pancreatitis was 10 points. Percutaneous catheter drainage was performed under sonographic guidance using preferably retroperitoneal approach, and transperitoneal access in selected cases. The medical records and imaging scans were reviewed retrospectively for each patient.Percutaneous catheter drainage resulted in a complete resolution of infected pancreatic necrosis in 6 of 18 patients (33 %). Twelve of 18 patients who were initially managed with PCD required eventually necrosectomy (67 %). The most common reason for crossover to surgical intervention was persistent sepsis (n = 7). Open necrosectomy was performed in 4 of these patients, and 3 patients underwent successful minimally invasive retroperitoneal necrosectomy. Five patients required conversion to open surgery because of procedure-related complications. In 3 cases, there was leakage of the necrotic material into the peritoneal cavity. Two other patients experienced hemorrhagic complications. Overall mortality rate was 17 %. The size of the largest necrotic collection in patients who were successfully treated with percutaneous drainage decreased by a median of 76 % shortly after the procedure, whereas it decreased only by a median of 16 % in cases of failure of percutaneous drainage.Ultrasound-guided percutaneous catheter drainage used in infected pancreatic necrosis is a technique with acceptably low morbidity and mortality that may be the definitive treatment or a bridge management to necrosectomy. A negligible decrease in size of the necrotic collection predicts failure of percutaneous drainage.

Ultrasound-guided percutaneous drainage of infected pancreatic necrosis

BackgroundThe role of percutaneous drainage in the management of infected pancreatic necrosis remains controversial, and ultrasound-guided technique is rarely used for this indication. The purpose of this study was to evaluate the safety and efficacy of sonographically guided percutaneous catheter drainage for infected pancreatic necrosis.MethodsThe patient group consisted of 16 men and 2 women. The mean age of the patients was 47 years. The median computed tomography severity index of acute pancreatitis was 10 points. Percutaneous catheter drainage was performed under sonographic guidance using preferably retroperitoneal approach, and transperitoneal access in selected cases. The medical records and imaging scans were reviewed retrospectively for each patient.ResultsPercutaneous catheter drainage resulted in a complete resolution of infected pancreatic necrosis in 6 of 18 patients (33 %). Twelve of 18 patients who were initially managed with PCD required eventually necrosectomy (67 %). The most common reason for crossover to surgical intervention was persistent sepsis (n = 7). Open necrosectomy was performed in 4 of these patients, and 3 patients underwent successful minimally invasive retroperitoneal necrosectomy. Five patients required conversion to open surgery because of procedure-related complications. In 3 cases, there was leakage of the necrotic material into the peritoneal cavity. Two other patients experienced hemorrhagic complications. Overall mortality rate was 17 %. The size of the largest necrotic collection in patients who were successfully treated with percutaneous drainage decreased by a median of 76 % shortly after the procedure, whereas it decreased only by a median of 16 % in cases of failure of percutaneous drainage.ConclusionsUltrasound-guided percutaneous catheter drainage used in infected pancreatic necrosis is a technique with acceptably low morbidity and mortality that may be the definitive treatment or a bridge management to necrosectomy. A negligible decrease in size of the necrotic collection predicts failure of percutaneous drainage.

Pancreatic surgery

Surgery of the pancreas is evolving as the understanding of pancreatic disease improves. This report reviews the work published over the last year related to pancreatic surgery and the diseases addressed by surgical techniques. Obesity is an important risk factor for many diseases of the pancreas, including pancreatic adenocarcinoma. Recent evidence suggests that obese patients with pancreatic cancer appear to have more advanced disease at the time of diagnosis and a worse outcome following resection. The issues surrounding adjuvant treatment for pancreatic cancer with chemotherapy and/or radiation therapy continue to be evaluated. Cystic lesions of the pancreas remain a vexing treatment dilemma, but as we learn more about their natural history, more thoughtful recommendations for management become possible. Resection of pancreatic endocrine neoplasms is often appropriate, even in the face of metastatic disease. Minimally invasive approaches to the drainage of infected pancreatic necrosis are beginning to gain acceptance. The pain of chronic pancreatitis may be lessened by operative intervention and possibly radiation. Each year more is learned about the natural history of pancreatic lesion. For those dedicated to the study and treatment of this gland, several new advances help the clinician with treatment decisions.

Minimally Invasive Necrosectomy for Infected Necrotizing Pancreatitis

Infected necrotizing pancreatitis represents a serious and therapeutically challenging complication. Percutaneous drainage of infected pancreatic necrosis is often unsuccessful. Alternatively, open necrosectomies are associated with high morbidity. Recently, minimally invasive necrosectomy techniques have been tried with satisfying results; however, they frequently necessitate multiple sessions for definitive necrosectomy. To evaluate results of single large-port laparoscopic necrosectomy for proven infected necrotizing pancreatitis. Eight patients presenting proven infected pancreatic necrosis during course of acute pancreatitis and not responding to radiological drainage were prospectively offered minimally invasive necrosectomy. Laparoscopic necrosectomy were performed using a single large port placed along the drain tract directly into the infected necrosis. In all patients, drainage was placed during laparoscopic necrosectomy for continuous postoperative lavage. No perioperative complications were recorded with a median operative time of 87 +/- 42 minutes. No blood transfusions were needed. No surgical postoperative morbidity and mortality were recorded. In all cases, except for one patient with multiple abscesses, only one session of necrosectomy was sufficient to completely clear the necrotic abscess. Laparoscopic necrosectomy was successful in all patients, and none required complementary surgical or radiological treatment. Minimally invasive necrosectomy has been safe and highly efficient through single large-port laparoscopy for infected pancreatic necrosis in our series of patients. Minimally invasive necrosectomy is a promising technique for infected necrotizing pancreatitis and should be regarded as a valid therapeutic option for necrotizing pancreatitis.

Percutaneous video-assisted necrosectomy for infected pancreatic necrosis

Percutaneous drainage of infected pancreatic necrosis is not always efficient and morbidity is high with open necrosectomy techniques. Minimally-invasive procedures have been developed to reduce this morbidity. We report our early experience with percutaneous video-assisted necrosectomy. Among 61 patients with acute pancreatitis treated between January 2001 and February 2003, seven developed infected pancreatic necrosis. Six of these seven patients underwent percutaneous video-assisted necrosectomy after failure of radio-guided percutaneous drainage. One to four sessions of percutaneous video-assisted necrosectomy were required. There was no death. Sepsis control was achieved in all patients. One patient developed postoperative peritonitis due to intraoperative contamination of the peritoneal cavity. Eighteen months after the last necrosectomy, one patient developed a pseudocyst which was successfully cured by percutaneous drainage. One patient developed diabetes mellitus. Early experience in six patients has shown that percutaneous video-assisted necrosectomy is feasible, safe and efficient, in accordance with reports in the literature. Further evaluation is necessary.

A technique for laparoscopic-assisted percutaneous drainage of infected pancreatic necrosis and pancreatic abscess.

Percutaneous drainage has been shown to be an acceptable method for treating both pancreatic abscesses and infected pancreatic necrosis. However, percutaneous techniques have certain shortcomings, including the time and labor required and failure of the catheters to adequately drain the particulate debris. Growing experience around the world indicates that there is a role for retroperitoneal laparoscopy as a means of facilitating the percutaneous drainage of infected pancreatic fluid collections and avoiding a laparotomy. Our technique is discussed in this paper. Once infection is documented in a pancreatic fluid collection by fine-needle aspiration, one or more percutaneous drains are placed into the fluid collection(s). A computed tomography (CT) scan is repeated. If further drainage is indicated, retroperitoneoscopic debridement is performed. Using a combination of the percutaneous drain(s) and the post-drain CT scan, ports are placed and retroperitoneoscopic debridement of the necrosectum is performed under direct visualization. Prior to completion of the operation, a postoperative lavage system is created. Six patients with infected pancreatic necrosis have been treated with this technique. Prior to commencement of our laparoscopic protocol, all six patients would have required open necrosectomy. Four of the six patients were managed with retroperitoneoscopic debridement and catheter drainage alone. Complications included a colocutaneous fistula and a small flank hernia. There were no bleeding complications and no deaths. Although open necrosectomy remains the standard of care for the treatment of infected pancreatic necrosis and pancreatic abscess, there is growing evidence that laparoscopic retroperitoneal debridement is feasible.

Laparoscopic assisted percutaneous drainage of infected pancreatic necrosis.

Percutaneous drainage of infected pancreatic fluid collections is often unsuccessful. Alternatively, open necrosectomy techniques are very morbid. We hypothesized that in selected cases, laparoscopic techniques could be used to facilitate percutaneous drainage of the residual particulate necrosectum and avoid a laparotomy. We report our experience with laparoscopic assisted retroperitoneal debridement as an adjunct to percutaneous drainage for patients with infected pancreatic necrosis. Case studies were reviewed retrospectively. We analyzed the course of six patients undergoing laparoscopic assisted debridement of infected pancreatic necrosis after failure of percutaneous drainage. With the drains and computed tomography (CT) scan used as a guide, laparoscopic debridement of the necrosectum was performed. Between November 1995 and December 1999, six patients were treated with this method. In four patients, laparoscopic assisted percutaneous drainage was successful. Two patients required open laparotomy. Complications included a self-limited enterocutaneous fistula and a small flank hernia. No deaths occurred. This early, limited experience has demonstrated the feasibility of laparoscopic assisted percutaneous drainage for infected pancreatic necrosis. With this technique, two-thirds of our patients avoided the morbidity of a laparotomy.

Drainage percutané des nécroses pancréatiques infectées : alternative à la chirurgie

Aim of the study To describe a technique of percutaneous CT guided catheter drainage of infected pancreatic necrosis and to report the results of this technique compared with those of the conventional surgical treatment and of other percutaneous drainage series. Patients and methods Between 1992 and 1997, the series included 32 patients who had a severe acute necrotizing pancreatitis with a mean Ranson score of 4.6, scored into grade D (n = 10), and grade E (n = 22), according to the Balthazar radiological staging. Modified Van Sonnenberg 24 F double lumen catheters were used for continuous irrigation and aspiration. Results Forty-nine drains were inserted for 41 infected necroses and eight abscesses. Among the 32 patients, the proof of infected necrosis was obtained in 26 patients by fine needle aspiration and culture (enteroccus, staphy-lococcus, pseudomonas). The average delay of catheter insertion was 23 days after onset of pancreatitis; the mean duration of drainage was 43 days, and an average of three catheters per patient was required. Five patients (15%) died, and among the survivors, 16 (59%) presented 21 complications including 14 enterocutaneous or pancreatic fistulas. A subsequent surgical 11procedure including two necrosectomies was necessary in six patients. Conclusion This study demonstrates that percutaneous drainage of infected pancreatic necrosis with a 15% mortality and 70% success rate, represents an interesting alternative to conventional surgery.

Management of infected pancreatic necrosis by open drainage.

Twenty-eight consecutive patients with infected pancreatic necrosis were managed by extensive unroofing of the superior retroperitoneum, blunt pancreatic sequestrectomy, laparotomy pad packing of the lesser sac over a layer of Adaptic gauze, and scheduled re-explorations at intervals of 2-3 days (open drainage). Wounds were permitted to heal by secondary intention. All patients were maintained on intravenous hyperalimentation. Three of the 28 patients died (11%); none died of sepsis. Procedure-specific complications included: pancreatic fistula (10 patients), incisional hernia (8 patients), persistent functional gastric outlet obstruction (2 patients), retroperitoneal venous hemorrhage (2 patients), and intestinal fistula (1 patient). Limited initial experience with dynamic pancreatography and serial monitoring of acute phase reactants as indicators of pancreatic necrosis is promising. Compared with historic controls, open drainage of infected pancreatic necrosis represents a significant advance over more conventional surgical approaches. Controlled studies and more widespread experience are necessary for further evaluation of this procedure.