Infected Peripancreatic Necrosis Research Articles

Pancreatic Debridement via Sinus Tract Endoscopy

Sinus tract endoscopy (STE) is a minimally invasive technique for debridement of dead or infected tissue. STE is usually used for treatment of infected pancreatic or peripancreatic necrosis, though other applications have been described. STE involves placement of a percutaneous drain followed by fluoroscopically guided dilation of the drain tract to allow placement of a working sheath. An endoscope is then introduced through the sheath and used to debride necrotic tissue. A drain is then replaced through the same tract at the conclusion of the procedure. In this case we use STE to debride infected peripancreatic necrosis caused by a traumatic pancreatic injury and complicated by an enteric fistula.

Combined minimally invasive management of infected peripancreatic necrosis: two cases report

Infected peripancreatic necrosis (IPN) is the most threatening complication of severe acute pancreatitis. Surgical necrosectomy is still the procedure of choice in the treatment of IPN and debridement is usually performed through laparotomy. Case 1: A 40-year-old man was referred for the complication of the acute pancreatitis after endoscopic ampullectomy due to tubular adenoma with severe dysplasia. CT scans revealed a diffuse acute necrotic collection (ANC) involving the body and tail of the pancreas which extended anterior and inferior to the pelvic cavity. The patient received maximal conservative treatment including intensive fluid replacement, enteral and parenteral nutrition after endoscopic pancreatic duct insertion. The patient's clinical condition deteriorated during the 4 week of the disease with fever and increased serum C-reactive protein of 28.mg/dL despite of antibiotics, endoscopic pancreatic drainage and two times of ultrasono-guided PCD. He underwent laparoscopic pancreatic necrosectomy through mesocolic window. The postnecrosectomy cavity was thoroughly irrigated and closed suction drains were left for negative pressue drainage. Patient was discharged on the 35th days after laparoscopic surgery and patient remains asymptomatic for 4 years. Case 2: Fifty six year-old man was admitted for abdominal pain after heavily alcoholic drinking. An abdominal CT showed diffuse infiltrating inflammation around the pancreas suggesting acute pancreatitis. Despite of conservative treatment, follow up CT showed huge infected peripancrtic necrotic abscess. H received multiple procedures for percutaneous cavity drainage(PCD) but failed in persistent fever. So he underwent laparoscopic peripancreatic necrosectomy and multiple drainages. He was improved with almost complete resolution during 3 month period.

PTU-002 EUS-Guided Insertion of Fully Covered Self-Expandable Metal Stents for Drainage of Pancreatic Walled-Off Necrosis Does Not Require Fluoroscopy

Introduction Transgastric placement of specially designed fully covered self-expandable metal stent (FCSMS) has improved the management and the outcome of walled-off necrosis (WON) after severe pancreatitis. Reduction of radiation exposure is of increasing importance. Therefore, we investigated whether transgastric insertion of FCMS for drainage of WON is possible only by EUS-guidance. Methods Patients with symptomatic pancreatic walled-off necrosis referred for endoscopic drainage were included. EUS-guided stent insertion was performed under concious sedation or endotracheal intubation. The pancreatic collection was accessed from the stomach using a linear echoendoscope with a 19 G access needle, a cystotome or directly using the hot Axios® device. After insertion of a guidewire and enlargement of the transgastric access by diathermy a fully covered self-expandable metal stent was inserted under EUS guidance without fluoroscopy. As clinically indicated, endoscopic necrosectomy was performed through the large diameter metal stent. When the collection had shrunk to less than 4 cm, symptoms and inflammatory parametrs had improved, the stent was endoscopically removed. Results 18 patients (median age: 55 years; range 48–63 years) with symptomatic WON (median diameter: 14 cm; range 8–18 cm) were referred for EUS-guided drainage. In 2 patients large traversing arteries within the cavity were detected by colour Doppler imaging during EUS, therefore the insertion of FCSMS was not attempted to avoid possible erosion of the vessels by the stent edges with reducing collection size. In all other patients (88.9%) the completely EUS-guided transgastric stent insertion without fluoroscopy was technically successful (6 AXIOS® and 10 Nagi® stents were inserted). The stent insertion into the cavity and the opening of the distal flange could be clearly visualised by EUS in all cases. After correct positioning of the FCSMS by EUS the proximal stent flange was deployed under endoscopic guidance. Two patients were readmitted with fever when the stent was blocked with debris. Seven patients required endoscopic necrosectomy through the FCSMS. One patient developed self-limiting bleeding. WON resolved in all patients within 8 weeks. Conclusion The good sonographic visibility of the FCSMS throughout the procedure allows safe and easy insertion of transgastric drainage under EUS-guidance without fluoroscopy. Reference 1 Seifert H, Wehrmann T, Schmitt T, Zeuzem S, Caspary WF. Retroperito-neal endoscopic debridement for infected peripancreatic necrosis. Lancet 2000; 356:653–5. Disclosure of Interest None Declared

Acute Pancreatitis Classifications: Basis and Key Goals.

To explore the efficacy of the revised Atlanta classification (RACAP) and the determinant-based classification of acute pancreatitis severity (DBCAPS) on the basis of clinical data and feedback from patients with acute pancreatitis (AP).The authors retrospectively investigated a total of 573 patients with AP admitted to our hospital between December 2011 and December 2014. The definitions of severity and local complications in AP using RACAP and DBCAPS are presented and common points and mutual differences between the 2 groups are analyzed and discussed.Classification according to RACAP and DBCAPS found 86 (15%) and 178 (31.1%) mild cases (P < 0.01), 269 (46.9%) and 176 (30.7%) moderate cases (P < 0.01), and 218 (38.0%) and 219 (38.2%) severe cases (P = 0.95), respectively. A major contribution of DBCAPS is the introduction of a new type of severe AP, critical AP, identified in 4 patients (0.7%). Complications were observed in 313 RACAP-defined cases and 153 DBCAPS-defined cases (P < 0.01). Among the 313 RACAP-defined cases, acute peripancreatic fluid collection (236 patients, 75.40%), pancreatic pseudocysts (20 patients, 6.4%), acute necrotic collection (42 patients, 13.4%), and walled-off necrosis (15 patients, 4.8%) were observed. Among the 153 DBCAPS-defined cases, sterile peripancreatic necrosis (105 patients, 68.6%), sterile pancreatic necrosis (44 patients, 28.8%), infected peripancreatic necrosis (2 patients, 1.3%), and infected pancreatic necrosis (2/153 patients, 1.3%) were observed.Both classifications adopted organ failure and complications as determinants of severity. Revised Atlanta classification refined local complications and DBCAPS modified severity to include critical AP. In accordance with the demands of precision medicine, a combination of the 2 could be important for further clinical practice and scientific research.

PTU-030 Eus-guided insertion of self-expandable metal stents facilitates access for endoscopic necrosectomy in walled-off necrosis

<h3>Introduction</h3> Wide flange fully covered self-expandable metallic stents (FCSEMS) have recently been developed for EUS-guided transmural drainage of pancreatic fluid collections. We used these wide calibre stents for transgastric access for endoscopic necrosectomy in patients requiring necrotic debridement. <h3>Method</h3> Patients referred with large, symptomatic walled off-necrosis for endoscopic therapy were included. Under EUS guidance, the necrotic cavity was accessed using the needle knife of a cystotome. After securing the access with a guidewire the new tract was enlarged to 10 F using the ring diathermy of the cystotome. This allowed a 2 or 3 cm long 14 mm diameter FCSEMS to be placed transmurally. If clinically required, endoscopic necrosectomy sessions were performed through the FCSEMS in weekly intervals. <h3>Results</h3> Six patients (5 men, median age 50 years) had a walled off-necrosis with a median size of 16 cm (range 12–17 cm) causing gastric outlet obstruction (5) or biliary compression (1). One patient with an endosonographically visible artery transversing the necrotic cavity was declined due to bleeding risk. In the other five patients, the insertion of a transgastric FCSEMS under EUS guidance was successful without immediate complications. In all five patients, the cavity reduced to &lt;3 cm after a mean of 3 (range 2–5) endoscopic necrosectomy sessions. There were no major complications. One stent migration occurred after the cavity had reduced to less than 3 cm. <h3>Conclusion</h3> EUS-guided insertion of FCSEMS into walled-off necrosis appears safe and results in effective drainage. Endoscopic necrosectomy can be performed through the transmural FCSEMS which provides endoscopic access for repeated debridement and flushing of the necrotic cavity. <h3>Disclosure of interest</h3> None Declared. <h3>References</h3> Seifert H, Wehrmann T, Schmitt T, Zeuzem S, Caspary WF. Retroperitoneal endoscopic debridement for infected peripancreatic necrosis. Lancet 2000;356(9230):653–5 Braden B, Dietrich CF. Endoscopic ultrasonography-guided endoscopic treatment of pancreatic pseudocysts and walled-off necrosis: new technical developments. World J Gastroenterol. 2014;20(43):16191–6. doi: 10.3748/wjg.v20.i43.16191

Minimally Invasive Retroperitoneal Pancreatic Necrosectomy in the Management of Infected Pancreatitis

Surgical debridement is the mainstay in the management of infected pancreatic necrosis. Minimally invasive techniques have been shown to minimize surgical insult. We aim to review our recent experience with minimally invasive retroperitoneal pancreatic necrosectomy (MIRP). The medical records of consecutive patients between October 2007 and April 2008 who underwent MIRP at our hospital were reviewed. All the patients had a preoperative computed tomography-guided aspiration and positive bacteriologic culture of the peripancreatic collection. Five patients underwent MIRP during the 8-month period. Fourteen procedures were carried out, with a median of 3 (range, 1 to 5) procedures per patient. Only 1 patient required postoperative intensive care monitoring. One patient had a left renal contusion that resolved, and 2 patients developed pancreatic fistula owing to pancreatic duct disruption requiring stenting of the pancreatic duct. There were no mortalities. MIRP is a good alternative technique in the management of selected patients with infected peripancreatic necrosis.

Open Abdomen after Severe Acute Pancreatitis.

The need for surgical decompression for abdominal compartment syndrome is becoming more frequent in patients with severe acute pancreatitis, especially in association with massive fluid resuscitation at the early stages of the disease. Decompression can be achieved with either a full-thickness laparostomy that can be performed through a vertical midline or transverse subcostal incision, or by performing a subcutaneous linea alba fasciotomy. Following a fullthickness laparostomy the open abdomen can be best managed with some form of negative abdominal pressure dressing. During dressing changes every 2-3 days, every attempt should be made to gradually close the fascial incision starting from edges, but avoiding recurrent abdominal compartment syndrome. Gradual closure is more likely to succeed in association with a negative fluid balance. Peripancreatic exploration or necrosectomy is seldom required at the initial laparostomy, unless performed for late onset abdominal compartment syndrome associated with infected peripancreatic necrosis. Primary fascial closure should always be attempted. If impossible and there is no need for subsequent abdominal re-exploration, the open wound should be covered with split-thickness skin grafting directly over the bowel loops. After a maturation period of 9-12 months definitive repair of the abdominal wall defect is performed utilizing the components separation technique, mesh repair, or a pedicular or microvascular tensor facia lata flap. Knowledge of the available decompression and reconstruction options is essential for individualized management of patients with severe acute pancreatitis and abdominal compartment syndrome. More research and comparative studies are needed to determine the most successful methods to be used.

Rupture of Infected Peripancreatic Necrosis to the Peritoneal Cavity With Fatal Outcome

Rupture of Infected Peripancreatic Necrosis to the Peritoneal Cavity With Fatal Outcome

Recent advances in the surgical management of necrotizing pancreatitis

To summarize advances and new concepts in the surgical management of necrotizing pancreatitis published within the past year with emphasis on the evolving importance of the recognition of abdominal compartment syndrome as a significant contributor to early development of organ failure. Underdiagnosed and untreated, abdominal compartment syndrome is a potential contributing factor to the development of early organ failure in patients with severe acute pancreatitis and warrants routine measurement of intra-abdominal pressure in patients treated for severe pancreatitis. The current estimate of the prevalence of intra-abdominal hypertension in severe acute pancreatitis is about 40%, with about 10% overall developing abdominal compartment syndrome, associated with increased hospital mortality rates. Early surgical decompression without exploring the pancreas further seems to be the most effective treatment. Primary fascial closure of the abdominal wall following abdominal decompression can be attempted, but in most cases the prolonged inflammatory process in the abdomen and the risk of recurrent abdominal compartment syndrome favors use of gradual closure or delayed reconstruction of the abdominal wall. Recent studies confirm the overall validity of the established surgical principles for necrotizing pancreatitis: delayed necrosectomy in patients with infected peripancreatic necrosis, mostly nonoperative management of sterile necrosis, and delayed cholecystectomy in severe gallstone-associated pancreatitis. The role of abdominal compartment syndrome as an important contributing factor to early development of multiple organ failure and the potential benefit of surgical decompression are gaining support from recent reports and should be carefully assessed in future studies.

New endoscopic method for debridement of infected peripancreatic necrosis

New endoscopic method for debridement of infected peripancreatic necrosis

Retroperitoneal endoscopic debridement for infected peripancreatic necrosis

Standard management of infected peripancreatic necrosis consists of open surgical debridement and lavage--a traumatic intervention with substantial morbidity and mortality. As an alternative and novel approach with minimum invasiveness, we present fenestration of the gastric wall and debridement of infected necrosis by direct retroperitoneal endoscopy. In three patients, this strategy led to rapid clinical improvement and no serious complications. Transgastric endoscopic therapy may be a less traumatic alternative to surgery and should be further assessed in prospective studies.