Infected Pancreatic Necrosis Research Articles

EMPHYSEMATOUS PANCREATITIS: A RARE COMPLICATION OF ACUTE PANCREATITIS

Abstract Introduction Emphysematous pancreatitis (EP) is a serious and rare complication within the spectrum of acute pancreatitis (AP). The diagnosis is based on clinical and radiological data, that presents intraparenchymal pancreatic air in the setting of necrotizing infection. This clinical and radiological manifestation of infected pancreatic necrosis has mortality rates of over 40%. Clinical case A 71-year-old male came to the emergency department due to epigastric pain of 48h duration associated with hypotension, bradycardia with elevated pancreatic enzymes, requiring admission to the Intensive Care Unit. Initial resuscitation treatment was established, and a CT scan was performed which showed abundant air in the retroperitoneum, associated with signs of inflammation of the pancreatic gland as well as obstructive choledocholithiasis and without being able to radiologically rule out an intestinal perforation. After fluid resuscitation and stabilization of the patient, urgent surgery was performed, which showed necrosis of the entire pancreatic gland with abscessed peripancreatic collections. Wide open necrosectomy, exploration of the bile duct with extraction of lithiasis, and cholecystectomy were performed. The patient had a slow and prolonged postoperative period, progressively improving until he was discharged home. Discussion Therapeutic options for EP range from conservative management to surgery. Surgery, in these patients, is the last therapeutic step, after endoscopic or percutaneous drainage. The video-assisted retroperitoneal approach is the better procedure to be considered, since it entails less morbidity and mortality than open necrosectomy.

Role of neutrophil extracellular traps in inflammatory evolution in severe acute pancreatitis.

Severe acute pancreatitis (SAP) is a life-threatening acute abdominal disease with two peaks of death: the first in the early stage, characterized by systemic inflammatory response-associated organ failure; and the second in the late stage, characterized by infectious complications. Neutrophils are the main immune cells participating in the whole process of SAP. In addition to the traditional recognition of neutrophils as the origination of chemokine and cytokine cascades or phagocytosis and degranulation of pathogens, neutrophil extracellular traps (NETs) also play an important roles in inflammatory reactions. We reviewed the role of NETs in the occurrence and development of SAP and its fatal complications, including multiple organs injury, infected pancreatic necrosis, and thrombosis. This review provides novel insights into the involvement of NETs throughout the entire process of SAP, showing that targeting NETs might be a promising strategy in SAP treatment. However, precision therapeutic options targeting NETs in different situations require further investigation.

Imaging classification and analysis of the diagnosis and treatment of infected pancreatic necrosis:a report of 126 cases

Objective: To explore the clinical characteristics of various types of infected pancreatic necrosis(IPN) and the prognosis of different treatment methods in the imaging classification of IPN proposed. Methods: The clinical data of 126 patients with IPN admitted to the Department of Pancreatic and Biliary Surgery, the First Affiliated Hospital of Harbin Medical University from December 2018 to December 2021 were analyzed retrospectively. There were 70 males(55.6%) and 56 females(44.4%), with age(M(IQR)) of 44(17)years (range: 12 to 87 years). There were 67 cases(53.2%) of severe acute pancreatitis and 59 cases (46.8%) of moderately severe acute pancreatitis. All cases were based on the diagnostic criteria of IPN. All cases were divided into Type Ⅰ(central IPN)(n=21), Type Ⅱ(peripheral IPN)(n=23), Type Ⅲ(mixed IPN)(n=74) and Type Ⅳ(isolated IPN)(n=8) according to the different sites of infection and necrosis on CT.According to different treatment strategies,they were divided into Step-up group(n=109) and Step-jump group(n=17). The clinical indicators and prognosis of each group were observed and analyzed by ANOVA,t-test,χ2 test or Fisher exact test,respectively. Results: There was no significant difference in mortality, complication rate and complication grade in each type of IPN(all P>0.05). Compared with other types of patients, the length of stay (69(40)days vs. 19(19)days) and hospitalization expenses(323 000(419 000)yuan vs. 60 000(78 000)yuan) were significantly increased in Type Ⅳ IPN(Z=-4.041, -3.972; both P<0.01). The incidence of postoperative residual infection of Type Ⅳ IPN was significantly higher than that of other types (χ2=16.350,P<0.01). There was no significant difference in the mortality of patients with different types of IPN between different treatment groups. The length of stay and hospitalization expenses of patients in the Step-up group were significantly less than those in the Step-jump group(19(20)days vs. 33(35)days, Z=-2.052, P=0.040;59 000(80 000)yuan vs. 122 000(109 000)yuan,Z=-2.317,P=0.020). Among the patients in Type Ⅳ IPN, the hospitalization expenses of Step-up group was significantly higher than that of Step-jump group(330 000(578 000)yuan vs. 141 000 yuan,Z=-2.000,P=0.046). The incidence of postoperative residual infection of Step-up group(17.4%(19/109)) was significantly lower than that of Step-jump group(10/17)(χ2=11.980, P=0.001). Conclusions: Type Ⅳ IPN is more serious than the other three types. It causes longer length of stay and more hospitalization expenses. The step-up approach is safe and effective in the treatment of IPN. However, for infected lesions which are deep in place,difficult to reach by conventional drainage methods, or mainly exhibit "dry necrosis", choosing the step-jump approach is a more positive choice.

Basic principles,methods and evaluation of minimally invasive treatment for infected pancreatic necrosis

Infected pancreatic necrosis(IPN) is the main surgical indication of acute pancreatitis. Minimally invasive debridement has become the mainstream surgical strategy of IPN,and it is only preserved for IPN patients who are not response for adequate non-surgical treatment. Transluminal or retroperitoneal drainage is preferred,and appropriate debridement can be performed. At present,it is reported that video assisted transluminal,trans-abdominal and retroperitoneal approaches can effectively control IPN infection. However,in terms of reducing pancreatic leakage and other complications,surgical and endoscopic transgastric debridement may be the future direction in the treatment of IPN.

A modified method for percutaneous drainage of acute necrotic collections in patients with infected pancreatic necrosis

To develop a modified method for percutaneous drainage of acute necrotic collections in patients with infected pancreatic necrosis. Minimally invasive surgical technologies were used in 74 patients with infected acute necrotic collections at the Krasnodar Regional Clinical Hospital No. 2 between 2017 and 2019. Of these, 59 (79.7%) people underwent percutaneous drainage as a final treatment. In 11 (14.9%) patients, video sequestrectomy through the fistula was additionally used to increase efficiency of percutaneous drainage. PCD in our modification implies delivery of double-lumen drains 26-32 Fr in the same plane to zones of necrosis, their programmed replacement for prevention of obstruction and flexible endoscopy for control of pathological process. Local purulent-necrotic parapancreatitis occurred in 31 (41.9%) patients, widespread parapancreatitis - in 43 (58.1%) patients. There were 339 minimally invasive interventions. Laparotomy was required in 4 (5.4%) patients. Incidence of perioperative complications was 10.6%, mortality - 16.2%. A modified percutaneous drainage method may be used as final surgical treatment in 79.7% of patients with infected pancreatic necrosis.

Candida spp. peritonitis (clinical cases, register analysis and literature review)

We present a case of fungal peritonitis in a patient secondary to intestinal perforation and repeated laparotomy. An analysis of data from the register of patients with invasive candidiasis is also presented. In the study were included 42 patients with candida peritonitis. The risk factors: antibiotics (100%), vascular catheters (95%), total parenteral nutrition (81%), repeated abdominal surgery (69%), sepsis (69%), bacteremia (50%), repeated perforations on the gastrointestinal tract (43%), oncopathology of the gastrointestinal tract (36%), infected pancreatic necrosis (26%). The etiology agents were C. albicans (50%), C. glabrata (14%), C. parapsilosis (7%). 45% of patients received prophylactic treatment (100% fluconazole). Empirical therapy was carried out by 52% of patients (triazoles – 38%, echinocandins – 14%). After receiving the results of the microbiological study, 3% of patients began to receive antifungal therapy (echinocandins). The 30 days overall survival rate was 66%.

ОПЫТ ЛЕЧЕНИЯ ОСТРОГО ПАНКРЕАТИТА БИЛИАРНОЙ ЭТИОЛОГИИ

The general characteristics of the methods and results of the treatment of acute pancreatitis of biliary etiology for the period from January 1, 2012 to December 31, 2021 are presented. Patients with acute biliary pancreatitis are cared for based on the key principles of acute pancreatitis treatment of any other etiology – the long-term multicomponent intensive therapy aimed to relieve the syndrome of the systemic inflammatory response, to prevent multiple organ failure and infection of pancreatic necrosis foci, to refuse direct surgical interventions at the early stage of the disease, the reasonable use of minimally invasive draining interventions and the use of a regimen of repeated programmed operations to actively control all areas of necrotic destruction and infection to prevent the development of intra-abdominal complications. Currently the key component of complex treatment of acute pancreatitis of biliary etiology is unanimously considered as the relief (conservative or surgical) of pancreatobiliary ductal hypertension. Early laparoscopic cholecystectomy with choledochal drainage according to Halsted is a pathogenetically substantiated method of choosing the final treatment for acute biliary pancreatitis and should be performed regardless of the severity of the disease during the current hospitalization in all patients, as soon as their condition allows them to transfer the intervention. Early laparoscopic cholecystectomy with choledochal drainage according to Halsted is a pathogenetically grounded method of choice of the definitive treatment of acute biliary pancreatitis etiology and should be carried out regardless of the disease severity in the period of the current hospitalization for all patients as soon as their state allows to survive the intervention. Lethal outcomes at moderately severe and severe acute biliary pancreatitis are almost evenly distributed according to the terms (till/later than 2 weeks) after the disease beginning; their main cause is progressing multiple organ failure both in the aseptic course of the disease and at pancreatic necrosis infection.

Gastroinstestinal Fistula in Acute Necrotising Pancreatitis with Septicaemia: A Case Report

Acute Pancreatitis (AP) is an inflammatory condition with cumbersome side effects. Gastropancreatic (GI) fistula is a rare complication seen in cases with infected pancreatic or peripancreatic necrosis. GI fistulas can result in severe haemorrhage and septicemia. Hereby, the authors present a case of 36-year-old male with a chief complaint of abdominal pain associated with abdominal distension and non bilious vomiting after binge consumption of alcohol for the past 10 days. Computed Tomography (CT) scan showed the presence of free gas in the abdomen. Contrast-Enhanced CT (CECT) imaging revealed diffuse enlargement affecting the head, uncinate process, body, and tail of the pancreas. There were also a few necrotic peripancreatic fluid collections with extensive peripancreatic fat stranding. Based on these findings, the diagnosis of acute necrotising pancreatitis was suggested. Despite treatment with antibiotics and necrosectomy with drainage of the abscess collection, the patient showed no improvement. A repeat CECT examination was performed due to the deterioration of the patient’s clinical condition, which showed a complete non enhancing pancreas. Additionally, a large defect measuring approximately 16 mm was observed in the posteroinferior wall of the stomach at the middle third of the body, with extravasation of contrast material into the pancreatic collection, suggestive of fistula formation. Subsequently, the patient underwent pancreatic necrosectomy with closure of the gastric perforation using feeding jejunostomy. A follow-up CT examination was performed four days later due to the deteriorating status of the patient, as well as new onset haematemesis and bloody discharge from the surgical drain. The CT scan revealed a few peripancreatic soft tissue infiltrates adjacent to the pancreatic head. Persistent collections were noted along the anterolateral surface of the right psoas, extending to the adjoining right anterior pararenal space and the left anterolateral abdominal wall in the left hypochondriac region. Thickening of the bilateral lateroconal fascia and anterior and posterior renal fascia was observed, likely due to inflammation. Following this, the patient underwent another surgery, and percutaneous drainage was performed with antibiotic coverage. The patient showed a significant reduction in the collection and improved clinical condition after 10 days. Imaging plays a crucial role in diagnosing such complications, enabling early detection and reducing mortality in these patients.

Sanitation Effect of Gaseous Ozone in the Treatment of Experimental Infected Pancreatic Necrosis: Microbiological Evaluation

Introduction. Search for new means and methods of sanitation of the abdominal cavity remains significant related to growing antibiotic resistance of bacterial pathogens in surgical infection. This challenge is of particular relevance in the development of purulent complications of acute pancreatitis due to the complexity of radical control of the inflammation source.The aim of the study was to evaluate outcomes of microbiological examination of peritoneal exudate, biopsies of the pancreas, arterial blood in the topical application of gaseous ozone for the treatment of experimental infected pancreatic necrosis.Methods. This prospective experimental study included 43 laboratory animals - Soviet Chinchilla rabbits. Group 1 consisted of 13 animals, groups 2 and 3 consisted of 12 animals each. All animals were infected with pancreatic necrosis simulated using a clinical strain of A. baumannii. Sanitation relaparotomies were performed in 24 hours and 60 hours under anesthesia: with 0.9% sodium chloride solution in animals of group 1, with 0.02% aqueous solution of chlorhexidine bigluconate in animals of group 2, with ozone-oxygen gas mixtures in animals of group 3. The control group included six sham-operated animals. Animals were withdrawn from the experiment in 96 hours with taking samples for microbiological investigations.Results. Animals of group 1 showed an increased frequency (from 23.1 to 100.0%, p=0.003) and degree (from 3.5 (3.0; 4.5) to 7.0 (5.5; 7. 5) lg COE/ml, p0.001) of bacterial contamination of peritoneal exudate within 24 to 96 hours. Most parameters in animals of group 2 were not significantly different from those achieved in animals of group 1. Notably, the bacterial count of A. baumannii in the peritoneal exudate in 60 hours (6.0 (5.7; 6.7) lg COE/ml), and the degree of secondary (enterogenic) contamination of the pancreas (5.5 (5 .0; 6.7) lg CFU/g) and peritoneal exudate in 96 hours (7.7 (7.0; 8.0) lg CFU/ml) in animals of group 2 significantly exceeded those in animals of group 1 (p 0.010). Intraperitoneal application of a directed flow of gaseous ozone in 24 and 60 hours allowed achieving elimination of A. baumannii in 80.0% of pancreatic biopsy samples by the end of the fourth day (p=0.002 and p=0.007 when compared with results of groups 1 and 2, respectively), prevent its spread into the peritoneal exudate and systemic circulation. The treatment with gaseous ozone was also accompanied by the decreased bacterial count of A. baumannii and the degree of secondary (enterogenic) contamination by other opportunistic microorganisms in the analyzed samples.Conclusion. Perspectives for translating the results obtained into clinical practice determine the relevance of studying modern molecular methods of bacteriological analysis. This should be combined with an adequate assessment of the safety of various targeted treatment options of the abdominal tissues and organs with an ozone-oxygen gas mixture.

Prediction of infected pancreatic necrosis in acute necrotizing pancreatitis by the modified pancreatitis activity scoring system.

Infected pancreatic necrosis (IPN) is a significant complication of acute necrotizing pancreatitis (ANP). Early identification of patients at high risk of IPN would enable appropriate treatment, but there is a lack of valid tools. This study aimed to assess the performance of the Pancreatitis Activity Scoring System (PASS) and its modifications (by removing or reducing the weight of opioid usage) in predicting IPN in a cohort of predicted severe ANP patients. Data was prospectively collected in the TRACE trial (2017-2020) involving 16 sites across China. The predictive performance of PASS, modified PASS (mPASS), and conventional indices were assessed by the area under the receiver operating characteristic curve (AUC), Hosmer-Lemeshow Ĉ-test, Brier score, and Fagan's nomogram. Multivariate logistic regression analysis (MLRA) was used to define the relationship between the best-performing PASS/mPASS model and IPN. A total of 508 subjects were enrolled (median age, 43years; 62.8% males) in the original trial, and 122 developed IPN (24%) within 90days after randomization. Compared with non-IPN patients, the scores of PASS and its modified models were significantly higher in the IPN patients (all p<0.001). Among the PASS and its modifications, mPASS-4 had the largest AUC, the lowest Brier score, and good calibration. The mPASS-4 model demonstrated an AUC of 0.752 in predicting IPN (the optimal cut-off for the mPASS-4 was 292.5) and outperformed the conventional indices. The MLRA results showed that mPASS-4 >292.5 was an independent risk factor of IPN (OR: 3.6, 95% CI: 2.1-6.3). The PASS and its modifications during the first week of ANP onset predict the development of IPN, with mPASS-4 performing best. The mPASS-4 model simplifies the original PASS, increasing the likelihood of clinical implementation.

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

BackgroundSurgical pancreatic necrosectomy (SPN) is an option for the management of infected pancreatic necrosis. The literature indicates that an escalating, combined endoscopic, interventional radiology and minimally invasive surgery “step-up” approach, such as video-assisted retroperitoneal debridement, may reduce the number of required SPNs and ICU complications, such as multiple organ failure. We hypothesized that complications for surgically treated severe necrotizing pancreatitis patients decreased during the period of adoption of the “step-up” approach.MethodsThe American college of surgeons national surgery quality improvement program database (ACS-NSQIP) was used to find SPN cases from 2007 to 2019 in ACS-NSQIP submitting hospitals. Mortality and Clavien-Dindo class 4 (CD4) ICU complications were collected. Predictors of outcomes were identified by univariate and multivariate analyses.ResultsThere were 2457 SPN cases. SPN cases decreased from 0.09% in 2007 to 0.01% in 2019 of NSQIP operative cases (p < 0.001). Overall mortality was 8.5% and did not decrease with time. CD4 complications decreased from 40 to 27% (p < 0.001). There was a 65% reduction in SPN cases requiring a return to the operating room. Multivariate predictors of complications were emergency general surgery (EGS, p < 0.001), serum albumin (p < 0.0001) and modified frailty index (mFI) (p < 0.0001). Multivariate predictors of mortality were EGS (p < 0.0001), serum albumin (p < 0.0001), and mFI (p < 0.04). The mFI decreased after 2010 (p < 0.001).ConclusionSPNs decreased after 2010, with decreasing CD4 complications, decreasing reoperation rates and stable mortality rates, likely indicating broad adoption of a “step-up” approach. Larger, prospective studies to compare indications and outcomes for “step up” versus open SPN are warranted.

Predicting the Success of Catheter Drainage in Infected Necrotising Pancreatitis: A Cross-Sectional Observational Study.

Background Management of acute necrotising pancreatitis is often challenging for clinicians. Secondary infection of the necrotic collections leads to sepsis and warrants intervention. Minimally invasive techniques like catheter drainage have recently been proposed over more risky and morbid traditional open procedures. Factors that can predict successful catheter drainage of the necrotic pancreatic collection are still unclear and not well established. Materials and methods This study is designed as a retrospective cross-sectional observational study to investigate the association of 21 factors in predicting successful catheter drainage. Data from 30 patients admitted with acute necrotising pancreatitis treated with catheter drainage were collected and analysed. Twenty-one factors, including demographic variables, disease severity factors, drainage criteria, and morphological criteria on imaging, were studied for their predictive association with successful outcomes. Univariate analysis was done for each variable against the outcome. The study was conducted between December 2012 to March 2017. P-value <0.05 was considered statistically significant. Results Patients with no organ involvement responded better to primary catheter drainage. Patients with BMI>25 and multi-organ failure were poor candidates for primary catheter drainage. Clinically unwell patients with a Bedside Index for Severity in Acute Pancreatitis (BISAP) score of ≥4 had a negative outcome on catheter drainage and usually ended up in a surgical procedure or eventually succumbed to the disease. Other variables included in our study did not statistically associate with the success or failure of percutaneous catheter drainage. Conclusion BMI >25, multiple organ failure, and BISAP score ≥ 4 are independent negative predictors for the success of catheter drainage in infected necrotising pancreatitis. No organ failure showed a positive predictor for successful catheter drainage. Further studies are required to explore these predictive factors in a larger sample size to predict the success of catheter drainage in infected pancreatic necrosis.

Dynamics of Serum Procalcitonin Can Predict Outcome in Patients of Infected Pancreatic Necrosis: A Prospective Analysis.

Timely intervention can alter outcome in patients of infected pancreatic necrosis (IPN) but lacks adequate biomarker. Role of serum procalcitonin (PCT) in the management of IPN is understudied, and hence, this study was planned. All patients of acute pancreatitis with IPN without prior intervention were included. Baseline demographic, radiological and laboratory parameters were documented. PCT was measured at baseline, prior to intervention, and thereafter every 72h. Patients were grouped into those having baseline PCT < 1.0ng/mL and those with PCT ≥ 1.0ng/mL and various outcome measures werecompared. Of the 242 patients screened, 103 cases(66 males; 64.1%) with IPN were grouped into 2: PCT < 1.0ng/mL (n = 29) and PCT ≥ 1.0ng/mL (n = 74). Patients with baseline PCT ≥ 1.0ng/mL had significantly more severe disease scores. 16 out of 19 patients with rise in PCT on day-7 post-intervention expired. PCT ≥ 1.0ng/mL group had higher need for ICU (p = 0.001) and mortality (p = 0.044). PCT > 2.25ng/mL (aOR 22.56; p = 0.013)at baseline and failure in reduction of PCT levels to < 60% of baseline at day-7 post-intervention (aOR 53.76; p = 0.001) were significant mortality predictors. Baseline PCT > 1.0ng/mL is associated with poor outcome. PCT > 2.25ng/mL and failure in reduction of PCT levels to < 60% of its baseline at day-7 post-intervention can identify high-mortality risk patients.

Correlative factor of death in patients with infected pancreatic necrosis after surgical intervention

Background: Acute pancreatitis (AP) was a potentially fatal disease with a variation in severity. Infected pancreatic necrosis was a common complication in AP which needed surgical intervention. The present study was to study the correlative factors of death in patients with infected pancreatic necrosis after surgical intervention. Methods: From January 2016 to October 2019, a total of 186 patients with infected pancreatic necrosis after surgical intervention in the First Medical Center, Chinese PLA General Hospital were retrospectively enrolled in this study. Of the 186 patients, 22 who died in the hospital were defined as a mortality group and the others as a survival group. The clinical characteristic of the 2 groups was compared and the relative risk of mortality in patients with infected pancreatic necrosis after the surgical intervention was studied. Results: Acute fluid collection, acute kidney injury, acute lung injury, acute liver injury, multiple organ dysfunction syndromes, abdominal bleeding, abdominal Acinetobacter baumannii infection, pulmonary infection, pulmonary A baumannii infection, positive blood culture, A baumannii of blood culture, severe acute pancreatitis according to Atlanta 2012, the use of continuous renal replacement therapy, mechanical ventilation and minimally invasive retroperitoneal pancreatic necrosectomy was associated with death in hospital. Older age, longer acute kidney injury lasting time, longer acute lung injury lasting time, longer acute liver injury lasting time, and longer multiple organ dysfunction syndromes lasting time in predicting mortality in patients with infected pancreatic necrosis after surgical intervention were (0.635 [95% confidence interval (CI): 0.512–0.758], P = .040), (0.877 [95% CI: 0.788–0.965], P = .000], (0.932 [95% CI: 0.897–0.968], P = .000), (0.822 [95% CI: 0.708–0.935], P = .000), and (0.943 [95% CI: 0.887–0.998], P = .000). Due to the small number of death cases, the results of the multivariate analyses were not available. Conclusion: In this single-center retrospective study of 186 cases of infected pancreas necrosis, the correlative factors of death are identified. The results warranted further strategies are needed especially focusing on elder patients to prevent blood infection and to protect the functions of vital organs.

Risk Factors and Outcomes of Multidrug-Resistant Bacteria Infection in Infected Pancreatic Necrosis Patients.

The incidence of acute pancreatitis (AP) is increasing. Twenty percent of AP patients with developing necrotizing pancreatitis (NP), while ~40-70% of NP patients develop potentially fatal infectious complications. When patients are suspected or confirmed infected pancreatic necrosis (IPN), antibiotics should be administered timeously to control the infection, but long-term use of antibiotics can lead to multidrug-resistant bacteria (MDRB) infection and eventually to increased mortality. Our study aimed to determine the incidence of MDRB infection and evaluate the risk factors for MDRB infection in IPN patients. Clinical data of IPN patients admitted to the general surgery department of Xuanwu Hospital of Capital Medical University between January 1, 2014, and December 31, 2021, were retrospectively analyzed. IPN patients (n = 267) were assigned to MDRB infection (n = 124) and non-MDRB infection (n = 143) groups. On admission, patients in the MDRB group had a higher modified computer tomography severity index (CTSI) score (P < 0.05), pancreatic necrosis degree, and PCT level (P < 0.05) than those in the non-MDRB group, and the prognosis of patients in MDRB group was poor. The most common gram-negative bacteria were Acinetobacter baumannii (n = 117), the most common gram-positive bacteria were Enterococcus faecium (n = 98), and the most common fungal infection was Candida albicans (n = 47). Multivariable analysis showed that complications of EPI (OR: 4.116, 95% CI: 1.381-12.271, P = 0.011), procalcitonin (PCT) level at admission (OR: 2.728, 95% CI: 1.502-4.954, P = 0.001), and degree of pancreatic necrosis (OR: 2.741, 95% CI: 1.109-6.775, P = 0.029) were independent risk factors for MDRB infection in IPN patients. We identified common infectious strains and risk factors for MDRB infection in IPN patients.

A Step-up Approach for the Management of Infected Pancreatic Necrosis

Acute pancreatitis (AP) is an acute inflammation of the pancreas. Many of the mild AP and moderately severe AP (SAP) are self-limiting with a good prognosis, but the management of 15%–20% of SAP is very difficult and results in a mortality rate of 36%–50%. It poses a great challenge in clinical diagnosis and treatment. Infected pancreatic necrosis develops in approximately 20% to 30% of patients with AP, which is treated with the use of a step-up approach, with catheter drainage often delayed until the infected necrosis is encapsulated.

Fibrinogen-like Protein 1 as a Predictive Marker for the Incidence of Severe Acute Pancreatitis and Infectious Pancreatic Necrosis.

Background and Objectives: Acute pancreatitis (AP) is defined as an acute inflammatory disorder of the pancreas and is a common gastrointestinal disease. Since currently used indicators lack specifics and cannot accurately reflect the phase of disease, better diagnostic approaches need to be explored. Fibrinogen-like protein 1 (FGL-1) is a reactant in acute inflammatory diseases and is increased in the plasma of AP patients. In the current study, we aim to investigate the clinical benefits of FGL-1 in predicting the severity of AP and infected pancreatic necrosis (IPN), which can improve the diagnostic efficiency of AP. Materials and Methods: In this study, 63 patients diagnosed with AP from December 2018 to September 2019 were enrolled. Regarding the severity of AP, patients were separated into severe acute pancreatitis (SAP, n = 12) and No-SAP groups (n = 51). On the basis of infective conditions, patients were divided into IPN (n = 9) and No-IPN (n = 54) groups. The demographic data (sex and age) and blood parameters (WBC, HCT, glucose, calcium, FIB, APTT, PCT, CRP, and FGL-1) were retrospectively analyzed. Results: The plasma FGL-1 levels were increased in both SAP (p < 0.01) and IPN (p < 0.05) subgroups compared to the healthy control group. Multivariate analysis showed that elevated plasma FGL-1 (p < 0.01) and PCT levels (p < 0.05) within 72 h after the onset of AP were positively correlated with the severity of AP, while increased plasma FGL-1 (p < 0.01) and CRP (p < 0.05) levels were positively correlated with the occurrence of IPN. The combination of FGL-1 and PCT showed superiority to both individual markers in SAP prediction. However, the combination of FGL-1 and CRP showed no diagnostic advantage over CRP in IPN prediction. Conclusions: Plasma FGL-1 within 72 h after the onset could be used for the stratification of AP and its infectious complications. The combination of PCT and FGL-1 presents an enormous advantage for the early identification of SAP.

Impact of multiple drug-resistant Gram-negative bacterial bacteraemia on infected pancreatic necrosis patients.

Multiple drug-resistant Gram-negative bacterial (MDR-GNB) bacteraemia poses a serious threat to patients in hospital. Infected pancreatic necrosis (IPN) patients are a vulnerable population to infectious complications during hospitalization. This study aims to evaluate the impact of MDR Gram-negative bacteraemia on IPN patients. A case-control study was performed with data collected from 1 January 2016 to 1 July 2022 in a Chinese tertiary teaching hospital. Clinical data of the IPN patients with MDR-GNB bacteraemia were analyzed and compared to those of a matched control group without MDR-GNB bacteraemia (case-control ratio of 1:2). Comparisons were performed between with/without MDR-GNB bacteraemia and different severities of acute pancreatitis (AP). Independent predictors of overall mortality were identified via univariate and multivariate binary logistic regression analyses. MDR-GNB bacteraemia was related to a higher mortality rate (62.5% vs. 8.3%, p < 0.001). Severe AP combined with MDR-GNB bacteraemia further increased mortality up to 81.3% (p = 0.025). MDR-GNB bacteraemia (odds ratio (OR) = 8.976, 95% confidence interval (CI) = 1.805 -44.620, p = 0.007) and severe AP (OR = 9.414, 95% CI = 1.742 -50.873, p = 0.009) were independent predictors of overall mortality. MDR- Klebsiella pneumoniae was the most common causative pathogen. A higher mortality rate in IPN patients was related to MDR-GNB bacteraemia and further increased in severe AP patients combined with MDR-GNB bacteraemia.

Interleukin-6 is better than C-reactive protein for the prediction of infected pancreatic necrosis and mortality in patients with acute pancreatitis.

This study aimed to identify whether interleukin-6 (IL-6) is better than C-reactive protein (CRP) for the prediction of severe acute pancreatitis (SAP), infected pancreatic necrosis (IPN), and mortality. Sixty-seven patients with acute pancreatitis (AP) who were hospitalized within 48h of onset and received serum CRP and IL-6 tests from September 2018 to September 2019 were included. Spearman's correlation was performed to assess their associations with severity. The areas under the curve (AUCs) for the prediction of SAP, organ failure, pancreatic necrosis, IPN, and mortality were estimated using receiver operating characteristic curves. Serum CRP and IL-6 levels were significantly positively correlated with the severity of AP (p < 0.05). The AUC for the prediction of SAP based on the CRP level was 0.78 (95% CI, 0.66-0.89) and that based on the IL-6 level was 0.69 (95% CI, 0.56-0.82). For the prediction of organ failure and pancreatic necrosis, CRP was more accurate than IL-6 (AUC 0.80 vs. 0.72 and 0.75 vs. 0.68, respectively). However, CRP was less accurate than IL-6 for predicting mortality and IPN (AUC 0.70 vs. 0.75 and 0.65 vs. 0.81, respectively). Systemic inflammatory response syndrome plus CRP was more accurate than systemic inflammatory response syndrome plus IL-6 (AUC 0.79 vs. 0.72) for the prediction of SAP. IL-6 was more accurate than CRP for predicting mortality and IPN in patients with AP.

Early-onset emphysematous pancreatitis indicates poor outcomes in patients with infected pancreatic necrosis.

Emphysematous pancreatitis (EP) is a subtype of infected pancreatic necrosis (IPN) characterized by presence of gas in (peri)pancreatic necrosis. However, the impacts of EP on outcomes of IPN are still controversial. A prospective database of consecutive patients with IPN in a tertiary hospital was post-hoc analyzed. Patients were assigned to EP and non-EP groups to perform a comprehensive comparison. A total of 178 patients with IPN were enrolled and the overall mortality was 30.9%. EP accounted for 20.8% (n=37) of cases and was significantly associated with higher incidences of Escherichia coli (45.9 versus 18.4%, P=0.001) and Klebsiella pneumoniae (56.8 versus 33.3%, P=0.009) infection. There was scarcely any disparity in clinical characteristics and outcomes between IPN patients with and without EP. However, patients with early-onset EP defined as air bubble signs occurring within 2 weeks from disease onset were significantly older and have higher prevalence of history of diabetes, and they were also associated with significantly higher mortality (57.1 versus 8.7%, P=0.015) compared with late-onset patients. The clinical outcomes of EP might be like those of non-emphysematous infection. However, when EP occurs within 2 weeks from disease onset, it is highly lethal.