Management Of Pancreatic Necrosis Research Articles

Evidence-Based Approach to the Surgical Management of Acute Pancreatitis.

Background Acute pancreatitis is a significant challenge to health services. Remarkable progress has been made in the last decade in optimizing its management. Methods This review is a comprehensive assessment of 7 guidelines employed in current clinical practice with an appraisal of the underlying evidence, including 15 meta-analyses/systematic reviews, 16 randomized controlled trials, and 31 cohort studies. Results Key tenets of early management of acute pancreatitis include severity stratification based on the degree of organ failure and early goal-directed fluid resuscitation. Rigorous determination of etiology reduces the risk of recurrence. Early enteral nutrition and consideration of epidural analgesia have been pioneered in recent years with promising results. Indications for invasive intervention are becoming increasingly refined. The definitive indications for endoscopic retrograde cholangiopancreatography in acute pancreatitis are associated with cholangitis and common bile duct obstruction. The role of open surgical necrosectomy has diminished with the development of a minimally invasive step-up necrosectomy protocol. Increasing use of endoscopic ultrasound-guided intervention in the management of pancreatic necrosis has helped reduce pancreatic fistula rates and hospital stay. Conclusion The optimal approach to surgical management of complicated pancreatitis depends on patient physiology and disease anatomy, in addition to the available resources and expertise. This is best achieved with a multidisciplinary approach. This review provides a distillation of the recommendations of clinical guidelines and critical discussion of the evidence that informs them and presents an algorithmic approach to key areas of patient management.

Percutaneous catheter drainage of pancreatic associated pathologies: A systematic review and meta-analysis

PurposeThe main goal of this systematic review was to assess the technical and clinical success, adverse events (AEs), surgery, and overall mortality proportion after percutaneous catheter drainage (PCD) of two pancreatic lesions. MethodsAn extant search in online databases including Scopus, PubMed (Medline), Embase (Elsevier), Web of Science, Cochrane library, and Google Scholar, was conducted to recognize all studies that used PCD intervention in the management of pancreatic necrosis (PN) and pancreatic pseudocysts (PP). Random effects meta-analysis was performed, and Cochrane’s Q test and I2statistic were utilized to determine heterogeneity. In addition, meta-regression was used to explore the influence of categorical variables on heterogeneity. ResultsThirty-two studies (1398 patients) including PN in 26 (1256 cases, 89.8%) studies and PP in 6 (142 cases, 10.2%) studies were identified. Technical success proportion was 100% (95% confidence interval [CI] 100%-100%, I2: 0.0%), clinical success 63% (95% CI 55%-71%, I2: 92.9%), AEs 26% (95% CI 21%-31%, I2: 78%), surgery after PCD intervention 33% (95% CI 25%-40%, I2: 92.4%), and overall mortality was 13% (95% CI 9%-17%, I2: 82.8%). The most common ADs after PCD intervention were development of fistula (106, 42.6%), hemorrhage (44, 17.7%), sepsis (40, 16.1%). ConclusionA significant clinical success proportion with low AEs, surgery, and overall mortality proportion after PCD intervention was found, although the results should be interpreted with caution due to the high heterogeneity.

924 – Complications of Percutaneous Drainage in Step-Up Approach for Management of Pancreatic Necrosis: Experience of Ten Years from a Tertiary Care Centre

924 – Complications of Percutaneous Drainage in Step-Up Approach for Management of Pancreatic Necrosis: Experience of Ten Years from a Tertiary Care Centre

Tu1440 A NOVEL TOOL FOR FAST AND EFFECTIVE ENDOSCOPIC REMOVAL OF PANCREATIC NECROSIS

Acute pancreatitis may run a severe course when pancreatic necrosis becomes infected. Invasive treatment of these patients is virtually always necessary and over the last decade the treatment has changed dramatically towards less invasive treatments. Endoscopic drainage and ensuing necrosectomy have been shown to be effective in the management of pancreatic necrosis. One of the main limitations during endoscopic management is the lack of dedicated and effective instruments to remove pancreatic necrotic tissue, resulting in time consuming procedures with marginal results and often necessitating multiple procedures. We aimed to evaluate the technical feasibility, safety and clinical outcome of the EndoRotor®, a novel automated mechanical endoscopic resection system to suck, cut and remove small pieces of tissue in patients with necrotizing pancreatitis. Subjects with infected walled-off pancreatic necrosis were endoscopically treated using the EndoRotor® device. Procedures were performed under conscious or propofol sedation by four endoscopists with a broad experience in advanced endoscopic procedures including conventional endoscopic necrosectomy. Endoscopists were additionally asked to fill out a short questionnaire about their experience using the EndoRotor®. Six patients have been endoscopically treated for pancreatic necrosis, five patients were men and the median age was 61.7 years (range 43-71). Imaging data of the pancreas revealed a mean necrotic collection size of 114.7mm diameter (range 50-180mm). Transgastric drainage was performed in all patients, four patients received plastic stents and two a fully covered lumen apposing stent. Three patients were previously treated unsuccessfully with conventional tools with a median of two procedures (range 1-3). Additionally, the EndoRotor® was used in six patients with a total of 16 procedures, the average procedure length was 46.5 minutes (range 32-80). To achieve complete removal of pancreatic necrosis, the median number of required procedures was two per patient (range 1-7). No procedure-related adverse events occurred. Endoscopists agree on the ease of use and effective removal of necrotic tissue with the EndoRotor®, rating both 8.3 on a 10-point scale. They are especially satisfied by the ability to manage the removal of necrotic tissue in a controlled way (8.6 on a 10-point scale). Moreover, they are convinced that this device is of additional value in the management of pancreatic necrosis (8.6) and are willing to use it again (9.3 on a 10-point scale). Initial experience with the EndoRotor® suggests that this device can safely, quickly and effectively remove pancreatic necrosis.

Pancreatic Necrosis: A Challenging Complication of Acute Pancreatitis

Pancreatic necrosis is a complex and challenging complication of severe acute pancreatitis and it occurs in to of patients with acute pancreatitis It represents one of the most serious complications of severe acute pancreatitis with a mortality rate of to Majority of necrosis are sterile and can be managed conservatively However approximately of pancreatic necrosis develop infection and need an invasive intervention due to aggressive course A minimal invasive step up approach using percutaneous catheter drainage or endoscopic transluminal drainage is currently replacing more invasive open necrosectomy This review provides an overview of patho physiology clinical feature and management of pancreatic necrosis

Minimally invasive pancreatic necrosectomy; a technical pictorial review.

Necrotizing pancreatitis is the most severe form of acute pancreatitis, which is associated with significant mortality and morbidity. Open necrosectomy has been one of the treatment modalities; however, it has been associated with high mortality rates and alternative minimally invasive procedures such as minimal invasive pancreatic necrosectomy (MIPN) were developed to improve on the outcomes. While current clinical evidence on MIPN showed significant advantages in terms of incidence of multiple organ failure, incisional hernias and new-onset diabetes there were no differences in terms of mortality rate. In this pictorial review we are presenting the technical details of MIPN as a minimally invasive procedure for the debridement of the necrotic pancreatic tissue and we will discuss the current evidence around the use of this procedure for the management of pancreatic necrosis.

Necrotizing Pancreatitis: Current Management and Therapies.

Acute necrotizing pancreatitis accounts for 10% of acute pancreatitis (AP) cases and is associated with a higher mortality and morbidity. Necrosis within the first 4 weeks of disease onset is defined as an acute necrotic collection (ANC), while walled off pancreatic necrosis (WOPN) develops after 4 weeks of disease onset. An infected or symptomatic WOPN requires drainage. The management of pancreatic necrosis has shifted away from open necrosectomy, as it is associated with a high morbidity, to less invasive techniques. In this review, we summarize the current management and therapies for acute necrotizing pancreatitis.

Management of Pancreatic Necrosis: A Comparison of Conservative, Percutaneous, Endoscopic, and Surgical Modalities and Their Clinical Outcomes

Introduction: Pancreatic necrosis is a morbid complication occurring in about 20% of patients with acute pancreatitis. Symptomatic sterile necrotic cavities and infected cavities are indications for drainage and debridement. Different modalities of treating pancreatic necrosis include conservative management, percutaneous drainage, endoscopic debridement and open surgical debridement. This study compares the clinical outcomes of all these modalities. Methods: We analyzed the period from December 2010 to October 2015 where 85 patients were treated for pancreatic necrosis at our hospital. We collected data with regards to their hospital course, investigational workup, management modalities utilized to treat them, complication rates, failure rates, ICU admission rate and mortality. Results: The mean age of patients was 54 ± 15 years. The major modality of therapy utilized was endoscopic necrosectomy (57.6%) (Figure 1) Overall rate of major and minor complications was 30.6% each. A logistic regression analysis did not find any difference in major complications between all 5 modalities. However, subgroup analysis revealed interesting results. (Table 1) Percutaneous drainage was associated with the highest re-intervention rate, ICU admission rate and certain major complications like intraabdominal bleeding, septic shock and/or multiorgan failure. Surgical necrosectomy was associated with a high ICU admission rate and the longest median length of ICU stay, however that may have been the case if patients needing surgery were very sick to begin with. Adjusted laboratory values pre- and postprocedure showed that percutaneous drainage had the highest impact in reducing the total white blood cell count whereas, surgical necrosectomy was associated with significant worsening of renal failure. Overall mortality rate at 30 days was 4%.Figure 1Figure 2Conclusion: Our study shows that each modality of treating pancreatic necrosectomy has its own advantages and disadvantages, with statistical analysis not revealing any significant difference. However, percutaneous drainage fared poorly compared to other interventions, possibly due to a higher systemic inflammatory response following puncture of the cystic cavity. Further research analyzing survival rates and hospitalization costs is needed to determine whether any particular procedure is superior to the others. For now, endoscopic necrosectomy seems to be the safer procedure with the least amount of morbidity or mortality.

Pancreatic endotherapy and necrosectomy.

There has been a paradigm shift in the management of pancreatic necrosis from open surgical debridement of infected necrosis to minimally invasive interventional radiologic, laparoscopic, and endoscopic drainage/debridement techniques. A step-up approach from less invasive to the more invasive modalities is recommended. An important distinction to make is between pseudocysts and walled-off necrosis (WON), as the interventions for each are different. Endoscopic or other interventions should be delayed for at least 4weeks for collections to encapsulate. Direct endoscopic necrosectomy (DEN) is an effective, minimally invasive option. Several variations in the technique, including the use of esophageal fully covered self-expanding metal stents (SEMS) and lumen-apposing SEMS have recently been described. The incremental effectiveness of these stents over conventional techniques needs to be studied. Dual-modality drainage with endoscopic transmural stent placement and lavage through percutaneous drains is also an effective option with low mortality and morbidity. Several minimally invasive surgical options, including video-assisted retroperitoneal debridement and sinus tract endoscopy are available and may be preferable to open surgical necrosectomy. An algorithmic, multidisciplinary management is warranted for successful outcomes. Disconnected pancreatic duct syndrome in the setting of necrotizing pancreatitis is challenging; long-term endoscopic transmural stent placement and/or distal pancreatectomy are potential treatment options.

The role of endoscopy in the management of pancreatic necrosis.

The management of acute pancreatitis has seen many advances over the past three decades. Attempts to improve care have led to new definitions, classification systems, and treatment strategies. Despite those efforts, considerable morbidity and mortality result from complications of severe acute pancreatitis. Much attention has been given to new ways to treat these complications, including inflammatory pancreatic fluid collections and associated infections. Endoscopy has become one of the established modalities for the treatment of these complications in many expert centers. This chapter will specifically address the role of endoscopy in the management of pancreatic necrosis.

Advances in management of pancreatic necrosis

Mercury emission fluxes (MEFs) under different surface coverage conditions in a landfill were investigated in this study. The results show similar diel patterns of Hg emission flux under different coverage conditions, with peak fluxes occurring at midday and decreasing during night. We examined the effects of environmental factors on MEFs, such as the physiological characteristics of vegetation and meteorological conditions. The results suggest that growth of vegetation in the daytime facilitates the release of Hg in the anaerobic unit, while in the semi-aerobic unit, where vegetation had been removed, the higher mercury content of the cover soil prompted the photo-reduction pathway to become the main path of mercury release and increased MEFs. MEFs are positively correlated with solar radiation and air temperature, but negatively correlated with relative humidity. The correlation coefficients for MEFs with different environmental parameters indicate that in the anaerobic unit, solar radiation was the main influence on MEFs in September, while air temperature became the main determining factor in December. These observations suggest that the effects of meteorological conditions on the mercury release mechanism varies depending on the vegetation and soil pathways.

Sa1373 Comparative Evaluation of Structural and Functional Changes in Pancreas After Endoscopic and Surgical Management of Pancreatic Necrosis

Sa1373 Comparative Evaluation of Structural and Functional Changes in Pancreas After Endoscopic and Surgical Management of Pancreatic Necrosis

Current Status of Direct Endoscopic Necrosectomy

The management of pancreatic necrosis has evolved. Sterile necrosis is now managed conservatively. Intervention is generally required for infected necrosis but is now deferred until four weeks after disease onset in order to permit encapsulation and demarcation of the necrotic collection. Demarcation facilitates necrosectomy and reduces complications related to the drainage and debridement procedures. The approach to pancreatic necrosectomy has evolved from primary open necrosectomy to minimally-invasive radiologic, surgical and endoscopic procedures. Direct endoscopic necrosectomy is a minimally-invasive technique that was introduced in recent years for the treatment of infected walled-off necrosis. A stoma is created endoscopically between the gastric lumen and the walled-off collection. An endoscope is then inserted directly into the cavity to perform endoscopic necrosectomy. This is followed by short-term placement of double pigtail transgastric stents and nasocystic catheter for post-procedural irrigation and drainage. This review will summarise the current status of direct endoscopic necrosectomy.

Endoscopic necrosectomy of pancreatic necrosis: a systematic review

To review the current status of the novel technique of endoscopic necrosectomy in the management of pancreatic necrosis after acute pancreatitis. Studies were identified by searching Medline, PubMed and Embase databases for articles from January 1990 to December 2009 using the keywords "acute pancreatitis", "pancreatic necrosis" and "endoscopy". Additional papers were identified by a manual search of the references from the key articles. Case series of fewer than five patients and case reports were excluded. Indications, techniques and outcomes of endoscopic necrosectomy were analysed. There were no randomised controlled trials identified. Ten case series were included in this analysis. There were a total of more than 1,100 endoscopic necrosectomy procedures in 260 patients with pancreatic necrosis. One hundred fifty-five were proven to be infected necrosis on culture. The overall mortality rate was 5%. The mean procedure-related morbidity rate was 27%. The rate of complete resolution of pancreatic necrosis with the endoscopic method alone was 76%. Endoscopic necrosectomy is a safe and effective treatment option in selected patients with pancreatic necrosis after acute pancreatitis. Future studies will be required to further define the selection criteria and the techniques for the endoscopic procedure.

Management of severe pancreatic necrosis

Pancreatic necrosis is a form of severe pancreatitis associated with high morbidity and mortality. In this condition there is necrosis of pancreatic tissue with pancreatic duct disruption leading to release and activation of pancreatic enzymes. This in turn causes peripancreatic necrosis and formation of fluid collections. The diagnosis of pancreatic necrosis is made by contrast-enhanced CT scan of the abdomen. The management of pancreatic necrosis is controversial. No randomized clinical trials are available for guidance in treatment of pancreatic necrosis. Experience, collaboration, and knowledge of the managing teams play a major role in successful treatment. Early percutaneous drainage with frequent monitoring of the catheters is the hallmark of our approach. Using this approach, it is possible to significantly decrease the rate of morbidity and mortality associated with this disease and its treatment.

Pancreatic necrosis: assessment of outcome related to quality of life and cost of management.

Ten patients with necrotizing pancreatitis admitted consecutively between August 1990 and August 1991 were studied. They comprised eight men and two women of median age 63 (range 29-73) years. One patient died. The median length of hospital stay was 74 (range 40-150) days. The median number of operations and endoscopic procedures performed per patient was 4 (range 2-7). Investigations performed included multiple bacteriological, radiological, haematological and biochemical tests. The mean cost of management was 18,441 pounds (range 9,296 pounds-33,796 pounds), of which hospitalization accounted for 65 per cent, operations and endoscopic procedures 20 per cent and investigations 16 per cent. Cost-utility analysis demonstrated a mean benefit per patient of 8.55 quality-adjusted life years gained at a cost of 2,157 pounds each. The management of pancreatic necrosis is expensive but justified by the excellent outcome in terms of quality of life.

Management of pancreatic necrosis in severe acute pancreatitis

Management of pancreatic necrosis in severe acute pancreatitis

Combined sinus tract endoscopy and endoscopic retrograde cholangiopancreatography in management of pancreatic necrosis and abscess

We report our experience of sinus tract endoscopy (STE) and endoscopic retrograde cholangiopancreatography (ERCP) in the treatment of pancreatic necrosis and abscess. Thirteen patients with extensive pancreatic necrosis were firstly managed with either percutaneous drainage (PD group; n = 9) or open necrosectomy (ON group; n = 4). Debridement of necrotic tissue was subsequently performed via the drain tract by STE. ERCP was performed only when there was a suspicious of persistent pancreatic duct disruption or choledocholithiasis. In the PD group, the median number of STE sessions required was 3 (range 2-8). The median hospital and ICU stay were 84 days (range 29-163 days) and 0 day (range 0-64 days), respectively, with an overall success rate of 67%. In the ON group, the median number of STE sessions required was 6.5 (range 1-18). The median hospital and ICU stay were 82 days (range 58-194 days) and 19 days (range 4-24 days), respectively. No mortality or failure was noted in the latter group. ERCP was required in nine of 13 patients. Combined ERCP and STE is a useful adjunct in treating pancreatic necrosis or abscess.

Closed lesser sac lavage in the management of pancreatic necrosis.

Surgery for pancreatic necrosis complicating acute severe pancreatitis carries a high risk of morbidity and mortality. We evaluated the efficacy of necrosectomy and closed lesser sac lavage as a method of management of pancreatic necrosis. Fifty-eight patients with pancreatic necrosis who underwent pancreatic necrosectomy consecutively in a tertiary care referral center were retrospectively analyzed. The technique of necrosectomy and postoperative lavage is described in detail. Details regarding the patient profile, disease severity, surgical details, postoperative morbidity, repeat interventions and the mortality are presented. Of the 58 patients, irrigation was able to be started in 48. Lavage was able to be continued until disease resolution or death in all but 10 patients. Post-operative locoregional complications were residual abscesses in 10, bleeding in eight, enteric fistulae in 12 and pancreatic fistulae in nine. Six patients needed postoperative percutaneous procedures, while 16 patients needed repeat surgery. Seventeen patients died (29%), all of whom had multiple organ failure involving more than two organs, while 11 developed sepsis. Pancreatic necrosectomy and postoperative closed lesser sac lavage is an effective method of managing these patients, with acceptable morbidity, re-operation rates and mortality.

Management of necrotizing pancreatitis.

Infection complicating pancreatic necrosis leads to persisting sepsis, multiple organ dysfunction syndrome and accounts for about half the deaths that occur following acute pancreatitis. Severe cases due to gallstones require urgent endoscopic sphincterotomy. Patients with pancreatic necrosis should be followed with serial contrast enhanced computed tomography (CE-CT) and if infection is suspected fine needle aspiration of the necrotic area for bacteriology (FNAB) should be undertaken. Treatment of sterile necrosis should initially be nonoperative. In the presence of infection necrosectomy is indicated. Although traditionally this has been by open surgery, minimally invasive procedures are a promising new alternative. There are many unresolved issues in the management of pancreatic necrosis. These include, the use of antibiotic prophylaxis, the precise indications for and frequency of repeat CE-CT and FNAB, and the role of enteral feeding.