Pancreatic Necrosectomy Research Articles

A Rare Complication of Sudden Cerebral Embolism After a Series of Beneficial Surgical Minimally Invasive Pancreatic Necrosectomy: a Case Report

Patients with acute pancreatitis can benefit more from step-up management. The minimally invasive approaches (MIA) could reduce complications, mortality, days, and expenses in hospitals. Even in these cases, they would still suffer fatal complications during the treatment. We present here a case of infected pancreatic necrosis (IPN) in a 51-year-old Chinese woman who developed a fatal cerebral embolism and died after a beneficial step-up procedure. The minimally invasive approach included surgical dual-scope necrosectomy and sequential non-narcotic nephroscopic pancreatic necrosectomy; a great improvement was made both in clinical condition and images after the advanced technique. Our case attempts to show that a dual-scope necrosectomy is a superior approach for patients with IPN. Cerebral embolism is a rare but life-threatening complication of severe acute pancreatitis (SAP). Patients with SAP may be at risk of cerebral embolism. If clinically suspected, necessary investigations should be arranged to look for causes. Once diagnosed, early treatment should be considered on a case-by-case basis.

Open Pancreatic Necrosectomy Is Still Safe and Effective Treatment for Pancreatic Necrosis Managed by Step-Up Approach

Open Pancreatic Necrosectomy Is Still Safe and Effective Treatment for Pancreatic Necrosis Managed by Step-Up Approach

Pancreatic Necrosectomy? An old fashioned Idea in the era of Interventional Radiological drainage?

Pancreatic Necrosectomy? An old fashioned Idea in the era of Interventional Radiological drainage?

Minimally Invasive Pancreatic Necrosectomy: A step-up approach towards ultra-low mortality in 103 consecutive procedures

Background: Infected pancreatic necrosis carries up to 70% risk of mortality. Open necrosectomy, previously regarded as standard treatment, carries very high risk of morbidity and mortality. Step-up management with percutaneous drainage followed by minimally invasive pancreatic necrosectomy (MIPN) has shown improved outcomes. We report the outcomes of the protocol developed at Cambridge of ‘early’ percutaneous drainage followed by ‘delayed’ MIPN. Materials and Methods: Cambridge University Hospital is a tertiary referral centre for pancreatic surgery including complicated pancreatitis. Retrospective analysis of all MIPNs between December 2009 and October 2018. Demographics, morbidity and mortality outcomes were reported. Results: During the 9-year period, 103 MIPNs were performed in 86 patients, with 12 (13.9%) needing multiple procedures. The mean age was 58 ±15 years, with 74.4% (n=64) being male gender and 50.0% (n=43) with BMI >30 Kg/m2.Thirty patients (34.9%) had required preoperative ITU admission for multi-organ support due to infected necrosis. The median time for insertion of percutaneous drain was 28 days (range 1-99). The median time of the MIPN from acute episode was 45 days (range 4-307). Thirteen patients (15.1%) required admission to ITU after MIPN with a median stay of 22 days (range 1-104). Complications of MIPN (n=29, 33.7%) included bleeding requiring intervention (n=5), pancreatic fistula (n=5) and multi-organ failure (n=19), which was considered as the morbidity rate. 30-day and 90-day mortality following MIPN was 2.3% (n=2) and 5.8% (n=5). All deaths were due to sepsis and multi-organ failure. Conclusions: This is the lowest reported mortality rate for patients with infected pancreatic necrosis. Minimally invasive management with early percutaneous drain insertion followed by delayed MIPN is associated with ultra-low mortality. Management of complicated necrotizing pancreatitis almost invariably requires tertiary referral expertise as it involves multimodal approaches, complex medical and ITU care, multiple procedures, prolonged admissions and long-term follow-up.

Gender Differences in Gastrointestinal, Hepatobiliary and Pancreatic Surgery and Perceived Relevance on Outcomes <br/>—A Single Center 22-Year Observational Study in India (1996-2018)

Introduction: Gender differences are still quite prevalent in the present time. Although there is literature regarding gender differences in healthcare expenditure in India, there is no data regarding gender differences in hospital stay, hospital seeking behaviors and mortality. Aim: To evaluate the Gender differences in a hospital seeking behavior, mortality and hospital stay. Methods: We prospectively analyzed, from a retrospective database, all patients who underwent surgical gastrointestinal, hepato-biliary, pancreatic and splenic surgeries from 1996 to 2018 in our unit. Patients were divided into groups based on gender, admission time period and priority of admission i.e., elective or emergency. Both the gender groups were compared with respect to total procedures done, hospital stay and mortality. Organ specific mortality was calculated as proportions, was analyzed and compared between the groups. Time trends of the same were observed and compared. Results: Of 12,411 patients, 7979 (64.3%) were males and 4432 (35.7%) were females. 9191 (74.1%) patients underwent elective procedures whereas 3220 (25.9%) had emergency procedures (p ≤ 0.001). Overall mortality was higher in males (n = 473, 5.92%) in comparison to females (n = 185, 4.17%) (p ≤ 0.001). Majority of surgeries in males were of small intestine (22.5%) in which small bowel resection was most commonly done (5.4%), whereas, gallbladder and biliary surgeries (27.4%) were the most common in females in which laparoscopic cholecystectomy was most commonly done (5.8%). Median hospital stay was higher in males (10 days vs 9 days), (p ≤ 0.001). Mortality was higher in females in all organ categories except in liver (6.34% vs 2.7%), pancreas (37.3% Vs 18.3%) and spleen (3.38% Vs 1.62%) where mortality was higher for male gender. Highest mortality for females was in small intestinal surgery (34%) and for males, it was pancreatic surgery (37.3%). Highest mortality in males was emergency open pancreatic necrosectomy (21.6%) and that in females was emergency small intestinal surgery (11.9%). Although the number of surgeries in females increased over time (380 in 1996-1999 Vs 951 in 2016-2018), the proportion remained constant (36.3% Vs 38.3% in 1996-1999 and 2016-2018 respectively). Conclusion: We conclude that mortality is found to be higher in males after gastrointestinal surgery, which may be explained by the fact that hospital seeking behavior is more in males though it is fairly increasing in females in the recent years.

On-and-off deployment technique of a lumen-apposing metal stent during endoscopic pancreatic necrosectomy.

On-and-off deployment technique of a lumen-apposing metal stent during endoscopic pancreatic necrosectomy.

Non-surgical treatment of acute pancreatitis with colonic fistula

Objective: To examine the effectiveness of non-operative of colonic fistula following acute pancreatitis. Methods: Retrospective analysis of 354 patients with acute pancreatitis who were admitted to Department of Hepatobiliary Surgery of Chinese People's Liberation Army General Hospital from January 2013 to December 2018. Age of the patients was (46±14) years (range: 14-85 years); 249 cases (70.3%) were males. There were 41 cases of acute edematous pancreatitis and 313 cases of acute necrotising pancreatitis. Two hundred and fifteen cases were diagnosed as moderate severe acute pancreatitis and 139 were diagnosed as severe acute pancreatitis. Among 313 cases of acute necrotising pancreatitis, 62 cases underwent non-surgical treatment, 251 cases underwent surgical treatment in which 218 of minimal access retroperitoneal pancreatic necrosectomy underwent percutaneous nephroliguectomy with peripancreatic necrotic tissue removal technique. Results: There were 15 cases of colon fistula following acute necrotising pancreatitis, and the incidence rate was 4.2%(15/354). There were 7 males and 8 females, with age of (39±8) years (range: 27 to 50 years). The median interval between acute pancreatitis onset and diagnosis of colonic fistula was 71 days(27-134) days. Two cases occurred at the hepatic flexure of the colon, 4 cases at transverse colon, and 9 cases at splenic flexure of colon. Of the 354 patients, 39 cases died and the mortality was 11.0%. Two patients underwent laparotomy, and one of them died. The remaining 13 patients underwent non-surgical treatment and were discharged. Conclusion: Acute pancreatitis with colonic fistula can be treated with non-surgical treatment and can achieve good prognosis.

A comparative study on transnasal gastroscopy and conventional gastroscopy for percutaneous endoscopic pancreatic necrosectomy

Objective To compare the therapeutic value of transnasal gastroscopy and conventional gastroscopy for infective pancreatic necrosis(IPN) through percutaneous endoscopic necrosectomy(PEN). Methods A total of 24 IPN patients who received PEN for IPN from December 2015 to March 2019 were divided into the conventional gastroscopy group (n=15) and the transnasal gastroscopy group (n=9). The clinical therapeutic indicators such as vital signs, APACHE Ⅱ score changes, operation duration, difference in preoperative and postoperative volumes of peripancreatic necrosis and other indicators were compared between the two groups. Results There was no significant difference in the variation curve fitting of APACHE Ⅱ scores between the two groups (t=0.378, P=0.710). The operation time of the transnasal gastroscopy group was significantly shorter than that of the conventional gastroscopy group (119.7±47.4 min VS 172.8±56.2 min, P=0.018). Peripancreatic necrotic volume significantly decreased after operation in the transnasal gastroscopy group (404.03±170.73 mL VS 468.9±137.37 mL, P=0.002), and in the conventional gastroscopy group (499.44±227.17 mL VS 722.50±292.96 mL, P<0.001). There was no significant difference in the decrease extent in the conventional gastroscopy group and the transnasal gastroscopy group (223.06±212.92 mL VS 64.87±54.94 mL, P= 0.094). Conclusion On the condition of poor drainage of percutaneous catheter drainage, PEN can significantly reduce the range of necrotic lesions. Transnasal gastroscopy has the advantages in operation time in PEN and clearing deep abscess cavities over conventional gastroscopy. Key words: Pancreatitis; Percutaneous endoscopic necrosectomy; Infective pancreatic necrosis

Ultrasonic Pressure Ballistic System-Assisted Minimally Invasive Pancreatic Necrosectomy for Necrotizing Pancreatitis.

Background: Although minimally invasive pancreatic necrosectomy (MIPN) is a new invasive technique for necrotizing pancreatitis, it has some disadvantages. This study aimed to improve the debridement technique with an ultrasonic pressure ballistic system. We hypothesized that this system would facilitate debridement and improve the safety of the procedure. Materials and Methods: Between October 2016 and January 2019, 5 patients diagnosed with necrotizing pancreatitis were enrolled in the clinical cohort. All patients underwent debridement due to infective necrosis. Access for debridement was typically established with percutaneous puncture. Then MIPN was performed. During the procedure, ultrasonic pressure was applied to liquefy the necrotic material and make it absorbable. The effect of debridement was assessed by analyzing the average bleeding volume, operation time, and complications. Postoperative clinical parameters were evaluated. Results: Debridement was performed successfully for all patients. Semisolid necrotic tissue was dissolved with ultrasonic pressure. Viscous pus was rapidly aspirated with the suction applied with negative pressure, which greatly enhanced efficiency. This approach enhanced the visibility of blood vessels, which improved safety. No major complications were encountered. Two patients (40%) developed puncture site infections. The average blood loss during the operation was 13 ± 6 mL. The average operation time was 78 ± 31 minutes. Postoperative APACHE II scores were significantly lower than preoperative scores (P < .05). White blood cells, C-reactive protein, and procalcitonin levels declined postoperatively. Conclusions: The ultrasonic pressure ballistic system could potentially enhance MIPN and make it safer.

Clinical efficacy of minimal access retroperitoneal pancreatic necrosectomy for infected pancreatic necrosis

Objective To investigate the clinical efficacy of minimal access retroperitoneal pancreatic necrosectomy (MARPN) for infected pancreatic necrosis (IPN). Methods The retrospective cohort study was conducted. The clinical data of 61 patients with IPN who were admitted to Union Hospital Affiliated to Tongji Medical College of Huazhong University of Science and Technology between January 2014 and December 2017 were collected. There were 39 males and 22 females, aged 36-67 years, with a median age of 49 years. Of 61 patients, 40 undergoing open surgery were allocated into open group, and 21 undergoing MARPN were allocated into MARPN group. All the patients underwent surgical treatments after standard non-surgical treatments according to the Guidelines for the diagnosis and treatment of severe acute pancreatitis (2014 edition). Observation indicators: (1) intraoperative and postoperative situations; (2) follow-up. Follow-up using telephone interview or outpatient examination was performed to detect weight loss, pathoglycemia, steatorrhea, intestinal obstruction, and pancreatic portal hypertension for one year after surgery up to December 2017. Measurement data with normal distribution were represented as Mean±SD, and comparison between groups was analyzed using the t test. Count data were represented as absolute numbers or percentages, and comparison between groups was done using the chi-square test. Results (1) Intraoperative and postoperative situations: operation time, time to out-of-bed activity, time to initial food intake, cases with reoperation, cases with postoperative multiple organ dysfunction syndrome (MODS), incidence rate of postoperative complications, mortality, time to drainage-tube removal, duration of hospital stay, and hospital expenses were (77±20)minutes, (13.0±3.6)days, (9.0±2.7)days, 8, 9, 45.0%(18/40), 7.5%(3/40), (37.0±6.3)days, (49±8)days, (84 321±8 872)yuan in the open group, and (59±20)minutes, (2.7±0.9)days, (1.9±0.4)days, 6, 2, 19.0%(4/21), 0, (21.0±2.7)days, (39±6)days, (58 594±3 576)yuan in the MARPN group, respectively, showing no significant difference in the cases with reoperation (χ2=0.69, P>0.05) but significant differences in the other indices between the two groups (t=4.24, 9.61, 15.34, χ2=23.76, 4.02, 36.03, t=11.07, 5.93, 8.43, P 0.05). Conclusion MARPN for IPN is safe and reliable, with certain efficacy, which can effectively reduce incidence of postoperative complication, motality and shorten hospital stay. Key words: Pancreatitis; Infection; Retroperitoneal approach; Pancreatic necrosectomy

1684 Paging Dr. MacGyver: A Novel Approach to Redeploying a Dislodged AXIOS Stent During a Pancreatic Necrosectomy

INTRODUCTION: Although multiple modalities exist for managing walled off and infected pancreatic necrosis, EUS-guided transmural drainage is often favored due to its minimally invasive and highly effective nature. The AXIOS stent has demonstrated clear superiority over double pigtail and fully covered self-expanding metal stents in this setting. Although the radial force from its wide luminal diameter and its dumbbell shape helps secure the stent in place, stent migration and dislodgement can still occur. Here, we present a case of stent dislodgement during a pancreatic necrosectomy, which was salvaged by stent extraction and endoscopic re-deployment using a stone extraction balloon catheter sheath. CASE DESCRIPTION/METHODS: A 68-year-old woman with a medical history notable for prior acute pancreatitis presented to the ED with abdominal pain, nausea, and vomiting. CT Abdomen revealed a large pancreatic fluid collection with surrounding necrosis. She was admitted to the SICU for management of necrotizing pancreatitis, and underwent cystgastrostomy with an AXIOS stent on day 14 of admission. During her necrosectomy one week later, the previously placed AXIOS stent was accidentally displaced into the stomach. The displaced stent was grasped with a rat tooth forceps and removed from the patient. One end of the extracted AXIOS stent was stretched so that it became thin enough to be inserted into an empty stone extraction balloon catheter sheath. The other end was then back-loaded into the larger channel of a double-channel gastroscope. The scope was then re-introduced and advanced into the pancreatic cyst cavity. A rat tooth forceps was inserted into the instrument channel and used to advance the back-loaded stent forward, re-deploying the stent under endoscopic guidance only, such that it again traversed the cystic cavity and stomach. The stent was then adjusted into its desired position using rat tooth forceps. DISCUSSION: As Interventional Endoscopy’s technologies continue to evolve, it will become increasingly important for the skilled endoscopist to understand the mechanics of the tools being used, and trouble shoot these technologies as unforeseen complications arise. The novel method for AXIOS stent re-deployment described here not only demonstrates this understanding, but also serves as an example of a cost saving recourse for dislodged AXIOS stent re-deployment. Indeed, in an era of cost-conscious care, one must trouble shoot in a manner that is both clinically effective and financially efficient. Watch the video: http://bit.ly/2O2RYbW.

2937 Endoscopic Ultrasound-Guided Drainage and Treatment of Symptomatic Walled-Off Pancreatic Necrosis: A Single Center Case Series

INTRODUCTION: Walled-off pancreatic necrosis (WOPN) develops within 4-6 weeks after acute necrotizing pancreatitis. Endoscopic transgastric pancreatic necrosectomy has emerged as a promising therapy for WOPN. We aim to evaluate the clinical success and outcomes of patients treated with endoscopic therapy for symptomatic WOPN. METHODS: Retrospective chart review of all patients who underwent endoscopic pancreatic necrosectomy from January 2015 until November 2018 was performed. Patients' demographics were obtained including etiology of pancreatitis, size of WON, number of endoscopic necrosectomies, time to resolution of necrosis, and outcome. RESULTS: 15 patients underwent endoscopic necrosectomy for symptomatic WOPN. 60% were male, average age was 56 years. Etiologies of pancreatitis included: Biliary (46%), alcohol induced (20%), hypertriglyceridemia (13%), and idiopathic (20%). Nine (60%) cases presented with infected necrosis diagnosed by cross-sectional imaging and clinical criteria. The Median size of peripancreatic fluid collections was 14 cm (Range: 8-20 cm). Endoscopic necrosectomy was performed through the transgastric route in all patients. All patients underwent initial necrosectomy at time of cystgastrostomy. 13 (87%) patients had luminal apposing stents (LAS) (Axios, Boston Scientific). Axios 15 mm × 10 mm were most common. The mean number of endoscopic therapy sessions was 3.4 (Range 1-8). Two (13%) patients had migrated LAS within 4 weeks. One patient underwent repeat cystgastrostomy to remove an internal migrated stent. There were no reported complications of bleeding, procedure-related infection, or perforation associated with cystgastrostomy or necrosectomy. None of the patients suffered death. Clinical success was achieved in 80% of our patient population defined by resolution of fluid collection and necrosis and clinical improvement. 3 (20%) patients required additional surgical intervention. One required surgical intervention for a pancreatic fluid collection not accessible by the endoscope. One underwent surgery prior to presenting to our center. The third had a large sized necrosis with multiple admission for sepsis and failure to thrive. CONCLUSION: Sequential endoscopic transgastric necrostectomy is a promising therapy for WOPN and should be the first modality to treat patients with infected or symptomatic walled-off necrosis. Large fluid collections, recurrent admissions, failure to thrive, and collections not accessible by the endoscope were indicators for surgical intervention.

1383 Making It Work With the Tools at Hand: Use of a Biliary Stent to Repair a Pancreatic Leak

INTRODUCTION: Pancreatic duct leaks (PDL) are primarily managed by advanced endoscopist, interventional radiologists, and sometimes by pancreatic surgeons. The mainstay of endotherapy for PDL is trans-papillary pancreatic duct stent placement bridging the PDL. Fully covered biliary metal stents are widely accepted in biliary leaks due to its radial force but there is no conventional fully covered metal stent (FCMS) in US for pancreatic duct for refractory PDL. We describe a patient with refractory PDL where biliary SEMS was used to successfully treat PDL. CASE DESCRIPTION/METHODS: Case Presentation A 43-year-old African American male presented to our hospital one month after admission for hemorrhagic pancreatitis attributed to dyslipidemia. Course was complicated by loculated retroperitoneal abscess tracking from pancreas to scrotum. Patient underwent exploratory laparotomy with pancreatic necrosectomy along with broad-spectrum antibiotics resulting in mild improvement in condition. Magnetic resonance cholangiopancreatography revealed PD injury confirmed on abdominal CT with contrast. ERCP confirmed PDL. A 5 F × 8 cm single pigtail plastic pancreatic stent (PPS) was placed. Unfortunately, PPS failed to maintain drainage and prevent leak as observed on contrasted abdominal CT 6 days later. PDL was confirmed again on repeat ERCP and an 8 mm × 6 cm biliary fully covered SEMS was placed in PD. Post stent placement, occlusion pancreatogram (OP) showed no leak. Four days later, repeat CT showed improving fluid collections without leak. After 4 weeks, third ERCP was performed, SEMS was removed with rat tooth forceps without complications, ERCP showed no PDL and a 7 F × 7 cm PPS was placed. Six weeks later, PPS was removed, ERCP showed no PDL and a 7 F × 4 cm PPS was placed. At this time, patient has continued to follow on outpatient basis without further incident. DISCUSSION: Discussion Endoscopic treatments for PDL have replaced surgical interventions in number of situations. Biflanged fully covered metal stents for PDL are only available outside US. In the meantime, cases like this emphasize the importance of considering alternative approaches in the treatment of PDL.

10 Transmural Pancreatic Necrosectomy: A Systematic Review and Meta-Analysis on Different Endoscopic Approaches

INTRODUCTION: Acute pancreatitis is complicated by necrosis of the peripancreatic tissue in about 20% of patients. Over the past few decades, endoscopic necrosectomy (EN) is increasingly gaining traction as primary management. EN techniques are subject to rapid innovations, recently fully covered self-expanding metal stents (FCSEMS), bi-flanged metal stent (BFMS), plastic and lumen-apposing metal stents (LAMS) has taken the place of direct endoscopic necrosectomy (DEN). This study sought to determine the efficacy and safety of these approaches. METHODS: The MedLine, Embase, and Cochrane databases were systematically searched since inception till Jan 2019 and 4678 articles were retrieved. Only 59 articles deemed relevant and were analyzed using the Meta-disc. RESULTS: The weighted mean number of days in the hospital for BFMS was lowest (4.1) compared to plastic (32) and LAMS (60). The pooled proportion of successful symptoms resolution after DEN was 78.27% ± 28.15% (16.70%–94%), compared to 90 and 94% for plastic and BFMS and 100% for FCSEMS and LAMS. Radiological resolution after DEN was recorded to be 84.75%, increasing to 98%, 98.85% and 100% after plastic, FCSEMS and BFMS respectively. Overall mean complications rate was significantly high 30.46% ± (18.58%, 0–71%) in the DEN group, followed by plastic stenting 23.72% (P = 0.002). FCSEMS (16%) and BFMS (7.50%) had the lowest proportion of complications. The weighted mean recurrence of disease post-FCSEMS procedure was 23.25% and 14.75% after DEN while no recurrence occurred after BFMS. For pancreatic necrosis that did not resolve, 100% of the LAMS group, more than half of plastic and FCSEMS, and only 47% of BFMS patients had a repeat procedure. The weighted mean of mortality was highest but statistically non-significant in FCSEMS 8.62% followed by direct ETN 8.07% and BFMS patients 3.20%. CONCLUSION: EN is emerging as an increasingly popular technique, rapidly expanding the domain of therapeutic endoscopists. The highest rate of complications with DEN can be explained by the aggressive nature of procedure devoid of stentings such as puncturing the gastric or duodenal wall. Plastic, FCSEMS, and BFMS have lower procedure-related complications, and hospital stays due to small stent size and a targeted approach. The clinical and radiological resolution with these approaches were also better than DEN, but repeat procedure for stent removal or EN revision was often required. The mortality was not significantly different for different approaches.

907 Endoscopic Pancreatic Necrosectomy Technique: Know Your "How" to Justify Your "Why"

INTRODUCTION: Walled-off necrosis (WON) is a feared complication of acute pancreatitis that carries significant morbidity. Direct endoscopic necrosectomy (DEN) is preferred over surgical one due to its minimally invasive nature and lower complication rates. However, no endoscopic technique and/or device has been adopted as a gold standard; and endoscopists differ significantly in their DEN preferences. The primary aim of this study was to report our DEN technique and its outcomes. METHODS: Medical records of patients who underwent EN from September 2016 – May 2019 were reviewed. Continuous data was described using mean and standard deviation (SD); categorical data as frequency and proportion (%); and interval data as median and (range). RESULTS: A total of 20 patients underwent DEN after initial drainage with a 10 × 15 mm electrocautery enhanced AXIOS lumen apposing metal stent (LAMS) (Table 1). A total of 23 LAMS were placed (22 trans-gastric and 1 trans-duodenal) Technical success (LAMS correctly deployed between the cavity and the gastric/duodenal lumen) was achieved in 100% of cases. All LAMS were dilated to 15 mm the same day of deployment, and the mean interval from drainage to first DEN was 5.4 days. DEN was repeated until the cavity was empty. A total of 66 DEN were performed. The mean number of DEN/patient was 3.3; each with a mean duration of 50 min. The most commonly used endoscope and device was the single channel gastroscope (83%) and the 27 mm snare (93.9%), respectively. The mean interval between each DEN was 7 days. All LAMS were removed after a mean of 27 days. Three patients were lost to follow up. After a median follow-up time of 14 months (1-28), clinical success (resolution of WON by imaging and patient’s symptoms on follow up visit) was achieved in 94% of cases. Only 1 subject had a major complication (cavity wall rupture with pneumoperitoneum that required surgery). Minor non-life-threatening complications occurred in 9 subjects (Table 2). CONCLUSION: At our center, the most commonly used endoscope and device to perform DEN is the single channel gastroscope and the 27 mm snare, respectively. An average of 3 DEN are required per patient, each one averaging 50 min. Our DEN technique is safe and effective in the management of WON, achieving clinical success in 94% of cases with minimal morbidity and no mortality.

Outcomes of Endoscopic and Surgical Pancreatic Necrosectomy: A Single Institution Experience

Pancreatic necrosis can be managed conservatively; however, infection of pancreatic necrosis usually dictates more aggressive management. Our study aimed to assess the outcomes of open pancreatic necrosectomy (OPN) and endoscopic pancreatic necrosectomy (EPN) in a single center. Data from patients undergoing pancreatic necrosectomy at the Geisinger Medical Center from January 1, 2007, to April 25, 2016, were collected and retrospectively analyzed. Cohorts were composed of EPN (n = 22) and OPN (n = 34) groups. The prevalence of preoperative respiratory failure, septic shock, and multiorgan dysfunction syndrome was higher in the OPN group. The OPN group presented with a higher Bedside Index Severity in Acute Pancreatitis score. Postoperative abscess, persistent kidney dysfunction, and death were more frequent in the OPN group. The EPN group had a higher readmission rate. The results of the univariate analysis for complication and mortality demonstrated that higher mortality and persistent kidney dysfunction were associated with the procedure type, specifically OPN and with a higher Bedside Index Severity in Acute Pancreatitis score. Patients who presented with higher severity of disease underwent an OPN, whereas EPN often was performed successfully in a more benign clinical setting. However, patients with infected necrosis are served best in a tertiary medical facility where multiple treatment modalities are available.

Quality investigation and analysis of discharge instructions for patients undergoing drainage after pancreatic necrosectomy

Objective To investigate the assessment of patients undergoing drainage after pancreatic necrosectomy on existing discharge instructions, and to provide a basis for satisfying the patients' health needs after discharge. Methods Totally 76 patients who received pancreatic necrosectomy and indwelling drainage tube in a Class Ⅲ Grade A hospital in Beijing between February and September 2018 were selected by convenient sampling, and investigated with the general information questionnaire and quality of discharge instruction scale. Results The quality of discharge instructions for the patients undergoing pancreatic necrosectomy totaled (147.11±17.51) , standing at a medium level, including (57.39±4.95) , (47.72±7.05) and (99.39±11.71) for the dimensions of content needed, content acquired, and instruction skills and effects, respectively. There were statistically significant differences in the total score of discharge instruction quality among patients with different educational background, working status and places of residence (t=3.422, 6.296, -2.605; P<0.05) . Conclusions The quality of discharge instructions for the patients undergoing pancreatic necrosectomy stands at a medium level. The patients have high demands for the content needed, but there is a lack in the content actually acquired as well as instruction skills and effects. Clinical nurses should develop innovative, targeted and simple approaches of discharge instructions based on patients' needs so as to improve the quality of instructions Key words: Pancreatitis; Necrosectomy; Drainage; Quality of discharge instruction; Investigation

The augmented role of pancreatic imaging in the era of endoscopic necrosectomy: an illustrative and pictorial review.

Endoscopic cystogastrostomy for mature pancreatic collections has long been recognized. However, FDA approval of newer lumen-apposing metallic stents in 2014 has now brought pancreatic necrosectomy to the endoscopic realm. Endoscopic drainage of Walled-off necrosis and direct endoscopic necrosectomy are technically challenging procedures with higher rates of complications. Collaborative clinical decision making both pre- and post-procedurally between the radiologist, endoscopist, and the surgeon can greatly improve outcomes in necrotizing pancreatitis. Herein, we review the basic pathophysiology that underlies progressive radiographic findings in NP, value of preprocedural imaging, current management algorithms, newer tools, and techniques as well as potential post-procedure complications on imaging follow-up after endoscopic interventions in necrotizing pancreatitis.

Outcomes from different minimally invasive approaches for infected necrotizing pancreatitis.

Infected necrotizing pancreatitis (INP), the leading cause of mortality in the late phase of acute pancreatitis, nearly always requires intervention. In recent years minimal invasive surgery is becoming more and more popular for the management of INP, but few studies compared different minimally invasive strategies. The objective of this observation study was to evaluate the safety and effectiveness with several minimal invasive treatment.We retrospectively reviewed cases of percutaneous catheter drainage (PCD), minimal access retroperitoneal pancreatic necrosectomy (MARPN), small incision pancreatic necrosectom (SIPN), single-incision access port retroperitoneoscopic debridement (SIAPRD) for INP between January 2013 and October 2018. Data were analyzed for the primary endpoints as well as secondary endpoints.Eighty-one patients with INP were treated by minimally invasive procedures including PCD (n = 32), MARPN (n = 18), SIPN (n = 16), and SIAPRD (n = 15). Overall mortality was greatest after PCD 34% (MARPN 11% vs SIPN 6% vs SIRLD6%). Problems after initial surgery were ongoing sepsis (PCD 56% vs MARPN 50% vs SIPN 31% vs SIAPRD13%; P < .05). There was a significant difference in number of interventions (median, 6 vs 5 vs 3 vs 2; P < .05). Time from onset of symptoms to recovery was less for SIAPRD than for PCD, MARPN, or SIPN (median, 45 vs 102 vs 80 vs 67 days; P < .05).SIAPRD remedy evidently improved outcomes, including systemic inflammatory response syndrome, number of interventions, length of hospital stay and overall cost. It is technically feasible, safe, and effective for INP, in contrast to others, and can achieve the best clinical results with the least cost. Furthermore, relevant multicentre randomized controlled trials are eager to prove these findings.

Surgical and intervention treatment of secondary pancreatic infections

Introduction. Many experimental and clinical studies have improved our understanding of the pathophysiology of acute pancreatitis. Today, there are no disagreements over the timing and basic indications for surgery in this disease, but there are still various surgical approaches.&#x0D; Methods. A retrospective and prospective two-center controlled study was conducted in 582 patients with acute pancreatitis treated in 2004–2018. Age of patients was 53 ± 12,5 years. The classification of the disease was used according to the recommendations of the International Consensus 2012. Patients included in the study were treated in accordance with the IAP/APA (2013) recommendations adapted to local resources and procedures. Of 582 patients, 387 (66,5%) patients with mild to moderate heaviness performed complex treatment, including 89 patients undergoing surgery. According to the goals and objectives of the study, other patients were divided into two groups: the main group – 103 patients with secondary pancreatic infection, who used the tactic of treatment «step-up approach»; а comparison group – 92 patients with open surgical intervention.&#x0D; Results. In the comparison group were used open necrosectomy and drainage. Postoperative complicationshavearisenin52 (56,2%)patients. After surgery died 26 patients (28,3%), 19 had a 30-day mortality and 7 had a 90-daymortalityof them. In the main group 62 (60,2%) patients were treated by percutaneous controlled ultrasound intervention, 26 (25,2%) by videolaparoscopic necrosectomy and drainage and at 5 (4,9%) drainage through the wall of the stomach or duodenum. In 10 (9,7%) open operations were performed (minilumbotomy, upper medial, left or right-winged minilaparotomy with formation of mini-bursostomy) with pancreatic necrosectomy, including at 5 decompressive VAC-laparostomy local access. Postoperative complications have arisen in 33 (32%) patients. After surgery died 15 patients (14,6%), 6 had a 30-day mortality and 9 had a 90-day mortality of them. When comparing the two strategies of the treatment-tactical approach, the number of postoperative complications and mortality were lower than in the group of patients who performed only open surgical interventions (х2 = 6,976, p = 0,011).&#x0D; Conclusion. The our research showed that an individualized approach to patients with secondary pancreatic infection using the step-up approach provides a reduction in the number of laparotomic pancreatic necrosectomies and allows postponing «open» surgical interventions for a period after the 4th week from the onset of the disease and reducing the number of postoperative complications and mortality (х2 = 6,976, р = 0,031).