Pancreatic Necrotic Collections Research Articles

Timing It Right: Endoscopic Necrosectomy for Infected Necrotizing Pancreatitis

AbstractThe endoscopic step-up drainage approach involving initial drainage followed by, if required, direct endoscopic necrosectomy (DEN) is the preferred management approach for symptomatic pancreatic necrotic collections. However, limited data suggests that immediate DEN during initial stent placement may hasten clinical recovery by quicker resolution of systemic inflammatory response. However, because of concerns about adverse effects, especially gastric perforation and bleeding, most endoscopists prefer delayed DEN. In this news and views, we discuss a recently published randomized controlled trial that compared upfront necrosectomy at the index intervention versus as a step-up for patients with infected necrotizing pancreatitis.

Early Endoscopic Interventions for Pancreatic Necrosis: Indications, Technique, and Outcomes.

Endoscopic transmural drainage is usually performed for symptomatic well-encapsulated walled-off necrosis (WON) that usually develops in the delayed phase (> 4weeks after disease onset) of acute necrotising pancreatitis (ANP). Endoscopic drainage is usually not advocated in the early (< 4weeks after disease onset) stage of illness because of the risk of complications due to an incompletely formed encapsulating wall and poor demarcation of viable from necrotic tissue. However, emerging data from expert tertiary care centres over the last few years shows that the early endoscopic transluminal drainage approach is effective and safe. The development of lumen-apposing metal stents and better accessories for endoscopic necrosectomy has fuelled the expansion of indications of endoscopic drainage of pancreatic necrosis. However, early endoscopic drainage is associated with higher rates of adverse events; therefore, careful patient selection is paramount. This article will review the current indications, techniques and outcomes of early endoscopic transluminal drainage in pancreatic necrotic collections.

Indications, Techniques and Future Perspectives of Walled-off Necrosis Management.

Necrotizing pancreatitis is a complex clinical condition burdened with significant morbidity and mortality. In recent years, the huge progress of interventional endoscopic ultrasound (EUS) has allowed a shift in the management of pancreatic necrotic collections from surgical/percutaneous approaches to mini-invasive endoscopic internal drainage and debridement procedures. The development of lumen-apposing metal stents (LAMSs), devices specifically dedicated to transmural EUS interventions, further prompted the diffusion of such techniques. Several studies have reported excellent outcomes of endoscopic interventions, in terms of technical success, clinical efficacy and safety compared to surgical interventions, and thus endoscopic drainage of walled-off necrosis (WON) has become a fundamental tool for the management of such conditions. Despite these advancements, some critical unresolved issues remain. Endoscopic therapeutic approaches to WON are still heterogeneous among different centers and experts. A standardized protocol on indication, timing and technique of endoscopic necrosectomy is still lacking, and experts often adopt a strategy based on personal experience more than robust data from well-conducted studies. In this review, we will summarize the available evidence on endoscopic management of WON and will discuss some unanswered questions in this rapidly evolving field.

Repetitive endoscopic drainage as initial intervention is safe and effective for early treatment of pancreatic necrotic collections.

While endoscopic step-up approach with delayed drainage (more than 28 days from diagnosis) was shown to produce the best outcomes in the treatment of pancreatic walled-off necrosis (WON), we assessed our single centre experience of early versus delayed endoscopic drainage of pancreatic necrotic collections. Patients who underwent endoscopic drainage of pancreatic necrotic collections between 2011 and 2022 under Monash Health were identified. They were excluded if below 18 years old or their follow up data were missing. The included patients' medical records, pathology results, and imaging findings were retrospectively reviewed. A total of 60 patients were included. 31.58% required percutaneous drainage and 15% received either endoscopic or surgical necrosectomy. The disease related mortality was 8.47% and the average length of stay (LOS) was 70.92 days. No significant difference was shown in disease-related mortality (10.5% vs. 7.5%, P = 0.697) or LOS (75.35 vs. 68.7, P = 0.644) between early and delayed drainage cohorts, but patients who received early drainage have higher qSOFA score on the day of drainage (2 vs. 0, P = 0.004). Repetitive endoscopic drainage with selective percutaneous drainage is effective in the management of pancreatic necrotic collections. Early drainage should be considered in patients who developed severe sepsis.

Endoscopic ultrasound–guided drainage of early pancreatic necrotic collection: Single-center retrospective study

Endoscopic ultrasound–guided drainage of early pancreatic necrotic collection: Single-center retrospective study

Early versus late endoscopic treatment of pancreatic necrotic collections: A systematic review and meta-analysis.

Background and study aims Recently studies have compared early (<4 weeks) vs. late or standard (>4 weeks) endoscopic treatment of pancreatic necrotic collections (PNC) and have reported favorable results for early treatment. In this meta-analysis, we compared the efficacy and safety of early vs. late endoscopic treatment of PNC. Patients and methods We reviewed several databases from inception to September 30, 2021 to identify studies that compared early with late endoscopic treatment of PNC. Our outcomes of interest were adverse events (AEs), resolution of PNC, performance of direct endoscopic necrosectomy, need for further interventions, and mean number of endoscopic necrosectomy sessions. We calculated pooled risk ratios (RRs) with 95% confidence intervals (CIs) for categorical variables and mean differences (MDs) with 95% CIs for continuous variables. Data were analyzed by random effect model. Heterogeneity was assessed by I 2 statistic. Results We included four studies with 427 patients. We found no significant difference in rates of AEs, RR (95% CI) 1.70 (range, 0.56-5.20), resolution of necrotic or fluid collections, RR (95% CI) 0.89 (range, 0.71-1.11), need for further interventions, RR (95% CI) 1.47 (range, 0.70-3.08), direct necrosectomy, RR (95% CI) 1.39 (range, 0.22-8.80), mortality, RR (95% CI) 2.37 (range, 0.26-21.72) and mean number of endoscopic necrosectomy sessions, MD (95% CI) 1.58 (range,-0.20-3.36) between groups. Conclusions Early endoscopic treatment of PNC can be considered for indications such as infected necrosis or sterile necrosis with symptoms or complications; however, future large multicenter studies are required to further evaluate its safety.

Timing of minimally invasive Step-up intervention for symptomatic pancreatic necrotic fluid collections: a systematic review and meta-analysis.

Minimally invasive step-up interventions are now the standard treatment recommended by current guidelines for symptomatic pancreatic necrotic fluid collections (PNFC); however, it is controversial whether delayed treatment after four weeks should always be used in patients who have failed conservative treatment and whose condition has not improved or worsened. The aim of this meta-analysis was to evaluate the impacts of the different timing of interventions on the clinical outcomes and prognosis of patients with symptomatic PNEC requiring intervention. We searched Embase, Cochrane Library, PubMed and Web of Science databases to identify comparative studies assessing the safety and efficacy of early and postponed interventions in treating symptomatic PNFC. Mortality. Secondary outcomes included some major complications, need for further minimally invasive necrosectomy and length of hospital stay. This meta-analysis included ten studies (2 RCTs and 8 observational studies) with a total of 1178 symptomatic PNFC patients who required intervention. Pooled results showed that there was no significant difference between early minimally invasive intervention and postponed intervention in mortality(OR 1.41, 95%CI 0.93-2.12;p=0.10) and the incidence of early and late complications, but the early intervention group had a significantly increased need for further minimally invasive necrosectomy compared with postponed intervention (OR 2.04,95%CI 1.04-4.03; p=0.04). There was no increase in length of stay for patients who received early intervention compared to postponed drainage (MD 3.53, 95% CI -4.20, 11.27; p=0.37). Intervention before four weeks should be considered for patients with PNFC complicated by persistent organ failure or infections, who have been treated conservatively to the maximum extent possible.

A291 CLINICAL OUTCOMES IN PATIENTS WITH MODERATE TO SEVERE PANCREATITIS AND PANCREATIC COLLECTIONS: A RETROSPECTIVE COHORT STUDY

Abstract Background Necrotizing pancreatitis occurs in approximately 20% of patients with pancreatitis and is associated with significant morbidity and mortality. Drainage of pancreatic collections is critical when there is associated infection but is also indicated in patients with biliary or gastric outlet obstruction or symptoms. Drainage strategies include percutaneous, endoscopic ultrasound (EUS) guided, and surgical. Data suggests that a step-up approach starting with EUS or percutaneous drainage is associated with lower mortality and morbidity at 3-6 months in comparison to surgery. Little is known about risk factors for pancreatic necrosis and long-term outcomes in patients with pancreatic collections, specifically those with necrotic collections. Purpose To improve knowledge about risk factors and long-term outcomes in patients with pancreatic collections. The primary objective was to compare mortality between patients with and without early necrotic collections. Secondary outcomes included ICU stay, recurrent collections and repeated interventions during follow-up. Method This was a retrospective cohort study of consecutive adults (&amp;gt; 18 years) with moderate to severe acute pancreatitis as per the Atlanta Criteria, admitted to a tertiary care centre in Ontario between January 2002 and January 2019 with radiological evidence of early pancreatic collections. Patients were identified using administrative codes and imaging reports from the Hospital’s data warehouse. Descriptive statistics were used. Comparisons between groups were made with chi-square and logistic regression for categorical variables. Result(s) 723 patients were identified and 276 were included in this report. The mean age was 54.5 years (SD 16) and 109 (39.5%) were females. The most common comorbidities were diabetes (33.3%), hypertension (38.4%) and obesity (14.8%). The most common pancreatitis etiologies were biliary (34.4%) alcohol misuse (17.0%) and post-ERCP pancreatitis (7.1%). Eighty-five (30.8%) patients were diagnosed with early necrotic collections and 53 (19.2%) with peri-pancreatic fluid collections during the initial 30 days of follow-up. Drainage was performed in 100 (36.2%) patients. Patients with necrotic collections were most likely to be obese (29.4% vs. 8.4%, P &amp;lt;0.001), have biliary pancreatitis (50.6% vs. 27.2%), require drainage of the collection (63.5% vs. 24.1%, P &amp;lt; 0.001), ICU stay (62.3% vs. 33.5%, P &amp;lt;0.001) and develop new collections during follow up (0% vs. 20.1%, P=0.04). Sixty-one (22.1%) patients died during a median follow up of 727 days (IQR 87-2042) and there were no differences between subgroups. Conclusion(s) Patients with pancreatic necrotic collections seem to have a more severe clinical course requiring ICU stay and interventions for drainage of the collection(s). Necrotic collections are more commonly seen in patient with biliary pancreatitis and obesity. No all-cause mortality differences were seen between groups during follow up. Please acknowledge all funding agencies by checking the applicable boxes below None Disclosure of Interest None Declared

Safety and clinical outcomes of early dual modality drainage (< 28days) compared to later drainage of pancreatic necrotic fluid collections: a propensity score-matched study.

Necrotizing pancreatitis can be complicated by Necrotic Fluid Collections (NFC). Guidelines recommend waiting for 4weeks from the onset of acute pancreatitis (AP) before considering endoscopic drainage. We aimed to compare outcomes and safety in patients undergoing early versus late drainage of NFC. We performed a retrospective review of all patients who underwent Dual Modality Drainage (DMD) [combined endoscopic and percutaneous drainage] for NFC from January 2007 to December 2020. Patients were stratified into the "early" group (DMD < 28days from AP onset) and were matched to "late" (DMD ≥ 28days) drainage group using propensity- core-matching. Primary outcomes of interest were technical success and adverse events. Secondary outcomes included clinical success, late complication rates, and mortality. We identified 278 patients who underwent DMD for NFC. Thirty-nine belonged to the early group and were matched to 174 patients from the late group. Technical success was similar in both early and late groups (97.4% vs 99.4%: P = 0.244) as were the procedural and early post-procedural (< 14days) adverse events rates (23.1% vs 27.6%: P = 0.565). Clinical success (92.3% vs 93.1%; P = 0.861) and late complication rates (23.1% vs 31.6%; P = 0.294) were similar. There were 2 deaths (5.7%) in the early vs. 9 (5.2%) in the late group, P = 0.991. When performed in a tertiary care center with expertise in therapeutic endoscopic ultrasound, early drainage of NFC appears to be feasible and safe. Further studies are needed to validate our results.

An Unusual Cause of Biliary Peritonitis on the Background of Acute Pancreatitis: A Case Report

Introduction Acute pancreatitis can cause a wide variety of local complications, sometimes pretty unusual. In the present report, we present a rather unusual cause of biliary peritonitis on the background of acute pancreatitis. Case Presentation A 41-year-old female patient with biliary acute pancreatitis and concomitant choledocholithiasis required an urgent laparotomy due to signs of sepsis and peritoneal irritation after a trial of conservative management. During laparotomy, the diagnosis of biliary peritonitis was established. Surprisingly, a residual gallstone obstructing the common bile duct at the level of the ampulla was causing bile to reflux, through the common channel, into the main pancreatic duct and subsequently into a partially ruptured acute pancreatic necrotic collection. Conclusion Dealing with the unexpected is a constant challenge for the surgical team dealing with acute pancreatitis patients. Although deferring surgical intervention during the course of acute pancreatitis, as much as possible, is the ideal strategy, this is not always possible. Deciding the treatment strategy based on the patients' clinical condition represents the most appropriate approach.

Early endoscopic treatment of symptomatic pancreatic necrotic collections

EUS-guided transmural endoscopic drainage is commonly used in the treatment of WOPN in the late phase of ANP. The role of endoscopic intervention remains unclear in the early phase of ANP. This study aimed to prospectively evaluate early endoscopic treatment of ANCs compared with endoscopic drainage of WOPN. Overall, 71 patients with ANP who underwent transmural endoscopic drainage for necrotic collections were included. Endoscopic intervention was performed within the first four weeks of ANP in 25 (35.21%) patients with ANC (Group 1) and in 46 (64.79%) patients after four weeks since the onset of ANP with WOPN (Group 2). The overall mean age of patients was 49.9 (22–79) years and 59 of them were males. The mean time of active drainage and duration of total endoscopic treatment was 26.8 and 16.9 days (P = 0.0001) and 270.8 and 164.2 days (P = 0.0001) in Groups 1 and 2, respectively. The average total number of endoscopic interventions was 9.5 and 4.5 in Groups 1 and 2, respectively (P = 0.0001). The clinical success rate, frequency of complications of endoscopic interventions, long-term success rate, and recurrence rate were not significantly different between the groups (P > 0.05 for each). Transmural endoscopic drainage is effective method of treatment of early ANCs within the first four weeks of ANP. However, compared with endoscopic intervention in WOPN, more interventions and longer duration of drainage are required.

Spontaneous Rupture of Splenic Artery Pseudoaneurysm into Walled-off Pancreatic Necrosis – A Rare Cause of Recurrent Hematochezia

Splenic artery pseudoaneurysm rupturing into walled-off pancreatic necrosis and manifesting as hematochezia is very uncommon. We report one such unusual presentation. A 36-year-old man presented with recurrent episodes of hematochezia requiring multiple blood transfusions in 2 months. Upper and lower gastrointestinal endoscopy ruled out any source of the bleed. CT angiography revealed pseudoaneurysm from the splenic artery leading onto a walled-off pancreatic necrotic collection; the collection had fistulous communication to the colon. The aneurysm was coil embolized and he was discharged in a clinically stable state.

Safety and Efficacy of Early (

BackgroundEndoscopic transmural drainage is usually not performed for pancreatic necrotic collection (PNC) < 4 weeks after onset of acute necrotizing pancreatitis (ANP) because of lack of encapsulating wall and increased risk of complications. ObjectiveStudy safety and efficacy of early (<4 weeks) endoscopic transluminal drainage in patients with symptomatic PNC. MethodsRetrospective analysis of data base of patients with PNC treated with endoscopic transmural drainage within 4 weeks of onset of ANP (early drainage) was done. The outcomes and complications were compared with patients with PNC who underwent delayed endoscopic drainage (≥4 weeks of onset of ANP). ResultsThirty-four patients (26 males; mean age: 35.9±8.6 years) underwent early and 136 patients (115 males; mean age: 37.9±9.4 years) underwent delayed endoscopic drainage. The PNC was significantly larger (12.3±2.1 cm vs 10.5±2.7 cm, p <0.001) with increased solid component (47.7 ± 8.9% vs 28.3 ± 11.7%, p <0.001) in the early group. Clinical success was achieved in 94% patients in the early group and all patients in the delayed group. Direct endoscopic necrosectomy was performed more frequently in the early group (50% vs 7.4%; p<0.001). There was increased mortality (5.7% vs 0%), need for rescue surgical necrosectomy (5.7% vs 0%), and clinically significant bleeding (20% vs 1.5%, p<0.001) in the early group as compared to the delayed group. ConclusionEarly endoscopic drainage of PNC is feasible and seems to be safe as well as effective but is associated with increased risk of complications as compared to delayed drainage.

S1436 Outcome of the Use of Corticosteroids for Treatment of Autoimmune Pancreatitis (AIP) in a COVID-19 Patient

INTRODUCTION: Autoimmune Pancreatitis (AIP) is a steroid-responsive disease of the pancreas. Due to poor outcomes in severe acute respiratory syndrome (SARS-CoV) and Middle East respiratory syndrome (MERS-CoV) outbreaks, the World Health Organization (WHO) advises against the use of corticosteroids in the treatment of 2019 Coronavirus Disease (COVID-19) except if steroid therapy is required for coexisting illness. We present a case of uncontrolled AIP which was treated with high dose steroids while the patient was hospitalized with COVID-19. CASE DESCRIPTION/METHODS: A 53-year-old male was hospitalized with COVID-19 and uncontrolled AIP. The patient had elevated IgG4 levels and negative work up for other etiology of pancreatitis in the past and was already taking prednisone 40 mg daily due to a recent AIP exacerbation. On physical exam, temperature of 101 F, heart rate 101 beats/minute, respiratory rate 20 breaths/minute while blood pressure was normal. Tenderness in the epigastric region was noted. Labs showed Hct 35.8%, WBC 12.32 thousand/uL, BUN 9 mg/dL, lipase 530 u/L and normal LFTs. CT abdomen showed severe necrotizing pancreatitis with infected necrosis (multiloculated collections of gas and fluid) (Image 1). Chest imaging showed bibasilar infiltrates consistent with COVID-19 pneumonia (Image 2). Patient was continued on steroids, started on meropenem, and supportive treatment for COVID-19. Due to persistent abdominal pain and inability to tolerate oral intake, the patient underwent CT-guided percutaneous drainage of the necrotic collection. Azathioprine (AZA) was added to treatment regimen due to uncontrolled AIP despite steroid therapy. Patient recovered clinically without need for oxygen supplementation or further complication from COVID-19. He was discharged from the hospital with a short antibiotic course, a prescription to continue AZA and prednisone 40 mg with plan to taper dose by 5 mg per week. He returned home to continue quarantine which he completed without problems. DISCUSSION: Despite having multiple risk factors associated with poor outcomes in COVID-19 (age greater than 45 years, male gender, comorbidity due to uncontrolled AIP and immunosupression with steroid treatment), our patient experienced complete resolution of the illness with supportive measures. Our case supports current recommendations advocating steroid therapy for co-existing diseases in patients with COVID-19.Figure 1.: Image 1. CT scan abdomen shows multiloculated ill-defined of herterogeneous consistency as well as presence of gas pockets in the pancreatic and peri-pancreatic tissues, consistent with infected pancreatic necrotic collection in (A) and (B).Figure 2.: Image 2: Bibasilar lower lung infiltrates seen on CT scan chest (A) and Chest X-ray PA view (B), consistent with COVID-19 pneumonia.

Outcomes of early endoscopic intervention for pancreatic necrotic collections: a matched case-control study

Pancreatic necrosis may be categorized as an acute necrotic collection (ANC) or walled-off necrosis (WON) based on complete encapsulation by a wall and collection age (≤4 weeks or >4 weeks). Endoscopic intervention of WON has become the standard of care, but little is known regarding the safety and efficacy of endoscopic intervention of pancreatic necrosis≤4 weeks from disease onset. Retrospective review of medical records and imaging studies of all patients undergoing early endoscopic intervention of pancreatic necrosis between 2008 and 2018 was carried out at 1 referral center. Patients who underwent previous interventional treatment were excluded. Control WON patients were matched to early intervention cases. The primary outcome was defined as resolution of the collection after endoscopic treatment, without surgery. Nineteen patients with early intervention were identified. The most common indication for intervention was infection. Median age of these collections at the time of initial endoscopic intervention was 23 days (range, 15-27 days), and all collections had a partial or complete wall discernable on contrast-enhanced CT. Eleven patients underwent concurrent endoscopic necrosectomy. The primary outcome was achieved in all patients in the early intervention group. Total duration of therapy was longer for early intervention compared with controls (103 vs 69 days, P= .042), with no mortality and similar adverse event rates compared with controls. Endoscopic intervention of pancreatic necrosis in the third and fourth weeks of illness appears effective and safe when a partial collection wall is present on cross-sectional imaging studies, with outcomes paralleling those reported for intervention of WON.

Bleeding During CT Guided Percutaneous Transgastric Drainage of Pancreatic Necrotic Collection

Bleeding During CT Guided Percutaneous Transgastric Drainage of Pancreatic Necrotic Collection

Impact of Antibiotic-Resistant Bacterial and Fungal Infections in Outcome of Acute Pancreatitis.

The knowledge about pathogens and their antibiotic susceptibility patterns is essential to select an appropriate antibiotic. We investigated the microbiological profile in pancreatic and extrapancreatic infections, and antibiotic sensitivity pattern in patients with acute pancreatitis. Of 556 patients with acute pancreatitis, only 189 developed bacterial infection; however, bacteremia was present in 42 patients (7.6%). Culture-proven infected pancreatic necrotic collection was present in 161 patients (29%). Escherichia coli and Klebsiella pneumoniae were the most common organisms. Among the bacterial infection cohort, 164 patients developed multidrug-resistant bacterial infection. Infection with multidrug-resistant bacteria, especially at multiple sites, increased mortality. Nearly 50% of patients (n = 94) acquired extremely drug-resistant bacterial infection at some time and emerged as key reason for prolonged hospital and intensive care unit stay. Colistin resistance and tigecycline resistance were documented in 2.1% and 17.2% of the specimens at admission and in 4.6% and 21% of specimens during the hospital stay. Of 556 patients, 102 patients developed fungal infection and 28 patients had only fungal infection without bacterial infection. Colistin and tigecycline are best reserved as last-resort antibiotics. Fungal infection was found to be associated with increased mortality, median hospital stay, and intensive care unit stay.

Peripancreatic fat necrosis worsens acute pancreatitis independent of pancreatic necrosis via unsaturated fatty acids increased in human pancreatic necrosis collections

Background and aimsPeripancreatic fat necrosis occurs frequently in necrotising pancreatitis. Distinguishing markers from mediators of severe acute pancreatitis (SAP) is important since targeting mediators may improve outcomes. We evaluated potential...

The growing applicability of transluminal endotherapy in organized pancreatic necrotic collections

Acute necrotizing pancreatitis is a serious condition with multiple possible causes. In a proportion of patients it complicates with development of necrotic peripancreatic collections and in some cases these become infected. The latter is a strong indication for aggressive treatment, which has classically been laparotomy with open necrosectomy. Surgery has major possible complications yielding a field for alternative treatment options such as endoscopic drainage and more recently direct debridement through transluminal orifices. This report describes interventional endoscopy to treat two patients with large peripancreatic necrotic and infected collections, focusing on its advantages, limitations and future indications.

Endoscopic Versus Surgical Necrosectomy for Patients With Symptomatic Pancreatic Necrotic Collections: A Retrospective Cohort Study

Endoscopic Versus Surgical Necrosectomy for Patients With Symptomatic Pancreatic Necrotic Collections: A Retrospective Cohort Study