Treatment Of Infected Pancreatic Necrosis Research Articles

Negative pressure irrigation and endoscopic necrosectomy through man-made sinus tract in infected necrotizing pancreatitis: a technical report.

BackgroundIn recent years, a step-up approach based on minimally invasive techniques was recommended by latest guidelines as initial invasive treatment for infected pancreatic necrosis (IPN). In this study, we aimed to describe a novel step-up approach for treating IPN consisting of four steps including negative pressure irrigation (NPI) and endoscopic necrosectomy (ED) as a bridge between percutaneous catheter drainage (PCD) and open necrosectomyMethodsA retrospective review of a prospectively collected internal database of patients with a diagnosis of IPN between Jan, 2012 to Dec, 2012 at a single institution was performed. All patients underwent the same drainage strategy including four steps: PCD, NPI, ED and open necrosectomy. The demographic characteristics and clinical outcomes of study patients were analyzed.ResultsA total of 71 consecutive patients (48 males and 23 females) were included in the analysis. No significant procedure-related complication was observed and the overall mortality was +21.1 % (15 of 71 patients). Seven different strategies like PCD+ NPI, PCD+NPI+ED, PCD+open necrosectomy, etcetera, were applied in study patients and a half of them received PCD alone. In general, each patient underwent a median of 2 drainage procedures and the median total drainage duration was 11 days (interquartile range, 6–21days).ConclusionsThis four-step approach is effective in treating IPN and adds no extra risk to patients when compared with other latest step-up strategies. The two novel techniques (NPI and ED) could offer distinct clinical benefits without posing unanticipated risks inherent to the procedures.Electronic supplementary materialThe online version of this article (doi:10.1186/s12893-016-0190-x) contains supplementary material, which is available to authorized users.

Experience of minimal-access video-assisted retroperitoneal debridement in treatment of infected pancreatic necrosis

Objective: To explore the experience of minimal-access video-assisted retroperitoneal debridement in treatment of infected pancreatic necrosis(IPN). Methods: A retrospective review was performed on 12 patients with IPN who underwent minimal-access video-assisted retroperitoneal debridement between June 2008 and June 2013 in People's Liberation Army General Hospital and First Affiliated Hospital of People's Liberation Army General Hospital, respectively.There were 10 male patients and 2 female patients aging from 33 to 55 years with mean age of(43±8)years.Pancreas infective necrosis, the serious complications of severe acute pancreatitis occurred in all of the patients among which there were 2 patients with infection after percutaneous catheter drainage(PCD)in early phase of disease, and 12 patients with spontaneous during the late phase. The technical strategies of the minimally invasive treatment mainly included PCD, minimal-access video-assisted retroperitoneal debridement, and irrigation. Results: Ten patients received PCD and the median time from onset of acute necrotizing pancreatitis to PCD was mean of 24 days(range 8-86 days). Minimal-access video-assisted retroperitoneal debridement was performed after 18 days(range 3-29 days) after PCD.Three patients died after surgery.Five patients had hemorrhage complication and 3 had colonic fistula.Pancreatic fistula occurred in 2 patients. Conclusions: The technique of minimal-access video-assisted retroperitoneal debridement has advantage and some minor disadvantage.Delayed minimal-access video-assisted retroperitoneal debridement is recommended.

Step-up mini-invasive surgery for infected pancreatic necrosis: Results from prospective cohort study

ObjectivesTo investigate the clinical efficacy and success predictors of mini-invasive techniques in the treatment of infected pancreatic necrosis (IPN). MethodsIPN patients admitted to our clinic for treatment by mini-invasive techniques were included in this study prospectively. Treatment was divided into four sequential phases: percutaneous catheter drainage (PCD), mini-incision drainage (MID), video assisted debridement (VAD) and open surgery. Patients progressed to next phase if the infection cannot be controlled. The frequency of surgery, treatment duration, cure rate, incidence of complication and overall mortality were recorded. Risk factors for failure of PCD and MID procedures were detected by logistic regression including demographics, disease severity and morphologic characteristics. ResultsFrom January 2012 to March 2015, a total of 54 consecutive IPN patients were treated, with an average age of 51.2 ± 3.1 years. Of the 54 cases, 18 (33.3%) were cured after PCD; 13 (24.1%) with uncontrolled infection were cured after MID; and the remaining 19 cases (35.2%) were cured after VAD. No open surgery was performed. Overall mortality was 7.4% (4/54), and the incidence of complications was 12.9% (7/54). In multivariable regression, the following factors were associated with high failure rate for both PCD and MID: heterogeneous fluid collection (odds ratio (OR) = 3.14; 95% confidence interval (CI): 1.32 ～ 4.25, P = 0.001 for PCD; OR = 2.99; 95% CI: 1.52 ～ 5.10, P = 0.006 for MID), multiple infected collections (OR = 4.51; 95% CI: 2.94 ～ 8.63; P = 0.000 for PCD; OR = 4.17; 95% CI: 2.77 ～ 8.12, P = 0.000 for MID), CT severity index (0 ～ 3/4 ～ 6/7 ～ 10: OR = 2.16; 95% CI: 1.83 ～ 3.62, P = 0.031 for PCD; OR = 2.72; 95% CI: 1.78 ～ 4.10, P = 0.005 for MID). ConclusionsStep-up mini-invasive techniques can be considered a first choice in the treatment of IPN. CT is effective to predict success of PCD and MID.

Wernicke Encephalopathy after Endoscopic Necrosectomy in Acute Necrotizing Pancreatitis with WOPN: A Case Report

Infected walled-off pancreatic necrosis (WOPN) is dangerous complication of acute pancreatitis. Open necrosectomy and post-operative irrigation of necrotic cavity have been conventional treatment for infected pancreatic necrosis, however, recently minimally invasive techniques such as endoscopic necrosectomy has been regarded as preferred treatment method for infected WOPN. Endoscopic necrosectomy provides a targeted approach with a reduction in the systemic inflammatory response and avoidance of wound complications. Non alcohol related Wernicke encephalopathy is rare disease caused by thiamine deficiency due to intravenous feeding, and presented an encephalopathy, oculomotor dysfunction, gait ataxia. We report herein a case of Wernicke encephalopathy after successful endoscopic necrosectomy for infected WOPN. Korean J Pancreatobiliary 2016;21(1):34-39

Transverse Laparotomy in the Treatment of Infected Pancreatic Necrosis

Aim. To compare the outcomes after transverse and midline laparotomy for infected pancreatic necrosis and to evaluate the safety and adequacy of drainage via transverse laparotomy. Material and Methods. Surgical treatment of 47 cases of infected pancreatic necrosis was analyzed. We compared two groups: 13 patients underwent transverse laparotomy (group 1), 34 patients underwent midline laparotomy (group 2). In the first group anterior and posterior sheets of rectus sheath were stitched on both sides of the transverse incision. Omentobursostomy (OBS) was formed by stitching of gastrocolic ligament with sewn edges of the rectus sheath. Intraoperative blood loss, intensive care unit (ICU)/hospital stay, postoperative complication rate and mortality were compared and analyzed. Results. Necrosectomy was performed in all patients. In group 1 OBS was performed in 12 (92.3%) cases, in group 2 – in 22 (64.7%) cases. In 12 patients of group 2 OBS was not made. There was less intraoperative blood in group 1 compared with group 2 (178.0 ± 31.2 ml vs. 317.1 ± 38.7 ml )(p 0.05). Conclusion. Necrosectomy through transverse laparotomy was accompanied by less intraoperative blood loss, fewer complications and provides adequate drainage that reduces ICU-stay.

Treatment of infected pancreatic necrosis: Outcome in a 9-year, single-center, consecutive series (2006-2014)

Treatment of infected pancreatic necrosis: Outcome in a 9-year, single-center, consecutive series (2006-2014)

PWE-203 Endoscopic transgastric pancreatic necrosectomy (ETN) – a safe and effective treatment for infected pancreatic necrosis

<h3>Introduction</h3> Infected pancreatic necrosis remains associated with high morbidity and mortality rates. Historically open necrosectomy operative mortality reached 50%. Minimally invasive techniques have been demonstrated to decrease morbidity but not mortality compared to open surgery as highlighted in the PANTER trial. We present our own series of patient results treated with this innovative procedure. <h3>Method</h3> All patients managed with ETN at our HPB unit were identified. Patient demographics, diagnosis, primary and secondary outcomes were recorded. Primary outcomes included 30 and 90 day mortality, major morbidity ie: new onset organ failure, haemorrhage or perforation. Secondary outcomes included length of stay in hospital, ITU stay, number of procedures, other interventions required and endocrine/exocrine insufficiency. <h3>Results</h3> 12 patients were treated with ETN, 8 males, 4 females with an age range of 21–81. All patients underwent endoscopic ultrasound guided cyst-gastroscopy with stent insertion as initial therapy. A median of two (1–6) endoscopic pancreatic necrosectomies were required with a median of three (1–4) admissions. Average length of stay per admission was 10 days (1–65). One patient was treated with a percutaneous drain initially and then went on to endoscopic treatment and early removal of drain. 25% of patients (3/12) required intensive care admission. No perforations, haemorrhage, 30 or 90 days deaths were recorded. <h3>Conclusion</h3> Endoscopic, transgastric pancreatic necrosectomy appears a safe and effective procedure for the management of this patient group. Our results compare favourably with those following open necrosectomy and are similar to published minimally invasive technique outcomes. <h3>Disclosure of interest</h3> None Declared. <h3>References</h3> Van Santvoort, Besselink MG, <i>et al</i>. A step up approach or open necrosectomy for necrotising pancreatitis. <i>N Eng J Med.</i>2010 Apr 22;362(16):1491–502. Kokosis G. Surgical managemnt of necrotising pancreatitis an overview. <i>Worls J of Gastroenterol</i>. 2014 Nov 21;20/43:16106–16112 Charnley RM. Endoscopic necrosectomy as primary therapy in management of infected pancreatic necrosis. Endoscopy 2006;38:925–928. Baron TH. Endoscopic therapy for organised pancreatic necrosis. Gastroenterology 1996;755–61. Branum G. Pancreatic necrosis results of necrosectomy packing and ultimate closure over drains. Ann Surg. 1998;227(6):870–877.

Necrotizing Pancreatitis: New Definitions and a New Era in Surgical Management

Necrotizing pancreatitis is a challenging condition that requires surgical treatment commonly and is associated with substantial morbidity and mortality. Over the past decade, new definitions have been developed for standardization of severity of acute and necrotizing pancreatitis, and new management techniques have emerged based on prospective, randomized clinical trials. Review of English-language literature. A new international classification of acute pancreatitis has been developed by PANCREA (Pancreatitis Across Nations Clinical Research and Education Alliance) to replace the Atlanta Classification. It is based on the actual local (whether pancreatic necrosis is present or not, whether it is sterile or infected) and systemic determinants (whether organ failure is present or not, whether it is transient or persistent) of severity. Early management requires goal-directed fluid resuscitation (with avoidance of over-resuscitation and abdominal compartment syndrome), assessment of severity of pancreatitis, diagnostic computed tomography (CT) imaging to assess for necrotizing pancreatitis, consideration of endoscopic retrograde cholangiopancreatography (ERCP) for biliary pancreatitis and early enteral nutrition support. Antibiotic prophylaxis is not recommended. Therapeutic antibiotics are required for treatment of documented infected pancreatic necrosis. The initial treatment of infected pancreatic necrosis is percutaneous catheter or endoscopic (transgastric/transduodenal) drainage with a second drain placement as required. Lack of clinical improvement after these initial procedures warrants consideration of minimally invasive techniques for pancreatic necrosectomy including video-assisted retroperitoneal debridement (VARD), minimally invasive retroperitoneal pancreatectomy (MIRP), or transluminal direct endoscopic necrosectomy (DEN). Open necrosectomy is associated with substantial morbidity, but to date no randomized trial has documented superiority of either minimally invasive or open surgical technique. Additional trials are underway to address this. Severe acute and necrotizing pancreatitis requires a multi-disciplinary treatment strategy that must be individualized for each patient. Optimal treatment of necrotizing pancreatitis now requires a staged, multi-disciplinary, minimally invasive "step-up" approach that includes a team of interventional radiologists, therapeutic endoscopists, and surgeons.

Therapeutic Alternatives for the Treatment of Infected Pancreatic Necrosis: An Overview

A pesar de los avances diagnosticos y terapeuticos, el tratamiento de la necrosis pancreatica infecciosa (NPI) sigue siendo un problema complejo de resolver. El objetivo de este estudio es evaluar la eficacia de las diferentes alternativas quirurgicas para el tratamiento del NPI. Fueron evaluados articulos publicados entre 2000 y 2013, relacionados con la efectividad de la cirugia abierta (CA) y el tratamiento minimamente invasivo (TMI) en pacientes diagnosticados con NPI. Se PubMed, MEDLINE, The Cochrane Database of Systematic Reviews, Cochrane Central Register RCT, DARE, IBECS, SciELO, LILACS, PAHO, WHOLIS, ASERNIP-S, NIHR, HTA, Clinical Excellence, York Health Economic Consortium y Tripdatabase, en busqueda de revisiones sistematicas (RS), ensayos clinicos aleatorios (ECA) y estudios observacionales (EO). En estos estudios se evaluo la eficacia de la cirugia y el TMI en relacion con diferentes variables, como la mortalidad, el sangrado intra-abdominal, el desarrollo de fistula enterocutanea o la perforacion de viscera hueca, el desarrollo de fistula pancreatica, reintervenciones por complicaciones, reintervenciones por necrosectomia, el desarrollo de diabetes mellitus y la necesidad de enzimas pancreaticas. Se consiguieron 389 articulos, de los cuales 10 cumplieron con los criterios de seleccion (2 RS, 1 ECA y 7 EO). Los estudios presentaron un nivel de evidencia de 2a, 2b, 3a y 4. El TMI se asocia con mejores resultados que la CA en todas las variables analizadas, pero en forma significativa solo en el desarrollo de la diabetes mellitus y la necesidad de enzimas pancreaticas. Los articulos encontrados son pocos y heterogeneos, lo que hace dificil poder alcanzar conclusiones significativas. Se necesitan estudios con un mejor nivel de evidencia, calidad metodologica y tamano de poblacion estudiada para poder establecer conclusiones y recomendaciones.

Single or multiport percutaneous endoscopic necrosectomy performed with the patient under conscious sedation is a safe and effective treatment for infected pancreatic necrosis (with video)

Infected pancreatic necrosis (IPN) is a dreaded adverse event of acute pancreatitis (AP). Most patients with IPN require drainage and necrosectomy, preferably by a minimally invasive method. To study the success and safety of an alternative form of minimally invasive necrosectomy for IPN. Observational study. Tertiary care academic center. Consecutive patients with IPN formed the study group. Patients with IPN were initially treated conservatively including percutaneous drainage. Those whofailed to improve underwent percutaneous endoscopic necrosectomy (PEN). Single- or multiport PEN was performed by using a flexible endoscope through the percutaneous tract. PEN involved vigorous lavage and suction followed by necrosectomy. Multiple sessions were undertaken depending on the size and number of collections and the amount of necrotic debris. Control of sepsis and resolution of collection(s) without the need for surgical necrosectomy. During the period from October 2012 to July 2013, 165 patients (mean age, 38.82 ± 14.99 years; 119male patients) were studied. Of them, 103 patients had necrotizing pancreatitis and IPN had developed in74. Of these 74 patients with IPN, 15 underwent PEN after a mean interval of 39.2 days. Fourteen of the 15patientsimproved after a mean of 5 sessions of PEN. Two of 15 patients had minor adverse events: self-limiting bleeding and pancreatic fistula in 1 patient each. One patient required surgery but died of organ failure. Lack of a control arm. PEN is a safe and effective minimally invasive technique for necrosectomy for IPN.

Minimally invasive techniques in the treatment of severe acute pancreatitis

Abstract Open necrosectomy, the standard surgical treatment of infected pancreatic necrosis (IPN), presents a high rate of postoperative complications and an associated mortality of 20–60%. In the last decade various minimally invasive approaches (MIA) have been proposed for the treatment of IPN and the results seem to improve on those reported with open necrosectomy. These MIA include: percutaneous, retroperitoneal, endoscopic (endoluminal) and laparoscopic (transperitoneal). The adoption of the step-up approach in the management of severe acute pancreatitis (SAP) facilitates the implementation of MIA as the surgical treatment of choice in most cases. Since MIA require the expertise of radiologists, endoscopists and surgeons, patients suffering SAP should be treated by multidisciplinary teams in referral centers. We describe the MIA currently available and discuss their advantages, disadvantages, and results.

Sa1501 Single or Multiport Percutaneous Endoscopic Necrosectomy Under Conscious Sedation Is a Safe and Effective Treatment for Infected Pancreatic Necrosis

Sa1501 Single or Multiport Percutaneous Endoscopic Necrosectomy Under Conscious Sedation Is a Safe and Effective Treatment for Infected Pancreatic Necrosis

Minimally invasive treatment of infected pancreatic necrosis.

Infected pancreatic necrosis is a challenging complication that worsens prognosis in acute pancreatitis. For years, open necrosectomy has been the mainstay treatment option in infected pancreatic necrosis, although surgical debridement still results in high morbidity and mortality rates. Recently, many reports on minimally invasive treatment in infected pancreatic necrosis have been published. This paper presents a review of minimally invasive techniques and attempts to define their role in the management of infected pancreatic necrosis.

Endoscopic Necrosectomy as Treatment for Infected Pancreatic Necrosis

Necrotising pancreatitis can be life-threatening, but the introduction of endoscopic necrosectomy has led to a tremendous reduction of lethality. This review describes the technique and role of this method between conservative treatment and other interventional methods such as percutaneous drainage and surgery of superinfected necrosis. A little more than a decade after its introduction, endoscopic necrosectomy has become the gold standard in the interventional treatment of superinfected necrosis.

Endoscopic Treatment of Necrotising Pancreatitis

Pancreatic necrosis and abscess are among the most severe complications of acute pancreatitis. Although open surgical necrosectomy for treatment of infected pancreatic necrosis is associated with high morbidity and mortality, endoscopic transgastric or transduodenal therapy with endoscopic necrosectomy is a safe and effective treatment for carefully selected patients. In case of unsuccessful necrosectomy and pseudocyst drainage, the implantation of a newly designed self expandable metal stent (SEMS) can help to provide a sufficiently large and secure access to ensure an adequate necrosectomy and necrotic cavity drainage. The case presented is of a 71-year-old patient with an infected pancreatic necrosis as a result of a biliary pancreatitis. Through the implantation of a newly designed SEMS, multiple dilations can be avoided and a large and easy access to the necrotic cavity for sufficient drainage and necrosectomy can be established. This article is part of an expert video encyclopedia.

Surgical Versus Nonsurgical Treatment of Infected Pancreatic Necrosis: More Arguments to Change the Paradigm

ObjectivesThis study aimed to compare primary surgical versus nonsurgical treatment in a series of patients with infected pancreatic necrosis (IPN) and to investigate whether the success of nonsurgical approach is related to a less severe disease. MethodsThirty-nine consecutive patients with IPN have been included and further subdivided into two groups: primary surgical (n = 21) versus nonsurgical (n = 18). Outcome measures were the differences in mortality, morbidity, and pancreatic function. Comorbidity, organ failure, and other severity indexes were compared between the two groups. ResultsMortality occurred in 16.7 % of cases in the nonsurgical group versus 42.9 % in the surgical group. In the primary nonsurgical group, seven were operated on due to failure of initial conservative treatment. In this latter group, mortality was 28.6 % and was performed significantly later than in the primary surgical group. The group of primary surgical treatment was associated with a significant higher rate of multiple organ failure (MOF) at IPN diagnosis, new onset or worsening of organ failure, and MOF and nosocomial infection after surgery. ConclusionsInitial nonsurgical approach in IPN is associated with better results both in cases which respond to this treatment as well as in those who, failing this conservative approach, have to be operated on after a delayed period. Primary surgically treated patients had a more severe disease at the time of IPN.

Comments on the article about the treatment of infected pancreatic necrosis

To the Editor, We read with interest the article by Wronski et al. [1] about evaluation of the safety and efficacy of sonographically guided percutaneous catheter drainage (PCD) for infected pancreatic necrosis (IPN). In their retrospective study, they analyzed the patient group of 16 men and 2 women, concluding that ultrasound-guided PCD used in IPN was a technique with acceptably low morbidity and mortality that could be the definitive treatment or a bridge management to necrosectomy. A negligible decrease in size of the necrotic collection predicts failure of PCD. Although the outcome of this series shows less success rate as definitive treatment for IPN (33 %) compared to the outcomes (84 %) of ours [2] and most of the previously reported similar studies [3, 4], there are certain limitations to this conclusion as a result of the clinical characteristics and the severity of the state of enrolled patients being different—and to a certain extent incomparable—among the studies. However, despite our long experience (over 20 years) in performing ultrasound-guided PCD in the treatment of necrotizing pancreatitis [5–9], we would like to comment on the possible reasons of the poor outcome of treatment in this study. Wronski et al. performed PCD via the preferably retroperitoneal approach through the left lumbar access (in 13 of 18 patients), placing catheters in tail areas of the pancreas, where collections would usually be located at the onset of the necrotizing pancreatitis. However, acute pancreatitis is a complex disease where, after the evacuation of collections from the tail of the pancreas, liquefaction of necroses continues and fluid collections can still be developed into other pancreatic and peripancreatic regions that are unavailable for the catheters placed in this manner. This causes the reemergence or continuation of sepsis and therefore may be the most common reason for crossover to surgical intervention rather than introduction of additional catheters into the new collections. But we consider that necrosectomy may represent overtreatment in these patients with a usually poor general condition, with the main difficulties being the discrimination between necrotic tissue and normal tissue during the procedure and a very high risk of bleeding from necrotized tissue vessels during or immediately after the intervention. Therefore, in such clinical settings, we would rather introduce additional catheters into new collections and perform percutaneous drainage with vigorous irrigation (up to 6 times in our series) [2]. Wronski et al. noted that ‘‘the indication for crossover to surgical debridement was lack of improvement despite percutaneous drainage with large-bore catheters or complications requiring surgery.’’ However, on the basis of our long-term experience, we believe that the removal of the infected necrotic tissue at the onset of the disease is difficult regardless of the size of the catheters used. However, during the course of the disease, the transition from solid necrotic tissue to more liquid content leads to higher success rate in evacuation of necrotic tissue from the cavities, regardless of the catheter size. We believe that the use of large-bore catheters cannot improve the success rate of the evacuation of the necrotic tissue, and it carries an increased risk of complications. Even though we used smaller catheters E. Zerem (&) Department of Gastroenterology, University Clinical Center Tuzla, Trnovac bb, 75000 Tuzla, Bosnia and Herzegovina e-mail: zerem@live.com

Sp614 Endoscopic Necrosectomy via a Fully Covered Esophageal Metal Stent: A New Efficacious Platform

A 34 year old man with type V hyperlipidemia was initially admitted with severe acute pancreatitis requiring a prolonged MICU stay due to sepsis. He underwent an ERCP with pancreatic duct stent placement due to duct disruption and endoscopic cystgastrostomy. Two weeks later, he was sent to the emergency department with fever and abdominal pain. His WBC was 17,000 and the CT showed a large enhancing multi-loculated collection surrounding the pancreatic tail, concerning for infected pancreatic necrosis. Endoscopic necrosectomy with PEG-J placement was performed. A traditional 24 F PEG tube is placed using the pull through technique. A bronchoscope is advanced through the PEG tube deep into the duodenum. A long guidewire is then advanced through the scope and beyond the Ligament of Treitz under fluoroscopic guidance. The scope is exchanged for a12 F jejunal tube. Contrast injection confirms location. An echoendoscope is used to locate the area of necrosis. Color flow Doppler is used to evaluate for local vasculature. A 19 gauge FNA needle is used to puncture the cavity in a transgastric fashion. Fluid is aspirated and is sent for microbiology analysis. A guidewire is advanced through the needle into the cyst cavity. Over the guidewire, a 15 mm dilating balloon is used to create a fistula. An 18 mm x 60 mm fully covered esophageal self expanding metal stent with flanged ends is deployed across the fistula under both endoscopic and fluoroscopic guidance yielding pus and debris. Surgical necrosectomy with post-operative irrigation was the standard method of treatment in the past. Alternative approaches of minimally invasive treatments emerged, including percutaneous and endoscopic techniques. Endoscopic necrosectomy has become the mainstay of treatment for infected pancreatic necrosis, and this technique continues to evolve in order to optimize outcomes. Initially, double pigtail plastic stents were used for drainage of necrotic cavities. More recently, dilation had been performed to permit advancement of the endoscope within the cavity for debridement. We propose utilizing fully covered self expanding metal esophageal stents in order to facilitate better drainage with a larger diameter stent and to provide a safer platform for active endoscopic irrigation and debridement with a standard gastroscope.

The efficiency of continuous regional intra-arterial infusion in the treatment of infected pancreatic necrosis

ObjectiveOur aim was to investigate the efficiency of continuous regional intra-arterial infusion (CRAI) with antisecretory agents and antibiotics in the treatment of infected pancreatic necrosis. Materials and methodsCRAI was used as a new clinical technique to treat acute pancreatitis patients during a 4-year period at the First Affiliated Hospital, Wenzhou Medical College, China. In this retrospective study, thirty-four patients with proven infected pancreatic necrosis were included. Twelve patients were treated with CRAI, and were matched according to age, sex, APACHE II scores, Ranson scores and remote organ dysfunction, with 22 patients with IPN treated surgically. The clinical outcome following surgery and CRAI were compared. ResultsNo difference was found between the two groups when comparing age, gender, APACHE II scores, Ranson scores and remote organ dysfunction (p > 0.05). The patients treated with CRAI had a lower incidence of complications (33.3% vs 72.7%), duration of hospitalization (27.1 ± 4.7 days vs 43.0 ± 12.0 days) and cost of hospitalization (4.09 ± 1.64 thousand RMB vs 8.77 ± 3.74 thousand RMB) as compared to patients treated with surgery (p < 0.05). The survival rate was significantly higher in the CRAI group as compared to the surgical group (91.7% vs 63.6%; p < 0.01). However, the two groups had similar rates of concomitant operative treatment and incidence of remote organ dysfunction (p > 0.05). ConclusionsCRAI or CRAI in combination with abscess drainage seemingly improve the clinical outcome in patients with infected pancreatic necrosis. Further confirmative prospective randomized multicenter studies are warranted prior to broad introduction of the CRAI concept.

Minimally Invasive Necrosectomy Versus Conventional Surgery in the Treatment of Infected Pancreatic Necrosis

The purpose of this meta-analysis and systematic review is to compare minimally invasive necrosectomy (MIN) versus open necrosectomy (ON) surgery for infected necrosis of acute pancreatitis. One randomized controlled trial and 3 clinical controlled trials were selected, with a total of 336 patients (215 patients who underwent MIN and 121 patients underwent ON) included after searching in the following databases: Medline, Embase, Cochrane Central Register of Controlled Trials, BioMed Central, Science Citation Index (from inception to August 2011), Greynet, SIGLE (System for Information on Grey Literature in Europe), National Technological Information Service, British Library Integrated catalogue, and the Current Controlled Trials. Statistical analysis is performed using the odds ratio (OR) and weighted mean difference with 95% confidence interval (CI). After the analysis of the data amenable to polling, significant advantages were found in favor of the MIN in terms of: incidence of multiple organ failure (OR, 0.16; 95% CI, 0.06-0.39) (P < 0.0001), incisional hernias (OR, 0.23; 95% CI, 0.06-0.90) (P = 0.03), new-onset diabetes (OR, 0.32; 95% CI, 0.12-0.88) (P = 0.03), and for the use of pancreatic enzymes (OR, 0.005; 95% CI, 0.04-0.57) (P = 0.005). No differences were found in terms of mortality rate (OR, 0.43; 95% CI, 0.18-1.05) (P = 0.06), multiple systemic complications (OR, 0.34; 95% CI, 0.01-8.60) (P = 0.51), surgical reintervention for further necrosectomy (OR, 0.16; 95% CI, 0.00-3.07) (P = 0.19), intra-abdominal bleeding (OR, 0.79; 95% CI, 0.41-1.50) (P = 0.46), enterocutaneous fistula or perforation of visceral organs (OR, 0.52; 95% CI, 0.27-1.00) (P = 0.05), pancreatic fistula (OR, 0.66; 95% CI, 0.30-1.46) (P = 0.30), and surgical reintervention for postoperative complications (OR, 0.50; 95% CI, 0.23-1.08) (P = 0.08). The lack of comparative studies and high heterogeneity of the data present in the literature did not permit to draw a definitive conclusion on this topic. The results of the present meta-analysis might be helpful to design future high-powered randomized studies that compare MIN with ON for acute necrotizing pancreatitis.