Treatment Of Infected Pancreatic Necrosis Research Articles

EUS-guided Endoscopic Necrosectomy and Temporary Cystogastrostomy for Infected Pancreatic Necrosis With Self-expanding Metallic Stents

Pancreatic pseudocyst with infected necrotic tissue is associated with necrotizing pancreatitis and carries a high rate of complications and death. Open cystogastrostomy with removal of necrotic material and necrosectomy is the standard treatment for infected pancreatic necrosis but is associated with significant morbidity, mortality, and prolonged hospital stay. Endoscopic cyst drainage with necrosectomy is an alternative and less invasive technique. We report a case of endoscopic ultrasound-guided cystogastrostomy with a fully covered 15-mm-diameter self-expandable metal stent and staged endoscopic necrosectomy through the stent. This is the first case, so far, to use this technique with complete removal of necrotic material without any complications.

The Evolving Management of Infected Pancreatic Necrosis

Management of infected pancreatic necrosis (IPN) has for decades been based on early operative débridement. This approach is associated with mortality rates as high as 58 per cent. Recently, the care of these patients has evolved and emphasizes delayed operation and early intervention with percutaneous drainage. In 2002, we began to incorporate these new principles for the treatment of IPN and herein characterize the recent UCLA experience with management of IPN. A retrospective review of patients with IPN treated at UCLA between 2002 and 2011 was conducted. Mean patient age was 53.4 years. Mean Ranson's score was 3.3±2.3 and average number of concurrent comorbidities 3.2±2.5. All patients were treated with intravenous antibiotics. Thirteen of 18 patients (72.2%) had percutaneous drainage catheters placed (mean 1.1 drains per patient). Two patients were treated with percutaneous drainage alone. Sixteen of 18 (88.9%) eventually underwent surgical débridement. Of the operative patients, mean time from diagnosis to surgery was 28.4 days. The mortality in this group was 16.7 per cent. In conclusion, antibiotics and percutaneous drainage is an acceptable and possibly preferable initial therapeutic strategy for patients with IPN. Delayed operation and early intervention with percutaneous drainage appears to improve mortality for these patients.

Percutaneous negative pressure irrigation and drainage for the treatment of infected pancreatic necrosis complicated by severe acute pancreatitis

Infected pancreatic necrosis is a fatal complication of severe acute pancreatitis ( SAP),while traditional laparotomy has many disadvantages,such as great trauma and many complications,in recent years,minimally invasive treatment has got great progress in clearing the necrotic tissue of pancreas,but its drainage effect is not optimal.From January 2010 to December 2011,19 patients with infected pancreatic necrosis complicated by SAP who were admitted to the Nanjing General Hospital of Nanjing Military Area were implemented computed tomography or ultrasound-guided Seldinger puncture.Along the puncture needle,a guide wire was inserted into the necrotic tissue,and then the sinus was expanded,in which a tube was placed for negative pressure irrigation and drainage.By continuous postoperative negative pressure irrigation and drainage,the necrotic tissue gradually dropped off and disappeared in 12 patients,and the other 7 patients were performed endoscopic necrotic tissue removal and drainage along the sinus.Systemic symptons of infection obviously improved in all of the 19 patients,and no organ dysfunction or complications occurred.Finally,16 patients were cured and 3 patients died.Continuous percutaneous negative pressure irrigation and drainage combined with the endoscopic necrotic tissue removal could become an important choice to treat the infected pancreatic necrosis. Key words: Severe acute pancreatitis; Infected pancreatic necrosis; Percutaneous puncture ; Negative pressure drainage; Endoscopy; Necrotic tissue removal

427 Conservative Treatment for Infected Pancreatic Necrosis: A Systematic Review and Meta-Analysis

427 Conservative Treatment for Infected Pancreatic Necrosis: A Systematic Review and Meta-Analysis

Endoscopic Transgastric Necrosectomy for Infected Necrotizing Pancreatitis

Endoscopic Transgastric Necrosectomy for Infected Necrotizing Pancreatitis

Necrotizing Acute Pancreatitis Current Status - Emerging New Strategies in Surgical Management

Despite that pancreatic necrosis complicates only 15 % of cases of acute pancreatitis (AP), it is associated with high morbidity and considerable mortality. In an attempt to improve prognosis, many surgical strategies have been described during the last few decades. Currently, necrosectomy remains the cornerstone in the surgical treatment of infected pancreatic necrosis and in selected cases of sterile necrotizing pancreatitis. Following necrosectomy, continuous closed lavage is recommended by many authors, while closed abdominal packing /drainage and repeated planned necrosectomies- commonly using the zipper technique-are also acceptable alternative strategies. Open abdomen (laparostomy) is rarely indicated in carefully selected cases (typically in abdominal compartment syndrome associated with necrotizing AP). During the last decade, minimally invasive techniques (including percutaneous drainage, retroperitoneal endoscopic approach, transgastric endoscopic approach etc) have been extensively studied by some groups not only in the management of pancreatic abscesses and / or pseudocysts, but also as primary methods of treatment of necrotizing AP. Results have been impressive, but experience currently is limited to only a few centers around the world.

Retroperitoneal Minimally Invasive Pancreatic Necrosectomy Using Single-port Access

Infected pancreatic necrosis is a life-threatening complication of acute pancreatitis that has been traditionally managed with open surgical debridement. Over the last decade, minimally invasive techniques have been increasingly used for the treatment of infected pancreatic necrosis and their results are encouraging. Percutaneous retroperitoneal pancreatic necrosectomy is one of the minimally invasive approaches used for debridement of pancreatic necrosis. We report our technique of retroperitoneoscopic necrosectomy using a single-port access.

Short-Term Outcomes from a Multicenter Retrospective Study in China Comparing Laparoscopic and Open Surgery for the Treatment of Infected Pancreatic Necrosis

Laparoscopic surgery for confirmed infected pancreatic necrosis (IPN) represents a relatively new solution. There are no studies comparing the outcomes of laparoscopic and open surgery for patients with IPN. The aims of this study were to investigate the feasibility of laparoscopic management for patients with IPN and to compare the outcomes of laparoscopic and open surgery. Seventy-six patients with IPN who underwent open surgery (Open-group) or laparoscopic surgery (Lap-group) were retrospectively reviewed. Demographic data, white blood cell count, and APACHE II score upon admission, operative findings, major complications, and mortality were compared between the Open-group and the Lap-group. The Lap-group was further divided into two subgroups (early and late), and the operative difficulty was compared between the two subgroups. There were no significant differences between the Open-group and the Lap-group with respect to demographic data, white blood cell count, and APACHE II score. Although the mean operative time was significantly shorter in the Open-group than in the Lap-group, the estimated blood loss was significantly greater in the Open-group than in the Lap-group, as was the rate of complications. The mean postoperative hospital stay in the Open-group was significant longer than in the Lap-group, too. In the Lap-group, the mean operating time, estimated blood loss, and conversion rate in the early subgroup were significantly lower than in the late subgroup. Laparoscopic necrosectomy and the placement of an intermittent irrigation and continuous suction drainage system for IPN is feasible, effective, and of minimal invasiveness. The late laparoscopic necrosectomy is relatively difficult.

Minimally invasive treatment of pancreatic necrosis

To systematically review these minimally invasive approaches to infected pancreatic necrosis. We used the MEDLINE database to investigate studies between 1996 and 2010 with greater than 10 patients that examined these techniques. Using a combination of Boolean operators, reports were retrieved addressing percutaneous therapy (341 studies), endoscopic necrosectomy (574 studies), laparoscopic necrosectomy via a transperitoneal approach (148 studies), and retroperitoneal necrosectomy (194 studies). Only cohorts with at least 10 or more patients were included. Non-English papers, letters, animal studies, duplicate series and reviews without original data were excluded, leaving a total of 27 studies for analysis. Twenty-seven studies with 947 patients total were examined (eight studies on percutaneous approach; ten studies on endoscopic necrosectomy; two studies on laparoscopic necrosectomy via a transperitoneal approach; five studies on retroperitoneal necrosectomy; and two studies on a combined percutaneous-retroperitoneal approach). Success rate, complications, mortality, and number of procedures were outcomes that were included in the review. We found that most published reports were retrospective in nature, and thus, susceptible to selection and publication bias. Few reports examined these techniques in a comparative, prospective manner. Each minimally invasive approach though was found to be safe and feasible in multiple reports. With these new techniques, treatment of infected pancreatic necrosis remains a challenge. We advocate a multidisciplinary approach to this complex problem with treatment individualized to each patient.

Minimally Invasive Management of Acute Necrotizing Pancreatitis

About 10% to 20% of patients with acute pancreatitis develop severe disease, which is characterized by intrapancreatic or peripancreatic necrosis [1-6]. Necrotizing pancreatitis is the most severe form of acute pancreatitis associated with high morbidity and mortality due to the development of infected pancreatic necrosis, and multisystem organ failure. In severe necrotizing pancreatitis, the mortality rate ranges from 10% to 40%, and it is especially high (up to 50%) when the necrosis is infected and progressing to sepsis and multiorgan failure [1-3,7]. The appropriate treatment of infected pancreatic necrosis remains the subject of much debate. It is generally accepted that in infected necrotizing pancreatitis the infected non-vital solid tissue has to be removed in order to control the sepsis. For decades, open surgery and immediate surgical necrosectomy was the gold standard treatment for patients with infected pancreatic necrosis [1,3,7,8]. However, several reports have shown that early surgical intervention for pancreatic necrosis could result in a worse prognosis compared to cases where surgery is delayed or avoided [9-13]. It has been suggested that the invasiveness of open surgery in an already critically ill patient may be the cause of high morbidity rates. Therefore, several groups worldwide have developed new minimal invasive approaches using conservative treatment, endoscopic necrosectomy or drainage therapy in the management of infected necrotizing pancreatitis [14-19].

Percutaneous Lavage as Primary Treatment for Infected Pancreatic Necrosis

The classic treatment of infected pancreatic necrosis (IPN) is surgical debridement and drainage. This study reviews our experience with nonoperative percutaneous catheter drainage and serial lavage as primary treatment in patients with IPN. Between 1993 and 2009, a prospective nonselected series of 63 consecutive patients with microbiologically confirmed IPN were enrolled with the intent of treating them nonoperatively, and they were retrospectively analyzed. Catheters were placed percutaneously in the interventional radiology (IR) suite, and were used to lavage and debride the necrosis 1-3 times per week. The lavages continued on an outpatient basis by IR, and the catheters were removed with disease resolution. One patient rapidly became unstable and had to be taken primarily for open debridement. In the remaining 62 patients, 57 survived, for an overall mortality rate of 8%. Fifty patients were treated solely with percutaneous lavage, and 47 survived. Mean hospital length of stay was 61 days, ranging from 6 to 190 days. Mean length of outpatient treatment was 42 days, ranging from 3 to 180 days. Mean number of lavages was 21, ranging from 11 to 75. Eleven patients (18%) deteriorated during percutaneous treatment and required laparotomy, and 9 of these survived. One patient treated percutaneously resolved his sepsis but had a persistent pancreatic fistula and was managed with pancreaticojejunostomy. Percutaneous catheter drainage and serial lavage are an effective alternative to open surgical debridement in patients with IPN. Overall survival is excellent, and most patients avoid the morbidity of open debridement. A minority of patients deteriorate, but most of those can be salvaged with open drainage.

Pancreatitis aguda

The present review discusses eight studies, selected for their clinical importance in the field of acute pancreatitis (AP). A multicenter clinical trial demonstrated that treatment of infected pancreatic necrosis through drainage, followed by video-assisted retroperitoneal debridement in patients with poor clinical course, was superior to classical open surgery in terms of costs and complications. A retrospective study analyzed the radiation from computed tomography received by patients with necrotizing AP and warned of the high dose administered, which could have significant carcinogenic effects. A multicenter retrospective study confirmed the utility of measuring blood urea nitrogen at admission and at 24 hours in predicting mortality due to AP. A prospective study of fluid therapy reported that inadequate or excess fluid administration in the first 24 hours of admission were related to poor outcome. Two studies analyzed the bedside index for severity in AP (BISAP) score at admission; this scoring system was useful in AP in general but not in the subgroup of patients requiring admission to the intensive care unit. Lastly, two studies showed the highly promising prognostic value of determining serum concentrations of angiogenic factors in AP.

Progress in the management of necrotizing pancreatitis

Evaluation of: van Santvoort HC, Besselink MG, Bakker OJ et al. A step-up approach or open necrosectomy for necrotizing pancreatitis. N. Engl. J. Med. 362, 1491–1502 (2010).Pancreatic necrosis, a complication of severe pancreatitis, may become infected, resulting in significant morbidity and potential mortality. Infected necrosis was heretofore considered a surgical condition, and despite aggressive operative management, the mortality remained high. With a better understanding of the natural history of necrosis, established methods to diagnose infection and the increasing use of minimally invasive techniques, less aggressive therapies have been utilized with some success. The present study evaluated a step-up approach for the treatment of infected pancreatic necrosis, utilizing endoscopic and percutaneous techniques, and if ineffective, necrosectomy with a minimally invasive retroperitoneal approach. They compared this step-up approach to the standard open necrosectomy. They demonstrated that when using such an approach compared with open necrosectomy, the frequency of major complications such as organ failure, perforation, fistula or even death was significantly less than in those who received conventional open necrosectomy. Indeed, for those randomized to the step-up approach, roughly a third of the patients were successfully treated with percutaneous drainage alone. In the long-term, development of diabetes was also less frequent in those receiving less aggressive therapy. These findings, in combination with other reports, suggest that the dogma that open necrosectomy is mandatory for all patients with infected necrosis should be re-evaluated, and that less aggressive treatments as part of a multidisciplinary approach can reduce morbidity and mortality.

Minimally Invasive Techniques in Pancreatic Necrosis

Traditional open surgical necrosectomy for treatment of infected pancreatic necrosis is associated with high morbidity and mortality, leading to a shift toward minimally invasive endoscopic, radiologic, and laparoscopic approaches. Percutaneous drainage is useful as a temporizing method to control sepsis and as an adjunctive treatment to surgical intervention. It is limited because of the requirement for frequent catheter care and the need for repeated procedures. Endoscopic transgastric or transduodenal therapies with endoscopic debridement/necrosectomy have recently been described and are highly successful in carefully selected patients. It avoids the need for open necrosectomy and can be used in poor operative candidates. Laparoscopic necrosectomy is also promising for treatment of pancreatic necrosis. However, the need for inducing a pneumoperitoneum and the potential risk of infection limit its usefulness in patients with critical illness. Retroperitoneal access with a nephroscope is used to directly approach the necrosis with complete removal of a sequestrum. Retroperitoneal drainage using the delay-until-liquefaction strategy also appears to be successful to treat pancreatic necrosis. The anatomic location of the necrosis, clinical comorbidities, and operator experience determine the best approach for a particular patient. Tertiary care centers with sufficient expertise are increasingly using minimally invasive procedures to manage pancreatic necrosis.

Management of Infected and Sterile Pancreatic Necrosis by Programmed Endoscopic Necrosectomy

Introduction: Necrosectomy is the gold standard treatment for infected pancreatic necrosis (IPN). A percutaneous and endoscopic approach has been accepted in selected cases. Endoscopic drainage (ED) of IPN can be performed by using transpapillary or transmural procedures, or a combination of both with or without endoscopic ultrasound. Aims: The aim of this study was to determine the indications, complications, success rate, and the importance of assessment of main pancreatic duct integrity by endoscopic retrograde pancreatography (ERP) in patients with IPN. Methods: Records of all patients who underwent endoscopic necrosectomy from January 2002 to December 2007 at Rio de Janeiro Federal University Hospital were reviewed. A total of 56 patients were included. ED was performed using daily transmural and transpapillary drainage. A diagnostic pancreatogram (ERP) to search for communications between the pancreatic duct and the collection were performed in all cases and in cases where communication existed. A pre-cut needle knife was used to puncture the cyst wall, aspirate the content and then enter at the cyst cavity (contrast was injected to ensure opacification of the cyst and subsequent drainage). Sphincterotomy catheter or balloons were used to enlarge and ensure a wide cystoenterostomy. All patients were followed with computerized tomography scans or ultrasound to ensure clinical resolution. Mean follow-up was 21 months. Results: 49/56 patients could be successfully treated. ED was successful in 49 patients (87%) and in 3 (13%) it failed. Mean follow-up was 21 months. During this period, there were 2 (10.5%) pseudocyst recurrences and only 1 (5.2%) recurrence of new episodes of pancreatic necrosis, and all were managed clinically and/or endoscopically. No mortality was related to the procedure. Conclusion: ED with daily necrosectomy is a useful method to remove infected and sterile pancreatic necrosis.

Endoscopic necrosectomy as primary treatment for infected peripancreatic fluid collections (with video)

The success of endoscopic intervention in the management of uncomplicated pancreatic pseudocysts has allowed endoscopists to be more aggressive in managing complicated pancreatic fluid collections. Surgery is considered the mainstay of therapy once pancreatic abscesses develop. As a second-line treatment, endoscopic drainage of pancreatic abscess has been performed in those who are not candidates for surgery. Our purpose was to report our experience with single-session endoscopic necrosectomy and drainage as the primary mode of treatment of infected pancreatic necrosis or abscesses. This was a case series. A single endoscopy unit based at a university medical center. Six consecutive patients who underwent endoscopic necrosectomy as the primary treatment modality for pancreatic abscess or necrosis between May 2006 and February 2007. Resolution of the infected pancreatic fluid collection and avoidance of surgery. Successful single-session endoscopic necrosectomy was performed in all 6 patients with impressive and immediate symptom relief. None needed surgery or other endoscopic or percutaneous interventions. Patients were discharged from the hospital in a median of 8.5 days. Complete resolution of pancreatic lesions were noted in 5 of 6 patients (1 patient had a small residual cyst) in median follow-up of 3.5 months (range 3-11 months). Endoscopic necrosectomy can be performed safely and efficiently for the primary treatment of pancreatic necrosis and abscess. Our data suggest that aggressive single-session necrosectomy can be adequate for the complete removal of infected and necrotic debris.

Transgastric endoscopic necrosectomy with temporary metallic esophageal stent placement for the treatment of infected pancreatic necrosis (with video)

Transgastric endoscopic necrosectomy with temporary metallic esophageal stent placement for the treatment of infected pancreatic necrosis (with video)

New acquisitions in treating infection due to necrotic pancreatitis: prevention or cure?

Early antibiotic treatment is still a therapeutic challenge in the clinical management of acute necrotic pancreatitis. The antibiotic of choice for the prevention of the infection of necrotic pancreatic tissue would appear to be imipenem and, more recently, meropenem has also been suggested. The latter belongs to the same family of antibiotics as imipenem but delivers greater stability in the presence of renal dehydropeptidase-I and an increase in activity against gram-negative bacteria, it offers similar efficacy to imipenem in preventing pancreatic infection and extrapancreatic infections when associated with severe acute pancreatitis. Two further studies have advised against prophylactic use of antibiotics in the prevention of acute necrotic pancreatitis. Most recently, probiotics have been suggested as useful in the prevention of pancreatic necrosis. In this paper we will critically review the most recent studies published on the prophylaxis and treatment of infected pancreatic necrosis and a critical evaluation of the same.

The Efficacy of Nonsurgical Treatment of Infected Pancreatic Necrosis

We conducted this study to evaluate the efficacy of nonsurgical treatment for patients with infected pancreatic necrosis (IPN). Among 224 patients with acute pancreatitis from 2000 to 2004, there were 31 patients diagnosed as having IPN complication. The diagnostic criteria for IPN were either a positive culture or free gas in the pancreas of patients with acute pancreatic necrosis. Nonsurgical management including percutaneous drainage or endoscopic drainage (ED) followed by vigorous irrigation was initially attempted in all patients. Surgery was planned only when there was no clinical improvement after the initial nonsurgical treatment. Percutaneous drainage or ED was performed in 18 and 5 patients, respectively. Eight patients received antibiotics only. Four patients (12.9%) (3 from percutaneous drainage group and 1 from ED group) required surgery. Sepsis or fistula developed in 32% and 6% of patients, respectively, and was managed successfully. One patient (3.2%) died as a result of rapidly progressing multiorgan failure. The mean duration of hospitalization was 37 days. During the follow-up period, 7 patients were readmitted because of fever; they were managed by reposition of the drainage tube. Intensive nonsurgical treatment is very effective and safe and should be considered as an initial treatment modality for patients with IPN.

Endoscopic necrosectomy as primary therapy in the management of infected pancreatic necrosis

Open pancreatic necrosectomy is the standard treatment for infected pancreatic necrosis but is associated with significant morbidity, mortality, and prolonged hospital stay. Percutaneous or endoscopic necrosectomy are alternative techniques. We evaluated the use of endoscopic necrosectomy for treatment of patients with necrosis that could be accessed through the posterior wall of the stomach. We retrospectively analyzed the indication, patient status according to acute physiology and chronic health evaluation (APACHE) 2 severity score, and success of endoscopic necrosectomy as primary treatment, in selected patients with localized infected pancreatic necrosis, who presented between May 2002 and October 2004. After the necrosis cavity had been accessed, with the assistance of endoscopic ultrasound, a large orifice was created and necrotic debris was removed using endoscopic accessories under radiological control. Follow-up was clinical and radiological. 13 patients (nine men, four women, mean age 53 years), 11 with positive bacteriology, underwent attempted endoscopic necrosectomy. Median APACHE 2 score on presentation was 8 (range 1-18). Four patients needed intensive therapy unit care and one other patient required (nonventilatory) high-dependency unit care only. Necrosis was successfully treated endoscopically in 12 patients, requiring a mean of 4 endoscopic interventions (range 1-10); one patient required open surgery; two underwent additional percutaneous necrosectomy and one required laparoscopic drainage. Two patients died of complications unrelated to the procedure. The 11 survivors have a median (range) follow-up of 16 (6-38) months. Endoscopic necrosectomy is a safe method for treatment of infected pancreatic necrosis. Multiple procedures are usually needed. It may be combined with other methods of surgical intervention. Larger prospective studies will more precisely define its role.