Walled-off Necrosis Research Articles

The role of MRCP for preventing pancreatic fluid collection recurrence after EUS-guided drainage of walled-off necrosis

Pancreatic fluid collections (PFCs) may recur after initial successful endoscopic drainage of walled-off necrosis (WON), most commonly due to disconnected pancreatic duct syndrome (DPDS). The primary aim of this study was to assess the role of MRCP for identifying DPDS to guide appropriate management and prevent PFC recurrence. Patients with WON undergoing lumen-apposing metal stent drainage of a PFC were retrospectively identified and categorized as those with MRCP versus those without MRCP before removal of transmural stents. Data on patient demographic characteristics, procedural details, cross-sectional imaging, and recurrence rates were collected through chart review. A total of 121 patients with WON were identified, of whom 44 (36.4%) had an MRCP before transmural stent removal. In patients without MRCP, 13 (16.8%) of 77 had PFC recurrence versus 0 of 44 (0%; P= .003) in those with MRCP. MRCP identified DPDS in 12 (27.2%) patients, all of whom were managed with indefinite drainage with double-pigtail plastic stents without recurrence. In the group without MRCP, PFCs recurred at a median interval of 284 days (interquartile range, 182-618 days) after transmural stent removal. Among the 13 patients with PFC recurrence, 11 (85%) had undiagnosed DPDS detected on subsequent imaging, of whom 9 were subsequently managed with indefinite double-pigtail plastic stents, with no further PFC recurrence. Patients with WON who underwent MRCP before transmural stent removal had a lower rate of PFC recurrence largely due to the identification of DPDS with appropriate endoscopic management.

Step-up approach for the treatment of infected necrotising pancreatitis: real life data from a single-centre experience with long-term follow-up

BackgroundAbout 20% of patients with acute pancreatitis develop a necrotising form with a worse prognosis due to frequent appearance of organ failure(s) and/or infection of necrosis. Aims of the present study was to evaluate the “step up” approach treatment of infected necrosis in terms of: feasibility, success in resolving infection, morbidity of procedures, risk factors associated with death and long-term sequels.MethodsIn this observational retrospective monocentric study in the real life, necrotizing acute pancreatitis at the stage of infected walled-off necrosis were treated as follow: first step with drainage (radiologic and/or endoscopic-ultrasound-guided with lumen apposing metal stent); in case of failure, minimally invasive necrosectomy sessions(s) by endoscopy through the stent and/or via retroperitoneal surgery (step 2); If necessary open surgery as a third step. Efficacy was assessed upon to a composite clinical-biological criterion: resolution of organ failure(s), decrease of at least two of clinico-biological criteria among fever, CRP serum level, and leucocytes count).ResultsForty-one consecutive patients were treated. The step-up strategy: (i) was feasible in 100% of cases; (ii) allowed the infection to be resolved in 33 patients (80.5%); (iii) Morbidity was mild and rapidly resolutive; (iv) the mortality rate at 6 months was of 19.5% (significant factors: SIRS and one or more organ failure(s) at admission, fungal infection, size of the largest collection ≥ 16 cm). During the follow-up (median 72 months): 27% of patients developed an exocrine pancreatic insufficiency, 45% developed or worsened a previous diabetes, 24% had pancreatic fistula and one parietal hernia.ConclusionsBeside a very good feasibility, the step-up approach for treatment of infected necrotizing pancreatitis in the real life displays a clinico-biological efficacy in 80% of cases with acceptable morbidity, mortality and long-term sequels regarding the severity of the disease.

Severe bleeding associated with lumen-apposing metal stent placement for walled-off necrosis: bloody memory in WONderland.

Severe bleeding associated with lumen-apposing metal stent placement for walled-off necrosis: bloody memory in WONderland.

Controversies in endoscopic ultrasonography-guided management of walled-off necrosis.

Walled-off necrosis (WON) develops as local complications afteracute necrotizing pancreatitis. Although less invasive interventions such as endoscopic ultrasonography (EUS)-guided drainage and endoscopic necrosectomy are selected over surgical interventions, delayed and step-up interventions are still preferred to avoid procedure-related adverse events. However, there is a controversy about the appropriate timing of drainage and subsequent necrosectomy. The advent of large-caliber lumen-apposing metal stents has also brought about potential advantages of proactive interventions, which still needs investigation in future trials. When step-up interventions of necrosectomy and additional drainage are necessary, a structured or protocoled approach for WON has been reported to improve safety and effectiveness of endoscopic and/or percutaneous treatment, but has not been standardized yet. Finally, long-term outcomes such as recurrence of WON, pancreatic endocrine, and exocrine function are increasingly investigated in association with disconnected pancreatic duct syndrome. In this review we discuss current evidence and controversy on EUS-guided management of WON.

LOCAL ANTIBACTERIAL TREATMENT IN PATIENTS WITH INFECTED PANCREATIC WALLED-OFF NECROSIS: A SYSTEMATIC REVIEW

Introduction. Systemic antibacterial treatment in patients with infected pancreatic necrosis often fails to resolve the infection due to impaired penetration in necrotic areas. The endoscopic step-up approach based on endoscopic transmural drainage followed, if necessary, by endoscopic necrosectomy has become the standard of care in patients who do not respond to systemic antibiotics. The additional local administration of antibiotics may increase their concentration in necrotic tissue. Aim. To evaluate the efficacy of local infusion of antibacterial agents to the site of infection in addition to systemic treatment after endoscopic drainage to resolve the infection and decrease the need for necrosectomy in patients with walled-off infected pancreatic necrosis. Materials and methods. Major databases were searched for clinical studies assessing the efficacy of local perfusion of antibiotics for the treatment of infected pancreatic necrosis. Results. Four studies were included, two cohort studies and two single-case reports. The majority of patients with infected pancreatic necrosis developed polymicrobial infection. More than one-third of patients additionally had fungal infection. Local irrigation of antibiotics in patients with infected pancreatic necrosis resulted in the eradication of bacteria and fungi, avoiding necrosectomy in almost half of cases. No local or systemic side effects were reported with this strategy. Conclusions. Evidence evaluating the efficacy of local antibiotics for the treatment of infected pancreatic necrosis is scarce. Simultaneous local and systemic administration of antibiotics after endoscopic drainage could reduce the need for necrosectomy. Randomized clinical trials are needed to evaluate the impact of adding local to systemic antibiotics in the prognosis of patients with infected pancreatic necrosis.

Alcoholic Acute Pancreatitis, a Retrospective Study about Clinical Risk Factors and Outcomes-A Seven-Year Experience of a Large Tertiary Center.

(1) Background: Alcohol consumption is one of the main causes of acute pancreatitis. (2) Material and Methods: In this unicentric retrospective cohort study, we selected 1855 patients from the Bucharest Acute Pancreatitis Index (BUC-API) who presented with acute pancreatitis. We investigated correlations between Alcoholic Acute Pancreatitis (AAP) and the rate of complications, cost, length of hospitalization and rate of recurrence. (3) Results: We found a moderately strong association between AAP and recurrence (p < 0.01) and observed that the disease is likelier to evolve with pseudocysts and walled-off necrosis than other forms of AP. Patients with AAP are less likely to have a morphologically normal pancreas than patients suffering from AP of other causes (p < 0.01), but a low probability of requiring intensive care unit admission (p < 0.01) significantly lowers daily cost (Md = 154.7 EUR compared to Md = 204.4 EUR) (p < 0.01). (4) Conclusions: This study's data show that patients with AAP have a greater rate of pseudocyst occurrence, lower intensive care unit admittance rate and lower cost of hospitalization than patients with AP of other causes. Typical Sketch: A middle-aged male tobacco smoker with recurrent AP, lower risk of in-hospital mortality and complications such as pseudocysts; treated in a gastroenterological ward and discharged at-will.

Balloon traction for lumen-apposing metal stent placement for walled-off necrosis: balloon adventure in WONderland.

Balloon traction for lumen-apposing metal stent placement for walled-off necrosis: balloon adventure in WONderland.

Accurately predict outcomes in acute necrotizing pancreatitis with walled-off necrosis patients.

Accurately predict outcomes in acute necrotizing pancreatitis with walled-off necrosis patients.

Vancomycin Resistant Enterococcus in Infected Walled Off Necrosis: Possible Causation &amp; Management

Peri-pancreatic fluid collections are frequently encountered by clinicians caring for patients who recover from acute or chronic pancreatitis. Although these fluid collections are common, the type of collection and resulting complications can significantly affect patient mortality. We present a 29-year-old female who originally presented with acetaminophen toxicity secondary to pain management for interstitial edematous pancreatitis (IEP) complicated by renal failure. The patient later developed intermittent fevers with concern for an underlying infection and was ultimately found to have walled-off necrosis (WON) infected by an uncommon hepaPeri-pancreatic fluid collections are frequently encountered by clinicians caring for patients who recover from acute or chronic pancreatitis. Although these fluid collections are common, the type of collection and resulting complications can significantly affect patient mortality. We present a 29-year-old female who originally presented with acetaminophen toxicity secondary to pain management for interstitial edematous pancreatitis (IEP) complicated by renal failure. The patient later developed intermittent fevers with concern for an underlying infection and was ultimately found to have walled-off necrosis (WON) infected by an uncommon hepatobiliary pathogen previously isolated in a urine culture despite asymptomatic bacteriuria. Background: Acute pancreatitis (AP) is divided into two categories: IEP and necrotizing pancreatitis (NP). Fluid collections are a common sequala for both subtypes. In IEP, fluid collections include acute peripancreatic fluid collections (APFCs) and pseudocysts (PC). Fluid collections in NP include acute necrotic collections (ANCs) and walled-off necrosis (WON) (1). All associated AP fluid collections carry an increased risk for infection, but speed and degree of management varies depending on the collection type (2). Objective: To report a case of AP complicated by a miscategorized fluid collection later determined to be WON with superimposed vancomycin resistant enterococcus (VRE) and discuss a unique approach to anti-microbial therapy selection. Atobiliary pathogen previously isolated in a urine culture despite asymptomatic bacteriuria.

Impact of long-term transmural plastic stents on recurrence after endoscopic treatment of walled-off pancreatic necrosis.

Endoscopic transmural drainage (ETD) using double-pigtail stents (DPSs) is a well-established treatment for walled-off pancreatic necrosis (WON). This study aimed to compare outcomes in patients undergoing ETD with DPSs left indwelling versus those where stents were removed or migrated. This retrospective multicenter cohort study included patients with WON who underwent ETD using DPSs between July 2001 and December 2019. The primary outcome was recurrence of a pancreatic fluid collection (PFC). Secondary outcomes were long-term complications and recurrence-associated factors. Competing risk regression analysis considered DPS removal or migration as time-varying covariates. Among 320 patients (median age 58; 36% women), DPSs were removed in 153 (47.8%), migrated spontaneously in 27 (8.4%), and remained indwelling in 140 (43.8%). PFC recurrence was observed in 57 patients (17.8%): after removal (n = 39; 25.5%); after migration (n = 4; 14.8%); in patients with indwelling DPSs (n = 14; 10.0%). In 25 patients (7.8%), drainage of recurrent PFC was indicated. Risk factors for recurrence were DPS removal or migration (hazard ratio [HR] 3.45, 95%CI 1.37-8.70) and presence of a disconnected pancreatic duct (HR 5.08, 95%CI 1.84-14.0). Among patients who undergo ETD of WON, leaving DPSs in situ seems to lower the risk of recurrent fluid collections, without any long-term DPS-related complications. These results suggest that DPSs should not be routinely removed and can be safely left indwelling indefinitely.

Postponed endoscopic necrosectomy results in a lower rate of additional intervention for infected walled-off necrosis

Although endoscopic necrosectomy (EN) is more frequently used to manage walled-off necrosis (WON), there is still debate over how much time should pass between the initial stent placement and the first necrosectomy. This study aims to determine the effect of performing EN within different timings after placing the initial stent on clinical outcomes for WON. A retrospective study on infected WON patients compared an early necrosectomy within one week after the initial stent placement with a necrosectomy that was postponed after a week. The primary outcomes compared the rate of clinical success and the need for additional intervention after EN to achieve WON resolution. 77 patients were divided into early and postponed necrosectomy groups. The complete resolution of WON within six months of follow-up was attained in 73.7% and 74.3% of patients in both the early and postponed groups. The early group tended to a greater need for additional intervention after EN (26.8% early necrosectomy vs. 8.3% postponed necrosectomy, P = 0.036). Our study does not demonstrate that early necrosectomy is superior to postponed necrosectomy in terms of clinical success rate, total count of necrosectomy procedures, procedure-related complications, length of hospitalization and prognosis. Conversely, patients in the postponed group received fewer additional interventions.

Tracking Wall Characteristics of Necrotic Pancreatic Fluid Collections in Acute Pancreatitis on Serial Contrast-Enhanced Computed Tomography

Abstract Background Encapsulated pancreatic fluid collection (PFC) is a requisite for endoscopic drainage procedures. The 4-week threshold for defining walled-off necrosis does not capture the dynamic process of encapsulation. We aim to investigate the changes in the wall characteristics of PFC in acute necrotizing pancreatitis (ANP) by comparing baseline contrast-enhanced computed tomography (CECT) with follow-up CT scans. Methods This retrospective study comprised consecutive patients with ANP who underwent a baseline CECT within first 2 weeks and follow-up CECT in the third to fifth weeks of illness. Presence, extent, and encapsulation thickness (defined as enhancing wall around the collection) on baseline CECT were compared with follow-up CT (done in the third–fifth weeks of illness). Results Thirty patients (19 males and 11 females; mean age 41.5 ± 13.5 years) were included in the study. The mean time to first CECT was 10 ± 3.6 days. There were 58 collections. The most common site was the lesser sac (n = 29), followed by the left pararenal space (n = 15). At baseline CT, 52 (89.7%) collections had varying degree of encapsulation (15.3%, complete encapsulation). Complete encapsulation was seen in 52 and 82.6% collections in third and fourth week, respectively. All collections in fifth week and beyond were encapsulated. The wall was thicker on follow-up CECT scans (p &lt; 0.01). The mean wall thickness was not significantly associated with the degree of encapsulation (p = 0.417). There was no significant association between the site and degree of encapsulation (p = 0.546). Conclusion Encapsulation is dynamic and collections may get “walled off” before 4 weeks. Walled-off collections should be defined based on imaging rather than a fixed 4-week revised Atlanta classification threshold.

Outcome of Management of Walled-off Necrosis: An Experience from University Hospital of Nepal

Background: The patients with walled-off necrosis after acute necrotizing pancreatitis may require multiple interventions and may be associated adverse outcomes. Intensive care unit admission for organ failure and multistage step-up approaches are the cornerstones of optimal management. This study was conducted to evaluate the clinical characteristics and outcomes of the different strategies for the management of walled-off necrosis. Methods: This is a retrospective study of the patients with walled-off necrosis, managed from July 2022 to January 2024. The demographic data, clinical parameters and outcomes of different strategies including percutaneous and endoscopic drainage and laparoscopic and open necrosectomy were analyzed. Results: Twenty five patients diagnosed with walled-off necrosis were evaluated. The mean age of those patients was 41.64 ±12.44 years, and 13 (52 %) were females. The median time interval between the onset of acute pancreatitis and PCD was 31 (28-42) days. Seventeen (68 %) patients were managed with percutaneous transgastric drainage. Among four (16 %) patients requiring step-up approach, one required endoscopic ultrasound guided drainage, two (8 %) underwent open necrosectomy, one underwent laparoscopic necrosectomy. The median length of hospital stay was 16 (3-60) days. There were four (16 %) mortalities, two (8 %) after percutaneous drainage only, one after EUS guided drainage and one after open necrosectomy, all due to sepsis and multiple organ failure. Conclusion: Initial percutaneous transgastric drainage is feasible, safe and effective in the management of majority of patients with walled-off necrosis, thereby reducing further invasive interventions and improving the overall outcomes of the patients.

Pancreatic Walled-Off Necrosis: Cross-Sectional Imaging Depiction of Debris Predicts the Success of Endoscopic Drainage Using Lumen-Apposing Metal Stents

Introduction: The use of endoscopic ultrasound (EUS)-guided transmural stent placement for pancreatic walled-off necrosis (WON) drainage is widespread. This study retrospectively analyzed imaging parameters predicting the outcomes of WON endoscopic drainage using lumen-apposing metal stents (LAMS). Methods: This study analyzed the data of 115 patients who underwent EUS-guided debridement using LAMS from 2011 to 2015. Pre-intervention CT or MRI was used to analyze the total volume of WON, percentage of debris, multilocularity, and density. Success measures included technical success, the number of endoscopic sessions, the requirement of percutaneous drainage, long-term success, and recurrence. Results: The primary cause of pancreatitis was gallstones (50.4%), followed by alcohol (27.8%), hypertriglyceridemia (11.3%), idiopathic (8.7%), and autoimmune (1.7%). The mean WON size was 674 mL. All patients underwent endoscopic necrosectomy, averaging 3.1 sessions. Stent placement was successful in 96.5% of cases. Procedural complications were observed in 13 patients (11.3%) and 6 patients (5.2%) who needed additional percutaneous drainage. No patients reported recurrent WON posttreatment. Univariate analysis indicated a significant correlation between debris percentage and the need for additional drainage and long-term success (p < 0.001). The number of endoscopic sessions correlated significantly with debris percentage (p < 0.001). Conclusion: Pre-procedural imaging, particularly debris percentage within WON, significantly predicts the number of endoscopic sessions, the need for further percutaneous drainage, and overall long-term success.

Acidic solution irrigation as a novel approach for treating infected walled-off pancreatic necrosis

Walled-off pancreatic necrosis (WOPN) is a severe complication of acute pancreatitis arising from pancreatic or peripancreatic necrosis complicated by infection, leading to elevated mortality rates. Extravasation of pancreatic juice creates a weakly alkaline microenvironment favorable for the survivial of translocated intestinal bacteria and activated pancreatic enzyme-mediated autodigestion of pancreatic and peripancreatic tissues. Conventional treatments for WOPN involve invasive procedures with irrigation to mitigate postoperative infections. However, there remains a lack of a unified standard for lavage fluid. Herein, we raise the hypothesis that the utilization of acidic solution irrigation may serve as a promising strategy for preventing and treating infected WOPN. Acidic solutions create an unfavorable environment for translocated intestinal bacteria in WOPN cases. Additionally, the acidic microenvironment may alleviate self-digestion of pancreatic and peripancreatic tissues by inhibiting pancreatic enzyme activity. This innovative approach holds potential for enhancing the management and outcomes of infected WOPN.

New-onset Diabetes Mellitus after EUS-guided Drainage with LAMS: A Pilot Study.

Walled-off necrosis (WON) is a serious complication of severe pancreatitis, patients with necrotizing pancreatitis having an increased risk of developing diabetes mellitus (DM). The aim of this study was to assess the frequency of new-onset diabetes (NOD) in patients with symptomatic WON after endoscopic ultrasound (EUS)-guided drainage with lumen-apposing metal stents (LAMS). We retrospectively analyzed a prospectively collected database of patients with symptomatic WON treated by EUS-guided drainage with LAMS in a tertiary referral center. The patients were followed-up for at least 12 months after stent removal. These patients were compared with age- and sex-matched asymptomatic WON controls without interventional treatment and healthy controls to assess the one-year occurrence of DM. Diabetes was defined according to the American Diabetes Association criteria. Of the 50 patients with symptomatic WON included in the study (male/female ratio, 33:17; median age, 60 years), 13 patients (26%) had pre-existing DM and were excluded. Ten of the remaining 37 patients (27%) without prior DM developed NOD within one year after stent removal, this frequency being higher than in asymptomatic WON controls (18.9%, p=0.581) and healthy controls (2%, p = 0.002). In the symptomatic WON group, NOD patients compared to non-DM patients were older (63.5 vs. 56 years old, p=0.042), had more frequent necrosis > 50% of the pancreatic parenchyma (p=0.002) and had a body-tail location of WON (p<0.001). On multivariate analysis, the number of direct endoscopic necrosectomy (DEN) sessions was the only significant factor for NOD occurrence (OR=7.05, p=0.010). NOD patients had poor glycemic control and required more DEN sessions to achieve WON resolution than patients with prior DM (p=0.017). In patients with symptomatic WON treated by EUS-guided drainage, DM occurred in 27% of previously non-diabetic patients within one year of follow-up. Patients with extensive pancreatic necrosis were more likely to develop NOD, a high number of DEN sessions being a significant risk factor for NOD occurrence.

Metal versus plastic stents for walled-off pancreatic necrosis: much alike, then which?

Metal versus plastic stents for walled-off pancreatic necrosis: much alike, then which?

Laparoscopic necrosectomy for acute necrotising pancreatitis: Retrospective analysis of a decade-long experience from a tertiary centre.

The objective of this study is to evaluate the role of minimally invasive surgery for the management of necrotising pancreatitis in acute settings and to propose tailor-made approaches to deal with various locations of pancreatic necrosis. Three hundred and thirteen patients underwent laparoscopic management of necrotising pancreatitis in this study period from January 2010 to June 2021, out of which 122 patients underwent minimally invasive necrosectomy for acute necrotising pancreatitis. The remaining 191 patients underwent laparoscopic internal drainage in the form of cystogastrostomy/cystojejunostomy for walled-off pancreatic necrosis. Mean body mass index was 26.45 ± 3.78 kg/sqm. Mean operating time was 56.40 ± 20.48 min and mean blood loss was 120 ± 31.45 mL. Ten patients required reoperation (6 underwent open procedure and 4 underwent laparoscopic redo necrosectomy). Six patients died of multi-organ failure. The mean duration of return of bowel function was 5 ± 1.8 days. The mean length of hospital stay after surgery was 10.19 ± 7.09 days. There were no major wound-related complications. A minimally invasive approach to pancreatic necrosectomy is safe and feasible with good outcomes in centres with advanced laparoscopic expertise. It requires not only careful case selection but also proper timing and the ideal route of access to achieve optimal outcomes.

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.

Efficacy and Safety of Anhydrous Ethanol-Assisted Endoscopic Ultrasound-Guided Transluminal Necrosectomy in Infected Necrotizing Pancreatitis.

Endoscopic necrosectomy has become the first-line treatment option for infectious necrotizing pancreatitis (INP), especially walled-off necrosis. However, the problems, including operation-related adverse events (AEs) and the need for multiple endoscopic procedures, have not been effectively addressed. We sought to evaluate the clinical safety and efficacy of anhydrous ethanol-assisted endoscopic ultrasound (EUS)-guided transluminal necrosectomy in INP. A single-center observational cohortstudy of INP patients was conducted in a tertiaryendoscopic center. Anhydrous ethanol-assisted EUS-guided transluminal necrosectomy (modified group) and conventional endoscopic necrosectomy (conventional group) were retrospectively compared in INP patients. The technical and clinical success rates, operation time, perioperative AEs, postoperative hospital stay, and recurrent INP rates were analyzed, respectively. Atotalof55patientswereenrolled. No statistically significant differences were observed between the two groups regarding baseline characteristics. Compared to patients in the conventional group, patients in the modified group demonstrated significantly reduced times of endoscopic transluminal necrosectomies (1.96 ± 0.89 vs. 2.73 ± 0.98; P = 0.004) and comparable perioperative AEs (P = 0.35). Meanwhile, no statistically significant differences were observed in the technical and clinical success rates (P = 0.92), operation time (P = 0.59), postoperative hospital stay (P = 0.36), and recurrent INP rates (P = 1.00) between the two groups. Anhydrous ethanol-assisted EUS-guided transluminal necrosectomy seemed safe and effective in treating INP. Compared with conventional endoscopic transluminal necrosectomy, its advantage was mainlyin reducing the number of endoscopic necrosectomies without increasing perioperative AEs.