scholarly journals Necrotizing Pancreatitis: Step Up Approach

2021 ◽  
Author(s):  
Betsabé Reyes ◽  
Javier Padilla ◽  
Pilar Elena González ◽  
Pablo Sanz
Keyword(s):  
Traditional Approach ◽  
Secondary Infection ◽  
Pancreatic Insufficiency ◽  
Necrotizing Pancreatitis ◽  
Severe Form ◽  
Sequential Treatment ◽  
Necrotic Tissue ◽  
Infected Necrosis ◽  
Life Threatening ◽  
Open Necrosectomy

Acute pancreatitis (AP) is a inflamatory condition of the pancreatic gland with or without involvement of peripancreatic tissues and distant organs. The incidence of AP is 20–35 cases per 100,000 inhabitants per year, with an overall mortality of 2–10%. In recent decades the incidence of AP has increased globally. Most cases follow a mild, self-limiting course, but 10–20% of patients develop a severe form with systemic and local life-threatening complications of pancreatic and peripancreatic necrosis come about 20–40% of patient with severe AP and aggravate organ functions. The traditional approach to the treatment of necrotizing pancreatitis with secondary infection of necrotic tissue is open necrosectomy to remove the infected necrotic tissue. But this is associated with high rates of complications, death and pancreatic insufficiency. The benefits of sequential treatment in cases of infected necrosis (“Step an approach”) compared to traditional open necrosectomy, showing less morbidity and lower costs. The sequential treatment is an alternative to open necrosectomy, including percutaneous drainage, endoscopic (transgastric) drainage, and minimally invasive retroperitoneal necrosectomy. With this approach, up to 35% of patients can be treated only with drainage, to avoid necrosectomy and to reduce the percentage of complications. In this chapter we present the step-by-step approach.

scholarly journals Necrosectomía endoscópica asistida por laparoscopia: un enfoque efectivo en la necrosis pancreática infectada

2020 ◽  
pp. 151-156
Author(s):  
Flávia Fernanda de Franqa ◽  
Izabella Maria Lopes Titon ◽  
Jonas Takada ◽  
Nickson Santana Souto ◽  
Rafael Antunes Delfes ◽  
...  
Keyword(s):  
Percutaneous Drainage ◽  
Open Surgery ◽  
Physiological Stress ◽  
Necrotizing Pancreatitis ◽  
Interventional Treatment ◽  
Necrotic Tissue ◽  
Infected Necrosis ◽  
Endoscopic Necrosectomy ◽  
Complex Process ◽  
Acute Condition

Acute pancreatitis is a disease characterized by intense inflammation caused by the degradation of the parenchyma and adjacent tissue, through activation and consequent protease output. Approximately 15% of patients with the disease progress to necrotizing form and subsequent infection of this necrotic tissue is a complex process and associated with significant morbidity and mortality. Interventional treatment is mandatory in the management of infected necrosis and open surgery has perpetuated for decades as a first-line treatment to remove infected necrotic tissue. In recent years, with the improvement in laparoscopy and other techniques, new approaches for the management of this condition have been advocated to the detriment of open surgery, in particular, the advent of the Step-up approach. This new approach allowed the management of infected necrosis in a gradual way. Percutaneous drainage is the first step, and is effective by itself in up to 35% of cases, then, if there is no clinical remission or if the collection drainage is not satisfactory, the invasiveness of the process increases. Techniques such as video-assisted retroperitoneal debridement (VARD) and endoscopic transgastric necrosectomy (ETN) are examples of minimally invasive procedures widely used and applied in these cases, as they allow access to the necrotic collection with minimal aggression, in addition to inducing low physiological stress, resulting in a lower incidence of unfavorable outcomes. We describe a case of a patient, male, 64 years old, hypertensive, with infected necrotizing pancreatitis, with 6 weeks of evolution. Following the parameters of the Step-up approach, treatment started with percutaneous drainage to resolve the acute condition and, sub- sequently, an alternative technique was used, employing endoscopic necrosectomy assisted by laparoscopy. The management of this case demonstrates an effective and fully feasible technique, which can be replicated in other hospital centers.

scholarly journals Comparison of Different Surgical Methods for Necrotizing Pancreatitis: A Meta-Analysis

2021 ◽  
Vol 8 ◽  
Author(s):  
Jianguo Xiao ◽  
Xiaojiao Quan ◽  
Fang Liu ◽  
Wen Li
Keyword(s):  
Minimally Invasive Surgery ◽  
Treatment Group ◽  
Minimally Invasive ◽  
Invasive Surgery ◽  
Enterocutaneous Fistula ◽  
Pancreatic Insufficiency ◽  
Necrotizing Pancreatitis ◽  
Cutaneous Fistula ◽  
Abdominal Bleeding ◽  
Open Necrosectomy

Purpose: To compare the effectiveness and safety of three methods of open necrosectomy, minimally invasive surgery and endoscopic step-up approach for necrotizing pancreatitis.Methods: We searched Pubmed, Embase, ScienceDirect, and CNKI full text database (CNKI) (to December 25, 2019). RCT, prospective cohort study (PCS), and retrospective cohort study (RCS) comparing the effectiveness and safety of any two of above-mentioned three methods were included.Results: There was no significant difference in major complications or death, and mortality between the minimally invasive surgery treatment group and the endoscopic step-up approach treatment group (RR = 1.66, 95%CI: 0.83–3.33, P = 0.15; RR = 1.05, 95%CI: 0.59–1.86, P = 0.87); the incidence rate of new-onset multiple organ failure, enterocutaneous fistula, pancreatic-cutaneous fistula, intra-abdominal bleeding, and endocrine pancreatic insufficiency in the endoscopic step-up approach treatment group was significantly lower than minimally invasive surgery group (RR = 2.65, 95%CI: 1.10–6.36, P = 0.03; RR = 6.63, 95%CI: 1.59–27.60, P = 0.009; RR = 7.73, 95%CI: 3.00–19.89, P < 0.0001; RR = 1.91, 95%CI: 1.13–3.24, P = 0.02; RR = 1.83, 95%CI: 1.9–3.16, P = 0.02); hospital stay in the endoscopic step-up approach group was significantly shorter than minimally invasive surgical treatment group (MD = 11.26, 95%CI: 5.46–17.05, P = 0.0001). The incidence of pancreatic-cutaneous fistula in the endoscopic escalation step therapy group was significantly lower than that in the open necrosectomy group (RR = 0.11, 95%CI: 0.02–0.58, P = 0.009).Conclusion: Compared with minimally invasive surgery and open necrosectomy, although endoscopic step-up approach cannot reduce the main complications or death and mortality of patients, it can significantly reduce the incidence of some serious complications, such as pancreatic-cutaneous fistula, enterocutaneous fistula, intra-abdominal bleeding, endocrine pancreatic insufficiency, and can significantly shorten the patient's hospital stay.

scholarly journals NECROTIZING PANCREATITIS: DESCRIPTION OF VIDEOSCOPIC ASSISTED RETROPERITONEAL DEBRIDEMENT (VARD) TECHNIQUE WITH COVERED METALLIC STENT

2018 ◽  
Vol 31 (2) ◽  
Author(s):  
Eduardo J. HOUGHTON ◽  
Alain A. García VÁZQUEZ ◽  
Manuel E. ZELEDÓN ◽  
Andrea ANDREACCHIO ◽  
Gabriel RUIZ ◽  
...  
Keyword(s):  
Guide Wire ◽  
Necrotizing Pancreatitis ◽  
Gastrointestinal Disorder ◽  
The United States ◽  
Metallic Stent ◽  
Partial Recovery ◽  
Invasive Treatment ◽  
Infected Necrosis ◽  
Treatment Techniques ◽  
Covered Metallic Stent

ABSTRACT Background : Acute pancreatitis is the third most common gastrointestinal disorder requiring hospitalization in the United States, with annual costs exceeding $2 billions. Severe necrotizing pancreatitis is a life-threatening complication developed in approximately 20% of patients. Its mortality rate range from 15% in patients with sterile necrosis to up 30% in case of infected one associated with multi-organ failure. Less invasive treatment techniques are increasingly being used. These techniques can be performed in a so-called step-up approach. Aim: To present the technique for videoscopic assisted retroperitoneal debridement (Vard technique) with covered metallic stent in necrotizing pancreatitis. Method: A guide wire was inserted through the previous catheter that was removed in the next step. Afterwards, the tract was dilated over the guide wire. Then, a partially covered metallic stent was deployed. A 30 degrees laparoscopic camera was inserted and the necrosis removed with forceps through the expanded stent under direct vision. Finally, the stent was removed and a new catheter left in place. Result : This technique was used in a 31-year-old man with acute pain in the upper abdomen and diagnosed as acute biliary pancreatitis with infected necrosis. He was treated with percutaneous drains at weeks 3, 6 and 8. Due to partial recovery, a left lateral VARD was performed (incomplete by fixed and adherent tissue) at 8th week. As the patient´s inflammatory response was reactivated, a second VARD attempt was performed in three weeks later. Afterwards, patient showed complete clinical and imaging resolution. Conclusions : Videoassisted retroperitoneal necrosectomy using partially covered metallic stent is a feasible technique for necrotizing pancreatitis.

(Un) conventional complicated pancreatitis

2021 ◽  
Vol 75 (1) ◽  
pp. 61-67
Author(s):  
Michal Rybár ◽  
Ivo Horný
Keyword(s):  
Acute Pancreatitis ◽  
Multidisciplinary Approach ◽  
Pancreatic Necrosis ◽  
Surgical Intervention ◽  
Secondary Infection ◽  
Abdominal Ultrasound ◽  
Stent Migration ◽  
Endoscopic Extraction ◽  
Threatening Condition ◽  
Life Threatening

Acute pancreatitis is sudden inflammatory disease of pancreas, which can vary from a mild form to severe life threatening condition. The management of pancreatitis usually consists of intensive care and multidisciplinary approach, often including surgical intervention or digestive endoscopy. In this article, we present a 68-year-old female with recidivous acute pancreatitis who underwent a series of endoscopic examinations and at the end also an unusual surgical intervention due to numerous complications. At first, it seemed that there was an idiopatic etiology because neither an anamnesis of alcohol consumption nor metabolic risks or CT signs of cholelithiasis were found. The condition was complicated by the development of acute necrotic collection, gastrointestinal bleeding and development of walled-off pancreatic necrosis (WOPN). Later, the biliary etiology was revealed after cholecystolithiasis was found on abdominal ultrasound. The WOPN was endoscopically drained because of the local compression syndrome. After the drainage, we noticed two cases of stent migration and the secondary infection of the WOPN. At the end, the migrated stents caused transient bowel obstruction and were stuck in the distal ileum. After three unsuccessful attempts to endoscopic extraction, the condition was solved by surgical intervention and double enterotomy was performed. The postoperative care was not easy anyway, being complicated by the dehiscence of the surgical wound with the need of opening the wound and use the VAC system to heal it up.

Abstract 17113: Secondary Infections Are Common in Patients Hospitalized for COVID-19 and Are Associated With Severe Outcomes

Circulation ◽  
2020 ◽  
Vol 142 (Suppl_3) ◽  
Author(s):  
Elizabeth R Anderson ◽  
Tariq Azam ◽  
Husam Shadid ◽  
Michael Pan ◽  
Hanna Berlin ◽  
...  
Keyword(s):  
Prospective Observational Study ◽  
Viral Infections ◽  
Clinical Laboratory ◽  
Secondary Infection ◽  
Kidney Injury ◽  
Outcome Data ◽  
Hospitalized Patients ◽  
Secondary Infections ◽  
Life Threatening ◽  
The Mean

Background: Secondary infections occur in 10-15% of critically ill sepsis patients. Anecdotal reports suggest secondary infections are common in coronavirus disease 2019 (COVID-19), however data are lacking. We examine the rate of secondary infections in hospitalized patients with COVID-19 and its impact on the cytokine surge and in-hospital outcomes. Methods: The Michigan Medicine Covid-19 Cohort (M2C2) is an ongoing prospective observational study in which detailed clinical, laboratory and outcome data were collected from chart review of consecutive adult patients hospitalized for COVID-19. Patients who were positive for SARS-CoV-2 infection but without respiratory symptoms were not included in this cohort. We define secondary infections as physician-diagnosed and treated bacterial or viral infections secondary to SARS-CoV-2. Results: Of 553 COVID-19 patients hospitalized at Michigan Medicine, 191 (34.5%) developed a secondary infection during hospitalization. The mean age of patients with a secondary infection was 60 years, 61.3% were male compared to 58.8 years, 53.5% male in patients with no secondary infection. Bacterial pneumonia, including ventilator-associated pneumonia, was the most prevalent secondary infection among hospitalized patients (78.5%). Other secondary infections included urosepsis (14.1%), bacteremia (16.8%), and 17.3% of patients developed other types of infections such as shingles and clostridium difficile. 25.8% of patients without secondary infections received antibiotics during their admission compared to 47.1% of patients with secondary infections. Multiple secondary infections (>1) occurred in 43 (8.2%) of patients. Patients with secondary infections were more likely to develop acute kidney injury (78.0% vs. 38.3%, p<0.0001), acute respiratory distress syndrome (78.0% vs. 22.3%, p<0.0001), and death (26.2% vs. 10.2%, p<0.0001) during their hospitalization compared to patients without secondary infections. Conclusions: Secondary infections are common in hospitalized patients with COVID-19 and are associated with life-threatening complications and high mortality. This study suggests that secondary infection prevention may be especially important in COVID-19 patients.

scholarly journals Preliminary report on the safety and utility of a novel automated mechanical endoscopic tissue resection tool for endoscopic necrosectomy: a case series

2020 ◽  
Vol 08 (03) ◽  
pp. E274-E280 ◽  
Author(s):  
S. E. van der Wiel ◽  
A. May ◽  
J. W. Poley ◽  
M. J. A. L. Grubben ◽  
J. Wetzka ◽  
...  
Keyword(s):  
Pancreatic Necrosis ◽  
De Novo ◽  
Necrotizing Pancreatitis ◽  
Case Series ◽  
Complete Removal ◽  
Endoscopic Drainage ◽  
Necrotic Tissue ◽  
Technical Feasibility ◽  
Operator Experience ◽  
Endoscopic Necrosectomy

Abstract Background and study aims Endoscopic drainage of walled-off necrosis and subsequent endoscopic necrosectomy has been shown to be an effective step-up management strategy in patients with acute necrotizing pancreatitis. One of the limitations of this endoscopic approach however, is the lack of dedicated and effective instruments to remove necrotic tissue. We aimed to evaluate the technical feasibility, safety, and clinical outcome of the EndoRotor, a novel automated mechanical endoscopic tissue resection tool, in patients with necrotizing pancreatitis. Methods Patients with infected necrotizing pancreatitis in need of endoscopic necrosectomy after initial cystogastroscopy, were treated using the EndoRotor. Procedures were performed under conscious or propofol sedation by six experienced endoscopists. Technical feasibility, safety, and clinical outcomes were evaluated and scored. Operator experience was assessed by a short questionnaire. Results Twelve patients with a median age of 60.6 years, underwent a total of 27 procedures for removal of infected pancreatic necrosis using the EndoRotor. Of these, nine patients were treated de novo. Three patients had already undergone unsuccessful endoscopic necrosectomy procedures using conventional tools. The mean size of the walled-off cavities was 117.5 ± 51.9 mm. An average of two procedures (range 1 – 7) per patient was required to achieve complete removal of necrotic tissue with the EndoRotor. No procedure-related adverse events occurred. Endoscopists deemed the device to be easy to use and effective for safe and controlled removal of the necrosis. Conclusions Initial experience with the EndoRotor suggests that this device can safely, rapidly, and effectively remove necrotic tissue in patients with (infected) walled-off pancreatic necrosis.

The burden of acute pancreatitis and early experience of step-up approach for acute necrotizing pancreatitis at Military Hospital

2019 ◽  
Vol 22 (2) ◽  
pp. 11-17
Author(s):  
Sushil Bahadur Rawal ◽  
Uttam Laudari ◽  
Basanta Khatiwada ◽  
Anup Thapa ◽  
Manoj Kumar Jha ◽  
...  
Keyword(s):  
Acute Pancreatitis ◽  
Severe Acute Pancreatitis ◽  
Necrotizing Pancreatitis ◽  
Early Experience ◽  
Acute Necrotizing Pancreatitis ◽  
Military Hospital ◽  
Army Hospital ◽  
Acute Necrotizing ◽  
Hospital Resources ◽  
Open Necrosectomy

Introduction: Twenty-five percent of acute pancreatitis develops severe acute pancreatitis (SAP). SAP patients have prolonged hospitalization and require a substantial amount of manpower and hospital resources. The aim of this study was to give an insight into the burden of acute pancreatitis at a tertiary level military hospital and to share the experience of managing pancreatic necrosis with the application of the step-up approach. Methods: A prospective descriptive study of consecutive patients was conducted at Shree Birendra Army Hospital from 2017 June to 2017 November. Patients with a diagnosis of acute pancreatitis admitted were stratified according to severity as per Revised Atlanta classification 2012. Patients with acute necrotizing pancreatitis were enrolled for the step-up approach. Patient’s demography, baseline investigations, radiology, prognostic scoring scales and type of intervention were analyzed. The burden of severe acute pancreatitis at our center and the early experience of the step-up approach at our centre within the study period were studied. Results: Out of 35 five patients with acute pancreatitis, 7 (20%) subsequently developed severe acute pancreatitis. Among them, five patients subsequently developed necrotizing pancreatitis who were managed according to the step-up approach. Out of them, three patients subsequently underwent operative intervention in the form of minimally invasive procedures like percutaneous drain placement, laparoscopic necrosectomy, video-assisted retroperitoneal debridement, and open necrosectomy. Conclusion: Acute pancreatitis is a common presentation at our centre. The step-up approach in the management of acute necrotizing pancreatitis is a safe and feasible approach.

scholarly journals Surgery in the Treatment of Acute Pancreatitis — Open Pancreatic Necrosectomy

2005 ◽  
Vol 94 (2) ◽  
pp. 130-134 ◽  
Author(s):  
J. Werner ◽  
W. Hartwig ◽  
T. Hackert ◽  
M. W. Büchler
Keyword(s):  
Acute Pancreatitis ◽  
Late Phase ◽  
Necrotizing Pancreatitis ◽  
Surgical Techniques ◽  
Interventional Therapy ◽  
Minimal Invasive ◽  
Infected Necrosis ◽  
Early Management ◽  
Pancreatic Infection ◽  
The Past

Management of acute necrotizing pancreatitis has changed significantly over the past years. Early management is non-surgically and solely supportive. Today, more patients survive the early phase of severe pancreatitis due to improvements of intensive-care-medicine. Pancreatic infection is the major risk factor with regard to morbidity and mortality in the late phase of severe acute pancreatitis. Whereas early surgery and surgery for sterile necrosis can only be recommended in selected cases, pancreatic infection is a well accepted indication for surgical treatment. Surgery should ideally be postponed until four weeks after the onset of symptoms as necrosis is well demarcated at that time. Four surgical techniques can be performed with comparable results regarding mortality: necrosectomy combined with (1) open packing, (2) planned staged relaparotomies with repeated lavage, (3) closed continuous lavage of the retroperitoneum, and (4) closed packing. However, closed continuous lavage of the retroperitoneum, and closed packing seem to be associated with a lower morbidity compared to the other two approaches. Advances in radiologic imaging, new developments of interventional radiology and other minimal access interventions have revolutionized the management of many surgical conditions over the past decades. However, minimal invasive surgery and interventional therapy for infected necrosis should be limited to specific indications in patients who are critically ill and otherwise unfit for conventional surgery. Open surgical debridement is the “gold standard” for treatment of infected pancreatic and peripancreatic necrosis.

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