No Debridement Is Necessary for Symptomatic or Infected Acute Necrotizing Pancreatitis: Delayed, Mini-Retroperitoneal Drainage for Acute Necrotizing Pancreatitis Without Debridement and Irrigation

We sought to determine if necrosectomy can be omitted for complicated acute necrotizing pancreatitis (ANP). Since 1996, we prospectively performed retroperitoneal drainage by introducing a sump drain to the pancreatic head area via a small left flank incision without debridement and irrigation on 19 consecutive complicated ANP patients. We purposely delayed surgery until liquefaction of retroperitoneal tissue reached the left flank. Our patients had a mean Ranson’s and APACHE II score of 5.9 (range, 4–8) and 20.1(range, 4–45), respectively. Sixteen available CT showed retroperitoneal liquefaction after 21.3 days (range, 14–26). Operations were delayed for 4.7 weeks (range, 1.3–9.0). No patient succumbed during this period. The indications were infected necrosis in 16 and severe abdominal pain/food intolerance in 3 patients. Average skin incision was 4.0 cm (range, 3–9). Fungi or bacteria were cultured in 15 patients (80.0%). The recovery courses were surprisingly uneventful. Oral intake began within 2.4 days (range, 1–5) and mean hospital stay (16 survivals) was 23.2 days (range, 4–120) after operation. Drains were completely removed 120.6 days (range, 60–250) later from these outpatients. One gastric perforation and one minor duodenal leak were the only procedure-related complications (10.5%). Three patients died (15.8%), although one had a healed ANP. In conclusion, this delay-until-liquefaction strategy without necrosectomy is an easy and effective treatment method.     

An Endoscopic Transluminal Approach,Compared With Minimally Invasive Surgery,Reduces Complications and Costs for Patients With Necrotizing Pancreatitis

1. Download high-res image (100KB)
2. Download full-size image

     

Risk Factors and Outcome for Massive Intra-Abdominal Bleeding Among Patients With Infected Necrotizing Pancreatitis

The incidence of acute bleeding is reported to be 13.5% in patients with acute necrotizing pancreatitis. However, of all the bleeding events, intra-abdominal bleeding was less studied in the literature and its risk factors have not been well defined yet. The purpose of the present study was to investigate the risk factors for massive intra-abdominal bleeding among the patients with infected necrotizing pancreatitis and assessed the outcome of these patients.Both univariate and multivariate logistic regression models were applied for evaluating risk factors for intra-abdominal bleeding using 33 indices, including age, sex, etiology of acute pancreatitis (AP), APACHE II score, etc. Outcome assessments such as mortality, hospital and intensive care unit (ICU) durations, and cost were also compared between patients with or without intra-abdominal bleeding.Acute kidney injury (AKI) (odds ratio [OR]: 7.54, 95% confidence interval [CI]: 2.53–22.52, P < 0.001) and number of operation (OR: 8.84, 95% CI: 2.01–38.86, P = 0.004) were 2 predictors for massive intra-abdominal bleeding in the patients with infected necrotizing pancreatitis. In addition, AP patients with intra-abdominal bleeding also showed significantly higher mortality rate, prolonged hospital and ICU durations, more complications and invasive treatments, as well as increased cost.Our study revealed that AKI and multiple operations were 2 critical factors increasing the risk of intra-abdominal bleeding among patients with infected necrotizing pancreatitis. Additionally, massive intra-abdominal bleeding was also associated with poor prognosis.     

Endoscopic Approach to Pancreatic Duct Calculi and Obstructive Pancreatitis

Twelve patients with chronic pancreatitis and obstructing pancreatic calculi underwent endoscopic retrograde cholangiopancreatography and attempted pancreatic stone extraction. This procedure, utilizing conventional stone baskets and balloons, as well as extracorporeal or laser lithotripsy in a subset, was ultimately successful in 11 of 12 patients. Nine of the 10 patients with relapsing pancreatitis have not had a symptomatic flare at a mean follow-up of 17 months. In contrast, neither of the patients who presented with chronic pain had convincing symptomatic improvement. The authors conclude that endoscopic removal of pancreatic duct calculi deserves further investigation in the treatment of relapsing attacks of chronic pancreatitis.     

EUS-Guided Endoscopic Transgastric Necrosectomy in Patients with Infected Necrosis in Acute Pancreatitis

Background: Infected pancreatic and peripancreatic necrosis in acute pancreatitis is potentially lethal, with mortality rates up to 35%. Therefore, there is growing interest in minimally invasive treatment options, such as (EUS-guided) endoscopic transgastric necrosectomy. Methods: Retrospective cohort study on EUS-guided endoscopie transgastric necrosectomy in patients with infected necrosis in acute pancreatitis. Results: 8 patients (age 38–75, mean 50 years) with documented infected peripancreatic or pancreatic necrosis were included. Median time to first intervention was 33 days (range 17–62) after onset of symptoms. At the time of first intervention 2 patients had organ failure. All patients were managed on the patient ward. Initial endoscopie drainage was successful in all patients, a median of 4 (range 2–6) subsequent endoscopie necrosectomies were needed to remove all necrotic tissue. Two patients needed additional surgical intervention because of pneumoperitoneum (n = 1) and insufficient endoscopie drainage (n = 1). Six patients recovered, with 1 mild relapse during follow-up (median 12, range 8–60 months). One patient died. Conclusion: EUS-guided endoscopie transgastric necrosectomy of infected necrosis in acute pancreatitis appears to be a feasible and relatively safe treatment option in patients who are not critically ill. Further randomized comparison with the current ‘gold standard’ is warranted to determine the place of this treatment modality.     

急性坏死性胰腺炎治疗的临床分析

目的:对急性坏死性胰腺炎(ANP)的内、外科治疗进行临床分析。方法:对58例ANP进行了分析,其中非手术组15例,手术组43例。在治疗的以下几个方面进行了对比:在非手术组中是否使用胰液/胰酶抑制剂;在手术组中72小时内和72小时后手术;在抗生素治疗上,二联用药(头孢唑啉 甲硝唑)与多联用药。结果:非手术组中用过胰液分泌抑制剂或胰酶抑制剂者死亡率为12、5％,显著低于未用过胰液分泌抑制剂或胰酶抑制剂者(71.4％,P<0.05);手术组中72小时以内手术者死亡率为36.7％,显著低于72小时以上者(84.6％,P<0.01);抗生素治疗方面,二联用药(头孢唑啉 甲硝唑)与广谱、多联用药的死亡率无显著差异(P>0.05)。结论:由于胰液/胰酶抑制剂能降低轻症ANP的死亡率,轻症病人应积极采用胰液/胰酶抑制剂为主的综合治疗,重症病人应早期手术;而在抗生素治疗上,除非有严重感染,一般仅需二联用药,无需多种广谱抗生素联用。     

Outcome of Surgical and Endoscopic Management of Biliary Pancreatitis

The aims of the study were to compare theoutcomes of biliary pancreatitis after endoscopic andsurgical treatment and define the demographic andclinical characteristics that affect the outcomes. Allinpatients with biliary pancreatitis followed at hospitalsof the Department of Veterans Affairs during 1988-1994were included in a case-control study. Of 2075 patientswith biliary pancreatitis, 650 were first treated by biliary endoscopy and 1425 bycholecystectomy. Compared with cholecystectomy, biliaryendoscopy was associated with older age, admission tononsurgical service, more complicated pancreatitis, andcholedocholithiasis. Seventy-one patients died. Death occurred moreoften in older patients with multiple comorbidconditions and complications of biliary pancreatitis.Overall length of hospital stay was positivelycorrelated with complications, choledocholithiasis,comorbidity, and deferment of endoscopic or surgicalprocedure. After adjusting for other confoundingvariables, both types of treatment resulted in similardeath rates and lengths of hospitalization. Inconclusion, compared with cholecystectomy, biliaryendoscopy is chosen preferentially in older patientswith choledocholithiasis or a complication of theirpancreatitis. Despite such selection bias, biliary endoscopyresults in similar outcomes as surgery. Earlyintervention by either strategy reduces the length ofhospital stay.