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Rana R, Mahapatra SJ, Garg PK. Endoscopic interventions for managing pancreatic fluid collections associated with acute pancreatitis: A state-of-the-art review (with videos). Indian J Gastroenterol 2025:10.1007/s12664-025-01755-x. [PMID: 40293669 DOI: 10.1007/s12664-025-01755-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/27/2024] [Accepted: 02/12/2025] [Indexed: 04/30/2025]
Abstract
Acute pancreatitis is an acute inflammatory disease, which may be associated with pancreatic and peri-pancreatic necrosis and development of (peri)pancreatic fluid collections (PFCs). Interventions in acute pancreatitis have evolved over the years with a paradigm shift from open surgical drainage and necrosectomy to minimally invasive approaches. Depending on the presence of necrosis, the PFCs may be acute necrotic collections or acute pancreatic fluid collections, which evolve over a period of three to four weeks to walled-off necrosis and pseudocysts, respectively. Patients with symptomatic and infected PFCs require drainage. In general, drainage should be delayed beyond three to four weeks when the collection wall has matured and the necrotic debris is liquefied. However, some patients may merit early drainage (within the first three to four weeks), if they have suspected infected pancreatic necrosis and worsening organ dysfunction despite antibiotics and supporting therapy. Endoscopic transmural drainage and necrosectomy have now emerged as the most favored treatment modality in suitable pancreatic collections located predominantly in the lesser sac. Being minimally invasive, per-oral endoscopic direct necrosectomy is as effective as surgical necrosectomy in patients with infected necrotic collections but with fewer adverse events. Percutaneous endoscopic necrosectomy is an important addition to our armamentarium for laterally placed collections as an effective alternative to surgical video-assisted retroperitoneal debridement. The current review provides an overview of the evolution, indications, approaches, techniques and outcomes of endoscopic interventions in the management of pancreatic fluid collections associated with acute pancreatitis. Future direction for better outcomes has been highlighted.
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Affiliation(s)
- Randeep Rana
- Department of Gastroenterology and Human Nutrition Unit, All India Institute of Medical Sciences, New Delhi, 110 029, India
- Department of Gastroenterology, Govind Ballabh Pant Institute of Postgraduate Medical Education and Research, New Delhi, 110 002, India
| | - Soumya Jagannath Mahapatra
- Department of Gastroenterology and Human Nutrition Unit, All India Institute of Medical Sciences, New Delhi, 110 029, India
| | - Pramod Kumar Garg
- Department of Gastroenterology and Human Nutrition Unit, All India Institute of Medical Sciences, New Delhi, 110 029, India.
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Paramythiotis D, Karlafti E, Tsavdaris D, Giakoustidis A, Panidis S, Ioannidis A, Prassopoulos P, Michalopoulos A. When to Intervene in Acute Necrotizing Pancreatitis: A Narrative Review of the Optimal Timing for Intervention Strategies. MEDICINA (KAUNAS, LITHUANIA) 2024; 60:1592. [PMID: 39459378 PMCID: PMC11509130 DOI: 10.3390/medicina60101592] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 09/04/2024] [Revised: 09/24/2024] [Accepted: 09/25/2024] [Indexed: 10/28/2024]
Abstract
Introduction: Acute necrotizing pancreatitis (ANP) is the acute inflammation of pancreatic parenchyma, most commonly due to alcohol abuse or cholelithiasis. The treatment can be either conservative or invasive, including a variety of techniques; however, it has not yet been established if the intervention should be early or if it should be delayed. The aim of this review is to investigate the optimal time for intervention in ANP. Methods: A literature search was conducted in PubMed and Scopus from inception until September 2024 for studies reporting the comparison between early and late intervention. Results: Early intervention, within 4 weeks of symptom onset, often involves drainage via percutaneous, endoscopic, or combined methods. Delayed intervention occurs after 4 weeks of symptom onset. This can be conducted either surgically or via minimally invasive means. The results of this review reveal that the time of intervention for ANP plays an important role in the prognosis and the course of the disease. In particular, early intervention is associated with higher mortality, which is also the primary clinical outcome. Delayed intervention is also superior regarding secondary clinical outcomes, specifically the complications associated with the intervention. Thus, it is accompanied by fewer episodes of new-onset organ failure, bleeding, gastrointestinal fistula, pancreatic fistula, wound infection, endocrine pancreatic insufficiency, and other complications. Finally, delayed intervention results in shorter stays, both in hospitals and the ICU. Conclusions: Delayed intervention is clearly more effective than early intervention and should be preferred. However, early intervention appears to be both safe and effective, and it is feasible.
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Affiliation(s)
- Daniel Paramythiotis
- First Propaedeutic Surgery Department, University General Hospital of Thessaloniki AHEPA, Aristotle University of Thessaloniki, 54636 Thessaloniki, Greece; (D.P.); (D.T.); (S.P.); (A.I.); (A.M.)
| | - Eleni Karlafti
- Emergency Department, University General Hospital of Thessaloniki AHEPA, Aristotle University of Thessaloniki, 54636 Thessaloniki, Greece
- First Propaedeutic Department of Internal Medicine, University General Hospital of Thessaloniki AHEPA, Aristotle University of Thessaloniki, 54636 Thessaloniki, Greece
| | - Dimitrios Tsavdaris
- First Propaedeutic Surgery Department, University General Hospital of Thessaloniki AHEPA, Aristotle University of Thessaloniki, 54636 Thessaloniki, Greece; (D.P.); (D.T.); (S.P.); (A.I.); (A.M.)
| | - Alexandros Giakoustidis
- First Surgery Department, University General Hospital of Thessaloniki Papageorgiou, Aristotle University of Thessaloniki, 54636 Thessaloniki, Greece;
| | - Stavros Panidis
- First Propaedeutic Surgery Department, University General Hospital of Thessaloniki AHEPA, Aristotle University of Thessaloniki, 54636 Thessaloniki, Greece; (D.P.); (D.T.); (S.P.); (A.I.); (A.M.)
| | - Aristeidis Ioannidis
- First Propaedeutic Surgery Department, University General Hospital of Thessaloniki AHEPA, Aristotle University of Thessaloniki, 54636 Thessaloniki, Greece; (D.P.); (D.T.); (S.P.); (A.I.); (A.M.)
| | - Panos Prassopoulos
- Department of Radiology, University General Hospital of Thessaloniki AHEPA, Aristotle University of Thessaloniki, 54636 Thessaloniki, Greece;
| | - Antonios Michalopoulos
- First Propaedeutic Surgery Department, University General Hospital of Thessaloniki AHEPA, Aristotle University of Thessaloniki, 54636 Thessaloniki, Greece; (D.P.); (D.T.); (S.P.); (A.I.); (A.M.)
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Paramythiotis D, Karlafti E, Tsavdaris D, Giakoustidis A, Panidis S, Ioannidis A, Prassopoulos P, Michalopoulos A. When to Intervene in Acute Necrotizing Pancreatitis: A Narrative Review of the Optimal Timing for Intervention Strategies. Medicina (B Aires) 2024; 60:1592. [DOI: https:/doi.org/10.3390/medicina60101592] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/16/2025] Open
Abstract
Introduction: Acute necrotizing pancreatitis (ANP) is the acute inflammation of pancreatic parenchyma, most commonly due to alcohol abuse or cholelithiasis. The treatment can be either conservative or invasive, including a variety of techniques; however, it has not yet been established if the intervention should be early or if it should be delayed. The aim of this review is to investigate the optimal time for intervention in ANP. Methods: A literature search was conducted in PubMed and Scopus from inception until September 2024 for studies reporting the comparison between early and late intervention. Results: Early intervention, within 4 weeks of symptom onset, often involves drainage via percutaneous, endoscopic, or combined methods. Delayed intervention occurs after 4 weeks of symptom onset. This can be conducted either surgically or via minimally invasive means. The results of this review reveal that the time of intervention for ANP plays an important role in the prognosis and the course of the disease. In particular, early intervention is associated with higher mortality, which is also the primary clinical outcome. Delayed intervention is also superior regarding secondary clinical outcomes, specifically the complications associated with the intervention. Thus, it is accompanied by fewer episodes of new-onset organ failure, bleeding, gastrointestinal fistula, pancreatic fistula, wound infection, endocrine pancreatic insufficiency, and other complications. Finally, delayed intervention results in shorter stays, both in hospitals and the ICU. Conclusions: Delayed intervention is clearly more effective than early intervention and should be preferred. However, early intervention appears to be both safe and effective, and it is feasible.
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Affiliation(s)
- Daniel Paramythiotis
- First Propaedeutic Surgery Department, University General Hospital of Thessaloniki AHEPA, Aristotle University of Thessaloniki, 54636 Thessaloniki, Greece
| | - Eleni Karlafti
- Emergency Department, University General Hospital of Thessaloniki AHEPA, Aristotle University of Thessaloniki, 54636 Thessaloniki, Greece
- First Propaedeutic Department of Internal Medicine, University General Hospital of Thessaloniki AHEPA, Aristotle University of Thessaloniki, 54636 Thessaloniki, Greece
| | - Dimitrios Tsavdaris
- First Propaedeutic Surgery Department, University General Hospital of Thessaloniki AHEPA, Aristotle University of Thessaloniki, 54636 Thessaloniki, Greece
| | - Alexandros Giakoustidis
- First Surgery Department, University General Hospital of Thessaloniki Papageorgiou, Aristotle University of Thessaloniki, 54636 Thessaloniki, Greece
| | - Stavros Panidis
- First Propaedeutic Surgery Department, University General Hospital of Thessaloniki AHEPA, Aristotle University of Thessaloniki, 54636 Thessaloniki, Greece
| | - Aristeidis Ioannidis
- First Propaedeutic Surgery Department, University General Hospital of Thessaloniki AHEPA, Aristotle University of Thessaloniki, 54636 Thessaloniki, Greece
| | - Panos Prassopoulos
- Department of Radiology, University General Hospital of Thessaloniki AHEPA, Aristotle University of Thessaloniki, 54636 Thessaloniki, Greece
| | - Antonios Michalopoulos
- First Propaedeutic Surgery Department, University General Hospital of Thessaloniki AHEPA, Aristotle University of Thessaloniki, 54636 Thessaloniki, Greece
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Ali H, Inayat F, Jahagirdar V, Jaber F, Afzal A, Patel P, Tahir H, Anwar MS, Rehman AU, Sarfraz M, Chaudhry A, Nawaz G, Dahiya DS, Sohail AH, Aziz M. Early versus delayed necrosectomy in pancreatic necrosis: A population-based cohort study on readmission, healthcare utilization, and in-hospital mortality. World J Methodol 2024; 14:91810. [PMID: 39310231 PMCID: PMC11230070 DOI: 10.5662/wjm.v14.i3.91810] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/14/2024] [Revised: 05/13/2024] [Accepted: 05/27/2024] [Indexed: 06/25/2024] Open
Abstract
BACKGROUND Acute necrotizing pancreatitis is a severe and life-threatening condition. It poses a considerable challenge for clinicians due to its complex nature and the high risk of complications. Several minimally invasive and open necrosectomy procedures have been developed. Despite advancements in treatment modalities, the optimal timing to perform necrosectomy lacks consensus. AIM To evaluate the impact of necrosectomy timing on patients with pancreatic necrosis in the United States. METHODS A national retrospective cohort study was conducted using the 2016-2019 Nationwide Readmissions Database. Patients with non-elective admissions for pancreatic necrosis were identified. The participants were divided into two groups based on the necrosectomy timing: The early group received intervention within 48 hours, whereas the delayed group underwent the procedure after 48 hours. The various intervention techniques included endoscopic, percutaneous, or surgical necrosectomy. The major outcomes of interest were 30-day readmission rates, healthcare utilization, and inpatient mortality. RESULTS A total of 1309 patients with pancreatic necrosis were included. After propensity score matching, 349 cases treated with early necrosectomy were matched to 375 controls who received delayed intervention. The early cohort had a 30-day readmission rate of 8.6% compared to 4.8% in the delayed cohort (P = 0.040). Early necrosectomy had lower rates of mechanical ventilation (2.9% vs 10.9%, P < 0.001), septic shock (8% vs 19.5%, P < 0.001), and in-hospital mortality (1.1% vs 4.3%, P = 0.01). Patients in the early intervention group incurred lower healthcare costs, with median total charges of $52202 compared to $147418 in the delayed group. Participants in the early cohort also had a relatively shorter median length of stay (6 vs 16 days, P < 0.001). The timing of necrosectomy did not significantly influence the risk of 30-day readmission, with a hazard ratio of 0.56 (95% confidence interval: 0.31-1.02, P = 0.06). CONCLUSION Our findings show that early necrosectomy is associated with better clinical outcomes and lower healthcare costs. Delayed intervention does not significantly alter the risk of 30-day readmission.
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Affiliation(s)
- Hassam Ali
- Division of Gastroenterology and Hepatology, East Carolina University Brody School of Medicine, Greenville, NC 27834, United States
| | - Faisal Inayat
- Department of Internal Medicine, Allama Iqbal Medical College, Lahore, Punjab 54550, Pakistan
| | - Vinay Jahagirdar
- Department of Internal Medicine, University of Missouri-Kansas City, Kansas City, MO 64108, United States
| | - Fouad Jaber
- Department of Internal Medicine, University of Missouri-Kansas City, Kansas City, MO 64108, United States
| | - Arslan Afzal
- Division of Gastroenterology and Hepatology, East Carolina University Brody School of Medicine, Greenville, NC 27834, United States
| | - Pratik Patel
- Division of Gastroenterology, Mather Hospital and Zucker School of Medicine at Hofstra University, Port Jefferson, NY 11777, United States
| | - Hamza Tahir
- Department of Internal Medicine, Jefferson Einstein Hospital, Philadelphia, PA 19141, United States
| | - Muhammad Sajeel Anwar
- Department of Internal Medicine, UHS Wilson Medical Center, Johnson City, NY 13790, United States
| | - Attiq Ur Rehman
- Division of Gastroenterology and Hepatology, Geisinger Wyoming Valley Medical Center, Wilkes-Barre, PA 18711, United States
| | - Muhammad Sarfraz
- Division of Gastroenterology and Hepatology, Geisinger Wyoming Valley Medical Center, Wilkes-Barre, PA 18711, United States
| | - Ahtshamullah Chaudhry
- Department of Internal Medicine, St. Dominic's Hospital, Jackson, MS 39216, United States
| | - Gul Nawaz
- Department of Internal Medicine, Allama Iqbal Medical College, Lahore, Punjab 54550, Pakistan
| | - Dushyant Singh Dahiya
- Division of Gastroenterology, Hepatology, and Motility, The University of Kansas School of Medicine, Kansas City, KS 66160, United States
| | - Amir H Sohail
- Department of Surgery, University of New Mexico School of Medicine, Albuquerque, NM 87106, United States
| | - Muhammad Aziz
- Division of Gastroenterology and Hepatology, The University of Toledo, Toledo, OH 43606, United States
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Niu CG, Zhang J, Zhu KW, Liu HL, Ashraf MF, Okolo PI. Comparison of early and late intervention for necrotizing pancreatitis: A systematic review and meta-analysis. J Dig Dis 2023; 24:321-331. [PMID: 37409681 DOI: 10.1111/1751-2980.13201] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/24/2023] [Revised: 06/20/2023] [Accepted: 07/03/2023] [Indexed: 07/07/2023]
Abstract
OBJECTIVES Postponed open necrosectomy or minimally invasive intervention has become the treatment option for necrotizing pancreatitis. Nevertheless, several studies point to the safety and efficacy of early intervention for necrotizing pancreatitis. Therefore, we conducted a systematic review and meta-analysis to compare clinical outcomes of acute necrotizing pancreatitis between early and late intervention. METHODS Literature search was performed in multiple databases for articles that compared the safety and clinical outcomes of early (<4 weeks from the onset of pancreatitis) versus late intervention (≥4 weeks from the onset of pancreatitis) for necrotizing pancreatitis published up to August 31, 2022. The meta-analysis was performed to determine pooled odds ratio (OR) of mortality rate and procedure-related complications. RESULTS Fourteen studies were included in the final analysis. For open necrosectomy intervention, the overall pooled OR of mortality rate with the late intervention compared with early intervention was 7.09 (95% confidence interval [CI] 2.33-21.60; I2 = 54%; P = 0.0006). For minimally invasive intervention, the overall pooled OR of mortality rate with the late intervention compared with early intervention was 1.56 (95% CI 1.11-2.20; I2 = 0%; P = 0.01). The overall pooled OR of pancreatic fistula with the late minimally invasive intervention compared with early intervention was 2.49 (95% CI 1.75-3.52; I2 = 0%; P < 0.00001). CONCLUSION These results showed the benefit of late interventions in patients with necrotizing pancreatitis in both minimally invasive procedures and open necrosectomy. Late intervention is preferred in the management of necrotizing pancreatitis.
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Affiliation(s)
- Chen Gu Niu
- Internal Medicine Residency Program, Rochester General Hospital, Rochester, New York, USA
| | - Jing Zhang
- Harbin Medical University, Harbin, Heilongjiang Province, China
| | - Kai Wen Zhu
- Internal Medicine Residency Program, Rochester General Hospital, Rochester, New York, USA
| | - Hong Li Liu
- Internal Medicine Residency Program, Rochester General Hospital, Rochester, New York, USA
| | | | - Patrick I Okolo
- Division of Gastroenterology, Rochester General Hospital, Rochester, New York, USA
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Nakai Y, Shiomi H, Hamada T, Ota S, Takenaka M, Iwashita T, Sato T, Saito T, Masuda A, Matsubara S, Iwata K, Mukai T, Isayama H, Yasuda I. Early versus delayed interventions for necrotizing pancreatitis: A systematic review and meta-analysis. DEN OPEN 2022; 3:e171. [PMID: 36247314 PMCID: PMC9549879 DOI: 10.1002/deo2.171] [Citation(s) in RCA: 23] [Impact Index Per Article: 7.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 08/08/2022] [Revised: 09/07/2022] [Accepted: 09/18/2022] [Indexed: 11/05/2022]
Abstract
Objectives Interventions for necrotizing pancreatitis are generally postponed until 4 weeks after the onset of acute pancreatitis, but there remains controversy about whether we should always wait >4 weeks or can intervene early when necessary. This meta‐analysis was conducted to evaluate treatment outcomes of necrotizing pancreatitis according to the cut‐off defined in the revised Atlanta classification (≤4 vs. >4 weeks). Methods Using PubMed, Web of Science, and the Cochrane database, we identified clinical studies published until March 2022 with data comparing outcomes of early and delayed interventions of necrotizing pancreatitis. We pooled data on adverse events, mortality, technical and clinical success rates, and needs for necrosectomy and open surgery, using the random‐effects model. Results We identified 11 retrospective studies, including 775 patients with early interventions and 725 patients with delayed interventions. Patients with early interventions tended to be complicated by organ failure. The rate of adverse events was comparable (OR 1.41, 95% CI 0.66–3.01; p = 0.38) but the rate of mortality was significantly higher (OR 1.70, 95% CI 1.21–2.40; p < 0.01) in early interventions. Technical success rates were similarly high but clinical success rates tended to be low (OR 0.39, 95% CI 0.15–1.00; p = 0.05) in early interventions, though not statistically significant. Pooled ORs for necrosectomy and open surgery were 2.14 and 1.23, respectively. Conclusions Early interventions for necrotizing pancreatitis were associated with higher mortality rates and did not reduce adverse events or improve clinical success. However, our results should be confirmed in prospective studies.
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Affiliation(s)
- Yousuke Nakai
- Department of GastroenterologyGraduate School of MedicineThe University of TokyoTokyoJapan,Department of Endoscopy and Endoscopic SurgeryThe University of Tokyo HospitalTokyoJapan
| | - Hideyuki Shiomi
- Division of Gastroenterology and Hepatobiliary and Pancreatic DiseasesDepartment of Internal MedicineHyogo Medical UniversityHyogoJapan
| | - Tsuyoshi Hamada
- Department of GastroenterologyGraduate School of MedicineThe University of TokyoTokyoJapan,Department of Hepato‐Biliary‐Pancreatic MedicineThe Cancer Institute Hospital of Japanese Foundation for Cancer ResearchTokyoJapan
| | - Shogo Ota
- Division of Gastroenterology and Hepatobiliary and Pancreatic DiseasesDepartment of Internal MedicineHyogo Medical UniversityHyogoJapan
| | - Mamoru Takenaka
- Department of Gastroenterology and HepatologyKindai University Faculty of MedicineOsakaJapan
| | - Takuji Iwashita
- First Department of Internal MedicineGifu University HospitalGifuJapan
| | - Tatsuya Sato
- Department of GastroenterologyGraduate School of MedicineThe University of TokyoTokyoJapan
| | - Tomotaka Saito
- Department of GastroenterologyGraduate School of MedicineThe University of TokyoTokyoJapan
| | - Atsuhiro Masuda
- Division of GastroenterologyDepartment of Internal MedicineKobe University Graduate School of MedicineHyogoJapan
| | - Saburo Matsubara
- Department of Gastroenterology and Hepatology, Saitama Medical CenterSaitama Medical UniversitySaitamaJapan
| | - Keisuke Iwata
- Department of GastroenterologyGifu Municipal HospitalGifuJapan
| | - Tsuyoshi Mukai
- Department of Gastroenterological EndoscopyKanazawa Medical UniversityIshikawaJapan
| | - Hiroyuki Isayama
- Department of GastroenterologyGraduate School of MedicineJuntendo UniversityTokyoJapan
| | - Ichiro Yasuda
- Third Department of Internal MedicineUniversity of ToyamaToyamaJapan
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Tang P, Zha Q, Zhou L, Yang Q, He M, Zhu S, Liu Y. Effectiveness of digestive endoscopy and surgery in the treatment of necrotizing pancreatitis: a meta-analysis and systematic review. Gland Surg 2021; 10:2754-2765. [PMID: 34733725 DOI: 10.21037/gs-21-516] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/21/2021] [Accepted: 09/09/2021] [Indexed: 12/12/2022]
Abstract
Background Digestive endoscopy and surgery are the primary invasive methods for the clinical treatment of necrotizing pancreatitis. However, there are relatively few studies evaluating the effectiveness and safety of these two methods. Methods Randomized controlled trials (RCTs) on endoscopic and surgical treatment of necrotizing pancreatitis published from January 2000 to December 2020 were searched in the PubMed, Medline, Embase, China Biology Medicine Disc (CBM), and WanFang databases. The Cochrane System Review Manual was adopted to evaluate the quality of the included literature, and Review Manager 5.3 was used for data analysis. Results Ten articles were included in this meta-analysis, involving a total of 401 patients, including 188 in the endoscopy group and 213 in the surgery group. Meta-analysis results revealed that the clinical remission rate (CRR) [odds ratio (OR) =1.30, 95% confidence interval (CI): 0.58-2.92, P=0.52], new organ failure rate (OFR) (OR =0.53, 95% CI: 0.26-1.09, P=0.08), abdominal bleeding rate (ABR) (OR =0.62, 95% CI: 0.33-1.15, P=0.13), and intensive care unit (ICU) stay time (IST) [mean deviation (MD) =-7.33, 95% CI: -16.76 to 2.11, P=0.13] were not significantly different between the endoscopy and surgery groups. In the endoscopy group, the mortality rate (OR =0.56, 95% CI: 0.31-1.02, P=0.05), intestinal fistula rate (IFR) or gastrointestinal perforation rate (GPR) (OR =0.50, 95% CI: 0.26-0.99, P=0.05), and pancreatic fistula rate (PFR) (OR =0.09, 95% CI: 0.04-0.23, P<0.00001) were markedly lower compared to the surgery group. Discussion There was no obvious difference in the clinical efficacy of endoscopic and surgical treatment of necrotizing pancreatitis. However, endoscopy can greatly reduce the incidence of postoperative death and major complications in patients.
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Affiliation(s)
- Peng Tang
- Department of Gastroenterology, Eastern Hospital, Sichuan Academy of Medical Sciences & Sichuan Provincial People's Hospital, Chengdu, China
| | - Qinqing Zha
- Digestive Endoscopy Center, Sichuan Academy of Medical Sciences & Sichuan Provincial People's Hospital, Chengdu, China
| | - Lihua Zhou
- Digestive Endoscopy Center, Sichuan Academy of Medical Sciences & Sichuan Provincial People's Hospital, Chengdu, China
| | - Qiulian Yang
- Second Internal Medicine, Yilong County People's Hospital, Nanchong, China
| | - Mingfeng He
- Digestive Endoscopy Center, Sichuan Academy of Medical Sciences & Sichuan Provincial People's Hospital, Chengdu, China
| | - Shaomin Zhu
- Department of Anesthesiology, Eastern Hospital, Sichuan Academy of Medical Sciences & Sichuan Provincial People's Hospital, Chengdu, China
| | - Yan Liu
- Department of Geriatric Internal Medicine, Sichuan Academy of Medical Sciences & Sichuan Provincial People's Hospital, Chengdu, China
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Xiao J, Quan X, Liu F, Li W. Comparison of Different Surgical Methods for Necrotizing Pancreatitis: A Meta-Analysis. Front Surg 2021; 8:723605. [PMID: 34631782 PMCID: PMC8493073 DOI: 10.3389/fsurg.2021.723605] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/11/2021] [Accepted: 08/09/2021] [Indexed: 12/12/2022] Open
Abstract
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.
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Affiliation(s)
- Jianguo Xiao
- Medicinal School of Chinese People's Liberation Army, Beijing, China
- Department of Critical Care Medicine, The First Medical Center, Chinese People's Liberation Army General Hospital, Beijing, China
| | - Xiaojiao Quan
- Department of Critical Care Medicine, Hainan Hospital of Chinese People's Liberation Army General Hospital, Sanya, China
| | - Fang Liu
- Medicinal School of Chinese People's Liberation Army, Beijing, China
- Department of Gastroenterology and Hepatology, The First Medical Center, Chinese People's Liberation Army General Hospital, Beijing, China
| | - Wen Li
- Department of Gastroenterology and Hepatology, The First Medical Center, Chinese People's Liberation Army General Hospital, Beijing, China
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Rebhun J, Nassani N, Pan A, Hong M, Shuja A. Outcomes of Open, Laparoscopic, and Percutaneous Drainage of Infected Walled-Off Pancreatic Necrosis: A Nationwide Inpatient Sample Study. Cureus 2021; 13:e12972. [PMID: 33654633 PMCID: PMC7913891 DOI: 10.7759/cureus.12972] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/05/2022] Open
Abstract
Background Walled-off pancreatic necrosis (WOPN) represents an encapsulated collection of necrotic pancreatic or peripancreatic tissue that tends to develop four weeks after the onset of acute necrotizing pancreatitis. When infected, it is managed initially by antibiotic therapy before drainage by endoscopic, percutaneous, or surgical means. This study aims to describe the morbidity, mortality, length of stay (LOS), and cost of care associated with open surgical, laparoscopic, and radiology-guided percutaneous drainage in adult patients with infected WOPN. Methods Using the Nationwide Inpatient Sample (NIS), patients aged 18 years and older discharged with the diagnosis of WOPN between January 1, 2016 and December 31, 2016 who underwent open, laparoscopic, or percutaneous drainage were included. Patients’ characteristics including age, gender, and body mass index were reported. The primary endpoints were the mortality rate as well as length and cost of stay in each group. The secondary endpoint was the rate of procedural complications in each arm. Endpoints were reported and compared with studies assessing similar outcomes. Statistical Analysis System (SAS) statistical software (SAS Institute Inc., Cary, NC, USA) was used to perform the analysis. Results A total of 229 patients with the diagnosis of acute pancreatitis with infected necrosis were identified. Of these 229 patients, 27, 15, and 20 underwent open, laparoscopic, and percutaneous drainage, respectively. A total of eight studies were used for comparison of outcome variables. Mortality rate was found to be similar among comparison studies. LOS and costs varied widely among studies. There were significantly fewer pancreatic fistula and significantly more multi-organ failure complications as a result of open necrosectomy in the NIS study sample. Conclusion Overall, in analyzing the outcomes of patients undergoing intervention for infected WOPN through the 2016 NIS database, it appears that the database is representative of the majority of outcomes seen in similar clinical trials.
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Affiliation(s)
- Jeffrey Rebhun
- Department of Internal Medicine, University of Illinois at Chicago, Chicago, USA
| | - Najib Nassani
- Department of Gastroenterology and Hepatology, University of Illinois at Chicago, Chicago, USA
| | - Alex Pan
- Department of Gastroenterology and Hepatology, University of Illinois at Chicago, Chicago, USA
| | - Mindy Hong
- Department of Dermatology, Northwestern University Feinberg School of Medicine, Chicago, USA
| | - Asim Shuja
- Department of Gastroenterology and Hepatology, University of Illinois at Chicago, Chicago, USA
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10
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Cai QC, Zhang YX, Liao Y, Gong JP, Xiong B. Is endoscopic drainage better than percutaneous drainage for patients with pancreatic fluid collections? A comparative meta-analysis. REVISTA ESPANOLA DE ENFERMEDADES DIGESTIVAS 2020; 113:454-462. [PMID: 33267596 DOI: 10.17235/reed.2020.7170/2020] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
INTRODUCTION though endoscopic and percutaneous drainage have emerged as the most common minimally invasive treatments for pancreatic fluid collections (PFCs), estimates of therapeutic superiority for either treatment have yielded inconsistent results. METHODS we retrieved studies comparing the efficacy and safety of these two approaches in PubMed, Embase, and the Cochrane Library. Primary outcomes were differences in technical success, clinical success, and adverse events, and secondary outcomes included differences in reintervention, need for surgical intervention, mortality, recurrence rate, and length of hospital stay. RESULTS there were nonsignificant differences in technical success rate (OR 0.54; CI: 0.15-1.86), clinical success rate (OR 1.39; CI: 0.82-2.37), adverse events rate (OR 1.21; CI: 0.70-2.11), mortality rate (OR 0.81; CI: 0.30-2.16), and recurrence rate (OR 1.94; CI 0.74-5.07) between the two groups. Reintervention rate (OR 0.19; CI: 0.08-0.45) and percentage of need for surgical intervention (OR 0.08; CI: 0.02-0.39) in the endoscopic drainage group were much lower than in the percutaneous drainage group. Total length of hospital stay (standard mean difference [SMD] -0.60; CI: -0.84 to -0.36) in the endoscopic drainage group was shorter; however, there was a nonsignificant difference in the length of post-procedure hospital stay (SMD: -0.30; CI: -1.05-0.44) between the two groups. CONCLUSION endoscopic drainage is effective for PFCs, and superior in terms of lower reintervention and need for surgery rates over traditional percutaneous drainage, despite a similar clinical efficacy and safety compared with traditional percutaneous drainage.
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Affiliation(s)
- Qi-Chen Cai
- Hepatobiliary Surgery. The Second Affiliated Hospital. Chongqing Medical University,Hepatobiliary Pancreatic Surgery. The Second People's Hospital of Chengdu
| | - Yu-Xin Zhang
- Hepatobiliary Surgery. The Second Affiliated Hospital. Chongqing Medical University
| | - Yang Liao
- Hepatobiliary Surgery. The Second Affiliated Hospital. Chongqing Medical University
| | - Jian-Ping Gong
- Hepatobiliary Surgery. The Second Affiliated Hospital. Chongqing Medical University
| | - Bin Xiong
- Hepatobiliary Surgery. The Second Affiliated Hospital. Chongqing Medical University
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11
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Hu Y, Li C, Zhao X, Cui Y. An endoscopic or minimally invasive surgical approach for infected necrotizing pancreatitis: a systematic review and meta-analysis. REVISTA ESPANOLA DE ENFERMEDADES DIGESTIVAS 2019; 111:471-480. [PMID: 31021167 DOI: 10.17235/reed.2019.5792/2018] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
BACKGROUND AND AIM the incidence of acute pancreatitis is rising across the world, thus further increasing the burden on healthcare services. Approximately 10% of patients with acute pancreatitis will develop infected necrotizing pancreatitis (INP), which is the leading cause of high mortality in the late phase. There is currently no consensus with regard to the use of endoscopic or minimally invasive surgery as the first-line therapy of choice for INP. However, more clinical research with regard to the superiority of an endoscopic approach has been recently published. Therefore, we conducted a systematic review and meta-analysis to determine which of the two treatments leads to a better prognosis. METHODS four databases (Medline, SINOMED, EMBASE and Cochrane Library) were searched for eligible studies from 1980 to 2018, comparing endoscopic and minimally invasive surgery for INP. RESULTS two randomized controlled trials (RCTs) and seven clinical cohort studies were included. After the analysis of data amenable to polling, significant advantages were found in favor of the endoscopic approach in terms of pancreatic fistulas (OR = 0.10, 95% CI 0.04-0.30, p < 0.001) and the length of hospital stay (weighted mean difference [WMD] = -24.72, 95% CI = -33.87 to -15.57, p < 0.001). No marked differences were found in terms of mortality, multiple organ failure, intra-abdominal bleeding, enterocutaneous fistula, recurrence of pseudocysts, and length of stay (LOS) in the Intensive Care Unit (ICU), endocrine insufficiency and exocrine insufficiency. CONCLUSION compared with minimally invasive surgery, an endoscopic approach evidently improved short-term outcomes for infected necrotizing pancreatitis, including pancreatic fistula and the length of hospital stay. Furthermore, relevant multicenter RCTs are eager to validate these findings.
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Affiliation(s)
- Yong Hu
- Surgery, Tianjin Medical University, china
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12
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Woo S, Walklin R, Ackermann T, Lo SW, Shilton H, Pilgrim C, Evans P, Burnes J, Croagh D. Comparison of endoscopic and percutaneous drainage of symptomatic necrotic collections in acute necrotizing pancreatitis. Asian J Endosc Surg 2019; 12:88-94. [PMID: 29747233 DOI: 10.1111/ases.12490] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/02/2018] [Revised: 03/08/2018] [Accepted: 03/18/2018] [Indexed: 12/17/2022]
Abstract
INTRODUCTION Primary endoscopic and percutaneous drainage for pancreatic necrotic collections is increasingly used. We aim to compare the relative effectiveness of both modalities in reducing the duration and severity of illness by measuring their effects on systemic inflammatory response syndrome (SIRS). METHODS We retrospectively reviewed all cases of endoscopic and percutaneous drainage for pancreatic necrotic collections performed in 2011-2016 at two hospitals. We assessed the post-procedure length of hospital stay, reduction in C-reactive protein levels, resolution of SIRS, the complication rates, and the number of procedures required for resolution. RESULTS Thirty-two patients were identified and 57 cases (36 endoscopic, 21 percutaneous) were included. There was no significant difference in C-reactive protein reduction between endoscopic and percutaneous drainage (69.5% vs 68.8%, P = 0.224). Resolution of SIRS was defined as the post-procedure normalization of white cell count (endoscopic vs percutaneous: 70.4% vs 64.3%, P = 0.477), temperature (endoscopic vs percutaneous: 93.3% vs 60.0%, P = 0.064), heart rate (endoscopic vs percutaneous: 56.0% vs 11.1%, P = 0.0234), and respiratory rate (endoscopic vs percutaneous: 83.3% vs 0.0%, P = 0.00339). Post-procedure length of hospital stay was 27 days with endoscopic drainage and 46 days with percutaneous drainage (P = 0.0183). CONCLUSION Endoscopic drainage was associated with a shorter post-procedure length of hospital stay and a greater rate of normalization of SIRS parameters than percutaneous drainage, although only the effects on heart rate and respiratory rate reached statistical significance. Further studies are needed to establish which primary drainage modality is superior for pancreatic necrotic collections.
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Affiliation(s)
- Shanan Woo
- Department of Surgery, School of Clinical Sciences at Monash Health, Monash University, Melbourne, Victoria, Australia.,Department of Upper Gastrointestinal/Hepatopancreaticobiliary Surgery, Monash Health, Melbourne, Victoria, Australia
| | - Ryan Walklin
- Monash Imaging, Monash Health, Melbourne, Victoria, Australia
| | - Travis Ackermann
- Department of Upper Gastrointestinal/Hepatopancreaticobiliary Surgery, Monash Health, Melbourne, Victoria, Australia.,Department of Upper Gastrointestinal Surgery, Peninsula Health, Melbourne, Victoria, Australia
| | - Sheng Wei Lo
- Department of Upper Gastrointestinal Surgery, Peninsula Health, Melbourne, Victoria, Australia
| | - Hamish Shilton
- Department of Upper Gastrointestinal/Hepatopancreaticobiliary Surgery, Monash Health, Melbourne, Victoria, Australia.,Department of Upper Gastrointestinal Surgery, Peninsula Health, Melbourne, Victoria, Australia
| | - Charles Pilgrim
- Department of Upper Gastrointestinal Surgery, Peninsula Health, Melbourne, Victoria, Australia
| | - Peter Evans
- Department of Upper Gastrointestinal Surgery, Peninsula Health, Melbourne, Victoria, Australia
| | - James Burnes
- Department of Surgery, School of Clinical Sciences at Monash Health, Monash University, Melbourne, Victoria, Australia.,Monash Imaging, Monash Health, Melbourne, Victoria, Australia
| | - Daniel Croagh
- Department of Surgery, School of Clinical Sciences at Monash Health, Monash University, Melbourne, Victoria, Australia.,Department of Upper Gastrointestinal/Hepatopancreaticobiliary Surgery, Monash Health, Melbourne, Victoria, Australia
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13
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Sorrentino L, Chiara O, Mutignani M, Sammartano F, Brioschi P, Cimbanassi S. Combined totally mini-invasive approach in necrotizing pancreatitis: a case report and systematic literature review. World J Emerg Surg 2017; 12:16. [PMID: 28331537 PMCID: PMC5356234 DOI: 10.1186/s13017-017-0126-5] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/28/2016] [Accepted: 03/06/2017] [Indexed: 12/11/2022] Open
Abstract
BACKGROUND Currently, both the step-up approach, combining percutaneous drainage (PD) and video-assisted retroperitoneal debridement (VARD), and endoscopic transgastric necrosectomy (ETN) are mini-invasive techniques for infected necrosis in severe acute pancreatitis. A combination of these approaches could maximize the management of necrotizing pancreatitis, conjugating the benefits from both the experiences. However, reporting of this combined strategy is anecdotal. This is the first reported case of severe necrotizing pancreatitis complicated by biliary fistula treated by a combination of ETN, PD, VARD, and endoscopic biliary stenting. Moreover, a systematic literature review of comparative studies on minimally invasive techniques in necrotizing pancreatitis has been provided. CASE PRESENTATION A 59-year-old patient was referred to our center for acute necrotizing pancreatitis associated with multi-organ failure. No invasive procedures were attempted in the first month from the onset: enteral feeding by a naso-duodenal tube was started, and antibiotics were administered to control sepsis. After 4 weeks, CT scans showed a central walled-off pancreatic necrosis (WOPN) of pancreatic head communicating bilateral retroperitoneal collections. ETN was performed, and bile leakage was found at the right margin of the WOPN. Endoscopic retrograde cholangiopancreatography confirmed the presence of a choledocal fistula within the WOPN, and a biliary stent was placed. An ultrasound-guided PD was performed on the left retroperitoneal collection. Due to the subsequent repeated onset of septic shocks and the evidence of size increase of the right retroperitoneal collection, a VARD was decided. The CT scans documented the resolution of all the collections, and the patient promptly recovered from sepsis. After 6 months, the patient is in good clinical condition. CONCLUSIONS No mini-invasive technique has demonstrated significantly better outcomes over the others, and each technique has specific indications, advantages, and pitfalls. Indeed, ETN could be suitable for central WOPNs, while VARD or PD could be suggested for lateral collections. A combination of different approaches is feasible and could significantly optimize the clinical management in critically ill patients affected by complicated necrotizing pancreatitis.
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Affiliation(s)
- Luca Sorrentino
- Trauma Team and Emergency Surgery, Niguarda Trauma Center, Niguarda Ca' Granda Hospital, Piazza Ospedale Maggiore 3, Milan, 20162 Italy
| | - Osvaldo Chiara
- Trauma Team and Emergency Surgery, Niguarda Trauma Center, Niguarda Ca' Granda Hospital, Piazza Ospedale Maggiore 3, Milan, 20162 Italy
| | - Massimiliano Mutignani
- Digestive Endoscopy Service, Niguarda Ca' Granda Hospital, Piazza Ospedale Maggiore 3, Milan, 20162 Italy
| | - Fabrizio Sammartano
- Trauma Team and Emergency Surgery, Niguarda Trauma Center, Niguarda Ca' Granda Hospital, Piazza Ospedale Maggiore 3, Milan, 20162 Italy
| | - Paolo Brioschi
- Intensive Care Unit, Niguarda Trauma Center, Niguarda Ca' Granda Hospital, Piazza Ospedale Maggiore 3, Milan, 20162 Italy
| | - Stefania Cimbanassi
- Trauma Team and Emergency Surgery, Niguarda Trauma Center, Niguarda Ca' Granda Hospital, Piazza Ospedale Maggiore 3, Milan, 20162 Italy
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Shilton H, Breen D, Gupta S, Evans P, Pilgrim C. Multiple interventions with prolonged length of stay are required for treatment of necrotizing pancreatitis. ANZ J Surg 2017; 88:E162-E166. [PMID: 28124490 DOI: 10.1111/ans.13883] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/21/2016] [Revised: 11/20/2016] [Accepted: 11/21/2016] [Indexed: 12/14/2022]
Abstract
BACKGROUND A proportion of patients with acute pancreatitis (AP) develop necrosis. Around a third will become infected, and this is associated with a significant requirement for intervention and support. We evaluated the burden of necrotizing pancreatitis (NP) in an Australian tertiary hospital with regards to morbidity, mortality and resource consumption. METHODS This is a retrospective case series of patients with AP admitted for at least 5 days to identify those with NP between 2009 and 2014. Data were analysed in groups according to the determinant-based classification of AP severity. RESULTS Of 1339 patients with AP, 546 stayed 5 days or longer, and 38 had necrosis. Overall mortality for those with necrosis was 10.5% (4/38). Infection complicated necrosis in 45% (17/38). Organ failure also occurred in 45% (17/38) of patients with necrosis. All patients in the critical category and severe category required admission to the intensive care unit for a median of 21 and 12 days, respectively. A total of 90% of patients with critical category disease developed multi-organ failure, whereas most with severe category disease developed single organ failure only. Overall length of stay increased with increasing severity of disease. Intervention was required in 82% of infected necrosis (median 4 procedures). Those without infection also required multiple radiological investigations (median 7). CONCLUSION Necrosis is uncommon in our cohort but is associated with a significant health-care burden. Almost half the patients with necrosis develop organ failure requiring prolonged hospital and intensive care unit stay. Patients require multiple investigations and interventions for infected necrosis. NP remains a costly, morbid disease in our society.
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Affiliation(s)
- Hamish Shilton
- Department of Surgery, Frankston Hospital, Peninsula Health, Melbourne, Victoria, Australia
| | - Daniel Breen
- Department of Surgery, Frankston Hospital, Peninsula Health, Melbourne, Victoria, Australia
| | - Sachin Gupta
- Department of Surgery, Frankston Hospital, Peninsula Health, Melbourne, Victoria, Australia
| | - Peter Evans
- Department of Surgery, Frankston Hospital, Peninsula Health, Melbourne, Victoria, Australia
| | - Charles Pilgrim
- Department of Surgery, Frankston Hospital, Peninsula Health, Melbourne, Victoria, Australia
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