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Acute necrotizing pancreatitis: Surgical indications and technical procedures.

ABSTRACT: Necrosis of pancreatic parenchyma or extrapancreatic tissues is present in 10%-20% of patients with acute pancreatitis, defining the necrotizing presentation frequently associated with high morbidity and mortality rates. During the initial phase of acute necrotizing pancreatitis the most important pillars of medical treatment are fluid resuscitation, early enteral nutrition, endoscopic retrograde colangiopancreatography if associated cholangitis and intensive care unit support. When infection of pancreatic or extrapancreatic necrosis occurs, surgical approach constitutes the most accepted therapeutic option. In this context, we have recently assited to changes in time for surgery (delaying the indication if possible to around 4 wk to deal with "walled-off" necrosis) and type of access for necrosectomy: from a classical open approach (with closure over large-bore drains for continued postoperative lavage or semiopen techniques with scheduled relaparotomies), trends have changed to a "step-up" philosophy with initial percutaneous drainage and posterior minimally invasive or endoscopic access to the retroperitoneal cavity for necrosectomy if no improvement has been previously achieved. These approaches are progressively gaining popularity and morbidity and mortality rates have decreased significantly. Therefore, a staged, multidisciplinary, step-up approach with minimally invasive or endoscopic access for necrosectomy is widely accepted nowadays for management of pancreatic necrosis.

SUBMITTER: Aranda-Narvaez JM

PROVIDER: S-EPMC4266831 | biostudies-literature | 2014 Dec

REPOSITORIES: biostudies-literature

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Acute necrotizing pancreatitis: Surgical indications and technical procedures.

Aranda-Narváez José Manuel JM González-Sánchez Antonio Jesús AJ Montiel-Casado María Custodia MC Titos-García Alberto A Santoyo-Santoyo Julio J

World journal of clinical cases 20141201 12

Necrosis of pancreatic parenchyma or extrapancreatic tissues is present in 10%-20% of patients with acute pancreatitis, defining the necrotizing presentation frequently associated with high morbidity and mortality rates. During the initial phase of acute necrotizing pancreatitis the most important pillars of medical treatment are fluid resuscitation, early enteral nutrition, endoscopic retrograde colangiopancreatography if associated cholangitis and intensive care unit support. When infection of ...[more]

PMID: 25516858

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Project description: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.

Project description:BackgroundAcute necrotizing pancreatitis (NP), a severe form of acute pancreatitis (AP), has higher mortality and worse outcome than non-necrotizing pancreatitis (non-NP). Infected NP is a devastating subgroup of NP. To date neither NP nor infected NP has robust prediction strategies, which may delay early recognition and timely intervention. Recent studies revealed correlations between disturbed gut microbiota and AP severity. Some features of intestinal microbiota have the potential to become biomarkers for NP prediction.MethodsWe performed 16S rRNA sequencing to analyze gut microbiota features in 20 healthy controls (HC), and 58 AP patients on hospital admission. The AP patients were later classified into NP and non-NP groups based on subsequent diagnostic imaging features. Random forest regression model and ROC curve were applied for NP and infected NP prediction. PIRCUSt2 was used for bacterial functional pathway prediction analysis.ResultsWe found that the three groups (HC, NP, and non-NP) had distinct microorganism composition. NP patients had reduced microbial diversity, higher abundance of Enterobacteriales, but lower abundance of Clostridiales and Bacteroidales compared with the non-NP group. Correlation analyses displayed that intestine bacterial taxonomic alterations were related to severity, ICU admission, and prognosis. By pathway prediction, species more abundant in NP patients had positive correlation with synthesis and degradation of ketone bodies, and benzoate degradation. Enterococcus faecium (ASV2) performed best in discriminating NP and non-NP patients. Finegoldia magna (ASV3) showed the maximal prediction capacity among all ASVs and had comparable accuracy with Balthazar CT to detect patients with infected NP.ConclusionsOur study suggests that NP patients have distinct intestinal microbiota on admission compared to non-NP patients. Dysbiosis of intestinal microbiota might influence NP progression through ketone body or benzoate metabolism. Enterococcus faecium and Finegoldia magna are potential predictors for NP and infected NP. Our findings explore biomarkers which may inform clinical decision-making in AP and shed light on further studies on NP pathophysiology and management.

Project description:ObjectivesThe purpose of this study was to comprehensively assess the heterogeneity of procedures in the diagnostic guidelines for acute pancreatitis and to identify gaps limiting knowledge in diagnosing this disease.MethodsA systematic search of a number of databases was performed to determine the guidelines for the diagnosis of acute pancreatitis in patients with severe pancreatitis. The guidelines for the diagnosis of severe pancreatitis were evaluated by AGREE II. The Measurement Scale of Rate of Agreement (MSRA) was used to assess the guidelines (2015-2020) and extract evidence supporting these recommendations for analysis.ResultsSeven diagnostic guidelines for acute pancreatitis were included. Only the 2019 WSES Guidelines for the Management of Severe Acute Pancreatitis and the Japanese Guidelines for the Management of Acute Pancreatitis: Japanese Guidelines 2015 had a total score of more than 60%, which is worthy of clinical recommendation. The average scores of the Scope and Purpose domain and the Clarity and Expression domain were the highest at 71.62% and 75.59%, respectively, while the average score of the Applicability area was the lowest at 16.67%. The included guidelines were further analyzed to determine the heterogeneity of the diagnosis of acute pancreatitis. The main reasons for the heterogeneity were the citation of low-quality evidence, the presence of far too many indicators for the classification of acute pancreatitis, unclear depictions of the standard, and poorly comprehensive recommendations for the diagnosis of the aetiology in the primary diagnosis of acute pancreatitis, the severity classification, the aetiological diagnosis, and the diagnosis of comorbidities.ConclusionsThe quality of different diagnostic guidelines for severe pancreatitis is uneven. The recommendations are largely based on low-quality evidence, and the guidelines still have much room for improvement to reach a high level of quality. The diagnostic procedures for acute pancreatitis vary widely in different guidelines. There are large differences between them, and resolving the abovementioned reasons would be a very wise choice for guideline developers to revise and upgrade the guidelines in the future.

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Acute necrotizing pancreatitis: Surgical indications and technical procedures.

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Acute necrotizing pancreatitis: Surgical indications and technical procedures.

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