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Acute pancreatitis (AP) ranges in severity from mild to severe with high mortality. Severe AP, similar to other critical illnesses, is associated with changes in cortisol level. Early increase of high-sensitivity C-reactive protein (hs-CRP) as an inflammatory marker could be an indicator of AP progression. We aimed to assess the level of cortisol and hs-CRP on initial diagnosis of AP and identify their prognostic value.This case-control study included patients with AP and a control group of healthy subjects. Laboratory tests such as liver profile, kidney functions, blood picture, lactate dehydrogenase, blood glucose, and lipogram were evaluated, the severity of AP was determined, the duration of hospitalization, complications, and outcomes were identified, and the serum levels of cortisol and hs-CRP were assessed.There were 90 patients with AP and 60 controls with a higher percent of females in both groups. Serum cortisol and hs-CRP were significantly higher in AP relative to controls and were higher in severe AP relative to mild AP. Significant positive correlation was present between high cortisol and severity of AP (r = 0.520 and p0.001) and negatively with pancreatic necrosis (r= - 0.303 and p = 0.007) and morality (r= - 0.432, p = 0.005) while hs-CRP did not show significant correlation.Different levels of serum cortisol in early AP should be considered on initial diagnosis. High cortisol level was a good prognostic indicator for AP with low mortality. This could have further implications on the appropriate initiation of steroid therapy to prevent necrotizing pancreatitis and lower the mortality. Meanwhile, hs-CRP has a low prognostic value in early AP.

Background and aims Traditional management for infected necrotizing pancreatitis (INP) often utilizes open necrosectomy, which carries high morbidity and complication rates. Thus, minimally invasive strategies have gained favor, specifically step-up approaches utilizing endoscopic or minimally-invasive surgery (MIS); however, the ideal management modality for INP has not been identified. Methods A decision tree model was designed to analyze costs and survival associated with open necrosectomy, endoscopic step-up, and MIS step-up protocols for management of INP after 4 weeks of necrosis development with adequate retroperitoneal access . Costs were based on a third-party payer perspective using Medicare reimbursement rates. The model's effectiveness was represented by quality-adjusted life-years (QALYs). Sensitivity analyses were performed to validate results. Results Endoscopic step-up was the dominant economic strategy with 7.92 QALYs for $90,864.09. Surgical step-up resulted in a decrease of 0.09 QALYs and a cost increase of $10,067.89 while open necrosectomy resulted in a decrease of 0.4 QALYs and an increased cost of $18,407.52 over endoscopic step-up. In 100,000 random-sampling simulations, 65.5% of simulations favored endoscopic step-up. MIS step-up was favored when MIS acute mortality rates fell and when MIS drainage success rates rose. Conclusions In our simulated patients with INP, the most cost-effective management strategy is endoscopic step-up. Cost-effectiveness varies with changes in acute mortality and drainage success, which will depend on local expertise.

Opie’s “pancreatic duct obstruction” and “common channel” theories are generally accepted as explanations of the mechanisms involved in gallstone acute pancreatitis (AP). Common channel elucidates the mechanism of necrotizing pancreatitis due to gallstones. For pancreatic duct obstruction, the clinical picture of most patients with ampullary stone impaction accompanied by biliopancreatic obstruction is dominated by life-threatening acute cholangitis rather than by AP, which clouds the understanding of the severity of gallstone AP. According to the revised Atlanta classification, it is difficult to consider these clinical features as indications of severe pancreatitis. Hence, the term “gallstone cholangiopancreatitis” is suggested to define severe disease complicated by acute cholangitis due to persistent ampullary stone impaction. It incorporates the terms “cholangitis” and “gallstone pancreatitis.” “Cholangitis” refers to acute cholangitis due to cholangiovenous reflux through the foci of extensive hepatocyte necrosis reflexed by marked elevation in transaminase levels caused by persistent ampullary obstruction. “Gallstone pancreatitis” refers to elevated pancreatic enzyme levels consequent to pancreatic duct obstruction. This pancreatic lesion is characterized by minimal or mild inflammation. Gallstone cholangiopancreatitis may be valuable in clinical practice for specifying gallstone AP that needs urgent endoscopic retrograde cholangiopancreatography with endoscopic sphincterotomy.

Item does not contain fulltext BACKGROUND: Infected necrotizing pancreatitis is a potentially lethal disease that is treated with the use of a step-up approach, with catheter drainage often delayed until the infected necrosis is encapsulated. Whether outcomes could be improved by earlier catheter drainage is unknown. METHODS: We conducted a multicenter, randomized superiority trial involving patients with infected necrotizing pancreatitis, in which we compared immediate drainage within 24 hours after randomization once infected necrosis was diagnosed with drainage that was postponed until the stage of walled-off necrosis was reached. The primary end point was the score on the Comprehensive Complication Index, which incorporates all complications over the course of 6 months of follow-up. RESULTS: A total of 104 patients were randomly assigned to immediate drainage (55 patients) or postponed drainage (49 patients). The mean score on the Comprehensive Complication Index (scores range from 0 to 100, with higher scores indicating more severe complications) was 57 in the immediate-drainage group and 58 in the postponed-drainage group (mean difference, -1; 95% confidence interval [CI], -12 to 10; P = 0.90). Mortality was 13% in the immediate-drainage group and 10% in the postponed-drainage group (relative risk, 1.25; 95% CI, 0.42 to 3.68). The mean number of interventions (catheter drainage and necrosectomy) was 4.4 in the immediate-drainage group and 2.6 in the postponed-drainage group (mean difference, 1.8; 95% CI, 0.6 to 3.0). In the postponed-drainage group, 19 patients (39%) were treated conservatively with antibiotics and did not require drainage; 17 of these patients survived. The incidence of adverse events was similar in the two groups. CONCLUSIONS: This trial did not show the superiority of immediate drainage over postponed drainage with regard to complications in patients with infected necrotizing pancreatitis. Patients randomly assigned to the postponed-drainage strategy received fewer invasive interventions. (Funded by Fonds NutsOhra and Amsterdam UMC; POINTER ISRCTN Registry number, ISRCTN33682933.).

Antecedentes: La fibrosis quística es una enfermedad de herencia autosómica recesiva, consistente en mutaciones en el gen regulador de la conductibilidad transmembrana, provocando una alteración en la viscosidad de las secreciones. Reporte de caso: Presentamos el caso de una paciente preescolar que ingresa por un cuadro de dolor abdominal crónico en quien se le diagnosticó pancreatitis necrosante como debut de fibrosis quística, quien requirió cuatro meses de hospitalización. Conclusión: La fibrosis quística es una enfermedad con alta tasa de morbimortalidad en la población pediátrica, por lo que se deben conocer sus posibles formas de debut y su clínica, para un manejo oportuno y seguimiento interdisciplinario.

Background: Acute pancreatitis is one of the most common abdominal pathologies having variable outcome ranging from self limiting abdominal pain to high mortality and morbidity due to organ failure, over the past five decades, various classification systems have emerged to classify pancreatitis according to its severity , and the associated complications have emerged to classify acute pancreatitis and its various complications, such as Apache Scoring , Ct Severity , Modified Ct Severity ,Ransen and Atlanta Classification. Objectives: We in our study will be classifying patients suffering from acute pancreatitis according to the revised Atlanta classification to divide them into interstitial edematous pancreatitis and necrotizing pancreatitis. The local complications will be classified according to CT imaging findings into acute necrotic collection, psuedocyst, acute necrotic collection and walled of necrosis. Organ failure will be assessed according to modified marshal scoring system into transient or persistent organ failure. Methodology: We will be carrying forward our study on Siemens 16 slice computer tomography machine over a sample of 140 patients coming to the outpatient department of our hospital which will be followed by a routine clinical follow up of the patient to find out their prognosis. Results: Will be tabulated at the end of the study using SPSS version 26 software. Conclusion: The revised Atlanta classification for acute pancreatitis, in conjunction with the Modified Marshall Scoring System for organ failure, if found useful, in our series in improving the prognosis of the patients, then it can be incorporated in management.

Background Endoscopic ultrasound-guided drainage is suggested as the first approach in the management of symptomatic and complex walled-off pancreatic necrosis. Dual approach with percutaneous drainage could be the best choice when the necrosis is deep extended till the pelvic paracolic gutter; however, the available catheter could not be large enough to drain solid necrosis neither to perform necrosectomy, entailing a higher need for surgery. Therefore, percutaneous endoscopic necrosectomy through a large bore percutaneous self-expandable metal stent has been proposed. Case presentation In this study, we present the case of a 61-year-old man admitted to our hospital with a history of sepsis and persistent multiorgan failure secondary to walled-off pancreatic necrosis due to acute necrotizing pancreatitis. Firstly, the patient underwent transgastric endoscopic ultrasound-guided drainage using a lumen-apposing metal stent and three sessions of direct endoscopic necrosectomy. Because of recurrence of multiorgan failure and the presence of the necrosis deeper to the pelvic paracolic gutter at computed tomography scan, we decided to perform percutaneous endoscopic necrosectomy using an esophageal self-expandable metal stent. After four sessions of necrosectomy, the collection was resolved without complications. Therefore, we perform a revision of the literature, in order to provide the state-of-art on this technique. The available data are, to date, derived by case reports and case series, which showed high rates both of technical and clinical success. However, a not negligible rate of adverse events has been reported, mainly represented by fistulas and abdominal pain. Conclusion Dual approach, using lumen apposing metal stent and percutaneous self-expandable metal stent, is a compelling option of treatment for patients affected by symptomatic, complex walled-off pancreatic necrosis, allowing to directly remove large amounts of necrosis avoiding surgery. Percutaneous endoscopic necrosectomy seems a promising technique that could be part of the step-up-approach, before emergency surgery. However, to date, it should be reserved in referral centers, where a multidisciplinary team is disposable.

Acute pancreatitis is one of the most commonly encountered etiologies in the emergency setting, with a broad spectrum of findings that varies in severity from mild interstitial pancreas to severe forms with significant local and systemic complications that are associated with a substantial degree of morbidity and mortality. In this article the radiological aspect of the terminology and classification of acute pancreatitis are reviewed. The roles of ultrasound, computed tomography, and magnetic resonance imaging in the diagnosis and evaluation of acute pancreatitis and its complications are discussed. The authors present a practical image-rich guide, applying the revised Atlanta classification system, with the goal of facilitating radiologists to write a correct report, and reinforcing the radiologist’s role as a key member of a multidisciplinary team in treating patients with acute pancreatitis. Computed tomography is the most performed imaging test for acute pancreatitis. Nevertheless, MRI is useful in many specific situations, due to its superiority soft tissue contrast resolution and better assessment of biliary and pancreatic duct, for example in the ductal disconnection. The purpose if this article is to review recent advances in imaging acquisition and analytic techniques in the evaluation of AP.

Bei etwa 20 % der Patienten mit einer akuten Pankreatitis entwickeln sich im Verlauf Komplikationen, die eine Operation oder Intervention notwendig machen. Die Radiologie ist dabei sowohl fur die Bildgebung (Verlauf der Verhalte, Detektion einer Superinfektion sowie von Komplikationen, Evaluation der Nekrosen) als auch in der Behandlung der vaskularen und nichtvaskularen Komplikationen von zentraler Bedeutung. Bei der Behandlung einer schweren oder nekrotisierenden Pankreatitis sollte ein multidisziplinares Stufenkonzept zum Einsatz kommen mit initial moglichst minimal-invasiven Therapien wie endoskopische oder perkutane Drainagen. Durch die Applikation von ausreichend vielen und kaliberstarken Drainagen und unter strikter Spultherapie mit Umpositionierung der Drainagen konnen die pankreatischen und peripankreatischen Verhalte oftmals erfolgreich ohne die Notwendigkeit eines spateren chirurgischen Debridements behandelt werden. Die arteriellen Komplikationen betreffen 1–10 % aller Patienten mit einer Pankreatitis, dabei handelt es sich uberwiegend um rupturierte Pseudoaneurysmata, welche die gefahrlichsten Blutungskomplikationen der Pankreatitis darstellen und mittels Blutungsembolisation und/oder endovaskularer Stentgraftapplikation mit einer hohen technischen Erfolgsrate behandelt werden konnen.

Background A minimally invasive step-up approach to necrotizing biliary pancreatitis often requires multiple interventions, delaying cholecystectomy. The risk of gallstone-related complications during this time interval is unknown, as is the feasibility and safety of cholecystectomy after minimally invasive step-up treatment. In this paper, we analyzed both. Methods Necrotizing pancreatitis patients treated with a minimally invasive step-up approach who underwent interval cholecystectomy at 2 tertiary care centers between 2014 and 2019 were included. Gallstone-related complications prior to cholecystectomy were examined, as were surgical approaches to cholecystectomy and complications. Necrotizing pancreatitis patients treated without mechanical intervention were also examined. Results Seven of 31 patients developed gallstone-related complications between minimally invasive step-up treatment initiation and cholecystectomy. One patient developed biliary colic. Six patients developed acute cholecystitis. Two of these patients also developed choledocholithiasis, and 1 developed cholangitis, all requiring endoscopic retrograde cholangiopancreatography. Cholecystectomy was performed laparoscopically in 27 of 31 patients. One patient required open conversion, and 3 patients underwent planned cholecystectomy during another open operation. Four patients developed postoperative complications. Two of 14 necrotizing pancreatitis patients treated without mechanical intervention developed recurrent pancreatitis while awaiting cholecystectomy. Conclusion Over 20% of necrotizing pancreatitis patients treated by a minimally invasive step-up approach developed gallstone-related complications while awaiting cholecystectomy. Laparoscopic cholecystectomy is feasible and safe in the great majority of necrotizing pancreatitis patients treated by a minimally invasive step-up approach.

Background Necrotizing pancreatitis is a common condition with high mortality; the acute care surgeon is frequently consulted for management recommendations. Furthermore, there has been substantial change in the timing, approach, and frequency of surgical intervention for this group of patients. Methods In this article we summarize key clinical and research developments regarding necrotizing pancreatitis, including current recommendations for treatment of patients requiring intensive care and those with common complications. Articles from all years were considered to provide proper historical context, and most recent management recommendations are identified. Results Epidemiology, diagnosis, treatment in the acute phase, and complications (both short-term and long-term) are discussed. Images of surgical interventions are included from our institutional experience. Conclusion Necrotizing pancreatitis management remains heavily based on clinical judgement, although technological advances and clinical trials have made decision making more straightforward.

Sphingobacterium Thalpophilum is a very rare, aerobic, gram-negative bacilli which was isolated from a blood sample of a 36 years old male with necrotizing pancreatitis and DVT. The patient was treated with three different types of antibiotics: Meropenem, Metronidazole and Tigecycline as dictated by the antibiotic sensitivity testing. Unfortunately, the patient’s condition deteriorated and had to be admitted to the ICU and transferred to a tertiary care unit. S. thalpophilum while uncommon to be isolated from human specimens; infections with this microorganism can be fatal according to literature. There are very few reports of infection with S. thalpophilum worldwide and this is the first reported case in the United Arab Emirates.

La pancreatitis aguda es una condición rara en el embarazo, asociada con una alta tasa de mortalidad. La hipertrigliceridemia representa su segunda causa más frecuente. Presentamos el caso de una mujer de 38 años en la semana 24 de gestación con antecedentes de hipertrigliceridemia y episodios recurrentes de pancreatitis . Ingresó en nuestro hospital con pancreatitis aguda por hipertrigliceridemia severa . Fue estabilizada y tratada con fibratos . A pesar de su clínica favorablecurso , desarrolló un segundo episodio de pancreatitis aguda complicado con disfunción multiorgánica y necrosis pancreática , que requirió una necrosectomía. El embarazo se interrumpió mediante cesárea , tras lo cual se realizaron tres sesiones de plasmaféresis . Actualmente se encuentra asintomática con triglicéridos estables . La pancreatitis aguda por hipertrigliceridemia representa un desafío diagnóstico y terapéutico en la gestante , asociado a graves complicaciones maternas y fetales . Cuando la hipertrigliceridemia primariase sospecha, como el síndrome de quilomicronemia familiar , el objetivo más importante es prevenir la aparición de pancreatitis . Acute pancreatitis is a rare condition in pregnancy, associated with a high mortality rate. Hypertriglyceridemia represents its second most common cause. We present the case of a 38-year-old woman in the 24th week of gestation with a history of hypertriglyceridemia and recurrent episodes of pancreatitis. She was admitted to our hospital with acute pancreatitis due to severe hypertriglyceridemia. She was stabilized and treated with fibrates. Despite her favorable clinical course, she developed a second episode of acute pancreatitis complicated by multi-organ dysfunction and pancreatic necrosis, requiring a necrosectomy. The pregnancy was ended by cesarean section, after which three plasmapheresis sessions were performed. She is currently asymptomatic with stable triglyceride levels. Acute pancreatitis due to hypertriglyceridemia represents a diagnostic and therapeutic challenge in pregnant women, associated with serious maternal and fetal complications. When primary hypertriglyceridemia is suspected, such as familial chylomicronemia syndrome, the most important objective is preventing the onset of pancreatitis.

Distant abscesses are uncommon during the episode of acute pancreatitis (AP). However, these are possible sequalae of necrotizing pancreatitis and should be treated appropriately to prevent serious septic complications. We demonstrate a case of a 56-year-old male patient who presented with severe necrotizing pancreatitis and distant retroperitoneal abscess that reached femoral region and was detected on diagnostic imaging scans. Combination of surgical and supportive therapy was employed, and the patient recovered well with no permanent consequences. Our article highlights the importance of quick and accurate diagnosis and timely intervention in this rare type of pancreatitis complication.

This article presents the clinical case of using combination of minimally invasive approaches of debridement in patient with infected necrotizing pancreatitis. The decision of using minimally invasive approaches: endoscopic transluminal pancreatic necrosectomy combined with percutaneous catheter drainage under US-navigation and video-assisted retroperitoneal debridement was made, due to the giant necrotic cavity, containing huge amount of necrotized tissues (diagnosed by instrumental methods—CT, US).Discussion: Acute necrotizing pancreatitis is still the important surgical problem, because of the great number of different complications and high level of mortality, despite achievements in the treatment of this group of patients. Many articles, focused on the use of modern minimally invasive approaches in case of infected necrotizing pancreatitis, have been published. Moreover, the combination of minimally invasive approaches is using in managing of some patients for better debridement (including minimally invasive methods of debridement).Conclusion: The combination of minimally invasive ways of debridement in patients with necrotizing pancreatitis is an effective surgical tactic, which leads to better results in treatment.

We hereby report a case of a 35-year-old male who presented to us with infected pancreatic necrosis, 4 weeks after an episode of acute alcoholic pancreatitis. Imaging investigations showed a predominantly left-sided pancreatic and peripancreatic infected collection. This case was managed successfully in a single sitting by retroperitoneoscopic intervention.

Background. In connection with a steady increase of patients with destructive forms of acute pancreatitis, the proportion of which takes from 10-15 to 20-30%, despite of the wide range of treatments for non-biliary necrotizing pancreatitis, the rate of mortality reaches 80-90% in case of infected forms and needs further improvement of therapies. Objective. The purpose of this study is to improve the results of treatment of patients with nonbiliary necrotizing pancreatitis, by optimizing surgical tactics. Methods. The study examined the cases of 120 patients, whose age ranged from 22 to 83 years, including patients under the age of 50 years old who accounted for 60.0%. There were 80 males (66.7%) and 40 females (33.3%). Disease duration up to 24 hours was found in 36 (30.0%) patients, from 25 to 72 hours - in 25 (20.8%) individuals, more than 72 hours - in 49 (49.2%) patients. Results. The research claims in non-necrotizing pancreatitis, left-sided retroperitoneal phlegmon often develops in 64.2% (mortality rate 26.0%) of patients, right-sided in 24.2% (mortality rate 6.8%) of patients, and bilateral - in 11, 6% (mortality rate 64.2%) individuals. Moreover, the highest mortality was observed with a combination of retroperitoneal phlegmon cellulose and abscess of the pancreas and/or omental bursa - 39.1%. Conclusions. The use of various surgical interventions depending on the involvement in the pathological process of various sections of the abdominal cavity/ retroperitoneal space, which made it possible to reduce mortality and hospitalization time of patients in the hospital by 1.5-2 times is proposed.

Purpose of review There have been significant advancements in different aspects of management of severe acute pancreatitis (SAP). Our review of the most recent literature focuses on severity prediction, fluid resuscitation, analgesic administration, nutrition, and endoscopic intervention for SAP and its extra-pancreatic complications. Recent findings Recent studies on serum cytokines for the prediction of SAP have shown superior prognostic performance when compared with conventional laboratory tests and clinical scoring systems. In patients with established SAP and vascular leak syndrome, intravenous fluids should be administered with caution to prevent intra-abdominal hypertension and volume overload. Endoscopic retrograde cholangiopancreatography improves outcomes only in AP patients with suspected cholangitis. Early enteral tube-feeding does not appear to be superior to on-demand oral feeding. Abdominal compartment syndrome is a highly lethal complication of SAP that requires percutaneous drainage or decompressive laparotomy. Endoscopic transmural drainage followed by necrosectomy (i.e., “step-up approach”) is the treatment strategy of choice in patients with symptomatic or infected walled-off pancreatic necrosis. Summary SAP is a complex clinical syndrome associated with a high mortality rate. Early prediction of SAP remains challenging due to the limited accuracy of the available prediction tools. Early fluid resuscitation, organ support, enteral nutrition, and prevention of/or prompt recognition of abdominal compartment syndrome remain cornerstones of its management. A step-up, minimally invasive drainage/debridement is the preferred approach for patients with infected pancreatic necrosis.

A Man with Abdominal Pain, Joint Swelling, and Skin Lesions A 55-year-old-man with a history of neurofibromatosis and chronic necrotizing pancreatitis presented with abdominal pain and recurrent pa...

Unplanned readmission rates in necrotizing pancreatitis (NP) are among the highest of any medical disease (72%). Recent work has identified several potentially preventable causes of unplanned readmission in NP. We hypothesized that intensive outpatient communication would identify developing problems and decrease unplanned hospital readmission.A review of NP patients treated at a single institution between 2016 and 2019 compared patients 2 y before (NP-pre, 2016-2018) and 1 y after (NP-post, 2018-2019) the establishment of a dedicated pancreatitis nurse coordinator. Unplanned hospital readmission and emergency room visits were compared between groups.A total of 178 NP patients were treated-112 patients in the NP-pre group and 66 patients in the NP-post group. No differences between groups were observed in age, sex, comorbidities, pancreatitis etiology, NP severity, or mortality. A mean of 5.4 ± 0.2 outpatient communications per patient with the pancreatitis nurse coordinator was documented in the NP-post group. Unplanned readmission rates decreased significantly from 64% (NP-pre) to 45% (NP-post; P = 0.02). The frequency of readmission decreased from 1.6 readmissions per patient (NP-pre) to 0.8 readmissions per patient (NP-post; P = 0.001). Readmissions because of symptomatic necrosis, failure to thrive, nonnecrosis infection, and drain dysfunction decreased (P 0.05). Overall disease duration was similar (NP-pre, 4.6 ± 0.3 mo; NP-post, 5.0 ± 0.3 mo; P = 0.4); however, the mean number of unplanned inpatient days decreased from 15.4 ± 2.2 d (NP-pre) to 7.8 ± 1.6 d (NP-post; P = 0.02).Improved outpatient communication identifies treatable problems and significantly decreases unplanned readmission in NP patients.

Background/objectives Operative pancreatic debridement (OPD) is the historic gold standard for treating necrotizing pancreatitis (NP). Recent success with minimally invasive NP treatment approaches have raised the question of which NP patients require OPD. We therefore sought to define contemporary outcomes of NP patients undergoing OPD. Methods A retrospective analysis was performed of 116 consecutive NP patients undergoing OPD using a prospectively maintained institutional NP database between 2006 and 2018. Results 86 (74%) patients underwent open pancreatic debridement (OD) and 30 (26%) underwent open transgastric debridement (TGD). Median follow-up was 16 months (interquartile range [IQR], 8–45 months). Median age was 51 years (IQR, 43–65 years); 73 (63%) were male. Pancreatitis etiology included biliary (53%), alcohol (22%), and idiopathic/other (25%). Median time from diagnosis to OPD was 64.5 days (IQR, 32–114.5 days). Mean APACHE-II score was: admission 8.5 (standard deviation [SD], 5.9); worst 12.6 (SD, 7.9); preoperatively 7.2 (SD, 4.6). 40 patients (34%) were initially managed with minimally invasive techniques (percutaneous drain only in 24, endoscopic only in 6, combination in 10). Median postoperative length of stay was 11 days (IQR, 7–19 days). 90-day morbidity and mortality were 70% and 2%, respectively. Conclusions NP patients who require OPD are critically and chronically ill. OPD is associated with substantial morbidity, but acceptable mortality in an experienced center with multidisciplinary support. This large contemporary series demonstrates that in properly selected patients, OPD remains an important treatment for NP.

Zusammenfassung Hintergrund Bei 15 – 20% der Patienten mit akuter Pankreatitis entwickelt sich eine nekrotisierende Form. Die Mortalität beträgt bis zu 20%. Entscheidende Säulen der Behandlung sind die intensivmedizinische Therapie sowie chirurgische und interventionelle Maßnahmen. Methoden Diese Übersichtsarbeit zur Indikationsstellung von chirurgischen und interventionellen Maßnahmen bei der nekrotisierenden Pankreatitis wurde auf der Basis einer systematischen Literaturrecherche verfasst. In der Analyse wurden 85 Artikel ausgewertet. Die Ergebnisse wurden im Delphi-Befragungsverfahren der Qualitätskommission der Deutschen Gesellschaft für Allgemein- und Viszeralchirurgie (DGAV) und Experten auf einer Sitzung des Viszeralmedizin-Kongresses in Wiesbaden 2019 vorgestellt. Bei der abschließenden Formulierung der Empfehlungen wurde ein starker Konsensus von 84% bei den Befragten erreicht. Ergebnisse Bei Nachweis oder Verdacht auf eine Infektion der Pankreasnekrosen besteht eine Indikation zur chirurgischen und interventionellen Behandlung (Empfehlungsgrad: stark; Evidenzstärke: schwach). In Ausnahmefällen stellen auch sterile Nekrosen eine Indikation zur Intervention dar. Wenn es der klinische Zustand erlaubt, sollte die Intervention bis in die 4. Krankheitswoche geschoben werden. Als Therapiestrategie wird mit hohem Evidenz- und Empfehlungsgrad der „step-up approach“ empfohlen. Diese Strategie der Therapieeskalation beinhaltet als 1. Maßnahme eine Drainagebehandlung und bei Erfolglosigkeit die minimalinvasive chirurgische oder endoskopische Nekrosektomie. Sind die minimalinvasiven Techniken nicht effektiv, ist die offene Nekrosektomie indiziert. Nach primärer Drainagebehandlung kann bei 35 – 50% der Patienten die 2. Therapiestufe der Nekrosektomie vermieden werden. Indikationen zur Notfalloperation sind Organperforation, Darmischämie, interventionell nicht stillbare Blutungen und das abdominelle Kompartmentsyndrom bei erfolgloser konservativer Therapie. Spätabszesse und symptomatische Pseudozysten sind Indikationen für eine interventionelle Drainagebehandlung. Bei der biliären Pankreatitis ist die Cholezystektomie indiziert, bei der milden Form frühelektiv und bei schwerem Verlauf frühestens nach 6 – 8 Wochen. Schlussfolgerung Die vorliegenden Empfehlungen enthalten Kriterien für die Indikationsstellung zur chirurgischen und interventionellen Behandlung der akuten Pankreatitis. Sie sollen als Referenzstandards für die Entscheidungsfindung in einem multidisziplinären Team dienen.

Background A minimally invasive step-up (MIS) approach has been associated with reduced morbidity compared with open surgical necrosectomy (OSN) for treatment of necrotizing pancreatitis. We sought to determine whether transitioning from an OSN to an MIS-based approach would result in reduced mortality. MIS interventions included percutaneous drainage, endoscopic transgastric necrosectomy, video-assisted retroperitoneal debridement, sinus tract endoscopic necrosectomy, or a combination of techniques, with selective use of OSN. Study Design We conducted an observational cohort study with retrospective comparison at a single tertiary referral center (2006 through 2019). Eighty-eight patients were treated with OSN and 91 were treated with an MIS-based approach. Baseline characteristics and clinical outcomes were compared between groups. The primary end point was 90-day mortality. Results There was no difference in baseline characteristics. Ninety-day mortality was 2% with MIS compared with 10% with OSN (p = 0.03). One-year mortality was 3% with MIS compared with 15% with OSN (p = 0.012). The rate of organ failure was lower with MIS (30% vs 45%; p = 0.029), but there was a higher bleeding rate (19% vs 9%; p = 0.064). In the MIS group, 9% were treated with percutaneous drainage, 32% with endoscopic transgastric necrosectomy, 8% with video-assisted retroperitoneal debridement, 15% with sinus tract endoscopic necrosectomy, and 27% with a combination of techniques. Conclusions Adoption of a multidisciplinary MIS-based approach to necrotizing pancreatitis resulted in a 5-fold decrease in mortality compared with OSN.

The article presents a clinical case of successful hybrid minimally invasive treatment of acute severe biliary necrotizing pancreatitis complicated by acute infected necrotic and fluid collections, abdominal sepsis. Endoscopic transgastric sequestrectomy in combination with polypositional percutaneous drainage and staged sanitation and drainage interventions allowed to avoid the traditional surgical treatment.

Background and study aims Infected necrotic collections extending deep into the retroperitoneum may not be amenable solely to endoscopic necrosectomy. Rendezvous transgastric and percutaneous sinus tract endoscopic necrosectomy was conceived to maximize debridement and obviate the need for open necrosectomy or video-assisted retroperitoneal debridement. Patients and methods Patients who underwent simultaneous rendezvous transgastric and sinus tract endoscopic transluminal necrosectomy at the same session were identified from a prospectively maintained database. Demographic data, clinical outcomes, immediate and late complications were evaluated. Results Among 415 patients with necrotizing pancreatitis, four patients (three males, median age 47 years) underwent this intervention after a median 29.5 days following placement of percutaneous drain. Intra-procedural bleeding following dilation of percutaneous tract required placement of esophageal stent for tamponade. No patients required rescue open necrosectomy or video assisted retroperitoneal debridement. Complete removal of percutaneous drains was accomplished in all patients after a median of 78.5 days. Conclusions Our novel approach is safe and effective and can expand the available armamentarium for management of large necrotic collection with deep retroperitoneal extension.

Background and objective: Acute pancreatitis (AP) is an inflammatory process of the pancreas, with variable involvement of peri-pancreatic tissues and remote organ systems. In this study we discuss surgical and conservative management of acute pancreatitis and its local complication. Methods: This retrospective study was carried out on 128 patients, who were admitted to Gastrointestinal Surgery Unit, Main Alexandria University Hospital, Alexandria University, and who were complaining of acute pancreatitis with fluid collections and sequels (PP, ANC and walled-off pancreatic necrosis (WOPN). Medical information was retrieved retrospectively from patient’s files recorded in Main Alexandria University Hospital and from computerized data system in Gastrointestinal Surgery Department, between October 2013 – October 2018. Results: Forty-five patients with acute edematous pancreatitis with free collection were managed conservatively successfully. Thirty-two patients with PP underwent drainage, endoscopic (n=17), or open (n=15) approach. Twentythree patients with WON underwent drainage and debridement whether by open (n=11), endoscopic (n=9), or PCD (n=3) approaches. Twenty-eight patients with necrotizing pancreatitis, 16 patients were managed conservatively, 12 patients needed intervention either, PCD (n=9) or open surgical necrosectomy (n=3). Conclusions: The operative management of acute pancreatitis is focused on managing the acute complications, and the long-term sequelae. However, the evolution of videoscopic and endoscopic techniques have greatly expanded the tools available.

Background/objectives Minimally invasive approaches, such as percutaneous drainage (PD), are increasingly utilized as initial treatment in necrotizing pancreatitis (NP) requiring intervention. Predictors of success of PD as definitive treatment are lacking. Our aim was to assess the application, predictors of success, and natural history of PD in NP. We hypothesized that necrosis morphology patterns and disconnected pancreatic duct syndrome (DPDS) may predict the ability of PD to provide definitive therapy. Methods 714 NP patients were treated from 2005 to 2018. Patients achieving disease resolution with PD alone (PD) were compared to those requiring an escalation in intervention (Step). Outcomes were compared between groups using independent samples t-test, Fisher’s exact test, and Pearson’s correlation, as appropriate. P Results 115 patients were initially managed with PD (42 PD, 73 Step). No difference in necrosis morphology was seen between the two groups. The PD group underwent significantly more repeat percutaneous interventions (PD, 3.2; Step, 2.0; P = 0.0006) including additional drain placement and drain upsize/reposition procedures. Patients with DPDS were more likely to require an escalation in intervention (odds ratio, 3.4; 95% confidence interval, 1.5–7.6; P = 0.003). The mean number of months to NP resolution was similar (PD, 5.7; Step, 5.8; P = 0.9). Mortality was similar (PD, 7%; Step 14%, P = 0.3). Conclusions Necrosis morphology in and of itself does not reliably predict successful definitive treatment by percutaneous drainage. However, patients with disconnected pancreatic duct syndrome were less likely to have definitive resolution with PD alone.

Background: Although minimally invasive pancreatic necrosectomy (MIPN) is a new invasive technique for necrotizing pancreatitis, it has some disadvantages. This study aimed to improve the debrideme...

Acute pancreatitis has a wide array of imaging presentations. Various classifications have been used in the past to standardize the terminology and reduce confusing and redundant terms. We aim to review the historical and current classifications of acute pancreatitis and propose a new reporting template which can improve communication between various medical teams by use of appropriate terminology and structured radiology template. The standardized reporting template not only conveys the most important imaging findings in a simplified yet comprehensive way but also allows structured data collection for future research and teaching purposes.

Background Disconnected pancreatic duct syndrome (DPDS) is common after necrotizing pancreatitis (NP). Surgical management may be by internal drainage or left (distal) pancreatectomy. Therapeutic decision-making must consider sinistral portal hypertension, parenchymal volume of disconnected pancreas, and timing relative to definitive management of pancreatic necrosis. The aim of this study is to evaluate outcomes after operative management for DPDS. Methods All patients with NP undergoing an operation for DPDS were included in the study (2005-2017). Perioperative outcomes and long-term durability were evaluated. Results Among 647 patients with NP, 299 (46%) had DPDS. Operative management was required in 202/299 (68%) patients with DPDS. Median follow-up was 30 mo (2-165). Definitive operative therapy included internal drainage (n = 111) or resection (n = 91). Time from NP diagnosis to operation was 126 d (20 d to 81 mo). Overall morbidity was 46%. Postoperative length of stay was 7 d (2-97). Readmission was required in 39 patients (19%). Mortality was 2%. Repeat pancreatic intervention was required in 23 patients (11%) at a median of 15 mo (1-98). Repeat pancreatectomy was performed in nine patients and the remaining 14 patients were managed with endoscopic therapy. Conclusions DPDS is a common and challenging consequence of NP. Appropriate operation is durable in nearly 90% of patients.

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.

Pancreatic necrosis is a highly morbid condition. It is most commonly associated with severe, acute pancreatitis, but can also be caused by trauma or chronic pancreatitis. Once diagnosed, management of pancreatic necrosis begins with supportive care, with an emphasis on early, and preferably, enteral nutrition. Intervention for necrosis, sterile or infected, is dictated by patient symptoms and response to conservative management. When possible, intervention should be delayed to allow the necrotic collection to form a capsule. First-line treatment for necrosis is with percutaneous drainage or endoscopic, transmural drainage. These strategies can be effective as monotherapy, but the need for repeated interventions, or for progression to more invasive interventions, is not uncommon. Necrosectomy may be performed using a previously established drainage tract, as in percutaneous endoscopic necrosectomy (PEN), video-assisted retroperitoneal debridement (VARD), and direct endoscopic necrosectomy (DEN). Although outcomes for these minimally-invasive techniques are better than for traditional necrosectomy, both laparoscopic and open techniques remain important for patients with extensive disease that cannot otherwise be adequately treated. This is especially true when pancreatic necrosis is complicated by disconnected pancreatic duct syndrome (DPDS), where necrosectomy remains standard of care.

The laparoscopic transgastric approach to infected pancreatic necrosis is an alternative to endoscopy deemed particularly interesting in patients with large retrogastric walled-off necrosis. It allows to carry out a cystogastrostomy and an initial extensive necrosectomy, adding the possibility of future endoscopic necrosectomies if needed. Frequently this technique is performed using an anterior gastrotomy to access the gastric lumen1,2 .

BACKGROUND: Mortality in infected pancreatic necrosis (IPN) is dynamic over the course of the disease, with type and timing of interventions as well as persistent organ failure being key determinants. The timing of infection onset and how it pertains to mortality is not well defined. OBJECTIVES: To determine the association between mortality and the development of early IPN. METHODS: International multicenter retrospective cohort study of patients with IPN, confirmed by a positive microbial culture from (peri) pancreatic collections. The association between timing of infection onset, timing of interventions and mortality were assessed using Cox regression analyses. RESULTS: A total of 743 patients from 19 centers across 3 continents with culture-confirmed IPN from 2000 to 2016 were evaluated, mortality rate was 20.9% (155/734). Early infection was associated with a higher mortality, when early infection occurred within the first 4 weeks from presentation with acute pancreatitis. After adjusting for comorbidity, advanced age, organ failure, enteral nutrition and parenteral nutrition, early infection (=4 weeks) and early open surgery (=4 weeks) were associated with increased mortality [HR: 2.45 (95% CI: 1.63-3.67), p 0.05). CONCLUSION: Early infection was associated with increased mortality, independent of interventions. Early surgery remains a strong predictor of excess mortality.

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.

Objectives Select patients with anatomically favorable walled off pancreatic necrosis may be treated by endoscopic (Endo-TGD) or operative (OR-TGD) transgastric debridement. We compared our experience with these two approaches. Summary background data Select necrotizing pancreatitis (NP) patients are suitable for transgastric debridement which may be accomplished endoscopically or surgically. Limited experience exists contrasting these techniques exists. Methods Patients undergoing Endo-TGD and OR-TGD at a single, high-volume pancreatic center between 2008-2019 were identified from a prospective database. Patient characteristics, procedural details, and outcomes of these two groups were compared. Results Among 498 NP patients undergoing necrosis intervention, 160 (32%) had TGD: 59 Endo-TGD and 101 OR-TGD. The groups were statistically similar in age, comorbidity, pancreatitis etiology, necrosis anatomy, pancreatitis severity, and timing of TGD from pancreatitis insult. OR-TGD required 1.1 ± 0.5 and Endo-TGD 3.0 ± 2.0 debridements/patient. Fewer hospital readmissions and repeat necrosis interventions, and shorter total inpatient length of stay were observed in OR-TGD patients. New onset organ failure [Endo-TGD (13%); OR-TGD (13%); P = 1.0] was similar between groups. Hospital length of stay after TGD was significantly longer in patients undergoing Endo-TGD (13.8 ± 20.8 days) compared to OR-TGD (9.4 ± 6.1 days; P = 0.047). Mortality was 7% in Endo-TGD and 1% in OR-TGD (P = 0.04). Conclusions Operative and endoscopic transgastric debridement achieve necrosis resolution with different temporal and procedural profiles. Clear multidisciplinary communication is essential to determine appropriate approach to individual necrotizing pancreatitis patients.

Background In patients with severe acute pancreatitis (SAP), infected pancreatic necrosis (IPN) is associated with a worsened outcome. We studied risk factors and consequences of IPN in patients with necrotizing SAP. Methods The study consisted of a retrospective cohort of 163 consecutive patients treated for necrotizing SAP at a university hospital intensive care unit (ICU) between 2010 and 2018. Results All patients had experienced at least one persistent organ failure and approximately 60% had multiple organ failure within the first 24 h from admission to the ICU. Forty-seven (28.8%) patients had IPN within 90 days. Independent risk factors for IPN were more extensive anatomical spread of necrotic collections (unilateral paracolic or retromesenteric (OR 5.7, 95% CI 1.5–21.1) and widespread (OR 21.8, 95% CI 6.1–77.8)) compared to local collections around the pancreas, postinterventional pancreatitis (OR 13.5, 95% CI 2.4–76.5), preceding bacteremia (OR 4.8, 95% CI 1.3–17.6), and preceding open abdomen treatment for abdominal compartment syndrome (OR 3.6, 95% CI 1.4–9.3). Patients with IPN had longer ICU and overall hospital lengths of stay, higher risk for necrosectomy, and higher readmission rate to ICU. Conclusions Wide anatomical spread of necrotic collections, postinterventional etiology, preceding bacteremia, and preceding open abdomen treatment were identified as independent risk factors for IPN.

Highlights • Infected WON cases are representing as challenging. • Step up approach is better than open necrosectomy in the treatment of infected WON. • Retroperitoneal necrosectomy represents a 2nd step in the step up approach. • Retroperitoneal necrosectomy using lavage circuit reduce the possible bleeding risk. • Retroperitoneal necrosectomy using lavage circuit is a simple and easy modification of VARD., Introduction Walled off necrosis (WON) is clarified according to the revised Atlanta classification, 2013, as a late phase complication of acute necrotizing pancreatitis. Not all cases with WON need intervention but, if indicated both open approach and minimally invasive techniques were clarified. We are discussing here, a case presented to us with infected WON. We adopted the step up approach as the main line of treatment; the case was managed by percutaneous catheter drainage (PCD) followed by retroperitoneal necrosectomy using lavage circuit. Case presentation Diabetic male patient aged 58 year old gave to us with left hypochondrial pain accompanied with easy fatigability and poorly controlled DM. The patient had an attack of acute pancreatitis (AP) 2 months before admission. Abdominal CECT revealed infected WON. The case was managed successfully by retroperitoneal necrozectomy using lavage circuit after failure of PCD. Discussion A step up approach is followed for determining the optimal interventional strategy for patients presented with infected necrosis. We adopt retroperitoneal debridement using lavage circuit as a 2nd step in this approach. The concept of this technique is to facilitate the detachment of necrotic tissue using the force of saline while minimizing the risk of bleeding. Conclusion Infected WON cases are representing as challenging, we require to get rid of the necrotic material with infected fluid and reduce the hazard of complications. In this technique, we have the advantage of retroperitoneal necrosectomy where we can remove only the loose necrotic tissue by saline force and so, reduce the possible bleeding risk.

Resumen La pancreatitis aguda es una entidad clínica grave con una incidencia anual de 5-80/100.000 habitantes en la población general. Es importante conocer las complicaciones derivadas de la pancreatitis aguda para un buen diagnóstico, tratamiento precoz y mejorar el pronóstico. Una de estas complicaciones es la formación de pseudoaneurismas. Presentamos el caso de un paciente con un pseudoaneurisma trilobulado dependiente de arteria mesentérica superior contenido en el interior de un área de necrosis encapsulada que se manejó de forma mínimamente invasiva mediante embolización selectiva con buena respuesta clínica.

Necrotizing pancreatitis is a very rare in children and is associated with high morbidity & mortality rates. We report a case of 5yr old boy who presented with upper abdominal pain, vomiting and non-passage of stool for 1day. After resuscitation and investigating the child, a provisional diagnosis of biliary ascariasis (BA) with acute pancreatitis was made. The child developed peritonitis after 2 days of admission and exploratory laparotomy was planned. An intraoperative diagnosis of necrotizing pancreatitis was made and the child was successfully managed.

Previous research focused on the qualitative discussion of the correlation between surgical time and mortality in acute pancreatitis (AP). Recommendations for surgical timing of necrotizing pancreatitis are delayed as far as possible, without recommendations for individuals. The aim of this article is to predict timing of surgical intervention in necrotizing pancreatitis with recurrent neural network (RNN). Time series data in AP were retrospectively extracted from a hospital in China (n = 15,813) to develop model, and the Cerner Health Facts database in the United States (n = 142,650) was used to externally validate. The developed model, time-aware Phased-Decay long short-term memory (LSTM), was used to predict timing of surgical intervention and critical clinical features in necrotizing pancreatitis based on laboratory tests, compared to other machine learning models. Area under the ROC curve (AUC) of RNN-based models was more than 0.70. The AUC of time-aware Phased-Decay LSTM (0.75) with more explanatory was similar to that (0.76) of Phased-Decay LSTM to predict surgical timing. The developed model visualized the specific surgical process and laboratory indicators changes for the patients with AP from the onset to discharge. Different clinical features had different contribution modes with time to the specific surgical event in AP. Heart function contributed the most to the prediction of surgical intervention at the onset and in the first week. Our developed model could monitor the specific surgical process from the onset of AP to discharge and extract the contribution modes of clinical features with time in necrotizing pancreatitis.

OBJECTIVE The aim of this study was to evaluate the role of surgical transgastric necrosectomy (TGN) for walled-off pancreatic necrosis (WON) in selected patients. BACKGROUND WON is a common consequence of severe pancreatitis and typically occurs 3 to 5 weeks after the onset of acute pancreatitis. When symptomatic, it can require intervention. METHODS A retrospective review of patients with WON undergoing surgical management at 3 high-volume pancreatic institutions was performed. Surgical indications, intervention timing, technical methodology, and patient outcomes were evaluated. Patients undergoing intervention

This report presents a case of necrotizing pancreatitis resulting in a large hepatic subcapsular hematoma that led to development of hepatic ischemia and early stages of liver failure. Following surgical decompression, liver function dramatically improved, but large areas of peripheral hepatic infarction had developed. This case demonstrates the risks of a rapidly expanding hepatic subcapsular hematoma, emphasizes the importance of recognizing and aggressively treating active bleeding, and cautions against administering anticoagulation and tissue-plasminogen activator in this clinical scenario. Keywords: Hepatic hematoma, Hepatic infarct, Necrotizing pancreatitis