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Introduction: Acute pancreatitis (AP) is a common and potentially lethal disease. Approximately 10–20% of the patients progress to necrotizing pancreatitis (NP). The step-up approach is the gold standard approach to managing an infected necrotizing pancreatitis with acceptable morbidity and mortality rates. Video-assisted retroperitoneal debridement (VARD) has been described as a safe and feasible approach with high success rates. Multiple studies in the American, European, and Asian populations evaluating the outcomes of VARD have been published; nevertheless, outcomes in the Latin American population are unknown. This study aims to describe a single-center experience of VARD for necrotizing pancreatitis in Colombia with a long-term follow-up. Methods: A prospective cohort study was conducted between 2016 and 2024. All patients over 18 years old who underwent VARD for necrotizing pancreatitis were included. Demographic, clinical variables, and postoperative outcomes at 30-day follow-up were described. Results: A total of 12 patients were included. The mean age was 55.9 years old (SD 13.73). The median follow-up was 365 days (P25 60; P75 547). Bile origin was the most frequent cause of pancreatitis in 90.1% of the patients. The mean time between diagnosis and surgical management was 78.5 days (SD 22.93). The mean size of the collection was 10.5 cm (SD 3.51). There was no evidence of intraoperative complications. The mean in-hospital length of stay was 65.18 days (SD 26.46). One patient died in a 30-day follow-up. One patient presented an incisional hernia one year after surgery, and there was no evidence of endocrine insufficiency at the follow-up. Conclusion: According to our data, the VARD procedure presents similar outcomes to those reported in the literature; a standardized procedure following the STEP-UP procedure minimizes the requirement of postoperative drainages. Long-term follow-up should be performed to rule out pancreatic insufficiency. [ABSTRACT FROM AUTHOR]

Abstract Introduction Acute pancreatitis (AP) is a common and potentially lethal disease. Approximately 10–20% of the patients progress to necrotizing pancreatitis (NP). The step-up approach is the gold standard approach to managing an infected necrotizing pancreatitis with acceptable morbidity and mortality rates. Video-assisted retroperitoneal debridement (VARD) has been described as a safe and feasible approach with high success rates. Multiple studies in the American, European, and Asian populations evaluating the outcomes of VARD have been published; nevertheless, outcomes in the Latin American population are unknown. This study aims to describe a single-center experience of VARD for necrotizing pancreatitis in Colombia with a long-term follow-up. Methods A prospective cohort study was conducted between 2016 and 2024. All patients over 18 years old who underwent VARD for necrotizing pancreatitis were included. Demographic, clinical variables, and postoperative outcomes at 30-day follow-up were described. Results A total of 12 patients were included. The mean age was 55.9 years old (SD 13.73). The median follow-up was 365 days (P25 60; P75 547). Bile origin was the most frequent cause of pancreatitis in 90.1% of the patients. The mean time between diagnosis and surgical management was 78.5 days (SD 22.93). The mean size of the collection was 10.5 cm (SD 3.51). There was no evidence of intraoperative complications. The mean in-hospital length of stay was 65.18 days (SD 26.46). One patient died in a 30-day follow-up. One patient presented an incisional hernia one year after surgery, and there was no evidence of endocrine insufficiency at the follow-up. Conclusion According to our data, the VARD procedure presents similar outcomes to those reported in the literature; a standardized procedure following the STEP-UP procedure minimizes the requirement of postoperative drainages. Long-term follow-up should be performed to rule out pancreatic insufficiency.

Necrotizing pancreatitis (NP) is a severe form of acute pancreatitis associated with high morbidity and mortality. The management of infected necrotizing pancreatitis (INP) has evolved from open surgical necrectomy to minimally invasive techniques, such as percutaneous catheter drainage (PCD). We report the case of a 71-year-old male with a history of cholelithiasis who presented with acute abdominal pain, nausea, and vomiting. Initial imaging revealed an enlarged pancreas with peripancreatic fluid collections. Conservative treatment improved his condition, but nine days later signs of sepsis, including a persistent fever were presented. Computed tomography (CT) verified several large gas-containing fluid collections spreading from the pancreas to the left iliac crest along with bilateral pleural effusions. The patient underwent PCD with multiple drains inserted. Microbiological analysis showed Meropenem-resistant E. coli , leading to a change in antibiotic therapy. Follow-up imaging confirmed the resolution of fluid collections, and the patient recovered without requiring laparotomy. PCD has emerged as a crucial component of the step-up approach in managing INP. Compared with open necrectomy, PCD offers lower mortality and morbidity rates. The PAncreatitis, Necrosectomy versus sTEp up appRoach (PANTER) trial and subsequent studies have validated the efficacy of PCD, demonstrating its ability to reduce complications and healthcare costs while improving patient outcomes. PCD is a safe and effective treatment for INP, representing a valuable alternative to traditional surgical methods. This case underscores the importance of minimally invasive strategies in the management of NP. [ABSTRACT FROM AUTHOR]

Aim: Endoscopic necrosectomy has become the first-line treatment option for infectious necrotizing pancreatitis (INP), especially walled-off necrosis. However, the problems, including operation-related adverse events (AEs) and the need for multiple endoscopic procedures, have not been effectively addressed. We sought to evaluate the clinical safety and efficacy of anhydrous ethanol-assisted endoscopic ultrasound (EUS)-guided transluminal necrosectomy in INP. Methods: A single-center observational cohort study of INP patients was conducted in a tertiary endoscopic center. Anhydrous ethanol-assisted EUS-guided transluminal necrosectomy (modified group) and conventional endoscopic necrosectomy (conventional group) were retrospectively compared in INP patients. The technical and clinical success rates, operation time, perioperative AEs, postoperative hospital stay, and recurrent INP rates were analyzed, respectively. Results: A total of 55 patients were enrolled. No statistically significant differences were observed between the two groups regarding baseline characteristics. Compared to patients in the conventional group, patients in the modified group demonstrated significantly reduced times of endoscopic transluminal necrosectomies (1.96 ± 0.89 vs. 2.73 ± 0.98; P = 0.004) and comparable perioperative AEs (P = 0.35). Meanwhile, no statistically significant differences were observed in the technical and clinical success rates (P = 0.92), operation time (P = 0.59), postoperative hospital stay (P = 0.36), and recurrent INP rates (P = 1.00) between the two groups. Conclusion: Anhydrous ethanol-assisted EUS-guided transluminal necrosectomy seemed safe and effective in treating INP. Compared with conventional endoscopic transluminal necrosectomy, its advantage was mainly in reducing the number of endoscopic necrosectomies without increasing perioperative AEs. [ABSTRACT FROM AUTHOR]

Objective: To compare the long-term outcomes of immediate drainage versus the postponed-drainage approach in patients with infected necrotizing pancreatitis. Background: In the randomized POINTER trial, patients assigned to the postponed-drainage approach using antibiotic treatment required fewer interventions, as compared with immediate drainage, and over a third were treated without any intervention. Methods: Clinical data of those patients alive after the initial 6-month follow-up were re-evaluated. The primary outcome was a composite of death and major complications. Results: Out of 104 patients, 88 were re-evaluated with a median follow-up of 51 months. After the initial 6-month follow-up, the primary outcome occurred in 7 of 47 patients (15%) in the immediate-drainage group and 7 of 41 patients (17%) in the postponed-drainage group (RR 0.87, 95% CI 0.33–2.28; P =0.78). Additional drainage procedures were performed in 7 patients (15%) versus 3 patients (7%) (RR 2.03; 95% CI 0.56–7.37; P =0.34). The median number of additional interventions was 0 (IQR 0–0) in both groups (P =0.028). In the total follow-up, the median number of interventions was higher in the immediate-drainage group than in the postponed-drainage group (4 vs. 1, P =0.001). Eventually, 14 of 15 patients (93%) in the postponed-drainage group who were successfully treated in the initial 6-month follow-up with antibiotics and without any intervention remained without intervention. At the end of follow-up, pancreatic function and quality of life were similar. Conclusions: Also, during long-term follow-up, a postponed-drainage approach using antibiotics in patients with infected necrotizing pancreatitis results in fewer interventions as compared with immediate drainage and should therefore be the preferred approach. Trial registration: ISRCTN33682933 [ABSTRACT FROM AUTHOR]

Acute pancreatitis is a common condition of the digestive system, but sometimes it develops into severe cases. In about 10–20% of patients, necrosis of the pancreas or its periphery occurs. Although most have aseptic necrosis, 30% of cases will develop infectious necrotizing pancreatitis. Infected necrotizing pancreatitis (INP) requires a critical treatment approach. Minimally invasive surgical approach (MIS) and endoscopy are the management methods. This meta-analysis compares the outcomes of MIS and endoscopic treatments. We searched a medical database until December 2022 to compare the results of endoscopic and MIS procedures for INP. We selected eligible randomized controlled trials (RCTs) that reported treatment complications for the meta-analysis. Five RCTs comparing a total of 284 patients were included in the meta-analysis. Among them, 139 patients underwent MIS, while 145 underwent endoscopic procedures. The results showed significant differences (p < 0.05) in the risk ratios (RRs) for major complications (RR: 0.69, 95% confidence interval (CI): 0.49–0.97), new onset of organ failure (RR: 0.29, 95% CI: 0.11–0.82), surgical site infection (RR: 0.26, 95% CI: 0.07–0.92), fistula or perforation (RR: 0.27, 95% CI: 0.12–0.64), and pancreatic fistula (RR: 0.14, 95% CI: 0.05–0.45). The hospital stay was significantly shorter for the endoscopic group compared to the MIS group, with a mean difference of 6.74 days (95% CI: −12.94 to −0.54). There were no significant differences (p > 0.05) in the RR for death, bleeding, incisional hernia, percutaneous drainage, pancreatic endocrine deficiency, pancreatic exocrine deficiency, or the need for enzyme use. Endoscopic management of INP performs better compared to surgical treatment due to its lower complication rate and higher patient life quality. [ABSTRACT FROM AUTHOR]

Background: For infected necrotizing pancreatitis (INP), percutaneous catheter drainage (PCD) is now widely acknowledged as the initial intervention in a step-up approach, followed, if necessary, by minimally invasive necrosectomy or even open pancreatic necrosectomy. However, an overemphasis on PCD may cause a patient's condition to deteriorate, leading to missed surgical opportunities or even death. This study aimed to develop a simple and convenient scoring tool for assessing the need for surgery in INP patients who received PCD procedures. Methods: In an observational study conducted between April 2015 and December 2020, PCD was utilized as the initial step to treat 143 consecutive INP patients. A surgical necrosectomy was performed when the patient failed to respond. Risk factors of PCD failure (i.e., need for surgical necrosectomy) were identified by multivariate logistic regression models. An integer-based risk scoring tool was developed using the β coefficients derived from the logistic regression model. Results: In 62 (43.4%) patients, PCD was successful, while the remaining 81 (56.6%) individuals required subsequent surgical necrosectomy. In the multivariate model, organ failure, percentage of pancreatic necrosis, extrapancreatic necrosis volume, and mean CT density of extrapancreatic necrosis volume were associated with a need for surgical necrosectomy. A predictive scoring tool based on these four factors demonstrated an area under the receiver operating characteristic curve (AUC) of 0.893. Under the scoring tool, a total score of 4 or more indicates a high possibility of surgical necrosectomy being required (at least 80%). Using the coordinates of the receiver operating characteristic curve (ROC), the sensitivity and specificity at this threshold are 0.802 and 0.903, respectively. Conclusions: A risk score model integrating organ failure, percentage of pancreatic necrosis, extrapancreatic necrosis volume, and mean CT density of extrapancreatic necrosis volume can identify INP patients at high risk for necrosectomy. The straightforward risk assessment tool assists clinicians in stratifying INP patients and making more judicious medical decisions. [ABSTRACT FROM AUTHOR]

AbstractBackground/Aims Acute pancreatitis is a common condition of the digestive system, but sometimes it develops into severe cases. In about 10–20% of patients, necrosis of the pancreas or its periphery occurs. Although most have aseptic necrosis, 30% of cases will develop infectious necrotizing pancreatitis. Infected necrotizing pancreatitis (INP) requires a critical treatment approach. Minimally invasive surgical approach (MIS) and endoscopy are the management methods. This meta-analysis compares the outcomes of MIS and endoscopic treatments.Methods We searched a medical database until December 2022 to compare the results of endoscopic and MIS procedures for INP. We selected eligible randomized controlled trials (RCTs) that reported treatment complications for the meta-analysis.Results Five RCTs comparing a total of 284 patients were included in the meta-analysis. Among them, 139 patients underwent MIS, while 145 underwent endoscopic procedures. The results showed significant differences (p 0.05) in the RR for death, bleeding, incisional hernia, percutaneous drainage, pancreatic endocrine deficiency, pancreatic exocrine deficiency, or the need for enzyme use.Conclusions Endoscopic management of INP performs better compared to surgical treatment due to its lower complication rate and higher patient life quality.

Background: Previous studies have shown that minimally invasive treatment for infected necrotizing pancreatitis (INP) may be safer and more effective than open necrosectomy (ON), but ON is still irreplaceable in a portion of INP patients. Furthermore, there is a lack of tools to identify INP patients at risk of minimally invasive step-up approach failure (eventually received ON or died), which may enable appropriate treatment for them. Our study aims to identify risk factors that can predict minimally invasive step-up approach failure in INP patients and to develop a nomogram for early prediction. Methods: Multivariate logistic regression was performed to evaluate the association between minimally invasive step-up approach failure and factors regarding demographics, disease severity, laboratory index, and the location of extrapancreatic necrotic collections. A novel nomogram was developed, and its performance was validated both internally and externally by its discrimination, calibration, and clinical usefulness. Results: There were 267, 89, and 107 patients in the training, internal, and external validation cohorts, respectively. Multivariate logistic regression demonstrated that the computed tomography severity index (CTSI) greater than 8 points, Acute Physiology and Chronic Health Evaluation II (APACHE II) score of 16 points or more, early spontaneous bleeding, fungi infection, granulocyte and platelet decrease within 30 days of acute pancreatitis onset, and extrapancreatic necrosis collection located in small bowel mesentery were independent risk factors for minimally invasive step-up approach failure. The area under the curve and coefficient of determination (R²) of the nomogram constructed from the above factors were 0.920 and 0.644, respectively. The Hosmer-Lemeshow test showed that the model had good fitness (P= 0.206). In addition, the nomogram performed well in both the internal and external validation cohorts. Conclusions: The nomogram had a good performance in predicting minimally invasive step-up approach failure, which may help clinicians distinguish INP patients at risk of minimally invasive step-up approach failure early. [ABSTRACT FROM AUTHOR]

Pancreatitis is a rare but serious condition in obstetric patients, associated with significant morbidity and mortality. It can range from mild acute pancreatitis to severe complications such as necrosis, abscesses, pseudocysts, and multi-organ failure. While hypertriglyceridemia is a common cause, pancreatitis has also been linked to preeclampsia and shock. We present the case of a 22-year-old primigravida who developed an infected pancreatic pseudocyst 27 days after a cesarean section performed at 35 + 1 weeks of gestation due to preeclampsia/hemolysis, elevated liver enzymes, and low platelets (HELLP) syndrome, complicated by disseminated intravascular coagulation (DIC) and shock. Initial CT scans revealed a large pseudocyst, which was managed conservatively with antibiotics and ultrasound-guided drainage. On the 46th postoperative day, the patient underwent a retroperitoneal incision and drainage. She was discharged three days after the procedure, and a follow-up two weeks later showed complete recovery and healing of the drainage wound. The current literature lacks established treatment guidelines for managing pancreatitis and its complications in obstetric patients. Based on this case and a review of previous reports, we recommend an approach that starts with conservative management, followed by minimally invasive procedures if necessary, for treating infected pancreatic pseudocysts in the postpartum period. Given that patients are already recovering from the stresses of pregnancy and delivery, avoiding highly invasive techniques that require additional anesthesia or surgery can help minimize stress and improve overall well-being., Competing Interests: Human subjects: Consent for treatment and open access publication was obtained or waived by all participants in this study. Conflicts of interest: In compliance with the ICMJE uniform disclosure form, all authors declare the following: Payment/services info: All authors have declared that no financial support was received from any organization for the submitted work. Financial relationships: All authors have declared that they have no financial relationships at present or within the previous three years with any organizations that might have an interest in the submitted work. Other relationships: All authors have declared that there are no other relationships or activities that could appear to have influenced the submitted work., (Copyright © 2024, Cheema et al.)

Necrotizing gallstone pancreatitis is a rare and severe form of pancreatitis, particularly uncommon in the pediatric population. While gallstone pancreatitis is increasingly recognized in children, necrotizing cases remain exceptional. We report a four-and-a-half-year-old Pakistani American male presenting with generalized weakness, abdominal pain, and vomiting. Initial symptoms followed a recent upper respiratory infection. Clinical evaluation revealed an intermittently drowsy-appearing patient with a Glasgow Coma Scale (GCS) of 15 when fully alert, hypotension, diffuse abdominal tenderness, and signs of possible sepsis. Laboratory tests showed elevated lipase levels and conjugated hyperbilirubinemia. Ultrasound identified gallstones and necrotizing changes in the pancreas, which were later confirmed by CT imaging. The patient was admitted to the pediatric intensive care unit for aggressive management of necrotizing pancreatitis, including fluid resuscitation, antibiotic therapy, and nutritional support. He underwent laparoscopic cholecystectomy and developed Clostridium difficile colitis, which was managed with targeted antibiotics. The patient had a 26-day hospital stay and was followed up with negative results from clinical exome sequencing for related disorders. This case underscores the diagnostic and management complexities associated with pediatric necrotizing gallstone pancreatitis. The need for a multidisciplinary approach and adherence to clinical guidelines is emphasized. This report contributes valuable insights into the rare presentation of necrotizing pancreatitis in children and highlights the importance of early and comprehensive intervention., Competing Interests: Human subjects: Consent was obtained or waived by all participants in this study. Conflicts of interest: In compliance with the ICMJE uniform disclosure form, all authors declare the following: Payment/services info: All authors have declared that no financial support was received from any organization for the submitted work. Financial relationships: All authors have declared that they have no financial relationships at present or within the previous three years with any organizations that might have an interest in the submitted work. Other relationships: This research was supported (in whole or in part) by HCA Healthcare and/or an HCA Healthcare affiliated entity. The views expressed in this publication represent those of the author(s) and do not necessarily represent the official views of HCA Healthcare or any of its affiliated entities., (Copyright © 2024, Farsani et al.)

The incidence of acute pancreatitis varies globally, and its rates are increasing. Timely intervention in cases of infected necrosis is crucial to effective management. The landscape of acute pancreatitis management has undergone transformation through adopting a "step-up" strategy, accentuating the shift towards minimally invasive techniques. A 63-year-old patient with acute pancreatitis and infected pancreatic necrosis underwent a challenging yet successful treatment using video-assisted retroperitoneal debridement employing a two-port approach facilitated access for an intricate area. The procedure, performed 45 days after admission, effectively reduced peripancreatic collections, demonstrating the efficacy of this approach in managing complex cases of infected pancreatic necrosis. The management of acute pancreatitis has evolved towards a comprehensive strategy involving early hydration, nutritional support, effective pain management, and interventions. Infected pancreatic necrosis poses a serious complication, with minimally invasive techniques such as video-assisted retroperitoneal debridement (VARD) emerging as preferred options. The efficacy and safety of VARD in complex cases are highlighted, although challenges persist, especially in extensive necrosis. The VARD procedure, a key component of the step-up approach, exhibits a remarkable safety profile, substantially reducing postoperative complications and mortality compared to open surgical counterparts. However, challenges persist in managing cases of infected Walled-Off Necrosis with deep extension, necessitating carefully considering a minimal-access approach. We report our experience using the VARD in a two-port approach. • Infected pancreatic necrosis poses high morbidity and mortality risks. • Management evolution: Shift from traditional open surgery to "step-up" strategy using minimally invasive techniques. • A 63-year-old patient with acute pancreatitis underwent video-assisted retroperitoneal debridement. • Timing is key: Delay intervention in sterile necrosis. Inmmediate action needed for infected necrosis to reduce mortality. • Managing infected necrosis is tough, sometimes needing extra open necrosectomy; consider minimal-access approaches. [ABSTRACT FROM AUTHOR]

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• 5% of patients with acute pancreatitis develop infected necrotizing pancreatitis. • The best approach for debridement of necrotizing pancreatitis is under debate. • Necrosectomy using a SILS port seems a good minimally invasive technique. Approximately 5% of patients with acute pancreatitis develop infected necrotizing pancreatitis, with reported mortality rates up to 32%. Surgical interventions are postponed as long as possible, but if surgical debridement is needed the optimal approach has not been found yet. A 47-year-old male was referred to our tertiary centre with infected necrotizing pancreatitis. Two months after initial presentation and repeated percutaneous drainage, surgical retroperitoneal debridement of the necrotic tissue was performed using a single incision laparoscopic surgery (SILS) port. Postoperatively, percutaneous drainage was performed two more times, but no additional surgical interventions were needed. The patient was discharged one month after the surgical procedure. This is the first report of a minimally invasive technique using a SILS port for debridement of necrotizing pancreatitis. The ability to create a stable pneumo-retroperitoneum leads to optimal visualisation, better haemostasis, more space to operate in, better instrument handling, and better tissue control. [ABSTRACT FROM AUTHOR]

Background/aim: This study aimed to investigate the effect of technical details of percutaneous catheter drainage (PCD) on the clinical outcomes of patients with infected necrotizing pancreatitis (INP). Materials and methods: A total of 44 INP patients treated in our hospital from October 2013 to October 2015 were included. The correlations of the first PCD treatment data and the clinical outcomes were analyzed. Results: The number of catheters was positively correlated with hospital readmission (r = 0.335, P = 0.032). Receiver operating characteristic curve analysis showed that patients with = 3 catheters were more likely to have hospital readmission. Patients with pleural effusion undergoing thoracentesis were more likely to have new intensive care unit admission (P = 0.025) and bleeding in need of intervention (P = 0.032). Patients with more effusion regions had higher incidences of mortality (P = 0.012) and new intensive care unit admissions (2.44 ± 1.03 vs. 1.88 ± 0.80; P = 0.059). Patients with PCD only were less likely to have new intensive care unit admissions (22.22% vs. 54.55%; P = 0.038) than those with PCD + small incision or/and videoscopic assisted retroperitoneal debridement. Conclusion: Number of catheters greater than three was associated with unfavorable outcomes of PCD treatment in INP patients. Patients that received PCD treatment only had better outcomes. [ABSTRACT FROM AUTHOR]

Necrotizing pancreatitis has historically been treated with open necrosectomy, which carries a high morbidity and mortality rate. More recently, there has been a shift towards endoscopic and percutaneous approaches employed as part of a minimally invasive step-up approach. Herein, we describe the technical approaches to video-assisted retroperitoneal debridement and sinus tract endoscopic debridement of pancreatic necrosis. Additionally, we review important patient selection considerations and the strengths and weaknesses of each of the approaches. [ABSTRACT FROM AUTHOR]

Purpose of Review: Endoscopic management of infected necrotizing pancreatitis has evolved rapidly over the past years and there have been interesting innovations in this field. This review provides an update on the most recently published literature regarding endoscopic management of infected necrotizing pancreatitis.Recent Findings: A recent randomized trial demonstrated no difference in mortality and major morbidity between endoscopic and surgical step-up treatment of infected necrotizing pancreatitis. However, endoscopic therapy resulted in shorter hospital stay and less pancreatic fistulas. Various innovations have been investigated with the aim to further optimize endoscopic therapy, in particular lumen-apposing metal stents. While major stent-related complications were also reported, findings from recent studies indicated that their use was associated with higher resolution rates of walled-off necrosis compared to double-pigtail stents. Other innovations, such as the multiple gateway technique and dual-modality mode, can be considered for treatment of particular cases. Furthermore, research suggests that irrigation of walled-off necrosis can be performed by using a nasocystic tube and discontinuation of proton-pump inhibitors may be considered.Summary: Endoscopic treatment should be the preferred treatment modality in patients with infected necrotizing pancreatitis who are eligible for endoscopic drainage. Although data suggests that lumen-apposing metal stents are superior to double-pigtail stents, prospective multicenter studies focusing on safety as well as long-term follow-up are first needed. [ABSTRACT FROM AUTHOR]

Background: Step-up therapy is the recommended therapy for infected necrotizing pancreatitis (INP). However, the most appropriate secondary therapy for use after initial drainage has not been fully determined. This meta-analysis was designed to evaluate the efficacy and safety of retroperitoneal versus open intraperitoneal necrosectomy as part of a step-up strategy for INP.Materials and Methods: Eight online databases were searched for randomized controlled trials (RCTs) and cohorts comparing retroperitoneal and open intraperitoneal step-up approaches for treating INP. The data was pooled with a random-effects model.Results: A total of 21 controlled studies (one RCT and twenty cohorts) and 2177 patients were included in this study. Our meta-analysis showed that the retroperitoneal group had a lower postoperative complication rate [risk ratio (RR) = 0.575, 95% confidence interval (CI) = 0.459 to 0.719, P < 0.001], lower postoperative mortality (RR = 0.525, 95% CI = 0.430 to 0.642, P < 0.001), higher technical success rate (RR = 1.313, 95% CI = 1.017 to 1.694, P = 0.037), similar surgical reintervention rate (RR = 0.930, 95% CI = 0.783 to 1.106, P = 0.411), shorter operative time [standardized mean difference (SMD) = -2.402, 95% CI = -3.642 to -1.161, P < 0.001], and shorter hospital stay (SMD = -2.034, 95% CI = -3.041 to -1.026, P < 0.001) than the open group. These results were supported by a subgroup analysis.Conclusion: For treating INP, the retroperitoneal approach is safer and more effective than the open intraperitoneal approach. [ABSTRACT FROM AUTHOR]

Pancreatic necrosectomy (PN) following percutaneous catheter drainage (PCD) is an effective method of treating patients with necrotizing pancreatitis, however, the predictive factors for PN after PCD have not yet been identified. A total of 74 patients with suspected infected necrotizing pancreatitis (INP) and peripancreatic fluid collection were enrolled in the current study between October 2010 and October 2015. These patients received ultrasound or computer topography guided PCD followed by PN. Patients were divided into two groups: i) A PCD-alone group (n=32) and ii) a PCD+necrosectomy group (n=42). Multivariate analysis revealed that reduction of fluid collection after PCD (P=0.021), maximum extent of peripancreatic necrosis (P=0.019) and multiple organ failure (P=0.017) were predictors of PN following PCD. A prediction model was produced to evaluate the aforementioned factors and indicated that the area under the receiver operating characteristic curve was 0.827. The probability of successful PCD was determined using a prognostic nomogram. Thus, the results of the current study demonstrated that a reduction of fluid collection by <50% following PCD, a maximum extent of peripancreatic necrosis of >50% and multiple organ failure are effective predictors of necrosectomy in patients with INP following PCD failure. [ABSTRACT FROM AUTHOR]

Introduction: At least 30% of patients with infected necrotizing pancreatitis are successfully treated with catheter drainage alone. It is currently not possible to predict which patients also need necrosectomy. We evaluated predictive factors for successful catheter drainage. Methods: This was a post hoc analysis of 130 prospectively included patients undergoing catheter drainage for (suspected) infected necrotizing pancreatitis. Using logistic regression, we evaluated the association between success of catheter drainage (ie, survival without necrosectomy) and 22 factors regarding demographics, disease severity (eg, Acute Physiology And Chronic Health Evaluation II score, organ failure), and morphologic characteristics on computed tomography (eg, percentage of necrosis). Results: Catheter drainage was performed percutaneously in 113 patients and endoscopically in 17 patients. Infected necrosis was confirmed in 116 patients (89%). Catheter drainage was successful in 45 patients (35%). In multivariable regression, the following factors were associated with a reduced chance of success: male sex [odds ratio (OR) 0.27; 95% confidence interval (CI): 0.09-0.55; P<0.01), multiple organ failure (OR=0.15; 95% CI: 0.04- 0.62; P<0.01), percentage of pancreatic necrosis (<30%/30%-50%/>50%: OR=0.54; 95% CI: 0.30-0.96; P=0.03), and heterogeneous collection (OR=0.21; 95% CI: 0.06-0.67; P<0.01). A prediction model incorporating these factors demonstrated an area under the receiver operating characteristic curve of 0.76. A prognostic nomogram yielded success probability of catheter drainage from 2% to 91%. Conclusions: Male sex, multiple organ failure, increasing percentage of pancreatic necrosis and heterogeneity of the collection are negative predictors for success of catheter drainage in infected necrotizing pancreatitis. The constructed nomogram can guide prognostication in clinical practice and risk stratification in clinical studies. [ABSTRACT FROM AUTHOR]

Infected necrotizing pancreatitis (INP) represents a severe condition in patients with acute pancreatitis. Invasive interventions are recommended in symptomatic INP. Growing evidence has suggested interventional strategies of INP evolving from traditional surgery to minimally invasive step-up endoscopic procedures. However, there is still no standardized protocol for endoscopic interventions. Recently, various studies have been published about the endoscopic management of INP. This article reviews published articles and guidelines to present the progress and challenges of endoscopic transluminal drainage and necrosectomy in INP., Competing Interests: Conflict-of-interest statement: All authors declare no conflicts of interest associated with this manuscript., (©The Author(s) 2023. Published by Baishideng Publishing Group Inc. All rights reserved.)

Open anterior necrosectomy is no longer considered the first approach for the up to 20% of patients with acute pancreatitis who develop infected necrosis. When endoscopic debridement and percutaneous drains fail, video assisted retroperitoneal debridement (VARD) is now the favored surgical approach. We report a current patient who underwent the VARD procedure and provide a seven-year follow-up on ten additional patients who underwent the VARD procedure for infected pancreatic necrosis between 2010 and 2015. We analyzed patient demographics, APACHE II scores, length of hospital stay, number of VARD procedures, and surgical complications. During this study period, we cared for 320 patients, 59 women, and 261 men, with acute necrotizing pancreatitis. Ten of our patients ultimately underwent the VARD procedure. We report a 50% overall complication rate and a 20% mortality rate. Two of the patients who underwent the VARD procedure had already undergone open necrosectomy; two additional patients in the VARD group required open necrosectomy after the VARD procedure. Our current case report demonstrates the effectiveness of the VARD procedure for patients with infected pancreatic necrosis. Our case series provides additional details regarding the significant morbidity and mortality associated with infected pancreatic necrosis. We acknowledge that despite following the step-up protocol, both VARD procedures and open necrosectomy may still be required. • VARD is a first option when surgery is required for infected necrotizing pancreatic necrosis. • The VARD procedure requires placement of percutaneous CT guided retroperitoneal flank drains. • Complications of the VARD procedure include bleeding, bowel injury, and pancreatic fistula. [ABSTRACT FROM AUTHOR]

Background/aim: This study aimed to investigate the effect of technical details of percutaneous catheter drainage (PCD) on the clinical outcomes of patients with infected necrotizing pancreatitis (INP)., Materials and Methods: A total of 44 INP patients treated in our hospital from October 2013 to October 2015 were included. The correlations of the first PCD treatment data and the clinical outcomes were analyzed., Results: The number of catheters was positively correlated with hospital readmission (r = 0.335, P = 0.032). Receiver operating characteristic curve analysis showed that patients with ≥ 3 catheters were more likely to have hospital readmission. Patients with pleural effusion undergoing thoracentesis were more likely to have new intensive care unit admission (P = 0.025) and bleeding in need of intervention (P = 0.032). Patients with more effusion regions had higher incidences of mortality (P = 0.012) and new intensive care unit admissions (2.44 ± 1.03 vs. 1.88 ± 0.80; P = 0.059). Patients with PCD only were less likely to have new intensive care unit admissions (22.22% vs. 54.55%; P = 0.038) than those with PCD + small incision or/and videoscopic assisted retroperitoneal debridement., Conclusion: Number of catheters greater than three was associated with unfavorable outcomes of PCD treatment in INP patients. Patients that received PCD treatment only had better outcomes., (This work is licensed under a Creative Commons Attribution 4.0 International License.)

Aim: To explore the value of three-dimensional (3D) visualization technology in the minimally invasive treatment for infected necrotizing pancreatitis (INP)., Methods: Clinical data of 18 patients with INP, who were admitted to the PLA General Hospital in 2017, were retrospectively analyzed. Two-dimensional images of computed tomography were converted into 3D images based on 3D visualization technology. The size, number, shape and position of lesions and their relationship with major abdominal vasculature were well displayed. Also, percutaneous catheter drainage (PCD) number and puncture paths were designed through virtual surgery (percutaneous nephroscopic necrosectomy) based on the principle of maximum removal of infected necrosis conveniently., Results: Abdominal 3D visualization images of all the patients were well reconstructed, and the optimal PCD puncture paths were well designed. Infected necrosis was conveniently removed in abundance using a nephroscope during the following surgery, and the median operation time was 102 (102 ± 20.7) min. Only 1 patient underwent endoscopic necrosectomy because of residual necrosis., Conclusion: The 3D visualization technology could optimize the PCD puncture paths, improving the drainage effect in patients with INP. Moreover, it significantly increased the efficiency of necrosectomy through the rigid nephroscope. As a result, it decreased operation times and improved the prognosis., Competing Interests: Conflict-of-interest statement: All authors declare no conflicts-of-interest related to this article.

Pancreatic necrosectomy (PN) following percutaneous catheter drainage (PCD) is an effective method of treating patients with necrotizing pancreatitis, however, the predictive factors for PN after PCD have not yet been identified. A total of 74 patients with suspected infected necrotizing pancreatitis (INP) and peripancreatic fluid collection were enrolled in the current study between October 2010 and October 2015. These patients received ultrasound or computer topography guided PCD followed by PN. Patients were divided into two groups: i) A PCD-alone group (n=32) and ii) a PCD+necrosectomy group (n=42). Multivariate analysis revealed that reduction of fluid collection after PCD (P=0.021), maximum extent of peripancreatic necrosis (P=0.019) and multiple organ failure (P=0.017) were predictors of PN following PCD. A prediction model was produced to evaluate the aforementioned factors and indicated that the area under the receiver operating characteristic curve was 0.827. The probability of successful PCD was determined using a prognostic nomogram. Thus, the results of the current study demonstrated that a reduction of fluid collection by <50% following PCD, a maximum extent of peripancreatic necrosis of >50% and multiple organ failure are effective predictors of necrosectomy in patients with INP following PCD failure.

In 1886, Senn stated that removing necrotic pancreatic and peripancreatic tissue would benefit patients with severe acute pancreatitis. Since then, necrosectomy has been a mainstay of surgical procedures for infected necrotizing pancreatitis (NP). No published report has successfully questioned the role of necrosectomy. Recently, however, increasing evidence shows good outcomes when treating walled-off necrotizing pancreatitis without a necrosectomy. The literature concerning NP published primarily after 2000 was reviewed; it demonstrates the feasibility of a paradigm shift. The majority (75%) of minimally invasive necrosectomies show higher completion rates: between 80% and 100%. Transluminal endoscopic necrosectomy has shown remarkable results when combined with percutaneous drainage or a metallic stent. Related morbidities range from 40% to 92%. Single-digit mortality rates have been achieved with transluminal endoscopic necrosectomy, but not with video-assisted retroperitoneal necrosectomy series. Drainage procedures without necrosectomy have evolved from percutaneous drainage to transluminal endoscopic drainage with or without percutaneous endoscopic gastrostomy access for laparoscopic instruments. Most series have reached higher success rates of 79%-93%, and even 100%, using transcystic multiple drainage methods. It is becoming evident that transluminal endoscopic drainage treatment of walled-off NP without a necrosectomy is feasible. With further refinement of the drainage procedures, a paradigm shift from necrosectomy to drainage is inevitable.