Minimally invasive endoscopic treatment of necrotizing pancreatitis: A case report with images and review of the literature

Summary Necrotizing pancreatitis with fluid collections can occur as a complication of acute pancreatitis. The management of these patients depends on the severity and involves multiple medical treatment modalities, as clinical intensive care and surgical intervention. In this article, we show a severe case of walled-off pancreatic necrosis that was conducted by endoscopic drainage with great clinical outcome.

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Step-up approach for the management of pancreatic necrosis: a review of the literature

Trauma Surgery & Acute Care Open ◽

10.1136/tsaco-2019-000308 ◽

2019 ◽

Vol 4 (1) ◽

pp. e000308 ◽

Cited By ~ 3

Author(s):

Melanie Kay Sion ◽

Kimberly A Davis

Keyword(s):

Inflammatory Response ◽

Treatment Strategy ◽

Percutaneous Drainage ◽

Pancreatic Necrosis ◽

Necrotizing Pancreatitis ◽

Endoscopic Drainage ◽

Review Of The Literature ◽

Less Invasive ◽

Video Assisted ◽

Optimal Treatment Strategy

Infected necrotizing pancreatitis is a challenging condition to treat because of the profound inflammatory response these patients undergo which can then be exacerbated by interventions. Treatment of this condition has evolved in timing of intervention as well as method of intervention and includes less invasive options for treatment such as percutaneous drainage and endoscopic drainage, in addition to less invasive endoscopic and video-assisted or laparoscopic debridements. The precise optimal treatment strategy for these patients is an ongoing topic of discussion and may be different for each patient as this is a heterogenous condition.

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Mechanisms and Management of Acute Pancreatitis

Gastroenterology Research and Practice ◽

10.1155/2018/6218798 ◽

2018 ◽

Vol 2018 ◽

pp. 1-8 ◽

Cited By ~ 16

Author(s):

Ari Garber ◽

Catherine Frakes ◽

Zubin Arora ◽

Prabhleen Chahal

Keyword(s):

Acute Pancreatitis ◽

Pancreatic Necrosis ◽

Surgical Intervention ◽

Outlet Obstruction ◽

Gallstone Pancreatitis ◽

Drainage Procedure ◽

Endoscopic Techniques ◽

Persistent Abdominal Pain ◽

Fluid Collections ◽

Walled Off Necrosis

Acute pancreatitis represents a disorder characterized by acute necroinflammatory changes of the pancreas and is histologically characterized by acinar cell destruction. Diagnosed clinically with the Revised Atlanta Criteria, and with alcohol and cholelithiasis/choledocholithiasis as the two most prominent antecedents, acute pancreatitis ranks first amongst gastrointestinal diagnoses requiring admission and 21st amongst all diagnoses requiring hospitalization with estimated costs approximating 2.6 billion dollars annually. Complications arising from acute pancreatitis follow a progression from pancreatic/peripancreatic fluid collections to pseudocysts and from pancreatic/peripancreatic necrosis to walled-off necrosis that typically occur over the course of a 4-week interval. Treatment relies heavily on fluid resuscitation and nutrition with advanced endoscopic techniques and cholecystectomy utilized in the setting of gallstone pancreatitis. When necessity dictates a drainage procedure (persistent abdominal pain, gastric or duodenal outlet obstruction, biliary obstruction, and infection), an endoscopic ultrasound with advanced endoscopic techniques and technology rather than surgical intervention is increasingly being utilized to manage symptomatic pseudocysts and walled-off pancreatic necrosis by performing a cystogastrostomy.

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Multiple extra-splanchnic venous thromboses - an unusual vascular complication of acute pancreatitis

Clinics and Practice ◽

10.4081/cp.2020.1226 ◽

2020 ◽

Vol 10 (3) ◽

Author(s):

Junare Parmeshwar Ramesh ◽

Chandnani Sanjay ◽

Suhas Udgirkar ◽

Nair Sujit ◽

Debnath Prasanta ◽

...

Keyword(s):

Acute Pancreatitis ◽

Venous Thrombosis ◽

Pancreatic Necrosis ◽

Necrotizing Pancreatitis ◽

Splenic Vein ◽

Vascular Complications ◽

Vascular Complication ◽

Consensus Guidelines ◽

Clinical Presentations ◽

Fluid Collections

Acute pancreatitis (AP) is an acute inflammatory process of the pancreas with variable clinical presentations. Splanchnic venous thrombosis is a well-known vascular complication of AP and commonly present as thrombosis of the splanchnic venous system: splenic vein (SplV), portal vein (PV) and superior mesenteric vein (SMV), either separately or in combinations. Involvement of extra-splanchnic vessels is rare and associated with morbidity and mortality. Vascular complications are late phenomena and usually associated with local complications of AP, namely acute fluid collections, necrotizing pancreatitis and walled-off pancreatic necrosis. Pathogenesis of venous thrombosis is multifactorial in which pancreatic inflammation and systemic inflammatory response play a key role. At present, there are no consensus guidelines on treatment and use of anticoagulation for venous thrombosis in the setting of AP. Limited literature suggests the use of anticoagulation in presence of PV with or without SMV thrombosis and extrasplanchnic vessel involvement. Literature on extra-splanchnic vessels involvement in acute pancreatitis is sparse. Here we present two cases with multiple extra-splanchnic vessels involvement and their management.

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Familial Chylomicronemia Syndrome-Induced Acute Necrotizing Pancreatitis during Pregnancy

Revista Brasileira de Ginecologia e Obstetrícia / RBGO Gynecology and Obstetrics ◽

10.1055/s-0040-1722173 ◽

2021 ◽

Vol 43 (03) ◽

pp. 220-224

Author(s):

Julia Cristina Coronado Arroyo ◽

Marcio José Concepción Zavaleta ◽

Eilhart Jorge García Villasante ◽

Mikaela Kcomt Lam ◽

Luis Alberto Concepción Urteaga ◽

...

Keyword(s):

Acute Pancreatitis ◽

Pancreatic Necrosis ◽

Clinical Course ◽

Necrotizing Pancreatitis ◽

Rare Condition ◽

Severe Hypertriglyceridemia ◽

Fetal Complications ◽

Acute Necrotizing ◽

History Of ◽

Important Objective

AbstractAcute 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.

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(Un) conventional complicated pancreatitis

Gastroenterologie a hepatologie ◽

10.48095/ccgh202161 ◽

2021 ◽

Vol 75 (1) ◽

pp. 61-67

Author(s):

Michal Rybár ◽

Ivo Horný

Keyword(s):

Acute Pancreatitis ◽

Multidisciplinary Approach ◽

Pancreatic Necrosis ◽

Surgical Intervention ◽

Secondary Infection ◽

Abdominal Ultrasound ◽

Stent Migration ◽

Endoscopic Extraction ◽

Threatening Condition ◽

Life Threatening

Acute pancreatitis is sudden inflammatory disease of pancreas, which can vary from a mild form to severe life threatening condition. The management of pancreatitis usually consists of intensive care and multidisciplinary approach, often including surgical intervention or digestive endoscopy. In this article, we present a 68-year-old female with recidivous acute pancreatitis who underwent a series of endoscopic examinations and at the end also an unusual surgical intervention due to numerous complications. At first, it seemed that there was an idiopatic etiology because neither an anamnesis of alcohol consumption nor metabolic risks or CT signs of cholelithiasis were found. The condition was complicated by the development of acute necrotic collection, gastrointestinal bleeding and development of walled-off pancreatic necrosis (WOPN). Later, the biliary etiology was revealed after cholecystolithiasis was found on abdominal ultrasound. The WOPN was endoscopically drained because of the local compression syndrome. After the drainage, we noticed two cases of stent migration and the secondary infection of the WOPN. At the end, the migrated stents caused transient bowel obstruction and were stuck in the distal ileum. After three unsuccessful attempts to endoscopic extraction, the condition was solved by surgical intervention and double enterotomy was performed. The postoperative care was not easy anyway, being complicated by the dehiscence of the surgical wound with the need of opening the wound and use the VAC system to heal it up.

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Preliminary report on the safety and utility of a novel automated mechanical endoscopic tissue resection tool for endoscopic necrosectomy: a case series

Endoscopy International Open ◽

10.1055/a-1079-5015 ◽

2020 ◽

Vol 08 (03) ◽

pp. E274-E280 ◽

Cited By ~ 1

Author(s):

S. E. van der Wiel ◽

A. May ◽

J. W. Poley ◽

M. J. A. L. Grubben ◽

J. Wetzka ◽

...

Keyword(s):

Pancreatic Necrosis ◽

De Novo ◽

Necrotizing Pancreatitis ◽

Case Series ◽

Complete Removal ◽

Endoscopic Drainage ◽

Necrotic Tissue ◽

Technical Feasibility ◽

Operator Experience ◽

Endoscopic Necrosectomy

Abstract Background and study aims Endoscopic drainage of walled-off necrosis and subsequent endoscopic necrosectomy has been shown to be an effective step-up management strategy in patients with acute necrotizing pancreatitis. One of the limitations of this endoscopic approach however, is the lack of dedicated and effective instruments to remove necrotic tissue. We aimed to evaluate the technical feasibility, safety, and clinical outcome of the EndoRotor, a novel automated mechanical endoscopic tissue resection tool, in patients with necrotizing pancreatitis. Methods Patients with infected necrotizing pancreatitis in need of endoscopic necrosectomy after initial cystogastroscopy, were treated using the EndoRotor. Procedures were performed under conscious or propofol sedation by six experienced endoscopists. Technical feasibility, safety, and clinical outcomes were evaluated and scored. Operator experience was assessed by a short questionnaire. Results Twelve patients with a median age of 60.6 years, underwent a total of 27 procedures for removal of infected pancreatic necrosis using the EndoRotor. Of these, nine patients were treated de novo. Three patients had already undergone unsuccessful endoscopic necrosectomy procedures using conventional tools. The mean size of the walled-off cavities was 117.5 ± 51.9 mm. An average of two procedures (range 1 – 7) per patient was required to achieve complete removal of necrotic tissue with the EndoRotor. No procedure-related adverse events occurred. Endoscopists deemed the device to be easy to use and effective for safe and controlled removal of the necrosis. Conclusions Initial experience with the EndoRotor suggests that this device can safely, rapidly, and effectively remove necrotic tissue in patients with (infected) walled-off pancreatic necrosis.

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Operative vs Non-Operative Management in Sterile Necrotizing Pancreatitis

HPB Surgery ◽

10.1155/1997/30279 ◽

1997 ◽

Vol 10 (3) ◽

pp. 188-191 ◽

Cited By ~ 6

Author(s):

Edward L. Bradley

Keyword(s):

Intensive Care ◽

Pancreatic Necrosis ◽

Necrotizing Pancreatitis ◽

Operative Management ◽

Needle Aspiration ◽

Apache Ii ◽

Intensive Care Treatment ◽

Intensive Care Therapy ◽

Care Treatment ◽

Organ Complications

Background: The clinical management of sterile pancreatic necrosis is still a matter of debate. In this study we analyzed the clinical course and outcome of patients with sterile necrotizing pancreatitis treated surgically versus nonsurgically.Study Design: Between May 1982 and December 1993, 249 patients with necrotizing pancreatitis (NP) entered this study, of which 172 (69 percent) had intraoperatively or fine needle aspiration-proven sterile NP. One hundred seven of 172 patients underwent surgery (S group) with necrosectomy and continuous postoperative closed lavage and 65 of 172 were treated by nonsurgical means (NS group).Results: Median Ranson and admission APACHE II scores were 4.7 (range, 1 to 10) and 11 (range, 1 to 29) in the S group, significantly higher than those in the NS group with 3.0 (range, 0 to 6) (p=0.022) and 8 (range, 1 to 23) (p=0.036). After 48 hours of intensive care treatment, APACHE II scores persisted at 10.5 (range, 1 to 29) in the S group and decreased to 6 (range, 0 to 15) (p=0.013) in the NS patients. Median Creactive protein (CRP) levels on admission were 179 mg/L and 68.5 mg/L (p=0.023), respectively. Within 72 hours, 61 (94 percent) of 65 NS-managed patients responded to intensive care therapy, whereas organ complications persisted or increased and thus led to surgery in the S group. Mortality rates were 13.1 percent in the surgically treated patients and 6.2 percent in the nonsurgically treated patients (p=NS).Conclusions: Most patients with limited and sterile pancreatic necrosis respond to intensive care treatment. Indication for surgery in sterile NP should be based on persisting or advancing organ complications despite intensive care therapy. APACHE II scores and adraission CRP levels represent a helpful tool in decision making for surgical or nonsurgical management of NP.

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Retrospective Validation of an Algorithmic Treatment Pathway for Necrotizing Pancreatitis

The American Surgeon ◽

10.1177/000313481908500834 ◽

2019 ◽

Vol 85 (8) ◽

pp. 840-847

Author(s):

Ryan C. Pickens ◽

Jesse K. Sulzer ◽

Allyson Cochran ◽

Dionisios Vrochides ◽

John B. Martinie ◽

...

Keyword(s):

Minimally Invasive ◽

Pancreatic Necrosis ◽

Surgical Intervention ◽

Necrotizing Pancreatitis ◽

Laparoscopic Approach ◽

High Volume ◽

Evidence Based ◽

Robot Assisted ◽

Delayed Treatment ◽

Open Necrosectomy

The role of surgical intervention for necrotizing pancreatitis has evolved; however, no widely accepted algorithm has been established to guide timing and optimal modality in the minimally invasive era. This study aimed to retrospectively validate an established institutional timing- and physiologic-based algorithm constructed from evidence-based guidelines in a high-volume hepatopancreatobiliary center. Patients with necrotizing pancreatitis requiring early (≤six weeks from symptom onset) or delayed (>six weeks) surgical intervention were reviewed over a four-year period (n = 100). Early intervention was provided through laparoscopic drain-guided retroperitoneal debridement (n = 15) after failed percutaneous drainage unless they required an emergent laparotomy (due to abdominal compartment syndrome, bowel necrosis/perforation, or hemorrhage) after which conservative, sequential open necrosectomy was performed (n = 47). Robot-assisted (n = 16) versus laparoscopic (n = 22) transgastric cystgastrostomy for the delayed management of walled-off pancreatic necrosis was compared, including patient factors, operative characteristics, and 90-day clinical outcomes. Major complications after early debridement were similarly high (open 25% and drain-guided 27%), yet 90-day mortality was low (open 8.5% and drain-guided 7.1%). Patient and operative characteristics and 90-day outcomes were statistically similar for robotic versus laparoscopic transgastric cystogastrostomy. Our evidence-based algorithm provides a stepwise approach for the management of necrotizing pancreatitis, emphasizing minimally invasive early and late interventions when feasible with low morbidity and mortality. Robot-assisted transgastric cystogastrostomy is an acceptable alternative to a laparoscopic approach for the delayed treatment of walled-off pancreatic necrosis.

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