Endoscopic necrosectomy of infected WON in acute necrotising pancreatitis – Development of an effective therapeutic algorithm based on a single-center consecutive patient cohort

Abstract

Objective Development of an effective therapeutic algorithm for interventional (minimally invasive) approach to infected walled-off necrosis (WON) in patients with necrotising pancreatitis reflecting real-word data.

Material/methods All consecutive patients who underwent endoscopic necrosectomy for necrotising pancreatitis through a defined study period were enclosed in this retrospective observational case study. The therapeutic approach was analysed for clinical success rate, complication spectrum and rate as well as mortality and compared with data from the literature. Finally, a therapeutic algorithm was derived.

Results From 2004 to 2019, 126 patients with necrotising pancreatitis (median of APACHE II score, 10.5 points) were treated. In 92.9 % of cases (n=117), an infected WON with microbial pathogen detection was found. After a median of 18 days from symptom onset, first intervention was performed (53.2 % as percutaneous drainage with programmed rinsing, 29.4 % as EUS-guided internal drainage). From 2004 to 2010, double pigtail stents were used. Later, lumen-apposing metal stent (LAMS) such as AXIOS^TM stent (Boston Scientific, Ratingen, Germany) was preferred. The combined percutaneous and internal drainage was performed in approximately 50 % of subjects.

Endoscopic transluminal necrosectomy was performed in 123 patients (97.6 %) at a median of 33 days from symptom onset. Endoscopic percutaneous necrosectomy was conducted in 11.1 % of the individuals. A median number of two endoscopic necrosectomy sessions per patient was necessary for the therapy. The clinical success rate (discharge without surgical intervention) was 82.5 %. The complication rate (bleeding and perforation) and the need for surgery were both 9.5 %. The overall mortality was 8.7 %.

Conclusion Therapy of necrotising pancreatitis with infected WON consists of early calculated antibiotic therapy with adequate drainage. Combined external and internal drainages with programmed rinsing seem to improve prognosis, as well as minimise i) the need for forced necrosectomies (mainly via a transluminal access site) and ii) complication rate as well as, thus, improve outcome.

Zusammenfassung

Ziel Erarbeitung eines Behandlungsalgorithmus für die interventionelle Therapie der infizierten „walled-off“-Nekrosen (WON) bei der nekrotisierenden Pankreatitis.

Material/Methoden Alle Patienten, die einer endoskopischen Nekrosektomie aufgrund einer nekrotisierenden Pankreatitis in den Jahren 2004 bis 2019 unterzogen wurden, sind in die retrospektive Fallstudie eingeschlossen worden. Das therapeutische Vorgehen wurde hinsichtlich des klinischen Erfolges, der Komplikationen und der Mortalität analysiert. Nach dem Vergleich mit der aktuellen Studienlage wurden die vorgeschlagenen therapeutischen Schritte in einem Algorithmus visualisiert.

Ergebnisse Im Betrachtungszeitraum wurden 126 Patienten mit nekrotisierender Pankreatitis (APACHE-II-Score im Median 10,5 Punkte) mittels endoskopischer Nekrosektomie therapiert. Bei 92,9 % der Patienten (n=117) zeigte sich eine infizierte WON mit mikrobiologischem Erregernachweis. Nach median 18 Tagen nach Symptombeginn erfolgte die erste Intervention (in 53,2 % als perkutane Drainage mit programmierter Spülung, in 29,4 % als EUS-geführte interne Drainage). Zu Beginn des Beobachtungszeitraumes wurden Doppel-Pigtail-Stents genutzt, ab 2011 kamen LAMS (lumen-apposing metal stent) wie der AXIOS^TM stent (Boston Scientific, Ratingen, Deutschland) zum Einsatz. Eine kombinierte perkutane und interne Drainage wurde bei der Hälfte der Patienten durchgeführt. Die endoskopische transluminale Nekrosektomie erfolgte bei 123 Patienten median 33 Tage nach Symptombeginn. Bei 11,1 % der Patienten wurde eine perkutane Nekrosektomie durchgeführt. Im Median erfolgten 2 endoskopische Nekrosektomie-Sitzungen. Die klinische Erfolgsrate (Entlassung ohne Operation) lag bei 82,5 %. Die Komplikationsraten bezüglich Blutung und Perforation und die Operationspflicht lagen jeweils bei 9,5 %. Die Gesamtmortalität betrug 8,7 %.

Schlussfolgerung Die Therapie der nekrotisierenden Pankreatitis mit infizierten Nekrosen in einer WON besteht in einer frühzeitigen kalkulierten antibiotischen Therapie mit adäquater Drainage. Eine kombinierte externe und interne Drainage mit programmierter Spülung scheint die Prognose zu verbessern, die Notwendigkeit forcierter Nekrosektomien und die Komplikationsraten zu minimieren.

Schlüsselwörter

akute (nekrotisierende) Pankreatitis - (infizierte) Walled-off necroses (WON) - endoskopische Nekrosektomie - therapeutischer Algorithmus

Keywords

Acute (necrotizing) pancreatitis - (Infected) Walled-off necroses (WON) - Endoscopic necrosectomy - Therapeutic algorithm

Publication History

Received: 17 November 2021

Accepted: 13 June 2022

Article published online:
20 September 2022

• References

• 1 Van Grinsven J, van Brunschot S, van Santvoort HC. Dutch Pancreatitis Study Group. The Value of a 24/7 Online Nationwide Multidisciplinary Expert Panel for Acute Necrotizing Pancreatitis. Gastroenterology 2017; 152: 685-688 DOI: 10.1186/1471-230X-13-161. (PMID: 24274589)
• 2 Banks P, Bollen TL, Dervenis C. et al. Classification of acute pancreatitis – 2012: revision of the Atlanta classification and definitions by international consensus. Gut 2013; 62: 102-111 DOI: 10.1136/gutjnl-2012-302779. (PMID: 23100216)
• 3 Baron TH, DiMaio CJ, Wang AY. et al. American Gastroenterological Association Clinical Practice Update: Management of Pancreatic Necrosis. Gastroenterology 2020; 158: 67-75 DOI: 10.1053/j.gastro.2019.07.064. (PMID: 31479658)
• 4 Boxhoorn L, Fockens P, Besselink MG. et al. Endoscopic Management of Infected Necrotizing Pancreatitis: an Evidence-Based Approach. Curr Treat Options Gastroenterol 2018; 16: 333-344 DOI: 10.1007/s11938-018-0189-8. (PMID: 30030678)
• 5 Arvanitakis M, Dumonceau JM, Albert J. et al. Endoscopic management of acute necrotizing pancreatitis: European Society of Gastrointestinal Endoscopy (ESGE) evidence-based multidisciplinary guidelines. Endoscopy 2018; 50: 524-546 DOI: 10.1055/a-0588-5365. (PMID: 29631305)
• 6 Sion MK, Davis KA. Step-up-Approach for the management of pancreatic necrosis: a review of the literature. Trauma Surg Acute Care Open 2019; 4: e000308 DOI: 10.1136/tsaco-2019-000308. (PMID: 31245622)
• 7 Ysuda I, Takahashi K. Endoscopic management of walled-off pancreatic necrosis. Dig Endosc 2021; 33: 335-341
• 8 Van Brunschot S, van Grinsven J, van Santvoort HC. et al. Endoscopic or surgical step-up approach for infected necrotising pancreatitis: a multicentre randomised trial. Lancet 2018; 391: 51-58 DOI: 10.1016/S0140-6736(17)32404-2. (PMID: 29108721)
• 9 Wundsam HV, Spaun GO, Bräuer F. et al. Evolution of Transluminal Necrosectomy for Acute Pancreatitis to Stent in Stent Therapy: Step-Up Approach Leads to Low Mortality and Morbidity Rates in 302 Consecutive Cases of Acute Pancreatitis. J Laparoendosc Adv Surg Tech A 2019; 29: 891-899 DOI: 10.1089/lap.2018.0768. (PMID: 30762470)
• 10 Bang JY, Arnoletti JP, Holt BA. et al. An Endoscopic Transluminal Approach, Compared With Minimally Invasive Surgery, Reduces Complications and Costs for Patients With Necrotizing Pancreatitis. Gastroenterology 2019; 156: 1027-1040 DOI: 10.1053/j.gastro.2018.11.031. (PMID: 30452918)
• 11 Khan MA, Kahaleh M, Khan Z. et al. Time for a Changing of Guard – From Minimally Invasive Surgery to Endoscopic Drainage for Management of Pancreatic Walled-off Necrosis. J Clin Gastroenterol 2019; 53: 81-88 DOI: 10.1097/MCG.0000000000001141. (PMID: 30383567)
• 12 Haney CM, Kowalewski KF, Schmidt MW. et al. Endoscopic versus surgical treatment for infected necrotizing pancreatitis: a systematic review and meta-analysis of randomized controlled trials. Surg Endosc 2020; 34: 2429-2444 DOI: 10.1007/s00464-020-07469-9. (PMID: 32112252)
• 13 Gornals JB, Consiglieri CF, Busquets J. et al. Endoscopic necrosectomy of walled-off pancreatic necrosis using a lumen-apposing metal stent and irrigation technique. Surg Endosc 2016; 30: 2592-2602 DOI: 10.1007/s00464-015-4505-2. (PMID: 26335077)
• 14 Seifert H, Biermer M, Schmitt W. et al. Transluminal endoscopic necrosectomy after acute pancreatitis: a multicentre study with long-term follow-up (the GEPARD Study). Gut 2009; 58: 1260-1266 DOI: 10.1136/gut.2008.163733. (PMID: 19282306)
• 15 Gardner TB, Coelho-Prabhu N, Gordon SR. et al. Direct endoscopic necrosectomy for the treatment of walled-off pancreatic necrosis: results from a multicentre U.S: series. Gastrointest Endosc 2011; 73: 718-726 DOI: 10.1016/j.gie.2010.10.053.
• 16 Yasuda I, Nakashima M, Iwai T. et al. Japanese multicenter experience of endoscopic necrosectomy for infected walled-off pancreatic necrosis: The JENIPaN study. Endoscopy 2013; 45: 627-634 DOI: 10.1055/s-0033-1344027. (PMID: 23807806)
• 17 Bansal RK, Puri R, Choudhary NS. et al. Endoscopic pancreatic necrosectomy: why scuff when you can flush the muck – make it an easy row to hoe. Endosc Int Open 2017; 5: E847-E853 DOI: 10.1055/s-0043-112854. (PMID: 28924588)
• 18 Bakker OJ, van Santvoort HC, van Brunschot S. et al. Endoscopic transgastric vs. surgical necrosectomy for infected necrotizing pancreatitis – a randomized trial. JAMA 2012; 307: 1053-1061 DOI: 10.1001/jama.2012.276. (PMID: 22416101)
• 19 Ang TL, Kwek AB, Tan SS. et al. Direct endoscopic necrosectomy: a minimally invasive endoscopic technique for the treatment of infected walled-off pancreatic necrosis and infected pseudocysts with solid debris. Singapore Med J 2013; 54: 206-211 DOI: 10.11622/smedj.2013074. (PMID: 23624447)
• 20 Schmidt PN, Novovic S, Roug S. et al. Endoscopic, transmural drainage and necrosectomy for walled-off pancreatic and peripancreatic necrosis is associated with low mortality – a single-center experience. Scand J Gastroenterol 2015; 50: 611-618 DOI: 10.3109/00365521.2014.946078. (PMID: 25648776)
• 21 Mathew A, Biswas A, Meitz KP. Endoscopic necrosectomy as primary treatment for infected peripancreatic fluid collections (with video). Gastrointest Endosc 2008; 68: 776-782 DOI: 10.1016/j.gie.2008.05.010. (PMID: 18926185)
• 22 Jagielski M, Smoczyński M, Adrych K. et al. Endoscopic necrosectomy under fluoroscopic guidance during transmural drainage of walled-off pancreatic necrosis (WOPN). Pol Przegl Chir 2019; 92: 12-17 DOI: 10.5604/01.3001.0013.5610. (PMID: 32312924)
• 23 Papachristou GI, Takahashi N, Chahal P. et al. Peroral endoscopic drainage/debridement of walled-off pancreatic necrosis. Ann Surg 2007; 245: 943-951 DOI: 10.1097/01.sla.0000254366.19366.69. (PMID: 17522520)
• 24 Charnley RM, Lochan R, Gray H. et al. Endoscopic necrosectomy as primary therapy in the management of infected pancreatic necrosis. Endoscopy 2006; 38: 925-928 DOI: 10.1055/s-2006-944731. (PMID: 16981111)
• 25 Seewald S, Groth S, Omar S. et al. Aggressive endoscopic therapy for pancreatic necrosis and pancreatic abscess: a new safe and effective treatment algorithm (Videos). Gastrointest Endosc 2005; 62: 92-100 DOI: 10.1016/s0016-5107(05)00541-9. (PMID: 15990825)
• 26 Escourrou J, Shehab H, Buscail L. et al. Peroral transgastric/transduodenal necrosectomy: success in the treatment of infected pancreatic necrosis. Ann Surg 2008; 248: 1074-1080 DOI: 10.1097/SLA.0b013e31818b728b. (PMID: 19092353)
• 27 Voermans RP, Veldkamp MC, Rauws EA. et al. Endoscopic transmural debridement of symptomatic organized pancreatic necrosis (with videos). Gastrointest Endosc 2007; 66: 909-916 DOI: 10.1016/j.gie.2007.05.043. (PMID: 17963877)
• 28 Weigand K, Mehrl A, Goessmann H. et al. Endoscopic Necrosectomy of Walled-Off Necrosis following Severe Pancreatitis Using a Hot Axios^TM Stent – A Case Series. Dig Dis 2019; 1-4 DOI: 10.1159/000503991.
• 29 Schrover IM, Weusten BL, Besselink MG. et al. EUS-guided endoscopic transgastric necrosectomy in patients with infected necrosis in acute pancreatitis. Pancreatology 2008; 8: 271-276 DOI: 10.1159/000134275. (PMID: 18497540)
• 30 Kumar N, Conwell DL, Thompson CC. Direct endoscopic necrosectomy versus step-up approach for walled-off pancreatic necrosis: comparison of clinical outcome and health care utilization. Pancreas 2014; 43: 1334-1339 DOI: 10.1097/MPA.0000000000000213. (PMID: 25083997)
• 31 Mendoza Ladd M, Bashashati M, Contreras A. et al. Endoscopic pancreatic necrosectomy in the United States – Mexico border: A cross sectional study. World J Gastrointest Endosc 2020; 12: 149-158 DOI: 10.4253/wjge.v12.i5.149.
• 32 Navaneethan U. et al. Endoscopic necrosectomy in the management of walled off pancreatic necrosis. Gastroenterol 2008; 103 (Suppl. 01) S514YS515
• 33 Minami K, Horibe M, Sanui M. et al. The effect of an invasive strategy for treating pancreatic necrosis on mortality: a retrospective multicenter cohort study. J Gastrointest Surg 2020; 24: 2037-2045 DOI: 10.1007/s11605-019-04333-7. (PMID: 31428962)
• 34 Gambitta P, Maffioli A, Spiropoulos J. et al. Endoscopic ultrasound-guided drainage of pancreatic fluid collections: The impact of evolving experience and new technologies in diagnosis and treatment over the last two decades. Hepatobiliary Pancreat Dis Int 2019; 19: 68-73 DOI: 10.1016/j.hbpd.2019.09.008. (PMID: 31610989)
• 35 Huggett MT, Oppong KW, Pereira SP. et al. Endoscopic drainage of walled-off pancreatic necrosis using a novel self-expanding metal stent. Endoscopy 2015; 47: 929-932 DOI: 10.1055/s-0034-1392413. (PMID: 26126156)
• 36 Burrowes DP, Choi HH, Rodgers SK. et al. Utility of ultrasound in acute pancreatitis. Abdom Radiol (NY) 2020; 45: 1253-1264 DOI: 10.1007/s00261-019-02364-x. (PMID: 31844915)
• 37 Mehta V, Kumar R, Parkash S. et al. Role of percutaneous catheter drainage as primary treatment of necrotizing pancreatitis. Turk J Gastroenterol 2019; 30: 184-187 DOI: 10.5152/tjg.2018.17542. (PMID: 30457559)
• 38 Grinsven J, van Santvoort HC, Boermeester MA. et al. Timing of catheter drainage in infected necrotizing pancreatitis. Nat Rev Gastroenterol Hepatol 2016; 13: 306-312 DOI: 10.1038/nrgastro.2016.23. (PMID: 26956064)
• 39 Law R, Baron TH. Endoscopic Ultrasonography-guided Drainage of Pancreatic Collections, Including the Role of Necrosectomy. Gastrointest Endosc Clin N Am 2017; 27: 715-726 DOI: 10.1016/j.giec.2017.06.007. (PMID: 28918807)
• 40 Han D, Inamdar S, Lee CW. et al. Lumen Apposing Metal Stents (LAMSs) for Drainage of Pancreatic and Gallbladder Collections A Meta-analysis. J Clin Gastroenterol 2018; 52: 835-844 DOI: 10.1097/MCG.0000000000000934. (PMID: 29016384)
• 41 Bazerbachi F, Sawas T, Vargas EJ. et al. Metal Stents Versus Plastic Stents for the Management of Pancreatic Walled-off Necrosis: A Systematic Review and Meta-Analysis. Gastrointest Endosc 2018; 87: 30-42.e15 DOI: 10.1016/j.gie.2017.08.025. (PMID: 28867073)
• 42 Amateau SK, Freeman ML. Avoidance, Recognition, and Management of Complications Associated with Lumen-Apposing Metal Stents. Gastrointest Endosc Clin N Am 2018; 28: 219-231 DOI: 10.1016/j.giec.2017.11.009. (PMID: 29519334)
• 43 Jha AK, Goenka MK, Kumar R. et al. Endotherapy for pancreatic necrosis: An update. JGH Open 2018; 3: 80-88 DOI: 10.1002/jgh3.12109. (PMID: 30834345)