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Timing of catheter drainage in infected necrotizing pancreatitis

Nature Reviews Gastroenterology & Hepatology volume 13, pages 306–312 (2016)Cite this article

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Abstract

Acute pancreatitis is the most common gastrointestinal indication for hospital admission, and infected pancreatic and/or extrapancreatic necrosis is a potentially lethal complication. Current standard treatment of infected necrosis is a step-up approach, consisting of catheter drainage followed, if necessary, by minimally invasive necrosectomy. International guidelines recommend postponing catheter drainage until the stage of 'walled-off necrosis' has been reached, a process that typically takes 4 weeks after onset of acute pancreatitis. This recommendation stems from the era of primary surgical necrosectomy. However, postponement of catheter drainage might not be necessary, and earlier detection and subsequent earlier drainage of infected necrosis could improve outcome. Strong data and consensus among international expert pancreatologists are lacking. Future clinical, preferably randomized, studies should focus on timing of catheter drainage in patients with infected necrotizing pancreatitis. In this Perspectives, we discuss challenges in the invasive treatment of patients with infected necrotizing pancreatitis, focusing on timing of catheter drainage.

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Figure 1: Current treatment algorithm for necrotizing pancreatitis according to the time after onset of symptoms.
Figure 2: Surgical step-up approach.
Figure 3: Endoscopic step-up approach.

References

  1. Peery, A. F. et al. Burden of gastrointestinal diseases in the United States: 2012 update. Gastroenterology 143, 1179–1187 (2012).

    Article  Google Scholar 

  2. Banks, P. A. et al. Classification of acute pancreatitis — 2012: revision of the Atlanta classification and definitions by international consensus. Gut 62, 102–111 (2013).

    Article  Google Scholar 

  3. Working Group IAP/APA Acute Pancreatitis Guidelines. IAP/APA evidence-based guidelines for the management of acute pancreatitis. Pancreatology 13, e1–e15 (2013).

  4. Tenner, S., Baillie, J., DeWitt, J. & Vege, S. S. American College of Gastroenterology guideline: management of acute pancreatitis. Am. J. Gastroenterol. 108, 1400–1415 (2013).

    Article  CAS  Google Scholar 

  5. The Italian Association for the Study of the Pancreas (AISP). Consensus guidelines on severe acute pancreatitis. Dig. Liver Dis. 47, 532–543 (2015).

  6. Beger, H. G., Rau, B., Mayer, J. & Pralle, U. Natural course of acute pancreatitis. World J. Surg. 21, 130–135 (1997).

    Article  CAS  Google Scholar 

  7. Bradley, E. L. 3rd A clinically based classification system for acute pancreatitis. Summary of the International Symposium on Acute Pancreatitis, Atlanta, Ga, September 11 through 13, 1992. Arch. Surg. 128, 586–590 (1993).

    Article  Google Scholar 

  8. Johnson, C. D. & Abu-Hilal, M. Persistent organ failure during the first week as a marker of fatal outcome in acute pancreatitis. Gut 53, 1340–1344 (2004).

    Article  CAS  Google Scholar 

  9. Ammori, B. J. et al. Early increase in intestinal permeability in patients with severe acute pancreatitis: correlation with endotoxemia, organ failure, and mortality. J. Gastrointest. Surg. 3, 252–262 (1999).

    Article  CAS  Google Scholar 

  10. Besselink, M. G. et al. Intestinal barrier dysfunction in a randomized trial of a specific probiotic composition in acute pancreatitis. Ann. Surg. 250, 712–719 (2009).

    Article  Google Scholar 

  11. Fritz, S. et al. Bacterial translocation and infected pancreatic necrosis in acute necrotizing pancreatitis derives from small bowel rather than from colon. Am. J. Surg. 200, 111–117 (2010).

    Article  Google Scholar 

  12. Rahman, S. H. et al. Intestinal hypoperfusion contributes to gut barrier failure in severe acute pancreatitis. J. Gastrointest. Surg. 7, 26–35 (2003).

    Article  Google Scholar 

  13. van Santvoort, H. C. et al. A step-up approach or open necrosectomy for necrotizing pancreatitis. N. Engl. J. Med. 362, 1491–1502 (2010).

    Article  CAS  Google Scholar 

  14. van Brunschot, S. et al. Transluminal endoscopic step-up approach versus minimally invasive surgical step-up approach in patients with infected necrotising pancreatitis (TENSION trial): design and rationale of a randomised controlled multicenter trial [ISRCTN09186711]. BMC Gastroenterol. 13, 161 (2013).

    Article  Google Scholar 

  15. van Baal, M. C. et al. Systematic review of percutaneous catheter drainage as primary treatment for necrotizing pancreatitis. Br. J. Surg. 98, 18–27 (2011).

    Article  CAS  Google Scholar 

  16. van Santvoort, H. C. et al. A conservative and minimally invasive approach to necrotizing pancreatitis improves outcome. Gastroenterology 141, 1254–1263 (2011).

    Article  Google Scholar 

  17. Büchler, M. W. et al. Acute necrotizing pancreatitis: treatment strategy according to the status of infection. Ann. Surg. 232, 619–626 (2000).

    Article  Google Scholar 

  18. van Baal, M. C. et al. The role of routine fine-needle aspiration in the diagnosis of infected necrotizing pancreatitis. Surgery 155, 442–448 (2014).

    Article  Google Scholar 

  19. Besselink, M. G. et al. Timing and impact of infections in acute pancreatitis. Br. J. Surg. 96, 267–273 (2009).

    Article  CAS  Google Scholar 

  20. Banks, P. A. et al. CT-guided aspiration of suspected pancreatic infection: bacteriology and clinical outcome. Int. J. Pancreatol. 18, 265–270 (1995).

    CAS  PubMed  Google Scholar 

  21. Paye, F., Rotman, N., Radier, C., Nouira, R. & Fagniez, P. L. Percutaneous aspiration for bacteriological studies in patients with necrotizing pancreatitis. Br. J. Surg. 85, 755–759 (1998).

    Article  CAS  Google Scholar 

  22. Gerzof, S. G. et al. Early diagnosis of pancreatic infection by computed tomography-guided aspiration. Gastroenterology 93, 1315–1320 (1987).

    Article  CAS  Google Scholar 

  23. van Grinsven, J. et al. Diagnostic strategy and timing of intervention in infected necrotizing pancreatitis: an international expert survey and case vignette study. HPB (Oxford) http://dx.doi.org/10.1111/hpb.12491, (2015).

  24. da Costa, D. W. et al. Staged multidisciplinary step-up management for necrotizing pancreatitis. Br. J. Surg. 101, e65–e79 (2014).

    Article  CAS  Google Scholar 

  25. Gagner, M. Laparoscopic treatment of acute necrotizing pancreatitis. Semin. Laparosc. Surg. 3, 21–28 (1996).

    CAS  PubMed  Google Scholar 

  26. Seifert, H. et al. Transluminal endoscopic necrosectomy after acute pancreatitis: a multicentre study with long-term follow-up (the GEPARD Study). Gut 58, 1260–1266 (2009).

    Article  CAS  Google Scholar 

  27. Horvath, K. D. et al. Laparoscopic assisted percutaneous drainage of infected pancreatic necrosis. Surg. Endosc. 15, 677–682 (2001).

    Article  CAS  Google Scholar 

  28. Beger, H. G. et al. Necrosectomy and postoperative local lavage in patients with necrotizing pancreatitis: results of a prospective clinical trial. World J. Surg. 12, 255–262 (1988).

    Article  CAS  Google Scholar 

  29. Traverso, L. W. & Kozarek, R. A. Pancreatic necrosectomy: definitions and technique. J. Gastrointest. Surg. 9, 436–439 (2005).

    Article  Google Scholar 

  30. Rau, B., Bothe, A. & Beger, H. G. Surgical treatment of necrotizing pancreatitis by necrosectomy and closed lavage: changing patient characteristics and outcome in a 19-year, single-center series. Surgery 138, 28–39 (2005).

    Article  CAS  Google Scholar 

  31. Rodriguez, J. R. et al. Debridement and closed packing for sterile or infected necrotizing pancreatitis: insights into indications and outcomes in 167 patients. Ann. Surg. 247, 294–299 (2008).

    Article  Google Scholar 

  32. Ashley, S. W. et al. Necrotizing pancreatitis: contemporary analysis of 99 consecutive cases. Ann. Surg. 234, 572–579 (2001).

    Article  CAS  Google Scholar 

  33. Connor, S. et al. Early and late complications after pancreatic necrosectomy. Surgery 137, 499–505 (2005).

    Article  CAS  Google Scholar 

  34. Tsiotos, G. G., Luque-de León, E. & Sarr, M. G. Long-term outcome of necrotizing pancreatitis treated by necrosectomy. Br. J. Surg. 85, 1650–1653 (1998).

    Article  CAS  Google Scholar 

  35. Carter, C. R., McKay, C. J. & Imrie, C. W. Percutaneous necrosectomy and sinus tract endoscopy in the management of infected pancreatic necrosis: an initial experience. Ann. Surg. 232, 175–180 (2000).

    Article  CAS  Google Scholar 

  36. Connor, S. et al. Minimally invasive retroperitoneal pancreatic necrosectomy. Dig. Surg. 20, 270–277 (2003).

    Article  CAS  Google Scholar 

  37. Horvath, K. et al. Safety and efficacy of video-assisted retroperitoneal debridement for infected pancreatic collections: a multicenter, prospective, single-arm phase 2 study. Arch. Surg. 145, 817–825 (2010).

    Article  Google Scholar 

  38. van Santvoort, H. C. et al. Videoscopic assisted retroperitoneal debridement in infected necrotizing pancreatitis. HPB (Oxford) 9, 156–159 (2007).

    Article  CAS  Google Scholar 

  39. van Brunschot, S. et al. Treatment of necrotizing pancreatitis. Clin. Gastroenterol. Hepatol. 10, 1190–1201 (2012).

    Article  Google Scholar 

  40. Baron, T. H., Thaggard, W. G., Morgan, D. E. & Stanley, R. J. Endoscopic therapy for organized pancreatic necrosis. Gastroenterology 111, 755–764 (1996).

    Article  CAS  Google Scholar 

  41. Bakker, O. J. et al. Endoscopic transgastric versus surgical necrosectomy for infected necrotizing pancreatitis: a randomized trial. JAMA 307, 1053–1061 (2012).

    Article  CAS  Google Scholar 

  42. Ramesh, H., Prakash, K., Lekha, V., Jacob, G. & Venugopal, A. Are some cases of infected pancreatic necrosis treatable without intervention? Dig. Surg. 20, 296–299 (2003).

    Article  CAS  Google Scholar 

  43. Fernández-del Castillo, C. et al. Debridement and closed packing for the treatment of necrotizing pancreatitis. Ann. Surg. 228, 676–684 (1998).

    Article  Google Scholar 

  44. Besselink, M. G. et al. Timing of surgical intervention in necrotizing pancreatitis. Arch. Surg. 142, 1194–1201 (2007).

    Article  Google Scholar 

  45. Mier, J., León, E. L., Castillo, A., Robledo, F. & Blanco, R. Early versus late necrosectomy in severe necrotizing pancreatitis. Am. J. Surg. 173, 71–75 (1997).

    Article  CAS  Google Scholar 

  46. Freeny, P. C., Hauptmann, E., Althaus, S. J., Traverso, L. W. & Sinanan, M. Percutaneous CT-guided catheter drainage of infected acute necrotizing pancreatitis: techniques and results. AJR Am. J. Roentgenol. 170, 969–975 (1998).

    Article  CAS  Google Scholar 

  47. Navalho, M. et al. Percutaneous drainage of infected pancreatic fluid collections in critically ill patients: correlation with C-reactive protein values. Clin. Imaging 30, 114–119 (2006).

    Article  Google Scholar 

  48. Lee, J. K. et al. The efficacy of nonsurgical treatment of infected pancreatic necrosis. Pancreas 34, 399–404 (2007).

    Article  Google Scholar 

  49. Bruennler, T. et al. Outcome of patients with acute, necrotizing pancreatitis requiring drainage — does drainage size matter? World J. Gastroenterol. 14, 725–730 (2008).

    Article  CAS  Google Scholar 

  50. Mortelé, K. J. et al. CT-guided percutaneous catheter drainage of acute necrotizing pancreatitis: clinical experience and observations in patients with sterile and infected necrosis. AJR Am. J. Roentgenol. 192, 110–116 (2009).

    Article  Google Scholar 

  51. Becker, V. et al. Infected necrosis in severe pancreatitis — combined nonsurgical multi-drainage with directed transabdominal high-volume lavage in critically ill patients. Pancreatology 9, 280–286 (2009).

    Article  CAS  Google Scholar 

  52. Bala, M., Almogy, G., Klimov, A., Rivkind, A. I. & Verstandig, A. Percutaneous 'stepped' drainage technique for infected pancreatic necrosis. Surg. Laparosc. Endosc. Percutan. Tech. 19, e113–e118 (2009).

    Article  Google Scholar 

  53. Baudin, G. et al. CT-guided percutaneous catheter drainage of acute infectious necrotizing pancreatitis: assessment of effectiveness and safety. AJR Am. J. Roentgenol. 199, 192–199 (2012).

    Article  Google Scholar 

  54. Tong, Z. et al. Percutaneous catheter drainage for infective pancreatic necrosis: is it always the first choice for all patients? Pancreas 41, 302–305 (2012).

    Article  Google Scholar 

  55. Pascual, I. et al. Surgical versus nonsurgical treatment of infected pancreatic necrosis: more arguments to change the paradigm. J. Gastrointest. Surg. 17, 1627–1633 (2013).

    Article  Google Scholar 

  56. Wronski, M. et al. Ultrasound-guided percutaneous drainage of infected pancreatic necrosis. Surg. Endosc. 27, 2841–2848 (2013).

    Article  Google Scholar 

  57. Kumar, N., Conwell, D. L. & Thompson, C. C. Direct endoscopic necrosectomy versus step-up approach for walled-off pancreatic necrosis: comparison of clinical outcome and health care utilization. Pancreas 43, 1334–1339 (2014).

    Article  Google Scholar 

  58. Ross, A. S. et al. Dual-modality drainage of infected and symptomatic walled-off pancreatic necrosis: long-term clinical outcomes. Gastrointest. Endosc. 79, 929–935 (2014).

    Article  Google Scholar 

  59. Poon, R. T. et al. External drainage of pancreatic duct with a stent to reduce leakage rate of pancreaticojejunostomy after pancreaticoduodenectomy: a prospective randomized trial. Ann. Surg. 246, 425–433 (2007).

    Article  Google Scholar 

  60. ISRCTN Registry. Postponed or immediate drainage of infected necrotizing pancreatitis (POINTER trial). http://dx.doi.org/10.1186/ISRCTN33682933 (2015).

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Author information

Author notes

  1. Paul Fockens is at the Department of Gastroenterology and Hepatology, Academic Medical Center, University of Amsterdam, Meibergdreef 9, 1105 AZ Amsterdam, Netherlands.

Authors and Affiliations

  1. Marja A. Boermeester and Marc G. Besselink are at the Department of Surgery, Janneke van Grinsven, Academic Medical Center, University of Amsterdam, Meibergdreef 9, 1105 AZ Amsterdam, Netherlands.,

    Janneke van Grinsven, Marja A. Boermeester, Paul Fockens & Marc G. Besselink

  2. Hjalmar C. van Santvoort is at the Department of Surgery, St Antonius Hospital, Koekoekslaan 1, 3435 CM Nieuwegein, Netherlands.,

    Hjalmar C. van Santvoort

  3. Cornelis H. Dejong is at the Department of Surgery, Maastricht University Medical Center and NUTRIM School for Nutrition and Translational Research in Metabolism, Maastricht University, PO Box 5800, 6200 AZ Maastricht, Netherlands.,

    Cornelis H. Dejong

  4. Casper H. van Eijck is at the Department of Surgery, Erasmus Medical Center, University of Rotterdam, 's-Gravendijkwal 230, 3015 CE Rotterdam, Netherlands.,

    Casper H. van Eijck

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Contributions

J.v.G. and M.G.B. researched the data and discussed content for the manuscript. J.v.G. wrote the article under supervision of M.G.B. H.C.v.S., M.A.B., C.H.D., C.H.v.E. and P.F. contributed to reviewing and editing the manuscript before submission.

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Correspondence to Marc G. Besselink.

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van Grinsven, J., van Santvoort, H., Boermeester, M. et al. Timing of catheter drainage in infected necrotizing pancreatitis. Nat Rev Gastroenterol Hepatol 13, 306–312 (2016). https://doi.org/10.1038/nrgastro.2016.23

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