Direct endoscopic necrosectomy in infected pancreatic necrosis using lumen-apposing metal stents: Early intervention does not compromise outcome

Abstract

Background and study aims Infection of pancreatic necrosis is a dreaded complication requiring an intervention. Nevertheless, the optimal timing of the first intervention is unclear, and consensus data are sparse. This retrospective two-center study evaluated direct endoscopic necrosectomy using lumen apposing metal stents in case of proven or suspected infected pancreatic necrosis in an early stage of the disease.

Patients and methods Forty-nine patients with infected pancreatic necrosis were included. Sequent direct endoscopic necrosectomies after lumen apposing metal stent insertion (LAMS) were performed until the resolution of necrosis. In all patients, the first endoscopic intervention was performed within the first 30 days after first proof of pancreatic necrosis. Primary outcome parameters were inflammatory activity, days spent in the Intensive Care Unit (ICU), and mortality.

Results The patient cohort received median 4 necrosectomies (3–5) after a median of 7 days (3–11) after first proof of pancreatic necrosis. Technical and clinical success were achieved in 98.3 % and 87.8 %, respectively; the mortality rate was 8.2 %. The median C-reactive protein level decreased from 241 mg/L (182.9–288.9) before the intervention to a median of 23.3 mg/L (18–60) after therapy. The median time period in the ICU was 5 days (3–9).

Conclusions Early endoscopic therapy in the form of direct endoscopic necrosectomy after LAMS placement within the first 30 days after proof of pancreatic necrosis is effective and does not result in poor outcome. Our retrospective data suggest that early intervention before walled-off necrosis is formed is tenable when it is essential due to the patient's clinical deterioration.

Publication History

Received: 17 August 2020

Accepted: 23 November 2020

Article published online:
22 February 2021

• References

• 1 Banks PA, 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
• 2 Wu BU, Johannes RS, Sun X. et al. The early prediction of mortality in acute pancreatitis: A large population based study. Gut 2008; 57: 1698-1703
• 3 Beger HG, Rau BM. Severe acute pancreatitis: Clinical course and management. World J Gastroenterol 2007; 13: 5043-5051
• 4 Petrov MS, Shanbhag S, Chakraborty M. et al. Organ failure and infection of pancreatic necrosis as determinants of mortality in patients with acute pancreatitis. Gastroenterology 2010; 139: 813-820
• 5 De Beaux AC, Palmer KR, Carter DC. Factors influencing morbidity and mortality in acute pancreatitis; an analysis of 279 cases. Gut 1995; 37: 121-126
• 6 Besselink MG, Verwer TJ, Schoenmakers EJ. et al. Timing of surgical intervention in necrotizing pancreatitis. Arch Surg 2007; 142: 1194-1201
• 7 Rodriguez JR, Razo AO, Targarona J. et al. Debridement and closed packing for sterile or infected necrotizing pancreatitis: insights into indications and outcomes in 167 patients. Ann Surg 2008; 247: 294-299
• 8 Van Santvoort HC, Besselink MG, Bakker OJ. et al. A step-up approach or open necrosectomy for necrotizing pancreatitis. N Eng J Med 2010; 362: 1491-1502
• 9 Petrov MS, Chong V, Windsor JA. Infected pancreatic necrosis: not necessarily a late event in acute pancreatitis. World J Gastroenterol 2011; 17: 3173-3176
• 10 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
• 11 Van Grinsven J, van Brunschot S, Bakker OJ. et al. Diagnostic strategy and timing of intervention in infected necrotizing pancreatitis: an international expert survey and case vignette study. HPB 2016; 18: 49-56
• 12 Besselink M, van Santvoort H, Freeman M. et al. IAP/APA evidence-based guidelines for the management of acute pancreatitis. Pancreatology 2013; 13: e1-15
• 13 Tenner S, Baillie J, deWitt J. et al. American college of Gastroenterology guideline: management of acute pancreatitis. Am J Gastroenterol 2013; 108: 1400-1415
• 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
• 15 Van Brunschot S, van Grinsven J, van Santvoort H. et al. Endoscopic or surgical step-up approach for infected necrotising pancreatitis: a multicentre randomised trial. Lancet 2018; 391: 51-58
• 16 Hartwig W, Maksan SM, Foitzik T. et al. Reduction in mortality with delayed surgical therapy of severe pancreatitis. J Gastrointest Surg 2002; 6: 481-487
• 17 Bakker OJ, Santvoort HC, van Brunschot S. et al. Endoscopic transgastric vs surgical necrosectomy for infected necrotizing pancreatitis: a randomized trial. JAMA 2012; 307: 1053-1061
• 18 Bang JY, Arnoletti JP, Holt BA. et al. An endoscopic transluminal approach, compared with minimal invasive surgery, reduces complication s and costs for patients with necrotizing pancreatitis. Gastroenterology 2019; 156: 1027-1040
• 19 Trikudanathan G, Tawfik P, Amateau S. et al. Early (<4 weeks) versus standard (>4 weeks) endoscopically centered step-up interventions for necrotizing pancreatitis. Am J Gastroenterol 2018; 113: 1550-1558
• 20 Yan L, Dargan A, Nieto J. et al. Direct endoscopic necrosectomy at the time of transmural stent placement results in earlier resolution of complex walled-off pancreatic necroisis: results from a large multicenter united states trial. Endosc Ultrasound 2019; 8: 172-179
• 21 Van Brunshot S, Fockens P, Bakker OJ. et al. Endoscopic transluminal necrosectomy in necrotizing pancreatitis: a systemic review. Surg Endosc 2014; 28: 1425-1438