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

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