Endoscopic drainage with local infusion of antibiotics to avoid necrosectomy of infected walled-off necrosis.
Aged
Aged, 80 and over
Anti-Bacterial Agents
/ administration & dosage
Drainage
/ methods
Endoscopy, Digestive System
/ methods
Female
Humans
Intraabdominal Infections
/ mortality
Male
Middle Aged
Pancreatectomy
Pancreatitis, Acute Necrotizing
/ mortality
Retrospective Studies
Stents
Treatment Outcome
Ultrasonography, Interventional
/ methods
Antibiotic resistance
Carbapenem
Endoscopic necrosectomy
Endosonography
Pancreatitis
Journal
Surgical endoscopy
ISSN: 1432-2218
Titre abrégé: Surg Endosc
Pays: Germany
ID NLM: 8806653
Informations de publication
Date de publication:
02 2021
02 2021
Historique:
received:
01
11
2019
accepted:
10
02
2020
pubmed:
23
2
2020
medline:
29
6
2021
entrez:
21
2
2020
Statut:
ppublish
Résumé
Current treatment of infected pancreatic necrosis (IPN) follows a step-up approach. Our group designed a step-up protocol that associates endoscopic drainage with local infusion of antibiotics through transmural nasocystic catheter. Aim of our study was to evaluate our step-up protocol for IPN in terms of proportion of patients avoiding necrosectomy. Retrospective analysis of patients admitted with acute pancreatitis (AP) between January 2015 and December 2018. The number of patients who responded to each therapeutic step were analysed: step 1, systemic antibiotics; step 2, endoscopic transmural drainage and local infusion of antibiotics; step 3, endoscopic necrosectomy. 1158 patients with AP were included. 110 patients (8.4%) suffered from necrotising pancreatitis; 48 of them had IPN (42.6% of necrotising pancreatitis) and were treated with systemic antibiotics. Nineteen patients (39.6% of IPN) responded and did not required any invasive therapy. Six patients with IPN on systemic antibiotics died within the first 4 weeks of disease before step 2 could be applied. Urgent surgical necrosectomy in the first 4 weeks was performed in three additional patients. Endoscopic drainage and local antibiotic therapy was performed in the remaining 20 patients; 9 (45% of them) did well and 9 patients underwent necrosectomy (18.7% of IPN). Two patients died on drainage. Overall mortality of the total cohort of AP was 2.53% CONCLUSIONS: Addition of local infusion of antibiotics to endoscopic drainage avoids the need of necrosectomy in half of patients with IPN not responding to systemic antibiotics.
Sections du résumé
BACKGROUND
Current treatment of infected pancreatic necrosis (IPN) follows a step-up approach. Our group designed a step-up protocol that associates endoscopic drainage with local infusion of antibiotics through transmural nasocystic catheter. Aim of our study was to evaluate our step-up protocol for IPN in terms of proportion of patients avoiding necrosectomy.
METHODS
Retrospective analysis of patients admitted with acute pancreatitis (AP) between January 2015 and December 2018. The number of patients who responded to each therapeutic step were analysed: step 1, systemic antibiotics; step 2, endoscopic transmural drainage and local infusion of antibiotics; step 3, endoscopic necrosectomy.
RESULTS
1158 patients with AP were included. 110 patients (8.4%) suffered from necrotising pancreatitis; 48 of them had IPN (42.6% of necrotising pancreatitis) and were treated with systemic antibiotics. Nineteen patients (39.6% of IPN) responded and did not required any invasive therapy. Six patients with IPN on systemic antibiotics died within the first 4 weeks of disease before step 2 could be applied. Urgent surgical necrosectomy in the first 4 weeks was performed in three additional patients. Endoscopic drainage and local antibiotic therapy was performed in the remaining 20 patients; 9 (45% of them) did well and 9 patients underwent necrosectomy (18.7% of IPN). Two patients died on drainage. Overall mortality of the total cohort of AP was 2.53% CONCLUSIONS: Addition of local infusion of antibiotics to endoscopic drainage avoids the need of necrosectomy in half of patients with IPN not responding to systemic antibiotics.
Identifiants
pubmed: 32076856
doi: 10.1007/s00464-020-07428-4
pii: 10.1007/s00464-020-07428-4
doi:
Substances chimiques
Anti-Bacterial Agents
0
Types de publication
Journal Article
Langues
eng
Sous-ensembles de citation
IM
Pagination
644-651Références
Xiao AY, Tan ML, Wu LM, Asrani VM, Windsor JA, Yadav D, Petrov MS (2016) Global incidence and mortality of pancreatic diseases: a systematic review, meta-analysis, and meta-regression of population-based cohort studies. Lancet Gastroenterol Hepatol 1:45–55
doi: 10.1016/S2468-1253(16)30004-8
Sternby H, Bolado F, Canaval-Zuleta HJ, Marra-López C, Hernando-Alonso AI, Del-Val-Antoñana A, García-Rayado G, Rivera-Irigoin R, Grau-García FJ, Oms L, Millastre-Bocos J, Pascual-Moreno I, Martínez-Ares D, Rodríguez-Oballe JA, López-Serrano A, Ruiz-Rebollo ML, Viejo-Almanzor A, González-de-la-Higuera B, Orive-Calzada A, Gómez-Anta I, Pamies-Guilabert J, Fernández-Gutiérrez-Del-Álamo F, Iranzo-González-Cruz I, Pérez-Muñante ME, Esteba MD, Pardillos-Tomé A, Zapater P, de-Madaria E. (2018) Determinants of severity in acute pancreatitis: a nation-wide multicenter prospective cohort study. Ann Surg 270(2):348–355. https://doi.org/10.1097/SLA.0000000000002766
doi: 10.1097/SLA.0000000000002766
Petrov MS, Shanbhag S, Chakraborty M, Phillips AR, Windsor JA (2010) Organ failure and infection of pancreatic necrosis as determinants of mortality in patients with acute pancreatitis. Gastroenterology 139:813–820
doi: 10.1053/j.gastro.2010.06.010
Uhl W, Warshaw A, Imrie C, Bassi C, McKay CJ, Lankisch PG, Carter R, Di Magno E, Banks PA, Whitcomb DC, Dervenis C, Ulrich CD, Satake K, Ghaneh P, Hartwig W, Werner J, McEntee G, Neoptolemos JP, Büchler MW, International Association of Pancreatology (2002) IAP guidelines for the surgical management of acute pancreatitis. Pancreatology 2002(2):565–573
doi: 10.1159/000067684
UK Working Party on Acute Pancreatitis (2005) UK guidelines for the management of acute pancreatitis. Gut 54(Suppl III):iii1–iii9
Garg PK, Sharma M, Madan K, Sahni P, Banerjee D, Goyal R (2010) Conservative treatment results in mortality comparable to surgery in patients with infected pancreatic necrosis. Clin Gastroenterol Hepatol 8:1089–1094
doi: 10.1016/j.cgh.2010.04.011
van Santvoort HC, Besselink M, Bakker OJ, Hofker HS, Boermeester MA, Dejong CH, van Goor H, Schaapherder AF, van Eijck CH, Bollen TL, van Ramshorst B, Nieuwenhuijs VB, Timmer R, Laméris JS, Kruyt PM, Manusama ER, van der Harst E, van der Schelling GP, Karsten T, Hesselink EJ, van Laarhoven CJ, Rosman C, Bosscha K, de Wit RJ, Houdijk AP, van Leeuwen MS, Buskens E, Gooszen HG, Dutch Pancreatitis Study Group (2010) A step-up approach or open necrosectomy for necrotizing pancreatitis. N Engl J Med 362:1491–1502
doi: 10.1056/NEJMoa0908821
Bakker OJ, van Santvoort HC, van Brunschot S, Geskus RB, Besselink MG, Bollen TL, van Eijck CH, Fockens P, Hazebroek EJ, Nijmeijer RM, Poley JW, van Ramshorst B, Vleggaar FP, Boermeester MA, Gooszen HG, Weusten BL, Timmer R, Dutch Pancreatitis Study Group (2012) Endoscopic transgastric vs surgical necrosectomy for infected necrotizing pancreatitis: a randomized trial. JAMA 307:1053–1061
doi: 10.1001/jama.2012.276
van Brunschot S, van Grinsven J, van Santvoort HC, Bakker OJ, Besselink MG, Boermeester MA, Bollen TL, Bosscha K, Bouwense SA, Bruno MJ, Cappendijk VC, Consten EC, Dejong CH, van Eijck CH, Erkelens WG, van Goor H, van Grevenstein WMU, Haveman JW, Hofker SH, Jansen JM, Laméris JS, van Lienden KP, Meijssen MA, Mulder CJ, Nieuwenhuijs VB, Poley JW, Quispel R, de Ridder RJ, Römkens TE, Scheepers JJ, Schepers NJ, Schwartz MP, Seerden T, Spanier BWM, Straathof JWA, Strijker M, Timmer R, Venneman NG, Vleggaar FP, Voermans RP, Witteman BJ, Gooszen HG, Dijkgraaf MG, Fockens P, Dutch Pancreatitis Study Group (2018) Endoscopic or surgical step-up approach for infected necrotising pancreatitis: a multicentre randomised trial. Lancet 391:51–58
doi: 10.1016/S0140-6736(17)32404-2
Tenner S, Baillie J, DeWitt J (2013) American College of Gastroenterology guideline: management of acute pancreatitis. Am J Gastroenterol 108:1400–1415
doi: 10.1038/ajg.2013.218
Working Group IAP/APA Acute Pancreatitis Guidelines (2013) IAP/APA evidence-based guidelines for the management of acute pancreatitis. Pancreatology 13(4 Suppl 2):e1–e15
Vege S, DiMagno MJ, Martel M, Barkun AN (2018) Initial medical treatment of acute pancreatitis: American Gastroenterological Association Institute Technical Review. Gastroenterology 154:1103–1139
doi: 10.1053/j.gastro.2018.01.031
Gornals JB, Consiglieri CF, Busquets J, Salord S, Hera M, Secanella L, Redondo S, Pelaez N, Fabregat J (2016) 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
González-López J, Macías-García F, Lariño-Noia J, Dominguez-Muñoz JE (2016) Theoretical approach to local infusion of antibiotics for infected pancreatic necrosis. Pancreatology 16:719–725
doi: 10.1016/j.pan.2016.05.396
Banks PA, Bollen TL, Dervenis C, Gooszen HG, Johnson CD, Sarr MG, Tsiotos GG, Vege S (2013) Acute Pancreatitis Classification Working Group. Classification of acute pancreatitis—2012: revision of the Atlanta classification and definitions by international consensus. Gut 62:102–111
doi: 10.1136/gutjnl-2012-302779
Berthoin K, Le Duff CS, Marchand-Brynaert J, Carryn S, Tulkens PM (2010) Stability of meropenem and doripenem solutions for administration by continuous infusion. J Antimicrob Chemother 65:1073–1075
van Brunschot S, Fockens P, Bakker OJ, Besselink MG, Voermans RP, Poley JW, Gooszen HG, Bruno M, van Santvoort HC (2014) Endoscopic transluminal necrosectomy in necrotising pancreatitis: a systematic review. Surg Endosc 2014(28):1425–1438
doi: 10.1007/s00464-013-3382-9
Bang JY, Arnoletti JP, Holt BA, Sutton B, Hasan MK, Navaneethan U, Feranec N, Wilcox CM, Tharian B, Hawes RH, Varadarajulu S (2019) An endoscopic transluminal approach, compared with minimally invasive surgery, reduces complications and costs for patients with necrotizing pancreatitis. Gastroenterology 156:1027–1040
doi: 10.1053/j.gastro.2018.11.031
Siddiqui AA, Kowalski TE, Loren DE, Khalid A, Soomro A, Mazhar SM, Isby L, Kahaleh M, Karia K, Yoo J, Ofosu A, Ng B, Sharaiha RZ (2017) Fully covered self-expanding metal stents versus lumen-apposing fully covered self-expanding metal stent versus plastic stents for endoscopic drainage of pancreatic walled-off necrosis: clinical outcomes and success. Gastrointest Endosc 85:758–765
doi: 10.1016/j.gie.2016.08.014
Chandran S, Efthymiou M, Kaffes A, Chen JW, Kwan V, Murray M, Chandran S, Efthymiou M, Kaffes A, Williams D, Nguyen NQ, Tam W, Welch C, Chong A, Gupta S, Devereaux B, Tagkalidis P, Parker F, Vaughan R (2015) Management of pancreatic collections with a novel endoscopically placed fully covered self-expandable metal stent: a national experience (with videos). Gastrointest Endosc 81:127–135
doi: 10.1016/j.gie.2014.06.025
Bang JY, Navaneethan U, Hasan MK, Sutton B, Hawes R, Varadarajulu S (2018) Non-superiority of lumen-apposing metal stents for drainage of walled-off necrosis in a randomised trial. Gut 68(7):1200–1209. https://doi.org/10.1136/gutjnl-2017-315335
doi: 10.1136/gutjnl-2017-315335
pubmed: 29858393
pmcid: 6582745
van Santvoort HC, Bakker OJ, Bollen TL, Besselink MG, Ahmed Ali U, Schrijver AM, Boermeester MA, van Goor H, Dejong CH, van Eijck CH, van Ramshorst B, Schaapherder AF, van der Harst E, Hofker S, Nieuwenhuijs VB, Brink MA, Kruyt PM, Manusama ER, van der Schelling GP, Karsten T, Hesselink EJ, van Laarhoven CJ, Rosman C, Bosscha K, de Wit RJ, Houdijk AP, Cuesta MA, Wahab PJ, Gooszen HG, Dutch Pancreatitis Study Group (2011) A conservative and minimally invasive approach to necrotizing pancreatitis improves outcome. Gastroenterology 141:1254–1263
Arvanitakis M, Dumonceau JM, Albert J, Badaoui A, Bali MA, Barthet M, Besselink M, Deviere J, Oliveira Ferreira A, Gyökeres T, Hritz I, Hucl T, Milashka M, Papanikolaou IS, Poley JW, Seewald S, Vanbiervliet G, van Lienden K, van Santvoort H, Voermans R, Delhaye M, van Hooft J (2018) Endoscopic management of acute necrotizing pancreatitis: European Society of Gastrointestinal Endoscopy (ESGE) evidence-based multidisciplinary guidelines. Endoscopy 50:524–546
doi: 10.1055/a-0588-5365
Mithöfer K, Fernández-del Castillo C, Ferraro MJ, Lewandrowski K, Rattner DW, Warshaw AL (1996) Antibiotic treatment improves survival in experimental acute necrotizing pancreatitis. Gastroenterology 110:232–240
doi: 10.1053/gast.1996.v110.pm8536862
Baron T, Thaggard W, Morgan D, Stanley RJ (1996) Endoscopic therapy for organized pancreatic necrosis. Gastroenterology 111: 755–764
Siddiqui AA, Dewitt JM, Strongin A, Singh H, Jordan S, Loren DE, Kowalski T, Eloubeidi MA (2013) Outcomes of EUS-guided drainage of debris-containing pancreatic pseudocysts by using combined endoprosthesis and a nasocystic drain. Gastrointest Endosc 78:589–595
doi: 10.1016/j.gie.2013.03.1337
Gurusamy KS, Pallari E, Hawkins N, Pereira SP, Davidson BR (2016) Management strategies for pancreatic pseudocysts. Cochrane Database Syst Rev 4:CD011392. https://doi.org/10.1002/14651858
Werge M, Novovic S, Roug S, Knudsen JD, Feldager E, Gluud LL, Schmidt PN (2018) Evaluation of local instillation of antibiotics in infected walled-off pancreatic necrosis. Pancreatology 18:642–646
doi: 10.1016/j.pan.2018.06.005
Mouli VP, Sreenivas V, Garg PK (2013) Efficacy of conservative treatment, without necrosectomy, for infected pancreatic necrosis: a systematic review and meta-analysis. Gastroenterology 144:333–340
doi: 10.1053/j.gastro.2012.10.004
Besselink MG, van Santvoort HC, Boermeester MA, Nieuwenhuijs VB, van Goor H, Dejong CH, Schaapherder AF, Gooszen HG, Dutch Acute Pancreatitis Study Group (2009) Timing and impact of infections in acute pancreatitis. Br J Surg 96:267–273
doi: 10.1002/bjs.6447