Step-up approach for the treatment of infected necrotising pancreatitis: real life data from a single-centre experience with long-term follow-up

Abstract

Background: About 20% of patients with acute pancreatitis develop a necrotising form with a worse prognosis due to frequent appearance of organ failure(s) and/or infection of necrosis. Aims of the present study was to evaluate the "step up" approach treatment of infected necrosis in terms of: feasibility, success in resolving infection, morbidity of procedures, risk factors associated with death and long-term sequels.

Methods: In this observational retrospective monocentric study in the real life, necrotizing acute pancreatitis at the stage of infected walled-off necrosis were treated as follow: first step with drainage (radiologic and/or endoscopic-ultrasound-guided with lumen apposing metal stent); in case of failure, minimally invasive necrosectomy sessions(s) by endoscopy through the stent and/or via retroperitoneal surgery (step 2); If necessary open surgery as a third step. Efficacy was assessed upon to a composite clinical-biological criterion: resolution of organ failure(s), decrease of at least two of clinico-biological criteria among fever, CRP serum level, and leucocytes count).

Results: Forty-one consecutive patients were treated. The step-up strategy: (i) was feasible in 100% of cases; (ii) allowed the infection to be resolved in 33 patients (80.5%); (iii) Morbidity was mild and rapidly resolutive; (iv) the mortality rate at 6 months was of 19.5% (significant factors: SIRS and one or more organ failure(s) at admission, fungal infection, size of the largest collection ≥ 16 cm). During the follow-up (median 72 months): 27% of patients developed an exocrine pancreatic insufficiency, 45% developed or worsened a previous diabetes, 24% had pancreatic fistula and one parietal hernia.

Conclusions: Beside a very good feasibility, the step-up approach for treatment of infected necrotizing pancreatitis in the real life displays a clinico-biological efficacy in 80% of cases with acceptable morbidity, mortality and long-term sequels regarding the severity of the disease.

Keywords: Acute pancreatitis; Infected necrosis; Lumen-apposing metal stent; Necrosectomy; Step-up approach; Walled-off necrosis.

Fig. 1

Algorithm of the Step-up approach that has been applied in the present study for the treatment of infected necrotising pancreatitis at the stage of walled-off necrosis

Fig. 2

Algorithm of the Step-up approach for the treatment of infected necrotising pancreatitis with: type of drainage and necrosectomy procedures, number of patients per procedure and improvement or not of the infection. 1: Thirty-two patients with lumen-apposing metal stent and 2 patients with double pig-tail stents; 2: Improvement was assessed by a composite criterion: resolution of organ failure(s) and at least two of the following clinical and biological criteria: apyrexia, decrease of at least 50% of CRP serum level, decrease of at least 25% of total leucocytes count; 3: Four patients died at this step; 4: Two patients went directly to the third step due to gravity of the disease; 5: The four patients died

Fig. 3

CRP levels (panel A) and white blood cell count (panel B) before and 7 and 14 days after the first procedure of drainage of walled-off necrosis. 35 patients were investigated for whom we had all dosages before drainage and thereafter at 7 and 14 days after drainage (paired Mann-Whitney test)