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 Table of Contents  
CASE REPORT
Year : 2022  |  Volume : 4  |  Issue : 1  |  Page : 8

A Step-up Approach for the Management of Infected Pancreatic Necrosis


Department of General Surgery, Xuanwu Hospital Capital Medical University, Beijing, China

Date of Submission26-Oct-2021
Date of Acceptance11-Mar-2022
Date of Web Publication20-Apr-2022

Correspondence Address:
Dr. Feng Cao
Department of General Surgery, Xuanwu Hospital Capital Medical University, Beijing
China
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/JTCCM_D-21-00022

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  Abstract 


Acute pancreatitis (AP) is an acute inflammation of the pancreas. Many of the mild AP and moderately severe AP (SAP) are self-limiting with a good prognosis, but the management of 15%–20% of SAP is very difficult and results in a mortality rate of 36%–50%. It poses a great challenge in clinical diagnosis and treatment. Infected pancreatic necrosis develops in approximately 20% to 30% of patients with AP, which is treated with the use of a step-up approach, with catheter drainage often delayed until the infected necrosis is encapsulated.

Keywords: Infected pancreatic necrosis, percutaneous catheter drainage, severe acute pancreatitis


How to cite this article:
Yao J, Liu D, Cao F. A Step-up Approach for the Management of Infected Pancreatic Necrosis. J Transl Crit Care Med 2022;4:8

How to cite this URL:
Yao J, Liu D, Cao F. A Step-up Approach for the Management of Infected Pancreatic Necrosis. J Transl Crit Care Med [serial online] 2022 [cited 2022 Aug 9];4:8. Available from: http://www.tccmjournal.com/text.asp?2022/4/1/8/343648




  Introduction Top


Acute pancreatitis (AP) is an acute inflammation of the pancreas. Many of the mild AP (MAP) and moderately severe AP (SAP) are self-limiting with a good prognosis, but the management of 15%–20% of SAP is very difficult and results in a mortality rate of 36%–50%. It poses a great challenge in clinical diagnosis and treatment.[1],[2] Infected pancreatic necrosis (IPN) develops in approximately 20% to 30% of patients with AP, which is treated with the use of a step-up approach, with catheter drainage often delayed until the infected necrosis is encapsulated.


  Case Report Top


A 47-year-old female patient suffered from epigastric pain after eating greasy foods for 3 weeks. It was a persistent pain, accompanied by nausea and vomiting. She went to a local hospital and had blood and abdominal computed tomography (CT) examinations. Blood amylase was 1228 IU/L, lipase was 1147 U/L, and triglyceride (TG) was 18.24 mmol/L. Abdominal CT showed pancreatic swelling and apparent peripancreatic exudation. She was diagnosed with acute hyperlipidemic pancreatitis and underwent fasting gastrointestinal decompression and treatment with fenofibrate, proton-pump inhibitor (PPI), somatostatin, and parenteral nutrition. The patient's symptoms were aggravated, and the abdominal distension became obvious and accompanied by anuria and respiratory distress. It was considered acute kidney injury (AKI) and acute respiratory distress syndrome (ARDS), and the conditions were treated with continuous renal replacement therapy (CRRT) and noninvasive ventilation followed by percutaneous catheter drainage (PCD) around the pancreas. The drainage fluid consisted of dark blood. One day before, the patient vomited blood and excreted tarry stool. For further treatment, she was referred to our hospital. She had a previous history of hypertension for 6 years and hyperlipidemia for 5 years.

On physical examination at the time of admission, she had a temperature of 37°C, pulse rate of 112 bpm, respiratory rate of 30 bpm, blood pressure of 101/60 mmHg, conscientiousness, anemic appearance, abdominal swelling, upper abdominal tenderness, no rebound pain, increased abdominal muscle tone, and weakened bowel sound. The APACHE II score was 29 points. Related examination after the admission revealed white blood cell (WBC)-20.7 × 109/L, neutrophil percentage-87.5%, hemoglobin-55 g/L, triglycerides-2.41 mmol/L, creatinine-337umol/L, K-6.88 mmol/L, Ca-2.01 mmol/L, and procalcitonin (PCT)-1.06 ng/ml. Abdominal CT showed that the pancreas was enlarged, the pancreatic edge was blurred, a large number of mixed density shadows were seen around the pancreas, and the bilateral anterior renal fascia was thickened. Liquid density shadows were seen around the pancreatic head, around the liver in the middle and lower abdomen, and pelvic cavity [Figure 1]. Diagnosis: SAP, acute renal insufficiency, ARDS, and upper gastrointestinal bleeding.
Figure 1: Abdominal computed tomography on the day of initial admission. (a) A large amount of fluid around the pancreas (b) Abdominal and pelvic effusion

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The patient underwent fasting, gastrointestinal decompression, CRRT, mechanical ventilation, red blood cell transfusion, and treatment with antibiotics, PPI, hemostatic drugs, somatostatin, and parenteral nutrition. As the patient developed abdominal compartment syndrome (ACS), ultrasound-guided PCD was performed to drain the peritoneal effusion. One week after the admission, the patient developed a persistent high fever, and the reexamination of the abdominal CT showed IPN. As the application of imipenem and cilastatin alone was ineffective, the patient underwent ultrasound-guided PCD, including the drainage from the left paracolic sulcus and pelvic cavity, to adequately drain the effusion. The drainage fluid was reserved for the bacterial culture, and the administration of antibiotics was adjusted according to the drug sensitivity results. Soon, the patient's infection was controlled, and the body temperature returned to normal. She was removed from the ventilator smoothly and the CRRT treatment was stopped. However, 1 month later, the patient's abdominal CT showed that the pancreas was swollen, the outline was unclear, and a large amount of fluid around the pancreas, in the bilateral prerenal space, at the lower edge of the liver, in the bilateral paracolic sulcus, and the intestinal space of the lower abdomen was noticed [Figure 2]. Then, we decided to perform a laparoscopic-assisted pancreatic debridement. We chose the left mid-axillary line of the patient to make a small incision, which was about 5 cm in length. During the operation, about 200 g of necrotic tissue was removed [Figure 3] and five drainage tubes were placed [Figure 4]. The patient recovered well after the surgical intervention, gradually resumed oral feeding, and was discharged from the hospital steadily.
Figure 2: Abdominal computed tomography 1 month after the admission. (a) A large amount of fluid around the pancreas (b) Abdominal and pelvic effusion

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Figure 3: (a) Large amounts of pancreatic necrotic tissue. (b) Laparoscopic-assisted pancreatic debridement

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Figure 4: Four days after the operation, abdominal computed tomography showed that the drainage tube was in good position and the peripancreatic effusion decreased. (a) Drainage tubes were placed around the pancreas (b) The peripancreatic effusion decreased

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One month after discharge, the patient developed abdominal pain and bloating, accompanied by stopping gas and defecation. Abdominal CT showed small bowel dilatation and acute intestinal obstruction [Figure 5]. She was admitted to the hospital again for enterostomy and intestinal adhesion release. The patient recovered well after the operation. One year later, small intestinal fistula closure and lateral short-circuit anastomosis of the transverse colon and descending colon for the suspected stricture of the colonic spleen area was performed. After 3 months of follow-up, the patient had no discomfort.
Figure 5: Abdominal computed tomography showed acute intestinal obstruction. (a) Dilated small intestine with large accumulation of fluid (b) Perihepatic and inter-intestinal effusions

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  Discussion Top


AP can cause systemic or local complications. The systemic complications mainly include systemic inflammatory response syndrome, sepsis, multiple organ dysfunction syndromes, abdominal hypertension, and ACS. Local complications are mainly related to pancreatic and peripancreatic fluid accumulation and tissue necrosis, including early acute peripancreatic fluid collection, acute necrotic collection, late pancreatic pseudocyst, and walled-off necrosis.[3] Other complications include gastrointestinal bleeding, intra-abdominal bleeding, biliary obstruction, intestinal obstruction, and enterocutaneous fistulas. At present, a nonsurgical treatment focusing on early supportive treatment is performed for the SAP, that is, early fluid resuscitation, maintenance and replacement of organ functions, antibiotic use, and nutritional support. This patient mainly developed ARDS, AKI, and ACS in the early stage of her illness, and her condition improved after supportive treatment such as mechanical ventilation and CRRT. Subsequently, the patient suffered gastrointestinal bleeding and intra-abdominal hemorrhage. Fortunately, she recovered after the conservative treatments such as the administration of hemostatic drugs, PPIs, red blood cells, and plasma infusions.

The later stage treatment of AP is mainly for its various local complications and IPN mainly needs surgical intervention. At this later stage, the patient mainly presented with persistent fever and abdominal pain, and the count WBC, C-reactive protein, interleukin 6, PCT, and other laboratory indicators were significantly increased. Some researchers believe that the PCT can provide an early and reliable assessment for the overall prognosis of the IPN.[4] The main treatments for the IPN include PCD, endoscopic transgastric drainage or endoscopic transgastric necrosectomy (ETN), and minimal access retroperitoneal pancreatic necrosectomy (MARPN). A prospective cohort study conducted by Babu et al.[5] showed that the PCD can reverse the sepsis in 62% of the SAP patients and surgical intervention saved 48% of the SAP patients. The ETN is generally guided by ultrasound endoscopy through a gastric or duodenal puncture, enters the pancreatic necrosis under the direct vision of the endoscopy for debridement and stents or the placement of nasobiliary drainage, resulting in minimal trauma and low mortality, however, it may cause complications such as bleeding. The main advantage of laparoscopic access to the abdominal cavity for the necrotic tissue debridement is a small trauma. A previous study showed that the MARPN reduced the incidence of postoperative multiple organ failures and reduced the proportion of the intensive care unit admissions for the patients with necrotizing pancreatitis compared with the open surgical pancreatic necrotizing tissue clearance, with the limitation that it was at risk of spread of intra-abdominal infection.[6] At present, it is generally believed that the preferred intervention strategy for the IPN is the “step-up” approach,[7] that is, puncture drainage is performed first, and video-assisted debridement and laparotomy[8] are sequentially performed on patients with poor drainage effect. The advantage of the PCD is to quickly improve the patient's general condition with less trauma, creating tolerance for the subsequent treatment. However, whether the outcome could be improved by earlier catheter drainage is unknown. A recent randomized controlled study[9] showed that immediate drainage was not superior to the postponed drainage in patients with the infected necrotizing pancreatitis. In this case, the patient suffered from recurrent fever in the late stage of the SAP, accompanied by pancytopenia, which was considered to be related to severe abdominal infection. First, we chose the PCD and placed drainage tubes in different infected areas to fully drain the effusion. At the same time, the drainage fluid was collected for bacterial culture. Since the culture results were positive for Enterococcus faecium and Klebsiella oxytoca, tigecycline (50 mg q12 h ivgtt), imipenem, and cilastatin (0.5 g q8 h ivgtt) were used according to the results of the drug sensitivity test. When the patient's condition was stable, the laparoscopic-assisted debridement was performed. There were no complications of postoperative bleeding, pancreatic leakage, and intestinal fistula, and a good therapeutic effect was achieved from this procedure.

Acute intestinal obstruction after the debridement of the SAP is rare in the clinical situation. In our case, the patient developed acute intestinal obstruction 1 month after discharge from the hospital. It can be either related to the intestinal adhesion caused by abdominal infection or to the stricture of the colonic spleen area. In terms of surgical intervention, the patient underwent jejunostomy and intestinal adhesiolysis to relieve the obstruction, and later, underwent the closure of enterostomy and short-circuited anastomosis between the transverse colon and descending colon. Eventually, her gastrointestinal function recovered well, and the diet could be gradually resumed without any discomfort reactions.

The clinical management of AP, especially SAP, is complex and individual differences are large. Clinicians need to adopt individualized treatment measures according to the specific conditions to achieve the most successful outcome. Many patients can obtain a good treatment effect through the “step-up” procedure strategy.

Ethical approval

It was approved by the Ethics Committee of Xuanwu Hospital Capital Medical Univessity.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
Banks PA, Bollen TL, Dervenis C, Gooszen HG, Johnson CD, Sarr MG, et al. Classification of acute pancreatitis--2012: Revision of the Atlanta classification and definitions by international consensus. Gut 2013;62:102-11.  Back to cited text no. 1
    
2.
Guo Q, Li A, Xia Q, Liu X, Tian B, Mai G, et al. The role of organ failure and infection in necrotizing pancreatitis: A prospective study. Ann Surg 2014;259:1201-7.  Back to cited text no. 2
    
3.
Hines OJ, Pandol SJ. Management of severe acute pancreatitis. BMJ 2019;367:l6227.  Back to cited text no. 3
    
4.
Rau BM, Kemppainen EA, Gumbs AA, Büchler MW, Wegscheider K, Bassi C, et al. Early assessment of pancreatic infections and overall prognosis in severe acute pancreatitis by procalcitonin (PCT): A prospective international multicenter study. Ann Surg 2007;245:745-54.  Back to cited text no. 4
    
5.
Babu RY, Gupta R, Kang M, Bhasin DK, Rana SS, Singh R. Predictors of surgery in patients with severe acute pancreatitis managed by the step-up approach. Ann Surg 2013;257:737-50.  Back to cited text no. 5
    
6.
Gomatos IP, Halloran CM, Ghaneh P, Raraty MG, Polydoros F, Evans JC, et al. Outcomes from minimal access retroperitoneal and open pancreatic necrosectomy in 394 patients with necrotizing pancreatitis. Ann Surg 2016;263:992-1001.  Back to cited text no. 6
    
7.
Hollemans RA, Bakker OJ, Boermeester MA, Bollen TL, Bosscha K, Bruno MJ, et al. Superiority of step-up approach vs. open necrosectomy in long-term follow-up of patients with necrotizing pancreatitis. Gastroenterology 2019;156:1016-26.  Back to cited text no. 7
    
8.
van Santvoort HC, Besselink MG, Bakker OJ, Hofker HS, Boermeester MA, Dejong CH, et al. A step-up approach or open necrosectomy for necrotizing pancreatitis. N Engl J Med 2010;362:1491-502.  Back to cited text no. 8
    
9.
Boxhoorn L, van Dijk SM, van Grinsven J, Verdonk RC, Boermeester MA, Bollen TL, et al. Immediate versus postponed intervention for infected necrotizing pancreatitis. N Engl J Med 2021;385:1372-81.  Back to cited text no. 9
    


    Figures

  [Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5]



 

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