PDF(1502 KB)
A 15-year analysis of surgical trends and outcomes for infected pancreatic necrosis in a single center
CAO Xin-tong, LIU Bai-qi, GUO Rong, LIN Jia-yan, NING Cai-hong, LI Jia-rong, HONG Xiao-yue, SUN Ze-fang, SHEN Ding-cheng, CHEN Lu, HUANG Geng-wen
Chinese Journal of Practical Surgery ›› 2025, Vol. 45 ›› Issue (11) : 1302-1308.
PDF(1502 KB)
PDF(1502 KB)
A 15-year analysis of surgical trends and outcomes for infected pancreatic necrosis in a single center
Objective To comprehensively evaluate the long-term trends in surgical intervention and clinical outcomes of infected pancreatic necrosis (IPN). Methods Clinical data of 418 consecutive IPN patients admitted to Xiangya Hospital, Central South University, between January 2010 and December 2024 were prospectively collected. Based on the surgical intervention strategy, patients were divided into a step-up group (n=356) and a step-down group (n=62). The clinical data of the two groups were compared, and the trends in surgical strategies, operative approaches, and clinical outcomes over the 15-year period were analyzed. Results The overall mortality rate of patients was 24.4%. Compared to the step-down group, the step-up group demonstrated a significantly higher mean frequency of total surgical interventions, percutaneous catheter drainage (PCD) procedures, and minimally invasive retroperitoneal pancreatic necrosectomy (MARPN) procedures, but a lower mean frequency of open pancreatic necrosectomy (OPN) procedures (all P<0.05). Cox proportional hazards regression analysis identified multiple organ failure, timing of the first surgical intervention, step-up intervention strategy, frequency of surgical interventions, frequency of MARPN procedures, frequency of OPN procedures, and bleeding as independent influencing factors for mortality (all P<0.05). Trend analysis across three time periods (2010-2014, 2015-2019, 2020-2024) revealed a significant increase in the application rate of the step-up strategy among all patients (P for trend <0.05). Within both the step-up and step-down groups, the utilization rate of MARPN showed a significant increasing trend (P for trend <0.05). Conversely, the application rates of PCD and OPN in the step-up group exhibited significant decreasing trends (P for trend <0.05). Regarding clinical outcomes, the step-up group had significantly lower incidences of enteric fistula, bleeding, mortality, and shorter mean ICU and total hospital stays compared to the step-down group (all P<0.05). Furthermore, within the step-up group, the rates of pancreatic fistula, mortality, and mean ICU and total hospital stay demonstrated significant downward trends over time (P for trend <0.05). Survival analysis indicated a significantly higher long-term survival rate in the step-up group (P<0.05). Conclusion Over study period, the step-up strategy and MARPN have become the mainstay therapeutic approaches for IPN, which accounts for reduced complications and improved outcomes.
infected pancreatic necrosis / severe acute pancreatitis / surgical intervention strategy / minimally access retroperitoneal pancreatic necrosectomy
| [1] |
|
| [2] |
孙备, 张灿. 重症急性胰腺炎治疗面临的挑战与对策[J]. 中国实用外科杂志, 2024, 44(05): 506-511. DOI: 10.19538/j.cjps.issn1005-2208.2024.05.04.
|
| [3] |
|
| [4] |
|
| [5] |
李非, 黄铂涵, 曹锋. 感染性胰腺坏死的微创外科处理策略、技术及评价[J]. 中国实用外科杂志, 2024, 44(5): 512-516. DOI: 10.19538/j.cjps.issn1005-2208.2024.05.05.
|
| [6] |
Various minimally invasive approaches have been described for infected necrotizing pancreatitis. This article describes a modified minimal-access retroperitoneal pancreatic necrosectomy (MARPN) procedure assisted by gas insufflation.
|
| [7] |
|
| [8] |
中华医学会外科学分会胰腺外科学组. 中国急性胰腺炎诊治指南(2021)[J]. 中国实用外科杂志, 2021, 41(7): 739-746. DOI:10.19538/j.cjps.issn1005-2208.2021.07.03.
|
| [9] |
In the United States, acute pancreatitis is one of the leading causes of hospital admission from gastrointestinal diseases, with approximately 300 000 emergency department visits each year. Outcomes from acute pancreatitis are influenced by risk stratification, fluid and nutritional management, and follow-up care and risk-reduction strategies, which are the subject of this review.MEDLINE was searched via PubMed as was the Cochrane databases for English-language studies published between January 2009 and August 2020 for current recommendations for predictive scoring tools, fluid management and nutrition, and follow-up and risk-reduction strategies for acute pancreatitis. Several scoring systems, such as the Bedside Index of Severity in Acute Pancreatitis (BISAP) and the Acute Physiology and Chronic Health Evaluation (APACHE) II tools, have good predictive capabilities for disease severity (mild, moderately severe, and severe per the revised Atlanta classification) and mortality, but no one tool works well for all forms of acute pancreatitis. Early and aggressive fluid resuscitation and early enteral nutrition are associated with lower rates of mortality and infectious complications, yet the optimal type and rate of fluid resuscitation have yet to be determined. The underlying etiology of acute pancreatitis should be sought in all patients, and risk-reduction strategies, such as cholecystectomy and alcohol cessation counseling, should be used during and after hospitalization for acute pancreatitis.Acute pancreatitis is a complex disease that varies in severity and course. Prompt diagnosis and stratification of severity influence proper management. Scoring systems are useful adjuncts but should not supersede clinical judgment. Fluid management and nutrition are very important aspects of care for acute pancreatitis.
|
| [10] |
The incidence of acute pancreatitis continues to rise, inducing substantial medical and social burden, with annual costs exceeding $2 billion in the United States alone. Although most patients develop mild pancreatitis, 20% develop severe and/or necrotizing pancreatitis, requiring advanced medical and interventional care. Morbidity resulting from local and systemic complications as well as invasive interventions result in mortality rates historically as high as 30%. There has been substantial evolution of strategies for interventions in recent years, from open surgery to minimally invasive surgical and endoscopic step-up approaches. In contrast to the advances in invasive procedures for complications, early management still lacks curative options and consists of adequate fluid resuscitation, analgesics, and monitoring. Many challenges remain, including comprehensive management of the entire spectrum of the disease, which requires close involvement of multiple disciplines at specialized centers.Copyright © 2019 AGA Institute. Published by Elsevier Inc. All rights reserved.
|
| [11] |
Acute pancreatitis (AP), defined as acute inflammation of the pancreas, is one of the most common diseases of the gastrointestinal tract leading to hospital admission in the United States. It is important for clinicians to appreciate that AP is heterogenous, progressing differently among patients and is often unpredictable. While most patients experience symptoms lasting a few days, almost one-fifth of patients will go on to experience complications, including pancreatic necrosis and/or organ failure, at times requiring prolonged hospitalization, intensive care, and radiologic, surgical, and/or endoscopic intervention. Early management is essential to identify and treat patients with AP to prevent complications. Patients with biliary pancreatitis typically will require surgery to prevent recurrent disease and may need early endoscopic retrograde cholangiopancreatography if the disease is complicated by cholangitis. Nutrition plays an important role in treating patients with AP. The safety of early refeeding and importance in preventing complications from AP are addressed. This guideline will provide an evidence-based practical approach to the management of patients with AP.Copyright © 2024 by The American College of Gastroenterology.
|
| [12] |
For decades, infected or symptomatic pancreatic necrosis was managed by open surgical necrosectomy, an approach that has now been largely supplanted by an array of techniques referred to as the step-up approach.
|
| [13] |
To assess the minimally invasive surgery into the step-up approach procedures as a standard treatment for severe acute pancreatitis and comparing its results with those obtained by classical management.Retrospective cohort study comparative with two groups treated over two consecutive, equal periods of time were defined: group A, classic management with open necrosectomy from January 2006 to June 2010; and group B, management with the step-up approach with minimally invasive surgery from July 2010 to December 2014.In group A, 83 patients with severe acute pancreatitis were treated, of whom 19 underwent at least one laparotomy, and in 5 any minimally invasive surgery. In group B, 81 patients were treated: minimally invasive surgery was necessary in 17 cases and laparotomy in 3. Among operated patients, the time from admission to first interventional procedures was significantly longer in group B (9 days vs. 18.5 days; p = 0.042). There were no significant differences in Intensive Care Unit stay or overall stay: 9.5 and 27 days (group A) vs. 8.5 and 21 days (group B). Mortality in operated patients and mortality overall were 50% and 18.1% in group A vs 0% and 6.2% in group B (p < 0.001 and p = 0.030).The combination of the step-up approach and minimally invasive surgery algorithm is feasible and could be considered as the standard of treatment for severe acute pancreatitis. The mortality rate deliberately descends when it is used.Copyright © 2018 IJS Publishing Group Ltd. Published by Elsevier Ltd. All rights reserved.
|
| [14] |
王刚, 徐德全, 周昊昕. 升阶梯时代对重症急性胰腺炎外科干预的再认识[J]. 中国实用外科杂志, 2024, 44(5): 516-520. DOI: 10.19538/j.cjps.issn1005-2208.2024.05.06.
|
| [15] |
|
| [16] |
|
| [17] |
Carbapenem-resistant Enterobacteriaceae (CRE) has emerged as a global threat to hospitalization patients. Infected pancreatic necrosis (IPN) leads to high risks of CRE infections with increasing mortality. Our study aims to determine the predictors related to 90-day overall mortality of CRE IPN.We retrospectively reviewed the drug resistance rates and clinical characteristics of CRE IPN patients from January 1, 2016, to January 1, 2021. Independent predictors of mortality were identified via univariate and multivariate analyses.During the 5-year period, 75 IPN patients suffered from 135 episodes of CRE infections with mortality up to 50.7%. CRE strains were highly resistant (> 50%) to nine of ten common antibiotics, except tigecycline (18%). The most common pathogen was carbapenem-resistant Klebsiella pneumoniae (84 of 135). Lung was the main site of extrapancreatic infections, followed by bloodstream and biliary tract. The independent predictors of mortality were Sequential Organ Failure Assessment (SOFA) score > 2 (hazard ratio 3.746, 95% confidence interval 1.209-11.609, P = 0.022) and procalcitonin > 6 ng/l (hazard ratio 2.428, 95% confidence interval 1.204-4.895, P = 0.013).CRE is widespread as a global challenge with a high mortality rate among IPN patients due to limited therapeutic options. Carbapenem-resistant K. pneumoniae is the leading category of CRE which requires more attention in clinical practice. High SOFA score and procalcitonin level represent two independent predictors of mortality in CRE IPN patients. Greater efforts are needed toward timely therapeutic intervention for CRE IPN.
|
| [18] |
With recent studies demonstrating the efficacy of minimally invasive approaches following infected necrotizing pancreatitis, latest guideline recommendations support their use. However, large scale studies are lacking and the national landscape following these guidelines remains poorly characterized. The present study examined trends in intervention strategies and the association of approach on clinical outcomes and resource use in a nationally representative cohort.The 2016-2019 National Inpatient Sample was queried for adult hospitalizations for pancreatitis with infected necrosis. Patients were classified as DO if they received only percutaneous or endoscopic drainage, MIS if they underwent endoscopic or laparoscopic debridement, and Open if they underwent open debridement. The primary outcome was in-hospital mortality while secondary outcomes included perioperative complications, home discharge, and resource use. Multivariable regression models were developed to evaluate the association of intervention with clinical and financial endpoints.Of 4,605 patients who received interventions, 1,735 (37.6%) were DO, 1,490 (32.4%) were MIS, and 1,380 (30.0%) were considered Open. The proportion of DO and MIS increased while Open declined (2016 - 47.0%, 2019 - 24.6%, p < 0.001). Compared to Open, MIS had lower rates of abdominal compartment syndrome while having greater rates of preoperative closed drainage (31.9% vs 13.8%, p < 0.001). After adjustment, odds of in-hospital mortality, respiratory failure, prolonged ventilation, and acute kidney injury were significantly higher in the Open cohort compared to MIS. Hospitalization duration was longer (β: +12.1 days, 95% CI: 6.8-17.5) and costs were higher (β: +$58.7 K, 95% CI: 33.5-83.9) in Open compared to MIS.Minimally invasive approaches for infected pancreatic necrosis has increased over time while open necrosectomy has declined. Open approaches compared to drainage only or minimally invasive debridement were associated with greater odds of numerous in-hospital complications and resource burden.Prognostic and epidemiological, IV.Copyright © 2023 Wolters Kluwer Health, Inc. All rights reserved.
|
| [19] |
黄耿文, 申鼎成, 亢浩, 等. 微创腹膜后入路胰腺坏死组织清除术治疗感染性胰腺坏死18例疗效分析[J]. 中国实用外科杂志, 2016, 36(11): 1197-1199. DOI: 10.7504/CJPS.ISSN1005-2208.2016.11.16.
目的 观察微创腹膜后入路胰腺坏死组织清除术（MARPN）治疗感染性胰腺坏死（IPN）的临床疗效并总结经验。方法 回顾性分析2013年9月至2016年7月中南大学湘雅医院收治的18例采用MARPN治疗的IPN病人的临床资料，其中15例行经皮穿刺引流术+MARPN，3例为开放手术+MARPN。结果 18例病人胰周引流液培养结果均为多重病原菌感染。15例（83.3%）行MARPN后脓毒症完全逆转痊愈出院，1例因并发出血和肠瘘中转开放手术。术后发生胰瘘7例（38.9%）、肠瘘5例（27.8%）、出血2例（11.1%）。3例（16.7%）病人因继发出血或肠瘘，最终导致多器官功能衰竭而死亡。结论 采用以MARPN为重要方式的升阶梯或降阶梯治疗方案是治疗IPN的有效策略。
|
| [20] |
Surgical pancreatic necrosectomy (SPN) is an option for the management of infected pancreatic necrosis. The literature indicates that an escalating, combined endoscopic, interventional radiology and minimally invasive surgery "step-up" approach, such as video-assisted retroperitoneal debridement, may reduce the number of required SPNs and ICU complications, such as multiple organ failure. We hypothesized that complications for surgically treated severe necrotizing pancreatitis patients decreased during the period of adoption of the "step-up" approach.The American college of surgeons national surgery quality improvement program database (ACS-NSQIP) was used to find SPN cases from 2007 to 2019 in ACS-NSQIP submitting hospitals. Mortality and Clavien-Dindo class 4 (CD4) ICU complications were collected. Predictors of outcomes were identified by univariate and multivariate analyses.There were 2457 SPN cases. SPN cases decreased from 0.09% in 2007 to 0.01% in 2019 of NSQIP operative cases (p < 0.001). Overall mortality was 8.5% and did not decrease with time. CD4 complications decreased from 40 to 27% (p < 0.001). There was a 65% reduction in SPN cases requiring a return to the operating room. Multivariate predictors of complications were emergency general surgery (EGS, p < 0.001), serum albumin (p < 0.0001) and modified frailty index (mFI) (p < 0.0001). Multivariate predictors of mortality were EGS (p < 0.0001), serum albumin (p < 0.0001), and mFI (p < 0.04). The mFI decreased after 2010 (p < 0.001).SPNs decreased after 2010, with decreasing CD4 complications, decreasing reoperation rates and stable mortality rates, likely indicating broad adoption of a "step-up" approach. Larger, prospective studies to compare indications and outcomes for "step up" versus open SPN are warranted.© 2022. The Author(s).
|
| [21] |
To examine the outcomes from minimal access retroperitoneal pancreatic necrosectomy (MARPN) and open pancreatic necrosectomy (OPN) for severe necrotizing pancreatitis in a single center.The optimal management of severe pancreatic necrosis is evolving with a few large center single series.Between 1997 and 2013, patients with necrotizing pancreatitis at the Liverpool Pancreas Center were reviewed. Outcome measures were retrospectively analyzed by intention to treat.There were 394 patients who had either MARPN (274, 69.5%) or OPN (120, 30.5%). Complications occurred in 174 MARPN patients (63.5%) and 98 (81.7%) OPN patients (P < 0.001). OPN was associated with increased postoperative multiorgan failure [42 (35%) vs 56 (20.4%), P = 0.001] and median (inter-quartile range) Acute Physiology and Chronic Health Evaluation II score 9 (6-11.5) vs 8 (5-11), P < 0.001] with intensive care required less frequently in MARPN patients [40.9% (112) vs 75% (90), P < 0.001]. The mortality rate was 42 (15.3%) in MARPNs and 28 (23.3%) in OPNs (P = 0.064). Both the mortality and the overall complication rates decreased between 1997-2008 and 2008-2013 [49 (23.8%) vs 21 (11.2%) P = 0.001, respectively; and 151 (73.3%) vs 121 (64.4%), P = 0.080, respectively). Increased mortality was independently associated with age (P < 0.001), preoperative intensive care stay (P = 0.014), and multiple organ failure (P < 0.001); operation before 2008 (P < 0.001) and conversion to OPN (P = 0.035). MARPN independently reduced mortality odds risk (odds ratio = 0.27; 95% confidence interval = 0.12-0.57; P < 0.001).Increasing experience and advances in perioperative care have led to improvement in outcomes. The role of MARPN in reducing complications and deaths within a multimodality approach remains substantial and should be used initially if feasible.
|
| [22] |
Infected pancreatic necrosis (IPN) is a severe complication of acute pancreatitis, with mortality rates ranging from 15 to 35%. However, limited studies exist to predict the survival of IPN patients and nomogram has never been built. This study aimed to identify predictors of mortality, estimate conditional survival (CS), and develop a CS nomogram and logistic regression nomogram for real-time prediction of survival in IPN patients.
|
| [23] |
|
| [24] |
Previous studies have shown that minimally invasive treatment for infected necrotizing pancreatitis (INP) may be safer and more effective than open necrosectomy (ON), but ON is still irreplaceable in a portion of INP patients. Furthermore, there is a lack of tools to identify INP patients at risk of minimally invasive step-up approach failure (eventually received ON or died), which may enable appropriate treatment for them. Our study aims to identify risk factors that can predict minimally invasive step-up approach failure in INP patients and to develop a nomogram for early prediction.
|
| [25] |
Acute pancreatitis is a common inflammatory pancreatic disorder, often caused by gallstone disease and frequently requiring hospitalization. In 80% of cases, a rapid and favourable outcome is described, while a necrosis of pancreatic parenchyma or extra-pancreatic tissues is reported in 10-20% of patients. The onset of pancreatic necrosis determines a significant increase of early organ failure rate and death that has higher incidence if infection of pancreatic necrosis (IPN) or extra-pancreatic collections occur. IPN always requires an invasive intervention, and, in the last decade, the advent of minimally invasive techniques has gradually replaced the employment of the open traditional approach. We report a series of three severe cases of IPN managed with primary open necrosectomy (ON) and a systematic review of the literature, in order to understand if emergency surgery still has a role in the current clinical practice.From January 2010 to January 2020, 3 cases of IPN were treated in our Academic Department of General and Emergency Surgery. We performed a PubMed MEDLINE search on the ON of IPN, selecting 20 from 654 articles for review.The 3 cases were male patients with a mean age of 61.3 years. All patients referred to our service complaining an evolving severe clinical condition evocating a sepsis due to IPN. CT scan was the main diagnostic tool. Patients were initially conservatively managed. In consideration of clinical worsening conditions, and at the failure of conservative and minimal invasive treatment, they were, finally, managed with emergency ON. Patients reported no complications nor procedure-related sequelae in the follow-up period.The ON is confirmed to be the last resort, useful in selected severe cases, with a defined timing and in case of proven non-feasibility and no advantage of other minimally invasive approaches.
|
| [26] |
|
| [27] |
宁彩虹, 朱帅, 申鼎成, 等. 开放胰腺坏死组织清除术治疗感染性胰腺坏死的适应证及临床价值分析[J]. 中国普通外科杂志, 2020, 29(9): 1105-1111. DOI:10.7659/j.issn.1005-6947.2020.09.011.
|
| [28] |
Multiple organ failure and early surgery are associated with high morbimortality after open necrosectomy. Data are mostly derived from historical cohorts with early necrosectomy bereft of step-up treatment algorithm implementation. Thus, mostly circumstantial evidence suggests a better clinical course following mini-invasive surgical and endoscopic necrosectomy. We studied the results of open necrosectomy in a contemporary cohort of patients with complicated pancreatic necrosis treated at a tertiary center.A retrospective cohort study from a university teaching hospital. Results of 109 consecutive patients treated with open necrosectomy during a 12-year period are reported.The overall 90-day mortality rate was 22.9%. The 90-day mortality rate was 10.6% if necrosectomy could be delayed until 4 weeks from symptom onset and the necrosis had become walled off on preoperative imaging. The risk factors for 90-day mortality were age over 60 years (OR 19.4), pre-existing co-morbidities (OR 16.9), necrosectomy within 4 weeks (OR 6.5), multiple organ failure (OR 12.2), white blood cell count over 23 × 10 (OR 21.4), and deterioration or prolonged organ failure as an indication for necrosectomy (OR 10.4). None or one of these risk factors was present in 52 patients (47.7% of all patients), and these patients had no mortality.Late open necrosectomy for walled-off necrosis has a low mortality risk. Open necrosectomy can be done without mortality in the absence of multiple risk factors for surgery.
|
/
| 〈 |
|
〉 |
