Percutaneous Interventions in Acute Necrotizing Pancreatitis

Abstract

Acute pancreatitis (AP) is a disease of varying severity with acute necrotizing pancreatitis (ANP) being the severe form of AP. ANP needs multidisciplinary management and is associated with significant mortality and morbidity. Local complications of ANP viz. acute necrotic collections (ANC) and walled off pancreatic necrosis (WOPN) need intervention if they are associated with symptoms, sepsis or worsening organ failure. As surgery is associated with higher morbidity and mortality, there is paradigm shift in the management of these local complications with an increased emphasis on conservative and minimally invasive treatment approach. Image-guided percutaneous drainage (PCD) is a minimally invasive intervention that helps in drainage of infected collections, temporizes sepsis and improves outcomes in these patients. The present review discusses the utility of various percutaneous interventions in management of variety of pancreatic collections occurring in ANP. The available evidence, technical details and complications and emerging innovations in the field are also summarized. Acute Pancreatitis (AP) is an acute inflammatory disease of the pancreas, which is characterized by the frequent development of local or systemic complications. It is broadly divided into two morphological patterns: interstitial, which is merely associated with edema of the pancreatic parenchyma or necrotizing, in which peri-pancreatic and/or pancreatic necrosis is present. [1][2][3] In the early phase of acute pancreatitis the heightened inflammatory response dominates the clinical picture while the late phase is characterized by development of local infective as well as non-infective complications. The pancreatic inflammation results in exudation of pancreatic juice and subsequent injury to the peri-pancreatic fat and tissues. 2,3 This results in formation of collections which may be associated with both interstitial and necrotizing pancreatitis. While the collections formed in relation to interstitial pancreatitis are predominantly fluid and are called as acute fluid collections (AFC), KEYWORDS:

Intestinal homeostasis and inflammation: Gut microbiota at the crossroads of pancreas–intestinal barrier axis

“…Using an acute pancreatitis (AP) mouse model, the same research group confirmed the correlations between the gut microbiota burden and AP severity [94]. ANP is a severe form of AP [37]. In other studies, an E. coli MG1655 mono‐colonized ANP rat model showed more severe pancreatic injury in comparison to a normal ANP rat model with significant upregulation of the TLR‐4‐mitogen‐activated protein pathway and activation of the endoplasmic reticulum stress pathway in intestinal epithelial cells [38].…”

“…Furthermore, bacteria can translocate to the pancreas under pathological conditions [35,36]. With the increase in intestinal microbes and by compromising the epithelial barrier function, pancreatitis is more severe and may lead to acute necrotizing pancreatitis (ANP) [37,38].…”

Drainage of pancreatic fluid collections in acute pancreatitis: A comprehensive overview

“…Drainage catheter is then inserted along the guidewire after adequate dilatation of the tract. Trocar technique employs advancing a co-axial combination of a sharp stylet, stiffening cannula, and the draining catheter[ 29 ]. Seldinger technique is more useful for deep collections but is more time-consuming as it involves multiple steps.…”

“…Seldinger technique is more useful for deep collections but is more time-consuming as it involves multiple steps. Trocar technique is useful in large and superficial collections but is more painful[ 29 ].…”

“…Initial catheter size is an important factor that may determine the success of PCD as well as other outcomes but has been inadequately addressed in the literature. It is generally believed that liquefied collections with a small amount of solid debris may be treated initially with small bore catheters ranging from 8-12 F, and organized, solid looking collections be treated with larger bore catheters but high level evidence is lacking[ 29 , 30 ]. Few retrospective studies and meta-analyses showed no significant difference in outcome with respect to mean catheter size[ 30 , 31 ].…”