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

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.

Video assisted retroperitoneal debridement for infected pancreatic necrosis: A two port approach for difficult access.

INTRODUCTION AND IMPORTANCE: The incidence of acute pancreatitis varies globally, and its rates are increasing. Timely intervention in cases of infected necrosis is crucial to effective management. The landscape of acute pancreatitis management has undergone transformation through adopting a "step-up" strategy, accentuating the shift towards minimally invasive techniques. CASE PRESENTATION: A 63-year-old patient with acute pancreatitis and infected pancreatic necrosis underwent a challenging yet successful treatment using video-assisted retroperitoneal debridement employing a two-port approach facilitated access for an intricate area. The procedure, performed 45 days after admission, effectively reduced peripancreatic collections, demonstrating the efficacy of this approach in managing complex cases of infected pancreatic necrosis. CLINICAL DISCUSSION: The management of acute pancreatitis has evolved towards a comprehensive strategy involving early hydration, nutritional support, effective pain management, and interventions. Infected pancreatic necrosis poses a serious complication, with minimally invasive techniques such as video-assisted retroperitoneal debridement (VARD) emerging as preferred options. The efficacy and safety of VARD in complex cases are highlighted, although challenges persist, especially in extensive necrosis. CONCLUSION: The VARD procedure, a key component of the step-up approach, exhibits a remarkable safety profile, substantially reducing postoperative complications and mortality compared to open surgical counterparts. However, challenges persist in managing cases of infected Walled-Off Necrosis with deep extension, necessitating carefully considering a minimal-access approach. We report our experience using the VARD in a two-port approach.

Step-Up Management in Acute Pancreatitis: A Tertiary Care Center's Experience From Southern India.

Background The clinical spectrum of acute pancreatitis (AP) ranges from mild disease to severe form associated with multiorgan failure, prolonged hospital stay, high morbidity, and mortality. Acute necrotizing pancreatitis (ANP) is a severe form of AP. This study evaluates AP's outcomes after applying principles of the step-up approach in a tertiary healthcare center in south India. Methodology This prospective observational study was carried out from January 2021 to December 2022. The study population includes patients admitted to our department with AP. Results Ninety patients were included in the study, most of them were middle-aged males with ethanol ingestion as the common etiology. Thirty-seven (41.1%) patients had mild AP, 25 (27.7%) had moderately severe AP, and 28 (31.1%) had severe AP. Organ failure at admission was noted in 36 (40%) patients. Twenty-three (25.5%) patients developed ANP. Infected necrosis was noted in 3 (3.33%) patients. Eighteen (20%) patients needed image-guided percutaneous drainage. Seven (38.8%) needed necrosectomy following percutaneous drainage. Mortality was observed in 8 (8.8%) patients. Specifically, mortality was noted in 6 (6.6%) patients who presented later in their disease course. Conclusions Percutaneous catheter drainage is a safe and effective therapy to tide over the initial phase of AP. It also serves as a bridging therapy till the patient is clinically fit for a necrosectomy. Severe AP cases presenting late in their course are associated with significant mortality even after step-up management. Standardized protocols for referral and management are essential to obtain a good clinical outcome.

Endoscopic Ultrasound-Guided Drainage of Pancreatic Fluid Collections: Not All Queries Are Already Solved.

Pancreatic fluid collections (PFCs) are well-known complications of acute pancreatitis. The overinfection of these collections leads to a worsening of the prognosis with an increase in the morbidity and mortality rate. The primary strategy for managing infected pancreatic necrosis (IPN) or symptomatic PFCs is a minimally invasive step-up approach, with endosonography-guided (EUS-guided) transmural drainage and debridement as the preferred and less invasive method. Different stents are available to drain PFCs: self-expandable metal stents (SEMSs), double pigtail stents (DPPSs), or lumen-apposing metal stents (LAMSs). In particular, LAMSs are useful when direct endoscopic necrosectomy is needed, as they allow easy access to the necrotic cavity; however, the rate of adverse events is not negligible, and to date, the superiority over DPPSs is still debated. Moreover, the timing for necrosectomy, the drainage technique, and the concurrent medical management are still debated. In this review, we focus attention on indications, timing, techniques, complications, and particularly on aspects that remain under debate concerning the EUS-guided drainage of PFCs.

Gastrointestinal Fistulas in Necrotizing Pancreatitis Receiving a Step-Up Approach Incidence, Risk Factors, Outcomes and Treatment.

Purpose: Necrotizing pancreatitis (NP) complicated by gastrointestinal fistula is challenging and understudied. As the treatment of necrotizing pancreatitis changed to a step-up strategy, we attempted to evaluate the incidence, risk factors, clinical outcomes and treatment of gastrointestinal fistulas in patients receiving a step-up approach. Methods: Clinical data from 1274 patients with NP from 2014-2022 were retrospectively analyzed. Multivariable logistic regression analysis was conducted to identify risk factors and propensity score matching (PSM) to explore clinical outcomes in patients with gastrointestinal fistulas. Results: Gastrointestinal fistulas occurred in 8.01% (102/1274) of patients. Of these, 10 were gastric fistulas, 52 were duodenal fistulas, 14 were jejunal or ileal fistulas and 41 were colonic fistulas. Low albumin on admission (OR, 0.936), higher CTSI (OR, 1.143) and invasive intervention prior to diagnosis of gastrointestinal fistula (OR, 5.84) were independent risk factors for the occurrence of gastrointestinal fistula, and early enteral nutrition (OR, 0.191) was a protective factor. Patients who developed a gastrointestinal fistula were in a worse condition on admission and had a poorer clinical outcome (p<0.05). After PSM, both groups of patients had similar baseline information and clinical characteristics at admission. The development of gastrointestinal fistulas resulted in new-onset persistent organ failure, increased open surgery, prolonged parenteral nutrition and hospitalization, but not increased mortality. The majority of patients received only conservative treatment and minimally invasive interventions, with 7 patients (11.3%) receiving surgery for upper gastrointestinal fistulas and 11 patients (26.9%) for colonic fistulas. Conclusion: Gastrointestinal fistulas occurred in 8.01% of NP patients. Independent risk factors were low albumin, high CTSI and early intervention, while early enteral nutrition was a protective factor. After PSM, gastrointestinal fistulas resulted in an increased proportion of NP patients receiving open surgery and prolonged hospitalization. The majority of patients with gastrointestinal fistulas treated with step-up therapy could avoid surgery.

Position of surgical treatment in step-up management of severe acute pancreatitis.

INTRODUCTION: The incidence of acute pancreatitis has been increasing over the past twenty years and there is still no causal treatment available. Although cases of severe acute pancreatitis account for only about a fifth of all cases of acute pancreatitis, high morbidity and lethality call for an optimization and unification of treatment procedures. METHODS: We operated on 27 patients suffering from severe acute pancreatitis in the past five years. We compared selected parameters such as gender, age, body mass index, aetiology, presence of type 2 diabetes, BISAP score, previous minimally invasive treatment and presence of the intraabdominal compartment syndrome. RESULTS: The average age of men and women was similar in our group. Most patients were overweight or obese. Alcoholic aetiology was more common in men while biliary aetiology prevailed in women. The mortality rate was 26% in our group. The intra-abdominal compartment syndrome followed by emergency decompression surgery was present in one fourth of the patients. A minimally invasive approach was used in approximately in one half of the patients, and surgical treatment was used only in cases where the minimally invasive approach failed. CONCLUSION: After each surgical revision, clinical deterioration of the patient´s condition occurs during the first two to three days in response to operative stress. Therefore, the current trend in the treatment of acute pancreatitis is to proceed as conservatively as possible, or using the minimally invasive approach, and surgical treatment should be reserved only for conditions that cannot be managed otherwise. If surgical treatment is used, it is advisable to perform cholecystectomy, whatever the aetiology of the pancreatitis.

Timing of minimally invasive step-up intervention for symptomatic pancreatic necrotic fluid collections: A systematic review and meta-analysis.

BACKGROUND AND AIMS: Minimally invasive step-up interventions are now the standard treatment recommended by current guidelines for symptomatic pancreatic necrotic fluid collections (PNFC); however, it is controversial whether delayed treatment after four weeks should always be used in patients who have failed conservative treatment and whose condition has not improved or worsened. The aim of this meta-analysis was to evaluate the impacts of the different timing of interventions on the clinical outcomes and prognosis of patients with symptomatic PNEC requiring intervention. METHODS: We searched Embase, Cochrane Library, PubMed and Web of Science databases to identify comparative studies assessing the safety and efficacy of early and postponed interventions in treating symptomatic PNFC. PRIMARY OUTCOME: Mortality. Secondary outcomes included some major complications, need for further minimally invasive necrosectomy and length of hospital stay. RESULTS: This meta-analysis included ten studies (2 RCTs and 8 observational studies) with a total of 1178 symptomatic PNFC patients who required intervention. Pooled results showed that there was no significant difference between early minimally invasive intervention and postponed intervention in mortality(OR 1.41, 95%CI 0.93-2.12;p = 0.10) and the incidence of early and late complications, but the early intervention group had a significantly increased need for further minimally invasive necrosectomy compared with postponed intervention (OR 2.04,95%CI 1.04-4.03; p = 0.04). There was no increase in length of stay for patients who received early intervention compared to postponed drainage (MD 3.53, 95% CI -4.20, 11.27; p = 0.37). CONCLUSION: Intervention before four weeks should be considered for patients with PNFC complicated by persistent organ failure or infections, who have been treated conservatively to the maximum extent possible.

Clinical Outcomes of the Endoscopic Step-Up Approach with or without Radiology-Guided Percutaneous Drainage for Symptomatic Walled-Off Pancreatic Necrosis.

Background and objectives: Symptomatic walled-off pancreatic necrosis is a serious local complication of acute necrotising pancreatitis. The endoscopic step-up approach is the standard treatment for symptomatic walled-off pancreatic necrosis; however, adjunctive radiologic percutaneous drainage for this condition is controversial. This study compared the clinical and radiologic resolution of walled-off pancreatic necrosis achieved with the endoscopic step-up approach with or without radiology-guided percutaneous drainage. Material and Methods: This retrospective, single-centre cohort study enrolled patients with symptomatic walled-off pancreatic necrosis who underwent endoscopic transmural drainage (ETD) followed by directed endoscopic necrosectomy (DEN) with or without radiology-guided drainage. A total of 34 patients (endoscopic approach, n = 22; combined modality approach, n = 12) underwent the endoscopic step-up approach (ETD followed by DEN). Baseline characteristics, clinical success, and resolution of necrosis were compared between groups. Results: All patients achieved symptom resolution from walled-off pancreatic necrosis. The mean patient age was 58.4 years, and 21 (61.8%) were men. Following treatment with the endoscopic approach and combined modality approach, clinical success was achieved in 90.9% of patients within 11.5 days, and 66.7% of patients within 16.5 days, respectively. Both length of hospital stay (55 days vs. 71 days; p = 0.071) and time to complete radiologic resolution were shorter (93 days vs. 124 days; p = 0.23) in the endoscopic approach group. Conclusion: Both the endoscopic step-up approach and the CMD approach resulted in a favourably high clinical resolution rates in patients with symptomatic WON. However, clinical success rates seemed to be higher, and the length of hospital stay tended to be shorter in the endoscopic approach than in the CMD approach, as well as the significantly shorter necrosectomy time in each procedure was observed. Of note, these findings might be from some inherited differences in baseline characteristics of the patients between the two groups, and a randomized controlled trial with a larger sample size to verify these results is warranted.

Computed tomography imaging-based predictors of the need for a step-up approach after initial endoscopic ultrasound-guided transmural drainage for pancreatic fluid collections.

BACKGROUND: A step-up approach is recommended as a new treatment algorithm for pancreatic fluid collections (PFCs). However, determining which patients with PFCs require a step-up approach after endoscopic ultrasound-guided transmural drainage (EUS-TD) is unclear. If the need for a step-up approach could be predicted, it could be performed early for relevant patients. We aimed to identify PFC-related predictive factors for a step-up approach after EUS-TD. METHODS: This retrospective cohort study included consecutive patients who had undergone EUS-TD for PFCs from January 2008 to May 2020. Multivariable logistic regression analyses were performed to investigate PFC factors related to requiring a step-up approach. A step-up approach was performed for patients who did not respond clinically to EUS-TD. RESULTS: We enrolled 81 patients, of whom 25 (30.9%) required a step-up approach. In multivariate logistic regression analysis, the pre-EUS-TD number of PFC-occupied regions ≥ 3 (multivariate odds ratio [OR] 16.2, 95% confidence interval [CI] 2.68-97.6, P = 0.002), the post-EUS-TD PFC-remaining percentage ≥ 35% (multivariate OR 19.9, 95% CI 2.91-136.1, P = 0.002), and a positive sponge sign, which is a distinctive computed tomography finding in the early stage after EUS-TD (multivariate OR 6.26, 95% CI 1.33-29.3, P = 0.020), were independent predictive factors associated with requiring a step-up approach for PFCs. CONCLUSION: Pre-EUS-TD PFC-occupied regions, post-EUS-TD PFC-remaining percentage, and a positive sponge sign were predictors of the need for a step-up approach. Patients with PFC with these findings should be offered a step-up approach whereas conservative treatment is recommended for patients without these findings. CLINICAL REGISTRATION NUMBER: UMIN 000030898.

SARS-CoV-2 and the pancreas: What do we know about acute pancreatitis in COVID-19 positive patients?

Severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) can cause pancreatic damage, both directly to the pancreas via angiotensin-converting enzyme 2 receptors (the transmembrane proteins required for SARS-CoV-2 entry, which are highly expressed by pancreatic cells) and indirectly through locoregional vasculitis and thrombosis. Despite that, there is no clear evidence that SARS-CoV-2 is an etiological agent of acute pancreatitis. Acute pancreatitis in coronavirus disease 2019 (COVID-19) positive patients often recognizes biliary or alcoholic etiology. The prevalence of acute pancreatitis in COVID-19 positive patients is not exactly known. However, COVID-19 positive patients with acute pancreatitis have a higher mortality and an increased risk of intensive care unit admission and necrosis compared to COVID-19 negative patients. Acute respiratory distress syndrome is the most frequent cause of death in COVID-19 positive patients and concomitant acute pancreatitis. In this article, we reported recent evidence on the correlation between COVID-19 infection and acute pancreatitis.

One-step laparoscopic pancreatic necrosectomy verse surgical step-up approach for infected pancreatic necrosis: a case-control study.

BACKGROUND: The surgical step-up approach often requires multiple debridements and might not be suitable for infected pancreatic necrosis (IPN) patients with various abscesses or no safe route for percutaneous catheter drainage (PCD). This case-control study aimed to investigate the safety and effectiveness of one-step laparoscopic pancreatic necrosectomy (LPN) in treating IPN. METHODS: This case-control study included IPN patients undergoing one-step LPN or surgical step-up in our center from January 2015 to December 2020. The short-term and long-term complications after surgery, length of hospital stay, and postoperative ICU stays in both groups were analyzed. Univariate and multivariate logistic regression analyses were performed to explore the risk factors of major complications or death. RESULTS: A total of 53 IPN patients underwent one-step LPN and 37 IPN patients underwent surgical step-up approach in this study. There was no significant difference in the incidence of death, major complications, new-onset diabetes, or new-onset pancreatic exocrine insufficiency between the two groups. However, the length of hospital stay in the one-step LPN group was significantly shorter than that in the surgical step-up group. Univariate regression analysis showed that the surgical approach (one-step/step-up) was not the risk factor for major complications or death. Multivariate logistic regression analysis indicated that computed tomography (CT) severity index, American Society of Anesthesiologists (ASA) class IV, and white blood cell (WBC) were the significant risk factors for major complications or death. CONCLUSION: One-step LPN is as safe and effective as the surgical step-up approach for treating IPN patients, and reduces total hospital stay.

A Pragmatic Approach to Pancreatic Trauma: A Single-Center Experience From a Tertiary Care Center.

Introduction Pancreatic trauma is rare and is usually associated with adjacent organ and vascular injuries, which adds to the high morbidity and mortality. In the American Association for the Surgery of Trauma (AAST) pancreatic trauma (PT) grading system, the higher grades are a composite of less and more severe extents of injuries. We hereby present an observational study of PT with management based on an indigenous algorithmic approach. Our protocol incorporating both the extent of disruption of the main pancreatic duct (MPD) and its amenability to interventions (endoscopic, radiological, or surgical) is pragmatic. Methods Ours is a retrospective observational study of 28 consecutive cases of PT, done over a three-year period in an academic institution, by an expert Surgical Gastroenterology unit. All patients diagnosed with PT on a contrast abdominal CT scan were included. After stabilization, they were stratified and managed according to an indigenous protocol. The primary outcome measure was treatment success in terms of recovery. The secondary outcome measure was morbidity of any form. Results One patient with Grade 1 PT was operated on for associated hollow viscus injury. Two patients with AAST Grade 2 and two patients with AAST Grade 3 injury were managed successfully without surgery. Twelve of 21 patients with Grade 3 PT underwent Kimura's splenic vessel preserving distal pancreatectomy. Distal pancreatectomy with splenectomy and central pancreatectomy with Roux-en-Y pancreaticojejunostomy (PJ) was done for 7/21 and 2/21 patients, respectively, with Grade 3 PT. Two with Grade 5 injury underwent trauma Whipple. The overall mortality and morbidity rates in our series were 15.7% and 64%, respectively. Conclusion The pathogenesis in PT is a dynamic process and shows temporal evolution. These patients require serial and periodical clinical and radiological monitoring, especially in those managed conservatively initially. PT can be low or high grade. Patients with isolated low-grade PT can be managed according to the standard step-up approach for acute pancreatitis. A carefully selected subgroup of patients with partial MPD disruption either in the head or body of the pancreas can be managed by endotherapy. Complete distal parenchymal transections require early surgery tailored to individual patients in the form of either splenic vessel preserving distal pancreatectomy (SPDP) or distal pancreatectomy with splenectomy (DP+S). Damage control surgery is the dictum in unstable patients with Grades 4 and 5 injuries not responding to resuscitative measures. A trauma Whipple can be done in a carefully selected subgroup of stable patients with proximal massive disruptions in an experienced hepato-pancreatico-biliary (HPB) unit.

A huge preperitoneal collection following acute necrotizing pancreatitis: A case report and the management approach.

Introduction and importance: Fluid collection is a critical complication of acute necrotizing pancreatitis. It is usually formed near the pancreas, but unusual collection sites have also been reported. Anterior extraperitoneal or preperitoneal collections following acute pancreatitis are rare and must be differentiated from pancreatic ascites, which is a collection of fluid in peritoneal cavity. Case presentation: A 68-year-old man with a suspected pancreatic mass presented to the emergency department, complaining of abdominal pain and gradual abdominal distention. He had experienced epigastric pain, nausea, vomiting, progressive abdominal distention, and icterus for two weeks prior to admission. An abdominopelvic CT scan revealed extensive necrotizing pancreatitis with a prominent extraperitoneal collection. The collection had extended from the retroperitoneal space to the anterior extraperitoneal or preperitoneal space and had pushed the abdominal viscera backward. We managed the patient with the "Step-up" approach, and the patient was discharged after four weeks. Clinical discussion & conclusion: Preperitoneal fluid collection can rarely occur following acute necrotizing pancreatitis. Here, we suggested two possible routes for fluid migration from the retroperitoneum to the preperitoneal space. Using minimally invasive techniques such as percutaneous drainage of peripancreatic collections could reduce morbidity and mortality in critically ill patients diagnosed with necrotizing pancreatitis.

Severe Pancreatitis Multidisciplinary Working Group: Exploratory Analysis to Optimize Care and Cost.

INTRODUCTION: The minimally invasive step-up approach to pancreatitis improves outcomes. Multidisciplinary working groups may best facilitate this approach. However, support for these working groups requires funding. We hypothesize that patients requiring surgical debridement generate sufficient revenue to sustain these working groups. Furthermore, patients selected for surgical debridement by the working group will have a higher rate of percutaneous and endoscopic intervention in adherence to the step-up approach. METHODS: We conducted an observational cohort study of all patients with severe acute and/or necrotizing pancreatitis whose care was overseen by our multidisciplinary working group (October 2015 through January 2019). Patient demographics, hospital treatments, and outcomes data were compared between those who underwent surgical debridement and those who did not. Hospital billing data were also collected from those who are undergoing surgical debridement and compared to institutional benchmarks for financial sustainability. RESULTS: A total of 108 patients received care overseen by the working group, 10 of which progressed to surgical debridement. The mean contribution margin percentages for each patient in the surgical debridement group were higher than the threshold value for financial sustainability, 39% (60.34% ± 16.66%; P = 0.004). Patients in the surgical debridement group were more likely to undergo intervention by interventional radiologist (odds ratio, 1.58; P = 0.005). The mortality was higher in the nonsurgical debridement group (odds ratio, 15; P = 0.008). CONCLUSIONS: Our multidisciplinary working group delivered step-up care to patients with pancreatitis. Patients requiring surgical debridement generated a significantly positive contribution margin that could be used to help support the costs associated with providing multidisciplinary care.

Endoscopic Versus Surgical Step-Up Approach for Infected Necrotizing Pancreatitis (ExTENSION): Long-term Follow-up of a Randomized Trial.

BACKGROUND & AIMS: Previous randomized trials, including the Transluminal Endoscopic Step-Up Approach Versus Minimally Invasive Surgical Step-Up Approach in Patients With Infected Pancreatic Necrosis (TENSION) trial, demonstrated that the endoscopic step-up approach might be preferred over the surgical step-up approach in patients with infected necrotizing pancreatitis based on favorable short-term outcomes. We compared long-term clinical outcomes of both step-up approaches after a period of at least 5 years. METHODS: In this long-term follow-up study, we reevaluated all clinical data on 83 patients (of the originally 98 included patients) from the TENSION trial who were still alive after the initial 6-month follow-up. The primary end point, similar to the TENSION trial, was a composite of death and major complications. Secondary end points included individual major complications, pancreaticocutaneous fistula, reinterventions, pancreatic insufficiency, and quality of life. RESULTS: After a mean follow-up period of 7 years, the primary end point occurred in 27 patients (53%) in the endoscopy group and in 27 patients (57%) in the surgery group (risk ratio [RR], 0.93; 95% confidence interval [CI], 0.65-1.32; P = .688). Fewer pancreaticocutaneous fistulas were identified in the endoscopy group (8% vs 34%; RR, 0.23; 95% CI, 0.08-0.83). After the initial 6-month follow-up, the endoscopy group needed fewer reinterventions than the surgery group (7% vs 24%; RR, 0.29; 95% CI, 0.09-0.99). Pancreatic insufficiency and quality of life did not differ between groups. CONCLUSIONS: At long-term follow-up, the endoscopic step-up approach was not superior to the surgical step-up approach in reducing death or major complications in patients with infected necrotizing pancreatitis. However, patients assigned to the endoscopic approach developed overall fewer pancreaticocutaneous fistulas and needed fewer reinterventions after the initial 6-month follow-up. Netherlands Trial Register no: NL8571.

JPN clinical practice guidelines 2021 with easy-to-understand explanations for the management of acute pancreatitis.

BACKGROUND: In preparing the Japanese (JPN) guidelines for the management of acute pancreatitis 2021, the committee focused the issues raised by the results of nationwide epidemiological survey in 2016 in Japan. METHOD: In addition to a systematic search using the previous JPN guidelines, papers published from January 2014 to September 2019 were searched for the contents to be covered by the guidelines based on the concept of GRADE system. RESULTS: Thirty-six clinical questions (CQ) were prepared in 15 subject areas. Based on the facts that patients diagnosed with severe disease by both Japanese prognostic factor score and contrast-enhanced computed tomography (CT) grade had a high fatality rate and that little prognosis improvement after 2 weeks of disease onset was not obtained, we emphasized the importance of Pancreatitis Bundles, which were shown to be effective in improving prognosis, and the CQ sections for local pancreatic complications had been expanded to ensure adoption of a step-up approach. Furthermore, on the facts that enteral nutrition for severe acute pancreatitis was not started early within 48 h of admission and that unnecessary prophylactic antibiotics was used in almost all cases, we emphasized early enteral nutrition in small amounts even if gastric feeding is used and no prophylactic antibiotics are administered in mild pancreatitis. CONCLUSION: All the members of the committee have put a lot of effort into preparing the extensively revised guidelines in the hope that more people will have a common understanding and that better medical care will be spread.

Step-up approach in emphysematous hepatitis: A case report.

BACKGROUND: Emphysematous hepatitis (EH) is a rare, rapidly progressive fulminant gas-forming infection of the liver parenchyma. It is often fatal and mostly affects diabetes patients. CASE SUMMARY: We report a case of EH successfully managed by a step-up approach consisting of aggressive hemodynamic support, intravenous antibiotics, and percutaneous drainage, ultimately followed by laparoscopic deroofing. Of 11 documented cases worldwide, only 1 of the patients survived, treated by urgent laparotomy and surgical debridement. CONCLUSION: EH is a life-threatening infection. Its high mortality rate makes timely diagnosis essential, in order to navigate treatment accordingly.

[Treatment of acute pancreatitis from the viewpoint of surgery]. / Die Behandlung der akuten Pankreatitis aus Sicht der Chirurgie.

The role of surgery in the treatment of acute pancreatitis has clearly changed over the years. In the 1990s a clear reduction in hospital mortality was achieved through surgery, whereas the value of surgery (open, in general) has slipped into the background due to the improvement in intensive care medicine in general and the development of minimally invasive treatment options. Nowadays, patients with acute pancreatitis are only operated on after exhaustion of intensive medical care treatment and minimally invasive interventions or when complications occur that cannot be treated in any other way (e.g. hollow organ perforation). This article provides an overview of the currently used treatment measures.

Current status and progress of pancreatic surgery in the past 20 years / 中华消化外科杂志

Pancreatic surgery is an important specialty in the field of general surgery. As the anatomical location of pancreas is deeply and complex, and the diseases of pancreatic surgery is various kinds of and serious with high difficulty in surgery, the development of pancreatic surgery is slowly in the past. In the recent 20 years, with the deepening of basic and clinical researches in related fields, researchers' cognition of pancreatic diseases has gradually deepened. A series of new con-cepts and techniques have been applied to pancreatic surgery, making pancreatic surgery enter a rapid development stage. At the same time, researchers also recognize that the existing medical concepts and technical means are not sufficient to solve all clinical problems. Therefore, the cancer of pancreatic surgery in China can be alive and flourishing by grasping the opportunities, making continuous exploration and innovation.