Occurrence and Risk Factors of Infected Pancreatic Necrosis in Intensive Care Unit–Treated Patients with Necrotizing Severe Acute Pancreatitis

Abstract

Background In patients with severe acute pancreatitis (SAP), infected pancreatic necrosis (IPN) is associated with a worsened outcome. We studied risk factors and consequences of IPN in patients with necrotizing SAP. Methods The study consisted of a retrospective cohort of 163 consecutive patients treated for necrotizing SAP at a university hospital intensive care unit (ICU) between 2010 and 2018. Results All patients had experienced at least one persistent organ failure and approximately 60% had multiple organ failure within the first 24 h from admission to the ICU. Forty-seven (28.8%) patients had IPN within 90 days. Independent risk factors for IPN were more extensive anatomical spread of necrotic collections (unilateral paracolic or retromesenteric (OR 5.7, 95% CI 1.5–21.1) and widespread (OR 21.8, 95% CI 6.1–77.8)) compared to local collections around the pancreas, postinterventional pancreatitis (OR 13.5, 95% CI 2.4–76.5), preceding bacteremia (OR 4.8, 95% CI 1.3–17.6), and preceding open abdomen treatment for abdominal compartment syndrome (OR 3.6, 95% CI 1.4–9.3). Patients with IPN had longer ICU and overall hospital lengths of stay, higher risk for necrosectomy, and higher readmission rate to ICU. Conclusions Wide anatomical spread of necrotic collections, postinterventional etiology, preceding bacteremia, and preceding open abdomen treatment were identified as independent risk factors for IPN.

Minimal-access video-assisted retroperitoneal and/or transperitoneal debridement (VARTD) in the management of infected walled-off pancreatic necrosis with deep extension: initial experience from a prospective single-arm study

“…Nevertheless, in the case of iWON with deep extension (iWONde, i.e., the necrosis is diffusely distributed throughout the abdomen), it is something that still represents a challenging scenario for those minimal-access approaches [ 2 , 3 ]. In this instance, debridement of the iWONde in many cases requires repeated interventions (percutaneous and/or endoscopic) or even additional open necrosectomy if needed because of the difficulty in achieving sufficient evacuation of the large burden and deep extension of the necrotic collections [ 2 , 3 , 10 ]. For example, the endoscopic step-up approaches are capable of debriding the necrosis located along the peri-gastric or duodenal regions; however, this fails to access the necrosum in the setting of the necrosis extends into areas that are distant from stomach [ 3 ].…”

“…Another example is that when the necrosis extends to the right of the mesenteric vessels, and it is considered to be refractory to the VARD approach [ 2 ]. Thus, some NP patients who had developed an iWONde, in the current era, still necessarily undergo open necrosectomy, which is deemed the best alternative on this occasion in spite of its related high mortality rates [ 1 – 3 , 10 , 12 , 24 – 27 ].…”

“…In the case of NP, necrosis of pancreatic parenchyma and/or peripancreatic tissues is categorized into two conditions according to the disease course demarcated by 4 weeks following the NP onsetacute necrotic collections (ANCs) and walled-off necrosis (WON) [1,[5][6][7][8]. The latter poses a prolonged and complicated clinical course [6][7][8][9][10]. Especially, when an infection occurs in the necrotic bed (i.e., infected WON, hereafter called iWON), it is strongly recommended that invasive interventions be used to perform a drainage, debridement, or necrosectomy of the necrotic collection [2,3,7,[9][10][11][12].…”

“…The latter poses a prolonged and complicated clinical course [6][7][8][9][10]. Especially, when an infection occurs in the necrotic bed (i.e., infected WON, hereafter called iWON), it is strongly recommended that invasive interventions be used to perform a drainage, debridement, or necrosectomy of the necrotic collection [2,3,7,[9][10][11][12].…”

Plasma metagenomic next-generation sequencing of microbial cell-free DNA detects pathogens in patients with suspected infected pancreatic necrosis

“…The diagnostic difficulty would potentially lead to irrational or prolonged use of antibiotics and unnecessary invasive procedures. Studies have shown that bacteremia was an independent risk factor for IPN [ 9 , 10 ]. However, blood culture has low sensitivity and is time-consuming.…”