Early prediction and prevention of infected pancreatic necrosis

Approximately 20%-30%of patients with acute necrotizing pancreatitis develop infected pancreatic necrosis(IPN),a highly morbid and potentially lethal complication.Early identification of patients at high risk of IPN may facilitate appropriate preventive measures to improve clinical outcomes.In the past two decades,several markers and predictive tools have been proposed and evaluated for this purpose.Conventional biomarkers like C-reactive protein,procalcitonin,lymphocyte count,interleukin-6,and interleukin-8,and newly developed biomarkers like angiopoietin-2 all showed significant association with IPN.On the other hand,scoring systems like the Acute Physiology and Chronic Health Evaluation II and Pancreatitis Activity Scoring System have also been tested,and the results showed that they may provide better accuracy.For early prevention of IPN,several new therapies were tested,including early enteral nutrition,anti-biotics,probiotics,immune enhancement,etc.,but the results varied.Taken together,several evidence-supported predictive markers and scoring systems are readily available for predicting IPN.However,effective treatments to reduce the incidence of IPN are still lacking apart from early enteral nutrition.In this editorial,we summarize evidence concerning early prediction and prevention of IPN,providing insights into future practice and study design.A more homo-geneous patient population with reliable risk-stratification tools may help find effective treatments to reduce the risk of IPN,thereby achieving individualized treatment.

Early versus delayed necrosectomy in pancreatic necrosis:A population-based cohort study on readmission,healthcare utilization,and in-hospital mortality

BACKGROUND Acute necrotizing pancreatitis is a severe and life-threatening condition.It poses a considerable challenge for clinicians due to its complex nature and the high risk of complications.Several minimally invasive and open necrosectomy procedures have been developed.Despite advancements in treatment modalities,the optimal timing to perform necrosectomy lacks consensus.AIM To evaluate the impact of necrosectomy timing on patients with pancreatic necrosis in the United States.METHODS A national retrospective cohort study was conducted using the 2016-2019 Nationwide Readmissions Database.Patients with non-elective admissions for pancreatic necrosis were identified.The participants were divided into two groups based on the necrosectomy timing:The early group received intervention within 48 hours,whereas the delayed group underwent the procedure after 48 hours.The various intervention techniques included endoscopic,percutaneous,or surgical necrosectomy.The major outcomes of interest were 30-day readmission rates,healthcare utilization,and inpatient mortality.RESULTS A total of 1309 patients with pancreatic necrosis were included.After propensity score matching,349 cases treated with early necrosectomy were matched to 375 controls who received delayed intervention.The early cohort had a 30-day readmission rate of 8.6% compared to 4.8%in the delayed cohort(P=0.040).Early necrosectomy had lower rates of mechanical ventilation(2.9%vs 10.9%,P<0.001),septic shock(8%vs 19.5%,P<0.001),and in-hospital mortality(1.1%vs 4.3%,P=0.01).Patients in the early intervention group incurred lower healthcare costs,with median total charges of $52202 compared to$147418 in the delayed group.Participants in the early cohort also had a relatively shorter median length of stay(6 vs 16 days,P<0.001).The timing of necrosectomy did not significantly influence the risk of 30-day readmission,with a hazard ratio of 0.56(95%confidence interval:0.31-1.02,P=0.06).CONCLUSION Our findings show that early necrosectomy is associated with better clinical outcomes and lower healthcare costs.Delayed intervention does not significantly alter the risk of 30-day readmission.

The microbiology of infected pancreatic necrosis

Background: Acute pancreatitis(AP) continues to cause significant morbidity and mortality, especially when it leads to infected pancreatic necrosis(IPN). Modern treatment of IPN frequently involves prolonged courses of antibiotics in combination with minimally invasive therapies. This study aimed to update the existing evidence base by identifying the pathogens causing IPN and therefore aid future selection of empirical antibiotics. Methods: Clinical data, including microbiology results, of consecutive patients with IPN undergoing minimally invasive necrosectomy at our institution between January 2009 and July 2016 were retrospectively reviewed. Results: The results of 40 patients(22 males and 18 females, median age 60 years) with IPN were reviewed. The etiology of AP was gallstones, alcohol, dyslipidemia and unknown in 31, 2, 2 and 5 patients, respectively. The most frequently identified microbes in microbiology cultures were Enterococcus faecalis and faecium(22.5% and 20.0%) and Escherichia coli(20.0%). In 19 cases the cultures grew multiple organisms. The antibiotics with the least resistance amongst the microbiota were teicoplanin(5.0%), linezolid(5.6%), ertapenem(6.5%), and meropenem(7.4%). Conclusion: The carbapenem antibiotics, ertapenem and meropenem provide good antimicrobial cover against the common, mainly enteral, microorganisms causing IPN. Culture and sensitivity results of acquired samples should be regularly reviewed to adjust prescribing and monitor for emergence of resistance.

Pancreatic necrosis and severity are independent risk factors for pancreatic endocrine insufficiency after acute pancreatitis: A long-term follow-up study

BACKGROUND Pancreatic endocrine insufficiency after acute pancreatitis(AP) has drawn increasing attention in recent years.AIM To assess the impact of risk factors on the development of pancreatic endocrine insufficiency after AP.METHODS This retrospective observational long-term follow-up study was conducted in a tertiary hospital. Endocrine function was evaluated by the oral glucose tolerance test. The data, including age, sex, body mass index, APACHE II score, history of smoking and drinking, organ failure, pancreatic necrosis, debridement of necrosis(minimally invasive and/or open surgery), and time interval, were collected from the record database.RESULTS A total of 361 patients were included in the study from January 1, 2012 to December 30, 2018. A total of 150(41.6%) patients were diagnosed with dysglycemia(including diabetes mellitus and impaired glucose tolerance), while211(58.4%) patients had normal endocrine function. The time intervals(mo) of the above two groups were 18.73 ± 19.10 mo and 31.53 ± 27.27 mo, respectively(P= 0.001). The morbidity rates of pancreatic endocrine insufficiency were 46.7%,28.0%, and 25.3%, respectively, in the groups with different follow-up times. The risk factors for pancreatic endocrine insufficiency after AP were severity(odds ratio [OR] = 3.489;95% confidence interval [CI]: 1.501-8.111;P = 0.004) and pancreatic necrosis(OR = 4.152;95%CI: 2.580-6.684;P = 0.001).CONCLUSION Pancreatic necrosis and severity are independent risk factors for pancreatic endocrine insufficiency after AP. The area of pancreatic necrosis can affect pancreatic endocrine function.

Infected pancreatic necrosis: Not necessarily a late event in acute pancreatitis

It is widely believed that infection of pancreatic necrosis is a late event in the natural course of acute pancreatitis. This paper discusses the available data on the timing of pancreatic infection. It appears that infected pancreatic necrosis occurs early in almost a quarter of patients. This has practical implications for the type, timing and duration of preventive strategies used in these patients. There are also implications for the classification of severity in patients with acute pancreatitis. Given that the main determinants of severity are both local and systemic complications and that they can occur both early and late in the course of acute pancreatitis, the classification of severity should be based on their presence or absence rather than on when they occur. To do otherwise, and in particular overlook early infected pancreatic necrosis, may lead to a misclassification error and fallacies of clinical studies in patients with 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.

Walled-off pancreatic necrosis

Walled-off pancreatic necrosis (WOPN), formerly known as pancreatic abscess is a late complication of acute pancreatitis. It can be lethal, even though it is rare. This critical review provides an overview of the continually expanding knowledge about WOPN, by review of current data from references identified in Medline and PubMed, to September 2009, using key words, such as WOPN, infected pseudocyst, severe pancreatitis, pancreatic abscess, acute necrotizing pancreatitis (ANP), pancreas, inflammation and alcoholism. WOPN comprises a later and local complication of ANP, occurring more than 4 wk after the initial attack, usually following development of pseudocysts and other pancreatic fluid collections. The mortality rate associated with WOPN is generally less than that of infected pancreatic necrosis. Surgical intervention had been the mainstay of treatment for infected peripancreatic fluid collection and abscesses for decades. Increasingly, percutaneous catheter drainage and endoscopic retrograde cholangiopancreatography have been used, and encourag-ing results have recently been reported in the medical literature, rendering these techniques invaluable in the treatment of WOPN. Applying the recommended therapeutic strategy, which comprises early treatment with antibiotics combined with restricted surgical intervention, fewer patients with ANP undergo surgery and interventions are ideally performed later in the course of the disease, when necrosis has become well demarcated.

Infection recurrence following minimally invasive treatment in patients with infectious pancreatic necrosis

BACKGROUND In recent decades,an increasing number of patients have received minimally invasive intervention for infected pancreatic necrosis(IPN)because of the benefits in reducing postoperative multiple organ failure and mortality.However,there are limited published data regarding infection recurrence after treatment of this patient population.AIM To investigate the incidence and prediction of infection recurrence following successful minimally invasive treatment in IPN patients.METHODS Medical records for 193 IPN patients,who underwent minimally invasive treatment between February 2014 and October 2018,were retrospectively reviewed.Patients,who survived after the treatment,were divided into two groups:one group with infection after drainage catheter removal and another group without infection.The morphological and clinical data were compared between the two groups.Significantly different variables were introduced into the correlation and multivariate logistic analysis to identify independent predictors for infection recurrence.Sensitivity and specificity for diagnostic performance were determined.RESULTS Of the 193 IPN patients,178 were recruited into the study.Of them,9(5.06%)patients died and 169 patients survived but infection recurred in 13 of 178 patients(7.30%)at 7(4-10)d after drainage catheters were removed.White blood cell(WBC)count,serum C-reactive protein(CRP),interleukin-6,and procalcitonin levels measured at the time of catheter removal were significantly higher in patients with infection than in those without(all P<0.05).In addition,drainage duration and length of the catheter measured by computerized tomography scan were significantly longer in patients with infection(P=0.025 and P<0.0001,respectively).Although these parameters all correlated positively with the incidence of infection(all P<0.05),only WBC,CRP,procalcitonin levels,and catheter length were identified as independent predictors for infection recurrence.The sensitivity and specificity for infection prediction were high in WBC count(≥9.95×109/L)and serum procalcitonin level(≥0.05 ng/mL)but moderate in serum CRP level(cut-off point≥7.37 mg/L).The catheter length(cut-off value≥8.05 cm)had a high sensitivity but low specificity to predict the infection recurrence.CONCLUSION WBC count,serum procalcitonin,and CRP levels may be valuable for predicting infection recurrence following minimally invasive intervention in IPN patients.These biomarkers should be considered before removing the drainage catheters.

Clinical and pathologic characteristics of pancreatic necrosis in critically ill children

BACKGROUND：Pancreatic damage in critically ill patients is associated with the progressive failure of multiple organs, but little is known about its clinical characteristics. At present, no guidelines are available for the diagnosis and management of pancreatic damage. This study was undertaken to analyze the clinical and pathologic characteristics of pancreatic necrosis in critically ill children, and to find some biological markers of pancreatic damage or pancreatic necrosis.METHODS： We retrospectively reviewed the clinical data, laboratory results, and autopsy findings of 25 children, who were admitted to Hunan Children＇s Hospital, China from 2003 to 2009, and died of multiple organ failure. The autopsy revealed pancreatic necrosis in 5 children, in whom sectional or gross autopsy was performed. RESULTS： The 5 children had acute onset and a fever. Two children had abdominal pain and 2 had abdominal bulging, flatulence and gastrointestinal bleeding. Four children had abnormal liver function, characterized by decreased albumin and 3 children had elevated level of C-reactive protein （CRP）. B-ultrasonography revealed abnormal acoustic image of the pancreas in all children, and autopsy confirmed pancreatic necrosis, which may be associated with the damage of the adrenal gland, liver, lung, heart, spleen, kidney, intestine, thymus, mediastinal and mesenteric lymph nodes and other organs. Children 1 and 2 died of acute hemorrhagic necrotizing pancreatitis （AHNP）; children 3-5 died of multiple organ dysfunction syndrome （MODS） due to pancreatic necrosis. CONCLUSION： Pancreatic damage or pancreatic necrosis in critically ill children is characterized by acute onset, severity, short course, multiple organ damage or failure. It may be asymptomatic in early stage, and easy to be ignored.

Risk factors of infected pancreatic necrosis secondary to severe acute pancreatitis

BACKGROUND： Severe acute pancreatitis（SAP） remains a clinical challenge with considerable morbidity and mortality.An early identification of infected pancreatic necrosis（IPN）, a life-threatening evolution secondary to SAP, is obliged for a more preferable prognosis. Thus, the present study was conducted to identify the risk factors of IPN secondary to SAP. METHODS： The clinical data of patients with SAP were retrospectively analyzed. Univariate and multivariate logistic regression analyses were sequentially performed to assess the associations between the variables and the development of IPN secondary to SAP. A receiver operating characteristic（ROC） curve was created for each of the qualified independent risk factors. RESULTS： Of the 115 eligible patients, 39（33.9%） progressed to IPN, and the overall in-hospital mortality was 11.3%（13/115）.The early enteral nutrition（EEN）（P=0.0092, OR=0.264）, maximum intra-abdominal pressure（IAP）（P=0.0398, OR=1.131）and maximum D-dimer level（P=0.0001, OR=1.006） in the first three consecutive days were independent risk factors associated with IPN secondary to SAP. The area under ROC curve（AUC） was 0.774 for the maximum D-dimer level in the first three consecutive days and the sensitivity was 90% and the specificity was 58% at a cut-off value of 933.5 μg/L; the AUC was 0.831 for the maximum IAP in the first three consecutive days and the sensitivity was 95% and specificity was 58%at a cut-off value of 13.5 mm Hg. CONCLUSIONS： The present study suggested that the maximum D-dimer level and/or maximum IAP in the first three consecutive days after admission were risk factors of IPN secondary to SAP; an EEN might be helpful to prevent the progression of IPN secondary to SAP.

Comparison of safety,efficacy,and long-term follow-up between“one-step”and“step-up”approaches for infected pancreatic necrosis

BACKGROUND Although the“Step-up”strategy is the primary surgical treatment for infected pancreatic necrosis,it is not suitable for all such patients.The“One-step”strategy represents a novel treatment,but the safety,efficacy,and long-term follow-up have not yet been compared between these two approaches.AIM To compare the safety,efficacy,and long-term follow-up of two surgical approaches to provide a reference for infected pancreatic necrosis treatment.METHODS This was a retrospective analysis of infectious pancreatic necrosis patients who underwent“One-step”or“Step-up”necrosectomy at Xuan Wu Hospital,Capital Medical University,from May 2014 to December 2020.The primary outcome was the composite endpoint of severe complications or death.Patients were followed up every 6 mo after discharge until death or June 30,2021.Statistical analysis was performed using SPSS 21.0 and GraphPad Prism 8.0,and statistical significance was set at P<0.05.RESULTS One-hundred-and-fifty-eight patients were enrolled,of whom 61 patients underwent“One-step”necrosectomy and 97 patients underwent“Step-up”necrosectomy.During the long-term follow-up period,40 patients in the“Onestep”group and 63 patients in the“Step-up”group survived.The time from disease onset to hospital admission(53.69±38.14 vs 32.20±20.75,P<0.001)and to initial surgical treatment was longer in the“Step-up”than in the“One-step”group(54.38±10.46 vs 76.58±17.03,P<0.001).Patients who underwent“Step up”necrosectomy had a longer hospitalization duration(65.41±28.14 vs 52.76±24.71,P=0.02),and more interventions(4.26±1.71 vs 3.18±1.39,P<0.001).Postoperative inflammatory indicator levels were significantly lower than preoperative levels in each group.Although the incisional hernia incidence was higher in the“One-step”group,no significant difference was found in the composite outcomes of severe complications or death,new-onset organ failure,postoperative complications,inflammatory indicators,long-term complications,quality of life,and medical costs between the groups(P>0.05).CONCLUSION Compared with the“Step-up”approach,the“One-step”approach is a safe and effective treatment method with better long-term quality of life and prognosis.It also provides an alternative surgical treatment strategy for patients with infected pancreatic necrosis.

Minimally invasive treatment of pancreatic necrosis

AIM: To systematically review these minimally invasive approaches to infected pancreatic necrosis. METHODS: We used the MEDLINE database to investigate studies between 1996 and 2010 with greater than 10 patients that examined these techniques. Using a combination of Boolean operators, reports were retrieved addressing percutaneous therapy (341 studies), endoscopic necrosectomy (574 studies), laparoscopic necrosectomy via a transperitoneal approach (148 studies), and retroperitoneal necrosectomy (194 studies). Only cohorts with at least 10 or more patients were included. Non-English papers, letters, animal studies, duplicate series and reviews without original data were excluded, leaving a total of 27 studies for analysis. RESULTS: Twenty-seven studies with 947 patients total were examined (eight studies on percutaneous approach; ten studies on endoscopic necrosectomy; two studies on laparoscopic necrosectomy via a transperitoneal approach; five studies on retroperitoneal necrosectomy; and two studies on a combined percutaneous-retroperitoneal approach). Success rate, complications, mortality, and number of procedures were outcomes that were included in the review. We found that most published reports were retrospective in nature, and thus, susceptible to selection and publication bias. Few reports examined these techniques in a comparative, prospective manner. CONCLUSION: Each minimally invasive approach though was found to be safe and feasible in multiple reports. With these new techniques, treatment of infected pancreatic necrosis remains a challenge. We advocate a multidisciplinary approach to this complex problem with treatment individualized to each patient.

Modified single transluminal gateway transcystic multiple drainage technique for a huge infected walled-off pancreatic necrosis: A case report

We report a successful endoscopic ultrasonographyguided drainage of a huge infected multilocular walledoff necrosis(WON) that was treated by a modified single transluminal gateway transcystic multiple drainage(SGTMD) technique. After placing a widecaliber fully covered metal stent, follow-up computed tomography revealed an undrained subcavity of WON. A large fistula that was created by the wide-caliber metal stent enabled the insertion of a forward-viewing upper endoscope directly into the main cavity, and the narrow connection route within the main cavity to the subcavity was identified with a direct view, leading to the successful drainage of the subcavity. This modified SGTMD technique appears to be useful for seeking connection routes between subcavities of WON in some cases.

Walled-off pancreatic necrosis:Wishing our pancreatitis nomenclature was correct

The ultimate reason why pancreatologists have strived to establish definitions for inflammatory pathologies of the pancreas is to improve patient care.Although the Atlanta Classification has been used for around for 17 years,considerable misunderstanding of the key elements of the nomenclature still persists.While a recent article by Stamatakos et al aimed to deal with an entity not clearly def ined in the 1993 document,it is replete with factual and conceptual errors as well as contradictory statements.

Establishment of RT-LAMP Assay for Infectious Pancreatic Necrosis Virus

The purpose of this study was to establish a method for the rapid detection of infectious pancreatic necrosis virus(IPNV,Jasper serotype)using reverse transcription loop-mediated isothermal amplification(RT-LAMP).Four groups of specific primers were designed,according to the genome sequence of a Chinese IPNV isolate ChRtm213.The results showed that primer set B2 had the best amplification effect.When the final concentration of Mg2+was 6 mmol·L-1,dNTPs were 1 mmol·L-1 and betaine was 0.4 mol·L-1,the reaction could be completed in a 63℃water bath within 60 min.This RT-LAMP assay for the detection of IPNV had no cross-reactivity with infectious hematopoietic necrosis virus,viral hemorrhagic septicemia virus,grass carp reovirus and spring viremia of carp virus.The detection limit was 3.2×10-12 ng·μL-1.The sensitivity of this method was 10-fold higher than that of a previously published RT-LAMP assay for detecting the Spajarup(Sp)serotype of IPNV.This method,aimed at detecting IPNV isolates that were currently prevalent in China,possessed the characteristics of strong specificity,high sensitivity and direct interpretation by the naked eyes.The IPNV RT-LAMP was successfully applied to determine the clinical samples,which indicated the IPNV RT-LAMP assay was suitable for the rapid and large-scale detections of IPNV in China.

Comparison of abdominal ultrasound,endoscopic ultrasound andmagnetic resonance imaging in detection of necrotic debris in walled-off pancreatic necrosis

Background:Walled-off pancreatic necrosis(WOPN)is an important complication of acute pancreatitis that is diagnosed by imaging modalities such as endoscopic ultrasound(EUS)or magnetic resonance imaging(MRI),which can clearly visualize necrotic debris.The effectiveness of abdominal ultrasound(USG)in detecting solid debris in WOPN is not clear.Methods:A total of 52 patients(37 males,mean age 38.9612.6 years)with symptomatic WOPN were prospectively studied using EUS,MRI and USG.These investigations were done at a mean of 11.765.5 weeks of onset of acute pancreatitis and within two days.Results:WOPN was detected by EUS&MRI in all patients,whereas USG could not detect it in 4(7.6%)patients(3 had predominantly solid WOPN,whereas one had air foci in WOPN).USG,MRI and EUS could detect solid debris in all patients with detectable WOPN.EUS and USG detected<10%debris in 10(20%)patients,whereas MRI detected<10%debris in 14(27%)patients.EUS and USG detected 10–40%debris in 33 patients whereas MRI detected 10–40%debris in 30(58%)patients.More than 40%debris was better characterized on EUS and MRI with both detecting>40%debris in 8 patients(15%)compared to 5(11%)patients having>40%debris on USG.EUS detected collaterals around WOPN that were not detected on USG or MRI.Conclusion:USG can characterize the majority of WOPN,with accuracy comparable to that of EUS/MRI.However its limitations are the inability to detect collaterals around WOPN and characterize collections with high solid content or air.

Correlative factor of death in patients with infected pancreatic necrosis after surgical intervention

Background:Acute pancreatitis(AP)was a potentially fatal disease with a variation in severity.Infected pancreatic necrosis was a common complication in AP which needed surgical intervention.The present study was to study the correlative factors of death in patients with infected pancreatic necrosis after surgical intervention.Methods:From January 2016 to October 2019,a total of 186 patients with infected pancreatic necrosis after surgical intervention in the First Medical Center,Chinese PLA General Hospital were retrospectively enrolled in this study.Of the 186 patients,22 who died in the hospital were defined as a mortality group and the others as a survival group.The clinical characteristic of the 2 groups was compared and the relative risk of mortality in patients with infected pancreatic necrosis after the surgical intervention was studied.Results:Acute fluid collection,acute kidney injury,acute lung injury,acute liver injury,multiple organ dysfunction syndromes,abdominal bleeding,abdominal Acinetobacter baumannii infection,pulmonary infection,pulmonary A baumannii infection,positive blood culture,A baumannii of blood culture,severe acute pancreatitis according to Atlanta 2012,the use of continuous renal replacement therapy,mechanical ventilation and minimally invasive retroperitoneal pancreatic necrosectomy was associated with death in hospital.Older age,longer acute kidney injury lasting time,longer acute lung injury lasting time,longer acute liver injury lasting time,and longer multiple organ dysfunction syndromes lasting time in predicting mortality in patients with infected pancreatic necrosis after surgical intervention were(0.635[95%confidence interval(CI):0.512-0.758],P=.040),(0.877[95%CI:0.788-0.965],P=.000),(0.932[95%CI:0.897-0.968],P=.000),(0.822[95%CI:0.708-0.935],P=.000),and(0.943[95%CI:0.887-0.998],P=.000).Due to the small number of death cases,the results of the multivariate analyses were not available.Conclusion:In this single-center retrospective study of 186 cases of infected pancreas necrosis,the correlative factors of death are identified.The results warranted further strategies are needed especially focusing on elder patients to prevent blood infection and to protect the functions of vital organs.

Timing, treatment strategies and approach for infected pancreatic necrosis:a narrative review

Infected pancreatic necrosis(IPN)is a serious complication resulting in organ failure and death in patients with acute pancreatitis,and surgery is an important way to treat this disease.An increasing number of high-quality studies have provided evidence for mini-invasive necrosectomy and have also changed the traditional treatment model.The advancements of surgical technology provide more choices for IPN treatment.Timing,strategies,and treatment approach are still the most critical issues,even in today’s era of minimally invasive surgery.Should“delayed surgery”or“postponed drainage”still be adhered to?The“step-up”approach has been proven to hold an advantage in the treatment of IPN in terms of reducing postoperative complications.However,there is growing evidence that"step-up"is not the only option for all patients.The one-step approach is also effective for selected patients.Currently,endoscopic surgery is increasingly widely used in the treatment of IPN.On the other hand,open debridement is still an position for patients who do not respond to minimally invasive surgery.How to personalize treatment strategies is still not fully clear.Multidisciplinary consulting treatment is bound to be the main direction of development for future studies.

Surgical cystogastrostomy: Is it still worthwhile?

The article by Ker et al explores the treatment of peripancreatic fluid collection(PFC).The use of percutaneous drainage,endoscopy,and surgery for managing PFC are discussed.Percutaneous drainage is noted for its low risk profile,while endoscopic cystogastrostomy is more effective due to the wider orifice of the metallic stent.Surgical cystogastrostomy is a definitive treatment with a reduced need for reintervention,especially for cases with extensive collections and significant necrosis.The choice of treatment modality should be tailored to individual patient characteristics and disease factors,considering the expertise available.

Endoscopic management of pancreatic fluid collectionsrevisited

The development of pancreatic fluid collections(PFC) is one of the most common complications of acute severe pancreatitis. Most of the acute pancreatic fluid collections resolve and do not require endoscopic drainage. However, a substantial proportion of acute necrotic collections get walled off and may require drainage. Endoscopic drainage of PFC is now the preferred mode of drainage due to reduced morbidity and mortality as compared to surgical or percutaneous drainage. With the introduction of new metal stents, the efficiency of endoscopic drainage has improved and the task of direct endoscopic necrosectomy has be-come easier. The requirement of re-intervention is less with new metal stents as compared to plastic stents. However, endoscopic drainage is not free of adverse events. Severe complications including bleeding, perforation, sepsis and embolism have been described with endoscopic approach to PFC. Therefore, the endoscopic management of PFC is a multidisciplinary affair and involves interventional radiologists as well as GI surgeons to deal with unplanned adverse events and failures. In this review we discuss the recent advances and controversies in the endoscopic management of PFC.