Epidemiology and risk factors for mortality in critically ill patients with pancreatic infection

Background:The AbSeS-classification defines specific phenotypes of patients with intra-abdominal infection based on the(1)setting of infection onset(community-acquired,early onset,or late-onset hospital-acquired),(2)presence or absence of either localized or diffuse peritonitis,and(3)severity of disease expression(infection,sepsis,or septic shock).This classification system demonstrated reliable risk stratification in intensive care unit(ICU)patients with intra-abdominal infection.This study aimed to describe the epidemiology of ICU patients with pancreatic infection and assess the relationship between the components of the AbSeS-classification and mortality.Methods:This was a secondary analysis of an international observational study(“AbSeS”)investigating ICU patients with intra-abdominal infection.Only patients with pancreatic infection were included in this analysis(n=165).Mortality was defined as ICU mortality within 28 days of observation for patients discharged earlier from the ICU.Relationships with mortality were assessed using logistic regression analysis and reported as odds ratio(OR)and 95%confidence interval(CI).Results:The overall mortality was 35.2%(n=58).The independent risk factors for mortality included older age(OR=1.03,95%CI:1.0 to 1.1 P=0.023),localized peritonitis(OR=4.4,95%CI:1.4 to 13.9 P=0.011),and persistent signs of inflammation at day 7(OR=9.5,95%CI:3.8 to 23.9,P<0.001)or after the implementation of additional source control interventions within the first week(OR=4.0,95%CI:1.3 to 12.2,P=0.013).Gramnegative bacteria were most frequently isolated(n=58,49.2%)without clinically relevant differences in microbial etiology between survivors and non-survivors.Conclusions:In pancreatic infection,a challenging source/damage control and ongoing pancreatic inflammation appear to be the strongest contributors to an unfavorable short-term outcome.In this limited series,essentials of the AbSeS-classification,such as the setting of infection onset,diffuse peritonitis,and severity of disease expression,were not associated with an increased mortality risk.

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.

Tight glycemic control using an artificial endocrine pancreas may play an important role in preventing infection after pancreatic resection

It is well known that perioperative hyperglycemia is the main cause of infectious complications after surgery.To improve perioperative glycemic control,we wish to highlight and comment on an interesting paper published recently by the Annals of Surgery entitled:"Early postoperative hyperglycemia is associated with postoperative complications after pancreatoduodenectomy(PD)" by Eshuis et al.The authors concluded that early postoperative glucose levels more than 140 mg/dL was significantly associated with complications after PD.Since we recommend that perioperative tight glycemic control(TGC) is an effective method to prevent postoperative complications including surgical site infection after distal,proximal,and total pancreatic resection,we support strongly this conclusion drawn in this article.However,if early postoperative glucose control in patients undergoing PD was administrated by conventional method such as sliding scale approach as described in this article,it is difficult to maintain TGC.Therefore,we introduce a novel perioperative glycemic control using an artificial endocrine pancreas against pancreatogenic diabetes after pancreatic resection including PD.

HBV and HCV infection and pancreatic ductal adenocarcinoma

Introduction Pancreatic ductal adenocarcinoma(PDAC)is a highly lethal malignancy,with a poor overall fiveyear survival.Its dismal prognosis,even after curative resection,depends on its advanced stage at diagnosis,early metastatic spread,aggressive biological behavior and inefficacy of available systemic therapies.[1]To date,epidemiological studies have identified some risk factors for this cancer,including cigarette smoking habit,family history as well as high dietary fat consumption,alcohol abuse,diabetes mellitus,metabolic syndrome and chronic pancreatitis history.[1]

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.

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.

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.

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.

Pancreatic tuberculosis in a human immunodeficiency virus positive patient:A case report

Despite the increased incidence of tuberculosis related to human immunodeficiency virus (HIV) in recent decades, pancreatic tuberculosis has rarely been described. We report a case of pancreatic tuberculosis in a 39-year- old African man who presented with progressive dysphagia, vomiting, weight loss and productive cough, accompanied by localized epigastric pain and one episode of melena. HIV-1 testing was positive and lymphocyte subset profile showed CD4 count of 9/mm3. Abdominal computed tomography (CT) scan with contrast revealed a cystic mass in the body of the pancreas, significant portal and retroperitoneal cystic adenopathy, and multiple cystic lesions in the spleen and liver. CT guided cyst aspiration and node biopsy detected Mycobacterium tuberculosis. The patient responded well on antituberculosis and antiretroviral therapy. Tuberculosis rarely involves the pancreas, probably due to the presence of pancreatic enzymes which interfere with the seeding of Mycobacterium tuberculosis. Pancreatic tuberculosis is considered to be the result of dissemination of the infection from nearby lymphatic nodes. Endoscopic ultrasound or CT guided fine needle aspiration for cytology is the recommended diagnostic technique. Although the prognosis is good with anti-tuberculosis treatment, it could be fatal without correct diagnosis and treatment. The clinician’s high index of suspicion of pancreatic tuberculosis and application of FNAB to obtain pathological evidence are extremely important to a correct diagnosis, especially in young HIV positive patients.

Percutaneous direct endoscopic pancreatic necrosectomy

Approximately 10%-20% of the cases of acute pancreatitis have acute necrotizing pancreatitis. The infection of pancreatic necrosis is typically associated with a prolonged course and poor prognosis. The multidisciplinary, minimally invasive “step-up” approach is the cornerstone of the management of infected pancreatic necrosis(IPN). Endosonography-guided transmural drainage and debridement is the preferred and minimally invasive technique for those with IPN. However, it is technically not feasible in patients with early pancreatic/peripancreatic fluid collections(PFC)(< 2-4 wk) where the wall has not formed;in PFC in paracolic gutters/pelvis;or in walled off pancreatic necrosis(WOPN) distant from the stomach/duodenum. Percutaneous drainage of these infected PFC or WOPN provides rapid infection control and patient stabilization. In a subset of patients where sepsis persists and necrosectomy is needed, the sinus drain tract between WOPN and skin-established after percutaneous drainage or surgical necrosectomy drain, can be used for percutaneous direct endoscopic necrosectomy(PDEN). There have been technical advances in PDEN over the last two decades.An esophageal fully covered self-expandable metal stent, like the lumen-apposing metal stent used in transmural direct endoscopic necrosectomy, keeps the drainage tract patent and allows easy and multiple passes of the flexible endoscope while performing PDEN. There are several advantages to the PDEN procedure. In expert hands, PDEN appears to be an effective, safe, and minimally invasive adjunct to the management of IPN and may particularly be considered when a conventional drain is in situ by virtue of previous percutaneous or surgical intervention. In this current review, we summarize the indications, techniques, advantages, and disadvantages of PDEN. In addition, we describe two cases of PDEN in distinct clinical situations, followed by a review of the most recent literature.

Establishment of an Infected Necrotizing Pancreatitis Model by Retrograde Pancreatic Duct Injection of Sodium Taurocholate and E. coli in Rats

A stable and reliable infected necrotizing pancreatitis （INP） model in rats was established in order to study the pathophysiological mechanism and pathological development role of INP and explore the new therapeutic methods for the diseases. Forty-six SD rats were randomly divided into 5 groups. The animals in group A received the injection of 5% sodium taurocholate into the pancreatic duct and those in group B underwent that of E. coli into the pancreatic duct. The rats in groups C, D and E were subjected to the injection of 5% sodium taurocholate in combination with different concentrations of E. coli （10^3, 10^4, 10^5/mE, respectively） into the pancreatic duct. The dose of injection was 0.1 mL/100 g and the velocity of injection was 0.2 mL/min in all the 5 groups. Eight h after the injection, the survival rate of animals was recorded and the surviving rats were killed to determine the serum content of amylase and perform pathological examination and germ cultivation of the pancreatic tissue. The results showed that acute necrotizing pancreatitis model was induced by injection of 5% sodium taurocholate into the pancreatic duct. The positive rate of germ cultivation in group A was 12.5%. The acute necrotizing pancreatitis model was not induced by injection of E. coli into the pancreatic duct and the positive rate of germ cultivation in group B was 0. The INP model was established in groups C to E. The positive rate of germ cultivation was 60%, 100% and 100% and 8-h survival-rate 100%, 100% and 70% in groups C, D and E, respectively. It was concluded that a stable and reliable model of INP was established by injection of 5% sodium taurocholate in combination with 10^4/mL E. coli into the pancreatic duct with a dose of 0.1 mL/100 g and a velocity of 0.2 mL/min. The pathogenesis of INP might be that the hemorrhage and necrosis of pancreatic tissue induced by sodium taurocholate results in weakness of pancreatic tissue in fighting against the germs. Meanwhile, the necrotic pancreatic tissue provides a good proliferative environment for the germs.

Successful outcome of retrograde pancreatojejunostomy for chronic pancreatitis and infected pancreatic cysts:A case report

BACKGROUND Chronic pancreatitis occasionally requires surgical treatment that can be performed with various techniques.Often,this type of surgery presents with postoperative complications.We report a case of a successful retrograde pancreatojejunostomy for chronic pancreatitis and infected pancreatic cysts.CASE SUMMARY A 62-year-old male with a 10-year history of chronic pancreatitis presented with epigastric pain for one week and a 20 kg weight loss over one year.Computed tomography showed stones in the pancreas(mainly the head),expansion of the main pancreatic duct,and thinning of the pancreatic parenchyma.Magnetic resonance imaging showed infected pancreatic cysts connected to the stomach with a fistula from the splenic hilum to the caudal portion of the liver’s lateral segment.An endoscopic retrograde pancreatography was performed;the guide wires could not pass through the stones in the pancreas and therefore,drainage of the main pancreatic duct was not achieved.Next,a distal pancreatomy and splenectomy were performed;however,the pancreatic juice in the remaining parenchyma was blocked by the stones.Hence,we performed a retrograde pancreatojejunostomy and Roux-en-Y anastomosis.The patient had no postoperative complications and was discharged from the hospital on postoperative day 14.CONCLUSION A distal pancreatomy,retrograde pancreatojejunostomy,and Roux-en-Y anastomosis could be an effective surgical procedure for intractable chronic pancreatitis.

Endoscopic transluminal drainage and necrosectomy for infected necrotizing pancreatitis:Progress and challenges

Infected necrotizing pancreatitis(INP)represents a severe condition in patients with acute pancreatitis.Invasive interventions are recommended in symptomatic INP.Growing evidence has suggested interventional strategies of INP evolving from traditional surgery to minimally invasive step-up endoscopic procedures.However,there is still no standardized protocol for endoscopic interventions.Recently,various studies have been published about the endoscopic management of INP.This article reviews published articles and guidelines to present the progress and challenges of endoscopic transluminal drainage and necrosectomy in INP.

Is necrosectomy obsolete for infected necrotizing pancreatitis? Is a paradigm shift needed?

In 1886,Senn stated that removing necrotic pancreatic and peripancreatic tissue would benefit patients with severe acute pancreatitis.Since then,necrosectomy has been a mainstay of surgical procedures for infected necrotizing pancreatitis(NP).No published report has successfully questioned the role of necrosectomy.Recently,however,increasing evidence shows good outcomes when treating walled-off necrotizing pancreatitis without a necrosectomy.The literature concerning NP published primarily after 2000 was reviewed;it demonstrates the feasibility of a paradigm shift.The majority(75%)of minimally invasive necrosectomies show higher completion rates:between 80%and 100%.Transluminal endoscopic necrosectomy has shown remarkable results when combined with percutaneous drainage or a metallic stent.Related morbidities range from 40%to 92%.Single-digit mortality rates have been achieved with transluminal endoscopic necrosectomy,but not with video-assisted retroperitoneal necrosectomy series.Drainage procedures without necrosectomy have evolved from percutaneous drainage to transluminal endoscopic drainage with or without percutaneous endoscopic gastrostomy access for laparoscopic instruments.Most series have reached higher success rates of 79%-93%,and even 100%,using transcystic multiple drainage methods.It is becoming evident that transluminal endoscopic drainage treatment of walledoff NP without a necrosectomy is feasible.With further refinement of the drainage procedures,a paradigm shift from necrosectomy to drainage is inevitable.

Antibiotic prophylaxis in patients with severe acute pancreatitis

BACKGROUND: The prophylactic use of antibiotics in pa- tients with severe acute pancreatitis remains contentious. This study was undertaken to review the current studies on antibiotic prophylaxis in patients with severe acute pancrea- titis. DATA RESOURCES: All papers found by a Medline search were relevant to human trials of antibiotic prophylaxis in patients with severe acute pancreatitis. RESULTS: In the 1970s, three small randomized studies of prophylactic ampicillin in the treatment of acute pancreati- tis showed no effect on mortality or morbidity, but the in- clusion of patients at low risk for infection and the use of an ineffective antibiotic were insufficient to detect any diffe- rences. From 1993 to 2001, eight prospective clinical trials of antibiotic prophylaxis were conducted in patients with severe acute pancreatitis ( SAP ). Seven of the 8 trials showed significant effect of the prophylaxis in prevention of pancreatic infections, and one showed significant improve- ment of clinical course documented by the Acute Physiolo- gy and Chronic Health Evaluation (APACHE ) scores. Only two trials did demonstrate the significance of the prophylaxis in lowering the mortality rate. Despite varia- tions in drug agents, study size and patient selection, dura- tion of treatment, and methodology ( None of the studies was double-blinded), a meta-analysis showed the positive effect of antibiotics in reducing the mortality. We suggested that antibiotic prophylaxis with proven efficacy in necrotic pancreatic tissues should be given to all patients with acute necrotizing pancreatitis. In recent years, however, the first double-blind, placebo-controlled multicenter study from Germany detected no benefit of antibiotic prophylaxis with respect to the risk of developing infected pancreatic necrosis. CONCLUSION: Prophylactic antibiotics for severe acute pancreatitis is still a matter of discussion and further studies are required to provide adequate data to answer many ques-tions and to define the role of antibiotic prophylaxis in pa- tients with severe acute pancreatitis.

Endoscopic fibrin glue injection for closure of pancreatocutaneous fistula following transgastric endoscopic necrosectomy

Transgastric endoscopic necrosectomy has been recently introduced as the effective and alternative management of infected pancreatic necrosis and pancreatic abscess. However,up to 40% of patients who undergo endoscopic necrosectomy may need an additional percutaneous approach for subsequent peripancreatic fluid collection or non-resolution of pancreatic necrosis. This percutaneous approach may lead to persistent pancreatocutaneous fistula,which remains a serious problem and usually requires prolonged hospitalization,or even open-abdominal surgery. We describe the first case of pancreatocutaneous fistula and concomitant abdominal wall defect following transgastric endoscopic necrosectomy and percutaneous drainage,which were endoscopically closed with fibrin glue injection via the necrotic cavity.

Management of pancreatic fluid collections in patients with acute pancreatitis

Acute pancreatitis is associated with development of pancreatic fluid collections(PFCs).Acute PFCs that develop in interstitial edematous pancreatitis mostly resolve but some may persist and evolve into pseudocysts.Acute necrotic collections occurring in acute necrotizing pancreatitis generally persist and evolve into walled-off necrosis(WON)after 3 to 4 weeks.Most acute fluid collections do not require drainage unless they are large and cause compression of adjacent organs,contribute to increase in intraabdominal pressure or become infected.Acute infected collections can be managed with antibiotics and percutaneous drainage but may require necrosectomy either by minimally invasive surgical or endoscopic methods such as video-assisted retroperitoneal debridement and percutaneous endoscopic necrosectomy.Mature sterile collections,that is,pseudocyst and WON with a defined wall are best treated by internal transmural drainage which can be achieved either by per-oral endoscopic or surgical,preferably laparoscopic,method.Of late,infected PFCs are increasingly being treated with an endoscopic step-up approach that has been shown to be better than minimally invasive surgical step-up approach in terms of lesser complications.Use of lumen apposing metal stents during endoscopic drainage has emerged as an attractive option that facilitates necrosectomy in infected WON.

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.