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.

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.

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.

Simultaneous endoscopic and video-assisted retroperitoneal debridement in walled-off pancreatic necrosis using a laparoscopic access platform:Two case reports

BACKGROUND Infected walled-off necrosis is a potentially life-threatening complication of necrotizing pancreatitis.While some patients can be treated by drainage alone,many patients also need evacuation of the infected debris.Central necroses in relation to the pancreatic bed are easily reached via an endoscopic transluminal approach,whereas necroses that involve the paracolic gutters and the pelvis are most efficiently treated via a percutaneous approach.Large and complex necroses may need a combination of the two methods.CASE SUMMARY Transluminal and percutaneous drainage followed by simultaneous endoscopic and modified video-assisted retroperitoneal debridement was carried out in two patients with very large(32-38 cm),infected walled-off necroses using a laparoscopic access platform.After 34 d and 86 d and a total of 9 and 14 procedures,respectively,complete regression of the walled-off necroses was achieved.The laparoscopic access platform improved both access to the cavities as well as the overview.Simultaneous transluminal and percutaneous necrosectomy are feasible with the laparoscopic access platform serving as a useful adjunctive.CONCLUSION This approach may be necessary to control infection and achieve regression in some patients with complex collections.

Robot-assisted trans-gastric drainage and debridement of walled-off pancreatic necrosis using the EndoWrist stapler for the da Vinci Xi:A case report

BACKGROUND Walled-off pancreatic necrosis (WOPN) is a late complication of acute pancreatitis. The management of a WOPN depends on its location and on patient's symptoms. Trans-gastric drainage and debridement of WOPN represents an important surgical treatment option for selected patients. The da Vinci surgical System has been developed to allow an easy, minimally invasive and fast surgery, also in challenging abdominal procedures. We present here a case of a WOPN treated with a robotic trans-gastric drainage using the da Vinci Xi. CASE SUMMARY A 63-year-old man with an episode of acute necrotizing pancreatitis was referred to our center. Six wk after the acute episode the patient developed a walled massive fluid collection, with an extensive pancreatic necrosis, causing obstruction of the gastrointestinal tract. The patient underwent a robotic transgastric drainage and debridement of the WOPN performed with the da Vinci Xi platform. Firstly, an anterior ideal gastrotomy was carried out, guided by intraoperative ultrasound (US)-scan using the TilePro? function. Then, through the gastrotomy, the best location for drainage on the posterior gastric wall was again US-guided identified. The anastomosis between the posterior gastric wall and the walled-off necrosis wall was carried out with the new EndoWrist stapler with vascular cartridge. Debridement and washing of the cavity through the anastomosis were performed. Finally, the anterior gastrotomy was closed and the cholecystectomy was performed. The postoperative course was uneventful and a post-operative computed tomography-scan showed the collapse of the fluid collection. CONCLUSION In selected cases of WOPN the da Vinci Surgical System can be safely used as a valid surgical treatment option.

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.

Endoscopic ultrasonography-guided endoscopic treatment of pancreatic pseudocysts and walled-off necrosis:New technical developments

In the last decades,the treatment of pancreatic pseudocysts and necrosis occurring in the clinical context of acute and chronic pancreatitis has shifted towards minimally invasive endoscopic interventions.Surgical procedures can be avoided in many cases by using endoscopically placed,Endoscopic ultrasonography-guided techniques and drainages.Endoscopic ultrasound enables the placement of transmural plastic and metal stents or nasocystic tubes for the drainage of peripancreatic fluid collections.The development of selfexpanding metal stents and exchange free delivering systems have simplified the drainage of pancreatic fluid collections.This review will discuss available therapeutic techniques and new developments.

Short-and long-term results of endoscopic ultrasoundguided transmural drainage for pancreatic pseudocysts and walled-off necrosis

AIM To evaluate the short-and long-term results of endoscopic ultrasound-guided transmural drainage(EUS-GTD) for pancreatic fluid collection(PFC) and identify the predictive factors of treatment outcome for walled-off necrosis(WON) managed by EUS-GTD alone.METHODS We investigated 103 consecutive patients with PFC who underwent EUS-GTD between September 1999 and August 2015. Patients were divided into four groups as follows: WON(n = 40), pancreatic pseudocyst(PPC; n = 11), chronic pseudocyst(n = 33), and others(n = 19). We evaluated the short-and long-term outcomes of the treatment. In cases of WON, multiple logistic regression analyses were performed to identify the predictor variables associated with the treatment success. In addition, PFC recurrence was examined in patients followed up for more than 6 mo and internal stent removal after successful EUS-GTD was confirmed.RESULTS In this study, the total technical success rate was 96.1%. The treatment success rate of WON, PPC, chronic pseudocyst, and others was 57.5%, 90.9%, 91.0%, and 89.5%, respectively. Contrast-enhanced computed tomography using the multivariate logistic regression analysis revealed that the treatment success rate of WON was significantly lower in patients with more than 50% pancreatic parenchymal necrosis(OR = 17.0; 95%CI: 1.9-150.7; P = 0.011) and in patients with more than 150 mm of PFC(OR = 27.9; 95%CI: 3.4-227.7; P = 0.002).The recurrence of PFC in the long term was 13.3%(median observation time, 38.8 mo). Mean amylase level in the cavity was significantly higher in the recurrence group than in the no recurrence group(P = 0.02).CONCLUSION The reduction of WON by EUS-GTD alone was associated with the proportion of necrotic tissue and extent of the cavity. The amylase level in the cavity may be a predictive factor for recurrence of PFC.

Endoscopic gastric fenestration of debriding pancreatic walled-off necrosis: A pilot study

BACKGROUND Endoscopic drainage of walled-off necrosis(WON) is still a challenge due to stentassociated problems. We explored endoscopic gastric fenestration(EGF) as an innovative alternative intervention.AIM To assess the feasibility, efficacy and safety of EGF for WON.METHODS Between March 2019 and March 2020, five patients with symptomatic WON in close contact with the stomach wall were treated by EGF. Endoscopic ultrasound(EUS) was used to select appropriate sites for gastric fenestration, which then proceeded layer by layer as in endoscopic submucosal dissection. Both the stomach muscularis propria and pseudocyst capsule were penetrated. Fenestrations were expanded up to 1.5-3 cm for drainage or subsequent necrosectomy.RESULTS EGF failed in Case 1 due to nonadherence of WON to the gastric wall. EGF was successfully implemented in the other four cases by further refinement of fenestration site selection according to computed tomography, endoscopy and EUS features. The average procedure time for EGF was 124 min(EUS assessment, 32.3 min;initial fenestration, 28.8 min;expanded fenestration, 33 min), and tended to decrease as experience gradually increased. The diameter of the fenestration site was 1.5-3 cm, beyond the caliber of a lumen-apposing metal stent(LAMS), to ensure effective drainage or subsequent necrosectomy. Fenestration sites showed surprising capacity for postoperative self-healing within 1-3 wk. No EGF-related complications were seen. WON disappeared within 3 wk after EGF. In Case 3, another separate WON, treated by endoscopic LAMS drainage, recurred within 4 d after LAMS removal due to stent-related hemorrhage, and resolved slowly over almost 3 mo. No recurrences were observed in the five patients.CONCLUSION EGF is an innovative and promising alternative intervention for WON adherent to the gastric wall. The challenge resides in the gauging of actual adherence and in selecting appropriate fenestration sites.

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.

Percutaneous endoscopic necrosectomy for walled-off necrosis in the retroperitoneal space of the elderly:A case report

BACKGROUND Walled-off necrosis(WON)is a late complication of acute pancreatitis possibly with a fatal outcome.Even for WON spreading to the retroperitoneal space,percutaneous endoscopic necrosectomy(PEN)can be an alternate approach to surgical necrosectomy,particularly for the older individuals or patients with poor condition because of WON.CASE SUMMARY An 88-year-old man was admitted to our hospital with a jaundice.Endoscopic retrograde cholangiopancreatography(ERCP)was performed to improve jaundice;however,post-ERCP pancreatitis developed.The inflammation of pancreatitis spread widely from the right retroperitoneal cavity to the pelvis,and WON was formed 4 wk later.A percutaneous drainage tube was placed into the WON under computed tomography guidance.However,the drainage did not ameliorate clinical symptoms including fever,which assured less invasive necrosectomy.A metallic stent for the upper gastrointestinal(GI)tract was placed from the percutaneous drainage route.An upper GI endoscope was inserted into the inside of the WON through the metallic stent,and the necrotic tissues were bluntly removed with a snare forceps.Ten times of these necrosectomies resulted in the near-complete removal of necrotic tissues.These procedures consequently abated his fever and remarkable improvement in blood tests.CONCLUSION PEN for WON occurring in the retroperitoneal space was safe and effective for very old individuals.

Effects of disease severity and necrosis on pancreatic dysfunction after acute pancreatitis

AIM:To evaluate the effects of disease severity and necrosis on organ dysfunctions in acute pancreatitis(AP).METHODS:One hundred and nine patients treated as AP between March 2003 and September 2007 with at least 6 mo follow-up were included.Patients were classified according to severity of the disease,necrosis ratio and localization.Subjective clinical evaluation and fecal pancreatic elastase-Ⅰ(FPE-Ⅰ)were used for exocrine dysfunction evaluation,and oral glucose tolerance test was completed for endocrine dysfunction.The correlation of disease severity,necrosis ratio and localization with exocrine and endocrine dysfunction were investigated.RESULTS:There were 58 male and 51 female patients,and mean age was 56.5±15.7.Of the patients,35.8%had severe AP(SAP)and 27.5%had pancreatic necrosis.Exocrine dysfunction was identified in 13.7%of the patients[17.9%were in SAP,11.4%were in mild AP(MAP)]and 34.7%of all of the patients had endocrine dysfunction(56.4%in SAP and 23.2%in MAP).In patients with SAP and necrotizing AP(NAP),FPE-Ⅰlevels were lower than the others(P<0.05 and0.001 respectively)and in patients having pancreatic head necrosis or near total necrosis,FPE-1 levels were lower than 200μg/g stool.Forty percent of the patients who had undergone necrosectomy developed exocrine dysfunction.Endocrine dysfunction was more significant in patients with SAP and NAP(P<0.001).All of the patients in the necrosectomy group had endocrine dysfunction.CONCLUSION:Patients with SAP,NAP,pancreatic head necrosis and necrosectomy should be followed for pancreatic functions.

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:Complications and changing trend of treatment

Incidence of acute pancreatitis seems to be increasing in the Western countries and has been associated with significantly increased morbidity. Nearly 80% of the patients with acute pancreatitis undergo resolution; some develop complications including pancreatic necrosis. Infection of pancreatic necrosis is the leading cause of death in these patients. A significant portion of these patients needs surgical interventions. Traditionally, the "gold standard" procedure has been the open surgical necrosectomy, which is now being completed by the relatively lesser invasive interventions. Minimally invasive surgical(MIS) procedures include endoscopic drainage, percutaneous image-guided catheter drainage, and retroperitoneal drainage. This review article discusses the open and MIS interventions for pancreatic necrosis with each having its own respective benefits and disadvantages are covered.

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.

Analysis of the delayed approach to the management of infected pancreatic necrosis

AIM: To analyze outcomes of delayed single-stage necrosectomy after early conservative management of patients with infected pancreatic necrosis (IPN) associated with severe acute pancreatitis (SAP). METHODS: Between January 1998 and December 2009, data from patients with SAP who developed IPN and were managed by pancreatic necrosectomy were analyzed. RESULTS: Fifty-nine of 61 pancreatic necrosectomies were performed by open surgery and 2 laparoscopically. In 55 patients, single-stage necrosectomy could be performed (90.2%). Patients underwent surgery at a median of 29 d (range 13-46 d) after diagnosis of acute pancreatitis. Sepsis and multiple organ failure accounted for the 9.8% mortality rate. Pancreatic fistulae (50.8%) predominantly accounted for the morbidity. The median hospital stay was 23 d, and the median interval for return to regular activities was 110 d.CONCLUSION: This series supports the concept of delayed single-stage open pancreatic necrosectomy for IPN. Advances in critical care, antibiotics and interventional radiology have played complementary role in improving the outcomes.

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.

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.

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.