Infected pancreatic necrosis complicating severe acute pancreatitis in critically ill patients: predicting catheter drainage failure and need for necrosectomy

Charlotte Garret, Marion Douillard, Arthur David, Morgane Péré, Lucille Quenehervé, Ludivine Legros, Isabelle Archambeaud, Frédéric Douane, Marc Lerhun, Nicolas Regenet, Jerome Gournay, Emmanuel Coron, Eric Frampas, Jean Reignier, Charlotte Garret, Marion Douillard, Arthur David, Morgane Péré, Lucille Quenehervé, Ludivine Legros, Isabelle Archambeaud, Frédéric Douane, Marc Lerhun, Nicolas Regenet, Jerome Gournay, Emmanuel Coron, Eric Frampas, Jean Reignier

Abstract

Background: Recent guidelines advocate a step-up approach for managing suspected infected pancreatic necrosis (IPN) during acute pancreatitis. Nearly half the patients require secondary necrosectomy after catheter drainage. Our primary objective was to assess the external validity of a previously reported nomogram for catheter drainage, based on four predictors of failure. Our secondary objectives were to identify other potential predictors of catheter-drainage failure. We retrospectively studied consecutive patients admitted to the intensive care units (ICUs) of three university hospitals in France between 2012 and 2016, for severe acute pancreatitis with suspected IPN requiring catheter drainage. We assessed drainage success and failure rates in 72 patients, with success defined as survival without subsequent necrosectomy and failure as death and/or subsequent necrosectomy required by inadequate improvement. We plotted the receiver operating characteristics (ROC) curve for the nomogram and computed the area under the curve (AUROC).

Results: Catheter drainage alone was successful in 32 (44.4%) patients. The nomogram predicted catheter-drainage failure with an AUROC of 0.71. By multivariate analysis, catheter-drainage failure was independently associated with a higher body mass index [odds ratio (OR), 1.12; 95% confidence interval (95% CI), 1.00-1.24; P = 0.048], heterogeneous collection (OR, 16.7; 95% CI, 1.83-152.46; P = 0.01), and respiratory failure onset within 24 h before catheter drainage (OR, 18.34; 95% CI, 2.18-154.3; P = 0.007).

Conclusion: Over half the patients required necrosectomy after failed catheter drainage. Newly identified predictors of catheter-drainage failure were heterogeneous collection and respiratory failure. Adding these predictors to the nomogram might help to identify patients at high risk of catheter-drainage failure.

Clinicaltrials: gov number: NCT03234166.

Keywords: Acute pancreatitis; Catheter drainage; Infected necrosis; Intensive care; Necrosectomy; Organ failure.

Conflict of interest statement

None of the authors has any competing interests to disclose.

© 2022. The Author(s).

Figures

Fig. 1
Fig. 1
Patient flowchart. IPN infected pancreatic necrosis
Fig. 2
Fig. 2
Receiver operating characteristic (ROC) curve of the multivariate regression model for predicting success of catheter drainage in patients with infected pancreatic necrosis using the Dutch nomogram based on male sex, multiorgan failure, percentage of pancreatic necrosis, and density of the collection [8]. The area under the curve was 0.71 (95% confidence interval, 0.5869; 0.8352)

References

    1. van Santvoort HC, Besselink MG, Bakker OJ, Hofker HS, Boermeester MA, Dejong CH, et al. A step-up approach or open necrosectomy for necrotizing pancreatitis. N Engl J Med. 2010;362:1491–1502. doi: 10.1056/NEJMoa0908821.
    1. Baron TH, DiMaio CJ, Wang AY, Morgan KA. American Gastroenterological Association clinical practice update: management of pancreatic necrosis. Gastroenterology. 2020;158:67–75.e1. doi: 10.1053/j.gastro.2019.07.064.
    1. van Brunschot S, van Grinsven J, van Santvoort HC, Bakker OJ, Besselink MG, Boermeester MA, et al. Endoscopic or surgical step-up approach for infected necrotising pancreatitis: a multicentre randomised trial. The Lancet. 2018;391:51–58. doi: 10.1016/S0140-6736(17)32404-2.
    1. Crockett SD, Wani S, Gardner TB, Falck-Ytter Y, Barkun AN, American Gastroenterological Association Institute Clinical Guidelines Committee American Gastroenterological Association Institute guideline on initial management of acute pancreatitis. Gastroenterology. 2018;154:1096–101. doi: 10.1053/j.gastro.2018.01.032.
    1. Singh AK, Samanta J, Gulati A, Gautam V, Bhatia A, Gupta P, et al. Outcome of percutaneous drainage in patients with pancreatic necrosis having organ failure. HPB. 2021;23:1030–1038. doi: 10.1016/j.hpb.2020.10.021.
    1. van Brunschot S, Hollemans RA, Bakker OJ, Besselink MG, Baron TH, Beger HG, et al. Minimally invasive and endoscopic versus open necrosectomy for necrotising pancreatitis: a pooled analysis of individual data for 1980 patients. Gut BMJ Publishing Group. 2018;67:697–706.
    1. van Brunschot S, van Grinsven J, Voermans RP, Bakker OJ, Besselink MGH, Boermeester MA, et al. Transluminal endoscopic step-up approach versus minimally invasive surgical step-up approach in patients with infected necrotising pancreatitis (TENSION trial): design and rationale of a randomised controlled multicenter trial [ISRCTN09186711] BMC Gastroenterol. 2013;13:161. doi: 10.1186/1471-230X-13-161.
    1. Hollemans RA, Bollen TL, van Brunschot S, Bakker OJ, Ali UA, van Goor H, et al. Predicting success of catheter drainage in infected necrotizing pancreatitis. Ann Surg. 2016;263:787–792. doi: 10.1097/SLA.0000000000001203.
    1. Babu RY, Gupta R, Kang M, Bhasin DK, Rana SS, Singh R. Predictors of surgery in patients with severe acute pancreatitis managed by the step-up approach. Ann Surg. 2013;257:737–750. doi: 10.1097/SLA.0b013e318269d25d.
    1. Arvanitakis M, Dumonceau J-M, Albert J, Badaoui A, Bali MA, Barthet M, et al. Endoscopic management of acute necrotizing pancreatitis: European Society of Gastrointestinal Endoscopy (ESGE) evidence-based multidisciplinary guidelines. Endoscopy. 2018;50:524–546. doi: 10.1055/a-0588-5365.
    1. Leppäniemi A, Tolonen M, Tarasconi A, Segovia-Lohse H, Gamberini E, Kirkpatrick AW, et al. 2019 WSES guidelines for the management of severe acute pancreatitis. World J Emerg Surg WJES. 2019;14:27. doi: 10.1186/s13017-019-0247-0.
    1. Greenberg JA, Hsu J, Bawazeer M, Marshall J, Friedrich JO, Nathens A, et al. Clinical practice guideline: management of acute pancreatitis. Can J Surg. 2016;59:128–140. doi: 10.1503/cjs.015015.
    1. De Waele JJ, Vogelaers D, Hoste E, Blot S, Colardyn F. Emergence of antibiotic resistance in infected pancreatic necrosis. Arch Surg Chic Ill. 1960;2004(139):1371–1375.
    1. Brusselaers N, Vogelaers D, Blot S. The rising problem of antimicrobial resistance in the intensive care unit. Ann Intensive Care. 2011;1:47. doi: 10.1186/2110-5820-1-47.
    1. Kochhar R, Ahammed SKM, Chakrabarti A, Ray P, Sinha SK, Dutta U, et al. Prevalence and outcome of fungal infection in patients with severe acute pancreatitis. J Gastroenterol Hepatol. 2009;24:743–747. doi: 10.1111/j.1440-1746.2008.05712.x.
    1. Yan L, Dargan A, Nieto J, Shariaha RZ, Binmoeller KF, Adler DG, et al. Direct endoscopic necrosectomy at the time of transmural stent placement results in earlier resolution of complex walled-off pancreatic necrosis: results from a large multicenter United States trial. Endosc Ultrasound. 2019;8:172–179. doi: 10.4103/eus.eus_108_17.
    1. Trikudanathan G, Tawfik P, Amateau SK, Munigala S, Arain M, Attam R, et al. Early (<4 weeks) versus standard (≥ 4 weeks) endoscopically centered step-up interventions for necrotizing pancreatitis. Am J Gastroenterol. 2018;113:1550–1558. doi: 10.1038/s41395-018-0232-3.
    1. Boxhoorn L, van Dijk SM, van Grinsven J, Verdonk RC, Boermeester MA, Bollen TL, et al. Immediate versus postponed intervention for infected necrotizing pancreatitis. N Engl J Med. 2021;385:1372–1381. doi: 10.1056/NEJMoa2100826.
    1. Vincent JL, de Mendonça A, Cantraine F, Moreno R, Takala J, Suter PM, et al. Use of the SOFA score to assess the incidence of organ dysfunction/failure in intensive care units: results of a multicenter, prospective study Working group on “sepsis-related problems” of the European Society of Intensive Care Medicine. Crit Care Med. 1998;26:1793–800. doi: 10.1097/00003246-199811000-00016.
    1. Banks PA, Bollen TL, Dervenis C, Gooszen HG, Johnson CD, Sarr MG, et al. Classification of acute pancreatitis–2012: revision of the Atlanta classification and definitions by international consensus. Gut. 2013;62:102–111. doi: 10.1136/gutjnl-2012-302779.
    1. Li A, Cao F, Li J, Fang Y, Wang X, Liu D, et al. Step-up mini-invasive surgery for infected pancreatic necrosis: results from prospective cohort study. Pancreatology. 2016;16:508–514. doi: 10.1016/j.pan.2016.03.014.
    1. Ji L, Wang G, Li L, Li Y-L, Hu J-S, Zhang G-Q, et al. Risk factors for the need of surgical necrosectomy after percutaneous catheter drainage in the management of infection secondary to necrotizing pancreatitis. Pancreas. 2018;47:436–443. doi: 10.1097/MPA.0000000000001031.
    1. van Santvoort HC, Bakker OJ, Bollen TL, Besselink MG, Ahmed Ali U, Schrijver AM, et al. A conservative and minimally invasive approach to necrotizing pancreatitis improves outcome. Gastroenterology. 2011;141:1254–1263. doi: 10.1053/j.gastro.2011.06.073.
    1. Seifert H, Biermer M, Schmitt W, Juergensen C, Will U, Gerlach R, et al. Transluminal endoscopic necrosectomy after acute pancreatitis: a multicentre study with long-term follow-up (the GEPARD Study) Gut. 2009;58:1260–1266. doi: 10.1136/gut.2008.163733.
    1. Besselink MGH, van Santvoort HC, Buskens E, Boermeester MA, van Goor H, Timmerman HM, et al. Probiotic prophylaxis in predicted severe acute pancreatitis: a randomised, double-blind, placebo-controlled trial. Lancet Lond Engl. 2008;371:651–659. doi: 10.1016/S0140-6736(08)60207-X.
    1. Shenvi S, Gupta R, Kang M, Khullar M, Rana SS, Singh R, et al. Timing of surgical intervention in patients of infected necrotizing pancreatitis not responding to percutaneous catheter drainage. Pancreatol Off J Int Assoc Pancreatol IAP Al. 2016;16:778–787.
    1. Cao X, Cao F, Li A, Gao X, Wang X-H, Liu D-G, et al. Predictive factors of pancreatic necrosectomy following percutaneous catheter drainage as a primary treatment of patients with infected necrotizing pancreatitis. Exp Ther Med. 2017;14:4397–4404.
    1. Zhou M-T. Acute lung injury and ARDS in acute pancreatitis: Mechanisms and potential intervention. World J Gastroenterol. 2010;16:2094. doi: 10.3748/wjg.v16.i17.2094.
    1. Premkumar R, Phillips ARJ, Petrov MS, Windsor JA. The clinical relevance of obesity in acute pancreatitis: targeted systematic reviews. Pancreatol Off J Int Assoc Pancreatol IAP Al. 2015;15:25–33.
    1. Ikarashi S, Kawai H, Hayashi K, Kohisa J, Sato T, Nozawa Y, et al. Risk factors for walled-off necrosis associated with severe acute pancreatitis: a multicenter retrospective observational study. J Hepato Biliary Pancreat Sci. 2020;27:887–895. doi: 10.1002/jhbp.787.
    1. Tong Z, Li W, Yu W, Geng Y, Ke L, Nie Y, et al. Percutaneous catheter drainage for infective pancreatic necrosis: is it always the first choice for all patients? Pancreas. 2012;41:302–305. doi: 10.1097/MPA.0b013e318229816f.
    1. Guo Q, Li A, Hu W. Predictive factors for successful ultrasound-guided percutaneous drainage in necrotizing pancreatitis. Surg Endosc. 2016;30:2929–2934. doi: 10.1007/s00464-015-4579-x.
    1. Siebert M, Le Fouler A, Sitbon N, Cohen J, Abba J, Poupardin E. Management of abdominal compartment syndrome in acute pancreatitis. J Visc Surg. 2021;158:411–419. doi: 10.1016/j.jviscsurg.2021.01.001.
    1. van Grinsven J, Timmerman P, van Lienden KP, Haveman JW, Boerma D, van Eijck CHJ, et al. Proactive versus standard percutaneous catheter drainage for infected necrotizing pancreatitis. Pancreas. 2017;46:518–523. doi: 10.1097/MPA.0000000000000785.
    1. van Grinsven J, van Brunschot S, Bakker OJ, Bollen TL, Boermeester MA, Bruno MJ, et al. Diagnostic strategy and timing of intervention in infected necrotizing pancreatitis: an international expert survey and case vignette study. HPB. 2016;18:49–56. doi: 10.1016/j.hpb.2015.07.003.

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