Endoscopic drainage with local infusion of antibiotics to avoid necrosectomy of infected walled-off necrosis

Abstract

Background

Current treatment of infected pancreatic necrosis (IPN) follows a step-up approach. Our group designed a step-up protocol that associates endoscopic drainage with local infusion of antibiotics through transmural nasocystic catheter. Aim of our study was to evaluate our step-up protocol for IPN in terms of proportion of patients avoiding necrosectomy.

Methods

Retrospective analysis of patients admitted with acute pancreatitis (AP) between January 2015 and December 2018. The number of patients who responded to each therapeutic step were analysed: step 1, systemic antibiotics; step 2, endoscopic transmural drainage and local infusion of antibiotics; step 3, endoscopic necrosectomy.

Results

1158 patients with AP were included. 110 patients (8.4%) suffered from necrotising pancreatitis; 48 of them had IPN (42.6% of necrotising pancreatitis) and were treated with systemic antibiotics. Nineteen patients (39.6% of IPN) responded and did not required any invasive therapy. Six patients with IPN on systemic antibiotics died within the first 4 weeks of disease before step 2 could be applied. Urgent surgical necrosectomy in the first 4 weeks was performed in three additional patients. Endoscopic drainage and local antibiotic therapy was performed in the remaining 20 patients; 9 (45% of them) did well and 9 patients underwent necrosectomy (18.7% of IPN). Two patients died on drainage. Overall mortality of the total cohort of AP was 2.53%

Conclusions

Addition of local infusion of antibiotics to endoscopic drainage avoids the need of necrosectomy in half of patients with IPN not responding to systemic antibiotics.

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Correspondence to Jose Lariño-Noia.

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Disclosures

José Lariño Noia, Julio Iglesias García and Enrique Dominguez Muñoz have received honoraria as speakers from Abbott, Mylan and Boston Scientific Company. Daniel de la Iglesia García have received honoraria as speaker from Mylan Company. Jaime González-Lopez, Javier Díaz-Lopez, Fernando Macías-García, Rafael Mejuto, Adriano Quiroga, Violeta Mauriz, Andrea Jardí have no conflict of interests or financial ties to disclose.

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Lariño-Noia, J., de la Iglesia-García, D., González-Lopez, J. et al. Endoscopic drainage with local infusion of antibiotics to avoid necrosectomy of infected walled-off necrosis. Surg Endosc 35, 644–651 (2021). https://doi.org/10.1007/s00464-020-07428-4

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Keywords

  • Pancreatitis
  • Endosonography
  • Carbapenem
  • Antibiotic resistance
  • Endoscopic necrosectomy