Extrapancreatic necrotizing pancreatitis with viable pancreas: a previously under-appreciated entity

doi:10.1016/S1072-7515(99)00045-9

Journal of the American College of Surgeons

Volume 188, Issue 6, June 1999, Pages 643-648

https://doi.org/10.1016/S1072-7515(99)00045-9 Get rights and content

Abstract

Background: Necrotizing pancreatitis is generally considered to involve the pancreatic parenchyma in all patients, and, as an extension of the necrotic process, the peripancreatic tissues as well. We identified a subgroup of patients in whom the necrotic process involves apparently extrapancreatic tissues alone (EXPN), as opposed to the usual combined parenchymal and peripancreatic necrosis (PN).

Study Design: The objective of this study was to compare clinical courses of EXPN and PN. Data were reviewed on 82 consecutive patients with necrotizing pancreatitis treated operatively between 1983 and 1997. The extent of pancreatic parenchymal necrosis (expressed as percent of pancreas based on contrast-enhanced CT and operative findings) was estimated in 62 patients. Diagnosis of EXPN required normal enhancement of entire pancreas on dynamic CT and operative documentation of viability of the gland.

Results: Twelve patients (19%) had EXPN and 50 (81%) had PN. Gender, age, body mass index, etiology of pancreatitis, prevalence, and type of infection were similar between groups, but APACHE-II scores on admission were less in EXPN (6 ± 2 versus 10 ± 1, p = 0.02). Patients with EXPN required fewer reoperative necrosectomies (0.7 versus 3.2, p = 0.009) and did not develop pancreatic or gastrointestinal fistulas (0 versus 19 patients) or hemorrhage (0 versus 8 patients). ICU stays were similar, but hospital stays in EXPN were shorter (29 ± 6 versus 54 ± 5 days, p = 0.01) and mortality was less (8% and 20%, p < 0.001).

Conclusions: Necrotizing pancreatitis manifesting as EXPN is not rare. EXPN is a less aggressive form of necrotizing pancreatitis, locally and systemically, and signifies a better prognosis.

Section snippets

Methods

Data on 82 consecutive patients with acute necrotizing pancreatitis as defined by the Atlanta classification5 treated at our institution between 1983 and 1997 were prospectively collected. Diagnosis of acute necrotizing pancreatitis was made in most with contrast-enhanced CT. Indications for operative treatment included positive cultures from percutaneous aspirates, extraluminal gas on CT, or, less commonly, clinical deterioration despite optimal medical management. Only patients with

Patient characteristics

Eighty-two patients underwent operative management of acute necrotizing pancreatitis. In 20 of these, the extent of pancreatic parenchymal necrosis was not able to be assessed reliably because of lack of a reliable contrast-enhanced CT, and they were therefore excluded from analysis. Of the remaining 62 patients, 12 (19%) were found to have EXPN. Ten (83%) were men and 2 (17%) were women, with a mean age of 55 years (range 33 to 93 years). The remaining 50 patients (mean age, 61 years; 36 men,

Discussion

Isolated extrapancreatic necrosis without clinically or radiographically evident pancreatic parenchymal necrosis is an under-appreciated form of necrotizing pancreatitis. EXPN is not rare; indeed, a surprisingly high frequency of EXPN (19%) was observed in our patients with necrotizing pancreatitis. EXPN has a more benign course and better outcomes. Although preoperative differentiation between EXPN and PN does not (and should not) influence initial management decision making, it connotes a

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To study the MRI characteristics of early extrapancreatic necrosis and compare them with those of peripancreatic fluid collections in acute pancreatitis (AP).
This retrospective study enrolled 70 AP patients who had extrapancreatic collections visible on MRI within 1 week of onset. Extrapancreatic collections were divided into extrapancreatic necrosis and peripancreatic fluid collections based on follow-up MRI, CT, or pathology. The number and area of extrapancreatic collections, extrapancreatic inflammation on MRI (EPIM) score, MR severity index score and clinical characteristics were evaluated and compared between the two groups.
Of the seventy AP patients, 32 (45.7%) had extrapancreatic necrosis, and 38 (54.3%) had peripancreatic fluid collections. The number and area of extrapancreatic collections, MR severity index score, EPIM score, and prevalence of associated hemorrhage were significantly higher in extrapancreatic necrosis patients than in those with peripancreatic fluid collections (p < 0.001). Among the single indicators, the accuracy of the area of extrapancreatic collections (AUC = 0.871) was comparable to that of the EPIM score for predicting extrapancreatic necrosis and was significantly higher than that of the other two indicators. The combination of all indicators showed the highest predictive accuracy (AUC = 0.949), and combinations of two or more indicators demonstrated significantly higher predictive accuracy for extrapancreatic necrosis than any single indicator (p < 0.05) except for the area of extrapancreatic collections (p > 0.05).
The MRI characteristics have the potential to differentiate early extrapancreatic necrosis from peripancreatic fluid collections and help indicate extrapancreatic necrosis.
Disconnected pancreatic duct syndrome predicts failure of percutaneous therapy in necrotizing pancreatitis: Percutaneous Drain in Necrotizing Pancreatitis
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Citation Excerpt :
Intuitively, certain morphology patterns might suggest a higher likelihood of successful management with PD alone. Necrosis involving only peripancreatic soft tissue (i.e. isolated peripancreatic necrosis) is felt by many to portend a better prognosis than pancreatic parenchyma necrosis [22–24]. In the current study, no pattern of necrosis when considered alone or in combination was predictive of successful resolution of pancreatic necrosis with PD alone; in fact, morphology was remarkably similar between groups.
Minimally invasive approaches, such as percutaneous drainage (PD), are increasingly utilized as initial treatment in necrotizing pancreatitis (NP) requiring intervention. Predictors of success of PD as definitive treatment are lacking. Our aim was to assess the application, predictors of success, and natural history of PD in NP. We hypothesized that necrosis morphology patterns and disconnected pancreatic duct syndrome (DPDS) may predict the ability of PD to provide definitive therapy.
714 NP patients were treated from 2005 to 2018. Patients achieving disease resolution with PD alone (PD) were compared to those requiring an escalation in intervention (Step). Outcomes were compared between groups using independent samples t-test, Fisher’s exact test, and Pearson’s correlation, as appropriate. P < 0.05 was accepted as statistically significant.
115 patients were initially managed with PD (42 PD, 73 Step). No difference in necrosis morphology was seen between the two groups. The PD group underwent significantly more repeat percutaneous interventions (PD, 3.2; Step, 2.0; P = 0.0006) including additional drain placement and drain upsize/reposition procedures. Patients with DPDS were more likely to require an escalation in intervention (odds ratio, 3.4; 95% confidence interval, 1.5–7.6; P = 0.003). The mean number of months to NP resolution was similar (PD, 5.7; Step, 5.8; P = 0.9). Mortality was similar (PD, 7%; Step 14%, P = 0.3).
Necrosis morphology in and of itself does not reliably predict successful definitive treatment by percutaneous drainage. However, patients with disconnected pancreatic duct syndrome were less likely to have definitive resolution with PD alone.
Isolated peripancreatic necrosis (PPN) is associated with better clinical outcomes compared with combined pancreatic and peripancreatic involvement (CPN)- a systematic review and meta-analysis
2020, Pancreatology
Citation Excerpt :
CPN is most common (Fig. 2), followed by PPN and isolated parenchymal necrosis. Since its initial description by Howard and Wagner in 1989 [8], multiple small series have emerged on PPN which is currently regarded as a distinct clinical entity [9–15]. Majority of these studies are small in number, given the relative infrequency of this entity.
Peripancreatic necrosis (PPN) is considered as a distinct entity with a better outcome when compared with combined pancreatic and peripancreatic necrosis (CPN), but there is no systematic review to summarize the evidence. Our study aimed to perform a meta-analysis of existing observational studies comparing the outcomes of PPN with CPN.
Studies in adult patients comparing the outcomes of PPN and CPN from PubMed, Medline, and Scopus databases from inception to November 2018 were systematically searched. The primary outcome was mortality, and secondary outcomes included multi-organ failure, persistent organ failure, infected necrosis, need for interventions including open necrosectomy. Pooled adjusted odds ratios, and 95% confidence intervals (CI) were obtained by the random-effects model. Forrest plots were constructed to show the summary pooled estimate. Heterogeneity was assessed by using I2 measure of inconsistency.
A total of 6 studies involving 1851 patients (1295 (70%) with CPN and 556 (30%) with PPN) were included. Patients with CPN had a significantly higher mortality (OR 2.49, 95% CI: 1.61–3.87), risk for multi-organ failure (OR 3.24, 95% CI: 2.38–4.43), persistent organ failure (OR 2.79, 95% CI: 1.53–5.08), and infected necrosis (OR 6.21, 95% CI: 3.85–10.03). They underwent more interventions (OR 5.86, 95% CI: 3.69–9.32), including open necrosectomy (OR 5.04, 95% CI: 3.33–7.63). Heterogeneity was low (I2 = 18.1, p = 0.296), and there was no publication bias.
Isolated peripancreatic necrosis portends an overall better prognosis when compared to necrosis involves pancreatic parenchyma. Clinicians should recognize this distinction for management decisions.
Significant inter-observer variation in the diagnosis of extrapancreatic necrosis and type of pancreatic collections in acute pancreatitis – An international multicenter evaluation of the revised Atlanta classification
2016, Pancreatology
For consistent reporting and better comparison of data in research the revised Atlanta classification (RAC) proposes new computed tomography (CT) criteria to describe the morphology of acute pancreatitis (AP). The aim of this study was to analyse the interobserver agreement among radiologists in evaluating CT morphology by using the new RAC criteria in patients with AP.
Patients with a first episode of AP who obtained a CT were identified and consecutively enrolled at six European centres backwards from January 2013 to January 2012. A local radiologist at each center and a central expert radiologist scored the CTs separately using the RAC criteria. Center dependent and independent interobserver agreement was determined using Kappa statistics.
In total, 285 patients with 388 CTs were included. For most CT criteria, interobserver agreement was moderate to substantial. In four categories, the center independent kappa values were fair: extrapancreatic necrosis (EXPN) (0.326), type of pancreatitis (0.370), characteristics of collections (0.408), and appropriate term of collections (0.356). The fair kappa values relate to discrepancies in the identification of extrapancreatic necrotic material. The local radiologists diagnosed EXPN (33% versus 59%, P < 0.0001) and non-homogeneous collections (35% versus 66%, P < 0.0001) significantly less frequent than the central expert. Cases read by the central expert showed superior correlation with clinical outcome.
Diagnosis of EXPN and recognition of non-homogeneous collections show only fair agreement potentially resulting in inconsistent reporting of morphologic findings.
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¹: No competing interests declared.

²: Dr Tsiotos’ current address is Department of Surgery, University of Missouri, Truman Medical Center, 2301 Holmes, Kansas City, MO 64108.

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Original Scientific ArticlesExtrapancreatic necrotizing pancreatitis with viable pancreas: a previously under-appreciated entity1

Abstract

Section snippets

Methods

Patient characteristics

Discussion

Pathol Res Pract

Pathol Res Pract

Am J Surg

Ueber selbstverdaung des Menschlichen Pankreas

Zeitschrift fur Heilkunde

Pathogenese der akuten und chronischen pankreatitis

Verh Dtsch Ges Ind Med

Human acute pancreatitisits pathogenesis in the light of immunocytochemical and ultrastructural findings in acinar cells

Virchows Arch [Pathol Anat]

How and where does acute pancreatitis begin?

Arch Surg

A clinically based classification system for acute pancreatitis

Arch Surg

Original Scientific Articles
Extrapancreatic necrotizing pancreatitis with viable pancreas: a previously under-appreciated entity1