The Efficiency Of Percutaneous Catheter Drainage In Treating With Sterile Pancreatic Fluid Collections Induced By Acute Pancreatitis In Different Phases Of The Disease

BackgroundPancreatic fluid collections (PFCs) in and around the pancreas occur often in acute pancreatitis (AP) and were defined by the Atlanta Symposium on Acute Pancreatitis in 1992 (1992-AC). The Atlanta classification of acute pancreatitis was revised in 2012(2012-RAC), and PFCs are currently categorized as acute peripancreatic fluid collection (APFC), pancreatic pseudocysts (PP), acute necrotic collection (ANC), and walled-off necrosis (WON). APFC and ANC occurred in the early phase of AP, and PP or WON always be seen in the late phase of the disease. PFCs arise as an adverse event of AP. In early phase, PFCs induces the increased release of a large number of inflammatory cytokines and mediates or worsens intra-abdominal hypertension, and exacerbate the disease. In late phase of AP, persistent or progressed PFCs can leading to various complications such as mass effect (gastric outlet obstruction); pseudoaneurysm formation and haemorrhage; thrombosis of the portal, splenic, or mesenteric veins. All kinds of PFCs are either sterile or may become infected during the course of disease. Since percutaneous catheter drainage (PCD) for infected fluid collections in treating infected necrotizing pancreatitis (INP) was first described by Freeny in 1998 and the technique has been increasingly used.In the opinion of the 1992-AC, most of sterile PFCs can be absorbed spontaneously, early intervention by PCD can increased the risk of infection. Although this theory seems reasonable, there is insufficient experimental evidence.2012-RAC defined the types of acute pancreatitis, redefined the severity of acute pancreatitis and revised the local complications of pancreatic collections. According to the nomenclature of 2012-RAC, most of severe acute pancreatitis (SAP) defined by 1992-AC can be bring into moderately severe acute pancreatitis (MSAP), which make the diagnosis of SAP be more accurate. On the basis of 2012-RAC definition of types of AP, ANC usually occurred in SAP. ANC contain significant amount of necrotic material, and necrotic material exceeding 5 cm rarely completely disappears. Maybe early PCD can relieve the state of AP. It is commonly accepted that asymptomatic and noninfectious PPs or WON does not need interventional treatment. Once GOO is confirmed, early and intensive treatments are required to minimize further complications. Most scholars agree that surgical drainage is an effective treatment, but the role of PCD on the treatment of GOO caused by PP or WON is unknown.Aim:The aim of the study was to evaluate the efficacy of percutaneous catheter drainage of sterile PFCs in AP with different severity and phase.Methods:1) 229 patients classified as SAP or MSAP according to 2012-RAC were further divided into 6 subgroups according to the speed of OF developing and the number of organs involved. SAP(a)+MOF:multiple OF occurred within 3 days; SAP(a)+SOF: single OF within 3 days; SAP(b)+MOF:MOF within 7 days; SAP(b)+SOF:SOF within 7 days; MSAP with OF and MSAP without OF.162 patients were found enough sterile APPFC to drain within 2 week, among them 105 patients received sPCD and conservative management was performed in remained 57 patients. Outcome measures were operation rate (OR), pancreatic infection rate (IR) and mortality.2) From June 2010 to June 2013,25 of 148 patients with AP suffered DGE. Among them,12 were caused by gastroparesis,1 was a result of obstruction froma Candida albicans plug, and 12 were GOO compressed by PP (n= 8) or WON (n= 4), which were treated by PCD.Results:1) The rate of large amount sterile PFCs were higher in SAP(a) and SAP(b)+MOF (>80%) than in SAP(b)+SOF and MSAP(<60%). In severer groups PCD reduced the OR (SAP(a)), IR(SAP(a)+SOF and SAP(b)) and mortality(SAP(a) and SAP(b)+MOF). In contrast, PCD raised the OR and IR in MSAP.2) All 12 cases of compressing GOO achieved resolution by PCD after 6 [1.86] and 37.25 [12.02] days for PP and WON, respectively. Five cases developed intracystic infection,3 cases had pancreatic fistulae whereas 2 achieved resolution and 1 underwent a pseudocyst jejunostomy.Conclusions:The amount of PFCs is positively related to the severity of pancreatitis, also the intensity of the development of organ failure. Sterile PCD in early stage may ameliorate the prognosis in severer AP but not in MSAP.Gastric outlet obstruction caused by a PP or WON is a major cause of DGE in patients with AP. Percutaneous catheter drainage with multiple sites, large-bore tubing, and lavage may be a good therapy due to high safety and minimal invasiveness.