Skip to main content
SpringerLink
Log in

A Risk Score for Predicting the Necessity of Surgical Necrosectomy in the Treatment of Infected Necrotizing Pancreatitis

  • Original Article
  • Published:
Journal of Gastrointestinal Surgery

Abstract

Background

For infected necrotizing pancreatitis (INP), percutaneous catheter drainage (PCD) is now widely acknowledged as the initial intervention in a step-up approach, followed, if necessary, by minimally invasive necrosectomy or even open pancreatic necrosectomy. However, an overemphasis on PCD may cause a patient’s condition to deteriorate, leading to missed surgical opportunities or even death. This study aimed to develop a simple and convenient scoring tool for assessing the need for surgery in INP patients who received PCD procedures.

Methods

In an observational study conducted between April 2015 and December 2020, PCD was utilized as the initial step to treat 143 consecutive INP patients. A surgical necrosectomy was performed when the patient failed to respond. Risk factors of PCD failure (i.e., need for surgical necrosectomy) were identified by multivariate logistic regression models. An integer-based risk scoring tool was developed using the β coefficients derived from the logistic regression model.

Results

In 62 (43.4%) patients, PCD was successful, while the remaining 81 (56.6%) individuals required subsequent surgical necrosectomy. In the multivariate model, organ failure, percentage of pancreatic necrosis, extrapancreatic necrosis volume, and mean CT density of extrapancreatic necrosis volume were associated with a need for surgical necrosectomy. A predictive scoring tool based on these four factors demonstrated an area under the receiver operating characteristic curve (AUC) of 0.893. Under the scoring tool, a total score of 4 or more indicates a high possibility of surgical necrosectomy being required (at least 80%). Using the coordinates of the receiver operating characteristic curve (ROC), the sensitivity and specificity at this threshold are 0.802 and 0.903, respectively.

Conclusions

A risk score model integrating organ failure, percentage of pancreatic necrosis, extrapancreatic necrosis volume, and mean CT density of extrapancreatic necrosis volume can identify INP patients at high risk for necrosectomy. The straightforward risk assessment tool assists clinicians in stratifying INP patients and making more judicious medical decisions.

This is a preview of subscription content, log in via an institution to check access.

Access this article

Log in via an institution

Price excludes VAT (USA)
Tax calculation will be finalised during checkout.

Instant access to the full article PDF.

Institutional subscriptions

Fig. 1
Fig. 2
Fig. 3
Fig. 4

Similar content being viewed by others

References

  1. Mederos MA, Reber HA, Girgis MD. Acute Pancreatitis: A Review. JAMA 2021;325:382-90.

    Article  CAS  PubMed  Google Scholar 

  2. Boxhoorn L, Voermans RP, Bouwense SA, Bruno MJ, Verdonk RC, Boermeester MA, et al. Acute pancreatitis. Lancet 2020;396:726-34.

    Article  PubMed  Google Scholar 

  3. Baron TH, DiMaio CJ, Wang AY, Morgan KA. American Gastroenterological Association Clinical Practice Update: Management of Pancreatic Necrosis. Gastroenterol 2020;158:67-75.

    Article  CAS  Google Scholar 

  4. 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;385:1372-81.

    Article  PubMed  Google Scholar 

  5. Hines OJ, Pandol SJ. Management of severe acute pancreatitis. BMJ 2019;367:l6227.

    Article  PubMed  Google Scholar 

  6. Maatman TK, Flick KF, Roch AM, Zyromski NJ. Operative pancreatic debridement: Contemporary outcomes in changing times. Pancreatol 2020;20:968-75.

    Article  Google Scholar 

  7. Huang D, Li Q, Lu Z, Jiang K, Wu J, Gao W, et al. From "step-up" to "step-jump": a leap-forward intervention for infected necrotizing pancreatitis. Chin Med J (Engl) 2021;135:285-7.

    Article  PubMed  Google Scholar 

  8. 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 2012;62:102-11.

    Article  PubMed  Google Scholar 

  9. van Grinsven J, van Dijk SM, Dijkgraaf MG, Boermeester MA, Bollen TL, Bruno MJ, et al. Postponed or immediate drainage of infected necrotizing pancreatitis (POINTER trial): study protocol for a randomized controlled trial. Trials 2019;20:239.

    Article  PubMed  PubMed Central  Google Scholar 

  10. Meyrignac O, Lagarde S, Bournet B, Mokrane FZ, Buscail L, Rousseau H, et al. Acute Pancreatitis: Extrapancreatic Necrosis Volume as Early Predictor of Severity. Radiol 2015;276:119-28.

    Article  Google Scholar 

  11. Hollemans RA, Bakker OJ, Boermeester MA, Bollen TL, Bosscha K, Bruno MJ, et al. Superiority of Step-up Approach vs Open Necrosectomy in Long-term Follow-up of Patients With Necrotizing Pancreatitis. Gastroenterol 2019;156:1016-26.

    Article  Google Scholar 

  12. 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. Lancet 2018;391:51-8.

    Article  PubMed  Google Scholar 

  13. 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;362:1491-502.

    Article  PubMed  Google Scholar 

  14. Harfouche M, Clark J, Kim K, Bruns B, Diaz JJ. Characteristics and Outcomes of Drainage Versus Surgery First in Severe Pancreatitis. Am Surg 2020; 86:1073-7.

    Article  PubMed  Google Scholar 

  15. Garg PK, Madan K, Pande GK, Khanna S, Sathyanarayan G, Bohidar NP, et al. Association of extent and infection of pancreatic necrosis with organ failure and death in acute necrotizing pancreatitis. Clin Gastroenterol Hepatol 2005;3:159-66.

    Article  PubMed  Google Scholar 

  16. 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;257:737-50.

    Article  PubMed  Google Scholar 

  17. Liu WH, Wang T, Yan HT, Chen T, Xu C, Ye P, et al. Predictors of percutaneous catheter drainage (PCD) after abdominal paracentesis drainage (APD) in patients with moderately severe or severe acute pancreatitis along with fluid collections. PLoS One 2015;10:e115348.

    Google Scholar 

  18. Hollemans RA, Bollen TL, van Brunschot S, Bakker OJ, Ahmed AU, van Goor H, et al. Predicting Success of Catheter Drainage in Infected Necrotizing Pancreatitis. Ann Surg 2016;263:787-92.

    Article  PubMed  Google Scholar 

  19. Ding L, Li XY, Tan JX, Xia L, He WH, Xiong HF, et al. Association between morphological features of necrotizing pancreatitis on endoscopic ultrasound and outcomes of the endoscopic transmural step-up approach. J Dig Dis 2022;23:174-82.

    Article  PubMed  Google Scholar 

  20. Ji L, Wang G, Li L, Li YL, Hu JS, Zhang GQ, 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;47:436-43.

    Article  PubMed  Google Scholar 

  21. Guo Q, Li A, Hu W. Predictive factors for successful ultrasound-guided percutaneous drainage in necrotizing pancreatitis. Surg Endosc 2016;30:2929-34.

    Article  PubMed  Google Scholar 

  22. Fu B, Feng H, Gao F, Fu X. Role of Extrapancreatic Necrosis Volume in Assessing the Severity and Predicting the Outcomes of Severe Acute Pancreatitis. Int J Gen Med 2021;14:9515-21.

    Article  PubMed  PubMed Central  Google Scholar 

  23. Cao X, Cao F, Li A, Gao X, Wang XH, Liu DG, 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;14:4397-404.

    CAS  PubMed  PubMed Central  Google Scholar 

  24. Bellam BL, Samanta J, Gupta P, Kumar MP, Sharma V, Dhaka N, et al. Predictors of outcome of percutaneous catheter drainage in patients with acute pancreatitis having acute fluid collection and development of a predictive model. Pancreatol 2019;19:658-64.

    Article  Google Scholar 

  25. 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;41:302-5.

    Article  PubMed  Google Scholar 

  26. Knaus WA, Draper EA, Wagner DP, Zimmerman JE. APACHE II: a severity of disease classification system. Crit Care Med 1985;13:818-29.

    Article  CAS  PubMed  Google Scholar 

Download references

Funding

This work was supported by a grant from the National Natural Sciences Foundation of China (No. 82173206).

Author information

Author notes

  1. Dongya Huang and Zipeng Lu contributed equally to this work.

Authors and Affiliations

  1. Pancreas Center, The First Affiliated Hospital of Nanjing Medical University, Nanjing, China

    Dongya Huang MD, PhD, Zipeng Lu MD, PhD, Qiang Li MD, PhD, Kuirong Jiang MD, PhD, Junli Wu MD, PhD, Wentao Gao MD, PhD & Yi Miao MD, PhD, FACS, FRCS, FICS(Hon)

  2. Pancreas Center, The Affiliated BenQ Hospital of Nanjing Medical University, Nanjing, China

    Yi Miao MD, PhD, FACS, FRCS, FICS(Hon)

Authors
  1. Dongya Huang MD, PhD
    View author publications

    You can also search for this author in PubMed Google Scholar

  2. Zipeng Lu MD, PhD
    View author publications

    You can also search for this author in PubMed Google Scholar

  3. Qiang Li MD, PhD
    View author publications

    You can also search for this author in PubMed Google Scholar

  4. Kuirong Jiang MD, PhD
    View author publications

    You can also search for this author in PubMed Google Scholar

  5. Junli Wu MD, PhD
    View author publications

    You can also search for this author in PubMed Google Scholar

  6. Wentao Gao MD, PhD
    View author publications

    You can also search for this author in PubMed Google Scholar

  7. Yi Miao MD, PhD, FACS, FRCS, FICS(Hon)
    View author publications

    You can also search for this author in PubMed Google Scholar

Contributions

Dong-ya Huang, data curation, investigation, formal analysis, project administration, writing—original draft, writing—review and editing; Zi-peng Lu, data curation, investigation, methodology; Qiang Li, data curation; Kui-rong Jiang, data curation; Jun-li Wu, data curation; Wen-tao Gao, data curation; Yi Miao, conceptualization, funding acquisition, methodology, project administration, supervision, writing—review and editing

Corresponding author

Correspondence to Yi Miao MD, PhD, FACS, FRCS, FICS(Hon).

Ethics declarations

Conflict of Interest

The authors declare no competing interests.

Additional information

Publisher’s Note

Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.

Rights and permissions

Springer Nature or its licensor (e.g. a society or other partner) holds exclusive rights to this article under a publishing agreement with the author(s) or other rightsholder(s); author self-archiving of the accepted manuscript version of this article is solely governed by the terms of such publishing agreement and applicable law.

Reprints and permissions

About this article

Check for updates. Verify currency and authenticity via CrossMark

Cite this article

Huang, D., Lu, Z., Li, Q. et al. A Risk Score for Predicting the Necessity of Surgical Necrosectomy in the Treatment of Infected Necrotizing Pancreatitis. J Gastrointest Surg 27, 2145–2154 (2023). https://doi.org/10.1007/s11605-023-05772-z

Download citation

  • Received:

  • Accepted:

  • Published:

  • Issue Date:

  • DOI: https://doi.org/10.1007/s11605-023-05772-z

Keywords

Search

Navigation