Percutaneous Endoscopic Step-Up Therapy Is an Effective Minimally Invasive Approach for Infected Necrotizing Pancreatitis.

BACKGROUND: Infected pancreatic necrosis (IPN) is a major complication of acute pancreatitis (AP), which may require necrosectomy. Minimally invasive surgical step-up therapy is preferred for IPN. AIM: To assess the effectiveness of percutaneous endoscopic step-up therapy in patients with IPN and identify predictors of its success. METHODS: Consecutive patients with AP hospitalized to our tertiary care academic center were studied prospectively. Patients with IPN formed the study group. The treatment protocol for IPN was percutaneous endoscopic step-up approach starting with antibiotics and percutaneous catheter drainage, and if required necrosectomy. Percutaneous endoscopic necrosectomy (PEN) was performed using a flexible endoscope through the percutaneous tract under conscious sedation. Control of sepsis with resolution of collection(s) was the primary outcome measure. RESULTS: A total of 415 patients with AP were included. Of them, 272 patients had necrotizing pancreatitis and 177 (65%) developed IPN. Of these 177 patients, 27 were treated conservatively with antibiotics alone, 56 underwent percutaneous drainage alone, 53 required underwent PEN as a step-up therapy, 1 per-oral endoscopic necrosectomy, and 52 required surgery. Of the 53 patients in the PEN group, 42 (79.2%) were treated successfully-34 after PEN alone and 8 after additional surgery. Eleven of 53 patients died due to organ failure-7 after PEN and 4 after surgery. Independent predictors of mortality were > 50% necrosis and early organ failure. CONCLUSION: Percutaneous endoscopic step-up therapy is an effective strategy for IPN. Organ failure and extensive pancreatic necrosis predicted a suboptimal outcome in patients with infected necrotizing pancreatitis.

Primary and Secondary Organ Failures Cause Mortality Differentially in Acute Pancreatitis and Should be Distinguished.

OBJECTIVE: The aim of this study was to study the development of early and late organ failure (OF) and their differential impact on mortality in patients with acute pancreatitis (AP). METHODS: Consecutive patients (N = 805) with acute pancreatitis were included in an observational study. Organ failure was categorized as primary if it occurred early due to pancreatitis per se and secondary if it occurred late due to infected pancreatic necrosis (IPN). Primary outcome was a relative contribution of primary OF, secondary OF, and IPN to mortality. RESULTS: Of the 614 patients (mean age, 38.8; standard deviation, 14.6 years; 430 males) in a derivation cohort, 274 (44.6%) developed OF, with 177 having primary OF and 97 secondary OF due to sepsis. Primary OF caused early mortality in 15.8% and was a risk factor for IPN in 76% of patients. Mortality in patients with primary OF and IPN was 49.5% versus 36% in those with IPN and secondary OF (P = 0.06) and 4% in those with IPN but without OF (P < 0.001). The results of the 191 patients in the validation cohort confirmed the relative contribution of primary and secondary OF to mortality. CONCLUSION: Primary and secondary OF contributed to mortality independently and are distinct in their timing, window of opportunity for intervention, and prognosis.

Prevalence of goitre and autoimmune thyroiditis in schoolchildren in Delhi, India, after two decades of salt iodisation.

Delhi lies in the sub-Himalayan plains and the existence of iodine deficiency is well established. Iodised salt was introduced in Delhi nearly two decades ago. The aim of the present study was to determine the status of iodine nutrition in school-aged children and the prevalence of autoimmune thyroiditis. A total of 4,320 schoolchildren (2,218 [51.3%] boys) aged 10-16 years were studied. Goitre was detected in 396 children, an overall goitre prevalence of 9.2%. Of the 396 children with goitre, 112 (28.3%) had evidence of autoimmune thyroiditis (AIT). The median urinary iodine (UI) excretion in the study population as a whole was 14.6 microg/dl. The median UI in the group of children with goiter was 13.3 microg/dl, whereas UI in children with goiter and evidence of AIT was 16.6 microg/dl (p <0.01). Of the 112 children with AIT, 77 (68.7%) were euthyroid, 23 (20.5%) had subclinical hypothyroidism, eight (7.2%) had hypothyroidism and the remaining four (3.6%) had hyperthyroidism. UI was high in goitrous children with AIT, and in children with thyroid dysfunction. Further studies are needed to clarify whether the higher UI in goitrous children with AIT is causally related to AIT or is due to the inability of the diseased thyroid to trap available iodine efficiently.