Is Contemporary Open Pancreatic Necrosectomy Still Useful In The Minimally Invasive Era?

BACKGROUND: Previous studies have shown that open pancreatic necrosectomy for infected pancreatic necrosis was associated with high morbidity and mortality. However, these results were mostly concluded from historical cohorts with traditional early necrosectomy in the absence of a minimally invasive step-up approach. OBJECTIVE: To explore the value of contemporary open pancreatic necrosectomy for infected pancreatic necrosis in the minimally invasive era. METHODS: A post hoc analysis was performed in a prospective maintained database of 320 patients with infected pancreatic necrosis from January 2011 to December 2022 at a large Chinese tertiary hospital. RESULTS: A total of 320 patients with infected pancreatic necrosis received either a minimally invasive step-up approach (245, 76.6%) or open pancreatic necrosectomy (75, 23.4%), which included upfront open pancreatic necrosectomy (32, 10.0%) and salvage open pancreatic necrosectomy (43, 13.4%). Upfront open pancreatic necrosectomy was associated with similar morbidity and mortality rates but fewer surgical interventions compared with a minimally invasive step-up approach. However, salvage open pancreatic necrosectomy was associated with significantly higher mortality (48.8% vs 18.8%, P = .007), gastrointestinal fistula (44.2% vs 18.8%, P = .021), hemorrhage (48.8% vs 15.6%, P = .003), and intensive care unit stay (25 vs 7 days, P = .040) compared with upfront open pancreatic necrosectomy. Multivariate analysis suggested that multiple organ failure (hazard ratio = 5.1; 95% confidence interval, 1.4-18.2, P = .013) and synchronous critical acute pancreatitis (hazard ratio = 3.0; 95% confidence interval, 1.1-8.6, P = .040) were 2 independent risk factors of death for patients who received open pancreatic necrosectomy. CONCLUSION: Patients undergoing upfront open pancreatic necrosectomy received fewer surgical interventions with comparable efficacy compared to the minimally invasive step-up approach. Salvage open pancreatic necrosectomy was potentially lifesaving, though it carried high morbidity and mortality. Multiple organ failure and synchronous critical acute pancreatitis were 2 independent risk factors of death for patients who received open pancreatic necrosectomy.

Metagenomic next-generation sequencing, instead of procalcitonin, could guide antibiotic usage in patients with febrile acute necrotizing pancreatitis: a multicenter, prospective cohort study.

BACKGROUNDS: The effectiveness of procalcitonin-based algorithms in guiding antibiotic usage for febrile acute necrotizing pancreatitis (ANP) remains controversial. Metagenomic next-generation sequencing (mNGS) has been applied to diagnose infectious diseases. The authors aimed to evaluate the effectiveness of blood mNGS in guiding antibiotic stewardship for febrile ANP. MATERIALS AND METHODS: The prospective multicenter clinical trial was conducted at seven hospitals in China. Blood samples were collected during fever (T ≥38.5°C) from ANP patients. The effectiveness of blood mNGS, procalcitonin, and blood culture in diagnosing pancreatic infection was evaluated and compared. Additionally, the real-world utilization of antibiotics and the potential mNGS-guided antimicrobial strategy in febrile ANP were also analyzed. RESULTS: From May 2023 to October 2023, a total of 78 patients with febrile ANP were enrolled and 30 patients (38.5%) were confirmed infected pancreatic necrosis (IPN). Compared with procalcitonin and blood culture, mNGS showed a significantly higher sensitivity rate (86.7% vs. 56.7% vs. 26.7%, P <0.001). Moreover, mNGS outperformed procalcitonin (89.5 vs. 61.4%, P <0.01) and blood culture (89.5 vs. 69.0%, P <0.01) in terms of negative predictive value. Blood mNGS exhibited the highest accuracy (85.7%) in diagnosing IPN and sterile pancreatic necrosis, significantly superior to both procalcitonin (65.7%) and blood culture (61.4%). In the multivariate analysis, positive blood mNGS (OR=60.2, P <0.001) and lower fibrinogen level (OR=2.0, P <0.05) were identified as independent predictors associated with IPN, whereas procalcitonin was not associated with IPN, but with increased mortality (Odds ratio=11.7, P =0.006). Overall, the rate of correct use of antibiotics in the cohort was only 18.6% (13/70) and would be improved to 81.4% (57/70) if adjusted according to the mNGS results. CONCLUSION: Blood mNGS represents important progress in the early diagnosis of IPN, with particular importance in guiding antibiotic usage for patients with febrile ANP.

Prediction of survival in patients with infected pancreatic necrosis: a prospective cohort study.

BACKGROUND: Infected pancreatic necrosis (IPN) is a severe complication of acute pancreatitis, with mortality rates ranging from 15 to 35%. However, limited studies exist to predict the survival of IPN patients and nomogram has never been built. This study aimed to identify predictors of mortality, estimate conditional survival (CS), and develop a CS nomogram and logistic regression nomogram for real-time prediction of survival in IPN patients. METHODS: A prospective cohort study was performed in 335 IPN patients consecutively enrolled at a large Chinese tertiary hospital from January 2011 to December 2022. The random survival forest method was first employed to identify the most significant predictors and capture clinically relevant nonlinear threshold effects. Instantaneous death risk and CS was first utilized to reveal the dynamic changes in the survival of IPN patients. A Cox model-based nomogram incorporating CS and a logistic regression-based nomogram were first developed and internally validated with a bootstrap method. RESULTS: The random survival forest model identified seven foremost predictors of mortality, including the number of organ failures, duration of organ failure, age, time from onset to first intervention, hemorrhage, bloodstream infection, and severity classification. Duration of organ failure and time from onset to first intervention showed distinct thresholds and nonlinear relationships with mortality. Instantaneous death risk reduced progressively within the first 30 days, and CS analysis indicated gradual improvement in real-time survival since diagnosis, with 90-day survival rates gradually increasing from 0.778 to 0.838, 0.881, 0.974, and 0.992 after surviving 15, 30, 45, 60, and 75 days, respectively. After further variables selection using step regression, five predictors (age, number of organ failures, hemorrhage, time from onset to first intervention, and bloodstream infection) were utilized to construct both the CS nomogram and logistic regression nomogram, both of which demonstrated excellent performance with 1000 bootstrap. CONCLUSION: Number of organ failures, duration of organ failure, age, time from onset to first intervention, hemorrhage, bloodstream infection, and severity classification were the most crucial predictors of mortality of IPN patients. The CS nomogram and logistic regression nomogram constructed by these predictors could help clinicians to predict real-time survival and optimize clinical decisions.

CONSTRUCTION OF SEPSIS DIAGNOSTIC MODELS AND IDENTIFICATION OF MACROPHAGE SUBPOPULATIONS BASED ON PYROPTOSIS-RELATED GENES.

ABSTRACT: Background: Numerous studies have shown that pyroptosis is associated with sepsis progression, which can lead to dysregulated host immune responses and organ dysfunction. Therefore, investigating the potential prognostic and diagnostic values of pyroptosis in patients with sepsis is essential. Methods: We conducted a study using bulk and single-cell RNA sequencing (scRNA-seq) from the Gene Expression Omnibus database to examine the role of pyroptosis in sepsis. Univariate logistic analysis, least absolute shrinkage, and selection operator regression analysis were used to identify pyroptosis-related genes (PRGs), construct a diagnostic risk score model, and evaluate the selected genes' diagnostic value. Consensus clustering analysis was used to identify the PRG-related sepsis subtypes with varying prognoses. Functional and immune infiltration analyses were used to explain the subtypes' distinct prognoses, and scRNA-seq data were used to differentiate immune-infiltrating cells and macrophage subsets and study cell-cell communication. Results: A risk model was established based on 10 key PRGs ( NAIP , ELANE , GSDMB , DHX9 , NLRP3 , CASP8 , GSDMD , CASP4 , APIP , and DPP9 ), of which four ( ELANE , DHX9 , GSDMD , and CASP4 ) were associated with prognosis. Two subtypes with different prognoses were identified based on the key PRG expressions. Functional enrichment analysis revealed diminished nucleotide oligomerization domain-like receptor pathway activity and enhanced neutrophil extracellular trap formation in the subtype with a poor prognosis. Immune infiltration analysis suggested a different immune status between the two sepsis subtypes, with the subtype with a poor prognosis exhibiting stronger immunosuppression. The single-cell analysis identified a macrophage subpopulation characterized by gasdermin D (GSDMD) expression that may be involved in pyroptosis regulation, which was associated with the prognosis of sepsis. Conclusion: We developed and validated a risk score for sepsis identification based on 10 PRGs, four of which also have potential value in the prognosis of sepsis. We identified a subset of gasdermin D macrophages associated with poor prognosis, providing new insights into the role of pyroptosis in sepsis.

Escherichia coli infection indicates favorable outcomes in patients with infected pancreatic necrosis.

Introduction: Infected pancreatic necrosis (IPN) is a severe complication of acute necrotizing pancreatitis with increasing morbidity. Escherichia coli is the most frequently cultured microorganism in IPN. However, the implications of Escherichia coli infection on the outcomes of patients with IPN remain unclear. Therefore, this study aimed to evaluate the clinical impacts of Escherichia coli infection on IPN. Methods: A prospective database with consecutive patients with IPN between January 2010 and April 2022 at a tertiary hospital was post-hoc analyzed. The clinical and microbiological characteristics, surgical management, and follow-up data of patients with and without Escherichia coli infection were compared. Results: A total of 294 IPN patients were enrolled in this cohort. Compared with non-Escherichia coli infection cases (n=80, 27.2%), patients with Escherichia coli infection (n=214, 72.8%) were characterized by more frequent polymicrobial infections (77.5% vs. 65.0%, P=0.04) but a lower occurrence of severe acute pancreatitis (SAP) (42.5% vs. 61.7%, P=0.003). In addition, significantly lower mortality (12.5% vs. 30.4%, p=0.002), fewer step-up surgical interventions (73.8% vs. 85.1%, P=0.025), and a lower rate of multiple organ failure (MOF) (25.0% vs. 40.2%, P=0.016) were also observed in patients with Escherichia coli infection. Multivariate analysis of mortality predictors indicated that MOF (odds ratio [OR], 6.197; 95% confidence interval [CI], 2.373-16.187; P<0.001) and hemorrhage (OR, 3.485; 95% CI, 1.623-7.487; P=0.001) were independent predictors associated with higher mortality in patients with IPN. Escherichia coli infection was significantly associated with a lower mortality (OR, 0.302; 95% CI, 0.121-0.751; P= 0.01). Conclusion: Escherichia coli infection indicates a favorable prognosis in patients with IPN, although the mechanism needs further investigation.

Application of metagenomic next-generation sequencing for suspected infected pancreatic necrosis.

BACKGROUND: Metagenomic next-generation sequencing (mNGS) is increasingly used for the clinical diagnosis of infectious diseases, but there is a paucity of data regarding the application of mNGS in the early diagnosis of infected pancreatic necrosis (IPN). OBJECTIVE: To investigate the clinical application value of mNGS in the pathogenic diagnosis of IPN. METHODS: Forty-two patients with suspected IPN were prospectively and consecutively enrolled from August 2019 to August 2021. Blood samples were collected for mNGS and microbial culture simultaneously during fever (T ≥ 38.5 °C). For patients who had indications of surgical interventions, peri-pancreatic specimens were collected for mNGS and microbial culture simultaneously during the first surgical intervention to confirm IPN. The clinical performance of mNGS and microbial culture were compared. RESULTS: A total of 21 patients (50.0%) were confirmed to have IPN during hospitalization. The sensitivity of blood mNGS was significantly higher than blood culture (95.2% vs. 23.8%, P < 0.001) in diagnosing IPN. The negative predictive value of blood mNGS was 90.0%. The turnaround time of mNGS was significantly shorter than that of microbial culture [(37.70 ± 1.44) vs. (115.23 ± 8.79) h, P < 0.01] and the average costs of mNGS accounted for 1.7% of the average total cost of hospitalization. The survival analysis demonstrates that the positive blood mNGS result was not associated with increased mortality (P = 0.119). CONCLUSIONS: With more valuable diagnostic performance and shorter turnaround time, clinical mNGS represents a potential step forward in the early diagnosis of IPN.

Early-onset emphysematous pancreatitis indicates poor outcomes in patients with infected pancreatic necrosis.

BACKGROUND: Emphysematous pancreatitis (EP) is a subtype of infected pancreatic necrosis (IPN) characterized by presence of gas in (peri)pancreatic necrosis. However, the impacts of EP on outcomes of IPN are still controversial. METHODS: A prospective database of consecutive patients with IPN in a tertiary hospital was post-hoc analyzed. Patients were assigned to EP and non-EP groups to perform a comprehensive comparison. RESULTS: A total of 178 patients with IPN were enrolled and the overall mortality was 30.9%. EP accounted for 20.8% (n = 37) of cases and was significantly associated with higher incidences of Escherichia coli (45.9 versus 18.4%, P = 0.001) and Klebsiella pneumoniae (56.8 versus 33.3%, P = 0.009) infection. There was scarcely any disparity in clinical characteristics and outcomes between IPN patients with and without EP. However, patients with early-onset EP defined as air bubble signs occurring within 2 weeks from disease onset were significantly older and have higher prevalence of history of diabetes, and they were also associated with significantly higher mortality (57.1 versus 8.7%, P = 0.015) compared with late-onset patients. CONCLUSIONS: The clinical outcomes of EP might be like those of non-emphysematous infection. However, when EP occurs within 2 weeks from disease onset, it is highly lethal.

Synchronous organ failure and infected pancreatic necrosis define genuine critical acute pancreatitis.

BACKGROUND: Critical acute pancreatitis (CAP) was supposed to be strongly associated with the highest risk of adverse outcomes. However, the definition of CAP needs to be further clarified. METHODS: A prospective database with consecutive patients of infected pancreatic necrosis (IPN) at a tertiary hospital was post-hoc analyzed. Patients were assigned to IPN alone, Metachronous-CAP (MCAP) and Synchronous-CAP group (SCAP) according to presence or absence of organ failure (OF) and the crosstalk between OF and IPN. Clinical interventions and outcomes were compared among groups. RESULTS: A total of 248 IPN patients were enrolled and the overall mortality was 25.8%. Compared with MCAP, SCAP was associated with higher mortality (66.2 versus 10.0%) and morbidity (41.2 versus 18.0%), longer duration of OF (median 35.5 versus 12.0 days), ICU length of stay (LOS) (median 28.0 versus 16.0 days) and hospital LOS (median 67.0 versus 60.0 days) (all P < 0.05). The IPN alone and MCAP had comparable mortality (10.8 versus 10.0%), morbidity and hospital LOS, except that MCAP patients were characterized with longer duration of OF and ICU LOS (P < 0.05). CONCLUSIONS: SCAP, characterized with synchronous persistent OF and IPN, was associated with higher mortality and morbidity and should be defined as genuine CAP.

Multiple organ failure might be an indication for prophylactic antifungal therapy in acute pancreatitis.

PURPOSE: Significant conflicts regarding prophylactic antifungal treatment in acute pancreatitis (AP) exist among current literatures and guidelines. The key to resolving this controversial issue is to identify risk factors for intra-abdominal fungal infection (AFI) among patients with AP. METHODS: A single-center, retrospective cohort of 826 patients with AP between January 2014 to December 2019 was analysed to study the risk factors of AFI. RESULTS: Of the 826 patients with AP, 10 patients (1.2%) developed AFI, including 2 cases in moderately severe AP (MSAP) and 8 in severe AP (SAP). The incidence of AFI was significantly higher in patients with SAP compared with MSAP and mild AP (10.3 vs. 0.8% vs. 0, P < 0.001). SAP patients with AFI were more likely to have multiple organ failure (MOF) (OR = 13.4; 95% CI 1.6-115.5), organ failure lasting more than 1 week (OR = 5.1; 95% CI 1.0-27.0), and surgical intervention within first week of admission (OR = 7.4; 95% CI 1.0-53.6). Multivariable analysis identified MOF (OR = 14.3; 95% CI 1.2-173.8) as the only independent risk factor of AFI. CONCLUSION: MOF might be the indication of prophylactic antifungal therapy in patients with AP.

Candidemia indicates poor outcome in patients with infected pancreatic necrosis.

BACKGROUND: Intra-abdominal fungal infection (AFI) and candidemia are common in patients with acute pancreatitis (AP), but with limited and conflicting reports on their clinical impacts. This study aims to evaluate the clinical impacts of AFI and candidemia in infected pancreatic necrosis (IPN). METHODS: A single-centre, prospective cohort including 235 consecutive patients with IPN between January 2010 and September 2020 was analysed to study the clinical impacts of AFI and candidemia. RESULTS: Of the 235 patients with IPN, 69 patients (29.4%) developed AFI and 13 patients (5.5%) developed candidemia. AFI was associated with higher intestinal leakage rate (27.5% vs 12.7%, P = .006), higher pancreatic fistula rate (53.6% vs 34.3%, P = .006) and longer hospital stays (72 vs 58 days, P = .003), but with similar mortality rate compared with patients without AFI (23.2% vs 24.7%, P = .806). However, candidemia was associated with significantly higher mortality rate compared with patients without candidemia (69.2% vs 21.6%, P < .001). Patients with candidemia had higher rate of multiple organ failure and AFI (69.2% vs 36.5%, P = .018; 69.2% vs 27.0%, P = .001, respectively). Multivariable analysis showed that age ≥ 50 years (OR = 2.8; 95% CI, 1.3-5.8; P = .007), severe category (OR = 11.2; 95% CI, 3.5-35.7; P < .001), multidrug-resistant organisms infection (OR = 2.5; 95% CI, 1.0-6.2; P = .039), candidemia (OR = 11.8; 95% CI, 2.5-56.5; P = .002), step-down surgical approach (OR = 3.2; 95% CI, 1.5-7.0; P = .004) were the independent predictors associated with higher mortality in IPN patients. CONCLUSION: Although AFI did not increase the mortality of IPN, patients with candidemia carried significantly higher mortality.

Classification of emphysematous pancreatitis and its relation to prognosis. / æ°”è‚¿åž‹èƒ°è ºç‚Žçš„åˆ†ç±»åŠå ¶ä¸Žé¢„åŽçš„å ³ç³».

OBJECTIVES: Emphysematous pancreatitis (EP) is a subtype of infectious pancreatic necrosis (IPN). It is characterized by the accumulation of gas inside or around the pancreatic necrotic tissue. This study aims to investigate the relation between classification and prognosis of EP, and to provide guidance for clinical diagnosis and treatment of IPN. METHODS: A prospective cohort of 228 cases of IPN from January 2010 to June 2020 in the Department of General Surgery of Xiangya Hospital, Central South University were analyzed. Among them, 120 cases without peritoneal/retroperitoneal surgical intervention before admission were included. The 120 cases of IPN were classified into the EP group and the non-EP group. The general clinical information and results of pathogenic microorganism between the EP and the non-EP group were compared. EP patients were divided into early-EP (within 2 weeks of onset) and late-EP (after 2 weeks of onset) according to the presence timing of air bubble sign, and they were divided into extensive-EP and common-EP according to the distribution characteristics of bubble sign. The clinical characteristics between the survivors and non-survivors of both IPN and EP were compared. RESULTS: Among the 120 IPN patients, 25 (20.8%) were EP patients and 95 (79.2%) were non-EP patients. According to the classifications, 8 were early-EP (32.0%) and 17 were late-EP (68.0%); 15 were common-EP (60.0%) and 10 were extensive-EP (40.0%). There was no significant difference in gender, age, etiology, and mortality between the EP group and the non-EP group (all P>0.05). The percentage of Escherichia coli infection in the EP group was significantly higher than that in non-EP group (52.0% vs 16.5%, P<0.05). Among the 120 IPN patients, 35 died (IPN non-survivors) and 85 patients survived (IPN survivors). The mortality rate of IPN was 29.2%. There was no significant difference in gender, age, and etiology between the IPN non-survivors and the IPN survivors (all P>0.05). The proportion of severe patients in IPN non-survivors was significantly higher than that in the IPN survivors (97.1% vs 54.1%, P<0.05). Among the 25 cases of EP, 8 died (EP non-survivors) and 17 survived (EP survivors). The mortality rate of EP was 32.0%. There was no significant difference in gender, age, etiology, and time from gas detected to surgical intervention between the EP non-survivors and the EP survivors (all P>0.05). The proportion of early-EP and extensive-EP in the EP non-survivors was significantly higher than that in the EP survivors (both P<0.05). The mortality was up to 100% in the early- and extensive-EP patients. All of the EP non-survivors were severe patients, while 58.8% of the EP survivors were moderate or severe patients, the difference was statistically significant (P<0.05). All of the EP survivors underwent step-up surgical treatment strategy. CONCLUSIONS: Air bubble sign is not associated with the prognosis of IPN. Early- and extensive-EP often indicate worse prognosis. Aggressive surgical intervention based on step-up approach should be considered with priority.

Adverse clinical outcomes associated with multidrug-resistant organisms in patients with infected pancreatic necrosis.

BACKGROUND: Multidrug-resistant organisms (MDROs) is becoming a serious worldwide threat to public health. However, the impact of MDROs on the outcomes of the patients with infected pancreatic necrosis (IPN) remains unclear. This study aims to evaluate the roles of MDROs in IPN. METHODS: A prospectively maintained database of 188 patients with IPN between January 2010 and May 2019 was analyzed. The microbiology profile of organisms isolated from wall-off necrosis (WON) was specifically investigated to correlate with the outcomes of the patients. RESULTS: Of the 188 patients with IPN, 108 patients (57.4%) had MDROs detected in aspirates from WON. Carbapenem-resistant Klebsiella pneumoniae (CRKP) accounted for 43.5% of the MDROs isolated (60/138), followed by Carbapenem-resistant Acinetobacter baumanii (CRAB) (34.8%, 48/138) and Escherichia coli producing an extended-spectrum beta-lactamase (ESBLp) (6.5%, 9/138). MDROs infection was associated with higher mortality (35.2% vs 11.3%, P < 0.001), higher rate of hemorrhage (36.1% vs 11.3%, P < 0.001), longer intensive care unit (ICU) stay (23 vs 12 days, P < 0.001), longer hospital stay (68 vs 51 days, P = 0.001) and more hospitalization expenses (45,190 ±â€¯31,680 vs 26,965 ±â€¯17,167 $, P < 0.001). Multivariate analysis of predictors of mortality indicated that MDROs infection (OR = 2.6; 95% confidence interval [CI], 1.0-6.5; P = 0.042), age ≥ 50 years (OR = 2.6; 95% CI, 1.2-5.8; P = 0.016), severe category (OR = 2.9; 95% CI, 1.1-8.0; P = 0.035), bloodstream infection (OR = 3.4; 95% CI, 1.5-7.6; P = 0.049), step-down surgical approach (OR = 2.7; 95% CI, 1.1-6.2; P = 0.023) were significant factors. CONCLUSIONS: MDROs infection was prevalent among patients with IPN and associated with adverse clinical outcomes and increased mortality.

Outcomes of infected pancreatic necrosis complicated with duodenal fistula in the era of minimally invasive techniques.

Background: Duodenal fistula (DF) was reportedly thought to be the second most common type of gastrointestinal fistula secondary to acute necrotizing pancreatitis. However, infected pancreatic necrosis (IPN) associated DF (IPN-DF) was rarely specifically reported in the literature. The outcome of IPN-DF was also less well recognized, especially in the era of minimally invasive techniques. A retrospective cohort study was designed mainly focused on the management and outcomes of IPN-DF in the era of minimally invasive techniques. Methods: One hundred and twenty-one consecutive patients diagnosed with IPN between January 2015 and May 2018 were enrolled retrospectively. Among them, 10 patients developed DF. The step-up minimal invasive techniques were highlighted and outcomes were analyzed. Results: Compared with patients without IPN-DF, patients with IPN-DF had longer hospital stay (95.8 vs. 63.5 days, p < .01), but similar mortality rates (10% vs. 21.6%, p > .05). The median interval between the onset of acute pancreatitis (AP) and detection of DF was 2.4 months (1-4 months). The median duration of DF was 1.5 months (0.5-3 months). Out of the 10 patients with DF, 9 had their fistulas resolve spontaneously over time by means of controlling the source of infection with the use of minimally invasive techniques and providing enteral nutritional support, while one patient died of uncontrolled sepsis. No open surgery was performed. On follow-up, the 9 patients recovered completely and remained free of infection and leakage. Conclusion: IPN-DF could be managed successfully using minimally invasive techniques in specialized acute pancreatitis (AP) center. Patients with IPN-DF suffered from a longer hospital stay, but similar mortality rate compared with patients without DF.

Prognostic factors of critical acute pancreatitis: A prospective cohort study.

BACKGROUND: Patients with critical acute pancreatitis (CAP) have the highest risk of mortality. However, there have been no studies specifically designed to evaluate the prognostic factors of CAP. AIMS & METHODS: This was a prospective observational cohort study involving patients with CAP. Three aspects including organ failure, (peri)pancreatic necrotic fluid cultures and surgical interventions were analyzed specifically to identify prognostic factors. RESULTS: Of the 102 consecutive patients with CAP, 83 patients (81.4%) received step-up surgical treatment, the mortality of the step-up group was 25.3% (21/83). 19 patients (18.6%) underwent step-down surgical treatment, the mortality of the step-down group was 57.9% (11/19). Overall mortality in the whole cohort was 31.4% (32/102). Multivariate analysis of death predictors indicated that multiple organ failure (MOF) (OR = 5.3; 95% CI, 1.5-18.2; p = 0.008), long duration (≥5 days) of organ failure (OR = 6.4; 95% CI, 1.2-54.3; p = 0.029), multidrug-resistant organisms (MDROs) infection (OR = 4.6; 95% CI, 1.3-15.8; p = 0.013), OPN (OR = 3.7; 95% CI, 1.5-8.8; p = 0.004) and step-down surgical treatment (OR = 3.5; 95% CI, 1.2-10.1; p = 0.019) were significant factors. CONCLUSION: Among patients with CAP, MOF, long duration (≥5 days) of organ failure, MDROs infection, OPN and step-down surgical treatment were identified as the predictors of mortality.

[Operative strategy and short-term efficacy of recurrent groin hernia].

OBJECTIVE: To explore the appropriate operative strategy in recurrent groin hernia repair. METHODS: Clinical and follow-up data of 82 patients with recurrent groin hernia undergoing operation at Department of Pancreatobiliary Surgery, Xiangya Hospital of Central South University from April 2010 to April 2017 were analyzed retrospectively. The operative approaches included laparoscopic transabdominal preperitoneal (TAPP) hernia repair, Lichtenstein repair and hybrid repair. Surgical method selection was based on the basis of European Hernia Society guidelines, combined with hernia histories, preoperative examination results and intra-operative results: (1) When an anterior approach (Lichtenstein, Bassini or Shouldice surgery) was adopted in the previous operation, TAPP was preferred for the recurrent groin hernia. (2) When the previous operation was an posterior approach [TAPP or total extraperitoneal hernioplasty (TEP)], Lichtenstein method was preferred. Moreover, Lichtenstein surgery with local anesthesia or nerve block was also selected when the patient could not tolerate general anesthesia. (3) When extensive preperitoneal adhesions were found in patients with previous anterior approach repair during laparoscopic exploration, especially in patients who had relapsed after multiple operations or had previous biochemical glues injection, hybrid surgery was preferred. RESULTS: All 82 patients completed operations smoothly. TAPP, Lichtenstein and hybrid operation were applied in 74, 4 and 4 patients, respectively, with median operative time of 70 minutes (40-130 minutes) in TAPP, 60 minutes (40-90 minutes) in Lichtenstein and 120 minutes (70-150 minutes) in hybrid operation, respectively. The median numerical rating scales (NRS) score was 2 (0-6) on postoperative day 1. The incidences of postoperative seroma, pain and urinary retention were 4.9% (4/82), 2.4% (2/82) and 1.2% (1/82) respectively. The median postoperative hospital stay was 2 days (1-6 days). Seventy-two patients were followed-up from 11 to 87 months. The median follow-up period was 27 months. The median inguinal pain questionnaire (IPQ) score was 2 (0-8) month after operation. One recurrent case was reported 1 year after operation. No incision or mesh infection and long-term inguinal chronic pain were observed. CONCLUSIONS: For recurrent patients with previous open anterior approach, TEP and TAPP repair are equivalent surgical techniques, and the choice should be tailored to the surgeon's expertise. For those with previous TAPP or TEP repair, Lichtenstein technique is recommended. For those with adhesions both in anterior transverse fascia and pre-peritoneum, hybrid operation may be the preferable choice according to adhesion conditions.