Evolution of AP into necrotizing pancreatitis has an increased rate of mortality, reaching 35% in some cases of series (19). Effectiveness in the treatment of peripancreatic collections associated with necrotic tissue are well described in the literature; in previous years, open necrosectomy was considered the gold standard in the management of this complication (19), however, minimally invasive approach was explored to avoid surgery, and prevent surgical morbidity (19). PANTER trial (19,20), demonstrate the numerous benefits of an “step - up” approach over open surgery; with lesser proportion of complications, and reduced time of recovery, and less rate of mortality in cases of percutaneous drainage (19,20); also, PENGUIN trial, shows benefit of endoscopic approach over surgery in the same postoperative outcomes (21). Surgical approach shows an increased rate of mortality, reaching almost 42% in some series reported (19). For that reason, the step-up approach in general surgery departments should be standardized to reduce mortality rates and prevent chronic morbidity.
Success rate of percutaneous drainage is in a range of 0-78% in some series of cases (22), and it is referred to most of the times in terms of avoiding surgical procedures or mortality rates (22). Freeny et al (23), was the first author to describe the effectiveness of percutaneous drainage and shows a success rate of 47% in well selected cases and be able to decrease the multi-organ failure (23). However, success rate is related to a multidisciplinary approach, gathering interventionist radiologists, gastroenterologists, general surgeons, pancreatic surgeons, and intensive care units’ members. Sharma et al (22), report a high rate of success in CT guided percutaneous drainage, with 85,7%, avoiding surgical approach in 75% of the cases. As well, Wronski et al (24), shows a 33% of success rate in ultrasound guided percutaneous drainage, and could be used as a definitive approach to avoid surgery and reach complete resolution of the complication (24). These results are comparable with ours, with a success rate of 94.4% of the cases, with no complications after 30 days of follow up.
Tomographic guide it’s the most frequent one used; only 4 authors described their experience using ultrasound guide in peripancreatic drainage (24); in our population no differences between the radiologic approach, however, it's important to declare that in cases of increased technical difficulty CT guide was preferred over ultrasound, depending on the radiologist experience.
Is well known that infected peripancreatic collections are related with bacterial infection (22), in the majority of the cases, E.Coli and and E. Faecioum were the most frequent bacteria isolated (22). In our population, no gram-positive bacteria were obtained, and E. Coli remains to be the most persistent bacteria isolated; however, fungi is a microbiological concern that needs to be in our minds in critically ill patients as we can see in our population with 11.1% of the cases.
The use of more than one catheter, it's related to increased success rates in patients with large collections with infected necrosis, lavage of the cavity could be related with better outcomes because, the use of saline solution could reduce the rate of debris and necrotic tissue that is susceptible of infection (22-24).
Some literature reports the trans gastric percutaneous approach in the drainage of pancreatic pseudocyst and collections (25-27), however, with the adveniment of endoscopic procedures, these interventions are abandoned, and replaced with endoscopic ultrasound guided drainage or cystogastrostomy. Nevertheless, in some low-income countries, interventionist endoscopy is not available, and expertise in interventionist radiologists have an increased importance in the management of these conditions.
In our population, trans-gastric approach shows comparable results with trans-abdominal approach, with increased rate of success, and achieves a 100% rate of avoiding surgical procedures, with no complications after 30 days of follow up. To the best of our knowledge, our study is the first one to describe the transgastric approach in the management of percutaneous infected necrosis, with an increased rate of success, comparable with endoscopic approach.
Limitations of our study, includes the retrospective nature, and the limited number of cases (related with the proportion of patients that develop infected pancreatic necrosis), as well, in our center the non-availability of ultrasound-endoscopic guide to perform endoscopic procedures could limit the comparison of the approach.