Hôpitaux Universitaires de Strasbourg, Nouvel Hôpital Civil, Pôle hépato-digestif, Service d’hépato-gastroentérologie, 1 place de l’hôpital, 67000 Strasbourg
IHU Strasbourg, Pôle Hépato-digestif, Strasbourg
Université de Strasbourg, Faculté de médecine de Strasbourg, Institut de recherche sur les maladies virales et hépatiques, Inserm U1110, LabEx HepSYS, Strasbourg
Infected walled off necrosis (WON) is a major complication of acute pancreatitis. It is associated with a mortality that can rise up to 20 to 30%. Its treatment is based on a multidisciplinary approach and requires antibiotics associated with drainage, which has to be as less invasive as possible.
Studies have been carried out to identify the main bacterias responsible for those infections and guide the antibiotherapy. The most recent series have shown less infections due do gram-negative bacilli. It has also shown an increased prevalence of gram-positive infections, the emergence of multidrug resistant bacteria, and an increase in fungal infections (Candida spp.). The overuse of antibiotics for non-infected WON might be in cause in these changes. Antibiotics should be adapted to microbiological samples taken from collections as much as possible.
The occurrence of WON infection is a formal indication for drainage. Therapeutic echo-endoscopy occupies a central place in the “step-up” approach, which favours the use of the least invasive techniques first. Indeed, endoscopic necrosectomy is associated with lower morbidity than surgery. The recently development luminal apposition metal stent can ease the drainage procedure, with a higher rate of technical and clinical success. Multidisciplinary management of WON infection is therefore the cornerstone of the management of this serious and sometimes fatal condition. Antibiotic therapy should be initiated when there is strong evidence of necrotic flow infection to avoid selecting bacteria with a high level of resistance and fungal superinfections.