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Carr-Locke DL. ERCP: a very personal history. Clin Liver Dis (Hoboken) 2023; 22:211-218. [PMID: 38143813 PMCID: PMC10745235 DOI: 10.1097/cld.0000000000000028] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/15/2022] [Accepted: 01/23/2023] [Indexed: 12/26/2023] Open
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Bruno MJ. Endoscopy in Gallstone Pancreatitis. Gastrointest Endosc Clin N Am 2023; 33:701-707. [PMID: 37709405 DOI: 10.1016/j.giec.2023.04.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 09/16/2023]
Abstract
The root cause for biliary pancreatitis is a transient impediment of the outflow of secretion from the pancreatic duct due to gallstones and sludge obstructing the ampulla of Vater. Based on meta-analyses and recent studies, clear recommendations can be formulated when and when not to perform an ERC in patients with biliary pancreatitis. ERC is indicated urgently in patients with biliary pancreatitis and concomitant cholangitis. Urgent ERC is not indicated in patients with predicted mild or severe biliary pancreatitis without cholangitis, even when stones or sludge are proven on EUS imaging.
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Affiliation(s)
- Marco J Bruno
- Department of Gastroenterology & Hepatology, Erasmus University Medical Center, Doctor Molewaterplein 40, Rotterdam 3015 GD, the Netherlands.
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Manrai M, Dawra S, Singh AK, Jha DK, Kochhar R. Controversies in the management of acute pancreatitis: An update. World J Clin Cases 2023; 11:2582-2603. [PMID: 37214572 PMCID: PMC10198120 DOI: 10.12998/wjcc.v11.i12.2582] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/27/2022] [Revised: 01/22/2023] [Accepted: 03/29/2023] [Indexed: 04/25/2023] Open
Abstract
This review summarized the current controversies in the management of acute pancreatitis (AP). The controversies in management range from issues involving fluid resuscitation, nutrition, the role of antibiotics and antifungals, which analgesic to use, role of anticoagulation and intervention for complications in AP. The interventions vary from percutaneous drainage, endoscopy or surgery. Active research and emerging data are helping to formulate better guidelines. The available evidence favors crystalloids, although the choice and type of fluid resuscitation is an area of dynamic research. The nutrition aspect does not have controversy as of now as early enteral feeding is preferred most often than not. The empirical use of antibiotics and antifungals are gray zones, and more data is needed for conclusive guidelines. The choice of analgesic is being studied, and the recommendations are still evolving. The position of using anticoagulation is still awaiting consensus. The role of intervention is well established, although the modality is constantly changing and favoring endoscopy or percutaneous drainage rather than surgery. It is evident that more multicenter randomized controlled trials are required for establishing the standard of care in these crucial management issues of AP to improve the morbidity and mortality worldwide.
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Affiliation(s)
- Manish Manrai
- Department of Internal Medicine, Armed Forces Medical College, Pune 411040, India
| | - Saurabh Dawra
- Department of Medicine and Gastroenterology, Command Hospital, Pune 411040, India
| | - Anupam K Singh
- Department of Gastroenterology, Post Graduate Institute of Medical Education and Research, Chandigarh 160012, India
| | - Daya Krishna Jha
- Department of Gastroenterology, Army Hospital (Research and Referral), New Delhi 11010, India
| | - Rakesh Kochhar
- Department of Gastroenterology, Post Graduate Institute of Medical Education and Research, Chandigarh 160012, India
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Mukai S, Itoi T, Tsuchiya T, Ishii K, Tanaka R, Tonozuka R, Sofuni A. Urgent and emergency endoscopic retrograde cholangiopancreatography for gallstone-induced acute cholangitis and pancreatitis. Dig Endosc 2023; 35:47-57. [PMID: 35702927 DOI: 10.1111/den.14379] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/01/2022] [Accepted: 06/13/2022] [Indexed: 01/17/2023]
Abstract
Urgent or emergency endoscopic retrograde cholangiopancreatography (ERCP) is indicated for gallstone-induced acute cholangitis and pancreatitis. The technique and optimal timing of ERCP depend on the disease state, its severity, anatomy, patient background, and the institutional situation. Endoscopic transpapillary biliary drainage within 24 h is recommended for moderate to severe acute cholangitis. The clinical outcomes of biliary drainage with nasobiliary drainage tube placement and plastic stent placement are comparable, and the choice is made on a case-by-case basis considering the advantages and disadvantages of each. The addition of endoscopic sphincterotomy (EST) is basically not necessary when performing drainage alone, but single-session stone removal following EST is acceptable in mild to moderate cholangitis cases without antithrombotic therapy or coagulopathy. For gallstone pancreatitis, early ERCP/EST are recommended in cases with impacted gallstones in the papilla. In some cases of gallstone pancreatitis, a gallstone impacted in the papilla has already spontaneously passed into the duodenum, and early ERCP/EST lacks efficacy in such cases, with unfavorable findings of cholangitis or cholestasis. If it is difficult to diagnose the presence of gallstones impacted in the papilla on imaging, endoscopic ultrasonography can be useful in determining the indication for ERCP.
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Affiliation(s)
- Shuntaro Mukai
- Department of Gastroenterology and Hepatology, Tokyo Medical University, Tokyo, Japan
| | - Takao Itoi
- Department of Gastroenterology and Hepatology, Tokyo Medical University, Tokyo, Japan
| | - Takayoshi Tsuchiya
- Department of Gastroenterology and Hepatology, Tokyo Medical University, Tokyo, Japan
| | - Kentaro Ishii
- Department of Gastroenterology and Hepatology, Tokyo Medical University, Tokyo, Japan
| | - Reina Tanaka
- Department of Gastroenterology and Hepatology, Tokyo Medical University, Tokyo, Japan
| | - Ryosuke Tonozuka
- Department of Gastroenterology and Hepatology, Tokyo Medical University, Tokyo, Japan
| | - Atsushi Sofuni
- Department of Gastroenterology and Hepatology, Tokyo Medical University, Tokyo, Japan
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Xu X, Guan L, Wu Y, Ke H, Zhao Y, Liu P. One hundred most cited articles related to Endoscopic retrograde cholangiopancreatography: A bibliometric analysis. Front Surg 2022; 9:1005771. [PMID: 36439532 PMCID: PMC9681810 DOI: 10.3389/fsurg.2022.1005771] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/28/2022] [Accepted: 10/20/2022] [Indexed: 11/11/2022] Open
Abstract
Background Endoscopic retrograde cholangiopancreatography (ERCP) has developed over the past few decades into a reliable technology for diagnostic and therapeutic purposes. Through a bibliometric analysis, this research attempted to evaluate the characteristics of the top 100 articles on ERCP that had the most citations. Methods We extracted pertinent publications from the Web of Science Core Collection (WoSCC) on July 9, 2022. The top 100 ERCP articles with the most citations were identified and analyzed. The following data were extracted: publication year, country/region, organization, total citation times, annual citation times, research type and research field, etc. To implement the network’s visual analysis, a bibliographic coupling network based on keywords was built using the VOSviewer 1.6.17 program. Results The journal with the most publications were GASTROINTESTINAL ENDOSCOPY, with 45 articles. Most of the top 100 articles came from the United States (n = 47) and Italy (n = 14). Indiana University and the University of Amsterdam were among the most important institutions in ERCP research. ML Freeman of the University of Minnesota contributed the highest number (n = 9) and the most highly cited paper. The age of the paper and article type is closely related to citation frequency. Of the 100 most-cited articles, clinical application in the field of ERCP has focused on three aspects: diagnosis, treatment, and complications. Clinical use of ERCP has shifted from diagnosis to treatment. Post-ERCP pancreatitis is the focus of attention, and the clinical application of technically complex therapeutic ERCP is the future development trend. Conclusion This study lists the most influential articles in ERCP by exposing the current state of the field, and showing the evolution of research trends to provide perspective for the future development of ERCP.
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Affiliation(s)
- Xuan Xu
- Department of Gastroenterology, The First Affiliated Hospital of Nanchang University, Nanchang, China
- First Clinical Medical College, Nanchang University, Nanchang, China
| | - Lulu Guan
- First Clinical Medical College, Nanchang University, Nanchang, China
| | - Yao Wu
- Department of Gastroenterology, The First Affiliated Hospital of Nanchang University, Nanchang, China
| | - Huajing Ke
- Department of Gastroenterology, The First Affiliated Hospital of Nanchang University, Nanchang, China
| | - Yuanbin Zhao
- Second Clinical Medical College, Nanchang University, Nanchang, China
| | - Pi Liu
- Department of Gastroenterology, The First Affiliated Hospital of Nanchang University, Nanchang, China
- Department of Gastroenterology, The People’s Hospital of Longhua, Shenzhen, China
- Correspondence: Pi Liu
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Takada T, Isaji S, Mayumi T, Yoshida M, Takeyama Y, Itoi T, Sano K, Iizawa Y, Masamune A, Hirota M, Okamoto K, Inoue D, Kitamura N, Mori Y, Mukai S, Kiriyama S, Shirai K, Tsuchiya A, Higuchi R, Hirashita T. JPN clinical practice guidelines 2021 with easy-to-understand explanations for the management of acute pancreatitis. JOURNAL OF HEPATO-BILIARY-PANCREATIC SCIENCES 2022; 29:1057-1083. [PMID: 35388634 DOI: 10.1002/jhbp.1146] [Citation(s) in RCA: 19] [Impact Index Per Article: 9.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/23/2021] [Revised: 02/02/2022] [Accepted: 02/08/2022] [Indexed: 11/09/2022]
Abstract
BACKGROUND In preparing the Japanese (JPN) guidelines for the management of acute pancreatitis 2021, the committee focused the issues raised by the results of nationwide epidemiological survey in 2016 in Japan METHOD: In addition to a systematic search using the previous JPN guidelines, papers published from January 2014 to September 2019 were searched for the contents to be covered by the guidelines based on the concept of GRADE system. RESULTS Thirty-six clinical questions (CQ) were prepared in 15 subject areas. Base on the facts that patients diagnosed with severe disease by both Japanese prognostic factor score and contrast-enhanced CT grade had a high fatality rate and that little prognosis improvement after 2 weeks of disease onset was not obtained, we emphasized the importance of Pancreatitis Bundles, which was shown to be effective in improving prognosis, and the CQ sections for local pancreatic complications had been expanded to ensure adoption of a step-up approach. Furthermore, on the facts that enteral nutrition for severe acute pancreatitis was not started early within 48 hours of admission and that unnecessary prophylactic antibiotics was used in almost all cases, we emphasized early enteral nutrition in small amounts even if gastric feeding is used and no prophylactic antibiotics in mild pancreatitis. CONCLUSION All the members of the committee have put a lot of effort into preparing the extensively revised guidelines in the hope that more people will have a common understanding and that better medical care will be spread.
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Affiliation(s)
- Tadahiro Takada
- Department of Surgery, Teikyo University School of Medicine, Tokyo, Japan
| | - Shuji Isaji
- Department of Hepato-Biliary-Pancreatic and Transplant Surgery, Mie University Graduate School of Medicine, Mie, Japan
| | - Toshihiko Mayumi
- Department of Emergency Medicine, School of Medicine, University of Occupational and Environmental Health, Fukuoka, Japan
| | - Masahiro Yoshida
- Department of Hepato-Biliary-Pancreatic and Gastrointestinal Surgery, School of Medicine, International University of Health & Welfare, Chiba, Japan
| | - Yoshifumi Takeyama
- Department of Surgery, Kindai University Faculty of Medicine, Osaka, Japan
| | - Takao Itoi
- Department. of Gastroenterology and Hepatology, Tokyo Medical University, Tokyo, Japan
| | - Keiji Sano
- Department of Surgery, Teikyo University School of Medicine, Tokyo, Japan
| | - Yusuke Iizawa
- Department of Hepato-Biliary-Pancreatic and Transplant Surgery, Mie University Graduate School of Medicine, Mie, Japan
| | - Atsushi Masamune
- Division of Gastroenterology, Tohoku University Graduate School of Medicine, Sendai, Japan
| | - Morihisa Hirota
- Division of Gastroenterology, Tohoku Medical and Pharmaceutical University, Sendai, Japan
| | - Kohji Okamoto
- Department of Surgery, Center for Gastroenterology and Liver Disease, Kitakyushu City Yahata Hospital, Fukuoka, Japan
| | - Dai Inoue
- Department of Radiology, Kanazawa University Hospital, Ishikawa, Japan
| | - Nobuya Kitamura
- Department of Emergency and Critical Care Medicine, Kimitsu Chuo Hospital, Chiba, Japan
| | - Yasuhisa Mori
- Department of Surgery I, School of Medicine, University of Occupational and Environmental Health, Fukuoka, Japan
| | - Shuntaro Mukai
- Department. of Gastroenterology and Hepatology, Tokyo Medical University, Tokyo, Japan
| | - Seiki Kiriyama
- Department of Gastroenterology, Ogaki Municipal Hospital, Gifu, Japan
| | - Kunihiro Shirai
- Department of Emergency, Disaster and Critical Care Medicine, Hyogo College of Medicine, Hyogo, Japan
| | - Asuka Tsuchiya
- Department of Emergency and Critical Care Medicine, Tokai University School of Medicine, Kanagawa, Japan
| | - Ryota Higuchi
- Department of Surgery, Institute of Gastroenterology, Tokyo Women's Medical University, Tokyo, Japan
| | - Teijiro Hirashita
- Department of Gastroenterological and Pediatric Surgery, Oita University Faculty of Medicine, Oita, Japan
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Shrestha DB, Budhathoki P, Sedhai YR, Adhikari A, Poudel A, Aryal BB, Gurung TM, Karki B, Karki BRR, Patel D. Urgent Endoscopic Retrograde Cholangiopancreatography (ERCP) vs. Conventional Approach in Acute Biliary Pancreatitis Without Cholangitis: An Updated Systematic Review and Meta-Analysis. Cureus 2022; 14:e21342. [PMID: 35198265 PMCID: PMC8852244 DOI: 10.7759/cureus.21342] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 01/15/2022] [Indexed: 12/13/2022] Open
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Ashraf H, Colombo JP, Marcucci V, Rhoton J, Olowoyo O. A Clinical Overview of Acute and Chronic Pancreatitis: The Medical and Surgical Management. Cureus 2021; 13:e19764. [PMID: 34938639 PMCID: PMC8684888 DOI: 10.7759/cureus.19764] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 11/20/2021] [Indexed: 11/05/2022] Open
Abstract
An inflammatory process involving the pancreas, known as pancreatitis, can be categorized as either acute or chronic and may present in one of many ways. The clinical manifestations of acute pancreatitis are generally limited to epigastric or right upper quadrant pain, while manifestations of chronic pancreatitis are broader and may include abdominal pain in tandem with signs and symptoms of pancreatic endocrine and exocrine insufficiency. An understanding of the initial insult, proper classification, and prognosis are all factors that are of paramount importance as it pertains to managing patients who are afflicted with this disease. Our review delves into the depths of pancreatitis by exploring the embryology and anatomy of the pancreas, the pathophysiology and etiology of acute and chronic pancreatitis, and the medical and surgical management of acute and chronic pancreatitis.
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Affiliation(s)
- Hamza Ashraf
- Medical Education, St. Peter's University Hospital, New Brunswick, USA
| | - John Paul Colombo
- Medical Research, St. Peter's University Hospital, New Brunswick, USA.,Medical Research, St. George's University School of Medicine, True Blue, GRD
| | | | - Jonathan Rhoton
- Surgery, Hackensack University Medical Center, Hackensack, USA
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Uğurlu ET, Kaya A. Management of our endoscopic retrograde cholangio pancreatography cases during the pandemic process. Int J Clin Pract 2021; 75:e14979. [PMID: 34633735 DOI: 10.1111/ijcp.14979] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/26/2021] [Accepted: 10/05/2021] [Indexed: 11/30/2022] Open
Abstract
AIM Endoscopic retrograde cholangio pancreatography (ERCP) is a technique in which endoscope and radiological imaging are used in combination in the diagnosis and treatment of diseases related to the pancreaticobiliary system. Our aim in this study is to discuss all aspects of approach strategies to ERCP patients whose operation is mandatory during the pandemic period, to draw the future perspective and to summarize the measures that the surgical team should take in terms of their own health and public health. MATERIALS AND METHODS During the pandemic period between 14 March and 31 December 2020, we accepted 270 patients to our ERCP unit. We made our analysis regarding the management of these cases under COVID-19 pandemic conditions. We presented our patients' form of application, application complaints, COVID- 19 contact stories, pre-procedure preparations, and our prevention methods to prevent COVID-19 transmission of the patient and healthcare team during the procedure, and post-procedure patient follow-up methods, and the management of our COVID-19-positive patients before the procedure. FINDINGS ERCP was applied to 270 patients. The COVID-19 test of 13 patients was positive before the procedure and they were taken to our COVID-19 isolated service. There was no problem in the anesthesia of patients who had positive COVID-19 PCR test and subsequently underwent ERCP. There was no difference in the discharge time after the ERCP procedure. CONCLUSION COVID-19 pandemic has significantly affected the management and safety of ERCP units. ERCP procedures should be performed by determining the urgency of patients so that their treatment needs are not delayed. Postponing cases without planning can develop an increased workload in centers offering ERCP, and this situation can lead to further delays or negative consequences.
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Affiliation(s)
- Esat Taylan Uğurlu
- General Surgery Clinic (Sağlık Bakanlığı Mehmet Akif İnan Eğitim Araştırma Hastanesi, Genel Cerrahi Kliniği), Şanlıurfa Mehmet Akif İnan Training and Research Hospital, Şanlıurfa, Turkey
| | - Ahmet Kaya
- Anesthesiology and Reanimation Clinic (Sağlık Bakanlığı Mehmet Akif İnan Eğitim Araştırma Hastanesi, Genel Cerrahi Kliniği), Şanlıurfa Mehmet Akif İnan Training and Research Hospital, Şanlıurfa, Turkey
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Yawar B, Marzouk A, Ali H, Asim A, Ghorab T, Bahli Z, Abousamra M, Fleville S. Acute Pancreatitis During COVID-19 Pandemic: An Overview of Patient Demographics, Disease Severity, Management and Outcomes in an Acute District Hospital in Northern Ireland. Cureus 2021; 13:e18520. [PMID: 34659920 PMCID: PMC8496563 DOI: 10.7759/cureus.18520] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 10/06/2021] [Indexed: 01/08/2023] Open
Abstract
Background Acute pancreatitis (AP) is a common disease requiring admissions under surgical and critical care units. The two most common causes are alcohol and gallstones. Coronavirus disease 2019 (COVID-19) pandemic had a significant impact on service delivery and patient management throughout all surgical specialties. In this study, the primary aim was to ascertain the incidence of COVID-19 in acute pancreatitis patients. Secondary objectives were to study aetiology, demographics, severity, 30-day mortality, outcomes and management of acute pancreatitis patients from 1st March, 2020 till 31st August, 2020. Methods A retrospective observational review of all patients admitted under the General Surgical team was performed. Information regarding demographics, severity of AP (using Glasgow score, Atlanta classification and CT severity index score), ICU admission and organ support, treatment modalities and follow-up data for outcomes was collected based on data collection tool used by COVID-PAN study and results were compared to outcomes results of COVID-PAN study. Results Forty-three (43) patients were admitted with AP. Only one patient (2.3%) was diagnosed with COVID-19 at the time of pancreatitis. Gallstones were noted to be the most common cause of AP in our population. Mortality was 7% (3 patients). Five patients (11%) needed ITU admission due to organ dysfunction. Three patients (7%) developed ARDS. Conclusion The overall incidence of COVID-19 in pancreatitis in our population of the study was low. The incidence of COVID-19 during the first wave in Derry/Londonderry area was low and this may explain why the incidence was low in our study as well. Patients with AP in our target population were mostly elderly, one in five had moderate to severe or severe pancreatitis and in 16.3% the aetiology could not be identified. As observed in other centres globally, urgent cholecystectomy for gallstone pancreatitis faced significant delays with no patients being offered index cholecystectomy and only 4 out of 19 patients having undergone interval cholecystectomy within six months of index admission for gallstone pancreatitis in our centre.
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Affiliation(s)
- Bakhat Yawar
- General Surgery, The Western Trust Health & Social Care Jobs in Northern Ireland (HSCNI) (Altnagelvin Area Hospital), Derry/Londonderry, GBR
| | - Ahmed Marzouk
- General Surgery, The Western Trust Health & Social Care Jobs in Northern Ireland (HSCNI) (Altnagelvin Area Hospital), Derry/Londonderry, GBR
| | - Heba Ali
- Radiology, The Western Trust Health & Social Care Jobs in Northern Ireland (HSCNI) (Altnagelvin Area Hospital), Derry/Londonderry, GBR
| | - Ayeisha Asim
- Geriatrics, The Western Trust Health & Social Care Jobs in Northern Ireland (HSCNI) (Altnagelvin Area Hospital), Derry/Londonderry, GBR
| | - Tamer Ghorab
- General Surgery, The Western Trust Health & Social Care Jobs in Northern Ireland (HSCNI) (Altnagelvin Area Hospital), Derry/Londonderry, GBR
| | - Zahid Bahli
- General Surgery, The Western Trust Health & Social Care Jobs in Northern Ireland (HSCNI) (Altnagelvin Area Hospital), Derry/Londonderry, GBR
| | - Mohammad Abousamra
- General Surgery, The Western Trust Health & Social Care Jobs in Northern Ireland (HSCNI) (Altnagelvin Area Hospital), Derry/Londonderry, GBR
| | - Samara Fleville
- General Surgery, The Western Trust Health & Social Care Jobs in Northern Ireland (HSCNI) (Altnagelvin Area Hospital), Derry/Londonderry, GBR
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Birda CL, Sharma V. Urgent endoscopic retrograde cholangiopancreatography for acute biliary pancreatitis: Few answers and more questions. THE NATIONAL MEDICAL JOURNAL OF INDIA 2021; 34:223-225. [PMID: 35112548 DOI: 10.25259/nmji_726_20] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Affiliation(s)
- Chhagan Lal Birda
- Department of Gastroenterology, Postgraduate Institute of Medical Education and Research, Chandigarh, India
| | - Vishal Sharma
- Department of Gastroenterology, Postgraduate Institute of Medical Education and Research, Chandigarh, India
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Novikov AA, Fieber JH, Saumoy M, Rosenblatt R, Mekelburg SAC, Shah SL, Crawford CV. ERCP improves mortality in acute biliary pancreatitis without cholangitis. Endosc Int Open 2021; 9:E927-E933. [PMID: 34079880 PMCID: PMC8159624 DOI: 10.1055/a-1320-0041] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/31/2020] [Accepted: 09/23/2020] [Indexed: 12/17/2022] Open
Abstract
Background and study aims Acute pancreatitis (AP) is an increasingly common indication for hospitalization in the United States. The necessity for endoscopic retrograde cholangiopancreatography (ERCP) and the timing of ERCP in acute gallstone-related pancreatitis without cholangitis (AGPNC) is controversial. The aim of this study was to evaluate the association of ERCP and its performance during admission with mortality and length of stay (LOS) in patients with AGPNC. Patients and methods We queried the Nationwide Inpatient Sample (NIS) from 2004 to 2014 to identify all patients with admissions for gallstone AP. We excluded patients with chronic pancreatitis or concurrent cholangitis, and those who were transferred from elsewhere for treatment. Our primary outcome measure was inpatient mortality. Our secondary outcome measure was hospital length of stay (LOS). Results We identified 491,011 records eligible for analysis. Of the patients, 30.6 % (150,101) had AGPNC. There were 1.34 deaths per 100 admissions in patients with AGPNC. The average LOS was 5.88 (± 6.38) days with a median stay of 4 days (range, 3-7). When adjusted for age, Elixhauser Comorbidity Index, and severe pancreatitis, patients with ERCP during admission were 43 % less likely to die. ERCP performed between Days 3 and 9 of hospitalization resulted in a significant mortality benefit. Among those who had ERCP, a shorter wait time for ERCP was associated with a shorter LOS after adjustment for demographics and severity of illness. Conclusion ERCP performed during inpatient admission for AGPNC was associated with decreased mortality. These data support early ERCP in patients with acute gallstone pancreatitis without cholangitis.
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Affiliation(s)
- Aleksey A. Novikov
- Department of Gastroenterology, Doylestown Hospital, Doylestown, Pennsylvania, United States
| | - Jennifer H. Fieber
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Department of Surgery, Hospital of the University of Pennsylvania,
Philadelphia, Pennsylvania, United States
| | - Monica Saumoy
- Division of Gastroenterology and Hepatology, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania, United States
| | - Russell Rosenblatt
- Division of Gastroenterology and Hepatology, Weill Cornell Medical College, New York, New York, United States
| | | | - Shawn L. Shah
- Division of Gastroenterology and Hepatology, Weill Cornell Medical College, New York, New York, United States
| | - Carl V. Crawford
- Division of Gastroenterology and Hepatology, Weill Cornell Medical College, New York, New York, United States
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13
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Kabaria S, Mutneja H, Makar M, Ahlawat S, Patel AV, Rustgi VK, Bhurwal A. Timing of endoscopic retrograde cholangiopancreatography in acute biliary pancreatitis without cholangitis: a nationwide inpatient cohort study. Ann Gastroenterol 2021; 34:575-581. [PMID: 34276198 PMCID: PMC8276366 DOI: 10.20524/aog.2021.0615] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/17/2020] [Accepted: 12/06/2020] [Indexed: 01/08/2023] Open
Abstract
Background The timing of endoscopic retrograde cholangiopancreatography (ERCP) in patients with acute biliary pancreatitis without cholangitis is unclear. We accessed a national database to analyze the outcomes of urgent (<24 h) and early (24-72 h) ERCP in this cohort. Methods The cohort was extracted from the Nationwide Inpatient Sample database. Hospital ERCP volumes were generated using unique hospital identifiers. Multivariate regression modeling was used to analyze the predictors of urgent vs. early ERCP use, and to determine various outcome variables between the 2 cohorts. Results Overall, 105,433 admissions were evaluated. There was a significant rise in urgent ERCP performed over the study period. Older patients, males, patients with comorbidities, African American and Hispanic patient populations were less likely to receive urgent ERCP. High ERCP volume hospitals, teaching hospitals, and hospitals in the Midwest and West were more likely to perform urgent ERCP. There were no differences in mortality rates or complication rates between the 2 cohorts. However, there were significant differences in length of stay and healthcare cost analysis. Conclusions The increasing use of urgent ERCP did not result in a clinically significant benefit in terms of mortality, length of stay, or healthcare cost analysis. The use of urgent ERCP is also not uniform across various demographic and hospital cohorts. Urgent ERCP may be over-utilized, and it may be reasonable to perform ERCP in this patient population based on the physician’s suspicion about the severity of disease.
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Affiliation(s)
- Savan Kabaria
- Internal Medicine, Robert Wood Johnson Medical School, Rutgers Biomedical and Health Sciences (RBHS), Rutgers University, New Brunswick, NJ (Savan Kabaria, Michael Makar, Sushil)
| | - Hemant Mutneja
- Gastroenterology and Hepatology, John H. Stroger Cook County Hospital, Chicago, Il (Hemant Mutneja)
| | - Michael Makar
- Internal Medicine, Robert Wood Johnson Medical School, Rutgers Biomedical and Health Sciences (RBHS), Rutgers University, New Brunswick, NJ (Savan Kabaria, Michael Makar, Sushil)
| | - Sushil Ahlawat
- Division of Gastroenterology & Hepatology, New Jersey Medical School, Rutgers Biomedical and Health Sciences (RBHS), Rutgers University, Newark, NJ (Sushil Ahlawat)
| | - Anish V Patel
- Division of Gastroenterology and Hepatology, Robert Wood Johnson School of Medicine, Rutgers Biomedical and Health Sciences (RBHS), Rutgers University, New Brunswick, NJ, (Anish V. Patel, Vinod K. Rustgi, Abhishek Bhurwal), USA
| | - Vinod K Rustgi
- Division of Gastroenterology and Hepatology, Robert Wood Johnson School of Medicine, Rutgers Biomedical and Health Sciences (RBHS), Rutgers University, New Brunswick, NJ, (Anish V. Patel, Vinod K. Rustgi, Abhishek Bhurwal), USA
| | - Abhishek Bhurwal
- Division of Gastroenterology and Hepatology, Robert Wood Johnson School of Medicine, Rutgers Biomedical and Health Sciences (RBHS), Rutgers University, New Brunswick, NJ, (Anish V. Patel, Vinod K. Rustgi, Abhishek Bhurwal), USA
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14
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Xu H, Fang W, Liu G, Fan J, Yu J, Zong Y, Jiang C, Shi G, Sun X. Feasibility of microscope-integrated swept-source optical coherence tomography in canaloplasty. ANNALS OF TRANSLATIONAL MEDICINE 2020; 8:1577. [PMID: 33437776 PMCID: PMC7791249 DOI: 10.21037/atm-20-3469] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
Background Several researchers have used commercial microscope-integrated optical coherence tomography (OCT) systems in glaucoma surgery, including ab interno trabeculectomy and canaloplasty. However, the 840 nm wavelength light source of the OCT systems is not ideal for imaging the anterior chamber angle structures because of its limited penetration. We evaluated the potential value of a microscope-integrated swept-source OCT system with a 1,310 nm center-wavelength light in canaloplasty for glaucoma. Methods Sixteen porcine eyes were used to simulate canaloplasty. The critical surgical steps were monitored using a prototype microscope-integrated OCT system with a 1,310 nm light source and a high axial scan rate of 100 kHz. The images from swept-source OCT and three-dimensional images from the microscope were projected simultaneously onto a liquid crystal display three-dimensional monitor (LMD-4251TD, Sony, Japan). The changes in the collector vessel (aqueous drainage structure in the porcine eye, similar to Schlemm’s canal in humans) were measured using Image J software. Histological sections stained with hematoxylin and eosin were used to assess surgical efficacy. Results High-resolution real-time images of the anterior segment were acquired during canaloplasty using the microscope-integrated OCT system. With the real-time OCT images, the position of the collector vessel was identified and the scleral flap could be created at the ideal location. The expansion of the collector vessel after viscoelastic injection was also visualized in real time. Compared with baseline, there was a significant increase in the cross-sectional area (from 14,502.98±9,242.55 to 59,499.04±20,506.41 µm2, P<0.001) of the collector vessel. Conclusions Using the microscope-integrated OCT system, real-time images of the anterior segment were successfully acquired during the operation. The microscope-integrated OCT system might be useful in future anti-glaucoma surgery.
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Affiliation(s)
- Huan Xu
- Department of Ophthalmology and Visual Science, Eye, Ear, Nose and Throat Hospital, Shanghai Medical College of Fudan University, Shanghai, China.,Key NHC Key Laboratory of Myopia (Fudan University), Laboratory of Myopia, Chinese Academy of Medical Sciences, Shanghai, China
| | - Wangyi Fang
- Department of Ophthalmology and Visual Science, Eye, Ear, Nose and Throat Hospital, Shanghai Medical College of Fudan University, Shanghai, China.,Key NHC Key Laboratory of Myopia (Fudan University), Laboratory of Myopia, Chinese Academy of Medical Sciences, Shanghai, China
| | - Guangxing Liu
- Jiangsu Key Laboratory of Medical Optics, Suzhou Institute of Biomedical Engineering and Technology, Chinese Academy of Sciences, Suzhou, China
| | - Jinyu Fan
- Jiangsu Key Laboratory of Medical Optics, Suzhou Institute of Biomedical Engineering and Technology, Chinese Academy of Sciences, Suzhou, China
| | - Jian Yu
- Department of Ophthalmology and Visual Science, Eye, Ear, Nose and Throat Hospital, Shanghai Medical College of Fudan University, Shanghai, China.,Key NHC Key Laboratory of Myopia (Fudan University), Laboratory of Myopia, Chinese Academy of Medical Sciences, Shanghai, China
| | - Yuan Zong
- Department of Ophthalmology and Visual Science, Eye, Ear, Nose and Throat Hospital, Shanghai Medical College of Fudan University, Shanghai, China.,Key NHC Key Laboratory of Myopia (Fudan University), Laboratory of Myopia, Chinese Academy of Medical Sciences, Shanghai, China
| | - Chunhui Jiang
- Department of Ophthalmology and Visual Science, Eye, Ear, Nose and Throat Hospital, Shanghai Medical College of Fudan University, Shanghai, China.,Key NHC Key Laboratory of Myopia (Fudan University), Laboratory of Myopia, Chinese Academy of Medical Sciences, Shanghai, China
| | - Guohua Shi
- Jiangsu Key Laboratory of Medical Optics, Suzhou Institute of Biomedical Engineering and Technology, Chinese Academy of Sciences, Suzhou, China.,CAS Center for Excellence in Brain Science and Intelligence Technology, Shanghai, China
| | - Xinghuai Sun
- Department of Ophthalmology and Visual Science, Eye, Ear, Nose and Throat Hospital, Shanghai Medical College of Fudan University, Shanghai, China.,Key NHC Key Laboratory of Myopia (Fudan University), Laboratory of Myopia, Chinese Academy of Medical Sciences, Shanghai, China
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15
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Heckler M, Hackert T, Hu K, Halloran CM, Büchler MW, Neoptolemos JP. Severe acute pancreatitis: surgical indications and treatment. Langenbecks Arch Surg 2020; 406:521-535. [PMID: 32910276 PMCID: PMC8106572 DOI: 10.1007/s00423-020-01944-6] [Citation(s) in RCA: 31] [Impact Index Per Article: 7.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/11/2020] [Accepted: 07/21/2020] [Indexed: 12/14/2022]
Abstract
Background Acute pancreatitis (AP) is defined as an acute inflammatory attack of the pancreas of sudden onset. Around 25% of patients have either moderately severe or severe disease with a mortality rate of 15–20%. Purpose The aim of this article was to summarize the advances being made in the understanding of this disease and the important role of surgery. Results and conclusions An accurate diagnosis should be made a soon as possible, initiating resuscitation with large volume intravenous fluids and oxygen by mask. Predicted severe disease will require intensive monitoring. Most deaths within the first week are due to multi-organ failure; thus, these patients will require intensive therapy unit management. During the second phase of the disease, death is due to local complications arising from the pancreatic inflammation, requiring accurate identification to determine the correct form of treatment. Acute peripancreatic fluid collections arise < 4 weeks after onset of interstitial edematous pancreatitis, not requiring any treatment. Most pancreatic pseudocysts arise > 4 weeks and largely resolve on conservative management. Necrotizing pancreatitis causing acute necrotic collections and later walled-off necrosis will require treatment if symptomatic or infected. Initial endoscopic transgastric or percutaneous drainage will resolve less serious collections but necrosectomy using minimally invasive approaches will be needed for more serious collections. To prevent recurrent attacks of AP, causative factors need to be removed where possible such as cholecystectomy and cessation of alcohol. Future progress requires improved management of multi-organ failure and more effective minimally invasive techniques for the removal of necrosis.
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Affiliation(s)
- Max Heckler
- Department of General, Visceral and Transplantation Surgery, University of Heidelberg, Im Neuenheimer Feld 110, 69120, Heidelberg, Baden-Württemberg, Germany
| | - Thilo Hackert
- Department of General, Visceral and Transplantation Surgery, University of Heidelberg, Im Neuenheimer Feld 110, 69120, Heidelberg, Baden-Württemberg, Germany
| | - Kai Hu
- Department of General, Visceral and Transplantation Surgery, University of Heidelberg, Im Neuenheimer Feld 110, 69120, Heidelberg, Baden-Württemberg, Germany
| | - Cristopher M Halloran
- Department of Molecular and Clinical Cancer Medicine, University of Liverpool, Liverpool, UK
| | - Markus W Büchler
- Department of General, Visceral and Transplantation Surgery, University of Heidelberg, Im Neuenheimer Feld 110, 69120, Heidelberg, Baden-Württemberg, Germany
| | - John P Neoptolemos
- Department of General, Visceral and Transplantation Surgery, University of Heidelberg, Im Neuenheimer Feld 110, 69120, Heidelberg, Baden-Württemberg, Germany.
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16
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Chen Q, Yang M, Liao GQ, Zhao YE, Yue DY, Yuan Y, Cheng B, Qin H. Precautionary Measures: Performing ERCP on a Patient With Juxtapapillary Duodenal Diverticula (JPDD)-Related Biliary Stone After COVID-19 Lockdown Restriction Lifted in Wuhan, China. Front Med (Lausanne) 2020; 7:564. [PMID: 33015107 PMCID: PMC7500472 DOI: 10.3389/fmed.2020.00564] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/14/2020] [Accepted: 08/11/2020] [Indexed: 12/24/2022] Open
Abstract
On April 8, 2020, after nearly 3 months of battling against the outbreak of COVID-19, Wuhan, where the pandemic began, began easing lockdown restrictions. However, given that asymptomatic carriers could continue to lead to transmission of COVID-19 during the very early stages, the endoscopists have taken precautions and conduct risk assessments to perform endoscopic intervention in this transition stage. Here, we have reported an urgent ERCP in a patient with acute pancreatitis secondary to JPDD-related biliary stone. Based on our experiences, the objective is to provide practical suggestions for the safe resumption of ERCP procedures in the setting of the COVID-19 pandemic with specific focus on patient risk assessment, personal protection equipment (PPE), and dress code modalities, all of which have been implemented in our hospital to reduce the risk of viral transmission.
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Affiliation(s)
- Qian Chen
- The Division of Gastroenterology and Hepatology, Department of Internal Medicine at Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology (HUST), Wuhan, China
| | - Min Yang
- The Division of Gastroenterology and Hepatology, Department of Internal Medicine at Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology (HUST), Wuhan, China
| | - Guang-Quan Liao
- The Division of Gastroenterology and Hepatology, Department of Internal Medicine at Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology (HUST), Wuhan, China
| | - Yu-Er Zhao
- The Division of Gastroenterology and Hepatology, Department of Internal Medicine at Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology (HUST), Wuhan, China
| | - Dao-Yuan Yue
- The Department of Laboratory Services at Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Yue Yuan
- Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Bin Cheng
- The Division of Gastroenterology and Hepatology, Department of Internal Medicine at Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology (HUST), Wuhan, China
| | - Hua Qin
- The Division of Gastroenterology and Hepatology, Department of Internal Medicine at Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology (HUST), Wuhan, China
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17
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Schepers NJ, Hallensleben NDL, Besselink MG, Anten MPGF, Bollen TL, da Costa DW, van Delft F, van Dijk SM, van Dullemen HM, Dijkgraaf MGW, van Eijck CHJ, Erkelens GW, Erler NS, Fockens P, van Geenen EJM, van Grinsven J, Hollemans RA, van Hooft JE, van der Hulst RWM, Jansen JM, Kubben FJGM, Kuiken SD, Laheij RJF, Quispel R, de Ridder RJJ, Rijk MCM, Römkens TEH, Ruigrok CHM, Schoon EJ, Schwartz MP, Smeets XJNM, Spanier BWM, Tan ACITL, Thijs WJ, Timmer R, Venneman NG, Verdonk RC, Vleggaar FP, van de Vrie W, Witteman BJ, van Santvoort HC, Bakker OJ, Bruno MJ. Urgent endoscopic retrograde cholangiopancreatography with sphincterotomy versus conservative treatment in predicted severe acute gallstone pancreatitis (APEC): a multicentre randomised controlled trial. Lancet 2020; 396:167-176. [PMID: 32682482 DOI: 10.1016/s0140-6736(20)30539-0] [Citation(s) in RCA: 65] [Impact Index Per Article: 16.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/28/2019] [Revised: 02/26/2020] [Accepted: 02/27/2020] [Indexed: 12/11/2022]
Abstract
BACKGROUND It remains unclear whether urgent endoscopic retrograde cholangiopancreatography (ERCP) with biliary sphincterotomy improves the outcome of patients with gallstone pancreatitis without concomitant cholangitis. We did a randomised trial to compare urgent ERCP with sphincterotomy versus conservative treatment in patients with predicted severe acute gallstone pancreatitis. METHODS In this multicentre, parallel-group, assessor-masked, randomised controlled superiority trial, patients with predicted severe (Acute Physiology and Chronic Health Evaluation II score ≥8, Imrie score ≥3, or C-reactive protein concentration >150 mg/L) gallstone pancreatitis without cholangitis were assessed for eligibility in 26 hospitals in the Netherlands. Patients were randomly assigned (1:1) by a web-based randomisation module with randomly varying block sizes to urgent ERCP with sphincterotomy (within 24 h after hospital presentation) or conservative treatment. The primary endpoint was a composite of mortality or major complications (new-onset persistent organ failure, cholangitis, bacteraemia, pneumonia, pancreatic necrosis, or pancreatic insufficiency) within 6 months of randomisation. Analysis was by intention to treat. This trial is registered with the ISRCTN registry, ISRCTN97372133. FINDINGS Between Feb 28, 2013, and March 1, 2017, 232 patients were randomly assigned to urgent ERCP with sphincterotomy (n=118) or conservative treatment (n=114). One patient from each group was excluded from the final analysis because of cholangitis (urgent ERCP group) and chronic pancreatitis (conservative treatment group) at admission. The primary endpoint occurred in 45 (38%) of 117 patients in the urgent ERCP group and in 50 (44%) of 113 patients in the conservative treatment group (risk ratio [RR] 0·87, 95% CI 0·64-1·18; p=0·37). No relevant differences in the individual components of the primary endpoint were recorded between groups, apart from the occurrence of cholangitis (two [2%] of 117 in the urgent ERCP group vs 11 [10%] of 113 in the conservative treatment group; RR 0·18, 95% CI 0·04-0·78; p=0·010). Adverse events were reported in 87 (74%) of 118 patients in the urgent ERCP group versus 91 (80%) of 114 patients in the conservative treatment group. INTERPRETATION In patients with predicted severe gallstone pancreatitis but without cholangitis, urgent ERCP with sphincterotomy did not reduce the composite endpoint of major complications or mortality, compared with conservative treatment. Our findings support a conservative strategy in patients with predicted severe acute gallstone pancreatitis with an ERCP indicated only in patients with cholangitis or persistent cholestasis. FUNDING The Netherlands Organization for Health Research and Development, Fonds NutsOhra, and the Dutch Patient Organization for Pancreatic Diseases.
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Affiliation(s)
- Nicolien J Schepers
- Department of Gastroenterology and Hepatology, Erasmus MC University Medical Center, Rotterdam, Netherlands; Department of Gastroenterology and Hepatology, St Antonius Hospital, Nieuwegein, Netherlands.
| | - Nora D L Hallensleben
- Department of Gastroenterology and Hepatology, Erasmus MC University Medical Center, Rotterdam, Netherlands; Department of Gastroenterology and Hepatology, St Antonius Hospital, Nieuwegein, Netherlands
| | - Marc G Besselink
- Department of Surgery, Amsterdam Gastroenterology and Metabolism, Amsterdam UMC, University of Amsterdam, Netherlands
| | - Marie-Paule G F Anten
- Department of Gastroenterology and Hepatology, Franciscus and Vlietland Hospital, Rotterdam, Netherlands
| | - Thomas L Bollen
- Department of Radiology, St Antonius Hospital, Nieuwegein, Netherlands
| | - David W da Costa
- Department of Radiology, St Antonius Hospital, Nieuwegein, Netherlands
| | - Foke van Delft
- Department of Gastroenterology and Hepatology, Amsterdam Gastroenterology and Metabolism, Amsterdam UMC, University of Amsterdam, Netherlands
| | - Sven M van Dijk
- Department of Surgery, St Antonius Hospital, Nieuwegein, Netherlands
| | - Hendrik M van Dullemen
- Department of Gastroenterology and Hepatology, University Medical Center Groningen, Groningen, Netherlands
| | - Marcel G W Dijkgraaf
- Department of Clinical Epidemiology, Biostatistics, and Bioinformatics, Amsterdam Gastroenterology and Metabolism, Amsterdam UMC, University of Amsterdam, Netherlands
| | - Casper H J van Eijck
- Department of Surgery, Erasmus MC University Medical Center, Rotterdam, Netherlands
| | - G Willemien Erkelens
- Department of Gastroenterology and Hepatology, Gelre Hospital, Apeldoorn, Netherlands
| | - Nicole S Erler
- Department of Biostatistics, Erasmus MC University Medical Center, Rotterdam, Netherlands
| | - Paul Fockens
- Department of Gastroenterology and Hepatology, Amsterdam Gastroenterology and Metabolism, Amsterdam UMC, University of Amsterdam, Netherlands
| | - Erwin J M van Geenen
- Department of Gastroenterology and Hepatology, Radboud University Nijmegen Medical Centre, Nijmegen, Netherlands
| | - Janneke van Grinsven
- Department of Surgery, Amsterdam Gastroenterology and Metabolism, Amsterdam UMC, University of Amsterdam, Netherlands
| | | | - Jeanin E van Hooft
- Department of Gastroenterology and Hepatology, Amsterdam Gastroenterology and Metabolism, Amsterdam UMC, University of Amsterdam, Netherlands
| | | | - Jeroen M Jansen
- Department of Gastroenterology and Hepatology, Onze Lieve Vrouwe Gasthuis, Amsterdam, Netherlands
| | - Frank J G M Kubben
- Department of Gastroenterology and Hepatology, Maasstad Hospital, Rotterdam, Netherlands
| | - Sjoerd D Kuiken
- Department of Gastroenterology and Hepatology, Onze Lieve Vrouwe Gasthuis, Amsterdam, Netherlands
| | - Robert J F Laheij
- Department of Gastroenterology and Hepatology, Elisabeth-TweeSteden Hospital, Tilburg, Netherlands
| | - Rutger Quispel
- Department of Gastroenterology and Hepatology, Reinier de Graaf Group, Delft, Netherlands
| | - Rogier J J de Ridder
- Department of Gastroenterology and Hepatology, Maastricht University Medical Center, Maastricht, Netherlands
| | - Marno C M Rijk
- Department of Gastroenterology and Hepatology, Amphia Hospital, Breda, Netherlands
| | - Tessa E H Römkens
- Department of Gastroenterology and Hepatology, Jeroen Bosch Hospital, Den Bosch, Netherlands
| | - Carola H M Ruigrok
- Department of Gastroenterology and Hepatology, Reinier de Graaf Group, Delft, Netherlands
| | - Erik J Schoon
- Department of Gastroenterology and Hepatology, Catharina Hospital, Eindhoven, Netherlands
| | - Matthijs P Schwartz
- Department of Gastroenterology and Hepatology, Meander Medical Center, Amersfoort, Netherlands
| | - Xavier J N M Smeets
- Department of Gastroenterology and Hepatology, Radboud University Nijmegen Medical Centre, Nijmegen, Netherlands
| | - B W Marcel Spanier
- Department of Gastroenterology and Hepatology, Rijnstate Hospital, Arnhem, Netherlands
| | - Adriaan C I T L Tan
- Department of Gastroenterology and Hepatology, Canisius Wilhelmina Hospital, Nijmegen, Netherlands
| | - Willem J Thijs
- Department of Gastroenterology and Hepatology, Martini Hospital, Groningen, Netherlands
| | - Robin Timmer
- Department of Gastroenterology and Hepatology, St Antonius Hospital, Nieuwegein, Netherlands
| | - Niels G Venneman
- Department of Gastroenterology and Hepatology, Medisch Spectrum Twente, Enschede, Netherlands
| | - Robert C Verdonk
- Department of Gastroenterology and Hepatology, St Antonius Hospital, Nieuwegein, Netherlands
| | - Frank P Vleggaar
- Department of Gastroenterology and Hepatology, University Medical Center Utrecht, Utrecht, Netherlands
| | - Wim van de Vrie
- Department of Gastroenterology and Hepatology, Albert Schweitzer Hospital, Dordrecht, Netherlands
| | - Ben J Witteman
- Department of Gastroenterology and Hepatology, Hospital Gelderse Vallei, Ede, Netherlands
| | - Hjalmar C van Santvoort
- Department of Surgery, St Antonius Hospital, Nieuwegein, Netherlands; Department of Surgery, University Medical Center Utrecht, Utrecht, Netherlands
| | - Olaf J Bakker
- Department of Surgery, St Antonius Hospital, Nieuwegein, Netherlands
| | - Marco J Bruno
- Department of Gastroenterology and Hepatology, Erasmus MC University Medical Center, Rotterdam, Netherlands
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18
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Higgins M, Divino C. Judicious use of ERCP in gallstone pancreatitis. Lancet 2020; 396:144-145. [PMID: 32682462 DOI: 10.1016/s0140-6736(20)31535-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/19/2020] [Accepted: 06/25/2020] [Indexed: 11/29/2022]
Affiliation(s)
- Madeleine Higgins
- Department of Surgery, The Mount Sinai Hospital, New York, NY 10029, USA
| | - Celia Divino
- Department of Surgery, The Mount Sinai Hospital, New York, NY 10029, USA.
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19
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Sundar V, Senthil Kumar KA, Manickam V, Ramasamy T. Current trends in pharmacological approaches for treatment and management of acute pancreatitis – a review. J Pharm Pharmacol 2020; 72:761-775. [DOI: 10.1111/jphp.13229] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/02/2019] [Accepted: 12/06/2019] [Indexed: 12/12/2022]
Abstract
Abstract
Objectives
Acute pancreatitis (AP) is an inimical disorder associated with overall mortality rates between 10-15%. It is a disorder of the exocrine pancreas which is characterized by local and systemic inflammatory responses primarily driven by oxidative stress and death of pancreatic acinar cells. The severity of AP ranges from mild pancreatic edema with complete recuperative possibilities to serious systemic inflammatory response resulting in peripancreatic/pancreatic necrosis, multiple organ failure, and death.
Key findings
We have retrieved the potential alternative approaches that are developed lately for efficacious treatment of AP from the currently available literature and recently reported experimental studies. This review summarizes the need for alternative approaches and combinatorial treatment strategies to deal with AP based on literature search using specific key words in PubMed and ScienceDirect databases.
Summary
Since AP results from perturbations of multiple signaling pathways, the so called “monotargeted smart drugs” of the past decade is highly unlikely to be effective. Also, the conventional treatment approaches were mainly involved in providing palliative care instead of curing the disease. Hence, many researchers are beginning to focus on developing alternate therapies to treat AP effectively. This review also summarizes the recent trends in the combinatorial approaches available for AP treatment.
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Affiliation(s)
- Vaishnavi Sundar
- School of Biosciences and Technology, Vellore Institute of Technology, Vellore, India
| | | | - Venkatraman Manickam
- School of Biosciences and Technology, Vellore Institute of Technology, Vellore, India
| | - Tamizhselvi Ramasamy
- School of Biosciences and Technology, Vellore Institute of Technology, Vellore, India
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20
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Schulz C, Schirra J, Mayerle J. Indications for endoscopic retrograde cholangiopancreatography and cholecystectomy in biliary pancreatitis. Br J Surg 2019; 107:11-13. [PMID: 31869457 DOI: 10.1002/bjs.11402] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/24/2019] [Accepted: 09/24/2019] [Indexed: 01/08/2023]
Affiliation(s)
- C Schulz
- Medical Department II, University Hospital, LMU, D-81377, Munich, Germany
| | - J Schirra
- Medical Department II, University Hospital, LMU, D-81377, Munich, Germany
| | - J Mayerle
- Medical Department II, University Hospital, LMU, D-81377, Munich, Germany
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21
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Aziret M, Karaman K, Ercan M, Vargöl E, Toka B, Arslan Y, Öter V, Bostancı EB, Parlak E. Early laparoscopic cholecystectomy is associated with less risk of complications after the removal of common bile duct stones by endoscopic retrograde cholangiopancreatography. TURKISH JOURNAL OF GASTROENTEROLOGY 2019; 30:336-344. [PMID: 30945646 DOI: 10.5152/tjg.2018.18272] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Abstract
BACKGROUND/AIMS Several studies recommend prompt laparoscopic cholecystectomy (LC) following endoscopic retrograde cholangiopancreatography (ERCP) for choledocholithiasis. However, histopathological alterations in the gallbladder during this time interval and the role played by ERCP in causing these changes have not been sufficiently elucidated. To compare early period LCs with delayed LCs following common bile duct stone extraction via ERCP with regard to operation time, hospitalization period, conversion to open cholecystectomy rate, morbidity, mortality, and histopathological alterations in the gallbladder wall. MATERIALS AND METHODS A total of 85 patients were retrospectively divided into three groups: early period LC group (48-72 h; n=30), moderate period LC group (72 h-6 weeks; n=25), and delayed period LC group (6-8 weeks; n=30). RESULTS The operation time was significantly shorter, and the total number of complication rates and hospital readmission was significantly less frequent in the early period LC group (p<0.05). Ultrasound showed a significantly thicker gallbladder wall (>3 mm) in the moderate and late period LC groups than in the early period LC group (p<0.001). Culture growth was significantly higher, and fibrosis/collagen deposition in the gallbladder wall with injury to the mucosal epithelium was significantly more frequently detected by histopathological examination in the moderate and late period LC groups than in the early period LC group (p<0.05). CONCLUSION Early period LC following stone extraction by ERCP is associated with shorter operation time, fewer fibrotic changes in the gallbladder, and lower risk for the development of complications. Therefore, LC can be performed safely in the early period after ERCP.
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Affiliation(s)
- Mehmet Aziret
- Department of General Surgery, Sakarya University Trainig and Research Hospital Sakarya, Turkey
| | - Kerem Karaman
- Department of General Surgery, Sakarya University Trainig and Research Hospital Sakarya, Turkey
| | - Metin Ercan
- Department of General Surgery, Sakarya University Trainig and Research Hospital Sakarya, Turkey
| | - Erdem Vargöl
- Department of Pathology, Sakarya University Trainig and Research Hospital, Sakarya, Turkey
| | - Bilal Toka
- Department of Gastroenterology, Sakarya University Training and Research Hospital Sakarya, Turkey
| | - Yusuf Arslan
- Department of General Surgery, Sakarya University Trainig and Research Hospital Sakarya, Turkey
| | - Volkan Öter
- Department of General Surgery, Sakarya University Trainig and Research Hospital Sakarya, Turkey
| | - Erdal Birol Bostancı
- Department of General Surgery, Sakarya University Trainig and Research Hospital Sakarya, Turkey
| | - Erkan Parlak
- Department of Gastroenterology, Hacettepe University School of Medicine Ankara, Turkey
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22
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Abstract
The risks, measurements of severity, and management of severe acute pancreatitis and its complications have evolved rapidly over the past decade. Evidence suggests that initial goal directed therapy, nutritional support, and vigilance for pancreatic complications are best practice. Patients can develop pancreatic fluid collections including acute pancreatic fluid collections, pancreatic pseudocysts, acute necrotic collections, and walled-off necrosis. Several randomized controlled trials and cohort studies have recently highlighted the advantage of managing these conditions with a progressive approach, with initial draining for infection followed by less invasive techniques. Surgery is no longer an early intervention and may not be needed. Instead, interventional radiologic and endoscopic methods seem to be safer with at least as good survival outcomes. Newly developed evidence based quality indicators are available to assess and improve performance. Development and clinical testing of drugs to target the mechanisms of disease are necessary for further advancements.
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Affiliation(s)
- O Joe Hines
- Department of Surgery, David Geffen School of Medicine at UCLA, Los Angeles, CA 90095-6904, USA
| | - Stephen J Pandol
- Department of Medicine, Cedar-Sinai Medical Center, Los Angeles, CA 90048, USA
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23
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Tarikci Kilic E, Kahraman R, Ozdil K. Evaluation of Safety and Outcomes of Endoscopic Retrograde Cholangiopancreatography in 1337 Patients at a Single Center. Medeni Med J 2019; 34:290-296. [PMID: 32821451 PMCID: PMC7433733 DOI: 10.5222/mmj.2019.58265] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/04/2019] [Accepted: 06/15/2019] [Indexed: 11/16/2022] Open
Abstract
Objective: Endoscopic retrograde cholangiopancreatography (ERCP) is the gold standard treatment for pancreaticobiliary diseases. The aim of this study was to evaluate the safety and review the outcomes of our experience of ERCP over the past 4 years. Method: The clinical records of patients aged 18-104 years who underwent ERCP at our gastroenterology clinic between 2014 and 2018 were included in the study. Data were acquired from the hospital archive system. Results: A total of 1337 patients with a mean age of 60.58±17.96 years. including 775 female, and 562 male cases were included in the study. The patients were in the age groups of 18-30 (n=39), 30-65 (n=694), 65-75 (n=274), 75-85 (n=258), and > 85 (n=72) years. Among them, 28.27% were rated as ASA III-IV on the American Society of Anesthesiologists scale. Although biliary cannulation with standard sphincterotomy was successful in 1303 (97.45%), patients it could not be performed in 34 (2.55%). patients Precut papillotomy was performed in 27 (79.41%) of 34 patients. Furthermore, no complication was observed in 1207 patients (90.27%), whereas 96 patients (7.18%) had minor and major procedure-related and anesthesia-related complications. The 30-day mortality rate was 1.64% (n=22). Conclusion: We concluded that ERCP, which is currently performed entirely for therapeutic purposes, is safe and lifesaving, with high clinical success rates.
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Affiliation(s)
- Ebru Tarikci Kilic
- Health Sciences University Ümraniye Training and Research Hospital, Department of Anesthesiology and Reanimation, Istanbul, Turkey
| | - Resul Kahraman
- Health Sciences University Ümraniye Training and Research Hospital, Department of Gastroenterology, Istanbul, Turkey
| | - Kamil Ozdil
- Health Sciences University Ümraniye Training and Research Hospital, Department of Gastroenterology, Istanbul, Turkey
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Population-based observational study of acute pancreatitis in southern England. Ann R Coll Surg Engl 2019; 101:487-494. [PMID: 31362520 PMCID: PMC6667964 DOI: 10.1308/rcsann.2019.0055] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 02/23/2019] [Indexed: 12/31/2022] Open
Abstract
INTRODUCTION Acute pancreatitis is a common surgical emergency. Identifying variations in presentation, incidence and management may assist standardisation and optimisation of care. The objective of the study was to document the current incidence management and outcomes of acute pancreatitis against international guidelines, and to assess temporal trends over the past 20 years. METHODS A prospective four-month audit of patients with acute pancreatitis was performed across the Wessex region. The Atlanta 2012 classifications were used to define cases, severity and complications. Outcomes were recorded using validated systems and correlated against guideline standards. Case ascertainment was validated with clinical coding and hospital episode statistics data. RESULTS A total of 283 patient admissions with acute pancreatitis were identified. Aetiology included 153 gallstones (54%), 65 idiopathic (23%), 29 alcohol (10%), 9 endoscopic retrograde cholangiopancreatography (3%), 6 drug related (2%), 5 tumour (2%) and 16 other (6%). Compliance with guidelines had improved compared with our previous regional audit. Results were 6.5% mortality, 74% severity stratification, 23% idiopathic cases, 65% definitive treatment of gallstones within 2 weeks, 39% computed tomography within 6-10 days of severe pancreatitis presentation and 82% severe pancreatitis critical care admission. The Atlanta 2012 severity criteria significantly correlated with critical care stay, length of stay, development of complications and mortality (2% vs 6% vs 36%, P < 0.0001). CONCLUSIONS The incidence of acute pancreatitis in southern England has risen substantially. The Atlanta 2012 classification identifies patients with severe pancreatitis who have a high risk of fatal outcome. Acute pancreatitis management is seen to have evolved in keeping with new evidence and updated clinical guidelines.
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Affiliation(s)
- PanWessex Study Group
- Department of Surgery, University Hospital Southampton NHS Foundation Trust, Southampton, UK
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Buxbaum JL, Abbas Fehmi SM, Sultan S, Fishman DS, Qumseya BJ, Cortessis VK, Schilperoort H, Kysh L, Matsuoka L, Yachimski P, Agrawal D, Gurudu SR, Jamil LH, Jue TL, Khashab MA, Law JK, Lee JK, Naveed M, Sawhney MS, Thosani N, Yang J, Wani SB. ASGE guideline on the role of endoscopy in the evaluation and management of choledocholithiasis. Gastrointest Endosc 2019; 89:1075-1105.e15. [PMID: 30979521 PMCID: PMC8594622 DOI: 10.1016/j.gie.2018.10.001] [Citation(s) in RCA: 238] [Impact Index Per Article: 47.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/04/2018] [Accepted: 10/05/2018] [Indexed: 12/11/2022]
Abstract
Each year choledocholithiasis results in biliary obstruction, cholangitis, and pancreatitis in a significant number of patients. The primary treatment, ERCP, is minimally invasive but associated with adverse events in 6% to 15%. This American Society for Gastrointestinal Endoscopy (ASGE) Standard of Practice (SOP) Guideline provides evidence-based recommendations for the endoscopic evaluation and treatment of choledocholithiasis. The Grading of Recommendations Assessment, Development and Evaluation (GRADE) framework was used to rigorously review and synthesize the contemporary literature regarding the following topics: EUS versus MRCP for diagnosis, the role of early ERCP in gallstone pancreatitis, endoscopic papillary dilation after sphincterotomy versus sphincterotomy alone for large bile duct stones, and impact of ERCP-guided intraductal therapy for large and difficult choledocholithiasis. Comprehensive systematic reviews were also performed to assess the following: same-admission cholecystectomy for gallstone pancreatitis, clinical predictors of choledocholithiasis, optimal timing of ERCP vis-à-vis cholecystectomy, management of Mirizzi syndrome and hepatolithiasis, and biliary stent therapy for choledocholithiasis. Core clinical questions were derived using an iterative process by the ASGE SOP Committee. This body developed all recommendations founded on the certainty of the evidence, balance of risks and harms, consideration of stakeholder preferences, resource utilization, and cost-effectiveness.
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Affiliation(s)
- James L Buxbaum
- Division of Gastrointestinal and Liver Diseases, Keck School of Medicine, University of Southern California, Los Angeles, California, USA
| | - Syed M Abbas Fehmi
- Division of Gastroenterology/Hepatology, University of California, San Diego, California, USA
| | - Shahnaz Sultan
- Center for Chronic Disease Outcomes Research, Minneapolis Veterans Affairs Medical Center, Minneapolis, Minnesota, USA; Division of Gastroenterology, Hepatology and Nutrition, University of Minnesota, Minneapolis, Minnesota, USA; Division of Gastroenterology, Hepatology & Nutrition, University of Florida College of Medicine, Gainesville, Florida, USA
| | - Douglas S Fishman
- Section of Pediatric Gastroenterology, Hepatology and Nutrition, Baylor College of Medicine, Texas Children's Hospital, Houston, Texas, USA
| | - Bashar J Qumseya
- Department of Gastroenterology, Archbold Medical Group, Thomasville, Georgia, USA
| | - Victoria K Cortessis
- Division of Gastrointestinal and Liver Diseases, Keck School of Medicine, University of Southern California, Los Angeles, California, USA
| | - Hannah Schilperoort
- Norris Medical Library, University of Southern California, Los Angeles, California, USA (now with Children's Hospital Los Angeles, Los Angeles, California, USA)
| | - Lynn Kysh
- Norris Medical Library, University of Southern California, Los Angeles, California, USA (now with Children's Hospital Los Angeles, Los Angeles, California, USA)
| | - Lea Matsuoka
- Division of Hepatobiliary Surgery & Liver Transplantation, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - Patrick Yachimski
- Division of Gastroenterology, Hepatology and Nutrition, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - Deepak Agrawal
- Division of Digestive and Liver Diseases, University of Texas Southwestern Medical Center, Dallas, Texas, USA
| | - Suryakanth R Gurudu
- Department of Gastroenterology and Hepatology, Mayo Clinic Arizona, Scottsdale, Arizona, USA
| | - Laith H Jamil
- Pancreatic and Biliary Diseases Program, Cedars-Sinai Medical Center, Los Angeles, California, USA
| | - Terry L Jue
- The Permanente Medical Group, Kaiser Permanente San Francisco Medical Center, San Francisco, California, USA
| | - Mouen A Khashab
- Division of Gastroenterology and Hepatology, Johns Hopkins University, Baltimore, Maryland, USA
| | - Joanna K Law
- Digestive Disease Institute, Virginia Mason Medical Center, Seattle, Washington, USA
| | - Jeffrey K Lee
- Department of Gastroenterology, Kaiser Permanente San Francisco Medical Center, San Francisco, California, USA
| | - Mariam Naveed
- Division of Gastroenterology and Hepatology, University of Iowa Hospitals & Clinics, Iowa City, Iowa, USA
| | - Mandeep S Sawhney
- Division of Gastroenterology, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts, USA
| | - Nirav Thosani
- Division of Gastroenterology, Hepatology and Nutrition, McGovern Medical School, UTHealth, Houston, Texas, USA
| | - Julie Yang
- Division of Gastroenterology, Montefiore Medical Center, Albert Einstein College of Medicine, Bronx, New York, USA
| | - Sachin B Wani
- Division of Gastroenterology and Hepatology, University of Colorado Anschutz Medical Center, Aurora, Colorado, USA.
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Is endoscopic sphincterotomy beneficial for the treatment of acute gallstone pancreatitis with small bile duct stone? Eur J Gastroenterol Hepatol 2019; 31:192-196. [PMID: 30576296 DOI: 10.1097/meg.0000000000001329] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/30/2023]
Abstract
BACKGROUND Acute gallstone pancreatitis occurs when a gallstone is impacted at the ampulla of Vater. The role of endoscopic retrograde cholangiopancreatography in the treatment of small choledocholithiasis in these patients is uncertain. The aim of this study was to compare outcomes of expectant management with endoscopic sphincterotomy for the treatment of small choledocholithiasis (≤5 mm) in patients with acute gallstone pancreatitis. PATIENTS AND METHODS Of the 258 patients admitted for acute gallstone pancreatitis from January 2010 to December 2014, 174 patients with small choledocholithiasis were reviewed retrospectively. Patients with coexisting acute cholangitis and/or pancreatobiliary malignancy were excluded. They were divided into an endoscopic sphincterotomy group (n=64) and an expectant management group (n=110). Severity index and outcomes of pancreatitis, complications, and overall mortality were compared. RESULTS Age and sex were not significantly different between the two groups. The mean Ranson, acute physiology and chronic health evaluation-II, and bedside index of severity in acute pancreatitis scores were not significantly different between the two groups. The computed tomography severity index score was significantly higher in the expectant management group than in the endoscopic sphincterotomy group (1.6±1.1 vs. 1.0±0.9, P<0.001). Duration of hospitalization, time for normalization of the white blood cell count, and time for oral feeding were similar in both groups. There was no significant difference between two groups in the incidence of development of pseudocyst or walled-off necrosis. In addition, no difference was observed in the rate of recurrence of acute pancreatitis and readmission because of recurrent choledocholithiasis. CONCLUSION Expectant management seems to be effective for the treatment of patients with acute gallstone pancreatitis and size of bile duct stones equal to or less than 5 mm.
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Abstract
PURPOSE OF REVIEW Acute pancreatitis is a common condition that affects patients with varying degrees of severity and may lead to significant morbidity and mortality. The present article will review the current paradigm in acute pancreatitis management within the first 72 h of diagnosis. RECENT FINDINGS Patients presenting with acute pancreatitis should be evaluated clinically for signs and symptoms of organ failure in order to appropriately triage. Initial management should focus on fluid resuscitation, with some data to support Ringer's lactate over physiological saline. Routine use of prophylactic antibiotics in acute pancreatitis is not recommended, nor is urgent endoscopic retrograde cholangiopancreatography in the absence of concomitant acute cholangitis. Early oral feeding should be encouraged, not avoided, and use of parenteral nutrition is discouraged. Cholecystectomy during the same admission of biliary pancreatitis should be performed in order to prevent future acute pancreatitis episodes. Patients with acute pancreatitis secondary to alcohol should receive alcohol counseling. Finally, there is ongoing interest in the development of prognostic laboratory tests in acute pancreatitis and pharmacological therapies to reduce the inflammation that occurs in acute pancreatitis. SUMMARY Acute pancreatitis is a common and heterogeneous condition with the potential for significant morbidity. Best practices in acute pancreatitis management focus on triage, hydration and enteral feeding.
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Affiliation(s)
- Theodore W. James
- Division of Gastroenterology and Hepatology, University of North Carolina School of Medicine, Chapel Hill, North Carolina
| | - Seth D. Crockett
- Division of Gastroenterology and Hepatology, University of North Carolina School of Medicine, Chapel Hill, North Carolina
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Role of Cholecystectomy After Endoscopic Sphincterotomy in the Management of Choledocholithiasis in High-risk Patients: A Systematic Review and Meta-Analysis. J Clin Gastroenterol 2018; 52:579-589. [PMID: 29912758 DOI: 10.1097/mcg.0000000000001076] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/26/2022]
Abstract
BACKGROUND Endoscopic retrograde cholangiography and endoscopic sphincterotomy (ES) with subsequent cholecystectomy is the standard of care for the management of patients with choledocholithiasis. There is conflicting evidence in terms of mortality reduction, prevention of complications specifically biliary pancreatitis and cholangitis with the use of early cholecystectomy particularly in high-risk surgical and elderly patients. AIMS We conducted this systematic review and meta-analysis of randomized controlled trials to compare the early cholecystectomy versus wait and watch strategy after ES. METHODS We searched Medline, Scopus, Web of Science, and Cochrane database for randomized controlled trials comparing the 2 strategies in the management of choledocholithiasis after ES. Our primary outcome of interest was difference in mortality. We evaluated several secondary outcomes including difference in development of acute pancreatitis, biliary colic and cholecystitis, cholangitis and recurrent jaundice, nonbiliary adverse events, and length of hospital stay. Risk ratios (RR) were calculated for categorical variables and difference in means was calculated for continuous variables. These were pooled using random effects model. RESULTS Seven studies with 916 patients (455 cholecystectomy group and 461 wait and watch group) were included in the meta-analysis. Pooled RR with 95% confidence interval for mortality was 1.43 (0.93-2.18), I=9%. In the high-risk patient group, pooled RR was 1.39 (0.64-3.03) and in low-risk population pooled RR was 1.53 (0.79-2.96). Pooled RR for acute pancreatitis was 1.64 (0.46-5.81) with no heterogeneity. There was no difference in the rate of acute pancreatitis patients based on high-risk versus low-risk patients. Pooled RR for occurrence of biliary colic and cholecystitis during follow-up was 9.82 (4.27-22.59), I=0%. Pooled RR for cholangitis and recurrent jaundice was 2.16 (1.14-4.07), I=0%. However, there was no difference in the rate of cholangitis between the 2 groups in low-risk patients. Length of stay was shorter in the wait and watch group with a pooled mean difference was -2.70 (-4.71, -0.70) with substantial heterogeneity. CONCLUSIONS Although we found no difference in mortality between the 2 strategies after ES, laparoscopic cholecystectomy should be recommended as it is associated with lower rates of subsequent recurrent cholecystitis, cholangitis, and biliary colic down the road even in high-risk surgical patients.
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Lee JK, Jang DK, Kang HW, Lee SH. Feasibility of Temporary Pancreatic Stenting after Early Endoscopic Retrograde Cholangiopancreatography in Patients with Acute Biliary Pancreatitis. THE KOREAN JOURNAL OF GASTROENTEROLOGY 2018; 70:247-252. [PMID: 29161794 DOI: 10.4166/kjg.2017.70.5.247] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/13/2023]
Abstract
Background/Aims To assess the safety and effectiveness of temporary pancreatic stenting after early endoscopic retrograde cholangiopancreatography (ERCP) in patients with acute biliary pancreatitis regardless of the severity or concomitant cholangitis. Methods Temporary pancreatic stenting was performed in 79 patients with visualized pancreatic duct during ERCP. The outcomes of 64 patients with adequate pancreatic stenting (PS) and 15 patients with inadequate pancreatic stenting (no PS) were compared in this prospective, observational trial. Results The baseline characteristics were similar. Development of systemic inflammatory response syndrome (7.8% for PS vs. 13.3% for no PS; p=0.50) and mortality (none for both groups; p=0.99) did not differ. However, fewer local complications occurred in PS than in no PS (4.7% for PS vs. 20.0% for no PS; p=0.04) and the difference was most outstanding in necrosis (1.6% for PS vs. 13.3% for no PS; p=0.03). Conclusions Temporary pancreatic stenting after early ERCP should be considered safe, as complications did not increase even in cases of inadequate stenting. However, if successful, there appears to be a reduction in local complications.
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Affiliation(s)
- Jun Kyu Lee
- Department of Internal Medicine, Dongguk University Ilsan Hospital, Goyang, Korea
| | - Dong Kee Jang
- Department of Internal Medicine, Dongguk University Ilsan Hospital, Goyang, Korea
| | - Hyun Woo Kang
- Department of Internal Medicine, Dongguk University Ilsan Hospital, Goyang, Korea
| | - Sang Hyub Lee
- Department of Internal Medicine and Liver Research Institute, Seoul National University Hospital, Seoul, Korea
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Mandalia A, Wamsteker EJ, DiMagno MJ. Recent advances in understanding and managing acute pancreatitis. F1000Res 2018; 7. [PMID: 30026919 DOI: 10.12688/f1000research.14244.1] [Citation(s) in RCA: 21] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 06/20/2018] [Indexed: 12/16/2022] Open
Abstract
This review highlights advances made in recent years in the diagnosis and management of acute pancreatitis (AP). We focus on epidemiological, clinical, and management aspects of AP. Additionally, we discuss the role of using risk stratification tools to guide clinical decision making. The majority of patients suffer from mild AP, and only a subset develop moderately severe AP, defined as a pancreatic local complication, or severe AP, defined as persistent organ failure. In mild AP, management typically involves diagnostic evaluation and supportive care resulting usually in a short hospital length of stay (LOS). In severe AP, a multidisciplinary approach is warranted to minimize morbidity and mortality over the course of a protracted hospital LOS. Based on evidence from guideline recommendations, we discuss five treatment interventions, including intravenous fluid resuscitation, feeding, prophylactic antibiotics, probiotics, and timing of endoscopic retrograde cholangiopancreatography (ERCP) in acute biliary pancreatitis. This review also highlights the importance of preventive interventions to reduce hospital readmission or prevent pancreatitis, including alcohol and smoking cessation, same-admission cholecystectomy for acute biliary pancreatitis, and chemoprevention and fluid administration for post-ERCP pancreatitis. Our review aims to consolidate guideline recommendations and high-quality studies published in recent years to guide the management of AP and highlight areas in need of research.
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Affiliation(s)
- Amar Mandalia
- Division of Gastroenterology and Hepatology, University of Michigan School of Medicine, Ann Arbor, MI, 48109, USA
| | - Erik-Jan Wamsteker
- Division of Gastroenterology and Hepatology, University of Michigan School of Medicine, Ann Arbor, MI, 48109, USA
| | - Matthew J DiMagno
- Division of Gastroenterology and Hepatology, University of Michigan School of Medicine, Ann Arbor, MI, 48109, USA
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Abstract
This review highlights advances made in recent years in the diagnosis and management of acute pancreatitis (AP). We focus on epidemiological, clinical, and management aspects of AP. Additionally, we discuss the role of using risk stratification tools to guide clinical decision making. The majority of patients suffer from mild AP, and only a subset develop moderately severe AP, defined as a pancreatic local complication, or severe AP, defined as persistent organ failure. In mild AP, management typically involves diagnostic evaluation and supportive care resulting usually in a short hospital length of stay (LOS). In severe AP, a multidisciplinary approach is warranted to minimize morbidity and mortality over the course of a protracted hospital LOS. Based on evidence from guideline recommendations, we discuss five treatment interventions, including intravenous fluid resuscitation, feeding, prophylactic antibiotics, probiotics, and timing of endoscopic retrograde cholangiopancreatography (ERCP) in acute biliary pancreatitis. This review also highlights the importance of preventive interventions to reduce hospital readmission or prevent pancreatitis, including alcohol and smoking cessation, same-admission cholecystectomy for acute biliary pancreatitis, and chemoprevention and fluid administration for post-ERCP pancreatitis. Our review aims to consolidate guideline recommendations and high-quality studies published in recent years to guide the management of AP and highlight areas in need of research.
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Affiliation(s)
- Amar Mandalia
- Division of Gastroenterology and Hepatology, University of Michigan School of Medicine, Ann Arbor, MI, 48109, USA
| | - Erik-Jan Wamsteker
- Division of Gastroenterology and Hepatology, University of Michigan School of Medicine, Ann Arbor, MI, 48109, USA
| | - Matthew J DiMagno
- Division of Gastroenterology and Hepatology, University of Michigan School of Medicine, Ann Arbor, MI, 48109, USA
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Early Endoscopic Retrograde Cholangiopancreatography Versus Conservative Treatment in Patients With Acute Biliary Pancreatitis: Systematic Review and Meta-analysis of Randomized Controlled Trials. Pancreas 2018. [PMID: 29517637 DOI: 10.1097/mpa.0000000000001032] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
OBJECTIVES The aim of the study was to evaluate the role of early endoscopic retrograde cholangiopancreatography (ERCP) in the treatment of acute biliary pancreatitis, in comparison with conservative treatment. METHODS Systematic review via databases (MEDLINE [PubMed], Latin-American and Caribbean Health Sciences Literature database, Embase, Cochrane Central, and the [Brazilian] Regional Library of Medicine) is conducted. We analyzed 10 randomized controlled trials (1091 patients). Outcomes were the following: local and systemic adverse events; acute cholangitis; death; length of hospital stay; cost; abdominal pain; and time to a reduction in body temperature. For the meta-analysis, we used risk difference (RD) and mean with standard deviation as measures of variability. RESULTS There was a statistically significant difference between the patients submitted to ERCP in terms of the following: local adverse events (RD, 0.74; 95% confidence interval [CI], 0.55-0.99), time to pain relief and time to a reduction in axillary temperature (RD, -5.01; 95% CI, -6.98 to -3.04, and RD, -1.70; 95 CI%, -2.33 to -1.08, respectively). Patients undergoing ERCP spent less time in hospital (RD, -11.04; 95% CI, -15.15 to -6.93). Cost was lower in the group treated with ERCP. CONCLUSIONS Early ERCP decreases local adverse events, shortening the time to pain relief, to a reduction in axillary temperature, hospital stays, and cost in patients with acute biliary pancreatitis.
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Vege SS, DiMagno MJ, Forsmark CE, Martel M, Barkun AN. Initial Medical Treatment of Acute Pancreatitis: American Gastroenterological Association Institute Technical Review. Gastroenterology 2018; 154:1103-1139. [PMID: 29421596 DOI: 10.1053/j.gastro.2018.01.031] [Citation(s) in RCA: 146] [Impact Index Per Article: 24.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Affiliation(s)
- Santhi Swaroop Vege
- Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, Minnesota.
| | - Matthew J DiMagno
- Division of Gastroenterology and Hepatology, University of Michigan, Ann Arbor, Michigan
| | - Chris E Forsmark
- Division of Gastroenterology, University of Florida, Gainesville, Florida
| | - Myriam Martel
- Division of Gastroenterology, McGill University Health Center, McGill University, Montreal, Canada
| | - Alan N Barkun
- Division of Gastroenterology, McGill University Health Center, McGill University, Montreal, Canada
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Lee HS, Chung MJ, Park JY, Bang S, Park SW, Song SY, Chung JB. Urgent endoscopic retrograde cholangiopancreatography is not superior to early ERCP in acute biliary pancreatitis with biliary obstruction without cholangitis. PLoS One 2018; 13:e0190835. [PMID: 29401491 PMCID: PMC5798765 DOI: 10.1371/journal.pone.0190835] [Citation(s) in RCA: 20] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/23/2017] [Accepted: 12/20/2017] [Indexed: 12/20/2022] Open
Abstract
Acute pancreatitis is a common diagnosis worldwide, with gallstone disease being the most prevalent cause (50%). The American College of Gastroenterology recommends urgent endoscopic retrograde cholangiopancreatography (ERCP) (within 24 h) for patients with biliary pancreatitis accompanied by cholangitis. Most international guidelines recommend that ERCP be performed within 72 h in patients with biliary pancreatitis and a bile duct obstruction without cholangitis, but the optimal timing for endoscopy is controversial. We investigated the optimal timing for ERCP in patients with biliary pancreatitis and a bile duct obstruction without cholangitis, and whether performing endoscopy within 24 h is superior to performing it after 24 h. We analyzed the clinical data of 505 patients with newly diagnosed acute pancreatitis, from January 1, 2005 to December 31, 2014. We divided the patients into two groups according to the timing of ERCP: < 24 h (urgent) and 24–72 h (early).Among the 505 patients, 73 were diagnosed with biliary pancreatitis and a bile duct obstruction without cholangitis. The mean age of the patients was 55 years (range: 26–90 years). Bile duct stones and biliary sludge were identified on endoscopy in 45 (61.6%) and 11 (15.0%) patients, respectively. The timing of ERCP within 72 h was not associated with ERCP-related complications (P = 0.113), and the total length of hospital stay was not different between urgent and early ERCP (5.9 vs. 5.7 days, P = 0.174). No significant differences were found in total length of hospitalization or procedural-related complications, in patients with biliary pancreatitis and a bile duct obstruction without cholangitis, according to the timing of ERCP (< 24 h vs. 24–72 h).
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Affiliation(s)
- Hee Seung Lee
- Department of Internal Medicine, Institute of Gastroenterology, Yonsei University College of Medicine, Seoul, Korea
| | - Moon Jae Chung
- Department of Internal Medicine, Institute of Gastroenterology, Yonsei University College of Medicine, Seoul, Korea
- * E-mail:
| | - Jeong Youp Park
- Department of Internal Medicine, Institute of Gastroenterology, Yonsei University College of Medicine, Seoul, Korea
| | - Seungmin Bang
- Department of Internal Medicine, Institute of Gastroenterology, Yonsei University College of Medicine, Seoul, Korea
| | - Seung Woo Park
- Department of Internal Medicine, Institute of Gastroenterology, Yonsei University College of Medicine, Seoul, Korea
| | - Si Young Song
- Department of Internal Medicine, Institute of Gastroenterology, Yonsei University College of Medicine, Seoul, Korea
| | - Jae Bock Chung
- Department of Internal Medicine, Institute of Gastroenterology, Yonsei University College of Medicine, Seoul, Korea
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Diagnostic value of magnetic resonance cholangiopancreatography to detect bile duct stones in acute biliary pancreatitis. Pancreatology 2018; 18:22-28. [PMID: 29246689 DOI: 10.1016/j.pan.2017.12.004] [Citation(s) in RCA: 20] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/18/2017] [Accepted: 12/07/2017] [Indexed: 12/11/2022]
Abstract
OBJECTIVES This study aims to evaluate the diagnostic value of magnetic resonance cholangiopancreatography (MRCP) in detecting common bile duct (CBD) stones in acute biliary pancreatitis (ABP). METHODS The medical records of patients presenting with ABP from January 2008 to July 2013 were reviewed to assess the value of MRCP in detecting CBD stones in ABP. Endoscopic retrograde cholangiopancreatography (ERCP) was used as the reference standard to assess the diagnostic yield of MRCP in detecting choledocholithiasis. When ERCP was unavailable, intraoperative cholangiography or clinical follow-up was used as the reference standard. RESULTS Seventy-eight patients who underwent MRCP were diagnosed with ABP, and thirty of the 78 patients (38%) were confirmed to have CBD stones per the study protocol. The sensitivity of MRCP in detecting CBD stones in ABP was 93.3% compared to 66.7% for abdominal CT (P < 0.008). The overall accuracy of MRCP in detecting choledocholithiasis was 85.9% compared to 74.0% for abdominal CT (P < 0.041). The area under the receiver operating characteristic curve (AUC) of MRCP in detecting CBD stones was 0.882, which was more accurate than the AUC of 0.727 for abdominal CT (P = 0.039). In 38 patients who underwent ERCP, the sensitivity and negative predictive value of MRCP in detecting CBD stones were both 100% regardless of the dilatation of the bile duct (≥7 mm versus < 7 mm). CONCLUSION MRCP is an effective, noninvasive modality to detect CBD stones in ABP and can help identify patients who require ERCP.
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van Dijk SM, Hallensleben NDL, van Santvoort HC, Fockens P, van Goor H, Bruno MJ, Besselink MG. Acute pancreatitis: recent advances through randomised trials. Gut 2017; 66:2024-2032. [PMID: 28838972 DOI: 10.1136/gutjnl-2016-313595] [Citation(s) in RCA: 225] [Impact Index Per Article: 32.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/20/2017] [Revised: 07/05/2017] [Accepted: 07/07/2017] [Indexed: 12/19/2022]
Abstract
Acute pancreatitis is one of the most common GI conditions requiring acute hospitalisation and has a rising incidence. In recent years, important insights on the management of acute pancreatitis have been obtained through numerous randomised controlled trials. Based on this evidence, the treatment of acute pancreatitis has gradually developed towards a tailored, multidisciplinary effort, with distinctive roles for gastroenterologists, radiologists and surgeons. This review summarises how to diagnose, classify and manage patients with acute pancreatitis, emphasising the evidence obtained through randomised controlled trials.
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Affiliation(s)
- Sven M van Dijk
- Department of Surgery, Amsterdam Gastroenterology and Metabolism, Academic Medical Center, Amsterdam, The Netherlands
| | - Nora D L Hallensleben
- Department of Gastroenterology & Hepatology, Erasmus University Medical Center, Rotterdam, The Netherlands
| | | | - Paul Fockens
- Department of Gastroenterology & Hepatology, Amsterdam Gastroenterology and Metabolism, Academic Medical Center, Amsterdam, The Netherlands
| | - Harry van Goor
- Department of Surgery, Radboud University Medical Center, Nijmegen, The Netherlands
| | - Marco J Bruno
- Department of Gastroenterology & Hepatology, Erasmus University Medical Center, Rotterdam, The Netherlands
| | - Marc G Besselink
- Department of Surgery, Amsterdam Gastroenterology and Metabolism, Academic Medical Center, Amsterdam, The Netherlands
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Badru F, Saxena S, Breeden R, Bourdillon M, Fitzpatrick C, Chatoorgoon K, Greenspon J, Villalona G. Optimal timing of cholecystectomy in children with gallstone pancreatitis. J Surg Res 2017; 215:225-230. [PMID: 28688652 DOI: 10.1016/j.jss.2017.03.045] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/04/2016] [Revised: 03/04/2017] [Accepted: 03/29/2017] [Indexed: 12/18/2022]
Abstract
BACKGROUND Little data exist regarding the recurrence of pancreatitis in pediatric patients with gallstone pancreatitis awaiting cholecystectomy. This study evaluates the recurrence rate of pancreatitis after acute gallstone pancreatitis based on the timing of cholecystectomy in pediatric patients. MATERIALS AND METHODS A retrospective chart review of all patients admitted with gallstone pancreatitis from 2007 to 2015 was performed. Children were divided into the following five groups. Group 1 had surgery during the index admission. Group 2 had surgery within 2 wk of discharge. Group 3 had surgery between 2 and 6 wk postdischarge. Group 4 had surgery 6 wk after discharge, and group 5 patients had no surgery. The recurrence rates of pancreatitis were calculated for all groups. RESULTS Forty-eight patients with gallstone pancreatitis were identified in this study. The 19 patients in group 1 had no recurrence of their pancreatitis. Of the remaining 29 patients, nine (31%) had recurrence of pancreatitis or required readmission for abdominal pain prior to their cholecystectomy. In group 2, two of the eight patients (25%) had recurrent pancreatitis. In group 3, three of eight patients (37.5%) developed recurrent pancreatitis. In group 4, three of five patients (60%), and in group 5, one of eight. No children in group 5 had demonstrable gallstones at presentation, only sludge in their gallbladder. CONCLUSIONS Cholecystectomy during the index admission is associated with no recurrence or readmission for pancreatitis. Therefore, we recommend that cholecystectomy be performed after resolution of an episode of gallstone pancreatitis during index admission.
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Affiliation(s)
- Faidah Badru
- Department of Pediatric Surgery, Cardinal Glennon Children's Hospital, St. Louis, Missouri.
| | - Saurabh Saxena
- Department of Pediatric Surgery, Cardinal Glennon Children's Hospital, St. Louis, Missouri
| | - Robert Breeden
- Department of Education, St. Louis University School of Medicine, St. Louis, Missouri
| | - Maximillan Bourdillon
- Department of Education, St. Louis University School of Medicine, St. Louis, Missouri
| | - Colleen Fitzpatrick
- Department of Pediatric Surgery, Cardinal Glennon Children's Hospital, St. Louis, Missouri
| | - Kaveer Chatoorgoon
- Department of Pediatric Surgery, Cardinal Glennon Children's Hospital, St. Louis, Missouri
| | - Jose Greenspon
- Department of Pediatric Surgery, Cardinal Glennon Children's Hospital, St. Louis, Missouri
| | - Gustavo Villalona
- Department of Pediatric Surgery, Cardinal Glennon Children's Hospital, St. Louis, Missouri
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Early management of acute pancreatitis: A review of the best evidence. Dig Liver Dis 2017; 49:585-594. [PMID: 28262458 DOI: 10.1016/j.dld.2017.01.168] [Citation(s) in RCA: 54] [Impact Index Per Article: 7.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/10/2016] [Revised: 01/27/2017] [Accepted: 01/27/2017] [Indexed: 12/11/2022]
Abstract
In the 20th century early management of acute pancreatitis often included surgical intervention, despite overwhelming mortality. The emergence of high-quality evidence (randomized controlled trials and meta-analyses) over the past two decades has notably shifted the treatment paradigm towards predominantly non-surgical management early in the course of acute pancreatitis. The present evidence-based review focuses on contemporary aspects of early management (which include analgesia, fluid resuscitation, antibiotics, nutrition, and endoscopic retrograde cholangiopancreatography) with a view to providing clear and succinct guidelines on early management of patients with acute pancreatitis in 2017 and beyond.
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Kim SB, Kim TN, Chung HH, Kim KH. Small Gallstone Size and Delayed Cholecystectomy Increase the Risk of Recurrent Pancreatobiliary Complications After Resolved Acute Biliary Pancreatitis. Dig Dis Sci 2017; 62:777-783. [PMID: 28035552 DOI: 10.1007/s10620-016-4428-3] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/13/2016] [Accepted: 12/19/2016] [Indexed: 12/12/2022]
Abstract
INTRODUCTION Acute biliary pancreatitis (ABP) is a severe complication of gallstone disease with considerable mortality, and its recurrence rate is reported as 50-90% for ABP patients who do not undergo cholecystectomy. However, the incidence of and risk factors for recurrent pancreatobiliary complications after the initial improvement of ABP are not well established in the literature. The aims of this study were to determine the risk factors for recurrent pancreatobiliary complications and to compare the outcomes between early (within 2 weeks after onset of pancreatitis) and delayed cholecystectomy in patients with ABP. METHODS Patients diagnosed with ABP at Yeungnam University Hospital from January 2004 to July 2016 were retrospectively reviewed. The following risk factors for recurrent pancreatobiliary complications (acute pancreatitis, acute cholecystitis, and acute cholangitis) were analyzed: demographic characteristics, laboratory data, size and number of gallstones, severity of pancreatitis, endoscopic sphincterotomy, and timing of cholecystectomy. Patients were categorized into two groups: patients with recurrent pancreatobiliary complications (Group A) and patients without pancreatobiliary complications (Group B). RESULTS Of the total 290 patients with ABP (age 66.8 ± 16.0 years, male 47.9%), 56 (19.3%) patients developed recurrent pancreatobiliary complications, of which 35 cases were acute pancreatitis, 11 cases were acute cholecystitis, and 10 cases were acute cholangitis. Endoscopic sphincterotomy and cholecystectomy were performed in 134 (46.2%) patients and 95 (32.8%) patients, respectively. Age, sex, BMI, diabetes, number of stone, severity of pancreatitis, and laboratory data were not significantly correlated with recurrent pancreatobiliary complications. The risk of recurrent pancreatobiliary complications was significantly increased in the delayed cholecystectomy group compared with the early cholecystectomy group (45.5 vs. 5.0%, p < 0.001). Based on the multivariate logistic regression analyses, two factors, size of gallstone less than or equal to 5 mm and delayed cholecystectomy, were found as risk factors associated with recurrent pancreatobiliary complications. CONCLUSION The incidence of recurrent pancreatobiliary complications was 19.3% and was significantly increased in patients with size of gallstone less than or equal to 5 mm and in those who underwent delayed cholecystectomy.
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Affiliation(s)
- Sung Bum Kim
- Division of Gastroenterology and Hepatology, Department of Internal Medicine, Yeungnam University College of Medicine, 317-1 Daemyung-dong, Nam-gu, Daegu, 705-717, Republic of Korea
| | - Tae Nyeun Kim
- Division of Gastroenterology and Hepatology, Department of Internal Medicine, Yeungnam University College of Medicine, 317-1 Daemyung-dong, Nam-gu, Daegu, 705-717, Republic of Korea.
| | - Hyun Hee Chung
- Division of Gastroenterology and Hepatology, Department of Internal Medicine, Yeungnam University College of Medicine, 317-1 Daemyung-dong, Nam-gu, Daegu, 705-717, Republic of Korea
| | - Kook Hyun Kim
- Division of Gastroenterology and Hepatology, Department of Internal Medicine, Yeungnam University College of Medicine, 317-1 Daemyung-dong, Nam-gu, Daegu, 705-717, Republic of Korea
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Young SH, Peng YL, Lin XH, Chen YT, Luo JC, Wang YP, Hou MC, Lee FY. Cholecystectomy Reduces Recurrent Pancreatitis and Improves Survival After Endoscopic Sphincterotomy. J Gastrointest Surg 2017; 21:294-301. [PMID: 27796634 DOI: 10.1007/s11605-016-3284-y] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/17/2016] [Accepted: 09/17/2016] [Indexed: 01/31/2023]
Abstract
BACKGROUND The aim of this study was to assess whether cholecystectomy can decrease the recurrent pancreatitis in the elderly patients who received endoscopic retrograde cholangiopancreatography (ERCP) with endoscopic sphincterotomy (EST) and successful clearance of bile duct (BD) stones after gallstone-related acute pancreatitis. METHODS We analyzed data from National Health Insurance Research Database of Taiwan. Elderly patients (age ≧70 years old) who had gallstone-related acute pancreatitis and underwent successful EST with BD stones clearance were eligible for enrollment. This nationwide, population-based, propensity score (PS)-matched cohort study involved two cohorts: (1) patients who underwent cholecystectomy after ERCP with BD stone clearance as study group and (2) those who adopted wait-and-see strategy (without cholecystectomy) after ERCP with BD stone clearance as control group. The primary and secondary endpoints were recurrent acute pancreatitis and all-cause mortality, respectively. RESULTS During the study period, a total of 670 elderly patients (male 291, female 379) with a mean age of 79.1 was enrolled for analysis after PS matching. The incidence rate of recurrent acute pancreatitis was 12.39 per 1000 person-years in the cholecystectomy cohort and 23.94 per 1000 person-years in the PS-matched control cohort. The risk of recurrent acute pancreatitis was significantly lower in the cholecystectomy cohort (HR, 0.56; 95 % confidence interval [CI], 0.34-0.91; P = 0.021). The HR for all-cause mortality among the cholecystectomy cohort was 0.75 (95 % CI, 0.59-0.95; P = 0.016) compared with the control cohort. CONCLUSIONS Cholecystectomy decreased the subsequent recurrent acute pancreatitis and the all-cause mortality in elderly patients with EST and clearance of BD stones after gallstone-related acute pancreatitis.
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Affiliation(s)
- Shih-Hao Young
- Department of Medicine, School of Medicine, National Yang-Ming University, Taipei, Taiwan.,Department of Medicine, Division of Gastroenterology and Hepatology, Taipei Veterans General Hospital, 201, Shih-Pai Road, Section 2, Taipei, 11217, Taiwan
| | - Yen-Ling Peng
- Department of Medicine, School of Medicine, National Yang-Ming University, Taipei, Taiwan.,Department of Medicine, Division of Gastroenterology and Hepatology, Taipei Veterans General Hospital, 201, Shih-Pai Road, Section 2, Taipei, 11217, Taiwan
| | - Xi-Hsuan Lin
- Department of Medicine, School of Medicine, National Yang-Ming University, Taipei, Taiwan.,Department of Medicine, Division of Gastroenterology and Hepatology, Taipei Veterans General Hospital, 201, Shih-Pai Road, Section 2, Taipei, 11217, Taiwan
| | - Yung-Tai Chen
- Department of Medicine, School of Medicine, National Yang-Ming University, Taipei, Taiwan. .,Department of Medicine, Taipei City Hospital Heping Fuyou Branch, 33, Zhonghua Road, Section 2, Taipei, Taiwan.
| | - Jiing-Chyuan Luo
- Department of Medicine, School of Medicine, National Yang-Ming University, Taipei, Taiwan. .,Department of Medicine, Division of Gastroenterology and Hepatology, Taipei Veterans General Hospital, 201, Shih-Pai Road, Section 2, Taipei, 11217, Taiwan. .,Endoscopic Center for Diagnosis and Therapy, Taipei Veterans General Hospital, Taipei, Taiwan.
| | - Yen-Po Wang
- Department of Medicine, School of Medicine, National Yang-Ming University, Taipei, Taiwan.,Endoscopic Center for Diagnosis and Therapy, Taipei Veterans General Hospital, Taipei, Taiwan
| | - Ming-Chih Hou
- Department of Medicine, School of Medicine, National Yang-Ming University, Taipei, Taiwan.,Department of Medicine, Division of Gastroenterology and Hepatology, Taipei Veterans General Hospital, 201, Shih-Pai Road, Section 2, Taipei, 11217, Taiwan.,Endoscopic Center for Diagnosis and Therapy, Taipei Veterans General Hospital, Taipei, Taiwan
| | - Fa-Yauh Lee
- Department of Medicine, School of Medicine, National Yang-Ming University, Taipei, Taiwan.,Department of Medicine, Division of Gastroenterology and Hepatology, Taipei Veterans General Hospital, 201, Shih-Pai Road, Section 2, Taipei, 11217, Taiwan
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42
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Rao SA, Kunte AR. Interleukin-6: An Early Predictive Marker for Severity of Acute Pancreatitis. Indian J Crit Care Med 2017; 21:424-428. [PMID: 28808361 PMCID: PMC5538089 DOI: 10.4103/ijccm.ijccm_478_16] [Citation(s) in RCA: 26] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022] Open
Abstract
Background and Aims: Interleukin (IL)-6, IL-8, IL-10, and C-reactive protein (CRP) have been evaluated for predicting outcomes of acute pancreatitis. However, there is considerable variation in their performance among different studies. We evaluate their accuracy in predicting progression to severe pancreatitis. Materials and Methods: Serum IL-6, IL-8, IL-10, and CRP levels were measured within 24 h of admission in forty patients of clinically predicted severe acute pancreatitis (SAP). Persistent organ failure (>48 h) defined SAP. The performance of inflammatory markers was evaluated in predicting the progression of pancreatitis. Results: IL-6 ≥28.90 pg/mL had a sensitivity of 62.86%, specificity of 80%, positive predictive value (PPV) of 95.65%, LR+ of 3.1429, LR− of 0.4643, and diagnostic odds ratio (DOR) of 6.7692; IL-8 ≥88.70 pg/mL had a sensitivity of 60%, specificity of 80%, PPV of 95.45%, LR+ of 3.000, LR− of 0.5000, and DOR of 6.000; IL-10 ≤5.70 pg/mL had DOR of 0.2647, sensitivity of 51.43%, specificity of 20%, PPV of 81.82%, LR+ of 0.6429, and LR− of 2.4286. CRP ≥110.00 mg/L had DOR of 2.3636, sensitivity of 37.14%, specificity of 80%, PPV of 92.86%, LR+ of 1.8571, and LR of 0.7857. Conclusions: IL-6 ≥28.90 pg/mL, measured within 48 h of onset is the best among the tested biomarkers in this study for predicting the progression to severe pancreatitis.
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Affiliation(s)
- Shilpa A Rao
- Department of General Surgery, KEM Hospital, Seth G.S. Medical College, Mumbai, Maharashtra, India
| | - Aditya R Kunte
- Department of General Surgery, KEM Hospital, Seth G.S. Medical College, Mumbai, Maharashtra, India
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43
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Clinical significance of Urinary Amylase in Acute Pancreatitis. ARCHIVES OF SURGERY AND CLINICAL RESEARCH 2017. [DOI: 10.29328/journal.ascr.1001004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/06/2022]
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44
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Párniczky A, Kui B, Szentesi A, Balázs A, Szűcs Á, Mosztbacher D, Czimmer J, Sarlós P, Bajor J, Gódi S, Vincze Á, Illés A, Szabó I, Pár G, Takács T, Czakó L, Szepes Z, Rakonczay Z, Izbéki F, Gervain J, Halász A, Novák J, Crai S, Hritz I, Góg C, Sümegi J, Golovics P, Varga M, Bod B, Hamvas J, Varga-Müller M, Papp Z, Sahin-Tóth M, Hegyi P. Prospective, Multicentre, Nationwide Clinical Data from 600 Cases of Acute Pancreatitis. PLoS One 2016; 11:e0165309. [PMID: 27798670 PMCID: PMC5087847 DOI: 10.1371/journal.pone.0165309] [Citation(s) in RCA: 149] [Impact Index Per Article: 18.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/06/2016] [Accepted: 10/10/2016] [Indexed: 12/28/2022] Open
Abstract
Objective The aim of this study was to analyse the clinical characteristics of acute pancreatitis (AP) in a prospectively collected, large, multicentre cohort and to validate the major recommendations in the IAP/APA evidence-based guidelines for the management of AP. Design Eighty-six different clinical parameters were collected using an electronic clinical research form designed by the Hungarian Pancreatic Study Group. Patients 600 adult patients diagnosed with AP were prospectively enrolled from 17 Hungarian centres over a two-year period from 1 January 2013. Main Results With respect to aetiology, biliary and alcoholic pancreatitis represented the two most common forms of AP. The prevalence of biliary AP was higher in women, whereas alcoholic AP was more common in men. Hyperlipidaemia was a risk factor for severity, lack of serum enzyme elevation posed a risk for severe AP, and lack of abdominal pain at admission demonstrated a risk for mortality. Abdominal tenderness developed in all the patients with severe AP, while lack of abdominal tenderness was a favourable sign for mortality. Importantly, lung injury at admission was associated with mortality. With regard to laboratory parameters, white blood cell count and CRP were the two most sensitive indicators for severe AP. The most common local complication was peripancreatic fluid, whereas the most common distant organ failure in severe AP was lung injury. Deviation from the recommendations in the IAP/APA evidence-based guidelines on fluid replacement, enteral nutrition and timing of interventions increased severity and mortality. Conclusions Analysis of a large, nationwide, prospective cohort of AP cases allowed for the identification of important determinants of severity and mortality. Evidence-based guidelines should be observed rigorously to improve outcomes in AP.
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Affiliation(s)
| | - Balázs Kui
- First Department of Medicine, University of Szeged, Szeged, Hungary
| | - Andrea Szentesi
- First Department of Medicine, University of Szeged, Szeged, Hungary.,Institute for Translational Medicine, University of Pécs, Pécs, Hungary
| | - Anita Balázs
- First Department of Medicine, University of Szeged, Szeged, Hungary
| | - Ákos Szűcs
- First Department of Surgery, Semmelweis University, Budapest, Hungary
| | - Dóra Mosztbacher
- Department of Pediatrics, Balassa János Hospital of County Tolna, Szekszárd, Hungary
| | - József Czimmer
- First Department of Medicine, University of Pécs, Pécs, Hungary
| | - Patrícia Sarlós
- First Department of Medicine, University of Pécs, Pécs, Hungary
| | - Judit Bajor
- First Department of Medicine, University of Pécs, Pécs, Hungary
| | - Szilárd Gódi
- First Department of Medicine, University of Pécs, Pécs, Hungary
| | - Áron Vincze
- First Department of Medicine, University of Pécs, Pécs, Hungary
| | - Anita Illés
- First Department of Medicine, University of Pécs, Pécs, Hungary
| | - Imre Szabó
- First Department of Medicine, University of Pécs, Pécs, Hungary
| | - Gabriella Pár
- First Department of Medicine, University of Pécs, Pécs, Hungary
| | - Tamás Takács
- First Department of Medicine, University of Szeged, Szeged, Hungary
| | - László Czakó
- First Department of Medicine, University of Szeged, Szeged, Hungary
| | - Zoltán Szepes
- First Department of Medicine, University of Szeged, Szeged, Hungary
| | - Zoltán Rakonczay
- First Department of Medicine, University of Szeged, Szeged, Hungary
| | - Ferenc Izbéki
- Szent György University Teaching Hospital of County Fejér, Székesfehérvár, Hungary
| | - Judit Gervain
- Szent György University Teaching Hospital of County Fejér, Székesfehérvár, Hungary
| | - Adrienn Halász
- Szent György University Teaching Hospital of County Fejér, Székesfehérvár, Hungary
| | - János Novák
- Pándy Kálmán Hospital of County Békés, Gyula, Hungary
| | - Stefan Crai
- Pándy Kálmán Hospital of County Békés, Gyula, Hungary
| | - István Hritz
- Bács-Kiskun County University Teaching Hospital, Kecskemét, Hungary
| | - Csaba Góg
- Healthcare Center of County Csongrád, Makó, Hungary
| | - János Sümegi
- Borsod-Abaúj-Zemplén County Hospital and University Teaching Hospital, Miskolc, Hungary
| | - Petra Golovics
- First Department of Medicine, Semmelweis University, Budapest, Hungary
| | | | | | | | | | - Zsuzsanna Papp
- Institute for Translational Medicine, University of Pécs, Pécs, Hungary
| | - Miklós Sahin-Tóth
- Department of Molecular and Cell Biology, Boston University Henry M. Goldman School of Dental Medicine, Boston, United States of America
| | - Péter Hegyi
- First Department of Medicine, University of Szeged, Szeged, Hungary.,Institute for Translational Medicine, University of Pécs, Pécs, Hungary.,Hungarian Academy of Sciences - University of Szeged, Momentum Gastroenterology Multidisciplinary Research Group, Szeged, Hungary
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EASL Clinical Practice Guidelines on the prevention, diagnosis and treatment of gallstones. J Hepatol 2016; 65:146-181. [PMID: 27085810 DOI: 10.1016/j.jhep.2016.03.005] [Citation(s) in RCA: 263] [Impact Index Per Article: 32.9] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/09/2016] [Accepted: 03/09/2016] [Indexed: 02/06/2023]
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46
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Seidner DL, Steinberg WM. Acute Pancreatitis: Work-up and Management. J Intensive Care Med 2016. [DOI: 10.1177/088506669000500603] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Acute pancreatitis is still a common clinical entity that causes significant morbidity and mortality. The most common etiological associations include chronic al coholism, biliary tract disease, iatrogenic (e.g., endo scopic retrograde cholangiopancreatography-induced), hypertriglyceridemia, and idiopathic varieties. New radiological techniques such as dynamic pancreatog raphy appear to be useful in diagnosing and determin ing the extent of necrotizing pancreatitis. Biochem ical variables such as the C-reactive protein and the trypsinogen-activated peptide seem promising in de tecting severe disease within the first few days of hospi talization. Computed tomographic-guided percutane ous aspiration of phlegmonous pancreatitis may be helpful in differentiating infected from noninfected masses. Although current studies have not identified any pharmacological agent as efficacious in improving sur vival, emergency sphincterotomy and removal of im pacted gallstones in severe gallstone pancreatitis may be beneficial in this regard. Prolonged (i.e., 7 day) perito neal dialysis may reduce the severity of pancreatic sep sis. Surgical drainage of infected fluid collections such as abscesses is a well-accepted adjunct to medical therapy. Surgical necrosectomy for necrotizing pancreatitis, however, which is advocated in some aggressive surgi cal units, is not yet commonplace and its role needs to be determined in controlled studies.
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Affiliation(s)
- Douglas L. Seidner
- Division of Gastroenterology and Nutrition, Department of Medicine, George Washington University Medical Center, Washington, DC
| | - William M. Steinberg
- Division of Gastroenterology and Nutrition, Department of Medicine, George Washington University Medical Center, Washington, DC
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47
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Riff BP, Chandrasekhara V. The Role of Endoscopic Retrograde Cholangiopancreatography in Management of Pancreatic Diseases. Gastroenterol Clin North Am 2016; 45:45-65. [PMID: 26895680 DOI: 10.1016/j.gtc.2015.10.009] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
Endoscopic retrograde cholangiopancreatography is an effective platform for a variety of therapies in the management of benign and malignant disease of the pancreas. Over the last 50 years, endotherapy has evolved into the first-line therapy in the majority of acute and chronic inflammatory diseases of the pancreas. As this field advances, it is important that gastroenterologists maintain an adequate knowledge of procedure indication, maintain sufficient procedure volume to handle complex pancreatic endotherapy, and understand alternate approaches to pancreatic diseases including medical management, therapy guided by endoscopic ultrasonography, and surgical options.
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Affiliation(s)
- Brian P Riff
- Division of Gastroenterology, Icahn School of Medicine at Mount Sinai, One Gustave L. Levy Place, Box 1069, New York, NY 10029, USA
| | - Vinay Chandrasekhara
- Division of Gastroenterology, University of Pennsylvania Perelman School of Medicine, 3400 Civic Center Boulevard, Perelman Center for Advanced Medicine South Pavilion, 7th Floor, Philadelphia, PA 19104, USA.
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48
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Abstract
BACKGROUND Biliary pancreatitis (BP) is common in adults and children. Current standard of care is to perform a cholecystectomy (CCE) to decrease the recurrence risk of pancreatitis. Controversy exists as to the timing of surgery, early versus delayed surgical intervention. Adult literature suggests a greater benefit of early CCE. Comparatively, there is limited pediatric literature as to the optimal timing of a CCE in children. We report a retrospective case series of children with BP who underwent early versus late CCE. METHODS A retrospective chart review was performed of children with BP for a period of 45 months. Reviewed information included patient demographics, timing of CCE, and the occurrence of adverse events preceding or following surgical intervention. Early CCE was defined as surgery during the index admission; late CCE was defined as surgery during a subsequent admission. RESULTS Nineteen children and adolescents (17 girls) were identified to have had BP with a subsequent CCE. Cholecystectomy was performed early in 9 patients with no adverse events. Ten patients had delayed surgery with 4 occurrences of adverse clinical events (recurrence of pancreatitis or biliary colic abdominal pain) while awaiting their CCE. CONCLUSIONS Adverse biliary-related events occur at a higher rate in children with mild BP who undergo a delayed CCE when compared to early CCE performance. Early CCE is safe to perform in children with mild BP.
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49
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Lee JK. [Recent Advances in Management of Acute Pancreatitis]. THE KOREAN JOURNAL OF GASTROENTEROLOGY 2015; 66:135-43. [PMID: 26642477 DOI: 10.4166/kjg.2015.66.3.135] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
Acute pancreatitis is common but remains a condition with significant morbidity and mortality. Despite a better understanding of the pathophysiology of acute pancreatitis achieved during the past few decades, there is no specific pharmacologic entity available. Therefore, supportive care is still the mainstay of treatment. Recently, novel interventions for increasing survival and minimizing morbidity have been investigated, which are highlighted in this review.
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50
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da Costa DW, Schepers NJ, Römkens TEH, Boerma D, Bruno MJ, Bakker OJ. Endoscopic sphincterotomy and cholecystectomy in acute biliary pancreatitis. Surgeon 2015; 14:99-108. [PMID: 26542765 DOI: 10.1016/j.surge.2015.10.002] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/17/2015] [Revised: 10/05/2015] [Accepted: 10/06/2015] [Indexed: 02/07/2023]
Abstract
BACKGROUND This review discusses current insights with regard to biliary tract management during and after acute biliary pancreatitis. METHODS A MEDLINE and EMBASE search was done and studies were selected based on methodological quality and publication date. The recommendations of recent guidelines are incorporated in this review. In absence of consensus in the literature, expert opinion is expressed. RESULTS There is no role for early endoscopic retrograde cholangiopancreatography (ERCP) in patients with (predicted) mild biliary pancreatitis to improve outcome. In case of persisting choledocholithiasis, ERCP with stone extraction is scheduled electively when the acute event has subsided. Whether early ERCP with sphincterotomy is beneficial in patients with predicted severe pancreatitis remains subject to debate. Regardless of disease severity, in case of concomitant cholangitis urgent endoscopic sphincterotomy (ES) is recommended. As a definitive treatment to reduce the risk of recurrent biliary events in the long term, ES is inferior to cholecystectomy and should be reserved for patients considered unfit for surgery. After severe biliary pancreatitis, cholecystectomy should be postponed until all signs of inflammation have subsided. In patients with mild pancreatitis, cholecystectomy during the primary admission reduces the risk of recurrent biliary complications. CONCLUSION Recent research has provided valuable data to guide biliary tract management in the setting of acute biliary pancreatitis with great value and benefit for patients and clinicians. Some important clinical dilemmas remain, but it is anticipated that on-going clinical trials will deliver some important insights and additional guidance soon.
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Affiliation(s)
- D W da Costa
- Department of Surgery, St. Antonius Hospital, Nieuwegein, The Netherlands
| | - N J Schepers
- Department of Gastroenterology and Hepatology, Erasmus Medical Center, Rotterdam, The Netherlands; Department of Gastroenterology and Hepatology, St. Antonius Hospital, Nieuwegein, The Netherlands
| | - T E H Römkens
- Department of Gastroenterology and Hepatology, Jeroen Bosch Hospital, 's-Hertogenbosch, The Netherlands
| | - D Boerma
- Department of Surgery, St. Antonius Hospital, Nieuwegein, The Netherlands
| | - M J Bruno
- Department of Gastroenterology and Hepatology, Erasmus Medical Center, Rotterdam, The Netherlands
| | - O J Bakker
- Department of Surgery, University Medical Center, Utrecht, The Netherlands.
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