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Sivakumar SG, Sekaran M, Muthukrishnan S, Natesan AV, Nalankilli VP, Senthilnathan P, Palanivelu C. Laparoscopic necrosectomy for acute necrotising pancreatitis: Retrospective analysis of a decade-long experience from a tertiary centre. J Minim Access Surg 2024; 20:127-135. [PMID: 38557646 PMCID: PMC11095801 DOI: 10.4103/jmas.jmas_215_22] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/03/2022] [Revised: 12/01/2023] [Accepted: 12/02/2023] [Indexed: 04/04/2024] Open
Abstract
INTRODUCTION The objective of this study is to evaluate the role of minimally invasive surgery for the management of necrotising pancreatitis in acute settings and to propose tailor-made approaches to deal with various locations of pancreatic necrosis. PATIENTS AND METHODS Three hundred and thirteen patients underwent laparoscopic management of necrotising pancreatitis in this study period from January 2010 to June 2021, out of which 122 patients underwent minimally invasive necrosectomy for acute necrotising pancreatitis. The remaining 191 patients underwent laparoscopic internal drainage in the form of cystogastrostomy/cystojejunostomy for walled-off pancreatic necrosis. RESULTS Mean body mass index was 26.45 ± 3.78 kg/sqm. Mean operating time was 56.40 ± 20.48 min and mean blood loss was 120 ± 31.45 mL. Ten patients required reoperation (6 underwent open procedure and 4 underwent laparoscopic redo necrosectomy). Six patients died of multi-organ failure. The mean duration of return of bowel function was 5 ± 1.8 days. The mean length of hospital stay after surgery was 10.19 ± 7.09 days. There were no major wound-related complications. CONCLUSION A minimally invasive approach to pancreatic necrosectomy is safe and feasible with good outcomes in centres with advanced laparoscopic expertise. It requires not only careful case selection but also proper timing and the ideal route of access to achieve optimal outcomes.
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Affiliation(s)
| | - Monika Sekaran
- Department of HPB, Minimal Access Surgery and Liver Transplant, Gem Hospital, Chennai, Tamil Nadu, India
| | - Srinivasan Muthukrishnan
- Department of HPB, Minimal Access Surgery and Liver Transplant, Gem Hospital, Chennai, Tamil Nadu, India
| | - Anand Vijai Natesan
- Department of HPB, Minimal Access Surgery and Liver Transplant, Gem Hospital, Chennai, Tamil Nadu, India
| | - V. P. Nalankilli
- Department of HPB, Minimal Access Surgery and Liver Transplant, Gem Hospital, Chennai, Tamil Nadu, India
| | - Palanisamy Senthilnathan
- Department of HPB, Minimal Access Surgery and Liver Transplant, Gem Hospital, Chennai, Tamil Nadu, India
| | - Chinnusamy Palanivelu
- Department of HPB, Minimal Access Surgery and Liver Transplant, Gem Hospital, Chennai, Tamil Nadu, India
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Yang Y, Liu Y, Liu Z, Peng T, Wang C, Wu H, Gou S. Laparoscopic necrosectomy for acute necrotizing pancreatitis: mesocolon-preserving approach and outcomes. Updates Surg 2024; 76:487-493. [PMID: 38429596 DOI: 10.1007/s13304-024-01773-y] [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] [Received: 10/27/2023] [Accepted: 01/29/2024] [Indexed: 03/03/2024]
Abstract
The surgical treatment of acute necrotizing pancreatitis has significantly evolved in recent years with the advent of enhanced imaging techniques and minimally invasive surgery. Various minimally invasive techniques, such as video-assisted retroperitoneal debridement (VARD) and endoscopic transmural necrosectomy (ETN), have been employed in the management of acute necrotizing pancreatitis and are often part of step-up approaches. However, almost all reported step-up approaches only employ a fixed minimally invasive technique prior to open surgery. In contrast, we implemented different minimally invasive techniques during the treatment of acute pancreatitis based on the extent of pancreatic necrosis. For acute necrotizing pancreatitis of the pancreatic bed with or without extension into the left retroperitoneum, we performed mesocolon-preserving laparoscopic necrosectomy for debridment. The quantitative indication for pancreatic debridment in our institute has been described previously. For acute necrotizing pancreatitis of the pancreatic bed with or without extension into the left retroperitoneum, mesocolon-preserving laparoscopic necrosectomy was performed for debridment. To safeguard the mesocolon, the pancreatic bed was entered via the gastrocolic ligament, and the left retroperitoneum was accessed via the lateral peritoneal attachments of the descending colon. Of the 77 patients requiring pancreatic debridment, 41 patients were deemed suitable for mesocolon-preserving laparoscopic necrosectomy by multiple disciplinary team and informed consent was acquired. Of these 41 patients, 27 underwent percutaneous drainage, 10 underwent transluminal drainage, and 2 underwent transluminal necrosectomy prior to laparoscopic necrosectomy. Two patients (4.88%) died of sepsis, three patients (7.32%) required further laparotomic necrosectomy, and five patients (12.20%) required additional percutaneous drainage for residual infection. Three patients (7.32%) experienced duodenal fistula, all of which were cured through non-surgical treatments. Nineteen patients (46.34%) developed pancreatic fistula that persisted for over 3 weeks, with 17 being successfully treated non-surgically. The remaining two patients had pancreatic fistulas that lasted over 3 months; an internal drainage procedure has been planned for them. No patient developed colonic fistula. Mesocolon-preserving laparoscopic necrosectomy proved to be safe and effective in selected patients. It can serve as a supplementary procedure for step-up approaches or as an alternative to other debridment procedures such as VARD, ETN, and laparotomic necrosectomy.
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Affiliation(s)
- Yuxin Yang
- Department of Pancreatic Surgery, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, 1277 Jifang Avenue, Wuhan, 430022, China
- Sino-German Laboratory of Personalized Medicine for Pancreatic Cancer, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Yang Liu
- Sino-German Laboratory of Personalized Medicine for Pancreatic Cancer, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
- Department of Gastrointestinal Surgery, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Zhiqiang Liu
- Department of Pancreatic Surgery, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, 1277 Jifang Avenue, Wuhan, 430022, China
- Sino-German Laboratory of Personalized Medicine for Pancreatic Cancer, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Tao Peng
- Department of Pancreatic Surgery, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, 1277 Jifang Avenue, Wuhan, 430022, China
- Sino-German Laboratory of Personalized Medicine for Pancreatic Cancer, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Chunyou Wang
- Department of Pancreatic Surgery, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, 1277 Jifang Avenue, Wuhan, 430022, China
- Sino-German Laboratory of Personalized Medicine for Pancreatic Cancer, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Heshui Wu
- Department of Pancreatic Surgery, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, 1277 Jifang Avenue, Wuhan, 430022, China
- Sino-German Laboratory of Personalized Medicine for Pancreatic Cancer, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Shanmiao Gou
- Department of Pancreatic Surgery, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, 1277 Jifang Avenue, Wuhan, 430022, China.
- Sino-German Laboratory of Personalized Medicine for Pancreatic Cancer, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China.
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Binda C, Perini B, Coluccio C, Giuffrida P, Fabbri S, Gibiino G, Vizzuso A, Giampalma E, Fabbri C. Metal stent and percutaneous endoscopic necrosectomy as dual approach for the management of complex walled-off pancreatic necrosis. Minerva Surg 2024; 79:183-196. [PMID: 38127434 DOI: 10.23736/s2724-5691.23.10132-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/23/2023]
Abstract
Pancreatic fluid collections (PFCs) are one of the local complications of acute pancreatitis and include walled-off pancreatic necrosis (WOPN), which are complex entities with challenging management. The infection of pancreatic necrosis leads to a poorer prognosis, with a growth of the mortality rate up to 30%. The primary strategy for managing PFCs is a minimally invasive step-up approach, with endosonography-guided transmural drainage and debridement as the preferred and less invasive method. Percutaneous drainage (PCD) can be the technique of choice when endoscopic drainage is not feasible, for example for early PFCs without a mature wall or for the anatomic location and extension to the paracolic gutter of the collection. As PCD alone may be ineffective, especially when a great amount of necrosis is present, a percutaneous endoscopic necrosectomy (PEN) has been proposed, showing interesting results. The technique consists of the placement of an esophageal fully or partially covered self-expandable metal stent (SEMS) percutaneously into the collection and a direct debridement can be performed using a flexible endoscope through the SEMS. In this review, we will discuss about the role of metal stent and PEN for the management of complex walled-off pancreatic necrosis.
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Affiliation(s)
- Cecilia Binda
- Unit of Gastroenterology and Digestive Endoscopy, Forlì-Cesena Hospitals, AUSL Romagna, Forlì-Cesena, Italy
| | - Barbara Perini
- Unit of Gastroenterology and Digestive Endoscopy, Forlì-Cesena Hospitals, AUSL Romagna, Forlì-Cesena, Italy -
- Department of Surgery, Oncology and Gastroenterology (DISCOG), University Hospital of Padua, Padua, Italy
| | - Chiara Coluccio
- Unit of Gastroenterology and Digestive Endoscopy, Forlì-Cesena Hospitals, AUSL Romagna, Forlì-Cesena, Italy
| | - Paolo Giuffrida
- Unit of Gastroenterology and Digestive Endoscopy, Forlì-Cesena Hospitals, AUSL Romagna, Forlì-Cesena, Italy
- Section of Gastroenterology and Hepatology, Department of Health Promotion Sciences Maternal and Infant Care, Internal Medicine and Medical Specialties, PROMISE, University of Palermo, Palermo, Italy
| | - Stefano Fabbri
- Unit of Gastroenterology and Digestive Endoscopy, Forlì-Cesena Hospitals, AUSL Romagna, Forlì-Cesena, Italy
| | - Giulia Gibiino
- Unit of Gastroenterology and Digestive Endoscopy, Forlì-Cesena Hospitals, AUSL Romagna, Forlì-Cesena, Italy
| | - Antonio Vizzuso
- Unit of Radiology, Morgagni-Pierantoni Hospital, AUSL Romagna, Forlì, Italy
| | - Emanuela Giampalma
- Unit of Radiology, Morgagni-Pierantoni Hospital, AUSL Romagna, Forlì, Italy
| | - Carlo Fabbri
- Unit of Gastroenterology and Digestive Endoscopy, Forlì-Cesena Hospitals, AUSL Romagna, Forlì-Cesena, Italy
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Clark CJ, Ray JW, Pawa S, Jahann D, McCullough M, Miller P, Mowery N, Miller M, Xiao T, Koutlas N, Pawa R. A location-based anatomic classification system for acute pancreatic fluid collections: Roadmap for optimal intervention in the step-up era. Surg Open Sci 2024; 18:1-5. [PMID: 38312303 PMCID: PMC10831243 DOI: 10.1016/j.sopen.2024.01.008] [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: 11/02/2023] [Revised: 01/02/2024] [Accepted: 01/10/2024] [Indexed: 02/06/2024] Open
Abstract
Walled-off pancreatic necrosis (WOPN) is a local complication of acute necrotizing pancreatitis frequently requiring intervention. Treatment is typically through the coordinated efforts of a multidisciplinary team. Current management guidelines recommend a step-up approach beginning with minimally invasive techniques (percutaneous or transmural endoscopic drainage) followed by escalation to more invasive procedures if needed. Although the step-up approach is an evidence-based treatment paradigm for management of pancreatic fluid collections, it lacks guidance regarding optimal invasive technique selection based on the anatomic characteristics of pancreatic fluid collections. Similarly, existing cross-sectional imaging-based classification systems of pancreatic fluid collections have been used to predict disease severity and prognosis; however, none of these systems are designed to guide intervention. We propose a novel classification system which incorporates anatomic characteristics of pancreatic fluid collections (location and presence of disconnected pancreatic duct) to guide intervention selection and clinical decision making. We believe adoption of this simple classification system will help streamline treatment algorithms and facilitate cross-study comparisons for pancreatic fluid collections.
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Affiliation(s)
- Clancy J. Clark
- Division of Surgical Oncology, Department of General Surgery, Wake Forest University Baptist Medical Center, Winston-Salem, NC, United States of America
| | - Jonathan W. Ray
- Division of Surgical Oncology, Department of General Surgery, Wake Forest University Baptist Medical Center, Winston-Salem, NC, United States of America
| | - Swati Pawa
- Division of Gastroenterology, Department of Internal Medicine, Wake Forest University Baptist Medical Center, Winston-Salem, NC, United States of America
| | - Darius Jahann
- Division of Gastroenterology, Department of Internal Medicine, Wake Forest University Baptist Medical Center, Winston-Salem, NC, United States of America
| | - MaryAlyce McCullough
- Division of Acute Care Surgery, Department of General Surgery, Wake Forest University Baptist Medical Center, Winston-Salem, NC, United States of America
| | - Preston Miller
- Division of Acute Care Surgery, Department of General Surgery, Wake Forest University Baptist Medical Center, Winston-Salem, NC, United States of America
| | - Nathan Mowery
- Division of Acute Care Surgery, Department of General Surgery, Wake Forest University Baptist Medical Center, Winston-Salem, NC, United States of America
| | - Michael Miller
- Division of Interventional Radiology, Department of Radiology, Wake Forest University Baptist Medical Center, Winston-Salem, NC, United States of America
| | - Ted Xiao
- Division of Gastroenterology, Department of Internal Medicine, Wake Forest University Baptist Medical Center, Winston-Salem, NC, United States of America
| | - Nicholas Koutlas
- Division of Gastroenterology, Department of Internal Medicine, Wake Forest University Baptist Medical Center, Winston-Salem, NC, United States of America
| | - Rishi Pawa
- Division of Gastroenterology, Department of Internal Medicine, Wake Forest University Baptist Medical Center, Winston-Salem, NC, United States of America
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5
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Eng NL, Fitzgerald CA, Fisher JG, Small WC, Willingham FF, Galloway JR, Kooby DA, Haack CI. Laparoscopic-Assisted Pancreatic Necrosectomy: Technique and Initial Outcomes. Am Surg 2023; 89:4459-4468. [PMID: 35575200 DOI: 10.1177/00031348221101495] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/01/2022]
Abstract
BACKGROUND Necrotizing pancreatitis (NP) may result de novo or following procedures such as ERCP or partial pancreatectomy (post-procedural), and may require surgical debridement. Video-assisted retroperitoneal debridement (VARD) is a standard approach for NP that employs a 5 cm incision with varying degrees of blind and open debridement. We describe our technique and outcomes of a modified VARD called laparoscopic-assisted pancreatic necrosectomy (LAPN) performed through a single 12 mm incision that uses direct laparoscopic visualization during debridement. METHODS At one medical center, all LAPN patients (2012-2020) were assessed for demographics, disease factors, and outcomes. Bivariate logistic regression analyses were performed to identify factors independently associated with recovery after LAPN for patients with de novo vs post-procedural necrosum. RESULTS Over 9 years, 60 patients underwent LAPN for NP. Median age was 57 years (IQR: 47-66) and 43 (69%) were men. Pancreas necrosum was de novo in 39 (63%) patients and post-procedural in 23 (37%). NP resolved with a median of 1 LAPN procedure and median hospitalization was 33 days. The LAPN major morbidity rate and in-hospital mortality rate were 47% and 5%. No significant differences were seen between NP etiology cohorts, although post-procedure NP patients trended towards a faster clinical recovery to baseline compared to de novo patients (193 vs 394 days; p-value = .07). CONCLUSIONS LAPN offers a smaller incision with excellent visualization and non-inferior outcomes, regardless of etiology, with likely faster recovery for patients with post-procedural vs de novo necrotizing pancreatitis.
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Affiliation(s)
- Nina L Eng
- Department of Surgery, Penn State College of Medicine, Hershey, PA, USA
| | | | - Jeremy G Fisher
- Department of Pediatric Surgery, University Surgical Associates, Chattanooga, TN, USA
| | - William C Small
- Department of Radiology, Emory University School of Medicine, Atlanta, GA, USA
| | - Field F Willingham
- Department of Gastroenterology, Emory University School of Medicine, Atlanta, GA, USA
| | - John R Galloway
- Department of Surgery, Emory University School of Medicine, Atlanta, GA, USA
| | - David A Kooby
- Department of Surgery, Emory University School of Medicine, Atlanta, GA, USA
| | - Carla I Haack
- Department of Surgery, Emory University School of Medicine, Atlanta, GA, USA
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6
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Mahapatra SJ, Garg PK. Percutaneous Endoscopic Necrosectomy. Gastrointest Endosc Clin N Am 2023; 33:737-751. [PMID: 37709408 DOI: 10.1016/j.giec.2023.04.011] [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
Patients with acute pancreatitis might develop infected necrotic fluid collections which are associated with significant morbidity and mortality. Patients with infected necrotizing pancreatitis not responding to antibiotics require drainage and subsequent necrosectomy (Step-up approach). Percutaneous endoscopic necrosectomy (PEN) has evolved as a minimally invasive approach for necrosectomy through the percutaneous catheter route using a flexible endoscope and can be done under conscious sedation. It is best suited for predominantly laterally placed infected necrotic fluid collections and also can be performed at the bedside for sick patients admitted to an ICU. PEN has a clinical success rate of 80% with minimal adverse events.
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Affiliation(s)
| | - Pramod Kumar Garg
- Department of Gastroenterology, All India Institute of Medical Sciences, New Delhi, India.
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7
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Sameera S, Mohammad T, Liao K, Shahid H, Sarkar A, Tyberg A, Kahaleh M. Management of Pancreatic Fluid Collections: An Evidence-based Approach. J Clin Gastroenterol 2023; 57:346-361. [PMID: 36040932 DOI: 10.1097/mcg.0000000000001750] [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] [Indexed: 12/10/2022]
Abstract
Managing pancreatic fluid collections (PFCs) remains a challenge for many clinicians. Recently, significant progress has been made in the therapy of PFCs, including improvements in technology and devices, as well as in the development of minimally invasive endoscopic techniques, many of which are proven less traumatic when compared with surgical options and more efficacious when compared with percutaneous techniques. This review will explore latest developments in the management of PFCs and how they incorporate into the current treatment algorithm.
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Affiliation(s)
- Sohini Sameera
- Department of Gastroenterology & Hepatology, Rutgers Robert Wood Johnson Medical School, New Brunswick, NJ
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Ramai D, Morgan AD, Gkolfakis P, Facciorusso A, Chandan S, Papaefthymiou A, Morris J, Arvanitakis M, Adler DG. Endoscopic management of pancreatic walled-off necrosis. Ann Gastroenterol 2023; 36:123-131. [PMID: 36864934 PMCID: PMC9932860 DOI: 10.20524/aog.2023.0772] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/30/2022] [Accepted: 11/30/2022] [Indexed: 02/05/2023] Open
Abstract
Pancreatic walled-off necrosis (WON) is a complication of severe pancreatitis. Endoscopic transmural drainage has been recognized as the first-line treatment for pancreatic fluid collections. Endoscopy offers a minimally invasive approach when compared to surgical drainage. Today, endoscopists may choose to use self-expanding metal stents, pigtail stents, or lumen-apposing metal stents to facilitate drainage of fluid collections. Current data suggest that all 3 approaches yield similar outcomes. It was previously thought that drainage should be performed 4 weeks from the initial event of pancreatitis, theoretically allowing the capsule to mature. However, current data show that both early (<4 weeks) and standard (≥4 weeks) endoscopic drainage are comparable. Herein, we provide an up-to-date state-of-the-art review of the indications, techniques, innovations, outcomes, and future perspectives following drainage of pancreatic WON.
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Affiliation(s)
- Daryl Ramai
- Gastroenterology & Hepatology, University of Utah Health, Salt Lake City, UT, USA (Daryl Ramai, John Morris)
| | | | - Paraskevas Gkolfakis
- Department of Gastroenterology, Hepatopancreatology, and Digestive Oncology, CUB Erasme Hospital, Université Libre de Bruxelles (ULB), Brussels, Belgium (Paraskevas Gkolfakis, Marianna Arvanitakis)
| | - Antonio Facciorusso
- Section of Gastroenterology, Department of Medical Sciences, University of Foggia, Italy (Antonio Facciorusso)
| | - Saurabh Chandan
- Division of Gastroenterology & Hepatology, CHI Health Creighton University Medical Center, Omaha, NE, USA (Saurabh Chandan)
| | - Apostolis Papaefthymiou
- Pancreaticobiliary Medicine Unit, University College London Hospitals (UCLH), London, UK (Apostolis Papaefthymiou)
| | - John Morris
- Gastroenterology & Hepatology, University of Utah Health, Salt Lake City, UT, USA (Daryl Ramai, John Morris)
| | - Marianna Arvanitakis
- Department of Gastroenterology, Hepatopancreatology, and Digestive Oncology, CUB Erasme Hospital, Université Libre de Bruxelles (ULB), Brussels, Belgium (Paraskevas Gkolfakis, Marianna Arvanitakis)
| | - Douglas G. Adler
- Center for Advanced Therapeutic Endoscopy (CATE), Porter Adventist Hospital/PEAK Gastroenterology, Denver, Colorado, USA (Douglas G. Adler)
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Liepert AE, Ventro G, Weaver JL, Berndtson AE, Godat LN, Adams LM, Santorelli J, Costantini TW, Doucet JJ. Decreasing use of pancreatic necrosectomy and NSQIP predictors of complications and mortality. World J Emerg Surg 2022; 17:60. [PMID: 36503680 PMCID: PMC9743619 DOI: 10.1186/s13017-022-00462-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/08/2022] [Accepted: 10/27/2022] [Indexed: 12/14/2022] Open
Abstract
BACKGROUND Surgical pancreatic necrosectomy (SPN) is an option for the management of infected pancreatic necrosis. The literature indicates that an escalating, combined endoscopic, interventional radiology and minimally invasive surgery "step-up" approach, such as video-assisted retroperitoneal debridement, may reduce the number of required SPNs and ICU complications, such as multiple organ failure. We hypothesized that complications for surgically treated severe necrotizing pancreatitis patients decreased during the period of adoption of the "step-up" approach. METHODS The American college of surgeons national surgery quality improvement program database (ACS-NSQIP) was used to find SPN cases from 2007 to 2019 in ACS-NSQIP submitting hospitals. Mortality and Clavien-Dindo class 4 (CD4) ICU complications were collected. Predictors of outcomes were identified by univariate and multivariate analyses. RESULTS There were 2457 SPN cases. SPN cases decreased from 0.09% in 2007 to 0.01% in 2019 of NSQIP operative cases (p < 0.001). Overall mortality was 8.5% and did not decrease with time. CD4 complications decreased from 40 to 27% (p < 0.001). There was a 65% reduction in SPN cases requiring a return to the operating room. Multivariate predictors of complications were emergency general surgery (EGS, p < 0.001), serum albumin (p < 0.0001) and modified frailty index (mFI) (p < 0.0001). Multivariate predictors of mortality were EGS (p < 0.0001), serum albumin (p < 0.0001), and mFI (p < 0.04). The mFI decreased after 2010 (p < 0.001). CONCLUSION SPNs decreased after 2010, with decreasing CD4 complications, decreasing reoperation rates and stable mortality rates, likely indicating broad adoption of a "step-up" approach. Larger, prospective studies to compare indications and outcomes for "step up" versus open SPN are warranted.
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Affiliation(s)
- Amy E. Liepert
- grid.266100.30000 0001 2107 4242Division of Trauma, Surgical Critical Care, Burns and Acute Care Surgery, Department of Surgery, University of California, San Diego, USA
| | - George Ventro
- grid.266100.30000 0001 2107 4242Division of Trauma, Surgical Critical Care, Burns and Acute Care Surgery, Department of Surgery, University of California, San Diego, USA
| | - Jessica L. Weaver
- grid.266100.30000 0001 2107 4242Division of Trauma, Surgical Critical Care, Burns and Acute Care Surgery, Department of Surgery, University of California, San Diego, USA
| | - Allison E. Berndtson
- grid.266100.30000 0001 2107 4242Division of Trauma, Surgical Critical Care, Burns and Acute Care Surgery, Department of Surgery, University of California, San Diego, USA
| | - Laura N. Godat
- grid.266100.30000 0001 2107 4242Division of Trauma, Surgical Critical Care, Burns and Acute Care Surgery, Department of Surgery, University of California, San Diego, USA
| | - Laura M. Adams
- grid.266100.30000 0001 2107 4242Division of Trauma, Surgical Critical Care, Burns and Acute Care Surgery, Department of Surgery, University of California, San Diego, USA
| | - Jarrett Santorelli
- grid.266100.30000 0001 2107 4242Division of Trauma, Surgical Critical Care, Burns and Acute Care Surgery, Department of Surgery, University of California, San Diego, USA
| | - Todd W. Costantini
- grid.266100.30000 0001 2107 4242Division of Trauma, Surgical Critical Care, Burns and Acute Care Surgery, Department of Surgery, University of California, San Diego, USA
| | - Jay J. Doucet
- grid.266100.30000 0001 2107 4242Division of Trauma, Surgical Critical Care, Burns and Acute Care Surgery, Department of Surgery, University of California, San Diego, USA
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Muacevic A, Adler JR. Predicting the Success of Catheter Drainage in Infected Necrotising Pancreatitis: A Cross-Sectional Observational Study. Cureus 2022; 14:e32289. [PMID: 36505951 PMCID: PMC9728500 DOI: 10.7759/cureus.32289] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 12/07/2022] [Indexed: 12/12/2022] Open
Abstract
Background Management of acute necrotising pancreatitis is often challenging for clinicians. Secondary infection of the necrotic collections leads to sepsis and warrants intervention. Minimally invasive techniques like catheter drainage have recently been proposed over more risky and morbid traditional open procedures. Factors that can predict successful catheter drainage of the necrotic pancreatic collection are still unclear and not well established. Materials and methods This study is designed as a retrospective cross-sectional observational study to investigate the association of 21 factors in predicting successful catheter drainage. Data from 30 patients admitted with acute necrotising pancreatitis treated with catheter drainage were collected and analysed. Twenty-one factors, including demographic variables, disease severity factors, drainage criteria, and morphological criteria on imaging, were studied for their predictive association with successful outcomes. Univariate analysis was done for each variable against the outcome. The study was conducted between December 2012 to March 2017. P-value <0.05 was considered statistically significant. Results Patients with no organ involvement responded better to primary catheter drainage. Patients with BMI>25 and multi-organ failure were poor candidates for primary catheter drainage. Clinically unwell patients with a Bedside Index for Severity in Acute Pancreatitis (BISAP) score of ≥4 had a negative outcome on catheter drainage and usually ended up in a surgical procedure or eventually succumbed to the disease. Other variables included in our study did not statistically associate with the success or failure of percutaneous catheter drainage. Conclusion BMI >25, multiple organ failure, and BISAP score ≥ 4 are independent negative predictors for the success of catheter drainage in infected necrotising pancreatitis. No organ failure showed a positive predictor for successful catheter drainage. Further studies are required to explore these predictive factors in a larger sample size to predict the success of catheter drainage in infected pancreatic necrosis.
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11
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Purschke B, Bolm L, Meyer MN, Sato H. Interventional strategies in infected necrotizing pancreatitis: Indications, timing, and outcomes. World J Gastroenterol 2022; 28:3383-3397. [PMID: 36158258 PMCID: PMC9346450 DOI: 10.3748/wjg.v28.i27.3383] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/20/2022] [Revised: 03/07/2022] [Accepted: 06/16/2022] [Indexed: 02/06/2023] Open
Abstract
Acute pancreatitis (AP) is one of the most common gastrointestinal diseases and remains a life-threatening condition. Although AP resolves to restitutio ad integrum in approximately 80% of patients, it can progress to necrotizing pancreatitis (NP). NP is associated with superinfection in a third of patients, leading to an increase in mortality rate of up to 40%. Accurate and early diagnosis of NP and associated complications, as well as state-of-the-art therapy are essential to improve patient prognoses. The emerging role of endoscopy and recent trials on multidisciplinary management of NP established the “step-up approach”. This approach starts with endoscopic interventions and can be escalated to other interventional and ultimately surgical procedures if required. Studies showed that this approach decreases the incidence of new multiple-organ failure as well as the risk of interventional complications. However, the optimal interventional sequence and timing of interventional procedures remain controversial. This review aims to summarize the indications, timing, and treatment outcomes for infected NP and to provide guidance on multidisciplinary decision-making.
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Affiliation(s)
- Birte Purschke
- Department of Gastrointestinal Surgery, Massachusetts General Hospital, Boston, MA 02114, United States
| | - Louisa Bolm
- Department of Gastrointestinal Surgery, Massachusetts General Hospital, Boston, MA 02114, United States
| | - Max Nikolaus Meyer
- Department of Radiation Oncology, Massachusetts General Hospital, Boston, MA 02114, United States
| | - Hiroki Sato
- Department of Medicine, Asahikawa Medical University, Asahikawa 0788510, Hokkaido, Japan
- Department of Gastroenterology, Asahikawa Kosei Hospital, Asahikawa 0788211, Hokkaido, Japan
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12
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Bansal A, Gupta P, Singh AK, Shah J, Samanta J, Mandavdhare HS, Sharma V, Sinha SK, Dutta U, Sandhu MS, Kochhar R. Drainage of pancreatic fluid collections in acute pancreatitis: A comprehensive overview. World J Clin Cases 2022; 10:6769-6783. [PMID: 36051118 PMCID: PMC9297419 DOI: 10.12998/wjcc.v10.i20.6769] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/26/2021] [Revised: 01/10/2022] [Accepted: 05/14/2022] [Indexed: 02/06/2023] Open
Abstract
Moderately severe and severe acute pancreatitis is characterized by local and systemic complications. Systemic complications predominate the early phase of acute pancreatitis while local complications are important in the late phase of the disease. Necrotic fluid collections represent the most important local complication. Drainage of these collections is indicated in the setting of infection, persistent or new onset organ failure, compressive or pressure symptoms, and intraabdominal hypertension. Percutaneous, endoscopic, and minimally invasive surgical drainage represents the various methods of drainage with each having its own advantages and disadvantages. These methods are often complementary. In this minireview, we discuss the indications, timing, and techniques of drainage of pancreatic fluid collections with focus on percutaneous catheter drainage. We also discuss the novel methods and techniques to improve the outcomes of percutaneous catheter drainage.
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Affiliation(s)
- Akash Bansal
- Department of Radiodiagnosis, Postgraduate Institute of Medical Education and Research, Chandigarh 160012, India
| | - Pankaj Gupta
- Department of Radiodiagnosis, Postgraduate Institute of Medical Education and Research, Chandigarh 160012, India
| | - Anupam K Singh
- Department of Gastroenterology, Postgraduate Institute of Medical Education and Research, Chandigarh 160012, India
| | - Jimil Shah
- Department of Gastroenterology, Postgraduate Institute of Medical Education and Research, Chandigarh 160012, India
| | - Jayanta Samanta
- Department of Gastroenterology, Postgraduate Institute of Medical Education and Research, Chandigarh 160012, India
| | - Harshal S Mandavdhare
- Department of Gastroenterology, Postgraduate Institute of Medical Education and Research, Chandigarh 160012, India
| | - Vishal Sharma
- Department of Gastroenterology, Postgraduate Institute of Medical Education and Research, Chandigarh 160012, India
| | - Saroj Kant Sinha
- Department of Gastroenterology, Postgraduate Institute of Medical Education and Research, Chandigarh 160012, India
| | - Usha Dutta
- Department of Gastroenterology, Postgraduate Institute of Medical Education and Research, Chandigarh 160012, India
| | - Manavjit Singh Sandhu
- Department of Radiodiagnosis, Postgraduate Institute of Medical Education and Research, Chandigarh 160012, India
| | - Rakesh Kochhar
- Department of Gastroenterology, Postgraduate Institute of Medical Education and Research, Chandigarh 160012, India
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13
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Percutaneous Endoscopic Necrosectomy—A Review of the Literature. J Clin Med 2022; 11:jcm11143932. [PMID: 35887696 PMCID: PMC9324430 DOI: 10.3390/jcm11143932] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/31/2022] [Revised: 07/03/2022] [Accepted: 07/05/2022] [Indexed: 12/10/2022] Open
Abstract
In this article, an attempt was made to clarify the role of percutaneous endoscopic necrosectomy (PEN) in the interventional treatment of pancreatic necrosis. A comprehensive review of the current literature was performed to identify publications on the role of PEN in patients with consequences of acute necrotizng pancreatitis. The aim of the study was to review the literature on minimal invasive necrosectomy, with emphasis on PEN using esophageal self-expanding metal stents (SEMS). The described results come from 15 studies after a review of the current literature. The study group comprised 52 patients (36 men and 16 women; mean age, 50.87 (13–75) years) with walled-off pancreatic necrosis, in whom PEN using a self-expandable esophageal stent had been performed. PEN was successfully completed in all 52 patients (100%). PEN complications were observed in 18/52 (34.62%) patients. Clinical success was achieved in 42/52 (80.77%) patients, with follow-up continuing for an average of 136 (14–557) days. In conclusion, the PEN technique is potentially effective, with an acceptable rate of complications and may be implemented with good clinical results in patients with pancreatic necrosis.
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14
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Prasath V, Quinn PL, Oliver JB, Arjani S, Ahlawat SK, Chokshi RJ. Cost-effectiveness analysis of infected necrotizing pancreatitis management in an academic setting. Pancreatology 2022; 22:185-193. [PMID: 34879998 DOI: 10.1016/j.pan.2021.11.011] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/14/2021] [Revised: 11/22/2021] [Accepted: 11/30/2021] [Indexed: 12/11/2022]
Abstract
BACKGROUND AND AIMS Traditional management for infected necrotizing pancreatitis (INP) often utilizes open necrosectomy, which carries high morbidity and complication rates. Thus, minimally invasive strategies have gained favor, specifically step-up approaches utilizing endoscopic or minimally-invasive surgery (MIS); however, the ideal management modality for INP has not been identified. METHODS A decision tree model was designed to analyze costs and survival associated with open necrosectomy, endoscopic step-up, and MIS step-up protocols for management of INP after 4 weeks of necrosis development with adequate retroperitoneal access. Costs were based on a third-party payer perspective using Medicare reimbursement rates. The model's effectiveness was represented by quality-adjusted life-years (QALYs). Sensitivity analyses were performed to validate results. RESULTS Endoscopic step-up was the dominant economic strategy with 7.92 QALYs for $90,864.09. Surgical step-up resulted in a decrease of 0.09 QALYs and a cost increase of $10,067.89 while open necrosectomy resulted in a decrease of 0.4 QALYs and an increased cost of $18,407.52 over endoscopic step-up. In 100,000 random-sampling simulations, 65.5% of simulations favored endoscopic step-up. MIS step-up was favored when MIS acute mortality rates fell and when MIS drainage success rates rose. CONCLUSIONS In our simulated patients with INP, the most cost-effective management strategy is endoscopic step-up. Cost-effectiveness varies with changes in acute mortality and drainage success, which will depend on local expertise.
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Affiliation(s)
- Vishnu Prasath
- Division of Surgical Oncology, Department of Surgery, Rutgers New Jersey Medical School, Newark, NJ, USA.
| | - Patrick L Quinn
- Division of Surgical Oncology, Department of Surgery, Rutgers New Jersey Medical School, Newark, NJ, USA.
| | - Joseph B Oliver
- Division of Minimally Invasive Surgery, Department of Surgery, Rutgers New Jersey Medical School, Newark, NJ, USA.
| | - Simran Arjani
- Division of Surgical Oncology, Department of Surgery, Rutgers New Jersey Medical School, Newark, NJ, USA.
| | - Sushil K Ahlawat
- Division of Gastroenterology and Hepatology, Department of Medicine, Rutgers New Jersey Medical School, Newark, NJ, USA.
| | - Ravi J Chokshi
- Division of Surgical Oncology, Department of Surgery, Rutgers New Jersey Medical School, Newark, NJ, USA.
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15
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Gupta P, Das GC, Bansal A, Samanta J, Mandavdhare HS, Sharma V, Naseem S, Gupta V, Yadav TD, Dutta U, Varma N, Sandhu MS, Kochhar R. Value of neutrophil-lymphocyte ratio in evaluating response to percutaneous catheter drainage in patients with acute pancreatitis. World J Clin Cases 2022; 10:91-103. [PMID: 35071509 PMCID: PMC8727280 DOI: 10.12998/wjcc.v10.i1.91] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/13/2021] [Revised: 07/22/2021] [Accepted: 11/28/2021] [Indexed: 02/06/2023] Open
Abstract
BACKGROUND Early prediction of response to percutaneous catheter drainage (PCD) of necrotic collections in acute pancreatitis (AP) using simple and objective tests is critical as it may determine patient prognosis. The role of white blood cell (WBC) count and neutrophil-lymphocyte ratio (NLR) has not been assessed as a tool of early prediction of PCD success and is the focus of this study.
AIM To assess the value of WBC and NLR in predicting response to PCD in AP.
METHODS This retrospective study comprised consecutive patients with AP who underwent PCD between June 2018 and December 2019. Severity and fluid collections were classified according to the revised Atlanta classification and organ failure was defined according to the modified Marshall Score. WBC and NLR were monitored 24 h prior PCD (WBC-0/NLR-0) and 24 h (WBC-1/NLR-1), 48 h (WBC-2/NLR-2) and 72 h (WBC-3/NLR-3) after PCD. NLR was calculated by dividing the number of neutrophils by the number of lymphocytes. The association of success of PCD (defined as survival without the need for surgery) with WBC and NLR was assessed. The trend of WBC and NLR was also assessed post PCD.
RESULTS One hundred fifty-five patients [median age 40 ± 13.6 (SD), 64.5% males, 53.5% severe AP] were included in the final analysis. PCD was done for acute necrotic collection in 99 (63.8%) patients and walled-off necrosis in 56 (36.1%) patients. Median pain to PCD interval was 24 ± 69.89 d. PCD was successful in 109 patients (group 1) and 46 patients (group 2) who failed to respond. There was no significant difference in the baseline characteristics between the two groups except the severity of AP and frequency of organ failure. Both WBC and NLR showed an overall decreasing trend. There was a significant difference between WBC-0 and WBC-1 (P = 0.0001). WBC-1 and NLR-1 were significantly different between the two groups (P = 0.048 and 0.003, respectively). The area under the curve of WBC-1 and NLR-1 for predicting the success of PCD was 0.602 and 0.682, respectively. At a cut-off value of 9.87 for NLR-1, the sensitivity and specificity for predicting the success of PCD were calculated to be 75% and 65.4% respectively.
CONCLUSION WBC and NLR can be used as simple tests for predicting response to PCD in patients with acute necrotizing pancreatitis.
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Affiliation(s)
- Pankaj Gupta
- Department of Radiodiagnosis, Postgraduate Institute of Medical Education and Research, Chandigarh 160012, India
| | - Gaurav Chayan Das
- Department of Radiodiagnosis, Postgraduate Institute of Medical Education and Research, Chandigarh 160012, India
| | - Akash Bansal
- Department of Radiodiagnosis, Postgraduate Institute of Medical Education and Research, Chandigarh 160012, India
| | - Jayanta Samanta
- Department of Gastroenterology, Postgraduate Institute of Medical Education and Research, Chandigarh 160012, India
| | - Harshal S Mandavdhare
- Department of Gastroenterology, Postgraduate Institute of Medical Education and Research, Chandigarh 160012, India
| | - Vishal Sharma
- Department of Gastroenterology, Postgraduate Institute of Medical Education and Research, Chandigarh 160012, India
| | - Shano Naseem
- Department of Hematology, Postgraduate Institute of Medical Education and Research, Chandigarh 160012, India
| | - Vikas Gupta
- Department of Surgical Gastroenterology, Postgraduate Institute of Medical Education and Research, Chandigarh 160012, India
| | - Thakur Deen Yadav
- Department of Surgical Gastroenterology, Postgraduate Institute of Medical Education and Research, Chandigarh 160012, India
| | - Usha Dutta
- Department of Gastroenterology, Postgraduate Institute of Medical Education and Research, Chandigarh 160012, India
| | - Neelam Varma
- Department of Hematology, Postgraduate Institute of Medical Education and Research, Chandigarh 160012, India
| | - Manavjit Singh Sandhu
- Department of Radiodiagnosis, Postgraduate Institute of Medical Education and Research, Chandigarh 160012, India
| | - Rakesh Kochhar
- Department of Gastroenterology, Postgraduate Institute of Medical Education and Research, Chandigarh 160012, India
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16
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The efficacy and efficiency of stent-assisted percutaneous endoscopic necrosectomy for infected pancreatic necrosis: a pilot clinical study using historical controls. Eur J Gastroenterol Hepatol 2021; 33:e435-e441. [PMID: 33731580 DOI: 10.1097/meg.0000000000002127] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
OBJECTIVES Minimally invasive interventions have become standard treatment for infected pancreatic necrosis (IPN). Despite the marginal clinical advantage of endoscopic approaches over the surgical approach shown in recent studies, percutaneous techniques still have a role when endoscopic treatment is not indicated. Stent-assisted percutaneous endoscopic necrosectomy (SAPEN) is an alternative option for surgical necrosectomy, but the theoretical advantages to this procedure remain unproven. This study aimed to report the efficacy and efficiency of SAPEN in patients with IPN. METHODS This is a retrospective, historically-controlled, cohort study. All IPN patients admitted to our center from January 2015 to December 2018 were screened for eligibility. Patients admitted between January 2015 and October 2017 were historical controls, and patients admitted thereafter were treated with additional self-expandable metal stent (SEMS). The primary endpoint was a composite of major complications and/or death. Other outcomes, including individual components of the primary endpoint, new-onset sepsis, length of ICU and hospital stay, and pancreatic fistula, were also compared. RESULTS There were 73 historical-control patients and 37 patients who had SAPEN included for analysis. The introduction of the SAPEN procedure failed to reduce the incidence of the primary endpoint (35 versus 52%, P = 0.095). However, significantly shorter hospital stay (38 versus 48 days, P = 0.035) and lower incidence of new-onset sepsis were observed in the SAPEN group (35 versus 56%, P = 0.037). CONCLUSION The application of SEMS in percutaneous endoscopic necrosectomy procedures shortened hospital stay, decreased new-onset sepsis, and allowed earlier necrosectomy.
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17
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Dani L, Carbonaro G, Natta F, Cavuoti G, Vaudano GP, Boghi A, Festa F, Cestino L, Soncini S, Quaglino F. Treatment of Acute Necrotising Pancreatitis and Its Complications: The Surgeon's Perspective. Case Rep Gastroenterol 2021; 15:759-764. [PMID: 34594177 PMCID: PMC8436666 DOI: 10.1159/000517935] [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] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/19/2021] [Accepted: 06/11/2021] [Indexed: 01/10/2023] Open
Abstract
Acute necrotising pancreatitis (ANP) is associated with high complication and mortality rates. It is still difficult for the surgeon to choose and schedule the most appropriate treatment. Compared to the past, the current minimally invasive "step-up" approach enables better outcomes in terms of morbidity/mortality, notwithstanding long periods of hospitalisation, and above all ensures better levels of residual pancreatic function. We hereby report the case of a patient hospitalised in our division for approximately 4 months with a diagnosis of ANP complicated by infection and late bleeding, handled with a sequential approach.
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Affiliation(s)
- Luca Dani
- General Surgery, ASL Città di Torino, Ospedale Maria Vittoria, Torino, Italy
| | - Giulia Carbonaro
- General Surgery, ASL Città di Torino, Ospedale Maria Vittoria, Torino, Italy
| | - Fabrizio Natta
- General Surgery, ASL Città di Torino, Ospedale Maria Vittoria, Torino, Italy
| | - Giuseppe Cavuoti
- General Surgery, ASL Città di Torino, Ospedale Maria Vittoria, Torino, Italy
| | | | - Andrea Boghi
- Neuroradiology, ASL Città di Torino, Ospedale San Giovanni Bosco, Torino, Italy
| | - Federico Festa
- General Surgery, ASL Città di Torino, Ospedale Maria Vittoria, Torino, Italy
| | - Luca Cestino
- General Surgery, ASL Città di Torino, Ospedale Maria Vittoria, Torino, Italy
| | - Stefania Soncini
- General Surgery, ASL Città di Torino, Ospedale Maria Vittoria, Torino, Italy
| | - Francesco Quaglino
- General Surgery, ASL Città di Torino, Ospedale Maria Vittoria, Torino, Italy
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18
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Rahnemai-Azar AA, Sutter C, Hayat U, Glessing B, Ammori J, Tavri S. Multidisciplinary Management of Complicated Pancreatitis: What Every Interventional Radiologist Should Know. AJR Am J Roentgenol 2021; 217:921-932. [PMID: 33470838 DOI: 10.2214/ajr.20.25168] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
Management of acute pancreatitis is challenging in the presence of local complications that include pancreatic and peripancreatic collections and vascular complications. This review, targeted for interventional radiologists, describes minimally invasive endoscopic, image-guided percutaneous, and surgical procedures for management of complicated pancreatitis and provides insight into the procedures' algorithmic application. Local complications are optimally managed in a multidisciplinary team setting that includes advanced endoscopists; pancreatic surgeons; diagnostic and interventional radiologists; and specialists in infectious disease, nutrition, and critical care medicine. Large symptomatic or complicated sterile collections and secondary infected collections warrant drainage or débridement. The drainage is usually delayed for 4-6 weeks unless clinical deterioration warrants early intervention. If collections are accessible by endoscopy, endoscopic procedures are preferred to avoid pancreaticocutaneous fistulas. Image-guided percutaneous drainage is indicated for symptomatic collections that are not accessible for endoscopic drainage or that present in the acute setting before developing a mature wall. Peripancreatic arterial pseudoaneurysms should be embolized before necrosectomy procedures to prevent potentially life-threatening hemorrhage. Surgical procedures are reserved for symptomatic collections that persist despite endoscopic or interventional drainage attempts. Understanding these procedures facilitates their integration by interventional radiologists into the complex longitudinal care of patients with complicated pancreatitis.
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Affiliation(s)
- Amir Ata Rahnemai-Azar
- Department of Radiology, University Hospitals Cleveland Medical Center, Case Western Reserve University School of Medicine, 11100 Euclid Ave, Cleveland, OH 44106
| | - Christopher Sutter
- Department of Radiology, University Hospitals Cleveland Medical Center, Case Western Reserve University School of Medicine, 11100 Euclid Ave, Cleveland, OH 44106
| | - Umar Hayat
- Department of Medicine, Division of Gastroenterology, University Hospitals Cleveland Medical Center, Case Western Reserve University School of Medicine, Cleveland, OH
| | - Brooke Glessing
- Department of Medicine, Division of Gastroenterology, University Hospitals Cleveland Medical Center, Case Western Reserve University School of Medicine, Cleveland, OH
| | - John Ammori
- Department of Surgery, Division of Surgical Oncology, University Hospitals Cleveland Medical Center, Case Western Reserve University School of Medicine, Cleveland, OH
| | - Sidhartha Tavri
- Department of Radiology, University Hospitals Cleveland Medical Center, Case Western Reserve University School of Medicine, 11100 Euclid Ave, Cleveland, OH 44106
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19
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Acharya A, Mohan N, Ardhanari R. Surgical Considerations in Acute Pancreatitis. Indian J Surg 2021. [DOI: 10.1007/s12262-019-02062-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/25/2022] Open
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20
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Pawar A, Sonika U, Kumar M, Saluja S, Srivastava S. RWON Study: The Real-World Walled-off Necrosis Study. Clin Endosc 2021; 54:909-915. [PMID: 33618506 PMCID: PMC8652152 DOI: 10.5946/ce.2020.175] [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] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/29/2020] [Accepted: 10/16/2020] [Indexed: 11/30/2022] Open
Abstract
Background/Aims The management of walled-off necrosis (WON) has undergone a paradigm shift from surgical to nonsurgical modalities. Real-world data on the management of symptomatic WON are scarce.
Methods Prospectively collected data of symptomatic WON cases were retrospectively evaluated. The treatment modalities used were medical management alone, percutaneous catheter drainage (PCD) or endoscopic drainage (ED), or a combination of PCD and ED. We compared clinical outcome among these modalities.
Results A total of 264 patients were evaluated. The most common indications for drainage were pain and fever. Of the patients, 28% was treated with medical therapy alone, 31% with ED, 37% with PCD, and 4% with a combined approach. Technical success and clinical success were achieved in 93% and 91% of patients in the endoscopic arm and in 90% and 81% patients in the PCD arm, respectively (p=0.0004 for clinical success). Lower rates of complications (7% vs. 22%, p=0.005), readmission (20% vs. 34%, p=0.04), and mortality (4% vs. 19%, p=0.0012), and shorter hospital stay (13 days vs. 19 days, p=0.0018) were observed in the endoscopic group than in the PCD group.
Conclusions ED of WON is better than PCD and is associated with lower mortality, fewer complications, and shorter hospitalization.
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Affiliation(s)
- Ankush Pawar
- Department of Gastroenterology, Govind Ballabh Pant Institute of Postgraduate Medical Education and Research, New Delhi, India
| | - Ujjwal Sonika
- Department of Gastroenterology, Govind Ballabh Pant Institute of Postgraduate Medical Education and Research, New Delhi, India
| | - Manish Kumar
- Department of Gastroenterology, Govind Ballabh Pant Institute of Postgraduate Medical Education and Research, New Delhi, India
| | - Sundeep Saluja
- Department of Gastrosurgery, Govind Ballabh Pant Institute of Postgraduate Medical Education and Research, New Delhi, India
| | - Siddharth Srivastava
- Department of Gastroenterology, Govind Ballabh Pant Institute of Postgraduate Medical Education and Research, New Delhi, India
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21
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Mohapatra N, Sasturkar SV, Falari S, Sandhyav R, Kumar N, Agrawal N, Arora A, Pamecha V, Chattopadhyay TK. Strategic approach to minimally invasive necrosectomy for necrotizing pancreatitis: technique, complications and predictors of outcome. ANZ J Surg 2021; 91:E104-E111. [PMID: 33522687 DOI: 10.1111/ans.16619] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/22/2020] [Revised: 12/20/2020] [Accepted: 01/07/2021] [Indexed: 12/15/2022]
Abstract
BACKGROUND Minimally invasive retroperitoneal necrosectomy has been an integral component of 'step-up' approach for infected pancreatic necrosis. Even though the clinical outcome of nephroscopic necrosectomy has been studied earlier, its predictor and morbidities following surgery have not been extensively evaluated. We aimed to evaluate the clinical outcome and early and late complications after percutaneous nephroscopic necrosectomy (PCNN). METHODS The pre- and intra-operative as well as post-operative and follow-up data of severe pancreatitis patients undergoing PCNN were collected prospectively. RESULTS Out of 115 patients requiring intervention, 40 patients (34.78%) improved with percutaneous drain alone and another 40 proceeded for PCNN. After exclusion, 37 patients successfully underwent 48 sessions of PCNN. Median number of PCNN session was 1 (1-4). Early complications were seen in 21 (56.75%) patients and mortality was experienced in eight (21.62%) patients. On median follow-up of 36 months, 12 (32.43%) patients experienced late complications. Persistent post-operative pancreatic fistula was observed in six (16.21%) patients. Of these, three developed late-onset pseudocyst, whereas one patient had disconnected duct syndrome. Seven patients experienced new-onset diabetes. Age, severity of pancreatitis, preoperative organ failure and multiorgan failure were significant predictors of mortality on univariate analysis (P ≤ 0.05 for each). The logistic regression analysis revealed presence of multiorgan failure before surgery as the sole predictor (P = 0.007; odds ratio 10.417; 95% confidence interval 1.759-61.672). CONCLUSION Preoperative multiorgan failure was the most important predictor of mortality following PCNN. Late complications were seen in nearly one-third of patients emphasizing the need for long-term follow-up.
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Affiliation(s)
- Nihar Mohapatra
- Department of HPB Surgery and Liver Transplantation, Institute of Liver and Biliary Sciences, New Delhi, India
| | - Shridhar V Sasturkar
- Department of HPB Surgery and Liver Transplantation, Institute of Liver and Biliary Sciences, New Delhi, India
| | - Sanyam Falari
- Department of HPB Surgery and Liver Transplantation, Institute of Liver and Biliary Sciences, New Delhi, India
| | - Rommel Sandhyav
- Department of HPB Surgery and Liver Transplantation, Institute of Liver and Biliary Sciences, New Delhi, India
| | - Niteen Kumar
- Department of HPB Surgery and Liver Transplantation, BLK Super Speciality Hospital, New Delhi, India
| | - Nikhil Agrawal
- Department of Gastrointestinal and HPB Surgical Oncology, Max Super Speciality Hospital Saket, New Delhi, India
| | - Asit Arora
- Department of Gastrointestinal and HPB Surgical Oncology, Max Super Speciality Hospital Saket, New Delhi, India
| | - Viniyendra Pamecha
- Department of HPB Surgery and Liver Transplantation, Institute of Liver and Biliary Sciences, New Delhi, India
| | - Tushar K Chattopadhyay
- Department of HPB Surgery and Liver Transplantation, Institute of Liver and Biliary Sciences, New Delhi, India
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22
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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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Namba Y, Matsugu Y, Furukawa M, Namba M, Sasaki T, Itamoto T. Step-up approach combined with negative pressure wound therapy for the treatment of severe necrotizing pancreatitis: a case report. Clin J Gastroenterol 2020; 13:1331-1337. [PMID: 32712840 DOI: 10.1007/s12328-020-01190-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/13/2020] [Accepted: 07/17/2020] [Indexed: 10/23/2022]
Abstract
A step-up approach and continuous drainage using NPWT was an effective strategy for the treatment of severe necrotizing pancreatitis. A 62-year-old woman developed severe necrotizing pancreatitis after endoscopic retrograde cholangiopancreatography, extending from the left anterior pararenal space to the interior renal pole. Endoscopic transluminal drainage and percutaneous catheter drainage were unsuccessful in controlling the disease. We proceeded with video-assisted retroperitoneal necrosectomy, at the pancreas and splenic hilum, and drainage, with two additional surgical drains located at the left inferior renal pole and, subcutaneously, at the incision wound. NPWT enhanced fluid drainage and facilitated surgical wound closure, which was infected and opened. Four subsequent endoscopic necrosectomy procedures were required, at the site of the draining fistula, to achieve complete resolution of fluid collection and wound closure.
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Affiliation(s)
- Yosuke Namba
- Department of Gastroenterological-Breast and Transplant Surgery, Hiroshima Prefectural Hospital, 1-5-54 Ujina-kanda, Minami-ku, Hiroshima, 734-8530, Japan
| | - Yasuhiro Matsugu
- Department of Gastroenterological-Breast and Transplant Surgery, Hiroshima Prefectural Hospital, 1-5-54 Ujina-kanda, Minami-ku, Hiroshima, 734-8530, Japan. .,Department of Gastroenterological and Transplant Surgery Applied Life Sciences, Institute of Biomedical and Health Sciences, Hiroshima University, Hiroshima, Japan.
| | - Masaru Furukawa
- Department of Gastroenterology, Hiroshima Prefectural Hospital, Hiroshima, Japan
| | - Maiko Namba
- Department of Gastroenterology and Metabolism, Institute of Biomedical and Health Sciences, Hiroshima University, Hiroshima, Japan
| | - Tamito Sasaki
- Department of Gastroenterology, Hiroshima Prefectural Hospital, Hiroshima, Japan.,Department of Gastroenterology and Metabolism, Institute of Biomedical and Health Sciences, Hiroshima University, Hiroshima, Japan
| | - Toshiyuki Itamoto
- Department of Gastroenterological-Breast and Transplant Surgery, Hiroshima Prefectural Hospital, 1-5-54 Ujina-kanda, Minami-ku, Hiroshima, 734-8530, Japan.,Department of Gastroenterological and Transplant Surgery Applied Life Sciences, Institute of Biomedical and Health Sciences, Hiroshima University, Hiroshima, Japan
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24
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Budkule D, Desai G, Pande P, Narkhede R, Wagle P, Varty P. An outcome analysis of videoscopic assisted retroperitoneal debridement in infected pancreatic necrosis: a single centre experience. Turk J Surg 2020; 35:214-222. [PMID: 32550331 DOI: 10.5578/turkjsurg.4289] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/15/2018] [Accepted: 10/10/2018] [Indexed: 11/15/2022]
Abstract
Objectives Infected pancreatic necrosis (IPN) is a dreadful complication of moderately severe and severe acute necrotising pancreatitis (ANP). Videoscopic assisted retroperitoneal debridement (VARD) is a minimally invasive surgical option for predominantly left sided, posterior and laterally located disease in patients not responding to conservative and percutaneous options. This study aimed to present an outcome analysis of VARD in the management of IPN at our tertiary care centre. Material and Methods The present retrospective analysis of prospectively entered data included 22 patients diagnosed as ANP with IPN from January 2015 to December 2017. These patients were admitted in the surgical gastroenterology unit of our tertiary care centre. The outcome of these patients managed with VARD was evaluated. Results The aetiology of ANP was idiopathic, and gallstones were found in 7 patients each and alcohol in 8. Twelve patients were managed with a single VARD procedure; whereas, 10 required a re-debridement due to suboptimal improvement. Eighteen out of 22 patients survived whereas 4 succumbed to major postoperative bleeding/severe sepsis and multiorgan failure (Mortality 18.2%). Hospital stay after the index procedure was between 6 to 11 weeks. Conclusion VARD is a safe and effective surgical option for the management of IPN that worsens or fails to respond to conservative and percutaneous drainage options after a minimum of 4 weeks of moderately severe and severe ANP. It decreases postoperative morbidity and mortality and avoids major laparotomy, and hence, it can be considered in a selected group of patients.
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Affiliation(s)
- Dattaraj Budkule
- Clinic of General Surgery and Surgical Gastroenterology, Lilavati Hospital and Research Centre, Mumbai, India
| | - Gunjan Desai
- Clinic of General Surgery and Surgical Gastroenterology, Lilavati Hospital and Research Centre, Mumbai, India
| | - Prasad Pande
- Clinic of General Surgery and Surgical Gastroenterology, Lilavati Hospital and Research Centre, Mumbai, India
| | - Rajvilas Narkhede
- Clinic of General Surgery and Surgical Gastroenterology, Lilavati Hospital and Research Centre, Mumbai, India
| | - Prasad Wagle
- Clinic of General Surgery and Surgical Gastroenterology, Lilavati Hospital and Research Centre, Mumbai, India
| | - Paresh Varty
- Clinic of General Surgery and Surgical Gastroenterology, Lilavati Hospital and Research Centre, Mumbai, India
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25
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Liu ZW, Yang SZ, Wang PF, Feng J, He L, Du JD, Xiao YY, Jiao HB, Zhou FH, Song Q, Zhou MT, Xin XL, Chen JY, Ren WZ, Lu SC, Cai SW, Dong JH. Minimal-access retroperitoneal pancreatic necrosectomy for infected necrotizing pancreatitis: a multicentre study of a step-up approach. Br J Surg 2020; 107:1344-1353. [PMID: 32449154 DOI: 10.1002/bjs.11619] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/28/2019] [Revised: 03/23/2019] [Accepted: 03/16/2020] [Indexed: 12/17/2022]
Abstract
BACKGROUND Various minimally invasive approaches have been described for infected necrotizing pancreatitis. This article describes a modified minimal-access retroperitoneal pancreatic necrosectomy (MARPN) procedure assisted by gas insufflation. METHODS This retrospective, observational study documented patients who had undergone a step-up MARPN between 1 January 2010 and 31 December 2016. A minimum follow-up of 1 year was required for inclusion. The step-up approach involved percutaneous catheter drainage followed by the modified MARPN and necrosectomy. If more than one access site was needed it was categorized as complex MARPN. RESULTS Of 212 patients with infected necrotizing pancreatitis, 164 (77·4 per cent) underwent a step-up approach. The median number of percutaneous catheter drains and MARPN procedures was 3 (range 1-7) and 1 (1-6) respectively. Ninety patients (54·9 per cent) underwent complex MARPN. For residual necrosis after MARPN, three patients (1·8 per cent) underwent sinus tract gastroscopy, and 11 (6·7 per cent) had sinography combined with a tube change. However, operations in 13 patients (7·9 per cent) required conversion to open surgery. Postoperative complications developed in 103 patients (62·8 per cent). The mortality rate was 6·1 per cent (10 deaths). CONCLUSION A step-up approach using a modified MARPN for infected necrotizing pancreatitis is a reasonable option.
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Affiliation(s)
- Z-W Liu
- Department of Hepato-pancreato-biliary Surgery, Beijing, China
| | - S-Z Yang
- Centre of Hepato-pancreato-biliary Diseases, Beijing Tsinghua Changgung Hospital, Tsinghua University, Beijing, China
| | - P-F Wang
- Department of Hepato-pancreato-biliary Surgery, Beijing, China
| | - J Feng
- Department of Hepato-pancreato-biliary Surgery, Beijing, China
| | - L He
- Department of Hepato-pancreato-biliary Surgery, Beijing, China
| | - J-D Du
- Department of Hepato-pancreato-biliary Surgery, First Affiliated Hospital of Chinese PLA General Hospital, Beijing, China
| | - Y-Y Xiao
- Department of Radiology, Beijing, China
| | - H-B Jiao
- Department of Hepato-pancreato-biliary Surgery, First Affiliated Hospital of Chinese PLA General Hospital, Beijing, China
| | - F-H Zhou
- Critical Care Medicine, Chinese People's Liberation Army (PLA) General Hospital, Beijing, China
| | - Q Song
- Critical Care Medicine, Chinese People's Liberation Army (PLA) General Hospital, Beijing, China
| | - M-T Zhou
- Pancreatitis Centre, First Affiliated Hospital of Wenzhou Medical University, Wenzhou, China
| | - X-L Xin
- Department of Hepato-pancreato-biliary Surgery, Beijing, China
| | - J-Y Chen
- Department of Hepato-pancreato-biliary Surgery, Beijing, China
| | - W-Z Ren
- Department of Hepato-pancreato-biliary Surgery, Beijing, China
| | - S-C Lu
- Department of Hepato-pancreato-biliary Surgery, Beijing, China
| | - S-W Cai
- Department of Hepato-pancreato-biliary Surgery, Beijing, China
| | - J-H Dong
- Centre of Hepato-pancreato-biliary Diseases, Beijing Tsinghua Changgung Hospital, Tsinghua University, Beijing, China
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26
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Jain S, Padhan R, Bopanna S, Jain SK, Dhingra R, Dash NR, Madhusudan KS, Gamanagatti SR, Sahni P, Garg PK. Percutaneous Endoscopic Step-Up Therapy Is an Effective Minimally Invasive Approach for Infected Necrotizing Pancreatitis. Dig Dis Sci 2020; 65:615-622. [PMID: 31187325 DOI: 10.1007/s10620-019-05696-2] [Citation(s) in RCA: 14] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/05/2019] [Accepted: 06/03/2019] [Indexed: 12/14/2022]
Abstract
BACKGROUND Infected pancreatic necrosis (IPN) is a major complication of acute pancreatitis (AP), which may require necrosectomy. Minimally invasive surgical step-up therapy is preferred for IPN. AIM To assess the effectiveness of percutaneous endoscopic step-up therapy in patients with IPN and identify predictors of its success. METHODS Consecutive patients with AP hospitalized to our tertiary care academic center were studied prospectively. Patients with IPN formed the study group. The treatment protocol for IPN was percutaneous endoscopic step-up approach starting with antibiotics and percutaneous catheter drainage, and if required necrosectomy. Percutaneous endoscopic necrosectomy (PEN) was performed using a flexible endoscope through the percutaneous tract under conscious sedation. Control of sepsis with resolution of collection(s) was the primary outcome measure. RESULTS A total of 415 patients with AP were included. Of them, 272 patients had necrotizing pancreatitis and 177 (65%) developed IPN. Of these 177 patients, 27 were treated conservatively with antibiotics alone, 56 underwent percutaneous drainage alone, 53 required underwent PEN as a step-up therapy, 1 per-oral endoscopic necrosectomy, and 52 required surgery. Of the 53 patients in the PEN group, 42 (79.2%) were treated successfully-34 after PEN alone and 8 after additional surgery. Eleven of 53 patients died due to organ failure-7 after PEN and 4 after surgery. Independent predictors of mortality were > 50% necrosis and early organ failure. CONCLUSION Percutaneous endoscopic step-up therapy is an effective strategy for IPN. Organ failure and extensive pancreatic necrosis predicted a suboptimal outcome in patients with infected necrotizing pancreatitis.
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Affiliation(s)
- Saransh Jain
- Department of Gastroenterology, All India Institute of Medical Sciences, New Delhi, India
| | - Rajesh Padhan
- Department of Gastroenterology, All India Institute of Medical Sciences, New Delhi, India
| | - Sawan Bopanna
- Department of Gastroenterology, All India Institute of Medical Sciences, New Delhi, India
| | - Sushil Kumar Jain
- Department of Gastroenterology, All India Institute of Medical Sciences, New Delhi, India
| | - Rajan Dhingra
- Department of Gastroenterology, All India Institute of Medical Sciences, New Delhi, India
| | - Nihar Ranjan Dash
- Department of Gastrointestinal Surgery, All India Institute of Medical Sciences, New Delhi, India
| | | | | | - Peush Sahni
- Department of Gastrointestinal Surgery, All India Institute of Medical Sciences, New Delhi, India
| | - Pramod Kumar Garg
- Department of Gastroenterology, All India Institute of Medical Sciences, New Delhi, India.
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Eid AI, Mueller P, Thabet A, Castillo CFD, Fagenholz P. A Step-Up Approach to Infected Abdominal Fluid Collections: Not Just for Pancreatitis. Surg Infect (Larchmt) 2019; 21:54-61. [PMID: 31429662 DOI: 10.1089/sur.2019.056] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023] Open
Abstract
Background: More than 145,500 abdominal abscesses occur annually in the U.S. Percutaneous catheter drainage (PCD) is the primary treatment for clinically significant intra-abdominal collections (IACs), but only approximately 90% of all IACs are treatable with PCD. This leaves a significant number of patients facing long courses of management, including multiple interventions. Minimally invasive debridement techniques are now employed regularly for the treatment of infected necrosis caused by acute pancreatitis. We describe the use of minimally invasive videoscopic debridement techniques employed as part of a "step-up" approach to resolve IACs of other etiologies that are unresponsive to PCD. Methods: Data of all patients undergoing this procedure at a tertiary referral academic center from 2015 to 2017 after failure of different PCD techniques were analyzed retrospectively. Results: Four men and two women, mean age 54.6 years (range 26-70 years), with refractory IACs (mean drainage time 91.3 days; mean number of drainage procedures 4.6) following a variety of surgical interventions and inflammatory conditions underwent either video-assisted retroperitoneal debridement or sinus tract endoscopic debridement with a rigid or flexible endoscope. Technical success was achieved in all cases, and clinical success was observed in five cases. No immediate procedural complications were detected. The mean hospital stay and post-procedure drainage times were 5.5 and 25.2 days, respectively. There were no recurrent IACs. Conclusion: Minimally invasive debridement techniques can safely resolve IACs refractory to standard PCD techniques. Employment of these techniques as part of a step-up approach may reduce the morbidity and duration of drainage for the thousands of patients treated annually who have refractory IACs, whatever their etiology.
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Affiliation(s)
- Ahmed I Eid
- Division of Trauma, Emergency Surgery and Surgical Critical Care, Department of Surgery, Massachusetts General Hospital, Boston, Massachusetts
| | - Peter Mueller
- Division of Abdominal Imaging and Intervention, Department of Radiology, Massachusetts General Hospital, Boston, Massachusetts
| | - Ashraf Thabet
- Division of Abdominal Imaging and Intervention, Department of Radiology, Massachusetts General Hospital, Boston, Massachusetts
| | | | - Peter Fagenholz
- Division of Trauma, Emergency Surgery and Surgical Critical Care, Department of Surgery, Massachusetts General Hospital, Boston, Massachusetts
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28
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Ke L, Mao W, Zhou J, Ye B, Li G, Zhang J, Wang P, Tong Z, Windsor J, Li W. Stent-Assisted Percutaneous Endoscopic Necrosectomy for Infected Pancreatic Necrosis: Technical Report and a Pilot Study. World J Surg 2019; 43:1121-1128. [PMID: 30569220 DOI: 10.1007/s00268-018-04878-9] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/07/2023]
Abstract
BACKGROUND AND AIMS A variety of minimally invasive techniques have been proposed to replace open surgery for the treatment of infected pancreatic necrosis (IPN). In this study, we evaluate the feasibility and safety of the stent-assisted percutaneous endoscopic necrosectomy (SAPEN) procedure. METHODS Data were collected on all patients who underwent the SAPEN procedure between October 2017 and March 2018. The demographic and clinical characteristics of the study patients were analyzed. A composite primary endpoint of major complications and/or death was used. Three different cases were selected to illustrate different technical aspects of the SAPEN procedure. RESULTS The placement of a percutaneous stent was successful in all of the 23 patients (17 males, six females). IPN was successfully managed in 16/23 (70%) patients, with the need for open surgery in seven patients (30%), with a median of two (range 1-5) SAPEN procedures. No significant procedure-related complications occurred. Overall 11/23 (48%) patients had a major complication and/or death. CONCLUSIONS In conclusion, the SAPEN procedure was effective in treating IPN without adding extra procedural risk. The role and benefits of the SAPEN procedure now need to be demonstrated in larger controlled study.
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Affiliation(s)
- Lu Ke
- Department of General Surgery, Jinling Hospital, Medical School of Nanjing University, No. 305 Zhongshan East Road, Nanjing, 210002, Nanjing Province, China
| | - Wenjian Mao
- Department of General Surgery, Jinling Hospital, Medical School of Nanjing University, No. 305 Zhongshan East Road, Nanjing, 210002, Nanjing Province, China
- Department of General Surgery, Jinling Clinical Medical College of Southern Medical University, No. 305 Zhongshan East Road, Nanjing, China
| | - Jing Zhou
- Department of General Surgery, Jinling Hospital, Medical School of Nanjing University, No. 305 Zhongshan East Road, Nanjing, 210002, Nanjing Province, China
| | - Bo Ye
- Department of General Surgery, Jinling Hospital, Medical School of Nanjing University, No. 305 Zhongshan East Road, Nanjing, 210002, Nanjing Province, China
| | - Gang Li
- Department of General Surgery, Jinling Hospital, Medical School of Nanjing University, No. 305 Zhongshan East Road, Nanjing, 210002, Nanjing Province, China
| | - Jingzhu Zhang
- Department of General Surgery, Jinling Hospital, Medical School of Nanjing University, No. 305 Zhongshan East Road, Nanjing, 210002, Nanjing Province, China
| | - Peng Wang
- Department of General Surgery, Jinling Hospital, Medical School of Nanjing University, No. 305 Zhongshan East Road, Nanjing, 210002, Nanjing Province, China
- Department of General Surgery, Jinling Clinical Medical College of Southern Medical University, No. 305 Zhongshan East Road, Nanjing, China
| | - Zhihui Tong
- Department of General Surgery, Jinling Hospital, Medical School of Nanjing University, No. 305 Zhongshan East Road, Nanjing, 210002, Nanjing Province, China.
| | - John Windsor
- Department of Surgery, University of Auckland, Auckland, New Zealand
| | - Weiqin Li
- Department of General Surgery, Jinling Hospital, Medical School of Nanjing University, No. 305 Zhongshan East Road, Nanjing, 210002, Nanjing Province, China.
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29
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Bang JY, Arnoletti JP, Holt BA, Sutton B, Hasan MK, Navaneethan U, Feranec N, Wilcox CM, Tharian B, Hawes RH, Varadarajulu S. An Endoscopic Transluminal Approach, Compared With Minimally Invasive Surgery, Reduces Complications and Costs for Patients With Necrotizing Pancreatitis. Gastroenterology 2019; 156:1027-1040.e3. [PMID: 30452918 DOI: 10.1053/j.gastro.2018.11.031] [Citation(s) in RCA: 173] [Impact Index Per Article: 34.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/28/2018] [Revised: 10/31/2018] [Accepted: 11/12/2018] [Indexed: 02/08/2023]
Abstract
BACKGROUND & AIMS Infected necrotizing pancreatitis is a highly morbid disease with poor outcomes. Intervention strategies have progressed from open necrosectomy to minimally invasive approaches. We compared outcomes of minimally invasive surgery vs endoscopic approaches for patients with infected necrotizing pancreatitis. METHODS We performed a single-center, randomized trial of 66 patients with confirmed or suspected infected necrotizing pancreatitis who required intervention from May 12, 2014, through March 24, 2017. Patients were randomly assigned to groups that received minimally invasive surgery (laparoscopic or video-assisted retroperitoneal debridement, depending on location of collection, n = 32) or an endoscopic step-up approach (transluminal drainage with or without necrosectomy, n = 34). The primary endpoint was a composite of major complications (new-onset multiple organ failure, new-onset systemic dysfunction, enteral or pancreatic-cutaneous fistula, bleeding and perforation of a visceral organ) or death during 6 months of follow-up. RESULTS The primary endpoint occurred in 11.8% of patients who received the endoscopic procedure and 40.6% of patients who received the minimally invasive surgery (risk ratio 0.29; 95% confidence interval 0.11-0.80; P = .007). Although there was no significant difference in mortality (endoscopy 8.8% vs surgery 6.3%; P = .999), none of the patients assigned to the endoscopic approach developed enteral or pancreatic-cutaneous fistulae compared with 28.1% of the patients who underwent surgery (P = .001). The mean number of major complications per patient was significantly higher in the surgery group (0.69 ± 1.03) compared with the endoscopy group (0.15 ± 0.44) (P = .007). The physical health scores for quality of life at 3 months was better with the endoscopic approach (P = .039) and mean total cost was lower ($75,830) compared with $117,492 for surgery (P = .039). CONCLUSIONS In a randomized trial of 66 patients, an endoscopic transluminal approach for infected necrotizing pancreatitis, compared with minimally invasive surgery, significantly reduced major complications, lowered costs, and increased quality of life. Clinicaltrials.gov no: NCT02084537.
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Affiliation(s)
- Ji Young Bang
- Center for Interventional Endoscopy, Florida Hospital, Orlando, Florida
| | | | - Bronte A Holt
- Center for Interventional Endoscopy, Florida Hospital, Orlando, Florida
| | - Bryce Sutton
- Center for Interventional Endoscopy, Florida Hospital, Orlando, Florida
| | - Muhammad K Hasan
- Center for Interventional Endoscopy, Florida Hospital, Orlando, Florida
| | | | | | - C Mel Wilcox
- Division of Gastroenterology-Hepatology, University of Alabama at Birmingham, Birmingham, Alabama
| | - Benjamin Tharian
- Center for Interventional Endoscopy, Florida Hospital, Orlando, Florida
| | - Robert H Hawes
- Center for Interventional Endoscopy, Florida Hospital, Orlando, Florida
| | - Shyam Varadarajulu
- Center for Interventional Endoscopy, Florida Hospital, Orlando, Florida.
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30
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[Video-assisted retroperitoneal debridement : Minimally invasive treatment and long-term results for necrotizing pancreatitis]. Chirurg 2018; 88:785-791. [PMID: 28180976 DOI: 10.1007/s00104-017-0377-4] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/22/2022]
Abstract
BACKGROUND Among patients with necrotizing pancreatitis 15-20% develop infected necrosis, which entails mortality rates of up to 20%. Particularly driven by the results of the Dutch Pancreatitis Study Group there has been a paradigm change from open necrosectomy to step-up treatment with initial percutaneous and/or endoscopic drainage followed, if necessary, by minimally invasive retroperitoneal debridement. AIM OF THE STUDY Description of case series in which patients underwent video-assisted retroperitoneal debridement (VARD) including follow-up focused on quality of life. METHODS Systematic cohort study including all patients who underwent a VARD procedure at the Department of General, Visceral and Transplantation Surgery at Aachen University Hospital from 2011 to 2015. Quality of life was recorded using the EORTC QLQ-C 30 questionnaire and compared to a representative sample of the German general population. RESULTS The VARD procedure was performed in 9 cases, although in 1 case conversion to an open approach due to an acute bleeding was necessary. There was no 30-day and 60-day mortality following VARD. During the postoperative stay no patient required specific treatment for surgical complications. In particular, no enterocutaneous fistula or organ perforation was observed. Regarding the quality of life score there was no significant difference concerning the global health status, compared to the sample from the general population. DISCUSSION Our data reinforce that a step-up approach in patients with necrotizing pancreatitis is a feasible and safe treatment procedure. For the first time, we could demonstrate satisfactory results in a long-term follow-up including QOL.
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Darrivere L, Lapidus N, Colignon N, Chafai N, Chaput U, Verdonk F, Paye F, Lescot T. Minimally invasive drainage in critically ill patients with severe necrotizing pancreatitis is associated with better outcomes: an observational study. CRITICAL CARE : THE OFFICIAL JOURNAL OF THE CRITICAL CARE FORUM 2018; 22:321. [PMID: 30466472 PMCID: PMC6249885 DOI: 10.1186/s13054-018-2256-x] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 07/13/2018] [Accepted: 11/04/2018] [Indexed: 12/17/2022]
Abstract
Background Infected pancreatic necrosis, which occurs in about 40% of patients admitted for acute necrotizing pancreatitis, requires combined antibiotic therapy and local drainage. Since 2010, drainage by open surgical necrosectomy has been increasingly replaced by less invasive methods such as percutaneous radiological drainage, endoscopic necrosectomy, and laparoscopic surgery, which proved effective in small randomized controlled trials in highly selected patients. Few studies have evaluated minimally invasive drainage methods used under the conditions of everyday hospital practice. The aim of this study was to determine whether, compared with conventional open surgery, minimally invasive drainage was associated with improved outcomes of critically ill patients with infection complicating acute necrotizing pancreatitis. Methods A single-center observational study was conducted in patients admitted to the intensive care unit for severe acute necrotizing pancreatitis to compare the characteristics, drainage techniques, and outcomes of the 62 patients managed between September 2006 and December 2010, chiefly with conventional open surgery, and of the 81 patients managed between January 2011 and August 2015 after the introduction of a minimally invasive drainage protocol. Results Surgical necrosectomy was more common in the early period (74% versus 41%; P <0.001), and use of minimally invasive drainage increased between the early and late periods (19% and 52%, respectively; P <0.001). The numbers of ventilator-free days and catecholamine-free days by day 30 were higher during the later period. The proportions of patients discharged from intensive care within the first 30 days and from the hospital within the first 90 days were higher during the second period. Hospital mortality was not significantly different between the early and late periods (19% and 22%, respectively). Conclusion In our study, the implementation of a minimally invasive drainage protocol in patients with infected pancreatic necrosis was associated with shorter times spent with organ dysfunction, in the intensive care unit, and in the hospital. Mortality was not significantly different. These results should be interpreted bearing in mind the limitations inherent in the before-after study design.
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Affiliation(s)
- Lucie Darrivere
- Department of Anesthesiology and Critical Care Medicine, Saint-Antoine Hospital, Assistance Publique-Hôpitaux de Paris, Paris, France
| | - Nathanael Lapidus
- Sorbonne University, INSERM, Institut Pierre Louis d'Epidémiologie et de Santé Publique IPLESP, Public Health Department, Saint-Antoine Hospital, Assistance Publique-Hôpitaux de Paris, Paris, France
| | - Nikias Colignon
- Radiology Department, Saint-Antoine Hospital, Assistance Publique-Hôpitaux de Paris, Paris, France
| | - Najim Chafai
- Digestive Surgery Department, Saint-Antoine Hospital, Assistance Publique-Hôpitaux de Paris, Paris, France
| | - Ulriikka Chaput
- Endoscopy Department, Saint-Antoine Hospital, Assistance Publique-Hôpitaux de Paris, Paris, France
| | - Franck Verdonk
- Sorbonne University, Department of Anesthesiology and Critical Care Medicine, Saint-Antoine Hospital, Assistance Publique-Hôpitaux de Paris, Paris, France
| | - François Paye
- Sorbonne University, Digestive Surgery Department, Saint-Antoine Hospital, Assistance Publique-Hôpitaux de Paris, Paris, France
| | - Thomas Lescot
- Sorbonne University, Department of Anesthesiology and Critical Care Medicine, Saint-Antoine Hospital, Assistance Publique-Hôpitaux de Paris, Paris, France.
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Houghton EJ, Vázquez AAG, Zeledón ME, Andreacchio A, Ruiz G, Palermo M, Gimenez ME. NECROTIZING PANCREATITIS: DESCRIPTION OF VIDEOSCOPIC ASSISTED RETROPERITONEAL DEBRIDEMENT (VARD) TECHNIQUE WITH COVERED METALLIC STENT. ACTA ACUST UNITED AC 2018; 31:e1379. [PMID: 29972407 PMCID: PMC6044201 DOI: 10.1590/0102-672020180001e1379] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/23/2018] [Accepted: 03/15/2018] [Indexed: 01/11/2023]
Abstract
Background: Acute pancreatitis is the third most common gastrointestinal disorder
requiring hospitalization in the United States, with annual costs exceeding
$2 billions. Severe necrotizing pancreatitis is a life-threatening
complication developed in approximately 20% of patients. Its mortality rate
range from 15% in patients with sterile necrosis to up 30% in case of
infected one associated with multi-organ failure. Less invasive treatment
techniques are increasingly being used. These techniques can be performed in
a so-called step-up approach. Aim: To present the technique for videoscopic assisted retroperitoneal debridement
(Vard technique) with covered metallic stent in necrotizing pancreatitis.
Method: A guide wire was inserted through the previous catheter that was removed in
the next step. Afterwards, the tract was dilated over the guide wire. Then,
a partially covered metallic stent was deployed. A 30 degrees laparoscopic
camera was inserted and the necrosis removed with forceps through the
expanded stent under direct vision. Finally, the stent was removed and a new
catheter left in place. Result: This technique was used in a 31-year-old man with acute pain in the upper
abdomen and diagnosed as acute biliary pancreatitis with infected necrosis.
He was treated with percutaneous drains at weeks 3, 6 and 8. Due to partial
recovery, a left lateral VARD was performed (incomplete by fixed and
adherent tissue) at 8th week. As the patient´s inflammatory
response was reactivated, a second VARD attempt was performed in three weeks
later. Afterwards, patient showed complete clinical and imaging resolution.
Conclusions: Videoassisted retroperitoneal necrosectomy using partially covered metallic
stent is a feasible technique for necrotizing pancreatitis.
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Affiliation(s)
- Eduardo J Houghton
- Minimally Invasive Surgery, Hospital Bernardino Rivadavia.,University of Buenos Aires.,DAICIM Foundation, Buenos Aires, Argentina
| | | | | | | | - Gabriel Ruiz
- Minimally Invasive Surgery, Hospital Bernardino Rivadavia
| | - Mariano Palermo
- Minimally Invasive Surgery, Hospital Bernardino Rivadavia.,DAICIM Foundation, Buenos Aires, Argentina.,Hospital Nacional Prof. Alejandro Posadas, Buenos aires, Argentina
| | - Mariano E Gimenez
- University of Buenos Aires.,DAICIM Foundation, Buenos Aires, Argentina
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Abstract
Acute pancreatitis represents a disorder characterized by acute necroinflammatory changes of the pancreas and is histologically characterized by acinar cell destruction. Diagnosed clinically with the Revised Atlanta Criteria, and with alcohol and cholelithiasis/choledocholithiasis as the two most prominent antecedents, acute pancreatitis ranks first amongst gastrointestinal diagnoses requiring admission and 21st amongst all diagnoses requiring hospitalization with estimated costs approximating 2.6 billion dollars annually. Complications arising from acute pancreatitis follow a progression from pancreatic/peripancreatic fluid collections to pseudocysts and from pancreatic/peripancreatic necrosis to walled-off necrosis that typically occur over the course of a 4-week interval. Treatment relies heavily on fluid resuscitation and nutrition with advanced endoscopic techniques and cholecystectomy utilized in the setting of gallstone pancreatitis. When necessity dictates a drainage procedure (persistent abdominal pain, gastric or duodenal outlet obstruction, biliary obstruction, and infection), an endoscopic ultrasound with advanced endoscopic techniques and technology rather than surgical intervention is increasingly being utilized to manage symptomatic pseudocysts and walled-off pancreatic necrosis by performing a cystogastrostomy.
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Morató O, Poves I, Ilzarbe L, Radosevic A, Vázquez-Sánchez A, Sánchez-Parrilla J, Burdío F, Grande L. Minimally invasive surgery in the era of step-up approach for treatment of severe acute pancreatitis. Int J Surg 2018; 51:164-169. [PMID: 29409791 DOI: 10.1016/j.ijsu.2018.01.017] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/12/2017] [Revised: 01/03/2018] [Accepted: 01/08/2018] [Indexed: 12/12/2022]
Abstract
OBJECTIVES To assess the minimally invasive surgery into the step-up approach procedures as a standard treatment for severe acute pancreatitis and comparing its results with those obtained by classical management. METHODS Retrospective cohort study comparative with two groups treated over two consecutive, equal periods of time were defined: group A, classic management with open necrosectomy from January 2006 to June 2010; and group B, management with the step-up approach with minimally invasive surgery from July 2010 to December 2014. RESULTS In group A, 83 patients with severe acute pancreatitis were treated, of whom 19 underwent at least one laparotomy, and in 5 any minimally invasive surgery. In group B, 81 patients were treated: minimally invasive surgery was necessary in 17 cases and laparotomy in 3. Among operated patients, the time from admission to first interventional procedures was significantly longer in group B (9 days vs. 18.5 days; p = 0.042). There were no significant differences in Intensive Care Unit stay or overall stay: 9.5 and 27 days (group A) vs. 8.5 and 21 days (group B). Mortality in operated patients and mortality overall were 50% and 18.1% in group A vs 0% and 6.2% in group B (p < 0.001 and p = 0.030). CONCLUSIONS The combination of the step-up approach and minimally invasive surgery algorithm is feasible and could be considered as the standard of treatment for severe acute pancreatitis. The mortality rate deliberately descends when it is used.
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Affiliation(s)
- Olga Morató
- Unit of Hepato-Biliary and Pancreatic Surgery, Department of Surgery, Autonomous University of Barcelona, Hospital del Mar, Barcelona, Spain.
| | - Ignasi Poves
- Unit of Hepato-Biliary and Pancreatic Surgery, Department of Surgery, Autonomous University of Barcelona, Hospital del Mar, Barcelona, Spain.
| | - Lucas Ilzarbe
- Department of Gastroenterology, Hospital del Mar, Barcelona, Spain.
| | | | | | | | - Fernando Burdío
- Unit of Hepato-Biliary and Pancreatic Surgery, Department of Surgery, Autonomous University of Barcelona, Hospital del Mar, Barcelona, Spain.
| | - Luís Grande
- Unit of Hepato-Biliary and Pancreatic Surgery, Department of Surgery, Autonomous University of Barcelona, Hospital del Mar, Barcelona, Spain.
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van Brunschot S, van Grinsven J, van Santvoort HC, Bakker OJ, Besselink MG, Boermeester MA, Bollen TL, Bosscha K, Bouwense SA, Bruno MJ, Cappendijk VC, Consten EC, Dejong CH, van Eijck CH, Erkelens WG, van Goor H, van Grevenstein WMU, Haveman JW, Hofker SH, Jansen JM, Laméris JS, van Lienden KP, Meijssen MA, Mulder CJ, Nieuwenhuijs VB, Poley JW, Quispel R, de Ridder RJ, Römkens TE, Scheepers JJ, Schepers NJ, Schwartz MP, Seerden T, Spanier BWM, Straathof JWA, Strijker M, Timmer R, Venneman NG, Vleggaar FP, Voermans RP, Witteman BJ, Gooszen HG, Dijkgraaf MG, Fockens P. Endoscopic or surgical step-up approach for infected necrotising pancreatitis: a multicentre randomised trial. Lancet 2018; 391:51-58. [PMID: 29108721 DOI: 10.1016/s0140-6736(17)32404-2] [Citation(s) in RCA: 402] [Impact Index Per Article: 67.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/30/2017] [Revised: 06/19/2017] [Accepted: 08/02/2017] [Indexed: 02/06/2023]
Abstract
BACKGROUND Infected necrotising pancreatitis is a potentially lethal disease and an indication for invasive intervention. The surgical step-up approach is the standard treatment. A promising alternative is the endoscopic step-up approach. We compared both approaches to see whether the endoscopic step-up approach was superior to the surgical step-up approach in terms of clinical and economic outcomes. METHODS In this multicentre, randomised, superiority trial, we recruited adult patients with infected necrotising pancreatitis and an indication for invasive intervention from 19 hospitals in the Netherlands. Patients were randomly assigned to either the endoscopic or the surgical step-up approach. The endoscopic approach consisted of endoscopic ultrasound-guided transluminal drainage followed, if necessary, by endoscopic necrosectomy. The surgical approach consisted of percutaneous catheter drainage followed, if necessary, by video-assisted retroperitoneal debridement. The primary endpoint was a composite of major complications or death during 6-month follow-up. Analyses were by intention to treat. This trial is registered with the ISRCTN registry, number ISRCTN09186711. FINDINGS Between Sept 20, 2011, and Jan 29, 2015, we screened 418 patients with pancreatic or extrapancreatic necrosis, of which 98 patients were enrolled and randomly assigned to the endoscopic step-up approach (n=51) or the surgical step-up approach (n=47). The primary endpoint occurred in 22 (43%) of 51 patients in the endoscopy group and in 21 (45%) of 47 patients in the surgery group (risk ratio [RR] 0·97, 95% CI 0·62-1·51; p=0·88). Mortality did not differ between groups (nine [18%] patients in the endoscopy group vs six [13%] patients in the surgery group; RR 1·38, 95% CI 0·53-3·59, p=0·50), nor did any of the major complications included in the primary endpoint. INTERPRETATION In patients with infected necrotising pancreatitis, the endoscopic step-up approach was not superior to the surgical step-up approach in reducing major complications or death. The rate of pancreatic fistulas and length of hospital stay were lower in the endoscopy group. The outcome of this trial will probably result in a shift to the endoscopic step-up approach as treatment preference. FUNDING The Dutch Digestive Disease Foundation, Fonds NutsOhra, and the Netherlands Organization for Health Research and Development.
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Affiliation(s)
- Sandra van Brunschot
- Department of Gastroenterology and Hepatology, Academic Medical Centre, University of Amsterdam, Amsterdam, Netherlands.
| | - Janneke van Grinsven
- Department of Gastroenterology and Hepatology, Academic Medical Centre, University of Amsterdam, Amsterdam, Netherlands; Department of Surgery, Academic Medical Centre, University of Amsterdam, Amsterdam, Netherlands
| | - Hjalmar C van Santvoort
- Department of Surgery, St Antonius Hospital, Nieuwegein, Netherlands; Department of Surgery, University Medical Centre Utrecht, Utrecht, Netherlands
| | - Olaf J Bakker
- Department of Surgery, University Medical Centre Utrecht, Utrecht, Netherlands
| | - Marc G Besselink
- Department of Surgery, Academic Medical Centre, University of Amsterdam, Amsterdam, Netherlands
| | - Marja A Boermeester
- Department of Surgery, Academic Medical Centre, University of Amsterdam, Amsterdam, Netherlands
| | - Thomas L Bollen
- Department of Radiology, St Antonius Hospital, Nieuwegein, Netherlands
| | - Koop Bosscha
- Department of Surgery, Jeroen Bosch Hospital, 's-Hertogenbosch, Netherlands
| | - Stefan A Bouwense
- Department of Surgery, Radboud University Medical Centre, Nijmegen, Netherlands
| | - Marco J Bruno
- Department of Gastroenterology and Hepatology, Erasmus MC, University Medical Centre, Rotterdam, Netherlands
| | | | - Esther C Consten
- Department of Surgery, Meander Medical Centre, Amersfoort, Netherlands
| | - Cornelis H Dejong
- Department of Surgery and NUTRIM School for Nutrition and Translational Research in Metabolism, Maastricht University Medical Centre, Maastricht, Netherlands
| | - Casper H van Eijck
- Department of Surgery, Erasmus MC, University Medical Centre, Rotterdam, Netherlands
| | | | - Harry van Goor
- Department of Surgery, Radboud University Medical Centre, Nijmegen, Netherlands
| | | | - Jan-Willem Haveman
- Department of Surgery, University Medical Centre Groningen, University of Groningen, Groningen, Netherlands
| | - Sijbrand H Hofker
- Department of Surgery, University Medical Centre Groningen, University of Groningen, Groningen, Netherlands
| | - Jeroen M Jansen
- Department of Gastroenterology, Onze Lieve Vrouwe Gasthuis, Amsterdam, Netherlands
| | - Johan S Laméris
- Department of Radiology, Academic Medical Centre, University of Amsterdam, Amsterdam, Netherlands
| | - Krijn P van Lienden
- Department of Radiology, Academic Medical Centre, University of Amsterdam, Amsterdam, Netherlands
| | | | - Chris J Mulder
- Department of Gastroenterology, VU Medical Centre, Amsterdam, Netherlands
| | | | - Jan-Werner Poley
- Department of Gastroenterology and Hepatology, Erasmus MC, University Medical Centre, Rotterdam, Netherlands
| | - Rutger Quispel
- Department of Gastroenterology, Reinier de Graaf Group, Delft, Netherlands
| | - Rogier J de Ridder
- Department of Gastroenterology, Maastricht University Medical Centre, Maastricht, Netherlands
| | - Tessa E Römkens
- Department of Gastroenterology, Jeroen Bosch Hospital, 's-Hertogenbosch, Netherlands
| | | | - Nicolien J Schepers
- Department of Gastroenterology and Hepatology, Erasmus MC, University Medical Centre, Rotterdam, Netherlands
| | - Matthijs P Schwartz
- Department of Gastroenterology, Meander Medical Centre, Amersfoort, Netherlands
| | - Tom Seerden
- Department of Gastroenterology, Amphia Hospital, Breda, Netherlands
| | | | | | - Marin Strijker
- Department of Surgery, Academic Medical Centre, University of Amsterdam, Amsterdam, Netherlands
| | - Robin Timmer
- Department of Gastroenterology, St Antonius Hospital, Nieuwegein, Netherlands
| | - Niels G Venneman
- Department of Gastroenterology, Medisch Spectrum Twente, Enschede, Netherlands
| | - Frank P Vleggaar
- Department of Gastroenterology and Hepatology, University Medical Centre Utrecht, Utrecht, Netherlands
| | - Rogier P Voermans
- Department of Gastroenterology and Hepatology, Academic Medical Centre, University of Amsterdam, Amsterdam, Netherlands
| | - Ben J Witteman
- Department of Gastroenterology, Hospital Gelderse Vallei, Ede, Netherlands
| | - Hein G Gooszen
- Department of OR/Evidence Based Surgery, Radboud University Medical Centre, Nijmegen, Netherlands
| | - Marcel G Dijkgraaf
- Clinical Research Unit, Academic Medical Centre, University of Amsterdam, Amsterdam, Netherlands
| | - Paul Fockens
- Department of Gastroenterology and Hepatology, Academic Medical Centre, University of Amsterdam, Amsterdam, Netherlands
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Jürgensen C, Brückner S, Reichel S, Kilian M, Pannach S, Distler M, Weitz J, Neser F, Hampe J, Will U. Flexible percutaneous endoscopic retroperitoneal necrosectomy as rescue therapy for pancreatic necroses beyond the reach of endoscopic ultrasonography: A case series. Dig Endosc 2017; 29:377-382. [PMID: 28112447 DOI: 10.1111/den.12817] [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: 09/09/2016] [Accepted: 01/18/2017] [Indexed: 02/08/2023]
Abstract
Minimally invasive or endoscopic transluminal drainage and necrosectomy are the standard of care for infected pancreatic fluid collections and necroses after pancreatitis. In an endoscopic treatment algorithm, necroses beyond the reach of safe endoscopic access are typically treated by percutaneous drainage. We aimed to evaluate percutaneous minimally invasive necrosectomy using a purely endoscopic technique in patients with extensive necrosis. In patients with necroses beyond safe transluminal reach, the percutaneous drainage canal was used for flexible endoscopic access and dilatation of the tract to 20 mm. Percutaneous endoscopic necrosectomy was carried out through this canal. We present a case series of 14 patients in whom between one and four necrosectomy (median two) sessions were done to remove solid necroses successfully in 13 out of 14 patients. There were no major complications apart from one patient with abdominal compartment syndrome secondary to delayed erosion of the splenic artery. Percutaneous flexible necrosectomy might evolve into an alternative to surgical minimally invasive necrosectomy in anatomical sites beyond transluminal endoscopic reach.
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Affiliation(s)
- Christian Jürgensen
- Department of Hepatology and Gastroenterology, Charité University Medicine, Berlin, Germany
| | - Stefan Brückner
- Medical Department 1, University Hospital Dresden, Technical University Dresden (TUD), Dresden, Germany
| | - Stephanie Reichel
- Department of Gastroenterology, Hepatology and General Internal Medicine, Wald-Klinikum General Hospital, Gera, Germany
| | - Maik Kilian
- Department of General, Visceral, Vascular and Thoracic Surgery, Charité University Medicine, Berlin, Germany
| | - Sven Pannach
- Department of Hepatology and Gastroenterology, Charité University Medicine, Berlin, Germany
| | - Marius Distler
- Department of Visceral, Thoracic and Vascular Surgery, University Hospital Dresden, Technical University Dresden (TUD), Dresden, Germany
| | - Jürgen Weitz
- Department of Visceral, Thoracic and Vascular Surgery, University Hospital Dresden, Technical University Dresden (TUD), Dresden, Germany
| | - Frank Neser
- Department of Gastroenterology, Endocrinology and Infectious Diseases, Klinikum Chemnitz GmbH, Chemnitz, Germany
| | - Jochen Hampe
- Medical Department 1, University Hospital Dresden, Technical University Dresden (TUD), Dresden, Germany
| | - Uwe Will
- Department of Gastroenterology, Hepatology and General Internal Medicine, Wald-Klinikum General Hospital, Gera, Germany
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38
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Tong Z, Ke L, Li B, Li G, Zhou J, Shen X, Li W, Li N, Li J. Negative pressure irrigation and endoscopic necrosectomy through man-made sinus tract in infected necrotizing pancreatitis: a technical report. BMC Surg 2016; 16:73. [PMID: 27832819 PMCID: PMC5105240 DOI: 10.1186/s12893-016-0190-x] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/01/2016] [Accepted: 11/01/2016] [Indexed: 01/07/2023] Open
Abstract
BACKGROUND In recent years, a step-up approach based on minimally invasive techniques was recommended by latest guidelines as initial invasive treatment for infected pancreatic necrosis (IPN). In this study, we aimed to describe a novel step-up approach for treating IPN consisting of four steps including negative pressure irrigation (NPI) and endoscopic necrosectomy (ED) as a bridge between percutaneous catheter drainage (PCD) and open necrosectomy METHODS: A retrospective review of a prospectively collected internal database of patients with a diagnosis of IPN between Jan, 2012 to Dec, 2012 at a single institution was performed. All patients underwent the same drainage strategy including four steps: PCD, NPI, ED and open necrosectomy. The demographic characteristics and clinical outcomes of study patients were analyzed. RESULTS A total of 71 consecutive patients (48 males and 23 females) were included in the analysis. No significant procedure-related complication was observed and the overall mortality was +21.1 % (15 of 71 patients). Seven different strategies like PCD+ NPI, PCD+NPI+ED, PCD+open necrosectomy, etcetera, were applied in study patients and a half of them received PCD alone. In general, each patient underwent a median of 2 drainage procedures and the median total drainage duration was 11 days (interquartile range, 6-21days). CONCLUSIONS This four-step approach is effective in treating IPN and adds no extra risk to patients when compared with other latest step-up strategies. The two novel techniques (NPI and ED) could offer distinct clinical benefits without posing unanticipated risks inherent to the procedures.
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Affiliation(s)
- Zhihui Tong
- SICU, Department of General Surgery, Jinling Hospital, Nanjing University School of Medicine, Nanjing, 210002, People's Republic of China
| | - Lu Ke
- SICU, Department of General Surgery, Jinling Hospital, Nanjing University School of Medicine, Nanjing, 210002, People's Republic of China
| | - Baiqiang Li
- SICU, Department of General Surgery, Jinling Hospital, Nanjing University School of Medicine, Nanjing, 210002, People's Republic of China
| | - Gang Li
- SICU, Department of General Surgery, Jinling Hospital, Nanjing University School of Medicine, Nanjing, 210002, People's Republic of China
| | - Jing Zhou
- SICU, Department of General Surgery, Jinling Hospital, Nanjing University School of Medicine, Nanjing, 210002, People's Republic of China
| | - Xiao Shen
- SICU, Department of General Surgery, Jinling Hospital, Nanjing University School of Medicine, Nanjing, 210002, People's Republic of China
| | - Weiqin Li
- SICU, Department of General Surgery, Jinling Hospital, Nanjing University School of Medicine, Nanjing, 210002, People's Republic of China. .,Department of SICU, Research Institute of General Surgery, Jinling Hospital, 305 East Zhongshan Road, Nanjing, 210002, Jiangsu Province, China.
| | - Ning Li
- Department of General Surgery, Jinling Hospital, Nanjing University School of Medicine, Nanjing, 210002, People's Republic of China
| | - Jieshou Li
- Department of General Surgery, Jinling Hospital, Nanjing University School of Medicine, Nanjing, 210002, People's Republic of China
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Li JW, Li JW, Ang TL, Ang TL. Is endoscopic necrosectomy the way to go? GASTROINTESTINAL INTERVENTION 2016. [DOI: 10.18528/gii160010] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/26/2022]
Affiliation(s)
- James Weiquan Li
- Department of Gastroenterology and Hepatology, Changi General Hospital, Singapore
| | - James Weiquan Li
- Department of Gastroenterology and Hepatology, Changi General Hospital, Singapore
| | - Tiing Leong Ang
- Department of Gastroenterology and Hepatology, Changi General Hospital, Singapore
| | - Tiing Leong Ang
- Department of Gastroenterology and Hepatology, Changi General Hospital, Singapore
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Abstract
INTRODUCTION At least 30% of patients with infected necrotizing pancreatitis are successfully treated with catheter drainage alone. It is currently not possible to predict which patients also need necrosectomy. We evaluated predictive factors for successful catheter drainage. METHODS This was a post hoc analysis of 130 prospectively included patients undergoing catheter drainage for (suspected) infected necrotizing pancreatitis. Using logistic regression, we evaluated the association between success of catheter drainage (ie, survival without necrosectomy) and 22 factors regarding demographics, disease severity (eg, Acute Physiology And Chronic Health Evaluation II score, organ failure), and morphologic characteristics on computed tomography (eg, percentage of necrosis). RESULTS Catheter drainage was performed percutaneously in 113 patients and endoscopically in 17 patients. Infected necrosis was confirmed in 116 patients (89%). Catheter drainage was successful in 45 patients (35%). In multivariable regression, the following factors were associated with a reduced chance of success: male sex [odds ratio (OR) = 0.27; 95% confidence interval (CI): 0.09-0.55; P <0.01), multiple organ failure (OR = 0.15; 95% CI: 0.04-0.62; P < 0.01), percentage of pancreatic necrosis (<30%/30%-50%/>50%: OR = 0.54; 95% CI: 0.30-0.96; P = 0.03), and heterogeneous collection (OR = 0.21; 95% CI: 0.06-0.67; P < 0.01). A prediction model incorporating these factors demonstrated an area under the receiver operating characteristic curve of 0.76. A prognostic nomogram yielded success probability of catheter drainage from 2% to 91%. CONCLUSIONS Male sex, multiple organ failure, increasing percentage of pancreatic necrosis and heterogeneity of the collection are negative predictors for success of catheter drainage in infected necrotizing pancreatitis. The constructed nomogram can guide prognostication in clinical practice and risk stratification in clinical studies.
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41
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Abstract
Acute pancreatitis is the most common gastrointestinal indication for hospital admission, and infected pancreatic and/or extrapancreatic necrosis is a potentially lethal complication. Current standard treatment of infected necrosis is a step-up approach, consisting of catheter drainage followed, if necessary, by minimally invasive necrosectomy. International guidelines recommend postponing catheter drainage until the stage of 'walled-off necrosis' has been reached, a process that typically takes 4 weeks after onset of acute pancreatitis. This recommendation stems from the era of primary surgical necrosectomy. However, postponement of catheter drainage might not be necessary, and earlier detection and subsequent earlier drainage of infected necrosis could improve outcome. Strong data and consensus among international expert pancreatologists are lacking. Future clinical, preferably randomized, studies should focus on timing of catheter drainage in patients with infected necrotizing pancreatitis. In this Perspectives, we discuss challenges in the invasive treatment of patients with infected necrotizing pancreatitis, focusing on timing of catheter drainage.
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Li A, Cao F, Li J, Fang Y, Wang X, Liu DG, Li F. Step-up mini-invasive surgery for infected pancreatic necrosis: Results from prospective cohort study. Pancreatology 2016; 16:508-14. [PMID: 27083075 DOI: 10.1016/j.pan.2016.03.014] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/14/2015] [Revised: 02/29/2016] [Accepted: 03/19/2016] [Indexed: 12/11/2022]
Abstract
OBJECTIVES To investigate the clinical efficacy and success predictors of mini-invasive techniques in the treatment of infected pancreatic necrosis (IPN). METHODS IPN patients admitted to our clinic for treatment by mini-invasive techniques were included in this study prospectively. Treatment was divided into four sequential phases: percutaneous catheter drainage (PCD), mini-incision drainage (MID), video assisted debridement (VAD) and open surgery. Patients progressed to next phase if the infection cannot be controlled. The frequency of surgery, treatment duration, cure rate, incidence of complication and overall mortality were recorded. Risk factors for failure of PCD and MID procedures were detected by logistic regression including demographics, disease severity and morphologic characteristics. RESULTS From January 2012 to March 2015, a total of 54 consecutive IPN patients were treated, with an average age of 51.2 ± 3.1 years. Of the 54 cases, 18 (33.3%) were cured after PCD; 13 (24.1%) with uncontrolled infection were cured after MID; and the remaining 19 cases (35.2%) were cured after VAD. No open surgery was performed. Overall mortality was 7.4% (4/54), and the incidence of complications was 12.9% (7/54). In multivariable regression, the following factors were associated with high failure rate for both PCD and MID: heterogeneous fluid collection (odds ratio (OR) = 3.14; 95% confidence interval (CI): 1.32 ~ 4.25, P = 0.001 for PCD; OR = 2.99; 95% CI: 1.52 ~ 5.10, P = 0.006 for MID), multiple infected collections (OR = 4.51; 95% CI: 2.94 ~ 8.63; P = 0.000 for PCD; OR = 4.17; 95% CI: 2.77 ~ 8.12, P = 0.000 for MID), CT severity index (0 ~ 3/4 ~ 6/7 ~ 10: OR = 2.16; 95% CI: 1.83 ~ 3.62, P = 0.031 for PCD; OR = 2.72; 95% CI: 1.78 ~ 4.10, P = 0.005 for MID). CONCLUSIONS Step-up mini-invasive techniques can be considered a first choice in the treatment of IPN. CT is effective to predict success of PCD and MID.
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Affiliation(s)
- Ang Li
- Department of General Surgery, Xuanwu Hospital, Capital Medical University, Beijing 100053, PR China
| | - Feng Cao
- Department of General Surgery, Xuanwu Hospital, Capital Medical University, Beijing 100053, PR China
| | - Jia Li
- Department of General Surgery, Xuanwu Hospital, Capital Medical University, Beijing 100053, PR China
| | - Yu Fang
- Department of General Surgery, Xuanwu Hospital, Capital Medical University, Beijing 100053, PR China
| | - Xiaohui Wang
- Department of General Surgery, Xuanwu Hospital, Capital Medical University, Beijing 100053, PR China
| | - Dian-Gang Liu
- Department of General Surgery, Xuanwu Hospital, Capital Medical University, Beijing 100053, PR China
| | - Fei Li
- Department of General Surgery, Xuanwu Hospital, Capital Medical University, Beijing 100053, PR China.
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Jimenez Rodriguez RM, Segura-Sampedro JJ, Flores-Cortés M, López-Bernal F, Martín C, Diaz VP, Ciuro FP, Ruiz JP. Laparoscopic approach in gastrointestinal emergencies. World J Gastroenterol 2016; 22:2701-2710. [PMID: 26973409 PMCID: PMC4777993 DOI: 10.3748/wjg.v22.i9.2701] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/04/2015] [Revised: 12/24/2015] [Accepted: 01/11/2016] [Indexed: 02/06/2023] Open
Abstract
This review focuses on the laparoscopic approach to gastrointestinal emergencies and its more recent indications. Laparoscopic surgery has a specific place in elective procedures, but that does not apply in emergency situations. In specific emergencies, there is a huge range of indications and different techniques to apply, and not all of them are equally settle. We consider that the most controversial points in minimally invasive procedures are indications in emergency situations due to technical difficulties. Some pathologies, such as oesophageal emergencies, obstruction due to colon cancer, abdominal hernias or incarcerated postsurgical hernias, are nearly always resolved by conventional surgery, that is, an open approach due to limited intraabdominal cavity space or due to the vulnerability of the bowel. These technical problems have been solved in many diseases, such as for perforated peptic ulcer or acute appendectomy for which a laparoscopic approach has become a well-known and globally supported procedure. On the other hand, endoscopic procedures have acquired further indications, relegating surgical solutions to a second place; this happens in cholangitis or pancreatic abscess drainage. This endoluminal approach avoids the need for laparoscopic development in these diseases. Nevertheless, new instruments and new technologies could extend the laparoscopic approach to a broader array of potentials procedures. There remains, however, a long way to go.
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Abstract
The surgical management of pancreatic diseases is rapidly evolving, encompassing advances in evidence-driven selection of patients amenable for surgical therapy, preoperative risk stratification, refinements in the technical conduct of pancreatic operations, and quantification of postoperative morbidity. These advances have resulted in dramatic reductions in mortality following pancreatic surgery, particularly at high-volume pancreatic centers. Surgical decision making is complex, and requires an intimate understanding of disease pathobiology, host physiology, technical considerations, and evolving trends. This article highlights key developments in the contemporary surgical management of pancreatic diseases.
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Affiliation(s)
- Jashodeep Datta
- Division of Gastrointestinal Surgery, Department of Surgery, University of Pennsylvania Perelman School of Medicine, 3400 Spruce Street, Philadelphia, PA 19104, USA
| | - Charles M Vollmer
- Division of Gastrointestinal Surgery, Department of Surgery, University of Pennsylvania Perelman School of Medicine, 3400 Spruce Street, Philadelphia, PA 19104, USA.
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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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Abstract
Surgery for acute pancreatitis has undergone significant changes over the last 3 decades. A better understanding of the pathophysiology has contributed to this, but the greatest driver for change has been the rise of less invasive interventions in the fields of laparoscopy, endoscopy and radiology. Surgery has a very limited role in the diagnosis of acute pancreatitis. The most common indication for intervention in acute pancreatitis is for the treatment of complications and most notably the treatment of infected walled off necrosis. Here, the step-up approach has become established, with prior drainage (either endoscopic or percutaneous) followed by delay for maturing of the wall and then debridement by endoscopic or minimally invasive surgical methods. Open surgery is only indicated when this approach fails. Other indications for surgery in acute pancreatitis are for the treatment of acute compartment syndrome, non-occlusive intestinal ischaemia and necrosis, enterocutaneous fistulae, vascular complications and pseudocyst. Surgery also has a role in the prevention of recurrent acute pancreatitis by cholecystectomy. Despite the more restricted role, surgeons have an important contribution to make in the multidisciplinary care of patients with complicated acute pancreatitis.
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Klink CD, Binnebösel M, Schmeding M, van Dam RM, Dejong CH, Junge K, Neumann UP. Video-assisted hepatic abscess debridement. HPB (Oxford) 2015; 17:732-5. [PMID: 26096195 PMCID: PMC4527859 DOI: 10.1111/hpb.12445] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/20/2015] [Accepted: 05/06/2015] [Indexed: 12/12/2022]
Abstract
BACKGROUND Pyogenic liver abscesses are currently treated by either percutaneous computer tomography (CT)-guided drainage or by laparoscopic and a conventional liver resection when conservative treatment fails but may be associated with substantial morbidity and mortality. METHODS A minimally invasive technique involving debridement of right liver abscesses was employed using a minimally invasive video-assisted hepatic abscess debridement (VAHD) after unsuccessful percutaneous CT-guided drainage. Clinical data, complication rates and outcomes of patients were recorded retrospectively. RESULTS Between 2011 and 2014, VAHD was performed on 10 patients at two centres with no observed recurrence of a liver abscess. The median age of the patients was 57 years (range 42-78) with a median pre-operative size of a liver abscess of 78 mm (range 40-115). The median operation time was 47 min (range 23-75), and the median postoperative hospital stay was 9 days (range 7-69). One patient developed a subcutaneous abscess that required further surgery. No patient died, and there were no major complications related to the VAHD. CONCLUSIONS Video-assisted hepatic abscess debridement is a feasible technique that shows promising results for the treatment of a recurrent right liver abscess.
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Affiliation(s)
- Christian D Klink
- Department of General, Visceral and Transplantation Surgery, RWTH Aachen University HospitalAachen, Germany,Correspondence Christian D. Klink, Department of General, Visceral and Transplantation Surgery, RWTH Aachen University Hospital, Pauwelsstrasse 30, 52074 Aachen, Germany. Tel.: +49 241 80 89500. Fax: +49 241 80 82417. E-mail:
| | - Marcel Binnebösel
- Department of General, Visceral and Transplantation Surgery, RWTH Aachen University HospitalAachen, Germany
| | - Maximilian Schmeding
- Department of General, Visceral and Transplantation Surgery, RWTH Aachen University HospitalAachen, Germany
| | - Ronald M van Dam
- Department of Surgery, Maastricht University Medical CentreMaastricht, The Netherlands
| | - Cornelis H Dejong
- Department of Surgery, Maastricht University Medical CentreMaastricht, The Netherlands
| | - Karsten Junge
- Department of General, Visceral and Transplantation Surgery, RWTH Aachen University HospitalAachen, Germany
| | - Ulf P Neumann
- Department of General, Visceral and Transplantation Surgery, RWTH Aachen University HospitalAachen, Germany
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Lim E, Sundaraamoorthy R, Tan D, Teh HS, Tan TJ, Cheng A. Step-up approach and video assisted retroperitoneal debridement in infected necrotizing pancreatitis: A case complicated by retroperitoneal bleeding and colonic fistula. Ann Med Surg (Lond) 2015; 4:225-9. [PMID: 26587229 PMCID: PMC4624569 DOI: 10.1016/j.amsu.2015.07.005] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/16/2015] [Revised: 07/11/2015] [Accepted: 07/20/2015] [Indexed: 12/12/2022] Open
Abstract
INTRODUCTION Infected Necrotizing Pancreatitis carries a high mortality and necessitates intervention to achieve sepsis control. The surgical strategy for proven infected necrosis has evolved, with abandonment of open necrosectomy to a step-up approach consisting of percutaneous drains and Video-assisted retroperitoneal debridement (VARD). We present a case that underwent VARD complicated by bleeding and colonic perforation and describe its management. PRESENTATION OF CASE A 38 year-old male with acute pancreatitis developed infected necrotizing pancreatitis. Initial treatment was by percutaneous drainage under radiological guidance and intravenous antibiotics. The infected retroperitoneal necrosis was then debrided using gasless laparoscopy through a mini-incision. Post-operatively, he developed peripancreatic bleeding which was controlled with angioembolisation. He also developed a descending colon fistula which was treated with laparotomy and defunctioning loop ileostomy. He recovered and subsequently had his ileostomy closed twelve months later. The colonic fistula recurred and was treated with endoscopic clips and histoacryl glue injection and finally closed. DISCUSSION Step-up approach consists of the 3 D's: Delay, drain and debride. VARD is recommended as it is replicable in general surgical units using standard laparoscopic instruments. Bleeding and colon perforation are potential complications which must have multi-disciplinary input, aggressive resuscitation and timely radiologic intervention. Defunctioning ileostomy is recommended to control sepsis in colonic fistulation. Novel fistula closing methods using endoscopic clips and histoacryl glue are potential treatment options. CONCLUSION Step-up approach and VARD is the new paradigm to treat necrotizing pancreatitis. Complications of bleeding and colon fistula are uncommon and require multi-disciplinary management.
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Affiliation(s)
- Eugene Lim
- Department of Surgery, Khoo Teck Puat Hospital, 90 Yishun Central, Singapore 768828, Singapore
- Corresponding author.
| | - R.S. Sundaraamoorthy
- Department of Surgery, Khoo Teck Puat Hospital, 90 Yishun Central, Singapore 768828, Singapore
| | - David Tan
- Department of Anaesthesia, Khoo Teck Puat Hospital, 90 Yishun Central, Singapore 768828, Singapore
| | - Hui-Seong Teh
- Department of Radiology, Khoo Teck Puat Hospital, 90 Yishun Central, Singapore 768828, Singapore
| | - Tzu-Jen Tan
- Department of Surgery, Khoo Teck Puat Hospital, 90 Yishun Central, Singapore 768828, Singapore
| | - Anton Cheng
- Department of Surgery, Khoo Teck Puat Hospital, 90 Yishun Central, Singapore 768828, Singapore
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Rohan Jeyarajah D, Osman HG, Patel S. Advances in management of pancreatic necrosis. Curr Probl Surg 2014; 51:374-408. [DOI: 10.1067/j.cpsurg.2014.07.001] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
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