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Shah J, Singh AK, Jearth V, Jena A, Dhanoa TS, Sakaray YR, Gupta P, Singh H, Sharma V, Dutta U. Endoscopic ultrasound-guided drainage of early pancreatic necrotic collection: Single-center retrospective study. Indian J Gastroenterol 2023:10.1007/s12664-023-01478-x. [PMID: 38102523 DOI: 10.1007/s12664-023-01478-x] [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: 06/25/2023] [Accepted: 10/24/2023] [Indexed: 12/17/2023]
Abstract
BACKGROUND Endoscopic ultrasound (EUS)-guided drainage is the standard of care for drainage of pancreatic necrosis. Though initially it was mainly used for drainage of only walled-off necrosis, recently, a few studies have also shown its safety in the management of acute necrotic collections. We did a retrospective study to evaluate the safety and efficacy of EUS-guided drainage in the early phase of pancreatitis as compared to interventions in the late phase. METHODS We retrieved baseline disease-related, procedure-related and outcome-related details of patients who underwent EUS-guided drainage of pancreatic necrosis. Patients were divided into early (≤ 28 days from onset of pancreatitis) or delayed (> 28 days) drainage groups. Both groups were compared for disease-related characteristics and outcomes. RESULTS Total 101 patients were included in the study. The mean age of included patients was 35.54 ± 13.58 years and 75 were male. Thirty-five patients (34.7%) underwent early drainage. In the early group, a majority of patients underwent intervention due to infected collection (88.6% vs. 18.2%; p < 0.001). More patients in the early group had < 30% wall formation (28.6% vs. 0%; p < 0.001) and > 30% solid debris within the collection (42.9% vs. 15.2%; p = 0.005). Patients in the early group were also more likely to require endoscopic necrosectomy (57.1% vs. 27.3%; p = 0.003) and additional percutaneous drainage (31.4% vs. 12.1%; p = 0.018). Overall, three patients in the early group and one patient in the delayed group had procedure-related complications. Four patients in the early group and one patient in the delayed group succumbed to illness (p = 0.029). CONCLUSION Though delayed interventions remain standard of care in the management of acute pancreatitis, some patients may require early intervention due to infected collection with deteriorating clinical status. Early EUS-guided interventions in such carefully selected patients have in similar clinical outcomes and complication rates compared to delayed intervention. However, such patients are more likely to require additional endoscopic or percutaneous interventions.
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Affiliation(s)
- Jimil Shah
- Department of Gastroenterology, Postgraduate Institute of Medical Education and Research, Chandigarh, 160 012, India.
| | - Anupam K Singh
- Department of Gastroenterology, Postgraduate Institute of Medical Education and Research, Chandigarh, 160 012, India
| | - Vaneet Jearth
- Department of Gastroenterology, Postgraduate Institute of Medical Education and Research, Chandigarh, 160 012, India
| | - Anuraag Jena
- Department of Gastroenterology, Postgraduate Institute of Medical Education and Research, Chandigarh, 160 012, India
| | - Tejdeep Singh Dhanoa
- Department of Radio-Diagnosis, Postgraduate Institute of Medical Education and Research, Chandigarh, 160 012, India
| | - Yashwant Raj Sakaray
- Department of General Surgery, Postgraduate Institute of Medical Education and Research, Chandigarh, 160 012, India
| | - Pankaj Gupta
- Department of Radio-Diagnosis, Postgraduate Institute of Medical Education and Research, Chandigarh, 160 012, India
| | - Harjeet Singh
- Department of Surgical Gastroenterology, Postgraduate Institute of Medical Education and Research, Chandigarh, 160 012, India
| | - Vishal Sharma
- Department of Gastroenterology, Postgraduate Institute of Medical Education and Research, Chandigarh, 160 012, India
| | - Usha Dutta
- Department of Gastroenterology, Postgraduate Institute of Medical Education and Research, Chandigarh, 160 012, India
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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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Kryvoruchko IA, Boyko VV, Sartelli M, Ivanova YV, Yevtushenko DO, Honcharov AS. Pancreatic Necrosis Infection as a Determinant of Multiple Organ Failure and Mortality in Acute Pancreatitis. Pathogens 2023; 12:pathogens12030428. [PMID: 36986350 PMCID: PMC10054645 DOI: 10.3390/pathogens12030428] [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: 11/30/2022] [Revised: 03/06/2023] [Accepted: 03/07/2023] [Indexed: 03/30/2023] Open
Abstract
Several recommendations and data on the treatment of acute necrotizing pancreatitis (ANP) are conflicting and different surgical approaches continue to exist. We conducted a study on 148 patients with ANP, who were divided into two groups: the main group (n = 95) when the tactics of the step-up approach were applied with the principles of the concept of Enhanced Recovery After Surgery (ERAS) in order to determine this approach on effectiveness in reducing complications and 30-day mortality (2017-2022); the comparison group (n = 53) when the same tactic of the treatment was used without ERAS principles (2015-2016). Treatment time for the main group in the intensive care unit was minimized (p ≤ 0.004); it has been shown to reduce the frequency of complications in these patients (p < 0.001) requiring conservative or surgical treatment without general anaesthesia (Clavien-Dindo I-IIIa); no statistically significant differences were observed for the total incidence of Clavien-Dindo IIIb-IVb complications (p > 0.05); the median duration of treatment for patients in the primary group was 23 days, and in the reference group-34 days (p ≤ 0.003). Pancreatic infections have been observed in 92 (62.2%) patients and gram-negative bacteria predominated in the overall pathogen structure with 222 (70.7%) strains. The only evidence of multiple organ failure before (AUC = 0.814) and after surgery (AUC = 0.931) was found to be predictive of mortality. Antibiotic sensitivity of all isolated bacteria better understood local epidemiology and identified the most effective antibiotics when treating patients.
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Affiliation(s)
- Igor A Kryvoruchko
- Department of Surgery No.2, Kharkiv National Medical University, Nezalezhnosti Avenue, 61022 Kharkiv, Ukraine
| | - Valeriy V Boyko
- Institute General and Emergency Surgery Named after V.T. Zaitcev of the National Academy of Medical Sciences of Ukraine, Balakireva Entry, 61103 Kharkiv, Ukraine
- Department of Surgery No.1, Kharkiv National Medical University, Balakireva Entry, 61103 Kharkiv, Ukraine
| | - Massimo Sartelli
- Department of Surgery, Macerata Hospital, Santa Lucia Street, 62100 Macerata, Italy
| | - Yulia V Ivanova
- Department of Surgery No.1, Kharkiv National Medical University, Balakireva Entry, 61103 Kharkiv, Ukraine
| | - Denys O Yevtushenko
- Department of Surgery No.1, Kharkiv National Medical University, Balakireva Entry, 61103 Kharkiv, Ukraine
| | - Andrij S Honcharov
- Department of Surgery No.2, Kharkiv National Medical University, Nezalezhnosti Avenue, 61022 Kharkiv, Ukraine
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Chida K, Ishido K, Sakamoto Y, Kimura N, Morohashi H, Miura T, Wakiya T, Yokoyama H, Nagase H, Ichinohe D, Suto A, Kuwata D, Ichisawa A, Nakamura A, Kasai D, Hakamada K. Necrotizing pancreatitis complicated by retroperitoneal emphysema: two case reports. Surg Case Rep 2022; 8:183. [PMID: 36163599 PMCID: PMC9512950 DOI: 10.1186/s40792-022-01542-2] [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: 07/30/2022] [Accepted: 09/22/2022] [Indexed: 12/02/2022] Open
Abstract
Background Emphysematous pancreatitis is acute pancreatitis associated with emphysema based on imaging studies and has been considered a subtype of necrotizing pancreatitis. Although some recent studies have reported the successful use of conservative treatment, it is still considered a serious condition. Computed tomography (CT) scan is useful in identifying emphysema associated with acute pancreatitis; however, whether the presence of emphysema correlates with the severity of pancreatitis remains controversial. In this study, we managed two cases of severe acute pancreatitis complicated with retroperitoneal emphysema successfully by treatment with lavage and drainage. Case presentation Case 1: A 76-year-old man was referred to our hospital after being diagnosed with acute pancreatitis. At post-admission, his abdominal symptoms worsened, and a repeat CT scan revealed increased retroperitoneal gas. Due to the high risk for gastrointestinal tract perforation, emergent laparotomy was performed. Fat necrosis was observed on the anterior surface of the pancreas, and a diagnosis of acute necrotizing pancreatitis with retroperitoneal emphysema was made. Thus, retroperitoneal drainage was performed. Case 2: A 50-year-old woman developed anaphylactic shock during the induction of general anesthesia for lumbar spine surgery, and peritoneal irritation symptoms and hypotension occurred on the same day. Contrast-enhanced CT scan showed necrotic changes in the pancreatic body and emphysema surrounding the pancreas. Therefore, she was diagnosed with acute necrotizing pancreatitis with retroperitoneal emphysema, and retroperitoneal cavity lavage and drainage were performed. In the second case, the intraperitoneal abscess occurred postoperatively, requiring time for drainage treatment. Both patients showed no significant postoperative course problems and were discharged on postoperative days 18 and 108, respectively. Conclusion Acute pancreatitis with emphysema from the acute phase highly indicates severe necrotizing pancreatitis. Surgical drainage should be chosen without hesitation in necrotizing pancreatitis with emphysema from early onset.
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Gupta P, Madhusudhan KS, Padmanabhan A, Khera PS. Indian College of Radiology and Imaging Consensus Guidelines on Interventions in Pancreatitis. Indian J Radiol Imaging 2022; 32:339-354. [PMID: 36177275 PMCID: PMC9514912 DOI: 10.1055/s-0042-1754313] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022] Open
Abstract
AbstractAcute pancreatitis (AP) is one of the common gastrointestinal conditions presenting as medical emergency. Clinically, the severity of AP ranges from mild to severe. Mild AP has a favorable outcome. Patients with moderately severe and severe AP, on the other hand, require hospitalization and considerable utilization of health care resources. These patients require a multidisciplinary management. Pancreatic fluid collections (PFCs) and arterial bleeding are the most important local complications of pancreatitis. PFCs may require drainage when infected or symptomatic. PFCs are drained endoscopically or percutaneously, based on the timing and the location of collection. Both the techniques are complementary, and many patients may undergo dual modality treatment. Percutaneous catheter drainage (PCD) remains the most extensively utilized method for drainage in patients with AP and necrotic PFCs. Besides being effective as a standalone treatment in a significant proportion of these patients, PCD also provides an access for percutaneous endoscopic necrosectomy and minimally invasive necrosectomy. Endovascular embolization is the mainstay of management of arterial complications in patients with AP and chronic pancreatitis. The purpose of the present guideline is to provide evidence-based recommendations for the percutaneous management of complications of pancreatitis.
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Affiliation(s)
- Pankaj Gupta
- Department of Radiodiagnosis and Imaging, Postgraduate Institute of Medical Education and Research, Chandigarh, India
| | | | - Aswin Padmanabhan
- Division of Clinical Radiology, Department of Interventional Radiology, Christian Medical College, Vellore, Tamil Nadu, India
| | - Pushpinder Singh Khera
- Department of Diagnostic and Interventional Radiology, All India Institute of Medical Sciences, Jodhpur, Rajasthan, India
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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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7
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Dost W, Qasemi F, Ali W, Aini T, Rasully MQ, Niazi J, Sarhadi jamal R, Sayer M, Qadar LT, Afzali SMS. Immediate Catheter Drainage Versus Delayed Drainage in the Management of Infected Necrotizing Pancreatitis. Cureus 2022; 14:e26485. [PMID: 35919210 PMCID: PMC9339159 DOI: 10.7759/cureus.26485] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 07/01/2022] [Indexed: 11/11/2022] Open
Abstract
Background: Immediate or delayed catheter drainage of infected pancreatic necrosis remains a subject of debate. The present study aimed to evaluate the optimum timing for drainage in patients with infected necrotizing pancreatitis. Methods: A prospective, observational study was undertaken at the Department of Surgery, Liaquat University of Medical & Health Sciences (LUMHS), between 1st March 2018 and 6th July 2020. All patients 18 years or older presenting with acute pancreatitis (AP) in whom necrotizing pancreatitis was confirmed or suspected were enrolled in the study. The exclusion criteria included prior intervention for necrotizing pancreatitis. Those who were diagnosed with infected necrotizing pancreatitis were labeled as Group A and Group B. Group A patients underwent immediate catheter drainage (within 24 h of admission) while Group B patients underwent delayed drainage (after 24 h). Clinical outcome variables including complication rate, mortality, length of hospital, and intensive care unit (ICU) stay were collected in a predefined pro forma. Results: One hundred and thirty patients were enrolled in the study. There were 65 patients in each group. The present study revealed no significant differences in patient outcomes in the immediate drainage group vs. the postponed drainage group. Overall, the mortality rate was 15.38% in Group A while the mortality rate was a little lower in Group B, i.e. 10.77% (p=0.44). The acute onset multiple organ failure was lower in Group A as compared to Group B, however, the difference was statistically insignificant (p=0.08). The rate of wound infection rate was 10.77% and 15.38% in Group A and Group B, respectively (p=0.61). Conclusion: In the present study, we failed to find any significant difference between the immediate and postponed drainage group in terms of patient outcome. As per current findings, the timing of drainage did not impact the prognosis of patients with necrotizing pancreatitis.
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Pinto S, Bellizzi S, Badas R, Canfora ML, Loddo E, Spada S, Khalaf K, Fugazza A, Bergamini S. Direct Endoscopic Necrosectomy: Timing and Technique. MEDICINA (KAUNAS, LITHUANIA) 2021; 57:medicina57121305. [PMID: 34946249 PMCID: PMC8707414 DOI: 10.3390/medicina57121305] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 10/18/2021] [Revised: 11/22/2021] [Accepted: 11/24/2021] [Indexed: 12/12/2022]
Abstract
Walled-off pancreatic necrosis (WOPN) is one of the local complications of acute pancreatitis (AP). Several interventional techniques have been developed over the last few years. The purpose of this narrative review is to explore such methodologies, with specific focus on endoscopic drainage and direct endoscopic necrosectomy (DEN), through evaluation of their indications and timing for intervention. Findings indicated how, after the introduction of lumen-apposing metal stents (LAMS), DEN is becoming the favorite technique to treat WOPN, especially when large solid debris or infection are present. Additionally, DEN is associated with a lower adverse events rate and hospital stay, and with improved clinical outcome.
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Affiliation(s)
- Sergio Pinto
- Digestive Endoscopy Unit, Department of Surgical Sciences, University Hospital of Cagliari, 09042 Cagliari, Italy; (R.B.); (M.L.C.); (E.L.); (S.S.); (S.B.)
- Correspondence: ; Tel.: +39-07051096423
| | - Saverio Bellizzi
- Medical Epidemiologist, Independent Consultant, 1202 Geneva, Switzerland;
| | - Roberta Badas
- Digestive Endoscopy Unit, Department of Surgical Sciences, University Hospital of Cagliari, 09042 Cagliari, Italy; (R.B.); (M.L.C.); (E.L.); (S.S.); (S.B.)
| | - Maria Laura Canfora
- Digestive Endoscopy Unit, Department of Surgical Sciences, University Hospital of Cagliari, 09042 Cagliari, Italy; (R.B.); (M.L.C.); (E.L.); (S.S.); (S.B.)
| | - Erica Loddo
- Digestive Endoscopy Unit, Department of Surgical Sciences, University Hospital of Cagliari, 09042 Cagliari, Italy; (R.B.); (M.L.C.); (E.L.); (S.S.); (S.B.)
| | - Simone Spada
- Digestive Endoscopy Unit, Department of Surgical Sciences, University Hospital of Cagliari, 09042 Cagliari, Italy; (R.B.); (M.L.C.); (E.L.); (S.S.); (S.B.)
| | - Kareem Khalaf
- Department of Biomedical Sciences, Humanitas University, Pieve Emanuele, 20090 Milano, Italy;
| | - Alessandro Fugazza
- Digestive Endoscopy Unit, Department of Gastroenterology, Humanitas Research Hospital-IRCCS, 20089 Rozzano, Italy;
| | - Silvio Bergamini
- Digestive Endoscopy Unit, Department of Surgical Sciences, University Hospital of Cagliari, 09042 Cagliari, Italy; (R.B.); (M.L.C.); (E.L.); (S.S.); (S.B.)
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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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Niu DG, Li WQ, Huang Q, Yang F, Tian WL, Li C, Ding LA, Fang HC, Zhao YZ. Open necrosectomy combined with continuous positive drainage and prophylactic diverting loop ileostomy for late infected pancreatic necrosis: a retrospective cohort study. BMC Gastroenterol 2020; 20:212. [PMID: 32640995 PMCID: PMC7341608 DOI: 10.1186/s12876-020-01343-7] [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: 01/20/2019] [Accepted: 06/09/2020] [Indexed: 12/02/2022] Open
Abstract
Background To evaluate an innovative open necrosectomy strategy with continuous positive drainage and prophylactic diverting loop ileostomy for the management of late infected pancreatic necrosis (LIPN). Methods Consecutive patients were divided into open necrosectomy (ON) group (n = 23), open necrosectomy with colonic segment resection (ON+CSR) group (n = 8) and open necrosectomy with prophylactic diverting loop ileostomy (ON+PDLI) group (n = 11). Continuous positive drainage (CPD) via double-lumen irrigation–suction tube (DLIST) was performed in ON+PDLI group. The primary endpoints were duration of organ failure after surgery, postoperative complication, the rate of re-surgery and mortality. The secondary endpoints were duration of hospitalization, cost, time interval between open surgery and total enteral nutrition (TEN). Results The recovery time of organ function in ON+PDLI group was shorter than that in other two groups. Colonic complications occurred in 13 patients (56.5%) in the ON group and 3 patients (27.3%) in the ON+PDLI group (p = 0.11). The length of stay in the ON+PDLI group was shorter than the ON group (p = 0.001). The hospitalization cost in the ON+PDLI group was less than the ON group (p = 0.0052). Conclusion ON+PDLI can avoid the intestinal dysfunction, re-ileostomy, the resection of innocent colon and reduce the intraoperative trauma. Despite being of colonic complications before or during operation, CPD + PDLI may show superior effectiveness, safety, and convenience in LIPN.
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Affiliation(s)
- Dong-Guang Niu
- Department of General Surgery, Jinling clinical college of Nanjing Medical University, Nanjing, 210002, Jiangsu, China.,Gastrointestinal Surgery Department, Affiliated Hospital of Qingdao University, Qingdao, 266000, Shandong, China
| | - Wei-Qin Li
- Department of General Surgery, Jinling clinical college of Nanjing Medical University, Nanjing, 210002, Jiangsu, China
| | - Qian Huang
- Department of General Surgery, Jinling clinical college of Nanjing Medical University, Nanjing, 210002, Jiangsu, China
| | - Fan Yang
- Department of General Surgery, Jinling clinical college of Nanjing Medical University, Nanjing, 210002, Jiangsu, China
| | - Wei-Liang Tian
- Department of General Surgery, Jinling clinical college of Nanjing Medical University, Nanjing, 210002, Jiangsu, China
| | - Chen Li
- Oncology Department, Xintai people's Hospital, Tai'an, 271200, Shandong, China
| | - Lian-An Ding
- Gastrointestinal Surgery Department, Affiliated Hospital of Qingdao University, Qingdao, 266000, Shandong, China
| | - Hong-Chun Fang
- Gastrointestinal Surgery Department, Affiliated Hospital of Qingdao University, Qingdao, 266000, Shandong, China
| | - Yun-Zhao Zhao
- Department of General Surgery, Jinling clinical college of Nanjing Medical University, Nanjing, 210002, Jiangsu, China. .,Department of General Surgery, Jinling clinical college of Nanjing Medical University, 305 East Zhongshan Road, Nanjing, 210000, Jiangsu, China.
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Surgical Transgastric Necrosectomy for Necrotizing Pancreatitis: A Single-stage Procedure for Walled-off Pancreatic Necrosis. Ann Surg 2020; 271:163-168. [PMID: 30216220 DOI: 10.1097/sla.0000000000003048] [Citation(s) in RCA: 36] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
OBJECTIVE The aim of this study was to evaluate the role of surgical transgastric necrosectomy (TGN) for walled-off pancreatic necrosis (WON) in selected patients. BACKGROUND WON is a common consequence of severe pancreatitis and typically occurs 3 to 5 weeks after the onset of acute pancreatitis. When symptomatic, it can require intervention. METHODS A retrospective review of patients with WON undergoing surgical management at 3 high-volume pancreatic institutions was performed. Surgical indications, intervention timing, technical methodology, and patient outcomes were evaluated. Patients undergoing intervention <30 days were excluded. Differences across centers were evaluated using a P value of <0.05 as significant. RESULTS One hundred seventy-eight total patients were analyzed (mean WON diameter = 14 cm, 64% male, mean age = 51 years) across 3 centers. The majority required inpatient admission with a median preoperative length of hospital stay of 29 days (25% required preoperative critical care support). Most (96%) patients underwent a TGN. The median duration of time between the onset of pancreatitis symptoms and operative intervention was 60 days. Thirty-nine percent of the necrosum was infected. Postoperative morbidity and mortality were 38% and 2%, respectively. The median postoperative length of hospital length of stay was 8 days, with the majority of patients discharged home. The median length of follow-up was 21 months, with 91% of patients having complete clinical resolution of symptoms at a median of 6 weeks. Readmission to hospital and/or a repeat intervention was also not infrequent (20%). CONCLUSION Surgical TGN is an excellent 1-stage surgical option for symptomatic WON in a highly selected group of patients. Precise surgical technique and long-term outpatient follow-up are mandatory for optimal patient outcomes.
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Maatman TK, Mahajan S, Roch AM, Ceppa EP, House MG, Nakeeb A, Schmidt CM, Zyromski NJ. Disconnected pancreatic duct syndrome predicts failure of percutaneous therapy in necrotizing pancreatitis. Pancreatology 2020; 20:362-368. [PMID: 32029378 DOI: 10.1016/j.pan.2020.01.014] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/23/2019] [Revised: 01/07/2020] [Accepted: 01/24/2020] [Indexed: 12/11/2022]
Abstract
BACKGROUND/OBJECTIVES Minimally invasive approaches, such as percutaneous drainage (PD), are increasingly utilized as initial treatment in necrotizing pancreatitis (NP) requiring intervention. Predictors of success of PD as definitive treatment are lacking. Our aim was to assess the application, predictors of success, and natural history of PD in NP. We hypothesized that necrosis morphology patterns and disconnected pancreatic duct syndrome (DPDS) may predict the ability of PD to provide definitive therapy. METHODS 714 NP patients were treated from 2005 to 2018. Patients achieving disease resolution with PD alone (PD) were compared to those requiring an escalation in intervention (Step). Outcomes were compared between groups using independent samples t-test, Fisher's exact test, and Pearson's correlation, as appropriate. P < 0.05 was accepted as statistically significant. RESULTS 115 patients were initially managed with PD (42 PD, 73 Step). No difference in necrosis morphology was seen between the two groups. The PD group underwent significantly more repeat percutaneous interventions (PD, 3.2; Step, 2.0; P = 0.0006) including additional drain placement and drain upsize/reposition procedures. Patients with DPDS were more likely to require an escalation in intervention (odds ratio, 3.4; 95% confidence interval, 1.5-7.6; P = 0.003). The mean number of months to NP resolution was similar (PD, 5.7; Step, 5.8; P = 0.9). Mortality was similar (PD, 7%; Step 14%, P = 0.3). CONCLUSIONS Necrosis morphology in and of itself does not reliably predict successful definitive treatment by percutaneous drainage. However, patients with disconnected pancreatic duct syndrome were less likely to have definitive resolution with PD alone.
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Affiliation(s)
- Thomas K Maatman
- Department of Surgery, Indiana University School of Medicine, Indianapolis, IN, USA
| | - Sarakshi Mahajan
- Department of Surgery, Indiana University School of Medicine, Indianapolis, IN, USA
| | - Alexandra M Roch
- Department of Surgery, Indiana University School of Medicine, Indianapolis, IN, USA
| | - Eugene P Ceppa
- Department of Surgery, Indiana University School of Medicine, Indianapolis, IN, USA
| | - Michael G House
- Department of Surgery, Indiana University School of Medicine, Indianapolis, IN, USA
| | - Attila Nakeeb
- Department of Surgery, Indiana University School of Medicine, Indianapolis, IN, USA
| | - C Max Schmidt
- Department of Surgery, Indiana University School of Medicine, Indianapolis, IN, USA
| | - Nicholas J Zyromski
- Department of Surgery, Indiana University School of Medicine, Indianapolis, IN, USA.
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13
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Gambitta P, Maffioli A, Spiropoulos J, Armellino A, Vertemati M, Aseni P. Endoscopic ultrasound-guided drainage of pancreatic fluid collections: The impact of evolving experience and new technologies in diagnosis and treatment over the last two decades. Hepatobiliary Pancreat Dis Int 2020; 19:68-73. [PMID: 31610989 DOI: 10.1016/j.hbpd.2019.09.008] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/07/2019] [Accepted: 09/27/2019] [Indexed: 02/07/2023]
Abstract
BACKGROUND Endoscopic ultrasound (EUS)-guided drainage is the preferred approach for drainage of pancreatic fluid collections (PFCs) due to the better experience and significant progress using newer stents and access devices during last decade. This study aimed to evaluate the role of the evolving experience and possible influence of new technological devices on the outcome of patients evaluated for PFCs and submitted to EUS-guided drainage during two different periods: the early period at the beginning of experience when a standardized technique was used and the late period when the increased experience of the operator, combined with different stents quality were introduced in the management of PFCs. METHODS We retrospectively analyzed the clinical data of a cohort of 91 consecutive patients, who underwent EUS-guided drainage of symptomatic PFCs from October 2001 to September 2017. Demographic, therapeutic results, complications, and outcomes were compared between early years' group (2001-2008) and late years' group (2009-2017). RESULTS Endoscopic treatment was successfully achieved in 55.6% (20/36) of patients in the early years' group, and in 96.4% (53/55) in the late years' group. Eighteen patients (12 in early years' and 6 in the late year's group) required additional open surgery. Procedural complications were observed in 5 patients, 4 in early years' and 1 in late years' group. Mortality was registered in two patients (2.2%), one for each group. CONCLUSIONS During our long-term survey using EUS-guided endoscopic drainage of PFCs, significantly better outcomes in term of improved success rate and decrease complications rate were observed during the late period.
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Affiliation(s)
- Pietro Gambitta
- Endoscopy Unit, ASST Grande Ospedale Metropolitano Niguarda, Milan, Italy; Endoscopy Unit, ASST Fatebenefratelli Sacco, Milan, Italy
| | - Anna Maffioli
- Chirurgia Generale 1, ASST Fatebenefratelli Sacco, Milan, Italy
| | | | - Antonio Armellino
- Endoscopy Division, Ospedale San Leopoldo Mandic di Merate, ASST Lecco, Lecco, Italy
| | - Maurizio Vertemati
- Dipartimento di Scienze Biomediche e Cliniche "L. Sacco", Università degli Studi di Milano, Milan, Italy
| | - Paolo Aseni
- Dipartimento di Scienze Biomediche e Cliniche "L. Sacco", Università degli Studi di Milano, Milan, Italy; Department of Emergency Medicine, ASST Grande Ospedale Metropolitano Niguarda, Milan, Italy.
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14
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van Grinsven J, van Dijk SM, Dijkgraaf MG, Boermeester MA, Bollen TL, Bruno MJ, van Brunschot S, Dejong CH, van Eijck CH, van Lienden KP, Boerma D, van Duijvendijk P, Hadithi M, Haveman JW, van der Hulst RW, Jansen JM, Lips DJ, Manusama ER, Molenaar IQ, van der Peet DL, Poen AC, Quispel R, Schaapherder AF, Schoon EJ, Schwartz MP, Seerden TC, Spanier BWM, Straathof JW, Venneman NG, van de Vrie W, Witteman BJ, van Goor H, Fockens P, van Santvoort HC, Besselink MG. Postponed or immediate drainage of infected necrotizing pancreatitis (POINTER trial): study protocol for a randomized controlled trial. Trials 2019; 20:239. [PMID: 31023380 PMCID: PMC6482524 DOI: 10.1186/s13063-019-3315-6] [Citation(s) in RCA: 34] [Impact Index Per Article: 6.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/13/2018] [Accepted: 03/21/2019] [Indexed: 12/12/2022] Open
Abstract
Background Infected necrosis complicates 10% of all acute pancreatitis episodes and is associated with 15–20% mortality. The current standard treatment for infected necrotizing pancreatitis is the step-up approach (catheter drainage, followed, if necessary, by minimally invasive necrosectomy). Catheter drainage is preferably postponed until the stage of walled-off necrosis, which usually takes 4 weeks. This delay stems from the time when open necrosectomy was the standard. It is unclear whether such delay is needed for catheter drainage or whether earlier intervention could actually be beneficial in the current step-up approach. The POINTER trial investigates if immediate catheter drainage in patients with infected necrotizing pancreatitis is superior to the current practice of postponed intervention. Methods POINTER is a randomized controlled multicenter superiority trial. All patients with necrotizing pancreatitis are screened for eligibility. In total, 104 adult patients with (suspected) infected necrotizing pancreatitis will be randomized to immediate (within 24 h) catheter drainage or current standard care involving postponed catheter drainage. Necrosectomy, if necessary, is preferably postponed until the stage of walled-off necrosis, in both treatment arms. The primary outcome is the Comprehensive Complication Index (CCI), which covers all complications between randomization and 6-month follow up. Secondary outcomes include mortality, complications, number of (repeat) interventions, hospital and intensive care unit (ICU) lengths of stay, quality-adjusted life years (QALYs) and direct and indirect costs. Standard follow-up is at 3 and 6 months after randomization. Discussion The POINTER trial investigates if immediate catheter drainage in infected necrotizing pancreatitis reduces the composite endpoint of complications, as compared with the current standard treatment strategy involving delay of intervention until the stage of walled-off necrosis. Trial registration ISRCTN, 33682933. Registered on 6 August 2015. Retrospectively registered. Electronic supplementary material The online version of this article (10.1186/s13063-019-3315-6) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Janneke van Grinsven
- Department of Surgery, Amsterdam UMC, University of Amsterdam, G4.196, PO Box 26000, 1105 AZ, Amsterdam, Netherlands. .,Department of Surgery, St. Antonius Hospital Nieuwegein, Nieuwegein, Netherlands.
| | - Sven M van Dijk
- Department of Surgery, Amsterdam UMC, University of Amsterdam, G4.196, PO Box 26000, 1105 AZ, Amsterdam, Netherlands.,Department of Surgery, St. Antonius Hospital Nieuwegein, Nieuwegein, Netherlands
| | - Marcel G Dijkgraaf
- Clinical Research Unit, Amsterdam UMC, University of Amsterdam, Amsterdam, Netherlands
| | - Marja A Boermeester
- Department of Surgery, Amsterdam UMC, University of Amsterdam, G4.196, PO Box 26000, 1105 AZ, Amsterdam, Netherlands
| | - Thomas L Bollen
- Department of Radiology, St. Antonius Hospital Nieuwegein, Nieuwegein, Netherlands
| | - Marco J Bruno
- Department of Gastroenterology and Hepatology, Erasmus MC University Medical Center Rotterdam, Rottedam, Netherlands
| | - Sandra van Brunschot
- Department of Gastroenterology and Hepatology, Amsterdam UMC, University of Amsterdam, Amsterdam, Netherlands.,Department of Surgery, University Medical Center Utrecht, Cancer Center, Utrecht, Netherlands
| | - Cornelis H Dejong
- Department of Surgery, Maastricht University Medical Center+, Maastricht, Netherlands.,NUTRIM School for Nutrition and Translational Research in Metabolism, Maastricht, Netherlands
| | - Casper H van Eijck
- Department of Surgery, Erasmus MC University Medical Center Rotterdam, Rotterdam, Netherlands
| | - Krijn P van Lienden
- Department of Radiology, Amsterdam UMC, University of Amsterdam, Amsterdam, Netherlands
| | - Djamila Boerma
- Department of Surgery, St. Antonius Hospital Nieuwegein, Nieuwegein, Netherlands
| | | | - Muhammed Hadithi
- Department of Gastroenterology and Hepatology, Maasstad Hospital Rotterdam, Rotterdam, Netherlands
| | - Jan Willem Haveman
- Department of Surgery, University Medical Center Groningen, University of Groningen, Groningen, Netherlands
| | - René W van der Hulst
- Department of Gastroenterology and Hepatology, Spaarne Gasthuis Haarlem, Haarlem, Netherlands
| | - Jeroen M Jansen
- Department of Gastroenterology and Hepatology, OLVG Amsterdam, Amsterdam, Netherlands
| | - Daan J Lips
- Department of Surgery, Jeroen Bosch Hospital, 's-Hertogenbosch, Netherlands
| | - Eric R Manusama
- Department of Surgery, Medical Center Leeuwarden, Leeuwarden, Netherlands
| | - I Quintus Molenaar
- Department of Surgery, University Medical Center Utrecht, Cancer Center, Utrecht, Netherlands
| | - Donald L van der Peet
- Department of Surgery, Amsterdam UMC, Vrije Universiteit Amsterdam, Amsterdam, Netherlands
| | - Alexander C Poen
- Department of Gastroenterology and Hepatology, Isala Clinics Zwolle, Zwolle, Netherlands
| | - Rutger Quispel
- Department of Gastroenterology and Hepatology, Reinier de Graaf Gasthuis Delft, Delft, Netherlands
| | | | - Erik J Schoon
- Department of Gastroenterology and Hepatology, Catharina Hospital Eindhoven, Eindhoven, Netherlands
| | - Matthijs P Schwartz
- Department of Gastroenterology and Hepatology, Meander Medical Center Amersfoort, Amersfoort, Netherlands
| | - Tom C Seerden
- Department of Gastroenterology and Hepatology, Amphia Hospital Breda, Breda, Netherlands
| | - B W Marcel Spanier
- Department of Gastroenterology and Hepatology, Rijnstate Hospital Arnhem, Arnhem, Netherlands
| | - Jan Willem Straathof
- Department of Gastroenterology and Hepatology, Maxima Medical Center Veldhoven, Veldhoven, Netherlands
| | - Niels G Venneman
- Department of Gastroenterology and Hepatology, Medisch Spectrum Twente Enschede, Enschede, Netherlands
| | - Wim van de Vrie
- Department of Gastroenterology and Hepatology, Albert Schweitzer Hospital Dordrecht, Dordrecht, Netherlands
| | - Ben J Witteman
- Department of Gastroenterology and Hepatology, Hospital Gelderse Vallei Ede, Ede, Netherlands
| | - Harry van Goor
- Department of Surgery, Radboud University Medical Center Nijmegen, Nijmegen, Netherlands
| | - Paul Fockens
- Department of Gastroenterology and Hepatology, Amsterdam UMC, University of Amsterdam, Amsterdam, Netherlands
| | - Hjalmar C van Santvoort
- Department of Surgery, St. Antonius Hospital Nieuwegein, Nieuwegein, Netherlands.,Department of Surgery, University Medical Center Utrecht, Cancer Center, Utrecht, Netherlands
| | - Marc G Besselink
- Department of Surgery, Amsterdam UMC, University of Amsterdam, G4.196, PO Box 26000, 1105 AZ, Amsterdam, Netherlands.
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15
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Bezmarević M, van Dijk SM, Voermans RP, van Santvoort HC, Besselink MG. Management of (Peri)Pancreatic Collections in Acute Pancreatitis. Visc Med 2019; 35:91-96. [PMID: 31192242 DOI: 10.1159/000499631] [Citation(s) in RCA: 17] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/01/2019] [Accepted: 03/15/2019] [Indexed: 12/12/2022] Open
Abstract
The development of (peri)pancreatic fluid collections are frequent local complications in acute pancreatitis. These collections are classified as early (acute peripancreatic fluid collection or acute necrotic collection) or late (walled-off necrosis or pseudocyst). The majority of pancreatic fluid collections resolve spontaneously and do not require intervention. However, infection may require intervention. Interventions may include endoscopic or percutaneous catheter drainage, or in a next step endoscopic or surgical necrosectomy, minimally invasive or open. The best timing for the first intervention is still under investigation. Whereas some use antibiotics to postpone intervention until the stage of walled-off necrosis, others drain earlier. Endoscopic drainage of (peri)pancreatic fluid collections is now the preferred approach of drainage due to reduced morbidity as compared to surgical or percutaneous drainage. However, each collection must be treated according to a tailored approach. The final treatment should take into consideration anatomic characteristics, patient preference, comorbidity profile of the patient, and physician discretion. This review summarizes the current evidence on the treatment of (peri)pancreatic fluid collections.
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Affiliation(s)
- Mihailo Bezmarević
- Department of Hepatobiliary and Pancreatic Surgery, Clinic for General Surgery, Military Medical Academy, University of Defense, Belgrade, Serbia.,Department of Surgery, Amsterdam Gastroenterology and Metabolism, Amsterdam UMC, University of Amsterdam, Amsterdam, The Netherlands
| | - Sven M van Dijk
- Department of Surgery, Amsterdam Gastroenterology and Metabolism, Amsterdam UMC, University of Amsterdam, Amsterdam, The Netherlands.,Department of Research and Development, St. Antonius Hospital, Nieuwegein, The Netherlands
| | - Rogier P Voermans
- Department of Gastroenterology and Hepatology, Amsterdam Gastroenterology and Metabolism, Amsterdam UMC, University of Amsterdam, Amsterdam, The Netherlands
| | - Hjalmar C van Santvoort
- Department of Surgery, St. Antonius Hospital, Utrecht, The Netherlands.,Department of Surgery, University Medical Center Utrecht, Utrecht, The Netherlands
| | - Marc G Besselink
- Department of Surgery, Amsterdam Gastroenterology and Metabolism, Amsterdam UMC, University of Amsterdam, Amsterdam, The Netherlands
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16
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Abstract
Background Acute pancreatitis still is a disease with overall high mortality. Continuously improved understanding of the pathophysiology, however, led to changes in treatment algorithms within the last decades, thus resulting in decreased mortality. This knowledge of acute pancreatitis enabled a new classification system introduced by an international expert panel. This classification system is helpful in initiating treatment strategies which are adapted to the course of acute pancreatitis. Especially the role of surgery experienced a paradigm shift towards a more conservative approach. Methods A specific literature search regarding the treatment of acute pancreatitis was performed in the PubMed database, and the results of key studies were compared. Results of these studies are discussed in the context of the most recent international classification system. Results and Conclusion Based upon the available data, we can summarize that conservative treatment of acute pancreatitis with pancreatic necrosis is a valid treatment option for selected cases and is associated with reduced mortality compared to more aggressive therapy. However, patients with acute pancreatitis should be treated in experienced centers.
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Affiliation(s)
- Christian Alberts
- Department of General, Thoracic, Vascular and Transplantation Surgery, University of Rostock, Rostock, Germany
| | - Guido Alsfasser
- Department of General, Thoracic, Vascular and Transplantation Surgery, University of Rostock, Rostock, Germany
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17
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Mallick B, Dhaka N, Gupta P, Gulati A, Malik S, Sinha SK, Yadav TD, Gupta V, Kochhar R. An audit of percutaneous drainage for acute necrotic collections and walled off necrosis in patients with acute pancreatitis. Pancreatology 2018; 18:727-733. [PMID: 30146334 DOI: 10.1016/j.pan.2018.08.010] [Citation(s) in RCA: 24] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/03/2018] [Revised: 07/18/2018] [Accepted: 08/19/2018] [Indexed: 12/11/2022]
Abstract
BACKGROUND AND OBJECTIVES Percutaneous catheter drainage (PCD) is used as a first step in the management of symptomatic fluid collections in patients with acute pancreatitis (AP). We aimed to compare the outcome of patients with acute necrotic collection (ANC) and those with walled-off necrosis (WON), who had undergone PCD as a part of management of AP. METHODS Consecutive patients of AP with symptomatic ANC or WON undergoing PCD were evaluated. Primary outcome measures were need for additional surgical necrosectomy and mortality. Secondary outcome measures were need for up-gradation of first PCD, need for additional drain, in-hospital as well as total duration of PCD and length of hospital stay. RESULTS Indications of PCD in 375 patients (258 with ANC and 117 with WON) were suspected infected pancreatic necrosis (n = 214), persistent organ failure (n = 117) and pressure symptoms (n = 44). Need for additional surgical necrosectomy was seen in 14% patients with ANC and in 12% of patients with WON (p = 0.364) and mortality was 19% in patients with ANC as compared to 13.7% in those with WON (p = 0.132). There was no significant difference in the secondary outcome parameters between patients who underwent PCD for ANC or WON. Complications of PCD were comparable between patients with ANC and WON except development of external pancreatic fistula which occurred more often in patients with WON than in those with ANC (24.4% versus 34.2% respectively, p = 0.034). CONCLUSION Persistent organ failure in more often an indication of PCD in patients with ANC than in WON and suspected infection is more commonly an indication in WON than in ANC. Early PCD is as efficacious and safe as delayed PCD.
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Affiliation(s)
- Bipadabhanjan Mallick
- Department of Gastroenterology, Postgraduate Institute of Medical Education and Research, Chandigarh, India
| | - Narendra Dhaka
- Department of Gastroenterology, Postgraduate Institute of Medical Education and Research, Chandigarh, India
| | - Pankaj Gupta
- Department of Radiodiagnosis, Postgraduate Institute of Medical Education and Research, Chandigarh, India
| | - Ajay Gulati
- Department of Radiodiagnosis, Postgraduate Institute of Medical Education and Research, Chandigarh, India
| | - Sarthak Malik
- Department of Gastroenterology, Postgraduate Institute of Medical Education and Research, Chandigarh, India
| | - Saroj K Sinha
- Department of Gastroenterology, Postgraduate Institute of Medical Education and Research, Chandigarh, India
| | - Thakur D Yadav
- Department of General Surgery, Postgraduate Institute of Medical Education and Research, Chandigarh, India
| | - Vikas Gupta
- Department of General Surgery, Postgraduate Institute of Medical Education and Research, Chandigarh, India
| | - Rakesh Kochhar
- Department of Gastroenterology, Postgraduate Institute of Medical Education and Research, Chandigarh, India.
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18
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van Grinsven J, van Brunschot S, van Baal MC, Besselink MG, Fockens P, van Goor H, van Santvoort HC, Bollen TL. Natural History of Gas Configurations and Encapsulation in Necrotic Collections During Necrotizing Pancreatitis. J Gastrointest Surg 2018; 22:1557-1564. [PMID: 29752684 DOI: 10.1007/s11605-018-3792-z] [Citation(s) in RCA: 41] [Impact Index Per Article: 6.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/15/2018] [Accepted: 03/01/2018] [Indexed: 01/31/2023]
Abstract
BACKGROUND Decision-making on invasive intervention in patients with clinical signs of infected necrotizing pancreatitis is often related to the presence of gas configurations and the degree of encapsulation in necrotic collections on imaging. Data on the natural history of gas configurations and encapsulation in necrotizing pancreatitis are, however, lacking. METHODS A post hoc analysis was performed of a previously described prospective cohort in 21 Dutch hospitals (2004-2008). All computed tomography scans (CTs) performed during hospitalization for necrotizing pancreatitis were categorized per week (1 to 8, and thereafter) and re-assessed by an abdominal radiologist. RESULTS A total of 639 patients with necrotizing pancreatitis were included, with median four (IQR 2-7) CTs per patient. The incidence of first onset of gas configurations varied per week without a linear correlation: 2-3-13-11-10-19-12-21-12%, respectively. Overall, gas configurations were found in 113/639 (18%) patients and in 113/202 (56%) patients with infected necrosis. The incidence of walled-off necrosis increased per week: 0-3-12-39-62-76-93-97-100% for weeks 1-8 and thereafter respectively. Clinically relevant walled-off necrosis (largely or fully encapsulated necrotic collections) was seen in 162/379 (43%) patients within the first 3 weeks. CONCLUSIONS Gas configurations occur in every phase of the disease and develop in half of the patients with infected necrotizing pancreatitis. Opposed to traditional views, clinically relevant walled-off necrosis occurs frequently within the first 3 weeks.
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Affiliation(s)
- Janneke van Grinsven
- Department of Surgery, Amsterdam Gastroenterology and Metabolism, Academic Medical Center Amsterdam, Amsterdam, the Netherlands.
- Department of Surgery, St. Antonius Hospital Nieuwegein, Nieuwegein, the Netherlands.
| | - Sandra van Brunschot
- Department of Gastroenterology and Hepatology, Amsterdam Gastroenterology and Metabolism, Academic Medical Center Amsterdam, Amsterdam, the Netherlands
- Department of Surgery, University Medical Center Utrecht, Utrecht, the Netherlands
| | - Mark C van Baal
- Department of Surgery, University Medical Center Utrecht, Utrecht, the Netherlands
| | - Marc G Besselink
- Department of Surgery, Amsterdam Gastroenterology and Metabolism, Academic Medical Center Amsterdam, Amsterdam, the Netherlands
| | - Paul Fockens
- Department of Gastroenterology and Hepatology, Amsterdam Gastroenterology and Metabolism, Academic Medical Center Amsterdam, Amsterdam, the Netherlands
| | - Harry van Goor
- Department of Surgery, Radboud University Medical Center Nijmegen, Nijmegen, the Netherlands
| | - Hjalmar C van Santvoort
- Department of Surgery, St. Antonius Hospital Nieuwegein, Nieuwegein, the Netherlands
- Department of Surgery, University Medical Center Utrecht, Utrecht, the Netherlands
| | - Thomas L Bollen
- Department of Radiology, St. Antonius Hospital, PO Box 2500, 3430 EM, Nieuwegein, the Netherlands.
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19
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Yip HC, Teoh AYB. Endoscopic Management of Peri-Pancreatic Fluid Collections. Gut Liver 2018; 11:604-611. [PMID: 28494574 PMCID: PMC5593321 DOI: 10.5009/gnl16178] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/04/2016] [Accepted: 08/10/2016] [Indexed: 12/23/2022] Open
Abstract
In the past decade, there has been a progressive paradigm shift in the management of peri-pancreatic fluid collections after acute pancreatitis. Refinements in the definitions of fluid collections from the updated Atlanta classification have enabled better communication amongst physicians in an effort to formulate optimal treatments. Endoscopic ultrasound (EUS)-guided drainage of pancreatic pseudocysts has emerged as the procedure of choice over surgical cystogastrostomy. The approach provides similar success rates with low complications and better quality of life compared with surgery. However, an endoscopic "step up" approach in the management of pancreatic walled-off necrosis has also been advocated. Both endoscopic and percutaneous drainage routes may be used depending on the anatomical location of the collections. New-generation large diameter EUS-specific stent systems have also recently been described. The device allows precise and effective drainage of the collections and permits endoscopic necrosectomy through the stents.
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Affiliation(s)
- Hon Chi Yip
- Department of Surgery, Prince of Wales Hospital, The Chinese University of Hong Kong, Hong Kong SAR, China
| | - Anthony Yuen Bun Teoh
- Department of Surgery, Prince of Wales Hospital, The Chinese University of Hong Kong, Hong Kong SAR, China
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20
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van Dijk SM, Hallensleben NDL, van Santvoort HC, Fockens P, van Goor H, Bruno MJ, Besselink MG. Acute pancreatitis: recent advances through randomised trials. Gut 2017; 66:2024-2032. [PMID: 28838972 DOI: 10.1136/gutjnl-2016-313595] [Citation(s) in RCA: 225] [Impact Index Per Article: 32.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/20/2017] [Revised: 07/05/2017] [Accepted: 07/07/2017] [Indexed: 12/19/2022]
Abstract
Acute pancreatitis is one of the most common GI conditions requiring acute hospitalisation and has a rising incidence. In recent years, important insights on the management of acute pancreatitis have been obtained through numerous randomised controlled trials. Based on this evidence, the treatment of acute pancreatitis has gradually developed towards a tailored, multidisciplinary effort, with distinctive roles for gastroenterologists, radiologists and surgeons. This review summarises how to diagnose, classify and manage patients with acute pancreatitis, emphasising the evidence obtained through randomised controlled trials.
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Affiliation(s)
- Sven M van Dijk
- Department of Surgery, Amsterdam Gastroenterology and Metabolism, Academic Medical Center, Amsterdam, The Netherlands
| | - Nora D L Hallensleben
- Department of Gastroenterology & Hepatology, Erasmus University Medical Center, Rotterdam, The Netherlands
| | | | - Paul Fockens
- Department of Gastroenterology & Hepatology, Amsterdam Gastroenterology and Metabolism, Academic Medical Center, Amsterdam, The Netherlands
| | - Harry van Goor
- Department of Surgery, Radboud University Medical Center, Nijmegen, The Netherlands
| | - Marco J Bruno
- Department of Gastroenterology & Hepatology, Erasmus University Medical Center, Rotterdam, The Netherlands
| | - Marc G Besselink
- Department of Surgery, Amsterdam Gastroenterology and Metabolism, Academic Medical Center, Amsterdam, The Netherlands
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21
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Surgical management of pancreatic necrosis: A practice management guideline from the Eastern Association for the Surgery of Trauma. J Trauma Acute Care Surg 2017; 83:316-327. [PMID: 28452889 DOI: 10.1097/ta.0000000000001510] [Citation(s) in RCA: 24] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
BACKGROUND Pancreatic or peripancreatic tissue necrosis confers substantial morbidity and mortality. New modalities have created a wide variation in approaches and timing of interventions for necrotizing pancreatitis. As acute care surgery evolves, its practitioners are increasingly being called upon to manage these complex patients. METHODS A systematic review of the MEDLINE database using PubMed was performed. English language articles regarding pancreatic necrosis from 1980 to 2014 were included. Letters to the editor, case reports, book chapters, and review articles were excluded. Topics of investigation included operative timing, the use of adjuvant therapy and the type of operative repair. Grading of Recommendations, Assessment, Development and Evaluations methodology was applied to question development, outcome prioritization, evidence quality assessments, and recommendation creation. RESULTS Eighty-eight studies were included and underwent full review. Increasing the time to surgical intervention had an improved outcome in each of the periods evaluated (72 hours, 12-14 days, 30 days) with a significant improvement in outcomes if surgery was delayed 30 days. The use of percutaneous and endoscopic procedures was shown to postpone surgery and potentially be definitive. The use of minimally invasive surgery for debridement and drainage has been shown to be safe and associated with reduced morbidity and mortality. CONCLUSION Acute Care Surgeons are uniquely trained to care for those with pancreatic necrosis due their training in critical care and complex surgery with ongoing shock. In adult patients with pancreatic necrosis, we recommend that pancreatic necrosectomy be delayed until at least day 12. During the first 30 days of symptoms with infected necrotic collections, we conditionally recommend surgical debridement only if the patients fail to improve after radiologic or endoscopic drainage. Finally, even with documented infected necrosis, we recommend that patients undergo a step-up approach to surgical intervention as the preferred surgical approach. LEVEL OF EVIDENCE Systematic review/guideline, level III.
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Lee JY, Kim TH, Chon HK. Isolated Pyogenic Pancreatic Abscess Successfully Treated via Endoscopic Ultrasound-guided Drainage. THE KOREAN JOURNAL OF GASTROENTEROLOGY 2017; 69:321-324. [PMID: 28539039 DOI: 10.4166/kjg.2017.69.5.321] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/13/2023]
Abstract
An isolated pyogenic pancreatic abscess (IPPA) without pancreatitis is extremely rare but can occur in patients with uncontrolled diabetes. This pathologic condition poses a clinical challenge in diagnosis and management because it can be confused easily with a malignancy. Endoscopic ultrasound (EUS) may be a useful diagnostic modality for indeterminate pancreatic lesions and IPPA. Here, we report two cases with elevated carbohydrate antigen 19-9 levels and pancreatic masses on cross sectional imaging. The patients were subsequently diagnosed with IPPA by EUS. EUS-guided drainage was performed successfully and the patients' clinical symptoms and radiologic findings improved. In our experience, EUS and EUS-guided drainage are crucial steps for the diagnosis and management of patients with an indeterminate pancreatic lesion. In addition, EUS-guided drainage has excellent technical and clinical outcomes for the treatment of IPPA.
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Affiliation(s)
- Jung Yeop Lee
- Department of Internal Medicine, Wonkwang University School of Medicine, Iksan, Korea
| | - Tae Hyeon Kim
- Department of Internal Medicine, Wonkwang University School of Medicine, Iksan, Korea
| | - Hyung Ku Chon
- Department of Internal Medicine, Wonkwang University School of Medicine, Iksan, Korea
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23
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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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24
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Greenberg JA, Hsu J, Bawazeer M, Marshall J, Friedrich JO, Nathens A, Coburn N, May GR, Pearsall E, McLeod RS. Clinical practice guideline: management of acute pancreatitis. Can J Surg 2016; 59:128-40. [PMID: 27007094 DOI: 10.1503/cjs.015015] [Citation(s) in RCA: 196] [Impact Index Per Article: 24.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022] Open
Abstract
ABSTRACT There has been an increase in the incidence of acute pancreatitis reported worldwide. Despite improvements in access to care, imaging and interventional techniques, acute pancreatitis continues to be associated with significant morbidity and mortality. Despite the availability of clinical practice guidelines for the management of acute pancreatitis, recent studies auditing the clinical management of the condition have shown important areas of noncompliance with evidence-based recommendations. This underscores the importance of creating understandable and implementable recommendations for the diagnosis and management of acute pancreatitis. The purpose of the present guideline is to provide evidence-based recommendations for the management of both mild and severe acute pancreatitis as well as the management of complications of acute pancreatitis and of gall stone-induced pancreatitis.
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Affiliation(s)
- Joshua A Greenberg
- From the Department of Surgery, University of Toronto, Toronto, Ont. (Greenberg, Bawazeer, Nathens, Coburn, Pearsall, McLeod); the Department of Medicine, University of Toronto, Toronto, Ont. (Hsu, Friedrich, May); the Department of Health Policy, Management and Evaluation, University of Toronto, Toronto, Ont. (McLeod); the Interdepartmental Division of Critical Care, University of Toronto, Toronto, Ont. (Bawazeer, Friedrich); the Division of General Surgery, Mount Sinai Hospital, Toronto, Ont. (McLeod); the Zane Cohen Centre for Digestive Diseases, Mount Sinai Hospital, Toronto, Ont. (Hsu, Pearsall, McLeod); the Samuel Lunenfeld Research Institute, Mount Sinai Hospital, Toronto, Ont. (McLeod); the Division of General Surgery, Sunnybrook Health Sciences Centre, Toronto, Ont. (Nathens, Coburn); and the Divisions of Gastroenterology and General Surgery (Marshall) and Critical Care (Friedrich), St. Michael's Hospital, Toronto, Ont
| | - Jonathan Hsu
- From the Department of Surgery, University of Toronto, Toronto, Ont. (Greenberg, Bawazeer, Nathens, Coburn, Pearsall, McLeod); the Department of Medicine, University of Toronto, Toronto, Ont. (Hsu, Friedrich, May); the Department of Health Policy, Management and Evaluation, University of Toronto, Toronto, Ont. (McLeod); the Interdepartmental Division of Critical Care, University of Toronto, Toronto, Ont. (Bawazeer, Friedrich); the Division of General Surgery, Mount Sinai Hospital, Toronto, Ont. (McLeod); the Zane Cohen Centre for Digestive Diseases, Mount Sinai Hospital, Toronto, Ont. (Hsu, Pearsall, McLeod); the Samuel Lunenfeld Research Institute, Mount Sinai Hospital, Toronto, Ont. (McLeod); the Division of General Surgery, Sunnybrook Health Sciences Centre, Toronto, Ont. (Nathens, Coburn); and the Divisions of Gastroenterology and General Surgery (Marshall) and Critical Care (Friedrich), St. Michael's Hospital, Toronto, Ont
| | - Mohammad Bawazeer
- From the Department of Surgery, University of Toronto, Toronto, Ont. (Greenberg, Bawazeer, Nathens, Coburn, Pearsall, McLeod); the Department of Medicine, University of Toronto, Toronto, Ont. (Hsu, Friedrich, May); the Department of Health Policy, Management and Evaluation, University of Toronto, Toronto, Ont. (McLeod); the Interdepartmental Division of Critical Care, University of Toronto, Toronto, Ont. (Bawazeer, Friedrich); the Division of General Surgery, Mount Sinai Hospital, Toronto, Ont. (McLeod); the Zane Cohen Centre for Digestive Diseases, Mount Sinai Hospital, Toronto, Ont. (Hsu, Pearsall, McLeod); the Samuel Lunenfeld Research Institute, Mount Sinai Hospital, Toronto, Ont. (McLeod); the Division of General Surgery, Sunnybrook Health Sciences Centre, Toronto, Ont. (Nathens, Coburn); and the Divisions of Gastroenterology and General Surgery (Marshall) and Critical Care (Friedrich), St. Michael's Hospital, Toronto, Ont
| | - John Marshall
- From the Department of Surgery, University of Toronto, Toronto, Ont. (Greenberg, Bawazeer, Nathens, Coburn, Pearsall, McLeod); the Department of Medicine, University of Toronto, Toronto, Ont. (Hsu, Friedrich, May); the Department of Health Policy, Management and Evaluation, University of Toronto, Toronto, Ont. (McLeod); the Interdepartmental Division of Critical Care, University of Toronto, Toronto, Ont. (Bawazeer, Friedrich); the Division of General Surgery, Mount Sinai Hospital, Toronto, Ont. (McLeod); the Zane Cohen Centre for Digestive Diseases, Mount Sinai Hospital, Toronto, Ont. (Hsu, Pearsall, McLeod); the Samuel Lunenfeld Research Institute, Mount Sinai Hospital, Toronto, Ont. (McLeod); the Division of General Surgery, Sunnybrook Health Sciences Centre, Toronto, Ont. (Nathens, Coburn); and the Divisions of Gastroenterology and General Surgery (Marshall) and Critical Care (Friedrich), St. Michael's Hospital, Toronto, Ont
| | - Jan O Friedrich
- From the Department of Surgery, University of Toronto, Toronto, Ont. (Greenberg, Bawazeer, Nathens, Coburn, Pearsall, McLeod); the Department of Medicine, University of Toronto, Toronto, Ont. (Hsu, Friedrich, May); the Department of Health Policy, Management and Evaluation, University of Toronto, Toronto, Ont. (McLeod); the Interdepartmental Division of Critical Care, University of Toronto, Toronto, Ont. (Bawazeer, Friedrich); the Division of General Surgery, Mount Sinai Hospital, Toronto, Ont. (McLeod); the Zane Cohen Centre for Digestive Diseases, Mount Sinai Hospital, Toronto, Ont. (Hsu, Pearsall, McLeod); the Samuel Lunenfeld Research Institute, Mount Sinai Hospital, Toronto, Ont. (McLeod); the Division of General Surgery, Sunnybrook Health Sciences Centre, Toronto, Ont. (Nathens, Coburn); and the Divisions of Gastroenterology and General Surgery (Marshall) and Critical Care (Friedrich), St. Michael's Hospital, Toronto, Ont
| | - Avery Nathens
- From the Department of Surgery, University of Toronto, Toronto, Ont. (Greenberg, Bawazeer, Nathens, Coburn, Pearsall, McLeod); the Department of Medicine, University of Toronto, Toronto, Ont. (Hsu, Friedrich, May); the Department of Health Policy, Management and Evaluation, University of Toronto, Toronto, Ont. (McLeod); the Interdepartmental Division of Critical Care, University of Toronto, Toronto, Ont. (Bawazeer, Friedrich); the Division of General Surgery, Mount Sinai Hospital, Toronto, Ont. (McLeod); the Zane Cohen Centre for Digestive Diseases, Mount Sinai Hospital, Toronto, Ont. (Hsu, Pearsall, McLeod); the Samuel Lunenfeld Research Institute, Mount Sinai Hospital, Toronto, Ont. (McLeod); the Division of General Surgery, Sunnybrook Health Sciences Centre, Toronto, Ont. (Nathens, Coburn); and the Divisions of Gastroenterology and General Surgery (Marshall) and Critical Care (Friedrich), St. Michael's Hospital, Toronto, Ont
| | - Natalie Coburn
- From the Department of Surgery, University of Toronto, Toronto, Ont. (Greenberg, Bawazeer, Nathens, Coburn, Pearsall, McLeod); the Department of Medicine, University of Toronto, Toronto, Ont. (Hsu, Friedrich, May); the Department of Health Policy, Management and Evaluation, University of Toronto, Toronto, Ont. (McLeod); the Interdepartmental Division of Critical Care, University of Toronto, Toronto, Ont. (Bawazeer, Friedrich); the Division of General Surgery, Mount Sinai Hospital, Toronto, Ont. (McLeod); the Zane Cohen Centre for Digestive Diseases, Mount Sinai Hospital, Toronto, Ont. (Hsu, Pearsall, McLeod); the Samuel Lunenfeld Research Institute, Mount Sinai Hospital, Toronto, Ont. (McLeod); the Division of General Surgery, Sunnybrook Health Sciences Centre, Toronto, Ont. (Nathens, Coburn); and the Divisions of Gastroenterology and General Surgery (Marshall) and Critical Care (Friedrich), St. Michael's Hospital, Toronto, Ont
| | - Gary R May
- From the Department of Surgery, University of Toronto, Toronto, Ont. (Greenberg, Bawazeer, Nathens, Coburn, Pearsall, McLeod); the Department of Medicine, University of Toronto, Toronto, Ont. (Hsu, Friedrich, May); the Department of Health Policy, Management and Evaluation, University of Toronto, Toronto, Ont. (McLeod); the Interdepartmental Division of Critical Care, University of Toronto, Toronto, Ont. (Bawazeer, Friedrich); the Division of General Surgery, Mount Sinai Hospital, Toronto, Ont. (McLeod); the Zane Cohen Centre for Digestive Diseases, Mount Sinai Hospital, Toronto, Ont. (Hsu, Pearsall, McLeod); the Samuel Lunenfeld Research Institute, Mount Sinai Hospital, Toronto, Ont. (McLeod); the Division of General Surgery, Sunnybrook Health Sciences Centre, Toronto, Ont. (Nathens, Coburn); and the Divisions of Gastroenterology and General Surgery (Marshall) and Critical Care (Friedrich), St. Michael's Hospital, Toronto, Ont
| | - Emily Pearsall
- From the Department of Surgery, University of Toronto, Toronto, Ont. (Greenberg, Bawazeer, Nathens, Coburn, Pearsall, McLeod); the Department of Medicine, University of Toronto, Toronto, Ont. (Hsu, Friedrich, May); the Department of Health Policy, Management and Evaluation, University of Toronto, Toronto, Ont. (McLeod); the Interdepartmental Division of Critical Care, University of Toronto, Toronto, Ont. (Bawazeer, Friedrich); the Division of General Surgery, Mount Sinai Hospital, Toronto, Ont. (McLeod); the Zane Cohen Centre for Digestive Diseases, Mount Sinai Hospital, Toronto, Ont. (Hsu, Pearsall, McLeod); the Samuel Lunenfeld Research Institute, Mount Sinai Hospital, Toronto, Ont. (McLeod); the Division of General Surgery, Sunnybrook Health Sciences Centre, Toronto, Ont. (Nathens, Coburn); and the Divisions of Gastroenterology and General Surgery (Marshall) and Critical Care (Friedrich), St. Michael's Hospital, Toronto, Ont
| | - Robin S McLeod
- From the Department of Surgery, University of Toronto, Toronto, Ont. (Greenberg, Bawazeer, Nathens, Coburn, Pearsall, McLeod); the Department of Medicine, University of Toronto, Toronto, Ont. (Hsu, Friedrich, May); the Department of Health Policy, Management and Evaluation, University of Toronto, Toronto, Ont. (McLeod); the Interdepartmental Division of Critical Care, University of Toronto, Toronto, Ont. (Bawazeer, Friedrich); the Division of General Surgery, Mount Sinai Hospital, Toronto, Ont. (McLeod); the Zane Cohen Centre for Digestive Diseases, Mount Sinai Hospital, Toronto, Ont. (Hsu, Pearsall, McLeod); the Samuel Lunenfeld Research Institute, Mount Sinai Hospital, Toronto, Ont. (McLeod); the Division of General Surgery, Sunnybrook Health Sciences Centre, Toronto, Ont. (Nathens, Coburn); and the Divisions of Gastroenterology and General Surgery (Marshall) and Critical Care (Friedrich), St. Michael's Hospital, Toronto, Ont
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25
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Abstract
The management of acute necrotizing pancreatitis (ANP) has undergone a change of paradigms during the last 2 decades with a decreasing impact of surgical interventions. Modern ANP management is done conservatively as long as possible and therapeutic approaches aim at volume resuscitation, pain management and early enteral nutrition. The diagnostic gold standard of contrast-enhanced CT scan helps to evaluate the extent of necrosis of the pancreas, which correlates with the risk of tissue infection. The crucial point for decision making is the proven existence of infected pancreatic necrosis. This can be achieved by diagnostic needle aspiration of the necrotic material and staining to prove bacterial and/or fungal infection. In case of infected necrosis - besides calculated antimicrobial treatment - an interventional or surgical approach is required to prevent systemic septic progression of the disease. As the first step, percutaneous interventional drainage and spilling of the necrosis are preferable. In case of insufficient clearing of the infectious focus, a step-up approach must be considered, which implies a retroperitoneoscopic or transabdominal minimally invasive necrosectomy and drain placement. Postoperatively, a continuous lavage should be performed using these drains. In case of further deterioration of the patient or development of associated intra-abdominal complications (e.g. bowel perforation or uncontrolled bleeding), an open surgical intervention must always be regarded as a salvage therapy and this offers the possibility to control complications and perform a further necrosectomy and extensive lavage for focus control. However, associated morbidity (e.g. pancreatic fistula, fluid collections, pseudocysts) is about 50-60% and mortality up to 20%. In summary, ANP is managed primarily by a conservative therapy. In case of infected necrosis, interventional and minimally invasive approaches are the therapy of choice. Open surgery should be considered for patients deteriorating despite other measures and should be postponed as long as possible.
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Affiliation(s)
- Thilo Hackert
- Department of General, University of Heidelberg, Heidelberg, Germany
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26
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Abstract
Acute pancreatitis (AP) is the most common indication for hospital admission and its incidence is rising. It has a variable prognosis, which is mainly dependent upon the development of persistent organ failure and infected necrotizing pancreatitis. In the past few years, based on large-scale multicenter randomized trials, some novel insights regarding clinical management have emerged. In patients with infected pancreatic necrosis, a step-up approach of percutaneous catheter drainage followed by necrosectomy only when the patient does not improve, reduces new-onset organ failure and prevents the need for necrosectomy in about a third of patients. A randomized pilot study comparing surgical to endoscopic necrosectomy in patients with infected necrotizing pancreatitis showed a striking reduction of the pro-inflammatory response following endoscopic necrosectomy. These promising results have recently been tested in a large multicenter randomized trial whose results are eagerly awaited. Contrary to earlier data from uncontrolled studies, a large multicenter randomized trial comparing early (within 24 h) nasoenteric tube feeding compared with an oral diet after 72 h, did not show that early nasoenteric tube feeding was superior in reducing the rate of infection or death in patients with AP at high risk for complications. Although early ERCP does not have a role in the treatment of predicted mild pancreatitis, except in the case of concomitant cholangitis, it may ameliorate the disease course in patients with predicted severe pancreatitis. Currently, a large-scale randomized study is underway and results are expected in 2017.
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Affiliation(s)
- Marco J. Bruno
- *Professor Marco J. Bruno, MD, PhD, Department of Gastroenterology and Hepatology Erasmus Medical Center, University Medical Center Rotterdam's Gravendijkwal 230, NL-3015 CE Rotterdam (The Netherlands) E-Mail
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27
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Ahmed A, Gibreel W, Sarr MG. Recognition and Importance of New Definitions of Peripancreatic Fluid Collections in Managing Patients with Acute Pancreatitis. Dig Surg 2016; 33:259-66. [PMID: 27216496 DOI: 10.1159/000445005] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/10/2022]
Abstract
Our understanding of the etiopathogenesis of acute pancreatitis has matured tremendously in the last 3 decades. Advanced cross-sectional imaging with 3-dimensional techniques along with use of intravenous contrast to image the presence or absence of organ tissue perfusion has allowed early recognition of necrotizing pancreatitis. With this knowledge, the old terms to describe what used to be called 'peri-pancreatic fluid collections' we now recognize are no longer accurate nor appropriate. The 2013 revised Atlanta Classification has introduced a new, accurate, objective classification of acute pancreatitis and terminology for the natural history of all forms of acute pancreatitis that is easy to use and will help in both the description of the disease and its appropriate treatment. This review will describe these pancreatic and peri-pancreatic collections with added insight into their natural history.
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Affiliation(s)
- Akram Ahmed
- Department of Surgery, Mayo Clinic, Rochester, Minn., USA
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28
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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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29
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Sharma SS, Singh B, Jain M, Maharshi S, Nijhawan S, Sapra B, Jhajharia A. Endoscopic management of pancreatic pseudocysts and walled-off pancreatic necrosis: A two-decade experience. Indian J Gastroenterol 2016; 35:40-7. [PMID: 26923376 DOI: 10.1007/s12664-016-0624-5] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/15/2015] [Accepted: 01/21/2016] [Indexed: 02/04/2023]
Abstract
AIM To determine long-term outcome of endoscopic management of pancreatic pseudocyst/walled-off pancreatic necrosis (WOPN) without necrosectomy. METHODS One-hundred and sixty-five pancreatic pseudocysts/WOPN managed endoscopically over a period of 22 years were analyzed retrospectively for technical success, complications, and recurrence. RESULTS Symptomatic 118 males and 47 females with mean age of 35.8 years were included. Alcohol was the most common etiology (41.2%). Transmural endoscopic drainage was done in 144 patients, while 21 patients underwent transpapillary drainage. All the patients were subjected to contrast computed tomography (CT) abdomen or routine/Doppler ultrasound. Endoscopic ultrasound was done in last 11 patients. One or two double pigtail 7 Fr stents were placed when clear watery fluid came out from cyst (130 patients, 78.8%), and nasocystic drainage (NCD) tubes were placed in addition to two 7 Fr stents when there were frank pus, thick dark fluid, or solid components inside the cyst (35 patients). All these patients settled on this treatment. Thirty-three of 35 patients of WOPN could be managed endoscopically without necrosectomy. Complications occurred in 9.2% of pseudocysts and 40% of WOPN. Thirty-five patients were followed up for more than 5 years (3 patients more than 10 years), and 130 patients were followed up for up to 5 years. Recurrence occurred in 8.1% of pseudocysts and 5.7% of WOPN. CONCLUSION Majority of pancreatic pseudocysts/WOPN can be managed with endoscopic drainage without necrosectomy with high success, low complication, and recurrence rates.
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Affiliation(s)
- Shyam S Sharma
- Department of Gastroenterology, Sawai Man Singh Medical College, Jawaharlal Nehru Marg, Gangawal Park, Jaipur, 302 004, India.
| | - Bir Singh
- Department of Gastroenterology, Sawai Man Singh Medical College, Jawaharlal Nehru Marg, Gangawal Park, Jaipur, 302 004, India
| | - Mukesh Jain
- Department of Gastroenterology, Sawai Man Singh Medical College, Jawaharlal Nehru Marg, Gangawal Park, Jaipur, 302 004, India
| | - Sudhir Maharshi
- Department of Gastroenterology, G B Pant Hospital, 1, Jawaharlal Nehru Marg, New Delhi, 110 002, India
| | - Sandeep Nijhawan
- Department of Gastroenterology, Sawai Man Singh Medical College, Jawaharlal Nehru Marg, Gangawal Park, Jaipur, 302 004, India
| | - Bharat Sapra
- Department of Gastroenterology, Sawai Man Singh Medical College, Jawaharlal Nehru Marg, Gangawal Park, Jaipur, 302 004, India
| | - Ashok Jhajharia
- Department of Gastroenterology, Sawai Man Singh Medical College, Jawaharlal Nehru Marg, Gangawal Park, Jaipur, 302 004, India
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30
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van Grinsven J, van Brunschot S, Bakker OJ, Bollen TL, Boermeester MA, Bruno MJ, Dejong CH, Dijkgraaf MG, van Eijck CH, Fockens P, van Goor H, Gooszen HG, Horvath KD, van Lienden KP, van Santvoort HC, Besselink MG. Diagnostic strategy and timing of intervention in infected necrotizing pancreatitis: an international expert survey and case vignette study. HPB (Oxford) 2016; 18:49-56. [PMID: 26776851 PMCID: PMC4766363 DOI: 10.1016/j.hpb.2015.07.003] [Citation(s) in RCA: 52] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/16/2015] [Revised: 05/11/2015] [Accepted: 07/10/2015] [Indexed: 02/07/2023]
Abstract
BACKGROUND The optimal diagnostic strategy and timing of intervention in infected necrotizing pancreatitis is subject to debate. We performed a survey on these topics amongst a group of international expert pancreatologists. METHODS An online survey including case vignettes was sent to 118 international pancreatologists. We evaluated the use and timing of fine needle aspiration (FNA), antibiotics, catheter drainage and (minimally invasive) necrosectomy. RESULTS The response rate was 74% (N = 87). None of the respondents use FNA routinely, 85% selectively and 15% never. Most respondents (87%) use a step-up approach in patients with infected necrosis. Walled-off necrosis (WON) is considered a prerequisite for endoscopic drainage and percutaneous drainage by 66% and 12%, respectively. After diagnosing infected necrosis, 55% routinely postpone invasive interventions, whereas 45% proceed immediately to intervention. Lack of consensus about timing of intervention was apparent on day 14 with proven infected necrosis (58% intervention vs. 42% non-invasive) as well as on day 20 with only clinically suspected infected necrosis (59% intervention vs. 41% non-invasive). DISCUSSION The step-up approach is the preferred treatment strategy in infected necrotizing pancreatitis amongst expert pancreatologists. There is no uniformity regarding the use of FNA and timing of intervention in the first 2-3 weeks of infected necrotizing pancreatitis.
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Affiliation(s)
- Janneke van Grinsven
- Dept. of Gastroenterology and Hepatology, Academic Medical Center, Amsterdam, The Netherlands; Dutch Pancreatitis Study Group, St. Antonius Hospital, Nieuwegein, The Netherlands.
| | - Sandra van Brunschot
- Dept. of Gastroenterology and Hepatology, Academic Medical Center, Amsterdam, The Netherlands
| | - Olaf J Bakker
- Dept. of Surgery, University Medical Center Utrecht, Utrecht, The Netherlands
| | - Thomas L Bollen
- Dept. of Radiology, St. Antonius Hospital, Nieuwegein, The Netherlands
| | | | - Marco J Bruno
- Dept. of Gastroenterology and Hepatology, Erasmus Medical Center, Rotterdam, The Netherlands
| | - Cornelis H Dejong
- Dept. of Surgery, Maastricht University Medical Center, Maastricht and NUTRIM School for Nutrition, Toxicology and Metabolism, The Netherlands
| | - Marcel G Dijkgraaf
- Clinical Research Unit, Academic Medical Center, Amsterdam, The Netherlands
| | | | - Paul Fockens
- Dept. of Gastroenterology and Hepatology, Academic Medical Center, Amsterdam, The Netherlands
| | - Harry van Goor
- Dept. of Surgery, Radboud University Medical Center, Nijmegen, The Netherlands
| | - Hein G Gooszen
- Dept. of OR/Evidence Based Surgery, Radboud University Medical Center, Nijmegen, The Netherlands
| | - Karen D Horvath
- Dept. of Surgery, University of Washington Medical Center, Seattle, United States
| | | | - Hjalmar C van Santvoort
- Dept. of Surgery, University Medical Center Utrecht, Utrecht, The Netherlands; Dept. of Surgery, Academic Medical Center, Amsterdam, The Netherlands
| | - Marc G Besselink
- Dept. of Surgery, Academic Medical Center, Amsterdam, The Netherlands.
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31
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Bugiantella W, Rondelli F, Boni M, Stella P, Polistena A, Sanguinetti A, Avenia N. Necrotizing pancreatitis: A review of the interventions. Int J Surg 2015; 28 Suppl 1:S163-71. [PMID: 26708848 DOI: 10.1016/j.ijsu.2015.12.038] [Citation(s) in RCA: 51] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/30/2015] [Revised: 04/11/2015] [Accepted: 05/10/2015] [Indexed: 02/06/2023]
Abstract
Acute pancreatitis may have a wide range of severity, from a clinically self-limiting to a quickly fatal course. Necrotizing pancreatitis (NP) is the most dreadful evolution associated to a poor prognosis: mortality is approximately 15% and up to 30-39% in case of infected necrosis, which is the major cause of death. Intervention is generally required for infected pancreatic necrosis and less commonly in patients with sterile necrosis who are symptomatic (gastric or duodenal outlet or biliary obstruction). Traditionally the most widely used approach to infected necrosis has been open surgical necrosectomy, but it is burdened by high morbidity (34-95%) and mortality (11-39%) rates. In the last two decades the treatment of NP has significantly evolved from open surgery towards minimally invasive techniques (percutaneous catheter drainage, per-oral endoscopic, laparoscopy and rigid retroperitoneal videoscopy). The objective of this review is to summarize the current state of the art of the management of NP and to clarify some aspects about its diagnosis and treatment.
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Affiliation(s)
- Walter Bugiantella
- General Surgery, "San Giovanni Battista Hospital", AUSL Umbria 2, Via M. Arcamone, 06034, Foligno, Perugia, Italy; University of Perugia, PhD School in Biotechnologies, Italy.
| | - Fabio Rondelli
- General Surgery, "San Giovanni Battista Hospital", AUSL Umbria 2, Via M. Arcamone, 06034, Foligno, Perugia, Italy; University of Perugia, Department of Surgical and Biomedical Sciences, Via G. Dottori, 06100, Perugia, Italy.
| | - Marcello Boni
- General Surgery, "San Giovanni Battista Hospital", AUSL Umbria 2, Via M. Arcamone, 06034, Foligno, Perugia, Italy.
| | - Paolo Stella
- General Surgery, "San Giovanni Battista Hospital", AUSL Umbria 2, Via M. Arcamone, 06034, Foligno, Perugia, Italy.
| | - Andrea Polistena
- General and Specialized Surgery, "Santa Maria" Hospital, Via T. Di Joannuccio, 05100, Terni, Italy.
| | - Alessandro Sanguinetti
- General and Specialized Surgery, "Santa Maria" Hospital, Via T. Di Joannuccio, 05100, Terni, Italy.
| | - Nicola Avenia
- General and Specialized Surgery, "Santa Maria" Hospital, Via T. Di Joannuccio, 05100, Terni, Italy.
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32
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Minimally Invasive Necrosectomy Techniques in Severe Acute Pancreatitis: Role of Percutaneous Necrosectomy and Video-Assisted Retroperitoneal Debridement. Gastroenterol Res Pract 2015; 2015:693040. [PMID: 26587018 PMCID: PMC4637484 DOI: 10.1155/2015/693040] [Citation(s) in RCA: 29] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/14/2014] [Accepted: 02/17/2015] [Indexed: 01/07/2023] Open
Abstract
Consensus advocating a principle of early organ support, nutritional optimisation, followed ideally by delayed minimally invasive intervention within a “step-up” framework where possible has radically changed the surgical approach to complications of acute pancreatitis in the last 20 years. The 2012 revision of the Atlanta Classification incorporates these changes, and provides a background which underpins the complexities of individual patient management decisions. This paper discusses the place for delayed minimally invasive surgical intervention (percutaneous necrosectomy, video-assisted retroperitoneal debridement (VARD)), and the rationale for opting to adopt a percutaneous approach over endoscopic or laparoscopic approaches in different clinical situations.
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van Grinsven J, van Brunschot S, Bakker OJ, Bollen TL, Boermeester MA, Bruno MJ, Dejong CH, Dijkgraaf MG, van Eijck CH, Fockens P, van Goor H, Gooszen HG, Horvath KD, van Lienden KP, van Santvoort HC, Besselink MG. Diagnostic strategy and timing of intervention in infected necrotizing pancreatitis: an international expert survey and case vignette study. HPB (Oxford) 2015:n/a-n/a. [PMID: 26475650 DOI: 10.1111/hpb.12491] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/16/2015] [Accepted: 07/10/2015] [Indexed: 12/12/2022]
Abstract
BACKGROUND The optimal diagnostic strategy and timing of intervention in infected necrotizing pancreatitis are subject to debate. A survey was performed on these topics amongst a group of international expert pancreatologists. METHODS An online survey including case vignettes was sent to 118 international pancreatologists. The use and timing of fine-needle aspiration (FNA), antibiotics, catheter drainage and (minimally invasive) necrosectomy were evaluated. RESULTS The response rate was 74% (N = 87). None of the respondents use FNA routinely, 85% selectively and 15% never. Most respondents (87%) use a step-up approach in patients with infected necrosis. Walled-off necrosis (WON) is considered a prerequisite for endoscopic drainage and percutaneous drainage by 66% and 12%, respectively. After diagnosing infected necrosis, 55% routinely postpone invasive interventions, whereas 45% proceed immediately to intervention. A lack of consensus about timing of intervention was apparent on day 14 with proven infected necrosis (58% intervention versus 42% non-invasive) as well as on day 20 with only clinically suspected infected necrosis (59% intervention versus 41% non-invasive). DISCUSSION The step-up approach is the preferred treatment strategy in infected necrotizing pancreatitis amongst expert pancreatologists. There is no uniformity regarding the use of FNA and timing of intervention in the first 2-3 weeks of infected necrotizing pancreatitis.
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Affiliation(s)
- Janneke van Grinsven
- Department of Gastroenterology and Hepatology, Academic Medical Center, Amsterdam, the Netherlands
- Dutch Pancreatitis Study Group, St. Antonius Hospital, Nieuwegein, the Netherlands
| | - Sandra van Brunschot
- Department of Gastroenterology and Hepatology, Academic Medical Center, Amsterdam, the Netherlands
| | - Olaf J Bakker
- Department of Surgery, University Medical Center Utrecht, Utrecht, the Netherlands
| | - Thomas L Bollen
- Department of Radiology, St. Antonius Hospital, Nieuwegein, the Netherlands
| | | | - Marco J Bruno
- Department of Gastroenterology and Hepatology, Erasmus Medical Center, Rotterdam, the Netherlands
| | - Cornelis H Dejong
- Department of Surgery, NUTRIM School for Nutrition, Toxicology and Metabolism, Maastricht University Medical Center, Maastricht, the Netherlands
| | - Marcel G Dijkgraaf
- Clinical Research Unit, Academic Medical Center, Amsterdam, the Netherlands
| | - Casper H van Eijck
- Department of Surgery, Erasmus Medical Center, Rotterdam, the Netherlands
| | - Paul Fockens
- Department of Gastroenterology and Hepatology, Academic Medical Center, Amsterdam, the Netherlands
| | - Harry van Goor
- Department of Surgery, Radboud University Medical Center, Nijmegen, the Netherlands
| | - Hein G Gooszen
- Department of OR/Evidence Based Surgery, Radboud University Medical Center, Nijmegen, the Netherlands
| | - Karen D Horvath
- Department of Surgery, University of Washington Medical Center, Seattle, WA, USA
| | - Krijn P van Lienden
- Department of Radiology, Academic Medical Center, Amsterdam, the Netherlands
| | - Hjalmar C van Santvoort
- Department of Surgery, University Medical Center Utrecht, Utrecht, the Netherlands
- Department of Surgery, Academic Medical Center, Amsterdam, the Netherlands
| | - Marc G Besselink
- Department of Surgery, Academic Medical Center, Amsterdam, the Netherlands
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Pezzilli R, Zerbi A, Campra D, Capurso G, Golfieri R, Arcidiacono PG, Billi P, Butturini G, Calculli L, Cannizzaro R, Carrara S, Crippa S, De Gaudio R, De Rai P, Frulloni L, Mazza E, Mutignani M, Pagano N, Rabitti P, Balzano G. Consensus guidelines on severe acute pancreatitis. Dig Liver Dis 2015; 47:532-43. [PMID: 25921277 DOI: 10.1016/j.dld.2015.03.022] [Citation(s) in RCA: 95] [Impact Index Per Article: 10.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/02/2015] [Revised: 03/17/2015] [Accepted: 03/24/2015] [Indexed: 02/07/2023]
Abstract
This Position Paper contains clinically oriented guidelines by the Italian Association for the Study of the Pancreas (AISP) for the diagnosis and treatment of severe acute pancreatitis. The statements were formulated by three working groups of experts who searched and analysed the most recent literature; a consensus process was then performed using a modified Delphi procedure. The statements provide recommendations on the most appropriate definition of the complications of severe acute pancreatitis, the diagnostic approach and the timing of conservative as well as interventional endoscopic, radiological and surgical treatments.
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Wroński M, Cebulski W, Pawłowski W, Krasnodębski IW, Słodkowski M. Walled-off necrosis: safety of watchful waiting. Dig Dis Sci 2015; 60:1081-6. [PMID: 25326117 PMCID: PMC4408372 DOI: 10.1007/s10620-014-3395-9] [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] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/25/2014] [Accepted: 10/08/2014] [Indexed: 12/11/2022]
Abstract
BACKGROUND Asymptomatic pancreatic necrosis should be managed conservatively, regardless of its extent. However, late sequelae and safety of non-interventional management in patients with asymptomatic walled-off necrosis remain unclear. AIMS The purpose of this study was to report the clinical outcome of outpatient expectant management in a cohort of patients with walled-off necrosis who were discharged asymptomatic after an episode of acute pancreatitis. METHODS Sixteen patients with walled-off necrosis asymptomatic at discharge were identified retrospectively from a single institution. Data were analyzed for the type of complications, their incidence and treatment. RESULTS Seven of 16 patients (44 %) did not experience any complications during a median follow-up of 17 months. Nine of 16 patients (56 %) became symptomatic or developed complications within a median follow-up of 49 days after discharge. The most common complication was infection of pancreatic necrosis which occurred in 7 of 9 patients. Six of these patients were successfully treated with minimally invasive techniques. In 5 of 7 patients, infection of necrosis was due to oral commensal bacteria. Acute intracavitary hemorrhage and intractable abdominal pain developed in one patient each. There was no mortality in this series. CONCLUSIONS Outpatient watchful waiting can be used safely in patients with asymptomatic walled-off necrosis, although nearly half of them eventually develop complications which require interventional treatment. Most late infections of pancreatic necrosis are probably due to a blood-borne transmission of oral commensal bacteria.
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Affiliation(s)
- Marek Wroński
- Department of General, Gastroenterological and Oncological Surgery, Medical University of Warsaw, ul. Banacha 1A, 02-097 Warsaw, Poland
| | - Włodzimierz Cebulski
- Department of General, Gastroenterological and Oncological Surgery, Medical University of Warsaw, ul. Banacha 1A, 02-097 Warsaw, Poland
| | - Waldemar Pawłowski
- Department of General, Gastroenterological and Oncological Surgery, Medical University of Warsaw, ul. Banacha 1A, 02-097 Warsaw, Poland
| | - Ireneusz W. Krasnodębski
- Department of General, Gastroenterological and Oncological Surgery, Medical University of Warsaw, ul. Banacha 1A, 02-097 Warsaw, Poland
| | - Maciej Słodkowski
- Department of General, Gastroenterological and Oncological Surgery, Medical University of Warsaw, ul. Banacha 1A, 02-097 Warsaw, Poland
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Single-stage cholecystectomy at the time of pancreatic necrosectomy is safe and prevents future biliary complications: a 20-year single institutional experience with 217 consecutive patients. J Gastrointest Surg 2015; 19:32-7; discussion 37-8. [PMID: 25270594 DOI: 10.1007/s11605-014-2650-x] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/29/2014] [Accepted: 08/28/2014] [Indexed: 01/31/2023]
Abstract
INTRODUCTION Current guidelines recommend cholecystectomy (CCY) during the index admission for mild to moderate biliary pancreatitis as delayed CCY is associated with a substantial risk of recurrent biliary events. Delayed CCY is recommended in severe pancreatitis. The optimal timing of CCY in necrotizing pancreatitis, however, has not been well studied. We sought to determine the safety of single-stage CCY performed at the time of necrosectomy and its effectiveness in preventing subsequent biliary complications. METHODS We retrospectively queried our institutional database of patients who underwent pancreatic necrosectomy for necrotizing pancreatitis from 1992 to 2012. RESULTS We identified 217 consecutive patients who underwent pancreatic necrosectomy during the study period. The most common etiologies of pancreatitis were biliary (41 %) and alcoholic (24%), with a median computed tomography (CT) severity index score of 6 ± 1.6 and a 63.6% incidence of infected necrosis. Ninety-eight patients had undergone CCY prior to necrosectomy. Seventy patients (59% of those with gallbladders in situ) underwent CCY at the time of pancreatic necrosectomy. CCY was not performed in the remaining 49 due to a clear non-biliary etiology (35%), technical difficulty (29%), intraoperative hemodynamic instability (18%), or surgeon preference (18%). Postoperative morbidity and mortality was no different between the CCY and no CCY groups, with no bile duct injury or bile leaks in patients undergoing CCY at the time of necrosectomy. Of the patients undergoing CCY, 43% of patients without cholelithiasis or biliary sludge on preoperative imaging had gallstones or sludge identified pathologically after single-stage CCY. Of those who did not receive a single-stage CCY, biliary complications developed in 17 (35%) of patients (21% cholecystitis, 14% recurrent gallstone pancreatitis) at a median time to incidence of 10 months. Seventeen (35%) patients eventually received a postnecrosectomy cholecystectomy, of which 75% required an open procedure. CONCLUSION Single-stage CCY at the time of pancreatic necrosectomy is safe in selected patients and should be performed if technically feasible to prevent future biliary complications and reduce the need for a subsequent separate, often open, CCY.
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Paradigm shift away from open surgical necrosectomy toward endoscopic interventions for necrotizing pancreatitis. GASTROINTESTINAL INTERVENTION 2014. [DOI: 10.1016/j.gii.2014.09.010] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
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Kokosis G, Perez A, Pappas TN. Surgical management of necrotizing pancreatitis: An overview. World J Gastroenterol 2014; 20:16106-16112. [PMID: 25473162 PMCID: PMC4239496 DOI: 10.3748/wjg.v20.i43.16106] [Citation(s) in RCA: 41] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/27/2014] [Revised: 04/23/2014] [Accepted: 05/26/2014] [Indexed: 02/06/2023] Open
Abstract
Necrotizing pancreatitis is an uncommon yet serious complication of acute pancreatitis with mortality rates reported up to 15% that reach 30% in case of infection. Traditionally open surgical debridement was the only tool in our disposal to manage this serious clinical entity. This approach is however associated with poor outcomes. Management has now shifted away from open surgical debridement to a more conservative management and minimally invasive approaches. Contemporary approach to patients with necrotizing pancreatitis and/or infectious pancreatitis is summarized in the 3Ds: Delay, Drain and Debride. Patients can be managed in the intensive care unit and any intervention should be delayed. Percutaneous drainage can be utilized first and early in the course of the disease, followed by endoscopic drainage or video assisted retroperitoneoscopic drainage if necrosectomy is deemed necessary. Open surgery is now less frequently performed and should be reserved for cases refractory to any other approach. The management of necrotizing pancreatitis therefore requires a multidisciplinary dynamic model of approach rather than being a surgical disease.
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Guo Q, Li A, Xia Q, Lu H, Ke N, Du X, Zhang Z, Hu W. Timing of intervention in necrotizing pancreatitis. J Gastrointest Surg 2014; 18:1770-6. [PMID: 25091844 DOI: 10.1007/s11605-014-2606-1] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/08/2014] [Accepted: 07/22/2014] [Indexed: 02/06/2023]
Abstract
BACKGROUND The best available evidence suggests that surgical intervention should be delayed where possible until four weeks after the onset of pancreatitis. Subgroups that may benefit from early or delayed intervention have not been identified. METHODS This study reviewed a prospective database with 223 patients of necrotizing pancreatitis who received intervention. A subgroup analysis was performed to compare the results of different surgical timing. RESULTS The median timing of intervention was 32 days. The mortality rates in the early (≤30 days) intervention and delayed intervention (>30 days) groups were 21% (28/136) and 10% (9/87), respectively (P = 0.04). In patients with persistent early organ failure, mortality and re-intervention rates were higher in the early group compared with the delayed group (23/61 vs. 3/21, P = 0.04; 17/61 vs. 2/21, P = 0.01). In patients without persistent early organ failure who underwent treatment, mortality rates, and re-intervention rates were similar between the early group and delayed group (5/75 vs. 6/66, P = 0.59; 7/75 vs. 3/66, P = 0.27). In patients with infected necrosis, mortality rate was similar with the early group and delayed group (17/77 vs. 7/57, P = 0.14). CONCLUSION Early intervention in patients without persistent organ failure showed similar outcomes with patients who received delayed intervention.
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Affiliation(s)
- Qiang Guo
- Pancreatic Surgery, West China Hospital, Sichuan University, Chengdu, 610041, Sichuan Province, China
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Surgical transgastric debridement of walled off pancreatic necrosis: an option for patients with necrotizing pancreatitis. Surg Endosc 2014; 29:575-82. [DOI: 10.1007/s00464-014-3700-x] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/25/2014] [Accepted: 06/22/2014] [Indexed: 12/15/2022]
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Fischer TD, Gutman DS, Hughes SJ, Trevino JG, Behrns KE. Disconnected pancreatic duct syndrome: disease classification and management strategies. J Am Coll Surg 2014; 219:704-12. [PMID: 25065360 DOI: 10.1016/j.jamcollsurg.2014.03.055] [Citation(s) in RCA: 54] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/31/2014] [Revised: 03/21/2014] [Accepted: 03/24/2014] [Indexed: 02/06/2023]
Abstract
BACKGROUND Disconnected pancreatic duct syndrome (DPDS) typically complicates acute necrotizing pancreatitis (ANP) and presents as a pseudocyst months after the initial episode of pancreatitis. However, our experience suggests that the presentation of DPDS may be quite varied and might require significant evaluation and judgment before surgical intervention. We sought to determine the presentations of DPDS and assess the management of the various forms of presentation. STUDY DESIGN A retrospective review of all patients with DPDS between July 2005 and June 2011 was performed. Patients were included when CT scan demonstrated a clear disconnected pancreas that was confirmed at operation. Medical records were reviewed in detail to determine clinical presentation, management, and outcomes. RESULTS Of the 50 patients identified, 66% were male, with a mean age of 53 ± 16 years. Mortality was 2% and 3 patients (6%) required late reoperation. The DPDS presented in 3 forms: diagnosed concurrently with ANP (concurrent DPDS; n = 28); delayed presentation with a pseudocyst (delayed DPDS; n = 15); and as a consequence of chronic pancreatitis (CP) (CP DPDS; n = 7). Concurrent DPDS was treated with necrosectomy including body/tail resection within 60 days of onset and complicated by a grade B/C fistula in 36%. Delayed DPDS required distal pancreatectomy 440 days after diagnosis, with a 7% fistula rate. Chronic pancreatitis DPDS was treated with lateral pancreatojejunostomy at 417 days with no fistulas. CONCLUSIONS Disconnected pancreatic duct syndrome presents concurrently with ANP, in a delayed fashion, or infrequently in the setting of CP. Prompt recognition and classification with appropriate operative therapy results in low mortality and nonoperatively managed pancreatic fistulas.
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Affiliation(s)
- Trevan D Fischer
- Department of Surgery, University of Florida College of Medicine, Gainesville, FL
| | - Daniel S Gutman
- Department of Surgery, University of Florida College of Medicine, Gainesville, FL
| | - Steven J Hughes
- Department of Surgery, University of Florida College of Medicine, Gainesville, FL
| | - Jose G Trevino
- Department of Surgery, University of Florida College of Medicine, Gainesville, FL
| | - Kevin E Behrns
- Department of Surgery, University of Florida College of Medicine, Gainesville, FL.
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Wormer BA, Swan RZ, Williams KB, Bradley JF, Walters AL, Augenstein VA, Martinie JB, Heniford BT. Outcomes of pancreatic debridement in acute pancreatitis: analysis of the nationwide inpatient sample from 1998 to 2010. Am J Surg 2014; 208:350-62. [PMID: 24933665 DOI: 10.1016/j.amjsurg.2013.12.030] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/18/2013] [Revised: 11/11/2013] [Accepted: 12/11/2013] [Indexed: 12/18/2022]
Abstract
BACKGROUND The objective of this study was to perform a national review of patients with acute pancreatitis (AP) who undergo pancreatic debridement (PD) to evaluate for risk factors of in-hospital mortality. METHODS The Nationwide Inpatient Sample was used to identify patients with AP who underwent PD between 1998 and 2010. Risk factors for in-hospital mortality were assessed with multivariate logistic regression. RESULTS From 1998 to 2010, there were 585,978 nonelective admissions with AP, of which 1,783 (.3%) underwent PD. From 1998 to 2010, the incidence of PD decreased from .44% to .25% (P < .01) and PD in-hospital mortality decreased from 29.0% to 15% (P < .05). Of patients undergoing PD, independent factors associated with increased odds of mortality were increased age (odds ratio [OR] 1.04, confidence interval [CI] 1.03 to 1.05; P < .01), sepsis with organ failure (OR 1.76, CI 1.24 to 2.51; P < .01), peptic ulcer disease (OR 1.83, CI 1.02 to 3.30; P < .05), liver disease (OR 2.27, CI 1.36 to 3.78; P < .01), and renal insufficiency (OR 1.78, CI 1.14 to 2.78; P < .05). CONCLUSIONS The incidence and operative mortality of PD have decreased significantly over the last decade in the United States with higher odds of dying in patients who are older, with chronic liver, renal, or ulcer disease, and higher rates of sepsis with organ failure.
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Affiliation(s)
| | - Ryan Z Swan
- Carolinas Medical Center, Charlotte, NC, USA
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Madenci AL, Michailidou M, Chiou G, Thabet A, Fernández-del Castillo C, Fagenholz PJ. A contemporary series of patients undergoing open debridement for necrotizing pancreatitis. Am J Surg 2014; 208:324-31. [PMID: 24767969 DOI: 10.1016/j.amjsurg.2013.11.004] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/13/2013] [Revised: 11/11/2013] [Accepted: 11/11/2013] [Indexed: 12/17/2022]
Abstract
BACKGROUND For patients with acute pancreatitis complicated by infected necrosis, minimally invasive techniques have taken hold without substantial comparison with open surgery. We present a contemporary series of open necrosectomies as a benchmark for newer techniques. METHODS Using a prospective database, we retrospectively identified consecutive patients undergoing debridement for necrotizing pancreatitis (2006 to 2009). The primary endpoint was in-hospital mortality. RESULTS Sixty-eight patients underwent debridement for pancreatic/peripancreatic necrosis. In-hospital mortality was 8.8% (n = 6). Infection (n = 43, 63%) and failure-to-thrive (n = 13, 19%) comprised the most common indications for necrosectomy. The false negative rate (FNR) for infection of percutaneous aspirate was 20.0%. Older age (P = .02), Acute Physiology and Chronic Health Evaluation II score upon admission (P = .03) or preoperatively (P < .01), preoperative intensive care unit admission (P = .01), and postoperative organ failure (P = .03) were associated with mortality. CONCLUSIONS Open debridement for necrotizing pancreatitis results in a low mortality, providing a useful comparator for other interventions. Given the high FNR of percutaneous aspirate, debridement should not be predicated on proven infection.
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Affiliation(s)
- Arin L Madenci
- Department of Surgery, Division of Trauma Emergency Surgery and Critical Care, Boston, MA 02114, USA
| | - Maria Michailidou
- Department of Surgery, Division of Trauma Emergency Surgery and Critical Care, Boston, MA 02114, USA
| | - Grace Chiou
- Department of Surgery, Division of Trauma Emergency Surgery and Critical Care, Boston, MA 02114, USA
| | - Ashraf Thabet
- Department of Radiology, Massachusetts General Hospital, 165 Cambridge Street, Boston, MA 02114, USA
| | | | - Peter J Fagenholz
- Department of Surgery, Division of Trauma Emergency Surgery and Critical Care, Boston, MA 02114, USA.
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Gibson SC, Robertson BF, Dickson EJ, McKay CJ, Carter CR. 'Step-port' laparoscopic cystgastrostomy for the management of organized solid predominant post-acute fluid collections after severe acute pancreatitis. HPB (Oxford) 2014; 16:170-6. [PMID: 23551864 PMCID: PMC3921013 DOI: 10.1111/hpb.12099] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/09/2013] [Accepted: 02/11/2013] [Indexed: 12/12/2022]
Abstract
BACKGROUND Post-acute pancreatic collections (PAPCs) may require intervention when persistent, large or symptomatic. An open cystgastrostomy is an effective treatment option particularly for larger, solid predominant collections. A laparoscopic cystgastrostomy (LCG) as initially described, could be technically challenging. This report describes the evolution of the operative technique and the results from LCG in a tertiary referral centre. METHODS Retrospective analysis of the unit's prospectively populated database was conducted. All patients who underwent a surgical cystgastrostomy (SCG) were identified. Patient demographics, outcome and complications were collected and analysed. RESULTS Forty-four patients underwent SCG: 8 open and 36 laparoscopic. Of the 36 LCG, 6 required open conversion, although with evolution of the technique all of the last 17 cases were completed laparoscopically. The median interquartile range (IQR) length of stay in patients completed laparoscopically was 6 (2-10) compared with 15.5 days (8-19) in those patients who were converted (P = 0.0351). The only peri-operative complication after a LCG was a self-limiting upper gastrointestinal bleed. With a median (IQR) follow-up of 891 days (527-1495) one patient required re-intervention for a residual collection with no recurrent collections identified. CONCLUSION LCG is a safe and effective procedure in patients with large, solid predominant PAPCs. With increased experience and technical expertise conversion rates can be lowered and outcome optimized.
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Affiliation(s)
- Simon C Gibson
- Correspondence Simon C Gibson, Crosshouse Hospital, Kilmarnock Road, Kilmarnock, UK. Tel: +44 1563 5211 133. Fax: +44 141 232 0701. E-mail:
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Laparoscopic pancreatic resections. Langenbecks Arch Surg 2013; 398:939-45. [PMID: 24006117 DOI: 10.1007/s00423-013-1108-z] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/19/2013] [Accepted: 08/22/2013] [Indexed: 02/06/2023]
Abstract
PURPOSE Pancreatic surgery is technically complex and requires considerable expertise. Laparoscopic pancreatic surgery adds the need for considerable experience with advanced laparoscopic techniques. Despite the technical difficulties, an increasing number of centers propagate the use of laparoscopy in pancreatic surgery over the last decade. METHODS In this review, we provide an overview of the literature regarding the advantages and disadvantages of laparoscopic pancreatic surgery. Larger prospective randomized studies have emerged in the subset of laparoscopic or retroperitoneoscopic surgery for acute pancreatitis, considerable single center experience has been reported for laparoscopic pancreatic tail resection, and laparoscopic pancreatic head resection, however, is still restricted to a few experienced centers worldwide. RESULTS AND CONCLUSIONS Laparoscopic pancreatic surgery is becoming more and more established, in particular for the treatment of benign and premalignant lesions of the pancreatic body and tail. It has been shown to decrease postoperative pain, narcotic use, and length of hospital stay in larger single center experience. However, prospective trials are needed in laparoscopic resective pancreatic surgery to evaluate its advantages, safety, and efficacy in the treatment of pancreatic neoplasms and in particular in malignant pancreatic tumors.
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Five-year cohort study of open pancreatic necrosectomy for necotizing pancreatitis suggests it is a safe and effective operation. J Gastrointest Surg 2013; 17:1634-42. [PMID: 23868057 DOI: 10.1007/s11605-013-2288-0] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/10/2013] [Accepted: 07/05/2013] [Indexed: 01/31/2023]
Abstract
INTRODUCTION Despite advances in the management of necrotizing pancreatitis, open necrosectomy remains an important management option for necrotizing pancreatitis, and patients undergoing necrosectomy suffer significant morbidity and mortality. The aim of this study was to report the outcomes of open necrosectomy from a recent large cohort of patients with necrotizing pancreatitis. METHODS Data are reported from a cohort of 276 consecutive patients with necrotizing pancreatitis who underwent open surgical debridement. Nutritional status, nutritional methods, bleeding, infection, demarcation of necrotic tissues, and time from onset of disease were scored. Scores ≥ 10 were considered as an indication for debridement. RESULTS One hundred sixty-two (58.7%) and 52 (18.8%) patients underwent minimally invasive peritoneal and retroperitoneal drainage, respectively, before necrosectomy. Median delay from disease onset to debridement was 48 days. Fifty-five patients (19.9%) underwent more than one operation; 352 operations were performed in total. There were 17 deaths (6.2%) postoperatively. CONCLUSION This study demonstrated the results for open debridement in a recent large cohort of patients. Although minimally invasive necrosectomy has been developed in recent years, open necrosectomy remains an important approach for the debridement of necrotizing pancreatitis effectively and safely.
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IAP/APA evidence-based guidelines for the management of acute pancreatitis. Pancreatology 2013; 13:e1-15. [PMID: 24054878 DOI: 10.1016/j.pan.2013.07.063] [Citation(s) in RCA: 926] [Impact Index Per Article: 84.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/05/2013] [Revised: 07/01/2013] [Accepted: 07/05/2013] [Indexed: 02/07/2023]
Abstract
BACKGROUND There have been substantial improvements in the management of acute pancreatitis since the publication of the International Association of Pancreatology (IAP) treatment guidelines in 2002. A collaboration of the IAP and the American Pancreatic Association (APA) was undertaken to revise these guidelines using an evidence-based approach. METHODS Twelve multidisciplinary review groups performed systematic literature reviews to answer 38 predefined clinical questions. Recommendations were graded using the Grading of Recommendations Assessment, Development and Evaluation (GRADE) system. The review groups presented their recommendations during the 2012 joint IAP/APA meeting. At this one-day, interactive conference, relevant remarks were voiced and overall agreement on each recommendation was quantified using plenary voting. RESULTS The 38 recommendations covered 12 topics related to the clinical management of acute pancreatitis: A) diagnosis of acute pancreatitis and etiology, B) prognostication/predicting severity, C) imaging, D) fluid therapy, E) intensive care management, F) preventing infectious complications, G) nutritional support, H) biliary tract management, I) indications for intervention in necrotizing pancreatitis, J) timing of intervention in necrotizing pancreatitis, K) intervention strategies in necrotizing pancreatitis, and L) timing of cholecystectomy. Using the GRADE system, 21 of the 38 (55%) recommendations, were rated as 'strong' and plenary voting revealed 'strong agreement' for 34 (89%) recommendations. CONCLUSIONS The 2012 IAP/APA guidelines provide recommendations concerning key aspects of medical and surgical management of acute pancreatitis based on the currently available evidence. These recommendations should serve as a reference standard for current management and guide future clinical research on acute pancreatitis.
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Tu Y, Jiao H, Tan X, Wang D, Du J, Sun L, Zhang W. Retroperitoneal laparoscopic debridement and drainage of infected retroperitoneal necrosis in severe acute pancreatitis. Asian J Surg 2013; 36:159-64. [PMID: 23786806 DOI: 10.1016/j.asjsur.2013.04.003] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/18/2012] [Revised: 11/06/2012] [Accepted: 04/03/2013] [Indexed: 12/12/2022] Open
Abstract
OBJECTIVE To explore the effect of retroperitoneal laparoscopic debridement and drainage on infected necrosis in severe acute pancreatitis. MATERIALS AND METHODS This retrospective study included 18 patients with severe acute pancreatitis (SAP) undergoing retroperitoneal laparoscopic debridement and drainage from May 2006 to April 2012 in our hospital. All patients had infected retroperitoneal necrosis and single or multiple peritoneal abscesses. Eleven patients transferred to our hospital were treated with the retroperitoneal laparoscopic debridement and drainage within 24-72 hours after admission. Conservative treatments were given to eight patients. Retroperitoneal laparoscopic debridement and drainage were applied 3-11 days after admission. RESULTS All patients had infection of necrotic pancreas or peripancreatic tissues. Twelve patients had organ failure. Three patients underwent secondary surgery. Laparotomy with debridement and drainage were applied to one patient who had a huge lesser sac abscess 7 days after first surgery. The other two patients were given secondary retroperitoneal laparoscopic debridement and drainage. One case was complicated by retroperitoneal hemorrhage, four cases had pancreatic leakage, and no intestinal fistula was found. The patients' heart rate, respiration, temperature, and white blood cell count were significantly improved 48 hours after surgery compared with those prior to surgery (p<0.05). The average length of stay in hospitals was 40.8 days (range, 6-121 days), and the drainage tube indwelling time was 44.4 days (range, 2-182 days). CONCLUSION Retroperitoneal laparoscopic debridement and drainage is an SAP surgical treatment with a minimally invasive procedure and a good effect, and can be applied for infected retroperitoneal necrosis in early SAP.
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Affiliation(s)
- Yuliang Tu
- Department of Hepatobiliary Surgery, First Affiliated Hospital of People's Liberation Army (PLA) General Hospital, Beijing, China
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Transluminal retroperitoneal endoscopic necrosectomy with the use of hydrogen peroxide and without external irrigation: a novel approach for the treatment of walled-off pancreatic necrosis. Surg Endosc 2013; 27:3911-20. [DOI: 10.1007/s00464-013-2948-x] [Citation(s) in RCA: 37] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/12/2012] [Accepted: 03/20/2013] [Indexed: 12/20/2022]
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van Brunschot S, Besselink MG, Bakker OJ, Boermeester MA, Gooszen HG, Horvath KD, van Santvoort HC. Video-Assisted Retroperitoneal Debridement (VARD) of Infected Necrotizing Pancreatitis: An Update. CURRENT SURGERY REPORTS 2013. [DOI: 10.1007/s40137-013-0015-0] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/22/2022]
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