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Wang Y, Yoshino O, Driedger MR, Beckman MJ, Vrochides D, Martinie JB. Robotic pancreatic necrosectomy and internal drainage for walled-off pancreatic necrosis. HPB (Oxford) 2023:S1365-182X(23)00099-0. [PMID: 37045742 DOI: 10.1016/j.hpb.2023.03.013] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/18/2022] [Revised: 01/29/2023] [Accepted: 03/19/2023] [Indexed: 04/14/2023]
Abstract
BACKGROUND Pancreatic necrosectomy with concomitant internal drainage is a single-stage treatment option for walled-off pancreatic necrosis (WOPN). However, an optimal minimally invasive technique has not been established. We evaluated the safety and single-intervention success rate of robotic pancreatic necrosectomy and internal drainage. METHODS Patients with WOPN undergoing robotic pancreatic necrosectomy and internal drainage at a single institution from 2011-2022 were identified. The primary outcome was the rate of clinical symptom resolution following the index surgical intervention. RESULTS 57 patients underwent robotic pancreatic necrosectomy and internal drainage, consisting of robotic cystgastrostomy (RCG, n = 37), robotic cystjejunostomy (RCJ, n = 13) and robotic fistulojejunostomy (RFJ, n = 7). Surgery was performed a median of 102 (range 28-1153) days following the onset of necrotizing pancreatitis. The median operative time was 187 (91-344) minutes and there were 2 (3.5%) conversions. The median length of hospital stay was 4 (2-38) days. Postoperative morbidity was 11%, and there was one (1.8%) 90-day mortality. At a median follow-up of 5.5 months, 53 (93%) patients had clinical symptom resolution after their index procedure and did not require any reintervention. CONCLUSION In select patients, robotic pancreatic necrosectomy and internal drainage is safe and achieves a high single-intervention success rate.
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Affiliation(s)
- Yifan Wang
- Division of Hepatopancreaticobiliary Surgery, Department of Surgery, Atrium Health Carolinas Medical Center, Charlotte, NC, USA; Department of Surgery, McGill University, Montreal, QC, Canada
| | - Osamu Yoshino
- Division of Hepatopancreaticobiliary Surgery, Department of Surgery, Atrium Health Carolinas Medical Center, Charlotte, NC, USA
| | - Michael R Driedger
- Division of Hepatopancreaticobiliary Surgery, Department of Surgery, Atrium Health Carolinas Medical Center, Charlotte, NC, USA
| | - Michael J Beckman
- Division of Hepatopancreaticobiliary Surgery, Department of Surgery, Atrium Health Carolinas Medical Center, Charlotte, NC, USA
| | - Dionisios Vrochides
- Division of Hepatopancreaticobiliary Surgery, Department of Surgery, Atrium Health Carolinas Medical Center, Charlotte, NC, USA
| | - John B Martinie
- Division of Hepatopancreaticobiliary Surgery, Department of Surgery, Atrium Health Carolinas Medical Center, Charlotte, NC, USA.
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2
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Affiliation(s)
- Amy Y Li
- Department of Surgery, Section of Surgical Oncology, Stanford University School of Medicine, 300 Pasteur Drive, Room H3591, Stanford, CA 94305, USA
| | - John R Bergquist
- Department of Surgery, Section of Surgical Oncology, Stanford University School of Medicine, 300 Pasteur Drive, Room H3591, Stanford, CA 94305, USA
| | - Brendan C Visser
- Department of Surgery, Section of Surgical Oncology, Stanford University School of Medicine, 300 Pasteur Drive, H3680, Stanford, CA 94305-5655, USA.
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3
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Sanchez RJ, Ge W, Wei W, Ponda MP, Rosenson RS. The association of triglyceride levels with the incidence of initial and recurrent acute pancreatitis. Lipids Health Dis 2021; 20:72. [PMID: 34275452 PMCID: PMC8286611 DOI: 10.1186/s12944-021-01488-8] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/19/2021] [Accepted: 06/10/2021] [Indexed: 12/15/2022] Open
Abstract
Background This retrospective cohort study assessed the annualized incidence rate (IR) of acute pancreatitis (AP) in a nationally representative US adult population, as well as the variation in the risk of AP events across strata of triglyceride (TG) levels. Methods Data were obtained from IQVIA’s US Ambulatory Electronic Medical Records (EMR) database linked with its LRxDx Open Claims database. Inclusion criteria included ≥1 serum TG value during the overlapping study period of the EMR and claims databases, ≥1 claim in the 12-month baseline period, and ≥ 1 claim in the 12 months post index. All TG measurements were assigned to the highest category reached: < 2.26, ≥2.26 to ≤5.65, > 5.65 to ≤9.94, > 9.94, and > 11.29 mmol/L (< 200, ≥200 to ≤500, > 500 to ≤880, > 880, and > 1000 mg/dL, respectively). The outcome of interest was AP, defined as a hospitalization event with AP as the principal diagnosis. Results In total, 7,119,195 patients met the inclusion/exclusion criteria, of whom 4158 (0.058%) had ≥1 AP events in the prior 12 months. Most patients (83%) had TGs < 2.26 mmol/L (< 200 mg/dL), while < 1% had TGs > 9.94 mmol/L (> 880 mg/dL). Overall, the IR of AP was low (0.08%; 95% confidence internal [CI], 0.08–0.08%), but increased with increasing TGs (0.08% in TGs < 2.26 mmol/L [< 200 mg/dL] to 1.21% in TGs > 11.29 mmol/L [> 1000 mg/dL]). In patients with a prior history of AP, the IR of AP increased dramatically; patients with ≥2 AP events at baseline had an IR of 29.98% (95% CI, 25.1–34.9%). Conclusion The risk of AP increases with increasing TG strata; however, the risk increases dramatically among patients with a recent history of AP.
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Affiliation(s)
| | - Wenzhen Ge
- Regeneron Pharmaceuticals, Inc., Tarrytown, New York, USA
| | - Wenhui Wei
- Regeneron Pharmaceuticals, Inc., Tarrytown, New York, USA
| | - Manish P Ponda
- Regeneron Pharmaceuticals, Inc., Tarrytown, New York, USA
| | - Robert S Rosenson
- Mount Sinai Heart, Icahn School of Medicine at Mount Sinai, One Gustav L. Levy Place, Hospital Box 1030, New York, NY, 10029, USA.
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4
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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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5
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Sağlam K, Alhan E, Türkyılmaz S, Vanizor BK, Erçin C. The anti-inflammatory effect of hydrogen sulphide on acute necrotizing pancreatitis in rats. Turk J Surg 2017; 33:158-163. [PMID: 28944326 DOI: 10.5152/ucd.2017.3653] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/18/2016] [Accepted: 09/04/2016] [Indexed: 01/23/2023]
Abstract
OBJECTIVE The aim of this study was to investigate the dose-dependent anti-inflammatory effect of the Hydrogen sulfidedonor sodiumhydrosulphide on acute necrotizing pancreatitis in rats. MATERIAL AND METHODS A total of 42 male Sprague-Dawley rats were divided into 4 groups: sham+saline (group 1), sham+NaHS (group 2), acute necrotizing pancreatitis+saline (group 3), and acute necrotizing pancreatitis+NaHS (group 4). Acute pancreatitis was induced in rats in groups 3 and 4 with the infusion of glycodeoxycholic acidinto the biliopancreatic canal and infusion of cerulein parenterally. In group 4, 10 mg/kg NaHS was administered intraperitoneally after cerulein infusion. Tests for liver and kidney function, interleukin-6, lactate dehydrogenase in bronchoalveolar lavage, and malonyaldehyde and myeloperoxidase activities in pancreas and lung tissue were performed, and histopathologic examination of pancreas was conducted. RESULTS In groups 3, a significant increase in amylase, alanine aminotransferase, urea, interleukine-6, lungmalondialdehyde and myeloperoxidase activities, pancreas myeloperoxidase activity, edema, and necrosis in pancreas tissue and a significant decrease in serum calcium levels were detected (p<0.05). In group 4, addition of NaHS resulted in a significant decrease in lactate dehydrogenase level in bronchoalveolar lavage, amount of urea, lung myeloperoxidase activity, and pancreatic edema (p<0.05). CONCLUSION Although not in pancreatic necrosis, hydrogen sulphide has an anti-inflammatory effect especially in the inflammatory process in lung and edema in pancreasin acute necrotizing pancreatitis at particular doses. With further studies evaluating the anti-inflammatory effects of hydrogen sulphide, we believe it can be used in the treatment of edematous acute pancreatitis and the related complications in lungs.
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Affiliation(s)
- Kutay Sağlam
- Department of General Surgery, Karadeniz Technical University School of Medicine, Trabzon, Turkey
| | - Etem Alhan
- Department of General Surgery, Karadeniz Technical University School of Medicine, Trabzon, Turkey
| | - Serdar Türkyılmaz
- Department of General Surgery, Karadeniz Technical University School of Medicine, Trabzon, Turkey
| | - Birgül Kural Vanizor
- Department of Medical Biochemistry, Karadeniz Technical University School of Medicine, Trabzon, Turkey
| | - Cengiz Erçin
- Department of Pathology, Kocaeli University School of Medicine, Kocaeli, Turkey
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6
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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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Worhunsky DJ, Qadan M, Dua MM, Park WG, Poultsides GA, Norton JA, Visser BC. Laparoscopic transgastric necrosectomy for the management of pancreatic necrosis. J Am Coll Surg 2014; 219:735-43. [PMID: 25158913 DOI: 10.1016/j.jamcollsurg.2014.04.012] [Citation(s) in RCA: 42] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/13/2014] [Revised: 04/05/2014] [Accepted: 04/07/2014] [Indexed: 12/16/2022]
Abstract
BACKGROUND Traditional open necrosectomy for pancreatic necrosis is associated with significant morbidity and mortality. Although minimally invasive techniques have been described and offer some promise, each has considerable limitations. This study assesses the safety and effectiveness of laparoscopic transgastric necrosectomy (LTN), a novel technique for the management of necrotizing pancreatitis. STUDY DESIGN Between 2009 and 2013, patients with retrogastric pancreatic necrosis requiring debridement were evaluated for LTN. Debridement was performed via a laparoscopic transgastric approach using 2 to 3 ports and the wide cystgastrostomy left open. Patient demographics, disease severity, operative characteristics, and outcomes were collected and analyzed. RESULTS Twenty-one patients (13 men, median age 54 years; interquartile range [IQR] 46 to 62 years) underwent LTN during the study period. The duration between pancreatitis onset and debridement was 65 days (IQR 53 to 124 years). Indications for operation included infection (7 patients) and persistent unwellness (14 patients). Median duration of LTN was 170 minutes (IQR 136 to 199 minutes); there were no conversions. Control of the necrosis was achieved via the single procedure in 19 of 21 patients. Median postoperative hospital stay was 5 days (IQR 3 to 14 days) and the majority (71%) of patients experienced no (n = 9) or only minor postoperative complications (n = 6) by Clavien-Dindo grade. Complications of Clavien-Dindo grade 3 or higher developed in 6 patients, including 1 death (5%). With a median follow-up of 11 months (IQR 7 to 22 months), none of the patients required additional operative debridement or had pancreatic/enteric fistulae or wound complications develop. CONCLUSIONS Laparoscopic transgastric necrosectomy is a novel, minimally invasive technique for the management of pancreatic necrosis that allows for debridement in a single operation. When feasible, LTN can reduce the morbidity associated with traditional open necrosectomy and avoid the limitations of other minimally invasive approaches.
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Affiliation(s)
- David J Worhunsky
- Department of Surgery, Stanford University Medical Center, Stanford, CA
| | - Motaz Qadan
- Department of Surgery, Stanford University Medical Center, Stanford, CA
| | - Monica M Dua
- Department of Surgery, Stanford University Medical Center, Stanford, CA
| | - Walter G Park
- Department of Gastroenterology and Hepatology, Stanford University Medical Center, Stanford, CA
| | | | - Jeffrey A Norton
- Department of Surgery, Stanford University Medical Center, Stanford, CA
| | - Brendan C Visser
- Department of Surgery, Stanford University Medical Center, Stanford, CA.
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8
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Ince AT, Senturk H, Singh VK, Yildiz K, Danalioğlu A, Cinar A, Uysal O, Kocaman O, Baysal B, Gürakar A. A randomized controlled trial of home monitoring versus hospitalization for mild non-alcoholic acute interstitial pancreatitis: a pilot study. Pancreatology 2014; 14:174-8. [PMID: 24854612 DOI: 10.1016/j.pan.2014.02.007] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/25/2013] [Revised: 01/31/2014] [Accepted: 02/25/2014] [Indexed: 12/11/2022]
Abstract
BACKGROUND/OBJECTIVES Acute pancreatitis (AP) is a disease typically requiring in-hospital treatment. We conducted a trial to assess the feasibility of early discharge from the hospital for patients with mild non-alcoholic acute pancreatitis (NAAP). METHODS Eighty-four patients with mild NAAP were randomized to home or hospital groups after a short hospital stay (≤24 h). AP was defined by the revised Atlanta criteria. Mild AP was defined as an Imrie score≤5 and a harmless acute pancreatitis score (HAPS)≤2 in the first 24-h of presentation. A nurse visited all patients in the home group on the 2nd, 3rd and 5th days. All patients presented for follow-up in clinic on the 7th, 14th, and 30th days. The primary outcome was the time to resolution of pain. Secondary outcomes evaluated included time to resumption of an oral diet, 30 day hospital readmission rate as well as the total costs associated with either approach to care. RESULTS There was no difference between the groups with regards to demographics, prognostic severity scores, symptoms, and biliary findings. No patients developed organ failure, pancreatic necrosis, or died in either group. Time to the resolution of pain and resumption of solid food intake were similar. Three (3.6%) patients required readmission within 30 days, 1 from home and 2 from the hospital groups. The total cost was significantly less in home group ($139 ± 73 vs. $951 ± 715,p < 0.001). CONCLUSIONS Mild NAAP can be safely treated at home with regular visits by a nurse under the supervision of a physician. Widespread adoption of this practice may result in large cost savings.
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Affiliation(s)
- Ali Tüzün Ince
- Gastroenterology Clinic, Bezmialem Vakıf University School of Medicine, İstanbul, Turkey
| | - Hakan Senturk
- Gastroenterology Clinic, Bezmialem Vakıf University School of Medicine, İstanbul, Turkey.
| | - Vikesh K Singh
- Division of Gastroenterology & Hepatology, Department of Medicine, Johns Hopkins Medical Institutions, Baltimore, MD, USA
| | - Kemal Yildiz
- Gastroenterology Clinic, Bezmialem Vakıf University School of Medicine, İstanbul, Turkey
| | - Ahmet Danalioğlu
- Gastroenterology Clinic, Bezmialem Vakıf University School of Medicine, İstanbul, Turkey
| | - Ahmet Cinar
- Gastroenterology Clinic, Bezmialem Vakıf University School of Medicine, İstanbul, Turkey
| | - Omer Uysal
- Gastroenterology Clinic, Bezmialem Vakıf University School of Medicine, İstanbul, Turkey
| | - Orhan Kocaman
- Gastroenterology Clinic, Bezmialem Vakıf University School of Medicine, İstanbul, Turkey
| | - Birol Baysal
- Gastroenterology Clinic, Bezmialem Vakıf University School of Medicine, İstanbul, Turkey
| | - Ahmet Gürakar
- Division of Gastroenterology & Hepatology, Department of Medicine, Johns Hopkins Medical Institutions, Baltimore, MD, USA
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9
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Tan J, Tan H, Hu B, Ke C, Ding X, Chen F, Leng J, Dong J. Short-term outcomes from a multicenter retrospective study in China comparing laparoscopic and open surgery for the treatment of infected pancreatic necrosis. J Laparoendosc Adv Surg Tech A 2012; 22:27-33. [PMID: 22217005 DOI: 10.1089/lap.2011.0248] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/10/2023] Open
Abstract
BACKGROUND Laparoscopic surgery for confirmed infected pancreatic necrosis (IPN) represents a relatively new solution. There are no studies comparing the outcomes of laparoscopic and open surgery for patients with IPN. The aims of this study were to investigate the feasibility of laparoscopic management for patients with IPN and to compare the outcomes of laparoscopic and open surgery. METHODS Seventy-six patients with IPN who underwent open surgery (Open-group) or laparoscopic surgery (Lap-group) were retrospectively reviewed. Demographic data, white blood cell count, and APACHE II score upon admission, operative findings, major complications, and mortality were compared between the Open-group and the Lap-group. The Lap-group was further divided into two subgroups (early and late), and the operative difficulty was compared between the two subgroups. RESULTS There were no significant differences between the Open-group and the Lap-group with respect to demographic data, white blood cell count, and APACHE II score. Although the mean operative time was significantly shorter in the Open-group than in the Lap-group, the estimated blood loss was significantly greater in the Open-group than in the Lap-group, as was the rate of complications. The mean postoperative hospital stay in the Open-group was significant longer than in the Lap-group, too. In the Lap-group, the mean operating time, estimated blood loss, and conversion rate in the early subgroup were significantly lower than in the late subgroup. CONCLUSION Laparoscopic necrosectomy and the placement of an intermittent irrigation and continuous suction drainage system for IPN is feasible, effective, and of minimal invasiveness. The late laparoscopic necrosectomy is relatively difficult.
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Affiliation(s)
- JingWang Tan
- Hepatobiliary Surgery Department, Northern Jiangsu People's Hospital, YangZhou University, YangZhou, China
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10
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Wani SV, Patankar RV, Mathur SK. Minimally invasive approach to pancreatic necrosectomy. J Laparoendosc Adv Surg Tech A 2011; 21:131-6. [PMID: 21284517 DOI: 10.1089/lap.2010.0401] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022] Open
Abstract
BACKGROUND Conventional open surgery for infected pancreatic necrosis is associated with significant surgical morbidity, that is, wound complications, facial dehiscence, and intestinal fistulae. In recent years, there has been interest in attempting to reduce this surgical morbidity by adopting a number of minimally invasive approaches. METHODS Fifteen patients with pancreatic necrosis underwent pancreatic necrosectomy by minimally invasive surgery (11 men, 4 women; age group: 25-64 years, mean age: 46 years). Apache II scores ranged from 5 to 14. Pancreatic necrosectomy was performed by laparoscopic transperitoneal approach in 12 patients (transmesocolic, 4 patients; transgastrocolic, 6 patients; and gastrohepatic omentum, 2 patients), by retroperitoneal approach in 2 patients, and by a combination of methods in 1 patient (endoscopic transgastric drainage followed by laparoscopic intracavity necrosectomy). Relook laparoscopy was done in 5 patients to assess for residual necrosis. RESULTS All the patients tolerated the procedure well, and there was no mortality. Two of them had pancreatic fistula, which eventually responded to conservative treatment. Three patients were converted to open necrosectomy because of bleeding or difficulty to access the area of necrosis. The mean operating time was 120 ± 10 minutes. There were no postoperative complications related to the procedure itself, such as major wound infections, intestinal fistulae, or postoperative hemorrhage. Postoperative computed tomographic scans confirmed adequacy of debridement. The average length of hospital stay after surgery was 14 days. CONCLUSIONS Minimally invasive necrosectomy is technically feasible and a body of evidence now suggests that acceptable outcomes can be achieved. There are no comparisons of results available, either with open surgery or among different minimally invasive techniques.
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Affiliation(s)
- Sachin V Wani
- Joy Hospital Pvt. Ltd., Institute for Special Surgery, Mumbai, India
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11
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Doctor N, Philip S, Gandhi V, Hussain M, Barreto SG. Analysis of the delayed approach to the management of infected pancreatic necrosis. World J Gastroenterol 2011; 17:366-71. [PMID: 21253397 PMCID: PMC3022298 DOI: 10.3748/wjg.v17.i3.366] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/20/2010] [Revised: 09/02/2010] [Accepted: 09/09/2010] [Indexed: 02/06/2023] Open
Abstract
AIM: To analyze outcomes of delayed single-stage necrosectomy after early conservative management of patients with infected pancreatic necrosis (IPN) associated with severe acute pancreatitis (SAP).
METHODS: Between January 1998 and December 2009, data from patients with SAP who developed IPN and were managed by pancreatic necrosectomy were analyzed.
RESULTS: Fifty-nine of 61 pancreatic necrosectomies were performed by open surgery and 2 laparoscopically. In 55 patients, single-stage necrosectomy could be performed (90.2%). Patients underwent surgery at a median of 29 d (range 13-46 d) after diagnosis of acute pancreatitis. Sepsis and multiple organ failure accounted for the 9.8% mortality rate. Pancreatic fistulae (50.8%) predominantly accounted for the morbidity. The median hospital stay was 23 d, and the median interval for return to regular activities was 110 d.
CONCLUSION: This series supports the concept of delayed single-stage open pancreatic necrosectomy for IPN. Advances in critical care, antibiotics and interventional radiology have played complementary role in improving the outcomes.
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12
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Szentkereszty Z, Kotán R, Damjanovich L, Sápy P. Surgical treatment of acute pancreatitis today. Orv Hetil 2010; 151:1697-701. [DOI: 10.1556/oh.2010.28956] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Abstract
Az enyhe akut pancreatitis kezelése alapvetően konzervatív, míg súlyos esetekben a sebészi kezelésnek jelentős szerepe van.
Módszer:
A szerzők az utóbbi 10 évben megjelent, a műtét kérdéseit taglaló közlemények alapján elemzik a sebészi kezelés indikációit, időzítését és a műtét technikai kérdéseit.
Eredmények/következtetések:
A steril pancreasnecrosis csak ritkán, a szeptikus necrosis azonban műtéti indikációt képez, ha a konzervatív kezelés eredménytelen. A terápiarezisztens sokszervi elégtelenség, a súlyos hasi kompartmentszindróma és egyéb sebészi szövődmény, mint a vérzés, perforáció is műtéti beavatkozást tesz szükségessé. Pancreatitist okozó epekövesség talaján kialakult cholestasis esetén sürgős endoszkópos sphincterotomia és később cholecystectomia javasolt. Pancreasnecrosis esetén a műtét ideális időpontja a betegség kezdetétől számított 21. nap utánra tehető, mivel a „korai” műtétek szövődmény- és halálozási aránya magas. Fontos a gondos necrectomia, amelynek a retrocolicus és retroduodenalis terekre is ki kell terjednie. A nyitott has kezelésének több a szövődménye, ezért csak válogatott esetekben javasolják. A műtétet posztoperatív bursa omentalis lavage-zsal érdemes kiegészíteni. Orv. Hetil., 2010,
41,
1697–1701.
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Affiliation(s)
- Zsolt Szentkereszty
- 1 Debreceni Egyetem, Orvos- és Egészségtudományi Centrum, Általános Orvostudományi Kar Sebészeti Intézet Debrecen Móricz Zs. krt. 22. 4032
| | - Róbert Kotán
- 1 Debreceni Egyetem, Orvos- és Egészségtudományi Centrum, Általános Orvostudományi Kar Sebészeti Intézet Debrecen Móricz Zs. krt. 22. 4032
| | - László Damjanovich
- 1 Debreceni Egyetem, Orvos- és Egészségtudományi Centrum, Általános Orvostudományi Kar Sebészeti Intézet Debrecen Móricz Zs. krt. 22. 4032
| | - Péter Sápy
- 1 Debreceni Egyetem, Orvos- és Egészségtudományi Centrum, Általános Orvostudományi Kar Sebészeti Intézet Debrecen Móricz Zs. krt. 22. 4032
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Cheung MT, Li WH, Kwok PCH, Hong JKF. Surgical management of pancreatic necrosis: towards lesser and later. JOURNAL OF HEPATO-BILIARY-PANCREATIC SCIENCES 2010; 17:338-44. [PMID: 20464564 DOI: 10.1007/s00534-009-0251-y] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/03/2009] [Accepted: 11/24/2009] [Indexed: 01/03/2023]
Abstract
BACKGROUND/PURPOSE Our aim was to determine the overall success rate and survival rate with respect to the timing of intervention in the management of pancreatic necrosis. The use of minimally invasive pancreatic necrosectomy was also examined. METHODS This was a retrospective study carried out in a tertiary referral hospital. The subjects were all patients who suffered from acute pancreatic necrosis with emergency interventions from January 2001 to December 2007. For outcome measures, special emphasis was placed on the overall success rate and survival rate with respect to the timing of intervention. The success rate of percutaneous pancreatic necrosectomy (PCPN) was examined. RESULTS A total of 26 patients with pancreatic necrosis were studied. The overall mortality rate was 26.9% and the rate was significantly higher in those patients who had earlier intervention (before 6 weeks). Eleven patients had PCPN. There were 2 failures due to PCPN in the early phase; 2 had partial success, while the procedure was completely successful to remove all the necrotic tissues in the other 7 patients. CONCLUSIONS With a multidisciplinary approach, particularly with sophisticated intensive care, most patients with pancreatic necrosis can survive the initial phase. Open surgery should be limited to simple drainage and laparostomy to relieve the abdominal tension. Active intervention preferably should be delayed until the necrosis has become walled off, when a variety of minimally invasive maneuvers, notably percutaneous necrosectomy, can be offered to remove the debris. The surgical management of pancreatic necrosis should change towards a strategy of "lesser and later".
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Affiliation(s)
- Moon-Tong Cheung
- Department of Surgery, Block H10, Queen Elizabeth Hospital, 33, Gascoigne Road, Kowloon, Hong Kong.
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Abstract
Traditional open surgical necrosectomy for treatment of infected pancreatic necrosis is associated with high morbidity and mortality, leading to a shift toward minimally invasive endoscopic, radiologic, and laparoscopic approaches. Percutaneous drainage is useful as a temporizing method to control sepsis and as an adjunctive treatment to surgical intervention. It is limited because of the requirement for frequent catheter care and the need for repeated procedures. Endoscopic transgastric or transduodenal therapies with endoscopic debridement/necrosectomy have recently been described and are highly successful in carefully selected patients. It avoids the need for open necrosectomy and can be used in poor operative candidates. Laparoscopic necrosectomy is also promising for treatment of pancreatic necrosis. However, the need for inducing a pneumoperitoneum and the potential risk of infection limit its usefulness in patients with critical illness. Retroperitoneal access with a nephroscope is used to directly approach the necrosis with complete removal of a sequestrum. Retroperitoneal drainage using the delay-until-liquefaction strategy also appears to be successful to treat pancreatic necrosis. The anatomic location of the necrosis, clinical comorbidities, and operator experience determine the best approach for a particular patient. Tertiary care centers with sufficient expertise are increasingly using minimally invasive procedures to manage pancreatic necrosis.
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Voermans RP, Fockens P. Endoscopic treatment of pancreatic fluid collections in 2008 and beyond. Gastrointest Endosc 2009; 69:S186-91. [PMID: 19179154 DOI: 10.1016/j.gie.2008.12.025] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
Affiliation(s)
- Rogier P Voermans
- Department of Gastroenterology and Hepatology, Academic Medical Center, University of Amsterdam, Amsterdam, The Netherlands
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Rocha FG, Balakrishnan A, Ashley SW, Clancy TE. A historic perspective on the contributions of surgeons to the understanding of acute pancreatitis. Am J Surg 2008; 196:442-9. [DOI: 10.1016/j.amjsurg.2008.01.028] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/06/2007] [Revised: 01/16/2008] [Accepted: 01/16/2008] [Indexed: 01/05/2023]
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Debridement and closed packing for sterile or infected necrotizing pancreatitis: insights into indications and outcomes in 167 patients. Ann Surg 2008; 247:294-9. [PMID: 18216536 DOI: 10.1097/sla.0b013e31815b6976] [Citation(s) in RCA: 250] [Impact Index Per Article: 15.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
OBJECTIVE To examine the surgical indications and clinical outcomes of a large cohort of patients with necrotizing pancreatitis. SUMMARY BACKGROUND DATA Mortality after debridement for necrotizing pancreatitis continues to be inordinately high. The clinical experience with patients who underwent uniform surgical treatment for necrotizing pancreatitis at the Massachusetts General Hospital over a 15-year period is described. METHODS Retrospective review of 167 patients with necrotizing pancreatitis who required intervention and were treated with single stage debridement and a closed packing technique. Particular emphasis was placed on the indication for surgery and the presence of infected necrosis. Multiple logistic regression models were used to identify predictors of mortality. RESULTS The primary preoperative indication for operation was infected necrosis (51%), but intraoperative cultures proved that 72% of the entire cohort was infected. The rate of reoperation was 12.6%, and 29.9% of patients required percutaneous interventional radiology drainage after initial debridement. Overall operative mortality was 11.4% (19/167), but higher in patients who were operated upon before 28 days (20.3% vs. 5.1%, P = 0.002). Other important predictors of mortality included organ failure > or =3 (OR = 2.4, P = 0.001), postoperative intensive care unit stay > or =6 days (OR = 15.9, P = 0.001), and female gender (OR = 5.41, P = 0.02). CONCLUSIONS Open, transperitoneal debridement followed by closed packing and drainage results in the lowest reported mortality and reoperation rates, and provides a standard for comparing other methods of treatment. A negative FNA does not reliably rule out infection. The clinical status of the patients and not proof of infection should determine the need for debridement.
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Voermans RP, Bruno MJ, van Berge Henegouwen MI, Fockens P. Review article: Translumenal endoscopic debridement of organized pancreatic necrosis--the first step towards natural orifice translumenal endoscopic surgery. Aliment Pharmacol Ther 2007; 26 Suppl 2:233-9. [PMID: 18081666 DOI: 10.1111/j.1365-2036.2007.03489.x] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/23/2022]
Abstract
BACKGROUND Over the last decades, gastrointestinal endoscopy has transformed from serving purely diagnostic purposes to therapeutic applications. One recent major progress is taking the endoscope beyond the gastrointestinal lumen into the peritoneal cavity for diagnostic and therapeutic procedures. The first step towards Natural Orifice Translumenal Endoscopic Surgery (NOTES) was translumenal endoscopic debridement of pancreatic necrosis. AIM To overview current status of endoscopic debridement of organized pancreatic necrosis. Finally, we take a short look into the potential future of translumenal endoscopic procedures. METHODS Medical databases were searched for relevant publications, dealing with endoscopic debridement of pancreatic necrosis and NOTES. RESULTS All current published studies concerning endoscopic debridement of organized pancreatic necrosis were retrospectively performed and relatively small (largest n = 25). Success rates varies from 80-93% and complication rates from 7-20%. There was no procedure related mortality reported. Published NOTES experiments showed feasibility of a variety of transgastric, transcolonic and transvaginal procedures in the porcine model. CONCLUSION Endoscopic debridement seems to be an effective and relatively safe minimally invasive therapy in patients with symptomatic organized pancreatic necrosis and is the first step towards NOTES. Further comparative studies need to define its definitive role in the management of these patients.
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Affiliation(s)
- R P Voermans
- Department of Gastroenterology and Hepatology, Academic Medical Center, University of Amsterdam, Amsterdam, The Netherlands
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Voermans RP, Veldkamp MC, Rauws EA, Bruno MJ, Fockens P. Endoscopic transmural debridement of symptomatic organized pancreatic necrosis (with videos). Gastrointest Endosc 2007; 66:909-16. [PMID: 17963877 DOI: 10.1016/j.gie.2007.05.043] [Citation(s) in RCA: 114] [Impact Index Per Article: 6.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/11/2006] [Accepted: 05/14/2007] [Indexed: 02/07/2023]
Abstract
BACKGROUND Surgical management of pancreatic necrosis is associated with significant morbidity and mortality. Several weeks after an episode of a necrotizing pancreatitis, necrosis can become organized. By the time necrosis becomes organized, endoscopic therapy has the potential to offer an alternative treatment to surgery. OBJECTIVE To evaluate the safety and efficacy of endoscopic debridement of organized pancreatic necrosis and to identify procedural aspects that may improve outcome. DESIGN Retrospective cohort study. SETTING Tertiary referral center. PATIENTS All consecutive patients who underwent this novel endoscopic approach were included. INTERVENTIONS Treatment started with a cystoenterostomy or a cystogastrostomy. The next steps consisted of balloon dilation, up to 18 mm; advancement of an endoscope into the retroperitoneal cavity; and endoscopic debridement of the collection under direct endoscopic vision. Debridement was repeated every 2 days until most necrotic material was evacuated. In addition, nasocystic catheter irrigation was performed manually with saline solution 6 to 8 times a day. MAIN OUTCOME MEASUREMENTS Clinical success, number of endoscopic procedures, and complications. RESULTS Twenty-five patients were identified, who had undergone debridement of 27 collections. In 11, 13, 2, and 1 collections, 1, 2, 3, and 4 endoscopic debridement procedures, respectively, were performed. There was no mortality. Severe complications that required surgery occurred in 2 patients: hemorrhage in 1 case and perforation of cyst wall in the other. During a median follow-up of 16 months (range 3-38 months), the overall clinical success rate with resolution of the collection and related symptoms was 93%. LIMITATIONS Retrospective study. CONCLUSIONS In this study, we showed that endoscopic debridement is an effective and relatively safe minimally invasive therapy in patients with symptomatic organized pancreatic necrosis. Further comparative studies are warranted to define its definitive role in the management of these patients.
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Affiliation(s)
- Rogier P Voermans
- Department of Gastroentorology and Hepatology, Academic Medical Center, University of Amsterdam, Amsterdam, The Netherlands
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Isenmann R, Henne-Bruns D. Prevention of infectious complications in severe acute pancreatitis with systemic antibiotics: where are we now? Expert Rev Anti Infect Ther 2007; 3:393-401. [PMID: 15954856 DOI: 10.1586/14787210.3.3.393] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/15/2023]
Abstract
Infectious complications are the leading cause of death in patients with severe acute pancreatitis. Currently, there is controversy concerning the therapeutic possibilities to reduce the incidence of bacterial infection in this disease. Numerous studies are available which apparently support the prophylactic use of antibiotics in patients with necrotizing pancreatitis. The results, however, are contradicting and interpretation is difficult as these studies have used various antibiotic drugs with different application schemes and heterogeneous study end points. This article gives a critical overview of the background of antibiotic treatment in severe acute pancreatitis, the published data on antibiotic treatment and an outlook on the topics that need to be addressed by future research.
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Affiliation(s)
- Rainer Isenmann
- Department of Abdominal and Transplantation Surgery, University of Ulm, Steinhoevelstrasse 9, 89075 Ulm, Germany.
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Muller CA, Vogeser M, Belyaev O, Gloor B, Strobel O, Weyhe D, Werner J, Borgstrom A, Buchler MW, Uhl W. Role of endogenous glucocorticoid metabolism in human acute pancreatitis*. Crit Care Med 2006; 34:1060-6. [PMID: 16484908 DOI: 10.1097/01.ccm.0000206285.69499.72] [Citation(s) in RCA: 29] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVE This study aimed to observe how levels of total cortisol, calculated free cortisol, corticosteroid-binding globulin, and adrenocorticotropic hormone change during the early course of human acute pancreatitis and to describe how these changes affect the development of pancreatic necrosis. DESIGN AND PATIENTS In a total of 109 consecutive patients with acute pancreatitis (74 with edematous pancreatitis, 35 with necrotizing pancreatitis), serial daily blood monitoring of total and free cortisol, adrenocorticotropic hormone, and corticosteroid-binding globulin was done after hospital admission, up to day 6 after the onset of pain; 30 healthy individuals served as controls. MEASUREMENTS Corticosteroid-binding globulin and total cortisol were measured by immunoassays, and free cortisol was calculated according to Coolens et al. The adrenocorticotropic hormone was measured with an enzyme-linked immunoassay. RESULTS Initially, highly elevated levels of calculated free cortisol (median, 86.2 ng/mL; quartile ranges, 50.6-106.7 ng/mL) and total cortisol (41.2 microg/dL, 30.4-51.1 microg/dL) and depressed levels of adrenocorticotropic hormone (0.2 pg/mL, 0.1-2.0 pg/mL) and corticosteroid-binding globulin (30.6 microg/mL, 24.1-35.5 microg/mL) were observed. Further, daily measurements revealed increasing adrenocorticotropic hormone levels, whereas cortisol levels decreased. CONCLUSIONS Although an increase in adrenocorticotropic hormone levels is suggested to increase corresponding cortisol levels, cortisol levels decreased during the development of necrotizing acute pancreatitis. This phenomenon, along with the continuously decreasing corticosteroid-binding globulin levels, brings up the hypothesis of a relative adrenal insufficiency, which favors acinar cell apoptosis and hence may trigger the development of necrosis in the initial vulnerable phase of acute pancreatitis.
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Affiliation(s)
- Christophe A Muller
- Department of General Surgery, St. Josef Hospital, Ruhr University, Bochum, Germany
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Cheung MT, Ho CNS, Siu KW, Kwok PCH. PERCUTANEOUS DRAINAGE AND NECROSECTOMY IN THE MANAGEMENT OF PANCREATIC NECROSIS. ANZ J Surg 2005; 75:204-7. [PMID: 15839965 DOI: 10.1111/j.1445-2197.2005.03366.x] [Citation(s) in RCA: 53] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/26/2022]
Abstract
BACKGROUND The degree of necrosis and presence of infection are the crucial determinants of the outcome in patients with pancreatic necrosis. In patients with sterile necrosis, the necrotic material can persist and subsequently results in sepsis. Some of these patients will ultimately require an operation to remove the necrotic material. Percutaneous necrosectomy has been introduced to remove this residual debris in a minimally invasive way. METHODS We retrospectively reviewed all patients with pancreatic necrosis who had percutaneous drainage (PCD) performed. Percutaneous pancreatic necrosectomy (PCPN) was done for those patients whose necrotic cavity failed to resolve. RESULTS Percutaneous drainage was performed in eight patients, four with evidence of infection by the positive culture in the aspirate. In three of them, the necrotic cavity completely resolved after drainage. Percutaneous necrosectomy was performed in another three patients through the tract placed by the radiologist and another one through a sinus tract after an operation. The necrotic cavity in three of them completely resolved after percutaneous necrosectomy. CONCLUSION Those patients who had 'organized necrosis' after the acute episode of pancreatitis could receive benefit from percutaneous necrosectomy. The persistent symptoms could be alleviated after the removal of the residual necrotic material. It could also be useful after an open surgery to remove any residual devitalized tissue.
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Affiliation(s)
- Thomas E Clancy
- Department of Surgery, Brigham and Women's Hospital/Harvard Medical School, Boston, Massachusetts 02115, USA
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Affiliation(s)
- John Baillie
- Department of Medicine, Division of Gastroenterology, Duke University Medical Center, Durham, North Carolina 27710, USA
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25
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Affiliation(s)
- John Baillie
- Division of Gastroenterology, Duke University Medical Center, Durham, North Carolina 27710, USA
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Kusnierz-Cabala B, Kedra B, Sierzega M. Current concepts on diagnosis and treatment of acute pancreatitis. Adv Clin Chem 2003; 37:47-81. [PMID: 12619705 DOI: 10.1016/s0065-2423(03)37006-4] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/22/2022]
Affiliation(s)
- B Kusnierz-Cabala
- Department of Clinical Biochemistry, Collegium, Medicum Jagiellonian University, Krakow, Poland
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27
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Leppäniemi A. Necrosectomy for Severe Acute Pancreatitis. Intensive Care Med 2003. [DOI: 10.1007/978-1-4757-5548-0_77] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
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Baron TH, Harewood GC, Morgan DE, Yates MR. Outcome differences after endoscopic drainage of pancreatic necrosis, acute pancreatic pseudocysts, and chronic pancreatic pseudocysts. Gastrointest Endosc 2002; 56:7-17. [PMID: 12085029 DOI: 10.1067/mge.2002.125106] [Citation(s) in RCA: 383] [Impact Index Per Article: 17.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
BACKGROUND Comparative outcomes after endoscopic drainage of specific types of symptomatic pancreatic fluid collections, defined by using standardized nomenclature, have not been described. This study sought to determine outcome differences after attempted endoscopic drainage of pancreatic fluid collections classified as pancreatic necrosis, acute pseudocyst, and chronic pseudocyst. METHODS Outcomes were retrospectively analyzed for consecutive patients with symptoms caused by pancreatic fluid collections referred for endoscopic transmural and/or transpapillary drainage. RESULTS Complete endoscopic resolution was achieved in 113 of 138 patients (82%). Resolution was significantly more frequent in patients with chronic pseudocysts (59/64, 92%) than acute pseudocysts (23/31, 74%, p = 0.02) or necrosis (31/43, 72%, p = 0.006). Complications were more common in patients with necrosis (16/43, 37%) than chronic (11/64, 17%, p = 0.02) or acute pseudocysts (6/31, 19%, p = NS). At a median follow-up of 2.1 years after successful endoscopic treatment (resolution), pancreatic fluid collections had recurred in 18 of 113 patients (16%). Recurrences developed more commonly in patients with necrosis (9/31, 29%) than acute pseudocysts (2/23, 9%, p = 0.07) or chronic pseudocysts (7/59, 12%, p = 0.047). CONCLUSIONS Successful resolution of pancreatic fluid collections may be achieved endoscopically by an experienced therapeutic endoscopist. Outcomes differ depending on the type of pancreatic fluid collection drained. Further studies of endoscopic drainage of pancreatic fluid collections must use defined terminology to allow meaningful comparisons.
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Affiliation(s)
- Todd H Baron
- Department of Medicine, Division of Gastroenterology, Mayo Medical Center, Rochester, Minnesota 55905, USA
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29
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Affiliation(s)
- Eduardo B V da Silveira
- Division of Gastroenterology, University of Miami, School of Medicine/Mt Sinai Medical Center, Florida, USA
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Hungness ES, Robb BW, Seeskin C, Hasselgren PO, Luchette FA. Early debridement for necrotizing pancreatitis: is it worthwhile? J Am Coll Surg 2002; 194:740-4; discussion 744-5. [PMID: 12081064 DOI: 10.1016/s1072-7515(02)01182-1] [Citation(s) in RCA: 38] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
BACKGROUND The timing for debridement of necrotizing pancreatitis is controversial. We reviewed our experience with early and delayed surgical debridement in patients with necrotizing pancreatitis. STUDY DESIGN The records of patients diagnosed with acute necrotizing pancreatitis from January 1993 through June 2000 were reviewed retrospectively. Data were analyzed with respect to Ranson's, APACHE II, and multiple organ failure scores, etiology, presence of infection, overall and ICU length of stay, time to first debridement, number of debridements, fluid requirements, days to enteral feeding, transfusion requirements, complications, and mortality. RESULTS Twenty-six patients (18 males, 8 females, mean age 51 years) were diagnosed with acute necrotizing pancreatitis. The admission Ranson's score was 4.8, the APACHE II score was 11.7, and multiple organ failure score was 4.2. All but one patient underwent pancreatic debridement (4.3 debridements per patient). Eighteen patients (69%) had infected pancreatic necrosis. The timing of debridement was based on patients' condition and surgeon's preference. The presentation and demographics of patients who underwent early (<2 weeks) or late (>2 weeks) debridement did not differ significantly. Patients debrided early had a trend toward higher mortality (29% versus 18%) and experienced a higher number of major complications (p < 0.05). The six patients (23%) who died were older, had multiple organ failure scores, and more often had Candida in the infected necrosis (p < .05). CONCLUSIONS Early debridement for acute necrotizing pancreatitis might not improve survival and might even be associated with increased number of complications. Most patients diagnosed with necrotizing pancreatitis eventually need debridement, but it might be beneficial to delay debridement if the patient's condition allows for it.
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Affiliation(s)
- Eric S Hungness
- Department of Surgery, University of Cincinnati Medical Center, OH, USA
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Abstract
The current clinical management of surgical patients with sepsis is governed by two principles: control of the source of infection and supportive management of the patient until recovery. Recently, there has been renewed interest in the concept of source control-in particular, its importance for evaluating and comparing clinical trials. This brief review highlights some of the developments in the surgical literature. Important recent publications center on source control, the management of systemic inflammatory response syndrome, necrotizing pancreatitis, acute diverticulitis, gastrointestinal fistulas, and the role of laparoscopy in surgical infections. Novel interventions in supportive care are being developed, and their clinical applicability and effectiveness will be improved with increased understanding of the pathophysiology of systemic inflammation.
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Affiliation(s)
- D Danielson
- Department of Surgery, Hennepin County Medical Center, Minneapolis, Minnesota, USA
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Ashley SW, Perez A, Pierce EA, Brooks DC, Moore FD, Whang EE, Banks PA, Zinner MJ. Necrotizing pancreatitis: contemporary analysis of 99 consecutive cases. Ann Surg 2001; 234:572-9; discussion 579-80. [PMID: 11573050 PMCID: PMC1422080 DOI: 10.1097/00000658-200110000-00016] [Citation(s) in RCA: 174] [Impact Index Per Article: 7.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Abstract
OBJECTIVE To analyze the impact of a conservative strategy of management in patients with necrotizing pancreatitis, reserving intervention for patients with documented infection or the late complications of organized necrosis. SUMMARY BACKGROUND DATA The role of surgery in patients with sterile pancreatic necrosis remains controversial. Although a conservative approach is being increasingly used, few studies have evaluated this strategy when applied to the entire spectrum of patients with necrotizing pancreatitis. METHODS The authors reviewed 1,110 consecutive patients with acute pancreatitis managed at Brigham and Women's Hospital between January 1, 1995, and January 1, 2000, focusing on those with pancreatic necrosis documented by contrast-enhanced computed tomography. Fine-needle aspiration, the presence of extraintestinal gas on computed tomography, or both were used to identify infection. RESULTS There were 99 (9%) patients with necrotizing pancreatitis treated, with an overall death rate of 14%. In three patients with underlying medical problems, the decision was made initially not to intervene. Of the other 62 patients without documented infection, all but 3 were managed conservatively; this group's death rate was 11%. Of these seven deaths, all were related to multiorgan failure. Five patients in this group eventually required surgery for organized necrosis, with no deaths. Of the 34 patients with infected necrosis, 31 underwent surgery and 3 underwent percutaneous drainage. Only four (12%) of these patients died, all of multiorgan failure. Of the total 11 patients who died, few if any would have been candidates for earlier surgical intervention. CONCLUSIONS These results suggest that conservative strategies can be applied successfully to manage most patients with necrotizing pancreatitis, although some will eventually require surgery for symptomatic organized necrosis. Few if any patients seem likely to benefit from a more aggressive strategy.
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Affiliation(s)
- S W Ashley
- Department of Surgery, Brigham and Women's Hospital/Harvard Medical School, 75 Francis St., Boston, MA 02115, USA.
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