1
|
de Jong DM, Stassen PMC, Schoots IG, Verdonk RC, Bruno MJ, Voermans RP, de Jonge PJF. Impact of long-term transmural plastic stents on recurrence after endoscopic treatment of walled-off pancreatic necrosis. Endoscopy 2024. [PMID: 38626890 DOI: 10.1055/a-2307-7123] [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] [Indexed: 05/31/2024]
Abstract
BACKGROUND Endoscopic transmural drainage (ETD) using double-pigtail stents (DPSs) is a well-established treatment for walled-off pancreatic necrosis (WON). This study aimed to compare outcomes in patients undergoing ETD with DPSs left indwelling versus those where stents were removed or migrated. METHODS This retrospective multicenter cohort study included patients with WON who underwent ETD using DPSs between July 2001 and December 2019. The primary outcome was recurrence of a pancreatic fluid collection (PFC). Secondary outcomes were long-term complications and recurrence-associated factors. Competing risk regression analysis considered DPS removal or migration as time-varying covariates. RESULTS Among 320 patients (median age 58; 36% women), DPSs were removed in 153 (47.8%), migrated spontaneously in 27 (8.4%), and remained indwelling in 140 (43.8%). PFC recurrence was observed in 57 patients (17.8%): after removal (n = 39; 25.5%); after migration (n = 4; 14.8%); in patients with indwelling DPSs (n = 14; 10.0%). In 25 patients (7.8%), drainage of recurrent PFC was indicated. Risk factors for recurrence were DPS removal or migration (hazard ratio [HR] 3.45, 95%CI 1.37-8.70) and presence of a disconnected pancreatic duct (HR 5.08, 95%CI 1.84-14.0). CONCLUSIONS Among patients who undergo ETD of WON, leaving DPSs in situ seems to lower the risk of recurrent fluid collections, without any long-term DPS-related complications. These results suggest that DPSs should not be routinely removed and can be safely left indwelling indefinitely.
Collapse
Affiliation(s)
- David M de Jong
- Gastroenterology and Hepatology, Erasmus MC University Medical Center, Rotterdam, Netherlands
| | - Pauline M C Stassen
- Gastroenterology and Hepatology, Erasmus MC University Medical Center, Rotterdam, Netherlands
| | - Ivo G Schoots
- Radiology, Erasmus MC University Medical Center, Rotterdam, Netherlands
| | - Robert C Verdonk
- Gastroenterology and Hepatology, St. Antonius Hospital, Nieuwegein, Netherlands
| | - Marco J Bruno
- Gastroenterology and Hepatology, Erasmus MC University Medical Center, Rotterdam, Netherlands
| | - Rogier P Voermans
- Gastroenterology and Hepatology, Amsterdam University Medical Center, Amsterdam, Netherlands
| | - Pieter Jan F de Jonge
- Gastroenterology and Hepatology, Erasmus MC University Medical Center, Rotterdam, Netherlands
| |
Collapse
|
2
|
Ebrahim M, Werge MP, Novovic S, Amin NEL, Karstensen JG, Jørgensen HL. Prediction of Admission to Intensive Care Unit and 1-Year Mortality After Acute Pancreatitis With Walled-Off Pancreatic Necrosis: A Retrospective, Single-Center Cohort Study. Pancreas 2024; 53:e386-e394. [PMID: 38416852 DOI: 10.1097/mpa.0000000000002314] [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: 03/01/2024]
Abstract
BACKGROUND AND AIMS Pancreatic walled-off necrosis (WON) carries significant mortality and morbidity risks, often necessitating intensive care unit (ICU) admission. This retrospective study aimed to evaluate whether routine biochemical parameters at the time of the index endoscopic procedure could predict ICU admission and 1-year mortality following endoscopic treatment of WON. MATERIALS AND METHODS We retrospectively identified 201 consecutive patients who underwent endoscopic drainage for WON between January 1, 2010, and December 31, 2020. Associations between routine biochemical blood tests and outcomes were assessed using logistic regression models. RESULTS Within 1 year of the index endoscopy, 31 patients (15.4%) died, and 40 (19.9%) were admitted to the ICU due to sepsis. Preoperative electrolyte disturbances were more prevalent among ICU-admitted patients and nonsurvivors. Hyperkalemia, hypoalbuminemia, and elevated urea were significant predictors of 1-year mortality, while hypernatremia, elevated serum creatinine, and hypoalbuminemia predicted ICU admission. Predictive models exhibited good discriminative ability, with an AUC of 0.84 (95% CI,0,75-0.93) for 1-year mortality and 0.86 (95%CI, 0.79-0.92) for ICU admission. CONCLUSIONS Preoperative imbalances in routine blood tests effectively predict adverse outcomes in endoscopically treated WON patients.
Collapse
Affiliation(s)
- Mohamed Ebrahim
- From the Pancreatitis Centre East, Gastrounit, Copenhagen University Hospital-Amager and Hvidovre, Hvidovre, Denmark
| | - Mikkel Parsberg Werge
- From the Pancreatitis Centre East, Gastrounit, Copenhagen University Hospital-Amager and Hvidovre, Hvidovre, Denmark
| | | | - Nadia Emad Lotfi Amin
- From the Pancreatitis Centre East, Gastrounit, Copenhagen University Hospital-Amager and Hvidovre, Hvidovre, Denmark
| | | | | |
Collapse
|
3
|
Jaeger K, Meyer F, Füldner F, Will U. Endoscopic necrosectomy of infected WON in acute necrotising pancreatitis - Development of an effective therapeutic algorithm based on a single-center consecutive patient cohort. ZEITSCHRIFT FUR GASTROENTEROLOGIE 2023; 61:665-675. [PMID: 36126931 DOI: 10.1055/a-1890-5674] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/09/2023]
Abstract
OBJECTIVE Development of an effective therapeutic algorithm for interventional (minimally invasive) approach to infected walled-off necrosis (WON) in patients with necrotising pancreatitis reflecting real-word data. MATERIAL/METHODS All consecutive patients who underwent endoscopic necrosectomy for necrotising pancreatitis through a defined study period were enclosed in this retrospective observational case study. The therapeutic approach was analysed for clinical success rate, complication spectrum and rate as well as mortality and compared with data from the literature. Finally, a therapeutic algorithm was derived. RESULTS From 2004 to 2019, 126 patients with necrotising pancreatitis (median of APACHE II score, 10.5 points) were treated. In 92.9 % of cases (n=117), an infected WON with microbial pathogen detection was found. After a median of 18 days from symptom onset, first intervention was performed (53.2 % as percutaneous drainage with programmed rinsing, 29.4 % as EUS-guided internal drainage). From 2004 to 2010, double pigtail stents were used. Later, lumen-apposing metal stent (LAMS) such as AXIOSTM stent (Boston Scientific, Ratingen, Germany) was preferred. The combined percutaneous and internal drainage was performed in approximately 50 % of subjects.Endoscopic transluminal necrosectomy was performed in 123 patients (97.6 %) at a median of 33 days from symptom onset. Endoscopic percutaneous necrosectomy was conducted in 11.1 % of the individuals. A median number of two endoscopic necrosectomy sessions per patient was necessary for the therapy. The clinical success rate (discharge without surgical intervention) was 82.5 %. The complication rate (bleeding and perforation) and the need for surgery were both 9.5 %. The overall mortality was 8.7 %. CONCLUSION Therapy of necrotising pancreatitis with infected WON consists of early calculated antibiotic therapy with adequate drainage. Combined external and internal drainages with programmed rinsing seem to improve prognosis, as well as minimise I) : the need for forced necrosectomies (mainly via a transluminal access site) and II) : complication rate as well as, thus, improve outcome.
Collapse
Affiliation(s)
- Kristin Jaeger
- Dept. of Internal Medicine III (Gastroenterology, Hepatology, General Internal Medicine), Municipal Hospital ("SRH Wald-Klinikum Gera GmbH"), Gera, Germany
| | - Frank Meyer
- Dept. of General, Abdominal, Vascular and Transplant Surgery, Otto-von-Guericke University with University Hospital, Magdeburg, Germany
| | - Frank Füldner
- Dept. of Internal Medicine III (Gastroenterology, Hepatology, General Internal Medicine), Municipal Hospital ("SRH Wald-Klinikum Gera GmbH"), Gera, Germany
| | - Uwe Will
- Dept. of Internal Medicine III (Gastroenterology, Hepatology, General Internal Medicine), Municipal Hospital ("SRH Wald-Klinikum Gera GmbH"), Gera, Germany
| |
Collapse
|
4
|
Dayyeh BKA, Chandrasekhara V, Shah RJ, Easler JJ, Storm AC, Topazian M, Levy MJ, Martin JA, Petersen BT, Takahashi N, Edmundowicz S, Hammad H, Wagh MS, Wani S, DeWitt J, Bick B, Gromski M, Al Haddad M, Sherman S, Merchant AA, Peetermans JA, Gjata O, McMullen E, Willingham FF. Combined Drainage and Protocolized Necrosectomy Through a Coaxial Lumen-apposing Metal Stent for Pancreatic Walled-off Necrosis: A Prospective Multicenter Trial. Ann Surg 2023; 277:e1072-e1080. [PMID: 35129503 DOI: 10.1097/sla.0000000000005274] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
OBJECTIVE We evaluated a protocolized endoscopic necrosectomy approach with a lumen-apposing metal stent (LAMS) in patients with large symptomatic walled-off pancreatic necrosis (WON) comprising significant necrotic content, with or without infection. SUMMARY BACKGROUND DATA Randomized trials have shown similar efficacy of endoscopic treatment compared with surgery for infected WON. DESIGN We conducted a regulatory, prospective, multicenter single-arm clinical trial examining the efficacy and safety of endoscopic ultrasound -guided LAMS with protocolized necrosectomy to treat symptomatic WON ≥6 cm in diameter with >30% solid necrosis. After LAMS placement, protocolized WON assessment was conducted and endoscopic necrosectomy was performed for insufficient WON size reduction and persistent symptoms. Patients with radiographic WON resolution to ≤ 3 cm and/or 60-day LAMS indwell had LAMS removal, then 6-month follow-up. Primary endpoints were probability of radiographic resolution by 60 days and procedure-related serious adverse events. RESULTS Forty consecutive patients were enrolled September 2018 to March 2020, of whom 27 (67.5%) were inpatients and 19 (47.5%) had clinical evidence of infection at their index procedure. Mean WON size was 15.0 ± 5.6 cm with mean 53.2% ± 16.7% solid necrosis. Radiographic WON resolution was seen in 97.5% (95% CI, 86.8%, 99.9%) by 60 days, without recurrence in 34 patients with 6-month follow-up data. Mean time to radiographic WON resolution was 34.1 ± 16.8 days. Serious adverse events occurred in 3 patients (7.5%), including sepsis, vancomycin-resistant enterococcal bacteremia and shock, and upper gastrointestinal bleeding. There were no procedure-related deaths. CONCLUSIONS Endoscopic ultrasound-guided drainage with protocolized endoscopic necrosectomy to treat large symptomatic or infected walled-off necrotic pancreatic collections was highly effective and safe. Clinicaltrials.-gov no: NCT03525808.
Collapse
Affiliation(s)
| | | | - Raj J Shah
- Division of Gastroenterology and Hepatology, University of colorado Anschutz Medical Campus, Aurora, CO
| | - Jeffrey J Easler
- Division of Gastroenterology and Hepatology, indiana University School of Medicine, indianapolis, IN
| | - Andrew C Storm
- Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, MN
| | - Mark Topazian
- Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, MN
| | - Michael J Levy
- Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, MN
| | - John A Martin
- Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, MN
| | - Bret T Petersen
- Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, MN
| | - Naoki Takahashi
- Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, MN
| | - Steven Edmundowicz
- Division of Gastroenterology and Hepatology, University of colorado Anschutz Medical Campus, Aurora, CO
| | - Hazem Hammad
- Division of Gastroenterology and Hepatology, University of colorado Anschutz Medical Campus, Aurora, CO
| | - Mihir S Wagh
- Division of Gastroenterology and Hepatology, University of colorado Anschutz Medical Campus, Aurora, CO
| | - Sachin Wani
- Division of Gastroenterology and Hepatology, University of colorado Anschutz Medical Campus, Aurora, CO
| | - John DeWitt
- Division of Gastroenterology and Hepatology, University of colorado Anschutz Medical Campus, Aurora, CO
| | - Benjamin Bick
- Division of Gastroenterology and Hepatology, University of colorado Anschutz Medical Campus, Aurora, CO
| | - Mark Gromski
- Division of Gastroenterology and Hepatology, indiana University School of Medicine, indianapolis, IN
| | - Mohammad Al Haddad
- Division of Gastroenterology and Hepatology, indiana University School of Medicine, indianapolis, IN
| | - Stuart Sherman
- Division of Gastroenterology and Hepatology, indiana University School of Medicine, indianapolis, IN
| | - Ambreen A Merchant
- Division of Digestive Diseases, Department of Medicine, Emory University, Atlanta, GA; and
| | | | - Ornela Gjata
- Endoscopy Division, Boston Scientific Corporation, Marl-borough, MA
| | - Edmund McMullen
- Endoscopy Division, Boston Scientific Corporation, Marl-borough, MA
| | - Field F Willingham
- Division of Digestive Diseases, Department of Medicine, Emory University, Atlanta, GA; and
| |
Collapse
|
5
|
Zeng Y, Yang J, Zhang JW. Endoscopic transluminal drainage and necrosectomy for infected necrotizing pancreatitis: Progress and challenges. World J Clin Cases 2023; 11:1888-1902. [PMID: 36998953 PMCID: PMC10044952 DOI: 10.12998/wjcc.v11.i9.1888] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/09/2022] [Revised: 02/06/2023] [Accepted: 03/01/2023] [Indexed: 03/16/2023] Open
Abstract
Infected necrotizing pancreatitis (INP) represents a severe condition in patients with acute pancreatitis. Invasive interventions are recommended in symptomatic INP. Growing evidence has suggested interventional strategies of INP evolving from traditional surgery to minimally invasive step-up endoscopic procedures. However, there is still no standardized protocol for endoscopic interventions. Recently, various studies have been published about the endoscopic management of INP. This article reviews published articles and guidelines to present the progress and challenges of endoscopic transluminal drainage and necrosectomy in INP.
Collapse
Affiliation(s)
- Yan Zeng
- Department of Psychology, The Second Affiliated Hospital of Chongqing Medical University, Chongqing 400010, China
| | - Jian Yang
- Department of Gastroenterology, The First Affiliated Hospital of Chongqing Medical University, Chongqing 400016, China
| | - Jun-Wen Zhang
- Department of Gastroenterology, The First Affiliated Hospital of Chongqing Medical University, Chongqing 400016, China
| |
Collapse
|
6
|
Karstensen JG, Novovic S, Hansen EF, Jensen AB, Jorgensen HL, Lauritsen ML, Werge MP, Schmidt PN. EUS-guided drainage of large walled-off pancreatic necroses using plastic versus lumen-apposing metal stents: a single-centre randomised controlled trial. Gut 2022; 72:1167-1173. [PMID: 36446550 DOI: 10.1136/gutjnl-2022-328225] [Citation(s) in RCA: 22] [Impact Index Per Article: 11.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/07/2022] [Accepted: 11/11/2022] [Indexed: 12/03/2022]
Abstract
OBJECTIVE In treating pancreatic walled-off necrosis (WON), lumen-apposing metal stents (LAMS) have not proven superior to the traditional double pigtail technique (DPT). Among patients with large WON (>15 cm) and their associated substantial risk of treatment failure, the increased drainage capacity of a novel 20-mm LAMS might improve clinical outcomes. Hence, we conducted a study comparing the DPT and 20-mm LAMS in patients with large WON. DESIGN A single-centre, open-label, randomised, controlled superiority trial using an endoscopic step-up approach in patients with WON exceeding 15 cm in size. The primary endpoint was the number of necrosectomies needed to achieve clinical success (clinical and CT resolution), while the secondary endpoints included technical success, adverse events, length of stay and mortality. RESULTS Twenty-two patients were included in the DPT group and 20 in the LAMS group, with no significant differences in patient characteristics. The median size of WON was 24.1 cm (P25-P75: 19.6-31.1). The technical success rates were 100% for DPT and 95% for LAMS (p=0.48), while clinical success rates were 95.5% and 94.7%, respectively (p=1.0). The mean number of necrosectomies was 2.2 for DPT and 3.2 for LAMS (p=0.42). Five patients (12%) developed procedure-related serious adverse events (DPT=4, LAMS=1, p=0.35). The median length of stay was 43 (P25-P75: 40-67) and 58 days (P25-P75: 40-86) in the DPT and LAMS groups (p=0.71), respectively, with an overall mortality of 4.8%. CONCLUSIONS For treating large WON, LAMS are not superior to DPT. The techniques are associated with comparable needs for necrosectomy and hospital stay, and no gross difference in adverse events. TRIAL REGISTRATION NUMBER NCT04057846.
Collapse
Affiliation(s)
- John Gásdal Karstensen
- Pancreatitis Centre East (PACE), Gastro Unit, Copenhagen University Hospital - Amager and Hvidovre, Hvidovre, Denmark .,Department of Clinical Medicine, University of Copenhagen, Copenhagen, Denmark
| | - Srdan Novovic
- Pancreatitis Centre East (PACE), Gastro Unit, Copenhagen University Hospital - Amager and Hvidovre, Hvidovre, Denmark.,Department of Clinical Medicine, University of Copenhagen, Copenhagen, Denmark
| | - Erik Feldager Hansen
- Pancreatitis Centre East (PACE), Gastro Unit, Copenhagen University Hospital - Amager and Hvidovre, Hvidovre, Denmark
| | - Annette Bojer Jensen
- Department of Radiology, Copenhagen University Hospital - Amager and Hvidovre, Hvidovre, Denmark
| | - Henrik Lovendahl Jorgensen
- Department of Clinical Medicine, University of Copenhagen, Copenhagen, Denmark.,Department of Clinical Biochemistry, Copenhagen University Hospital - Amager and Hvidovre, Hvidovre, Denmark
| | - Morten Laksafoss Lauritsen
- Pancreatitis Centre East (PACE), Gastro Unit, Copenhagen University Hospital - Amager and Hvidovre, Hvidovre, Denmark.,Department of Clinical Medicine, University of Copenhagen, Copenhagen, Denmark
| | - Mikkel Parsberg Werge
- Pancreatitis Centre East (PACE), Gastro Unit, Copenhagen University Hospital - Amager and Hvidovre, Hvidovre, Denmark
| | - Palle Nordblad Schmidt
- Pancreatitis Centre East (PACE), Gastro Unit, Copenhagen University Hospital - Amager and Hvidovre, Hvidovre, Denmark
| |
Collapse
|
7
|
Nøjgaard C, Werge M, Naver A, Wilkens Knudsen A, Wewer Albrechtsen NJ, Møller S, Gluud LL, Novovic S. Long-term changes of pancreatic function in patients with complicated walled-off necrosis. Scand J Gastroenterol 2022; 57:1257-1263. [PMID: 35546222 DOI: 10.1080/00365521.2022.2072176] [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] [Indexed: 02/04/2023]
Abstract
OBJECTIVES Walled-off necrosis (WON) is a serious complication to necrotizing acute pancreatitis with a high morbidity and mortality. The aim of this study was to investigate the long-term changes in pancreatic function, metabolic function and body composition in patients with WON. MATERIAL AND METHODS Observational study including patients with WON who underwent endoscopic transmural drainage and necrosectomy. Patients were prospectively evaluated at baseline, 3-6 months after discharge, and 12 months after discharge. Patients were characterized with fecal elastase, blood samples, computer tomography, dual energy X-ray absorptiometry and Lundh's test. RESULTS The study includes 17 patients (11 men) with WON. The etiologies were gallstones (53%) alcohol intake (35%) and 12% had an unknown etiology. The body mass index (BMI) dropped during baseline and 3 months after discharge (p = .03) and increased 12 months after discharge (p = .002). Twelve months after discharge, 29% had mild exocrine insufficiency, 7% moderate insufficiency and 50% severe insufficiency based on the Lundh's test. Fecal elastase was <100 μg/g in 35% and <200 μg/g in 59% 12 months after discharge. Only, 24% required pancreatic enzyme substitution. Endocrine insufficiency developed in 24%. These patients also had exocrine insufficiency. CONCLUSIONS A considerable proportion of patients with WON experience both endocrine and exocrine pancreatic insufficiency suggesting that long-term follow-up is needed in order to ensure adequate treatment.
Collapse
Affiliation(s)
- Camilla Nøjgaard
- Pancreatitis Centre East (PACE), Copenhagen University Hospital, Hvidovre, Denmark
| | - Mikkel Werge
- Pancreatitis Centre East (PACE), Copenhagen University Hospital, Hvidovre, Denmark
| | - Astrid Naver
- Medical Department, Zealand University Hospital, Køge, Denmark
| | - Anne Wilkens Knudsen
- The Dietitians and Nutritional Research Unit, EATEN, Herlev Gentofte University Hospital, Herlev, Denmark
| | - Nicolai J Wewer Albrechtsen
- Department of Clinical Biochemistry, Rigshospitalet, University of Copenhagen, Copenhagen, Denmark.,NNF Center for Protein Research, Faculty of Health and Medical Sciences, University of Copenhagen, Copenhagen, Denmark
| | - Søren Møller
- Department of Clinical Physiology and Nuclear Medicine, Center for Functional and Diagnostic Imaging and Research, Copenhagen University Hospital, Hvidovre, Denmark.,Department of Clinical Medicine, Faculty of Health Sciences University of Copenhagen, Copenhagen, Denmark
| | - Lise Lotte Gluud
- Pancreatitis Centre East (PACE), Copenhagen University Hospital, Hvidovre, Denmark.,Department of Clinical Medicine, Faculty of Health Sciences University of Copenhagen, Copenhagen, Denmark
| | - Srdan Novovic
- Pancreatitis Centre East (PACE), Copenhagen University Hospital, Hvidovre, Denmark.,Department of Clinical Medicine, Faculty of Health Sciences University of Copenhagen, Copenhagen, Denmark
| |
Collapse
|
8
|
Lindgaard L, Lauritsen ML, Novovic S, Hansen EF, Karstensen JG, Schmidt PN. Simultaneous endoscopic and video-assisted retroperitoneal debridement in walled-off pancreatic necrosis using a laparoscopic access platform: Two case reports. World J Gastroenterol 2022; 28:588-593. [PMID: 35316956 PMCID: PMC8905021 DOI: 10.3748/wjg.v28.i5.588] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/04/2021] [Revised: 05/03/2021] [Accepted: 12/28/2021] [Indexed: 02/06/2023] Open
Abstract
BACKGROUND Infected walled-off necrosis is a potentially life-threatening complication of necrotizing pancreatitis. While some patients can be treated by drainage alone, many patients also need evacuation of the infected debris. Central necroses in relation to the pancreatic bed are easily reached via an endoscopic transluminal approach, whereas necroses that involve the paracolic gutters and the pelvis are most efficiently treated via a percutaneous approach. Large and complex necroses may need a combination of the two methods.
CASE SUMMARY Transluminal and percutaneous drainage followed by simultaneous endoscopic and modified video-assisted retroperitoneal debridement was carried out in two patients with very large (32-38 cm), infected walled-off necroses using a laparoscopic access platform. After 34 d and 86 d and a total of 9 and 14 procedures, respectively, complete regression of the walled-off necroses was achieved. The laparoscopic access platform improved both access to the cavities as well as the overview. Simultaneous transluminal and percutaneous necrosectomy are feasible with the laparoscopic access platform serving as a useful adjunctive.
CONCLUSION This approach may be necessary to control infection and achieve regression in some patients with complex collections.
Collapse
Affiliation(s)
- Lars Lindgaard
- Pancreatitis Centre East (PACE), Gastro Unit,Copenhagen University Hospital–Amager and Hvidovre, Hvidovre 2650, Capital Region, Denmark
| | - Morten Laksáfoss Lauritsen
- Pancreatitis Centre East (PACE), Gastro Unit,Copenhagen University Hospital–Amager and Hvidovre, Hvidovre 2650, Capital Region, Denmark
- Department of Clinical Medicine, University of Copenhagen, Copenhagen 2100, Capital Region, Denmark
| | - Srdan Novovic
- Pancreatitis Centre East (PACE), Gastro Unit,Copenhagen University Hospital–Amager and Hvidovre, Hvidovre 2650, Capital Region, Denmark
- Department of Clinical Medicine, University of Copenhagen, Copenhagen 2100, Capital Region, Denmark
| | - Erik Feldager Hansen
- Pancreatitis Centre East (PACE), Gastro Unit,Copenhagen University Hospital–Amager and Hvidovre, Hvidovre 2650, Capital Region, Denmark
| | - John Gásdal Karstensen
- Pancreatitis Centre East (PACE), Gastro Unit,Copenhagen University Hospital–Amager and Hvidovre, Hvidovre 2650, Capital Region, Denmark
- Department of Clinical Medicine, University of Copenhagen, Copenhagen 2100, Capital Region, Denmark
| | - Palle Nordblad Schmidt
- Pancreatitis Centre East (PACE), Gastro Unit,Copenhagen University Hospital–Amager and Hvidovre, Hvidovre 2650, Capital Region, Denmark
| |
Collapse
|
9
|
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.
Collapse
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.)
| |
Collapse
|
10
|
Pereira F, Caldeira A, Leite S, Marques S, Moreira T, Moutinho-Ribeiro P, Nunes N, Bispo M. GRUPUGE Perspective: Endoscopic Ultrasound-Guided Drainage of Peripancreatic Collections. GE PORTUGUESE JOURNAL OF GASTROENTEROLOGY 2020; 28:39-51. [PMID: 33564703 PMCID: PMC7841806 DOI: 10.1159/000509193] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/14/2020] [Accepted: 05/20/2020] [Indexed: 04/28/2023]
Abstract
Pancreatic and peripancreatic collections (PPC) are a known complication of acute pancreatitis. They are categorized into four types of collection: (1) acute peripancreatic fluid collection, (2) pseudocyst, (3) acute necrotic collection and (4) walled-off necrosis. Most PPC resolve spontaneously or are persistent but asymptomatic. Intervention is needed in a minority of patients with infected or symptomatic collection. Endoscopic ultrasound-guided transmural drainage is currently the first-line treatment option for PPC management. It has shown great technical and clinical success, similar to percutaneous or surgical approaches, but with lower morbidity and costs and better quality of life. In this review article, the GRUPUGE presents an updated perspective on the potential role of endoscopic ultrasound-guided drainage of peripancreatic collections, addressing the selection criteria and the technical issues of different techniques and analysing emerging data on their efficacy and safety.
Collapse
Affiliation(s)
- Flávio Pereira
- Department of Gastroenterology, Hospital Amato Lusitano, Castelo Branco, Portugal
- *Flávio Pereira, Department of Gastroenterology, Hospital Amato Lusitano, Av. Pedro Álvares Cabral, PT–6000-085 Castelo Branco (Portugal),
| | - Ana Caldeira
- Department of Gastroenterology, Hospital Amato Lusitano, Castelo Branco, Portugal
| | - Sílvia Leite
- Department of Gastroenterology, Hospital da Senhora da Oliveira, Guimarães, Portugal
| | - Susana Marques
- Department of Gastroenterology and Digestive Endoscopy, Champalimaud Foundation, Lisbon, Portugal
| | - Teresa Moreira
- Department of Gastroenterology, Hospital de Santo António, Porto, Portugal
| | - Pedro Moutinho-Ribeiro
- Department of Gastroenterology, Centro Hospitalar e Universitário de São João, Porto, Portugal
| | - Nuno Nunes
- Department of Gastroenterology, Hospital do Divino Espírito Santo, Ponta Delgada, Portugal
| | - Miguel Bispo
- Department of Gastroenterology and Digestive Endoscopy, Champalimaud Foundation, Lisbon, Portugal
| |
Collapse
|
11
|
Bartholdy A, Werge M, Novovic S, Hadi A, Nøjgaard C, Borch A, Feldager E, Gluud LL, Schmidt PN. Endoscopic treatment with transmural drainage and necrosectomy for walled-off necrosis provides favourable long-term outcomes on pancreatic function. United European Gastroenterol J 2020; 8:552-558. [PMID: 32326877 DOI: 10.1177/2050640620916029] [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] [Indexed: 01/20/2023] Open
Abstract
BACKGROUND AND AIMS Several studies have shown improved short-term outcome with endoscopic transmural drainage and necrosectomy for the treatment of walled-off pancreatic necrosis. However, knowledge on the long-term prognosis after such treatment is limited. The aim of present study was to evaluate long-term outcomes in patients endoscopically treated with transmural drainage and necrosectomy. METHODS We retrospectively follow up 125 patients with walled-off pancreatic necrosis treated with endoscopic transmural drainage and necrosectomy in 2010-2017. All patients received plastic pigtail stents and nasocystic catheter. Additional external drainage was performed in 41 patients. Main outcomes were survival, pancreatic function, development of co-morbidities, ability to work and social status. RESULTS During a median follow-up of 4.3 years, nine (7%) patients died. Seven deaths were unrelated to pancreatic disease, and two patients died of pancreatic cancer. Twenty-two (18%) patients developed exocrine pancreatic insufficiency. Thirty-six (32%) previous non-diabetics developed endocrine insufficiency. Endoscopic necrosectomy during admission (odds ratio (OR) = 1.28, 95% confidence interval (CI) 1.05-1.56; p = 0.015) and therapy on the main pancreatic duct (OR = 8.08, 95% CI 2.43-26.9; p < 0.001) during follow-up predicted development of exocrine insufficiency. Severity on computed tomography predicted endocrine insufficiency (OR = 1.61, 95% CI 1.24-2.09; p < 0.001). Most patients regained their working capacity and preserved their marital status. CONCLUSIONS This study provides robust data on the long-term outcome of patients with walled-off pancreatic necrosis treated with endoscopic transmural drainage and necrosectomy. The favourable outcomes on survival, pancreatic function and social status support current recommendations of endoscopic transmural drainage and necrosectomy being the treatment of choice for walled-off pancreatic necrosis.
Collapse
Affiliation(s)
- Andreas Bartholdy
- Department of Gastroenterology and Gastrointestinal Surgery, Hvidovre University Hospital, Hvidovre, Denmark
| | - Mikkel Werge
- Department of Gastroenterology and Gastrointestinal Surgery, Hvidovre University Hospital, Hvidovre, Denmark
| | - Srdan Novovic
- Department of Gastroenterology and Gastrointestinal Surgery, Hvidovre University Hospital, Hvidovre, Denmark
| | - Amer Hadi
- Department of Gastroenterology and Gastrointestinal Surgery, Hvidovre University Hospital, Hvidovre, Denmark
| | - Camilla Nøjgaard
- Department of Gastroenterology and Gastrointestinal Surgery, Hvidovre University Hospital, Hvidovre, Denmark
| | - Anders Borch
- Department of Gastroenterology and Gastrointestinal Surgery, Hvidovre University Hospital, Hvidovre, Denmark
| | - Erik Feldager
- Department of Gastroenterology and Gastrointestinal Surgery, Hvidovre University Hospital, Hvidovre, Denmark
| | - Lise Lotte Gluud
- Department of Gastroenterology and Gastrointestinal Surgery, Hvidovre University Hospital, Hvidovre, Denmark
| | - Palle Nordblad Schmidt
- Department of Gastroenterology and Gastrointestinal Surgery, Hvidovre University Hospital, Hvidovre, Denmark
| |
Collapse
|
12
|
The cost of endoscopic treatment for walled-off pancreatic necrosis. Pancreatology 2019; 19:828-833. [PMID: 31383574 DOI: 10.1016/j.pan.2019.07.042] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/14/2018] [Revised: 04/12/2019] [Accepted: 07/26/2019] [Indexed: 02/07/2023]
Abstract
BACKGROUND Use of minimally invasive techniques has reduced mortality in walled-off pancreatic necrosis (WON) but may be costly. The aim of this study was to evaluate the actual costs associated with the endoscopic management of patients with WON. METHODS We included a retrospective cohort of WON patients treated with endoscopic, transgastric drainage and necrosectomy (ETDN) during 2013-2014. Costs were calculated for six sub-areas based on a micro-costing model. Students T-test and non-parametric analysis of variance were performed to evaluate costs in relation to disease etiology and outcome. RESULTS We included 58 patients (50% men, median age 57 years). The most common etiologies were gallstones (57%) and alcohol (19%). Nine patients (16%) died during admission. The median length of stay was 50 days (IQR 31 days). Eighteen patients (31%) needed treatment in our intensive care unit with a median length of stay of 16 days (IQR 31 days). The mean costs and standard deviation of costs (SD) per patient were: diagnostic imaging $2,431 ($2,301), laboratory tests $3,579 ($2,477), blood products $982 ($1,734), endoscopic treatment $3,794 ($1,777), medicine $5,440 ($6,656), and ward cost $41,260 ($35,854). The mean total cost was $57,486 ($46,739). Post-ERCP pancreatitis and mortality predicted higher costs. CONCLUSIONS This study sheds light on the different costs associated with endoscopic treatment of WON. As nearly three quarters of the costs are related to ward care, initiatives aimed at reducing the length of hospital stay may have a great impact on making endoscopic treatment more cost effective.
Collapse
|
13
|
Puri N, Hallac A, Srikureja W. Early experience with cap-assisted endoscopic pancreatic necrosectomy: A technique to enhance safe tissue extraction and decrease interventions. Endosc Int Open 2019; 7:E912-E915. [PMID: 31304235 PMCID: PMC6624114 DOI: 10.1055/a-0918-5772] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/10/2018] [Accepted: 03/16/2019] [Indexed: 10/26/2022] Open
Abstract
Background and study aim Endoscopic treatment of walled-off pancreatic necrosis (WOPN) has been established as an alternative to operative intervention for well selected patients for many years. Patients and methods A retrospective database of patients who underwent cap-assisted endoscopic necrosectomy of symptomatic or infected WOPN using the assistance of a sterilized banding cap was constructed. All procedures were performed at a single center between January 2017 and June 2018. Results Eight patients met the inclusion criteria for this study. Contrast computed tomography scan was obtained between the initial percutaneous or trans-gastric access and initial necrosectomy. The WOPN had a median length of 9.5 cm (range 3.2 - 14) and width of 5.3 cm (range 2.8 - 11.6). Median duration of endoscopic debridement was 69 minutes (range 21 - 105). Four of six patients underwent a second debridement with a median duration of 95 minutes (range 16 - 108). No periprocedural adverse events occurred. Follow-up was at 6 months, and there were no additional endoscopic or percutaneous interventions for recurrent pancreatic fluid collections. Conclusion The technique of cap-assisted necrosectomy can allow for safe and efficient method of endoscopically treating WOPN.
Collapse
Affiliation(s)
- Nishant Puri
- Providence Gastroenterology, Spokane, Washington, United States
| | | | | |
Collapse
|
14
|
Rashid MU, Hussain I, Jehanzeb S, Ullah W, Ali S, Jain AG, Khetpal N, Ahmad S. Pancreatic necrosis: Complications and changing trend of treatment. World J Gastrointest Surg 2019; 11:198-217. [PMID: 31123558 PMCID: PMC6513789 DOI: 10.4240/wjgs.v11.i4.198] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/12/2019] [Revised: 04/19/2019] [Accepted: 04/23/2019] [Indexed: 02/06/2023] Open
Abstract
Incidence of acute pancreatitis seems to be increasing in the Western countries and has been associated with significantly increased morbidity. Nearly 80% of the patients with acute pancreatitis undergo resolution; some develop complications including pancreatic necrosis. Infection of pancreatic necrosis is the leading cause of death in these patients. A significant portion of these patients needs surgical interventions. Traditionally, the “gold standard” procedure has been the open surgical necrosectomy, which is now being completed by the relatively lesser invasive interventions. Minimally invasive surgical (MIS) procedures include endoscopic drainage, percutaneous image-guided catheter drainage, and retroperitoneal drainage. This review article discusses the open and MIS interventions for pancreatic necrosis with each having its own respective benefits and disadvantages are covered.
Collapse
Affiliation(s)
- Mamoon Ur Rashid
- Department of Internal Medicine, Advent Health Graduate Medical Education, Orlando, FL 32804, United States
| | - Ishtiaq Hussain
- Department of Gastroenterology, Cleveland Clinic, Weston, FL 33326, United States
| | - Sundas Jehanzeb
- Department of Gastroenterology, Cleveland Clinic, Weston, FL 33326, United States
| | - Waqas Ullah
- Internal Medicine, Abington Hospital, Abington, PA 19001, United States
| | - Saeed Ali
- Department of Internal Medicine, Advent Health Graduate Medical Education, Orlando, FL 32804, United States
| | - Akriti Gupta Jain
- Department of Internal Medicine, Advent Health Graduate Medical Education, Orlando, FL 32804, United States
| | - Neelam Khetpal
- Department of Internal Medicine, Advent Health Graduate Medical Education, Orlando, FL 32804, United States
| | - Sarfraz Ahmad
- Department of Gynecologic Oncology, Advent Health Cancer Institute, Orlando, FL 32804, United States
| |
Collapse
|
15
|
Smith ZL, Gregory MH, Elsner J, Alajlan BA, Kodali D, Hollander T, Sayuk GS, Lang GD, Das KK, Mullady DK, Early DS, Kushnir VM. Health-related quality of life and long-term outcomes after endoscopic therapy for walled-off pancreatic necrosis. Dig Endosc 2019; 31:77-85. [PMID: 30152143 DOI: 10.1111/den.13264] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/21/2018] [Accepted: 08/20/2018] [Indexed: 12/17/2022]
Abstract
BACKGROUND AND AIM Walled-off pancreatic necrosis (WON) frequently develops after necrotizing pancreatitis. Endoscopic drainage has become the preferred modality for symptomatic or infected WON. The aim of the present study was to assess health-related quality of life (HR-QOL) and long-term outcomes in patients undergoing endoscopic drainage for WON. METHODS Patients undergoing endoscopic drainage of WON from January 2006 to May 2016 were identified. Data recorded included demographic information, and the incidence of long-term sequelae including pancreatic endocrine and exocrine insufficiency. Attempts were made to contact all patients. HR-QOL was assessed using the SF-36 questionnaire. RESULTS Eighty patients were analyzed, 41 (51.3%) of whom completed the SF-36. One-year all-cause mortality was 6.2%, and disease-related mortality was 3.7%. A notable proportion of patients developed exocrine insufficiency (32.5%), endocrine insufficiency (27.7%), and long-term opiate use (42.5%). Development of exocrine insufficiency was predictive of lower total SF-36 scores (P = 0.016). Patients with WON had better HR-QOL compared with cohorts of irritable bowel syndrome (IBS) and inflammatory bowel disease (IBD). In patients developing exocrine insufficiency versus healthy controls, poorer scores in the physical role (P < 0.001), general health (P < 0.001), vitality (P = 0.001), and emotional role (P = 0.029) domains were observed. Exocrine insufficiency patients had better HR-QOL than the IBS and IBD cohorts, although these differences were less pronounced. CONCLUSION After undergoing endoscopic drainage for WON, patients have relatively preserved HR-QOL. The subset of patients that develop exocrine insufficiency have significantly poorer HR-QOL compared to healthy controls, although not to the degree of chronic gastrointestinal disorders such as IBS and IBD.
Collapse
Affiliation(s)
- Zachary L Smith
- Division of Gastroenterology, Washington University School of Medicine, St Louis, USA
| | - Martin H Gregory
- Division of Gastroenterology, Washington University School of Medicine, St Louis, USA
| | - Jeffrey Elsner
- Division of Gastroenterology, Washington University School of Medicine, St Louis, USA
| | - Bader A Alajlan
- Division of Gastroenterology, Washington University School of Medicine, St Louis, USA
| | - Divya Kodali
- Division of Gastroenterology, Washington University School of Medicine, St Louis, USA
| | - Thomas Hollander
- Division of Gastroenterology, Washington University School of Medicine, St Louis, USA
| | - Gregory S Sayuk
- Division of Gastroenterology, Washington University School of Medicine, St Louis, USA
| | - Gabriel D Lang
- Division of Gastroenterology, Washington University School of Medicine, St Louis, USA
| | - Koushik K Das
- Division of Gastroenterology, Washington University School of Medicine, St Louis, USA
| | - Daniel K Mullady
- Division of Gastroenterology, Washington University School of Medicine, St Louis, USA
| | - Dayna S Early
- Division of Gastroenterology, Washington University School of Medicine, St Louis, USA
| | - Vladimir M Kushnir
- Division of Gastroenterology, Washington University School of Medicine, St Louis, USA
| |
Collapse
|
16
|
Mohan BP, Jayaraj M, Asokkumar R, Shakhatreh M, Pahal P, Ponnada S, Navaneethan U, Adler DG. Lumen apposing metal stents in drainage of pancreatic walled-off necrosis, are they any better than plastic stents? A systematic review and meta-analysis of studies published since the revised Atlanta classification of pancreatic fluid collections. Endosc Ultrasound 2019; 8:82-90. [PMID: 31006706 PMCID: PMC6482598 DOI: 10.4103/eus.eus_7_19] [Citation(s) in RCA: 42] [Impact Index Per Article: 8.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/16/2022] Open
Abstract
Lumen-apposing metal stents (LAMS) are increasingly being used in the drainage of pancreatic walled-off necrosis (WON). Best choice of stent is subject to argument, and studies are varied in the reported outcomes between LAMS and plastic stents (PS) to this end. We conducted a comprehensive search of multiple electronic databases and conference proceedings including PubMed, EMBASE, and Web of Science databases (earliest inception through July 2018) to identify studies that reported on the use of LAMS and PS in WON drainage. Studies published since the release of the revised Atlanta classification for pancreatic fluid collections (2014 to current) were included in the analysis. The outcomes were to estimate and compare the pooled rates of clinical success, and adverse-events. A total of 9 studies (737 patients) for LAMS and 6 studies (527 patients) for PS were included in the analysis. The pooled rate of clinical-success with LAMS was 88.5% (95% CI 82.5-92.6, I2 = 71.7) and with PS was 88.1% (95% CI 80.5-93.0, I2 = 78.1) and the difference was not statistically significant, P = 0.93. No difference was noted in the pooled rates of all adverse-events, LAMS: 11.2% (6.8-17.9, I2 = 82.0); vs PS: 15.9% (8.4-27.8, I2 = 78.8); P = 0.38. Based on our meta-analysis, LAMS and PS demonstrate equal clinical outcomes and equal adverse-events in the drainage of pancreatic WON.
Collapse
Affiliation(s)
- Babu P Mohan
- Department of Inpatient Medicine, University of Arizona, Banner University Medical Center, Tucson, Arizona, USA
| | - Mahendran Jayaraj
- Division of Gastroenterology/Hepatology, University of Nevada, Las Vegas, USA
| | | | - Mohammed Shakhatreh
- Department of Hospital Medicine, Rapides Regional Medical Center, Alexandria, Louisiana, USA
| | - Parul Pahal
- Department of Inpatient Medicine, University of Arizona, Banner University Medical Center, Tucson, Arizona, USA
| | - Suresh Ponnada
- Department of Hospital Medicine, Carilion Roanoke Memorial Hospital, Roanoke, Virginia, USA
| | | | - Douglas G Adler
- Division of Gastroenterology and Hepatology, University of Utah School of Medicine, Salt Lake City, Utah, USA
| |
Collapse
|
17
|
Thorsen A, Borch AM, Novovic S, Schmidt PN, Gluud LL. Endoscopic Necrosectomy Through Percutaneous Self-Expanding Metal Stents May Be a Promising Additive in Treatment of Necrotizing Pancreatitis. Dig Dis Sci 2018; 63:2456-2465. [PMID: 29796908 DOI: 10.1007/s10620-018-5131-3] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/24/2018] [Accepted: 05/18/2018] [Indexed: 01/07/2023]
Abstract
BACKGROUND The recommended treatment of infected walled-off necrosis (WON) in necrotizing pancreatitis entails a step-up treatment approach starting with endoscopic necrosectomy (ETDN). AIMS To report a small number of cases from 2013 to 2016 that were not amenable to or failed to respond to ETDN, and to describe a new, minimally invasive technique that may be a promising supplement to ETDN in this difficult patient population. METHODS Using the Seldinger technique, a fully covered self-expanding metal stent (SEMS) was placed percutaneously in order to drain, irrigate, and debride WON. After resolution, the stent was removed. We reviewed electronic patient records and defined clinical success as complete WON resolution with removal of internal as well as percutaneous drains and stents. RESULTS Five patients underwent treatment with SEMS placement. The mean length of the WON was 33.4 cm. Clinical success was achieved in four patients after an average of 5.75 necrosectomy sessions. One patient died from severe sepsis. Adverse events included severe abdominal pain and productive cutaneous fistulae (two patients). CONCLUSIONS In our small case series, endoscopic necrosectomy through a percutaneous SEMS seemed beneficial and safe in the treatment of infected WON.
Collapse
Affiliation(s)
- Andreas Thorsen
- Department of Gastroenterology and Gastrointestinal Surgery, Copenhagen University Hospital Hvidovre, Kettegård Allé 30, 2650, Hvidovre, Denmark.
| | - Anders Malthe Borch
- Department of Gastroenterology and Gastrointestinal Surgery, Copenhagen University Hospital Hvidovre, Kettegård Allé 30, 2650, Hvidovre, Denmark
| | - Srdan Novovic
- Department of Gastroenterology and Gastrointestinal Surgery, Copenhagen University Hospital Hvidovre, Kettegård Allé 30, 2650, Hvidovre, Denmark
| | - Palle Nordblad Schmidt
- Department of Gastroenterology and Gastrointestinal Surgery, Copenhagen University Hospital Hvidovre, Kettegård Allé 30, 2650, Hvidovre, Denmark
| | - Lise Lotte Gluud
- Department of Gastroenterology and Gastrointestinal Surgery, Copenhagen University Hospital Hvidovre, Kettegård Allé 30, 2650, Hvidovre, Denmark
| |
Collapse
|
18
|
Evaluation of local instillation of antibiotics in infected walled-off pancreatic necrosis. Pancreatology 2018; 18:642-646. [PMID: 29958817 DOI: 10.1016/j.pan.2018.06.005] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/07/2018] [Revised: 05/31/2018] [Accepted: 06/19/2018] [Indexed: 02/08/2023]
Abstract
BACKGROUND Infected walled-off pancreatic necrosis (WON) is associated with increased morbidity and mortality. Systemic antibiotics are the main treatment, but are associated with adverse reactions and risk of superinfections. This study evaluates the efficacy of local instillation of antibiotics into WON. METHODS We performed a retrospective cohort study of all consecutive patients with infected WON, who were treated with endoscopic transmural drainage and necrosectomy (ETDN) at a tertiary referral hospital between 2012 and 2016. A total of 91 patients were included. Patients often received concomitant intravenous and local antibiotics. Local antibiotics were added to the irrigation fluid depending on microbiological findings. A beneficial response was defined as the eradication of a microbe on subsequent culturing. Univariable and multivariable logistic regression analyses were used to evaluate antimicrobial efficacy. RESULTS At the first drainage 81 (86%) patients had infected and 10 sterile WON. Among patients with bacterial infections, neither local nor systemic antibiotics were associated with the eradication of microbes between first and second culture. Between the second and third culture, the use of local antibiotics was associated with the eradication of microbes (OR, 2.54; 95% CI, 1.25-5.18; p = 0.01), but not systemic antibiotics (OR, 0.75; 95% CI, 0.38-1.38; p = 0.33). Twelve patients had fungal infections treated with local amphotericin B between first and second culture. The fungus was eradicated in all 12 patients. CONCLUSION Local instillation of antibiotics may be a promising supplement to systemic administration.
Collapse
|
19
|
Metal stents versus plastic stents for the management of pancreatic walled-off necrosis: a systematic review and meta-analysis. Gastrointest Endosc 2018; 87:30-42.e15. [PMID: 28867073 DOI: 10.1016/j.gie.2017.08.025] [Citation(s) in RCA: 66] [Impact Index Per Article: 11.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/25/2017] [Accepted: 08/20/2017] [Indexed: 02/08/2023]
Abstract
BACKGROUND AND AIMS Endoscopic transluminal drainage of symptomatic walled-off necrosis (WON) is a good management option, although the optimal choice of drainage site stent is unclear. We performed a systematic review and meta-analysis to compare metal stents (MSs) and plastic stents (PSs) in terms of WON resolution, likelihood of resolution after 1 procedure, and adverse events. METHODS An expert librarian queried several databases to identify studies that assessed WON management, and selection was according to a priori criteria. Publication bias, heterogeneity, and study quality were evaluated with the appropriate tools. We performed single and 2-arm meta-analyses for noncomparative and comparative studies using event rate random-effects model and odds ratio (OR)/difference in means, respectively. RESULTS We included 41 studies involving 2213 patients. In 2-arm study meta-analysis, WON resolution was more likely with MSs compared with PSs (OR, 2.8; 95% confidence interval, 1.7-4.6; P < .001). Resolution with a single endoscopic procedure was similar between stents (47% vs 44%), although for those cases requiring more than 1 intervention, the MS group had fewer interventions, favored by a mean difference of -.9 procedures (95% CI, -1.283 to -.561). In single-arm study meta-analysis, when compared with PSs, MS use was associated with lower bleeding (5.6% vs 12.6%; P = .02), a trend toward lower perforation and stent occlusion (2.8% vs 4.3%, P = .2, and 9.5% vs 17.4%, P = .07), although with higher migration (8.1% vs 5.1%; P = .1). CONCLUSION Evidence suggests that MSs are superior for WON resolution, with fewer bleeding events, trend toward less occlusion and perforation rate, but increased migration rate compared with PSs.
Collapse
|
20
|
Rysgaard S, Rasmussen D, Novovic S, Schmidt PN, Gluud LL. Effect of overweight and obesity on weight loss and length of stay in patients with walled-off pancreatic necrosis. Nutrition 2017; 38:109-112. [PMID: 28526375 DOI: 10.1016/j.nut.2017.01.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/03/2016] [Revised: 01/09/2017] [Accepted: 01/19/2017] [Indexed: 11/17/2022]
Abstract
OBJECTIVE The aim of this study was to assess the association between admission weight, weight loss, and length of stay (LOS) in patients with walled-off pancreatic necrosis. METHODS We classified the admission body mass index (BMI) of 18.5 to <25 kg/m2 as normal weight, 25 to <30 kg/m2 as overweight, and ≥30 kg/m2 as obesity. The Nutritional Risk Screening score-2002 was calculated to identify patients at risk for undernutrition. RESULTS We included 38 patients (61% men, 68% with infected necrosis; 40% normal weight; 60% overweight/obesity). Four patients (11%) required treatment at the semi-intensive care unit, 11 (29%) developed pneumonia, and 10 (26%) developed septicemia. One patient died due to respiratory failure and hemorrhage. The remaining patients were discharged after a median of 49 d (36-64 d). During admission, 14 patients (38%) achieved an energy-protein intake of at least 75% and 17 (46%) achieved ≥70% coverage. The percentage weight loss was different (P < 0.01) for patients with normal weight (4%), overweight (9%), and obesity (14%). There was no difference between groups regarding percentage of energy or protein coverage. Patients with overweight/obesity had a longer hospital LOS (P = 0.016). In univariable regression analysis, overweight, obesity, energy, and protein coverage predicted weight loss. LOS did not predict weight loss. In multivariable regression analysis, overweight and obesity were the only remaining significant predictors of weight loss. CONCLUSIONS Patients with walled-off pancreatic necrosis are at considerable risk for undernutrition. A BMI >25 kg/m2 predicts greater weight loss and longer LOS.
Collapse
Affiliation(s)
- Sisse Rysgaard
- Department of Gastroenterology and Gastrointestinal Surgery, Copenhagen University Hospital Hvidovre, Hvidovre, Denmark.
| | - Ditlev Rasmussen
- Department of Gastroenterology and Gastrointestinal Surgery, Copenhagen University Hospital Hvidovre, Hvidovre, Denmark
| | - Srdan Novovic
- Department of Gastroenterology and Gastrointestinal Surgery, Copenhagen University Hospital Hvidovre, Hvidovre, Denmark
| | - Palle N Schmidt
- Department of Gastroenterology and Gastrointestinal Surgery, Copenhagen University Hospital Hvidovre, Hvidovre, Denmark
| | - Lise L Gluud
- Department of Gastroenterology and Gastrointestinal Surgery, Copenhagen University Hospital Hvidovre, Hvidovre, Denmark
| |
Collapse
|