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González-Haba Ruiz M, Betés Ibáñez MT, Martínez Moreno B, Repiso Ortega A, de la Serna Higuera C, Iglesias García J, Sendino García O, Moris Felgueroso M, Agudo Castillo B, Esteban López-Jamar JM, Lindo Ricce MD, Soria San Teodoro MT, Moya Valverde E, Muñoz López D, Uribarri González L, Sevilla Ribota S, Lariño Noia J, Pérez Miranda M, Aparicio Tormo JR, Vila Costas JJ, Vázquez Sequeiros E, Subtil Íñigo JC, Pérez-Cuadrado-Robles E, Sánchez Yagüe A, Núñez Otero JA, Foruny Olcina JR. Endoscopic management of pancreatic collections. Endoscopic Ultrasound Group from the Spanish Society of Digestive Endoscopy (GSEED-USE) Clinical Guidelines. REVISTA ESPANOLA DE ENFERMEDADES DIGESTIVAS 2024. [PMID: 38305682 DOI: 10.17235/reed.2024.10276/2024] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 02/03/2024]
Abstract
Acute pancreatitis is associated with significant morbidity and mortality. It can develop complications such as fluid collections and necrosis. Infection of necrosis occurs in about 20-40% of patients with severe acute pancreatitis, and is associated with organ failure and worse prognosis. In the past years, the treatment of pancreatic collections has shifted from open surgery to minimally invasive techniques, such as endoscopic ultrasound guided drainage. These guidelines from a selection of experts among the Endoscopic Ultrasound Group from the Spanish Society of Gastrointestinal Endoscopy (GSEED-USE) have the purpose to provide advice on the management of pancreatic collections based on a thorough review of the available scientific evidence. It also reflects the experience and clinical practice of the authors, who are advanced endoscopists or clinical pancreatologists with extensive experience in managing patients with acute pancreatitis.
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Gjeorgjievski M, Bhurwal A, Chouthai AA, Abdelqader A, Gaidhane M, Shahid H, Tyberg A, Sarkar A, Kahaleh M. Percutaneous endoscopic necrosectomy (PEN) for treatment of necrotizing pancreatitis: a systematic review and meta-analysis. Endosc Int Open 2023; 11:E258-E267. [PMID: 36968976 PMCID: PMC10036203 DOI: 10.1055/a-1935-4738] [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: 10/27/2021] [Accepted: 08/10/2022] [Indexed: 03/25/2023] Open
Abstract
Background and study aims
Endoscopic necrosectomy is limited by the proximity of necrosis to the gastrointestinal tract. Percutaneous endoscopic necrosectomy (PEN) is a minimally invasive endoscopic method of percutaneous debridement. Studies regarding its efficacy and safety are lacking. The purpose of this study was to assess the efficacy and safety of PEN in necrotizing pancreatitis.
Methods
Pubmed, Ovid, Cochrane, Scopus and Web of Science Database were searched from inception through February 2021. Dual extraction and quality assessment of studies using Cochrane risk of bias tool were performed independently by two authors. The primary outcome was defined as clinical success of PEN. Secondary outcomes included periprocedural morbidity, mortality, and long-term morbidity and mortality.
Results
Sixteen observational studies including 282 subjects were analyzed. The average reported age of the participants was 50.3 years. Patients with reported gender included 39 % females and 61 % males. The success rate as defined by complete resolution of necrosis and removal of drainage catheters/stents was 82 % (95 % confidence interval 77–87). The mean size of pancreatic necrosis was 14.86 cm (5–54 cm). The periprocedural morbidity rate was 10 %, while there was no reported periprocedural mortality. The long-term morbidity rate was reported as 23 % and mortality at follow-up was 16 %.
Conclusions
PEN is a novel method of endoscopic management of pancreatic necrosis. Based on our meta-analysis of retrospective studies, it represents a safe treatment modality with high rates of clinical success and low rates of perioperative morbidity and mortality. This study supports the use of PEN when conventional endoscopic therapy is not feasible.
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Affiliation(s)
- Mihajlo Gjeorgjievski
- Division of Gastroenterology, Rutgers, Robert Wood Johnson Medical School, New Brunswick, New Jersey, United States
| | - Abishek Bhurwal
- Division of Gastroenterology, Rutgers, Robert Wood Johnson Medical School, New Brunswick, New Jersey, United States
| | - Abhishek A. Chouthai
- Division of Gastroenterology, Rutgers, Robert Wood Johnson Medical School, New Brunswick, New Jersey, United States
| | - Abdelhai Abdelqader
- Division of Gastroenterology, Rutgers, Robert Wood Johnson Medical School, New Brunswick, New Jersey, United States
| | - Monica Gaidhane
- Division of Gastroenterology, Rutgers, Robert Wood Johnson Medical School, New Brunswick, New Jersey, United States
| | - Haroon Shahid
- Division of Gastroenterology, Rutgers, Robert Wood Johnson Medical School, New Brunswick, New Jersey, United States
| | - Amy Tyberg
- Division of Gastroenterology, Rutgers, Robert Wood Johnson Medical School, New Brunswick, New Jersey, United States
| | - Avik Sarkar
- Division of Gastroenterology, Rutgers, Robert Wood Johnson Medical School, New Brunswick, New Jersey, United States
| | - Michel Kahaleh
- Division of Gastroenterology, Rutgers, Robert Wood Johnson Medical School, New Brunswick, New Jersey, United States
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Pattarapuntakul T, Charoenrit T, Wong T, Netinatsunton N, Ovartlarnporn B, Yaowmaneerat T, Tubtawee T, Boonsri P, Sripongpun P. Clinical Outcomes of the Endoscopic Step-Up Approach with or without Radiology-Guided Percutaneous Drainage for Symptomatic Walled-Off Pancreatic Necrosis. Medicina (B Aires) 2023; 59:medicina59030569. [PMID: 36984570 PMCID: PMC10058734 DOI: 10.3390/medicina59030569] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/23/2023] [Revised: 03/05/2023] [Accepted: 03/13/2023] [Indexed: 03/17/2023] Open
Abstract
Background and objectives: Symptomatic walled-off pancreatic necrosis is a serious local complication of acute necrotising pancreatitis. The endoscopic step-up approach is the standard treatment for symptomatic walled-off pancreatic necrosis; however, adjunctive radiologic percutaneous drainage for this condition is controversial. This study compared the clinical and radiologic resolution of walled-off pancreatic necrosis achieved with the endoscopic step-up approach with or without radiology-guided percutaneous drainage. Material and Methods: This retrospective, single-centre cohort study enrolled patients with symptomatic walled-off pancreatic necrosis who underwent endoscopic transmural drainage (ETD) followed by directed endoscopic necrosectomy (DEN) with or without radiology-guided drainage. A total of 34 patients (endoscopic approach, n = 22; combined modality approach, n = 12) underwent the endoscopic step-up approach (ETD followed by DEN). Baseline characteristics, clinical success, and resolution of necrosis were compared between groups. Results: All patients achieved symptom resolution from walled-off pancreatic necrosis. The mean patient age was 58.4 years, and 21 (61.8%) were men. Following treatment with the endoscopic approach and combined modality approach, clinical success was achieved in 90.9% of patients within 11.5 days, and 66.7% of patients within 16.5 days, respectively. Both length of hospital stay (55 days vs. 71 days; p = 0.071) and time to complete radiologic resolution were shorter (93 days vs. 124 days; p = 0.23) in the endoscopic approach group. Conclusion: Both the endoscopic step-up approach and the CMD approach resulted in a favourably high clinical resolution rates in patients with symptomatic WON. However, clinical success rates seemed to be higher, and the length of hospital stay tended to be shorter in the endoscopic approach than in the CMD approach, as well as the significantly shorter necrosectomy time in each procedure was observed. Of note, these findings might be from some inherited differences in baseline characteristics of the patients between the two groups, and a randomized controlled trial with a larger sample size to verify these results is warranted.
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Affiliation(s)
- Tanawat Pattarapuntakul
- Gastroenterology and Hepatology Unit, Division of Internal Medicine, Faculty of Medicine, Prince of Songkla University, Hat Yai 90110, Songkhla, Thailand (P.S.)
- Correspondence:
| | - Tummarong Charoenrit
- Gastroenterology and Hepatology Unit, Division of Internal Medicine, Faculty of Medicine, Prince of Songkla University, Hat Yai 90110, Songkhla, Thailand (P.S.)
| | - Thanawin Wong
- Gastroenterology and Hepatology Unit, Division of Internal Medicine, Faculty of Medicine, Prince of Songkla University, Hat Yai 90110, Songkhla, Thailand (P.S.)
| | - Nisa Netinatsunton
- Nantana-Kriangkrai Chotiwattanaphan (NKC) Institute of Gastroenterology and Hepatology, Faculty of Medicine, Prince of Songkla University, Hat Yai 90110, Songkhla, Thailand
| | - Bancha Ovartlarnporn
- Nantana-Kriangkrai Chotiwattanaphan (NKC) Institute of Gastroenterology and Hepatology, Faculty of Medicine, Prince of Songkla University, Hat Yai 90110, Songkhla, Thailand
| | - Thanapon Yaowmaneerat
- Nantana-Kriangkrai Chotiwattanaphan (NKC) Institute of Gastroenterology and Hepatology, Faculty of Medicine, Prince of Songkla University, Hat Yai 90110, Songkhla, Thailand
| | - Teeravut Tubtawee
- Division of Radiology, Faculty of Medicine, Prince of Songkla University, Hat Yai 90110, Songkhla, Thailand
| | - Pattira Boonsri
- Division of Radiology, Faculty of Medicine, Prince of Songkla University, Hat Yai 90110, Songkhla, Thailand
| | - Pimsiri Sripongpun
- Gastroenterology and Hepatology Unit, Division of Internal Medicine, Faculty of Medicine, Prince of Songkla University, Hat Yai 90110, Songkhla, Thailand (P.S.)
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Wei W, Tang Y, Peng Z, Xie J, Deng Z, Yuan T, Tang C, Pi R, Wang S, Zhao S, Wang L, Li C, Wang Y, Zhang P, Wu Z, Wan Y, Ma Y, Tang W, Liang X, Liu K, Wang W, Liang X, Zeng D, Li S, Liu H. Minimal-access video-assisted retroperitoneal and/or transperitoneal debridement (VARTD) in the management of infected walled-off pancreatic necrosis with deep extension: initial experience from a prospective single-arm study. Eur J Med Res 2023; 28:72. [PMID: 36755332 PMCID: PMC9909852 DOI: 10.1186/s40001-023-01030-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/30/2022] [Accepted: 01/24/2023] [Indexed: 02/10/2023] Open
Abstract
BACKGROUND The currently preferred minimally invasive approaches have substantially improved outcomes of infected walled-off pancreatic necrosis (iWON). However, iWON with deep extension (iWONde) still poses a tricky challenge for sufficient necrosis evacuation by one stand-alone approach, often requiring repeated interventions. The aim of this study was to assess the effectiveness and safety of a minimal-access video-assisted retroperitoneal and/or transperitoneal debridement (hereafter called VARTD) in the management of iWONde. METHODS Patients who had developed an iWONde were recruited to receive the VARTD in this prospective single-arm study. The primary efficacy endpoint was clinical improvement up to day 28 after the VARTD, defined as a ≥ 75% reduction in size of necrotic collection (in any axis) on CT and clinical resolution of sepsis or organ dysfunction. The primary safety endpoint was a composite of major complications or death during follow-up. Six-month postdischarge follow-up was available. RESULTS Between July 18, 2018, and November 12, 2020, we screened 95 patients with necrotizing pancreatitis; of these, 21 iWONde patients (mean [SD] age, 42.9 [11.7] years; 10 [48%] women) were finally enrolled. The primary efficacy endpoint was achieved by most participants (14/21, 67%). No participants required repeated interventions. The primary safety endpoint occurred in six patients (29%). Except one in-hospital death attributable to repeated intra-abdominal hemorrhage, others were discharged without any major complication. CONCLUSIONS The VARTD approach appears to have a reasonable efficacy with acceptable complication rates and thus might be an option for improving clinical management of iWONde. TRIAL REGISTRATION This study is registered with Chinese Clinical Trial Registry (chictr.org.cn number, ChiCTR1800016950).
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Affiliation(s)
- Wanjie Wei
- grid.410570.70000 0004 1760 6682Department of Hepatobiliary Surgery, Daping Hospital, Army Medical University, 10 Changjiang Branch Rd, Yuzhong District, Chongqing, 400042 China
| | - Yongliang Tang
- grid.410570.70000 0004 1760 6682Department of Hepatobiliary Surgery, Daping Hospital, Army Medical University, 10 Changjiang Branch Rd, Yuzhong District, Chongqing, 400042 China
| | - Zuxiang Peng
- grid.410570.70000 0004 1760 6682Department of Hepatobiliary Surgery, Daping Hospital, Army Medical University, 10 Changjiang Branch Rd, Yuzhong District, Chongqing, 400042 China
| | - Jun Xie
- grid.410570.70000 0004 1760 6682Department of Hepatobiliary Surgery, Daping Hospital, Army Medical University, 10 Changjiang Branch Rd, Yuzhong District, Chongqing, 400042 China
| | - Zhaoxia Deng
- grid.410570.70000 0004 1760 6682Department of Emergency, Southwest Hospital, Army Medical University, Chongqing, China
| | - Tao Yuan
- grid.410570.70000 0004 1760 6682Department of Hepatobiliary Surgery, Daping Hospital, Army Medical University, 10 Changjiang Branch Rd, Yuzhong District, Chongqing, 400042 China
| | - Chun Tang
- grid.410570.70000 0004 1760 6682Department of Hepatobiliary Surgery, Daping Hospital, Army Medical University, 10 Changjiang Branch Rd, Yuzhong District, Chongqing, 400042 China
| | - Ruxian Pi
- grid.410570.70000 0004 1760 6682Department of Hepatobiliary Surgery, Daping Hospital, Army Medical University, 10 Changjiang Branch Rd, Yuzhong District, Chongqing, 400042 China
| | - Shunan Wang
- grid.410570.70000 0004 1760 6682Department of Radiology, Daping Hospital, Army Medical University, Chongqing, China
| | - Siqi Zhao
- grid.410570.70000 0004 1760 6682Department of Radiology, Daping Hospital, Army Medical University, Chongqing, China
| | - Lu Wang
- grid.410570.70000 0004 1760 6682Department of Radiology, Daping Hospital, Army Medical University, Chongqing, China
| | - Chunxue Li
- grid.410570.70000 0004 1760 6682Department of General Surgery, Daping Hospital, Army Medical University, Chongqing, China
| | - Yaoli Wang
- grid.410570.70000 0004 1760 6682Intensive Care Unit, Daping Hospital, Army Medical University, Chongqing, China
| | - Peng Zhang
- grid.410570.70000 0004 1760 6682Intensive Care Unit, Daping Hospital, Army Medical University, Chongqing, China
| | - Zhengbin Wu
- grid.410570.70000 0004 1760 6682Intensive Care Unit, Daping Hospital, Army Medical University, Chongqing, China
| | - Yafeng Wan
- grid.410570.70000 0004 1760 6682Department of Hepatobiliary Surgery, Daping Hospital, Army Medical University, 10 Changjiang Branch Rd, Yuzhong District, Chongqing, 400042 China
| | - Yan Ma
- grid.410570.70000 0004 1760 6682Department of Hepatobiliary Surgery, Daping Hospital, Army Medical University, 10 Changjiang Branch Rd, Yuzhong District, Chongqing, 400042 China
| | - Wen Tang
- grid.410570.70000 0004 1760 6682Department of Gastroenterology, Daping Hospital, Army Medical University, Chongqing, China
| | - Xianchun Liang
- grid.410570.70000 0004 1760 6682Department of Hepatobiliary Surgery, Daping Hospital, Army Medical University, 10 Changjiang Branch Rd, Yuzhong District, Chongqing, 400042 China
| | - Kun Liu
- grid.410570.70000 0004 1760 6682Department of Hepatobiliary Surgery, Daping Hospital, Army Medical University, 10 Changjiang Branch Rd, Yuzhong District, Chongqing, 400042 China
| | - Wei Wang
- grid.410570.70000 0004 1760 6682Department of Hepatobiliary Surgery, Daping Hospital, Army Medical University, 10 Changjiang Branch Rd, Yuzhong District, Chongqing, 400042 China
| | - Xianyi Liang
- grid.410570.70000 0004 1760 6682Department of Hepatobiliary Surgery, Daping Hospital, Army Medical University, 10 Changjiang Branch Rd, Yuzhong District, Chongqing, 400042 China
| | - Dongmei Zeng
- grid.410570.70000 0004 1760 6682Department of Information, Daping Hospital, Army Medical University, Chongqing, China
| | - Shan Li
- Department of Hepatobiliary Surgery, Daping Hospital, Army Medical University, 10 Changjiang Branch Rd, Yuzhong District, Chongqing, 400042, China.
| | - Hongming Liu
- Department of Hepatobiliary Surgery, Daping Hospital, Army Medical University, 10 Changjiang Branch Rd, Yuzhong District, Chongqing, 400042, China.
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Ischemic Pancreatitis Is an Important Cause of Acute Pancreatitis in the Intensive Care Unit. J Clin Gastroenterol 2023; 57:97-102. [PMID: 34974492 DOI: 10.1097/mcg.0000000000001651] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/03/2021] [Accepted: 11/12/2021] [Indexed: 12/14/2022]
Abstract
BACKGROUND Ischemic pancreatitis (IP) has mainly been described in case reports. The aims of the study were to assess the frequency, clinical characteristics and outcomes in patients with IP among patients hospitalized in the intensive care unit (ICU) for acute pancreatitis (AP). METHODS All patients with first time AP between 2011 and 2018 in the ICU of Landspitali Hospital, Iceland were retrospectively included. IP as an etiology required a clinical setting of circulatory shock, arterial hypotension, hypovolemia and/or arterial hypoxemia [PaO 2 of 60 mm Hg (8.0 kPa), or less] before the diagnosis of AP without prior history of abdominal pain to this episode. Other causes of AP were ruled out. IP patients were compared with patients with AP of other etiologies, also hospitalized in the ICU. RESULTS Overall 67 patients with AP were identified (median age 60 y, 37% females), 31% idiopathic, 24% alcoholic, 22% IP, 15% biliary, and 8% other causes. Overall, 15 (22%) fulfilled the predetermined criteria for IP, 9 males (64%), median age 62 years (interquartile range: 46 to 65). IP was preceded mainly by systemic shock (73%). Other causes included dehydration, hypoxia, or vessel occlusion to the pancreas. Necrosis of the pancreas was rare with one patient requiring pancreatic necrosectomy. Inpatient mortality was higher among patients with IP than in other patients with AP (33% vs. 14%, P =0.12). CONCLUSIONS IP was found in a significant proportion of AP patients hospitalized in the ICU. The main causes of IP were systemic shock and hypoxia. IP was associated with ∼30% mortality.
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Lopushkov AV, Turovets MI, Ekstrem AV, Popov AS, Burchuladze NS, Kitaeva AV, Vorobyova AA, Mikhin IV. [Influence of early surgery and endoscopic interventions on the risk of infection in patients with pancreatic necrosis]. Khirurgiia (Mosk) 2023:56-62. [PMID: 38010018 DOI: 10.17116/hirurgia202311156] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2023]
Abstract
OBJECTIVE To prevent purulent-septic complications in patients with destructive pancreatitis. MATERIAL AND METHODS A cohort study included 488 patients with pancreatic necrosis: group 1 (n=331) - active surgical strategy, group 2 (n=157) - follow-up and therapy. We used binary logistic regression to predict purulent-septic complications. RESULTS Original model of independent variables significantly (p<0.001) revealed 5.3 times higher risk of infectious complications after laparotomy within the first week after hospitalization. Incidence of these events increased by 2.8 times in patients biliary pancreatitis compared to alcohol-alimentary pancreatitis. Complication rate was higher in older patients (by 2.1% for each year). Risk of purulent-septic complications decreased by 57.4% in women compared to men. There was no significant correlation between risk of infectious complications and endoscopic procedures. Specificity and sensitivity of the model was 74.2 and 72.6%, respectively. CONCLUSION Original model significantly predicts the risk of purulent-septic complications within the first week after hospitalization. Refusal of early active surgical strategy in these patients will significantly reduce the likelihood of purulent-septic complications.
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Affiliation(s)
- A V Lopushkov
- Volgograd State Medical University, Volgograd, Russia
| | - M I Turovets
- Volgograd State Medical University, Volgograd, Russia
| | - A V Ekstrem
- Volgograd State Medical University, Volgograd, Russia
| | - A S Popov
- Volgograd State Medical University, Volgograd, Russia
| | | | - A V Kitaeva
- Volgograd State Medical University, Volgograd, Russia
| | - A A Vorobyova
- Volgograd State Medical University, Volgograd, Russia
| | - I V Mikhin
- Volgograd State Medical University, Volgograd, Russia
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Hocke M, Burmeister S, Braden B, Jenssen C, Arcidiacono PG, Iglesias-Garcia J, Ignee A, Larghi A, Möller K, Rimbas M, Siyu S, Vanella G, Dietrich CF. Controversies in EUS-guided treatment of walled-off necrosis. Endosc Ultrasound 2022; 11:442-457. [PMID: 35313415 PMCID: PMC9921978 DOI: 10.4103/eus-d-21-00189] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Abstract
This review gives an overview of different techniques in the treatment of post-acute complications of acute pancreatitis. The endoscopic treatment of those complications is currently standard of care. EUS opened up the broad implementation of internal drainage methods to make them safe and effective. Due to different endoscopic approaches worldwide, controversies have arisen that are pointed out in this paper. The main focus was placed on weighing up evidence to find the optimal approach. However, if no evidence can be provided, the authors, experienced in the field, give their personal advice.
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Affiliation(s)
- Michael Hocke
- Medical Department II, Helios Klinikum Meiningen, Meiningen, Germany
| | - Sean Burmeister
- Hepato-Pancreatico-Biliary Unit, Groote Schuur Hospital, Cape Town, South Africa
| | - Barbara Braden
- Translational Gastroenterology Unit, Oxford University Hospitals, Oxford, UK
| | - Christian Jenssen
- Medical Department, Krankenhaus Maerkisch-Oderland, Strausberg; Brandenburg Institute of Clinical Medicine at Medical University Brandenburg, Neuruppin, Germany
| | - Paolo Giorgio Arcidiacono
- Pancreatobiliary Endoscopy and Endosonography Division, IRCCS San Raffaele Scientific Institute, Vita-Salute San Raffaele University, Milan, Italy
| | - Julio Iglesias-Garcia
- Department of Gastroenterology and Hepatology, Health Research Institute of Santiago de Compostela (IDIS), University Hospital of Santiago de Compostela, Spain
| | - André Ignee
- Medical Department, Caritas-Krankenhaus, Bad Mergentheim, Germany
| | - Alberto Larghi
- Digestive Endoscopy Unit, Fondazione Policlinico Universitario A. Gemelli IRCCS, Rome, Italy
| | - Kathleen Möller
- Medical Department I/Gastroenterology, Sana Hospital Lichtenberg, Berlin, Germany
| | - Mihai Rimbas
- Gastroenterology and Internal Medicine Departments, Colentina Clinical Hospital, Carol Davila University of Medicine, Bucharest, Romania
| | - Sun Siyu
- Department of Endoscopy Center, Shengjing Hospital of China Medical University, Liaoning Province, China
| | - Giuseppe Vanella
- Pancreatobiliary Endoscopy and Endosonography Division, IRCCS San Raffaele Scientific Institute, Vita-Salute San Raffaele University, Milan, Italy
| | - Christoph F Dietrich
- Department Allgemeine Innere Medizin, Kliniken Hirslanden, Beau Site, Salem und Permanence, Bern, Switzerland
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8
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Jearth V, Rana SS. Endoscopic step up: When and how. Surg Open Sci 2022; 10:135-144. [PMID: 36193259 PMCID: PMC9526220 DOI: 10.1016/j.sopen.2022.09.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/24/2022] [Revised: 05/16/2022] [Accepted: 09/12/2022] [Indexed: 11/01/2022] Open
Abstract
The management of (peri)pancreatic collections has undergone a paradigm shift from open surgical drainage to minimally invasive endoscopic, percutaneous, or surgical interventions. Minimally invasive interventions are associated with less morbidity and mortality compared to open necrosectomy. The (peri)pancreatic collections are currently treated with a “step-up approach” of an initial drainage procedure followed, if necessary, by a more invasive debridement. The step-up approach for management of (peri)pancreatic collections is mainly of two types, namely, surgical and endoscopic. Surgical step up includes initial image-guided percutaneous catheter drainage followed, if necessary, by minimally invasive video-assisted retroperitoneal debridement. Endoscopic step-up approach includes endoscopic transluminal drainage followed, if necessary by direct endoscopic necrosectomy. The development of endoscopic ultrasound and lumen apposing metal stents (LAMSs) has revolutionized the endoscopic management of (peri)pancreatic collections. Compared to surgical step-up approach, endoscopic step-up treatment approach has been reported to be associated with less new-onset organ failure, pancreatic fistula, enterocutaneous fistula, or perforation of visceral organ and shorter hospital/intensive care unit stay. This review will mainly focus on indications, techniques, timing, and recent advances related to endoscopic step-up approach in management of symptomatic(peri)pancreatic collections.
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Abstract
Necrotizing pancreatitis affects 10% to 15% of all patients with acute pancreatitis. Despite improved understanding of this complex disease, it is still attended by up to 15% mortality. Necrotizing pancreatitis provides the clinical challenges of working in a multi-disciplinary group, determining proper timing for intervention, and identifying appropriate intervention approaches. The step-up approach consists of supportive care initially. When there is documented infected necrosis, treatment begins with antibiotics, progressing to minimally invasive mechanical necrosis intervention, and reserving surgery as the final treatment modality. However, treatment must be tailored to the individual patient. This article provides an overview of necrotizing pancreatitis.
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Affiliation(s)
- Thomas K Maatman
- Department of Surgery, Indiana University School of Medicine, 545 Barnhill Dr. EH 519, Indianapolis, IN 46202, USA
| | - Nicholas J Zyromski
- Department of Surgery, Indiana University School of Medicine, 545 Barnhill Dr. EH 519, Indianapolis, IN 46202, USA.
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10
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Dirweesh A, Trikudanathan G, Freeman ML. Endoscopic Management of Complications in Chronic Pancreatitis. Dig Dis Sci 2022; 67:1624-1634. [PMID: 35226223 DOI: 10.1007/s10620-022-07391-1] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 01/04/2022] [Indexed: 12/11/2022]
Abstract
PURPOSE OF REVIEW Management of complications in patients with chronic pancreatitis is often suboptimal. This review discusses detailed endoscopic approaches for managing complications in CP. LITERATURE FINDINGS CP is characterized by progressive and irreversible destruction of pancreatic parenchyma and ductal system resulting in fibrosis, scarring, and loss of glandular function. Abdominal pain remains is the most common symptom of the disease and the main aim of medical, endoscopic, and surgical therapy is to help relieve symptoms, prevent disease progression, and manage complications related to CP. In fact, advances in our understanding of CP have improved medical care and quality of life in these patients. With significant sequela, morbidity and a progressive nature, a thorough understanding of the pathophysiology, natural course, diagnostic approaches, and optimal management strategies for this disease is warranted. The existing modalities and new innovations in this field are safe, effective, and likely to have a positive impact on management of complication in CP whenever used in the right context.
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Affiliation(s)
- Ahmed Dirweesh
- Division of Gastroenterology, Hepatology and Nutrition, University of Minnesota, MMC 36, 420 Delaware St SE, Minneapolis, MN, 55455, USA
| | - Guru Trikudanathan
- Division of Gastroenterology, Hepatology and Nutrition, University of Minnesota, MMC 36, 420 Delaware St SE, Minneapolis, MN, 55455, USA
| | - Martin L Freeman
- Division of Gastroenterology, Hepatology and Nutrition, University of Minnesota, MMC 36, 420 Delaware St SE, Minneapolis, MN, 55455, USA.
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Morita M, Yokota T, Yano R, Amano M, Ochi H, Azemoto N, Mashiba T, Joko K. A case of walled-off necrosis extending into the pelvic cavity successfully treated by endoscopic necrosectomy using a lumen-apposing metal stent. DEN OPEN 2022; 2:e120. [PMID: 35873503 PMCID: PMC9302297 DOI: 10.1002/deo2.120] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 02/04/2022] [Revised: 03/31/2022] [Accepted: 04/03/2022] [Indexed: 01/04/2023]
Abstract
A 31‐year‐old man developed massive walled‐off necrosis extending into the pelvic cavity following severe acute alcoholic pancreatitis. Endoscopic ultrasound‐guided fistula drainage was performed using a lumen‐apposing metal stent, but this was insufficiently effective, and endoscopic necrosectomy was also performed, after which the patient improved. Percutaneous drainage and surgery are other options for the treatment of walled‐off necrosis extending into the pelvic cavity, but a valuable case in which the patient improved with endoscopic treatment alone is presented.
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Affiliation(s)
- Makoto Morita
- Center for Liver-Biliary-Pancreatic Diseases Matsuyama Red Cross Hospital Ehime Japan
| | - Tomoyuki Yokota
- Center for Liver-Biliary-Pancreatic Diseases Matsuyama Red Cross Hospital Ehime Japan
| | - Ryo Yano
- Center for Liver-Biliary-Pancreatic Diseases Matsuyama Red Cross Hospital Ehime Japan
| | - Michiko Amano
- Center for Liver-Biliary-Pancreatic Diseases Matsuyama Red Cross Hospital Ehime Japan
| | - Hironori Ochi
- Center for Liver-Biliary-Pancreatic Diseases Matsuyama Red Cross Hospital Ehime Japan
| | - Nobuaki Azemoto
- Center for Liver-Biliary-Pancreatic Diseases Matsuyama Red Cross Hospital Ehime Japan
| | - Toshie Mashiba
- Center for Liver-Biliary-Pancreatic Diseases Matsuyama Red Cross Hospital Ehime Japan
| | - Kouji Joko
- Center for Liver-Biliary-Pancreatic Diseases Matsuyama Red Cross Hospital Ehime Japan
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12
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Ding L, Li XY, Tan JX, Xia L, He WH, Xiong HF, Zhu Y, Liu P, Shu X, Liu ZJ, Zhu Y, Chen YX, Lu NH. Association between morphological features of necrotizing pancreatitis on endoscopic ultrasound and outcomes of the endoscopic transmural step-up approach. J Dig Dis 2022; 23:174-182. [PMID: 35076989 DOI: 10.1111/1751-2980.13083] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/18/2021] [Revised: 01/17/2022] [Accepted: 01/19/2022] [Indexed: 12/11/2022]
Abstract
OBJECTIVE To investigate the association between necrotic collections on endoscopic ultrasound (EUS) and outcomes of the endoscopic transmural step-up approach in necrotizing pancreatitis (NP). METHODS Adult NP patients who had undergone endoscopic transmural step-up approach, endoscopic transmural drainage or endoscopic transmural necrosectomy, were retrospectively enrolled, and divided into groups 1, 2 and 3 based on the amount of solid necrotic debris (quantified as a percentage of the total collection size of <30%, 30%-50%, and >50%). RESULTS A total of 134 patients were included, of whom 52, 59 and 23 patients were categorized into groups 1, 2 and 3. Patients with more solid necrotic debris required more necrosectomy sessions (group 3 vs group 2 vs group 1: 2.0 vs 1.0 vs 1.0, P < 0.001), were more likely to experience stent occlusion (group 3 vs group 2 vs group 1: 34.8% vs 16.9% vs 9.6%, P = 0.011), and had a longer hospitalization (group 3 vs group 2 vs group 1: 40.0 d vs 28.0 d vs 25.5 d, P = 0.015). High procalcitonin level (adjusted odds ratio [aOR] 6.14, 95% confidence interval [CI] 1.40-26.94, P = 0.016) and any organ failure (aOR 11.51, 95% CI 2.42-54.78, P = 0.002) were independently associated with clinical failure of endoscopic transmural step-up approach. CONCLUSIONS More solid necrotic debris on EUS is related to more necrosectomy sessions, higher incidence of stent occlusion and longer hospitalization. A nomogram combining procalcitonin and any organ failure performs well in predicting clinical failure of endoscopic transmural step-up approach.
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Affiliation(s)
- Ling Ding
- Department of Gastroenterology, First Affiliated Hospital of Nanchang University, Nanchang, Jiangxi Province, China
| | - Xue Yang Li
- Department of Gastroenterology, First Affiliated Hospital of Nanchang University, Nanchang, Jiangxi Province, China
| | - Ji Xue Tan
- Queen Mary School, Nanchang University, Nanchang, Jiangxi Province, China
| | - Liang Xia
- Department of Gastroenterology, First Affiliated Hospital of Nanchang University, Nanchang, Jiangxi Province, China
| | - Wen Hua He
- Department of Gastroenterology, First Affiliated Hospital of Nanchang University, Nanchang, Jiangxi Province, China
| | - Hui Fang Xiong
- Department of Gastroenterology, First Affiliated Hospital of Nanchang University, Nanchang, Jiangxi Province, China
| | - Yong Zhu
- Department of Gastroenterology, First Affiliated Hospital of Nanchang University, Nanchang, Jiangxi Province, China
| | - Pi Liu
- Department of Gastroenterology, First Affiliated Hospital of Nanchang University, Nanchang, Jiangxi Province, China
| | - Xu Shu
- Department of Gastroenterology, First Affiliated Hospital of Nanchang University, Nanchang, Jiangxi Province, China
| | - Zhi Jian Liu
- Department of Gastroenterology, First Affiliated Hospital of Nanchang University, Nanchang, Jiangxi Province, China
| | - Yin Zhu
- Department of Gastroenterology, First Affiliated Hospital of Nanchang University, Nanchang, Jiangxi Province, China
| | - You Xiang Chen
- Department of Gastroenterology, First Affiliated Hospital of Nanchang University, Nanchang, Jiangxi Province, China
| | - Nong Hua Lu
- Department of Gastroenterology, First Affiliated Hospital of Nanchang University, Nanchang, Jiangxi Province, China
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13
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Zhu Y, Ding L, Xia L, He W, Xiong H, Liu P, Shu X, Liu Z, Zhu Y, Chen Y, Lu N. A Novel Strategy for Transmural Stent Removal in Necrotizing Pancreatitis Undergoing Endoscopic Transmural Necrosectomy. Surg Laparosc Endosc Percutan Tech 2022; 32:197-202. [PMID: 35034066 DOI: 10.1097/sle.0000000000001013] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/26/2021] [Accepted: 07/30/2021] [Indexed: 11/26/2022]
Abstract
BACKGROUND Although metal stents have been widely used in the endoscopic step-up approach for necrotizing pancreatitis, the exact timing of transmural stent removal has not been well studied. Here, we report a novel strategy for stent removal and compare it with the conventional strategy. MATERIALS AND METHODS This retrospective, nested, case-control study analyzed all adult necrotizing pancreatitis patients who underwent endoscopic transmural necrosectomy (ETN). Clinical outcomes were compared between case group (a novel strategy in which the stents were removed during the last necrosectomy when the ETN endpoint was achieved) and 1:1 necrosis extent matched control group (the conventional strategy). RESULTS Baseline characteristics was comparable between case group (n=37) and control group (n=37). Three (8.1%) patients in case group and 1 (2.7%) patient in control group needed additional ETN after stent removal (P>0.05). Nearly all patients (case: 97.3%; control: 94.6%) achieved clinical success. There was no difference in disease-related (case: 40.5%; control: 37.8%) or stent-related (case: 27.0%; control: 16.2%) complications. Case group had a trend of shorter length of stent placement (median: 20.0 vs. 29.5 d, P>0.05). CONCLUSIONS The novel strategy of transmural stent removal during last necrosectomy might be feasible which needed further validation. Compared with the convention strategy, the novel strategy avoids one endoscopy procedure and should be considered in clinical practice.
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Affiliation(s)
- Yong Zhu
- Department of Gastroenterology, The First Affiliated Hospital of Nanchang University, Nanchang, Jiangxi Province, China
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14
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Planz V, Galgano SJ. Percutaneous biopsy and drainage of the pancreas. Abdom Radiol (NY) 2022; 47:2584-2603. [PMID: 34410433 PMCID: PMC8375282 DOI: 10.1007/s00261-021-03244-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/28/2021] [Revised: 08/05/2021] [Accepted: 08/07/2021] [Indexed: 01/18/2023]
Abstract
Percutaneous pancreatic interventions performed by abdominal radiologists play important diagnostic and therapeutic roles in the management of a wide range of pancreatic pathology. While often performed with endoscopy, pancreatic mass biopsy obtained via a percutaneous approach may serve as the only feasible option for diagnosis in patients with post-surgical anatomy, severe cardiopulmonary conditions, or prior non-diagnostic endoscopic attempts. Biopsy of pancreatic transplants are commonly performed percutaneously due to inaccessible location of the allograft by endoscopy, usually in the right lower quadrant or pelvis. Percutaneous drainage of collections in acute pancreatitis is primarily indicated for infection with clinical deterioration and may be performed alone or in combination with endoscopic drainage. Post-surgical pancreatic collections related to pancreatic duct fistula or leak also often warrant therapeutic percutaneous drainage. Knowledge of appropriate indications, strategies of approach, technique, and complications associated with these procedures is critical for a successful clinical practice.
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Affiliation(s)
- Virginia Planz
- Department of Radiology, Vanderbilt University Medical Center, Nashville, TN USA
| | - Samuel J. Galgano
- Department of Radiology, University of Alabama at Birmingham, 619 19th St S, JT J779, Birmingham, AL 35249 USA
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15
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Rahnemai-Azar AA, Sutter C, Hayat U, Glessing B, Ammori J, Tavri S. Multidisciplinary Management of Complicated Pancreatitis: What Every Interventional Radiologist Should Know. AJR Am J Roentgenol 2021; 217:921-932. [PMID: 33470838 DOI: 10.2214/ajr.20.25168] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
Management of acute pancreatitis is challenging in the presence of local complications that include pancreatic and peripancreatic collections and vascular complications. This review, targeted for interventional radiologists, describes minimally invasive endoscopic, image-guided percutaneous, and surgical procedures for management of complicated pancreatitis and provides insight into the procedures' algorithmic application. Local complications are optimally managed in a multidisciplinary team setting that includes advanced endoscopists; pancreatic surgeons; diagnostic and interventional radiologists; and specialists in infectious disease, nutrition, and critical care medicine. Large symptomatic or complicated sterile collections and secondary infected collections warrant drainage or débridement. The drainage is usually delayed for 4-6 weeks unless clinical deterioration warrants early intervention. If collections are accessible by endoscopy, endoscopic procedures are preferred to avoid pancreaticocutaneous fistulas. Image-guided percutaneous drainage is indicated for symptomatic collections that are not accessible for endoscopic drainage or that present in the acute setting before developing a mature wall. Peripancreatic arterial pseudoaneurysms should be embolized before necrosectomy procedures to prevent potentially life-threatening hemorrhage. Surgical procedures are reserved for symptomatic collections that persist despite endoscopic or interventional drainage attempts. Understanding these procedures facilitates their integration by interventional radiologists into the complex longitudinal care of patients with complicated pancreatitis.
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Affiliation(s)
- Amir Ata Rahnemai-Azar
- Department of Radiology, University Hospitals Cleveland Medical Center, Case Western Reserve University School of Medicine, 11100 Euclid Ave, Cleveland, OH 44106
| | - Christopher Sutter
- Department of Radiology, University Hospitals Cleveland Medical Center, Case Western Reserve University School of Medicine, 11100 Euclid Ave, Cleveland, OH 44106
| | - Umar Hayat
- Department of Medicine, Division of Gastroenterology, University Hospitals Cleveland Medical Center, Case Western Reserve University School of Medicine, Cleveland, OH
| | - Brooke Glessing
- Department of Medicine, Division of Gastroenterology, University Hospitals Cleveland Medical Center, Case Western Reserve University School of Medicine, Cleveland, OH
| | - John Ammori
- Department of Surgery, Division of Surgical Oncology, University Hospitals Cleveland Medical Center, Case Western Reserve University School of Medicine, Cleveland, OH
| | - Sidhartha Tavri
- Department of Radiology, University Hospitals Cleveland Medical Center, Case Western Reserve University School of Medicine, 11100 Euclid Ave, Cleveland, OH 44106
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16
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Thiruvengadam NR, Miranda J, Kim C, Behr S, Arain MA. The Pancreatitis Activity Scoring System Predicts Clinical Outcomes in Patients With Infected Pancreatic Necrosis. Pancreas 2021; 50:859-866. [PMID: 34347734 DOI: 10.1097/mpa.0000000000001838] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
OBJECTIVES The Pancreatitis Activity Scoring System (PASS) is an objective tool validated in acute pancreatitis but not in infected pancreatic necrosis (IPN). Our aim was to evaluate the role of PASS in IPN. METHODS We performed a retrospective cohort study of IPN patients admitted to the University of California, San Francisco from January 2011 to March 2019. Daily PASS scores were calculated for each patient. Receiver operator characteristic analysis was used to define the optimal cutoff PASS score to predict outcomes. The primary and secondary outcomes were 72 hours postintervention multiorgan failure (MOF) and early readmission (within 30 days), respectively. RESULTS One hundred and four patients underwent intervention (median age, 55 years). Thirty-five patients (33.6%) developed MOF postintervention. A 72-hour postintervention PASS greater than 250 was strongly associated with postintervention MOF (area under curve, 0.87; adjusted odds ratio, 26.83; 95% confidence interval, 6.37-112.86; P < 0.001). Discharge PASS greater than 150 was associated with 30-day readmission (area under curve, 0.82; adjusted odds ratio, 26.44; 95% confidence interval, 8.48-82.43; P < 0.001). CONCLUSIONS The PASS score was associated with postintervention clinical outcomes and early readmission, suggesting it is a valid measure of disease activity in patients with IPN. Further prospective validation of PASS in IPN is needed.
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Affiliation(s)
| | | | - Christopher Kim
- Abdominal Imaging Section, Department of Radiology, University of California San Francisco, San Francisco, CA
| | - Spencer Behr
- Abdominal Imaging Section, Department of Radiology, University of California San Francisco, San Francisco, CA
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17
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Thiruvengadam NR, Miranda J, Kim C, Behr S, Corvera C, Dai SC, Kirkwood K, Harris HW, Hirose K, Nakakura E, Ostroff JW, Kochman ML, Arain MA. Burden of Ionizing Radiation in the Diagnosis and Management of Necrotizing Pancreatitis. Clin Transl Gastroenterol 2021; 12:e00347. [PMID: 33904509 PMCID: PMC8081480 DOI: 10.14309/ctg.0000000000000347] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/27/2021] [Accepted: 03/12/2021] [Indexed: 02/07/2023] Open
Abstract
INTRODUCTION A step-up endoscopic or percutaneous approach improves outcomes in necrotizing pancreatitis (NP). However, these require multiple radiographic studies and fluoroscopic procedures, which use low-dose ionizing radiation. The cumulative radiation exposure for treatment of NP has not been well defined. METHODS We conducted a retrospective study of consecutive patients with NP admitted to University of California San Francisco Medical Center from January 2011 to June 2019. We calculated effective doses for fluoroscopic procedures using the dose area product and used the National Cancer Institute tool for computed tomography studies. The primary outcome was the cumulative effective dose (CED). Multivariable logistic regression was used to evaluate risk factors of high exposure (CED > 500 mSv). RESULTS One hundred seventy-one patients with NP (mean follow-up 40 ± 18 months) underwent a median of 7 (interquartile range [IQR] 5-11) computed tomography scans and 7 (IQR 5-12) fluoroscopic procedures. The median CED was 274 mSv (IQR 177-245) and 30% (51) of patients received high exposure. Risk factors of high exposure include multiorgan failure (aOR 3.47, 95%-CI: 1.53-9.88, P = 0.003), infected necrosis (adjusted odds ratio [aOR] 3.89 95%-CI:1.53-9.88, P = 0.005), and step-up endoscopic approach (aOR 1.86, 95%-CI: 1.41-1.84, P = 0.001) when compared with step-up percutaneous approach. DISCUSSION Patients with NP were exposed to a substantial amount of ionizing radiation (257 mSv) as a part of their treatment, and 30% received more than 500 mSv, which corresponds with a 5% increase in lifetime cancer risk. Severity of NP and a step-up endoscopic approach were associated with CED > 500 mSv. Further studies are needed to help develop low-radiation treatment protocols for NP, particularly in patients receiving endoscopic therapy.
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Affiliation(s)
- Nikhil R. Thiruvengadam
- Division of Gastroenterology and Hepatology, University of Pennsylvania, Philadelphia, Pennsylvania, USA
- Center for Endoscopic Innovation, Research and Training, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania, USA
- Division of Gastroenterology and Hepatology, University of California San Francisco, San Francisco, California, USA
| | - Janille Miranda
- Division of Gastroenterology and Hepatology, University of California San Francisco, San Francisco, California, USA
| | - Christopher Kim
- Abdominal Imaging Section, Department of Radiology, University of California San Francisco, San Francisco, California, USA
| | - Spencer Behr
- Abdominal Imaging Section, Department of Radiology, University of California San Francisco, San Francisco, California, USA
| | - Carlos Corvera
- Department of Surgery, University of California San Francisco, San Francisco, California, USA
| | - Sun-Chuan Dai
- Division of Gastroenterology and Hepatology, University of California San Francisco, San Francisco, California, USA
| | - Kimberly Kirkwood
- Department of Surgery, University of California San Francisco, San Francisco, California, USA
| | - Hobart W. Harris
- Department of Surgery, University of California San Francisco, San Francisco, California, USA
| | - Kenzo Hirose
- Department of Surgery, University of California San Francisco, San Francisco, California, USA
| | - Eric Nakakura
- Department of Surgery, University of California San Francisco, San Francisco, California, USA
| | - James W. Ostroff
- Division of Gastroenterology and Hepatology, University of California San Francisco, San Francisco, California, USA
| | - Michael L. Kochman
- Division of Gastroenterology and Hepatology, University of Pennsylvania, Philadelphia, Pennsylvania, USA
- Center for Endoscopic Innovation, Research and Training, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Mustafa A. Arain
- Division of Gastroenterology and Hepatology, University of California San Francisco, San Francisco, California, USA
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18
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Yasuda I, Takahashi K. Endoscopic management of walled-off pancreatic necrosis. Dig Endosc 2021; 33:335-341. [PMID: 32306430 DOI: 10.1111/den.13699] [Citation(s) in RCA: 29] [Impact Index Per Article: 9.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/26/2020] [Revised: 04/10/2020] [Accepted: 04/13/2020] [Indexed: 12/11/2022]
Abstract
Walled-off pancreatic necrosis (WON) can develop in the late phase of necrotizing pancreatitis. When the WON is accompanied by an infection in the necrotic bed, it becomes a life-threatening complication. Open necrosectomy with drainage has been the standard treatment; however, it is associated with a significant morbidity and high mortality. Therefore, minimally invasive therapeutic alternatives are in demand. Recently, a new treatment algorithm for necrotizing pancreatitis, known as the step-up approach, has been proposed. The initial report on it consisted of percutaneous drainage followed by, if necessary, a minimally invasive retroperitoneal necrosectomy. However, the endoscopic step-up approach, which consists of EUS-guided transluminal drainage followed by, if necessary, endoscopic necrosectomy, was later introduced. Recent studies have suggested that an endoscopic step-up approach might be more advantageous than a minimally invasive surgical step-up approach. A lumen apposing metal stent (LAMS) with a cautery-enhanced delivery system is currently preferred over the conventional plastic stents for endoscopic interventions, because it decreases the technical difficulty of the procedure and may obviate the need for an adjunctive debridement procedure. However, some recent findings suggest that LAMS could be associated with a higher risk of stent-related complications than conventional plastic stents, especially in patients with long-term placement. Therefore, early removal of LAMS at 3 weeks post-intervention is proposed if the WON is resolved on CT examination. Thus, endoscopic interventions have emerged as a key player in the management of WON. However, multidisciplinary treatment approaches should be considered because the endoscopic approach has limitations in treating complicated WON.
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Affiliation(s)
- Ichiro Yasuda
- Third Department of Internal Medicine, University of Toyama, Toyama, Japan
| | - Kosuke Takahashi
- Third Department of Internal Medicine, University of Toyama, Toyama, Japan
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19
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Boxhoorn L, Voermans RP, Bouwense SA, Bruno MJ, Verdonk RC, Boermeester MA, van Santvoort HC, Besselink MG. Acute pancreatitis. Lancet 2020; 396:726-734. [PMID: 32891214 DOI: 10.1016/s0140-6736(20)31310-6] [Citation(s) in RCA: 378] [Impact Index Per Article: 94.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/30/2019] [Revised: 03/20/2020] [Accepted: 05/29/2020] [Indexed: 02/07/2023]
Abstract
Acute pancreatitis is an unpredictable and potentially lethal disease. The prognosis mainly depends on the development of organ failure and secondary infection of pancreatic or peripancreatic necrosis. In the past 10 years, treatment of acute pancreatitis has moved towards a multidisciplinary, tailored, and minimally invasive approach. Despite improvements in treatment and critical care, severe acute pancreatitis is still associated with high mortality rates. In this Seminar, we outline the latest evidence on diagnostic and therapeutic strategies for acute pancreatitis.
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Affiliation(s)
- Lotte Boxhoorn
- Department of Gastroenterology and Hepatology, Amsterdam Gastroenterology Endocrinology Metabolism, Amsterdam UMC, University of Amsterdam, Amsterdam, Netherlands
| | - Rogier P Voermans
- Department of Gastroenterology and Hepatology, Amsterdam Gastroenterology Endocrinology Metabolism, Amsterdam UMC, University of Amsterdam, Amsterdam, Netherlands
| | - Stefan A Bouwense
- Department of Surgery, Maastricht University Medical Center+, Maastricht, Netherlands
| | - Marco J Bruno
- Department of Gastroenterology and Hepatology, Erasmus University Medical Center, Rotterdam, Netherlands
| | - Robert C Verdonk
- Department of Gastroenterology and Hepatology, St Antonius Hospital, Nieuwegein, Netherlands
| | - Marja A Boermeester
- Department of Surgery, Amsterdam Gastroenterology Endocrinology Metabolism, Amsterdam UMC, University of Amsterdam, Amsterdam, Netherlands
| | - Hjalmar C van Santvoort
- Department of Surgery, St Antonius Hospital, Nieuwegein, Netherlands; Department of Surgery, University Medical Center Utrecht, Utrecht, Netherlands
| | - Marc G Besselink
- Department of Surgery, Amsterdam Gastroenterology Endocrinology Metabolism, Amsterdam UMC, University of Amsterdam, Amsterdam, Netherlands.
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20
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Zhang JB, Sun B. Comparison between video-assisted retroperitoneal debridement and small incision pancreatic necrosectomy in infected pancreatic necrosis. ANZ J Surg 2020; 90:2020-2025. [PMID: 32783340 DOI: 10.1111/ans.16181] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/25/2020] [Revised: 06/25/2020] [Accepted: 07/03/2020] [Indexed: 12/13/2022]
Abstract
BACKGROUND Debridement and drainage have always been mainstream treatment for infected pancreatic necrosis (IPN), and the application of minimally invasive necrosectomy is becoming increasingly widespread. However, few studies have compared video-assisted retroperitoneal debridement (VARD) and small incision pancreatic necrosectomy (SIPN) individually. Our aim was to compare VARD and SIPN by evaluating outcomes. METHODS We retrospectively reviewed patients with IPN who underwent either VARD or SIPN between 2010 and 2019 in China. Data relative to patient demographics, major complications, health care resource utilization and mortality were collected. Statistical analyses used were the two-tailed Student's t-test and the chi-squared test. RESULTS Of 59 patients, 31 patients underwent SIPN and 28 patients were treated with VARD. SIPN and VARD had similar treatment success and mortality rates. The rate of reintervention due to lack of clinical improvement was significantly lower in the SIPN group (32% versus 61%; P = 0.028). In addition, the length of total hospital stay was 60 days in the SIPN group and 72 days in the VARD group (P < 0.0001) and mean total costs was significantly less in the SIPN group than in the VARD group (P = 0.008). CONCLUSION Given the shorter hospitalization period, lower total cost and lower rate of reinterventions, SIPN may be superior to the step-up approach for patients with IPN than for those with VARD.
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Affiliation(s)
- Jin-Bao Zhang
- Department of Pancreatic and Biliary Surgery, The First Affiliated Hospital of Harbin Medical University, Harbin, China
| | - Bei Sun
- Department of Pancreatic and Biliary Surgery, The First Affiliated Hospital of Harbin Medical University, Harbin, China.,Key Laboratory of Hepatosplenic Surgery, Ministry of Education, Harbin, China
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21
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Baron TH, DiMaio CJ, Wang AY, Morgan KA. American Gastroenterological Association Clinical Practice Update: Management of Pancreatic Necrosis. Gastroenterology 2020; 158:67-75.e1. [PMID: 31479658 DOI: 10.1053/j.gastro.2019.07.064] [Citation(s) in RCA: 303] [Impact Index Per Article: 75.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/06/2019] [Revised: 07/08/2019] [Accepted: 07/31/2019] [Indexed: 12/12/2022]
Abstract
DESCRIPTION The purpose of this American Gastroenterological Association (AGA) Institute Clinical Practice Update is to review the available evidence and expert recommendations regarding the clinical care of patients with pancreatic necrosis and to offer concise best practice advice for the optimal management of patients with this highly morbid condition. METHODS This expert review was commissioned and approved by the AGA Institute Clinical Practice Updates Committee and the AGA Governing Board to provide timely guidance on a topic of high clinical importance to the AGA membership, and underwent internal peer review by the Clinical Practice Updates Committee and external peer review through standard procedures of Gastroenterology. This review is framed around the 15 best practice advice points agreed upon by the authors, which reflect landmark and recent published articles in this field. This expert review also reflects the experiences of the authors, who are advanced endoscopists or hepatopancreatobiliary surgeons with extensive experience in managing and teaching others to care for patients with pancreatic necrosis. BEST PRACTICE ADVICE 1: Pancreatic necrosis is associated with substantial morbidity and mortality and optimal management requires a multidisciplinary approach, including gastroenterologists, surgeons, interventional radiologists, and specialists in critical care medicine, infectious disease, and nutrition. In situations where clinical expertise may be limited, consideration should be given to transferring patients with significant pancreatic necrosis to an appropriate tertiary-care center. BEST PRACTICE ADVICE 2: Antimicrobial therapy is best indicated for culture-proven infection in pancreatic necrosis or when infection is strongly suspected (ie, gas in the collection, bacteremia, sepsis, or clinical deterioration). Routine use of prophylactic antibiotics to prevent infection of sterile necrosis is not recommended. BEST PRACTICE ADVICE 3: When infected necrosis is suspected, broad-spectrum intravenous antibiotics with ability to penetrate pancreatic necrosis should be favored (eg, carbapenems, quinolones, and metronidazole). Routine use of antifungal agents is not recommended. Computed tomography-guided fine-needle aspiration for Gram stain and cultures is unnecessary in the majority of cases. BEST PRACTICE ADVICE 4: In patients with pancreatic necrosis, enteral feeding should be initiated early to decrease the risk of infected necrosis. A trial of oral nutrition is recommended immediately in patients in whom there is absence of nausea and vomiting and no signs of severe ileus or gastrointestinal luminal obstruction. When oral nutrition is not feasible, enteral nutrition by either nasogastric/duodenal or nasojejunal tube should be initiated as soon as possible. Total parenteral nutrition should be considered only in cases where oral or enteral feeds are not feasible or tolerated. BEST PRACTICE ADVICE 5: Drainage and/or debridement of pancreatic necrosis is indicated in patients with infected necrosis. Drainage and/or debridement may be required in patients with sterile pancreatic necrosis and persistent unwellness marked by abdominal pain, nausea, vomiting, and nutritional failure or with associated complications, including gastrointestinal luminal obstruction; biliary obstruction; recurrent acute pancreatitis; fistulas; or persistent systemic inflammatory response syndrome. BEST PRACTICE ADVICE 6: Pancreatic debridement should be avoided in the early, acute period (first 2 weeks), as it has been associated with increased morbidity and mortality. Debridement should be optimally delayed for 4 weeks and performed earlier only when there is an organized collection and a strong indication. BEST PRACTICE ADVICE 7: Percutaneous drainage and transmural endoscopic drainage are both appropriate first-line, nonsurgical approaches in managing patients with walled-off pancreatic necrosis (WON). Endoscopic therapy through transmural drainage of WON may be preferred, as it avoids the risk of forming a pancreatocutaneous fistula. BEST PRACTICE ADVICE 8: Percutaneous drainage of pancreatic necrosis should be considered in patients with infected or symptomatic necrotic collections in the early, acute period (<2 weeks), and in those with WON who are too ill to undergo endoscopic or surgical intervention. Percutaneous drainage should be strongly considered as an adjunct to endoscopic drainage for WON with deep extension into the paracolic gutters and pelvis or for salvage therapy after endoscopic or surgical debridement with residual necrosis burden. BEST PRACTICE ADVICE 9: Self-expanding metal stents in the form of lumen-apposing metal stents appear to be superior to plastic stents for endoscopic transmural drainage of necrosis. BEST PRACTICE ADVICE 10: The use of direct endoscopic necrosectomy should be reserved for those patients with limited necrosis who do not adequately respond to endoscopic transmural drainage using large-bore, self-expanding metal stents/lumen-apposing metal stents alone or plastic stents combined with irrigation. Direct endoscopic necrosectomy is a therapeutic option in patients with large amounts of infected necrosis, but should be performed at referral centers with the necessary endoscopic expertise and interventional radiology and surgical backup. BEST PRACTICE ADVICE 11: Minimally invasive operative approaches to the debridement of acute necrotizing pancreatitis are preferred to open surgical necrosectomy when possible, given lower morbidity. BEST PRACTICE ADVICE 12: Multiple minimally invasive surgical techniques are feasible and effective, including videoscopic-assisted retroperitoneal debridement, laparoscopic transgastric debridement, and open transgastric debridement. Selection of approach is best determined by pattern of disease, physiology of the patient, experience and expertise of the multidisciplinary team, and available resources. BEST PRACTICE ADVICE 13: Open operative debridement maintains a role in the modern management of acute necrotizing pancreatitis in cases not amenable to less invasive endoscopic and/or surgical procedures. BEST PRACTICE ADVICE 14: For patients with disconnected left pancreatic remnant after acute necrotizing mid-body necrosis, definitive surgical management with distal pancreatectomy should be undertaken in patients with reasonable operative candidacy. Insufficient evidence exists to support the management of the disconnected left pancreatic remnant with long-term transenteric endoscopic stenting. BEST PRACTICE ADVICE 15: A step-up approach consisting of percutaneous drainage or endoscopic transmural drainage using either plastic stents and irrigation or self-expanding metal stents/lumen-apposing metal stents alone, followed by direct endoscopic necrosectomy, and then surgical debridement is reasonable, although approaches may vary based on the available clinical expertise.
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Affiliation(s)
- Todd H Baron
- Division of Gastroenterology and Hepatology, University of North Carolina, Chapel Hill, North Carolina
| | - Christopher J DiMaio
- Division of Gastroenterology, Icahn School of Medicine at Mount Sinai, New York, New York
| | - Andrew Y Wang
- Division of Gastroenterology and Hepatology, University of Virginia, Charlottesville, Virginia.
| | - Katherine A Morgan
- Division of Gastrointestinal and Laparoscopic Surgery, Medical University of South Carolina, Charleston, South Carolina
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22
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Rana SS, Verma S, Kang M, Gorsi U, Sharma R, Gupta R. Comparison of endoscopic versus percutaneous drainage of symptomatic pancreatic necrosis in the early (< 4 weeks) phase of illness. Endosc Ultrasound 2020; 9:402-409. [PMID: 33318376 PMCID: PMC7811710 DOI: 10.4103/eus.eus_65_20] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/12/2022] Open
Abstract
Background and Objective Pancreatic fluid collections in early phase of illness <4 weeks after onset of acute pancreatitis (AP) are usually treated with percutaneous drainage (PCD). There is a paucity of data comparing early (<4 weeks) endoscopic transluminal drainage (ETD) with PCD in patients with symptomatic pancreatic necrosis (PN). The objective of this study is to compare the safety and efficacy of early ETD with PCD in patients with symptomatic PN. Patients and Methods Retrospective analysis of database of patients with symptomatic PN treated early (<4 weeks of onset of AP) with either ETD (encapsulated wall on EUS) or PCD. Results Twenty-three patients (19 M; mean age: 36.1 years) were treated with ETD and 41 patients (29 M; mean age: 39.6 years) were treated with PCD, respectively. ETD and PCD were done 24.2 ± 2.3 and 24.2 ± 2.0 days after onset of AP, respectively (P = 0.84). In the ETD group, 35% of patients were treated with self-expanding metallic stents and 48% of patients required direct endoscopic necrosectomy. In the PCD group, 74% of patients were treated with multiple catheters and 91% of patients with either saline or streptokinase irrigation. As compared to the ETD group, patients in the PCD group took longer time for resolution (61.9 ± 22.9 days vs. 30.9 ± 5.6 days; P < 0.00001), increased need for surgery (30% vs. 4%; P = 0.01), and frequency of formation of external pancreatic fistula (EPF) (22% vs. nil; P = 0.02). Conclusions ETD of PN in early phase of illness is associated with a shorter duration for resolution and infrequent need of salvage surgery compared to PCD. EPF formation is a significant adverse event with PCD.
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Affiliation(s)
- Surinder Singh Rana
- Department of Gastroenterology, Postgraduate Institute of Medical Education and Research, Chandigarh, India
| | - Suhang Verma
- Department of Gastroenterology, Postgraduate Institute of Medical Education and Research, Chandigarh, India
| | - Mandeep Kang
- Department of Radiodiagnosis, Postgraduate Institute of Medical Education and Research, Chandigarh, India
| | - Ujjwal Gorsi
- Department of Radiodiagnosis, Postgraduate Institute of Medical Education and Research, Chandigarh, India
| | - Ravi Sharma
- Department of Gastroenterology, Postgraduate Institute of Medical Education and Research, Chandigarh, India
| | - Rajesh Gupta
- Department of Surgical Gastroenterology, Postgraduate Institute of Medical Education and Research, Chandigarh, India
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23
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Rerknimitr R. Endoscopic Transmural Necrosectomy: Timing, Indications, and Methods. Clin Endosc 2019; 53:49-53. [PMID: 31530792 PMCID: PMC7003012 DOI: 10.5946/ce.2019.131] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/02/2019] [Accepted: 08/22/2019] [Indexed: 12/31/2022] Open
Abstract
Walled-off necrosis is considered one of the most severe complications after an episode of severe acute pancreatitis. Traditionally, percutaneous drainage is selected as the first treatment step, while open surgery can be planned as a secondary option if necrosectomy is required. In recent years, endoscopic necrosectomy has evolved as a more favorable approach. To date, a step-up treatment strategy is recommended, particularly when a plastic stent is selected as the drainage device. Multi-gateway endoscopic therapy may be used in a step-up fashion if only one stent fails to clear debris. Over many years, there has been an evolution in stent selection, from plastic to metallic stents. Within a few years of its clinical usage, lumen-apposing stents are gaining more popularity as they offer direct endoscopic necrosectomy and only require a few sessions.
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Affiliation(s)
- Rungsun Rerknimitr
- Division of Gastroenterology, Department of Medicine, Faculty of Medicine, Chulalongkorn University and King Chulalongkorn Memorial Hospital, Bangkok, Thailand.,Center of Excellence for Innovation and Endoscopy in Gastrointestinal Oncology, Chulalongkorn University, Bangkok, Thailand
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24
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Nguyen AK, Song AJ, Swopes T, Ko A, Lim BS. Percutaneous Endoscopic Necrosectomy of Complex Walled-Off Lateral Necrosis of the Pancreas with the Aid of Laparoscopic Babcock Forceps: A Case Report of an Endoscopic and Radiologic Team Approach. Perm J 2019; 23:18-230. [PMID: 31314716 DOI: 10.7812/tpp/18-230] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/24/2023]
Abstract
INTRODUCTION The initial therapeutic intervention for infected necrotizing pancreatitis usually begins with endoscopic cystogastrostomy for drainage, followed by endoscopic necrosectomy. Endoscopic pancreatic necrosectomy is commonly performed transluminally through transgastric or transduodenal routes. This case describes necrosectomy via a transcutaneous route for laterally located walled-off pancreatic necrosis and the novel use of Babcock forceps for an obstructed fully covered metal stent. CASE PRESENTATION A 62-year-old woman presented with abdominal pain, nausea, and vomiting. After multiple admissions and repeated abdominal imaging, she was found to have laterally located, infected, walled-off pancreatic necrosis. Initially, a drainage catheter was placed by an interventional radiologist and was eventually upsized to a 28F catheter. Subsequently, a fully covered metal stent was placed in the gastroenterology suite under fluoroscopic guidance and was used to gain access for percutaneous sessions of necrosectomy. A percutaneous sinus tract endoscopic necrosectomy was performed under direct endoscopic view. However, difficulties occurred with removing necrotic debris even through this large covered stent. Thus, laparoscopic Babcock forceps were used under fluoroscopy to remove lodged debris from the midstent. Repeat abdominal computed tomography scan 3 days after necrosectomy showed near resolution of the walled-off pancreatic necrosis. DISCUSSION This Babcock technique with endoscopic necrosectomy has not been previously described in the literature, to our knowledge. Babcock forceps were an ideal tool in our case because they were able to gain access to the obstruction in the stent, but the "teeth" are small and dull enough to prevent from catching onto the metal stent mesh.
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Affiliation(s)
- Andrew K Nguyen
- University of California, Riverside, School of Medicine.,Department of Internal Medicine, Riverside Medical Center, CA
| | - Andrew J Song
- Department of Radiology, Riverside Medical Center, CA
| | - Tanya Swopes
- Department of Surgery, Riverside Medical Center, CA
| | - Albert Ko
- Department of Surgery, Riverside Medical Center, CA
| | - Brian S Lim
- University of California, Riverside, School of Medicine.,Department of Gastroenterology, Riverside Medical Center, CA
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25
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Trikudanathan G, Wolbrink DRJ, van Santvoort HC, Mallery S, Freeman M, Besselink MG. Current Concepts in Severe Acute and Necrotizing Pancreatitis: An Evidence-Based Approach. Gastroenterology 2019; 156:1994-2007.e3. [PMID: 30776347 DOI: 10.1053/j.gastro.2019.01.269] [Citation(s) in RCA: 172] [Impact Index Per Article: 34.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/08/2018] [Revised: 01/01/2019] [Accepted: 01/15/2019] [Indexed: 02/07/2023]
Abstract
The incidence of acute pancreatitis continues to rise, inducing substantial medical and social burden, with annual costs exceeding $2 billion in the United States alone. Although most patients develop mild pancreatitis, 20% develop severe and/or necrotizing pancreatitis, requiring advanced medical and interventional care. Morbidity resulting from local and systemic complications as well as invasive interventions result in mortality rates historically as high as 30%. There has been substantial evolution of strategies for interventions in recent years, from open surgery to minimally invasive surgical and endoscopic step-up approaches. In contrast to the advances in invasive procedures for complications, early management still lacks curative options and consists of adequate fluid resuscitation, analgesics, and monitoring. Many challenges remain, including comprehensive management of the entire spectrum of the disease, which requires close involvement of multiple disciplines at specialized centers.
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Affiliation(s)
- Guru Trikudanathan
- Division of Gastroenterology, Hepatology and Nutrition, University of Minnesota, Minneapolis, Minnesota.
| | | | - Hjalmar C van Santvoort
- Department of Surgery, the University Medical Center Utrecht and the St. Antonius Hospital Nieuwegein, the Netherlands
| | - Shawn Mallery
- Division of Gastroenterology, Hepatology and Nutrition, University of Minnesota, Minneapolis, Minnesota
| | - Martin Freeman
- Division of Gastroenterology, Hepatology and Nutrition, University of Minnesota, Minneapolis, Minnesota
| | - Marc G Besselink
- Department of Surgery, Amsterdam Gastroenterology and Metabolism, Amsterdam UMC, University of Amsterdam, the Netherlands
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26
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Tamura T, Itonaga M, Tanioka K, Kawaji Y, Nuta J, Hatamaru K, Yamashita Y, Yoshida T, Ida Y, Maekita T, Iguchi M, Kitano M. Radical treatment for walled-off necrosis: Transmural nasocyst continuous irrigation. Dig Endosc 2019; 31:307-315. [PMID: 30565758 DOI: 10.1111/den.13319] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/25/2018] [Accepted: 12/13/2018] [Indexed: 02/08/2023]
Abstract
BACKGROUND AND AIM Treatment efficiency of walled-off necrosis (WON) using endoscopic ultrasound-guided drainage (EUS-D) with a double pigtail stent (DPS) is limited. Endoscopic necrosectomy is often carried out if EUS-D fails. However, endoscopic necrosectomy is associated with significant morbidity and mortality. Thus, we developed transmural nasocyst continuous irrigation (TNCCI) as an alternative therapeutic option for WON. This study aimed to evaluate the usefulness of TNCCI therapy for WON. METHODS Between April 2009 and March 2018, 19 of 39 patients admitted with WON underwent EUS-D. Ten consecutive patients also received TNCCI therapy (TNCCI group) between May 2015 and March 2018. TNCCI was carried out by inserting an external tube from the gastroduodenal lumen into the WON under endoscopic ultrasonography guidance and then continuously irrigating the WON with saline at a rate of 40 ml/h. Nine consecutive patients who underwent EUS-D without TNCCI therapy between April 2009 and April 2015 were used for comparison (control group). Various parameters were compared between the TNCCI and control groups. RESULTS Time taken to reduce WON (6 vs 32 days, P = 0.001), implementation rate of endoscopic necrosectomy (0% vs 55.6%, P = 0.01), and number of endoscopic necrosectomy sessions per patient (0 vs 0.8 ± 1.0, P = 0.008) were significantly lower in the TNCCI group than in the control group. CONCLUSIONS Walled-off necrosis can be effectively and safely treated by endoscopic drainage with a DPS and TNCCI. This technique can be an alternative therapeutic option before carrying out endoscopic necrosectomy.
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Affiliation(s)
- Takashi Tamura
- Second Department of Internal Medicine, Wakayama Medical University, Wakayama, Japan
| | - Masahiro Itonaga
- Second Department of Internal Medicine, Wakayama Medical University, Wakayama, Japan
| | - Kensuke Tanioka
- Clinical Study Support Center, Wakayama Medical University Hospital, Wakayama, Japan
| | - Yuki Kawaji
- Second Department of Internal Medicine, Wakayama Medical University, Wakayama, Japan
| | - Junya Nuta
- Second Department of Internal Medicine, Wakayama Medical University, Wakayama, Japan
| | - Keiichi Hatamaru
- Second Department of Internal Medicine, Wakayama Medical University, Wakayama, Japan
| | - Yasunobu Yamashita
- Second Department of Internal Medicine, Wakayama Medical University, Wakayama, Japan
| | - Takeichi Yoshida
- Second Department of Internal Medicine, Wakayama Medical University, Wakayama, Japan
| | - Yoshiyuki Ida
- Second Department of Internal Medicine, Wakayama Medical University, Wakayama, Japan
| | - Takao Maekita
- Second Department of Internal Medicine, Wakayama Medical University, Wakayama, Japan
| | - Mikitaka Iguchi
- Second Department of Internal Medicine, Wakayama Medical University, Wakayama, Japan
| | - Masayuki Kitano
- Second Department of Internal Medicine, Wakayama Medical University, Wakayama, Japan
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Endoscopic Transgastric Versus Surgical Approach for Infected Necrotizing Pancreatitis: A Systematic Review and Meta-Analysis. Surg Laparosc Endosc Percutan Tech 2019; 29:141-149. [PMID: 30676541 DOI: 10.1097/sle.0000000000000632] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
Surgical approach (SA) is the standard treatment for infected necrotizing pancreatitis (INP) and endoscopic transgastric approach (ETA) is a promising alternative treatment. This systematic review and meta-analysis aimed to compare the effectiveness and safety of ETA versus SA in INP. Several databases were systematically searched for eligible studies that compared ETA with SA for INP. Predefined criteria were used for study selection. Three reviewers independently assessed the risk of bias. Primary outcomes included clinical resolution rate, short-term mortality, major complications, and hospital stay. Study-specific effect sizes and their 95% confidence interval (CI) were combined to calculate the pooled value using fixed-effects or random-effects model. Six studies were included with 295 patients. Major complication rate [odds ratio (OR), 0.13; 95% CI, 0.06-0.29], new-onset organ failure rate (OR, 0.26; 95% CI, 0.12-0.54), postoperative pancreatic fistula rate (OR, 0.09; 95% CI, 0.03-0.28), and incisional hernia rate (OR, 0.10; 95% CI, 0.01-0.85) were lower in the ETA group. There was a shorter hospital stay (mean difference, -17.72; 95% CI, -21.30 to -14.13) in the ETA group. No differences were found in clinical resolution, short-term mortality, postoperative bleeding, perforation of visceral organ, and endocrine or exocrine insufficiency. Compared with SA, ETA showed comparable effectiveness and safety for the treatment of INP based on current evidence.
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28
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Woo S, Walklin R, Ackermann T, Lo SW, Shilton H, Pilgrim C, Evans P, Burnes J, Croagh D. Comparison of endoscopic and percutaneous drainage of symptomatic necrotic collections in acute necrotizing pancreatitis. Asian J Endosc Surg 2019; 12:88-94. [PMID: 29747233 DOI: 10.1111/ases.12490] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/02/2018] [Revised: 03/08/2018] [Accepted: 03/18/2018] [Indexed: 12/17/2022]
Abstract
INTRODUCTION Primary endoscopic and percutaneous drainage for pancreatic necrotic collections is increasingly used. We aim to compare the relative effectiveness of both modalities in reducing the duration and severity of illness by measuring their effects on systemic inflammatory response syndrome (SIRS). METHODS We retrospectively reviewed all cases of endoscopic and percutaneous drainage for pancreatic necrotic collections performed in 2011-2016 at two hospitals. We assessed the post-procedure length of hospital stay, reduction in C-reactive protein levels, resolution of SIRS, the complication rates, and the number of procedures required for resolution. RESULTS Thirty-two patients were identified and 57 cases (36 endoscopic, 21 percutaneous) were included. There was no significant difference in C-reactive protein reduction between endoscopic and percutaneous drainage (69.5% vs 68.8%, P = 0.224). Resolution of SIRS was defined as the post-procedure normalization of white cell count (endoscopic vs percutaneous: 70.4% vs 64.3%, P = 0.477), temperature (endoscopic vs percutaneous: 93.3% vs 60.0%, P = 0.064), heart rate (endoscopic vs percutaneous: 56.0% vs 11.1%, P = 0.0234), and respiratory rate (endoscopic vs percutaneous: 83.3% vs 0.0%, P = 0.00339). Post-procedure length of hospital stay was 27 days with endoscopic drainage and 46 days with percutaneous drainage (P = 0.0183). CONCLUSION Endoscopic drainage was associated with a shorter post-procedure length of hospital stay and a greater rate of normalization of SIRS parameters than percutaneous drainage, although only the effects on heart rate and respiratory rate reached statistical significance. Further studies are needed to establish which primary drainage modality is superior for pancreatic necrotic collections.
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Affiliation(s)
- Shanan Woo
- Department of Surgery, School of Clinical Sciences at Monash Health, Monash University, Melbourne, Victoria, Australia.,Department of Upper Gastrointestinal/Hepatopancreaticobiliary Surgery, Monash Health, Melbourne, Victoria, Australia
| | - Ryan Walklin
- Monash Imaging, Monash Health, Melbourne, Victoria, Australia
| | - Travis Ackermann
- Department of Upper Gastrointestinal/Hepatopancreaticobiliary Surgery, Monash Health, Melbourne, Victoria, Australia.,Department of Upper Gastrointestinal Surgery, Peninsula Health, Melbourne, Victoria, Australia
| | - Sheng Wei Lo
- Department of Upper Gastrointestinal Surgery, Peninsula Health, Melbourne, Victoria, Australia
| | - Hamish Shilton
- Department of Upper Gastrointestinal/Hepatopancreaticobiliary Surgery, Monash Health, Melbourne, Victoria, Australia.,Department of Upper Gastrointestinal Surgery, Peninsula Health, Melbourne, Victoria, Australia
| | - Charles Pilgrim
- Department of Upper Gastrointestinal Surgery, Peninsula Health, Melbourne, Victoria, Australia
| | - Peter Evans
- Department of Upper Gastrointestinal Surgery, Peninsula Health, Melbourne, Victoria, Australia
| | - James Burnes
- Department of Surgery, School of Clinical Sciences at Monash Health, Monash University, Melbourne, Victoria, Australia.,Monash Imaging, Monash Health, Melbourne, Victoria, Australia
| | - Daniel Croagh
- Department of Surgery, School of Clinical Sciences at Monash Health, Monash University, Melbourne, Victoria, Australia.,Department of Upper Gastrointestinal/Hepatopancreaticobiliary Surgery, Monash Health, Melbourne, Victoria, Australia
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29
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Abstract
PURPOSE OF REVIEW Acute pancreatitis can result in a number of localized complications such as pancreatic pseudocysts, walled-off pancreatic necrosis (WON), and disconnected pancreatic duct syndrome (DPDS). The management of these conditions has evolved over the past three decades such that minimally invasive endoscopic drainage and debridement methods are now the favored, first-line approach. This article will review the latest developments and controversies regarding the endoscopic management of these conditions. RECENT FINDINGS For patients with pancreatic pseudocysts, it remains to be clear what the role of routine ERCP is in this population. For WON, it is clear that when expertise is available, a minimally invasive approach may be the most suitable option. There is a growing literature raising concern about LAMS-associated bleeding in this group, however. Alterations in LAMS placement and stent dwell time may reduce this risk. Lastly, recognition of the DPDS is an important factor that needs to be recognized whenever present, as these patients will require a long-term management strategy and may require multimodality intervention. SUMMARY Despite the development of new endoscopic techniques and dedicated devices for managing pancreatic fluid collections and disconnected pancreatic duct syndrome, a number of issues remain unresolved in terms of best practice methods.
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