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Liu Z, Liu P, Xu X, Yao Q, Xiong Y. Timing of minimally invasive step-up intervention for symptomatic pancreatic necrotic fluid collections: A systematic review and meta-analysis. Clin Res Hepatol Gastroenterol 2023; 47:102105. [PMID: 36858278 DOI: 10.1016/j.clinre.2023.102105] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/25/2022] [Revised: 02/17/2023] [Accepted: 02/24/2023] [Indexed: 03/03/2023]
Abstract
BACKGROUND AND AIMS Minimally invasive step-up interventions are now the standard treatment recommended by current guidelines for symptomatic pancreatic necrotic fluid collections (PNFC); however, it is controversial whether delayed treatment after four weeks should always be used in patients who have failed conservative treatment and whose condition has not improved or worsened. The aim of this meta-analysis was to evaluate the impacts of the different timing of interventions on the clinical outcomes and prognosis of patients with symptomatic PNEC requiring intervention. METHODS We searched Embase, Cochrane Library, PubMed and Web of Science databases to identify comparative studies assessing the safety and efficacy of early and postponed interventions in treating symptomatic PNFC. PRIMARY OUTCOME Mortality. Secondary outcomes included some major complications, need for further minimally invasive necrosectomy and length of hospital stay. RESULTS This meta-analysis included ten studies (2 RCTs and 8 observational studies) with a total of 1178 symptomatic PNFC patients who required intervention. Pooled results showed that there was no significant difference between early minimally invasive intervention and postponed intervention in mortality(OR 1.41, 95%CI 0.93-2.12;p = 0.10) and the incidence of early and late complications, but the early intervention group had a significantly increased need for further minimally invasive necrosectomy compared with postponed intervention (OR 2.04,95%CI 1.04-4.03; p = 0.04). There was no increase in length of stay for patients who received early intervention compared to postponed drainage (MD 3.53, 95% CI -4.20, 11.27; p = 0.37). CONCLUSION Intervention before four weeks should be considered for patients with PNFC complicated by persistent organ failure or infections, who have been treated conservatively to the maximum extent possible.
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Affiliation(s)
- ZheYu Liu
- Department of Gastroenterology, The First Affiliated Hospital of Nanchang University, Nanchang, Jiangxi, China
| | - Pi Liu
- Department of Gastroenterology, Affiliated Longhua People's Hospital, Southern Medical University, 518109, Shenzhen, China.
| | - Xuan Xu
- Department of Gastroenterology, The First Affiliated Hospital of Nanchang University, Nanchang, Jiangxi, China
| | - Qian Yao
- Department of Gastroenterology, The First Affiliated Hospital of Nanchang University, Nanchang, Jiangxi, China
| | - YuWen Xiong
- Department of Gastroenterology, The First Affiliated Hospital of Nanchang University, Nanchang, Jiangxi, China
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2
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Tsujimae M, Shiomi H, Sakai A, Masuda A, Inomata N, Kohashi S, Nagao K, Uemura H, Masuda S, Gonda M, Abe S, Ashina S, Yamakawa K, Tanaka T, Nakano R, Kobayashi T, Kodama Y. Computed tomography imaging-based predictors of the need for a step-up approach after initial endoscopic ultrasound-guided transmural drainage for pancreatic fluid collections. Surg Endosc 2023; 37:1096-106. [PMID: 36123547 DOI: 10.1007/s00464-022-09610-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/14/2022] [Accepted: 09/03/2022] [Indexed: 12/03/2022]
Abstract
BACKGROUND A step-up approach is recommended as a new treatment algorithm for pancreatic fluid collections (PFCs). However, determining which patients with PFCs require a step-up approach after endoscopic ultrasound-guided transmural drainage (EUS-TD) is unclear. If the need for a step-up approach could be predicted, it could be performed early for relevant patients. We aimed to identify PFC-related predictive factors for a step-up approach after EUS-TD. METHODS This retrospective cohort study included consecutive patients who had undergone EUS-TD for PFCs from January 2008 to May 2020. Multivariable logistic regression analyses were performed to investigate PFC factors related to requiring a step-up approach. A step-up approach was performed for patients who did not respond clinically to EUS-TD. RESULTS We enrolled 81 patients, of whom 25 (30.9%) required a step-up approach. In multivariate logistic regression analysis, the pre-EUS-TD number of PFC-occupied regions ≥ 3 (multivariate odds ratio [OR] 16.2, 95% confidence interval [CI] 2.68-97.6, P = 0.002), the post-EUS-TD PFC-remaining percentage ≥ 35% (multivariate OR 19.9, 95% CI 2.91-136.1, P = 0.002), and a positive sponge sign, which is a distinctive computed tomography finding in the early stage after EUS-TD (multivariate OR 6.26, 95% CI 1.33-29.3, P = 0.020), were independent predictive factors associated with requiring a step-up approach for PFCs. CONCLUSION Pre-EUS-TD PFC-occupied regions, post-EUS-TD PFC-remaining percentage, and a positive sponge sign were predictors of the need for a step-up approach. Patients with PFC with these findings should be offered a step-up approach whereas conservative treatment is recommended for patients without these findings. CLINICAL REGISTRATION NUMBER UMIN 000030898.
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3
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Brisinda G, Chiarello MM, Tropeano G, Altieri G, Puccioni C, Fransvea P, Bianchi V. SARS-CoV-2 and the pancreas: What do we know about acute pancreatitis in COVID-19 positive patients? World J Gastroenterol 2022; 28:5240-5249. [PMID: 36185634 PMCID: PMC9521525 DOI: 10.3748/wjg.v28.i36.5240] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/17/2022] [Revised: 06/23/2022] [Accepted: 09/07/2022] [Indexed: 02/06/2023] Open
Abstract
Severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) can cause pancreatic damage, both directly to the pancreas via angiotensin-converting enzyme 2 receptors (the transmembrane proteins required for SARS-CoV-2 entry, which are highly expressed by pancreatic cells) and indirectly through locoregional vasculitis and thrombosis. Despite that, there is no clear evidence that SARS-CoV-2 is an etiological agent of acute pancreatitis. Acute pancreatitis in coronavirus disease 2019 (COVID-19) positive patients often recognizes biliary or alcoholic etiology. The prevalence of acute pancreatitis in COVID-19 positive patients is not exactly known. However, COVID-19 positive patients with acute pancreatitis have a higher mortality and an increased risk of intensive care unit admission and necrosis compared to COVID-19 negative patients. Acute respiratory distress syndrome is the most frequent cause of death in COVID-19 positive patients and concomitant acute pancreatitis. In this article, we reported recent evidence on the correlation between COVID-19 infection and acute pancreatitis.
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Affiliation(s)
- Giuseppe Brisinda
- Department of Medical and Surgical Sciences, Fondazione Policlinico Universitario A Gemelli IRCCS, Rome 00168, Italy
- Department of Medicine and Surgery, Università Cattolica del Sacro Cuore, Rome 00168, Italy
| | | | - Giuseppe Tropeano
- Emergency Surgery and Trauma Center, Fondazione Policlinico Universitario A Gemelli IRCCS, Rome 00168, Italy
| | - Gaia Altieri
- Emergency Surgery and Trauma Center, Fondazione Policlinico Universitario A Gemelli IRCCS, Rome 00168, Italy
| | - Caterina Puccioni
- Emergency Surgery and Trauma Center, Fondazione Policlinico Universitario A Gemelli IRCCS, Rome 00168, Italy
| | - Pietro Fransvea
- Emergency Surgery and Trauma Center, Fondazione Policlinico Universitario A Gemelli IRCCS, Rome 00168, Italy
| | - Valentina Bianchi
- Emergency Surgery and Trauma Center, Fondazione Policlinico Universitario A Gemelli IRCCS, Rome 00168, Italy
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4
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Francois S, Aerts M, Reynaert H, Van Lancker R, Van Laethem J, Kunda R, Messaoudi N. Step-up approach in emphysematous hepatitis: A case report. World J Hepatol 2022; 14:464-470. [PMID: 35317184 PMCID: PMC8891666 DOI: 10.4254/wjh.v14.i2.464] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/05/2021] [Revised: 12/27/2021] [Accepted: 01/12/2022] [Indexed: 02/06/2023] Open
Abstract
BACKGROUND Emphysematous hepatitis (EH) is a rare, rapidly progressive fulminant gas-forming infection of the liver parenchyma. It is often fatal and mostly affects diabetes patients.
CASE SUMMARY We report a case of EH successfully managed by a step-up approach consisting of aggressive hemodynamic support, intravenous antibiotics, and percutaneous drainage, ultimately followed by laparoscopic deroofing. Of 11 documented cases worldwide, only 1 of the patients survived, treated by urgent laparotomy and surgical debridement.
CONCLUSION EH is a life-threatening infection. Its high mortality rate makes timely diagnosis essential, in order to navigate treatment accordingly.
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Affiliation(s)
- Silke Francois
- Department of Gastroenterology, Universitair Ziekenhuis Brussel, Brussels 1090, Belgium
| | - Maridi Aerts
- Department of Gastroenterology and Hepatology, Vrije Universiteit Brussel, Universitair Ziekenhuis Brussel, Brussels 1090, Belgium
| | - Hendrik Reynaert
- Department of Gastroenterology and Hepatology, Vrije Universiteit Brussel, Universitair Ziekenhuis Brussel, Brussels 1090, Belgium
| | - Ruth Van Lancker
- Department of Intensive Care, Vrije Universiteit Brussel, Universitair Ziekenhuis Brussel, Brussels 1090, Belgium
| | - Johan Van Laethem
- Department of Infectious Diseaeses, Vrije Universiteit Brussel, Universitair Ziekenhuis Brussel, Brussels 1090, Belgium
| | - Rastislav Kunda
- Department of Surgery, Vrije Universiteit Brussel, Universitair Ziekenhuis Brussel, Brussels 1090, Belgium
| | - Nouredin Messaoudi
- Department of Surgery, Vrije Universiteit Brussel, Universitair Ziekenhuis Brussel, Brussels 1090, Belgium
- Department of Surgery, Europe Hospitals, Brussels 1180, Belgium
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5
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Schorn S, Demir IE, Friess H. [Treatment of acute pancreatitis from the viewpoint of surgery]. Chirurg 2021; 93:913-922. [PMID: 34783867 DOI: 10.1007/s00104-021-01532-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 10/11/2021] [Indexed: 10/19/2022]
Abstract
The role of surgery in the treatment of acute pancreatitis has clearly changed over the years. In the 1990s a clear reduction in hospital mortality was achieved through surgery, whereas the value of surgery (open, in general) has slipped into the background due to the improvement in intensive care medicine in general and the development of minimally invasive treatment options. Nowadays, patients with acute pancreatitis are only operated on after exhaustion of intensive medical care treatment and minimally invasive interventions or when complications occur that cannot be treated in any other way (e.g. hollow organ perforation). This article provides an overview of the currently used treatment measures.
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Affiliation(s)
| | | | - Helmut Friess
- Klinik und Poliklinik für Chirurgie, Medizinische Fakultät, Technische Universität München, Klinikum rechts der Isar, Ismaninger Straße 22, 81675, München, Deutschland.
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6
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Affiliation(s)
- Amy Y Li
- Department of Surgery, Section of Surgical Oncology, Stanford University School of Medicine, 300 Pasteur Drive, Room H3591, Stanford, CA 94305, USA
| | - John R Bergquist
- Department of Surgery, Section of Surgical Oncology, Stanford University School of Medicine, 300 Pasteur Drive, Room H3591, Stanford, CA 94305, USA
| | - Brendan C Visser
- Department of Surgery, Section of Surgical Oncology, Stanford University School of Medicine, 300 Pasteur Drive, H3680, Stanford, CA 94305-5655, USA.
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7
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Kreso A, Yamada K, Irani Z, Kalva S, Fagenholz P. Novel techniques for management of portal system hemorrhage in acute pancreatitis. Pancreatology 2020; 20:1576-1581. [PMID: 33077381 DOI: 10.1016/j.pan.2020.09.022] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/06/2020] [Revised: 08/21/2020] [Accepted: 09/30/2020] [Indexed: 12/11/2022]
Abstract
Current management of infected pancreatic necrosis is focused on a minimally invasive step-up approach. The step-up approach consists of initial percutaneous or endoscopic drainage of infected pancreatic necrosis, followed, if necessary, by minimally invasive surgical or endoscopic debridement. While there is reduced morbidity and mortality, vascular complications can be life-threatening. Reported vascular complications have been limited to arterial bleeding. Venous bleeding has not been previously reported. We present two cases of portal venous bleeding in patients who underwent treatment for infected pancreatic necrosis with a step-up approach. We discuss the clinical presentation, diagnosis, and initial management. Moreover, we present two different techniques that can be used to successfully manage venous bleeding in patients who have percutaneous drains in place as part of a step-up approach. These techniques involve tamponading the cavity or drain tract with topical hemostatics and direct embolization of the bleeding vein. These experiences can serve as a guide for managing portal venous bleeding in patients with infected pancreatic necrosis.
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Affiliation(s)
| | - Kei Yamada
- Department of Interventional Radiology, Massachusetts General Hospital, Boston, MA, USA
| | - Zubin Irani
- Department of Interventional Radiology, Massachusetts General Hospital, Boston, MA, USA
| | - Sanjeeva Kalva
- Department of Interventional Radiology, Massachusetts General Hospital, Boston, MA, USA
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8
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Namba Y, Matsugu Y, Furukawa M, Namba M, Sasaki T, Itamoto T. Step-up approach combined with negative pressure wound therapy for the treatment of severe necrotizing pancreatitis: a case report. Clin J Gastroenterol 2020; 13:1331-1337. [PMID: 32712840 DOI: 10.1007/s12328-020-01190-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/13/2020] [Accepted: 07/17/2020] [Indexed: 10/23/2022]
Abstract
A step-up approach and continuous drainage using NPWT was an effective strategy for the treatment of severe necrotizing pancreatitis. A 62-year-old woman developed severe necrotizing pancreatitis after endoscopic retrograde cholangiopancreatography, extending from the left anterior pararenal space to the interior renal pole. Endoscopic transluminal drainage and percutaneous catheter drainage were unsuccessful in controlling the disease. We proceeded with video-assisted retroperitoneal necrosectomy, at the pancreas and splenic hilum, and drainage, with two additional surgical drains located at the left inferior renal pole and, subcutaneously, at the incision wound. NPWT enhanced fluid drainage and facilitated surgical wound closure, which was infected and opened. Four subsequent endoscopic necrosectomy procedures were required, at the site of the draining fistula, to achieve complete resolution of fluid collection and wound closure.
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Affiliation(s)
- Yosuke Namba
- Department of Gastroenterological-Breast and Transplant Surgery, Hiroshima Prefectural Hospital, 1-5-54 Ujina-kanda, Minami-ku, Hiroshima, 734-8530, Japan
| | - Yasuhiro Matsugu
- Department of Gastroenterological-Breast and Transplant Surgery, Hiroshima Prefectural Hospital, 1-5-54 Ujina-kanda, Minami-ku, Hiroshima, 734-8530, Japan. .,Department of Gastroenterological and Transplant Surgery Applied Life Sciences, Institute of Biomedical and Health Sciences, Hiroshima University, Hiroshima, Japan.
| | - Masaru Furukawa
- Department of Gastroenterology, Hiroshima Prefectural Hospital, Hiroshima, Japan
| | - Maiko Namba
- Department of Gastroenterology and Metabolism, Institute of Biomedical and Health Sciences, Hiroshima University, Hiroshima, Japan
| | - Tamito Sasaki
- Department of Gastroenterology, Hiroshima Prefectural Hospital, Hiroshima, Japan.,Department of Gastroenterology and Metabolism, Institute of Biomedical and Health Sciences, Hiroshima University, Hiroshima, Japan
| | - Toshiyuki Itamoto
- Department of Gastroenterological-Breast and Transplant Surgery, Hiroshima Prefectural Hospital, 1-5-54 Ujina-kanda, Minami-ku, Hiroshima, 734-8530, Japan.,Department of Gastroenterological and Transplant Surgery Applied Life Sciences, Institute of Biomedical and Health Sciences, Hiroshima University, Hiroshima, Japan
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9
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Garret C, Canet E, Corvec S, Boutoille D, Péron M, Archambeaud I, Le Thuaut A, Lascarrou JB, Douane F, Lerhun M, Regenet N, Coron E, Reignier J. Impact of prior antibiotics on infected pancreatic necrosis microbiology in ICU patients: a retrospective cohort study. Ann Intensive Care 2020; 10:82. [PMID: 32542577 PMCID: PMC7295875 DOI: 10.1186/s13613-020-00698-0] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/29/2020] [Accepted: 06/05/2020] [Indexed: 12/12/2022] Open
Abstract
Background Recent guidelines advise against prophylactic antibiotics in patients with necrotizing pancreatitis, advocating instead a step-up drainage and necrosectomy strategy with antibiotics as dictated by microbiological findings. However, prompt antibiotic therapy is recommended in patients with sepsis or septic shock, a possible presentation of infected pancreatic necrosis (IPN). Consequently, in many critically ill patients with IPN, pancreatic samples are collected only after broad-spectrum antibiotic therapy initiation. Whether this prior antibiotic exposure alters the microbiological findings is unknown. The main objective was to determine whether prior antibiotic exposure sterilized the samples collected during procedures for suspected IPN in patients admitted to the intensive care unit (ICU) for acute pancreatitis with suspected IPN. We retrospectively studied 56 consecutive ICU patients admitted with suspected IPN. We collected details on the microbiological samples and antimicrobials used. A definite diagnosis of IPN was given when bacteria were identified in pancreatic samples. Results In all, 137 pancreatic samples were collected, including 91 (66.4%) after antibiotic therapy initiation. IPN was confirmed in 48 (86%) patients. The proportion of positive samples was 74 (81.3%) in antibiotic-exposed patients and 32/46 (69.5%) in unexposed patients (p = 0.58). Of the 74 positive samples from exposed patients, 62 (84%) had organisms susceptible to the antibiotics used. One-third of samples contained more than one organism. Among patients with IPN, 37.5% had positive blood cultures. Multidrug- or extensively drug-resistant bacteria were identified at some point in half the patients. Enterobacter cloacae complex was more frequent in the exposed group (p = 0.02), as were Gram-negative anaerobic bacteria (p = 0.03). Conclusion Antibiotic exposure before sampling did not seem to affect culture positivity of pancreatic samples to confirm IPN, but may affect microbiological findings. Our results suggest that, in patients with sepsis and suspected IPN, antibiotics should be started immediately and pancreatic samples obtained as soon as possible thereafter. In other situations, antibiotics can be withheld until the microbiological results of pancreatic samples are available, to ensure accurate targeting of the spectrum to bacterial susceptibility patterns. ClinicalTrials.gov number NCT03253861
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Affiliation(s)
- Charlotte Garret
- Service de Médecine Intensive et Réanimation, Centre Hospitalier Universitaire de Nantes, 1 Place Alexis Ricordeau, 44093, Nantes, France.
| | - Emmanuel Canet
- Service de Médecine Intensive et Réanimation, Centre Hospitalier Universitaire de Nantes, 1 Place Alexis Ricordeau, 44093, Nantes, France
| | - Stéphane Corvec
- Service de Bactériologie-Hygiène Hospitalière, CHU de Nantes, 1 Place Alexis Ricordeau, 44093, Nantes, France
| | | | - Matthieu Péron
- Service de Maladies Infectieuses et Tropicales, CHU de Nantes, 1 Place Alexis Ricordeau, 44093, Nantes, France
| | - Isabelle Archambeaud
- Service de Maladies Infectieuses et Tropicales, CHU de Nantes, 1 Place Alexis Ricordeau, 44093, Nantes, France
| | - Aurélie Le Thuaut
- Institut des Maladies de l'appareil Digestif, CHU de Nantes, 1 Place Alexis Ricordeau, 44093, Nantes, France
| | - Jean-Baptiste Lascarrou
- Service de Médecine Intensive et Réanimation, Centre Hospitalier Universitaire de Nantes, 1 Place Alexis Ricordeau, 44093, Nantes, France
| | - Frédéric Douane
- Département de Biostatistiques, CHU de Nantes, 1 Place Alexis Ricordeau, 44093, Nantes, France
| | - Marc Lerhun
- Service de Maladies Infectieuses et Tropicales, CHU de Nantes, 1 Place Alexis Ricordeau, 44093, Nantes, France
| | - Nicolas Regenet
- Service de Maladies Infectieuses et Tropicales, CHU de Nantes, 1 Place Alexis Ricordeau, 44093, Nantes, France
| | - Emmanuel Coron
- Service de Maladies Infectieuses et Tropicales, CHU de Nantes, 1 Place Alexis Ricordeau, 44093, Nantes, France
| | - Jean Reignier
- Service de Médecine Intensive et Réanimation, Centre Hospitalier Universitaire de Nantes, 1 Place Alexis Ricordeau, 44093, Nantes, France
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10
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Sun B, Li GQ. [Surgical intervention strategy for severe acute pancreatitis in minimally invasive era]. Zhonghua Wai Ke Za Zhi 2019; 57:6-10. [PMID: 31510725 DOI: 10.3760/cma.j.issn.0529-5815.2019.10.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
With the development of minimally invasive concept, the treatment mode of severe acute pancreatitis has changed greatly. The tendency of surgical intervention has changed from excessive intervention to inadequate intervention. The timing of intervention has changed from earlier to later, and the mode of intervention has changed from openness as the main way to minimally invasive as the guidance. The transformation of surgical intervention tendency conforms to both minimally invasive trend and the step-up approach, but there are still some shortcomings: inadequate surgical intervention, inappropriate timing and indications, and over dependence on minimally invasive surgery. Correctly grasping the indications of surgical intervention, accurately grasping the timing of surgical intervention, and reasonably choosing the mode of surgical intervention are the keys to solve the insufficiency of surgical intervention. Laying emphasis on multidisciplinary team and correctly recognizing the role and status of surgical intervention can effectively reduce the mortality of severe acute pancreatitis patients.
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Affiliation(s)
- B Sun
- Department of Pancreatic and Biliary Surgery, the First Affiliated Hospital of Harbin Medical University, China Key Laboratory of Hepatosplenic Surgery, Ministry of Education, Harbin 150001, China
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11
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van Grinsven J, van Dijk SM, Dijkgraaf MG, Boermeester MA, Bollen TL, Bruno MJ, van Brunschot S, Dejong CH, van Eijck CH, van Lienden KP, Boerma D, van Duijvendijk P, Hadithi M, Haveman JW, van der Hulst RW, Jansen JM, Lips DJ, Manusama ER, Molenaar IQ, van der Peet DL, Poen AC, Quispel R, Schaapherder AF, Schoon EJ, Schwartz MP, Seerden TC, Spanier BWM, Straathof JW, Venneman NG, van de Vrie W, Witteman BJ, van Goor H, Fockens P, van Santvoort HC, Besselink MG. Postponed or immediate drainage of infected necrotizing pancreatitis (POINTER trial): study protocol for a randomized controlled trial. Trials 2019; 20:239. [PMID: 31023380 PMCID: PMC6482524 DOI: 10.1186/s13063-019-3315-6] [Citation(s) in RCA: 34] [Impact Index Per Article: 6.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/13/2018] [Accepted: 03/21/2019] [Indexed: 12/12/2022] Open
Abstract
Background Infected necrosis complicates 10% of all acute pancreatitis episodes and is associated with 15–20% mortality. The current standard treatment for infected necrotizing pancreatitis is the step-up approach (catheter drainage, followed, if necessary, by minimally invasive necrosectomy). Catheter drainage is preferably postponed until the stage of walled-off necrosis, which usually takes 4 weeks. This delay stems from the time when open necrosectomy was the standard. It is unclear whether such delay is needed for catheter drainage or whether earlier intervention could actually be beneficial in the current step-up approach. The POINTER trial investigates if immediate catheter drainage in patients with infected necrotizing pancreatitis is superior to the current practice of postponed intervention. Methods POINTER is a randomized controlled multicenter superiority trial. All patients with necrotizing pancreatitis are screened for eligibility. In total, 104 adult patients with (suspected) infected necrotizing pancreatitis will be randomized to immediate (within 24 h) catheter drainage or current standard care involving postponed catheter drainage. Necrosectomy, if necessary, is preferably postponed until the stage of walled-off necrosis, in both treatment arms. The primary outcome is the Comprehensive Complication Index (CCI), which covers all complications between randomization and 6-month follow up. Secondary outcomes include mortality, complications, number of (repeat) interventions, hospital and intensive care unit (ICU) lengths of stay, quality-adjusted life years (QALYs) and direct and indirect costs. Standard follow-up is at 3 and 6 months after randomization. Discussion The POINTER trial investigates if immediate catheter drainage in infected necrotizing pancreatitis reduces the composite endpoint of complications, as compared with the current standard treatment strategy involving delay of intervention until the stage of walled-off necrosis. Trial registration ISRCTN, 33682933. Registered on 6 August 2015. Retrospectively registered. Electronic supplementary material The online version of this article (10.1186/s13063-019-3315-6) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Janneke van Grinsven
- Department of Surgery, Amsterdam UMC, University of Amsterdam, G4.196, PO Box 26000, 1105 AZ, Amsterdam, Netherlands. .,Department of Surgery, St. Antonius Hospital Nieuwegein, Nieuwegein, Netherlands.
| | - Sven M van Dijk
- Department of Surgery, Amsterdam UMC, University of Amsterdam, G4.196, PO Box 26000, 1105 AZ, Amsterdam, Netherlands.,Department of Surgery, St. Antonius Hospital Nieuwegein, Nieuwegein, Netherlands
| | - Marcel G Dijkgraaf
- Clinical Research Unit, Amsterdam UMC, University of Amsterdam, Amsterdam, Netherlands
| | - Marja A Boermeester
- Department of Surgery, Amsterdam UMC, University of Amsterdam, G4.196, PO Box 26000, 1105 AZ, Amsterdam, Netherlands
| | - Thomas L Bollen
- Department of Radiology, St. Antonius Hospital Nieuwegein, Nieuwegein, Netherlands
| | - Marco J Bruno
- Department of Gastroenterology and Hepatology, Erasmus MC University Medical Center Rotterdam, Rottedam, Netherlands
| | - Sandra van Brunschot
- Department of Gastroenterology and Hepatology, Amsterdam UMC, University of Amsterdam, Amsterdam, Netherlands.,Department of Surgery, University Medical Center Utrecht, Cancer Center, Utrecht, Netherlands
| | - Cornelis H Dejong
- Department of Surgery, Maastricht University Medical Center+, Maastricht, Netherlands.,NUTRIM School for Nutrition and Translational Research in Metabolism, Maastricht, Netherlands
| | - Casper H van Eijck
- Department of Surgery, Erasmus MC University Medical Center Rotterdam, Rotterdam, Netherlands
| | - Krijn P van Lienden
- Department of Radiology, Amsterdam UMC, University of Amsterdam, Amsterdam, Netherlands
| | - Djamila Boerma
- Department of Surgery, St. Antonius Hospital Nieuwegein, Nieuwegein, Netherlands
| | | | - Muhammed Hadithi
- Department of Gastroenterology and Hepatology, Maasstad Hospital Rotterdam, Rotterdam, Netherlands
| | - Jan Willem Haveman
- Department of Surgery, University Medical Center Groningen, University of Groningen, Groningen, Netherlands
| | - René W van der Hulst
- Department of Gastroenterology and Hepatology, Spaarne Gasthuis Haarlem, Haarlem, Netherlands
| | - Jeroen M Jansen
- Department of Gastroenterology and Hepatology, OLVG Amsterdam, Amsterdam, Netherlands
| | - Daan J Lips
- Department of Surgery, Jeroen Bosch Hospital, 's-Hertogenbosch, Netherlands
| | - Eric R Manusama
- Department of Surgery, Medical Center Leeuwarden, Leeuwarden, Netherlands
| | - I Quintus Molenaar
- Department of Surgery, University Medical Center Utrecht, Cancer Center, Utrecht, Netherlands
| | - Donald L van der Peet
- Department of Surgery, Amsterdam UMC, Vrije Universiteit Amsterdam, Amsterdam, Netherlands
| | - Alexander C Poen
- Department of Gastroenterology and Hepatology, Isala Clinics Zwolle, Zwolle, Netherlands
| | - Rutger Quispel
- Department of Gastroenterology and Hepatology, Reinier de Graaf Gasthuis Delft, Delft, Netherlands
| | | | - Erik J Schoon
- Department of Gastroenterology and Hepatology, Catharina Hospital Eindhoven, Eindhoven, Netherlands
| | - Matthijs P Schwartz
- Department of Gastroenterology and Hepatology, Meander Medical Center Amersfoort, Amersfoort, Netherlands
| | - Tom C Seerden
- Department of Gastroenterology and Hepatology, Amphia Hospital Breda, Breda, Netherlands
| | - B W Marcel Spanier
- Department of Gastroenterology and Hepatology, Rijnstate Hospital Arnhem, Arnhem, Netherlands
| | - Jan Willem Straathof
- Department of Gastroenterology and Hepatology, Maxima Medical Center Veldhoven, Veldhoven, Netherlands
| | - Niels G Venneman
- Department of Gastroenterology and Hepatology, Medisch Spectrum Twente Enschede, Enschede, Netherlands
| | - Wim van de Vrie
- Department of Gastroenterology and Hepatology, Albert Schweitzer Hospital Dordrecht, Dordrecht, Netherlands
| | - Ben J Witteman
- Department of Gastroenterology and Hepatology, Hospital Gelderse Vallei Ede, Ede, Netherlands
| | - Harry van Goor
- Department of Surgery, Radboud University Medical Center Nijmegen, Nijmegen, Netherlands
| | - Paul Fockens
- Department of Gastroenterology and Hepatology, Amsterdam UMC, University of Amsterdam, Amsterdam, Netherlands
| | - Hjalmar C van Santvoort
- Department of Surgery, St. Antonius Hospital Nieuwegein, Nieuwegein, Netherlands.,Department of Surgery, University Medical Center Utrecht, Cancer Center, Utrecht, Netherlands
| | - Marc G Besselink
- Department of Surgery, Amsterdam UMC, University of Amsterdam, G4.196, PO Box 26000, 1105 AZ, Amsterdam, Netherlands.
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12
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Darrivere L, Lapidus N, Colignon N, Chafai N, Chaput U, Verdonk F, Paye F, Lescot T. Minimally invasive drainage in critically ill patients with severe necrotizing pancreatitis is associated with better outcomes: an observational study. Crit Care 2018; 22:321. [PMID: 30466472 PMCID: PMC6249885 DOI: 10.1186/s13054-018-2256-x] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 07/13/2018] [Accepted: 11/04/2018] [Indexed: 12/17/2022]
Abstract
Background Infected pancreatic necrosis, which occurs in about 40% of patients admitted for acute necrotizing pancreatitis, requires combined antibiotic therapy and local drainage. Since 2010, drainage by open surgical necrosectomy has been increasingly replaced by less invasive methods such as percutaneous radiological drainage, endoscopic necrosectomy, and laparoscopic surgery, which proved effective in small randomized controlled trials in highly selected patients. Few studies have evaluated minimally invasive drainage methods used under the conditions of everyday hospital practice. The aim of this study was to determine whether, compared with conventional open surgery, minimally invasive drainage was associated with improved outcomes of critically ill patients with infection complicating acute necrotizing pancreatitis. Methods A single-center observational study was conducted in patients admitted to the intensive care unit for severe acute necrotizing pancreatitis to compare the characteristics, drainage techniques, and outcomes of the 62 patients managed between September 2006 and December 2010, chiefly with conventional open surgery, and of the 81 patients managed between January 2011 and August 2015 after the introduction of a minimally invasive drainage protocol. Results Surgical necrosectomy was more common in the early period (74% versus 41%; P <0.001), and use of minimally invasive drainage increased between the early and late periods (19% and 52%, respectively; P <0.001). The numbers of ventilator-free days and catecholamine-free days by day 30 were higher during the later period. The proportions of patients discharged from intensive care within the first 30 days and from the hospital within the first 90 days were higher during the second period. Hospital mortality was not significantly different between the early and late periods (19% and 22%, respectively). Conclusion In our study, the implementation of a minimally invasive drainage protocol in patients with infected pancreatic necrosis was associated with shorter times spent with organ dysfunction, in the intensive care unit, and in the hospital. Mortality was not significantly different. These results should be interpreted bearing in mind the limitations inherent in the before-after study design.
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Affiliation(s)
- Lucie Darrivere
- Department of Anesthesiology and Critical Care Medicine, Saint-Antoine Hospital, Assistance Publique-Hôpitaux de Paris, Paris, France
| | - Nathanael Lapidus
- Sorbonne University, INSERM, Institut Pierre Louis d'Epidémiologie et de Santé Publique IPLESP, Public Health Department, Saint-Antoine Hospital, Assistance Publique-Hôpitaux de Paris, Paris, France
| | - Nikias Colignon
- Radiology Department, Saint-Antoine Hospital, Assistance Publique-Hôpitaux de Paris, Paris, France
| | - Najim Chafai
- Digestive Surgery Department, Saint-Antoine Hospital, Assistance Publique-Hôpitaux de Paris, Paris, France
| | - Ulriikka Chaput
- Endoscopy Department, Saint-Antoine Hospital, Assistance Publique-Hôpitaux de Paris, Paris, France
| | - Franck Verdonk
- Sorbonne University, Department of Anesthesiology and Critical Care Medicine, Saint-Antoine Hospital, Assistance Publique-Hôpitaux de Paris, Paris, France
| | - François Paye
- Sorbonne University, Digestive Surgery Department, Saint-Antoine Hospital, Assistance Publique-Hôpitaux de Paris, Paris, France
| | - Thomas Lescot
- Sorbonne University, Department of Anesthesiology and Critical Care Medicine, Saint-Antoine Hospital, Assistance Publique-Hôpitaux de Paris, Paris, France.
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Hozaka Y, Kurahara H, Mataki Y, Kawasaki Y, Iino S, Sakoda M, Mori S, Maemura K, Shinchi H, Natsugoe S. Successful treatment for severe pancreatitis with colonic perforation using video-assisted retroperitoneal debridement: A case report. Int J Surg Case Rep 2018; 52:23-27. [PMID: 30308424 PMCID: PMC6176850 DOI: 10.1016/j.ijscr.2018.09.046] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/20/2018] [Revised: 09/17/2018] [Accepted: 09/24/2018] [Indexed: 12/21/2022] Open
Abstract
Severe acute pancreatitis with necrotizing colonic perforation is refractory and the mortality is high. Step-up approach for severe acute pancreatitis with infectious walled-off necrosis has been increasingly used. We performed percutaneous drainage, ileostomy, and video-assisted retroperitoneal debridement (VARD) as a step-up approach. VARD enable sufficient washing of the abscess and radical debridement of the necrotic tissues under direct view.
Introduction Colorectal complications including penetration and perforation in acute pancreatitis often become severe and fatal. Effective drainage is pivotal for successful treatment. We present a case of large retroperitoneal abscess with colonic necrotizing perforation due to severe acute pancreatitis treated with video-assisted retroperitoneal debridement (VARD) in a step-up approach. Presentation of case A 31-year-old man was admitted to a general hospital with a diagnosis of severe acute pancreatitis. Ten days after onset, he was referred to our hospital for more intensive treatment. On day 16, he experienced melena and shock, and embolization of the three straight arteries of the descending colon was performed. On day 30, percutaneous drainage was performed for large retroperitoneal abscess. On day 36, ileostomy was performed because the drained pus from the retroperitoneal abscess became feces-like. On day 58, VARD was performed to treat the refractory retroperitoneal abscesses causing high systemic inflammation due to insufficient drainage. On day 85, fluoroscopic examination showed disappearance of the abscess cavity. He was transferred to the previous hospital on day 89. Discussion Colonic perforation due to severe acute pancreatitis often causes sepsis and fatal condition of patients, and drainage of the retroperitoneal abscesses via laparotomy is thought to be highly invasive and risky. VARD enables radical necrosectomy and drainage less invasively. Conclusions VARD enabled less invasive treatment for patients with large retroperitoneal abscess due to colonic necrotizing perforation in severe pancreatitis.
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Affiliation(s)
- Yuto Hozaka
- Department of Digestive Surgery, Breast and Thyroid Surgery, Graduate School of Medical Sciences, Kagoshima University, Japan
| | - Hiroshi Kurahara
- Department of Digestive Surgery, Breast and Thyroid Surgery, Graduate School of Medical Sciences, Kagoshima University, Japan.
| | - Yuko Mataki
- Department of Digestive Surgery, Breast and Thyroid Surgery, Graduate School of Medical Sciences, Kagoshima University, Japan
| | - Yota Kawasaki
- Department of Digestive Surgery, Breast and Thyroid Surgery, Graduate School of Medical Sciences, Kagoshima University, Japan
| | - Satoshi Iino
- Department of Digestive Surgery, Breast and Thyroid Surgery, Graduate School of Medical Sciences, Kagoshima University, Japan
| | - Masahiko Sakoda
- Department of Digestive Surgery, Breast and Thyroid Surgery, Graduate School of Medical Sciences, Kagoshima University, Japan
| | - Shinichiro Mori
- Department of Digestive Surgery, Breast and Thyroid Surgery, Graduate School of Medical Sciences, Kagoshima University, Japan
| | - Kosei Maemura
- Department of Digestive Surgery, Breast and Thyroid Surgery, Graduate School of Medical Sciences, Kagoshima University, Japan
| | | | - Shoji Natsugoe
- Department of Digestive Surgery, Breast and Thyroid Surgery, Graduate School of Medical Sciences, Kagoshima University, Japan
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14
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Abstract
Acute necrotizing pancreatitis is a prevalent disease with high morbidity and mortality. The development of radiologic and endoscopic techniques to manage pancreatic necrosis commands a multidisciplinary approach, which has considerably decreased the need for laparotomy. The objective of this update is to define the role of surgery in the multidisciplinary approach to management of necrotizing acute pancreatitis.
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Affiliation(s)
- I El Boukili
- Service de chirurgie générale, endocrinienne et digestive, hospices civils de Lyon, CHU Lyon Sud, 165, chemin du grand-revoyet, 69495 Pierre Bénite cedex, France.
| | - G Boschetti
- Service de gastro-entérologie et radiologie, hospices civils de Lyon, centre hospitalier Lyon Sud, 69495 Pierre-Bénite, France.
| | - H Belkhodja
- Service de gastro-entérologie et radiologie, hospices civils de Lyon, centre hospitalier Lyon Sud, 69495 Pierre-Bénite, France.
| | - V Kepenekian
- Service de chirurgie générale, endocrinienne et digestive, hospices civils de Lyon, CHU Lyon Sud, 165, chemin du grand-revoyet, 69495 Pierre Bénite cedex, France; Université Lyon 1, EMR 37-38, 69000 Lyon, France.
| | - P Rousset
- Université Lyon 1, EMR 37-38, 69000 Lyon, France; Centre hospitalier Lyon Sud, hospices civils de Lyon, 69495 Pierre-Bénite, France.
| | - G Passot
- Service de chirurgie générale, endocrinienne et digestive, hospices civils de Lyon, CHU Lyon Sud, 165, chemin du grand-revoyet, 69495 Pierre Bénite cedex, France; Université Lyon 1, EMR 37-38, 69000 Lyon, France.
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15
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Aparna D, Kumar S, Kamalkumar S. Mortality and morbidity in necrotizing pancreatitis managed on principles of step-up approach: 7 years experience from a single surgical unit. World J Gastrointest Surg 2017; 9:200-208. [PMID: 29109852 PMCID: PMC5661125 DOI: 10.4240/wjgs.v9.i10.200] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/23/2016] [Revised: 07/31/2017] [Accepted: 10/03/2017] [Indexed: 02/06/2023] Open
Abstract
AIM To determine percentage of patients of necrotizing pancreatitis (NP) requiring intervention and the types of interventions performed. Outcomes of patients of step up necrosectomy to those of direct necrosectomy were compared. Operative mortality, overall mortality, morbidity and overall length of stay were determined.
METHODS After institutional ethics committee clearance and waiver of consent, records of patients of pancreatitis were reviewed. After excluding patients as per criteria, epidemiologic and clinical data of patients of NP was noted. Treatment protocol was reviewed. Data of patients in whom step-up approach was used was compared to those in whom it was not used.
RESULTS A total of 41 interventions were required in 39% patients. About 60% interventions targeted the pancreatic necrosis while the rest were required to deal with the complications of the necrosis. Image guided percutaneous catheter drainage was done in 9 patients for infected necrosis all of whom required further necrosectomy and in 3 patients with sterile necrosis. Direct retroperitoneal or anterior necrosectomy was performed in 15 patients. The average time to first intervention was 19.6 d in the non step-up group (range 11-36) vs 18.22 d in the Step-up group (range 13-25). The average hospital stay in non step-up group was 33.3 d vs 38 d in step up group. The mortality in the step-up group was 0% (0/9) vs 13% (2/15) in the non step up group. Overall mortality was 10.3% while post-operative mortality was 8.3%. Average hospital stay was 22.25 d.
CONCLUSION Early conservative management plays an important role in management of NP. In patients who require intervention, the approach used and the timing of intervention should be based upon the clinical condition and local expertise available. Delaying intervention and use of minimal invasive means when intervention is necessary is desirable. The step-up approach should be used whenever possible. Even when the classical retroperitoneal catheter drainage is not feasible, there should be an attempt to follow principles of step-up technique to buy time. The outcome of patients in the step-up group compared to the non step-up group is comparable in our series. Interventions for bowel diversion, bypass and hemorrhage control should be done at the appropriate times.
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Affiliation(s)
- Deshpande Aparna
- Department of Surgery, Seth G.S.Medical College and K.E.M. Hospital, Parel, Mumbai 400012, India
| | - Sunil Kumar
- Department of Surgery, Seth G.S.Medical College and K.E.M. Hospital, Parel, Mumbai 400012, India
| | - Shukla Kamalkumar
- Department of Surgery, Seth G.S.Medical College and K.E.M. Hospital, Parel, Mumbai 400012, India
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16
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Sorrentino L, Chiara O, Mutignani M, Sammartano F, Brioschi P, Cimbanassi S. Combined totally mini-invasive approach in necrotizing pancreatitis: a case report and systematic literature review. World J Emerg Surg 2017; 12:16. [PMID: 28331537 PMCID: PMC5356234 DOI: 10.1186/s13017-017-0126-5] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/28/2016] [Accepted: 03/06/2017] [Indexed: 12/11/2022] Open
Abstract
BACKGROUND Currently, both the step-up approach, combining percutaneous drainage (PD) and video-assisted retroperitoneal debridement (VARD), and endoscopic transgastric necrosectomy (ETN) are mini-invasive techniques for infected necrosis in severe acute pancreatitis. A combination of these approaches could maximize the management of necrotizing pancreatitis, conjugating the benefits from both the experiences. However, reporting of this combined strategy is anecdotal. This is the first reported case of severe necrotizing pancreatitis complicated by biliary fistula treated by a combination of ETN, PD, VARD, and endoscopic biliary stenting. Moreover, a systematic literature review of comparative studies on minimally invasive techniques in necrotizing pancreatitis has been provided. CASE PRESENTATION A 59-year-old patient was referred to our center for acute necrotizing pancreatitis associated with multi-organ failure. No invasive procedures were attempted in the first month from the onset: enteral feeding by a naso-duodenal tube was started, and antibiotics were administered to control sepsis. After 4 weeks, CT scans showed a central walled-off pancreatic necrosis (WOPN) of pancreatic head communicating bilateral retroperitoneal collections. ETN was performed, and bile leakage was found at the right margin of the WOPN. Endoscopic retrograde cholangiopancreatography confirmed the presence of a choledocal fistula within the WOPN, and a biliary stent was placed. An ultrasound-guided PD was performed on the left retroperitoneal collection. Due to the subsequent repeated onset of septic shocks and the evidence of size increase of the right retroperitoneal collection, a VARD was decided. The CT scans documented the resolution of all the collections, and the patient promptly recovered from sepsis. After 6 months, the patient is in good clinical condition. CONCLUSIONS No mini-invasive technique has demonstrated significantly better outcomes over the others, and each technique has specific indications, advantages, and pitfalls. Indeed, ETN could be suitable for central WOPNs, while VARD or PD could be suggested for lateral collections. A combination of different approaches is feasible and could significantly optimize the clinical management in critically ill patients affected by complicated necrotizing pancreatitis.
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Affiliation(s)
- Luca Sorrentino
- Trauma Team and Emergency Surgery, Niguarda Trauma Center, Niguarda Ca' Granda Hospital, Piazza Ospedale Maggiore 3, Milan, 20162 Italy
| | - Osvaldo Chiara
- Trauma Team and Emergency Surgery, Niguarda Trauma Center, Niguarda Ca' Granda Hospital, Piazza Ospedale Maggiore 3, Milan, 20162 Italy
| | - Massimiliano Mutignani
- Digestive Endoscopy Service, Niguarda Ca' Granda Hospital, Piazza Ospedale Maggiore 3, Milan, 20162 Italy
| | - Fabrizio Sammartano
- Trauma Team and Emergency Surgery, Niguarda Trauma Center, Niguarda Ca' Granda Hospital, Piazza Ospedale Maggiore 3, Milan, 20162 Italy
| | - Paolo Brioschi
- Intensive Care Unit, Niguarda Trauma Center, Niguarda Ca' Granda Hospital, Piazza Ospedale Maggiore 3, Milan, 20162 Italy
| | - Stefania Cimbanassi
- Trauma Team and Emergency Surgery, Niguarda Trauma Center, Niguarda Ca' Granda Hospital, Piazza Ospedale Maggiore 3, Milan, 20162 Italy
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Shenvi S, Gupta R, Kang M, Khullar M, Rana SS, Singh R, Bhasin DK. Timing of surgical intervention in patients of infected necrotizing pancreatitis not responding to percutaneous catheter drainage. Pancreatology 2016; 16:778-87. [PMID: 27592206 DOI: 10.1016/j.pan.2016.08.006] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/07/2016] [Revised: 04/21/2016] [Accepted: 08/10/2016] [Indexed: 12/11/2022]
Abstract
BACKGROUND The timing of surgery in patients not responding to percutaneous catheter drainage (PCD) in infected pancreatic necrosis remains challenging. MATERIALS AND METHODS A randomized controlled trial was designed to establish the optimal timings of surgery following PCD in patients with infected pancreatic necrosis (IPN). Patients who did not improve by day 10 after PCD insertion were included in the present study and were randomized to group A (step-up approach as a bridge to surgery) or group B (step-up approach with intention to avoid surgery). Weekly inflammatory and nutritional markers were monitored in both groups (clinical trials. gov identifier NCT-01527084). RESULTS From July 2011 to December 2012, 40 patients underwent treatment with PCD. The first 8 patients were randomized into two groups. The trial was stopped prematurely because of difficulty in accrual and poor progress. All subsequent patients were managed with step-up approach with the intention to avoid surgery. Of 35 patients, 24 patients were managed by PCD alone while 11 patients required surgery. In patients who did not require surgery; levels of serum high sensitivity C-reactive protein (hsCRP), interleukin-6(IL6) and prealbumin showed a falling trend. This group also had higher baseline albumin and higher albumin at 4 weeks. CONCLUSION During the present study, randomization into surgery at a predetermined time in step-up approach was discontinued due to poor progress. Step-up approach with the intention to avoid surgery led to a success rate of 68.5%. The present study failed to predict the optimal timing of surgery after PCD. Patients who needed surgery were sicker at the time of admission, had higher incidence of organ failure, and spent more time in the ICU compared to patients who did not need surgery. In future, inflammatory and nutritional markers may be useful to identify patients who are unlikely to respond to PCD and may help determine the timing of surgery.
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Affiliation(s)
- Sunil Shenvi
- Transplant Surgery Division, Department of Surgery, Medical University of South Carolina, Charleston, SC, USA
| | - Rajesh Gupta
- Surgical Gastroenterology Division, Department of General Surgery, Postgraduate Institute of Medical Education and Research, Chandigarh, India.
| | - Mandeep Kang
- Department of Radiodiagnosis and Imaging, Postgraduate Institute of Medical Education and Research, Chandigarh, India
| | - Madhu Khullar
- Department of Experimental Medicine, Postgraduate Institute of Medical Education and Research, Chandigarh, India
| | - Surinder Singh Rana
- Department of Gastroenterology, Postgraduate Institute of Medical Education and Research, Chandigarh, India
| | - Rajinder Singh
- Surgical Gastroenterology Division, Department of General Surgery, Postgraduate Institute of Medical Education and Research, Chandigarh, India
| | - Deepak Kumar Bhasin
- Department of Gastroenterology, Postgraduate Institute of Medical Education and Research, Chandigarh, India
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Hamada S, Masamune A, Shimosegawa T. Management of acute pancreatitis in Japan: Analysis of nationwide epidemiological survey. World J Gastroenterol 2016; 22:6335-6344. [PMID: 27605870 PMCID: PMC4968116 DOI: 10.3748/wjg.v22.i28.6335] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/14/2016] [Revised: 05/22/2016] [Accepted: 06/13/2016] [Indexed: 02/06/2023] Open
Abstract
Acute pancreatitis (AP) is an acute inflammatory disease of the exocrine pancreas. In Japan, nationwide epidemiological surveys have been conducted every 4 to 5 years by the Research Committee of Intractable Pancreatic Diseases, under the support of the Ministry of Health, Labour, and Welfare of Japan. We reviewed the results of the nationwide surveys focusing on the severity assessment and changes in the therapeutic strategy for walled-off necrosis. The severity assessment system currently used in Japan consists of 9 prognostic factors and the imaging grade on contrast-enhanced computed tomography. By univariate analysis, all of the 9 prognostic factors were associated with AP-related death. A multivariate analysis identified 4 out of the 9 prognostic factors (base excess or shock, renal failure, systemic inflammatory response syndrome criteria, and age) that were associated with AP-related death. Receiver-operating characteristics curve analysis showed that the area under the curve was 0.82 for these 4 prognostic factors and 0.84 for the 9 prognostic factors, suggesting the comparable utility of these 4 factors in the severity assessment. We also examined the temporal changes in treatment strategy for walled-off necrosis in Japan according to the 2003, 2007, and 2011 surveys. Step-up approaches and less-invasive endoscopic therapies were uncommon in 2003 and 2007, but became popular in 2011. Mortality has been decreasing in patients who require intervention for walled-off necrosis. In conclusion, the nationwide survey revealed the comparable utility of 4 prognostic factors in the severity assessment and the increased use of less-invasive, step-up approaches with improved clinical outcomes in the management of walled-off necrosis.
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Lim E, Sundaraamoorthy R, Tan D, Teh HS, Tan TJ, Cheng A. Step-up approach and video assisted retroperitoneal debridement in infected necrotizing pancreatitis: A case complicated by retroperitoneal bleeding and colonic fistula. Ann Med Surg (Lond) 2015; 4:225-9. [PMID: 26587229 PMCID: PMC4624569 DOI: 10.1016/j.amsu.2015.07.005] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/16/2015] [Revised: 07/11/2015] [Accepted: 07/20/2015] [Indexed: 12/12/2022] Open
Abstract
INTRODUCTION Infected Necrotizing Pancreatitis carries a high mortality and necessitates intervention to achieve sepsis control. The surgical strategy for proven infected necrosis has evolved, with abandonment of open necrosectomy to a step-up approach consisting of percutaneous drains and Video-assisted retroperitoneal debridement (VARD). We present a case that underwent VARD complicated by bleeding and colonic perforation and describe its management. PRESENTATION OF CASE A 38 year-old male with acute pancreatitis developed infected necrotizing pancreatitis. Initial treatment was by percutaneous drainage under radiological guidance and intravenous antibiotics. The infected retroperitoneal necrosis was then debrided using gasless laparoscopy through a mini-incision. Post-operatively, he developed peripancreatic bleeding which was controlled with angioembolisation. He also developed a descending colon fistula which was treated with laparotomy and defunctioning loop ileostomy. He recovered and subsequently had his ileostomy closed twelve months later. The colonic fistula recurred and was treated with endoscopic clips and histoacryl glue injection and finally closed. DISCUSSION Step-up approach consists of the 3 D's: Delay, drain and debride. VARD is recommended as it is replicable in general surgical units using standard laparoscopic instruments. Bleeding and colon perforation are potential complications which must have multi-disciplinary input, aggressive resuscitation and timely radiologic intervention. Defunctioning ileostomy is recommended to control sepsis in colonic fistulation. Novel fistula closing methods using endoscopic clips and histoacryl glue are potential treatment options. CONCLUSION Step-up approach and VARD is the new paradigm to treat necrotizing pancreatitis. Complications of bleeding and colon fistula are uncommon and require multi-disciplinary management.
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Affiliation(s)
- Eugene Lim
- Department of Surgery, Khoo Teck Puat Hospital, 90 Yishun Central, Singapore 768828, Singapore
- Corresponding author.
| | - R.S. Sundaraamoorthy
- Department of Surgery, Khoo Teck Puat Hospital, 90 Yishun Central, Singapore 768828, Singapore
| | - David Tan
- Department of Anaesthesia, Khoo Teck Puat Hospital, 90 Yishun Central, Singapore 768828, Singapore
| | - Hui-Seong Teh
- Department of Radiology, Khoo Teck Puat Hospital, 90 Yishun Central, Singapore 768828, Singapore
| | - Tzu-Jen Tan
- Department of Surgery, Khoo Teck Puat Hospital, 90 Yishun Central, Singapore 768828, Singapore
| | - Anton Cheng
- Department of Surgery, Khoo Teck Puat Hospital, 90 Yishun Central, Singapore 768828, Singapore
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