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Rana SS, Sharma RK, Gupta P, Gupta R. Natural course of asymptomatic walled off pancreatic necrosis. Dig Liver Dis 2019; 51:730-734. [PMID: 30467075 DOI: 10.1016/j.dld.2018.10.010] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/10/2018] [Revised: 10/12/2018] [Accepted: 10/15/2018] [Indexed: 12/11/2022]
Abstract
INTRODUCTION There is paucity of data on natural course of asymptomatic walled off necrosis (WON). OBJECTIVE To study the natural course as well as outcome of conservative management in patients with asymptomatic WON. METHODS Retrospective analysis of prospectively maintained data base of patients with asymptomatic WON presenting to us 4-6 weeks after an episode of acute necrotising pancreatitis (ANP). RESULTS Forty three patients (37 M; mean age: 38.2 ± 10.4 years) with asymptomatic WON were studied. The size of WON ranged from 5 to 16 cm (mean 8.2 ± 2.2 cm). The site of WON was head, body and tail in 5 (11%), 34 (79%) and 4 (10%) patients respectively. Thirty of 43 patients (70%) patients did not have any complications during the expectant management period of 3 weeks-32 months with 13 (30%) patients having spontaneous resolution within 6.2 ± 3.4 months. Thirteen (30%) patients became symptomatic or developed complication within 3.2 ± 1.3 months. These were refractory pain (n = 7), infection (n = 4), spontaneous rupture into gastrointestinal tract (n = 5; stomach in 3, duodenum in 1 and colon in 1 patient respectively) and bleeding from splenic artery pseudoaneursym in 1 patient. CONCLUSIONS Majority of patients with asymptomatic WON have an uneventful clinical course. However, one third patients will develop symptoms/complications requiring interventional treatment.
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Affiliation(s)
- Surinder Singh Rana
- Departments of Gastroenterology and Surgery, Post Graduate Institute of Medical Education and Research (PGIMER), Chandigarh, India.
| | - Ravi Kumar Sharma
- Departments of Gastroenterology and Surgery, Post Graduate Institute of Medical Education and Research (PGIMER), Chandigarh, India
| | - Pankaj Gupta
- Departments of Gastroenterology and Surgery, Post Graduate Institute of Medical Education and Research (PGIMER), Chandigarh, India
| | - Rajesh Gupta
- Department of Surgery, Post Graduate Institute of Medical Education and Research (PGIMER), Chandigarh, India
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102
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Rashid MU, Hussain I, Jehanzeb S, Ullah W, Ali S, Jain AG, Khetpal N, Ahmad S. Pancreatic necrosis: Complications and changing trend of treatment. World J Gastrointest Surg 2019; 11:198-217. [PMID: 31123558 PMCID: PMC6513789 DOI: 10.4240/wjgs.v11.i4.198] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/12/2019] [Revised: 04/19/2019] [Accepted: 04/23/2019] [Indexed: 02/06/2023] Open
Abstract
Incidence of acute pancreatitis seems to be increasing in the Western countries and has been associated with significantly increased morbidity. Nearly 80% of the patients with acute pancreatitis undergo resolution; some develop complications including pancreatic necrosis. Infection of pancreatic necrosis is the leading cause of death in these patients. A significant portion of these patients needs surgical interventions. Traditionally, the “gold standard” procedure has been the open surgical necrosectomy, which is now being completed by the relatively lesser invasive interventions. Minimally invasive surgical (MIS) procedures include endoscopic drainage, percutaneous image-guided catheter drainage, and retroperitoneal drainage. This review article discusses the open and MIS interventions for pancreatic necrosis with each having its own respective benefits and disadvantages are covered.
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Affiliation(s)
- Mamoon Ur Rashid
- Department of Internal Medicine, Advent Health Graduate Medical Education, Orlando, FL 32804, United States
| | - Ishtiaq Hussain
- Department of Gastroenterology, Cleveland Clinic, Weston, FL 33326, United States
| | - Sundas Jehanzeb
- Department of Gastroenterology, Cleveland Clinic, Weston, FL 33326, United States
| | - Waqas Ullah
- Internal Medicine, Abington Hospital, Abington, PA 19001, United States
| | - Saeed Ali
- Department of Internal Medicine, Advent Health Graduate Medical Education, Orlando, FL 32804, United States
| | - Akriti Gupta Jain
- Department of Internal Medicine, Advent Health Graduate Medical Education, Orlando, FL 32804, United States
| | - Neelam Khetpal
- Department of Internal Medicine, Advent Health Graduate Medical Education, Orlando, FL 32804, United States
| | - Sarfraz Ahmad
- Department of Gynecologic Oncology, Advent Health Cancer Institute, Orlando, FL 32804, United States
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103
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Bezmarević M, van Dijk SM, Voermans RP, van Santvoort HC, Besselink MG. Management of (Peri)Pancreatic Collections in Acute Pancreatitis. Visc Med 2019; 35:91-96. [PMID: 31192242 DOI: 10.1159/000499631] [Citation(s) in RCA: 17] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/01/2019] [Accepted: 03/15/2019] [Indexed: 12/12/2022] Open
Abstract
The development of (peri)pancreatic fluid collections are frequent local complications in acute pancreatitis. These collections are classified as early (acute peripancreatic fluid collection or acute necrotic collection) or late (walled-off necrosis or pseudocyst). The majority of pancreatic fluid collections resolve spontaneously and do not require intervention. However, infection may require intervention. Interventions may include endoscopic or percutaneous catheter drainage, or in a next step endoscopic or surgical necrosectomy, minimally invasive or open. The best timing for the first intervention is still under investigation. Whereas some use antibiotics to postpone intervention until the stage of walled-off necrosis, others drain earlier. Endoscopic drainage of (peri)pancreatic fluid collections is now the preferred approach of drainage due to reduced morbidity as compared to surgical or percutaneous drainage. However, each collection must be treated according to a tailored approach. The final treatment should take into consideration anatomic characteristics, patient preference, comorbidity profile of the patient, and physician discretion. This review summarizes the current evidence on the treatment of (peri)pancreatic fluid collections.
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Affiliation(s)
- Mihailo Bezmarević
- Department of Hepatobiliary and Pancreatic Surgery, Clinic for General Surgery, Military Medical Academy, University of Defense, Belgrade, Serbia.,Department of Surgery, Amsterdam Gastroenterology and Metabolism, Amsterdam UMC, University of Amsterdam, Amsterdam, The Netherlands
| | - Sven M van Dijk
- Department of Surgery, Amsterdam Gastroenterology and Metabolism, Amsterdam UMC, University of Amsterdam, Amsterdam, The Netherlands.,Department of Research and Development, St. Antonius Hospital, Nieuwegein, The Netherlands
| | - Rogier P Voermans
- Department of Gastroenterology and Hepatology, Amsterdam Gastroenterology and Metabolism, Amsterdam UMC, University of Amsterdam, Amsterdam, The Netherlands
| | - Hjalmar C van Santvoort
- Department of Surgery, St. Antonius Hospital, Utrecht, The Netherlands.,Department of Surgery, University Medical Center Utrecht, Utrecht, The Netherlands
| | - Marc G Besselink
- Department of Surgery, Amsterdam Gastroenterology and Metabolism, Amsterdam UMC, University of Amsterdam, Amsterdam, The Netherlands
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104
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Moon SH. Drainage Procedures for the Treatment of Walled-Off Pancreatic Necrosis: Is More Refinement Necessary? Gut Liver 2019; 13:135-137. [PMID: 30893983 PMCID: PMC6430434 DOI: 10.5009/gnl19055] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/24/2023] Open
Affiliation(s)
- Sung-Hoon Moon
- Department of Internal Medicine, Hallym University Sacred Heart Hospital, Hallym University College of Medicine, Anyang, Korea
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105
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Bang JY, Arnoletti JP, Holt BA, Sutton B, Hasan MK, Navaneethan U, Feranec N, Wilcox CM, Tharian B, Hawes RH, Varadarajulu S. An Endoscopic Transluminal Approach, Compared With Minimally Invasive Surgery, Reduces Complications and Costs for Patients With Necrotizing Pancreatitis. Gastroenterology 2019; 156:1027-1040.e3. [PMID: 30452918 DOI: 10.1053/j.gastro.2018.11.031] [Citation(s) in RCA: 173] [Impact Index Per Article: 34.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/28/2018] [Revised: 10/31/2018] [Accepted: 11/12/2018] [Indexed: 02/08/2023]
Abstract
BACKGROUND & AIMS Infected necrotizing pancreatitis is a highly morbid disease with poor outcomes. Intervention strategies have progressed from open necrosectomy to minimally invasive approaches. We compared outcomes of minimally invasive surgery vs endoscopic approaches for patients with infected necrotizing pancreatitis. METHODS We performed a single-center, randomized trial of 66 patients with confirmed or suspected infected necrotizing pancreatitis who required intervention from May 12, 2014, through March 24, 2017. Patients were randomly assigned to groups that received minimally invasive surgery (laparoscopic or video-assisted retroperitoneal debridement, depending on location of collection, n = 32) or an endoscopic step-up approach (transluminal drainage with or without necrosectomy, n = 34). The primary endpoint was a composite of major complications (new-onset multiple organ failure, new-onset systemic dysfunction, enteral or pancreatic-cutaneous fistula, bleeding and perforation of a visceral organ) or death during 6 months of follow-up. RESULTS The primary endpoint occurred in 11.8% of patients who received the endoscopic procedure and 40.6% of patients who received the minimally invasive surgery (risk ratio 0.29; 95% confidence interval 0.11-0.80; P = .007). Although there was no significant difference in mortality (endoscopy 8.8% vs surgery 6.3%; P = .999), none of the patients assigned to the endoscopic approach developed enteral or pancreatic-cutaneous fistulae compared with 28.1% of the patients who underwent surgery (P = .001). The mean number of major complications per patient was significantly higher in the surgery group (0.69 ± 1.03) compared with the endoscopy group (0.15 ± 0.44) (P = .007). The physical health scores for quality of life at 3 months was better with the endoscopic approach (P = .039) and mean total cost was lower ($75,830) compared with $117,492 for surgery (P = .039). CONCLUSIONS In a randomized trial of 66 patients, an endoscopic transluminal approach for infected necrotizing pancreatitis, compared with minimally invasive surgery, significantly reduced major complications, lowered costs, and increased quality of life. Clinicaltrials.gov no: NCT02084537.
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Affiliation(s)
- Ji Young Bang
- Center for Interventional Endoscopy, Florida Hospital, Orlando, Florida
| | | | - Bronte A Holt
- Center for Interventional Endoscopy, Florida Hospital, Orlando, Florida
| | - Bryce Sutton
- Center for Interventional Endoscopy, Florida Hospital, Orlando, Florida
| | - Muhammad K Hasan
- Center for Interventional Endoscopy, Florida Hospital, Orlando, Florida
| | | | | | - C Mel Wilcox
- Division of Gastroenterology-Hepatology, University of Alabama at Birmingham, Birmingham, Alabama
| | - Benjamin Tharian
- Center for Interventional Endoscopy, Florida Hospital, Orlando, Florida
| | - Robert H Hawes
- Center for Interventional Endoscopy, Florida Hospital, Orlando, Florida
| | - Shyam Varadarajulu
- Center for Interventional Endoscopy, Florida Hospital, Orlando, Florida.
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Garg PK, Zyromski NJ, Freeman ML. Infected Necrotizing Pancreatitis: Evolving Interventional Strategies From Minimally Invasive Surgery to Endoscopic Therapy-Evidence Mounts, But One Size Does Not Fit All. Gastroenterology 2019; 156:867-871. [PMID: 30776344 DOI: 10.1053/j.gastro.2019.02.015] [Citation(s) in RCA: 20] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
Affiliation(s)
- Pramod K Garg
- Department of Gastroenterology, All India Institute of Medical Sciences, New Delhi, India.
| | - Nicholas J Zyromski
- Department of Surgery, Indiana University School of Medicine, Indianapolis, Indiana
| | - Martin L Freeman
- Departments of Medicine and Pediatrics, Chief, Division of Gastroenterology, Hepatology and Nutrition, University of Minnesota, Minneapolis, Minnesota
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Pizzicannella M, Pandolfi M, Andrisani G, Signoretti M, Martino M, Rea R, Di Matteo FM. EUS-guided trans-esophageal drainage of a mediastinal necrotic fluid collection using the axios electrocautery enhanced delivery system™. Scand J Gastroenterol 2019; 54:137-139. [PMID: 30714430 DOI: 10.1080/00365521.2019.1568542] [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] [Indexed: 02/04/2023]
Abstract
Mediastinal collection secondary to necrotic acute pancreatitis, is an extremely rare event caused by the posterior rupture of the pancreatic duct into the retroperitoneal space with the penetration of the pancreatic fluid through the diaphragmatic orifices. Infection of the necrotic collection may occur with a consequent substantial increase of the mortality rate. Due to the rarity of this severe condition, no consensus is known about the management of infected mediastinal necrotic collections. We reported the case of a 61-year-old male who was critically unwell secondary to a large mediastinal necrotic collections after necrotic acute pancreatitis with no improvement after surgery. The patient was successfully treated by EUS-guided trans-esophageal drainage using the AXIOS Electrocautery Enhanced Delivery System™. This procedure proved in this case to be a safe and effective option for the management of infected necrotic mediastinal collections.
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Affiliation(s)
| | - Monica Pandolfi
- a Digestive Endoscopy Unit, Campus Bio-Medico , University of Rome , Rome , Italy
| | - Gianluca Andrisani
- a Digestive Endoscopy Unit, Campus Bio-Medico , University of Rome , Rome , Italy
| | - Marianna Signoretti
- a Digestive Endoscopy Unit, Campus Bio-Medico , University of Rome , Rome , Italy
| | - Margareth Martino
- a Digestive Endoscopy Unit, Campus Bio-Medico , University of Rome , Rome , Italy
| | - Roberta Rea
- a Digestive Endoscopy Unit, Campus Bio-Medico , University of Rome , Rome , Italy
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108
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Li J, Chen J, Tang W. The consensus of integrative diagnosis and treatment of acute pancreatitis-2017. J Evid Based Med 2019; 12:76-88. [PMID: 30806495 DOI: 10.1111/jebm.12342] [Citation(s) in RCA: 21] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/27/2018] [Indexed: 01/11/2023]
Abstract
Acute pancreatitis (AP) is one of the most common acute abdominal diseases. The digestive disease committee, Chinese Association of Integrative Medicine, released Integrated traditional Chinese and Western medicine for diagnosis and treatment of acute pancreatitis in 2010.1 Since then, further studies and great progress have been made by domestic and foreign counterparts from the perspective of both Chinese and Western medicine in AP, including the classification, fluid resuscitation, organ function maintenance, surgery intervention, enteral nutrition (EN), and syndrome differentiation and treatment. It is necessary to update the consensus on diagnosis and treatment of integrated Chinese and Western medicine to meet clinical needs. Therefore, the 2012 Revision of the Atlanta Classification Standard (RAC) by the International AP Consensus,2 the 2013 the Management of Acute Pancreatitis by the American College of Gastroenterology,3, 4 the 2014 Guidelines for diagnosis and treatment of the acute pancreatitis guide (2014) by the Chinese medical association branch,5 the 2014 Guidelines on Integrative Medicine for Severe Acute Pancreatitis by the General Surgery Committee of the Chinese Society of Integrated Traditional Chinese and Western Medicine,6 and Traditional Chinese Medicine Consensus on the Diagnosis and Treatment for Acute Pancreatitis by the Spleen and Stomach committee of China Association of Traditional Chinese Medicine7, 8 were taken into account for the revision of the consensus published in 2010. The digestive specialists in Chinese and Western medicine had a discussion on traditional Chinese medicine (TCM) types, syndrome differentiation, the main points of integrative medicine, and so on. According to the Delphi method, Consensus of Integrative Diagnosis and Treatment of Acute Pancreatitis (the 2017 revision) has been passed after three rounds votes. (The voting options are as follows: (a) totally agree; (b) agree, but with some reservations; (c) agree, but with larger reservations; (d) disagree, but reserved; and (e) absolutely disagree. If more than two out of three choose (a), or over 85% choose (a) + (b), the consensus will be passed.) The final validation was carried out by the core expert group in Taizhou, Jiangsu on June 9, 2017. The full text is as follows.
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Affiliation(s)
- Junxiang Li
- Digestive Disease Committee, Chinese Association of Integrative Medicine
| | - Jing Chen
- Digestive Disease Committee, Chinese Association of Integrative Medicine
| | - Wenfu Tang
- Digestive Disease Committee, Chinese Association of Integrative Medicine
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109
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Govil D, Shafi M. Thoracic Epidural Analgesia for Severe Acute Pancreatitis: Quo Vadis Intensivist? Indian J Crit Care Med 2019; 23:59-60. [PMID: 31086447 PMCID: PMC6487610 DOI: 10.5005/jp-journals-10071-23117] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022] Open
Abstract
How to cite this article: Govil D, Shafi M. Thoracic Epidural Analgesia for Severe Acute Pancreatitis: Quo Vadis Intensivist? Indian J of Crit Care Med 2019;23(2):59-60.
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Affiliation(s)
- Deepak Govil
- Institute of Anesthesia and Critical Care, Medanta The Medicity, Gurugram, Haryana, India
| | - Mozammil Shafi
- Institute of Anesthesia and Critical Care, Medanta The Medicity, Gurugram, Haryana, India
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Smith ZL, Gregory MH, Elsner J, Alajlan BA, Kodali D, Hollander T, Sayuk GS, Lang GD, Das KK, Mullady DK, Early DS, Kushnir VM. Health-related quality of life and long-term outcomes after endoscopic therapy for walled-off pancreatic necrosis. Dig Endosc 2019; 31:77-85. [PMID: 30152143 DOI: 10.1111/den.13264] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/21/2018] [Accepted: 08/20/2018] [Indexed: 12/17/2022]
Abstract
BACKGROUND AND AIM Walled-off pancreatic necrosis (WON) frequently develops after necrotizing pancreatitis. Endoscopic drainage has become the preferred modality for symptomatic or infected WON. The aim of the present study was to assess health-related quality of life (HR-QOL) and long-term outcomes in patients undergoing endoscopic drainage for WON. METHODS Patients undergoing endoscopic drainage of WON from January 2006 to May 2016 were identified. Data recorded included demographic information, and the incidence of long-term sequelae including pancreatic endocrine and exocrine insufficiency. Attempts were made to contact all patients. HR-QOL was assessed using the SF-36 questionnaire. RESULTS Eighty patients were analyzed, 41 (51.3%) of whom completed the SF-36. One-year all-cause mortality was 6.2%, and disease-related mortality was 3.7%. A notable proportion of patients developed exocrine insufficiency (32.5%), endocrine insufficiency (27.7%), and long-term opiate use (42.5%). Development of exocrine insufficiency was predictive of lower total SF-36 scores (P = 0.016). Patients with WON had better HR-QOL compared with cohorts of irritable bowel syndrome (IBS) and inflammatory bowel disease (IBD). In patients developing exocrine insufficiency versus healthy controls, poorer scores in the physical role (P < 0.001), general health (P < 0.001), vitality (P = 0.001), and emotional role (P = 0.029) domains were observed. Exocrine insufficiency patients had better HR-QOL than the IBS and IBD cohorts, although these differences were less pronounced. CONCLUSION After undergoing endoscopic drainage for WON, patients have relatively preserved HR-QOL. The subset of patients that develop exocrine insufficiency have significantly poorer HR-QOL compared to healthy controls, although not to the degree of chronic gastrointestinal disorders such as IBS and IBD.
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Affiliation(s)
- Zachary L Smith
- Division of Gastroenterology, Washington University School of Medicine, St Louis, USA
| | - Martin H Gregory
- Division of Gastroenterology, Washington University School of Medicine, St Louis, USA
| | - Jeffrey Elsner
- Division of Gastroenterology, Washington University School of Medicine, St Louis, USA
| | - Bader A Alajlan
- Division of Gastroenterology, Washington University School of Medicine, St Louis, USA
| | - Divya Kodali
- Division of Gastroenterology, Washington University School of Medicine, St Louis, USA
| | - Thomas Hollander
- Division of Gastroenterology, Washington University School of Medicine, St Louis, USA
| | - Gregory S Sayuk
- Division of Gastroenterology, Washington University School of Medicine, St Louis, USA
| | - Gabriel D Lang
- Division of Gastroenterology, Washington University School of Medicine, St Louis, USA
| | - Koushik K Das
- Division of Gastroenterology, Washington University School of Medicine, St Louis, USA
| | - Daniel K Mullady
- Division of Gastroenterology, Washington University School of Medicine, St Louis, USA
| | - Dayna S Early
- Division of Gastroenterology, Washington University School of Medicine, St Louis, USA
| | - Vladimir M Kushnir
- Division of Gastroenterology, Washington University School of Medicine, St Louis, USA
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111
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[Video-assisted retroperitoneal debridement : Minimally invasive treatment and long-term results for necrotizing pancreatitis]. Chirurg 2018; 88:785-791. [PMID: 28180976 DOI: 10.1007/s00104-017-0377-4] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/22/2022]
Abstract
BACKGROUND Among patients with necrotizing pancreatitis 15-20% develop infected necrosis, which entails mortality rates of up to 20%. Particularly driven by the results of the Dutch Pancreatitis Study Group there has been a paradigm change from open necrosectomy to step-up treatment with initial percutaneous and/or endoscopic drainage followed, if necessary, by minimally invasive retroperitoneal debridement. AIM OF THE STUDY Description of case series in which patients underwent video-assisted retroperitoneal debridement (VARD) including follow-up focused on quality of life. METHODS Systematic cohort study including all patients who underwent a VARD procedure at the Department of General, Visceral and Transplantation Surgery at Aachen University Hospital from 2011 to 2015. Quality of life was recorded using the EORTC QLQ-C 30 questionnaire and compared to a representative sample of the German general population. RESULTS The VARD procedure was performed in 9 cases, although in 1 case conversion to an open approach due to an acute bleeding was necessary. There was no 30-day and 60-day mortality following VARD. During the postoperative stay no patient required specific treatment for surgical complications. In particular, no enterocutaneous fistula or organ perforation was observed. Regarding the quality of life score there was no significant difference concerning the global health status, compared to the sample from the general population. DISCUSSION Our data reinforce that a step-up approach in patients with necrotizing pancreatitis is a feasible and safe treatment procedure. For the first time, we could demonstrate satisfactory results in a long-term follow-up including QOL.
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112
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Jha AK, Goenka MK, Kumar R, Suchismita A. Endotherapy for pancreatic necrosis: An update. JGH OPEN 2018; 3:80-88. [PMID: 30834345 PMCID: PMC6386747 DOI: 10.1002/jgh3.12109] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 09/15/2018] [Revised: 09/28/2018] [Accepted: 10/11/2018] [Indexed: 12/16/2022]
Abstract
Approximately 20% of patients with acute pancreatitis develop pancreatic necrosis. The presence of necrosis in a pancreatic collection significantly worsens the prognosis. Pancreatic necrosis is associated with high mortality and morbidity. In the last few decades, there has been a significant revolution in the treatment of infected pancreatic necrosis. A step‐up approach has been proposed, from less invasive procedures to the operative intervention. Minimally invasive treatment modalities such as endoscopic drainage and necrosectomy, percutaneous drainage, and minimally invasive surgery have recently replaced open surgical necrosectomy as the first‐line treatment option. Endoscopic intervention for pancreatic necrosis is being increasingly performed with good success and a lower complication rate. However, techniques of endotherapy are still not uniform and vary as per local expertise, and there are still many unresolved questions with regard to the interventions in patients with pancreatic necrosis. The objective of this paper is to critically review the literature and update the concepts of endoscopic interventional therapy of pancreatic necrosis.
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Affiliation(s)
- Ashish K Jha
- Department of Gastroenterology Indira Gandhi Institute of Medical Sciences Patna India
| | - Mahesh K Goenka
- Department of Gastrosciences, Institute of Gastrosciences, Apollo Gleneagles Hospital Kolkata India
| | - Ramesh Kumar
- Department of Gastroenterology, All India Institute of Medical Sciences Patna India
| | - Arya Suchismita
- Department of Pediatrics Indira Gandhi Institute of Medical Sciences Patna India
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113
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Abstract
Background Acute pancreatitis still is a disease with overall high mortality. Continuously improved understanding of the pathophysiology, however, led to changes in treatment algorithms within the last decades, thus resulting in decreased mortality. This knowledge of acute pancreatitis enabled a new classification system introduced by an international expert panel. This classification system is helpful in initiating treatment strategies which are adapted to the course of acute pancreatitis. Especially the role of surgery experienced a paradigm shift towards a more conservative approach. Methods A specific literature search regarding the treatment of acute pancreatitis was performed in the PubMed database, and the results of key studies were compared. Results of these studies are discussed in the context of the most recent international classification system. Results and Conclusion Based upon the available data, we can summarize that conservative treatment of acute pancreatitis with pancreatic necrosis is a valid treatment option for selected cases and is associated with reduced mortality compared to more aggressive therapy. However, patients with acute pancreatitis should be treated in experienced centers.
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Affiliation(s)
- Christian Alberts
- Department of General, Thoracic, Vascular and Transplantation Surgery, University of Rostock, Rostock, Germany
| | - Guido Alsfasser
- Department of General, Thoracic, Vascular and Transplantation Surgery, University of Rostock, Rostock, Germany
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114
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Obaitan I, Hayat U, Hashmi H, Trikudanathan G. Imaging in pancreatitis: current status and recent advances. Expert Opin Orphan Drugs 2018. [DOI: 10.1080/21678707.2018.1536539] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/28/2022]
Affiliation(s)
- Itegbemie Obaitan
- Department of Medicine, University of Minnesota, Minneapolis, MN, USA
| | - Umar Hayat
- Division of Gastroenterology, Hepatology and Nutrition, University of Minnesota, Minneapolis, MN, USA
| | - Hiba Hashmi
- Division of Gastroenterology, Hepatology and Nutrition, University of Minnesota, Minneapolis, MN, USA
| | - Guru Trikudanathan
- Division of Gastroenterology, Hepatology and Nutrition, University of Minnesota, Minneapolis, MN, USA
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115
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Early (<4 Weeks) Versus Standard (≥ 4 Weeks) Endoscopically Centered Step-Up Interventions for Necrotizing Pancreatitis. Am J Gastroenterol 2018; 113:1550-1558. [PMID: 30279466 DOI: 10.1038/s41395-018-0232-3] [Citation(s) in RCA: 98] [Impact Index Per Article: 16.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/26/2017] [Accepted: 07/19/2018] [Indexed: 02/06/2023]
Abstract
OBJECTIVES Current guidelines for necrotizing pancreatitis (NP) recommend delay in drainage ± necrosectomy until 4 or more weeks after initial presentation to allow collections to wall off. However, evidence of infection with clinical deterioration despite maximum support may mandate earlier (<4 weeks) intervention. There are concerns, but scant data regarding risk of complications and outcomes with early endoscopic intervention. Our aim was to compare the results of an endoscopic centered step-up approach to NP when initiated before versus 4 or more weeks. METHODS All patients undergoing intervention for NP were managed using an endoscopically centered step-up approach, with transluminal drainage whenever feasible, ±necrosectomy, and/or percutaneous catheter drainage as needed, with surgery only for failures. Interventions were categorized as early or standard based on timing of intervention (<4 weeks or ≥ 4 weeks from onset of pancreatitis). Demographic data, indications and timing for interventions, number and type of intervention, mortality and morbidity (length of stay in hospital and ICU) and complications were compared. RESULTS Of 305 patients with collections associated with NP, 193 (63%) (median age-52 years) required intervention, performed by a step-up approach. Of the 193 patients, 76 patients underwent early and 117 patients standard intervention. 144 (75%) interventions included endoscopic drainage ± necrosectomy. As compared with standard intervention, early intervention was more often performed for infection (91% vs. 39%, p < 0.05), more associated with acute kidney injury (43% vs. 32%, p = 0.09), respiratory failure (41% vs. 22%, p = 0.005), and shock (13% vs. 4%, p < 0.05). Organ failure improved significantly after intervention in both groups. There was a significant difference in mortality (13% vs. 4%, p = 0.02) and need for rescue open necrosectomy (7% vs. 1%, p = 0.03) between groups. Patients undergoing early intervention had increased median hospital (37 days vs. 26 days, p = 0.01) and ICU stay (median 2.5 days vs. 0 days, p = 0.001). There was no difference in complications. CONCLUSIONS When using an endoscopically centered step-up strategy in necrotizing pancreatitis, early (<4 weeks) interventions were more often performed for infection and organ failure, with no increase in complications, similar improvement in organ failure, slightly increased need for surgery, and relatively low mortality. Early endoscopic drainage ± necrosectomy should be considered when there is a strong indication for intervention.
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Case BM, Jensen KK, Bakis G, Enestvedt BK, Shaaban AM, Foster BR. Endoscopic Interventions in Acute Pancreatitis: What the Advanced Endoscopist Wants to Know. Radiographics 2018; 38:2002-2018. [PMID: 30265612 DOI: 10.1148/rg.2018180066] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/01/2023]
Abstract
Endoscopic interventions play an important role in the modern management of pancreatic fluid collections. Successful management of pancreatitis is dependent on proper classification of the disease and its local complications. The 2012 revised Atlanta classification divides acute pancreatitis into subtypes of necrotizing pancreatitis and interstitial edematous pancreatitis (IEP) on the basis of the radiologic presence or absence of necrosis, respectively. Local complications of IEP include acute pancreatic fluid collections and pseudocysts, which contain fluid only and are differentiated by the time elapsed since the onset of symptoms. Local complications of necrotizing pancreatitis include acute necrotic collections and walled-off necrosis, which contain nonliquefied necrotic debris and are differentiated by the time elapsed since the onset of symptoms. Endoscopic techniques are used to treat local complications of pancreatitis, often in a step-up approach, by which less invasive techniques are preferred initially with potential subsequent use of more invasive procedures, dependent on the patient's clinical response and collection evolution. Common interventions performed by the advanced endoscopist include endoscopic transmural drainage and endoscopic transmural necrosectomy. However, some collections require a multimodal approach with adjunctive placement of percutaneous drainage catheters or the use of videoscopic-assisted retroperitoneal débridement. Additional endoscopic interventions may be required in the setting of pancreatic or biliary duct stones or strictures. Common complications of endoscopic intervention in the setting of pancreatitis include bleeding, infection, perforation, and stent migration. This article reviews the classification of acute pancreatitis, familiarizes radiologists with the common endoscopic techniques used in its management, and improves identification of the clinically relevant imaging findings and procedural complications related to endoscopic interventions in pancreatitis. ©RSNA, 2018.
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Affiliation(s)
- Brendan M Case
- From the Department of Diagnostic Radiology (B.M.C., K.K.J., B.R.F.) and Department of Medicine, Division of Gastroenterology (B.K.E.), Oregon Health and Science University, 3181 SW Sam Jackson Park Rd, Portland, OR 97239; Portland Gastroenterology Center, Portland, Maine (G.B.); and Department of Radiology and Imaging Sciences, University of Utah, Salt Lake City, Utah (A.M.S.)
| | - Kyle K Jensen
- From the Department of Diagnostic Radiology (B.M.C., K.K.J., B.R.F.) and Department of Medicine, Division of Gastroenterology (B.K.E.), Oregon Health and Science University, 3181 SW Sam Jackson Park Rd, Portland, OR 97239; Portland Gastroenterology Center, Portland, Maine (G.B.); and Department of Radiology and Imaging Sciences, University of Utah, Salt Lake City, Utah (A.M.S.)
| | - Gene Bakis
- From the Department of Diagnostic Radiology (B.M.C., K.K.J., B.R.F.) and Department of Medicine, Division of Gastroenterology (B.K.E.), Oregon Health and Science University, 3181 SW Sam Jackson Park Rd, Portland, OR 97239; Portland Gastroenterology Center, Portland, Maine (G.B.); and Department of Radiology and Imaging Sciences, University of Utah, Salt Lake City, Utah (A.M.S.)
| | - Brintha K Enestvedt
- From the Department of Diagnostic Radiology (B.M.C., K.K.J., B.R.F.) and Department of Medicine, Division of Gastroenterology (B.K.E.), Oregon Health and Science University, 3181 SW Sam Jackson Park Rd, Portland, OR 97239; Portland Gastroenterology Center, Portland, Maine (G.B.); and Department of Radiology and Imaging Sciences, University of Utah, Salt Lake City, Utah (A.M.S.)
| | - Akram M Shaaban
- From the Department of Diagnostic Radiology (B.M.C., K.K.J., B.R.F.) and Department of Medicine, Division of Gastroenterology (B.K.E.), Oregon Health and Science University, 3181 SW Sam Jackson Park Rd, Portland, OR 97239; Portland Gastroenterology Center, Portland, Maine (G.B.); and Department of Radiology and Imaging Sciences, University of Utah, Salt Lake City, Utah (A.M.S.)
| | - Bryan R Foster
- From the Department of Diagnostic Radiology (B.M.C., K.K.J., B.R.F.) and Department of Medicine, Division of Gastroenterology (B.K.E.), Oregon Health and Science University, 3181 SW Sam Jackson Park Rd, Portland, OR 97239; Portland Gastroenterology Center, Portland, Maine (G.B.); and Department of Radiology and Imaging Sciences, University of Utah, Salt Lake City, Utah (A.M.S.)
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Waller A, Long B, Koyfman A, Gottlieb M. Acute Pancreatitis: Updates for Emergency Clinicians. J Emerg Med 2018; 55:769-779. [PMID: 30268599 DOI: 10.1016/j.jemermed.2018.08.009] [Citation(s) in RCA: 26] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/22/2018] [Accepted: 08/03/2018] [Indexed: 12/12/2022]
Abstract
BACKGROUND Acute pancreatitis is a frequent reason for patient presentation to the emergency department (ED) and the most common gastrointestinal disease resulting in admission. Emergency clinicians are often responsible for the diagnosis and initial management of acute pancreatitis. OBJECTIVE This review article provides emergency clinicians with a focused overview of the diagnosis and management of pancreatitis. DISCUSSION Pancreatitis is an inflammatory process within the pancreas. While the disease is often mild, severe forms can have a mortality rate of up to 30%. The diagnosis of pancreatitis requires two of the following three criteria: epigastric abdominal pain, an elevated lipase, and imaging findings of pancreatic inflammation. The most common etiologies include gallbladder disease and alcohol use. After the diagnosis has been made, it is important to identify underlying etiologies requiring specific intervention, as well as obtain a right upper quadrant ultrasound. The initial management of choice is fluid resuscitation and pain control. Recent data have suggested that more cautious fluid resuscitation in the first 24 h might be more appropriate for some patients. Intravenous opiates are generally safe if used judiciously. Appropriate disposition is a multifactorial decision, which can be facilitated by using Ranson criteria or the Bedside Index of Severity in Acute Pancreatitis score. Complications, though rare, can be severe. CONCLUSIONS Pancreatitis is a potentially deadly disease that commonly presents to most emergency departments. It is important for clinicians to be aware of the current evidence regarding the diagnosis, treatment, and disposition of these patients.
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Affiliation(s)
- Anna Waller
- Department of Emergency Medicine, Brooke Army Medical Center, Fort Sam Houston, Texas
| | - Brit Long
- Department of Emergency Medicine, Brooke Army Medical Center, Fort Sam Houston, Texas
| | - Alex Koyfman
- Department of Emergency Medicine, The University of Texas Southwestern Medical Center, Dallas, Texas
| | - Michael Gottlieb
- Department of Emergency Medicine, Rush University Medical Center, Chicago, Illinois
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Falk V, Kenshil S, Sandha S, Teshima C, D'Souza P, Sandha G. The Evolution of EUS-Guided Transluminal Drainage for the Treatment of Pancreatic Fluid Collections: A Comparison of Clinical and Cost Outcomes with Double-Pigtail Plastic Stents, Conventional Metal Stents and Lumen-Apposing Metal Stents. J Can Assoc Gastroenterol 2018; 3:26-35. [PMID: 34169224 PMCID: PMC8218535 DOI: 10.1093/jcag/gwy049] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/11/2022] Open
Abstract
Background While most pancreatic fluid collections (PFCs) resolve spontaneously, endoscopic ultrasound-guided transluminal drainage (EUS-TD) may be necessary. EUS-TD has evolved from multiple double-pigtail plastic stents (DPPS) to fully covered self-expanding metal stents (FCSEMS) and lumen-apposing metal stents (LAMS). This study compares clinical attributes of DPPS, FCSEMS and LAMS. Methods This is a single-centre retrospective review of EUS-TD for PFCs. The primary outcome was clinical success. Secondary outcomes were technical success, procedure time, hospital length of stay (HLOS), number of endoscopies, need for necrosectomy, adverse events (AEs) and overall cost. Results Fifty-eight patients (37 male, average age 49 years) underwent a total of 60 EUS-TD procedures for PFCs (average size 11.2 cm with 29 pseudocysts and 29 walled-off necrosis). Ten patients (17%) underwent EUS-TD with DPPS and 48 patients (83%) with metal stents (32 FCSEMS, 16 LAMS). Overall technical and clinical success was 100% and 84%, respectively. Lumen-apposing metal stents had shorter procedure times (14.9 versus 63.6 DPPS, 39.1 min FCSEMS, P < 0.001), and no difference in AEs (3 of 16 versus 4 of 10 DPPS, 12 of 34 FCSEMS, ns). Double-pigtail plastic stents required more endoscopies (3.7 versus 2.3 LAMS, 2.3 FCSEMS, P = 0.013) and necrosectomies (4 of 10 [40%]) compared with 5 of 34 [15%] in the FCSEMS group and 3 of 16 [19%] in the LAMS group, respectively, P = 0.001) to achieve clinical resolution. The overall cost and HLOS was not significantly different between groups. Conclusion The use of LAMS for PFCs is not associated with any significant increase in cost despite technical (shorter procedure time) and clinical advantages (shorter indwell time, reduced need for necrosectomy and no increase in AEs).
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Affiliation(s)
- Vanessa Falk
- Division of Gastroenterology, University of Alberta Hospital, Edmonton, Alberta, Canada.,Department of General Surgery, Medical University of Newfoundland, St. John's, Newfoundland, Canada
| | - Sana Kenshil
- Division of Gastroenterology, University of Ottawa, Ottawa, Ontario, Canada
| | - Simrat Sandha
- Division of Gastroenterology, University of Alberta Hospital, Edmonton, Alberta, Canada
| | - Christopher Teshima
- Division of Gastroenterology, St. Michael's Hospital, Toronto, Ontario, Canada
| | - Pernilla D'Souza
- Division of Gastroenterology, University of Alberta Hospital, Edmonton, Alberta, Canada
| | - Gurpal Sandha
- Division of Gastroenterology, University of Alberta Hospital, Edmonton, Alberta, Canada
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Thorsen A, Borch AM, Novovic S, Schmidt PN, Gluud LL. Endoscopic Necrosectomy Through Percutaneous Self-Expanding Metal Stents May Be a Promising Additive in Treatment of Necrotizing Pancreatitis. Dig Dis Sci 2018; 63:2456-2465. [PMID: 29796908 DOI: 10.1007/s10620-018-5131-3] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/24/2018] [Accepted: 05/18/2018] [Indexed: 01/07/2023]
Abstract
BACKGROUND The recommended treatment of infected walled-off necrosis (WON) in necrotizing pancreatitis entails a step-up treatment approach starting with endoscopic necrosectomy (ETDN). AIMS To report a small number of cases from 2013 to 2016 that were not amenable to or failed to respond to ETDN, and to describe a new, minimally invasive technique that may be a promising supplement to ETDN in this difficult patient population. METHODS Using the Seldinger technique, a fully covered self-expanding metal stent (SEMS) was placed percutaneously in order to drain, irrigate, and debride WON. After resolution, the stent was removed. We reviewed electronic patient records and defined clinical success as complete WON resolution with removal of internal as well as percutaneous drains and stents. RESULTS Five patients underwent treatment with SEMS placement. The mean length of the WON was 33.4 cm. Clinical success was achieved in four patients after an average of 5.75 necrosectomy sessions. One patient died from severe sepsis. Adverse events included severe abdominal pain and productive cutaneous fistulae (two patients). CONCLUSIONS In our small case series, endoscopic necrosectomy through a percutaneous SEMS seemed beneficial and safe in the treatment of infected WON.
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Affiliation(s)
- Andreas Thorsen
- Department of Gastroenterology and Gastrointestinal Surgery, Copenhagen University Hospital Hvidovre, Kettegård Allé 30, 2650, Hvidovre, Denmark.
| | - Anders Malthe Borch
- Department of Gastroenterology and Gastrointestinal Surgery, Copenhagen University Hospital Hvidovre, Kettegård Allé 30, 2650, Hvidovre, Denmark
| | - Srdan Novovic
- Department of Gastroenterology and Gastrointestinal Surgery, Copenhagen University Hospital Hvidovre, Kettegård Allé 30, 2650, Hvidovre, Denmark
| | - Palle Nordblad Schmidt
- Department of Gastroenterology and Gastrointestinal Surgery, Copenhagen University Hospital Hvidovre, Kettegård Allé 30, 2650, Hvidovre, Denmark
| | - Lise Lotte Gluud
- Department of Gastroenterology and Gastrointestinal Surgery, Copenhagen University Hospital Hvidovre, Kettegård Allé 30, 2650, Hvidovre, Denmark
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120
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Vege SS, Pandol SJ. Advances in Pancreatic Cancer, Intraductal Papillary Mucinous Neoplasms, and Pancreatitis. Gastroenterology 2018; 155:581-583. [PMID: 29753841 PMCID: PMC6785012 DOI: 10.1053/j.gastro.2018.05.019] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/16/2018] [Revised: 05/03/2018] [Accepted: 05/03/2018] [Indexed: 12/12/2022]
Abstract
According to the theme of the Golden Jubilee Issue of our journal, we present a commentary on landmark contributions reported in the journal on pancreatic cancer, pancreatic cysts, and intraductal papillary mucinous neoplasms (IPMN) and pancreatitis.
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121
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Rasslan R, Novo FDCF, Bitran A, Utiyama EM, Rasslan S. Management of infected pancreatic necrosis: state of the art. ACTA ACUST UNITED AC 2018; 44:521-529. [PMID: 29019583 DOI: 10.1590/0100-69912017005015] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/25/2017] [Accepted: 06/01/2017] [Indexed: 02/08/2023]
Abstract
Pancreatic necrosis occurs in 15% of acute pancreatitis. The presence of infection is the most important factor in the evolution of pancreatitis. The diagnosis of infection is still challenging. Mortality in infected necrosis is 20%; in the presence of organic dysfunction, mortality reaches 60%. In the last three decades, there has been a real revolution in the treatment of infected pancreatic necrosis. However, the challenges persist and there are many unsolved questions: antibiotic treatment alone, tomography-guided percutaneous drainage, endoscopic drainage, video-assisted extraperitoneal debridement, extraperitoneal access, open necrosectomy? A step up approach has been proposed, beginning with less invasive procedures and reserving the operative intervention for patients in which the previous procedure did not solve the problem definitively. Indication and timing of the intervention should be determined by the clinical course. Ideally, the intervention should be done only after the fourth week of evolution, when it is observed a better delimitation of necrosis. Treatment should be individualized. There is no procedure that should be the first and best option for all patients. The objective of this work is to critically review the current state of the art of the treatment of infected pancreatic necrosis.
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Affiliation(s)
- Roberto Rasslan
- - University of São Paulo School of Medicine, Division of General Surgery and Trauma, Department of Surgery, São Paulo, SP, Brazil
| | - Fernando da Costa Ferreira Novo
- - University of São Paulo School of Medicine, Division of General Surgery and Trauma, Department of Surgery, São Paulo, SP, Brazil
| | - Alberto Bitran
- - University of São Paulo School of Medicine, Division of General Surgery and Trauma, Department of Surgery, São Paulo, SP, Brazil
| | - Edivaldo Massazo Utiyama
- - University of São Paulo School of Medicine, Division of General Surgery and Trauma, Department of Surgery, São Paulo, SP, Brazil
| | - Samir Rasslan
- - University of São Paulo School of Medicine, Division of General Surgery and Trauma, Department of Surgery, São Paulo, SP, Brazil
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Abstract
Acute pancreatitis is an inflammation of the glandular parenchyma of the retroperitoneal organ that leads to injury with or without subsequent destruction of the pancreatic acini. This inflammatory process can either result in a self-limited disease or involve life-threatening multiorgan complications. Chronic pancreatitis consists of endocrine and exocrine gland dysfunction that develops secondary to progressive inflammation and chronic fibrosis of the pancreatic acini with permanent structural damage. Recurrent attacks of acute pancreatitis can result in chronic pancreatitis; acute and chronic pancreatitis are different diseases with separate morphologic patterns. Acute pancreatitis has an increasing incidence but a decreasing mortality.
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Affiliation(s)
- Abdulrahman Y Hammad
- Department of Surgery, Allegheny General Hospital, 320 East North Avenue, Pittsburgh, PA 15212, USA
| | - Michael Ditillo
- Department of Surgery, Allegheny General Hospital, 320 East North Avenue, Pittsburgh, PA 15212, USA
| | - Lourdes Castanon
- Department of Surgery, Allegheny General Hospital, 320 East North Avenue, Pittsburgh, PA 15212, USA.
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123
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Mandalia A, Wamsteker EJ, DiMagno MJ. Recent advances in understanding and managing acute pancreatitis. F1000Res 2018; 7. [PMID: 30026919 DOI: 10.12688/f1000research.14244.1] [Citation(s) in RCA: 21] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 06/20/2018] [Indexed: 12/16/2022] Open
Abstract
This review highlights advances made in recent years in the diagnosis and management of acute pancreatitis (AP). We focus on epidemiological, clinical, and management aspects of AP. Additionally, we discuss the role of using risk stratification tools to guide clinical decision making. The majority of patients suffer from mild AP, and only a subset develop moderately severe AP, defined as a pancreatic local complication, or severe AP, defined as persistent organ failure. In mild AP, management typically involves diagnostic evaluation and supportive care resulting usually in a short hospital length of stay (LOS). In severe AP, a multidisciplinary approach is warranted to minimize morbidity and mortality over the course of a protracted hospital LOS. Based on evidence from guideline recommendations, we discuss five treatment interventions, including intravenous fluid resuscitation, feeding, prophylactic antibiotics, probiotics, and timing of endoscopic retrograde cholangiopancreatography (ERCP) in acute biliary pancreatitis. This review also highlights the importance of preventive interventions to reduce hospital readmission or prevent pancreatitis, including alcohol and smoking cessation, same-admission cholecystectomy for acute biliary pancreatitis, and chemoprevention and fluid administration for post-ERCP pancreatitis. Our review aims to consolidate guideline recommendations and high-quality studies published in recent years to guide the management of AP and highlight areas in need of research.
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Affiliation(s)
- Amar Mandalia
- Division of Gastroenterology and Hepatology, University of Michigan School of Medicine, Ann Arbor, MI, 48109, USA
| | - Erik-Jan Wamsteker
- Division of Gastroenterology and Hepatology, University of Michigan School of Medicine, Ann Arbor, MI, 48109, USA
| | - Matthew J DiMagno
- Division of Gastroenterology and Hepatology, University of Michigan School of Medicine, Ann Arbor, MI, 48109, USA
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Abstract
This review highlights advances made in recent years in the diagnosis and management of acute pancreatitis (AP). We focus on epidemiological, clinical, and management aspects of AP. Additionally, we discuss the role of using risk stratification tools to guide clinical decision making. The majority of patients suffer from mild AP, and only a subset develop moderately severe AP, defined as a pancreatic local complication, or severe AP, defined as persistent organ failure. In mild AP, management typically involves diagnostic evaluation and supportive care resulting usually in a short hospital length of stay (LOS). In severe AP, a multidisciplinary approach is warranted to minimize morbidity and mortality over the course of a protracted hospital LOS. Based on evidence from guideline recommendations, we discuss five treatment interventions, including intravenous fluid resuscitation, feeding, prophylactic antibiotics, probiotics, and timing of endoscopic retrograde cholangiopancreatography (ERCP) in acute biliary pancreatitis. This review also highlights the importance of preventive interventions to reduce hospital readmission or prevent pancreatitis, including alcohol and smoking cessation, same-admission cholecystectomy for acute biliary pancreatitis, and chemoprevention and fluid administration for post-ERCP pancreatitis. Our review aims to consolidate guideline recommendations and high-quality studies published in recent years to guide the management of AP and highlight areas in need of research.
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Affiliation(s)
- Amar Mandalia
- Division of Gastroenterology and Hepatology, University of Michigan School of Medicine, Ann Arbor, MI, 48109, USA
| | - Erik-Jan Wamsteker
- Division of Gastroenterology and Hepatology, University of Michigan School of Medicine, Ann Arbor, MI, 48109, USA
| | - Matthew J DiMagno
- Division of Gastroenterology and Hepatology, University of Michigan School of Medicine, Ann Arbor, MI, 48109, USA
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Isolated pancreatic tail remnants after transgastric necrosectomy can be observed. J Surg Res 2018; 231:109-115. [PMID: 30278917 DOI: 10.1016/j.jss.2018.05.020] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/01/2018] [Revised: 04/16/2018] [Accepted: 05/17/2018] [Indexed: 12/30/2022]
Abstract
BACKGROUND Severe necrotizing pancreatitis may result in midbody necrosis and ductal disruption leaving an isolated pancreatic tail. The purpose of this study was to characterize outcomes among patients with an isolated tail remnant who underwent transgastric drainage or necrosectomy (endoscopic or surgical) and determine the need for subsequent operative management. MATERIALS AND METHODS Patients with necrotizing pancreatitis and retrogastric walled-off collections treated by surgical transgastric necrosectomy or endoscopic cystgastrostomy ± necrosectomy between 2009 and 2017 were identified by a retrospective chart review. All available preprocedure and postprocedure imaging was reviewed for evidence of isolated distal pancreatic tail remnants. RESULTS Seventy-four patients were included (40 surgical and 34 endoscopic). All the patients in the surgical group underwent laparoscopic transgastric necrosectomy; the endoscopic group consisted of 26 patients for pseudocyst drainage and eight patients for necrosectomy. A disconnected pancreatic tail was identified in 22 (29%) patients (13 laparoscopic and nine endoscopic). After the creation of the "cystgastrostomy," there were no external fistulas despite the viable tail. Of the 22 patients, four patients developed symptoms at a median of 23 months (two, recurrent episodic pancreatitis; two, intractable pain). Two patients (both initially in endoscopic group) ultimately required distal pancreatectomy and splenectomy at 24 and 6 months after index procedure. CONCLUSIONS Patients with a walled-off retrogastric collection and an isolated viable tail are effectively managed by a transgastric approach. Despite this seemingly "unstable anatomy," the creation of an internal fistula via surgical or endoscopic "cystgastrostomy" avoids external fistulas/drains and the short-term necessity of surgical distal pancreatectomy. A very small subset requires intervention for late symptoms.
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Lin K, Ofori E, Lin AN, Lin S, Lin T, Rasheed A, Vasudevan V, Reddy M. Hypothermia-Related Acute Pancreatitis. Case Rep Gastroenterol 2018; 12:217-223. [PMID: 29928186 PMCID: PMC6006605 DOI: 10.1159/000489296] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/05/2018] [Accepted: 04/17/2018] [Indexed: 02/02/2023] Open
Abstract
Acute pancreatitis (AP) is an inflammatory disease presenting from mild localized inflammation to severe infected necrotic pancreatic tissue. In the literature, there are a few cases of hypothermia-induced AP. However, the association between hypothermia and AP is still a myth. Generally, mortality from acute pancreatitis is nearly 3-6%. Here, we present a 40-year-old chronic alcoholic female who presented with acute pancreatitis induced by transient hypothermia. A 40-year-old chronic alcoholic female was hypothermic at 81°F on arrival which was improved to 91.7°F with warming blanket and then around 97°F in 8 h. Laboratory tests including complete blood count, lipid panel, and comprehensive metabolic panels were within the normal limit. Serum alcohol level was 0.01, amylase 498, lipase 1,200, ammonia 26, serum carboxyhemoglobin level 2.4, and β-HCG was negative. The entire sepsis workup was negative. During rewarming period, she had one episode of witnessed generalized tonic-clonic seizure. It was followed by transient hypotension. Fluid challenge was successful with 2 L of normal saline. Sonogram (abdomen) showed fatty liver and trace ascites. CAT scan (abdomen and pelvis) showed evidence of acute pancreatitis without necrosis, peripancreatic abscess, pancreatic mass, or radiopaque gallstones. The patient was managed medically and later discharged from the hospital on the 4th day as she tolerated a normal low-fat diet. In our patient, transient hypothermia from chronic alcohol abuse and her social circumstances might predispose to microcirculatory disturbance resulting in acute pancreatitis. Early and aggressive fluid resuscitation prevents complications.
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Affiliation(s)
- Kyawzaw Lin
- Department of Internal Medicine, The Brooklyn Hospital Center, Affiliate of the Mount Sinai Hospital, Brooklyn, New York, USA
| | - Emmanuel Ofori
- GI Department, The Brooklyn Hospital Center, Affiliate of the Mount Sinai Hospital, Brooklyn, New York, USA
| | - Aung Naing Lin
- Department of Internal Medicine, The Brooklyn Hospital Center, Affiliate of the Mount Sinai Hospital, Brooklyn, New York, USA
| | - Sithu Lin
- Department of Internal Medicine, The Brooklyn Hospital Center, Affiliate of the Mount Sinai Hospital, Brooklyn, New York, USA
| | - Thinzar Lin
- Department of Internal Medicine, The Brooklyn Hospital Center, Affiliate of the Mount Sinai Hospital, Brooklyn, New York, USA
| | - Ameer Rasheed
- MICU, The Brooklyn Hospital Center, Affiliate of the Mount Sinai Hospital, Brooklyn, New York, USA
| | - Viswanath Vasudevan
- Critical Care Department, The Brooklyn Hospital Center, Affiliate of the Mount Sinai Hospital, Brooklyn, New York, USA
| | - Madhavi Reddy
- GI Department, The Brooklyn Hospital Center, Affiliate of the Mount Sinai Hospital, Brooklyn, New York, USA
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Park SW. Is Percutaneous Endoscopic Necrosectomy Really Safe and Effective for Symptomatic Laterally Placed Walled-off Necrosis? Clin Endosc 2018; 51:213-214. [PMID: 29739185 PMCID: PMC5997073 DOI: 10.5946/ce.2018.064] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/09/2018] [Accepted: 04/20/2018] [Indexed: 12/23/2022] Open
Affiliation(s)
- Se Woo Park
- Division of Gastroenterology, Department of Internal Medicine, Hallym University Dongtan Sacred Heart Hospital, Hallym University College of Medicine, Hwaseong, Korea
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Pérez S, Finamor I, Martí-Andrés P, Pereda J, Campos A, Domingues R, Haj F, Sabater L, de-Madaria E, Sastre J. Role of obesity in the release of extracellular nucleosomes in acute pancreatitis: a clinical and experimental study. Int J Obes (Lond) 2018; 43:158-168. [PMID: 29717278 DOI: 10.1038/s41366-018-0073-6] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/08/2017] [Revised: 02/12/2018] [Accepted: 02/18/2018] [Indexed: 02/07/2023]
Abstract
BACKGROUND/OBJECTIVES A high body mass index increases the risk of severe pancreatitis and associated mortality. Our aims were: (1) To determine whether obesity affects the release of extracellular nucleosomes in patients with pancreatitis; (2) To determine whether pancreatic ascites confers lipotoxicity and triggers the release of extracellular nucleosomes in lean and obese rats. METHODS DNA and nucleosomes were determined in plasma from patients with mild or moderately severe acute pancreatitis either with normal or high body mass index (BMI). Lipids from pancreatic ascites from lean and obese rats were analyzed and the associated toxicity measured in vitro in RAW 264.7 macrophages. The inflammatory response, extracellular DNA and nucleosomes were determined in lean or obese rats with pancreatitis after peritoneal lavage. RESULTS Nucleosome levels in plasma from obese patients with mild pancreatitis were higher than in normal BMI patients; these levels markedly increased in obese patients with moderately severe pancreatitis vs. those with normal BMI. Ascites from obese rats exhibited high levels of palmitic, oleic, stearic, and arachidonic acids. Necrosis and histone 4 citrullination-marker of extracellular traps-increased in macrophages incubated with ascites from obese rats but not with ascites from lean rats. Peritoneal lavage abrogated the increase in DNA and nucleosomes in plasma from lean or obese rats with pancreatitis. It prevented fat necrosis and induction of HIF-related genes in lung. CONCLUSIONS Extracellular nucleosomes are intensely released in obese patients with acute pancreatitis. Pancreatitis-associated ascitic fluid triggers the release of extracellular nucleosomes in rats with severe pancreatitis.
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Affiliation(s)
- Salvador Pérez
- Department of Physiology, School of Pharmacy, University of Valencia, Av. Vicente Andrés Estellés s/n, 46100, Burjasot, Valencia, Spain
| | - Isabela Finamor
- Department of Physiology, School of Pharmacy, University of Valencia, Av. Vicente Andrés Estellés s/n, 46100, Burjasot, Valencia, Spain.,Department of Physiology and Pharmacology, Federal University of Santa Maria (UFSM), 1000, Santa Maria, Brazil
| | - Pablo Martí-Andrés
- Department of Physiology, School of Pharmacy, University of Valencia, Av. Vicente Andrés Estellés s/n, 46100, Burjasot, Valencia, Spain
| | - Javier Pereda
- Department of Physiology, School of Pharmacy, University of Valencia, Av. Vicente Andrés Estellés s/n, 46100, Burjasot, Valencia, Spain
| | - Ana Campos
- Department of Chemistry, University of Aveiro, 3810-193, Aveiro, Portugal
| | - Rosário Domingues
- Department of Chemistry, University of Aveiro, 3810-193, Aveiro, Portugal
| | - Fawaz Haj
- Department of Nutrition, University of California Davis, One Shields Ave, Davis, CA, 95616, USA
| | - Luis Sabater
- Department of Surgery, University of Valencia, University Clinic Hospital, Av. Blasco Ibañez 15, 46010, Valencia, Spain
| | - Enrique de-Madaria
- Department of Gastroenterology, University General Hospital of Alicante, Institute of Sanitary and Biomedical Research of Alicante (ISABIAL), Alicante, Spain
| | - Juan Sastre
- Department of Physiology, School of Pharmacy, University of Valencia, Av. Vicente Andrés Estellés s/n, 46100, Burjasot, Valencia, Spain.
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Sahar N, Kozarek RA, Kanji ZS, Chihara S, Gan SI, Irani S, Larsen M, Ross AS, Gluck M. The microbiology of infected pancreatic necrosis in the era of minimally invasive therapy. Eur J Clin Microbiol Infect Dis 2018; 37:1353-1359. [PMID: 29675786 DOI: 10.1007/s10096-018-3259-x] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/14/2018] [Accepted: 04/10/2018] [Indexed: 12/21/2022]
Abstract
We aimed to determine the microbiology of infected walled-off pancreatic necrosis (WON) in an era of minimally invasive treatment, since current knowledge is based on surgical specimens performed over two decades ago. We retrospectively analyzed a prospectively maintained database of patients who were treated for symptomatic WON using combined endoscopic and percutaneous drainage between 2008 and 2017. Aspirates from WON at initial treatment were evaluated. One hundred eighty-two patients were included with a mean age of 56 of whom 67% were male. Culture results were obtained at a median of 45 days from onset of acute pancreatitis of which 41% were infected. Candida spp. accounted for 27%; yet, multidrug-resistant organisms were found in only five patients. Approximately 64% were transferred to our institution for continuation of care. Of those, 55% were infected, most frequently with Candida spp., Enterococcus spp., and coagulase-negative Staphylococcus. Patients seen and admitted initially at our institution had milder forms of pancreatitis, fewer comorbidities, and 85% had symptomatic sterile WON. Empiric antibiotic use successfully predicted infection 70% of the time. Multivariate analysis demonstrated that elderly age, severity of pancreatitis, and prior use of antibiotics were indicators of infection. Necrotic pancreatic tissue remains sterile in the majority of cases treated with minimally invasive therapy, enabling judicious selection of antibiotics. Candida and Enterococcus spp. were common. Patients at highest risk for infection were previously treated with antibiotics and those transferred from outside institutions.
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Affiliation(s)
- Nadav Sahar
- Digestive Disease Institute, Virginia Mason Medical Center, 1100 9th Avenue, C3-GAS, Seattle, WA, 98101, USA
| | - Richard A Kozarek
- Digestive Disease Institute, Virginia Mason Medical Center, 1100 9th Avenue, C3-GAS, Seattle, WA, 98101, USA
| | - Zaheer S Kanji
- Digestive Disease Institute, Virginia Mason Medical Center, 1100 9th Avenue, C3-GAS, Seattle, WA, 98101, USA
| | - Shingo Chihara
- Section of Infectious Diseases, Department of Internal Medicine, Virginia Mason Medical Center, Seattle, USA
| | - S Ian Gan
- Digestive Disease Institute, Virginia Mason Medical Center, 1100 9th Avenue, C3-GAS, Seattle, WA, 98101, USA
| | - Shayan Irani
- Digestive Disease Institute, Virginia Mason Medical Center, 1100 9th Avenue, C3-GAS, Seattle, WA, 98101, USA
| | - Michael Larsen
- Digestive Disease Institute, Virginia Mason Medical Center, 1100 9th Avenue, C3-GAS, Seattle, WA, 98101, USA
| | - Andrew S Ross
- Digestive Disease Institute, Virginia Mason Medical Center, 1100 9th Avenue, C3-GAS, Seattle, WA, 98101, USA
| | - Michael Gluck
- Digestive Disease Institute, Virginia Mason Medical Center, 1100 9th Avenue, C3-GAS, Seattle, WA, 98101, USA.
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Naringenin Protects against Acute Pancreatitis in Two Experimental Models in Mice by NLRP3 and Nrf2/HO-1 Pathways. Mediators Inflamm 2018; 2018:3232491. [PMID: 29849486 PMCID: PMC5911315 DOI: 10.1155/2018/3232491] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/12/2017] [Revised: 01/28/2018] [Accepted: 02/05/2018] [Indexed: 01/11/2023] Open
Abstract
Background Naringenin (Nar) is a type of flavonoid and has been shown to have anti-inflammatory and antioxidative properties. However, the effects of Nar on acute pancreatitis (AP) have not been well studied. In this study, we aimed to investigate the function of Nar in a mouse model of AP. Methods Mild acute pancreatitis (MAP) was induced by caerulein (Cae), and severe acute pancreatitis (SAP) was induced by L-arginine in mice. Nar was administered intraperitoneally at doses of 25, 50, or 100 mg/kg following MAP induction and at a dose of 100 mg/kg following SAP induction. The serum levels of cytokines, lipase, and amylase were determined, and pancreatic and pulmonary tissues were harvested. Results The serum levels of amylase, lipase, and cytokines were significantly decreased in both MAP and SAP models after Nar treatment. The malondialdehyde (MDA) levels of the pancreatic tissue was significantly reduced in both MAP and SAP after Nar treatment. In contrast, glutathione peroxidase (GPx), glutathione reductase (GR), glutathione S-transferase (GST), total sulfhydryl (T-SH), and non-proteinsulthydryl (NP-SH) were markedly increased in both MAP and SAP after Nar treatment. The injury in pancreatic and pulmonary tissues was markedly improved as evidenced by the inhibited expression of myeloperoxidase, nod-like receptor protein 3, and interleukin 1 beta as well as the enhanced expression of nuclear factor erythroid 2-related factor 2/heme oxygenase-1 in pancreatic tissues. Conclusions Nar exerted protective effects on Cae-induced MAP and L-arginine-induced SAP in mice, suggesting that Nar may be a potential therapeutic intervention for AP.
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The Development of Endoscopic Techniques for Treatment of Walled-Off Pancreatic Necrosis: A Single-Center Experience. Gastroenterol Res Pract 2018; 2018:8149410. [PMID: 29805446 PMCID: PMC5902068 DOI: 10.1155/2018/8149410] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/16/2017] [Accepted: 03/11/2018] [Indexed: 12/12/2022] Open
Abstract
Background Endotherapy is a common method of treatment in patients with symptomatic walled-off pancreatic necrosis (WOPN). The aim of this study is to indicate the potential therapeutic possibilities created by the combination of several new endoscopic techniques and the evaluation of their efficacy in the treatment of WOPN. Methods The retrospective analysis of results and complications in the group of 101 patients, who underwent endoscopic treatment of symptomatic WOPN between years 2011 and 2015. Results Endoscopic treatment was started in 101 patients (71 men, 30 women; mean age 50.97 years) with symptomatic WOPN. Single transluminal gateway technique (SGT) was used in 93/101 (92.08%) patients. SGT in combination with multiple transluminal gateway technique (MTGT) was exploited in 4/93 (4.30%) patients, while in combination with single transluminal gateway transcystic multiple drainage (SGTMD) in 22/93 (23.66%) patients. Transpapillary access was used in 11/101 (10.89%) patients. 20/101 (19.80%) patients underwent percutaneous drainage. Fluoroscopy-guided endoscopic necrosectomy was performed in 19/101 (18.81%) patients. The combinations of endoscopic techniques depended on the extent of necrosis. Procedure-related complications occurred in 16/101 (15.84%) patients. The mortality rate was 0.99% (1/101 patient). Therapeutic success was achieved in 99/101 (98.02%) patients. The long-term success of endoscopic treatment was achieved in 97/101 (96.04%) patients with symptomatic WOPN. Conclusions Application of new endoscopic techniques in the treatment of the patients with symptomatic WOPN significantly improves the efficiency of endotherapy with an acceptable amount of complications.
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Smoczyński M, Jagielski M, Siepsiak M, Adrych K. Endoscopic necrosectomy through the major duodenal papilla under fluoroscopy imaging. Arch Med Sci 2018; 14:470-474. [PMID: 29593824 PMCID: PMC5868669 DOI: 10.5114/aoms.2016.61903] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/18/2015] [Accepted: 09/25/2015] [Indexed: 12/14/2022] Open
Affiliation(s)
- Marian Smoczyński
- Department of Gastroenterology and Hepatology, Medical University of Gdansk, Gdansk, Poland
| | - Mateusz Jagielski
- Department of Gastroenterology and Hepatology, Medical University of Gdansk, Gdansk, Poland
| | - Magdalena Siepsiak
- Department of Gastroenterology and Hepatology, Medical University of Gdansk, Gdansk, Poland
| | - Krystian Adrych
- Department of Gastroenterology and Hepatology, Medical University of Gdansk, Gdansk, Poland
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Endoscopic drainage combined with percutaneous drainage in treatment of walled-off pancreatic necrosis - a single-center experience. GASTROENTEROLOGY REVIEW 2018; 13:137-142. [PMID: 30002773 PMCID: PMC6040101 DOI: 10.5114/pg.2018.72604] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 12/05/2017] [Accepted: 12/11/2017] [Indexed: 12/21/2022]
Abstract
Introduction In last three decades we have been observing development of minimally invasive walled-off pancreatic necrosis (WOPN) treatment techniques. The choice of access to the necrosis and technique of treatment depends not only on the position and spread of necrosis, but in the first place on the experience of the medical center. Aim To assess the effectiveness and safety of combined endoscopic and percutaneous drainage of WOPN. Material and methods We performed a retrospective analysis of 64 consecutive patients with symptomatic WOPN, who underwent endoscopic treatment in our department between 2011 and 2013. Results Additional percutaneous drainage was executed during endoscopic treatment in 20/64 (31.25%) patients. Complications of treatment occurred in 4/20 (20%) patients. Complications of treatment occurred in 4/20 (20%) patients. All these complications were related to endoscopic treatment. No complications related to percutaneous drainage were noted. There were no deaths. Therapeutic success was achieved in all 20 patients. No patients required surgery. The average time of endoscopic drainage was 41.4 (11–173) days. The mean number of endoscopic procedures was 4.2 (2–12). The average time of percutaneous drainage was 11.3 (5–20) days. The medium time of follow-up was 54 (48–64) months. During the observation the recurrence of WOPN was noted in 2/20 (10%) patients. Long-term success of combined drainage was achieved in 18/20 (90%) patients. Conclusions In selected patients with symptomatic WOPN combined endoscopic and percutaneous drainage enables a high success rate with a low procedure-related complication rate.
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Goenka MK, Goenka U, Mujoo MY, Tiwary IK, Mahawar S, Rai VK. Pancreatic Necrosectomy through Sinus Tract Endoscopy. Clin Endosc 2018; 51:279-284. [PMID: 29301065 PMCID: PMC5997064 DOI: 10.5946/ce.2017.066] [Citation(s) in RCA: 12] [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: 05/06/2017] [Accepted: 09/13/2017] [Indexed: 12/24/2022] Open
Abstract
Background/Aims Direct endoscopic pancreatic necrosectomy is increasingly being utilized to treat infected or symptomatic walled-off necrosis (WON) located close to the stomach or duodenum. Laterally-placed WON has traditionally been treated surgically. We evaluated a less utilized technique of sinus tract endoscopy (STE) for symptomatic laterally-placed WON.
Methods Two hundred seventy-six patients with acute pancreatitis admitted in our hospital, 32 had symptomatic or infected WON requiring intervention. Of the 12 patients with laterally placed WON, 10 were treated by STE. STE was performed with a standard adult gastroscope passed through a percutaneous tract created by the placement of a 32-Fr drain.
Results Ten patients (7 males; mean age, 43.8 years) underwent STE. Mean number of sessions was 2.3 (range, 1–4), with mean time of 70 minutes for each session (range, 15–70 minutes). While 9 patients had complete success, 1 patient had fever and chose to undergo surgery. Two patients developed pneumoperitoneum, which was treated conservatively. There was no mortality, cutaneous fistula, or recurrence during follow-up.
Conclusions Laterally placed WON can be successfully managed by STE performed through a percutaneously placed drain. Details of the technique and end-points of STE require further evaluation.
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Affiliation(s)
| | - Usha Goenka
- Department of Clinical Imaging and Interventional Radiology, Apollo Gleneagles Hospitals, Kolkata, India
| | - Md Yasin Mujoo
- Institute of Gastrosciences, Apollo Gleneagles Hospitals, Kolkata, India
| | | | - Sanjay Mahawar
- Institute of Gastrosciences, Apollo Gleneagles Hospitals, Kolkata, India
| | - Vijay Kumar Rai
- Institute of Gastrosciences, Apollo Gleneagles Hospitals, Kolkata, India
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Metal stents versus plastic stents for the management of pancreatic walled-off necrosis: a systematic review and meta-analysis. Gastrointest Endosc 2018; 87:30-42.e15. [PMID: 28867073 DOI: 10.1016/j.gie.2017.08.025] [Citation(s) in RCA: 66] [Impact Index Per Article: 11.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/25/2017] [Accepted: 08/20/2017] [Indexed: 02/08/2023]
Abstract
BACKGROUND AND AIMS Endoscopic transluminal drainage of symptomatic walled-off necrosis (WON) is a good management option, although the optimal choice of drainage site stent is unclear. We performed a systematic review and meta-analysis to compare metal stents (MSs) and plastic stents (PSs) in terms of WON resolution, likelihood of resolution after 1 procedure, and adverse events. METHODS An expert librarian queried several databases to identify studies that assessed WON management, and selection was according to a priori criteria. Publication bias, heterogeneity, and study quality were evaluated with the appropriate tools. We performed single and 2-arm meta-analyses for noncomparative and comparative studies using event rate random-effects model and odds ratio (OR)/difference in means, respectively. RESULTS We included 41 studies involving 2213 patients. In 2-arm study meta-analysis, WON resolution was more likely with MSs compared with PSs (OR, 2.8; 95% confidence interval, 1.7-4.6; P < .001). Resolution with a single endoscopic procedure was similar between stents (47% vs 44%), although for those cases requiring more than 1 intervention, the MS group had fewer interventions, favored by a mean difference of -.9 procedures (95% CI, -1.283 to -.561). In single-arm study meta-analysis, when compared with PSs, MS use was associated with lower bleeding (5.6% vs 12.6%; P = .02), a trend toward lower perforation and stent occlusion (2.8% vs 4.3%, P = .2, and 9.5% vs 17.4%, P = .07), although with higher migration (8.1% vs 5.1%; P = .1). CONCLUSION Evidence suggests that MSs are superior for WON resolution, with fewer bleeding events, trend toward less occlusion and perforation rate, but increased migration rate compared with PSs.
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Abu Dayyeh BK, Mukewar S, Majumder S, Zaghlol R, Vargas Valls EJ, Bazerbachi F, Levy MJ, Baron TH, Gostout CJ, Petersen BT, Martin J, Gleeson FC, Pearson RK, Chari ST, Vege SS, Topazian MD. Large-caliber metal stents versus plastic stents for the management of pancreatic walled-off necrosis. Gastrointest Endosc 2018; 87:141-149. [PMID: 28478030 DOI: 10.1016/j.gie.2017.04.032] [Citation(s) in RCA: 49] [Impact Index Per Article: 8.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/15/2016] [Accepted: 04/17/2017] [Indexed: 12/11/2022]
Abstract
BACKGROUND AND AIMS Symptomatic pancreatic walled-off necrosis (WON) may be managed by endoscopic transmural drainage and endoscopic transmural necrosectomy, with stent placement at endoscopic drainage sites. The optimal stent choice is yet to be determined. We compared outcomes after endoscopic management of WON using either large-caliber fully covered self-expandable metal stents (LC-SEMSs) or double-pigtail plastic stents (DPPSs). METHODS We performed a retrospective comparison of outcomes among patients who received LC-SEMSs or DPPSs before endoscopic transmural necrosectomy for WON. RESULTS Among 94 patients included, WON resolution rates did not differ between the DPPS (36 patients) and LC-SEMS (58 patients) groups, whether concomitant percutaneous drainage was considered a failure (75% vs 82.8%; P = .36) or not (91.7% vs 94.8%; P = .55). Of 75 patients (80%) successfully treated without percutaneous drainage, 37 (49%) underwent endoscopic transmural drainage without subsequent endoscopic transmural necrosectomy. WON was more likely to resolve without subsequent endoscopic transmural necrosectomy in the LC-SEMS group than the DPPS group (60.4% vs 30.8%; P = .01). WON resolution without subsequent endoscopic transmural necrosectomy remained more likely with LC-SEMSs (odds ratio, 4.5 [95% confidence interval, 1.5-15.5]) after adjusting for patient age and size and location of WON. Rates of adverse events were similar except for clinically significant bleeding requiring endoscopic intervention, which was higher with DPPSs than LC-SEMSs (14% vs 2%; P = .02). CONCLUSION Management of pancreatic WON with LC-SEMSs appears to decrease both the need for repeated necrosectomy procedures and the risk of intervention-related hemorrhage.
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Affiliation(s)
- Barham K Abu Dayyeh
- Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, Minnesota, USA
| | - Saurabh Mukewar
- Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, Minnesota, USA
| | - Shounak Majumder
- Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, Minnesota, USA
| | - Raja Zaghlol
- Division of Gastroenterology, University of North Carolina, Chapel Hill, North Carolina, USA
| | | | - Fateh Bazerbachi
- Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, Minnesota, USA
| | - Michael J Levy
- Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, Minnesota, USA
| | - Todd H Baron
- Division of Gastroenterology, University of North Carolina, Chapel Hill, North Carolina, USA
| | | | - Bret T Petersen
- Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, Minnesota, USA
| | - John Martin
- Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, Minnesota, USA
| | - Ferga C Gleeson
- Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, Minnesota, USA
| | - Randall K Pearson
- Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, Minnesota, USA
| | - Suresh T Chari
- Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, Minnesota, USA
| | - Santhi S Vege
- Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, Minnesota, USA
| | - Mark D Topazian
- Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, Minnesota, USA
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Roch AM, Maatman T, Carr RA, Easler JJ, Schmidt CM, House MG, Nakeeb A, Ceppa EP, Zyromski NJ. Evolving treatment of necrotizing pancreatitis. Am J Surg 2017; 215:526-529. [PMID: 29167024 DOI: 10.1016/j.amjsurg.2017.11.020] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/08/2017] [Revised: 11/12/2017] [Accepted: 11/13/2017] [Indexed: 10/18/2022]
Abstract
BACKGROUND Over the past decade, the treatment of necrotizing pancreatitis (NP) has incorporated greater use of minimally invasive techniques, including percutaneous drainage and endoscopic debridement. No study has yet compared outcomes of patients treated with all available techniques. We sought to evaluate the evolution of NP treatment at our high volume pancreas center. We hypothesized that minimally invasive techniques (medical only, percutaneous, and endoscopic) were used more frequently in later years. METHODS Treatment strategy of NP patients at a single academic medical center between 2005 and 2014 was reviewed. Definitive management of pancreatic necrosis was categorized as: 1) medical treatment only; 2) surgical only; 3) percutaneous (interventional radiology - IR) only; 4) endoscopic only; and 5) combination (Surgery ± IR ± Endoscopy). RESULTS 526 NP patients included biliary (45%), alcoholic (17%), and idiopathic (20%) etiology. Select patients were managed exclusively by medical, IR, or endoscopic treatment; use of these therapies remained relatively consistent over time. A combination of therapies was used in about 30% of patients. Over time, the percentage of NP patients managed without operation increased from 28% to 41%. 247 (47%) of patients had operation as the only NP treatment; an additional 143 (27%) required surgery as part of a multidisciplinary management. CONCLUSION Select NP patients may be managed exclusively by medical, IR, or endoscopic treatment. Combination treatment is necessary in many NP patients, and surgical treatment continues to play an important role in the definitive therapy of necrotizing pancreatitis patients.
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Affiliation(s)
- Alexandra M Roch
- Department of Surgery, Indiana University School of Medicine, Indianapolis, IN, USA
| | - Thomas Maatman
- Department of Surgery, Indiana University School of Medicine, Indianapolis, IN, USA
| | - Rose A Carr
- Department of Surgery, Indiana University School of Medicine, Indianapolis, IN, USA
| | - Jeffrey J Easler
- Department of Medicine, Division of Gastroenterology and Hepatology, Indiana University School of Medicine, Indianapolis, IN, USA
| | - C Max Schmidt
- Department of Surgery, Indiana University School of Medicine, Indianapolis, IN, USA
| | - Michael G House
- Department of Surgery, Indiana University School of Medicine, Indianapolis, IN, USA
| | - Attila Nakeeb
- Department of Surgery, Indiana University School of Medicine, Indianapolis, IN, USA
| | - Eugene P Ceppa
- Department of Surgery, Indiana University School of Medicine, Indianapolis, IN, USA
| | - Nicholas J Zyromski
- Department of Surgery, Indiana University School of Medicine, Indianapolis, IN, USA.
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Sahar N, Kozarek R, Kanji ZS, Ross AS, Gluck M, Gan SI, Larsen M, Irani S. Do lumen-apposing metal stents (LAMS) improve treatment outcomes of walled-off pancreatic necrosis over plastic stents using dual-modality drainage? Endosc Int Open 2017; 5:E1052-E1059. [PMID: 29090245 PMCID: PMC5658217 DOI: 10.1055/s-0043-111794] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/21/2016] [Accepted: 05/15/2017] [Indexed: 12/12/2022] Open
Abstract
BACKGROUND AND STUDY AIMS Endoscopic ultrasound-guided drainage of symptomatic walled-off pancreatic necrosis (WON) usually has been performed with double pigtail plastic stents (DPS) and more recently, with lumen-apposing metal stents (LAMS). However, LAMS are significantly more expensive and there are no comparative studies with DPS. Accordingly, we compared our experience with combined endoscopic and percutaneous drainage (dual-modality drainage [DMD]) for symptomatic WON using LAMS versus DPS. PATIENTS AND METHODS Patients who underwent DMD of WON between July 2011 and June 2016 using LAMS were compared with a matched group treated with DPS. Technical success, clinical success, need for reintervention and adverse events (AE) were recorded. RESULTS A total of 50 patients (31 males, 25 patients treated with LAMS and 25 patients treated with DPS) were matched for age, sex, computed tomography severity index, and disconnected pancreatic ducts. Technical success was achieved in all patients. Mean days hospitalized post-intervention (14.5 vs. 13.1, P = 0.72), time to resolution of WON (77 days vs. 63 days, P = 0.57) and mean follow-up (207 days vs. 258 days, P = 0.34) were comparable in both groups. AEs were similar in both groups (6 vs. 8, P = 0.53). Patients treated with LAMS had significantly more reinterventions per patient (1.5 vs. 0.72, P = 0.01). CONCLUSIONS In treatment of symptomatic WON using DMD, LAMS did not shorten time to percutaneous drain removal and was not associated with fewer AEs.
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Affiliation(s)
- Nadav Sahar
- Division of Gastroenterology and Hepatology, Virginia Mason Medical Center, Seattle, Washington, United States
| | - Richard Kozarek
- Division of Gastroenterology and Hepatology, Virginia Mason Medical Center, Seattle, Washington, United States
| | - Zaheer S. Kanji
- Division of Gastroenterology and Hepatology, Virginia Mason Medical Center, Seattle, Washington, United States
| | - Andrew S. Ross
- Division of Gastroenterology and Hepatology, Virginia Mason Medical Center, Seattle, Washington, United States
| | - Michael Gluck
- Division of Gastroenterology and Hepatology, Virginia Mason Medical Center, Seattle, Washington, United States
| | - S. Ian Gan
- Division of Gastroenterology and Hepatology, Virginia Mason Medical Center, Seattle, Washington, United States
| | - Michael Larsen
- Division of Gastroenterology and Hepatology, Virginia Mason Medical Center, Seattle, Washington, United States
| | - Shayan Irani
- Division of Gastroenterology and Hepatology, Virginia Mason Medical Center, Seattle, Washington, United States,Corresponding author Shayan Irani Division of Gastroenterology and HepatologyVirginia Mason Medical Center1100 Ninth Avenue, C3-GASSeattle, WA 98101+1-206-625-7195
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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] [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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140
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Abstract
PURPOSE OF REVIEW The obesity pandemic poses a unique set of problems for acute pancreatitis - both by increasing acute pancreatitis incidence, and worsening acute pancreatitis severity. This review explores these associations, underlying mechanisms, and potential therapies. RECENT FINDINGS We review how the obesity associated increase in gallstones, surgical, and endoscopic interventions for obesity management, diabetes, and related medications such as incretin-based therapies and hypertriglyceridemia may increase the incidence of acute pancreatitis. The mechanism of how obesity may increase acute pancreatitis severity are discussed with a focus on cytokines, adipokines, damage-associated molecular patterns and unsaturated fatty acid-mediated lipotoxicity. The role of obesity in exacerbating pancreatic necrosis is discussed; focusing on obesity-associated pancreatic steatosis. We also discuss how peripancreatic fat necrosis worsens organ failure independent of pancreatic necrosis. Last, we discuss emerging therapies including choice of intravenous fluids and the use of lipase inhibitors which have shown promise during severe acute pancreatitis. SUMMARY We discuss how obesity may contribute to increasing acute pancreatitis incidence, the role of lipolytic unsaturated fatty acid release in worsening acute pancreatitis, and potential approaches, including appropriate fluid management and lipase inhibition in improving acute pancreatitis outcomes.
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141
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Predictive Value of Computed Tomography Scans and Clinical Findings for the Need of Endoscopic Necrosectomy in Walled-off Necrosis From Pancreatitis. Pancreas 2017; 46:1039-1045. [PMID: 28796138 DOI: 10.1097/mpa.0000000000000881] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/23/2022]
Abstract
OBJECTIVES Choosing the best treatment option at the optimal point of time for patients with walled-off necrosis (WON) is crucial. We aimed to identify imaging parameters and clinical findings predicting the need of necrosectomy in patients with WON. METHODS All patients with endoscopically diagnosed WON and pseudocyst were retrospectively identified. Post hoc analysis of pre-interventional contrast-enhanced computed tomography was performed for factors predicting the need of necrosectomy. RESULTS Sixty-five patients were included in this study. Forty patients (61.5%) were diagnosed with pseudocyst and 25 patients (38.5%) with WON. Patients with WON mostly had acute pancreatitis with biliary cause compared with more chronic pancreatitis and toxic cause in pseudocyst group (P = 0.002 and P = 0.004, respectively). Logistic regression revealed diabetes as a risk factor for WON. Computed tomography scans revealed 4.62% (n = 3) patients as false positive and 24.6% (n = 16) as false negative findings for WON. Reduced perfusion and detection of solid findings were independent risk factors for WON. CONCLUSIONS Computed tomography scans are of low diagnostic yield when needed to predict treatment of patients with pancreatic cysts. Reduced pancreatic perfusion and solid findings seem to be a risk factor for WON, whereas patients with diabetes seem to be at higher risk of developing WON.
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142
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Describing Peripancreatic Collections According to the Revised Atlanta Classification of Acute Pancreatitis: An International Interobserver Agreement Study. Pancreas 2017; 46:850-857. [PMID: 28697123 DOI: 10.1097/mpa.0000000000000863] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/22/2022]
Abstract
OBJECTIVES Severe acute pancreatitis is associated with peripancreatic morphologic changes as seen on imaging. Uniform communication regarding these morphologic findings is crucial for accurate diagnosis and treatment. For the original 1992 Atlanta classification, interobserver agreement is poor. We hypothesized that for the revised Atlanta classification, interobserver agreement will be better. METHODS An international, interobserver agreement study was performed among expert and nonexpert radiologists (n = 14), surgeons (n = 15), and gastroenterologists (n = 8). Representative computed tomographies of all stages of acute pancreatitis were selected from 55 patients and were assessed according to the revised Atlanta classification. The interobserver agreement was calculated among all reviewers and subgroups, that is, expert and nonexpert reviewers; interobserver agreement was defined as poor (≤0.20), fair (0.21-0.40), moderate (0.41-0.60), good (0.61-0.80), or very good (0.81-1.00). RESULTS Interobserver agreement among all reviewers was good (0.75 [standard deviation, 0.21]) for describing the type of acute pancreatitis and good (0.62 [standard deviation, 0.19]) for the type of peripancreatic collection. Expert radiologists showed the best and nonexpert clinicians the lowest interobserver agreement. CONCLUSIONS Interobserver agreement was good for the revised Atlanta classification, supporting the importance for widespread adaption of this revised classification for clinical and research communications.
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143
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Nemoto Y, Attam R, Arain MA, Trikudanathan G, Mallery S, Beilman GJ, Freeman ML. Interventions for walled off necrosis using an algorithm based endoscopic step-up approach: Outcomes in a large cohort of patients. Pancreatology 2017; 17:663-668. [PMID: 28803859 DOI: 10.1016/j.pan.2017.07.195] [Citation(s) in RCA: 29] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/06/2016] [Revised: 07/05/2017] [Accepted: 07/30/2017] [Indexed: 12/11/2022]
Abstract
OBJECTIVES The minimally invasive step-up approach for treatment of walled off necrosis (WON) involves drainage followed by later necrosectomy as needed, and is superior to primary surgical necrosectomy. Reported series of endoscopic transluminal necrosectomy include highly selected patients. We report outcomes of a large series of patients with WON managed by an algorithm based on an endoscopically centered step-up approach. METHODS Consecutive patients with necrotizing pancreatitis from 2009 to 2014, with intervention only for infected or persistently symptomatic WON. The primary approach involved endoscopic transluminal drainage plus minus necrosectomy whenever feasible, with percutaneous catheter drainage (PCD) plus minus sinus tract endoscopy if not feasible or sufficient. Surgery was reserved for failures of the step up approach. RESULTS Of 109 consecutive patients with necrotizing pancreatitis, intervention was required in 83, including endoscopic transluminal drainage in 73 (88%) (alone in 49 and combined with PCD in 24), and PCD alone in 10 (12%). 64 (77%) of the 83 patients required endoscopic transluminal and/or sinus tract necrosectomy. Adverse events occurred in 11 (13%). Three patients (4%) failed step up approach and required open surgical necrosectomy. All-cause mortality occurred in 6 (7%) of 83 patients after intervention, including 2 of 3 requiring surgery. CONCLUSIONS An algorithm based step-up approach for interventions in necrotizing pancreatitis using primarily endoscopic techniques with adjunctive percutaneous approaches as needed resulted in favorable outcomes with small numbers proceeding to open surgery, and with acceptable rates of major complications and mortality. A purely endoscopic transluminal approach was feasible in approximately 60% of patients requiring intervention in this series.
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Affiliation(s)
- Yukako Nemoto
- Division of Gastroenterology, Hepatology and Nutrition, University of Minnesota, United States; Division of Gastroenterology and Hepatology, Department of Internal Medicine, Toho University Ohashi Medical Center, Japan; Department of Gastroenterology, Kohsei Chuo General Hospital, Japan
| | - Rajeev Attam
- Division of Gastroenterology, Hepatology and Nutrition, University of Minnesota, United States; Advanced Endoscopy, Southern California Permanente Medical Group, Kaiser Permanente Downey, United States
| | - Mustafa A Arain
- Division of Gastroenterology, Hepatology and Nutrition, University of Minnesota, United States
| | - Guru Trikudanathan
- Division of Gastroenterology, Hepatology and Nutrition, University of Minnesota, United States
| | - Shawn Mallery
- Division of Gastroenterology, Hepatology and Nutrition, University of Minnesota, United States
| | | | - Martin L Freeman
- Division of Gastroenterology, Hepatology and Nutrition, University of Minnesota, United States.
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144
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Mok SRS, Ho HC, Shah P, Patel M, Gaughan JP, Elfant AB. Response. Gastrointest Endosc 2017; 86:249-250. [PMID: 28610863 DOI: 10.1016/j.gie.2017.03.017] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/10/2017] [Accepted: 03/10/2017] [Indexed: 02/08/2023]
Affiliation(s)
- Shaffer R S Mok
- Cooper Medical School of Rowan University, MD Anderson Cancer Center at Cooper, Department of Medicine, Division of Gastroenterology and Liver Diseases, Mount Laurel, New Jersey, USA
| | - Henry C Ho
- Cooper Medical School of Rowan University, MD Anderson Cancer Center at Cooper, Department of Medicine, Division of Gastroenterology and Liver Diseases, Mount Laurel, New Jersey, USA
| | - Paurush Shah
- Cooper Medical School of Rowan University, MD Anderson Cancer Center at Cooper, Department of Medicine, Division of Gastroenterology and Liver Diseases, Mount Laurel, New Jersey, USA
| | - Milan Patel
- Cooper Medical School of Rowan University, MD Anderson Cancer Center at Cooper, Department of Medicine, Division of Gastroenterology and Liver Diseases, Mount Laurel, New Jersey, USA
| | - John P Gaughan
- Cooper Medical School of Rowan University, MD Anderson Cancer Center at Cooper, Department of Medicine, Division of Gastroenterology and Liver Diseases, Mount Laurel, New Jersey, USA
| | - Adam B Elfant
- Cooper Medical School of Rowan University, MD Anderson Cancer Center at Cooper, Department of Medicine, Division of Gastroenterology and Liver Diseases, Mount Laurel, New Jersey, USA
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145
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Dhar VK, Sutton JM, Xia BT, Levinsky NC, Wilson GC, Smith M, Choe KA, Moulton J, Vu D, Ristagno R, Sussman JJ, Edwards MJ, Abbott DE, Ahmad SA. Fistulojejunostomy Versus Distal Pancreatectomy for the Management of the Disconnected Pancreas Remnant Following Necrotizing Pancreatitis. J Gastrointest Surg 2017; 21:1121-1127. [PMID: 28397026 DOI: 10.1007/s11605-017-3419-9] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/19/2017] [Accepted: 03/30/2017] [Indexed: 01/31/2023]
Abstract
BACKGROUND A disconnected distal pancreas (DDP) remnant is a morbid sequela of necrotizing pancreatitis. Definitive surgical management can be accomplished by either fistulojejunostomy (FJ) or distal pancreatectomy (DP). It is unclear which operative approach is superior with regard to short- and long-term outcomes. METHODS Between 2002 and 2014, patients undergoing either FJ or DP for DDP were retrospectively identified at a center specializing in pancreatic diseases. Patient demographics, perioperative, and postoperative variables were evaluated. RESULTS Forty-two patients with DDP secondary to necrotizing pancreatitis underwent either a FJ (n = 21) or DP (n = 21). Between the two cohorts, there were no significant differences in overall lengths of stay, pancreatic leak rates, or readmission rates (all p > 0.05). DP was associated with higher estimated blood loss, increased transfusion requirements, and worsening endocrine function (all p < 0.05). At a median follow-up of 18 months, four patients that underwent a FJ developed a recurrent fluid collection requiring re-intervention. Overall, FJ was successful in 80% of patients as compared to a 95% success rate for DP (p = 0.15). CONCLUSIONS Although DP was associated with higher intraoperative blood loss, increased transfusion requirements, and worsening of preoperative diabetes, this procedure provides superior long-term resolution of a DDP when compared to FJ.
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Affiliation(s)
- Vikrom K Dhar
- Department of Surgery, Division of Surgical Oncology, University of Cincinnati Medical Center, 231 Albert Sabin Way, ML 0558, SRU Room 1466, Cincinnati, OH, 45219, USA
| | - Jeffrey M Sutton
- Department of Surgery, Division of Surgical Oncology, University of Cincinnati Medical Center, 231 Albert Sabin Way, ML 0558, SRU Room 1466, Cincinnati, OH, 45219, USA
| | - Brent T Xia
- Department of Surgery, Division of Surgical Oncology, University of Cincinnati Medical Center, 231 Albert Sabin Way, ML 0558, SRU Room 1466, Cincinnati, OH, 45219, USA
| | - Nick C Levinsky
- Department of Surgery, Division of Surgical Oncology, University of Cincinnati Medical Center, 231 Albert Sabin Way, ML 0558, SRU Room 1466, Cincinnati, OH, 45219, USA
| | - Gregory C Wilson
- Department of Surgery, Division of Surgical Oncology, University of Cincinnati Medical Center, 231 Albert Sabin Way, ML 0558, SRU Room 1466, Cincinnati, OH, 45219, USA
| | - Milton Smith
- Department of Medicine, Division of Gastroenterology, University of Cincinnati, Cincinnati, OH, USA
| | - Kyuran A Choe
- Department of Radiology, University of Cincinnati, Cincinnati, OH, USA
| | - Jonathan Moulton
- Department of Radiology, University of Cincinnati, Cincinnati, OH, USA
| | - Doan Vu
- Department of Radiology, University of Cincinnati, Cincinnati, OH, USA
| | - Ross Ristagno
- Department of Radiology, University of Cincinnati, Cincinnati, OH, USA
| | - Jeffrey J Sussman
- Department of Surgery, Division of Surgical Oncology, University of Cincinnati Medical Center, 231 Albert Sabin Way, ML 0558, SRU Room 1466, Cincinnati, OH, 45219, USA
| | - Michael J Edwards
- Department of Surgery, Division of Surgical Oncology, University of Cincinnati Medical Center, 231 Albert Sabin Way, ML 0558, SRU Room 1466, Cincinnati, OH, 45219, USA
| | - Daniel E Abbott
- Department of Surgery, Division of Surgical Oncology, University of Wisconsin, Madison, WI, USA
| | - Syed A Ahmad
- Department of Surgery, Division of Surgical Oncology, University of Cincinnati Medical Center, 231 Albert Sabin Way, ML 0558, SRU Room 1466, Cincinnati, OH, 45219, USA.
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146
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Dua MM, Worhunsky DJ, Malhotra L, Park WG, Poultsides GA, Norton JA, Visser BC. Transgastric pancreatic necrosectomy-expedited return to prepancreatitis health. J Surg Res 2017; 219:11-17. [PMID: 29078869 DOI: 10.1016/j.jss.2017.05.089] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/10/2017] [Revised: 04/23/2017] [Accepted: 05/24/2017] [Indexed: 12/30/2022]
Abstract
BACKGROUND The best operative strategy for necrotizing pancreatitis remains controversial. Traditional surgical necrosectomy is associated with significant morbidity; endoscopic and percutaneous strategies require repeated interventions with prolonged hospitalizations. We have developed a transgastric approach to pancreatic necrosectomy to overcome the shortcomings of the other techniques described. MATERIALS AND METHODS Patients with necrotizing pancreatitis treated from 2009 to 2016 at an academic center were retrospectively reviewed. Open or laparoscopic transgastric necrosectomy was performed if the area of necrosis was walled-off and in a retrogastric position on cross-sectional imaging. Study endpoints included postoperative complications and mortality. RESULTS Forty-six patients underwent transgastric necrosectomy (nine open and 37 laparoscopic). Median (interquartile range) preoperative Acute Physiologic and Chronic Health Evaluation II score was 6 (3-12). Seventy percent of patients had >30% necrosis on preoperative imaging; infected necrosis was present in 35%. Median total length of stay (LOS) was 6 (3-12) d. No patient required a second operative debridement; four patients (9%) had short-term postoperative percutaneous drainage for residual fluid collections. Median follow-up was 1 y; there were no fistula or wound complications. Six patients (13%) had postoperative bleeding; five patients received treatment by image-guided embolization. There was one death in the cohort. CONCLUSIONS Transgastric pancreatic necrosectomy allows for effective debridement with a single definitive operation. When anatomically suitable, this operative strategy offers expedited recovery and avoids long-term morbidity associated with fistulas and prolonged drainage.
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Affiliation(s)
- Monica M Dua
- Division of Surgical Oncology, Department of Surgery, Stanford University School of Medicine, Stanford, California.
| | - David J Worhunsky
- Division of Surgical Oncology, Department of Surgery, Stanford University School of Medicine, Stanford, California
| | - Lavina Malhotra
- Division of Surgical Oncology, Department of Surgery, Stanford University School of Medicine, Stanford, California
| | - Walter G Park
- Division of Gastroenterology, Department of Medicine, Stanford University School of Medicine, Stanford, California
| | - George A Poultsides
- Division of Surgical Oncology, Department of Surgery, Stanford University School of Medicine, Stanford, California
| | - Jeffrey A Norton
- Division of Surgical Oncology, Department of Surgery, Stanford University School of Medicine, Stanford, California
| | - Brendan C Visser
- Division of Surgical Oncology, Department of Surgery, Stanford University School of Medicine, Stanford, California
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147
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Endoscopic treatment of multilocular walled-off pancreatic necrosis with the multiple transluminal gateway technique. Wideochir Inne Tech Maloinwazyjne 2017; 12:199-205. [PMID: 28694909 PMCID: PMC5502345 DOI: 10.5114/wiitm.2017.68298] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/20/2016] [Accepted: 05/21/2017] [Indexed: 01/03/2023] Open
Abstract
The development of minimally invasive techniques allowed access to the necrotic cavity through transperitoneal, retroperitoneal, transmural and transpapillary routes. The choice of access to walled-off pancreatic necrosis (WOPN) should depend not only on the spread of necrosis, but also on the experience of the clinical center. Herein we describe treatment of a patient with multilocular symptomatic walled-off pancreatic necrosis using minimally invasive techniques. The single transmural access (single transluminal gateway technique - SGT) to the necrotic collection of the patient was ineffective. The second gastrocystostomy was performed using the same minimally invasive technique as an extra way of access to the necrosis (multiple transluminal gateway technique - MTGT). In the described case the performance of the new technique consisting in endoscopic multiplexing transmural access (MTGT) was effective enough and led to complete recovery of the patient.
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148
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Samadi K, Arellano RS. Drainage of Intra-abdominal Abscesses. CURRENT TRAUMA REPORTS 2017. [DOI: 10.1007/s40719-017-0097-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
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149
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Boumitri C, Brown E, Kahaleh M. Necrotizing Pancreatitis: Current Management and Therapies. Clin Endosc 2017; 50:357-365. [PMID: 28516758 PMCID: PMC5565044 DOI: 10.5946/ce.2016.152] [Citation(s) in RCA: 44] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/09/2016] [Revised: 02/10/2017] [Accepted: 02/22/2017] [Indexed: 12/16/2022] Open
Abstract
Acute necrotizing pancreatitis accounts for 10% of acute pancreatitis (AP) cases and is associated with a higher mortality and morbidity. Necrosis within the first 4 weeks of disease onset is defined as an acute necrotic collection (ANC), while walled off pancreatic necrosis (WOPN) develops after 4 weeks of disease onset. An infected or symptomatic WOPN requires drainage. The management of pancreatic necrosis has shifted away from open necrosectomy, as it is associated with a high morbidity, to less invasive techniques. In this review, we summarize the current management and therapies for acute necrotizing pancreatitis.
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Affiliation(s)
- Christine Boumitri
- Division of Gastroenterology and Hepatology, Department of Medicine, University of Missouri, Columbia, MO, USA
| | - Elizabeth Brown
- Division of Gastroenterology and Hepatology, Department of Medicine, Weill Cornell Medicine, New York, NY, USA
| | - Michel Kahaleh
- Division of Gastroenterology and Hepatology, Department of Medicine, Weill Cornell Medicine, New York, NY, USA
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150
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Foster BR, Jensen KK, Bakis G, Shaaban AM, Coakley FV. Revised Atlanta Classification for Acute Pancreatitis: A Pictorial Essay. Radiographics 2017; 36:675-87. [PMID: 27163588 DOI: 10.1148/rg.2016150097] [Citation(s) in RCA: 115] [Impact Index Per Article: 16.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
The 2012 revised Atlanta classification is an update of the original 1992 Atlanta classification, a standardized clinical and radiologic nomenclature for acute pancreatitis and associated complications based on research advances made over the past 2 decades. Acute pancreatitis is now divided into two distinct subtypes, necrotizing pancreatitis and interstitial edematous pancreatitis (IEP), based on the presence or absence of necrosis, respectively. The revised classification system also updates confusing and sometimes inaccurate terminology that was previously used to describe pancreatic and peripancreatic collections. As such, use of the terms acute pseudocyst and pancreatic abscess is now discouraged. Instead, four distinct collection subtypes are identified on the basis of the presence of pancreatic necrosis and time elapsed since the onset of pancreatitis. Acute peripancreatic fluid collections (APFCs) and pseudocysts occur in IEP and contain fluid only. Acute necrotic collections (ANCs) and walled-off necrosis (WON) occur only in patients with necrotizing pancreatitis and contain variable amounts of fluid and necrotic debris. APFCs and ANCs occur within 4 weeks of disease onset. After this time, APFCs or ANCs may either resolve or persist, developing a mature wall to become a pseudocyst or a WON, respectively. Any collection subtype may become infected and manifest as internal gas, though this occurs most commonly in necrotic collections. In this review, the authors present a practical image-rich guide to the revised Atlanta classification system, with the goal of fostering implementation of the revised system into radiology practice, thereby facilitating accurate communication among clinicians and reinforcing the radiologist's role as a key member of a multidisciplinary team in treating patients with acute pancreatitis. (©)RSNA, 2016.
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Affiliation(s)
- Bryan R Foster
- From the Department of Diagnostic Radiology, Oregon Health & Science University, 3181 SW Sam Jackson Park Rd, Portland, OR 97239 (B.R.F., K.K.J., G.B., F.V.C.); and Department of Radiology, University of Utah, Salt Lake City, Utah (A.M.S.)
| | - Kyle K Jensen
- From the Department of Diagnostic Radiology, Oregon Health & Science University, 3181 SW Sam Jackson Park Rd, Portland, OR 97239 (B.R.F., K.K.J., G.B., F.V.C.); and Department of Radiology, University of Utah, Salt Lake City, Utah (A.M.S.)
| | - Gene Bakis
- From the Department of Diagnostic Radiology, Oregon Health & Science University, 3181 SW Sam Jackson Park Rd, Portland, OR 97239 (B.R.F., K.K.J., G.B., F.V.C.); and Department of Radiology, University of Utah, Salt Lake City, Utah (A.M.S.)
| | - Akram M Shaaban
- From the Department of Diagnostic Radiology, Oregon Health & Science University, 3181 SW Sam Jackson Park Rd, Portland, OR 97239 (B.R.F., K.K.J., G.B., F.V.C.); and Department of Radiology, University of Utah, Salt Lake City, Utah (A.M.S.)
| | - Fergus V Coakley
- From the Department of Diagnostic Radiology, Oregon Health & Science University, 3181 SW Sam Jackson Park Rd, Portland, OR 97239 (B.R.F., K.K.J., G.B., F.V.C.); and Department of Radiology, University of Utah, Salt Lake City, Utah (A.M.S.)
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