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van Grinsven J, van Brunschot S, van Santvoort HC. The Value of a 24/7 Online Nationwide Multidisciplinary Expert Panel for Acute Necrotizing Pancreatitis. Gastroenterology 2017; 152:685-688.e6. [PMID: 28163063 DOI: 10.1053/j.gastro.2017.01.040] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Affiliation(s)
- Janneke van Grinsven
- Academic Medical Center, University of Amsterdam, and St. Antonius Hospital, Nieuwegein, the Netherlands
| | - Sandra van Brunschot
- Academic Medical Center, University of Amsterdam, and St. Antonius Hospital, Nieuwegein, the Netherlands
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152
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153
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Wang W, Xiang HP, Wang HP, Zhu LX, Geng XP. CD4 + CD25 + CD127 high cells as a negative predictor of multiple organ failure in acute pancreatitis. World J Emerg Surg 2017; 12:7. [PMID: 28174597 PMCID: PMC5290669 DOI: 10.1186/s13017-017-0116-7] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/17/2016] [Accepted: 01/11/2017] [Indexed: 01/07/2023] Open
Abstract
Background It has been suggested that severity of the immune response induced by immune cells is associated with morbidity and mortality from acute pancreatitis. The authors investigated and evaluated the relationship between distinct peripheral lymphocyte subsets at admission and clinical outcome prior to hospital discharge so as to find a predictor to the prognosis of acute pancreatitis in lymphocyte profile. Methods Lymphocyte subsets in admission peripheral venous blood were tested through flow cytometry on 48 patients with acute pancreatitis. Clinical data was recorded as well. The primary observational outcomes were multiple organ failure (MOF) and infection. Results There was a significant difference in natural killer cells between two subgroups sorted by the presence or absence of infection (25.5 ± 4.47 [95% CI 14.4, 36.6] vs 14.8 ± 7.62 [95% CI 12.5,1 7.1] p = 0.021). Patients who developed MOF had lower CD4 + CD25 + CD127high (4.49 ± 1.5 (MOF) [95% CI 3.83, 5.16] vs 6.57 ± 2.65 (non-MOF) [95% CI 5.5, 7.64] p = 0.002) and higher CD127low/high cell counts (1.35 ± 0.66 [95% CI 1.06, 1.65] vs 0.97 ± 0.44 [95% CI 0.79, 1.15] p = 0.02). MOF patients were significantly older (55 ± 14.58 [95% CI 48.49,61.42] vs 46 ± 15.59 [95% CI 39.39,51.99] p = 0.04), and had higher Acute Physiology and Chronic Health Evaluation IIscores (7 ± 3.66 [95% CI 5.5,7.64] vs 4 ± 2.89 [95% CI 2.45,4.78] p = 0.001) and C reactive protein (100.53 ± 94.38 [95% CI 58.69,142.48] vs 50.8 ± 59.2 [95% CI 26.88,74.71] p = 0.04). In a multivariate regression model, only CD4 + CD25 + CD127high cell was a significant predictor of non-MOF. For the detection of non-MOF, CD4 + CD25 + CD127high cell generated a receiver operating characteristic (ROC) curve with an area under the curve of 0.74. Conclusion CD4 + CD25 + CD127high cell at early phase of acute pancreatitis yields good specificity in detecting non-MOF at a suggested cutoff value 6.41%. Patients with fewer natural killer cells may be at risk in developing secondary infection.
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Affiliation(s)
- Wei Wang
- Department of Emergency Surgery, The Second Affiliated Hospital of Anhui Medical University, 678 Furong Road, Hefei, 230601 Anhui Province People's Republic of China
| | - He-Ping Xiang
- Department of Emergency Surgery, The Second Affiliated Hospital of Anhui Medical University, 678 Furong Road, Hefei, 230601 Anhui Province People's Republic of China
| | - Hui-Ping Wang
- Hematology department, The Second Affiliated Hospital of Anhui Medical University, Hefei, 230601 Anhui Province People's Republic of China
| | - Li-Xin Zhu
- Central lab of the First Affiliated Hospital of Anhui Medical University, Hefei, 230022 Anhui Province People's Republic of China
| | - Xiao-Ping Geng
- Department of General Surgery, The Second Affiliated Hospital of Anhui Medical University, Hefei, 230601 Anhui Province People's Republic of China
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Rasslan R, da Costa Ferreira Novo F, Rocha MC, Bitran A, de Souza Rocha M, de Oliveira Bernini C, Rasslan S, Utiyama EM. Pancreatic Necrosis and Gas in the Retroperitoneum: Treatment with Antibiotics Alone. Clinics (Sao Paulo) 2017; 72:87-94. [PMID: 28273241 PMCID: PMC5314426 DOI: 10.6061/clinics/2017(02)04] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/15/2016] [Accepted: 11/18/2016] [Indexed: 12/13/2022] Open
Abstract
OBJECTIVE: To present our experience in the management of patients with infected pancreatic necrosis without drainage. METHODS: The records of patients with pancreatic necrosis admitted to our facility from 2011 to 2015 were retrospectively reviewed. RESULTS: We identified 61 patients with pancreatic necrosis. Six patients with pancreatic necrosis and gas in the retroperitoneum were treated exclusively with clinical support without any type of drainage. Only 2 patients had an APACHE II score >8. The first computed tomography scan revealed the presence of gas in 5 patients. The Balthazar computed tomography severity index score was >9 in 5 of the 6 patients. All patients were treated with antibiotics for at least 3 weeks. Blood cultures were positive in only 2 patients. Parenteral nutrition was not used in these patients. The length of hospital stay exceeded three weeks for 5 patients; 3 patients had to be readmitted. A cholecystectomy was performed after necrosis was completely resolved; pancreatitis recurred in 2 patients before the operation. No patients died. CONCLUSIONS: In selected patients, infected pancreatic necrosis (gas in the retroperitoneum) can be treated without percutaneous drainage or any additional surgical intervention. Intervention procedures should be performed for patients who exhibit clinical and laboratory deterioration.
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Affiliation(s)
- Roberto Rasslan
- Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo, Departamento de Cirurgia - Disciplina de Cirurgia Geral e Trauma, São Paulo/SP, Brazil
- *Corresponding author. E-mail:
| | - Fernando da Costa Ferreira Novo
- Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo, Departamento de Cirurgia - Disciplina de Cirurgia Geral e Trauma, São Paulo/SP, Brazil
| | - Marcelo Cristiano Rocha
- Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo, Departamento de Cirurgia - Disciplina de Cirurgia Geral e Trauma, São Paulo/SP, Brazil
| | - Alberto Bitran
- Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo, Departamento de Cirurgia - Disciplina de Cirurgia Geral e Trauma, São Paulo/SP, Brazil
| | - Manoel de Souza Rocha
- Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo, Departamento de Radiologia e Oncologia, São Paulo/SP, Brazil
| | - Celso de Oliveira Bernini
- Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo, Departamento de Cirurgia - Disciplina de Cirurgia Geral e Trauma, São Paulo/SP, Brazil
| | - Samir Rasslan
- Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo, Departamento de Cirurgia - Disciplina de Cirurgia Geral e Trauma, São Paulo/SP, Brazil
| | - Edivaldo Massazo Utiyama
- Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo, Departamento de Cirurgia - Disciplina de Cirurgia Geral e Trauma, São Paulo/SP, Brazil
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Jagielski M, Smoczyński M, Drelich-Góreczna B, Adrych K. Transduodenal drainage of symptomatic walled-off pancreatic necrosis in a patient with ansa pancreatica anatomic variation. Arch Med Sci 2017; 13:267-269. [PMID: 28144282 PMCID: PMC5206381 DOI: 10.5114/aoms.2017.64724] [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: 01/31/2015] [Accepted: 03/05/2015] [Indexed: 01/03/2023] Open
Affiliation(s)
- Mateusz Jagielski
- Department of Gastroenterology and Hepatology, Medical University of Gdansk, Gdansk, Poland
| | - Marian Smoczyński
- Department of Gastroenterology and Hepatology, Medical University of Gdansk, Gdansk, Poland
| | - Beata Drelich-Góreczna
- 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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156
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Abstract
Identifying sources of infection and establishing source control is an essential component of the workup and treatment of sepsis. Investigation with history, physical examination, laboratory tests, and imaging can in identifying sources of infection. All organ systems have the potential to develop sources of infection. However, there are inherent difficulties presented by some that require additional diligence, namely, urinalysis, chest radiographs, and intraabdominal infections. Interventions include administration of antibiotics and may require surgical or other specialist intervention. This is highlighted by the Surviving Sepsis Campaign with specific recommendations for time to antibiotics and expeditious time to surgical source control.
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Affiliation(s)
- Zeke P Oliver
- Emergency Medicine, Department of Emergency Medicine, Carilion Clinic Virginia Tech School of Medicine, 1 Riverside Circle, 4th Floor, Roanoke, VA 24014, USA.
| | - Jack Perkins
- Emergency Medicine, Department of Emergency Medicine, Carilion Clinic Virginia Tech School of Medicine, 1 Riverside Circle, 4th Floor, Roanoke, VA 24014, USA
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157
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Abstract
Pancreatic fluid collections (PFCs) may develop due to inflammation secondary to acute and/or chronic pancreatitis, trauma, surgery, or obstruction from solid or cystic neoplasms. PFCs can be drained percutaneously, surgically, or endoscopically with endoscopic ultrasound-guided cyst gastrostomy and/or transpapillary drainage through endoscopic retrograde cholangiopancreatography. There has been a paradigm shift in the endoscopic management of PFCs in the past few years with newer techniques including utilization of self-expanding metal stents and multiport devices. This review is a comprehensive update on the classification of PFC, indications for drainage, optimal approach, and techniques.
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158
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Cruz-Monserrate Z, Conwell DL, Krishna SG. The Impact of Obesity on Gallstone Disease, Acute Pancreatitis, and Pancreatic Cancer. Gastroenterol Clin North Am 2016; 45:625-637. [PMID: 27837777 DOI: 10.1016/j.gtc.2016.07.010] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
Obesity is a well-recognized risk factor for gallstone formation and increases the risk for gallstone-related complications. Pancreatic diseases are impacted adversely by obesity. Although weight loss surgery increases the risk of gallstone disease, evidence suggests that bariatric surgery mitigates the obesity-associated adverse prognostication in acute pancreatitis. Obesity is also a significant risk factor for pancreatic cancer. Obesity is a global epidemic and is increasing worldwide and among all age groups. There is an urgent need for focused health policies aimed at reducing the incidence and prevalence of obesity. This article summarizes the current literature highlighting the association between obesity and the pathophysiology and outcome of gallstone disease, pancreatitis, and pancreatic cancer.
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Affiliation(s)
- Zobeida Cruz-Monserrate
- Section of Pancreatic Diseases, Division of Gastroenterology, Hepatology and Nutrition, The Ohio State University Wexner Medical Center, 395 West 12th Avenue, 2nd Floor, Columbus, OH, USA; The James Comprehensive Cancer Center, The Ohio State University Wexner Medical Center, Columbus, OH, USA
| | - Darwin L Conwell
- Section of Pancreatic Diseases, Division of Gastroenterology, Hepatology and Nutrition, The Ohio State University Wexner Medical Center, 395 West 12th Avenue, 2nd Floor, Columbus, OH, USA
| | - Somashekar G Krishna
- Section of Pancreatic Diseases, Division of Gastroenterology, Hepatology and Nutrition, The Ohio State University Wexner Medical Center, 395 West 12th Avenue, 2nd Floor, Columbus, OH, USA.
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159
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Affiliation(s)
- Chris E Forsmark
- From the Division of Gastroenterology, Hepatology, and Nutrition, University of Florida, Gainesville (C.E.F.); the Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, MN (S.S.V.); and the Division of Gastroenterology and Hepatology, University of Alabama, Birmingham (C.M.W.)
| | - Santhi Swaroop Vege
- From the Division of Gastroenterology, Hepatology, and Nutrition, University of Florida, Gainesville (C.E.F.); the Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, MN (S.S.V.); and the Division of Gastroenterology and Hepatology, University of Alabama, Birmingham (C.M.W.)
| | - C Mel Wilcox
- From the Division of Gastroenterology, Hepatology, and Nutrition, University of Florida, Gainesville (C.E.F.); the Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, MN (S.S.V.); and the Division of Gastroenterology and Hepatology, University of Alabama, Birmingham (C.M.W.)
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160
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Umapathy C, Raina A, Saligram S, Tang G, Papachristou GI, Rabinovitz M, Chennat J, Zeh H, Zureikat AH, Hogg ME, Lee KK, Saul MI, Whitcomb DC, Slivka A, Yadav D. Natural History After Acute Necrotizing Pancreatitis: a Large US Tertiary Care Experience. J Gastrointest Surg 2016; 20:1844-1853. [PMID: 27619808 DOI: 10.1007/s11605-016-3264-2] [Citation(s) in RCA: 36] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/16/2016] [Accepted: 08/24/2016] [Indexed: 02/06/2023]
Abstract
BACKGROUND Most studies of acute necrotizing pancreatitis (ANP) focus on short-term outcomes. We evaluated long-term survival and outcomes following ANP. METHODS Patients treated for ANP at the University of Pittsburgh Medical Center from 2001 to 2008 were studied. Data on presentation and course during initial hospitalization and follow-up (median 34 months) was extracted. RESULTS Mean age of patients (n = 167) was 53 ± 16 years; 70 % were male, 94 % white, 71 % transfers, 52 % biliary etiology, and 78 % had first-attack of acute pancreatitis. Majority had severe disease with high Acute Physiology and Chronic Health Evaluation II (APACHE-II) score (median 11), length of stay (median 26 days), intensive care unit (ICU) admission (87 %), presence of systemic inflammatory response syndrome (SIRS) (90 %), persistent organ failure (60 %), and infected necrosis (50 %). Intervention was needed in 74 %. Eighteen (10.8 %) patients died during index hospitalization, 9 (5.4 %) during the first year, and 13 (7.8 %) after 1 year. Median survival was significantly shorter when compared with age- and sex-matched US general population (9.1 vs. 26.1 years, p < 0.001). Increasing age (HR 1.05), persistent organ failure (HR 4.5), and >50 % necrosis (HR 3.8) were independent predictors of death at 1 year. In eligible patients, new-onset diabetes, oral pancreatic enzyme replacement therapy, and disability were noted in 45, 25, and 53 %, respectively. CONCLUSION ANP significantly impacts long-term survival. A high proportion of patients develop functional derangement and disability following ANP.
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Affiliation(s)
| | - Amit Raina
- Division of Gastroenterology, Hepatology, and Nutrition, East Carolina University, Greenville, NC, USA
| | - Shreyas Saligram
- Division of Gastroenterology, Hepatology, and Motility, University of Kansas Medical Center, Kansas City, KS, USA
| | - Gong Tang
- Department of Biostatistics, University of Pittsburgh, Pittsburgh, PA, USA
| | - Georgios I Papachristou
- Division of Gastroenterology, Hepatology, and Nutrition, University of Pittsburgh School of Medicine, 200 Lothrop Street, M-2, C-Wing, Pittsburgh, PA, 15213, USA
| | - Mordechai Rabinovitz
- Division of Gastroenterology, Hepatology, and Nutrition, University of Pittsburgh School of Medicine, 200 Lothrop Street, M-2, C-Wing, Pittsburgh, PA, 15213, USA
| | - Jennifer Chennat
- Division of Gastroenterology, Hepatology, and Nutrition, University of Pittsburgh School of Medicine, 200 Lothrop Street, M-2, C-Wing, Pittsburgh, PA, 15213, USA
| | - Herbert Zeh
- Division of Surgical Oncology, University of Pittsburgh, Pittsburgh, PA, USA
| | - Amer H Zureikat
- Division of Surgical Oncology, University of Pittsburgh, Pittsburgh, PA, USA
| | - Melissa E Hogg
- Division of Surgical Oncology, University of Pittsburgh, Pittsburgh, PA, USA
| | - Kenneth K Lee
- Division of Surgical Oncology, University of Pittsburgh, Pittsburgh, PA, USA
| | - Melissa I Saul
- Department of Biomedical Informatics, University of Pittsburgh, Pittsburgh, PA, USA
| | - David C Whitcomb
- Division of Gastroenterology, Hepatology, and Nutrition, University of Pittsburgh School of Medicine, 200 Lothrop Street, M-2, C-Wing, Pittsburgh, PA, 15213, USA
| | - Adam Slivka
- Division of Gastroenterology, Hepatology, and Nutrition, University of Pittsburgh School of Medicine, 200 Lothrop Street, M-2, C-Wing, Pittsburgh, PA, 15213, USA
| | - Dhiraj Yadav
- Division of Gastroenterology, Hepatology, and Nutrition, University of Pittsburgh School of Medicine, 200 Lothrop Street, M-2, C-Wing, Pittsburgh, PA, 15213, USA.
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161
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Abstract
Acute pancreatitis is a common disease that can progress to gland necrosis, which imposes significant risk of morbidity and mortality. In general, the treatment for pancreatitis is a supportive therapy. However, there are several reasons to escalate to surgery or another intervention. This review discusses the pathophysiology as well as medical and interventional management of necrotizing pancreatitis. Current evidence suggests that patients are best served by delaying interventions for at least 4 weeks, draining as a first resort, and debriding recalcitrant tissue using minimally invasive techniques to promote or enhance postoperative recovery while reducing wound-related complications.
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162
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Dick JF, Gardner TB, Merrens EJ. Acute pancreatitis: New developments and strategies for the hospitalist. J Hosp Med 2016; 11:724-729. [PMID: 27240854 DOI: 10.1002/jhm.2615] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/12/2016] [Revised: 04/01/2016] [Accepted: 04/24/2016] [Indexed: 11/07/2022]
Abstract
Acute pancreatitis (AP) remains the most common reason for hospital admission of all the gastrointestinal illnesses in the United States. Since the last narrative review in the Journal of Hospital Medicine in 2010, new developments in regard to diagnosis and classification, fluid resuscitation, antibiotic use, nutritional support, and management of complications have helped refine the approach and improve outcomes in this disease. Whereas there is still no proven pharmacologic therapy to specifically combat the inflammatory consequences of AP, recent interventions have led to increased survival, shorter length of stay, and more appropriate transfer criteria for pancreatitis patients. This case-oriented review will highlight these developments and emphasize the primary role of the hospitalist in managing AP over the course of the admission. It will focus on when to coordinate with subspecialists, how to deliver effective yet efficient hospitalized care, and how to optimize appropriate discharge planning. Journal of Hospital Medicine 2016;11:724-729. © 2016 Society of Hospital Medicine.
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Affiliation(s)
- John F Dick
- Geisel School of Medicine, Section of Hospital Medicine, Dartmouth-Hitchcock Medical Center, Lebanon, New Hampshire.
| | - Timothy B Gardner
- Geisel School of Medicine, Section of Gastroenterology and Hepatology, Dartmouth-Hitchcock Medical Center, Lebanon, New Hampshire
| | - Edward J Merrens
- Geisel School of Medicine, Section of Hospital Medicine, Dartmouth-Hitchcock Medical Center, Lebanon, New Hampshire
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163
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Acute pancreatitis: a comparison of intervention rates precipitated by early vs guideline CT scan timing. Clin Radiol 2016; 71:993-996. [DOI: 10.1016/j.crad.2016.06.113] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/24/2016] [Revised: 04/25/2016] [Accepted: 06/13/2016] [Indexed: 02/03/2023]
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164
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Jang JW, Kim MH, Oh D, Cho DH, Song TJ, Park DH, Lee SS, Seo DW, Lee SK, Moon SH. Factors and outcomes associated with pancreatic duct disruption in patients with acute necrotizing pancreatitis. Pancreatology 2016; 16:958-965. [PMID: 27681504 DOI: 10.1016/j.pan.2016.09.009] [Citation(s) in RCA: 42] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/04/2016] [Revised: 08/08/2016] [Accepted: 09/20/2016] [Indexed: 12/11/2022]
Abstract
BACKGROUND AND AIMS Acute necrotizing pancreatitis (ANP) can affect main pancreatic duct (MPD) as well as parenchyma. However, the incidence and outcomes of MPD disruption has not been well studied in the setting of ANP. METHODS This retrospective study investigated 84 of 465 patients with ANP who underwent magnetic resonance cholangiopancreatography and/or endoscopic retrograde cholangiopancreatography. The MPD disruption group was subclassified into complete and partial disruption. RESULTS MPD disruption was documented in 38% (32/84) of the ANP patients. Extensive necrosis, enlarging/refractory pancreatic fluid collections (PFCs), persistence of amylase-rich output from percutaneous drainage, and amylase-rich ascites/pleural effusion were more frequently associated with MPD disruption. Hospital stay was prolonged (mean 55 vs. 29 days) and recurrence of PFCs (41% vs. 14%) was more frequent in the MPD disruption group, although mortality did not differ between ANP patients with and without MPD disruption. Subgroup analysis between complete disruption (n = 14) and partial disruption (n = 18) revealed a more frequent association of extensive necrosis and full-thickness glandular necrosis with complete disruption. The success rate of endoscopic transpapillary pancreatic stenting across the stricture site was lower in complete disruption (20% vs. 92%). Patients with complete MPD disruption also showed a high rate of PFC recurrence (71% vs. 17%) and required surgery more often (43% vs. 6%). CONCLUSIONS MPD disruption is not uncommon in patients with ANP with clinical suspicion on ductal disruption. Associated MPD disruption may influence morbidity, but not mortality of patients with ANP. Complete MPD disruption is often treated by surgery, whereas partial MPD disruption can be managed successfully with endoscopic transpapillary stenting and/or transmural drainage. Further prospective studies are needed to study these items.
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Affiliation(s)
- Ji Woong Jang
- Department of Internal Medicine, Eulji University College of Medicine, Eulji University Hospital, Daejeon, South Korea
| | - Myung-Hwan Kim
- Department of Internal Medicine, University of Ulsan College of Medicine, Asan Medical Center, Seoul, South Korea.
| | - Dongwook Oh
- Department of Internal Medicine, University of Ulsan College of Medicine, Asan Medical Center, Seoul, South Korea
| | - Dong Hui Cho
- Department of Internal Medicine, University of Ulsan College of Medicine, Asan Medical Center, Seoul, South Korea
| | - Tae Jun Song
- Department of Internal Medicine, University of Ulsan College of Medicine, Asan Medical Center, Seoul, South Korea
| | - Do Hyun Park
- Department of Internal Medicine, University of Ulsan College of Medicine, Asan Medical Center, Seoul, South Korea
| | - Sang Soo Lee
- Department of Internal Medicine, University of Ulsan College of Medicine, Asan Medical Center, Seoul, South Korea
| | - Dong-Wan Seo
- Department of Internal Medicine, University of Ulsan College of Medicine, Asan Medical Center, Seoul, South Korea
| | - Sung Koo Lee
- Department of Internal Medicine, University of Ulsan College of Medicine, Asan Medical Center, Seoul, South Korea
| | - Sung-Hoon Moon
- Department of Internal Medicine, Hallym University College of Medicine, Hallym University Sacred Heart Hospital, Anyang, South Korea.
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165
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Velagapudi A, McKay M, Barry T, Bann S, Wickremesekera SK. A Low Impact Approach to Infected Pancreatic Necrosis: Review of a Case Series. Surg Infect (Larchmt) 2016; 17:749-754. [PMID: 27643484 DOI: 10.1089/sur.2015.178] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/23/2022] Open
Abstract
BACKGROUND Infected pancreatic necrosis develops in approximately one third of patients with necrotizing pancreatitis and can lead to significant morbidity and mortality rates. Historically, open necrosectomy has been the mainstay of management for these patients but is in itself a morbid procedure. In recent times, minimally invasive techniques have evolved to allow a less invasive approach to these patients. Percutaneous catheter drainage of infected pancreatic necrosis is a technique that has been demonstrated to be potentially useful in the treatment of this group of patients. PATIENTS AND METHODS The aim of this study was to review outcomes and define the technique of percutaneous catheter drainage in patients with infected pancreatic necrosis. All patients with infected pancreatic necrosis were exclusively treated with percutaneous drainage over the study period. Acute Physiology and Chronic Health Evaluation (APACHE) II score, number and size of drains, drainage technique and drain management, hospital and intensive care unit (ICU) stay, nutritional requirements, and morbidity and mortality data were evaluated for the patient group. Computed tomography (CT) scans were used to assess the progression of the disease process and the effectiveness of the treatment. RESULTS There were nine patients with infected pancreatic necrosis in this case series between 2007 and 2012, all of whom were treated with percutaneous catheter drainage alone. The median APACHE II score in the patient group was 11, with a median stay in the ICU of 3 d and median hospital stay of 41 d. On average, nine CT scans were performed per patient during the hospital admission. A median of three drains were inserted per patient, and in the course of the study, it was evident that the larger drain size was the most effective. In eight of the nine patients in the group, complications developed that were both directly and indirectly related to the pancreatitis, but were effectively managed. There were no deaths. CONCLUSION Percutaneous catheter drainage as a stand-alone intervention is an alternative strategy for infected pancreatic necrosis and can be used with acceptable morbidity and mortality rates in this challenging group of patients.
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Affiliation(s)
- Amit Velagapudi
- Department of Surgery, Capital and Coast District Health Board , Wellington, New Zealand
| | - Matthew McKay
- Department of Surgery, Capital and Coast District Health Board , Wellington, New Zealand
| | - Tasmin Barry
- Department of Surgery, Capital and Coast District Health Board , Wellington, New Zealand
| | - Simon Bann
- Department of Surgery, Capital and Coast District Health Board , Wellington, New Zealand
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166
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Sarkar A, Sadek R, Lissauer M, Pawa S. Case report of EUS-guided endoscopic transduodenal necrosectomy in a patient with sleeve gastrectomy. BMC OBESITY 2016; 3:38. [PMID: 27651917 PMCID: PMC5022238 DOI: 10.1186/s40608-016-0119-z] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 11/06/2015] [Accepted: 09/06/2016] [Indexed: 12/30/2022]
Abstract
BACKGROUND After an acute attack of pancreatitis, walled-off pancreatic fluid collections (PFC) occur in approximately 10 % of cases. Drainage of the cavity is recommended when specific indications are met. Endoscopic drainage has been adopted as the main intervention for symptomatic walled-off PFC. Altered gastric anatomy in these patients poses an interesting challenge. We present the first case of a patient with sleeve gastrectomy who underwent successful endoscopic transduodenal necrosectomy (TDN). CASE PRESENTATION Forty year old woman with history of morbid obesity status post sleeve gastrectomy in 2009 was found to have symptomatic gallstone disease complicated by severe necrotizing gallstone pancreatitis and further complicated by symptomatic walled off pancreatic necrosis (WOPN). Imaging significant for 10.8 × 7.6 cm fluid collection with necrotic debris in the body and tail of the pancreas and endoscopic necrosectomy was attempted. EGD showed tubular gastric body and antrum, with extrinsic compression in the antrum and duodenal bulb from the pancreatic cyst. Duodenal bulb was selected as the preferred fistula site due to sleeve gastrectomy. Patient underwent successful TDN in two sessions. Patient had symptomatic improvement at follow-up with resolution of WOPN. CONCLUSION To our knowledge, this is the first reported case of EUS-guided endoscopic necrosectomy in a patient with sleeve gastrectomy. The duodenal approach was used in our patient due to history of sleeve gastrectomy.
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Affiliation(s)
- Avik Sarkar
- Division of Gastroenterology, Department of Internal Medicine, Rutgers - Robert Wood Johnson Medical School, 1 Robert Wood Johnson Place, Medical Education Building Room 478, New Brunswick, NJ 08901 USA
| | - Ragui Sadek
- Department of Surgery, Rutgers - Robert Wood Johnson Medical School, New Brunswick, NJ USA
| | - Matthew Lissauer
- Department of Surgery, Rutgers - Robert Wood Johnson Medical School, New Brunswick, NJ USA
| | - Swati Pawa
- Division of Gastroenterology, Department of Internal Medicine, Rutgers - Robert Wood Johnson Medical School, 1 Robert Wood Johnson Place, Medical Education Building Room 478, New Brunswick, NJ 08901 USA
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Isayama H, Nakai Y, Rerknimitr R, Khor C, Lau J, Wang HP, Seo DW, Ratanachu-Ek T, Lakhtakia S, Ang TL, Ryozawa S, Hayashi T, Kawakami H, Yamamoto N, Iwashita T, Itokawa F, Kuwatani M, Kitano M, Hanada K, Kogure H, Hamada T, Ponnudurai R, Moon JH, Itoi T, Yasuda I, Irisawa A, Maetani I. Asian consensus statements on endoscopic management of walled-off necrosis. Part 2: Endoscopic management. J Gastroenterol Hepatol 2016; 31:1555-65. [PMID: 27042957 DOI: 10.1111/jgh.13398] [Citation(s) in RCA: 29] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/13/2016] [Revised: 03/03/2016] [Accepted: 03/22/2016] [Indexed: 12/11/2022]
Abstract
Walled-off necrosis (WON) is a new term for encapsulated necrotic tissue after severe acute pancreatitis. Various terminologies such as pseudocyst, necroma, pancreatic abscess, and infected necrosis were previously used in the literature, resulting in confusion. The current and past terminologies must be reconciled to meaningfully interpret past data. Recently, endoscopic necrosectomy was introduced as a treatment option and is now preferred over surgical necrosectomy when the expertise is available. However, high-quality evidence is still lacking, and there is no standard management strategy for WON. The consensus meeting aimed to clarify the diagnostic criteria for WON and the role of endoscopic interventions in its management. In the Consensus Conference, 27 experts from eight Asian countries took an active role and examined key clinical aspects of WON diagnosis and endoscopic management. Statements were crafted based on literature review and expert opinion, employing the modified Delphi method. All statements were substantiated by the level of evidence and the strength of the recommendation. We created 27 consensus statements for WON diagnosis and management, including details of endoscopic procedures. When there was not enough solid evidence to support the statements, this was clearly acknowledged to facilitate future research. Proposed management strategies were formulated and are illustrated using flow charts. These recommendations, which are based on the best current scientific evidence and expert opinion, will be useful for guiding endoscopic management of WON. Part 2 of this statement focused on the endoscopic management of WON.
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Affiliation(s)
- Hiroyuki Isayama
- Department of Gastroenterology, Graduate School of Medicine, The University of Tokyo, Tokyo, Japan.
| | - Yousuke Nakai
- Department of Gastroenterology, Graduate School of Medicine, The University of Tokyo, Tokyo, Japan
| | - Rungsun Rerknimitr
- Division of Gastroenterology, Department of Medicine, Chulalongkorn University, Bangkok, Thailand
| | - Christopher Khor
- Department of Gastroenterology and Hepatology, Singapore General Hospital, Singapore, Singapore
| | - James Lau
- Department of Surgery, Endoscopic Center, Prince of Wales Hospital, The Chinese University of Hong Kong, Hong Kong, China
| | - Hsiu-Po Wang
- Endoscopic Division, National Taiwan University Hospital, National Taiwan University, Taipei, Taiwan
| | - Dong Wan Seo
- Department of Internal Medicine, University of Ulsan College of Medicine, Asan Medical Center, Seoul, Korea
| | | | | | - Tiing Leong Ang
- Department of Gastroenterology and Hepatology, Changi General Hospital, Singapore, Singapore
| | - Shomei Ryozawa
- Department of Gastroenterology, Saitama Medical University International Medical Center, Saitama, Japan
| | - Tsuyoshi Hayashi
- Department of Gastroenterology, Hokkaido Cancer Center, Sapporo, Japan
| | - Hiroshi Kawakami
- Department of Gastroenterology and Hepatology, Hokkaido University Hospital, Sapporo, Japan
| | - Natusyo Yamamoto
- Department of Gastroenterology, Graduate School of Medicine, The University of Tokyo, Tokyo, Japan
| | - Takuji Iwashita
- First Department of Internal Medicine, Gifu University Hospital, Gifu, Japan
| | - Fumihide Itokawa
- Department of Gastroenterology and Hepatology, Tokyo Medical University, Tokyo, Japan
| | - Masaki Kuwatani
- Division of Endoscopy, Hokkaido University Hospital, Sapporo, Japan
| | - Masayuki Kitano
- Department of Gastroenterology and Hepatology, Kinki University Faculty of Medicine, Osaka-sayama, Japan
| | - Keiji Hanada
- Department of Gastroenterology, Onomichi General Hospital, Onomichi, Japan
| | - Hirofumi Kogure
- Department of Gastroenterology, Graduate School of Medicine, The University of Tokyo, Tokyo, Japan
| | - Tsuyoshi Hamada
- Department of Gastroenterology, Graduate School of Medicine, The University of Tokyo, Tokyo, Japan
| | | | - Jong Ho Moon
- Digestive Disease Center and Research Institute, Department of Internal Medicine, Soon Chun Hyang University School of Medicine, Bucheon/Seoul, Korea
| | - Takao Itoi
- Department of Gastroenterology and Hepatology, Tokyo Medical University, Tokyo, Japan
| | - Ichiro Yasuda
- Department of Gastroenterology, Teikyo University Mizonokuchi Hospital, Kanagawa, Japan
| | - Atsushi Irisawa
- Department of Gastroenterology, Fukushima Medical University, Aizu Medical Center, Aizuwakamatsu, Japan
| | - Iruru Maetani
- Division of Gastroenterology and Hepatology, Department of Internal Medicine, Toho University Ohashi Medical Center, Tokyo, Japan
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168
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Theoretical approach to local infusion of antibiotics for infected pancreatic necrosis. Pancreatology 2016; 16:719-25. [PMID: 27267056 DOI: 10.1016/j.pan.2016.05.396] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/18/2016] [Revised: 05/03/2016] [Accepted: 05/29/2016] [Indexed: 12/11/2022]
Abstract
BACKGROUND/OBJECTIVES Infected pancreatic necrosis is a major complications of acute pancreatitis. If drainage is required, local administration of antibiotics through transmural nasocystic or percutaneous catheter may allow increasing local antibiotic concentrations. Drug diffusion becomes the main factor influencing local drug tissue penetration. The present study aims at providing the rationale for the design of new research protocols evaluating the efficacy of local antibiotics for infected pancreatic necrosis. METHODS A review of microbiological data was performed for the most common organisms causing the infection, antibiotics spectrum and minimum inhibitory concentrations (MIC). A search of the physico-chemical properties of antibiotics was performed to calculate the diffusion coefficients. An estimation of the antibiotic concentrations in pancreatic tissue was obtained using a mathematical model. Efficacy factors (EF) were calculated and the stability of the antibiotic solutions were evaluated to optimize the dosing regimen. RESULTS Piperacillin, vancomycin and metronidazole achieve high concentrations in the surrounding tissue very fast. Imipenem, ceftriaxone, ciprofloxacin, gentamicin, linezolid and cloxacillin achieve intermediate concentration values. Tigecycline, showed the lowest concentration values (<2 mg/L). Calculated EF is highest for piperacillin and imipenem short after administration and near to surface diffusion area (0.5 cm), but EF of imipenem is higher at deeper areas and longer time after administration. CONCLUSIONS Considering obtained results, some solutions are proposed using saline as diluent and 25 °C of temperature during administration. Imipenem has the best theoretical results in empiric local treatment. Linezolid and tigecycline solutions are not recommended.
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169
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Kamal A, Singh VK, Akshintala VS, Kawamoto S, Tsai S, Haider M, Fishman EK, Kamel IR, Zaheer A. CT and MRI assessment of symptomatic organized pancreatic fluid collections and pancreatic duct disruption: an interreader variability study using the revised Atlanta classification 2012. ACTA ACUST UNITED AC 2016; 40:1608-16. [PMID: 25425489 DOI: 10.1007/s00261-014-0303-x] [Citation(s) in RCA: 51] [Impact Index Per Article: 6.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
PURPOSE Compare CT and MRI for fluid/debris component estimate and pancreatic duct (PD) communication with organized pancreatic fluid collections in acute pancreatitis. Evaluate fat density globules on CT as marker for debris. METHODS 29 Patients with 46 collections with CECT and MRI performed ≥4 weeks of symptom onset assessed for necrotizing pancreatitis, estimated percentage of fluid volume and PD involvement by two radiologists on separate occasions. T2WI used as standard for estimated percentage of fluid volume. Presence of fat globules and fluid attenuation on CT was recorded. Spearman rank correlation and kappa statistics were used to assess the correlation between imaging techniques and interreader agreement, respectively. RESULTS Necrotizing pancreatitis seen on CT in 27 (93%, κ 0.119) vs. 20 (69%, κ 0.748) patients on MRI. CT identified 42 WON and 4 pseudocysts vs. 34 WON, and 12 pseudocysts on MRI. Higher interreader agreement for percentage fluid volume on MRI (κ = 0.55) vs. CT (κ = 0.196). Accuracy of CT in evaluation of percentage fluid volume was 65% using T2WI MRI used as standard. Fat globules identified on CT in 13(65%) out of 20 collections containing <75% fluid vs. 4(15%) out of 26 collections containing >75% fluid (p = 0.0001). PD involvement confidently excluded on CT in 68% collections vs. 93% on MRI. CONCLUSION MRI demonstrates higher reproducibility for fluid to debris component estimation. Fat globules on CT were frequently seen in organized pancreatic fluid collections with large amount of debris. PD disruption more confidently excluded on MRI. This information may be helpful for pre-procedure planning.
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Affiliation(s)
- Ayesha Kamal
- The Russell H. Morgan Department of Radiology and Radiological Science, Johns Hopkins Medical Institutions, 601 N. Caroline Street, JHOC 3235 A, Baltimore, MD, 21231, USA,
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170
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The Atlanta Classification, Revised Atlanta Classification, and Determinant-Based Classification of Acute Pancreatitis: Which Is Best at Stratifying Outcomes? Pancreas 2016; 45:510-5. [PMID: 26474431 DOI: 10.1097/mpa.0000000000000477] [Citation(s) in RCA: 33] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Abstract
OBJECTIVES To determine which classification is more accurate in stratifying severity. METHODS The study used a retrospective analysis of a prospective acute pancreatitis database (June 2005-December 2007). Acute pancreatitis severity was stratified according to the Atlanta classification (AC) 1992, the revised Atlanta classification (RAC) 2012, and the determinant-based classification (DBC) 2012. Receiver operating characteristic analysis (area under the curve) compared the accuracy of each classification. Logistic regression identified predictors of mortality. RESULTS 338 patients were analyzed: 13% had persistent organ failure (POF) (>48 hours), of whom 37% had multisystem POF, and 11% had pancreatic necrosis, of whom 19% had infected necrosis. Mortality was 4.1%. For predicting mortality (area under the curve), the RAC (0.91) and DBC (0.92) were comparable (P = 0.404); both outperformed the AC (0.81) (P < 0.001). For intensive care unit admission, the RAC (0.85) and DBC (0.85) were comparable (P = 0.949); both outperformed the AC (0.79) (P < 0.05). There were 2 patients in the critical category of the DBC. Multisystem POF was an independent predictor of mortality (odds ratio, 75.0; 95% confidence interval, 13.7-410.6; P < 0.001), whereas single-system POF, sterile necrosis, and infected necrosis were not. CONCLUSION The RAC and DBC were generally comparable in stratifying severity. The paucity of patients in the critical category in the DBC limits its utility. Neither classification accounts for the impact of multisystem POF, which was the strongest predictor of mortality.
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171
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Tyberg A, Karia K, Gabr M, Desai A, Doshi R, Gaidhane M, Sharaiha RZ, Kahaleh M. Management of pancreatic fluid collections: A comprehensive review of the literature. World J Gastroenterol 2016; 22:2256-2270. [PMID: 26900288 PMCID: PMC4735000 DOI: 10.3748/wjg.v22.i7.2256] [Citation(s) in RCA: 115] [Impact Index Per Article: 14.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/19/2015] [Revised: 12/14/2015] [Accepted: 12/30/2015] [Indexed: 02/06/2023] Open
Abstract
Pancreatic fluid collections (PFCs) are a frequent complication of pancreatitis. It is important to classify PFCs to guide management. The revised Atlanta criteria classifies PFCs as acute or chronic, with chronic fluid collections subdivided into pseudocysts and walled-off pancreatic necrosis (WOPN). Establishing adequate nutritional support is an essential step in the management of PFCs. Early attempts at oral feeding can be trialed in patients with mild pancreatitis. Enteral feeding should be implemented in patients with moderate to severe pancreatitis. Jejunal feeding remains the preferred route of enteral nutrition. Symptomatic PFCs require drainage; options include surgical, percutaneous, or endoscopic approaches. With the advent of newer and more advanced endoscopic tools and expertise, and an associated reduction in health care costs, minimally invasive endoscopic drainage has become the preferable approach. An endoscopic ultrasonography-guided approach using a seldinger technique is the preferred endoscopic approach. Both plastic stents and metal stents are efficacious and safe; however, metal stents may offer an advantage, especially in infected pseudocysts and in WOPN. Direct endoscopic necrosectomy is often required in WOPN. Lumen apposing metal stents that allow for direct endoscopic necrosectomy and debridement through the stent lumen are preferred in these patients. Endoscopic retrograde cholangio pancreatography with pancreatic duct (PD) exploration should be performed concurrent to PFC drainage. PD disruption is associated with an increased severity of pancreatitis, an increased risk of recurrent attacks of pancreatitis and long-term complications, and a decreased rate of PFC resolution after drainage. Any pancreatic ductal disruption should be bridged with endoscopic stenting.
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172
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Abstract
Acute pancreatitis results in nearly 250,000 admissions annually. Acute pancreatitis varies widely in its clinical presentation. Pancreatic necrosis accounts for substantial additional morbidity, with mortality rates remaining as high as 10% to 20% despite advances in critical care. The extent of necrosis correlates well with the incidence of infected necrosis, multiorgan failure, need for pancreatic debridement, and morbidity and mortality. Having established the diagnosis of pancreatic necrosis, goals of appropriately aggressive resuscitation should be established and adhered to in a multidisciplinary approach involving both medical and surgical critical care.
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173
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Noel P, Patel K, Durgampudi C, Trivedi RN, de Oliveira C, Crowell MD, Pannala R, Lee K, Brand R, Chennat J, Slivka A, Papachristou GI, Khalid A, Whitcomb DC, DeLany JP, Cline RA, Acharya C, Jaligama D, Murad FM, Yadav D, Navina S, Singh VP. Peripancreatic fat necrosis worsens acute pancreatitis independent of pancreatic necrosis via unsaturated fatty acids increased in human pancreatic necrosis collections. Gut 2016; 65:100-11. [PMID: 25500204 PMCID: PMC4869971 DOI: 10.1136/gutjnl-2014-308043] [Citation(s) in RCA: 103] [Impact Index Per Article: 12.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/15/2014] [Accepted: 11/17/2014] [Indexed: 02/06/2023]
Abstract
BACKGROUND AND AIMS Peripancreatic fat necrosis occurs frequently in necrotising pancreatitis. Distinguishing markers from mediators of severe acute pancreatitis (SAP) is important since targeting mediators may improve outcomes. We evaluated potential agents in human pancreatic necrotic collections (NCs), pseudocysts (PCs) and pancreatic cystic neoplasms and used pancreatic acini, peripheral blood mononuclear cells (PBMC) and an acute pancreatitis (AP) model to determine SAP mediators. METHODS We measured acinar and PBMC injury induced by agents increased in NCs and PCs. Outcomes of caerulein pancreatitis were studied in lean rats coadministered interleukin (IL)-1β and keratinocyte chemoattractant/growth-regulated oncogene, triolein alone or with the lipase inhibitor orlistat. RESULTS NCs had higher fatty acids, IL-8 and IL-1β versus other fluids. Lipolysis of unsaturated triglyceride and resulting unsaturated fatty acids (UFA) oleic and linoleic acids induced necro-apoptosis at less than half the concentration in NCs but other agents did not do so at more than two times these concentrations. Cytokine coadministration resulted in higher pancreatic and lung inflammation than caerulein alone, but only triolein coadministration caused peripancreatic fat stranding, higher cytokines, UFAs, multisystem organ failure (MSOF) and mortality in 97% animals, which were prevented by orlistat. CONCLUSIONS UFAs, IL-1β and IL-8 are elevated in NCs. However, UFAs generated via peripancreatic fat lipolysis causes worse inflammation and MSOF, converting mild AP to SAP.
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Affiliation(s)
- Pawan Noel
- Departments of Medicine, Mayo Clinic, Scottsdale, Arizona, USA
| | - Krutika Patel
- Departments of Medicine, Mayo Clinic, Scottsdale, Arizona, USA
| | - Chandra Durgampudi
- Departments of Medicine, University of Pittsburgh Medical Center, Pasavant, Pennsylvania, USA
| | - Ram N Trivedi
- Departments of Medicine, Mayo Clinic, Scottsdale, Arizona, USA
| | | | | | - Rahul Pannala
- Departments of Medicine, Mayo Clinic, Scottsdale, Arizona, USA
| | - Kenneth Lee
- Departments of Surgery, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, USA
| | - Randall Brand
- Departments of Medicine, University of Pittsburgh, Pittsburgh, Pennsylvania, USA
| | - Jennifer Chennat
- Departments of Medicine, University of Pittsburgh, Pittsburgh, Pennsylvania, USA
| | - Adam Slivka
- Departments of Medicine, University of Pittsburgh, Pittsburgh, Pennsylvania, USA
| | | | - Asif Khalid
- Departments of Medicine, University of Pittsburgh, Pittsburgh, Pennsylvania, USA
| | - David C Whitcomb
- Departments of Medicine, University of Pittsburgh, Pittsburgh, Pennsylvania, USA
| | - James P DeLany
- Departments of Medicine, University of Pittsburgh, Pittsburgh, Pennsylvania, USA
| | - Rachel A Cline
- Departments of Medicine, University of Pittsburgh, Pittsburgh, Pennsylvania, USA
| | - Chathur Acharya
- Departments of Medicine, University of Pittsburgh Medical Center, Pasavant, Pennsylvania, USA
| | - Deepthi Jaligama
- Departments of Medicine, University of Pittsburgh Medical Center, Pasavant, Pennsylvania, USA
| | - Faris M Murad
- Departments of Medicine, Washington University, Saint Louis, Missouri, USA
| | - Dhiraj Yadav
- Departments of Medicine, University of Pittsburgh, Pittsburgh, Pennsylvania, USA
| | - Sarah Navina
- Departments of Pathology, University of Pittsburgh, Pittsburgh, Pennsylvania, USA
| | - Vijay P Singh
- Departments of Medicine, Mayo Clinic, Scottsdale, Arizona, USA
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174
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Smoczyński M, Jagielski M, Jabłońska A, Adrych K. Transpapillary drainage of walled-off pancreatic necrosis - a single center experience. Wideochir Inne Tech Maloinwazyjne 2016; 10:527-33. [PMID: 26865888 PMCID: PMC4729724 DOI: 10.5114/wiitm.2015.55677] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/10/2015] [Accepted: 10/21/2015] [Indexed: 12/18/2022] Open
Abstract
INTRODUCTION Walled-off pancreatic necrosis (WOPN) often coexists with disruption of the main pancreatic duct that manifests as a leak of contrast medium into the necrotic collection during endoscopic retrograde pancreatography. AIM To assess the efficacy and safety of treatment of patients with symptomatic WOPN and disruption of the main pancreatic duct, who underwent endoscopic transpapillary drainage as the only access to the necrosis cavity. MATERIAL AND METHODS In 22 patients with symptomatic WOPN, active endoscopic transpapillary drainage was performed. During endoscopic retrograde pancreatography (ERP), partial disruption of the main pancreatic duct was observed in 14 patients and complete disruption in 8 patients. After the active drainage was finished, a transpapillary pancreatic stent was inserted into the main pancreatic duct, which was later exchanged after 6, 12 and 24 months or when no extravasation of contrast from the pancreatic duct was observed. The results of treatment and complications were compared retrospectively. RESULTS The mean duration of active drainage was 22 (range: 7-94) days. Complications of endotherapy occurred in 3/22 patients. The mean time of the main pancreatic duct stenting was 304 (range: 85-519) days. Success of endoscopic treatment of WOPN and pancreatic duct disruption was achieved in 20/22 patients. During a 1-year follow-up, recurrence of the collection was noted in 4/20 patients. Long-term success was achieved in 16/22 patients. CONCLUSIONS In patients with WOPN who cannot undergo transmural drainage when there is a communication between the necrotic collection and the main pancreatic duct, transpapillary access may be an effective and safe method of treatment.
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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
| | - Anna Jabłońska
- 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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175
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Bugiantella W, Rondelli F, Boni M, Stella P, Polistena A, Sanguinetti A, Avenia N. Necrotizing pancreatitis: A review of the interventions. Int J Surg 2015; 28 Suppl 1:S163-71. [PMID: 26708848 DOI: 10.1016/j.ijsu.2015.12.038] [Citation(s) in RCA: 51] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/30/2015] [Revised: 04/11/2015] [Accepted: 05/10/2015] [Indexed: 02/06/2023]
Abstract
Acute pancreatitis may have a wide range of severity, from a clinically self-limiting to a quickly fatal course. Necrotizing pancreatitis (NP) is the most dreadful evolution associated to a poor prognosis: mortality is approximately 15% and up to 30-39% in case of infected necrosis, which is the major cause of death. Intervention is generally required for infected pancreatic necrosis and less commonly in patients with sterile necrosis who are symptomatic (gastric or duodenal outlet or biliary obstruction). Traditionally the most widely used approach to infected necrosis has been open surgical necrosectomy, but it is burdened by high morbidity (34-95%) and mortality (11-39%) rates. In the last two decades the treatment of NP has significantly evolved from open surgery towards minimally invasive techniques (percutaneous catheter drainage, per-oral endoscopic, laparoscopy and rigid retroperitoneal videoscopy). The objective of this review is to summarize the current state of the art of the management of NP and to clarify some aspects about its diagnosis and treatment.
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Affiliation(s)
- Walter Bugiantella
- General Surgery, "San Giovanni Battista Hospital", AUSL Umbria 2, Via M. Arcamone, 06034, Foligno, Perugia, Italy; University of Perugia, PhD School in Biotechnologies, Italy.
| | - Fabio Rondelli
- General Surgery, "San Giovanni Battista Hospital", AUSL Umbria 2, Via M. Arcamone, 06034, Foligno, Perugia, Italy; University of Perugia, Department of Surgical and Biomedical Sciences, Via G. Dottori, 06100, Perugia, Italy.
| | - Marcello Boni
- General Surgery, "San Giovanni Battista Hospital", AUSL Umbria 2, Via M. Arcamone, 06034, Foligno, Perugia, Italy.
| | - Paolo Stella
- General Surgery, "San Giovanni Battista Hospital", AUSL Umbria 2, Via M. Arcamone, 06034, Foligno, Perugia, Italy.
| | - Andrea Polistena
- General and Specialized Surgery, "Santa Maria" Hospital, Via T. Di Joannuccio, 05100, Terni, Italy.
| | - Alessandro Sanguinetti
- General and Specialized Surgery, "Santa Maria" Hospital, Via T. Di Joannuccio, 05100, Terni, Italy.
| | - Nicola Avenia
- General and Specialized Surgery, "Santa Maria" Hospital, Via T. Di Joannuccio, 05100, Terni, Italy.
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176
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Lee JK. [Recent Advances in Management of Acute Pancreatitis]. THE KOREAN JOURNAL OF GASTROENTEROLOGY 2015; 66:135-43. [PMID: 26642477 DOI: 10.4166/kjg.2015.66.3.135] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
Acute pancreatitis is common but remains a condition with significant morbidity and mortality. Despite a better understanding of the pathophysiology of acute pancreatitis achieved during the past few decades, there is no specific pharmacologic entity available. Therefore, supportive care is still the mainstay of treatment. Recently, novel interventions for increasing survival and minimizing morbidity have been investigated, which are highlighted in this review.
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177
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Rosenberg A, Steensma EA, Napolitano LM. Necrotizing pancreatitis: new definitions and a new era in surgical management. Surg Infect (Larchmt) 2015; 16:1-13. [PMID: 25761075 DOI: 10.1089/sur.2014.123] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022] Open
Abstract
BACKGROUND Necrotizing pancreatitis is a challenging condition that requires surgical treatment commonly and is associated with substantial morbidity and mortality. Over the past decade, new definitions have been developed for standardization of severity of acute and necrotizing pancreatitis, and new management techniques have emerged based on prospective, randomized clinical trials. METHODS Review of English-language literature. RESULTS A new international classification of acute pancreatitis has been developed by PANCREA (Pancreatitis Across Nations Clinical Research and Education Alliance) to replace the Atlanta Classification. It is based on the actual local (whether pancreatic necrosis is present or not, whether it is sterile or infected) and systemic determinants (whether organ failure is present or not, whether it is transient or persistent) of severity. Early management requires goal-directed fluid resuscitation (with avoidance of over-resuscitation and abdominal compartment syndrome), assessment of severity of pancreatitis, diagnostic computed tomography (CT) imaging to assess for necrotizing pancreatitis, consideration of endoscopic retrograde cholangiopancreatography (ERCP) for biliary pancreatitis and early enteral nutrition support. Antibiotic prophylaxis is not recommended. Therapeutic antibiotics are required for treatment of documented infected pancreatic necrosis. The initial treatment of infected pancreatic necrosis is percutaneous catheter or endoscopic (transgastric/transduodenal) drainage with a second drain placement as required. Lack of clinical improvement after these initial procedures warrants consideration of minimally invasive techniques for pancreatic necrosectomy including video-assisted retroperitoneal debridement (VARD), minimally invasive retroperitoneal pancreatectomy (MIRP), or transluminal direct endoscopic necrosectomy (DEN). Open necrosectomy is associated with substantial morbidity, but to date no randomized trial has documented superiority of either minimally invasive or open surgical technique. Additional trials are underway to address this. CONCLUSIONS Severe acute and necrotizing pancreatitis requires a multi-disciplinary treatment strategy that must be individualized for each patient. Optimal treatment of necrotizing pancreatitis now requires a staged, multi-disciplinary, minimally invasive "step-up" approach that includes a team of interventional radiologists, therapeutic endoscopists, and surgeons.
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Affiliation(s)
- Andrew Rosenberg
- Division of Acute Care Surgery [Trauma, Burn, Surgical Critical Care, Emergency Surgery], Department of Surgery, University of Michigan Medical Center , Ann Arbor, Michigan
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178
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Clinical outcomes of combined necrotizing pancreatitis versus extrapancreatic necrosis alone. Pancreatology 2015; 16:57-65. [PMID: 26626203 DOI: 10.1016/j.pan.2015.10.010] [Citation(s) in RCA: 25] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/01/2015] [Revised: 10/25/2015] [Accepted: 10/28/2015] [Indexed: 12/11/2022]
Abstract
INTRODUCTION Extrapancreatic necrosis (EPN) alone, i.e., in the absence of pancreatic parenchyma necrosis has gradually come to be regarded as a separate entity of acute necrotizing pancreatitis (ANP). However, data regarding the prognostic significance of EPN are quite limited, and the outcomes of interventions for patients with EPN alone are not well elucidated. The aim of this study was to explore the differences in the outcomes of patients with EPN alone and patients with both the pancreatic parenchyma and extrapancreatic necrosis (combined necrosis). METHODS From January 2009 to December 2013, a total of 334 patients with ANP who had received interventions in the West China Hospital in China were included. Based on the extent of necrosis as assessed with contrast-enhanced CT, the patients were divided into Group 1 (n = 285) in which the necrosis involved both the pancreatic parenchyma and extrapancreatic tissues (combined necrosis) and Group 2 (n = 49) in which the necrosis involved only the extrapancreatic tissues. Additionally, Group 3 included 443 patients with interstitial pancreatitis who were also included in the analyses. The demographic characteristics, support treatment information, organ failure information, infection necrosis, persistent systemic inflammatory response syndrome (SIRS) in the first week of onset, CT severity index, and intervention types, as well as the postoperative stay lengths, ICU utility, and complications were collected and compared. RESULTS Compared with the patients in Group 1, the patients in Group 2 suffered less persistent SIRS in the first week of onset (12/24.5% vs. 145/50.9%; P < 0.05), less persistent organ failure (6/12.2% vs. 95/33.3%; P < 0.05), less persistent multiple organ failure (3/6.1% vs. 67/23.5%; P < 0.05), and less bacteremia (5/10.2% vs. 107/37.5%; P < 0.001). The intervention types were significantly different between the two groups (P < 0.001); initial open necrosectomy was performed in 174/61.6% and 8/16.3% of the patients in Groups 1 and 2, respectively, and initial percutaneous catheter drainage (PCD) was performed in 73/25.6% and 29/59.2% of the patients in the two respective groups. Second open necrosectomies following PCD were required in 61/83.5% and 9/31.0% of the patients in Groups 1 and 2, respectively (P < 0.001). A greater number of patients in Group 1 were diagnosed with infected necrosis (204/71.6% vs. 10/20.4%; P < 0.001) and had to be sent to the ICU for further postoperative care (221/77.5% vs. 23/46.9%; P < 0.001). The postoperative stay was longer for Group 1 (median: 43.0 vs. 26.5 days; P < 0.001). Residual necrotic tissue or abscess was the most common postoperative complication in both groups. The mortality was higher in Group 1 (52/18.2% vs. 1/2.1%; P < 0.05). Compared with the patients in Group 2, the patients with interstitial pancreatitis exhibited milder courses and better outcomes. Subgroup comparisons with Group 1 indicated that early multiple organ failure was significantly associated with higher mortality. CONCLUSION The patients with EPN alone exhibited significantly better prognoses than those with combined necrosis, and EPN alone should be regarded as a separate group of acute necrotizing pancreatitis. Open necrosectomy can be avoided in the majority of patients with EPN alone, who receive PCD as the initial first intervention.
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179
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Shyu JY, Sainani NI, Sahni VA, Chick JF, Chauhan NR, Conwell DL, Clancy TE, Banks PA, Silverman SG. Necrotizing pancreatitis: diagnosis, imaging, and intervention. Radiographics 2015; 34:1218-39. [PMID: 25208277 DOI: 10.1148/rg.345130012] [Citation(s) in RCA: 73] [Impact Index Per Article: 8.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
Acute necrotizing pancreatitis is a severe form of acute pancreatitis characterized by necrosis in and around the pancreas and is associated with high rates of morbidity and mortality. Although acute interstitial edematous pancreatitis is diagnosed primarily on the basis of signs, symptoms, and laboratory test findings, the diagnosis and severity assessment of acute necrotizing pancreatitis are based in large part on imaging findings. On the basis of the revised Atlanta classification system of 2012, necrotizing pancreatitis is subdivided anatomically into parenchymal, peripancreatic, and combined subtypes, and temporally into clinical early (within 1 week of onset) and late (>1 week after onset) phases. Associated collections are categorized as "acute necrotic" or "walled off" and can be sterile or infected. Imaging, primarily computed tomography and magnetic resonance imaging, plays an essential role in the diagnosis of necrotizing pancreatitis and the identification of complications, including infection, bowel and biliary obstruction, hemorrhage, pseudoaneurysm formation, and venous thrombosis. Imaging is also used to help triage patients and guide both temporizing and definitive management. A "step-up" method for the management of necrotizing pancreatitis that makes use of imaging-guided percutaneous catheter drainage of fluid collections prior to endoscopic or surgical necrosectomy has been shown to improve clinical outcomes. The authors present an algorithmic approach to the care of patients with necrotizing pancreatitis and review the use of imaging and interventional techniques in the diagnosis and management of this pathologic condition.
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Affiliation(s)
- Jeffrey Y Shyu
- From the Department of Radiology, Division of Abdominal Imaging and Intervention (J.Y.S., N.I.S., V.A.S., J.F.C., N.R.C., S.G.S.), Department of Medicine, Division of Gastroenterology, Hepatology and Endoscopy (D.L.C., P.A.B.), and Department of Surgery, Division of Surgical Oncology (T.E.C.), Brigham and Women's Hospital, Harvard Medical School, 75 Francis St, Boston, MA 02115
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180
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Dua MM, Worhunsky DJ, Tran TB, Rumma RT, Poultsides GA, Norton JA, Park WG, Visser BC. Severe acute pancreatitis in the community: confusion reigns. J Surg Res 2015; 199:44-50. [DOI: 10.1016/j.jss.2015.04.054] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/03/2015] [Revised: 04/03/2015] [Accepted: 04/15/2015] [Indexed: 12/21/2022]
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181
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Abstract
An international symposium entitled "Acute pancreatitis: progress and challenges" was held on November 5, 2014 at the Hapuna Beach Hotel, Big Island, Hawaii, as part of the 45th Anniversary Meeting of the American Pancreatic Association and the Japanese Pancreas Society. The course was organized and directed by Drs. Stephen Pandol, Tooru Shimosegawa, Robert Sutton, Bechien Wu, and Santhi Swaroop Vege. The symposium objectives were to: (1) highlight current issues in management of acute pancreatitis, (2) discuss promising treatments, (3) consider development of quality indicators and improved measures of disease activity, and (4) present a framework for international collaboration for development of new therapies. This article represents a compilation and adaptation of brief summaries prepared by speakers at the symposium with the purpose of broadly disseminating information and initiatives.
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182
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Hu ZL, Kang PC, Cui YF. Percutaneous catheter drainage in severe acute pancreatitis: Application and problems. Shijie Huaren Xiaohua Zazhi 2015; 23:4215-4220. [DOI: 10.11569/wcjd.v23.i26.4215] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023] Open
Abstract
Severe acute pancreatitis (SAP) is an acute abdominal disease which has a number of complications and a high mortality rate. The prognosis had improved much since the use of multidisciplinary comprehensive therapy and minimally invasive treatment in this disease. Percutaneous catheter drainage (PCD) can be used as a step-up minimally invasive treatment for SAP, and as a bridge between internal conservative therapy and open surgery for removal of necrotic tissue. PCD has a therapeutic effect on the local complications of SAP, such as abdominal free effusion, retroperitoneal necrosis infection and pancreatic pseudocyst, and can help to choose the operation timing when the necrotic tissue encapsulation is confirmed in patients with SAP. Clinical therapy should be slected based on the lesion location, quantity and consistency of effusion. When the effusion is located in shallow location, PCD shuold be guided by ultrasound; if the effusion is located in location deep, CT guidance should be adopted. After PCD is finished, the catheter should be cared carefully by keeping the drainage tube patent, rinsing the tube and adjusting its position in time. All of these are the necessary measures to maintain the PCD effectively. When the drainage fluid is less than 10 mL/d and imaging shows that the lesions disappear, it is the best time to remove the tube.
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183
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Eliason K, Adler DG. Endoscopic ultrasound-guided transmural drainage of infected pancreatic necrosis developing 2 years after acute pancreatitis. Endosc Ultrasound 2015; 4:260-5. [PMID: 26374588 PMCID: PMC4568642 DOI: 10.4103/2303-9027.163020] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/08/2023] Open
Abstract
This is a case report of endoscopic ultrasound guided transmural drainage of a large infected pancreatic necrosis. The infected necrosis was treated by placement of a fully covered metal stent with subsequent endoscopic necrosectomy to remove solid debris. The case is notable for the fact that the patient developed infection of a long-standing and previously stable area of walled-off pancreatic necrosis 2 years after it formed. We believe this is the longest time ever reported between necrotizing pancreatitis and the development of infected pancreatic necrosis.
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Affiliation(s)
| | - Douglas G Adler
- Department of Gastroenterology and Hepatology, University of Utah School of Medicine, Salt Lake City, Utah, USA
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184
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Jagielski M, Smoczyński M, Adrych K. Transpapillary drainage of pancreatic parenchymal necrosis. Wideochir Inne Tech Maloinwazyjne 2015; 10:491-4. [PMID: 26649102 PMCID: PMC4653261 DOI: 10.5114/wiitm.2015.54075] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/12/2014] [Revised: 01/04/2015] [Accepted: 06/14/2015] [Indexed: 01/03/2023] Open
Abstract
In the last two decades the strategy of treatment of necrotizing pancreatitis has changed. Endoscopic therapy of patients with symptomatic walled-off pancreatic necrosis has a high rate of efficiency. Here we present a description of a patient with parenchymal limited necrosis of the pancreas and a disruption of the main pancreatic duct. In the treatment, active transpapillary drainage of the pancreatic necrosis (through the major duodenal papilla) was performed and insertion of an endoprosthesis into the main pancreatic duct (through the minor duodenal papilla) was applied, which enabled a bypass over the infiltration and resulted in complete resolution.
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Affiliation(s)
- Mateusz Jagielski
- Department of Gastroenterology and Hepatology, Medical University of Gdansk, Gdansk, Poland
| | - Marian Smoczyński
- 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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185
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Stahl CC, Moulton J, Vu D, Ristagno R, Choe K, Sussman JJ, Shah SA, Ahmad SA, Abbott DE. Routine use of U-tube drainage for necrotizing pancreatitis: a step toward less morbidity and resource utilization. Surgery 2015; 158:919-26; discussion 926-8. [PMID: 26271525 DOI: 10.1016/j.surg.2015.07.006] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/11/2015] [Revised: 06/24/2015] [Accepted: 07/07/2015] [Indexed: 02/06/2023]
Abstract
BACKGROUND A U-tube drainage catheter (UTDC) is a novel intervention for necrotizing pancreatitis, with multiple benefits: bidirectional flushing, greater interface with large fluid collections, less risk of dislodgement, and creation of a large-diameter fistula tract for potential fistulojejunostomy. We report the first clinical experience with UTDC for necrotizing pancreatitis. METHODS From 2011 to 2014, all patients undergoing UTDC for necrotizing pancreatitis at our institution were identified. Clinical variables including patient, disease, and intervention-specific characteristics as well as long-term outcomes populated our dataset. RESULTS Twenty-two patients underwent UTDC for necrotizing pancreatitis; the median follow-up was 10.2 months. Necrotizing pancreatitis was most commonly owing to gallstones (n = 9; 41%), idiopathic disease (n = 5; 23%), and alcohol abuse (n = 4; 18%). During the course of UTDC and definitive operative therapy (when required), patients had median hospital stays of 31 days, 6 interventional radiology procedures, and 6 CT scans. Operative intervention was not necessary in 9 patients (41%). Among the other 13 patients, 4 patients underwent distal pancreatectomy/splenectomy, 8 had a fistulojejunostomy performed, and 1 underwent both procedures. CONCLUSION UTDC for necrotizing pancreatitis patients is associated with effective drainage and low morbidity/hospital resource utilization. With skilled interventional radiologists and multidisciplinary coordination, this technique is a valuable means of minimizing morbidity for patients with necrotizing pancreatitis.
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Affiliation(s)
| | - Jonathan Moulton
- Department of Radiology, University of Cincinnati, Cincinnati, OH
| | - Doan Vu
- Department of Radiology, University of Cincinnati, Cincinnati, OH
| | - Ross Ristagno
- Department of Radiology, University of Cincinnati, Cincinnati, OH
| | - Kyuran Choe
- Department of Radiology, University of Cincinnati, Cincinnati, OH
| | | | - Shimul A Shah
- Department of Surgery, University of Cincinnati, Cincinnati, OH
| | - Syed A Ahmad
- Department of Surgery, University of Cincinnati, Cincinnati, OH
| | - Daniel E Abbott
- Department of Surgery, University of Cincinnati, Cincinnati, OH.
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Abstract
Acute pancreatitis, an inflammatory disorder of the pancreas, is the leading cause of admission to hospital for gastrointestinal disorders in the USA and many other countries. Gallstones and alcohol misuse are long-established risk factors, but several new causes have emerged that, together with new aspects of pathophysiology, improve understanding of the disorder. As incidence (and admission rates) of acute pancreatitis increase, so does the demand for effective management. We review how to manage patients with acute pancreatitis, paying attention to diagnosis, differential diagnosis, complications, prognostic factors, treatment, and prevention of second attacks, and the possible transition from acute to chronic pancreatitis.
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Affiliation(s)
- Paul Georg Lankisch
- Department of General Internal Medicine and Gastroenterology, Clinical Centre of Lüneburg, Lüneburg, Germany.
| | - Minoti Apte
- Pancreatic Research Group, South Western Sydney Clinical School, Faculty of Medicine, University of New South Wales, Sydney, NSW, Australia; Ingham Institute for Applied Medical Research, Liverpool Hospital, Liverpool, NSW, Australia
| | - Peter A Banks
- Division of Gastroenterology, Hepatology, and Endoscopy, Harvard Medical School, and Brigham and Women's Hospital, Boston, MA, USA
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187
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Cresswell AB, Nageswaran H, Belgaumkar A, Kumar R, Menezes N, Riga A, Worthington TR, Karanjia ND. The two-port laparoscopic retroperitoneal approach for minimal access pancreatic necrosectomy. Ann R Coll Surg Engl 2015; 97:354-8. [PMID: 26264086 PMCID: PMC5096554 DOI: 10.1308/003588415x14181254789961] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 01/11/2015] [Indexed: 01/25/2023] Open
Abstract
INTRODUCTION Despite advances in surgery and critical care, severe pancreatitis continues to be associated with a high rate of mortality, which is increased significantly in the presence of infected pancreatic necrosis. Controversy persists around the optimal treatment for such cases, with specialist units variously advocating open necrosectomy, simple percutaneous drainage or one of several minimal access approaches. We describe our technique and outcomes with a two-port laparoscopic retroperitoneal necrosectomy (2P-LRN). METHODS Thirteen consecutive patients with proven infected pancreatic necrosis were treated by 2P-LRN over a three-year period in the setting of a specialist hepatopancreatobiliary unit. The median patient age was 46 years (range: 28-87 years) and 10 of the patients were male. RESULTS The median number of procedures required to clear the necrosis was 2 (range: 1-5), with a median time to discharge following the procedure of 44 days (range: 10-135 days). There was no 90-day mortality and the morbidity rate was 38%, consisting of pancreatic fistula (31%) and bleeding (23%). CONCLUSIONS Two-port laparoscopic retroperitoneal necrosectomy has been demonstrated to confer similar or better outcomes to other techniques for necrosectomy. It carries the additional advantages of better visualisation, leading to fewer procedures and the opportunity to deploy simple laparoscopic instruments such as diathermy or haemostatic clips.
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Affiliation(s)
- AB Cresswell
- Royal Surrey County Hospital NHS Foundation Trust, UK
| | - H Nageswaran
- Royal Surrey County Hospital NHS Foundation Trust, UK
| | - A Belgaumkar
- Royal Surrey County Hospital NHS Foundation Trust, UK
| | - R Kumar
- Royal Surrey County Hospital NHS Foundation Trust, UK
| | - N Menezes
- Royal Surrey County Hospital NHS Foundation Trust, UK
| | - A Riga
- Royal Surrey County Hospital NHS Foundation Trust, UK
| | | | - ND Karanjia
- Royal Surrey County Hospital NHS Foundation Trust, UK
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Pezzilli R, Zerbi A, Campra D, Capurso G, Golfieri R, Arcidiacono PG, Billi P, Butturini G, Calculli L, Cannizzaro R, Carrara S, Crippa S, De Gaudio R, De Rai P, Frulloni L, Mazza E, Mutignani M, Pagano N, Rabitti P, Balzano G. Consensus guidelines on severe acute pancreatitis. Dig Liver Dis 2015; 47:532-43. [PMID: 25921277 DOI: 10.1016/j.dld.2015.03.022] [Citation(s) in RCA: 95] [Impact Index Per Article: 10.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/02/2015] [Revised: 03/17/2015] [Accepted: 03/24/2015] [Indexed: 02/07/2023]
Abstract
This Position Paper contains clinically oriented guidelines by the Italian Association for the Study of the Pancreas (AISP) for the diagnosis and treatment of severe acute pancreatitis. The statements were formulated by three working groups of experts who searched and analysed the most recent literature; a consensus process was then performed using a modified Delphi procedure. The statements provide recommendations on the most appropriate definition of the complications of severe acute pancreatitis, the diagnostic approach and the timing of conservative as well as interventional endoscopic, radiological and surgical treatments.
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189
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Jagielski M, Smoczyński M, Jabłońska A, Marek I, Dubowik M, Adrych K. The role of endoscopic ultrasonography in endoscopic debridement of walled-off pancreatic necrosis--A single center experience. Pancreatology 2015; 15:503-507. [PMID: 26122305 DOI: 10.1016/j.pan.2015.06.001] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/06/2014] [Revised: 01/07/2015] [Accepted: 06/05/2015] [Indexed: 02/06/2023]
Abstract
BACKGROUND In recent years the significance of endoscopic ultrasonography (EUS) has increased. In our center we have also performed EUS-guided cystostomy since 2011. Earlier we had performed this procedure without EUS. Introduction of EUS in our hospital has inspired us to perform a retrospective analysis of the influence of EUS use on the risk of complications and the effectiveness of endoscopic treatment of patients with WOPN. METHODS Between years 2001 and 2013 176 patients with symptomatic WOPN underwent endoscopic treatment in the Department of Gastroenterology and Hepatology of Medical University of Gdańsk. The results and complications of treatment in relation to the use of EUS during drainage/debridement were compared retrospectively. RESULTS 64 patients underwent EUS-guided drainage/debridement of WOPN (group 1). In the case of 112 patients endoscopic drainage/debridement was performed without EUS control (group 2). In group 1 therapeutic success was achieved in 60/64 (93.75%) patients in comparison to 104/112 (92.9%) patients in group 2 (P = 0.870). The mean duration of drainage/debridement in both groups was 25 days - 4-173 days in group 1 and 4-112 days in group 2 (P = 0.519). The complications of endotherapy occurred in 9/64 (14.06%) patients from group 1 in comparison to 29/112 (25.9%) patients from group 2 (P = 0.047). CONCLUSIONS In our study the use of EUS during endoscopic drainage/debridement of WOPN significantly reduced the number of procedure-related complications, mainly gastrointestinal bleeding. However, it had no influence on the duration of treatment or the effectiveness of therapy.
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Affiliation(s)
- Mateusz Jagielski
- Department of Gastroenterology and Hepatology, Medical University of Gdansk, Gdansk, Poland.
| | - Marian Smoczyński
- Department of Gastroenterology and Hepatology, Medical University of Gdansk, Gdansk, Poland
| | - Anna Jabłońska
- Department of Gastroenterology and Hepatology, Medical University of Gdansk, Gdansk, Poland
| | - Iwona Marek
- Department of Gastroenterology and Hepatology, Medical University of Gdansk, Gdansk, Poland
| | - Michał Dubowik
- 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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Zerem E, Hauser G, Loga-Zec S, Kunosić S, Jovanović P, Crnkić D. Minimally invasive treatment of pancreatic pseudocysts. World J Gastroenterol 2015; 21:6850-6860. [PMID: 26078561 PMCID: PMC4462725 DOI: 10.3748/wjg.v21.i22.6850] [Citation(s) in RCA: 31] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/24/2015] [Revised: 03/29/2015] [Accepted: 04/28/2015] [Indexed: 02/07/2023] Open
Abstract
A pancreatic pseudocyst (PPC) is typically a complication of acute and chronic pancreatitis, trauma or pancreatic duct obstruction. The diagnosis of PPC can be made if an acute fluid collection persists for 4 to 6 wk and is enveloped by a distinct wall. Most PPCs regress spontaneously and require no treatment, whereas some may persist and progress until complications occur. The decision whether to treat a patient who has a PPC, as well as when and with what treatment modalities, is a difficult one. PPCs can be treated with a variety of methods: percutaneous catheter drainage (PCD), endoscopic transpapillary or transmural drainage, laparoscopic surgery, or open pseudocystoenterostomy. The recent trend in the management of symptomatic PPC has moved toward less invasive approaches such as endoscopic- and image-guided PCD. The endoscopic approach is suitable because most PPCs lie adjacent to the stomach. The major advantage of the endoscopic approach is that it creates a permanent pseudocysto-gastric track with no spillage of pancreatic enzymes. However, given the drainage problems, the monitoring, catheter manipulation and the analysis of cystic content are very difficult or impossible to perform endoscopically, unlike in the PCD approach. Several conditions must be met to achieve the complete obliteration of the cyst cavity.
Pancreatic duct anatomy is an important factor in the prognosis of the treatment outcome, and the recovery of disrupted pancreatic ducts is the main prognostic factor for successful treatment of PPC, regardless of the treatment method used. In this article, we review and evaluate the minimally invasive approaches in the management of PPCs.
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191
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Endoscopic necrosectomy under fluoroscopic guidance - a single center experience. Wideochir Inne Tech Maloinwazyjne 2015; 10:237-43. [PMID: 26240624 PMCID: PMC4520837 DOI: 10.5114/wiitm.2015.52058] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/30/2014] [Revised: 02/06/2015] [Accepted: 03/05/2015] [Indexed: 01/06/2023] Open
Abstract
INTRODUCTION Our report presents a technique of necrotic tissue removal during transmural drainage of walled-off pancreatic necrosis (WOPN) that is an alternative to the one that has already been described in the literature. AIM To assess the effectiveness and safety of endoscopic necrosectomy performed during transmural drainage of symptomatic WOPN. MATERIAL AND METHODS Within the years 2012-2013, 64 patients underwent endoscopic treatment of symptomatic WOPN in our center. Eight patients underwent endoscopic necrosectomy during transmural drainage. Fragments of necrotic tissues were removed from the collection's cavity under fluoroscopic guidance using a Dormia basket. The results and complications of treatment were compared retrospectively. RESULTS Sixty-four patients with WOPN underwent transmural drainage under endoscopic ultrasonography (EUS) guidance. Eight patients (12.5%, 5 women and 3 men, mean age 57.25 years) were qualified for endoscopic necrosectomy. Transmural transgastric access was made in 7 patients and transduodenal access in 1 patient. Additional percutaneous drainage was used in 2 patients. Active drainage was continued for 24 days (11-44 days). The mean number of endoscopic procedures was 4.75 (3-9). The average number of necrosectomy procedures during drainage was 1.75 (1-4). Complications of endotherapy occurred in 2/8 (25%) patients, and they were not directly connected with necrosectomy. Therapeutic success after the end of active drainage was achieved in all patients. During a 6-month follow-up no recurrence of the collection was observed. CONCLUSIONS Endoscopic necrosectomy under fluoroscopic guidance is an effective and safe method of minimally invasive treatment in a selected group of patients with symptomatic WOPN.
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Mohkam K, Farges O, Pruvot FR, Muscari F, Régimbeau JM, Regenet N, Sa Cunha A, Dokmak S, Mabrut JY. Toward a standard technique for laparoscopic distal pancreatectomy? Synthesis of the 2013 ACHBT Spring workshop. J Visc Surg 2015; 152:167-78. [DOI: 10.1016/j.jviscsurg.2015.04.002] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
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Nononcologic applications of diffusion-weighted imaging in the gastrointestinal system. AJR Am J Roentgenol 2015; 204:758-67. [PMID: 25794064 DOI: 10.2214/ajr.14.12729] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Abstract
OBJECTIVE The purpose of this article is to review infectious, inflammatory, and auto-immune-mediated processes in the gastrointestinal system where diffusion-weighted imaging can be helpful as well as pitfalls associated with its use. CONCLUSION Diffusion-weighted imaging has become an important and widely used tool in abdominal and pelvic MRI, but it has been used primarily for oncologic applications. As more body MRI protocols are routinely including diffusion-weighted imaging, this sequence can be useful in evaluating an increasing number of nononcologic processes.
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Lewis A, Partridge B, Haluszka O. The role of endoscopy in the management of pancreatic necrosis. Curr Gastroenterol Rep 2015; 16:406. [PMID: 25113041 DOI: 10.1007/s11894-014-0406-0] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/22/2022]
Abstract
The management of acute pancreatitis has seen many advances over the past three decades. Attempts to improve care have led to new definitions, classification systems, and treatment strategies. Despite those efforts, considerable morbidity and mortality result from complications of severe acute pancreatitis. Much attention has been given to new ways to treat these complications, including inflammatory pancreatic fluid collections and associated infections. Endoscopy has become one of the established modalities for the treatment of these complications in many expert centers. This chapter will specifically address the role of endoscopy in the management of pancreatic necrosis.
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Affiliation(s)
- Aaron Lewis
- Department of Gastroenterology, Naval Medical Center San Diego, 34800 Bob Wilson Dr, San Diego, CA, 92134, USA,
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Ruiz-Clavijo D, Higuera BGDL, Vila JJ. Advances in the endoscopic management of pancreatic collections. World J Gastrointest Endosc 2015; 7:381-388. [PMID: 25901217 PMCID: PMC4400627 DOI: 10.4253/wjge.v7.i4.381] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/29/2014] [Revised: 12/30/2014] [Accepted: 01/19/2015] [Indexed: 02/05/2023] Open
Abstract
Treatment of pancreatic collections has experienced great progress in recent years with the emergence of alternative minimally invasive techniques comparing to the classic surgical treatment. Such techniques have been shown to improve outcomes of morbidity vs surgical treatment. The recent emergence of endoscopic drainage is noteworthy. The advent of endoscopic ultrasonography has been crucial for treatment of these specific lesions. They can be characterized, their relationships with neighboring structures can be evaluated and the drainage guided by this technique has been clearly improved compared with the conventional endoscopic drainage. Computed tomography is the technique of choice to characterize the recently published new classification of pancreatic collections. For this reason, the radiologist’s role establishing and classifying in a rigorously manner the collections according to the new nomenclature is essential to making therapeutic decisions. Ideal scenario for comprehensive treatment of these collections would be those centers with endoscopic ultrasound and interventional radiology expertise together with hepatobiliopancreatic surgery. This review describes the different types of pancreatic collections: acute peripancreatic fluid collection, pancreatic pseudocysts, acute necrotic collection and walled-off necrosis; the indications and the contraindications for endoscopic drainage, the drainage technique and their outcomes. The integrated management of pancreatic collections according to their type and evolution time is discussed.
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Dhingra R, Srivastava S, Behra S, Vadiraj PK, Venuthurimilli A, Dash NR, Madhusudhan KS, Gamanagatti SR, Garg PK. Single or multiport percutaneous endoscopic necrosectomy performed with the patient under conscious sedation is a safe and effective treatment for infected pancreatic necrosis (with video). Gastrointest Endosc 2015; 81:351-9. [PMID: 25293824 DOI: 10.1016/j.gie.2014.07.060] [Citation(s) in RCA: 42] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/26/2013] [Accepted: 07/24/2014] [Indexed: 01/06/2023]
Abstract
BACKGROUND Infected pancreatic necrosis (IPN) is a dreaded adverse event of acute pancreatitis (AP). Most patients with IPN require drainage and necrosectomy, preferably by a minimally invasive method. OBJECTIVE To study the success and safety of an alternative form of minimally invasive necrosectomy for IPN. DESIGN Observational study. SETTING Tertiary care academic center. PATIENTS Consecutive patients with IPN formed the study group. INTERVENTION Patients with IPN were initially treated conservatively including percutaneous drainage. Those who failed to improve underwent percutaneous endoscopic necrosectomy (PEN). Single- or multiport PEN was performed by using a flexible endoscope through the percutaneous tract. PEN involved vigorous lavage and suction followed by necrosectomy. Multiple sessions were undertaken depending on the size and number of collections and the amount of necrotic debris. MAIN OUTCOME MEASUREMENTS Control of sepsis and resolution of collection(s) without the need for surgical necrosectomy. RESULTS During the period from October 2012 to July 2013, 165 patients (mean age, 38.82 ± 14.99 years; 119 male patients) were studied. Of them, 103 patients had necrotizing pancreatitis and IPN had developed in 74. Of these 74 patients with IPN, 15 underwent PEN after a mean interval of 39.2 days. Fourteen of the 15 patients improved after a mean of 5 sessions of PEN. Two of 15 patients had minor adverse events: self-limiting bleeding and pancreatic fistula in 1 patient each. One patient required surgery but died of organ failure. LIMITATIONS Lack of a control arm. CONCLUSION PEN is a safe and effective minimally invasive technique for necrosectomy for IPN.
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Affiliation(s)
- Rajan Dhingra
- Department of Gastroenterology, All India Institute of Medical Sciences, New Delhi, India
| | - Saurabh Srivastava
- Department of Gastroenterology, All India Institute of Medical Sciences, New Delhi, India
| | - Sanatan Behra
- Department of Gastroenterology, All India Institute of Medical Sciences, New Delhi, India
| | | | - Arun Venuthurimilli
- Department of Gastrointestinal Surgery, All India Institute of Medical Sciences, New Delhi, India
| | - Nihar Ranjan Dash
- Department of Gastrointestinal Surgery, All India Institute of Medical Sciences, New Delhi, India
| | | | | | - Pramod Kumar Garg
- Department of Gastroenterology, All India Institute of Medical Sciences, New Delhi, India
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Wittel UA, Schmidt AI, Poxleitner PJ, Seifert GJ, Chikhladze S, Puolakkainen P, Hopt UT, Kylänpää L. The chemokine ligand CXCL16 is an indicator of bacterial infection in necrotizing pancreatitis. Pancreatology 2015; 15:124-30. [PMID: 25661686 DOI: 10.1016/j.pan.2015.01.004] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/17/2014] [Revised: 01/13/2015] [Accepted: 01/14/2015] [Indexed: 12/11/2022]
Abstract
OBJECTIVES Current guidelines tell us that intervention in severe necrotizing pancreatitis ought to be performed as late as possible. However, when pancreatic necrosis becomes infected, the necrotic tissue needs to be removed. Unfortunately, bacterial infection can only be proven by invasive methods. METHODS Necrotizing pancreatitis with sterile or infected necrosis was induced in mice. Mice serum samples were examined by antibody-based protein array. After identifying candidate proteins that showed strong regulation, the serum concentration of these proteins was examined by sandwich ELISA. Then, human serum samples were collected from patients with mild pancreatitis, severe pancreatitis with and without pancreatic necrosis and patients with microbiologically proven infection of pancreatic necrosis. These serum samples were then analyzed by sandwich ELISA. RESULTS In mice 6 proteins were strongly up-regulated and were further investigated by ELISAs. Of these proteins, CXCL16 and TRANCE (RANKL) concentrations were analyzed in human serum samples. CXCL16 and TRANCE were increased in patients with pancreatic necrosis and abdominal infection. Receiver operated characteristics showed that CXCL16 was superior in predicting infected pancreatic necrosis when compared to C-reactive protein and TRANCE. CONCLUSIONS Serum CXCL16 is increased in severe pancreatitis with infected pancreatic necrosis and identifies patients who benefit from surgical necrosectomy.
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Affiliation(s)
- Uwe A Wittel
- Department of General and Visceral Surgery, Universitätsklinik Freiburg, Freiburg, Germany.
| | - Andrea I Schmidt
- Department of General and Visceral Surgery, Universitätsklinik Freiburg, Freiburg, Germany
| | - Philipp J Poxleitner
- Department of General and Visceral Surgery, Universitätsklinik Freiburg, Freiburg, Germany
| | - Gabriel J Seifert
- Department of General and Visceral Surgery, Universitätsklinik Freiburg, Freiburg, Germany
| | - Sophia Chikhladze
- Department of General and Visceral Surgery, Universitätsklinik Freiburg, Freiburg, Germany
| | - Pauli Puolakkainen
- Department of Surgery, Helsinki University Central Hospital, Helsinki, Finland
| | - Ulrich T Hopt
- Department of General and Visceral Surgery, Universitätsklinik Freiburg, Freiburg, Germany
| | - Leena Kylänpää
- Department of Surgery, Helsinki University Central Hospital, Helsinki, Finland
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Wroński M, Cebulski W, Pawłowski W, Krasnodębski IW, Słodkowski M. Walled-off necrosis: safety of watchful waiting. Dig Dis Sci 2015; 60:1081-6. [PMID: 25326117 PMCID: PMC4408372 DOI: 10.1007/s10620-014-3395-9] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/25/2014] [Accepted: 10/08/2014] [Indexed: 12/11/2022]
Abstract
BACKGROUND Asymptomatic pancreatic necrosis should be managed conservatively, regardless of its extent. However, late sequelae and safety of non-interventional management in patients with asymptomatic walled-off necrosis remain unclear. AIMS The purpose of this study was to report the clinical outcome of outpatient expectant management in a cohort of patients with walled-off necrosis who were discharged asymptomatic after an episode of acute pancreatitis. METHODS Sixteen patients with walled-off necrosis asymptomatic at discharge were identified retrospectively from a single institution. Data were analyzed for the type of complications, their incidence and treatment. RESULTS Seven of 16 patients (44 %) did not experience any complications during a median follow-up of 17 months. Nine of 16 patients (56 %) became symptomatic or developed complications within a median follow-up of 49 days after discharge. The most common complication was infection of pancreatic necrosis which occurred in 7 of 9 patients. Six of these patients were successfully treated with minimally invasive techniques. In 5 of 7 patients, infection of necrosis was due to oral commensal bacteria. Acute intracavitary hemorrhage and intractable abdominal pain developed in one patient each. There was no mortality in this series. CONCLUSIONS Outpatient watchful waiting can be used safely in patients with asymptomatic walled-off necrosis, although nearly half of them eventually develop complications which require interventional treatment. Most late infections of pancreatic necrosis are probably due to a blood-borne transmission of oral commensal bacteria.
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Affiliation(s)
- Marek Wroński
- Department of General, Gastroenterological and Oncological Surgery, Medical University of Warsaw, ul. Banacha 1A, 02-097 Warsaw, Poland
| | - Włodzimierz Cebulski
- Department of General, Gastroenterological and Oncological Surgery, Medical University of Warsaw, ul. Banacha 1A, 02-097 Warsaw, Poland
| | - Waldemar Pawłowski
- Department of General, Gastroenterological and Oncological Surgery, Medical University of Warsaw, ul. Banacha 1A, 02-097 Warsaw, Poland
| | - Ireneusz W. Krasnodębski
- Department of General, Gastroenterological and Oncological Surgery, Medical University of Warsaw, ul. Banacha 1A, 02-097 Warsaw, Poland
| | - Maciej Słodkowski
- Department of General, Gastroenterological and Oncological Surgery, Medical University of Warsaw, ul. Banacha 1A, 02-097 Warsaw, Poland
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Single-stage cholecystectomy at the time of pancreatic necrosectomy is safe and prevents future biliary complications: a 20-year single institutional experience with 217 consecutive patients. J Gastrointest Surg 2015; 19:32-7; discussion 37-8. [PMID: 25270594 DOI: 10.1007/s11605-014-2650-x] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/29/2014] [Accepted: 08/28/2014] [Indexed: 01/31/2023]
Abstract
INTRODUCTION Current guidelines recommend cholecystectomy (CCY) during the index admission for mild to moderate biliary pancreatitis as delayed CCY is associated with a substantial risk of recurrent biliary events. Delayed CCY is recommended in severe pancreatitis. The optimal timing of CCY in necrotizing pancreatitis, however, has not been well studied. We sought to determine the safety of single-stage CCY performed at the time of necrosectomy and its effectiveness in preventing subsequent biliary complications. METHODS We retrospectively queried our institutional database of patients who underwent pancreatic necrosectomy for necrotizing pancreatitis from 1992 to 2012. RESULTS We identified 217 consecutive patients who underwent pancreatic necrosectomy during the study period. The most common etiologies of pancreatitis were biliary (41 %) and alcoholic (24%), with a median computed tomography (CT) severity index score of 6 ± 1.6 and a 63.6% incidence of infected necrosis. Ninety-eight patients had undergone CCY prior to necrosectomy. Seventy patients (59% of those with gallbladders in situ) underwent CCY at the time of pancreatic necrosectomy. CCY was not performed in the remaining 49 due to a clear non-biliary etiology (35%), technical difficulty (29%), intraoperative hemodynamic instability (18%), or surgeon preference (18%). Postoperative morbidity and mortality was no different between the CCY and no CCY groups, with no bile duct injury or bile leaks in patients undergoing CCY at the time of necrosectomy. Of the patients undergoing CCY, 43% of patients without cholelithiasis or biliary sludge on preoperative imaging had gallstones or sludge identified pathologically after single-stage CCY. Of those who did not receive a single-stage CCY, biliary complications developed in 17 (35%) of patients (21% cholecystitis, 14% recurrent gallstone pancreatitis) at a median time to incidence of 10 months. Seventeen (35%) patients eventually received a postnecrosectomy cholecystectomy, of which 75% required an open procedure. CONCLUSION Single-stage CCY at the time of pancreatic necrosectomy is safe in selected patients and should be performed if technically feasible to prevent future biliary complications and reduce the need for a subsequent separate, often open, CCY.
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