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Lu J, Zheng Z, Ding Y, Qu Y, Mei W, Fang Z, Qu C, Feng Y, Guo Y, Gao C, Cao F, Li F. Characteristics and Incidence of Colon Complication in Necrotizing pancreatitis: A Propensity Score-Matched Study. J Inflamm Res 2023; 16:127-144. [PMID: 36660375 PMCID: PMC9843501 DOI: 10.2147/jir.s388305] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/19/2022] [Accepted: 12/24/2022] [Indexed: 01/11/2023] Open
Abstract
Objective To clarify the incidence of colonic complications in patients with NP and their impact on prognosis. Methods The clinical data of NP patients admitted to the Department of General Surgery of Xuanwu Hospital, Capital Medical University from January 2014 to December 2020 were retrospectively analyzed. Patients were grouped according to the presence or absence of colonic complications, and the clinical prognosis of the two groups was analyzed after matching using a 1:1 propensity score, The primary study endpoint was patient mortality during hospitalization. Data are reported as median (range) or percentage of patients (%). Results A total of 306 patients with NP were included in this study, and the incidence of colonic complications was 12.4%, including 15 cases of colonic obstruction, 17 cases of colonic fistula, and 9 cases of colonic hemorrhage. Before matching, patients in the colonic group had severe admissions and poor clinical outcomes (P<0.05). After matching, the baseline data and clinical characteristics at admission were comparable between the two groups of patients. In terms of clinical outcomes, although the mortality was similar in the two groups (P>0.05), but patients in the colonic group were more likely to have multiorgan failure, length of nutrition support, number of minimally invasive interventions, number of extra-pancreatic infections, length of ICU stay and total length of stay were significantly higher than those of patients in the group without colonic complications (P<0.05). During long-term follow-up, patients in the colonic group were more likely to develop recurrent pancreatitis. Conclusion About 12.4% of NP patients developed colonic complications, and after PSM it was found that colonic complications only led to a longer hospital stay and an increased number of clinical interventions in NP patients and did not increase the mortality.
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Affiliation(s)
- Jiongdi Lu
- Clinical Center of Acute Pancreatitis, Capital Medical University, Beijing, People’s Republic of China,Department of General Surgery, Xuanwu Hospital, Capital Medical University, Beijing, People’s Republic of China
| | - Zhi Zheng
- Department of General Surgery, Beijing Friendship Hospital, Capital Medical University, Beijing, People’s Republic of China
| | - Yixuan Ding
- Clinical Center of Acute Pancreatitis, Capital Medical University, Beijing, People’s Republic of China,Department of General Surgery, Xuanwu Hospital, Capital Medical University, Beijing, People’s Republic of China
| | - Yuanxu Qu
- Clinical Center of Acute Pancreatitis, Capital Medical University, Beijing, People’s Republic of China,Department of General Surgery, Xuanwu Hospital, Capital Medical University, Beijing, People’s Republic of China
| | - Wentong Mei
- Clinical Center of Acute Pancreatitis, Capital Medical University, Beijing, People’s Republic of China,Department of General Surgery, Xuanwu Hospital, Capital Medical University, Beijing, People’s Republic of China
| | - Zhen Fang
- Clinical Center of Acute Pancreatitis, Capital Medical University, Beijing, People’s Republic of China,Department of General Surgery, Xuanwu Hospital, Capital Medical University, Beijing, People’s Republic of China
| | - Chang Qu
- Clinical Center of Acute Pancreatitis, Capital Medical University, Beijing, People’s Republic of China,Department of General Surgery, Xuanwu Hospital, Capital Medical University, Beijing, People’s Republic of China
| | - Yulu Feng
- Chui Yang Liu Hospital Affiliated Tsinghua University, Beijing, People’s Republic of China
| | - Yulin Guo
- Clinical Center of Acute Pancreatitis, Capital Medical University, Beijing, People’s Republic of China,Department of General Surgery, Xuanwu Hospital, Capital Medical University, Beijing, People’s Republic of China
| | - Chongchong Gao
- Clinical Center of Acute Pancreatitis, Capital Medical University, Beijing, People’s Republic of China,Department of General Surgery, Xuanwu Hospital, Capital Medical University, Beijing, People’s Republic of China
| | - Feng Cao
- Clinical Center of Acute Pancreatitis, Capital Medical University, Beijing, People’s Republic of China,Department of General Surgery, Xuanwu Hospital, Capital Medical University, Beijing, People’s Republic of China,Feng Cao, Clinical Center of Acute Pancreatitis, Department of General Surgery, Xuanwu Hospital of Capital Medical University, No. 45, Changchun Street, Xicheng District, Beijing, 100053, People’s Republic of China, Email
| | - Fei Li
- Clinical Center of Acute Pancreatitis, Capital Medical University, Beijing, People’s Republic of China,Department of General Surgery, Xuanwu Hospital, Capital Medical University, Beijing, People’s Republic of China,Correspondence: Fei Li, Clinical Center of Acute Pancreatitis, Department of General Surgery, Department of Surgery, Xuanwu Hospital of Capital Medical University, No. 45, Changchun Street, Xicheng District, Beijing, 100053, People’s Republic of China, Tel +86-10-83198731, Fax +86-10-83198868, Email
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Zaafouri H, Dawood A, Mesbahi M, Alotaibi T, Ahmadi MAL, Aiat M. Descending colon fistula: Unusual complication of severe acute pancreatitis a case report. Ann Med Surg (Lond) 2022; 75:103426. [PMID: 35386763 PMCID: PMC8977942 DOI: 10.1016/j.amsu.2022.103426] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/11/2021] [Revised: 02/17/2022] [Accepted: 02/27/2022] [Indexed: 02/08/2023] Open
Abstract
Introduction The incidence of colonic complications from acute pancreatitis (AP) and severe AP are 3.3% and 15%, respectively. We report a case of descending colon fistula secondary to severe AP and its management. Case presentation We report a case of a 35-year-old male hospitalized in our department for severe acute pancreatitis (grade E of Balthazar classification). Initially, the evolution was favorable under medical management. Two months later, he was readmitted for infection of the necrosis with a descending colon fistula. As we did not have the possibility of performing a CT scan drainage, our plan was to do surgical drainage under general anesthesia. Conclusion The colonic involvement following AP or severe AP is rare and difficult to diagnoses. Conservative treatment when some conditions are available should be the best choice; it is associated with lower risk of morbidity and mortality. Knowledge about colonic complications from AP has been limited to few case reports. Thus diagnostic and management dilemmas continue to persist. The clinical presentation can be variable. Nonspecific and could occur quite late in the disease process. For the management. There are no evidence-based guidelines.
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Affiliation(s)
- Haithem Zaafouri
- Department of General Surgery, King Abdul Aziz Hospital, Jeddah, Saudi Arabia
| | - Atif Dawood
- Department of General Surgery, King Abdul Aziz Hospital, Jeddah, Saudi Arabia
| | - Meriam Mesbahi
- General Surgery Department, Habib Thameur Hospital, Tunis, Tunisia
| | - Turki Alotaibi
- Department of General Surgery, King Abdul Aziz Hospital, Jeddah, Saudi Arabia
| | - Mourouj A L Ahmadi
- Department of General Surgery, King Abdul Aziz Hospital, Jeddah, Saudi Arabia
| | - Maged Aiat
- Department of General Surgery, King Abdul Aziz Hospital, Jeddah, Saudi Arabia
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3
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Zaafouri H, Dawood A, Mesbahi M, Alotaibi T, Ahmadi MA, Aiat M. Descending colon fistula: Unusual complication of severe acute pancreatitis a case report. Ann Med Surg (Lond) 2022. [DOI: https://doi.org/10.1016/j.amsu.2022.103426] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022] Open
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4
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Jena SS, Obili RCR, Das SAP, Ray S, Yadav A, Mehta NN, Nundy S. Intestinal obstruction in a tertiary care centre in India: Are the differences with the western experience becoming less? Ann Med Surg (Lond) 2021; 72:103125. [PMID: 34925821 PMCID: PMC8648950 DOI: 10.1016/j.amsu.2021.103125] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/07/2021] [Revised: 11/26/2021] [Accepted: 11/30/2021] [Indexed: 11/29/2022] Open
Abstract
Background Patients with intestinal obstruction consist of a major proportion of emergency room visits and the complication is associated with a significant morbidity and mortality. It has a diverse aetiology which varies from country to country. In developed countries it is mainly due to adhesions and in developing countries due to obstructed hernias. Although there are numerous studies from the western world on this subject there have been few recent publications from the developing world. Patients and methods We retrospectively analyzed all the patients admitted with intestinal obstruction to our department from January 1996 to December 2019. Their demographic data, duration of symptoms before presenting to the hospital and interval between admission and surgery were noted along with the cause and level of obstruction. The type of procedure, post-operative complications, mortality or whether re-exploration was done were also noted. Post-operative complications were graded according to the Clavien Dindo classification. Results A total of 986 patients presented with intestinal obstruction during this period out of which 743 patients underwent surgery. The commonest cause of obstruction was adhesions in 273 (36.7%) – the proportion increased significantly from 23% in 1996–2004 to 51.6% in 2013–2019. This was followed by carcinoma [130(17.5%)], tuberculosis [111(14.9%)], strictures [94(12.7%)] and hernia (5.4%). Colorectal surgery was the most common previous procedure in the adhesions group [85(31.1%)].The overall operative mortality was 41 (5.5%). Conclusion The aetiology of intestinal obstruction in our hospital is now mainly due to adhesions and is thus shifting towards the western pattern. But tuberculosis and obstructed inguinal hernias still constitute of a sizable proportion of our patients. Post-operative adhesions have now become a common cause of intestinal obstruction our tertiary care centre situated in a developing country. These were most commonly preceded by operations on the colon and rectum. Our overall mortality rate was comparable with those reported from the west. Old age, malignancy and strangulation were associated with a higher risk of mortality as has been the experience from other centres. Compared to Western reports our patient population was younger, males predominated. Although the proportion of patients with adhesions is rising tuberculosis continues to be an important cause for intestinal obstruction.
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Yoshikawa K, Lefor AK, Kubota T. Acute pancreatitis followed by retroperitoneal perforation of the descending colon and a duodenal fistula: Report of a case. Int J Surg Case Rep 2020; 72:599-602. [PMID: 32698297 PMCID: PMC7332503 DOI: 10.1016/j.ijscr.2020.05.095] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/26/2020] [Accepted: 05/30/2020] [Indexed: 12/11/2022] Open
Abstract
Retroperitoneal perforation of the colon must be considered in patients with acute pancreatitis. The most common site of perforation is the transverse and descending colon. Retroperitoneal drainage may lead to expansion of the perforation site, necessitating a diverting stoma.
Introduction There are several reports of colon perforation in patients with acute pancreatitis, but the mechanism is not understood. We describe a patient with acute pancreatitis followed by retroperitoneal perforation of the descending colon and a duodenal fistula. Case presentation A 51-year-old male presented with acute pancreatitis. He was hemodynamically unstable, had respiratory failure on admission and was treated in the intensive care unit (ICU). He recovered and left the ICU on day 13. Although his general condition improved, a computed tomography (CT) scan showed air and fluid in the left retroperitoneum. Gastrografin enema and CT scan showed extraluminal leakage in the descending colon and retroperitoneal drainage was performed on day 27. After drainage, there was continuous voluminous feculent discharge, and a loop ileostomy was performed on day 34. A repeat CT scan revealed ascites. A percutaneous catheter injected with contrast showed a duodenal fistula. After drainage, the fever resolved and the patient was discharged on hospital day 106. Discussion Although there is no clear mechanism of colonic perforation in patients with acute pancreatitis, one hypothesis is that ischemia secondary to inflammation caused by pancreatitis plays a role. The involved area is usually in the watershed areas of the colon. Retroperitoneal drainage of the colon perforation may have necessitated creation of a diverting loop ileostomy. Conclusion Retroperitoneal colon perforation must be considered in patients with acute pancreatitis.
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Affiliation(s)
- Kentaro Yoshikawa
- Department of Surgery, Tokyo Bay Urayasu Ichikawa Medical Center, 3-4-32 Toudaijima, Urayasu, Chiba 279-0001, Japan.
| | - Alan Kawarai Lefor
- Department of Surgery, Jichi Medical University, 3311-1, Yakushiji, Shimotsuke, Tochigi 329-0498, Japan
| | - Tadao Kubota
- Department of Surgery, Tokyo Bay Urayasu Ichikawa Medical Center, 3-4-32 Toudaijima, Urayasu, Chiba 279-0001, Japan
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Niu DG, Li WQ, Huang Q, Yang F, Tian WL, Li C, Ding LA, Fang HC, Zhao YZ. Open necrosectomy combined with continuous positive drainage and prophylactic diverting loop ileostomy for late infected pancreatic necrosis: a retrospective cohort study. BMC Gastroenterol 2020; 20:212. [PMID: 32640995 PMCID: PMC7341608 DOI: 10.1186/s12876-020-01343-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/20/2019] [Accepted: 06/09/2020] [Indexed: 12/02/2022] Open
Abstract
Background To evaluate an innovative open necrosectomy strategy with continuous positive drainage and prophylactic diverting loop ileostomy for the management of late infected pancreatic necrosis (LIPN). Methods Consecutive patients were divided into open necrosectomy (ON) group (n = 23), open necrosectomy with colonic segment resection (ON+CSR) group (n = 8) and open necrosectomy with prophylactic diverting loop ileostomy (ON+PDLI) group (n = 11). Continuous positive drainage (CPD) via double-lumen irrigation–suction tube (DLIST) was performed in ON+PDLI group. The primary endpoints were duration of organ failure after surgery, postoperative complication, the rate of re-surgery and mortality. The secondary endpoints were duration of hospitalization, cost, time interval between open surgery and total enteral nutrition (TEN). Results The recovery time of organ function in ON+PDLI group was shorter than that in other two groups. Colonic complications occurred in 13 patients (56.5%) in the ON group and 3 patients (27.3%) in the ON+PDLI group (p = 0.11). The length of stay in the ON+PDLI group was shorter than the ON group (p = 0.001). The hospitalization cost in the ON+PDLI group was less than the ON group (p = 0.0052). Conclusion ON+PDLI can avoid the intestinal dysfunction, re-ileostomy, the resection of innocent colon and reduce the intraoperative trauma. Despite being of colonic complications before or during operation, CPD + PDLI may show superior effectiveness, safety, and convenience in LIPN.
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Affiliation(s)
- Dong-Guang Niu
- Department of General Surgery, Jinling clinical college of Nanjing Medical University, Nanjing, 210002, Jiangsu, China.,Gastrointestinal Surgery Department, Affiliated Hospital of Qingdao University, Qingdao, 266000, Shandong, China
| | - Wei-Qin Li
- Department of General Surgery, Jinling clinical college of Nanjing Medical University, Nanjing, 210002, Jiangsu, China
| | - Qian Huang
- Department of General Surgery, Jinling clinical college of Nanjing Medical University, Nanjing, 210002, Jiangsu, China
| | - Fan Yang
- Department of General Surgery, Jinling clinical college of Nanjing Medical University, Nanjing, 210002, Jiangsu, China
| | - Wei-Liang Tian
- Department of General Surgery, Jinling clinical college of Nanjing Medical University, Nanjing, 210002, Jiangsu, China
| | - Chen Li
- Oncology Department, Xintai people's Hospital, Tai'an, 271200, Shandong, China
| | - Lian-An Ding
- Gastrointestinal Surgery Department, Affiliated Hospital of Qingdao University, Qingdao, 266000, Shandong, China
| | - Hong-Chun Fang
- Gastrointestinal Surgery Department, Affiliated Hospital of Qingdao University, Qingdao, 266000, Shandong, China
| | - Yun-Zhao Zhao
- Department of General Surgery, Jinling clinical college of Nanjing Medical University, Nanjing, 210002, Jiangsu, China. .,Department of General Surgery, Jinling clinical college of Nanjing Medical University, 305 East Zhongshan Road, Nanjing, 210000, Jiangsu, China.
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7
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Berman CF, Lobetti RG, Lindquist E. Comparison of clinical findings in 293 dogs with suspect acute pancreatitis: Different clinical presentation with left lobe, right lobe or diffuse involvement of the pancreas. J S Afr Vet Assoc 2020; 91:e1-e10. [PMID: 32370532 PMCID: PMC7203193 DOI: 10.4102/jsava.v91i0.2022] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/20/2019] [Revised: 11/29/2019] [Accepted: 02/12/2020] [Indexed: 12/13/2022] Open
Abstract
Pancreatitis is a common clinical condition seen in companion animals. The correlation of the region of the pancreas affected to the presentation of clinical signs has not been previously described. A retrospective study on the clinical findings in 293 client-owned dogs diagnosed with suspect pancreatitis based on history, clinical signs, laboratory testing and abdominal ultrasonography was performed. Based on ultrasonography, dogs were divided into three groups: group 1: 41 dogs with ultrasonographic changes consistent with pancreatitis within the left lobe of the pancreas; group 2: 105 dogs with ultrasonographic changes compatible with pancreatitis within the right lobe of the pancreas; and group 3: 147 dogs with ultrasonographic evidence of diffuse pancreatitis. No significant differences regarding age, breed and sex were evident. Furthermore, statistical significance was demonstrated with the presence of pain in group 3; poor appetite in groups 2 and 3; and vomiting and diarrhoea in group 3. Pain is expected to occur with a higher frequency in diffuse pancreatitis, but it is not a common clinical sign. This may represent a more severe form of the disease when the pancreas is diffusely affected. Vomiting was more common than diarrhoea with both clinical signs more prevalent in dogs with diffuse pancreatitis, and this could be ascribed to gastric and intestinal tract involvement. Poor appetite occurred more frequently in dogs with diffuse and right lobe pancreatitis. A possible explanation can be attributed to the fact that the duodenum has many receptors and is referred to as the 'organ of nausea'.
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Affiliation(s)
- Chad F Berman
- Bryanston Veterinary Hospital, Johannesburg, South Africa; and, Department of Companion Animal and Clinical Studies, Onderstepoort.
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Koichopolos J, Keow J, Parfitt J, Yoshy C, Wiseman D, Leslie K. Complete duodenal necrosis associated with non-traumatic duodenal hematoma requiring emergent pancreatico-duodenectomy. Int J Surg Case Rep 2019; 66:53-57. [PMID: 31812122 PMCID: PMC6906656 DOI: 10.1016/j.ijscr.2019.11.026] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/07/2019] [Revised: 08/14/2019] [Accepted: 11/13/2019] [Indexed: 11/21/2022] Open
Abstract
INTRODUCTION Duodenal necrosis is a rare complication of acute pancreatitis but can occur given the shared blood supply to the head of the pancreas and the duodenum. PRESENTATION OF CASE A 55-year-old male presented with acute-on-chronic pancreatitis and a duodenal hematoma. The hematoma expanded to occlude the biliary tree and, shortly after, the duodenum necrosed and perforated. The patient required an emergent pancreaticoduodenectomy performed in two stages. DISCUSSION Surgical management is complex and a difficult challenge for a general surgeon. Many advocate for wide drainage to create a controlled fistula using a malecot through the wall defect/separate duodenotomy/a retrograde jejunostomy tube. This case represents an extreme variation on this issue which was best managed by definitive resection given the extent of the necrosis. CONCLUSION This case report demonstrates that duodenal hematoma and necrosis should be recognized as part of the spectrum of consequences of acute pancreatitis. General surgeons should have a surgical approach to this complication whether that be diversion or definitive resection.
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Affiliation(s)
- Jennifer Koichopolos
- Department of Surgery, London Health Sciences Center, London, ON, Canada; Schulich School of Medicine & Dentistry, Western University, London, ON, Canada.
| | - Jonathan Keow
- Schulich School of Medicine & Dentistry, Western University, London, ON, Canada; Department of Pathology, London Health Sciences Center, London, ON, Canada
| | - Jeremy Parfitt
- Schulich School of Medicine & Dentistry, Western University, London, ON, Canada; Department of Pathology, London Health Sciences Center, London, ON, Canada
| | - Cathy Yoshy
- Schulich School of Medicine & Dentistry, Western University, London, ON, Canada; Department of Radiology, London Health Sciences Center, London, ON, Canada
| | - Daniele Wiseman
- Schulich School of Medicine & Dentistry, Western University, London, ON, Canada; Department of Radiology, London Health Sciences Center, London, ON, Canada
| | - Kenneth Leslie
- Department of Surgery, London Health Sciences Center, London, ON, Canada; Schulich School of Medicine & Dentistry, Western University, London, ON, Canada
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Kimura J, Lefor AK, Fukai S, Kubota T. Use of a stent to treat colonic stenosis secondary to acute pancreatitis: A case report. Int J Surg Case Rep 2019; 61:26-29. [PMID: 31310857 PMCID: PMC6626977 DOI: 10.1016/j.ijscr.2019.06.065] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/19/2019] [Revised: 06/15/2019] [Accepted: 06/30/2019] [Indexed: 11/25/2022] Open
Abstract
A colonic stent was used to treat colonic stenosis secondary to acute pancreatitis. Surgery should be postponed until the inflammation and obstruction improve. Use of enteric stents could be used as a temporizing measure before surgery.
Introduction We report a patient for whom a colonic stent was successfully used to treat colonic stenosis secondary to acute pancreatitis. Presentation of case A 70-year-old male presented with epigastric pain. A choledocholith and bile duct dilatation were found on abdominal computed tomography scan. Endoscopic retrograde cholangiopancreatography was performed and a common bile duct stent was placed. Ten hours after stent placement, severe epigastric pain developed. Contrast enhanced abdominal computed tomography scan revealed increased density of fat tissue around the pancreas. He was diagnosed with severe acute pancreatitis and treated in the intensive care unit. On the twenty-eighth hospital day, he vomited. His abdomen was distended and tender to palpation. Contrast enhanced abdominal computed tomography scan revealed stenosis of the descending colon and proximally dilated colon and small bowel. He was diagnosed with colonic stenosis secondary to acute pancreatitis. A colonic stent was placed in the descending colon. Eight months after this episode, elective subtotal colectomy was performed. The postoperative course was unremarkable. Discussion The overall documented leak rate for segmental colectomy with or without on-table lavage following large bowel obstruction is about 4%. In addition, in the acute phase of severe acute pancreatitis, inflammation makes surgery difficult. Use of enteric stents in patients with pancreatitis could be used as a temporizing measure until the inflammation and obstruction improve. Conclusion Colonic stenting is useful as a bridge to surgery in the management of large bowel obstruction.
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Affiliation(s)
- Jiro Kimura
- Department of Surgery, Tokyo Bay Urayasu Ichikawa Medical Center, Chiba, Japan.
| | | | - Shota Fukai
- Department of Surgery, Tokyo Bay Urayasu Ichikawa Medical Center, Chiba, Japan.
| | - Tadao Kubota
- Department of Surgery, Tokyo Bay Urayasu Ichikawa Medical Center, Chiba, Japan.
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Jang DK, Moon JY, Lee SH, Lee JK. Severe necrotizing pancreatitis after endoscopic papillectomy in a patient with ampullary adenoma. INTERNATIONAL JOURNAL OF GASTROINTESTINAL INTERVENTION 2019. [DOI: 10.18528/ijgii190003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Affiliation(s)
- Dong Kee Jang
- Department Internal Medicine, Dongguk University College of Medicine, Dongguk University Ilsan Hospital, Goyang, Korea
| | - Jeong Yeon Moon
- Department Internal Medicine, Dongguk University College of Medicine, Dongguk University Ilsan Hospital, Goyang, Korea
| | - Sang Hyub Lee
- Department of Internal Medicine and Liver Research Institute, Seoul National University Hospital, Seoul, Korea
| | - Jun Kyu Lee
- Department Internal Medicine, Dongguk University College of Medicine, Dongguk University Ilsan Hospital, Goyang, Korea
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Rashid MU, Hussain I, Jehanzeb S, Ullah W, Ali S, Jain AG, Khetpal N, Ahmad S. Pancreatic necrosis: Complications and changing trend of treatment. World J Gastrointest Surg 2019; 11:198-217. [PMID: 31123558 PMCID: PMC6513789 DOI: 10.4240/wjgs.v11.i4.198] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/12/2019] [Revised: 04/19/2019] [Accepted: 04/23/2019] [Indexed: 02/06/2023] Open
Abstract
Incidence of acute pancreatitis seems to be increasing in the Western countries and has been associated with significantly increased morbidity. Nearly 80% of the patients with acute pancreatitis undergo resolution; some develop complications including pancreatic necrosis. Infection of pancreatic necrosis is the leading cause of death in these patients. A significant portion of these patients needs surgical interventions. Traditionally, the “gold standard” procedure has been the open surgical necrosectomy, which is now being completed by the relatively lesser invasive interventions. Minimally invasive surgical (MIS) procedures include endoscopic drainage, percutaneous image-guided catheter drainage, and retroperitoneal drainage. This review article discusses the open and MIS interventions for pancreatic necrosis with each having its own respective benefits and disadvantages are covered.
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Affiliation(s)
- Mamoon Ur Rashid
- Department of Internal Medicine, Advent Health Graduate Medical Education, Orlando, FL 32804, United States
| | - Ishtiaq Hussain
- Department of Gastroenterology, Cleveland Clinic, Weston, FL 33326, United States
| | - Sundas Jehanzeb
- Department of Gastroenterology, Cleveland Clinic, Weston, FL 33326, United States
| | - Waqas Ullah
- Internal Medicine, Abington Hospital, Abington, PA 19001, United States
| | - Saeed Ali
- Department of Internal Medicine, Advent Health Graduate Medical Education, Orlando, FL 32804, United States
| | - Akriti Gupta Jain
- Department of Internal Medicine, Advent Health Graduate Medical Education, Orlando, FL 32804, United States
| | - Neelam Khetpal
- Department of Internal Medicine, Advent Health Graduate Medical Education, Orlando, FL 32804, United States
| | - Sarfraz Ahmad
- Department of Gynecologic Oncology, Advent Health Cancer Institute, Orlando, FL 32804, United States
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Mandal AK, Kafle P, Puri P, Chaulagai B, Hassan M, Bhattarai B, Kanth R, Gayam V. Acute Pancreatitis Causing Descending Colonic Stricture: A Rare Sequelae. J Investig Med High Impact Case Rep 2019; 7:2324709619834594. [PMID: 30917672 PMCID: PMC6440023 DOI: 10.1177/2324709619834594] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Abstract
An isolated descending colonic stricture is an unlikely complication of acute pancreatitis, with the nonspecific symptoms of colonic stricture making the overall diagnosis difficult. Crohn's disease (CD) and tuberculosis (TB) are the two common etiologies of an isolated colonic stricture and may present similarly to colonic stricture related to acute pancreatitis. Unfortunately, colonoscopy and biopsy often cannot determine the etiology, and surgical resection may be needed to provide both symptomatic relief and confirm the diagnosis. As a result, descending colonic stricture may produce a diagnostic dilemma with CD and TB as all 3 conditions may be radiologically and endoscopically indistinguishable. We describe a young male with weight loss and abdominal pain. TB testing was negative, with radiography and ELISA (enzyme-linked immunosorbent assay) testing supporting a diagnosis of the CD. The patient was initiated on sulfasalazine but worsened over the next month. Further investigations revealed that the patient had descending colonic stricture without CD. Therefore, the stricture's etiology was most likely related to an episode of acute pancreatitis the patient had 2 months before admission and was found to have left colonic segment adherent to the pancreas eventually requiring segmentectomy. Although the pathophysiology of colonic stricture after pancreatitis is unclear, we speculate that inflammatory injury to the colon is an important component. Finally, we emphasize that colonic stricture is a rare complication of pancreatitis.
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Affiliation(s)
| | | | - Pradip Puri
- 1 Interfaith Medical Center, Brooklyn, NY, USA
| | | | | | | | | | - Vijay Gayam
- 1 Interfaith Medical Center, Brooklyn, NY, USA
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Dhadlie S, Ratnayake S. A rare case report of ascending colon perforation secondary to acute pancreatitis. Int J Surg Case Rep 2019; 55:62-65. [PMID: 30690284 PMCID: PMC6351346 DOI: 10.1016/j.ijscr.2018.12.010] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/14/2018] [Revised: 12/01/2018] [Accepted: 12/22/2018] [Indexed: 12/14/2022] Open
Abstract
INTRODUCTION Severe acute pancreatitis is associated with high morbidity and mortality. This is a result of the development of pancreatic and extra-pancreatic necrosis with subsequent infection which can lead to multiorgan failure. Complications include localized ileus, abscess formation, mechanical obstruction, rupture and perforation into the gastrointestinal tract and fistula formation (Aldridge et al., 1989; Bassi et al., 2001 [1,2]). CASE PRESENTATION A 72 year old man attended the emergency department with acute epigastric pain. Biochemistry results were reviewed with a lipase of 1680 U/L (ref range <60 U/L). He was treated conservatively. He had a labile course throughout his admission and on day 7 he had significant deterioration. Abdominal CT scan demonstrated marked mechanical large bowel obstruction at the level of the sigmoid colon, caecum dilated with features suggestive of ischaemia in the caecal wall and backflow dilatation of the small bowel loops. The patient was transferred to a tertiary centre for subsequent laparotomy and bowel resection. DISCUSSION Colonic complications of acute pancreatitis are uncommon. An analysis of pooled data reports the incidence of colonic complications from acute pancreatitis to be 3.3% and those from severe acute pancreatitis 15% (Bassi et al., 2001 [2]). Knowledge about colonic perforation from acute pancreatitis has been limited to few case reports, thus diagnostic and management dilemmas continue to persist. CONCLUSIONS We report a rare case of ascending colon perforation in severe acute pancreatitis. This is particularly unusual given the anatomical propensity for splenic flexure involvement or transverse colon involvement being noted in literature. This highlights the high index of suspicion required for colonic complications given the varied, non-specific and often delayed presentation of complications.
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Affiliation(s)
- Sunny Dhadlie
- Caboolture Hospital, 120 McKean Street, 4510 Queenland, Australia.
| | - Sujith Ratnayake
- Caboolture Hospital, 120 McKean Street, 4510 Queenland, Australia.
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Aldoori J, Cast J, Hunter IA. Percutaneous caecostomy for the management of closed loop large bowel obstruction: A delayed complication of severe gallstone pancreatitis. Ann R Coll Surg Engl 2019; 101:e17-e19. [PMID: 30286633 PMCID: PMC6303819 DOI: 10.1308/rcsann.2018.0164] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 07/13/2018] [Indexed: 11/22/2022] Open
Abstract
Colonic complications following pancreatitis are unusual events ranging from 1% to 15%. In a patient with a hostile abdomen and multiple previous laparotomies, surgical management of a closed-loop large-bowel obstruction risks significant morbidity and mortality for the patient, necessitating other strategies for management. Caecostomy in the management of large bowel obstruction is an often forgotten weapon in the general surgeons' armoury.
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Affiliation(s)
- J Aldoori
- Castle Hill Hospital, Cottingham, UK
| | - J Cast
- Castle Hill Hospital, Cottingham, UK
| | - IA Hunter
- Castle Hill Hospital, Cottingham, UK
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Hozaka Y, Kurahara H, Mataki Y, Kawasaki Y, Iino S, Sakoda M, Mori S, Maemura K, Shinchi H, Natsugoe S. Successful treatment for severe pancreatitis with colonic perforation using video-assisted retroperitoneal debridement: A case report. Int J Surg Case Rep 2018; 52:23-27. [PMID: 30308424 PMCID: PMC6176850 DOI: 10.1016/j.ijscr.2018.09.046] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/20/2018] [Revised: 09/17/2018] [Accepted: 09/24/2018] [Indexed: 12/21/2022] Open
Abstract
Severe acute pancreatitis with necrotizing colonic perforation is refractory and the mortality is high. Step-up approach for severe acute pancreatitis with infectious walled-off necrosis has been increasingly used. We performed percutaneous drainage, ileostomy, and video-assisted retroperitoneal debridement (VARD) as a step-up approach. VARD enable sufficient washing of the abscess and radical debridement of the necrotic tissues under direct view.
Introduction Colorectal complications including penetration and perforation in acute pancreatitis often become severe and fatal. Effective drainage is pivotal for successful treatment. We present a case of large retroperitoneal abscess with colonic necrotizing perforation due to severe acute pancreatitis treated with video-assisted retroperitoneal debridement (VARD) in a step-up approach. Presentation of case A 31-year-old man was admitted to a general hospital with a diagnosis of severe acute pancreatitis. Ten days after onset, he was referred to our hospital for more intensive treatment. On day 16, he experienced melena and shock, and embolization of the three straight arteries of the descending colon was performed. On day 30, percutaneous drainage was performed for large retroperitoneal abscess. On day 36, ileostomy was performed because the drained pus from the retroperitoneal abscess became feces-like. On day 58, VARD was performed to treat the refractory retroperitoneal abscesses causing high systemic inflammation due to insufficient drainage. On day 85, fluoroscopic examination showed disappearance of the abscess cavity. He was transferred to the previous hospital on day 89. Discussion Colonic perforation due to severe acute pancreatitis often causes sepsis and fatal condition of patients, and drainage of the retroperitoneal abscesses via laparotomy is thought to be highly invasive and risky. VARD enables radical necrosectomy and drainage less invasively. Conclusions VARD enabled less invasive treatment for patients with large retroperitoneal abscess due to colonic necrotizing perforation in severe pancreatitis.
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Affiliation(s)
- Yuto Hozaka
- Department of Digestive Surgery, Breast and Thyroid Surgery, Graduate School of Medical Sciences, Kagoshima University, Japan
| | - Hiroshi Kurahara
- Department of Digestive Surgery, Breast and Thyroid Surgery, Graduate School of Medical Sciences, Kagoshima University, Japan.
| | - Yuko Mataki
- Department of Digestive Surgery, Breast and Thyroid Surgery, Graduate School of Medical Sciences, Kagoshima University, Japan
| | - Yota Kawasaki
- Department of Digestive Surgery, Breast and Thyroid Surgery, Graduate School of Medical Sciences, Kagoshima University, Japan
| | - Satoshi Iino
- Department of Digestive Surgery, Breast and Thyroid Surgery, Graduate School of Medical Sciences, Kagoshima University, Japan
| | - Masahiko Sakoda
- Department of Digestive Surgery, Breast and Thyroid Surgery, Graduate School of Medical Sciences, Kagoshima University, Japan
| | - Shinichiro Mori
- Department of Digestive Surgery, Breast and Thyroid Surgery, Graduate School of Medical Sciences, Kagoshima University, Japan
| | - Kosei Maemura
- Department of Digestive Surgery, Breast and Thyroid Surgery, Graduate School of Medical Sciences, Kagoshima University, Japan
| | | | - Shoji Natsugoe
- Department of Digestive Surgery, Breast and Thyroid Surgery, Graduate School of Medical Sciences, Kagoshima University, Japan
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Colopancreatic Fistula: An Uncommon Complication of Recurrent Acute Pancreatitis. Case Rep Gastrointest Med 2018; 2018:4521632. [PMID: 29785309 PMCID: PMC5892304 DOI: 10.1155/2018/4521632] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/04/2017] [Revised: 01/28/2018] [Accepted: 02/22/2018] [Indexed: 11/24/2022] Open
Abstract
Colonic complications, including colopancreatic fistulas (CPFs), are uncommon after acute and chronic pancreatitis. However, they have been reported and are serious. CPFs are less likely to close spontaneously and are associated with a higher risk of complications. Therefore, more definitive treatment is required that includes surgical and endoscopic options. We present a case of a 62-year-old male patient with a history of heavy alcohol intake and recurrent acute pancreatitis who presented with a 6-month history of watery diarrhea and abdominal pain. His abdominal imaging showed a possible connection between the colon and the pancreas. A further multidisciplinary workup by the gastroenterology and surgery teams, including endoscopic ultrasound, endoscopic retrograde cholangiopancreatography, and colonoscopy, resulted in a diagnosis of CPF. A distal pancreatectomy and left hemicolectomy were performed, and the diagnosis of CPF was confirmed intraoperatively. The patient showed improvement afterward.
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El Boukili I, Boschetti G, Belkhodja H, Kepenekian V, Rousset P, Passot G. Update: Role of surgery in acute necrotizing pancreatitis. J Visc Surg 2017; 154:413-420. [PMID: 29113713 DOI: 10.1016/j.jviscsurg.2017.06.008] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
Acute necrotizing pancreatitis is a prevalent disease with high morbidity and mortality. The development of radiologic and endoscopic techniques to manage pancreatic necrosis commands a multidisciplinary approach, which has considerably decreased the need for laparotomy. The objective of this update is to define the role of surgery in the multidisciplinary approach to management of necrotizing acute pancreatitis.
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Affiliation(s)
- I El Boukili
- Service de chirurgie générale, endocrinienne et digestive, hospices civils de Lyon, CHU Lyon Sud, 165, chemin du grand-revoyet, 69495 Pierre Bénite cedex, France.
| | - G Boschetti
- Service de gastro-entérologie et radiologie, hospices civils de Lyon, centre hospitalier Lyon Sud, 69495 Pierre-Bénite, France.
| | - H Belkhodja
- Service de gastro-entérologie et radiologie, hospices civils de Lyon, centre hospitalier Lyon Sud, 69495 Pierre-Bénite, France.
| | - V Kepenekian
- Service de chirurgie générale, endocrinienne et digestive, hospices civils de Lyon, CHU Lyon Sud, 165, chemin du grand-revoyet, 69495 Pierre Bénite cedex, France; Université Lyon 1, EMR 37-38, 69000 Lyon, France.
| | - P Rousset
- Université Lyon 1, EMR 37-38, 69000 Lyon, France; Centre hospitalier Lyon Sud, hospices civils de Lyon, 69495 Pierre-Bénite, France.
| | - G Passot
- Service de chirurgie générale, endocrinienne et digestive, hospices civils de Lyon, CHU Lyon Sud, 165, chemin du grand-revoyet, 69495 Pierre Bénite cedex, France; Université Lyon 1, EMR 37-38, 69000 Lyon, France.
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18
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Sunkara T, Etienne D, Caughey ME, Gaduputi V. Small Bowel Obstruction Secondary to Acute Pancreatitis. Gastroenterology Res 2017; 10:42-44. [PMID: 28270876 PMCID: PMC5330692 DOI: 10.14740/gr758w] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 01/09/2017] [Indexed: 11/11/2022] Open
Abstract
While an uncommon occurrence, it is possible for patients diagnosed with acute pancreatitis to develop colonic ileus, obstruction, or perforation. By extension, it is also possible to develop a small bowel obstruction following an episode of acute pancreatitis. Here, we present the case of a 44-year-old male, who after repeated attacks of acute pancreatitis, came to the emergency department with continuous, non-bloody vomiting. This patient also complained of both left upper quadrant and epigastric pain, and was subsequently diagnosed with a small bowel obstruction involving the proximal jejunum.
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Affiliation(s)
- Tagore Sunkara
- Department of Gastroenterology and Hepatology, The Brooklyn Hospital Center, Clinical Affiliate of The Mount Sinai Hospital, 121 Dekalb Ave., Brooklyn, NY 11201, USA
| | - Denzil Etienne
- Department of Gastroenterology and Hepatology, The Brooklyn Hospital Center, Clinical Affiliate of The Mount Sinai Hospital, 121 Dekalb Ave., Brooklyn, NY 11201, USA
| | - Megan E Caughey
- New York Institute of Technology College of Osteopathic Medicine, Old Westbury, NY, USA
| | - Vinaya Gaduputi
- Department of Gastroenterology and Hepatology, SBH Health System, 4422 Third Ave., Bronx, NY 10457, USA
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Large Bowel Obstruction, a Delayed Complication of Severe Gallstone Pancreatitis. Case Rep Surg 2016; 2016:1034929. [PMID: 27847668 PMCID: PMC5101381 DOI: 10.1155/2016/1034929] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/21/2016] [Accepted: 10/11/2016] [Indexed: 11/29/2022] Open
Abstract
Colonic complications are rare after acute pancreatitis but are associated with a high mortality. Possible complications include mechanical obstruction, ischaemic necrosis, haemorrhage, and fistula. We report a case of large bowel obstruction in a 31-year-old postpartum female, secondary to severe gallstone pancreatitis. The patient required emergency laparotomy and segmental bowel resection, as well as cholecystectomy. Presentation of obstruction occurs during the acute episode or can be delayed for several weeks. The most common site is the splenic flexure owing to its proximity to the pancreas. Initial management may be conservative, stenting, or surgical. CT is an acceptable baseline investigation in all cases of new onset bowel obstruction. Although bowel obstruction is a rare complication of pancreatitis, clinicians should be aware of it due to its high mortality. Obstruction can occur after a significant delay following the resolution of pancreatitis. Those patients with evidence of colonic involvement on pancreatic imaging warrant further large bowel evaluation. Bowel resection may be required electively or acutely. Colonic stenting has an increasing role in the management of large bowel obstruction but is a modality of treatment that needs further evaluation in this setting.
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20
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Jiang W, Tong Z, Yang D, Ke L, Shen X, Zhou J, Li G, Li W, Li J. Gastrointestinal Fistulas in Acute Pancreatitis With Infected Pancreatic or Peripancreatic Necrosis: A 4-Year Single-Center Experience. Medicine (Baltimore) 2016; 95:e3318. [PMID: 27057908 PMCID: PMC4998824 DOI: 10.1097/md.0000000000003318] [Citation(s) in RCA: 35] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/13/2022] Open
Abstract
Gastrointestinal (GI) fistula is a well-recognized complication of acute pancreatitis (AP). However, it has been reported in limited literature. This study aimed to evaluate the incidence and outcome of GI fistulas in AP patients complicated with infected pancreatic or peripancreatic necrosis (IPN).Between 2010 and 2013 AP patients with IPN who diagnosed with GI fistula in our center were analyzed in this retrospective study. And we also conducted a comparison between patients with and without GI fistula regarding the baseline characteristics and outcomes.Over 4 years, a total of 928 AP patients were admitted into our center, of whom 119 patients with IPN were diagnosed with GI fistula and they developed 160 GI fistulas in total. Colonic fistula found in 72 patients was the most common form of GI fistula followed with duodenal fistula. All duodenal fistulas were managed by nonsurgical management. Ileostomy or colostomy was performed for 44 (61.1%) of 72 colonic fistulas. Twenty-one (29.2%) colonic fistulas were successfully treated by percutaneous drainage or continuous negative pressure irrigation. Mortality of patients with GI fistula did not differ significantly from those without GI fistula (28.6% vs 21.9%, P = 0.22). However, a significantly higher mortality (34.7%) was observed in those with colonic fistula.GI fistula is a common finding in patients of AP with IPN. Most of these fistulas can be successfully managed with different procedures depending on their sites of origin. Colonic fistula is related with higher mortality than those without GI fistula.
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Affiliation(s)
- Wei Jiang
- From the Research Institute of General Surgery, Jinling Hospital, Medical School of Nanjing University, Nanjing, China
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Wei AL, Guo Q, Wang MJ, Hu WM, Zhang ZD. Early complications after interventions in patients with acute pancreatitis. World J Gastroenterol 2016; 22:2828-2836. [PMID: 26973421 PMCID: PMC4778005 DOI: 10.3748/wjg.v22.i9.2828] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/01/2015] [Revised: 11/04/2015] [Accepted: 11/24/2015] [Indexed: 02/06/2023] Open
Abstract
AIM: To identify the possible predictors of early complications after the initial intervention in acute necrotizing pancreatitis.
METHODS: We collected the medical records of 334 patients with acute necrotizing pancreatitis who received initial intervention in our center. Complications associated with predictors were analyzed.
RESULTS: The postoperative mortality rate was 16% (53/334). Up to 31% of patients were successfully treated with percutaneous catheter drainage alone. The rates of intra-abdominal bleeding, colonic fistula, and progressive infection were 15% (50/334), 20% (68/334), and 26% (87/334), respectively. Multivariate analysis indicated that Marshall score upon admission, multiple organ failure, preoperative respiratory infection, and sepsis were the predictors of postoperative progressive infection (P < 0.05). Single organ failure, systemic inflammatory response syndrome upon admission, and C-reactive protein level upon admission were the risk factors of postoperative colonic fistula (P < 0.05). Moreover, preoperative Marshall score, organ failure, sepsis, and preoperative systemic inflammatory response syndrome were the risk factors of postoperative intra-abdominal bleeding (P < 0.05).
CONCLUSION: Marshall score, organ failures, preoperative respiratory infection, sepsis, preoperative systemic inflammatory response syndrome, and C-reactive protein level upon admission are associated with postoperative complications.
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Colonic Necrosis in a 4-Year-Old with Hyperlipidemic Acute Pancreatitis. Case Rep Pediatr 2016; 2016:9123163. [PMID: 26925282 PMCID: PMC4748093 DOI: 10.1155/2016/9123163] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/14/2015] [Revised: 12/17/2015] [Accepted: 12/30/2015] [Indexed: 11/17/2022] Open
Abstract
Here we report the case of a 4-year-old male with severe acute pancreatitis due to hyperlipidemia, who presented with abdominal pain, metabolic abnormalities, and colonic necrosis. This colonic complication was secondary to the extension of a large peripancreatic fluid collection causing direct serosal autodigestion by pancreatic enzymes. Two weeks following the initial presentation, the peripancreatic fluid collection developed into a mature pancreatic pseudocyst, which was percutaneously drained. To our knowledge, this is the youngest documented pediatric case of colonic necrosis due to severe pancreatitis and the first descriptive pediatric case of a colonic complication due to hyperlipidemia-induced acute pancreatitis.
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Nakanishi N, Shimono T, Yamamoto A, Miki Y. CT evaluation and clinical factors predicting delayed colonic perforation following acute pancreatitis. Jpn J Radiol 2015; 34:10-5. [PMID: 26507985 DOI: 10.1007/s11604-015-0491-5] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/24/2015] [Accepted: 10/13/2015] [Indexed: 01/21/2023]
Abstract
PURPOSE Delayed colonic perforation after acute pancreatitis (AP) is a potentially lethal complication. This study investigated the frequency and predictors of delayed colonic perforation (DCP) following AP by reviewing the earliest laboratory data and computed tomography (CT) examination findings after pancreatitis onset. MATERIALS AND METHODS This retrospective study examined 75 consecutive cases of AP treated between April 2009 and April 2014. Laboratory data after onset and imaging features from earliest CT examinations (Balthazar grade, CT Severity Index) were reviewed. To clarify relationships between these data and DCP, univariate analyses were undertaken between perforated and nonperforated groups. RESULTS Delayed colonic perforation occurred in four of the 75 patients (5.3 %). Median duration to perforation after onset was 13 days (range 6-47). All four patients with DCP showed grade E according to Balthazar grade (≥2 peripancreatic collections and/or gas bubbles in or adjacent to pancreas). Univariate analyses identified Balthazar grade E as a risk factor for DCP (p = 0.0087). CONCLUSION Delayed colonic perforation is not uncommon and can occur a week or more after AP. Balthazar grade E on earliest CT after onset represents a risk factor for DCP.
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Affiliation(s)
- Noah Nakanishi
- Department of Diagnostic and Interventional Radiology, Osaka City University Graduate School of Medicine, 1-4-3 Asahi-machi, Abeno-ku, Osaka, 545-8585, Japan.
| | - Taro Shimono
- Department of Diagnostic and Interventional Radiology, Osaka City University Graduate School of Medicine, 1-4-3 Asahi-machi, Abeno-ku, Osaka, 545-8585, Japan.
| | - Akira Yamamoto
- Department of Diagnostic and Interventional Radiology, Osaka City University Graduate School of Medicine, 1-4-3 Asahi-machi, Abeno-ku, Osaka, 545-8585, Japan.
| | - Yukio Miki
- Department of Diagnostic and Interventional Radiology, Osaka City University Graduate School of Medicine, 1-4-3 Asahi-machi, Abeno-ku, Osaka, 545-8585, Japan.
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Lim E, Sundaraamoorthy R, Tan D, Teh HS, Tan TJ, Cheng A. Step-up approach and video assisted retroperitoneal debridement in infected necrotizing pancreatitis: A case complicated by retroperitoneal bleeding and colonic fistula. Ann Med Surg (Lond) 2015; 4:225-9. [PMID: 26587229 PMCID: PMC4624569 DOI: 10.1016/j.amsu.2015.07.005] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/16/2015] [Revised: 07/11/2015] [Accepted: 07/20/2015] [Indexed: 12/12/2022] Open
Abstract
INTRODUCTION Infected Necrotizing Pancreatitis carries a high mortality and necessitates intervention to achieve sepsis control. The surgical strategy for proven infected necrosis has evolved, with abandonment of open necrosectomy to a step-up approach consisting of percutaneous drains and Video-assisted retroperitoneal debridement (VARD). We present a case that underwent VARD complicated by bleeding and colonic perforation and describe its management. PRESENTATION OF CASE A 38 year-old male with acute pancreatitis developed infected necrotizing pancreatitis. Initial treatment was by percutaneous drainage under radiological guidance and intravenous antibiotics. The infected retroperitoneal necrosis was then debrided using gasless laparoscopy through a mini-incision. Post-operatively, he developed peripancreatic bleeding which was controlled with angioembolisation. He also developed a descending colon fistula which was treated with laparotomy and defunctioning loop ileostomy. He recovered and subsequently had his ileostomy closed twelve months later. The colonic fistula recurred and was treated with endoscopic clips and histoacryl glue injection and finally closed. DISCUSSION Step-up approach consists of the 3 D's: Delay, drain and debride. VARD is recommended as it is replicable in general surgical units using standard laparoscopic instruments. Bleeding and colon perforation are potential complications which must have multi-disciplinary input, aggressive resuscitation and timely radiologic intervention. Defunctioning ileostomy is recommended to control sepsis in colonic fistulation. Novel fistula closing methods using endoscopic clips and histoacryl glue are potential treatment options. CONCLUSION Step-up approach and VARD is the new paradigm to treat necrotizing pancreatitis. Complications of bleeding and colon fistula are uncommon and require multi-disciplinary management.
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Affiliation(s)
- Eugene Lim
- Department of Surgery, Khoo Teck Puat Hospital, 90 Yishun Central, Singapore 768828, Singapore
- Corresponding author.
| | - R.S. Sundaraamoorthy
- Department of Surgery, Khoo Teck Puat Hospital, 90 Yishun Central, Singapore 768828, Singapore
| | - David Tan
- Department of Anaesthesia, Khoo Teck Puat Hospital, 90 Yishun Central, Singapore 768828, Singapore
| | - Hui-Seong Teh
- Department of Radiology, Khoo Teck Puat Hospital, 90 Yishun Central, Singapore 768828, Singapore
| | - Tzu-Jen Tan
- Department of Surgery, Khoo Teck Puat Hospital, 90 Yishun Central, Singapore 768828, Singapore
| | - Anton Cheng
- Department of Surgery, Khoo Teck Puat Hospital, 90 Yishun Central, Singapore 768828, Singapore
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Matsubayashi H, Kishida Y, Yoshida Y, Yoshida M, Tanaka Y, Igarashi K, Imai K, Ono H. Autoimmune pancreatitis with colonic stenosis: an unusual complication and atypical pancreatographic finding. BMC Gastroenterol 2014; 14:173. [PMID: 25280867 PMCID: PMC4192343 DOI: 10.1186/1471-230x-14-173] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/18/2014] [Accepted: 09/29/2014] [Indexed: 01/22/2023] Open
Abstract
BACKGROUND Type 1 autoimmune pancreatitis (AIP) often accompanies various systematic disorders such as sclerosing cholangitis, sialoadenitis, retroperitoneal fibrosis, interstitial pneumonitis and nephritis. Although rarely reported in acute pancreatitis, colonic stenosis is an uncommon complication in cases with AIP. CASE PRESENTATION A 69-year-old Japanese man complained of abdominal pain and continuous diarrhea, resistant to intake of antimuscarinic and probiotic agents. A colonoscopy demonstrated a stenosis at the splenic flexure. Computed tomography revealed a focal enlargement of the pancreatic tail with a capsule-like rim, contacting with the descending colon. Endoscopic retrograde pancreatography (ERP) was unable to visualize the main pancreatic duct (MPD) at the pancreatic tail, despite a full contrast injection. A high serum IgG4 level (1060 mg/dL) and exclusion of pancreatic cancer by endoscopic ultrasound guided-fine needle aspiration suggested AIP, but did not fulfill the diagnostic criteria, and steroid therapy was initiated. One month after starting steroid intake, pancreatic swelling was minimized and the MPD was visualized by ERP, fulfilling the international consensus diagnostic criteria (ICDC) of AIP. Colonic stenosis was relieved and the patient's symptoms disappeared. CONCLUSION The present case is the first report of AIP developing colonic stenosis by the inflammatory infiltration. In this case, steroid therapy was effective for the diagnosis and treatment of pancreatic mass involving the descending colon.
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Affiliation(s)
- Hiroyuki Matsubayashi
- Division of Endoscopy, Shizuoka Cancer Center, Nagaizumi, Suntogun, Shizuoka 411-8777, Japan.
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Boopathy V, Balasubramanian P, Alexander T, Koshy R. Spontaneous fistulisation of infected walled-off necrosis (WON) into the duodenum in a patient following acute necrotising pancreatitis. BMJ Case Rep 2014; 2014:bcr-2013-202863. [PMID: 24414192 DOI: 10.1136/bcr-2013-202863] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/26/2022] Open
Abstract
Infected walled-off necrosis (WON), previously referred to by various terminologies including pancreatic abscess, is one of the well-known local complications of acute necrotising pancreatitis. Very rarely they can spontaneously rupture or fistulise into adjacent structures, leading to either further complications or resolution. More often these events lead to complications rather than resolution of the condition. We report a case of an infected WON following an episode of acute necrotising pancreatitis with spontaneous fistulisation into the duodenum resulting in a complete resolution of the symptoms.
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Affiliation(s)
- Vinoth Boopathy
- Department of Gastroenterology, Pondicherry Institute of Medical Sciences, Pondicherry, India
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Successful management of postoperative necrotizing pancreatitis after infrarenal abdominal aortic aneurysm repair. Ann Vasc Surg 2013; 27:1184.e13-6. [PMID: 23953667 DOI: 10.1016/j.avsg.2012.10.028] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/07/2012] [Revised: 10/15/2012] [Accepted: 10/17/2012] [Indexed: 11/23/2022]
Abstract
We present a case of severe necrotizing pancreatitis that developed after elective repair of an abdominal aortic aneurysm. Surgeons are confronted in cases of postoperative acute pancreatitis with the dilemma of potential intraabdominal infection and the high risk of a subsequent infection of the retroperitoneal synthetic material. The therapeutic options range from a restrictive regime to radical necrosectomy and multivisceral resection.
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Fei JZ, DeMuro JP. Percutaneous endoscopic gastrostomy in the open abdomen patient. JPEN J Parenter Enteral Nutr 2012; 37:695-6. [PMID: 23114265 DOI: 10.1177/0148607112465437] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Nutrition support of critically ill patients is an integral element to their multimodal care. We describe the placement of a percutaneous endoscopic gastrostomy (PEG) for long-term enteral access in a patient with an open abdomen. To our knowledge, this is the third successfully reported case that demonstrates the viability of PEG in this uncommon population. In critically ill and malnourished surgical patients with contraindications for immediate abdominal closure, PEG should be strongly considered as a procedure for enteral feedings.
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Nagpal AP, Soni H, Haribhakti S. Severe Colonic Complications requiring Sub-Total Colectomy in Acute Necrotizing Pancreatitis-A Retrospective Study of 8 Patients. Indian J Surg 2012; 77:3-6. [PMID: 25829703 DOI: 10.1007/s12262-012-0717-z] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/25/2010] [Accepted: 07/20/2012] [Indexed: 12/28/2022] Open
Abstract
Colonic involvement in acute pancreatitis is associated with high mortality. Diagnosis of colonic pathology complicating acute pancreatitis is difficult. The treatment of choice is resection of the affected segment. The aim of this study is to evaluate the feasibility of aggressive surgical approach when colonic complication is suspected. Retrospectively, 8 patients with acute necrotizing pancreatitis and colonic complications (2006-2010) were reviewed. Eight patients with acute necrotizing pancreatitis requiring colonic resection were evaluated. Presentation was varied, including rectal bleeding (2), clinical deterioration during severe pancreatitis (4), colonic contrast leak on CT scan (1) and large bowel obstruction (1). Typically, patients with severe acute pancreatitis had colonic pathology obscured and unrecognized initially because of the ongoing, fulminant inflammatory process. All eight patients underwent Sub-total colectomy & ileostomy for suspected imminent or overt ischemia/perforation, based on the outer aspect of the colon. There was one mortality due to severe sepsis and multiorgan dysfunction syndrome. All other patients recovered well and later underwent closure of the stoma. Recognition of large bowel involvement may be difficult because of nonspecific symptoms or be masked by the systemic features of a critical illness. Clinicians should be aware that acute pancreatitis may erode or inflame the large bowel, resulting in lifethreatening colonic necrosis, bleeding or perforation. In our series of eight patients, we observed that mortality can be reduced by this aggressive surgical approach. We recommend a low threshold for colonic resection due to unreliable detection of ischemia or imminent perforation by outside inspection during surgery for acute necrotizing pancreatitis.
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Affiliation(s)
- Anish P Nagpal
- Department of Surgical Gastroenterology, Haribhakti Surgical Hospital, 508, Sangita Complex, Opp Doctor House, Nr. Parimal Crossing, Ahmedabad, 380006, Gujarat India
| | - Harshad Soni
- Department of Surgical Gastroenterology, Haribhakti Surgical Hospital, 508, Sangita Complex, Opp Doctor House, Nr. Parimal Crossing, Ahmedabad, 380006, Gujarat India
| | - Sanjiv Haribhakti
- Department of Surgical Gastroenterology, Haribhakti Surgical Hospital, 508, Sangita Complex, Opp Doctor House, Nr. Parimal Crossing, Ahmedabad, 380006, Gujarat India
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Martin LCE, Stavrou M, El-Madani F, Naik V, Jain K, Gupta S. A rare case of perforated caecum after acute pancreatitis. Ann R Coll Surg Engl 2012; 94:e168-70. [PMID: 22613291 DOI: 10.1308/003588412x13171221590692] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
Isolated caecal perforation following pancreatitis is a rare event. We report a case of severe non-necrotising pancreatitis complicated by caecal perforation that was managed successfully.
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33
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A case of pancreatic abscess associated with colonic fistula successfully treated by endoscopic transgastric drainage using a metallic stent. Clin J Gastroenterol 2011; 4:331-335. [DOI: 10.1007/s12328-011-0249-2] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/29/2011] [Accepted: 06/23/2011] [Indexed: 11/27/2022]
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Abstract
Colonic complications of severe acute pancreatitis occur rarely. Although there have been several theories on how pancreatic pseudocysts rupture into the colon, the exact pathogenesis remains unknown. We report an unusual case of pseudocysts complicating severe acute pancreatitis presenting with colonic perforation in a 71-year-old man with a history of chronic mesenteric ischemia. Pressure effects from a giant pseudocyst and intravascular volume depletion with acute insult on chronic mesenteric ischemia are highlighted as possible etiologic factors.
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35
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Mohamed SR, Siriwardena AK. Understanding the colonic complications of pancreatitis. Pancreatology 2008; 8:153-8. [PMID: 18382101 DOI: 10.1159/000123607] [Citation(s) in RCA: 52] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/17/2007] [Accepted: 11/06/2007] [Indexed: 12/11/2022]
Abstract
BACKGROUND Colonic necrosis, fistula and stricture are infrequent but potentially lethal complications of pancreatitis. As any individual unit will have only limited experience, this study aims to provide a structured, systematic appraisal of published experience to identify any consistent trends and disease patterns that may help in practical management. METHODS A computerized search of the MEDLINE databases for the period January 1950 through January 2006 yielded 43 articles. Pooled extracted data were examined for type of pancreatitis and colonic complications, method and time of diagnosis, treatment and outcome. RESULTS 43 reports provided pooled data on 97 patients. Colonic complications were more frequent in severe disease, occurring in 15%. The principal presentations were necrosis, fistula and stricture. All episodes of colonic necrosis complicated severe acute pancreatitis, were diagnosed operatively, presented at a median of 25 (1-55) days into the episode and were associated with a mortality of 54%. In contrast, stricture presented at a median of 50 (10-270) days. Surgical resection without anastomosis is the mainstay of management of necrosis. Trial of conservative management in a stable patient with a fistula may facilitate spontaneous closure. CONCLUSIONS This study highlights several consistent trends: preoperative diagnosis is difficult, colonic necrosis and fistula are rare complications principally of severe acute pancreatitis and they present either as ongoing abdominal sepsis or rectal bleeding. Surgical resection remains the mainstay of management. A high index of suspicion should be maintained in patients with severe acute pancreatitis, with ongoing sepsis and evidence of gastrointestinal blood loss.
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Affiliation(s)
- Samy R Mohamed
- Hepatobiliary Surgical Unit, Department of Surgery, Manchester Royal Infirmary, Manchester, UK
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36
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Suzuki A, Suzuki S, Sakaguchi T, Oishi K, Fukumoto K, Ota S, Inaba K, Takehara Y, Sugimura H, Uchiyama T, Konno H. Colonic fistula associated with severe acute pancreatitis: report of two cases. Surg Today 2008; 38:178-83. [PMID: 18239882 DOI: 10.1007/s00595-007-3593-6] [Citation(s) in RCA: 28] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/25/2006] [Accepted: 06/21/2007] [Indexed: 01/21/2023]
Abstract
Colonic fistula is a rare and potentially critical sequela of severe acute pancreatitis, which requires surgical treatment. We report two cases that were successfully treated by a colectomy for colonic fistula associated with severe acute pancreatitis. Case 1 is a 71-year-old man infected with pseudocysts owing to severe acute pancreatitis that developed into a colonic fistula as an early complication with a resulting pancreatic abscess. This patient underwent a left hemicolectomy, a transverse colostomy, and drainage of the pancreatic abscess. He has done well without recurrent disease for 35 months following surgery. Case 2 is a 58-year-old woman who had a past history of drainage during a laparotomy for a pancreatic abscess induced by endoscopic retrograde cholangiopancreatography 10 years earlier. She was admitted to our hospital with left lateral abdominal pain and low-grade fever. Abdominal magnetic resonance imaging showed a retroperitoneal abscess and fistula to the descending colon. She underwent a left hemicolectomy and drainage of the retroperitoneal abscess. She has remained symptom-free for 20 months following surgery. The colonic fistula should therefore be recognized as a late complication during long-term follow-up as well as an early sequela associated with severe acute pancreatitis.
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Affiliation(s)
- Atsushi Suzuki
- Second Department of Surgery, Hamamatsu University School of Medicine, 1-20-1 Handayama, Hamamatsu, 431-3192, Japan
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37
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Schellhammer F, Krömeke O, Poll L, Fürst G, Mödder U. [Nonocclusive ischemia of the right colon]. Radiologe 2006; 47:721-4. [PMID: 16541274 DOI: 10.1007/s00117-005-1331-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
BACKGROUND Nonocclusive disease (NOD) is known to be a common cause of ischemic colitis, which is frequently underestimated. MATERIAL AND METHODS A computer-assisted search of radiological reports at our institute over a period of 18 months, describing ischemic colitis of the ascending colon with an unimpaired perfusion of the superior mesenteric artery, was performed. RESULTS A retrospective analysis of the clinical and radiological data of 14 patients was performed. In ten cases colonic ischemia was confirmed clinically or intraoperatively. Most of our patients needed intravenous catecholamines due to severe hypotension. However, no significant radiographic predictors could be identified. CONCLUSION Awareness of NOD seems to be crucial. Especially in cases of acute abdominal pain associated with severe hypotension, renal insufficiency, or pancreatitis, one should include NOD as a differential diagnosis at an early stage.
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Affiliation(s)
- F Schellhammer
- Institut für diagnostische Radiologie, Heinrich-Heine-Universität, Moorenstrasse 5, 40225 Düsseldorf, Germany.
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38
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Pascual M, Pera M, Martínez I, Miquel R, Grande L. [Intestinal occlusion due to pancreatitis mimicking stenosing neoplasm of the splenic angle of the colon]. GASTROENTEROLOGIA Y HEPATOLOGIA 2005; 28:326-8. [PMID: 15989813 DOI: 10.1157/13076349] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/21/2022]
Abstract
Colonic involvement in patients with severe acute pancreatitis or chronic pancreatitis is common and complications such as paralytic ileus, segmental necrosis and pancreatic-colonic fistulae have been described. However, mechanical occlusion of the colon due to pancreatitis is infrequent. We present the case of a 45-year-old man with occlusion of the colon secondary to asymptomatic pancreatitis mimicking a locally advanced stenosing neoplasm of the splenic angle. Ten years prior to the present episode the patient had presented acute alcoholic pancreatitis complicated by a pseudocyst requiring surgery. The current reason for admission was abdominal colic pain and constipation with onset 5 days previously. Contrast enema was administered showing colonic occlusion caused by stenosis at the splenic flexure, suggesting the presence of a neoplasm. Urgent laparotomy showed the presence of a tumor originating in the colon that infiltrated the splenic hilum. Subtotal colectomy and en-bloc splenectomy were performed. Histopathological analysis showed pericolonic inflammation and fibrosis secondary to pancreatitis; the colonic mucosa showed no tumoral infiltration. To date, fewer than 30 cases of this infrequent complication have been published.
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Affiliation(s)
- M Pascual
- Unidad de Cirugía Colorrectal, Servicio de Cirugía, Hospital del Mar, Barcelona, Spain
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39
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Radenkovic DV, Bajec DD, Tsiotos GG, Karamarkovic AR, Milic NM, Stefanovic BD, Bumbasirevic V, Gregoric PM, Masulovic D, Milicevic MM. Planned Staged Reoperative Necrosectomy Using an Abdominal Zipper in the Treatment of Necrotizing Pancreatitis. Surg Today 2005; 35:833-40. [PMID: 16175464 DOI: 10.1007/s00595-005-3045-0] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/09/2003] [Accepted: 01/18/2005] [Indexed: 12/16/2022]
Abstract
PURPOSE The optimal operative treatment for severe necrotizing pancreatitis (SNP) still remains controversial. This article describes the operative approach with a planned staged necrosectomy using the "zipper" technique. METHODS Between 1996 and 2000, 35 patients with SNP were treated with this approach. The patient demographics, etiology and severity of SNP, hospital course, and outcome were recorded and comparisons of several parameters were made between the patients who survived and those who died. RESULTS Hospital mortality was 34%. A total of 16 fistulae developed in 11 patients (31%), recurrent intra-abdominal abscesses in 4 (11%), and hemorrhaging in 5 (14%). The patients who died compared with those who survived had a higher Acute Physiology and Chronic Health Evaluation (APACHE)-II score on admission (14.5 vs 9, P < 0.001), extrapancreatic extension of necrosis more often (100% vs 65%, P = 0.02), and developed postoperative hemorrhaging more often (33% vs 4%, P = 0.038). A multivariate logistic analysis revealed an APACHE-II score of > 13 on admission (P = 0.018) and an extension of necrosis behind both paracolic gutters (P < 0.001) to both be prognostic factors for mortality. CONCLUSIONS Severe necrotizing pancreatitis still carries significant morbidity and mortality. This surgical approach facilitates the removal of all devitalized tissue and seems to decrease the incidence of recurrent intra-abdominal infection requiring reoperation. An APACHE-II score of > or = 13 and an extension of necrosis behind both paracolic gutters was thus found to signify a worse outcome.
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Affiliation(s)
- Dejan V Radenkovic
- Center of Emergency Surgery, Clinical Center of Serbia and School of Medicine, University of Belgrade, 2 Pasterova Street, 11000, Belgrade, Serbia and Montenegro
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40
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Takahashi Y, Fukushima JI, Fukusato T, Shiga J, Tanaka F, Imamura T, Fukayama M, Inoue T, Shimizu S, Mori S. Prevalence of ischemic enterocolitis in patients with acute pancreatitis. J Gastroenterol 2005; 40:827-32. [PMID: 16143888 DOI: 10.1007/s00535-005-1637-5] [Citation(s) in RCA: 23] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/09/2004] [Accepted: 03/18/2005] [Indexed: 02/04/2023]
Abstract
BACKGROUND A considerable number of acute pancreatitis cases have been reported to be complicated by nonocclusive mesenteric ischemia. However, no reports have ever referred to the incidence of ischemic enterocolitis in patients with acute pancreatitis, using a series of autopsy cases. Here, we report our review of autopsy cases of patients with acute pancreatitis to examine the incidence of associated ischemic enterocolitis. METHODS The intestinal and pancreatic slides of 48 autopsy cases of patients with acute pancreatitis were reviewed and the incidence of ischemic enterocolitis was determined. Clinical case records were also reviewed. RESULTS Thirteen (27%) of 48 autopsy cases of patients with acute pancreatitis were complicated by ischemic enterocolitis. The frequency of shock was significantly higher in patients with ischemic enterocolitis than in those without ischemic enterocolitis. The intestinal lesion was diffuse in many cases and gangrene was not an unusual finding. CONCLUSIONS The incidence of ischemic enterocolitis in patients with acute pancreatitis was much higher than that in the previous reports. Clinicians who treat patients with acute pancreatitis should consider ischemic enterocolitis as one of the frequent and severe complications of this condition.
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Affiliation(s)
- Yoshihisa Takahashi
- Department of Pathology, Teikyo University School of Medicine, 2-11-1 Kaga, Itabashi-ku, Tokyo, 173-8605, Japan
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41
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Hirota M, Inoue K, Kimura Y, Mizumoto T, Kuwata K, Ohmuraya M, Ishiko T, Beppu T, Ogawa M. Non-occlusive mesenteric ischemia and its associated intestinal gangrene in acute pancreatitis. Pancreatology 2004; 3:316-22. [PMID: 12890994 DOI: 10.1159/000071770] [Citation(s) in RCA: 51] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/21/2002] [Accepted: 04/25/2003] [Indexed: 12/11/2022]
Abstract
BACKGROUND/AIMS Non-occlusive mesenteric ischemia (NOMI) has been defined as diffuse intestinal ischemia that often results in intestinal gangrene in the presence of a patent arterial trunk. The prevalence and nature of NOMI in acute pancreatitis was investigated. METHODS A total of 120 consecutive patients with acute pancreatitis managed in the Department of Surgery II, Kumamoto University Medical School, from April 1992 through December 2002, were investigated retrospectively. Among them, 60 patients had the severe form. RESULTS The overall mortality of acute pancreatitis patients was 8.3% (10/120). The prevalence and mortality of acute pancreatitis associated with NOMI were 6.7% (8/120) and 63% (5/8), respectively, while those of patients with NOMI-associated intestinal gangrene were 4.2% (5/120) and 100% (5/5), respectively. The mortality of patients with severe acute pancreatitis who did not develop NOMI was 10% (5/52). All patients with NOMI-associated intestinal gangrene quickly progressed and subsequently died of multiple organ failure. Plasma creatine phosphokinase (CPK) and lactate levels were elevated significantly in patients with NOMI. CONCLUSION Acute pancreatitis associated with NOMI was extremely severe. If the plasma CPK and lactate levels are extremely high, NOMI should be suspected.
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Affiliation(s)
- Masahiko Hirota
- Department of Surgery II, Kumamoto University Medical School, Kumamoto City, Kumamoto, Japan
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42
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Abstract
INTRODUCTION Colonic involvement in pancreatic disorders is rare but potentially fatal. Extension of contiguous inflammation or neoplasm, autodigestive effects of enzymes, or dissection of a pseudocyst or abscess may involve the colon producing obstruction, perforation, hemorrhage, or abdominal pain. RESULTS Nine patients with pancreatic disease requiring colonic resection were identified. Cases included pancreatic abscess producing colonic necrosis (2). pancreatic carcinoma invading the colon (3). extension of pancreatitis producing a colonic stricture (3). and pseudocyst eroding into the splenic flexure (1). Presentation was varied, including rectal bleeding (2). clinical deterioration during severe pancreatitis (4). and large bowel obstruction (3). The 3 cases due to malignancy, 1 of which was recurrent, presented with primary large bowel symptoms suggesting intestinal obstruction rather than pancreatic disease. Typically, patients with severe acute pancreatitis had colonic pathology obscured and unrecognized initially because of the ongoing, fulminant inflammatory process. CONCLUSIONS Recognition of large bowel involvement may be difficult because of nonspecific symptoms or be masked by the systemic features of a critical illness. Colonoscopy, contrast x-rays, or CT scan may be vital in selected cases to detect underlying pathology. Clinicians should be aware that acute or chronic pancreatitis or pancreatic carcinoma may compress, erode, or inflame the large bowel, resulting in life-threatening colonic necrosis, bleeding, obstruction, or perforation.
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43
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Inoue K, Hirota M, Kimura Y, Kuwata K, Ohmuraya M, Ogawa M. Further evidence for endothelin as an important mediator of pancreatic and intestinal ischemia in severe acute pancreatitis. Pancreas 2003; 26:218-23. [PMID: 12657945 DOI: 10.1097/00006676-200304000-00002] [Citation(s) in RCA: 46] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
INTRODUCTION Severe acute pancreatitis is occasionally associated with pancreatic and intestinal necrosis. Mesenteric vasoconstriction is one of the most probable types of pathogenesis of these complications. AIM To investigate the involvement of endothelin-1 (ET-1), a potent vasoconstrictor. METHODOLOGY AND RESULTS Plasma ET-1 concentrations were extremely high in patients with pancreatic and/or diffuse intestinal necrosis. ET-1 mRNA was demonstrated in the rat pancreas, and the production of ET-1 protein by human umbilical vein endothelial cells was enhanced by tumor necrosis factor-alpha, thrombin, and protease-activated receptor-2-activating peptide. Administration of ET-1 in vivo induced mesenteric arterial spasm and decreased pancreatic and intestinal blood flow. CONCLUSION These results suggest the following: ET-1 is produced in and around the pancreas, mainly by endothelial cells, in severe acute pancreatitis; in the inflammatory setting, cytokines, activated thrombin and trypsin, may stimulate ET-1 production in a paracrine fashion; produced ET-1 may exaggerate the splanchnic microcirculation; and progressive ischemia may lead to necrosis of the pancreas and intestine.
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Affiliation(s)
- Kotaro Inoue
- Department of Surgery II, Kumamoto University Medical School, Kumamoto-city, Japan
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44
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Maisonnette F, Abita T, Pichon N, Lachachi F, Cessot F, Valleix D, Durand-Fontanier S, Descottes B. Development of colonic stenosis following severe acute pancreatitis. HPB (Oxford) 2003; 5:183-5. [PMID: 18332982 PMCID: PMC2020575 DOI: 10.1080/13651820310000901] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
BACKGROUND Colonic necrosis after acute pancreatitis is rare. When it does occur, it is commonly due to ischaemia or inflammation and may necessitate early colonic resection. CASE OUTLINE A 72-year-old man developed colonic necrosis 6 weeks after severe acute pancreatitis. CT scan revealed a bulky mass near the left colon. Barium enema and colonoscopy revealed stenosis of the left colonic flexure, and this segment of bowel was successfully resected. DISCUSSION Severe acute pancreatitis must be recognised as a cause of colonic ischaemia and necrosis. The possible pathogenic mechanisms include severe local inflammation and an ischaemic process. This complication is associated with a very poor prognosis despite surgical intervention, but a timely resection may prevent further problems.
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Affiliation(s)
- F Maisonnette
- Departments of Visceral and Transplantation Surgery, Dupuytren HospitalLimogesFrance
| | - T Abita
- Departments of Visceral and Transplantation Surgery, Dupuytren HospitalLimogesFrance
| | - N Pichon
- Gastroenterology, Dupuytren HospitalLimogesFrance
| | - F Lachachi
- Departments of Visceral and Transplantation Surgery, Dupuytren HospitalLimogesFrance
| | - F Cessot
- Gastroenterology, Dupuytren HospitalLimogesFrance
| | - D Valleix
- Departments of Visceral and Transplantation Surgery, Dupuytren HospitalLimogesFrance
| | - S Durand-Fontanier
- Departments of Visceral and Transplantation Surgery, Dupuytren HospitalLimogesFrance
| | - B Descottes
- Departments of Visceral and Transplantation Surgery, Dupuytren HospitalLimogesFrance
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45
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Srikanth G, Sikora SS, Baijal SS, Ayyagiri A, Kumar A, Saxena R, Kapoor VK. Pancreatic abscess: 10 years experience. ANZ J Surg 2002; 72:881-6. [PMID: 12485225 DOI: 10.1046/j.1445-2197.2002.02584.x] [Citation(s) in RCA: 19] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Abstract
BACKGROUND Secondary infections of pancreatic and peripancreatic necrosis account for most of the deaths following acute pancreatitis. These infections occur in the form of 'infected pancreatic necrosis' and 'pancreatic abscess'. The latter is a rare complication of acute pancreatitis in comparison with the former. METHODS Twenty-one patients with pancreatic abscess were managed over a 10-year period at a tertiary care centre in Northern India. The present report details the clinical profile, investigations performed and management strategy (surgery and intervention radiology) of these patients. The role of surgery and percutaneous catheter drainage (PCD) in the management of pancreatic abscess is discussed, with emphasis on the successful outcome seen in a properly selected group of patients managed by PCD. RESULTS Of the 21 patients, 12 were managed by percutaneous intervention, nine were managed surgically (of these, two had a prior PCD) and two patients were managed conservatively. The overall mortality was 9.5% (2/21). Thus, percutaneous management was suitable for 57% patients, was successful in 83.3%, with a mortality of 8.3%. Surgical therapy alone was offered to 33% of patients, was successful in 85.7%, with a mortality of 14.2%. Complications were seen in four of the nine patients managed by percutaneous drainage alone and eight of the nine patients managed surgically. CONCLUSIONS Pancreatic abscess is a potentially lethal complication in patients recovering from acute pancreatitis. Early diagnosis and prompt intervention with careful selection of patients based on computed tomography imaging for surgical or percutaneous radio-logical management, is met with a successful outcome in a majority of patients. The roles of surgery and PCD are complementary.
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Affiliation(s)
- G Srikanth
- Department of Surgical Gastroenterology, Sanjay Gandhi Post Graduate Institute of Medical Sciences, Lucknow, India
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46
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Affiliation(s)
- Y Takeyama
- First Department of Surgery, Kobe University School of Medicine, Japan
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47
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Hotz HG, Foitzik T, Rohweder J, Schulzke JD, Fromm M, Runkel NS, Buhr HJ. Intestinal microcirculation and gut permeability in acute pancreatitis: early changes and therapeutic implications. J Gastrointest Surg 1998; 2:518-25. [PMID: 10458730 DOI: 10.1016/s1091-255x(98)80051-6] [Citation(s) in RCA: 50] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Abstract
Translocation of bacteria from the intestine causes local and systemic infection in severe acute pancreatitis. Increased intestinal permeability is considered a promoter of bacterial translocation. The mechanism leading to increased gut permeability may involve impaired intestinal capillary blood flow. The aim of this study was to evaluate and correlate early changes in capillary blood flow and permeability of the colon in acute rodent pancreatitis of graded severity. Edematous pancreatitis was induced by intravenous cerulein; necrotizing pancreatitis by intravenous cerulein and intraductal glycodeoxycholic acid. Six hours after induction of pancreatitis, the permeability of the ascending colon was assessed by the Ussing chamber technique; capillary perfusion of the pancreas and colon (mucosal and subserosal) was determined by intravital microscopy. In mild pancreatitis, pancreatic capillary perfusion remained unchanged (2.13 c 0.06 vs. 1.98 +/-0.04 nl x min(-1) x cap(-1) [control]; P = NS), whereas mucosal (1.59 +/-0.03 vs. 2.28 +/-0.03 nl x min(-1) x cap((-1))[control]; P <0.01) and subserosal (2.47 +/-0.04 vs. 3.74 +/-0.05 nl x min(-1) x cap((-1))[control]; P <0.01) colonic capillary blood flow was significantly reduced. Severe pancreatitis was associated with a marked reduction in both pancreatic (1.06 +/-0.03 vs. 1.98 +/-0.04 nl x min(-1) x cap(-1) [control]; P <0. 01) and colonic (mucosal: 0.59 +/-0.01 vs. 2.28 +/-0.03 nl x min(-1) x cap((-1))[control], P <0.01; subserosal: 1.96 +/-0.05 vs. 3.74 +/-0.05 nl x min(-1) x cap(-1) [control], P <0.01) capillary perfusion. Colon permeability tended to increase with the severity of the disease (control: 147 +/-19 nmol x thr(-1) x cm(-2); mild pancreatitis: 158 +/-23 nmol x hr(-1) x cm(-2); severe pancreatitis: 181 +/-33 nmol x hr(-1) x cm(-2); P = NS). Impairment of colonic capillary perfusion correlates with the severity of pancreatitis. A decrease in capillary blood flow in the colon, even in mild pancreatitis not associated with significant protease activation and acinar cell necrosis or impairment of pancreatic capillary perfusion, suggests that colonic microcirculation is especially susceptible to inflammatory injury. There was no significant change in intestinal permeability in the early stage of pancreatitis, suggesting a window of opportunity for therapeutic interventions to prevent the later-observed increase in gut permeability, which could result in improved intestinal microcirculation.
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Affiliation(s)
- H G Hotz
- Department of Surgery, Universitätsklinikum Benjamin Franklin, Freie Universität Berlin, Berlin, Germany.
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48
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Bosscha K, Hulstaert PF, Hennipman A, Visser MR, Gooszen HG, van Vroonhoven TJ, v d Werken C. Fulminant acute pancreatitis and infected necrosis: results of open management of the abdomen and "planned" reoperations. J Am Coll Surg 1998; 187:255-62. [PMID: 9740182 DOI: 10.1016/s1072-7515(98)00153-7] [Citation(s) in RCA: 61] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
Abstract
BACKGROUND Controversy still surrounds the management of fulminant acute necrotizing pancreatitis. Because mortality rates continue to be high, especially in patients with fulminant acute pancreatitis and infected necrosis, aggressive surgical techniques, such as open management of the abdomen and "planned" reoperations, seem to be justified. STUDY DESIGN From 1988 through 1995, 28 patients with fulminant acute pancreatitis and infected necrosis were treated with open management of the abdomen followed by planned reoperations at our surgical intensive care unit. RESULTS All patients had infected necrosis with severe clinical deterioration: 12 patients had an Acute Physiology and Chronic Health Evaluation (APACHE) II score > or = 20 and 16 patients had a Simplified Acute Physiology Score (SAPS) > or = 15. Nineteen patients suffered from severe multiorgan failure; the remaining 9 patients needed only ventilatory and inotropic support. The mean number of reoperations was 17. In 14 patients, major bleeding occurred; fistula developed in 7. Later, 9 abscesses were drained percutaneously. The hospital mortality rate was 39%. Longterm morbidity in survivors was substantial, especially concerning abdominal-wall defects. CONCLUSIONS Open management of the abdomen followed by planned reoperations is an aggressive but reasonably successful surgical treatment strategy for patients with fulminant acute pancreatitis and infected necrosis. Morbidity and mortality rates were high, but in these critically ill patients, such high rates could be expected. Because management and clinical surveillance require specific expertise, management of these patients is best undertaken in specialized centers.
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Affiliation(s)
- K Bosscha
- Department of Surgery, University Hospital Utrecht, The Netherlands
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Tsiotos GG, Luque-de León E, Söreide JA, Bannon MP, Zietlow SP, Baerga-Varela Y, Sarr MG. Management of necrotizing pancreatitis by repeated operative necrosectomy using a zipper technique. Am J Surg 1998; 175:91-8. [PMID: 9515522 DOI: 10.1016/s0002-9610(97)00277-8] [Citation(s) in RCA: 116] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
METHODS From 1983 to 1995, 72 patients with necrotizing pancreatitis were treated with a general approach involving planned reoperative necrosectomies and interval abdominal wound closure using a zipper. RESULTS Hospital mortality was 25%. Multiple organ failure without sepsis caused early mortality in 3 of 4 patients and sepsis caused late mortality in 11 of the remaining 14. The mean number of reoperative necrosectomies/debridements was 2 (0 to 7). Fistulae developed in 25 patients (35%); 64% were treated conservatively. Recurrent intraabdominal abscesses developed in 9 patients (13%) but were drained percutaneously in 5. Hemorrhage required intervention in 13 patients (18%). Prognostic factors included APACHE-II score on admission < 13 (P = 0.005), absence of postoperative hemorrhage (P = 0.01), and peripancreatic tissue necrosis alone (P < 0.05). CONCLUSIONS The zipper approach effectively maximizes the necrosectomy and decreases the incidence of recurrent intraabdominal infection requiring reoperation. APACHE-II score > or = 13, extensive parenchymal necrosis, and postoperative hemorrhage signify worse outcome.
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Affiliation(s)
- G G Tsiotos
- Department of Surgery, Mayo Clinic and Mayo Foundation, Rochester, Minnesota 55905, USA
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Chaudhary A, Dhar P, Sachdev A, Agarwal AK. Surgical management of pancreatic necrosis presenting with locoregional complications. Br J Surg 1997; 84:965-8. [PMID: 9240137 DOI: 10.1002/bjs.1800840716] [Citation(s) in RCA: 18] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
BACKGROUND Local complications of pancreatic necrosis may occur after surgery, but when they occur spontaneously render surgical treatment more hazardous and impair prognosis. METHODS A retrospective review was carried out of 83 patients who underwent surgery for pancreatic necrosis from 1988 to 1995, to determine the incidence, type, treatment and outcome of locoregional complications caused by pancreatic necrosis associated with acute pancreatitis. RESULTS Seventeen patients (20 per cent) were identified to have intra-abdominal complications with pancreatic necrosis either before operation or at the time of surgery. The majority of patients had a delay in intervention (mean 46 days). At presentation ten of the 17 patients had one or more organ system failures. Fourteen patients had gastrointestinal tract involvement, two had involvement of the biliary tract and one patient had a splenic rupture. Six patients died. CONCLUSIONS In patients with pancreatic necrosis, development of locoregional complications is associated with a high mortality rate. The presence of gastrointestinal bleeding, peritonitis, jaundice or pneumoperitoneum in such patients suggests the presence of a complication of the necrotic process and should prompt early intervention. Early referral of patients with severe acute pancreatitis to specialized units may reduce the risk of locoregional complications.
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Affiliation(s)
- A Chaudhary
- Department of Gastrointestinal Surgery, Govind Ballabh Pant Hospital, New Delhi, India
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