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Velickovic D, Stosic K, Stefanovic AD, Kovac JD, Sekulic D, Milosevic S, Miletic M, Saponjski DJ, Lukic B, Tadic B, Jovanovic MM, Cvetic V. The Importance of Early Detection and Minimally Invasive Treatment of Pseudoaneurysms Due to Chronic Pancreatitis: Case Report. MEDICINA (KAUNAS, LITHUANIA) 2024; 60:714. [PMID: 38792897 PMCID: PMC11123147 DOI: 10.3390/medicina60050714] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/01/2024] [Revised: 04/19/2024] [Accepted: 04/24/2024] [Indexed: 05/26/2024]
Abstract
The occurrence of the pseudoaneurysm of visceral arteries in the field of chronic pancreatitis is a very rare complication that represents a life-threatening condition. The higher frequency of this complication is in the necrotic form of pancreatic inflammation, especially in patients with formed peripancreatic necrotic collections. The degradation of the arterial wall leads to bleeding and transforms these necrotic collections into a pseudoaneurysm. Urgent endovascular angioembolization is the first choice in the therapeutic approach as a valid minimally invasive solution with very satisfactory immediate and long-term outcomes. This successfully avoids open surgery, which is associated with a high mortality rate in these patients, especially in acute-on-chronic pancreatitis.
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Affiliation(s)
- Dejan Velickovic
- Department of Stomach and Esophageal Surgery, Clinic for Digestive Surgery, University Clinical Centre of Serbia, Koste Todorovica Street No. 6, 11000 Belgrade, Serbia
- Department for Surgery with Anesthesiology, Faculty of Medicine, University of Belgrade, Dr Subotica No. 8, 11000 Belgrade, Serbia
| | - Katarina Stosic
- Center for Radiology and Magnetic Resonance Imaging, University Clinical Centre of Serbia, Pasterova No. 2, 11000 Belgrade, Serbia
| | - Aleksandra Djuric Stefanovic
- Center for Radiology and Magnetic Resonance Imaging, University Clinical Centre of Serbia, Pasterova No. 2, 11000 Belgrade, Serbia
- Department for Radiology, Faculty of Medicine, University of Belgrade, Dr Subotica No. 8, 11000 Belgrade, Serbia
| | - Jelena Djokic Kovac
- Center for Radiology and Magnetic Resonance Imaging, University Clinical Centre of Serbia, Pasterova No. 2, 11000 Belgrade, Serbia
- Department for Radiology, Faculty of Medicine, University of Belgrade, Dr Subotica No. 8, 11000 Belgrade, Serbia
| | - Danijela Sekulic
- Center for Radiology and Magnetic Resonance Imaging, University Clinical Centre of Serbia, Pasterova No. 2, 11000 Belgrade, Serbia
| | - Stefan Milosevic
- Center for Radiology and Magnetic Resonance Imaging, University Clinical Centre of Serbia, Pasterova No. 2, 11000 Belgrade, Serbia
| | - Marko Miletic
- Center for Radiology and Magnetic Resonance Imaging, University Clinical Centre of Serbia, Pasterova No. 2, 11000 Belgrade, Serbia
| | - Dusan Jovica Saponjski
- Center for Radiology and Magnetic Resonance Imaging, University Clinical Centre of Serbia, Pasterova No. 2, 11000 Belgrade, Serbia
- Department for Radiology, Faculty of Medicine, University of Belgrade, Dr Subotica No. 8, 11000 Belgrade, Serbia
| | - Borivoje Lukic
- Center for Radiology and Magnetic Resonance Imaging, University Clinical Centre of Serbia, Pasterova No. 2, 11000 Belgrade, Serbia
- Department for Radiology, Faculty of Medicine, University of Belgrade, Dr Subotica No. 8, 11000 Belgrade, Serbia
| | - Boris Tadic
- Department for Surgery with Anesthesiology, Faculty of Medicine, University of Belgrade, Dr Subotica No. 8, 11000 Belgrade, Serbia
- Department for HPB Surgery, Clinic for Digestive Surgery, University Clinical Centre of Serbia, Koste Todorovica Street, No. 6, 11000 Belgrade, Serbia
| | - Milica Mitrovic Jovanovic
- Center for Radiology and Magnetic Resonance Imaging, University Clinical Centre of Serbia, Pasterova No. 2, 11000 Belgrade, Serbia
- Department for Radiology, Faculty of Medicine, University of Belgrade, Dr Subotica No. 8, 11000 Belgrade, Serbia
| | - Vladimir Cvetic
- Center for Radiology and Magnetic Resonance Imaging, University Clinical Centre of Serbia, Pasterova No. 2, 11000 Belgrade, Serbia
- Department for Radiology, Faculty of Medicine, University of Belgrade, Dr Subotica No. 8, 11000 Belgrade, Serbia
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2
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Siew HQ, Yeh ML. A case of upper gastrointestinal bleeding due to pancreatic pseudoaneurysm rupture. Kaohsiung J Med Sci 2024; 40:413-414. [PMID: 38363154 DOI: 10.1002/kjm2.12810] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/30/2023] [Revised: 01/21/2024] [Accepted: 01/22/2024] [Indexed: 02/17/2024] Open
Affiliation(s)
- Hui-Qi Siew
- School of Medicine, College of Medicine, Kaohsiung Medical University, Kaohsiung, Taiwan
| | - Ming-Lun Yeh
- School of Medicine, College of Medicine, Kaohsiung Medical University, Kaohsiung, Taiwan
- Division of Hepatobiliary, Department of Internal Medicine, Kaohsiung Medical University Hospital, Kaohsiung, Taiwan
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3
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Lam HT, Nguyen TD, Ho PT, Van Nguyen A, Nguyen THN, Van Le P, Vo TD. Upper Gastrointestinal Bleeding Caused by Rupture of Pancreatic Pseudoaneurysms. Case Rep Crit Care 2023; 2023:7888990. [PMID: 37799271 PMCID: PMC10550486 DOI: 10.1155/2023/7888990] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/06/2023] [Accepted: 09/13/2023] [Indexed: 10/07/2023] Open
Abstract
Pseudoaneurysm rupture in patients with pancreatitis is a rare but fatal etiology of upper gastrointestinal bleeding. We report a rare case of upper gastrointestinal bleeding in a patient who presented simultaneously with two pseudoaneurysms, a potential cause of severe gastrointestinal bleeding. Angiography was successfully performed with coil embolization of the target arteries and both pseudoaneurysmal sacs. The patient was discharged 9 days after admission without further events within a 3-month follow-up period.
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Affiliation(s)
- Huong Tu Lam
- Department of Internal Medicine, Faculty of Medicine, University of Medicine and Pharmacy at Ho Chi Minh City, Ho Chi Minh, Vietnam
| | - Thang Dinh Nguyen
- Department of Internal Medicine, Faculty of Medicine, University of Medicine and Pharmacy at Ho Chi Minh City, Ho Chi Minh, Vietnam
| | - Phat Tan Ho
- Department of Gastroenterology, Cho Ray Hospital, Ho Chi Minh, Vietnam
| | - Ai Van Nguyen
- Department of Gastroenterology, Cho Ray Hospital, Ho Chi Minh, Vietnam
| | | | - Phuoc Van Le
- Department of Radiology, Cho Ray Hospital, Ho Chi Minh, Vietnam
| | - Thong Duy Vo
- Department of Internal Medicine, Faculty of Medicine, University of Medicine and Pharmacy at Ho Chi Minh City, Ho Chi Minh, Vietnam
- Department of Gastroenterology, Cho Ray Hospital, Ho Chi Minh, Vietnam
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4
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Walia D, Saraya A, Gunjan D. Vascular complications of chronic pancreatitis and its management. World J Gastrointest Surg 2023; 15:1574-1590. [PMID: 37701688 PMCID: PMC10494584 DOI: 10.4240/wjgs.v15.i8.1574] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/28/2023] [Revised: 05/16/2023] [Accepted: 06/06/2023] [Indexed: 08/25/2023] Open
Abstract
Chronic pancreatitis is a chronic fibro-inflammatory disorder of the pancreas, resulting in recurrent abdominal pain, diabetes mellitus, and malnutrition. It may lead to various other complications such as pseudocyst formation, benign biliary stricture, gastric outlet obstruction; and vascular complications like venous thrombosis, variceal and pseudoaneurysmal bleed. Development of varices is usually due to chronic venous thrombosis with collateral formation and variceal bleeding can easily be tackled by endoscopic therapy. Pseudoaneurysmal bleed can be catastrophic and requires radiological interventions including digital subtraction angiography followed by endovascular obliteration, or sometimes with a percutaneous or an endoscopic ultrasound-guided approach in technically difficult situations. Procedure-related bleed is usually venous and mostly managed conservatively. Procedure-related arterial bleed, however, may require radiological interventions.
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Affiliation(s)
- Dinesh Walia
- Gastroenterology and Human Nutrition Unit, All India Institute of Medical Sciences, New Delhi 110029, India
| | - Anoop Saraya
- Gastroenterology and Human Nutrition Unit, All India Institute of Medical Sciences, New Delhi 110029, India
| | - Deepak Gunjan
- Gastroenterology and Human Nutrition Unit, All India Institute of Medical Sciences, New Delhi 110029, India
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5
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Dhar J, Samanta J. Endoscopic ultrasound-guided vascular interventions: An expanding paradigm. World J Gastrointest Endosc 2023; 15:216-239. [PMID: 37138933 PMCID: PMC10150286 DOI: 10.4253/wjge.v15.i4.216] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/17/2022] [Revised: 01/09/2023] [Accepted: 03/15/2023] [Indexed: 04/14/2023] Open
Abstract
Endoscopic ultrasound (EUS) has expanded its arena from a mere diagnostic modality to an essential therapeutic tool in managing gastrointestinal (GI) diseases. The proximity of the GI tract to the vascular structures in the mediastinum and the abdomen has facilitated the growth of EUS in the field of vascular interventions. EUS provides important clinical and anatomical information related to the vessels' size, appearance and location. Its excellent spatial resolution, use of colour doppler with or without contrast enhancement and ability to provide images “real-time” helps in precision while intervening vascular structures. Additionally, structures such as venous collaterals or varices can be dealt with optimally using EUS. EUS-guided vascular therapy with coil and glue combination has revolutionized the management of portal hypertension. It also helps to avoid radiation exposure in addition to being minimally invasive. These advantages have led EUS to become an upcoming modality to complement traditional interventional radiology in the field of vascular interventions. EUS-guided portal vein (PV) access and therapy is a new kid on the block. EUS-guided portal pressure gradient measurement, injecting chemotherapy in PV and intrahepatic portosystemic shunt has expanded the horizons of endo-hepatology. Lastly, EUS has also forayed into cardiac interventions allowing pericardial fluid aspiration and tumour biopsy with experimental data on access to valvular apparatus. Herein, we provide a comprehensive review of the expanding paradigm of EUS-guided vascular interventions in GI bleeding, portal vein access and its related therapeutic interventions, cardiac access, and therapy. A synopsis of all the technical details involving each procedure and the available data has been tabulated, and the future trends in this area have been highlighted.
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Affiliation(s)
- Jahnvi Dhar
- Gastroenterology, Sohana Multispeciality Hospital, Mohali 140308, India
| | - Jayanta Samanta
- Gastroenterology, Post Graduate Institute of Medical Education and Research, Chandigarh 160012, India
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6
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Gupta P, Madhusudhan KS, Padmanabhan A, Khera PS. Indian College of Radiology and Imaging Consensus Guidelines on Interventions in Pancreatitis. Indian J Radiol Imaging 2022; 32:339-354. [PMID: 36177275 PMCID: PMC9514912 DOI: 10.1055/s-0042-1754313] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022] Open
Abstract
AbstractAcute pancreatitis (AP) is one of the common gastrointestinal conditions presenting as medical emergency. Clinically, the severity of AP ranges from mild to severe. Mild AP has a favorable outcome. Patients with moderately severe and severe AP, on the other hand, require hospitalization and considerable utilization of health care resources. These patients require a multidisciplinary management. Pancreatic fluid collections (PFCs) and arterial bleeding are the most important local complications of pancreatitis. PFCs may require drainage when infected or symptomatic. PFCs are drained endoscopically or percutaneously, based on the timing and the location of collection. Both the techniques are complementary, and many patients may undergo dual modality treatment. Percutaneous catheter drainage (PCD) remains the most extensively utilized method for drainage in patients with AP and necrotic PFCs. Besides being effective as a standalone treatment in a significant proportion of these patients, PCD also provides an access for percutaneous endoscopic necrosectomy and minimally invasive necrosectomy. Endovascular embolization is the mainstay of management of arterial complications in patients with AP and chronic pancreatitis. The purpose of the present guideline is to provide evidence-based recommendations for the percutaneous management of complications of pancreatitis.
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Affiliation(s)
- Pankaj Gupta
- Department of Radiodiagnosis and Imaging, Postgraduate Institute of Medical Education and Research, Chandigarh, India
| | | | - Aswin Padmanabhan
- Division of Clinical Radiology, Department of Interventional Radiology, Christian Medical College, Vellore, Tamil Nadu, India
| | - Pushpinder Singh Khera
- Department of Diagnostic and Interventional Radiology, All India Institute of Medical Sciences, Jodhpur, Rajasthan, India
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7
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Patel S, Chandnani S, Gutte A, Rathi PM. Placement of a flow diverter-like stent together with coil embolisation for treatment of pancreatic pseudoaneurysm involving the origin of the gastroduodenal artery. BMJ Case Rep 2022; 15:e248946. [PMID: 35820732 PMCID: PMC9277387 DOI: 10.1136/bcr-2022-248946] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/03/2022] Open
Abstract
A pancreatic pseudoaneurysm can occur following an attack of pancreatitis. This occurs due to erosion of the pancreatic or peripancreatic artery by the pancreatic enzyme-rich pancreatic secretion pseudocyst. If left untreated, it may cause massive and even fatal haemorrhage. Interventional radiology with coil embolisation of the pseudoaneurysm is the standard of care in such cases. We describe a patient who developed a pseudoaneurysm involving the origin of the gastroduodenal artery (GDA). This was successfully managed by coil embolisation of the pseudoaneurysm along with placement of a flow diverter-like stent in the common hepatic artery across the origin of the GDA leading to exclusion of the diseased segment.
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Affiliation(s)
- Sameet Patel
- Gastroenterology, Topiwala National Medical College, Mumbai, India
| | - Sanjay Chandnani
- Gastroenterology, Topiwala National Medical College, Mumbai, India
| | - Avinash Gutte
- Department of Interventional Radiology, Grant Medical College and Sir JJ Group of Hospitals, Mumbai, Maharashtra, India
| | - Pravin M Rathi
- Gastroenterology, Topiwala National Medical College, Mumbai, India
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8
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Splenic Artery Pseudoaneurysms: The Role of ce-CT for Diagnosis and Treatment Planning. Diagnostics (Basel) 2022; 12:diagnostics12041012. [PMID: 35454060 PMCID: PMC9024490 DOI: 10.3390/diagnostics12041012] [Citation(s) in RCA: 11] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/28/2022] [Revised: 04/07/2022] [Accepted: 04/13/2022] [Indexed: 01/19/2023] Open
Abstract
Splenic artery pseudoaneurysm (PSA) is a contained vascular wall lesion associated with a high mortality rate, generally related to pancreatitis, trauma, malignancy, iatrogenic injury, and segmental arterial mediolysis. Computed tomography angiography allows us to visualize the vascular anatomy, differentiate a PSA from an aneurysm, and provide adequate information for endovascular/surgical treatment. The present review reports on the main state-of-the-art splenic artery PSA diagnosis, differentiating between the pros and cons of the imaging methods and about the endovascular treatment.
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9
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Dhali A, Ray S, Sarkar A, Khamrui S, Das S, Mandal TS, Biswas DN, Dhali GK. Peripancreatic arterial pseudoaneurysm in the background of chronic pancreatitis: clinical profile, management, and outcome. Updates Surg 2021; 74:1367-1373. [PMID: 34816352 DOI: 10.1007/s13304-021-01208-y] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/15/2021] [Accepted: 11/18/2021] [Indexed: 01/04/2023]
Abstract
BACKGROUND Bleeding pseudoaneurysm (PSA) is a rare but potentially lethal complication of chronic pancreatitis (CP). It requires expeditious management by a multidisciplinary team. The study aims to report our experience with PSA in the background of CP. METHODS All the patients, who underwent intervention for CP-related PSA between August 2007 and December 2020 in the Department of Surgical gastroenterology, Institute of Postgraduate Medical Education and Research, Kolkata, India were retrospectively reviewed. RESULTS Of the total 26 patients, 25 (96%) were men with a median age of 38 (11-63) years. The most commonly involved vessel was the splenic artery (n = 18, 69%). The interval between onset of GI bleed and intervention was 7 (0-120) days. Embolization was attempted in 11(42%) patients and was successful in six patients. Surgery was performed in 20 (77%) patients including five patients after failed embolization. The most commonly performed operation was distal pancreatectomy with splenectomy. The median operating time was 216 (115-313) minutes. The median intraoperative blood loss was 325 (100-1000) ml. Seventeen (85%) patients' required intraoperative blood transfusion. Four patients in the embolization group and five patients in the surgical group developed procedure-related complications. The most common postoperative complication was wound infection followed by pancreatic fistula. There was no procedure-related death. Over a median follow-up of 24 (6-122) months, no patient developed recurrent hemorrhage. CONCLUSIONS Both embolization and surgery play an important role in the management of PSA. The choice of procedure depends upon the local availability and feasibility of a particular technique.
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Affiliation(s)
- Arkadeep Dhali
- Department of GI Surgery, Institute of Postgraduate Medical Education and Research, 244 A. J. C. Bose Road, Kolkata, 700020, West Bengal, India
| | - Sukanta Ray
- Department of GI Surgery, Institute of Postgraduate Medical Education and Research, 244 A. J. C. Bose Road, Kolkata, 700020, West Bengal, India.
| | - Avik Sarkar
- Department of Radiology, Institute of Postgraduate Medical Education and Research, 244 A. J. C. Bose Road, Kolkata, 700020, West Bengal, India
| | - Sujan Khamrui
- Department of GI Surgery, Institute of Postgraduate Medical Education and Research, 244 A. J. C. Bose Road, Kolkata, 700020, West Bengal, India
| | - Somak Das
- Department of GI Surgery, Institute of Postgraduate Medical Education and Research, 244 A. J. C. Bose Road, Kolkata, 700020, West Bengal, India
| | - Tuhin Subhra Mandal
- Department of GI Surgery, Institute of Postgraduate Medical Education and Research, 244 A. J. C. Bose Road, Kolkata, 700020, West Bengal, India
| | - Dijendra Nath Biswas
- Department of Radiology, Institute of Postgraduate Medical Education and Research, 244 A. J. C. Bose Road, Kolkata, 700020, West Bengal, India
| | - Gopal Krishna Dhali
- Department of Gastroenterology, Institute of Postgraduate Medical Education and Research, 244 A. J. C. Bose Road, Kolkata, 700020, West Bengal, India
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10
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Ekezie C, Gill KG, Pfau PR, Johannes AR, Woods M, Pinchot J, Furuya KN, O’Connell DM, Ratchford T, Sigurdsson L, Walkiewicz D, Valentyne A, St. Clair NE, Ehlenbach ML, Woodring T, Danko I. Hemosuccus Pancreaticus Following Acute Pancreatitis in a 12-years-old Boy Secondary to Pancreatic Pseudoaneurysm Treated With Endovascular Coil Embolization. JPGN REPORTS 2021; 2:e125. [PMID: 37206448 PMCID: PMC10191555 DOI: 10.1097/pg9.0000000000000125] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 02/22/2021] [Accepted: 06/10/2021] [Indexed: 05/21/2023]
Abstract
Hemosuccus pancreaticus is a very rare cause of upper gastrointestinal bleeding in children. It is defined as bleeding from the pancreatic or peripancreatic vessels into the main pancreatic duct and may be life-threatening. We present the case of a 12-year-old boy with hematemesis and severe anemia that developed following an episode of acute pancreatitis. Upper endoscopy did not reveal a bleeding source. An endoscopic retrograde cholangiopancreatography performed for the evaluation of common bile duct obstruction identified bleeding from the pancreatic duct. Subsequently, the bleeding source, a pseudoaneurysm of the splenic artery, was identified by conventional angiography and occluded with coil embolization. The diagnosis of hemosuccus pancreaticus may be difficult in children due to rare occurrence and the unusual anatomical site; hence, a high index of suspicion is needed in a patient with a history of pancreatitis who presents with intermittent upper gastrointestinal bleeding and normal upper endoscopy.
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Affiliation(s)
- Christiana Ekezie
- From the Department of Pediatrics, University of Wisconsin, School of Medicine and Public Health, Madison, WI
| | - Kara G. Gill
- Division of Pediatric Radiology, Department of Radiology, University of Wisconsin, School of Medicine and Public Health, Madison, WI
| | - Patrick R. Pfau
- Division of Gastroenterology and Hepatology, Department of Medicine, University of Wisconsin, School of Medicine and Public Health, Madison, WI
| | - Andrew R. Johannes
- Division of Gastroenterology and Hepatology, Department of Medicine, University of Wisconsin, School of Medicine and Public Health, Madison, WI
| | - Michael Woods
- Division of Interventional Radiology, Department of Radiology, University of Wisconsin, School of Medicine and Public Health, Madison, WI
| | - Jason Pinchot
- Division of Interventional Radiology, Department of Radiology, University of Wisconsin, School of Medicine and Public Health, Madison, WI
| | - Katryn N. Furuya
- Division of Pediatric Gastroenterology Hepatology and Nutrition, Department of Pediatrics, University of Wisconsin, School of Medicine and Public Health, Madison, WI
| | - Daniel M. O’Connell
- Division of Pediatric Gastroenterology Hepatology and Nutrition, Department of Pediatrics, University of Wisconsin, School of Medicine and Public Health, Madison, WI
| | - Thomas Ratchford
- Division of Pediatric Gastroenterology Hepatology and Nutrition, Department of Pediatrics, University of Wisconsin, School of Medicine and Public Health, Madison, WI
| | - Luther Sigurdsson
- Division of Pediatric Gastroenterology Hepatology and Nutrition, Department of Pediatrics, University of Wisconsin, School of Medicine and Public Health, Madison, WI
| | - Dorota Walkiewicz
- Division of Pediatric Gastroenterology Hepatology and Nutrition, Department of Pediatrics, University of Wisconsin, School of Medicine and Public Health, Madison, WI
| | - Alyssa Valentyne
- University of Wisconsin, School of Medicine and Public Health, Madison, WI
| | - Nicole E. St. Clair
- Division of Pediatric Hospital Medicine, Department of Pediatrics, University of Wisconsin, School of Medicine and Public Health, Madison, WI
| | - Mary L. Ehlenbach
- Division of Pediatric Hospital Medicine, Department of Pediatrics, University of Wisconsin, School of Medicine and Public Health, Madison, WI
| | - Therese Woodring
- Division of Pediatric Hospital Medicine, Department of Pediatrics, University of Wisconsin, School of Medicine and Public Health, Madison, WI
| | - Istvan Danko
- Division of Pediatric Gastroenterology Hepatology and Nutrition, Department of Pediatrics, University of Wisconsin, School of Medicine and Public Health, Madison, WI
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11
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Madhusudhan KS, Gopi S, Singh AN, Agarwal L, Gunjan D, Srivastava DN, Garg PK. Immediate and Long-Term Outcomes of Percutaneous Radiological Interventions for Hemorrhagic Complications in Acute and Chronic Pancreatitis. J Vasc Interv Radiol 2021; 32:1591-1600.e1. [PMID: 34416367 DOI: 10.1016/j.jvir.2021.08.004] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/26/2021] [Revised: 08/03/2021] [Accepted: 08/09/2021] [Indexed: 12/23/2022] Open
Abstract
PURPOSE To evaluate and compare the immediate and long-term outcomes of radiological interventions for hemorrhagic complications in patients with acute and chronic pancreatitis. MATERIALS AND METHODS This retrospective study, conducted between January 2014 and June 2020, included all patients with acute and chronic pancreatitis presenting with hemorrhagic complications who underwent angiography and/or embolization. Their clinical, angiographic, and embolization details were evaluated and correlated with procedure success, complications, recurrence, and mortality. The patients were subgrouped into groups A (acute pancreatitis) and C (chronic pancreatitis), and comparisons were made. RESULTS The study included 141 patients (mean age, 36.3 ± 11.2 years; 124 men), of whom 106 patients had abnormal angiography findings and underwent embolization. Of them, group A had 50 patients (56 lesions) and group C had 56 patients (61 lesions). All the patients in group A had severe acute pancreatitis, with a mean computed tomography severity index of 7.6. The technical and clinical success rates of embolization, complications, recurrence, and long-term outcomes were not significantly different between the groups. Group A had significantly higher mortality due to sepsis and organ failure. Embolic agents did not have any significant association with complications, recurrence, and mortality. After a mean follow-up of 2 years, 72.5% of the patients were asymptomatic, and none had symptoms attributable to embolization. CONCLUSIONS Success, complications, and recurrence after embolization for hemorrhagic complications were comparable between acute and chronic pancreatitis. Acute pancreatitis was associated with significantly higher mortality. Embolic agents did not significantly influence the outcomes. None had long-term adverse effects attributable to embolization.
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Affiliation(s)
- Kumble Seetharama Madhusudhan
- Department of Radiodiagnosis and Interventional Radiology, All India Institute of Medical Sciences, New Delhi, India.
| | - Srikanth Gopi
- Department of Gastroenterology, All India Institute of Medical Sciences, New Delhi, India
| | - Anand Narayan Singh
- Department of Gastrointestinal Surgery, All India Institute of Medical Sciences, New Delhi, India
| | - Lokesh Agarwal
- Department of Gastrointestinal Surgery, All India Institute of Medical Sciences, New Delhi, India
| | - Deepak Gunjan
- Department of Gastroenterology, All India Institute of Medical Sciences, New Delhi, India
| | - Deep N Srivastava
- Department of Radiodiagnosis and Interventional Radiology, All India Institute of Medical Sciences, New Delhi, India
| | - Pramod Kumar Garg
- Department of Gastroenterology, All India Institute of Medical Sciences, New Delhi, India
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12
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Gorsi U, Agarwal V, Nair V, Kang M, Kalra N, Sreedhara BC, Gupta R, Rana SS, Dutta U, Sandhu MS. Endovascular and percutaneous transabdominal embolisation of pseudoaneurysms in pancreatitis: an experience from a tertiary-care referral centre. Clin Radiol 2021; 76:314.e17-314.e23. [PMID: 33526255 DOI: 10.1016/j.crad.2020.12.016] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/18/2020] [Accepted: 12/24/2020] [Indexed: 12/31/2022]
Abstract
AIM To analyse the technical challenges, clinical success, and associated complications of endovascular and percutaneous embolisation of pancreatitis-related pseudoaneurysms. MATERIALS AND METHODS A retrospective study of patients referred for embolisation of pancreatitis-related pseudoaneurysms between January 2014 and March 2019 was conducted. Computed tomography angiography (CTA) was performed to assess the morphology of the aneurysms prior to any intervention. Percutaneous or endovascular embolisation was performed. Details of CTA and methods of embolisation were recorded. Technical success, clinical success, and complications were reported. RESULTS A total of 80 patients (mean age, 40.69 ± 13.41 years, 73 male) underwent embolisation during the study period. Pseudoaneurysms were related to chronic pancreatitis (CP) in 44 (55%) patients and acute pancreatitis (AP) in 36 (45%) patients. Pseudoaneurysms were detected in 65 (81.2%) patients on CTA. The most common site of pseudoaneurysms was gastroduodenal artery (GDA) followed by splenic artery. Seven patients were treated with percutaneous thrombin injection and five were treated with percutaneous glue injection under ultrasound/fluoroscopy guidance. The remaining patients (n=68) underwent catheter angiography with endovascular embolisation. Technical success was achieved in 4/7 (57%) percutaneous thrombin cases and in all the cases (5/5, 100%) with percutaneous glue or endovascular (68/68,100%) embolisation. CONCLUSION Endovascular or percutaneous embolisation of pseudoaneurysms has high technical success with an excellent safety profile.
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Affiliation(s)
- U Gorsi
- Department of Radiodiagnosis, PGIMER, Chandigarh, India.
| | - V Agarwal
- Department of Radiodiagnosis, PGIMER, Chandigarh, India
| | - V Nair
- Department of Radiodiagnosis, PGIMER, Chandigarh, India
| | - M Kang
- Department of Radiodiagnosis, PGIMER, Chandigarh, India
| | - N Kalra
- Department of Radiodiagnosis, PGIMER, Chandigarh, India
| | - B C Sreedhara
- Department of Radiodiagnosis, PGIMER, Chandigarh, India
| | - R Gupta
- Department of Surgery, PGIMER, Chandigarh, India
| | - S S Rana
- Department of Gastroenterology, PGIMER, Chandigarh, India
| | - U Dutta
- Department of Gastroenterology, PGIMER, Chandigarh, India
| | - M S Sandhu
- Department of Radiodiagnosis, PGIMER, Chandigarh, India
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Sagar S, Soundarajan R, Gupta P, Praveen Kumar M, Samanta J, Sharma V, Kochhar R. Efficacy of endovascular embolization of arterial pseudoaneurysms in pancreatitis: A systematic review and meta-analysis. Pancreatology 2021; 21:46-58. [PMID: 33303372 DOI: 10.1016/j.pan.2020.11.017] [Citation(s) in RCA: 19] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/24/2020] [Revised: 08/16/2020] [Accepted: 11/22/2020] [Indexed: 12/11/2022]
Abstract
BACKGROUND There is a significant variability in the reported outcomes following endovascular embolization of arterial pseudoaneurysms in pancreatitis. The objective of this systematic review and meta-analysis is to evaluate the efficacy of endovascular embolization of pancreatitis-related pseudoaneurysms. METHODS Searches of MEDLINE, EMBASE, and SCOPUS databases were performed through July 1, 2019 in accordance with PRISMA guidelines. All studies with ≥10 patients reporting technical success, clinical success, complications, and mortality were included. Generalized linear mixed method with random effects model was used for assessing pooled incidence rates and corresponding 95% confidence intervals (CIs). RESULTS A total of 29 studies (n = 840 with 638 pseudoaneurysms) were included. The pooled incidence rates of pseudoaneurysms in acute and chronic pancreatitis were 0.05% and 0.03%, respectively (odds ratio, 0.91, 95% CI-0.24-3.43). The most common site of pseudoaneurysm was splenic artery (37.7%). The most common embolization agent was coil (n = 415). The follow up period was 54.7 months (range, 21 days to 40.5 months). Pooled technical success rate was 97% (95% CI-92-99%, I2 83%). Clinical success rates at ≤3 months, 3-12 months, and >12 months were 82% (95% CI-70-90%, I2 42%), 86% (95% CI-75-92%, I2 44%), and 88% (95% CI-83-91%, I2 0%), respectively. There was no significant difference in the technical or clinical success between acute and chronic pancreatitis on subgroup analysis. Mortality was lower in chronic pancreatitis (OR 4.27 (95% CI 1.35-13.53, I2 0%)). Splenic infarction was the most common complication (n = 47). CONCLUSION Endovascular embolization is associated with a high technical and clinical success.
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Affiliation(s)
- Sathya Sagar
- Department of Radiodiagnosis, Postgraduate Institute of Medical Education and Research (PGIMER), Chandigarh, 160012, India
| | - Raghuraman Soundarajan
- Department of Radiodiagnosis, Postgraduate Institute of Medical Education and Research (PGIMER), Chandigarh, 160012, India
| | - Pankaj Gupta
- Department of Radiodiagnosis, Postgraduate Institute of Medical Education and Research (PGIMER), Chandigarh, 160012, India.
| | - M Praveen Kumar
- Department of Pharmacology, Pharmacology, Postgraduate Institute of Medical Education and Research (PGIMER), Chandigarh, 160012, India
| | - Jayanta Samanta
- Department of Gastroenterology, Postgraduate Institute of Medical Education and Research (PGIMER), Chandigarh, 160012, India
| | - Vishal Sharma
- Department of Gastroenterology, Postgraduate Institute of Medical Education and Research (PGIMER), Chandigarh, 160012, India
| | - Rakesh Kochhar
- Department of Gastroenterology, Postgraduate Institute of Medical Education and Research (PGIMER), Chandigarh, 160012, India
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Mitrovic M, Dugalic V, Kovac J, Tadic B, Milosevic S, Lukic B, Lekic N, Cvetic V. Successful Embolization of Posterior Inferior Pancreaticoduodenal Artery Pseudoaneurysm on the Grounds of Chronic Pancreatitis-Case Report and Literature Review. ACTA ACUST UNITED AC 2020; 56:medicina56110617. [PMID: 33207736 PMCID: PMC7696778 DOI: 10.3390/medicina56110617] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/05/2020] [Revised: 11/11/2020] [Accepted: 11/12/2020] [Indexed: 12/18/2022]
Abstract
Pancreatic pseudoaneurysm is a rare but life-threatening clinical entity. In this paper, we present a case of a 74-year-old man, who was admitted to our clinic with a diagnosis of an acute on chronic pancreatitis complicated by walled-off-pancreatic-necrosis, with subsequent development of peripancreatic pseudoaneurysm. After initial conservative management, the patient recovered and was discharged from the hospital. However, he soon returned feeling anxious due to a pulsatile abdominal mass. Abdominal Color–Doppler examination, CT scan, and angiography revealed large pancreatic necrotic collection in the total size of 9 cm, with centrally enhancing area of 3.5 cm that corresponded to pseudoaneurysm originating from the posterior pancreaticoduodenal vascular arcade. Considering the size, location of the pseudoaneurysm, feeding vessel, and poor general patients condition, we opted for minimally invasive treatment. Pseudoaneurysm was successfully managed by endovascular coil embolization, i.e., “sandwich technique”.
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Affiliation(s)
- Milica Mitrovic
- Center for Radiology and Magnetic Resonance Imaging, Clinical Centre of Serbia, Pasterova No. 2, 11000 Belgrade, Serbia; (M.M.); (J.K.); (S.M.); (B.L.); (V.C.)
| | - Vladimir Dugalic
- Department for HPB Surgery, Clinic for Digestive Surgery, Clinical Centre of Serbia, Koste Todorovica Street, No. 6, 11000 Belgrade, Serbia; (V.D.); (N.L.)
- Department for Surgery, Faculty of Medicine, University of Belgrade, Dr Subotica No. 8, 11000 Belgrade, Serbia
| | - Jelena Kovac
- Center for Radiology and Magnetic Resonance Imaging, Clinical Centre of Serbia, Pasterova No. 2, 11000 Belgrade, Serbia; (M.M.); (J.K.); (S.M.); (B.L.); (V.C.)
- Department for Radiology, Faculty of Medicine, University of Belgrade, Dr Subotica No. 8, 11000 Belgrade, Serbia
| | - Boris Tadic
- Department for HPB Surgery, Clinic for Digestive Surgery, Clinical Centre of Serbia, Koste Todorovica Street, No. 6, 11000 Belgrade, Serbia; (V.D.); (N.L.)
- Department for Surgery, Faculty of Medicine, University of Belgrade, Dr Subotica No. 8, 11000 Belgrade, Serbia
- Correspondence: ; Tel.: +381-62-388-288
| | - Stefan Milosevic
- Center for Radiology and Magnetic Resonance Imaging, Clinical Centre of Serbia, Pasterova No. 2, 11000 Belgrade, Serbia; (M.M.); (J.K.); (S.M.); (B.L.); (V.C.)
| | - Borivoje Lukic
- Center for Radiology and Magnetic Resonance Imaging, Clinical Centre of Serbia, Pasterova No. 2, 11000 Belgrade, Serbia; (M.M.); (J.K.); (S.M.); (B.L.); (V.C.)
- Department for Radiology, Faculty of Medicine, University of Belgrade, Dr Subotica No. 8, 11000 Belgrade, Serbia
| | - Nebojsa Lekic
- Department for HPB Surgery, Clinic for Digestive Surgery, Clinical Centre of Serbia, Koste Todorovica Street, No. 6, 11000 Belgrade, Serbia; (V.D.); (N.L.)
- Department for Surgery, Faculty of Medicine, University of Belgrade, Dr Subotica No. 8, 11000 Belgrade, Serbia
| | - Vladimir Cvetic
- Center for Radiology and Magnetic Resonance Imaging, Clinical Centre of Serbia, Pasterova No. 2, 11000 Belgrade, Serbia; (M.M.); (J.K.); (S.M.); (B.L.); (V.C.)
- Department for Radiology, Faculty of Medicine, University of Belgrade, Dr Subotica No. 8, 11000 Belgrade, Serbia
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Larger bore percutaneous catheter in necrotic pancreatic fluid collection is associated with better outcomes. Eur Radiol 2020; 31:3439-3446. [PMID: 33151396 DOI: 10.1007/s00330-020-07411-6] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/31/2020] [Revised: 09/03/2020] [Accepted: 10/12/2020] [Indexed: 02/07/2023]
Abstract
OBJECTIVE To evaluate the impact of initial catheter size on the clinical outcomes in acute pancreatitis (AP). METHODS This retrospective study comprised consecutive patients with AP who underwent percutaneous catheter drainage (PCD) between January 2018 and May 2019. Three hundred fifteen consecutive patients underwent PCD during the study period. Based on the initial catheter size, patients were divided into group I (≤ 12 F) and group II (> 12 F). The differences in the clinical outcomes between the two groups, as well as multiple subgroups (based on the severity, timing of drainage, and presence of organ failure (OF)), were evaluated. RESULTS One hundred forty-six patients (mean age, 41.2 years, 114 males) fulfilled the inclusion criteria. Ninety-nine (67.8%) patients had severe AP based on revised Atlanta classification. The mean pain to PCD was 22 days (range, 3-267 days). Mean length of hospitalization (LOH) was 27.9 ± 15.8 days. Necrosectomy was performed in 20.5% of patients, and mortality was 16.4%. Group I and II comprised 74 and 72 patients, respectively. There was no significant difference in baseline characteristics, except for a greater number of patients with OF in group II (p = 0.048). The intensive care unit stay was significantly shorter, and multiple readmissions were less frequent in group II (p = 0.037 and 0.013, respectively). Patients with severe AP and moderately severe AP in group II had significantly reduced rates of readmissions (p = 0.035) and significantly shorter LOH (p = 0.041), respectively. CONCLUSION Large-sized catheters were associated with better clinical outcomes regardless of disease severity and other baseline disease characteristics. KEY POINTS • Larger catheter size for initial PCD was associated with better clinical outcomes in AP. • The benefits were independent of the severity of AP, timing of PCD (ANC vs. WON) and presence of organ failure.
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Anand A, Gunjan D, Agarwal S, Kaushal K, Sharma S, Gopi S, Mohta S, Madhusudhan KS, Singh N, Saraya A. Vascular complications of chronic pancreatitis: A tertiary center experience. Pancreatology 2020; 20:1085-1091. [PMID: 32800648 DOI: 10.1016/j.pan.2020.07.005] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/11/2020] [Revised: 06/22/2020] [Accepted: 07/10/2020] [Indexed: 12/11/2022]
Abstract
INTRODUCTION Vascular complications such as venous thrombosis (VT) and pseudoaneurysm are not uncommon in patients with chronic pancreatitis (CP). The aim of this study to was to evaluate the prevalence and risk factors for vascular complications in patients with CP. METHODS A retrospective analysis of a prospectively maintained database of patients with CP presenting from January 2002 to August 2019 was performed. Venous thrombosis and pseudoaneurysm were identified using radiological imaging, and their risk factors were identified using multivariate Cox-proportional hazards. RESULTS Of 1363 patients with CP, 166 (12.2%) had vascular complications. Isolated VT was present in 132, pseudoaneurysm in 17, and both in 17 patients. They were more commonly seen in males and alcoholic CP (ACP), and less commonly in patients with pancreatic atrophy and calcification. It involved the vessels in the closest proximity to the pancreas, VT most commonly involving the splenic vein whereas pseudoaneurysm most commonly involved the splenic artery. Alcoholic CP [odds ratio (OR) 2.1, p = 0.002], pseudocyst (OR 4.6, p < 0.001) and inflammatory head mass (OR 3.1, p = 0.006) were independent risk factors for VT, whereas ACP (OR 3.49, p = 0.006) and pseudocyst (OR 3.2, p = 0.002) were independent risk factors for pseudoaneurysm. Gastrointestinal bleed occurred in 3.5% patients, and more commonly in patients with pseudoaneurysm than VT (64.7% vs 15.9%), and in patients with ACP in comparison to other etiologies (p < 0.001). CONCLUSION Vascular complications are a common complication of CP, VT being more frequent than pseudoaneurysm. Pseudocyst and ACP are independent risk factors for the development of vascular complications.
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Affiliation(s)
- Abhinav Anand
- Department of Gastroenterology and Human Nutrition Unit, All India Institute of Medical Sciences, New Delhi, 110029, India
| | - Deepak Gunjan
- Department of Gastroenterology and Human Nutrition Unit, All India Institute of Medical Sciences, New Delhi, 110029, India
| | - Samagra Agarwal
- Department of Gastroenterology and Human Nutrition Unit, All India Institute of Medical Sciences, New Delhi, 110029, India
| | - Kanav Kaushal
- Department of Gastroenterology and Human Nutrition Unit, All India Institute of Medical Sciences, New Delhi, 110029, India
| | - Sanchit Sharma
- Department of Gastroenterology and Human Nutrition Unit, All India Institute of Medical Sciences, New Delhi, 110029, India
| | - Srikanth Gopi
- Department of Gastroenterology and Human Nutrition Unit, All India Institute of Medical Sciences, New Delhi, 110029, India
| | - Srikant Mohta
- Department of Gastroenterology and Human Nutrition Unit, All India Institute of Medical Sciences, New Delhi, 110029, India
| | | | - Namrata Singh
- Department of Gastroenterology and Human Nutrition Unit, All India Institute of Medical Sciences, New Delhi, 110029, India
| | - Anoop Saraya
- Department of Gastroenterology and Human Nutrition Unit, All India Institute of Medical Sciences, New Delhi, 110029, India.
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Complications of Percutaneous Drainage in Step-Up Approach for Management of Pancreatic Necrosis: Experience of 10 Years from a Tertiary Care Center. J Gastrointest Surg 2020; 24:598-609. [PMID: 31845144 DOI: 10.1007/s11605-019-04470-z] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/20/2019] [Accepted: 11/06/2019] [Indexed: 01/31/2023]
Abstract
INTRODUCTION Percutaneous catheter drainage (PCD) as initial intervention in necrotizing pancreatitis has led to improved outcomes and obviated need for surgery in a significant proportion. However, there can be difficulty in accessing deep-seated necrotic collections by percutaneous catheter and complications are likely. METHODS The present study involves a retrospective analysis of a prospectively maintained database of patients with necrotizing pancreatitis managed by a step-up approach. All patients who underwent PCD were studied for catheter-related complications. RESULTS A total of 707 PCD catheters were used in 314 patients (median 2, interquartile range IQR 1-3). The total number of interventions were 1194 (median 3, IQR 2-5). Enteric communication was seen in 8.9%, of which colonic fistula occurred in 71.4%, duodenal in 17.8%, and jejunal in 10.7% of patients. Majority (78.5%) of the fistulae were managed conservatively by withdrawal of the drain. Operative management was required in 30% of colonic and 40% of duodenal fistulae. Need for surgery, length of hospital stay, and mortality were not significantly different between patients with and without fistulae. Bleeding complications were seen in 7.3% of patients, out of which 34.7% were managed conservatively, 21.7% required angioembolization of pseudo-aneurysms, and 34.7% needed surgery. Patients with bleeding had significantly higher requirement for surgery and mechanical ventilation compared to those with no bleeding. There was no significant increase in hospital stay, ICU stay, and mortality. CONCLUSION Hollow viscus and vascular injuries are important complications seen with catheter drainage of necrotic collections. Majority of patients with enteric communication were managed conservatively, with no added morbidity or mortality. Bleeding complications related to PCD had higher requirement for surgical intervention, but mortality rates remained similar to those of patients with no bleeding complications.
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