Interventional and surgical treatment of pancreatic abscess

Evaluation of viscosities of typical drainage fluids to promote more evidence-based catheter size selection

Percutaneous drainage is a first-line therapy for abscesses and other fluid collections. However, experimental data on the viscosity of body fluids are scarce. This study analyses the apparent viscosity of serous, purulent and biliary fluids to provide reference data for the evaluation of drainage catheters. Serous, purulent and biliary fluid samples were collected during routine drainage procedures. In a first setup, the apparent kinematic viscosity of 50 fluid samples was measured using an Ubbelohde viscometer. In a second setup, the apparent dynamic viscosity of 20 fluid samples obtained during CT-guided percutaneous drainage was measured using an in-house designed capillary extrusion experiment. The median apparent kinematic viscosity was 0.96 mm2/s (IQR 0.90-1.15 mm2/s) for serous samples, 0.98 mm2/s (IQR 0.97-0.99 mm2/s) for purulent samples and 2.77 mm2/s (IQR 1.75-3.70 mm2/s) for biliary samples. The median apparent dynamic viscosity was 1.63 mPa*s (IQR 1.27-2.09 mPa*s) for serous samples, 2.45 mPa*s (IQR 1.69-3.22 mPa*s) for purulent samples and 3.50 mPa*s (IQR 2.81-3.90 mPa*s) for biliary samples (all differences p < 0.01). Relative to water, dynamic viscosities were increased by a factor of 1.36 for serous fluids, 2.26 for purulent fluids, and 4.03 for biliary fluids. Serous fluids have apparent viscosities similar to water, but biliary and purulent fluids are more viscous. These data can be used as a reference when selecting the drainage catheter size, with 8F catheters being appropriate for most percutaneous drainage cases.

Medical and surgical management of pancreatic fluid accumulations in dogs: A retrospective study of 15 cases

BACKGROUND

Limited data exist on the diagnosis and successful medical management of suspected pancreatic abscessation, and the appropriate terminology of this condition.

HYPOTHESIS/OBJECTIVES

To describe the diagnosis and management of pancreatic fluid accumulations in dogs where pancreatic fluid cytology results were available, to describe those medically and surgically managed at the same institution, and reconsider the terminology describing acute pancreatitis with pancreatic fluid accumulation.

ANIMALS

Fifteen dogs treated for suspected pancreatic abscessation at a university teaching hospital between January 2010 and March 2020.

METHODS

Retrospective descriptive study.

RESULTS

Ultrasonographic findings described pancreatic fluid accumulations as hypoechoic in 10/15 and anechoic in 2/15 cases, ranging between 1.6 and 7 cm in diameter (median, 3.5 cm). No complications were documented after ultrasound guided fine-needle aspiration. Cytologically, all samples revealed a predominantly neutrophilic inflammation. 11/15 samples yielded a negative culture (9/11 received antimicrobials before sampling) and in 4 cases culture was positive. 7/15 were initially managed surgically including all 4 infected cases. 4/7 surgically managed cases were discharged, including 2 infected cases. The remaining 3/7 surgically managed cases were euthanized due poor quality of life. 8/15 cases were managed medically; 7/8 were discharged, 1 died. 3/7 then represented, and underwent successful surgical intervention after recrudescence of clinical signs, and all were discharged. The remaining 4 medically managed cases did not require further therapeutic intervention, with no clinical deterioration on reassessment.

CONCLUSIONS AND CLINICAL IMPORTANCE

Medical management is a viable treatment option for some dogs with pancreatic fluid accumulation, or as a prequel to surgical management. Subclassifications of pancreatic fluid accumulations using diagnostic findings could enable more tailored management approaches and accurate prognostication.

ACR Appropriateness Criteria® Radiologic Management of Infected Fluid Collections

Infected fluid collections are common and occur in a variety of clinical scenarios throughout the body. Minimally invasive image-guided management strategies for infected fluid collections are often preferred over more invasive options, given their low rate of complications and high rates of success. However, specific clinical scenarios, anatomic considerations, and prior or ongoing treatments must be considered when determining the optimal management strategy. As such, several common scenarios relating to infected fluid collections were developed using evidence-based guidelines for management. The American College of Radiology Appropriateness Criteria are evidence-based guidelines for specific clinical conditions that are reviewed annually by a multidisciplinary expert panel. The guideline development and revision include an extensive analysis of current medical literature from peer reviewed journals and the application of well-established methodologies (RAND/UCLA Appropriateness Method and Grading of Recommendations Assessment, Development, and Evaluation or GRADE) to rate the appropriateness of imaging and treatment procedures for specific clinical scenarios. In those instances where evidence is lacking or equivocal, expert opinion may supplement the available evidence to recommend imaging or treatment.

Minimally invasive percutaneous catheter drainage versus open laparotomy with temporary closure for treatment of abdominal compartment syndrome in patients with early-stage severe acute pancreatitis

This study aimed to examine the clinical efficacy of minimally invasive percutaneous catheter drainage (PCD) versus open laparotomy with temporary closure in the treatment of abdominal compartment syndrome (ACS) in patients with early-stage severe acute pancreatitis (SAP). Clinical data of 212 patients who underwent PCD and 61 patients who were given open laparotomy with temporary closure in our hospital over the last 10-year period were retrospectively analyzed, and outcomes were compared, including total and post-decompression intensive care unit (ICU) and hospital stays, physiological data, organ dysfunction, complications, and mortality. The results showed that the organ dysfunction scores were similar between the PCD and open laparotomy groups 72 h after decompression. In the PCD group, 134 of 212 (63.2%) patients required postoperative ICU support versus 60 of 61 (98.4%) in the open laparotomy group (P<0.001). Additionally, 87 (41.0%) PCD patients experienced complications as compared to 49 of 61 (80.3%) in the open laparotomy group (P<0.001). There were 40 (18.9%) and 32 (52.5%) deaths, respectively, in the PCD and open laparotomy groups (P<0.001). In conclusion, minimally invasive PCD is superior to open laparotomy with temporary closure, with fewer complications and deaths occurring in PCD group.

Laparoscopic pancreatic resections

PURPOSE

Pancreatic surgery is technically complex and requires considerable expertise. Laparoscopic pancreatic surgery adds the need for considerable experience with advanced laparoscopic techniques. Despite the technical difficulties, an increasing number of centers propagate the use of laparoscopy in pancreatic surgery over the last decade.

METHODS

In this review, we provide an overview of the literature regarding the advantages and disadvantages of laparoscopic pancreatic surgery. Larger prospective randomized studies have emerged in the subset of laparoscopic or retroperitoneoscopic surgery for acute pancreatitis, considerable single center experience has been reported for laparoscopic pancreatic tail resection, and laparoscopic pancreatic head resection, however, is still restricted to a few experienced centers worldwide.

RESULTS AND CONCLUSIONS

Laparoscopic pancreatic surgery is becoming more and more established, in particular for the treatment of benign and premalignant lesions of the pancreatic body and tail. It has been shown to decrease postoperative pain, narcotic use, and length of hospital stay in larger single center experience. However, prospective trials are needed in laparoscopic resective pancreatic surgery to evaluate its advantages, safety, and efficacy in the treatment of pancreatic neoplasms and in particular in malignant pancreatic tumors.

Video-assisted Laparoscopic Débridement for Retroperitoneal Pancreatic Collections: A Reliable Step-up Approach

Several minimal access routes have been implemented as a step-up approach to treat infected pancreatic necrosis. We evaluate our experience with a series of consecutive patients with pancreatic collections treated with video-assisted retroperitoneal débridement (VARD). Seven patients were consecutively treated with VARD: five patients after acute necrotizing pancreatitis, one chronic pancreatitis, and one patient with perforation after endoscopic sphincterotomy. The indication for VARD was: development of sepsis, positive direct culture of the necrosis, and compartment syndrome. The procedure was performed under general anesthesia and modified lateral decubitus. There were four left, two right, and one bilateral VARD. Mean hospital stay since admission to VARD procedure was 30 days (range, 12 to 72 days). Mean operative time was 63 minutes. There were no intraoperative complications. Two patients needed a second procedure to control sepsis. Most patients had a long intensive care unit (ICU) stay with 6.1 days (range, 2 to 22 days) mean postoperative ICU stay. One patient had a hypernatremia as a consequence of saline lavage and three patients presented pancreatic fistula that were managed with conservative treatment. There was no mortality. VARD approach is a recommended step-up approach to treat infected pancreatic necrosis, and its indication may be extended to treat other retroperitoneal collections.

The role of imaging-guided percutaneous procedures in the multidisciplinary approach to treatment of pancreatic fluid collections

Pancreatic fluid collections include a wide range of entities such as cystic neoplasms, both benign and malignant; vascular pathology such as pseudoaneurysms and hematomas; and a host of other entities such as pseudocysts, seromas, abscesses, and bilomas. The distinction between these entities requires correlating an often complex and overlapping clinical presentation with findings on imaging studies, typically computed tomography, magnetic resonance imaging, and ultrasound. As complex as the diagnostic work-up may be, the treatment of pancreatic collections poses its own set of challenges and often requires a multidisciplinary collaboration among interventional radiologists, surgeons, and gastroenterologists. The best treatment algorithm is determined by careful review of radiologic imaging studies combined with endoscopic retrograde cholangiopancreatography to apply therapies such as surgical resection; drainage or debridement; endoscopic ultrasound-guided drainage; aspiration or biopsy; and imaging-guided percutaneous drainage, aspiration, or biopsy. This article focuses on the diagnosis and multidisciplinary management of pancreatic fluid collections such as abscesses, pseudocysts, and necrosis.

Evolution of the Whipple procedure at the Massachusetts General Hospital

BACKGROUND

Since Allen O. Whipple published his seminal paper in 1935, the procedure that bears his name has been performed widely throughout the world and is now a common operation in major medical centers. The goal of this study was to investigate the evolution of pancreatoduodenectomy at the Massachusetts General Hospital (MGH).

METHODS

We sought to identify all pancreatoduodenectomies performed at the MGH since 1935. Cases were obtained from a computerized database, hospital medical records, and the MGH historical archive. Demographics, diagnosis, intraoperative variables and short-term surgical outcomes were recorded.

RESULTS

The first pancreatoduodenectomy at the MGH was carried out in 1941; since then, 2,050 Whipple procedures have been performed. Pancreatic ductal adenocarcinoma was the most frequent indication (36%). Pylorus preservation has been the most important variation in technique, accounting for 45% of Whipple procedures in the 1980s; observation of frequent delayed gastric emptying after this procedure led to decline in its use. Pancreatic fistula was the most frequent complication (13%). Operative blood replacement and reoperation rates have decreased markedly over time; the most frequent indication for reoperation was intra-abdominal bleeding. Mortality has decreased from 45% to 0.8%, with sepsis and hypovolemic shock being the most frequent causes of death. Mean duration of hospital stay has decreased from >30 to 9.5 days, along with an increasing readmission rate (currently 19%).

CONCLUSION

The Whipple procedure in the 21st century is a well-established operation. Improvements in operative technique and perioperative care have contributed in making it a safe operation that continues evolving.

Minimally invasive operations for acute necrotizing pancreatitis: comparison of minimally invasive retroperitoneal necrosectomy with endoscopic transgastric necrosectomy

BACKGROUND

A "step-up" approach is currently the treatment of choice for acute necrotizing pancreatitis. Our aim was to evaluate the outcome of minimally invasive retroperitoneal necrosectomy (MINE) and endoscopic transgastric necrosectomy (ETG) and to compare it to open necrosectomy (ONE).

METHODS

Patients with acute pancreatitis admitted to our institution from 1998 to 2010 (n = 334) were identified. From these, patients who underwent either ONE, MINE, or ETG were selected for further analysis. Statistical analysis employed 2-sided Fisher's exact test and Mann-Whitney U-test.

RESULTS

From 2002 to 2010, 32 patients with acute necrotizing pancreatitis were treated by minimally invasive procedures including MINE (n = 14) and ETG (n = 18) or with the classic technique of ONE (n = 30). Time from onset of symptoms to intervention was less for ONE than for MINE or ETG (median, 11 vs 39 vs 54 days; P < .05). The rate of critically ill patients with sepsis or septic shock was greatest in ONE (93%) and MINE (71%) compared with ETG (17%; P < .05). Problems after ONE and MINE were ongoing sepsis (ONE 73% vs MINE 29% vs ETG 11%) and bleeding requiring intervention (ONE 26% vs MINE 21% vs ETG 17%). A specific complication of ETG was gastric perforation into the peritoneal cavity during the procedure (28%), requiring immediate open pseudocystogastrostomy. Laparotomy was necessary in 21% after MINE and 28% after ETG owing to specific complications or persistent infected necrosis. Overall mortality was greatest after ONE (ONE 63% vs MINE 21% vs ETG 6%; P < .05).

CONCLUSION

Morbidity and mortality remains high in acute necrotizing pancreatitis. Operative procedures should be delayed as long as possible to decrease morbidity and mortality. Minimally invasive procedures can avoid laparotomy, but also introduce specific complications requiring immediate or secondary open operative treatment. Minimally invasive procedures require unique expertise and therefore should only be performed at specialized centers.

Percutaneous catheter drainage for infective pancreatic necrosis: is it always the first choice for all patients?

OBJECTIVE

To learn the clinical outcome of percutaneous catheter drainage (PCD) for patients with infective pancreatic necrosis and the possible influencing factors.

METHODS

A retrospective review of medical records of patients with infective pancreatic necrosis who received PCD as the first choice for treatment in the recent 2 years. The patients were divided into 2 groups: (1) PCD success group and (2) PCD alteration group. Characteristics, complications, and PCD process were compared.

RESULTS

In this study, 19 of 34 patients were cured by PCD alone (55.9%), whereas open necrosectomy were needed for 15 patients (44.1%). Between these 2 groups, most baseline and clinical characteristics did not show any statistical difference, including the number and size of catheter used and the bacterial culture result. The PCD alteration group had higher mean computed tomographic density (P = 0.012) and larger distribution range of infected pancreatic necrosis (4.53 ± 1.35 vs 5.93 ± 1.62; P = 0.009) than the PCD success group (P < 0.01). The logistic regression analysis revealed the same facts.

CONCLUSION

The mean computed tomographic density and distribution range of infective pancreatic necrosis could significantly influence the success rate of PCD; higher values of them indicate less appropriate for PCD; thus, it should be considered seriously before the treatment decision.

Percutaneous management of pancreatic abscesses: long term results in a single center

BACKGROUND

Several authors consider that surgical intervention is the gold standard for treatment of pancreatic abscesses. Recently, considerable interest has been generated in the minimally invasive management of pancreatic abscess with mixed results reported in the literature.

AIM

To evaluate the efficacy of percutaneous aspiration and/or drainage for patients with pancreatic abscesses.

METHODS

We performed a retrospective analysis of 62 patients with 87 pancreatic abscesses treated by percutaneous management from 1989 to 2009. All patients received appropriate antibiotic therapy. Patients with pancreatic abscess <50mm in diameter were initially treated by ultrasound-guided percutaneous needle aspiration (PNA) and those with abscess ≥50mm were initially treated by ultrasound-guided percutaneous catheter drainage (PCD). Surgery was planned only when there was no clinical improvement after the initial percutaneous treatment. Primary outcome was conversion rate to surgery.

RESULTS

Two patients (3.2%) received supportive treatment only and one of them died. PNA was performed in 16 patients (25.8%), and 8 of them required PCD because of recurrence of abscess. In 44 patients (70.1%), PCD was performed initially. PCD was performed twice in 6 patients and 3 times in 2 patients. There were 5 patients converted to surgery (8.1%) and one of them died. Medians (interquartile ranges) of hospital stay and catheter dwell-time were 17 (12-26) and 12 (9-21) days, respectively. There were no complications related to the procedure.

CONCLUSIONS

Percutaneous aspiration and/or drainage are effective and safe for the treatment of pancreatic abscesses.

Fluid collections in and around the pancreas in acute pancreatitis

The advent of computed tomographic scan with its wide use in the evaluation of acute pancreatitis has opened up a new topic in pancreatology i.e. fluid collections. Fluid collections in and around the pancreas occur often in acute pancreatitis and were defined by the Atlanta Symposium on Acute Pancreatitis in 1992. Two decades since the Atlanta Conference additional experience has brought to light the inadequacy and poor understanding of the terms used by different specialists involved in the care of patients with acute pancreatitis when interpreting imaging modalities and the need for a uniformly used classification system. The deficiencies of the Atlanta definitions and advances in medicine have led to a proposed revision of the Atlanta classification promulgated by the Acute Pancreatitis Classification Working Group. The newly used terms "acute peripancreatic fluid collections," "pancreatic pseudocyst," "postnecrotic pancreatic/peripancreatic fluid collections," and "walled-off pancreatic necrosis" are to be clearly understood in the interpretation of imaging studies. The current treatment methods for fluid collections are diverse and depend on accurate interpretations of radiologic tests. Management options include conservative treatment, percutaneous catheter drainage, open and laparoscopic surgery, and endoscopic drainage. The choice of treatment depends on a correct diagnosis of the type of fluid collection. In this study we have attempted to clarify the management and clinical features of different types of fluid collections as they have been initially defined under the 1992 Atlanta Classification and revised by the Working Group's proposed categorization.

Systematic review of percutaneous catheter drainage as primary treatment for necrotizing pancreatitis

BACKGROUND

The role of percutaneous catheter drainage (PCD) in patients with (infected) necrotizing pancreatitis was evaluated.

METHODS

A systematic literature search was performed. Inclusion criteria were: consecutive cohort of patients with necrotizing pancreatitis undergoing PCD as primary treatment for peripancreatic collections; indication for PCD either (suspected) infected necrosis or symptomatic sterile pancreatic necrosis; and outcomes reported to include percentage of infected peripancreatic collections, need for additional surgical necrosectomy, complications and deaths. Exclusion criteria were: cohort of fewer than five patients; cohort included patients with chronic pancreatitis; selected subgroup of patients with acute pancreatitis studied, such as those with pseudocysts, pancreatic abscesses and/or exclusively sterile pancreatic necrosis; and cohort in which PCD was combined with another minimally invasive strategy and results for PCD alone not reported separately.

RESULTS

Eleven studies, including 384 patients, fulfilled the inclusion criteria. Only one study was a randomized controlled trial; most others were retrospective case series. Four studies reported on the presence of organ failure before PCD; this occurred in 67·2 per cent of 116 patients. Infected necrosis was proven in 271 (70·6 per cent) of 384 patients. No additional surgical necrosectomy was required after PCD in 214 (55·7 per cent) of 384 patients. Complications consisted mostly of internal and external pancreatic fistulas. The overall mortality rate was 17·4 per cent (67 of 384 patients). Nine of 11 studies reported mortality separately for patients with infected necrosis undergoing PCD; the mortality rate in this group was 15·4 per cent (27 of 175).

CONCLUSION

A considerable number of patients can be treated with PCD without the need for surgical necrosectomy.

Infected pancreatic necrosis: minimizing the cut

The challenge for the pancreatologist managing patients with infected pancreatic necrosis is to devise a treatment algorithm that enables recovery but at the same time limits the morbidity and mortality. The current gold standard remains open necrosectomy. Recent literature contains scattered reports of endoscopic, radiologic, laparoscopic, percutaneous and lumbotomy approaches to managing patients with this condition. This literature review addresses the role of techniques that aim to minimize the physiological insult to the patient with infected pancreatic necrosis.

ACR Appropriateness Criteria on percutaneous catheter drainage of infected fluid collections

Abnormal fluid collections occur throughout the body and represent a wide range of pathologies, including abscesses, pseudocysts, cysts, lymphoceles, seromas, bilomas, hematomas, urinomas, and infected neoplasms. Appropriate management often depends on clinical presentation, location, type of collection, early response to treatment, and the presence of complicating factors such as fistulas, septations, and increased viscosity. Physicians should carefully review clinical and imaging findings and make evidence-based recommendations for the best treatment, which may include antibiotics, needle aspiration, percutaneous drainage, endoscopic drainage, or surgical drainage. This paper addresses percutaneous catheter drainage and alternative treatment options for the management of fluid collections and is the result of evidence-based consensus by the ACR Appropriateness Criteria Expert Panel on Interventional Radiology.

Percutaneous "stepped" drainage technique for infected pancreatic necrosis

INTRODUCTION

Aggressive surgical pancreatic debridement remains the standard of care, may require multiple abdominal explorations and is associated with high mortality. We have introduced the stepped technique of percutaneous treatment of infected peripancreatic fluid collections.

METHODS

We performed a retrospective review of patients with severe infected necrotizing pancreatitis who were managed percutaneously. Culture results, number of radiological interventions, length of stay, and complications were recorded.

RESULTS

There were 8 patients with a median number of Ranson's criteria of 4.5. Sixty invasive procedures were performed. A median number of two separate catheter sites per patient were necessary for the removal of necrotic material. Median duration of percutaneous intervention was 71.5 days with complete removal of necrotic material and resolution of infected collections in all patients.

CONCLUSIONS

Surgeons and interventional radiologists should be familiar with this evolving technique which is less invasive then surgery, but may prolong the time necessary for complete resolution.

[Minimally invasive interventions in the treatment of pancreatic diseases]

We have used minimal invasive therapy in the treatment of pancreatic diseases for a long time. CT and/or ultrasound guided techniques have been used for the treatment of pancreatic pseudocysts for more than 20 years. The development of technology has also made an opportunity for the extensive use of laparoscopic surgery at patients suffering from pancreatic diseases. Currently, almost every type of open operation has a laparoscopic version, too. By now we can take part in the combined use of the CT/US and laparoscopic techniques. Recently the new NOTES procedures have appeared. Based on the literary items, the author summarizes the possibilities of minimal invasive treatments in pancreatic diseases.

Minimally invasive and standard surgical therapy for complications of pancreatitis and for benign tumors of the pancreas and duodenal papilla

The treatment of severe pancreatitis and its complications is rapidly evolving because of increasing clinical application of effective, minimally invasive techniques. With ongoing innovations in therapeutic endoscopy, image-guided percutaneous techniques, and minimally invasive surgery, the long-standing traditional management algorithms have recently changed. A multidisciplinary approach is necessary for the treatment of complicated inflammatory diseases of the pancreas and benign periampullary tumors. Surgeons, gastroenterologists, and therapeutic radiologists combine expertise as members of a team to offer their patients improved outcomes and faster recovery.

Pancreatic mass with an unusual pathology: a case report

Intra-abdominal abscesses formation in patients with no preceding symptoms is rare. Infection of the pancreas occurs in 5–9% of patients with acute pancreatitis, more commonly as a complication of necrotising or severe pancreatitis. We have reported a case of a 64-year-old almost entirely asymptomatic man who underwent a Whipple's procedure following extensive investigation of a pancreatic mass. The pathology and histology showed no evidence of malignancy, and instead a true pancreatic abscess, centred around an impacted cholesterol calculus in the distal CBD. Of suspicious pancreatic masses that are resected, chronic choledocholithiasis is the aetiology in less than 5% of nonmalignant or “false positives.” This report describes such a case.

Role of interventional radiology in the management of complications after pancreaticoduodenectomy

BACKGROUND

This study evaluated the role of interventional radiology (IR) procedures to manage complications after pancreaticoduodenectomy.

METHODS

A retrospective review was made of the records of patients with postsurgical complications managed with IR.

RESULTS

Among the 440 patients reviewed, the mortality, morbidity and reoperation rates were 1.6%, 36%, and 2%, respectively. Complications occurred in 159 patients, of which 39 (25%) required > or = 1 IR procedures. Of those 39 patients, 72% underwent percutaneous drainage of an intra-abdominal abscess, 18% underwent percutaneous biliary drainage, and 10% underwent angiography for gastrointestinal bleeding or pseudoaneurysm. The reoperation rate among the 159 patients with complications was 6% (n = 9). Reoperation was avoided in 90% of patients receiving IR. Four patients underwent reoperation despite IR for persistent abscess, pancreatic fistula, anastomotic disruption, or mesenteric venous bleeding.

CONCLUSIONS

The majority of complications occurring after pancreaticoduodenectomy can be managed effectively using IR, thus minimizing morbidity and the need for reoperation.

Minimally invasive necrosectomy for infected necrotizing pancreatitis

OBJECTIVES

Infected necrotizing pancreatitis represents a serious and therapeutically challenging complication. Percutaneous drainage of infected pancreatic necrosis is often unsuccessful. Alternatively, open necrosectomies are associated with high morbidity. Recently, minimally invasive necrosectomy techniques have been tried with satisfying results; however, they frequently necessitate multiple sessions for definitive necrosectomy. To evaluate results of single large-port laparoscopic necrosectomy for proven infected necrotizing pancreatitis.

METHODS

Eight patients presenting proven infected pancreatic necrosis during course of acute pancreatitis and not responding to radiological drainage were prospectively offered minimally invasive necrosectomy. Laparoscopic necrosectomy were performed using a single large port placed along the drain tract directly into the infected necrosis. In all patients, drainage was placed during laparoscopic necrosectomy for continuous postoperative lavage.

RESULTS

No perioperative complications were recorded with a median operative time of 87 +/- 42 minutes. No blood transfusions were needed. No surgical postoperative morbidity and mortality were recorded. In all cases, except for one patient with multiple abscesses, only one session of necrosectomy was sufficient to completely clear the necrotic abscess. Laparoscopic necrosectomy was successful in all patients, and none required complementary surgical or radiological treatment.

CONCLUSIONS

Minimally invasive necrosectomy has been safe and highly efficient through single large-port laparoscopy for infected pancreatic necrosis in our series of patients. Minimally invasive necrosectomy is a promising technique for infected necrotizing pancreatitis and should be regarded as a valid therapeutic option for necrotizing pancreatitis.

The Atlanta Classification of acute pancreatitis revisited

BACKGROUND

In a complex disease such as acute pancreatitis, correct terminology and clear definitions are important. The clinically based Atlanta Classification was formulated in 1992, but in recent years it has been increasingly criticized. No formal evaluation of the use of the Atlanta definitions in the literature has ever been performed.

METHODS

A Medline literature search sought studies published after 1993. Guidelines, review articles and their cross-references were reviewed to assess whether the Atlanta or alternative definitions were used.

RESULTS

A total of 447 articles was assessed, including 12 guidelines and 82 reviews. Alternative definitions of predicted severity of acute pancreatitis, actual severity and organ failure were used in more than half of the studies. There was a large variation in the interpretation of the Atlanta definitions of local complications, especially relating to the content of peripancreatic collections.

CONCLUSION

The Atlanta definitions for acute pancreatitis are often used inappropriately, and alternative definitions are frequently applied. Such lack of consensus illustrates the need for a revision of the Atlanta Classification.

Toward an update of the atlanta classification on acute pancreatitis: review of new and abandoned terms

OBJECTIVES

The 1992 Atlanta classification is a clinically based classification system that defines the severity and complications of acute pancreatitis. The purpose of this review was to assess whether the terms abandoned by the Atlanta classification are really discarded in the literature. The second objective was to review what new terms have appeared in the literature since the Atlanta symposium.

METHODS

We followed a Medline search strategy in review and guideline articles after the publication of the Atlanta classification. This search included the abandoned terms: "phlegmon," "infected pseudocyst," "hemorrhagic pancreatitis," and "persistent pancreatitis."

RESULTS

A total of 239 publications were reviewed, including 10 guideline articles and 42 reviews. The abandoned terms "hemorrhagic pancreatitis" and "persistent pancreatitis" are hardly encountered, in contrast, both "infected pseudocyst" and "phlegmon" are frequently used, and several authors question their abandonment. New terminology in acute pancreatitis consists of "organized pancreatic necrosis," "necroma," "extrapancreatic necrosis," and "central gland necrosis."

CONCLUSIONS

This review demonstrates that the Atlanta classification is still not universally accepted. Several abandoned terms are frequently used, and new terms have emerged that describe manifestations in acute pancreatitis that were not specifically addressed during the Atlanta symposium.

The role of percutaneous external drainage in the treatment of fluid collections associated with severe acute pancreatitis. What, when and how to drain?

A súlyos akut pancreatitist kísérő folyadékgyülem-képződéssel járó lokális szövődmények perkután drenázskezelése, főleg steril esetekben, nem széles körben alkalmazott eljárás. Jelen közlemény célja a perkután drenázs indikációjának, technikájának, korlátjainak és eredményének elemzése az irodalom alapján. A perkután drenázskezelés a súlyos akut pancreatitist kísérő akut folyadékgyülem, az akut pseudocysta és a hasnyálmirigytályog, valamint az elfolyósodott nekrózis kezelésében jelentős szerepet játszik. A fertőzött folyadékgyülemek kezelésére a perkután drenázs mint első kezelés ajánlható. A steril akut folyadékgyülem és pseudocysta kezelésében a drenázskezelés, a sterilitás szabályainak fokozott betartása mellett, a iatrogén fertőzés relatív gyakorisága miatt csak komoly panaszokat okozó esetekben ajánlott. Az elfolyósodott steril és szeptikus nekrózis kezelésében a legjobb eredménnyel a 20–30F vastagságú katéterekkel végzett drenázskezelés, a „sinus tract endoscopy” és a laparoszkóppal asszisztált necrectomia kecsegtet. Az esetek több mint 25%-ában a drenázs a konzervatív kezelés mellett a beteg végleges gyógyulásához vezet. Más esetekben a műtét időpontjának prolongálására, a „korai” műtét elkerülésére hasznos eljárás.

Feasibility of minimally invasive approaches in patients with infected necrotizing pancreatitis

Background

Minimally invasive procedures to treat infected necrotizing pancreatitis (INP) are gaining popularity. The proportion of patients suitable for this approach remains unknown.

Methods

Preoperative computed tomography (CT) scans were reviewed from 106 consecutive patients who had surgery for INP between 2000 and 2003 in 11 Dutch hospitals. Collections related to the pancreas were classified according to their distance from the left abdominal wall. Five radiologists judged ‘accessibility’ for drain placement and the likelihood that there was a fluid component that would drain (‘drainability’). Agreement between radiologists was determined.

Results

CT scans of 80 (75 per cent) patients were available (59 men; age range 29–80 years). The median interval between hospital admission and preoperative CT scan was 20 days. In 55 (69 per cent) patients, the lateral border of the collection was less than 5 cm from the left abdominal wall. Placement of a drain was deemed feasible in 67 (84 (range 77–89) per cent) patients; mean(s.d.) kappa 0·428(0·096). In 45 (56 per cent) patients, a drain could be placed through the left retroperitoneum. In 43 (54 (range 49–82) per cent) patients, collections were judged to contain a drainable fluid component. Interobserver agreement on ‘drainability’ was poor, mean(s.d.) kappa 0·289(0·101).

Conclusion

Most peripancreatic collections in INP were considered accessible to a minimally invasive approach.

No debridement is necessary for symptomatic or infected acute necrotizing pancreatitis: delayed, mini-retroperitoneal drainage for acute necrotizing pancreatitis without debridement and irrigation

We sought to determine if necrosectomy can be omitted for complicated acute necrotizing pancreatitis (ANP). Since 1996, we prospectively performed retroperitoneal drainage by introducing a sump drain to the pancreatic head area via a small left flank incision without debridement and irrigation on 19 consecutive complicated ANP patients. We purposely delayed surgery until liquefaction of retroperitoneal tissue reached the left flank. Our patients had a mean Ranson's and APACHE II score of 5.9 (range, 4-8) and 20.1(range, 4-45), respectively. Sixteen available CT showed retroperitoneal liquefaction after 21.3 days (range, 14-26). Operations were delayed for 4.7 weeks (range, 1.3-9.0). No patient succumbed during this period. The indications were infected necrosis in 16 and severe abdominal pain/food intolerance in 3 patients. Average skin incision was 4.0 cm (range, 3-9). Fungi or bacteria were cultured in 15 patients (80.0%). The recovery courses were surprisingly uneventful. Oral intake began within 2.4 days (range, 1-5) and mean hospital stay (16 survivals) was 23.2 days (range, 4-120) after operation. Drains were completely removed 120.6 days (range, 60-250) later from these outpatients. One gastric perforation and one minor duodenal leak were the only procedure-related complications (10.5%). Three patients died (15.8%), although one had a healed ANP. In conclusion, this delay-until-liquefaction strategy without necrosectomy is an easy and effective treatment method.

Surgical intervention in patients with necrotizing pancreatitis

BACKGROUND

This study evaluated the various surgical strategies for treatment of (suspected) infected necrotizing pancreatitis (INP) and patient referrals for this condition in the Netherlands.

METHODS

This retrospective study included all 106 consecutive patients who had surgical treatment for INP in the period 2000-2003 in one of eight Dutch university medical centres including three teaching hospitals. Surgical approaches included an open abdomen strategy, laparotomy with continuous postoperative lavage, minimally invasive procedures or laparotomy with primary abdominal closure. The National Hospital Registration System was searched to identify patients with acute pancreatitis who were admitted to the 90 Dutch hospitals that did not participate in the present study.

RESULTS

The overall mortality rate was 34.0 per cent, 70 per cent (16 of 23) for the open abdomen strategy, 25 per cent (13 of 53) for continuous peritoneal lavage, 11 per cent (two of 18) for minimally invasive procedures and 42 per cent (five of 12) for primary abdominal closure (P < 0.001). During the study interval, 44 (12.2 per cent) of 362 patients with acute pancreatitis who were likely to require surgical intervention had been referred to university medical centres.

CONCLUSION

Laparotomy with continuous postoperative lavage is the surgical strategy most often used in the Netherlands. The results of the open abdomen strategy are poor whereas a minimally invasive approach seems promising.

Strategic management of severe acute pancreatitis in the Jehovah's witness

Haemorrhage can be a lethal complication of severe acute pancreatitis. Management includes identification and control of the source of bleeding and supportive therapy such as blood transfusion. Individuals who refuse transfusion on the grounds of religious belief can provide a further major challenge. The management in these individuals can be focused from the outset with a strategy that aims to avert anaemia and transfusion. This article reports a case of severe acute pancreatitis in a woman of the Jehovah's Witness faith. The episode was complicated by infected pancreatic necrosis requiring surgical intervention. Careful strategic planning is critical to the management of severe acute pancreatitis in patients of the Jehovah's Witness faith. In this case, acute pancreatitis complicated by infected necrosis was successfully managed by the use of preoperative erythropoietin, venesection using paediatric blood vials, meticulous intraoperative attention to haemostasis and the use of adjunctive intraoperative techniques such as argon diathermy.

Serum elastase in the diagnosis of acute pancreatitis: a prospective study

BACKGROUND

The aim of the present study was to evaluate the usefulness of the elastase 1 (E1) enzyme-linked immunosorbent assay (ELISA) in the diagnosis of acute pancreatitis. This is the first Australian evaluation of the E1 ELISA.

METHODS

Three groups of patients were prospectively assessed: control patients, patients with acute pancreatitis, and patients with acute non-pancreatitic abdominal pain. Serum was collected on all patients on admission and the sensitivity, specificity and diagnostic accuracy of serum elastase, amylase and lipase was determined.

RESULTS

Twenty-nine patients with 30 episodes of pancreatitis, 38 patients with acute non-pancreatitic abdominal pain and 121 control patients were studied. For all patient episodes E1 ELISA at a cut-off of 3.5 ng/mL had a sensitivity of 80%, specificity of 96% and an efficiency of 94% in the diagnosis of acute pancreatitis. For episodes more than 48 h after onset of symptoms, sensitivity was 100%, specificity was 96% and diagnostic efficiency was 96%. This performance was equivalent to amylase but inferior to lipase.

CONCLUSION

Of the biochemical markers for pancreatitis currently available, lipase is the most useful. The relatively inferior sensitivity and problematic reference range for the ELISA E1, together with its limitations in measuring total elastase, currently prevent its widespread use.

Aggressive endoscopic therapy for pancreatic necrosis and pancreatic abscess: a new safe and effective treatment algorithm (videos)

BACKGROUND

Pancreatic necrosis and pancreatic abscess are severe complications of acute pancreatitis. Surgery is associated with significant morbidity and mortality in these critically ill patients. Endoscopic therapy has the potential to offer a safer and more effective alternative treatment modality. However, its role needs to be further investigated.

METHODS

This is a retrospective study of the outcome of consecutive patients with pancreatic necrosis and pancreatic abscess, all unfit to undergo surgery, who underwent a new aggressive endoscopic approach. The treatment includes (1) synchronous EUS-guided multiple transmural and/or transpapillary drainage procedures followed by balloon dilation of the cystogastrostoma or cystoduodenostoma, (2) daily endoscopic necrosectomy and saline solution lavage, and (3) sealing of pancreatic fistula by N-butyl-2-cyanoacrylate.

RESULTS

Pancreatic necrosis and pancreatic abscesses were successfully drained in 13 patients, thus avoiding emergency surgery as an initial treatment. Surgery was completely avoided in 9 patients over a median follow-up of 8.3 months (range 3-81 months). Surgery was combined with endoscopic therapy in one patient because of abscess extension into the right paracolic gutter, which was not manageable by endoscopic drainage. Because of the "disconnected-duct syndrome," two patients later developed recurrent pseudocysts and underwent elective surgery. Complications included minor bleeding after balloon dilation and necrosectomy in 4 cases, which were self limiting or controlled endoscopically.

CONCLUSIONS

This aggressive endoscopic approach shows promising results. It expands the potential for endoscopic treatment in patients with pancreatic necrosis and/or pancreatic abscess.

[Percutaneous ultrasound-guided drainage in the surgical treatment of acute severe pancreatitis]

AIM OF THE STUDY

To report results of percutaneous ultrasound-guided drainage, performed by a surgeon, in the treatment of complications of acute pancreatitis (AP), and to determine the role of this technique in the therapeutic armamentarium of severe AP.

PATIENTS AND METHODS

From 1986 to 2001, 59 patients were included in this retrospective study. All patients initially had severe necrotizing AP (mean Ranson score = 4.1 ; range : 2-7). Anatomical lesions included pancreatic abscess in 6 patients and necrosis in 53 (17 stage D and 36 stage E according to Balthazar's classification). Necrosis was infected in 42 and sterile in 11 respectively. Drainage was performed under ultrasound guidance and local anaesthesia using small-diameter drains (7-14 French).

RESULTS

Drainage was performed on average 23 days after onset of AP. Infection was proven by fine-needle aspiration in 47 (80 %) patients (41 infected necrosis and 6 localized abscess). In one patient, culture of aspirated fluid was negative but necrosis was infected (one false negative). Culture of aspirated fluid was negative and necrosis was sterile in 11 patients. Nineteen (32%) patients healed without subsequent surgery: 7 (16%) in the infected necrosis group, 6(55%) in the sterile necrosis group, and 6 (100%) in the abscess group. Forty (68%) patients had subsequent necrosectomy including 8 (14%) who died. Twenty (34 %) digestive fistulas healed spontaneously, except one treated by diversion stomia. Of the 16 (27 %) pancreatic fistulas, 6 needed subsequent interventional treatment.

CONCLUSION

In selected patients, percutaneous drainage can represent an alternative to surgery with a 14% mortality rate. The high rate of subsequent necrosectomy suggests that drains with larger diameter, possibly associated with continuous irrigation, should be used.

Trends in the management of severe acute pancreatitis: interventions and outcome

BACKGROUND

Severe acute pancreatitis (SAP) in the intensive care unit (ICU) is a complex and challenging problem. The aim of the present study was to identify trends in management of SAP patients admitted to a tertiary level ICU, and to relate these to changes in interventions and outcome.

METHODS

Patients admitted to the Department of Critical Care Medicine (DCCM), Auckland Public Hospital with SAP from 1988 to 2001 (inclusive) were identified from the DCCM prospective database, and data were extracted from several sources.

RESULTS

One hundred and twelve patients (men 69, women 43, mean age (+/-SD) 57.3 years +/- 14.3) were admitted with SAP to DCCM in the 13-year period. Aetiology was gallstones (42%), alcohol (29%), or idiopathic (29%). At admission to DCCM the median duration of symptoms was 7 days (range 1-100) and the mean (+/-SD) Acute Physiology and Chronic Health Evaluation II score was 19.9 +/- 8.2. Ninety-nine patients (88%) had respiratory failure and 79 (71%) had circulatory failure. The number of necrosectomies peaked between 1991 and 1995 (17/35 patients (49%) compared to 4/22 (18%) prior 1991; chi(2) = 6.90, P = 0.032). Abdominal decompression, enteral nutrition, percutaneous tracheostomy, and the use of stents in endoscopic retrograde cholangiopancreatography were introduced over the study period. The length of stay in DCCM did not alter (median 4 days, range 1-60) but there was a reduction in the length of hospital stay (median 36 days to 15 days; anova= 6.16, P = 0.046). The overall mortality was 31% (35/112) and did not alter over the study period.

CONCLUSIONS

SAP remains a formidable disease with a high mortality despite a number of changes in intensive care and surgical management.

Approaches to the drainage of pancreatic pseudocysts

PURPOSE OF REVIEW

Review the current methods for the drainage of pancreatic pseudocysts, focusing on the recent developments in the new methods of endoscopic drainage.

RECENT FINDINGS

Pancreatic pseudocysts are collections of inflammatory fluid associated with acute and chronic pancreatitis. A leak in the pancreatic ductal system is most commonly the source of the fluid accumulation in these inflammatory cavities adjacent to the pancreas. Although most pseudocysts are not symptomatic and many resolve spontaneously over time, drainage of pseudocysts is occasionally required. There are several different approaches to the drainage: surgical, radiologic, and endoscopic. Surgical drainage is accomplished using the creation of a large anastomosis between the gastrointestinal tract and the pseudocyst cavity. Radiologically, pseudocysts are drained externally using a percutaneous, transabdominal drainage catheter. Endoscopy has offered the most recent advance, using the placement of transgastric or transduodenal stents. Most recently, therapeutic endoscopic ultrasound scopes have been used to introduce large stents that provide drainage into the upper gastrointestinal tract.

SUMMARY

Of the three methods for the drainage of a pancreatic pseudocyst, only the endoscopic approach can provide minimally invasive internal drainage.

Computed Tomography-guided Drainage of Intra-abdominal Infections

Image-guided percutaneous abscess drainage has become a standard method of treatment of most abdominal abscesses. In most cases, it should be considered the treatment of choice, but there are selected areas and circumstances that require specific approaches and methods. Typical abscesses within solid parenchyma organs or those in the peritoneal spaces can be reliably detected and efficiently drained. Abscesses that are multiple or long and circuitous require careful placement of catheters. Management of the drainage catheters includes irrigation with fluid to minimize accumulations of material that may impair egress of fluid. In selected cases, fibrinolytic agents have proved effective in shortening the drainage times and shortening hospital stays. Some controversial areas such as splenic abscesses, pancreatic abscesses, echinococcal abscesses, and fungal abscesses should only be attempted with careful selection and meticulous technique. Successful treatment is most likely with candid consultation among the various clinical services.

Infectious complications of acute pancreatitis

Disease severity in patients with acute pancreatitis varies from mild disease with minimal morbidity, to severe disease in which a whole spectrum of local and systemic complications may occur. Infectious complications frequently arise, and especially infection of pancreatic necrosis is an important risk factor for mortality. Several strategies have been devised to reduce this risk, and the use of prophylactic therapy, e.g. selective digestive decontamination, can be considered in patients with documented necrosis fo the pancreas. Pancreatic abscesses and infected pseudocysts arise later in the course of disease, and should be considered as separate entities, due to differences in therapy and outcome of these patients. When infection occurs, source control using either surgical or percutaneous drainage techniques, is essential to avoid systemic complications.

Deferoxamine and meropenem combination therapy in experimental acute pancreatitis

INTRODUCTION

Recent data from the experimental clinical studies suggest that antibiotics having good penetration to pancreas may reduce mortality by preventing pancreatic infection, which is the most important prognostic factor in acute pancreatitis (AP). Deferoxamine is an active free oxygen radical scavenger, which has been shown to have a protective role in development of acute pancreatitis.

AIM

To determine the effects of combination of deferoxamine and meropenem in acute necrotizing pancreatitis.

METHODOLOGY

One hundred male Sprague-Dawley rats were randomly divided into 5 groups. All rats underwent laparotomy with cannulation of biliopancreatic duct. Group 1 received intraductal saline injection. Acute necrotizing pancreatitis was induced in group 2, 3, 4, and 5 by intraductal injection of 3% taurocholate. Group 1 (sham operated) and group 2 were injected with saline of 0.3 mL/kg intraperitoneally (i.p). Group 3 was injected with meropenem 60 mg/kg/d i.p, group 4 with deferoxamine 80 mg/kg/d s.c and group 5 with combination of these 2 agents at the same doses. While meropenem was started 2 hours later, all treatments were started immediately after the induction of pancreatitis. All rats were killed at the 48th hour of the treatment and blood and tissue samples were collected for amylase determinations, pathologic examinations, and culture.

RESULTS

There was no difference in serum amylase levels between AP induced groups (P > 0.05). Pancreatic histology scores were significantly low in rats treated with deferoxamine (group 4), and combination regimen (group 5) (P < 0.001). Meropenem significantly reduced the incidence of pancreatic infection. Although combination of deferoxamine with meropenem showed better effects than meropenem alone in terms of pancreatic infection, the difference did not reach to statistical significance.

CONCLUSIONS

Meropenem treatment reduces secondary pancreatic infections in acute pancreatitis. Treatment with deferoxamine and meropenem combination may be more beneficial than single therapies in reducing the severity of pancreatitis. Further studies investigating the effects of this combination on survival are needed.