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Gao L, Zhang JZ, Gao K, Zhou J, Li G, Li BQ, Ye B, Ke L, Tong ZH, Li WQ. Management of colonic fistulas in patients with infected pancreatic necrosis being treated with a step-up approach. HPB (Oxford) 2020; 22:1738-1744. [PMID: 32349924 DOI: 10.1016/j.hpb.2020.03.021] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/06/2020] [Revised: 03/15/2020] [Accepted: 03/20/2020] [Indexed: 12/12/2022]
Abstract
BACKGROUND Colonic fistula is a potentially fatal complication in acute necrotizing pancreatitis (ANP), especially in patients with infected pancreatic necrosis (IPN). The aim of this study was to evaluate the feasibility of a step-up approach including percutaneous catheter drainage (PCD) and continuous negative pressure irrigation (CNPI) in a group of patients with colonic fistula. METHODS A retrospective review of a prospectively collected data was performed. Data were extracted for patients complicated by colonic fistula from January 2010 to January 2017. RESULTS A total of 1750 patients were admitted with ANP during the study period. Of these patients, 711 (41%) developed IPN and colonic fistula was present in 132 (19%). A step-up approach was adopted for all patients, with 47% avoiding surgery. The mortality in patients requiring surgery (37%) was higher than that in patients managed non-surgically (19%) constituting an overall mortality rate of 29%. In patients managed conservatively, 92% had spontaneous closure of the fistula. CONCLUSION Colonic fistula is not a rare complication in ANP occurring in 19% of patients with IPN in the current study. A step-up approach was effective and safe in managing colonic fistula and surgery could be obviated in nearly half of the patients.
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Affiliation(s)
- Lin Gao
- Center of Severe Acute Pancreatitis (CSAP), Department of General Surgery, Jinling Hospital, Medical School of Nanjing University, No. 305 Zhongshan East Road, Nanjing 210002, Jiangsu, China
| | - Jing-Zhu Zhang
- Center of Severe Acute Pancreatitis (CSAP), Department of General Surgery, Jinling Hospital, Medical School of Nanjing University, No. 305 Zhongshan East Road, Nanjing 210002, Jiangsu, China
| | - Kun Gao
- Center of Severe Acute Pancreatitis (CSAP), Department of General Surgery, Jinling Hospital, Medical School of Nanjing University, No. 305 Zhongshan East Road, Nanjing 210002, Jiangsu, China
| | - Jing Zhou
- Center of Severe Acute Pancreatitis (CSAP), Department of General Surgery, Jinling Hospital, Medical School of Nanjing University, No. 305 Zhongshan East Road, Nanjing 210002, Jiangsu, China
| | - Gang Li
- Center of Severe Acute Pancreatitis (CSAP), Department of General Surgery, Jinling Hospital, Medical School of Nanjing University, No. 305 Zhongshan East Road, Nanjing 210002, Jiangsu, China
| | - Bai-Qiang Li
- Center of Severe Acute Pancreatitis (CSAP), Department of General Surgery, Jinling Hospital, Medical School of Nanjing University, No. 305 Zhongshan East Road, Nanjing 210002, Jiangsu, China
| | - Bo Ye
- Center of Severe Acute Pancreatitis (CSAP), Department of General Surgery, Jinling Hospital, Medical School of Nanjing University, No. 305 Zhongshan East Road, Nanjing 210002, Jiangsu, China
| | - Lu Ke
- Center of Severe Acute Pancreatitis (CSAP), Department of General Surgery, Jinling Hospital, Medical School of Nanjing University, No. 305 Zhongshan East Road, Nanjing 210002, Jiangsu, China.
| | - Zhi-Hui Tong
- Center of Severe Acute Pancreatitis (CSAP), Department of General Surgery, Jinling Hospital, Medical School of Nanjing University, No. 305 Zhongshan East Road, Nanjing 210002, Jiangsu, China.
| | - Wei-Qin Li
- Center of Severe Acute Pancreatitis (CSAP), Department of General Surgery, Jinling Hospital, Medical School of Nanjing University, No. 305 Zhongshan East Road, Nanjing 210002, Jiangsu, China
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Sato Y, Hara K, Okuno N, Murata S, Hasegawa T, Morinaga H, Kimbara Y, Imai Y, Yamaura H, Inaba Y. Endoscopic necrosectomy through a self-expandable metallic stent placed percutaneously for walled-off pancreatic necrosis. INTERNATIONAL JOURNAL OF GASTROINTESTINAL INTERVENTION 2020. [DOI: 10.18528/ijgii200015] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Affiliation(s)
- Yozo Sato
- Department of Diagnostic and Interventional Radiology, Aichi Cancer Center Hospital, Nagoya, Japan
| | - Kazuo Hara
- Department of Gastroenterology, Aichi Cancer Center Hospital, Nagoya, Japan
| | - Nozomi Okuno
- Department of Gastroenterology, Aichi Cancer Center Hospital, Nagoya, Japan
| | - Shinichi Murata
- Department of Diagnostic and Interventional Radiology, Aichi Cancer Center Hospital, Nagoya, Japan
| | - Takaaki Hasegawa
- Department of Diagnostic and Interventional Radiology, Aichi Cancer Center Hospital, Nagoya, Japan
| | - Hiroyuki Morinaga
- Department of Diagnostic and Interventional Radiology, Aichi Cancer Center Hospital, Nagoya, Japan
| | - Yuki Kimbara
- Department of Diagnostic and Interventional Radiology, Aichi Cancer Center Hospital, Nagoya, Japan
| | - Yugo Imai
- Department of Diagnostic and Interventional Radiology, Aichi Cancer Center Hospital, Nagoya, Japan
| | - Hidekazu Yamaura
- Department of Diagnostic and Interventional Radiology, Aichi Cancer Center Hospital, Nagoya, Japan
| | - Yoshitaka Inaba
- Department of Diagnostic and Interventional Radiology, Aichi Cancer Center Hospital, Nagoya, Japan
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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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D'Onofrio M, Beleù A, De Robertis R. Ultrasound-guided percutaneous procedures in pancreatic diseases: new techniques and applications. Eur Radiol Exp 2019; 3:2. [PMID: 30671676 PMCID: PMC6342746 DOI: 10.1186/s41747-018-0081-2] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/04/2018] [Accepted: 12/14/2018] [Indexed: 02/08/2023] Open
Abstract
Ultrasound (US) is not only an important diagnostic tool for the evaluation of the pancreas, but is also a fundamental imaging technique to guide percutaneous interventions for several pancreatic diseases (fluid aspiration and drainage; invasive diagnosis by means fine-needle aspiration and core-needle biopsy; tumour ablation by radiofrequency, microwaves, irreversible electroporation, cryoablation, and high-intensity focused US). Technical improvements, such as contrast media and fusion imaging, have recently increased precision and safety and reduced procedure-related complications. New treatment US techniques for the ablation of pancreatic tumours, such as contrast-enhanced US and multimodality fusion imaging, have been recently developed and have elicited a growing interest worldwide. The purpose of this article was to review the most up-to-date role of US in percutaneous procedures for pancreatic diseases.
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Affiliation(s)
- Mirko D'Onofrio
- Department of Radiology, G.B. Rossi Hospital - University of Verona, Piazzale L.A. Scuro 10, 37134, Verona, Italy
| | - Alessandro Beleù
- Department of Radiology, G.B. Rossi Hospital - University of Verona, Piazzale L.A. Scuro 10, 37134, Verona, Italy.
| | - Riccardo De Robertis
- PhD Programme in Inflammation, Immunity and Cancer, University of Verona, Piazzale L.A. Scuro 10, 37134, Verona, Italy
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Jagielski M, Smoczyński M, Adrych K. Endoscopic treatment of walled-off pancreatic necrosis complicated with pancreaticocolonic fistula. Surg Endosc 2018; 32:1572-1580. [PMID: 29344783 PMCID: PMC5807501 DOI: 10.1007/s00464-018-6032-4] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/13/2017] [Accepted: 01/03/2018] [Indexed: 12/12/2022]
Abstract
Background Pancreaticocolonic fistulas (PCFs) are serious complication of acute pancreatitis related with high mortality. The aim of this study was to evaluate the efficiency and safety of endoscopic treatment in patients with walled-off pancreatic necrosis (WOPN) complicated with PCF. Methods This is a retrospective analysis of results and complications in the group of 226 patients, who underwent endoscopic treatment of symptomatic WOPN between years 2001 and 2016 in the Department of Gastroenterology and Hepatology of Medical University of Gdańsk. Results PCF was recognized in 21/226 (9.29%) patients. Transmural drainage was performed in 20/21 (95.24%) patients. Transpapillary drainage was used in 2/21 (9.52) patients. The mean time since the start of endotherapy to the diagnosis of a fistulas was 9 (3–21) days. Fluoroscopic nasocystic tube-check imaging of an existing drain was the initial imaging diagnosis of a PCF in 19/21 (90.48%) patients. The mean duration of endoscopic drainage of WOPN was 39.29 (15–87) days. Procedure-related adverse events occurred in 10/21 (47.62%) patients and most of them were treated conservatively. Three patients required surgical treatment. One patient died during endotherapy. The closure of PCF was confirmed via imaging in 17/21 (80.95%) patients. The average time since the recognition till the closure of PCF was 21 (14–48) days. Complete therapeutic success of WOPN complicated with PCF was reached in 16/21 (76.19%) patients. Long-term success of endoscopic treatment was achieved in 15/21 (71.43%) patients. Conclusions Endoscopic treatment of patients with WOPN complicated with PCF is an effective method with an acceptable number of complications. The complete regression of the WOPN may lead to spontaneous closure of pancreaticocolonic fistulas. Electronic supplementary material The online version of this article (10.1007/s00464-018-6032-4) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Mateusz Jagielski
- Department of Gastroenterology and Hepatology, Medical University of Gdansk, Smoluchowskiego 17, 80-214, Gdansk, Poland.
| | - Marian Smoczyński
- Department of Gastroenterology and Hepatology, Medical University of Gdansk, Smoluchowskiego 17, 80-214, Gdansk, Poland
| | - Krystian Adrych
- Department of Gastroenterology and Hepatology, Medical University of Gdansk, Smoluchowskiego 17, 80-214, Gdansk, Poland
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Banday IA, Gattoo I, Khan AM, Javeed J, Gupta G, Latief M. Modified Computed Tomography Severity Index for Evaluation of Acute Pancreatitis and its Correlation with Clinical Outcome: A Tertiary Care Hospital Based Observational Study. J Clin Diagn Res 2015; 9:TC01-5. [PMID: 26436014 DOI: 10.7860/jcdr/2015/14824.6368] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/08/2015] [Accepted: 07/08/2015] [Indexed: 01/21/2023]
Abstract
BACKGROUND Acute Pancreatitis is a very common condition leading to the emergency visits in both developed and developing countries. Computed Tomography plays a pivotal role in the diagnosis and subsequent management of pancreatitis. The modified CT severity index includes a simplified assessment of pancreatic inflammation and necrosis as well as an assessment of extra pancreatic complications. AIM To study role of modified computed tomography severity index in evaluation of acute pancreatitis and its correlation with clinical outcome. MATERIALS AND METHODS This was a hospital based prospective correlative study done on patients of all age groups referred to the Department of Radio diagnosis from the various indoor and outdoor departments of the hospital, with clinical/Laboratory/ultrasonography findings suggestive of acute pancreatitis. The severity of pancreatitis was scored using Modified CT severity index & CT severity index and classified into mild, moderate and severe categories. Total of 50 patients of acute pancreatitis presenting to the emergency department of our hospital were included in the study. Clinical outcome parameters for correlation collected from respective referral departments included, the length of hospital stay (in days), need for surgical intervention, need for percutaneous intervention (aspiration and drainage), evidence of infection in any organ system (combination of a fever > 100°F and elevated WBC >15,000/ mm(3)), evidence of organ failure (PaO2 < 60 mm Hg or need of ventilation, systolic BP of < 90 mm Hg, serum creatinine of >300μmoles/L or urine output of < 500 ml / 24 h) and death. RESULTS The age of the patients in the study group was in the range of 17 to 80 years. Maximum patients were in the age group 40-50 years (42.0%). The mean age was 42.32 years. Out of 50 cases, 33 (66%) were male and 17 (34%) were females with a male to female ratio of 2:1. Cholelithiasis was found to be most common aetiological factor for acute pancreatitis in 40% cases. Alcoholic pancreatitis was seen in 36% of cases. Together cholelithiasis and alcoholism accounted for 76% of cases. Pleural effusion was the most common extra-pancreatic complication, 28 patients (56%), followed by ascites. Majority of patients were categorized as severe pancreatitis (44%). 38% patients were grouped into moderate pancreatitis and 18% were categorized in mild pancreatitis. The outcome parameters in terms of length of hospital stay, need of intervention, development of infection, and development of organ failure were more in patients with higher modified CT severity index. CONCLUSION In conclusion CECT was found to be an excellent imaging modality for diagnosis, establishing the extent of disease process and in grading its severity. The Modified CT Severity Index is a simpler scoring tool and more accurate than the Balthazar CT Severity Index. In this study, it had a stronger statistical correlation with the clinical outcome, be it the length of hospital stay, development of infection, occurrence of organ failure and overall mortality. It could also predict the need for interventional procedures.
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Affiliation(s)
- Irshad Ahmad Banday
- Resident, Post Graduate, Department of Radiodiagnosis, Government Medical College Jammu, J&K, India
| | - Imran Gattoo
- Registrar, Post Graduate, Department of Paediatrics, Government Medical College Srinagar, J&K, India
| | | | - Jasima Javeed
- Resident, Government Medical College Srinagar, J&K, India
| | - Ghanshyam Gupta
- Professor and Head, Post Graduate Department of Radiodiagnosis, Government Medical College Jammu, India
| | - Mohmad Latief
- Resident, Government Medical College Srinagar, J&K, India
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Paradigm shift away from open surgical necrosectomy toward endoscopic interventions for necrotizing pancreatitis. GASTROINTESTINAL INTERVENTION 2014. [DOI: 10.1016/j.gii.2014.09.010] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
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Bhattacharya A, Kochhar R, Sharma S, Ray P, Kalra N, Khandelwal N, Mittal BR. PET/CT with 18F-FDG-labeled autologous leukocytes for the diagnosis of infected fluid collections in acute pancreatitis. J Nucl Med 2014; 55:1267-72. [PMID: 24994930 DOI: 10.2967/jnumed.114.137232] [Citation(s) in RCA: 35] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/07/2014] [Accepted: 05/09/2014] [Indexed: 01/08/2023] Open
Abstract
UNLABELLED Early detection of infection in acute pancreatitis (AP) affects the choice of treatment and clinical outcome. We used PET/CT with (18)F-FDG-labeled autologous leukocytes to detect infection in pancreatic or peripancreatic fluid collections in patients with AP. METHODS Forty-one patients (28 men and 13 women) who were 21-69 y old (mean ± SD, 41 ± 11.5) and had AP and radiologic evidence of a fluid collection in or around the pancreas were studied. Leukocytes were separated from the patient's venous blood, labeled with (18)F-FDG, and reinjected intravenously; PET/CT images were acquired 2 h later. A final diagnosis of infection was based on microbiologic culture of fluid aspirated from the collection. Patients were treated with supportive care and antibiotics; percutaneous drainage or laparotomy was performed when indicated. RESULTS Blood glucose level, total leukocyte count, neutrophil count, and leukocyte labeling efficiency varied from 83 to 212 mg/100 mL (118 ± 30), 4,600 to 24,200/mm(3) (11,648 ± 5,376), 55% to 90% (73 ± 10), and 31% to 97% (81 ± 17), respectively. Increased tracer uptake in the fluid collection was seen in 12 of 41 patients; 10 had culture-proven infection and underwent percutaneous drainage, and aspiration was unsuccessful in 2. The scan results were negative for infection in 29 patients; 25 had fluid culture results that were negative for infection, and aspiration was unsuccessful in 4. The sensitivity, specificity, and accuracy of the scan were all 100% in 35 patients for whom fluid culture reports were available. CONCLUSION PET/CT with (18)F-FDG-labeled leukocytes is a noninvasive and reliable method for the diagnosis of infection in pancreatic or peripancreatic fluid collections in patients with AP.
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Affiliation(s)
- Anish Bhattacharya
- Department of Nuclear Medicine, Postgraduate Institute of Medical Education and Research, Chandigarh, India
| | - Rakesh Kochhar
- Department of Gastroenterology, Postgraduate Institute of Medical Education and Research, Chandigarh, India
| | - Sarika Sharma
- Department of Nuclear Medicine, Postgraduate Institute of Medical Education and Research, Chandigarh, India
| | - Pallab Ray
- Department of Medical Microbiology, Postgraduate Institute of Medical Education and Research, Chandigarh, India; and
| | - Naveen Kalra
- Department of Radiodiagnosis, Postgraduate Institute of Medical Education and Research, Chandigarh, India
| | - Niranjan Khandelwal
- Department of Radiodiagnosis, Postgraduate Institute of Medical Education and Research, Chandigarh, India
| | - Bhagwant R Mittal
- Department of Nuclear Medicine, Postgraduate Institute of Medical Education and Research, Chandigarh, India
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Dupuis CS, Baptista V, Whalen G, Karam AR, Singh A, Wassef W, Kim YH. Diagnosis and management of acute pancreatitis and its complications. GASTROINTESTINAL INTERVENTION 2013. [DOI: 10.1016/j.gii.2013.03.001] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
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10
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Predictors of surgery in patients with severe acute pancreatitis managed by the step-up approach. Ann Surg 2013; 257:737-50. [PMID: 22968079 DOI: 10.1097/sla.0b013e318269d25d] [Citation(s) in RCA: 107] [Impact Index Per Article: 9.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
BACKGROUND Initial management of severe acute pancreatitis (SAP) is conservative. As a step-up approach, percutaneous catheter drainage (PCD) with saline irrigation is reported to be effective. Factors leading to surgery are unclear. METHODS In this ongoing prospective study, 70 consecutive patients with SAP were recruited. As a step-up approach, all patients initially received medical management and later underwent PCD and surgery as per the indication. RESULTS Of the 70 consecutive patients with SAP, 14 were managed medically, 29 managed with PCD alone, whereas 27 required surgery after initial PCD. Sepsis reversal was achieved with PCD alone in 62.5%. The curative efficacy of PCD alone was in 27 patients (48%). Overall mortality in the whole group was 24%. On univariate analysis, factors significantly affecting surgical intervention included initial acute physiology and chronic health evaluation (APACHE) II score, APACHE II score at first intervention, sepsis reversal by PCD within a week, number of organs failed, organ failure within a week of the onset of disease, number of bacteria isolated per patient, renal failure, respiratory failure, Escherichia coli, computerized tomography severity index score at admission, parenteral nutrition requirement before or after radiological intervention, maximum extent of necrosis of more than 50% of the pancreas, and extrapancreatic necrosis. On multivariate analysis, renal failure (P = -0.03), APACHE II score at first intervention (P = -0.006), and the number of bacteria isolated per patient (P = -0.01) remained independent predictors of surgery. An APACHE II score of more than 7.5 at first intervention (PCD) had the ability to predict surgery with a sensitivity of 88.9% and a specificity of 69%. CONCLUSIONS PCD reversed sepsis in 62% and avoided surgery in 48% of the patients. Reversal of sepsis within a week of PCD, APACHE II score at first intervention (PCD), and organ failure within a week of the onset of disease could predict the need for surgery in the early course of disease.
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11
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Heeter ZR, Hauptmann E, Crane R, Fotoohi M, Robinson D, Siegal J, Kozarek RA, Gluck M. Pancreaticocolonic fistulas secondary to severe acute pancreatitis treated by percutaneous drainage: successful nonsurgical outcomes in a single-center case series. J Vasc Interv Radiol 2012. [PMID: 23176965 DOI: 10.1016/j.jvir.2012.09.020] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022] Open
Abstract
PURPOSE Pancreaticocolonic fistulas (PCFs) are uncommon complications of acute necrotizing pancreatitis (ANP). Studies advocating primary surgical treatment showed severe morbidity and mortality with nonsurgical treatment, with survival rates of approximately 50%. However, a nonsurgical treatment scheme with primary percutaneous drainage and other interventions may show improved outcomes. This retrospective single-center study describes the presentation, diagnosis, course, treatment strategy, and outcome of successfully treated PCFs, with an emphasis on nonsurgical interventions. MATERIALS AND METHODS Twenty patients with PCFs caused by ANP were treated with percutaneous drainage and medical therapy. Additional interventions included endoscopic transenteric drainage and pancreatic duct (PD) stent placement. Surgery was reserved for patients in whom this nonsurgical management failed. RESULTS All PCFs closed during a median follow-up of 56 days (mean, 106 d; range, 13-827 d). Treatment included percutaneous drainage of the PCF-related collection in all patients, PD stents in 60%, transenteric drainage in 15%, and definitive surgery in 15%. Indications for surgery included severe PCF-related symptoms, large feculent peritoneal collection, and colonic stricture. Two patients (10%) died, one of complications of ANP and one of esophageal carcinoma. Additional enteric fistulas were identified in 50% of patients. Median time from the most recent diagnosis of pancreatitis to PCF diagnosis was 89 days (mean, 113 d; range, 13-394 d). CONCLUSIONS A nonsurgical approach to PCFs caused by ANP, including percutaneous drainage and other techniques, yields good survival, with surgery reserved for cases in which this approach fails.
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Affiliation(s)
- Zachary R Heeter
- Department of Radiology, Virginia Mason Medical Center, Seattle, WA 98101, USA.
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12
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Rustagi T, Uy EM, Rai M. Pyogenic liver abscesses secondary to pylephlebitis complicating acute on chronic pancreatitis. J Dig Dis 2012; 13:439-43. [PMID: 22788930 DOI: 10.1111/j.1751-2980.2012.00608.x] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Affiliation(s)
- Tarun Rustagi
- Department of Internal Medicine, University of Connecticut, Farmington, Connecticut 06032, USA.
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13
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Thoeni RF. The revised Atlanta classification of acute pancreatitis: its importance for the radiologist and its effect on treatment. Radiology 2012; 262:751-64. [PMID: 22357880 DOI: 10.1148/radiol.11110947] [Citation(s) in RCA: 244] [Impact Index Per Article: 20.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
An international working group has modified the Atlanta classification for acute pancreatitis to update the terminology and provide simple functional clinical and morphologic classifications. The modifications (a) address the clinical course and severity of disease, (b) divide acute pancreatitis into interstitial edematous pancreatitis and necrotizing pancreatitis, (c) distinguish an early phase (1st week) and a late phase (after the 1st week), and (d) emphasize systemic inflammatory response syndrome and multisystem organ failure. In the 1st week, only clinical parameters are important for treatment planning. After the 1st week, morphologic criteria defined on the basis of computed tomographic findings are combined with clinical parameters to help determine care. This revised classification introduces new terminology for pancreatic fluid collections. Depending on presence or absence of necrosis, acute collections in the first 4 weeks are called acute necrotic collections or acute peripancreatic fluid collections. Once an enhancing capsule develops, persistent acute peripancreatic fluid collections are referred to as pseudocysts; and acute necrotic collections, as walled-off necroses. All can be sterile or infected. Terms such as pancreatic abscess and intrapancreatic pseudocyst have been abandoned. The goal is for radiologists, gastroenterologists, surgeons, and pathologists to use the revised classifications to standardize imaging terminology to facilitate treatment planning and enable precise comparison of results among different departments and institutions.
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Affiliation(s)
- Ruedi F Thoeni
- University of California San Francisco Medical School, Department of Radiology and Biomedical Imaging, PO Box 1325, San Francisco, CA 94143-1325, USA.
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14
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Interventional radiology for necrotizing pancreatitis. J Gastrointest Surg 2011; 15:1101-3. [PMID: 21503832 DOI: 10.1007/s11605-011-1507-9] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/30/2011] [Accepted: 03/23/2011] [Indexed: 01/31/2023]
Abstract
Necrotic pancreatitis is a complex clinical entity that requires collaboration of care from surgeons, gastroenterologists, and interventional radiologists. CT scans play a pivotal role in the diagnosis of pancreatic necrosis, while image-guided percutaneous pancreatic drainage is a safe and effective treatment method in certain cases. The diagnostic criteria for pancreatic necrosis, indications for pancreatic drainage, technique, and efficacy are discussed in this article.
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Gardner TB, Coelho-Prabhu N, Gordon SR, Gelrud A, Maple JT, Papachristou GI, Freeman ML, Topazian MD, Attam R, Mackenzie TA, Baron TH. Direct endoscopic necrosectomy for the treatment of walled-off pancreatic necrosis: results from a multicenter U.S. series. Gastrointest Endosc 2011; 73:718-26. [PMID: 21237454 DOI: 10.1016/j.gie.2010.10.053] [Citation(s) in RCA: 199] [Impact Index Per Article: 15.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/07/2010] [Accepted: 10/27/2010] [Indexed: 02/06/2023]
Abstract
BACKGROUND Direct endoscopic necrosectomy (DEN) for treatment of walled-off pancreatic necrosis (WOPN) has been performed as an alternative to operative or percutaneous therapy. OBJECTIVE To report the largest combined experience of DEN performed for WOPN. DESIGN Retrospective chart review. SETTING Six U.S. tertiary medical centers. PATIENTS A total of 104 patients with a history of acute pancreatitis and symptomatic WOPN since 2003. INTERVENTIONS DEN for WOPN. MAIN OUTCOME MEASUREMENTS Resolution or near-resolution of WOPN without the need for surgical or percutaneous intervention and procedural complications. RESULTS Successful resolution was achieved in 95 of 104 patients (91%). Of the patients in whom it failed, 5 died during follow-up before resolution, 2 underwent operative drainage for persistent WOPN, 1 required surgery for massive bleeding on fistula tract dilation, and 1 died periprocedurally. The mean time to resolution from the initial DEN was 4.1 months. The first débridement was performed a mean of 63 days after the initial onset of acute pancreatitis. In 73%, the entry was transgastric with median tract dilation diameter of 18 mm. The median number of procedures was 3 with 2 débridements. Complications occurred in approximately 14% and included 5 retrogastric perforations/pneumoperitoneum, which were managed nonoperatively. Univariate analysis identified a body mass index >32 as a risk factor for failed DEN. LIMITATIONS Retrospective, highly specialized centers. CONCLUSIONS This large, multicenter series demonstrates that transmural, minimally invasive endoscopic débridement of WOPN performed in the United States is an efficacious and reproducible technique with an acceptable safety profile.
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Affiliation(s)
- Timothy B Gardner
- Section of Gastroenterology and Hepatology, Department of Medicine, Dartmouth-Hitchcock Medical Center, Lebanon, New Hampshire, USA
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16
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Bharwani N, Patel S, Prabhudesai S, Fotheringham T, Power N. Acute pancreatitis: the role of imaging in diagnosis and management. Clin Radiol 2010; 66:164-75. [PMID: 21216333 DOI: 10.1016/j.crad.2010.09.003] [Citation(s) in RCA: 32] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/27/2010] [Revised: 08/17/2010] [Accepted: 09/17/2010] [Indexed: 02/06/2023]
Abstract
Acute pancreatitis is one of the more commonly encountered aetiologies in the emergency setting and its incidence is rising. Presentations range from a mild-self limiting condition which usually responds to conservative management to one with significant morbidity and mortality in its most severe forms. While clinical criteria are necessary to make the initial diagnosis, contrast-enhanced CT is the mainstay of imaging and has a vital role in assessing the extent and evolution of the disease and its associated complications. The purpose of this article is to summarise the natural course of acute severe pancreatitis, clarify confusing nomenclature, demonstrate the morphological stages in conjunction with radiological scoring systems and illustrate the complications. We will review and illustrate the increasing and significant role interventional radiology has in the management of these patients, which are often life-saving and surgery-sparing.
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Affiliation(s)
- Nishat Bharwani
- Imaging Department, Barts & The London NHS Trust, St Bartholomew's Hospital, Ground Floor, King George V Wing, London EC1A 7BE, United Kingdom.
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17
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Abstract
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.
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Affiliation(s)
- A Peter Wysocki
- Department of Surgery, Logan Hospital, Meadowbrook, Queensland, Australia.
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18
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Abstract
Acute pancreatitis is a common disease most frequently caused by gallstone disease or excess alcohol ingestion. Diagnosis is usually based on characteristic symptoms, often in conjunction with elevated serum pancreatic enzymes. Imaging is not always necessary, but may be performed for many reasons, such as to confirm a diagnosis of pancreatitis, rule out other causes of abdominal pain, elucidate the cause of pancreatitis, or to evaluate for complications such as necrosis or pseudocysts. Though the majority of patients will have mild, self-limiting disease, some will develop severe disease associated with organ failure. These patients are at risk to develop complications from ongoing pancreatic inflammation such as pancreatic necrosis, fluid collections, pseudocysts, and pancreatic duct disruption. Validated scoring systems can help predict the severity of pancreatitis, and thus, guide monitoring and intervention.Treatment of acute pancreatitis involves supportive care with fluid replacement, pain control, and controlled initiation of regular food intake. Prophylactic antibiotics are not recommended in acute pancreatitis if there is no evidence of pancreatic infection. In patients who fail to improve, further evaluation is necessary to assess for complications that require intervention such as pseudocysts or pancreatic necrosis. Endoscopy, including ERCP and EUS, and/or cholecystectomy may be indicated in the appropriate clinical setting. Ultimately, the management of the patient with severe acute pancreatitis will require a multidisciplinary approach.
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Affiliation(s)
- Melissa A Munsell
- Division of Gastroenterology and Hepatology, Johns Hopkins University School of Medicine, Johns Hopkins Hospital, Baltimore, Maryland, USA.
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19
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Vijayaraghavan G, Kurup D, Singh A. Imaging of acute abdomen and pelvis: common acute pathologies. Semin Roentgenol 2009; 44:221-7. [PMID: 19715787 DOI: 10.1053/j.ro.2009.05.009] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Affiliation(s)
- Gopal Vijayaraghavan
- Department of Radiology, University of Massachusetts Memorial Health Center, Worcester, MA, USA
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20
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Gardner TB, Chahal P, Papachristou GI, Vege SS, Petersen BT, Gostout CJ, Topazian MD, Takahashi N, Sarr MG, Baron TH. A comparison of direct endoscopic necrosectomy with transmural endoscopic drainage for the treatment of walled-off pancreatic necrosis. Gastrointest Endosc 2009; 69:1085-94. [PMID: 19243764 DOI: 10.1016/j.gie.2008.06.061] [Citation(s) in RCA: 174] [Impact Index Per Article: 11.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/17/2008] [Accepted: 06/30/2008] [Indexed: 12/13/2022]
Abstract
BACKGROUND Endoscopic therapy of walled-off pancreatic necrosis (WOPN) via direct intracavitary debridement is described. OBJECTIVE To compare direct endoscopic necrosectomy with conventional transmural endoscopic drainage for the treatment of WOPN. DESIGN Retrospective, comparative study. SETTING Academic tertiary-care center. PATIENTS Patients referred to Mayo Clinic, Rochester, Minnesota, since April 1998 for endoscopic drainage of WOPN. INTERVENTIONS Each patient underwent standard endoscopic drainage that consisted of transmural cavity puncture, dilation of the fistula tract, and placement of a large-bore stent(s). Patients were classified into the direct endoscopic necrosectomy group if, during any of their procedures, adjunctive direct endoscopic necrosectomy was performed; all others were in the standard drainage group. MAIN OUTCOME MEASUREMENTS Success was defined as resolution of the necrotic cavity without the need for operative or percutaneous intervention. RESULTS Forty-five patients were identified who met study criteria: 25 underwent direct endoscopic necrosectomy, and 20 underwent standard endoscopic drainage. There were no differences in baseline patient or cavity characteristics. Successful resolution was accomplished in 88% who underwent direct endoscopic necrosectomy versus 45% who received standard drainage (P < .01), without a change in the total number of procedures. The maximum size of tract dilation was larger in the direct endoscopic necrosectomy group (17 mm vs 14 mm, P < .02). Complications were limited to mild periprocedural bleeding with equivalent rates between groups. LIMITATIONS Retrospective, referral bias, single center. CONCLUSIONS Direct endoscopic necrosectomy achieves higher rates of resolution, without a concomitant change in the number of endoscopic procedures, complication rate, or time to resolution compared with standard endoscopic drainage for WOPN. The need for fewer postprocedural inpatient hospital days and a decrease in the rate of cavity recurrence are also likely benefits of this technique.
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Affiliation(s)
- Timothy B Gardner
- Section of Gastroenterology and Hepatology, Dartmouth-Hitchcock Medical Center, Lebanon, New Hampshire, USA
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21
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Childs DD, Tchelepi H. Ultrasound and Abdominal Intervention: New Luster on an Old Gem. ACTA ACUST UNITED AC 2009. [DOI: 10.1016/j.cult.2009.03.004] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/07/2023]
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22
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Abstract
This review describes the microbiology, diagnosis, and management of intra-abdominal infections. These infections include secondary peritonitis, abdominal abscesses, and cholangitis. The infection generally occurs because enteric microorganisms enter the peritoneal cavity through a defect in the wall of the intestine or other viscus as a result of obstruction, infarction, or direct trauma. Mixed aerobic and anaerobic flora can be recovered. The predominant aerobic isolates are Escherichia coli, etc. The aerobic isolates are Escherichia coli, and enterococci, and the main anaerobic bacteria are Bacteroides fragilis group Peptostreptococcus spp. and Clostridium spp. The treatment of abdominal infection includes surgical correction and drainage of pus and administration of antimicrobials effective against both the aerobic and anaerobic pathogens.
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23
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Bollen TL, van Santvoort HC, Besselink MGH, van Es WH, Gooszen HG, van Leeuwen MS. Update on acute pancreatitis: ultrasound, computed tomography, and magnetic resonance imaging features. Semin Ultrasound CT MR 2008; 28:371-83. [PMID: 17970553 DOI: 10.1053/j.sult.2007.06.002] [Citation(s) in RCA: 46] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
Imaging of patients with acute pancreatitis requires an understanding of the subtypes and complications that were defined at the Atlanta symposium in 1992. In the last decade, several new entities have been recognized with important clinical implications. In this article, the radiological aspects of the terminology and classification of acute pancreatitis are reviewed and new entities are clarified. The roles of ultrasound, computed tomography, and magnetic resonance imaging in the diagnosis and evaluation of acute pancreatitis and its complications are discussed and the limitations of each imaging technique, when interpreting pancreatic and peripancreatic inflammatory disease, are addressed.
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Affiliation(s)
- Thomas L Bollen
- Department of Radiology, St. Antonius Hospital, Nieuwegein, The Netherlands.
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24
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Rickes S, Mönkemüller K, Malfertheiner P. Acute severe pancreatitis: contrast-enhanced sonography. ACTA ACUST UNITED AC 2007; 32:362-4. [PMID: 17514345 DOI: 10.1007/s00261-007-9250-0] [Citation(s) in RCA: 23] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/10/2023]
Abstract
Early assessment and differentiation of oedematous acute pancreatitis and necrotizing or severe acute pancreatitis allow distinct therapeutic algorithms. Spiral computed tomography is currently considered the gold standard for staging of acute severe pancreatitis. Conventional transabdominal ultrasound plays only a limited role in the staging of acute pancreatitis. The problem is that with this procedure a detection of pancreatic necrosis is difficult because it cannot assess organ perfusion. Through the use of contrast-enhancers, however, even ultrasound can nowadays examine the vascularization behaviour of the pancreas and liver parenchyma in sufficient detail. The aim of the present update article is to explain the usefulness of contrast-enhanced ultrasound in the detection of parenchymal necrosis in patients with acute severe pancreatitis.
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Affiliation(s)
- Steffen Rickes
- Department of Gastroenterology, Hepatology and Infectious Diseases Otto-von-Guericke-University, Leipziger Str. 44, 39120, Magdeburg, Germany.
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25
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Segal D, Mortele KJ, Banks PA, Silverman SG. Acute necrotizing pancreatitis: role of CT-guided percutaneous catheter drainage. ACTA ACUST UNITED AC 2007; 32:351-61. [PMID: 17502982 DOI: 10.1007/s00261-007-9221-5] [Citation(s) in RCA: 42] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
Necrotizing pancreatitis is the most severe form of acute pancreatitis associated with high morbidity and mortality. Percutaneous CT-guided catheter drainage is an important treatment option that can be effective whether used alone, or as an adjunct to operation. Existing literature describing the role of percutaneous catheter drainage of necrotizing pancreatitis is limited. This update reviews techniques, indications, outcomes, and complications of CT-guided percutaneous treatment of acute necrotizing pancreatitis.
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Affiliation(s)
- Dmitri Segal
- Division of Abdominal Imaging and Intervention, Department of Radiology, Brigham and Women's Hospital, Harvard Medical School, Boston, MA 02115, USA.
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26
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Szentkereszty Z, Sápy P. The role of percutaneous external drainage in the treatment of fluid collections associated with severe acute pancreatitis. What, when and how to drain? Orv Hetil 2007; 148:1395-9. [PMID: 17631476 DOI: 10.1556/oh.2007.27999] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/23/2022]
Abstract
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.
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Affiliation(s)
- Zsolt Szentkereszty
- Debreceni Egyetem, Orvos- és Egészségtudományi Centrum, Orvostudományi Kar Sebészeti Intézet, Auguszta Sebészeti Központ Debrecen.
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27
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Nouira K, Bedioui H, Azaiez O, Belhiba H, Messaoud MB, Ksantini R, Jouini M, Menif E. Percutaneous Drainage of Suppurative Pylephlebitis Complicating Acute Pancreatitis. Cardiovasc Intervent Radiol 2007; 30:1242-4. [PMID: 17587080 DOI: 10.1007/s00270-007-9102-x] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
Suppurative pylephlebitis is a rare condition with a significant mortality rate, ranging from 50% to 80%. We report a case of suppurative pylephlebitis complicating acute pancreatitis treated by percutaneous drainage in a 40-year-old woman. The patient had an uneventful recovery.
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Affiliation(s)
- Kais Nouira
- Department of Radiology, La Rabta Hospital, Tunis, Tunisia.
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28
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Abstract
Acute pancreatitis is a common disease with potentially serious outcomes. Multiple imaging modalities can be used to evaluate the disease process and its associated complications. Familiarity with the pathogenesis of this disease, indications for imaging, imaging protocols, staging systems, and the strengths and weaknesses of various modalities will help the radiologist optimize patient care.
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Affiliation(s)
- Anuradha Saokar
- Department of Abdominal Imaging and Interventional Radiology, Massachusetts General Hospital-White 270, 55 Fruit Street, Boston, MA 02114, USA
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29
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Abstract
Increasing in popularity
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Affiliation(s)
- J A Windsor
- Department of Surgery, Faculty of Medical and Health Science, University of Auckland, Park Road, Grafton, Auckland, New Zealand.
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30
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Imaging and Intervention in Acute Pancreatic Conditions. Emerg Radiol 2007. [DOI: 10.1007/978-3-540-68908-9_25] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
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31
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Warren O, Kinross J, Paraskeva P, Darzi A. Emergency laparoscopy--current best practice. World J Emerg Surg 2006; 1:24. [PMID: 16945124 PMCID: PMC1564132 DOI: 10.1186/1749-7922-1-24] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/21/2006] [Accepted: 08/31/2006] [Indexed: 12/18/2022] Open
Abstract
Emergency laparoscopic surgery allows both the evaluation of acute abdominal pain and the treatment of many common acute abdominal disorders. This review critically evaluates the current evidence base for the use of laparoscopy, both diagnostic and interventional, in the emergency abdomen, and provides guidance for surgeons as to current best practise. Laparoscopic surgery is firmly established as the best intervention in acute appendicitis, acute cholecystitis and most gynaecological emergencies but requires further randomised controlled trials to definitively establish its role in other conditions.
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Affiliation(s)
- Oliver Warren
- Department of BioSurgery and Surgical Technology, Imperial College of Science, Technology and Medicine, St. Mary's Hospital, London, UK
| | - James Kinross
- Department of BioSurgery and Surgical Technology, Imperial College of Science, Technology and Medicine, St. Mary's Hospital, London, UK
| | - Paraskevas Paraskeva
- Department of BioSurgery and Surgical Technology, Imperial College of Science, Technology and Medicine, St. Mary's Hospital, London, UK
| | - Ara Darzi
- Department of BioSurgery and Surgical Technology, Imperial College of Science, Technology and Medicine, St. Mary's Hospital, London, UK
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32
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Navalho M, Pires F, Duarte A, Gonçalves A, Alexandrino P, Távora I. Percutaneous drainage of infected pancreatic fluid collections in critically ill patients: correlation with C-reactive protein values. Clin Imaging 2006; 30:114-9. [PMID: 16500542 DOI: 10.1016/j.clinimag.2005.09.026] [Citation(s) in RCA: 32] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/20/2005] [Revised: 09/07/2005] [Accepted: 09/07/2005] [Indexed: 01/27/2023]
Abstract
The objective of this study was to assess the efficacy of percutaneous catheter drainage, of early infected pancreatic fluid collections, in critically ill patients with severe acute pancreatitis. The patients in our series had a mean Ranson's score of 5.4. Nineteen (63.3%) of the 30 patients were cured with percutaneous drainage. In this group, the mean C-reactive protein value at the beginning of treatment was 172.8 U/l and 102.5 U/l at the end (P<.001). Cultures yielded multiple organisms in 23 patients (76.7%). The most frequently seen organisms were Escherichia coli, Staphylococcus aureus, and Enterococcus faecium.
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Affiliation(s)
- Márcio Navalho
- Radiology Department, University Hospital of Santa Maria, Avenida Professor Egas Moniz, 1649-035 Lisbon, Portugal.
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33
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Mayerle J, Hlouschek V, Lerch MM. Current management of acute pancreatitis. ACTA ACUST UNITED AC 2005; 2:473-83. [PMID: 16224479 DOI: 10.1038/ncpgasthep0293] [Citation(s) in RCA: 50] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/14/2005] [Accepted: 08/26/2005] [Indexed: 02/07/2023]
Abstract
The incidence of acute pancreatitis varies considerably between regions and is estimated at 5-80 per 100,000 population. The mortality rate of acute edematous-interstitial pancreatitis is below 1%, whereas 10-24% of patients with severe acute pancreatitis die. The early prognostic factors that can be used to determine whether the clinical course is likely to be severe are three or more signs of organ failure according to the Ranson or Imrie scores, the presence of nonpancreatic complications, and the detection of pancreatic necrosis by imaging techniques. Elevated C-reactive protein levels above 130 mg/l can also predict a severe course of acute pancreatitis with high sensitivity. Although no causal treatment exists, replacing the dramatic fluid loss that takes place in the early disease phase is critical and determines the patient's prognosis. Adequate pain relief with opiates is another therapeutic priority. In patients with pancreatic necrosis, the high mortality rate between the third and fourth week after the initial episode is determined largely by the development of pancreatic infection, and can therefore be reduced by early antibiotic treatment. Early enteral nutrition for the treatment of acute pancreatitis has been shown to be superior and much more cost-effective than parenteral nutrition. Infected pancreatic necrosis or pancreatic abscess are two of the few remaining indications for open surgery in acute pancreatitis. Even when indicated, surgery is frequently delayed or even replaced by minimally invasive surgical techniques.
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Affiliation(s)
- Julia Mayerle
- Department of Gastroenterology, Endocrinology and Nutrition, Klinik für Innere Medizin A, Ernst-Moritz-Arndt Universität Greifswald, Greifswald, Germany
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