The effect of a novel minimally invasive strategy for infected necrotizing pancreatitis

Clinical Effect of Electroacupuncture on Acute Pancreatitis: Efficacies and Mechanisms

Acute pancreatitis (AP) is a common acute abdomen and the number one cause of acute digestive hospitalizations in the United States. Abdominal pain is the main clinical manifestation of abdominal symptoms, so reducing the abdominal symptoms caused by inflammation is very important to alleviate the pain of patients. Electroacupuncture (EA) as a traditional Chinese medicine (TCM) therapy has significant conditioning effects on various inflammatory diseases including AP. Continuous studies in recent years have shown that EA conditioning has significant effects on reducing inflammation and regulating gastrointestinal symptoms in AP. At the same time, there is sufficient evidence to further elucidate the mechanism of EA. In this review, we will summarize the effect of EA on AP and its mechanism, so as to better serve clinical practice in the treatment of AP in the future.

Involvement of transverse mesocolon is associated with development of colonic fistula in patients with acute necrotizing pancreatitis

BACKGROUND

Involvement of transverse mesocolon (TM) during acute necrotizing pancreatitis(ANP) indicates that inflammation has spread from retroperitoneal space to peritoneum. Nevertheless, the impact of TM involvement, as confirmed by contrast-enhanced computed tomography (CECT), on local complications and clinical outcomes was poorly investigated.

PURPOSE

This study aimed to explore the association between CECT-diagnosed TM involvement and the development of colonic fistula in a cohort of ANP patients.

METHODS

This is a single-center, retrospective cohort study involving ANP patients admitted from January 2020 to December 2020. TM involvement was diagnosed by two experienced radiologists. The study subjects were enrolled consecutively and divided into two groups: TM involvement and non-TM involvement. The primary outcome was colonic fistula during the index admission. Clinical outcomes were compared between the two groups, and the association between the TM involvement and the development of colonic fistula was assessed using multivariable analysis to adjust for baseline unbalances.

RESULTS

A total of 180 patients with ANP were enrolled, and 86 (47.8%) patients had TM involvement. The incidence of the colonic fistula is significantly higher in patients with TM involvement (16.3% vs. 5.3%;p = 0.017). Moreover, the length of hospital stay was 24(13,68) days in patients with TM involvement and 15(7,31) days in those not (p = 0.001). Analysis of multivariable logistic regression revealed that TM involvement is an independent risk factor for the development of colonic fistula (odds ratio: 10.253, 95% CI: 2.206-47.650, p = 0.003).

CONCLUSION

TM involvement in ANP patients is associated with development of colonic fistula in ANP patients.

Early versus delayed intervention in necrotizing acute pancreatitis complicated by persistent organ failure

BACKGROUND

Current guidelines for the treatment of patients with necrotizing acute pancreatitis (NAP) recommend that invasive intervention for pancreatic necrosis should be deferred to 4 or more weeks from disease onset to allow necrotic collections becoming "walled-off". However, for patients showing signs of clinical deterioration, especially those with persistent organ failure (POF), it is controversial whether this delayed approach should always be adopted. In this study, we aimed to assess the impact of differently timed intervention on clinical outcomes in a group of NAP patients complicated by POF.

METHODS

All NAP patients admitted to our hospital from January 2013 to December 2017 were screened for potential inclusion. They were divided into two groups based on the timing of initial intervention (within 4 weeks and beyond 4 weeks). All the data were extracted from a prospectively collected database.

RESULTS

Overall, 131 patients were included for analysis. Among them, 100 (76.3%) patients were intervened within 4 weeks and 31 (23.7%) underwent delayed interventions. As for organ failure prior to intervention, the incidences of respiratory failure, renal failure and cardiovascular failure were not significantly different between the two groups (P > 0.05). The mortality was not significantly different between the two groups (35.0% vs. 32.3%, P = 0.83). The incidences of new-onset multiple organ failure (8.0% vs. 6.5%, P = 1.00), gastrointestinal fistula (29.0% vs. 12.9%, P = 0.10) and bleeding (35.0% vs. 35.5%, P = 1.00), and length of ICU (30.0 vs. 22.0 days, P = 0.61) and hospital stay (42.5 vs. 40.0 days, P = 0.96) were comparable between the two groups.

CONCLUSION

Intervention within 4 weeks did not worsen the clinical outcomes in NAP patients complicated by POF.

The efficacy and efficiency of stent-assisted percutaneous endoscopic necrosectomy for infected pancreatic necrosis: a pilot clinical study using historical controls

OBJECTIVES

Minimally invasive interventions have become standard treatment for infected pancreatic necrosis (IPN). Despite the marginal clinical advantage of endoscopic approaches over the surgical approach shown in recent studies, percutaneous techniques still have a role when endoscopic treatment is not indicated. Stent-assisted percutaneous endoscopic necrosectomy (SAPEN) is an alternative option for surgical necrosectomy, but the theoretical advantages to this procedure remain unproven. This study aimed to report the efficacy and efficiency of SAPEN in patients with IPN.

METHODS

This is a retrospective, historically-controlled, cohort study. All IPN patients admitted to our center from January 2015 to December 2018 were screened for eligibility. Patients admitted between January 2015 and October 2017 were historical controls, and patients admitted thereafter were treated with additional self-expandable metal stent (SEMS). The primary endpoint was a composite of major complications and/or death. Other outcomes, including individual components of the primary endpoint, new-onset sepsis, length of ICU and hospital stay, and pancreatic fistula, were also compared.

RESULTS

There were 73 historical-control patients and 37 patients who had SAPEN included for analysis. The introduction of the SAPEN procedure failed to reduce the incidence of the primary endpoint (35 versus 52%, P = 0.095). However, significantly shorter hospital stay (38 versus 48 days, P = 0.035) and lower incidence of new-onset sepsis were observed in the SAPEN group (35 versus 56%, P = 0.037).

CONCLUSION

The application of SEMS in percutaneous endoscopic necrosectomy procedures shortened hospital stay, decreased new-onset sepsis, and allowed earlier necrosectomy.

Multifunctional Irrigation-Assisted Vacuum Drainage versus Traditional Drainage in the Treatment of Odontogenic Deep Fascial Infection: A Retrospective Cohort Study

Purpose

Odontogenic deep fascial space infection in the head and neck is a common potentially fatal clinical problem. Traditional drainage method is considered laborious and gravity-dependent. In this study, we aimed to evaluate the clinical effect of a modified multifunctional irrigation-assisted vacuum drainage (MIVD) by comparing it with the traditional drainage method in the treatment of odontogenic deep fascial infection.

Patients and Methods

Patients diagnosed with odontogenic deep fascial space infection in the Second Affiliated Hospital, Zhejiang University School of Medicine, China between March 2018 and March 2021 were studied. We divided the patients into two groups based on the drainage method they received: patients with the MIVD device were included in the MIVD group, patients with traditional drainage were included in the traditional group. Data were collected retrospectively including baseline characteristics and treatment outcome variables.

Results

A total of 65 patients were included. All the patients were eventually cured. There were no significant differences in age, gender, diabetes, end stage renal disease, autoimmune diseases, other systemic diseases, tobacco use, number of the infected spaces, preoperative white blood cell count and C-reactive protein between the two groups. The number and frequency of manual irrigation by clinicians (MIC), time required for white blood cell count to return to normal levels (TWBC), time required for C-reactive protein to return to normal levels (TCRP), the length of hospitalization and the length and total cost of antibiotics use were significantly less in the MIVD group. There was no significant difference in the cost of hospitalization between the 2 groups.

Conclusion

The MIVD device significantly reduced the number and frequency of MIC, TWBC, TCRP, the length of hospitalization and the length and total cost of antibiotics use in comparison with the traditional drainage method. It provided a favorable treatment method for patients with odontogenic deep fascial space infection in the head and neck.

Early on-demand drainage or standard management for acute pancreatitis patients with acute necrotic collections and persistent organ failure: A pilot randomized controlled trial

BACKGROUND/PURPOSE

The current standard care for acute pancreatitis with acute necrotic collections (ANC) is to postpone invasive intervention for 4 weeks when indicated. However, in patients with persistent organ failure (POF), this delayed approach may prolong organ failure. In this study, we aimed to assess the feasibility and safety of earlier drainage for acute pancreatitis patients with ANC and POF.

METHODS

A single-center, randomized controlled trial was conducted. Eligible patients were randomly assigned to either the early on-demand (EOD) group or the standard management (SM) group. Within 21 days of randomization, early drainage was triggered by unremitted or worsening organ failure in the EOD group. The primary endpoint was a composite of major complications/death during 90-days follow-up.

RESULTS

Thirty patients were randomized. Within 21 days of randomization, eight of the 15 patients (53%) in the EOD group underwent percutaneous drainage compared to four of the 15 patients (27%) in the SM group (P = 0.26). The primary outcome occurred in three of the 15 (20%) patients in the EOD group and seven of the 15(46.7%) in the controls (P = 0.25, relative risk 0.43, 95%CI 0.14 to 1.35).

CONCLUSIONS

Although the EOD approach did not result in significant differences between groups, the primary outcome assessed in this trial demonstrated the potential for clinical benefits favoring early drainage.

Open necrosectomy combined with continuous positive drainage and prophylactic diverting loop ileostomy for late infected pancreatic necrosis: a retrospective cohort study

Background

To evaluate an innovative open necrosectomy strategy with continuous positive drainage and prophylactic diverting loop ileostomy for the management of late infected pancreatic necrosis (LIPN).

Methods

Consecutive patients were divided into open necrosectomy (ON) group (n = 23), open necrosectomy with colonic segment resection (ON+CSR) group (n = 8) and open necrosectomy with prophylactic diverting loop ileostomy (ON+PDLI) group (n = 11). Continuous positive drainage (CPD) via double-lumen irrigation–suction tube (DLIST) was performed in ON+PDLI group. The primary endpoints were duration of organ failure after surgery, postoperative complication, the rate of re-surgery and mortality. The secondary endpoints were duration of hospitalization, cost, time interval between open surgery and total enteral nutrition (TEN).

Results

The recovery time of organ function in ON+PDLI group was shorter than that in other two groups. Colonic complications occurred in 13 patients (56.5%) in the ON group and 3 patients (27.3%) in the ON+PDLI group (p = 0.11). The length of stay in the ON+PDLI group was shorter than the ON group (p = 0.001). The hospitalization cost in the ON+PDLI group was less than the ON group (p = 0.0052).

Conclusion

ON+PDLI can avoid the intestinal dysfunction, re-ileostomy, the resection of innocent colon and reduce the intraoperative trauma. Despite being of colonic complications before or during operation, CPD + PDLI may show superior effectiveness, safety, and convenience in LIPN.

Management of Splenic Abscess after Splenic Arterial Embolization in Severe Acute Pancreatitis: A 5-Year Single-Center Experience

Objective

To describe the management and prognosis of splenic abscess after splenic arterial embolization in severe acute pancreatitis (SAP) patients.

Methods

This is a retrospective observational study. From August 2012 to August 2017, SAP patients with infected pancreatic necrosis (IPN) who underwent splenic arterial embolization after massive hemorrhage of the splenic artery were screened and those who developed splenic abscess were included for analysis. The demographic characteristics, etiology, treatment of splenic abscess, and clinical outcomes of these cases were collected and analyzed.

Results

A total of 18 patients with splenic abscess formed after splenic arterial embolization were included for data analysis. The median age of the 18 patients was 46 years. The etiologies included biliary AP, hypertriglyceridemic AP (HTG-AP), and other causes. Ten patients underwent minimally invasive percutaneous drainage only for splenic abscess while the other eight patients received splenectomy. One patient died due to uncontrolled infection and another patient died due to massive bleeding, and the remaining sixteen patients survived.

Conclusion

The incidence of splenic abscess was high in patients requiring splenic arterial embolization due to massive bleeding. Our data showed that most splenic abscess could be successfully managed with minimally invasive interventions, and traditional splenectomy should serve as a backup treatment.

Stent-Assisted Percutaneous Endoscopic Necrosectomy for Infected Pancreatic Necrosis: Technical Report and a Pilot Study

BACKGROUND AND AIMS

A variety of minimally invasive techniques have been proposed to replace open surgery for the treatment of infected pancreatic necrosis (IPN). In this study, we evaluate the feasibility and safety of the stent-assisted percutaneous endoscopic necrosectomy (SAPEN) procedure.

METHODS

Data were collected on all patients who underwent the SAPEN procedure between October 2017 and March 2018. The demographic and clinical characteristics of the study patients were analyzed. A composite primary endpoint of major complications and/or death was used. Three different cases were selected to illustrate different technical aspects of the SAPEN procedure.

RESULTS

The placement of a percutaneous stent was successful in all of the 23 patients (17 males, six females). IPN was successfully managed in 16/23 (70%) patients, with the need for open surgery in seven patients (30%), with a median of two (range 1-5) SAPEN procedures. No significant procedure-related complications occurred. Overall 11/23 (48%) patients had a major complication and/or death.

CONCLUSIONS

In conclusion, the SAPEN procedure was effective in treating IPN without adding extra procedural risk. The role and benefits of the SAPEN procedure now need to be demonstrated in larger controlled study.