Aggressive Percutaneous Catheter Drainage Protocol for Necrotic Pancreatic Collections

Endoscopic ultrasound-guided pancreatic duct drainage: a comprehensive state of the art review

INTRODUCTION

Endoscopic retrograde pancreatography (ERP) has traditionally been the standard modality for pancreatic endotherapy. However, in certain situations, failure of retrograde ductal access may warrant an alternative modality of drainage. This can occur in various settings like difficult and/or surgically altered anatomy or duodenal obstruction. Endoscopic ultrasound-guided pancreatic duct drainage (EUS-PDD) is a relatively newer addition to the armamentarium for endoscopic access to the PD.

AREAS COVERED

This comprehensive state-of-art review aims to give an overview of the indications, technical details, different approaches, and outcomes of EUS-PDD, with the latest evidence available in scientific literature.

EXPERT OPINION

Akin to its biliary drainage counterpart, EUS-PDD enables an EUS-assisted-ERP using rendezvous technique or EUS-guided drainage through transmural stenting. The technique has evolved over the ensuing years with multitude of accessories, approaches, and devices to optimize the outcomes. However, the technical success and adverse events rates need to be further improved. Additionally, it has a steep learning curve with requirements of advanced technical skill and optimum infrastructure back-up. Meticulous patient selection, precise knowledge of ductal anatomy, appropriate approach, and carefully chosen accessories can improve its clinical outcomes.

Infected pancreatic necrosis-Current trends in management

Acute necrotizing pancreatitis is a common gastrointestinal disease requiring hospitalization and multiple interventions resulting in higher morbidity and mortality. Development of infection in such necrotic tissue is one of the sentinel events in natural history of necrotizing pancreatitis. Infected necrosis develops in around 1/3rd of patients with necrotizing pancreatitis resulting in higher mortality. So, timely diagnosis of infected necrosis using clinical, laboratory and radiological parameters is of utmost importance. Though initial conservative management with antibiotics and organ support system is effective in some patients, a majority of patients still requires drainage of the collection by various modalities. Mode of drainage of infected pancreatic necrosis depends on various factors such as the clinical status of the patient, location and characteristics of collection and availability of the expertise and includes endoscopic, percutaneous and minimally invasive or open surgical approaches. Endoscopic drainage has proved to be a game changer in the management of infected pancreatic necrosis in the last decade with rapid evolution in procedure techniques, development of novel metal stent and dedicated necrosectomy devices for better clinical outcome. Despite widespread adoption of endoscopic transluminal drainage of pancreatic necrosis with excellent clinical outcomes, peripheral collections are still not amenable for endoscopic drainage and in such scenario, the role of percutaneous catheter drainage or minimally invasive surgical necrosectomy cannot be understated. In a nutshell, the management of patients with infected pancreatic necrosis involves a multi-disciplinary team including a gastroenterologist, an intensivist, an interventional radiologist and a surgeon for optimum clinical outcomes.

Different timing for abdominal paracentesis catheter placement and drainage in severe acute pancreatitis complicated by intra-abdominal fluid accumulation

BACKGROUND

Non-surgical methods such as percutaneous drainage are crucial for the treatment of patients with severe acute pancreatitis (SAP). However, there is still an ongoing debate regarding the optimal timing for abdominal paracentesis catheter placement and drainage.

AIM

To explore the influence of different timing for abdominal paracentesis catheter placement and drainage in SAP complicated by intra-abdominal fluid accumulation.

METHODS

Using a retrospective approach, 184 cases of SAP complicated by intra-abdominal fluid accumulation were enrolled and categorized into three groups based on the timing of catheter placement: group A (catheter placement within 2 d of symptom onset, n = 89), group B (catheter placement between days 3 and 5 after symptom onset, n = 55), and group C (catheter placement between days 6 and 7 after symptom onset, n = 40). The differences in progression rate, mortality rate, and the number of cases with organ dysfunction were compared among the three groups.

RESULTS

The progression rate of group A was significantly lower than those in groups B and groups C (2.25% vs 21.82% and 32.50%, P < 0.05). Further, the proportion of patients with at least one organ dysfunction in group A was significantly lower than those in groups B and groups C (41.57% vs 70.91% and 75.00%, P < 0.05). The mortality rates in group A, group B, and group C were similar (P > 0.05). At postoperative day 3, the levels of C-reactive protein (55.41 ± 19.32 mg/L vs 82.25 ± 20.41 mg/L and 88.65 ± 19.14 mg/L, P < 0.05), procalcitonin (1.36 ± 0.51 ng/mL vs 3.20 ± 0.97 ng/mL and 3.41 ± 0.98 ng/mL, P < 0.05), tumor necrosis factor-alpha (15.12 ± 6.63 pg/L vs 22.26 ± 9.96 pg/L and 23.39 ± 9.12 pg/L, P < 0.05), interleukin-6 (332.14 ± 90.16 ng/L vs 412.20 ± 88.50 ng/L and 420.08 ± 87.65ng/L, P < 0.05), interleukin-8 (415.54 ± 68.43 ng/L vs 505.80 ± 66.90 ng/L and 510.43 ± 68.23ng/L, P < 0.05) and serum amyloid A (270.06 ± 78.49 mg/L vs 344.41 ± 81.96 mg/L and 350.60 ± 80.42 mg/L, P < 0.05) were significantly lower in group A compared to those in groups B and group C. The length of hospital stay in group A was significantly lower than those in groups B and group C (24.50 ± 4.16 d vs 35.54 ± 6.62 d and 38.89 ± 7.10 d, P < 0.05). The hospitalization expenses in group A were also significantly lower than those in groups B and groups C [2.70 (1.20, 3.55) ten-thousand-yuan vs 5.50 (2.98, 7.12) ten-thousand-yuan and 6.00 (3.10, 8.05) ten-thousand-yuan, P < 0.05). The incidence of complications in group A was markedly lower than that in group C (5.62% vs 25.00%, P < 0.05), and similar to group B (P > 0.05).

CONCLUSION

Percutaneous catheter drainage for the treatment of SAP complicated by intra-abdominal fluid accumulation is most effective when performed within 2 d of onset.

Early vs. late percutaneous catheter drainage of acute necrotic collections in patients with necrotizing pancreatitis

PURPOSE

It is recommended to drain the pancreatic fluid collections later in the course of the acute necrotizing pancreatitis (ANP). However, earlier drainage may be indicated. We compared early (≤ 2 weeks) vs. late (3rd to 4th week) percutaneous catheter drainage (PCD) of acute necrotic collections (ANC).

MATERIALS AND METHODS

This retrospective study comprised ANP patients who underwent PCD of ANC. The diagnosis of ANP was based on revised Atlanta classification criteria and computed tomography performed between 5 and 7 days of illness. Patients were divided into two groups [1st 2 weeks (group I) and 3rd-4th weeks (group II)] based on the interval between the onset of pain and insertion of catheter. The technical success, clinical success, complications, and clinical outcomes were compared between the two groups.

RESULTS

One hundred forty-eight patients (74 in each group) were evaluated. The procedures were technically successful in all patients. The clinical success rate was 67.6% in group I vs. 77% in group II (p = 0.069). The incidence of complications was significantly higher in group I (n = 12, 16%) than group II (n = 4, 5.4%) (p = 0.034). These included 15 minor (11 in group I and 4 in group II) and one major complication (group I). Of the clinical outcomes, the need for surgery was significantly higher in group I than in group II (13 patients vs. 5 patients, p = 0.031).

CONCLUSION

Early PCD is as technically successful as late PCD in the management of ANC. However, early PCD is associated with higher surgical rate and higher incidence of complications.

Indian College of Radiology and Imaging Consensus Guidelines on Interventions in Pancreatitis

Acute pancreatitis (AP) is one of the common gastrointestinal conditions presenting as medical emergency. Clinically, the severity of AP ranges from mild to severe. Mild AP has a favorable outcome. Patients with moderately severe and severe AP, on the other hand, require hospitalization and considerable utilization of health care resources. These patients require a multidisciplinary management. Pancreatic fluid collections (PFCs) and arterial bleeding are the most important local complications of pancreatitis. PFCs may require drainage when infected or symptomatic. PFCs are drained endoscopically or percutaneously, based on the timing and the location of collection. Both the techniques are complementary, and many patients may undergo dual modality treatment. Percutaneous catheter drainage (PCD) remains the most extensively utilized method for drainage in patients with AP and necrotic PFCs. Besides being effective as a standalone treatment in a significant proportion of these patients, PCD also provides an access for percutaneous endoscopic necrosectomy and minimally invasive necrosectomy. Endovascular embolization is the mainstay of management of arterial complications in patients with AP and chronic pancreatitis. The purpose of the present guideline is to provide evidence-based recommendations for the percutaneous management of complications of pancreatitis.

Retroperitoneal versus transperitoneal percutaneous catheter drainage of necrotic pancreatic collections: a comparative analysis

PURPOSE

To compare the success rate, clinical outcomes, and complications of retroperitoneal (RP) versus transperitoneal (TP) percutaneous catheter drainage (PCD) of the necrotic pancreatic fluid collections.

MATERIALS AND METHODS

This retrospective study comprised consecutive patients with acute pancreatitis who underwent PCD of lesser sac collections amenable to drainage via both TP and RP routes. The patients were divided into two groups based on the route of drainage (group I, RP, and group II, TP). The technical success, clinical success, complications, and clinical outcomes were compared between the groups. Subgroup analysis was performed based on the timing of drainage (acute necrotic collections, ANC vs. walled-off necrosis, WON) and organ failure (OF).

RESULTS

Seventy-nine patients [mean age, 38.7 ± 12.3 years, 54 males] were included in the study. Group I and II comprised 22 (27.8%) and 57 (72.2%) patients, respectively. The procedures were technically successful in all the patients. There was no significant difference in the complication rate between the two groups. The clinical success was higher in group II (75.4%) as compared to group I (54.5%). However, the difference was not statistically significant (p = 0.070). There was no significant difference in the hospital stay (p = 0.298), intensive care unit stay (p = 0.401), need for surgical necrosectomy (p = 0.243), and mortality (p = 0.112) between the two groups. The outcomes in patients with OF and ANC were not affected by the route of PCD. Clinical success rate was significantly higher in WON undergoing TP drainage (p = 0.009).

CONCLUSION

Both RP and TP routes of PCD are safe and effective. Clinical success rate was significantly higher in WON undergoing TP drainage.

Unusual Sites of Necrotic Collections in Acute Necrotizing Pancreatitis: Association with Parenchymal Necrosis and Clinical Outcomes

BACKGROUND

The presence of necrotic collection in acute necrotizing pancreatitis (ANP) at intra-abdominal sites other than the retroperitoneum has not been systematically studied.

AIM

To investigate unusual sites of necrotic collections at computed tomography (CT) and to evaluate association with pancreatic necrosis and clinical outcomes.

METHODS

This retrospective study comprised of consecutive patients with ANP evaluated between January 2018 and March 2019. Based on CT findings, patients were divided into two groups: collections at unusual sites (small bowel mesentery, mesocolon, omentum, subcapsular collections along liver and spleen, pelvis, anterior abdominal wall, and inguinoscrotal regions) and collections at usual retroperitoneal locations (lesser sac, gastrosplenic location, anterior and posterior pararenal spaces, and paracolic gutters). The differences in CT findings and clinical outcomes (need for drainage, length of hospitalization, intensive care unit admission, surgery, and death) between the two groups were evaluated.

RESULTS

A total of 75 patients with ANP were evaluated. There were 25 (33.3%) patients with collections in unusual locations. These included mesentery (n = 17), splenic subcapsular location (n = 7), omentum (n = 6), hepatic subcapsular location (n = 4), anterior abdominal wall (n = 3), pelvis (n = 2), and inguinoscrotal location (n = 1). Compared to patients with collections at usual locations (n = 50), there were no differences in the CT findings except complete parenchymal necrosis (32% vs. 0%, P = .001). There were no statistically significant differences in the clinical outcomes between the two groups.

CONCLUSIONS

Mesenteric collections are frequent in ANP. The other non-retroperitoneal sites are infrequently involved. There is no association between unusual sites of collection and clinical outcomes.

Computed Tomography Findings in Intraabdominal Hypertension in Patients with Acute Pancreatitis

Purpose  Intraabdominal hypertension (IAH) in acute pancreatitis (AP) may reduce tissue perfusion and impair organ function and has been shown to portend poor prognosis. We investigated the computed tomography (CT) findings in patients with AP with IAH. Methods  This retrospective study comprised of consecutive patients with AP from June 2016 to June 2018 in whom intraabdominal pressure (IAP) was measured. The patients who underwent a contrast-enhanced CT within 7 days of IAP measurement were included. Using a cutoff of 12 mm Hg for IAP, the patients were divided into IAH and non-IAH groups. Measures of severity and clinical outcome were evaluated. CT parameters were compared between the groups. Results  The IAH group comprised of 41 patients, while there were 20 patients in the non-IAH group. The IAH group was characterized by severe disease, increased incidence of organ failure, increased requirement for drainage and surgery, prolonged hospital and intensive care unit stay. The mortality was not significantly different between the two groups. On univariate analysis, the CT features that were found to be significantly different between the two groups were the presence of collection ( p = 0.036), the maximum dimension of collection ( p = 0.004), volume of collection ( p = 0.019), biliary dilatation ( p = 0.011), and the presence of moderate-to-severe pleural effusion ( p = 0.009). On multivariate analysis, all these parameters except biliary dilatation were found to be statistically significant. Conclusion  CT findings in patients with AP may suggest IAH. This can be used as an additional marker for severity of AP.

Development and validation of a computed tomography index for assessing outcomes in patients with acute pancreatitis: "SMART-CT" index

PURPOSE

The existing CT indices do not allow quantitative prediction of clinical outcomes in acute pancreatitis (AP). The aim of this study was to develop and validate a revised CT index using a nomogram-based approach.

METHODS

This retrospective study comprised consecutive patients with AP who underwent contrast-enhanced CT between June 2017 and March 2019. 123 CT scans were randomly divided into training (n = 103) and validation groups (n = 20). Two radiologists analyzed CT scans for findings described in modified CT severity index and additional exploratory items (13 items). Seven items (pancreatic necrosis, number of collections, size of collections, ascites, pleural effusion, celiac artery involvement, and liver steatosis) found to be statistically significant were used for development of index. Synthetic minority oversampling technique (SMOTE) was employed to balance representation of minority classes and hence this index was named "SMOTE Application for Reading CT in AcuTe Pancreatitis (SMART-CT index)". Binomial logistic regression was used for development of prediction algorithm. Nomograms were then created and validated for each outcome.

RESULTS

The new CT index had area under the curve (AUC) of 0.79 [95% CI 0.65-0.93], 0.66 (95% CI 0.54-0.77), 0.75 (95% CI 0.65-0.85), 0.83 (95% CI 0.69-0.96), 0.70 (95% CI 0.60-0.81), and 0.64 (95% CI 0.53-0.75) for mortality, intensive care unit (ICU) stay, length of hospitalization, length of ICU stay, number of admissions, and severity, respectively. The AUC of validation cohort was comparable to the training cohort.

CONCLUSION

The novel nomogram-based index predicts occurrence of clinical outcome with moderate accuracy.

Novel Dual-Lumen Drainage Catheter to Enhance the Active Evacuation of Complex Fluid Collections

PURPOSE

To compare the performance of a dual-lumen flushable drainage catheter to a conventional catheter for complex fluid collection drainage.

METHODS

Two prototype catheters (20- and 28-F) were created by incorporating a customized infusion lumen within the wall of a large-bore conventional drainage catheter, which facilitated simultaneous irrigation of the drainage lumen and the targeted collection via inward- and outward-facing infusion side holes. These were tested against unaltered 20- and 28-F conventional catheters to determine if the injection of a dedicated flush lumen improved rapidity and completeness of gravity drainage. In vitro models were created to simulate serous fluid, purulent/exudative fluid, particulate debris, and acute hematoma.

RESULTS

In the purulent model, mean drainage rate was 19.9 ± 8.0 and 9.5±1.4 mL/min for the 20-F prototype and control (P < .001) and 63.9 ± 4.3 and 35.4 ± 3.4 mL/min for the 28-F prototype and control (P = .006), respectively, with complete drainage achieved in all trials. In the particulate model, mean drainage rate was 24.5 ± 9.7 and 12.0 ± 12.5 mL/min for the 28-F prototype and control (P = .003), respectively, with 69.0% versus 41.1% total drainage achieved over 24 minutes (P = .029). In the hematoma model, mean drainage rate was 22.7 ± 4.6 and 4.8 ± 4.3 mL/min for the 28-F prototype and control (P = .022), respectively, with 80.3% versus 20.1% drainage achieved over 15 minutes (P = .003). Particulate and hematoma 20-F prototypes and conventional trials failed due to immediate occlusion.

CONCLUSIONS

The proposed dual-lumen drainage catheter with irrigation of a dedicated flush lumen improved evacuation of complex fluid collections in vitro.

Larger bore percutaneous catheter in necrotic pancreatic fluid collection is associated with better outcomes

OBJECTIVE

To evaluate the impact of initial catheter size on the clinical outcomes in acute pancreatitis (AP).

METHODS

This retrospective study comprised consecutive patients with AP who underwent percutaneous catheter drainage (PCD) between January 2018 and May 2019. Three hundred fifteen consecutive patients underwent PCD during the study period. Based on the initial catheter size, patients were divided into group I (≤ 12 F) and group II (> 12 F). The differences in the clinical outcomes between the two groups, as well as multiple subgroups (based on the severity, timing of drainage, and presence of organ failure (OF)), were evaluated.

RESULTS

One hundred forty-six patients (mean age, 41.2 years, 114 males) fulfilled the inclusion criteria. Ninety-nine (67.8%) patients had severe AP based on revised Atlanta classification. The mean pain to PCD was 22 days (range, 3-267 days). Mean length of hospitalization (LOH) was 27.9 ± 15.8 days. Necrosectomy was performed in 20.5% of patients, and mortality was 16.4%. Group I and II comprised 74 and 72 patients, respectively. There was no significant difference in baseline characteristics, except for a greater number of patients with OF in group II (p = 0.048). The intensive care unit stay was significantly shorter, and multiple readmissions were less frequent in group II (p = 0.037 and 0.013, respectively). Patients with severe AP and moderately severe AP in group II had significantly reduced rates of readmissions (p = 0.035) and significantly shorter LOH (p = 0.041), respectively.

CONCLUSION

Large-sized catheters were associated with better clinical outcomes regardless of disease severity and other baseline disease characteristics.

KEY POINTS

• Larger catheter size for initial PCD was associated with better clinical outcomes in AP. • The benefits were independent of the severity of AP, timing of PCD (ANC vs. WON) and presence of organ failure.

Interventional radiological management of hepatobiliary disorders in pregnancy

Hepatobiliary disorders are common in pregnancy and pose a management challenge. Minimally invasive interventional radiological (IR) techniques allow safe and effective management of these disorders. However, the available literature is scarce. Radiological interventions in this group of patients mandate a clear understanding of the risks of radiation to the fetus. The IR physician involved in the care of these patients should be aware of the measures to minimize the exposure to ionizing radiation. Additionally, the risk-benefit ratio should be clearly defined in a multidisciplinary discussion involving IR physicians, obstetricians, and gastroenterologists. This review is an effort to address issues related to the application of IR procedures for hepatobiliary disorders in pregnant patients.

Kissing catheter technique for percutaneous catheter drainage of necrotic pancreatic collections in acute pancreatitis

One of the critical factors for predicting the success of percutaneous catheter drainage (PCD) is the mean CT density of collection. A higher CT density suggests more necrotic solid tissue within the collection. In the present study, a novel technique for PCD of the necrotic pancreatic collection with a higher mean CT density was evaluated. It was a retrospective study of patients with acute pancreatitis (AP) who underwent PCD of pancreatic collections between May 2018 and December 2018. Patients with pancreatic collections having a CT density of >30 Hounsfield Units (HU) were considered for PCD using the kissing catheter technique. This technique involved placing two catheters side-by-side through a single cutaneous entry site, as the conventional technique of PCD may not be effective. The technical details, outcomes and complications of this technique were recorded. A total of 10 patients with a mean age of 30 years underwent PCD using this technique. All patients had severe pancreatitis with a mean CT severity index of 9 (range, 8-10). The mean CT density was 37 HU (range, 32-56). Successful management with PCD alone was achieved in 8 patients. The other 2 patients underwent surgical necrosectomy. One patient who underwent surgical necrosectomy died. Minor complications occurred in 3 patients. The kissing catheter technique allows for a higher success rate of PCD compared with that of the conventional method of PCD, in collections with a higher mean CT density.