1
|
González-Haba Ruiz M, Betés Ibáñez MT, Martínez Moreno B, Repiso Ortega A, de la Serna Higuera C, Iglesias García J, Sendino García O, Moris Felgueroso M, Agudo Castillo B, Esteban López-Jamar JM, Lindo Ricce MD, Soria San Teodoro MT, Moya Valverde E, Muñoz López D, Uribarri González L, Sevilla Ribota S, Lariño Noia J, Pérez Miranda M, Aparicio Tormo JR, Vila Costas JJ, Vázquez Sequeiros E, Subtil Íñigo JC, Pérez-Cuadrado-Robles E, Sánchez Yagüe A, Núñez Otero JA, Foruny Olcina JR. Endoscopic management of pancreatic collections. Endoscopic Ultrasound Group, Spanish Society of Digestive Endoscopy (GSEED-USE) Clinical Guidelines. REVISTA ESPANOLA DE ENFERMEDADES DIGESTIVAS 2024; 116:423-437. [PMID: 38305682 DOI: 10.17235/reed.2024.10276/2024] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 02/03/2024]
Abstract
Acute pancreatitis is associated with significant morbidity and mortality. It can develop complications such as fluid collections and necrosis. Infection of necrosis occurs in about 20-40 % of patients with severe acute pancreatitis, and is associated with organ failure and worse prognosis. In the past few years the treatment of pancreatic collections has shifted from open surgery to minimally invasive techniques such as endoscopic ultrasound-guided drainage. These guidelines from a selection of experts among the Endoscopic Ultrasound Group, Spanish Society of Gastrointestinal Endoscopy (GSEED-USE) are intended to provide advice on the management of pancreatic collections based on a thorough review of the available scientific evidence. It also reflects the experience and clinical practice of the authors, who are advanced endoscopists or clinical pancreatologists with extensive experience in managing patients with acute pancreatitis.
Collapse
|
2
|
Trikudanathan G, Abdallah M, Munigala S, Vantanasiri K, Jonason D, Faizi N, Schat R, Chauhan A, Freeman ML, Bellin MD. Visceral Fat Predicts New-Onset Diabetes After Necrotizing Pancreatitis. Pancreas 2024; 53:e240-e246. [PMID: 38266226 DOI: 10.1097/mpa.0000000000002292] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/26/2024]
Abstract
OBJECTIVES We aimed to estimate the incidence of new-onset diabetes (NOD) and identify risk factors for NOD in patients with necrotizing pancreatitis (NP). METHODS Necrotizing pancreatitis patients were reviewed for NOD, diagnosed >90 days after acute pancreatitis. Baseline demographics, comorbidities, clinical outcomes, computed tomography (CT) characteristics of necrotic collections, and CT-derived abdominal fat measurements were analyzed to identify predictors for NOD. RESULTS Among 390 eligible NP patients (66% men; median age, 51 years; interquartile range [IQR], 36-64) with a median follow-up of 400 days (IQR, 105-1074 days), NOD developed in 101 patients (26%) after a median of 216 days (IQR, 92-749 days) from NP. Of the NOD patients, 84% required insulin and 69% developed exocrine pancreatic insufficiency (EPI). Age (odds ratio [OR], 0.98), male sex (OR, 2.7), obesity (OR, 2.1), presence of EPI (OR, 2.7), and diffuse pancreatic necrosis (OR, 2.4) were independent predictors. In a separate multivariable model assessing abdominal fat on CT, visceral fat area (highest quartile) was an independent predictor for NOD (OR, 3.01). CONCLUSIONS New-onset diabetes was observed in 1 of 4 patients with NP, most within the first year and requiring insulin. Male sex, obesity, diffuse pancreatic necrosis, development of EPI, and high visceral adiposity identified those at highest risk.
Collapse
Affiliation(s)
- Guru Trikudanathan
- From the Division of Gastroenterology, Hepatology and Nutrition, University of Minnesota, Minneapolis, MN
| | - Mohamed Abdallah
- From the Division of Gastroenterology, Hepatology and Nutrition, University of Minnesota, Minneapolis, MN
| | - Satish Munigala
- Division of Infectious diseases, Washington University, St Louis, MO
| | | | | | | | | | | | - Martin L Freeman
- From the Division of Gastroenterology, Hepatology and Nutrition, University of Minnesota, Minneapolis, MN
| | | |
Collapse
|
3
|
Chhabra M, Gupta P, Shah J, Samanta J, Mandavdhare H, Sharma V, Sinha SK, Dutta U, Kochhar R. Imaging Diagnosis and Management of Fistulas in Pancreatitis. Dig Dis Sci 2024; 69:335-348. [PMID: 38114791 DOI: 10.1007/s10620-023-08173-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/03/2023] [Accepted: 10/27/2023] [Indexed: 12/21/2023]
Abstract
Pancreatic fistula is a highly morbid complication of pancreatitis. External pancreatic fistulas result when pancreatic secretions leak externally into the percutaneous drains or external wound (following surgery) due to the communication of the peripancreatic collection with the main pancreatic duct (MPD). Internal pancreatic fistulas include communication of the pancreatic duct (directly or via intervening collection) with the pleura, pericardium, mediastinum, peritoneal cavity, or gastrointestinal tract. Cross-sectional imaging plays an essential role in the management of pancreatic fistulas. With the help of multiplanar imaging, fistulous tracts can be delineated clearly. Thin computed tomography sections and magnetic resonance cholangiopancreatography images may demonstrate the communication between MPD and pancreatic fluid collections or body cavities. Endoscopic retrograde cholangiography (ERCP) is diagnostic as well as therapeutic. In this review, we discuss the imaging diagnosis and management of various types of pancreatic fistulas with the aim to sensitize radiologists to timely diagnosis of this critical complication of pancreatitis.
Collapse
Affiliation(s)
- Manika Chhabra
- Department of Radiodiagnosis and Imaging, Postgraduate Institute of Medical Education and Research, Chandigarh, India
| | - Pankaj Gupta
- Department of Radiodiagnosis and Imaging, Postgraduate Institute of Medical Education and Research, Chandigarh, India.
| | - Jimil Shah
- Department of Gastroenterology, Postgraduate Institute of Medical Education and Research, Chandigarh, India
| | - Jayanta Samanta
- Department of Gastroenterology, Postgraduate Institute of Medical Education and Research, Chandigarh, India
| | - Harshal Mandavdhare
- Department of Gastroenterology, Postgraduate Institute of Medical Education and Research, Chandigarh, India
| | - Vishal Sharma
- Department of Gastroenterology, Postgraduate Institute of Medical Education and Research, Chandigarh, India
| | - Saroj K Sinha
- Department of Gastroenterology, Postgraduate Institute of Medical Education and Research, Chandigarh, India
| | - Usha Dutta
- Department of Gastroenterology, Postgraduate Institute of Medical Education and Research, Chandigarh, India
| | - Rakesh Kochhar
- Department of Gastroenterology, Postgraduate Institute of Medical Education and Research, Chandigarh, India
| |
Collapse
|
4
|
Basha J, Lakhtakia S. Management of Disconnected Pancreatic Duct. Gastrointest Endosc Clin N Am 2023; 33:753-770. [PMID: 37709409 DOI: 10.1016/j.giec.2023.04.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 09/16/2023]
Abstract
Disconnected pancreatic duct (DPD) is common after acute necrotizing pancreatitis (ANP). Its clinical implications vary according to the course of disease. In the early phase of ANP, parenchymal necrosis along with disruption of pancreatic duct cause acute necrotic collection that evolves into walled-off necrosis (WON). In the later phase, DPD becomes evident as confirmed by magnetic resonance cholangiopancreatography. Clinical manifestations of DPD can vary from being asymptomatic, recurrent pain, recurrent pancreatic fluid collection (PFC), obstructive pancreatitis, or external pancreatic fistula (EPF). Few patients develop new-onset diabetes. Long-term indwelling plastic stents have been proposed to prevent the recurrent PFC.
Collapse
Affiliation(s)
- Jahangeer Basha
- Department of Gastroenterology, Asian Institute of Gastroenterology, AIG Hospitals, Gachibowli, Hyderabad 500032, Telangana, India
| | - Sundeep Lakhtakia
- Department of Gastroenterology, Asian Institute of Gastroenterology, AIG Hospitals, Gachibowli, Hyderabad 500032, Telangana, India.
| |
Collapse
|
5
|
Song LJ, Xiao B. Acute pancreatitis: Structured report template of magnetic resonance imaging. World J Radiol 2023; 15:157-169. [PMID: 37424735 PMCID: PMC10324496 DOI: 10.4329/wjr.v15.i6.157] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/27/2023] [Revised: 05/25/2023] [Accepted: 06/16/2023] [Indexed: 06/28/2023] Open
Abstract
Acute pancreatitis (AP) is a common acute abdomen disease of the digestive system. It has a potentially fatal risk because of its variable severity and various complications. With the widespread application of the Revised Atlanta Classification, new requirements for AP imaging reports are introduced. Experts in abdominal radiology and pancreatology in the United States published the first structured computed tomography reporting template for AP in 2020. However, there is no corresponding structured magnetic resonance imaging (MRI) reporting template globally. Therefore, this article focuses on the structured MRI report of AP images from our pancreatitis imaging center, which is intended to improve the systematic understanding of this disease and standardize the writing of MRI structured reports. In the meantime, we aim to promote the clinical diagnosis and assessment of MRI efficacy for AP and its multiple complications. It is further intended to facilitate academic exchanges and scientific research between different medical centers.
Collapse
Affiliation(s)
- Ling-Ji Song
- Department of Radiology, Sichuan Key Laboratory of Medical Imaging, The Affiliated Hospital of North Sichuan Medical College, Nanchong 637000, Sichuan Province, China
| | - Bo Xiao
- Department of Radiology, Sichuan Key Laboratory of Medical Imaging, The Affiliated Hospital of North Sichuan Medical College, Nanchong 637000, Sichuan Province, China
| |
Collapse
|
6
|
Sameera S, Mohammad T, Liao K, Shahid H, Sarkar A, Tyberg A, Kahaleh M. Management of Pancreatic Fluid Collections: An Evidence-based Approach. J Clin Gastroenterol 2023; 57:346-361. [PMID: 36040932 DOI: 10.1097/mcg.0000000000001750] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/10/2022]
Abstract
Managing pancreatic fluid collections (PFCs) remains a challenge for many clinicians. Recently, significant progress has been made in the therapy of PFCs, including improvements in technology and devices, as well as in the development of minimally invasive endoscopic techniques, many of which are proven less traumatic when compared with surgical options and more efficacious when compared with percutaneous techniques. This review will explore latest developments in the management of PFCs and how they incorporate into the current treatment algorithm.
Collapse
Affiliation(s)
- Sohini Sameera
- Department of Gastroenterology & Hepatology, Rutgers Robert Wood Johnson Medical School, New Brunswick, NJ
| | | | | | | | | | | | | |
Collapse
|
7
|
Sathyanathan BP, Vennimalai S. Disconnected Pancreatic Duct Syndrome—An Often-Overlooked Complication of Acute Necrotizing Pancreatitis. Indian J Radiol Imaging 2023; 33:281-283. [PMID: 37123582 PMCID: PMC10132864 DOI: 10.1055/s-0042-1760280] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/05/2023] Open
Affiliation(s)
| | - Suria Vennimalai
- Barnard Institute of Radiology, Madras Medical College, Chennai, Tamil Nadu, India
| |
Collapse
|
8
|
Wang ZJ, Song YH, Li SY, He ZX, Li ZS, Wang SL, Bai Y. Endoscopic management of pancreatic fluid collections with disconnected pancreatic duct syndrome. Endosc Ultrasound 2023; 12:29-37. [PMID: 36861506 PMCID: PMC10134920 DOI: 10.4103/eus-d-21-00272] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/15/2021] [Accepted: 03/01/2022] [Indexed: 11/04/2022] Open
Abstract
Disconnected pancreatic duct syndrome (DPDS) is an important and common complication of acute necrotizing pancreatitis. Endoscopic approach has been established as the first-line treatment for pancreatic fluid collections (PFCs) with less invasion and satisfactory outcome. However, the presence of DPDS significantly complicates the management of PFC; besides, there is no standardized treatment for DPDS. The diagnosis of DPDS presents the first step of management, which can be preliminarily established by imaging methods including contrast-enhanced computed tomography, ERCP, magnetic resonance cholangiopancreatography (MRCP), and EUS. Historically, ERCP is considered as the gold standard for the diagnosis of DPDS, and secretin-enhanced MRCP is recommended as an appropriate diagnostic method in existing guidelines. With the development of endoscopic techniques and accessories, the endoscopic approach, mainly including transpapillary and transmural drainage, has been developed as the preferred treatment over percutaneous drainage and surgery for the management of PFC with DPDS. Many studies concerning various endoscopic treatment strategies have been published, especially in the recent 5 years. Nonetheless, existing current literature has reported inconsistent and confusing results. In this article, the latest evidence is summarized to explore the optimal endoscopic management of PFC with DPDS.
Collapse
Affiliation(s)
- Zhi-Jie Wang
- Department of Gastroenterology, Changhai Hospital, Second Military Medical University/Naval Medical University, Shanghai, China
| | - Yi-Hang Song
- Department of Gastroenterology, Changhai Hospital, Second Military Medical University/Naval Medical University, Shanghai, China
| | - Shi-Yu Li
- Department of Gastroenterology, Changhai Hospital, Second Military Medical University/Naval Medical University, Shanghai, China
| | - Zi-Xuan He
- Department of Gastroenterology, Changhai Hospital, Second Military Medical University/Naval Medical University, Shanghai, China
| | - Zhao-Shen Li
- Department of Gastroenterology, Changhai Hospital, Second Military Medical University/Naval Medical University, Shanghai, China
| | - Shu-Ling Wang
- Department of Gastroenterology, Changhai Hospital, Second Military Medical University/Naval Medical University, Shanghai, China
| | - Yu Bai
- Department of Gastroenterology, Changhai Hospital, Second Military Medical University/Naval Medical University, Shanghai, China
| |
Collapse
|
9
|
Meng Y, Ding J, Tian C, Wang M, Tang K. Endoscopic transpapillary drainage for walled-off pancreatic necrosis with complete main pancreatic duct disruption by metallic stent placement: A retrospective study. Front Med (Lausanne) 2022; 9:1064463. [PMID: 36569130 PMCID: PMC9767958 DOI: 10.3389/fmed.2022.1064463] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/08/2022] [Accepted: 11/15/2022] [Indexed: 12/12/2022] Open
Abstract
Background Walled-off pancreatic necrosis (WOPN) is a serious complication of acute necrotizing pancreatitis (ANP) and may lead to disruption of the main pancreatic duct (MPD). Endoscopic passive transpapillary drainage (PTD) is an effective method for treating MPD disruptions. However, WOPN with complete MPD disruption is usually accompanied by disconnected pancreatic duct syndrome (DPDS), especially with infected necrosis. Endoscopic PTD with a fully covered self-expanding metallic stent (FCSEMS) and a plastic stent placement may have the potential for future application in treating complete MPD disruption in patients with WOPN. Methods Patients with WOPN caused by ANP were classified according to the 2012 Atlanta classification and definition. In all patients, ERCP was performed 2 times. First, 3 patients were diagnosed with complete MPD disruption by ERCP. At the time of diagnosis, a plastic pancreatic stent (7Fr) was placed. Second, they underwent endoscopic PTD for WOPN with complete MPD disruption in which an FCSEMS and plastic stent placement were the only access routes to the necrotic cavity. Results The etiology of pancreatitis in these patients was of biliary, lipogenic, and alcoholic origin. The WOPN lesion size ranged from 6.5 to 10.2 cm in this study, and the type of WOPN was mixed in two cases and central in one case. The type of MPD disruption was complete in all three patients. The locations of disruption included the pancreatic body and head. The time from occurrence to the first ERCP was 18, 23, and 26 days, respectively. The main symptoms were abdominal pain, abdominal distention, fever, gastrointestinal obstruction, and/or weight loss. The three patients with symptomatic WOPN and MPD disruption underwent endoscopic PTD with FCSEMS and plastic pancreatic stent placement. Technical and therapeutic successes were achieved in 3/3 of patients. The mean time of stenting was 28-93 days. The clinical symptoms connected with WOPN and collection disappeared postoperatively in all three patients. During the follow-up period of 4-18 months, no patient developed collection recurrence or other complications, such as gastrointestinal bleeding or reinfection. All patients recovered uneventfully. Conclusion In patients with WOPN with complete MPD disruption, endoscopic PTD with FCSEMSs and plastic stent placement may be an effective and safe method of treatment.
Collapse
|
10
|
Disconnected pancreatic duct syndrome in patients with necrotizing pancreatitis. Surg Open Sci 2022; 11:19-25. [DOI: 10.1016/j.sopen.2022.10.009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/21/2022] [Accepted: 10/21/2022] [Indexed: 11/13/2022] Open
|
11
|
Pawa R, Dorrell R, Russell G, Gilliam J, Mishra G, Pawa S. Long-term transmural drainage of pancreatic fluid collections with double pigtail stents following lumen-apposing metal stent placement improves recurrence-free survival in disconnected pancreatic duct syndrome. Dig Endosc 2022; 34:1234-1241. [PMID: 35148447 DOI: 10.1111/den.14266] [Citation(s) in RCA: 15] [Impact Index Per Article: 7.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/22/2021] [Revised: 01/24/2022] [Accepted: 02/06/2022] [Indexed: 02/08/2023]
Abstract
OBJECTIVES Disconnected pancreatic duct syndrome (DPDS) is the most common cause of pancreatic fluid collection (PFC) recurrence. While long-term transmural drainage with plastic stents is the preferred endoscopic approach, there is a paucity of literature on patients undergoing initial drainage with lumen-apposing metal stents (LAMS). We describe our experience managing patients with DPDS. METHODS A retrospective review of a prospectively maintained database (November 2015-September 2020) was performed looking at clinical outcomes and overall survival for patients undergoing endoscopic management of PFCs using LAMS. The primary outcome was to assess recurrence-free survival in PFC patients with DPDS managed with or without double pigtail stents (DPS) replacement after LAMS removal. RESULTS Of 96 patients with PFCs, 48 with DPDS were included in the study. The median follow-up was 20.1 months. LAMS replacement with DPS was successful in 21/48 (43.8%) patients. Recurrence was seen in 1/21 (5%) patients with DPS replacement and 10/27 (37%) without DPS replacement. In multivariable models, a longer duration of LAMS placement was negatively associated with successful DPS replacement (odds ratio 1.33, 95% confidence interval [CI] 1.11, 1.59, P = 0.0019) and successful LAMS replacement with DPS in patients with DPDS improved recurrence-free survival (hazard ratio 0.09, 95% CI 0.01, 0.83, P = 0.033). CONCLUSION In patients with PFCs and DPDS, early replacement of LAMS with DPS improves the likelihood of successful long-term transmural drainage and decreases recurrences.
Collapse
Affiliation(s)
- Rishi Pawa
- Department of Medicine, Section on Gastroenterology, Wake Forest School of Medicine, Winston-Salem, USA
| | - Robert Dorrell
- Department of Medicine, Wake Forest School of Medicine, Winston-Salem, USA
| | - Greg Russell
- Biostatistics and Data Science, Wake Forest School of Medicine, Winston-Salem, USA
| | - John Gilliam
- Department of Medicine, Section on Gastroenterology, Wake Forest School of Medicine, Winston-Salem, USA
| | - Girish Mishra
- Department of Medicine, Section on Gastroenterology, Wake Forest School of Medicine, Winston-Salem, USA
| | - Swati Pawa
- Department of Medicine, Section on Gastroenterology, Wake Forest School of Medicine, Winston-Salem, USA
| |
Collapse
|
12
|
Bansal A, Ramegowda R, Gupta P, Shah J, Samanta J, Mandavdhare H, Sharma V, Kochhar R, Sandhu MS. Abbreviated non-enhanced magnetic resonance imaging in patients with acute necrotizing pancreatitis. ABDOMINAL RADIOLOGY (NEW YORK) 2022; 47:2381-2389. [PMID: 35507068 DOI: 10.1007/s00261-022-03531-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/27/2021] [Revised: 04/12/2022] [Accepted: 04/12/2022] [Indexed: 12/31/2022]
Abstract
AIM To investigate the performance of T2-weighted abbreviated magnetic resonance imaging (T2W-AMRI) protocol in evaluating patients with acute necrotizing pancreatitis (ANP). METHODS A retrospective analysis of consecutive hospitalized patients with ANP who underwent MRI (contrast-enhanced, CE or non-contrast, NC) between January 2017 and November 2020 was performed. The T2W-AMRI and complete MRI (cMRI) sequences were anonymized, and subsequently, two separate sets of data (AMRI and cMRI) were created for presentation to the radiologists involved in reading the data. The T2W-AMRI was based on a single-axial T2 half-Fourier acquisition single-shot turbo spin-echo (HASTE) sequence. The pancreatic and extrapancreatic findings were recorded and tabulated independently by two radiologists on T2W-AMRI and cMRI. In addition, the interobserver agreement and association of findings between T2W-AMRI and cMRI were analyzed. RESULTS Twenty-eight patients (mean age 31.7 ± 12.2 years, 17 females) were included. Thirteen patients had CE-cMRI, while the rest underwent NC-cMRI. There was no significant difference in the identification of pancreatic necrosis on T2W-AMRI vs. cMRI (p = 1.00). However, T2W-AMRI underestimated necrosis in one patient. Collections were accurately detected in all patients on T2W-AMRI. The mean size of the collection was larger on cMRI (6.5 ± 3.7 cm) than T2W-AMRI (6 ± 3.7 cm) with p = 0.006. cMRI detected more patients with disrupted pancreatic duct (n = 9) than T2W-AMRI (n = 6). However, the difference was not statistically significant (p = 0.375). There was a good to an excellent interobserver agreement between the readers for T2W-AMRI (k = 0.62-1). CONCLUSION T2W-AMRI may offer a suitable alternative to cMRI in ANP, especially severe disease, as it can be acquired rapidly without the need for contrast injection.
Collapse
Affiliation(s)
- Akash Bansal
- Department of Radiodiagnosis and Imaging, Postgraduate Institute of Medical Education and Research, Chandigarh, India
| | - Rajath Ramegowda
- Department of Radiodiagnosis and Imaging, Postgraduate Institute of Medical Education and Research, Chandigarh, India
| | - Pankaj Gupta
- Department of Radiodiagnosis and Imaging, Postgraduate Institute of Medical Education and Research, Chandigarh, India.
| | - Jimil Shah
- Department of Gastroenterology, Postgraduate Institute of Medical Education and Research, Chandigarh, India
| | - Jayanta Samanta
- Department of Gastroenterology, Postgraduate Institute of Medical Education and Research, Chandigarh, India
| | - Harshal Mandavdhare
- Department of Gastroenterology, Postgraduate Institute of Medical Education and Research, Chandigarh, India
| | - Vishal Sharma
- Department of Gastroenterology, Postgraduate Institute of Medical Education and Research, Chandigarh, India
| | - Rakesh Kochhar
- Department of Gastroenterology, Postgraduate Institute of Medical Education and Research, Chandigarh, India
| | - Manavjit Singh Sandhu
- Department of Radiodiagnosis and Imaging, Postgraduate Institute of Medical Education and Research, Chandigarh, India
| |
Collapse
|
13
|
Hamada T, Iwashita T, Saito T, Shiomi H, Takenaka M, Isayama H, Yasuda I, Nakai Y. Disconnected pancreatic duct syndrome and outcomes of endoscopic ultrasound-guided treatment of pancreatic fluid collections: Systematic review and meta-analysis. Dig Endosc 2022; 34:676-686. [PMID: 34544204 DOI: 10.1111/den.14142] [Citation(s) in RCA: 18] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/22/2021] [Accepted: 09/16/2021] [Indexed: 12/12/2022]
Abstract
BACKGROUND Disconnected pancreatic duct syndrome (DPDS) frequently occurs in patients with acute necrotizing pancreatitis and resultant pancreatic fluid collection (PFC). We performed a systematic review and meta-analysis to evaluate outcomes of endoscopic ultrasound-guided treatment of PFCs according to the presence of DPDS. METHODS Using PubMed, Embase, and the Cochrane database, we identified clinical studies published until January 2021 with data comparing outcomes of endoscopic ultrasound-guided drainage of PFCs between DPDS and non-DPDS patients. We pooled data on technical and clinical success rates, PFC recurrence, and adverse events using the random-effects model. RESULTS We identified five eligible articles including 941 PFC patients treated with endoscopic ultrasound-guided interventions. Clinical success, defined as resolution of the PFC and symptoms, was achieved in a majority of the cases irrespective of DPDS (pooled odds ratio [OR] comparing DPDS to non-DPDS patients, 0.77; 95% confidence interval [CI] 0.33-1.81). Compared to patients without DPDS, patients with DPDS were more likely to undergo PFC recurrence (pooled OR 6.72; 95% CI 2.72-16.6) after clinical resolution of PFC. Prolonged plastic stent placement following the clinical resolution was more frequently performed in DPDS patients than in non-DPDS patients (pooled OR 15.9; 95% CI 2.76-91.9). No statistically significant difference was observed between the groups in terms of the rate of technical success, adverse events, or mortality. CONCLUSION Disconnected pancreatic duct syndrome was associated with higher rate of PFC recurrence after successful endoscopic treatment of PFCs. Future studies should evaluate effectiveness and optimal duration of long-term placement of transmural plastic stents for PFCs with DPDS.
Collapse
Affiliation(s)
- Tsuyoshi Hamada
- Department of Gastroenterology, Graduate School of Medicine, The University of Tokyo, Tokyo, Japan.,Department of Hepato-Biliary-Pancreatic Medicine, Cancer Institute Hospital of Japanese Foundation for Cancer Research, Tokyo, Japan
| | - Takuji Iwashita
- First Department of Internal Medicine, Gifu University Hospital, Gifu, Japan
| | - Tomotaka Saito
- Department of Gastroenterology, Graduate School of Medicine, The University of Tokyo, Tokyo, Japan
| | - Hideyuki Shiomi
- Division of Gastroenterology and Hepato-biliary-pancreatology, Department of Internal Medicine, Hyogo College of Medicine, Hyogo, Japan
| | - Mamoru Takenaka
- Department of Gastroenterology and Hepatology, Faculty of Medicine, Kindai University, Osaka, Japan
| | - Hiroyuki Isayama
- Department of Gastroenterology, Graduate School of Medicine, Juntendo University, Tokyo, Japan
| | - Ichiro Yasuda
- Third Department of Internal Medicine, University of Toyama, Toyama, Japan
| | - Yousuke Nakai
- Department of Gastroenterology, Graduate School of Medicine, The University of Tokyo, Tokyo, Japan.,Department of Endoscopy and Endoscopic Surgery, The University of Tokyo Hospital, Tokyo, Japan
| | | |
Collapse
|
14
|
Bhatia H, Yadav N, Gupta P. Radiological criteria for disconnected pancreatic duct syndrome: a targeted literature review. Expert Rev Gastroenterol Hepatol 2022; 16:121-127. [PMID: 35051345 DOI: 10.1080/17474124.2022.2031978] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
INTRODUCTION In patients with acute necrotizing pancreatitis (ANP), parenchymal necrosis may involve the pancreatic duct, isolating a segment of the pancreas that remains functional but drains its secretions into the peripancreatic fluid collections, leading to disconnected pancreatic duct syndrome (DPDS). DPDS is an important complication of ANP associated with long-term morbidity and mortality. Unfortunately, this critical entity is under-recognized by radiologists. Endoscopic retrograde cholangiopancreatography (ERCP) is considered the gold standard for diagnosing and treating such patients. However, considering the invasiveness of the ERCP, a noninvasive diagnosis based on radiological tests is desirable. Radiological literature concerning the diagnosis of DPDS is scarce, and there is substantial ambiguity regarding the radiological definitions of DPDS. AREAS COVERED Considering the scarcity of published literature regarding the reliable radiologic diagnosis of DPDS, we performed a thorough review of the existing literature to identify definitions and features of this entity on computed tomography (CT) and magnetic resonance imaging (MRI). EXPERT OPINION Existing literature regarding radiologic diagnosis of DPDS was reviewed and analyzed and a comprehensive imaging definition of DPDS was proposed.
Collapse
Affiliation(s)
- Harsimran Bhatia
- Department of Radiodiagnosis and Imaging, Postgraduate Institute of Medical Education and Research, Chandigarh, India
| | - Neha Yadav
- Department of Radiodiagnosis and Imaging, Postgraduate Institute of Medical Education and Research, Chandigarh, India
| | - Pankaj Gupta
- Department of Radiodiagnosis and Imaging, Postgraduate Institute of Medical Education and Research, Chandigarh, India
| |
Collapse
|
15
|
Thiruvengadam NR, Forde KA, Miranda J, Kim C, Behr S, Masharani U, Arain MA. Disconnected Pancreatic Duct Syndrome: Pancreatitis of the Disconnected Pancreas and Its Role in the Development of Diabetes Mellitus. Clin Transl Gastroenterol 2022; 13:e00457. [PMID: 35060942 PMCID: PMC8865505 DOI: 10.14309/ctg.0000000000000457] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/02/2021] [Accepted: 12/28/2021] [Indexed: 11/23/2022] Open
Abstract
INTRODUCTION Disconnected pancreatic duct syndrome (DPDS) is a recognized complication of necrotizing pancreatitis (NP). Manifestations include recurrent peripancreatic fluid collections (R-PFC) and pancreatocutaneous fistulae (PC-Fistulae). Pancreatitis of the disconnected pancreatic segment (DPDS-P) and its relationship to new-onset diabetes after pancreatitis (NODAP) are not well characterized. METHODS We performed a retrospective cohort study of consecutive patients with NP admitted to University of California, San Francisco from January 2011 to June 2019. A diagnosis of a disconnected pancreatic duct (PD) was confirmed using computed tomography and magnetic resonance cholangiopancreatography/endoscopic retrograde cholangiopancreatography. DPDS was defined as a disconnected PD presenting with R-PFC, PC-Fistulae, or DPDS-P. The primary outcome was NODAP, defined as diabetes mellitus (DM) occurring >3 months after NP. Cox proportional hazards regression was used to evaluate the relationship between DPDS and NODAP. RESULTS Of 171 patients with NP in this study, the mean clinical follow-up was 46 ± 18 months and the imaging follow-up was 38 ± 20 months. Twenty-seven patients (16%) developed DPDS-P at a median of 28 months. New-onset DM occurred in 54 of the 148 patients (36%), with 22% developing DM within 3 months of NP and 14% developing NODAP at a median of 31 months after AP. DPDS-P was associated with NODAP when compared with non-DPDS patients (adjusted hazard ratio 5.63 95% confidence interval: 1.69-18.74, P = 0.005) while R-PFCs and PC-Fistulae were not. DISCUSSION DPDS and NODAP occurred in 28% and 14% of the patients, respectively. Pancreatitis of the disconnected pancreas occurred in 16% of the patients and was associated with higher rates of NODAP when compared with patients with other manifestations of DPDS and patients without DPDS.
Collapse
Affiliation(s)
- Nikhil R. Thiruvengadam
- Division of Gastroenterology and Hepatology, Loma Linda University School of Medicine, Loma Linda, California, USA;
- Division of Gastroenterology and Hepatology, University of Pennsylvania, Philadelphia, Pennsylvania, USA;
- Center for Endoscopic Innovation, Research and Training, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania, USA;
- Division of Gastroenterology and Hepatology, University of California San Francisco, San Francisco, California, USA;
| | - Kimberly A. Forde
- Division of Gastroenterology and Hepatology, Temple University, Philadelphia, Pennsylvania
| | - Janille Miranda
- Division of Gastroenterology and Hepatology, University of California San Francisco, San Francisco, California, USA;
| | - Christopher Kim
- Abdominal Imaging Section, Department of Radiology, University of California San Francisco, San Francisco, California, USA;
| | - Spencer Behr
- Abdominal Imaging Section, Department of Radiology, University of California San Francisco, San Francisco, California, USA;
| | - Umesh Masharani
- Division of Endocrinology and Metabolism, Department of Medicine, The University of California, San Francisco, California, USA.
| | - Mustafa A. Arain
- Division of Gastroenterology and Hepatology, University of California San Francisco, San Francisco, California, USA;
- Center for Interventional Endoscopy, AdventHealth, Orlando, Florida, USA.
| |
Collapse
|
16
|
Gattani MG, Chauhan SG, Sethiya PR, Chandak PC, Lad SG, Singh GK, Kolhe KM, Khairnar HB, Pandey VR, Ingle MA. Safety and Efficacy of Early Endotherapy in Management of Pancreatic Ascites: Western Indian Experience. JOURNAL OF DIGESTIVE ENDOSCOPY 2022. [DOI: 10.1055/s-0041-1741515] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/19/2022] Open
Abstract
Abstract
Background Pancreatic ascites is rare but a known complication of pancreatitis. We aimed to study the timings, safety, and efficacy of therapeutic approaches in its management and the outcomes.
Methods We retrospectively studied patients with pancreatic ascites managed in the past 5 years at a single tertiary care center. Therapeutic approaches included conservative therapy, early endoscopic therapy, and surgery. We used descriptive statistics to summarize characteristics of the study population, and performed univariate and binary logistic regression analyses to compare treatment outcomes.
Results Of the 125 patients screened, 70 (male, 81.4%) were included. Disruption in the pancreatic duct (PD) was seen in 51.4% of patients on magnetic resonance cholangiopancreatography (MRCP) and 73.3% of patients on endoscopic retrograde cholangiopancreatography (ERCP). The PD in the body region (46.7%) was the most frequent site of disruption. Early endotherapy included a stent bridging the disruption site in 63.3% of patients and sphincterotomy in 76.7% of patients with a median time to ERCP from symptom onset being 8.5 days. The success rate in early endotherapy was 81.7%, while the recurrence rate was 8%. For conservative therapy only, the success rate was 60% with recurrence in two-thirds. The variables crucial in the success of endotherapy were a partial disruption (p < 0.001), ductal disruption site (p = 0.004), sphincterotomy (p = 0.013), and a bridging stent (p = 0.001). Significant pancreatic necrosis (p < 0.001) and intraductal calculi (p = 0.002) were the factors responsible for failure in endotherapy.
Conclusions Early endotherapy is safe and effective in the treatment of pancreatic ascites. The efficacy of endotherapy is augmented by PD stenting combined with pancreatic sphincterotomy and a bridging stent.
Collapse
Affiliation(s)
- Mayur G. Gattani
- Department of Gastroenterology, Lokmanya Tilak Municipal Medical College & General Hospital, Mumbai, India
| | - Shamshersingh G. Chauhan
- Department of Gastroenterology, Lokmanya Tilak Municipal Medical College & General Hospital, Mumbai, India
| | - Pratik R. Sethiya
- Department of Gastroenterology, Lokmanya Tilak Municipal Medical College & General Hospital, Mumbai, India
| | - Pooja C. Chandak
- Department of Radiology, Lokmanya Tilak Municipal Medical College & General Hospital, Mumbai, India
| | - Saiprasad G. Lad
- Department of Gastroenterology, Lokmanya Tilak Municipal Medical College & General Hospital, Mumbai, India
| | - Gaurav K. Singh
- Department of Gastroenterology, Lokmanya Tilak Municipal Medical College & General Hospital, Mumbai, India
| | - Kailash M. Kolhe
- Department of Gastroenterology, Lokmanya Tilak Municipal Medical College & General Hospital, Mumbai, India
| | - Harshad B. Khairnar
- Department of Gastroenterology, Lokmanya Tilak Municipal Medical College & General Hospital, Mumbai, India
| | - Vikas R. Pandey
- Department of Gastroenterology, Lokmanya Tilak Municipal Medical College & General Hospital, Mumbai, India
| | - Meghraj A. Ingle
- Department of Gastroenterology, Lokmanya Tilak Municipal Medical College & General Hospital, Mumbai, India
| |
Collapse
|
17
|
Fedorov AV, Ektov VN, Khodorkovsky MA. [Disconnected pancreatic duct syndrome in acute pancreatitis]. Khirurgiia (Mosk) 2022:83-89. [PMID: 35920227 DOI: 10.17116/hirurgia202208183] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/15/2023]
Abstract
The review is devoted to diagnosis and treatment of disconnected pancreatic duct syndrome (DPDS) in patients with acute pancreatitis. Data on terminology, indications and options for endoscopic transluminal interventions are presented in detail. The results of numerous studies evaluating clinical efficacy of various endoscopic and open surgical procedures are analyzed. Available data confirm advisability of staged treatment of DPDS with primary endoscopic drainage of pancreatic fluid accumulations in specialized centers.
Collapse
Affiliation(s)
- A V Fedorov
- Evdokimov Moscow State University of Medicine and Dentistry, Moscow, Russia
| | - V N Ektov
- Burdenko Voronezh State Medical University, Voronezh, Russia
| | | |
Collapse
|
18
|
Spontaneous Internal Pancreatic Fistulae Complicating Acute Pancreatitis. Am J Gastroenterol 2021; 116:1381-1386. [PMID: 34183576 DOI: 10.14309/ajg.0000000000001282] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/17/2021] [Accepted: 03/12/2021] [Indexed: 12/11/2022]
Abstract
Spontaneous pancreatic fistula (PF) is a rare but challenging complication of acute pancreatitis (AP). The fistulae could be internal (draining into another viscera or cavity, e.g., pancreaticocolonic, gastric, duodenal, jejunal, ileal, pleural, or bronchial) or external (draining to skin, i.e., pancreaticocutaneous). Internal fistulae constitute the majority of PF and will be discussed in this review. Male sex, alcohol abuse, severe AP, and infected necrosis are the major risk factors for development of internal PF. A high index of suspicion is required to diagnose PF. Broad availability of computed tomography makes it the initial test of choice. Magnetic resonance cholangiopancreatography and endoscopic retrograde cholangiopancreatography have higher sensitivity compared with computed tomography scan and also allow for assessment of pancreatic duct for leak or disconnection, which affects treatment approaches. Certain complications of PF including hemorrhage and sepsis could be life-threatening and require urgent intervention. In nonurgent/chronic cases, management of internal PF involves control of sepsis, which requires effective drainage of any residual pancreatic collection/necrosis, sometimes by enlarging the fistula. Decreasing fistula output with somatostatin analogs (in pancreaticopleural fistula) and decreasing intraductal pressure with endoscopic retrograde cholangiopancreatography or endoscopic ultrasound/interventional radiology-guided interventions or surgery are commonly used strategies for management of PF. More than 60% of the internal PF close with medical and nonsurgical interventions. Colonic fistula, medical refractory-PF, or PF associated with disconnected pancreatic duct can require surgical intervention including bowel resection or distal pancreatectomy. In conclusion, AP-induced spontaneous internal PF is a complex complication requiring multidisciplinary care for successful management.
Collapse
|
19
|
|
20
|
Boxhoorn L, Voermans RP, Bouwense SA, Bruno MJ, Verdonk RC, Boermeester MA, van Santvoort HC, Besselink MG. Acute pancreatitis. Lancet 2020; 396:726-734. [PMID: 32891214 DOI: 10.1016/s0140-6736(20)31310-6] [Citation(s) in RCA: 444] [Impact Index Per Article: 111.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/30/2019] [Revised: 03/20/2020] [Accepted: 05/29/2020] [Indexed: 02/07/2023]
Abstract
Acute pancreatitis is an unpredictable and potentially lethal disease. The prognosis mainly depends on the development of organ failure and secondary infection of pancreatic or peripancreatic necrosis. In the past 10 years, treatment of acute pancreatitis has moved towards a multidisciplinary, tailored, and minimally invasive approach. Despite improvements in treatment and critical care, severe acute pancreatitis is still associated with high mortality rates. In this Seminar, we outline the latest evidence on diagnostic and therapeutic strategies for acute pancreatitis.
Collapse
Affiliation(s)
- Lotte Boxhoorn
- Department of Gastroenterology and Hepatology, Amsterdam Gastroenterology Endocrinology Metabolism, Amsterdam UMC, University of Amsterdam, Amsterdam, Netherlands
| | - Rogier P Voermans
- Department of Gastroenterology and Hepatology, Amsterdam Gastroenterology Endocrinology Metabolism, Amsterdam UMC, University of Amsterdam, Amsterdam, Netherlands
| | - Stefan A Bouwense
- Department of Surgery, Maastricht University Medical Center+, Maastricht, Netherlands
| | - Marco J Bruno
- Department of Gastroenterology and Hepatology, Erasmus University Medical Center, Rotterdam, Netherlands
| | - Robert C Verdonk
- Department of Gastroenterology and Hepatology, St Antonius Hospital, Nieuwegein, Netherlands
| | - Marja A Boermeester
- Department of Surgery, Amsterdam Gastroenterology Endocrinology Metabolism, Amsterdam UMC, University of Amsterdam, Amsterdam, Netherlands
| | - Hjalmar C van Santvoort
- Department of Surgery, St Antonius Hospital, Nieuwegein, Netherlands; Department of Surgery, University Medical Center Utrecht, Utrecht, Netherlands
| | - Marc G Besselink
- Department of Surgery, Amsterdam Gastroenterology Endocrinology Metabolism, Amsterdam UMC, University of Amsterdam, Amsterdam, Netherlands.
| |
Collapse
|