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Palumbo R, Schuster KM. Contemporary management of acute pancreatitis: What you need to know. J Trauma Acute Care Surg 2024; 96:156-165. [PMID: 37722072 DOI: 10.1097/ta.0000000000004143] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 09/20/2023]
Abstract
ABSTRACT Acute pancreatitis and management of its complications is a common consult for the acute care surgeon. With the ongoing development of both operative and endoscopic treatment modalities, management recommendations continue to evolve. We describe the current diagnostic and treatment guidelines for acute pancreatitis through the lens of acute care surgery. Topics, including optimal nutrition, timing of cholecystectomy in gallstone pancreatitis, and the management of peripancreatic fluid collections, are discussed. Although the management severe acute pancreatitis can include advanced interventional modalities including endoscopic, percutaneous, and surgical debridement, the initial management of acute pancreatitis includes fluid resuscitation, early enteral nutrition, and close monitoring with consideration of cross-sectional imaging and antibiotics in the setting of suspected superimposed infection. Several scoring systems including the Revised Atlanta Criteria, the Bedside Index for Severity in Acute Pancreatitis score, and the American Association for the Surgery of Trauma grade have been devised to classify and predict the development of the severe acute pancreatitis. In biliary pancreatitis, cholecystectomy prior to discharge is recommended in mild disease and within 8 weeks of necrotizing pancreatitis, while early peripancreatic fluid collections should be managed without intervention. Underlying infection or ongoing symptoms warrant delayed intervention with technique selection dependent on local expertise, anatomic location of the fluid collection, and the specific clinical scenario. Landmark trials have shifted therapy from maximally invasive necrosectomy to more minimally invasive step-up approaches. The acute care surgeon should maintain a skill set that includes these minimally invasive techniques to successfully manage these patients. Overall, the management of acute pancreatitis for the acute care surgeon requires a strong understanding of both the clinical decisions and the options for intervention should this be necessary.
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Affiliation(s)
- Rachael Palumbo
- From the Department of Surgery, Yale School of Medicine, New Haven, Connecticut
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2
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Ektov VN, Fedorov AV, Khodorkovsky MA, Kurkin AV. [Transgastric necrectomy for acute pancreatitis]. Khirurgiia (Mosk) 2024:73-79. [PMID: 39422008 DOI: 10.17116/hirurgia202410173] [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: 10/19/2024]
Abstract
The review is devoted to transgastric necrectomy in the treatment of infected forms of acute pancreatitis. The authors discuss the indications for transgastric necrectomy and technical features of these interventions (direct endoscopic necrectomy, laparoscopic and open transgastric necrectomy). Numerous studies devoted to results of transgastric necrectomy indicate advisability of this procedure in carefully selected patients and interdisciplinary interaction of various specialists before and after surgery. Regional specialized centers for the treatment of severe acute pancreatitis are necessary for wider introduction of minimally invasive surgical technologies and their personalization.
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Affiliation(s)
- V N Ektov
- Burdenko Voronezh State Medical University, Voronezh, Russia
| | - A V Fedorov
- Vishnevsky National Medical Research Center of Surgery, Moscow, Russia
- Evdokimov Moscow State University of Medicine and Dentistry, Moscow, Russia
| | | | - A V Kurkin
- Burdenko Voronezh State Medical University, Voronezh, Russia
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3
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McGuire SP, Maatman TK, Zyromski NJ. Transgastric pancreatic necrosectomy: Tricks of the trade. Surg Open Sci 2023; 14:1-4. [PMID: 37599671 PMCID: PMC10436174 DOI: 10.1016/j.sopen.2023.06.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/25/2022] [Revised: 05/17/2023] [Accepted: 06/03/2023] [Indexed: 08/22/2023] Open
Abstract
Necrotizing pancreatitis (NP) affects 20 % of the 300,000 patients diagnosed with acute pancreatitis every year. Mechanical intervention to debride necrotic and/or infected pancreatic and peripancreatic tissue is frequently required. Minimally invasive approaches to treat pancreatic necrosis have gained popularity over the last two decades, including transgastric pancreatic necrosectomy. The purpose of this report is to review the indications, surgical technique, advantages, and limitations of surgical transgastric necrosectomy.
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Affiliation(s)
- Sean P. McGuire
- Indiana University, Department of General Surgery, United States of America
| | - Thomas K. Maatman
- Indiana University, Department of General Surgery, United States of America
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4
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Wang Y, Yoshino O, Driedger MR, Beckman MJ, Vrochides D, Martinie JB. Robotic pancreatic necrosectomy and internal drainage for walled-off pancreatic necrosis. HPB (Oxford) 2023; 25:813-819. [PMID: 37045742 DOI: 10.1016/j.hpb.2023.03.013] [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] [Received: 10/18/2022] [Revised: 01/29/2023] [Accepted: 03/19/2023] [Indexed: 04/14/2023]
Abstract
BACKGROUND Pancreatic necrosectomy with concomitant internal drainage is a single-stage treatment option for walled-off pancreatic necrosis (WOPN). However, an optimal minimally invasive technique has not been established. We evaluated the safety and single-intervention success rate of robotic pancreatic necrosectomy and internal drainage. METHODS Patients with WOPN undergoing robotic pancreatic necrosectomy and internal drainage at a single institution from 2011-2022 were identified. The primary outcome was the rate of clinical symptom resolution following the index surgical intervention. RESULTS 57 patients underwent robotic pancreatic necrosectomy and internal drainage, consisting of robotic cystgastrostomy (RCG, n = 37), robotic cystjejunostomy (RCJ, n = 13) and robotic fistulojejunostomy (RFJ, n = 7). Surgery was performed a median of 102 (range 28-1153) days following the onset of necrotizing pancreatitis. The median operative time was 187 (91-344) minutes and there were 2 (3.5%) conversions. The median length of hospital stay was 4 (2-38) days. Postoperative morbidity was 11%, and there was one (1.8%) 90-day mortality. At a median follow-up of 5.5 months, 53 (93%) patients had clinical symptom resolution after their index procedure and did not require any reintervention. CONCLUSION In select patients, robotic pancreatic necrosectomy and internal drainage is safe and achieves a high single-intervention success rate.
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Affiliation(s)
- Yifan Wang
- Division of Hepatopancreaticobiliary Surgery, Department of Surgery, Atrium Health Carolinas Medical Center, Charlotte, NC, USA; Department of Surgery, McGill University, Montreal, QC, Canada
| | - Osamu Yoshino
- Division of Hepatopancreaticobiliary Surgery, Department of Surgery, Atrium Health Carolinas Medical Center, Charlotte, NC, USA
| | - Michael R Driedger
- Division of Hepatopancreaticobiliary Surgery, Department of Surgery, Atrium Health Carolinas Medical Center, Charlotte, NC, USA
| | - Michael J Beckman
- Division of Hepatopancreaticobiliary Surgery, Department of Surgery, Atrium Health Carolinas Medical Center, Charlotte, NC, USA
| | - Dionisios Vrochides
- Division of Hepatopancreaticobiliary Surgery, Department of Surgery, Atrium Health Carolinas Medical Center, Charlotte, NC, USA
| | - John B Martinie
- Division of Hepatopancreaticobiliary Surgery, Department of Surgery, Atrium Health Carolinas Medical Center, Charlotte, NC, USA.
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5
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Abstract
Necrotizing pancreatitis affects 10% to 15% of all patients with acute pancreatitis. Despite improved understanding of this complex disease, it is still attended by up to 15% mortality. Necrotizing pancreatitis provides the clinical challenges of working in a multi-disciplinary group, determining proper timing for intervention, and identifying appropriate intervention approaches. The step-up approach consists of supportive care initially. When there is documented infected necrosis, treatment begins with antibiotics, progressing to minimally invasive mechanical necrosis intervention, and reserving surgery as the final treatment modality. However, treatment must be tailored to the individual patient. This article provides an overview of necrotizing pancreatitis.
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Affiliation(s)
- Thomas K Maatman
- Department of Surgery, Indiana University School of Medicine, 545 Barnhill Dr. EH 519, Indianapolis, IN 46202, USA
| | - Nicholas J Zyromski
- Department of Surgery, Indiana University School of Medicine, 545 Barnhill Dr. EH 519, Indianapolis, IN 46202, USA.
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6
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Prasath V, Quinn PL, Oliver JB, Arjani S, Ahlawat SK, Chokshi RJ. Cost-effectiveness analysis of infected necrotizing pancreatitis management in an academic setting. Pancreatology 2022; 22:185-193. [PMID: 34879998 DOI: 10.1016/j.pan.2021.11.011] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/14/2021] [Revised: 11/22/2021] [Accepted: 11/30/2021] [Indexed: 12/11/2022]
Abstract
BACKGROUND AND AIMS Traditional management for infected necrotizing pancreatitis (INP) often utilizes open necrosectomy, which carries high morbidity and complication rates. Thus, minimally invasive strategies have gained favor, specifically step-up approaches utilizing endoscopic or minimally-invasive surgery (MIS); however, the ideal management modality for INP has not been identified. METHODS A decision tree model was designed to analyze costs and survival associated with open necrosectomy, endoscopic step-up, and MIS step-up protocols for management of INP after 4 weeks of necrosis development with adequate retroperitoneal access. Costs were based on a third-party payer perspective using Medicare reimbursement rates. The model's effectiveness was represented by quality-adjusted life-years (QALYs). Sensitivity analyses were performed to validate results. RESULTS Endoscopic step-up was the dominant economic strategy with 7.92 QALYs for $90,864.09. Surgical step-up resulted in a decrease of 0.09 QALYs and a cost increase of $10,067.89 while open necrosectomy resulted in a decrease of 0.4 QALYs and an increased cost of $18,407.52 over endoscopic step-up. In 100,000 random-sampling simulations, 65.5% of simulations favored endoscopic step-up. MIS step-up was favored when MIS acute mortality rates fell and when MIS drainage success rates rose. CONCLUSIONS In our simulated patients with INP, the most cost-effective management strategy is endoscopic step-up. Cost-effectiveness varies with changes in acute mortality and drainage success, which will depend on local expertise.
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Affiliation(s)
- Vishnu Prasath
- Division of Surgical Oncology, Department of Surgery, Rutgers New Jersey Medical School, Newark, NJ, USA.
| | - Patrick L Quinn
- Division of Surgical Oncology, Department of Surgery, Rutgers New Jersey Medical School, Newark, NJ, USA.
| | - Joseph B Oliver
- Division of Minimally Invasive Surgery, Department of Surgery, Rutgers New Jersey Medical School, Newark, NJ, USA.
| | - Simran Arjani
- Division of Surgical Oncology, Department of Surgery, Rutgers New Jersey Medical School, Newark, NJ, USA.
| | - Sushil K Ahlawat
- Division of Gastroenterology and Hepatology, Department of Medicine, Rutgers New Jersey Medical School, Newark, NJ, USA.
| | - Ravi J Chokshi
- Division of Surgical Oncology, Department of Surgery, Rutgers New Jersey Medical School, Newark, NJ, USA.
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7
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Vellalta G, Lopez R, D'Angelo E, Vidal L, Dopazo C, Puig O. Laparoscopic intragastric approach to transgastric necrosectomy. JOURNAL OF HEPATO-BILIARY-PANCREATIC SCIENCES 2021; 29:e75-e76. [PMID: 34855268 DOI: 10.1002/jhbp.1086] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/18/2021] [Revised: 10/24/2021] [Accepted: 10/28/2021] [Indexed: 12/18/2022]
Affiliation(s)
| | | | | | - Laura Vidal
- BARNALAP and Clínica Corachan, Barcelona, Spain
| | - Cristina Dopazo
- Department of HPB Surgery and Transplants, Hospital Universitari Vall d´Hebron, Universitat Autònoma de Barcelona, Barcelona, Spain
| | - Oriol Puig
- BARNALAP and Clínica Corachan, Barcelona, Spain
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Cao F, Li A, Wang X, Gao C, Li J, Li F. Laparoscopic transgastric necrosectomy in treatment of walled-off pancreatic necrosis with sinistral portal hypertension. BMC Surg 2021; 21:362. [PMID: 34629061 PMCID: PMC8502321 DOI: 10.1186/s12893-021-01361-6] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/06/2021] [Accepted: 09/24/2021] [Indexed: 12/16/2022] Open
Abstract
Background Laparoscopic transgastric necrosectomy (LTGN) has been used in treatment of walled-off pancreatic necrosis (WON) for more than a decade. However, the safety and effectiveness of LTGN for WON with sinistral portal hypertension was still unclear. Methods WON patients with sinistral portal hypertension treated in our department between January 2011 and December 2018 were included and retrospectively analyzed in this study. Patients were divided into two groups according to different surgical approaches, LTNG or laparoscopic assisted trans-lesser sac necrosectomy (LATLSN). Perioperative and long-term outcomes were compared between two groups. Results 312 cases diagnosed with WON were screened and 53 were finally included in this study. Of the included patients, 21 and 32 cases were received LTGN and LATLSN, respectively. LTGN was associated with significantly lower morbidity than LATLSN (19.0% vs 46.9%, p = 0.04) and similar severe complication (Clavien–Dindo ≥ III) rate (12.5% vs 19.0%, p = 0.70). LTGN did not increase the rate of postoperative hemorrhage (9.5% vs 6.3%, p = 1.00) and mortality (9.5% vs 9.4%, p = 1.00). After 39 (11–108) months follow-up, the recurrence rate of WON and long-term complications were also comparable between groups. Conclusion From current data, LTGN was safe and effective in treatment of WON patients with sinistral portal hypertension in terms of short- and long-term outcomes.
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Affiliation(s)
- Feng Cao
- Department of General Surgery, Xuanwu Hospital, Capital Medical University, No. 45, Xicheng, Beijing, 100053, People's Republic of China.,Clinical Center for Acute Pancreatitis, Capital Medical University, No. 45, Xicheng, Beijing, 100053, People's Republic of China
| | - Ang Li
- Department of General Surgery, Xuanwu Hospital, Capital Medical University, No. 45, Xicheng, Beijing, 100053, People's Republic of China.,Clinical Center for Acute Pancreatitis, Capital Medical University, No. 45, Xicheng, Beijing, 100053, People's Republic of China
| | - Xiaohui Wang
- Department of General Surgery, Xuanwu Hospital, Capital Medical University, No. 45, Xicheng, Beijing, 100053, People's Republic of China.,Clinical Center for Acute Pancreatitis, Capital Medical University, No. 45, Xicheng, Beijing, 100053, People's Republic of China
| | - Chongchong Gao
- Department of General Surgery, Xuanwu Hospital, Capital Medical University, No. 45, Xicheng, Beijing, 100053, People's Republic of China.,Clinical Center for Acute Pancreatitis, Capital Medical University, No. 45, Xicheng, Beijing, 100053, People's Republic of China
| | - Jia Li
- Department of General Surgery, Xuanwu Hospital, Capital Medical University, No. 45, Xicheng, Beijing, 100053, People's Republic of China. .,Clinical Center for Acute Pancreatitis, Capital Medical University, No. 45, Xicheng, Beijing, 100053, People's Republic of China.
| | - Fei Li
- Department of General Surgery, Xuanwu Hospital, Capital Medical University, No. 45, Xicheng, Beijing, 100053, People's Republic of China. .,Clinical Center for Acute Pancreatitis, Capital Medical University, No. 45, Xicheng, Beijing, 100053, People's Republic of China.
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Affiliation(s)
- Amy Y Li
- Department of Surgery, Section of Surgical Oncology, Stanford University School of Medicine, 300 Pasteur Drive, Room H3591, Stanford, CA 94305, USA
| | - John R Bergquist
- Department of Surgery, Section of Surgical Oncology, Stanford University School of Medicine, 300 Pasteur Drive, Room H3591, Stanford, CA 94305, USA
| | - Brendan C Visser
- Department of Surgery, Section of Surgical Oncology, Stanford University School of Medicine, 300 Pasteur Drive, H3680, Stanford, CA 94305-5655, USA.
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10
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Abstract
OBJECTIVE To investigate the incidence, risk factors, and outcomes of colon involvement in patients with necrotizing pancreatitis. SUMMARY/BACKGROUND DATA Necrotizing pancreatitis is characterized by a profound inflammatory response with local and systemic implications. Mesocolic involvement can compromise colonic blood supply leading to ischemic complications; however, few data exist regarding this problem. We hypothesized that the development of colon involvement in necrotizing pancreatitis (NP) negatively affects morbidity and mortality. METHODS Six hundred forty-seven NP patients treated between 2005 and 2017 were retrospectively reviewed to identify patients with colon complications, including ischemia, perforation, fistula, stricture/obstruction, and fulminant Clostridium difficile colitis. Clinical characteristics were analyzed to identify risk factors and effect of colon involvement on morbidity and mortality. RESULTS Colon involvement was seen in 11% (69/647) of NP patients. Ischemia was the most common pathology (n = 29) followed by perforation (n = 18), fistula (n = 12), inflammatory stricture (n = 7), and fulminant C difficile colitis (n = 3). Statistically significant risk factors for developing colon pathology include tobacco use (odds ratio (OR), 2.0; 95% confidence interval (CI), 1.2-3.4, P = 0.009), coronary artery disease (OR, 1.9; 95% CI, 1.1-3.7; P = 0.04), and respiratory failure (OR, 4.7; 95% CI, 1.1-26.3; P = 0.049). When compared with patients without colon involvement, NP patients with colon involvement had significantly increased overall morbidity (86% vs 96%, P = 0.03) and mortality (8% vs 19%, P = 0.002). CONCLUSION Colon involvement in necrotizing pancreatitis is common; clinical deterioration should prompt its evaluation. Risk factors include tobacco use, coronary artery disease, and respiratory failure. Colon involvement in necrotizing pancreatitis is associated with substantial morbidity and mortality.
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Maatman TK, Zyromski NJ. Transgastric Pancreatic Debridement: a Step-by-step Guide to a Single-staged Procedure for Walled-off Pancreatic Necrosis. J Gastrointest Surg 2020; 24:1720. [PMID: 32128680 DOI: 10.1007/s11605-019-04375-x] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/27/2019] [Accepted: 08/14/2019] [Indexed: 01/31/2023]
Abstract
Treatment of necrotizing pancreatitis (NP) requiring intervention must be tailored to each patient's individual clinical situation. Surgical transgastric debridement addresses necrosis confined to the lesser sac with the option to perform cholecystectomy in a single intervention.1 With proper patient selection, this technique achieves resolution of necrosis in 90% of patients.2 In the setting of disconnected pancreatic duct syndrome, cystogastrostomy achieves pancreatic tail drainage with durable long-term success in 80% of patients.3 This case presentation and step-by-step walkthrough demonstrates critical technical aspects and decision-making for surgical transgastric debridement of walled-off pancreatic necrosis.
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Affiliation(s)
- Thomas K Maatman
- Department of Surgery, Indiana University School of Medicine, 545 Barnhill Dr., EH 519, Indianapolis, IN, 46202, USA
| | - Nicholas J Zyromski
- Department of Surgery, Indiana University School of Medicine, 545 Barnhill Dr., EH 519, Indianapolis, IN, 46202, USA.
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12
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Maatman TK, Flick KF, Roch AM, Zyromski NJ. Operative pancreatic debridement: Contemporary outcomes in changing times. Pancreatology 2020; 20:968-975. [PMID: 32622760 DOI: 10.1016/j.pan.2020.05.024] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/22/2020] [Revised: 05/21/2020] [Accepted: 05/24/2020] [Indexed: 02/06/2023]
Abstract
BACKGROUND/OBJECTIVES Operative pancreatic debridement (OPD) is the historic gold standard for treating necrotizing pancreatitis (NP). Recent success with minimally invasive NP treatment approaches have raised the question of which NP patients require OPD. We therefore sought to define contemporary outcomes of NP patients undergoing OPD. METHODS A retrospective analysis was performed of 116 consecutive NP patients undergoing OPD using a prospectively maintained institutional NP database between 2006 and 2018. RESULTS 86 (74%) patients underwent open pancreatic debridement (OD) and 30 (26%) underwent open transgastric debridement (TGD). Median follow-up was 16 months (interquartile range [IQR], 8-45 months). Median age was 51 years (IQR, 43-65 years); 73 (63%) were male. Pancreatitis etiology included biliary (53%), alcohol (22%), and idiopathic/other (25%). Median time from diagnosis to OPD was 64.5 days (IQR, 32-114.5 days). Mean APACHE-II score was: admission 8.5 (standard deviation [SD], 5.9); worst 12.6 (SD, 7.9); preoperatively 7.2 (SD, 4.6). 40 patients (34%) were initially managed with minimally invasive techniques (percutaneous drain only in 24, endoscopic only in 6, combination in 10). Median postoperative length of stay was 11 days (IQR, 7-19 days). 90-day morbidity and mortality were 70% and 2%, respectively. CONCLUSIONS NP patients who require OPD are critically and chronically ill. OPD is associated with substantial morbidity, but acceptable mortality in an experienced center with multidisciplinary support. This large contemporary series demonstrates that in properly selected patients, OPD remains an important treatment for NP.
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Affiliation(s)
- Thomas K Maatman
- Department of Surgery, Indiana University School of Medicine, Indianapolis, IN, USA
| | - Katelyn F Flick
- Department of Surgery, Indiana University School of Medicine, Indianapolis, IN, USA
| | - Alexandra M Roch
- Department of Surgery, Indiana University School of Medicine, Indianapolis, IN, USA
| | - Nicholas J Zyromski
- Department of Surgery, Indiana University School of Medicine, Indianapolis, IN, USA.
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13
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Surgical Transgastric Necrosectomy for Necrotizing Pancreatitis: A Single-stage Procedure for Walled-off Pancreatic Necrosis. Ann Surg 2020; 271:163-168. [PMID: 30216220 DOI: 10.1097/sla.0000000000003048] [Citation(s) in RCA: 36] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
OBJECTIVE The aim of this study was to evaluate the role of surgical transgastric necrosectomy (TGN) for walled-off pancreatic necrosis (WON) in selected patients. BACKGROUND WON is a common consequence of severe pancreatitis and typically occurs 3 to 5 weeks after the onset of acute pancreatitis. When symptomatic, it can require intervention. METHODS A retrospective review of patients with WON undergoing surgical management at 3 high-volume pancreatic institutions was performed. Surgical indications, intervention timing, technical methodology, and patient outcomes were evaluated. Patients undergoing intervention <30 days were excluded. Differences across centers were evaluated using a P value of <0.05 as significant. RESULTS One hundred seventy-eight total patients were analyzed (mean WON diameter = 14 cm, 64% male, mean age = 51 years) across 3 centers. The majority required inpatient admission with a median preoperative length of hospital stay of 29 days (25% required preoperative critical care support). Most (96%) patients underwent a TGN. The median duration of time between the onset of pancreatitis symptoms and operative intervention was 60 days. Thirty-nine percent of the necrosum was infected. Postoperative morbidity and mortality were 38% and 2%, respectively. The median postoperative length of hospital length of stay was 8 days, with the majority of patients discharged home. The median length of follow-up was 21 months, with 91% of patients having complete clinical resolution of symptoms at a median of 6 weeks. Readmission to hospital and/or a repeat intervention was also not infrequent (20%). CONCLUSION Surgical TGN is an excellent 1-stage surgical option for symptomatic WON in a highly selected group of patients. Precise surgical technique and long-term outpatient follow-up are mandatory for optimal patient outcomes.
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Maatman TK, Mahajan S, Roch AM, Ceppa EP, House MG, Nakeeb A, Schmidt CM, Zyromski NJ. Disconnected pancreatic duct syndrome predicts failure of percutaneous therapy in necrotizing pancreatitis. Pancreatology 2020; 20:362-368. [PMID: 32029378 DOI: 10.1016/j.pan.2020.01.014] [Citation(s) in RCA: 16] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/23/2019] [Revised: 01/07/2020] [Accepted: 01/24/2020] [Indexed: 12/11/2022]
Abstract
BACKGROUND/OBJECTIVES Minimally invasive approaches, such as percutaneous drainage (PD), are increasingly utilized as initial treatment in necrotizing pancreatitis (NP) requiring intervention. Predictors of success of PD as definitive treatment are lacking. Our aim was to assess the application, predictors of success, and natural history of PD in NP. We hypothesized that necrosis morphology patterns and disconnected pancreatic duct syndrome (DPDS) may predict the ability of PD to provide definitive therapy. METHODS 714 NP patients were treated from 2005 to 2018. Patients achieving disease resolution with PD alone (PD) were compared to those requiring an escalation in intervention (Step). Outcomes were compared between groups using independent samples t-test, Fisher's exact test, and Pearson's correlation, as appropriate. P < 0.05 was accepted as statistically significant. RESULTS 115 patients were initially managed with PD (42 PD, 73 Step). No difference in necrosis morphology was seen between the two groups. The PD group underwent significantly more repeat percutaneous interventions (PD, 3.2; Step, 2.0; P = 0.0006) including additional drain placement and drain upsize/reposition procedures. Patients with DPDS were more likely to require an escalation in intervention (odds ratio, 3.4; 95% confidence interval, 1.5-7.6; P = 0.003). The mean number of months to NP resolution was similar (PD, 5.7; Step, 5.8; P = 0.9). Mortality was similar (PD, 7%; Step 14%, P = 0.3). CONCLUSIONS Necrosis morphology in and of itself does not reliably predict successful definitive treatment by percutaneous drainage. However, patients with disconnected pancreatic duct syndrome were less likely to have definitive resolution with PD alone.
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Affiliation(s)
- Thomas K Maatman
- Department of Surgery, Indiana University School of Medicine, Indianapolis, IN, USA
| | - Sarakshi Mahajan
- Department of Surgery, Indiana University School of Medicine, Indianapolis, IN, USA
| | - Alexandra M Roch
- Department of Surgery, Indiana University School of Medicine, Indianapolis, IN, USA
| | - Eugene P Ceppa
- Department of Surgery, Indiana University School of Medicine, Indianapolis, IN, USA
| | - Michael G House
- Department of Surgery, Indiana University School of Medicine, Indianapolis, IN, USA
| | - Attila Nakeeb
- Department of Surgery, Indiana University School of Medicine, Indianapolis, IN, USA
| | - C Max Schmidt
- Department of Surgery, Indiana University School of Medicine, Indianapolis, IN, USA
| | - Nicholas J Zyromski
- Department of Surgery, Indiana University School of Medicine, Indianapolis, IN, USA.
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15
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Shen D, Ning C, Huang G, Liu Z. Outcomes of infected pancreatic necrosis complicated with duodenal fistula in the era of minimally invasive techniques. Scand J Gastroenterol 2019; 54:766-772. [PMID: 31136208 DOI: 10.1080/00365521.2019.1619831] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
Background: Duodenal fistula (DF) was reportedly thought to be the second most common type of gastrointestinal fistula secondary to acute necrotizing pancreatitis. However, infected pancreatic necrosis (IPN) associated DF (IPN-DF) was rarely specifically reported in the literature. The outcome of IPN-DF was also less well recognized, especially in the era of minimally invasive techniques. A retrospective cohort study was designed mainly focused on the management and outcomes of IPN-DF in the era of minimally invasive techniques. Methods: One hundred and twenty-one consecutive patients diagnosed with IPN between January 2015 and May 2018 were enrolled retrospectively. Among them, 10 patients developed DF. The step-up minimal invasive techniques were highlighted and outcomes were analyzed. Results: Compared with patients without IPN-DF, patients with IPN-DF had longer hospital stay (95.8 vs. 63.5 days, p < .01), but similar mortality rates (10% vs. 21.6%, p > .05). The median interval between the onset of acute pancreatitis (AP) and detection of DF was 2.4 months (1-4 months). The median duration of DF was 1.5 months (0.5-3 months). Out of the 10 patients with DF, 9 had their fistulas resolve spontaneously over time by means of controlling the source of infection with the use of minimally invasive techniques and providing enteral nutritional support, while one patient died of uncontrolled sepsis. No open surgery was performed. On follow-up, the 9 patients recovered completely and remained free of infection and leakage. Conclusion: IPN-DF could be managed successfully using minimally invasive techniques in specialized acute pancreatitis (AP) center. Patients with IPN-DF suffered from a longer hospital stay, but similar mortality rate compared with patients without DF.
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Affiliation(s)
- Dingcheng Shen
- Department of Biliopancreatic Surgery, Xiangya Hospital, Central South University , Changsha , Hunan Province , China.,Department of General Surgery, Xiangya Hospital, Central South University , Changsha , Hunan Province , China.,National Clinical Research Center for Geriatric Disorders, Xiangya Hospital, Central South University , Changsha , Hunan Province , China
| | - Caihong Ning
- Department of Biliopancreatic Surgery, Xiangya Hospital, Central South University , Changsha , Hunan Province , China.,Department of General Surgery, Xiangya Hospital, Central South University , Changsha , Hunan Province , China.,National Clinical Research Center for Geriatric Disorders, Xiangya Hospital, Central South University , Changsha , Hunan Province , China
| | - Gengwen Huang
- Department of Biliopancreatic Surgery, Xiangya Hospital, Central South University , Changsha , Hunan Province , China.,Department of General Surgery, Xiangya Hospital, Central South University , Changsha , Hunan Province , China.,National Clinical Research Center for Geriatric Disorders, Xiangya Hospital, Central South University , Changsha , Hunan Province , China
| | - Zhiyong Liu
- National Clinical Research Center for Geriatric Disorders, Xiangya Hospital, Central South University , Changsha , Hunan Province , China.,Department of Critical Care Medicine, Xiangya Hospital, Central South University , Changsha , Hunan Province , China
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16
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Abstract
Walled of pancreatic necrosis (WOPN) is a new term coined for encapsulated fluid collection developing after acute necrotising pancreatitis (ANP). It is a heterogeneous collection containing varying amount of liquid as well as solid necrotic material. The literature on its natural history as well as appropriate management is gradually expanding thereby improving treatment outcomes of this enigmatic disease. Areas covered: This review discusses currently available literature on etiology, frequency, natural history, and imaging features WOPN. Also, updated treatment options including endoscopic, radiological and surgical drainage are discussed. Expert opinion: WOPN is alocal complication of ANP occurring in the delayed phase of ANP and may be asymptomatic (50%) or present with pain, fever, jaundice, or gastric outlet obstruction. Natural courses of asymptomatic WOPN have been infrequently studied, and it appears that the majority remain asymptomatic and resolve spontaneously. Magnetic resonance imaging and endoscopic ultrasound are the best imaging modalities to evaluate solid necrotic debris. Symptomatic WOPN usually needs immediate drainage, this can be done endoscopically, radiologically, or surgically. Current evidence suggests that endoscopic transluminal drainage is the preferred drainage technique as it is effective and associated with lower mortality, risk of organ failure, adverse effects, and length of hospital stay.
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Affiliation(s)
- Surinder Singh Rana
- a Department of Gastroenterology , Post Graduate Institute of Medical Education and Research (PGIMER) , Chandigarh , India
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17
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Bang JY, Arnoletti JP, Holt BA, Sutton B, Hasan MK, Navaneethan U, Feranec N, Wilcox CM, Tharian B, Hawes RH, Varadarajulu S. An Endoscopic Transluminal Approach, Compared With Minimally Invasive Surgery, Reduces Complications and Costs for Patients With Necrotizing Pancreatitis. Gastroenterology 2019; 156:1027-1040.e3. [PMID: 30452918 DOI: 10.1053/j.gastro.2018.11.031] [Citation(s) in RCA: 183] [Impact Index Per Article: 36.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/28/2018] [Revised: 10/31/2018] [Accepted: 11/12/2018] [Indexed: 02/08/2023]
Abstract
BACKGROUND & AIMS Infected necrotizing pancreatitis is a highly morbid disease with poor outcomes. Intervention strategies have progressed from open necrosectomy to minimally invasive approaches. We compared outcomes of minimally invasive surgery vs endoscopic approaches for patients with infected necrotizing pancreatitis. METHODS We performed a single-center, randomized trial of 66 patients with confirmed or suspected infected necrotizing pancreatitis who required intervention from May 12, 2014, through March 24, 2017. Patients were randomly assigned to groups that received minimally invasive surgery (laparoscopic or video-assisted retroperitoneal debridement, depending on location of collection, n = 32) or an endoscopic step-up approach (transluminal drainage with or without necrosectomy, n = 34). The primary endpoint was a composite of major complications (new-onset multiple organ failure, new-onset systemic dysfunction, enteral or pancreatic-cutaneous fistula, bleeding and perforation of a visceral organ) or death during 6 months of follow-up. RESULTS The primary endpoint occurred in 11.8% of patients who received the endoscopic procedure and 40.6% of patients who received the minimally invasive surgery (risk ratio 0.29; 95% confidence interval 0.11-0.80; P = .007). Although there was no significant difference in mortality (endoscopy 8.8% vs surgery 6.3%; P = .999), none of the patients assigned to the endoscopic approach developed enteral or pancreatic-cutaneous fistulae compared with 28.1% of the patients who underwent surgery (P = .001). The mean number of major complications per patient was significantly higher in the surgery group (0.69 ± 1.03) compared with the endoscopy group (0.15 ± 0.44) (P = .007). The physical health scores for quality of life at 3 months was better with the endoscopic approach (P = .039) and mean total cost was lower ($75,830) compared with $117,492 for surgery (P = .039). CONCLUSIONS In a randomized trial of 66 patients, an endoscopic transluminal approach for infected necrotizing pancreatitis, compared with minimally invasive surgery, significantly reduced major complications, lowered costs, and increased quality of life. Clinicaltrials.gov no: NCT02084537.
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Affiliation(s)
- Ji Young Bang
- Center for Interventional Endoscopy, Florida Hospital, Orlando, Florida
| | | | - Bronte A Holt
- Center for Interventional Endoscopy, Florida Hospital, Orlando, Florida
| | - Bryce Sutton
- Center for Interventional Endoscopy, Florida Hospital, Orlando, Florida
| | - Muhammad K Hasan
- Center for Interventional Endoscopy, Florida Hospital, Orlando, Florida
| | | | | | - C Mel Wilcox
- Division of Gastroenterology-Hepatology, University of Alabama at Birmingham, Birmingham, Alabama
| | - Benjamin Tharian
- Center for Interventional Endoscopy, Florida Hospital, Orlando, Florida
| | - Robert H Hawes
- Center for Interventional Endoscopy, Florida Hospital, Orlando, Florida
| | - Shyam Varadarajulu
- Center for Interventional Endoscopy, Florida Hospital, Orlando, Florida.
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18
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Roch AM, Maatman T, Carr RA, Easler JJ, Schmidt CM, House MG, Nakeeb A, Ceppa EP, Zyromski NJ. Evolving treatment of necrotizing pancreatitis. Am J Surg 2017; 215:526-529. [PMID: 29167024 DOI: 10.1016/j.amjsurg.2017.11.020] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/08/2017] [Revised: 11/12/2017] [Accepted: 11/13/2017] [Indexed: 10/18/2022]
Abstract
BACKGROUND Over the past decade, the treatment of necrotizing pancreatitis (NP) has incorporated greater use of minimally invasive techniques, including percutaneous drainage and endoscopic debridement. No study has yet compared outcomes of patients treated with all available techniques. We sought to evaluate the evolution of NP treatment at our high volume pancreas center. We hypothesized that minimally invasive techniques (medical only, percutaneous, and endoscopic) were used more frequently in later years. METHODS Treatment strategy of NP patients at a single academic medical center between 2005 and 2014 was reviewed. Definitive management of pancreatic necrosis was categorized as: 1) medical treatment only; 2) surgical only; 3) percutaneous (interventional radiology - IR) only; 4) endoscopic only; and 5) combination (Surgery ± IR ± Endoscopy). RESULTS 526 NP patients included biliary (45%), alcoholic (17%), and idiopathic (20%) etiology. Select patients were managed exclusively by medical, IR, or endoscopic treatment; use of these therapies remained relatively consistent over time. A combination of therapies was used in about 30% of patients. Over time, the percentage of NP patients managed without operation increased from 28% to 41%. 247 (47%) of patients had operation as the only NP treatment; an additional 143 (27%) required surgery as part of a multidisciplinary management. CONCLUSION Select NP patients may be managed exclusively by medical, IR, or endoscopic treatment. Combination treatment is necessary in many NP patients, and surgical treatment continues to play an important role in the definitive therapy of necrotizing pancreatitis patients.
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Affiliation(s)
- Alexandra M Roch
- Department of Surgery, Indiana University School of Medicine, Indianapolis, IN, USA
| | - Thomas Maatman
- Department of Surgery, Indiana University School of Medicine, Indianapolis, IN, USA
| | - Rose A Carr
- Department of Surgery, Indiana University School of Medicine, Indianapolis, IN, USA
| | - Jeffrey J Easler
- Department of Medicine, Division of Gastroenterology and Hepatology, Indiana University School of Medicine, Indianapolis, IN, USA
| | - C Max Schmidt
- Department of Surgery, Indiana University School of Medicine, Indianapolis, IN, USA
| | - Michael G House
- Department of Surgery, Indiana University School of Medicine, Indianapolis, IN, USA
| | - Attila Nakeeb
- Department of Surgery, Indiana University School of Medicine, Indianapolis, IN, USA
| | - Eugene P Ceppa
- Department of Surgery, Indiana University School of Medicine, Indianapolis, IN, USA
| | - Nicholas J Zyromski
- Department of Surgery, Indiana University School of Medicine, Indianapolis, IN, USA.
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19
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Successful Open and Endoscopic Transgastric Necrosectomy for Huge Infected Walled-Off Pancreatic Necrosis: A Case Report. Pancreas 2017; 46:e69-e70. [PMID: 28796142 DOI: 10.1097/mpa.0000000000000884] [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: 12/10/2022]
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