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Clark CJ, Ray JW, Pawa S, Jahann D, McCullough M, Miller P, Mowery N, Miller M, Xiao T, Koutlas N, Pawa R. A location-based anatomic classification system for acute pancreatic fluid collections: Roadmap for optimal intervention in the step-up era. Surg Open Sci 2024; 18:1-5. [PMID: 38312303 PMCID: PMC10831243 DOI: 10.1016/j.sopen.2024.01.008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/02/2023] [Revised: 01/02/2024] [Accepted: 01/10/2024] [Indexed: 02/06/2024] Open
Abstract
Walled-off pancreatic necrosis (WOPN) is a local complication of acute necrotizing pancreatitis frequently requiring intervention. Treatment is typically through the coordinated efforts of a multidisciplinary team. Current management guidelines recommend a step-up approach beginning with minimally invasive techniques (percutaneous or transmural endoscopic drainage) followed by escalation to more invasive procedures if needed. Although the step-up approach is an evidence-based treatment paradigm for management of pancreatic fluid collections, it lacks guidance regarding optimal invasive technique selection based on the anatomic characteristics of pancreatic fluid collections. Similarly, existing cross-sectional imaging-based classification systems of pancreatic fluid collections have been used to predict disease severity and prognosis; however, none of these systems are designed to guide intervention. We propose a novel classification system which incorporates anatomic characteristics of pancreatic fluid collections (location and presence of disconnected pancreatic duct) to guide intervention selection and clinical decision making. We believe adoption of this simple classification system will help streamline treatment algorithms and facilitate cross-study comparisons for pancreatic fluid collections.
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Affiliation(s)
- Clancy J. Clark
- Division of Surgical Oncology, Department of General Surgery, Wake Forest University Baptist Medical Center, Winston-Salem, NC, United States of America
| | - Jonathan W. Ray
- Division of Surgical Oncology, Department of General Surgery, Wake Forest University Baptist Medical Center, Winston-Salem, NC, United States of America
| | - Swati Pawa
- Division of Gastroenterology, Department of Internal Medicine, Wake Forest University Baptist Medical Center, Winston-Salem, NC, United States of America
| | - Darius Jahann
- Division of Gastroenterology, Department of Internal Medicine, Wake Forest University Baptist Medical Center, Winston-Salem, NC, United States of America
| | - MaryAlyce McCullough
- Division of Acute Care Surgery, Department of General Surgery, Wake Forest University Baptist Medical Center, Winston-Salem, NC, United States of America
| | - Preston Miller
- Division of Acute Care Surgery, Department of General Surgery, Wake Forest University Baptist Medical Center, Winston-Salem, NC, United States of America
| | - Nathan Mowery
- Division of Acute Care Surgery, Department of General Surgery, Wake Forest University Baptist Medical Center, Winston-Salem, NC, United States of America
| | - Michael Miller
- Division of Interventional Radiology, Department of Radiology, Wake Forest University Baptist Medical Center, Winston-Salem, NC, United States of America
| | - Ted Xiao
- Division of Gastroenterology, Department of Internal Medicine, Wake Forest University Baptist Medical Center, Winston-Salem, NC, United States of America
| | - Nicholas Koutlas
- Division of Gastroenterology, Department of Internal Medicine, Wake Forest University Baptist Medical Center, Winston-Salem, NC, United States of America
| | - Rishi Pawa
- Division of Gastroenterology, Department of Internal Medicine, Wake Forest University Baptist Medical Center, Winston-Salem, NC, United States of America
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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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