1
|
Wu G, Cui C, Song Q. Minimally invasive surgery compared to endoscopic intervention for treating infected pancreatic necrosis. A meta-analysis. Wideochir Inne Tech Maloinwazyjne 2024; 19:141-151. [PMID: 38973796 PMCID: PMC11223556 DOI: 10.5114/wiitm.2024.139175] [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: 03/20/2024] [Accepted: 04/02/2024] [Indexed: 07/09/2024] Open
Abstract
Introduction The current study aimed to compare the outcomes of endoscopic and minimally invasive surgical treatment for infected necrotizing pancreatitis. Material and methods A meta-analysis of clinical studies on minimally invasive operations for necrotic infection was conducted. A systematic review and study inclusion were done on multiple databases. English-language prospective comparison studies were included. Random design was used to analyze research with continuous and dichotomous variables. Results Ten studies were included in the current study. When compared to minimally invasive surgery, endoscopic procedures showed significant beneficial outcomes regarding low post-operative complication rates (p = 0.006), new onset organ failure (p < 0.001), and pancreatic fistula (p < 0.001). However, there was no significant difference between the two interventions regarding hospital stay, postoperative bleeding, incisional hernia, endocrine insufficiency, and perforation of a visceral organ. Conclusions Endoscopic therapy appears to have potential advantages over minimally invasive surgery. However, there is no difference between interventions regarding several parameters.
Collapse
Affiliation(s)
- Guangjiang Wu
- Department of Infection Management and Disease Prevention and Control, Beijing Youan Hospital, Capital Medical University, Beijing, China
| | - Can Cui
- Department of Infection Management and Disease Prevention and Control, Beijing Youan Hospital, Capital Medical University, Beijing, China
| | - Qingkun Song
- Center of Biobank, Beijing Youan Hospital, Capital Medical University, Beijing, China
| |
Collapse
|
2
|
Valente R, Zarantonello L, Del Chiaro M, Vujasinovic M, Baldaque-Silva F, Scandavini CM, Rangelova E, Vespasiano F, Anzillotti G, Löhr JM, Arnelo U. Lumen apposing metal stents vs. double pigtail plastic stents for the drainage of pancreatic walled-off necrosis. Minerva Gastroenterol (Torino) 2024; 70:1-9. [PMID: 35112820 DOI: 10.23736/s2724-5985.22.03055-8] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
BACKGROUND Few studies compared lumen-apposing metal stents (LAMS) and standard double pigtail plastic stents (PS) for the endoscopic drainage of pancreatic walled-off necrosis (WON). Albeit sometimes large, previously described cohorts display considerable heterogeneity and often pooled together data from several centers, involving multiple operators and techniques. Moreover, they often lack a control group for the comparison of outcomes. The aim of this study was to compare clinical efficacy and safety of PS versus LAMS for the endoscopic drainage of infected WON. METHODS Thirty patients were enrolled between 2011 and 2017. The present study is a single-center, 1:1 case-control study. We compared patients undergoing endoscopic drainages of infected WON through LAMS (cases) or PS (controls). The primary endpoint was the clinical efficacy (resolution of the WON/sepsis), the secondary endpoint was safety (procedure-related complications). RESULTS Cases and controls were homogeneous in terms of etiology and clinical characteristics: 93% of cases and 86.7% of controls were clinically successfully treated, with no significant differences in rates of postoperative infections, bleedings, and stent migrations (respectively 13.3% vs. 21.4%; P=0.65; 13.3% vs. 0%; P=0.48; 13.3% vs. 7.1%; P=1.00). No difference was shown regarding the need for additional percutaneous or surgical treatments (33.3% vs. 13.3%; P=0.39). Cases, however, displayed a significantly prolonged mean hospital stay (90.2 days vs. 18.5 days; P<0.01) and a higher mean number of endoscopic procedures per patient (4.8 vs. 1.5; P<0.01). CONCLUSIONS PS might be not inferior to LAMS for the treatment WONs. Further prospective RCT is needed to compare clinical efficacy and safety in the two groups.
Collapse
Affiliation(s)
- Roberto Valente
- Department of Surgery, Karolinska Institute, Stockholm, Sweden -
- Department of Surgical Oncology, Anschutz Medical Campus, University of Colorado, Denver, CO, USA -
- Department of Surgery and Perioperative Sciences, Umeå University Hospital, Umeå, Sweden -
| | | | - Marco Del Chiaro
- Department of Surgical Oncology, Anschutz Medical Campus, University of Colorado, Denver, CO, USA
| | - Miroslav Vujasinovic
- Department of Upper Digestive Diseases, Karolinska University Hospital, Stockholm, Sweden
| | | | - Chiara M Scandavini
- Department of Surgery and Perioperative Sciences, Umeå University Hospital, Umeå, Sweden
| | - Elena Rangelova
- Department of Surgery, Sahlgrenska Hospital, Gothenburg, Sweden
| | - Francesca Vespasiano
- Department of Upper Digestive Diseases, Karolinska University Hospital, Stockholm, Sweden
| | - Giuseppe Anzillotti
- Department of Upper Digestive Diseases, Karolinska University Hospital, Stockholm, Sweden
| | - Johannes M Löhr
- Department of Surgery, Karolinska Institute, Stockholm, Sweden
- Department of Upper Digestive Diseases, Karolinska University Hospital, Stockholm, Sweden
| | - Urban Arnelo
- Department of Surgery, Karolinska Institute, Stockholm, Sweden
- Department of Surgery and Perioperative Sciences, Umeå University Hospital, Umeå, Sweden
| |
Collapse
|
3
|
Jaeger K, Meyer F, Füldner F, Will U. Endoscopic necrosectomy of infected WON in acute necrotising pancreatitis - Development of an effective therapeutic algorithm based on a single-center consecutive patient cohort. ZEITSCHRIFT FUR GASTROENTEROLOGIE 2023; 61:665-675. [PMID: 36126931 DOI: 10.1055/a-1890-5674] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/09/2023]
Abstract
OBJECTIVE Development of an effective therapeutic algorithm for interventional (minimally invasive) approach to infected walled-off necrosis (WON) in patients with necrotising pancreatitis reflecting real-word data. MATERIAL/METHODS All consecutive patients who underwent endoscopic necrosectomy for necrotising pancreatitis through a defined study period were enclosed in this retrospective observational case study. The therapeutic approach was analysed for clinical success rate, complication spectrum and rate as well as mortality and compared with data from the literature. Finally, a therapeutic algorithm was derived. RESULTS From 2004 to 2019, 126 patients with necrotising pancreatitis (median of APACHE II score, 10.5 points) were treated. In 92.9 % of cases (n=117), an infected WON with microbial pathogen detection was found. After a median of 18 days from symptom onset, first intervention was performed (53.2 % as percutaneous drainage with programmed rinsing, 29.4 % as EUS-guided internal drainage). From 2004 to 2010, double pigtail stents were used. Later, lumen-apposing metal stent (LAMS) such as AXIOSTM stent (Boston Scientific, Ratingen, Germany) was preferred. The combined percutaneous and internal drainage was performed in approximately 50 % of subjects.Endoscopic transluminal necrosectomy was performed in 123 patients (97.6 %) at a median of 33 days from symptom onset. Endoscopic percutaneous necrosectomy was conducted in 11.1 % of the individuals. A median number of two endoscopic necrosectomy sessions per patient was necessary for the therapy. The clinical success rate (discharge without surgical intervention) was 82.5 %. The complication rate (bleeding and perforation) and the need for surgery were both 9.5 %. The overall mortality was 8.7 %. CONCLUSION Therapy of necrotising pancreatitis with infected WON consists of early calculated antibiotic therapy with adequate drainage. Combined external and internal drainages with programmed rinsing seem to improve prognosis, as well as minimise I) : the need for forced necrosectomies (mainly via a transluminal access site) and II) : complication rate as well as, thus, improve outcome.
Collapse
Affiliation(s)
- Kristin Jaeger
- Dept. of Internal Medicine III (Gastroenterology, Hepatology, General Internal Medicine), Municipal Hospital ("SRH Wald-Klinikum Gera GmbH"), Gera, Germany
| | - Frank Meyer
- Dept. of General, Abdominal, Vascular and Transplant Surgery, Otto-von-Guericke University with University Hospital, Magdeburg, Germany
| | - Frank Füldner
- Dept. of Internal Medicine III (Gastroenterology, Hepatology, General Internal Medicine), Municipal Hospital ("SRH Wald-Klinikum Gera GmbH"), Gera, Germany
| | - Uwe Will
- Dept. of Internal Medicine III (Gastroenterology, Hepatology, General Internal Medicine), Municipal Hospital ("SRH Wald-Klinikum Gera GmbH"), Gera, Germany
| |
Collapse
|
4
|
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
|
5
|
Pattarapuntakul T, Charoenrit T, Wong T, Netinatsunton N, Ovartlarnporn B, Yaowmaneerat T, Tubtawee T, Boonsri P, Sripongpun P. Clinical Outcomes of the Endoscopic Step-Up Approach with or without Radiology-Guided Percutaneous Drainage for Symptomatic Walled-Off Pancreatic Necrosis. Medicina (B Aires) 2023; 59:medicina59030569. [PMID: 36984570 PMCID: PMC10058734 DOI: 10.3390/medicina59030569] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/23/2023] [Revised: 03/05/2023] [Accepted: 03/13/2023] [Indexed: 03/17/2023] Open
Abstract
Background and objectives: Symptomatic walled-off pancreatic necrosis is a serious local complication of acute necrotising pancreatitis. The endoscopic step-up approach is the standard treatment for symptomatic walled-off pancreatic necrosis; however, adjunctive radiologic percutaneous drainage for this condition is controversial. This study compared the clinical and radiologic resolution of walled-off pancreatic necrosis achieved with the endoscopic step-up approach with or without radiology-guided percutaneous drainage. Material and Methods: This retrospective, single-centre cohort study enrolled patients with symptomatic walled-off pancreatic necrosis who underwent endoscopic transmural drainage (ETD) followed by directed endoscopic necrosectomy (DEN) with or without radiology-guided drainage. A total of 34 patients (endoscopic approach, n = 22; combined modality approach, n = 12) underwent the endoscopic step-up approach (ETD followed by DEN). Baseline characteristics, clinical success, and resolution of necrosis were compared between groups. Results: All patients achieved symptom resolution from walled-off pancreatic necrosis. The mean patient age was 58.4 years, and 21 (61.8%) were men. Following treatment with the endoscopic approach and combined modality approach, clinical success was achieved in 90.9% of patients within 11.5 days, and 66.7% of patients within 16.5 days, respectively. Both length of hospital stay (55 days vs. 71 days; p = 0.071) and time to complete radiologic resolution were shorter (93 days vs. 124 days; p = 0.23) in the endoscopic approach group. Conclusion: Both the endoscopic step-up approach and the CMD approach resulted in a favourably high clinical resolution rates in patients with symptomatic WON. However, clinical success rates seemed to be higher, and the length of hospital stay tended to be shorter in the endoscopic approach than in the CMD approach, as well as the significantly shorter necrosectomy time in each procedure was observed. Of note, these findings might be from some inherited differences in baseline characteristics of the patients between the two groups, and a randomized controlled trial with a larger sample size to verify these results is warranted.
Collapse
Affiliation(s)
- Tanawat Pattarapuntakul
- Gastroenterology and Hepatology Unit, Division of Internal Medicine, Faculty of Medicine, Prince of Songkla University, Hat Yai 90110, Songkhla, Thailand (P.S.)
- Correspondence:
| | - Tummarong Charoenrit
- Gastroenterology and Hepatology Unit, Division of Internal Medicine, Faculty of Medicine, Prince of Songkla University, Hat Yai 90110, Songkhla, Thailand (P.S.)
| | - Thanawin Wong
- Gastroenterology and Hepatology Unit, Division of Internal Medicine, Faculty of Medicine, Prince of Songkla University, Hat Yai 90110, Songkhla, Thailand (P.S.)
| | - Nisa Netinatsunton
- Nantana-Kriangkrai Chotiwattanaphan (NKC) Institute of Gastroenterology and Hepatology, Faculty of Medicine, Prince of Songkla University, Hat Yai 90110, Songkhla, Thailand
| | - Bancha Ovartlarnporn
- Nantana-Kriangkrai Chotiwattanaphan (NKC) Institute of Gastroenterology and Hepatology, Faculty of Medicine, Prince of Songkla University, Hat Yai 90110, Songkhla, Thailand
| | - Thanapon Yaowmaneerat
- Nantana-Kriangkrai Chotiwattanaphan (NKC) Institute of Gastroenterology and Hepatology, Faculty of Medicine, Prince of Songkla University, Hat Yai 90110, Songkhla, Thailand
| | - Teeravut Tubtawee
- Division of Radiology, Faculty of Medicine, Prince of Songkla University, Hat Yai 90110, Songkhla, Thailand
| | - Pattira Boonsri
- Division of Radiology, Faculty of Medicine, Prince of Songkla University, Hat Yai 90110, Songkhla, Thailand
| | - Pimsiri Sripongpun
- Gastroenterology and Hepatology Unit, Division of Internal Medicine, Faculty of Medicine, Prince of Songkla University, Hat Yai 90110, Songkhla, Thailand (P.S.)
| |
Collapse
|
6
|
Jearth V, Rana SS. Endoscopic step up: When and how. Surg Open Sci 2022; 10:135-144. [PMID: 36193259 PMCID: PMC9526220 DOI: 10.1016/j.sopen.2022.09.001] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/24/2022] [Revised: 05/16/2022] [Accepted: 09/12/2022] [Indexed: 11/01/2022] Open
Abstract
The management of (peri)pancreatic collections has undergone a paradigm shift from open surgical drainage to minimally invasive endoscopic, percutaneous, or surgical interventions. Minimally invasive interventions are associated with less morbidity and mortality compared to open necrosectomy. The (peri)pancreatic collections are currently treated with a “step-up approach” of an initial drainage procedure followed, if necessary, by a more invasive debridement. The step-up approach for management of (peri)pancreatic collections is mainly of two types, namely, surgical and endoscopic. Surgical step up includes initial image-guided percutaneous catheter drainage followed, if necessary, by minimally invasive video-assisted retroperitoneal debridement. Endoscopic step-up approach includes endoscopic transluminal drainage followed, if necessary by direct endoscopic necrosectomy. The development of endoscopic ultrasound and lumen apposing metal stents (LAMSs) has revolutionized the endoscopic management of (peri)pancreatic collections. Compared to surgical step-up approach, endoscopic step-up treatment approach has been reported to be associated with less new-onset organ failure, pancreatic fistula, enterocutaneous fistula, or perforation of visceral organ and shorter hospital/intensive care unit stay. This review will mainly focus on indications, techniques, timing, and recent advances related to endoscopic step-up approach in management of symptomatic(peri)pancreatic collections.
Collapse
|
7
|
Przybyłkowski A, Nehring P. Endoscopic ultrasound-guided drainage of peripancreatic fluid collections: What impacts treatment duration? Hepatobiliary Pancreat Dis Int 2022; 22:310-316. [PMID: 35568680 DOI: 10.1016/j.hbpd.2022.05.001] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/21/2021] [Accepted: 03/30/2022] [Indexed: 02/05/2023]
Abstract
BACKGROUND Peripancreatic fluid collections (PFCs) are complications resulting from acute or chronic pancreatitis and require treatment in certain clinical conditions. The present study aimed to identify the factors influencing the duration of endoscopic ultrasound (EUS)-guided drainage of symptomatic pancreatic pseudocysts (PPCs), walled-off necrosis (WON), and acute necrotic collections (ANCs). METHODS This was a retrospective cohort study of 68 patients with PFCs who underwent EUS-guided drainage. The timing and duration of EUS-guided drainage of various PFCs (ANC, WON, and PPCs) were compared, and the factors influencing the duration of endoscopic treatment were identified. RESULTS The mean time to first EUS-guided PFC drainage since the acute pancreatitis episode was 372.0, 505.0, and 18.7 days for WON, PPC, and ANC, respectively, and the mean duration of treatment was 90, 60, and 63 days, respectively. A disconnected pancreatic duct, a history of percutaneous drainage, and an infected PFC were identified as factors influencing the treatment duration. A positive correlation was observed between the treatment duration and patients' age. Patients with a disconnected pancreatic duct had to undergo more procedures. In patients with PPC, clinically successful drainage was more frequently achieved after a single procedure without the need for repeated procedures than in those with WON (90% vs. 59%, P = 0.01). CONCLUSIONS Patients with a history of percutaneous drainage, disconnected pancreatic duct, or PFC infection may require longer endoscopic treatment.
Collapse
Affiliation(s)
- Adam Przybyłkowski
- Department of Gastroenterology and Internal Medicine, Medical University of Warsaw, Warsaw, Poland.
| | - Piotr Nehring
- Department of Gastroenterology and Internal Medicine, Medical University of Warsaw, Warsaw, Poland
| |
Collapse
|
8
|
Cosgrove N, Shetty A, Mclean R, Vitta S, Faisal MF, Mahmood S, Early D, Mullady D, Das K, Lang G, Thai T, Syed T, Maple J, Jonnalagadda S, Andresen K, Hollander T, Kushnir V. Radiologic Predictors of Increased Number of Necrosectomies During Endoscopic Management of Walled-off Pancreatic Necrosis. J Clin Gastroenterol 2022; 56:457-463. [PMID: 33883512 DOI: 10.1097/mcg.0000000000001549] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/22/2020] [Accepted: 03/14/2021] [Indexed: 12/10/2022]
Abstract
GOALS No established methods exist to predict who will require a higher number of endoscopic necrosectomy sessions for walled-off necrosis (WON). We aim to identify radiologic predictors for requiring a greater number of necrosectomy sessions. This may help to identify patients who benefit from aggressive endoscopic management. MATERIALS AND METHODS This is a multicenter retrospective study of patients with WON at 3 tertiary care centers. WON characteristics on preintervention computed tomography imaging were evaluated to determine if they were predictive of requiring more endoscopic necrosectomy. RESULTS A total of 104 patients were included. Seventy patients (67.3%) underwent endoscopic necrosectomy, with median of 2 necrosectomies. WON largest transverse diameters (P=0.02), largest coronal diameters (P=0.01), necrosis pattern [likelihood ratio (LR)=17.85, P<0.001], spread (LR=11.02, P=0.01), hemorrhage (LR=8.64, P=0.003), and presence of disconnected pancreatic duct (LR=6.80, P=0.01) were associated with undergoing ≥2 necrosectomies. Patients with septations/loculations were significantly less likely to undergo ≥2 necrosectomies (LR=4.86, P=0.03). CONCLUSIONS Several computed tomography radiologic features were significantly associated with undergoing ≥2 necrosectomies. These could help identify patients who will undergo a higher number of endoscopic necrosectomy sessions.
Collapse
Affiliation(s)
| | | | - Richard Mclean
- Department of Internal Medicine, Washington University in St. Louis, St. Louis
| | - Swaroop Vitta
- Department of Internal Medicine, Washington University in St. Louis, St. Louis
| | - Mir F Faisal
- Division of Gastroenterology, University of Missouri, Kansas City
| | | | | | | | | | | | | | - Taseen Syed
- Department of Internal Medicine, University of Oklahoma Health Sciences, Oklahoma City, OK
| | | | | | - Kelli Andresen
- Division of Radiology, St. Luke's Hospital of Kansas City, Kansas City, MO
| | | | | |
Collapse
|
9
|
Bhakta D, de Latour R, Khanna L. Management of pancreatic fluid collections. Transl Gastroenterol Hepatol 2022; 7:17. [PMID: 35548474 PMCID: PMC9081921 DOI: 10.21037/tgh-2020-06] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/04/2020] [Accepted: 02/10/2021] [Indexed: 12/28/2023] Open
Abstract
Pancreatic fluid collections often develop as a complication of acute pancreatitis but can be seen in a variety of conditions including chronic pancreatitis, trauma, malignancy or post-operatively. It is important to classify a pancreatic fluid collection in order to optimize treatment strategies and management. Most interventions are targeted towards the management of delayed complications of pancreatitis, including pancreatic pseudocysts and walled-off necrosis (WON), which often develop days to weeks after the initial episode of pancreatitis. Surgical, percutaneous, and endoscopic interventions are all possible methods for treatment of pancreatic fluid collections, however endoscopic drainage with endoscopic ultrasound has become first-line. Advances within endoscopic drainage strategies have also led to innovative changes in the specific stents used for treatment, with possible options including double pigtail plastic stents, fully covered self-expanding metal stents and lumen-apposing metal stents (LAMS).
Collapse
Affiliation(s)
- Dimpal Bhakta
- New York University School of Medicine, New York, USA
| | | | - Lauren Khanna
- New York University School of Medicine, New York, USA
| |
Collapse
|
10
|
Hentschel V, Walter B, Harder N, Arnold F, Seufferlein T, Wagner M, Müller M, Kleger A. Microbial Spectra and Clinical Outcomes from Endoscopically Drained Pancreatic Fluid Collections: A Descriptive Cohort Study. Antibiotics (Basel) 2022; 11:antibiotics11030420. [PMID: 35326883 PMCID: PMC8944472 DOI: 10.3390/antibiotics11030420] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/14/2022] [Revised: 03/04/2022] [Accepted: 03/12/2022] [Indexed: 12/10/2022] Open
Abstract
Pancreatic pseudocyst (PC) and walled-off necrosis (WON) are dreaded complications of acute pancreatitis. Standard therapy consists of endoscopic ultrasound-guided transmural placement of stents to expedite resolution through internal drainage of fluids or necrotic material. Either double pigtail plastic stents (DPPS) or lumen-apposing metal stents (LAMS), or a combination of both, are available for this purpose. The objective of this study was to examine the impact of different stent types on infection rates in addition to clinical outcome measures such as periprocedural adverse events. We conducted a retrospective study comprising 77 patients who had undergone endoscopic drainage for PC or WON in a pancreatitis tertiary referral center. Analysis revealed that both bacterial and fungal infections occurred more frequently in patients treated with LAMS with or without DPPS compared to DPPS only. The use of antibiotics and antimycotics followed the same pattern. Furthermore, a prolonged length of hospital stay and a higher likelihood of transfer to an intermediate care unit were observed in patients with LAMS with or without DPPS. These differences were eliminated if only WON patients were analyzed. Our data imply that the clinical course is primarily influenced by the complexity of the pancreatic fluid collection (PFC) itself rather than the stent type. Prospective large-scale cohort studies are mandatory to underpin these findings.
Collapse
Affiliation(s)
- Viktoria Hentschel
- Department of Gastroenterology, Clinic of Internal Medicine 1, University Hospital of Ulm, 89081 Ulm, Germany; (V.H.); (B.W.); (N.H.); (F.A.); (T.S.); (M.W.); (M.M.)
- Interdisciplinary Endoscopy Unit, University Hospital of Ulm, 89081 Ulm, Germany
| | - Benjamin Walter
- Department of Gastroenterology, Clinic of Internal Medicine 1, University Hospital of Ulm, 89081 Ulm, Germany; (V.H.); (B.W.); (N.H.); (F.A.); (T.S.); (M.W.); (M.M.)
- Interdisciplinary Endoscopy Unit, University Hospital of Ulm, 89081 Ulm, Germany
| | - Noemi Harder
- Department of Gastroenterology, Clinic of Internal Medicine 1, University Hospital of Ulm, 89081 Ulm, Germany; (V.H.); (B.W.); (N.H.); (F.A.); (T.S.); (M.W.); (M.M.)
| | - Frank Arnold
- Department of Gastroenterology, Clinic of Internal Medicine 1, University Hospital of Ulm, 89081 Ulm, Germany; (V.H.); (B.W.); (N.H.); (F.A.); (T.S.); (M.W.); (M.M.)
| | - Thomas Seufferlein
- Department of Gastroenterology, Clinic of Internal Medicine 1, University Hospital of Ulm, 89081 Ulm, Germany; (V.H.); (B.W.); (N.H.); (F.A.); (T.S.); (M.W.); (M.M.)
- Interdisciplinary Endoscopy Unit, University Hospital of Ulm, 89081 Ulm, Germany
| | - Martin Wagner
- Department of Gastroenterology, Clinic of Internal Medicine 1, University Hospital of Ulm, 89081 Ulm, Germany; (V.H.); (B.W.); (N.H.); (F.A.); (T.S.); (M.W.); (M.M.)
- Interdisciplinary Endoscopy Unit, University Hospital of Ulm, 89081 Ulm, Germany
| | - Martin Müller
- Department of Gastroenterology, Clinic of Internal Medicine 1, University Hospital of Ulm, 89081 Ulm, Germany; (V.H.); (B.W.); (N.H.); (F.A.); (T.S.); (M.W.); (M.M.)
- Interdisciplinary Endoscopy Unit, University Hospital of Ulm, 89081 Ulm, Germany
| | - Alexander Kleger
- Department of Gastroenterology, Clinic of Internal Medicine 1, University Hospital of Ulm, 89081 Ulm, Germany; (V.H.); (B.W.); (N.H.); (F.A.); (T.S.); (M.W.); (M.M.)
- Interdisciplinary Endoscopy Unit, University Hospital of Ulm, 89081 Ulm, Germany
- Correspondence: ; Tel.: +49-731-5000
| |
Collapse
|
11
|
Easler JJ. The role of endoscopic therapy in the minimally invasive management of pancreatic necrosis. Korean J Intern Med 2021; 36:32-44. [PMID: 33472284 PMCID: PMC7820657 DOI: 10.3904/kjim.2020.542] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/02/2020] [Accepted: 11/02/2020] [Indexed: 12/12/2022] Open
Abstract
Pancreatic necrosis is among the most frequently encountered local complications of acute pancreatitis and associates with severe disease. Infected pancreatic necrosis further enhances the risk for morbidity and mortality. Pancreatic fluid collections that result from pancreatic necrosis evolve from acute necrotic collections to walled off necrosis and are defined by their distinct characteristics on cross sectional imaging. A variety of interventions spanning multiple disciplines are available for the drainage and debridement of pancreatic necrosis. Prospective, randomized trials have identified management strategies that incorporate minimally invasive interventions as having the best outcomes for patients with symptomatic pancreatic necrosis. The scientific literature has confidently positioned endoscopic drainage and necrosectomy among the most effective interventions for patients with symptomatic walled off necrosis. Innovations such as the use of metallic stents, chemical debridement and multiple modalities for drainage of pancreatic necrosis show promise in improving outcomes for patients managed with endoscopic interventions.
Collapse
Affiliation(s)
- Jeffrey James Easler
- Division of Gastroenterology and Hepatology, Indiana University School of Medicine, Indianapolis, IN, USA
- Correspondence to Jeffrey James Easler, M.D. Division of Gastroenterology and Hepatology, Indiana University School of Medicine, 550 N. University Blvd, Suite 1634, Indianapolis, IN 46202, USA Tel: +1-3179484978 Fax: +1-3179681265 E-mail:
| |
Collapse
|
12
|
Pereira F, Caldeira A, Leite S, Marques S, Moreira T, Moutinho-Ribeiro P, Nunes N, Bispo M. GRUPUGE Perspective: Endoscopic Ultrasound-Guided Drainage of Peripancreatic Collections. GE PORTUGUESE JOURNAL OF GASTROENTEROLOGY 2020; 28:39-51. [PMID: 33564703 PMCID: PMC7841806 DOI: 10.1159/000509193] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/14/2020] [Accepted: 05/20/2020] [Indexed: 04/28/2023]
Abstract
Pancreatic and peripancreatic collections (PPC) are a known complication of acute pancreatitis. They are categorized into four types of collection: (1) acute peripancreatic fluid collection, (2) pseudocyst, (3) acute necrotic collection and (4) walled-off necrosis. Most PPC resolve spontaneously or are persistent but asymptomatic. Intervention is needed in a minority of patients with infected or symptomatic collection. Endoscopic ultrasound-guided transmural drainage is currently the first-line treatment option for PPC management. It has shown great technical and clinical success, similar to percutaneous or surgical approaches, but with lower morbidity and costs and better quality of life. In this review article, the GRUPUGE presents an updated perspective on the potential role of endoscopic ultrasound-guided drainage of peripancreatic collections, addressing the selection criteria and the technical issues of different techniques and analysing emerging data on their efficacy and safety.
Collapse
Affiliation(s)
- Flávio Pereira
- Department of Gastroenterology, Hospital Amato Lusitano, Castelo Branco, Portugal
- *Flávio Pereira, Department of Gastroenterology, Hospital Amato Lusitano, Av. Pedro Álvares Cabral, PT–6000-085 Castelo Branco (Portugal),
| | - Ana Caldeira
- Department of Gastroenterology, Hospital Amato Lusitano, Castelo Branco, Portugal
| | - Sílvia Leite
- Department of Gastroenterology, Hospital da Senhora da Oliveira, Guimarães, Portugal
| | - Susana Marques
- Department of Gastroenterology and Digestive Endoscopy, Champalimaud Foundation, Lisbon, Portugal
| | - Teresa Moreira
- Department of Gastroenterology, Hospital de Santo António, Porto, Portugal
| | - Pedro Moutinho-Ribeiro
- Department of Gastroenterology, Centro Hospitalar e Universitário de São João, Porto, Portugal
| | - Nuno Nunes
- Department of Gastroenterology, Hospital do Divino Espírito Santo, Ponta Delgada, Portugal
| | - Miguel Bispo
- Department of Gastroenterology and Digestive Endoscopy, Champalimaud Foundation, Lisbon, Portugal
| |
Collapse
|
13
|
Abstract
OBJECTIVES Because infected pancreatic necrosis (IPN) has multiple presentations, not all patients are likely to benefit from the same first-line treatment. Our objective was to evaluate morbidity and mortality in a series of patients treated with a multimodal therapeutic approach. METHODS Between May 2012 and May 2019, 51 patients diagnosed with IPN were treated. The 5 initial treatment alternatives were as follows: percutaneous drainage, minimally invasive necrosectomy, antibiotics alone, transgastric necrosectomy, and temporizing percutaneous/endoscopic drainage. Initial treatment selection depended on evolution, clinical condition, and extension of pancreatic necrosis. Success, morbidity, and mortality rates were determined. RESULTS In terms of determinant-based classification, 37 were classified as severe, and 14 as critical. Percutaneous, temporizing drainage, minimally invasive necrosectomy, antibiotics alone and transgastric necrosectomy approaches were used in 21, 10, 11, 4, and 5 patients, respectively. Necrosectomy was not required in 18 patients (35%). There were no significant differences in mortality among the different treatment approaches (P < 0.45). Overall success, morbidity, and mortality rates were 68.6%, 52.9%, and 7.8%, respectively. CONCLUSIONS The multimodal approach seems to be a rational and efficient strategy for the initial treatment of IPN.
Collapse
|
14
|
Minghetti M, Lauro A, Pagano N, Vaccari S, D'Andrea V, Marino IR, Cervellera M, Tonini V. Two's a Charm: Endoscopic Therapy of Multiple Pancreatic Pseudocysts. Dig Dis Sci 2020; 65:66-70. [PMID: 31732908 DOI: 10.1007/s10620-019-05947-2] [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] [Indexed: 02/08/2023]
Abstract
Pancreatic pseudocysts commonly complicate acute pancreatitis. They can evolve either asymptomatically or with important symptoms. Treatment can be surgical, endoscopic, or percutaneous. The authors present a case report of a 78-year-old man who developed symptoms of an acute abdomen during hospitalization. A CT scan showed two pancreatic pseudocysts (diameters 10 cm and 7.5 cm) that were successfully drained endoscopically. Multiple pancreatic pseudocysts can be treated successfully via an endoscopic approach.
Collapse
Affiliation(s)
- M Minghetti
- Surgery Emergency and GI Department, St. Orsola University Hospital, Bologna, Italy
| | - A Lauro
- Surgery Emergency and GI Department, St. Orsola University Hospital, Bologna, Italy.
| | - N Pagano
- Surgery Emergency and GI Department, St. Orsola University Hospital, Bologna, Italy
| | - S Vaccari
- Surgery Emergency and GI Department, St. Orsola University Hospital, Bologna, Italy
| | - V D'Andrea
- Department of Surgical Sciences, La Sapienza University, Umberto I Hospital, Rome, Italy
| | - I R Marino
- Sidney Kimmel Medical College, Thomas Jefferson University, Philadelphia, PA, USA
| | - M Cervellera
- Surgery Emergency and GI Department, St. Orsola University Hospital, Bologna, Italy
| | - V Tonini
- Surgery Emergency and GI Department, St. Orsola University Hospital, Bologna, Italy
| |
Collapse
|
15
|
Rizzatti G, Rimbaş M, Larghi A. Endoscopic Ultrasound-Guided Drainage for Infected Necrotizing Pancreatitis: Better Than Surgery But Still Lacking Treatment Protocol Standardization. Gastroenterology 2019; 157:582-583. [PMID: 31102662 DOI: 10.1053/j.gastro.2019.01.274] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/20/2018] [Accepted: 01/08/2019] [Indexed: 01/26/2023]
Affiliation(s)
- Gianenrico Rizzatti
- Digestive Endoscopy Unit, Fondazione Policlinico Universitario A. Gemelli, IRCCS, Rome, Italy
| | - Mihai Rimbaş
- Gastroenterology Department, Colentina Clinical Hospital, Carol Davila University of Medicine, Bucharest, Romania
| | - Alberto Larghi
- Digestive Endoscopy Unit, Fondazione Policlinico Universitario A. Gemelli, IRCCS, Rome, Italy
| |
Collapse
|
16
|
Sion MK, Davis KA. Step-up approach for the management of pancreatic necrosis: a review of the literature. Trauma Surg Acute Care Open 2019; 4:e000308. [PMID: 31245622 PMCID: PMC6560663 DOI: 10.1136/tsaco-2019-000308] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/01/2019] [Revised: 04/19/2019] [Accepted: 04/30/2019] [Indexed: 12/12/2022] Open
Abstract
Infected necrotizing pancreatitis is a challenging condition to treat because of the profound inflammatory response these patients undergo which can then be exacerbated by interventions. Treatment of this condition has evolved in timing of intervention as well as method of intervention and includes less invasive options for treatment such as percutaneous drainage and endoscopic drainage, in addition to less invasive endoscopic and video-assisted or laparoscopic debridements. The precise optimal treatment strategy for these patients is an ongoing topic of discussion and may be different for each patient as this is a heterogenous condition.
Collapse
|
17
|
Trikudanathan G, Wolbrink DRJ, van Santvoort HC, Mallery S, Freeman M, Besselink MG. Current Concepts in Severe Acute and Necrotizing Pancreatitis: An Evidence-Based Approach. Gastroenterology 2019; 156:1994-2007.e3. [PMID: 30776347 DOI: 10.1053/j.gastro.2019.01.269] [Citation(s) in RCA: 194] [Impact Index Per Article: 38.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/08/2018] [Revised: 01/01/2019] [Accepted: 01/15/2019] [Indexed: 02/07/2023]
Abstract
The incidence of acute pancreatitis continues to rise, inducing substantial medical and social burden, with annual costs exceeding $2 billion in the United States alone. Although most patients develop mild pancreatitis, 20% develop severe and/or necrotizing pancreatitis, requiring advanced medical and interventional care. Morbidity resulting from local and systemic complications as well as invasive interventions result in mortality rates historically as high as 30%. There has been substantial evolution of strategies for interventions in recent years, from open surgery to minimally invasive surgical and endoscopic step-up approaches. In contrast to the advances in invasive procedures for complications, early management still lacks curative options and consists of adequate fluid resuscitation, analgesics, and monitoring. Many challenges remain, including comprehensive management of the entire spectrum of the disease, which requires close involvement of multiple disciplines at specialized centers.
Collapse
Affiliation(s)
- Guru Trikudanathan
- Division of Gastroenterology, Hepatology and Nutrition, University of Minnesota, Minneapolis, Minnesota.
| | | | - Hjalmar C van Santvoort
- Department of Surgery, the University Medical Center Utrecht and the St. Antonius Hospital Nieuwegein, the Netherlands
| | - Shawn Mallery
- Division of Gastroenterology, Hepatology and Nutrition, University of Minnesota, Minneapolis, Minnesota
| | - Martin Freeman
- Division of Gastroenterology, Hepatology and Nutrition, University of Minnesota, Minneapolis, Minnesota
| | - Marc G Besselink
- Department of Surgery, Amsterdam Gastroenterology and Metabolism, Amsterdam UMC, University of Amsterdam, the Netherlands
| |
Collapse
|