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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.
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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
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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).
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Affiliation(s)
- Dimpal Bhakta
- New York University School of Medicine, New York, USA
| | | | - Lauren Khanna
- New York University School of Medicine, New York, USA
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Reimer S, Seyfried F, Flemming S, Brand M, Weich A, Widder A, Plaßmeier L, Kraus P, Döring A, Hering I, Hankir MK, Meining A, Germer CT, Lock JF, Groneberg K. Evolution of endoscopic vacuum therapy for upper gastrointestinal leakage over a 10-year period: a quality improvement study. Surg Endosc 2022; 36:9169-9178. [PMID: 35852622 PMCID: PMC9652162 DOI: 10.1007/s00464-022-09400-w] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/28/2021] [Accepted: 06/19/2022] [Indexed: 01/06/2023]
Abstract
BACKGROUND Endoscopic vacuum therapy (EVT) is an effective treatment option for leakage of the upper gastrointestinal (UGI) tract. The aim of this study was to evaluate the clinical impact of quality improvements in EVT management on patients' outcome. METHODS All patients treated by EVT at our center during 2012-2021 were divided into two consecutive and equal-sized cohorts (period 1 vs. period 2). Over time several quality improvement strategies were implemented including the earlier diagnosis and EVT treatment and technical optimization of endoscopy. The primary endpoint was defined as the composite score MTL30 (mortality, transfer, length-of-stay > 30 days). Secondary endpoints included EVT efficacy, complications, in-hospital mortality, length-of-stay (LOS) and nutrition status at discharge. RESULTS A total of 156 patients were analyzed. During the latter period the primary endpoint MTL30 decreased from 60.8 to 39.0% (P = .006). EVT efficacy increased from 80 to 91% (P = .049). Further, the need for additional procedures for leakage management decreased from 49.9 to 29.9% (P = .013) and reoperations became less frequent (38.0% vs.15.6%; P = .001). The duration of leakage therapy and LOS were shortened from 25 to 14 days (P = .003) and 38 days to 25 days (P = .006), respectively. Morbidity (as determined by the comprehensive complication index) decreased from 54.6 to 46.5 (P = .034). More patients could be discharged on oral nutrition (70.9% vs. 84.4%, P = .043). CONCLUSIONS Our experience confirms the efficacy of EVT for the successful management of UGI leakage. Our quality improvement analysis demonstrates significant changes in EVT management resulting in accelerated recovery, fewer complications and improved functional outcome.
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Affiliation(s)
- Stanislaus Reimer
- Department of Gastroenterology, University Hospital of Würzburg, Würzburg, Germany
| | - Florian Seyfried
- Department of General, Visceral, Transplantation, Vascular and Pediatric Surgery, Center of Operative Medicine (ZOM), University Hospital of Würzburg, Würzburg, Germany.
| | - Sven Flemming
- Department of General-, Visceral-, Transplant-, Vascular- and Pediatric Surgery, University Hospital of Würzburg, Würzburg, Germany
| | - Markus Brand
- Department of Gastroenterology, University Hospital of Würzburg, Würzburg, Germany
| | - Alexander Weich
- Department of Gastroenterology, University Hospital of Würzburg, Würzburg, Germany
| | - Anna Widder
- Department of General-, Visceral-, Transplant-, Vascular- and Pediatric Surgery, University Hospital of Würzburg, Würzburg, Germany
| | - Lars Plaßmeier
- Department of General-, Visceral-, Transplant-, Vascular- and Pediatric Surgery, University Hospital of Würzburg, Würzburg, Germany
| | - Peter Kraus
- Department of Gastroenterology, University Hospital of Würzburg, Würzburg, Germany
| | - Anna Döring
- Department of General-, Visceral-, Transplant-, Vascular- and Pediatric Surgery, University Hospital of Würzburg, Würzburg, Germany
| | - Ilona Hering
- Department of General-, Visceral-, Transplant-, Vascular- and Pediatric Surgery, University Hospital of Würzburg, Würzburg, Germany
| | - Mohammed K Hankir
- Department of General-, Visceral-, Transplant-, Vascular- and Pediatric Surgery, University Hospital of Würzburg, Würzburg, Germany
| | - Alexander Meining
- Department of Gastroenterology, University Hospital of Würzburg, Würzburg, Germany
| | - Christoph-Thomas Germer
- Department of General-, Visceral-, Transplant-, Vascular- and Pediatric Surgery, University Hospital of Würzburg, Würzburg, Germany
| | - Johan F Lock
- Department of General-, Visceral-, Transplant-, Vascular- and Pediatric Surgery, University Hospital of Würzburg, Würzburg, Germany
| | - Kaja Groneberg
- Department of Gastroenterology, University Hospital of Würzburg, Würzburg, Germany
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He YG, Li J, Peng XH, Wu J, Xie MX, Tang YC, Zheng L, Huang XB. Sequential therapy with combined trans-papillary endoscopic naso-pancreatic and endoscopic retrograde pancreatic drainage for pancreatic pseudocysts. World J Clin Cases 2021; 9:6254-6267. [PMID: 34434992 PMCID: PMC8362563 DOI: 10.12998/wjcc.v9.i22.6254] [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: 04/02/2021] [Revised: 05/07/2021] [Accepted: 06/03/2021] [Indexed: 02/06/2023] Open
Abstract
BACKGROUND Endoscopic retrograde pancreatic drainage (ERPD) and stent implantation has become the major treatment method for pancreatic pseudocysts. However, it is associated with a high recurrence rate and infection.
AIM To manage pancreatic pseudocysts by sequential therapy with endoscopic naso-pancreatic drainage (ENPD) combined with ERPD and evaluate the treatment outcome.
METHODS One hundred and sixty-two cases of pancreatic pseudocyst confirmed by endoscopic examination at our hospital between January 2014 and January 2020 were retrospectively analyzed. There were 152 cases of intubation via the duodenal papilla, of which 92 involved pancreatic duct stent implantation and 60 involved sequential therapy with combined ENPD and ERPD (two-step procedure). The success rate of the procedure, incidence of complications (infection, bleeding, etc.), recurrence, and length and cost of hospitalization were compared between the two groups.
RESULTS The incidence of infection was significantly higher in the ERPD group (12 cases) than in the two-step procedure group (2 cases). Twelve patients developed infection in the ERPD group, and anti-infection therapy was effective in five cases but not in the remaining seven cases. Infection presented as fever and chills in the two-step procedure group. The reoperation rate was significantly higher in the ERPD group with seven cases compared with zero cases in the two-step procedure group (P < 0.05). Similarly, the recurrence rate was significantly higher in the ERPD group (19 cases) than in the two-step procedure group (0 cases).
CONCLUSION Sequential therapy with combined ENPD and ERPD is safe and effective in patients with pancreatic pseudocysts.
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Affiliation(s)
- Yong-Gang He
- Department of Hepatobiliary Surgery, The Second Affiliated Hospital of Army Medical University, Chongqing 400037, China
| | - Jing Li
- Department of Hepatobiliary Surgery, The Second Affiliated Hospital of Army Medical University, Chongqing 400037, China
| | - Xue-Hui Peng
- Department of Hepatobiliary Surgery, The Second Affiliated Hospital of Army Medical University, Chongqing 400037, China
| | - Jing Wu
- Department of Hepatobiliary Surgery, The Second Affiliated Hospital of Army Medical University, Chongqing 400037, China
| | - Ming-Xun Xie
- Department of Radiology, The Second Affiliated Hospital of Army Medical University, Chongqing 400037, China
| | - Yi-Chen Tang
- Department of Hepatobiliary Surgery, The Second Affiliated Hospital of Army Medical University, Chongqing 400037, China
| | - Lu Zheng
- Department of Hepatobiliary Surgery, The Second Affiliated Hospital of Army Medical University, Chongqing 400037, China
| | - Xiao-Bing Huang
- Department of Hepatobiliary Surgery, The Second Affiliated Hospital of Army Medical University, Chongqing 400037, China
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Binda C, Coluccio C, Sbrancia M, Fabbri C. Role of endoscopic ultrasonography in the management of peripancreatic collections. Diagnostic and therapeutic approach. Minerva Gastroenterol (Torino) 2021; 68:162-176. [PMID: 33988009 DOI: 10.23736/s2724-5985.21.02874-6] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
Pancreatic fluid collections are surrounded by a wall of granulation tissue and may contain necrotic debris. They occur following a severe acute pancreatitis and most of the cases resolve spontaneously after several weeks. However, their management may lead to a very hardto-treat condition, requiring a multidisciplinary approach. During the last decades we assisted to a change of paradigm involving Endoscopic Ultrasonography, from a pure diagnostic technique to an interventional-therapeutic one, allowing an effective, safe and less invasive approach than other existing treatment standards, historically consisting of surgical and percutaneous drainage. Treatment of pancreatic fluid collections is indicated if they become infected or symptomatic. Over the past years, exponential developments were done in interventional endoscopic approach, making it the first line suggested modality. The use of endoscopic ultrasound allows assessment of the collection, even when it is not directly bulging on gastrointestinal wall, creation of an internal fistulous tract, checking for surrounding vessels with the use of Doppler, and deployment of a stent avoiding the discomfort of external tubes. Several types of stent have been used for endoscopic drainage: plastic double pigtail stents, fully covered self-expanding metal stents and, more recently, lumen apposing metal stents, which are considered revolutionary because of their two-side flanges and wide and short internal channel, a new design that made easier direct endoscopic necrosectomy. This review aims to go through currently available literature on the diagnostic and therapeutic role of Endoscopic Ultrasonography to handle pancreatic fluid collections.
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Affiliation(s)
- Cecilia Binda
- Gastroenterology and Digestive Endoscopy Unit, Forlì-Cesena Hospitals, AUSL Romagna, Forlì-Cesena, Italy
| | - Chiara Coluccio
- Gastroenterology and Digestive Endoscopy Unit, Forlì-Cesena Hospitals, AUSL Romagna, Forlì-Cesena, Italy -
| | - Monica Sbrancia
- Gastroenterology and Digestive Endoscopy Unit, Forlì-Cesena Hospitals, AUSL Romagna, Forlì-Cesena, Italy
| | - Carlo Fabbri
- Gastroenterology and Digestive Endoscopy Unit, Forlì-Cesena Hospitals, AUSL Romagna, Forlì-Cesena, Italy
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Suggs P, NeCamp T, Carr JA. A Comparison of Endoscopic Versus Surgical Creation of a Cystogastrostomy to Drain Pancreatic Pseudocysts and Walled-Off Pancreatic Necrosis in 5500 Patients. ANNALS OF SURGERY OPEN 2020; 1:e024. [PMID: 37637446 PMCID: PMC10455460 DOI: 10.1097/as9.0000000000000024] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/16/2020] [Accepted: 10/20/2020] [Indexed: 11/25/2022] Open
Abstract
Objective To determine the success, morbidity, and mortality rates of endoscopic and surgical creation of pancreatic cystenterostomies for the drainage of peripancreatic fluid collections, pseudocysts with necrotic debris, and walled-off pancreatic necrosis. Summary Background Data Endoscopic methods of cystenterostomy creation to drain pancreatic pseudocysts (with and without necrotic debris) and infected peripancreatic fluid collections are perceived to be less morbid than surgery. Contemporary reports document a very high complication rate with endoscopic methods. Methods A meta-analysis of 5500 patients. Results Open and laparoscopic surgical techniques to drain chronic pancreatic pseudocysts, infected pancreatic fluid collections, and walled-off pancreatic necrosis are more successful with less morbidity and mortality than endoscopic methods. Conclusions In regards to a surgical step-up approach to treat chronic infected pancreatic fluid collections or walled-off pancreatic necrosis, surgical creation of a cystenterostomy is more successful with fewer complications than endoscopic methods and should be given priority if less invasive or conservative methods fail.
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Affiliation(s)
- Patrick Suggs
- From the The Department of General Surgery, St. Joseph Mercy Medical Center, Ann Arbor, MI
| | - Timothy NeCamp
- The Department of Statistics, University of Michigan, Ann Arbor, MI
| | - John Alfred Carr
- The Department of Trauma Surgery, Mid-Michigan Medical Center, Midland, MI
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Gabr MM, Frost T, Kudaravalli P, Bills GS, Priyadarshini S, McDonough S, Adler DG. Why is EUS-guided cyst-gastrostomy more common than cyst-duodenostomy: A disease state or endoscopist preference. Endosc Ultrasound 2020; 9:352-353. [PMID: 32687072 PMCID: PMC7811725 DOI: 10.4103/eus.eus_39_20] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/05/2022] Open
Affiliation(s)
- Moamen M Gabr
- Division of Digestive Health and Nutrition, University of Kentucky, Lexington, Kentucky, USA
| | - Taylor Frost
- University of Utah School of Medicine, Gastroenterology and Hepatology, Salt Lake City, Utah, USA
| | - Praneeth Kudaravalli
- Department of Internal Medicine, Division of Hospital Medicine, University of Kentucky, Lexington, Kentucky, USA
| | - Gregory S Bills
- Division of Digestive Health and Nutrition, University of Kentucky, Lexington, Kentucky, USA
| | - Shista Priyadarshini
- Division of Digestive Health and Nutrition, University of Kentucky, Lexington, Kentucky, USA
| | - Stephanie McDonough
- University of Utah School of Medicine, Gastroenterology and Hepatology, Salt Lake City, Utah, USA
| | - Douglas G Adler
- University of Utah School of Medicine, Gastroenterology and Hepatology, Salt Lake City, Utah, USA
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