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Hu WM, Hua TR, Zhang YL, Chen GR, Song K, Pendharkar S, Wu D, Windsor JA. Prognostic significance of organ failure and infected pancreatic necrosis in acute pancreatitis: An updated systematic review and meta-analysis. J Dig Dis 2023; 24:648-659. [PMID: 38037512 DOI: 10.1111/1751-2980.13243] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/18/2023] [Revised: 10/15/2023] [Accepted: 11/21/2023] [Indexed: 12/02/2023]
Abstract
OBJECTIVES In patients with acute pancreatitis (AP), minimally invasive treatment and the step-up approach have been widely used to deal with infected pancreatic necrosis (IPN) in the last decade. It is unclear whether IPN has become a less important determinant of mortality relative to organ failure (OF). We aimed to statistically aggregate recent evidence from published studies to determine the relative importance of IPN and OF as determinants of mortality in patients with AP (PROSPERO: CRD42020176989). METHODS Relevant studies were sourced from MEDLINE and EMBASE databases. Relative risk (RR) or weighted mean difference (WMD) was analyzed as outcomes. A two-sided P value of less than 0.05 was regarded as statistical significance. RESULTS Forty-three studies comprising 11 601 patients with AP were included. The mortality was 28% for OF patients and 24% for those with IPN. Patients with OF without IPN had a significantly higher risk of mortality compared to those with IPN but without OF (RR 3.72, P < 0.0001). However, patients with both OF and IPN faced the highest risk of mortality. Additionally, IPN increased length of stay in hospital for OF patients (WMD 28.75, P = 0.032). CONCLUSION Though IPN remains a significant concern, which leads to increased morbidity and longer hospital stay, it is a less critical mortality determinant compared to OF in AP.
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Affiliation(s)
- Wen Mo Hu
- Department of Gastroenterology, State Key Laboratory of Complex Severe and Rare Diseases, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Tian Rui Hua
- Department of Gastroenterology, State Key Laboratory of Complex Severe and Rare Diseases, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Yue Lun Zhang
- Medical Research Center, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
- Clinical Epidemiology Unit, International Clinical Epidemiology Network, Beijing, China
| | - Guo Rong Chen
- Department of Gastroenterology, State Key Laboratory of Complex Severe and Rare Diseases, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Kai Song
- Department of Gastroenterology, State Key Laboratory of Complex Severe and Rare Diseases, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Sayali Pendharkar
- Surgical and Translational Research Centre, Faculty of Medical and Health Sciences, University of Auckland, Auckland, New Zealand
| | - Dong Wu
- Department of Gastroenterology, State Key Laboratory of Complex Severe and Rare Diseases, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
- Clinical Epidemiology Unit, International Clinical Epidemiology Network, Beijing, China
| | - John A Windsor
- Surgical and Translational Research Centre, Faculty of Medical and Health Sciences, University of Auckland, Auckland, New Zealand
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Zeng Y, Yang J, Zhang JW. Endoscopic transluminal drainage and necrosectomy for infected necrotizing pancreatitis: Progress and challenges. World J Clin Cases 2023; 11:1888-1902. [PMID: 36998953 PMCID: PMC10044952 DOI: 10.12998/wjcc.v11.i9.1888] [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: 12/09/2022] [Revised: 02/06/2023] [Accepted: 03/01/2023] [Indexed: 03/16/2023] Open
Abstract
Infected necrotizing pancreatitis (INP) represents a severe condition in patients with acute pancreatitis. Invasive interventions are recommended in symptomatic INP. Growing evidence has suggested interventional strategies of INP evolving from traditional surgery to minimally invasive step-up endoscopic procedures. However, there is still no standardized protocol for endoscopic interventions. Recently, various studies have been published about the endoscopic management of INP. This article reviews published articles and guidelines to present the progress and challenges of endoscopic transluminal drainage and necrosectomy in INP.
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Affiliation(s)
- Yan Zeng
- Department of Psychology, The Second Affiliated Hospital of Chongqing Medical University, Chongqing 400010, China
| | - Jian Yang
- Department of Gastroenterology, The First Affiliated Hospital of Chongqing Medical University, Chongqing 400016, China
| | - Jun-Wen Zhang
- Department of Gastroenterology, The First Affiliated Hospital of Chongqing Medical University, Chongqing 400016, China
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Ghabili K, Shaikh J, Pollak J, Elwood D, Majdalany BS, Nezami N. Percutaneous Chemical and Mechanical Necrosectomy for Walled-Off Pancreatic Necrosis. J Vasc Interv Radiol 2023; 34:454-459.e2. [PMID: 36423816 DOI: 10.1016/j.jvir.2022.11.011] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/18/2022] [Revised: 10/07/2022] [Accepted: 11/09/2022] [Indexed: 11/22/2022] Open
Abstract
PURPOSE To test the hypothesis that percutaneous combined chemical and mechanical necrosectomy using a Malecot anchor drain and an Arrow-Trerotola percutaneous thrombolytic device (PTD) in patients with walled-off pancreatic necrosis (WOPN) is feasible, safe, and effective compared with a control group undergoing mechanical necrosectomy alone. MATERIALS AND METHODS In a retrospective analysis, patients with WOPN not amenable to endoscopic-guided cystogastrostomy placement were studied as case and control groups. The patients in the case group underwent percutaneous combined chemical (hydrogen peroxide 3%) and mechanical necrosectomy using a Malecot anchor drain and/or Arrow-Trerotola PTD from December 2020 to April 2022. The controls underwent mechanical necrosectomy alone without chemical necrosectomy. Clinical success was defined as complete resolution of the cavity on follow-up noncontrast computed tomography scans with subsequent drain removal. RESULTS Thirteen patients in the case group and 11 patients in the control group underwent percutaneous drain placement followed by percutaneous combined chemical and mechanical necrosectomy (case group) or mechanical necrosectomy only (control group) for WOPN. Drain placement and necrosectomy were technically successful in all patients studied. One patient in the case group developed postprocedural sepsis because of communication between the cavity and the splenic vein. Another patient in the case group developed bleeding from a branch of the pancreaticoduodenal artery on postnecrosectomy day 9, which was successfully embolized by interventional radiology. No pancreaticocutaneous fistula was reported at the 3-month follow-up. The clinical success rates in the case and control groups were 100% and 38.4%, respectively (P = .003). CONCLUSIONS Percutaneous combined chemical and mechanical necrosectomy is a feasible, safe, and effective treatment of WOPN.
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Affiliation(s)
- Kamyar Ghabili
- Department of Radiology and Biomedical Imaging, Yale University School of Medicine, New Haven, Connecticut
| | - Jamil Shaikh
- Division of Interventional Radiology and Image-Guided Medicine, Department of Radiology and Imaging Sciences, Emory University School of Medicine, Atlanta, Georgia; Department of Vascular and Interventional Radiology, Tampa General Hospital, University of South Florida, Morsani College of Medicine, Tampa, Florida
| | - Jeffrey Pollak
- Department of Radiology and Biomedical Imaging, Yale University School of Medicine, New Haven, Connecticut
| | - David Elwood
- Division of General and Gastrointestinal Surgery, Department of Surgery, Emory University School of Medicine, Atlanta, Georgia
| | - Bill S Majdalany
- Division of Interventional Radiology and Image-Guided Medicine, Department of Radiology and Imaging Sciences, Emory University School of Medicine, Atlanta, Georgia
| | - Nariman Nezami
- Division of Interventional Radiology and Image-Guided Medicine, Department of Radiology and Imaging Sciences, Emory University School of Medicine, Atlanta, Georgia; Division of Vascular and Interventional Radiology, Department of Diagnostic Radiology and Nuclear Medicine, University of Maryland School of Medicine, Baltimore, Maryland; Experimental Therapeutics Program, University of Maryland Marlene and Stewart Greenebaum Comprehensive Cancer Center, Baltimore, Maryland.
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4
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Abstract
Importance For decades, infected or symptomatic pancreatic necrosis was managed by open surgical necrosectomy, an approach that has now been largely supplanted by an array of techniques referred to as the step-up approach. Observations This review describes the evidence base behind the step-up approach, when to use the different techniques, and their technical basics. The most common treatment strategies are included: percutaneous drainage, video-assisted retroperitoneal debridement, sinus tract endoscopy, endoscopic transgastric necrosectomy, and surgical transgastric necrosectomy. Also included is the evidence base around management of common complications that can occur during step-up management, such as hemorrhage, intestinal fistula, and thrombosis, in addition to associated issues that can arise during step-up management, such as the need for cholecystectomy and disconnected pancreatic duct syndrome. Conclusions and Relevance The treatment strategies highlighted in this review are those most commonly used during step-up management, and this review is designed as a guide to the evidence base underlying these strategies, as surgeons tailor their therapeutic approach to individual patients.
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Affiliation(s)
- Lydia R Maurer
- Department of Surgery, Massachusetts General Hospital, Boston
| | - Peter J Fagenholz
- Division of Trauma, Emergency Surgery, and Surgical Critical Care, Massachusetts General Hospital, Boston
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Oh CH, Lee JK, Song TJ, Park JS, Lee JM, Son JH, Jang DK, Choi M, Byeon JS, Lee IS, Lee ST, Choi HS, Kim HG, Chun HJ, Park CG, Cho JY. Clinical Practice Guidelines for the Endoscopic Management of Peripancreatic Fluid Collections. Clin Endosc 2021; 54:505-521. [PMID: 34305047 PMCID: PMC8357592 DOI: 10.5946/ce.2021.185] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/08/2021] [Accepted: 07/20/2021] [Indexed: 12/13/2022] Open
Abstract
Endoscopic ultrasonography-guided intervention has gradually become a standard treatment for peripancreatic fluid collections (PFCs). However, it is difficult to popularize the procedure in Korea because of restrictions on insurance claims regarding the use of endoscopic accessories, as well as the lack of standardized Korean clinical practice guidelines. The Korean Society of Gastrointestinal Endoscopy (KSGE) appointed a Task Force to develope medical guidelines by referring to the manual for clinical practice guidelines development prepared by the National Evidence-Based Healthcare Collaborating Agency. Previous studies on PFCs were searched, and certain studies were selected with the help of experts. Then, a set of key questions was selected, and treatment guidelines were systematically reviewed. Answers to these questions and recommendations were selected via peer review. This guideline discusses endoscopic management of PFCs and makes recommendations on Indications for the procedure, pre-procedural preparations, optimal approach for drainage, procedural considerations (e.g., types of stent, advantages and disadvantages of plastic and metal stents, and accessories), adverse events of endoscopic intervention, and procedural quality issues. This guideline was reviewed by external experts and suggests best practices recommended based on the evidence available at the time of preparation. This will be revised as necessary to address advances and changes in technology and evidence obtained in clinical practice and future studies.
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Affiliation(s)
- Chi Hyuk Oh
- Division of Gastroenterology, Department of Internal Medicine, Kyung Hee University Hospital, Seoul, Korea
| | - Jun Kyu Lee
- Division of Gastroenterology, Department of Internal Medicine, Dongguk University Ilsan Hospital, Goyang, Korea
| | - Tae Jun Song
- Division of Gastroenterology, Department of Internal Medicine, Asan Medical Center, Seoul, Korea
| | - Jin-Seok Park
- Division of Gastroenterology, Department of Internal Medicine, Inha University Hospital, Incheon, Korea
| | - Jae Min Lee
- Division of Gastroenterology, Department of Internal Medicine, Korea University Anam Hospital, Seoul, Korea
| | - Jun Hyuk Son
- Division of Gastroenterology, Department of Internal Medicine, Inje University Ilsan Paik Hospital, Goyang, Korea
| | - Dong Kee Jang
- Division of Gastroenterology, Department of Internal Medicine, Dongguk University Ilsan Hospital, Goyang, Korea
| | - Miyoung Choi
- National Evidence-based Healthcare Collaborating Agency, Seoul, Korea
| | - Jeong-Sik Byeon
- Division of Gastroenterology, Department of Internal Medicine, Asan Medical Center, Seoul, Korea
| | - In Seok Lee
- Division of Gastroenterology, Department of Internal Medicine, The Catholic University of Korea Seoul ST. Mary's Hospital, Seoul, Korea
| | - Soo Teik Lee
- Division of Gastroenterology, Department of Internal Medicine, Jeonbuk National University Hospital, Jeonju, Korea
| | - Ho Soon Choi
- Division of Gastroenterology, Department of Internal Medicine, Hanyang University Seoul Hospital, Seoul, Korea
| | - Ho Gak Kim
- Division of Gastroenterology, Department of Internal Medicine, Daegu Catholic University Hospital, Daegu, Korea
| | - Hoon Jai Chun
- Division of Gastroenterology, Department of Internal Medicine, Korea University Anam Hospital, Seoul, Korea
| | - Chan Guk Park
- Division of Gastroenterology, Department of Internal Medicine, Chosun University Hospital, Gwangju, Korea
| | - Joo Young Cho
- Division of Gastroenterology, Department of Internal Medicine, Cha University Bundang Medical Center, Seongnam, Korea
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6
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Oh CH, Song TJ, Lee JK, Park JS, Lee JM, Son JH, Jang DK, Choi M, Byeon JS, Lee IS, Lee ST, Choi HS, Kim HG, Chun HJ, Park CG, Cho JY. Clinical Practice Guidelines for the Endoscopic Management of Peripancreatic Fluid Collections. Gut Liver 2021; 15:677-693. [PMID: 34305047 PMCID: PMC8444102 DOI: 10.5009/gnl210001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/13/2021] [Revised: 04/26/2021] [Accepted: 05/12/2021] [Indexed: 11/21/2022] Open
Abstract
Endoscopic ultrasonography-guided intervention has gradually become a standard treatment for peripancreatic fluid collections (PFCs). However, it is difficult to popularize the procedure in Korea because of restrictions on insurance claims regarding the use of endoscopic accessories, as well as the lack of standardized Korean clinical practice guidelines. The Korean Society of Gastrointestinal Endoscopy appointed a Task Force to develop medical guidelines by referring to the manual for clinical practice guidelines development prepared by the National Evidence-Based Healthcare Collaborating Agency. Previous studies on PFCs were searched, and certain studies were selected with the help of experts. Then, a set of key questions was selected, and treatment guidelines were systematically reviewed. Answers to these questions and recommendations were selected via peer review. This guideline discusses endoscopic management of PFCs and makes recommendations on Indications for the procedure, pre-procedural preparations, optimal approach for drainage, procedural considerations (e.g., types of stent, advantages and disadvantages of plastic and metal stents, and accessories), adverse events of endoscopic intervention, and procedural quality issues. This guideline was reviewed by external experts and suggests best practices recommended based on the evidence available at the time of preparation. This will be revised as necessary to address advances and changes in technology and evidence obtained in clinical practice and future studies. (Gut Liver 2021;15:-693)
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Affiliation(s)
- Chi Hyuk Oh
- Division of Gastroenterology, Department of Internal Medicine, Kyung Hee University Hospital, Seoul, Kore
| | - Tae Jun Song
- Division of Gastroenterology, Department of Internal Medicine, Asan Medical Center, Seoul, Korea
| | - Jun Kyu Lee
- Division of Gastroenterology, Department of Internal Medicine, Dongguk University Ilsan Hospital, Goyang, Korea
| | - Jin-Seok Park
- Division of Gastroenterology, Department of Internal Medicine, Inha University Hospital, Incheon, Korea
| | - Jae Min Lee
- Division of Gastroenterology, Department of Internal Medicine, Korea University Anam Hospital, Seoul, Korea
| | - Jun Hyuk Son
- Division of Gastroenterology, Department of Internal Medicine, Inje University Ilsan Paik Hospital, Goyang, Korea
| | - Dong Kee Jang
- Division of Gastroenterology, Department of Internal Medicine, Dongguk University Ilsan Hospital, Goyang, Korea
| | - Miyoung Choi
- National Evidence-Based Healthcare Collaborating Agency, Seoul, Korea
| | - Jeong-Sik Byeon
- Division of Gastroenterology, Department of Internal Medicine, Asan Medical Center, Seoul, Korea
| | - In Seok Lee
- Division of Gastroenterology, Department of Internal Medicine, The Catholic University of Korea Seoul St. Mary's Hospital, Seoul, Korea
| | - Soo Teik Lee
- Division of Gastroenterology, Department of Internal Medicine, Jeonbuk National University Hospital, Jeonju, Korea
| | | | - Ho Gak Kim
- Division of Gastroenterology, Department of Internal Medicine, Daegu Catholic University Hospital, Daegu, Korea
| | - Hoon Jai Chun
- Division of Gastroenterology, Department of Internal Medicine, Korea University Anam Hospital, Seoul, Korea
| | - Chan Guk Park
- Division of Gastroenterology, Department of Internal Medicine, Chosun University Hospital, Gwangju, Korea
| | - Joo Young Cho
- Division of Gastroenterology, Department of Internal Medicine, CHA University Bundang Medical Center, Seongnam, Korea
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Pawar A, Sonika U, Kumar M, Saluja S, Srivastava S. RWON Study: The Real-World Walled-off Necrosis Study. Clin Endosc 2021; 54:909-915. [PMID: 33618506 PMCID: PMC8652152 DOI: 10.5946/ce.2020.175] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/29/2020] [Accepted: 10/16/2020] [Indexed: 11/30/2022] Open
Abstract
Background/Aims The management of walled-off necrosis (WON) has undergone a paradigm shift from surgical to nonsurgical modalities. Real-world data on the management of symptomatic WON are scarce.
Methods Prospectively collected data of symptomatic WON cases were retrospectively evaluated. The treatment modalities used were medical management alone, percutaneous catheter drainage (PCD) or endoscopic drainage (ED), or a combination of PCD and ED. We compared clinical outcome among these modalities.
Results A total of 264 patients were evaluated. The most common indications for drainage were pain and fever. Of the patients, 28% was treated with medical therapy alone, 31% with ED, 37% with PCD, and 4% with a combined approach. Technical success and clinical success were achieved in 93% and 91% of patients in the endoscopic arm and in 90% and 81% patients in the PCD arm, respectively (p=0.0004 for clinical success). Lower rates of complications (7% vs. 22%, p=0.005), readmission (20% vs. 34%, p=0.04), and mortality (4% vs. 19%, p=0.0012), and shorter hospital stay (13 days vs. 19 days, p=0.0018) were observed in the endoscopic group than in the PCD group.
Conclusions ED of WON is better than PCD and is associated with lower mortality, fewer complications, and shorter hospitalization.
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Affiliation(s)
- Ankush Pawar
- Department of Gastroenterology, Govind Ballabh Pant Institute of Postgraduate Medical Education and Research, New Delhi, India
| | - Ujjwal Sonika
- Department of Gastroenterology, Govind Ballabh Pant Institute of Postgraduate Medical Education and Research, New Delhi, India
| | - Manish Kumar
- Department of Gastroenterology, Govind Ballabh Pant Institute of Postgraduate Medical Education and Research, New Delhi, India
| | - Sundeep Saluja
- Department of Gastrosurgery, Govind Ballabh Pant Institute of Postgraduate Medical Education and Research, New Delhi, India
| | - Siddharth Srivastava
- Department of Gastroenterology, Govind Ballabh Pant Institute of Postgraduate Medical Education and Research, New Delhi, India
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Gallyamov EA, Agapov MA, Busyrev YB, Gallyamov EE, Kakotkin VV, Allakhverdieva AR. [Comparison of minimal invasive technologies for treatment of infected pancreatic necrosis]. Khirurgiia (Mosk) 2020:22-28. [PMID: 32271733 DOI: 10.17116/hirurgia202003122] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/11/2023]
Abstract
AIM the assessment of the role of minimally invasive interventional procedures in the treatment of patients with infected pancreatic necrosis and their safety, as well as comparison of the results of the most common modern minimally invasive techniques among themselves. METHODS The results of treatment of 310 patients are presented with infected destructive pancreatitis from 2013 to 2018 on the basis of the city clinical hospital named after I.V. Davydovsky. The patients were divided into three groups: in the first one (n=170) patients underwent puncture followed by drainage of necrotic foci under ultrasound and CT control, in the second (n=98) patients underwent sanation of foci completely by laparoscopic access, in the third (n=42) a series of retroperitoneoscopy was used for the same purpose. RESULTS In 114 (67.1%) cases, patients from the first group did not require further surgical intervention. The results of percutaneous drainage were successful. The average length of hospital stay in the first group was 27 days, in the second and third groups - 31 days (the ratio in the 2nd and 3rd groups was 1.03 (95% CI 0.97-1.08; p<0.05)). In the course of treatment, complications were identified in 35 (35.7%) patients in the 2nd and 17 (40.4%) patients in the 3rd group (ratio 0.88 (95% CI 0.82-0.94)). There were 22 (7.1%) deaths. The causes of death were: 1 (0.3%) of the patient had arrosive bleeding, 2 (0.7%) had duodenal fistulas, 19 (6.1%) multiple organ failure against the background of widespread retroperitoneal phlegmon. CONCLUSION The efficacy of treatment of infected pancreatic necrosis depends on the possibility of full drainage of the necrotic focus, regardless of approach. Minimally invasive techniques can reduce intraoperative trauma by reducing the wound surface, which contribute to develop systemic inflammatory response syndrome.
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Affiliation(s)
- E A Gallyamov
- Sechenov First Moscow State Medical University of the Ministry of Health of Russia, Moscow, Russia
| | - M A Agapov
- Lomonosov Moscow State University, Faculty of Fundamental Medicine, Moscow, Russia
| | - Yu B Busyrev
- Sechenov First Moscow State Medical University of the Ministry of Health of Russia, Moscow, Russia
| | - E E Gallyamov
- Federal Medical and Biological Agency of Russia, Moscow, Russia
| | - V V Kakotkin
- Lomonosov Moscow State University, Faculty of Fundamental Medicine, Moscow, Russia
| | - A R Allakhverdieva
- Sechenov First Moscow State Medical University of the Ministry of Health of Russia, Moscow, Russia
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Rashid MU, Hussain I, Jehanzeb S, Ullah W, Ali S, Jain AG, Khetpal N, Ahmad S. Pancreatic necrosis: Complications and changing trend of treatment. World J Gastrointest Surg 2019; 11:198-217. [PMID: 31123558 PMCID: PMC6513789 DOI: 10.4240/wjgs.v11.i4.198] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/12/2019] [Revised: 04/19/2019] [Accepted: 04/23/2019] [Indexed: 02/06/2023] Open
Abstract
Incidence of acute pancreatitis seems to be increasing in the Western countries and has been associated with significantly increased morbidity. Nearly 80% of the patients with acute pancreatitis undergo resolution; some develop complications including pancreatic necrosis. Infection of pancreatic necrosis is the leading cause of death in these patients. A significant portion of these patients needs surgical interventions. Traditionally, the “gold standard” procedure has been the open surgical necrosectomy, which is now being completed by the relatively lesser invasive interventions. Minimally invasive surgical (MIS) procedures include endoscopic drainage, percutaneous image-guided catheter drainage, and retroperitoneal drainage. This review article discusses the open and MIS interventions for pancreatic necrosis with each having its own respective benefits and disadvantages are covered.
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Affiliation(s)
- Mamoon Ur Rashid
- Department of Internal Medicine, Advent Health Graduate Medical Education, Orlando, FL 32804, United States
| | - Ishtiaq Hussain
- Department of Gastroenterology, Cleveland Clinic, Weston, FL 33326, United States
| | - Sundas Jehanzeb
- Department of Gastroenterology, Cleveland Clinic, Weston, FL 33326, United States
| | - Waqas Ullah
- Internal Medicine, Abington Hospital, Abington, PA 19001, United States
| | - Saeed Ali
- Department of Internal Medicine, Advent Health Graduate Medical Education, Orlando, FL 32804, United States
| | - Akriti Gupta Jain
- Department of Internal Medicine, Advent Health Graduate Medical Education, Orlando, FL 32804, United States
| | - Neelam Khetpal
- Department of Internal Medicine, Advent Health Graduate Medical Education, Orlando, FL 32804, United States
| | - Sarfraz Ahmad
- Department of Gynecologic Oncology, Advent Health Cancer Institute, Orlando, FL 32804, United States
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10
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Siy AB, Rendell VR, Winslow ER. Analysis of National Presentations of Surgical Case Series Discussions: What Matters to Surgeons? J Surg Res 2019; 238:240-247. [PMID: 30776743 DOI: 10.1016/j.jss.2019.01.037] [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: 09/14/2018] [Revised: 12/05/2018] [Accepted: 01/11/2019] [Indexed: 11/10/2022]
Abstract
BACKGROUND Although the surgical case series is a useful study design for surgical disciplines, elements of its presentation have not been standardized with a widely accepted reporting guideline. Hence, case series may not include all components necessary for surgeons to best interpret their results. We aimed to determine core elements of case series through qualitative analysis of discussions after presentations at national meetings. METHODS Case series with accompanying discussions in three high-impact journals from 2010 to 2015 were analyzed with conventional content analysis. All interrogative sentences were selected for analysis and were classified by a redundant iterative process into descriptive categories and subcategories. RESULTS Two hundred twenty-one case series were identified, 56 of which included discussion transcripts. Four hundred seventy six unique interrogatives were classified into 4 categories and 13 subcategories. The main categories identified were "Application of Results to Patient Care," "Clarification of Study Methodology," "Facilitation of Author Insight," and "Request for Additional Study-Specific Data." The most frequent subcategories of inquiry pertained to the changes to current standard of care, clarification of study variables, and subgroup data and outcomes. CONCLUSIONS We determined major themes of inquiry that reflected core elements surgeons use to evaluate case series for relevance and applicability to their own practice. Discussants frequently questioned how the study's results changed the author's standard of care. Specifically encouraging surgical case series authors to comment on changes they made to their practice as a result of their findings would allow the surgical audience to quickly assess potential clinical applicability.
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Affiliation(s)
- Alexander B Siy
- Department of Surgery, University of Wisconsin School of Medicine and Public Health, Madison, Wisconsin
| | - Victoria R Rendell
- Department of Surgery, University of Wisconsin School of Medicine and Public Health, Madison, Wisconsin
| | - Emily R Winslow
- Department of Surgery, University of Wisconsin School of Medicine and Public Health, Madison, Wisconsin.
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11
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He WH, Zhu Y, Zhu Y, Liu P, Zeng H, Xia L, Yu C, Chen HM, Shu X, Liu ZJ, Chen YX, Lu NH. The outcomes of initial endoscopic transluminal drainage are superior to percutaneous drainage for patients with infected pancreatic necrosis: a prospective cohort study. Surg Endosc 2017; 31:3004-3013. [PMID: 28205028 DOI: 10.1007/s00464-016-5324-9] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/09/2016] [Accepted: 10/31/2016] [Indexed: 12/23/2022]
Abstract
BACKGROUND AND STUDY AIM The commonly used minimally invasive methods for patients with infected pancreatic necrosis (IPN) are initial endoscopic transluminal drainage (ETD) and percutaneous catheter drainage (PCD), which are followed, if necessary, by endoscopic or surgical necrosectomy. This study intends to explore which of the two minimally invasive treatments leads to a better prognosis. PATIENTS AND METHODS Patients with IPN and an indication for intervention were prospectively enrolled and underwent either initial ETD or PCD followed, if necessary, by endoscopic or surgical necrosectomy. RESULTS Initial treatment success occurred in 8 of 11 patients after ETD (72.7%) and in 3 of 13 patients after PCD (30.8%) (risk ratio [RR] with ETD, 2.36; 95% CI 0.97-5.77; P = 0.04). After 1 year of follow-up, 72.7% of patients survived with ETD, and 69.2% survived with PCD (RR 1.05; 95% CI 0.63-1.75; P = 0.85). Intestinal fistula seems to have occurred less in the patients who received initial ETD rather than PCD therapy (9.1 vs. 38.5%; RR 0.24; 95% CI 0.03-1.73; P = 0.098). Fewer patients who underwent an initial ETD were transferred to surgery (9.1 vs. 46.2%; RR 0.20; 95% CI 0.03-1.40; P = 0.047). A higher rate of new-onset diabetes (3 cases) or impaired glucose tolerance (1 case) occurred in initial PCD compared to ETD (40 vs. 0%, P = 0.042). CONCLUSION The outcomes of initial endoscopic transluminal drainage are superior to percutaneous drainage for patients with infected pancreatic necrosis (ChiCTR-ONRC-13003653).
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Affiliation(s)
- Wen-Hua He
- Department of Gastroenterology, The First Affiliated Hospital of Nanchang University, 17 Yong Wai Zheng Street, Nanchang, 330006, Jiangxi, People's Republic of China
| | - Yong Zhu
- Department of Gastroenterology, The First Affiliated Hospital of Nanchang University, 17 Yong Wai Zheng Street, Nanchang, 330006, Jiangxi, People's Republic of China
| | - Yin Zhu
- Department of Gastroenterology, The First Affiliated Hospital of Nanchang University, 17 Yong Wai Zheng Street, Nanchang, 330006, Jiangxi, People's Republic of China
| | - Pi Liu
- Department of Gastroenterology, The First Affiliated Hospital of Nanchang University, 17 Yong Wai Zheng Street, Nanchang, 330006, Jiangxi, People's Republic of China
| | - Hao Zeng
- Department of Gastroenterology, The First Affiliated Hospital of Nanchang University, 17 Yong Wai Zheng Street, Nanchang, 330006, Jiangxi, People's Republic of China
| | - Liang Xia
- Department of Gastroenterology, The First Affiliated Hospital of Nanchang University, 17 Yong Wai Zheng Street, Nanchang, 330006, Jiangxi, People's Republic of China
| | - Chen Yu
- Department of Radiology, The First Affiliated Hospital of Nanchang University, Nanchang, People's Republic of China
| | - Hai-Ming Chen
- Department of Surgery, The First Affiliated Hospital of Nanchang University, Nanchang, People's Republic of China
| | - Xu Shu
- Department of Gastroenterology, The First Affiliated Hospital of Nanchang University, 17 Yong Wai Zheng Street, Nanchang, 330006, Jiangxi, People's Republic of China
| | - Zhi-Jian Liu
- Department of Gastroenterology, The First Affiliated Hospital of Nanchang University, 17 Yong Wai Zheng Street, Nanchang, 330006, Jiangxi, People's Republic of China
| | - You-Xiang Chen
- Department of Gastroenterology, The First Affiliated Hospital of Nanchang University, 17 Yong Wai Zheng Street, Nanchang, 330006, Jiangxi, People's Republic of China
| | - Nong-Hua Lu
- Department of Gastroenterology, The First Affiliated Hospital of Nanchang University, 17 Yong Wai Zheng Street, Nanchang, 330006, Jiangxi, People's Republic of China.
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Umapathy C, Raina A, Saligram S, Tang G, Papachristou GI, Rabinovitz M, Chennat J, Zeh H, Zureikat AH, Hogg ME, Lee KK, Saul MI, Whitcomb DC, Slivka A, Yadav D. Natural History After Acute Necrotizing Pancreatitis: a Large US Tertiary Care Experience. J Gastrointest Surg 2016; 20:1844-1853. [PMID: 27619808 DOI: 10.1007/s11605-016-3264-2] [Citation(s) in RCA: 36] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/16/2016] [Accepted: 08/24/2016] [Indexed: 02/06/2023]
Abstract
BACKGROUND Most studies of acute necrotizing pancreatitis (ANP) focus on short-term outcomes. We evaluated long-term survival and outcomes following ANP. METHODS Patients treated for ANP at the University of Pittsburgh Medical Center from 2001 to 2008 were studied. Data on presentation and course during initial hospitalization and follow-up (median 34 months) was extracted. RESULTS Mean age of patients (n = 167) was 53 ± 16 years; 70 % were male, 94 % white, 71 % transfers, 52 % biliary etiology, and 78 % had first-attack of acute pancreatitis. Majority had severe disease with high Acute Physiology and Chronic Health Evaluation II (APACHE-II) score (median 11), length of stay (median 26 days), intensive care unit (ICU) admission (87 %), presence of systemic inflammatory response syndrome (SIRS) (90 %), persistent organ failure (60 %), and infected necrosis (50 %). Intervention was needed in 74 %. Eighteen (10.8 %) patients died during index hospitalization, 9 (5.4 %) during the first year, and 13 (7.8 %) after 1 year. Median survival was significantly shorter when compared with age- and sex-matched US general population (9.1 vs. 26.1 years, p < 0.001). Increasing age (HR 1.05), persistent organ failure (HR 4.5), and >50 % necrosis (HR 3.8) were independent predictors of death at 1 year. In eligible patients, new-onset diabetes, oral pancreatic enzyme replacement therapy, and disability were noted in 45, 25, and 53 %, respectively. CONCLUSION ANP significantly impacts long-term survival. A high proportion of patients develop functional derangement and disability following ANP.
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Affiliation(s)
| | - Amit Raina
- Division of Gastroenterology, Hepatology, and Nutrition, East Carolina University, Greenville, NC, USA
| | - Shreyas Saligram
- Division of Gastroenterology, Hepatology, and Motility, University of Kansas Medical Center, Kansas City, KS, USA
| | - Gong Tang
- Department of Biostatistics, University of Pittsburgh, Pittsburgh, PA, USA
| | - Georgios I Papachristou
- Division of Gastroenterology, Hepatology, and Nutrition, University of Pittsburgh School of Medicine, 200 Lothrop Street, M-2, C-Wing, Pittsburgh, PA, 15213, USA
| | - Mordechai Rabinovitz
- Division of Gastroenterology, Hepatology, and Nutrition, University of Pittsburgh School of Medicine, 200 Lothrop Street, M-2, C-Wing, Pittsburgh, PA, 15213, USA
| | - Jennifer Chennat
- Division of Gastroenterology, Hepatology, and Nutrition, University of Pittsburgh School of Medicine, 200 Lothrop Street, M-2, C-Wing, Pittsburgh, PA, 15213, USA
| | - Herbert Zeh
- Division of Surgical Oncology, University of Pittsburgh, Pittsburgh, PA, USA
| | - Amer H Zureikat
- Division of Surgical Oncology, University of Pittsburgh, Pittsburgh, PA, USA
| | - Melissa E Hogg
- Division of Surgical Oncology, University of Pittsburgh, Pittsburgh, PA, USA
| | - Kenneth K Lee
- Division of Surgical Oncology, University of Pittsburgh, Pittsburgh, PA, USA
| | - Melissa I Saul
- Department of Biomedical Informatics, University of Pittsburgh, Pittsburgh, PA, USA
| | - David C Whitcomb
- Division of Gastroenterology, Hepatology, and Nutrition, University of Pittsburgh School of Medicine, 200 Lothrop Street, M-2, C-Wing, Pittsburgh, PA, 15213, USA
| | - Adam Slivka
- Division of Gastroenterology, Hepatology, and Nutrition, University of Pittsburgh School of Medicine, 200 Lothrop Street, M-2, C-Wing, Pittsburgh, PA, 15213, USA
| | - Dhiraj Yadav
- Division of Gastroenterology, Hepatology, and Nutrition, University of Pittsburgh School of Medicine, 200 Lothrop Street, M-2, C-Wing, Pittsburgh, PA, 15213, USA.
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Operative Trends for Pancreatic Diseases in the USA: Analysis of the Nationwide Inpatient Sample from 1998-2011. J Gastrointest Surg 2016; 20:803-11. [PMID: 26791389 DOI: 10.1007/s11605-015-3067-x] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/23/2015] [Accepted: 12/28/2015] [Indexed: 01/31/2023]
Abstract
The epidemiology of pancreatic diseases is changing. Our aim was to determine the change in indications, frequency, and type of operations being performed for primary pancreatic diseases in the USA. Using the Nationwide Inpatient Sample, all patients aged ≥18 years who underwent pancreatic operations for a primary pancreatic indication between 1998-2011 were identified. Age- and sex-adjusted rates per million adult population were calculated using the 2010 US population as reference. Changes in patient characteristics and outcomes were analyzed. Of 151,454 operations, 82% were resections and 64% were performed for tumors (malignant 52%, benign 12%). Operative rates/million population increased from 41.36 in 1998 to 62.3 in 2011. Population rates increased significantly for distal pancreatectomy, but decreased significantly for drainage procedures (p < 0.05). Additionally, operative rates increased significantly for tumors and cysts/pseudocysts, but decreased significantly for acute pancreatitis (p < 0.05). During this period, mean age, and comorbidity burden for patients undergoing pancreatic operations increased significantly, while their length of hospital stay and in-hospital mortality decreased significantly (p trend <0.05). The number of pancreatic operations performed in the USA is increasing. Although being offered to older patients with more comorbidities, surgeries are being performed with increasing safety and better outcomes.
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Casillas J, Sleeman D, Ahualli J, Ruiz-Cordero R, Echenique A. Acute Pancreatitis (AP). MULTIDISCIPLINARY TEACHING ATLAS OF THE PANCREAS 2016. [PMCID: PMC7120089 DOI: 10.1007/978-3-662-46745-9_14] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
All of these conditions can be associated with acute pancreatitis,except?
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Affiliation(s)
- Javier Casillas
- Department of Radiology, Jackson Memorial Hospital, University of Miami Miller School of Medicine, 1611 NW 12 Avenue, WW-279, Miami, FL 33136 USA
| | - Danny Sleeman
- Department of Surgery, Jackson Memorial Hospital, University of Miami Miller School of Medicine, Clinical Research Building, 410L 1120 N.W. 14 th Street, Miami, FL 33136 USA
| | - Jorge Ahualli
- Department of Radiology, University of Tucuman School of Medicine, Tucuman, Argentina
| | - Roberto Ruiz-Cordero
- Department of Pathology, Jackson Memorial Hospital, 1611 NW 12 Avenue, Miami, FL 33136 USA
| | - Ana Echenique
- Department of Radiology, Jackson Memorial Hospital, University of Miami Miller School of Medicine, 1611 NW 12 Avenue, WW-279, Miami, FL 33136 USA
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Munigala S, Yadav D. Case-fatality from acute pancreatitis is decreasing but its population mortality shows little change. Pancreatology 2016; 16:542-50. [PMID: 27161172 PMCID: PMC4961591 DOI: 10.1016/j.pan.2016.04.008] [Citation(s) in RCA: 27] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/06/2015] [Revised: 04/13/2016] [Accepted: 04/16/2016] [Indexed: 12/11/2022]
Abstract
BACKGROUND/OBJECTIVES The reasons for changing epidemiology of acute pancreatitis (AP) are poorly defined. We hypothesized that trends for severity, case-fatality and population mortality from AP will provide an insight into the rising burden of AP in the population. We evaluated trends in the hospitalizations, case-fatality, severity and population mortality related to AP in the US population. STUDY We used the National Hospital Discharge Survey to calculate age, sex and race standardized hospitalizations of and case-fatality rates for AP, and Vital Statistics to calculate AP-related population mortality from 1983 to 2010, using 2010 US census as the reference. RESULTS Number of discharges per 100,000 population with primary diagnosis of AP increased 2 times from 42.4 (95% CI 38.2-46.5) during 1983-1986 to 85.4 (95% CI 62.8-108.1) during 2007-2010. During corresponding intervals, case-fatality from AP decreased 62% from 2.02% (95% CI 2.01-2.04) to 0.79% (95% CI 0.78-0.80), but population mortality per million population due to AP as primary cause remained stable from 9.28 (95% CI 8.94-9.62) to 9.91 (95% CI 9.56-10.26), and from AP as any cause decreased significantly (but only 12%) from 20.87 (95% CI 20.36-21.38) to 18.48 (95% CI 18.00-18.96). Prevalence of severe AP increased from 5% (95% CI 4.95-5.05%) during 1991-1994 to 9.78% (95% CI 9.73-9.83%) during 2007-2010. CONCLUSION An increasing prevalence of severe disease suggests true population increase to be an important contributor to the rising incidence of AP. A lack of proportional increase in population mortality suggests the impact of medical advances in the evaluation and management of AP.
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Affiliation(s)
- Satish Munigala
- Saint Louis University Center for Outcomes Research (SLUCOR) and Department of Internal Medicine, Division of Gastroenterology and Hepatology, St. Louis University, St. Louis, MO, USA
| | - Dhiraj Yadav
- Department of Internal Medicine, Division of Gastroenterology, Hepatology & Nutrition, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA.
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Rosenberg A, Steensma EA, Napolitano LM. Necrotizing pancreatitis: new definitions and a new era in surgical management. Surg Infect (Larchmt) 2015; 16:1-13. [PMID: 25761075 DOI: 10.1089/sur.2014.123] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022] Open
Abstract
BACKGROUND Necrotizing pancreatitis is a challenging condition that requires surgical treatment commonly and is associated with substantial morbidity and mortality. Over the past decade, new definitions have been developed for standardization of severity of acute and necrotizing pancreatitis, and new management techniques have emerged based on prospective, randomized clinical trials. METHODS Review of English-language literature. RESULTS A new international classification of acute pancreatitis has been developed by PANCREA (Pancreatitis Across Nations Clinical Research and Education Alliance) to replace the Atlanta Classification. It is based on the actual local (whether pancreatic necrosis is present or not, whether it is sterile or infected) and systemic determinants (whether organ failure is present or not, whether it is transient or persistent) of severity. Early management requires goal-directed fluid resuscitation (with avoidance of over-resuscitation and abdominal compartment syndrome), assessment of severity of pancreatitis, diagnostic computed tomography (CT) imaging to assess for necrotizing pancreatitis, consideration of endoscopic retrograde cholangiopancreatography (ERCP) for biliary pancreatitis and early enteral nutrition support. Antibiotic prophylaxis is not recommended. Therapeutic antibiotics are required for treatment of documented infected pancreatic necrosis. The initial treatment of infected pancreatic necrosis is percutaneous catheter or endoscopic (transgastric/transduodenal) drainage with a second drain placement as required. Lack of clinical improvement after these initial procedures warrants consideration of minimally invasive techniques for pancreatic necrosectomy including video-assisted retroperitoneal debridement (VARD), minimally invasive retroperitoneal pancreatectomy (MIRP), or transluminal direct endoscopic necrosectomy (DEN). Open necrosectomy is associated with substantial morbidity, but to date no randomized trial has documented superiority of either minimally invasive or open surgical technique. Additional trials are underway to address this. CONCLUSIONS Severe acute and necrotizing pancreatitis requires a multi-disciplinary treatment strategy that must be individualized for each patient. Optimal treatment of necrotizing pancreatitis now requires a staged, multi-disciplinary, minimally invasive "step-up" approach that includes a team of interventional radiologists, therapeutic endoscopists, and surgeons.
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Affiliation(s)
- Andrew Rosenberg
- Division of Acute Care Surgery [Trauma, Burn, Surgical Critical Care, Emergency Surgery], Department of Surgery, University of Michigan Medical Center , Ann Arbor, Michigan
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Successful Resolution of Gastric Outlet Obstruction Caused by Pancreatic Pseudocyst or Walled-Off Necrosis After Acute Pancreatitis: The Role of Percutaneous Catheter Drainage. Pancreas 2015; 44:1290-5. [PMID: 26465954 PMCID: PMC4947542 DOI: 10.1097/mpa.0000000000000429] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
OBJECTIVE Delayed gastric emptying (DGE) in patients with acute pancreatitis (AP) can be caused by gastroparesis or gastric outlet obstruction, which may occur when pancreatic pseudocyst (PP) or walled-off necrosis (WON) compresses the stomach. The aim of the study was to explore a proper surgical treatment. METHODS From June 2010 to June 2013, 25 of 148 patients with AP suffered DGE. Among them, 12 were caused by gastroparesis, 1 was a result of obstruction from a Candida albicans plug, and 12 were gastric outlet obstruction (GOO) compressed by PP (n = 8) or WON (n = 4), which were treated by percutaneous catheter drainage (PCD). RESULTS All 12 cases of compressing GOO achieved resolution by PCD after 6 [1.86] and 37.25 [12.02] days for PP and WON, respectively. Five cases developed intracystic infection, 3 cases had pancreatic fistulae whereas 2 achieved resolution and 1 underwent a pseudocyst jejunostomy. CONCLUSIONS Gastric outlet obstruction caused by a PP or WON is a major cause of DGE in patients with AP. Percutaneous catheter drainage with multiple sites, large-bore tubing, and lavage may be a good therapy due to high safety and minimal invasiveness.
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Khreiss M, Zenati M, Clifford A, Lee KK, Hogg ME, Slivka A, Chennat J, Gelrud A, Zeh HJ, Papachristou GI, Zureikat AH. Cyst Gastrostomy and Necrosectomy for the Management of Sterile Walled-Off Pancreatic Necrosis: a Comparison of Minimally Invasive Surgical and Endoscopic Outcomes at a High-Volume Pancreatic Center. J Gastrointest Surg 2015; 19:1441-8. [PMID: 26033038 DOI: 10.1007/s11605-015-2864-6] [Citation(s) in RCA: 27] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/13/2015] [Accepted: 05/25/2015] [Indexed: 01/31/2023]
Abstract
INTRODUCTION Walled-off pancreatic necrosis (WON) is a sequela of acute necrotizing pancreatitis in 15-40% of cases. We sought to compare the outcomes of minimally invasive surgical and endoscopic cyst gastrostomy (CG) and necrosectomy for the management for sterile WON at a tertiary care high-volume pancreas center. METHOD This is a retrospective review of patients who underwent minimally invasive surgical or endoscopic CG and necrosectomy for clinically sterile WON between 2008 and 2013. Peri-procedural outcomes including costs were analyzed and compared. RESULTS Twenty patients underwent minimally invasive surgical (robotic = 14, laparoscopic = 6) CG and necrosectomy, and 20 patients underwent endoscopic treatment. The surgical cohort had a larger median cyst size and higher CCI score. For the surgical cohort, median OR time was 167.5 min, estimated blood loss was 30 ml, and 65% underwent concomitant cholecystectomy. There was no mortality in either group and no difference in complication rates (20%). The failure rate was similar (15 versus 10%, P = 0.66). Although surgery was associated with a lower re-intervention rate (0 versus 1, P = 0.008), the endotherapy group was associated with shorter total LOS (inclusive of re-interventions) (7 versus 3 days, P = 0.032). The cost of the index procedure was significantly higher for the surgery group (P = 0.014); however, when considering all readmissions and re-interventions until resolution of the WON, the total cost was similar for both groups. CONCLUSION Minimally invasive surgical and endoscopic CG and necrosectomy are comparable treatments for sterile WON in terms of outcomes and overall cost. The surgical approach may be considered advantageous when a concomitant cholecystectomy is required.
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Affiliation(s)
- Mohammad Khreiss
- Department of Surgery, School of Medicine, University of Pittsburgh, Pittsburgh, PA, USA
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Minimally invasive treatment of infected pancreatic necrosis. GASTROENTEROLOGY REVIEW 2014; 9:317-24. [PMID: 25653725 PMCID: PMC4300346 DOI: 10.5114/pg.2014.47893] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 07/21/2012] [Revised: 08/25/2012] [Accepted: 11/15/2012] [Indexed: 12/13/2022]
Abstract
Infected pancreatic necrosis is a challenging complication that worsens prognosis in acute pancreatitis. For years, open necrosectomy has been the mainstay treatment option in infected pancreatic necrosis, although surgical debridement still results in high morbidity and mortality rates. Recently, many reports on minimally invasive treatment in infected pancreatic necrosis have been published. This paper presents a review of minimally invasive techniques and attempts to define their role in the management of infected pancreatic necrosis.
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Worhunsky DJ, Qadan M, Dua MM, Park WG, Poultsides GA, Norton JA, Visser BC. Laparoscopic transgastric necrosectomy for the management of pancreatic necrosis. J Am Coll Surg 2014; 219:735-43. [PMID: 25158913 DOI: 10.1016/j.jamcollsurg.2014.04.012] [Citation(s) in RCA: 42] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/13/2014] [Revised: 04/05/2014] [Accepted: 04/07/2014] [Indexed: 12/16/2022]
Abstract
BACKGROUND Traditional open necrosectomy for pancreatic necrosis is associated with significant morbidity and mortality. Although minimally invasive techniques have been described and offer some promise, each has considerable limitations. This study assesses the safety and effectiveness of laparoscopic transgastric necrosectomy (LTN), a novel technique for the management of necrotizing pancreatitis. STUDY DESIGN Between 2009 and 2013, patients with retrogastric pancreatic necrosis requiring debridement were evaluated for LTN. Debridement was performed via a laparoscopic transgastric approach using 2 to 3 ports and the wide cystgastrostomy left open. Patient demographics, disease severity, operative characteristics, and outcomes were collected and analyzed. RESULTS Twenty-one patients (13 men, median age 54 years; interquartile range [IQR] 46 to 62 years) underwent LTN during the study period. The duration between pancreatitis onset and debridement was 65 days (IQR 53 to 124 years). Indications for operation included infection (7 patients) and persistent unwellness (14 patients). Median duration of LTN was 170 minutes (IQR 136 to 199 minutes); there were no conversions. Control of the necrosis was achieved via the single procedure in 19 of 21 patients. Median postoperative hospital stay was 5 days (IQR 3 to 14 days) and the majority (71%) of patients experienced no (n = 9) or only minor postoperative complications (n = 6) by Clavien-Dindo grade. Complications of Clavien-Dindo grade 3 or higher developed in 6 patients, including 1 death (5%). With a median follow-up of 11 months (IQR 7 to 22 months), none of the patients required additional operative debridement or had pancreatic/enteric fistulae or wound complications develop. CONCLUSIONS Laparoscopic transgastric necrosectomy is a novel, minimally invasive technique for the management of pancreatic necrosis that allows for debridement in a single operation. When feasible, LTN can reduce the morbidity associated with traditional open necrosectomy and avoid the limitations of other minimally invasive approaches.
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Affiliation(s)
- David J Worhunsky
- Department of Surgery, Stanford University Medical Center, Stanford, CA
| | - Motaz Qadan
- Department of Surgery, Stanford University Medical Center, Stanford, CA
| | - Monica M Dua
- Department of Surgery, Stanford University Medical Center, Stanford, CA
| | - Walter G Park
- Department of Gastroenterology and Hepatology, Stanford University Medical Center, Stanford, CA
| | | | - Jeffrey A Norton
- Department of Surgery, Stanford University Medical Center, Stanford, CA
| | - Brendan C Visser
- Department of Surgery, Stanford University Medical Center, Stanford, CA.
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Mouli VP, Sreenivas V, Garg PK. Efficacy of conservative treatment, without necrosectomy, for infected pancreatic necrosis: a systematic review and meta-analysis. Gastroenterology 2013; 144:333-340.e2. [PMID: 23063972 DOI: 10.1053/j.gastro.2012.10.004] [Citation(s) in RCA: 115] [Impact Index Per Article: 10.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/13/2012] [Revised: 10/04/2012] [Accepted: 10/08/2012] [Indexed: 02/07/2023]
Abstract
BACKGROUND & AIMS Conservative treatment (intensive care, a combination of antimicrobial agents, and nutritional support, with or without drainage of the infected fluid) has recently been shown to be effective for patients with infected pancreatic necrosis (IPN), but the data from individual studies are not robust enough to recommend it as the standard of care. We performed a systematic review and meta-analysis of studies related to primary conservative management for IPN. METHODS We performed a literature search of MEDLINE/PubMed from January 1990 to March 2012 for studies of a priori protocols for primary conservative treatment, without necrosectomy, for consecutive patients with IPN. We analyzed data from 8 studies, comprising 324 patients with IPN who received primary conservative management. We then analyzed an additional 4 studies (comprising 157 patients) that reported the efficacy of percutaneous drainage in nonconsecutive patients with IPN. Outcome measures were the success of conservative management strategy, need for necrosectomy, and mortality. RESULTS There was significant heterogeneity in results among the studies. Based on a random effects model, conservative management was successful for 64% of patients (95% confidence interval [CI], 51%-78%); mortality was 12% (95% CI, 6%-18%), and 26% of patients required necrosectomy or additional surgery for complications (95% CI, 15%-37%). A separate analysis of 4 studies that reported outcomes of nonconsecutive patients with IPN following percutaneous drainage had comparable results; 50% had successful outcomes (95% CI, 43%-58%), mortality was 18% (95% CI, 6%-30%), and 38% of patients required surgery (95% CI, 20%-56%). CONCLUSIONS Conservative management without necrosectomy is a successful approach for 64% of patients with IPN. This approach has low mortality and prevents surgical necrosectomy.
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Affiliation(s)
- Venigalla Pratap Mouli
- Department of Gastroenterology, All India Institute of Medical Sciences, New Delhi, India
| | | | - Pramod Kumar Garg
- Department of Gastroenterology, All India Institute of Medical Sciences, New Delhi, India.
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Chen J, Fukami N, Li Z. Endoscopic approach to pancreatic pseudocyst, abscess and necrosis: review on recent progress. Dig Endosc 2012; 24:299-308. [PMID: 22925280 DOI: 10.1111/j.1443-1661.2012.01298.x] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
AIM The aim of this study is to introduce recent progress in the treatment of pancreatic pseudocyst, abscess and necrosis using the endoscopic approach. METHODS Studies on PubMed and MEDLINE from the last 30 years on progress in the management of the complications from severe pancreatitis were researched and reviewed. Herein, the indication for intervention, definition of fluid collection associated with acute pancreatitis and treatment modalities of these complications are summarized. RESULTS Three types of management are employed for complications of severe pancreatitis: the endoscopic, surgical and percutaneous approaches. CONCLUSIONS Over the years, as technical expertise has increased and instruments for endoscopy have improved, patients who had endoscopic surgery to address the complications of severe pancreatitis have had higher survival rates, lower mortality rates and lower complication rates than those having open debridement. However, traditional open abdominal surgery should be advocated when minimally invasive management fails or necrosis is extensive and extends diffusely to areas such as the paracolic gutter and the groin (i.e. locations not accessible by endoscopy).
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Affiliation(s)
- Jie Chen
- Department of Gastroenterology, Changhai Hospital, Shanghai, China.
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Mosna LC, Moon J, Hernandez F, Hodgkinson P, Fan J, Selvaggi G, Tekin A, Nishida S, Levi D, Tzakis AG. Use of the subcutaneous route and polytetrafluoroethylene grafts for arterial revascularization in liver transplantation. Liver Transpl 2012; 18:499-500. [PMID: 22271617 DOI: 10.1002/lt.23390] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/12/2023]
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