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Wang Y, Yoshino O, Driedger MR, Beckman MJ, Vrochides D, Martinie JB. Robotic pancreatic necrosectomy and internal drainage for walled-off pancreatic necrosis. HPB (Oxford) 2023:S1365-182X(23)00099-0. [PMID: 37045742 DOI: 10.1016/j.hpb.2023.03.013] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/18/2022] [Revised: 01/29/2023] [Accepted: 03/19/2023] [Indexed: 04/14/2023]
Abstract
BACKGROUND Pancreatic necrosectomy with concomitant internal drainage is a single-stage treatment option for walled-off pancreatic necrosis (WOPN). However, an optimal minimally invasive technique has not been established. We evaluated the safety and single-intervention success rate of robotic pancreatic necrosectomy and internal drainage. METHODS Patients with WOPN undergoing robotic pancreatic necrosectomy and internal drainage at a single institution from 2011-2022 were identified. The primary outcome was the rate of clinical symptom resolution following the index surgical intervention. RESULTS 57 patients underwent robotic pancreatic necrosectomy and internal drainage, consisting of robotic cystgastrostomy (RCG, n = 37), robotic cystjejunostomy (RCJ, n = 13) and robotic fistulojejunostomy (RFJ, n = 7). Surgery was performed a median of 102 (range 28-1153) days following the onset of necrotizing pancreatitis. The median operative time was 187 (91-344) minutes and there were 2 (3.5%) conversions. The median length of hospital stay was 4 (2-38) days. Postoperative morbidity was 11%, and there was one (1.8%) 90-day mortality. At a median follow-up of 5.5 months, 53 (93%) patients had clinical symptom resolution after their index procedure and did not require any reintervention. CONCLUSION In select patients, robotic pancreatic necrosectomy and internal drainage is safe and achieves a high single-intervention success rate.
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Affiliation(s)
- Yifan Wang
- Division of Hepatopancreaticobiliary Surgery, Department of Surgery, Atrium Health Carolinas Medical Center, Charlotte, NC, USA; Department of Surgery, McGill University, Montreal, QC, Canada
| | - Osamu Yoshino
- Division of Hepatopancreaticobiliary Surgery, Department of Surgery, Atrium Health Carolinas Medical Center, Charlotte, NC, USA
| | - Michael R Driedger
- Division of Hepatopancreaticobiliary Surgery, Department of Surgery, Atrium Health Carolinas Medical Center, Charlotte, NC, USA
| | - Michael J Beckman
- Division of Hepatopancreaticobiliary Surgery, Department of Surgery, Atrium Health Carolinas Medical Center, Charlotte, NC, USA
| | - Dionisios Vrochides
- Division of Hepatopancreaticobiliary Surgery, Department of Surgery, Atrium Health Carolinas Medical Center, Charlotte, NC, USA
| | - John B Martinie
- Division of Hepatopancreaticobiliary Surgery, Department of Surgery, Atrium Health Carolinas Medical Center, Charlotte, NC, USA.
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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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Latif J, Creedon L, Mistry P, Thurley P, Bhatti I, Awan A. Complicated Severe Acute Pancreatitis: Open and Laparoscopic Infracolic Approach. J Gastrointest Surg 2022; 26:1686-1696. [PMID: 35581460 DOI: 10.1007/s11605-022-05350-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/18/2022] [Accepted: 04/30/2022] [Indexed: 01/31/2023]
Abstract
INTRODUCTION The heterogeneous nature of severe acute pancreatitis (SAP) renders decisions related to complications challenging. Central solid collections at the root of the mesentery are difficult to access with traditional techniques. Here we describe a case series of laparoscopic infracolic necrosectomy (ICN) and open or laparoscopic infracolic necrosectomy with Roux-en Y cystjejunostomy (ICN-RYCJ) for the management of complicated SAP. MATERIALS AND METHODS A retrospective analysis of a prospectively maintained database identified all patients treated with infracolic necrosectomy or drainage of pancreatic collections for complicated SAP between 2012 and 2021 inclusive at a single institution. RESULTS Forty patients were identified (median age 53 years)-ICN group 9 patients (median time to intervention-22 days) and ICN-RYCJ group 31 patients (median time to intervention-99 days). Two patients in ICN group underwent interval fistula-tract jejunostomy. Thirty-one patients had laparoscopic surgery and 9 patients underwent an open approach. Four patients required intervention post-operatively. Nineteen patients were discharged from follow-up at two years. CONCLUSION Infracolic approach with selective Roux-en Y cystjejunostomy, as a single or staged intervention, is an effective and safe operative option to add to the armamentarium of the pancreatic surgeon when dealing with complicated SAP not amenable to drainage/debridement by traditional techniques.
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Affiliation(s)
- Javed Latif
- Department of Pancreaticobiliary, Advanced Laparoscopic and Robotic Surgery, University Hospitals of Derby & Burton, Uttoxeter Road, Derby, DE22 3NE, UK.
| | - Lee Creedon
- Department of Pancreaticobiliary, Advanced Laparoscopic and Robotic Surgery, University Hospitals of Derby & Burton, Uttoxeter Road, Derby, DE22 3NE, UK
| | - Pritesh Mistry
- Department of Upper Gastro-Intestinal Surgery, Countess of Chester Hospital, Liverpool Road, Liverpool Road, Chester, CH2 1UL, UK
| | - Peter Thurley
- Department of Interventional & Clinical Radiology, University Hospitals of Derby & Burton, Uttoxeter Road, Derby, DE22 3NE, UK
| | - Imran Bhatti
- Department of Pancreaticobiliary, Advanced Laparoscopic and Robotic Surgery, University Hospitals of Derby & Burton, Uttoxeter Road, Derby, DE22 3NE, UK
| | - Altaf Awan
- Department of Pancreaticobiliary, Advanced Laparoscopic and Robotic Surgery, University Hospitals of Derby & Burton, Uttoxeter Road, Derby, DE22 3NE, UK
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Brito-Carmona R, Cuendis-Velázquez A, Chávez-Hernández A, Galván-Cruz A, Cárdenas-Lailson L. Indocyanine green-guided laparoendoscopic treatment of walled-off pancreatic necrosis. REVISTA DE GASTROENTEROLOGÍA DE MÉXICO 2022; 87:388-390. [DOI: 10.1016/j.rgmxen.2022.05.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/23/2021] [Accepted: 10/14/2021] [Indexed: 11/29/2022]
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5
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Prasath V, Quinn PL, Oliver JB, Arjani S, Ahlawat SK, Chokshi RJ. Cost-effectiveness analysis of infected necrotizing pancreatitis management in an academic setting. Pancreatology 2022; 22:185-193. [PMID: 34879998 DOI: 10.1016/j.pan.2021.11.011] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/14/2021] [Revised: 11/22/2021] [Accepted: 11/30/2021] [Indexed: 12/11/2022]
Abstract
BACKGROUND AND AIMS Traditional management for infected necrotizing pancreatitis (INP) often utilizes open necrosectomy, which carries high morbidity and complication rates. Thus, minimally invasive strategies have gained favor, specifically step-up approaches utilizing endoscopic or minimally-invasive surgery (MIS); however, the ideal management modality for INP has not been identified. METHODS A decision tree model was designed to analyze costs and survival associated with open necrosectomy, endoscopic step-up, and MIS step-up protocols for management of INP after 4 weeks of necrosis development with adequate retroperitoneal access. Costs were based on a third-party payer perspective using Medicare reimbursement rates. The model's effectiveness was represented by quality-adjusted life-years (QALYs). Sensitivity analyses were performed to validate results. RESULTS Endoscopic step-up was the dominant economic strategy with 7.92 QALYs for $90,864.09. Surgical step-up resulted in a decrease of 0.09 QALYs and a cost increase of $10,067.89 while open necrosectomy resulted in a decrease of 0.4 QALYs and an increased cost of $18,407.52 over endoscopic step-up. In 100,000 random-sampling simulations, 65.5% of simulations favored endoscopic step-up. MIS step-up was favored when MIS acute mortality rates fell and when MIS drainage success rates rose. CONCLUSIONS In our simulated patients with INP, the most cost-effective management strategy is endoscopic step-up. Cost-effectiveness varies with changes in acute mortality and drainage success, which will depend on local expertise.
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Affiliation(s)
- Vishnu Prasath
- Division of Surgical Oncology, Department of Surgery, Rutgers New Jersey Medical School, Newark, NJ, USA.
| | - Patrick L Quinn
- Division of Surgical Oncology, Department of Surgery, Rutgers New Jersey Medical School, Newark, NJ, USA.
| | - Joseph B Oliver
- Division of Minimally Invasive Surgery, Department of Surgery, Rutgers New Jersey Medical School, Newark, NJ, USA.
| | - Simran Arjani
- Division of Surgical Oncology, Department of Surgery, Rutgers New Jersey Medical School, Newark, NJ, USA.
| | - Sushil K Ahlawat
- Division of Gastroenterology and Hepatology, Department of Medicine, Rutgers New Jersey Medical School, Newark, NJ, USA.
| | - Ravi J Chokshi
- Division of Surgical Oncology, Department of Surgery, Rutgers New Jersey Medical School, Newark, NJ, USA.
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6
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Han SB, Chen JH, Hu P, Chen D, Chen QY, Zheng H, Xu P, Wang CY, Zhao G. One-step laparoscopic pancreatic necrosectomy verse surgical step-up approach for infected pancreatic necrosis: a case-control study. World J Emerg Med 2022; 13:274-282. [PMID: 35837558 PMCID: PMC9233970 DOI: 10.5847/wjem.j.1920-8642.2022.058] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/26/2021] [Accepted: 01/21/2022] [Indexed: 08/10/2023] Open
Abstract
BACKGROUND The surgical step-up approach often requires multiple debridements and might not be suitable for infected pancreatic necrosis (IPN) patients with various abscesses or no safe route for percutaneous catheter drainage (PCD). This case-control study aimed to investigate the safety and effectiveness of one-step laparoscopic pancreatic necrosectomy (LPN) in treating IPN. METHODS This case-control study included IPN patients undergoing one-step LPN or surgical step-up in our center from January 2015 to December 2020. The short-term and long-term complications after surgery, length of hospital stay, and postoperative ICU stays in both groups were analyzed. Univariate and multivariate logistic regression analyses were performed to explore the risk factors of major complications or death. RESULTS A total of 53 IPN patients underwent one-step LPN and 37 IPN patients underwent surgical step-up approach in this study. There was no significant difference in the incidence of death, major complications, new-onset diabetes, or new-onset pancreatic exocrine insufficiency between the two groups. However, the length of hospital stay in the one-step LPN group was significantly shorter than that in the surgical step-up group. Univariate regression analysis showed that the surgical approach (one-step/step-up) was not the risk factor for major complications or death. Multivariate logistic regression analysis indicated that computed tomography (CT) severity index, American Society of Anesthesiologists (ASA) class IV, and white blood cell (WBC) were the significant risk factors for major complications or death. CONCLUSION One-step LPN is as safe and effective as the surgical step-up approach for treating IPN patients, and reduces total hospital stay.
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Affiliation(s)
- Sheng-bo Han
- Department of Emergency Surgery, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan 430022, China
| | - Jin-huang Chen
- Department of Emergency Surgery, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan 430022, China
| | - Ping Hu
- Department of Emergency Surgery, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan 430022, China
| | - Ding Chen
- Department of Emergency Surgery, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan 430022, China
| | - Qing-yong Chen
- Department of Emergency Surgery, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan 430022, China
| | - Hai Zheng
- Department of Emergency Surgery, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan 430022, China
| | - Peng Xu
- Department of Emergency Surgery, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan 430022, China
| | - Chun-you Wang
- Department of Pancreatic Surgery, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan 430022, China
| | - Gang Zhao
- Department of Emergency Surgery, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan 430022, China
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7
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Vellalta G, Lopez R, D'Angelo E, Vidal L, Dopazo C, Puig O. Laparoscopic intragastric approach to transgastric necrosectomy. JOURNAL OF HEPATO-BILIARY-PANCREATIC SCIENCES 2021; 29:e75-e76. [PMID: 34855268 DOI: 10.1002/jhbp.1086] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/18/2021] [Revised: 10/24/2021] [Accepted: 10/28/2021] [Indexed: 12/18/2022]
Affiliation(s)
| | | | | | - Laura Vidal
- BARNALAP and Clínica Corachan, Barcelona, Spain
| | - Cristina Dopazo
- Department of HPB Surgery and Transplants, Hospital Universitari Vall d´Hebron, Universitat Autònoma de Barcelona, Barcelona, Spain
| | - Oriol Puig
- BARNALAP and Clínica Corachan, Barcelona, Spain
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8
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Cao F, Li A, Wang X, Gao C, Li J, Li F. Laparoscopic transgastric necrosectomy in treatment of walled-off pancreatic necrosis with sinistral portal hypertension. BMC Surg 2021; 21:362. [PMID: 34629061 PMCID: PMC8502321 DOI: 10.1186/s12893-021-01361-6] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/06/2021] [Accepted: 09/24/2021] [Indexed: 12/16/2022] Open
Abstract
Background Laparoscopic transgastric necrosectomy (LTGN) has been used in treatment of walled-off pancreatic necrosis (WON) for more than a decade. However, the safety and effectiveness of LTGN for WON with sinistral portal hypertension was still unclear. Methods WON patients with sinistral portal hypertension treated in our department between January 2011 and December 2018 were included and retrospectively analyzed in this study. Patients were divided into two groups according to different surgical approaches, LTNG or laparoscopic assisted trans-lesser sac necrosectomy (LATLSN). Perioperative and long-term outcomes were compared between two groups. Results 312 cases diagnosed with WON were screened and 53 were finally included in this study. Of the included patients, 21 and 32 cases were received LTGN and LATLSN, respectively. LTGN was associated with significantly lower morbidity than LATLSN (19.0% vs 46.9%, p = 0.04) and similar severe complication (Clavien–Dindo ≥ III) rate (12.5% vs 19.0%, p = 0.70). LTGN did not increase the rate of postoperative hemorrhage (9.5% vs 6.3%, p = 1.00) and mortality (9.5% vs 9.4%, p = 1.00). After 39 (11–108) months follow-up, the recurrence rate of WON and long-term complications were also comparable between groups. Conclusion From current data, LTGN was safe and effective in treatment of WON patients with sinistral portal hypertension in terms of short- and long-term outcomes.
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Affiliation(s)
- Feng Cao
- Department of General Surgery, Xuanwu Hospital, Capital Medical University, No. 45, Xicheng, Beijing, 100053, People's Republic of China.,Clinical Center for Acute Pancreatitis, Capital Medical University, No. 45, Xicheng, Beijing, 100053, People's Republic of China
| | - Ang Li
- Department of General Surgery, Xuanwu Hospital, Capital Medical University, No. 45, Xicheng, Beijing, 100053, People's Republic of China.,Clinical Center for Acute Pancreatitis, Capital Medical University, No. 45, Xicheng, Beijing, 100053, People's Republic of China
| | - Xiaohui Wang
- Department of General Surgery, Xuanwu Hospital, Capital Medical University, No. 45, Xicheng, Beijing, 100053, People's Republic of China.,Clinical Center for Acute Pancreatitis, Capital Medical University, No. 45, Xicheng, Beijing, 100053, People's Republic of China
| | - Chongchong Gao
- Department of General Surgery, Xuanwu Hospital, Capital Medical University, No. 45, Xicheng, Beijing, 100053, People's Republic of China.,Clinical Center for Acute Pancreatitis, Capital Medical University, No. 45, Xicheng, Beijing, 100053, People's Republic of China
| | - Jia Li
- Department of General Surgery, Xuanwu Hospital, Capital Medical University, No. 45, Xicheng, Beijing, 100053, People's Republic of China. .,Clinical Center for Acute Pancreatitis, Capital Medical University, No. 45, Xicheng, Beijing, 100053, People's Republic of China.
| | - Fei Li
- Department of General Surgery, Xuanwu Hospital, Capital Medical University, No. 45, Xicheng, Beijing, 100053, People's Republic of China. .,Clinical Center for Acute Pancreatitis, Capital Medical University, No. 45, Xicheng, Beijing, 100053, People's Republic of China.
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9
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Rahnemai-Azar AA, Sutter C, Hayat U, Glessing B, Ammori J, Tavri S. Multidisciplinary Management of Complicated Pancreatitis: What Every Interventional Radiologist Should Know. AJR Am J Roentgenol 2021; 217:921-932. [PMID: 33470838 DOI: 10.2214/ajr.20.25168] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
Management of acute pancreatitis is challenging in the presence of local complications that include pancreatic and peripancreatic collections and vascular complications. This review, targeted for interventional radiologists, describes minimally invasive endoscopic, image-guided percutaneous, and surgical procedures for management of complicated pancreatitis and provides insight into the procedures' algorithmic application. Local complications are optimally managed in a multidisciplinary team setting that includes advanced endoscopists; pancreatic surgeons; diagnostic and interventional radiologists; and specialists in infectious disease, nutrition, and critical care medicine. Large symptomatic or complicated sterile collections and secondary infected collections warrant drainage or débridement. The drainage is usually delayed for 4-6 weeks unless clinical deterioration warrants early intervention. If collections are accessible by endoscopy, endoscopic procedures are preferred to avoid pancreaticocutaneous fistulas. Image-guided percutaneous drainage is indicated for symptomatic collections that are not accessible for endoscopic drainage or that present in the acute setting before developing a mature wall. Peripancreatic arterial pseudoaneurysms should be embolized before necrosectomy procedures to prevent potentially life-threatening hemorrhage. Surgical procedures are reserved for symptomatic collections that persist despite endoscopic or interventional drainage attempts. Understanding these procedures facilitates their integration by interventional radiologists into the complex longitudinal care of patients with complicated pancreatitis.
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Affiliation(s)
- Amir Ata Rahnemai-Azar
- Department of Radiology, University Hospitals Cleveland Medical Center, Case Western Reserve University School of Medicine, 11100 Euclid Ave, Cleveland, OH 44106
| | - Christopher Sutter
- Department of Radiology, University Hospitals Cleveland Medical Center, Case Western Reserve University School of Medicine, 11100 Euclid Ave, Cleveland, OH 44106
| | - Umar Hayat
- Department of Medicine, Division of Gastroenterology, University Hospitals Cleveland Medical Center, Case Western Reserve University School of Medicine, Cleveland, OH
| | - Brooke Glessing
- Department of Medicine, Division of Gastroenterology, University Hospitals Cleveland Medical Center, Case Western Reserve University School of Medicine, Cleveland, OH
| | - John Ammori
- Department of Surgery, Division of Surgical Oncology, University Hospitals Cleveland Medical Center, Case Western Reserve University School of Medicine, Cleveland, OH
| | - Sidhartha Tavri
- Department of Radiology, University Hospitals Cleveland Medical Center, Case Western Reserve University School of Medicine, 11100 Euclid Ave, Cleveland, OH 44106
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10
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Affiliation(s)
- Amy Y Li
- Department of Surgery, Section of Surgical Oncology, Stanford University School of Medicine, 300 Pasteur Drive, Room H3591, Stanford, CA 94305, USA
| | - John R Bergquist
- Department of Surgery, Section of Surgical Oncology, Stanford University School of Medicine, 300 Pasteur Drive, Room H3591, Stanford, CA 94305, USA
| | - Brendan C Visser
- Department of Surgery, Section of Surgical Oncology, Stanford University School of Medicine, 300 Pasteur Drive, H3680, Stanford, CA 94305-5655, USA.
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11
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Reinke CE, Lim RB. Minimally Invasive Acute Care Surgery. Curr Probl Surg 2021. [DOI: 10.1016/j.cpsurg.2021.101033] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/07/2022]
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12
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Reinke CE, Lim RB. Minimally invasive acute care surgery. Curr Probl Surg 2021; 59:101031. [DOI: 10.1016/j.cpsurg.2021.101031] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/07/2021] [Accepted: 05/16/2021] [Indexed: 12/07/2022]
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13
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Laparoscopic hepatic lobectomy for symptomatic polycystic liver disease. HPB (Oxford) 2021; 23:56-62. [PMID: 32451237 DOI: 10.1016/j.hpb.2020.04.010] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/27/2020] [Revised: 04/15/2020] [Accepted: 04/20/2020] [Indexed: 12/12/2022]
Abstract
BACKGROUND Laparoscopic fenestration has largely replaced open fenestration of liver cysts. However, most hepatectomies for polycystic liver disease (PCLD) are performed open. Outcomes data on laparoscopic hepatectomy for PCLD are lacking. METHODS Patients who underwent surgery for PCLD at a single institution between 2010 and 2019 were reviewed and grouped by operative approach. Pre- and post-operative volumes were calculated for patients who underwent resection. Primary outcomes were: volume reduction, re-admission and postoperative complications. RESULTS Twenty-six patients were treated for PCLD: 13 laparoscopic fenestration, nine laparoscopic hepatectomy, three open hepatectomy and one liver transplantation. Median length of stay for patients after laparoscopic resection was 3 days (IQR 2-3). The only complication was post-operative atrial fibrillation in one patient. There were no readmissions. Overall volume reduction was 51% (range 22-69) for all resections, 32% (range 22-46) after open resection and 56% (range 39-69) after laparoscopic resection. CONCLUSION Volume reduction achieved through laparoscopic approach exceeded open volume reduction at this institution and is comparable to volume reduction in previously published open resection series. Adequate volume reduction can be accomplished by laparoscopic means with acceptable postoperative morbidity.
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14
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Gao CC, Li J, Cao F, Wang XH, Li A, Wang Z, Li F. Infection recurrence following minimally invasive treatment in patients with infectious pancreatic necrosis. World J Gastroenterol 2020; 26:3087-3097. [PMID: 32587450 PMCID: PMC7304114 DOI: 10.3748/wjg.v26.i22.3087] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/02/2020] [Revised: 03/27/2020] [Accepted: 05/12/2020] [Indexed: 02/06/2023] Open
Abstract
BACKGROUND In recent decades, an increasing number of patients have received minimally invasive intervention for infected pancreatic necrosis (IPN) because of the benefits in reducing postoperative multiple organ failure and mortality. However, there are limited published data regarding infection recurrence after treatment of this patient population.
AIM To investigate the incidence and prediction of infection recurrence following successful minimally invasive treatment in IPN patients.
METHODS Medical records for 193 IPN patients, who underwent minimally invasive treatment between February 2014 and October 2018, were retrospectively reviewed. Patients, who survived after the treatment, were divided into two groups: one group with infection after drainage catheter removal and another group without infection. The morphological and clinical data were compared between the two groups. Significantly different variables were introduced into the correlation and multivariate logistic analysis to identify independent predictors for infection recurrence. Sensitivity and specificity for diagnostic performance were determined.
RESULTS Of the 193 IPN patients, 178 were recruited into the study. Of them, 9 (5.06%) patients died and 169 patients survived but infection recurred in 13 of 178 patients (7.30%) at 7 (4-10) d after drainage catheters were removed. White blood cell (WBC) count, serum C-reactive protein (CRP), interleukin-6, and procalcitonin levels measured at the time of catheter removal were significantly higher in patients with infection than in those without (all P < 0.05). In addition, drainage duration and length of the catheter measured by computerized tomography scan were significantly longer in patients with infection (P = 0.025 and P < 0.0001, respectively). Although these parameters all correlated positively with the incidence of infection (all P < 0.05), only WBC, CRP, procalcitonin levels, and catheter length were identified as independent predictors for infection recurrence. The sensitivity and specificity for infection prediction were high in WBC count (≥ 9.95 × 109/L) and serum procalcitonin level (≥ 0.05 ng/mL) but moderate in serum CRP level (cut-off point ≥ 7.37 mg/L). The catheter length (cut-off value ≥ 8.05 cm) had a high sensitivity but low specificity to predict the infection recurrence.
CONCLUSION WBC count, serum procalcitonin, and CRP levels may be valuable for predicting infection recurrence following minimally invasive intervention in IPN patients. These biomarkers should be considered before removing the drainage catheters.
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Affiliation(s)
- Chong-Chong Gao
- Department of General Surgery, Xuanwu Hospital, Capital Medical University, Beijing 100053, China
| | - Jia Li
- Department of General Surgery, Xuanwu Hospital, Capital Medical University, Beijing 100053, China
| | - Feng Cao
- Department of General Surgery, Xuanwu Hospital, Capital Medical University, Beijing 100053, China
| | - Xiao-Hui Wang
- Department of General Surgery, Xuanwu Hospital, Capital Medical University, Beijing 100053, China
| | - Ang Li
- Department of General Surgery, Xuanwu Hospital, Capital Medical University, Beijing 100053, China
| | - Zhe Wang
- Department of General Surgery, Xuanwu Hospital, Capital Medical University, Beijing 100053, China
| | - Fei Li
- Department of General Surgery, Xuanwu Hospital, Capital Medical University, Beijing 100053, China
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15
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Haney CM, Kowalewski KF, Schmidt MW, Koschny R, Felinska EA, Kalkum E, Probst P, Diener MK, Müller-Stich BP, Hackert T, Nickel F. Endoscopic versus surgical treatment for infected necrotizing pancreatitis: a systematic review and meta-analysis of randomized controlled trials. Surg Endosc 2020; 34:2429-2444. [PMID: 32112252 PMCID: PMC7214487 DOI: 10.1007/s00464-020-07469-9] [Citation(s) in RCA: 16] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/06/2019] [Accepted: 02/19/2020] [Indexed: 02/07/2023]
Abstract
OBJECTIVE To compare outcomes of endoscopic and surgical treatment for infected necrotizing pancreatitis (INP) based on results of randomized controlled trials (RCT). BACKGROUND Treatment of INP has changed in the last two decades with adoption of interventional, endoscopic and minimally invasive surgical procedures for drainage and necrosectomy. However, this relies mostly on observational studies. METHODS We performed a systematic review following Cochrane and PRISMA guidelines and AMSTAR-2 criteria and searched CENTRAL, Medline and Web of Science. Randomized controlled trails that compared an endoscopic treatment to a surgical treatment for patients with infected walled-off necrosis and included one of the main outcomes were eligible for inclusion. The main outcomes were mortality and new onset multiple organ failure. Prospero registration ID: CRD42019126033 RESULTS: Three RCTs with 190 patients were included. Intention to treat analysis showed no difference in mortality. However, patients in the endoscopic group had statistically significant lower odds of experiencing new onset multiple organ failure (odds ratio (OR) confidence interval [CI] 0.31 [0.10, 0.98]) and were statistically less likely to suffer from perforations of visceral organs or enterocutaneous fistulae (OR [CI] 0.31 [0.10, 0.93]), and pancreatic fistulae (OR [CI] 0.09 [0.03, 0.28]). Patients with endoscopic treatment had a statistically significant lower mean hospital stay (Mean difference [CI] - 7.86 days [- 14.49, - 1.22]). No differences in bleeding requiring intervention, incisional hernia, exocrine or endocrine insufficiency or ICU stay were apparent. Overall certainty of evidence was moderate. CONCLUSION There seem to be possible benefits of endoscopic treatment procedure. Given the heterogenous procedures in the surgical group as well as the low amount of randomized evidence, further studies are needed to evaluate the combination of different approaches and appropriate timepoints for interventions.
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Affiliation(s)
- C M Haney
- Department of General, Visceral and Transplantation Surgery, Heidelberg University Hospital, Im Neuenheimer Feld 110, 69120, Heidelberg, Germany
| | - K F Kowalewski
- Department of General, Visceral and Transplantation Surgery, Heidelberg University Hospital, Im Neuenheimer Feld 110, 69120, Heidelberg, Germany
| | - M W Schmidt
- Department of General, Visceral and Transplantation Surgery, Heidelberg University Hospital, Im Neuenheimer Feld 110, 69120, Heidelberg, Germany
| | - R Koschny
- Department of Gastroenterology, Heidelberg University Hospital, Im Neuenheimer Feld 410, 69120, Heidelberg, Germany
| | - E A Felinska
- Department of General, Visceral and Transplantation Surgery, Heidelberg University Hospital, Im Neuenheimer Feld 110, 69120, Heidelberg, Germany
| | - E Kalkum
- The Study Center of the German Surgical Society (SDGC), University of Heidelberg, Im Neuenheimer Feld 130.3, 69120, Heidelberg, Germany
| | - P Probst
- Department of General, Visceral and Transplantation Surgery, Heidelberg University Hospital, Im Neuenheimer Feld 110, 69120, Heidelberg, Germany
- The Study Center of the German Surgical Society (SDGC), University of Heidelberg, Im Neuenheimer Feld 130.3, 69120, Heidelberg, Germany
| | - M K Diener
- Department of General, Visceral and Transplantation Surgery, Heidelberg University Hospital, Im Neuenheimer Feld 110, 69120, Heidelberg, Germany
- The Study Center of the German Surgical Society (SDGC), University of Heidelberg, Im Neuenheimer Feld 130.3, 69120, Heidelberg, Germany
| | - B P Müller-Stich
- Department of General, Visceral and Transplantation Surgery, Heidelberg University Hospital, Im Neuenheimer Feld 110, 69120, Heidelberg, Germany
| | - T Hackert
- Department of General, Visceral and Transplantation Surgery, Heidelberg University Hospital, Im Neuenheimer Feld 110, 69120, Heidelberg, Germany
| | - F Nickel
- Department of General, Visceral and Transplantation Surgery, Heidelberg University Hospital, Im Neuenheimer Feld 110, 69120, Heidelberg, Germany.
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Liu ZW, Yang SZ, Wang PF, Feng J, He L, Du JD, Xiao YY, Jiao HB, Zhou FH, Song Q, Zhou MT, Xin XL, Chen JY, Ren WZ, Lu SC, Cai SW, Dong JH. Minimal-access retroperitoneal pancreatic necrosectomy for infected necrotizing pancreatitis: a multicentre study of a step-up approach. Br J Surg 2020; 107:1344-1353. [PMID: 32449154 DOI: 10.1002/bjs.11619] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/28/2019] [Revised: 03/23/2019] [Accepted: 03/16/2020] [Indexed: 12/17/2022]
Abstract
BACKGROUND Various minimally invasive approaches have been described for infected necrotizing pancreatitis. This article describes a modified minimal-access retroperitoneal pancreatic necrosectomy (MARPN) procedure assisted by gas insufflation. METHODS This retrospective, observational study documented patients who had undergone a step-up MARPN between 1 January 2010 and 31 December 2016. A minimum follow-up of 1 year was required for inclusion. The step-up approach involved percutaneous catheter drainage followed by the modified MARPN and necrosectomy. If more than one access site was needed it was categorized as complex MARPN. RESULTS Of 212 patients with infected necrotizing pancreatitis, 164 (77·4 per cent) underwent a step-up approach. The median number of percutaneous catheter drains and MARPN procedures was 3 (range 1-7) and 1 (1-6) respectively. Ninety patients (54·9 per cent) underwent complex MARPN. For residual necrosis after MARPN, three patients (1·8 per cent) underwent sinus tract gastroscopy, and 11 (6·7 per cent) had sinography combined with a tube change. However, operations in 13 patients (7·9 per cent) required conversion to open surgery. Postoperative complications developed in 103 patients (62·8 per cent). The mortality rate was 6·1 per cent (10 deaths). CONCLUSION A step-up approach using a modified MARPN for infected necrotizing pancreatitis is a reasonable option.
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Affiliation(s)
- Z-W Liu
- Department of Hepato-pancreato-biliary Surgery, Beijing, China
| | - S-Z Yang
- Centre of Hepato-pancreato-biliary Diseases, Beijing Tsinghua Changgung Hospital, Tsinghua University, Beijing, China
| | - P-F Wang
- Department of Hepato-pancreato-biliary Surgery, Beijing, China
| | - J Feng
- Department of Hepato-pancreato-biliary Surgery, Beijing, China
| | - L He
- Department of Hepato-pancreato-biliary Surgery, Beijing, China
| | - J-D Du
- Department of Hepato-pancreato-biliary Surgery, First Affiliated Hospital of Chinese PLA General Hospital, Beijing, China
| | - Y-Y Xiao
- Department of Radiology, Beijing, China
| | - H-B Jiao
- Department of Hepato-pancreato-biliary Surgery, First Affiliated Hospital of Chinese PLA General Hospital, Beijing, China
| | - F-H Zhou
- Critical Care Medicine, Chinese People's Liberation Army (PLA) General Hospital, Beijing, China
| | - Q Song
- Critical Care Medicine, Chinese People's Liberation Army (PLA) General Hospital, Beijing, China
| | - M-T Zhou
- Pancreatitis Centre, First Affiliated Hospital of Wenzhou Medical University, Wenzhou, China
| | - X-L Xin
- Department of Hepato-pancreato-biliary Surgery, Beijing, China
| | - J-Y Chen
- Department of Hepato-pancreato-biliary Surgery, Beijing, China
| | - W-Z Ren
- Department of Hepato-pancreato-biliary Surgery, Beijing, China
| | - S-C Lu
- Department of Hepato-pancreato-biliary Surgery, Beijing, China
| | - S-W Cai
- Department of Hepato-pancreato-biliary Surgery, Beijing, China
| | - J-H Dong
- Centre of Hepato-pancreato-biliary Diseases, Beijing Tsinghua Changgung Hospital, Tsinghua University, Beijing, China
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Surgical Transgastric Necrosectomy for Necrotizing Pancreatitis: A Single-stage Procedure for Walled-off Pancreatic Necrosis. Ann Surg 2020; 271:163-168. [PMID: 30216220 DOI: 10.1097/sla.0000000000003048] [Citation(s) in RCA: 36] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
OBJECTIVE The aim of this study was to evaluate the role of surgical transgastric necrosectomy (TGN) for walled-off pancreatic necrosis (WON) in selected patients. BACKGROUND WON is a common consequence of severe pancreatitis and typically occurs 3 to 5 weeks after the onset of acute pancreatitis. When symptomatic, it can require intervention. METHODS A retrospective review of patients with WON undergoing surgical management at 3 high-volume pancreatic institutions was performed. Surgical indications, intervention timing, technical methodology, and patient outcomes were evaluated. Patients undergoing intervention <30 days were excluded. Differences across centers were evaluated using a P value of <0.05 as significant. RESULTS One hundred seventy-eight total patients were analyzed (mean WON diameter = 14 cm, 64% male, mean age = 51 years) across 3 centers. The majority required inpatient admission with a median preoperative length of hospital stay of 29 days (25% required preoperative critical care support). Most (96%) patients underwent a TGN. The median duration of time between the onset of pancreatitis symptoms and operative intervention was 60 days. Thirty-nine percent of the necrosum was infected. Postoperative morbidity and mortality were 38% and 2%, respectively. The median postoperative length of hospital length of stay was 8 days, with the majority of patients discharged home. The median length of follow-up was 21 months, with 91% of patients having complete clinical resolution of symptoms at a median of 6 weeks. Readmission to hospital and/or a repeat intervention was also not infrequent (20%). CONCLUSION Surgical TGN is an excellent 1-stage surgical option for symptomatic WON in a highly selected group of patients. Precise surgical technique and long-term outpatient follow-up are mandatory for optimal patient outcomes.
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Baron TH, DiMaio CJ, Wang AY, Morgan KA. American Gastroenterological Association Clinical Practice Update: Management of Pancreatic Necrosis. Gastroenterology 2020; 158:67-75.e1. [PMID: 31479658 DOI: 10.1053/j.gastro.2019.07.064] [Citation(s) in RCA: 322] [Impact Index Per Article: 80.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/06/2019] [Revised: 07/08/2019] [Accepted: 07/31/2019] [Indexed: 12/12/2022]
Abstract
DESCRIPTION The purpose of this American Gastroenterological Association (AGA) Institute Clinical Practice Update is to review the available evidence and expert recommendations regarding the clinical care of patients with pancreatic necrosis and to offer concise best practice advice for the optimal management of patients with this highly morbid condition. METHODS This expert review was commissioned and approved by the AGA Institute Clinical Practice Updates Committee and the AGA Governing Board to provide timely guidance on a topic of high clinical importance to the AGA membership, and underwent internal peer review by the Clinical Practice Updates Committee and external peer review through standard procedures of Gastroenterology. This review is framed around the 15 best practice advice points agreed upon by the authors, which reflect landmark and recent published articles in this field. This expert review also reflects the experiences of the authors, who are advanced endoscopists or hepatopancreatobiliary surgeons with extensive experience in managing and teaching others to care for patients with pancreatic necrosis. BEST PRACTICE ADVICE 1: Pancreatic necrosis is associated with substantial morbidity and mortality and optimal management requires a multidisciplinary approach, including gastroenterologists, surgeons, interventional radiologists, and specialists in critical care medicine, infectious disease, and nutrition. In situations where clinical expertise may be limited, consideration should be given to transferring patients with significant pancreatic necrosis to an appropriate tertiary-care center. BEST PRACTICE ADVICE 2: Antimicrobial therapy is best indicated for culture-proven infection in pancreatic necrosis or when infection is strongly suspected (ie, gas in the collection, bacteremia, sepsis, or clinical deterioration). Routine use of prophylactic antibiotics to prevent infection of sterile necrosis is not recommended. BEST PRACTICE ADVICE 3: When infected necrosis is suspected, broad-spectrum intravenous antibiotics with ability to penetrate pancreatic necrosis should be favored (eg, carbapenems, quinolones, and metronidazole). Routine use of antifungal agents is not recommended. Computed tomography-guided fine-needle aspiration for Gram stain and cultures is unnecessary in the majority of cases. BEST PRACTICE ADVICE 4: In patients with pancreatic necrosis, enteral feeding should be initiated early to decrease the risk of infected necrosis. A trial of oral nutrition is recommended immediately in patients in whom there is absence of nausea and vomiting and no signs of severe ileus or gastrointestinal luminal obstruction. When oral nutrition is not feasible, enteral nutrition by either nasogastric/duodenal or nasojejunal tube should be initiated as soon as possible. Total parenteral nutrition should be considered only in cases where oral or enteral feeds are not feasible or tolerated. BEST PRACTICE ADVICE 5: Drainage and/or debridement of pancreatic necrosis is indicated in patients with infected necrosis. Drainage and/or debridement may be required in patients with sterile pancreatic necrosis and persistent unwellness marked by abdominal pain, nausea, vomiting, and nutritional failure or with associated complications, including gastrointestinal luminal obstruction; biliary obstruction; recurrent acute pancreatitis; fistulas; or persistent systemic inflammatory response syndrome. BEST PRACTICE ADVICE 6: Pancreatic debridement should be avoided in the early, acute period (first 2 weeks), as it has been associated with increased morbidity and mortality. Debridement should be optimally delayed for 4 weeks and performed earlier only when there is an organized collection and a strong indication. BEST PRACTICE ADVICE 7: Percutaneous drainage and transmural endoscopic drainage are both appropriate first-line, nonsurgical approaches in managing patients with walled-off pancreatic necrosis (WON). Endoscopic therapy through transmural drainage of WON may be preferred, as it avoids the risk of forming a pancreatocutaneous fistula. BEST PRACTICE ADVICE 8: Percutaneous drainage of pancreatic necrosis should be considered in patients with infected or symptomatic necrotic collections in the early, acute period (<2 weeks), and in those with WON who are too ill to undergo endoscopic or surgical intervention. Percutaneous drainage should be strongly considered as an adjunct to endoscopic drainage for WON with deep extension into the paracolic gutters and pelvis or for salvage therapy after endoscopic or surgical debridement with residual necrosis burden. BEST PRACTICE ADVICE 9: Self-expanding metal stents in the form of lumen-apposing metal stents appear to be superior to plastic stents for endoscopic transmural drainage of necrosis. BEST PRACTICE ADVICE 10: The use of direct endoscopic necrosectomy should be reserved for those patients with limited necrosis who do not adequately respond to endoscopic transmural drainage using large-bore, self-expanding metal stents/lumen-apposing metal stents alone or plastic stents combined with irrigation. Direct endoscopic necrosectomy is a therapeutic option in patients with large amounts of infected necrosis, but should be performed at referral centers with the necessary endoscopic expertise and interventional radiology and surgical backup. BEST PRACTICE ADVICE 11: Minimally invasive operative approaches to the debridement of acute necrotizing pancreatitis are preferred to open surgical necrosectomy when possible, given lower morbidity. BEST PRACTICE ADVICE 12: Multiple minimally invasive surgical techniques are feasible and effective, including videoscopic-assisted retroperitoneal debridement, laparoscopic transgastric debridement, and open transgastric debridement. Selection of approach is best determined by pattern of disease, physiology of the patient, experience and expertise of the multidisciplinary team, and available resources. BEST PRACTICE ADVICE 13: Open operative debridement maintains a role in the modern management of acute necrotizing pancreatitis in cases not amenable to less invasive endoscopic and/or surgical procedures. BEST PRACTICE ADVICE 14: For patients with disconnected left pancreatic remnant after acute necrotizing mid-body necrosis, definitive surgical management with distal pancreatectomy should be undertaken in patients with reasonable operative candidacy. Insufficient evidence exists to support the management of the disconnected left pancreatic remnant with long-term transenteric endoscopic stenting. BEST PRACTICE ADVICE 15: A step-up approach consisting of percutaneous drainage or endoscopic transmural drainage using either plastic stents and irrigation or self-expanding metal stents/lumen-apposing metal stents alone, followed by direct endoscopic necrosectomy, and then surgical debridement is reasonable, although approaches may vary based on the available clinical expertise.
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Affiliation(s)
- Todd H Baron
- Division of Gastroenterology and Hepatology, University of North Carolina, Chapel Hill, North Carolina
| | - Christopher J DiMaio
- Division of Gastroenterology, Icahn School of Medicine at Mount Sinai, New York, New York
| | - Andrew Y Wang
- Division of Gastroenterology and Hepatology, University of Virginia, Charlottesville, Virginia.
| | - Katherine A Morgan
- Division of Gastrointestinal and Laparoscopic Surgery, Medical University of South Carolina, Charleston, South Carolina
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Medina-Donoso G, Espinosa-Calderón P, Gonzalez-Pardo S, Báez-Morales W. Laparoscopic cystogastrostomy as a treatment for pancreatic pseudocyst: a case report. BIONATURA 2019. [DOI: 10.21931/rb/2019.04.04.9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022] Open
Abstract
The pancreatic pseudocyst is one of the late local complications of acute pancreatitis, for the management of this entity, there are multiple strategies that range from expectant management, minimally invasive therapy and surgical resolution. Since surgery is the definitive treatment, the laparoscopic approach takes force as a strategy in selected patients. A 47-year-old female patient with multiple comorbidities with pancreatitis of bile origin with subsequent development of pancreatic pseudocyst in whom surgical resolution with a laparoscopic approach is decided. Discussion: The laparoscopic approach shows favorable results; with a procedure duration of 170 minutes on average; the open technique shows several complications: pancreatic fistulas in 40%, enteric fistulas of 20%, incisional hernia of 25%, and mortality of 9 to 25%; Laparoscopic gastrocystostomy allows a much wider communication between the cyst and stomach compared to the endoscopic approach, safe hemostasis and better management of complications. Surgery for the treatment of pseudocyst continues to be the cornerstone; The laparoscopic approach shows the advantages of laparoscopy, with lower morbidity rates compared to open procedures.
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Affiliation(s)
- Gabriel Medina-Donoso
- Médico Cirujano, Servicio de Cirugía General Hospital IESS-Ibarra. Docente Universidad Católica del Ecuador-Facultad de Medicina. Ecuador
| | - Paúl Espinosa-Calderón
- Médico Anestesiólogo, Servicio de Anestesiología Hospital IESS-Ibarra. Docente Universidad Técnica del Norte - Facultad Ciencias de la Salud. Ecuador
| | - Secundino Gonzalez-Pardo
- Médico Anestesiólogo. Docente Investigador Universidad Técnica del Norte - Facultad Ciencias de la Salud. Ecuador
| | - Widmark Báez-Morales
- Médico Magíster en Gerencia de Salud y Desarrollo Local. Docente Investigador Universidad Técnica del Norte - Facultad Ciencias de la Salud. Ecuador
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Morelli L, Furbetta N, Gianardi D, Palmeri M, Di Franco G, Bianchini M, Stefanini G, Guadagni S, Di Candio G. Robot-assisted trans-gastric drainage and debridement of walled-off pancreatic necrosis using the EndoWrist stapler for the da Vinci Xi: A case report. World J Clin Cases 2019; 7:1461-1466. [PMID: 31363474 PMCID: PMC6656665 DOI: 10.12998/wjcc.v7.i12.1461] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/25/2019] [Revised: 04/24/2019] [Accepted: 05/02/2019] [Indexed: 02/05/2023] Open
Abstract
BACKGROUND Walled-off pancreatic necrosis (WOPN) is a late complication of acute pancreatitis. The management of a WOPN depends on its location and on patient's symptoms. Trans-gastric drainage and debridement of WOPN represents an important surgical treatment option for selected patients. The da Vinci surgical System has been developed to allow an easy, minimally invasive and fast surgery, also in challenging abdominal procedures. We present here a case of a WOPN treated with a robotic trans-gastric drainage using the da Vinci Xi.
CASE SUMMARY A 63-year-old man with an episode of acute necrotizing pancreatitis was referred to our center. Six wk after the acute episode the patient developed a walled massive fluid collection, with an extensive pancreatic necrosis, causing obstruction of the gastrointestinal tract. The patient underwent a robotic trans-gastric drainage and debridement of the WOPN performed with the da Vinci Xi platform. Firstly, an anterior ideal gastrotomy was carried out, guided by intraoperative ultrasound (US)-scan using the TilePro™ function. Then, through the gastrotomy, the best location for drainage on the posterior gastric wall was again US-guided identified. The anastomosis between the posterior gastric wall and the walled-off necrosis wall was carried out with the new EndoWrist stapler with vascular cartridge. Debridement and washing of the cavity through the anastomosis were performed. Finally, the anterior gastrotomy was closed and the cholecystectomy was performed. The postoperative course was uneventful and a post-operative computed tomography-scan showed the collapse of the fluid collection.
CONCLUSION In selected cases of WOPN the da Vinci Surgical System can be safely used as a valid surgical treatment option.
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Affiliation(s)
- Luca Morelli
- General Surgery Unit, Department of Translational Research and New Technologies in Medicine and Surgery, University of Pisa, Pisa 56124, Italy
- EndoCAS (Center for Computer Assisted Surgery), University of Pisa, Pisa 56124, Italy
| | - Niccolò Furbetta
- General Surgery Unit, Department of Translational Research and New Technologies in Medicine and Surgery, University of Pisa, Pisa 56124, Italy
| | - Desirée Gianardi
- General Surgery Unit, Department of Translational Research and New Technologies in Medicine and Surgery, University of Pisa, Pisa 56124, Italy
| | - Matteo Palmeri
- General Surgery Unit, Department of Translational Research and New Technologies in Medicine and Surgery, University of Pisa, Pisa 56124, Italy
| | - Gregorio Di Franco
- General Surgery Unit, Department of Translational Research and New Technologies in Medicine and Surgery, University of Pisa, Pisa 56124, Italy
| | - Matteo Bianchini
- General Surgery Unit, Department of Translational Research and New Technologies in Medicine and Surgery, University of Pisa, Pisa 56124, Italy
| | - Gianni Stefanini
- General Surgery Unit, Department of Translational Research and New Technologies in Medicine and Surgery, University of Pisa, Pisa 56124, Italy
| | - Simone Guadagni
- General Surgery Unit, Department of Translational Research and New Technologies in Medicine and Surgery, University of Pisa, Pisa 56124, Italy
| | - Giulio Di Candio
- General Surgery Unit, Department of Translational Research and New Technologies in Medicine and Surgery, University of Pisa, Pisa 56124, Italy
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Ke L, Mao W, Zhou J, Ye B, Li G, Zhang J, Wang P, Tong Z, Windsor J, Li W. Stent-Assisted Percutaneous Endoscopic Necrosectomy for Infected Pancreatic Necrosis: Technical Report and a Pilot Study. World J Surg 2019; 43:1121-1128. [PMID: 30569220 DOI: 10.1007/s00268-018-04878-9] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/07/2023]
Abstract
BACKGROUND AND AIMS A variety of minimally invasive techniques have been proposed to replace open surgery for the treatment of infected pancreatic necrosis (IPN). In this study, we evaluate the feasibility and safety of the stent-assisted percutaneous endoscopic necrosectomy (SAPEN) procedure. METHODS Data were collected on all patients who underwent the SAPEN procedure between October 2017 and March 2018. The demographic and clinical characteristics of the study patients were analyzed. A composite primary endpoint of major complications and/or death was used. Three different cases were selected to illustrate different technical aspects of the SAPEN procedure. RESULTS The placement of a percutaneous stent was successful in all of the 23 patients (17 males, six females). IPN was successfully managed in 16/23 (70%) patients, with the need for open surgery in seven patients (30%), with a median of two (range 1-5) SAPEN procedures. No significant procedure-related complications occurred. Overall 11/23 (48%) patients had a major complication and/or death. CONCLUSIONS In conclusion, the SAPEN procedure was effective in treating IPN without adding extra procedural risk. The role and benefits of the SAPEN procedure now need to be demonstrated in larger controlled study.
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Affiliation(s)
- Lu Ke
- Department of General Surgery, Jinling Hospital, Medical School of Nanjing University, No. 305 Zhongshan East Road, Nanjing, 210002, Nanjing Province, China
| | - Wenjian Mao
- Department of General Surgery, Jinling Hospital, Medical School of Nanjing University, No. 305 Zhongshan East Road, Nanjing, 210002, Nanjing Province, China
- Department of General Surgery, Jinling Clinical Medical College of Southern Medical University, No. 305 Zhongshan East Road, Nanjing, China
| | - Jing Zhou
- Department of General Surgery, Jinling Hospital, Medical School of Nanjing University, No. 305 Zhongshan East Road, Nanjing, 210002, Nanjing Province, China
| | - Bo Ye
- Department of General Surgery, Jinling Hospital, Medical School of Nanjing University, No. 305 Zhongshan East Road, Nanjing, 210002, Nanjing Province, China
| | - Gang Li
- Department of General Surgery, Jinling Hospital, Medical School of Nanjing University, No. 305 Zhongshan East Road, Nanjing, 210002, Nanjing Province, China
| | - Jingzhu Zhang
- Department of General Surgery, Jinling Hospital, Medical School of Nanjing University, No. 305 Zhongshan East Road, Nanjing, 210002, Nanjing Province, China
| | - Peng Wang
- Department of General Surgery, Jinling Hospital, Medical School of Nanjing University, No. 305 Zhongshan East Road, Nanjing, 210002, Nanjing Province, China
- Department of General Surgery, Jinling Clinical Medical College of Southern Medical University, No. 305 Zhongshan East Road, Nanjing, China
| | - Zhihui Tong
- Department of General Surgery, Jinling Hospital, Medical School of Nanjing University, No. 305 Zhongshan East Road, Nanjing, 210002, Nanjing Province, China.
| | - John Windsor
- Department of Surgery, University of Auckland, Auckland, New Zealand
| | - Weiqin Li
- Department of General Surgery, Jinling Hospital, Medical School of Nanjing University, No. 305 Zhongshan East Road, Nanjing, 210002, Nanjing Province, China.
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Abstract
Walled of pancreatic necrosis (WOPN) is a new term coined for encapsulated fluid collection developing after acute necrotising pancreatitis (ANP). It is a heterogeneous collection containing varying amount of liquid as well as solid necrotic material. The literature on its natural history as well as appropriate management is gradually expanding thereby improving treatment outcomes of this enigmatic disease. Areas covered: This review discusses currently available literature on etiology, frequency, natural history, and imaging features WOPN. Also, updated treatment options including endoscopic, radiological and surgical drainage are discussed. Expert opinion: WOPN is alocal complication of ANP occurring in the delayed phase of ANP and may be asymptomatic (50%) or present with pain, fever, jaundice, or gastric outlet obstruction. Natural courses of asymptomatic WOPN have been infrequently studied, and it appears that the majority remain asymptomatic and resolve spontaneously. Magnetic resonance imaging and endoscopic ultrasound are the best imaging modalities to evaluate solid necrotic debris. Symptomatic WOPN usually needs immediate drainage, this can be done endoscopically, radiologically, or surgically. Current evidence suggests that endoscopic transluminal drainage is the preferred drainage technique as it is effective and associated with lower mortality, risk of organ failure, adverse effects, and length of hospital stay.
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Affiliation(s)
- Surinder Singh Rana
- a Department of Gastroenterology , Post Graduate Institute of Medical Education and Research (PGIMER) , Chandigarh , India
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23
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Isolated pancreatic tail remnants after transgastric necrosectomy can be observed. J Surg Res 2018; 231:109-115. [PMID: 30278917 DOI: 10.1016/j.jss.2018.05.020] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/01/2018] [Revised: 04/16/2018] [Accepted: 05/17/2018] [Indexed: 12/30/2022]
Abstract
BACKGROUND Severe necrotizing pancreatitis may result in midbody necrosis and ductal disruption leaving an isolated pancreatic tail. The purpose of this study was to characterize outcomes among patients with an isolated tail remnant who underwent transgastric drainage or necrosectomy (endoscopic or surgical) and determine the need for subsequent operative management. MATERIALS AND METHODS Patients with necrotizing pancreatitis and retrogastric walled-off collections treated by surgical transgastric necrosectomy or endoscopic cystgastrostomy ± necrosectomy between 2009 and 2017 were identified by a retrospective chart review. All available preprocedure and postprocedure imaging was reviewed for evidence of isolated distal pancreatic tail remnants. RESULTS Seventy-four patients were included (40 surgical and 34 endoscopic). All the patients in the surgical group underwent laparoscopic transgastric necrosectomy; the endoscopic group consisted of 26 patients for pseudocyst drainage and eight patients for necrosectomy. A disconnected pancreatic tail was identified in 22 (29%) patients (13 laparoscopic and nine endoscopic). After the creation of the "cystgastrostomy," there were no external fistulas despite the viable tail. Of the 22 patients, four patients developed symptoms at a median of 23 months (two, recurrent episodic pancreatitis; two, intractable pain). Two patients (both initially in endoscopic group) ultimately required distal pancreatectomy and splenectomy at 24 and 6 months after index procedure. CONCLUSIONS Patients with a walled-off retrogastric collection and an isolated viable tail are effectively managed by a transgastric approach. Despite this seemingly "unstable anatomy," the creation of an internal fistula via surgical or endoscopic "cystgastrostomy" avoids external fistulas/drains and the short-term necessity of surgical distal pancreatectomy. A very small subset requires intervention for late symptoms.
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Cao X, Cao F, Li A, Gao X, Wang XH, Liu DG, Fang Y, Guo DH, Li F. Predictive factors of pancreatic necrosectomy following percutaneous catheter drainage as a primary treatment of patients with infected necrotizing pancreatitis. Exp Ther Med 2017; 14:4397-4404. [PMID: 29104650 DOI: 10.3892/etm.2017.5107] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/20/2016] [Accepted: 06/15/2017] [Indexed: 12/18/2022] Open
Abstract
Pancreatic necrosectomy (PN) following percutaneous catheter drainage (PCD) is an effective method of treating patients with necrotizing pancreatitis, however, the predictive factors for PN after PCD have not yet been identified. A total of 74 patients with suspected infected necrotizing pancreatitis (INP) and peripancreatic fluid collection were enrolled in the current study between October 2010 and October 2015. These patients received ultrasound or computer topography guided PCD followed by PN. Patients were divided into two groups: i) A PCD-alone group (n=32) and ii) a PCD+necrosectomy group (n=42). Multivariate analysis revealed that reduction of fluid collection after PCD (P=0.021), maximum extent of peripancreatic necrosis (P=0.019) and multiple organ failure (P=0.017) were predictors of PN following PCD. A prediction model was produced to evaluate the aforementioned factors and indicated that the area under the receiver operating characteristic curve was 0.827. The probability of successful PCD was determined using a prognostic nomogram. Thus, the results of the current study demonstrated that a reduction of fluid collection by <50% following PCD, a maximum extent of peripancreatic necrosis of >50% and multiple organ failure are effective predictors of necrosectomy in patients with INP following PCD failure.
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Affiliation(s)
- Xi Cao
- Department of General Surgery, Xuanwu Hospital, Capital Medical University, Beijing 100053, P.R. China.,Department of General Surgery, Ordos Central Hospital, Ordos, Inner Mongolia 017000, P.R. China
| | - Feng Cao
- Department of General Surgery, Xuanwu Hospital, Capital Medical University, Beijing 100053, P.R. China
| | - Ang Li
- Department of General Surgery, Xuanwu Hospital, Capital Medical University, Beijing 100053, P.R. China
| | - Xiang Gao
- Department of General Surgery, Xuanwu Hospital, Capital Medical University, Beijing 100053, P.R. China
| | - Xiao-Hui Wang
- Department of General Surgery, Xuanwu Hospital, Capital Medical University, Beijing 100053, P.R. China
| | - Dian-Gang Liu
- Department of General Surgery, Xuanwu Hospital, Capital Medical University, Beijing 100053, P.R. China
| | - Yu Fang
- Department of General Surgery, Xuanwu Hospital, Capital Medical University, Beijing 100053, P.R. China
| | - Dong-Hai Guo
- Department of General Surgery, Ordos Central Hospital, Ordos, Inner Mongolia 017000, P.R. China
| | - Fei Li
- Department of General Surgery, Xuanwu Hospital, Capital Medical University, Beijing 100053, P.R. China
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Dua MM, Worhunsky DJ, Malhotra L, Park WG, Poultsides GA, Norton JA, Visser BC. Transgastric pancreatic necrosectomy-expedited return to prepancreatitis health. J Surg Res 2017; 219:11-17. [PMID: 29078869 DOI: 10.1016/j.jss.2017.05.089] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/10/2017] [Revised: 04/23/2017] [Accepted: 05/24/2017] [Indexed: 12/30/2022]
Abstract
BACKGROUND The best operative strategy for necrotizing pancreatitis remains controversial. Traditional surgical necrosectomy is associated with significant morbidity; endoscopic and percutaneous strategies require repeated interventions with prolonged hospitalizations. We have developed a transgastric approach to pancreatic necrosectomy to overcome the shortcomings of the other techniques described. MATERIALS AND METHODS Patients with necrotizing pancreatitis treated from 2009 to 2016 at an academic center were retrospectively reviewed. Open or laparoscopic transgastric necrosectomy was performed if the area of necrosis was walled-off and in a retrogastric position on cross-sectional imaging. Study endpoints included postoperative complications and mortality. RESULTS Forty-six patients underwent transgastric necrosectomy (nine open and 37 laparoscopic). Median (interquartile range) preoperative Acute Physiologic and Chronic Health Evaluation II score was 6 (3-12). Seventy percent of patients had >30% necrosis on preoperative imaging; infected necrosis was present in 35%. Median total length of stay (LOS) was 6 (3-12) d. No patient required a second operative debridement; four patients (9%) had short-term postoperative percutaneous drainage for residual fluid collections. Median follow-up was 1 y; there were no fistula or wound complications. Six patients (13%) had postoperative bleeding; five patients received treatment by image-guided embolization. There was one death in the cohort. CONCLUSIONS Transgastric pancreatic necrosectomy allows for effective debridement with a single definitive operation. When anatomically suitable, this operative strategy offers expedited recovery and avoids long-term morbidity associated with fistulas and prolonged drainage.
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Affiliation(s)
- Monica M Dua
- Division of Surgical Oncology, Department of Surgery, Stanford University School of Medicine, Stanford, California.
| | - David J Worhunsky
- Division of Surgical Oncology, Department of Surgery, Stanford University School of Medicine, Stanford, California
| | - Lavina Malhotra
- Division of Surgical Oncology, Department of Surgery, Stanford University School of Medicine, Stanford, California
| | - Walter G Park
- Division of Gastroenterology, Department of Medicine, Stanford University School of Medicine, Stanford, California
| | - George A Poultsides
- Division of Surgical Oncology, Department of Surgery, Stanford University School of Medicine, Stanford, California
| | - Jeffrey A Norton
- Division of Surgical Oncology, Department of Surgery, Stanford University School of Medicine, Stanford, California
| | - Brendan C Visser
- Division of Surgical Oncology, Department of Surgery, Stanford University School of Medicine, Stanford, California
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Kirks RC, Sola R, Iannitti DA, Martinie JB, Vrochides D. Robotic transgastric cystgastrostomy and pancreatic debridement in the management of pancreatic fluid collections following acute pancreatitis. J Vis Surg 2016; 2:127. [PMID: 29078515 DOI: 10.21037/jovs.2016.07.04] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/21/2016] [Accepted: 06/29/2016] [Indexed: 12/17/2022]
Abstract
Pancreatic and peripancreatic fluid collections may develop after severe acute pancreatitis. Organized fluid collections such as pancreatic pseudocyst and walled-off pancreatic necrosis (WOPN) that mature over time may require intervention to treat obstructive or constitutional symptoms related to the size and location of the collection as well as possible infection. Endoscopic, open surgical and minimally invasive techniques are described to treat post-inflammatory pancreatic fluid collections. Surgical intervention may be required to treat collections containing necrotic pancreatic parenchyma or in locations not immediately apposed to the stomach or duodenum. Comprising a blend of the surgical approach and the clinical benefits of minimally invasive surgery, the robot-assisted technique of pancreatic cystgastrostomy with pancreatic debridement is described.
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Affiliation(s)
- Russell C Kirks
- Division of Hepatobiliary and Pancreatic Surgery, Department of General Surgery, Carolinas Medical Center, Charlotte, North Carolina, USA
| | - Richard Sola
- Division of Hepatobiliary and Pancreatic Surgery, Department of General Surgery, Carolinas Medical Center, Charlotte, North Carolina, USA
| | - David A Iannitti
- Division of Hepatobiliary and Pancreatic Surgery, Department of General Surgery, Carolinas Medical Center, Charlotte, North Carolina, USA
| | - John B Martinie
- Division of Hepatobiliary and Pancreatic Surgery, Department of General Surgery, Carolinas Medical Center, Charlotte, North Carolina, USA
| | - Dionisios Vrochides
- Division of Hepatobiliary and Pancreatic Surgery, Department of General Surgery, Carolinas Medical Center, Charlotte, North Carolina, USA
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Jimenez Rodriguez RM, Segura-Sampedro JJ, Flores-Cortés M, López-Bernal F, Martín C, Diaz VP, Ciuro FP, Ruiz JP. Laparoscopic approach in gastrointestinal emergencies. World J Gastroenterol 2016; 22:2701-2710. [PMID: 26973409 PMCID: PMC4777993 DOI: 10.3748/wjg.v22.i9.2701] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/04/2015] [Revised: 12/24/2015] [Accepted: 01/11/2016] [Indexed: 02/06/2023] Open
Abstract
This review focuses on the laparoscopic approach to gastrointestinal emergencies and its more recent indications. Laparoscopic surgery has a specific place in elective procedures, but that does not apply in emergency situations. In specific emergencies, there is a huge range of indications and different techniques to apply, and not all of them are equally settle. We consider that the most controversial points in minimally invasive procedures are indications in emergency situations due to technical difficulties. Some pathologies, such as oesophageal emergencies, obstruction due to colon cancer, abdominal hernias or incarcerated postsurgical hernias, are nearly always resolved by conventional surgery, that is, an open approach due to limited intraabdominal cavity space or due to the vulnerability of the bowel. These technical problems have been solved in many diseases, such as for perforated peptic ulcer or acute appendectomy for which a laparoscopic approach has become a well-known and globally supported procedure. On the other hand, endoscopic procedures have acquired further indications, relegating surgical solutions to a second place; this happens in cholangitis or pancreatic abscess drainage. This endoluminal approach avoids the need for laparoscopic development in these diseases. Nevertheless, new instruments and new technologies could extend the laparoscopic approach to a broader array of potentials procedures. There remains, however, a long way to go.
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Abstract
The surgical management of pancreatic diseases is rapidly evolving, encompassing advances in evidence-driven selection of patients amenable for surgical therapy, preoperative risk stratification, refinements in the technical conduct of pancreatic operations, and quantification of postoperative morbidity. These advances have resulted in dramatic reductions in mortality following pancreatic surgery, particularly at high-volume pancreatic centers. Surgical decision making is complex, and requires an intimate understanding of disease pathobiology, host physiology, technical considerations, and evolving trends. This article highlights key developments in the contemporary surgical management of pancreatic diseases.
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Affiliation(s)
- Jashodeep Datta
- Division of Gastrointestinal Surgery, Department of Surgery, University of Pennsylvania Perelman School of Medicine, 3400 Spruce Street, Philadelphia, PA 19104, USA
| | - Charles M Vollmer
- Division of Gastrointestinal Surgery, Department of Surgery, University of Pennsylvania Perelman School of Medicine, 3400 Spruce Street, Philadelphia, PA 19104, USA.
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Zyromski NJ, Nakeeb A, House MG, Jester AL. Transgastric Pancreatic Necrosectomy: How I Do It. J Gastrointest Surg 2016; 20:445-9. [PMID: 26691148 DOI: 10.1007/s11605-015-3058-y] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/24/2015] [Accepted: 12/09/2015] [Indexed: 01/31/2023]
Abstract
Necrotizing pancreatitis is a serious medical problem that often requires intervention to debride necrotic pancreatic and peripancreatic tissue. Recently, minimally invasive approaches have been applied to pancreatic necrosectomy. The purpose of this report is to review the history of transgastric pancreatic debridement, identify appropriate patient selection criteria, and highlight technical "pearls." We present this subject matter in the context of our own clinical experience, with a primary focus on a "How I Do It" type of technical description.
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Affiliation(s)
- Nicholas J Zyromski
- Department of Surgery, Indiana University School of Medicine, 545 Barnhill Drive, EH 519, Indianapolis, IN, 46202, USA.
| | - Attila Nakeeb
- Department of Surgery, Indiana University School of Medicine, 545 Barnhill Drive, EH 519, Indianapolis, IN, 46202, USA
| | - Michael G House
- Department of Surgery, Indiana University School of Medicine, 545 Barnhill Drive, EH 519, Indianapolis, IN, 46202, USA
| | - Andrea L Jester
- Department of Surgery, Indiana University School of Medicine, 545 Barnhill Drive, EH 519, Indianapolis, IN, 46202, USA
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Minimally Invasive Necrosectomy Techniques in Severe Acute Pancreatitis: Role of Percutaneous Necrosectomy and Video-Assisted Retroperitoneal Debridement. Gastroenterol Res Pract 2015; 2015:693040. [PMID: 26587018 PMCID: PMC4637484 DOI: 10.1155/2015/693040] [Citation(s) in RCA: 29] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/14/2014] [Accepted: 02/17/2015] [Indexed: 01/07/2023] Open
Abstract
Consensus advocating a principle of early organ support, nutritional optimisation, followed ideally by delayed minimally invasive intervention within a “step-up” framework where possible has radically changed the surgical approach to complications of acute pancreatitis in the last 20 years. The 2012 revision of the Atlanta Classification incorporates these changes, and provides a background which underpins the complexities of individual patient management decisions. This paper discusses the place for delayed minimally invasive surgical intervention (percutaneous necrosectomy, video-assisted retroperitoneal debridement (VARD)), and the rationale for opting to adopt a percutaneous approach over endoscopic or laparoscopic approaches in different clinical situations.
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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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