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Bharath PN, Rana SS. Early Endoscopic Interventions for Pancreatic Necrosis: Indications, Technique, and Outcomes. Dig Dis Sci 2024; 69:1571-1582. [PMID: 38528209 DOI: 10.1007/s10620-024-08347-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/02/2024] [Accepted: 02/08/2024] [Indexed: 03/27/2024]
Abstract
Endoscopic transmural drainage is usually performed for symptomatic well-encapsulated walled-off necrosis (WON) that usually develops in the delayed phase (> 4 weeks after disease onset) of acute necrotising pancreatitis (ANP). Endoscopic drainage is usually not advocated in the early (< 4 weeks after disease onset) stage of illness because of the risk of complications due to an incompletely formed encapsulating wall and poor demarcation of viable from necrotic tissue. However, emerging data from expert tertiary care centres over the last few years shows that the early endoscopic transluminal drainage approach is effective and safe. The development of lumen-apposing metal stents and better accessories for endoscopic necrosectomy has fuelled the expansion of indications of endoscopic drainage of pancreatic necrosis. However, early endoscopic drainage is associated with higher rates of adverse events; therefore, careful patient selection is paramount. This article will review the current indications, techniques and outcomes of early endoscopic transluminal drainage in pancreatic necrotic collections.
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Affiliation(s)
- Pardhu Neelam Bharath
- Department of Gastroenterology, Post Graduate Institute of Medical Education and Research (PGIMER), Sector 12, Chandigarh, 160012, India
| | - Surinder Singh Rana
- Department of Gastroenterology, Post Graduate Institute of Medical Education and Research (PGIMER), Sector 12, Chandigarh, 160012, India.
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Rana SS. Endoscopic treatment of pancreatic necrosis: Still searching for perfection! J Gastroenterol Hepatol 2023; 38:1252-1258. [PMID: 37309053 DOI: 10.1111/jgh.16262] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/03/2023] [Accepted: 06/01/2023] [Indexed: 06/14/2023]
Abstract
Over last few years, there has been a paradigm shift in the management of infected pancreatic necrosis with endoscopic and minimally invasive "step-up" management approach replacing open surgical necrosectomy. Because of being associated with reduced occurrence of new onset multi-organ failure, external pancreatic fistulae, shorter hospital stay, lower costs, and better quality of life compared with minimally invasive surgical approach, endoscopic "step-up" management approach is the preferred intervention for endoscopically accessible pancreatic necrotic collections at expert centers with endoscopic expertise. Development of lumen apposing metal stents and improvised accessories for interventional endoscopic ultrasound has revolutionized the endoscopic management of pancreatic necrosis making it more effective and safer. Despite these promising developments, endoscopic transluminal necrosectomy (ETN) remains the Achilles heel. Lack of dedicated endoscopic accessories, poor endoscopic visualization within the necrotic cavity, limited diameter of the instrument channel of the endoscope that is a significant impediment to remove large amount of necrotic material, and uncertain ability to avoid vessels and vital structures in the necrotic cavity are important limitations during endoscopic necrosectomy. Recent devices and solutions including use of cap assisted necrosectomy, over the scope grasper and powered endoscopic debridement device are welcome steps in our pursuit for an ideal, safer, and efficacious ETN device. This review will discuss recent advances as well as challenges in the endoscopic management of pancreatic necrosis.
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Affiliation(s)
- Surinder Singh Rana
- Department of Gastroenterology, Postgraduate Institute of Medical Education and Research (PGIMER), Chandigarh, India
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Bhargava MV, Rana SS, Gorsi U, Kang M, Gupta R. Assessing the Efficacy and Outcomes Following Irrigation with Streptokinase Versus Hydrogen Peroxide in Necrotizing Pancreatitis: A Randomized Pilot Study. Dig Dis Sci 2022; 67:4146-4153. [PMID: 34405362 DOI: 10.1007/s10620-021-07201-0] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/07/2021] [Accepted: 07/26/2021] [Indexed: 02/07/2023]
Abstract
BACKGROUND Percutaneous catheter drainage (PCD's) are prone to blockage because of necrosum. To improve the efficacy of PCD, necrolytic agents have been used. The present study compared the use of Streptokinase with H2O2 in saline irrigation. MATERIALS AND METHODS This is a single-center randomized pilot study (from July 2018 to Dec 2019). Patients with infected pancreatic necrosis not showing response to PCD and saline irrigation were included in the study. Patients received either Streptokinase (Streptokinase group 50,000 IU in 100 ml normal saline) or 3% H2O2 (3% H2O2 in 100 ml normal saline in 1:10 dilution). Primary endpoints were the need for surgery and mortality while secondary endpoints were hospital stay and complications attributable to necrolytic agents. RESULTS There were 30 patients in the study, 15 in each arm. Organ failure was seen in 23 (76.6%), single organ failure was present in 11 (47%), and multi-organ failure in 12 (53%). Bleeding complications (20% in H2O2 vs 6.6% in Streptokinase), need for surgery (73% in H2O2 vs 33.3% in Streptokinase) and mortality (60% in H2O2 vs 33% in Streptokinase) were higher in H2O2 group but the difference was not significant statistically. Post-irrigation hospital stay was lesser in the Streptokinase group compared to H2O2 group but the difference did not reach statistical significance (14.1 ± 7.7 vs 19.2 ± 11.7, p = 0.09) CONCLUSIONS: Streptokinase irrigation led to a trend for reduced need for necrosectomy and mortality. H2O2 group had more bleeding complications. Post-irrigation hospital stay was lesser in Streptokinase group.
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Affiliation(s)
| | - Surinder Singh Rana
- Department of Gastroenterology, Postgraduate Institute of Medical Education and Research, Chandigarh, 160012, India
| | - Ujjwal Gorsi
- Department of Radio Diagnosis and Imaging, Postgraduate Institute of Medical Education and Research, Chandigarh, 160012, India
| | - Mandeep Kang
- Department of Radio Diagnosis and Imaging, Postgraduate Institute of Medical Education and Research, Chandigarh, 160012, India
| | - Rajesh Gupta
- Department of Surgical Gastroenterology, Postgraduate Institute of Medical Education and Research, Chandigarh, 160012, India.
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Gupta P, Madhusudhan KS, Padmanabhan A, Khera PS. Indian College of Radiology and Imaging Consensus Guidelines on Interventions in Pancreatitis. Indian J Radiol Imaging 2022; 32:339-354. [PMID: 36177275 PMCID: PMC9514912 DOI: 10.1055/s-0042-1754313] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022] Open
Abstract
AbstractAcute pancreatitis (AP) is one of the common gastrointestinal conditions presenting as medical emergency. Clinically, the severity of AP ranges from mild to severe. Mild AP has a favorable outcome. Patients with moderately severe and severe AP, on the other hand, require hospitalization and considerable utilization of health care resources. These patients require a multidisciplinary management. Pancreatic fluid collections (PFCs) and arterial bleeding are the most important local complications of pancreatitis. PFCs may require drainage when infected or symptomatic. PFCs are drained endoscopically or percutaneously, based on the timing and the location of collection. Both the techniques are complementary, and many patients may undergo dual modality treatment. Percutaneous catheter drainage (PCD) remains the most extensively utilized method for drainage in patients with AP and necrotic PFCs. Besides being effective as a standalone treatment in a significant proportion of these patients, PCD also provides an access for percutaneous endoscopic necrosectomy and minimally invasive necrosectomy. Endovascular embolization is the mainstay of management of arterial complications in patients with AP and chronic pancreatitis. The purpose of the present guideline is to provide evidence-based recommendations for the percutaneous management of complications of pancreatitis.
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Affiliation(s)
- Pankaj Gupta
- Department of Radiodiagnosis and Imaging, Postgraduate Institute of Medical Education and Research, Chandigarh, India
| | | | - Aswin Padmanabhan
- Division of Clinical Radiology, Department of Interventional Radiology, Christian Medical College, Vellore, Tamil Nadu, India
| | - Pushpinder Singh Khera
- Department of Diagnostic and Interventional Radiology, All India Institute of Medical Sciences, Jodhpur, Rajasthan, India
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Bhargava V, Gupta R, Vaswani P, Jha B, Rana SS, Gorsi U, Kang M, Gupta R. Streptokinase irrigation through a percutaneous catheter helps decrease the need for necrosectomy and reduces mortality in necrotizing pancreatitis as part of a step-up approach. Surgery 2021; 170:1532-1537. [PMID: 34127302 DOI: 10.1016/j.surg.2021.05.028] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/09/2021] [Revised: 05/13/2021] [Accepted: 05/14/2021] [Indexed: 12/13/2022]
Abstract
BACKGROUND Percutaneous catheter drainage in pancreatic necrosis with a predominant solid component has a reduced success rate. To improve the efficacy of percutaneous catheter drainage, we used streptokinase in the irrigation fluid in the present study. METHODS In this retrospective analysis of 4 prospective randomized studies performed at our center from 2014 to 2019, 108 patients were evaluated. We assessed the safety, feasibility, and efficacy of streptokinase irrigation compared to saline irrigation. Data were also analyzed between 50,000 IU and 150,000 IU streptokinase. RESULTS There were 53 patients in the streptokinase irrigation group and 55 in the saline irrigation group, and both groups were comparable in terms of age, sex, etiology, APACHE II score, and percutaneous catheter drainage characteristics. The modified computerised tomography severity index and modified Marshall score at the onset of pain were significantly higher in the streptokinase group. Sepsis reversal was significantly higher in the streptokinase group (75% vs 36%), and the need for necrosectomy (34% vs 54%) was also lower in the streptokinase group. Mortality was lower in the streptokinase group than in the saline group (32% vs 40%). The incidence of bleeding in the streptokinase group was lower than that in the saline group (7% vs 18%). A higher dose of streptokinase (150,000 IU) resulted in lower rates of necrosectomy, bleeding, and mortality compared to those with 50,000 IU streptokinase. CONCLUSION Significant reductions in the need for surgery and sepsis reversal were noted in the streptokinase group. The results using 150,000 IU streptokinase were superior to those using 50,000 IU streptokinase.
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Affiliation(s)
- Venu Bhargava
- Department of Surgical Gastroenterology, Postgraduate Institute of Medical Education and Research, Chandigarh, India
| | - Rahul Gupta
- Department of Surgical Gastroenterology, Postgraduate Institute of Medical Education and Research, Chandigarh, India
| | - Prateek Vaswani
- Department of Surgical Gastroenterology, Postgraduate Institute of Medical Education and Research, Chandigarh, India
| | - Bhairavi Jha
- Department of Surgical Gastroenterology, Postgraduate Institute of Medical Education and Research, Chandigarh, India
| | - Surinder Singh Rana
- Department of Gastroenterology, Postgraduate Institute of Medical Education and Research, Chandigarh, India
| | - Ujwal Gorsi
- Department of Radio Diagnosis and Imaging, Postgraduate Institute of Medical Education and Research, Chandigarh, India
| | - Mandeep Kang
- Department of Radio Diagnosis and Imaging, Postgraduate Institute of Medical Education and Research, Chandigarh, India
| | - Rajesh Gupta
- Department of Surgical Gastroenterology, Postgraduate Institute of Medical Education and Research, Chandigarh, India.
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Dang JQ, Jia TJ, Zhang ZQ, Gong XL, Wang HY, Ren YS. Efficacy of large-volume lavage through a double-lumen drainage tube and continuous negative pressure drainage for infectious pancreatic necrosis. Shijie Huaren Xiaohua Zazhi 2021; 29:21-28. [DOI: 10.11569/wcjd.v29.i1.21] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023] Open
Abstract
BACKGROUND Infectious pancreatic necrosis (IPN) is usually treated by surgery. However, the drainage of residual tissues still has problems such as insufficient drainage and easy blockage of the drainage tube. In this study, we compared the efficacy of large-volume lavage through a peripancreatic double-lumen drainage tube and continuous negative pressure drainage vs conventional drainage for IPN.
AIM To evaluate the clinical efficacy of large-volume lavage through a peripancreatic double-lumen drainage tube and continuous negative pressure drainage for IPN after operation.
METHODS The clinical data of 57 cases of IPN who received surgical treatment at the Department of Hepatobiliary, Pancreatic and Splenic Surgery, People's Hospital of Tongchuan from June 2015 to June 2019 were retrospectively analyzed. According to the method of postoperative drainage used, the patients were divided into either a double-lumen drainage tube group or a conventional drainage tube group.
RESULTS The two groups had no significant differences in demographic data, etiology and severity of pancreatitis, operation time, intraoperative blood loss, and duration of intensive care unit stay. There were also no significant differences between the two groups in the number of reversals of postoperative continuous organ failure (84.21% vs 56.25%, P = 0.13) and the incidence of serious complications (16.67% vs 33.33%, P = 0.14). The overall mortality rate was 12.28%. The mortality rate was higher in the conventional drainage tube group, but there was no statistically significant difference between the two groups (P = 0.17). Compared to the conventional drainage tube group, the double-lumen drainage tube group had significantly reduced APACHEⅡ score (8.03 ± 2.13 vs 3.85 ± 1.29, P < 0.01) and reoperation cases (0 vs 22.22%, P = 0.008), shorter hospitalization, more unobstructed drainage tubes, and earlier removal of drainage tubes (P < 0.01).
CONCLUSION Large volume lavage through a double-lumen drainage tube and continuous negative pressure drainage is an effective method for IPN, which can be used to treat IPN effectively.
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Affiliation(s)
- Jun-Qiang Dang
- Department of Hepatobiliary, Pancreatic and Splenic Surgery, People's Hospital of Tongchuan, Tongchuan 727031, Shaanxi Province, China
| | - Ting-Jie Jia
- Department of General Surgery, Hospital of Lanzhou University, Lanzhou 730000, Gansu Province, China
| | - Zhi-Qiang Zhang
- Department of Hepatobiliary, Pancreatic and Splenic Surgery, People's Hospital of Tongchuan, Tongchuan 727031, Shaanxi Province, China
| | - Xin-Li Gong
- Department of Hepatobiliary, Pancreatic and Splenic Surgery, People's Hospital of Tongchuan, Tongchuan 727031, Shaanxi Province, China
| | - Hao-Yu Wang
- Department of Hepatobiliary, Pancreatic and Splenic Surgery, People's Hospital of Tongchuan, Tongchuan 727031, Shaanxi Province, China
| | - Yan-Shun Ren
- Department of Hepatobiliary, Pancreatic and Splenic Surgery, People's Hospital of Tongchuan, Tongchuan 727031, Shaanxi Province, China
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Maatman TK, Mahajan S, Roch AM, Ceppa EP, House MG, Nakeeb A, Schmidt CM, Zyromski NJ. Disconnected pancreatic duct syndrome predicts failure of percutaneous therapy in necrotizing pancreatitis. Pancreatology 2020; 20:362-368. [PMID: 32029378 DOI: 10.1016/j.pan.2020.01.014] [Citation(s) in RCA: 16] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/23/2019] [Revised: 01/07/2020] [Accepted: 01/24/2020] [Indexed: 12/11/2022]
Abstract
BACKGROUND/OBJECTIVES Minimally invasive approaches, such as percutaneous drainage (PD), are increasingly utilized as initial treatment in necrotizing pancreatitis (NP) requiring intervention. Predictors of success of PD as definitive treatment are lacking. Our aim was to assess the application, predictors of success, and natural history of PD in NP. We hypothesized that necrosis morphology patterns and disconnected pancreatic duct syndrome (DPDS) may predict the ability of PD to provide definitive therapy. METHODS 714 NP patients were treated from 2005 to 2018. Patients achieving disease resolution with PD alone (PD) were compared to those requiring an escalation in intervention (Step). Outcomes were compared between groups using independent samples t-test, Fisher's exact test, and Pearson's correlation, as appropriate. P < 0.05 was accepted as statistically significant. RESULTS 115 patients were initially managed with PD (42 PD, 73 Step). No difference in necrosis morphology was seen between the two groups. The PD group underwent significantly more repeat percutaneous interventions (PD, 3.2; Step, 2.0; P = 0.0006) including additional drain placement and drain upsize/reposition procedures. Patients with DPDS were more likely to require an escalation in intervention (odds ratio, 3.4; 95% confidence interval, 1.5-7.6; P = 0.003). The mean number of months to NP resolution was similar (PD, 5.7; Step, 5.8; P = 0.9). Mortality was similar (PD, 7%; Step 14%, P = 0.3). CONCLUSIONS Necrosis morphology in and of itself does not reliably predict successful definitive treatment by percutaneous drainage. However, patients with disconnected pancreatic duct syndrome were less likely to have definitive resolution with PD alone.
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Affiliation(s)
- Thomas K Maatman
- Department of Surgery, Indiana University School of Medicine, Indianapolis, IN, USA
| | - Sarakshi Mahajan
- Department of Surgery, Indiana University School of Medicine, Indianapolis, IN, USA
| | - Alexandra M Roch
- Department of Surgery, Indiana University School of Medicine, Indianapolis, IN, USA
| | - Eugene P Ceppa
- Department of Surgery, Indiana University School of Medicine, Indianapolis, IN, USA
| | - Michael G House
- Department of Surgery, Indiana University School of Medicine, Indianapolis, IN, USA
| | - Attila Nakeeb
- Department of Surgery, Indiana University School of Medicine, Indianapolis, IN, USA
| | - C Max Schmidt
- Department of Surgery, Indiana University School of Medicine, Indianapolis, IN, USA
| | - Nicholas J Zyromski
- Department of Surgery, Indiana University School of Medicine, Indianapolis, IN, USA.
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Rana SS, Verma S, Kang M, Gorsi U, Sharma R, Gupta R. Comparison of endoscopic versus percutaneous drainage of symptomatic pancreatic necrosis in the early (< 4 weeks) phase of illness. Endosc Ultrasound 2020; 9:402-409. [PMID: 33318376 PMCID: PMC7811710 DOI: 10.4103/eus.eus_65_20] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/12/2022] Open
Abstract
Background and Objective Pancreatic fluid collections in early phase of illness <4 weeks after onset of acute pancreatitis (AP) are usually treated with percutaneous drainage (PCD). There is a paucity of data comparing early (<4 weeks) endoscopic transluminal drainage (ETD) with PCD in patients with symptomatic pancreatic necrosis (PN). The objective of this study is to compare the safety and efficacy of early ETD with PCD in patients with symptomatic PN. Patients and Methods Retrospective analysis of database of patients with symptomatic PN treated early (<4 weeks of onset of AP) with either ETD (encapsulated wall on EUS) or PCD. Results Twenty-three patients (19 M; mean age: 36.1 years) were treated with ETD and 41 patients (29 M; mean age: 39.6 years) were treated with PCD, respectively. ETD and PCD were done 24.2 ± 2.3 and 24.2 ± 2.0 days after onset of AP, respectively (P = 0.84). In the ETD group, 35% of patients were treated with self-expanding metallic stents and 48% of patients required direct endoscopic necrosectomy. In the PCD group, 74% of patients were treated with multiple catheters and 91% of patients with either saline or streptokinase irrigation. As compared to the ETD group, patients in the PCD group took longer time for resolution (61.9 ± 22.9 days vs. 30.9 ± 5.6 days; P < 0.00001), increased need for surgery (30% vs. 4%; P = 0.01), and frequency of formation of external pancreatic fistula (EPF) (22% vs. nil; P = 0.02). Conclusions ETD of PN in early phase of illness is associated with a shorter duration for resolution and infrequent need of salvage surgery compared to PCD. EPF formation is a significant adverse event with PCD.
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Affiliation(s)
- Surinder Singh Rana
- Department of Gastroenterology, Postgraduate Institute of Medical Education and Research, Chandigarh, India
| | - Suhang Verma
- Department of Gastroenterology, Postgraduate Institute of Medical Education and Research, Chandigarh, India
| | - Mandeep Kang
- Department of Radiodiagnosis, Postgraduate Institute of Medical Education and Research, Chandigarh, India
| | - Ujjwal Gorsi
- Department of Radiodiagnosis, Postgraduate Institute of Medical Education and Research, Chandigarh, India
| | - Ravi Sharma
- Department of Gastroenterology, Postgraduate Institute of Medical Education and Research, Chandigarh, India
| | - Rajesh Gupta
- Department of Surgical Gastroenterology, Postgraduate Institute of Medical Education and Research, Chandigarh, India
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Lavage through percutaneous catheter drains in severe acute pancreatitis: Does it help?A randomized control trial. Pancreatology 2019; 19:929-934. [PMID: 31521496 DOI: 10.1016/j.pan.2019.09.003] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/26/2019] [Revised: 08/19/2019] [Accepted: 09/07/2019] [Indexed: 02/07/2023]
Abstract
AIMS There is no study comparing large volume lavage through image guided percutaneously placed drains in severe acute pancreatitis. METHODS Of the 114 randomized patients, 60 eligible candidates were randomly allocated to - Lavage Treatment (LT) group (28 patients) and Dependent Drainage (DD) group (32 patients). Primary end point was reversal of pre-existing organ failure, development of new onset organ failure, need for surgery, mortality and hospital stay. RESULTS Both the groups were comparable in terms of demographic data, onset and severity of pancreatitis. LT group had higher infected pancreatic necrosis (75% vs 50%,p = 0.047). On intention to treat analysis, lavage treatment group showed a significant reversal of persistent organ failure (84% vs 50%, p = 0.23), reduction in APACHEII scores (3.5 ± 3.405 vs 1.16 ± 3.811 p = 0.012), as measured at the time of placement of PCD to cessation of intervention. There was no difference in development of new onset organ failure in the two groups (25% vs37.5% p=.290). 75% in LT group and 69% in DD group improved with PCD alone. There was no difference in the catheter related complications and number of catheters used. The need for surgical intervention was comparable in two groups (18.8% vs 14.3% p=.737). There was a trend toward decreased mortality in group A (18.8% vs 28.8% p=.370). CONCLUSION Large volume lavage trough PCD improves organ failure and this translates into trend towards reduced mortality.
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Sharma V, Rana SS, Bhasin DK. Endoscopic ultrasound guided interventional procedures. World J Gastrointest Endosc 2015; 7:628-42. [PMID: 26078831 PMCID: PMC4461937 DOI: 10.4253/wjge.v7.i6.628] [Citation(s) in RCA: 34] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/31/2014] [Revised: 01/24/2015] [Accepted: 02/09/2015] [Indexed: 02/05/2023] Open
Abstract
Endoscopic ultrasound (EUS) has emerged as an important diagnostic and therapeutic modality in the field of gastrointestinal endoscopy. EUS provides access to many organs and lesions which are in proximity to the gastrointestinal tract and thus giving an opportunity to target them for therapeutic and diagnostic purposes. This modality also provides a real time opportunity to target the required area while avoiding adjacent vascular and other structures. Therapeutic EUS has found role in management of pancreatic fluid collections, biliary and pancreatic duct drainage in cases of failed endoscopic retrograde cholangiopancreatography, drainage of gallbladder, celiac plexus neurolysis/blockage, drainage of mediastinal and intra-abdominal abscesses and collections and in targeted cancer chemotherapy and radiotherapy. Infact, therapeutic EUS has emerged as the therapy of choice for management of pancreatic pseudocysts and recent innovations like fully covered removable metallic stents have improved results in patients with organised necrosis. Similarly, EUS guided drainage of biliary tract and pancreatic duct helps drainage of these systems in patients with failed cannulation, inaccessible papilla as with duodenal/gastric obstruction or surgically altered anatomy. EUS guided gall bladder drainage is a useful emergent procedure in patients with acute cholecystitis who are not fit for surgery. EUS guided celiac plexus neurolysis and blockage is more effective and less morbid vis-à-vis the percutaneous technique. The field of interventional EUS is rapidly advancing and many more interventions are being continuously added. This review focuses on the current status of evidence vis-à-vis the established indications of therapeutic EUS.
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Aspect of thrombolytic therapy: a review. ScientificWorldJournal 2014; 2014:586510. [PMID: 25574487 PMCID: PMC4276353 DOI: 10.1155/2014/586510] [Citation(s) in RCA: 31] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/10/2014] [Accepted: 11/16/2014] [Indexed: 01/23/2023] Open
Abstract
Thrombolytic therapy, also known as clot busting drug, is a breakthrough treatment which has saved untold lives. It has been used in the clinical area to treat venous and arterial thromboembolic complaints which are a foremost cause of death. In 1761, Morgagni lead the way of thrombolytic therapy. Now day's different types of thrombolytic drugs are currently available in market: alteplase, anistreplase, urokinase, streptokinase, tenecteplase, and so forth. Thrombolytic therapy should be given with maintaining proper care in order to minimize the risk of clinically important bleeding as well as enhance the chances of successfully thrombolysis of clot. These cares include preinfusion care, during the infusion care, and postinfusion care. Besides proper knowledge of contraindication, evolutionary factor, and combination of drug is essential for successful thrombolytic therapy. In these review we discussed about these aspect of thrombolytic therapy.
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