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Shah J, Fernandez Y Viesca M, Jagodzinski R, Arvanitakis M. Infected pancreatic necrosis-Current trends in management. Indian J Gastroenterol 2024; 43:578-591. [PMID: 38625518 DOI: 10.1007/s12664-023-01506-w] [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: 11/06/2023] [Accepted: 12/11/2023] [Indexed: 04/17/2024]
Abstract
Acute necrotizing pancreatitis is a common gastrointestinal disease requiring hospitalization and multiple interventions resulting in higher morbidity and mortality. Development of infection in such necrotic tissue is one of the sentinel events in natural history of necrotizing pancreatitis. Infected necrosis develops in around 1/3rd of patients with necrotizing pancreatitis resulting in higher mortality. So, timely diagnosis of infected necrosis using clinical, laboratory and radiological parameters is of utmost importance. Though initial conservative management with antibiotics and organ support system is effective in some patients, a majority of patients still requires drainage of the collection by various modalities. Mode of drainage of infected pancreatic necrosis depends on various factors such as the clinical status of the patient, location and characteristics of collection and availability of the expertise and includes endoscopic, percutaneous and minimally invasive or open surgical approaches. Endoscopic drainage has proved to be a game changer in the management of infected pancreatic necrosis in the last decade with rapid evolution in procedure techniques, development of novel metal stent and dedicated necrosectomy devices for better clinical outcome. Despite widespread adoption of endoscopic transluminal drainage of pancreatic necrosis with excellent clinical outcomes, peripheral collections are still not amenable for endoscopic drainage and in such scenario, the role of percutaneous catheter drainage or minimally invasive surgical necrosectomy cannot be understated. In a nutshell, the management of patients with infected pancreatic necrosis involves a multi-disciplinary team including a gastroenterologist, an intensivist, an interventional radiologist and a surgeon for optimum clinical outcomes.
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Affiliation(s)
- Jimil Shah
- Department of Gastroenterology, Postgraduate Institute of Medical Education and Research, Chandigarh, 160 012, India
| | - Michael Fernandez Y Viesca
- Department of Gastroenterology, Hepatopancreatology, and Digestive Oncology, Erasme University Hospital, HUB, Université Libre de Bruxelles, Brussels, Belgium
| | | | - Marianna Arvanitakis
- Department of Gastroenterology, Hepatopancreatology, and Digestive Oncology, Erasme University Hospital, HUB, Université Libre de Bruxelles, Brussels, Belgium.
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González-Haba Ruiz M, Betés Ibáñez MT, Martínez Moreno B, Repiso Ortega A, de la Serna Higuera C, Iglesias García J, Sendino García O, Moris Felgueroso M, Agudo Castillo B, Esteban López-Jamar JM, Lindo Ricce MD, Soria San Teodoro MT, Moya Valverde E, Muñoz López D, Uribarri González L, Sevilla Ribota S, Lariño Noia J, Pérez Miranda M, Aparicio Tormo JR, Vila Costas JJ, Vázquez Sequeiros E, Subtil Íñigo JC, Pérez-Cuadrado-Robles E, Sánchez Yagüe A, Núñez Otero JA, Foruny Olcina JR. Endoscopic management of pancreatic collections. Endoscopic Ultrasound Group from the Spanish Society of Digestive Endoscopy (GSEED-USE) Clinical Guidelines. REVISTA ESPANOLA DE ENFERMEDADES DIGESTIVAS 2024. [PMID: 38305682 DOI: 10.17235/reed.2024.10276/2024] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 02/03/2024]
Abstract
Acute pancreatitis is associated with significant morbidity and mortality. It can develop complications such as fluid collections and necrosis. Infection of necrosis occurs in about 20-40% of patients with severe acute pancreatitis, and is associated with organ failure and worse prognosis. In the past years, the treatment of pancreatic collections has shifted from open surgery to minimally invasive techniques, such as endoscopic ultrasound guided drainage. These guidelines from a selection of experts among the Endoscopic Ultrasound Group from the Spanish Society of Gastrointestinal Endoscopy (GSEED-USE) have the purpose to provide advice on the management of pancreatic collections based on a thorough review of the available scientific evidence. It also reflects the experience and clinical practice of the authors, who are advanced endoscopists or clinical pancreatologists with extensive experience in managing patients with acute pancreatitis.
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Gilman AJ, Baron TH. Endoscopic Necrosectomy. Gastrointest Endosc Clin N Am 2023; 33:709-724. [PMID: 37709406 DOI: 10.1016/j.giec.2023.04.010] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 09/16/2023]
Abstract
The management of walled-off necrosis has evolved substantially over the past 23 years since its first description. In this article, we review its history and the evidence supporting modern treatment, which is still subject to heterogeneity across centers and among endoscopists. This allows for creativity and customization of what can be an endoscopic marathon. Our typical practice is discussed with image and video guides aimed at improving procedure success.
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Affiliation(s)
- Andrew J Gilman
- Division of Gastroenterology & Hepatology, University of North Carolina, 130 Mason Farm Road, Bioinformatics Building CB# 7080, Chapel Hill, NC 27599-7080, USA. https://twitter.com/a_gilman
| | - Todd H Baron
- Division of Gastroenterology & Hepatology, University of North Carolina, 130 Mason Farm Road, Bioinformatics Building CB# 7080, Chapel Hill, NC 27599-7080, USA.
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Supportive treatment during the periprocedural period of endoscopic treatment for pancreatic fluid collections: a critical review of current knowledge and future perspectives. J Gastroenterol 2023; 58:98-111. [PMID: 36342540 DOI: 10.1007/s00535-022-01935-y] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/09/2022] [Accepted: 10/28/2022] [Indexed: 11/09/2022]
Abstract
Pancreatic fluid collections (PFCs) commonly develop as complications of acute pancreatitis and ductal disruption due to chronic pancreatitis. In the revised Atlanta classification, PFCs were classified based on the presence of necrosis and duration following the onset of acute pancreatitis. Interventions are required in cases of symptomatic pancreatic pseudocysts or walled-off necrosis (WON). In the management of these PFCs, endoscopic ultrasound-guided transluminal drainage and subsequent direct endoscopic necrosectomy for WON are increasingly utilized as less invasive treatment modalities compared to surgical debridement. To date, researchers have focused predominantly on the technical aspects of endoscopic therapy for symptomatic PFCs. Given the poor physical condition of patients receiving endoscopic treatment for PFCs, systemic support may have a substantial impact on the short- and long-term outcomes of these patients. A multidisciplinary approach is required to improve the clinical outcomes of patients with infected PFCs and their associated comorbidities. However, non-interventional support during the periprocedural period of endoscopic treatment of PFCs has not been fully discussed, and there have been considerable variations in the selection of treatment options between endoscopists and centers. To address these unmet needs in the clinical management of PFCs and promote future research to improve the clinical outcomes, we conducted a review of the literature within a multicenter consortium of expert endoscopists with specific expertise in the endoscopic treatment of PFCs. In this review, we summarize the current evidence on non-interventional supportive care (e.g., continuous lavage, medications, nutritional support, and antimicrobials) and propose potential topics for future research.
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Karstensen JG, Novovic S, Hansen EF, Jensen AB, Jorgensen HL, Lauritsen ML, Werge MP, Schmidt PN. EUS-guided drainage of large walled-off pancreatic necroses using plastic versus lumen-apposing metal stents: a single-centre randomised controlled trial. Gut 2022; 72:1167-1173. [PMID: 36446550 DOI: 10.1136/gutjnl-2022-328225] [Citation(s) in RCA: 22] [Impact Index Per Article: 11.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/07/2022] [Accepted: 11/11/2022] [Indexed: 12/03/2022]
Abstract
OBJECTIVE In treating pancreatic walled-off necrosis (WON), lumen-apposing metal stents (LAMS) have not proven superior to the traditional double pigtail technique (DPT). Among patients with large WON (>15 cm) and their associated substantial risk of treatment failure, the increased drainage capacity of a novel 20-mm LAMS might improve clinical outcomes. Hence, we conducted a study comparing the DPT and 20-mm LAMS in patients with large WON. DESIGN A single-centre, open-label, randomised, controlled superiority trial using an endoscopic step-up approach in patients with WON exceeding 15 cm in size. The primary endpoint was the number of necrosectomies needed to achieve clinical success (clinical and CT resolution), while the secondary endpoints included technical success, adverse events, length of stay and mortality. RESULTS Twenty-two patients were included in the DPT group and 20 in the LAMS group, with no significant differences in patient characteristics. The median size of WON was 24.1 cm (P25-P75: 19.6-31.1). The technical success rates were 100% for DPT and 95% for LAMS (p=0.48), while clinical success rates were 95.5% and 94.7%, respectively (p=1.0). The mean number of necrosectomies was 2.2 for DPT and 3.2 for LAMS (p=0.42). Five patients (12%) developed procedure-related serious adverse events (DPT=4, LAMS=1, p=0.35). The median length of stay was 43 (P25-P75: 40-67) and 58 days (P25-P75: 40-86) in the DPT and LAMS groups (p=0.71), respectively, with an overall mortality of 4.8%. CONCLUSIONS For treating large WON, LAMS are not superior to DPT. The techniques are associated with comparable needs for necrosectomy and hospital stay, and no gross difference in adverse events. TRIAL REGISTRATION NUMBER NCT04057846.
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Affiliation(s)
- John Gásdal Karstensen
- Pancreatitis Centre East (PACE), Gastro Unit, Copenhagen University Hospital - Amager and Hvidovre, Hvidovre, Denmark .,Department of Clinical Medicine, University of Copenhagen, Copenhagen, Denmark
| | - Srdan Novovic
- Pancreatitis Centre East (PACE), Gastro Unit, Copenhagen University Hospital - Amager and Hvidovre, Hvidovre, Denmark.,Department of Clinical Medicine, University of Copenhagen, Copenhagen, Denmark
| | - Erik Feldager Hansen
- Pancreatitis Centre East (PACE), Gastro Unit, Copenhagen University Hospital - Amager and Hvidovre, Hvidovre, Denmark
| | - Annette Bojer Jensen
- Department of Radiology, Copenhagen University Hospital - Amager and Hvidovre, Hvidovre, Denmark
| | - Henrik Lovendahl Jorgensen
- Department of Clinical Medicine, University of Copenhagen, Copenhagen, Denmark.,Department of Clinical Biochemistry, Copenhagen University Hospital - Amager and Hvidovre, Hvidovre, Denmark
| | - Morten Laksafoss Lauritsen
- Pancreatitis Centre East (PACE), Gastro Unit, Copenhagen University Hospital - Amager and Hvidovre, Hvidovre, Denmark.,Department of Clinical Medicine, University of Copenhagen, Copenhagen, Denmark
| | - Mikkel Parsberg Werge
- Pancreatitis Centre East (PACE), Gastro Unit, Copenhagen University Hospital - Amager and Hvidovre, Hvidovre, Denmark
| | - Palle Nordblad Schmidt
- Pancreatitis Centre East (PACE), Gastro Unit, Copenhagen University Hospital - Amager and Hvidovre, Hvidovre, Denmark
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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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Bansal A, Gupta P, Singh AK, Shah J, Samanta J, Mandavdhare HS, Sharma V, Sinha SK, Dutta U, Sandhu MS, Kochhar R. Drainage of pancreatic fluid collections in acute pancreatitis: A comprehensive overview. World J Clin Cases 2022; 10:6769-6783. [PMID: 36051118 PMCID: PMC9297419 DOI: 10.12998/wjcc.v10.i20.6769] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/26/2021] [Revised: 01/10/2022] [Accepted: 05/14/2022] [Indexed: 02/06/2023] Open
Abstract
Moderately severe and severe acute pancreatitis is characterized by local and systemic complications. Systemic complications predominate the early phase of acute pancreatitis while local complications are important in the late phase of the disease. Necrotic fluid collections represent the most important local complication. Drainage of these collections is indicated in the setting of infection, persistent or new onset organ failure, compressive or pressure symptoms, and intraabdominal hypertension. Percutaneous, endoscopic, and minimally invasive surgical drainage represents the various methods of drainage with each having its own advantages and disadvantages. These methods are often complementary. In this minireview, we discuss the indications, timing, and techniques of drainage of pancreatic fluid collections with focus on percutaneous catheter drainage. We also discuss the novel methods and techniques to improve the outcomes of percutaneous catheter drainage.
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Affiliation(s)
- Akash Bansal
- Department of Radiodiagnosis, Postgraduate Institute of Medical Education and Research, Chandigarh 160012, India
| | - Pankaj Gupta
- Department of Radiodiagnosis, Postgraduate Institute of Medical Education and Research, Chandigarh 160012, India
| | - Anupam K Singh
- Department of Gastroenterology, Postgraduate Institute of Medical Education and Research, Chandigarh 160012, India
| | - Jimil Shah
- Department of Gastroenterology, Postgraduate Institute of Medical Education and Research, Chandigarh 160012, India
| | - Jayanta Samanta
- Department of Gastroenterology, Postgraduate Institute of Medical Education and Research, Chandigarh 160012, India
| | - Harshal S Mandavdhare
- Department of Gastroenterology, Postgraduate Institute of Medical Education and Research, Chandigarh 160012, India
| | - Vishal Sharma
- Department of Gastroenterology, Postgraduate Institute of Medical Education and Research, Chandigarh 160012, India
| | - Saroj Kant Sinha
- Department of Gastroenterology, Postgraduate Institute of Medical Education and Research, Chandigarh 160012, India
| | - Usha Dutta
- Department of Gastroenterology, Postgraduate Institute of Medical Education and Research, Chandigarh 160012, India
| | - Manavjit Singh Sandhu
- Department of Radiodiagnosis, Postgraduate Institute of Medical Education and Research, Chandigarh 160012, India
| | - Rakesh Kochhar
- Department of Gastroenterology, Postgraduate Institute of Medical Education and Research, Chandigarh 160012, India
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8
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Fan N, Hu Y, Shen H, Liu S, Zhao G, Sun L, Li C, Zhao X, Li Y, Wang J, Cui Y. Compositional and drug-resistance profiling of pathogens in patients with severe acute pancreatitis: a retrospective study. BMC Gastroenterol 2020; 20:405. [PMID: 33261570 PMCID: PMC7709241 DOI: 10.1186/s12876-020-01563-x] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/17/2020] [Accepted: 11/26/2020] [Indexed: 12/15/2022] Open
Abstract
Background Infection is one of the important causes of death in patients with severe acute pancreatitis (SAP), but the bacterial spectrum and antibiotic resistance are constantly changing. Making good use of antibiotics and controlling multi-drug-resistant (MDR) bacterial infections are of vital importance in improving the cure rate of SAP. We conducted a retrospective study in the hope of providing references for antibiotic selection and control of drug-resistant bacteria. Methods Retrospective analysis was performed on the data of patients hospitalized in our hospital due to acute pancreatitis (AP) in the past 5 years. General data were classified and statistically analyzed. Subsequently, the bacterial spectrum characteristics and the data related to drug-resistant bacterial infection of 569 AP patients were analyzed. Finally, unconditional logistic regression analysis was conducted to analyze the risk factors of MDR infection. Results A total of 398 patients were enrolled in this study and the hospitalization data and associated results were analyzed. A total of 461 strains of pathogenic bacteria were detected, including 223 (48.4%) gram-negative bacterial strains, 190 (41.2%) gram-positive bacterial strains and 48 (10.4%) fungal strains. The detection rates of resistance in gram-negative and gram-positive bacterial strains were 48.0% (107/223) and 25.3% (48/190), respectively. There were significant differences between the MDR group and the non-MDR group for the factors of precautionary antibiotic use, kinds of antibiotics used, receipt of carbapenem, tracheal intubation, hemofiltration and number of hospitalization days in the intensive care unit. Unconditional logistic regression revealed 2 risk factors for MDR bacterial infection. Conclusions Our results illustrate that gram-negative bacteria were the most common pathogens in SAP infection, and the proportion of gram-positive bacteria increased notably. The rate of antibiotic resistance was higher than previously reported. Unconditional logistic regression analysis showed that using more types of antibiotics and the number of hospitalization days in the ICU were the risk factors associated with MDR bacterial infection.
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Affiliation(s)
- Ning Fan
- Department of Surgery, Beichen Chinese Medicine Hospital, Tianjin University of Traditional Chinese Medicine, Tianjin, China
| | - Yong Hu
- Zhongnan Hospital of Wuhan University, No. 167, Donghu Road, Wuchang District, Wuhan, 430000, China
| | - Hong Shen
- Department of Surgery, Characteristic Medical Center of the Chinese People's Armed Police Force, Tianjin, China
| | - Shengjie Liu
- Tianjin University of Traditional Chinese Medicine, Tianjin, China
| | - Guang Zhao
- Tianjin Nankai Hospital, Nankai Clinical School of Medicine, Tianjin Medical University, Tianjin, China
| | - Lanju Sun
- Tianjin Nankai Hospital, Nankai Clinical School of Medicine, Tianjin Medical University, Tianjin, China
| | - Chunyan Li
- Department of Gastroenterology, Affiliated Hospital of Panzhihua University, Nanchong, China
| | - Xin Zhao
- Department of Breast Surgery,Affiliated Cancer Hospital of Zhengzhou University, Henan Cancer Hospital, Zhengzhou, China
| | - Yanning Li
- Department of Surgery, Beichen Chinese Medicine Hospital, Tianjin University of Traditional Chinese Medicine, Tianjin, China
| | - Jianhua Wang
- Department of Surgery, Beichen Chinese Medicine Hospital, Tianjin University of Traditional Chinese Medicine, Tianjin, China
| | - Yunfeng Cui
- Tianjin Nankai Hospital, Nankai Clinical School of Medicine, Tianjin Medical University, Tianjin, China. .,Department of Surgery, Tianjin Nankai Hospital, Nankai Clinical School of Medicine, Tianjin Medical University, 122 Sanwei Road Nankai District, Tianjin, China.
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Gupta P, Gupta J, Kumar C, Samanta J, Mandavdhare H, Sharma V, Sinha SK, Gupta V, Yadav TD, Dutta U, Kochhar R. Aggressive Percutaneous Catheter Drainage Protocol for Necrotic Pancreatic Collections. Dig Dis Sci 2020; 65:3696-3701. [PMID: 32026280 DOI: 10.1007/s10620-020-06116-6] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/02/2019] [Accepted: 01/27/2020] [Indexed: 12/14/2022]
Abstract
BACKGROUND Percutaneous catheter drainage (PCD) performed pro-actively for collections in acute pancreatitis (AP) is associated with better outcomes. However, there are only a few studies describing this protocol. AIM We aimed to evaluate an aggressive PCD protocol. METHODS Consecutive patients with AP who underwent PCD with an aggressive protocol between January 2018 and January 2019 were included. This protocol involved catheter upsizing at a pre-specified interval (every 4-6 days) as well as drainage of all the new collections. The indications and technical details of PCD and clinical outcomes were compared with patients who underwent standard PCD. RESULTS Out of the 185 patients with AP evaluated during the study period, 110 (59.4%) underwent PCD, all with the aggressive protocol. The historical cohort of standard PCD comprised of 113 patients. There was no significant difference in the indication of PCD and interval from pain onset to PCD between the two groups. The mean number of catheters was significantly higher in the aggressive PCD group (1.86 ± 0.962 vs. 1.44 ± 0.667, p = 0.002). Additional catheters were inserted in 54.2% of patients in aggressive group vs. 36.2% in the standard group (p = 0.006). Length of hospital stay and intensive care unit (ICU) stay were significantly longer in the standard PCD group (34.3 ± 20.14 vs. 27.45 ± 14.2 days, p < 0.001 and 10.46 ± 12.29 vs. 4.12 ± 8.5, p = 0.009, respectively). There was no significant difference in mortality and surgery between the two groups. CONCLUSION Aggressive PCD protocol results in reduced length of hospital stay and ICU stay and can reduce hospitalization costs.
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Affiliation(s)
- Pankaj Gupta
- Department of Gastroenterology, Postgraduate Institute of Medical Education and Research (PGIMER), Chandigarh, 160012, India
| | - Jyoti Gupta
- Department of Radiodiagnosis and Imaging, Postgraduate Institute of Medical Education and Research (PGIMER), Chandigarh, 160012, India
| | - Chandan Kumar
- Department of Radiodiagnosis and Imaging, Postgraduate Institute of Medical Education and Research (PGIMER), Chandigarh, 160012, India
| | - Jayanta Samanta
- Department of Gastroenterology, Postgraduate Institute of Medical Education and Research (PGIMER), Chandigarh, 160012, India
| | - Harshal Mandavdhare
- Department of Gastroenterology, Postgraduate Institute of Medical Education and Research (PGIMER), Chandigarh, 160012, India
| | - Vishal Sharma
- Department of Gastroenterology, Postgraduate Institute of Medical Education and Research (PGIMER), Chandigarh, 160012, India
| | - Saroj K Sinha
- Department of Gastroenterology, Postgraduate Institute of Medical Education and Research (PGIMER), Chandigarh, 160012, India
| | - Vikas Gupta
- Department of Surgery, Postgraduate Institute of Medical Education and Research (PGIMER), Chandigarh, 160012, India
| | - Thakur Deen Yadav
- Department of Surgery, Postgraduate Institute of Medical Education and Research (PGIMER), Chandigarh, 160012, India
| | - Usha Dutta
- Department of Gastroenterology, Postgraduate Institute of Medical Education and Research (PGIMER), Chandigarh, 160012, India
| | - Rakesh Kochhar
- Department of Gastroenterology, Postgraduate Institute of Medical Education and Research (PGIMER), Chandigarh, 160012, India.
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García García de Paredes A, López-Durán S, Foruny Olcina JR, Albillos A, Vázquez-Sequeiros E. Management of pancreatic collections: an update. REVISTA ESPANOLA DE ENFERMEDADES DIGESTIVAS 2020; 112:483-490. [PMID: 32450706 DOI: 10.17235/reed.2020.6814/2019] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
Pancreatic fluid collections frequently occur in the context of moderate and severe acute pancreatitis, and may also appear as a complication of chronic pancreatitis, pancreatic surgery or trauma. It is essential to adhere to the Atlanta classification nomenclature that subclassifies them into four categories (acute peripancreatic fluid collections, acute necrotic collections, pseudocysts, and walled-off necrosis) since it has an impact on prognosis and management. Pseudocysts and walled-off pancreatic necrosis are encapsulated pancreatic fluid collections characterized by a surrounding inflammatory wall, which typically develops three to four weeks after the onset of acute pancreatitis. Most pancreatic fluid collections resolve spontaneously and do not require intervention. However, when they become symptomatic or complicated drainage is indicated, and endoscopic ultrasound-guided drainage has become first-line treatment of encapsulated collections. Drainage of pseudocysts is relatively straightforward due to their liquid content. However, in walled-off necrosis the presence of solid necrotic debris can make treatment more challenging and therefore multidisciplinary management in experienced centers is recommended, being a step-up approach the current standard of care. In this review, we aim to address the management of pancreatic fluid collections with an especial focus on endoscopic drainage.
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Affiliation(s)
| | - Sergio López-Durán
- Gastroenterología y Hepatología, Hospital Universitario Ramón y Cajal. Unviersidad de Alcalá. IRYICIS, España
| | - José Ramón Foruny Olcina
- Gastroenterología y Hepatología, Hospital Universitario Ramón y Cajal. Unviersidad de Alcalá. IRYICIS, España
| | - Agustín Albillos
- Gastroenterología y Hepatología, Hospital Universitario Ramón y Cajal. Unviersidad de Alcalá. IRYICIS, España
| | - Enrique Vázquez-Sequeiros
- Gastroenterología y Hepatología, Hospital Universitario Ramón y Cajal. Unviersidad de Alcalá. IRYICIS, España
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11
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Lariño-Noia J, de la Iglesia-García D, González-Lopez J, Díaz-Lopez J, Macías-García F, Mejuto R, Quiroga A, Mauriz V, Jardí A, Iglesias-García J, Domínguez-Muñoz JE. Endoscopic drainage with local infusion of antibiotics to avoid necrosectomy of infected walled-off necrosis. Surg Endosc 2020; 35:644-651. [PMID: 32076856 DOI: 10.1007/s00464-020-07428-4] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/01/2019] [Accepted: 02/10/2020] [Indexed: 12/29/2022]
Abstract
BACKGROUND Current treatment of infected pancreatic necrosis (IPN) follows a step-up approach. Our group designed a step-up protocol that associates endoscopic drainage with local infusion of antibiotics through transmural nasocystic catheter. Aim of our study was to evaluate our step-up protocol for IPN in terms of proportion of patients avoiding necrosectomy. METHODS Retrospective analysis of patients admitted with acute pancreatitis (AP) between January 2015 and December 2018. The number of patients who responded to each therapeutic step were analysed: step 1, systemic antibiotics; step 2, endoscopic transmural drainage and local infusion of antibiotics; step 3, endoscopic necrosectomy. RESULTS 1158 patients with AP were included. 110 patients (8.4%) suffered from necrotising pancreatitis; 48 of them had IPN (42.6% of necrotising pancreatitis) and were treated with systemic antibiotics. Nineteen patients (39.6% of IPN) responded and did not required any invasive therapy. Six patients with IPN on systemic antibiotics died within the first 4 weeks of disease before step 2 could be applied. Urgent surgical necrosectomy in the first 4 weeks was performed in three additional patients. Endoscopic drainage and local antibiotic therapy was performed in the remaining 20 patients; 9 (45% of them) did well and 9 patients underwent necrosectomy (18.7% of IPN). Two patients died on drainage. Overall mortality of the total cohort of AP was 2.53% CONCLUSIONS: Addition of local infusion of antibiotics to endoscopic drainage avoids the need of necrosectomy in half of patients with IPN not responding to systemic antibiotics.
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Affiliation(s)
- Jose Lariño-Noia
- Department of Gastroenterology and Hepatology, University Hospital of Santiago de Compostela, C/Choupana S/N, 15706, Santiago de Compostela, Spain.
| | - Daniel de la Iglesia-García
- Department of Gastroenterology and Hepatology, University Hospital of Santiago de Compostela, C/Choupana S/N, 15706, Santiago de Compostela, Spain
| | - Jaime González-Lopez
- Department of Pharmacy, University Hospital of Santiago de Compostela, Santiago de Compostela, Spain
| | - Javier Díaz-Lopez
- Department of Gastroenterology and Hepatology, University Hospital of Santiago de Compostela, C/Choupana S/N, 15706, Santiago de Compostela, Spain
| | - Fernando Macías-García
- Department of Gastroenterology and Hepatology, University Hospital of Santiago de Compostela, C/Choupana S/N, 15706, Santiago de Compostela, Spain
| | - Rafael Mejuto
- Department of Gastroenterology and Hepatology, University Hospital of Santiago de Compostela, C/Choupana S/N, 15706, Santiago de Compostela, Spain
| | - Adriano Quiroga
- Department of Gastroenterology and Hepatology, University Hospital of Santiago de Compostela, C/Choupana S/N, 15706, Santiago de Compostela, Spain
| | - Violeta Mauriz
- Department of Gastroenterology and Hepatology, University Hospital of Santiago de Compostela, C/Choupana S/N, 15706, Santiago de Compostela, Spain
| | - Andrea Jardí
- Department of Gastroenterology and Hepatology, University Hospital of Santiago de Compostela, C/Choupana S/N, 15706, Santiago de Compostela, Spain
| | - Julio Iglesias-García
- Department of Gastroenterology and Hepatology, University Hospital of Santiago de Compostela, C/Choupana S/N, 15706, Santiago de Compostela, Spain
| | - J Enrique Domínguez-Muñoz
- Department of Gastroenterology and Hepatology, University Hospital of Santiago de Compostela, C/Choupana S/N, 15706, Santiago de Compostela, Spain
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Trikudanathan G, Wolbrink DRJ, van Santvoort HC, Mallery S, Freeman M, Besselink MG. Current Concepts in Severe Acute and Necrotizing Pancreatitis: An Evidence-Based Approach. Gastroenterology 2019; 156:1994-2007.e3. [PMID: 30776347 DOI: 10.1053/j.gastro.2019.01.269] [Citation(s) in RCA: 185] [Impact Index Per Article: 37.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/08/2018] [Revised: 01/01/2019] [Accepted: 01/15/2019] [Indexed: 02/07/2023]
Abstract
The incidence of acute pancreatitis continues to rise, inducing substantial medical and social burden, with annual costs exceeding $2 billion in the United States alone. Although most patients develop mild pancreatitis, 20% develop severe and/or necrotizing pancreatitis, requiring advanced medical and interventional care. Morbidity resulting from local and systemic complications as well as invasive interventions result in mortality rates historically as high as 30%. There has been substantial evolution of strategies for interventions in recent years, from open surgery to minimally invasive surgical and endoscopic step-up approaches. In contrast to the advances in invasive procedures for complications, early management still lacks curative options and consists of adequate fluid resuscitation, analgesics, and monitoring. Many challenges remain, including comprehensive management of the entire spectrum of the disease, which requires close involvement of multiple disciplines at specialized centers.
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Affiliation(s)
- Guru Trikudanathan
- Division of Gastroenterology, Hepatology and Nutrition, University of Minnesota, Minneapolis, Minnesota.
| | | | - Hjalmar C van Santvoort
- Department of Surgery, the University Medical Center Utrecht and the St. Antonius Hospital Nieuwegein, the Netherlands
| | - Shawn Mallery
- Division of Gastroenterology, Hepatology and Nutrition, University of Minnesota, Minneapolis, Minnesota
| | - Martin Freeman
- Division of Gastroenterology, Hepatology and Nutrition, University of Minnesota, Minneapolis, Minnesota
| | - Marc G Besselink
- Department of Surgery, Amsterdam Gastroenterology and Metabolism, Amsterdam UMC, University of Amsterdam, the Netherlands
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