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Pavlek G, Romic I, Kekez D, Zedelj J, Bubalo T, Petrovic I, Deban O, Baotic T, Separovic I, Strajher IM, Bicanic K, Pavlek AE, Silic V, Tolic G, Silovski H. Step-Up versus Open Approach in the Treatment of Acute Necrotizing Pancreatitis: A Case-Matched Analysis of Clinical Outcomes and Long-Term Pancreatic Sufficiency. J Clin Med 2024; 13:3766. [PMID: 38999333 PMCID: PMC11242895 DOI: 10.3390/jcm13133766] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/03/2024] [Revised: 06/18/2024] [Accepted: 06/19/2024] [Indexed: 07/14/2024] Open
Abstract
Background/Objectives: Acute necrotizing pancreatitis (ANP) with secondary infection of necrotic tissue is associated with a high rate of complications and mortality. The optimal approach is still debatable, but the minimally invasive modality has gained great attention in the last decade as it follows the principle of applying minimal surgical trauma to achieve a satisfying therapeutic objective. We compared clinical outcomes between the step-up approach (SUA) and open necrosectomy (ON) in the treatment of acute necrotizing pancreatitis. Methods: A prospective cohort study over the period of 2011-2021 in a university teaching hospital was performed. Results of 99 consecutive patients with ANP who required surgical/radiological intervention were collected. A case match analysis (2:1) was performed, and the final groups comprised 40 patients in the OA group and 20 patients in the SUA group. Demographic, clinicopathologic, and treatment data were reviewed. Results: Baseline characteristics and disease severity were comparable between the two groups. The patients from the SUA group had a significantly lower morbidity rate and rate of pancreatic insufficiency. Death occurred in 4 of 20 patients (20%) in the SUA group and in 11 of 40 patients (27.5%) in the ON group (risk ratio with the step-up approach, 0.72; 95% confidence interval, 0.26 to 1.99; p = 0.53). Conclusions: A minimally invasive step-up approach provides comparable outcomes to open necrosectomy in the treatment of ANP with infected pancreatic necrosis. While mortality and hospital stay were comparable between the groups, morbidity and pancreatic insufficiency were significantly lower in the SUA group. Further studies on a larger number of patients are required to define the place of SUA in the modern treatment of ANP.
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Affiliation(s)
- Goran Pavlek
- Department of Surgery, University Hospital Centre Zagreb, 10000 Zagreb, Croatia; (G.P.); (J.Z.); (T.B.); (I.P.)
| | - Ivan Romic
- Department of Surgery, University Hospital Centre Zagreb, 10000 Zagreb, Croatia; (G.P.); (J.Z.); (T.B.); (I.P.)
| | - Domina Kekez
- Department of Oncology, University Hospital Centre Zagreb, 10000 Zagreb, Croatia;
| | - Jurica Zedelj
- Department of Surgery, University Hospital Centre Zagreb, 10000 Zagreb, Croatia; (G.P.); (J.Z.); (T.B.); (I.P.)
| | - Tomislav Bubalo
- Department of Surgery, University Hospital Centre Zagreb, 10000 Zagreb, Croatia; (G.P.); (J.Z.); (T.B.); (I.P.)
| | - Igor Petrovic
- Department of Surgery, University Hospital Centre Zagreb, 10000 Zagreb, Croatia; (G.P.); (J.Z.); (T.B.); (I.P.)
| | - Ognjan Deban
- Department of Surgery, University Hospital Centre Zagreb, 10000 Zagreb, Croatia; (G.P.); (J.Z.); (T.B.); (I.P.)
| | - Tomislav Baotic
- Department of Surgery, University Hospital Centre Zagreb, 10000 Zagreb, Croatia; (G.P.); (J.Z.); (T.B.); (I.P.)
| | - Ivan Separovic
- Department of Surgery, University Hospital Centre Zagreb, 10000 Zagreb, Croatia; (G.P.); (J.Z.); (T.B.); (I.P.)
| | - Iva Martina Strajher
- Department of Surgery, University Hospital Centre Zagreb, 10000 Zagreb, Croatia; (G.P.); (J.Z.); (T.B.); (I.P.)
| | - Kristina Bicanic
- Department of Surgery, University Hospital Centre Zagreb, 10000 Zagreb, Croatia; (G.P.); (J.Z.); (T.B.); (I.P.)
| | | | - Vanja Silic
- Department of Anesthesiology and Intensive Care Medicine, University Hospital Centre Zagreb, 10000 Zagreb, Croatia
| | - Gaja Tolic
- Department of Surgery, University Hospital Centre Zagreb, 10000 Zagreb, Croatia; (G.P.); (J.Z.); (T.B.); (I.P.)
| | - Hrvoje Silovski
- Department of Surgery, University Hospital Centre Zagreb, 10000 Zagreb, Croatia; (G.P.); (J.Z.); (T.B.); (I.P.)
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Zhu H, Wei X. Optimal Timing of Cholecystectomy for Severe Acute Pancreatitis and Understanding Complications and Comorbidities. JAMA Surg 2024; 159:465-466. [PMID: 38198171 DOI: 10.1001/jamasurg.2023.6929] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/11/2024]
Affiliation(s)
- Hong Zhu
- Department of HPB Surgery, The Second Affiliated Hospital of Kunming Medical University, Kunming, Yunnan, China
| | - Xiaoping Wei
- Department of HPB Surgery, The Second Affiliated Hospital of Kunming Medical University, Kunming, Yunnan, China
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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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Internet+Continuous Nursing Mode in Home Nursing of Patients with T-Tube after Hepatolithiasis Surgery. COMPUTATIONAL AND MATHEMATICAL METHODS IN MEDICINE 2022; 2022:9490483. [PMID: 35685900 PMCID: PMC9173949 DOI: 10.1155/2022/9490483] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 04/04/2022] [Revised: 05/11/2022] [Accepted: 05/14/2022] [Indexed: 11/28/2022]
Abstract
This study was to explore the effect of a continuous nursing model based on the mobile Internet in the home nursing of patients with T-tube after hepatolithiasis surgery. A continuous nursing system based on the mobile Internet was constructed, and 94 discharged patients with T-tube after biliary tract surgery were selected as the study subjects. The differences of complication rate, referral rate, nursing satisfaction, self-care ability, and quality of life score through the 36-item short form health survey (SF-36) after routine health education nursing (control group, n = 47) and continuous nursing mode based on the Internet (observation group, n = 47) were explored. The results showed that the success rate of the continuous nursing system based on mobile Internet in processing user requests was 96.2%. After nursing, the total complication rates of the control group and the observation group were 34.0% and 6.4%, the total satisfaction rates were 42.6% and 87.2%, and the referral rates were 23.4% and 6.4%, respectively, and the difference was statistically significant (P < 0.05). After nursing, the scores of self-care ability and SF-36 quality of life in the observation group were higher than those in the control group, and the difference was statistically significant (P < 0.05). In summary, the continuous nursing platform based on mobile Internet technology can meet the needs of users, and the nursing mode can significantly improve the home self-care ability of discharged patients with T-tube after surgery and improve the nursing effect, which is conducive to the rehabilitation of patients.
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