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Cardinal von Widdern J, Stangl F, Wohlgemuth WA, Brill R, Kleeff J, Rosendahl J. Persisting Cutaneous Pancreatic Fistula in a Patient With Necrotizing Pancreatitis: A Novel Approach of Transfistulous Histoacryl Occlusion. ACG Case Rep J 2024; 11:e01456. [PMID: 39176215 PMCID: PMC11340911 DOI: 10.14309/crj.0000000000001456] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/01/2024] [Accepted: 07/01/2024] [Indexed: 08/24/2024] Open
Abstract
Necrotizing pancreatitis with superinfection of necrotic tissue is associated with a high rate of complications and mortality. The step-up approach is a well-established treatment strategy for necrotizing pancreatitis, emphasizing minimally invasive and endoscopic interventions before considering surgical options. Minimally invasive strategies often involve percutaneous drainage of collections, which carries the risk of persisting cutaneous pancreatic fistulas. Since there is currently no guidance for managing this scenario, we present a novel treatment approach that utilized tissue glue to occlude a persisting and clinically compromising percutaneous fistula. In addition, we summarize the current knowledge in the treatment of percutaneous pancreatic fistulas and provide a potential therapeutic algorithm for further evaluation.
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Affiliation(s)
- Julian Cardinal von Widdern
- Department for Internal Medicine I (Gastroenterology, Pulmonology), University Hospital Halle (Saale), Halle, Germany
| | - Franz Stangl
- Department for Diagnostic and Interventional Radiology, University Hospital Halle (Saale), Halle, Germany
- Department of Diagnostic and Interventional Neuroradiology, University Hospital Augsburg, Augsburg, Germany
| | - Walter A. Wohlgemuth
- Department for Diagnostic and Interventional Radiology, University Hospital Halle (Saale), Halle, Germany
| | - Richard Brill
- Department for Diagnostic and Interventional Radiology, University Hospital Halle (Saale), Halle, Germany
| | - Jörg Kleeff
- Department of Visceral, Vascular and Endocrine Surgery, University Hospital Halle (Saale), Halle, Germany
| | - Jonas Rosendahl
- Department for Internal Medicine I (Gastroenterology, Pulmonology), University Hospital Halle (Saale), Halle, Germany
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Chhabra M, Gupta P, Shah J, Samanta J, Mandavdhare H, Sharma V, Sinha SK, Dutta U, Kochhar R. Imaging Diagnosis and Management of Fistulas in Pancreatitis. Dig Dis Sci 2024; 69:335-348. [PMID: 38114791 DOI: 10.1007/s10620-023-08173-z] [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: 10/27/2023] [Indexed: 12/21/2023]
Abstract
Pancreatic fistula is a highly morbid complication of pancreatitis. External pancreatic fistulas result when pancreatic secretions leak externally into the percutaneous drains or external wound (following surgery) due to the communication of the peripancreatic collection with the main pancreatic duct (MPD). Internal pancreatic fistulas include communication of the pancreatic duct (directly or via intervening collection) with the pleura, pericardium, mediastinum, peritoneal cavity, or gastrointestinal tract. Cross-sectional imaging plays an essential role in the management of pancreatic fistulas. With the help of multiplanar imaging, fistulous tracts can be delineated clearly. Thin computed tomography sections and magnetic resonance cholangiopancreatography images may demonstrate the communication between MPD and pancreatic fluid collections or body cavities. Endoscopic retrograde cholangiography (ERCP) is diagnostic as well as therapeutic. In this review, we discuss the imaging diagnosis and management of various types of pancreatic fistulas with the aim to sensitize radiologists to timely diagnosis of this critical complication of pancreatitis.
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Affiliation(s)
- Manika Chhabra
- Department of Radiodiagnosis and Imaging, Postgraduate Institute of Medical Education and Research, Chandigarh, India
| | - Pankaj Gupta
- Department of Radiodiagnosis and Imaging, Postgraduate Institute of Medical Education and Research, Chandigarh, India.
| | - Jimil Shah
- Department of Gastroenterology, Postgraduate Institute of Medical Education and Research, Chandigarh, India
| | - Jayanta Samanta
- Department of Gastroenterology, Postgraduate Institute of Medical Education and Research, Chandigarh, India
| | - Harshal Mandavdhare
- Department of Gastroenterology, Postgraduate Institute of Medical Education and Research, Chandigarh, India
| | - Vishal Sharma
- Department of Gastroenterology, Postgraduate Institute of Medical Education and Research, Chandigarh, India
| | - Saroj K Sinha
- Department of Gastroenterology, Postgraduate Institute of Medical Education and Research, Chandigarh, India
| | - Usha Dutta
- Department of Gastroenterology, Postgraduate Institute of Medical Education and Research, Chandigarh, India
| | - Rakesh Kochhar
- Department of Gastroenterology, Postgraduate Institute of Medical Education and Research, Chandigarh, India
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3
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Basha J, Lakhtakia S. Management of Disconnected Pancreatic Duct. Gastrointest Endosc Clin N Am 2023; 33:753-770. [PMID: 37709409 DOI: 10.1016/j.giec.2023.04.004] [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
Disconnected pancreatic duct (DPD) is common after acute necrotizing pancreatitis (ANP). Its clinical implications vary according to the course of disease. In the early phase of ANP, parenchymal necrosis along with disruption of pancreatic duct cause acute necrotic collection that evolves into walled-off necrosis (WON). In the later phase, DPD becomes evident as confirmed by magnetic resonance cholangiopancreatography. Clinical manifestations of DPD can vary from being asymptomatic, recurrent pain, recurrent pancreatic fluid collection (PFC), obstructive pancreatitis, or external pancreatic fistula (EPF). Few patients develop new-onset diabetes. Long-term indwelling plastic stents have been proposed to prevent the recurrent PFC.
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Affiliation(s)
- Jahangeer Basha
- Department of Gastroenterology, Asian Institute of Gastroenterology, AIG Hospitals, Gachibowli, Hyderabad 500032, Telangana, India
| | - Sundeep Lakhtakia
- Department of Gastroenterology, Asian Institute of Gastroenterology, AIG Hospitals, Gachibowli, Hyderabad 500032, Telangana, India.
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Ödemiş B, Durak MB, Atay A, Başpınar B, Erdoğan Ç. A Step-Up Approach Using Alternative Endoscopic Modalities Is an Effective Strategy for Postoperative and Traumatic Pancreatic Duct Disruption. Dig Dis Sci 2023; 68:3745-3755. [PMID: 37358637 DOI: 10.1007/s10620-023-07996-0] [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: 10/10/2022] [Accepted: 02/21/2023] [Indexed: 06/27/2023]
Abstract
BACKGROUND AND AIMS Standard endotherapy for pancreatic duct (PD) disruption is pancreatic stenting and sphincterotomy. In patients refractory to standard treatment, treatment algorithm is currently not standardized. This study aims to report the 10-year experience with the endoscopic treatment of postoperative or traumatic PD disruption and to share our algorithmic approach. METHODS This retrospective study was conducted on 30 consecutive patients who underwent endoscopic treatment for postoperative (n = 26) or traumatic (n = 4) PD disruption between 2011 and 2021. Standard treatment was initially applied to all patients. Endoscopic modalities used with a step-up approach in patients unresponsive to standard treatment were stent upsizing and N-butyl-2-cyanoacrilate (NBCA) injection for partial disruption, and the bridging of the disruption with a stent and cystogastrostomy for complete disruption. RESULTS PD disruption was partial in 26 and complete in 4 patients. Cannulation and stenting of PD was successful in all patients and sphincterotomy was performed in 22 patients. Standard treatment was successful in 20 patients (66.6%). The resolution of PD disruption in 9 of 10 patients refractory to standard treatment was achieved with stent upsizing in 4, NBCA injection in 2, the bridging of the complete disruption in one, and cystogastrostomy after spontaneously and intentionally developed pseudocyst in one patient each. Overall, therapeutic success rate was 96.6% (100% for partial, 75% for complete disruption). Procedural complications occurred in 7 patients. CONCLUSIONS Standart treatment for PD disruption is usually effective. In patients refractory to standard treatment, the outcome may be improved by step-up approach using alternative endoscopic modalities.
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Affiliation(s)
- Bülent Ödemiş
- Department of Gastroenterology, Ankara City Hospital, University of Health Sciences, Bilkent Avenue, 06800, Çankaya, Ankara, Turkey.
| | - Muhammed Bahaddin Durak
- Department of Gastroenterology, Ankara City Hospital, University of Health Sciences, Bilkent Avenue, 06800, Çankaya, Ankara, Turkey
| | - Ali Atay
- Department of Gastroenterology, Ankara City Hospital, University of Health Sciences, Bilkent Avenue, 06800, Çankaya, Ankara, Turkey
| | - Batuhan Başpınar
- Department of Gastroenterology, Ankara City Hospital, University of Health Sciences, Bilkent Avenue, 06800, Çankaya, Ankara, Turkey
| | - Çağdaş Erdoğan
- Department of Gastroenterology, Ankara City Hospital, University of Health Sciences, Bilkent Avenue, 06800, Çankaya, Ankara, Turkey
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Zerem E, Kurtcehajic A, Kunosić S, Zerem Malkočević D, Zerem O. Current trends in acute pancreatitis: Diagnostic and therapeutic challenges. World J Gastroenterol 2023; 29:2747-2763. [PMID: 37274068 PMCID: PMC10237108 DOI: 10.3748/wjg.v29.i18.2747] [Citation(s) in RCA: 20] [Impact Index Per Article: 20.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/09/2023] [Revised: 02/07/2023] [Accepted: 04/18/2023] [Indexed: 05/11/2023] Open
Abstract
Acute pancreatitis (AP) is an inflammatory disease of the pancreas, which can progress to severe AP, with a high risk of death. It is one of the most complicated and clinically challenging of all disorders affecting the abdomen. The main causes of AP are gallstone migration and alcohol abuse. Other causes are uncommon, controversial and insufficiently explained. The disease is primarily characterized by inappropriate activation of trypsinogen, infiltration of inflammatory cells, and destruction of secretory cells. According to the revised Atlanta classification, severity of the disease is categorized into three levels: Mild, moderately severe and severe, depending upon organ failure and local as well as systemic complications. Various methods have been used for predicting the severity of AP and its outcome, such as clinical evaluation, imaging evaluation and testing of various biochemical markers. However, AP is a very complex disease and despite the fact that there are of several clinical, biochemical and imaging criteria for assessment of severity of AP, it is not an easy task to predict its subsequent course. Therefore, there are existing controversies regarding diagnostic and therapeutic modalities, their effectiveness and complications in the treatment of AP. The main reason being the fact, that the pathophysiologic mechanisms of AP have not been fully elucidated and need to be studied further. In this editorial article, we discuss the efficacy of the existing diagnostic and therapeutic modalities, complications and treatment failure in the management of AP.
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Affiliation(s)
- Enver Zerem
- Department of Medical Sciences, The Academy of Sciences and Arts of Bosnia and Herzegovina, Sarajevo 71000, Bosnia and Herzegovina
| | - Admir Kurtcehajic
- Department of Gastroenterology and Hepatology, Plava Medical Group, Tuzla 75000, Bosnia and Herzegovina
| | - Suad Kunosić
- Department of Physics, Faculty of Natural Sciences and Mathematics, University of Tuzla, Tuzla 75000, Bosnia and Herzegovina
| | - Dina Zerem Malkočević
- Department of Internal Medicine, Cantonal Hospital “Safet Mujić“ Mostar, Mostar 88000, Bosnia and Herzegovina
| | - Omar Zerem
- Department of Internal Medicine, Cantonal Hospital “Safet Mujić“ Mostar, Mostar 88000, Bosnia and Herzegovina
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Grover AS, Gugig R, Barakat MT. Endoscopy and Pediatric Pancreatitis. Gastrointest Endosc Clin N Am 2023; 33:363-378. [PMID: 36948751 DOI: 10.1016/j.giec.2022.11.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/24/2023]
Abstract
Children and adolescents are increasingly impacted by pancreatic disease. Interventional endoscopic procedures, including endoscopic retrograde cholangiopancreatography) and endoscopic ultrasonography, are integral to the diagnosis and management of many pancreatic diseases in the adult population. In the past decade, pediatric interventional endoscopic procedures have become more widely available, with invasive surgical procedures now being replaced by safer and less disruptive endoscopic interventions.
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Affiliation(s)
- Amit S Grover
- Division of Gastroenterology, Hepatology and Nutrition, Boston Children's Hospital, Boston, MA 02115, USA
| | - Roberto Gugig
- Division of Pediatric Gastroenterology, Lucille Packard Children's Hospital at Stanford University Medical Center, Stanford, CA 94305, USA
| | - Monique T Barakat
- Division of Pediatric Gastroenterology, Lucille Packard Children's Hospital at Stanford University Medical Center, Stanford, CA 94305, USA; Division of Gastroenterology, Stanford University Medical Center, Stanford, CA 94305, USA.
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7
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Dhali A, Ray S, Mandal TS, Das S, Sarkar A, Khamrui S, Dhali GK. Outcome of surgery for chronic pancreatitis related pancreatic ascites and pancreatic pleural effusion. Ann Med Surg (Lond) 2022; 74:103261. [PMID: 35111305 PMCID: PMC8790598 DOI: 10.1016/j.amsu.2022.103261] [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] [Received: 12/18/2021] [Revised: 01/05/2022] [Accepted: 01/13/2022] [Indexed: 11/20/2022] Open
Abstract
Background An internal pancreatic fistula involves an abnormality in the way that the pancreas communicates with organs and spaces within the body. This is usually due to a disrupted pancreatic duct or psuedocyst leakage (Ascitic or pleural fluid amylase level >1000 S units/dl and fluid protein level >3 g/dl). The study aims to report our experience with surgery for chronic pancreatitis-related pancreatic ascites and pancreatic pleural effusions. Methods All the patients, who underwent surgical intervention for pancreatic ascites and pancreatic pleural effusion between August 2007 and December 2020 in the Department of Surgical gastroenterology, Institute of Postgraduate Medical Education and Research, Kolkata, India were retrospectively reviewed. Results Of the total 14 patients, 10 (71.4%) were men with a median age of 40 (4–49) years. The median interval between onset of symptoms of CP and diagnosis of IPF was 27 (3–60) months. All patients had a history of chronic abdominal pain and 5 (35.7%) had a prior history of hospitalization for pain. Eleven patients (78.5%) presented with abdominal distension and 3 (21.4%) patients had respiratory distress. Six (42.8%) patients had undergone endotherapy before surgery. Contrast-enhanced computed tomography detected pancreatic pseudocyst in 10 (71.42%) patients. The most commonly performed operation was lateral pancreaticojejunostomy (n = 11, 78.5%). Seven postoperative complications developed in 4 (28.5%) patients. After a median follow-up of 60 (6–86) months, no patient developed recurrence of pancreatic ascites or pleural effusion. Conclusion In the experienced hand, surgery can be performed with acceptable perioperative morbidity and mortality and long-term satisfactory outcomes. Internal Pancreatic fistula is a rare complication of chronic pancreatitis. Surgery is indicated after failure of medical and endoscopic therapy. Surgery can be performed with acceptable perioperative morbidity and mortality and long-term good results.
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Ramouz A, Shafiei S, Ali-Hasan-Al-Saegh S, Khajeh E, Rio-Tinto R, Fakour S, Brandl A, Goncalves G, Berchtold C, Büchler MW, Mehrabi A. Systematic review and meta-analysis of endoscopic ultrasound drainage for the management of fluid collections after pancreas surgery. Surg Endosc 2022; 36:3708-3720. [PMID: 35246738 PMCID: PMC9085703 DOI: 10.1007/s00464-022-09137-6] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/09/2021] [Accepted: 02/13/2022] [Indexed: 02/07/2023]
Abstract
BACKGROUND The outcomes of endoscopic ultrasonography-guided drainage (EUSD) in treatment of pancreas fluid collection (PFC) after pancreas surgeries have not been evaluated systematically. The current systematic review and meta-analysis aim to evaluate the outcomes of EUSD in patients with PFC after pancreas surgery and compare it with percutaneous drainage (PCD). METHODS PubMed and Web of Science databases were searched for studies reporting outcomes EUSD in treatment of PFC after pancreas surgeries, from their inception until January 2022. Two meta-analyses were performed: (A) a systematic review and single-arm meta-analysis of EUSD (meta-analysis A) and (B) two-arm meta-analysis comparing the outcomes of EUSD and PCD (meta-analysis B). Pooled proportion of the outcomes in meta-analysis A as well as odds ratio (OR) and mean difference (MD) in meta-analysis B was calculated to determine the technical and clinical success rates, complications rate, hospital stay, and recurrence rate. ROBINS-I tool was used to assess the risk of bias. RESULTS The literature search retrieved 610 articles, 25 of which were eligible for inclusion. Included clinical studies comprised reports on 695 patients. Twenty-five studies (477 patients) were included in meta-analysis A and eight studies (356 patients) were included in meta-analysis B. In meta-analysis A, the technical and clinical success rates of EUSD were 94% and 87%, respectively, with post-procedural complications of 14% and recurrence rates of 9%. Meta-analysis B showed comparable technical and clinical success rates as well as complications rates between EUSD and PCD. EUSD showed significantly shorter duration of hospital stay compared to that of patients treated with PCD. CONCLUSION EUSD seems to be associated with high technical and clinical success rates, with low rates of procedure-related complications. Although EUSD leads to shorter hospital stay compared to PCD, the certainty of evidence was low in this regard.
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Affiliation(s)
- Ali Ramouz
- Department of General, Visceral, and Transplantation Surgery, University Hospital Heidelberg, Im Neuenheimer Feld 420, 69120 Heidelberg, Germany
| | - Saeed Shafiei
- Department of General, Visceral, and Transplantation Surgery, University Hospital Heidelberg, Im Neuenheimer Feld 420, 69120 Heidelberg, Germany
| | - Sadeq Ali-Hasan-Al-Saegh
- Department of General, Visceral, and Transplantation Surgery, University Hospital Heidelberg, Im Neuenheimer Feld 420, 69120 Heidelberg, Germany
| | - Elias Khajeh
- Department of General, Visceral, and Transplantation Surgery, University Hospital Heidelberg, Im Neuenheimer Feld 420, 69120 Heidelberg, Germany
| | - Ricardo Rio-Tinto
- Department of Gastroenterology, Digestive Oncology Unit, Champalimaud Foundation, Lisbon, Portugal
| | - Sanam Fakour
- Department of General, Visceral, and Transplantation Surgery, University Hospital Heidelberg, Im Neuenheimer Feld 420, 69120 Heidelberg, Germany
| | - Andreas Brandl
- Department of Digestive Surgery, Hepato-Pancreato-Biliary Surgery Unit, Champalimaud Foundation, Lisbon, Portugal
| | - Gil Goncalves
- Department of Digestive Surgery, Hepato-Pancreato-Biliary Surgery Unit, Champalimaud Foundation, Lisbon, Portugal
| | - Christoph Berchtold
- Department of General, Visceral, and Transplantation Surgery, University Hospital Heidelberg, Im Neuenheimer Feld 420, 69120 Heidelberg, Germany
| | - Markus W. Büchler
- Department of General, Visceral, and Transplantation Surgery, University Hospital Heidelberg, Im Neuenheimer Feld 420, 69120 Heidelberg, Germany
| | - Arianeb Mehrabi
- Department of General, Visceral, and Transplantation Surgery, University Hospital Heidelberg, Im Neuenheimer Feld 420, 69120 Heidelberg, Germany
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Shirakawa C, Watanabe M, Shimamura T, Koshizuka Y, Kawamura N, Goto R, Soyama T, Iwami D, Hotta K, Taketomi A, Abo D. A case report of percutaneous direct injection of N-butyl-2-cyanoacrylate (NBCA) to treat a pancreatic duodenal stump leak after a simultaneous pancreas and kidney transplantation. Surg Case Rep 2021; 7:139. [PMID: 34101045 PMCID: PMC8187509 DOI: 10.1186/s40792-021-01219-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/30/2021] [Accepted: 05/28/2021] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Simultaneous pancreas and kidney transplantation (SPK) is a treatment option for patients with end-stage renal disease due to type 1 diabetes mellitus. We report a patient with a refractory fistula due to leakage from the duodenal stump of the pancreas graft after an SPK with bladder drainage who was successfully treated with a percutaneous direct injection of N-butyl-2-cyanoacrylate (NBCA). CASE PRESENTATION A 60-year-old female with a 33-year history of type 1 diabetes mellitus and a 10-year history of renal replacement therapy underwent an SPK in 2015. At the time of transplantation, an abdominal aortic aneurysm with a high risk of rupture was treated by a Y-graft replacement prior to the SPK. Bladder drainage of the pancreas graft was chosen to avoid a vessel graft infection. The patient's postoperative course was uneventful. The patient was discharged on postoperative day 93 with good-functioning pancreas and kidney grafts. One and a half years after the operation, the patient was found to have acute graft pancreatitis and a leak from the duodenal stump of the pancreas graft due to a paralytic neurogenic bladder. The insertion of an indwelling catheter into the bladder and the endoscopic-guided insertion of a catheter into the graft pancreatic duct through the duodenum/bladder anastomosis did not result in the closure of the fistula. Therefore, NBCA was injected at the site of the leak point using CT-guided technique. The fistula was completely closed immediately after the injection, with no recurrences of leaks. CONCLUSIONS A percutaneous direct injection of NBCA is one of the treatment options to treat intractable fistulas.
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Affiliation(s)
- Chisato Shirakawa
- Department of Gastroenterological Surgery, Faculty of Medicine and Graduate School of Medicine, Hokkaido University, Kita-15 Nishi-7, kita-ku, Sapporo, 060-8638, Japan
| | - Masaaki Watanabe
- Department of Transplant Surgery, Faculty of Medicine and Graduate School of Medicine, Hokkaido University, Kita-15 Nishi-7, kita-ku, Sapporo, 060-8638, Japan.
| | - Tsuyoshi Shimamura
- Division of Organ Transplantation, Hokkaido University Hospital, Kita-15 Nishi-7, kita-ku, Sapporo, 060-8638, Japan
| | - Yasuyuki Koshizuka
- Department of Gastroenterological Surgery, Faculty of Medicine and Graduate School of Medicine, Hokkaido University, Kita-15 Nishi-7, kita-ku, Sapporo, 060-8638, Japan
| | - Norio Kawamura
- Department of Transplant Surgery, Faculty of Medicine and Graduate School of Medicine, Hokkaido University, Kita-15 Nishi-7, kita-ku, Sapporo, 060-8638, Japan
| | - Ryoichi Goto
- Department of Gastroenterological Surgery, Faculty of Medicine and Graduate School of Medicine, Hokkaido University, Kita-15 Nishi-7, kita-ku, Sapporo, 060-8638, Japan
| | - Takeshi Soyama
- Department of Diagnostic and Interventional Radiology, Hokkaido University Hospital, Kita-15 Nishi-7, kita-ku, Sapporo, 060-8638, Japan
| | - Daiki Iwami
- Department of Urology, Hokkaido University Hospital, Kita-15 Nishi-7, kita-ku, Sapporo, 060-8638, Japan
| | - Kiyohiko Hotta
- Department of Urology, Hokkaido University Hospital, Kita-15 Nishi-7, kita-ku, Sapporo, 060-8638, Japan
| | - Akinobu Taketomi
- Department of Gastroenterological Surgery, Faculty of Medicine and Graduate School of Medicine, Hokkaido University, Kita-15 Nishi-7, kita-ku, Sapporo, 060-8638, Japan
| | - Daisuke Abo
- Department of Diagnostic and Interventional Radiology, Hokkaido University Hospital, Kita-15 Nishi-7, kita-ku, Sapporo, 060-8638, Japan
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10
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Li X, Paz-Fumagalli R, Wang W, Toskich BB, Stauffer JA, Frey GT, McKinney JM, Nguyen JH. Percutaneous direct pancreatic duct intervention in management of pancreatic fistulas: a primary treatment or temporizing therapy to prepare for elective surgery. BMC Gastroenterol 2021; 21:44. [PMID: 33509111 PMCID: PMC7844943 DOI: 10.1186/s12876-021-01620-z] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/19/2020] [Accepted: 01/18/2021] [Indexed: 01/08/2023] Open
Abstract
BACKGROUND This study evaluates preliminary results of image-guided percutaneous direct pancreatic duct intervention in the management of pancreatic fistula after surgery or pancreatitis when initially ineligible for surgical or endoscopic therapy. METHODS Between 2001 and 2018 the medical records of all patients that underwent percutaneous pancreatic duct intervention for radiographically confirmed pancreatic fistula initially ineligible for surgical or endoscopic repair were reviewed for demographics, clinical history, procedure details, adverse events, procedure related imaging and laboratory results, ability to directly catheterized the main pancreatic duct, and whether desired clinical objectives were met. RESULTS In 10 of 11patients (6 male and 5 female with mean age 60.5, range 39-89) percutaneous pancreatic duct cannulation was possible. The 10 duct interventions included direct ductal suction drainage in 7, percutaneous duct closure in 3 and stent placement in 1. Pancreatic fistulas closed in 7 of 10, 2 were temporized until elective surgery, and 1 palliated until death from malignancy. The single patient with failed duct cannulation resolved the fistula with prolonged catheter drainage of the peri-pancreatic cavity. There were no major adverse events related to intervention. CONCLUSION In patients with pancreatic fistulas initially ineligible for endoscopic therapy or elective surgery, direct percutaneous pancreatic duct interventions are possible, can achieve improvement without major morbidity or mortality, and can improve and maintain the medical condition of patients in preparation for definitive surgery.
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Affiliation(s)
- Xi Li
- Interventional Radiology Department, The Fifth Affiliated Hospital of Sun Yat-Sen University, Zhuhai, Guandong, China.,Division of Interventional Radiology, Mayo Clinic, Jacksonville, FL, 32224, USA
| | | | - Weiping Wang
- Division of Interventional Radiology, Mayo Clinic, Jacksonville, FL, 32224, USA
| | - Beau B Toskich
- Division of Interventional Radiology, Mayo Clinic, Jacksonville, FL, 32224, USA
| | - John A Stauffer
- Department of General Surgery, Mayo Clinic, Jacksonville, FL, USA
| | - Gregory T Frey
- Division of Interventional Radiology, Mayo Clinic, Jacksonville, FL, 32224, USA
| | - J Mark McKinney
- Division of Interventional Radiology, Mayo Clinic, Jacksonville, FL, 32224, USA
| | - Justin H Nguyen
- Department of Transplantation, Mayo Clinic, Jacksonville, FL, USA
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11
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Schneider Bordat L, El Amrani M, Truant S, Branche J, Zerbib P. Management of pancreatic ascites complicating alcoholic chronic pancreatitis. J Visc Surg 2021; 158:370-377. [PMID: 33461889 DOI: 10.1016/j.jviscsurg.2020.11.015] [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: 11/18/2022]
Abstract
INTRODUCTION Pancreatic ascites (PA) is an unusual and little studied complication of chronic alcoholic pancreatitis. Management is complex and is based mainly on empirical data. The aim of this retrospective work was to analyse the management of PA at our centre. PATIENTS AND METHODS A total of 24 patients with PA complicating chronic alcoholic pancreatitis were managed at the Lille University Hospital between 2004 and 2018. Treatment was initially medical and then, in case of failure, interventional (endoscopic, radiological and/or surgical). Data regarding epidemiology, therapeutic and follow-up data were collected retrospectively. RESULTS Twenty-four patients were analysed; median follow-up was 18.5 months [6.75-34.25]. Exclusively medical treatment was effective in three of four patients, but, based on intention to treat, medical therapy alone was effective in only two out of 24 patients. Of 17 patients treated endoscopically, treatment was successful in 15 of them. Of the 15 who underwent surgery, external surgical drainage was effective in 13. Multimodal treatment, initiated after 6.5 days [4-13.5] of medical treatment, was effective in 12 out of 14 patients. In total, 21 patients were successfully treated (87%) with a morbidity rate of 79% and a mortality rate of 12.5% (n=3). CONCLUSION PA gives rise to significant morbidity and mortality. Conservative medical treatment has only a limited role. If medical treatment fails, endoscopic and then surgical treatment allow a favourable outcome in more than 80% of patients.
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Affiliation(s)
- L Schneider Bordat
- Department of digestive surgery and transplantation, university of Lille Nord de France, Claude-Huriez Hospital, CHU de Lille, rue Michel-Polonowski, 59037 Lille, France.
| | - M El Amrani
- Department of digestive surgery and transplantation, university of Lille Nord de France, Claude-Huriez Hospital, CHU de Lille, rue Michel-Polonowski, 59037 Lille, France
| | - S Truant
- Department of digestive surgery and transplantation, university of Lille Nord de France, Claude-Huriez Hospital, CHU de Lille, rue Michel-Polonowski, 59037 Lille, France
| | - J Branche
- Gastroenterology department, university of Lille Nord de France, Claude-Huriez Hospital, CHU de Lille, 59037 Lille, France
| | - P Zerbib
- Department of digestive surgery and transplantation, university of Lille Nord de France, Claude-Huriez Hospital, CHU de Lille, rue Michel-Polonowski, 59037 Lille, France
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12
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Schulman AR, Watson RR, Abu Dayyeh BK, Bhutani MS, Chandrasekhara V, Jirapinyo P, Krishnan K, Kumta NA, Melson J, Pannala R, Parsi MA, Trikudanathan G, Trindade AJ, Maple JT, Lichtenstein DR. Endoscopic devices and techniques for the management of bariatric surgical adverse events (with videos). Gastrointest Endosc 2020; 92:492-507. [PMID: 32800313 DOI: 10.1016/j.gie.2020.04.002] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/30/2020] [Accepted: 04/02/2020] [Indexed: 12/11/2022]
Abstract
BACKGROUND AND AIMS As the prevalence of obesity continues to rise, increasing numbers of patients undergo bariatric surgery. Management of adverse events of bariatric surgery may be challenging and often requires a multidisciplinary approach. Endoscopic intervention is often the first line of therapy for management of these adverse events. This document reviews technologies and techniques used for endoscopic management of adverse events of bariatric surgery, organized by surgery type. METHODS The MEDLINE database was searched through May 2018 for articles related to endoscopic management of adverse events of bariatric interventions by using relevant keywords such as adverse events related to "gastric bypass," "sleeve gastrectomy," "laparoscopic adjustable banding," and "vertical banded sleeve gastroplasty," in addition to "endoscopic treatment" and "endoscopic management," among others. Available data regarding efficacy, safety, and financial considerations are summarized. RESULTS Common adverse events of bariatric surgery include anastomotic ulcers, luminal stenoses, fistulae/leaks, and inadequate initial weight loss or weight regain. Devices used for endoscopic management of bariatric surgical adverse events include balloon dilators (hydrostatic, pneumatic), mechanical closure devices (clips, endoscopic suturing system, endoscopic plication platform), luminal stents (covered esophageal stents, lumen-apposing metal stents, plastic stents), and thermal therapy (argon plasma coagulation, needle-knives), among others. Available data, composed mainly of case series and retrospective cohort studies, support the primary role of endoscopic management. Multiple procedures and techniques are often required to achieve clinical success, and existing management algorithms are evolving. CONCLUSIONS Endoscopy is a less invasive alternative for management of adverse events of bariatric surgery and for revisional procedures. Endoscopic procedures are frequently performed in the context of multidisciplinary management with bariatric surgeons and interventional radiologists. Treatment algorithms and standards of practice for endoscopic management will continue to be refined as new dedicated technology and data emerge.
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Affiliation(s)
- Allison R Schulman
- Department of Gastroenterology, Michigan Medicine, University of Michigan, Ann Arbor, Michigan, USA
| | - Rabindra R Watson
- Department of Gastroenterology, Interventional Endoscopy Services, California Pacific Medical Center, San Francisco, California, USA
| | - Barham K Abu Dayyeh
- Department of Gastroenterology and Hepatology, Mayo Clinic, Rochester, Minnesota, USA
| | - Manoop S Bhutani
- Department of Gastroenterology Hepatology and Nutrition, Division of Internal Medicine, The University of Texas MD Anderson Cancer Center, Houston, Texas, USA
| | - Vinay Chandrasekhara
- Department of Gastroenterology and Hepatology, Mayo Clinic, Rochester, Minnesota, USA
| | - Pichamol Jirapinyo
- Division of Gastroenterology, Hepatology and Endoscopy, Brigham and Women's Hospital, Boston, Massachusetts, USA
| | - Kumar Krishnan
- Division of Gastroenterology, Department of Internal Medicine, Harvard Medical School and Massachusetts General Hospital, Boston, Massachusetts, USA
| | - Nikhil A Kumta
- Division of Gastroenterology, Mount Sinai Hospital, New York, New York, USA
| | - Joshua Melson
- Division of Digestive Diseases, Department of Internal Medicine, Rush University Medical Center, Chicago, Illinois, USA
| | - Rahul Pannala
- Department of Gastroenterology and Hepatology, Mayo Clinic, Scottsdale, Arizona, USA
| | - Mansour A Parsi
- Section for Gastroenterology and Hepatology, Tulane University Health Sciences Center, New Orleans, Louisiana, USA
| | - Guru Trikudanathan
- Department of Gastroenterology, Hepatology and Nutrition, University of Minnesota, Minneapolis, Minnesota, USA
| | - Arvind J Trindade
- Department of Gastroenterology, Zucker School of Medicine at Hofstra/Northwell, Long Island Jewish Medical Center, New Hyde Park, New York, USA
| | - John T Maple
- Division of Digestive Diseases and Nutrition, University of Oklahoma Health Sciences Center, Oklahoma City, Oklahoma, USA
| | - David R Lichtenstein
- Division of Gastroenterology, Boston Medical Center, Boston University School of Medicine, Boston, Massachusetts, USA
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Kitano M, Gress TM, Garg PK, Itoi T, Irisawa A, Isayama H, Kanno A, Takase K, Levy M, Yasuda I, Lévy P, Isaji S, Fernandez-Del Castillo C, Drewes AM, Sheel ARG, Neoptolemos JP, Shimosegawa T, Boermeester M, Wilcox CM, Whitcomb DC. International consensus guidelines on interventional endoscopy in chronic pancreatitis. Recommendations from the working group for the international consensus guidelines for chronic pancreatitis in collaboration with the International Association of Pancreatology, the American Pancreatic Association, the Japan Pancreas Society, and European Pancreatic Club. Pancreatology 2020; 20:1045-1055. [PMID: 32792253 DOI: 10.1016/j.pan.2020.05.022] [Citation(s) in RCA: 38] [Impact Index Per Article: 9.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/18/2019] [Revised: 05/29/2020] [Accepted: 05/30/2020] [Indexed: 12/11/2022]
Abstract
BACKGROUND/OBJECTIVES This paper is part of the international consensus guidelines on chronic pancreatitis, presenting for interventional endoscopy. METHODS An international working group with experts on interventional endoscopy evaluated 26 statements generated from evidence on 9 clinically relevant questions. The Grading of Recommendations Assessment, Development, and Evaluation approach was used to evaluate the level of evidence. To determine the level of agreement, a nine-point Likert scale was used for voting on the statements. RESULTS Strong consensus was obtained for 15 statements relating to nine questions including the recommendation that endoscopic intervention should be offered to patients with persistent severe pain but not to those without pain. Endoscopic decompression of the pancreatic duct could be used for immediate pain relief, and then offered surgery if this fails or needs repeated endoscopy. Endoscopic drainage is preferred for portal-splenic vein thrombosis and pancreatic fistula. A plastic stent should be placed and replaced 2-3 months later after insertion. Endoscopic extraction is indicated for stone fragments remaining after ESWL. Interventional treatment should be performed for symptomatic/complicated pancreatic pseudocysts. Endoscopic treatment is recommended for bile duct obstruction and afterwards surgery if this fails or needs repeated endoscopy. Surgery may be offered if there is significant calcification and/or mass of the pancreatic head. Percutaneous endovascular treatment is preferred for hemosuccus pancreaticus. Surgical treatment is recommended for duodenal stenosis due to chronic pancreatitis. CONCLUSIONS This international expert consensus guideline provides evidenced-based statements concerning indications and key aspects for interventional endoscopy in the management of patients with chronic pancreatitis.
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Affiliation(s)
- Masayuki Kitano
- Second Department of Internal Medicine, Wakayama Medical University, 811-1 Kimiidera, Wakayama, 641-8509, Japan.
| | - Thomas M Gress
- Department of Gastroenterology, Endocrinology, Metabolism and Infectiology, University Hospital, Philipps-Universität Marburg, Marburg, Germany.
| | - Pramod K Garg
- Department of Gastroenterology, All India Institute of Medical Sciences, New Delhi, India.
| | - Takao Itoi
- Department of Gastroenterology and Hepatology, Tokyo Medical University, Tokyo, Japan.
| | - Atsushi Irisawa
- Department of Gastroenterology, Dokkyo Medical University, Mibu, Tochigi, Japan.
| | - Hiroyuki Isayama
- Department of Gastroenterology, Graduate School of Medicine, Juntendo University, Tokyo, Japan.
| | - Atsushi Kanno
- Department of Gastroenterology, Tohoku University Graduate School of Medicine, Sendai, Japan.
| | - Kei Takase
- Department of Diagnostic Radiology, Tohoku University Graduate School of Medicine, Sendai, Japan.
| | - Michael Levy
- Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, MN, USA.
| | - Ichiro Yasuda
- Third Department of Internal Medicine, University of Toyama, Toyama, Japan.
| | - Phillipe Lévy
- Service de Pancréatologie-Gastroentérologie, Pôle des Maladies de l'Appareil Digestif, DHU UNITY, Hôpital Beaujon, APHP, Clichy Cedex, Université Paris 7, France.
| | - Shuiji Isaji
- Department of Surgery, Mie University Graduate School of Medicine, Tsu, Japan.
| | | | - Asbjørn M Drewes
- Centre for Pancreatic Diseases, Department of Gastroenterology, Aalborg University Hospital, Aalborg, Denmark.
| | - Andrea R G Sheel
- Department of Molecular and Clinical Cancer Medicine, Institute of Translational Medicine, University of Liverpool, Liverpool, UK.
| | - John P Neoptolemos
- Department of General Surgery, University of Heidelberg, Heidelberg, Germany.
| | - Tooru Shimosegawa
- Division of Gastroenterology, Tohoku University Graduate School of Medicine, Sendai, Japan.
| | - Marja Boermeester
- Department of Surgery, Amsterdam University Medical Centers, location AMC, and Amsterdam Gastroenterology & Metabolism, Amsterdam, the Netherlands.
| | - C Mel Wilcox
- Division of Gastroenterology and Hepatology, University of Alabama at Birmingham, Birmingham, AL, USA.
| | - David C Whitcomb
- Departments of Medicine, Cell Biology & Molecular Physiology and Human Genetics, Division of Gastroenterology, Hepatology and Nutrition, University of Pittsburgh and UPMC, Pittsburgh, PA, USA.
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14
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Ramai D, Bivona A, Latson W, Ofosu A, Ofori E, Reddy M, Adler DG. Endoscopic management of tracheoesophageal fistulas. Ann Gastroenterol 2018; 32:24-29. [PMID: 30598588 PMCID: PMC6302189 DOI: 10.20524/aog.2018.0321] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/26/2018] [Accepted: 09/24/2018] [Indexed: 02/06/2023] Open
Abstract
Tracheoesophageal fistulas (TEF) are pathologic communications between the trachea and esophagus. TEF can lead to significant respiratory distress that may result in lethal respiratory compromise, often due to recurrent and intractable infections. Through the use of endoscopy, some TEF can be successfully repaired using different approaches depending on the size, location, availability, and experience of the treating endoscopist. The aim of this manuscript is to provide an up-to-date review of the endoscopic management of TEF for gastroenterologists.
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Affiliation(s)
- Daryl Ramai
- Department of Medicine, The Brooklyn Hospital Center, NY (Daryl Ramai)
| | - Alexis Bivona
- School of Medicine, St George's University, True Blue, Grenada, WI (Alexis Bivona, William Latson)
| | - William Latson
- School of Medicine, St George's University, True Blue, Grenada, WI (Alexis Bivona, William Latson)
| | - Andrew Ofosu
- Division of Gastroenterology and Hepatology, The Brooklyn Hospital Center, NY (Andrew Ofosu)
| | - Emmanuel Ofori
- Division of Gastroenterology and Hepatology, University of Utah School of Medicine, Huntsman Cancer Center, Salt Lake City, Utah (Emmanuel Ofori, Madhavi Reddy, Douglas G. Adler), USA
| | - Madhavi Reddy
- Division of Gastroenterology and Hepatology, University of Utah School of Medicine, Huntsman Cancer Center, Salt Lake City, Utah (Emmanuel Ofori, Madhavi Reddy, Douglas G. Adler), USA
| | - Douglas G Adler
- Division of Gastroenterology and Hepatology, University of Utah School of Medicine, Huntsman Cancer Center, Salt Lake City, Utah (Emmanuel Ofori, Madhavi Reddy, Douglas G. Adler), USA
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15
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Sahakian AB, Jayaram P, Marx MV, Matsushima K, Park C, Buxbaum JL. Metallic coil and N-butyl-2-cyanoacrylate for closure of pancreatic duct leak (with video). Gastrointest Endosc 2018; 87:1122-1125. [PMID: 28843585 DOI: 10.1016/j.gie.2017.08.015] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/03/2017] [Accepted: 08/06/2017] [Indexed: 12/11/2022]
Abstract
BACKGROUND AND AIMS Pancreatic fistula is a challenging yet common adverse event of partial pancreatectomy. Our objective is to determine the feasibility of endoscopic closure of a pancreatic fistula using a combination of a metallic coil and N-butyl-2-cyanoacrylate (NBCA) glue. METHODS A patient with a postoperative pancreatic stump leak recalcitrant to conservative management and pancreatic duct stent placement underwent endoscopic/fluoroscopic placement of a metallic coil in the pancreatic duct followed by injection of .5 mL NBCA and lipiodol mixture directed at the coil. The patient's clinical condition, Jackson-Pratt (JP) drain output, and pancreatic enzyme content were monitored daily after the procedure. RESULTS The patient's clinical condition improved. JP drain output and amylase/lipase levels progressively decreased to resolution within 7 days of the procedure. No adverse events occurred as a result of the procedure. CONCLUSIONS Endoscopic closure of pancreatic fistula with a metallic coil and NBCA glue is feasible and may be a useful modality for treatment of refractory postpancreatectomy-related fistula.
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Affiliation(s)
- Ara B Sahakian
- Division of Gastrointestinal and Liver Diseases, University of Southern California Keck School of Medicine, Los Angeles, California, USA
| | - Preeth Jayaram
- Division of Gastrointestinal and Liver Diseases, University of Southern California Keck School of Medicine, Los Angeles, California, USA
| | - M Victoria Marx
- Department of Radiology, University of Southern California Keck School of Medicine, Los Angeles, California, USA
| | - Kazuhide Matsushima
- Division of Acute Care Surgery, Los Angeles County + University of Southern California Medical Center, Los Angeles, California, USA
| | - Caroline Park
- Division of Acute Care Surgery, Los Angeles County + University of Southern California Medical Center, Los Angeles, California, USA
| | - James L Buxbaum
- Division of Gastrointestinal and Liver Diseases, University of Southern California Keck School of Medicine, Los Angeles, California, USA
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16
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Korde JM, Kandasubramanian B. Biocompatible alkyl cyanoacrylates and their derivatives as bio-adhesives. Biomater Sci 2018; 6:1691-1711. [DOI: 10.1039/c8bm00312b] [Citation(s) in RCA: 46] [Impact Index Per Article: 7.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/23/2022]
Abstract
Cyanoacrylate adhesives and their homologues have elicited interest over the past few decades owing to their applications in the biomedical sector, extending from tissue adhesives to scaffolds to implants to dental material and adhesives, because of their inherent biocompatibility and ability to polymerize solely with moisture, thanks to which they adhere to any substrate containing moisture such as the skin.
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Affiliation(s)
- Jay M. Korde
- Biocomposite Fabrication Lab
- Department of Metallurgical and Materials Engineering
- DIAT (DU)
- Ministry of Defence
- Pune-411025
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17
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Mutignani M, Dokas S, Tringali A, Forti E, Pugliese F, Cintolo M, Manta R, Dioscoridi L. Pancreatic Leaks and Fistulae: An Endoscopy-Oriented Classification. Dig Dis Sci 2017; 62:2648-2657. [PMID: 28780610 DOI: 10.1007/s10620-017-4697-5] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/08/2017] [Accepted: 07/26/2017] [Indexed: 02/06/2023]
Abstract
BACKGROUND Pancreatic leaks occur as a complication of upper gastrointestinal surgery, acute pancreatitis, or abdominal trauma. Pancreatic fistulas and leaks are primarily managed conservatively. Overall, conservative measures are successful in more than half of cases. Whenever conservative treatment is not efficient, surgery is usually considered the treatment of choice. Nowadays however, endoscopic treatment is being increasingly considered and employed in many cases, as a surgery sparing intervention. AIM To introduce a classification of pancreatic fistulas according to the location of the leak and ductal anatomy and finally propose the best suited endoscopic method to treat the leak according to current literature. METHODS We performed an extensive review of the literature on pancreatic fistulae and leaks. RESULTS In this paper, we review the various types of leaks and propose a novel endoscopic classification of pancreatic fistulas in order to standardize and improve endoscopic treatment. CONCLUSIONS A proper and precise diagnosis should be made before embarking on endoscopic treatment for pancreatic leaks in order to obtain prime therapeutic results. A multidisciplinary team of interventional endoscopists, pancreatic surgeons, and interventional radiologists is best suited to care for these patients.
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Affiliation(s)
- Massimiliano Mutignani
- Digestive and Interventional Endoscopy Unit, Ospedale Ca'Granda Niguarda, Piazza dell'Ospedale Maggiore, 3, 20162, Milan, Italy
| | - Stefanos Dokas
- Endoscopy Department, St Lukes Private Hospital, 55236, Panorama, Thessaloníki, Greece.
| | - Alberto Tringali
- Digestive and Interventional Endoscopy Unit, Ospedale Ca'Granda Niguarda, Piazza dell'Ospedale Maggiore, 3, 20162, Milan, Italy
| | - Edoardo Forti
- Digestive and Interventional Endoscopy Unit, Ospedale Ca'Granda Niguarda, Piazza dell'Ospedale Maggiore, 3, 20162, Milan, Italy
| | - Francesco Pugliese
- Digestive and Interventional Endoscopy Unit, Ospedale Ca'Granda Niguarda, Piazza dell'Ospedale Maggiore, 3, 20162, Milan, Italy
| | - Marcello Cintolo
- Digestive and Interventional Endoscopy Unit, Ospedale Ca'Granda Niguarda, Piazza dell'Ospedale Maggiore, 3, 20162, Milan, Italy
| | - Raffaele Manta
- Digestive Endoscopy Unit, Nuovo Ospedale Civile S. Agostino Estense di Baggiovara, Via Pietro Giardini, 1355, 41126, Baggiovara, MO, Italy
| | - Lorenzo Dioscoridi
- Digestive and Interventional Endoscopy Unit, Ospedale Ca'Granda Niguarda, Piazza dell'Ospedale Maggiore, 3, 20162, Milan, Italy
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18
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Devaraj P, Gavini H. Endoscopic management of postoperative fistulas and leaks. GASTROINTESTINAL INTERVENTION 2017. [DOI: 10.18528/gii160032] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/01/2023]
Affiliation(s)
- Prathab Devaraj
- Department of Gastroenterology, Hepatology, and Nutrition, Banner University Medical Center, Tucson, AZ, USA
| | - Hemanth Gavini
- Department of Gastroenterology, Hepatology, and Nutrition, Banner University Medical Center, Tucson, AZ, USA
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19
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The Use of Interventional Radiology Techniques in the Treatment of Pancreatic Fistula. Surg Laparosc Endosc Percutan Tech 2016; 26:473-475. [PMID: 27846166 DOI: 10.1097/sle.0000000000000343] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
One of the complications of pancreatic disease is the formation of pancreatic fistulae. The presence of fistula leads to body wasting and cachexia. The standard treatment is intubation of the Wirsung duct and in cases where there are no improvements the next proposed form of treatment is surgery. The aim of the study was to evaluate the efficacy of pancreatic fistula closure using interventional radiology techniques. In 2009 to 2014, 46 patients diagnosed with pancreatic fistula were treated with interventional radiology techniques. Treatment consisted of vascular coil implanted at the entry of the fistula and then sealed with tissue glue adhesive during endoscopic procedure. Technical success of vascular coil implantation and the use of tissue glue adhesive were reported in all patients. Pancreatic fistula recurred in 7 patients (15.2%). The latter group of patients underwent statistical analysis to determine what the risk factors in recurring pancreatic fistulas were. The results indicate a significant relationship between etiology of the fistula and treatment effect. IN CONCLUSION (1) the use of interventional radiology methods in the closure of pancreatic fistula is an effective and safe procedure; and (2) the recurrence of fistula is dependent on the etiology and often occurs after surgery or trauma.
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20
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Rodrigues-Pinto E, Baron TH. Endoscopic ultrasound-guided internalization of a pancreaticocutaneous fistula without need for percutaneous manipulation. Endosc Ultrasound 2016; 5:276-8. [PMID: 27503164 PMCID: PMC4989413 DOI: 10.4103/2303-9027.187895] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/24/2022] Open
Affiliation(s)
- Eduardo Rodrigues-Pinto
- Department of Gastroenterology, Centro Hospitalar São João, Porto, Portugal; Division of Gastroenterology and Hepatology, School of Medicine, University of North Carolina, Chapel Hill, North Carolina, USA,
| | - Todd Huntley Baron
- Division of Gastroenterology and Hepatology, School of Medicine, University of North Carolina, Chapel Hill, North Carolina, USA
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21
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Abstract
This paper is designed to report the endoscopic treatment for a rare esophagopleural fistula after total gastrectomy. Esophagopleural fistula is a rare complication following total gastrectomy. Nonoperative treatment using endoscopic injection of tissue glue is a less invasive and effective option. The history, treatment, and options for managing an esophagopleural fistula following gastrectomy are discussed. A 53-year-old female patient underwent total gastrectomy for advanced gastric cancer. An anastomotic leak with esophagopleural fistula formation developed at the esophagojejunostomy site. The fistula was successfully managed by endoscopic injection with n-butyl-2-cyanoacrylate into the fistula, chest tube drainage, systemic antibiotics, and total parenteral nutrition. This case report suggests that combing effective drainage and the use of n-butyl-2-cyanoacrylate of nonoperative treatment options for esophagopleural fistula.
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22
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Endoscopic gluing for intrathoracic anastomotic fistula following esophagectomy: a case report. Esophagus 2015. [DOI: 10.1007/s10388-014-0461-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 08/30/2023]
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23
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Abstract
Disconnected pancreatic duct syndrome is a sequela of necrotizing pancreatitis or pancreatic trauma in which necrosis of a segment of the pancreas leads to lack of continuity between viable secreting pancreatic tissue (eg, body or tail) and the gastrointestinal tract. The endoscopic retrograde cholangiopancreatography showing total cutoff of the pancreatic duct along with an enhancing distal pancreas on contrast-enhanced computed tomography remains the criterion standard for diagnosis. Recently, the evolving literature supports a role for magnetic resonance cholangiopancreaticography, especially with secretin stimulation. A multidisciplinary approach is extremely important in the management of this condition. Conservative measures are usually not helpful, and interventional radiology, endoscopic, or surgical intervention is almost always needed for management of these patients. Recently, endoscopic ultrasonography-guided drainage procedures in conjunction with endoscopic retrograde cholangiopancreatography-assisted pancreatic duct stenting have emerged as a novel technique to manage this condition. The aim of this review was to give a detailed overview about the diagnosis and management of disconnected pancreatic duct syndrome with emphasis on the changing paradigm in endoscopic and surgical management.
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24
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Farag A, Parikh PP, Malik T, Kauffman S. A novel approach using liquid embolic agent for the treatment of pancreatic-cutaneous fistulas: Report of a case. Int J Surg Case Rep 2014; 6C:157-9. [PMID: 25544480 PMCID: PMC4334636 DOI: 10.1016/j.ijscr.2014.10.082] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/22/2014] [Revised: 10/21/2014] [Accepted: 10/23/2014] [Indexed: 11/17/2022] Open
Abstract
Novel approach for treating pancreatic-cutaneous fistulas developed post-pancreaticoduodenectomy. Use of liquid embolic agent to treat a high-output pancreatic-cutaneous fistula after a Whipple procedure, which to the best of our knowledge, has not been performed before. Minimally invasive treatment for a difficult problem that often results in additional surgery or prolonged drainage and TPN.
Pancreatic fistula formation remains one of the most dreadful complications after pancreaticoduodenectomies, resulting in extended hospital stays, increased healthcare costs, along with significantly increased morbidity and mortality. Little is mentioned in the literature about the use of percutaneous techniques to resolve this complication when conservative treatments fail. Thus, we developed a novel technique for treating pancreatic-cutaneous fistulas that develop post-pancreaticoduodenectomy. This work describes a novel approach of using a liquid embolic agent to treat a high-output pancreatic-cutaneous fistula after a Whipple procedure, which to the best of our knowledge after extensive literature searches, has not been performed before.
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Affiliation(s)
- Amye Farag
- Wright State University, Boonshoft School of Medicine, Dayton, OH, USA
| | - Priti P Parikh
- Wright State University, Department of Surgery, Dayton, OH, USA.
| | - Tamer Malik
- Wright State University, Department of Surgery, Dayton, OH, USA
| | - Shannon Kauffman
- Interventional Radiology, Radiology Physicians, Inc., Dayton, OH, USA
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25
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Abstract
Laparoscopic cholecystectomy has become the procedure of choice for management of symptomatic cholelithiasis. Although it has distinct advantages over open cholecystectomy, bile leak is more common. Endoscopic retrograde cholangiopancreatography is the diagnostic and therapeutic modality of choice for management of postcholecystectomy bile leaks and has a high success rate with the placement of plastic biliary stents. Repeat endoscopic retrograde cholangiopancreatography with placement of multiple plastic stents, a covered metal stent, or possibly cyanoacrylate therapy may be effective in refractory cases. This review will discuss the indications, efficacy, and complications of endoscopic therapy.
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26
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Kawakami H, Itoi T, Sakamoto N. Endoscopic ultrasound-guided transluminal drainage for peripancreatic fluid collections: where are we now? Gut Liver 2014; 8:341-55. [PMID: 25071899 PMCID: PMC4113054 DOI: 10.5009/gnl.2014.8.4.341] [Citation(s) in RCA: 39] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/21/2014] [Accepted: 04/02/2014] [Indexed: 12/13/2022] Open
Abstract
Endoscopic drainage for pancreatic and peripancreatic fluid collections (PFCs) has been increasingly used as a minimally invasive alternative to surgical or percutaneous drainage. Recently, endoscopic ultrasound-guided transluminal drainage (EUS-TD) has become the standard of care and a safe procedure for nonsurgical PFC treatment. EUS-TD ensures a safe puncture, avoiding intervening blood vessels. Single or multiple plastic stents (combined with a nasocystic catheter) were used for the treatment of PFCs for EUS-TD. More recently, the use of covered self-expandable metallic stents (CSEMSs) has provided a safer and more efficient approach route for internal drainage. We focused our review on the best approach and stent to use in endoscopic drainage for PFCs. We reviewed studies of EUS-TD for PFCs based on the original Atlanta Classification, including case reports, case series, and previous review articles. Data on clinical outcomes and adverse events were collected retrospectively. A total of 93 patients underwent EUS-TD of pancreatic pseudocysts using CSEMSs. The treatment success and adverse event rates were 94.6% and 21.1%, respectively. The majority of complications were of mild severity and resolved with conservative therapy. A total of 56 patients underwent EUS-TD using CSEMSs for pancreatic abscesses or infected walled-off necroses. The treatment success and adverse event rates were 87.8% and 9.5%, respectively. EUS-TD can be performed safely and efficiently for PFC treatment. Larger diameter CSEMSs without additional fistula tract dilation for the passage of a standard scope are needed to access and drain for PFCs with solid debris.
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Affiliation(s)
- Hiroshi Kawakami
- Department of Gastroenterology and Hepatology, Hokkaido University Graduate School of Medicine, Sapporo, Japan
| | - Takao Itoi
- Department of Gastroentero logy and Hepatology, Tokyo Medical University, Tokyo, Japan
| | - Naoya Sakamoto
- Department of Gastroenterology and Hepatology, Hokkaido University Graduate School of Medicine, Sapporo, Japan
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López J, Rodriguez K, Targarona EM, Guzman H, Corral I, Gameros R, Reyes A. Systematic review of cyanoacrylate embolization for refractory gastrointestinal fistulae: a promising therapy. Surg Innov 2014; 22:88-96. [PMID: 24902686 DOI: 10.1177/1553350614535860] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
BACKGROUND Surgical management of gastrointestinal fistulae has been reported to carry a 30-day morbidity rate up to 82% and a mortality rate ranging from 2% to 4.8%; thus nonoperative alternatives are required. The aim of the present study was to assess the current experience on the use of cyanoacrylates in the management of these fistulae. METHODS A systematic review was carried out on Medline, Embase, The Cochrane database, Academic Search Complete, MedicLatina, and SciELO for English, Spanish, and Portuguese articles dealing with refractory fistulae by means of cyanoacrylate embolization therapy. Publication dates were restricted from 1969 to present. Outcome parameters were study design, number of participants, etiology of the fistula, approach, material used, success rate, complications, and mortality. RESULTS Electronic search yielded a total of 377 articles. After a meticulous screening, only 14 studies dealing with foregut/midgut fistulae and 6 addressing hindgut fistulae were included. All the included articles were prospective and retrospective case series. Cumulative success rate was 81% (range 0% to 100%) and 3 out of 203 patients (1%) developed minor complications. CONCLUSION Cyanoacrylate embolization of nearly all types of refractory gastrointestinal fistulae is a feasible and harmless technique. Prospective controlled studies are required to support the available evidence.
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Affiliation(s)
- Julio López
- Mexican Institute for Social Security, HGZ 11, Delicias, Mexico
| | | | | | - Heber Guzman
- Mexican Institute for Social Security, UMAE 25, Monterrey, Mexico
| | - Iván Corral
- Mexican Institute for Social Security, HGZ 6, Juarez, Mexico
| | - Rene Gameros
- Mexican Institute for Social Security, Chihuahua, Mexico
| | - Arturo Reyes
- Mexican Institute for Social Security, Chihuahua, Mexico
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Ramia JM, Fabregat J, Pérez-Miranda M, Figueras J. [Disconnected panreatic duct syndrome]. Cir Esp 2014; 92:4-10. [PMID: 23845879 DOI: 10.1016/j.ciresp.2013.02.024] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/06/2013] [Revised: 02/15/2013] [Accepted: 02/19/2013] [Indexed: 02/07/2023]
Abstract
Disconnected pancreatic duct syndrome (DPDS) is characterized by disruption of the main pancreatic duct with a loss of continuity between the pancreatic duct and the gastrointestinal tract caused by ductal necrosis after severe acute necrotizing pancreatitis treated medically, by percutaneous drainage, or necrosectomy. There are no clear epidemiological data on the real incidence of DPDS; approximately 10 to 30% of patients with severe acute pancreatitis could develop DPDS. The existing literature is scarce, the terminology is confusing and therapeutic algorithms are not clearly defined. Both endoscopic and surgical management have been described. We have performed a sytematic review of the literature on DPDS.
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Affiliation(s)
- Jose Manuel Ramia
- Unidad de Cirugía Hepatobiliopancreática, Servicio de Cirugía General y Aparato Digestivo, Hospital Universitario de Guadalajara, Guadalajara, España.
| | - Joan Fabregat
- Unidad de Cirugía Hepatobiliopancreática, Servicio de Cirugía General y Aparato Digestivo, Hospital Universitario de Bellvitge, Barcelona, España
| | | | - Joan Figueras
- Unidad de Cirugía Hepatobiliopancreática, Servicio de Cirugía General y Aparato Digestivo, Hospital Josep Trueta, Gerona, España
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Ang TL, Kwek ABE, Tan SS, Ibrahim S, Fock KM, Teo EK. Direct endoscopic necrosectomy: a minimally invasive endoscopic technique for the treatment of infected walled-off pancreatic necrosis and infected pseudocysts with solid debris. Singapore Med J 2013; 54:206-11. [PMID: 23624447 DOI: 10.11622/smedj.2013074] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Abstract
INTRODUCTION Endoscopic transenteric stenting is the standard treatment for pseudocysts, but it may be inadequate for treating infected collections with solid debris. Surgical necrosectomy results in significant morbidity. Direct endoscopic necrosectomy (DEN), a minimally invasive treatment, may be a viable option. This study examined the efficacy and safety of DEN for the treatment of infected walled-off pancreatic necrosis and infected pseudocysts with solid debris. METHODS This study was a retrospective analysis of data collected from a prospective database of patients who underwent DEN in the presence of infected walled-off pancreatic necrosis or infected pseudocysts with solid debris from April 2007 to October 2011. DEN was performed as a staged procedure. Endoscopic ultrasonography-guided transgastric stenting was performed during the first session for initial drainage and to establish endoscopic access to the infected collection. In the second session, the drainage tract was dilated endoscopically to allow transgastric passage of an endoscope for endoscopic necrosectomy. Outcome data included technical success, clinical success and complication rates. RESULTS Eight patients with infected walled-off pancreatic necrosis or infected pseudocysts with solid debris (mean size 12.5 cm; range 7.8-17.2 cm) underwent DEN. Underlying aetiologies included severe acute pancreatitis (n = 6) and post-pancreatic surgery (n = 2). DEN was technically successful in all patients. Clinical resolution was achieved in seven patients. One patient with recurrent collection opted for surgery instead of repeat endotherapy. No procedural complications were encountered. CONCLUSION DEN is a safe and effective minimally invasive treatment for infected walled-off pancreatic necrosis and infected pseudocysts.
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Affiliation(s)
- Tiing Leong Ang
- Department of Gastroenterology, Changi General Hospital, 2 Simei Street 3, Singapore.
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Varadarajulu S, Rana SS, Bhasin DK. Endoscopic therapy for pancreatic duct leaks and disruptions. Gastrointest Endosc Clin N Am 2013; 23:863-92. [PMID: 24079795 DOI: 10.1016/j.giec.2013.06.008] [Citation(s) in RCA: 75] [Impact Index Per Article: 6.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
Pancreatitis, whether acute or chronic, can lead to a plethora of complications, such as fluid collections, pseudocysts, fistulas, and necrosis, all of which are secondary to leakage of secretions from the pancreatic ductal system. Partial and side branch duct disruptions can be managed successfully by transpapillary pancreatic duct stent placement, whereas patients with disconnected pancreatic duct syndrome require more complex endoscopic interventions or multidisciplinary care for optimal treatment outcomes. This review discusses the current status of endoscopic management of pancreatic duct leaks and emerging concepts for the treatment of disconnected pancreatic duct syndrome.
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Affiliation(s)
- Shyam Varadarajulu
- Center for Interventional Endoscopy, Florida Hospital, 601 East Rollins Street, Orlando, FL 32803, USA.
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Bhat YM, Banerjee S, Barth BA, Chauhan SS, Gottlieb KT, Konda V, Maple JT, Murad FM, Pfau PR, Pleskow DK, Siddiqui UD, Tokar JL, Wang A, Rodriguez SA. Tissue adhesives: cyanoacrylate glue and fibrin sealant. Gastrointest Endosc 2013; 78:209-15. [PMID: 23867370 DOI: 10.1016/j.gie.2013.04.166] [Citation(s) in RCA: 95] [Impact Index Per Article: 8.6] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/03/2013] [Accepted: 04/03/2013] [Indexed: 12/11/2022]
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Cameron R, Binmoeller KF. Cyanoacrylate applications in the GI tract. Gastrointest Endosc 2013; 77:846-57. [PMID: 23540441 DOI: 10.1016/j.gie.2013.01.028] [Citation(s) in RCA: 26] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/03/2012] [Accepted: 01/22/2013] [Indexed: 02/06/2023]
Affiliation(s)
- Rees Cameron
- Paul May & Frank Stein Interventional Endoscopy Center, California Pacific Medical Center, San Francisco, CA, USA
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Kumar N, Thompson CC. Endoscopic therapy for postoperative leaks and fistulae. Gastrointest Endosc Clin N Am 2013; 23:123-36. [PMID: 23168123 DOI: 10.1016/j.giec.2012.10.002] [Citation(s) in RCA: 53] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
Endoscopic techniques for the treatment of postoperative fistulae and leaks are rapidly developing. Conventional surgical therapy for postsurgical leaks and fistulae is associated with significant morbidity and mortality. Novel endoscopic therapies have demonstrated safety, despite the inherent challenges of intervention in this patient population, and are steadily building evidence for efficacy relative to surgical management. The article examines endoscopic therapy for leaks and fistulae after esophageal, gastric, bariatric, colonic, and pancreaticobiliary surgery.
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Affiliation(s)
- Nitin Kumar
- Division of Gastroenterology, Brigham and Women's Hospital, Boston, MA 02115, USA
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35
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Ang TL. Current Status of Direct Endoscopic Necrosectomy. PROCEEDINGS OF SINGAPORE HEALTHCARE 2012. [DOI: 10.1177/201010581202100305] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Abstract
The management of pancreatic necrosis has evolved. Sterile necrosis is now managed conservatively. Intervention is generally required for infected necrosis but is now deferred until four weeks after disease onset in order to permit encapsulation and demarcation of the necrotic collection. Demarcation facilitates necrosectomy and reduces complications related to the drainage and debridement procedures. The approach to pancreatic necrosectomy has evolved from primary open necrosectomy to minimally-invasive radiologic, surgical and endoscopic procedures. Direct endoscopic necrosectomy is a minimally-invasive technique that was introduced in recent years for the treatment of infected walled-off necrosis. A stoma is created endoscopically between the gastric lumen and the walled-off collection. An endoscope is then inserted directly into the cavity to perform endoscopic necrosectomy. This is followed by short-term placement of double pigtail transgastric stents and nasocystic catheter for post-procedural irrigation and drainage. This review will summarise the current status of direct endoscopic necrosectomy.
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Affiliation(s)
- Tiing Leong Ang
- Department of Gastroenterology, Changi General Hospital, Singapore
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36
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Irani S, Gluck M, Ross A, Gan SI, Crane R, Brandabur JJ, Hauptmann E, Fotoohi M, Kozarek RA. Resolving external pancreatic fistulas in patients with disconnected pancreatic duct syndrome: using rendezvous techniques to avoid surgery (with video). Gastrointest Endosc 2012; 76:586-93.e1-3. [PMID: 22898416 DOI: 10.1016/j.gie.2012.05.006] [Citation(s) in RCA: 61] [Impact Index Per Article: 5.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/08/2012] [Accepted: 05/04/2012] [Indexed: 02/08/2023]
Abstract
BACKGROUND An external pancreatic fistula (EPF) generally results from an iatrogenic manipulation of a pancreatic fluid collection (PFC), such as walled-off pancreatic necrosis (WOPN). Severe necrotizing pancreatitis can lead to complete duct disruption, causing disconnected pancreatic duct syndrome (DPDS) with viable upstream pancreas draining out of a low-pressure fistula created surgically or by a percutaneous catheter. The EPF can persist for months to years, and distal pancreatectomy, often the only permanent solution, carries a high morbidity and defined mortality. OBJECTIVE To describe 3 endoscopic and percutaneous rendezvous techniques to completely resolve EPFs in the setting of DPDS. DESIGN A retrospective review of a prospective database of 15 patients who underwent rendezvous internalization of EPFs. SETTING Tertiary-care pancreatic referral center. PATIENTS Fifteen patients between October 2002 and October 2011 with EPFs in the setting of DPDS and resolved WOPN. INTERVENTION Three rendezvous techniques that combined endoscopic and percutaneous procedures to internalize EPFs by transgastric, transduodenal, or transpapillary methods. MAIN OUTCOME MEASUREMENTS EPF resolution and morbidity. RESULTS Fifteen patients (12 men) with a median age of 51 years (range 24-65 years) with EPFs and DPDS (cutoff/blowout of pancreatic duct, with inability to demonstrate upstream body/tail of pancreas on pancreatogram) resulting from severe necrotizing pancreatitis underwent 1 of 3 rendezvous procedures to eliminate the EPFs. All patients were either poor surgical candidates or refused surgery. At the time of the rendezvous procedure, WOPN had fully resolved, DPDS was confirmed on pancreatography, and the EPF had persisted for a median of 5 months (range 1-48 months), producing a median output of 200 mL/day (range 50-700 mL/day). The rendezvous technique in 10 patients used the existing percutaneous drainage fistula to puncture into the stomach/duodenum to deliver wires that were captured endoscopically. The transenteric fistula was dilated and two endoprostheses placed into the lesser sac. A second technique was used in 3 patients where EUS was used to avoid large varices and create a fistula to the percutaneous drainage catheter. Wires were delivered transenterally then grasped by an interventional radiologist. The new fistula was dilated, and, again, two endoprostheses were placed. Two patients underwent a rendezvous technique that resulted in transpapillary stents and removal of percutaneous catheters. The median duration to EPF closure was 7 days (range 1-73 days) during a median follow-up of 25 months (range 6-113 months). No EPF has recurred in any patient, although 3 symptomatic fluid collections have occurred. These collections have been successfully treated with combined percutaneous and endoscopic treatment or endoscopic treatment alone. One patient had postprocedural fever. There were no associated deaths. LIMITATIONS Small, selected group of patients without a comparative group. CONCLUSION The management of EPFs in the setting of DPDS is challenging but can be treated effectively by combined endoscopic and percutaneous rendezvous techniques. The rendezvous procedures were associated with minimal morbidity, no mortality, avoidance of surgery, and complete elimination of the EPFs.
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Affiliation(s)
- Shayan Irani
- Digestive Disease Institute, Virginia Mason Medical Center, Seattle, Washington 98111, USA
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Pannu DS, Draganov PV. Therapeutic endoscopic retrograde cholangiopancreatography and instrumentation. Gastrointest Endosc Clin N Am 2012; 22:401-16. [PMID: 22748239 DOI: 10.1016/j.giec.2012.05.003] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
Over the last 40 years, endoscopic retrograde cholangiopancreatography (ERCP) has evolved from being a purely diagnostic to a primarily therapeutic procedure. The 2 recent developments in ERCP-based stricture management include the increased use of cholangioscopy-guided sampling and self-expandable metal stents. The role of ERCP in pancreatic diseases continues to evolve; ERCP-based pancreatic therapy requires advanced endoscopic expertise and is associated with a high rate of postprocedure complications. Therefore, a multidisciplinary team approach at a center with expertise in pancreatic therapy should serve as a basis for very careful patient selection.
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Affiliation(s)
- Davinderbir S Pannu
- Division of Internal Medicine, Department of Medicine, University of Florida, Gainesville, FL 32610-0214, USA
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Cruz-Santamaría DM, Taxonera C, Giner M. Update on pathogenesis and clinical management of acute pancreatitis. World J Gastrointest Pathophysiol 2012; 3:60-70. [PMID: 22737590 PMCID: PMC3382704 DOI: 10.4291/wjgp.v3.i3.60] [Citation(s) in RCA: 24] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/31/2011] [Revised: 05/22/2012] [Accepted: 06/12/2012] [Indexed: 02/06/2023] Open
Abstract
Acute pancreatitis (AP), defined as the acute nonbacterial inflammatory condition of the pancreas, is derived from the early activation of digestive enzymes found inside the acinar cells, with variable compromise of the gland itself, nearby tissues and other organs. So, it is an event that begins with pancreatic injury, elicits an acute inflammatory response, encompasses a variety of complications and generally resolves over time. Different conditions are known to induce this disorder, although the innermost mechanisms and how they act to develop the disease are still unknown. We summarize some well established aspects. A phase sequence has been proposed: etiology factors generate other conditions inside acinar cells that favor the AP development with some systemic events; genetic factors could be involved as susceptibility and modifying elements. AP is a disease with extremely different clinical expressions. Most patients suffer a mild and limited disease, but about one fifth of cases develop multi organ failure, accompanied by high mortality. This great variability in presentation, clinical course and complications has given rise to the confusion related to AP related terminology. However, consensus meetings have provided uniform definitions, including the severity of the illness. The clinical management is mainly based on the disease´s severity and must be directed to correct the underlying predisposing factors and control the inflammatory process itself. The first step is to determine if it is mild or severe. We review the principal aspects to be considered in this treatment, as reflected in several clinical practice guidelines. For the last 25 years, there has been a global increase in incidence of AP, along with many advances in diagnosis and treatment. However, progress in knowledge of its pathogenesis is scarce.
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Kim JY, Kwon YH, Lee SJ, Jang SY, Yang HM, Jeon SW, Kweon YO. [Abscesso-colonic fistula following radiofrequency ablation therapy for hepatocellular carcinoma; a case successfully treated with histoacryl embolization]. THE KOREAN JOURNAL OF GASTROENTEROLOGY 2012; 58:270-4. [PMID: 22113044 DOI: 10.4166/kjg.2011.58.5.270] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/03/2022]
Abstract
Hepatocellular carcinoma (HCC) is one of the most common malignant neoplasms occuring worldwide. Although surgical resection still remains the treatment of choice for HCC, radiofrequency ablation (RFA) has emerged as reliable alternatives to resection. It is less invasive and can be repeated after short intervals for sequential ablation in case of multiple lesions. The most common complication of RFA is liver abscess, and bile duct injury such as bile duct stricture has been reported. This is a case report of a rare complication of abscesso-colonic fistula after RFA for HCC. The case was treated by percutaneous abscess drainage and antibiotics and occlusion of abscesso-colonic fistula with n-butyl-2-cyanoacrylate embolization.
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Affiliation(s)
- Ji Yeon Kim
- Department of Internal Medicine, Kyungpook National University School of Medicine, Daegu, Korea
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Endoscopic management of peri-pancreatic collections. Gastroenterol Res Pract 2012; 2012:906381. [PMID: 22536223 PMCID: PMC3296159 DOI: 10.1155/2012/906381] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/01/2011] [Revised: 10/30/2011] [Accepted: 11/07/2011] [Indexed: 01/06/2023] Open
Abstract
Endotherapy of peripancreatic fluid collections is an increasing utilized procedure in interventional endoscopy. The aim of this paper is to provide a general overview of the topic, highlighting the indications, technique, and important management issues relating to endoscopic management of the various forms of peri-pancreatic fluid collections.
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Seewald S, Ang TL, Richter H, Teng KYK, Zhong Y, Groth S, Omar S, Soehendra N. Long-term results after endoscopic drainage and necrosectomy of symptomatic pancreatic fluid collections. Dig Endosc 2012; 24:36-41. [PMID: 22211410 DOI: 10.1111/j.1443-1661.2011.01162.x] [Citation(s) in RCA: 61] [Impact Index Per Article: 5.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Abstract
AIMS To determine the immediate and long-term results of endoscopic drainage and necrosectomy for symptomatic pancreatic fluid collections. METHODS The data of 80 patients with symptomatic pancreatic fluid collections (mean diameter: 11.7 cm, range 3-20; pseudocysts: 24/80, abscess: 20/80, infected walled-off necrosis: 36/80) referred for endoscopic management from October 1997 to March 2008 were analyzed retrospectively. RESULTS Endoscopic drainage techniques included endoscopic ultrasound (EUS)-guided aspiration (2/80), EUS-guided transenteric drainage (70/80) and non-EUS-guided drainage across a spontaneous transenteric fistula (8/80). Endoscopic necrosectomy was carried out in 49/80 (abscesses: 14/20; infected necrosis: 35/36). Procedural complications were bleeding (12/80), perforation (7/80), portal air embolism (1/80) and Ogilvie Syndrome (1/80). Initial technical success was achieved in 78/80 (97.5%) and clinical resolution of the collections was achieved endoscopically in 67/80 (83.8%), with surgery required in 13/80 (perforation: four; endoscopically inaccessible areas: two; inadequate drainage: seven). Within 6 months five patients required surgery due to recurrent fluid collections; over a mean follow up of 31 months, surgery was required in four more patients due to recurrent collections as a consequence of underlying pancreatic duct abnormalities that could not be treated endoscopically. The long-term success of endoscopic treatment was 58/80 (72.5%). CONCLUSIONS Endoscopic drainage of symptomatic pancreatic fluid collections is safe and effective, with excellent immediate and long-term results. Endoscopic necrosectomy has a risk of serious complications. The underlying pancreatic duct abnormalities must be addressed to prevent recurrence of fluid collections.
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Affiliation(s)
- Stefan Seewald
- Center of Gastroenterology, Klinik Hirslanden, Zurich, Switzerland.
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Abstract
Chronic pancreatitis (CP) is a debilitating disease that can result in chronic abdominal pain, malnutrition, and other related complications. The main aims of treatment are to control symptoms, prevent disease progression, and correct any complications. A multidisciplinary approach involving medical, endoscopic, and surgical therapy is important. Endoscopic therapy plays a specific role in carefully selected patients as primary interventional therapy when medical measures fail or in patients who are not suitable for surgery. Endoscopic therapy is also used as a bridge to surgery or as a means to assess the potential response to pancreatic surgery. This review addresses the role of endoscopic therapy in relief of obstruction of the pancreatic duct (PD) and bile du ct, closure of PD leaks, and drainage of pseudocysts in CP. The role of endoscopic ultrasound-guided celiac plexus block for pain in chronic pancreatitis is also discussed.
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Affiliation(s)
- Damien Meng Yew Tan
- Department of Gastroenterology and Hepatology, Singapore General Hospital, Singapore.
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Abstract
Chronic pancreatitis (CP) can have debilitating clinical course due to chronic abdominal pain, malnutrition and related complications. Medical, endoscopic and surgical treatment of CP should aim at control of symptoms, prevention of progression of the disease and correction of complications. Endoscopic management plays a specific role in carefully selected patients as primary interventional therapy when medical measures fail or in high-risk surgical candidates. Endotherapy for CP is utilized also as a bridge to surgery or to assess potential response to pancreatic surgery. In this review we address the role of endotherapy for the relief of obstruction of the pancreatic duct (PD) and bile duct, closure of PD leaks and drainage of pseudocysts in the setting of CP. In addition, endotherapy for relief of pancreatic pain by endoscopic ultrasound-guided celiac plexus block for CP is discussed.
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Affiliation(s)
- Haritha Avula
- Division of Gastroenterology/ Hepatology, Indiana University Medical Center, Indianapolis, IN, USA
| | - Stuart Sherman
- Division of Gastroenterology/ Hepatology, Indiana University Medical Center - Internal Medicine, UH 4100, IN 46202, USA
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Christodoulou DK, Tsianos EV. Role of endoscopic retrograde cholangiopancreatography in pancreatic diseases. World J Gastroenterol 2010; 16:4755-61. [PMID: 20939103 PMCID: PMC2955244 DOI: 10.3748/wjg.v16.i38.4755] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023] Open
Abstract
Over the last 15 years, endoscopic retrograde cholangiopancreatography (ERCP) has evolved from a diagnostic tool to one that is primarily used to provide therapy. This development occurred first for biliary disorders and subsequently to a lesser extent for pancreatic diseases. Computed tomography, magnetic resonance imaging, magnetic resonance cholangiopancreatography and endoscopic ultrasonography suggest a diagnosis in the majority of patients with pancreatic diseases today and can help physicians and patients avoid unnecessary ERCP. However, a selected number of patients with pancreatic diseases may benefit from pancreatic endotherapy and avoid complex surgery and chronic use of medications. Pancreatic sphincterotomy, pancreatic stenting and pancreatic cyst drainage are some of the most effective and challenging endoscopic pancreatic interventions and should be performed with caution by expert therapeutic endoscopists. There has been a paucity of randomized studies investigating endoscopic techniques in comparison with surgery and medical therapy for the treatment of most benign and malignant pancreatic disorders due to the limited number of patients and the expertise required to attempt these procedures.
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Labori KJ, Trondsen E, Buanes T, Hauge T. Endoscopic sealing of pancreatic fistulas: four case reports and review of the literature. Scand J Gastroenterol 2010; 44:1491-6. [PMID: 19883276 DOI: 10.3109/00365520903362610] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/05/2023]
Abstract
We report four patients with pancreatic fistulas that failed to respond to conservative treatment. The fistulas were closed by endoscopic injection of N-butyl-2-cyanoacrylate (Histoacryl) diluted with an oily contrast agent (Lipiodol). A literature review revealed 32 similar cases in which endoscopic treatment with fibrin sealants (n = 11) or cyanoacrylate (n = 21) was used to close the fistulas. Based on our own experience and the literature review, we conclude that endoscopic sealing of pancreatic fistulas can be performed safely and effectively by experienced endoscopists in a tertiary centre. The procedure seems useful in the management of complicated pancreatic fistulas which do not respond to conservative treatment and may obviate the need for surgery.
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Affiliation(s)
- Knut Jørgen Labori
- Department of Gastroenterological Surgery, Oslo University Hospital, Oslo, Norway.
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Aning JJ, Stott MA, Watkinson AF. Glue ablation of a late-presentation urinary fistula after partial nephrectomy. Br J Radiol 2010; 82:e246-8. [PMID: 19934065 DOI: 10.1259/bjr/93776392] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/22/2022] Open
Abstract
Urinary fistula is an acknowledged complication of partial nephrectomy. We describe a case of a urinary fistula that failed to respond to conventional treatment and the subsequent use of percutaneous Hystoacryl glue to achieve its resolution.
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Affiliation(s)
- J J Aning
- Department of Urology, Royal Devon and Exeter Hospital, UK.
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Ang TL, Teo EK, Fock KM. Endoscopic drainage and endoscopic necrosectomy in the management of symptomatic pancreatic collections. J Dig Dis 2009; 10:213-24. [PMID: 19659790 DOI: 10.1111/j.1751-2980.2009.00388.x] [Citation(s) in RCA: 14] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
OBJECTIVE To evaluate the role of endoscopic drainage and endoscopic necrosectomy in the management of symptomatic pancreatic fluid collection. METHODS The clinical data of patients with symptomatic pancreatic fluid collection referred for endoscopic drainage were captured prospectively and analyzed. Pancreatic duct disruption was treated with stenting. Endosonography-guided transmural drainage and endoscopic necrosectomy were performed when indicated. RESULTS Fifteen consecutive patients (mean age 53.7 years; range 23-82 years) underwent endoscopic management of pancreatic fluid collections (pseudocysts: six; abscesses: six; infected walled-off necrosis: three). Pancreatic duct fistulas were present in 13 patients. The drainage techniques used were: (i) transpapillary drainage; five; (ii) transmural drainage; two (these two patients had no pancreatic duct fistulas); and (iii) combined transpapillary and transmural drainage; eight. An additional transgastric endoscopic necrosectomy was performed in five patients. The endoscopic treatment was successful in all cases. The only complication was asymptomatic pneumo-peritoneum that occurred in one patient. Combined transpapillary and transmural drainage led to the faster resolution of the fluid collection compared to transpapillary drainage (75.6 vs 147 days, P = 0.03). No recurrence occurred over a mean follow up of 486 days. CONCLUSION Endoscopic drainage and endoscopic necrosectomy are safe and effective techniques for the treatment of symptomatic pancreatic fluid collection.
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Affiliation(s)
- Tiing Leong Ang
- Division of Gastroenterology, Changi General Hospital, Singapore.
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Seewald S, Ang TL, Teng KCYK, Soehendra N. EUS-guided drainage of pancreatic pseudocysts, abscesses and infected necrosis. Dig Endosc 2009; 21 Suppl 1:S61-5. [PMID: 19691738 DOI: 10.1111/j.1443-1661.2009.00860.x] [Citation(s) in RCA: 50] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
Endoscopic ultrasound (EUS)-guided drainage has emerged as the leading treatment modality for symptomatic pancreatic fluid collections. Endoscopic ultrasound-guided endoscopic drainage is less invasive than surgery and avoids local complications related to percutaneous drainage. In addition, unlike non-EUS guided endoscopic drainage, EUS-guided drainage is able to drain non-bulging fluid collections and may reduce the risk of procedure-related bleeding. Excellent treatment success rates exceeding 90% have been reported for pancreatic pseudocysts and abscesses. In the context of infected pancreatic necrosis, adjunctive endoscopic necrosectomy is required for effective treatment. With such an aggressive approach, the treatment success rate may reach 81%-92%. The potential complications of concern for EUS-guided drainage are severe bleeding and perforation. To minimize risk, only fluid collections with a mature wall and within 1 cm of the gastrointestinal lumen should undergo endoscopic drainage. Any coagulopathy, if present, should be corrected. Patients with pseudocysts undergoing drainage should also receive prophylactic antibiotics in order to prevent secondary infection of a sterile collection.
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Affiliation(s)
- Stefan Seewald
- Center of Gastroenterology, Klinik Hirslanden, Zurich, Switzerland.
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Pai CG, Suvarna D, Bhat G. Endoscopic treatment as first-line therapy for pancreatic ascites and pleural effusion. J Gastroenterol Hepatol 2009; 24:1198-202. [PMID: 19486258 DOI: 10.1111/j.1440-1746.2009.05796.x] [Citation(s) in RCA: 42] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
BACKGROUND Ascites and pleural effusion are well recognized complications of pancreatic diseases. Drug therapy of these is limited by high cost, prolonged hospitalization and failure rates; surgery is invasive and is associated with considerable morbidity and mortality. OBJECTIVE To analyze the data on patients with pancreatic ascites and/or pleural effusion treated endoscopically over a ten-year period. METHODS Patients with symptomatic ascites/pleural effusion for at least 3 weeks with a fluid amylase level of > 1000 S units/dl and underlying pancreatic disease were included. The interventions were a 5 mm sized pancreatic sphincterotomy and placement of a 7 Fr pancreatic stent. Somatostatin/octreotide and parenteral nutrition were not used after endoscopic therapy. RESULTS Of the 28 patients included (22 men), 17 (60.7%) had chronic pancreatitis. The causes were tropical pancreatitis (13, 46.4%), alcohol abuse (10, 35.7%), idiopathic acute pancreatitis (4, 14.3%) and resective surgery for gastric cancer (1, 3.6%). Ascites alone was seen in 15, pleural effusion alone in 6 and both in 7 patients. Ten patients (35.7%) had 14 pseudocysts. Endotherapy was successful in 27 (96.4%). Twenty-six (92.8%) patients had complete resolution of ascites/effusion over a median 5 weeks. The stents were removed 3-6 weeks later without any recurrence over the next 6-36 (median = 17) months. Complications (7, 25%) included severe pain in 2 (7.1%) and fever in 5 (17.8%) of which 3 (10.7%) had infection of residual fluid collections. No patient died. CONCLUSION Endoscopic therapy offers an excellent therapeutic alternative in patients with pancreatic ascites and pleural effusion.
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Affiliation(s)
- C Ganesh Pai
- Department of Gastroenterology & Hepatology, Kasturba Medical College, Manipal, India.
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