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Miyamoto R, Takahashi A, Ogura T, Kitamura K, Ishida H, Matsudaira S, Suzuki Y, Shimizu S, Kawashima Y. Impact of endoscopic ultrasound-guided transmural drainage for postoperative pancreatic fistula after pancreatic surgery. DEN OPEN 2024; 4:e270. [PMID: 37404728 PMCID: PMC10315642 DOI: 10.1002/deo2.270] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 04/02/2023] [Revised: 06/20/2023] [Accepted: 06/22/2023] [Indexed: 07/06/2023]
Abstract
Objectives Postoperative pancreatic fistula (POPF) is a major cause of morbidity after pancreatic surgery. Recently, endoscopic ultrasound-guided transmural drainage (EUS-TD) has been widely used to manage pancreatic pseudocysts after acute pancreatitis. Several studies have reported the effectiveness of EUS-TD for POPF, although there is insufficient evidence regarding the performance of EUS-TD for POPF. We herein report on the safety, efficacy, and appropriate timing of EUS-TD for POPF compared with conventional percutaneous intervention. Methods Eight patients who underwent EUS-TD of POPF and 36 patients who underwent percutaneous intervention were retrospectively enrolled. Clinical outcomes, including technical success, clinical success, and complications, were analyzed among the two groups. Results In terms of clinical outcomes between the EUS-TD and percutaneous intervention groups, significant differences were observed in the number of interventions (1 vs. 4, p = 0.011), period of clinical success (6 days vs. 11 days, p = 0.001), incidence of complications (0 vs. 3, p = 0.021), postoperative hospital stays (27 days vs. 34 days, p = 0.027), and recurrence of POPF (0 vs. 5, p = 0.001). Conclusions EUS-TD for POPF appears to be safe and technically feasible. This approach should be considered a therapeutic option in patients with POPF after pancreatic surgery.
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Affiliation(s)
- Ryoichi Miyamoto
- Department of Gastroenterological SurgerySaitama Cancer CenterSaitamaJapan
- Department of Gastroenterological SurgeryTokyo Medical University Ibaraki Medical CenterIbarakiJapan
| | - Amane Takahashi
- Department of Gastroenterological SurgerySaitama Cancer CenterSaitamaJapan
| | - Toshiro Ogura
- Department of Gastroenterological SurgerySaitama Cancer CenterSaitamaJapan
| | - Kei Kitamura
- Department of Gastroenterological SurgerySaitama Cancer CenterSaitamaJapan
| | - Hiroyuki Ishida
- Department of Gastroenterological SurgerySaitama Cancer CenterSaitamaJapan
| | | | - Yuko Suzuki
- Department of GastroenterologySaitama Cancer CenterSaitamaJapan
| | - Satoshi Shimizu
- Department of GastroenterologySaitama Cancer CenterSaitamaJapan
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Kapoor H, Issa M, Winkler MA, Nair RT, Wesam F, Ganesh H. The augmented role of pancreatic imaging in the era of endoscopic necrosectomy: an illustrative and pictorial review. Abdom Radiol (NY) 2020; 45:1534-1549. [PMID: 31197462 DOI: 10.1007/s00261-019-02093-1] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
Abstract
Endoscopic cystogastrostomy for mature pancreatic collections has long been recognized. However, FDA approval of newer lumen-apposing metallic stents in 2014 has now brought pancreatic necrosectomy to the endoscopic realm. Endoscopic drainage of Walled-off necrosis and direct endoscopic necrosectomy are technically challenging procedures with higher rates of complications. Collaborative clinical decision making both pre- and post-procedurally between the radiologist, endoscopist, and the surgeon can greatly improve outcomes in necrotizing pancreatitis. Herein, we review the basic pathophysiology that underlies progressive radiographic findings in NP, value of preprocedural imaging, current management algorithms, newer tools, and techniques as well as potential post-procedure complications on imaging follow-up after endoscopic interventions in necrotizing pancreatitis.
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3
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Hughes D, Hughes I, Khanna A. Management of Staple Line Leaks Following Sleeve Gastrectomy—a Systematic Review. Obes Surg 2019; 29:2759-2772. [DOI: 10.1007/s11695-019-03896-3] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
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4
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Donatelli G, Fuks D, Cereatti F, Pourcher G, Perniceni T, Dumont JL, Tuszynski T, Vergeau BM, Meduri B, Gayet B. Endoscopic transmural management of abdominal fluid collection following gastrointestinal, bariatric, and hepato-bilio-pancreatic surgery. Surg Endosc 2017; 32:2281-2287. [DOI: 10.1007/s00464-017-5922-1] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/03/2017] [Accepted: 10/08/2017] [Indexed: 12/21/2022]
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Tarantino I, Ligresti D, Tuzzolino F, Barresi L, Curcio G, Granata A, Traina M. Clinical impact of EUS treatment of walled-off pancreatic necrosis with dedicated devices. Endosc Int Open 2017; 5:E784-E791. [PMID: 28791329 PMCID: PMC5546896 DOI: 10.1055/s-0043-112494] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/15/2016] [Accepted: 03/29/2017] [Indexed: 02/08/2023] Open
Abstract
BACKGROUND AND STUDY AIMS Walled-off pancreatic necrosis (WOPN) represents the major risk factor for sepsis-related multiple organ failure. Surgical debridement is an invasive approach associated with high rates of adverse events (AEs) and death. As an alternative, endoscopic ultrasound-guided cysto-gastro-anastomosis has emerged as an effective treatment for WOPNs. Recently a new dedicated-lumen apposing metal stent (LAMS) has been used with satisfactory results in treating peri-pancreatic fluid collections, including WOPNs. The primary outcomes of this study were to evaluate survival and clinical success. Secondary outcomes included: technical success, adverse events and recurrence rate. PATIENTS AND METHODS All consecutive patients with infected WOPN between February 2014 and June 2016 were retrospectively reviewed. Patients underwent placement of a new LAMS incorporated in an electrocautery-enhanced delivery system and direct endoscopic necrosectomy (DEN). DEN was performed immediately after stent deployment and repeated every 3 to 7 days until complete resolution. RESULTS In the study period we treated 20 consecutive patients with infected WOPN using the new LAMS. Technical success was achieved in 95 % of patients. Clinical success was achieved in 73 % and 84.2 % of patients at 1 and 3 months, respectively. Survival rate was 84.2 % and 79 %. Mean length of hospital stay was 19 days (range 3 - 43). No AEs occurred. Patients were followed up after stent retrieval for a mean time of 554,7 days (range 70 - 986) and no recurrence was observed. CONCLUSIONS DEN following "1-step, exchange-free" LAMS positioning recorded excellent results. We believe that simplicity of procedure plays a key role in terms of safety.
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Affiliation(s)
- Ilaria Tarantino
- Endoscopy Service, Department of Diagnostic and Therapeutic Services, IRCCS-ISMETT (Istituto Mediterraneo per i Trapianti e Terapie ad alta specializzazione), Palermo, Italy,Corresponding author Ilaria Tarantino, MD Endoscopy ServiceDepartment of Diagnostic and Therapeutic ServicesIRCCS-ISMETTVia Tricomi 590127 PalermoItaly+39 091 21 92 400
| | - Dario Ligresti
- Endoscopy Service, Department of Diagnostic and Therapeutic Services, IRCCS-ISMETT (Istituto Mediterraneo per i Trapianti e Terapie ad alta specializzazione), Palermo, Italy
| | - Fabio Tuzzolino
- Research Office, IRCCS-ISMETT (Istituto Mediterraneo per i Trapianti e Terapie ad alta specializzazione)
| | - Luca Barresi
- Endoscopy Service, Department of Diagnostic and Therapeutic Services, IRCCS-ISMETT (Istituto Mediterraneo per i Trapianti e Terapie ad alta specializzazione), Palermo, Italy
| | - Gabriele Curcio
- Endoscopy Service, Department of Diagnostic and Therapeutic Services, IRCCS-ISMETT (Istituto Mediterraneo per i Trapianti e Terapie ad alta specializzazione), Palermo, Italy
| | - Antonino Granata
- Endoscopy Service, Department of Diagnostic and Therapeutic Services, IRCCS-ISMETT (Istituto Mediterraneo per i Trapianti e Terapie ad alta specializzazione), Palermo, Italy
| | - Mario Traina
- Endoscopy Service, Department of Diagnostic and Therapeutic Services, IRCCS-ISMETT (Istituto Mediterraneo per i Trapianti e Terapie ad alta specializzazione), Palermo, Italy
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Madácsy L, Kaltsidis H. Endoscopic ultrasound-guided extraluminal drainage: Novel concepts, challenges and future directions. INTERNATIONAL JOURNAL OF GASTROINTESTINAL INTERVENTION 2017. [DOI: 10.18528/gii160020] [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: 11/22/2022] Open
Affiliation(s)
- László Madácsy
- Department of Gastroenterology and Endoscopy, Bács-Kiskun County Teaching Hospital, University of Szeged, Kecskemét, Hungary
| | - Harry Kaltsidis
- Department of Gastroenterology, University Hospitals of South Manchester, Manchester, UK
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7
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Keane MG, Sze SF, Cieplik N, Murray S, Johnson GJ, Webster GJ, Thorburn D, Pereira SP. Endoscopic versus percutaneous drainage of symptomatic pancreatic fluid collections: a 14-year experience from a tertiary hepatobiliary centre. Surg Endosc 2015; 30:3730-40. [PMID: 26675934 PMCID: PMC4992018 DOI: 10.1007/s00464-015-4668-x] [Citation(s) in RCA: 66] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/17/2015] [Accepted: 10/14/2015] [Indexed: 12/20/2022]
Abstract
INTRODUCTION Endoscopic transmural drainage (ED) or percutaneous drainage (PD) has mostly replaced surgery for the initial management of patients with symptomatic pancreatic fluid collections (PFCs). This study aimed to compare outcomes for patients undergoing ED or PD of symptomatic PFCs. METHODS Between January 2000 and December 2013, all patients who required PD or ED of a PFC were included. Rates of treatment success, length of hospital stay, adverse events, re-interventions and length of follow-up were recorded retrospectively in all cases. RESULTS In total, 164 patients were included in the study; 109 patients underwent ED; and 55 had PD alone. During the 14-year study period, the incidence of ED increased and PD fell. In the 109 patients who were managed by ED, treatment success was considerably higher than in those managed by PD (70 vs. 31 %). Rates of procedural adverse events were higher in the ED cohort compared to the PD group (10 vs. 1 %), but patients managed by ED required fewer interventions (median of 1.8 vs. 3.3) had lower rates of residual collections (21 vs. 67 %) and need for surgical intervention (4 vs. 11 %). In the ED group, treatment success was similar for walled-off pancreatic necrosis (WOPN) and pseudocysts (67 vs. 72 %, P = 0.77). There were no procedure-related deaths. CONCLUSION Compared with PD, ED of symptomatic PFCs was associated with higher rates of treatment success, lower rates of re-intervention, including surgery and shorter lengths of hospital stay. Outcomes in WOPN were comparable to those in patients with pseudocysts.
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Affiliation(s)
- Margaret G Keane
- Institute for Liver and Digestive Health, Royal Free Hospital, University College London, Pond St, London, NW3 2PF, UK.
| | - Shun Fung Sze
- Institute for Liver and Digestive Health, Royal Free Hospital, University College London, Pond St, London, NW3 2PF, UK
| | - Natascha Cieplik
- Institute for Liver and Digestive Health, Royal Free Hospital, University College London, Pond St, London, NW3 2PF, UK
| | - Sam Murray
- Department of Gastroenterology, University College London Hospitals NHS Foundation Trust, 235 Euston Road, London, NW1 2BG, UK
| | - Gavin J Johnson
- Department of Gastroenterology, University College London Hospitals NHS Foundation Trust, 235 Euston Road, London, NW1 2BG, UK
| | - George J Webster
- Department of Gastroenterology, University College London Hospitals NHS Foundation Trust, 235 Euston Road, London, NW1 2BG, UK
| | - Douglas Thorburn
- Institute for Liver and Digestive Health, Royal Free Hospital, University College London, Pond St, London, NW3 2PF, UK
| | - Stephen P Pereira
- Institute for Liver and Digestive Health, Royal Free Hospital, University College London, Pond St, London, NW3 2PF, UK.
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Zerem E, Hauser G, Loga-Zec S, Kunosić S, Jovanović P, Crnkić D. Minimally invasive treatment of pancreatic pseudocysts. World J Gastroenterol 2015; 21:6850-6860. [PMID: 26078561 PMCID: PMC4462725 DOI: 10.3748/wjg.v21.i22.6850] [Citation(s) in RCA: 31] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/24/2015] [Revised: 03/29/2015] [Accepted: 04/28/2015] [Indexed: 02/07/2023] Open
Abstract
A pancreatic pseudocyst (PPC) is typically a complication of acute and chronic pancreatitis, trauma or pancreatic duct obstruction. The diagnosis of PPC can be made if an acute fluid collection persists for 4 to 6 wk and is enveloped by a distinct wall. Most PPCs regress spontaneously and require no treatment, whereas some may persist and progress until complications occur. The decision whether to treat a patient who has a PPC, as well as when and with what treatment modalities, is a difficult one. PPCs can be treated with a variety of methods: percutaneous catheter drainage (PCD), endoscopic transpapillary or transmural drainage, laparoscopic surgery, or open pseudocystoenterostomy. The recent trend in the management of symptomatic PPC has moved toward less invasive approaches such as endoscopic- and image-guided PCD. The endoscopic approach is suitable because most PPCs lie adjacent to the stomach. The major advantage of the endoscopic approach is that it creates a permanent pseudocysto-gastric track with no spillage of pancreatic enzymes. However, given the drainage problems, the monitoring, catheter manipulation and the analysis of cystic content are very difficult or impossible to perform endoscopically, unlike in the PCD approach. Several conditions must be met to achieve the complete obliteration of the cyst cavity.
Pancreatic duct anatomy is an important factor in the prognosis of the treatment outcome, and the recovery of disrupted pancreatic ducts is the main prognostic factor for successful treatment of PPC, regardless of the treatment method used. In this article, we review and evaluate the minimally invasive approaches in the management of PPCs.
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Masrour F, Mallat D. Endoscopic Ultrasound-Guided Self-Expandable Metal Stent Placement for the Treatment of Infected Pancreatic Pseudocysts. Gastroenterology Res 2014; 7:105-110. [PMID: 27785279 PMCID: PMC5040526 DOI: 10.14740/gr607e] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 06/27/2014] [Indexed: 11/11/2022] Open
Abstract
The standard endoscopic ultrasound (EUS) approach of cystogastrostomy involves the use of series of plastic pigtail stents that are placed through the wall of the cyst. The use of a single stent has also been described in the literature. Here we describe five cases of EUS-guided cystogastrostomy with irrigation of infected pancreatic pseudocysts using a single self-expandable metal stent (SEMS). To our knowledge this has not been described in the literature in the United States. This novice approach will have significant implications in the management of infected pseudocysts with a lower morbidity, mortality and overall cost compared to conventional management such as surgery or percutaneous drainage.
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10
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Saxena P, Singh VK, Messallam A, Kamal A, Zaheer A, Kumbhari V, Lennon AM, Canto MI, Kalloo AN, Baron TH, Khashab MA. Resolution of walled-off pancreatic necrosis by EUS-guided drainage when using a fully covered through-the-scope self-expandable metal stent in a single procedure (with video). Gastrointest Endosc 2014; 80:319-24. [PMID: 25034838 DOI: 10.1016/j.gie.2014.04.041] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/04/2013] [Accepted: 04/21/2014] [Indexed: 12/15/2022]
Abstract
BACKGROUND Walled-off pancreatic necrosis (WOPN) is effectively managed with percutaneous and endoscopic techniques such as direct endoscopic necrosectomy. However, they require repeat interventions and lengthy hospital stays. OBJECTIVE To evaluate a new platform to manage WOPNs by using a large-bore, through-the-scope, fully covered, self-expandable metal stent (FCSEMS) to overcome the need for repeat interventions and extended hospital stays. DESIGN Retrospective, single-center study. SETTING Academic tertiary care center. PATIENTS Five consecutive patients with symptomatic WOPN underwent EUS-guided drainage of WOPN by using a large-bore FCSEMSs. INTERVENTIONS EUS-guided transgastric drainage of WOPN by using a large-bore FCSEMS. Cross-sectional imaging was repeated at 6- to 8-week intervals. The FCSEMS was removed after WOPN resolution. MAIN OUTCOME MEASUREMENTS Clinical success, number of repeat interventions, and length of hospital stay. RESULTS Five patients (mean age 60 years) with WOPN (mean diameter, 12.3 cm; range 9.8-14.3 cm) underwent drainage with the described technique. Technical and clinical success was achieved in 100% of patients. Direct endoscopic necrosectomy was not required in any patient. The median number of endoscopic procedures was 1. The median length of hospital stay was 1 day. There were no adverse events. LIMITATIONS Small, retrospective study. CONCLUSIONS The described novel platform facilitates resolution of WOPN with a single procedure, avoiding the need for repeat interventions and lengthy hospital stays.
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Affiliation(s)
- Payal Saxena
- Department of Medicine, Division of Gastroenterology and Hepatology, The Johns Hopkins Medical Institutions, Baltimore, Maryland, USA
| | - Vikesh K Singh
- Department of Medicine, Division of Gastroenterology and Hepatology, The Johns Hopkins Medical Institutions, Baltimore, Maryland, USA
| | - Ahmed Messallam
- Department of Medicine, Division of Gastroenterology and Hepatology, The Johns Hopkins Medical Institutions, Baltimore, Maryland, USA
| | - Ayesha Kamal
- Department of Radiology, The Johns Hopkins Medical Institutions, Baltimore, Maryland, USA
| | - Atif Zaheer
- Department of Radiology, The Johns Hopkins Medical Institutions, Baltimore, Maryland, USA
| | - Vivek Kumbhari
- Department of Medicine, Division of Gastroenterology and Hepatology, The Johns Hopkins Medical Institutions, Baltimore, Maryland, USA
| | - Anne Marie Lennon
- Department of Medicine, Division of Gastroenterology and Hepatology, The Johns Hopkins Medical Institutions, Baltimore, Maryland, USA
| | - Marcia Irene Canto
- Department of Medicine, Division of Gastroenterology and Hepatology, The Johns Hopkins Medical Institutions, Baltimore, Maryland, USA
| | - Anthony N Kalloo
- Department of Medicine, Division of Gastroenterology and Hepatology, The Johns Hopkins Medical Institutions, Baltimore, Maryland, USA
| | - Todd H Baron
- Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, Minnesota, USA
| | - Mouen A Khashab
- Department of Medicine, Division of Gastroenterology and Hepatology, The Johns Hopkins Medical Institutions, Baltimore, Maryland, USA
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11
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Rotman SR, Kahaleh M. Pancreatic fluid collection drainage by endoscopic ultrasound: new perspectives. Endosc Ultrasound 2014; 1:61-8. [PMID: 24949339 PMCID: PMC4062209 DOI: 10.7178/eus.02.002] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/23/2012] [Accepted: 04/26/2012] [Indexed: 12/13/2022] Open
Abstract
Since the introduction of endoscopic ultrasonography (EUS), many centers have utilized this imaging modality for transmural pancreatic fluid collection (PFC) drainage. The expanded use of EUS has resulted in increased safety and efficacy of endoscopic PFC drainage. The major procedural steps include EUS-guided transgastric or transduodenal fistula creation into the PFC, and stent placement or nasocystic drain deployment to decompress the collection. In this and other applications, EUS has become a major therapeutic advancement in the field of endoscopy and has figured in myriad diagnostic applications. Recent research indicates a number of situations in which EUS-guided PFC drainage is appropriate. These include unusual location of the collection, small window of entry, non-bulging collections, coagulopathy, intervening varices, or failed conventional transmural drainage. In this study, we discuss the EUS-guided technique and review current literatures.
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Affiliation(s)
- Stephen R Rotman
- Division of Gastroenterology and Hepatology, Weill Cornell Medical College, Presbyterian Hospital, New York, NY 10021, USA
| | - Michel Kahaleh
- Division of Gastroenterology and Hepatology, Weill Cornell Medical College, Presbyterian Hospital, New York, NY 10021, USA
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12
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Abstract
BACKGROUND Endoscopic necrosectomy for necrotizing pancreatitis has been increasingly used as an alternative to surgical or percutaneous interventions. The use of fully covered esophageal self-expandable metallic stents may provide a safer and more efficient route for internal drainage. The aim of this study was to evaluate the safety and efficacy of endoscopic treatment of pancreatic necrosis with these stents. METHODS A retrospective study at 2 US academic hospitals included patients with infected pancreatic necrosis from July 2009 to November 2012. These patients underwent transgastric placement of fully covered esophageal metallic stents draining the necrosis. After necrosectomy, patients underwent regular sessions of endoscopic irrigation and debridement of cystic contents. The efficacy endpoint was successful resolution of infected pancreatic necrosis without the need for surgical or percutaneous interventions. RESULTS Seventeen patients were included with the mean age of 41±12 years. A mean of 5.3±3.4 sessions were required for complete drainage and the follow-up period was 237.6±165 days. Etiology included gallstone pancreatitis (6), alcohol abuse (6), s/p distal pancreatectomy (2), postendoscopic retrograde cholangiopancreatography pancreatitis (1), medication-induced pancreatitis (1), and hyperlipidemia (1). Mean size of the necrosis was 14.8 cm (SD 5.6 cm), ranging from 8 to 19 cm. Two patients failed endoscopic intervention and required surgery. The only complication was a perforation during tract dilation, which was managed conservatively. Fifteen patients (88%) achieved complete resolution. CONCLUSIONS Endoscopic necrosectomy with covered esophageal metal stents is a safe and successful treatment option for infected pancreatic necrosis.
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13
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McDermott S, Levis DA, Arellano RS. Approaches to the difficult drainage and biopsy. Semin Intervent Radiol 2013; 29:256-63. [PMID: 24293798 DOI: 10.1055/s-0032-1330059] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/12/2023]
Abstract
Percutaneous abscess drainage and percutaneous biopsy are effective and widely used techniques in the diagnosis and treatment of patients with abdominal or pelvic abscesses and lesions. Some abscesses and lesions can initially appear unsuitable for percutaneous access for a variety of reasons. This article reviews the circumstances in which collections or lesions may appear undrainable or inaccessible to percutaneous biopsy, and it describes techniques for overcoming these circumstances.
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Affiliation(s)
- Shaunagh McDermott
- Division of Abdominal Imaging and Interventional Radiology, Department of Radiology, Massachusetts General Hospital, Boston, Massachusetts
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14
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Tilara A, Gerdes H, Allen P, Jarnagin W, Kingham P, Fong Y, DeMatteo R, D'Angelica M, Schattner M. Endoscopic ultrasound-guided transmural drainage of postoperative pancreatic collections. J Am Coll Surg 2013; 218:33-40. [PMID: 24099888 DOI: 10.1016/j.jamcollsurg.2013.09.001] [Citation(s) in RCA: 40] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/25/2013] [Revised: 08/05/2013] [Accepted: 09/04/2013] [Indexed: 02/06/2023]
Abstract
BACKGROUND Pancreatic leak is a major cause of morbidity after pancreatectomy. Traditionally, peripancreatic fluid collections have been managed by percutaneous or operative drainage. Data for endoscopic ultrasound (EUS)-guided drainage of postoperative fluid collections are limited. Here we report on the safety, efficacy, and timing of EUS-guided drainage of postoperative peripancreatic collections. STUDY DESIGN This is a retrospective review of 31 patients who underwent EUS-guided drainage of fluid collections after pancreatic resection. Technical success was defined as successful transgastric deployment of at least one double pigtail plastic stent. Clinical success was defined as resolution of the fluid collection on follow-up CT scan and resolution of symptoms. Early drainage was defined as initial transmural stent placement within 30 days after surgery. RESULTS Endoscopic ultrasound-guided drainage was performed effectively with a technical success rate of 100%. Clinical success was achieved in 29 of 31 patients (93%). Nineteen of the 29 patients (65%) had complete resolution of their symptoms and collection with the first endoscopic procedure. Repeat drainage procedures, including some with necrosectomy, were required in the remaining 10 patients, with eventual resolution of collection and symptoms. Two patients who did not achieve durable clinical success required percutaneous drainage by interventional radiology. Seventeen (55%) of 31 patients had successful early drainage completed within 30 days of their operation. CONCLUSIONS Endoscopic ultrasound-guided drainage of fluid collections after pancreatic resection is safe and effective. Early drainage (<30 days) of postoperative pancreatic fluid collections was not associated with increased complications in this series.
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Affiliation(s)
- Amy Tilara
- Gastroenterology and Nutrition Service, Department of Medicine, Memorial Sloan-Kettering Cancer Center, New York, NY
| | - Hans Gerdes
- Gastroenterology and Nutrition Service, Department of Medicine, Memorial Sloan-Kettering Cancer Center, New York, NY
| | - Peter Allen
- Hepatopancreatobiliary Surgery Service, Department of Surgery, Memorial Sloan-Kettering Cancer Center, New York, NY
| | - William Jarnagin
- Hepatopancreatobiliary Surgery Service, Department of Surgery, Memorial Sloan-Kettering Cancer Center, New York, NY
| | - Peter Kingham
- Hepatopancreatobiliary Surgery Service, Department of Surgery, Memorial Sloan-Kettering Cancer Center, New York, NY
| | - Yuman Fong
- Hepatopancreatobiliary Surgery Service, Department of Surgery, Memorial Sloan-Kettering Cancer Center, New York, NY
| | - Ronald DeMatteo
- Hepatopancreatobiliary Surgery Service, Department of Surgery, Memorial Sloan-Kettering Cancer Center, New York, NY
| | - Michael D'Angelica
- Hepatopancreatobiliary Surgery Service, Department of Surgery, Memorial Sloan-Kettering Cancer Center, New York, NY
| | - Mark Schattner
- Gastroenterology and Nutrition Service, Department of Medicine, Memorial Sloan-Kettering Cancer Center, New York, NY.
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15
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Singhal S, Rotman SR, Gaidhane M, Kahaleh M. Pancreatic fluid collection drainage by endoscopic ultrasound: an update. Clin Endosc 2013; 46:506-14. [PMID: 24143313 PMCID: PMC3797936 DOI: 10.5946/ce.2013.46.5.506] [Citation(s) in RCA: 73] [Impact Index Per Article: 6.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/01/2013] [Revised: 07/25/2013] [Accepted: 08/01/2013] [Indexed: 12/14/2022] Open
Abstract
Endoscopic management of symptomatic pancreatic fluid collections (PFCs) is now considered to be first line therapy. Expanded use of endoscopic ultrasound (EUS) techniques has resulted in increased applicability, safety, and efficacy of endoscopic transluminal PFC drainage. Steps include EUS-guided trangastric or transduodenal fistula creation into the PFC followed by stent placement or nasocystic drain deployment in order to decompress the collection. With the remarkable improvement in the available accessories and stents and development of exchange free access device; EUS drainage techniques have become simpler and less time consuming. The use of self-expandable metal stents with modifications to drain PFC has helped in overcoming some previously encountered challenges. PFCs considered suitable for endoscopic drainage include collection present for greater than 4 weeks, possessing a well-formed wall, position accessible endoscopically and located within 1 cm of the duodenal or gastric walls. Indications for EUS-guided drainage have been increasing which include unusual location of the collection, small window of entry, nonbulging collections, coagulopathy, intervening varices, failed conventional transmural drainage, indeterminate adherence of PFC to the luminal wall or suspicion of malignancy. In this article, we present a review of literature to date and discuss the recent developments in EUS-guided PFC drainage.
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Affiliation(s)
- Shashideep Singhal
- Division of Digestive and Liver Diseases, Columbia University Medical Center, New York, NY, USA
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16
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Endoscopic ultrasonography-guided drainage is an effective and relatively safe treatment for peripancreatic fluid collections in a cohort of 108 symptomatic patients. Eur J Gastroenterol Hepatol 2013; 25:958-63. [PMID: 23571613 DOI: 10.1097/meg.0b013e3283612f03] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
BACKGROUND AND STUDY AIMS Endoscopic drainage [i.e. conventional, endoscopic ultrasonography (EUS)-assisted, or EUS-guided] is an accepted treatment modality for symptomatic peripancreatic fluid collections (PFC), but data on the efficacy and safety of EUS-guided drainage performed in a large patient cohort are not widely available. Our aim was to evaluate the clinical success and complication rate of EUS-guided drainage of PFCs and to identify prognostic factors for complications and recurrence of PFCs. PATIENTS AND METHODS A retrospective analysis was carried out of consecutive patients undergoing EUS-guided drainage of a symptomatic PFC in the period 2004-2011. Technical success was defined as the ability to enter and drain a PFC by the placement of one or more double-pigtail stents, whereas clinical success was defined as complete resolution of a PFC on follow-up computed tomography. RESULTS In total, 108 patients [56% men, mean age 55 (SD 14) years], underwent EUS-guided drainage of a symptomatic PFC. The procedure was technically successful in 105/108 (97%) patients and a median of 2 (range 1-3) pigtail stents were placed. Clinical success was observed in 87/104 (84%) patients after a median follow-up of 53 (interquartile range 21-130) weeks, whereas PFC recurrence was noted in 15/83 (18%) patients. Complications occurred in 21/105 (20%) patients and procedure-related mortality was not observed. Prognostic factors for complications and recurrence of PFCs could not be identified. CONCLUSION EUS-guided drainage of PFCs is effective in the majority of patients. Although the complication rate of the procedure is not negligible (20%), they could be managed in almost all patients by conservative and/or endoscopic means and did not result in mortality.
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Wiggermann A, Hunold P. Radiologisch-interventionelle Drainage bei abdomineller Sepsis. VISZERALMEDIZIN 2013. [DOI: 10.1159/000346997] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
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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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Kahaleh M. Endoscopic necrosectomy for walled-off pancreatic necrosis. Clin Endosc 2012; 45:313-5. [PMID: 22977825 PMCID: PMC3429759 DOI: 10.5946/ce.2012.45.3.313] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/14/2012] [Revised: 07/20/2012] [Accepted: 07/20/2012] [Indexed: 12/27/2022] Open
Abstract
Approximately 20% of patients with acute pancreatitis develop pancreatic necrosis with significant mortality. Surgical debridement is the traditional management of necrotizing pancreatitis, but it is associated with significant morbidity and mortality. Endoscopic necrosectomy using repeats session of debridement and stent insertion has been more frequently used within the last decade and half. This technique continues to evolve as we attempt to optimize the post-procedural outcomes.
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Affiliation(s)
- Michel Kahaleh
- Division of Gastroenterology and Hepatology, Department of Medicine, Weill Cornell Medical College, New York, NY, USA
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Thoeni RF. The revised Atlanta classification of acute pancreatitis: its importance for the radiologist and its effect on treatment. Radiology 2012; 262:751-64. [PMID: 22357880 DOI: 10.1148/radiol.11110947] [Citation(s) in RCA: 244] [Impact Index Per Article: 20.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
An international working group has modified the Atlanta classification for acute pancreatitis to update the terminology and provide simple functional clinical and morphologic classifications. The modifications (a) address the clinical course and severity of disease, (b) divide acute pancreatitis into interstitial edematous pancreatitis and necrotizing pancreatitis, (c) distinguish an early phase (1st week) and a late phase (after the 1st week), and (d) emphasize systemic inflammatory response syndrome and multisystem organ failure. In the 1st week, only clinical parameters are important for treatment planning. After the 1st week, morphologic criteria defined on the basis of computed tomographic findings are combined with clinical parameters to help determine care. This revised classification introduces new terminology for pancreatic fluid collections. Depending on presence or absence of necrosis, acute collections in the first 4 weeks are called acute necrotic collections or acute peripancreatic fluid collections. Once an enhancing capsule develops, persistent acute peripancreatic fluid collections are referred to as pseudocysts; and acute necrotic collections, as walled-off necroses. All can be sterile or infected. Terms such as pancreatic abscess and intrapancreatic pseudocyst have been abandoned. The goal is for radiologists, gastroenterologists, surgeons, and pathologists to use the revised classifications to standardize imaging terminology to facilitate treatment planning and enable precise comparison of results among different departments and institutions.
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Affiliation(s)
- Ruedi F Thoeni
- University of California San Francisco Medical School, Department of Radiology and Biomedical Imaging, PO Box 1325, San Francisco, CA 94143-1325, USA.
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Endoscopic ultrasound-guided transmural drainage for pancreatic fistula or pancreatic duct dilation after pancreatic surgery. Surg Endosc 2011; 26:1710-7. [PMID: 22179480 DOI: 10.1007/s00464-011-2097-z] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/22/2011] [Accepted: 11/26/2011] [Indexed: 01/11/2023]
Abstract
BACKGROUND Endoscopic ultrasound (EUS)-guided drainage is widely used to manage pancreatic pseudocysts. Several studies have reported the use of EUS-guided drainage for pancreatic fistula and stasis of pancreatic juice caused by stricture of the pancreatic duct after pancreatic resection. METHODS At the authors' hospital, 262 patients underwent surgery involving pancreatic resection from April 2005 to March 2010. In 90 of these patients (34%), a grade B or C postoperative pancreatic fistula developed that required additional treatment. The authors performed EUS-guided transmural drainage (EUS-TD) for six patients (2.1%) with a pancreatic fistula or dilation of the main pancreatic duct visible by EUS. Percutaneous drainage was provided for 18 patients (6.8%). The success rates for EUS-TD and percutaneous drainage were compared in a retrospective analysis. RESULTS In all six cases, EUS-TD was performed successfully without complications. Five of the six patients were successfully treated with only one trial of EUS-TD. The final technical success rate was 100% for both EUS-TD and percutaneous drainage. Both the short- and long-term clinical success rates for EUS-TD were 100% and those for percutaneous drainage were 61.1 and 83%, respectively. The differences in these rates were not significant (short-term success, P = 0.091 vs. long-term success, P = 0.403). However, the time to clinical success was significantly shorter with EUS-TD (5.8 days) than with percutaneous drainage (30.4 days; P = 0.0013) in the current series. CONCLUSIONS The EUS-TD approach appears to be a safe and technically feasible alternative to percutaneous drainage and may be considered as first-line therapy for pancreatic fistulas visible by EUS.
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Galasso D, Voermans RP, Fockens P. Role of endosonography in drainage of fluid collections and other NOTES procedures. Best Pract Res Clin Gastroenterol 2009; 23:781-9. [PMID: 19744640 DOI: 10.1016/j.bpg.2009.06.009] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/04/2009] [Accepted: 06/22/2009] [Indexed: 02/07/2023]
Abstract
Endosonography (EUS) has become the accepted procedure for drainage of pancreatic fluid collections in the past decade. EUS was shown to be safe and effective and it has been the first-line therapy for uncomplicated pseudocysts. Where walled-off pancreatic necrosis was originally thought to be a contraindication for endoscopic treatment, multiple case series have now shown that these fluid collections also can be treated endoscopically with low morbidity and mortality. Analogous to the treatment of pancreatic fluid collections, others, such as abscesses in the lower and upper abdomen, have also been treated successfully, although there is limited literature in this regard, EUS appears to be a useful technique in natural orifice transluminal endoscopic surgery (NOTES) procedures as well.
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Affiliation(s)
- Domenico Galasso
- Department of Gastroenterology and Hepatology, Academic Medical Center, University of Amsterdam, The Netherlands
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Acute pancreatitis: radiologic scores in predicting severity and outcome. ACTA ACUST UNITED AC 2009; 35:349-61. [PMID: 19437067 DOI: 10.1007/s00261-009-9522-y] [Citation(s) in RCA: 22] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/04/2009] [Accepted: 04/19/2009] [Indexed: 02/06/2023]
Abstract
Acute pancreatitis (AP) is a common inflammatory disease which can be mild and self-limiting without complications or severe with prolonged hospitalization, high morbidity, and high mortality. Different radiological scoring systems to predict severity and outcome in AP have been developed since the early 1990s. In the meantime, new insights in the pathophysiology of AP and consequently, therapeutic management of these patients have been introduced. The purpose of this review is therefore (1) to describe the current terminology and new concepts in the pathophysiology, (2) to outline the long existing and newly developed radiological scoring systems in prediction of severity and outcome with their respective advantages and limitations, and (3) to define the role of radiological prognostic scoring systems in the new environment of perception of the last decade. Risk stratification in AP requires scoring systems that can be calculated early in the course of disease which allows time for intervention. For that reason, scoring systems based on necrosis are not useful in severity prediction. The recent developed radiological scoring systems based on signs of systemic inflammatory response syndrome and organ dysfunction are promising in prediction of severity early after onset of AP.
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Seewald S, Ang TL, Kida M, Teng KYK, Soehendra N. EUS 2008 Working Group document: evaluation of EUS-guided drainage of pancreatic-fluid collections (with video). Gastrointest Endosc 2009; 69:S13-21. [PMID: 19179137 DOI: 10.1016/j.gie.2008.10.061] [Citation(s) in RCA: 68] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/22/2008] [Accepted: 10/28/2008] [Indexed: 12/13/2022]
Affiliation(s)
- Stefan Seewald
- Department of Interdisciplinary Endoscopy, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
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Childs DD, Tchelepi H. Ultrasound and Abdominal Intervention: New Luster on an Old Gem. ACTA ACUST UNITED AC 2009. [DOI: 10.1016/j.cult.2009.03.004] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/07/2023]
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Talreja JP, Shami VM, Ku J, Morris TD, Ellen K, Kahaleh M. Transenteric drainage of pancreatic-fluid collections with fully covered self-expanding metallic stents (with video). Gastrointest Endosc 2008; 68:1199-203. [PMID: 19028232 DOI: 10.1016/j.gie.2008.06.015] [Citation(s) in RCA: 140] [Impact Index Per Article: 8.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/07/2008] [Accepted: 06/15/2008] [Indexed: 12/13/2022]
Abstract
BACKGROUND Drainage of pancreatic-fluid collections (PFCs) by using fully covered self-expanding metallic stents (CSEMSs) offers the option of providing a larger-diameter access fistula for drainage when compared with plastic stents. OBJECTIVE To evaluate the efficacy and safety of transenteric drainage of PFCs by using CSEMSs. DESIGN A prospective case series. SETTING A tertiary-referral center. PATIENTS Between January 2007 and September 2007, 18 patients underwent drainage of PFCs by using CSEMSs. Follow-up and final results were prospectively recorded until May 2008. INTERVENTIONS Placement of CSEMSs with a double-pigtail stent placed alongside (4 cases) or into the CSEMS (14 cases) to prevent migration. MAIN OUTCOME MEASUREMENTS The number of sessions and time to resolution of the PFCs. RESULTS A median of 1 session was required to achieve drainage (range 1-4) when using CSEMSs. Complications included superinfection (5), bleeding (2), and inner migration (1). A total of 17 of 18 patients (95%) responded successfully, with 14 patients (78%) achieving complete resolution of their PFC. The mean (+/- SD) time of follow-up until final resolution was 77 +/- 80 days (range 15-310 days). CONCLUSIONS Placement of CSEMSs seems to offer an effective and safe alternative for the drainage of PFCs. A randomized controlled trial should be performed to compare this technique with plastic-stent drainage.
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Affiliation(s)
- Jayant P Talreja
- Digestive Health Center of Excellence, University of Virginia Health System, Charlottesville, Virginia 22908-0708, USA
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Romano A, Spaggiari M, Masetti M, Sassatelli R, Di Benedetto F, De Ruvo N, Montalti R, Guerrini GP, Ballarin R, De Blasiis MG, Gerunda GE. A new endoscopic treatment for pancreatic fistula after distal pancreatectomy: case report and review of the literature. Gastrointest Endosc 2008; 68:798-801. [PMID: 18514650 DOI: 10.1016/j.gie.2008.02.036] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/06/2007] [Accepted: 02/15/2008] [Indexed: 02/08/2023]
Affiliation(s)
- Antonio Romano
- Liver and Multivisceral Transplantation Center, University of Modena, Modena, Italy
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Subtil C, Moutardier V, Vitton V, Gasmi M, Desjeux A, Grimaud JC, Brunet C, Berdah S, Barthet M. [Endoscopic management of postoperative pancreatic collections]. ACTA ACUST UNITED AC 2008; 32:128-33. [PMID: 18494154 DOI: 10.1016/j.gcb.2008.01.007] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
Abstract
INTRODUCTION Treatment of pancreatic postoperative collections are usually managed with a multidisciplinary team. Different managements are possible: abstention, external drainage, endoscopic treatment or surgery. METHODS We report on a case series of five patients with a postoperative pancreatic collection, endoscopically managed. Patients underwent all a CT scan associated or not with endoscopic ultrasonography. RESULTS An endoscopic cystenterosotomy was performed in all the cases, with two double pig tail stents sometimes associated with nasocystic drainage for clearing the cyst lumen and with transpapillary drainage in one case. All the procedures were successful and patients healed in all the cases with the disappearance of the radiological image within a 33 days to three months range with one complication due to superinfection of the drained cyst, endoscopically managed with a nasocystic catheter. CONCLUSION Therapeutic endoscopy, with a multidisciplinary approach, is a promising way to manage postoperative pancreatic collections.
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Affiliation(s)
- C Subtil
- Département de gastroentérologie et hépatologie, hôpital Nord, chemin des Bourrely, 13915 Marseille cedex 20, France
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Lu X, Uchida E, Yokomuro S, Nakamura Y, Aimoto T, Tajiri T. Features and choice of treatment of acute and chronic pancreatic pseudocysts--with special reference to invasive intervention. Pancreatology 2008; 8:30-5. [PMID: 18235214 DOI: 10.1159/000114853] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/11/2006] [Accepted: 09/02/2007] [Indexed: 12/11/2022]
Abstract
AIMS It was the aim of this study to characterize the features of acute and chronic pancreatic pseudocysts (PPs) and to identify the factors predictive of the need for invasive treatment. METHODS Thirty-six patients with PPs treated at Nippon Medical School between January 1995 and December 2004 were studied retrospectively. The cases were divided into 4 groups based on 4 features: association with acute pancreatitis, association with chronic pancreatitis, spontaneous resolution, and persistent symptoms requiring therapeutic intervention. Group 1 included 9 patients with acute PPs which resolved spontaneously. Group 2 included 9 patients with acute PPs with persistent symptoms or associated complications requiring interventional treatment. Group 3 included 9 patients with chronic PPs which resolved spontaneously, and group 4 included 9 patients with chronic PPs with persistent symptoms or associated complications requiring interventional treatment. RESULTS Among the 36 patients, 13 were women and 23 were men. The etiologies were pancreatitis due to alcoholism in 18 cases (50.0%), biliary tract disease in 8 cases (22.2%) and other conditions in 10 cases (27.8%). The average duration of follow-up was 24.2 +/- 18.5 months. The patients in group 1 were significantly older than those in group 2 (67.6 +/- 16.1 vs. 40.6 +/- 14.1 years; p = 0.011). The mean size of the PPs was significantly larger in groups 1 and 4 than in group 3 (p < 0.05) and significantly larger in group 2 than in group 4 (p < 0.05). There were no significant differences between groups 1 and 2 in the size of the PPs or in the Ranson score of previous pancreatitis. The increase in size of the PPs during follow-up in each of the spontaneously resolved groups (groups 1 and 3) differed significantly from that in each of the interventional treatment groups (groups 2 and 4; p < 0.05). The main cause of the acute pancreatitis in group 1 was biliary tract disease, while that in group 2 was alcoholism (significantly different, p < 0.05). The number of patients with symptoms related to pseudocysts at the time of diagnosis was significantly higher in group 1 than in group 3. CONCLUSIONS Growth of the PPs during follow-up is the strongest predictor of the need for invasive treatment in both acute and chronic cases. Among acute PPs, the size of the pseudocyst is not in itself a predictor of invasive treatment. Invasive treatment may pose higher risks for pseudocysts with an etiology of alcoholic acute pancreatitis. However, the size of the pseudocyst may be a more important prognostic factor than an etiology of pancreatitis. and IAP.
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Affiliation(s)
- Xiaolan Lu
- Department of Gastroenterology, Second Hospital of Xi'an Jiaotong University, Xi'an, China
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Bollen TL, van Santvoort HC, Besselink MG, van Leeuwen MS, Horvath KD, Freeny PC, Gooszen HG. The Atlanta Classification of acute pancreatitis revisited. Br J Surg 2008; 95:6-21. [PMID: 17985333 DOI: 10.1002/bjs.6010] [Citation(s) in RCA: 190] [Impact Index Per Article: 11.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
BACKGROUND In a complex disease such as acute pancreatitis, correct terminology and clear definitions are important. The clinically based Atlanta Classification was formulated in 1992, but in recent years it has been increasingly criticized. No formal evaluation of the use of the Atlanta definitions in the literature has ever been performed. METHODS A Medline literature search sought studies published after 1993. Guidelines, review articles and their cross-references were reviewed to assess whether the Atlanta or alternative definitions were used. RESULTS A total of 447 articles was assessed, including 12 guidelines and 82 reviews. Alternative definitions of predicted severity of acute pancreatitis, actual severity and organ failure were used in more than half of the studies. There was a large variation in the interpretation of the Atlanta definitions of local complications, especially relating to the content of peripancreatic collections. CONCLUSION The Atlanta definitions for acute pancreatitis are often used inappropriately, and alternative definitions are frequently applied. Such lack of consensus illustrates the need for a revision of the Atlanta Classification.
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Affiliation(s)
- T L Bollen
- Department of Radiology, St Antonius Hospital Nieuwegein, The Netherlands
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Mahnken AH, Günther RW, Winograd R. Percutaneous transgastric snaring for repositioning of a dislocated internal drain from a pancreatic pseudocyst. Cardiovasc Intervent Radiol 2007; 31 Suppl 2:S217-20. [PMID: 17763902 DOI: 10.1007/s00270-007-9152-0] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/27/2007] [Accepted: 07/18/2007] [Indexed: 12/15/2022]
Abstract
Pancreatic pseudocysts may occur in up to 10% of patients with acute or chronic pancreatitis. Symptomatic, persistent, and infected pancreatic pseudocysts require interventional therapy. We present the case of a patient with complete dislocation of a double pigtail catheter into an infected pseudocyst and the repositioning of the drainage catheter using a transgastric snaring technique. The combination of CT-guided percutaneous puncture and fluoroscopic snaring permitted minimally invasive management of this rare complication.
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Affiliation(s)
- Andreas H Mahnken
- Department of Diagnostic Radiology, University Hospital, RWTH Aachen University, Pauwelsstrasse 30, 52074 Aachen, Germany.
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Bollen TL, Besselink MGH, van Santvoort HC, Gooszen HG, van Leeuwen MS. Toward an update of the atlanta classification on acute pancreatitis: review of new and abandoned terms. Pancreas 2007; 35:107-13. [PMID: 17632315 DOI: 10.1097/mpa.0b013e31804fa189] [Citation(s) in RCA: 50] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/15/2023]
Abstract
OBJECTIVES The 1992 Atlanta classification is a clinically based classification system that defines the severity and complications of acute pancreatitis. The purpose of this review was to assess whether the terms abandoned by the Atlanta classification are really discarded in the literature. The second objective was to review what new terms have appeared in the literature since the Atlanta symposium. METHODS We followed a Medline search strategy in review and guideline articles after the publication of the Atlanta classification. This search included the abandoned terms: "phlegmon," "infected pseudocyst," "hemorrhagic pancreatitis," and "persistent pancreatitis." RESULTS A total of 239 publications were reviewed, including 10 guideline articles and 42 reviews. The abandoned terms "hemorrhagic pancreatitis" and "persistent pancreatitis" are hardly encountered, in contrast, both "infected pseudocyst" and "phlegmon" are frequently used, and several authors question their abandonment. New terminology in acute pancreatitis consists of "organized pancreatic necrosis," "necroma," "extrapancreatic necrosis," and "central gland necrosis." CONCLUSIONS This review demonstrates that the Atlanta classification is still not universally accepted. Several abandoned terms are frequently used, and new terms have emerged that describe manifestations in acute pancreatitis that were not specifically addressed during the Atlanta symposium.
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Affiliation(s)
- Thomas L Bollen
- Department of Radiology, St. Antonius Hospital, Nieuwegein, The Netherlands.
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Arvanitakis M, Delhaye M, Bali MA, Matos C, De Maertelaer V, Le Moine O, Devière J. Pancreatic-fluid collections: a randomized controlled trial regarding stent removal after endoscopic transmural drainage. Gastrointest Endosc 2007; 65:609-19. [PMID: 17324413 DOI: 10.1016/j.gie.2006.06.083] [Citation(s) in RCA: 179] [Impact Index Per Article: 10.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/13/2006] [Accepted: 06/20/2006] [Indexed: 02/08/2023]
Abstract
BACKGROUND Endoscopic transmural drainage is obtained by creating a communication between the intestinal tract and the pancreatic-fluid collection, and then inserting 1 or more stents. Collection recurrence after therapy is noted in 10% to 30% of cases. It is not known whether leaving the stents in position reduces recurrence rates. OBJECTIVE To test the hypothesis that patients who have undergone previous successful pancreatic-collection drainage and whose stents are retrieved have higher recurrence rates. DESIGN Randomized controlled trial. SETTING Tertiary referral center. PATIENTS During a period of 27 months, 46 of 77 patients who had undergone endoscopic transmural drainage for pancreatic collections met inclusion or exclusion criteria, and 28 of these patients were randomized. INTERVENTIONS Fifteen patients were assigned to group A, whose stents were left in place, and 13 were assigned to group B, whose stents were removed after collection resolution. The remaining 18 patients, who were not randomized, also had their stents left in place. All 46 patients were similarly followed. MAIN OUTCOME MEASUREMENT Recurrence of the same pancreatic collection that required therapy. RESULTS All patients were followed for a median period of 14 months (interquartile range, 8.2-22 months) after treatment. The primary end point was reached in 5 patients in group B (stent retrieval), as opposed to none in group A (P = .013). Moreover, no recurrence was observed in the remaining 18 nonrandomized patients. LIMITATIONS Small sample size. CONCLUSIONS In patients who underwent successful transmural drainage of pancreatic collections, stent retrieval was associated with higher recurrence rates.
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Arvanitakis M, Delhaye M, Bali MA, Matos C, Le Moine O, Devière J. Endoscopic treatment of external pancreatic fistulas: when draining the main pancreatic duct is not enough. Am J Gastroenterol 2007; 102:516-24. [PMID: 17335445 DOI: 10.1111/j.1572-0241.2006.01014.x] [Citation(s) in RCA: 39] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
OBJECTIVES Transpapillary drainage of the main pancreatic duct (MPD) has been proposed for the treatment of external pancreatic fistulas (EPF) but may not suffice to treat complex cases. The aim of the present study was to explore the efficacy of various endoscopic or combined percutaneous and endoscopic techniques in the treatment of EPFs. METHODS Sixteen patients presenting with EPFs were treated in our department. The techniques applied and patients' clinical outcome are described. RESULTS All but three patients underwent transpapillary MPD drainage by pancreatic sphincterotomy (N = 13). Additional endoscopic procedures performed were: (a) pancreatic fluid collection (PFC) drainage (N = 5), (b) transmural drainage between the fistula path and the gastrointestinal (GI) tract (N = 5), and (c) endoscopic ultrasound (EUS)-guided pancreaticoduodenostomy because of complete pancreatic duct rupture (N = 1). Fistula closure was achieved in all patients except one, who required surgery. During a median follow-up period of 18 months (range 6-52) three patients had fistula recurrence, and two, PFC recurrence. Both conditions were cured successfully by repeated endoscopic therapy. All recurrences occurred within 3 months of initial successful treatment. CONCLUSIONS Combined endoscopic and percutaneous treatment appears to be safe and effective for the management of complex cases of EPFs.
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Hookey LC, Debroux S, Delhaye M, Arvanitakis M, Le Moine O, Devière J. Endoscopic drainage of pancreatic-fluid collections in 116 patients: a comparison of etiologies, drainage techniques, and outcomes. Gastrointest Endosc 2006; 63:635-43. [PMID: 16564865 DOI: 10.1016/j.gie.2005.06.028] [Citation(s) in RCA: 253] [Impact Index Per Article: 14.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/27/2005] [Accepted: 06/09/2005] [Indexed: 02/08/2023]
Abstract
BACKGROUND Pancreatic-fluid collections are frequent sequelae of acute and chronic pancreatitis, and endoscopic drainage of these collections has gained acceptance as an alternative to surgical drainage. METHODS Patient data, collection characteristics, drainage technique, and outcomes were obtained through chart review and prospective follow-up for 116 patients with attempted endoscopic drainage of symptomatic pancreatic-fluid collections. RESULTS A total of 116 patients presented with fluid collections classified as acute fluid collection (n = 5), necrosis (n = 8), acute pseudocyst (n = 30), chronic pseudocyst (n = 64), and pancreatic abscess (n = 9). The median diameter of the collection drained was 60 mm (15-275 mm). Median follow-up after drainage was 21 months. The drainage technique was transpapillary in 15 patients, transmural in 60, and both in 41. Successful resolution of symptoms and collection occurred in 87.9% of cases. No difference in success rates was observed between patients with acute pancreatitis and those with chronic pancreatitis. However, drainage of organized necrosis was associated with a significantly higher failure rate than other collections. No significant differences were observed regarding success when disease, drainage technique, or site of drainage was considered. Complications occurred in 13 patients (11%), and there were 6 deaths in the 30 days after drainage, including one that was procedure related. CONCLUSIONS Endoscopic drainage of pancreatic-fluid collections is successful in the majority of patients and is accompanied by an acceptable complication rate.
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Affiliation(s)
- Lawrence C Hookey
- Gastroenterology Division, Queen's University, Kingston, Ontario, Canada
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Abstract
OBJECTIVE Few abdominal or pelvic cystic lesions come to the attention of the interventional radiologist, and those that do are symptomatic. Differentiation of cysts from cystic-appearing masses is not difficult when a multitechnique imaging approach is used. Our objective is to summarize the principles and specifics for management of symptomatic cysts through percutaneous catheter techniques. CONCLUSION Percutaneous aspiration of cysts can relieve symptoms without the need for surgery. A sound knowledge of the various types of cysts that may be found in the abdomen and pelvis enables the radiologist to select those patients who will benefit the most from percutaneous management.
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Affiliation(s)
- Brian C Lucey
- Division of Body Imaging, Department of Radiology, Boston University Medical Center, 88 East Newton St., Atrium 2, Boston, MA 02118, USA.
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Abstract
Advances in minimally invasive surgery have revolutionized the field of surgery. Despite the great strides in equipment and experience, operative conduct remains confined by the limits of exposure. Retroperitoneal fat can be abundant and can contribute greatly to difficulty in exposure. Visceral organs ventral to the retroperitoneum preclude direct access and require optimal patient positioning to operate. Additionally, the major vascular pedicles all originate in the retroperitoneum off of the abdominal aorta or enter the inferior vena cava. The pancreas, in particular, is surrounded by the portal vein, celiac axis, superior mesenteric vein and artery, and splenic vein and artery. If injured during surgery, these vessels can present a life-threatening emergency. The issues related to the vasculature, coupled with the difficulty in resecting portions of the pancreas and the relative paucity of pancreatic procedures, have greatly concentrated these cases at tertiary care centers staffed by experienced laparoscopists. However, as surgical technology improves and fellowships train more surgeons with advanced laparoscopic skills, minimally invasive pancreatic surgery may diffuse with more community-based health care networks.
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Affiliation(s)
- Daniel Tseng
- Department of Surgery, Oregon Health and Science University, Portland, Oregon 97201, USA
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Abstract
AIM: To explore the implications of underlying diseases in treatment of pancreatic pseudocysts (PPC).
METHODS: Clinical data of 73 cases of pancreatic pseudocyst treated in a 12-year period were reviewed comprehensively. Pancreatic pseudocysts were classified according to the etiological criteria proposed by D’Egidio. The correlation between the etiological classification, measure of treatment and clinical outcome of the patients was analyzed.
RESULTS: According to the etiological criteria proposed by D’Egidio, 73 patients were divided into three groups. Group I was comprised of 37 patients with type I pseudocyst, percutaneous drainage was successful in the majority (9/11, 82%) while external or internal drainage was not satisfactory with a low success rate (8/16, 50%). Group II was comprised of 24 patients with type II pseudocyst, and internal drainage was curative for most of the cases (11/12, 92%), but the success rate of percutaneous or external drainage was unacceptably low (4/9, 44%). Group III consisted of 12 patients with type III pseudocyst. Internal drainage or pancreatic resection performed in 10 of these patients produced a curative rate of 80% (8/10) with the correction of the ductal pathology as a prerequisite.
CONCLUSION: The classification of pancreatic pseudocyst based on its underlying diseases is meaningful for its management. Awareness of the underlying diseases of pancreatic pseudocyst and detection of the ductal pathology in type II and III pancreatic pseudocysts with endoscopic retrograde cholangiopancreatography may help make better decisions of treatment to reduce the rate of complications and recurrence.
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Affiliation(s)
- Ai-Bin Zhang
- Department of Hepatobiliary Pancreatic Surgery, First Hospital, College of Medicine, Zhejiang University, Hangzhou 310003, Zhejiang Province, China.
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Le Moine O, Matos C, Closset J, Devière J. Endoscopic management of pancreatic fistula after pancreatic and other abdominal surgery. Best Pract Res Clin Gastroenterol 2004; 18:957-75. [PMID: 15494289 DOI: 10.1016/j.bpg.2004.06.027] [Citation(s) in RCA: 25] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Abstract
Post-operative pancreatic fistulae represent a challenge for all the actors in gastroenterology: for surgeons, because they want to prevent and treat conservatively this complication since re-operation is associated with high morbidity and mortality rates; for radiologists, because they have to provide the best staging and informations without any additional risk; and for endoscopists, because endoluminal treatment is emerging as a safe and effective procedure provided it is performed in highly experienced tertiary centres in the setting of a multidisciplinary approach. Herein, we review the definitions, the causes, the staging and the possible options to prevent or treat post-operative pancreatic fistulae. Special attention is paid to the endoscopic management of this complication: including the relief of ductal obstructions, the stenting of leakages and the drainage of bulging or non-bulging fluid collections. Practical problems and issues are clearly outlined as well as the need for future improvements in staging and management of the patients having such complications.
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Affiliation(s)
- Olivier Le Moine
- Department of Gastroenterology, ULB-Hôpital Erasme, 808 route de lennik, B-1070 Brussels, Belgium.
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Jerram RM, Warman CG, Davies ESS, Robson MC, Walker AM. Successful treatment of a pancreatic pseudocyst by omentalisation in a dog. N Z Vet J 2004; 52:197-201. [PMID: 15726131 DOI: 10.1080/00480169.2004.36429] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
Abstract
CASE HISTORY A 3-year-old male Labrador retriever was presented with a history of dietary indiscretion followed by vomiting and abdominal pain. CLINICAL FINDINGS AND TREATMENT Abdominal ultrasonography revealed the presence of a fluid-filled cystic structure in the region of the pancreas. Flocculent, dark fluid was drained from the cystic structure during exploratory celiotomy prior to resection of the lateral cystic wall. Omentum was sutured into the cystic cavity to provide drainage and enhance immune response. A jejunostomy feeding tube was placed. Post-surgical care consisted of antibiotic therapy. The dog was clinically normal at 1 and 7 months post-operatively and the pancreas appeared normal on final ultrasonographic examination. CLINICAL RELEVANCE This case describes the use of omentum to provide physiological drainage of a pancreatic pseudocyst. This surgical technique may help clinicians manage patients with this condition in the future.
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Affiliation(s)
- R M Jerram
- Veterinary Specialist Group, 97 Carrington Road, Mount Albert, Auckland, New Zealand.
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Affiliation(s)
- Betty J Tsuei
- Department of Surgery, University of Kentucky College of Medicine, Lexington, Kentucky 40536, USA
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Bhattacharya D, Ammori BJ. Minimally invasive approaches to the management of pancreatic pseudocysts: review of the literature. Surg Laparosc Endosc Percutan Tech 2003; 13:141-8. [PMID: 12819495 DOI: 10.1097/00129689-200306000-00001] [Citation(s) in RCA: 75] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
Although one third or more of pancreatic pseudocysts might resolve spontaneously, interventional therapy is required for most. Several minimally invasive management approaches are now available, including percutaneous drainage under radiologic control, endoscopic transpapillary or transmural drainage, and laparoscopic internal drainage. This paper reviews the methodology, applications, advantages, shortcomings, and results of these management approaches. A computerized search was made of the MEDLINE, PREMEDLINE, and EMBASE databases using the search words pancreatic and pseudocysts and all relevant articles in English Language or with English abstracts were retrieved. In addition, cross-references from the identified articles were reviewed. Percutaneous drainage is best applied to pseudocysts complicated with secondary infection and in critically ill patients or those unfit for surgery. Radiologic drainage, however, risks the introduction of secondary infection and the formation of an external pancreatic fistula, and is associated with high recurrence rates. Endoscopic transpapillary drainage is beneficial for pseudocysts that communicate with the pancreatic duct and when a dependent drainage could be established. Endoscopic transmural (transgastric or transduodenal) drainage offers good results in the management of suitably located pseudocysts that complicate chronic pancreatitis, but is associated with high rates of failure to drain, secondary infection, and recurrence when pseudocysts that complicate acute necrotizing pancreatitis are approached. Laparoscopic pseudocyst gastrostomy or pseudocyst jejunostomy achieves adequate internal drainage, facilitates concomitant debridement of necrotic tissue within acute pseudocysts, and achieves good results with minimal morbidity. A randomized controlled trial that compares laparoscopic and endoscopic drainage techniques of retrogastric pseudocysts of chronic pancreatitis is required.
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Abstract
In the past decade, our understanding of the genetic basis, pathogenesis, and natural history of pancreatitis has grown strikingly. In severe acute pancreatitis, intensive medical support and non-surgical intervention for complications keeps patients alive; surgical drainage (necrosectomy) is reserved for patients with infected necrosis for whom supportive measures have failed. Enteral feeding has largely replaced the parenteral route; controversy remains with respect to use of prophylactic antibiotics. Although gene therapy for chronic pancreatitis is years away, our understanding of the roles of gene mutations in hereditary and sporadic pancreatitis offers tantalising clues about the disorder's pathogenesis. The division between acute and chronic pancreatitis has always been blurred: now, genetics of the disorder suggest a continuous range of disease rather than two separate entities. With recognition of pancreatic intraepithelial neoplasia, we see that chronic pancreatitis is a premalignant disorder in some patients. Magnetic resonance cholangiopancreatography and endoscopic ultrasound are destined to replace endoscopic retrograde cholangiopancreatography for many diagnostic indications in pancreatic disease.
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Affiliation(s)
- R M S Mitchell
- Division of Gastroenterology, Duke University Medical Center, Durham, NC 27710, USA
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Gandolfi L, Torresan F, Solmi L, Puccetti A. The role of ultrasound in biliary and pancreatic diseases. EUROPEAN JOURNAL OF ULTRASOUND : OFFICIAL JOURNAL OF THE EUROPEAN FEDERATION OF SOCIETIES FOR ULTRASOUND IN MEDICINE AND BIOLOGY 2003; 16:141-59. [PMID: 12573783 DOI: 10.1016/s0929-8266(02)00068-x] [Citation(s) in RCA: 45] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
The possibilities and the limits of transabdominal ultrasonography (US) in the diagnosis of bilio-pancreatic diseases are reviewed here in the light of the last 10 years' research. US remains the method of choice for the diagnosis of gallstones and is generally accepted as an initial imaging technique in gallstone complications, such as acute cholecystitis. Moreover the method can be useful for the detection of the biliary complications after laparoscopic cholecystectomy and after liver transplantation. US is still considered the first diagnostic procedure when stones are suspected in the common bile duct. The use of color Doppler can provide a differential diagnosis of gallbladder cancer with respect to other benign inflammatory or polypoid lesions. Color Doppler US allows to detect vascular complications of acute pancreatitis such as pseudoaneurysms. US is still considered useful for the initial screening of the pancreatic cancer. However, for staging other imaging techniques must be employed. With US useful informations are obtained in the diagnosis of cystic tumors of the pancreas and of pancreatic metastases. US is generally of little use for the diagnosis of endocrine tumors.
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Affiliation(s)
- Lionello Gandolfi
- Section of Gastroenterology, Policlinic Hospital S.Orsola-Malpighi, Via Albertoni 15, 40138 Bologna, Italy.
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Wagholikar GD, Ibrarullah M, Venkataramanapa M. Gastric intramural pseudocyst--a complication of percutaneous drainage of an acute pancreatic pseudocyst. Am J Gastroenterol 2003; 98:229-31. [PMID: 12526979 DOI: 10.1111/j.1572-0241.2003.07192.x] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
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Byrne MF, Mitchell RM, Baillie J. Pancreatic Pseudocysts. CURRENT TREATMENT OPTIONS IN GASTROENTEROLOGY 2002; 5:331-338. [PMID: 12207856 DOI: 10.1007/s11938-002-0021-2] [Citation(s) in RCA: 23] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
Pseudocysts complicate acute pancreatitis in less than 5% of cases and chronic pancreatitis in 20% to 40% of cases. A pseudocyst is a localized collection of pancreatic fluid surrounded by a wall of granulation tissue and collagen. It takes 4 to 6 weeks for a fluid collection to mature and become a true pseudocyst. Unlike other cystic lesions of the pancreas from which they should be differentiated, pseudocysts lack an epithelial layer. Patients with pseudocysts present with a range of symptoms and signs. Pseudocysts are imaged using transabdominal ultrasound, CT, endoscopic ultrasound (EUS), and MRI. EUS confers an advantage over other imaging modalities in that certain EUS features are suggestive of pseudocysts over other cystic lesions. The diagnostic accuracy of EUS has improved further with the use of EUS-guided fine-needle aspiration. Therapeutic options include watchful observation or intervention. In our opinion, if acute pseudocysts are uncomplicated, asymptomatic, and do not appear to be enlarging on serial imaging, it is preferable to withhold intervention because many of these cysts resolve spontaneously. However, one needs to beware of the possibility of complications such as infection in unresolved pseudocysts. Pseudocysts associated with chronic pancreatitis are less likely to resolve spontaneously and are drained by intervention more frequently. Of the three interventional options, namely endoscopic, percutaneous, and surgical drainage, endoscopic drainage should be the treatment of choice if certain criteria are met. Preinterventional endoscopic retrograde cholangiopancreatography is mandatory to define ductal anatomy. If there is communication between the pseudocyst and the pancreatic duct, a transpapillary approach is preferred. Use of EUS should increase the number of cases in which pseudocysts can be drained endoscopically. Surgery should be reserved for cases in which there is a concern about malignancy or when there is glandular disruption.
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Abstract
The mortality in undrained abdominal abscesses is high with a mortality rate ranging between 45 and 100%. The outcome in abdominal abscesses, however, has improved due to advances in image guided percutaneous interventional techniques. The main indications for the catheter drainage include treatment or palliation of sepsis associated with an infected fluid collection, and alleviation of the symptoms that may be caused by fluid collections by virtue of their size, like pancreatic pseudocele or lymphocele. The single liver abscesses may be drained with ultrasound guidance only, whereas the multiple abscesses usually require computed tomography (CT) guidance and placement of multiple catheters. The pancreatic abscesses are generally drained routinely and urgently. Non-infected pancreatic pseudocysts may be simply observed unless they are symptomatic or cause problems such as pain or obstruction of the biliary or the gastrointestinal tract. Percutaneous routes that have been described to drain pelvic abscesses include transrectal or transvaginal approach with sonographic guidance, a transgluteal, paracoccygeal-infragluteal, or perineal approach through the greater sciatic foramen with CT guidance. Both the renal and the perirenal abscesses are amenable to percutaneous drainage. Percutaneous drainage provides an effective and safe alternative to more invasive surgical drainage in most patients with psoas abscesses as well.
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Affiliation(s)
- Süleyman Men
- Department of Radiology, Medical School, Dokuz Eylul University, TR-35340 Inciralti, Izmir, Turkey.
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