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Rey Chaves CE, Azula Uribe MC, Benavides Largo S, Becerra Sarmiento L, Gómez-Gutierrez MA, Cuevas López L. Video-assisted retroperitoneal debridement for necrotizing pancreatitis: a single center experience in Colombia. BMC Surg 2024; 24:293. [PMID: 39375651 PMCID: PMC11457398 DOI: 10.1186/s12893-024-02586-x] [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] [Received: 07/09/2024] [Accepted: 09/24/2024] [Indexed: 10/09/2024] Open
Abstract
INTRODUCTION Acute pancreatitis (AP) is a common and potentially lethal disease. Approximately 10-20% of the patients progress to necrotizing pancreatitis (NP). The step-up approach is the gold standard approach to managing an infected necrotizing pancreatitis with acceptable morbidity and mortality rates. Video-assisted retroperitoneal debridement (VARD) has been described as a safe and feasible approach with high success rates. Multiple studies in the American, European, and Asian populations evaluating the outcomes of VARD have been published; nevertheless, outcomes in the Latin American population are unknown. This study aims to describe a single-center experience of VARD for necrotizing pancreatitis in Colombia with a long-term follow-up. METHODS A prospective cohort study was conducted between 2016 and 2024. All patients over 18 years old who underwent VARD for necrotizing pancreatitis were included. Demographic, clinical variables, and postoperative outcomes at 30-day follow-up were described. RESULTS A total of 12 patients were included. The mean age was 55.9 years old (SD 13.73). The median follow-up was 365 days (P25 60; P75 547). Bile origin was the most frequent cause of pancreatitis in 90.1% of the patients. The mean time between diagnosis and surgical management was 78.5 days (SD 22.93). The mean size of the collection was 10.5 cm (SD 3.51). There was no evidence of intraoperative complications. The mean in-hospital length of stay was 65.18 days (SD 26.46). One patient died in a 30-day follow-up. One patient presented an incisional hernia one year after surgery, and there was no evidence of endocrine insufficiency at the follow-up. CONCLUSION According to our data, the VARD procedure presents similar outcomes to those reported in the literature; a standardized procedure following the STEP-UP procedure minimizes the requirement of postoperative drainages. Long-term follow-up should be performed to rule out pancreatic insufficiency.
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Affiliation(s)
- Carlos Eduardo Rey Chaves
- Estudiante de Posgrado Cirugía General, Pontificia Universidad Javeriana, Facultad de Medicina, Carrera 6A #51A-48, Bogotá D.C, 111711, Colombia.
| | - María Camila Azula Uribe
- Cirugía General, Pontificia Universidad Javeriana, Facultad de Medicina, Hospital Universitario San Ignacio, Bogotá, Colombia
| | - Sebastián Benavides Largo
- Cirugía General, Pontificia Universidad Javeriana, Facultad de Medicina, Hospital Universitario San Ignacio, Bogotá, Colombia
| | | | | | - Liliana Cuevas López
- Cirugía General, Pontificia Universidad Javeriana, Facultad de Medicina, Hospital Universitario San Ignacio, Bogotá, Colombia
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Kotecha K, Yeh J, Chui JN, Tree K, Greer D, Boue A, Gall T, McKay S, Mittal A, Samra JS. Waterjet pulse lavage as a safe adjunct to video assisted retroperitoneal debridement in necrotising pancreatitis. Surg Endosc 2024:10.1007/s00464-024-11297-6. [PMID: 39367136 DOI: 10.1007/s00464-024-11297-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/19/2024] [Accepted: 09/15/2024] [Indexed: 10/06/2024]
Abstract
BACKGROUND Minimally invasive surgical necrosectomy plays an important role in the management of infected pancreatic necrosis, with a goal of removing debris and debriding necrotic tissue. Pulse lavage is designed to simultaneously hydrostatically debride and remove the infected necrotic tissue with suction. It is also able to remove significant amounts of debris without traumatic manipulation of the necrotic tissue which may be adherent to surrounding tissue and can result in injury. METHODS AND RESULTS The surgical technique of utilising a waterjet pulse lavage device during the minimally invasive necrosectomy is detailed. Sixteen patients being managed via a step-up approach underwent endoscopic necrosectomy via a radiologically placed drain tract. All sixteen patients were successfully managed endoscopically without conversion to open necrosectomy, and survived their admission. There were no complications associated with the use of the waterjet pulse lavage. CONCLUSION Waterjet pulse lavage is a useful adjunct in minimally invasive necrosectomy, which reduces the length of the necrosectomy procedure, and facilitates removal of necrotic tissue while minimising the risk of traumatising healthy tissue.
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Affiliation(s)
- Krishna Kotecha
- Department of Upper Gastrointestinal Surgery, Royal North Shore Hospital, Reserve Road, St Leonards, 2065 NSW, Australia.
- Northern Clinical School, University of Sydney, St Leonards, Australia.
| | - John Yeh
- Department of Upper Gastrointestinal Surgery, Royal North Shore Hospital, Reserve Road, St Leonards, 2065 NSW, Australia
| | - Juanita N Chui
- Department of Upper Gastrointestinal Surgery, Royal North Shore Hospital, Reserve Road, St Leonards, 2065 NSW, Australia
| | - Kevin Tree
- Department of Upper Gastrointestinal Surgery, Royal North Shore Hospital, Reserve Road, St Leonards, 2065 NSW, Australia
| | - Douglas Greer
- Department of Upper Gastrointestinal Surgery, Royal North Shore Hospital, Reserve Road, St Leonards, 2065 NSW, Australia
| | - Alex Boue
- Department of Upper Gastrointestinal Surgery, Royal North Shore Hospital, Reserve Road, St Leonards, 2065 NSW, Australia
| | - Tamara Gall
- Department of Upper Gastrointestinal Surgery, Royal North Shore Hospital, Reserve Road, St Leonards, 2065 NSW, Australia
| | - Siobhan McKay
- Department of Upper Gastrointestinal Surgery, Royal North Shore Hospital, Reserve Road, St Leonards, 2065 NSW, Australia
- Institute of Cancer and Genomic Science, University of Birmingham, Edgbaston, Birmingham, B15 2TT, UK
| | - Anubhav Mittal
- Department of Upper Gastrointestinal Surgery, Royal North Shore Hospital, Reserve Road, St Leonards, 2065 NSW, Australia
- Northern Clinical School, University of Sydney, St Leonards, Australia
- School of Medicine, University of Notre Dame, Sydney, Australia
| | - Jaswinder S Samra
- Department of Upper Gastrointestinal Surgery, Royal North Shore Hospital, Reserve Road, St Leonards, 2065 NSW, Australia
- Northern Clinical School, University of Sydney, St Leonards, Australia
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Giri S, Das S, Nemani P, Mohanty SK, Nath P, Mohapatra V. Does the site, size, and number of necrotic collections affect the outcome of necrotizing pancreatitis? - a prospective analysis. Emerg Radiol 2024; 31:687-693. [PMID: 38995466 DOI: 10.1007/s10140-024-02261-x] [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] [Received: 06/10/2024] [Accepted: 06/26/2024] [Indexed: 07/13/2024]
Abstract
PURPOSE In patients with acute necrotizing pancreatitis (ANP), the site, size, and the number of acute necrotic collections (ANC) may determine the outcome of patients. The current study aimed to correlate the nature of ANC with the adverse outcomes in ANP patients. METHODS This was a single-center, prospective study (August 2019-August 2022) recruiting patients with ANP, correlating the site, size, and number of ANC with the length of hospital stay, intensive care unit (ICU) stays, development of organ failure and infection, need for intervention, and mortality. RESULTS A total of 114 patients (mean age: 37.3 ± 13.4 years, 85.1% males) with ANP were included in the study. The number and maximum diameter of collections significantly correlated with the length of the hospital and ICU stay and the need for intervention. Taking a cut-off size of 8 cm, the sensitivity and specificity for predicting the need for intervention were 82.7% and 74.2%, respectively. ANCs located in the perinephric, paracolic, subhepatic, and epigastric regions had a significant correlation with two or more adverse outcomes. Additional points were added to the modified CT severity index (mCTSI) based on the present study's findings. The new score had significantly higher AUROC than mCTSI for predicting infection, need for intervention, ICU stay > 1 week, and mortality. CONCLUSION The site, size, and number of EPNs have a significant correlation with adverse clinical outcomes in patients with ANP. The inclusion of these parameters, along with present scoring systems, will help further improve the prognostication of patients.
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Affiliation(s)
- Suprabhat Giri
- Department of Gastroenterology & Hepatology, Kalinga Institute of Medical Sciences, Bhubaneswar, India
| | - Swati Das
- Department of Radiology, Kalinga Institute of Medical Sciences, Bhubaneswar, India
| | - Prashanthi Nemani
- Department of General Surgery, Kalinga Institute of Medical Sciences, Bhubaneswar, India
| | - Subrat Kumar Mohanty
- Department of General Surgery, Kalinga Institute of Medical Sciences, Bhubaneswar, India
- Department of Pediatric Surgery, Kalinga Institute of Medical Sciences, Bhubaneswar, India
| | - Preetam Nath
- Department of Gastroenterology & Hepatology, Kalinga Institute of Medical Sciences, Bhubaneswar, India
| | - Vedavyas Mohapatra
- Department of Surgical Gastroenterology, Kalinga Institute of Medical Sciences, Patia, Bhubaneswar, Odisha, 751024, India.
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Gupta P, Siddiqui R, Singh S, Pradhan N, Shah J, Samanta J, Jearth V, Singh A, Mandavdhare H, Sharma V, Mukund A, Birda CL, Kumar I, Kumar N, Patidar Y, Agarwal A, Yadav T, Sureka B, Tiwari A, Verma A, Kumar A, Sinha SK, Dutta U. Application of deep learning models for accurate classification of fluid collections in acute necrotizing pancreatitis on computed tomography: a multicenter study. Abdom Radiol (NY) 2024:10.1007/s00261-024-04607-y. [PMID: 39347977 DOI: 10.1007/s00261-024-04607-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/23/2024] [Revised: 09/05/2024] [Accepted: 09/17/2024] [Indexed: 10/01/2024]
Affiliation(s)
- Pankaj Gupta
- Department of Radiodiagnosis and Imaging, Postgraduate Institute of Medical Education and Research, Chandigarh, India.
| | - Ruby Siddiqui
- Department of Radiodiagnosis and Imaging, Postgraduate Institute of Medical Education and Research, Chandigarh, India
| | - Shravya Singh
- Department of Radiodiagnosis and Imaging, Postgraduate Institute of Medical Education and Research, Chandigarh, India
| | - Nikita Pradhan
- 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
| | - Vaneet Jearth
- Department of Gastroenterology, Postgraduate Institute of Medical Education and Research, Chandigarh, India
| | - Anupam Singh
- 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
| | - Amar Mukund
- Department of Interventional Radiology, Institute of Liver and Biliary Science, New Delhi, India
| | - Chhagan Lal Birda
- Department of Gastroenterology, All India Institute of Medical Sciences, Jodhpur, India
| | - Ishan Kumar
- Department of Radiodiagnosis and Imaging, Institute of Medical Sciences, Banaras Hindu University, Varanasi, India
| | - Niraj Kumar
- Department of Interventional Radiology, Institute of Liver and Biliary Science, New Delhi, India
| | - Yashwant Patidar
- Department of Interventional Radiology, Institute of Liver and Biliary Science, New Delhi, India
| | - Ashish Agarwal
- Department of Gastroenterology, All India Institute of Medical Sciences, Jodhpur, India
| | - Taruna Yadav
- Department of Diagnostic and Interventional Radiology, All India Institute of Medical Sciences, Jodhpur, India
| | - Binit Sureka
- Department of Diagnostic and Interventional Radiology, All India Institute of Medical Sciences, Jodhpur, India
| | - Anurag Tiwari
- Department of Gastroenterology, Institute of Medical Sciences, Banaras Hindu University, Varanasi, India
| | - Ashish Verma
- Department of Radiodiagnosis and Imaging, Institute of Medical Sciences, Banaras Hindu University, Varanasi, India
| | - Ashish Kumar
- Department of Radiodiagnosis and Imaging, Institute of Medical Sciences, Banaras Hindu University, Varanasi, 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
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Ali H, Inayat F, Jahagirdar V, Jaber F, Afzal A, Patel P, Tahir H, Anwar MS, Rehman AU, Sarfraz M, Chaudhry A, Nawaz G, Dahiya DS, Sohail AH, Aziz M. Early versus delayed necrosectomy in pancreatic necrosis: A population-based cohort study on readmission, healthcare utilization, and in-hospital mortality. World J Methodol 2024; 14:91810. [PMID: 39310231 PMCID: PMC11230070 DOI: 10.5662/wjm.v14.i3.91810] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/14/2024] [Revised: 05/13/2024] [Accepted: 05/27/2024] [Indexed: 06/25/2024] Open
Abstract
BACKGROUND Acute necrotizing pancreatitis is a severe and life-threatening condition. It poses a considerable challenge for clinicians due to its complex nature and the high risk of complications. Several minimally invasive and open necrosectomy procedures have been developed. Despite advancements in treatment modalities, the optimal timing to perform necrosectomy lacks consensus. AIM To evaluate the impact of necrosectomy timing on patients with pancreatic necrosis in the United States. METHODS A national retrospective cohort study was conducted using the 2016-2019 Nationwide Readmissions Database. Patients with non-elective admissions for pancreatic necrosis were identified. The participants were divided into two groups based on the necrosectomy timing: The early group received intervention within 48 hours, whereas the delayed group underwent the procedure after 48 hours. The various intervention techniques included endoscopic, percutaneous, or surgical necrosectomy. The major outcomes of interest were 30-day readmission rates, healthcare utilization, and inpatient mortality. RESULTS A total of 1309 patients with pancreatic necrosis were included. After propensity score matching, 349 cases treated with early necrosectomy were matched to 375 controls who received delayed intervention. The early cohort had a 30-day readmission rate of 8.6% compared to 4.8% in the delayed cohort (P = 0.040). Early necrosectomy had lower rates of mechanical ventilation (2.9% vs 10.9%, P < 0.001), septic shock (8% vs 19.5%, P < 0.001), and in-hospital mortality (1.1% vs 4.3%, P = 0.01). Patients in the early intervention group incurred lower healthcare costs, with median total charges of $52202 compared to $147418 in the delayed group. Participants in the early cohort also had a relatively shorter median length of stay (6 vs 16 days, P < 0.001). The timing of necrosectomy did not significantly influence the risk of 30-day readmission, with a hazard ratio of 0.56 (95% confidence interval: 0.31-1.02, P = 0.06). CONCLUSION Our findings show that early necrosectomy is associated with better clinical outcomes and lower healthcare costs. Delayed intervention does not significantly alter the risk of 30-day readmission.
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Affiliation(s)
- Hassam Ali
- Division of Gastroenterology and Hepatology, East Carolina University Brody School of Medicine, Greenville, NC 27834, United States
| | - Faisal Inayat
- Department of Internal Medicine, Allama Iqbal Medical College, Lahore, Punjab 54550, Pakistan
| | - Vinay Jahagirdar
- Department of Internal Medicine, University of Missouri-Kansas City, Kansas City, MO 64108, United States
| | - Fouad Jaber
- Department of Internal Medicine, University of Missouri-Kansas City, Kansas City, MO 64108, United States
| | - Arslan Afzal
- Division of Gastroenterology and Hepatology, East Carolina University Brody School of Medicine, Greenville, NC 27834, United States
| | - Pratik Patel
- Division of Gastroenterology, Mather Hospital and Zucker School of Medicine at Hofstra University, Port Jefferson, NY 11777, United States
| | - Hamza Tahir
- Department of Internal Medicine, Jefferson Einstein Hospital, Philadelphia, PA 19141, United States
| | - Muhammad Sajeel Anwar
- Department of Internal Medicine, UHS Wilson Medical Center, Johnson City, NY 13790, United States
| | - Attiq Ur Rehman
- Division of Gastroenterology and Hepatology, Geisinger Wyoming Valley Medical Center, Wilkes-Barre, PA 18711, United States
| | - Muhammad Sarfraz
- Division of Gastroenterology and Hepatology, Geisinger Wyoming Valley Medical Center, Wilkes-Barre, PA 18711, United States
| | - Ahtshamullah Chaudhry
- Department of Internal Medicine, St. Dominic's Hospital, Jackson, MS 39216, United States
| | - Gul Nawaz
- Department of Internal Medicine, Allama Iqbal Medical College, Lahore, Punjab 54550, Pakistan
| | - Dushyant Singh Dahiya
- Division of Gastroenterology, Hepatology, and Motility, The University of Kansas School of Medicine, Kansas City, KS 66160, United States
| | - Amir H Sohail
- Department of Surgery, University of New Mexico School of Medicine, Albuquerque, NM 87106, United States
| | - Muhammad Aziz
- Division of Gastroenterology and Hepatology, The University of Toledo, Toledo, OH 43606, United States
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Badia JM, Amador S, González-Sánchez C, Rubio-Pérez I, Manuel-Vázquez A, Juvany M, Membrilla E, Balibrea JM, Guirao X. Appropriate Use of Antibiotics in Acute Pancreatitis: A Scoping Review. Antibiotics (Basel) 2024; 13:894. [PMID: 39335067 PMCID: PMC11428601 DOI: 10.3390/antibiotics13090894] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/21/2024] [Revised: 09/14/2024] [Accepted: 09/15/2024] [Indexed: 09/30/2024] Open
Abstract
BACKGROUND While selective use of antibiotics for infected pancreatic necrosis (IPN) in acute pancreatitis (AP) is recommended, studies indicate a high rate of inadequate treatment. METHODS A search of PubMed, Scopus, and Cochrane databases was conducted, focusing on primary research and meta-analyses. Data were categorized based on core concepts, and a narrative synthesis was performed. RESULTS The search identified a total of 1016 publications. After evaluating 203 full texts and additional sources from the grey literature, 80 studies were included in the review. The answers obtained were: (1) Preventive treatment does not decrease the incidence of IPN or mortality. Given the risks of bacterial resistance and fungal infections, antibiotics should be reserved for highly suspected or confirmed IPN; (2) The diagnosis of IPN does not always require microbiological samples, as clinical suspicion or computed tomography signs can suffice. Early diagnosis and treatment may be improved by using biomarkers such as procalcitonin and novel microbiological methods; (3) When indicated, early initiation of antibiotics is a key determinant in reducing mortality associated with IPN; (4) Antibiotics with good penetration into pancreatic tissue covering Gram-negative and Gram-positive bacteria should be used. Routine antifungal therapy is not recommended; (5) The step-up approach, including antibiotics, is the standard for IPN management; (6) Antibiotic duration should be kept to a minimum and should be based on the quality of source control and patient condition. CONCLUSIONS Early antibiotic therapy is essential for the treatment of IPN, but prophylactic antibiotics are not recommended in AP. High-quality randomized controlled trials are required to better understand the role of antibiotics and antifungals in AP management.
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Affiliation(s)
- Josep M Badia
- Department of Surgery, Hospital General Granollers, School of Medicine, Universitat Internacional de Catalunya, Av Francesc Ribas 1, 08402 Granollers, Spain
| | - Sara Amador
- Department of Surgery, Hospital General Granollers, School of Medicine, Universitat Internacional de Catalunya, Av Francesc Ribas 1, 08402 Granollers, Spain
| | | | - Inés Rubio-Pérez
- Department of Surgery, Hospital Universitario La Paz, 28046 Madrid, Spain
| | - Alba Manuel-Vázquez
- Department of Surgery, Hospital Universitario de Getafe, Getafe, 28905 Madrid, Spain
| | | | | | - José M Balibrea
- Department of Surgery, Hospital Universitari Germans Trias, 08916 Badalona, Spain
| | - Xavier Guirao
- Department of Surgery, Hospital Universitari Parc Taulí, 08208 Sabadell, Spain
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7
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Devière J. Walled-off necrosis treatment: additional evidence. Endoscopy 2024. [PMID: 39236744 DOI: 10.1055/a-2398-9160] [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: 09/07/2024]
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8
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Bai R, Sui Y, Lu T, Chen H, Wang G, Kong R, Tan H, Wang Y, Li G, Sun B. Effect of the Step-Jump Approach in Infected Pancreatic Necrosis: A Propensity Score-Matched Study. J Inflamm Res 2024; 17:6005-6021. [PMID: 39253564 PMCID: PMC11382799 DOI: 10.2147/jir.s461740] [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: 01/29/2024] [Accepted: 07/10/2024] [Indexed: 09/11/2024] Open
Abstract
Purpose The effects of the step-jump approach on the survival and prognosis of infected pancreatic necrosis (IPN) patients have not yet been determined. Patients and Methods Between November 2018 and June 2023, 188 patients were included in this study. There were 144 patients in the step-up group (the SU group) and 44 in the step-jump group (the SJ group). In the SU group, patients successfully treated with percutaneous catheter drainage (PCD) alone were classified into the SU-1 group (n=101), while those requiring additional surgery after PCD were categorized into the SU-2 group (n=43). In the SJ group, patients who underwent minimally invasive necrosectomy (MIN) without PCD were assigned to the SJ-1 group (n=34), whereas those who initially underwent PCD followed by immediate open surgery were placed in the SJ-2 group (n=10). Propensity score matching (PSM) was used to mitigate bias. Results After PSM, a total of 34 pairs were successfully matched. A comparison of the SU group with the SJ-1 group (upfront MIN without PCD) revealed similar mortality rates (P=0.239); however, the incidences of multiple drug-resistant organisms (MDROs) (P=0.029) and surgical complications (P<0.001) were significantly lower in the SJ-1 group. After comparing the SU-2 and SJ-2 groups (patients who underwent direct open necrosectomy without MIN after PCD failure), the incidences of surgical complications and MDRO in the SJ-2 group were significantly lower (P<0.05). Conclusion Compared with the step-up approach, the step-jump approach is safer and more effective and can significantly reduce the incidence of MDRO and surgical complications.
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Affiliation(s)
- Rui Bai
- Department of Pancreatic and Biliary Surgery, The First Affiliated Hospital of Harbin Medical University, Harbin, 150001, People's Republic of China
- Key Laboratory of Hepatosplenic Surgery, Ministry of Education, The First Affiliated Hospital of Harbin Medical University, Harbin, 150001, People's Republic of China
| | - Yuhang Sui
- Department of Pancreatic and Biliary Surgery, The First Affiliated Hospital of Harbin Medical University, Harbin, 150001, People's Republic of China
- Key Laboratory of Hepatosplenic Surgery, Ministry of Education, The First Affiliated Hospital of Harbin Medical University, Harbin, 150001, People's Republic of China
| | - Tianqi Lu
- Department of Pancreatic and Biliary Surgery, The First Affiliated Hospital of Harbin Medical University, Harbin, 150001, People's Republic of China
- Key Laboratory of Hepatosplenic Surgery, Ministry of Education, The First Affiliated Hospital of Harbin Medical University, Harbin, 150001, People's Republic of China
| | - Hua Chen
- Department of Pancreatic and Biliary Surgery, The First Affiliated Hospital of Harbin Medical University, Harbin, 150001, People's Republic of China
- Key Laboratory of Hepatosplenic Surgery, Ministry of Education, The First Affiliated Hospital of Harbin Medical University, Harbin, 150001, People's Republic of China
| | - Gang Wang
- Department of Pancreatic and Biliary Surgery, The First Affiliated Hospital of Harbin Medical University, Harbin, 150001, People's Republic of China
- Key Laboratory of Hepatosplenic Surgery, Ministry of Education, The First Affiliated Hospital of Harbin Medical University, Harbin, 150001, People's Republic of China
| | - Rui Kong
- Department of Pancreatic and Biliary Surgery, The First Affiliated Hospital of Harbin Medical University, Harbin, 150001, People's Republic of China
- Key Laboratory of Hepatosplenic Surgery, Ministry of Education, The First Affiliated Hospital of Harbin Medical University, Harbin, 150001, People's Republic of China
| | - Hongtao Tan
- Department of Pancreatic and Biliary Surgery, The First Affiliated Hospital of Harbin Medical University, Harbin, 150001, People's Republic of China
- Key Laboratory of Hepatosplenic Surgery, Ministry of Education, The First Affiliated Hospital of Harbin Medical University, Harbin, 150001, People's Republic of China
| | - Yongwei Wang
- Department of Pancreatic and Biliary Surgery, The First Affiliated Hospital of Harbin Medical University, Harbin, 150001, People's Republic of China
- Key Laboratory of Hepatosplenic Surgery, Ministry of Education, The First Affiliated Hospital of Harbin Medical University, Harbin, 150001, People's Republic of China
| | - Guanqun Li
- Department of Pancreatic and Biliary Surgery, The First Affiliated Hospital of Harbin Medical University, Harbin, 150001, People's Republic of China
- Key Laboratory of Hepatosplenic Surgery, Ministry of Education, The First Affiliated Hospital of Harbin Medical University, Harbin, 150001, People's Republic of China
| | - Bei Sun
- Department of Pancreatic and Biliary Surgery, The First Affiliated Hospital of Harbin Medical University, Harbin, 150001, People's Republic of China
- Key Laboratory of Hepatosplenic Surgery, Ministry of Education, The First Affiliated Hospital of Harbin Medical University, Harbin, 150001, People's Republic of China
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9
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Selznick S, Mitrou N, Peck D, Hocking D, Sey M, Yan BM, Tang E, Leslie K, Hawel J. Not just a BLiP: early experience with a novel multidisciplinary case conference for benign hepatopancreatobiliary disease at a tertiary Canadian healthcare center. Surg Endosc 2024:10.1007/s00464-024-11196-w. [PMID: 39225794 DOI: 10.1007/s00464-024-11196-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/30/2024] [Accepted: 08/17/2024] [Indexed: 09/04/2024]
Abstract
BACKGROUND Benign Liver and Pancreas (BLiPs) rounds, implemented in 2022 at our Canadian tertiary care center, are a novel concept of a multidisciplinary case conference (MCC) for discussion of benign hepatopancreatobiliary (HPB) disease. BLiPs Rounds are a monthly virtual meeting of surgeons, gastroenterologists, and interventional radiologists experienced in biliary and pancreatic disease. METHODS This case series was completed to review the patient cases discussed over the first year of BLiPs rounds, and to evaluate the effect of the multidisciplinary discussion on patient management plans. Meeting minutes were reviewed for BLiPs rounds between May 2022 and July 2023. Data were collected retrospectively on all discussed patients by review of the electronic medical record, and analyzed using frequencies and means with standard deviations. RESULTS Between May 2022 and July 2023, 56 cases were discussed at 12 case conferences. 68% of cases concerned pancreatic pathology, 25% concerned biliary pathology, the remainder liver or duodenal pathology. 49 cases (88%) were presented to discuss therapeutic options, and 7 presented as diagnostic challenges. Cases were usually presented once, but 7 patients were discussed at multiple conferences due to complex issues or ongoing symptomatology. 40 patients (71%) had undergone previous endoscopic, percutaneous, or surgical interventions prior to discussion. Endoscopic intervention was recommended in 32% of cases, percutaneous interventional approach in 13%, a combined endoscopic and percutaneous approach in 9%, and surgery in 18%. Repeat imaging or observation was recommended in 29% of cases. Discussion at rounds led to a change or adjustment in the proposed management in 46 cases (82%). The plan recommended by the MCC was carried out in 71% of cases. CONCLUSION BLiPs case conference provides a valuable venue to discuss cases, encourage interdisciplinary collaboration, and refine treatment approaches, leading to a change in proposed management plan in over three-quarters of cases presented.
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Affiliation(s)
- Sydney Selznick
- Division of General Surgery, Western University, London, ON, Canada
- CSTAR (Canadian Surgical Technologies & Advanced Robotics), London Health Sciences Centre, 339 Windermere Rd, London, ON, N6A 5A5, Canada
- Lawson Health Research Institute, London Health Sciences Centre, London, ON, Canada
| | - Nicholas Mitrou
- Division of General Surgery, Western University, London, ON, Canada
- CSTAR (Canadian Surgical Technologies & Advanced Robotics), London Health Sciences Centre, 339 Windermere Rd, London, ON, N6A 5A5, Canada
- Lawson Health Research Institute, London Health Sciences Centre, London, ON, Canada
| | - David Peck
- Department of Medical Imaging, Western University, London, ON, Canada
| | - David Hocking
- Department of Medical Imaging, Western University, London, ON, Canada
| | - Michael Sey
- Lawson Health Research Institute, London Health Sciences Centre, London, ON, Canada
- Division of Gastroenterology, Western University, London, ON, Canada
| | - Brian M Yan
- Lawson Health Research Institute, London Health Sciences Centre, London, ON, Canada
- Division of Gastroenterology, Western University, London, ON, Canada
| | - Ephraim Tang
- Division of General Surgery, Western University, London, ON, Canada
- CSTAR (Canadian Surgical Technologies & Advanced Robotics), London Health Sciences Centre, 339 Windermere Rd, London, ON, N6A 5A5, Canada
- Lawson Health Research Institute, London Health Sciences Centre, London, ON, Canada
| | - Ken Leslie
- Division of General Surgery, Western University, London, ON, Canada
- CSTAR (Canadian Surgical Technologies & Advanced Robotics), London Health Sciences Centre, 339 Windermere Rd, London, ON, N6A 5A5, Canada
- Lawson Health Research Institute, London Health Sciences Centre, London, ON, Canada
| | - Jeff Hawel
- Division of General Surgery, Western University, London, ON, Canada.
- CSTAR (Canadian Surgical Technologies & Advanced Robotics), London Health Sciences Centre, 339 Windermere Rd, London, ON, N6A 5A5, Canada.
- Lawson Health Research Institute, London Health Sciences Centre, London, ON, Canada.
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10
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Luo J, Zhang SW, He JL, Tian LX, Peng X, Nie XB, Ye SS, Zuo Y, Lin H, Bai JY, Liu E, Yang SM, Fan CQ. Selection strategy for endoscopic necrosectomy approaches of infected walled-off pancreatic necrosis: Analysis of 101 patients from a single center with long-term follow-up. J Dig Dis 2024. [PMID: 39227029 DOI: 10.1111/1751-2980.13310] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/08/2024] [Revised: 06/20/2024] [Accepted: 08/07/2024] [Indexed: 09/05/2024]
Abstract
OBJECTIVES Endoscopic necrosectomy (EN) is a promising minimally invasive approach for treating infected walled-off pancreatic necrosis (WOPN). Multiple EN approaches are currently available, though criteria for selecting the optimal approaches are lacking. We aimed to propose a rational selection strategy of EN and to retrospectively evaluate its safety and effectiveness. METHODS Altogether 101 patients who underwent EN for infected WOPN at a tertiary hospital between June 2009 and February 2023 were retrospectively included for analysis. Demographic characteristics, details of the EN procedures, procedure-related adverse events, and clinical outcomes were investigated. RESULTS Among these 101 patients with WOPN, 56 (55.4%) underwent transluminal EN, 38 (37.6%) underwent percutaneous EN, and seven (6.9%) underwent combined approach, respectively. Clinical success was achieved in 94 (93.1%) patients. Seven (6.9%) experienced procedure-related adverse events, and seven (6.9%) died during the treatment period. During a median follow-up of 50 months, 5 (5.3%) of the 94 patients had disease recurrence, 17.0% (16/94) had new-onset diabetes mellitus, and 6.4% (6/94) needed oral pancreatic enzyme supplementation. The clinical success rate, procedure-related adverse event rate, and long-term follow-up outcomes were not significantly different among the three groups. High APACHE-II scores (≥15) and organ failure were identified as factors related to treatment failure. CONCLUSIONS A selection strategy for EN approaches, based on the extent of necrosis and its distance from the gastrointestinal lumen (using a threshold of 15 mm), is safe and effective for treating infected WOPN in both short-term and long-term outcomes.
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Affiliation(s)
- Jie Luo
- Department of Gastroenterology, Xinqiao Hospital, Army Medical University, Chongqing, China
| | - Sheng Wei Zhang
- Department of Gastroenterology, Xinqiao Hospital, Army Medical University, Chongqing, China
| | - Jia Lin He
- Department of Gastroenterology, Xinqiao Hospital, Army Medical University, Chongqing, China
| | - Li Xing Tian
- Department of Gastroenterology, Xinqiao Hospital, Army Medical University, Chongqing, China
| | - Xue Peng
- Department of Gastroenterology, Xinqiao Hospital, Army Medical University, Chongqing, China
| | - Xu Biao Nie
- Department of Gastroenterology, Xinqiao Hospital, Army Medical University, Chongqing, China
| | - Shao Song Ye
- Department of Gastroenterology, Xinqiao Hospital, Army Medical University, Chongqing, China
| | - Ying Zuo
- Department of Gastroenterology, Xinqiao Hospital, Army Medical University, Chongqing, China
| | - Hui Lin
- Department of Epidemiology, Army Medical University, Chongqing, China
| | - Jian Ying Bai
- Department of Gastroenterology, Xinqiao Hospital, Army Medical University, Chongqing, China
| | - En Liu
- Department of Gastroenterology, Xinqiao Hospital, Army Medical University, Chongqing, China
| | - Shi Ming Yang
- Department of Gastroenterology, Xinqiao Hospital, Army Medical University, Chongqing, China
| | - Chao Qiang Fan
- Department of Gastroenterology, Xinqiao Hospital, Army Medical University, Chongqing, China
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11
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Zohar N, Gorgov E, Yeo TP, Lavu H, Bowne W, Yeo CJ, Nevler A. Incisional hernia after major pancreatic resection: long term risk assessment from two distinct sources - A large multi-institutional network and a single high-volume center. HPB (Oxford) 2024:S1365-182X(24)02282-2. [PMID: 39327220 DOI: 10.1016/j.hpb.2024.08.009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/25/2024] [Revised: 08/06/2024] [Accepted: 08/29/2024] [Indexed: 09/28/2024]
Abstract
BACKGROUND Post-operative incisional hernia (IH) is a common complication following abdominal surgery. Data regarding IH after major pancreatic surgery are limited. We aim to evaluate the long-term risk of IH following major pancreatic resection. METHODS A dual-approach study: a large multi-institutional research network (RN) was investigated for IH incidence and risk factors in propensity-score matched survivors after pancreaticoduodenectomy (PD) and distal pancreatectomy (DP), was complemented by a patient-reported questionnaire. RESULTS RN analysis identified 22,113 patients that underwent pancreatic surgery. 11.0% of PD patients and 8.6% of DP patients developed IH (P < 0.0001). IH rates were higher with open surgery compared with minimally invasive approaches in PD (OR = 1.56, P = 0.03) and DP (OR = 1.94, P = 0.003). BMI>35 was found to correlate with increased IH rates for PD and DP (OR = 1.87, and OR = 1.86, respectively, P < 0.0001 each), as did postoperative intraabdominal infections (P < 0.0001). Patient-based survey of 104 patients, revealed that 16 patients (15%) reported post-operative IH during the follow-up period. BMI≥30, SSI and intra-abdominal abscesses were associated with increased IH risk (P < 0.05). CONCLUSION Improved survival after pancreatic resection has led to an increased prevalence of long-term surgical sequela. In this study, we demonstrate significant rates of IH among long-term survivors and assess potential risk factors.
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Affiliation(s)
- Nitzan Zohar
- Jefferson Pancreas, Biliary and Related Cancer Centre, Department of Surgery, Thomas Jefferson University, Philadelphia, PA, USA
| | - Eliyahu Gorgov
- Jefferson Pancreas, Biliary and Related Cancer Centre, Department of Surgery, Thomas Jefferson University, Philadelphia, PA, USA
| | - Theresa P Yeo
- Jefferson Pancreas, Biliary and Related Cancer Centre, Department of Surgery, Thomas Jefferson University, Philadelphia, PA, USA
| | - Harish Lavu
- Jefferson Pancreas, Biliary and Related Cancer Centre, Department of Surgery, Thomas Jefferson University, Philadelphia, PA, USA
| | - Wilbur Bowne
- Jefferson Pancreas, Biliary and Related Cancer Centre, Department of Surgery, Thomas Jefferson University, Philadelphia, PA, USA
| | - Charles J Yeo
- Jefferson Pancreas, Biliary and Related Cancer Centre, Department of Surgery, Thomas Jefferson University, Philadelphia, PA, USA
| | - Avinoam Nevler
- Jefferson Pancreas, Biliary and Related Cancer Centre, Department of Surgery, Thomas Jefferson University, Philadelphia, PA, USA.
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12
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Zhang AL, How R, Efron DT, Nigam R, Harfouche MN. To Drain or Not: Drainage Procedures Remain a Central Tenet of Management of Infected Collections in Acute Pancreatitis. Am Surg 2024; 90:2325-2327. [PMID: 38655580 DOI: 10.1177/00031348241241721] [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: 04/26/2024]
Abstract
Recent literature advocates for delayed or avoidance of catheter drainage of infected peri-pancreatic collections (IPCs) in acute pancreatitis (AP). This may not be realistic for patients at academic centers, many of whom are critically ill. We retrospectively reviewed 72 patients admitted to our institution from 2016-2021 with AP and IPCs. 34.7% had a Bedside Index of Severity in Acute Pancreatitis (BISAP) score ≥3, and 56.9% had a Balthazar score of E. 65.3% were admitted to the ICU, 51.4% experienced respiratory failure, and 47.2% had acute renal failure. In-hospital mortality was 9.7%. Catheter-based drainage alone was the most frequent intervention. Only 8 individuals did not undergo any drainage. Individuals with severe AP complicated by IPCs are critically ill. Avoidance or delay of source control could lead to significant morbidity. Until further research is done on this population, drainage should remain a central tenet of management of IPCs.
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Affiliation(s)
- Ashling L Zhang
- Department of Surgery, University of Maryland School of Medicine, Baltimore, MD, USA
| | - Remealle How
- Department of Surgery, University of Maryland School of Medicine, Baltimore, MD, USA
| | - David T Efron
- Department of Surgery, University of Maryland School of Medicine, Baltimore, MD, USA
| | | | - Melike N Harfouche
- Department of Surgery, University of Maryland School of Medicine, Baltimore, MD, USA
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13
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Trikudanathan G, Yazici C, Evans Phillips A, Forsmark CE. Diagnosis and Management of Acute Pancreatitis. Gastroenterology 2024; 167:673-688. [PMID: 38759844 DOI: 10.1053/j.gastro.2024.02.052] [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: 09/04/2023] [Revised: 01/03/2024] [Accepted: 02/18/2024] [Indexed: 05/19/2024]
Abstract
Acute pancreatitis (AP) is increasing in incidence across the world, and in all age groups. Major changes in management have occurred in the last decade. Avoiding total parenteral nutrition and prophylactic antibiotics, avoiding overly aggressive fluid resuscitation, initiating early feeding, avoiding endoscopic retrograde cholangiopancreatography in the absence of concomitant cholangitis, same-admission cholecystectomy, and minimally invasive approaches to infected necrosis should now be standard of care. Increasing recognition of the risk of recurrence of AP, and progression to chronic pancreatitis, along with the unexpectedly high risk of diabetes and exocrine insufficiency after AP is the subject of large ongoing studies. In this review, we provide an update on important changes in management for this increasingly common disease.
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Affiliation(s)
- Guru Trikudanathan
- Division of Gastroenterology, Hepatology, and Nutrition, University of Minnesota, Minneapolis, Minnesota
| | - Cemal Yazici
- Division of Gastroenterology and Hepatology, University of Illinois, Chicago, Illinois
| | - Anna Evans Phillips
- Division of Gastroenterology, Hepatology, and Nutrition, University of Pittsburgh, Pittsburgh, Pennsylvania
| | - Chris E Forsmark
- Division of Gastroenterology, Hepatology, and Nutrition, University of Florida, Gainesville, Florida.
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14
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Søreide K, Barreto SG, Pandanaboyana S. Severe acute pancreatitis. Br J Surg 2024; 111:znae170. [PMID: 39107064 DOI: 10.1093/bjs/znae170] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/23/2024] [Accepted: 06/15/2024] [Indexed: 08/09/2024]
Affiliation(s)
- Kjetil Søreide
- Department of Gastrointestinal Surgery, Stavanger University Hospital, Stavanger, Norway
- Department of Clinical Medicine, University of Bergen, Bergen, Norway
- Division of Surgery and Oncology, Department of Clinical Science, Intervention and Technology, Karolinska Institutet, Karolinska University Hospital, Stockholm, Sweden
| | - S George Barreto
- College of Medicine and Public Health, Flinders University, Adelaide, South Australia, Australia
- HPB and Liver Transplant Unit, Flinders Medical Centre, Adelaide, South Australia, Australia
| | - Sanjay Pandanaboyana
- Hepatopancreatobiliary and Transplant Unit, Freeman Hospital, Newcastle upon Tyne, UK
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15
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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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16
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Shaw BI, Fabricius MM, Nauser CL, Zani S, Knechtle SJ. Video-assisted Retroperitoneal Debridement for Graft Pancreatitis. Transplant Direct 2024; 10:e1682. [PMID: 39076521 PMCID: PMC11286245 DOI: 10.1097/txd.0000000000001682] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/05/2024] [Revised: 05/21/2024] [Accepted: 05/29/2024] [Indexed: 07/31/2024] Open
Affiliation(s)
| | | | | | - Sabino Zani
- Department of Surgery, Duke University, Durham, NC
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17
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Timmerhuis HC, Ngongoni RF, Li A, McGuire SP, Lewellen KA, Dua MM, Chughtai K, Zyromski NJ, Visser BC. The Potential Clinical Benefits of Direct Surgical Transgastric Pancreatic Necrosectomy for Patients With Infected Necrotizing Pancreatitis. Pancreas 2024; 53:e573-e578. [PMID: 38986078 DOI: 10.1097/mpa.0000000000002334] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 07/12/2024]
Abstract
OBJECTIVE Surgical transgastric pancreatic necrosectomy (STGN) has the potential to overcome the shortcomings (ie, repeat interventions, prolonged hospitalization) of the step-up approach for infected necrotizing pancreatitis. We aimed to determine the outcomes of STGN for infected necrotizing pancreatitis. MATERIALS AND METHODS This observational cohort study included adult patients who underwent STGN for infected necrosis at two centers from 2008 to 2022. Patients with a procedure for pancreatic necrosis before STGN were excluded. Primary outcomes included mortality, length of hospital and intensive care unit (ICU) stay, new-onset organ failure, repeat interventions, pancreatic fistulas, readmissions, and time to episode closure. RESULTS Forty-three patients underwent STGN at a median of 48 days (interquartile range [IQR] 32-70) after disease onset. Mortality rate was 7% (n = 3). After STGN, the median length of hospital was 8 days (IQR 6-17), 23 patients (53.5%) required ICU admission (2 days [IQR 1-7]), and new-onset organ failure occurred in 8 patients (18.6%). Three patients (7%) required a reintervention, 1 (2.3%) developed a pancreatic fistula, and 11 (25.6%) were readmitted. The median time to episode closure was 11 days (IQR 6-22). CONCLUSIONS STGN allows for treatment of retrogastric infected necrosis in one procedure and with rapid episode resolution. With these advantages and few pancreatic fistulas, direct STGN challenges the step-up approach.
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Affiliation(s)
- Hester C Timmerhuis
- From the Department of Surgery, Stanford University School of Medicine, Stanford CA
| | - Rejoice F Ngongoni
- From the Department of Surgery, Stanford University School of Medicine, Stanford CA
| | - Amy Li
- From the Department of Surgery, Stanford University School of Medicine, Stanford CA
| | - Sean P McGuire
- Departments of Surgery and Division of Gastroenterology, Indiana University School of Medicine and Indiana University Health, Indianapolis, IN
| | - Kyle A Lewellen
- Departments of Surgery and Division of Gastroenterology, Indiana University School of Medicine and Indiana University Health, Indianapolis, IN
| | - Monica M Dua
- From the Department of Surgery, Stanford University School of Medicine, Stanford CA
| | - Komal Chughtai
- Department of Radiology, Stanford University School of Medicine, Stanford, CA
| | - Nicholas J Zyromski
- Departments of Surgery and Division of Gastroenterology, Indiana University School of Medicine and Indiana University Health, Indianapolis, IN
| | - Brendan C Visser
- From the Department of Surgery, Stanford University School of Medicine, Stanford CA
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18
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Shinn B, Burdick J, Berk K, Hwang JH, El-Dika S, Juakiem W, Han S, Krishna SG, Khashab MA, Mony S, Kadkhodayan K, Khara HS, Ahmed AM, Boortalary T, Agnohortri A, Kumar A, Chiang A, Kamal F, Schlachterman A, Loren D, Kowalski T. Safety, efficacy, and clinical utility of the 5.1-mm debridement catheter for treatment of walled-off pancreatic necrosis (with video). Gastrointest Endosc 2024; 100:240-246. [PMID: 38431104 DOI: 10.1016/j.gie.2024.02.016] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/18/2023] [Revised: 12/28/2023] [Accepted: 02/18/2024] [Indexed: 03/05/2024]
Abstract
BACKGROUND AND AIMS Direct endoscopic necrosectomy (DEN) is a recommended strategy for treatment of walled-off necrosis (WON). DEN uses a variety of devices including the EndoRotor (Interscope, Inc, Northbridge, Mass, USA) debridement catheter. Recently, a 5.1-mm EndoRotor with an increased chamber size and rate of tissue removal was introduced. The aim of this study was to assess the efficacy and safety of this device. METHODS A multicenter cohort study was conducted at 8 institutions including patients who underwent DEN with the 5.1-mm EndoRotor. The primary outcome was the number of DEN sessions needed for WON resolution. Secondary outcomes were the average percentage of reduction in solid WON debris and decrease in WON area per session, total time spent performing EndoRotor therapy for WON resolution, and adverse events (AEs). RESULTS Sixty-four procedures in 41 patients were included. For patients in which the 5.1-mm EndoRotor catheter was the sole therapeutic modality, an average of 1.6 DEN sessions resulted in WON resolution with an average cumulative time of 85.5 minutes. Of the 21 procedures with data regarding percentage of solid debris, the average reduction was 85% ± 23% per session. Of the 19 procedures with data regarding WON area, the mean area significantly decreased from 97.6 ± 72.0 cm2 to 27.1 ± 35.5 cm2 (P < .001) per session. AEs included 2 intraprocedural dislodgements of lumen-apposing metal stents managed endoscopically and 3 perforations, none of which was related to the EndoRotor. Bleeding was reported in 7 cases, in which none required embolic or surgical therapy and 2 required blood transfusions. CONCLUSIONS This is the first multicenter retrospective study to investigate the efficacy and safety of the 5.1-mm EndoRotor catheter for WON. Results from this study showed an average of 1.6 DEN sessions were needed to achieve WON resolution with an 85% single-session reduction in solid debris and a 70% single-session decrease in WON area with minimal AEs.
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Affiliation(s)
- Brianna Shinn
- Department of Medicine, Division of Gastroenterology and Hepatology, Thomas Jefferson University Hospital, Philadelphia, Pennsylvania, USA
| | | | | | - Joo Ha Hwang
- Department of Medicine, Division of Gastroenterology and Hepatology, Stanford University Medical Center, Palo Alto, California, USA
| | - Samer El-Dika
- Department of Medicine, Division of Gastroenterology and Hepatology, Stanford University Medical Center, Palo Alto, California, USA
| | - Wassem Juakiem
- Department of Medicine, Division of Gastroenterology and Hepatology, Stanford University Medical Center, Palo Alto, California, USA
| | - Samuel Han
- Department of Medicine, Division of Gastroenterology, Hepatology and Nutrition, The Ohio State University Wexner Medical Center, Columbus, Ohio, USA
| | - Somashekar G Krishna
- Department of Medicine, Division of Gastroenterology, Hepatology and Nutrition, The Ohio State University Wexner Medical Center, Columbus, Ohio, USA
| | - Mouen A Khashab
- Department of Medicine, Division of Gastroenterology and Hepatology, Johns Hopkins University Hospital, Baltimore, Maryland, USA
| | - Shruti Mony
- Department of Medicine, Division of Gastroenterology and Hepatology, Johns Hopkins University Hospital, Baltimore, Maryland, USA
| | - Kambiz Kadkhodayan
- Center for Interventional Endoscopy, AdventHealth Orlando, Orlando, Florida, USA
| | - Harshit S Khara
- Department of Medicine, Division of Gastroenterology, Geisinger Medical Center, Danville, Pennsylvania, USA
| | - Ali M Ahmed
- Department of Medicine, Division of Gastroenterology and Hepatology, University of Alabama Medical Center, Birmingham, Alabama, USA
| | - Tina Boortalary
- Department of Medicine, Division of Gastroenterology and Hepatology, Thomas Jefferson University Hospital, Philadelphia, Pennsylvania, USA
| | - Abhishek Agnohortri
- Department of Medicine, Division of Gastroenterology and Hepatology, Thomas Jefferson University Hospital, Philadelphia, Pennsylvania, USA
| | - Anand Kumar
- Department of Medicine, Division of Gastroenterology and Hepatology, Thomas Jefferson University Hospital, Philadelphia, Pennsylvania, USA
| | - Austin Chiang
- Department of Medicine, Division of Gastroenterology and Hepatology, Thomas Jefferson University Hospital, Philadelphia, Pennsylvania, USA
| | - Faisal Kamal
- Department of Medicine, Division of Gastroenterology and Hepatology, Thomas Jefferson University Hospital, Philadelphia, Pennsylvania, USA
| | - Alexander Schlachterman
- Department of Medicine, Division of Gastroenterology and Hepatology, Thomas Jefferson University Hospital, Philadelphia, Pennsylvania, USA
| | - David Loren
- Department of Medicine, Division of Gastroenterology and Hepatology, Thomas Jefferson University Hospital, Philadelphia, Pennsylvania, USA
| | - Thomas Kowalski
- Department of Medicine, Division of Gastroenterology and Hepatology, Thomas Jefferson University Hospital, Philadelphia, Pennsylvania, USA
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19
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Capurso G, Coluccio C, Rizzo GEM, Crinò SF, Cucchetti A, Facciorusso A, Hassan C, Amato A, Auriemma F, Bertani H, Binda C, Cipolletta F, Forti E, Fugazza A, Lisotti A, Maida M, Sinagra E, Sbrancia M, Spadaccini M, Tacelli M, Vanella G, Anderloni A, Fabbri C, Tarantino I. The 1st i-EUS consensus on the management of pancreatic fluid collections - Part 2. Dig Liver Dis 2024:S1590-8658(24)00814-4. [PMID: 39030137 DOI: 10.1016/j.dld.2024.06.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/21/2024] [Accepted: 06/10/2024] [Indexed: 07/21/2024]
Abstract
Pancreatic fluid collections (PFCs), including pancreatic pseudocysts (PPs) and walled-off pancreatic necrosis (WON), are common complications of pancreatitis and pancreatic surgery. Historically, the treatment of these conditions has relied on surgical and radiological approaches. The treatment of patients with PFCs has already focused toward an endoscopy-based approach, and with the development of dedicated lumen-apposing metal stents (LAMS), it has almost totally shifted towards interventional Endoscopic Ultrasound (EUS)-guided procedures. However, there is still limited consensus on several aspects of PFCs treatment within the multidisciplinary management. The interventional endoscopy and ultrasound (i-EUS) group is an Italian network of clinicians and scientists with special interest in biliopancreatic interventional endoscopy, especially interventional EUS. This manuscript focuses on the second part of the results of a consensus conference organized by i-EUS, with the aim of providing evidence-based guidance on several intra- and post-procedural aspects of PFCs drainage, such as clinical management and follow-up.
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Affiliation(s)
- Gabriele Capurso
- Pancreatico/Biliary Endoscopy & Endosonography Division, Pancreas Translational & Clinical Research Center San Raffaele Scientific Institute, Milan, Italy
| | - Chiara Coluccio
- Gastroenterology and Digestive Endoscopy Unit, Forlì-Cesena Hospitals, AUSL Romagna, Forlì-Cesena, Italy
| | - Giacomo Emanuele Maria Rizzo
- Endoscopy Service, Department of Diagnostic and Therapeutic Services, IRCCS - ISMETT, Palermo, Italy; Department of Precision Medicine in Medical, Surgical and Critical Care (Me.Pre.C.C.), University of Palermo, Palermo, Italy.
| | - Stefano Francesco Crinò
- Diagnostic and Interventional Endoscopy of Pancreas, The Pancreas Institute, G.B. Rossi University Hospital, 37134, Verona, Italy
| | - Alessandro Cucchetti
- Department of Medical and Surgical Sciences - DIMEC, Alma Mater Studiorum - Univeristy of Bologna, Bologna, Italy
| | - Antonio Facciorusso
- Gastroenterology Unit, Department of Medical Sciences, University of Foggia, Foggia, Italy
| | - Cesare Hassan
- Humanitas University, Department of Biomedical Sciences, Pieve Emanuele, Italy; Division of Gastroenterology and Digestive Endoscopy, Humanitas Research Hospital - IRCCS, Rozzano, Milano, Italy
| | - Arnaldo Amato
- Digestive Endoscopy and Gastroenterology Department, ASST Lecco, Italy
| | - Francesco Auriemma
- Gastrointestinal Endoscopy Unit, Humanitas Mater Domini, Castellanza, Italy
| | - Helga Bertani
- Gastroenterologia ed Endoscopia Digestiva Azienda Ospedaliero-Universitaria Policlinico di Modena, Modena, Italy
| | - Cecilia Binda
- Gastroenterology and Digestive Endoscopy Unit, Forlì-Cesena Hospitals, AUSL Romagna, Forlì-Cesena, Italy
| | - Fabio Cipolletta
- Department of Gastroenterology, Ospedale del Mare, ASL NA1 Centro, Naples, Italy
| | - Edoardo Forti
- Digestive and Interventional Endoscopy Unit, ASST Niguarda Hospital, Milan, Italy
| | - Alessandro Fugazza
- Division of Gastroenterology and Digestive Endoscopy, Humanitas Research Hospital - IRCCS, Rozzano, Milano, Italy
| | - Andrea Lisotti
- Gastroenterology Unit, Hospital of Imola, University of Bologna, Imola, Italy
| | - Marcello Maida
- Gastroenterology Unit, Umberto I Hospital - Department of Medicine and Surgery, University of Enna 'Kore', Enna, Italy
| | - Emanuele Sinagra
- Gastroenterology & Endoscopy Unit, Fondazione Istituto G. Giglio, Cefalù, Italy
| | - Monica Sbrancia
- Gastroenterology and Digestive Endoscopy Unit, Forlì-Cesena Hospitals, AUSL Romagna, Forlì-Cesena, Italy
| | - Marco Spadaccini
- Humanitas University, Department of Biomedical Sciences, Pieve Emanuele, Italy
| | - Matteo Tacelli
- Pancreato-biliary Endoscopy and EUS Division, San Raffaele Scientific Institute IRCCS, Milan, Italy
| | - Giuseppe Vanella
- Pancreato-biliary Endoscopy and EUS Division, San Raffaele Scientific Institute IRCCS, Milan, Italy
| | - Andrea Anderloni
- Gastroenterology and Digestive Endoscopy Unit, IRCCS Foundation Policlinico San Matteo, Pavia, Italy
| | - Carlo Fabbri
- Gastroenterology and Digestive Endoscopy Unit, Forlì-Cesena Hospitals, AUSL Romagna, Forlì-Cesena, Italy
| | - Ilaria Tarantino
- Endoscopy Service, Department of Diagnostic and Therapeutic Services, IRCCS - ISMETT, Palermo, Italy
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20
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Bhatia H, Vermani S, Gupta P, Farook S, Kumar A, Johnson J, Shah J, Singh A, Jearth V, Samanta J, Mandavdhare H, Sharma V, Sinha SK, Dutta U, Kocchar R. Impact of the Timing of Percutaneous Catheter Drainage following Endoscopic Drainage on Outcomes in Acute Necrotizing Pancreatitis. Indian J Radiol Imaging 2024; 34:441-448. [PMID: 38912235 PMCID: PMC11188745 DOI: 10.1055/s-0044-1779303] [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] [Indexed: 06/25/2024] Open
Abstract
Background The role of dual-modality drainage of walled-off necrosis (WON) in patients with acute pancreatitis (AP) is established. However, there are no data on the association of clinical outcomes with the timing of percutaneous catheter drainage (PCD). We investigated the impact of the timing of PCD following endoscopic drainage of WON on clinical outcomes in AP. Materials and Methods This retrospective study comprised consecutive patients with necrotizing AP who underwent endoscopic cystogastrostomy (CG) of WON followed by PCD between September 2018 and March 2023. Based on endoscopic CG to PCD interval, patients were divided into groups (≤ and >3 days, ≤ and >1 week, ≤ and >10 days, and ≤ and >2 weeks). Baseline characteristics and indications of CG and PCD were recorded. Clinical outcomes were compared between the groups, including length of hospitalization, length of intensive care unit stay, need for surgical necrosectomy, and death during hospitalization. Results Thirty patients (mean age ± standard deviation, 35.5 ± 12.7 years) were evaluated. The mean CG to PCD interval was 11.2 ± 7.5 days. There were no significant differences in baseline characteristics and indications of CG and PCD between the groups. The mean pain to CG interval was not significantly different between the groups. Endoscopic necrosectomy was performed in a significantly greater proportion of patients undergoing CG after 10 days ( p = 0.003) and after 2 weeks ( p = 0.032). There were no significant differences in the complications and clinical outcomes between the groups. Conclusion The timing of PCD following endoscopic CG does not affect clinical outcomes.
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Affiliation(s)
- Harsimran Bhatia
- Department of Radiodiagnosis and Imaging, Postgraduate Institute of Medical Education and Research, Chandigarh, India
| | - Sanya Vermani
- 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
| | - Shameema Farook
- Department of Radiodiagnosis and Imaging, Postgraduate Institute of Medical Education and Research, Chandigarh, India
| | - Abhishek Kumar
- Department of Radiodiagnosis and Imaging, Postgraduate Institute of Medical Education and Research, Chandigarh, India
| | - Joseph Johnson
- 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
| | - Anupam Singh
- Department of Gastroenterology, Postgraduate Institute of Medical Education and Research, Chandigarh, India
| | - Vaneet Jearth
- 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 Kocchar
- Department of Gastroenterology, Postgraduate Institute of Medical Education and Research, Chandigarh, India
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21
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Brown NG, Sethi A. Endoscopic Drainage of Pancreatic Fluid Collections. Gastrointest Endosc Clin N Am 2024; 34:553-575. [PMID: 38796299 DOI: 10.1016/j.giec.2024.02.008] [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: 05/28/2024]
Abstract
Pancreatic fluid collections (PFCs) are commonly encountered complications of acute and chronic pancreatitis. With the advancement of endoscopic ultrasound (EUS) techniques and devices, EUS-directed transmural drainage of symptomatic or infected PFCs has become the standard of care. Traditionally, plastic stents have been used for drainage, although lumen-apposing metal stents (LAMSs) are now favored by most endoscopists due to ease of use and reduced procedure time. While safety has been repeatedly demonstrated, follow-up care for these patients is critical as delayed adverse events of indwelling drains are known to occur.
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Affiliation(s)
- Nicholas G Brown
- Department of Medicine, Columbia University Irving Medical Center, Weill Cornell Medicine, NewYork-Presbyterian/Brooklyn Methodist Hospital, 515 6th Street, Concourse, Brooklyn, NY 11215, USA; Weill Cornell, 1283 York Avenue, New York, NY 10065, USA; Division of Digestive and Liver Disease, Columbia University Irving Medical Center, 630 West 168th Street, P&S 3-401, New York, NY 10032, USA.
| | - Amrita Sethi
- Division of Digestive and Liver Disease, Columbia University Irving Medical Center, 630 West 168th Street, P&S 3-401, New York, NY 10032, USA
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22
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Chon HK, Kozarek RA. History of the Interventional Pancreaticobiliary Endoscopy. Gastrointest Endosc Clin N Am 2024; 34:383-403. [PMID: 38796288 DOI: 10.1016/j.giec.2023.12.001] [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: 05/28/2024]
Abstract
With the introduction of endoscopic retrograde cholangiopancreatography and linear endoscopic ultrasound, interventional pancreaticobiliary (PB) endoscopy has had an enormous impact in the management of pancreatic and biliary diseases. Continuous efforts to improve various devices and techniques have revolutionized these treatment modalities as viable alternatives to surgery. In recent years, trends toward combining endoscopic techniques with other modalities, such as laparoscopic and radiological interventions, for complex PB diseases have emerged using a multidisciplinary approach. Ongoing research and clinical experience will lead to refinements in interventional PB endoscopic techniques and subsequently improve outcomes and reduce complication rates.
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Affiliation(s)
- Hyung Ku Chon
- Division of Biliopancreas, Department of Internal Medicine, Wonkwang University Medical School, and Hospital, Iksan, Republic of Korea; Institution of Wonkwang Medical Science, Iksan, Republic of Korea
| | - Richard A Kozarek
- Division of Gastroenterology and Hepatology, Center for Digestive Health, Virginia Mason Franciscan Health, 1100 Ninth Avenue, Seattle, WA 98101, USA; Center for Interventional Immunology, Benaroya Research Institute, Virginia Mason Franciscan Health, 1201 Ninth Avenue, Seattle, WA 98101, USA.
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23
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Valentin C, Le Cosquer G, Tuyeras G, Culetto A, Barange K, Hervieu PE, Carrère N, Muscari F, Mokrane F, Otal P, Bournet B, Suc B, Buscail L. Step-up approach for the treatment of infected necrotising pancreatitis: real life data from a single-centre experience with long-term follow-up. BMC Gastroenterol 2024; 24:213. [PMID: 38943052 PMCID: PMC11214239 DOI: 10.1186/s12876-024-03289-6] [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: 08/27/2023] [Accepted: 06/07/2024] [Indexed: 07/01/2024] Open
Abstract
BACKGROUND About 20% of patients with acute pancreatitis develop a necrotising form with a worse prognosis due to frequent appearance of organ failure(s) and/or infection of necrosis. Aims of the present study was to evaluate the "step up" approach treatment of infected necrosis in terms of: feasibility, success in resolving infection, morbidity of procedures, risk factors associated with death and long-term sequels. METHODS In this observational retrospective monocentric study in the real life, necrotizing acute pancreatitis at the stage of infected walled-off necrosis were treated as follow: first step with drainage (radiologic and/or endoscopic-ultrasound-guided with lumen apposing metal stent); in case of failure, minimally invasive necrosectomy sessions(s) by endoscopy through the stent and/or via retroperitoneal surgery (step 2); If necessary open surgery as a third step. Efficacy was assessed upon to a composite clinical-biological criterion: resolution of organ failure(s), decrease of at least two of clinico-biological criteria among fever, CRP serum level, and leucocytes count). RESULTS Forty-one consecutive patients were treated. The step-up strategy: (i) was feasible in 100% of cases; (ii) allowed the infection to be resolved in 33 patients (80.5%); (iii) Morbidity was mild and rapidly resolutive; (iv) the mortality rate at 6 months was of 19.5% (significant factors: SIRS and one or more organ failure(s) at admission, fungal infection, size of the largest collection ≥ 16 cm). During the follow-up (median 72 months): 27% of patients developed an exocrine pancreatic insufficiency, 45% developed or worsened a previous diabetes, 24% had pancreatic fistula and one parietal hernia. CONCLUSIONS Beside a very good feasibility, the step-up approach for treatment of infected necrotizing pancreatitis in the real life displays a clinico-biological efficacy in 80% of cases with acceptable morbidity, mortality and long-term sequels regarding the severity of the disease.
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Affiliation(s)
- Claire Valentin
- Department of Gastroenterology and Pancreatology, Toulouse Rangueil University Hospital, 1 avenue Jean Poulhès, TSA 50032, Toulouse Cedex 9, 31059, France
| | - Guillaume Le Cosquer
- Department of Gastroenterology and Pancreatology, Toulouse Rangueil University Hospital, 1 avenue Jean Poulhès, TSA 50032, Toulouse Cedex 9, 31059, France
| | - Géraud Tuyeras
- Department of Digestive Surgery, Toulouse Rangueil University Hospital, Toulouse, France
| | - Adrian Culetto
- Department of Gastroenterology and Pancreatology, Toulouse Rangueil University Hospital, 1 avenue Jean Poulhès, TSA 50032, Toulouse Cedex 9, 31059, France
| | - Karl Barange
- Department of Hepatology, Toulouse Rangueil University Hospital, Toulouse, France
| | - Pierre-Emmanuel Hervieu
- Department of Gastroenterology and Pancreatology, Toulouse Rangueil University Hospital, 1 avenue Jean Poulhès, TSA 50032, Toulouse Cedex 9, 31059, France
| | - Nicolas Carrère
- Department of Digestive Surgery, Toulouse Rangueil University Hospital, Toulouse, France
| | - Fabrice Muscari
- Department of Digestive Surgery, Toulouse Rangueil University Hospital, Toulouse, France
| | - Fatima Mokrane
- Department of Radiology, Toulouse Rangueil University Hospital, Toulouse, France
| | - Philippe Otal
- Department of Radiology, Toulouse Rangueil University Hospital, Toulouse, France
| | - Barbara Bournet
- Department of Gastroenterology and Pancreatology, Toulouse Rangueil University Hospital, 1 avenue Jean Poulhès, TSA 50032, Toulouse Cedex 9, 31059, France
| | - Bertrand Suc
- Department of Digestive Surgery, Toulouse Rangueil University Hospital, Toulouse, France
| | - Louis Buscail
- Department of Gastroenterology and Pancreatology, Toulouse Rangueil University Hospital, 1 avenue Jean Poulhès, TSA 50032, Toulouse Cedex 9, 31059, France.
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24
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Pavlek G, Romic I, Kekez D, Zedelj J, Bubalo T, Petrovic I, Deban O, Baotic T, Separovic I, Strajher IM, Bicanic K, Pavlek AE, Silic V, Tolic G, Silovski H. Step-Up versus Open Approach in the Treatment of Acute Necrotizing Pancreatitis: A Case-Matched Analysis of Clinical Outcomes and Long-Term Pancreatic Sufficiency. J Clin Med 2024; 13:3766. [PMID: 38999333 PMCID: PMC11242895 DOI: 10.3390/jcm13133766] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/03/2024] [Revised: 06/18/2024] [Accepted: 06/19/2024] [Indexed: 07/14/2024] Open
Abstract
Background/Objectives: Acute necrotizing pancreatitis (ANP) with secondary infection of necrotic tissue is associated with a high rate of complications and mortality. The optimal approach is still debatable, but the minimally invasive modality has gained great attention in the last decade as it follows the principle of applying minimal surgical trauma to achieve a satisfying therapeutic objective. We compared clinical outcomes between the step-up approach (SUA) and open necrosectomy (ON) in the treatment of acute necrotizing pancreatitis. Methods: A prospective cohort study over the period of 2011-2021 in a university teaching hospital was performed. Results of 99 consecutive patients with ANP who required surgical/radiological intervention were collected. A case match analysis (2:1) was performed, and the final groups comprised 40 patients in the OA group and 20 patients in the SUA group. Demographic, clinicopathologic, and treatment data were reviewed. Results: Baseline characteristics and disease severity were comparable between the two groups. The patients from the SUA group had a significantly lower morbidity rate and rate of pancreatic insufficiency. Death occurred in 4 of 20 patients (20%) in the SUA group and in 11 of 40 patients (27.5%) in the ON group (risk ratio with the step-up approach, 0.72; 95% confidence interval, 0.26 to 1.99; p = 0.53). Conclusions: A minimally invasive step-up approach provides comparable outcomes to open necrosectomy in the treatment of ANP with infected pancreatic necrosis. While mortality and hospital stay were comparable between the groups, morbidity and pancreatic insufficiency were significantly lower in the SUA group. Further studies on a larger number of patients are required to define the place of SUA in the modern treatment of ANP.
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Affiliation(s)
- Goran Pavlek
- Department of Surgery, University Hospital Centre Zagreb, 10000 Zagreb, Croatia; (G.P.); (J.Z.); (T.B.); (I.P.)
| | - Ivan Romic
- Department of Surgery, University Hospital Centre Zagreb, 10000 Zagreb, Croatia; (G.P.); (J.Z.); (T.B.); (I.P.)
| | - Domina Kekez
- Department of Oncology, University Hospital Centre Zagreb, 10000 Zagreb, Croatia;
| | - Jurica Zedelj
- Department of Surgery, University Hospital Centre Zagreb, 10000 Zagreb, Croatia; (G.P.); (J.Z.); (T.B.); (I.P.)
| | - Tomislav Bubalo
- Department of Surgery, University Hospital Centre Zagreb, 10000 Zagreb, Croatia; (G.P.); (J.Z.); (T.B.); (I.P.)
| | - Igor Petrovic
- Department of Surgery, University Hospital Centre Zagreb, 10000 Zagreb, Croatia; (G.P.); (J.Z.); (T.B.); (I.P.)
| | - Ognjan Deban
- Department of Surgery, University Hospital Centre Zagreb, 10000 Zagreb, Croatia; (G.P.); (J.Z.); (T.B.); (I.P.)
| | - Tomislav Baotic
- Department of Surgery, University Hospital Centre Zagreb, 10000 Zagreb, Croatia; (G.P.); (J.Z.); (T.B.); (I.P.)
| | - Ivan Separovic
- Department of Surgery, University Hospital Centre Zagreb, 10000 Zagreb, Croatia; (G.P.); (J.Z.); (T.B.); (I.P.)
| | - Iva Martina Strajher
- Department of Surgery, University Hospital Centre Zagreb, 10000 Zagreb, Croatia; (G.P.); (J.Z.); (T.B.); (I.P.)
| | - Kristina Bicanic
- Department of Surgery, University Hospital Centre Zagreb, 10000 Zagreb, Croatia; (G.P.); (J.Z.); (T.B.); (I.P.)
| | | | - Vanja Silic
- Department of Anesthesiology and Intensive Care Medicine, University Hospital Centre Zagreb, 10000 Zagreb, Croatia
| | - Gaja Tolic
- Department of Surgery, University Hospital Centre Zagreb, 10000 Zagreb, Croatia; (G.P.); (J.Z.); (T.B.); (I.P.)
| | - Hrvoje Silovski
- Department of Surgery, University Hospital Centre Zagreb, 10000 Zagreb, Croatia; (G.P.); (J.Z.); (T.B.); (I.P.)
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25
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Nakai Y, Saito T, Hamada T, Sato T, Hakuta R, Takahara N, Isayama H, Yasuda I, Fujishiro M. Controversies in endoscopic ultrasonography-guided management of walled-off necrosis. Dig Endosc 2024. [PMID: 38895801 DOI: 10.1111/den.14869] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/06/2024] [Accepted: 05/26/2024] [Indexed: 06/21/2024]
Abstract
Walled-off necrosis (WON) develops as local complications after acute necrotizing pancreatitis. Although less invasive interventions such as endoscopic ultrasonography (EUS)-guided drainage and endoscopic necrosectomy are selected over surgical interventions, delayed and step-up interventions are still preferred to avoid procedure-related adverse events. However, there is a controversy about the appropriate timing of drainage and subsequent necrosectomy. The advent of large-caliber lumen-apposing metal stents has also brought about potential advantages of proactive interventions, which still needs investigation in future trials. When step-up interventions of necrosectomy and additional drainage are necessary, a structured or protocoled approach for WON has been reported to improve safety and effectiveness of endoscopic and/or percutaneous treatment, but has not been standardized yet. Finally, long-term outcomes such as recurrence of WON, pancreatic endocrine, and exocrine function are increasingly investigated in association with disconnected pancreatic duct syndrome. In this review we discuss current evidence and controversy on EUS-guided management of WON.
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Affiliation(s)
- Yousuke Nakai
- Department of Gastroenterology, Graduate School of Medicine, The University of Tokyo, Tokyo, Japan
- Department of Internal Medicine, Institute of Gastroenterology, Tokyo Women's Medical University, Tokyo, Japan
| | - Tomotaka Saito
- Department of Gastroenterology, Graduate School of Medicine, The University of Tokyo, Tokyo, Japan
| | - Tsuyoshi Hamada
- Department of Gastroenterology, Graduate School of Medicine, The University of Tokyo, Tokyo, Japan
- Department of Hepato-Biliary-Pancreatic Medicine, The Cancer Institute Hospital of Japanese Foundation for Cancer Research, Tokyo, Japan
| | - Tatsuya Sato
- Department of Gastroenterology, Graduate School of Medicine, The University of Tokyo, Tokyo, Japan
| | - Ryunosuke Hakuta
- Department of Gastroenterology, Graduate School of Medicine, The University of Tokyo, Tokyo, Japan
- Department of Internal Medicine, Institute of Gastroenterology, Tokyo Women's Medical University, Tokyo, Japan
| | - Naminatsu Takahara
- Department of Gastroenterology, Graduate School of Medicine, The University of Tokyo, Tokyo, Japan
| | - Hiroyuki Isayama
- Department of Gastroenterology, Graduate School of Medicine, Juntendo University, Tokyo, Japan
| | - Ichiro Yasuda
- Third Department of Internal Medicine, University of Toyama, Toyama, Japan
| | - Mitsuhiro Fujishiro
- Department of Gastroenterology, Graduate School of Medicine, The University of Tokyo, Tokyo, Japan
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26
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Singh AK, Manrai M, Kochhar R. Endoscopic ultrasound-guided pancreatic fluid collection drainage: Where are we? World J Gastrointest Endosc 2024; 16:273-281. [PMID: 38946852 PMCID: PMC11212513 DOI: 10.4253/wjge.v16.i6.273] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/26/2024] [Revised: 04/19/2024] [Accepted: 05/27/2024] [Indexed: 06/13/2024] Open
Abstract
Pancreatic fluid collections (PFCs) result from injury to the pancreas from acute or chronic pancreatitis, surgery, or trauma. Management of these collections has evolved over the last 2 decades. The choice of interventions includes percutaneous, endoscopic, minimally invasive surgery, or a combined approach. Endoscopic drainage is the drainage of PFCs by creating an artificial communication between the collection and gastrointestinal lumen that is maintained by placing a stent across the fistulous tract. In this editorial, we endeavored to update the current status of endoscopic ultrasound-guided drainage of PFCs.
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Affiliation(s)
- Anupam Kumar Singh
- Department of Gastroenterology, Postgraduate Institute of Medical Education and Research, Chandigarh 160012, India
| | - Manish Manrai
- Department of Gastroenterology, Command Hospital, Lucknow 226002, India
| | - Rakesh Kochhar
- Department of Gastroenterology, Paras Hospital, Panchkula 134109, India
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Padula D, Mauro A, Maggioni P, Kurihara H, Di Sabatino A, Anderloni A. Practical approach to acute pancreatitis: from diagnosis to the management of complications. Intern Emerg Med 2024:10.1007/s11739-024-03666-9. [PMID: 38850357 DOI: 10.1007/s11739-024-03666-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/13/2024] [Accepted: 05/28/2024] [Indexed: 06/10/2024]
Abstract
The purpose of this review is to provide a practical guide for the clinical care of patients with acute pancreatitis (AP) from the management of the early phases of disease to the treatment of local complications. AP is one of the most frequent causes of gastroenterological admission in emergency departments. It is characterized by a dynamic and unpredictable course and in its most severe forms, is associated with organ dysfunction and/or local complications, requiring intensive care with significant morbidity and mortality. Initial therapy includes adequate fluid resuscitation, nutrition, analgesia, and when necessary critical care support. In recent years, the development of minimally invasive tailored treatments for local complications, such as endoscopic drainage, has improved patients' acceptance and outcomes. Despite this, the management of AP remains a challenge for clinicians. The present review was conducted by the authors, who formulated specific questions addressing the most critical and current aspects of the clinical course of AP with the aim of providing key messages.
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Affiliation(s)
- Donatella Padula
- Emergency Department and Medicine, Fondazione IRCCS Cà Granda Ospedale Maggiore Policlinico, via F Sforza 35, Milan, Italy
| | - Aurelio Mauro
- Gastroenterology and Digestive Endoscopy Unit, Fondazione I.R.C.C.S. Policlinico San Matteo, Viale Camillo Golgi, 19, Pavia, Italy.
| | - Paolo Maggioni
- Emergency Department and Medicine, Fondazione IRCCS Cà Granda Ospedale Maggiore Policlinico, via F Sforza 35, Milan, Italy
- Scuola di Specializzazione in Medicina di Emergenza-Urgenza, Università Degli Studi Di Milano, Milan, Italy
| | - Hayato Kurihara
- Emergency Surgery Unit, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, via F. Sforza 35, Milan, Italy
| | - Antonio Di Sabatino
- Department of Internal Medicine and Medical Therapeutics, University of Pavia, Pavia, Italy
- First Department of Internal Medicine, Fondazione IRCCS Policlinico San Matteo, Pavia, Italy
| | - Andrea Anderloni
- Gastroenterology and Digestive Endoscopy Unit, Fondazione I.R.C.C.S. Policlinico San Matteo, Viale Camillo Golgi, 19, Pavia, Italy
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Gómez-Carrillo D, Chaves CER, Romero MV, Cruz J, Fajardo R, Díaz F. Video assisted retroperitoneal debridement for infected pancreatic necrosis: A two port approach for difficult access. Int J Surg Case Rep 2024; 119:109740. [PMID: 38728969 PMCID: PMC11101862 DOI: 10.1016/j.ijscr.2024.109740] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/06/2024] [Accepted: 05/06/2024] [Indexed: 05/12/2024] Open
Abstract
INTRODUCTION AND IMPORTANCE The incidence of acute pancreatitis varies globally, and its rates are increasing. Timely intervention in cases of infected necrosis is crucial to effective management. The landscape of acute pancreatitis management has undergone transformation through adopting a "step-up" strategy, accentuating the shift towards minimally invasive techniques. CASE PRESENTATION A 63-year-old patient with acute pancreatitis and infected pancreatic necrosis underwent a challenging yet successful treatment using video-assisted retroperitoneal debridement employing a two-port approach facilitated access for an intricate area. The procedure, performed 45 days after admission, effectively reduced peripancreatic collections, demonstrating the efficacy of this approach in managing complex cases of infected pancreatic necrosis. CLINICAL DISCUSSION The management of acute pancreatitis has evolved towards a comprehensive strategy involving early hydration, nutritional support, effective pain management, and interventions. Infected pancreatic necrosis poses a serious complication, with minimally invasive techniques such as video-assisted retroperitoneal debridement (VARD) emerging as preferred options. The efficacy and safety of VARD in complex cases are highlighted, although challenges persist, especially in extensive necrosis. CONCLUSION The VARD procedure, a key component of the step-up approach, exhibits a remarkable safety profile, substantially reducing postoperative complications and mortality compared to open surgical counterparts. However, challenges persist in managing cases of infected Walled-Off Necrosis with deep extension, necessitating carefully considering a minimal-access approach. We report our experience using the VARD in a two-port approach.
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Affiliation(s)
| | - Carlos Eduardo Rey Chaves
- Estudiante de posgrado Cirugía General, Pontificia Universidad Javeriana, Facultad de Medicina, Bogotá, Colombia
| | - María Valentina Romero
- Estudiante de posgrado Cirugía General, Pontificia Universidad Javeriana, Facultad de Medicina, Bogotá, Colombia
| | - Jaime Cruz
- Pontificia Universidad Javeriana, Bogotá, Colombia
| | - Roosevelt Fajardo
- Estudiante de posgrado Cirugía General, Pontificia Universidad Javeriana, Facultad de Medicina, Bogotá, Colombia; Department of Surgery, Hospital Universitario Fundación Santa Fe de Bogotá, Colombia
| | - Francisco Díaz
- Estudiante de posgrado Cirugía General, Pontificia Universidad Javeriana, Facultad de Medicina, Bogotá, Colombia; Department of Surgery, Hospital Universitario Fundación Santa Fe de Bogotá, Colombia
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29
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Farrell MS, Alseidi A, Byerly S, Fockens P, Giberson FA, Glaser J, Horvath K, Jones D, Luckhurst C, Mowery N, Robinson BRH, Rodriguez A, Singh VK, Siriwardena AK, Vege SS, Trikudanathan G, Visser BC, Voermans RP, Yeh DD, Gelbard RB. A core outcome set for acute necrotizing pancreatitis: An Eastern Association for the Surgery of Trauma modified Delphi method consensus study. J Trauma Acute Care Surg 2024; 96:965-970. [PMID: 38407209 DOI: 10.1097/ta.0000000000004281] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/27/2024]
Abstract
BACKGROUND The management of acute necrotizing pancreatitis (ANP) has changed dramatically over the past 20 years including the use of less invasive techniques, the timing of interventions, nutritional management, and antimicrobial management. This study sought to create a core outcome set (COS) to help shape future research by establishing a minimal set of essential outcomes that will facilitate future comparisons and pooling of data while minimizing reporting bias. METHODS A modified Delphi process was performed through involvement of ANP content experts. Each expert proposed a list of outcomes for consideration, and the panel anonymously scored the outcomes on a 9-point Likert scale. Core outcome consensus defined a priori as >70% of scores receiving 7 to 9 points and <15% of scores receiving 1 to 3 points. Feedback and aggregate data were shared between rounds with interclass correlation trends used to determine the end of the study. RESULTS A total of 19 experts agreed to participate in the study with 16 (84%) participating through study completion. Forty-three outcomes were initially considered with 16 reaching consensuses after four rounds of the modified Delphi process. The final COS included outcomes related to mortality, organ failure, complications, interventions/management, and social factors. CONCLUSION Through an iterative consensus process, content experts agreed on a COS for the management of ANP. This will help shape future research to generate data suitable for pooling and other statistical analyses that may guide clinical practice. LEVEL OF EVIDENCE Therapeutic/Care Management; Level V.
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Affiliation(s)
- Michael S Farrell
- From the Division of General and Trauma Surgery, Department of Surgery (M.S.F., J.G.), Lehigh Valley Health Network, Allentown, Pennsylvania; Department of Surgery (A.A.), University of California, San Francisco, California; Division of Trauma/Surgical Critical Care, Department of Surgery (S.B.), University of Tennessee Health Science Center, Memphis, Tennessee; Department of Gastroenterology and Hepatology (P.F.), Amsterdam University Medical Centers, University of Amsterdam/Free University; Amsterdam Gastroenterology Endocrinology Metabolism (P.F., R.P.V.), Research Institute; Cancer Center Amsterdam (P.F., R.P.V.), Amsterdam, the Netherlands; Department of Surgery (F.A.G.), Institution Christiana Care Health Services, Newark, Delaware; Department of Surgery (K.H.), University of Washington, Seattle, Washington; National Pancreas Foundation (D.J.), Chicago, Illinois; Department of Trauma, Emergency Surgery and Surgical Critical Care (C.L.), Massachusetts General Hospital, Boston, Massachusetts; Department of Surgery (N.M.), Wake Forest University, Winston Salem, North Carolina; Department of Surgery (B.R.H.R.), Harborview Medical Center, Seattle, Washington; National Pancreas Foundation (A.R.), Rockland, New York; Division of Gastroenterology, Department of Medicine (V.K.S.), Johns Hopkins Medical Institutions, Baltimore, Maryland; Regional Hepato-Pancreato-Biliary Unit (A.K.S.), Manchester Royal Infirmary, Manchester, England; Division of Gastroenterology and Hepatology (S.S.V.), Mayo Clinic, Rochester, Minnesota; Division of Gastroenterology, Hepatology, and Nutrition, Department of Medicine (G.T.), University of Minnesota Medical Center, Minneapolis, Minnesota; Department of Surgery (B.C.V.), Stanford University School of Medicine, Stanford, California; Department of Gastroenterology and Hepatology (R.P.V.), Amsterdam UMC, University of Amsterdam, Amsterdam, the Netherlands; Department of Surgery (D.D.Y.), Denver Health, Denver, Colorado; and Department of Surgery (R.B.G.), University of Alabama at Birmingham, Birmingham, Alabama
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Kapadia F, Bharadwaj S, Sharma R. Is "Less be More" Still a Valid Concept in Intensive Care? A Review of Critical Care Randomized Clinical Trials from the New England Journal of Medicine. Indian J Crit Care Med 2024; 28:533-551. [PMID: 39130397 PMCID: PMC11310669 DOI: 10.5005/jp-journals-10071-24717] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/05/2024] [Accepted: 04/17/2024] [Indexed: 08/13/2024] Open
Abstract
The concept of "Less is more" has been gaining increasing awareness and acceptance in Critical Care. In 2017, we attempted to systematically answer the question "Can less be more in intensive care" with empirical data. We reviewed all the critical care randomized clinical trials (RCTs) between 1 January 2008 and 5 October 2016 in the New England Journal of Medicine (NEJM). This article attempts to repeat the earlier exercise using data from 5 October 2016 to 31 December 2023. This analysis of critical care RCTs in the NEJM has shown three findings. Approximately three-quarter of RCTs in critical care in the NEJM between 2008 and 2023 failed to show benefit or harm. In the years 2008-2016, patients in the intervention cohort had a higher mortality compared to controls, but in the years 2016-2023, the difference in overall mortality in patients in the intervention and control arms was not statistically significant. Compared to the years 2008-2016, in the years from 2016 to 2023, the number of RCTs showing harm decreased and those showing benefit increased. How to cite this article Kapadia F, Bharadwaj S, Sharma R. Is "Less be More" Still a Valid Concept in Intensive Care? A Review of Critical Care Randomized Clinical Trials from the New England Journal of Medicine. Indian J Crit Care Med 2024;28(6):533-551.
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Affiliation(s)
- Farhad Kapadia
- Department of Intensive Care, PD Hinduja Hospital & Medical Research Center, Mumbai, Maharashtra, India
| | - Shreya Bharadwaj
- Department of Intensive Care, PD Hinduja Hospital & Medical Research Center, Mumbai, Maharashtra, India
| | - Ritika Sharma
- Department of Critical Care, Sir HN Reliance Foundation Hospital and Research Centre, Mumbai, Maharashtra, India
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Shah J, Fernandez Y Viesca M, Jagodzinski R, Arvanitakis M. Infected pancreatic necrosis-Current trends in management. Indian J Gastroenterol 2024; 43:578-591. [PMID: 38625518 DOI: 10.1007/s12664-023-01506-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/06/2023] [Accepted: 12/11/2023] [Indexed: 04/17/2024]
Abstract
Acute necrotizing pancreatitis is a common gastrointestinal disease requiring hospitalization and multiple interventions resulting in higher morbidity and mortality. Development of infection in such necrotic tissue is one of the sentinel events in natural history of necrotizing pancreatitis. Infected necrosis develops in around 1/3rd of patients with necrotizing pancreatitis resulting in higher mortality. So, timely diagnosis of infected necrosis using clinical, laboratory and radiological parameters is of utmost importance. Though initial conservative management with antibiotics and organ support system is effective in some patients, a majority of patients still requires drainage of the collection by various modalities. Mode of drainage of infected pancreatic necrosis depends on various factors such as the clinical status of the patient, location and characteristics of collection and availability of the expertise and includes endoscopic, percutaneous and minimally invasive or open surgical approaches. Endoscopic drainage has proved to be a game changer in the management of infected pancreatic necrosis in the last decade with rapid evolution in procedure techniques, development of novel metal stent and dedicated necrosectomy devices for better clinical outcome. Despite widespread adoption of endoscopic transluminal drainage of pancreatic necrosis with excellent clinical outcomes, peripheral collections are still not amenable for endoscopic drainage and in such scenario, the role of percutaneous catheter drainage or minimally invasive surgical necrosectomy cannot be understated. In a nutshell, the management of patients with infected pancreatic necrosis involves a multi-disciplinary team including a gastroenterologist, an intensivist, an interventional radiologist and a surgeon for optimum clinical outcomes.
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Affiliation(s)
- Jimil Shah
- Department of Gastroenterology, Postgraduate Institute of Medical Education and Research, Chandigarh, 160 012, India
| | - Michael Fernandez Y Viesca
- Department of Gastroenterology, Hepatopancreatology, and Digestive Oncology, Erasme University Hospital, HUB, Université Libre de Bruxelles, Brussels, Belgium
| | | | - Marianna Arvanitakis
- Department of Gastroenterology, Hepatopancreatology, and Digestive Oncology, Erasme University Hospital, HUB, Université Libre de Bruxelles, Brussels, Belgium.
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Au KP, Chok KSH. Surgical cystogastrostomy: Is it still worthwhile? World J Gastroenterol 2024; 30:2298-2301. [PMID: 38813046 PMCID: PMC11130567 DOI: 10.3748/wjg.v30.i17.2298] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/12/2024] [Revised: 03/10/2024] [Accepted: 04/15/2024] [Indexed: 04/30/2024] Open
Abstract
The article by Ker et al explores the treatment of peripancreatic fluid collection (PFC). The use of percutaneous drainage, endoscopy, and surgery for managing PFC are discussed. Percutaneous drainage is noted for its low risk profile, while endoscopic cystogastrostomy is more effective due to the wider orifice of the metallic stent. Surgical cystogastrostomy is a definitive treatment with a reduced need for reintervention, especially for cases with extensive collections and significant necrosis. The choice of treatment modality should be tailored to individual patient characteristics and disease factors, considering the expertise available.
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Affiliation(s)
- Kin Pan Au
- Department of Surgery, Queen Mary Hospital, The University of Hong Kong, Hong Kong 999077, China
| | - Kenneth Siu Ho Chok
- Department of Surgery, The Chinese University of Hong Kong, Hong Kong 999077, China
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Fichtl A, Sheikhani A, Wagner M, Kleger A, Müller M, Sturm N, Walter B, Franz AM. Implementing an electromagnetic tracking navigation system improves the precision of endoscopic transgastric necrosectomy in an ex vivo model. Sci Rep 2024; 14:10055. [PMID: 38698058 PMCID: PMC11066121 DOI: 10.1038/s41598-024-60647-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/29/2023] [Accepted: 04/25/2024] [Indexed: 05/05/2024] Open
Abstract
Endoscopic transgastric necrosectomy is crucial in the management of complications resulting from necrotizing pancreatitis. However, both real-time and visual-spatial information is lacking during the procedure, thereby jeopardizing a precise positioning of the endoscope. We conducted a proof-of-concept study with the aim of overcoming these technical difficulties. For this purpose, a three-dimensional (3D) phantom of a stomach and pancreatic necroses was 3D-printed based on spatial information from individual patient CT scans and subsequently integrated into a silicone torso. An electromagnetic (EM) sensor was adjusted inside the endoscope´s working channel. A software interface enabled real time visualization. The accuracy of this novel assistant system was tested ex vivo by four experienced interventional endoscopists who were supposed to reach seven targets inside the phantom in six different experimental runs of simulated endoscopic transgastric necrosectomy. Supported by endoscopic camera view combined with real-time 3D visualization, all endoscopists reached the targets with a targeting error ranging between 2.6 and 6.5 mm in a maximum of eight minutes. In summary, the EM tracking system might increase efficacy and safety of endoscopic transgastric necrosectomy at the experimental level by enhancing visualization. Yet, a broader feasibility study and further technical improvements are mandatory before aiming at implementation into clinical setting.
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Affiliation(s)
- Anna Fichtl
- Department of Internal Medicine I, University Hospital Ulm, Albert-Einstein-Allee 23, 89081, Ulm, Germany.
- Endoscopic Research Unit, University Hospital Ulm, Albert-Einstein-Allee 23, 89081, Ulm, Germany.
| | - Alaan Sheikhani
- Institute for Medical Engineering and Mechatronics, University of Applied Sciences Ulm, Albert-Einstein-Allee 53-55, 89081, Ulm, Germany
| | - Martin Wagner
- Department of Internal Medicine I, University Hospital Ulm, Albert-Einstein-Allee 23, 89081, Ulm, Germany
| | - Alexander Kleger
- Institute of Molecular Oncology and Stem Cell Biology, University Hospital Ulm, Albert-Einstein-Allee 23, 89081, Ulm, Germany
- Division of Interdisciplinary Pancreatology, Department of Internal Medicine I, University Hospital Ulm, Albert-Einstein-Allee 23, 89081, Ulm, Germany
| | - Martin Müller
- Department of Internal Medicine I, University Hospital Ulm, Albert-Einstein-Allee 23, 89081, Ulm, Germany
| | - Niklas Sturm
- Department of Internal Medicine I, University Hospital Ulm, Albert-Einstein-Allee 23, 89081, Ulm, Germany
- Endoscopic Research Unit, University Hospital Ulm, Albert-Einstein-Allee 23, 89081, Ulm, Germany
| | - Benjamin Walter
- Department of Internal Medicine I, University Hospital Ulm, Albert-Einstein-Allee 23, 89081, Ulm, Germany
- Endoscopic Research Unit, University Hospital Ulm, Albert-Einstein-Allee 23, 89081, Ulm, Germany
| | - Alfred Michael Franz
- Institute for Medical Engineering and Mechatronics, University of Applied Sciences Ulm, Albert-Einstein-Allee 53-55, 89081, Ulm, Germany
- Division of Intelligent Medical Systems, German Cancer Research Center (DKFZ), Im Neuenheimer Feld 223, 69120, Heidelberg, Germany
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Ramai D, Ahmed Z, Chandan S, Facciorusso A, Deliwala SS, Alastal Y, Nawras A, Maida M, Barakat MT, Anderloni A, Adler DG. Safety and efficacy of the EndoRotor device for the treatment of walled-off pancreatic necrosis after EUS-guided cystenterostomy: A systematic review and meta-analysis. Endosc Ultrasound 2024; 13:165-170. [PMID: 39318651 PMCID: PMC11419429 DOI: 10.1097/eus.0000000000000031] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/07/2022] [Accepted: 06/13/2023] [Indexed: 09/26/2024] Open
Abstract
Debridement of infected walled-off pancreatic necrosis is indicated to treat and prevent sepsis-related multiorgan failure. The aim of this study was to evaluate the efficacy and safety of the EndoRotor-powered endoscopic debridement system to remove solid debris under direct endoscopic visualization. Search strategies were developed for PubMed, EMBASE, and Cochrane Library databases from inception to June 2022, in accordance with Preferred Reporting items for Systematic Reviews and Meta-Analyses and Meta-Analysis of Observational Studies in Epidemiology guidelines. Outcomes of interest included technical success defined as successful use of device for debridement, clinical success defined as complete debridement and cyst resolution, and procedure-related adverse events. A random-effects model was used for analysis, and results were expressed as odds ratio along with 95% confidence interval. A total of 7 studies (n = 79 patients) were included. The mean walled-off pancreatic necrosis size was 154.6 ± 34.0 mm, whereas the mean procedure time was 71.4 minutes. The mean number of necrosectomy sessions required was 2.2 (range, 1-7). The pooled rate of clinical success was 96% (95% confidence interval, 91%-100%; I 2 = 0%) with a pooled technical success rate of 96% (91%-100%; I 2 = 0%). The pooled procedure-related adverse event rate was 8% (2%-14%; I 2 = 6%), which included procedure-associated bleeding, pneumoperitoneum, peritonitis, pleural effusion, and dislodgement of lumen-apposing metal stents. Our study shows that the novel EndoRotor device seems to be safe and effective for treating pancreatic necrosis. Patients undergoing endoscopic necrosectomy with the EndoRotor seem to require less debridement sessions when compared with studies using conventional instruments.
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Affiliation(s)
- Daryl Ramai
- Gastroenterology & Hepatology, University of Utah Health, Salt Lake City, UT, USA
| | - Zohaib Ahmed
- Department of Internal Medicine, University of Toledo Medical Center, Toledo, OH, USA
| | - Saurabh Chandan
- Division of Gastroenterology & Hepatology, CHI Health Creighton University Medical Center, Omaha, NE, USA
| | - Antonio Facciorusso
- Section of Gastroenterology, Department of Medical Sciences, University of Foggia, Foggia, Italy
| | - Smit S. Deliwala
- Department of Internal Medicine, Michigan State University at Hurley Medical Center, Flint, MI, USA
| | - Yaseen Alastal
- Department of Gastroenterology and Hepatology, University of Toledo Medical Center, Toledo, OH, USA
| | - Ali Nawras
- Department of Gastroenterology and Hepatology, University of Toledo Medical Center, Toledo, OH, USA
| | - Marcello Maida
- Gastroenterology and Endoscopy Unit, S. Elia-Raimondi Hospital, Caltanissetta, Italy
| | | | - Andrea Anderloni
- Digestive Endoscopy Unit, Humanitas Clinical, and Research Center—IRCCS, Milano, Italy
| | - Douglas G. Adler
- Center for Advanced Therapeutic Endoscopy (CATE), Porter Adventist Hospital/PEAK Gastroenterology, Denver, CO, USA
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Ning C, Sun Z, Shen D, Lin C, Li J, Wei Q, Chen L, Huang G. Is Contemporary Open Pancreatic Necrosectomy Still Useful In The Minimally Invasive Era? Surgery 2024; 175:1394-1401. [PMID: 38378349 DOI: 10.1016/j.surg.2024.01.021] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/15/2023] [Revised: 10/19/2023] [Accepted: 01/18/2024] [Indexed: 02/22/2024]
Abstract
BACKGROUND Previous studies have shown that open pancreatic necrosectomy for infected pancreatic necrosis was associated with high morbidity and mortality. However, these results were mostly concluded from historical cohorts with traditional early necrosectomy in the absence of a minimally invasive step-up approach. OBJECTIVE To explore the value of contemporary open pancreatic necrosectomy for infected pancreatic necrosis in the minimally invasive era. METHODS A post hoc analysis was performed in a prospective maintained database of 320 patients with infected pancreatic necrosis from January 2011 to December 2022 at a large Chinese tertiary hospital. RESULTS A total of 320 patients with infected pancreatic necrosis received either a minimally invasive step-up approach (245, 76.6%) or open pancreatic necrosectomy (75, 23.4%), which included upfront open pancreatic necrosectomy (32, 10.0%) and salvage open pancreatic necrosectomy (43, 13.4%). Upfront open pancreatic necrosectomy was associated with similar morbidity and mortality rates but fewer surgical interventions compared with a minimally invasive step-up approach. However, salvage open pancreatic necrosectomy was associated with significantly higher mortality (48.8% vs 18.8%, P = .007), gastrointestinal fistula (44.2% vs 18.8%, P = .021), hemorrhage (48.8% vs 15.6%, P = .003), and intensive care unit stay (25 vs 7 days, P = .040) compared with upfront open pancreatic necrosectomy. Multivariate analysis suggested that multiple organ failure (hazard ratio = 5.1; 95% confidence interval, 1.4-18.2, P = .013) and synchronous critical acute pancreatitis (hazard ratio = 3.0; 95% confidence interval, 1.1-8.6, P = .040) were 2 independent risk factors of death for patients who received open pancreatic necrosectomy. CONCLUSION Patients undergoing upfront open pancreatic necrosectomy received fewer surgical interventions with comparable efficacy compared to the minimally invasive step-up approach. Salvage open pancreatic necrosectomy was potentially lifesaving, though it carried high morbidity and mortality. Multiple organ failure and synchronous critical acute pancreatitis were 2 independent risk factors of death for patients who received open pancreatic necrosectomy.
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Affiliation(s)
- Caihong Ning
- Department of Pancreatic Surgery, Xiangya Hospital, Central South University, Changsha, Hunan Province, China; Department of General Surgery, Xiangya Hospital, Central South University, Changsha, Hunan Province, China; Department of Hernia and Abdominal Wall Surgery, Xiangya Hospital, Central South University, Changsha, Hunan Province, China; National Clinical Research Center for Geriatric Disorders, Xiangya Hospital, Central South University, Changsha, Hunan Province, China
| | - Zefang Sun
- Department of Pancreatic Surgery, Xiangya Hospital, Central South University, Changsha, Hunan Province, China; Department of General Surgery, Xiangya Hospital, Central South University, Changsha, Hunan Province, China; Department of Hernia and Abdominal Wall Surgery, Xiangya Hospital, Central South University, Changsha, Hunan Province, China; National Clinical Research Center for Geriatric Disorders, Xiangya Hospital, Central South University, Changsha, Hunan Province, China
| | - Dingcheng Shen
- Department of Pancreatic Surgery, Xiangya Hospital, Central South University, Changsha, Hunan Province, China; Department of General Surgery, Xiangya Hospital, Central South University, Changsha, Hunan Province, China; Department of Hernia and Abdominal Wall Surgery, Xiangya Hospital, Central South University, Changsha, Hunan Province, China; National Clinical Research Center for Geriatric Disorders, Xiangya Hospital, Central South University, Changsha, Hunan Province, China
| | - Chiayen Lin
- Department of Pancreatic Surgery, Xiangya Hospital, Central South University, Changsha, Hunan Province, China; Department of General Surgery, Xiangya Hospital, Central South University, Changsha, Hunan Province, China; Department of Hernia and Abdominal Wall Surgery, Xiangya Hospital, Central South University, Changsha, Hunan Province, China; National Clinical Research Center for Geriatric Disorders, Xiangya Hospital, Central South University, Changsha, Hunan Province, China
| | - Jiarong Li
- Department of Pancreatic Surgery, Xiangya Hospital, Central South University, Changsha, Hunan Province, China; Department of General Surgery, Xiangya Hospital, Central South University, Changsha, Hunan Province, China; Department of Hernia and Abdominal Wall Surgery, Xiangya Hospital, Central South University, Changsha, Hunan Province, China; National Clinical Research Center for Geriatric Disorders, Xiangya Hospital, Central South University, Changsha, Hunan Province, China
| | - Qin Wei
- Department of Pancreatic Surgery, Xiangya Hospital, Central South University, Changsha, Hunan Province, China; Department of General Surgery, Xiangya Hospital, Central South University, Changsha, Hunan Province, China; Department of Hernia and Abdominal Wall Surgery, Xiangya Hospital, Central South University, Changsha, Hunan Province, China; National Clinical Research Center for Geriatric Disorders, Xiangya Hospital, Central South University, Changsha, Hunan Province, China
| | - Lu Chen
- Department of Pancreatic Surgery, Xiangya Hospital, Central South University, Changsha, Hunan Province, China; Department of General Surgery, Xiangya Hospital, Central South University, Changsha, Hunan Province, China; Department of Hernia and Abdominal Wall Surgery, Xiangya Hospital, Central South University, Changsha, Hunan Province, China; National Clinical Research Center for Geriatric Disorders, Xiangya Hospital, Central South University, Changsha, Hunan Province, China
| | - Gengwen Huang
- Department of Pancreatic Surgery, Xiangya Hospital, Central South University, Changsha, Hunan Province, China; Department of General Surgery, Xiangya Hospital, Central South University, Changsha, Hunan Province, China; Department of Hernia and Abdominal Wall Surgery, Xiangya Hospital, Central South University, Changsha, Hunan Province, China; National Clinical Research Center for Geriatric Disorders, Xiangya Hospital, Central South University, Changsha, Hunan Province, China.
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Varadarajulu S, Cangelosi MJ, Cramer GR, Kuipers K, Reimer S, Roy AK. Clinical and Economic Implications of Interventions in Pancreatic Fluid Collections: An Assessment From a National Claims Database. Pancreas 2024; 53:e410-e415. [PMID: 38598366 DOI: 10.1097/mpa.0000000000002317] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 04/12/2024]
Abstract
OBJECTIVE To compare clinical and economic implications of percutaneous and endoscopic treatment approaches in patients with pancreatic fluid collections (PFCs). MATERIALS AND METHODS This is a retrospective claims analysis of Medicare beneficiaries who underwent inpatient endoscopic or percutaneous PFC drainage procedures (2016-2020). We performed longitudinal analysis of claims for all-cause mortality and rehospitalization during 180-day follow-up. Main outcome was mortality. Other outcomes were rehospitalization and direct costs. RESULTS A total of 1311 patients underwent endoscopic (n = 727) or percutaneous (n = 584) drainage. Percutaneous as compared with endoscopic approach was associated with higher mortality (23.08% vs 16.7%, P = 0.004), rehospitalization (58.9% vs 53.3%, P = 0.04), and mean direct hospital costs ($37,107 [SD = $67,833] vs $27,800 [SD = $43,854], P = 0.004). On multivariable analysis, percutaneous drainage (adjusted hazard ratio [HR], 1.38; 95% confidence interval [CI], 1.02-1.86; P = 0.039), older age (hazard ratio [HR], 1.04; 95% CI, 1.01-1.04; P < 0.001), intensive care unit stay (HR, 1.02; 95% CI, 1.01-1.03; P < 0.001), and multiple comorbidities (HR, 1.07; 95% CI, 1.05-1.09; P < 0.001) were significantly associated with mortality. Percutaneous drainage (adjusted odds ratio [OR], 1.30; 95% CI, 1.04-1.63; P = 0.027) and older age (OR, 0.98; 95% CI, 0.97-0.99; P < 0.001) were significantly associated with rehospitalizations. CONCLUSIONS As percutaneous drainage may be associated with higher mortality, rehospitalization, and costs, when requisite expertise is available, endoscopy should be preferred for treatment of PFC amenable to such an approach. Randomized trials are required to validate these findings.
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Affiliation(s)
| | | | | | | | | | - Ann K Roy
- Boston Scientific Corporation, Marlborough, MA
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Mahapatra SJ, Olesen SS. Guideline adherence in acute pancreatitis: Still a long way to go. Pancreatology 2024; 24:325-326. [PMID: 38448347 DOI: 10.1016/j.pan.2024.03.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/15/2024] [Accepted: 03/01/2024] [Indexed: 03/08/2024]
Affiliation(s)
| | - Søren Schou Olesen
- Centre for Pancreatic Diseases, Department of Gastroenterology, Aalborg University Hospital, Aalborg, Denmark.
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Bharath PN, Rana SS. Early Endoscopic Interventions for Pancreatic Necrosis: Indications, Technique, and Outcomes. Dig Dis Sci 2024; 69:1571-1582. [PMID: 38528209 DOI: 10.1007/s10620-024-08347-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/02/2024] [Accepted: 02/08/2024] [Indexed: 03/27/2024]
Abstract
Endoscopic transmural drainage is usually performed for symptomatic well-encapsulated walled-off necrosis (WON) that usually develops in the delayed phase (> 4 weeks after disease onset) of acute necrotising pancreatitis (ANP). Endoscopic drainage is usually not advocated in the early (< 4 weeks after disease onset) stage of illness because of the risk of complications due to an incompletely formed encapsulating wall and poor demarcation of viable from necrotic tissue. However, emerging data from expert tertiary care centres over the last few years shows that the early endoscopic transluminal drainage approach is effective and safe. The development of lumen-apposing metal stents and better accessories for endoscopic necrosectomy has fuelled the expansion of indications of endoscopic drainage of pancreatic necrosis. However, early endoscopic drainage is associated with higher rates of adverse events; therefore, careful patient selection is paramount. This article will review the current indications, techniques and outcomes of early endoscopic transluminal drainage in pancreatic necrotic collections.
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Affiliation(s)
- Pardhu Neelam Bharath
- Department of Gastroenterology, Post Graduate Institute of Medical Education and Research (PGIMER), Sector 12, Chandigarh, 160012, India
| | - Surinder Singh Rana
- Department of Gastroenterology, Post Graduate Institute of Medical Education and Research (PGIMER), Sector 12, Chandigarh, 160012, India.
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Chan KS, Shelat VG. The Ongoing Debate on the Use of Prophylactic Antibiotics in Acute Pancreatitis-Is There a Conclusion? A Comprehensive Narrative Review. Antibiotics (Basel) 2024; 13:411. [PMID: 38786140 PMCID: PMC11117274 DOI: 10.3390/antibiotics13050411] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/03/2024] [Revised: 04/28/2024] [Accepted: 04/28/2024] [Indexed: 05/25/2024] Open
Abstract
Acute pancreatitis (AP) is a common but often self-limiting disease in the majority of patients. However, in the minority, who may progress to moderately severe or severe AP, high mortality risk has been reported. Infected pancreatitis necrosis (IPN) in necrotising pancreatitis has been shown to result in more than twice the mortality rate compared with in sterile pancreatic necrosis. This raises the question on whether prophylactic antibiotics (PABs) should be given in subgroups of AP to prevent superimposed infection to improve survival outcomes. Despite numerous randomised controlled trials (RCTs), meta-analyses, and guidelines on the management of AP, there is a lack of strong evidence to suggest the use of PABs in AP. Additionally, use of PABs is associated with antimicrobial resistance. Considerable heterogeneity exists and limits the interpretation of results-subgroup of AP benefitting from PAB use, choice/class of PAB, and timing of administration from symptom onset and duration of PAB use. Only a minority of existing meta-analyses suggest mortality benefits and reduction in IPN. The majority of existing guidelines do not recommend the use of PABs in AP. More research is required to make more definitive conclusions. Currently, PAB should only be administered after multidisciplinary discussions led by pancreatology experts.
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Affiliation(s)
- Kai Siang Chan
- Department of General Surgery, Tan Tock Seng Hospital, 11 Jalan Tan Tock Seng, Singapore 308433, Singapore;
- Lee Kong Chian School of Medicine, Nanyang Technological University, Singapore 308232, Singapore
| | - Vishal G. Shelat
- Department of General Surgery, Tan Tock Seng Hospital, 11 Jalan Tan Tock Seng, Singapore 308433, Singapore;
- Lee Kong Chian School of Medicine, Nanyang Technological University, Singapore 308232, Singapore
- Yong Loo Lin School of Medicine, National University of Singapore, Singapore 117597, Singapore
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40
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Lin L, Liu T, Deng B, Fu H, Xiang X, Liang Z, Liang D, Tang G. A new sight to acute pancreatitis through paracolic gutter exudation, a multicenter retrospective study. Heliyon 2024; 10:e29531. [PMID: 38644818 PMCID: PMC11033130 DOI: 10.1016/j.heliyon.2024.e29531] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/17/2023] [Revised: 02/25/2024] [Accepted: 04/09/2024] [Indexed: 04/23/2024] Open
Abstract
Objectives Paracolic gutter exudation (PGE) may influence the severity of acute pancreatitis, but no study has explored it extensively. The objective of this study was to evaluate PGE for assessing the severity of disease. Methods We performed a retrospective analysis of 488 patients from three tertiary hospitals in Guangxi, China. General clinical information, severity, and clinical courses were recorded. The PGE score were classified as follows: 0 for no exudation, 1 for unilateral exudation, and 2 for bilateral exudation. We used ROC curves to assess the predictive value of the PGE score, and logistic regression analysis to determine risk factors associated with death, ICU admission, and the occurrence of MODS. Results This study included 352 patients with moderately severe acute pancreatitis (MSAP) and 136 patients with severe acute pancreatitis (SAP). Patients who had PGE experienced higher total hospitalization costs, longer hospital stays, a higher incidence of SAP, higher mortality rates, higher ICU admission rates, a higher incidence of MODS, and higher incidence of infections than those without (P < 0.05). Diagnostic efficacy in predicting severity in patients with MSAP and SAP increased after BISAP, MCTSI, modified Marshall, and SOFA scores combined with PGE score respectively. The PGE score of >1 is an independent risk factor for ICU admission and MODS occurrence. (P < 0.05). Conclusion The PGE provides reliable and objective information for assessing severity and clinical course of patients with MSAP and SAP.
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Affiliation(s)
- Lianjie Lin
- Department of Gastroenterology, The First Affiliated Hospital of Guangxi Medical University, Nanning, PR China
| | - Tao Liu
- Department of Spleen, Stomach and Hepatology, Guangxi International Zhuang Medicine Hospital, Nanning, PR China
| | - Bingli Deng
- Department of Gastroenterology, The Second People's Hospital of Qinzhou, Guangxi, PR China
| | - Hongzong Fu
- Department of Spleen, Stomach and Hepatology, Guangxi International Zhuang Medicine Hospital, Nanning, PR China
| | - Xuelian Xiang
- Department of Gastroenterology, The First Affiliated Hospital of Guangxi Medical University, Nanning, PR China
| | - Zhihai Liang
- Department of Gastroenterology, The First Affiliated Hospital of Guangxi Medical University, Nanning, PR China
| | - Dongsheng Liang
- Department of Gastroenterology, The Second People's Hospital of Qinzhou, Guangxi, PR China
| | - Guodu Tang
- Department of Gastroenterology, The First Affiliated Hospital of Guangxi Medical University, Nanning, PR China
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Li Z, Siddiqui A, Singh G, Redstone E, Weinstein J, Mitchell DG. Pancreatic Walled-Off Necrosis: Cross-Sectional Imaging Depiction of Debris Predicts the Success of Endoscopic Drainage Using Lumen-Apposing Metal Stents. Dig Dis 2024; 42:380-388. [PMID: 38663364 DOI: 10.1159/000538472] [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: 10/19/2023] [Accepted: 03/12/2024] [Indexed: 06/05/2024]
Abstract
INTRODUCTION The use of endoscopic ultrasound (EUS)-guided transmural stent placement for pancreatic walled-off necrosis (WON) drainage is widespread. This study retrospectively analyzed imaging parameters predicting the outcomes of WON endoscopic drainage using lumen-apposing metal stents (LAMS). METHODS This study analyzed the data of 115 patients who underwent EUS-guided debridement using LAMS from 2011 to 2015. Pre-intervention CT or MRI was used to analyze the total volume of WON, percentage of debris, multilocularity, and density. Success measures included technical success, the number of endoscopic sessions, the requirement of percutaneous drainage, long-term success, and recurrence. RESULTS The primary cause of pancreatitis was gallstones (50.4%), followed by alcohol (27.8%), hypertriglyceridemia (11.3%), idiopathic (8.7%), and autoimmune (1.7%). The mean WON size was 674 mL. All patients underwent endoscopic necrosectomy, averaging 3.1 sessions. Stent placement was successful in 96.5% of cases. Procedural complications were observed in 13 patients (11.3%) and 6 patients (5.2%) who needed additional percutaneous drainage. No patients reported recurrent WON posttreatment. Univariate analysis indicated a significant correlation between debris percentage and the need for additional drainage and long-term success (p < 0.001). The number of endoscopic sessions correlated significantly with debris percentage (p < 0.001). CONCLUSION Pre-procedural imaging, particularly debris percentage within WON, significantly predicts the number of endoscopic sessions, the need for further percutaneous drainage, and overall long-term success.
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Affiliation(s)
- Zhenteng Li
- Department of Radiology, St. Luke's University Health Network, Bethlehem, Pennsylvania, USA
- Department of Radiology, Thomas Jefferson University, Philadelphia, Pennsylvania, USA
| | - Ali Siddiqui
- Division of Gastroenterology, Inova Health System, Fairfax, Virginia, USA
| | - Gurshawn Singh
- Department of Gastroenterology, St. Luke's University Health Network, Bethlehem, Pennsylvania, USA
| | - Ellen Redstone
- Department of Radiology, St. Luke's University Health Network, Bethlehem, Pennsylvania, USA
| | - Jonathan Weinstein
- Department of Radiology, Thomas Jefferson University, Philadelphia, Pennsylvania, USA
- Department of Radiology, Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, Plainview, New York, USA
| | - Donald G Mitchell
- Department of Radiology, Thomas Jefferson University, Philadelphia, Pennsylvania, USA
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Hollemans RA, Timmerhuis HC, Besselink MG, Bouwense SAW, Bruno M, van Duijvendijk P, van Geenen EJ, Hadithi M, Hofker S, Van-Hooft JE, Kager LM, Manusama ER, Poley JW, Quispel R, Römkens T, van der Schelling GP, Schwartz MP, Spanier BWM, Stommel M, Tan A, Venneman NG, Vleggaar F, van Wanrooij RLJ, Bollen TL, Voermans RP, Verdonk RC, van Santvoort HC. Long-term follow-up study of necrotising pancreatitis: interventions, complications and quality of life. Gut 2024; 73:787-796. [PMID: 38267201 DOI: 10.1136/gutjnl-2023-329735] [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: 02/16/2023] [Accepted: 01/07/2024] [Indexed: 01/26/2024]
Abstract
OBJECTIVE To describe the long-term consequences of necrotising pancreatitis, including complications, the need for interventions and the quality of life. DESIGN Long-term follow-up of a prospective multicentre cohort of 373 necrotising pancreatitis patients (2005-2008) was performed. Patients were prospectively evaluated and received questionnaires. Readmissions (ie, for recurrent or chronic pancreatitis), interventions, pancreatic insufficiency and quality of life were compared between initial treatment groups: conservative, endoscopic/percutaneous drainage alone and necrosectomy. Associations of patient and disease characteristics during index admission with outcomes during follow-up were assessed. RESULTS During a median follow-up of 13.5 years (range 12-15.5 years), 97/373 patients (26%) were readmitted for recurrent pancreatitis. Endoscopic or percutaneous drainage was performed in 47/373 patients (13%), of whom 21/47 patients (45%) were initially treated conservatively. Pancreatic necrosectomy or pancreatic surgery was performed in 31/373 patients (8%), without differences between treatment groups. Endocrine insufficiency (126/373 patients; 34%) and exocrine insufficiency (90/373 patients; 38%), developed less often following conservative treatment (p<0.001 and p=0.016, respectively). Quality of life scores did not differ between groups. Pancreatic gland necrosis >50% during initial admission was associated with percutaneous/endoscopic drainage (OR 4.3 (95% CI 1.5 to 12.2)), pancreatic surgery (OR 3.2 (95% CI 1.1 to 9.5) and development of endocrine insufficiency (OR13.1 (95% CI 5.3 to 32.0) and exocrine insufficiency (OR6.1 (95% CI 2.4 to 15.5) during follow-up. CONCLUSION Acute necrotising pancreatitis carries a substantial disease burden during long-term follow-up in terms of recurrent disease, the necessity for interventions and development of pancreatic insufficiency, even when treated conservatively during the index admission. Extensive (>50%) pancreatic parenchymal necrosis seems to be an important predictor of interventions and complications during follow-up.
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Affiliation(s)
- Robbert A Hollemans
- Department of Surgery, St Antonius Hospital Location, Utrecht, Netherlands
- Department of Research and Development, St. Antonius Hospital, Nieuwegein, Netherlands
| | | | - Marc G Besselink
- Department of Surgery, Amsterdam UMC, University of Amsterdam, Amsterdam, Netherlands
- Amsterdam Gastroenterology Endocrinology Metabolism, Amsterdam, Netherlands
| | - Stefan A W Bouwense
- Department of Surgery, Maastricht Universitair Medisch Centrum+, Maastricht, Netherlands
| | - Marco Bruno
- Gastroenterology and Hepatology, Erasmus Medical Center, Rotterdam, Netherlands
| | | | - Erwin-Jan van Geenen
- Department of Gastroenterology and Hepatology, Radboudumc, Nijmegen, Netherlands
| | - Muhammed Hadithi
- Department of Gastroenterology and Hepatology, Maasstad Hospital, Rotterdam, Netherlands
| | - Sybrand Hofker
- Department of Surgery, University Medical Centre, Groningen, Netherlands
| | - Jeanin E Van-Hooft
- Department of Gastroenterology & Hepatology, Leiden Universitair Medisch Centrum, Leiden, Netherlands
| | - Liesbeth M Kager
- Department of Gastroenterology & Hepatology, Noordwest Ziekenhuisgroep, Alkmaar, Netherlands
| | - Eric R Manusama
- Department of Surgery, Medical Centre Leeuwarden, Leeuwarden, Netherlands
| | - Jan-Werner Poley
- Department of Gastroenterology and Hepatology, Maastricht University Medical Centre+, Maastricht, Netherlands
| | - Rutger Quispel
- Department of Gastroenterology and Hepatology, Reinier de Graaf Gasthuis, Delft, Netherlands
| | - Tessa Römkens
- Department of Gastroenterology and Hepatology, Jeroen Bosch Ziekenhuis, Den Bosch, Netherlands
| | | | - Matthijs P Schwartz
- Department of Gastroenterology and Hepatology, Meander Medical Centre, Amersfoort, Netherlands
| | - Bernhard W M Spanier
- Department of Gastroenterology and Hepatology, Rijnstate Hospital, Arnhem, Netherlands
| | | | - Adriaan Tan
- Canisius Wilhelmina Hospital, Nijmegen, Netherlands
| | - Niels G Venneman
- Department of Gastroenterology and Hepatology, Medical Spectrum Twente, Enschede, Netherlands
| | - Frank Vleggaar
- Department of Gastroenterology and Hepatology, University Medical Centre, Utrecht, Netherlands
| | - Roy L J van Wanrooij
- Department of Gastroenterology and Hepatology, Amsterdam UMC Locatie VUmc, Amsterdam, Netherlands
| | - Thomas L Bollen
- Department of Radiology, St Antonius Hospital Location, Utrecht, Netherlands
| | - Rogier P Voermans
- Department of Gastroenterology and Hepatology, Amsterdam UMC, University of Amsterdam, Amsterdam, Netherlands
| | - Robert C Verdonk
- Department of Gastroenterology and Hepatology, St Antonius Hospital Location, Utrecht, Netherlands
| | - Hjalmar C van Santvoort
- Department of Surgery, St Antonius Hospital Location, Utrecht, Netherlands
- Department of Surgery, University Medical Centre, Utrecht, Netherlands
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Kherabi Y, Michoud C, Villageois-Tran K, Bert F, Pioche M, Lefort A, Lévy P, Rebours V, Zarrouk V. Epidemiology, treatment and outcomes of infected pancreatic necrosis in France: a bicenter study. Infect Dis Now 2024; 54:104866. [PMID: 38367772 DOI: 10.1016/j.idnow.2024.104866] [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] [Received: 08/16/2023] [Revised: 02/05/2024] [Accepted: 02/09/2024] [Indexed: 02/19/2024]
Abstract
INTRODUCTION Acute necrotizing pancreatitis (ANP) mortality increases when pancreatic necrosis is infected (IPN). Current treatment of IPN relies on prolonged antibiotic therapies associated with a step-up strategy of drainage. The objective of this study was to analyze IPN treatment outcomes in two referral centers in France. METHODS Data of consecutive patients with documented IPN hospitalized in two expert centers in France between 2014 and 2019 were retrospectively reviewed. The composite primary outcome was the proportion of unsuccessful management outcome, defined as new emergency drainage to treat sepsis with organ failure, an unplanned new antibiotic course, an unplanned prolongation of antibiotic course and/or death by septic shock, within three months following the diagnosis of ANP. RESULTS All in all, 187 patients (138 males; 74.0%), with documented IPN were included. The most frequently identified microorganism was Escherichia coli (26.2%). Ninety-eight patients (52.4%) were admitted to an intensive care unit or resuscitation ward within the first two days of ANP care. Overall, 126 patients (67.4%) endured an unsuccessful outcome: new emergency drainage to treat acute sepsis (62.0%), unplanned new antibiotic course (47.1%), unplanned prolongation of antibiotic course (44.9%) and/or death by septic shock complicating IPN (8.0%). CONCLUSION The unfavorable evolution in two thirds of patients shows that determination of optimal drainage timing and choice of antibiotic therapy remain major challenges in 2024.
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Affiliation(s)
- Yousra Kherabi
- Internal Medicine Department, AP-HP.Nord, Hôpital Beaujon, Université Paris Cité, Clichy, France.
| | - Claire Michoud
- Gastroenterology Department, Hospices Civils de Lyon, Hôpital Edouard Herriot, Université Claude Bernard Lyon 1, France
| | - Khanh Villageois-Tran
- Microbiology Department, AP-HP.Nord, Hôpital Beaujon, Université Paris Cité, Clichy, France
| | - Frédéric Bert
- Microbiology Department, AP-HP.Nord, Hôpital Beaujon, Université Paris Cité, Clichy, France
| | - Mathieu Pioche
- Gastroenterology Department, Hospices Civils de Lyon, Hôpital Edouard Herriot, Université Claude Bernard Lyon 1, France
| | - Agnès Lefort
- Internal Medicine Department, AP-HP.Nord, Hôpital Beaujon, Université Paris Cité, Clichy, France
| | - Philippe Lévy
- Pancreatology Department, AP-HP.Nord, Hôpital Beaujon, Université Paris Cité, Clichy, France
| | - Vinciane Rebours
- Pancreatology Department, AP-HP.Nord, Hôpital Beaujon, Université Paris Cité, Clichy, France
| | - Virginie Zarrouk
- Internal Medicine Department, AP-HP.Nord, Hôpital Beaujon, Université Paris Cité, Clichy, France
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Sivakumar SG, Sekaran M, Muthukrishnan S, Natesan AV, Nalankilli VP, Senthilnathan P, Palanivelu C. Laparoscopic necrosectomy for acute necrotising pancreatitis: Retrospective analysis of a decade-long experience from a tertiary centre. J Minim Access Surg 2024; 20:127-135. [PMID: 38557646 PMCID: PMC11095801 DOI: 10.4103/jmas.jmas_215_22] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/03/2022] [Revised: 12/01/2023] [Accepted: 12/02/2023] [Indexed: 04/04/2024] Open
Abstract
INTRODUCTION The objective of this study is to evaluate the role of minimally invasive surgery for the management of necrotising pancreatitis in acute settings and to propose tailor-made approaches to deal with various locations of pancreatic necrosis. PATIENTS AND METHODS Three hundred and thirteen patients underwent laparoscopic management of necrotising pancreatitis in this study period from January 2010 to June 2021, out of which 122 patients underwent minimally invasive necrosectomy for acute necrotising pancreatitis. The remaining 191 patients underwent laparoscopic internal drainage in the form of cystogastrostomy/cystojejunostomy for walled-off pancreatic necrosis. RESULTS Mean body mass index was 26.45 ± 3.78 kg/sqm. Mean operating time was 56.40 ± 20.48 min and mean blood loss was 120 ± 31.45 mL. Ten patients required reoperation (6 underwent open procedure and 4 underwent laparoscopic redo necrosectomy). Six patients died of multi-organ failure. The mean duration of return of bowel function was 5 ± 1.8 days. The mean length of hospital stay after surgery was 10.19 ± 7.09 days. There were no major wound-related complications. CONCLUSION A minimally invasive approach to pancreatic necrosectomy is safe and feasible with good outcomes in centres with advanced laparoscopic expertise. It requires not only careful case selection but also proper timing and the ideal route of access to achieve optimal outcomes.
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Affiliation(s)
| | - Monika Sekaran
- Department of HPB, Minimal Access Surgery and Liver Transplant, Gem Hospital, Chennai, Tamil Nadu, India
| | - Srinivasan Muthukrishnan
- Department of HPB, Minimal Access Surgery and Liver Transplant, Gem Hospital, Chennai, Tamil Nadu, India
| | - Anand Vijai Natesan
- Department of HPB, Minimal Access Surgery and Liver Transplant, Gem Hospital, Chennai, Tamil Nadu, India
| | - V. P. Nalankilli
- Department of HPB, Minimal Access Surgery and Liver Transplant, Gem Hospital, Chennai, Tamil Nadu, India
| | - Palanisamy Senthilnathan
- Department of HPB, Minimal Access Surgery and Liver Transplant, Gem Hospital, Chennai, Tamil Nadu, India
| | - Chinnusamy Palanivelu
- Department of HPB, Minimal Access Surgery and Liver Transplant, Gem Hospital, Chennai, Tamil Nadu, India
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Van Veldhuisen CL, Sissingh NJ, Boxhoorn L, van Dijk SM, van Grinsven J, Verdonk RC, Boermeester MA, Bouwense SA, Bruno MJ, Cappendijk VC, van Duijvendijk P, van Eijck CHJ, Fockens P, van Goor H, Hadithi M, Haveman JW, Jacobs MA, Jansen JM, Kop MP, Manusama ER, Mieog JSD, Molenaar IQ, Nieuwenhuijs VB, Poen AC, Poley JW, Quispel R, Römkens TE, Schwartz MP, Seerden TC, Dijkgraaf MG, Stommel MW, Straathof JWA, Venneman NG, Voermans RP, van Hooft JE, van Santvoort HC, Besselink MG. Long-Term Outcome of Immediate Versus Postponed Intervention in Patients With Infected Necrotizing Pancreatitis (POINTER): Multicenter Randomized Trial. Ann Surg 2024; 279:671-678. [PMID: 37450701 PMCID: PMC10922655 DOI: 10.1097/sla.0000000000006001] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 07/18/2023]
Abstract
OBJECTIVE To compare the long-term outcomes of immediate drainage versus the postponed-drainage approach in patients with infected necrotizing pancreatitis. BACKGROUND In the randomized POINTER trial, patients assigned to the postponed-drainage approach using antibiotic treatment required fewer interventions, as compared with immediate drainage, and over a third were treated without any intervention. METHODS Clinical data of those patients alive after the initial 6-month follow-up were re-evaluated. The primary outcome was a composite of death and major complications. RESULTS Out of 104 patients, 88 were re-evaluated with a median follow-up of 51 months. After the initial 6-month follow-up, the primary outcome occurred in 7 of 47 patients (15%) in the immediate-drainage group and 7 of 41 patients (17%) in the postponed-drainage group (RR 0.87, 95% CI 0.33-2.28; P =0.78). Additional drainage procedures were performed in 7 patients (15%) versus 3 patients (7%) (RR 2.03; 95% CI 0.56-7.37; P =0.34). The median number of additional interventions was 0 (IQR 0-0) in both groups ( P =0.028). In the total follow-up, the median number of interventions was higher in the immediate-drainage group than in the postponed-drainage group (4 vs. 1, P =0.001). Eventually, 14 of 15 patients (93%) in the postponed-drainage group who were successfully treated in the initial 6-month follow-up with antibiotics and without any intervention remained without intervention. At the end of follow-up, pancreatic function and quality of life were similar. CONCLUSIONS Also, during long-term follow-up, a postponed-drainage approach using antibiotics in patients with infected necrotizing pancreatitis results in fewer interventions as compared with immediate drainage and should therefore be the preferred approach. TRIAL REGISTRATION ISRCTN33682933.
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Affiliation(s)
- Charlotte L. Van Veldhuisen
- Department of Surgery, Amsterdam UMC, University of Amsterdam, Amsterdam, The Netherlands
- Amsterdam Gastroenterology Endocrinology Metabolism, The Netherlands
- Department of Research and Development, St. Antonius Hospital, Nieuwegein, The Netherlands
| | - Noor J. Sissingh
- Department of Research and Development, St. Antonius Hospital, Nieuwegein, The Netherlands
- Department of Gastroenterology and Hepatology, Leiden University Medical Centre, Leiden, The Netherlands
| | - Lotte Boxhoorn
- Amsterdam Gastroenterology Endocrinology Metabolism, The Netherlands
- Department of Gastroenterology and Hepatology, Amsterdam UMC, location University of Amsterdam, Amsterdam, The Netherlands
| | - Sven M. van Dijk
- Department of Surgery, Amsterdam UMC, University of Amsterdam, Amsterdam, The Netherlands
- Amsterdam Gastroenterology Endocrinology Metabolism, The Netherlands
| | - Janneke van Grinsven
- Department of Surgery, Amsterdam UMC, University of Amsterdam, Amsterdam, The Netherlands
- Amsterdam Gastroenterology Endocrinology Metabolism, The Netherlands
| | - Robert C. Verdonk
- Department of Gastroenterology and Hepatology, St. Antonius Hospital, Nieuwegein, The Netherlands
| | - Marja A. Boermeester
- Department of Surgery, Amsterdam UMC, University of Amsterdam, Amsterdam, The Netherlands
- Amsterdam Gastroenterology Endocrinology Metabolism, The Netherlands
| | - Stefan A.W. Bouwense
- Department of Surgery, Maastricht University Medical Centre+, Maastricht, The Netherlands
| | - Marco J. Bruno
- Department of Gastroenterology and Hepatology, Erasmus Medical Centre, Rotterdam, The Netherlands
| | | | | | | | - Paul Fockens
- Amsterdam Gastroenterology Endocrinology Metabolism, The Netherlands
- Department of Gastroenterology and Hepatology, Amsterdam UMC, location University of Amsterdam, Amsterdam, The Netherlands
| | - Harry van Goor
- Department of Surgery, Radboud University Medical Centre, Nijmegen, The Netherlands
| | - Muhammed Hadithi
- Department of Gastroenterology and Hepatology, Maasstad Hospital, Rotterdam, The Netherlands
| | - Jan Willem Haveman
- Department of Surgery, University Medical Centre Groningen, University of Groningen, Groningen, The Netherlands
| | - Maarten A.J.M. Jacobs
- Department of Gastroenterology and Hepatology, Amsterdam UMC, location Vrije Universiteit Amsterdam, Amsterdam, The Netherlands
| | - Jeroen M. Jansen
- Department of Gastroenterology and Hepatology, OLVG, Amsterdam, The Netherlands
| | - Marnix P.M. Kop
- Amsterdam Gastroenterology Endocrinology Metabolism, The Netherlands
- Department of Radiology, Amsterdam UMC, location University of Amsterdam, Amsterdam, The Netherlands
| | - Eric R. Manusama
- Department of Surgery, Medical Centre Leeuwarden, Leeuwarden, The Netherlands
| | - J. Sven D. Mieog
- Department of Surgery, Leiden University Medical Centre, Leiden, The Netherlands
| | - I. Quintus Molenaar
- Department of Surgery, University Medical Centre Utrecht, Utrecht, The Netherlands
| | | | - Alexander C. Poen
- Department of Gastroenterology and Hepatology, Isala Clinics, Zwolle, The Netherlands
| | - Jan-Werner Poley
- Department of Gastroenterology and Hepatology, Maastricht University Medical Centre+, Maastricht, The Netherlands
| | - Rutger Quispel
- Department of Gastroenterology and Hepatology, Reinier de Graaf Group, Delft, The Netherlands
| | - Tessa E.H. Römkens
- Department of Gastroenterology and Hepatology, Jeroen Bosch Hospital, Den Bosch, The Netherlands
| | - Matthijs P. Schwartz
- Department of Gastroenterology and Hepatology, Meander Medical Centre, Amersfoort, The Netherlands
| | - Tom C. Seerden
- Department of Gastroenterology and Hepatology, Amphia Hospital, Breda, The Netherlands
| | - Marcel G.W. Dijkgraaf
- Department of Epidemiology and Data Science, Amsterdam UMC, location University of Amsterdam, Amsterdam Public Health, Amsterdam, The Netherlands
| | - Martijn W.J. Stommel
- Department of Surgery, Radboud University Medical Centre, Nijmegen, The Netherlands
| | - Jan Willem A. Straathof
- Department of Gastroenterology and Hepatology, Máxima Medical Centre, Veldhoven, The Netherlands
| | - Niels G. Venneman
- Department of Gastroenterology and Hepatology, Medisch Spectrum Twente, Enschede, The Netherlands
| | - Rogier P. Voermans
- Amsterdam Gastroenterology Endocrinology Metabolism, The Netherlands
- Department of Gastroenterology and Hepatology, Amsterdam UMC, location University of Amsterdam, Amsterdam, The Netherlands
| | - Jeanin E. van Hooft
- Department of Gastroenterology and Hepatology, Leiden University Medical Centre, Leiden, The Netherlands
| | - Hjalmar C. van Santvoort
- Department of Surgery, St. Antonius Hospital, Nieuwegein, The Netherlands
- Department of Surgery, University Medical Center Utrecht, The Netherlands
| | - Marc G. Besselink
- Department of Surgery, Amsterdam UMC, University of Amsterdam, Amsterdam, The Netherlands
- Amsterdam Gastroenterology Endocrinology Metabolism, The Netherlands
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Sissingh NJ, Timmerhuis HC, Groen JV, de Jong MJP, Besselink MG, Boekestijn B, Bollen TL, Bonsing BA, Bouwense SAW, Hazen WL, Klok FA, van Santvoort HC, van Eijck CHJ, Verdonk RC, Mieog JSD, van Hooft JE. Splanchnic vein thrombosis in necrotizing pancreatitis: a post-hoc analysis of a nationwide prospective cohort. HPB (Oxford) 2024; 26:548-557. [PMID: 38336603 DOI: 10.1016/j.hpb.2024.01.011] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/23/2023] [Revised: 01/02/2024] [Accepted: 01/22/2024] [Indexed: 02/12/2024]
Abstract
BACKGROUND Treatment guidelines for splanchnic vein thrombosis in necrotizing pancreatitis are lacking due to insufficient data on the full clinical spectrum. METHODS We performed a post-hoc analysis of a nationwide prospective necrotizing pancreatitis cohort. Multivariable analyses were used to identify risk factors and compare the clinical course of patients with and without SVT. RESULTS SVT was detected in 97 of the 432 included patients (22%) (median onset: 4 days). Risk factors were left, central, or subtotal necrosis (OR 28.52; 95% CI 20.11-40.45), right or diffuse necrosis (OR 5.76; 95% CI 3.89-8.51), and younger age (OR 0.94; 95% CI 0.90-0.97). Patients with SVT had higher rates of bleeding (n = 10,11%) and bowel ischemia (n = 4,4%) compared to patients without SVT (n = 14,4% and n = 2,0.6%; OR 3.24; 95% CI 1.27-8.23 and OR 7.29; 95% CI 1.31-40.4, respectively), and were independently associated with ICU admission (adjusted OR 2.53; 95% CI 1.37-4.68). Spontaneous recanalization occurred in 62% of patients (n = 40/71). Radiological and clinical outcomes did not differ between patients treated with and without anticoagulants. DISCUSSION SVT is a common and early complication of necrotizing pancreatitis, associated with parenchymal necrosis and younger age. SVT is associated with increased complications and a worse clinical course, whereas anticoagulant use does not appear to affect outcomes.
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Affiliation(s)
- Noor J Sissingh
- Department of Gastroenterology and Hepatology, Leiden University Medical Center, Leiden, the Netherlands; Department of Research and Development, St Antonius Hospital, Nieuwegein, the Netherlands.
| | - Hester C Timmerhuis
- Department of Research and Development, St Antonius Hospital, Nieuwegein, the Netherlands; Department of Surgery, St. Antonius Hospital, Nieuwegein, the Netherlands
| | - Jesse V Groen
- Department of Surgery, Leiden University Medical Center, Leiden, the Netherlands
| | - Mike J P de Jong
- Department of Research and Development, St Antonius Hospital, Nieuwegein, the Netherlands; Department of Gastroenterology and Hepatology, Radboud University Medical Center, Nijmegen, the Netherlands
| | - Marc G Besselink
- Amsterdam UMC, Location University of Amsterdam, Department of Surgery, Amsterdam, the Netherlands; Amsterdam Gastroenterology Endocrinology Metabolism, the Netherlands
| | - Bas Boekestijn
- Department of Radiology, Leiden University Medical Center, Leiden, the Netherlands
| | - Thomas L Bollen
- Department of Radiology, St. Antonius Hospital, Nieuwegein, the Netherlands
| | - Bert A Bonsing
- Department of Surgery, Leiden University Medical Center, Leiden, the Netherlands
| | - Stefan A W Bouwense
- Department of Surgery, Maastricht University Medical Center, Maastricht, the Netherlands; NUTRIM, School of Nutrition and Translational Research in Metabolism, Maastricht University, Maastricht, the Netherlands
| | - Wouter L Hazen
- Department of Gastroenterology and Hepatology, Elisabeth TweeSteden Hospital, Tilburg, the Netherlands
| | - Frederikus A Klok
- Department of Medicine - Thrombosis and Hemostasis, Leiden University Medical Center, Leiden, the Netherlands
| | - Hjalmar C van Santvoort
- Department of Surgery, St. Antonius Hospital, Nieuwegein, the Netherlands; Department of Surgery, University Medical Center Utrecht, Utrecht, the Netherlands
| | | | - Robert C Verdonk
- Department of Gastroenterology and Hepatology, St. Antonius Hospital, Nieuwegein, the Netherlands
| | - J Sven D Mieog
- Department of Surgery, Leiden University Medical Center, Leiden, the Netherlands
| | - Jeanin E van Hooft
- Department of Gastroenterology and Hepatology, Leiden University Medical Center, Leiden, the Netherlands.
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Earjala JK, Muthukumarasamy T, Govindaraj Raman SK, V C K, Micheal M, Nath VG, A AR, Aravindan U. Step-Up Management in Acute Pancreatitis: A Tertiary Care Center's Experience From Southern India. Cureus 2024; 16:e58971. [PMID: 38800167 PMCID: PMC11128138 DOI: 10.7759/cureus.58971] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 04/25/2024] [Indexed: 05/29/2024] Open
Abstract
Background The clinical spectrum of acute pancreatitis (AP) ranges from mild disease to severe form associated with multiorgan failure, prolonged hospital stay, high morbidity, and mortality. Acute necrotizing pancreatitis (ANP) is a severe form of AP. This study evaluates AP's outcomes after applying principles of the step-up approach in a tertiary healthcare center in south India. Methodology This prospective observational study was carried out from January 2021 to December 2022. The study population includes patients admitted to our department with AP. Results Ninety patients were included in the study, most of them were middle-aged males with ethanol ingestion as the common etiology. Thirty-seven (41.1%) patients had mild AP, 25 (27.7%) had moderately severe AP, and 28 (31.1%) had severe AP. Organ failure at admission was noted in 36 (40%) patients. Twenty-three (25.5%) patients developed ANP. Infected necrosis was noted in 3 (3.33%) patients. Eighteen (20%) patients needed image-guided percutaneous drainage. Seven (38.8%) needed necrosectomy following percutaneous drainage. Mortality was observed in 8 (8.8%) patients. Specifically, mortality was noted in 6 (6.6%) patients who presented later in their disease course. Conclusions Percutaneous catheter drainage is a safe and effective therapy to tide over the initial phase of AP. It also serves as a bridging therapy till the patient is clinically fit for a necrosectomy. Severe AP cases presenting late in their course are associated with significant mortality even after step-up management. Standardized protocols for referral and management are essential to obtain a good clinical outcome.
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Affiliation(s)
- Joel Kumar Earjala
- Surgical Gastroenterology and GI Oncology, Thanjavur Medical College, Thanjavur, IND
| | | | | | | | - Mathews Micheal
- Surgical Gastroenterology and GI Oncology, Thanjavur Medical College, Thanjavur, IND
| | - Vivek G Nath
- Surgical Gastroenterology, All India Institute of Medical Sciences, Bhubaneswar, IND
- Surgical Gastroenterology and GI Oncology, Thanjavur Medical College, Thanjavur, IND
| | - Arun Raja A
- Surgical Gastroenterology and GI Oncology, Thanjavur Medical College, Thanjavur, IND
| | - U Aravindan
- Surgical Gastroenterology and GI Oncology, Thanjavur Medical College, Thanjavur, IND
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Stefanovic S, Adler DG, Arlt A, Baron TH, Binmoeller KF, Bronswijk M, Bruno MJ, Chevaux JB, Crinò SF, Degroote H, Deprez PH, Draganov PV, Eisendrath P, Giovannini M, Perez-Miranda M, Siddiqui AA, Voermans RP, Yang D, Hindryckx P. International Consensus Recommendations for Safe Use of LAMS for On- and Off-Label Indications Using a Modified Delphi Process. Am J Gastroenterol 2024; 119:671-681. [PMID: 37934190 DOI: 10.14309/ajg.0000000000002571] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/30/2023] [Accepted: 10/02/2023] [Indexed: 11/08/2023]
Abstract
INTRODUCTION The study aimed to develop international consensus recommendations on the safe use of lumen-apposing metal stents (LAMSs) for on- and off-label indications. METHODS Based on the available literature, statements were formulated and grouped into the following categories: general safety measures, peripancreatic fluid collections, endoscopic ultrasound (EUS)-biliary drainage, EUS-gallbladder drainage, EUS-gastroenterostomy, and gastric access temporary for endoscopy. The evidence level of each statement was determined using the Grading of Recommendations Assessment, Development, and Evaluation methodology.International LAMS experts were invited to participate in a modified Delphi process. When no 80% consensus was reached, the statement was modified based on expert feedback. Statements were rejected if no consensus was reached after the third Delphi round. RESULTS Fifty-six (93.3%) of 60 formulated statements were accepted, of which 35 (58.3%) in the first round. Consensus was reached on the optimal learning path, preprocedural imaging, the need for airway protection and essential safety measures during the procedure, such as the use of Doppler, and measurement of the distance between the gastrointestinal lumen and the target structure. Specific consensus recommendations were generated for the different LAMS indications, covering, among others, careful patient selection, the preferred size of the LAMS, the need for antibiotics, the preferred anatomic location of the LAMS, the need for coaxial pigtail placement, and the appropriate management of LAMS-related adverse events. DISCUSSION Through a modified international Delphi process, we developed general and indication-specific experience- and evidence-based recommendations on the safe use of LAMS.
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Affiliation(s)
- Sebastian Stefanovic
- Department of Gastroenterology, Ghent University Hospital, Ghent, Belgium
- Diagnostic Center Bled Group, Bled, Slovenia
| | - Douglas G Adler
- Centura Health, Center for Advanced Therapeutic Endoscopy, Colorado, Englewood, USA
| | - Alexander Arlt
- Department of Internal Medicine and Gastroenterology, Carl von Ossietzky University Oldenburg, Oldenburg, Germany
| | - Todd H Baron
- Division of Gastroenterology and Hepatology, University of North Carolina, Chapel Hill, North Carolina, USA
| | - Kenneth F Binmoeller
- Interventional Endoscopy Services, California Pacific Medical Center, San Francisco, California, USA
| | - Michiel Bronswijk
- Gastroenterology and Hepatology, Imelda Hospital Bonheiden and University Hospitals Leuven, Belgium
| | - Marco J Bruno
- Department of Gastroenterology and Hepatology, Erasmus MC University Medical Center, Rotterdam, Netherlands
| | | | - Stefano Francesco Crinò
- Department of Medicine, Gastroenterology and Digestive Endoscopy Unit, The Pancreas Institute, University Hospital of Verona, Verona, Italy
| | - Helena Degroote
- Department of Gastroenterology, Ghent University Hospital, Ghent, Belgium
| | - Pierre H Deprez
- Cliniques Universitaires Saint-Luc, Université Catholique de Louvain, Department of Hepatogastroenterology, Brussels, Belgium
| | | | - Pierre Eisendrath
- Department of Gastroenterology, Hepatopancreatology and Digestive Oncology, Saint-Pierre University Hospital, Université Libre de Bruxelles, Brussels, Belgium
| | - Marc Giovannini
- Digestive Endoscopy Unit, Paoli Calmettes Institute, Marseille Cedex 9, France
| | - Manuel Perez-Miranda
- Gastroenterology Department, Hospital Universitario Río Hortega, Valladolid, Spain
| | - Ali A Siddiqui
- Department of Gastroenterology and Hepatology, Inova Fairfax Hospital, Falls Church, Virginia, USA
| | - Rogier P Voermans
- Amsterdam University Medical Center, Department of Gastroenterology and Hepatology, University of Amsterdam, Amsterdam, Netherlands
| | - Dennis Yang
- Center for Interventional Endoscopy, AdventHealth, Orlando, Florida, USA
| | - Pieter Hindryckx
- Department of Gastroenterology, Ghent University Hospital, Ghent, Belgium
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Yang Y, Liu Y, Liu Z, Peng T, Wang C, Wu H, Gou S. Laparoscopic necrosectomy for acute necrotizing pancreatitis: mesocolon-preserving approach and outcomes. Updates Surg 2024; 76:487-493. [PMID: 38429596 DOI: 10.1007/s13304-024-01773-y] [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] [Received: 10/27/2023] [Accepted: 01/29/2024] [Indexed: 03/03/2024]
Abstract
The surgical treatment of acute necrotizing pancreatitis has significantly evolved in recent years with the advent of enhanced imaging techniques and minimally invasive surgery. Various minimally invasive techniques, such as video-assisted retroperitoneal debridement (VARD) and endoscopic transmural necrosectomy (ETN), have been employed in the management of acute necrotizing pancreatitis and are often part of step-up approaches. However, almost all reported step-up approaches only employ a fixed minimally invasive technique prior to open surgery. In contrast, we implemented different minimally invasive techniques during the treatment of acute pancreatitis based on the extent of pancreatic necrosis. For acute necrotizing pancreatitis of the pancreatic bed with or without extension into the left retroperitoneum, we performed mesocolon-preserving laparoscopic necrosectomy for debridment. The quantitative indication for pancreatic debridment in our institute has been described previously. For acute necrotizing pancreatitis of the pancreatic bed with or without extension into the left retroperitoneum, mesocolon-preserving laparoscopic necrosectomy was performed for debridment. To safeguard the mesocolon, the pancreatic bed was entered via the gastrocolic ligament, and the left retroperitoneum was accessed via the lateral peritoneal attachments of the descending colon. Of the 77 patients requiring pancreatic debridment, 41 patients were deemed suitable for mesocolon-preserving laparoscopic necrosectomy by multiple disciplinary team and informed consent was acquired. Of these 41 patients, 27 underwent percutaneous drainage, 10 underwent transluminal drainage, and 2 underwent transluminal necrosectomy prior to laparoscopic necrosectomy. Two patients (4.88%) died of sepsis, three patients (7.32%) required further laparotomic necrosectomy, and five patients (12.20%) required additional percutaneous drainage for residual infection. Three patients (7.32%) experienced duodenal fistula, all of which were cured through non-surgical treatments. Nineteen patients (46.34%) developed pancreatic fistula that persisted for over 3 weeks, with 17 being successfully treated non-surgically. The remaining two patients had pancreatic fistulas that lasted over 3 months; an internal drainage procedure has been planned for them. No patient developed colonic fistula. Mesocolon-preserving laparoscopic necrosectomy proved to be safe and effective in selected patients. It can serve as a supplementary procedure for step-up approaches or as an alternative to other debridment procedures such as VARD, ETN, and laparotomic necrosectomy.
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Affiliation(s)
- Yuxin Yang
- Department of Pancreatic Surgery, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, 1277 Jifang Avenue, Wuhan, 430022, China
- Sino-German Laboratory of Personalized Medicine for Pancreatic Cancer, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Yang Liu
- Sino-German Laboratory of Personalized Medicine for Pancreatic Cancer, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
- Department of Gastrointestinal Surgery, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Zhiqiang Liu
- Department of Pancreatic Surgery, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, 1277 Jifang Avenue, Wuhan, 430022, China
- Sino-German Laboratory of Personalized Medicine for Pancreatic Cancer, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Tao Peng
- Department of Pancreatic Surgery, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, 1277 Jifang Avenue, Wuhan, 430022, China
- Sino-German Laboratory of Personalized Medicine for Pancreatic Cancer, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Chunyou Wang
- Department of Pancreatic Surgery, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, 1277 Jifang Avenue, Wuhan, 430022, China
- Sino-German Laboratory of Personalized Medicine for Pancreatic Cancer, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Heshui Wu
- Department of Pancreatic Surgery, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, 1277 Jifang Avenue, Wuhan, 430022, China
- Sino-German Laboratory of Personalized Medicine for Pancreatic Cancer, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Shanmiao Gou
- Department of Pancreatic Surgery, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, 1277 Jifang Avenue, Wuhan, 430022, China.
- Sino-German Laboratory of Personalized Medicine for Pancreatic Cancer, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China.
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50
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Singla V, Gupta PK, Singh P, Bopanna S, Shawl MR, Soni H, Goel A, Madan K, Garg P, Bhargava R. Novel treatment with double scope technique for disconnected pancreatic duct syndrome with external pancreatic fistula. Endosc Int Open 2024; 12:E593-E597. [PMID: 38654964 PMCID: PMC11039061 DOI: 10.1055/a-2290-0768] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/16/2024] [Accepted: 03/12/2024] [Indexed: 04/26/2024] Open
Abstract
Background and study aims External pancreatic fistula in association with disconnected pancreatic duct syndrome is a common sequelae of the percutaneous step-up approach for infected pancreatic necrosis and is associated with significant morbidity. The present study aimed to report the initial outcome of a novel technique of two-scope guided tractogastrostomy for management of this condition. Patients and methods The present study was a retrospective analysis of data from patients with external pancreatic fistula and disconnected pancreatic duct syndrome, who underwent two-scope-guided tractogastrostomy. All the patients had a 24F or larger drain placed in the left retroperitoneum. Transgastric echo endoscopy and sinus tract endoscopy were performed simultaneously to place a stent between the gastric lumen and the sinus tract. Technical success was defined as placement of the stent between the tract and the stomach. Clinical success was defined as successful removal of the percutaneous drain without the occurrence of pancreatic fluid collection, ascites, external fistula, or another intervention 12 weeks after the procedure. Results Three patients underwent two scope-guided tractogastrostomy. Technical and clinical success were achieved in all the patients. No procedure-related side effects or recurrence occurred in any of the patients. Conclusions Two-scope-guided tractogastrostomy for treatment of external pancreatic fistula due to disconnected pancreatic duct syndrome is a feasible technique and can be further evaluated.
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Affiliation(s)
- Vikas Singla
- Institute of Liver and Gastrointestinal Sciences, Max Super Speciality Hospital Saket, New Delhi, India
| | - Pankaj Kumar Gupta
- Gastroeneterology, Max Super Speciality Hospital Saket, New Delhi, India
| | - Pankaj Singh
- Institute of Liver and Gastrointestinal Sciences, Max Super Speciality Hospital Saket, New Delhi, India
| | - Sawan Bopanna
- Institute of Liver and Gastrointestinal Sciences, Max Super Speciality Hospital Saket, New Delhi, India
| | - Muzaffer Rashid Shawl
- Institute of Liver and Gastrointestinal Sciences, Max Super Speciality Hospital Saket, New Delhi, India
| | - Harish Soni
- Institute of Liver and Gastrointestinal Sciences, Max Super Speciality Hospital Saket, New Delhi, India
| | - Akash Goel
- Institute of Liver and Gastrointestinal Sciences, Max Super Speciality Hospital Saket, New Delhi, India
| | - Kaushal Madan
- Institute of Liver and Gastrointestinal Sciences, Max Super Speciality Hospital Saket, New Delhi, India
| | - Pallavi Garg
- Institute of Liver and Gastrointestinal Sciences, Max Super Speciality Hospital Saket, New Delhi, India
| | - Richa Bhargava
- Institute of Liver and Gastrointestinal Sciences, Max Super Speciality Hospital Saket, New Delhi, India
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