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Mehta MS. Acute pancreatitis in children: risk factors, management, and outcomes. Curr Opin Pediatr 2023; 35:590-595. [PMID: 37594373 DOI: 10.1097/mop.0000000000001285] [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: 08/19/2023]
Abstract
PURPOSE OF REVIEW Pediatric acute pancreatitis is an infrequent but potentially serious condition in children. Most have mild cases with spontaneous resolution, but up to one-third of patients can have moderate or severe disease or progress to recurrent or chronic pancreatitis. RECENT FINDINGS Significant advances have been made in the field of pediatric pancreatology with a recognition that pediatric acute pancreatitis can vary significantly from adult disease with different risk factors and outcomes. There is better understanding of appropriate management for pediatric pancreatitis as well as growing literature in complications of pancreatitis. SUMMARY The most common risk factors for pediatric acute pancreatitis include biliary disease, drug/toxin and idiopathic. Management involves adequate fluid resuscitation, early enteral nutrition and appropriate pain control. Systemic and local complications, including SIRS, necrosis and fluid collections, can occur in up to one-third of patients and care is largely supportive with a careful step-up approach to fluid collections and necrosis.
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Affiliation(s)
- Megha S Mehta
- Division of Pediatric Gastroenterology, UT Southwestern Medical Center, Dallas, Texas, USA
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2
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Li G, Li S, Cao L, Mao W, Zhou J, Ye B, Zhang J, Ding L, Zhu Y, Ke L, Liu Y, Tong Z, Li W. Nomogram development and validation for predicting minimally invasive step-up approach failure in infected necrotizing pancreatitis patients: a retrospective cohort study. Int J Surg 2023; 109:1677-1687. [PMID: 37144670 PMCID: PMC10389492 DOI: 10.1097/js9.0000000000000415] [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: 05/06/2023]
Abstract
BACKGROUND Previous studies have shown that minimally invasive treatment for infected necrotizing pancreatitis (INP) may be safer and more effective than open necrosectomy (ON), but ON is still irreplaceable in a portion of INP patients. Furthermore, there is a lack of tools to identify INP patients at risk of minimally invasive step-up approach failure (eventually received ON or died), which may enable appropriate treatment for them. Our study aims to identify risk factors that can predict minimally invasive step-up approach failure in INP patients and to develop a nomogram for early prediction. METHODS Multivariate logistic regression was performed to evaluate the association between minimally invasive step-up approach failure and factors regarding demographics, disease severity, laboratory index, and the location of extrapancreatic necrotic collections. A novel nomogram was developed, and its performance was validated both internally and externally by its discrimination, calibration, and clinical usefulness. RESULTS There were 267, 89, and 107 patients in the training, internal, and external validation cohorts, respectively. Multivariate logistic regression demonstrated that the computed tomography severity index (CTSI) greater than 8 points, Acute Physiology and Chronic Health Evaluation II (APACHE II) score of 16 points or more, early spontaneous bleeding, fungi infection, granulocyte and platelet decrease within 30 days of acute pancreatitis onset, and extrapancreatic necrosis collection located in small bowel mesentery were independent risk factors for minimally invasive step-up approach failure. The area under the curve and coefficient of determination ( R2 ) of the nomogram constructed from the above factors were 0.920 and 0.644, respectively. The Hosmer-Lemeshow test showed that the model had good fitness ( P =0.206). In addition, the nomogram performed well in both the internal and external validation cohorts. CONCLUSIONS The nomogram had a good performance in predicting minimally invasive step-up approach failure, which may help clinicians distinguish INP patients at risk of minimally invasive step-up approach failure early.
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Affiliation(s)
- Gang Li
- Department of Critical Care Medicine, Center of Severe Acute Pancreatitis (CSAP), Jinling Hospital, Medical School of Nanjing University
- Department of Critical Care Medicine, Center of Severe Acute Pancreatitis (CSAP), Jinling Hospital, Medical School of Nanjing Medical University
| | - Shuai Li
- Department of Critical Care Medicine, Center of Severe Acute Pancreatitis (CSAP), Jinling Hospital, Medical School of Nanjing University
| | - Longxiang Cao
- Department of Critical Care Medicine, Center of Severe Acute Pancreatitis (CSAP), Jinling Hospital, Medical School of Nanjing University
| | - Wenjian Mao
- Department of Critical Care Medicine, Center of Severe Acute Pancreatitis (CSAP), Jinling Hospital, Medical School of Nanjing University
- Department of Critical Care Medicine, Center of Severe Acute Pancreatitis (CSAP), Jinling Hospital, Medical School of Nanjing Medical University
| | - Jing Zhou
- Department of Critical Care Medicine, Center of Severe Acute Pancreatitis (CSAP), Jinling Hospital, Medical School of Nanjing University
- Department of Critical Care Medicine, Center of Severe Acute Pancreatitis (CSAP), Jinling Hospital, Medical School of Nanjing Medical University
| | - Bo Ye
- Department of Critical Care Medicine, Center of Severe Acute Pancreatitis (CSAP), Jinling Hospital, Medical School of Nanjing University
- Department of Critical Care Medicine, Center of Severe Acute Pancreatitis (CSAP), Jinling Hospital, Medical School of Nanjing Medical University
| | - Jingzhu Zhang
- Department of Critical Care Medicine, Center of Severe Acute Pancreatitis (CSAP), Jinling Hospital, Medical School of Nanjing University
- Department of Critical Care Medicine, Center of Severe Acute Pancreatitis (CSAP), Jinling Hospital, Medical School of Nanjing Medical University
| | - Ling Ding
- Department of Medical Statistics, Jinling Hospital, Medical School of Nanjing University
| | - Yin Zhu
- Department of Medical Statistics, Jinling Hospital, Medical School of Nanjing University
| | - Lu Ke
- Department of Critical Care Medicine, Center of Severe Acute Pancreatitis (CSAP), Jinling Hospital, Medical School of Nanjing University
- Department of Critical Care Medicine, Center of Severe Acute Pancreatitis (CSAP), Jinling Hospital, Medical School of Nanjing Medical University
- National Institute of Healthcare Data Science, Nanjing University, Nanjing, Jiangsu
| | - Yuxiu Liu
- Department of Critical Care Medicine, Center of Severe Acute Pancreatitis (CSAP), Jinling Hospital, Medical School of Nanjing University
- Department of Critical Care Medicine, Center of Severe Acute Pancreatitis (CSAP), Jinling Hospital, Medical School of Nanjing Medical University
- Department of Gastroenterology, Digestive Disease Hospital, The First Affiliated Hospital of Nanchang University, Nanchang, Jiangxi, People’s Republic of China
| | - Zhihui Tong
- Department of Critical Care Medicine, Center of Severe Acute Pancreatitis (CSAP), Jinling Hospital, Medical School of Nanjing University
- Department of Critical Care Medicine, Center of Severe Acute Pancreatitis (CSAP), Jinling Hospital, Medical School of Nanjing Medical University
| | - Weiqin Li
- Department of Critical Care Medicine, Center of Severe Acute Pancreatitis (CSAP), Jinling Hospital, Medical School of Nanjing University
- Department of Critical Care Medicine, Center of Severe Acute Pancreatitis (CSAP), Jinling Hospital, Medical School of Nanjing Medical University
- National Institute of Healthcare Data Science, Nanjing University, Nanjing, Jiangsu
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Purschke B, Bolm L, Meyer MN, Sato H. Interventional strategies in infected necrotizing pancreatitis: Indications, timing, and outcomes. World J Gastroenterol 2022; 28:3383-3397. [PMID: 36158258 PMCID: PMC9346450 DOI: 10.3748/wjg.v28.i27.3383] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/20/2022] [Revised: 03/07/2022] [Accepted: 06/16/2022] [Indexed: 02/06/2023] Open
Abstract
Acute pancreatitis (AP) is one of the most common gastrointestinal diseases and remains a life-threatening condition. Although AP resolves to restitutio ad integrum in approximately 80% of patients, it can progress to necrotizing pancreatitis (NP). NP is associated with superinfection in a third of patients, leading to an increase in mortality rate of up to 40%. Accurate and early diagnosis of NP and associated complications, as well as state-of-the-art therapy are essential to improve patient prognoses. The emerging role of endoscopy and recent trials on multidisciplinary management of NP established the “step-up approach”. This approach starts with endoscopic interventions and can be escalated to other interventional and ultimately surgical procedures if required. Studies showed that this approach decreases the incidence of new multiple-organ failure as well as the risk of interventional complications. However, the optimal interventional sequence and timing of interventional procedures remain controversial. This review aims to summarize the indications, timing, and treatment outcomes for infected NP and to provide guidance on multidisciplinary decision-making.
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Affiliation(s)
- Birte Purschke
- Department of Gastrointestinal Surgery, Massachusetts General Hospital, Boston, MA 02114, United States
| | - Louisa Bolm
- Department of Gastrointestinal Surgery, Massachusetts General Hospital, Boston, MA 02114, United States
| | - Max Nikolaus Meyer
- Department of Radiation Oncology, Massachusetts General Hospital, Boston, MA 02114, United States
| | - Hiroki Sato
- Department of Medicine, Asahikawa Medical University, Asahikawa 0788510, Hokkaido, Japan
- Department of Gastroenterology, Asahikawa Kosei Hospital, Asahikawa 0788211, Hokkaido, Japan
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4
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Samanta J, Dhar J, Muktesh G, Gupta P, Kumar-M P, Das A, Agarwala R, Bellam BL, Chauhan R, Kumar KH, Yadav TD, Gupta V, Sinha SK, Kochhar R, Facciorusso A. Endoscopic drainage versus percutaneous drainage for the management of infected walled-off necrosis: a comparative analysis. Expert Rev Gastroenterol Hepatol 2022; 16:297-305. [PMID: 35227141 DOI: 10.1080/17474124.2022.2047649] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
BACKGROUND Comparative data on percutaneous catheter drainage (PCD) vs EUS-guided drainage (EUS-D) for management of symptomatic walled-off-necrosis (WON), specially infected WON with/without organ failure(OF) is limited. METHODS Patients with symptomatic WON were divided into two groups of PCD and EUS-D, depending on the modality of drainage. Resolution of OF, adverse events, and other outcome measures were recorded. The two modalities were compared among infected WON sub-cohort and also degree of solid component (SC). RESULTS 218 patients (175 males; 80.3%) were included who underwent either PCD (n = 102) or EUS-D (n = 116). Clinical success was significantly higher in the EUS-D group (92.1% vs 64.6%; p < 0.0001) and even for infected WON (n = 128) (p = 0.004), with higher (p = 0.007) and faster (p < 0.0001) OF resolution. Other outcome measures including mortality were significantly higher in the PCD group. Among subgroups, PCD with >40% SC had the worst clinical success/OF resolution rates, while EUS-D with <40% SC had the best outcomes. CONCLUSION EUS-D should be preferred over PCD in the management of WON, infected or otherwise, for higher clinical success, and higher/faster resolution of OF. PCD should be avoided in WON with>40% SC.
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Affiliation(s)
- Jayanta Samanta
- Department of Gastroenterology, Post Graduate Institute of Medical Education and Research, Chandigarh, India
| | - Jahnvi Dhar
- Department of Gastroenterology, Post Graduate Institute of Medical Education and Research, Chandigarh, India
| | - Gaurav Muktesh
- Department of Gastroenterology, Post Graduate Institute of Medical Education and Research, Chandigarh, India
| | - Pankaj Gupta
- Department of Gastroenterology, Post Graduate Institute of Medical Education and Research, Chandigarh, India
| | - Praveen Kumar-M
- Department of Pharmacology, Post Graduate Institute of Medical Education and Research, Chandigarh, India
| | - Aritra Das
- Expert epidemiologist, CARE India Solutions, New Delhi, India
| | - Roshan Agarwala
- Department of Gastroenterology, Post Graduate Institute of Medical Education and Research, Chandigarh, India
| | - Balaji L Bellam
- Department of Gastroenterology, Post Graduate Institute of Medical Education and Research, Chandigarh, India
| | - Rajeev Chauhan
- Department of Anaesthesiology, Post Graduate Institute of Medical Education and Research, Chandigarh, India
| | - K Hemanth Kumar
- Department of Surgery, Post Graduate Institute of Medical Education and Research, Chandigarh, India
| | - Thakur Deen Yadav
- Department of Surgery, Post Graduate Institute of Medical Education and Research, Chandigarh, India
| | - Vikas Gupta
- Department of Surgery, Post Graduate Institute of Medical Education and Research, Chandigarh, India
| | - Saroj K Sinha
- Department of Gastroenterology, Post Graduate Institute of Medical Education and Research, Chandigarh, India
| | - Rakesh Kochhar
- Department of Gastroenterology, Post Graduate Institute of Medical Education and Research, Chandigarh, India
| | - Antonio Facciorusso
- Department of Medical and Surgical Sciences, Gastroenterology Unit, University of Foggia, Foggia, Italy
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5
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Cohen RZ, Freeman AJ. Pancreatitis in Children. Pediatr Clin North Am 2021; 68:1273-1291. [PMID: 34736589 DOI: 10.1016/j.pcl.2021.07.012] [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] [Indexed: 11/24/2022]
Abstract
Pediatric pancreatitis describes a spectrum covering acute pancreatitis, acute recurrent pancreatitis, and chronic pancreatitis, each with varying clinical manifestations and risk factors requiring a tailored diagnostic approach. We emphasize management strategies based on age, risk factors, recurrence, and complications. A discussion of the role of therapeutic endoscopy is reviewed and highlights the growing role of endoscopic ultrasound and endoscopic retrograde cholangiopancreatography in children with pancreatitis. Particular diagnostic challenges in autoimmune pancreatitis are reviewed with an emphasis on differentiating this entity from alternate pancreaticobiliary pathologies. Finally, we explore a multidisciplinary approach to acute recurrent and chronic pancreatitis.
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Affiliation(s)
- Reuven Zev Cohen
- Division of Pediatric Gastroenterology, Hepatology, and Nutrition, Emory University School of Medicine, Children's Healthcare of Atlanta, 1400 Tullie Road Northeast, Atlanta, GA 30329, USA.
| | - A Jay Freeman
- Division of Pediatric Gastroenterology, Hepatology, and Nutrition, Emory University School of Medicine, Children's Healthcare of Atlanta, 1400 Tullie Road Northeast, Atlanta, GA 30329, USA
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6
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Zhang H, Wen XD, Ma X, Zhu YQ, Jiang ZW, Huang SQ, Wang T, Liu WH. Triple guidance of choledochoscopy, ultrasonography, and computed tomography facilitates percutaneous catheter drainage of infected walled-off necrosis. Insights Imaging 2021; 12:137. [PMID: 34580791 PMCID: PMC8476709 DOI: 10.1186/s13244-021-01087-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/24/2021] [Accepted: 08/12/2021] [Indexed: 11/12/2022] Open
Abstract
Objectives Percutaneous catheter drainage (PCD) is usually performed to treat acute pancreatitis complicated by infected walled-off necrosis (WON). Insufficient drainage of infected WON may lead to a prolonged recovery process. Here, we introduce a modified PCD strategy that uses the triple guidance of choledochoscopy, ultrasonography, and computed tomography (CUC-PCD) to improve the therapeutic efficiency. Methods This study retrospectively analysed 73 patients with acute pancreatitis-related WON from January 2015 to January 2021. The first 38 patients were treated by ultrasonography/computed tomography-guided PCD (UC-PCD), and the next consecutive 35 patients by CUC-PCD. Perioperative data, procedural technical information, treatment outcomes, and follow-up data were collected. Results Demographic characteristics were statistically comparable between the two treatment groups (p > 0.05). After 48 h of PCD treatment, the CUC-PCD group achieved a significantly smaller size of the infected WON (p = 0.023), lower inflammatory response indexes (p = 0.020 for white blood cells, and p = 0.031 for C-reactive protein), and severity scores than the UC-PCD group (p < 0.05). Less catheter duration (p = 0.001), hospitalisation duration (p = 0.000), and global costs (p = 0.000) were observed in the CUC-PCD group compared to the UC-PCD group. There were no differences between the two groups regarding the rate of complications. Conclusions CUC-PCD is a safe and efficient approach with potential clinical applicability for treating infected WON owing to its feasibility in placing the drainage catheter at the optimal location in real time and performing primary necrosectomy without sinus tract formation and enlargement.
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Affiliation(s)
- Hui Zhang
- General Surgery Center, The General Hospital of Western Theater Command (Chengdu Military General Hospital), Chengdu, 610083, Sichuan Province, China
| | - Xu-Dong Wen
- Department of Gastroenterology and Hepatology, Chengdu First People's Hospital, Chengdu, 610016, Sichuan Province, China
| | - Xiao Ma
- General Surgery Center, The General Hospital of Western Theater Command (Chengdu Military General Hospital), Chengdu, 610083, Sichuan Province, China
| | - Yong-Qiang Zhu
- General Surgery Center, The General Hospital of Western Theater Command (Chengdu Military General Hospital), Chengdu, 610083, Sichuan Province, China
| | - Zhi-Wei Jiang
- General Surgery Center, The General Hospital of Western Theater Command (Chengdu Military General Hospital), Chengdu, 610083, Sichuan Province, China
| | - Shang-Qing Huang
- General Surgery Center, The General Hospital of Western Theater Command (Chengdu Military General Hospital), Chengdu, 610083, Sichuan Province, China
| | - Tao Wang
- General Surgery Center, The General Hospital of Western Theater Command (Chengdu Military General Hospital), Chengdu, 610083, Sichuan Province, China.
| | - Wei-Hui Liu
- Department of Gastroenterology and Hepatology, Sichuan Provincial People's Hospital, University of Electronic Science and Technology of China, Chengdu, 610072, Sichuan Province, China.
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7
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Sánchez Aldehuelo R, Albillos A, Vazquez-Sequeiros E. A novel EUS-guided rescue therapy for non-drainable walled-off pancreatic necrosis. GASTROENTEROLOGIA Y HEPATOLOGIA 2021; 45 Suppl 1:83-84. [PMID: 33746029 DOI: 10.1016/j.gastrohep.2021.01.015] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/26/2020] [Revised: 12/13/2020] [Accepted: 01/24/2021] [Indexed: 11/16/2022]
Affiliation(s)
- Rubén Sánchez Aldehuelo
- Endoscopy Unit. Gastroenterology and Hepatology Service. IRYCIS. University Hospital Ramón y Cajal, Madrid, Spain
| | - Agustin Albillos
- Endoscopy Unit. Gastroenterology and Hepatology Service. IRYCIS. University Hospital Ramón y Cajal, Madrid, Spain
| | - Enrique Vazquez-Sequeiros
- Endoscopy Unit. Gastroenterology and Hepatology Service. IRYCIS. University Hospital Ramón y Cajal, Madrid, Spain.
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Freeman AJ, Maqbool A, Bellin MD, Goldschneider KR, Grover AS, Hartzell C, Piester TL, Szabo F, Kiernan BD, Khalaf R, Kumar R, Rios M, Husain SZ, Morinville VD, Abu-El-Haija M. Medical Management of Chronic Pancreatitis in Children: A Position Paper by the North American Society for Pediatric Gastroenterology, Hepatology, and Nutrition Pancreas Committee. J Pediatr Gastroenterol Nutr 2021; 72:324-340. [PMID: 33230082 PMCID: PMC8054312 DOI: 10.1097/mpg.0000000000003001] [Citation(s) in RCA: 24] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
ABSTRACT This position paper summarizes the current understanding of the medical management of chronic pancreatitis (CP) in children in light of the existing medical literature, incorporating recent advances in understanding of nutrition, pain, lifestyle considerations, and sequelae of CP. This article complements and is intended to integrate with parallel position papers on endoscopic and surgical aspects of CP in children. Concepts and controversies related to pancreatic enzyme replacement therapy (PERT), the use of antioxidants and other CP medical therapies are also reviewed. Highlights include inclusion of tools for medical decision-making for PERT, CP-related diabetes, and multimodal pain management (including an analgesia ladder). Gaps in our understanding of CP in children and avenues for further investigations are also reviewed.
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Affiliation(s)
- A. Jay Freeman
- Department of Gastroenterology, Hepatology and Nutrition, Children’s Healthcare of Atlanta, Emory University School of Medicine, Atlanta, GA
| | - Asim Maqbool
- Division of Gastroenterology, Hepatology, and Nutrition, Children’s Hospital of Philadelphia, University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania
| | - Melena D. Bellin
- Department of Pediatrics, Division of Endocrinology and Diabetes, University of Minnesota Masonic Children’s Hospital, Minneapolis, MN
| | | | - Amit S. Grover
- Division of Gastroenterology, Hepatology and Nutrition, Boston Children’s Hospital, Harvard Medical School, Boston, MA
| | - Cheryl Hartzell
- Division of Pediatric Anesthesiology, Department of Anesthesiology, Emory University School of Medicine, Children’s Healthcare of Atlanta, Atlanta, GA
| | - Travis L. Piester
- Division of Gastroenterology, Hepatology and Nutrition, Children’s Hospital Los Angeles, University of Southern California, Los Angeles, CA
| | - Flora Szabo
- Division of Pediatric Gastroenterology and Nutrition, Children’s Hospital of Richmond, Virginia Commonwealth University, Richmond, VA
| | - Bridget Dowd Kiernan
- Division of Gastroenterology, Hepatology, and Nutrition, Children’s Hospital of Philadelphia, University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania
| | - Racha Khalaf
- Digestive Health Institute, Children’s Hospital Colorado, Section of Pediatric Gastroenterology, Hepatology and Nutrition, University of Colorado School of Medicine, Aurora, CO
| | - Rakesh Kumar
- Department of Gastroenterology, Hepatology and Nutrition, Promedica Toledo Children’s Hospital, Toledo, OH
| | - Mirta Rios
- Food and Nutrition Department, Nicklaus Children’s Hospital, Miami, FL
| | - Sohail Z. Husain
- Department of Pediatrics, Stanford University, and the Lucile Packard Children’s Hospital, Palo Alto, CA
| | - Veronique D. Morinville
- Division of Pediatric Gastroenterology and Nutrition, Montreal Children’s Hospital, McGill University Health Center, Montreal, Quebec, Canada
| | - Maisam Abu-El-Haija
- Division of Pediatric Gastroenterology, Hepatology and Nutrition, Cincinnati Children’s Hospital Medical Center, Cincinnati, OH
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Rebhun J, Nassani N, Pan A, Hong M, Shuja A. Outcomes of Open, Laparoscopic, and Percutaneous Drainage of Infected Walled-Off Pancreatic Necrosis: A Nationwide Inpatient Sample Study. Cureus 2021; 13:e12972. [PMID: 33654633 PMCID: PMC7913891 DOI: 10.7759/cureus.12972] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/05/2022] Open
Abstract
Background Walled-off pancreatic necrosis (WOPN) represents an encapsulated collection of necrotic pancreatic or peripancreatic tissue that tends to develop four weeks after the onset of acute necrotizing pancreatitis. When infected, it is managed initially by antibiotic therapy before drainage by endoscopic, percutaneous, or surgical means. This study aims to describe the morbidity, mortality, length of stay (LOS), and cost of care associated with open surgical, laparoscopic, and radiology-guided percutaneous drainage in adult patients with infected WOPN. Methods Using the Nationwide Inpatient Sample (NIS), patients aged 18 years and older discharged with the diagnosis of WOPN between January 1, 2016 and December 31, 2016 who underwent open, laparoscopic, or percutaneous drainage were included. Patients’ characteristics including age, gender, and body mass index were reported. The primary endpoints were the mortality rate as well as length and cost of stay in each group. The secondary endpoint was the rate of procedural complications in each arm. Endpoints were reported and compared with studies assessing similar outcomes. Statistical Analysis System (SAS) statistical software (SAS Institute Inc., Cary, NC, USA) was used to perform the analysis. Results A total of 229 patients with the diagnosis of acute pancreatitis with infected necrosis were identified. Of these 229 patients, 27, 15, and 20 underwent open, laparoscopic, and percutaneous drainage, respectively. A total of eight studies were used for comparison of outcome variables. Mortality rate was found to be similar among comparison studies. LOS and costs varied widely among studies. There were significantly fewer pancreatic fistula and significantly more multi-organ failure complications as a result of open necrosectomy in the NIS study sample. Conclusion Overall, in analyzing the outcomes of patients undergoing intervention for infected WOPN through the 2016 NIS database, it appears that the database is representative of the majority of outcomes seen in similar clinical trials.
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Affiliation(s)
- Jeffrey Rebhun
- Department of Internal Medicine, University of Illinois at Chicago, Chicago, USA
| | - Najib Nassani
- Department of Gastroenterology and Hepatology, University of Illinois at Chicago, Chicago, USA
| | - Alex Pan
- Department of Gastroenterology and Hepatology, University of Illinois at Chicago, Chicago, USA
| | - Mindy Hong
- Department of Dermatology, Northwestern University Feinberg School of Medicine, Chicago, USA
| | - Asim Shuja
- Department of Gastroenterology and Hepatology, University of Illinois at Chicago, Chicago, USA
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Mitrovic M, Dugalic V, Kovac J, Tadic B, Milosevic S, Lukic B, Lekic N, Cvetic V. Successful Embolization of Posterior Inferior Pancreaticoduodenal Artery Pseudoaneurysm on the Grounds of Chronic Pancreatitis-Case Report and Literature Review. ACTA ACUST UNITED AC 2020; 56:medicina56110617. [PMID: 33207736 PMCID: PMC7696778 DOI: 10.3390/medicina56110617] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/05/2020] [Revised: 11/11/2020] [Accepted: 11/12/2020] [Indexed: 12/18/2022]
Abstract
Pancreatic pseudoaneurysm is a rare but life-threatening clinical entity. In this paper, we present a case of a 74-year-old man, who was admitted to our clinic with a diagnosis of an acute on chronic pancreatitis complicated by walled-off-pancreatic-necrosis, with subsequent development of peripancreatic pseudoaneurysm. After initial conservative management, the patient recovered and was discharged from the hospital. However, he soon returned feeling anxious due to a pulsatile abdominal mass. Abdominal Color–Doppler examination, CT scan, and angiography revealed large pancreatic necrotic collection in the total size of 9 cm, with centrally enhancing area of 3.5 cm that corresponded to pseudoaneurysm originating from the posterior pancreaticoduodenal vascular arcade. Considering the size, location of the pseudoaneurysm, feeding vessel, and poor general patients condition, we opted for minimally invasive treatment. Pseudoaneurysm was successfully managed by endovascular coil embolization, i.e., “sandwich technique”.
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Affiliation(s)
- Milica Mitrovic
- Center for Radiology and Magnetic Resonance Imaging, Clinical Centre of Serbia, Pasterova No. 2, 11000 Belgrade, Serbia; (M.M.); (J.K.); (S.M.); (B.L.); (V.C.)
| | - Vladimir Dugalic
- Department for HPB Surgery, Clinic for Digestive Surgery, Clinical Centre of Serbia, Koste Todorovica Street, No. 6, 11000 Belgrade, Serbia; (V.D.); (N.L.)
- Department for Surgery, Faculty of Medicine, University of Belgrade, Dr Subotica No. 8, 11000 Belgrade, Serbia
| | - Jelena Kovac
- Center for Radiology and Magnetic Resonance Imaging, Clinical Centre of Serbia, Pasterova No. 2, 11000 Belgrade, Serbia; (M.M.); (J.K.); (S.M.); (B.L.); (V.C.)
- Department for Radiology, Faculty of Medicine, University of Belgrade, Dr Subotica No. 8, 11000 Belgrade, Serbia
| | - Boris Tadic
- Department for HPB Surgery, Clinic for Digestive Surgery, Clinical Centre of Serbia, Koste Todorovica Street, No. 6, 11000 Belgrade, Serbia; (V.D.); (N.L.)
- Department for Surgery, Faculty of Medicine, University of Belgrade, Dr Subotica No. 8, 11000 Belgrade, Serbia
- Correspondence: ; Tel.: +381-62-388-288
| | - Stefan Milosevic
- Center for Radiology and Magnetic Resonance Imaging, Clinical Centre of Serbia, Pasterova No. 2, 11000 Belgrade, Serbia; (M.M.); (J.K.); (S.M.); (B.L.); (V.C.)
| | - Borivoje Lukic
- Center for Radiology and Magnetic Resonance Imaging, Clinical Centre of Serbia, Pasterova No. 2, 11000 Belgrade, Serbia; (M.M.); (J.K.); (S.M.); (B.L.); (V.C.)
- Department for Radiology, Faculty of Medicine, University of Belgrade, Dr Subotica No. 8, 11000 Belgrade, Serbia
| | - Nebojsa Lekic
- Department for HPB Surgery, Clinic for Digestive Surgery, Clinical Centre of Serbia, Koste Todorovica Street, No. 6, 11000 Belgrade, Serbia; (V.D.); (N.L.)
- Department for Surgery, Faculty of Medicine, University of Belgrade, Dr Subotica No. 8, 11000 Belgrade, Serbia
| | - Vladimir Cvetic
- Center for Radiology and Magnetic Resonance Imaging, Clinical Centre of Serbia, Pasterova No. 2, 11000 Belgrade, Serbia; (M.M.); (J.K.); (S.M.); (B.L.); (V.C.)
- Department for Radiology, Faculty of Medicine, University of Belgrade, Dr Subotica No. 8, 11000 Belgrade, Serbia
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Abstract
PURPOSE OF REVIEW The purpose of this review is to discuss the role of endoscopic ultrasound (EUS) in the diagnosis and treatment of chronic pancreatitis (CP). RECENT FINDINGS EUS has evolved and become invaluable in diagnosing early CP with the use of elastography and contrast enhancement. Lumen-apposing metal stents have allowed for easier transmural drainage and necrosectomy for pancreatic pseudocyst and walled of necrosis. EUS-guided pancreatic duct drainage is being utilized for pancreatic duct complications including stenosis, stones, and duct disruptions that are not amendable to endoscopic retrograde cholangiopancreatography. EUS is an effective tool that assists with the diagnosis and treatment of CP. The technology continues to evolve allowing for diagnosis of CP in earlier stages, which enables more effective therapy. The development of new EUS-guided tools and techniques has improved the treatment of complications from CP.
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Abstract
Pancreatic fluid collections (PFC), including pancreatic pseudocysts and walled-off pancreatic necrosis, are a known complication of severe acute pancreatitis. A majority of the PFCs remain asymptomatic and resolve spontaneously. However, some PFCs persist and can become symptomatic. Persistent PFCs can also cause further complications such as the gastric outlet, intestinal, or biliary obstruction and infection. Surgical interventions are indicated for the drainage of symptomatic sterile and infected PFCs. Management of PFCs has evolved from a primarily surgical or percutaneous approach to a less invasive endoscopic approach. Endoscopic interventions are associated with improved outcomes with lesser chances of complications, faster recovery time, and lower healthcare utilization. Endoscopic ultrasound-guided drainage of PFCs using lumen-apposing metal stents has become the preferred approach for the management of symptomatic and complicated PFCs.
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Sousa D, Freitas Ferreira AC, Raimundo P, Maio R. Walled-off pancreatic necrosis: a staged multidisciplinary step-up approach. BMJ Case Rep 2020; 13:13/3/e232952. [PMID: 32221010 DOI: 10.1136/bcr-2019-232952] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022] Open
Abstract
Walled-off pancreatic necrosis (WOPN) is a rare complication of pancreatitis. We present the case of a woman in her eighties admitted for diffuse abdominal pain. She had a palpable abdominal mass and the CT scan showed necrosis throughout the tail of the pancreas, a peripancreatic and retrogastric hydroaerial collection (19 cm of diameter) and a calculus in the main biliary duct, thus establishing a diagnosis of emphysematous necrotising obstructive pancreatitis. A step-up approach was decided, first with removal of the biliary calculus, followed by a waiting period of 4 weeks in which the patient was under intravenous antibiotics. At re-evaluation, the CT scan showed a smaller and more organised collection, bounded by a wall, defining WOPN. At this stage, transgastric drainage via echoendoscopy was attempted, without success, followed by percutaneous CT-guided drainage, also with little effect. Surgical necrosectomy was then executed, as a final step, with a successful outcome.
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Affiliation(s)
- Débora Sousa
- Department of Internal Medicine, Hospital da Luz Lisboa, Lisboa, Portugal
| | - Ana Carolina Freitas Ferreira
- Department of Internal Medicine, Hospital do Divino Espírito Santo de Ponta Delgada EPE, Ponta Delgada, Ilha de São Miguel, Portugal
| | - Pedro Raimundo
- Department of Internal Medicine, Hospital da Luz Lisboa, Lisboa, Portugal
| | - Rui Maio
- Department of Surgery, Hospital da Luz Lisboa, Lisboa, Lisboa, Portugal
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