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Manrai M, Dawra S, Singh AK, Jha DK, Kochhar R. Controversies in the management of acute pancreatitis: An update. World J Clin Cases 2023; 11:2582-2603. [PMID: 37214572 PMCID: PMC10198120 DOI: 10.12998/wjcc.v11.i12.2582] [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: 11/27/2022] [Revised: 01/22/2023] [Accepted: 03/29/2023] [Indexed: 04/25/2023] Open
Abstract
This review summarized the current controversies in the management of acute pancreatitis (AP). The controversies in management range from issues involving fluid resuscitation, nutrition, the role of antibiotics and antifungals, which analgesic to use, role of anticoagulation and intervention for complications in AP. The interventions vary from percutaneous drainage, endoscopy or surgery. Active research and emerging data are helping to formulate better guidelines. The available evidence favors crystalloids, although the choice and type of fluid resuscitation is an area of dynamic research. The nutrition aspect does not have controversy as of now as early enteral feeding is preferred most often than not. The empirical use of antibiotics and antifungals are gray zones, and more data is needed for conclusive guidelines. The choice of analgesic is being studied, and the recommendations are still evolving. The position of using anticoagulation is still awaiting consensus. The role of intervention is well established, although the modality is constantly changing and favoring endoscopy or percutaneous drainage rather than surgery. It is evident that more multicenter randomized controlled trials are required for establishing the standard of care in these crucial management issues of AP to improve the morbidity and mortality worldwide.
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Affiliation(s)
- Manish Manrai
- Department of Internal Medicine, Armed Forces Medical College, Pune 411040, India
| | - Saurabh Dawra
- Department of Medicine and Gastroenterology, Command Hospital, Pune 411040, India
| | - Anupam K Singh
- Department of Gastroenterology, Post Graduate Institute of Medical Education and Research, Chandigarh 160012, India
| | - Daya Krishna Jha
- Department of Gastroenterology, Army Hospital (Research and Referral), New Delhi 11010, India
| | - Rakesh Kochhar
- Department of Gastroenterology, Post Graduate Institute of Medical Education and Research, Chandigarh 160012, India
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Yang Y, Zhang Y, Wen S, Cui Y. The optimal timing and intervention to reduce mortality for necrotizing pancreatitis: a systematic review and network meta-analysis. World J Emerg Surg 2023; 18:9. [PMID: 36707836 PMCID: PMC9883927 DOI: 10.1186/s13017-023-00479-7] [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: 11/08/2022] [Accepted: 01/19/2023] [Indexed: 01/28/2023] Open
Abstract
BACKGROUND A series of randomized controlled trials have investigated the efficacy and safety of different timings of interventions and methods of intervention. However, the optimal treatment strategy is not yet clear. METHODS We searched PubMed, EMBASE, ClinicalTrials.gov and the Cochrane Library until November 30, 2022. A systematic review and Bayesian network meta-analysis were performed following the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. Trials comparing different treatment strategies for necrotizing pancreatitis were included. This study was registered in the Prospective Register of Systematic Reviews (CRD42022364409) to ensure transparency. RESULTS We analyzed a total of 10 studies involving 570 patients and 8 treatment strategies. Although no statistically significant differences were identified comparing odds ratios, trends were confirmed by the surface under the cumulative ranking (SUCRA) scores. The interventions with a low rate of mortality were delayed surgery (DS), delayed surgical step-up approach (DSU) and delayed endoscopic step-up approach (DEU), while the interventions with a low rate of major complications were DSU, DEU and DS. According to the clustered ranking plot, DSU performed the best overall in reducing mortality and major complications, while DD performed the worst. Analysis of the secondary endpoints confirmed the superiority of DEU and DSU in terms of individual components of major complications (organ failure, pancreatic fistula, bleeding, and visceral organ or enterocutaneous fistula), exocrine insufficiency, endocrine insufficiency and length of stay. Overall, DSU was superior to other interventions. CONCLUSION DSU was the optimal treatment strategy for necrotizing pancreatitis. Drainage alone should be avoided in clinical practice. Any interventions should be postponed for at least 4 weeks if possible. The step-up approach was preferred.
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Affiliation(s)
- Yang Yang
- grid.265021.20000 0000 9792 1228Department of Surgery, Tianjin Medical University, Tianjin, 300070 China ,grid.417036.7Department of Surgery, Tianjin Nankai Hospital, Nankai Clinical School of Medicine, 122 Sanwei Road, Nankai District, Tianjin, 300110 China
| | - Yu Zhang
- grid.265021.20000 0000 9792 1228Department of Surgery, Tianjin Medical University, Tianjin, 300070 China ,grid.417036.7Department of Surgery, Tianjin Nankai Hospital, Nankai Clinical School of Medicine, 122 Sanwei Road, Nankai District, Tianjin, 300110 China
| | - Shuaiyong Wen
- grid.265021.20000 0000 9792 1228Department of Surgery, Tianjin Medical University, Tianjin, 300070 China ,grid.417036.7Department of Surgery, Tianjin Nankai Hospital, Nankai Clinical School of Medicine, 122 Sanwei Road, Nankai District, Tianjin, 300110 China
| | - Yunfeng Cui
- Department of Surgery, Tianjin Medical University, Tianjin, 300070, China. .,Department of Surgery, Tianjin Nankai Hospital, Nankai Clinical School of Medicine, 122 Sanwei Road, Nankai District, Tianjin, 300110, China.
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3
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Percutaneous catheter drainage of pancreatic associated pathologies: A systematic review and meta-analysis. Eur J Radiol 2021; 144:109978. [PMID: 34607289 DOI: 10.1016/j.ejrad.2021.109978] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/07/2021] [Revised: 09/15/2021] [Accepted: 09/23/2021] [Indexed: 12/13/2022]
Abstract
PURPOSE The main goal of this systematic review was to assess the technical and clinical success, adverse events (AEs), surgery, and overall mortality proportion after percutaneous catheter drainage (PCD) of two pancreatic lesions. METHODS An extant search in online databases including Scopus, PubMed (Medline), Embase (Elsevier), Web of Science, Cochrane library, and Google Scholar, was conducted to recognize all studies that used PCD intervention in the management of pancreatic necrosis (PN) and pancreatic pseudocysts (PP). Random effects meta-analysis was performed, and Cochrane's Q test and I2statistic were utilized to determine heterogeneity. In addition, meta-regression was used to explore the influence of categorical variables on heterogeneity. RESULTS Thirty-two studies (1398 patients) including PN in 26 (1256 cases, 89.8%) studies and PP in 6 (142 cases, 10.2%) studies were identified. Technical success proportion was 100% (95% confidence interval [CI] 100%-100%, I2: 0.0%), clinical success 63% (95% CI 55%-71%, I2: 92.9%), AEs 26% (95% CI 21%-31%, I2: 78%), surgery after PCD intervention 33% (95% CI 25%-40%, I2: 92.4%), and overall mortality was 13% (95% CI 9%-17%, I2: 82.8%). The most common ADs after PCD intervention were development of fistula (106, 42.6%), hemorrhage (44, 17.7%), sepsis (40, 16.1%). CONCLUSION A significant clinical success proportion with low AEs, surgery, and overall mortality proportion after PCD intervention was found, although the results should be interpreted with caution due to the high heterogeneity.
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4
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Affiliation(s)
- Amy Y Li
- Department of Surgery, Section of Surgical Oncology, Stanford University School of Medicine, 300 Pasteur Drive, Room H3591, Stanford, CA 94305, USA
| | - John R Bergquist
- Department of Surgery, Section of Surgical Oncology, Stanford University School of Medicine, 300 Pasteur Drive, Room H3591, Stanford, CA 94305, USA
| | - Brendan C Visser
- Department of Surgery, Section of Surgical Oncology, Stanford University School of Medicine, 300 Pasteur Drive, H3680, Stanford, CA 94305-5655, USA.
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5
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Wan J, Wu D, He W, Zhu Y, Zhu Y, Zeng H, Liu P, Xia L, Lu N. Comparison of percutaneous vs endoscopic drainage in the management of pancreatic fluid collections: A prospective cohort study. J Gastroenterol Hepatol 2020; 35:2170-2175. [PMID: 32473080 DOI: 10.1111/jgh.15121] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/16/2019] [Revised: 04/26/2020] [Accepted: 05/25/2020] [Indexed: 12/13/2022]
Abstract
BACKGROUND AND AIM Currently, endoscopic drainage (ED) and percutaneous drainage (PD) are both widely used effective interventions in the management of patients with symptomatic pancreatic fluid collections (PFCs). This study aimed to compare the clinical effectiveness and safety of ED to those of PD in the treatment of PFCs. METHODS A prospective cohort study of PFC patients who underwent ED or PD was conducted between January 2009 and December 2017. In this study, the initial success rate, adverse events, intervention, requirement of surgical treatment, hospital mortality within 30 days, length of hospital stay, and expenses during hospitalization were monitored, and a follow-up investigation of treatment outcome was conducted. Long-term recovery, recurrence, and mortality were determined according to telephone follow up. RESULTS In total, 129 patients were included in the study; 62 patients underwent ED, and 67 patients underwent PD during the 8-year study period. Initial treatment success was considerably higher in patients whose PFCs were managed by ED than in patients whose PFCs were managed by PD (94.9% vs 65.0%, P = 0.003). The rate of procedural adverse events, reintervention, length of hospitalization, and expense were all higher in the PD group than in the ED group, but the long-term recovery rate and requirement of surgical intervention were not clearly different between patients who underwent the two treatment measures. CONCLUSION ED of symptomatic PFCs was associated with higher rates of initial treatment success, lower rates of reintervention and adverse events, and a shorter hospital stay than PD of symptomatic PFCs.
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Affiliation(s)
- Jianhua Wan
- Department of Gastroenterology, The First Affiliated Hospital of Nanchang University, Nanchang, China
| | - Dangyan Wu
- Department of Gastroenterology, The First Affiliated Hospital of Nanchang University, Nanchang, China
| | - Wenhua He
- Department of Gastroenterology, The First Affiliated Hospital of Nanchang University, Nanchang, China
| | - Yin Zhu
- Department of Gastroenterology, The First Affiliated Hospital of Nanchang University, Nanchang, China
| | - Yong Zhu
- Department of Gastroenterology, The First Affiliated Hospital of Nanchang University, Nanchang, China
| | - Hao Zeng
- Department of Gastroenterology, The First Affiliated Hospital of Nanchang University, Nanchang, China
| | - Pi Liu
- Department of Gastroenterology, The First Affiliated Hospital of Nanchang University, Nanchang, China
| | - Liang Xia
- Department of Gastroenterology, The First Affiliated Hospital of Nanchang University, Nanchang, China
| | - Nonghua Lu
- Department of Gastroenterology, The First Affiliated Hospital of Nanchang University, Nanchang, China
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6
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Management of pancreatic fluid collections in patients with acute pancreatitis. JOURNAL OF PANCREATOLOGY 2019. [DOI: 10.1097/jp9.0000000000000026] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022] Open
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7
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Trikudanathan G, Wolbrink DRJ, van Santvoort HC, Mallery S, Freeman M, Besselink MG. Current Concepts in Severe Acute and Necrotizing Pancreatitis: An Evidence-Based Approach. Gastroenterology 2019; 156:1994-2007.e3. [PMID: 30776347 DOI: 10.1053/j.gastro.2019.01.269] [Citation(s) in RCA: 185] [Impact Index Per Article: 37.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/08/2018] [Revised: 01/01/2019] [Accepted: 01/15/2019] [Indexed: 02/07/2023]
Abstract
The incidence of acute pancreatitis continues to rise, inducing substantial medical and social burden, with annual costs exceeding $2 billion in the United States alone. Although most patients develop mild pancreatitis, 20% develop severe and/or necrotizing pancreatitis, requiring advanced medical and interventional care. Morbidity resulting from local and systemic complications as well as invasive interventions result in mortality rates historically as high as 30%. There has been substantial evolution of strategies for interventions in recent years, from open surgery to minimally invasive surgical and endoscopic step-up approaches. In contrast to the advances in invasive procedures for complications, early management still lacks curative options and consists of adequate fluid resuscitation, analgesics, and monitoring. Many challenges remain, including comprehensive management of the entire spectrum of the disease, which requires close involvement of multiple disciplines at specialized centers.
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Affiliation(s)
- Guru Trikudanathan
- Division of Gastroenterology, Hepatology and Nutrition, University of Minnesota, Minneapolis, Minnesota.
| | | | - Hjalmar C van Santvoort
- Department of Surgery, the University Medical Center Utrecht and the St. Antonius Hospital Nieuwegein, the Netherlands
| | - Shawn Mallery
- Division of Gastroenterology, Hepatology and Nutrition, University of Minnesota, Minneapolis, Minnesota
| | - Martin Freeman
- Division of Gastroenterology, Hepatology and Nutrition, University of Minnesota, Minneapolis, Minnesota
| | - Marc G Besselink
- Department of Surgery, Amsterdam Gastroenterology and Metabolism, Amsterdam UMC, University of Amsterdam, the Netherlands
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van Grinsven J, van Dijk SM, Dijkgraaf MG, Boermeester MA, Bollen TL, Bruno MJ, van Brunschot S, Dejong CH, van Eijck CH, van Lienden KP, Boerma D, van Duijvendijk P, Hadithi M, Haveman JW, van der Hulst RW, Jansen JM, Lips DJ, Manusama ER, Molenaar IQ, van der Peet DL, Poen AC, Quispel R, Schaapherder AF, Schoon EJ, Schwartz MP, Seerden TC, Spanier BWM, Straathof JW, Venneman NG, van de Vrie W, Witteman BJ, van Goor H, Fockens P, van Santvoort HC, Besselink MG. Postponed or immediate drainage of infected necrotizing pancreatitis (POINTER trial): study protocol for a randomized controlled trial. Trials 2019; 20:239. [PMID: 31023380 PMCID: PMC6482524 DOI: 10.1186/s13063-019-3315-6] [Citation(s) in RCA: 34] [Impact Index Per Article: 6.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/13/2018] [Accepted: 03/21/2019] [Indexed: 12/12/2022] Open
Abstract
Background Infected necrosis complicates 10% of all acute pancreatitis episodes and is associated with 15–20% mortality. The current standard treatment for infected necrotizing pancreatitis is the step-up approach (catheter drainage, followed, if necessary, by minimally invasive necrosectomy). Catheter drainage is preferably postponed until the stage of walled-off necrosis, which usually takes 4 weeks. This delay stems from the time when open necrosectomy was the standard. It is unclear whether such delay is needed for catheter drainage or whether earlier intervention could actually be beneficial in the current step-up approach. The POINTER trial investigates if immediate catheter drainage in patients with infected necrotizing pancreatitis is superior to the current practice of postponed intervention. Methods POINTER is a randomized controlled multicenter superiority trial. All patients with necrotizing pancreatitis are screened for eligibility. In total, 104 adult patients with (suspected) infected necrotizing pancreatitis will be randomized to immediate (within 24 h) catheter drainage or current standard care involving postponed catheter drainage. Necrosectomy, if necessary, is preferably postponed until the stage of walled-off necrosis, in both treatment arms. The primary outcome is the Comprehensive Complication Index (CCI), which covers all complications between randomization and 6-month follow up. Secondary outcomes include mortality, complications, number of (repeat) interventions, hospital and intensive care unit (ICU) lengths of stay, quality-adjusted life years (QALYs) and direct and indirect costs. Standard follow-up is at 3 and 6 months after randomization. Discussion The POINTER trial investigates if immediate catheter drainage in infected necrotizing pancreatitis reduces the composite endpoint of complications, as compared with the current standard treatment strategy involving delay of intervention until the stage of walled-off necrosis. Trial registration ISRCTN, 33682933. Registered on 6 August 2015. Retrospectively registered. Electronic supplementary material The online version of this article (10.1186/s13063-019-3315-6) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Janneke van Grinsven
- Department of Surgery, Amsterdam UMC, University of Amsterdam, G4.196, PO Box 26000, 1105 AZ, Amsterdam, Netherlands. .,Department of Surgery, St. Antonius Hospital Nieuwegein, Nieuwegein, Netherlands.
| | - Sven M van Dijk
- Department of Surgery, Amsterdam UMC, University of Amsterdam, G4.196, PO Box 26000, 1105 AZ, Amsterdam, Netherlands.,Department of Surgery, St. Antonius Hospital Nieuwegein, Nieuwegein, Netherlands
| | - Marcel G Dijkgraaf
- Clinical Research Unit, Amsterdam UMC, University of Amsterdam, Amsterdam, Netherlands
| | - Marja A Boermeester
- Department of Surgery, Amsterdam UMC, University of Amsterdam, G4.196, PO Box 26000, 1105 AZ, Amsterdam, Netherlands
| | - Thomas L Bollen
- Department of Radiology, St. Antonius Hospital Nieuwegein, Nieuwegein, Netherlands
| | - Marco J Bruno
- Department of Gastroenterology and Hepatology, Erasmus MC University Medical Center Rotterdam, Rottedam, Netherlands
| | - Sandra van Brunschot
- Department of Gastroenterology and Hepatology, Amsterdam UMC, University of Amsterdam, Amsterdam, Netherlands.,Department of Surgery, University Medical Center Utrecht, Cancer Center, Utrecht, Netherlands
| | - Cornelis H Dejong
- Department of Surgery, Maastricht University Medical Center+, Maastricht, Netherlands.,NUTRIM School for Nutrition and Translational Research in Metabolism, Maastricht, Netherlands
| | - Casper H van Eijck
- Department of Surgery, Erasmus MC University Medical Center Rotterdam, Rotterdam, Netherlands
| | - Krijn P van Lienden
- Department of Radiology, Amsterdam UMC, University of Amsterdam, Amsterdam, Netherlands
| | - Djamila Boerma
- Department of Surgery, St. Antonius Hospital Nieuwegein, Nieuwegein, Netherlands
| | | | - Muhammed Hadithi
- Department of Gastroenterology and Hepatology, Maasstad Hospital Rotterdam, Rotterdam, Netherlands
| | - Jan Willem Haveman
- Department of Surgery, University Medical Center Groningen, University of Groningen, Groningen, Netherlands
| | - René W van der Hulst
- Department of Gastroenterology and Hepatology, Spaarne Gasthuis Haarlem, Haarlem, Netherlands
| | - Jeroen M Jansen
- Department of Gastroenterology and Hepatology, OLVG Amsterdam, Amsterdam, Netherlands
| | - Daan J Lips
- Department of Surgery, Jeroen Bosch Hospital, 's-Hertogenbosch, Netherlands
| | - Eric R Manusama
- Department of Surgery, Medical Center Leeuwarden, Leeuwarden, Netherlands
| | - I Quintus Molenaar
- Department of Surgery, University Medical Center Utrecht, Cancer Center, Utrecht, Netherlands
| | - Donald L van der Peet
- Department of Surgery, Amsterdam UMC, Vrije Universiteit Amsterdam, Amsterdam, Netherlands
| | - Alexander C Poen
- Department of Gastroenterology and Hepatology, Isala Clinics Zwolle, Zwolle, Netherlands
| | - Rutger Quispel
- Department of Gastroenterology and Hepatology, Reinier de Graaf Gasthuis Delft, Delft, Netherlands
| | | | - Erik J Schoon
- Department of Gastroenterology and Hepatology, Catharina Hospital Eindhoven, Eindhoven, Netherlands
| | - Matthijs P Schwartz
- Department of Gastroenterology and Hepatology, Meander Medical Center Amersfoort, Amersfoort, Netherlands
| | - Tom C Seerden
- Department of Gastroenterology and Hepatology, Amphia Hospital Breda, Breda, Netherlands
| | - B W Marcel Spanier
- Department of Gastroenterology and Hepatology, Rijnstate Hospital Arnhem, Arnhem, Netherlands
| | - Jan Willem Straathof
- Department of Gastroenterology and Hepatology, Maxima Medical Center Veldhoven, Veldhoven, Netherlands
| | - Niels G Venneman
- Department of Gastroenterology and Hepatology, Medisch Spectrum Twente Enschede, Enschede, Netherlands
| | - Wim van de Vrie
- Department of Gastroenterology and Hepatology, Albert Schweitzer Hospital Dordrecht, Dordrecht, Netherlands
| | - Ben J Witteman
- Department of Gastroenterology and Hepatology, Hospital Gelderse Vallei Ede, Ede, Netherlands
| | - Harry van Goor
- Department of Surgery, Radboud University Medical Center Nijmegen, Nijmegen, Netherlands
| | - Paul Fockens
- Department of Gastroenterology and Hepatology, Amsterdam UMC, University of Amsterdam, Amsterdam, Netherlands
| | - Hjalmar C van Santvoort
- Department of Surgery, St. Antonius Hospital Nieuwegein, Nieuwegein, Netherlands.,Department of Surgery, University Medical Center Utrecht, Cancer Center, Utrecht, Netherlands
| | - Marc G Besselink
- Department of Surgery, Amsterdam UMC, University of Amsterdam, G4.196, PO Box 26000, 1105 AZ, Amsterdam, Netherlands.
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Abstract
Walled of pancreatic necrosis (WOPN) is a new term coined for encapsulated fluid collection developing after acute necrotising pancreatitis (ANP). It is a heterogeneous collection containing varying amount of liquid as well as solid necrotic material. The literature on its natural history as well as appropriate management is gradually expanding thereby improving treatment outcomes of this enigmatic disease. Areas covered: This review discusses currently available literature on etiology, frequency, natural history, and imaging features WOPN. Also, updated treatment options including endoscopic, radiological and surgical drainage are discussed. Expert opinion: WOPN is alocal complication of ANP occurring in the delayed phase of ANP and may be asymptomatic (50%) or present with pain, fever, jaundice, or gastric outlet obstruction. Natural courses of asymptomatic WOPN have been infrequently studied, and it appears that the majority remain asymptomatic and resolve spontaneously. Magnetic resonance imaging and endoscopic ultrasound are the best imaging modalities to evaluate solid necrotic debris. Symptomatic WOPN usually needs immediate drainage, this can be done endoscopically, radiologically, or surgically. Current evidence suggests that endoscopic transluminal drainage is the preferred drainage technique as it is effective and associated with lower mortality, risk of organ failure, adverse effects, and length of hospital stay.
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Affiliation(s)
- Surinder Singh Rana
- a Department of Gastroenterology , Post Graduate Institute of Medical Education and Research (PGIMER) , Chandigarh , India
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10
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Abstract
OBJECTIVES Guidelines advocate minimally invasive drainage rather than open surgery for infected pancreatic necrosis (IPN) after acute pancreatitis. We hypothesized that the conservative approach could be extended even further by treating patients using an antibiotics-only protocol. PATIENTS AND METHODS Between June 2009 and July 2017, patients with IPN were selectively managed with carbapenem antibiotics for a minimum of 6 weeks. We compared these patients with patients who underwent minimal access retroperitoneal pancreatic necrosectomy (MARPN) for IPN to identify characteristics of this patient group. RESULTS Of 33 patients with radiologically proven IPN, 13 patients received antibiotics without any surgical or radiological intervention and resulted in no disease-specific mortality and one case of pancreatic insufficiency. In comparison, 44 patients underwent MARPN with a mortality of 20%, and 81.8% developed pancreatic insufficiency. The modified Glasgow score and computed tomography severity score was less in the antibiotic-only group (P<0.001 and P=0.014, respectively). Patients who underwent MARPN had lower serum haemoglobin and albumin levels (P=0.030 and 0.001, respectively), and a higher C-reactive protein (P=0.027). CONCLUSION Conservative treatment of IPN with antibiotics is a valid management option for haemodynamically stable patients experiencing less severe disease, requiring careful selection by experienced clinicians.
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11
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Mallick B, Dhaka N, Gupta P, Gulati A, Malik S, Sinha SK, Yadav TD, Gupta V, Kochhar R. An audit of percutaneous drainage for acute necrotic collections and walled off necrosis in patients with acute pancreatitis. Pancreatology 2018; 18:727-733. [PMID: 30146334 DOI: 10.1016/j.pan.2018.08.010] [Citation(s) in RCA: 24] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/03/2018] [Revised: 07/18/2018] [Accepted: 08/19/2018] [Indexed: 12/11/2022]
Abstract
BACKGROUND AND OBJECTIVES Percutaneous catheter drainage (PCD) is used as a first step in the management of symptomatic fluid collections in patients with acute pancreatitis (AP). We aimed to compare the outcome of patients with acute necrotic collection (ANC) and those with walled-off necrosis (WON), who had undergone PCD as a part of management of AP. METHODS Consecutive patients of AP with symptomatic ANC or WON undergoing PCD were evaluated. Primary outcome measures were need for additional surgical necrosectomy and mortality. Secondary outcome measures were need for up-gradation of first PCD, need for additional drain, in-hospital as well as total duration of PCD and length of hospital stay. RESULTS Indications of PCD in 375 patients (258 with ANC and 117 with WON) were suspected infected pancreatic necrosis (n = 214), persistent organ failure (n = 117) and pressure symptoms (n = 44). Need for additional surgical necrosectomy was seen in 14% patients with ANC and in 12% of patients with WON (p = 0.364) and mortality was 19% in patients with ANC as compared to 13.7% in those with WON (p = 0.132). There was no significant difference in the secondary outcome parameters between patients who underwent PCD for ANC or WON. Complications of PCD were comparable between patients with ANC and WON except development of external pancreatic fistula which occurred more often in patients with WON than in those with ANC (24.4% versus 34.2% respectively, p = 0.034). CONCLUSION Persistent organ failure in more often an indication of PCD in patients with ANC than in WON and suspected infection is more commonly an indication in WON than in ANC. Early PCD is as efficacious and safe as delayed PCD.
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Affiliation(s)
- Bipadabhanjan Mallick
- Department of Gastroenterology, Postgraduate Institute of Medical Education and Research, Chandigarh, India
| | - Narendra Dhaka
- Department of Gastroenterology, Postgraduate Institute of Medical Education and Research, Chandigarh, India
| | - Pankaj Gupta
- Department of Radiodiagnosis, Postgraduate Institute of Medical Education and Research, Chandigarh, India
| | - Ajay Gulati
- Department of Radiodiagnosis, Postgraduate Institute of Medical Education and Research, Chandigarh, India
| | - Sarthak Malik
- 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
| | - Thakur D Yadav
- Department of General Surgery, Postgraduate Institute of Medical Education and Research, Chandigarh, India
| | - Vikas Gupta
- Department of General Surgery, Postgraduate Institute of Medical Education and Research, Chandigarh, India
| | - Rakesh Kochhar
- Department of Gastroenterology, Postgraduate Institute of Medical Education and Research, Chandigarh, India.
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Rasslan R, Novo FDCF, Bitran A, Utiyama EM, Rasslan S. Management of infected pancreatic necrosis: state of the art. ACTA ACUST UNITED AC 2018; 44:521-529. [PMID: 29019583 DOI: 10.1590/0100-69912017005015] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/25/2017] [Accepted: 06/01/2017] [Indexed: 02/08/2023]
Abstract
Pancreatic necrosis occurs in 15% of acute pancreatitis. The presence of infection is the most important factor in the evolution of pancreatitis. The diagnosis of infection is still challenging. Mortality in infected necrosis is 20%; in the presence of organic dysfunction, mortality reaches 60%. In the last three decades, there has been a real revolution in the treatment of infected pancreatic necrosis. However, the challenges persist and there are many unsolved questions: antibiotic treatment alone, tomography-guided percutaneous drainage, endoscopic drainage, video-assisted extraperitoneal debridement, extraperitoneal access, open necrosectomy? A step up approach has been proposed, beginning with less invasive procedures and reserving the operative intervention for patients in which the previous procedure did not solve the problem definitively. Indication and timing of the intervention should be determined by the clinical course. Ideally, the intervention should be done only after the fourth week of evolution, when it is observed a better delimitation of necrosis. Treatment should be individualized. There is no procedure that should be the first and best option for all patients. The objective of this work is to critically review the current state of the art of the treatment of infected pancreatic necrosis.
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Affiliation(s)
- Roberto Rasslan
- - University of São Paulo School of Medicine, Division of General Surgery and Trauma, Department of Surgery, São Paulo, SP, Brazil
| | - Fernando da Costa Ferreira Novo
- - University of São Paulo School of Medicine, Division of General Surgery and Trauma, Department of Surgery, São Paulo, SP, Brazil
| | - Alberto Bitran
- - University of São Paulo School of Medicine, Division of General Surgery and Trauma, Department of Surgery, São Paulo, SP, Brazil
| | - Edivaldo Massazo Utiyama
- - University of São Paulo School of Medicine, Division of General Surgery and Trauma, Department of Surgery, São Paulo, SP, Brazil
| | - Samir Rasslan
- - University of São Paulo School of Medicine, Division of General Surgery and Trauma, Department of Surgery, São Paulo, SP, Brazil
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Morató O, Poves I, Ilzarbe L, Radosevic A, Vázquez-Sánchez A, Sánchez-Parrilla J, Burdío F, Grande L. Minimally invasive surgery in the era of step-up approach for treatment of severe acute pancreatitis. Int J Surg 2018; 51:164-169. [PMID: 29409791 DOI: 10.1016/j.ijsu.2018.01.017] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/12/2017] [Revised: 01/03/2018] [Accepted: 01/08/2018] [Indexed: 12/12/2022]
Abstract
OBJECTIVES To assess the minimally invasive surgery into the step-up approach procedures as a standard treatment for severe acute pancreatitis and comparing its results with those obtained by classical management. METHODS Retrospective cohort study comparative with two groups treated over two consecutive, equal periods of time were defined: group A, classic management with open necrosectomy from January 2006 to June 2010; and group B, management with the step-up approach with minimally invasive surgery from July 2010 to December 2014. RESULTS In group A, 83 patients with severe acute pancreatitis were treated, of whom 19 underwent at least one laparotomy, and in 5 any minimally invasive surgery. In group B, 81 patients were treated: minimally invasive surgery was necessary in 17 cases and laparotomy in 3. Among operated patients, the time from admission to first interventional procedures was significantly longer in group B (9 days vs. 18.5 days; p = 0.042). There were no significant differences in Intensive Care Unit stay or overall stay: 9.5 and 27 days (group A) vs. 8.5 and 21 days (group B). Mortality in operated patients and mortality overall were 50% and 18.1% in group A vs 0% and 6.2% in group B (p < 0.001 and p = 0.030). CONCLUSIONS The combination of the step-up approach and minimally invasive surgery algorithm is feasible and could be considered as the standard of treatment for severe acute pancreatitis. The mortality rate deliberately descends when it is used.
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Affiliation(s)
- Olga Morató
- Unit of Hepato-Biliary and Pancreatic Surgery, Department of Surgery, Autonomous University of Barcelona, Hospital del Mar, Barcelona, Spain.
| | - Ignasi Poves
- Unit of Hepato-Biliary and Pancreatic Surgery, Department of Surgery, Autonomous University of Barcelona, Hospital del Mar, Barcelona, Spain.
| | - Lucas Ilzarbe
- Department of Gastroenterology, Hospital del Mar, Barcelona, Spain.
| | | | | | | | - Fernando Burdío
- Unit of Hepato-Biliary and Pancreatic Surgery, Department of Surgery, Autonomous University of Barcelona, Hospital del Mar, Barcelona, Spain.
| | - Luís Grande
- Unit of Hepato-Biliary and Pancreatic Surgery, Department of Surgery, Autonomous University of Barcelona, Hospital del Mar, Barcelona, Spain.
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Abstract
The last decade has seen dramatic shift in paradigm in the management of pancreatic fluid collections with the rise of endoscopic therapy over radiologic or surgical management. Endosonographic drainage is now considered the gold standard therapy for pancreatic pseudocyst. Infected pancreatic necroses are being offered endoscopic necrosectomy that has been facilitated by the arrival on the market of large diameter lumen-apposing metal stent. Severe pancreatitis or failure to thrive should receive enteral nutrition while pancreatic ductal disruption or strictures are best treated by pancreatic stenting.
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Affiliation(s)
- Iman Andalib
- Department of Gastroenterology and Hepatology, Weill Cornell Medical College, New York, NY
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Goenka MK, Goenka U, Mujoo MY, Tiwary IK, Mahawar S, Rai VK. Pancreatic Necrosectomy through Sinus Tract Endoscopy. Clin Endosc 2018; 51:279-284. [PMID: 29301065 PMCID: PMC5997064 DOI: 10.5946/ce.2017.066] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/06/2017] [Accepted: 09/13/2017] [Indexed: 12/24/2022] Open
Abstract
Background/Aims Direct endoscopic pancreatic necrosectomy is increasingly being utilized to treat infected or symptomatic walled-off necrosis (WON) located close to the stomach or duodenum. Laterally-placed WON has traditionally been treated surgically. We evaluated a less utilized technique of sinus tract endoscopy (STE) for symptomatic laterally-placed WON.
Methods Two hundred seventy-six patients with acute pancreatitis admitted in our hospital, 32 had symptomatic or infected WON requiring intervention. Of the 12 patients with laterally placed WON, 10 were treated by STE. STE was performed with a standard adult gastroscope passed through a percutaneous tract created by the placement of a 32-Fr drain.
Results Ten patients (7 males; mean age, 43.8 years) underwent STE. Mean number of sessions was 2.3 (range, 1–4), with mean time of 70 minutes for each session (range, 15–70 minutes). While 9 patients had complete success, 1 patient had fever and chose to undergo surgery. Two patients developed pneumoperitoneum, which was treated conservatively. There was no mortality, cutaneous fistula, or recurrence during follow-up.
Conclusions Laterally placed WON can be successfully managed by STE performed through a percutaneously placed drain. Details of the technique and end-points of STE require further evaluation.
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Affiliation(s)
| | - Usha Goenka
- Department of Clinical Imaging and Interventional Radiology, Apollo Gleneagles Hospitals, Kolkata, India
| | - Md Yasin Mujoo
- Institute of Gastrosciences, Apollo Gleneagles Hospitals, Kolkata, India
| | | | - Sanjay Mahawar
- Institute of Gastrosciences, Apollo Gleneagles Hospitals, Kolkata, India
| | - Vijay Kumar Rai
- Institute of Gastrosciences, Apollo Gleneagles Hospitals, Kolkata, India
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Aparna D, Kumar S, Kamalkumar S. Mortality and morbidity in necrotizing pancreatitis managed on principles of step-up approach: 7 years experience from a single surgical unit. World J Gastrointest Surg 2017; 9:200-208. [PMID: 29109852 PMCID: PMC5661125 DOI: 10.4240/wjgs.v9.i10.200] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/23/2016] [Revised: 07/31/2017] [Accepted: 10/03/2017] [Indexed: 02/06/2023] Open
Abstract
AIM To determine percentage of patients of necrotizing pancreatitis (NP) requiring intervention and the types of interventions performed. Outcomes of patients of step up necrosectomy to those of direct necrosectomy were compared. Operative mortality, overall mortality, morbidity and overall length of stay were determined.
METHODS After institutional ethics committee clearance and waiver of consent, records of patients of pancreatitis were reviewed. After excluding patients as per criteria, epidemiologic and clinical data of patients of NP was noted. Treatment protocol was reviewed. Data of patients in whom step-up approach was used was compared to those in whom it was not used.
RESULTS A total of 41 interventions were required in 39% patients. About 60% interventions targeted the pancreatic necrosis while the rest were required to deal with the complications of the necrosis. Image guided percutaneous catheter drainage was done in 9 patients for infected necrosis all of whom required further necrosectomy and in 3 patients with sterile necrosis. Direct retroperitoneal or anterior necrosectomy was performed in 15 patients. The average time to first intervention was 19.6 d in the non step-up group (range 11-36) vs 18.22 d in the Step-up group (range 13-25). The average hospital stay in non step-up group was 33.3 d vs 38 d in step up group. The mortality in the step-up group was 0% (0/9) vs 13% (2/15) in the non step up group. Overall mortality was 10.3% while post-operative mortality was 8.3%. Average hospital stay was 22.25 d.
CONCLUSION Early conservative management plays an important role in management of NP. In patients who require intervention, the approach used and the timing of intervention should be based upon the clinical condition and local expertise available. Delaying intervention and use of minimal invasive means when intervention is necessary is desirable. The step-up approach should be used whenever possible. Even when the classical retroperitoneal catheter drainage is not feasible, there should be an attempt to follow principles of step-up technique to buy time. The outcome of patients in the step-up group compared to the non step-up group is comparable in our series. Interventions for bowel diversion, bypass and hemorrhage control should be done at the appropriate times.
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Affiliation(s)
- Deshpande Aparna
- Department of Surgery, Seth G.S.Medical College and K.E.M. Hospital, Parel, Mumbai 400012, India
| | - Sunil Kumar
- Department of Surgery, Seth G.S.Medical College and K.E.M. Hospital, Parel, Mumbai 400012, India
| | - Shukla Kamalkumar
- Department of Surgery, Seth G.S.Medical College and K.E.M. Hospital, Parel, Mumbai 400012, India
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Abstract
OBJECTIVES Percutaneous catheter drainage (PCD) is often the first invasive treatment step for infected necrotizing pancreatitis. A proactive PCD strategy, including frequent and early drain revising and upsizing, may reduce the need for surgical necrosectomy and could improve outcomes, but data are lacking. METHODS Necrotizing pancreatitis patients were identified from in-hospital databases (2004-2014). Patients with primary PCD for infected necrotizing pancreatitis were included. Outcomes of patients from 1 center using a proactive PCD strategy were compared with 3 standard strategy centers. RESULTS In total, 369 (25.9%) of 1427 patients received a diagnosis of necrotizing pancreatitis, and 117 (31.7%) of 369 patients underwent primary PCD for infected necrosis: 42 in the proactive group versus 75 in the standard group. Patients in the proactive group had more drain-related procedures (median, 3; interquartile range [IQR], 2-4; versus 2; IQR, 1-2; P < 0.001) and larger final drain sizes (median, 16F; IQR, 14F-20F; versus 14F; IQR, 12F-14F; P < 0.001). Fewer patients underwent additional necrosectomy in the proactive group, 12 (28.6%) versus 39 (52.0%) (adjusted odds ratio, 0.349; 95% confidence interval, 0.137-0.889; P = 0.027), with similar hospital stay and mortality. CONCLUSIONS A proactive PCD strategy is associated with reduced need for necrosectomy in infected necrotizing pancreatitis, compared with standard PCD, with similar clinical outcomes.
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Rasslan R, da Costa Ferreira Novo F, Rocha MC, Bitran A, de Souza Rocha M, de Oliveira Bernini C, Rasslan S, Utiyama EM. Pancreatic Necrosis and Gas in the Retroperitoneum: Treatment with Antibiotics Alone. Clinics (Sao Paulo) 2017; 72:87-94. [PMID: 28273241 PMCID: PMC5314426 DOI: 10.6061/clinics/2017(02)04] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/15/2016] [Accepted: 11/18/2016] [Indexed: 12/13/2022] Open
Abstract
OBJECTIVE: To present our experience in the management of patients with infected pancreatic necrosis without drainage. METHODS: The records of patients with pancreatic necrosis admitted to our facility from 2011 to 2015 were retrospectively reviewed. RESULTS: We identified 61 patients with pancreatic necrosis. Six patients with pancreatic necrosis and gas in the retroperitoneum were treated exclusively with clinical support without any type of drainage. Only 2 patients had an APACHE II score >8. The first computed tomography scan revealed the presence of gas in 5 patients. The Balthazar computed tomography severity index score was >9 in 5 of the 6 patients. All patients were treated with antibiotics for at least 3 weeks. Blood cultures were positive in only 2 patients. Parenteral nutrition was not used in these patients. The length of hospital stay exceeded three weeks for 5 patients; 3 patients had to be readmitted. A cholecystectomy was performed after necrosis was completely resolved; pancreatitis recurred in 2 patients before the operation. No patients died. CONCLUSIONS: In selected patients, infected pancreatic necrosis (gas in the retroperitoneum) can be treated without percutaneous drainage or any additional surgical intervention. Intervention procedures should be performed for patients who exhibit clinical and laboratory deterioration.
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Affiliation(s)
- Roberto Rasslan
- Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo, Departamento de Cirurgia - Disciplina de Cirurgia Geral e Trauma, São Paulo/SP, Brazil
- *Corresponding author. E-mail:
| | - Fernando da Costa Ferreira Novo
- Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo, Departamento de Cirurgia - Disciplina de Cirurgia Geral e Trauma, São Paulo/SP, Brazil
| | - Marcelo Cristiano Rocha
- Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo, Departamento de Cirurgia - Disciplina de Cirurgia Geral e Trauma, São Paulo/SP, Brazil
| | - Alberto Bitran
- Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo, Departamento de Cirurgia - Disciplina de Cirurgia Geral e Trauma, São Paulo/SP, Brazil
| | - Manoel de Souza Rocha
- Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo, Departamento de Radiologia e Oncologia, São Paulo/SP, Brazil
| | - Celso de Oliveira Bernini
- Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo, Departamento de Cirurgia - Disciplina de Cirurgia Geral e Trauma, São Paulo/SP, Brazil
| | - Samir Rasslan
- Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo, Departamento de Cirurgia - Disciplina de Cirurgia Geral e Trauma, São Paulo/SP, Brazil
| | - Edivaldo Massazo Utiyama
- Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo, Departamento de Cirurgia - Disciplina de Cirurgia Geral e Trauma, São Paulo/SP, Brazil
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Isayama H, Nakai Y, Rerknimitr R, Khor C, Lau J, Wang HP, Seo DW, Ratanachu-Ek T, Lakhtakia S, Ang TL, Ryozawa S, Hayashi T, Kawakami H, Yamamoto N, Iwashita T, Itokawa F, Kuwatani M, Kitano M, Hanada K, Kogure H, Hamada T, Ponnudurai R, Moon JH, Itoi T, Yasuda I, Irisawa A, Maetani I. Asian consensus statements on endoscopic management of walled-off necrosis Part 1: Epidemiology, diagnosis, and treatment. J Gastroenterol Hepatol 2016; 31:1546-54. [PMID: 27044023 DOI: 10.1111/jgh.13394] [Citation(s) in RCA: 41] [Impact Index Per Article: 5.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/13/2016] [Revised: 03/03/2016] [Accepted: 03/22/2016] [Indexed: 12/12/2022]
Abstract
Walled-off necrosis (WON) is a relatively new term for encapsulated necrotic tissue after severe acute pancreatitis. Various terminologies such as pseudocyst, necroma, pancreatic abscess, and infected necrosis were previously used in the literature, resulting in confusion. The current and past terminologies must be reconciled to meaningfully interpret past data. Recently, endoscopic necrosectomy was introduced as a treatment option and is now preferred over surgical necrosectomy when the expertise is available. However, high-quality evidence is still lacking, and there is no standard management strategy for WON. The consensus meeting aimed to clarify the diagnostic criteria for WON and the role of endoscopic interventions in its management. In the Consensus Conference, 27 experts from eight Asian countries took an active role and examined key clinical aspects of WON diagnosis and endoscopic management. Statements were crafted based on literature review and expert opinion, employing the modified Delphi method. All statements were substantiated by the level of evidence and the strength of the recommendation. We created 27 consensus statements for WON diagnosis and management, including details of endoscopic procedures. When there was not enough solid evidence to support the statements, this was clearly acknowledged to facilitate future research. Proposed management strategies were formulated and are illustrated using flow charts. These recommendations, which are based on the best current scientific evidence and expert opinion, will be useful for guiding endoscopic management of WON. Part 1 of this statement focused on the epidemiology, diagnosis, and timing of intervention.
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Affiliation(s)
- Hiroyuki Isayama
- Department of Gastroenterology, Graduate School of Medicine, The University of Tokyo, Tokyo, Japan.
| | - Yousuke Nakai
- Department of Gastroenterology, Graduate School of Medicine, The University of Tokyo, Tokyo, Japan
| | - Rungsun Rerknimitr
- Division of Gastroenterology, Department of Medicine, Chulalongkorn University, Bangkok, Thailand
| | - Christopher Khor
- Department of Gastroenterology & Hepatology, Singapore General Hospital, Singapore, Singapore
| | - James Lau
- Department of Surgery, Endoscopic Center, Prince of Wales Hospital, The Chinese University of Hong Kong, Hong Kong, China
| | - Hsiu-Po Wang
- Endoscopic Division, National Taiwan University Hospital, National Taiwan University, Taipei, Taiwan
| | - Dong Wan Seo
- Department of Internal Medicine, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | | | | | - Tiing Leong Ang
- Department of Gastroenterology and Hepatology, Changi General Hospital, Singapore, Singapore
| | - Shomei Ryozawa
- Department of Gastroenterology, Saitama Medical University International Medical Center, Saitama, Japan
| | - Tsuyoshi Hayashi
- Department of Gastroenterology, Hokkaido Cancer Center, Sapporo, Japan
| | - Hiroshi Kawakami
- Department of Gastroenterology and Hepatology, Hokkaido University Hospital, Sapporo, Japan
| | - Natusyo Yamamoto
- Department of Gastroenterology, Graduate School of Medicine, The University of Tokyo, Tokyo, Japan
| | - Takuji Iwashita
- First Department of Internal Medicine, Gifu University Hospital, Gifu, Japan
| | - Fumihide Itokawa
- Department of Gastroenterology and Hepatology, Tokyo Medical University, Tokyo, Japan
| | - Masaki Kuwatani
- Division of Endoscopy, Hokkaido University Hospital, Sapporo, Japan
| | - Masayuki Kitano
- Department of Gastroenterology and Hepatology, Kinki University Faculty of Medicine, Osaka-sayama, Japan
| | - Keiji Hanada
- Department of Gastroenterology, Onomichi General Hospital, Onomichi, Japan
| | - Hirofumi Kogure
- 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
| | | | - Jong Ho Moon
- Digestive Disease Center and Research Institute, Department of Internal Medicine, Soon Chun Hyang University School of Medicine, Bucheon/Seoul, Korea
| | - Takao Itoi
- Department of Gastroenterology and Hepatology, Tokyo Medical University, Tokyo, Japan
| | - Ichiro Yasuda
- Department of Gastroenterology, Teikyo University Mizonokuchi Hospital, Kanagawa, Japan
| | - Atsushi Irisawa
- Department of Gastroenterology, Aizu Medical Center, Fukushima Medical University, Aizuwakamatsu, Japan
| | - Iruru Maetani
- Division of Gastroenterology and Hepatology, Department of Internal Medicine, Toho University Ohashi Medical Center, Tokyo, Japan
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20
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Abstract
Acute pancreatitis is the most common gastrointestinal indication for hospital admission, and infected pancreatic and/or extrapancreatic necrosis is a potentially lethal complication. Current standard treatment of infected necrosis is a step-up approach, consisting of catheter drainage followed, if necessary, by minimally invasive necrosectomy. International guidelines recommend postponing catheter drainage until the stage of 'walled-off necrosis' has been reached, a process that typically takes 4 weeks after onset of acute pancreatitis. This recommendation stems from the era of primary surgical necrosectomy. However, postponement of catheter drainage might not be necessary, and earlier detection and subsequent earlier drainage of infected necrosis could improve outcome. Strong data and consensus among international expert pancreatologists are lacking. Future clinical, preferably randomized, studies should focus on timing of catheter drainage in patients with infected necrotizing pancreatitis. In this Perspectives, we discuss challenges in the invasive treatment of patients with infected necrotizing pancreatitis, focusing on timing of catheter drainage.
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Better Outcomes if Percutaneous Drainage Is Used Early and Proactively in the Course of Necrotizing Pancreatitis. J Vasc Interv Radiol 2016; 27:418-25. [PMID: 26806694 DOI: 10.1016/j.jvir.2015.11.054] [Citation(s) in RCA: 37] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/19/2015] [Revised: 11/23/2015] [Accepted: 11/23/2015] [Indexed: 02/06/2023] Open
Abstract
PURPOSE To compare outcomes after percutaneous catheter drainage (PCD) for acute necrotizing pancreatitis versus those in a randomized controlled trial as a reference standard. MATERIALS AND METHODS Between September 2010 and August 2014, CT-guided PCD was the primary treatment for 39 consecutive patients with pancreatic necrosis. The indication for PCD was the clinical finding of uncontrolled pancreatic juice leakage rather than infected necrosis. Subsequent to PCD, the drains were proactively studied with fluoroscopic contrast medium every 3 days to ensure patency and position. Drains were ultimately maneuvered to the site of leakage. These 39 patients were compared with 43 patients from the Pancreatitis, Necrosectomy versus Step-up Approach (PANTER) trial. RESULTS The CT severity index was similar between studies (median of 8 in each). Time from onset of acute pancreatitis to PCD was shorter in the present series (median, 23 d vs 30 d). The total number of procedures (PCD and subsequent fluoroscopic drain studies) per patient was greater in the present series (mean, 14 vs 2). More patients in the PANTER trial had organ failure (62% vs 84%), required open or endoscopic necrosectomy (0% vs 60%), and experienced in-hospital mortality (0% vs 19%; P < .05 for all). CONCLUSIONS Even though patients in the present series had a similar CT severity index as those in the PANTER trial, the former group showed lower incidences of organ failure, need for necrosectomy, and in-hospital mortality. The use of a proactive PCD protocol early, before the development of severe sepsis, appeared to be effective.
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Lee JK. [Recent Advances in Management of Acute Pancreatitis]. THE KOREAN JOURNAL OF GASTROENTEROLOGY 2015; 66:135-43. [PMID: 26642477 DOI: 10.4166/kjg.2015.66.3.135] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
Acute pancreatitis is common but remains a condition with significant morbidity and mortality. Despite a better understanding of the pathophysiology of acute pancreatitis achieved during the past few decades, there is no specific pharmacologic entity available. Therefore, supportive care is still the mainstay of treatment. Recently, novel interventions for increasing survival and minimizing morbidity have been investigated, which are highlighted in this review.
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Chang YC. Is necrosectomy obsolete for infected necrotizing pancreatitis? Is a paradigm shift needed? World J Gastroenterol 2014; 20:16925-16934. [PMID: 25493005 PMCID: PMC4258561 DOI: 10.3748/wjg.v20.i45.16925] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/28/2014] [Revised: 07/07/2014] [Accepted: 09/30/2014] [Indexed: 02/06/2023] Open
Abstract
In 1886, Senn stated that removing necrotic pancreatic and peripancreatic tissue would benefit patients with severe acute pancreatitis. Since then, necrosectomy has been a mainstay of surgical procedures for infected necrotizing pancreatitis (NP). No published report has successfully questioned the role of necrosectomy. Recently, however, increasing evidence shows good outcomes when treating walled-off necrotizing pancreatitis without a necrosectomy. The literature concerning NP published primarily after 2000 was reviewed; it demonstrates the feasibility of a paradigm shift. The majority (75%) of minimally invasive necrosectomies show higher completion rates: between 80% and 100%. Transluminal endoscopic necrosectomy has shown remarkable results when combined with percutaneous drainage or a metallic stent. Related morbidities range from 40% to 92%. Single-digit mortality rates have been achieved with transluminal endoscopic necrosectomy, but not with video-assisted retroperitoneal necrosectomy series. Drainage procedures without necrosectomy have evolved from percutaneous drainage to transluminal endoscopic drainage with or without percutaneous endoscopic gastrostomy access for laparoscopic instruments. Most series have reached higher success rates of 79%-93%, and even 100%, using transcystic multiple drainage methods. It is becoming evident that transluminal endoscopic drainage treatment of walled-off NP without a necrosectomy is feasible. With further refinement of the drainage procedures, a paradigm shift from necrosectomy to drainage is inevitable.
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Endoscopic interventions for necrotizing pancreatitis. Am J Gastroenterol 2014; 109:969-81; quiz 982. [PMID: 24957157 DOI: 10.1038/ajg.2014.130] [Citation(s) in RCA: 47] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/30/2013] [Accepted: 03/11/2014] [Indexed: 02/06/2023]
Abstract
Interventions for necrotizing pancreatitis have undergone a paradigm shift away from open surgical necrosectomy and toward minimally invasive techniques, with endoscopic transmural drainage (ETD) and necrosectomy emerging as principle forms of treatment. Recent multicenter studies, randomized trials, evidence-based guidelines, and consensus statements have endorsed the safety and efficacy of endoscopic and other minimally invasive techniques for the treatment of walled-off necrosis. A comprehensive review of indications, standard and novel approaches, outcomes, complications, and controversies regarding ETD and necrosectomy is presented. Given the inherent challenges and associated risks, endoscopic techniques for the management of necrotizing pancreatitis should be performed at specialized multidisciplinary centers by expert endoscopists well versed in the management of necrotizing pancreatitis.
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Park J, Yang U. Systemic Review for The Effectiveness of Current Conservative Treatment in Necrotizing Pancreatitis. KOSIN MEDICAL JOURNAL 2014. [DOI: 10.7180/kmj.2014.29.1.11] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022] Open
Abstract
The standard treatment of pancreatic necrosis has been surgical necrosectomy. There has been debate on whether early surgical intervention can reduced by infected pancreatic necrosis (IPN). Early emergency laparotomy and multiple organ failure remain associated with high mortality. However, reports have presented during the last 10 years of survival of severe acute pancreatitis with medical management. Large and multicenter study showed that about two thirds of patients with necrotizing pancreatitis can be treated conservatively with relatively low mortality. Patients with IPN benefit from postponding intervention and minimal invasive treatment. We reviewed 4 literatures including 2 Korean institute reseached reports concerning non-surgical, conservative treatments of necrotizing pancreatitis including IPN. Large and multicenter study showed that about two thirds of patients with necrotizing pancreatitis can be treated conservatively with relatively low mortality.
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Evolution and results of the surgical management of 143 cases of severe acute pancreatitis in a referral centre. Cir Esp 2014; 92:595-603. [PMID: 24916318 DOI: 10.1016/j.ciresp.2014.04.009] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/22/2014] [Revised: 04/09/2014] [Accepted: 04/22/2014] [Indexed: 02/08/2023]
Abstract
INTRODUCTION Surgery is the accepted treatment for infected acute pancreatitis, although mortality remains high. As an alternative, a staged management has been proposed to improve results. Initial percutaneous drainage could allow surgery to be postponed, and improve postoperative results. Few centres in Spain have published their results of surgery for acute pancreatitis. OBJECTIVE To review the results obtained after surgical treatment of acute pancreatitis during a period of 12 years, focusing on postoperative mortality. MATERIAL AND METHODS We have reviewed the experience in the surgical treatment of severe acute pancreatitis (SAP) at Bellvitge University Hospital from 1999 to 2011. To analyse the results, 2 periods were considered, before and after 2005. A descriptive and analytical study of risk factors for postoperative mortality was performed RESULTS A total of 143 patients were operated on for SAP, and necrosectomy or debridement of pancreatic and/or peripancreatic necrosis was performed, or exploratory laparotomy in cases of massive intestinal ischemia. Postoperative mortality was 25%. Risk factors were advanced age (over 65 years), the presence of organ failure, sterility of the intraoperative simple, and early surgery (< 7 days). The only risk factor for mortality in the multivariant analysis was the time from the start of symptoms to surgery of<7 days; furthermore, 50% of these patients presented infection in one of the intraoperative cultures. CONCLUSIONS Pancreatic infection can appear at any moment in the evolution of the disease, even in early stages. Surgery for SAP has a high mortality rate, and its delay is a factor to be considered in order to improve results.
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Surgical versus nonsurgical treatment of infected pancreatic necrosis: more arguments to change the paradigm. J Gastrointest Surg 2013; 17:1627-33. [PMID: 23820801 DOI: 10.1007/s11605-013-2266-6] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/22/2013] [Accepted: 06/12/2013] [Indexed: 01/31/2023]
Abstract
OBJECTIVES This study aimed to compare primary surgical versus nonsurgical treatment in a series of patients with infected pancreatic necrosis (IPN) and to investigate whether the success of nonsurgical approach is related to a less severe disease. METHODS Thirty-nine consecutive patients with IPN have been included and further subdivided into two groups: primary surgical (n = 21) versus nonsurgical (n = 18). Outcome measures were the differences in mortality, morbidity, and pancreatic function. Comorbidity, organ failure, and other severity indexes were compared between the two groups. RESULTS Mortality occurred in 16.7% of cases in the nonsurgical group versus 42.9% in the surgical group. In the primary nonsurgical group, seven were operated on due to failure of initial conservative treatment. In this latter group, mortality was 28.6% and was performed significantly later than in the primary surgical group. The group of primary surgical treatment was associated with a significant higher rate of multiple organ failure (MOF) at IPN diagnosis, new onset or worsening of organ failure, and MOF and nosocomial infection after surgery. CONCLUSIONS Initial nonsurgical approach in IPN is associated with better results both in cases which respond to this treatment as well as in those who, failing this conservative approach, have to be operated on after a delayed period. Primary surgically treated patients had a more severe disease at the time of IPN.
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Yuan S, Sun DY. Application of bedside emergency ERCP in the treatment of severe acute biliary pancreatitis. Shijie Huaren Xiaohua Zazhi 2013; 21:2217-2220. [DOI: 10.11569/wcjd.v21.i22.2217] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023] Open
Abstract
AIM: To investigate the reliability and validity of bedside emergency endoscopic retrograde cholangiopancreatography (ERCP) without X-ray guidance in the treatment of severe acute biliary pancreatitis.
METHODS: Thirty-four patients with severe acute biliary pancreatitis in intensive care unit were enrolled into this prospective study. These patients were divided into either a treatment group (n = 14) or a control group (n = 18). The control group underwent routine comprehensive medical treatment. The treatment group was treated by bedside emergency ERCP without X-ray guidance. Selective bile duct cannulation was performed, and the success of intubation was confirmed by pumping back bile through ducts. Duodenal papilla sphincterotomy lithotomy, routine indwelling nose bile drainage, and secondary ERCP were conducted in case of necessity. Clinical effectiveness and costs were compared between the two groups.
RESULTS: All patients in the treatment group received successful selective bile duct intubation, and six of them needed secondary ERCP. Average time of abdominal pain relief was significantly less in the treatment group than in the control group (4.38 d ± 1.31 d vs 11.72 d ± 2.76 d, P < 0.05). The average hospitalization time was significantly shorter (12.69 d ± 3.09 d vs 25.61 d ± 7.41 d), P < 0.05) and the cost of hospitalization was significantly lower (4.77 × 104 RMB ± 0.97 × 104 RMB vs 10.04 × 104 RMB ± 2.29 × 104 RMB, P < 0.05) in the treatment group than in the control group. Incidence of complications was significantly lower in the treatment group than in the control group (6.25% vs 44.44%, P < 0.05). No statistic difference in mortality was found between the two groups.
CONCLUSION: Bedside emergency ERCP without X-ray guidance is a safe and effective treatment for severe acute biliary pancreatitis.
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Pupelis G, Fokin V, Zeiza K, Plaudis H, Suhova A, Drozdova N, Boka V. Focused open necrosectomy in necrotizing pancreatitis. HPB (Oxford) 2013; 15:535-40. [PMID: 23458703 PMCID: PMC3692024 DOI: 10.1111/hpb.12004] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/26/2012] [Accepted: 10/15/2012] [Indexed: 12/12/2022]
Abstract
BACKGROUND The control of sepsis is the primary goal of surgical intervention in patients with infected necrosis. Simple surgical approaches that are easy to reproduce may improve outcomes when specialists in endoscopy are not available. The aim of the present study was to describe the experience with a focused open necrosectomy (FON) in patients with infected necrosis. METHOD A prospective pilot study conducted to compare a semi-open/closed drainage laparotomy and FON with the assistance of peri-operative ultrasound. The incidence of sepsis, dynamics of C-reactive protein (CRP), intensive care unit (ICU)/hospital stay, complication rate and mortality were compared and analysed. RESULTS From a total of 58 patients, 36 patients underwent a conventional open necrosectomy and 22 patients underwent FON. The latter method resulted in a faster resolution of sepsis and a significant decrease in mean CRP on Day 3 after FON, P = 0.001. Post-operative bleeding was in 1 versus 7 patients and the incidence of intestinal and pancreatic fistula was 2 versus 8 patients when comparing FON to the conventional approach. The median ICU stay was 11.6 versus 23 days and the hospital stay was significantly shorter, 57 versus 72 days, P = 0.024 when comparing FON versus the conventional group. One patient died in the FON group and seven patients died in the laparotomy group, P = 0.139. DISCUSSION FON can be an alternative method to conventional open necrosectomy in patients with infected necrosis and unresolved sepsis.
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Affiliation(s)
- Guntars Pupelis
- Department of General and Emergency Surgery, Riga East Clinical University Hospital Gailezers, Riga, Latvia.
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Trikudanathan G, Arain M, Attam R, Freeman ML. Interventions for necrotizing pancreatitis: an overview of current approaches. Expert Rev Gastroenterol Hepatol 2013; 7:463-75. [PMID: 23899285 DOI: 10.1586/17474124.2013.811055] [Citation(s) in RCA: 28] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
The management of necrotizing pancreatitis has undergone a paradigm shift toward minimally invasive techniques for necrosectomy, obviating the need for open necrosectomy in most cases. There is increasing evidence that minimally invasive approaches including a step-up approach that incorporates percutaneous catheter or endoscopic transluminal drainage, followed by video-assisted retroperitoneal or endoscopic debridement are associated with improved outcomes over traditional open necrosectomy for patients with infected necrosis. A recent international multidisciplinary consensus conference emphasized the superiority of minimally invasive approaches over standard surgical approaches. The success of these techniques depends on concerted efforts of a multidisciplinary team of interventional endoscopists, radiologists, intensivists and surgeons dedicated to the management of severe acute pancreatitis and its complications. This review provides an overview of minimally invasive techniques for management of necrotizing pancreatitis, including indications, timing, advantages and disadvantages.
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Affiliation(s)
- Guru Trikudanathan
- Division of Gastroenterology, University of Minnesota, Minneapolis, Minnesota, USA
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Wroński M, Cebulski W, Karkocha D, Słodkowski M, Wysocki L, Jankowski M, Krasnodębski IW. Ultrasound-guided percutaneous drainage of infected pancreatic necrosis. Surg Endosc 2013; 27:2841-8. [PMID: 23404151 PMCID: PMC3710405 DOI: 10.1007/s00464-013-2831-9] [Citation(s) in RCA: 32] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/13/2012] [Accepted: 01/11/2013] [Indexed: 02/06/2023]
Abstract
Background The role of percutaneous drainage in the management of infected pancreatic necrosis remains controversial, and ultrasound-guided technique is rarely used for this indication. The purpose of this study was to evaluate the safety and efficacy of sonographically guided percutaneous catheter drainage for infected pancreatic necrosis. Methods The patient group consisted of 16 men and 2 women. The mean age of the patients was 47 years. The median computed tomography severity index of acute pancreatitis was 10 points. Percutaneous catheter drainage was performed under sonographic guidance using preferably retroperitoneal approach, and transperitoneal access in selected cases. The medical records and imaging scans were reviewed retrospectively for each patient. Results Percutaneous catheter drainage resulted in a complete resolution of infected pancreatic necrosis in 6 of 18 patients (33 %). Twelve of 18 patients who were initially managed with PCD required eventually necrosectomy (67 %). The most common reason for crossover to surgical intervention was persistent sepsis (n = 7). Open necrosectomy was performed in 4 of these patients, and 3 patients underwent successful minimally invasive retroperitoneal necrosectomy. Five patients required conversion to open surgery because of procedure-related complications. In 3 cases, there was leakage of the necrotic material into the peritoneal cavity. Two other patients experienced hemorrhagic complications. Overall mortality rate was 17 %. The size of the largest necrotic collection in patients who were successfully treated with percutaneous drainage decreased by a median of 76 % shortly after the procedure, whereas it decreased only by a median of 16 % in cases of failure of percutaneous drainage. Conclusions Ultrasound-guided percutaneous catheter drainage used in infected pancreatic necrosis is a technique with acceptably low morbidity and mortality that may be the definitive treatment or a bridge management to necrosectomy. A negligible decrease in size of the necrotic collection predicts failure of percutaneous drainage.
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Affiliation(s)
- Marek Wroński
- Department of General, Gastroenterological and Oncological Surgery, Medical University of Warsaw, ul. Banacha 1A, 02-097 Warsaw, Poland.
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Bello B, Matthews JB. Minimally invasive treatment of pancreatic necrosis. World J Gastroenterol 2012; 18:6829-35. [PMID: 23239921 PMCID: PMC3520172 DOI: 10.3748/wjg.v18.i46.6829] [Citation(s) in RCA: 41] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/18/2012] [Revised: 09/03/2012] [Accepted: 09/06/2012] [Indexed: 02/06/2023] Open
Abstract
AIM: To systematically review these minimally invasive approaches to infected pancreatic necrosis.
METHODS: We used the MEDLINE database to investigate studies between 1996 and 2010 with greater than 10 patients that examined these techniques. Using a combination of Boolean operators, reports were retrieved addressing percutaneous therapy (341 studies), endoscopic necrosectomy (574 studies), laparoscopic necrosectomy via a transperitoneal approach (148 studies), and retroperitoneal necrosectomy (194 studies). Only cohorts with at least 10 or more patients were included. Non-English papers, letters, animal studies, duplicate series and reviews without original data were excluded, leaving a total of 27 studies for analysis.
RESULTS: Twenty-seven studies with 947 patients total were examined (eight studies on percutaneous approach; ten studies on endoscopic necrosectomy; two studies on laparoscopic necrosectomy via a transperitoneal approach; five studies on retroperitoneal necrosectomy; and two studies on a combined percutaneous-retroperitoneal approach). Success rate, complications, mortality, and number of procedures were outcomes that were included in the review. We found that most published reports were retrospective in nature, and thus, susceptible to selection and publication bias. Few reports examined these techniques in a comparative, prospective manner.
CONCLUSION: Each minimally invasive approach though was found to be safe and feasible in multiple reports. With these new techniques, treatment of infected pancreatic necrosis remains a challenge. We advocate a multidisciplinary approach to this complex problem with treatment individualized to each patient.
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Abstract
Pancreatic and peripancreatic necrosis may result in significant morbidity and mortality in patients with acute pancreatitis. Many recommendations have been made for management of necrotizing pancreatitis, but no published guidelines have incorporated the many recent developments in minimally invasive techniques for necrosectomy. Hence, a multidisciplinary conference was convened to develop a consensus on interventions for necrotizing pancreatitis. Participants included most international experts from multiple disciplines. The evidence for efficacy of interventions was reviewed, presentations were given by experts, and a consensus was reached on each topic. In summary, intervention is primarily indicated for infected necrosis, less often for symptomatic sterile necrosis, and should ideally be delayed as long as possible, preferably 4 weeks or longer after the onset of disease, for better demarcation and liquefaction of the necrosis. Both the step-up approach using percutaneous drainage followed by minimally invasive video-assisted retroperitoneal debridement and per-oral endoscopic necrosectomy have been shown to have superior outcomes to traditional open necrosectomy with respect to short-term and long-term morbidity and are emerging as treatments of choice. Applicability of these techniques depends on the availability of specialized expertise and a multidisciplinary team dedicated to the management of severe acute pancreatitis and its complications.
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CT-guided percutaneous catheter drainage of acute infectious necrotizing pancreatitis: assessment of effectiveness and safety. AJR Am J Roentgenol 2012; 199:192-9. [PMID: 22733912 DOI: 10.2214/ajr.11.6984] [Citation(s) in RCA: 52] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
OBJECTIVE The purpose of this study is to assess retrospectively the effectiveness and safety of CT-guided percutaneous drainage and to determine the factors influencing clinical success and mortality in patients with infectious necrotizing pancreatitis. MATERIALS AND METHODS From April 1997 to December 2005, 48 consecutive patients (33 men and 15 women; median age, 58.5 years) with proven infectious necrotizing pancreatitis underwent percutaneous catheter drainage via CT guidance. Evaluated factors included clinical, biologic, and radiologic scores; drainage and catheter characteristics; and complications. Clinical success was defined as control of sepsis without requirement for surgery. Univariate analysis was performed to determine factors that could have affected the clinical success and the mortality rates. RESULTS Clinical success was achieved in 31 of 48 patients (64.6%) and was significantly associated with Ranson score (p = 0.01) and with the delay between admission and the beginning of the drainage (p = 0.005), with a calculated threshold delay of 18 days (p = 0.001). The global mortality rate (14/48 [29%]) was also influenced by the Ranson score (p = 01) and the delay of drainage (p = 0.04) with the same threshold delay (p = 0.01). Only two major nonlethal procedure-related complications were observed. CONCLUSION Percutaneous catheter drainage is a safe and effective technique to treat acute infectious necrotizing pancreatitis.
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Zerem E, Pavlović-Čalić N, Sušić A, Haračić B. Percutaneous management of pancreatic abscesses: long term results in a single center. Eur J Intern Med 2011; 22:e50-4. [PMID: 21925043 DOI: 10.1016/j.ejim.2011.01.015] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/14/2010] [Revised: 01/21/2011] [Accepted: 01/28/2011] [Indexed: 12/13/2022]
Abstract
BACKGROUND Several authors consider that surgical intervention is the gold standard for treatment of pancreatic abscesses. Recently, considerable interest has been generated in the minimally invasive management of pancreatic abscess with mixed results reported in the literature. AIM To evaluate the efficacy of percutaneous aspiration and/or drainage for patients with pancreatic abscesses. METHODS We performed a retrospective analysis of 62 patients with 87 pancreatic abscesses treated by percutaneous management from 1989 to 2009. All patients received appropriate antibiotic therapy. Patients with pancreatic abscess <50mm in diameter were initially treated by ultrasound-guided percutaneous needle aspiration (PNA) and those with abscess ≥50mm were initially treated by ultrasound-guided percutaneous catheter drainage (PCD). Surgery was planned only when there was no clinical improvement after the initial percutaneous treatment. Primary outcome was conversion rate to surgery. RESULTS Two patients (3.2%) received supportive treatment only and one of them died. PNA was performed in 16 patients (25.8%), and 8 of them required PCD because of recurrence of abscess. In 44 patients (70.1%), PCD was performed initially. PCD was performed twice in 6 patients and 3 times in 2 patients. There were 5 patients converted to surgery (8.1%) and one of them died. Medians (interquartile ranges) of hospital stay and catheter dwell-time were 17 (12-26) and 12 (9-21) days, respectively. There were no complications related to the procedure. CONCLUSIONS Percutaneous aspiration and/or drainage are effective and safe for the treatment of pancreatic abscesses.
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Affiliation(s)
- Enver Zerem
- University Clinical Center, Tuzla, 75000 Tuzla, Bosnia and Herzegovina.
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Zerem E, Imamović G, Sušić A, Haračić B. Step-up approach to infected necrotising pancreatitis: a 20-year experience of percutaneous drainage in a single centre. Dig Liver Dis 2011; 43:478-83. [PMID: 21478061 DOI: 10.1016/j.dld.2011.02.020] [Citation(s) in RCA: 65] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/18/2010] [Revised: 02/12/2011] [Accepted: 02/26/2011] [Indexed: 12/11/2022]
Abstract
AIM To evaluate the efficacy of step-up approach to infected necrotising pancreatitis. METHODS Retrospective analysis of 86 patients treated by step-up approach from 1989 to 2009. Infection was confirmed by examination of aspirated material or by presence of free pancreatic gas at contrast-enhanced computed tomography. Conservative treatment was initially attempted in all patients; percutaneous catheter drainage was performed when conservative therapy failed; surgery was planned only if no clinical improvement was observed. Primary outcome was mortality. RESULTS Fifteen patients (17.4%) were successfully treated with conservative treatment only. Percutaneous catheter drainage was performed in 69 (80.2%). Eight patients (9.3%) died, two at week 1 without drainage or surgery and six after percutaneous catheter drainage and surgery. Eleven patients were converted to surgery (12.8%). Organ failure occurred in 59/86 (68.6%) and multiorgan failure in 25/86 (29.1%). Median (interquartile ranges) hospital stay and catheter dwell times were 13 (9-47) and 15 (7-34) days, respectively. There were 2.61 catheter problems and 1.68 catheter changes per patient. CONCLUSIONS The step-up approach is an effective and safe strategy for the treatment of infected necrotising pancreatitis. Percutaneous drainage can avert the need for surgery in the majority of patients.
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Affiliation(s)
- Enver Zerem
- University Clinical Center, Tuzla, Bosnia and Herzegovina.
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van Baal MC, van Santvoort HC, Bollen TL, Bakker OJ, Besselink MG, Gooszen HG. Systematic review of percutaneous catheter drainage as primary treatment for necrotizing pancreatitis. Br J Surg 2011; 98:18-27. [PMID: 21136562 DOI: 10.1002/bjs.7304] [Citation(s) in RCA: 252] [Impact Index Per Article: 19.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
BACKGROUND The role of percutaneous catheter drainage (PCD) in patients with (infected) necrotizing pancreatitis was evaluated. METHODS A systematic literature search was performed. Inclusion criteria were: consecutive cohort of patients with necrotizing pancreatitis undergoing PCD as primary treatment for peripancreatic collections; indication for PCD either (suspected) infected necrosis or symptomatic sterile pancreatic necrosis; and outcomes reported to include percentage of infected peripancreatic collections, need for additional surgical necrosectomy, complications and deaths. Exclusion criteria were: cohort of fewer than five patients; cohort included patients with chronic pancreatitis; selected subgroup of patients with acute pancreatitis studied, such as those with pseudocysts, pancreatic abscesses and/or exclusively sterile pancreatic necrosis; and cohort in which PCD was combined with another minimally invasive strategy and results for PCD alone not reported separately. RESULTS Eleven studies, including 384 patients, fulfilled the inclusion criteria. Only one study was a randomized controlled trial; most others were retrospective case series. Four studies reported on the presence of organ failure before PCD; this occurred in 67·2 per cent of 116 patients. Infected necrosis was proven in 271 (70·6 per cent) of 384 patients. No additional surgical necrosectomy was required after PCD in 214 (55·7 per cent) of 384 patients. Complications consisted mostly of internal and external pancreatic fistulas. The overall mortality rate was 17·4 per cent (67 of 384 patients). Nine of 11 studies reported mortality separately for patients with infected necrosis undergoing PCD; the mortality rate in this group was 15·4 per cent (27 of 175). CONCLUSION A considerable number of patients can be treated with PCD without the need for surgical necrosectomy.
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Affiliation(s)
- M C van Baal
- Department of Surgery, University Medical Centre Utrecht, Utrecht, The Netherlands
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Affiliation(s)
- Jordan R Stem
- Department of Surgery, The University of Chicago Medical Center, 5841 South Maryland Avenue, Chicago, IL 60637, USA
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Abstract
The challenge for the pancreatologist managing patients with infected pancreatic necrosis is to devise a treatment algorithm that enables recovery but at the same time limits the morbidity and mortality. The current gold standard remains open necrosectomy. Recent literature contains scattered reports of endoscopic, radiologic, laparoscopic, percutaneous and lumbotomy approaches to managing patients with this condition. This literature review addresses the role of techniques that aim to minimize the physiological insult to the patient with infected pancreatic necrosis.
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Affiliation(s)
- A Peter Wysocki
- Department of Surgery, Logan Hospital, Meadowbrook, Queensland, Australia.
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Chow AW, Evans GA, Nathens AB, Ball CG, Hansen G, Harding GKM, Kirkpatrick AW, Weiss K, Zhanel GG. Canadian practice guidelines for surgical intra-abdominal infections. THE CANADIAN JOURNAL OF INFECTIOUS DISEASES & MEDICAL MICROBIOLOGY = JOURNAL CANADIEN DES MALADIES INFECTIEUSES ET DE LA MICROBIOLOGIE MEDICALE 2010; 21:11-37. [PMID: 21358883 PMCID: PMC2852280 DOI: 10.1155/2010/580340] [Citation(s) in RCA: 36] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
Affiliation(s)
- Anthony W Chow
- Division of Infectious Disease, Department of Medicine, University of British Columbia and Vancouver Hospital and Health Sciences Centre, Vancouver, British Columbia
| | - Gerald A Evans
- Division of Infectious Diseases, Department of Medicine, Queen’s University, Kingston
| | - Avery B Nathens
- Department of Surgery, University of Toronto, Toronto, Ontario
| | - Chad G Ball
- Department of Surgery, University of Calgary, Calgary, Alberta
| | - Glen Hansen
- Departments of Pathology and Laboratory Medicine, University of Minnesota and Hennepin County Medical Center, Minnesota, USA
| | - Godfrey KM Harding
- Department of Medical Microbiology and Medicine, University of Manitoba, Winnipeg, Manitoba
| | | | - Karl Weiss
- Department of Infectious Diseases and Microbiology, Hôspital Maisonneuve-Rosemont, University of Montreal, Montreal, Quebec
| | - George G Zhanel
- Department of Medical Microbiology and Medicine, University of Manitoba, Winnipeg, Manitoba
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Amano H, Takada T, Isaji S, Takeyama Y, Hirata K, Yoshida M, Mayumi T, Yamanouchi E, Gabata T, Kadoya M, Hattori T, Hirota M, Kimura Y, Takeda K, Wada K, Sekimoto M, Kiriyama S, Yokoe M, Hirota M, Arata S. Therapeutic intervention and surgery of acute pancreatitis. JOURNAL OF HEPATO-BILIARY-PANCREATIC SCIENCES 2009; 17:53-9. [PMID: 20012651 DOI: 10.1007/s00534-009-0211-6] [Citation(s) in RCA: 35] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/01/2009] [Accepted: 09/01/2009] [Indexed: 02/08/2023]
Abstract
The clinical course of acute pancreatitis varies from mild to severe. Assessment of severity and etiology of acute pancreatitis is important to determine the strategy of management for acute pancreatitis. Acute pancreatitis is classified according to its morphology into edematous pancreatitis and necrotizing pancreatitis. Edematous pancreatitis accounts for 80-90% of acute pancreatitis and remission can be achieved in most of the patients without receiving any special treatment. Necrotizing pancreatitis occupies 10-20% of acute pancreatitis and the mortality rate is reported to be 14-25%. The mortality rate is particularly high (34-40%) for infected pancreatic necrosis that is accompanied by bacterial infection in the necrotic tissue of the pancreas (Widdison and Karanjia in Br J Surg 80:148-154, 1993; Ogawa et al. in Research of the actual situations of acute pancreatitis. Research Group for Specific Retractable Diseases, Specific Disease Measure Research Work Sponsored by Ministry of Health, Labour, and Welfare. Heisei 12 Research Report, pp 17-33, 2001). On the other hand, the mortality rate is reported to be 0-11% for sterile pancreatic necrosis which is not accompanied by bacterial infection (Ogawa et al. 2001; Bradely and Allen in Am J Surg 161:19-24, 1991; Rattner et al. in Am J Surg 163:105-109, 1992). The Japanese (JPN) Guidelines were designed to provide recommendations regarding the management of acute pancreatitis in patients having a variety of clinical characteristics. This article describes the guidelines for the surgical management and interventional therapy of acute pancreatitis by incorporating the latest evidence for the management of acute pancreatitis in the Japanese-language version of JPN guidelines 2010. Eleven clinical questions (CQ) are proposed: (1) worsening clinical manifestations and hematological data, positive blood bacteria culture test, positive blood endotoxin test, and the presence of gas bubbles in and around the pancreas on CT scan are indirect findings of infected pancreatic necrosis; (2) bacteriological examination by fine needle aspiration is useful for making a definitive diagnosis of infected pancreatic necrosis; (3) conservative treatment should be performed in sterile pancreatic necrosis; (4) infected pancreatic necrosis is an indication for interventional therapy. However, conservative treatment by antibiotic administration is also available in patients who are in stable general condition; (5) early surgery for necrotizing pancreatitis is not recommended, and it should be delayed as long as possible; (6) necrosectomy is recommended as a surgical procedure for infected necrosis; (7) after necrosectomy, a long-term follow-up paying attention to pancreatic function and complications including the stricture of the bile duct and the pancreatic duct is necessary; (8) drainage including percutaneous, endoscopic and surgical procedure should be performed for pancreatic abscess; (9) if the clinical findings of pancreatic abscess are not improved by percutaneous or endoscopic drainage, surgical drainage should be performed; (10) interventional treatment should be performed for pancreatic pseudocysts that give rise to symptoms, accompany complications or increase the diameter of cysts and (11) percutaneous drainage, endoscopic drainage or surgical procedures are selected in accordance with the conditions of individual cases.
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Affiliation(s)
- Hodaka Amano
- Department of Surgery, Teikyo University School of Medicine, 2-11-1, Kaga-cho, Itabashi, Tokyo, 173-8605, Japan.
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Treatment strategy for acute pancreatitis. JOURNAL OF HEPATO-BILIARY-PANCREATIC SCIENCES 2009; 17:79-86. [PMID: 20012325 DOI: 10.1007/s00534-009-0218-z] [Citation(s) in RCA: 27] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/01/2009] [Accepted: 09/01/2009] [Indexed: 12/16/2022]
Abstract
When a diagnosis of acute pancreatitis (AP) is made, fundamental medical treatment consisting of fasting, intravenous (IV) fluid replacement, and analgesics with a close monitoring of vital signs should be immediately started. In parallel with fundamental medical treatment, assessment of severity based on clinical signs, blood test, urinalysis and imaging tests should be performed to determine the way of treatment for each patient. A repeat evaluation of severity is important since the condition is unstable especially in the early stage of AP. At the time of initial diagnosis, the etiology should be investigated by means of blood test, urinalysis and diagnostic imaging. If a biliary pancreatitis accompanied with acute cholangitis or biliary stasis is diagnosed or suspected, an early endoscopic retrograde cholangiopancreatography with or without endoscopic sphincterotomy (ERCP/ES) is recommended in addition to the fundamental medical treatment. In mild cases, the fundamental medical treatment should be continued until clinical symptom is subsided with normal laboratory data. In cases with severe acute pancreatitis (SAP) referral should be considered to medical centers experienced in the treatment of SAP, and intensive care is recommended for preventing both organ failures and infectious complications. Hemodynamic stabilization with vigorous fluid resuscitation, respiratory support and antibiotics are the major parts of intensive care in the early period of SAP. Continuous hemodiafiltration (CHDF) and continuous regional arterial infusion (CRAI) of protease inhibitor and/or antibiotics may be effective to improve pathophysiology of AP especially in the early stage of the disease. In the late stage of AP, infectious complications are critical. If an infectious complication is suspected based on clinical signs, blood test and imaging, a fine needle aspiration (FNA) is recommended to establish a diagnosis. The accuracy of FNA is reported to be 89 ~ 100%. For patients with sterile pancreatitis, non-surgical treatment should be indicated. For patients with infected pancreatic necrosis, therapeutic intervention either by percutaneous, endoscopic, laparoscopic or surgical approach are indicated. The most preferred surgical intervention is necrosectomy, however, non-surgical treatment with antibiotics is still the treatment of choice if the general condition is stable. Necrosectomy should be performed as late as possible. For patients with pancreatic abscess, drainage is recommended.
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Carvalho FRD, Santos JSD, Elias Junior J, Kemp R, Sankarankutty AK, Fukumori OY, Souza MCLDA, Castro-e-Silva OD. The influence of treatment access regulation and technological resources on the mortality profile of acute biliary pancreatitis. Acta Cir Bras 2009; 23 Suppl 1:143-50; discussion 150. [PMID: 18516462 DOI: 10.1590/s0102-86502008000700023] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/12/2023] Open
Abstract
PURPOSE The influence of treatment access regulation and technological resources on the mortality profile of acute biliary pancreatitis (ABP) was evaluated. METHODS The cases seen in a tertiary hospital were studied during two periods of time: 1995-1999 and 2000-2004, i.e., before and after the implementation of medical regulation. RESULTS Among the 727 patients with acute pancreatitis, 267 had ABP and were classified according to APACHE II scores. The cases being referred to the tertiary hospital decreased from 441 to 286 (p < 0.001). The patients' profile regarding age, gender, severity, cholestasis incidence and mortality were similar during the first and second periods of study (n = 154 and n = 113, respectively). The number of patients with hematocrit > or =44% was smaller during the second study period (p<0.002). The use of magnetic resonance cholangiography, videolaparoscopic cholecystectomy, and access to the ICU were found to be more frequent during the second study period. Regarding the deaths occurring within 14 days of hospitalisation, 73.4% and 81.3% were observed during the first and second study periods, respectively. CONCLUSION Since the improvement in clinical and technological approach was not enough to modify the mortality profile of ABP, further studies on the treatment of inflammatory responses should be carried out.
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Affiliation(s)
- Francisco Ribeiro de Carvalho
- Division of Digestive Surgery, Department of Surgery and Anatomy, Ribeirão Preto Faculty of Medicine, University of São Paulo, SP, Brazil.
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Pap A. [Invasive endoscopy or surgery for pancreatic disorders?]. Orv Hetil 2008; 149:2325-8. [PMID: 19042184 DOI: 10.1556/oh.2008.28483] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
Abstract
Endoscopic double papillotomy occupied the place of surgical transduodenal double sphincteroplasty for disorders of papilla of Vater or chronic pancreatitis several years ago. Endoscopic cystoenterostomy and cystogastrostomy can also replace surgery in the treatment of pseudocysts and walled-of necrosis even in cases of severe acute pancreatitis with/or without sepsis. In chronic pancreatitis endotherapy may be the treatment of choice at first, although surgical techniques give somewhat better long-term results for pain relief. Extracorporeal shock wave lithotripsy, stone resolution or extraction and multiple pancreatic stents without aggressive balloon dilatation can progressively calibrate dominant stricture of the main pancreatic duct without further damage, ischemia or obstruction of side branches. Relapse-free period becomes longer (also after stents removal) if alcohol consumption and smoking are stopped definitively. Well-controlled, randomised studies are still needed to demonstrate clinical advantage of multiple endoscopic stent placement in comparison to surgery.
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Affiliation(s)
- Akos Pap
- Országos Onkológiai Intézet Gasztroenterológia/Endoszkópia Budapest Ráth György u. 7-9. 1122.
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Winternitz T. [Minimally invasive interventions in the treatment of pancreatic diseases]. Orv Hetil 2008; 149:2277-81. [PMID: 19028650 DOI: 10.1556/oh.2008.28484] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
Abstract
We have used minimal invasive therapy in the treatment of pancreatic diseases for a long time. CT and/or ultrasound guided techniques have been used for the treatment of pancreatic pseudocysts for more than 20 years. The development of technology has also made an opportunity for the extensive use of laparoscopic surgery at patients suffering from pancreatic diseases. Currently, almost every type of open operation has a laparoscopic version, too. By now we can take part in the combined use of the CT/US and laparoscopic techniques. Recently the new NOTES procedures have appeared. Based on the literary items, the author summarizes the possibilities of minimal invasive treatments in pancreatic diseases.
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Affiliation(s)
- Tamás Winternitz
- Semmelweis Egyetem, Altalános Orvostudományi Kar I. Sebészeti Klinika Budapest Ullôi út 78. 1082.
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Navarro S, Amador J, Argüello L, Ayuso C, Boadas J, de Las Heras G, Farré A, Fernández-Cruz L, Ginés A, Guarner L, López Serrano A, Llach J, Lluis F, de Madaria E, Martínez J, Mato R, Molero X, Oms L, Pérez-Mateo M, Vaquero E. [Recommendations of the Spanish Biliopancreatic Club for the Treatment of Acute Pancreatitis. Consensus development conference]. GASTROENTEROLOGIA Y HEPATOLOGIA 2008; 31:366-87. [PMID: 18570814 DOI: 10.1157/13123605] [Citation(s) in RCA: 23] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Affiliation(s)
- Salvador Navarro
- Servicio de Gastroenterología, Institut de Malalties Digestives i Metabóliques, Hospital Clínic, Barcelona, Spain.
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Abstract
The past two decades have seen major advances in the understanding and clinical management of acute pancreatitis, yet it still lacks a specific treatment, and management is largely supportive and reactive. Surgery is seeing a diminishing role in the early phase of acute pancreatitis but still predominates in the management of infected pancreatic necrosis--the most lethal complication. This review focuses on recent literature but begins with an account of the evolution of infected necrosis management, which serves to place current treatment into context. Although surgeons initially emphasized less invasive approaches to pancreatic necrosis, they now compete with new techniques developed by pioneering physicians, radiologists, and interventional endoscopists. Clinicians adopting the new techniques will need to emulate the dedication and commitment that the current pioneers demonstrate. Although new techniques are still evolving, they should be evaluated against existing standards of treatment.
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Affiliation(s)
- Mike Larvin
- Division of Surgery, School of Graduate Entry Medicine and Health, University of Nottingham at Derby, Derby City General Hospital, Derby, DE22 3DT, UK.
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