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Timmerhuis HC, Ngongoni RF, Li A, McGuire SP, Lewellen KA, Dua MM, Chughtai K, Zyromski NJ, Visser BC. The Potential Clinical Benefits of Direct Surgical Transgastric Pancreatic Necrosectomy for Patients With Infected Necrotizing Pancreatitis. Pancreas 2024; 53:e573-e578. [PMID: 38986078 DOI: 10.1097/mpa.0000000000002334] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 07/12/2024]
Abstract
OBJECTIVE Surgical transgastric pancreatic necrosectomy (STGN) has the potential to overcome the shortcomings (ie, repeat interventions, prolonged hospitalization) of the step-up approach for infected necrotizing pancreatitis. We aimed to determine the outcomes of STGN for infected necrotizing pancreatitis. MATERIALS AND METHODS This observational cohort study included adult patients who underwent STGN for infected necrosis at two centers from 2008 to 2022. Patients with a procedure for pancreatic necrosis before STGN were excluded. Primary outcomes included mortality, length of hospital and intensive care unit (ICU) stay, new-onset organ failure, repeat interventions, pancreatic fistulas, readmissions, and time to episode closure. RESULTS Forty-three patients underwent STGN at a median of 48 days (interquartile range [IQR] 32-70) after disease onset. Mortality rate was 7% (n = 3). After STGN, the median length of hospital was 8 days (IQR 6-17), 23 patients (53.5%) required ICU admission (2 days [IQR 1-7]), and new-onset organ failure occurred in 8 patients (18.6%). Three patients (7%) required a reintervention, 1 (2.3%) developed a pancreatic fistula, and 11 (25.6%) were readmitted. The median time to episode closure was 11 days (IQR 6-22). CONCLUSIONS STGN allows for treatment of retrogastric infected necrosis in one procedure and with rapid episode resolution. With these advantages and few pancreatic fistulas, direct STGN challenges the step-up approach.
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Affiliation(s)
- Hester C Timmerhuis
- From the Department of Surgery, Stanford University School of Medicine, Stanford CA
| | - Rejoice F Ngongoni
- From the Department of Surgery, Stanford University School of Medicine, Stanford CA
| | - Amy Li
- From the Department of Surgery, Stanford University School of Medicine, Stanford CA
| | - Sean P McGuire
- Departments of Surgery and Division of Gastroenterology, Indiana University School of Medicine and Indiana University Health, Indianapolis, IN
| | - Kyle A Lewellen
- Departments of Surgery and Division of Gastroenterology, Indiana University School of Medicine and Indiana University Health, Indianapolis, IN
| | - Monica M Dua
- From the Department of Surgery, Stanford University School of Medicine, Stanford CA
| | - Komal Chughtai
- Department of Radiology, Stanford University School of Medicine, Stanford, CA
| | - Nicholas J Zyromski
- Departments of Surgery and Division of Gastroenterology, Indiana University School of Medicine and Indiana University Health, Indianapolis, IN
| | - Brendan C Visser
- From the Department of Surgery, Stanford University School of Medicine, Stanford CA
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Valentin C, Le Cosquer G, Tuyeras G, Culetto A, Barange K, Hervieu PE, Carrère N, Muscari F, Mokrane F, Otal P, Bournet B, Suc B, Buscail L. Step-up approach for the treatment of infected necrotising pancreatitis: real life data from a single-centre experience with long-term follow-up. BMC Gastroenterol 2024; 24:213. [PMID: 38943052 PMCID: PMC11214239 DOI: 10.1186/s12876-024-03289-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/27/2023] [Accepted: 06/07/2024] [Indexed: 07/01/2024] Open
Abstract
BACKGROUND About 20% of patients with acute pancreatitis develop a necrotising form with a worse prognosis due to frequent appearance of organ failure(s) and/or infection of necrosis. Aims of the present study was to evaluate the "step up" approach treatment of infected necrosis in terms of: feasibility, success in resolving infection, morbidity of procedures, risk factors associated with death and long-term sequels. METHODS In this observational retrospective monocentric study in the real life, necrotizing acute pancreatitis at the stage of infected walled-off necrosis were treated as follow: first step with drainage (radiologic and/or endoscopic-ultrasound-guided with lumen apposing metal stent); in case of failure, minimally invasive necrosectomy sessions(s) by endoscopy through the stent and/or via retroperitoneal surgery (step 2); If necessary open surgery as a third step. Efficacy was assessed upon to a composite clinical-biological criterion: resolution of organ failure(s), decrease of at least two of clinico-biological criteria among fever, CRP serum level, and leucocytes count). RESULTS Forty-one consecutive patients were treated. The step-up strategy: (i) was feasible in 100% of cases; (ii) allowed the infection to be resolved in 33 patients (80.5%); (iii) Morbidity was mild and rapidly resolutive; (iv) the mortality rate at 6 months was of 19.5% (significant factors: SIRS and one or more organ failure(s) at admission, fungal infection, size of the largest collection ≥ 16 cm). During the follow-up (median 72 months): 27% of patients developed an exocrine pancreatic insufficiency, 45% developed or worsened a previous diabetes, 24% had pancreatic fistula and one parietal hernia. CONCLUSIONS Beside a very good feasibility, the step-up approach for treatment of infected necrotizing pancreatitis in the real life displays a clinico-biological efficacy in 80% of cases with acceptable morbidity, mortality and long-term sequels regarding the severity of the disease.
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Affiliation(s)
- Claire Valentin
- Department of Gastroenterology and Pancreatology, Toulouse Rangueil University Hospital, 1 avenue Jean Poulhès, TSA 50032, Toulouse Cedex 9, 31059, France
| | - Guillaume Le Cosquer
- Department of Gastroenterology and Pancreatology, Toulouse Rangueil University Hospital, 1 avenue Jean Poulhès, TSA 50032, Toulouse Cedex 9, 31059, France
| | - Géraud Tuyeras
- Department of Digestive Surgery, Toulouse Rangueil University Hospital, Toulouse, France
| | - Adrian Culetto
- Department of Gastroenterology and Pancreatology, Toulouse Rangueil University Hospital, 1 avenue Jean Poulhès, TSA 50032, Toulouse Cedex 9, 31059, France
| | - Karl Barange
- Department of Hepatology, Toulouse Rangueil University Hospital, Toulouse, France
| | - Pierre-Emmanuel Hervieu
- Department of Gastroenterology and Pancreatology, Toulouse Rangueil University Hospital, 1 avenue Jean Poulhès, TSA 50032, Toulouse Cedex 9, 31059, France
| | - Nicolas Carrère
- Department of Digestive Surgery, Toulouse Rangueil University Hospital, Toulouse, France
| | - Fabrice Muscari
- Department of Digestive Surgery, Toulouse Rangueil University Hospital, Toulouse, France
| | - Fatima Mokrane
- Department of Radiology, Toulouse Rangueil University Hospital, Toulouse, France
| | - Philippe Otal
- Department of Radiology, Toulouse Rangueil University Hospital, Toulouse, France
| | - Barbara Bournet
- Department of Gastroenterology and Pancreatology, Toulouse Rangueil University Hospital, 1 avenue Jean Poulhès, TSA 50032, Toulouse Cedex 9, 31059, France
| | - Bertrand Suc
- Department of Digestive Surgery, Toulouse Rangueil University Hospital, Toulouse, France
| | - Louis Buscail
- Department of Gastroenterology and Pancreatology, Toulouse Rangueil University Hospital, 1 avenue Jean Poulhès, TSA 50032, Toulouse Cedex 9, 31059, France.
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Jaeger K, Meyer F, Füldner F, Will U. Endoscopic necrosectomy of infected WON in acute necrotising pancreatitis - Development of an effective therapeutic algorithm based on a single-center consecutive patient cohort. ZEITSCHRIFT FUR GASTROENTEROLOGIE 2023; 61:665-675. [PMID: 36126931 DOI: 10.1055/a-1890-5674] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/09/2023]
Abstract
OBJECTIVE Development of an effective therapeutic algorithm for interventional (minimally invasive) approach to infected walled-off necrosis (WON) in patients with necrotising pancreatitis reflecting real-word data. MATERIAL/METHODS All consecutive patients who underwent endoscopic necrosectomy for necrotising pancreatitis through a defined study period were enclosed in this retrospective observational case study. The therapeutic approach was analysed for clinical success rate, complication spectrum and rate as well as mortality and compared with data from the literature. Finally, a therapeutic algorithm was derived. RESULTS From 2004 to 2019, 126 patients with necrotising pancreatitis (median of APACHE II score, 10.5 points) were treated. In 92.9 % of cases (n=117), an infected WON with microbial pathogen detection was found. After a median of 18 days from symptom onset, first intervention was performed (53.2 % as percutaneous drainage with programmed rinsing, 29.4 % as EUS-guided internal drainage). From 2004 to 2010, double pigtail stents were used. Later, lumen-apposing metal stent (LAMS) such as AXIOSTM stent (Boston Scientific, Ratingen, Germany) was preferred. The combined percutaneous and internal drainage was performed in approximately 50 % of subjects.Endoscopic transluminal necrosectomy was performed in 123 patients (97.6 %) at a median of 33 days from symptom onset. Endoscopic percutaneous necrosectomy was conducted in 11.1 % of the individuals. A median number of two endoscopic necrosectomy sessions per patient was necessary for the therapy. The clinical success rate (discharge without surgical intervention) was 82.5 %. The complication rate (bleeding and perforation) and the need for surgery were both 9.5 %. The overall mortality was 8.7 %. CONCLUSION Therapy of necrotising pancreatitis with infected WON consists of early calculated antibiotic therapy with adequate drainage. Combined external and internal drainages with programmed rinsing seem to improve prognosis, as well as minimise I) : the need for forced necrosectomies (mainly via a transluminal access site) and II) : complication rate as well as, thus, improve outcome.
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Affiliation(s)
- Kristin Jaeger
- Dept. of Internal Medicine III (Gastroenterology, Hepatology, General Internal Medicine), Municipal Hospital ("SRH Wald-Klinikum Gera GmbH"), Gera, Germany
| | - Frank Meyer
- Dept. of General, Abdominal, Vascular and Transplant Surgery, Otto-von-Guericke University with University Hospital, Magdeburg, Germany
| | - Frank Füldner
- Dept. of Internal Medicine III (Gastroenterology, Hepatology, General Internal Medicine), Municipal Hospital ("SRH Wald-Klinikum Gera GmbH"), Gera, Germany
| | - Uwe Will
- Dept. of Internal Medicine III (Gastroenterology, Hepatology, General Internal Medicine), Municipal Hospital ("SRH Wald-Klinikum Gera GmbH"), Gera, Germany
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Sameera S, Mohammad T, Liao K, Shahid H, Sarkar A, Tyberg A, Kahaleh M. Management of Pancreatic Fluid Collections: An Evidence-based Approach. J Clin Gastroenterol 2023; 57:346-361. [PMID: 36040932 DOI: 10.1097/mcg.0000000000001750] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/10/2022]
Abstract
Managing pancreatic fluid collections (PFCs) remains a challenge for many clinicians. Recently, significant progress has been made in the therapy of PFCs, including improvements in technology and devices, as well as in the development of minimally invasive endoscopic techniques, many of which are proven less traumatic when compared with surgical options and more efficacious when compared with percutaneous techniques. This review will explore latest developments in the management of PFCs and how they incorporate into the current treatment algorithm.
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Affiliation(s)
- Sohini Sameera
- Department of Gastroenterology & Hepatology, Rutgers Robert Wood Johnson Medical School, New Brunswick, NJ
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Hydrogen peroxide assisted endoscopic necrosectomy for walled-off pancreatic necrosis: A systematic review and meta-analysis. Pancreatology 2021; 21:1540-1547. [PMID: 34565668 DOI: 10.1016/j.pan.2021.09.007] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/03/2021] [Revised: 09/04/2021] [Accepted: 09/17/2021] [Indexed: 12/11/2022]
Abstract
BACKGROUND AND AIMS Endoscopic necrosectomy (EN) is the preferred approach for management of symptomatic or infected walled-off pancreatic necrosis (WOPN). Hydrogen peroxide (H2O2) has been reported to be a good adjunctive therapy for EN. We performed a systematic review and meta-analysis to evaluate effectiveness and safety of H2O2 assisted EN for WOPN. METHODS A comprehensive search of multiple databases (through December 2020) was performed to identify studies that reported outcomes of H2O2 assisted EN for WOPN. Outcomes assessed included clinical success, technical success, and adverse events. RESULTS A total of 454 patients with mean age (47.3 ± 7.9 years) and WOPN size (12.4 ± 3.1 cm) were included from 15 studies. The median H2O2 concentration was 3% (range 0.1-3%), with dilution and volume ranging from 1:1 to 10:1 and 20 ml to 1 L, respectively. The rates of technical success, clinical success and adverse events was 97.3% (95% confidence interval [CI]: 94.8-98.6, I2 = 0), 89.8% (95% CI: 86.3-92.5, I2 = 0) and 17.9% (95% CI: 12.6-24.7, I2 = 38), respectively. The most common adverse event was bleeding (7.1%) followed by stent migration (5.3%). On meta-regression, WOPN size, patient age, use of metal stent, number of necrosectomies and transgastric access were not significant predictor for technical success, clinical success or adverse events. CONCLUSION H2O2 assisted EN is effective and safe for management of WOPN. Its use may be encouraged, and future randomized controlled studies are needed to study the optimal technique, concentration and best predictors of success.
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Pinto S, Bellizzi S, Badas R, Canfora ML, Loddo E, Spada S, Khalaf K, Fugazza A, Bergamini S. Direct Endoscopic Necrosectomy: Timing and Technique. MEDICINA (KAUNAS, LITHUANIA) 2021; 57:medicina57121305. [PMID: 34946249 PMCID: PMC8707414 DOI: 10.3390/medicina57121305] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 10/18/2021] [Revised: 11/22/2021] [Accepted: 11/24/2021] [Indexed: 12/12/2022]
Abstract
Walled-off pancreatic necrosis (WOPN) is one of the local complications of acute pancreatitis (AP). Several interventional techniques have been developed over the last few years. The purpose of this narrative review is to explore such methodologies, with specific focus on endoscopic drainage and direct endoscopic necrosectomy (DEN), through evaluation of their indications and timing for intervention. Findings indicated how, after the introduction of lumen-apposing metal stents (LAMS), DEN is becoming the favorite technique to treat WOPN, especially when large solid debris or infection are present. Additionally, DEN is associated with a lower adverse events rate and hospital stay, and with improved clinical outcome.
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Affiliation(s)
- Sergio Pinto
- Digestive Endoscopy Unit, Department of Surgical Sciences, University Hospital of Cagliari, 09042 Cagliari, Italy; (R.B.); (M.L.C.); (E.L.); (S.S.); (S.B.)
- Correspondence: ; Tel.: +39-07051096423
| | - Saverio Bellizzi
- Medical Epidemiologist, Independent Consultant, 1202 Geneva, Switzerland;
| | - Roberta Badas
- Digestive Endoscopy Unit, Department of Surgical Sciences, University Hospital of Cagliari, 09042 Cagliari, Italy; (R.B.); (M.L.C.); (E.L.); (S.S.); (S.B.)
| | - Maria Laura Canfora
- Digestive Endoscopy Unit, Department of Surgical Sciences, University Hospital of Cagliari, 09042 Cagliari, Italy; (R.B.); (M.L.C.); (E.L.); (S.S.); (S.B.)
| | - Erica Loddo
- Digestive Endoscopy Unit, Department of Surgical Sciences, University Hospital of Cagliari, 09042 Cagliari, Italy; (R.B.); (M.L.C.); (E.L.); (S.S.); (S.B.)
| | - Simone Spada
- Digestive Endoscopy Unit, Department of Surgical Sciences, University Hospital of Cagliari, 09042 Cagliari, Italy; (R.B.); (M.L.C.); (E.L.); (S.S.); (S.B.)
| | - Kareem Khalaf
- Department of Biomedical Sciences, Humanitas University, Pieve Emanuele, 20090 Milano, Italy;
| | - Alessandro Fugazza
- Digestive Endoscopy Unit, Department of Gastroenterology, Humanitas Research Hospital-IRCCS, 20089 Rozzano, Italy;
| | - Silvio Bergamini
- Digestive Endoscopy Unit, Department of Surgical Sciences, University Hospital of Cagliari, 09042 Cagliari, Italy; (R.B.); (M.L.C.); (E.L.); (S.S.); (S.B.)
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7
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Mat E, Kale A, Yıldız G, Başol G, Gündogdu EC. Alternative method for the diagnosis of acid cases of unknown cause: Transvaginal natural orifice transluminal endoscopic surgery. J Obstet Gynaecol Res 2020; 47:645-652. [PMID: 33197989 DOI: 10.1111/jog.14575] [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: 07/14/2020] [Revised: 10/20/2020] [Accepted: 11/03/2020] [Indexed: 12/21/2022]
Abstract
AIM To evaluate the efficacy and reliability of transvaginal natural orifice transluminal endoscopic surgery (vNOTES) technique in making the diagnosis of ascites with unknown cause. METHODS Seven patients with ascites with unknown cause and diagnosed with vNOTES between November 2018 and May 2019 were analyzed retrospectively. The following data were collected retrospectively: body mass index, age, parity, previous abdominal or pelvic surgery, total operating time, perioperative complications and visual analog scale scores for evaluation of postoperative pain. After general anesthesia and disinfection, a 2-3 cm incision was made in the posterior fornix of the vagina. In all of the vNOTES procedures, a handmade glove port system comprised of a glove-wound retractor NOTES port was used. RESULTS Transvaginal natural orifice transluminal endoscopic surgery for diagnostic peritoneoscopy was successfully performed in seven patients. Following postoperative pathological examination; three patients were established to have peritoneal carcinomatosis, one patient abdominal tuberculous, one patient ovarian fibroma, one patient ovarian mature cystic teratoma and one patient stomach cancer. In 1-year follow-up period after vNOTES procedure, no adverse events occurred in patients. CONCLUSION In making histological diagnosis of ascites with unknown cause, vNOTES is a feasible, safe and efficient technique. Due to its high performance in diagnosis, this technique helps to initiate treatment early in some diseases in addition to preventing unnecessary treatment and examination in benign diseases. Besides, via obtaining a detailed and enlarged image of abdominal cavity, this procedure also guides the clinician in the evaluation of the suitability of patient for operation.
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Affiliation(s)
- Emre Mat
- Department of Obstetrics and Gynecology, University of Health Sciences, Kartal Dr. Lutfi Kirdar Research and Training Hospital, Istanbul, Turkey
| | - Ahmet Kale
- Department of Obstetrics and Gynecology, University of Health Sciences, Kartal Dr. Lutfi Kirdar Research and Training Hospital, Istanbul, Turkey
| | - Gazi Yıldız
- Department of Obstetrics and Gynecology, University of Health Sciences, Kartal Dr. Lutfi Kirdar Research and Training Hospital, Istanbul, Turkey
| | - Gülfem Başol
- Department of Obstetrics and Gynecology, University of Health Sciences, Kartal Dr. Lutfi Kirdar Research and Training Hospital, Istanbul, Turkey
| | - Elif C Gündogdu
- Department of Obstetrics and Gynecology, University of Health Sciences, Kartal Dr. Lutfi Kirdar Research and Training Hospital, Istanbul, Turkey
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Liu ZW, Yang SZ, Wang PF, Feng J, He L, Du JD, Xiao YY, Jiao HB, Zhou FH, Song Q, Zhou MT, Xin XL, Chen JY, Ren WZ, Lu SC, Cai SW, Dong JH. Minimal-access retroperitoneal pancreatic necrosectomy for infected necrotizing pancreatitis: a multicentre study of a step-up approach. Br J Surg 2020; 107:1344-1353. [PMID: 32449154 DOI: 10.1002/bjs.11619] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/28/2019] [Revised: 03/23/2019] [Accepted: 03/16/2020] [Indexed: 12/17/2022]
Abstract
BACKGROUND Various minimally invasive approaches have been described for infected necrotizing pancreatitis. This article describes a modified minimal-access retroperitoneal pancreatic necrosectomy (MARPN) procedure assisted by gas insufflation. METHODS This retrospective, observational study documented patients who had undergone a step-up MARPN between 1 January 2010 and 31 December 2016. A minimum follow-up of 1 year was required for inclusion. The step-up approach involved percutaneous catheter drainage followed by the modified MARPN and necrosectomy. If more than one access site was needed it was categorized as complex MARPN. RESULTS Of 212 patients with infected necrotizing pancreatitis, 164 (77·4 per cent) underwent a step-up approach. The median number of percutaneous catheter drains and MARPN procedures was 3 (range 1-7) and 1 (1-6) respectively. Ninety patients (54·9 per cent) underwent complex MARPN. For residual necrosis after MARPN, three patients (1·8 per cent) underwent sinus tract gastroscopy, and 11 (6·7 per cent) had sinography combined with a tube change. However, operations in 13 patients (7·9 per cent) required conversion to open surgery. Postoperative complications developed in 103 patients (62·8 per cent). The mortality rate was 6·1 per cent (10 deaths). CONCLUSION A step-up approach using a modified MARPN for infected necrotizing pancreatitis is a reasonable option.
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Affiliation(s)
- Z-W Liu
- Department of Hepato-pancreato-biliary Surgery, Beijing, China
| | - S-Z Yang
- Centre of Hepato-pancreato-biliary Diseases, Beijing Tsinghua Changgung Hospital, Tsinghua University, Beijing, China
| | - P-F Wang
- Department of Hepato-pancreato-biliary Surgery, Beijing, China
| | - J Feng
- Department of Hepato-pancreato-biliary Surgery, Beijing, China
| | - L He
- Department of Hepato-pancreato-biliary Surgery, Beijing, China
| | - J-D Du
- Department of Hepato-pancreato-biliary Surgery, First Affiliated Hospital of Chinese PLA General Hospital, Beijing, China
| | - Y-Y Xiao
- Department of Radiology, Beijing, China
| | - H-B Jiao
- Department of Hepato-pancreato-biliary Surgery, First Affiliated Hospital of Chinese PLA General Hospital, Beijing, China
| | - F-H Zhou
- Critical Care Medicine, Chinese People's Liberation Army (PLA) General Hospital, Beijing, China
| | - Q Song
- Critical Care Medicine, Chinese People's Liberation Army (PLA) General Hospital, Beijing, China
| | - M-T Zhou
- Pancreatitis Centre, First Affiliated Hospital of Wenzhou Medical University, Wenzhou, China
| | - X-L Xin
- Department of Hepato-pancreato-biliary Surgery, Beijing, China
| | - J-Y Chen
- Department of Hepato-pancreato-biliary Surgery, Beijing, China
| | - W-Z Ren
- Department of Hepato-pancreato-biliary Surgery, Beijing, China
| | - S-C Lu
- Department of Hepato-pancreato-biliary Surgery, Beijing, China
| | - S-W Cai
- Department of Hepato-pancreato-biliary Surgery, Beijing, China
| | - J-H Dong
- Centre of Hepato-pancreato-biliary Diseases, Beijing Tsinghua Changgung Hospital, Tsinghua University, Beijing, China
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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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10
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Endoscopic Transgastric Versus Surgical Approach for Infected Necrotizing Pancreatitis: A Systematic Review and Meta-Analysis. Surg Laparosc Endosc Percutan Tech 2019; 29:141-149. [PMID: 30676541 DOI: 10.1097/sle.0000000000000632] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
Surgical approach (SA) is the standard treatment for infected necrotizing pancreatitis (INP) and endoscopic transgastric approach (ETA) is a promising alternative treatment. This systematic review and meta-analysis aimed to compare the effectiveness and safety of ETA versus SA in INP. Several databases were systematically searched for eligible studies that compared ETA with SA for INP. Predefined criteria were used for study selection. Three reviewers independently assessed the risk of bias. Primary outcomes included clinical resolution rate, short-term mortality, major complications, and hospital stay. Study-specific effect sizes and their 95% confidence interval (CI) were combined to calculate the pooled value using fixed-effects or random-effects model. Six studies were included with 295 patients. Major complication rate [odds ratio (OR), 0.13; 95% CI, 0.06-0.29], new-onset organ failure rate (OR, 0.26; 95% CI, 0.12-0.54), postoperative pancreatic fistula rate (OR, 0.09; 95% CI, 0.03-0.28), and incisional hernia rate (OR, 0.10; 95% CI, 0.01-0.85) were lower in the ETA group. There was a shorter hospital stay (mean difference, -17.72; 95% CI, -21.30 to -14.13) in the ETA group. No differences were found in clinical resolution, short-term mortality, postoperative bleeding, perforation of visceral organ, and endocrine or exocrine insufficiency. Compared with SA, ETA showed comparable effectiveness and safety for the treatment of INP based on current evidence.
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11
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Jha AK, Goenka MK, Kumar R, Suchismita A. Endotherapy for pancreatic necrosis: An update. JGH OPEN 2018; 3:80-88. [PMID: 30834345 PMCID: PMC6386747 DOI: 10.1002/jgh3.12109] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 09/15/2018] [Revised: 09/28/2018] [Accepted: 10/11/2018] [Indexed: 12/16/2022]
Abstract
Approximately 20% of patients with acute pancreatitis develop pancreatic necrosis. The presence of necrosis in a pancreatic collection significantly worsens the prognosis. Pancreatic necrosis is associated with high mortality and morbidity. In the last few decades, there has been a significant revolution in the treatment of infected pancreatic necrosis. A step‐up approach has been proposed, from less invasive procedures to the operative intervention. Minimally invasive treatment modalities such as endoscopic drainage and necrosectomy, percutaneous drainage, and minimally invasive surgery have recently replaced open surgical necrosectomy as the first‐line treatment option. Endoscopic intervention for pancreatic necrosis is being increasingly performed with good success and a lower complication rate. However, techniques of endotherapy are still not uniform and vary as per local expertise, and there are still many unresolved questions with regard to the interventions in patients with pancreatic necrosis. The objective of this paper is to critically review the literature and update the concepts of endoscopic interventional therapy of pancreatic necrosis.
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Affiliation(s)
- Ashish K Jha
- Department of Gastroenterology Indira Gandhi Institute of Medical Sciences Patna India
| | - Mahesh K Goenka
- Department of Gastrosciences, Institute of Gastrosciences, Apollo Gleneagles Hospital Kolkata India
| | - Ramesh Kumar
- Department of Gastroenterology, All India Institute of Medical Sciences Patna India
| | - Arya Suchismita
- Department of Pediatrics Indira Gandhi Institute of Medical Sciences Patna India
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Yoon SB, Chang JH, Lee IS. [Treatment of Pancreatic Fluid Collections]. THE KOREAN JOURNAL OF GASTROENTEROLOGY 2018; 72:97-103. [PMID: 30270591 DOI: 10.4166/kjg.2018.72.3.97] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/26/2022]
Abstract
Pancreatic Fluid Collection (PFC) develops as a result of acute pancreatitis, chronic pancreatitis, trauma, and postoperation. Although percutaneous drainage, surgery and Endoscopic Retrograde Panceatogram are used as conventional treatments in complicated PFC, the clinical course of PFC is unsatisfactory due to its clinical success rate and the risk of procedure-related complications. Endoscopic ultrasonography-guided transmural drainage of PFC is a safe and effective modality for the management of PFC, particularly in patients with pancreas necrosis. A range of techniques and stents have been introduced and a newly designed metal stent is now available.
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Affiliation(s)
- Seung Bae Yoon
- Department of Internal Medicine, College of Medicine, The Catholic University of Korea, Seoul, Korea
| | - Jae Hyuck Chang
- Department of Internal Medicine, College of Medicine, The Catholic University of Korea, Seoul, Korea
| | - In Seok Lee
- Department of Internal Medicine, College of Medicine, The Catholic University of Korea, Seoul, Korea
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van Brunschot S, van Grinsven J, van Santvoort HC, Bakker OJ, Besselink MG, Boermeester MA, Bollen TL, Bosscha K, Bouwense SA, Bruno MJ, Cappendijk VC, Consten EC, Dejong CH, van Eijck CH, Erkelens WG, van Goor H, van Grevenstein WMU, Haveman JW, Hofker SH, Jansen JM, Laméris JS, van Lienden KP, Meijssen MA, Mulder CJ, Nieuwenhuijs VB, Poley JW, Quispel R, de Ridder RJ, Römkens TE, Scheepers JJ, Schepers NJ, Schwartz MP, Seerden T, Spanier BWM, Straathof JWA, Strijker M, Timmer R, Venneman NG, Vleggaar FP, Voermans RP, Witteman BJ, Gooszen HG, Dijkgraaf MG, Fockens P. Endoscopic or surgical step-up approach for infected necrotising pancreatitis: a multicentre randomised trial. Lancet 2018; 391:51-58. [PMID: 29108721 DOI: 10.1016/s0140-6736(17)32404-2] [Citation(s) in RCA: 416] [Impact Index Per Article: 69.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/30/2017] [Revised: 06/19/2017] [Accepted: 08/02/2017] [Indexed: 02/06/2023]
Abstract
BACKGROUND Infected necrotising pancreatitis is a potentially lethal disease and an indication for invasive intervention. The surgical step-up approach is the standard treatment. A promising alternative is the endoscopic step-up approach. We compared both approaches to see whether the endoscopic step-up approach was superior to the surgical step-up approach in terms of clinical and economic outcomes. METHODS In this multicentre, randomised, superiority trial, we recruited adult patients with infected necrotising pancreatitis and an indication for invasive intervention from 19 hospitals in the Netherlands. Patients were randomly assigned to either the endoscopic or the surgical step-up approach. The endoscopic approach consisted of endoscopic ultrasound-guided transluminal drainage followed, if necessary, by endoscopic necrosectomy. The surgical approach consisted of percutaneous catheter drainage followed, if necessary, by video-assisted retroperitoneal debridement. The primary endpoint was a composite of major complications or death during 6-month follow-up. Analyses were by intention to treat. This trial is registered with the ISRCTN registry, number ISRCTN09186711. FINDINGS Between Sept 20, 2011, and Jan 29, 2015, we screened 418 patients with pancreatic or extrapancreatic necrosis, of which 98 patients were enrolled and randomly assigned to the endoscopic step-up approach (n=51) or the surgical step-up approach (n=47). The primary endpoint occurred in 22 (43%) of 51 patients in the endoscopy group and in 21 (45%) of 47 patients in the surgery group (risk ratio [RR] 0·97, 95% CI 0·62-1·51; p=0·88). Mortality did not differ between groups (nine [18%] patients in the endoscopy group vs six [13%] patients in the surgery group; RR 1·38, 95% CI 0·53-3·59, p=0·50), nor did any of the major complications included in the primary endpoint. INTERPRETATION In patients with infected necrotising pancreatitis, the endoscopic step-up approach was not superior to the surgical step-up approach in reducing major complications or death. The rate of pancreatic fistulas and length of hospital stay were lower in the endoscopy group. The outcome of this trial will probably result in a shift to the endoscopic step-up approach as treatment preference. FUNDING The Dutch Digestive Disease Foundation, Fonds NutsOhra, and the Netherlands Organization for Health Research and Development.
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Affiliation(s)
- Sandra van Brunschot
- Department of Gastroenterology and Hepatology, Academic Medical Centre, University of Amsterdam, Amsterdam, Netherlands.
| | - Janneke van Grinsven
- Department of Gastroenterology and Hepatology, Academic Medical Centre, University of Amsterdam, Amsterdam, Netherlands; Department of Surgery, Academic Medical Centre, University of Amsterdam, Amsterdam, Netherlands
| | - Hjalmar C van Santvoort
- Department of Surgery, St Antonius Hospital, Nieuwegein, Netherlands; Department of Surgery, University Medical Centre Utrecht, Utrecht, Netherlands
| | - Olaf J Bakker
- Department of Surgery, University Medical Centre Utrecht, Utrecht, Netherlands
| | - Marc G Besselink
- Department of Surgery, Academic Medical Centre, University of Amsterdam, Amsterdam, Netherlands
| | - Marja A Boermeester
- Department of Surgery, Academic Medical Centre, University of Amsterdam, Amsterdam, Netherlands
| | - Thomas L Bollen
- Department of Radiology, St Antonius Hospital, Nieuwegein, Netherlands
| | - Koop Bosscha
- Department of Surgery, Jeroen Bosch Hospital, 's-Hertogenbosch, Netherlands
| | - Stefan A Bouwense
- Department of Surgery, Radboud University Medical Centre, Nijmegen, Netherlands
| | - Marco J Bruno
- Department of Gastroenterology and Hepatology, Erasmus MC, University Medical Centre, Rotterdam, Netherlands
| | | | - Esther C Consten
- Department of Surgery, Meander Medical Centre, Amersfoort, Netherlands
| | - Cornelis H Dejong
- Department of Surgery and NUTRIM School for Nutrition and Translational Research in Metabolism, Maastricht University Medical Centre, Maastricht, Netherlands
| | - Casper H van Eijck
- Department of Surgery, Erasmus MC, University Medical Centre, Rotterdam, Netherlands
| | | | - Harry van Goor
- Department of Surgery, Radboud University Medical Centre, Nijmegen, Netherlands
| | | | - Jan-Willem Haveman
- Department of Surgery, University Medical Centre Groningen, University of Groningen, Groningen, Netherlands
| | - Sijbrand H Hofker
- Department of Surgery, University Medical Centre Groningen, University of Groningen, Groningen, Netherlands
| | - Jeroen M Jansen
- Department of Gastroenterology, Onze Lieve Vrouwe Gasthuis, Amsterdam, Netherlands
| | - Johan S Laméris
- Department of Radiology, Academic Medical Centre, University of Amsterdam, Amsterdam, Netherlands
| | - Krijn P van Lienden
- Department of Radiology, Academic Medical Centre, University of Amsterdam, Amsterdam, Netherlands
| | | | - Chris J Mulder
- Department of Gastroenterology, VU Medical Centre, Amsterdam, Netherlands
| | | | - Jan-Werner Poley
- Department of Gastroenterology and Hepatology, Erasmus MC, University Medical Centre, Rotterdam, Netherlands
| | - Rutger Quispel
- Department of Gastroenterology, Reinier de Graaf Group, Delft, Netherlands
| | - Rogier J de Ridder
- Department of Gastroenterology, Maastricht University Medical Centre, Maastricht, Netherlands
| | - Tessa E Römkens
- Department of Gastroenterology, Jeroen Bosch Hospital, 's-Hertogenbosch, Netherlands
| | | | - Nicolien J Schepers
- Department of Gastroenterology and Hepatology, Erasmus MC, University Medical Centre, Rotterdam, Netherlands
| | - Matthijs P Schwartz
- Department of Gastroenterology, Meander Medical Centre, Amersfoort, Netherlands
| | - Tom Seerden
- Department of Gastroenterology, Amphia Hospital, Breda, Netherlands
| | | | | | - Marin Strijker
- Department of Surgery, Academic Medical Centre, University of Amsterdam, Amsterdam, Netherlands
| | - Robin Timmer
- Department of Gastroenterology, St Antonius Hospital, Nieuwegein, Netherlands
| | - Niels G Venneman
- Department of Gastroenterology, Medisch Spectrum Twente, Enschede, Netherlands
| | - Frank P Vleggaar
- Department of Gastroenterology and Hepatology, University Medical Centre Utrecht, Utrecht, Netherlands
| | - Rogier P Voermans
- Department of Gastroenterology and Hepatology, Academic Medical Centre, University of Amsterdam, Amsterdam, Netherlands
| | - Ben J Witteman
- Department of Gastroenterology, Hospital Gelderse Vallei, Ede, Netherlands
| | - Hein G Gooszen
- Department of OR/Evidence Based Surgery, Radboud University Medical Centre, Nijmegen, Netherlands
| | - Marcel G Dijkgraaf
- Clinical Research Unit, Academic Medical Centre, University of Amsterdam, Amsterdam, Netherlands
| | - Paul Fockens
- Department of Gastroenterology and Hepatology, Academic Medical Centre, University of Amsterdam, Amsterdam, Netherlands
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14
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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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15
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Predictive Value of Computed Tomography Scans and Clinical Findings for the Need of Endoscopic Necrosectomy in Walled-off Necrosis From Pancreatitis. Pancreas 2017; 46:1039-1045. [PMID: 28796138 DOI: 10.1097/mpa.0000000000000881] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/23/2022]
Abstract
OBJECTIVES Choosing the best treatment option at the optimal point of time for patients with walled-off necrosis (WON) is crucial. We aimed to identify imaging parameters and clinical findings predicting the need of necrosectomy in patients with WON. METHODS All patients with endoscopically diagnosed WON and pseudocyst were retrospectively identified. Post hoc analysis of pre-interventional contrast-enhanced computed tomography was performed for factors predicting the need of necrosectomy. RESULTS Sixty-five patients were included in this study. Forty patients (61.5%) were diagnosed with pseudocyst and 25 patients (38.5%) with WON. Patients with WON mostly had acute pancreatitis with biliary cause compared with more chronic pancreatitis and toxic cause in pseudocyst group (P = 0.002 and P = 0.004, respectively). Logistic regression revealed diabetes as a risk factor for WON. Computed tomography scans revealed 4.62% (n = 3) patients as false positive and 24.6% (n = 16) as false negative findings for WON. Reduced perfusion and detection of solid findings were independent risk factors for WON. CONCLUSIONS Computed tomography scans are of low diagnostic yield when needed to predict treatment of patients with pancreatic cysts. Reduced pancreatic perfusion and solid findings seem to be a risk factor for WON, whereas patients with diabetes seem to be at higher risk of developing WON.
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Madácsy L, Kaltsidis H. Endoscopic ultrasound-guided extraluminal drainage: Novel concepts, challenges and future directions. INTERNATIONAL JOURNAL OF GASTROINTESTINAL INTERVENTION 2017. [DOI: 10.18528/gii160020] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Affiliation(s)
- László Madácsy
- Department of Gastroenterology and Endoscopy, Bács-Kiskun County Teaching Hospital, University of Szeged, Kecskemét, Hungary
| | - Harry Kaltsidis
- Department of Gastroenterology, University Hospitals of South Manchester, Manchester, UK
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Dua MM, Worhunsky DJ, Malhotra L, Park WG, Poultsides GA, Norton JA, Visser BC. Transgastric pancreatic necrosectomy-expedited return to prepancreatitis health. J Surg Res 2017; 219:11-17. [PMID: 29078869 DOI: 10.1016/j.jss.2017.05.089] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/10/2017] [Revised: 04/23/2017] [Accepted: 05/24/2017] [Indexed: 12/30/2022]
Abstract
BACKGROUND The best operative strategy for necrotizing pancreatitis remains controversial. Traditional surgical necrosectomy is associated with significant morbidity; endoscopic and percutaneous strategies require repeated interventions with prolonged hospitalizations. We have developed a transgastric approach to pancreatic necrosectomy to overcome the shortcomings of the other techniques described. MATERIALS AND METHODS Patients with necrotizing pancreatitis treated from 2009 to 2016 at an academic center were retrospectively reviewed. Open or laparoscopic transgastric necrosectomy was performed if the area of necrosis was walled-off and in a retrogastric position on cross-sectional imaging. Study endpoints included postoperative complications and mortality. RESULTS Forty-six patients underwent transgastric necrosectomy (nine open and 37 laparoscopic). Median (interquartile range) preoperative Acute Physiologic and Chronic Health Evaluation II score was 6 (3-12). Seventy percent of patients had >30% necrosis on preoperative imaging; infected necrosis was present in 35%. Median total length of stay (LOS) was 6 (3-12) d. No patient required a second operative debridement; four patients (9%) had short-term postoperative percutaneous drainage for residual fluid collections. Median follow-up was 1 y; there were no fistula or wound complications. Six patients (13%) had postoperative bleeding; five patients received treatment by image-guided embolization. There was one death in the cohort. CONCLUSIONS Transgastric pancreatic necrosectomy allows for effective debridement with a single definitive operation. When anatomically suitable, this operative strategy offers expedited recovery and avoids long-term morbidity associated with fistulas and prolonged drainage.
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Affiliation(s)
- Monica M Dua
- Division of Surgical Oncology, Department of Surgery, Stanford University School of Medicine, Stanford, California.
| | - David J Worhunsky
- Division of Surgical Oncology, Department of Surgery, Stanford University School of Medicine, Stanford, California
| | - Lavina Malhotra
- Division of Surgical Oncology, Department of Surgery, Stanford University School of Medicine, Stanford, California
| | - Walter G Park
- Division of Gastroenterology, Department of Medicine, Stanford University School of Medicine, Stanford, California
| | - George A Poultsides
- Division of Surgical Oncology, Department of Surgery, Stanford University School of Medicine, Stanford, California
| | - Jeffrey A Norton
- Division of Surgical Oncology, Department of Surgery, Stanford University School of Medicine, Stanford, California
| | - Brendan C Visser
- Division of Surgical Oncology, Department of Surgery, Stanford University School of Medicine, Stanford, California
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18
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Wroński M, Cebulski W, Witkowski B, Jankowski M, Kluciński A, Krasnodębski IW, Słodkowski M. Comparison between minimally invasive and open surgical treatment in necrotizing pancreatitis. J Surg Res 2016; 210:22-31. [PMID: 28457332 DOI: 10.1016/j.jss.2016.10.022] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/10/2016] [Revised: 09/20/2016] [Accepted: 10/26/2016] [Indexed: 12/12/2022]
Abstract
BACKGROUND Minimal access techniques have gained popularity for the management of necrotizing pancreatitis, but only a few studies compared open necrosectomy with a less invasive treatment. The aim of this study was to evaluate the outcomes of minimally invasive treatment for necrotizing pancreatitis in comparison with open necrosectomy. MATERIALS AND METHODS This retrospective study included 70 patients who underwent minimally invasive intervention or open surgical debridement for necrotizing pancreatitis between January 2007 and December 2014. Data were analyzed for postoperative morbidity and outcome. RESULTS Of 70 patients, 22 patients underwent primary open necrosectomy and 48 patients were treated with minimally invasive techniques. Percutaneous and endoscopic drainage were successful in 34.9% and 75.0% of patients, respectively. The rates of postoperative new-onset organ failure and intensive care unit stay were significantly lower in the minimally invasive group (25.0% versus 54.5%; P = 0.016, and 29.2% versus 54.5%; P = 0.041, respectively). Gastrointestinal fistulas occurred more frequently after primary open necrosectomy (36.4% versus 10.4%; P = 0.009). Mortality was comparable in both groups (18.6% versus 27.3%; P = 0.420). Mortality for salvage open necrosectomy was similar to that for primary open debridement (28.6% versus 27.3%; P = 0.924). The independent risk factors for major postoperative complications were primary open necrosectomy (P = 0.028) and shorter interval to first intervention (P = 0.020). Mortality was independently associated only with older age (P = 0.009). CONCLUSIONS Minimally invasive treatment should be preferred over open necrosectomy for initial management of necrotizing pancreatitis.
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Affiliation(s)
- Marek Wroński
- Department of General, Gastroenterological and Oncological Surgery, Medical University of Warsaw, Warsaw, Poland.
| | - Włodzimierz Cebulski
- Department of General, Gastroenterological and Oncological Surgery, Medical University of Warsaw, Warsaw, Poland
| | - Bartosz Witkowski
- Division of Probabilistic Methods, College of Economic Analysis, Warsaw School of Economics, Warsaw, Poland
| | - Mieczysław Jankowski
- Department of General, Gastroenterological and Oncological Surgery, Medical University of Warsaw, Warsaw, Poland
| | - Andrzej Kluciński
- Department of General, Gastroenterological and Oncological Surgery, Medical University of Warsaw, Warsaw, Poland
| | - Ireneusz W Krasnodębski
- Department of General, Gastroenterological and Oncological Surgery, Medical University of Warsaw, Warsaw, Poland
| | - Maciej Słodkowski
- Department of General, Gastroenterological and Oncological Surgery, Medical University of Warsaw, Warsaw, Poland
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19
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Li JW, Li JW, Ang TL, Ang TL. Is endoscopic necrosectomy the way to go? GASTROINTESTINAL INTERVENTION 2016. [DOI: 10.18528/gii160010] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/26/2022]
Affiliation(s)
- James Weiquan Li
- Department of Gastroenterology and Hepatology, Changi General Hospital, Singapore
| | - James Weiquan Li
- Department of Gastroenterology and Hepatology, Changi General Hospital, Singapore
| | - Tiing Leong Ang
- Department of Gastroenterology and Hepatology, Changi General Hospital, Singapore
| | - Tiing Leong Ang
- Department of Gastroenterology and Hepatology, Changi General Hospital, Singapore
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20
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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 2: Endoscopic management. J Gastroenterol Hepatol 2016; 31:1555-65. [PMID: 27042957 DOI: 10.1111/jgh.13398] [Citation(s) in RCA: 29] [Impact Index Per Article: 3.6] [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: 12/11/2022]
Abstract
Walled-off necrosis (WON) is a 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 2 of this statement focused on the endoscopic management of WON.
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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 and 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, University of Ulsan College of Medicine, Asan Medical Center, 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, Fukushima Medical University, Aizu Medical Center, Aizuwakamatsu, Japan
| | - Iruru Maetani
- Division of Gastroenterology and Hepatology, Department of Internal Medicine, Toho University Ohashi Medical Center, Tokyo, Japan
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Abstract
The management of acute necrotizing pancreatitis (ANP) has undergone a change of paradigms during the last 2 decades with a decreasing impact of surgical interventions. Modern ANP management is done conservatively as long as possible and therapeutic approaches aim at volume resuscitation, pain management and early enteral nutrition. The diagnostic gold standard of contrast-enhanced CT scan helps to evaluate the extent of necrosis of the pancreas, which correlates with the risk of tissue infection. The crucial point for decision making is the proven existence of infected pancreatic necrosis. This can be achieved by diagnostic needle aspiration of the necrotic material and staining to prove bacterial and/or fungal infection. In case of infected necrosis - besides calculated antimicrobial treatment - an interventional or surgical approach is required to prevent systemic septic progression of the disease. As the first step, percutaneous interventional drainage and spilling of the necrosis are preferable. In case of insufficient clearing of the infectious focus, a step-up approach must be considered, which implies a retroperitoneoscopic or transabdominal minimally invasive necrosectomy and drain placement. Postoperatively, a continuous lavage should be performed using these drains. In case of further deterioration of the patient or development of associated intra-abdominal complications (e.g. bowel perforation or uncontrolled bleeding), an open surgical intervention must always be regarded as a salvage therapy and this offers the possibility to control complications and perform a further necrosectomy and extensive lavage for focus control. However, associated morbidity (e.g. pancreatic fistula, fluid collections, pseudocysts) is about 50-60% and mortality up to 20%. In summary, ANP is managed primarily by a conservative therapy. In case of infected necrosis, interventional and minimally invasive approaches are the therapy of choice. Open surgery should be considered for patients deteriorating despite other measures and should be postponed as long as possible.
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Affiliation(s)
- Thilo Hackert
- Department of General, University of Heidelberg, Heidelberg, Germany
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22
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Tyberg A, Karia K, Gabr M, Desai A, Doshi R, Gaidhane M, Sharaiha RZ, Kahaleh M. Management of pancreatic fluid collections: A comprehensive review of the literature. World J Gastroenterol 2016; 22:2256-2270. [PMID: 26900288 PMCID: PMC4735000 DOI: 10.3748/wjg.v22.i7.2256] [Citation(s) in RCA: 122] [Impact Index Per Article: 15.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/19/2015] [Revised: 12/14/2015] [Accepted: 12/30/2015] [Indexed: 02/06/2023] Open
Abstract
Pancreatic fluid collections (PFCs) are a frequent complication of pancreatitis. It is important to classify PFCs to guide management. The revised Atlanta criteria classifies PFCs as acute or chronic, with chronic fluid collections subdivided into pseudocysts and walled-off pancreatic necrosis (WOPN). Establishing adequate nutritional support is an essential step in the management of PFCs. Early attempts at oral feeding can be trialed in patients with mild pancreatitis. Enteral feeding should be implemented in patients with moderate to severe pancreatitis. Jejunal feeding remains the preferred route of enteral nutrition. Symptomatic PFCs require drainage; options include surgical, percutaneous, or endoscopic approaches. With the advent of newer and more advanced endoscopic tools and expertise, and an associated reduction in health care costs, minimally invasive endoscopic drainage has become the preferable approach. An endoscopic ultrasonography-guided approach using a seldinger technique is the preferred endoscopic approach. Both plastic stents and metal stents are efficacious and safe; however, metal stents may offer an advantage, especially in infected pseudocysts and in WOPN. Direct endoscopic necrosectomy is often required in WOPN. Lumen apposing metal stents that allow for direct endoscopic necrosectomy and debridement through the stent lumen are preferred in these patients. Endoscopic retrograde cholangio pancreatography with pancreatic duct (PD) exploration should be performed concurrent to PFC drainage. PD disruption is associated with an increased severity of pancreatitis, an increased risk of recurrent attacks of pancreatitis and long-term complications, and a decreased rate of PFC resolution after drainage. Any pancreatic ductal disruption should be bridged with endoscopic stenting.
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Affiliation(s)
- Ayesha Kamal
- Division of Gastroenterology, Department of Medicine, *,Department of Gastroenterology, Johns Hopkins Hospital, 600 N Wolfe St, Blalock 406, Baltimore MD 21287 †
| | - Vikesh K Singh
- Division of Gastroenterology, Department of Medicine, *,Pancreatitis Center, ‡ and
| | - Atif Zaheer
- Pancreatitis Center, ‡ and.,Russell H. Morgan Department of Radiology and Radiological Science, § Johns Hopkins Medical Institutions, Baltimore, Md
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Khreiss M, Zenati M, Clifford A, Lee KK, Hogg ME, Slivka A, Chennat J, Gelrud A, Zeh HJ, Papachristou GI, Zureikat AH. Cyst Gastrostomy and Necrosectomy for the Management of Sterile Walled-Off Pancreatic Necrosis: a Comparison of Minimally Invasive Surgical and Endoscopic Outcomes at a High-Volume Pancreatic Center. J Gastrointest Surg 2015; 19:1441-8. [PMID: 26033038 DOI: 10.1007/s11605-015-2864-6] [Citation(s) in RCA: 27] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/13/2015] [Accepted: 05/25/2015] [Indexed: 01/31/2023]
Abstract
INTRODUCTION Walled-off pancreatic necrosis (WON) is a sequela of acute necrotizing pancreatitis in 15-40% of cases. We sought to compare the outcomes of minimally invasive surgical and endoscopic cyst gastrostomy (CG) and necrosectomy for the management for sterile WON at a tertiary care high-volume pancreas center. METHOD This is a retrospective review of patients who underwent minimally invasive surgical or endoscopic CG and necrosectomy for clinically sterile WON between 2008 and 2013. Peri-procedural outcomes including costs were analyzed and compared. RESULTS Twenty patients underwent minimally invasive surgical (robotic = 14, laparoscopic = 6) CG and necrosectomy, and 20 patients underwent endoscopic treatment. The surgical cohort had a larger median cyst size and higher CCI score. For the surgical cohort, median OR time was 167.5 min, estimated blood loss was 30 ml, and 65% underwent concomitant cholecystectomy. There was no mortality in either group and no difference in complication rates (20%). The failure rate was similar (15 versus 10%, P = 0.66). Although surgery was associated with a lower re-intervention rate (0 versus 1, P = 0.008), the endotherapy group was associated with shorter total LOS (inclusive of re-interventions) (7 versus 3 days, P = 0.032). The cost of the index procedure was significantly higher for the surgery group (P = 0.014); however, when considering all readmissions and re-interventions until resolution of the WON, the total cost was similar for both groups. CONCLUSION Minimally invasive surgical and endoscopic CG and necrosectomy are comparable treatments for sterile WON in terms of outcomes and overall cost. The surgical approach may be considered advantageous when a concomitant cholecystectomy is required.
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Affiliation(s)
- Mohammad Khreiss
- Department of Surgery, School of Medicine, University of Pittsburgh, Pittsburgh, PA, USA
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Cresswell AB, Nageswaran H, Belgaumkar A, Kumar R, Menezes N, Riga A, Worthington TR, Karanjia ND. The two-port laparoscopic retroperitoneal approach for minimal access pancreatic necrosectomy. Ann R Coll Surg Engl 2015; 97:354-8. [PMID: 26264086 PMCID: PMC5096554 DOI: 10.1308/003588415x14181254789961] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 01/11/2015] [Indexed: 01/25/2023] Open
Abstract
INTRODUCTION Despite advances in surgery and critical care, severe pancreatitis continues to be associated with a high rate of mortality, which is increased significantly in the presence of infected pancreatic necrosis. Controversy persists around the optimal treatment for such cases, with specialist units variously advocating open necrosectomy, simple percutaneous drainage or one of several minimal access approaches. We describe our technique and outcomes with a two-port laparoscopic retroperitoneal necrosectomy (2P-LRN). METHODS Thirteen consecutive patients with proven infected pancreatic necrosis were treated by 2P-LRN over a three-year period in the setting of a specialist hepatopancreatobiliary unit. The median patient age was 46 years (range: 28-87 years) and 10 of the patients were male. RESULTS The median number of procedures required to clear the necrosis was 2 (range: 1-5), with a median time to discharge following the procedure of 44 days (range: 10-135 days). There was no 90-day mortality and the morbidity rate was 38%, consisting of pancreatic fistula (31%) and bleeding (23%). CONCLUSIONS Two-port laparoscopic retroperitoneal necrosectomy has been demonstrated to confer similar or better outcomes to other techniques for necrosectomy. It carries the additional advantages of better visualisation, leading to fewer procedures and the opportunity to deploy simple laparoscopic instruments such as diathermy or haemostatic clips.
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Affiliation(s)
- AB Cresswell
- Royal Surrey County Hospital NHS Foundation Trust, UK
| | - H Nageswaran
- Royal Surrey County Hospital NHS Foundation Trust, UK
| | - A Belgaumkar
- Royal Surrey County Hospital NHS Foundation Trust, UK
| | - R Kumar
- Royal Surrey County Hospital NHS Foundation Trust, UK
| | - N Menezes
- Royal Surrey County Hospital NHS Foundation Trust, UK
| | - A Riga
- Royal Surrey County Hospital NHS Foundation Trust, UK
| | | | - ND Karanjia
- Royal Surrey County Hospital NHS Foundation Trust, UK
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Schmidt PN, Novovic S, Roug S, Feldager E. Endoscopic, transmural drainage and necrosectomy for walled-off pancreatic and peripancreatic necrosis is associated with low mortality--a single-center experience. Scand J Gastroenterol 2015; 50:611-8. [PMID: 25648776 DOI: 10.3109/00365521.2014.946078] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
OBJECTIVE Endoscopic transmural drainage and necrosectomy (ETDN) is a promising alternative to percutaneous drainage and surgical intervention in the treatment of walled-off pancreatic and peripancreatic necroses (WONs). We assessed the outcome and safety profile of ETDN in a single-center patient cohort. MATERIALS AND METHODS In November 2005, ETDN for WON was introduced in our tertiary referral center. During a 6-year period (Nov 2005-Nov 2011), we retrospectively collected data on all patients who underwent ETDN. RESULTS Eighty-one patients were treated with ETDN (median age 54, 52 men). Gallstones were the predominant etiology of pancreatitis (41%), followed by alcohol (33%). Median time from debut of symptoms to first endoscopic treatment was 44 (9-246) days. Culture-proven infected necrosis was found in 71% of the cases. Twenty-three patients (28%) required admission in intensive care unit. The technical and clinical success rates were 99% and 89%, respectively. Procedure-related complications occurred in 10 (12%) patients, of which 1 was procedure-related death. In-hospital mortality was 11%. CONCLUSION ETDN in patients with necrotizing pancreatitis and infected necrosis performed in a single, high-volume center has an acceptable safety profile and is associated with a low mortality.
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Affiliation(s)
- Palle Nordblad Schmidt
- Department of Gastroenterology and Gastrointestinal Surgery, Hvidovre Hospital , Copenhagen , Denmark
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Predictors of percutaneous catheter drainage (PCD) after abdominal paracentesis drainage (APD) in patients with moderately severe or severe acute pancreatitis along with fluid collections. PLoS One 2015; 10:e0115348. [PMID: 25659143 PMCID: PMC4319763 DOI: 10.1371/journal.pone.0115348] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/17/2014] [Accepted: 11/22/2014] [Indexed: 02/06/2023] Open
Abstract
Aims Although we previously demonstrated abdominal paracentesis drainage (APD) preceding percutaneous catheter drainage (PCD) as the central step for treating patients with moderately severe (MSAP) or severe acute pancreatitis (SAP), the predictors leading to PCD after APD have not been studied. Methods Consecutive patients with MSAP or SAP were recruited between June 2011 and June 2013. As a step-up approach, all patients initially received medical management, later underwent ultrasound-guided APD before PCD, if necessary, followed by endoscopic necrosectomy through the path formed by PCD. APD primarily targeted fluid in the abdominal or pelvic cavities, whereas PCD aimed at (peri)pancreatic fluid. Results Of the 92 enrolled patients, 40 were managed with APD alone and 52 received PCD after APD (14 required necrosectomy after initial PCD). The overall mortality was 6.5%. Univariate analysis showed that among the 20 selected parameters, 13 factors significantly affected PCD intervention after APD. Multivariate analysis revealed that infected (peri)pancreatic collections (P = -0.001), maximum extent of necrosis of more than 30% of the pancreas (P = -0.024), size of the largest necrotic peri(pancreatic) collection (P = -0.007), and reduction of (peri)pancreatic fluid collections by <50% after APD (P = -0.008) were all independent predictors of PCD. Conclusions Infected (peri)pancreatic collections, a largest necrotic peri(pancreatic) collection of more than 100 ml, and reduction of (peri)pancreatic fluid collections by <50% after APD could effectively predict the need for PCD in the early course of the disease.
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Dhingra R, Srivastava S, Behra S, Vadiraj PK, Venuthurimilli A, Dash NR, Madhusudhan KS, Gamanagatti SR, Garg PK. Single or multiport percutaneous endoscopic necrosectomy performed with the patient under conscious sedation is a safe and effective treatment for infected pancreatic necrosis (with video). Gastrointest Endosc 2015; 81:351-9. [PMID: 25293824 DOI: 10.1016/j.gie.2014.07.060] [Citation(s) in RCA: 48] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/26/2013] [Accepted: 07/24/2014] [Indexed: 01/06/2023]
Abstract
BACKGROUND Infected pancreatic necrosis (IPN) is a dreaded adverse event of acute pancreatitis (AP). Most patients with IPN require drainage and necrosectomy, preferably by a minimally invasive method. OBJECTIVE To study the success and safety of an alternative form of minimally invasive necrosectomy for IPN. DESIGN Observational study. SETTING Tertiary care academic center. PATIENTS Consecutive patients with IPN formed the study group. INTERVENTION Patients with IPN were initially treated conservatively including percutaneous drainage. Those who failed to improve underwent percutaneous endoscopic necrosectomy (PEN). Single- or multiport PEN was performed by using a flexible endoscope through the percutaneous tract. PEN involved vigorous lavage and suction followed by necrosectomy. Multiple sessions were undertaken depending on the size and number of collections and the amount of necrotic debris. MAIN OUTCOME MEASUREMENTS Control of sepsis and resolution of collection(s) without the need for surgical necrosectomy. RESULTS During the period from October 2012 to July 2013, 165 patients (mean age, 38.82 ± 14.99 years; 119 male patients) were studied. Of them, 103 patients had necrotizing pancreatitis and IPN had developed in 74. Of these 74 patients with IPN, 15 underwent PEN after a mean interval of 39.2 days. Fourteen of the 15 patients improved after a mean of 5 sessions of PEN. Two of 15 patients had minor adverse events: self-limiting bleeding and pancreatic fistula in 1 patient each. One patient required surgery but died of organ failure. LIMITATIONS Lack of a control arm. CONCLUSION PEN is a safe and effective minimally invasive technique for necrosectomy for IPN.
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Affiliation(s)
- Rajan Dhingra
- Department of Gastroenterology, All India Institute of Medical Sciences, New Delhi, India
| | - Saurabh Srivastava
- Department of Gastroenterology, All India Institute of Medical Sciences, New Delhi, India
| | - Sanatan Behra
- Department of Gastroenterology, All India Institute of Medical Sciences, New Delhi, India
| | | | - Arun Venuthurimilli
- Department of Gastrointestinal Surgery, All India Institute of Medical Sciences, New Delhi, India
| | - Nihar Ranjan Dash
- Department of Gastrointestinal Surgery, All India Institute of Medical Sciences, New Delhi, India
| | | | | | - Pramod Kumar Garg
- Department of Gastroenterology, All India Institute of Medical Sciences, New Delhi, India
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Minimally invasive treatment of infected pancreatic necrosis. GASTROENTEROLOGY REVIEW 2014; 9:317-24. [PMID: 25653725 PMCID: PMC4300346 DOI: 10.5114/pg.2014.47893] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 07/21/2012] [Revised: 08/25/2012] [Accepted: 11/15/2012] [Indexed: 12/13/2022]
Abstract
Infected pancreatic necrosis is a challenging complication that worsens prognosis in acute pancreatitis. For years, open necrosectomy has been the mainstay treatment option in infected pancreatic necrosis, although surgical debridement still results in high morbidity and mortality rates. Recently, many reports on minimally invasive treatment in infected pancreatic necrosis have been published. This paper presents a review of minimally invasive techniques and attempts to define their role in the management of infected pancreatic necrosis.
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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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Tan V, Charachon A, Lescot T, Chafaï N, Le Baleur Y, Delchier JC, Paye F. Endoscopic transgastric versus surgical necrosectomy in infected pancreatic necrosis. Clin Res Hepatol Gastroenterol 2014; 38:770-6. [PMID: 25153999 DOI: 10.1016/j.clinre.2014.06.016] [Citation(s) in RCA: 24] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/23/2013] [Revised: 03/22/2014] [Accepted: 06/13/2014] [Indexed: 02/04/2023]
Abstract
Surgical necrosectomy, but is still associated with a high morbidity. Indications of the endoscopic route, a new less invasive technique are not defined yet. To compare characteristics and clinical outcome of patients treated by the two techniques, a bi-centric retrospective comparison of 21 patients treated by surgical necrosectomy in one center (group S) with 11 patients treated in another center by endoscopic transgastric necrosectomy (group E) was performed. Clinical severity scores were significantly higher in group S although CT severity score did not differ between groups. Acute postoperative complications including pancreatic fistula occurred more frequently in group S (86% vs. 27%, P=0.002). ICU and hospital length of stay were higher in group S (84 vs. 4 days; P=0.008 and 58 vs. 15 days; P=0.005 respectively). Long-term complication did not differ between groups. Compared to surgery, endoscopic necrosectomy exhibited lower rate of complications and reduced hospital length of stays. Endoscopic transgastric necrosectomy appears as a safe and effective procedure and has to be included in the therapeutic algorithm of infected pancreatic necrosis.
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Affiliation(s)
- Virianne Tan
- AP-HP, Saint-Antoine University Hospital, Department of Digestive Surgery, 75012 Paris, France
| | - Antoine Charachon
- AP-HP, Henri-Mondor University Hospital, Department of Gastroenterology, 94000 Créteil, France
| | - Thomas Lescot
- AP-HP, Saint-Antoine University Hospital, Surgical Intensive Care Unit, 75012 Paris, France; UPMC University Paris 06, 75005 Paris, France
| | - Najim Chafaï
- AP-HP, Saint-Antoine University Hospital, Department of Digestive Surgery, 75012 Paris, France
| | - Yann Le Baleur
- AP-HP, Henri-Mondor University Hospital, Department of Gastroenterology, 94000 Créteil, France
| | - Jean-Charles Delchier
- AP-HP, Henri-Mondor University Hospital, Department of Gastroenterology, 94000 Créteil, France
| | - François Paye
- AP-HP, Saint-Antoine University Hospital, Department of Digestive Surgery, 75012 Paris, France; UPMC University Paris 06, 75005 Paris, France.
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Paradigm shift away from open surgical necrosectomy toward endoscopic interventions for necrotizing pancreatitis. GASTROINTESTINAL INTERVENTION 2014. [DOI: 10.1016/j.gii.2014.09.010] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
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Bai Y, Qiao WG, Zhu HM, He Q, Wang N, Cai JQ, Jiang B, Zhi FC. Role of transgastric natural orifice transluminal endoscopic surgery in the diagnosis of ascites of unknown origin (with videos). Gastrointest Endosc 2014; 80:807-16. [PMID: 24818547 DOI: 10.1016/j.gie.2014.03.025] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/30/2013] [Accepted: 03/14/2014] [Indexed: 12/25/2022]
Abstract
BACKGROUND Natural orifice transluminal endoscopic surgery (NOTES) has been established in animal models and human studies. OBJECTIVE The aim of this study was to assess the feasibility and efficacy of applying transgastric NOTES to diagnose patients with ascites of unknown origin. DESIGN Prospective study. SETTING Two university and teaching hospitals. PATIENTS Patients with ascites of unknown origin. INTERVENTIONS Diagnostic transgastric NOTES. MAIN OUTCOME MEASUREMENTS Characteristic of ascites cases, conditions of the abdominal cavity, diagnostic accuracy, adverse events, and follow-up time. RESULTS Transgastric NOTES was performed successfully in 78 patients with ascites of unknown origin, and 72 cases (92.3%) were clearly diagnosed. They included malignant tumors (39 cases), tuberculous peritonitis (28 cases), chronic hepatic inflammation (3 cases), necrotizing lymphadenitis (1 case), and eosinophilic serositis of the small intestine (1 case). In addition, there were 6 nondiagnostic cases, and no severe adverse events were found. LIMITATIONS Nonrandomized control analysis. CONCLUSION Transgastric NOTES in combination with biopsy can elucidate the causes of ascites of unknown origin in the majority of cases. Therefore, it is a feasible and effective approach to access the peritoneal cavity and also a valuable modality to detect the cause of diseases with ascites of unknown origin.
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Affiliation(s)
- Yang Bai
- Guangdong Provincial Key Laboratory of Gastroenterology, Guangdong, China; Department of Gastroenterology, Nanfang Hospital, Southern Medical University, Guangzhou, China
| | - Wei-guang Qiao
- Guangdong Provincial Key Laboratory of Gastroenterology, Guangdong, China; Department of Gastroenterology, Nanfang Hospital, Southern Medical University, Guangzhou, China
| | - Hui-ming Zhu
- Department of Gastroenterology, The Second Affiliated Clinical Medical College, Shenzhen People's Hospital, Shenzhen, China
| | - Qiong He
- Department of Gastroenterology, The Third Affiliated Hospital of Southern Medical University, Guangzhou, China
| | - Na Wang
- Department of Gastroenterology, The Second Affiliated Clinical Medical College, Shenzhen People's Hospital, Shenzhen, China
| | - Jian-qun Cai
- Guangdong Provincial Key Laboratory of Gastroenterology, Guangdong, China; Department of Gastroenterology, Nanfang Hospital, Southern Medical University, Guangzhou, China
| | - Bo Jiang
- Guangdong Provincial Key Laboratory of Gastroenterology, Guangdong, China; Department of Gastroenterology, Nanfang Hospital, Southern Medical University, Guangzhou, China
| | - Fa-chao Zhi
- Guangdong Provincial Key Laboratory of Gastroenterology, Guangdong, China; Department of Gastroenterology, Nanfang Hospital, Southern Medical University, Guangzhou, China
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Voermans RP, Besselink MG, Fockens P. Endoscopic management of walled-off pancreatic necrosis. JOURNAL OF HEPATO-BILIARY-PANCREATIC SCIENCES 2014; 22:20-6. [DOI: 10.1002/jhbp.180] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Affiliation(s)
- Rogier P. Voermans
- Department of Gastroenterology and Hepatology; Academic Medical Center; University of Amsterdam; Meibergdreef 9 1105 AZ Amsterdam The Netherlands
| | - Marc G. Besselink
- Department of Surgery; Academic Medical Center; University of Amsterdam; Amsterdam The Netherlands
| | - Paul Fockens
- Department of Gastroenterology and Hepatology; Academic Medical Center; University of Amsterdam; Meibergdreef 9 1105 AZ Amsterdam The Netherlands
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Saxena P, Singh VK, Messallam A, Kamal A, Zaheer A, Kumbhari V, Lennon AM, Canto MI, Kalloo AN, Baron TH, Khashab MA. Resolution of walled-off pancreatic necrosis by EUS-guided drainage when using a fully covered through-the-scope self-expandable metal stent in a single procedure (with video). Gastrointest Endosc 2014; 80:319-24. [PMID: 25034838 DOI: 10.1016/j.gie.2014.04.041] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/04/2013] [Accepted: 04/21/2014] [Indexed: 12/15/2022]
Abstract
BACKGROUND Walled-off pancreatic necrosis (WOPN) is effectively managed with percutaneous and endoscopic techniques such as direct endoscopic necrosectomy. However, they require repeat interventions and lengthy hospital stays. OBJECTIVE To evaluate a new platform to manage WOPNs by using a large-bore, through-the-scope, fully covered, self-expandable metal stent (FCSEMS) to overcome the need for repeat interventions and extended hospital stays. DESIGN Retrospective, single-center study. SETTING Academic tertiary care center. PATIENTS Five consecutive patients with symptomatic WOPN underwent EUS-guided drainage of WOPN by using a large-bore FCSEMSs. INTERVENTIONS EUS-guided transgastric drainage of WOPN by using a large-bore FCSEMS. Cross-sectional imaging was repeated at 6- to 8-week intervals. The FCSEMS was removed after WOPN resolution. MAIN OUTCOME MEASUREMENTS Clinical success, number of repeat interventions, and length of hospital stay. RESULTS Five patients (mean age 60 years) with WOPN (mean diameter, 12.3 cm; range 9.8-14.3 cm) underwent drainage with the described technique. Technical and clinical success was achieved in 100% of patients. Direct endoscopic necrosectomy was not required in any patient. The median number of endoscopic procedures was 1. The median length of hospital stay was 1 day. There were no adverse events. LIMITATIONS Small, retrospective study. CONCLUSIONS The described novel platform facilitates resolution of WOPN with a single procedure, avoiding the need for repeat interventions and lengthy hospital stays.
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Affiliation(s)
- Payal Saxena
- Department of Medicine, Division of Gastroenterology and Hepatology, The Johns Hopkins Medical Institutions, Baltimore, Maryland, USA
| | - Vikesh K Singh
- Department of Medicine, Division of Gastroenterology and Hepatology, The Johns Hopkins Medical Institutions, Baltimore, Maryland, USA
| | - Ahmed Messallam
- Department of Medicine, Division of Gastroenterology and Hepatology, The Johns Hopkins Medical Institutions, Baltimore, Maryland, USA
| | - Ayesha Kamal
- Department of Radiology, The Johns Hopkins Medical Institutions, Baltimore, Maryland, USA
| | - Atif Zaheer
- Department of Radiology, The Johns Hopkins Medical Institutions, Baltimore, Maryland, USA
| | - Vivek Kumbhari
- Department of Medicine, Division of Gastroenterology and Hepatology, The Johns Hopkins Medical Institutions, Baltimore, Maryland, USA
| | - Anne Marie Lennon
- Department of Medicine, Division of Gastroenterology and Hepatology, The Johns Hopkins Medical Institutions, Baltimore, Maryland, USA
| | - Marcia Irene Canto
- Department of Medicine, Division of Gastroenterology and Hepatology, The Johns Hopkins Medical Institutions, Baltimore, Maryland, USA
| | - Anthony N Kalloo
- Department of Medicine, Division of Gastroenterology and Hepatology, The Johns Hopkins Medical Institutions, Baltimore, Maryland, USA
| | - Todd H Baron
- Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, Minnesota, USA
| | - Mouen A Khashab
- Department of Medicine, Division of Gastroenterology and Hepatology, The Johns Hopkins Medical Institutions, Baltimore, Maryland, USA
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Fabbri C, Luigiano C, Lisotti A, Cennamo V, Virgilio C, Caletti G, Fusaroli P. Endoscopic ultrasound-guided treatments: are we getting evidence based--a systematic review. World J Gastroenterol 2014; 20:8424-48. [PMID: 25024600 PMCID: PMC4093695 DOI: 10.3748/wjg.v20.i26.8424] [Citation(s) in RCA: 90] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/01/2013] [Revised: 01/30/2014] [Accepted: 03/12/2014] [Indexed: 02/07/2023] Open
Abstract
The continued need to develop less invasive alternatives to surgical and radiologic interventions has driven the development of endoscopic ultrasound (EUS)-guided treatments. These include EUS-guided drainage of pancreatic fluid collections, EUS-guided necrosectomy, EUS-guided cholangiography and biliary drainage, EUS-guided pancreatography and pancreatic duct drainage, EUS-guided gallbladder drainage, EUS-guided drainage of abdominal and pelvic fluid collections, EUS-guided celiac plexus block and celiac plexus neurolysis, EUS-guided pancreatic cyst ablation, EUS-guided vascular interventions, EUS-guided delivery of antitumoral agents and EUS-guided fiducial placement and brachytherapy. However these procedures are technically challenging and require expertise in both EUS and interventional endoscopy, such as endoscopic retrograde cholangiopancreatography and gastrointestinal stenting. We undertook a systematic review to record the entire body of literature accumulated over the past 2 decades on EUS-guided interventions with the objective of performing a critical appraisal of published articles, based on the classification of studies according to levels of evidence, in order to assess the scientific progress made in this field.
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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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Whitehead DA, Gardner TB. Evidence-Based Management of Necrotizing Pancreatitis. ACTA ACUST UNITED AC 2014; 12:322-32. [DOI: 10.1007/s11938-014-0018-7] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
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Worhunsky DJ, Qadan M, Dua MM, Park WG, Poultsides GA, Norton JA, Visser BC. Laparoscopic transgastric necrosectomy for the management of pancreatic necrosis. J Am Coll Surg 2014; 219:735-43. [PMID: 25158913 DOI: 10.1016/j.jamcollsurg.2014.04.012] [Citation(s) in RCA: 42] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/13/2014] [Revised: 04/05/2014] [Accepted: 04/07/2014] [Indexed: 12/16/2022]
Abstract
BACKGROUND Traditional open necrosectomy for pancreatic necrosis is associated with significant morbidity and mortality. Although minimally invasive techniques have been described and offer some promise, each has considerable limitations. This study assesses the safety and effectiveness of laparoscopic transgastric necrosectomy (LTN), a novel technique for the management of necrotizing pancreatitis. STUDY DESIGN Between 2009 and 2013, patients with retrogastric pancreatic necrosis requiring debridement were evaluated for LTN. Debridement was performed via a laparoscopic transgastric approach using 2 to 3 ports and the wide cystgastrostomy left open. Patient demographics, disease severity, operative characteristics, and outcomes were collected and analyzed. RESULTS Twenty-one patients (13 men, median age 54 years; interquartile range [IQR] 46 to 62 years) underwent LTN during the study period. The duration between pancreatitis onset and debridement was 65 days (IQR 53 to 124 years). Indications for operation included infection (7 patients) and persistent unwellness (14 patients). Median duration of LTN was 170 minutes (IQR 136 to 199 minutes); there were no conversions. Control of the necrosis was achieved via the single procedure in 19 of 21 patients. Median postoperative hospital stay was 5 days (IQR 3 to 14 days) and the majority (71%) of patients experienced no (n = 9) or only minor postoperative complications (n = 6) by Clavien-Dindo grade. Complications of Clavien-Dindo grade 3 or higher developed in 6 patients, including 1 death (5%). With a median follow-up of 11 months (IQR 7 to 22 months), none of the patients required additional operative debridement or had pancreatic/enteric fistulae or wound complications develop. CONCLUSIONS Laparoscopic transgastric necrosectomy is a novel, minimally invasive technique for the management of pancreatic necrosis that allows for debridement in a single operation. When feasible, LTN can reduce the morbidity associated with traditional open necrosectomy and avoid the limitations of other minimally invasive approaches.
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Affiliation(s)
- David J Worhunsky
- Department of Surgery, Stanford University Medical Center, Stanford, CA
| | - Motaz Qadan
- Department of Surgery, Stanford University Medical Center, Stanford, CA
| | - Monica M Dua
- Department of Surgery, Stanford University Medical Center, Stanford, CA
| | - Walter G Park
- Department of Gastroenterology and Hepatology, Stanford University Medical Center, Stanford, CA
| | | | - Jeffrey A Norton
- Department of Surgery, Stanford University Medical Center, Stanford, CA
| | - Brendan C Visser
- Department of Surgery, Stanford University Medical Center, Stanford, CA.
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Zhao G, Hu M, Liu R, Zhiming Z, Xu Y, Zhou H, Wang X, Zhang X. Two Anatomical Pathways for Retroperitoneoscopic Pancreatectomy: Indications for the Posterior and Lateral Approaches. World J Surg 2014; 38:3023-32. [DOI: 10.1007/s00268-014-2654-4] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
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van Brunschot S, Fockens P, Bakker OJ, Besselink MG, Voermans RP, Poley JW, Gooszen HG, Bruno M, van Santvoort HC. Endoscopic transluminal necrosectomy in necrotising pancreatitis: a systematic review. Surg Endosc 2014; 28:1425-38. [PMID: 24399524 DOI: 10.1007/s00464-013-3382-9] [Citation(s) in RCA: 109] [Impact Index Per Article: 10.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/27/2013] [Accepted: 12/04/2013] [Indexed: 02/07/2023]
Abstract
OBJECTIVE We performed a systematic review to assess the outcome of endoscopic transluminal necrosectomy in necrotising pancreatitis with additional focus on indication, disease severity, and methodological quality of studies. DESIGN We searched the literature published between January 2005 and June 2013. Cohorts, including patients with (infected) necrotising pancreatitis, undergoing endoscopic necrosectomy were included. Indication, disease severity, and methodological quality were described. The main outcomes were mortality, major complications, number of endoscopic sessions, and definitive successful treatment with endoscopic necrosectomy alone. RESULTS After screening 581 papers, 14 studies, including 455 patients, fulfilled the eligibility criteria. All included studies were retrospective analyses except for one randomized, controlled trial. Overall methodological quality was moderate to low (mean 5, range 2-9). Less than 50 % of studies reported on pre-procedural severity of disease: mean APACHE-II score before intervention was 8; organ failure was present in 23 % of patients; and infected necrosis in 57 % of patients. On average, four (range 1-23) endoscopic interventions were performed per patient. With endoscopic necrosectomy alone, definitive successful treatment was achieved in 81 % of patients. Mortality was 6 % (28/460 patients) and complications occurred in 36 % of patients. Bleeding was the most common complication. CONCLUSIONS Endoscopic transluminal necrosectomy is an effective treatment for the majority of patients with necrotising pancreatitis with acceptable mortality and complication rates. It should be noted that methodological quality of the available studies is limited and that the combined patient population of endoscopically treated patients is only moderately ill.
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Affiliation(s)
- Sandra van Brunschot
- Department of OR/Clinical Surgical Research, Radboud University Nijmegen Medical Center, Nijmegen, The Netherlands,
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Puli SR, Graumlich JF, Pamulaparthy SR, Kalva N. Endoscopic transmural necrosectomy for walled-off pancreatic necrosis: a systematic review and meta-analysis. Can J Gastroenterol Hepatol 2014; 28:50-3. [PMID: 24212912 PMCID: PMC4071909 DOI: 10.1155/2014/539783] [Citation(s) in RCA: 46] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/19/2013] [Accepted: 09/15/2013] [Indexed: 12/15/2022] Open
Abstract
BACKGROUND Endoscopic transmural necrosectomy (ETN) is emerging as a viable treatment option for walled-off pancreatic necrosis. This NOTES-type procedure is significantly less invasive than an extensive surgical debridement; however, published data regarding the success of ETN in treating pancreatic necrosis have varied. OBJECTIVE To evaluate the published medical literature to determine the success of treating walled-off pancreatic necrosis with ETN. METHODS Studies using ETN as a primary mode of therapy to treat organized pancreatic necrosis were selected. Success was defined as resolution of the necrotic cavity proven by radiology. Articles were searched in Medline, PubMed, Ovid journals, CINAH, old Medline, Medline nonindexed citations and the Cochrane controlled trials registry. The summary estimates were expressed as pooled proportions. First, the individual study proportions were transformed into a quantity using Freeman-Tukey variant of the arcsine square root transformed proportion. The pooled proportion was calculated as the back-transform of the weighted mean of the transformed proportions, using inverse arcsine variance weights for the fixed-effects model and DerSimonian-Laird weights for the random-effects model. Publication bias was calculated using the Begg-Mazumdar and Harbord bias estimators. RESULTS The initial search identified 920 reference articles, of which 129 relevant articles were selected and reviewed. Data were extracted from eight studies (n=233) that met the inclusion criteria. Organization of pancreatic necrosis was determined by computed tomography scan in all of the studies. The mean time of ETN after onset of acute pancreatitis⁄abdominal pain was seven weeks. The weighted mean size of the necrotic cavity was 12.87 cm (95% CI 10.54 cm to 15.20 cm). The weighted mean number of endoscopic procedures needed to resolve the necrotic cavity was 4.09 (95% CI 2.31 to 5.87). Pooled proportion of successful resolution of pancreatic necrosis using ETN was 81.84% (95% CI 76.73% to 86.44%). The pooled proportion of recurrence in the form of necrotic cavity or pseudocyst after ETN was 10.88% (95% CI 7.27% to 15.11%). Complications were noted in 21.33% (95% CI 16.40% to 26.72%) of patients and included bleeding, sepsis and perforation. The weighted mean number of days in hospital after ETN was 32.85 days (95% CI 10.50 to 55.20 days). For pancreatic necrosis that did not resolve, surgery had to be performed in 12.98% (95% CI 9.05% to 17.51%) of patients. The fixed-effect model was used to report all of the pooled proportions. Estimates calculated using fixed- and random-effects models were similar. Test of heterogeneity yielded P>0.10, indicating that the studies could be combined. The publication bias calculated using Begg-Mazumdar bias indicator yielded a Kendall's tau b value of -0.07 (P=0.72) and the same using Harbord bias indicator gave a value of 0.33 (95% CI -1.35 to 2.01; P=0.60). Both of these indicators show that there was no publication bias. CONCLUSION The present meta-analysis showed that ETN is safe and effective at treating patients with symptomatic walled-off necrosis. ETN offers the advantage of minimally invasive endoscopic treatment without transabdominal surgery; however, better techniques and equipment are still needed to improve procedural efficiency. Decisions to perform ETN should be made by advanced endoscopists in collaboration with a multidisciplinary team with the facilities and personnel to manage these complex patients.
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Affiliation(s)
- Srinivas R Puli
- Division of Gastroenterology and Hepatology, University of Illinois College of Medicine at Peoria, Peoria, Illinois, USA
| | - James F Graumlich
- Division of General Internal Medicine, University of Illinois College of Medicine at Peoria, Peoria, Illinois, USA
| | - Smitha R Pamulaparthy
- Division of Gastroenterology and Hepatology, University of Illinois College of Medicine at Peoria, Peoria, Illinois, USA
| | - Nikhil Kalva
- Division of General Internal Medicine, University of Illinois College of Medicine at Peoria, Peoria, Illinois, USA
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van Brunschot S, van Grinsven J, Voermans RP, Bakker OJ, Besselink MGH, Boermeester MA, Bollen TL, Bosscha K, Bouwense SA, Bruno MJ, Cappendijk VC, Consten EC, Dejong CH, Dijkgraaf MGW, van Eijck CH, Erkelens GW, van Goor H, Hadithi M, Haveman JW, Hofker SH, Jansen JJM, Laméris JS, van Lienden KP, Manusama ER, Meijssen MA, Mulder CJ, Nieuwenhuis VB, Poley JW, de Ridder RJ, Rosman C, Schaapherder AF, Scheepers JJ, Schoon EJ, Seerden T, Spanier BWM, Straathof JWA, Timmer R, Venneman NG, Vleggaar FP, Witteman BJ, Gooszen HG, van Santvoort HC, Fockens P. Transluminal endoscopic step-up approach versus minimally invasive surgical step-up approach in patients with infected necrotising pancreatitis (TENSION trial): design and rationale of a randomised controlled multicenter trial [ISRCTN09186711]. BMC Gastroenterol 2013; 13:161. [PMID: 24274589 PMCID: PMC4222267 DOI: 10.1186/1471-230x-13-161] [Citation(s) in RCA: 85] [Impact Index Per Article: 7.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/08/2013] [Accepted: 11/13/2013] [Indexed: 02/06/2023] Open
Abstract
Background Infected necrotising pancreatitis is a potentially lethal disease that nearly always requires intervention. Traditionally, primary open necrosectomy has been the treatment of choice. In recent years, the surgical step-up approach, consisting of percutaneous catheter drainage followed, if necessary, by (minimally invasive) surgical necrosectomy has become the standard of care. A promising minimally invasive alternative is the endoscopic transluminal step-up approach. This approach consists of endoscopic transluminal drainage followed, if necessary, by endoscopic transluminal necrosectomy. We hypothesise that the less invasive endoscopic step-up approach is superior to the surgical step-up approach in terms of clinical and economic outcomes. Methods/Design The TENSION trial is a randomised controlled, parallel-group superiority multicenter trial. Patients with (suspected) infected necrotising pancreatitis with an indication for intervention and in whom both treatment modalities are deemed possible, will be randomised to either an endoscopic transluminal or a surgical step-up approach. During a 4 year study period, 98 patients will be enrolled from 24 hospitals of the Dutch Pancreatitis Study Group. The primary endpoint is a composite of death and major complications within 6 months following randomisation. Secondary endpoints include complications such as pancreaticocutaneous fistula, exocrine or endocrine pancreatic insufficiency, need for additional radiological, endoscopic or surgical intervention, the need for necrosectomy after drainage, the number of (re-)interventions, quality of life, and total direct and indirect costs. Discussion The TENSION trial will answer the question whether an endoscopic step-up approach reduces the combined primary endpoint of death and major complications, as well as hospital stay and related costs compared with a surgical step-up approach in patients with infected necrotising pancreatitis.
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Affiliation(s)
- Sandra van Brunschot
- Department of Gastroenterology and Hepatology, University of Amsterdam, Amsterdam, The Netherlands.
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Fisher JM, Gardner TB. Endoscopic therapy of necrotizing pancreatitis and pseudocysts. Gastrointest Endosc Clin N Am 2013; 23:787-802. [PMID: 24079790 DOI: 10.1016/j.giec.2013.06.013] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
Endoscopic therapy has become an essential component in the management of postpancreatitis complications, such as infected and/or symptomatic pancreatic pseudocysts and walled-off necrosis. However, although there have been 2 recent randomized, controlled trials performed, a general lack of comparative effectiveness data regarding the timing, indications, and outcomes of these procedures has been a barrier to the development of practice standards for therapeutic endoscopists managing these issues. This article reviews the available data and expert consensus regarding indications for endoscopic intervention, timing of procedures, endoscopic technique, periprocedural considerations, and complications.
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Affiliation(s)
- Jessica M Fisher
- Division of Gastroenterology, Department of Medicine, University of Washington, 1959 Northeast Pacific Street, Box 356424, Seattle, WA 98195, USA
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Tu Y, Jiao H, Tan X, Wang D, Du J, Sun L, Zhang W. Retroperitoneal laparoscopic debridement and drainage of infected retroperitoneal necrosis in severe acute pancreatitis. Asian J Surg 2013; 36:159-64. [PMID: 23786806 DOI: 10.1016/j.asjsur.2013.04.003] [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: 07/18/2012] [Revised: 11/06/2012] [Accepted: 04/03/2013] [Indexed: 12/12/2022] Open
Abstract
OBJECTIVE To explore the effect of retroperitoneal laparoscopic debridement and drainage on infected necrosis in severe acute pancreatitis. MATERIALS AND METHODS This retrospective study included 18 patients with severe acute pancreatitis (SAP) undergoing retroperitoneal laparoscopic debridement and drainage from May 2006 to April 2012 in our hospital. All patients had infected retroperitoneal necrosis and single or multiple peritoneal abscesses. Eleven patients transferred to our hospital were treated with the retroperitoneal laparoscopic debridement and drainage within 24-72 hours after admission. Conservative treatments were given to eight patients. Retroperitoneal laparoscopic debridement and drainage were applied 3-11 days after admission. RESULTS All patients had infection of necrotic pancreas or peripancreatic tissues. Twelve patients had organ failure. Three patients underwent secondary surgery. Laparotomy with debridement and drainage were applied to one patient who had a huge lesser sac abscess 7 days after first surgery. The other two patients were given secondary retroperitoneal laparoscopic debridement and drainage. One case was complicated by retroperitoneal hemorrhage, four cases had pancreatic leakage, and no intestinal fistula was found. The patients' heart rate, respiration, temperature, and white blood cell count were significantly improved 48 hours after surgery compared with those prior to surgery (p<0.05). The average length of stay in hospitals was 40.8 days (range, 6-121 days), and the drainage tube indwelling time was 44.4 days (range, 2-182 days). CONCLUSION Retroperitoneal laparoscopic debridement and drainage is an SAP surgical treatment with a minimally invasive procedure and a good effect, and can be applied for infected retroperitoneal necrosis in early SAP.
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Affiliation(s)
- Yuliang Tu
- Department of Hepatobiliary Surgery, First Affiliated Hospital of People's Liberation Army (PLA) General Hospital, Beijing, China
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EUS-guided endoscopic necrosectomy and temporary cystogastrostomy for infected pancreatic necrosis with self-expanding metallic stents. Surg Laparosc Endosc Percutan Tech 2013; 22:e319-21. [PMID: 23047418 DOI: 10.1097/sle.0b013e3182657e03] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
Pancreatic pseudocyst with infected necrotic tissue is associated with necrotizing pancreatitis and carries a high rate of complications and death. Open cystogastrostomy with removal of necrotic material and necrosectomy is the standard treatment for infected pancreatic necrosis but is associated with significant morbidity, mortality, and prolonged hospital stay. Endoscopic cyst drainage with necrosectomy is an alternative and less invasive technique. We report a case of endoscopic ultrasound-guided cystogastrostomy with a fully covered 15-mm-diameter self-expandable metal stent and staged endoscopic necrosectomy through the stent. This is the first case, so far, to use this technique with complete removal of necrotic material without any complications.
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Transluminal retroperitoneal endoscopic necrosectomy with the use of hydrogen peroxide and without external irrigation: a novel approach for the treatment of walled-off pancreatic necrosis. Surg Endosc 2013; 27:3911-20. [DOI: 10.1007/s00464-013-2948-x] [Citation(s) in RCA: 37] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/12/2012] [Accepted: 03/20/2013] [Indexed: 12/20/2022]
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Hocke M, Will U, Dietrich C. Interventionelle Endosonographie. DER GASTROENTEROLOGE 2013; 8:100-105. [DOI: 10.1007/s11377-012-0721-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/27/2023]
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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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