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Shah J, Fernandez Y Viesca M, Jagodzinski R, Arvanitakis M. Infected pancreatic necrosis-Current trends in management. Indian J Gastroenterol 2024; 43:578-591. [PMID: 38625518 DOI: 10.1007/s12664-023-01506-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/06/2023] [Accepted: 12/11/2023] [Indexed: 04/17/2024]
Abstract
Acute necrotizing pancreatitis is a common gastrointestinal disease requiring hospitalization and multiple interventions resulting in higher morbidity and mortality. Development of infection in such necrotic tissue is one of the sentinel events in natural history of necrotizing pancreatitis. Infected necrosis develops in around 1/3rd of patients with necrotizing pancreatitis resulting in higher mortality. So, timely diagnosis of infected necrosis using clinical, laboratory and radiological parameters is of utmost importance. Though initial conservative management with antibiotics and organ support system is effective in some patients, a majority of patients still requires drainage of the collection by various modalities. Mode of drainage of infected pancreatic necrosis depends on various factors such as the clinical status of the patient, location and characteristics of collection and availability of the expertise and includes endoscopic, percutaneous and minimally invasive or open surgical approaches. Endoscopic drainage has proved to be a game changer in the management of infected pancreatic necrosis in the last decade with rapid evolution in procedure techniques, development of novel metal stent and dedicated necrosectomy devices for better clinical outcome. Despite widespread adoption of endoscopic transluminal drainage of pancreatic necrosis with excellent clinical outcomes, peripheral collections are still not amenable for endoscopic drainage and in such scenario, the role of percutaneous catheter drainage or minimally invasive surgical necrosectomy cannot be understated. In a nutshell, the management of patients with infected pancreatic necrosis involves a multi-disciplinary team including a gastroenterologist, an intensivist, an interventional radiologist and a surgeon for optimum clinical outcomes.
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Affiliation(s)
- Jimil Shah
- Department of Gastroenterology, Postgraduate Institute of Medical Education and Research, Chandigarh, 160 012, India
| | - Michael Fernandez Y Viesca
- Department of Gastroenterology, Hepatopancreatology, and Digestive Oncology, Erasme University Hospital, HUB, Université Libre de Bruxelles, Brussels, Belgium
| | | | - Marianna Arvanitakis
- Department of Gastroenterology, Hepatopancreatology, and Digestive Oncology, Erasme University Hospital, HUB, Université Libre de Bruxelles, Brussels, Belgium.
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Avudiappan M, Bhargava V, Kulkarni A, Kang M, Rana SS, Gupta R. Evaluating the role of the Minimal Incision Retroperitoneal Necrosectomy (MIRN) in the management of infected pancreatic necrosis: Experience from a tertiary care center. Surg Open Sci 2023; 15:38-42. [PMID: 37609368 PMCID: PMC10440548 DOI: 10.1016/j.sopen.2023.07.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/27/2023] [Accepted: 07/16/2023] [Indexed: 08/24/2023] Open
Abstract
Background The conventional open necrosectomy was associated with high mortality and morbidities like secondary organ failure, incisional hernia, enterocutaneous fistula, and external pancreatic fistula. In acute pancreatitis, collections are primarily confined to the retroperitoneal space. Hence, the retroperitoneal approach can be used to drain the collection and necrotic material. It benefits smaller incisions and better outcomes in terms of morbidity and mortality than the conventional open necrosectomy. This study primarily aims to describe the effects of minimal incision retroperitoneal necrosectomy versus conventional open necrosectomy for treating INP. Moreover, it provides evidence supporting the efficacy and safety of this method. Methods A single-center retrospective study of the prospectively maintained database from April 2008 to December 2021. Results A total of 122 patients were included in the study. Seventy-eight patients had an open necrosectomy, 30 had a MIRN, and 14 had a VARD procedure. These three groups were comparable in demographic variables. Preoperative variables like APACHE II at presentation, Modified CTSI, percentage of necrosis, multi-organ failure, time to surgery, and need for preoperative ICU stay were comparable among the three groups. Postoperative mortality was low in the MIRN group{open 35.8 % vs. MIRN 20.5 % vs. VARD 35.7 %, p = 0.066}. The postoperative stay was also significantly low in the MIRN and VARD group {open 23.62 ± 16.61 vs. MIRN 11.77 ± 7.73, VARD 8.86 ± 2.98, p = 0.00}. No significant difference in re-intervention rate, postoperative bleeding, and enterocutaneous fistula. Conclusion MIRN is a simple and easy-to-adapt procedure for infected pancreatic necrosis in the appropriately selected patient group.
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Affiliation(s)
- Mohanasundaram Avudiappan
- Department of Surgical Gastroenterology, Postgraduate Institute of Medical Education and Research, Chandigarh 160012, India
| | - Venu Bhargava
- Department of Surgical Gastroenterology, Postgraduate Institute of Medical Education and Research, Chandigarh 160012, India
| | - Aditya Kulkarni
- Department of Surgical Gastroenterology, Postgraduate Institute of Medical Education and Research, Chandigarh 160012, India
| | - Mandeep Kang
- Department of Radio Diagnosis and Imaging, Postgraduate Institute of Medical Education and Research, Chandigarh 160012, India
| | - Surinder Singh Rana
- Department of Gastroenterology, Postgraduate Institute of Medical Education and Research, Chandigarh 160012,India
| | - Rajesh Gupta
- Department of Surgical Gastroenterology, Postgraduate Institute of Medical Education and Research, Chandigarh 160012, India
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Ghabili K, Shaikh J, Pollak J, Elwood D, Majdalany BS, Nezami N. Percutaneous Chemical and Mechanical Necrosectomy for Walled-Off Pancreatic Necrosis. J Vasc Interv Radiol 2023; 34:454-459.e2. [PMID: 36423816 DOI: 10.1016/j.jvir.2022.11.011] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/18/2022] [Revised: 10/07/2022] [Accepted: 11/09/2022] [Indexed: 11/22/2022] Open
Abstract
PURPOSE To test the hypothesis that percutaneous combined chemical and mechanical necrosectomy using a Malecot anchor drain and an Arrow-Trerotola percutaneous thrombolytic device (PTD) in patients with walled-off pancreatic necrosis (WOPN) is feasible, safe, and effective compared with a control group undergoing mechanical necrosectomy alone. MATERIALS AND METHODS In a retrospective analysis, patients with WOPN not amenable to endoscopic-guided cystogastrostomy placement were studied as case and control groups. The patients in the case group underwent percutaneous combined chemical (hydrogen peroxide 3%) and mechanical necrosectomy using a Malecot anchor drain and/or Arrow-Trerotola PTD from December 2020 to April 2022. The controls underwent mechanical necrosectomy alone without chemical necrosectomy. Clinical success was defined as complete resolution of the cavity on follow-up noncontrast computed tomography scans with subsequent drain removal. RESULTS Thirteen patients in the case group and 11 patients in the control group underwent percutaneous drain placement followed by percutaneous combined chemical and mechanical necrosectomy (case group) or mechanical necrosectomy only (control group) for WOPN. Drain placement and necrosectomy were technically successful in all patients studied. One patient in the case group developed postprocedural sepsis because of communication between the cavity and the splenic vein. Another patient in the case group developed bleeding from a branch of the pancreaticoduodenal artery on postnecrosectomy day 9, which was successfully embolized by interventional radiology. No pancreaticocutaneous fistula was reported at the 3-month follow-up. The clinical success rates in the case and control groups were 100% and 38.4%, respectively (P = .003). CONCLUSIONS Percutaneous combined chemical and mechanical necrosectomy is a feasible, safe, and effective treatment of WOPN.
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Affiliation(s)
- Kamyar Ghabili
- Department of Radiology and Biomedical Imaging, Yale University School of Medicine, New Haven, Connecticut
| | - Jamil Shaikh
- Division of Interventional Radiology and Image-Guided Medicine, Department of Radiology and Imaging Sciences, Emory University School of Medicine, Atlanta, Georgia; Department of Vascular and Interventional Radiology, Tampa General Hospital, University of South Florida, Morsani College of Medicine, Tampa, Florida
| | - Jeffrey Pollak
- Department of Radiology and Biomedical Imaging, Yale University School of Medicine, New Haven, Connecticut
| | - David Elwood
- Division of General and Gastrointestinal Surgery, Department of Surgery, Emory University School of Medicine, Atlanta, Georgia
| | - Bill S Majdalany
- Division of Interventional Radiology and Image-Guided Medicine, Department of Radiology and Imaging Sciences, Emory University School of Medicine, Atlanta, Georgia
| | - Nariman Nezami
- Division of Interventional Radiology and Image-Guided Medicine, Department of Radiology and Imaging Sciences, Emory University School of Medicine, Atlanta, Georgia; Division of Vascular and Interventional Radiology, Department of Diagnostic Radiology and Nuclear Medicine, University of Maryland School of Medicine, Baltimore, Maryland; Experimental Therapeutics Program, University of Maryland Marlene and Stewart Greenebaum Comprehensive Cancer Center, Baltimore, Maryland.
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Vyawahare MA, Gulghane S, Titarmare R, Bawankar T, Mudaliar P, Naikwade R, Timane JM. Percutaneous direct endoscopic pancreatic necrosectomy. World J Gastrointest Surg 2022; 14:731-742. [PMID: 36157371 PMCID: PMC9453331 DOI: 10.4240/wjgs.v14.i8.731] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/09/2022] [Revised: 05/23/2022] [Accepted: 08/05/2022] [Indexed: 02/07/2023] Open
Abstract
Approximately 10%-20% of the cases of acute pancreatitis have acute necrotizing pancreatitis. The infection of pancreatic necrosis is typically associated with a prolonged course and poor prognosis. The multidisciplinary, minimally invasive “step-up” approach is the cornerstone of the management of infected pancreatic necrosis (IPN). Endosonography-guided transmural drainage and debridement is the preferred and minimally invasive technique for those with IPN. However, it is technically not feasible in patients with early pancreatic/peripancreatic fluid collections (PFC) (< 2-4 wk) where the wall has not formed; in PFC in paracolic gutters/pelvis; or in walled off pancreatic necrosis (WOPN) distant from the stomach/duodenum. Percutaneous drainage of these infected PFC or WOPN provides rapid infection control and patient stabilization. In a subset of patients where sepsis persists and necrosectomy is needed, the sinus drain tract between WOPN and skin-established after percutaneous drainage or surgical necrosectomy drain, can be used for percutaneous direct endoscopic necrosectomy (PDEN). There have been technical advances in PDEN over the last two decades. An esophageal fully covered self-expandable metal stent, like the lumen-apposing metal stent used in transmural direct endoscopic necrosectomy, keeps the drainage tract patent and allows easy and multiple passes of the flexible endoscope while performing PDEN. There are several advantages to the PDEN procedure. In expert hands, PDEN appears to be an effective, safe, and minimally invasive adjunct to the management of IPN and may particularly be considered when a conventional drain is in situ by virtue of previous percutaneous or surgical intervention. In this current review, we summarize the indications, techniques, advantages, and disadvantages of PDEN. In addition, we describe two cases of PDEN in distinct clinical situations, followed by a review of the most recent literature.
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Affiliation(s)
- Manoj A Vyawahare
- Department of Medical Gastroenterology, American Oncology Institute at Nangia Specialty Hospital, Nagpur 440028, Maharashtra, India
| | - Sushant Gulghane
- Department of Internal Medicine and Critical Care, American Oncology Institute at Nangia Specialty Hospital, MIDC Hingna, Nagpur 440028, Maharashtra, India
| | - Rajkumar Titarmare
- Department of Anaesthesiology, American Oncology Institute at Nangia Specialty Hospital, MIDC Hingna, Nagpur 440028, Maharashtra, India
| | - Tushar Bawankar
- Department of Anaesthesiology, American Oncology Institute at Nangia Specialty Hospital, MIDC Hingna, Nagpur 440028, Maharashtra, India
| | - Prashant Mudaliar
- Department of Radiology, American Oncology Institute at Nangia Specialty Hospital, MIDC Hingna, Nagpur 440028, Maharashtra, India
| | - Rahul Naikwade
- Department of Surgery, American Oncology Institute at Nangia Specialty Hospital, MIDC Hingna, Nagpur 440028, Maharashtra, India
| | - Jayesh M Timane
- Department of Internal Medicine and Critical Care, American Oncology Institute at Nangia Specialty Hospital, MIDC Hingna, Nagpur 440028, Maharashtra, India
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Wu CC, Martin DT, Bauman BD, Amateau SK, Azeem N, Harmon JV. Video-assisted retroperitoneal debridement for infected pancreatic necrosis: A single center series. Int J Surg Case Rep 2022. [PMCID: PMC9168180 DOI: 10.1016/j.ijscr.2022.107254] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/01/2022] Open
Abstract
Introduction and importance Case presentation Clinical discussion Conclusion VARD is a first option when surgery is required for infected necrotizing pancreatic necrosis. The VARD procedure requires placement of percutaneous CT guided retroperitoneal flank drains. Complications of the VARD procedure include bleeding, bowel injury, and pancreatic fistula.
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Zhang H, Wen XD, Ma X, Zhu YQ, Jiang ZW, Huang SQ, Wang T, Liu WH. Triple guidance of choledochoscopy, ultrasonography, and computed tomography facilitates percutaneous catheter drainage of infected walled-off necrosis. Insights Imaging 2021; 12:137. [PMID: 34580791 PMCID: PMC8476709 DOI: 10.1186/s13244-021-01087-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/24/2021] [Accepted: 08/12/2021] [Indexed: 11/12/2022] Open
Abstract
Objectives Percutaneous catheter drainage (PCD) is usually performed to treat acute pancreatitis complicated by infected walled-off necrosis (WON). Insufficient drainage of infected WON may lead to a prolonged recovery process. Here, we introduce a modified PCD strategy that uses the triple guidance of choledochoscopy, ultrasonography, and computed tomography (CUC-PCD) to improve the therapeutic efficiency. Methods This study retrospectively analysed 73 patients with acute pancreatitis-related WON from January 2015 to January 2021. The first 38 patients were treated by ultrasonography/computed tomography-guided PCD (UC-PCD), and the next consecutive 35 patients by CUC-PCD. Perioperative data, procedural technical information, treatment outcomes, and follow-up data were collected. Results Demographic characteristics were statistically comparable between the two treatment groups (p > 0.05). After 48 h of PCD treatment, the CUC-PCD group achieved a significantly smaller size of the infected WON (p = 0.023), lower inflammatory response indexes (p = 0.020 for white blood cells, and p = 0.031 for C-reactive protein), and severity scores than the UC-PCD group (p < 0.05). Less catheter duration (p = 0.001), hospitalisation duration (p = 0.000), and global costs (p = 0.000) were observed in the CUC-PCD group compared to the UC-PCD group. There were no differences between the two groups regarding the rate of complications. Conclusions CUC-PCD is a safe and efficient approach with potential clinical applicability for treating infected WON owing to its feasibility in placing the drainage catheter at the optimal location in real time and performing primary necrosectomy without sinus tract formation and enlargement.
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Affiliation(s)
- Hui Zhang
- General Surgery Center, The General Hospital of Western Theater Command (Chengdu Military General Hospital), Chengdu, 610083, Sichuan Province, China
| | - Xu-Dong Wen
- Department of Gastroenterology and Hepatology, Chengdu First People's Hospital, Chengdu, 610016, Sichuan Province, China
| | - Xiao Ma
- General Surgery Center, The General Hospital of Western Theater Command (Chengdu Military General Hospital), Chengdu, 610083, Sichuan Province, China
| | - Yong-Qiang Zhu
- General Surgery Center, The General Hospital of Western Theater Command (Chengdu Military General Hospital), Chengdu, 610083, Sichuan Province, China
| | - Zhi-Wei Jiang
- General Surgery Center, The General Hospital of Western Theater Command (Chengdu Military General Hospital), Chengdu, 610083, Sichuan Province, China
| | - Shang-Qing Huang
- General Surgery Center, The General Hospital of Western Theater Command (Chengdu Military General Hospital), Chengdu, 610083, Sichuan Province, China
| | - Tao Wang
- General Surgery Center, The General Hospital of Western Theater Command (Chengdu Military General Hospital), Chengdu, 610083, Sichuan Province, China.
| | - Wei-Hui Liu
- Department of Gastroenterology and Hepatology, Sichuan Provincial People's Hospital, University of Electronic Science and Technology of China, Chengdu, 610072, Sichuan Province, China.
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Affiliation(s)
- Amy Y Li
- Department of Surgery, Section of Surgical Oncology, Stanford University School of Medicine, 300 Pasteur Drive, Room H3591, Stanford, CA 94305, USA
| | - John R Bergquist
- Department of Surgery, Section of Surgical Oncology, Stanford University School of Medicine, 300 Pasteur Drive, Room H3591, Stanford, CA 94305, USA
| | - Brendan C Visser
- Department of Surgery, Section of Surgical Oncology, Stanford University School of Medicine, 300 Pasteur Drive, H3680, Stanford, CA 94305-5655, USA.
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Gomes CA, Di Saverio S, Sartelli M, Segallini E, Cilloni N, Pezzilli R, Pagano N, Gomes FC, Catena F. Severe acute pancreatitis: eight fundamental steps revised according to the 'PANCREAS' acronym. Ann R Coll Surg Engl 2020; 102:555-559. [PMID: 32159357 PMCID: PMC7538721 DOI: 10.1308/rcsann.2020.0029] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 01/11/2020] [Indexed: 12/15/2022] Open
Abstract
Severe acute pancreatitis remains a life-threatening condition, responsible for many disorders of homeostasis and organ dysfunction. By means of a mnemonic 'PANCREAS', eight important steps in the management of severe acute pancreatitis are highlighted. These steps follow the principle of goal-directed therapy and should be borne in mind after diagnosis and during clinical treatment. The first step is perfusion: the goal is to reach a central venous pressure of 12-15mmHg, urinary output 0.5-1ml/kg/hour and inferior vena cava collapse index greater than 48%. Next is analgesia: multimodal, systemic and combined pharmacological agent and epidural block are possibilities. Third is nutrition: precocity, enteral feeding in gastric or post-pyloric position. Parenteral nutrition works best in difficult cases to achieve the individual total caloric value. Fourth is clinical: mild, moderate or severe pancreatitis according to the Atlanta criteria. Radiology is fifth: abdominal computed tomography on the fourth day for prognosis or to modify management. Endoscopy is sixth: endoscopic retrograde cholangiopancreatography (cholangitis, unpredicted clinical course and ascending jaundice); management of pancreatic fluid collection and 'walled-off necrosis'. Antibiotics come next: infectious complications are common causes of morbidity. The only rational indication for antibiotics is documented pancreatic infection. The last step is surgery: the dogma is represented by the 'three Ds' (delay, drain, debride). The preferred method is a minimally invasive step-up approach, which allows for gradually more invasive procedures when the previous treatment fails.
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Affiliation(s)
- C A Gomes
- Therezinha de Jesus University Hospital, Juiz de Fora, Brazil
| | - S Di Saverio
- Cambridge University Hospitals NHS Foundation Trust, Addenbrooke's Hospital, Cambridge, UK
| | | | - E Segallini
- Maggiore Hospital Regional Emergency Surgery and Trauma Centre, Bologna Local Health District, Bologna, Italy
| | - N Cilloni
- Maggiore Hospital, Bologna Local Health District, Bologna, Italy
| | - R Pezzilli
- Internal Medicine, Pancreas Unit, Department of Medical and Surgical Sciences, University of Bologna, Bologna, Italy
| | - N Pagano
- Department of Gastroenterology, Department of Medical and Surgical Sciences, University of Bologna, Bologna, Italy
| | - F C Gomes
- Hospital LifeCenter, Belo Horizonte, Brazil
| | - F Catena
- Maggiore Hospital, Parma, Italy
- 'Infermi' Hospital, Rimini, Italy
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Sgaramella LI, Gurrado A, Pasculli A, Prete FP, Catena F, Testini M. Open necrosectomy is feasible as a last resort in selected cases with infected pancreatic necrosis: a case series and systematic literature review. World J Emerg Surg 2020; 15:44. [PMID: 32727508 PMCID: PMC7391590 DOI: 10.1186/s13017-020-00326-z] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/12/2020] [Accepted: 07/21/2020] [Indexed: 02/08/2023] Open
Abstract
BACKGROUND Acute pancreatitis is a common inflammatory pancreatic disorder, often caused by gallstone disease and frequently requiring hospitalization. In 80% of cases, a rapid and favourable outcome is described, while a necrosis of pancreatic parenchyma or extra-pancreatic tissues is reported in 10-20% of patients. The onset of pancreatic necrosis determines a significant increase of early organ failure rate and death that has higher incidence if infection of pancreatic necrosis (IPN) or extra-pancreatic collections occur. IPN always requires an invasive intervention, and, in the last decade, the advent of minimally invasive techniques has gradually replaced the employment of the open traditional approach. We report a series of three severe cases of IPN managed with primary open necrosectomy (ON) and a systematic review of the literature, in order to understand if emergency surgery still has a role in the current clinical practice. METHODS From January 2010 to January 2020, 3 cases of IPN were treated in our Academic Department of General and Emergency Surgery. We performed a PubMed MEDLINE search on the ON of IPN, selecting 20 from 654 articles for review. RESULTS The 3 cases were male patients with a mean age of 61.3 years. All patients referred to our service complaining an evolving severe clinical condition evocating a sepsis due to IPN. CT scan was the main diagnostic tool. Patients were initially conservatively managed. In consideration of clinical worsening conditions, and at the failure of conservative and minimal invasive treatment, they were, finally, managed with emergency ON. Patients reported no complications nor procedure-related sequelae in the follow-up period. CONCLUSION The ON is confirmed to be the last resort, useful in selected severe cases, with a defined timing and in case of proven non-feasibility and no advantage of other minimally invasive approaches.
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Affiliation(s)
- Lucia Ilaria Sgaramella
- Unit of General Surgery "V. Bonomo", Department of Biomedical Sciences and Human Oncology, University of Bari "A. Moro", Polyclinic of Bari, Piazza Giulio Cesare, 11, 70124, Bari, Italy
| | - Angela Gurrado
- Unit of General Surgery "V. Bonomo", Department of Biomedical Sciences and Human Oncology, University of Bari "A. Moro", Polyclinic of Bari, Piazza Giulio Cesare, 11, 70124, Bari, Italy
| | - Alessandro Pasculli
- Unit of General Surgery "V. Bonomo", Department of Biomedical Sciences and Human Oncology, University of Bari "A. Moro", Polyclinic of Bari, Piazza Giulio Cesare, 11, 70124, Bari, Italy
| | - Francesco Paolo Prete
- Unit of General Surgery "V. Bonomo", Department of Biomedical Sciences and Human Oncology, University of Bari "A. Moro", Polyclinic of Bari, Piazza Giulio Cesare, 11, 70124, Bari, Italy
| | - Fausto Catena
- Department of Emergency and Trauma Surgery, Parma University Hospital, Viale Antonio Gramsci, 14, 43126, Parma, Italy
| | - Mario Testini
- Unit of General Surgery "V. Bonomo", Department of Biomedical Sciences and Human Oncology, University of Bari "A. Moro", Polyclinic of Bari, Piazza Giulio Cesare, 11, 70124, Bari, Italy.
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Jain S, Padhan R, Bopanna S, Jain SK, Dhingra R, Dash NR, Madhusudan KS, Gamanagatti SR, Sahni P, Garg PK. Percutaneous Endoscopic Step-Up Therapy Is an Effective Minimally Invasive Approach for Infected Necrotizing Pancreatitis. Dig Dis Sci 2020; 65:615-622. [PMID: 31187325 DOI: 10.1007/s10620-019-05696-2] [Citation(s) in RCA: 14] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/05/2019] [Accepted: 06/03/2019] [Indexed: 12/14/2022]
Abstract
BACKGROUND Infected pancreatic necrosis (IPN) is a major complication of acute pancreatitis (AP), which may require necrosectomy. Minimally invasive surgical step-up therapy is preferred for IPN. AIM To assess the effectiveness of percutaneous endoscopic step-up therapy in patients with IPN and identify predictors of its success. METHODS Consecutive patients with AP hospitalized to our tertiary care academic center were studied prospectively. Patients with IPN formed the study group. The treatment protocol for IPN was percutaneous endoscopic step-up approach starting with antibiotics and percutaneous catheter drainage, and if required necrosectomy. Percutaneous endoscopic necrosectomy (PEN) was performed using a flexible endoscope through the percutaneous tract under conscious sedation. Control of sepsis with resolution of collection(s) was the primary outcome measure. RESULTS A total of 415 patients with AP were included. Of them, 272 patients had necrotizing pancreatitis and 177 (65%) developed IPN. Of these 177 patients, 27 were treated conservatively with antibiotics alone, 56 underwent percutaneous drainage alone, 53 required underwent PEN as a step-up therapy, 1 per-oral endoscopic necrosectomy, and 52 required surgery. Of the 53 patients in the PEN group, 42 (79.2%) were treated successfully-34 after PEN alone and 8 after additional surgery. Eleven of 53 patients died due to organ failure-7 after PEN and 4 after surgery. Independent predictors of mortality were > 50% necrosis and early organ failure. CONCLUSION Percutaneous endoscopic step-up therapy is an effective strategy for IPN. Organ failure and extensive pancreatic necrosis predicted a suboptimal outcome in patients with infected necrotizing pancreatitis.
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Affiliation(s)
- Saransh Jain
- Department of Gastroenterology, All India Institute of Medical Sciences, New Delhi, India
| | - Rajesh Padhan
- Department of Gastroenterology, All India Institute of Medical Sciences, New Delhi, India
| | - Sawan Bopanna
- Department of Gastroenterology, All India Institute of Medical Sciences, New Delhi, India
| | - Sushil Kumar Jain
- Department of Gastroenterology, All India Institute of Medical Sciences, New Delhi, India
| | - Rajan Dhingra
- Department of Gastroenterology, 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
| | | | | | - Peush Sahni
- 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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11
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Lahiri RP, Karanjia ND. Acute necrotising pancreatitis - early management in the district general hospital and tertiary hepato-pancreatico-biliary unit. J Intensive Care Soc 2019; 20:263-267. [PMID: 31447922 DOI: 10.1177/1751143718783605] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/08/2023] Open
Abstract
Acute pancreatitis is a common general surgical emergency presentation. Up to 20% of cases are severe and can involve necrosis with high associated morbidity and mortality. It is most commonly due to gallstones and excess alcohol consumption. All patients with acute pancreatitis need to be scored for severity and patients with severe acute pancreatitis should be managed on the high dependency unit. The mainstay of early treatment is supportive, with care to ensure strict fluid balance and optimisation of end organ perfusion. There is no role for early antibiotic use in acute necrotising pancreatitis and antibiotics should only be used in the presence of positive cultures. Nutritional support is vitally important in improving outcomes in necrotising pancreatitis. This should ideally be provided enterally using an naso-jejunal tube if the patient cannot tolerate oral intake. Patients with significant early necrosis, persisting organ dysfunction, infected walled off necrosis requiring intervention or haemorrhagic pancreatitis should be referred to a regional hepato-pancreatico-biliary unit for advice or transfer. Percutaneous and endoscopic necrosectomy has replaced open surgery due to improved outcomes. Acute necrotising pancreatitis remains a complex surgical emergency with high morbidity and mortality that requires a multidisciplinary approach to attain optimum outcomes. The mainstay of treatment is supportive care and nutritional support. Patients with significant pancreatic necrosis or infected collections requiring drainage require input from a tertiary HPB unit to guide management.
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Affiliation(s)
- Rajiv P Lahiri
- Department of HPB Surgery, Royal Surrey County Hospital, Guildford, UK
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12
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Zhang ZH, Dıng YX, Wu YD, Gao CC, Lı F. The effect of technical details of percutaneous catheter drainage on the clinical outcomes of infected necrotizing pancreatitis patients. Turk J Med Sci 2019; 49:1079-1084. [PMID: 31340633 PMCID: PMC7018392 DOI: 10.3906/sag-1805-111] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/03/2022] Open
Abstract
Background/aim This study aimed to investigate the effect of technical details of percutaneous catheter drainage (PCD) on the clinical outcomes of patients with infected necrotizing pancreatitis (INP). Materials and methods A total of 44 INP patients treated in our hospital from October 2013 to October 2015 were included. The correlations of the first PCD treatment data and the clinical outcomes were analyzed. Results The number of catheters was positively correlated with hospital readmission (r = 0.335, P = 0.032). Receiver operating characteristic curve analysis showed that patients with ≥ 3 catheters were more likely to have hospital readmission. Patients with pleural effusion undergoing thoracentesis were more likely to have new intensive care unit admission (P = 0.025) and bleeding in need of intervention (P = 0.032). Patients with more effusion regions had higher incidences of mortality (P = 0.012) and new intensive care unit admissions (2.44 ± 1.03 vs. 1.88 ± 0.80; P = 0.059). Patients with PCD only were less likely to have new intensive care unit admissions (22.22% vs. 54.55%; P = 0.038) than those with PCD + small incision or/and videoscopic assisted retroperitoneal debridement. Conclusion Number of catheters greater than three was associated with unfavorable outcomes of PCD treatment in INP patients. Patients that received PCD treatment only had better outcomes.
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Affiliation(s)
- Zhi-Hua Zhang
- Department of General Surgery, Beijing Xuanwu Hospital, Capital Medical University, Beijing, P.R. China,Department of Hepatobiliary Surgery, Beijing Chaoyang Hospital, Capital Medical University, Beijing, P.R. China
| | - Yi-Xuan Dıng
- Department of General Surgery, Beijing Xuanwu Hospital, Capital Medical University, Beijing, P.R. China
| | - Yu-Duo Wu
- Department of General Surgery, Beijing Xuanwu Hospital, Capital Medical University, Beijing, P.R. China
| | - Chong-Chong Gao
- Department of General Surgery, Beijing Xuanwu Hospital, Capital Medical University, Beijing, P.R. China
| | - Fei Lı
- Department of General Surgery, Beijing Xuanwu Hospital, Capital Medical University, Beijing, P.R. China
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Changala M, Laberge J, Kerlan R, Taylor A, Arain M, Kirkwood K. Managing Refractory Postoperative Fistulas as Chronic Wounds Using Video-Assisted Hydrodebridement (VAHD). J Gastrointest Surg 2019; 23:608-612. [PMID: 30465188 DOI: 10.1007/s11605-018-4046-9] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/10/2018] [Accepted: 11/03/2018] [Indexed: 01/31/2023]
Abstract
Postoperative fistula formation remains a serious complication following abdominal surgical procedures. Refractory fistulas requiring further surgical intervention delay adjuvant chemotherapy and functional recovery. Here, we present six cases of refractory fistulas and describe a new management technique, which we call video-assisted hydrodebridement. We postulate that refractory fistulas are a type of chronic wound, for which hydrodebridement may be used to hasten wound healing. In all cases, patients had undergone a prolonged period of conservative management and surgical intervention was not considered appropriate. Here, we describe the steps of the procedure in detail. We achieved timely closure of the refractory fistula in five of six cases. The median duration of attempted conservative management was 122 days (63-346 days) and median time to fistula closure after the procedure was 35 days (22-64 days) in the five successful cases. The findings during each procedure are discussed. We suspect that this procedure applies the same benefits to refractory fistulas that hydrodebridement provides to chronic wounds. The combination of endoscopic exploration and hydrodebridement can elucidate barriers to fistula resolution while creating a clean base for wound healing. This technique may be a useful tool to reduce the morbidity of refractory fistula management.
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Affiliation(s)
- Marguerite Changala
- Department of Surgery, UCSF School of Medicine, University of California, San Francisco, 600 16th Street, S512F Genentech Hall, San Francisco, CA, 94158, USA
| | - Jeanne Laberge
- Department of Radiology, University of California, San Francisco, San Francisco, CA, 94158, USA
| | - Robert Kerlan
- Department of Radiology, University of California, San Francisco, San Francisco, CA, 94158, USA
| | - Andrew Taylor
- Department of Radiology, University of California, San Francisco, San Francisco, CA, 94158, USA
| | - Mustafa Arain
- Department of Medicine, University of California, San Francisco, San Francisco, CA, 94158, USA
| | - Kimberly Kirkwood
- Department of Surgery, UCSF School of Medicine, University of California, San Francisco, 600 16th Street, S512F Genentech Hall, San Francisco, CA, 94158, USA.
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Adler DG, Shah J, Nieto J, Binmoeller K, Bhat Y, Taylor LJ, Siddiqui AA. Placement of lumen-apposing metal stents to drain pseudocysts and walled-off pancreatic necrosis can be safely performed on an outpatient basis: A multicenter study. Endosc Ultrasound 2019; 8:36-42. [PMID: 29770780 PMCID: PMC6400089 DOI: 10.4103/eus.eus_30_17] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023] Open
Abstract
Backgrounds and Objectives: No study on the use of lumen-apposing fully covered self-expanding metal stent (LAMS) to drain pancreatic fluid collections (PFCs) has evaluated outcomes of patients in the outpatient setting. The objective of this multicenter study was to evaluate the clinical outcomes, success rate, and adverse events of the LAMS for endoscopic ultrasound (EUS)-guided transmural drainage of patients with symptomatic PFCs on an inpatient versus an outpatient basis. Methods: This was a multicenter, retrospective study conducted at 4 tertiary care centers. Results: We identified eighty patients with PFCs in whom EUS-guided transmural drainage using the LAMS was performed. The mean age of the patients was 53.1 years old. Mean size of the PFC was 11.8 ± 5.1 cm. A total of 33 patients had PFCs drained in an outpatient setting while 47 patients underwent PFC drainage as inpatients. The overall technical success (ability to access and drain a PFC by placement of transmural stents) was 98.7% (79 patients). There was no statistically significant difference in the technical success rate between the inpatient and outpatient groups (100% vs. 98%, respectively, P = 1). There was no significant difference in resolution of PFCs in the inpatient and outpatient groups (91% vs. 87% respectively; P = 1). The number of procedures required for PFC resolution was significantly lower in the inpatient group as compared to the outpatients (2.3 vs. 3.1 respectively, P = 0.025). Procedure-related adverse events were significantly lower in the inpatient group compared to the outpatient group (P < 0.01). There was no significant difference in the 2 groups in terms of development of adverse events requiring endoscopic reintervention within 30 days of initial stent placement (P = 0.69). Conclusion: This study shows that LAMS placement for PFCs can be performed safely on an outpatient basis with overall technical and clinical outcomes that are comparable to those seen in inpatients.
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Affiliation(s)
- Douglas G Adler
- Division of Gastroenterology and Hepatology, University of Utah Hospital, Salt Lake City, UT, USA
| | - Janak Shah
- Division of Gastroenterology, California Pacific Medical Center, San Francisco, CA, USA
| | - Jose Nieto
- Department of Gastroenterology, Borland-Groover Clinic, Jacksonville, FL, USA
| | - Kenneth Binmoeller
- Division of Gastroenterology, California Pacific Medical Center, San Francisco, CA, USA
| | - Yasser Bhat
- Division of Gastroenterology, California Pacific Medical Center, San Francisco, CA, USA
| | - Linda Jo Taylor
- Division of Gastroenterology and Hepatology, University of Utah Hospital, Salt Lake City, UT, USA
| | - Ali A Siddiqui
- Division of Gastroenterology and Hepatology, Thomas Jefferson University Hospital, Philadelphia, PA, USA
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Branco JC, Cardoso MF, Lourenço LC, Santos L, Horta DV, Coimbra É, Reis JA. A Rare Cause of Abdominal Pain in a Patient with Acute Necrotizing Pancreatitis. GE-PORTUGUESE JOURNAL OF GASTROENTEROLOGY 2018; 25:253-257. [PMID: 30320164 DOI: 10.1159/000484939] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/24/2017] [Revised: 11/03/2017] [Indexed: 11/19/2022]
Abstract
Introduction Walled-off necrosis (WON) is a potentially lethal late complication of acute pancreatitis (AP) and occurs in less than 10% of AP cases. It can be located in or outside the pancreas. When infected, the mortality rate increases and can reach 100% if the collection is not drained. Its treatment is complex and includes, at the beginning, intravenous antibiotics, which permit sepsis control and a delay in the therapeutic intervention, like drainage. Nowadays, a minimally invasive approach is advised. Depending on the location of the collection, computed tomography (CT)-guided drainage or endoscopic necrosectomy are the primary options, then complemented by surgical necrosectomy if needed. Infected WON of the abdominal wall has been rarely described in the literature and there is no report of any infection with Citrobacter freundii. Case We present the case of a 61-year-old man with necrotizing AP complicated by WON of the left abdominal wall, infected with Citrobacter freundii that was successfully treated with CT-guided percutaneous drainage and intravenous antibiotics. Conclusion Infected WON accounts for considerable mortality and its location in the abdominal wall is rare; it can be treated with antibiotics and CT-guided drainage with no need for further intervention.
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Affiliation(s)
- Joana C Branco
- Serviço de Gastrenterologia, Hospital Professor Doutor Fernando Fonseca, Amadora, Lisbon, Portugal
| | - Mariana F Cardoso
- Serviço de Gastrenterologia, Hospital Professor Doutor Fernando Fonseca, Amadora, Lisbon, Portugal
| | - Luís Carvalho Lourenço
- Serviço de Gastrenterologia, Hospital Professor Doutor Fernando Fonseca, Amadora, Lisbon, Portugal
| | - Liliana Santos
- Serviço de Gastrenterologia, Hospital Professor Doutor Fernando Fonseca, Amadora, Lisbon, Portugal
| | - David Valadas Horta
- Serviço de Gastrenterologia, Hospital Professor Doutor Fernando Fonseca, Amadora, Lisbon, Portugal
| | - Élia Coimbra
- Serviço de Imagiologia, Hospital Cruz Vermelha, Lisbon, Portugal
| | - Jorge A Reis
- Serviço de Gastrenterologia, Hospital Professor Doutor Fernando Fonseca, Amadora, Lisbon, Portugal
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Abstract
Since the original description of pancreatic fluid collections (PFC) in 1761 by Morgagni, their diagnosis, description, and management have continued to evolve. The mainstay of therapy for symptomatic PFCs has been the creation of a communication between a PFC and the stomach, to enable drainage. Surgical creation of these drainage conduits had been the gold standard of therapy; however, there has been a paradigm shift in recent years with an increasing role of endoscopic drainage. The techniques of endoscopic drainage have evolved from blind fluid aspiration to include endoscopic necrosectomy and the placement of lumen-apposing metal stents.
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Affiliation(s)
- Steven Shamah
- University of Chicago Medical Center, CERT Division, 5700 South Maryland Avenue, MC 8043, Chicago, IL 60637, USA
| | - Patrick I Okolo
- Division of Gastroenterology, Lenox Hill Hospital, 100 East 77th Street, 2nd Floor, New York, NY 10075, USA.
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17
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Rasslan R, Novo FDCF, Bitran A, Utiyama EM, Rasslan S. Management of infected pancreatic necrosis: state of the art. ACTA ACUST UNITED AC 2018; 44:521-529. [PMID: 29019583 DOI: 10.1590/0100-69912017005015] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/25/2017] [Accepted: 06/01/2017] [Indexed: 02/08/2023]
Abstract
Pancreatic necrosis occurs in 15% of acute pancreatitis. The presence of infection is the most important factor in the evolution of pancreatitis. The diagnosis of infection is still challenging. Mortality in infected necrosis is 20%; in the presence of organic dysfunction, mortality reaches 60%. In the last three decades, there has been a real revolution in the treatment of infected pancreatic necrosis. However, the challenges persist and there are many unsolved questions: antibiotic treatment alone, tomography-guided percutaneous drainage, endoscopic drainage, video-assisted extraperitoneal debridement, extraperitoneal access, open necrosectomy? A step up approach has been proposed, beginning with less invasive procedures and reserving the operative intervention for patients in which the previous procedure did not solve the problem definitively. Indication and timing of the intervention should be determined by the clinical course. Ideally, the intervention should be done only after the fourth week of evolution, when it is observed a better delimitation of necrosis. Treatment should be individualized. There is no procedure that should be the first and best option for all patients. The objective of this work is to critically review the current state of the art of the treatment of infected pancreatic necrosis.
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Affiliation(s)
- Roberto Rasslan
- - University of São Paulo School of Medicine, Division of General Surgery and Trauma, Department of Surgery, São Paulo, SP, Brazil
| | - Fernando da Costa Ferreira Novo
- - University of São Paulo School of Medicine, Division of General Surgery and Trauma, Department of Surgery, São Paulo, SP, Brazil
| | - Alberto Bitran
- - University of São Paulo School of Medicine, Division of General Surgery and Trauma, Department of Surgery, São Paulo, SP, Brazil
| | - Edivaldo Massazo Utiyama
- - University of São Paulo School of Medicine, Division of General Surgery and Trauma, Department of Surgery, São Paulo, SP, Brazil
| | - Samir Rasslan
- - University of São Paulo School of Medicine, Division of General Surgery and Trauma, Department of Surgery, São Paulo, SP, Brazil
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18
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Houghton EJ, Vázquez AAG, Zeledón ME, Andreacchio A, Ruiz G, Palermo M, Gimenez ME. NECROTIZING PANCREATITIS: DESCRIPTION OF VIDEOSCOPIC ASSISTED RETROPERITONEAL DEBRIDEMENT (VARD) TECHNIQUE WITH COVERED METALLIC STENT. ACTA ACUST UNITED AC 2018; 31:e1379. [PMID: 29972407 PMCID: PMC6044201 DOI: 10.1590/0102-672020180001e1379] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/23/2018] [Accepted: 03/15/2018] [Indexed: 01/11/2023]
Abstract
Background: Acute pancreatitis is the third most common gastrointestinal disorder
requiring hospitalization in the United States, with annual costs exceeding
$2 billions. Severe necrotizing pancreatitis is a life-threatening
complication developed in approximately 20% of patients. Its mortality rate
range from 15% in patients with sterile necrosis to up 30% in case of
infected one associated with multi-organ failure. Less invasive treatment
techniques are increasingly being used. These techniques can be performed in
a so-called step-up approach. Aim: To present the technique for videoscopic assisted retroperitoneal debridement
(Vard technique) with covered metallic stent in necrotizing pancreatitis.
Method: A guide wire was inserted through the previous catheter that was removed in
the next step. Afterwards, the tract was dilated over the guide wire. Then,
a partially covered metallic stent was deployed. A 30 degrees laparoscopic
camera was inserted and the necrosis removed with forceps through the
expanded stent under direct vision. Finally, the stent was removed and a new
catheter left in place. Result: This technique was used in a 31-year-old man with acute pain in the upper
abdomen and diagnosed as acute biliary pancreatitis with infected necrosis.
He was treated with percutaneous drains at weeks 3, 6 and 8. Due to partial
recovery, a left lateral VARD was performed (incomplete by fixed and
adherent tissue) at 8th week. As the patient´s inflammatory
response was reactivated, a second VARD attempt was performed in three weeks
later. Afterwards, patient showed complete clinical and imaging resolution.
Conclusions: Videoassisted retroperitoneal necrosectomy using partially covered metallic
stent is a feasible technique for necrotizing pancreatitis.
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Affiliation(s)
- Eduardo J Houghton
- Minimally Invasive Surgery, Hospital Bernardino Rivadavia.,University of Buenos Aires.,DAICIM Foundation, Buenos Aires, Argentina
| | | | | | | | - Gabriel Ruiz
- Minimally Invasive Surgery, Hospital Bernardino Rivadavia
| | - Mariano Palermo
- Minimally Invasive Surgery, Hospital Bernardino Rivadavia.,DAICIM Foundation, Buenos Aires, Argentina.,Hospital Nacional Prof. Alejandro Posadas, Buenos aires, Argentina
| | - Mariano E Gimenez
- University of Buenos Aires.,DAICIM Foundation, Buenos Aires, Argentina
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19
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Li Y, Ye Y, Yang M, Ruan H, Yu Y. Application of semi-automated ultrasonography on nutritional support for severe acute pancreatitis. Comput Med Imaging Graph 2018; 67:40-44. [PMID: 29753963 DOI: 10.1016/j.compmedimag.2018.04.006] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/02/2018] [Revised: 03/13/2018] [Accepted: 04/23/2018] [Indexed: 02/08/2023]
Abstract
OBJECTIVE To evaluate the application value of semi-automated ultrasound on the guidance of nasogastrojejunal tube replacement for patients with acute severe pancreatitis (ASP), as well as the value of the nutritional support for standardized treatment in clinical practice. METHODS The retrospective research was performed in our hospital, and 34 patients suffering from ASP were enrolled into this study. All these identified participants ever received CT scans in order to make definitive diagnoses. Following, these patients received semi-automated ultrasound examinations within 1 days after their onset, in order to provide enteral nutrititon treatment via nasogastrojejunal tube, or freehand nasogastrojejunal tube replacement. In terms of statistical analysis, the application value of semi-automated ultrasound guidance on nasogastrojejunal tube replacement was evaluated, and was compared with tube replacement of no guidance. After cathetering, the additional enteral nutrition was provided, and its therapeutic effect on SAP was analyzed in further. RESULTS A total of 34 patients with pancreatitis were identified in this research, 29 cases with necrosis of pancreas parenchyma. After further examinations, 32 cases were SAP, 2 cases were mild acute pancreatitis. When the firm diagnosis was made, additional enteral nutrition (EN) was given, all the patient conditions appeared good, and they all were satisfied with this kind of nutritional support. According to our clinical experience, when there was 200-250 ml liquid in the stomach, the successful rate of intubation appeared higher. Additionally, the comparison between ultrasound-guided and freehand nasogastrojejunal tube replacement was made. According to the statistical results, in terms of the utilization ratio of nutritional support, it was better in ultrasound-guided group, when compared with it in freehand group, within 1 day, after 3 days and after 7 days (7/20 versus 2/14; P < 0.05; 14/20 versus 6/14; P < 0.05; 20/20 versus 12/14; P < 0.05). Besides, the complications caused by cathetering between two groups was not statistically different (P > 0.05). CONCLUSIONS It can be indicated that semi-automated ultrasound guidance is a reliable method for nasogastrojejunal tube replacement, and should be substituted for no guidance of cathetering. In terms of therapeutic effect of EN, additional nutritional support contributed to significantly improve the prognosis of SAP patients, and should be widely recommended in clinical practice. Surely, this conclusion should be evaluated in further, by means of randomized controlled trials and economic evaluation.
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Affiliation(s)
- Ying Li
- Department of Critical Care Medicine, Second People's Hospital of Shenzhen, Shenzhen, 518035, PR China.
| | - Yu Ye
- Department of Neurosurgery, Longgang Central Hospital of Shenzhen, Shenzhen, 518116, PR China.
| | - Mei Yang
- Department of Critical Care Medicine, Second People's Hospital of Shenzhen, Shenzhen, 518035, PR China.
| | - Haiying Ruan
- Department of Critical Care Medicine, Second People's Hospital of Shenzhen, Shenzhen, 518035, PR China.
| | - Yuan Yu
- Department of Critical Care Medicine, Second People's Hospital of Shenzhen, Shenzhen, 518035, PR China.
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20
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Rana SS, Gupta R, Kang M, Sharma V, Sharma R, Gorsi U, Bhasin DK. Percutaneous catheter drainage followed by endoscopic transluminal drainage/necrosectomy for treatment of infected pancreatic necrosis in early phase of illness. Endosc Ultrasound 2018; 7:41-47. [PMID: 29451168 PMCID: PMC5838727 DOI: 10.4103/eus.eus_94_17] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/14/2022] Open
Abstract
Background and Objectives: Infected pancreatic necrosis (IPN) in the early phase is treated with “step up approach” involving initial percutaneous catheter drainage (PCD) followed by necrosectomy. There is a paucity of data on a combined approach of initial PCD followed by endoscopic drainage and necrosectomy. A retrospectively study on safety and efficacy of initial PCD followed by endoscopic transluminal drainage and necrosectomy in IPN. Methods: Retrospective analysis of data of 23 patients with IPN who were treated with a combined approach. Patients were divided into two groups as follows: patients with central necrosis in whom PCD and endoscopic drainage were done in the same collection (n = 11) and patients with combined central and peripheral necrosis where PCD was placed in peripheral necrosis, and endoscopic drainage was done for central necrosis (n = 12). Results: Endoscopic drainage could be done successfully in all 23 patients with mean time for the resolution being 4.0 ± 0.9 weeks. Fifteen (65.2%) patients were successfully treated using multiple plastic stents while direct endoscopic necrosectomy (DEN) was needed in 8 (34.8%) patients and fully covered self-expanding metal stent was inserted in 6 (26%) patients. The number of endoscopic sessions needed were 3 in 3 (13%), 4 in 9 (39%) patients, 5 in 5 (22%), 6 in 3 (13%), and 7 in 3 (13%) patients, respectively. Patients of central walled-off pancreatic necrosis (WOPN) with PCD catheter in situ needed more endoscopic sessions for resolution as well as more frequently needed DEN in comparison to patients with central WOPN with no PCD catheter. Conclusion: The combined approach of initial PCD followed by endoscopic drainage and necrosectomy is safe and effective treatment alternative for patients with IPN.
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Affiliation(s)
- Surinder Singh Rana
- Department of Gastroenterology, Post Graduate Institute of Medical Education and Research, Chandigarh, India
| | - Rajesh Gupta
- Department of Surgery, Post Graduate Institute of Medical Education and Research, Chandigarh, India
| | - Mandeep Kang
- Department of Radiodiagnosis, Post Graduate Institute of Medical Education and Research, Chandigarh, India
| | - Vishal Sharma
- Department of Gastroenterology, Post Graduate Institute of Medical Education and Research, Chandigarh, India
| | - Ravi Sharma
- Department of Gastroenterology, Post Graduate Institute of Medical Education and Research, Chandigarh, India
| | - Ujjwal Gorsi
- Department of Radiodiagnosis, Post Graduate Institute of Medical Education and Research, Chandigarh, India
| | - Deepak K Bhasin
- Department of Gastroenterology, Post Graduate Institute of Medical Education and Research, Chandigarh, India
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İlhan M, Üçüncü M, Gök AFK, Öner G, Agolli E, Canbay B, Bakır B, Güloğlu R, Ertekin C. Comparison of contrast-enhanced CT with diffusion -weighted MRI in the Evaluation of patients with acute biliary pancreatitis. Turk J Surg 2017; 33:153-157. [PMID: 28944325 DOI: 10.5152/ucd.2016.3573] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/04/2016] [Accepted: 05/28/2016] [Indexed: 12/23/2022]
Abstract
OBJECTIVE The aim of this study was to compare contrast-enhanced computed tomography with diffusion-weighted magnetic resonance imaging in the evaluation of patients with acute biliary pancreatitis. MATERIAL AND METHODS Fifty-three patients diagnosed with acute biliary pancreatitis, between February 2012 and July 2015, were evaluated using diffusion-weighted magnetic resonance imaging and magnetic resonance cholangiopancreatography to explain the elevation of cholestasis enzymes and bilirubin levels at "stanbul University. Contrast-enhanced computed tomography imaging was applied within 8 h following first evaluation. Demographic data, severity of pancreatitis, pancreatic apparent diffusion coefficient, and computed tomography severity index were compared. The significance of the results was evaluated using Statistical Package for the Social Sciences 21.0 program. RESULTS Median age was 53.39 (22-90) years in these 53 patients (26 were males and 27 were females). The mean Ranson criterion was 0.96 (0-4) and mean hospitalization duration was 16.02 (3-100) days. Twenty-eight patients were evaluated to have mild acute pancreatitis, whereas 16 were moderately severe and nine were severe based on the Revised Atlanta Classification. Mild pancreatitis score was 0.89, moderately severe pancreatitis score was 3.50, and severe pancreatitis score was 5.78 using the Balthazar score. Elevated C-reactive protein levels were not correlated with necrosis and the clinical severity score (p>0.05). There was no significant difference among the Balthazar score, magnetic resonance cholangiopancreatography-apparent diffusion coefficient score, and Revised Atlanta score in the evaluation of the severity of pancreatitis when the two techniques were compared. A statistically insignificant difference was found between the Balthazar score and magnetic resonance imaging results of clinically confirmed necrosis and non-necrosis patients. CONCLUSION It can be concluded that diffusion-weighted magnetic resonance imaging might be better than contrast-enhanced computed tomography in the diagnosis of acute pancreatitis as it avoids radiation exposure as well as the development of renal failure and pancreatitis aggravation due to the use of contrast for computed tomography. These results need to be confirmed with randomized prospective controlled studies.
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Affiliation(s)
- Mehmet İlhan
- Department of General Surgery, İstanbul University İstanbul School of Medicine, İstanbul, Turkey
| | - Muhammet Üçüncü
- Clinic of General Surgery, Arnavutköy State Hospital, İstanbul, Turkey
| | - Ali Fuat Kaan Gök
- Department of General Surgery, İstanbul University İstanbul School of Medicine, İstanbul, Turkey
| | - Gizem Öner
- Department of General Surgery, İstanbul University İstanbul School of Medicine, İstanbul, Turkey
| | - Elidor Agolli
- Department of Radiology, İstanbul University İstanbul School of Medicine, İstanbul, Turkey
| | - Bahar Canbay
- Department of General Surgery, İstanbul University İstanbul School of Medicine, İstanbul, Turkey
| | - Barış Bakır
- Department of Radiology, İstanbul University İstanbul School of Medicine, İstanbul, Turkey
| | - Recep Güloğlu
- Department of General Surgery, İstanbul University İstanbul School of Medicine, İstanbul, Turkey
| | - Cemalettin Ertekin
- Department of General Surgery, İstanbul University İstanbul School of Medicine, İstanbul, Turkey
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Is minimally invasive surgical treatment justified for severe acute necrotizing pancreatitis patients with dysfunction of two or more organ systems? Wideochir Inne Tech Maloinwazyjne 2017; 12:225-230. [PMID: 29062441 PMCID: PMC5649498 DOI: 10.5114/wiitm.2017.68792] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/19/2017] [Accepted: 05/31/2017] [Indexed: 12/17/2022] Open
Abstract
Introduction When minimally invasive therapy was introduced, it became possible to cure some patients without open surgery, or at least delay the operation for longer than a month. Aim To determine the optimal timing to operate on patients with severe acute necrotizing pancreatitis based on the severity of organ insufficiency. Material and methods A retrospective analysis was performed in all severe acute necrotizing pancreatitis patients treated in Vilnius University Hospital Santaros Klinikos (VUL SK) from 2007 to 2016. The patients were divided into groups based on the number of dysfunctional organ systems (one or more) and whether the minimally invasive step-up approach to treatment was used. Results The patients with one organ dysfunction had a delay of 35 (without the step-up approach) and 36 (with the step-up approach) days before the open surgery, while the patients with two or more organ systems’ dysfunction had almost an identical delay of 28 days, using both surgical treatment methods. The mortality of the patients who had one organ dysfunction and in whom the step-up approach was used was 0%, while in patients without the step-up approach it was 41.7%. In the two or more organ systems’ dysfunction group, the mortality for those treated with a step-up approach was 64.3%, and without it 70.7%. Conclusions The surgical treatment should be initiated with a minimally invasive procedure. Additionally, the surgery on patients with two or more organ systems’ dysfunction should not be delayed for more than one month.
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23
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The effect of a novel minimally invasive strategy for infected necrotizing pancreatitis. Surg Endosc 2017; 31:4603-4616. [DOI: 10.1007/s00464-017-5522-0] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/16/2016] [Accepted: 03/15/2017] [Indexed: 12/19/2022]
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24
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Video-assisted retroperitoneal pancreatic debridement: A video-based guide to the technique. J Trauma Acute Care Surg 2017; 83:200-203. [PMID: 28376017 DOI: 10.1097/ta.0000000000001464] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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Sorrentino L, Chiara O, Mutignani M, Sammartano F, Brioschi P, Cimbanassi S. Combined totally mini-invasive approach in necrotizing pancreatitis: a case report and systematic literature review. World J Emerg Surg 2017; 12:16. [PMID: 28331537 PMCID: PMC5356234 DOI: 10.1186/s13017-017-0126-5] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/28/2016] [Accepted: 03/06/2017] [Indexed: 12/11/2022] Open
Abstract
BACKGROUND Currently, both the step-up approach, combining percutaneous drainage (PD) and video-assisted retroperitoneal debridement (VARD), and endoscopic transgastric necrosectomy (ETN) are mini-invasive techniques for infected necrosis in severe acute pancreatitis. A combination of these approaches could maximize the management of necrotizing pancreatitis, conjugating the benefits from both the experiences. However, reporting of this combined strategy is anecdotal. This is the first reported case of severe necrotizing pancreatitis complicated by biliary fistula treated by a combination of ETN, PD, VARD, and endoscopic biliary stenting. Moreover, a systematic literature review of comparative studies on minimally invasive techniques in necrotizing pancreatitis has been provided. CASE PRESENTATION A 59-year-old patient was referred to our center for acute necrotizing pancreatitis associated with multi-organ failure. No invasive procedures were attempted in the first month from the onset: enteral feeding by a naso-duodenal tube was started, and antibiotics were administered to control sepsis. After 4 weeks, CT scans showed a central walled-off pancreatic necrosis (WOPN) of pancreatic head communicating bilateral retroperitoneal collections. ETN was performed, and bile leakage was found at the right margin of the WOPN. Endoscopic retrograde cholangiopancreatography confirmed the presence of a choledocal fistula within the WOPN, and a biliary stent was placed. An ultrasound-guided PD was performed on the left retroperitoneal collection. Due to the subsequent repeated onset of septic shocks and the evidence of size increase of the right retroperitoneal collection, a VARD was decided. The CT scans documented the resolution of all the collections, and the patient promptly recovered from sepsis. After 6 months, the patient is in good clinical condition. CONCLUSIONS No mini-invasive technique has demonstrated significantly better outcomes over the others, and each technique has specific indications, advantages, and pitfalls. Indeed, ETN could be suitable for central WOPNs, while VARD or PD could be suggested for lateral collections. A combination of different approaches is feasible and could significantly optimize the clinical management in critically ill patients affected by complicated necrotizing pancreatitis.
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Affiliation(s)
- Luca Sorrentino
- Trauma Team and Emergency Surgery, Niguarda Trauma Center, Niguarda Ca' Granda Hospital, Piazza Ospedale Maggiore 3, Milan, 20162 Italy
| | - Osvaldo Chiara
- Trauma Team and Emergency Surgery, Niguarda Trauma Center, Niguarda Ca' Granda Hospital, Piazza Ospedale Maggiore 3, Milan, 20162 Italy
| | - Massimiliano Mutignani
- Digestive Endoscopy Service, Niguarda Ca' Granda Hospital, Piazza Ospedale Maggiore 3, Milan, 20162 Italy
| | - Fabrizio Sammartano
- Trauma Team and Emergency Surgery, Niguarda Trauma Center, Niguarda Ca' Granda Hospital, Piazza Ospedale Maggiore 3, Milan, 20162 Italy
| | - Paolo Brioschi
- Intensive Care Unit, Niguarda Trauma Center, Niguarda Ca' Granda Hospital, Piazza Ospedale Maggiore 3, Milan, 20162 Italy
| | - Stefania Cimbanassi
- Trauma Team and Emergency Surgery, Niguarda Trauma Center, Niguarda Ca' Granda Hospital, Piazza Ospedale Maggiore 3, Milan, 20162 Italy
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Abstract
Pancreatic fluid collections (PFCs) may develop due to inflammation secondary to acute and/or chronic pancreatitis, trauma, surgery, or obstruction from solid or cystic neoplasms. PFCs can be drained percutaneously, surgically, or endoscopically with endoscopic ultrasound-guided cyst gastrostomy and/or transpapillary drainage through endoscopic retrograde cholangiopancreatography. There has been a paradigm shift in the endoscopic management of PFCs in the past few years with newer techniques including utilization of self-expanding metal stents and multiport devices. This review is a comprehensive update on the classification of PFC, indications for drainage, optimal approach, and techniques.
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Abstract
Intraabdominal infections represent a diagnostic and therapeutic challenge in the elderly population. Atypical presentations, diagnostic delays, additional comorbidities, and decreased physiologic reserve contribute to high morbidity and mortality, particularly among frail patients undergoing emergency abdominal surgery. While many infections are the result of age-related inflammatory, mechanical, or obstructive processes, infectious complications of feeding tubes are also common. The pillars of treatment are source control of the infection and judicious use of antibiotics. A patient-centered approach considering the invasiveness, risk, and efficacy of a procedure for achieving the desired outcomes is recommended. Structured communication and time-limited trials help ensure goal-concordant treatment.
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