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Oppong K. Advancing the diagnostic and therapeutic role of EUS in pancreaticobiliary disease: Hopkins Lecture 2016. Frontline Gastroenterol 2017; 8:115-118. [PMID: 28839895 PMCID: PMC5369446 DOI: 10.1136/flgastro-2016-100759] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/11/2016] [Accepted: 10/17/2016] [Indexed: 02/04/2023] Open
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Khan KH, Khan MF, Khan TJ. Gastric perforation without generalized peritonitis; A very rare complication after necrosectomy for necrotizing pancreatitis. Pak J Med Sci 2016; 32:782-5. [PMID: 27375733 PMCID: PMC4928442 DOI: 10.12669/pjms.323.9726] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/08/2016] [Accepted: 04/12/2016] [Indexed: 12/12/2022] Open
Abstract
Gastric perforation is a very rare complication of necrotizing pancreatitis. We present an interesting case of gastric perforation after necrosectomy for necrotizing pancreatitis without generalized peritonitis. Abdominal drain was seen inside the stomach on endoscopy and there were no clinical features of generalized peritonitis even after 10 days of surgery. Patient was re-explored. The drain was removed and stomach was primarily repaired. The patient recovered uneventfully and was discharged home on 6(th) post operative day. On follow-up visit after one month patient was doing very well and had no complications.
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Affiliation(s)
- Kamran Hakeem Khan
- Dr. Kamran Hakeem Khan, Registrar Department of Surgery, North West General Hospital & Research Center, North West General Hospital & Research Center, Hayatabad, Peshawar, Pakistan
| | - Mohammad Farid Khan
- Dr. Mohammad Farid Khan, FRCS. Consultant Department of General surgery, North West General Hospital & Research Center, North West General Hospital & Research Center, Hayatabad, Peshawar, Pakistan
| | - Tariq Jabbar Khan
- Dr. Tariq Jabbar Khan, FRCS. Consultant Department of General surgery, North West General Hospital & Research Center, Hayatabad, Peshawar, Pakistan
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Afghani E, Singh VK. EUS-guided aspiration of peripancreatic fluid collections for culture: colonization or infection? Gastrointest Endosc 2014; 79:536. [PMID: 24528829 DOI: 10.1016/j.gie.2013.08.022] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/15/2013] [Accepted: 08/19/2013] [Indexed: 02/08/2023]
Affiliation(s)
- Elham Afghani
- Pancreatitis Center, Division of Gastroenterology, Johns Hopkins Medical Institutions, Baltimore, Maryland, USA
| | - Vikesh K Singh
- Pancreatitis Center, Division of Gastroenterology, Johns Hopkins Medical Institutions, Baltimore, Maryland, USA
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Laparoscopic pancreatic resections. Langenbecks Arch Surg 2013; 398:939-45. [PMID: 24006117 DOI: 10.1007/s00423-013-1108-z] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/19/2013] [Accepted: 08/22/2013] [Indexed: 02/06/2023]
Abstract
PURPOSE Pancreatic surgery is technically complex and requires considerable expertise. Laparoscopic pancreatic surgery adds the need for considerable experience with advanced laparoscopic techniques. Despite the technical difficulties, an increasing number of centers propagate the use of laparoscopy in pancreatic surgery over the last decade. METHODS In this review, we provide an overview of the literature regarding the advantages and disadvantages of laparoscopic pancreatic surgery. Larger prospective randomized studies have emerged in the subset of laparoscopic or retroperitoneoscopic surgery for acute pancreatitis, considerable single center experience has been reported for laparoscopic pancreatic tail resection, and laparoscopic pancreatic head resection, however, is still restricted to a few experienced centers worldwide. RESULTS AND CONCLUSIONS Laparoscopic pancreatic surgery is becoming more and more established, in particular for the treatment of benign and premalignant lesions of the pancreatic body and tail. It has been shown to decrease postoperative pain, narcotic use, and length of hospital stay in larger single center experience. However, prospective trials are needed in laparoscopic resective pancreatic surgery to evaluate its advantages, safety, and efficacy in the treatment of pancreatic neoplasms and in particular in malignant pancreatic tumors.
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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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The role of open necrosectomy in the current management of acute necrotizing pancreatitis: a review article. ISRN SURGERY 2013; 2013:579435. [PMID: 23431472 PMCID: PMC3569915 DOI: 10.1155/2013/579435] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 12/20/2012] [Accepted: 01/07/2013] [Indexed: 12/12/2022]
Abstract
The optimal management of necrotizing pancreatitis continues to evolve. Currently, conservative intensive care treatment represents the primary therapy of acute severe necrotizing pancreatitis, aiming at prevention of organ failure. Following this mode of treatment most patients with sterile necroses can be managed successfully. Surgery might be considered as an option in the late phase of the disease for patients with proven infected pancreatic necroses and organ failure. For these patients surgical debridement is still considered the treatment of choice. However, even for this subgroup of patients, the concept of operative strategy has been recently challenged. Nowadays, it is generally accepted that necrotizing pancreatitis with proven infected necroses as well as septic complications directly caused by pancreatic infection are strong indications for surgical management. However, the question of the most appropriate surgical technique for the treatment of pancreatic necroses remains unsettled. At the same time, recent advances in radiological imaging, new developments in interventional radiology, and other minimal access interventions have revolutionised the management of necrotizing pancreatitis. In light of these controversies, the present paper will focus on the current role of surgery in terms of open necrosectomy in the management of severe acute necrotizing pancreatitis.
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Bausch D, Wellner U, Kahl S, Kuesters S, Richter-Schrag HJ, Utzolino S, Hopt UT, Keck T, Fischer A. Minimally invasive operations for acute necrotizing pancreatitis: comparison of minimally invasive retroperitoneal necrosectomy with endoscopic transgastric necrosectomy. Surgery 2012; 152:S128-34. [PMID: 22770962 DOI: 10.1016/j.surg.2012.05.021] [Citation(s) in RCA: 44] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/10/2012] [Accepted: 05/11/2012] [Indexed: 12/17/2022]
Abstract
BACKGROUND A "step-up" approach is currently the treatment of choice for acute necrotizing pancreatitis. Our aim was to evaluate the outcome of minimally invasive retroperitoneal necrosectomy (MINE) and endoscopic transgastric necrosectomy (ETG) and to compare it to open necrosectomy (ONE). METHODS Patients with acute pancreatitis admitted to our institution from 1998 to 2010 (n = 334) were identified. From these, patients who underwent either ONE, MINE, or ETG were selected for further analysis. Statistical analysis employed 2-sided Fisher's exact test and Mann-Whitney U-test. RESULTS From 2002 to 2010, 32 patients with acute necrotizing pancreatitis were treated by minimally invasive procedures including MINE (n = 14) and ETG (n = 18) or with the classic technique of ONE (n = 30). Time from onset of symptoms to intervention was less for ONE than for MINE or ETG (median, 11 vs 39 vs 54 days; P < .05). The rate of critically ill patients with sepsis or septic shock was greatest in ONE (93%) and MINE (71%) compared with ETG (17%; P < .05). Problems after ONE and MINE were ongoing sepsis (ONE 73% vs MINE 29% vs ETG 11%) and bleeding requiring intervention (ONE 26% vs MINE 21% vs ETG 17%). A specific complication of ETG was gastric perforation into the peritoneal cavity during the procedure (28%), requiring immediate open pseudocystogastrostomy. Laparotomy was necessary in 21% after MINE and 28% after ETG owing to specific complications or persistent infected necrosis. Overall mortality was greatest after ONE (ONE 63% vs MINE 21% vs ETG 6%; P < .05). CONCLUSION Morbidity and mortality remains high in acute necrotizing pancreatitis. Operative procedures should be delayed as long as possible to decrease morbidity and mortality. Minimally invasive procedures can avoid laparotomy, but also introduce specific complications requiring immediate or secondary open operative treatment. Minimally invasive procedures require unique expertise and therefore should only be performed at specialized centers.
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Affiliation(s)
- Dirk Bausch
- Department of General and Visceral Surgery, Universitätsklinikum Freiburg, Freiburg, Germany
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Pearson EG, Scaife CL, Mulvihill SJ, Glasgow RE. Roux-en-Y drainage of a pancreatic fistula for disconnected pancreatic duct syndrome after acute necrotizing pancreatitis. HPB (Oxford) 2012; 14:26-31. [PMID: 22151448 PMCID: PMC3252988 DOI: 10.1111/j.1477-2574.2011.00397.x] [Citation(s) in RCA: 33] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
BACKGROUND After acute necrotizing pancreatitis (ANP), a pancreatic fistula may occur from disconnected pancreatic duct syndrome (DPDS) where a segment of the pancreas is no longer in continuity with the main pancreatic duct. AIM To study the outcome of patients treated using Roux-Y pancreatic fistula tract-jejunostomy for DPDS after ANP. METHODS Between 2002 and 2011, patients treated for DPDS in the setting of endoscopic retrograde cholangiopancreatography (ERCP) or magnetic resonance cholangiopanreatography (MRCP) documented main pancreatic duct disruption with Roux-Y pancreatic fistula tract-jejunostomy. RESULTS In all, seven patients with DPDS were treated. The median age was 62 years (range 49-78) and five were men. The cause of ANP was gallstones (2), alcohol (1), ERCP (1) and idiopathic (3). Pancreatic necrosectomy was done in six patients. Time from onset of pancreatitis to fistula drainage was 270 days (164-365). Pancreatic fistulae arose from DPDS in the head/neck (4) and body/tail (3). Patients had a median fistula output of 140 ml (100-200) per day before surgery. The median operative time was 142 min (75-367) and estimated blood loss was 150 ml (25 to 500). Patients began an oral diet on post-operative day 4 (3-6) and were hospitalized for a median of 7 days (5-12). The median follow-up was 264 days (29-740). Subsequently, one patient required a distal pancreatectomy. After surgery, three patients required oral hypoglycaemics. No patient developed pancreatic exocrine insufficiency. CONCLUSION Internal surgical drainage using Roux-en-Y pancreatic fistula tract-jejunostomy is a safe and definitive treatment for patients with DPDS.
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Affiliation(s)
- Erik G Pearson
- Department of Surgery, University of Utah, Salt Lake City, 84132, USA
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代 学, 王 文, 申屠 阳, 张 杰. [Expression and prognostic value of VEGF-C and lymphangeogenesis in lung adenocarcinoma and squamous cell carcinoma]. ZHONGGUO FEI AI ZA ZHI = CHINESE JOURNAL OF LUNG CANCER 2011; 14:774-9. [PMID: 22008106 PMCID: PMC5999940 DOI: 10.3779/j.issn.1009-3419.2011.10.02] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 07/25/2011] [Revised: 08/18/2011] [Indexed: 12/13/2022]
Abstract
BACKGROUND AND OBJECTIVE Vascular endothelial growth factor-C (VEGF-C), a member of the VEGF family, has been proven to be a relatively special VEGF. When binding to its receptor VEGFR-3, it activates lymphangiogenesis, which likely induces lymph node metastasis in tumors. The aim of this study is to characterize the expression and prognostic value of VEGF-C and lymphangiogenesis in lung adenocarcinoma and squamous cell carcinoma. METHODS Through immunohistochemistry, the lymph vessel endothelial cells undergoing lymphangiogenesis were stained with podoplanin to detect the expression of VEGF-C and lymphangiogenesis in 98 cases with stage IIIa (N2) lung adenocarcinoma and squamous cell carcinoma. RESULTS The expression rate of the VEGF-C was positively correlated with the lymphatic microvessel density (LMVD; r=0.783, P<0.01). The LMVD was remarkably higher in VEGF-C positive expression group than that in the VEGF-C negative expression group. The expression rate of VEGF-C and lymphangiogenesis in lung adenocarcinoma was significantly higher than that in lung squamous cell carcinoma (P<0.01). Kaplan-Meier analysis showed that the survival rates in patients with positive VEGF-C expression were significantly lower than those in patients with negative VEGF-C expression (P<0.05). CONCLUSIONS Lymphangiogenesis rates are significantly higher in lung adenocarcinoma than that in squamous cell carcinoma. VEGF-C expression is an independent prognostic factor of stage IIIa (N2) lung adenocarcinoma and squamous cell carcinoma.
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Affiliation(s)
- 学利 代
- 200030 上海,上海交通大学附属胸科医院/上海市肺部肿瘤临床医学中心胸外科Department of Thoracic Surgery, Shanghai Chest Hospital/Shanghai Lung Tumor Clinical Medical Center, Shanghai 200030, China
| | - 文利 王
- 200030 上海,上海交通大学附属胸科医院/上海市肺部肿瘤临床医学中心胸外科Department of Thoracic Surgery, Shanghai Chest Hospital/Shanghai Lung Tumor Clinical Medical Center, Shanghai 200030, China
| | - 阳 申屠
- 200030 上海,上海交通大学附属胸科医院/上海市肺部肿瘤临床医学中心胸外科Department of Thoracic Surgery, Shanghai Chest Hospital/Shanghai Lung Tumor Clinical Medical Center, Shanghai 200030, China
| | - 杰 张
- 200030 上海,上海交通大学附属胸科医院/上海市肺部肿瘤临床医学中心病理科Department of Pathology, Shanghai Chest Hospital/Shanghai Lung Tumor Clinical Medical Center, Shanghai 200030, China
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Brisinda G, Vanella S, Crocco A, Mazzari A, Tomaiuolo P, Santullo F, Grossi U, Crucitti A. Severe acute pancreatitis: advances and insights in assessment of severity and management. Eur J Gastroenterol Hepatol 2011; 23:541-51. [PMID: 21659951 DOI: 10.1097/meg.0b013e328346e21e] [Citation(s) in RCA: 35] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/05/2023]
Abstract
The patients with acute pancreatitis are at risk to develop different complications from ongoing pancreatic inflammation. Often, there is no correlation between the degree of structural damage to pancreas and clinical manifestation of the disease. The effectiveness of any treatment is related to the ability to predict severity accurately, but there is no ideal predictive system or biochemical marker. Severity assessment is indispensable to the selection of proper initial treatment in the management of acute pancreatitis. The use of multiparametric criteria and the evaluation of severity index permit us to select high-risk patients. Furthermore, contrast-enhanced computed tomographic scanning and contrast-enhanced MRI play an important role in severity assessment. The adoption of multiparametric criteria proposed together with morphological evaluation consents the formulation of a discreetly reliable prognosis on the evolution of the disease a few days from onset.
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Affiliation(s)
- Giuseppe Brisinda
- Department of Surgery, Catholic School of Medicine, University Hospital Agostino Gemelli, Largo Agostino Gemelli 8, Rome, Italy.
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Ahmad HA, Samarasam I, Hamdorf JM. Minimally invasive retroperitoneal pancreatic necrosectomy. Pancreatology 2011; 11:52-6. [PMID: 21455014 DOI: 10.1159/000323960] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/07/2010] [Accepted: 12/01/2010] [Indexed: 12/11/2022]
Abstract
INTRODUCTION This article describes a case series outlining the experience and results of the retroperitoneal minimally invasive pancreatic necrosectomy (MIPN) procedure performed by, or done under the supervision of, a single surgeon. METHODS All data of the patients who underwent MIPN from 2006 to 2008 were entered into a prospectively maintained, computerized database. RESULTS A total of 93 MIPN procedures were performed on 32 patients. All patients had severe acute pancreatitis. The median number of MIPN procedures per patient was 3. Only 6 patients needed intensive care unit (ICU) admission after MIPN. There were 15 complications, which included bleeding requiring transfusion (n = 3), bowel fistulae (n = 7), thromboembolic events (n = 2) and acute myocardial infarction (n = 3). Four patients died after the procedure (13%); 1 died of ongoing multiorgan failure in spite of the MIPN. Four patients developed pancreatic pseudocysts within the follow-up period of 2 years. Three of these patients required intervention. CONCLUSION This case series demonstrates that MIPN can be performed with acceptable morbidity and mortality and with good end results. The ICU dependency after the procedure is minimal. As seen in this series, multiple MIPNs may be needed to eradicate the necrosis satisfactorily. and IAP.
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Affiliation(s)
- Hairul A Ahmad
- School of Surgery, The University of Western Australia, Perth, W.A., Australia.
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Koo JE, Park DH, Oh J, Lee YH, Moon SH, Lee SS, Seo DW, Lee SK, Kim MH. EUS-Guided Multitransgastric Endoscopic Necrosectomy for Infected Pancreatic Necrosis with Noncontagious Retroperitoneal and Peritoneal Extension. Gut Liver 2010; 4:140-5. [PMID: 20479929 DOI: 10.5009/gnl.2010.4.1.140] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/11/2009] [Accepted: 09/15/2009] [Indexed: 12/13/2022] Open
Abstract
Endoscopic necrosectomy was introduced as a safe and effective treatment modality for infected pancreatic necrosis. Although there have been many reports of endoscopic drainage of retroperitoneal pancreatic necrosis, the optimal endoscopic management of pancreatic necrosis extending to the noncontagious retroperitoneal and peritoneal spaces has yet to be established. We report herein a patient with infected pancreatic necrosis with noncontagious retroperitoneal and peritoneal extension who was treated successfully by endoscopic ultrasound (EUS)-guided multiple cystogastrostomy and endoscopic necrosectomy. EUS-guided multitransgastric necrosectomy may be technically feasible and effective for the management of infected pancreatic necrosis with noncontagious retroperitoneal and peritoneal extension that demonstrates suitable anatomy. Further studies to assess the efficacy and safety of this technique are needed before its routine clinical use can be recommended.
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Affiliation(s)
- Ja Eun Koo
- Division of Gastroenterology, Department of Internal Medicine, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
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Babu BI, Siriwardena AK. Practical strategies for case selection in minimally invasive necrosectomy. Pancreatology 2008; 9:9-12. [PMID: 19077450 DOI: 10.1159/000178861] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
BACKGROUND Minimally invasive necrosectomy is an umbrella term encapsulating the retroperitoneal, endoscopic and laparoscopic approaches. However, current evidence is unclear in terms of which approach to select in any particular setting. METHODS/RESULTS This leading article provides a pragmatic guide to approach selection in treating pancreatic necrosis with particular reference to the use of minimally invasive approaches. Current evidence in relation to timing of surgery, use of fine-needle aspiration and detailed imaging by magnetic resonance scanning is incorporated into a modern treatment algorithm. CONCLUSION The era of minimally invasive necrosectomy has arrived. In the absence of randomised trial evidence, the keys to contemporary management of pancreatic necrosis are good multidisciplinary care, adequate high-quality imaging and careful consideration of all available treatment options including traditional open approaches.
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Jang JW, Park DH, Moon SH, Lee SS, Seo DW, Lee SK, Kim MH. Endoscopic fibrin glue injection for closure of pancreatocutaneous fistula following transgastric endoscopic necrosectomy. World J Gastroenterol 2008; 14:6093-5. [PMID: 18932292 PMCID: PMC2760186 DOI: 10.3748/wjg.14.6093] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023] Open
Abstract
Transgastric endoscopic necrosectomy has been recently introduced as the effective and alternative management of infected pancreatic necrosis and pancreatic abscess. However, up to 40% of patients who undergo endoscopic necrosectomy may need an additional percutaneous approach for subsequent peripancreatic fluid collection or non-resolution of pancreatic necrosis. This percutaneous approach may lead to persistent pancreatocutaneous fistula, which remains a serious problem and usually requires prolonged hospitalization, or even open-abdominal surgery. We describe the first case of pancreatocutaneous fistula and concomitant abdominal wall defect following transgastric endoscopic necrosectomy and percutaneous drainage, which were endoscopically closed with fibrin glue injection via the necrotic cavity.
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Debridement and drainage of walled-off pancreatic necrosis by a novel laparoendoscopic rendezvous maneuver: experience with 6 cases. Gastrointest Endosc 2008; 67:871-8. [PMID: 18367186 DOI: 10.1016/j.gie.2007.10.059] [Citation(s) in RCA: 22] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/04/2007] [Accepted: 10/30/2007] [Indexed: 02/08/2023]
Abstract
BACKGROUND Walled-off pancreatic necrosis (WOPN) is a known complication of acute and chronic pancreatitis. Indications for treatment of WOPN are infection, a rapid increase in size, pain, or biliary or duodenal obstruction. Endoscopic transgastric treatment of pseudocysts with liquid content is successful in approximately 90% of patients; however, the treatment of WOPN is less satisfactory. OBJECTIVE A demonstration of a novel minimally invasive approach to adequately remove and drain pancreatic necrosis. DESIGN Between June 2004 and June 2006, a nonrandomized observational study was conducted with 6 consecutive patients. WOPN was treated by a minimally invasive laparoendoscopic rendezvous technique. SETTING All patients were examined at the university hospital in Freiburg, Germany. PATIENTS Six patients were treated for WOPN of an average diameter of 13 cm (range 9-20 cm). In 5 cases, the WOPN was a consequence of acute pancreatitis; there was 1 case of chronic pancreatitis. The average interval between diagnosis and initial treatment was 14 weeks (range 6-20 weeks). RESULTS Conventional surgery was avoided in 5 patients (83%) over a median follow-up of 14 months (range 1.5-27 months). Six endoscopic sessions (range 4-11) were performed during the entire treatment period. One patient needed emergency surgery on day 4 after the intervention for a perforation because of gastric-wall separation from the necrotic cavity. There was 1 lethal gastric variceal bleeding, which occurred when a gastrostomy tube was removed 46 days after the initial treatment. LIMITATION The small number of patients. CONCLUSIONS In selected cases, minimally invasive laparoendoscopic treatment of WOPN is possible without the need of laparotomy or laparoscopy.
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Kang SG, Park DH, Kwon TH, Park JY, Park SH, Park JH, Lee SH, Chung IK, Kim HS, Kim SJ. Transduodenal endoscopic necrosectomy via pancreaticoduodenal fistula for infected peripancreatic necrosis with left pararenal space extension (with videos). Gastrointest Endosc 2008; 67:380-3. [PMID: 17945226 DOI: 10.1016/j.gie.2007.05.047] [Citation(s) in RCA: 13] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/17/2007] [Accepted: 05/31/2007] [Indexed: 02/08/2023]
Affiliation(s)
- Sang Goo Kang
- Division of Gastroenterology, Department of Internal Medicine, Soon Chun Hyang University Cheonan Hospital, Cheonan, Choongnam, Korea
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17
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Affiliation(s)
- Peter A Banks
- Division of Gastroenterology, Center for Pancreatic Disease, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts, USA
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Isaji S, Takada T, Kawarada Y, Hirata K, Mayumi T, Yoshida M, Sekimoto M, Hirota M, Kimura Y, Takeda K, Koizumi M, Otsuki M, Matsuno S. JPN Guidelines for the management of acute pancreatitis: surgical management. ACTA ACUST UNITED AC 2006; 13:48-55. [PMID: 16463211 PMCID: PMC2779397 DOI: 10.1007/s00534-005-1051-7] [Citation(s) in RCA: 56] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
Acute pancreatitis represents a spectrum of disease ranging from a mild, self-limited course to a rapidly progressive, severe illness. The mortality rate of severe acute pancreatitis exceeds 20%, and some patients diagnosed as mild to moderate acute pancreatitis at the onset of the disease may progress to a severe, life-threatening illness within 2–3 days. The Japanese (JPN) guidelines were designed to provide recommendations regarding the management of acute pancreatitis in patients having a diversity of clinical characteristics. This article sets forth the JPN guidelines for the surgical management of acute pancreatitis, excluding gallstone pancreatitis, by incorporating the latest evidence for the surgical management of severe pancreatitis in the Japanese-language version of the evidence-based Guidelines for the Management of Acute Pancreatitis published in 2003. Ten guidelines are proposed: (1) computed tomography-guided or ultrasound-guided fine-needle aspiration for bacteriology should be performed in patients suspected of having infected pancreatic necrosis; (2) infected pancreatic necrosis accompanied by signs of sepsis is an indication for surgical intervention; (3) patients with sterile pancreatic necrosis should be managed conservatively, and surgical intervention should be performed only in selected cases, such as those with persistent organ complications or severe clinical deterioration despite maximum intensive care; (4) early surgical intervention is not recommended for necrotizing pancreatitis; (5) necrosectomy is recommended as the surgical procedure for infected pancreatic necrosis; (6) simple drainage should be avoided after necrosectomy, and either continuous closed lavage or open drainage should be performed; (7) surgical or percutaneous drainage should be performed for pancreatic abscess; (8) pancreatic abscesses for which clinical findings are not improved by percutaneous drainage should be subjected to surgical drainage immediately; (9) pancreatic pseudocysts that produce symptoms and complications or the diameter of which increases should be drained percutaneously or endoscopically; and (10) pancreatic pseudocysts that do not tend to improve in response to percutaneous drainage or endoscopic drainage should be managed surgically.
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Affiliation(s)
- Shuji Isaji
- Department of Hepatobiliary Pancreatic Surgery and Breast Surgery, Mie University Graduate School of Medicine, Tsu, Mie 514-8507, Japan
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Mareninova OA, Sung KF, Hong P, Lugea A, Pandol SJ, Gukovsky I, Gukovskaya AS. Cell death in pancreatitis: caspases protect from necrotizing pancreatitis. J Biol Chem 2005; 281:3370-81. [PMID: 16339139 DOI: 10.1074/jbc.m511276200] [Citation(s) in RCA: 213] [Impact Index Per Article: 11.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022] Open
Abstract
Mechanisms of cell death in pancreatitis remain unknown. Parenchymal necrosis is a major complication of pancreatitis; also, the severity of experimental pancreatitis correlates directly with necrosis and inversely with apoptosis. Thus, shifting death responses from necrosis to apoptosis may have a therapeutic value. To determine cell death pathways in pancreatitis and the possibility of necrosis/apoptosis switch, we utilized the differences between the rat model of cerulein pancreatitis, with relatively high apoptosis and low necrosis, and the mouse model, with little apoptosis and high necrosis. We found that caspases were greatly activated during cerulein pancreatitis in the rat but not mouse. Endogenous caspase inhibitor X-linked inhibitor of apoptosis protein (XIAP) underwent complete degradation in the rat but remained intact in the mouse model. Furthermore, XIAP inhibition with embelin triggered caspase activation in the mouse model, implicating XIAP in caspase blockade in pancreatitis. Caspase inhibitors decreased apoptosis and markedly stimulated necrosis in the rat model, worsening pancreatitis parameters. Conversely, caspase induction with embelin stimulated apoptosis and decreased necrosis in mouse model. Thus, caspases not only mediate apoptosis but also protect from necrosis in pancreatitis. One protective mechanism is through degradation of receptor-interacting protein (RIP), a key mediator of "programmed" necrosis. We found that RIP was cleaved (i.e. inactivated) in the rat but not the mouse model. Caspase inhibition restored RIP levels; conversely, caspase induction with embelin triggered RIP cleavage. Our results indicate key roles for caspases, XIAP, and RIP in the regulation of cell death in pancreatitis. Manipulating these signals to change the pattern of death responses presents a therapeutic strategy for treatment of pancreatitis.
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Affiliation(s)
- Olga A Mareninova
- Veterans Affairs Greater Los Angeles Healthcare System and Department of Medicine, David Geffen School of Medicine, University of California at Los Angeles, Los Angeles, California 90073, USA
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Radenković D, Bajec D, Karamarković A, Stefanović B, Gregorić P, Milićević M. [Advantages and disadvantages of planned staged relaparotomy using the zipper technique in surgical treatment of necrotizing pancreatitis]. ACTA CHIRURGICA IUGOSLAVICA 2004; 50:99-103. [PMID: 14994576 DOI: 10.2298/aci0302099r] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
The rationale of surgical intervention during acute necrotizing pancreatitis is to remove necrotic tissue preserving healthy glandular parenchyma and other adjacent structures, thus limiting severe complications. Necrosectomy and debridement are the crucial in surgical management, further treatment of pancreatic bed and peripancreatic tissue are still a matter of debate among pancreatic surgeons. Zipper technique is one of the three recognized methods [table: see text] for the surgical management of necrotizing pancreatitis. The aim this study was to review the literature data about treatment using this technique, as well to compare the results of treatment with other techniques, in order to present the advantage and disadvantage of zipper technique. The main advantage of this technique is a high level of control of intraabdominal infection and other septic complications associated with necrotizing pancreatitis and its surgical management. Increased risk of development of gastrointestinal and pancreatic fistulas as well of intraabdominal bleeding is probably the main disadvantage. A flexible approach focused on the individual patients is a reasonable solution in the surgical management of the necrotizing pancreatitis.
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Affiliation(s)
- D Radenković
- Centar za Urgentnu hirurgiju, Urgentni Centar, KCS, Beograd
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