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Çinaroğlu OS, Acar H, Çamyar H, Bora ES, Efgan MG, Korkmaz UB, Yurtsever G, Kanter E. The success of SII, MII-1, MII-2, MII-3, and QT dispersion in predicting the walled-off pancreatic necrosis development in acute pancreatitis in the emergency department: An observational study. Medicine (Baltimore) 2024; 103:e38599. [PMID: 38905406 PMCID: PMC11192009 DOI: 10.1097/md.0000000000038599] [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: 03/06/2024] [Accepted: 05/24/2024] [Indexed: 06/23/2024] Open
Abstract
walled-off pancreatic necrosis (WOPN) is one of the complications of acute pancreatitis (AP) with high mortality. A method to predict the development of WOPN in AP patients admitted to the emergency department may guide life-saving practices such as early initiation of antibiotic therapy and, when necessary, referral of the patient to a center where necrosectomy can be performed. This study is a prospective observational study. One hundred eleven AP patients who applied to the emergency department were included in the study. The mean of QT interval (QT) dispersion, systemic immune-inflammation Index (SII), multi-inflammatory index-I (MII-1), multi-inflammatory index-II (MII-2), and multi-inflammatory index-III (MII-3) were compared between patients who developed WOPN and patients who did not develop WOPN during their hospitalization. In the study, the mean of QT dispersion, SII, MII-1, MII-2, and MII-3 were significantly lower in the patient group who developed WOPN compared to those who did not develop WOPN. In the receiver operating characteristic analysis, all methods except SII were found to be successful in predicting WOPN. QT dispersion, SII, MII-1, MII-2, and MII-3 are valuable tools that provide rapid results and successfully predict the development of WOPN in AP. However, MII-2 and QT dispersion appears to be slightly more successful than the others.
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Affiliation(s)
- Osman Sezer Çinaroğlu
- Medicine Faculty, Emergency Medicine Department, İzmir Katip Çelebi University, İzmir, Turkey
| | - Hüseyin Acar
- Medicine Faculty, Emergency Medicine Department, İzmir Katip Çelebi University, İzmir, Turkey
| | - Hakan Çamyar
- Medicine Faculty, Gastroenterology Department, İzmir Katip Çelebi University, İzmir, Turkey
| | - Ejeder Saylav Bora
- Medicine Faculty, Emergency Medicine Department, İzmir Katip Çelebi University, İzmir, Turkey
| | - Mehet Göktuğ Efgan
- Medicine Faculty, Emergency Medicine Department, İzmir Katip Çelebi University, İzmir, Turkey
| | - Uğur Bayram Korkmaz
- Medicine Faculty, Emergency Medicine Department, İzmir Katip Çelebi University, İzmir, Turkey
| | - Güner Yurtsever
- Emergency Medicine Department, İzmir Atatürk Training and Research Hospital, İzmir, Turkey
| | - Efe Kanter
- Emergency Medicine Department, İzmir Atatürk Training and Research Hospital, İzmir, Turkey
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Dayyeh BKA, Chandrasekhara V, Shah RJ, Easler JJ, Storm AC, Topazian M, Levy MJ, Martin JA, Petersen BT, Takahashi N, Edmundowicz S, Hammad H, Wagh MS, Wani S, DeWitt J, Bick B, Gromski M, Al Haddad M, Sherman S, Merchant AA, Peetermans JA, Gjata O, McMullen E, Willingham FF. Combined Drainage and Protocolized Necrosectomy Through a Coaxial Lumen-apposing Metal Stent for Pancreatic Walled-off Necrosis: A Prospective Multicenter Trial. Ann Surg 2023; 277:e1072-e1080. [PMID: 35129503 DOI: 10.1097/sla.0000000000005274] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
OBJECTIVE We evaluated a protocolized endoscopic necrosectomy approach with a lumen-apposing metal stent (LAMS) in patients with large symptomatic walled-off pancreatic necrosis (WON) comprising significant necrotic content, with or without infection. SUMMARY BACKGROUND DATA Randomized trials have shown similar efficacy of endoscopic treatment compared with surgery for infected WON. DESIGN We conducted a regulatory, prospective, multicenter single-arm clinical trial examining the efficacy and safety of endoscopic ultrasound -guided LAMS with protocolized necrosectomy to treat symptomatic WON ≥6 cm in diameter with >30% solid necrosis. After LAMS placement, protocolized WON assessment was conducted and endoscopic necrosectomy was performed for insufficient WON size reduction and persistent symptoms. Patients with radiographic WON resolution to ≤ 3 cm and/or 60-day LAMS indwell had LAMS removal, then 6-month follow-up. Primary endpoints were probability of radiographic resolution by 60 days and procedure-related serious adverse events. RESULTS Forty consecutive patients were enrolled September 2018 to March 2020, of whom 27 (67.5%) were inpatients and 19 (47.5%) had clinical evidence of infection at their index procedure. Mean WON size was 15.0 ± 5.6 cm with mean 53.2% ± 16.7% solid necrosis. Radiographic WON resolution was seen in 97.5% (95% CI, 86.8%, 99.9%) by 60 days, without recurrence in 34 patients with 6-month follow-up data. Mean time to radiographic WON resolution was 34.1 ± 16.8 days. Serious adverse events occurred in 3 patients (7.5%), including sepsis, vancomycin-resistant enterococcal bacteremia and shock, and upper gastrointestinal bleeding. There were no procedure-related deaths. CONCLUSIONS Endoscopic ultrasound-guided drainage with protocolized endoscopic necrosectomy to treat large symptomatic or infected walled-off necrotic pancreatic collections was highly effective and safe. Clinicaltrials.-gov no: NCT03525808.
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Affiliation(s)
| | | | - Raj J Shah
- Division of Gastroenterology and Hepatology, University of colorado Anschutz Medical Campus, Aurora, CO
| | - Jeffrey J Easler
- Division of Gastroenterology and Hepatology, indiana University School of Medicine, indianapolis, IN
| | - Andrew C Storm
- Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, MN
| | - Mark Topazian
- Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, MN
| | - Michael J Levy
- Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, MN
| | - John A Martin
- Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, MN
| | - Bret T Petersen
- Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, MN
| | - Naoki Takahashi
- Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, MN
| | - Steven Edmundowicz
- Division of Gastroenterology and Hepatology, University of colorado Anschutz Medical Campus, Aurora, CO
| | - Hazem Hammad
- Division of Gastroenterology and Hepatology, University of colorado Anschutz Medical Campus, Aurora, CO
| | - Mihir S Wagh
- Division of Gastroenterology and Hepatology, University of colorado Anschutz Medical Campus, Aurora, CO
| | - Sachin Wani
- Division of Gastroenterology and Hepatology, University of colorado Anschutz Medical Campus, Aurora, CO
| | - John DeWitt
- Division of Gastroenterology and Hepatology, University of colorado Anschutz Medical Campus, Aurora, CO
| | - Benjamin Bick
- Division of Gastroenterology and Hepatology, University of colorado Anschutz Medical Campus, Aurora, CO
| | - Mark Gromski
- Division of Gastroenterology and Hepatology, indiana University School of Medicine, indianapolis, IN
| | - Mohammad Al Haddad
- Division of Gastroenterology and Hepatology, indiana University School of Medicine, indianapolis, IN
| | - Stuart Sherman
- Division of Gastroenterology and Hepatology, indiana University School of Medicine, indianapolis, IN
| | - Ambreen A Merchant
- Division of Digestive Diseases, Department of Medicine, Emory University, Atlanta, GA; and
| | | | - Ornela Gjata
- Endoscopy Division, Boston Scientific Corporation, Marl-borough, MA
| | - Edmund McMullen
- Endoscopy Division, Boston Scientific Corporation, Marl-borough, MA
| | - Field F Willingham
- Division of Digestive Diseases, Department of Medicine, Emory University, Atlanta, GA; and
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Pawa R, Dorrell R, Clark C, Russell G, Gilliam J, Pawa S. Delayed endoscopic necrosectomy improves hospital length of stay and reduces endoscopic interventions in patients with symptomatic walled‐off necrosis. DEN OPEN 2023; 3:e162. [PMID: 36090191 PMCID: PMC9453323 DOI: 10.1002/deo2.162] [Citation(s) in RCA: 9] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 03/16/2022] [Revised: 07/23/2022] [Accepted: 08/15/2022] [Indexed: 01/16/2023]
Abstract
Objectives Advancements in the endoscopic management of walled‐off necrosis using lumen apposing metal stents have improved outcomes over its surgical and percutaneous alternatives. The ideal procedural technique and timing of direct endoscopic necrosectomy (DEN) have yet to be clarified. Methods From November 2015 to June 2021, a retrospective comparative cohort analysis was performed comparing clinical outcomes for patients undergoing immediate DEN (iDEN) versus delayed DEN (dDEN). Subgroups were identified based on the quantification of necrosis. Wilcoxon two‐sample tests were used to compare continuous variables and Fisher's exact test was used to compare categorical variables. Results A total of 80 patients underwent DEN for management of walled‐off necrosis (iDEN = 43, dDEN = 37). Technical success was achieved in all patients. Clinical success was seen in 39 (91%) patients in the iDEN group and 34 (92%) in the dDEN group. Amongst iDEN patients, the mean number of necrosectomies was 2.5 (standard deviation [SD] 1.4) in comparison to 1.5 (SD 1.0) for dDEN (p‐value = 0.0011). The median index hospital length of stay was longer with iDEN than dDEN (7.5 days vs. 3.0 days respectively, p‐value = 0.010). Subgroup analysis was performed based on the percentage of necrosis (<25% vs. >25% necrosis). iDEN was associated with more necrosectomies than dDEN regardless of the percentage of necrosis (p = 0.017 and 0.0067, respectively). Conclusion Patients undergoing dDEN had a shorter index hospital stay and fewer necrosectomies than iDEN. The large diameter of lumen apposing metal stents permits adequate drainage allowing a less aggressive approach thereby improving clinical outcomes and avoiding unnecessary interventions.
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Affiliation(s)
- Rishi Pawa
- Department of Medicine, Division of Gastroenterology Wake Forest University School of Medicine Winston‐Salem USA
| | - Robert Dorrell
- Department of Medicine Wake Forest University School of Medicine Winston‐Salem USA
| | - Clancy Clark
- Department of General Surgery Wake Forest University School of Medicine Winston‐Salem USA
| | - Greg Russell
- Department of Biostatistics and Data Science Wake Forest University School of Medicine Winston‐Salem USA
| | - John Gilliam
- Department of Medicine, Division of Gastroenterology Wake Forest University School of Medicine Winston‐Salem USA
| | - Swati Pawa
- Department of Medicine, Division of Gastroenterology Wake Forest University School of Medicine Winston‐Salem USA
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Analysis of pancreatic pseudocyst drainage procedural outcomes: a population based study. Surg Endosc 2023; 37:156-164. [PMID: 35879571 DOI: 10.1007/s00464-022-09427-z] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/22/2021] [Accepted: 06/29/2022] [Indexed: 01/18/2023]
Abstract
BACKGROUND A pancreatic pseudocyst is a collection of fluid surrounded by a well-defined wall that contains no solid material. Studies on outcomes of pancreatic pseudocyst drainage have largely been limited to small cohorts. This study aims to take a population based approach to evaluate differences in inpatient outcomes among laparoscopic, percutaneous, and endoscopic drainage for pancreatic pseudocysts. METHODS The National Inpatient Sample database was used to identify inpatient stays for pancreatic pseudocysts in which a single drainage approach was conducted. Baseline characteristic differences were compared with Rao-Scott chi squared and Mann-Whitney U tests. Propensity score matching controlling for clinical and demographic covariates followed by multivariable regression was used to pairwise compare drainage outcomes. Primary outcomes were length of stay, total charge, mortality, and disposition. Secondary outcomes were procedure related complication rates. RESULTS Among a total of 35,640 weighted pancreatic pseudocyst cases, 3235 underwent drainage via a single procedure. Percutaneous was the most frequent drainage method performed (44.5%) and was more likely to be performed at nonteaching hospitals than laparoscopic (17% vs 9%, p = 0.04). Percutaneous drainage was associated with longer LOS (aIRR 1.42, 95% CI 1.07-1.86, p = 0.01) versus endoscopic and lower rates of routine disposition (aOR 0.45, 95% CI 0.23-0.89, p = 0.02) relative to endoscopic and laparoscopic (aOR 0.41, 95% CI 0.27-0.61, p < 0.01) drainage. There were no differences in primary outcomes in laparoscopic versus endoscopic drainage. Percutaneous drainage was associated with higher rates of septic shock than laparoscopic drainage (aOR 2.59, 95% CI 1.15-5.82, p = 0.02). CONCLUSIONS Endoscopic and laparoscopic pancreatic pseudocyst drainage are associated with the least short term procedure related complications and more favorable in-hospital outcomes compared to percutaneous approaches. However, percutaneous drainage was the most commonly performed method in the 2017 NIS database.
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Jagielski M, Kupczyk W, Piątkowski J, Jackowski M. The Role of Antibiotics in Endoscopic Transmural Drainage of Post-Inflammatory Pancreatic and Peripancreatic Fluid Collections. Front Cell Infect Microbiol 2022; 12:939138. [PMID: 35865817 PMCID: PMC9294148 DOI: 10.3389/fcimb.2022.939138] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/08/2022] [Accepted: 06/13/2022] [Indexed: 11/23/2022] Open
Abstract
Background Although endoscopic treatment of symptomatic post-inflammatory pancreatic and peripancreatic fluid collections (PPPFCs) is an established treatment method, some aspects of endotherapy and periprocedural management remain controversial. The role of antibiotics is one of the most controversial issues in interventional endoscopic management of local complications of pancreatitis. Methods This study was a randomized, non-inferiority, placebo-controlled, and double-blinded clinical trial to investigate the role of antibiotic prophylaxis in endoscopic transmural drainage in patients with symptomatic non-infected PPPFCs and assess the influence of antibiotic treatment on the results of endotherapy in patients with symptomatic infected PPPFCs. This trial included 62 patients treated endoscopically for PPPFCs in 2020 at our medical center. Patients were divided into two groups; group 1 comprised patients who had received empirical intravenous antibiotic therapy during endotherapy and group 2 comprised patients who did not receive antibiotic therapy during endoscopic drainage of PPPFCs. The end points were clinical success and long-term success of endoscopic treatment. Results Thirty-one patients were included in group 1 (walled-off pancreatic necrosis [WOPN, 51.6%; pseudocyst, 48.4%) and 31 patients in group 2 (WOPN, 58.1%; pseudocyst, 41.9%) (p=0.6098/nonsignificant statistical [NS]). Infection with PPPFCs was observed in 15/31 (48.39%) patients in group 1 and in 15/31 (48.39%) patients in group 2 (p=1.0/NS). The average time of active (with flushing through nasocystic drainage) drainage in group 1 was 13.0 (6 – 21) days and was 14.0 (7 – 25) days in group 2 (p=0.405/NS). The average total number endoscopic procedures on one patient was 3.3 (2 – 5) in group 1 and 3.4 (2 – 7) in group 2 (p=0.899/NS). Clinical success of PPPFCs was observed in 29/31 (93.5%) patients from group 1 and in 30/31 (96.8%) patients from group 2 (p=0.5540/NS). Complications of endotherapy were noted in 8/31 (25.8%) patients in group 1 and in 10/31 (32.3%) patients in group 2 (p=0.576/NS). Long-term success in group 1 and 2 was reported in 26/31 (83.9%) and 24/31 (77.4%) patients, respectively (p=0.520/NS). Conclusions The effective endoscopic drainage of sterile PPPFCs requires no preventive or prophylactic use of antibiotics. In infected PPPFCs, antibiotic therapy is not required for effective endoscopic transmural drainage.
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6
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Hickman K, Sadler T, Zhang T, Boninsegna E, Majcher V, Godfrey E. Pancreatic cystic lesions and the role of contrast enhanced endoscopic ultrasound. Clin Radiol 2022; 77:418-427. [DOI: 10.1016/j.crad.2022.02.017] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/19/2021] [Accepted: 02/22/2022] [Indexed: 11/16/2022]
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7
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Kim KT, Clark J, Ghneim M, Feliciano DV, Diaz JJ, Harfouche M. Not All Fluid Collections Are Created Equal: Clinical Course and Outcomes of Pancreatic Pseudocysts and Acute Peripancreatic Fluid Collections Requiring Intervention. Am Surg 2022:31348221078955. [DOI: 10.1177/00031348221078955] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
Background Knowledge on pancreatic pseudocyst (PP) management has mostly involved large database analysis, which limits understanding of a complex and heterogeneous disease. We aimed to review the clinical course and outcomes of PP and acute peripancreatic fluid collections (APFC) that require intervention at 1 high-volume center. Methods Retrospective review of patients with APFC and PP undergoing drainage (2011-2018) was performed. Patients were divided into groups based on initial intervention: surgical (SR), percutaneous (PC), or endoscopic (EN) drainage. Primary outcome was mortality by initial intervention type. Secondary outcomes included subsequent interventions required, length of stay (LOS), readmission rates, and discharge disposition. Results Of 88 patients, 40 (46.1%) underwent SR, 40 (44.9%) PC, and 8 (9.0%) EN. No patients in EN group had APACHE II scores>20. Pancreatic necrosis was higher in SR (80.5%) and PC (62.5%) groups ( P = .006). There were no differences in mortality, LOS, or readmission rates. Ten patients in the PC group underwent subsequent surgical intervention, of which 9 were due to bowel ischemia. The PC group was 3.4 times more likely to be discharged to rehabilitation over home when compared to the other 2 groups ( P = .04). Conclusion Patients undergoing surgical or percutaneous drainage of APFC and PP have a greater burden of illness and more local complications requiring intervention compared to endoscopic drainage. The heterogeneity in presentation of peripancreatic fluid collections in acute pancreatitis must be considered when evaluating the benefits of each intervention.
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Affiliation(s)
- Kevin T Kim
- University of Maryland School of Medicine, Baltimore, ML, USA
| | - Jaclyn Clark
- University of Maryland School of Medicine, Baltimore, ML, USA
| | - Mira Ghneim
- University of Maryland School of Medicine, Baltimore, ML, USA
| | | | - Jose J Diaz
- University of Maryland School of Medicine, Baltimore, ML, USA
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Pinto S, Bellizzi S, Badas R, Canfora ML, Loddo E, Spada S, Khalaf K, Fugazza A, Bergamini S. Direct Endoscopic Necrosectomy: Timing and Technique. MEDICINA (KAUNAS, LITHUANIA) 2021; 57:medicina57121305. [PMID: 34946249 PMCID: PMC8707414 DOI: 10.3390/medicina57121305] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 10/18/2021] [Revised: 11/22/2021] [Accepted: 11/24/2021] [Indexed: 12/12/2022]
Abstract
Walled-off pancreatic necrosis (WOPN) is one of the local complications of acute pancreatitis (AP). Several interventional techniques have been developed over the last few years. The purpose of this narrative review is to explore such methodologies, with specific focus on endoscopic drainage and direct endoscopic necrosectomy (DEN), through evaluation of their indications and timing for intervention. Findings indicated how, after the introduction of lumen-apposing metal stents (LAMS), DEN is becoming the favorite technique to treat WOPN, especially when large solid debris or infection are present. Additionally, DEN is associated with a lower adverse events rate and hospital stay, and with improved clinical outcome.
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Affiliation(s)
- Sergio Pinto
- Digestive Endoscopy Unit, Department of Surgical Sciences, University Hospital of Cagliari, 09042 Cagliari, Italy; (R.B.); (M.L.C.); (E.L.); (S.S.); (S.B.)
- Correspondence: ; Tel.: +39-07051096423
| | - Saverio Bellizzi
- Medical Epidemiologist, Independent Consultant, 1202 Geneva, Switzerland;
| | - Roberta Badas
- Digestive Endoscopy Unit, Department of Surgical Sciences, University Hospital of Cagliari, 09042 Cagliari, Italy; (R.B.); (M.L.C.); (E.L.); (S.S.); (S.B.)
| | - Maria Laura Canfora
- Digestive Endoscopy Unit, Department of Surgical Sciences, University Hospital of Cagliari, 09042 Cagliari, Italy; (R.B.); (M.L.C.); (E.L.); (S.S.); (S.B.)
| | - Erica Loddo
- Digestive Endoscopy Unit, Department of Surgical Sciences, University Hospital of Cagliari, 09042 Cagliari, Italy; (R.B.); (M.L.C.); (E.L.); (S.S.); (S.B.)
| | - Simone Spada
- Digestive Endoscopy Unit, Department of Surgical Sciences, University Hospital of Cagliari, 09042 Cagliari, Italy; (R.B.); (M.L.C.); (E.L.); (S.S.); (S.B.)
| | - Kareem Khalaf
- Department of Biomedical Sciences, Humanitas University, Pieve Emanuele, 20090 Milano, Italy;
| | - Alessandro Fugazza
- Digestive Endoscopy Unit, Department of Gastroenterology, Humanitas Research Hospital-IRCCS, 20089 Rozzano, Italy;
| | - Silvio Bergamini
- Digestive Endoscopy Unit, Department of Surgical Sciences, University Hospital of Cagliari, 09042 Cagliari, Italy; (R.B.); (M.L.C.); (E.L.); (S.S.); (S.B.)
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Xu N, Zhai YQ, Li LS, Chai NL. Multiple hidden vessels in walled-off necrosis with high-risk bleeding: Report of two cases. World J Clin Cases 2021; 9:8214-8219. [PMID: 34621883 PMCID: PMC8462217 DOI: 10.12998/wjcc.v9.i27.8214] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/08/2021] [Revised: 06/17/2021] [Accepted: 07/05/2021] [Indexed: 02/06/2023] Open
Abstract
BACKGROUND Walled-off necrosis (WON), as a local complication of acute necrotizing pancreatitis, is difficult to differentiate from pancreatic pseudocysts (PPC). Imaging modalities such as computed tomography show a lower accuracy than endoscopic ultrasound (EUS) in confirming the diagnosis. EUS-guided cystogastrostomy following direct endoscopic necrosectomy has achieved excellent results and has been regarded as a preferred alternative to traditional surgery. However, high-risk bleeding is one of the greatest concerns.
CASE SUMMARY Two patients with symptomatic pancreatic fluid collections (PFCs) were admitted to our hospital for EUS-guided lumen-apposing metal stent therapy. The female patient suffered from intermittent abdominal pain and underwent two perioperative CT examinations. The male patient had recurrent pancreatitis and showed a growing PFC. The initial diagnosis was a PPC according to contrast-enhanced CT. However, the evidence of solid contents on EUS prompted revision of the diagnosis to WON. An endoscope was inserted into the cavity, and some necrotic debris and multiple hidden vascular structures were observed. Owing to conservative treatment by irrigation with sterile water instead of direct necrosectomy, we successfully avoided damaging hidden vessels and reduced the risk of intraoperative bleeding.
CONCLUSION The application of EUS is helpful for the identification of PFCs. Careful intervention should be conducted for WON with multiple vessels to prevent bleeding.
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Affiliation(s)
- Ning Xu
- Department of Gastroenterology and Hepatology, Chinese PLA General Hospital, Beijing 100853, China
| | - Ya-Qi Zhai
- Department of Gastroenterology and Hepatology, Chinese PLA General Hospital, Beijing 100853, China
| | - Long-Song Li
- Department of Gastroenterology and Hepatology, Chinese PLA General Hospital, Beijing 100853, China
| | - Ning-Li Chai
- Department of Gastroenterology and Hepatology, Chinese PLA General Hospital, Beijing 100853, China
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Fujiwara J, Matsumoto S, Sekine M, Mashima H. C-reactive protein predicts the development of walled-off necrosis in patients with severe acute pancreatitis. JGH OPEN 2021; 5:907-914. [PMID: 34386599 PMCID: PMC8341195 DOI: 10.1002/jgh3.12605] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 04/01/2021] [Revised: 06/01/2021] [Accepted: 06/22/2021] [Indexed: 11/17/2022]
Abstract
Background and Aim Walled‐off necrosis (WON) is reported to occur in 1–9% of patients with acute pancreatitis. However, the factors associated with the onset of this condition have not been elucidated. This study aimed to investigate the potential predictive factors for WON in patients diagnosed with severe acute pancreatitis at our hospital. Methods This study included 26 patients with severe acute pancreatitis identified among the 211 patients with acute pancreatitis admitted to our hospital between January 2014 and December 2018. Patients with and without WON (WON and non‐WON groups, respectively) were compared to identify potential factors involved in the onset of this condition. Results The 26 patients had a median age of 67 years, and 65% were male. WON occurred in 15 patients (57.7%). In a univariate analysis, the WON and non‐WON groups differed significantly in terms of maximum C‐reactive protein (CRP) levels (median) (322.7 mg/L vs 163.8 mg/L [P = 0.001]). In a multivariate analysis, a significant association was identified between the maximum CRP level and the onset of WON (odds ratio: 1.20, 95% confidence interval: 1.05–1.37). The CRP level peaked within 3 days in 88%. Conclusion The maximum CRP level was identified as a predictive factor for the onset of WON, and a high proportion of patients with WON exhibited elevated CRP levels within 3 days after diagnosis. This work suggests the clinical importance of continuous monitoring at an early stage after diagnosis to identify the maximum CRP level.
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Affiliation(s)
- Junichi Fujiwara
- Department of Gastroenterology, Saitama Medical Center Jichi Medical University Saitama-shi Saitama Japan
| | - Satohiro Matsumoto
- Department of Gastroenterology, Saitama Medical Center Jichi Medical University Saitama-shi Saitama Japan
| | - Masanari Sekine
- Department of Gastroenterology, Saitama Medical Center Jichi Medical University Saitama-shi Saitama Japan
| | - Hirosato Mashima
- Department of Gastroenterology, Saitama Medical Center Jichi Medical University Saitama-shi Saitama Japan
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Rebhun J, Nassani N, Pan A, Hong M, Shuja A. Outcomes of Open, Laparoscopic, and Percutaneous Drainage of Infected Walled-Off Pancreatic Necrosis: A Nationwide Inpatient Sample Study. Cureus 2021; 13:e12972. [PMID: 33654633 PMCID: PMC7913891 DOI: 10.7759/cureus.12972] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/05/2022] Open
Abstract
Background Walled-off pancreatic necrosis (WOPN) represents an encapsulated collection of necrotic pancreatic or peripancreatic tissue that tends to develop four weeks after the onset of acute necrotizing pancreatitis. When infected, it is managed initially by antibiotic therapy before drainage by endoscopic, percutaneous, or surgical means. This study aims to describe the morbidity, mortality, length of stay (LOS), and cost of care associated with open surgical, laparoscopic, and radiology-guided percutaneous drainage in adult patients with infected WOPN. Methods Using the Nationwide Inpatient Sample (NIS), patients aged 18 years and older discharged with the diagnosis of WOPN between January 1, 2016 and December 31, 2016 who underwent open, laparoscopic, or percutaneous drainage were included. Patients’ characteristics including age, gender, and body mass index were reported. The primary endpoints were the mortality rate as well as length and cost of stay in each group. The secondary endpoint was the rate of procedural complications in each arm. Endpoints were reported and compared with studies assessing similar outcomes. Statistical Analysis System (SAS) statistical software (SAS Institute Inc., Cary, NC, USA) was used to perform the analysis. Results A total of 229 patients with the diagnosis of acute pancreatitis with infected necrosis were identified. Of these 229 patients, 27, 15, and 20 underwent open, laparoscopic, and percutaneous drainage, respectively. A total of eight studies were used for comparison of outcome variables. Mortality rate was found to be similar among comparison studies. LOS and costs varied widely among studies. There were significantly fewer pancreatic fistula and significantly more multi-organ failure complications as a result of open necrosectomy in the NIS study sample. Conclusion Overall, in analyzing the outcomes of patients undergoing intervention for infected WOPN through the 2016 NIS database, it appears that the database is representative of the majority of outcomes seen in similar clinical trials.
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Affiliation(s)
- Jeffrey Rebhun
- Department of Internal Medicine, University of Illinois at Chicago, Chicago, USA
| | - Najib Nassani
- Department of Gastroenterology and Hepatology, University of Illinois at Chicago, Chicago, USA
| | - Alex Pan
- Department of Gastroenterology and Hepatology, University of Illinois at Chicago, Chicago, USA
| | - Mindy Hong
- Department of Dermatology, Northwestern University Feinberg School of Medicine, Chicago, USA
| | - Asim Shuja
- Department of Gastroenterology and Hepatology, University of Illinois at Chicago, Chicago, USA
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12
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Abstract
Pancreatic fluid collections (PFC), including pancreatic pseudocysts and walled-off pancreatic necrosis, are a known complication of severe acute pancreatitis. A majority of the PFCs remain asymptomatic and resolve spontaneously. However, some PFCs persist and can become symptomatic. Persistent PFCs can also cause further complications such as the gastric outlet, intestinal, or biliary obstruction and infection. Surgical interventions are indicated for the drainage of symptomatic sterile and infected PFCs. Management of PFCs has evolved from a primarily surgical or percutaneous approach to a less invasive endoscopic approach. Endoscopic interventions are associated with improved outcomes with lesser chances of complications, faster recovery time, and lower healthcare utilization. Endoscopic ultrasound-guided drainage of PFCs using lumen-apposing metal stents has become the preferred approach for the management of symptomatic and complicated PFCs.
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13
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Gong L, Shu B, Feng X, Dong J. Ultrasonic Pressure Ballistic System-Assisted Minimally Invasive Pancreatic Necrosectomy for Necrotizing Pancreatitis. J Laparoendosc Adv Surg Tech A 2019; 30:438-443. [PMID: 31718418 DOI: 10.1089/lap.2019.0581] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
Background: Although minimally invasive pancreatic necrosectomy (MIPN) is a new invasive technique for necrotizing pancreatitis, it has some disadvantages. This study aimed to improve the debridement technique with an ultrasonic pressure ballistic system. We hypothesized that this system would facilitate debridement and improve the safety of the procedure. Materials and Methods: Between October 2016 and January 2019, 5 patients diagnosed with necrotizing pancreatitis were enrolled in the clinical cohort. All patients underwent debridement due to infective necrosis. Access for debridement was typically established with percutaneous puncture. Then MIPN was performed. During the procedure, ultrasonic pressure was applied to liquefy the necrotic material and make it absorbable. The effect of debridement was assessed by analyzing the average bleeding volume, operation time, and complications. Postoperative clinical parameters were evaluated. Results: Debridement was performed successfully for all patients. Semisolid necrotic tissue was dissolved with ultrasonic pressure. Viscous pus was rapidly aspirated with the suction applied with negative pressure, which greatly enhanced efficiency. This approach enhanced the visibility of blood vessels, which improved safety. No major complications were encountered. Two patients (40%) developed puncture site infections. The average blood loss during the operation was 13 ± 6 mL. The average operation time was 78 ± 31 minutes. Postoperative APACHE II scores were significantly lower than preoperative scores (P < .05). White blood cells, C-reactive protein, and procalcitonin levels declined postoperatively. Conclusions: The ultrasonic pressure ballistic system could potentially enhance MIPN and make it safer.
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Affiliation(s)
- Lei Gong
- Center of Hepatopancreatobiliary Diseases, Beijing Tsinghua Changgung Hospital, School of Clinical Medicine, Tsinghua University, Beijing, China
| | - Bin Shu
- Center of Hepatopancreatobiliary Diseases, Beijing Tsinghua Changgung Hospital, School of Clinical Medicine, Tsinghua University, Beijing, China
| | - Xiaobin Feng
- Center of Hepatopancreatobiliary Diseases, Beijing Tsinghua Changgung Hospital, School of Clinical Medicine, Tsinghua University, Beijing, China
| | - Jiahong Dong
- Center of Hepatopancreatobiliary Diseases, Beijing Tsinghua Changgung Hospital, School of Clinical Medicine, Tsinghua University, Beijing, China
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Hemodynamic Instability Secondary to Inferior Vena Cava Compression: A Rare Complication of Massive Walled-off Pancreatic Necrosis. ACG Case Rep J 2019; 6:e00269. [PMID: 31832482 PMCID: PMC6855531 DOI: 10.14309/crj.0000000000000269] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/19/2019] [Accepted: 09/30/2019] [Indexed: 11/17/2022] Open
Abstract
Necrosis developing 4 weeks after the initial acute pancreatitis attack is known as walled-off pancreatic necrosis (WOPN). Complications of WOPN include spontaneous rupture into the peritoneal cavity or hollow viscus obstruction by compression of surrounding structures, including the colon, stomach, duodenum, and common bile duct. There have also been cases of pseudocyst rupture into blood vessels. This case report is unique in that it highlights a patient with inferior vena cava compression leading to hemodynamic instability due to the mass effect of WOPN and has not been previously reported.
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15
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Endoscopic Management of Giant Walled-Off Pancreatic Necrosis With a High Risk of Bleeding. ACG Case Rep J 2019; 6:e00199. [PMID: 31737728 PMCID: PMC6791649 DOI: 10.14309/crj.0000000000000199] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/06/2019] [Accepted: 07/10/2019] [Indexed: 12/15/2022] Open
Abstract
Walled-off pancreatic necrosis (WOPN) is one of the late complications of acute pancreatitis. We present a 37-year-old man who developed a large WOPN 6 weeks after treatment of severe complicated pancreatitis. Imaging studies revealed a necrotic retroperitoneal fluid collection measuring 27 × 12 × 27 cm with large crossing blood vessels. Cystogastrostomy was performed using a lumen-apposing metal stent. He underwent multiple necrosectomies with significant improvement in the cyst size. Bleeding is a major complication of direct endoscopic necrosectomy; hence, specific imaging and a careful approach should be taken into consideration, especially in WOPN with a high risk of bleeding.
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16
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Hui D, Hutchinson C, Maine R, Raff L. A Case of Spontaneous Intraperitoneal Rupture of an Acute Necrotic Fluid Collection Associated with Necrotizing Pancreatitis. AMERICAN JOURNAL OF CASE REPORTS 2019; 20:459-464. [PMID: 30951519 PMCID: PMC6463786 DOI: 10.12659/ajcr.914571] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Abstract
Patient: Male, 61 Final Diagnosis: Intraperitoneal rupture of acute necrotic peri-pancreatic fluid collection Symptoms: Abdominal and/or epigastric pain • abdominal distension • hypotension • shock Medication: — Clinical Procedure: Exploratory laparotomy with external pancreatic drainage • exploratory laparotomy, cholecystectomy, cystgastrostomy Specialty: Surgery
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Affiliation(s)
- Donovan Hui
- Department of Surgery, University of North Carolina Medical Center, Chapel Hill, NC, USA
| | - Chelsea Hutchinson
- Department of Surgery, University of North Carolina Medical Center, Chapel Hill, NC, USA
| | - Rebecca Maine
- Department of Surgery, University of North Carolina Medical Center, Chapel Hill, NC, USA
| | - Lauren Raff
- Department of Surgery, University of North Carolina Medical Center, Chapel Hill, NC, USA
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17
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Abstract
Walled of pancreatic necrosis (WOPN) is a new term coined for encapsulated fluid collection developing after acute necrotising pancreatitis (ANP). It is a heterogeneous collection containing varying amount of liquid as well as solid necrotic material. The literature on its natural history as well as appropriate management is gradually expanding thereby improving treatment outcomes of this enigmatic disease. Areas covered: This review discusses currently available literature on etiology, frequency, natural history, and imaging features WOPN. Also, updated treatment options including endoscopic, radiological and surgical drainage are discussed. Expert opinion: WOPN is alocal complication of ANP occurring in the delayed phase of ANP and may be asymptomatic (50%) or present with pain, fever, jaundice, or gastric outlet obstruction. Natural courses of asymptomatic WOPN have been infrequently studied, and it appears that the majority remain asymptomatic and resolve spontaneously. Magnetic resonance imaging and endoscopic ultrasound are the best imaging modalities to evaluate solid necrotic debris. Symptomatic WOPN usually needs immediate drainage, this can be done endoscopically, radiologically, or surgically. Current evidence suggests that endoscopic transluminal drainage is the preferred drainage technique as it is effective and associated with lower mortality, risk of organ failure, adverse effects, and length of hospital stay.
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Affiliation(s)
- Surinder Singh Rana
- a Department of Gastroenterology , Post Graduate Institute of Medical Education and Research (PGIMER) , Chandigarh , India
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18
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Imai M, Takahashi Y, Sato T, Maruyama M, Isokawa O. Endoscopic ultrasound-guided internalization of a pancreaticocutaneous fistula utilizing a balloon-target technique: A case report. Medicine (Baltimore) 2018; 97:e13564. [PMID: 30558018 PMCID: PMC6320205 DOI: 10.1097/md.0000000000013564] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/25/2022] Open
Abstract
RATIONALE Endoscopic ultrasound (EUS)-guided treatment has been recently described for internalizing refractory pancreaticocutaneous fistulas (PCFs). However, the existing techniques are limited because of the difficulty in accessing nondilated pancreatic ducts or fistulas. In an attempt to overcome this limitation, we present a case where a EUS-guided intervention utilizing a balloon-target technique was employed to internalize a PCF into the stomach. PATIENT CONCERNS A 78-year-old woman underwent percutaneous drainage and 4 percutaneous endoscopic necrosectomies for walled-off pancreatic necrosis (WOPN) after severe acute pancreatitis due to choledocholithiasis. Although the WOPN was resolved, refractory PCFs remained. DIAGNOSIS Pancreaticocutaneous fistulas. INTERVENTIONS An echoendoscope was introduced into the stomach, but the narrow PCF lumen made visualization of the fistula by EUS difficult. Subsequently, a balloon catheter was percutaneously inserted into the fistula, and then the inflated balloon was visualized by EUS from the stomach. The balloon was punctured with a 19-gauge fine needle through the posterior wall of the upper body of the stomach (balloon-target technique). A guidewire was then passed through the fistula to the outside of the body through the EUS scope. After dilating the gastro-fistula space with an 8-mm balloon dilation catheter, a 7-French double pigtail catheter was placed from the stomach into the PCF. OUTCOMES The percutaneous drainage tube was removed after one week, and the patient was discharged 6 months after admission. No adverse outcomes have been observed in the 2 years since the procedure. LESSONS PCFs can be successfully managed using EUS-guided internalization with a balloon-target technique.
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19
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Imaging of endoscopic cystogastrostomy in pancreatic walled-off necrosis: what the radiologist needs to know. Abdom Radiol (NY) 2018; 43:3043-3053. [PMID: 29619526 DOI: 10.1007/s00261-018-1584-2] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
Acute pancreatitis is a frequent entity encountered by radiologists. In 2012, the Atlanta criteria were revised to help radiologists use a common nomenclature when describing acute pancreatitis and its complications. One delayed complication of acute necrotizing pancreatitis in walled-off necrosis, a collection seen at least 4 weeks after an episode of acute pancreatic necrosis and/or acute peripancreatic necrosis. Multiple treatments have been adapted in the setting of walled-off necrosis, including endoscopic cystogastrostomy. The focus of this article is to familiarize the radiologist with the imaging appearance of this procedure as well as, review the outcomes and potential complications of endoscopic cystogastrostomy.
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20
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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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21
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Ramachandran A, Sharma S, Shalimar, Sharma R, Madhusudhan KS. Pancreatic Walled-Off Necrosis Eroding into the Inferior Vena Cava. Curr Probl Diagn Radiol 2018; 48:519-521. [PMID: 29496357 DOI: 10.1067/j.cpradiol.2018.01.007] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/02/2018] [Accepted: 01/19/2018] [Indexed: 11/22/2022]
Abstract
Walled-off necrosis (WON) is a well-known delayed local complication of acute necrotizing pancreatitis. Occasionally, WON may spontaneously rupture into the gastrointestinal tract or peritoneal cavity. However, erosion of a WON to a systemic vein has not been reported in literature so far. We report an unusual case of a 63-year-old male with acute necrotizing pancreatitis in whom WON was eroding into the inferior vena cava resulting in its thrombosis. Our patient also had a bunch of other well-described complications of pancreatitis including splanchnic venous thrombosis.
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Affiliation(s)
- Anupama Ramachandran
- Department of Radiodiagnosis, All India Institute of Medical Sciences, New Delhi, India
| | - Sanchit Sharma
- Department of Gastroenterology, All India Institute of Medical Sciences, New Delhi, India
| | - Shalimar
- Department of Gastroenterology, All India Institute of Medical Sciences, New Delhi, India
| | - Raju Sharma
- Department of Radiodiagnosis, All India Institute of Medical Sciences, New Delhi, India
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22
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Predictive Value of Computed Tomography Scans and Clinical Findings for the Need of Endoscopic Necrosectomy in Walled-off Necrosis From Pancreatitis. Pancreas 2017; 46:1039-1045. [PMID: 28796138 DOI: 10.1097/mpa.0000000000000881] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/23/2022]
Abstract
OBJECTIVES Choosing the best treatment option at the optimal point of time for patients with walled-off necrosis (WON) is crucial. We aimed to identify imaging parameters and clinical findings predicting the need of necrosectomy in patients with WON. METHODS All patients with endoscopically diagnosed WON and pseudocyst were retrospectively identified. Post hoc analysis of pre-interventional contrast-enhanced computed tomography was performed for factors predicting the need of necrosectomy. RESULTS Sixty-five patients were included in this study. Forty patients (61.5%) were diagnosed with pseudocyst and 25 patients (38.5%) with WON. Patients with WON mostly had acute pancreatitis with biliary cause compared with more chronic pancreatitis and toxic cause in pseudocyst group (P = 0.002 and P = 0.004, respectively). Logistic regression revealed diabetes as a risk factor for WON. Computed tomography scans revealed 4.62% (n = 3) patients as false positive and 24.6% (n = 16) as false negative findings for WON. Reduced perfusion and detection of solid findings were independent risk factors for WON. CONCLUSIONS Computed tomography scans are of low diagnostic yield when needed to predict treatment of patients with pancreatic cysts. Reduced pancreatic perfusion and solid findings seem to be a risk factor for WON, whereas patients with diabetes seem to be at higher risk of developing WON.
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23
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Dhar VK, Sutton JM, Xia BT, Levinsky NC, Wilson GC, Smith M, Choe KA, Moulton J, Vu D, Ristagno R, Sussman JJ, Edwards MJ, Abbott DE, Ahmad SA. Fistulojejunostomy Versus Distal Pancreatectomy for the Management of the Disconnected Pancreas Remnant Following Necrotizing Pancreatitis. J Gastrointest Surg 2017; 21:1121-1127. [PMID: 28397026 DOI: 10.1007/s11605-017-3419-9] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/19/2017] [Accepted: 03/30/2017] [Indexed: 01/31/2023]
Abstract
BACKGROUND A disconnected distal pancreas (DDP) remnant is a morbid sequela of necrotizing pancreatitis. Definitive surgical management can be accomplished by either fistulojejunostomy (FJ) or distal pancreatectomy (DP). It is unclear which operative approach is superior with regard to short- and long-term outcomes. METHODS Between 2002 and 2014, patients undergoing either FJ or DP for DDP were retrospectively identified at a center specializing in pancreatic diseases. Patient demographics, perioperative, and postoperative variables were evaluated. RESULTS Forty-two patients with DDP secondary to necrotizing pancreatitis underwent either a FJ (n = 21) or DP (n = 21). Between the two cohorts, there were no significant differences in overall lengths of stay, pancreatic leak rates, or readmission rates (all p > 0.05). DP was associated with higher estimated blood loss, increased transfusion requirements, and worsening endocrine function (all p < 0.05). At a median follow-up of 18 months, four patients that underwent a FJ developed a recurrent fluid collection requiring re-intervention. Overall, FJ was successful in 80% of patients as compared to a 95% success rate for DP (p = 0.15). CONCLUSIONS Although DP was associated with higher intraoperative blood loss, increased transfusion requirements, and worsening of preoperative diabetes, this procedure provides superior long-term resolution of a DDP when compared to FJ.
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Affiliation(s)
- Vikrom K Dhar
- Department of Surgery, Division of Surgical Oncology, University of Cincinnati Medical Center, 231 Albert Sabin Way, ML 0558, SRU Room 1466, Cincinnati, OH, 45219, USA
| | - Jeffrey M Sutton
- Department of Surgery, Division of Surgical Oncology, University of Cincinnati Medical Center, 231 Albert Sabin Way, ML 0558, SRU Room 1466, Cincinnati, OH, 45219, USA
| | - Brent T Xia
- Department of Surgery, Division of Surgical Oncology, University of Cincinnati Medical Center, 231 Albert Sabin Way, ML 0558, SRU Room 1466, Cincinnati, OH, 45219, USA
| | - Nick C Levinsky
- Department of Surgery, Division of Surgical Oncology, University of Cincinnati Medical Center, 231 Albert Sabin Way, ML 0558, SRU Room 1466, Cincinnati, OH, 45219, USA
| | - Gregory C Wilson
- Department of Surgery, Division of Surgical Oncology, University of Cincinnati Medical Center, 231 Albert Sabin Way, ML 0558, SRU Room 1466, Cincinnati, OH, 45219, USA
| | - Milton Smith
- Department of Medicine, Division of Gastroenterology, University of Cincinnati, Cincinnati, OH, USA
| | - Kyuran A Choe
- Department of Radiology, University of Cincinnati, Cincinnati, OH, USA
| | - Jonathan Moulton
- Department of Radiology, University of Cincinnati, Cincinnati, OH, USA
| | - Doan Vu
- Department of Radiology, University of Cincinnati, Cincinnati, OH, USA
| | - Ross Ristagno
- Department of Radiology, University of Cincinnati, Cincinnati, OH, USA
| | - Jeffrey J Sussman
- Department of Surgery, Division of Surgical Oncology, University of Cincinnati Medical Center, 231 Albert Sabin Way, ML 0558, SRU Room 1466, Cincinnati, OH, 45219, USA
| | - Michael J Edwards
- Department of Surgery, Division of Surgical Oncology, University of Cincinnati Medical Center, 231 Albert Sabin Way, ML 0558, SRU Room 1466, Cincinnati, OH, 45219, USA
| | - Daniel E Abbott
- Department of Surgery, Division of Surgical Oncology, University of Wisconsin, Madison, WI, USA
| | - Syed A Ahmad
- Department of Surgery, Division of Surgical Oncology, University of Cincinnati Medical Center, 231 Albert Sabin Way, ML 0558, SRU Room 1466, Cincinnati, OH, 45219, USA.
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Dual drainage using a percutaneous pancreatic duct technique contributed to resolution of severe acute pancreatitis. Clin J Gastroenterol 2017; 10:191-195. [PMID: 28236277 DOI: 10.1007/s12328-017-0720-9] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/21/2016] [Accepted: 02/07/2017] [Indexed: 01/12/2023]
Abstract
A 66-year-old man was admitted for severe acute alcoholic pancreatitis with infected pancreatic necrosis (IPN). Abdominal computed tomography revealed an inflamed pancreatic head, a dilated main pancreatic duct (MPD), and a large cavity with heterogeneous fluid containing gas adjacent to the pancreatic head, and extending to the pelvis. The cavity was drained percutaneously near the pancreatic head on admission; another tube was inserted into the pelvic cavity on hospital day 3. The drained fluid contained pus with high amylase concentration. Nasopancreatic drainage tube placement was unsuccessfully attempted on hospital day 9. On hospital day 23, percutaneous puncture of the MPD and placement of a pancreatic duct drainage tube was performed. Pancreatography revealed major extravasation from the pancreatic head. The IPN cavity receded; the percutaneous IPN drainage tube was removed on hospital day 58. On hospital day 83, the pancreatic drainage was changed to a transpapillary pancreatic stent, and the patient was discharged. Measuring the amylase concentration of peripancreatic fluid collections can aid in the diagnosis of pancreatic duct disruption; moreover, dual percutaneous necrotic cavity drainage plus pancreatic duct drainage may be essential for treating IPN. If transpapillary drainage tube placement is difficult, percutaneous pancreatic duct drainage may be feasible.
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25
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Kirks RC, Sola R, Iannitti DA, Martinie JB, Vrochides D. Robotic transgastric cystgastrostomy and pancreatic debridement in the management of pancreatic fluid collections following acute pancreatitis. J Vis Surg 2016; 2:127. [PMID: 29078515 DOI: 10.21037/jovs.2016.07.04] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/21/2016] [Accepted: 06/29/2016] [Indexed: 12/17/2022]
Abstract
Pancreatic and peripancreatic fluid collections may develop after severe acute pancreatitis. Organized fluid collections such as pancreatic pseudocyst and walled-off pancreatic necrosis (WOPN) that mature over time may require intervention to treat obstructive or constitutional symptoms related to the size and location of the collection as well as possible infection. Endoscopic, open surgical and minimally invasive techniques are described to treat post-inflammatory pancreatic fluid collections. Surgical intervention may be required to treat collections containing necrotic pancreatic parenchyma or in locations not immediately apposed to the stomach or duodenum. Comprising a blend of the surgical approach and the clinical benefits of minimally invasive surgery, the robot-assisted technique of pancreatic cystgastrostomy with pancreatic debridement is described.
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Affiliation(s)
- Russell C Kirks
- Division of Hepatobiliary and Pancreatic Surgery, Department of General Surgery, Carolinas Medical Center, Charlotte, North Carolina, USA
| | - Richard Sola
- Division of Hepatobiliary and Pancreatic Surgery, Department of General Surgery, Carolinas Medical Center, Charlotte, North Carolina, USA
| | - David A Iannitti
- Division of Hepatobiliary and Pancreatic Surgery, Department of General Surgery, Carolinas Medical Center, Charlotte, North Carolina, USA
| | - John B Martinie
- Division of Hepatobiliary and Pancreatic Surgery, Department of General Surgery, Carolinas Medical Center, Charlotte, North Carolina, USA
| | - Dionisios Vrochides
- Division of Hepatobiliary and Pancreatic Surgery, Department of General Surgery, Carolinas Medical Center, Charlotte, North Carolina, USA
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Successful Resolution of Gastric Outlet Obstruction Caused by Pancreatic Pseudocyst or Walled-Off Necrosis After Acute Pancreatitis: The Role of Percutaneous Catheter Drainage. Pancreas 2015; 44:1290-5. [PMID: 26465954 PMCID: PMC4947542 DOI: 10.1097/mpa.0000000000000429] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
OBJECTIVE Delayed gastric emptying (DGE) in patients with acute pancreatitis (AP) can be caused by gastroparesis or gastric outlet obstruction, which may occur when pancreatic pseudocyst (PP) or walled-off necrosis (WON) compresses the stomach. The aim of the study was to explore a proper surgical treatment. METHODS From June 2010 to June 2013, 25 of 148 patients with AP suffered DGE. Among them, 12 were caused by gastroparesis, 1 was a result of obstruction from a Candida albicans plug, and 12 were gastric outlet obstruction (GOO) compressed by PP (n = 8) or WON (n = 4), which were treated by percutaneous catheter drainage (PCD). RESULTS All 12 cases of compressing GOO achieved resolution by PCD after 6 [1.86] and 37.25 [12.02] days for PP and WON, respectively. Five cases developed intracystic infection, 3 cases had pancreatic fistulae whereas 2 achieved resolution and 1 underwent a pseudocyst jejunostomy. CONCLUSIONS Gastric outlet obstruction caused by a PP or WON is a major cause of DGE in patients with AP. Percutaneous catheter drainage with multiple sites, large-bore tubing, and lavage may be a good therapy due to high safety and minimal invasiveness.
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Acute Pancreatitis: Revised Atlanta Classification and the Role of Cross-Sectional Imaging. AJR Am J Roentgenol 2015; 205:W32-41. [PMID: 26102416 DOI: 10.2214/ajr.14.14056] [Citation(s) in RCA: 43] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
OBJECTIVE The 2012 revision of the Atlanta Classification emphasizes accurate characterization of collections that complicate acute pancreatitis: acute peripancreatic fluid collections, pseudocysts, acute necrotic collections, and walled-off necroses. As a result, the role of imaging in the management of acute pancreatitis has substantially increased. CONCLUSION This article reviews the imaging findings associated with acute pancreatitis and its complications on cross-sectional imaging and discusses the role of imaging in light of this revision.
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Eguchi T, Tsuji Y, Yamashita H, Fukuchi T, Kanamori A, Matsumoto K, Hasegawa T, Koizumi A, Kitada R, Tsujimae M, Iwatsubo T, Koyama S, Ubukata S, Fujita M, Okada A. Efficacy of recombinant human soluble thrombomodulin in preventing walled-off necrosis in severe acute pancreatitis patients. Pancreatology 2015; 15:485-490. [PMID: 26320826 DOI: 10.1016/j.pan.2015.08.002] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/25/2015] [Revised: 06/04/2015] [Accepted: 08/12/2015] [Indexed: 12/11/2022]
Abstract
OBJECTIVE To investigate the efficacy of recombinant human soluble thrombomodulin (rTM) in preventing the development of walled-off necrosis (WON) in severe acute pancreatitis (SAP) patients. METHODS We retrospectively analyzed 54 SAP patients divided into two groups: SAP patients treated by rTM (rTM group, 24 patients) and not treated by rTM (control group, 30 patients). rTM was administered to patients with disseminated intravascular coagulation (DIC). Initially, on the admission day, we recorded patient severity and pancreatic necrosis/ischemia positive or negative. Then we investigated development of WON using 4 weeks later CT/MRI. Finally we compared the proportions of patients developing WON in the rTM group and the control group. RESULTS On the admission day, the condition of patients treated by rTM was significantly worse than patients in the control group; rTM group vs. CONTROL 71.8 ± 13.9 vs. 59.8 ± 15.3 years for age, 10.7 ± 3.5 vs. 8.0 ± 4.4 for Acute Physiology and Chronic Health Evaluation II (APACHE II) score, and 3.3 ± 1.8 vs. 2.2 ± 1.8 for sequential organ failure assessment (SOFA) score (p < 0.05). We found no significant differences on the admission day in rate of pancreatic necrosis/ischemia between patients treated by rTM and controls (58.3% vs. 63.3%, p = 0.71). Nevertheless, the proportion of patients developing WON was significantly lower among those administered rTM than in those not administered rTM {29.2% (7/24 patients) vs. 56.7% (17/30 patients), p < 0.05}. CONCLUSION Treatment of SAP patients treated by rTM may prevent progression from pancreatic necrosis/ischemia to WON.
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Affiliation(s)
- Takaaki Eguchi
- Department of Gastroenterology and Hepatology, Osaka Saiseikai Nakatsu Hospital, 2-10-39 Shibata Kitaku, Osaka 530-0012, Japan
| | - Yoshihisa Tsuji
- Department of Gastroenterology and Hepatology, Kyoto University Graduate School of Medicine, Kawaramachi 54, Shogoin, Sakyo-ku, Kyoto 606-8507, Japan
| | - Hiroshi Yamashita
- Department of Gastroenterology and Hepatology, Osaka Saiseikai Nakatsu Hospital, 2-10-39 Shibata Kitaku, Osaka 530-0012, Japan
| | - Takumi Fukuchi
- Department of Gastroenterology and Hepatology, Osaka Saiseikai Nakatsu Hospital, 2-10-39 Shibata Kitaku, Osaka 530-0012, Japan
| | - Atsushi Kanamori
- Department of Gastroenterology and Hepatology, Osaka Saiseikai Nakatsu Hospital, 2-10-39 Shibata Kitaku, Osaka 530-0012, Japan
| | - Kei Matsumoto
- Department of Gastroenterology and Hepatology, Osaka Saiseikai Nakatsu Hospital, 2-10-39 Shibata Kitaku, Osaka 530-0012, Japan
| | - Takashi Hasegawa
- Department of Gastroenterology and Hepatology, Osaka Saiseikai Nakatsu Hospital, 2-10-39 Shibata Kitaku, Osaka 530-0012, Japan
| | - Akio Koizumi
- Department of Gastroenterology and Hepatology, Osaka Saiseikai Nakatsu Hospital, 2-10-39 Shibata Kitaku, Osaka 530-0012, Japan
| | - Ryuki Kitada
- Department of Gastroenterology and Hepatology, Osaka Saiseikai Nakatsu Hospital, 2-10-39 Shibata Kitaku, Osaka 530-0012, Japan
| | - Masahiro Tsujimae
- Department of Gastroenterology and Hepatology, Osaka Saiseikai Nakatsu Hospital, 2-10-39 Shibata Kitaku, Osaka 530-0012, Japan
| | - Taro Iwatsubo
- Department of Gastroenterology and Hepatology, Osaka Saiseikai Nakatsu Hospital, 2-10-39 Shibata Kitaku, Osaka 530-0012, Japan
| | - Shintaro Koyama
- Department of Gastroenterology and Hepatology, Osaka Saiseikai Nakatsu Hospital, 2-10-39 Shibata Kitaku, Osaka 530-0012, Japan
| | - Satoshi Ubukata
- Department of Gastroenterology and Hepatology, Osaka Saiseikai Nakatsu Hospital, 2-10-39 Shibata Kitaku, Osaka 530-0012, Japan
| | - Mikio Fujita
- Department of Gastroenterology and Hepatology, Osaka Saiseikai Nakatsu Hospital, 2-10-39 Shibata Kitaku, Osaka 530-0012, Japan
| | - Akihiko Okada
- Department of Gastroenterology and Hepatology, Osaka Saiseikai Nakatsu Hospital, 2-10-39 Shibata Kitaku, Osaka 530-0012, Japan.
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Khreiss M, Zenati M, Clifford A, Lee KK, Hogg ME, Slivka A, Chennat J, Gelrud A, Zeh HJ, Papachristou GI, Zureikat AH. Cyst Gastrostomy and Necrosectomy for the Management of Sterile Walled-Off Pancreatic Necrosis: a Comparison of Minimally Invasive Surgical and Endoscopic Outcomes at a High-Volume Pancreatic Center. J Gastrointest Surg 2015; 19:1441-8. [PMID: 26033038 DOI: 10.1007/s11605-015-2864-6] [Citation(s) in RCA: 27] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/13/2015] [Accepted: 05/25/2015] [Indexed: 01/31/2023]
Abstract
INTRODUCTION Walled-off pancreatic necrosis (WON) is a sequela of acute necrotizing pancreatitis in 15-40% of cases. We sought to compare the outcomes of minimally invasive surgical and endoscopic cyst gastrostomy (CG) and necrosectomy for the management for sterile WON at a tertiary care high-volume pancreas center. METHOD This is a retrospective review of patients who underwent minimally invasive surgical or endoscopic CG and necrosectomy for clinically sterile WON between 2008 and 2013. Peri-procedural outcomes including costs were analyzed and compared. RESULTS Twenty patients underwent minimally invasive surgical (robotic = 14, laparoscopic = 6) CG and necrosectomy, and 20 patients underwent endoscopic treatment. The surgical cohort had a larger median cyst size and higher CCI score. For the surgical cohort, median OR time was 167.5 min, estimated blood loss was 30 ml, and 65% underwent concomitant cholecystectomy. There was no mortality in either group and no difference in complication rates (20%). The failure rate was similar (15 versus 10%, P = 0.66). Although surgery was associated with a lower re-intervention rate (0 versus 1, P = 0.008), the endotherapy group was associated with shorter total LOS (inclusive of re-interventions) (7 versus 3 days, P = 0.032). The cost of the index procedure was significantly higher for the surgery group (P = 0.014); however, when considering all readmissions and re-interventions until resolution of the WON, the total cost was similar for both groups. CONCLUSION Minimally invasive surgical and endoscopic CG and necrosectomy are comparable treatments for sterile WON in terms of outcomes and overall cost. The surgical approach may be considered advantageous when a concomitant cholecystectomy is required.
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Affiliation(s)
- Mohammad Khreiss
- Department of Surgery, School of Medicine, University of Pittsburgh, Pittsburgh, PA, USA
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31
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Pezzilli R, Zerbi A, Campra D, Capurso G, Golfieri R, Arcidiacono PG, Billi P, Butturini G, Calculli L, Cannizzaro R, Carrara S, Crippa S, De Gaudio R, De Rai P, Frulloni L, Mazza E, Mutignani M, Pagano N, Rabitti P, Balzano G. Consensus guidelines on severe acute pancreatitis. Dig Liver Dis 2015; 47:532-43. [PMID: 25921277 DOI: 10.1016/j.dld.2015.03.022] [Citation(s) in RCA: 95] [Impact Index Per Article: 10.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/02/2015] [Revised: 03/17/2015] [Accepted: 03/24/2015] [Indexed: 02/07/2023]
Abstract
This Position Paper contains clinically oriented guidelines by the Italian Association for the Study of the Pancreas (AISP) for the diagnosis and treatment of severe acute pancreatitis. The statements were formulated by three working groups of experts who searched and analysed the most recent literature; a consensus process was then performed using a modified Delphi procedure. The statements provide recommendations on the most appropriate definition of the complications of severe acute pancreatitis, the diagnostic approach and the timing of conservative as well as interventional endoscopic, radiological and surgical treatments.
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Smith IB, Gutierrez JP, Ramesh J, Wilcox CM, Mönkemüller KE. Endoscopic extra-cavitary drainage of pancreatic necrosis with fully covered self-expanding metal stents (fcSEMS) and staged lavage with a high-flow water jet system. Endosc Int Open 2015; 3:E154-60. [PMID: 26135660 PMCID: PMC4477029 DOI: 10.1055/s-0034-1391481] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/22/2014] [Accepted: 07/07/2014] [Indexed: 01/06/2023] Open
Abstract
AIM To present a novel, less-invasive method of endoscopic drainage (ED) for walled-off pancreatic necrosis (WON).We describe the feasibility, success rate, and complications of combined ED extra-cavitary lavage and debridement of WON using a biliary catheter and high-flow water jet system (water pump). PATIENTS AND METHODS Endoscopic ultrasound (EUS)-guided drainage was performed with insertion of two 7-Fr, 4-cm double pigtail stents. Subsequently a fully covered self-expanding metal stent (fcSEMS) was placed. The key aspect of the debridement was the insertion of a 5-Fr biliary catheter through or along the fcSEMS into the cavity, with ensuing saline lavage using a high-flow water jet system. The patients were then brought back for repeated, planned endoscopic lavages of the WON. No endoscopic intra-cavitary exploration was performed. RESULTS A total of 17 patients (15 men, 2 women; mean age 52.6, range 24 - 69; mean American Society of Anesthesiologists [ASA] score of 3) underwent ED of WON with this new method. The mean initial WON diameter was 9.5 cm, range 8 to 26 cm. The total number of ED was 84, range 2 to 13. The mean stenting period was 42.5 days. The mean follow-up was 51 days, range 3 to 370. A resolution of the WON was achieved in 14 patients (82.3 %). There were no major complications associated with this method. CONCLUSION ED of complex WON with fcSEMS followed by repeated endoscopic extra-cavitary lavage and debridement using a biliary catheter and high-flow water jet system is a minimally invasive, feasible method with high technical and clinical success and minimal complications.
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Affiliation(s)
- Ioana B. Smith
- Department of Gastroenterology, University of Alabama at Birmingham, Birmingham, AL, USA,Division of Internal Medicine, University of Alabama at Birmingham, Birmingham, AL, USA
| | - Juan P. Gutierrez
- Department of Gastroenterology, University of Alabama at Birmingham, Birmingham, AL, USA
| | - Jayapal Ramesh
- Department of Gastroenterology, University of Alabama at Birmingham, Birmingham, AL, USA
| | - C. Mel Wilcox
- Department of Gastroenterology, University of Alabama at Birmingham, Birmingham, AL, USA
| | - Klaus E. Mönkemüller
- Department of Gastroenterology, University of Alabama at Birmingham, Birmingham, AL, USA,Corresponding author Klaus E. Mönkemüller, MD, PhD Department of GastroenterologyUniversity of Alabama at BirminghamBDB 3891808 7th Ave. SBirmingham, AL 35294USA+1-205-934-1578
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Surgical transgastric debridement of walled off pancreatic necrosis: an option for patients with necrotizing pancreatitis. Surg Endosc 2014; 29:575-82. [DOI: 10.1007/s00464-014-3700-x] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/25/2014] [Accepted: 06/22/2014] [Indexed: 12/15/2022]
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Abstract
Magnetic resonance (MR) imaging of the pancreas is useful as both a problem-solving tool and an initial imaging examination of choice. With newer imaging sequences such as diffusion-weighted imaging, MR offers improved ability to detect and characterize lesions and identify and stage tumors and inflammation. MR cholangiopancreatography can be used to visualize the pancreatic and biliary ductal system. In this article, the use of MR to evaluate the pancreas, including recent advances, is reviewed and the normal appearance of the pancreas on different imaging sequences, as well as inflammatory diseases, congenital abnormalities, and neoplasms of the pancreas, are discussed.
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Affiliation(s)
- Erin O'Neill
- Department of Radiology, Feinberg School of Medicine, Northwestern Memorial Hospital, Northwestern University, 676 North Saint Clair Street, Suite 800, Chicago, IL 60611, USA
| | - Nancy Hammond
- Department of Radiology, Feinberg School of Medicine, Northwestern Memorial Hospital, Northwestern University, 676 North Saint Clair Street, Suite 800, Chicago, IL 60611, USA
| | - Frank H Miller
- Department of Radiology, Feinberg School of Medicine, Northwestern Memorial Hospital, Northwestern University, 676 North Saint Clair Street, Suite 800, Chicago, IL 60611, USA.
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Simo KA, Niemeyer DJ, Swan RZ, Sindram D, Martinie JB, Iannitti DA. Laparoscopic transgastric endolumenal cystogastrostomy and pancreatic debridement. Surg Endosc 2014; 28:1465-72. [PMID: 24671349 DOI: 10.1007/s00464-013-3317-5] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/09/2013] [Accepted: 11/05/2013] [Indexed: 01/03/2023]
Abstract
BACKGROUND Cystogastrostomy is commonly performed for internal drainage of pancreatic pseudocysts (PP) and concomitant debridement of walled-off pancreatic necrosis (WOPN). While an open approach to cystogastrostomy is well established, an optimal minimally invasive technique continues to evolve. This laparoscopic transgastric endolumenal cystogastrostomy presented here allows for a large cystogastrostomy with complete debridement of necrosis and internal drainage through a minimally invasive approach. METHODS We performed a retrospective review of 22 patients with symptomatic PP/WOPN treated with attempted laparoscopic transgastric endolumenal cystogastrostomy (Lap-TEC) and pancreatic debridement. Short- and long-term outcomes were assessed. RESULTS From November 2006 to March 2013, a total of 22 Lap-TEC/pancreatic debridement procedures were attempted; 15 were completed laparoscopically. The median age of the cohort was 49.5 ± 12 years (range = 18-71), average body mass index = 29.1 kg/m(2), 77 % had an ASA score ≥ 3, and 10 were female. Gallstones were the most common etiology (50 %), and median time between initial presentation and surgery was 86 days (range = 0-360). Median operative time and estimated blood loss were 213 min and 100 cc, respectively. Forty-one percent of the patients were admitted to the ICU postoperatively and the average length of stay was 14 days (range = 4-50). Median follow-up was 2 months (range = 0-62.5), with one patient having a procedure-related complication. No other reoperations, late complications, or mortalities occurred. All patients had resolution of their symptoms and fluid collections. CONCLUSION This technique of internal drainage via Lap-TEC and pancreatic debridement has been successful in achieving primary drainage and relieving symptoms of PP/WOPN with no mortality and minimal morbidity.
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Affiliation(s)
- Kerri A Simo
- Section of Hepatobiliary and Pancreas Surgery, Department of General Surgery, Carolinas Medical Center, Charlotte, NC, USA
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ISAJI S, TANEMURA A, AZUMI Y. Concept and definition of walled-off necrosis (WON) in acute pancreatitis. ACTA ACUST UNITED AC 2014. [DOI: 10.2958/suizo.29.202] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
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Brown C, Kang L, Kim ST. Percutaneous drainage of abdominal and pelvic abscesses in children. Semin Intervent Radiol 2013; 29:286-94. [PMID: 24293801 DOI: 10.1055/s-0032-1330062] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
It has only been in the last several decades that abscesses within deep compartments, particularly within the abdomen and pelvis, have become safely accessible with imaging guidance. Since that time, percutaneous abscess drainage has become the standard of care in children. We review the clinical features, diagnosis, and image-guided management of abdominal and pelvic abscesses in children.
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Affiliation(s)
- Colin Brown
- Department of Radiology, University of Chicago, Chicago, Illinois
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Transluminal retroperitoneal endoscopic necrosectomy with the use of hydrogen peroxide and without external irrigation: a novel approach for the treatment of walled-off pancreatic necrosis. Surg Endosc 2013; 27:3911-20. [DOI: 10.1007/s00464-013-2948-x] [Citation(s) in RCA: 37] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/12/2012] [Accepted: 03/20/2013] [Indexed: 12/20/2022]
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40
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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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A case of video-assisted retroperitoneal debridement in a patient with HELLP syndrome. Surg Laparosc Endosc Percutan Tech 2012; 22:e152-4. [PMID: 22678339 DOI: 10.1097/sle.0b013e318248f92b] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
Hemolysis, elevated liver enzymes, low platelet count (HELLP) syndrome describes a cohort of disease processes that may have devastating consequences for the peripartum patient. Although the hemopoetic and hepatic systems are classically involved, we illustrate a case of walled-off pancreatic necrosis occurring in a woman with HELLP syndrome. Initially managed with resuscitation, steroids, and plasmapheresis, the patient developed necrotizing pancreatitis that overtime became walled-off. Despite attempts at percutaneous drainage, the patient ultimately had a video-assisted retroperitoneal debridement. As there are no descriptions in the literature of walled-off pancreatic necrosis stemming from HELLP syndrome, this case provides a new avenue from which to study the pathophysiology and provides a management strategy for this problem.
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Denzer UW, Rösch T. Endoskopische Drainage von Pankreaspseudozysten. Visc Med 2012. [DOI: 10.1159/000345922] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022] Open
Abstract
<b><i>Hintergrund: </i></b>Die Pankreaspseudozyste ist eine häufige Komplikation der akuten oder chronischen Pankreatitis. Bei symptomatischer Zyste mit Vorliegen von abdominellen Schmerzen, einer Magenausgangsstenose, Gewichtsverlust, Ikterus, Infektion oder Größenzunahme stellt die endoskopische Drainage (transpapillär und/ oder transmural) eine effektive Erstlinientherapie dar. <b><i>Methode: </i></b>Die Übersicht basiert auf einer strukturierten Analyse der aktuellen, in Pubmed gelisteten Studien. <b><i>Ergebnisse: </i></b>Die Langzeitregressionsraten liegen bei 71–90%; die Komplikationsrate beträgt 3–35% mit einer geringen Mortalität von 0–1%. Die wesentlichen Komplikationen der endoskopischen Pseudozystendrainage sind Blutungen in bis zu 9%, Infektionen in bis zu 8%, retroperitoneale Perforation in bis zu 5% und Zystenrekurrenz in bis zu 14% der Fälle. Differenziert zu betrachten sind die infizierte Nekrose und der Pankreasabszess (walled-off necrosis) nach akuter Pankreatitis. In diesen Fällen ist die endoskopische Therapie technisch komplexer und im Vergleich zur unkomplizierten Pankreaspseudozyste mit höherer Morbidität und geringerem Langzeitansprechen verbunden. Dennoch stellt die endoskopische Drainage bei technischer Machbarkeit für beide Entitäten die Methode der ersten Wahl dar. Dies basiert insbesondere auf der nach aktuellen Daten geringeren Morbidität der Methode im Vergleich zu chirurgischen Drainageverfahren. <b><i>Schlussfolgerung: </i></b>Der vorliegende Review gibt einen Überblick über Therapieindikation und Differenzialdiagnose von Pankreaspseudozysten, erläutert die Drainagetechniken und stellt die Daten zu Effektivität und Komplikationen der endoskopischen Zystendrainage umfassend dar.
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Abstract
Acute pancreatitis is a common cause of hospitalization and a major source of morbidity worldwide. When it is severe, and especially when it progresses to include necrosis of the pancreas, the risk of infection rises and mortality increases. Early reports suggested prophylactic antibiotics given in severe pancreatitis prevent infection and death. More recent clinical trials do not support this benefit, and meta-analyses on the topic offer conflicting recommendations. In this article, we evaluate the body of published literature examining the use of antibiotics as a preventive measure in acute pancreatitis. The highest quality, currently available data fail to support prophylactic use of antibiotics, which should be added to treatment regimens only where infection has been proven.
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Abstract
The ultimate reason why pancreatologists have strived to establish definitions for inflammatory pathologies of the pancreas is to improve patient care. Although the Atlanta Classification has been used for around for 17 years, considerable misunderstanding of the key elements of the nomenclature still persists. While a recent article by Stamatakos et al aimed to deal with an entity not clearly defined in the 1993 document, it is replete with factual and conceptual errors as well as contradictory statements.
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