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Bomman S, Sanders D, Coy D, La Selva D, Pham Q, Zehr T, Law J, Larsen M, Irani S, Kozarek RA, Ross A, Krishnamoorthi R. Safety and clinical outcomes of early dual modality drainage (< 28 days) compared to later drainage of pancreatic necrotic fluid collections: a propensity score-matched study. Surg Endosc 2023; 37:902-911. [PMID: 36038648 DOI: 10.1007/s00464-022-09561-8] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/06/2021] [Accepted: 08/12/2022] [Indexed: 11/29/2022]
Abstract
BACKGROUND Necrotizing pancreatitis can be complicated by Necrotic Fluid Collections (NFC). Guidelines recommend waiting for 4 weeks from the onset of acute pancreatitis (AP) before considering endoscopic drainage. We aimed to compare outcomes and safety in patients undergoing early versus late drainage of NFC. METHODS We performed a retrospective review of all patients who underwent Dual Modality Drainage (DMD) [combined endoscopic and percutaneous drainage] for NFC from January 2007 to December 2020. Patients were stratified into the "early" group (DMD < 28 days from AP onset) and were matched to "late" (DMD ≥ 28 days) drainage group using propensity- core-matching. Primary outcomes of interest were technical success and adverse events. Secondary outcomes included clinical success, late complication rates, and mortality. RESULTS We identified 278 patients who underwent DMD for NFC. Thirty-nine belonged to the early group and were matched to 174 patients from the late group. Technical success was similar in both early and late groups (97.4% vs 99.4%: P = 0.244) as were the procedural and early post-procedural (< 14 days) adverse events rates (23.1% vs 27.6%: P = 0.565). Clinical success (92.3% vs 93.1%; P = 0.861) and late complication rates (23.1% vs 31.6%; P = 0.294) were similar. There were 2 deaths (5.7%) in the early vs. 9 (5.2%) in the late group, P = 0.991. CONCLUSIONS When performed in a tertiary care center with expertise in therapeutic endoscopic ultrasound, early drainage of NFC appears to be feasible and safe. Further studies are needed to validate our results.
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Affiliation(s)
- Shivanand Bomman
- Center for Digestive Health, Virginia Mason Franciscan Health, 1100, 9th Avenue, Mail stop: C3-GAS, Seattle, WA, 98101, USA
| | - David Sanders
- Center for Digestive Health, Virginia Mason Franciscan Health, 1100, 9th Avenue, Mail stop: C3-GAS, Seattle, WA, 98101, USA
| | - David Coy
- Center for Digestive Health, Virginia Mason Franciscan Health, 1100, 9th Avenue, Mail stop: C3-GAS, Seattle, WA, 98101, USA
| | - Danielle La Selva
- Center for Digestive Health, Virginia Mason Franciscan Health, 1100, 9th Avenue, Mail stop: C3-GAS, Seattle, WA, 98101, USA
| | - Quincy Pham
- Center for Digestive Health, Virginia Mason Franciscan Health, 1100, 9th Avenue, Mail stop: C3-GAS, Seattle, WA, 98101, USA
| | - Troy Zehr
- Center for Digestive Health, Virginia Mason Franciscan Health, 1100, 9th Avenue, Mail stop: C3-GAS, Seattle, WA, 98101, USA
| | - Joanna Law
- Center for Digestive Health, Virginia Mason Franciscan Health, 1100, 9th Avenue, Mail stop: C3-GAS, Seattle, WA, 98101, USA
| | - Michael Larsen
- Center for Digestive Health, Virginia Mason Franciscan Health, 1100, 9th Avenue, Mail stop: C3-GAS, Seattle, WA, 98101, USA
| | - Shayan Irani
- Center for Digestive Health, Virginia Mason Franciscan Health, 1100, 9th Avenue, Mail stop: C3-GAS, Seattle, WA, 98101, USA
| | - Richard A Kozarek
- Center for Digestive Health, Virginia Mason Franciscan Health, 1100, 9th Avenue, Mail stop: C3-GAS, Seattle, WA, 98101, USA
| | - Andrew Ross
- Center for Digestive Health, Virginia Mason Franciscan Health, 1100, 9th Avenue, Mail stop: C3-GAS, Seattle, WA, 98101, USA
| | - Rajesh Krishnamoorthi
- Center for Digestive Health, Virginia Mason Franciscan Health, 1100, 9th Avenue, Mail stop: C3-GAS, Seattle, WA, 98101, USA.
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Gao L, Zhang H, Li G, Ye B, Zhou J, Tong Z, Ke L, Windsor JA, Li W. The clinical outcome from early versus delayed minimally invasive intervention for infected pancreatic necrosis: a systematic review and meta-analysis. J Gastroenterol 2022; 57:397-406. [PMID: 35488104 DOI: 10.1007/s00535-022-01876-6] [Citation(s) in RCA: 12] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/17/2022] [Accepted: 04/20/2022] [Indexed: 02/04/2023]
Abstract
BACKGROUND While the management of infected pancreatic necrosis (IPN) has evolved in the last two decades with the adoption of minimally invasive interventions (drainage ± debridement), it is unknown whether the principle of delaying intervention inherited from the open surgery era still applies. The aim of the current study was to investigate the impact of the timing of minimally invasive intervention on the outcomes of patients with IPN requiring intervention. METHODS PubMed, Embase, MEDLINE and Web of Science databases were searched for appropriate studies. The primary outcome of interest was hospital mortality, the secondary outcomes were the incidence of complications during the hospitalization, including new-onset organ failure, gastrointestinal fistula or perforation, bleeding and length of hospital or intensive care unit (ICU) stay. RESULTS Seven clinical studies were included with a total of 742 patients with IPN requiring intervention, of whom 321 received early intervention and 421 delayed intervention. Results from the meta-analysis showed that early minimally invasive intervention did not increase hospital mortality (odds ratio 1.65, 95% confidence interval 0.97-2.81; p = 0.06) but was associated with a remarkably prolonged hospital stay and an increased incidence of gastrointestinal fistula or perforation when compared with delayed intervention. CONCLUSIONS Although no firm conclusion can be drawn because of the quality of available studies, it does appear that timing of intervention is a risk factor for adverse outcomes and ought to be investigated more rigorously in prospective studies.
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Affiliation(s)
- Lin Gao
- Center of Severe Acute Pancreatitis (CSAP), Department of Critical Care Medicine, Jinling Hospital, Medical School of Nanjing University, Nanjing, Jiangsu, China
| | - He Zhang
- Center of Severe Acute Pancreatitis (CSAP), Department of Critical Care Medicine, Jinling Hospital, Medical School of Nanjing University, Nanjing, Jiangsu, China
| | - Gang Li
- Center of Severe Acute Pancreatitis (CSAP), Department of Critical Care Medicine, Jinling Hospital, Medical School of Nanjing University, Nanjing, Jiangsu, China
| | - Bo Ye
- Center of Severe Acute Pancreatitis (CSAP), Department of Critical Care Medicine, Jinling Hospital, Medical School of Nanjing University, Nanjing, Jiangsu, China
| | - Jing Zhou
- Center of Severe Acute Pancreatitis (CSAP), Department of Critical Care Medicine, Jinling Hospital, Medical School of Nanjing University, Nanjing, Jiangsu, China
| | - Zhihui Tong
- Center of Severe Acute Pancreatitis (CSAP), Department of Critical Care Medicine, Jinling Hospital, Medical School of Nanjing University, Nanjing, Jiangsu, China
| | - Lu Ke
- Center of Severe Acute Pancreatitis (CSAP), Department of Critical Care Medicine, Jinling Hospital, Medical School of Nanjing University, Nanjing, Jiangsu, China. .,National Institute of Healthcare Data Science, Nanjing University, Nanjing, 210010, Jiangsu, China.
| | - John A Windsor
- Surgical and Translational Research Centre, Faculty of Medical and Health Sciences, School of Medicine, University of Auckland, Auckland, New Zealand
| | - Weiqin Li
- Center of Severe Acute Pancreatitis (CSAP), Department of Critical Care Medicine, Jinling Hospital, Medical School of Nanjing University, Nanjing, Jiangsu, China. .,National Institute of Healthcare Data Science, Nanjing University, Nanjing, 210010, Jiangsu, China.
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Planz V, Galgano SJ. Percutaneous biopsy and drainage of the pancreas. Abdom Radiol (NY) 2022; 47:2584-2603. [PMID: 34410433 PMCID: PMC8375282 DOI: 10.1007/s00261-021-03244-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/28/2021] [Revised: 08/05/2021] [Accepted: 08/07/2021] [Indexed: 01/18/2023]
Abstract
Percutaneous pancreatic interventions performed by abdominal radiologists play important diagnostic and therapeutic roles in the management of a wide range of pancreatic pathology. While often performed with endoscopy, pancreatic mass biopsy obtained via a percutaneous approach may serve as the only feasible option for diagnosis in patients with post-surgical anatomy, severe cardiopulmonary conditions, or prior non-diagnostic endoscopic attempts. Biopsy of pancreatic transplants are commonly performed percutaneously due to inaccessible location of the allograft by endoscopy, usually in the right lower quadrant or pelvis. Percutaneous drainage of collections in acute pancreatitis is primarily indicated for infection with clinical deterioration and may be performed alone or in combination with endoscopic drainage. Post-surgical pancreatic collections related to pancreatic duct fistula or leak also often warrant therapeutic percutaneous drainage. Knowledge of appropriate indications, strategies of approach, technique, and complications associated with these procedures is critical for a successful clinical practice.
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Affiliation(s)
- Virginia Planz
- Department of Radiology, Vanderbilt University Medical Center, Nashville, TN USA
| | - Samuel J. Galgano
- Department of Radiology, University of Alabama at Birmingham, 619 19th St S, JT J779, Birmingham, AL 35249 USA
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Albers D, Meining A, Hann A, Ayoub YK, Schumacher B. Direct endoscopic necrosectomy in infected pancreatic necrosis using lumen-apposing metal stents: Early intervention does not compromise outcome. Endosc Int Open 2021; 9:E490-E495. [PMID: 33655055 PMCID: PMC7899788 DOI: 10.1055/a-1341-0654] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/17/2020] [Accepted: 11/23/2020] [Indexed: 12/12/2022] Open
Abstract
Background and study aims Infection of pancreatic necrosis is a dreaded complication requiring an intervention. Nevertheless, the optimal timing of the first intervention is unclear, and consensus data are sparse. This retrospective two-center study evaluated direct endoscopic necrosectomy using lumen apposing metal stents in case of proven or suspected infected pancreatic necrosis in an early stage of the disease. Patients and methods Forty-nine patients with infected pancreatic necrosis were included. Sequent direct endoscopic necrosectomies after lumen apposing metal stent insertion (LAMS) were performed until the resolution of necrosis. In all patients, the first endoscopic intervention was performed within the first 30 days after first proof of pancreatic necrosis. Primary outcome parameters were inflammatory activity, days spent in the Intensive Care Unit (ICU), and mortality. Results The patient cohort received median 4 necrosectomies (3-5) after a median of 7 days (3-11) after first proof of pancreatic necrosis. Technical and clinical success were achieved in 98.3 % and 87.8 %, respectively; the mortality rate was 8.2 %. The median C-reactive protein level decreased from 241 mg/L (182.9-288.9) before the intervention to a median of 23.3 mg/L (18-60) after therapy. The median time period in the ICU was 5 days (3-9). Conclusions Early endoscopic therapy in the form of direct endoscopic necrosectomy after LAMS placement within the first 30 days after proof of pancreatic necrosis is effective and does not result in poor outcome. Our retrospective data suggest that early intervention before walled-off necrosis is formed is tenable when it is essential due to the patient's clinical deterioration.
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Affiliation(s)
- David Albers
- Department of Gastroenterology, Elisabeth-Krankenhaus Essen, academic hospital of the University of Duisburg-Essen, Germany
| | - Alexander Meining
- Department of Gastroenterology, University Hospital Wuerzburg, Germany
| | - Alexander Hann
- Department of Gastroenterology, University Hospital Wuerzburg, Germany
| | | | - Brigitte Schumacher
- Department of Gastroenterology, Elisabeth-Krankenhaus Essen, academic hospital of the University of Duisburg-Essen, Germany
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Occurrence and Risk Factors of Infected Pancreatic Necrosis in Intensive Care Unit-Treated Patients with Necrotizing Severe Acute Pancreatitis. J Gastrointest Surg 2021; 25:2289-2298. [PMID: 33987740 PMCID: PMC8118108 DOI: 10.1007/s11605-021-05033-x] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/11/2021] [Accepted: 04/28/2021] [Indexed: 01/31/2023]
Abstract
BACKGROUND In patients with severe acute pancreatitis (SAP), infected pancreatic necrosis (IPN) is associated with a worsened outcome. We studied risk factors and consequences of IPN in patients with necrotizing SAP. METHODS The study consisted of a retrospective cohort of 163 consecutive patients treated for necrotizing SAP at a university hospital intensive care unit (ICU) between 2010 and 2018. RESULTS All patients had experienced at least one persistent organ failure and approximately 60% had multiple organ failure within the first 24 h from admission to the ICU. Forty-seven (28.8%) patients had IPN within 90 days. Independent risk factors for IPN were more extensive anatomical spread of necrotic collections (unilateral paracolic or retromesenteric (OR 5.7, 95% CI 1.5-21.1) and widespread (OR 21.8, 95% CI 6.1-77.8)) compared to local collections around the pancreas, postinterventional pancreatitis (OR 13.5, 95% CI 2.4-76.5), preceding bacteremia (OR 4.8, 95% CI 1.3-17.6), and preceding open abdomen treatment for abdominal compartment syndrome (OR 3.6, 95% CI 1.4-9.3). Patients with IPN had longer ICU and overall hospital lengths of stay, higher risk for necrosectomy, and higher readmission rate to ICU. CONCLUSIONS Wide anatomical spread of necrotic collections, postinterventional etiology, preceding bacteremia, and preceding open abdomen treatment were identified as independent risk factors for IPN.
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PGC-1α expression is increased in leukocytes in experimental acute pancreatitis. Inflammation 2015; 37:1231-9. [PMID: 24562467 DOI: 10.1007/s10753-014-9850-0] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/20/2023]
Abstract
Severe acute pancreatitis (AP) induces a systemic inflammatory disease that is responsible for high mortality rates, particularly when it is complicated by infection. Therefore, differentiating sepsis from the systemic inflammation caused by AP is a serious clinical challenge. Considering the high metabolic rates of leukocytes in response to stress induced by infection, we hypothesized that the transcription coactivator peroxisome proliferator-activated receptor gamma coactivator 1 (PGC-1α), a master regulator of mitochondrial biogenesis and function, would be distinctly expressed during inflammation or infection and, therefore, could constitute a useful marker to differentiate between these two conditions. Rats were subjected to injection of taurocholate into the main pancreatic duct, which caused a severe AP with high amylase levels and white blood cell counts. In these animals, a marked increase in PGC-1α mRNA levels in circulating leukocytes was observed 48 h after the surgical procedure, a time when bacteremia is present. Antibiotic treatment abolished PGC-1α up-regulation. Moreover, PGC-1α expression was higher in peritoneal macrophages from animals subjected to a bacterial insult (cecal ligation and puncture) than in animals with AP. In isolated macrophages, we also observed that PGC-1α expression is more prominent in the presence of a phagocytic stimulus (zymosan) when compared to lipopolysaccharide-induced aseptic inflammation. Moreover, abolishing PGC-1α expression with antisense oligos impaired zymosan phagocytosis. Together, these findings suggest that PGC-1α is differentially expressed during aseptic inflammation and infection and that it is necessary for adequate phagocytosis. These results could be useful in developing new tests for differentiating infection from inflammation for clinical purposes in patients with AP.
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Mao L, Qiu Y. The classification of acute pancreatitis: Current status. Intractable Rare Dis Res 2012; 1:134-7. [PMID: 25343085 PMCID: PMC4204601 DOI: 10.5582/irdr.v1.3.134] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/19/2012] [Revised: 08/24/2012] [Accepted: 08/25/2012] [Indexed: 12/22/2022] Open
Abstract
The Atlanta Classification of acute pancreatitis (AP) is widely accepted and has been used by physicians and radiologists since 1992. However, advances in knowledge of the disease process, improved imaging, and ever-changing treatment options have rendered some of its definitions ambiguous and highlighted the inadequacy of its classification of severity. This review discusses revision of the Atlanta Classification (2008) and it describes a new determinant-based classification (2012). In contrast to the Atlanta Classification, the revised version and new classification are based on evidence but still need to be developed through systematic review of new data and further international consultation.
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Affiliation(s)
- Liang Mao
- Department of Hepatobiliary Surgery, the Affiliated Drum Tower Hospital of Nanjing University Medical School, Nanjing, Jiangsu, China
| | - Yudong Qiu
- Department of Hepatobiliary Surgery, the Affiliated Drum Tower Hospital of Nanjing University Medical School, Nanjing, Jiangsu, China
- Address correspondence to: Dr. Yudong Qiu, Department of Hepatobiliary Surgery, the Affiliated Drum Tower Hospital of Nanjing University Medical School, 321 Zhongshan Road, Gulou (Drum Tower) District, Nanjing, Jiangsu 210008, China. E-mail:
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