Minimally invasive procedures in severe acute pancreatitis treatment - assessment of benefits and possibilities of use

Minimally invasive surgery compared to endoscopic intervention for treating infected pancreatic necrosis. A meta-analysis

Introduction

The current study aimed to compare the outcomes of endoscopic and minimally invasive surgical treatment for infected necrotizing pancreatitis.

Material and methods

A meta-analysis of clinical studies on minimally invasive operations for necrotic infection was conducted. A systematic review and study inclusion were done on multiple databases. English-language prospective comparison studies were included. Random design was used to analyze research with continuous and dichotomous variables.

Results

Ten studies were included in the current study. When compared to minimally invasive surgery, endoscopic procedures showed significant beneficial outcomes regarding low post-operative complication rates (p = 0.006), new onset organ failure (p < 0.001), and pancreatic fistula (p < 0.001). However, there was no significant difference between the two interventions regarding hospital stay, postoperative bleeding, incisional hernia, endocrine insufficiency, and perforation of a visceral organ.

Conclusions

Endoscopic therapy appears to have potential advantages over minimally invasive surgery. However, there is no difference between interventions regarding several parameters.

Interventional strategies in infected necrotizing pancreatitis: Indications, timing, and outcomes

Acute pancreatitis (AP) is one of the most common gastrointestinal diseases and remains a life-threatening condition. Although AP resolves to restitutio ad integrum in approximately 80% of patients, it can progress to necrotizing pancreatitis (NP). NP is associated with superinfection in a third of patients, leading to an increase in mortality rate of up to 40%. Accurate and early diagnosis of NP and associated complications, as well as state-of-the-art therapy are essential to improve patient prognoses. The emerging role of endoscopy and recent trials on multidisciplinary management of NP established the “step-up approach”. This approach starts with endoscopic interventions and can be escalated to other interventional and ultimately surgical procedures if required. Studies showed that this approach decreases the incidence of new multiple-organ failure as well as the risk of interventional complications. However, the optimal interventional sequence and timing of interventional procedures remain controversial. This review aims to summarize the indications, timing, and treatment outcomes for infected NP and to provide guidance on multidisciplinary decision-making.

Percutaneous Endoscopic Necrosectomy-A Review of the Literature

In this article, an attempt was made to clarify the role of percutaneous endoscopic necrosectomy (PEN) in the interventional treatment of pancreatic necrosis. A comprehensive review of the current literature was performed to identify publications on the role of PEN in patients with consequences of acute necrotizng pancreatitis. The aim of the study was to review the literature on minimal invasive necrosectomy, with emphasis on PEN using esophageal self-expanding metal stents (SEMS). The described results come from 15 studies after a review of the current literature. The study group comprised 52 patients (36 men and 16 women; mean age, 50.87 (13-75) years) with walled-off pancreatic necrosis, in whom PEN using a self-expandable esophageal stent had been performed. PEN was successfully completed in all 52 patients (100%). PEN complications were observed in 18/52 (34.62%) patients. Clinical success was achieved in 42/52 (80.77%) patients, with follow-up continuing for an average of 136 (14-557) days. In conclusion, the PEN technique is potentially effective, with an acceptable rate of complications and may be implemented with good clinical results in patients with pancreatic necrosis.

The Role of Antibiotics in Endoscopic Transmural Drainage of Post-Inflammatory Pancreatic and Peripancreatic Fluid Collections

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.

Early endoscopic treatment of symptomatic pancreatic necrotic collections

EUS-guided transmural endoscopic drainage is commonly used in the treatment of WOPN in the late phase of ANP. The role of endoscopic intervention remains unclear in the early phase of ANP. This study aimed to prospectively evaluate early endoscopic treatment of ANCs compared with endoscopic drainage of WOPN. Overall, 71 patients with ANP who underwent transmural endoscopic drainage for necrotic collections were included. Endoscopic intervention was performed within the first four weeks of ANP in 25 (35.21%) patients with ANC (Group 1) and in 46 (64.79%) patients after four weeks since the onset of ANP with WOPN (Group 2). The overall mean age of patients was 49.9 (22–79) years and 59 of them were males. The mean time of active drainage and duration of total endoscopic treatment was 26.8 and 16.9 days (P = 0.0001) and 270.8 and 164.2 days (P = 0.0001) in Groups 1 and 2, respectively. The average total number of endoscopic interventions was 9.5 and 4.5 in Groups 1 and 2, respectively (P = 0.0001). The clinical success rate, frequency of complications of endoscopic interventions, long-term success rate, and recurrence rate were not significantly different between the groups (P > 0.05 for each). Transmural endoscopic drainage is effective method of treatment of early ANCs within the first four weeks of ANP. However, compared with endoscopic intervention in WOPN, more interventions and longer duration of drainage are required.

The Role of Lumen-Apposing Metal Stents in Transmural Endoscopic Drainage of Postinflammatory Pancreatic and Peripancreatic Fluid Collections

Rapid development of advanced gastrointestinal endoscopic techniques contributed to the appearance of new biomedical materials including polymers, which are used for the production of different types of endoprostheses. Endotherapy (ET) of postinflammatory pancreatic and peripancreatic fluid collections (PPFCs) with the use of lumen-apposing metal stent (LAMS) is an effective method of treatment. This paper describes the high efficacy of ET and its potential complications, which are mostly related to the design of the LAMS used. The high efficacy of LAMS in the transmural drainage of PPFCs is associated with lower safety of treatment. Complications of ET presented in the manuscript are mainly related to endoprosthesis' construction. This paper presents possible directions of development in the field of transmural LAMSs, which in the future may contribute to the invention of an innovative type of LAMS based on new biomedical technologies. Possibly, subsequent novel endoprosthesis projects, based on the above results, will be able to meet the current needs and requirements associated with endoscopic transmural drainage procedures in cases of postinflammatory PPFCs. The ultimate goal is to improve safety of minimally invasive techniques for treatment of the local consequences of pancreatitis.

Abdominal rebleeding after transcatheter arterial embolization for ruptured pseudoaneurysms associated with severe acute pancreatitis: a retrospective study

Introduction

Patients are at risk of abdominal rebleeding after transcatheter arterial embolization (TAE) for pancreatitis-related pseudoaneurysm, which increases the mortality rate.

Aim

This study was performed to evaluate the effects of an intestinal fistula (IF) and the anatomical location of the pseudoaneurysm on abdominal rebleeding after TAE of a ruptured pseudoaneurysm associated with severe acute pancreatitis (SAP).

Material and methods

From February 2013 to November 2019, 24 patients with SAP-related pseudoaneurysm rupture and hemorrhage in our hospital underwent TAE. All patients’ epidemiological data and related medical histories were collected and statistically analyzed. We classified the pseudoaneurysms as type I, II, and III according to their anatomical locations and as type A (without an IF) and type B (with an IF).

Results

The interventions for abdominal infection in patients with type I pseudoaneurysms were percutaneous drainage in 6 patients, endoscopic necrotic tissue removal in 5, and surgical necrotic tissue removal or enterostomy in none, with a rebleeding rate of 33.3% (3/9 patients). The interventions for abdominal infection in patients with type II pseudoaneurysms were percutaneous drainage in 7 patients, endoscopy in three, and surgery in one, with a rebleeding rate of 20.0% (2/10 patients). The interventions for abdominal infection in patients with type III pseudoaneurysms were percutaneous drainage in 3 patients, endoscopy in 1, and surgery in 2, with a rebleeding rate of 80.0% (4/5 patients). There was no statistically significant difference in the types of interventions for abdominal infection among patients with type I, II, and III pseudoaneurysms (p = 0.355) or in the rate of abdominal rebleeding after TAE for type III pseudoaneurysms (p = 0.111). The interventions for abdominal infection in patients with type A pseudoaneurysms were percutaneous drainage in 13 patients, endoscopy in 6, and surgery in 1, with a rebleeding rate of 22.2% (4/18 patients) and mortality rate of 11.1% (2/18 patients). The interventions for abdominal infection in patients with type B pseudoaneurysms were percutaneous drainage in 3 patients, endoscopy in 3, and surgery in 2, with a rebleeding rate of 83.3% (5/6 patients) and mortality rate of 66.7% (4/6 patients). There was no significant difference in the types of interventions for abdominal infection in patients with and without IF (p = 0.215); however, the rebleeding rate and mortality rate were significantly higher in patients with IF (p = 0.015 and 0.018, respectively).

Conclusions

IF may increase the rate of abdominal rebleeding after TAE for ruptured SAP-related pseudoaneurysms, while the anatomical location of the pseudoaneurysm may not affect the rate of rebleeding after TAE.

Various Endoscopic Techniques for Treatment of Consequences of Acute Necrotizing Pancreatitis: Practical Updates for the Endoscopist

Despite great progress in acute pancreatitis (AP) treatment over the last 30 years, treatment of the consequences of acute necrotizing pancreatitis (ANP) remains controversial. While numerous reports on minimally invasive treatment of the consequences of ANP have been published, several aspects of interventional treatment, particularly endoscopy, are still unclear. In this article, we attempt to discuss these aspects and summarize the current knowledge on endoscopic therapy for pancreatic necrosis. Endotherapy has been shown to be a safe and effective minimally invasive treatment modality in patients with consequences of ANP. The evolution of endoscopic techniques has made endoscopic drainage more effective and reduced the use of other minimally invasive therapies for pancreatic necrosis.

Investigating Risk Factors for Complications after Ileostomy Reversal in Low Anterior Rectal Resection Patients: An Observational Study

Introduction: Defunctioning ileostomy has been widely used in patients undergoing low anterior rectal resection to reduce the rate of postoperative leakage. It is still not clear whether interval between primary procedure and ileostomy reversal has an impact on treatment outcomes. Methods: In our prospective observational study we reviewed 164 consecutive cases of patients who underwent total mesorectal excision with primary anastomosis. Univariate and multivariate regression models were used to search for risk factors for prolonged length of stay and complications after defunctioning ileostomy reversal. Receiver operating characteristic curves were utilized to set cut-off points for prolonged length of stay and perioperative morbidity. Results: In total, 132 patients were included in the statistical analysis. The median interval between primary procedure and defunctioning ileostomy reversal was 134 (range: 17-754) days, while median length of stay was 5 days (4-6 interquartile range (IQR)). Prolonged length of stay cut-off was established at 6 days. Regression models revealed that interval between primary surgery and stoma closure as well as complications after primary procedure are risk factors for complications after defunctioning ileostomy reversal. Prolonged length of stay has been found to be related primarily to interval between primary surgery and stoma closure. Conclusions: In our study interval between primary surgery and stoma closure along with complication occurrence after primary procedure are risk factors for perioperative morbidity and prolonged length of stay (LOS) after ileostomy reversal. The effort should be made to minimize the interval to ileostomy reversal. However, randomized studies are necessary to avoid the bias which appears in this observational study and confirm our findings.

Endovascular embolization of arterial bleeding in patients with severe acute pancreatitis

Introduction

Severe acute pancreatitis (SAP) has a high mortality rate of 20% to 30%, with death often resulting from hemorrhage.

Aim

To investigate the role of digital subtraction angiography (DSA) and endovascular embolization in the management of arterial bleeding in SAP patients.

Material and methods

Seventy-six patients with SAP admitted to our hospital between January 2010 and May 2016 underwent DSA. DSA revealed arterial bleeding in 22 of these patients, who were treated with transcatheter endovascular embolization with coils and/or gelfoam particles. Patient demographics, angiographic features of vascular abnormalities, and outcomes of embolization were assessed.

Results

Arterial bleeding was the most common vascular abnormality (22/76 patients; 28.9%). DSA enabled the identification of 27 bleeding arteries in 22 patients. The splenic artery was the most commonly affected vessel (11/27; 40.7%). Among the 27 arteries treated with endovascular embolization, successful hemostasis was achieved in 96.3% (26/27). Two patients developed major complications (hepatic and splenic abscess). These patients were treated with abdominal catheter drainage and anti-infection measures and ultimately recovered. The mean interval between initial onset of SAP and angiographic diagnosis of arterial bleeding was 56 days. Rebleeding was diagnosed in 5 patients (5/22; 22.7%) during repeat angiography, with bleeding from new sites in four of these patients. The mean interval between successive angiography treatments was 38 days.

Conclusions

Endovascular embolization is a safe and effective method to localize bleeding arteries and achieve complete hemostasis in patients with SAP-related arterial bleeding.

Laparoscopic adrenalectomy: lateral transperitoneal versus posterior retroperitoneal approach - prospective randomized trial

INTRODUCTION

Laparoscopic adrenalectomy has become the gold standard of surgical treatment for benign adrenal masses. Two alternative surgical approaches are currently advocated: the lateral transperitoneal approach (LTA) and the posterior retroperitoneal approach (PRA). Several randomized trials have compared LTA to PRA, but most of them included small numbers of patients or had stringent inclusion criteria.

AIM

To compare clinical results of LTA and PRA endoscopic adrenalectomies for tumors < 8 cm with wide inclusion criteria.

MATERIAL AND METHODS

We randomized 77 patients to either LTA (n = 33) or PRA (n = 44). The groups were comparable in terms of age, gender proportions, body mass index, tumor size, clinical and pathological diagnosis. We analyzed duration of surgery, intraoperative blood loss, postoperative pain, length of hospital stay and postoperative morbidity.

RESULTS

The follow-up concerned 98.8% of patients and was on average 28 (8-47) months long. There were no conversions. We identified significantly lower intensity of pain assessed 24 h after surgery in the PRA group (3.4 ±1), as compared to LTA (4.2 ±1), with lower prevalence of shoulder pain (2.3% vs. 30.3%, respectively). Postoperative hospital stay was shorter in the PRA (1.14 ±0.4) than in the LTA (1.36 ±0.5) group. Perioperative morbidity concerned 4 patients in each group with pain requiring oral analgesia > 7 days.

CONCLUSIONS

To our knowledge this is the largest prospective randomized study comparing LTA to PRA. We demonstrated safety, efficacy and very low morbidity of both techniques. The PRA proved superior to LTA in terms of lower intensity of postoperative pain and shorter hospital stay.

Single transluminal gateway transcystic multiple drainage for extensive walled-off pancreatic necrosis - a single-centre experience

INTRODUCTION

In last three decades we have observed development in minimally invasive techniques in the treatment of walled-off pancreatic necrosis (WOPN). Endoscopic treatment of the consequences of acute necrotising pancreatitis is a accepted and common minimally invasive method.

AIM

Evaluation of the efficiency and safety of the innovative endoscopic treatment method (single transluminal gateway transcystic multiple drainage - SGTMD) in patients with extensive walled-off pancreatic necrosis.

MATERIAL AND METHODS

The retrospective analysis of 114 consecutive patients with symptomatic WOPN, who were treated endoscopically in our medical centre between 2011 and 2016.

RESULTS

Single transluminal gateway transcystic multiple drainage was performed in 21/114 (18.42%) patients. Endoscopic necrosectomy under fluoroscopic guidance was performed in 12/21 (57.14%) patients. Complications of treatment appeared in 7/21 (33.33%) patients. The most common of complication was upper gastrointestinal bleeding treated conservatively with packed red blood cells transfusions. There were no deaths. Therapeutic success was reached in 20/21 (95.24%) patients. No patient required surgery. The medium time of follow-up was 22 months (16-47). During the observation the recurrence of pancreatic fluid collection was noticed in 1/21 (4.76%) patients. Long-term success of endoscopic treatment was achieved in 19/21 (90.47%) patients.

CONCLUSIONS

Single transluminal gateway transcystic multiple drainage is an effective method of endoscopic treatment for extensive walled-off pancreatic necrosis with an acceptable amount of complications. However, the method of interventional treatment of pancreatic necrosis should depend not only on the location of necrosis, but also on the experience of the medical centre.

Emergency surgery in older patients

Introduction

At present, emergency guidelines do not differentiate between younger adults and older persons. The changing socioeconomic situation associated with the aging population will be challenging for the healthcare system and requires new medical guidelines to best accommodate it.

Aim

To analyze whether the age and comorbidities of a patient affect acute care surgical outcomes.

Material and methods

We performed a retrospective study of 161 patients who were admitted in emergency to the Department of General, Minimally Invasive and Elderly Surgery in Olsztyn between May and October 2017. Patients were divided into three age groups. Outcomes in patients older than 80 years were compared with corresponding statistical predictions of morbidity and mortality, as calculated using the Physiologic and Operative Severity Score for the enUmeration of Mortality and Morbidity (POSSUM).

Results

Patients in the 80+ age group had a higher mortality rate in comparison with those in the other age groups, and a higher number of comorbidities (p = 0.002 and p = 0.001, respectively). The POSSUM morbidity and mortality rates were significantly higher for the older patients who died than for the older patients who were discharged (p = 0.013 and p = 0.003, respectively).

Conclusions

Decisions about suitable therapy in the acute care setting should be made after consideration of the overall health of a patient. This study shows that age itself has a huge impact on postoperative results. The older the patient is, the higher the risk of perioperative death. We recommend patient evaluation using the POSSUM scale to better predict this risk.

Injection laryngoplasty as miniinvasive office-based surgery in patients with unilateral vocal fold paralysis - voice quality outcomes

Introduction

Injection laryngoplasty (glottis augmentation) is the preferred method in surgical management of unilateral vocal fold paralysis (UVFP). Traditionally, these procedures are performed in the operating room. Nowadays, however, these procedures have moved into the office.

Aim

To evaluate the voice quality after transoral injection laryngoplasty under local anaesthesia in patients with unilateral vocal fold paralysis.

Material and methods

Fourteen subjects (5 women and 9 men) with unilateral vocal fold paresis (9 with right vocal fold paresis and 5 with left vocal fold paresis) were included in the study. The mean age of the group was 57.8 ±19.0 years (32–83 years). All of the injection laryngoplasties were performed transorally, under local anaesthesia. The injection material was calcium hydroxylapatite. Before and 1, 3 and 6 months after the procedure the following variables were evaluated: voice perception, videostroboscopy, acoustic analysis, aerodynamic evaluation, and the subjective rating of the voice quality by the patient.

Results

After injection laryngoplasty, complete glottal closure was achieved or there was a significant improvement in the glottal closure of each subject. We noted great improvement in the post-injection objective and subjective voice outcomes and patients reported improvement in the voice-related quality of life.

Conclusions

The transoral approach for injection laryngoplasty under local anaesthesia is an effective and safe way to treat incomplete glottal closure in patients with UVFP. The transoral approach is an efficient alternative to other surgical techniques used for vocal fold injection.

Endoscopic treatment of multilocular walled-off pancreatic necrosis with the multiple transluminal gateway technique

The development of minimally invasive techniques allowed access to the necrotic cavity through transperitoneal, retroperitoneal, transmural and transpapillary routes. The choice of access to walled-off pancreatic necrosis (WOPN) should depend not only on the spread of necrosis, but also on the experience of the clinical center. Herein we describe treatment of a patient with multilocular symptomatic walled-off pancreatic necrosis using minimally invasive techniques. The single transmural access (single transluminal gateway technique - SGT) to the necrotic collection of the patient was ineffective. The second gastrocystostomy was performed using the same minimally invasive technique as an extra way of access to the necrosis (multiple transluminal gateway technique - MTGT). In the described case the performance of the new technique consisting in endoscopic multiplexing transmural access (MTGT) was effective enough and led to complete recovery of the patient.

Transpapillary drainage of walled-off pancreatic necrosis - a single center experience

INTRODUCTION

Walled-off pancreatic necrosis (WOPN) often coexists with disruption of the main pancreatic duct that manifests as a leak of contrast medium into the necrotic collection during endoscopic retrograde pancreatography.

AIM

To assess the efficacy and safety of treatment of patients with symptomatic WOPN and disruption of the main pancreatic duct, who underwent endoscopic transpapillary drainage as the only access to the necrosis cavity.

MATERIAL AND METHODS

In 22 patients with symptomatic WOPN, active endoscopic transpapillary drainage was performed. During endoscopic retrograde pancreatography (ERP), partial disruption of the main pancreatic duct was observed in 14 patients and complete disruption in 8 patients. After the active drainage was finished, a transpapillary pancreatic stent was inserted into the main pancreatic duct, which was later exchanged after 6, 12 and 24 months or when no extravasation of contrast from the pancreatic duct was observed. The results of treatment and complications were compared retrospectively.

RESULTS

The mean duration of active drainage was 22 (range: 7-94) days. Complications of endotherapy occurred in 3/22 patients. The mean time of the main pancreatic duct stenting was 304 (range: 85-519) days. Success of endoscopic treatment of WOPN and pancreatic duct disruption was achieved in 20/22 patients. During a 1-year follow-up, recurrence of the collection was noted in 4/20 patients. Long-term success was achieved in 16/22 patients.

CONCLUSIONS

In patients with WOPN who cannot undergo transmural drainage when there is a communication between the necrotic collection and the main pancreatic duct, transpapillary access may be an effective and safe method of treatment.

Transpapillary drainage of pancreatic parenchymal necrosis

In the last two decades the strategy of treatment of necrotizing pancreatitis has changed. Endoscopic therapy of patients with symptomatic walled-off pancreatic necrosis has a high rate of efficiency. Here we present a description of a patient with parenchymal limited necrosis of the pancreas and a disruption of the main pancreatic duct. In the treatment, active transpapillary drainage of the pancreatic necrosis (through the major duodenal papilla) was performed and insertion of an endoprosthesis into the main pancreatic duct (through the minor duodenal papilla) was applied, which enabled a bypass over the infiltration and resulted in complete resolution.