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Rana R, Mahapatra SJ, Garg PK. Endoscopic interventions for managing pancreatic fluid collections associated with acute pancreatitis: A state-of-the-art review (with videos). Indian J Gastroenterol 2025:10.1007/s12664-025-01755-x. [PMID: 40293669 DOI: 10.1007/s12664-025-01755-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/27/2024] [Accepted: 02/12/2025] [Indexed: 04/30/2025]
Abstract
Acute pancreatitis is an acute inflammatory disease, which may be associated with pancreatic and peri-pancreatic necrosis and development of (peri)pancreatic fluid collections (PFCs). Interventions in acute pancreatitis have evolved over the years with a paradigm shift from open surgical drainage and necrosectomy to minimally invasive approaches. Depending on the presence of necrosis, the PFCs may be acute necrotic collections or acute pancreatic fluid collections, which evolve over a period of three to four weeks to walled-off necrosis and pseudocysts, respectively. Patients with symptomatic and infected PFCs require drainage. In general, drainage should be delayed beyond three to four weeks when the collection wall has matured and the necrotic debris is liquefied. However, some patients may merit early drainage (within the first three to four weeks), if they have suspected infected pancreatic necrosis and worsening organ dysfunction despite antibiotics and supporting therapy. Endoscopic transmural drainage and necrosectomy have now emerged as the most favored treatment modality in suitable pancreatic collections located predominantly in the lesser sac. Being minimally invasive, per-oral endoscopic direct necrosectomy is as effective as surgical necrosectomy in patients with infected necrotic collections but with fewer adverse events. Percutaneous endoscopic necrosectomy is an important addition to our armamentarium for laterally placed collections as an effective alternative to surgical video-assisted retroperitoneal debridement. The current review provides an overview of the evolution, indications, approaches, techniques and outcomes of endoscopic interventions in the management of pancreatic fluid collections associated with acute pancreatitis. Future direction for better outcomes has been highlighted.
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Affiliation(s)
- Randeep Rana
- Department of Gastroenterology and Human Nutrition Unit, All India Institute of Medical Sciences, New Delhi, 110 029, India
- Department of Gastroenterology, Govind Ballabh Pant Institute of Postgraduate Medical Education and Research, New Delhi, 110 002, India
| | - Soumya Jagannath Mahapatra
- Department of Gastroenterology and Human Nutrition Unit, All India Institute of Medical Sciences, New Delhi, 110 029, India
| | - Pramod Kumar Garg
- Department of Gastroenterology and Human Nutrition Unit, All India Institute of Medical Sciences, New Delhi, 110 029, India.
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Mehta V, Gupta YK, Gupta A, Kumar Y, Khubber M, Sood A, Sehgal T, Mehta P, Vuthaluru AR, Goyal MK. Efficacy and Safety of Endoscopic Ultrasound (EUS)-Guided Lumen-Apposing Metal Stents (LAMS) as a Primary Treatment for Walled-Off Pancreatic Necrosis. Cureus 2025; 17:e78177. [PMID: 40026971 PMCID: PMC11869351 DOI: 10.7759/cureus.78177] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 01/29/2025] [Indexed: 03/05/2025] Open
Abstract
Pancreatic necrosis, a severe complication of acute pancreatitis, is associated with significant morbidity and mortality. The use of lumen-apposing metal stents (LAMS) as a primary treatment offers a less invasive approach that may improve patient outcomes. This study evaluates the efficacy and safety of endoscopic ultrasound (EUS)-guided LAMS for treating walled-off pancreatic necrosis. In this retrospective cohort study, 95 patients treated with EUS-guided LAMS between March 2020 and October 2023 were included. Data were collected on the technical success of stent placement, clinical improvement, and management of symptomatic patients. Patients with other primary interventions, preexisting chronic pancreatitis, or incomplete clinical data were excluded. The technical success rate for LAMS placement was 100%, with a clinical success rate of 92.63%. Seven patients (7.37%) did not respond to LAMS treatment: five underwent video-assisted retroperitoneal drainage, and two had percutaneous drainage. Stent occlusion occurred in seven patients within the first week, managed through saline irrigation or direct endoscopic necrosectomy. No procedure-related complications were reported. The use of LAMS significantly reduced hospital stays and eliminated the need for additional surgeries in most cases. These findings suggest that LAMS is a highly effective and safe primary treatment for pancreatic necrosis, with high success rates and no related complications. The study's strengths include a large sample size and comprehensive follow-up, although its retrospective, single-center design may limit generalizability. These results support the use of LAMS as a primary treatment option for pancreatic necrosis, with future research needed to refine patient selection and explore long-term outcomes.
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Affiliation(s)
- Varun Mehta
- Gastroenterology, Dayanand Medical College & Hospital, Ludhiana, IND
| | - Yogesh K Gupta
- Gastroenterology, Dayanand Medical College & Hospital, Ludhiana, IND
| | - Abhinav Gupta
- Gastroenterology, Dayanand Medical College & Hospital, Ludhiana, IND
| | - Yogesh Kumar
- Gastroenterology, Dayanand Medical College & Hospital, Ludhiana, IND
| | - Manisha Khubber
- Gastroenterology, Dayanand Medical College & Hospital, Ludhiana, IND
| | - Ajit Sood
- Gastroenterology, Dayanand Medical College & Hospital, Ludhiana, IND
| | - Tanisha Sehgal
- Medicine and Surgery, Dayanand Medical College & Hospital, Ludhiana, IND
| | - Prabhav Mehta
- Medicine and Surgery, Dayanand Medical College & Hospital, Ludhiana, IND
| | - Ashita R Vuthaluru
- Anesthesia and Critical Care, All India Institute of Medical Sciences, New Delhi, New Delhi, IND
| | - Manjeet K Goyal
- Gastroenterology and Hepatology, Dayanand Medical College & Hospital, Ludhiana, IND
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Jaeger K, Meyer F, Füldner F, Will U. Endoscopic necrosectomy of infected WON in acute necrotising pancreatitis - Development of an effective therapeutic algorithm based on a single-center consecutive patient cohort. ZEITSCHRIFT FUR GASTROENTEROLOGIE 2023; 61:665-675. [PMID: 36126931 DOI: 10.1055/a-1890-5674] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/09/2023]
Abstract
OBJECTIVE Development of an effective therapeutic algorithm for interventional (minimally invasive) approach to infected walled-off necrosis (WON) in patients with necrotising pancreatitis reflecting real-word data. MATERIAL/METHODS All consecutive patients who underwent endoscopic necrosectomy for necrotising pancreatitis through a defined study period were enclosed in this retrospective observational case study. The therapeutic approach was analysed for clinical success rate, complication spectrum and rate as well as mortality and compared with data from the literature. Finally, a therapeutic algorithm was derived. RESULTS From 2004 to 2019, 126 patients with necrotising pancreatitis (median of APACHE II score, 10.5 points) were treated. In 92.9 % of cases (n=117), an infected WON with microbial pathogen detection was found. After a median of 18 days from symptom onset, first intervention was performed (53.2 % as percutaneous drainage with programmed rinsing, 29.4 % as EUS-guided internal drainage). From 2004 to 2010, double pigtail stents were used. Later, lumen-apposing metal stent (LAMS) such as AXIOSTM stent (Boston Scientific, Ratingen, Germany) was preferred. The combined percutaneous and internal drainage was performed in approximately 50 % of subjects.Endoscopic transluminal necrosectomy was performed in 123 patients (97.6 %) at a median of 33 days from symptom onset. Endoscopic percutaneous necrosectomy was conducted in 11.1 % of the individuals. A median number of two endoscopic necrosectomy sessions per patient was necessary for the therapy. The clinical success rate (discharge without surgical intervention) was 82.5 %. The complication rate (bleeding and perforation) and the need for surgery were both 9.5 %. The overall mortality was 8.7 %. CONCLUSION Therapy of necrotising pancreatitis with infected WON consists of early calculated antibiotic therapy with adequate drainage. Combined external and internal drainages with programmed rinsing seem to improve prognosis, as well as minimise I) : the need for forced necrosectomies (mainly via a transluminal access site) and II) : complication rate as well as, thus, improve outcome.
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Affiliation(s)
- Kristin Jaeger
- Dept. of Internal Medicine III (Gastroenterology, Hepatology, General Internal Medicine), Municipal Hospital ("SRH Wald-Klinikum Gera GmbH"), Gera, Germany
| | - Frank Meyer
- Dept. of General, Abdominal, Vascular and Transplant Surgery, Otto-von-Guericke University with University Hospital, Magdeburg, Germany
| | - Frank Füldner
- Dept. of Internal Medicine III (Gastroenterology, Hepatology, General Internal Medicine), Municipal Hospital ("SRH Wald-Klinikum Gera GmbH"), Gera, Germany
| | - Uwe Will
- Dept. of Internal Medicine III (Gastroenterology, Hepatology, General Internal Medicine), Municipal Hospital ("SRH Wald-Klinikum Gera GmbH"), Gera, Germany
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Sameera S, Mohammad T, Liao K, Shahid H, Sarkar A, Tyberg A, Kahaleh M. Management of Pancreatic Fluid Collections: An Evidence-based Approach. J Clin Gastroenterol 2023; 57:346-361. [PMID: 36040932 DOI: 10.1097/mcg.0000000000001750] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/10/2022]
Abstract
Managing pancreatic fluid collections (PFCs) remains a challenge for many clinicians. Recently, significant progress has been made in the therapy of PFCs, including improvements in technology and devices, as well as in the development of minimally invasive endoscopic techniques, many of which are proven less traumatic when compared with surgical options and more efficacious when compared with percutaneous techniques. This review will explore latest developments in the management of PFCs and how they incorporate into the current treatment algorithm.
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Affiliation(s)
- Sohini Sameera
- Department of Gastroenterology & Hepatology, Rutgers Robert Wood Johnson Medical School, New Brunswick, NJ
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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: 10] [Impact Index Per Article: 2.5] [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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Nayar MK, Bekkali NLH, Bourne D, Young S, Leeds JS, Oppong KW, Logue JL, Sen G, French JJ, Scott J, Cressey D, Pandanaboyana S, Charnley RM. Novel multidisciplinary hub-and-spoke tertiary service for the management of severe acute pancreatitis. BMJ Open Gastroenterol 2021; 8:bmjgast-2020-000501. [PMID: 33789915 PMCID: PMC8016076 DOI: 10.1136/bmjgast-2020-000501] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/27/2020] [Revised: 11/26/2020] [Accepted: 02/28/2021] [Indexed: 01/04/2023] Open
Abstract
OBJECTIVE Severe acute pancreatitis (SAP) is associated with high mortality (15%-30%). Current guidelines recommend these patients are best managed in a multidisciplinary team setting. This study reports experience in the management of SAP within the UK's first reported hub-and-spoke pancreatitis network. DESIGN All patients with SAP referred to the remote care pancreatitis network between 2015 and 2017 were prospectively entered onto a database by a dedicated pancreatitis specialist nurse. Baseline characteristics, aetiology, intensive care unit (ICU) stay, interventions, complications, mortality and follow-up were analysed. RESULTS 285 patients admitted with SAP to secondary care hospitals during the study period were discussed with the dedicated pancreatitis specialist nurse and referred to the regional service. 83/285 patients (29%; 37 male) were transferred to the specialist centre mainly for drainage of infected pancreatic fluid collections (PFC) in 95% (n=79) of patients. Among the patients transferred; 29 (35%) patients developed multiorgan failure with an inpatient mortality of 14% (n=12/83). The median follow-up was 18.2 months (IQR=11.25-35.51). Multivariate analysis showed that transferred patients had statistically significant longer overall hospital stay (p<0.001) but less ICU stay (p<0.012). CONCLUSION This hub-and-spoke model facilitates the management of the majority of patients with SAP in secondary care setting. 29% warranted transfer to our tertiary centre, predominantly for endoscopic drainage of PFCs. An evidence-based approach with a low threshold for transfer to tertiary care centre can result in lower mortality for SAP and fewer days in ICU.
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Affiliation(s)
- Manu K Nayar
- HPB Medicine & Translational and Clinical Research Institute, Newcastle University, Freeman Hospital, Newcastle upon Tyne, UK
| | | | - David Bourne
- Newcastle Nutrition, Freeman Hospital, Newcastle upon Tyne, UK
| | - Sophie Young
- HPB Surgical Unit, Freeman Hospital, Newcastle upon Tyne, UK
| | - John S Leeds
- HPB Unit, Freeman Hospital, Newcastle upon Tyne, UK
| | - Kofi W Oppong
- HPB Medicine & Translational and Clinical Research Institute, Newcastle University, Freeman Hospital, Newcastle upon Tyne, UK
| | | | - Gourab Sen
- HPB Surgical Unit, Freeman Hospital, Newcastle upon Tyne, UK
| | - Jeremy J French
- HPB Surgical Unit, Freeman Hospital, Newcastle upon Tyne, UK
| | - John Scott
- Department of Radiology, Freeman Hospital, Newcastle upon Tyne, UK
| | - David Cressey
- Department of Intensive Care Medicine, Freeman Hospital, Newcastle upon Tyne, UK
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Martinez M, Cole J, Dove J, Blansfield J, Shabahang M, Wild J, Widom K, Torres D, Factor M. Outcomes of Endoscopic and Surgical Pancreatic Necrosectomy: A Single Institution Experience. Am Surg 2020. [DOI: 10.1177/000313481908500946] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Abstract
Pancreatic necrosis can be managed conservatively; however, infection of pancreatic necrosis usually dictates more aggressive management. Our study aimed to assess the outcomes of open pancreatic necrosectomy (OPN) and endoscopic pancreatic necrosectomy (EPN) in a single center. Data from patients undergoing pancreatic necrosectomy at the Geisinger Medical Center from January 1, 2007, to April 25, 2016, were collected and retrospectively analyzed. Cohorts were composed of EPN (n = 22) and OPN (n = 34) groups. The prevalence of preoperative respiratory failure, septic shock, and multiorgan dysfunction syndrome was higher in the OPN group. The OPN group presented with a higher Bedside Index Severity in Acute Pancreatitis score. Postoperative abscess, persistent kidney dysfunction, and death were more frequent in the OPN group. The EPN group had a higher read-mission rate. The results of the univariate analysis for complication and mortality demonstrated that higher mortality and persistent kidney dysfunction were associated with the procedure type, specifically OPN and with a higher Bedside Index Severity in Acute Pancreatitis score. Patients who presented with higher severity of disease underwent an OPN, whereas EPN often was performed successfully in a more benign clinical setting. However, patients with infected necrosis are served best in a tertiary medical facility where multiple treatment modalities are available.
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Affiliation(s)
- Manuel Martinez
- From the Department of General Surgery, Geisinger Medical Center, Danville, Pennsylvania
| | - Joshua Cole
- From the Department of General Surgery, Geisinger Medical Center, Danville, Pennsylvania
| | - James Dove
- From the Department of General Surgery, Geisinger Medical Center, Danville, Pennsylvania
| | - Joseph Blansfield
- From the Department of General Surgery, Geisinger Medical Center, Danville, Pennsylvania
| | - Mohsen Shabahang
- From the Department of General Surgery, Geisinger Medical Center, Danville, Pennsylvania
| | - Jeffrey Wild
- From the Department of General Surgery, Geisinger Medical Center, Danville, Pennsylvania
| | - Kenneth Widom
- From the Department of General Surgery, Geisinger Medical Center, Danville, Pennsylvania
| | - Denise Torres
- From the Department of General Surgery, Geisinger Medical Center, Danville, Pennsylvania
| | - Matthew Factor
- From the Department of General Surgery, Geisinger Medical Center, Danville, Pennsylvania
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8
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Management of pancreatic fluid collections in patients with acute pancreatitis. JOURNAL OF PANCREATOLOGY 2019. [DOI: 10.1097/jp9.0000000000000026] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022] Open
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Rashid MU, Hussain I, Jehanzeb S, Ullah W, Ali S, Jain AG, Khetpal N, Ahmad S. Pancreatic necrosis: Complications and changing trend of treatment. World J Gastrointest Surg 2019; 11:198-217. [PMID: 31123558 PMCID: PMC6513789 DOI: 10.4240/wjgs.v11.i4.198] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/12/2019] [Revised: 04/19/2019] [Accepted: 04/23/2019] [Indexed: 02/06/2023] Open
Abstract
Incidence of acute pancreatitis seems to be increasing in the Western countries and has been associated with significantly increased morbidity. Nearly 80% of the patients with acute pancreatitis undergo resolution; some develop complications including pancreatic necrosis. Infection of pancreatic necrosis is the leading cause of death in these patients. A significant portion of these patients needs surgical interventions. Traditionally, the “gold standard” procedure has been the open surgical necrosectomy, which is now being completed by the relatively lesser invasive interventions. Minimally invasive surgical (MIS) procedures include endoscopic drainage, percutaneous image-guided catheter drainage, and retroperitoneal drainage. This review article discusses the open and MIS interventions for pancreatic necrosis with each having its own respective benefits and disadvantages are covered.
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Affiliation(s)
- Mamoon Ur Rashid
- Department of Internal Medicine, Advent Health Graduate Medical Education, Orlando, FL 32804, United States
| | - Ishtiaq Hussain
- Department of Gastroenterology, Cleveland Clinic, Weston, FL 33326, United States
| | - Sundas Jehanzeb
- Department of Gastroenterology, Cleveland Clinic, Weston, FL 33326, United States
| | - Waqas Ullah
- Internal Medicine, Abington Hospital, Abington, PA 19001, United States
| | - Saeed Ali
- Department of Internal Medicine, Advent Health Graduate Medical Education, Orlando, FL 32804, United States
| | - Akriti Gupta Jain
- Department of Internal Medicine, Advent Health Graduate Medical Education, Orlando, FL 32804, United States
| | - Neelam Khetpal
- Department of Internal Medicine, Advent Health Graduate Medical Education, Orlando, FL 32804, United States
| | - Sarfraz Ahmad
- Department of Gynecologic Oncology, Advent Health Cancer Institute, Orlando, FL 32804, United States
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Jha AK, Goenka MK, Kumar R, Suchismita A. Endotherapy for pancreatic necrosis: An update. JGH Open 2019; 3:80-88. [PMID: 30834345 PMCID: PMC6386747 DOI: 10.1002/jgh3.12109] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/15/2018] [Revised: 09/28/2018] [Accepted: 10/11/2018] [Indexed: 12/16/2022]
Abstract
Approximately 20% of patients with acute pancreatitis develop pancreatic necrosis. The presence of necrosis in a pancreatic collection significantly worsens the prognosis. Pancreatic necrosis is associated with high mortality and morbidity. In the last few decades, there has been a significant revolution in the treatment of infected pancreatic necrosis. A step-up approach has been proposed, from less invasive procedures to the operative intervention. Minimally invasive treatment modalities such as endoscopic drainage and necrosectomy, percutaneous drainage, and minimally invasive surgery have recently replaced open surgical necrosectomy as the first-line treatment option. Endoscopic intervention for pancreatic necrosis is being increasingly performed with good success and a lower complication rate. However, techniques of endotherapy are still not uniform and vary as per local expertise, and there are still many unresolved questions with regard to the interventions in patients with pancreatic necrosis. The objective of this paper is to critically review the literature and update the concepts of endoscopic interventional therapy of pancreatic necrosis.
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Affiliation(s)
- Ashish K Jha
- Department of GastroenterologyIndira Gandhi Institute of Medical SciencesPatnaIndia
| | - Mahesh K Goenka
- Department of Gastrosciences, Institute of Gastrosciences, Apollo Gleneagles HospitalKolkataIndia
| | - Ramesh Kumar
- Department of Gastroenterology, All India Institute of Medical SciencesPatnaIndia
| | - Arya Suchismita
- Department of PediatricsIndira Gandhi Institute of Medical SciencesPatnaIndia
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Yoon SB, Chang JH, Lee IS. [Treatment of Pancreatic Fluid Collections]. THE KOREAN JOURNAL OF GASTROENTEROLOGY = TAEHAN SOHWAGI HAKHOE CHI 2018; 72:97-103. [PMID: 30270591 DOI: 10.4166/kjg.2018.72.3.97] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/26/2022]
Abstract
Pancreatic Fluid Collection (PFC) develops as a result of acute pancreatitis, chronic pancreatitis, trauma, and postoperation. Although percutaneous drainage, surgery and Endoscopic Retrograde Panceatogram are used as conventional treatments in complicated PFC, the clinical course of PFC is unsatisfactory due to its clinical success rate and the risk of procedure-related complications. Endoscopic ultrasonography-guided transmural drainage of PFC is a safe and effective modality for the management of PFC, particularly in patients with pancreas necrosis. A range of techniques and stents have been introduced and a newly designed metal stent is now available.
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Affiliation(s)
- Seung Bae Yoon
- Department of Internal Medicine, College of Medicine, The Catholic University of Korea, Seoul, Korea
| | - Jae Hyuck Chang
- Department of Internal Medicine, College of Medicine, The Catholic University of Korea, Seoul, Korea
| | - In Seok Lee
- Department of Internal Medicine, College of Medicine, The Catholic University of Korea, Seoul, Korea
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12
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Goenka MK, Goenka U, Mujoo M, Tiwary IK, Mahawar S, Rai VK. Pancreatic Necrosectomy through Sinus Tract Endoscopy. Clin Endosc 2018; 51:279-284. [PMID: 29301065 PMCID: PMC5997064 DOI: 10.5946/ce.2017.066] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/06/2017] [Revised: 07/19/2017] [Accepted: 09/13/2017] [Indexed: 12/24/2022] Open
Abstract
BACKGROUND/AIMS Direct endoscopic pancreatic necrosectomy is increasingly being utilized to treat infected or symptomatic walled-off necrosis (WON) located close to the stomach or duodenum. Laterally-placed WON has traditionally been treated surgically. We evaluated a less utilized technique of sinus tract endoscopy (STE) for symptomatic laterally-placed WON. METHODS Two hundred seventy-six patients with acute pancreatitis admitted in our hospital, 32 had symptomatic or infected WON requiring intervention. Of the 12 patients with laterally placed WON, 10 were treated by STE. STE was performed with a standard adult gastroscope passed through a percutaneous tract created by the placement of a 32-Fr drain. RESULTS Ten patients (7 males; mean age, 43.8 years) underwent STE. Mean number of sessions was 2.3 (range, 1-4), with mean time of 70 minutes for each session (range, 15-70 minutes). While 9 patients had complete success, 1 patient had fever and chose to undergo surgery. Two patients developed pneumoperitoneum, which was treated conservatively. There was no mortality, cutaneous fistula, or recurrence during follow-up. CONCLUSIONS Laterally placed WON can be successfully managed by STE performed through a percutaneously placed drain. Details of the technique and end-points of STE require further evaluation.
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Affiliation(s)
| | - Usha Goenka
- Department of Clinical Imaging and Interventional Radiology, Apollo Gleneagles Hospitals, Kolkata, India
| | - Md.Yasin Mujoo
- Institute of Gastrosciences, Apollo Gleneagles Hospitals, Kolkata, India
| | | | - Sanjay Mahawar
- Institute of Gastrosciences, Apollo Gleneagles Hospitals, Kolkata, India
| | - Vijay Kumar Rai
- Institute of Gastrosciences, Apollo Gleneagles Hospitals, Kolkata, India
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13
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van Brunschot S, van Grinsven J, van Santvoort HC, Bakker OJ, Besselink MG, Boermeester MA, Bollen TL, Bosscha K, Bouwense SA, Bruno MJ, Cappendijk VC, Consten EC, Dejong CH, van Eijck CH, Erkelens WG, van Goor H, van Grevenstein WMU, Haveman JW, Hofker SH, Jansen JM, Laméris JS, van Lienden KP, Meijssen MA, Mulder CJ, Nieuwenhuijs VB, Poley JW, Quispel R, de Ridder RJ, Römkens TE, Scheepers JJ, Schepers NJ, Schwartz MP, Seerden T, Spanier BWM, Straathof JWA, Strijker M, Timmer R, Venneman NG, Vleggaar FP, Voermans RP, Witteman BJ, Gooszen HG, Dijkgraaf MG, Fockens P. Endoscopic or surgical step-up approach for infected necrotising pancreatitis: a multicentre randomised trial. Lancet 2018; 391:51-58. [PMID: 29108721 DOI: 10.1016/s0140-6736(17)32404-2] [Citation(s) in RCA: 461] [Impact Index Per Article: 65.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/30/2017] [Revised: 06/19/2017] [Accepted: 08/02/2017] [Indexed: 02/06/2023]
Abstract
BACKGROUND Infected necrotising pancreatitis is a potentially lethal disease and an indication for invasive intervention. The surgical step-up approach is the standard treatment. A promising alternative is the endoscopic step-up approach. We compared both approaches to see whether the endoscopic step-up approach was superior to the surgical step-up approach in terms of clinical and economic outcomes. METHODS In this multicentre, randomised, superiority trial, we recruited adult patients with infected necrotising pancreatitis and an indication for invasive intervention from 19 hospitals in the Netherlands. Patients were randomly assigned to either the endoscopic or the surgical step-up approach. The endoscopic approach consisted of endoscopic ultrasound-guided transluminal drainage followed, if necessary, by endoscopic necrosectomy. The surgical approach consisted of percutaneous catheter drainage followed, if necessary, by video-assisted retroperitoneal debridement. The primary endpoint was a composite of major complications or death during 6-month follow-up. Analyses were by intention to treat. This trial is registered with the ISRCTN registry, number ISRCTN09186711. FINDINGS Between Sept 20, 2011, and Jan 29, 2015, we screened 418 patients with pancreatic or extrapancreatic necrosis, of which 98 patients were enrolled and randomly assigned to the endoscopic step-up approach (n=51) or the surgical step-up approach (n=47). The primary endpoint occurred in 22 (43%) of 51 patients in the endoscopy group and in 21 (45%) of 47 patients in the surgery group (risk ratio [RR] 0·97, 95% CI 0·62-1·51; p=0·88). Mortality did not differ between groups (nine [18%] patients in the endoscopy group vs six [13%] patients in the surgery group; RR 1·38, 95% CI 0·53-3·59, p=0·50), nor did any of the major complications included in the primary endpoint. INTERPRETATION In patients with infected necrotising pancreatitis, the endoscopic step-up approach was not superior to the surgical step-up approach in reducing major complications or death. The rate of pancreatic fistulas and length of hospital stay were lower in the endoscopy group. The outcome of this trial will probably result in a shift to the endoscopic step-up approach as treatment preference. FUNDING The Dutch Digestive Disease Foundation, Fonds NutsOhra, and the Netherlands Organization for Health Research and Development.
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Affiliation(s)
- Sandra van Brunschot
- Department of Gastroenterology and Hepatology, Academic Medical Centre, University of Amsterdam, Amsterdam, Netherlands.
| | - Janneke van Grinsven
- Department of Gastroenterology and Hepatology, Academic Medical Centre, University of Amsterdam, Amsterdam, Netherlands; Department of Surgery, Academic Medical Centre, University of Amsterdam, Amsterdam, Netherlands
| | - Hjalmar C van Santvoort
- Department of Surgery, St Antonius Hospital, Nieuwegein, Netherlands; Department of Surgery, University Medical Centre Utrecht, Utrecht, Netherlands
| | - Olaf J Bakker
- Department of Surgery, University Medical Centre Utrecht, Utrecht, Netherlands
| | - Marc G Besselink
- Department of Surgery, Academic Medical Centre, University of Amsterdam, Amsterdam, Netherlands
| | - Marja A Boermeester
- Department of Surgery, Academic Medical Centre, University of Amsterdam, Amsterdam, Netherlands
| | - Thomas L Bollen
- Department of Radiology, St Antonius Hospital, Nieuwegein, Netherlands
| | - Koop Bosscha
- Department of Surgery, Jeroen Bosch Hospital, 's-Hertogenbosch, Netherlands
| | - Stefan A Bouwense
- Department of Surgery, Radboud University Medical Centre, Nijmegen, Netherlands
| | - Marco J Bruno
- Department of Gastroenterology and Hepatology, Erasmus MC, University Medical Centre, Rotterdam, Netherlands
| | | | - Esther C Consten
- Department of Surgery, Meander Medical Centre, Amersfoort, Netherlands
| | - Cornelis H Dejong
- Department of Surgery and NUTRIM School for Nutrition and Translational Research in Metabolism, Maastricht University Medical Centre, Maastricht, Netherlands
| | - Casper H van Eijck
- Department of Surgery, Erasmus MC, University Medical Centre, Rotterdam, Netherlands
| | | | - Harry van Goor
- Department of Surgery, Radboud University Medical Centre, Nijmegen, Netherlands
| | | | - Jan-Willem Haveman
- Department of Surgery, University Medical Centre Groningen, University of Groningen, Groningen, Netherlands
| | - Sijbrand H Hofker
- Department of Surgery, University Medical Centre Groningen, University of Groningen, Groningen, Netherlands
| | - Jeroen M Jansen
- Department of Gastroenterology, Onze Lieve Vrouwe Gasthuis, Amsterdam, Netherlands
| | - Johan S Laméris
- Department of Radiology, Academic Medical Centre, University of Amsterdam, Amsterdam, Netherlands
| | - Krijn P van Lienden
- Department of Radiology, Academic Medical Centre, University of Amsterdam, Amsterdam, Netherlands
| | | | - Chris J Mulder
- Department of Gastroenterology, VU Medical Centre, Amsterdam, Netherlands
| | | | - Jan-Werner Poley
- Department of Gastroenterology and Hepatology, Erasmus MC, University Medical Centre, Rotterdam, Netherlands
| | - Rutger Quispel
- Department of Gastroenterology, Reinier de Graaf Group, Delft, Netherlands
| | - Rogier J de Ridder
- Department of Gastroenterology, Maastricht University Medical Centre, Maastricht, Netherlands
| | - Tessa E Römkens
- Department of Gastroenterology, Jeroen Bosch Hospital, 's-Hertogenbosch, Netherlands
| | | | - Nicolien J Schepers
- Department of Gastroenterology and Hepatology, Erasmus MC, University Medical Centre, Rotterdam, Netherlands
| | - Matthijs P Schwartz
- Department of Gastroenterology, Meander Medical Centre, Amersfoort, Netherlands
| | - Tom Seerden
- Department of Gastroenterology, Amphia Hospital, Breda, Netherlands
| | | | | | - Marin Strijker
- Department of Surgery, Academic Medical Centre, University of Amsterdam, Amsterdam, Netherlands
| | - Robin Timmer
- Department of Gastroenterology, St Antonius Hospital, Nieuwegein, Netherlands
| | - Niels G Venneman
- Department of Gastroenterology, Medisch Spectrum Twente, Enschede, Netherlands
| | - Frank P Vleggaar
- Department of Gastroenterology and Hepatology, University Medical Centre Utrecht, Utrecht, Netherlands
| | - Rogier P Voermans
- Department of Gastroenterology and Hepatology, Academic Medical Centre, University of Amsterdam, Amsterdam, Netherlands
| | - Ben J Witteman
- Department of Gastroenterology, Hospital Gelderse Vallei, Ede, Netherlands
| | - Hein G Gooszen
- Department of OR/Evidence Based Surgery, Radboud University Medical Centre, Nijmegen, Netherlands
| | - Marcel G Dijkgraaf
- Clinical Research Unit, Academic Medical Centre, University of Amsterdam, Amsterdam, Netherlands
| | - Paul Fockens
- Department of Gastroenterology and Hepatology, Academic Medical Centre, University of Amsterdam, Amsterdam, Netherlands
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14
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Bekkali NLH, Nayar MK, Leeds JS, Charnley RM, Huggett MT, Oppong KW. A comparison of outcomes between a lumen-apposing metal stent with electrocautery-enhanced delivery system and a bi-flanged metal stent for drainage of walled-off pancreatic necrosis. Endosc Int Open 2017; 5:E1189-E1196. [PMID: 29202002 PMCID: PMC5698007 DOI: 10.1055/s-0043-120831] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/02/2017] [Accepted: 07/31/2017] [Indexed: 02/07/2023] Open
Abstract
BACKGROUND AND STUDY AIMS Bi-flanged metal stents (BFMS) have shown promise in the drainage of walled-off pancreatic necrosis (WON), but their placement requires multiple steps and the use of other devices. More recently, a novel device consisting of a combined lumen-apposing metal stent (LAMS) and electrocautery-enhanced delivery system has been introduced. The aim of this study was to compare the placement and outcomes of the two devices. PATIENTS AND METHODS This was a retrospective review of consecutive patients undergoing endoscopic ultrasound-guided placement of BFMS or LAMS for drainage of symptomatic WON. Data from procedures between October 2012 and December 2016 were taken from a prospectively maintained database. We compared technical and clinical success, procedure time, costs, and composite end point of significant events (adverse events, stent migration, additional percutaneous drainage) between BFMS and LAMS. RESULTS 72 consecutive patients underwent placement of BFMS (40 patients, 44 stents) or LAMS (32 patients, 33 stents). Technical success was 91 % for BFMS and 97 % for LAMS. Clinical success was 65 % vs. 78 %, respectively. Median in-room procedure time was significantly shorter in the LAMS group (45 minutes [range 30 - 80]) than in the BFMS group (62.5 minutes [range 35 - 135]; P < 0.001) and fewer direct endoscopic necrosectomies (DEN) were performed (median 1 [0 - 2.0] vs. 2 [0 - 3.7], respectively; P = 0.005). If only inpatients were considered (35 BFMS and 19 LAMS), there was no significant difference in DEN 2 (range 0 - 11) and 2 (range 0 - 8), respectively. The composite end point of 32 % vs. 24 % was not significantly different. Median procedural costs for all patients with successful stent placement for WON treatment was €4427 (range 1630 - 12 926) for BFMS vs. €3500 (range 2509 - 13 393) for LAMS ( P = 0.10). CONCLUSION LAMS was superior to BFMS in terms of procedure time, with comparable adverse events, success, and costs.
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Affiliation(s)
- Noor L. H. Bekkali
- HPB Unit, Freeman Hospital, Newcastle upon Tyne, United Kingdom,Department of Gastroenterology, Freeman Hospital, Newcastle upon Tyne, United Kingdom
| | - Manu K. Nayar
- HPB Unit, Freeman Hospital, Newcastle upon Tyne, United Kingdom,Department of Gastroenterology, Freeman Hospital, Newcastle upon Tyne, United Kingdom
| | - John S. Leeds
- HPB Unit, Freeman Hospital, Newcastle upon Tyne, United Kingdom,Department of Gastroenterology, Freeman Hospital, Newcastle upon Tyne, United Kingdom
| | - Richard M. Charnley
- Department of Gastroenterology, Freeman Hospital, Newcastle upon Tyne, United Kingdom,Department of Surgery, Freeman Hospital, Newcastle upon Tyne, United Kingdom
| | - Matthew T. Huggett
- Department of Gastroenterology, St. James’s University Hospital, Leeds, United Kingdom
| | - Kofi W. Oppong
- HPB Unit, Freeman Hospital, Newcastle upon Tyne, United Kingdom,Department of Gastroenterology, Freeman Hospital, Newcastle upon Tyne, United Kingdom,Corresponding author Kofi W. Oppong, MD HPB UnitFreeman HospitalNewcastle upon Tyne NE7 7DNUnited Kingdom+44-191-2231249
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15
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Law R, Baron TH. Endoscopic Ultrasonography-guided Drainage of Pancreatic Collections, Including the Role of Necrosectomy. Gastrointest Endosc Clin N Am 2017; 27:715-726. [PMID: 28918807 DOI: 10.1016/j.giec.2017.06.007] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
In recent years, the management of symptoms of pancreatic fluid collections has shifted from surgical and percutaneous interventions to endoscopic techniques. Available data show that endoscopic drainage can be achieved with minimal morbidity and procedural-related mortality, a high degree of technical and clinical success, and acceptable risk of adverse events. Although endoscopic management of walled-off necrosis provides a durable, minimally invasive treatment option, it is still generally performed only in tertiary care medical centers because of the overall complexity of this clinical scenario.
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Affiliation(s)
- Ryan Law
- Division of Gastroenterology, University of Michigan, 3912 Taubman Center, 1500 East Medical Center Drive, SPC 5362, Ann Arbor, MI 48109-5362, USA
| | - Todd H Baron
- Division of Gastroenterology and Hepatology, The University of North Carolina at Chapel Hill, 130 Mason Farm Road, CB 7080, Chapel Hill, NC 27599-0001, USA.
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16
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Rana SS, Sharma R, Ahmed SU, Gupta R. Endoscopic ultrasound-guided transmural drainage of walled-off pancreatic necrosis in patients with portal hypertension and intra-abdominal collaterals. Indian J Gastroenterol 2017; 36:400-404. [PMID: 28971378 DOI: 10.1007/s12664-017-0792-y] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/22/2017] [Accepted: 09/16/2017] [Indexed: 02/04/2023]
Abstract
BACKGROUND Acute necrotizing pancreatitis (ANP) is complicated with segmental portal hypertension (PHT) and formation of venous collaterals. Presence of collaterals in vicinity of endoscopic transmural tract can lead to potentially catastrophic situation. Here, we report safety and outcome of EUS-guided transmural drainage of walled-off pancreatic necrosis (WOPN) in patients with PHT and intra-abdominal collaterals. METHODS Retrospective analysis of collected database of patients (n=18; age 40.94±8.43 years; 17 males) who underwent EUS-guided transmural drainage of WOPN and had PHT with collaterals. RESULTS Etiology of ANP: alcohol in 14 and gallstones in 3 patients. Mean size of collection was 10.7±3.5 cm, and all 18 patients had splenic vein thrombosis with 1 patient also having portal vein thrombosis. Drainage was not feasible in 1 patient as no window free of collaterals could be found. One patient with gastric variceal bleeding underwent drainage after successful obliteration of varix with glue. Multiple plastic stents were placed in 15 patients and fully covered self-expanding metallic stent (FCSEMS) in 1 patient and 1 patient required direct endoscopic necrosectomy (DEN). Mean procedures required were 3 ± 0.79 and time to resolution was 4.4 ± 1.3 weeks. One patient had post-drainage bleeding that was successfully managed with intravenous terlipressin and intermittent irrigation via nasocystic catheter. Successfully treated patients have been asymptomatic over follow up period of 15.65±12.2 weeks. CONCLUSION EUS-guided drainage of WOPN seems to be safe and effective in patients with portal hypertension and intra-abdominal collaterals.
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Affiliation(s)
- Surinder S Rana
- Department of Gastroenterology, Postgraduate Institute of Medical Education and Research, Chandigarh, 160 012, India.
| | - Ravi Sharma
- Department of Gastroenterology, Postgraduate Institute of Medical Education and Research, Chandigarh, 160 012, India
| | - Sobur Uddin Ahmed
- Department of Gastroenterology, Postgraduate Institute of Medical Education and Research, Chandigarh, 160 012, India
| | - Rajesh Gupta
- Department of Surgery, Postgraduate Institute of Medical Education and Research, Chandigarh, 160 012, India
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17
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Madácsy L, Kaltsidis H. Endoscopic ultrasound-guided extraluminal drainage: Novel concepts, challenges and future directions. INTERNATIONAL JOURNAL OF GASTROINTESTINAL INTERVENTION 2017. [DOI: 10.18528/gii160020] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Affiliation(s)
- László Madácsy
- Department of Gastroenterology and Endoscopy, Bács-Kiskun County Teaching Hospital, University of Szeged, Kecskemét, Hungary
| | - Harry Kaltsidis
- Department of Gastroenterology, University Hospitals of South Manchester, Manchester, UK
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18
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Venkatachalapathy S, Nayar MK. Therapeutic endoscopic ultrasound. Frontline Gastroenterol 2017; 8:119-123. [PMID: 28261439 PMCID: PMC5318651 DOI: 10.1136/flgastro-2016-100774] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/05/2016] [Revised: 12/13/2016] [Accepted: 12/15/2016] [Indexed: 02/07/2023] Open
Abstract
Endoscopic ultrasound (EUS) is now firmly established as one of the essential tools for diagnosis in most gastrointestinal MDTs across the UK. However, the ability to provide therapy with EUS has resulted in a significant impact on the management of the patients. These include drainage of peripancreatic collections, EUS-guided endoscopic retrograde cholangiopancreatogram, EUS-guided coeliac plexus blocks, etc. The rapid development of this area in endoscopy is a combination of newer tools and increasing expertise by endosonographers to push the boundaries of intervention with EUS. However, the indications are limited and we are at the start of the learning curve for these high-risk procedures. These therapies should, therefore, be confined to centres with a robust multidisciplinary team, including interventional endoscopists, radiologists and surgeons.
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Affiliation(s)
- Suresh Venkatachalapathy
- Department of Gastroenterology and Hepatology, Nottingham University Hospitals NHS Trust, Nottingham, UK
| | - Manu K Nayar
- HPB Unit, Freeman Hospital, Newcastle Upon Tyne, UK
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19
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Oppong K. Advancing the diagnostic and therapeutic role of EUS in pancreaticobiliary disease: Hopkins Lecture 2016. Frontline Gastroenterol 2017; 8:115-118. [PMID: 28839895 PMCID: PMC5369446 DOI: 10.1136/flgastro-2016-100759] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/11/2016] [Accepted: 10/17/2016] [Indexed: 02/04/2023] Open
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20
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Rana SS, Sharma V, Sharma R, Gupta R, Bhasin DK. Endoscopic ultrasound guided transmural drainage of walled off pancreatic necrosis using a "step - up" approach: A single centre experience. Pancreatology 2017; 17:203-208. [PMID: 28202234 DOI: 10.1016/j.pan.2017.02.007] [Citation(s) in RCA: 31] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/14/2016] [Revised: 02/06/2017] [Accepted: 02/07/2017] [Indexed: 12/11/2022]
Abstract
BACKGROUND Walled off necrosis (WON) can be treated endoscopically using multiple transmural plastic stents or fully covered self-expandable metallic stent (FCSEMS) and direct endoscopic necrosectomy (DEN). We evaluated the efficacy of "step-up" endoscopic transmural approach for treatment of WON. METHODS Retrospective analysis of data of 86 patients with WON who were treated with attempted endoscopic ultrasound (EUS) guided "step up" transmural drainage during last 5 years was done. Initially multiple plastic stents were placed and patients not responding underwent FCSEMS placement and/or DEN. RESULTS Patients presented 10.8 ± 2.8 weeks after an acute attack of acute pancreatitis and mean size of WON was 10.7 ± 2.9 cm. EUS guided transmural drainage was technically successful in 85/86 (98.8%) patients and 70 (82.4%) were drained with multiple 7/10Fr plastic stents alone while DEN was needed in 9 (10.6%) and FCSEMS was inserted in 6 (7%) patients. All patients had successful outcome with none requiring surgery. The patients who needed DEN/FCSEMS presented earlier and had large size collection with more solid necrotic debris as compared to patients treated with multiple plastic stents alone. The complications were pneumoperitoneum (n = 1), bile leak following cholecystecomy (n = 1), development of external pancreatic fistula following percutaneous drainage (n = 1) and gastrointestinal bleed (n = 1). CONCLUSIONS "Step up" endoscopic transmural drainage using multiple plastic stents as an initial therapy is safe and effective treatment of WON and avoids more aggressive DEN in majority of patients. Large size WON with more necrotic debris may require DEN.
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Affiliation(s)
- Surinder S Rana
- Department of Gastroenterology, Post Graduate Institute of Medical Education and Research (PGIMER), Sector 12, Chandigarh 160012, India.
| | - Vishal Sharma
- Department of Gastroenterology, Post Graduate Institute of Medical Education and Research (PGIMER), Sector 12, Chandigarh 160012, India
| | - Ravi Sharma
- Department of Gastroenterology, Post Graduate Institute of Medical Education and Research (PGIMER), Sector 12, Chandigarh 160012, India
| | - Rajesh Gupta
- Department of Surgery, Post Graduate Institute of Medical Education and Research (PGIMER), Sector 12, Chandigarh 160012, India
| | - Deepak K Bhasin
- Department of Gastroenterology, Post Graduate Institute of Medical Education and Research (PGIMER), Sector 12, Chandigarh 160012, India
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21
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Li JW, Li JW, Ang TL, Ang TL. Is endoscopic necrosectomy the way to go? GASTROINTESTINAL INTERVENTION 2016. [DOI: 10.18528/gii160010] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/26/2022]
Affiliation(s)
- James Weiquan Li
- Department of Gastroenterology and Hepatology, Changi General Hospital, Singapore
| | - James Weiquan Li
- Department of Gastroenterology and Hepatology, Changi General Hospital, Singapore
| | - Tiing Leong Ang
- Department of Gastroenterology and Hepatology, Changi General Hospital, Singapore
| | - Tiing Leong Ang
- Department of Gastroenterology and Hepatology, Changi General Hospital, Singapore
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22
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Isayama H, Nakai Y, Rerknimitr R, Khor C, Lau J, Wang HP, Seo DW, Ratanachu-Ek T, Lakhtakia S, Ang TL, Ryozawa S, Hayashi T, Kawakami H, Yamamoto N, Iwashita T, Itokawa F, Kuwatani M, Kitano M, Hanada K, Kogure H, Hamada T, Ponnudurai R, Moon JH, Itoi T, Yasuda I, Irisawa A, Maetani I. Asian consensus statements on endoscopic management of walled-off necrosis. Part 2: Endoscopic management. J Gastroenterol Hepatol 2016; 31:1555-65. [PMID: 27042957 DOI: 10.1111/jgh.13398] [Citation(s) in RCA: 29] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/13/2016] [Revised: 03/03/2016] [Accepted: 03/22/2016] [Indexed: 12/11/2022]
Abstract
Walled-off necrosis (WON) is a new term for encapsulated necrotic tissue after severe acute pancreatitis. Various terminologies such as pseudocyst, necroma, pancreatic abscess, and infected necrosis were previously used in the literature, resulting in confusion. The current and past terminologies must be reconciled to meaningfully interpret past data. Recently, endoscopic necrosectomy was introduced as a treatment option and is now preferred over surgical necrosectomy when the expertise is available. However, high-quality evidence is still lacking, and there is no standard management strategy for WON. The consensus meeting aimed to clarify the diagnostic criteria for WON and the role of endoscopic interventions in its management. In the Consensus Conference, 27 experts from eight Asian countries took an active role and examined key clinical aspects of WON diagnosis and endoscopic management. Statements were crafted based on literature review and expert opinion, employing the modified Delphi method. All statements were substantiated by the level of evidence and the strength of the recommendation. We created 27 consensus statements for WON diagnosis and management, including details of endoscopic procedures. When there was not enough solid evidence to support the statements, this was clearly acknowledged to facilitate future research. Proposed management strategies were formulated and are illustrated using flow charts. These recommendations, which are based on the best current scientific evidence and expert opinion, will be useful for guiding endoscopic management of WON. Part 2 of this statement focused on the endoscopic management of WON.
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Affiliation(s)
- Hiroyuki Isayama
- Department of Gastroenterology, Graduate School of Medicine, The University of Tokyo, Tokyo, Japan.
| | - Yousuke Nakai
- Department of Gastroenterology, Graduate School of Medicine, The University of Tokyo, Tokyo, Japan
| | - Rungsun Rerknimitr
- Division of Gastroenterology, Department of Medicine, Chulalongkorn University, Bangkok, Thailand
| | - Christopher Khor
- Department of Gastroenterology and Hepatology, Singapore General Hospital, Singapore, Singapore
| | - James Lau
- Department of Surgery, Endoscopic Center, Prince of Wales Hospital, The Chinese University of Hong Kong, Hong Kong, China
| | - Hsiu-Po Wang
- Endoscopic Division, National Taiwan University Hospital, National Taiwan University, Taipei, Taiwan
| | - Dong Wan Seo
- Department of Internal Medicine, University of Ulsan College of Medicine, Asan Medical Center, Seoul, Korea
| | | | | | - Tiing Leong Ang
- Department of Gastroenterology and Hepatology, Changi General Hospital, Singapore, Singapore
| | - Shomei Ryozawa
- Department of Gastroenterology, Saitama Medical University International Medical Center, Saitama, Japan
| | - Tsuyoshi Hayashi
- Department of Gastroenterology, Hokkaido Cancer Center, Sapporo, Japan
| | - Hiroshi Kawakami
- Department of Gastroenterology and Hepatology, Hokkaido University Hospital, Sapporo, Japan
| | - Natusyo Yamamoto
- Department of Gastroenterology, Graduate School of Medicine, The University of Tokyo, Tokyo, Japan
| | - Takuji Iwashita
- First Department of Internal Medicine, Gifu University Hospital, Gifu, Japan
| | - Fumihide Itokawa
- Department of Gastroenterology and Hepatology, Tokyo Medical University, Tokyo, Japan
| | - Masaki Kuwatani
- Division of Endoscopy, Hokkaido University Hospital, Sapporo, Japan
| | - Masayuki Kitano
- Department of Gastroenterology and Hepatology, Kinki University Faculty of Medicine, Osaka-sayama, Japan
| | - Keiji Hanada
- Department of Gastroenterology, Onomichi General Hospital, Onomichi, Japan
| | - Hirofumi Kogure
- Department of Gastroenterology, Graduate School of Medicine, The University of Tokyo, Tokyo, Japan
| | - Tsuyoshi Hamada
- Department of Gastroenterology, Graduate School of Medicine, The University of Tokyo, Tokyo, Japan
| | | | - Jong Ho Moon
- Digestive Disease Center and Research Institute, Department of Internal Medicine, Soon Chun Hyang University School of Medicine, Bucheon/Seoul, Korea
| | - Takao Itoi
- Department of Gastroenterology and Hepatology, Tokyo Medical University, Tokyo, Japan
| | - Ichiro Yasuda
- Department of Gastroenterology, Teikyo University Mizonokuchi Hospital, Kanagawa, Japan
| | - Atsushi Irisawa
- Department of Gastroenterology, Fukushima Medical University, Aizu Medical Center, Aizuwakamatsu, Japan
| | - Iruru Maetani
- Division of Gastroenterology and Hepatology, Department of Internal Medicine, Toho University Ohashi Medical Center, Tokyo, Japan
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23
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Greenberg JA, Hsu J, Bawazeer M, Marshall J, Friedrich JO, Nathens A, Coburn N, May GR, Pearsall E, McLeod RS. Clinical practice guideline: management of acute pancreatitis. Can J Surg 2016; 59:128-40. [PMID: 27007094 DOI: 10.1503/cjs.015015] [Citation(s) in RCA: 233] [Impact Index Per Article: 25.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022] Open
Abstract
ABSTRACT There has been an increase in the incidence of acute pancreatitis reported worldwide. Despite improvements in access to care, imaging and interventional techniques, acute pancreatitis continues to be associated with significant morbidity and mortality. Despite the availability of clinical practice guidelines for the management of acute pancreatitis, recent studies auditing the clinical management of the condition have shown important areas of noncompliance with evidence-based recommendations. This underscores the importance of creating understandable and implementable recommendations for the diagnosis and management of acute pancreatitis. The purpose of the present guideline is to provide evidence-based recommendations for the management of both mild and severe acute pancreatitis as well as the management of complications of acute pancreatitis and of gall stone-induced pancreatitis.
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Affiliation(s)
- Joshua A Greenberg
- From the Department of Surgery, University of Toronto, Toronto, Ont. (Greenberg, Bawazeer, Nathens, Coburn, Pearsall, McLeod); the Department of Medicine, University of Toronto, Toronto, Ont. (Hsu, Friedrich, May); the Department of Health Policy, Management and Evaluation, University of Toronto, Toronto, Ont. (McLeod); the Interdepartmental Division of Critical Care, University of Toronto, Toronto, Ont. (Bawazeer, Friedrich); the Division of General Surgery, Mount Sinai Hospital, Toronto, Ont. (McLeod); the Zane Cohen Centre for Digestive Diseases, Mount Sinai Hospital, Toronto, Ont. (Hsu, Pearsall, McLeod); the Samuel Lunenfeld Research Institute, Mount Sinai Hospital, Toronto, Ont. (McLeod); the Division of General Surgery, Sunnybrook Health Sciences Centre, Toronto, Ont. (Nathens, Coburn); and the Divisions of Gastroenterology and General Surgery (Marshall) and Critical Care (Friedrich), St. Michael's Hospital, Toronto, Ont
| | - Jonathan Hsu
- From the Department of Surgery, University of Toronto, Toronto, Ont. (Greenberg, Bawazeer, Nathens, Coburn, Pearsall, McLeod); the Department of Medicine, University of Toronto, Toronto, Ont. (Hsu, Friedrich, May); the Department of Health Policy, Management and Evaluation, University of Toronto, Toronto, Ont. (McLeod); the Interdepartmental Division of Critical Care, University of Toronto, Toronto, Ont. (Bawazeer, Friedrich); the Division of General Surgery, Mount Sinai Hospital, Toronto, Ont. (McLeod); the Zane Cohen Centre for Digestive Diseases, Mount Sinai Hospital, Toronto, Ont. (Hsu, Pearsall, McLeod); the Samuel Lunenfeld Research Institute, Mount Sinai Hospital, Toronto, Ont. (McLeod); the Division of General Surgery, Sunnybrook Health Sciences Centre, Toronto, Ont. (Nathens, Coburn); and the Divisions of Gastroenterology and General Surgery (Marshall) and Critical Care (Friedrich), St. Michael's Hospital, Toronto, Ont
| | - Mohammad Bawazeer
- From the Department of Surgery, University of Toronto, Toronto, Ont. (Greenberg, Bawazeer, Nathens, Coburn, Pearsall, McLeod); the Department of Medicine, University of Toronto, Toronto, Ont. (Hsu, Friedrich, May); the Department of Health Policy, Management and Evaluation, University of Toronto, Toronto, Ont. (McLeod); the Interdepartmental Division of Critical Care, University of Toronto, Toronto, Ont. (Bawazeer, Friedrich); the Division of General Surgery, Mount Sinai Hospital, Toronto, Ont. (McLeod); the Zane Cohen Centre for Digestive Diseases, Mount Sinai Hospital, Toronto, Ont. (Hsu, Pearsall, McLeod); the Samuel Lunenfeld Research Institute, Mount Sinai Hospital, Toronto, Ont. (McLeod); the Division of General Surgery, Sunnybrook Health Sciences Centre, Toronto, Ont. (Nathens, Coburn); and the Divisions of Gastroenterology and General Surgery (Marshall) and Critical Care (Friedrich), St. Michael's Hospital, Toronto, Ont
| | - John Marshall
- From the Department of Surgery, University of Toronto, Toronto, Ont. (Greenberg, Bawazeer, Nathens, Coburn, Pearsall, McLeod); the Department of Medicine, University of Toronto, Toronto, Ont. (Hsu, Friedrich, May); the Department of Health Policy, Management and Evaluation, University of Toronto, Toronto, Ont. (McLeod); the Interdepartmental Division of Critical Care, University of Toronto, Toronto, Ont. (Bawazeer, Friedrich); the Division of General Surgery, Mount Sinai Hospital, Toronto, Ont. (McLeod); the Zane Cohen Centre for Digestive Diseases, Mount Sinai Hospital, Toronto, Ont. (Hsu, Pearsall, McLeod); the Samuel Lunenfeld Research Institute, Mount Sinai Hospital, Toronto, Ont. (McLeod); the Division of General Surgery, Sunnybrook Health Sciences Centre, Toronto, Ont. (Nathens, Coburn); and the Divisions of Gastroenterology and General Surgery (Marshall) and Critical Care (Friedrich), St. Michael's Hospital, Toronto, Ont
| | - Jan O Friedrich
- From the Department of Surgery, University of Toronto, Toronto, Ont. (Greenberg, Bawazeer, Nathens, Coburn, Pearsall, McLeod); the Department of Medicine, University of Toronto, Toronto, Ont. (Hsu, Friedrich, May); the Department of Health Policy, Management and Evaluation, University of Toronto, Toronto, Ont. (McLeod); the Interdepartmental Division of Critical Care, University of Toronto, Toronto, Ont. (Bawazeer, Friedrich); the Division of General Surgery, Mount Sinai Hospital, Toronto, Ont. (McLeod); the Zane Cohen Centre for Digestive Diseases, Mount Sinai Hospital, Toronto, Ont. (Hsu, Pearsall, McLeod); the Samuel Lunenfeld Research Institute, Mount Sinai Hospital, Toronto, Ont. (McLeod); the Division of General Surgery, Sunnybrook Health Sciences Centre, Toronto, Ont. (Nathens, Coburn); and the Divisions of Gastroenterology and General Surgery (Marshall) and Critical Care (Friedrich), St. Michael's Hospital, Toronto, Ont
| | - Avery Nathens
- From the Department of Surgery, University of Toronto, Toronto, Ont. (Greenberg, Bawazeer, Nathens, Coburn, Pearsall, McLeod); the Department of Medicine, University of Toronto, Toronto, Ont. (Hsu, Friedrich, May); the Department of Health Policy, Management and Evaluation, University of Toronto, Toronto, Ont. (McLeod); the Interdepartmental Division of Critical Care, University of Toronto, Toronto, Ont. (Bawazeer, Friedrich); the Division of General Surgery, Mount Sinai Hospital, Toronto, Ont. (McLeod); the Zane Cohen Centre for Digestive Diseases, Mount Sinai Hospital, Toronto, Ont. (Hsu, Pearsall, McLeod); the Samuel Lunenfeld Research Institute, Mount Sinai Hospital, Toronto, Ont. (McLeod); the Division of General Surgery, Sunnybrook Health Sciences Centre, Toronto, Ont. (Nathens, Coburn); and the Divisions of Gastroenterology and General Surgery (Marshall) and Critical Care (Friedrich), St. Michael's Hospital, Toronto, Ont
| | - Natalie Coburn
- From the Department of Surgery, University of Toronto, Toronto, Ont. (Greenberg, Bawazeer, Nathens, Coburn, Pearsall, McLeod); the Department of Medicine, University of Toronto, Toronto, Ont. (Hsu, Friedrich, May); the Department of Health Policy, Management and Evaluation, University of Toronto, Toronto, Ont. (McLeod); the Interdepartmental Division of Critical Care, University of Toronto, Toronto, Ont. (Bawazeer, Friedrich); the Division of General Surgery, Mount Sinai Hospital, Toronto, Ont. (McLeod); the Zane Cohen Centre for Digestive Diseases, Mount Sinai Hospital, Toronto, Ont. (Hsu, Pearsall, McLeod); the Samuel Lunenfeld Research Institute, Mount Sinai Hospital, Toronto, Ont. (McLeod); the Division of General Surgery, Sunnybrook Health Sciences Centre, Toronto, Ont. (Nathens, Coburn); and the Divisions of Gastroenterology and General Surgery (Marshall) and Critical Care (Friedrich), St. Michael's Hospital, Toronto, Ont
| | - Gary R May
- From the Department of Surgery, University of Toronto, Toronto, Ont. (Greenberg, Bawazeer, Nathens, Coburn, Pearsall, McLeod); the Department of Medicine, University of Toronto, Toronto, Ont. (Hsu, Friedrich, May); the Department of Health Policy, Management and Evaluation, University of Toronto, Toronto, Ont. (McLeod); the Interdepartmental Division of Critical Care, University of Toronto, Toronto, Ont. (Bawazeer, Friedrich); the Division of General Surgery, Mount Sinai Hospital, Toronto, Ont. (McLeod); the Zane Cohen Centre for Digestive Diseases, Mount Sinai Hospital, Toronto, Ont. (Hsu, Pearsall, McLeod); the Samuel Lunenfeld Research Institute, Mount Sinai Hospital, Toronto, Ont. (McLeod); the Division of General Surgery, Sunnybrook Health Sciences Centre, Toronto, Ont. (Nathens, Coburn); and the Divisions of Gastroenterology and General Surgery (Marshall) and Critical Care (Friedrich), St. Michael's Hospital, Toronto, Ont
| | - Emily Pearsall
- From the Department of Surgery, University of Toronto, Toronto, Ont. (Greenberg, Bawazeer, Nathens, Coburn, Pearsall, McLeod); the Department of Medicine, University of Toronto, Toronto, Ont. (Hsu, Friedrich, May); the Department of Health Policy, Management and Evaluation, University of Toronto, Toronto, Ont. (McLeod); the Interdepartmental Division of Critical Care, University of Toronto, Toronto, Ont. (Bawazeer, Friedrich); the Division of General Surgery, Mount Sinai Hospital, Toronto, Ont. (McLeod); the Zane Cohen Centre for Digestive Diseases, Mount Sinai Hospital, Toronto, Ont. (Hsu, Pearsall, McLeod); the Samuel Lunenfeld Research Institute, Mount Sinai Hospital, Toronto, Ont. (McLeod); the Division of General Surgery, Sunnybrook Health Sciences Centre, Toronto, Ont. (Nathens, Coburn); and the Divisions of Gastroenterology and General Surgery (Marshall) and Critical Care (Friedrich), St. Michael's Hospital, Toronto, Ont
| | - Robin S McLeod
- From the Department of Surgery, University of Toronto, Toronto, Ont. (Greenberg, Bawazeer, Nathens, Coburn, Pearsall, McLeod); the Department of Medicine, University of Toronto, Toronto, Ont. (Hsu, Friedrich, May); the Department of Health Policy, Management and Evaluation, University of Toronto, Toronto, Ont. (McLeod); the Interdepartmental Division of Critical Care, University of Toronto, Toronto, Ont. (Bawazeer, Friedrich); the Division of General Surgery, Mount Sinai Hospital, Toronto, Ont. (McLeod); the Zane Cohen Centre for Digestive Diseases, Mount Sinai Hospital, Toronto, Ont. (Hsu, Pearsall, McLeod); the Samuel Lunenfeld Research Institute, Mount Sinai Hospital, Toronto, Ont. (McLeod); the Division of General Surgery, Sunnybrook Health Sciences Centre, Toronto, Ont. (Nathens, Coburn); and the Divisions of Gastroenterology and General Surgery (Marshall) and Critical Care (Friedrich), St. Michael's Hospital, Toronto, Ont
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Werge M, Novovic S, Schmidt PN, Gluud LL. Infection increases mortality in necrotizing pancreatitis: A systematic review and meta-analysis. Pancreatology 2016; 16:698-707. [PMID: 27449605 DOI: 10.1016/j.pan.2016.07.004] [Citation(s) in RCA: 126] [Impact Index Per Article: 14.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/25/2016] [Revised: 06/07/2016] [Accepted: 07/06/2016] [Indexed: 02/09/2023]
Abstract
OBJECTIVES To assess the influence of infection on mortality in necrotizing pancreatitis. METHODS Eligible prospective and retrospective studies were identified through manual and electronic searches (August 2015). The risk of bias was assessed using the Newcastle-Ottawa Scale (NOS). Meta-analyses were performed with subgroup, sensitivity, and meta-regression analyses to evaluate sources of heterogeneity. RESULTS We included 71 studies (n = 6970 patients). Thirty-seven (52%) studies used a prospective design and 25 scored ≥5 points on the NOS suggesting a low risk of bias. Forty studies were descriptive and 31 studies evaluated invasive interventions. In total, 801 of 2842 patients (28%) with infected necroses and 537 of 4128 patients (13%) with sterile necroses died with an odds ratio [OR] of 2.57 (95% confidence interval [CI], 2.00-3.31) based on all studies and 2.02 (95%CI, 1.61-2.53) in the studies with the lowest bias risk. The OR for prospective studies was 2.96 (95%CI, 2.51-3.50). In sensitivity analyses excluding studies evaluating invasive interventions, the OR was 3.30 (95%CI, 2.81-3.88). Patients with infected necrosis and organ failure had a mortality of 35.2% while concomitant sterile necrosis and organ failure was associated with a mortality of 19.8%. If the patients had infected necrosis without organ failure the mortality was 1.4%. CONCLUSIONS Patients with necrotizing pancreatitis are more than twice as likely to die if the necrosis becomes infected. Both organ failure and infected necrosis increase mortality in necrotizing pancreatitis.
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Affiliation(s)
- Mikkel Werge
- Department of Gastroenterology and Gastrointestinal Surgery, Copenhagen University Hospital Hvidovre, Denmark
| | - Srdan Novovic
- Department of Gastroenterology and Gastrointestinal Surgery, Copenhagen University Hospital Hvidovre, Denmark
| | - Palle N Schmidt
- Department of Gastroenterology and Gastrointestinal Surgery, Copenhagen University Hospital Hvidovre, Denmark
| | - Lise L Gluud
- Department of Gastroenterology and Gastrointestinal Surgery, Copenhagen University Hospital Hvidovre, Denmark.
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25
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Gomatos IP, Halloran CM, Ghaneh P, Raraty MGT, Polydoros F, Evans JC, Smart HL, Yagati-Satchidanand R, Garry JM, Whelan PA, Hughes FE, Sutton R, Neoptolemos JP. Outcomes From Minimal Access Retroperitoneal and Open Pancreatic Necrosectomy in 394 Patients With Necrotizing Pancreatitis. Ann Surg 2016; 263:992-1001. [PMID: 26501713 DOI: 10.1097/sla.0000000000001407] [Citation(s) in RCA: 69] [Impact Index Per Article: 7.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
OBJECTIVE To examine the outcomes from minimal access retroperitoneal pancreatic necrosectomy (MARPN) and open pancreatic necrosectomy (OPN) for severe necrotizing pancreatitis in a single center. BACKGROUND The optimal management of severe pancreatic necrosis is evolving with a few large center single series. METHODS Between 1997 and 2013, patients with necrotizing pancreatitis at the Liverpool Pancreas Center were reviewed. Outcome measures were retrospectively analyzed by intention to treat. RESULTS There were 394 patients who had either MARPN (274, 69.5%) or OPN (120, 30.5%). Complications occurred in 174 MARPN patients (63.5%) and 98 (81.7%) OPN patients (P < 0.001). OPN was associated with increased postoperative multiorgan failure [42 (35%) vs 56 (20.4%), P = 0.001] and median (inter-quartile range) Acute Physiology and Chronic Health Evaluation II score 9 (6-11.5) vs 8 (5-11), P < 0.001] with intensive care required less frequently in MARPN patients [40.9% (112) vs 75% (90), P < 0.001]. The mortality rate was 42 (15.3%) in MARPNs and 28 (23.3%) in OPNs (P = 0.064). Both the mortality and the overall complication rates decreased between 1997-2008 and 2008-2013 [49 (23.8%) vs 21 (11.2%) P = 0.001, respectively; and 151 (73.3%) vs 121 (64.4%), P = 0.080, respectively). Increased mortality was independently associated with age (P < 0.001), preoperative intensive care stay (P = 0.014), and multiple organ failure (P < 0.001); operation before 2008 (P < 0.001) and conversion to OPN (P = 0.035). MARPN independently reduced mortality odds risk (odds ratio = 0.27; 95% confidence interval = 0.12-0.57; P < 0.001). CONCLUSIONS Increasing experience and advances in perioperative care have led to improvement in outcomes. The role of MARPN in reducing complications and deaths within a multimodality approach remains substantial and should be used initially if feasible.
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Affiliation(s)
- Ilias P Gomatos
- *Clinical Directorate of General Surgery, National Institutes of Health Research Liverpool Pancreas Biomedical Research Unit, Royal Liverpool and Broadgreen University Hospitals NHS Trust, Liverpool, UK †Liverpool Clinical Trials Unit, University of Liverpool, Liverpool, UK ‡Clinical Directorate of Radiology, National Institutes of Health Research Liverpool Pancreas Biomedical Research Unit, Royal Liverpool and Broadgreen University Hospitals NHS Trust, Liverpool, UK §Clinical Directorate of Gastroenterology, National Institutes of Health Research Liverpool Pancreas Biomedical Research Unit, Royal Liverpool University Hospital NHS Trust, Liverpool, UK
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26
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Schmidt PN, Novovic S, Roug S, Feldager E. Endoscopic, transmural drainage and necrosectomy for walled-off pancreatic and peripancreatic necrosis is associated with low mortality--a single-center experience. Scand J Gastroenterol 2015; 50:611-8. [PMID: 25648776 DOI: 10.3109/00365521.2014.946078] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
OBJECTIVE Endoscopic transmural drainage and necrosectomy (ETDN) is a promising alternative to percutaneous drainage and surgical intervention in the treatment of walled-off pancreatic and peripancreatic necroses (WONs). We assessed the outcome and safety profile of ETDN in a single-center patient cohort. MATERIALS AND METHODS In November 2005, ETDN for WON was introduced in our tertiary referral center. During a 6-year period (Nov 2005-Nov 2011), we retrospectively collected data on all patients who underwent ETDN. RESULTS Eighty-one patients were treated with ETDN (median age 54, 52 men). Gallstones were the predominant etiology of pancreatitis (41%), followed by alcohol (33%). Median time from debut of symptoms to first endoscopic treatment was 44 (9-246) days. Culture-proven infected necrosis was found in 71% of the cases. Twenty-three patients (28%) required admission in intensive care unit. The technical and clinical success rates were 99% and 89%, respectively. Procedure-related complications occurred in 10 (12%) patients, of which 1 was procedure-related death. In-hospital mortality was 11%. CONCLUSION ETDN in patients with necrotizing pancreatitis and infected necrosis performed in a single, high-volume center has an acceptable safety profile and is associated with a low mortality.
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Affiliation(s)
- Palle Nordblad Schmidt
- Department of Gastroenterology and Gastrointestinal Surgery, Hvidovre Hospital , Copenhagen , Denmark
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27
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Abstract
Over the last several years, there have been refinements in the understanding and nomenclature regarding the natural history of acute pancreatitis. Patients with acute pancreatitis frequently develop acute pancreatic collections that, over time, may evolve into pancreatic pseudocysts or walled-off necrosis. Endoscopic management of these local complications of acute pancreatitis continues to evolve. Treatment strategies range from simple drainage of liquefied contents to repeated direct endoscopic necrosectomy of a complex necrotic collection. In patients with chronic pancreatitis, pancreatic pseudocysts may arise as a consequence of pancreatic ductal obstruction that then leads to pancreatic ductal disruption. In this review, we focus on the indications, techniques and outcomes for endoscopic therapy of pancreatic pseudocysts and walled-off necrosis.
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Affiliation(s)
- Ryan Law
- Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, MN, USA
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28
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Dhingra R, Srivastava S, Behra S, Vadiraj PK, Venuthurimilli A, Dash NR, Madhusudhan KS, Gamanagatti SR, Garg PK. Single or multiport percutaneous endoscopic necrosectomy performed with the patient under conscious sedation is a safe and effective treatment for infected pancreatic necrosis (with video). Gastrointest Endosc 2015; 81:351-9. [PMID: 25293824 DOI: 10.1016/j.gie.2014.07.060] [Citation(s) in RCA: 51] [Impact Index Per Article: 5.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/26/2013] [Accepted: 07/24/2014] [Indexed: 01/06/2023]
Abstract
BACKGROUND Infected pancreatic necrosis (IPN) is a dreaded adverse event of acute pancreatitis (AP). Most patients with IPN require drainage and necrosectomy, preferably by a minimally invasive method. OBJECTIVE To study the success and safety of an alternative form of minimally invasive necrosectomy for IPN. DESIGN Observational study. SETTING Tertiary care academic center. PATIENTS Consecutive patients with IPN formed the study group. INTERVENTION Patients with IPN were initially treated conservatively including percutaneous drainage. Those who failed to improve underwent percutaneous endoscopic necrosectomy (PEN). Single- or multiport PEN was performed by using a flexible endoscope through the percutaneous tract. PEN involved vigorous lavage and suction followed by necrosectomy. Multiple sessions were undertaken depending on the size and number of collections and the amount of necrotic debris. MAIN OUTCOME MEASUREMENTS Control of sepsis and resolution of collection(s) without the need for surgical necrosectomy. RESULTS During the period from October 2012 to July 2013, 165 patients (mean age, 38.82 ± 14.99 years; 119 male patients) were studied. Of them, 103 patients had necrotizing pancreatitis and IPN had developed in 74. Of these 74 patients with IPN, 15 underwent PEN after a mean interval of 39.2 days. Fourteen of the 15 patients improved after a mean of 5 sessions of PEN. Two of 15 patients had minor adverse events: self-limiting bleeding and pancreatic fistula in 1 patient each. One patient required surgery but died of organ failure. LIMITATIONS Lack of a control arm. CONCLUSION PEN is a safe and effective minimally invasive technique for necrosectomy for IPN.
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Affiliation(s)
- Rajan Dhingra
- Department of Gastroenterology, All India Institute of Medical Sciences, New Delhi, India
| | - Saurabh Srivastava
- Department of Gastroenterology, All India Institute of Medical Sciences, New Delhi, India
| | - Sanatan Behra
- Department of Gastroenterology, All India Institute of Medical Sciences, New Delhi, India
| | | | - Arun Venuthurimilli
- Department of Gastrointestinal Surgery, All India Institute of Medical Sciences, New Delhi, India
| | - Nihar Ranjan Dash
- Department of Gastrointestinal Surgery, All India Institute of Medical Sciences, New Delhi, India
| | | | | | - Pramod Kumar Garg
- Department of Gastroenterology, All India Institute of Medical Sciences, New Delhi, India
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Terayama T, Hifumi T, Kiriu N, Kato H, Koido Y, Ichinose Y, Morimoto K, Yasuhiro K. A minimally invasive multiple percutaneous drainage technique for acute necrotizing pancreatitis. World J Emerg Med 2014; 5:310-2. [PMID: 25548607 DOI: 10.5847/wjem.j.issn.1920-8642.2014.04.012] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/12/2014] [Accepted: 09/25/2014] [Indexed: 12/16/2022] Open
Abstract
BACKGROUND In approximately 20% of patients, necrotizing pancreatitis is complicated with severe acute pancreatitis, with high morbidity and mortality rates. Minimally invasive step-up approach is both safe and effective, but sometimes requires multiple access sites. METHODS A 62-year-old woman was admitted with diabetic ketoacidosis, and initial computed tomography (CT) revealed no evidence of acute pancreatitis. She was clinically improved with insulin therapy, fluid administration, and electrolyte replacement. However, on the 14(th) day of admission, she developed a high-grade fever, and CT demonstrated evidence of acute necrotizing pancreatitis with a large collection of peripancreatic fluid. Percutaneous transgastric drainage was performed and a 14 French gauge (Fr) pigtail catheter was placed 1 week later, which drained copious pus. Because of persistent high-grade fever and poor clinical improvement, multiple 8 and 10 Fr pigtail catheters were placed via the initial drainage route, allowing the safe and effective drainage of the extensive necrotic tissue that was occupying the bilateral anterior pararenal space. RESULTS After drainage, the patient recovered well and the last catheter was removed on day 123 of admission. CONCLUSIONS Multiple percutaneous drainage requires both careful judgment and specialist skills. The perforation of the colon and small bowel as well as the injury of the kidney and major vessels can occur. The current technique appears to be safe and minimally invasive compared with other drainage methods in patients with extended, infected necrotic pancreatic pseudocysts.
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Affiliation(s)
- Takero Terayama
- Division of Critical Care Medicine and Trauma, National Hospital Organization Disaster Medical Center, Tachikawa, Tokyo 190-0014, Japan
| | - Toru Hifumi
- Emergency Medical Center, Kagawa University Hospital, Miki, Kita, Kagawa 761-0793, Japan
| | - Nobuaki Kiriu
- Division of Critical Care Medicine and Trauma, National Hospital Organization Disaster Medical Center, Tachikawa, Tokyo 190-0014, Japan
| | - Hiroshi Kato
- Division of Critical Care Medicine and Trauma, National Hospital Organization Disaster Medical Center, Tachikawa, Tokyo 190-0014, Japan
| | - Yuichi Koido
- Division of Critical Care Medicine and Trauma, National Hospital Organization Disaster Medical Center, Tachikawa, Tokyo 190-0014, Japan
| | - Yoshiaki Ichinose
- Division of Radiology, National Hospital Organization Disaster Medical Center, Tachikawa, Tokyo 190-0014, Japan
| | - Kohei Morimoto
- Division of Radiology, National Hospital Organization Disaster Medical Center, Tachikawa, Tokyo 190-0014, Japan
| | - Kuroda Yasuhiro
- Division of Critical Care Medicine and Trauma, National Hospital Organization Disaster Medical Center, Tachikawa, Tokyo 190-0014, Japan
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Minimally invasive treatment of infected pancreatic necrosis. GASTROENTEROLOGY REVIEW 2014; 9:317-24. [PMID: 25653725 PMCID: PMC4300346 DOI: 10.5114/pg.2014.47893] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 07/21/2012] [Revised: 08/25/2012] [Accepted: 11/15/2012] [Indexed: 12/13/2022]
Abstract
Infected pancreatic necrosis is a challenging complication that worsens prognosis in acute pancreatitis. For years, open necrosectomy has been the mainstay treatment option in infected pancreatic necrosis, although surgical debridement still results in high morbidity and mortality rates. Recently, many reports on minimally invasive treatment in infected pancreatic necrosis have been published. This paper presents a review of minimally invasive techniques and attempts to define their role in the management of infected pancreatic necrosis.
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31
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Tan V, Charachon A, Lescot T, Chafaï N, Le Baleur Y, Delchier JC, Paye F. Endoscopic transgastric versus surgical necrosectomy in infected pancreatic necrosis. Clin Res Hepatol Gastroenterol 2014; 38:770-6. [PMID: 25153999 DOI: 10.1016/j.clinre.2014.06.016] [Citation(s) in RCA: 24] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/23/2013] [Revised: 03/22/2014] [Accepted: 06/13/2014] [Indexed: 02/04/2023]
Abstract
Surgical necrosectomy, but is still associated with a high morbidity. Indications of the endoscopic route, a new less invasive technique are not defined yet. To compare characteristics and clinical outcome of patients treated by the two techniques, a bi-centric retrospective comparison of 21 patients treated by surgical necrosectomy in one center (group S) with 11 patients treated in another center by endoscopic transgastric necrosectomy (group E) was performed. Clinical severity scores were significantly higher in group S although CT severity score did not differ between groups. Acute postoperative complications including pancreatic fistula occurred more frequently in group S (86% vs. 27%, P=0.002). ICU and hospital length of stay were higher in group S (84 vs. 4 days; P=0.008 and 58 vs. 15 days; P=0.005 respectively). Long-term complication did not differ between groups. Compared to surgery, endoscopic necrosectomy exhibited lower rate of complications and reduced hospital length of stays. Endoscopic transgastric necrosectomy appears as a safe and effective procedure and has to be included in the therapeutic algorithm of infected pancreatic necrosis.
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Affiliation(s)
- Virianne Tan
- AP-HP, Saint-Antoine University Hospital, Department of Digestive Surgery, 75012 Paris, France
| | - Antoine Charachon
- AP-HP, Henri-Mondor University Hospital, Department of Gastroenterology, 94000 Créteil, France
| | - Thomas Lescot
- AP-HP, Saint-Antoine University Hospital, Surgical Intensive Care Unit, 75012 Paris, France; UPMC University Paris 06, 75005 Paris, France
| | - Najim Chafaï
- AP-HP, Saint-Antoine University Hospital, Department of Digestive Surgery, 75012 Paris, France
| | - Yann Le Baleur
- AP-HP, Henri-Mondor University Hospital, Department of Gastroenterology, 94000 Créteil, France
| | - Jean-Charles Delchier
- AP-HP, Henri-Mondor University Hospital, Department of Gastroenterology, 94000 Créteil, France
| | - François Paye
- AP-HP, Saint-Antoine University Hospital, Department of Digestive Surgery, 75012 Paris, France; UPMC University Paris 06, 75005 Paris, France.
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32
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Paradigm shift away from open surgical necrosectomy toward endoscopic interventions for necrotizing pancreatitis. GASTROINTESTINAL INTERVENTION 2014. [DOI: 10.1016/j.gii.2014.09.010] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
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Saxena P, Singh VK, Messallam A, Kamal A, Zaheer A, Kumbhari V, Lennon AM, Canto MI, Kalloo AN, Baron TH, Khashab MA. Resolution of walled-off pancreatic necrosis by EUS-guided drainage when using a fully covered through-the-scope self-expandable metal stent in a single procedure (with video). Gastrointest Endosc 2014; 80:319-24. [PMID: 25034838 DOI: 10.1016/j.gie.2014.04.041] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/04/2013] [Accepted: 04/21/2014] [Indexed: 12/15/2022]
Abstract
BACKGROUND Walled-off pancreatic necrosis (WOPN) is effectively managed with percutaneous and endoscopic techniques such as direct endoscopic necrosectomy. However, they require repeat interventions and lengthy hospital stays. OBJECTIVE To evaluate a new platform to manage WOPNs by using a large-bore, through-the-scope, fully covered, self-expandable metal stent (FCSEMS) to overcome the need for repeat interventions and extended hospital stays. DESIGN Retrospective, single-center study. SETTING Academic tertiary care center. PATIENTS Five consecutive patients with symptomatic WOPN underwent EUS-guided drainage of WOPN by using a large-bore FCSEMSs. INTERVENTIONS EUS-guided transgastric drainage of WOPN by using a large-bore FCSEMS. Cross-sectional imaging was repeated at 6- to 8-week intervals. The FCSEMS was removed after WOPN resolution. MAIN OUTCOME MEASUREMENTS Clinical success, number of repeat interventions, and length of hospital stay. RESULTS Five patients (mean age 60 years) with WOPN (mean diameter, 12.3 cm; range 9.8-14.3 cm) underwent drainage with the described technique. Technical and clinical success was achieved in 100% of patients. Direct endoscopic necrosectomy was not required in any patient. The median number of endoscopic procedures was 1. The median length of hospital stay was 1 day. There were no adverse events. LIMITATIONS Small, retrospective study. CONCLUSIONS The described novel platform facilitates resolution of WOPN with a single procedure, avoiding the need for repeat interventions and lengthy hospital stays.
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Affiliation(s)
- Payal Saxena
- Department of Medicine, Division of Gastroenterology and Hepatology, The Johns Hopkins Medical Institutions, Baltimore, Maryland, USA
| | - Vikesh K Singh
- Department of Medicine, Division of Gastroenterology and Hepatology, The Johns Hopkins Medical Institutions, Baltimore, Maryland, USA
| | - Ahmed Messallam
- Department of Medicine, Division of Gastroenterology and Hepatology, The Johns Hopkins Medical Institutions, Baltimore, Maryland, USA
| | - Ayesha Kamal
- Department of Radiology, The Johns Hopkins Medical Institutions, Baltimore, Maryland, USA
| | - Atif Zaheer
- Department of Radiology, The Johns Hopkins Medical Institutions, Baltimore, Maryland, USA
| | - Vivek Kumbhari
- Department of Medicine, Division of Gastroenterology and Hepatology, The Johns Hopkins Medical Institutions, Baltimore, Maryland, USA
| | - Anne Marie Lennon
- Department of Medicine, Division of Gastroenterology and Hepatology, The Johns Hopkins Medical Institutions, Baltimore, Maryland, USA
| | - Marcia Irene Canto
- Department of Medicine, Division of Gastroenterology and Hepatology, The Johns Hopkins Medical Institutions, Baltimore, Maryland, USA
| | - Anthony N Kalloo
- Department of Medicine, Division of Gastroenterology and Hepatology, The Johns Hopkins Medical Institutions, Baltimore, Maryland, USA
| | - Todd H Baron
- Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, Minnesota, USA
| | - Mouen A Khashab
- Department of Medicine, Division of Gastroenterology and Hepatology, The Johns Hopkins Medical Institutions, Baltimore, Maryland, USA
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Fabbri C, Luigiano C, Lisotti A, Cennamo V, Virgilio C, Caletti G, Fusaroli P. Endoscopic ultrasound-guided treatments: are we getting evidence based--a systematic review. World J Gastroenterol 2014; 20:8424-8448. [PMID: 25024600 PMCID: PMC4093695 DOI: 10.3748/wjg.v20.i26.8424] [Citation(s) in RCA: 98] [Impact Index Per Article: 8.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/01/2013] [Revised: 01/30/2014] [Accepted: 03/12/2014] [Indexed: 02/07/2023] Open
Abstract
The continued need to develop less invasive alternatives to surgical and radiologic interventions has driven the development of endoscopic ultrasound (EUS)-guided treatments. These include EUS-guided drainage of pancreatic fluid collections, EUS-guided necrosectomy, EUS-guided cholangiography and biliary drainage, EUS-guided pancreatography and pancreatic duct drainage, EUS-guided gallbladder drainage, EUS-guided drainage of abdominal and pelvic fluid collections, EUS-guided celiac plexus block and celiac plexus neurolysis, EUS-guided pancreatic cyst ablation, EUS-guided vascular interventions, EUS-guided delivery of antitumoral agents and EUS-guided fiducial placement and brachytherapy. However these procedures are technically challenging and require expertise in both EUS and interventional endoscopy, such as endoscopic retrograde cholangiopancreatography and gastrointestinal stenting. We undertook a systematic review to record the entire body of literature accumulated over the past 2 decades on EUS-guided interventions with the objective of performing a critical appraisal of published articles, based on the classification of studies according to levels of evidence, in order to assess the scientific progress made in this field.
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Endoscopic interventions for necrotizing pancreatitis. Am J Gastroenterol 2014; 109:969-81; quiz 982. [PMID: 24957157 DOI: 10.1038/ajg.2014.130] [Citation(s) in RCA: 47] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/30/2013] [Accepted: 03/11/2014] [Indexed: 02/06/2023]
Abstract
Interventions for necrotizing pancreatitis have undergone a paradigm shift away from open surgical necrosectomy and toward minimally invasive techniques, with endoscopic transmural drainage (ETD) and necrosectomy emerging as principle forms of treatment. Recent multicenter studies, randomized trials, evidence-based guidelines, and consensus statements have endorsed the safety and efficacy of endoscopic and other minimally invasive techniques for the treatment of walled-off necrosis. A comprehensive review of indications, standard and novel approaches, outcomes, complications, and controversies regarding ETD and necrosectomy is presented. Given the inherent challenges and associated risks, endoscopic techniques for the management of necrotizing pancreatitis should be performed at specialized multidisciplinary centers by expert endoscopists well versed in the management of necrotizing pancreatitis.
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Rana SS, Bhasin DK, Sharma RK, Kathiresan J, Gupta R. Do the morphological features of walled off pancreatic necrosis on endoscopic ultrasound determine the outcome of endoscopic transmural drainage? Endosc Ultrasound 2014; 3:118-22. [PMID: 24955341 PMCID: PMC4064159 DOI: 10.4103/2303-9027.131039] [Citation(s) in RCA: 66] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/29/2013] [Accepted: 11/27/2013] [Indexed: 12/13/2022] Open
Abstract
Background and Objective: Endoscopic transmural drainage is an effective, but technically demanding treatment modality for walled off pancreatic necrosis (WOPN). The factors that determine the outcome of endoscopic treatment for WOPN have been infrequently studied. We aim to retrospectively correlate the morphological features of WOPN on endoscopic ultrasound (EUS) with the outcome of endoscopic transmural drainage. Patients and Methods: Over the last 3 years, 43 patients (36 males; mean age 36.04 ± 10.06 years) with symptomatic WOPN were treated by an attempted endoscopic drainage. The correlation between the morphological features of WOPN and the type of treatment offered as well as the number of endoscopic procedures undergone by the patient was assessed. Results: The mean size of WOPN was 9.95 ± 2.75 cm with <10%, 10-40% and >40% solid debris being present in 6, 33, and 4 patients, respectively. Patients with <10% necrotic debris needed only single session of endoscopic drainage, whereas patients with 10-40% solid debris needed two or more sessions. Patients with >40% solid debris either needed direct endoscopic debridement or surgical necrosectomy. The extent of necrosis correlated significantly (r = 0.703, P < 0.001) with the type of treatment received by the patient. With increasing size of the collection (r = 0.320, P = 0.047) and the amount of the solid debris (r = 0.800, P < 0.001), there was a significant increase in the number of endoscopic procedures required for successful outcome by the patient. Conclusions: The morphological features of WOPN on EUS have important therapeutic implications with collections having large size and more solid debris needing more aggressive therapeutic method for the successful outcome.
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Affiliation(s)
- Surinder Singh Rana
- Department of Gastroenterology, Post Graduate Institute of Medical Education and Research, Sector 12, Chandigarh - 160 012, India
| | - Deepak Kumar Bhasin
- Department of Gastroenterology, Post Graduate Institute of Medical Education and Research, Sector 12, Chandigarh - 160 012, India
| | - Ravi Kumar Sharma
- Department of Gastroenterology, Post Graduate Institute of Medical Education and Research, Sector 12, Chandigarh - 160 012, India
| | - Jeyashree Kathiresan
- School of Public Health, Post Graduate Institute of Medical Education and Research, Sector 12, Chandigarh - 160 012, India
| | - Rajesh Gupta
- Department of Surgery, Post Graduate Institute of Medical Education and Research, Sector 12, Chandigarh - 160 012, India
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Lin H, Zhan XB, Sun SY, Yang XJ, Jin ZD, Zou DW, Li ZS. Stent selection for endoscopic ultrasound-guided drainage of pancreatic fluid collections: a multicenter study in china. Gastroenterol Res Pract 2014; 2014:193562. [PMID: 25018767 PMCID: PMC4074944 DOI: 10.1155/2014/193562] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/14/2014] [Accepted: 05/26/2014] [Indexed: 12/17/2022] Open
Abstract
Aims. We attempted to establish some guidelines for the selection of transmural stents during endoscopic drainage of PFCs by retrospective review of the clinical data obtained from three tertiary hospitals. Patients and Methods. Clinical data of 93 patients with attempted endoscopic drainage of symptomatic PFCs were obtained through chart review and prospective follow-up. Results. Treatment success for acute pseudocyst (n = 67), chronic pseudocyst (n = 9), and WOPN (n = 17) was 95.3%, 100%, and 88.2%, respectively (P = 0.309). Clinical success for single-stent drainage was 93.9% (46/49) versus 97.4% (37/38) for multiple-stent drainage (P = 0.799). Secondary infection for single-stent drainage was 18.4% (9/49) versus 5.3% (2/38) for multiple-stent drainage (P = 0.134). Secondary infection for stent diameter less than or equal to 8.5 F was 3.4% (1/29) versus 17.2% (10/58) for stent diameter larger than or equal to 10 F (P = 0.138). Conclusion. EUS-guided transmural drainage is an effective therapy for PFCs. Single-stent transmural drainage of PFCs is enough and does not seem to influence clinical success. The number or diameter of stents does not seem to be associated with secondary infection.
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Affiliation(s)
- Hui Lin
- Department of Gastroenterology, Shanghai Tenth People's Hospital, Tongji University School of Medicine, Shanghai 200072, China
| | - Xian-Bao Zhan
- Department of Gastroenterology, Changhai Hospital, Second Military Medical University, Shanghai 200433, China
| | - Si-Yu Sun
- Digestive Endoscopy Center, Sheng Jing Hospital of China Medical University, Shenyang 110004, China
| | - Xiu-Jiang Yang
- Digestive Endoscopy Center, Fudan University Shanghai Cancer Center, Shanghai 200032, China
| | - Zhen-Dong Jin
- Department of Gastroenterology, Changhai Hospital, Second Military Medical University, Shanghai 200433, China
| | - Duo-Wu Zou
- Department of Gastroenterology, Changhai Hospital, Second Military Medical University, Shanghai 200433, China
| | - Zhao-Shen Li
- Department of Gastroenterology, Changhai Hospital, Second Military Medical University, Shanghai 200433, China
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Whitehead DA, Gardner TB. Evidence-Based Management of Necrotizing Pancreatitis. ACTA ACUST UNITED AC 2014; 12:322-32. [DOI: 10.1007/s11938-014-0018-7] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
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van Brunschot S, Fockens P, Bakker OJ, Besselink MG, Voermans RP, Poley JW, Gooszen HG, Bruno M, van Santvoort HC. Endoscopic transluminal necrosectomy in necrotising pancreatitis: a systematic review. Surg Endosc 2014; 28:1425-38. [PMID: 24399524 DOI: 10.1007/s00464-013-3382-9] [Citation(s) in RCA: 114] [Impact Index Per Article: 10.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/27/2013] [Accepted: 12/04/2013] [Indexed: 02/07/2023]
Abstract
OBJECTIVE We performed a systematic review to assess the outcome of endoscopic transluminal necrosectomy in necrotising pancreatitis with additional focus on indication, disease severity, and methodological quality of studies. DESIGN We searched the literature published between January 2005 and June 2013. Cohorts, including patients with (infected) necrotising pancreatitis, undergoing endoscopic necrosectomy were included. Indication, disease severity, and methodological quality were described. The main outcomes were mortality, major complications, number of endoscopic sessions, and definitive successful treatment with endoscopic necrosectomy alone. RESULTS After screening 581 papers, 14 studies, including 455 patients, fulfilled the eligibility criteria. All included studies were retrospective analyses except for one randomized, controlled trial. Overall methodological quality was moderate to low (mean 5, range 2-9). Less than 50 % of studies reported on pre-procedural severity of disease: mean APACHE-II score before intervention was 8; organ failure was present in 23 % of patients; and infected necrosis in 57 % of patients. On average, four (range 1-23) endoscopic interventions were performed per patient. With endoscopic necrosectomy alone, definitive successful treatment was achieved in 81 % of patients. Mortality was 6 % (28/460 patients) and complications occurred in 36 % of patients. Bleeding was the most common complication. CONCLUSIONS Endoscopic transluminal necrosectomy is an effective treatment for the majority of patients with necrotising pancreatitis with acceptable mortality and complication rates. It should be noted that methodological quality of the available studies is limited and that the combined patient population of endoscopically treated patients is only moderately ill.
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Affiliation(s)
- Sandra van Brunschot
- Department of OR/Clinical Surgical Research, Radboud University Nijmegen Medical Center, Nijmegen, The Netherlands,
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Puli SR, Graumlich JF, Pamulaparthy SR, Kalva N. Endoscopic transmural necrosectomy for walled-off pancreatic necrosis: a systematic review and meta-analysis. Can J Gastroenterol Hepatol 2014; 28:50-3. [PMID: 24212912 PMCID: PMC4071909 DOI: 10.1155/2014/539783] [Citation(s) in RCA: 51] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/19/2013] [Accepted: 09/15/2013] [Indexed: 12/15/2022] Open
Abstract
BACKGROUND Endoscopic transmural necrosectomy (ETN) is emerging as a viable treatment option for walled-off pancreatic necrosis. This NOTES-type procedure is significantly less invasive than an extensive surgical debridement; however, published data regarding the success of ETN in treating pancreatic necrosis have varied. OBJECTIVE To evaluate the published medical literature to determine the success of treating walled-off pancreatic necrosis with ETN. METHODS Studies using ETN as a primary mode of therapy to treat organized pancreatic necrosis were selected. Success was defined as resolution of the necrotic cavity proven by radiology. Articles were searched in Medline, PubMed, Ovid journals, CINAH, old Medline, Medline nonindexed citations and the Cochrane controlled trials registry. The summary estimates were expressed as pooled proportions. First, the individual study proportions were transformed into a quantity using Freeman-Tukey variant of the arcsine square root transformed proportion. The pooled proportion was calculated as the back-transform of the weighted mean of the transformed proportions, using inverse arcsine variance weights for the fixed-effects model and DerSimonian-Laird weights for the random-effects model. Publication bias was calculated using the Begg-Mazumdar and Harbord bias estimators. RESULTS The initial search identified 920 reference articles, of which 129 relevant articles were selected and reviewed. Data were extracted from eight studies (n=233) that met the inclusion criteria. Organization of pancreatic necrosis was determined by computed tomography scan in all of the studies. The mean time of ETN after onset of acute pancreatitis⁄abdominal pain was seven weeks. The weighted mean size of the necrotic cavity was 12.87 cm (95% CI 10.54 cm to 15.20 cm). The weighted mean number of endoscopic procedures needed to resolve the necrotic cavity was 4.09 (95% CI 2.31 to 5.87). Pooled proportion of successful resolution of pancreatic necrosis using ETN was 81.84% (95% CI 76.73% to 86.44%). The pooled proportion of recurrence in the form of necrotic cavity or pseudocyst after ETN was 10.88% (95% CI 7.27% to 15.11%). Complications were noted in 21.33% (95% CI 16.40% to 26.72%) of patients and included bleeding, sepsis and perforation. The weighted mean number of days in hospital after ETN was 32.85 days (95% CI 10.50 to 55.20 days). For pancreatic necrosis that did not resolve, surgery had to be performed in 12.98% (95% CI 9.05% to 17.51%) of patients. The fixed-effect model was used to report all of the pooled proportions. Estimates calculated using fixed- and random-effects models were similar. Test of heterogeneity yielded P>0.10, indicating that the studies could be combined. The publication bias calculated using Begg-Mazumdar bias indicator yielded a Kendall's tau b value of -0.07 (P=0.72) and the same using Harbord bias indicator gave a value of 0.33 (95% CI -1.35 to 2.01; P=0.60). Both of these indicators show that there was no publication bias. CONCLUSION The present meta-analysis showed that ETN is safe and effective at treating patients with symptomatic walled-off necrosis. ETN offers the advantage of minimally invasive endoscopic treatment without transabdominal surgery; however, better techniques and equipment are still needed to improve procedural efficiency. Decisions to perform ETN should be made by advanced endoscopists in collaboration with a multidisciplinary team with the facilities and personnel to manage these complex patients.
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Affiliation(s)
- Srinivas R Puli
- Division of Gastroenterology and Hepatology, University of Illinois College of Medicine at Peoria, Peoria, Illinois, USA
| | - James F Graumlich
- Division of General Internal Medicine, University of Illinois College of Medicine at Peoria, Peoria, Illinois, USA
| | - Smitha R Pamulaparthy
- Division of Gastroenterology and Hepatology, University of Illinois College of Medicine at Peoria, Peoria, Illinois, USA
| | - Nikhil Kalva
- Division of General Internal Medicine, University of Illinois College of Medicine at Peoria, Peoria, Illinois, USA
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Ang TL, Kwek ABE, Tan SS, Ibrahim S, Fock KM, Teo EK. Direct endoscopic necrosectomy: a minimally invasive endoscopic technique for the treatment of infected walled-off pancreatic necrosis and infected pseudocysts with solid debris. Singapore Med J 2013; 54:206-11. [PMID: 23624447 DOI: 10.11622/smedj.2013074] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Abstract
INTRODUCTION Endoscopic transenteric stenting is the standard treatment for pseudocysts, but it may be inadequate for treating infected collections with solid debris. Surgical necrosectomy results in significant morbidity. Direct endoscopic necrosectomy (DEN), a minimally invasive treatment, may be a viable option. This study examined the efficacy and safety of DEN for the treatment of infected walled-off pancreatic necrosis and infected pseudocysts with solid debris. METHODS This study was a retrospective analysis of data collected from a prospective database of patients who underwent DEN in the presence of infected walled-off pancreatic necrosis or infected pseudocysts with solid debris from April 2007 to October 2011. DEN was performed as a staged procedure. Endoscopic ultrasonography-guided transgastric stenting was performed during the first session for initial drainage and to establish endoscopic access to the infected collection. In the second session, the drainage tract was dilated endoscopically to allow transgastric passage of an endoscope for endoscopic necrosectomy. Outcome data included technical success, clinical success and complication rates. RESULTS Eight patients with infected walled-off pancreatic necrosis or infected pseudocysts with solid debris (mean size 12.5 cm; range 7.8-17.2 cm) underwent DEN. Underlying aetiologies included severe acute pancreatitis (n = 6) and post-pancreatic surgery (n = 2). DEN was technically successful in all patients. Clinical resolution was achieved in seven patients. One patient with recurrent collection opted for surgery instead of repeat endotherapy. No procedural complications were encountered. CONCLUSION DEN is a safe and effective minimally invasive treatment for infected walled-off pancreatic necrosis and infected pseudocysts.
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Affiliation(s)
- Tiing Leong Ang
- Department of Gastroenterology, Changi General Hospital, 2 Simei Street 3, Singapore.
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van Brunschot S, van Grinsven J, Voermans RP, Bakker OJ, Besselink MGH, Boermeester MA, Bollen TL, Bosscha K, Bouwense SA, Bruno MJ, Cappendijk VC, Consten EC, Dejong CH, Dijkgraaf MGW, van Eijck CH, Erkelens GW, van Goor H, Hadithi M, Haveman JW, Hofker SH, Jansen JJM, Laméris JS, van Lienden KP, Manusama ER, Meijssen MA, Mulder CJ, Nieuwenhuis VB, Poley JW, de Ridder RJ, Rosman C, Schaapherder AF, Scheepers JJ, Schoon EJ, Seerden T, Spanier BWM, Straathof JWA, Timmer R, Venneman NG, Vleggaar FP, Witteman BJ, Gooszen HG, van Santvoort HC, Fockens P. Transluminal endoscopic step-up approach versus minimally invasive surgical step-up approach in patients with infected necrotising pancreatitis (TENSION trial): design and rationale of a randomised controlled multicenter trial [ISRCTN09186711]. BMC Gastroenterol 2013; 13:161. [PMID: 24274589 PMCID: PMC4222267 DOI: 10.1186/1471-230x-13-161] [Citation(s) in RCA: 90] [Impact Index Per Article: 7.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/08/2013] [Accepted: 11/13/2013] [Indexed: 02/06/2023] Open
Abstract
Background Infected necrotising pancreatitis is a potentially lethal disease that nearly always requires intervention. Traditionally, primary open necrosectomy has been the treatment of choice. In recent years, the surgical step-up approach, consisting of percutaneous catheter drainage followed, if necessary, by (minimally invasive) surgical necrosectomy has become the standard of care. A promising minimally invasive alternative is the endoscopic transluminal step-up approach. This approach consists of endoscopic transluminal drainage followed, if necessary, by endoscopic transluminal necrosectomy. We hypothesise that the less invasive endoscopic step-up approach is superior to the surgical step-up approach in terms of clinical and economic outcomes. Methods/Design The TENSION trial is a randomised controlled, parallel-group superiority multicenter trial. Patients with (suspected) infected necrotising pancreatitis with an indication for intervention and in whom both treatment modalities are deemed possible, will be randomised to either an endoscopic transluminal or a surgical step-up approach. During a 4 year study period, 98 patients will be enrolled from 24 hospitals of the Dutch Pancreatitis Study Group. The primary endpoint is a composite of death and major complications within 6 months following randomisation. Secondary endpoints include complications such as pancreaticocutaneous fistula, exocrine or endocrine pancreatic insufficiency, need for additional radiological, endoscopic or surgical intervention, the need for necrosectomy after drainage, the number of (re-)interventions, quality of life, and total direct and indirect costs. Discussion The TENSION trial will answer the question whether an endoscopic step-up approach reduces the combined primary endpoint of death and major complications, as well as hospital stay and related costs compared with a surgical step-up approach in patients with infected necrotising pancreatitis.
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Affiliation(s)
- Sandra van Brunschot
- Department of Gastroenterology and Hepatology, University of Amsterdam, Amsterdam, The Netherlands.
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Smoczyński M, Marek I, Dubowik M, Rompa G, Kobiela J, Studniarek M, Pieńkowska J, Adrych K. Endoscopic drainage/debridement of walled-off pancreatic necrosis--single center experience of 112 cases. Pancreatology 2013; 14:137-42. [PMID: 24650969 DOI: 10.1016/j.pan.2013.11.005] [Citation(s) in RCA: 29] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/27/2013] [Revised: 10/08/2013] [Accepted: 11/15/2013] [Indexed: 12/11/2022]
Abstract
BACKGROUND Endoscopic drainage of the pancreatic pseudocysts has been accepted as a valid alternative to surgical and percutaneous drainage. Endoscopic treatment of the symptomatic walled-off necrosis was not, however, univocally accepted by all authors. THE AIM The aim of this study was to assessed the effectiveness and safety of the endoscopic drainage of walled-off necrosis. METHODS AND MATERIAL Between 2001 and 2011 one hundred and twelve patients with symptomatic walled-off necrosis were treated in the Department of Gastroenterology and Hepatology of the Medical University of Gdansk, using endoscopic drainage. The drainage system was set up by introducing endoprostheses and drains through gastric and duodenal fistulas, transpapillary, and additionally--in cases when the necrosis was spreading outside of the lesser sac--percutaneously. The results and complications of the endoscopic treatment were assessed retrospectively. RESULTS Initial success was achieved in 104/112 (92.9%) patients. Long term success was achieved in 94/112 (83.9%) patients in intention to treat analysis and 94/102 (90.4%) patients in per protocol analysis. Recurrence of pancreatic fluid collection was observed in 19/97(19.6%) patients. Procedure-related complications were observed in 29/112 patients (25.9%). Most of them were treated conservatively. Procedure-related mortality was 1.8%. CONCLUSIONS In a large group of selected patients with symptomatic walled-off necrosis, endoscopic drainage enables high success rate with acceptable complication rate and low procedure-related mortality.
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Affiliation(s)
- M Smoczyński
- Department of Gastroenterology and Hepatology of Medical University of Gdańsk, Gdańsk, Poland.
| | - I Marek
- Department of Gastroenterology and Hepatology of Medical University of Gdańsk, Gdańsk, Poland
| | - M Dubowik
- Department of Gastroenterology and Hepatology of Medical University of Gdańsk, Gdańsk, Poland
| | - G Rompa
- Department of Gastroenterology and Hepatology of Medical University of Gdańsk, Gdańsk, Poland
| | - J Kobiela
- Department of General, Endocrine and Transplant Surgery of Medical University of Gdańsk, Poland
| | - M Studniarek
- Department of Radiology of Medical University of Gdańsk, Poland
| | - J Pieńkowska
- Department of Radiology of Medical University of Gdańsk, Poland
| | - K Adrych
- Department of Gastroenterology and Hepatology of Medical University of Gdańsk, Gdańsk, Poland
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Fisher JM, Gardner TB. Endoscopic therapy of necrotizing pancreatitis and pseudocysts. Gastrointest Endosc Clin N Am 2013; 23:787-802. [PMID: 24079790 DOI: 10.1016/j.giec.2013.06.013] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
Endoscopic therapy has become an essential component in the management of postpancreatitis complications, such as infected and/or symptomatic pancreatic pseudocysts and walled-off necrosis. However, although there have been 2 recent randomized, controlled trials performed, a general lack of comparative effectiveness data regarding the timing, indications, and outcomes of these procedures has been a barrier to the development of practice standards for therapeutic endoscopists managing these issues. This article reviews the available data and expert consensus regarding indications for endoscopic intervention, timing of procedures, endoscopic technique, periprocedural considerations, and complications.
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Affiliation(s)
- Jessica M Fisher
- Division of Gastroenterology, Department of Medicine, University of Washington, 1959 Northeast Pacific Street, Box 356424, Seattle, WA 98195, USA
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Rana SS, Bhasin DK, Rao C, Sharma R, Gupta R. Consequences of long term indwelling transmural stents in patients with walled off pancreatic necrosis & disconnected pancreatic duct syndrome. Pancreatology 2013; 13:486-90. [PMID: 24075512 DOI: 10.1016/j.pan.2013.07.284] [Citation(s) in RCA: 51] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/23/2013] [Revised: 07/08/2013] [Accepted: 07/22/2013] [Indexed: 12/11/2022]
Abstract
INTRODUCTION There is limited data on the long term consequences and safety profile of long term indwelling transmural stents after successful treatment of walled off pancreatic necrosis (WOPN). AIM To retrospectively evaluate consequences of long term indwelling transmural stents in patients with WOPN. METHODS The records of patients who underwent endoscopic transmural drainage of WOPN and had disconnected pancreatic duct syndrome (DPDS) were analyzed. RESULTS Thirty patients (26 M; mean age 37.1 ± 7.8 years) with long term indwelling transmural stents and DPDS were followed up for a mean of 20.4 ± 12.2 months (range: 3-38 months). The etiology of acute necrotizing pancreatitis was alcohol in 21, gall stones in 7 and idiopathic in 2 patients. In all patients two or three, 7 (17 patients) or 10 Fr (13 patients) 5 cm double pigtail stents were placed. ERCP revealed disconnected PD at the pancreatic head, body and tail region in 22, 7, and 1 patient respectively. Five patients (16.6%) had spontaneous migration of stents (both the stents in four patients and one stent in one patient; 7 Fr in four and 10 Fr in one patient respectively). Stent migration led to recurrence of pancreatic fluid collection (PFC) in one patient whereas in the remaining 4 patients it did not cause any symptoms. There was no recurrence of symptomatic PFC in remaining 25 patients. CONCLUSION Long term indwelling transmural stents in patients with WOPN and DPDS seem to be safe and also appear to decrease the risk of PFC recurrence.
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Affiliation(s)
- Surinder Singh Rana
- Department of Gastroenterology, Post Graduate Institute of Medical Education and Research (PGIMER), Sector 12, Chandigarh 160012, India.
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Minimally invasive necrosectomy versus conventional surgery in the treatment of infected pancreatic necrosis: a systematic review and a meta-analysis of comparative studies. Surg Laparosc Endosc Percutan Tech 2013; 23:8-20. [PMID: 23386143 DOI: 10.1097/sle.0b013e3182754bca] [Citation(s) in RCA: 37] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
AIM The purpose of this meta-analysis and systematic review is to compare minimally invasive necrosectomy (MIN) versus open necrosectomy (ON) surgery for infected necrosis of acute pancreatitis. METHODS One randomized controlled trial and 3 clinical controlled trials were selected, with a total of 336 patients (215 patients who underwent MIN and 121 patients underwent ON) included after searching in the following databases: Medline, Embase, Cochrane Central Register of Controlled Trials, BioMed Central, Science Citation Index (from inception to August 2011), Greynet, SIGLE (System for Information on Grey Literature in Europe), National Technological Information Service, British Library Integrated catalogue, and the Current Controlled Trials. Statistical analysis is performed using the odds ratio (OR) and weighted mean difference with 95% confidence interval (CI). RESULTS After the analysis of the data amenable to polling, significant advantages were found in favor of the MIN in terms of: incidence of multiple organ failure (OR, 0.16; 95% CI, 0.06-0.39) (P < 0.0001), incisional hernias (OR, 0.23; 95% CI, 0.06-0.90) (P = 0.03), new-onset diabetes (OR, 0.32; 95% CI, 0.12-0.88) (P = 0.03), and for the use of pancreatic enzymes (OR, 0.005; 95% CI, 0.04-0.57) (P = 0.005). No differences were found in terms of mortality rate (OR, 0.43; 95% CI, 0.18-1.05) (P = 0.06), multiple systemic complications (OR, 0.34; 95% CI, 0.01-8.60) (P = 0.51), surgical reintervention for further necrosectomy (OR, 0.16; 95% CI, 0.00-3.07) (P = 0.19), intra-abdominal bleeding (OR, 0.79; 95% CI, 0.41-1.50) (P = 0.46), enterocutaneous fistula or perforation of visceral organs (OR, 0.52; 95% CI, 0.27-1.00) (P = 0.05), pancreatic fistula (OR, 0.66; 95% CI, 0.30-1.46) (P = 0.30), and surgical reintervention for postoperative complications (OR, 0.50; 95% CI, 0.23-1.08) (P = 0.08). CONCLUSIONS The lack of comparative studies and high heterogeneity of the data present in the literature did not permit to draw a definitive conclusion on this topic. The results of the present meta-analysis might be helpful to design future high-powered randomized studies that compare MIN with ON for acute necrotizing pancreatitis.
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Pupelis G, Fokin V, Zeiza K, Plaudis H, Suhova A, Drozdova N, Boka V. Focused open necrosectomy in necrotizing pancreatitis. HPB (Oxford) 2013; 15:535-40. [PMID: 23458703 PMCID: PMC3692024 DOI: 10.1111/hpb.12004] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/26/2012] [Accepted: 10/15/2012] [Indexed: 12/12/2022]
Abstract
BACKGROUND The control of sepsis is the primary goal of surgical intervention in patients with infected necrosis. Simple surgical approaches that are easy to reproduce may improve outcomes when specialists in endoscopy are not available. The aim of the present study was to describe the experience with a focused open necrosectomy (FON) in patients with infected necrosis. METHOD A prospective pilot study conducted to compare a semi-open/closed drainage laparotomy and FON with the assistance of peri-operative ultrasound. The incidence of sepsis, dynamics of C-reactive protein (CRP), intensive care unit (ICU)/hospital stay, complication rate and mortality were compared and analysed. RESULTS From a total of 58 patients, 36 patients underwent a conventional open necrosectomy and 22 patients underwent FON. The latter method resulted in a faster resolution of sepsis and a significant decrease in mean CRP on Day 3 after FON, P = 0.001. Post-operative bleeding was in 1 versus 7 patients and the incidence of intestinal and pancreatic fistula was 2 versus 8 patients when comparing FON to the conventional approach. The median ICU stay was 11.6 versus 23 days and the hospital stay was significantly shorter, 57 versus 72 days, P = 0.024 when comparing FON versus the conventional group. One patient died in the FON group and seven patients died in the laparotomy group, P = 0.139. DISCUSSION FON can be an alternative method to conventional open necrosectomy in patients with infected necrosis and unresolved sepsis.
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Affiliation(s)
- Guntars Pupelis
- Department of General and Emergency Surgery, Riga East Clinical University Hospital Gailezers, Riga, Latvia.
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Hritz I, Fejes R, Székely A, Székely I, Horváth L, Sárkány &A, Altorjay &A, Madácsy L. Endoscopic transluminal pancreatic necrosectomy using a self-expanding metal stent and high-flow water-jet system. World J Gastroenterol 2013; 19:3685-3692. [PMID: 23801873 PMCID: PMC3691031 DOI: 10.3748/wjg.v19.i23.3685] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/13/2012] [Revised: 02/14/2013] [Accepted: 03/15/2013] [Indexed: 02/06/2023] Open
Abstract
Walled-off pancreatic necrosis and a pancreatic abscess are the most severe complications of acute pancreatitis. Surgery in such critically ill patients is often associated with significant morbidity and mortality within the first few weeks after the onset of symptoms. Minimal invasive approaches with high success and low mortality rates are therefore of considerable interest. Endoscopic therapy has the potential to offer safe and effective alternative treatment. We report here on 3 consecutive patients with infected walled-off pancreatic necrosis and 1 patient with a pancreatic abscess who underwent direct endoscopic necrosectomy 19-21 d after the onset of acute pancreatitis. The infected pancreatic necrosis or abscess was punctured transluminally with a cystostome and, after balloon dilatation, a non-covered self-expanding biliary metal stent was placed into the necrotic cavity. Following stent deployment, a nasobiliary pigtail catheter was placed into the cavity to ensure continuous irrigation. After 5-7 d, the metal stent was removed endoscopically and the necrotic cavity was entered with a therapeutic gastroscope. Endoscopic debridement was performed via the simultaneous application of a high-flow water-jet system; using a flush knife, a Dormia basket, and hot biopsy forceps. The transluminal endotherapy was repeated 2-5 times daily during the next 10 d. Supportive care included parenteral antibiotics and jejunal feeding. All patients improved dramatically and with resolution of their septic conditions; 3 patients were completely cured without any further complications or the need for surgery. One patient died from a complication of prolonged ventilation severe bilateral pneumonia, not related to the endoscopic procedure. No procedure related complications were observed. Transluminal endoscopic necrosectomy with temporary application of a self-expanding metal stent and a high-flow water-jet system shows promise for enhancing the potential of this endoscopic approach in patients with walled-off pancreatic necrosis and/or a pancreatic abscess.
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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: 3.1] [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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Ulagendra Perumal S, Pillai SA, Perumal S, Sathyanesan J, Palaniappan R. Outcome of video-assisted translumbar retroperitoneal necrosectomy and closed lavage for severe necrotizing pancreatitis. ANZ J Surg 2013; 84:270-4. [DOI: 10.1111/ans.12107] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 01/24/2013] [Indexed: 12/26/2022]
Affiliation(s)
- Srinivasan Ulagendra Perumal
- Institute of Surgical Gastroenterology and Liver Transplantation; Government Stanley Medical College; Chennai India
| | - Sastha Ahanatha Pillai
- Institute of Surgical Gastroenterology and Liver Transplantation; Government Stanley Medical College; Chennai India
| | - Senthilkumar Perumal
- Institute of Surgical Gastroenterology and Liver Transplantation; Government Stanley Medical College; Chennai India
| | - Jeswanth Sathyanesan
- Institute of Surgical Gastroenterology and Liver Transplantation; Government Stanley Medical College; Chennai India
| | - Ravichandran Palaniappan
- Institute of Surgical Gastroenterology and Liver Transplantation; Government Stanley Medical College; Chennai India
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