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Sahu SK, Giri S, Das S, Patro CD, Praharaj DL, Mallick B, Nath P, Panigrahi SC, Anand AC. Approach to the Diagnosis and Management of Infected Pancreatic Necrosis: A Narrative Review. Cureus 2025; 17:e83020. [PMID: 40421342 PMCID: PMC12104691 DOI: 10.7759/cureus.83020] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/12/2025] [Accepted: 04/25/2025] [Indexed: 05/28/2025] Open
Abstract
Infected pancreatic necrosis (IPN) is a dreaded complication of acute necrotizing pancreatitis and is linked to persistent organ failure, sepsis, and increased morbidity and mortality. Clinical indicators of IPN include fever, clinical deterioration, and worsening inflammatory markers. The diagnosis of IPN is based on clinical signs, microbiological confirmation, and radiological evidence, with contrast-enhanced CT being the preferred imaging modality. In the absence of tests with high sensitivity, a high clinical suspicion is required for early recognition and treatment. Although there is no way to prevent IPN, a systematic management approach with parenteral antibiotics, nutritional management, and minimally invasive procedures has become the cornerstone of the treatment. The step-up approach includes minimally invasive procedures that minimize procedure-related complications and are associated with improved outcomes. The percutaneous route remains the most common route for drainage, while endoscopic interventions are preferred for perigastric or periduodenal encapsulated collections. The use of lumen-apposing metal stents is associated with excellent outcomes in cases of infected walled-off necrosis. Patients with significant quantities of infected necrosis may benefit from direct or percutaneous endoscopic necrosectomy. Minimally invasive surgical techniques followed by open surgeries are reserved for patients who do not improve with percutaneous or endoscopic necrosectomies. The outcome can be maximized through a multidisciplinary approach by a team of interventional radiologists, advanced therapeutic endoscopists, and surgeons.
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Affiliation(s)
- Saroj K Sahu
- Gastroenterology and Hepatology, Kalinga Institute of Medical Sciences, Bhubaneswar, IND
| | - Suprabhat Giri
- Gastroenterology and Hepatology, Kalinga Institute of Medical Sciences, Bhubaneswar, IND
| | - Swati Das
- Radiodiagnosis, Kalinga Institute of Medical Sciences, Bhubaneswar, IND
| | | | - Dibya L Praharaj
- Gastroenterology and Hepatology, Kalinga Institute of Medical Sciences, Bhubaneswar, IND
| | - Bipadabhanjan Mallick
- Gastroenterology and Hepatology, Kalinga Institute of Medical Sciences, Bhubaneswar, IND
| | - Preetam Nath
- Gastroenterology and Hepatology, Kalinga Institute of Medical Sciences, Bhubaneswar, IND
| | | | - Anil C Anand
- Gastroenterology and Hepatology, Kalinga Institute of Medical Sciences, Bhubaneswar, IND
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Huang D, Lu Z, Li Q, Jiang K, Wu J, Gao W, Miao Y. A Risk Score for Predicting the Necessity of Surgical Necrosectomy in the Treatment of Infected Necrotizing Pancreatitis. J Gastrointest Surg 2023; 27:2145-2154. [PMID: 37488423 DOI: 10.1007/s11605-023-05772-z] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/17/2023] [Accepted: 06/24/2023] [Indexed: 07/26/2023]
Abstract
BACKGROUND For infected necrotizing pancreatitis (INP), percutaneous catheter drainage (PCD) is now widely acknowledged as the initial intervention in a step-up approach, followed, if necessary, by minimally invasive necrosectomy or even open pancreatic necrosectomy. However, an overemphasis on PCD may cause a patient's condition to deteriorate, leading to missed surgical opportunities or even death. This study aimed to develop a simple and convenient scoring tool for assessing the need for surgery in INP patients who received PCD procedures. METHODS In an observational study conducted between April 2015 and December 2020, PCD was utilized as the initial step to treat 143 consecutive INP patients. A surgical necrosectomy was performed when the patient failed to respond. Risk factors of PCD failure (i.e., need for surgical necrosectomy) were identified by multivariate logistic regression models. An integer-based risk scoring tool was developed using the β coefficients derived from the logistic regression model. RESULTS In 62 (43.4%) patients, PCD was successful, while the remaining 81 (56.6%) individuals required subsequent surgical necrosectomy. In the multivariate model, organ failure, percentage of pancreatic necrosis, extrapancreatic necrosis volume, and mean CT density of extrapancreatic necrosis volume were associated with a need for surgical necrosectomy. A predictive scoring tool based on these four factors demonstrated an area under the receiver operating characteristic curve (AUC) of 0.893. Under the scoring tool, a total score of 4 or more indicates a high possibility of surgical necrosectomy being required (at least 80%). Using the coordinates of the receiver operating characteristic curve (ROC), the sensitivity and specificity at this threshold are 0.802 and 0.903, respectively. CONCLUSIONS A risk score model integrating organ failure, percentage of pancreatic necrosis, extrapancreatic necrosis volume, and mean CT density of extrapancreatic necrosis volume can identify INP patients at high risk for necrosectomy. The straightforward risk assessment tool assists clinicians in stratifying INP patients and making more judicious medical decisions.
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Affiliation(s)
- Dongya Huang
- Pancreas Center, The First Affiliated Hospital of Nanjing Medical University, Nanjing, China
| | - Zipeng Lu
- Pancreas Center, The First Affiliated Hospital of Nanjing Medical University, Nanjing, China
| | - Qiang Li
- Pancreas Center, The First Affiliated Hospital of Nanjing Medical University, Nanjing, China
| | - Kuirong Jiang
- Pancreas Center, The First Affiliated Hospital of Nanjing Medical University, Nanjing, China
| | - Junli Wu
- Pancreas Center, The First Affiliated Hospital of Nanjing Medical University, Nanjing, China
| | - Wentao Gao
- Pancreas Center, The First Affiliated Hospital of Nanjing Medical University, Nanjing, China
| | - Yi Miao
- Pancreas Center, The First Affiliated Hospital of Nanjing Medical University, Nanjing, China.
- Pancreas Center, The Affiliated BenQ Hospital of Nanjing Medical University, Nanjing, China.
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Manrai M, Dawra S, Singh AK, Jha DK, Kochhar R. Controversies in the management of acute pancreatitis: An update. World J Clin Cases 2023; 11:2582-2603. [PMID: 37214572 PMCID: PMC10198120 DOI: 10.12998/wjcc.v11.i12.2582] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/27/2022] [Revised: 01/22/2023] [Accepted: 03/29/2023] [Indexed: 04/25/2023] Open
Abstract
This review summarized the current controversies in the management of acute pancreatitis (AP). The controversies in management range from issues involving fluid resuscitation, nutrition, the role of antibiotics and antifungals, which analgesic to use, role of anticoagulation and intervention for complications in AP. The interventions vary from percutaneous drainage, endoscopy or surgery. Active research and emerging data are helping to formulate better guidelines. The available evidence favors crystalloids, although the choice and type of fluid resuscitation is an area of dynamic research. The nutrition aspect does not have controversy as of now as early enteral feeding is preferred most often than not. The empirical use of antibiotics and antifungals are gray zones, and more data is needed for conclusive guidelines. The choice of analgesic is being studied, and the recommendations are still evolving. The position of using anticoagulation is still awaiting consensus. The role of intervention is well established, although the modality is constantly changing and favoring endoscopy or percutaneous drainage rather than surgery. It is evident that more multicenter randomized controlled trials are required for establishing the standard of care in these crucial management issues of AP to improve the morbidity and mortality worldwide.
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Affiliation(s)
- Manish Manrai
- Department of Internal Medicine, Armed Forces Medical College, Pune 411040, India
| | - Saurabh Dawra
- Department of Medicine and Gastroenterology, Command Hospital, Pune 411040, India
| | - Anupam K Singh
- Department of Gastroenterology, Post Graduate Institute of Medical Education and Research, Chandigarh 160012, India
| | - Daya Krishna Jha
- Department of Gastroenterology, Army Hospital (Research and Referral), New Delhi 11010, India
| | - Rakesh Kochhar
- Department of Gastroenterology, Post Graduate Institute of Medical Education and Research, Chandigarh 160012, India
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Muacevic A, Adler JR. Predicting the Success of Catheter Drainage in Infected Necrotising Pancreatitis: A Cross-Sectional Observational Study. Cureus 2022; 14:e32289. [PMID: 36505951 PMCID: PMC9728500 DOI: 10.7759/cureus.32289] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 12/07/2022] [Indexed: 12/12/2022] Open
Abstract
Background Management of acute necrotising pancreatitis is often challenging for clinicians. Secondary infection of the necrotic collections leads to sepsis and warrants intervention. Minimally invasive techniques like catheter drainage have recently been proposed over more risky and morbid traditional open procedures. Factors that can predict successful catheter drainage of the necrotic pancreatic collection are still unclear and not well established. Materials and methods This study is designed as a retrospective cross-sectional observational study to investigate the association of 21 factors in predicting successful catheter drainage. Data from 30 patients admitted with acute necrotising pancreatitis treated with catheter drainage were collected and analysed. Twenty-one factors, including demographic variables, disease severity factors, drainage criteria, and morphological criteria on imaging, were studied for their predictive association with successful outcomes. Univariate analysis was done for each variable against the outcome. The study was conducted between December 2012 to March 2017. P-value <0.05 was considered statistically significant. Results Patients with no organ involvement responded better to primary catheter drainage. Patients with BMI>25 and multi-organ failure were poor candidates for primary catheter drainage. Clinically unwell patients with a Bedside Index for Severity in Acute Pancreatitis (BISAP) score of ≥4 had a negative outcome on catheter drainage and usually ended up in a surgical procedure or eventually succumbed to the disease. Other variables included in our study did not statistically associate with the success or failure of percutaneous catheter drainage. Conclusion BMI >25, multiple organ failure, and BISAP score ≥ 4 are independent negative predictors for the success of catheter drainage in infected necrotising pancreatitis. No organ failure showed a positive predictor for successful catheter drainage. Further studies are required to explore these predictive factors in a larger sample size to predict the success of catheter drainage in infected pancreatic necrosis.
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Garret C, Douillard M, David A, Péré M, Quenehervé L, Legros L, Archambeaud I, Douane F, Lerhun M, Regenet N, Gournay J, Coron E, Frampas E, Reignier J. Infected pancreatic necrosis complicating severe acute pancreatitis in critically ill patients: predicting catheter drainage failure and need for necrosectomy. Ann Intensive Care 2022; 12:71. [PMID: 35916981 PMCID: PMC9346045 DOI: 10.1186/s13613-022-01039-z] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/20/2021] [Accepted: 06/25/2022] [Indexed: 11/27/2022] Open
Abstract
Background Recent guidelines advocate a step-up approach for managing suspected infected pancreatic necrosis (IPN) during acute pancreatitis. Nearly half the patients require secondary necrosectomy after catheter drainage. Our primary objective was to assess the external validity of a previously reported nomogram for catheter drainage, based on four predictors of failure. Our secondary objectives were to identify other potential predictors of catheter-drainage failure. We retrospectively studied consecutive patients admitted to the intensive care units (ICUs) of three university hospitals in France between 2012 and 2016, for severe acute pancreatitis with suspected IPN requiring catheter drainage. We assessed drainage success and failure rates in 72 patients, with success defined as survival without subsequent necrosectomy and failure as death and/or subsequent necrosectomy required by inadequate improvement. We plotted the receiver operating characteristics (ROC) curve for the nomogram and computed the area under the curve (AUROC). Results Catheter drainage alone was successful in 32 (44.4%) patients. The nomogram predicted catheter-drainage failure with an AUROC of 0.71. By multivariate analysis, catheter-drainage failure was independently associated with a higher body mass index [odds ratio (OR), 1.12; 95% confidence interval (95% CI), 1.00–1.24; P = 0.048], heterogeneous collection (OR, 16.7; 95% CI, 1.83–152.46; P = 0.01), and respiratory failure onset within 24 h before catheter drainage (OR, 18.34; 95% CI, 2.18–154.3; P = 0.007). Conclusion Over half the patients required necrosectomy after failed catheter drainage. Newly identified predictors of catheter-drainage failure were heterogeneous collection and respiratory failure. Adding these predictors to the nomogram might help to identify patients at high risk of catheter-drainage failure. ClinicalTrials.gov number: NCT03234166. Supplementary Information The online version contains supplementary material available at 10.1186/s13613-022-01039-z.
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Affiliation(s)
- Charlotte Garret
- Service de Médecine Intensive Réanimation, Centre Hospitalier Universitaire de Nantes, 44000, Nantes, France.
| | - Marion Douillard
- Institut des Maladies de L'Appareil Digestif, Centre Hospitalier Universitaire de Nantes, 44000, Nantes, France
| | - Arthur David
- Radiologie, Centre Hospitalier Universitaire de Nantes, Nantes, France
| | - Morgane Péré
- Plateforme de Méthodologie et Biostatistique, Direction de la Recherche, Centre Hospitalier Universitaire de Nantes, 44000, Nantes, France
| | - Lucille Quenehervé
- Service d'Hépatogastroentérologie, Centre Hospitalier Universitaire de Brest, 29200, Brest, France
| | - Ludivine Legros
- Service d'Hépatogastroentérologie, Centre Hospitalier Universitaire de Rennes, 35203, Rennes, France
| | - Isabelle Archambeaud
- Institut des Maladies de L'Appareil Digestif, Centre Hospitalier Universitaire de Nantes, 44000, Nantes, France
| | - Frédéric Douane
- Radiologie, Centre Hospitalier Universitaire de Nantes, Nantes, France
| | - Marc Lerhun
- Institut des Maladies de L'Appareil Digestif, Centre Hospitalier Universitaire de Nantes, 44000, Nantes, France
| | - Nicolas Regenet
- Institut des Maladies de L'Appareil Digestif, Centre Hospitalier Universitaire de Nantes, 44000, Nantes, France
| | - Jerome Gournay
- Institut des Maladies de L'Appareil Digestif, Centre Hospitalier Universitaire de Nantes, 44000, Nantes, France
| | - Emmanuel Coron
- Institut des Maladies de L'Appareil Digestif, Centre Hospitalier Universitaire de Nantes, 44000, Nantes, France
| | - Eric Frampas
- Radiologie, Centre Hospitalier Universitaire de Nantes, Nantes, France
| | - Jean Reignier
- Service de Médecine Intensive Réanimation, Centre Hospitalier Universitaire de Nantes, 44000, Nantes, France
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Percutaneous catheter drainage of pancreatic associated pathologies: A systematic review and meta-analysis. Eur J Radiol 2021; 144:109978. [PMID: 34607289 DOI: 10.1016/j.ejrad.2021.109978] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/07/2021] [Revised: 09/15/2021] [Accepted: 09/23/2021] [Indexed: 12/13/2022]
Abstract
PURPOSE The main goal of this systematic review was to assess the technical and clinical success, adverse events (AEs), surgery, and overall mortality proportion after percutaneous catheter drainage (PCD) of two pancreatic lesions. METHODS An extant search in online databases including Scopus, PubMed (Medline), Embase (Elsevier), Web of Science, Cochrane library, and Google Scholar, was conducted to recognize all studies that used PCD intervention in the management of pancreatic necrosis (PN) and pancreatic pseudocysts (PP). Random effects meta-analysis was performed, and Cochrane's Q test and I2statistic were utilized to determine heterogeneity. In addition, meta-regression was used to explore the influence of categorical variables on heterogeneity. RESULTS Thirty-two studies (1398 patients) including PN in 26 (1256 cases, 89.8%) studies and PP in 6 (142 cases, 10.2%) studies were identified. Technical success proportion was 100% (95% confidence interval [CI] 100%-100%, I2: 0.0%), clinical success 63% (95% CI 55%-71%, I2: 92.9%), AEs 26% (95% CI 21%-31%, I2: 78%), surgery after PCD intervention 33% (95% CI 25%-40%, I2: 92.4%), and overall mortality was 13% (95% CI 9%-17%, I2: 82.8%). The most common ADs after PCD intervention were development of fistula (106, 42.6%), hemorrhage (44, 17.7%), sepsis (40, 16.1%). CONCLUSION A significant clinical success proportion with low AEs, surgery, and overall mortality proportion after PCD intervention was found, although the results should be interpreted with caution due to the high heterogeneity.
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Gupta P, Bansal A, Samanta J, Mandavdhare H, Sharma V, Gupta V, Yadav TD, Dutta U, Kochhar R, Singh Sandhu M. Larger bore percutaneous catheter in necrotic pancreatic fluid collection is associated with better outcomes. Eur Radiol 2021; 31:3439-3446. [PMID: 33151396 DOI: 10.1007/s00330-020-07411-6] [Citation(s) in RCA: 16] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/31/2020] [Revised: 09/03/2020] [Accepted: 10/12/2020] [Indexed: 02/07/2023]
Abstract
OBJECTIVE To evaluate the impact of initial catheter size on the clinical outcomes in acute pancreatitis (AP). METHODS This retrospective study comprised consecutive patients with AP who underwent percutaneous catheter drainage (PCD) between January 2018 and May 2019. Three hundred fifteen consecutive patients underwent PCD during the study period. Based on the initial catheter size, patients were divided into group I (≤ 12 F) and group II (> 12 F). The differences in the clinical outcomes between the two groups, as well as multiple subgroups (based on the severity, timing of drainage, and presence of organ failure (OF)), were evaluated. RESULTS One hundred forty-six patients (mean age, 41.2 years, 114 males) fulfilled the inclusion criteria. Ninety-nine (67.8%) patients had severe AP based on revised Atlanta classification. The mean pain to PCD was 22 days (range, 3-267 days). Mean length of hospitalization (LOH) was 27.9 ± 15.8 days. Necrosectomy was performed in 20.5% of patients, and mortality was 16.4%. Group I and II comprised 74 and 72 patients, respectively. There was no significant difference in baseline characteristics, except for a greater number of patients with OF in group II (p = 0.048). The intensive care unit stay was significantly shorter, and multiple readmissions were less frequent in group II (p = 0.037 and 0.013, respectively). Patients with severe AP and moderately severe AP in group II had significantly reduced rates of readmissions (p = 0.035) and significantly shorter LOH (p = 0.041), respectively. CONCLUSION Large-sized catheters were associated with better clinical outcomes regardless of disease severity and other baseline disease characteristics. KEY POINTS • Larger catheter size for initial PCD was associated with better clinical outcomes in AP. • The benefits were independent of the severity of AP, timing of PCD (ANC vs. WON) and presence of organ failure.
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Affiliation(s)
- Pankaj Gupta
- Department of Radiodiagnosis and Imaging, Postgraduate Institute of Medical Education and Research (PGIMER), Chandigarh, 160012, India.
| | - Akash Bansal
- Department of Radiodiagnosis and Imaging, Postgraduate Institute of Medical Education and Research (PGIMER), Chandigarh, 160012, India
| | - Jayanta Samanta
- Department of Gastroenterology, Postgraduate Institute of Medical Education and Research (PGIMER), Chandigarh, 160012, India
| | - Harshal Mandavdhare
- Department of Gastroenterology, Postgraduate Institute of Medical Education and Research (PGIMER), Chandigarh, 160012, India
| | - Vishal Sharma
- Department of Gastroenterology, Postgraduate Institute of Medical Education and Research (PGIMER), Chandigarh, 160012, India
| | - Vikas Gupta
- Department of Surgery, Postgraduate Institute of Medical Education and Research (PGIMER), Chandigarh, 160012, India
| | - Thakur Deen Yadav
- Department of Surgery, Postgraduate Institute of Medical Education and Research (PGIMER), Chandigarh, 160012, India
| | - Usha Dutta
- Department of Gastroenterology, Postgraduate Institute of Medical Education and Research (PGIMER), Chandigarh, 160012, India
| | - Rakesh Kochhar
- Department of Gastroenterology, Postgraduate Institute of Medical Education and Research (PGIMER), Chandigarh, 160012, India
| | - Manavjit Singh Sandhu
- Department of Radiodiagnosis and Imaging, Postgraduate Institute of Medical Education and Research (PGIMER), Chandigarh, 160012, India
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Minami K, Horibe M, Sanui M, Sasaki M, Iwasaki E, Sawano H, Goto T, Ikeura T, Takeda T, Oda T, Yasuda H, Ogura Y, Miyazaki D, Kitamura K, Chiba N, Ozaki T, Yamashita T, Koinuma T, Oshima T, Yamamoto T, Hirota M, Tokuhira N, Azumi Y, Nagata K, Takeda K, Furuya T, Lefor AK, Mayumi T, Kanai T. The Effect of an Invasive Strategy for Treating Pancreatic Necrosis on Mortality: a Retrospective Multicenter Cohort Study. J Gastrointest Surg 2020; 24:2037-2045. [PMID: 31428962 DOI: 10.1007/s11605-019-04333-7] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/24/2019] [Accepted: 07/16/2019] [Indexed: 02/07/2023]
Abstract
BACKGROUND Infected acute necrotic collections (ANC) and walled-off necrosis (WON) of the pancreas are associated with high mortality. The difference in mortality between open necrosectomy and minimally invasive therapies in these patients remains unclear. METHODS This retrospective multicenter cohort study was conducted among 44 institutions in Japan from 2009 to 2013. Patients who had undergone invasive treatment for suspected infected ANC/WON were enrolled and classified into open necrosectomy and minimally invasive treatment (laparoscopic, percutaneous, and endoscopic) groups. The association of each treatment with mortality was evaluated and compared. RESULTS Of 1159 patients with severe acute pancreatitis, 122 with suspected infected ANC or WON underwent the following treatments: open necrosectomy (33) and minimally invasive treatment (89), (laparoscopic three, percutaneous 49, endoscopic 37). Although the open necrosectomy group had a significantly higher mortality on univariate analysis (p = 0.047), multivariate analysis showed no significant associations between open necrosectomy or Charlson index and mortality (p = 0.29, p = 0.19, respectively). However, age (for each additional 10 years, p = 0.012, odds ratio [OR] 1.50, 95% confidence interval [CI] 1.09-2.06) and revised Atlanta criteria-severe (p = 0.001, OR 7.84, 95% CI 2.40-25.6) were significantly associated with mortality. CONCLUSIONS In patients with acute pancreatitis and infected ANC/WON, age and revised Atlanta criteria-severe classification are significantly associated with mortality whereas open necrosectomy is not. The mortality risk for patients undergoing open necrosectomy and minimally invasive treatment does not differ significantly. Although minimally invasive surgery is generally preferred for patients with infected ANC/WON, open necrosectomy may be considered if clinically indicated.
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Affiliation(s)
- Kazuhiro Minami
- Division of Gastroenterology and Hepatology, Department of Internal Medicine, Keio University School of Medicine, 35 Shinanomachi, Shinjuku-ku, Tokyo, Japan
| | - Masayasu Horibe
- Division of Gastroenterology and Hepatology, Department of Internal Medicine, Keio University School of Medicine, 35 Shinanomachi, Shinjuku-ku, Tokyo, Japan
- Department of Gastroenterology and Hepatology, Tokyo Metropolitan Tama Medical Center, 2-8-29, Musashidai, Fuchu City, Tokyo, Japan
| | - Masamitsu Sanui
- Department of Anesthesiology and Critical Care Medicine, Division of Critical Care Medicine, Jichi Medical University Saitama Medical Center, 1-847 Amanumachou, Omiya-ku, Saitama, Saitama, 330-8503, Japan.
| | - Mitsuhito Sasaki
- Department of Hepatobiliary and Pancreatic Oncology, National Cancer Center Hospital, 5-1-1 Tsukiji, Chuo-ku, Tokyo, Japan
| | - Eisuke Iwasaki
- Division of Gastroenterology and Hepatology, Department of Internal Medicine, Keio University School of Medicine, 35 Shinanomachi, Shinjuku-ku, Tokyo, Japan
| | - Hirotaka Sawano
- Senri Critical Care Medical Center, Osaka Saiseikai Senri Hospital, 1-1-6 Tsukumodai, Suita, Osaka, Japan
| | - Takashi Goto
- Department of Anesthesiology and Intensive Care, Hiroshima City Hiroshima Citizens Hospital, 7-33 Motomachi, Naka-ku, Hiroshima City, Hiroshima, Japan
| | - Tsukasa Ikeura
- Third Department of Internal Medicine, Kansai Medical University, 2-5-1, Shinmachi, Hirakata, Osaka, Japan
| | - Tsuyoshi Takeda
- Department of Gastroenterology, Graduate School of Medicine, The University of Tokyo, 7-3-1 Hongo, Bunkyo-ku, Tokyo, Japan
| | - Takuya Oda
- Department of General Internal Medicine, Iizuka Hospital, 3-83 Yoshiomachi, Iizuka-shi, Fukuoka, Japan
| | - Hideto Yasuda
- Department of Emergency and Critical Care Medicine, Japanese Red Cross Musashino Hospital, 1-26-1 Kyounancho, Musashino City, Tokyo, Japan
| | - Yuki Ogura
- Department of Gastroenterology and Hepatology, Tokyo Metropolitan Tama Medical Center, 2-8-29, Musashidai, Fuchu City, Tokyo, Japan
| | - Dai Miyazaki
- Advanced Emergency Medical and Critical Care Center, Japanese Red Cross Maebashi Hospital, 3-21-36 Asahi-cho, Maebashi City, Gunma, Japan
| | - Katsuya Kitamura
- Division of Gastroenterology, Department of Medicine, Showa University School of Medicine, 1-5-8 Hatanodai, Shinagawa-ku, Tokyo, Japan
- Department of Gastroenterology and Hepatology, Tokyo Medical University Hachioji Medical Center, 1163 Tatemachi, Hachioji-shi, Tokyo, Japan
| | - Nobutaka Chiba
- Department of Emergency and Critical Care Medicine, Nihon University Hospital, 1-6 Kanda-Surugadai, Chiyoda-ku, Tokyo, Japan
| | - Tetsu Ozaki
- Department of Acute care and General Medicine, Saiseikai Kumamoto Hospital, 5-3-1 Chikami, Minami-ku, Kumamoto City, Kumamoto, Japan
| | - Takahiro Yamashita
- Emergency Medical Center, Fukuyama City Hospital, 5-23-1 Zao-cho, Fukuyama City, Hiroshima, Japan
- Acute Care Medical Center, Hyogo Prefectural Kakogawa Medical Center, 203 Kanno, Kanno-cho, Kakogawa City, Hyogo, Japan
| | - Toshitaka Koinuma
- Division of Intensive Care, Department of Anesthesiology and Intensive Care Medicine, Jichi Medical University School of Medicine, 3311-1 Yakushiji, Shimotsuke, Tochigi, Japan
| | - Taku Oshima
- Department of Emergency and Critical Care Medicine, Chiba University Graduate School of Medicine, 1-8-1 Inohana, Chuo-ku, Chiba City, Chiba, Japan
| | - Tomonori Yamamoto
- Department of Traumatology and Critical Care Medicine, Osaka City University, 1-4-3 Asahimachi, Abenoku, Osaka City, Osaka, Japan
| | - Morihisa Hirota
- Division of Gastroenterology, Tohoku Medical and Pharmaceutical University, 1-15-1 Fukumuro, Miyagino-ku, Sendai, Miyagi, Japan
| | - Natsuko Tokuhira
- Division of Intensive Care Medicine, University Hospital, Kyoto Prefectural University of Medicine, 465 Kajii-cho, Kamigyo-ku, Kyoto, Japan
| | - Yoshinori Azumi
- Department of Hepatobiliary Pancreatic and Transplant Surgery, Mie University Graduate School of Medicine, 2-174 Edobashi, Tsu, Mie, Japan
| | - Keiji Nagata
- Department of Critical Care Medicine University Hospital, University of Occupational and Environmental Health, 1-1 Iseigaoka, Yahata-nishi-ku, Kitakyushu, Fukuoka, Japan
| | - Kazunori Takeda
- Miyagi Branch Office, Health Insurance Claims Review and Reimbursement Services, 5-1-27, Tsutsujigaoka, Miyagino-ku, Sendai, Miyagi, Japan
| | - Tomoki Furuya
- Department of Emergency and Critical Care Medicine, Akita University Graduate School of Medicine, 1-1-1 Hondo, Akita, Japan
| | - Alan Kawarai Lefor
- Department of Surgery, Jichi Medical University School of Medicine, 3311-1 Yakushiji, Shimotsuke, Tochigi, Japan
| | - Toshihiko Mayumi
- Department of Emergency Medicine, School of Medicine, University of Occupational and Environmental Health, 1-1 Iseigaoka, Yahata Nishi, Kitakyushu, Fukuoka, Japan
| | - Takanori Kanai
- Division of Gastroenterology and Hepatology, Department of Internal Medicine, Keio University School of Medicine, 35 Shinanomachi, Shinjuku-ku, Tokyo, Japan
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Gupta P, Koshi S, Samanta J, Mandavdhare H, Sharma V, K Sinha S, Dutta U, Kochhar R. Kissing catheter technique for percutaneous catheter drainage of necrotic pancreatic collections in acute pancreatitis. Exp Ther Med 2020; 20:2311-2316. [PMID: 32765710 PMCID: PMC7401886 DOI: 10.3892/etm.2020.8897] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/04/2019] [Accepted: 04/29/2020] [Indexed: 12/13/2022] Open
Abstract
One of the critical factors for predicting the success of percutaneous catheter drainage (PCD) is the mean CT density of collection. A higher CT density suggests more necrotic solid tissue within the collection. In the present study, a novel technique for PCD of the necrotic pancreatic collection with a higher mean CT density was evaluated. It was a retrospective study of patients with acute pancreatitis (AP) who underwent PCD of pancreatic collections between May 2018 and December 2018. Patients with pancreatic collections having a CT density of >30 Hounsfield Units (HU) were considered for PCD using the kissing catheter technique. This technique involved placing two catheters side-by-side through a single cutaneous entry site, as the conventional technique of PCD may not be effective. The technical details, outcomes and complications of this technique were recorded. A total of 10 patients with a mean age of 30 years underwent PCD using this technique. All patients had severe pancreatitis with a mean CT severity index of 9 (range, 8-10). The mean CT density was 37 HU (range, 32-56). Successful management with PCD alone was achieved in 8 patients. The other 2 patients underwent surgical necrosectomy. One patient who underwent surgical necrosectomy died. Minor complications occurred in 3 patients. The kissing catheter technique allows for a higher success rate of PCD compared with that of the conventional method of PCD, in collections with a higher mean CT density.
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Affiliation(s)
- Pankaj Gupta
- Department of Radiodiagnosis and Imaging, Postgraduate Institute of Medical Imaging and Research, Chandigarh, Punjab 160012, India
| | - Suzanne Koshi
- Department of Radiodiagnosis and Imaging, Postgraduate Institute of Medical Imaging and Research, Chandigarh, Punjab 160012, India
| | - Jayanta Samanta
- Department of Gastroenterology, Nehru Hospital, Postgraduate Institute of Medical Imaging and Research, Chandigarh, Punjab 160012, India
| | - Harshal Mandavdhare
- Department of Gastroenterology, Nehru Hospital, Postgraduate Institute of Medical Imaging and Research, Chandigarh, Punjab 160012, India
| | - Vishal Sharma
- Department of Gastroenterology, Nehru Hospital, Postgraduate Institute of Medical Imaging and Research, Chandigarh, Punjab 160012, India
| | - Saroj K Sinha
- Department of Gastroenterology, Nehru Hospital, Postgraduate Institute of Medical Imaging and Research, Chandigarh, Punjab 160012, India
| | - Usha Dutta
- Department of Gastroenterology, Nehru Hospital, Postgraduate Institute of Medical Imaging and Research, Chandigarh, Punjab 160012, India
| | - Rakesh Kochhar
- Department of Gastroenterology, Nehru Hospital, Postgraduate Institute of Medical Imaging and Research, Chandigarh, Punjab 160012, India
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Abstract
OBJECTIVES Because infected pancreatic necrosis (IPN) has multiple presentations, not all patients are likely to benefit from the same first-line treatment. Our objective was to evaluate morbidity and mortality in a series of patients treated with a multimodal therapeutic approach. METHODS Between May 2012 and May 2019, 51 patients diagnosed with IPN were treated. The 5 initial treatment alternatives were as follows: percutaneous drainage, minimally invasive necrosectomy, antibiotics alone, transgastric necrosectomy, and temporizing percutaneous/endoscopic drainage. Initial treatment selection depended on evolution, clinical condition, and extension of pancreatic necrosis. Success, morbidity, and mortality rates were determined. RESULTS In terms of determinant-based classification, 37 were classified as severe, and 14 as critical. Percutaneous, temporizing drainage, minimally invasive necrosectomy, antibiotics alone and transgastric necrosectomy approaches were used in 21, 10, 11, 4, and 5 patients, respectively. Necrosectomy was not required in 18 patients (35%). There were no significant differences in mortality among the different treatment approaches (P < 0.45). Overall success, morbidity, and mortality rates were 68.6%, 52.9%, and 7.8%, respectively. CONCLUSIONS The multimodal approach seems to be a rational and efficient strategy for the initial treatment of IPN.
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Liu T, Sun S, Gao H, Gao Y, Xu Q, Liu X, Miao Y, Wei J. CT-guided percutaneous catheter drainage of pancreatic postoperative collections. MINIM INVASIV THER 2019; 29:269-274. [PMID: 31304803 DOI: 10.1080/13645706.2019.1641524] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/26/2022]
Abstract
Objective: To examine the clinical characteristics of fluid collections after pancreatic surgery and evaluate the safety and effectiveness of CT-guided percutaneous catheter drainage (CT-PCD).Material and methods: A retrospective, cross-sectional study was carried out. 51 patients enrolled in this study underwent CT-PCD for collections after pancreatic surgery. The clinical and imaging data were collected and analysed.Results: In all 51 cases, CT scans showed that the samples were collected from the upper abdomen in 94.1% (48/51) of the patients. Apparent clinical symptoms before puncture manifested in 88.2% (45/51) of the patients. The average interval between surgery and puncture was 14.3 ± 7.9 days. In 76.4% (39/51) of the patients, the abdominal drainage catheter inserted during surgery was still not removed during CT-PCD. Amylase levels in drainage fluid were more than three times that of serum amylase in 66.7% (24/36) of the patients. The drainage fluid of 37 patients was sent for bacterial cultures; of these, 64.9% (24/37) tested positive. Full recovery after single puncture procedure occurred in 84.3% (43/51) of the patients. The incidence of puncture-related complications was 3.9%.Conclusions: Pancreatic postoperative collections requiring clinical puncture were mostly located in the upper abdomen. CT-PCD is a safe technique with good therapeutic effects in patients with collections.
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Affiliation(s)
- Tongtai Liu
- The Pancreas Center of the First Affiliated Hospital of Nanjing Medical University, Nanjing Medical University, Nanjing, China
| | - Shuwen Sun
- The Department of Radiology of thee First Affiliated Hospital of Nanjing Medical University, Nanjing Medical University, Nanjing, China
| | - Hao Gao
- The Pancreas Center of the First Affiliated Hospital of Nanjing Medical University, Nanjing Medical University, Nanjing, China
| | - Yong Gao
- The Pancreas Center of the First Affiliated Hospital of Nanjing Medical University, Nanjing Medical University, Nanjing, China
| | - Qing Xu
- The Department of Radiology of thee First Affiliated Hospital of Nanjing Medical University, Nanjing Medical University, Nanjing, China
| | - Xisheng Liu
- The Department of Radiology of thee First Affiliated Hospital of Nanjing Medical University, Nanjing Medical University, Nanjing, China
| | - Yi Miao
- The Pancreas Center of the First Affiliated Hospital of Nanjing Medical University, Nanjing Medical University, Nanjing, China
| | - Jishu Wei
- The Pancreas Center of the First Affiliated Hospital of Nanjing Medical University, Nanjing Medical University, Nanjing, China
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12
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Abstract
Walled of pancreatic necrosis (WOPN) is a new term coined for encapsulated fluid collection developing after acute necrotising pancreatitis (ANP). It is a heterogeneous collection containing varying amount of liquid as well as solid necrotic material. The literature on its natural history as well as appropriate management is gradually expanding thereby improving treatment outcomes of this enigmatic disease. Areas covered: This review discusses currently available literature on etiology, frequency, natural history, and imaging features WOPN. Also, updated treatment options including endoscopic, radiological and surgical drainage are discussed. Expert opinion: WOPN is alocal complication of ANP occurring in the delayed phase of ANP and may be asymptomatic (50%) or present with pain, fever, jaundice, or gastric outlet obstruction. Natural courses of asymptomatic WOPN have been infrequently studied, and it appears that the majority remain asymptomatic and resolve spontaneously. Magnetic resonance imaging and endoscopic ultrasound are the best imaging modalities to evaluate solid necrotic debris. Symptomatic WOPN usually needs immediate drainage, this can be done endoscopically, radiologically, or surgically. Current evidence suggests that endoscopic transluminal drainage is the preferred drainage technique as it is effective and associated with lower mortality, risk of organ failure, adverse effects, and length of hospital stay.
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Affiliation(s)
- Surinder Singh Rana
- a Department of Gastroenterology , Post Graduate Institute of Medical Education and Research (PGIMER) , Chandigarh , India
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13
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Zhang ZH, Ding YX, Wu YD, Gao CC, Li F. A meta-analysis and systematic review of percutaneous catheter drainage in treating infected pancreatitis necrosis. Medicine (Baltimore) 2018; 97:e12999. [PMID: 30461605 PMCID: PMC6392933 DOI: 10.1097/md.0000000000012999] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/13/2022] Open
Abstract
BACKGROUND In the current meta-analysis, we focus on the exploration of percutaneous catheter drainage (PCD) in terms of its overall safety as well as efficacy in the treatment of infected pancreatitis necrosis based on qualified studies. METHODS The following electronic databases were searched to identify eligible studies through the use of index words updated to May 2018: PubMed, Cochrane, and Embase. Relative risk (RR) or mean difference (MD) along with 95% confidence interval (95% CI) were utilized for the main outcomes. RESULTS A total of 622 patients in the PCD group and 650 patients in the control group from 13 studies were included in the present meta-analysis. The aggregated results indicated that the incidence of bleeding was decreased significantly (RR: 0.42, 95% CI: 0.25-0.70) in the PCD group as compared with the control group. In addition, PCD decreased the mortality (RR: 0.76, 95% CI: 0.41-1.42), hospital duration (SMD: -0.22, 95% CI: -0.77 to -0.33), duration in intensive care unit (ICU) (SMD: -0.13, 95% CI: -0.30 to -0.04), pancreatic fistula (RR: 0.73, 95% CI: 0.46-1.17), and organ failure (RR: 0.91, 95% CI: 0.45-1.82) in comparison with the control group, but without statistical significance. CONCLUSION Our findings provide evidence for the treatment effect of PCD in the decrease of bleeding, mortality, duration in hospital and ICU, pancreatic fistula, organ failure as compared with the surgical treatment. In conclusion, further studies based on high-quality RCTs with larger sample size and long-term follow-ups are warranted for the confirmation of PCD efficacy in treating infected pancreatitis necrosis.
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Affiliation(s)
- Zhi-Hua Zhang
- Department of Hepatobiliary Surgery, Beijing Chaoyang Hospital
| | - Yi-Xuan Ding
- Department of General Surgery, Xuanwu Hospital, Capital Medical University, Beijing, China
| | - Yu-Duo Wu
- Department of General Surgery, Xuanwu Hospital, Capital Medical University, Beijing, China
| | - Chong-Chong Gao
- Department of General Surgery, Xuanwu Hospital, Capital Medical University, Beijing, China
| | - Fei Li
- Department of General Surgery, Xuanwu Hospital, Capital Medical University, Beijing, China
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Mallick B, Dhaka N, Gupta P, Gulati A, Malik S, Sinha SK, Yadav TD, Gupta V, Kochhar R. An audit of percutaneous drainage for acute necrotic collections and walled off necrosis in patients with acute pancreatitis. Pancreatology 2018; 18:727-733. [PMID: 30146334 DOI: 10.1016/j.pan.2018.08.010] [Citation(s) in RCA: 36] [Impact Index Per Article: 5.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/03/2018] [Revised: 07/18/2018] [Accepted: 08/19/2018] [Indexed: 12/11/2022]
Abstract
BACKGROUND AND OBJECTIVES Percutaneous catheter drainage (PCD) is used as a first step in the management of symptomatic fluid collections in patients with acute pancreatitis (AP). We aimed to compare the outcome of patients with acute necrotic collection (ANC) and those with walled-off necrosis (WON), who had undergone PCD as a part of management of AP. METHODS Consecutive patients of AP with symptomatic ANC or WON undergoing PCD were evaluated. Primary outcome measures were need for additional surgical necrosectomy and mortality. Secondary outcome measures were need for up-gradation of first PCD, need for additional drain, in-hospital as well as total duration of PCD and length of hospital stay. RESULTS Indications of PCD in 375 patients (258 with ANC and 117 with WON) were suspected infected pancreatic necrosis (n = 214), persistent organ failure (n = 117) and pressure symptoms (n = 44). Need for additional surgical necrosectomy was seen in 14% patients with ANC and in 12% of patients with WON (p = 0.364) and mortality was 19% in patients with ANC as compared to 13.7% in those with WON (p = 0.132). There was no significant difference in the secondary outcome parameters between patients who underwent PCD for ANC or WON. Complications of PCD were comparable between patients with ANC and WON except development of external pancreatic fistula which occurred more often in patients with WON than in those with ANC (24.4% versus 34.2% respectively, p = 0.034). CONCLUSION Persistent organ failure in more often an indication of PCD in patients with ANC than in WON and suspected infection is more commonly an indication in WON than in ANC. Early PCD is as efficacious and safe as delayed PCD.
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Affiliation(s)
- Bipadabhanjan Mallick
- Department of Gastroenterology, Postgraduate Institute of Medical Education and Research, Chandigarh, India
| | - Narendra Dhaka
- Department of Gastroenterology, Postgraduate Institute of Medical Education and Research, Chandigarh, India
| | - Pankaj Gupta
- Department of Radiodiagnosis, Postgraduate Institute of Medical Education and Research, Chandigarh, India
| | - Ajay Gulati
- Department of Radiodiagnosis, Postgraduate Institute of Medical Education and Research, Chandigarh, India
| | - Sarthak Malik
- Department of Gastroenterology, Postgraduate Institute of Medical Education and Research, Chandigarh, India
| | - Saroj K Sinha
- Department of Gastroenterology, Postgraduate Institute of Medical Education and Research, Chandigarh, India
| | - Thakur D Yadav
- Department of General Surgery, Postgraduate Institute of Medical Education and Research, Chandigarh, India
| | - Vikas Gupta
- Department of General Surgery, Postgraduate Institute of Medical Education and Research, Chandigarh, India
| | - Rakesh Kochhar
- Department of Gastroenterology, Postgraduate Institute of Medical Education and Research, Chandigarh, India.
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Rasslan R, Novo FDCF, Bitran A, Utiyama EM, Rasslan S. Management of infected pancreatic necrosis: state of the art. ACTA ACUST UNITED AC 2018; 44:521-529. [PMID: 29019583 DOI: 10.1590/0100-69912017005015] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/25/2017] [Accepted: 06/01/2017] [Indexed: 02/08/2023]
Abstract
Pancreatic necrosis occurs in 15% of acute pancreatitis. The presence of infection is the most important factor in the evolution of pancreatitis. The diagnosis of infection is still challenging. Mortality in infected necrosis is 20%; in the presence of organic dysfunction, mortality reaches 60%. In the last three decades, there has been a real revolution in the treatment of infected pancreatic necrosis. However, the challenges persist and there are many unsolved questions: antibiotic treatment alone, tomography-guided percutaneous drainage, endoscopic drainage, video-assisted extraperitoneal debridement, extraperitoneal access, open necrosectomy? A step up approach has been proposed, beginning with less invasive procedures and reserving the operative intervention for patients in which the previous procedure did not solve the problem definitively. Indication and timing of the intervention should be determined by the clinical course. Ideally, the intervention should be done only after the fourth week of evolution, when it is observed a better delimitation of necrosis. Treatment should be individualized. There is no procedure that should be the first and best option for all patients. The objective of this work is to critically review the current state of the art of the treatment of infected pancreatic necrosis.
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Affiliation(s)
- Roberto Rasslan
- - University of São Paulo School of Medicine, Division of General Surgery and Trauma, Department of Surgery, São Paulo, SP, Brazil
| | - Fernando da Costa Ferreira Novo
- - University of São Paulo School of Medicine, Division of General Surgery and Trauma, Department of Surgery, São Paulo, SP, Brazil
| | - Alberto Bitran
- - University of São Paulo School of Medicine, Division of General Surgery and Trauma, Department of Surgery, São Paulo, SP, Brazil
| | - Edivaldo Massazo Utiyama
- - University of São Paulo School of Medicine, Division of General Surgery and Trauma, Department of Surgery, São Paulo, SP, Brazil
| | - Samir Rasslan
- - University of São Paulo School of Medicine, Division of General Surgery and Trauma, Department of Surgery, São Paulo, SP, Brazil
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16
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Zhang W, Sun J, Shen X, Xue Y, Meng C, Yuan S. Percutaneous catheter drainage combined with peritoneal dialysis for treating acute severe pancreatitis: a single-center prospective study. MINERVA CHIR 2018; 74:207-212. [PMID: 29843500 DOI: 10.23736/s0026-4733.18.07813-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
BACKGROUND To investigate the efficacy of percutaneous catheter drainage (PCD) and peritoneal dialysis (PD) in the treatment of severe acute pancreatitis (SAP) and its underlying mechanism. METHODS Totally 64 SAP patients were included in our study and randomly assigned into PCD+PD group (the combination group, N.=32) and convention group (N.=32). SAP patients in the combination group were treated with percutaneous catheter drainage combined with peritoneal dialysis, while those in the convention group were treated with conventional method. The treatment efficacy of both methods were evaluated by comparing levels of plasma inflammatory cytokines (IL-6, IL-8, TNF-α, C-reactive protein, procalcitonin and leukocyte count), relative indexes of important organs (aspartate aminotransferase, alanine aminotransferase, creatinine and urea nitrogen) and other clinical data (amelioration time of abdominal pain and abdominal distension, Balthazar CT scores, acute physiology and chronic health enquiry II score, length of hospital stay, complications and prognosis). RESULTS The expression levels of inflammatory cytokines were significantly decreased in the combination group in a time-dependent manner in comparison with those of the convention group. In addition, the amelioration time of abdominal pain and abdominal distension, length of hospital stay, Balthazar CT scores and the acute physiology and chronic health care II scores in the combination group were also significantly decreased in comparison with those of the convention group. CONCLUSIONS The combination treatment of PCD and PD effectively relieves the clinical symptoms of SAP by clearing plasma inflammatory cytokines.
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Affiliation(s)
- Wenhao Zhang
- Department of Critical Care Medicine, Nanjing First Hospital, Nanjing Medical University, Nanjing, China
| | - Jiakui Sun
- Department of Critical Care Medicine, Nanjing First Hospital, Nanjing Medical University, Nanjing, China
| | - Xiao Shen
- Department of Critical Care Medicine, Nanjing First Hospital, Nanjing Medical University, Nanjing, China
| | - Yinying Xue
- Department of Critical Care Medicine, Nanjing First Hospital, Nanjing Medical University, Nanjing, China
| | - Chao Meng
- Department of Critical Care Medicine, Nanjing First Hospital, Nanjing Medical University, Nanjing, China
| | - Shoutao Yuan
- Department of Critical Care Medicine, Nanjing First Hospital, Nanjing Medical University, Nanjing, China -
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17
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The effect of a novel minimally invasive strategy for infected necrotizing pancreatitis. Surg Endosc 2017; 31:4603-4616. [DOI: 10.1007/s00464-017-5522-0] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/16/2016] [Accepted: 03/15/2017] [Indexed: 12/19/2022]
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Abstract
OBJECTIVES Percutaneous catheter drainage (PCD) is often the first invasive treatment step for infected necrotizing pancreatitis. A proactive PCD strategy, including frequent and early drain revising and upsizing, may reduce the need for surgical necrosectomy and could improve outcomes, but data are lacking. METHODS Necrotizing pancreatitis patients were identified from in-hospital databases (2004-2014). Patients with primary PCD for infected necrotizing pancreatitis were included. Outcomes of patients from 1 center using a proactive PCD strategy were compared with 3 standard strategy centers. RESULTS In total, 369 (25.9%) of 1427 patients received a diagnosis of necrotizing pancreatitis, and 117 (31.7%) of 369 patients underwent primary PCD for infected necrosis: 42 in the proactive group versus 75 in the standard group. Patients in the proactive group had more drain-related procedures (median, 3; interquartile range [IQR], 2-4; versus 2; IQR, 1-2; P < 0.001) and larger final drain sizes (median, 16F; IQR, 14F-20F; versus 14F; IQR, 12F-14F; P < 0.001). Fewer patients underwent additional necrosectomy in the proactive group, 12 (28.6%) versus 39 (52.0%) (adjusted odds ratio, 0.349; 95% confidence interval, 0.137-0.889; P = 0.027), with similar hospital stay and mortality. CONCLUSIONS A proactive PCD strategy is associated with reduced need for necrosectomy in infected necrotizing pancreatitis, compared with standard PCD, with similar clinical outcomes.
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He WH, Zhu Y, Zhu Y, Liu P, Zeng H, Xia L, Yu C, Chen HM, Shu X, Liu ZJ, Chen YX, Lu NH. The outcomes of initial endoscopic transluminal drainage are superior to percutaneous drainage for patients with infected pancreatic necrosis: a prospective cohort study. Surg Endosc 2017; 31:3004-3013. [PMID: 28205028 DOI: 10.1007/s00464-016-5324-9] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/09/2016] [Accepted: 10/31/2016] [Indexed: 12/23/2022]
Abstract
BACKGROUND AND STUDY AIM The commonly used minimally invasive methods for patients with infected pancreatic necrosis (IPN) are initial endoscopic transluminal drainage (ETD) and percutaneous catheter drainage (PCD), which are followed, if necessary, by endoscopic or surgical necrosectomy. This study intends to explore which of the two minimally invasive treatments leads to a better prognosis. PATIENTS AND METHODS Patients with IPN and an indication for intervention were prospectively enrolled and underwent either initial ETD or PCD followed, if necessary, by endoscopic or surgical necrosectomy. RESULTS Initial treatment success occurred in 8 of 11 patients after ETD (72.7%) and in 3 of 13 patients after PCD (30.8%) (risk ratio [RR] with ETD, 2.36; 95% CI 0.97-5.77; P = 0.04). After 1 year of follow-up, 72.7% of patients survived with ETD, and 69.2% survived with PCD (RR 1.05; 95% CI 0.63-1.75; P = 0.85). Intestinal fistula seems to have occurred less in the patients who received initial ETD rather than PCD therapy (9.1 vs. 38.5%; RR 0.24; 95% CI 0.03-1.73; P = 0.098). Fewer patients who underwent an initial ETD were transferred to surgery (9.1 vs. 46.2%; RR 0.20; 95% CI 0.03-1.40; P = 0.047). A higher rate of new-onset diabetes (3 cases) or impaired glucose tolerance (1 case) occurred in initial PCD compared to ETD (40 vs. 0%, P = 0.042). CONCLUSION The outcomes of initial endoscopic transluminal drainage are superior to percutaneous drainage for patients with infected pancreatic necrosis (ChiCTR-ONRC-13003653).
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Affiliation(s)
- Wen-Hua He
- Department of Gastroenterology, The First Affiliated Hospital of Nanchang University, 17 Yong Wai Zheng Street, Nanchang, 330006, Jiangxi, People's Republic of China
| | - Yong Zhu
- Department of Gastroenterology, The First Affiliated Hospital of Nanchang University, 17 Yong Wai Zheng Street, Nanchang, 330006, Jiangxi, People's Republic of China
| | - Yin Zhu
- Department of Gastroenterology, The First Affiliated Hospital of Nanchang University, 17 Yong Wai Zheng Street, Nanchang, 330006, Jiangxi, People's Republic of China
| | - Pi Liu
- Department of Gastroenterology, The First Affiliated Hospital of Nanchang University, 17 Yong Wai Zheng Street, Nanchang, 330006, Jiangxi, People's Republic of China
| | - Hao Zeng
- Department of Gastroenterology, The First Affiliated Hospital of Nanchang University, 17 Yong Wai Zheng Street, Nanchang, 330006, Jiangxi, People's Republic of China
| | - Liang Xia
- Department of Gastroenterology, The First Affiliated Hospital of Nanchang University, 17 Yong Wai Zheng Street, Nanchang, 330006, Jiangxi, People's Republic of China
| | - Chen Yu
- Department of Radiology, The First Affiliated Hospital of Nanchang University, Nanchang, People's Republic of China
| | - Hai-Ming Chen
- Department of Surgery, The First Affiliated Hospital of Nanchang University, Nanchang, People's Republic of China
| | - Xu Shu
- Department of Gastroenterology, The First Affiliated Hospital of Nanchang University, 17 Yong Wai Zheng Street, Nanchang, 330006, Jiangxi, People's Republic of China
| | - Zhi-Jian Liu
- Department of Gastroenterology, The First Affiliated Hospital of Nanchang University, 17 Yong Wai Zheng Street, Nanchang, 330006, Jiangxi, People's Republic of China
| | - You-Xiang Chen
- Department of Gastroenterology, The First Affiliated Hospital of Nanchang University, 17 Yong Wai Zheng Street, Nanchang, 330006, Jiangxi, People's Republic of China
| | - Nong-Hua Lu
- Department of Gastroenterology, The First Affiliated Hospital of Nanchang University, 17 Yong Wai Zheng Street, Nanchang, 330006, Jiangxi, People's Republic of China.
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20
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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 1: Epidemiology, diagnosis, and treatment. J Gastroenterol Hepatol 2016; 31:1546-54. [PMID: 27044023 DOI: 10.1111/jgh.13394] [Citation(s) in RCA: 41] [Impact Index Per Article: 4.6] [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: 12/12/2022]
Abstract
Walled-off necrosis (WON) is a relatively 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 1 of this statement focused on the epidemiology, diagnosis, and timing of intervention.
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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 & 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, Asan Medical Center, University of Ulsan College of Medicine, 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, Aizu Medical Center, Fukushima Medical University, Aizuwakamatsu, Japan
| | - Iruru Maetani
- Division of Gastroenterology and Hepatology, Department of Internal Medicine, Toho University Ohashi Medical Center, Tokyo, Japan
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Ke L, Li J, Hu P, Wang L, Chen H, Zhu Y. Percutaneous Catheter Drainage in Infected Pancreatitis Necrosis: a Systematic Review. Indian J Surg 2016; 78:221-228. [PMID: 27358518 PMCID: PMC4907923 DOI: 10.1007/s12262-016-1495-9] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/20/2015] [Accepted: 04/28/2016] [Indexed: 02/06/2023] Open
Abstract
The primary aim of this study was to present the outcomes of percutaneous catheter drainage (PCD) in patients with infected pancreatitis necrosis. A second aim was to focus on disease severity, catheter size, and additional surgical intervention. A literature search of the PubMed/MEDLINE/Cochrane Library (January 1998 to February 2015) databases was conducted. All randomized, non-randomized, and retrospective studies with data on PCD techniques and outcomes in patients with infected pancreatitis necrosis were included. Studies that reported data on PCD along with other interventions without the possibility to discriminate results specific to PCD were excluded. The main outcomes were mortality, major complications, and definitive successful treatment with percutaneous catheter drainage alone. Fifteen studies of 577 patients were included. There was only one randomized, controlled trial, and most others were retrospective case series. Organ failure before PCD occurred in 55.3 % of patients. With PCD alone, definitive successful treatment was 56.2 % of patients. Additional surgical intervention was required after PCD in 38.5 % of patients. The overall mortality rate was 18 % (104 of 577 patients). Complications occurred in 25.1 % of patients, and fistula was the most common complication. PCD is an efficient tool for treatment in the majority of patients with infected pancreatitis necrosis as the only intervention. Multiple organ failures before PCD are negative parameters for the outcome of the disease. Large catheters fail to prove to be more effective for draining necrotic tissue. However, in the extent of multi-morbid patients, to determine one single prognostic factor seems to be difficult.
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Affiliation(s)
- Lichi Ke
- />Department of Surgery, The First Affiliated Hospital of Nanchang University, No. 17 Yongwai Street, Nanchang, Jiangxi Province 330006 People’s Republic of China
| | - Junhua Li
- />Department of Surgery, The First Affiliated Hospital of Nanchang University, No. 17 Yongwai Street, Nanchang, Jiangxi Province 330006 People’s Republic of China
| | - Peihong Hu
- />Department of Surgery, The First Affiliated Hospital of Nanchang University, No. 17 Yongwai Street, Nanchang, Jiangxi Province 330006 People’s Republic of China
| | - Lianqun Wang
- />Department of Surgery, The First Affiliated Hospital of Nanchang University, No. 17 Yongwai Street, Nanchang, Jiangxi Province 330006 People’s Republic of China
| | - Haiming Chen
- />Department of Surgery, The First Affiliated Hospital of Nanchang University, No. 17 Yongwai Street, Nanchang, Jiangxi Province 330006 People’s Republic of China
| | - Yaping Zhu
- />Department of Surgery, The Zhuhai Hospital of Jinan University, No. 79 Kangning Street, Zhuhai, Guangdong Province 519000 People’s Republic of China
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Abstract
Acute pancreatitis is the most common gastrointestinal indication for hospital admission, and infected pancreatic and/or extrapancreatic necrosis is a potentially lethal complication. Current standard treatment of infected necrosis is a step-up approach, consisting of catheter drainage followed, if necessary, by minimally invasive necrosectomy. International guidelines recommend postponing catheter drainage until the stage of 'walled-off necrosis' has been reached, a process that typically takes 4 weeks after onset of acute pancreatitis. This recommendation stems from the era of primary surgical necrosectomy. However, postponement of catheter drainage might not be necessary, and earlier detection and subsequent earlier drainage of infected necrosis could improve outcome. Strong data and consensus among international expert pancreatologists are lacking. Future clinical, preferably randomized, studies should focus on timing of catheter drainage in patients with infected necrotizing pancreatitis. In this Perspectives, we discuss challenges in the invasive treatment of patients with infected necrotizing pancreatitis, focusing on timing of catheter drainage.
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Peng T, Dong LM, Zhao X, Xiong JX, Zhou F, Tao J, Cui J, Yang ZY. Minimally invasive percutaneous catheter drainage versus open laparotomy with temporary closure for treatment of abdominal compartment syndrome in patients with early-stage severe acute pancreatitis. JOURNAL OF HUAZHONG UNIVERSITY OF SCIENCE AND TECHNOLOGY. MEDICAL SCIENCES = HUA ZHONG KE JI DA XUE XUE BAO. YI XUE YING DE WEN BAN = HUAZHONG KEJI DAXUE XUEBAO. YIXUE YINGDEWEN BAN 2016; 36:99-105. [PMID: 26838748 DOI: 10.1007/s11596-016-1549-z] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/03/2015] [Revised: 11/15/2015] [Indexed: 12/18/2022]
Abstract
This study aimed to examine the clinical efficacy of minimally invasive percutaneous catheter drainage (PCD) versus open laparotomy with temporary closure in the treatment of abdominal compartment syndrome (ACS) in patients with early-stage severe acute pancreatitis (SAP). Clinical data of 212 patients who underwent PCD and 61 patients who were given open laparotomy with temporary closure in our hospital over the last 10-year period were retrospectively analyzed, and outcomes were compared, including total and post-decompression intensive care unit (ICU) and hospital stays, physiological data, organ dysfunction, complications, and mortality. The results showed that the organ dysfunction scores were similar between the PCD and open laparotomy groups 72 h after decompression. In the PCD group, 134 of 212 (63.2%) patients required postoperative ICU support versus 60 of 61 (98.4%) in the open laparotomy group (P<0.001). Additionally, 87 (41.0%) PCD patients experienced complications as compared to 49 of 61 (80.3%) in the open laparotomy group (P<0.001). There were 40 (18.9%) and 32 (52.5%) deaths, respectively, in the PCD and open laparotomy groups (P<0.001). In conclusion, minimally invasive PCD is superior to open laparotomy with temporary closure, with fewer complications and deaths occurring in PCD group.
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Affiliation(s)
- Tao Peng
- Pancreatic Disease Institute, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, 430022, China
| | - Li-Ming Dong
- Pancreatic Disease Institute, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, 430022, China
| | - Xing Zhao
- Pancreatic Disease Institute, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, 430022, China
| | - Jiong-Xin Xiong
- Pancreatic Disease Institute, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, 430022, China
| | - Feng Zhou
- Pancreatic Disease Institute, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, 430022, China
| | - Jing Tao
- Pancreatic Disease Institute, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, 430022, China
| | - Jing Cui
- Pancreatic Disease Institute, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, 430022, China
| | - Zhi-Yong Yang
- Pancreatic Disease Institute, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, 430022, China.
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Better Outcomes if Percutaneous Drainage Is Used Early and Proactively in the Course of Necrotizing Pancreatitis. J Vasc Interv Radiol 2016; 27:418-25. [PMID: 26806694 DOI: 10.1016/j.jvir.2015.11.054] [Citation(s) in RCA: 35] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/19/2015] [Revised: 11/23/2015] [Accepted: 11/23/2015] [Indexed: 02/06/2023] Open
Abstract
PURPOSE To compare outcomes after percutaneous catheter drainage (PCD) for acute necrotizing pancreatitis versus those in a randomized controlled trial as a reference standard. MATERIALS AND METHODS Between September 2010 and August 2014, CT-guided PCD was the primary treatment for 39 consecutive patients with pancreatic necrosis. The indication for PCD was the clinical finding of uncontrolled pancreatic juice leakage rather than infected necrosis. Subsequent to PCD, the drains were proactively studied with fluoroscopic contrast medium every 3 days to ensure patency and position. Drains were ultimately maneuvered to the site of leakage. These 39 patients were compared with 43 patients from the Pancreatitis, Necrosectomy versus Step-up Approach (PANTER) trial. RESULTS The CT severity index was similar between studies (median of 8 in each). Time from onset of acute pancreatitis to PCD was shorter in the present series (median, 23 d vs 30 d). The total number of procedures (PCD and subsequent fluoroscopic drain studies) per patient was greater in the present series (mean, 14 vs 2). More patients in the PANTER trial had organ failure (62% vs 84%), required open or endoscopic necrosectomy (0% vs 60%), and experienced in-hospital mortality (0% vs 19%; P < .05 for all). CONCLUSIONS Even though patients in the present series had a similar CT severity index as those in the PANTER trial, the former group showed lower incidences of organ failure, need for necrosectomy, and in-hospital mortality. The use of a proactive PCD protocol early, before the development of severe sepsis, appeared to be effective.
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Predictive factors for successful ultrasound-guided percutaneous drainage in necrotizing pancreatitis. Surg Endosc 2015; 30:2929-34. [PMID: 26487212 DOI: 10.1007/s00464-015-4579-x] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/21/2015] [Accepted: 09/19/2015] [Indexed: 02/08/2023]
Abstract
BACKGROUND Percutaneous catheter drainage (PCD) is now regarded as an initial minimal access technique of step-up approach for necrotizing pancreatitis. Factors that led to surgical intervention after initial management with PCD have rarely been reported. This study was to evaluate the safety and efficacy of ultrasound-guided PCD in patients with necrotizing pancreatitis and identify a subgroup of patients where PCD alone would be effective. METHODS We performed a retrospective review of patients with necrotizing pancreatitis who underwent intervention in West China Hospital from January 1, 2009, to March 31, 2013. RESULTS Patients who underwent initial PCD therapy had lower intra-abdominal bleeding rate (41/235 vs. 1/51, P = 0.002), lower enterocutaneous fistula rate (28/235 vs. 0/51, P = 0.004), and lower mortality rate (46/235 vs. 3/51, P = 0.001) when compared with the patients who underwent operative intervention. The successful PCD group had lower computed tomography (CT) mean density of necrotic fluid collection (18 HU vs. 25 HU, P = 0.01) and higher prevalence of walled-off necrosis (20/35 vs. 5/16, P = 0.04) when compared with failed PCD group. Multivariate analysis of the predictors of surgery showed that only CT mean density of necrotic fluid collection [odd ratio (OR) 1.63, 95 % confidence interval (CI) 1.04-2.94, P = 0.006] was identified as significant factor. CONCLUSION CT mean density of necrotic fluid collection and the existence of acute necrotic collection could influence the success rate of PCD.
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Hu ZL, Kang PC, Cui YF. Percutaneous catheter drainage in severe acute pancreatitis: Application and problems. Shijie Huaren Xiaohua Zazhi 2015; 23:4215-4220. [DOI: 10.11569/wcjd.v23.i26.4215] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023] Open
Abstract
Severe acute pancreatitis (SAP) is an acute abdominal disease which has a number of complications and a high mortality rate. The prognosis had improved much since the use of multidisciplinary comprehensive therapy and minimally invasive treatment in this disease. Percutaneous catheter drainage (PCD) can be used as a step-up minimally invasive treatment for SAP, and as a bridge between internal conservative therapy and open surgery for removal of necrotic tissue. PCD has a therapeutic effect on the local complications of SAP, such as abdominal free effusion, retroperitoneal necrosis infection and pancreatic pseudocyst, and can help to choose the operation timing when the necrotic tissue encapsulation is confirmed in patients with SAP. Clinical therapy should be slected based on the lesion location, quantity and consistency of effusion. When the effusion is located in shallow location, PCD shuold be guided by ultrasound; if the effusion is located in location deep, CT guidance should be adopted. After PCD is finished, the catheter should be cared carefully by keeping the drainage tube patent, rinsing the tube and adjusting its position in time. All of these are the necessary measures to maintain the PCD effectively. When the drainage fluid is less than 10 mL/d and imaging shows that the lesions disappear, it is the best time to remove the tube.
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Sugimoto M, Sonntag DP, Flint GS, Boyce CJ, Kirkham JC, Harris TJ, Carr SM, Nelson BD, Barton JG, Traverso LW. A percutaneous drainage protocol for severe and moderately severe acute pancreatitis. Surg Endosc 2015; 29:3282-91. [PMID: 25631111 DOI: 10.1007/s00464-015-4077-1] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/30/2014] [Accepted: 01/12/2015] [Indexed: 12/19/2022]
Abstract
BACKGROUND According to the revised Atlanta classification, severe and moderately severe acute pancreatitis (AP) includes patients with pancreatic and peripancreatic collections with or without organ failure. These collections suggest the presence of pancreatic juice leakage. The aim of this study was to evaluate the efficacy of a percutaneous catheter drainage (PCD) protocol designed to control leakage and decrease disease severity. METHODS Among 663 patients with clinical AP, 122 were classified as moderately severe or severe AP (all had collections). The computed tomography severity index (CTSI) score was calculated. The indication for PCD was based on progressive clinical signs and symptoms. Drain patency, position, and need for additional drainage sites were assessed using CT scans and drain studies initially every 3 days using a proactive protocol. Drain fluid was examined for amylase concentration and microbiological culture. Clinicopathological variables for patients with and without PCD were compared. Since there was no mortality, we used prolonged drainage time to measure the success of PCD. Within the group treated with PCD, variables that resulted in prolonged drainage time were analyzed. RESULTS PCD was used in 47/122 (39 %) patients of which 33/47 (70 %) had necrosis. PCD cases had a median CTSI of 8 and were classified as moderately severe AP (57 %) and severe AP (43 %). Inhospital mortality was zero. Surgical necrosectomy was not required for patients with necrosis. Independent risk factors for prolonged drainage time were persistent organ failure >48 h (P = 0.001), CTSI 8-10 (P = 0.038), prolonged duration of amylase-rich fluid in drains (P < 0.001), and polymicrobial culture fluid in drains (P = 0.015). CONCLUSIONS A proactive PCD protocol persistently maintaining drain patency advanced to the site of leak controlled the prolonged amylase in drainage fluid resulting in a mortality rate of zero.
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Affiliation(s)
- Motokazu Sugimoto
- Center for Pancreatic and Liver Disease, St. Luke's Health System, 100 East Idaho Street, Suite 301, Boise, ID, 83712, USA.
| | - David P Sonntag
- Department of Interventional Radiology, St. Luke's Health System, 100 East Idaho Street, Suite 301, Boise, ID, 83712, USA
| | - Greggory S Flint
- Center for Pancreatic and Liver Disease, St. Luke's Health System, 100 East Idaho Street, Suite 301, Boise, ID, 83712, USA
| | - Cody J Boyce
- Department of Diagnostic Radiology, St. Luke's Health System, 100 East Idaho Street, Suite 301, Boise, ID, 83712, USA
| | - John C Kirkham
- Department of Diagnostic Radiology, St. Luke's Health System, 100 East Idaho Street, Suite 301, Boise, ID, 83712, USA
| | - Tyler J Harris
- Department of Interventional Radiology, St. Luke's Health System, 100 East Idaho Street, Suite 301, Boise, ID, 83712, USA
| | - Sean M Carr
- Department of Interventional Radiology, St. Luke's Health System, 100 East Idaho Street, Suite 301, Boise, ID, 83712, USA
| | - Brent D Nelson
- Department of Interventional Radiology, St. Luke's Health System, 100 East Idaho Street, Suite 301, Boise, ID, 83712, USA
| | - Joshua G Barton
- Center for Pancreatic and Liver Disease, St. Luke's Health System, 100 East Idaho Street, Suite 301, Boise, ID, 83712, USA
| | - L William Traverso
- Center for Pancreatic and Liver Disease, St. Luke's Health System, 100 East Idaho Street, Suite 301, Boise, ID, 83712, USA
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Zhou J, Ke L, Tong Z, Li G, Li W, Li N, Li J. Risk factors and outcome of splanchnic venous thrombosis in patients with necrotizing acute pancreatitis. Thromb Res 2014; 135:68-72. [PMID: 25466845 DOI: 10.1016/j.thromres.2014.10.021] [Citation(s) in RCA: 25] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/06/2014] [Revised: 09/24/2014] [Accepted: 10/27/2014] [Indexed: 12/18/2022]
Abstract
BACKGROUND Splanchnic venous thrombosis (SVT) is considered a rare but important complication in patients with acute pancreatitis (AP) and literatures regarding this topic were sparse. The aim of the present study was to investigate the risk factors of SVT in necrotizing acute pancreatitis (NAP) and assess the prognosis of these patients. METHODS Both univariate and multivariate logistic regression analyses were applied using 15 indices including age, gender, Acute Physiology and Chronic Health Evaluation II scores (APACHE II), CRP (C - reactive protein) levels, etc to explore potential risk factors for the development of SVT in NAP patients. Moreover, clinical outcome measures such as mortality, organ failure and length of hospital and ICU stay were also compared between NAP patients with or without SVT. RESULTS According to the statistical results, only intra-abdominal pressure (IAP) was proved to be an independent risk factor for SVT (OR, 1.283; 95% CI, 1.091-1.509,P=0.003). In addition, Balthazar's CT score and occurrence of IPN (infected pancreatic necrosis) also reached statistical significance (P=0.040 and 0.047, respectively), but the 95% confidence interval shown in the multivariate logistic regression suggested that the observed ORs are not significant (1.326;95% CI 0.984-1.787 and 2.61;95 CI 0.972-7.352, respectively), which indicates weaker association between the two parameters and SVT. Regarding the clinical outcomes, patients with SVT showed higher mortality, longer hospital and intensive care unit duration, higher rates of a variety of complications and more utilization of invasive interventions. CONCLUSIONS IAP is an independent risk factor for the development of SVT in patients with NAP, while Balthazar's CT score and occurrence of IPN are also associated with SVT, although not as strong as IAP. Moreover, occurrence of SVT relates with extremely poor prognosis in NAP patients, evidenced by increased mortality, morbidity and need for invasive interventions.
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Affiliation(s)
- Jing Zhou
- Department of General Surgery, Jinling Hospital, Nanjing University School of Medicine, Nanjing 210002, People's Repubic of China
| | - Lu Ke
- Department of General Surgery, Jinling Hospital, Nanjing University School of Medicine, Nanjing 210002, People's Repubic of China
| | - Zhihui Tong
- Department of General Surgery, Jinling Hospital, Nanjing University School of Medicine, Nanjing 210002, People's Repubic of China
| | - Gang Li
- Department of General Surgery, Jinling Hospital, Nanjing University School of Medicine, Nanjing 210002, People's Repubic of China
| | - Weiqin Li
- Department of General Surgery, Jinling Hospital, Nanjing University School of Medicine, Nanjing 210002, People's Repubic of China.
| | - Ning Li
- Department of General Surgery, Jinling Hospital, Nanjing University School of Medicine, Nanjing 210002, People's Repubic of China
| | - Jieshou Li
- Department of General Surgery, Jinling Hospital, Nanjing University School of Medicine, Nanjing 210002, People's Repubic of China
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Abstract
Background. Video-assisted retroperitoneal necrosectomy is a minimally invasive surgical technique for the treatment of severe acute pancreatitis. This study evaluated the safety and feasibility of a modified single-stage video-assisted retroperitoneal necrosectomy, retroperitoneoscopic anatomical necrosectomy (REAN). Methods. Between September 2010 and May 2012, a total of 17 patients with infected necrotizing pancreatitis underwent REAN. The surgical procedures were similar to retroperitoneoscopic pancreatectomy, in which 3 trocars are utilized. Briefly, the perirenal space was entered through the posterior pararenal space. Dissection proceeded from posterior to anterior direction to expose the dorsal side of the perirenal fascia. This was opened to reach the anterior perirenal space, where the peripancreatic abscess was located. Necrotic tissue was then debrided and catheter drainage was performed in a single stage. Results. Operating time ranged from 45 to 100 minutes with minimal blood loss. All patients recovered except for one who died. Major perisurgical complications included peritoneal injury (1 patient), splenic vein injury (1 patient), retroperitoneal infection with paralytic ileus (1 patient), hydrothorax and atelectasis (2 patients), and subcutaneous cellulitis beneath the incision (3 patients). Two patients required additional percutaneous catheter drainage, and 1 patient required a laparotomy to debride the remaining necrotic tissue. Postoperative hospital stay ranged from 21 to 64 days. Conclusions. This study demonstrates that REAN, a modified single-stage video-assisted retroperitoneal approach, was safe and feasible for the treatment of infected necrotizing pancreatitis. The advantages of this procedure include direct access with shorter operating time, complete necrotic tissue debridement, easy hemostasis, simple manipulation, and easy drainage.
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Affiliation(s)
- Guodong Zhao
- Chinese People’s Liberation Army (PLA) General Hospital, Beijing, China
| | - Minggen Hu
- Chinese People’s Liberation Army (PLA) General Hospital, Beijing, China
| | - Rong Liu
- Chinese People’s Liberation Army (PLA) General Hospital, Beijing, China
| | - Yong Xu
- The 1st Affiliated Hospital of Chinese People’s Liberation Army (PLA) General Hospital, Beijing, China
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