ABSTRACT
Objective:To study the safety and efficacy of using the ultrasonic lithotripsy system (ULS) in assisting percutaneous nephroscopic retroperitoneal pancreatic necrosectomy in patients with acute necrotizing pancreatitis (ANP) extending to both sides of the retroperitoneal regions.Methods:The clinical data of 47 patients with extensive ANP who underwent video-assisted retroperitoneal debridement (VARD) from January 2017 to October 2022 at the Affiliated Hangzhou First People's Hospital, Zhejiang University School of Medicine, were analyzed retrospectively. There were 32 males and 15 females, aged [ M( Q1, Q3)] 60(43, 75) years old. The patients were divided into two groups based on the debridement methods: patients treated by nephroscopic pancreatic necrosectomy (NPN) were included in the NPN group ( n=22), while patients treated by the ULS-assisted treatment were included in the ULS group ( n=25). The surgical debridement time, operation time and complications of the two groups were compared. Follow up on recurrence and death of patients was done by telephone, outpatient and/or re-hospitalization records. Results:All patients underwent the VARD operation successfully, without any need for conversion to laparotomy, transfer to intensive care unit and death related to the operations. The pancreatic exocrine function was not damaged in both groups. When compared with the ULS group, the NPN group required significantly more debridement time [3(2, 4) times/person vs. 2(1, 2) times/person], longer operation time [65(40, 85) min vs. 35(30, 50) min] and longer hospitalization time [91(76, 130) d vs. 72(62, 102) d, all P<0.05]. No complications occurred in the ULS group. In the NPN group, postoperative hemorrhage occurred in 3 patients, colon fistula in 1 patient, and delayed viral encephalitis in 1 patient. The incidence of postoperative complications in the NPN group was significantly higher than that in the ULS group [22.7%(5/22) vs. 0(0/25), P=0.032]. All the 47 patients with extensive ANP were followed up for a median of 28 months (range 3 to 60 months), and there were no patients who developed residual recurrence and death. Conclusion:For patients with extensive ANP, ULS-assisted nephroscopic pancreatic necrosectomy was safe and feasible. When compared with NPN, the ULS-assisted procedure showed more advantages in debridement efficiency, operation time and hospital stay.
ABSTRACT
Emphysematous pancreatitis is one of the rare and potentially fatal complications of acute pancreatitis. We present here the case of a 69-year-old man who presented with abdominal discomfort, vomiting, and constipation with features of sepsis due to Klebsiella pneumoniae bacteremia and new-onset diabetes mellitus. Elevated serum lipase levels and abdominal computed tomography scan showing pancreatic necrosis with air bubbles suggestive of emphysematous pancreatitis. He was managed conservatively as the surgical intervention was differed in view of unstable hemodynamics and thrombocytopenia. The entire emphysematous pancreatitis and sepsis resolved with medical management alone although surgical necrosectomy may be indicated at presentation.
ABSTRACT
Introducción: La necrosectomía pancreática abierta es una técnica quirúrgica empleada en la infección de la necrosis. Objetivo: Identificar los factores relacionados con el pronóstico en pacientes operados con el diagnóstico de pancreatitis aguda necrotizante. Método: Se realizó una cohorte prospectiva en enfermos operados con el diagnóstico de pancreatitis aguda necrotizante, en la Unidad de Cuidados Intensivos del Hospital General Universitario "Carlos Manuel de Céspedes" de Bayamo, Granma, en el período 2018 - 2020. Se incluyeron 61 pacientes con este diagnóstico. Se estudiaron variables demográficas, clínicas, humorales y quirúrgicas. Se utilizó una estrategia bivariado y multivariado. Resultados: En el análisis bivariado se destacó la influencia de la edad (RR 3,34 IC 95 por ciento 0,17-0,68) y el índice de severidad tomográfica (RR 1,85 IC 95 por ciento 0,66-2,37), la disfunción múltiple de órganos (RR 5,06 IC 95 por ciento 1,08-2,15), la cirugía precoz (2,78 IC 95 por ciento 1,00-3,34) y la infección de la necrosis (RR 6,60 IC 95 por ciento 1,01-5,23). En el modelo de regresión logística multivariado quedaron incluidos como variables independientes asociadas al pronóstico la disfunción múltiple de órganos (RR 6,58 IC 95 por ciento 2,40-18,08) y la infección de la necrosis (RR, 14,20 IC 95 por ciento 5,93 -34,01) Conclusiones: El análisis de la mortalidad evidenció que los factores que demostraron asociación significativa fueron la disfunción múltiple de órganos y la infección de la necrosis(AU)
Introduction: Open pancreatic necrosectomy is a surgical technique used in necrosis infection. Objective: To identify the factors related to prognosis in patients operated on under the diagnosis of acute necrotizing pancreatitis. Methods: A prospective cohort study was carried out in patients operated on under the diagnosis of acute necrotizing pancreatitis, in the intensive care unit of Carlos Manuel de Céspedes General University Hospital of Bayamo, Granma, Cuba, in the period 2018-2020. Sixty-one patients with this diagnosis were included. Demographic, clinical, humoral and surgical variables were studied. A bivariate and multivariate strategy was used. Results: In the bivariate analysis, the influence of age (relative risk [RR]=3.34; 95 percent confidence interval [CI]: 0.17-0.68) and tomographic severity index (RR=1.85; 95 percent CI: 0.66-2.37), as well as multiple organ dysfunction (RR=5.06; 95 percent CI: 1.08-2.15), early surgery (RR=2.78; 95 percent CI: 1.00-3.34) and necrosis infection (RR=6.60; 95 percent CI: 1.01-5.23) were highlighted. In the multivariate logistic regression model, multiple organ dysfunction (RR=6.58; 95 percent CI: 2.40-18.08) and infection of necrosis (RR=14.20; 95 percent CI: 5.93-34.01) were included as independent variables associated with prognosis. Conclusions: Mortality analysis evidenced that the factors that showed significant association were multiple organ dysfunction and necrosis infection(AU)
Subject(s)
Humans , Pancreatitis, Acute Necrotizing , Intensive Care Units , Necrosis/mortality , Prospective Studies , Cohort Studies , Pancreatitis, Acute Necrotizing/surgeryABSTRACT
Introducción: La isquemia anal aguda con gangrena es una entidad infrecuente, con escasa literatura publicada al respecto, cuyas cifras de mortalidad descritas se sitúan en un 20 por ciento - 40 por ciento de los casos. Debe considerarse en ancianos con enfermedad aterosclerótica que presenten síntomas gastrointestinales inferiores y shock hipotensivo. Puede ser causada por oclusión vascular aguda, enfermedad vascular grave o un estado de bajo flujo, aunque en algunos casos se presenta sin enfermedad vascular preexistente. Objetivo: Presentar la literatura existente acerca del manejo diagnóstico y terapéutico de la isquemia de canal anal en base a un caso clínico diagnosticado y tratado de urgencia en el hospital "Marina Baixa". Caso clínico: Se presenta un caso de isquemia espontánea de canal anal en paciente de 76 años de edad con morbilidad cardiovascular asociada. Debuta como cuadro séptico sin evidencia de causa desencadenante. Conclusiones: Las pruebas endoscópicas y radiológicas deben realizarse con urgencia y la valoración quirúrgica está siempre justificada en estos pacientes debido a la alta tasa de mortalidad descrita en el manejo conservador del cuadro. En casos graves, la reanimación preoperatoria y cirugía urgente para resecar el segmento gangrenoso es necesaria. Sin embargo, el tratamiento de la proctitis isquémica aguda es controvertido y depende, en parte, del estado basal del paciente y los hallazgos clínicos, siendo importante examinar otras posibles etiologías de proctitis isquémica y así determinar qué pacientes necesitan intervención quirúrgica temprana en comparación con una actitud más conservadora(AU)
Introduction: Acute ischemic gangrene of the anus is an infrequent entity, with little published literature, whose reported mortality figures are 20-40 percent of cases. It should be considered in elderlies with atherosclerotic disease who present lower gastrointestinal symptoms and hypotensive shock. It can be caused by acute vascular occlusion, severe vascular disease, or a low-flow state, although in some cases it presents without pre-existing vascular disease. Objective: To present the existing literature on diagnostic and therapeutic management of ischemia of the anal canal upon the base of a clinical case diagnosed and treated as an urgency at Marina Baixa hospital. Clinical case: The case is presented of a 76-year-old patient with spontaneous ischemia of the anal canal and associated cardiovascular morbidity. It debuts as a septic condition without evidence of a triggering cause. Conclusions: Endoscopic and radiological tests should be performed urgently. Surgical assessment is always justified in these patients, due to the high mortality rate described in the conservative management of the condition. In severe cases, preoperative resuscitation and urgent surgery to resect the gangrenous segment is necessary. However, managment of acute ischemic proctitis is controversial and depends, in part, on the patient's baseline status and clinical findings, while it is important to examine other possible etiologies of ischemic proctitis and thus determine which patients need early surgical intervention compared to a more conservative attitude(AU)
Subject(s)
Humans , Female , Aged , Anal Canal/injuries , Surgical Procedures, Operative/methods , Vascular Diseases/etiology , Ischemia/diagnostic imaging , Review Literature as Topic , Conservative Treatment/methodsABSTRACT
Objective@#To compare the therapeutic value of transnasal gastroscopy and conventional gastroscopy for infective pancreatic necrosis(IPN) through percutaneous endoscopic necrosectomy(PEN).@*Methods@#A total of 24 IPN patients who received PEN for IPN from December 2015 to March 2019 were divided into the conventional gastroscopy group (n=15) and the transnasal gastroscopy group (n=9). The clinical therapeutic indicators such as vital signs, APACHE Ⅱ score changes, operation duration, difference in preoperative and postoperative volumes of peripancreatic necrosis and other indicators were compared between the two groups.@*Results@#There was no significant difference in the variation curve fitting of APACHE Ⅱ scores between the two groups (t=0.378, P=0.710). The operation time of the transnasal gastroscopy group was significantly shorter than that of the conventional gastroscopy group (119.7±47.4 min VS 172.8±56.2 min, P=0.018). Peripancreatic necrotic volume significantly decreased after operation in the transnasal gastroscopy group (404.03±170.73 mL VS 468.9±137.37 mL, P=0.002), and in the conventional gastroscopy group (499.44±227.17 mL VS 722.50±292.96 mL, P<0.001). There was no significant difference in the decrease extent in the conventional gastroscopy group and the transnasal gastroscopy group (223.06±212.92 mL VS 64.87±54.94 mL, P= 0.094).@*Conclusion@#On the condition of poor drainage of percutaneous catheter drainage, PEN can significantly reduce the range of necrotic lesions. Transnasal gastroscopy has the advantages in operation time in PEN and clearing deep abscess cavities over conventional gastroscopy.
ABSTRACT
Objective@#To investigate the feasibility and safety of stent-assisted percutaneous endoscopic necrosectomy (SAPEN) in the treatment of infected pancreatic necrosis (IPN).@*Methods@#The patients with severe acute pancreatitis (SAP) who received the treatment of SAPEN for IPN were sequentially included from January 2018 to September 2018 in the Eastern Theater General Hospital of People′s Liberation Army. The demographic and clinical data were analyzed. The mortality and incidence of major organ dysfunctions were used as the primary observation endpoints.@*Results@#A total of 40 IPN patients were enrolled including 27 men and 13 women. The percutaneous covered stent placement procedures were successful in all cases; the median number of SAPEN operations was 1 (range 1-3), and no operation-related complications occurred. 32 patients were successfully cured by SAPEN, and the treatment effective rate was 80.0%. 5 patients (12.5%) required further open surgery after SAPEN. 12 patients developed new important organ dysfunction and 6 patients eventually died.@*Conclusions@#SAPEN was an effective and feasible minimally invasive method for the treatment of IPN, but its technical advantages still need to be further validated in large scale studies.
ABSTRACT
Objective@#To examine the effectiveness of non-operative of colonic fistula following acute pancreatitis.@*Methods@#Retrospective analysis of 354 patients with acute pancreatitis who were admitted to Department of Hepatobiliary Surgery of Chinese People′s Liberation Army General Hospital from January 2013 to December 2018. Age of the patients was (46±14) years (range: 14-85 years); 249 cases (70.3%) were males. There were 41 cases of acute edematous pancreatitis and 313 cases of acute necrotising pancreatitis. Two hundred and fifteen cases were diagnosed as moderate severe acute pancreatitis and 139 were diagnosed as severe acute pancreatitis. Among 313 cases of acute necrotising pancreatitis, 62 cases underwent non-surgical treatment, 251 cases underwent surgical treatment in which 218 of minimal access retroperitoneal pancreatic necrosectomy underwent percutaneous nephroliguectomy with peripancreatic necrotic tissue removal technique.@*Results@#There were 15 cases of colon fistula following acute necrotising pancreatitis, and the incidence rate was 4.2%(15/354). There were 7 males and 8 females, with age of (39±8) years (range: 27 to 50 years). The median interval between acute pancreatitis onset and diagnosis of colonic fistula was 71 days(27-134) days. Two cases occurred at the hepatic flexure of the colon, 4 cases at transverse colon, and 9 cases at splenic flexure of colon. Of the 354 patients, 39 cases died and the mortality was 11.0%. Two patients underwent laparotomy, and one of them died. The remaining 13 patients underwent non-surgical treatment and were discharged.@*Conclusion@#Acute pancreatitis with colonic fistula can be treated with non-surgical treatment and can achieve good prognosis.
ABSTRACT
Objective@#To investigate the clinical efficacy of minimal access retroperitoneal pancreatic necrosectomy (MARPN) for infected pancreatic necrosis (IPN).@*Methods@#The retrospective cohort study was conducted. The clinical data of 61 patients with IPN who were admitted to Union Hospital Affiliated to Tongji Medical College of Huazhong University of Science and Technology between January 2014 and December 2017 were collected. There were 39 males and 22 females, aged 36-67 years, with a median age of 49 years. Of 61 patients, 40 undergoing open surgery were allocated into open group, and 21 undergoing MARPN were allocated into MARPN group. All the patients underwent surgical treatments after standard non-surgical treatments according to the Guidelines for the diagnosis and treatment of severe acute pancreatitis (2014 edition). Observation indicators: (1) intraoperative and postoperative situations; (2) follow-up. Follow-up using telephone interview or outpatient examination was performed to detect weight loss, pathoglycemia, steatorrhea, intestinal obstruction, and pancreatic portal hypertension for one year after surgery up to December 2017. Measurement data with normal distribution were represented as Mean±SD, and comparison between groups was analyzed using the t test. Count data were represented as absolute numbers or percentages, and comparison between groups was done using the chi-square test.@*Results@#(1) Intraoperative and postoperative situations: operation time, time to out-of-bed activity, time to initial food intake, cases with reoperation, cases with postoperative multiple organ dysfunction syndrome (MODS), incidence rate of postoperative complications, mortality, time to drainage-tube removal, duration of hospital stay, and hospital expenses were (77±20)minutes, (13.0±3.6)days, (9.0±2.7)days, 8, 9, 45.0%(18/40), 7.5%(3/40), (37.0±6.3)days, (49±8)days, (84 321±8 872)yuan in the open group, and (59±20)minutes, (2.7±0.9)days, (1.9±0.4)days, 6, 2, 19.0%(4/21), 0, (21.0±2.7)days, (39±6)days, (58 594±3 576)yuan in the MARPN group, respectively, showing no significant difference in the cases with reoperation (χ2=0.69, P>0.05) but significant differences in the other indices between the two groups (t=4.24, 9.61, 15.34, χ2=23.76, 4.02, 36.03, t=11.07, 5.93, 8.43, P<0.05). There were 18 patients with postoperative complications in the open group, including 2 with digestive hemorrhage, 3 with abdominal hemorrhage, 9 with pancreatic leakage, and 4 with intestinal leakage. There were 4 patients with postoperative complications in the MARPN group, including 3 with pancreatic leakage, and 1 with intestinal leakage. Patients with complications were treated by endoscopy, interventional therapy, placement of jejunal nutrition tube, and ileum stoma. Three patients in the open group died, and all the patients in the MARPN group were cured. (2) Follow-up: 47 of 61 patients were followed up for one year, including 31 in the open group and 16 in the MARPN group. During the follow-up, weight loss, pathoglycemia, steatorrhea, intestinal obstruction, and pancreatic portal hypertension were detected in 4, 11, 5, 4, 5 patients of the open group and in 2, 6, 2, 0, 3 patients of the MARPN group, showing no statistically significant difference between the two groups (χ2=0.18, 0.02, 0.01, 0.03, 0.90, P>0.05).@*Conclusion@#MARPN for IPN is safe and reliable, with certain efficacy, which can effectively reduce incidence of postoperative complication, motality and shorten hospital stay.
ABSTRACT
Objective To investigate the clinical efficacy of minimal access retroperitoneal pancreatic necrosectomy (MARPN) for infected pancreatic necrosis (IPN).Methods The retrospective cohort study was conducted.The clinical data of 61 patients with IPN who were admitted to Union Hospital Affiliated to Tongji Medical College of Huazhong University of Science and Technology between January 2014 and December 2017 were collected.There were 39 males and 22 females,aged 36-67 years,with a median age of 49 years.Of 61 patients,40 undergoing open surgery were allocated into open group,and 21 undergoing MARPN were allocated into MARPN group.All the patients underwent surgical treatments after standard non-surgical treatments according to the Guidelines for the diagnosis and treatment of severe acute pancreatitis (2014 edition).Observation indicators:(1) intraoperative and postoperative situations;(2) follow-up.Follow-up using telephone interview or outpatient examination was performed to detect weight loss,pathoglycemia,steatorrhea,intestinal obstruction,and pancreatic portal hypertension for one year after surgery up to December 2017.Measurement data with normal distribution were represented as Mean±SD,and comparison between groups was analyzed using the t test.Count data were represented as absolute numbers or percentages,and comparison between groups was done using the chi-square test.Results (1) Intraoperative and postoperative situations:operation time,time to out-of-bed activity,time to initial food intake,cases with reoperation,cases with postoperative multiple organ dysfunction syndrome (MODS),incidence rate of postoperative complications,mortality,time to drainage-tube removal,duration of hospital stay,and hospital expenses were (77±20)minutes,(13.0±3.6) days,(9.0±2.7)days,8,9,45.0％ (18/40),7.5％(3/40),(37.0±6.3)days,(49±8)days,(84 321±8 872)yuan in the open group,and (59± 20) minutes,(2.7±0.9) days,(1.9 ± 0.4) days,6,2,19.0％ (4/21),0,(21.0± 2.7) days,(39 ± 6) days,(58 594±3 576) yuan in the MARPN group,respectively,showing no significant difference in the cases with reoperation (x2=0.69,P＞0.05) but significant differences in the other indices between the two groups (t =4.24,9.61,15.34,x2=23.76,4.02,36.03,t=11.07,5.93,8.43,P＜0.05).There were 18 patients with postoperative complications in the open group,including 2 with digestive hemorrhage,3 with abdominal hemorrhage,9 with pancreatic leakage,and 4 with intestinal leakage.There were 4 patients with postoperative complications in the MARPN group,including 3 with pancreatic leakage,and 1 with intestinal leakage.Patients with complications were treated by endoscopy,interventional therapy,placement of jejunal nutrition tube,and ileum stoma.Three patients in the open group died,and all the patients in the MARPN group were cured.(2) Follow-up:47 of 61 patients were followed up for one year,including 31 in the open group and 16 in the MARPN group.During the follow-up,weight loss,pathoglycemia,steatorrhea,intestinal obstruction,and pancreatic portal hypertension were detected in 4,11,5,4,5 patients of the open group and in 2,6,2,0,3 patients of the MARPN group,showing no statistically significant difference between the two groups (x2=0.18,0.02,0.01,0.03,0.90,P＞0.05).Conclusion MARPN for IPN is safe and reliable,with certain efficacy,which can effectively reduce incidence of postoperative complication,motality and shorten hospital stay.
ABSTRACT
Objective To investigate the feasibility and safety of stent-assisted percutaneous endoscopic necrosectomy (SAPEN) in the treatment of infected pancreatic necrosis (IPN). Methods The patients with severe acute pancreatitis ( SAP) who received the treatment of SAPEN for IPN were sequentially included from January 2018 to September 2018 in the Eastern Theater General Hospital of People's Liberation Army. The demographic and clinical data were analyzed. The mortality and incidence of major organ dysfunctions were used as the primary observation endpoints. Results A total of 40 IPN patients were enrolled including 27 men and 13 women. The percutaneous covered stent placement procedures were successful in all cases;the median number of SAPEN operations was 1 ( range 1-3 ) , and no operation-related complications occurred. 32 patients were successfully cured by SAPEN, and the treatment effective rate was 80. 0％. 5 patients (12. 5％) required further open surgery after SAPEN. 12 patients developed new important organ dysfunction and 6 patients eventually died. Conclusions SAPEN was an effective and feasible minimally invasive method for the treatment of IPN, but its technical advantages still need to be further validated in large scale studies.
ABSTRACT
American Gastroenterological Association(AGA)has published the latest clinical practice update in Gastroenterology in August 2019. The purpose of this AGA clinical practice update is to review the available evidence and expert recommendations regarding the clinical care of patients with pancreatic necrosis and to offer concise best practice advice for the optimal management of patients with this highly morbid condition. In recent decades,with the improvement in clinical practice,the management of pancreatic necrosis in patients with acute pancreatitis(AP)has undergone great changes. The well-defined step-up approach has been more advocated rather than the traditional open surgery. The treatment of pancreatic necrosis mainly includes two aspects,conservative methods, which consist of antimicrobial therapy as well as nutrition support,and invasive interventions.Drainage and/or debridement of pancreatic necrosis is best indicated in patients with infected necrosis or patients with sterile pancreatic necrosis and persistent clinical symptoms,which need proactive management. A step-up approach consists of percutaneous drainage or endoscopic transmural drainage, followed by direct endoscopic/percutaneous minimally invasive necrosectomy, and then surgical debridement is reasonable. As for the comparison between percutaneous surgical or endoscopic step-up approach,no studies have shown that there are differences between the two in the main clinical outcomes,for instance,mortality. Hence,the choice of specific treatment strategy in different AP centers depends mainly on their available clinical expertise and medical resources.
ABSTRACT
Objective To study the effect of combined laparoscopic and percutaneous nephroscopic necrosectomy in the treatment of peripancreatic abscesses.Methods The clinical data of 8 patients with peripancreatic abscesses treated by combined laparoscopic and percutaneous nephroscopic necrosectomy in our hospital from June 2015 to June 2017 were retrospectively analyzed.Results 8 patients were treated with percutaneous puncture and drainage under Ultrasonic / Computed Tomography guidance.Combined laparoscopic and percutaneous nephroscopic necrosectomy was then carried out.Two patients underwent percutaneous nephroscopic surgery twice and laparoscopic surgery once,and 3 patients underwent percutaneous nephroscopic surgery thrice,and 3 patients underwent percutaneous nephroscopic surgery 4 times and laparoscopic surgery once.One patient after percutaneous nephroscopic necrosectomy was complicated with sinus tract hemorrhage,which was treated by haemostasis through a small incision.Two patients who developed postoperative colonic fistula were treated successfully by conservative treatment.The average length of hospital stay was 80 d (60 ～ 153 d),and there was no death.Conclusion Combined laparoscopic and percutaneous nephroscopic necrosectomy was a minimally invasive and efficacious method to treat peripancreatic abscesses.
ABSTRACT
Objective@#To investigate the safety and efficiency of small incision minimally invasive approach pancreatic necrosectomy in the treatment of infected pancreatic necrosis.@*Methods@#The data of 164 patients who underwent small incision minimally invasive approach pancreatic necrosectomy for infected pancreatic necrosis at Department of Pancreatic and Biliary Surgery, the First Affiliated Hospital of Harbin Medical University from January 2012 to December 2016 were analyzed retrospectively.Among 164 patients, there were 102 male and 62 female patients.The median age was 46 years(ranging from 19 to 79 years). One hundred and one patients(61.6%) suffered from severe acute pancreatitis and 63 patients(38.4%) suffered from moderately severe acute pancreatitis.Following step-up approach principle, the surgical procedures were performed for 131 patients(79.9%) who suffered from sepsis which could not be alleviated via percutaneous catheter drainage(PCD). The other 33 patients(20.1%) who did not undergo PCD directly took small incision minimally invasive approach pancreatic necrosectomy.Preoperative CT images were used to determine the location of the lesion.The PCD puncture points or the points where the abscess was closest to the skin were chosen as the incision.Gradually, the small incision minimally invasive approach pancreatic necrosectomy were performed via cutting all layers into the abscess.@*Results@#The median time from the onset of symptom to first operation was 32 days(ranging from 23 to 45 days). The average hospital stay was 46 days(ranging from 29 to 103 days). The average number of drainage tubes placed was 4 pieces(ranging from 2 to 8 pieces). Ninety-two patients(56.0%) underwent minimal access retroperitoneal pancreatic necrosectomy. Thirty-six patients(22.0%) underwent minimal invasive approach lesser omentum sac pancreatic necrosectomy.Thirty-six patients(22.0%) underwent minimal invasive approach lesser omentum sac pancreatic necrosectomy combined with minimal access retroperitoneal pancreatic necrosectomy.A total of 148 cases(90.2%) were cured via minimally invasive approach pancreatic necrosectomy, 8 cases(4.9%) were cured after transfering to open pancreatic necrosectomy.The cure rate was 95.1%(156/164). The mainly postoperative complications included pancreatic fistula(25 cases), intra-abdominal hemorrhage(10 cases), gastric fistula (2 cases), duodenal fistula(4 cases) and colonic fistula(3 cases). The overall incidence rate of complications was 26.8%(44/164). Eight cases were dead after surgery and the in-hospital mortality was 4.9%(8/164).@*Conclusion@#In summary, small incision minimally invasive approach pancreatic necrosectomy is an effective way to clean up necrotic tissue, improve the drainage, reduce complications in dealing with infected pancreatic necrosis.
ABSTRACT
ABSTRACT Background : Acute pancreatitis is the third most common gastrointestinal disorder requiring hospitalization in the United States, with annual costs exceeding $2 billions. Severe necrotizing pancreatitis is a life-threatening complication developed in approximately 20% of patients. Its mortality rate range from 15% in patients with sterile necrosis to up 30% in case of infected one associated with multi-organ failure. Less invasive treatment techniques are increasingly being used. These techniques can be performed in a so-called step-up approach. Aim: To present the technique for videoscopic assisted retroperitoneal debridement (Vard technique) with covered metallic stent in necrotizing pancreatitis. Method: A guide wire was inserted through the previous catheter that was removed in the next step. Afterwards, the tract was dilated over the guide wire. Then, a partially covered metallic stent was deployed. A 30 degrees laparoscopic camera was inserted and the necrosis removed with forceps through the expanded stent under direct vision. Finally, the stent was removed and a new catheter left in place. Result : This technique was used in a 31-year-old man with acute pain in the upper abdomen and diagnosed as acute biliary pancreatitis with infected necrosis. He was treated with percutaneous drains at weeks 3, 6 and 8. Due to partial recovery, a left lateral VARD was performed (incomplete by fixed and adherent tissue) at 8th week. As the patient´s inflammatory response was reactivated, a second VARD attempt was performed in three weeks later. Afterwards, patient showed complete clinical and imaging resolution. Conclusions : Videoassisted retroperitoneal necrosectomy using partially covered metallic stent is a feasible technique for necrotizing pancreatitis.
RESUMO Racional: A pancreatite aguda é a terceira doença gastrointestinal mais comum que requer hospitalização nos Estados Unidos, com custos anuais superiores a $ 2 bilhões. A pancreatite necrosante grave é uma complicação potencialmente fatal, desenvolvida em aproximadamente 20% dos pacientes. A taxa de mortalidade varia de 15% em pacientes com necrose estéril para 30% no caso de uma infecção infectada com falência multiorgânica. As técnicas de tratamento menos invasivas são cada vez mais utilizadas. Elas podem ser realizadas em uma abordagem chamada "step-up". Objetivo: Apresentar a técnica de desbridamento retroperitoneal assistido com videografia (técnica VARD) com stent metálico coberto em pancreatite necrosante. Método: Um fio guia é inserido através do cateter anterior que foi removido no próximo passo. Depois, o trajeto é dilatado sobre o fio guia. Em seguida, um stent metálico parcialmente coberto é implantado. Uma câmera laparoscópica de 30º é inserida e a necrose removida com fórceps através do stent expandido sob visão direta. Finalmente, o stent é removido e um novo cateter deixado no lugar. Resultado: Esta técnica foi utilizada em um homem de 31 anos com dor aguda na parte superior do abdome e diagnosticado como pancreatite biliar aguda com necrose infectada. Ele foi tratado com drenos percutâneos nas semanas 3, 6 e 8. Devido à recuperação parcial, realizou-se um VARD lateral esquerdo (incompleto por tecido fixo e aderente) na 8ª semana. À medida que a resposta inflamatória do paciente foi reativada, uma segunda tentativa VARD foi realizada em três semanas mais tarde. Posteriormente, o paciente apresentou resolução clínica e de imagem completa. Conclusão: A necrosectomia retroperitoneal assistida em vídeo com stent metálico parcialmente coberto é uma técnica viável para pancreatite necrosante.
Subject(s)
Humans , Male , Adult , Stents , Pancreatitis, Acute Necrotizing/surgery , Debridement/methods , Prosthesis Design , Retroperitoneal Space , Video Recording , Laparoscopy , Surgery, Computer-AssistedABSTRACT
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.
Subject(s)
Adult , Humans , Male , Cutaneous Fistula , Duodenum , Endoscopy , Fever , Follow-Up Studies , Gastroscopes , Mortality , Necrosis , Pancreatitis , Pancreatitis, Acute Necrotizing , Pneumoperitoneum , Recurrence , StomachABSTRACT
Pancreatic necrosis (IPN) is a serious complication of acute pancreatitis (AP), with a mortality reported to be as great as 32.0%. At present, it is considered that patients with proven or suspected infected necrotizing pancreatitis, invasive intervention (i.e. percutaneous catheter drainage, endoscopic transluminal drainage/ necrosectomy, minimally invasive or open necrosectomy) should be delayed where possible until at least 4 weeks after initial presentation to allow the collection to become 'walled-off'. With the development of endoscopic technology, endoscopic transmural (stomach or duodenum) drainage and necrosectomy has been recommended as one of the preferred methods for walled-off necrosis. This article introduces the diagnosis and evaluation of the walled-off necrosis ; the indications, operation procedures, postoperative evaluation and management of postoperative complications of endoscopic transmural drainage and necrosectomy. At last, the research progress of endoscopic drainage and debridement in recent years was introduced.
ABSTRACT
Objective To evaluate the therapeutic effect of percutaneous endoscopic necrosectomy (PEN) in treating infectious pancreatic necrosis (IPN).Methods A retrospective review of clinical data of 6 patients with IPN who received PEN in Changhai Hospital, Second Military Medical University from Dec 2015 to Sep 2016 was performed.Clinical parameters were recorded, including basic information, severity evaluation and therapeutic methods and times.In addition, vital sign parameters and inflammatory marks before and after PEN treatment were compared.Results There were 4 patients with severe acute pancreatitis (SAP) and 2 patients with moderately severe acute pancreatitis (MSAP) in these 6 patients with IPN.Mean APACHEⅡ score was 12 (10~15), and mean MCTSI scores was 9.3(8~10).All 6 patients received a total of 13 times PEN treatments, with a mean of 2.2(1~3) times.Each patient was treated with a mean of 2.5(1~4) drainage tubes placed in the peripancreatic abscess after PEN treatment, and the mean time for drainage was 139 d(106~183 d).Besides, the mean hospitalization time was 116 d (48~223 d).All the patients′ condition was improved significantly after PEN treatment, including reduced heart rate, body temperature and inflammatory markers, without bleeding or other serious complications.Only 1 patient had pancreatic fistula after treatment, and no patients needed open abdominal drainage surgery.Patients with higher MCTSI scores likely required more times of PEN and more drainage catheters, longer length of drainage and hospital stay.Conclusions PEN was safe and effective for treating patient with IPN, but those with higher MCTSI scores were associated with more PEN treatments, more drainage tubes, and longer time of drainage and hospitalization.
ABSTRACT
Lumen-apposing metal stents (LAMS) represent a new innovation in gastrointestinal endoscopy. These devices have a saddle-shaped design and larger inner lumen diameter than either plastic or metal biliary stents, which should decrease the risk of migration and allows for an endoscope to pass into pancreatic fluid collections as well as the ability to perform direct endoscopic necrosectomy. LAMS were originally conceived and designed for transmural pancreatic fluid collection drainage but are currently also being used for many off label indications. There are three different LAMS available at this time around the globe. This manuscript will review the current state of the art with regards to LAMS and their indications, usage, and outcomes.
Subject(s)
Drainage , Endoscopes , Endoscopy, Gastrointestinal , Plastics , StentsABSTRACT
Endoscopic ultrasound (EUS)-guided management of abdominal fluid collections adjacent to the gastroduodenal lumen is a relatively new concept attracting a lot of interest in recent years. The ability of EUS to identify and drain these collections in the same session accounts for the surge of interest in these novel techniques. On the other hand, the complexity of these interventions and associated serious complications has moderated the enthusiasm of novice endoscopists to some extent and reiterated that focused research and technical innovations are needed to make EUS-guided drainage simpler and safer. Self-expandable metallic stents (SEMS) have emerged in the last decade in the endoscopic management of malignant luminal gastrointestinal strictures. The use of SEMS in the management of benign conditions (biliary, pancreatic, and colonic strictures) is also rapidly expanding. Recently, fully-covered (FC)-SEMS have been successfully used for drainage of peripancreatic and pericholecystic fluid collections. Here we will review the existing data and future directions in the use of FC-SEMS for such drainage procedures. We will also review the literature on novel “purpose-made” prostheses, such as the lumen-apposing metallic stents, which aim to address technical problems arising in EUS-guided drainage procedures when conventional SEMS are used. Further development of these and other similar devices may transform EUS-guided drainage procedures from an esoteric concept to “mainstream”, first-line intervention.