Minimal-access approaches to complications of acute pancreatitis and benign neoplasms of the pancreas (original) (raw)
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Walled-off pancreatic necrosis
World Journal of Gastroenterology, 2010
Walled-off pancreatic necrosis (WOPN), formerly known as pancreatic abscess is a late complication of acute pancreatitis. It can be lethal, even though it is rare. This critical review provides an overview of the continually expanding knowledge about WOPN, by review of current data from references identified in Medline and PubMed, to September 2009, using key words, such as WOPN, infected pseudocyst, severe pancreatitis, pancreatic abscess, acute necrotizing pancreatitis (ANP), pancreas, inflammation and alcoholism. WOPN comprises a later and local complication of ANP, occurring more than 4 wk after the initial attack, usually following development of pseudocysts and other pancreatic fluid collections. The mortality rate associated with WOPN is generally less than that of infected pancreatic necrosis. Surgical intervention had been the mainstay of treatment for infected peripancreatic fluid collection and abscesses for decades. Increasingly, percutaneous catheter drainage and endoscopic retrograde cholangiopancreatography have been used, and encourag-ing results have recently been reported in the medical literature, rendering these techniques invaluable in the treatment of WOPN. Applying the recommended therapeutic strategy, which comprises early treatment with antibiotics combined with restricted surgical intervention, fewer patients with ANP undergo surgery and interventions are ideally performed later in the course of the disease, when necrosis has become well demarcated.
Annals of Surgery, 2005
To study the magnitude of complications associated with the nonoperative management of peripancreatic fluid collections and pseudocysts and to assess the surgical management of these complications. These are compared with complications associated with operative management. Summary Background Data: Pancreatic pseudocysts and peripancreatic fluid collections associated with acute pancreatitis have been managed with success using nonoperative techniques for more than a decade. When successful, these techniques have clear advantages compared with operative management. There has, however, been little focus on the magnitude and outcomes after complications sustained by nonoperative management. Our report focuses on these complications and pseudocysts and on the surgical management. We have been struck by the high percentage of patients who sustain significant and at times life-threatening complications related to the nonoperative management of fluid collections. We further define an association between the main pancreatic ductal anatomy and the likelihood of major complications after nonoperative management. Methods: Between 1992 and 2003, all patients admitted to our service with peripancreatic fluid collections or pseudocysts were monitored. We evaluated complications patients managed with percutaneous (PD) or endoscopic drainage (E). Data were collected regarding patient characteristics, need for intensive care unit (ICU) stays, hemorrhage, hypotension, renal failure, and ventilator support. We further focused on the duration of fistula drainage from patients who have had a percutaneous drainage, and we assessed the necessity for urgent or emergent operation. By protocol, all patients had pancreatic ductal anatomy evaluated by means of endoscopic retrograde cholangiopancreatography (ERCP) or magnetic resonance cholangiopancreatography (MRCP). Patients with complications of E and PD were compared with 100 consecutive patients who underwent operative management of pseudocyst and fluid collections as their sole mode of intervention. Results: A total of 79 patients with complications of PD, E, or both were studied. There were 41 males and 38 females in the group of patients who sustained complications (mean age 49 years). Sixty-six of the 79 subsequently required operation to manage their peripancreatic fluid collection, 37 urgent or emergent. The mean elapsed time from diagnosis to nonoperative intervention was 18.1 days. This group of 79 patients had mean 3.1 Ϯ 0.7 hospitalization (range, 1-7) and length-of-stay 42.7 Ϯ 4.1 days. ICU stays were required in 36 of the 79 (46%). A defined episode of clinical sepsis was identified in 72 of 79 (91%) and was by far the most common complication. Hemorrhage requiring transfusion was identified in 16 of the 79 (20%), clinical shock 51 of the 79 (65%), renal failure 16 of the 79 (20%), ventilator support for longer than 24 hours 19 of the 79 (24%). A persistent pancreatic fistula occurred in 66 of the 79 patients (84%); mean duration was 61.4 Ϯ 9.6 days. Sixty-three of the 79 patients with complications of E or PD had ductal anatomy (ERCP/MRCP) which predicted failure because of significant disruption or stenosis of the main pancreatic duct. Among the 100 operated patients, 69 complications occurred in 6 of the 100 (6%). Operation was initiated electively a mean interval of 42.7 days after diagnosis of pseudocyst. Hemorrhage, hypotension, renal failure, sepsis, persistent fistula, or urgent operation all were not seen in the complications associated with operated patients. CT imaging obtained at least 6 months after intervention documented complete resolution after surgery alone in 91 and 9 with cystic structures less than 2 cm. In patients with operation after failed nonoperative therapy, 6 patients had persistent cystic lesions less than 2 cm in diameter. Conclusion: These data support the premise that a choice between operative and nonoperative management for peripancreatic fluid collections and pseudocysts should be made with careful assessment of the pancreatic ductal anatomy, with a clear recognition of the magnitude of complications which are likely to occur should nonoperative measures be used in patients most likely to sustain complications. It is vital to recognize the magnitude and severity of complications of nonoperative measures as one chooses a modality. Ductal anatomy predicts patients who will have complications or failure of management of their peripancreatic fluid collection.
Changing concepts in the surgical management of acute pancreatitis
Best Practice & Research Clinical Gastroenterology, 1999
Most episodes of acute pancreatitis are mild and self-limiting, but severe disease complicated by multiple system organ failure develops in up to 20% of cases. Early detection of those patients who subsequently develop necrotizing pancreatitis allows the start of supportive treatment in the intensive care unit before organ failure occurs. Conservative treatment in the intensive care unit, including the administration of intravenous antibiotics, is the gold standard. Surgery is indicated in patients with infected pancreatic necrosis but not in patients with sterile necrosis in the absence of deteriorating multi-organ failure despite maximal intensive care unit treatment, or other specific surgical complications. At our institution, out of 44 patients with necrotizing pancreatitis 29 (66%) had sterile necrosis and were managed conservatively while 15 (34%) had infected pancreatic necrosis and were treated by necrosectomy and continuous closed retroperitoneal lavage. There were two deaths resulting in an overall mortality of 5% in patients with severe acute pancreatitis.
Percutaneous Drainage and Necrosectomy in the Management of Pancreatic Necrosis
ANZ Journal of Surgery, 2005
The degree of necrosis and presence of infection are the crucial determinants of the outcome in patients with pancreatic necrosis. In patients with sterile necrosis, the necrotic material can persist and subsequently results in sepsis. Some of these patients will ultimately require an operation to remove the necrotic material. Percutaneous necrosectomy has been introduced to remove this residual debris in a minimally invasive way. Methods: We retrospectively reviewed all patients with pancreatic necrosis who had percutaneous drainage (PCD) performed. Percutaneous pancreatic necrosectomy (PCPN) was done for those patients whose necrotic cavity failed to resolve. Results: Percutaneous drainage was performed in eight patients, four with evidence of infection by the positive culture in the aspirate. In three of them, the necrotic cavity completely resolved after drainage. Percutaneous necrosectomy was performed in another three patients through the tract placed by the radiologist and another one through a sinus tract after an operation. The necrotic cavity in three of them completely resolved after percutaneous necrosectomy. Conclusion: Those patients who had 'organized necrosis' after the acute episode of pancreatitis could receive benefit from percutaneous necrosectomy. The persistent symptoms could be alleviated after the removal of the residual necrotic material. It could also be useful after an open surgery to remove any residual devitalized tissue.
International journal of surgery science, 2022
To evaluate the indication and outcome of different surgical management modalities in local complications of acute pancreatitis. Methodology: A hospital-based observational study was conducted in the department of surgery Shri Shankaracharya Institute of medical sciences, Bhilai, India after approval from the institutional ethical committee. A purposive sampling method was utilized to recruit the patients. Patients who underwent laparoscopic or open surgical procedures transperitoneal or retroperitoneal for the management of local complications of acute pancreatitis for the period of 1 year were included. Clinical, laboratory and imaging findings including, contrast-enhanced CT scan findings of all the cases, were recorded as per the proforma. In addition, the indication of each procedure, perioperative outcome and associated complications were evaluated in all the studied cases. All minimally invasive procedures were performed under general anesthesia by the surgical team experienced in pancreatic surgery. Results: Total 496 patients were admitted to the surgery department with the diagnosis of acute pancreatitis or with complications of acute pancreatitis. Among them, 80 patients had local complications due to acute pancreatitis. All patients were managed using the step-up approach, starting with conservative management and minimally invasive intervention when warranted. 24 patients required surgical intervention due to failure of endoscopic or radiological intervention or positions of lesions being inaccessible to these techniques. Among the 24 patients in the study, 4 patients had PPC, all of whom were managed with external drainage due to persistent symptoms. 6 patients who had ANC were initially subjected to conservative management. In addition, WON was noted in 4 patients and 10 patients had pseudocyst. Due to clinical deterioration and high suspicion of infected necrosis in patients with WON, FNAC was performed in all patients, revealing growth in culture. Conclusion: Patients who have local complications of pancreatitis respond best to treatment at a tertiary care centre that is staffed with pancreatic surgeons. Surgery is still the primary treatment option for pancreatic necrosis and pancreatic fluid collection, despite the proliferation of endoscopic procedures designed to treat these conditions.
Survey of trends in minimally invasive intervention for necrotizing pancreatitis
ANZ Journal of Surgery, 2011
Minimally invasive techniques to manage infected pancreatic necrosis have been recently developed and changes in their pattern of use are unknown. The aims of this survey were to determine the trends in the role of minimally invasive techniques to manage infected complications of necrotizing pancreatitis and the barriers to performing minimally invasive necrosectomy in Australia and New Zealand. Methods: Members of the Australian and New Zealand Hepatic Pancreatic and Biliary Association were surveyed. Participant demographics and necrotizing pancreatitis caseload were determined. The perceived role of percutaneous catheter drainage and minimally invasive necrosectomy for pancreatic abscess, infected pseudocyst and infected pancreatic necrosis were scored on Likert scales, comparing 2002 with 2007. Barriers to performing minimally invasive necrosectomy were scored. Results: The response rate was 49% (44/90). Between 2002 and 2007, the role of percutaneous catheter drainage became more important as primary (P = 0.05) and secondary (P = 0.01) treatment for pancreatic abscess, and prior to minimally invasive necrosectomy for abscess, pseudocyst and necrosis (P < 0.01). Minimally invasive necrosectomy became increasingly important as primary treatment for infected necrosis (P < 0.01) and had been used by 47% of respondents. The greatest barriers to performing minimally invasive necrosectomy were lack of training and experience in the techniques, and the anatomical position and complexity of the target lesion. Conclusion: Minimally invasive techniques have an increasingly important perceived role in the management of pancreatic abscess, infected pseudocyst and infected pancreatic necrosis. Further evidence is required to determine the best techniques for treating each form of infection associated with necrotizing pancreatitis.
Combined endoscopic and percutaneous drainage of organized pancreatic necrosis
Gastrointestinal Endoscopy, 2010
Background: Severe acute pancreatitis is often complicated by organized necrosis, which can lead to abscess formation and clinical deterioration. We sought to devise a combined endoscopic and percutaneous approach to drainage of organized pancreatic necrosis, with the primary goal of preventing the formation of chronic pancreaticocutaneous fistulae, and secondary goals of avoiding the need for surgical necrosectomy and reducing endoscopic resource utilization.