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Bofill A, Law R, Storm AC, Vargas EJ, Martin JA, Petersen BT, Majumder S, Vege S, Abu Dayyeh BK, Chandrasekhara V. The role of MRCP for preventing pancreatic fluid collection recurrence after EUS-guided drainage of walled-off necrosis. Gastrointest Endosc 2025; 101:608-616. [PMID: 39053654 DOI: 10.1016/j.gie.2024.07.009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/12/2024] [Revised: 06/21/2024] [Accepted: 07/08/2024] [Indexed: 07/27/2024]
Abstract
BACKGROUND AND AIMS Pancreatic fluid collections (PFCs) may recur after initial successful endoscopic drainage of walled-off necrosis (WON), most commonly due to disconnected pancreatic duct syndrome (DPDS). The primary aim of this study was to assess the role of MRCP for identifying DPDS to guide appropriate management and prevent PFC recurrence. METHODS Patients with WON undergoing lumen-apposing metal stent drainage of a PFC were retrospectively identified and categorized as those with MRCP versus those without MRCP before removal of transmural stents. Data on patient demographic characteristics, procedural details, cross-sectional imaging, and recurrence rates were collected through chart review. RESULTS A total of 121 patients with WON were identified, of whom 44 (36.4%) had an MRCP before transmural stent removal. In patients without MRCP, 13 (16.8%) of 77 had PFC recurrence versus 0 of 44 (0%; P = .003) in those with MRCP. MRCP identified DPDS in 12 (27.2%) patients, all of whom were managed with indefinite drainage with double-pigtail plastic stents without recurrence. In the group without MRCP, PFCs recurred at a median interval of 284 days (interquartile range, 182-618 days) after transmural stent removal. Among the 13 patients with PFC recurrence, 11 (85%) had undiagnosed DPDS detected on subsequent imaging, of whom 9 were subsequently managed with indefinite double-pigtail plastic stents, with no further PFC recurrence. CONCLUSIONS Patients with WON who underwent MRCP before transmural stent removal had a lower rate of PFC recurrence largely due to the identification of DPDS with appropriate endoscopic management.
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Affiliation(s)
- Aliana Bofill
- Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, Minnesota, USA
| | - Ryan Law
- Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, Minnesota, USA
| | - Andrew C Storm
- Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, Minnesota, USA
| | - Eric J Vargas
- Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, Minnesota, USA
| | - John A Martin
- Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, Minnesota, USA
| | - Bret T Petersen
- Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, Minnesota, USA
| | - Shounak Majumder
- Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, Minnesota, USA
| | - Santhi Vege
- Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, Minnesota, USA
| | - Barham K Abu Dayyeh
- Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, Minnesota, USA
| | - Vinay Chandrasekhara
- Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, Minnesota, USA.
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Rana SS, Ancil S. Management of Pancreatic Duct Strictures, Leaks, and Disconnected Pancreatic Duct Syndrome. Gastroenterol Clin North Am 2025; 54:75-95. [PMID: 39880534 DOI: 10.1016/j.gtc.2024.08.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/31/2025]
Abstract
Pancreatic duct (PD) strictures, leaks, and disconnected ducts are important morphologic consequences of inflammatory disease of the pancreas, resulting in abdominal pain, pancreatic ascites, pancreatic pleural effusion, and external pancreatic fistula. Traditionally, these PD complications were treated surgically, but a better understanding of their pathophysiology, along with advancement in endoscopic interventions, has transformed the therapy from morbid surgical interventions to minimally invasive, safe, and effective endoscopic treatment. This review discusses the current diagnostic and management strategies for PD strictures, leaks, and disconnected pancreatic ducts.
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Affiliation(s)
- Surinder Singh Rana
- Unit III, Department of Gastroenterology, Post Graduate Institute of Medical Education and Research (PGIMER), Sector 12, Chandigarh 160012, India.
| | - Sanish Ancil
- Department of Gastroenterology, Post Graduate Institute of Medical Education and Research (PGIMER), Sector 12, Chandigarh 160012, India
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Takenaka M, Saito T, Hamada T, Omoto S, Shiomi H, Iwashita T, Masuda A, Matsubara S, Maruta A, Iwata K, Mukai T, Isayama H, Yasuda I, Nakai Y. Disconnected pancreatic duct syndrome: diagnostic and therapeutic challenges and future directions. Expert Rev Gastroenterol Hepatol 2024; 18:631-645. [PMID: 39420546 DOI: 10.1080/17474124.2024.2419056] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/06/2024] [Revised: 08/29/2024] [Accepted: 10/16/2024] [Indexed: 10/19/2024]
Abstract
INTRODUCTION Disconnected pancreatic duct syndrome (DPDS) is a pathological condition that causes various symptoms due to the continuous secretion of pancreatic enzymes from the pancreas upstream, which has been separated due to disconnection of the pancreatic duct (DPD) for various reasons.Acute necrotizing pancreatitis includes a certain probability of DPDS appearance, which makes it necessary to provide various treatments for DPDS. Furthermore, DPDS can impact long-term results, such as recurrence and impaired pancreatic function. Although the development of various modalities has contributed to diagnosis and treatment, especially less invasive endoscopic therapy, DPDS is often overlooked, and the diagnosis can be delayed due to the lack of consensus on its definition and classification. This review summarizes the current knowledge and challenges of DPDS and discusses the optimal strategy for its diagnosis and treatment, as well as future perspectives. AREAS COVERED Given the lack of established definition, diagnosis, and treatment of DPDS, we conducted a thorough review of the existing literature. EXPERT OPINION It is emphasized that a standardized definition and classification of DPDS is essential for designing and conducting clinical studies to address current unmet needs in managing patients with DPDS.
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Affiliation(s)
- Mamoru Takenaka
- Department of Gastroenterology and Hepatology, Faculty of Medicine, Kindai University, Osaka, Japan
| | - Tomotaka Saito
- 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
- Department of Hepato-Biliary-Pancreatic Medicine, The Cancer Institute Hospital of Japanese Foundation for Cancer Research, Tokyo, Japan
| | - Shunsuke Omoto
- Department of Gastroenterology and Hepatology, Faculty of Medicine, Kindai University, Osaka, Japan
| | - Hideyuki Shiomi
- Department of Gastroenterology, Division of Hepatobiliary and Pancreatic Disease, Hyogo Medical University, Hyogo, Japan
| | - Takuji Iwashita
- First Department of Internal Medicine, Gifu University Hospital, Gifu, Japan
| | - Atsuhiro Masuda
- Division of Gastroenterology, Department of Internal Medicine, Kobe University Graduate School of Medicine, Hyogo, Japan
| | - Saburo Matsubara
- Department of Gastroenterology and Hepatology, Saitama Medical Center, Saitama Medical University, Saitama, Japan
| | - Akinori Maruta
- Department of Gastroenterology, Gifu Prefectural General Medical Center, Gifu, Japan
| | - Keisuke Iwata
- Department of Gastroenterology, Gifu Municipal Hospital, Gifu, Japan
| | - Tsuyoshi Mukai
- Department of Gastroenterological Endoscopy, Kanazawa Medical University, Ishikawa, Japan
| | - Hiroyuki Isayama
- Department of Gastroenterology, Graduate School of Medicine, Juntendo University, Tokyo, Japan
| | - Ichiro Yasuda
- Third Department of Internal Medicine, University of Toyama, Toyama, Japan
| | - Yousuke Nakai
- Department of Gastroenterology, Graduate School of Medicine, The University of Tokyo, Tokyo, Japan
- Department of Internal Medicine, Institute of Gastroenterology, Tokyo Women's Medical University, Tokyo, Japan
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Basha J, Lakhtakia S. Management of Disconnected Pancreatic Duct. Gastrointest Endosc Clin N Am 2023; 33:753-770. [PMID: 37709409 DOI: 10.1016/j.giec.2023.04.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 09/16/2023]
Abstract
Disconnected pancreatic duct (DPD) is common after acute necrotizing pancreatitis (ANP). Its clinical implications vary according to the course of disease. In the early phase of ANP, parenchymal necrosis along with disruption of pancreatic duct cause acute necrotic collection that evolves into walled-off necrosis (WON). In the later phase, DPD becomes evident as confirmed by magnetic resonance cholangiopancreatography. Clinical manifestations of DPD can vary from being asymptomatic, recurrent pain, recurrent pancreatic fluid collection (PFC), obstructive pancreatitis, or external pancreatic fistula (EPF). Few patients develop new-onset diabetes. Long-term indwelling plastic stents have been proposed to prevent the recurrent PFC.
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Affiliation(s)
- Jahangeer Basha
- Department of Gastroenterology, Asian Institute of Gastroenterology, AIG Hospitals, Gachibowli, Hyderabad 500032, Telangana, India
| | - Sundeep Lakhtakia
- Department of Gastroenterology, Asian Institute of Gastroenterology, AIG Hospitals, Gachibowli, Hyderabad 500032, Telangana, India.
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Vitali F, Zundler S, Jesper D, Strobel D, Wildner D, de Pretis N, Frulloni L, Crinó SF, Neurath MF. Endoscopic Ultrasound in Pancreatology: Focus on Inflammatory Diseases and Interventions. Visc Med 2023; 39:131-139. [PMID: 37899796 PMCID: PMC10601533 DOI: 10.1159/000533433] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/05/2023] [Accepted: 08/03/2023] [Indexed: 10/31/2023] Open
Abstract
Background Endoscopic ultrasound (EUS) is a main tool in pancreatology for both diagnosis and therapy. It allows minimally invasive differentiation of various diseases, with a minimal degree of inflammation or anatomic variations. EUS also enables interventional direct access to the pancreatic parenchyma and the retroperitoneal space, the pancreatic duct, the pancreatic masses, cysts, vascular structures for diagnostic and therapeutic purposes. Summary This review aimed to summarize the new developments of EUS in the field of pancreatology, with special interest on inflammation and interventions. EUS enables way to perform pseudocyst drainage, necrosectomy, transenteral drainage and transenteric access of the main pancreatic duct, or the direct visualization or therapy of vascular structures adjacent to the pancreas. Key Messages EUS has a deep impact on pancreatology, and the development of new diagnostic and interventional approaches to the retroperitoneal space and the pancreas has increased in the last years exponentially, allowing minimal invasive diagnostics and therapy and avoiding surgery and percutaneous therapy.
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Affiliation(s)
- Francesco Vitali
- Department of Medicine 1, University Hospital Erlangen, Friedrich-Alexander-University Erlangen-Nuremberg, Erlangen, Germany
| | - Sebastian Zundler
- Department of Medicine 1, University Hospital Erlangen, Friedrich-Alexander-University Erlangen-Nuremberg, Erlangen, Germany
| | - Daniel Jesper
- Department of Medicine 1, University Hospital Erlangen, Friedrich-Alexander-University Erlangen-Nuremberg, Erlangen, Germany
| | - Deike Strobel
- Department of Medicine 1, University Hospital Erlangen, Friedrich-Alexander-University Erlangen-Nuremberg, Erlangen, Germany
| | - Dane Wildner
- Department of Medicine 1, University Hospital Erlangen, Friedrich-Alexander-University Erlangen-Nuremberg, Erlangen, Germany
| | - Nicoló de Pretis
- Gastroenterology and Digestive Endoscopy Unit, The Pancreas Institute, G.B. Rossi University Hospital, Verona, Italy
| | - Luca Frulloni
- Gastroenterology and Digestive Endoscopy Unit, The Pancreas Institute, G.B. Rossi University Hospital, Verona, Italy
| | - Stefano Francesco Crinó
- Gastroenterology and Digestive Endoscopy Unit, The Pancreas Institute, G.B. Rossi University Hospital, Verona, Italy
| | - Markus F. Neurath
- Department of Medicine 1, University Hospital Erlangen, Friedrich-Alexander-University Erlangen-Nuremberg, Erlangen, Germany
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Short- and long-term outcomes of a disruption and disconnection of the pancreatic duct in necrotizing pancreatitis: a multicenter cohort study in 896 patients : Disrupted pancreatic duct in acute pancreatitis. Am J Gastroenterol 2022; 118:880-891. [PMID: 36707931 DOI: 10.14309/ajg.0000000000002157] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/02/2022] [Accepted: 12/06/2022] [Indexed: 01/29/2023]
Abstract
OBJECTIVES Necrotizing pancreatitis may result in a disrupted or disconnected pancreatic duct (DPD) with the potential for long lasting negative impact on a patient's clinical outcome. There is a lack of detailed data on the full clinical spectrum of DPD which is critical for the development of better diagnostic and treatment strategies. METHODS We performed a long-term post-hoc analysis of a prospectively collected nationwide cohort of 896 patients with necrotizing pancreatitis (2005-2015). The median follow-up after hospital admission was 75 months (P25-P75:41-151). Clinical outcomes of patients with and without DPD were compared using regression analyses, adjusted for potential confounders. Predictive features for DPD were explored. RESULTS DPD was confirmed in 243 (27%) of the 896 patients and resulted in worse clinical outcomes during both the patient's initial admission and follow-up. During hospital admission, DPD was associated with an increased rate of new-onset intensive care unit admission (adjusted-OR2.52 [95%-CI 1.62-3.93]), new-onset organ failure (adjusted-OR2.26 [95%-CI 1.45-3.55]), infected necrosis (adjusted-OR4.63 [95%-CI 2.87-7.64]) and pancreatic interventions (adjusted-OR7.55 [95%-CI 4.23-13.96]). During long-term follow-up, DPD increased the risk of pancreatic intervention (adjusted-OR9.71 [95%-CI 5.37-18.30], recurrent pancreatitis (adjusted-OR2.08 [95%-CI 1.32-3.29]), chronic pancreatitis (adjusted-OR2.73 [95%-CI 1.47-5.15]) and endocrine pancreatic insufficiency (adjusted-OR1.63 [95%-CI 1.05-2.53]).Central or subtotal pancreatic necrosis on computed tomography (CT), (OR9.49 [95%-CI 6.31-14.29] and a high levels of serum C-reactive protein (CRP) in the first 48 hours after admission (per 10 points increase, OR1.02 [95%-CI 1.00-1.03] were identified as independent predictors for developing DPD. CONCLUSIONS At least one of every four patients with necrotizing pancreatitis suffer from DPD which is associated with detrimental, short and long-term interventions and complications. Central and subtotal pancreatic necrosis and high levels of serum CRP in the first 48 hours are independent predictors for DPD.
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7
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Disconnected pancreatic duct syndrome in patients with necrotizing pancreatitis. Surg Open Sci 2022; 11:19-25. [DOI: 10.1016/j.sopen.2022.10.009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/21/2022] [Accepted: 10/21/2022] [Indexed: 11/13/2022] Open
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Mind the Gap-Disconnected Duct Syndrome: A Review of Current Diagnostic and Management Strategies. Pancreas 2022; 51:911-915. [PMID: 36607934 DOI: 10.1097/mpa.0000000000002133] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/07/2023]
Abstract
ABSTRACT Disconnected duct syndrome (DDS) is an adverse sequela of acute necrotizing pancreatitis in which there is disruption of the pancreatic duct leading to a failure to deliver pancreatic secretions into the duodenum. Its presentation may range from a persistent external pancreatic fistula to a treatment-resistant pancreatic pseudocyst. The diagnosis is often delayed in the acute setting if there is concurrent necrosis as management is often directed to the associated peripancreatic fluid collection. A combination of imaging modalities may be required to evaluate ductal anatomy. No definitive consensus has been achieved regarding the optimal treatment strategy for DDS, and there is a lack of published level I evidence on the topic. Treatment should be tailored to each individual patient, depending on the anatomy of ductal disruption, the presence of sepsis, the degree of physiological derangement, and the patients' performance status. Patients with DDS represent a specific cohort of patients with complex pancreatic disease that requires the input from a diverse multidisciplinary team to ensure that a good clinical outcome can be achieved.
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9
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Minaga K, Kudo M. Connected or disconnected: What's next after successful transmural drainage of pancreatic fluid collection? Dig Endosc 2022; 34:1242-1244. [PMID: 35645001 DOI: 10.1111/den.14331] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/10/2022] [Revised: 04/03/2022] [Accepted: 04/15/2022] [Indexed: 02/08/2023]
Affiliation(s)
- Kosuke Minaga
- Department of Gastroenterology and Hepatology, Kindai University Faculty of Medicine, Osaka, Japan
| | - Masatoshi Kudo
- Department of Gastroenterology and Hepatology, Kindai University Faculty of Medicine, Osaka, Japan
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Fabbri C, Baron TH, Gibiino G, Arcidiacono PG, Binda C, Anderloni A, Rizzatti G, Pérez-Miranda M, Lisotti A, Correale L, Gornals JB, Tarantino I, Petrone MC, Cecinato P, Fusaroli P, Larghi A. The endoscopic ultrasound features of pancreatic fluid collections and their impact on therapeutic decisions: an interobserver agreement study. Endoscopy 2022; 54:555-562. [PMID: 34496421 DOI: 10.1055/a-1640-4365] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
BACKGROUND A validated classification of endoscopic ultrasound (EUS) morphological characteristics and consequent therapeutic intervention(s) in pancreatic and peripancreatic fluid collections (PFCs) is lacking. We performed an interobserver agreement study among expert endosonographers assessing EUS-related PFC features and the therapeutic approaches used. METHODS 50 EUS videos of PFCs were independently reviewed by 12 experts and evaluated for PFC type, percentage solid component, presence of infection, recognition of and communication with the main pancreatic duct (MPD), stent choice for drainage, and direct endoscopic necrosectomy (DEN) performance and timing. The Gwet's AC1 coefficient was used to assess interobserver agreement. RESULTS A moderate agreement was found for lesion type (AC1, 0.59), presence of infection (AC1, 0.41), and need for DEN (AC1, 0.50), while fair or poor agreements were stated for percentage solid component (AC1, 0.15) and MPD recognition (AC1, 0.31). Substantial agreement was rated for ability to assess PFC-MPD communication (AC1, 0.69), decision between placing a plastic versus lumen-apposing metal stent (AC1, 0.62), and timing of DEN (AC1, 0.75). CONCLUSIONS Interobserver agreement between expert endosonographers regarding morphological features of PFCs appeared suboptimal, while decisions on therapeutic approaches seemed more homogeneous. Studies to achieve standardization of the diagnostic endosonographic criteria and therapeutic approaches to PFCs are warranted.
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Affiliation(s)
- Carlo Fabbri
- Unit of Gastroenterology and Digestive Endoscopy, Morgagni-Pierantoni Hospital of Forlì and Bufalini Hospital of Cesena, AUSL Romagna, Italy
| | - Todd H Baron
- Division of Gastroenterology and Hepatology, University of North Carolina, Chapel Hill, North Carolina, USA
| | - Giulia Gibiino
- Unit of Gastroenterology and Digestive Endoscopy, Morgagni-Pierantoni Hospital of Forlì and Bufalini Hospital of Cesena, AUSL Romagna, Italy
| | - Paolo Giorgio Arcidiacono
- Pancreato-biliary Endoscopy and Endosonography Division, Pancreas Translational and Clinical Research Center, San Raffaele Scientific Institute IRCCS, Milan, Italy
| | - Cecilia Binda
- Unit of Gastroenterology and Digestive Endoscopy, Morgagni-Pierantoni Hospital of Forlì and Bufalini Hospital of Cesena, AUSL Romagna, Italy
| | - Andrea Anderloni
- Digestive Endoscopy Unit, Division of Gastroenterology, Humanitas Research Hospital, Rozzano, Milano, Italy
| | - Gianenrico Rizzatti
- Digestive Endoscopy Unit, Fondazione Policlinico Universitario A. Gemelli IRCCS, Rome, Italy
- CERTT, Center for Endoscopic Research Therapeutics and Training, Catholic University, Rome, Italy
| | - Manuel Pérez-Miranda
- Department of Gastroenterology and Hepatology, Hospital Universitario Rio Hortega, Valladolid, Spain
| | - Andrea Lisotti
- Gastroenterology Unit, Hospital of Imola, Department of Medical and Surgical Sciences, University of Bologna, Bologna, Italy
| | - Loredana Correale
- Digestive Endoscopy Unit, Fondazione Policlinico Universitario A. Gemelli IRCCS, Rome, Italy
| | - Joan B Gornals
- Endoscopy Unit, Digestive Diseases Department, Hospital Universitari de Bellvitge, Bellvitge Biomedical Research Institute (IDIBELL), University of Barcelona, Barcelona, Spain
| | - Ilaria Tarantino
- Endoscopy Service, Department of Diagnostic and Therapeutic Services, IRCCS-ISMETT, Palermo, Italy
| | - Maria Chiara Petrone
- Pancreato-biliary Endoscopy and Endosonography Division, Pancreas Translational and Clinical Research Center, San Raffaele Scientific Institute IRCCS, Milan, Italy
| | - Paolo Cecinato
- Gastroenterology and Digestive Endoscopy Unit, Arcispedale Santa Maria Nuova di Reggio Emilia, AUSL-IRCCS di Reggio Emilia, Reggio Emilia, Italy
| | - Pietro Fusaroli
- Gastroenterology Unit, Hospital of Imola, Department of Medical and Surgical Sciences, University of Bologna, Bologna, Italy
| | - Alberto Larghi
- Digestive Endoscopy Unit, Fondazione Policlinico Universitario A. Gemelli IRCCS, Rome, Italy
- CERTT, Center for Endoscopic Research Therapeutics and Training, Catholic University, Rome, Italy
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Hamada T, Iwashita T, Saito T, Shiomi H, Takenaka M, Isayama H, Yasuda I, Nakai Y. Disconnected pancreatic duct syndrome and outcomes of endoscopic ultrasound-guided treatment of pancreatic fluid collections: Systematic review and meta-analysis. Dig Endosc 2022; 34:676-686. [PMID: 34544204 DOI: 10.1111/den.14142] [Citation(s) in RCA: 18] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/22/2021] [Accepted: 09/16/2021] [Indexed: 12/12/2022]
Abstract
BACKGROUND Disconnected pancreatic duct syndrome (DPDS) frequently occurs in patients with acute necrotizing pancreatitis and resultant pancreatic fluid collection (PFC). We performed a systematic review and meta-analysis to evaluate outcomes of endoscopic ultrasound-guided treatment of PFCs according to the presence of DPDS. METHODS Using PubMed, Embase, and the Cochrane database, we identified clinical studies published until January 2021 with data comparing outcomes of endoscopic ultrasound-guided drainage of PFCs between DPDS and non-DPDS patients. We pooled data on technical and clinical success rates, PFC recurrence, and adverse events using the random-effects model. RESULTS We identified five eligible articles including 941 PFC patients treated with endoscopic ultrasound-guided interventions. Clinical success, defined as resolution of the PFC and symptoms, was achieved in a majority of the cases irrespective of DPDS (pooled odds ratio [OR] comparing DPDS to non-DPDS patients, 0.77; 95% confidence interval [CI] 0.33-1.81). Compared to patients without DPDS, patients with DPDS were more likely to undergo PFC recurrence (pooled OR 6.72; 95% CI 2.72-16.6) after clinical resolution of PFC. Prolonged plastic stent placement following the clinical resolution was more frequently performed in DPDS patients than in non-DPDS patients (pooled OR 15.9; 95% CI 2.76-91.9). No statistically significant difference was observed between the groups in terms of the rate of technical success, adverse events, or mortality. CONCLUSION Disconnected pancreatic duct syndrome was associated with higher rate of PFC recurrence after successful endoscopic treatment of PFCs. Future studies should evaluate effectiveness and optimal duration of long-term placement of transmural plastic stents for PFCs with DPDS.
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Affiliation(s)
- Tsuyoshi Hamada
- Department of Gastroenterology, Graduate School of Medicine, The University of Tokyo, Tokyo, Japan.,Department of Hepato-Biliary-Pancreatic Medicine, Cancer Institute Hospital of Japanese Foundation for Cancer Research, Tokyo, Japan
| | - Takuji Iwashita
- First Department of Internal Medicine, Gifu University Hospital, Gifu, Japan
| | - Tomotaka Saito
- Department of Gastroenterology, Graduate School of Medicine, The University of Tokyo, Tokyo, Japan
| | - Hideyuki Shiomi
- Division of Gastroenterology and Hepato-biliary-pancreatology, Department of Internal Medicine, Hyogo College of Medicine, Hyogo, Japan
| | - Mamoru Takenaka
- Department of Gastroenterology and Hepatology, Faculty of Medicine, Kindai University, Osaka, Japan
| | - Hiroyuki Isayama
- Department of Gastroenterology, Graduate School of Medicine, Juntendo University, Tokyo, Japan
| | - Ichiro Yasuda
- Third Department of Internal Medicine, University of Toyama, Toyama, Japan
| | - Yousuke Nakai
- Department of Gastroenterology, Graduate School of Medicine, The University of Tokyo, Tokyo, Japan.,Department of Endoscopy and Endoscopic Surgery, The University of Tokyo Hospital, Tokyo, Japan
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Bang JY, Wilcox CM, Hawes R, Varadarajulu S. Outcomes of a Structured, Stepwise Approach to Endoscopic Necrosectomy. J Clin Gastroenterol 2021; 55:631-637. [PMID: 32657959 DOI: 10.1097/mcg.0000000000001392] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/09/2020] [Accepted: 06/08/2020] [Indexed: 12/12/2022]
Abstract
BACKGROUND AND AIM Despite the increasing number of procedures being performed, there is no consensus on the optimal approach to performing direct endoscopic necrosectomy (DEN), which is a labor-intensive, nonstandardized intervention. We prospectively validated the usefulness of a predefined, structured, stepwise approach to DEN with the objective of improving procedural efficiency and resource use. MATERIALS AND METHODS A prospective study of patients with necrotizing pancreatitis who after endoscopic transluminal drainage did not have clinical improvement and required DEN. The study was undertaken in 2 phases. Phase I was a retrospective analysis of interventions performed using an unstructured, conventional approach. Median of 3 necrosectomy sessions (range, 2 to 3) were required to achieve 80% treatment success in 20 patients. On the basis of these observations, a structured approach that included 3 steps (debridement, necrosis extraction, and irrigation) was developed and validated prospectively in phase II in 39 patients. The main outcome was to compare procedural efficiency defined as a number of necrosectomy sessions to achieve treatment success. RESULTS Although there was no significant difference in treatment success (phase I=80.0 vs. phase II=94.9%, P=0.17), the procedure was more efficient in phase II [median session, 2 (interquartile range=1 to 3) vs. 3 (interquartile range=2 to 3); P=0.003]. Multiple logistic regression analysis revealed that a structured, stepwise approach was associated with fewer necrosectomy sessions to achieve treatment success (odds ratio=4.7; 95% confidence interval=1.5-15.0; P=0.008) when adjusted for patient demographics, lab parameters, and disease characteristics. CONCLUSIONS By decreasing the number of necrosectomy sessions, a structured, stepwise approach to endoscopic necrosectomy seems to improve procedural efficiency.
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Affiliation(s)
- Ji Young Bang
- Center for Interventional Endoscopy, AdventHealth Orlando, Orlando, FL
| | - Charles Mel Wilcox
- Division of Gastroenterology & Hepatology, University of Alabama at Birmingham, Birmingham, AL
| | - Robert Hawes
- Center for Interventional Endoscopy, AdventHealth Orlando, Orlando, FL
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Boxhoorn L, Timmerhuis HC, Verdonk RC, Besselink MG, Bollen TL, Bruno MJ, Elmunzer BJ, Fockens P, Horvath KD, van Santvoort HC, Voermans RP. Diagnosis and treatment of pancreatic duct disruption or disconnection: an international expert survey and case vignette study. HPB (Oxford) 2021; 23:1201-1208. [PMID: 33541807 DOI: 10.1016/j.hpb.2020.11.1148] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/20/2020] [Revised: 10/13/2020] [Accepted: 11/29/2020] [Indexed: 12/12/2022]
Abstract
BACKGROUND Pancreatic duct disruption or disconnection is a potentially severe complication of necrotizing pancreatitis. With no existing treatment guidelines, it is unclear whether there is any consensus among experts in clinical practice. We evaluated current expert opinion regarding the diagnosis and treatment of pancreatic duct disruption and disconnection in an international case vignette study. METHODS An online case vignette survey was sent to 110 international expert pancreatologists. Expert selection was based on publications in the last 5 years and/or participation in development of IAP/APA and ESGE guidelines on acute pancreatitis. Consensus was defined as agreement by at least 75% of the experts. RESULTS The response rate was 51% (n = 56). Forty-four experts (79%) obtained a MRI/MRCP and 52 experts (93%) measured amylase levels in percutaneous drain fluid to evaluate pancreatic duct integrity. The majority of experts favored endoscopic transluminal drainage for infected (peri)pancreatic necrosis and pancreatic duct disruption (84%, n = 45) or disconnection (88%, n = 43). Consensus was lacking regarding the treatment of patients with persistent percutaneous drain production, and with persistent sterile necrosis. CONCLUSION This international survey of experts demonstrates that there are many areas for which no consensus existed, providing clear focus for future investigation.
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Affiliation(s)
- Lotte Boxhoorn
- Department of Gastroenterology and Hepatology, Amsterdam Gastroenterology Endocrinology Metabolism, Amsterdam UMC, University of Amsterdam, Amsterdam, the Netherlands; Department of Research and Development, St. Antonius Hospital, Nieuwegein, the Netherlands
| | - Hester C Timmerhuis
- Department of Research and Development, St. Antonius Hospital, Nieuwegein, the Netherlands; Department of Surgery, St. Antonius Hospital, Nieuwegein, the Netherlands
| | - Robert C Verdonk
- Department of Gastroenterology and Hepatology, St. Antonius Hospital, Nieuwegein, the Netherlands
| | - Marc G Besselink
- Department of Surgery, Amsterdam Gastroenterology Endocrinology Metabolism, Amsterdam UMC, University of Amsterdam, Amsterdam, the Netherlands
| | - Thomas L Bollen
- Department of Radiology, St. Antonius Hospital, Nieuwegein, the Netherlands
| | - Marco J Bruno
- Department of Gastroenterology and Hepatology, Erasmus MC University Medical Center, Rotterdam, the Netherlands
| | - B Joseph Elmunzer
- Division of Gastroenterology and Hepatology, Medical University of South Carolina, Charleston, SC, USA
| | - Paul Fockens
- Department of Gastroenterology and Hepatology, Amsterdam Gastroenterology Endocrinology Metabolism, Amsterdam UMC, University of Amsterdam, Amsterdam, the Netherlands
| | - Karen D Horvath
- Department of Surgery, University of Washington, Seattle, WA, USA
| | - Hjalmar C van Santvoort
- Department of Surgery, St. Antonius Hospital, Nieuwegein, the Netherlands; Department of Surgery, University Medical Center Utrecht, Utrecht, the Netherlands
| | - Rogier P Voermans
- Department of Gastroenterology and Hepatology, Amsterdam Gastroenterology Endocrinology Metabolism, Amsterdam UMC, University of Amsterdam, Amsterdam, the Netherlands.
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14
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Wang L, Elhanafi S, Storm AC, Topazian MD, Majumder S, Abu Dayyeh BK, Levy MJ, Petersen BT, Martin JA, Chari ST, Vege SS, Chandrasekhara V. Impact of disconnected pancreatic duct syndrome on endoscopic ultrasound-guided drainage of pancreatic fluid collections. Endoscopy 2021; 53:603-610. [PMID: 32629484 DOI: 10.1055/a-1213-1489] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
BACKGROUND Endoscopic intervention for pancreatic fluid collections (PFCs) with disconnected pancreatic duct syndrome (DPDS) has been associated with failures and increased need for additional endoscopic and non-endoscopic interventions. The primary aim of this study was to determine the outcomes of endoscopic ultrasound (EUS)-guided transmural drainage of PFCs in patients with DPDS. METHODS In patients undergoing EUS-guided drainage of PFCs from January 2013 to January 2018, demographic profiles, procedural indications and details, adverse events, outcomes, and subsequent interventions were retrospectively collected. Overall treatment success was determined by PFC resolution on follow-up imaging or stent removal without recurrence. RESULTS EUS-guided drainage of PFCs was performed in 141 patients. DPDS was present in 57 of them (40 %) and walled-off necrosis was the most frequent type of PFC (55 %). DPDS was not associated with lower clinical success, increased number of repeat interventions, or increased time to PFC resolution. Patients with DPDS were more likely to be treated with permanent transmural plastic double-pigtail stents (odds ratio [OR] 6.4; 95 % confidence interval [CI] 2.5 - 16.5; P < 0.001). However, when stents were removed, DPDS was associated with increased PFC recurrence after stent removal (OR 8.0; 95 %CI 1.2 - 381.8; P = 0.04). CONCLUSIONS DPDS frequently occurs in patients with PFCs but does not negatively impact successful resolution. DPDS is associated with increased PFC recurrence after stent removal.
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Affiliation(s)
- Lillian Wang
- Division of Gastroenterology and Hepatology, Mayo Clinic at Rochester, Rochester, Minnesota, USA
| | - Sherif Elhanafi
- Division of Gastroenterology, Texas Tech University Health Sciences Center, El Paso, Texas, USA
| | - Andrew C Storm
- Division of Gastroenterology and Hepatology, Mayo Clinic at Rochester, Rochester, Minnesota, USA
| | - Mark D Topazian
- Division of Gastroenterology and Hepatology, Mayo Clinic at Rochester, Rochester, Minnesota, USA
| | - Shounak Majumder
- Division of Gastroenterology and Hepatology, Mayo Clinic at Rochester, Rochester, Minnesota, USA
| | - Barham K Abu Dayyeh
- Division of Gastroenterology and Hepatology, Mayo Clinic at Rochester, Rochester, Minnesota, USA
| | - Michael J Levy
- Division of Gastroenterology and Hepatology, Mayo Clinic at Rochester, Rochester, Minnesota, USA
| | - Bret T Petersen
- Division of Gastroenterology and Hepatology, Mayo Clinic at Rochester, Rochester, Minnesota, USA
| | - John A Martin
- Division of Gastroenterology and Hepatology, Mayo Clinic at Rochester, Rochester, Minnesota, USA
| | - Suresh T Chari
- Division of Gastroenterology and Hepatology, Mayo Clinic at Rochester, Rochester, Minnesota, USA
| | - Santhi S Vege
- Division of Gastroenterology and Hepatology, Mayo Clinic at Rochester, Rochester, Minnesota, USA
| | - Vinay Chandrasekhara
- Division of Gastroenterology and Hepatology, Mayo Clinic at Rochester, Rochester, Minnesota, USA
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15
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Bang JY, Mel Wilcox C, Arnoletti JP, Varadarajulu S. Importance of Disconnected Pancreatic Duct Syndrome in Recurrence of Pancreatic Fluid Collections Initially Drained Using Lumen-Apposing Metal Stents. Clin Gastroenterol Hepatol 2021; 19:1275-1281.e2. [PMID: 32683101 DOI: 10.1016/j.cgh.2020.07.022] [Citation(s) in RCA: 35] [Impact Index Per Article: 8.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/26/2020] [Revised: 07/11/2020] [Accepted: 07/14/2020] [Indexed: 02/07/2023]
Abstract
BACKGROUND & AIMS Indwelling plastic endoprosthesis in patients with disconnected pancreatic duct syndrome (DPDS) reduces the risk of pancreatic fluid collection (PFC) recurrence. Although lumen-apposing metal stents (LAMS) are used with increasing frequency for PFC drainage, they require timely removal and little is known about their effects in patients with DPDS and recurrence of PFC. METHODS We performed a prospective study of patients who underwent endoscopic ultrasound-guided drainage of PFC using LAMS and were found to have DPDS. After resolution of PFC, LAMS were replaced with double-pigtail plastic stents. The primary outcome was to compare PFC recurrence between patients with DPDS who did vs did not receive replacements with plastic stents after removal of the LAMS. RESULTS Of 188 PFC patients treated with LAMS, 94 had DPDS, 71 had intact pancreatic ducts, and duct patency was unknown in 23. In patients with DPDS, replacement of LAMS with plastic stents was successful in 70 patients (74.5%) and technically unsuccessful in 24 patients (25.5%). At a median follow up of 183 days (interquartile range, 179-188 days), although none of the patients with an intact duct had a recurrence of PFC, 7 of the 94 patients with DPDS had recurrence of PFC (7.4%) (P = .020). PFC recurred in 1 of 70 patients with DPDS in whom replacement of LAMS with plastic stent was successful (1.4%) and in 6 of 24 patients with unsuccessful stent replacement (25.0%) (P = .001). CONCLUSIONS In treatment of PFCs with LAMS in patients with DPDS, it is important to replace the LAMS with indwelling plastic stents to minimize PFC recurrence and reduce morbidity. Clinicaltrials.gov no: NCT02422095.
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Affiliation(s)
- Ji Young Bang
- Center for Interventional Endoscopy, AdventHealth Orlando, Orlando, Florida
| | - C Mel Wilcox
- Division of Gastroenterology and Hepatology, University of Alabama at Birmingham, Birmingham, Alabama
| | | | - Shyam Varadarajulu
- Center for Interventional Endoscopy, AdventHealth Orlando, Orlando, Florida.
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16
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Timmerhuis HC, van Dijk SM, Verdonk RC, Bollen TL, Bruno MJ, Fockens P, van Hooft JE, Voermans RP, Besselink MG, van Santvoort HC, for the Dutch Pancreatitis Study Group. Various Modalities Accurate in Diagnosing a Disrupted or Disconnected Pancreatic Duct in Acute Pancreatitis: A Systematic Review. Dig Dis Sci 2021; 66:1415-1424. [PMID: 32594462 PMCID: PMC8053185 DOI: 10.1007/s10620-020-06413-0] [Citation(s) in RCA: 20] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/13/2020] [Accepted: 06/14/2020] [Indexed: 12/12/2022]
Abstract
BACKGROUND Severe pancreatitis may result in a disrupted pancreatic duct, which is associated with a complicated clinical course. Diagnosis of a disrupted pancreatic duct is not standardized in clinical practice or international guidelines. We performed a systematic review of the literature on imaging modalities for diagnosing a disrupted pancreatic duct in patients with acute pancreatitis. METHODS A systematic search was performed in PubMed, Embase and Cochrane library databases to identify all studies evaluating diagnostic modalities for the diagnosis of a disrupted pancreatic duct in acute pancreatitis. All data regarding diagnostic accuracy were extracted. RESULTS We included 8 studies, evaluating five different diagnostic modalities in 142 patients with severe acute pancreatitis. Study quality was assessed, with proportionally divided high and low risk of bias and low applicability concerns in 75% of the studies. A sensitivity of 100% was reported for endoscopic ultrasound and endoscopic retrograde cholangiopancreatography. The sensitivity of magnetic resonance cholangiopancreatography with or without secretin was 83%. A sensitivity of 92% was demonstrated for a combined cohort of secretin-magnetic resonance cholangiopancreatography and magnetic resonance cholangiopancreatography. A sensitivity of 100% and specificity of 50% was found for amylase measurements in drain fluid compared with ERCP. CONCLUSIONS This review suggests that various diagnostic modalities are accurate in diagnosing a disrupted pancreatic duct in patients with acute pancreatitis. Amylase measurement in drain fluid should be standardized. Given the invasive nature of other modalities, secretin-magnetic resonance cholangiopancreatography or magnetic resonance cholangiopancreatography would be recommended as first diagnostic modality. Further prospective studies, however, are needed.
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Affiliation(s)
- Hester C. Timmerhuis
- Department of Research and Development, St. Antonius Hospital, PO 2500, 3430 EM Nieuwegein, The Netherlands
- Department of Surgery, St. Antonius Hospital, PO 2500, 3430 EM Nieuwegein, The Netherlands
| | - Sven M. van Dijk
- Department of Research and Development, St. Antonius Hospital, PO 2500, 3430 EM Nieuwegein, The Netherlands
- Department of Surgery, Amsterdam Gastroenterology and Metabolism, Amsterdam UMC, University of Amsterdam, PO 22660, 1100 DD Amsterdam, The Netherlands
| | - Robert C. Verdonk
- Department of Gastroenterology and Hepatology, St. Antonius Hospital, PO 2500, 3430 EM Nieuwegein, The Netherlands
| | - Thomas L. Bollen
- Department of Radiology, St. Antonius Hospital, PO 2500, 3430 EM Nieuwegein, The Netherlands
| | - Marco J. Bruno
- Department of Gastroenterology, Erasmus MC University Medical Center, PO 2040, 3000 CA Rotterdam, The Netherlands
| | - Paul Fockens
- Department of Gastroenterology and Hepatology, Amsterdam Gastroenterology and Metabolism, Amsterdam UMC, University of Amsterdam, PO 22660, 1100 DD Amsterdam, The Netherlands
| | - Jeanin E. van Hooft
- Department of Gastroenterology and Hepatology, Amsterdam Gastroenterology and Metabolism, Amsterdam UMC, University of Amsterdam, PO 22660, 1100 DD Amsterdam, The Netherlands
| | - Rogier P. Voermans
- Department of Gastroenterology and Hepatology, Amsterdam Gastroenterology and Metabolism, Amsterdam UMC, University of Amsterdam, PO 22660, 1100 DD Amsterdam, The Netherlands
| | - Marc G. Besselink
- Department of Surgery, Amsterdam Gastroenterology and Metabolism, Amsterdam UMC, University of Amsterdam, PO 22660, 1100 DD Amsterdam, The Netherlands
| | - Hjalmar C. van Santvoort
- Department of Surgery, St. Antonius Hospital, PO 2500, 3430 EM Nieuwegein, The Netherlands
- Department of Surgery, University Medical Center Utrecht, P.O. Box 85500, 3508 GA Utrecht, The Netherlands
| | - for the Dutch Pancreatitis Study Group
- Department of Research and Development, St. Antonius Hospital, PO 2500, 3430 EM Nieuwegein, The Netherlands
- Department of Surgery, St. Antonius Hospital, PO 2500, 3430 EM Nieuwegein, The Netherlands
- Department of Surgery, Amsterdam Gastroenterology and Metabolism, Amsterdam UMC, University of Amsterdam, PO 22660, 1100 DD Amsterdam, The Netherlands
- Department of Gastroenterology and Hepatology, St. Antonius Hospital, PO 2500, 3430 EM Nieuwegein, The Netherlands
- Department of Radiology, St. Antonius Hospital, PO 2500, 3430 EM Nieuwegein, The Netherlands
- Department of Gastroenterology, Erasmus MC University Medical Center, PO 2040, 3000 CA Rotterdam, The Netherlands
- Department of Gastroenterology and Hepatology, Amsterdam Gastroenterology and Metabolism, Amsterdam UMC, University of Amsterdam, PO 22660, 1100 DD Amsterdam, The Netherlands
- Department of Surgery, University Medical Center Utrecht, P.O. Box 85500, 3508 GA Utrecht, The Netherlands
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17
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Chong E, Ratnayake CB, Saikia S, Nayar M, Oppong K, French JJ, Windsor JA, Pandanaboyana S. Endoscopic transmural drainage is associated with improved outcomes in disconnected pancreatic duct syndrome: a systematic review and meta-analysis. BMC Gastroenterol 2021; 21:87. [PMID: 33632128 PMCID: PMC7905849 DOI: 10.1186/s12876-021-01663-2] [Citation(s) in RCA: 14] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/15/2020] [Accepted: 02/12/2021] [Indexed: 12/15/2022] Open
Abstract
BACKGROUND Disconnected pancreatic duct syndrome (DPDS) is a complication of acute necrotizing pancreatitis in the neck and body of the pancreas often manifesting as persistent pancreatic fluid collection (PFC) or external pancreatic fistula (EPF). This systematic review and pairwise meta-analysis aimed to review the definitions, clinical presentation, intervention, and outcomes for DPDS. METHODS The PubMed, EMBASE, MEDLINE, and SCOPUS databases were systematically searched until February 2020 using the PRISMA framework. A meta-analysis was performed to assess the success rates of endoscopic and surgical interventions for the treatment of DPDS. Success of DPDS treatment was defined as long-term resolution of symptoms without recurrence of PFC, EPF, or pancreatic ascites. RESULTS Thirty studies were included in the quantitative analysis comprising 1355 patients. Acute pancreatitis was the most common etiology (95.3%, 936/982), followed by chronic pancreatitis (3.1%, 30/982). DPDS commonly presented with PFC (83.2%, 948/1140) and EPF (13.4%, 153/1140). There was significant heterogeneity in the definition of DPDS in the literature. Weighted success rate of endoscopic transmural drainage (90.6%, 95%-CI 81.0-95.6%) was significantly higher than transpapillary drainage (58.5%, 95%-CI 36.7-77.4). Pairwise meta-analysis showed comparable success rates between endoscopic and surgical intervention, which were 82% (weighted 95%-CI 68.6-90.5) and 87.4% (95%-CI 81.2-91.8), respectively (P = 0.389). CONCLUSIONS Endoscopic transmural drainage was superior to transpapillary drainage for the management of DPDS. Endoscopic and surgical interventions had comparable success rates. The significant variability in the definitions and treatment strategies for DPDS warrant standardisation for further research.
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Affiliation(s)
- Eric Chong
- Surgical and Translational Research Centre, Faculty of Medical and Health Sciences, University of Auckland, Auckland, New Zealand
| | - Chathura Bathiya Ratnayake
- Surgical and Translational Research Centre, Faculty of Medical and Health Sciences, University of Auckland, Auckland, New Zealand
| | - Samantha Saikia
- Department of Radiology, Freeman Hospital, Newcastle upon Tyne, UK
| | - Manu Nayar
- Department of Gastroenterology, Freeman Hospital, Newcastle upon Tyne, UK
| | - Kofi Oppong
- Department of Gastroenterology, Freeman Hospital, Newcastle upon Tyne, UK
| | - Jeremy J French
- HPB and Transplant Unit, Department of Hepatobiliary, Pancreatic and Transplant Surgery, Freeman Hospital, Newcastle upon Tyne, UK
| | - John A Windsor
- Surgical and Translational Research Centre, Faculty of Medical and Health Sciences, University of Auckland, Auckland, New Zealand
| | - Sanjay Pandanaboyana
- HPB and Transplant Unit, Department of Hepatobiliary, Pancreatic and Transplant Surgery, Freeman Hospital, Newcastle upon Tyne, UK. .,Population Health Sciences, Newcastle University, Newcastle upon Tyne, UK.
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18
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Verma S, Rana SS. Disconnected pancreatic duct syndrome: Updated review on clinical implications and management. Pancreatology 2020; 20:1035-1044. [PMID: 32800651 DOI: 10.1016/j.pan.2020.07.402] [Citation(s) in RCA: 43] [Impact Index Per Article: 8.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/24/2020] [Revised: 06/23/2020] [Accepted: 07/24/2020] [Indexed: 02/06/2023]
Abstract
Disconnected Pancreatic Duct Syndrome (DPDS) is an important but often overlooked complication of acute necrotising pancreatitis (ANP) that occurs due to necrosis of the main pancreatic duct (PD). This segmental necrosis leads on to disconnection between the viable upstream pancreatic parenchyma and the duodenum. The disconnected and functional segment of pancreas continues to secrete pancreatic juice that is not drained into the gastrointestinal tract and lead on to recurrent pancreatic fluid collections (PFC), refractory external pancreatic flstulae and chronic abdominal pain/recurrent pancreatitis. Because of lack of awareness of this important complication of ANP, the diagnosis of DPDS is usually delayed. The delay in diagnosis increases the morbidity of the disease as well as increase the cost of treatment and duration of hospital stay. Surgery has remained the cornerstone for management of patients with DPDS. The conventional surgical approaches have been either resection or internal drainage procedures. Surgery for DPDS in the setting of ANP is often difficult due to presence of local inflammation and extensive venous collaterals in the operative field due to splenic vein thrombosis and therefore is associated with significant morbidity. Advancement in therapeutic endoscopy, especially advent of therapeutic endoscopic ultrasound has opened an exciting new field of minimally invasive therapeutic options for management of DPDS. The present review discusses the current understanding of the clinical manifestations, imaging features and management strategies in patients with DPDS.
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Affiliation(s)
- Suhang Verma
- Department of Gastroenterology, Post Graduate Institute of Medical Education and Research (PGIMER), Sector 12, Chandigarh, 160012, India
| | - Surinder S Rana
- Department of Gastroenterology, Post Graduate Institute of Medical Education and Research (PGIMER), Sector 12, Chandigarh, 160012, India.
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19
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van Dijk SM, Timmerhuis HC, Verdonk RC, Reijnders E, Bruno MJ, Fockens P, Voermans RP, Besselink MG, van Santvoort HC. Treatment of disrupted and disconnected pancreatic duct in necrotizing pancreatitis: A systematic review and meta-analysis. Pancreatology 2019; 19:905-915. [PMID: 31473083 DOI: 10.1016/j.pan.2019.08.006] [Citation(s) in RCA: 22] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/05/2019] [Revised: 08/08/2019] [Accepted: 08/12/2019] [Indexed: 12/11/2022]
Abstract
BACKGROUND Necrotizing pancreatitis may lead to loss of integrity of the pancreatic duct, resulting in leakage of pancreatic fluid. Pancreatic duct disruption or disconnection is associated with a prolonged disease course and particular complications. Since a standard treatment for this condition is currently lacking, we performed a systematic review of the literature to compare outcomes of various treatment strategies. METHODS A systematic review was performed according to the PRISMA guidelines in the PubMed, EMBASE and Cochrane databases. Included were articles considering the treatment of patients with disrupted or disconnected pancreatic duct resulting from acute necrotizing pancreatitis. RESULTS Overall, 21 observational cohort studies were included comprising a total of 583 relevant patients. The most frequently used treatment strategies included endoscopic transpapillary drainage, endoscopic transluminal drainage, surgical drainage or resection, or combined procedures. Pooled analysis showed success rates of 81% (95%-CI: 60-92%) for transpapillary and 92% (95%-CI: 77-98%) for transluminal drainage, 80% (95%-CI: 67-89%) for distal pancreatectomy and 84% (95%-CI: 73-91%) for cyst-jejunostomy. Success rates did not differ between surgical procedures (cyst-jejunostomy and distal pancreatectomy (risk ratio = 1.06, p = .26)) but distal pancreatectomy was associated with a higher incidence of endocrine pancreatic insufficiency (risk ratio = 3.06, p = .01). The success rate of conservative treatment is unknown. DISCUSSION Different treatment strategies for pancreatic duct disruption and duct disconnection after necrotizing pancreatitis show high success rates but various sources of bias in the available studies are likely. High-quality prospective, studies, including unselected patients, are needed to establish the most effective treatment in specific subgroups of patients, including timing of treatment and long-term follow-up.
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Affiliation(s)
- Sven M van Dijk
- Department of Research & Development, St. Antonius Hospital, Nieuwegein, the Netherlands; Department of Surgery, Amsterdam Gastroenterology and Metabolism, Amsterdam UMC, University of Amsterdam, Amsterdam, the Netherlands.
| | - Hester C Timmerhuis
- Department of Research & Development, St. Antonius Hospital, Nieuwegein, the Netherlands; Department of Surgery, St. Antonius Hospital, Nieuwegein, the Netherlands
| | - Robert C Verdonk
- Department of Gastroenterology and Hepatology, St. Antonius Hospital, Nieuwegein, the Netherlands
| | - Evelien Reijnders
- Department of Surgery, Amsterdam Gastroenterology and Metabolism, Amsterdam UMC, University of Amsterdam, Amsterdam, the Netherlands
| | - Marco J Bruno
- Department of Gastroenterology and Hepatology, Erasmus Medical Center, Rotterdam, the Netherlands
| | - Paul Fockens
- Department of Gastroenterology and Hepatology, Amsterdam Gastroenterology and Metabolism, Amsterdam UMC, University of Amsterdam, Amsterdam, the Netherlands
| | - Rogier P Voermans
- Department of Gastroenterology and Hepatology, Amsterdam Gastroenterology and Metabolism, Amsterdam UMC, University of Amsterdam, Amsterdam, the Netherlands
| | - Marc G Besselink
- Department of Surgery, Amsterdam Gastroenterology and Metabolism, Amsterdam UMC, University of Amsterdam, Amsterdam, the Netherlands
| | - Hjalmar C van Santvoort
- Department of Surgery, St. Antonius Hospital, Nieuwegein, the Netherlands; Department of Surgery, University Medical Center Utrecht, Utrecht, the Netherlands.
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20
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Abstract
PURPOSE OF REVIEW To review the current management of walled-off pancreatic necrosis (WOPN). RECENT FINDINGS The management of WOPN has evolved. Many collections do not require intervention and may resolve over time. Nutritional support and treatment of infection are two critical components of medical management. For collections requiring drainage, minimally invasive endoscopic therapies now play a primary role. Endoscopic transmural puncture with stent placement may provide access for drainage and decompression. More complex collections may require transluminal instrumentation with lavage, debridement, and necrosectomy. Concurrent pancreatic duct injuries including strictures, leaks, and disconnections are very common. Addressing the pancreatic ductal injury is a key component in the long-term success of management strategies. Providing high-level care for patients requires a multidisciplinary approach with providers specialized in the management of severe acute pancreatitis and associated complications. SUMMARY Minimally invasive management strategies improve the outcomes for patients with WOPN. Close follow-up, medical therapy, and nutritional support are required for most patients. Endoscopic transmural drainage and necrosectomy are the primary approaches for collections requiring intervention. Protocols for endoscopic drainage are being refined to reduce side effects and decrease the number of interventions required for resolution.
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21
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Yamada R, Umeda Y, Shiono Y, Okuse H, Kuroda N, Tsuboi J, Inoue H, Hamada Y, Tanaka K, Horiki N, Takei Y. Management of the late effects of disconnected pancreatic duct syndrome: A case report. World J Clin Cases 2019; 7:1053-1059. [PMID: 31123678 PMCID: PMC6511923 DOI: 10.12998/wjcc.v7.i9.1053] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/17/2019] [Revised: 03/14/2019] [Accepted: 03/26/2019] [Indexed: 02/05/2023] Open
Abstract
BACKGROUND There have been few reports about the late effects of disconnected pancreatic duct syndrome (DPDS). Although few reports have described the recurrence interval of pancreatitis, it might be rare for recurrence to occur more than 5 years later. Herein, we describe a case of recurrence in an 81-year-old man after the treatment of walled-off necrosis (WON) with pancreatic transection 7 years ago.
CASE SUMMARY An 81-year-old man visited our hospital with chief complaints of fever and abdominal pain 7 years after the onset of WON due to severe necrotic pancreatitis. His medical history included an abdominal aortic aneurysm (AAA), hypertension, dyslipidemia, and chronic kidney disease. Computed tomography (CT) scan showed that the pancreatic fluid collection (PFC) had spread to the aorta with inflammation surrounding it, and CT findings suggested that bleeding occurred from the vasodilation due to splenic vein occlusion. First, we attempted to perform transpapillary drainage because of venous dilation around the residual stomach and the PFC. However, pancreatic duct drainage failed because of complete main pancreatic duct disruption. Second, we performed endoscopic ultrasound-guided drainage. After transmural drainage, the inflammation improved and stenting for the AAA was performed successfully. The inflammation was resolved, and he has been free from infection for more than 2 years after the procedure.
CONCLUSION This case highlights the importance of continued follow-up of patients for recurrence after the treatment of WON with pancreatic transection.
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Affiliation(s)
- Reiko Yamada
- Department of Gastroenterology and Hepatology, Mie University Graduate School of Medicine, Tsu, Mie 514-8507, Japan
| | - Yuhei Umeda
- Department of Gastroenterology and Hepatology, Mie University Graduate School of Medicine, Tsu, Mie 514-8507, Japan
| | - Yasunori Shiono
- Department of Gastroenterology and Hepatology, Mie University Graduate School of Medicine, Tsu, Mie 514-8507, Japan
| | - Hiroaki Okuse
- Department of Gastroenterology and Hepatology, Mie University Graduate School of Medicine, Tsu, Mie 514-8507, Japan
| | - Naoki Kuroda
- Department of Gastroenterology and Hepatology, Mie University Graduate School of Medicine, Tsu, Mie 514-8507, Japan
| | - Junya Tsuboi
- Department of Endoscopy, Mie University Graduate School of Medicine, Tsu, Mie 514-8507, Japan
| | - Hiroyuki Inoue
- Department of Gastroenterology and Hepatology, Mie University Graduate School of Medicine, Tsu, Mie 514-8507, Japan
| | - Yasuhiko Hamada
- Department of Endoscopy, Mie University Graduate School of Medicine, Tsu, Mie 514-8507, Japan
| | - Kyosuke Tanaka
- Department of Endoscopy, Mie University Graduate School of Medicine, Tsu, Mie 514-8507, Japan
| | - Noriyuki Horiki
- Department of Endoscopy, Mie University Graduate School of Medicine, Tsu, Mie 514-8507, Japan
| | - Yoshiyuki Takei
- Department of Gastroenterology and Hepatology, Mie University Graduate School of Medicine, Tsu, Mie 514-8507, Japan
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Trikudanathan G, Wolbrink DRJ, van Santvoort HC, Mallery S, Freeman M, Besselink MG. Current Concepts in Severe Acute and Necrotizing Pancreatitis: An Evidence-Based Approach. Gastroenterology 2019; 156:1994-2007.e3. [PMID: 30776347 DOI: 10.1053/j.gastro.2019.01.269] [Citation(s) in RCA: 244] [Impact Index Per Article: 40.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/08/2018] [Revised: 01/01/2019] [Accepted: 01/15/2019] [Indexed: 02/07/2023]
Abstract
The incidence of acute pancreatitis continues to rise, inducing substantial medical and social burden, with annual costs exceeding $2 billion in the United States alone. Although most patients develop mild pancreatitis, 20% develop severe and/or necrotizing pancreatitis, requiring advanced medical and interventional care. Morbidity resulting from local and systemic complications as well as invasive interventions result in mortality rates historically as high as 30%. There has been substantial evolution of strategies for interventions in recent years, from open surgery to minimally invasive surgical and endoscopic step-up approaches. In contrast to the advances in invasive procedures for complications, early management still lacks curative options and consists of adequate fluid resuscitation, analgesics, and monitoring. Many challenges remain, including comprehensive management of the entire spectrum of the disease, which requires close involvement of multiple disciplines at specialized centers.
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Affiliation(s)
- Guru Trikudanathan
- Division of Gastroenterology, Hepatology and Nutrition, University of Minnesota, Minneapolis, Minnesota.
| | | | - Hjalmar C van Santvoort
- Department of Surgery, the University Medical Center Utrecht and the St. Antonius Hospital Nieuwegein, the Netherlands
| | - Shawn Mallery
- Division of Gastroenterology, Hepatology and Nutrition, University of Minnesota, Minneapolis, Minnesota
| | - Martin Freeman
- Division of Gastroenterology, Hepatology and Nutrition, University of Minnesota, Minneapolis, Minnesota
| | - Marc G Besselink
- Department of Surgery, Amsterdam Gastroenterology and Metabolism, Amsterdam UMC, University of Amsterdam, the Netherlands
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Bang JY, Arnoletti JP, Holt BA, Sutton B, Hasan MK, Navaneethan U, Feranec N, Wilcox CM, Tharian B, Hawes RH, Varadarajulu S. An Endoscopic Transluminal Approach, Compared With Minimally Invasive Surgery, Reduces Complications and Costs for Patients With Necrotizing Pancreatitis. Gastroenterology 2019; 156:1027-1040.e3. [PMID: 30452918 DOI: 10.1053/j.gastro.2018.11.031] [Citation(s) in RCA: 216] [Impact Index Per Article: 36.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/28/2018] [Revised: 10/31/2018] [Accepted: 11/12/2018] [Indexed: 02/08/2023]
Abstract
BACKGROUND & AIMS Infected necrotizing pancreatitis is a highly morbid disease with poor outcomes. Intervention strategies have progressed from open necrosectomy to minimally invasive approaches. We compared outcomes of minimally invasive surgery vs endoscopic approaches for patients with infected necrotizing pancreatitis. METHODS We performed a single-center, randomized trial of 66 patients with confirmed or suspected infected necrotizing pancreatitis who required intervention from May 12, 2014, through March 24, 2017. Patients were randomly assigned to groups that received minimally invasive surgery (laparoscopic or video-assisted retroperitoneal debridement, depending on location of collection, n = 32) or an endoscopic step-up approach (transluminal drainage with or without necrosectomy, n = 34). The primary endpoint was a composite of major complications (new-onset multiple organ failure, new-onset systemic dysfunction, enteral or pancreatic-cutaneous fistula, bleeding and perforation of a visceral organ) or death during 6 months of follow-up. RESULTS The primary endpoint occurred in 11.8% of patients who received the endoscopic procedure and 40.6% of patients who received the minimally invasive surgery (risk ratio 0.29; 95% confidence interval 0.11-0.80; P = .007). Although there was no significant difference in mortality (endoscopy 8.8% vs surgery 6.3%; P = .999), none of the patients assigned to the endoscopic approach developed enteral or pancreatic-cutaneous fistulae compared with 28.1% of the patients who underwent surgery (P = .001). The mean number of major complications per patient was significantly higher in the surgery group (0.69 ± 1.03) compared with the endoscopy group (0.15 ± 0.44) (P = .007). The physical health scores for quality of life at 3 months was better with the endoscopic approach (P = .039) and mean total cost was lower ($75,830) compared with $117,492 for surgery (P = .039). CONCLUSIONS In a randomized trial of 66 patients, an endoscopic transluminal approach for infected necrotizing pancreatitis, compared with minimally invasive surgery, significantly reduced major complications, lowered costs, and increased quality of life. Clinicaltrials.gov no: NCT02084537.
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Affiliation(s)
- Ji Young Bang
- Center for Interventional Endoscopy, Florida Hospital, Orlando, Florida
| | | | - Bronte A Holt
- Center for Interventional Endoscopy, Florida Hospital, Orlando, Florida
| | - Bryce Sutton
- Center for Interventional Endoscopy, Florida Hospital, Orlando, Florida
| | - Muhammad K Hasan
- Center for Interventional Endoscopy, Florida Hospital, Orlando, Florida
| | | | | | - C Mel Wilcox
- Division of Gastroenterology-Hepatology, University of Alabama at Birmingham, Birmingham, Alabama
| | - Benjamin Tharian
- Center for Interventional Endoscopy, Florida Hospital, Orlando, Florida
| | - Robert H Hawes
- Center for Interventional Endoscopy, Florida Hospital, Orlando, Florida
| | - Shyam Varadarajulu
- Center for Interventional Endoscopy, Florida Hospital, Orlando, Florida.
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24
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Boxhoorn L, Fockens P, Besselink MG, Bruno MJ, van Hooft JE, Verdonk RC, Voermans RP. Endoscopic Management of Infected Necrotizing Pancreatitis: an Evidence-Based Approach. CURRENT TREATMENT OPTIONS IN GASTROENTEROLOGY 2018; 16:333-344. [PMID: 30030678 PMCID: PMC6153579 DOI: 10.1007/s11938-018-0189-8] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
PURPOSE OF REVIEW Endoscopic management of infected necrotizing pancreatitis has evolved rapidly over the past years and there have been interesting innovations in this field. This review provides an update on the most recently published literature regarding endoscopic management of infected necrotizing pancreatitis. RECENT FINDINGS A recent randomized trial demonstrated no difference in mortality and major morbidity between endoscopic and surgical step-up treatment of infected necrotizing pancreatitis. However, endoscopic therapy resulted in shorter hospital stay and less pancreatic fistulas. Various innovations have been investigated with the aim to further optimize endoscopic therapy, in particular lumen-apposing metal stents. While major stent-related complications were also reported, findings from recent studies indicated that their use was associated with higher resolution rates of walled-off necrosis compared to double-pigtail stents. Other innovations, such as the multiple gateway technique and dual-modality mode, can be considered for treatment of particular cases. Furthermore, research suggests that irrigation of walled-off necrosis can be performed by using a nasocystic tube and discontinuation of proton-pump inhibitors may be considered. Endoscopic treatment should be the preferred treatment modality in patients with infected necrotizing pancreatitis who are eligible for endoscopic drainage. Although data suggests that lumen-apposing metal stents are superior to double-pigtail stents, prospective multicenter studies focusing on safety as well as long-term follow-up are first needed.
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Affiliation(s)
- Lotte Boxhoorn
- Department of Gastroenterology & Hepatology, Amsterdam Gastroenterology and Metabolism, Amsterdam UMC, University of Amsterdam, Meibergdreef 9, 1105 AZ, Amsterdam, the Netherlands
| | - Paul Fockens
- Department of Gastroenterology & Hepatology, Amsterdam Gastroenterology and Metabolism, Amsterdam UMC, University of Amsterdam, Meibergdreef 9, 1105 AZ, Amsterdam, the Netherlands
| | - Marc G Besselink
- Department of Surgery, Amsterdam Gastroenterology and Metabolism, Amsterdam UMC, University of Amsterdam, Meibergdreef 9, Amsterdam, 1105 AZ, the Netherlands
| | - Marco J Bruno
- Department of Gastroenterology & Hepatology, Erasmus MC University Medical Center, Rotterdam, the Netherlands
| | - Jeanin E van Hooft
- Department of Gastroenterology & Hepatology, Amsterdam Gastroenterology and Metabolism, Amsterdam UMC, University of Amsterdam, Meibergdreef 9, 1105 AZ, Amsterdam, the Netherlands
| | - Robert C Verdonk
- Department of Gastroenterology & Hepatology, St. Antonius Hospital, Nieuwegein, the Netherlands
| | - Rogier P Voermans
- Department of Gastroenterology & Hepatology, Amsterdam Gastroenterology and Metabolism, Amsterdam UMC, University of Amsterdam, Meibergdreef 9, 1105 AZ, Amsterdam, the Netherlands.
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Bang JY, Wilcox CM, Navaneethan U, Hasan MK, Peter S, Christein J, Hawes R, Varadarajulu S. Impact of Disconnected Pancreatic Duct Syndrome on the Endoscopic Management of Pancreatic Fluid Collections. Ann Surg 2018; 267:561-568. [PMID: 27849658 DOI: 10.1097/sla.0000000000002082] [Citation(s) in RCA: 91] [Impact Index Per Article: 13.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
OBJECTIVE To study the effect of disconnected pancreatic duct syndrome (DPDS) on endoscopic management of pancreatic fluid collections (PFCs). BACKGROUND Data on the impact of DPDS in patients undergoing endoscopic treatment of PFCs are limited. METHODS Retrospective study of patients undergoing endoscopic drainage of PFCs from 2003 to 2015. If treatment response was suboptimal following initial endoscopic or endoscopic ultrasound-guided transmural drainage, hybrid interventions (endoscopic ultrasound-guided multigate/dual modality technique, endoscopic/percutaneous sinus tract necrosectomy) were performed. Transmural stents were left permanently in situ in DPDS patients from 2008 onwards. Main outcome measures were to evaluate the effect of DPDS on need for hybrid treatment, reinterventions, rescue surgery, length of stay, and overall treatment success. RESULTS Of 361 patients, 34 (9.4%) were acute collections, 178 (49.3%) pseudocysts, and 149 (41.3%) walled-off necrosis (WON). DPDS was present in 167 (46.3%) patients, absent in 124 (34.3%), unknown in 70 (19.4%), and occurred more frequently in WON compared to other PFCs (68.3% vs 31.7%; P < 0.001). Although there was no difference in treatment success, more patients with DPDS required hybrid treatment (31.1% vs 4.8%, P < 0.001), reinterventions (30% vs 18.5%, P = 0.03), rescue-surgery (13.2% vs 4.8%, P = 0.02), and longer length of stay [median (interquartile range) days, 3 (2-10) vs 2 (1-4), P = 0.003]. PFC recurrence was lower in patients with DPDS with permanent transmural stents (17.4% vs 1.7%, P < 0.001). On multivariate logistic regression, DPDS [odds ratio (OR) 2.99], WON (OR 3.37), PFC size of 100 mm or more (OR 2.66), and multiple PFCs (OR 10.6) were associated with need for hybrid treatment. CONCLUSIONS DPDS has a significant effect on endoscopic management of PFCs as more patients required hybrid treatment, reinterventions, and rescue surgery for achieving optimal clinical outcomes.
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Affiliation(s)
- Ji Young Bang
- Center for Interventional Endoscopy, Florida Hospital, Orlando, FL
| | - Charles Melbern Wilcox
- Division of Gastroenterology and Hepatology, University of Alabama at Birmingham, Birmingham, AL
| | | | - Muhammad K Hasan
- Center for Interventional Endoscopy, Florida Hospital, Orlando, FL
| | - Shajan Peter
- Division of Gastroenterology and Hepatology, University of Alabama at Birmingham, Birmingham, AL
| | - John Christein
- Department of Surgery, University of Alabama at Birmingham, Birmingham, AL
| | - Robert Hawes
- Center for Interventional Endoscopy, Florida Hospital, Orlando, FL
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