Justin Siegal

Combined endoscopic and percutaneous drainage of organized pancreatic necrosis

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. DESIGN Retrospective review of an institutional review board-approved database. SETTING Single North American tertiary referral center. PATIENTS Patients with severe acute pancreatitis complicated by organized necrosis requiring drainage. INTERVENTIONS CT-guided percutaneous drain, followed immediately by endoscopic transenteric drainage. MAIN OUTCOME MEASUREMENTS Development of chronic pancreaticocutaneous fistulae, number of endoscopic procedures requiring follow-up drainage, need for surgical necrosectomy, procedure-related morbidity, and mortality. RESULTS Fifteen patients (12 males, 3 females; mean age, 58 years) underwent combined modality drainage. All procedures were technically successful. Immediate complications included fever and hypotension (n = 2); late complications included parenchymal infection after drain removal (n = 1). Twenty-five total endoscopies (4 for drain manipulation) were performed in the cohort subsequent to the initial drainage. After a median duration of follow-up of 189 days, percutaneous drains were removed in all 13 patients in whom this was attempted; no patients had development of chronic pancreaticocutaneous fistulae. There were no deaths, and no patients required surgery. LIMITATIONS Highly selected patient population, lack of comparison group, single-center experience. CONCLUSIONS In some highly selected patients with infected or symptomatic organized pancreatic necrosis, combined modality drainage results in favorable clinical outcomes with low associated, procedure-related morbidity. Pancreaticocutaneous fistulae and surgical necrosectomy were avoided with minimal endoscopic resource utilization.

Endoscopic and Percutaneous Drainage of Symptomatic Walled-Off Pancreatic Necrosis Reduces Hospital Stay and Radiographic Resources

BACKGROUND & AIMS Walled-off pancreatic necrosis (WOPN), a complication of severe acute pancreatitis (SAP), can become infected, obstruct adjacent structures, and result in clinical deterioration of patients. Patients with WOPN have prolonged hospitalizations, needing multiple radiologic and medical interventions. We compared an established treatment of WOPN, standard percutaneous drainage (SPD), with combined modality therapy (CMT), in which endoscopic transenteric stents were added to a regimen of percutaneous drains. METHODS Symptomatic patients with WOPN between January 2006 and August 2009 were treated with SPD (n = 43, 28 male) or CMT (n = 23, 17 male) and compared by disease severity, length of hospitalization, duration of drainage, complications, and number of radiologic and endoscopic procedures. RESULTS Patient age (59 vs 54 years), sex (77% vs 58% male), computed tomography severity index (8.0 vs 7.2), number of endoscopic retrograde cholangiopancreatographies (2.0 vs 2.6), and percentage with disconnected pancreatic ducts (50% vs 46%) were equivalent in the CMT and SPD arms, respectively. Patients undergoing CMT had significantly decreased length of hospitalization (26 vs 55 days, P < .0026), duration of external drainage (83.9 vs 189 days, P < .002), number of computed tomography scans (8.95 vs 14.3, P < .002), and drain studies (6.5 vs 13, P < .0001). Patients in the SPD arm had more complications. CONCLUSIONS For patients with symptomatic WOPN, CMT provided a more effective and safer management technique, resulting in shorter hospitalizations and fewer radiologic procedures than SPD.

Dual Modality Drainage for Symptomatic Walled-Off Pancreatic Necrosis Reduces Length of Hospitalization, Radiological Procedures, and Number of Endoscopies Compared to Standard Percutaneous Drainage

BackgroundSymptomatic walled-off pancreatic necrosis (WOPN) treated with dual modality endoscopic and percutaneous drainage (DMD) has been shown to decrease length of hospitalization (LOH) and use of radiological resources in comparison to standard percutaneous drainage (SPD).AimThe aim of this study is to demonstrate that as the cohort of DMD and SPD patients expand, the original conclusions are durable.MethodsThe database of patients receiving treatment for WOPN between January 2006 and April 2011 was analyzed retrospectively.PatientsOne hundred two patients with symptomatic WOPN who had no previous drainage procedures were evaluated: 49 with DMD and 46 with SPD; 7 were excluded due to a salvage procedure.ResultsPatient characteristics including age, sex, etiology of pancreatitis, and severity of disease based on computed tomographic severity index were indistinguishable between the two cohorts. The DMD cohort had shorter LOH, time until removal of percutaneous drains, fewer CT scans, drain studies, and endoscopic retrograde cholangiopancreatography (ERCPs; p < 0.05 for all). There were 12 identifiable complications during DMD, which were successfully treated without the need for surgery. The 30-day mortality in DMD was 4% (one multi-system organ failure and one out of the hospital with congestive heart failure). Three patients receiving SPD had surgery, and three (7%) died in the hospital.ConclusionDMD for symptomatic WOPN reduces LOH, radiological procedures, and number of ERCPs compared to SPD.

Pancreaticocolonic fistulas secondary to severe acute pancreatitis treated by percutaneous drainage: successful nonsurgical outcomes in a single-center case series.

PURPOSE Pancreaticocolonic fistulas (PCFs) are uncommon complications of acute necrotizing pancreatitis (ANP). Studies advocating primary surgical treatment showed severe morbidity and mortality with nonsurgical treatment, with survival rates of approximately 50%. However, a nonsurgical treatment scheme with primary percutaneous drainage and other interventions may show improved outcomes. This retrospective single-center study describes the presentation, diagnosis, course, treatment strategy, and outcome of successfully treated PCFs, with an emphasis on nonsurgical interventions. MATERIALS AND METHODS Twenty patients with PCFs caused by ANP were treated with percutaneous drainage and medical therapy. Additional interventions included endoscopic transenteric drainage and pancreatic duct (PD) stent placement. Surgery was reserved for patients in whom this nonsurgical management failed. RESULTS All PCFs closed during a median follow-up of 56 days (mean, 106 d; range, 13-827 d). Treatment included percutaneous drainage of the PCF-related collection in all patients, PD stents in 60%, transenteric drainage in 15%, and definitive surgery in 15%. Indications for surgery included severe PCF-related symptoms, large feculent peritoneal collection, and colonic stricture. Two patients (10%) died, one of complications of ANP and one of esophageal carcinoma. Additional enteric fistulas were identified in 50% of patients. Median time from the most recent diagnosis of pancreatitis to PCF diagnosis was 89 days (mean, 113 d; range, 13-394 d). CONCLUSIONS A nonsurgical approach to PCFs caused by ANP, including percutaneous drainage and other techniques, yields good survival, with surgery reserved for cases in which this approach fails.

635 Dual Modality Drainage for Infected and Symptomatic Walled off Pancreatic Necrosis: Clinical Outcomes in 98 Consecutive Patients

75 patients (87.2%) had severe disease {Atlanta (1992)}, and persistent organ failure was observed in 30 (34.9%) patients. The mean CT severity index (CTSI) score was 7.4±2.25. Twenty two (25.6%) patients underwent intervention (percutaneous radiologic catheter/ endoscopic drainage) for the local complications. Nine patients (10.5%) succumbed to their illness. Themean plasmaOPN levels on admissionwere 13.6±8.10 ng/mL (normal: 3.58±1.43 ng/mL). The mean CRP levels on admission were 57.8±10.7 mg/L (normal ,10mg/L). Plasma OPN level were significantly higher in patients who developed persistent organ failure (p,0.001), necrosis (p=0.015), CTSI≥7 (P=0.006) and severe pancreatitis (p=0.015) compared to those who did not. However, OPN levels were similar between non survivors & survivors (p=0.733) & those who did & did not require intervention (p=0.968). CRP levels were significantly higher in patients with persistent organ failure (p ,0.001) compared to those who did not (Table 1). However, CRP levels were comparable between survivors & non survivors (p=0.866), with & without necrosis (p=0.986), with and without severe disease (p=0.986) & those who did & did not require intervention (p=0.669) On ROC curve, OPN levels of 12.1 ng/mL could predict necrosis with a sensitivity and specificity of 65% and 64% (AUROC: 0.733), of 12.1 ng/mL could predict severe disease with a sensitivity and specificity of 65% and 64% (AUROC: 0.733), and levels of 16.3 ng/mL could predict POF with a sensitivity and specificity of 66% and 66% (AUROC: 0.721). CRP levels at 57.6 mg/L could predict POF with a sensitivity and specificity of 53% and 54% (AUROC: 0.550). Conclusion: Plasma OPN level at admission is a useful predictor of the severity and complications in AP. Plasma OPN and CRP Levels and Relation to the Outcome Parameters in Acute Pancreatitis