Mehran Fotoohi

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.

Intervention in necrotizing pancreatitis: An evidence-based review of surgical and percutaneous alternatives

Interventional therapy in necrotizing pancreatitis is evolving. Efforts to modify or prevent pancreatic necrosis by intra-arterial infusion of antibiotics and antiproteases have been described. Moreover, traditional approaches to the surgical management of infected pancreatic necrosis are being challenged by a host of endoscopic and percutaneous techniques. While these approaches are potentially valuable additions to interventional therapy in necrotizing pancreatitis, few evidence-based studies are available to support their supplanting more traditional approaches at this time. Cooperative evidence-based multiinstitutional studies will be required to address the validity of these proposals.

Resolving external pancreatic fistulas in patients with disconnected pancreatic duct syndrome: using rendezvous techniques to avoid surgery (with video)

BACKGROUND An external pancreatic fistula (EPF) generally results from an iatrogenic manipulation of a pancreatic fluid collection (PFC), such as walled-off pancreatic necrosis (WOPN). Severe necrotizing pancreatitis can lead to complete duct disruption, causing disconnected pancreatic duct syndrome (DPDS) with viable upstream pancreas draining out of a low-pressure fistula created surgically or by a percutaneous catheter. The EPF can persist for months to years, and distal pancreatectomy, often the only permanent solution, carries a high morbidity and defined mortality. OBJECTIVE To describe 3 endoscopic and percutaneous rendezvous techniques to completely resolve EPFs in the setting of DPDS. DESIGN A retrospective review of a prospective database of 15 patients who underwent rendezvous internalization of EPFs. SETTING Tertiary-care pancreatic referral center. PATIENTS Fifteen patients between October 2002 and October 2011 with EPFs in the setting of DPDS and resolved WOPN. INTERVENTION Three rendezvous techniques that combined endoscopic and percutaneous procedures to internalize EPFs by transgastric, transduodenal, or transpapillary methods. MAIN OUTCOME MEASUREMENTS EPF resolution and morbidity. RESULTS Fifteen patients (12 men) with a median age of 51 years (range 24-65 years) with EPFs and DPDS (cutoff/blowout of pancreatic duct, with inability to demonstrate upstream body/tail of pancreas on pancreatogram) resulting from severe necrotizing pancreatitis underwent 1 of 3 rendezvous procedures to eliminate the EPFs. All patients were either poor surgical candidates or refused surgery. At the time of the rendezvous procedure, WOPN had fully resolved, DPDS was confirmed on pancreatography, and the EPF had persisted for a median of 5 months (range 1-48 months), producing a median output of 200 mL/day (range 50-700 mL/day). The rendezvous technique in 10 patients used the existing percutaneous drainage fistula to puncture into the stomach/duodenum to deliver wires that were captured endoscopically. The transenteric fistula was dilated and two endoprostheses placed into the lesser sac. A second technique was used in 3 patients where EUS was used to avoid large varices and create a fistula to the percutaneous drainage catheter. Wires were delivered transenterally then grasped by an interventional radiologist. The new fistula was dilated, and, again, two endoprostheses were placed. Two patients underwent a rendezvous technique that resulted in transpapillary stents and removal of percutaneous catheters. The median duration to EPF closure was 7 days (range 1-73 days) during a median follow-up of 25 months (range 6-113 months). No EPF has recurred in any patient, although 3 symptomatic fluid collections have occurred. These collections have been successfully treated with combined percutaneous and endoscopic treatment or endoscopic treatment alone. One patient had postprocedural fever. There were no associated deaths. LIMITATIONS Small, selected group of patients without a comparative group. CONCLUSION The management of EPFs in the setting of DPDS is challenging but can be treated effectively by combined endoscopic and percutaneous rendezvous techniques. The rendezvous procedures were associated with minimal morbidity, no mortality, avoidance of surgery, and complete elimination of the EPFs.

A comparison of 50 initial endoluminal endograft repairs for abdominal aortic aneurysm with 50 concurrent open repairs

PURPOSE To review the results of our initial experience with endovascular repair of abdominal aortic aneurysm (AAA) with respect to morbidity and mortality and to compare these outcomes with those of transabdominal repair. METHODS We reviewed the first 50 consecutive endovascular AAA repairs performed at our institution from November 1999 to January 2002. Pre-operative risk factors, intraoperative variables and post-operative outcomes were assessed. All endovascular patients were followed with periodic examination, contrast-enhanced computed tomography and/or duplex scanning. Comparison was made to 50 patients undergoing standard open repair over a similar time period. RESULTS Fifty patients underwent endovascular AAA repair (mean age 72.5, AAA size 5.5 cm). Endovascular devices employed were manufactured by Ancure (Guidant Corp.), and AneuRx (Medtronic). Preoperative risk factors were similar to patients undergoing transabdominal repair. Mean operative time was 169 minutes and estimated blood loss was 450cc with average blood replacement of.18 units. Median ICU stay was 0 days and mean hospital stay was 2.3 nights. There were no conversions to open repair, however there was one aborted endovascular attempt. Morbidity included MI (2%), colon ischemia (1%), acute renal insufficiency (4%) and leg ischemia (4%). There was one death within 30 days. Seven endoleaks were identified (6 type II and 1 type I) and were managed angiographically. CONCLUSIONS The short-term surgical morbidity and mortality rates for endovascular repair of AAA are acceptably low and are comparable to the transabdominal approach.

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