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Gao L, Zhang JZ, Gao K, Zhou J, Li G, Li BQ, Ye B, Ke L, Tong ZH, Li WQ. Management of colonic fistulas in patients with infected pancreatic necrosis being treated with a step-up approach. HPB (Oxford) 2020; 22:1738-1744. [PMID: 32349924 DOI: 10.1016/j.hpb.2020.03.021] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/06/2020] [Revised: 03/15/2020] [Accepted: 03/20/2020] [Indexed: 12/12/2022]
Abstract
BACKGROUND Colonic fistula is a potentially fatal complication in acute necrotizing pancreatitis (ANP), especially in patients with infected pancreatic necrosis (IPN). The aim of this study was to evaluate the feasibility of a step-up approach including percutaneous catheter drainage (PCD) and continuous negative pressure irrigation (CNPI) in a group of patients with colonic fistula. METHODS A retrospective review of a prospectively collected data was performed. Data were extracted for patients complicated by colonic fistula from January 2010 to January 2017. RESULTS A total of 1750 patients were admitted with ANP during the study period. Of these patients, 711 (41%) developed IPN and colonic fistula was present in 132 (19%). A step-up approach was adopted for all patients, with 47% avoiding surgery. The mortality in patients requiring surgery (37%) was higher than that in patients managed non-surgically (19%) constituting an overall mortality rate of 29%. In patients managed conservatively, 92% had spontaneous closure of the fistula. CONCLUSION Colonic fistula is not a rare complication in ANP occurring in 19% of patients with IPN in the current study. A step-up approach was effective and safe in managing colonic fistula and surgery could be obviated in nearly half of the patients.
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Affiliation(s)
- Lin Gao
- Center of Severe Acute Pancreatitis (CSAP), Department of General Surgery, Jinling Hospital, Medical School of Nanjing University, No. 305 Zhongshan East Road, Nanjing 210002, Jiangsu, China
| | - Jing-Zhu Zhang
- Center of Severe Acute Pancreatitis (CSAP), Department of General Surgery, Jinling Hospital, Medical School of Nanjing University, No. 305 Zhongshan East Road, Nanjing 210002, Jiangsu, China
| | - Kun Gao
- Center of Severe Acute Pancreatitis (CSAP), Department of General Surgery, Jinling Hospital, Medical School of Nanjing University, No. 305 Zhongshan East Road, Nanjing 210002, Jiangsu, China
| | - Jing Zhou
- Center of Severe Acute Pancreatitis (CSAP), Department of General Surgery, Jinling Hospital, Medical School of Nanjing University, No. 305 Zhongshan East Road, Nanjing 210002, Jiangsu, China
| | - Gang Li
- Center of Severe Acute Pancreatitis (CSAP), Department of General Surgery, Jinling Hospital, Medical School of Nanjing University, No. 305 Zhongshan East Road, Nanjing 210002, Jiangsu, China
| | - Bai-Qiang Li
- Center of Severe Acute Pancreatitis (CSAP), Department of General Surgery, Jinling Hospital, Medical School of Nanjing University, No. 305 Zhongshan East Road, Nanjing 210002, Jiangsu, China
| | - Bo Ye
- Center of Severe Acute Pancreatitis (CSAP), Department of General Surgery, Jinling Hospital, Medical School of Nanjing University, No. 305 Zhongshan East Road, Nanjing 210002, Jiangsu, China
| | - Lu Ke
- Center of Severe Acute Pancreatitis (CSAP), Department of General Surgery, Jinling Hospital, Medical School of Nanjing University, No. 305 Zhongshan East Road, Nanjing 210002, Jiangsu, China.
| | - Zhi-Hui Tong
- Center of Severe Acute Pancreatitis (CSAP), Department of General Surgery, Jinling Hospital, Medical School of Nanjing University, No. 305 Zhongshan East Road, Nanjing 210002, Jiangsu, China.
| | - Wei-Qin Li
- Center of Severe Acute Pancreatitis (CSAP), Department of General Surgery, Jinling Hospital, Medical School of Nanjing University, No. 305 Zhongshan East Road, Nanjing 210002, Jiangsu, China
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Yim SK, Kim SH, Seo SY, Yang HC, Lee SO. Feasibility of Adopting the "Step-up Approach" in Managing Necrotizing Pancreatitis-induced Pancreatic-colonic Fistula. THE KOREAN JOURNAL OF GASTROENTEROLOGY 2019; 73:365-369. [PMID: 31234628 DOI: 10.4166/kjg.2019.73.6.365] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/01/2019] [Revised: 02/18/2019] [Accepted: 03/10/2019] [Indexed: 11/03/2022]
Abstract
Managing acute pancreatitis is clinically challenging because of the generally poor patient condition, the variety of treatment options depending on the severity and complications, and the uncertainty of outcomes. Recently, the step-up approach, which involves less invasive initial treatment and more invasive subsequent treatment, where necessary, has been proposed as the mainstay of managing pancreatitis. This paper presents a case of a 57-year-old man with severe acute pancreatitis, who developed an unexpected fistula in the rectum, which was treated successfully using the step-up approach. In managing this case, the authors faced clinical challenges in determining the infection of necrotic tissue in the early phase of the disease, the optimal timing and method of drainage, and the fistula closure or repair technique. Successful management of this case using the step-up approach validated current recommendations and suggests that it is a reasonable treatment strategy for pancreatic-colonic fistulas. This case also highlights the importance of an awareness that pancreatitis-associated complications can develop in an unexpected manner.
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Affiliation(s)
- Sung Kyun Yim
- Division of Gastroenterology, Department of Internal Medicine, Biomedical Research Institute, Chonbuk National University Hospital, Jeonju, Korea
| | - Seong Hun Kim
- Division of Gastroenterology, Department of Internal Medicine, Biomedical Research Institute, Chonbuk National University Hospital, Jeonju, Korea
| | - Seung Young Seo
- Division of Gastroenterology, Department of Internal Medicine, Biomedical Research Institute, Chonbuk National University Hospital, Jeonju, Korea
| | - Hee Chan Yang
- Division of Gastroenterology, Department of Internal Medicine, Biomedical Research Institute, Chonbuk National University Hospital, Jeonju, Korea
| | - Seung Ok Lee
- Division of Gastroenterology, Department of Internal Medicine, Biomedical Research Institute, Chonbuk National University Hospital, Jeonju, Korea
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Lünse S, Höhn J, Glitsch A, Keßler W, Simon P, Heidecke CD, Schreiber A. Over-the-Scope Clip Closure of Pancreatico-Colonic Fistula Secondary to Acute or Chronic Pancreatitis: A Case Series. J Laparoendosc Adv Surg Tech A 2019; 29:1000-1004. [PMID: 31070500 DOI: 10.1089/lap.2019.0166] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/05/2023] Open
Abstract
Introduction: Pancreatico-colonic fistula (PCF) is a rare adverse effect secondary to severe acute or chronic pancreatitis and potentially life-threatening because of abdominal sepsis. Over-the-scope clip (OTSC®) system is a recently developed endoscopic device and has been successfully used for bleeding and perforations of the gastrointestinal tract. We hereby report a series of patients with PCFs in whom OTSC was used. Materials and Methods: From January 2011 to December 2018, we retrospectively collected data on cases of PCFs with endoscopic treatment using the OTSC system. After conservative management, the endoscopic intervention was carried out on patients in deep sedation by single skilled operators. Results: A total of 9 patients were enrolled and patients were treated with 14/6 t-type OTSC. PCF occurred secondary to chronic (n = 5) and acute pancreatitis (n = 4). There were no adverse effects related to the endoscopic procedure itself. Further endoscopic evaluation was performed 8 weeks later and revealed a successful fistula closure in 4 patients with chronic pancreatitis (80%) and in 2 patients with acute pancreatitis (50%). An insufficient fistula closure was observed in 3 cases because of dislocation of the OTSC and an additional surgical procedure was required. Conclusion: The OTSC system seems to be safe and effective in short-term management of PCFs because of acute or chronic pancreatitis in addition to the already established nonsurgical therapy. However, the OTSC closure of PCFs in patients with acute pancreatitis seems to be associated with a higher failure rate. To sum up, more evidence and long-term studies are needed to determine the criteria for the use of OTSC in closure of PCFs owing to acute or chronic pancreatitis.
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Affiliation(s)
- Sebastian Lünse
- 1Department of General Surgery, Visceral, Thoracic and Vascular Surgery, Division of Interdisciplinary Endoscopy, Universitätsmedizin Greifswald, Greifswald, Germany
| | - Johannes Höhn
- 1Department of General Surgery, Visceral, Thoracic and Vascular Surgery, Division of Interdisciplinary Endoscopy, Universitätsmedizin Greifswald, Greifswald, Germany
| | - Anne Glitsch
- 1Department of General Surgery, Visceral, Thoracic and Vascular Surgery, Division of Interdisciplinary Endoscopy, Universitätsmedizin Greifswald, Greifswald, Germany
| | - Wolfram Keßler
- 1Department of General Surgery, Visceral, Thoracic and Vascular Surgery, Division of Interdisciplinary Endoscopy, Universitätsmedizin Greifswald, Greifswald, Germany
| | - Peter Simon
- 2Department of Medicine A, Division of Interdisciplinary Endoscopy, Universitätsmedizin Greifswald, Greifswald, Germany
| | - Claus-Dieter Heidecke
- 1Department of General Surgery, Visceral, Thoracic and Vascular Surgery, Division of Interdisciplinary Endoscopy, Universitätsmedizin Greifswald, Greifswald, Germany
| | - André Schreiber
- 1Department of General Surgery, Visceral, Thoracic and Vascular Surgery, Division of Interdisciplinary Endoscopy, Universitätsmedizin Greifswald, Greifswald, Germany
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Sato K, Takahashi K, Aruga Y, Yamazaki F, Kumaki D, Yamakawa M, Hirano M, Funakoshi K, Terai S. A case of pancreatic pseudocysts accompanied by infection, pseudoaneurysm ruptures, and pseudocystocolonic fistulae. Clin J Gastroenterol 2019; 12:615-620. [PMID: 31016682 DOI: 10.1007/s12328-019-00986-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/26/2019] [Accepted: 04/18/2019] [Indexed: 12/01/2022]
Abstract
Pancreatic pseudocysts (PPs) can be accompanied by infection, pseudoaneurysm ruptures, and fistulae to other organs, which can be fatal without appropriate treatment. Herein, we present the case of an 82-year-old man with PPs accompanied by infection, pseudoaneurysm rupture, and pseudocystocolonic fistula that were managed via multidisciplinary treatment. Computed tomography (CT) revealed two inflamed PPs, one each in the pancreatic head and tail. He was, therefore, diagnosed with infectious PPs. The pancreatic head PP shrunk on endoscopic nasopancreatic drainage (ENPD), but the pancreatic tail PP did not. Endoscopic ultrasound (EUS)-guided transluminal drainage was performed to treat the pancreatic tail PP; his symptoms improved. However, he vomited blood at 14 day post-drainage. Angiography revealed pseudoaneurysm rupture in a left gastric artery branch. After successful angioembolization, he developed hematochezia 2 days later. We suspected re-bleeding of the pseudoaneurysm. The bleeding stopped spontaneously, but CT and radiography revealed the presence of a pseudocystocolonic fistula. Careful follow-up was performed, and he has not had any symptoms at 9 month post-discharge. We managed PP-related complications via ENPD, EUS-guided transluminal drainage, angioembolization, and careful follow-up. Infection, pseudoaneurysm rupture, and pseudocystocolonic fistula are rare, but can occur simultaneously. Therefore, clinicians should consider these complications when treating patients with PPs.
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Affiliation(s)
- Kosuke Sato
- Department of Internal Medicine, Niigata Prefectural Central Hospital, 205 Shinnancho, Joetsu, Niigata, 943-0192, Japan
| | - Kazuya Takahashi
- Department of Internal Medicine, Niigata Prefectural Central Hospital, 205 Shinnancho, Joetsu, Niigata, 943-0192, Japan. .,Division of Gastroenterology and Hepatology, Graduate School of Medical and Dental Sciences, Niigata University, Niigata, Japan.
| | - Yukio Aruga
- Department of Internal Medicine, Niigata Prefectural Central Hospital, 205 Shinnancho, Joetsu, Niigata, 943-0192, Japan
| | - Fusako Yamazaki
- Department of Internal Medicine, Niigata Prefectural Central Hospital, 205 Shinnancho, Joetsu, Niigata, 943-0192, Japan
| | - Daisuke Kumaki
- Department of Internal Medicine, Niigata Prefectural Central Hospital, 205 Shinnancho, Joetsu, Niigata, 943-0192, Japan
| | - Masashi Yamakawa
- Department of Internal Medicine, Niigata Prefectural Central Hospital, 205 Shinnancho, Joetsu, Niigata, 943-0192, Japan
| | - Masaaki Hirano
- Department of Internal Medicine, Niigata Prefectural Central Hospital, 205 Shinnancho, Joetsu, Niigata, 943-0192, Japan
| | - Kazuhiro Funakoshi
- Department of Internal Medicine, Niigata Prefectural Central Hospital, 205 Shinnancho, Joetsu, Niigata, 943-0192, Japan
| | - Shuji Terai
- Division of Gastroenterology and Hepatology, Graduate School of Medical and Dental Sciences, Niigata University, Niigata, Japan
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Colopancreatic Fistula: An Uncommon Complication of Recurrent Acute Pancreatitis. Case Rep Gastrointest Med 2018; 2018:4521632. [PMID: 29785309 PMCID: PMC5892304 DOI: 10.1155/2018/4521632] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/04/2017] [Revised: 01/28/2018] [Accepted: 02/22/2018] [Indexed: 11/24/2022] Open
Abstract
Colonic complications, including colopancreatic fistulas (CPFs), are uncommon after acute and chronic pancreatitis. However, they have been reported and are serious. CPFs are less likely to close spontaneously and are associated with a higher risk of complications. Therefore, more definitive treatment is required that includes surgical and endoscopic options. We present a case of a 62-year-old male patient with a history of heavy alcohol intake and recurrent acute pancreatitis who presented with a 6-month history of watery diarrhea and abdominal pain. His abdominal imaging showed a possible connection between the colon and the pancreas. A further multidisciplinary workup by the gastroenterology and surgery teams, including endoscopic ultrasound, endoscopic retrograde cholangiopancreatography, and colonoscopy, resulted in a diagnosis of CPF. A distal pancreatectomy and left hemicolectomy were performed, and the diagnosis of CPF was confirmed intraoperatively. The patient showed improvement afterward.
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Kwon JC, Kim BY, Kim AL, Kim TH, Park MI, Jung HJ, Lim JH, Jung JK, Kim HS, Lee DW. Pancreatic pseudocystocolonic fistula treated without surgical or endoscopic intervention. World J Gastroenterol 2014; 20:1882-1886. [PMID: 24587667 PMCID: PMC3930988 DOI: 10.3748/wjg.v20.i7.1882] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/11/2013] [Revised: 11/25/2013] [Accepted: 12/13/2013] [Indexed: 02/06/2023] Open
Abstract
We report here a case of pancreatic pseudocystocolic fistula that was treated without surgical or endoscopic intervention. A 76-year-old woman, presenting with a fever and epigastric pain, was referred to our institution. Three months prior to this admission, the patient had been admitted to the hospital for acute pancreatitis. Abdominal computerized tomography (CT) revealed a 9 cm pseudocyst containing air, and a fistular opening was observed via colonoscopy. After colonoscopy, the abdominal pain was slightly improved, the fever subsided and laboratory results showed decreased C-reactive protein levels. The observed improvement was likely due to the cleansing of the bowel, which induced spontaneous drainage from the pseudocyst into the colon. Antibiotic therapy was administered and daily bowel cleansing was performed using a polyethylene glycol solution. After three weeks, a follow-up CT revealed that the size of the pseudocyst had decreased significantly from 9 to 5.3 cm. In addition, laboratory tests were improved. The patient was able to resume a normal diet and was discharged in good overall health from the hospital, without aggravation of the symptoms. A colonoscopy performed 3 mo later and a follow-up CT performed 6 mo later confirmed that both the fistula and pseudocyst had completely disappeared.
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Endoscopic treatment of internal gastrointestinal fistulas with fibrin glue. Surg Laparosc Endosc Percutan Tech 2013; 23:37-40. [PMID: 23386148 DOI: 10.1097/sle.0b013e318277d3cb] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/30/2022]
Abstract
OBJECTIVE Gastrointestinal fistulae are a heterogenous entity originating from various etiologies. When occurring, these fistulae are associated with considerable morbidity and even mortality. One third of the fistulae heal spontaneously and the rest have traditionally required major revisional surgery at a later stage. Even after surgery, the healing rate remains at a level of 75% to 90%. During the last years, gastrointestinal fistulae have been successfully treated endoscopically with fibrin glue. METHODS All (n = 8) consecutive patients with diagnosed internal upper or lower gastrointestinal fistula treated endoscopically with fibrin glue. RESULTS During the minimum follow-up of 11 months, 7 of 8 patients (87.5%) were successfully treated endoscopically, and in only 1 case (12.5%) with a major diagnostic delay, a reoperation was required. CONCLUSIONS Our results support the view that endoscopic treatment with fibrin glue may be considered as a first-line therapy to treat small caliber gastrointestinal fistulas.
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Gray DM, Mullady DK. Attempted endoscopic closure of a pancreaticocolonic fistula with an over-the-scope clip. JOP : JOURNAL OF THE PANCREAS 2012. [PMID: 23183409 DOI: 10.6092/1590-8577/12209] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Subscribe] [Scholar Register] [Indexed: 01/16/2023]
Abstract
CONTEXT Spontaneous development of fistulae is an uncommon complication of acute pancreatitis. Until recently, surgical management has been the standard of care. Endoscopic treatment has been described with hemoclips and glue. CASE REPORT We report a case of a gentleman with a history of recurrent episodes of acute pancreatitis who presented with symptoms correlating with the development of a pancreatic-colonic fistula. Closure of the fistula was attempted with an over-the-scope clip. CONCLUSION More evidence is needed to determine criteria for use of over-the-scope clip in closure of GI and pancreatic fistulae.
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Affiliation(s)
- Darrell M Gray
- Department of Medicine, Washington University School of Medicine. St. Louis, MO, USA.
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