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Luo J, Zhang SW, He JL, Tian LX, Peng X, Nie XB, Ye SS, Zuo Y, Lin H, Bai JY, Liu E, Yang SM, Fan CQ. Selection strategy for endoscopic necrosectomy approaches of infected walled-off pancreatic necrosis: Analysis of 101 patients from a single center with long-term follow-up. J Dig Dis 2024; 25:525-536. [PMID: 39227029 DOI: 10.1111/1751-2980.13310] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/08/2024] [Revised: 06/20/2024] [Accepted: 08/07/2024] [Indexed: 09/05/2024]
Abstract
OBJECTIVES Endoscopic necrosectomy (EN) is a promising minimally invasive approach for treating infected walled-off pancreatic necrosis (WOPN). Multiple EN approaches are currently available, though criteria for selecting the optimal approaches are lacking. We aimed to propose a rational selection strategy of EN and to retrospectively evaluate its safety and effectiveness. METHODS Altogether 101 patients who underwent EN for infected WOPN at a tertiary hospital between June 2009 and February 2023 were retrospectively included for analysis. Demographic characteristics, details of the EN procedures, procedure-related adverse events, and clinical outcomes were investigated. RESULTS Among these 101 patients with WOPN, 56 (55.4%) underwent transluminal EN, 38 (37.6%) underwent percutaneous EN, and seven (6.9%) underwent combined approach, respectively. Clinical success was achieved in 94 (93.1%) patients. Seven (6.9%) experienced procedure-related adverse events, and seven (6.9%) died during the treatment period. During a median follow-up of 50 months, 5 (5.3%) of the 94 patients had disease recurrence, 17.0% (16/94) had new-onset diabetes mellitus, and 6.4% (6/94) needed oral pancreatic enzyme supplementation. The clinical success rate, procedure-related adverse event rate, and long-term follow-up outcomes were not significantly different among the three groups. High APACHE-II scores (≥15) and organ failure were identified as factors related to treatment failure. CONCLUSIONS A selection strategy for EN approaches, based on the extent of necrosis and its distance from the gastrointestinal lumen (using a threshold of 15 mm), is safe and effective for treating infected WOPN in both short-term and long-term outcomes.
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Affiliation(s)
- Jie Luo
- Department of Gastroenterology, Xinqiao Hospital, Army Medical University, Chongqing, China
| | - Sheng Wei Zhang
- Department of Gastroenterology, Xinqiao Hospital, Army Medical University, Chongqing, China
| | - Jia Lin He
- Department of Gastroenterology, Xinqiao Hospital, Army Medical University, Chongqing, China
| | - Li Xing Tian
- Department of Gastroenterology, Xinqiao Hospital, Army Medical University, Chongqing, China
| | - Xue Peng
- Department of Gastroenterology, Xinqiao Hospital, Army Medical University, Chongqing, China
| | - Xu Biao Nie
- Department of Gastroenterology, Xinqiao Hospital, Army Medical University, Chongqing, China
| | - Shao Song Ye
- Department of Gastroenterology, Xinqiao Hospital, Army Medical University, Chongqing, China
| | - Ying Zuo
- Department of Gastroenterology, Xinqiao Hospital, Army Medical University, Chongqing, China
| | - Hui Lin
- Department of Epidemiology, Army Medical University, Chongqing, China
| | - Jian Ying Bai
- Department of Gastroenterology, Xinqiao Hospital, Army Medical University, Chongqing, China
| | - En Liu
- Department of Gastroenterology, Xinqiao Hospital, Army Medical University, Chongqing, China
| | - Shi Ming Yang
- Department of Gastroenterology, Xinqiao Hospital, Army Medical University, Chongqing, China
| | - Chao Qiang Fan
- Department of Gastroenterology, Xinqiao Hospital, Army Medical University, Chongqing, China
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Binda C, Perini B, Coluccio C, Giuffrida P, Fabbri S, Gibiino G, Vizzuso A, Giampalma E, Fabbri C. Metal stent and percutaneous endoscopic necrosectomy as dual approach for the management of complex walled-off pancreatic necrosis. Minerva Surg 2024; 79:183-196. [PMID: 38127434 DOI: 10.23736/s2724-5691.23.10132-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/23/2023]
Abstract
Pancreatic fluid collections (PFCs) are one of the local complications of acute pancreatitis and include walled-off pancreatic necrosis (WOPN), which are complex entities with challenging management. The infection of pancreatic necrosis leads to a poorer prognosis, with a growth of the mortality rate up to 30%. The primary strategy for managing PFCs is a minimally invasive step-up approach, with endosonography-guided transmural drainage and debridement as the preferred and less invasive method. Percutaneous drainage (PCD) can be the technique of choice when endoscopic drainage is not feasible, for example for early PFCs without a mature wall or for the anatomic location and extension to the paracolic gutter of the collection. As PCD alone may be ineffective, especially when a great amount of necrosis is present, a percutaneous endoscopic necrosectomy (PEN) has been proposed, showing interesting results. The technique consists of the placement of an esophageal fully or partially covered self-expandable metal stent (SEMS) percutaneously into the collection and a direct debridement can be performed using a flexible endoscope through the SEMS. In this review, we will discuss about the role of metal stent and PEN for the management of complex walled-off pancreatic necrosis.
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Affiliation(s)
- Cecilia Binda
- Unit of Gastroenterology and Digestive Endoscopy, Forlì-Cesena Hospitals, AUSL Romagna, Forlì-Cesena, Italy
| | - Barbara Perini
- Unit of Gastroenterology and Digestive Endoscopy, Forlì-Cesena Hospitals, AUSL Romagna, Forlì-Cesena, Italy -
- Department of Surgery, Oncology and Gastroenterology (DISCOG), University Hospital of Padua, Padua, Italy
| | - Chiara Coluccio
- Unit of Gastroenterology and Digestive Endoscopy, Forlì-Cesena Hospitals, AUSL Romagna, Forlì-Cesena, Italy
| | - Paolo Giuffrida
- Unit of Gastroenterology and Digestive Endoscopy, Forlì-Cesena Hospitals, AUSL Romagna, Forlì-Cesena, Italy
- Section of Gastroenterology and Hepatology, Department of Health Promotion Sciences Maternal and Infant Care, Internal Medicine and Medical Specialties, PROMISE, University of Palermo, Palermo, Italy
| | - Stefano Fabbri
- Unit of Gastroenterology and Digestive Endoscopy, Forlì-Cesena Hospitals, AUSL Romagna, Forlì-Cesena, Italy
| | - Giulia Gibiino
- Unit of Gastroenterology and Digestive Endoscopy, Forlì-Cesena Hospitals, AUSL Romagna, Forlì-Cesena, Italy
| | - Antonio Vizzuso
- Unit of Radiology, Morgagni-Pierantoni Hospital, AUSL Romagna, Forlì, Italy
| | - Emanuela Giampalma
- Unit of Radiology, Morgagni-Pierantoni Hospital, AUSL Romagna, Forlì, Italy
| | - Carlo Fabbri
- Unit of Gastroenterology and Digestive Endoscopy, Forlì-Cesena Hospitals, AUSL Romagna, Forlì-Cesena, Italy
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Onnekink AM, Boxhoorn L, Timmerhuis HC, Bac ST, Besselink MG, Boermeester MA, Bollen TL, Bosscha K, Bouwense SAW, Bruno MJ, van Brunschot S, Cappendijk VC, Consten ECJ, Dejong CH, Dijkgraaf MGW, van Eijck CHJ, Erkelens WG, van Goor H, van Grinsven J, Haveman JW, van Hooft JE, Jansen JM, van Lienden KP, Meijssen MAC, Nieuwenhuijs VB, Poley JW, Quispel R, de Ridder RJ, Römkens TEH, van Santvoort HC, Scheepers JJ, Schwartz MP, Seerden T, Spanier MBW, Straathof JWA, Timmer R, Venneman NG, Verdonk RC, Vleggaar FP, van Wanrooij RL, Witteman BJM, Fockens P, Voermans RP. Endoscopic Versus Surgical Step-Up Approach for Infected Necrotizing Pancreatitis (ExTENSION): Long-term Follow-up of a Randomized Trial. Gastroenterology 2022; 163:712-722.e14. [PMID: 35580661 DOI: 10.1053/j.gastro.2022.05.015] [Citation(s) in RCA: 40] [Impact Index Per Article: 13.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/23/2021] [Revised: 05/02/2022] [Accepted: 05/11/2022] [Indexed: 01/02/2023]
Abstract
BACKGROUND & AIMS Previous randomized trials, including the Transluminal Endoscopic Step-Up Approach Versus Minimally Invasive Surgical Step-Up Approach in Patients With Infected Pancreatic Necrosis (TENSION) trial, demonstrated that the endoscopic step-up approach might be preferred over the surgical step-up approach in patients with infected necrotizing pancreatitis based on favorable short-term outcomes. We compared long-term clinical outcomes of both step-up approaches after a period of at least 5 years. METHODS In this long-term follow-up study, we reevaluated all clinical data on 83 patients (of the originally 98 included patients) from the TENSION trial who were still alive after the initial 6-month follow-up. The primary end point, similar to the TENSION trial, was a composite of death and major complications. Secondary end points included individual major complications, pancreaticocutaneous fistula, reinterventions, pancreatic insufficiency, and quality of life. RESULTS After a mean follow-up period of 7 years, the primary end point occurred in 27 patients (53%) in the endoscopy group and in 27 patients (57%) in the surgery group (risk ratio [RR], 0.93; 95% confidence interval [CI], 0.65-1.32; P = .688). Fewer pancreaticocutaneous fistulas were identified in the endoscopy group (8% vs 34%; RR, 0.23; 95% CI, 0.08-0.83). After the initial 6-month follow-up, the endoscopy group needed fewer reinterventions than the surgery group (7% vs 24%; RR, 0.29; 95% CI, 0.09-0.99). Pancreatic insufficiency and quality of life did not differ between groups. CONCLUSIONS At long-term follow-up, the endoscopic step-up approach was not superior to the surgical step-up approach in reducing death or major complications in patients with infected necrotizing pancreatitis. However, patients assigned to the endoscopic approach developed overall fewer pancreaticocutaneous fistulas and needed fewer reinterventions after the initial 6-month follow-up. Netherlands Trial Register no: NL8571.
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Affiliation(s)
- Anke M Onnekink
- Department of Gastroenterology and Hepatology, Amsterdam UMC, location University of Amsterdam, Amsterdam, the Netherlands; Amsterdam Gastroenterology Endocrinology Metabolism, Amsterdam UMC, Amsterdam, the Netherlands; Department of Research and Development, St. Antonius Hospital, Nieuwegein, the Netherlands
| | - Lotte Boxhoorn
- Department of Gastroenterology and Hepatology, Amsterdam UMC, location University of Amsterdam, Amsterdam, the Netherlands; Amsterdam Gastroenterology Endocrinology Metabolism, Amsterdam UMC, 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
| | - Simon T Bac
- Amsterdam Gastroenterology Endocrinology Metabolism, Amsterdam UMC, Amsterdam, the Netherlands
| | - Marc G Besselink
- Amsterdam Gastroenterology Endocrinology Metabolism, Amsterdam UMC, Amsterdam, the Netherlands; Department of Surgery, Amsterdam UMC, location University of Amsterdam, Amsterdam, the Netherlands
| | - Marja A Boermeester
- Amsterdam Gastroenterology Endocrinology Metabolism, Amsterdam UMC, Amsterdam, the Netherlands; Department of Surgery, Amsterdam UMC, location University of Amsterdam, Amsterdam, the Netherlands
| | - Thomas L Bollen
- Department of Radiology, St. Antonius Hospital, Nieuwegein, the Netherlands
| | - Koop Bosscha
- Department of Surgery, Jeroen Bosch Hospital, 's-Hertogenbosch, the Netherlands
| | - Stefan A W Bouwense
- Department of Surgery, Maastricht University Medical Center+, Maastricht, the Netherlands
| | - Marco J Bruno
- Department of Gastroenterology and Hepatology, Erasmus MC University Medical Center, Rotterdam, the Netherlands
| | - Sandra van Brunschot
- Department of Research and Development, St. Antonius Hospital, Nieuwegein, the Netherlands
| | - Vincent C Cappendijk
- Department of Radiology, Jeroen Bosch Hospital, 's-Hertogenbosch, the Netherlands
| | - Esther C J Consten
- Department of Gastroenterology and Hepatology, Meander Medical Center, Amersfoort, the Netherlands
| | - Cornelis H Dejong
- Department of Surgery, Maastricht University Medical Center+, Maastricht, the Netherlands
| | - Marcel G W Dijkgraaf
- Amsterdam Gastroenterology Endocrinology Metabolism, Amsterdam UMC, Amsterdam, the Netherlands; Epidemiology and Data Science, Amsterdam UMC, location University of Amsterdam, Amsterdam, the Netherlands
| | - Casper H J van Eijck
- Department of Surgery, Erasmus MC University Medical Center, Rotterdam, the Netherlands
| | - Willemien G Erkelens
- Department of Gastroenterology and Hepatology, Gelre Hospital, Apeldoorn, the Netherlands
| | - Harry van Goor
- Department of Surgery, Radboudumc, University Medical Center, Nijmegen, the Netherlands
| | - Janneke van Grinsven
- Amsterdam Gastroenterology Endocrinology Metabolism, Amsterdam UMC, Amsterdam, the Netherlands; Department of Surgery, Amsterdam UMC, location University of Amsterdam, Amsterdam, the Netherlands
| | - Jan-Willem Haveman
- Department of Surgery, University Medical Center Groningen, Groningen, the Netherlands
| | - Jeanin E van Hooft
- Department of Gastroenterology and Hepatology, Leiden University Medical Center, Leiden, the Netherlands
| | - Jeroen M Jansen
- Department of Gastroenterology and Hepatology, Onze Lieve Vrouwe Gasthuis (OLVG), Amsterdam, the Netherlands
| | - Krijn P van Lienden
- Department of Radiology, Amsterdam UMC, location University of Amsterdam, Amsterdam, the Netherlands
| | - Maarten A C Meijssen
- Department of Gastroenterology and Hepatology, Isala Clinics, Zwolle, the Netherlands
| | | | - Jan-Werner Poley
- Department of Gastroenterology and Hepatology, Erasmus MC University Medical Center, Rotterdam, the Netherlands
| | - Rutger Quispel
- Department of Gastroenterology and Hepatology, Reinier de Graaf Group, Delft, the Netherlands
| | - Rogier J de Ridder
- Department of Gastroenterology and Hepatology, Maastricht University Medical Center+, Maastricht, the Netherlands
| | - Tessa E H Römkens
- Department of Gastroenterology and Hepatology, Jeroen Bosch Hospital, 's-Hertogenbosch, 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
| | - Joris J Scheepers
- Department of Surgery, Reinier de Graaf Group, Delft, the Netherlands
| | - Matthijs P Schwartz
- Department of Gastroenterology and Hepatology, Meander Medical Center, Amersfoort, the Netherlands
| | - Tom Seerden
- Department of Gastroenterology and Hepatology, Amphia Hospital, Breda, the Netherlands
| | - Marcel B W Spanier
- Department of Gastroenterology and Hepatology, Rijnstate Hospital, Arnhem, the Netherlands
| | - Jan Willem A Straathof
- Department of Gastroenterology and Hepatology, Máxima Medical Center, Veldhoven, the Netherlands
| | - Robin Timmer
- Department of Gastroenterology and Hepatology, St. Antonius Hospital, Nieuwegein, the Netherlands
| | - Niels G Venneman
- Department of Gastroenterology and Hepatology, Medisch Spectrum Twente, Enschede, the Netherlands
| | - Robert C Verdonk
- Department of Gastroenterology and Hepatology, St. Antonius Hospital, Nieuwegein, the Netherlands
| | - Frank P Vleggaar
- Department of Gastroenterology and Hepatology, University Medical Center Utrecht, Utrecht, the Netherlands
| | - Roy L van Wanrooij
- Amsterdam Gastroenterology Endocrinology Metabolism, Amsterdam UMC, Amsterdam, the Netherlands; Department of Gastroenterology and Hepatology, Amsterdam UMC, VU University Amsterdam, Amsterdam Gastroenterology Endocrinology Metabolism, Amsterdam, the Netherlands
| | - Ben J M Witteman
- Department of Gastroenterology and Hepatology, Hospital Gelderse Vallei, Ede, the Netherlands
| | - Paul Fockens
- Department of Gastroenterology and Hepatology, Amsterdam UMC, location University of Amsterdam, Amsterdam, the Netherlands; Amsterdam Gastroenterology Endocrinology Metabolism, Amsterdam UMC, Amsterdam, the Netherlands
| | - Rogier P Voermans
- Department of Gastroenterology and Hepatology, Amsterdam UMC, location University of Amsterdam, Amsterdam, the Netherlands; Amsterdam Gastroenterology Endocrinology Metabolism, Amsterdam UMC, Amsterdam, the Netherlands.
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Vyawahare MA, Gulghane S, Titarmare R, Bawankar T, Mudaliar P, Naikwade R, Timane JM. Percutaneous direct endoscopic pancreatic necrosectomy. World J Gastrointest Surg 2022; 14:731-742. [PMID: 36157371 PMCID: PMC9453331 DOI: 10.4240/wjgs.v14.i8.731] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/09/2022] [Revised: 05/23/2022] [Accepted: 08/05/2022] [Indexed: 02/07/2023] Open
Abstract
Approximately 10%-20% of the cases of acute pancreatitis have acute necrotizing pancreatitis. The infection of pancreatic necrosis is typically associated with a prolonged course and poor prognosis. The multidisciplinary, minimally invasive “step-up” approach is the cornerstone of the management of infected pancreatic necrosis (IPN). Endosonography-guided transmural drainage and debridement is the preferred and minimally invasive technique for those with IPN. However, it is technically not feasible in patients with early pancreatic/peripancreatic fluid collections (PFC) (< 2-4 wk) where the wall has not formed; in PFC in paracolic gutters/pelvis; or in walled off pancreatic necrosis (WOPN) distant from the stomach/duodenum. Percutaneous drainage of these infected PFC or WOPN provides rapid infection control and patient stabilization. In a subset of patients where sepsis persists and necrosectomy is needed, the sinus drain tract between WOPN and skin-established after percutaneous drainage or surgical necrosectomy drain, can be used for percutaneous direct endoscopic necrosectomy (PDEN). There have been technical advances in PDEN over the last two decades. An esophageal fully covered self-expandable metal stent, like the lumen-apposing metal stent used in transmural direct endoscopic necrosectomy, keeps the drainage tract patent and allows easy and multiple passes of the flexible endoscope while performing PDEN. There are several advantages to the PDEN procedure. In expert hands, PDEN appears to be an effective, safe, and minimally invasive adjunct to the management of IPN and may particularly be considered when a conventional drain is in situ by virtue of previous percutaneous or surgical intervention. In this current review, we summarize the indications, techniques, advantages, and disadvantages of PDEN. In addition, we describe two cases of PDEN in distinct clinical situations, followed by a review of the most recent literature.
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Affiliation(s)
- Manoj A Vyawahare
- Department of Medical Gastroenterology, American Oncology Institute at Nangia Specialty Hospital, Nagpur 440028, Maharashtra, India
| | - Sushant Gulghane
- Department of Internal Medicine and Critical Care, American Oncology Institute at Nangia Specialty Hospital, MIDC Hingna, Nagpur 440028, Maharashtra, India
| | - Rajkumar Titarmare
- Department of Anaesthesiology, American Oncology Institute at Nangia Specialty Hospital, MIDC Hingna, Nagpur 440028, Maharashtra, India
| | - Tushar Bawankar
- Department of Anaesthesiology, American Oncology Institute at Nangia Specialty Hospital, MIDC Hingna, Nagpur 440028, Maharashtra, India
| | - Prashant Mudaliar
- Department of Radiology, American Oncology Institute at Nangia Specialty Hospital, MIDC Hingna, Nagpur 440028, Maharashtra, India
| | - Rahul Naikwade
- Department of Surgery, American Oncology Institute at Nangia Specialty Hospital, MIDC Hingna, Nagpur 440028, Maharashtra, India
| | - Jayesh M Timane
- Department of Internal Medicine and Critical Care, American Oncology Institute at Nangia Specialty Hospital, MIDC Hingna, Nagpur 440028, Maharashtra, India
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