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

Published:September 27, 2010DOI:https://doi.org/10.1016/j.cgh.2010.09.010

      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.

      Keywords

      Abbreviations used in this paper:

      CMT (combined modality therapy), CT (computed tomography), CTSI (CT scoring index), ERCP (endoscopic retrograde cholangiopancreatography), LOH (length of hospitalization), PCF (pancreatic-cutaneous fistula), SAP (severe acute pancreatitis), SPD (standard percutaneous drainage), WOPN (walled-off pancreatic necrosis)
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      References

        • Forsmark C.E.
        • Baillie J.
        AGA institute technical review on acute pancreatitis.
        Gastroenterology. 2007; 132: 2022-2044
        • Baron T.H.
        • Morgan D.E.
        Acute necrotizing pancreatitis.
        N Engl J Med. 1999; 340: 1412-1418
        • Van Santvoort H.C.
        • Besselink M.G.
        • Bakker O.J.
        • et al.
        A step-up approach or open necrosectomy for necrotizing pancreatitis.
        N Engl J Med. 2010; 362: 1491-1502
        • Bradley E.L.
        A fifteen year experience with open drainage for infected pancreatic necrosis.
        Surg Gynecol Obstet. 1993; 177: 215-222
        • Werner J.
        • Feuerbach S.
        • Uhl W.
        • et al.
        Management of acute pancreatitis: from surgery to interventional intensive care.
        Gut. 2005; 54: 426-436
        • Connor S.
        • Neoptolomas J.P.
        Surgery for pancreatic necrosis: “whom, when and what.”.
        World J Gastroenterol. 2004; 10: 1697-1698
        • Freeny P.C.
        • Hauptmann E.
        • Althaus S.J.
        • et al.
        Percutaneous CT-guided catheter drainage of infected acute necrotizing pancreatitis.
        AJR Am J Roentgenol. 1998; 170: 969-975
        • Echenique A.M.
        • Sleeman D.
        • Yrizarry J.
        • et al.
        Percutaneous catheter-directed debridement of infected pancreatic necrosis: results in 20 patients.
        J Vasc Interv Radiol. 1998; 9: 565-571
        • Endlicher E.
        • Feuerbach S.
        • Scholmerich J.
        • et al.
        Long term follow-up of patients with necrotizing pancreatitis treated by percutaneous necrosectomy.
        Hepatogastroenterology. 2003; 50: 2225-2228
        • van Sonnenberg E.
        • Wittich G.R.
        • Chon K.S.
        • et al.
        Percutaneous radiologic drainage of pancreatic abscesses.
        AJR Am J Roentgenol. 1997; 168: 979-984
        • Ross A.
        • Gluck M.
        • Irani S.
        • et al.
        Combined endoscopic and percutaneous drainage of organized pancreatic necrosis.
        Gastrointest Endosc. 2010; 71: 79-84
        • Balthazar E.J.
        • Freeny P.C.
        • van Sonnenberg E.
        Imaging and intervention in acute pancreatitis.
        Radiology. 1994; 193: 297-306
        • Balthazar E.J.
        Acute pancreatitis: assessment of severity with clinical CT evaluation.
        Radiology. 2002; 223: 603-613
        • Connor S.
        • Alexakis N.
        • Raraty Gt
        • et al.
        Early and late complications after pancreatic necrosectomy.
        Surgery. 2005; 137: 499-505
        • Rau B.
        • Uhl W.
        • Buchler M.W.
        • et al.
        Surgical treatment of infected necrosis.
        World J Surg. 1997; 21: 155-161
        • Fernandez-del Castillo C.
        • Rattner D.W.
        • Makary M.A.
        • et al.
        Debridement and closed packing for the treatment of necrotizing pancreatitis.
        Ann Surg. 1998; 5: 676-684
        • Mier J.
        • Luque-deLeon E.
        • Castillo A.
        • et al.
        Early versus late necrosectomy in severe necrotizing pancreatitis.
        Am J Surg. 1997; 173: 71-75
        • Bradley 3rd, E.L.
        • Allen K.
        A prospective longitudinal study of observation versus surgical intervention in the management of necrotizing pancreatitis.
        Am J Surg. 1991; 161: 19-24
        • Beattie G.C.
        • Mason J.
        • Swan D.
        • et al.
        Outcome of necrosectomy in acute pancreatitis: the case for continued vigilance.
        Scand J Gastroenterol. 2002; 12: 1449-1453
        • Chang Y.C.
        • Tsai H.-M.
        • Lin X.-Z.
        • et al.
        No debridement is necessary for symptomatic or infected acute necrotizing pancreatitis.
        Dig Dis Sci. 2006; 51: 1388-1395
        • Parekh D.
        Laparoscopic-assisted pancreatic necrosectomy.
        Arch Surg. 2006; 141: 895-903
        • Carter C.R.
        • McKay C.J.
        • Imri C.W.
        Percutaneous necrosectomy and sinus tract endoscopy in the management of infected pancreatic necrosis: an initial experience.
        Ann Surg. 2000; 232: 175-180
        • Ammori B.J.
        Laparoscopic transgastric pancreatic necrosectomy for infected pancreatic necrosis.
        Surg Endosc. 2002; 16: 1362
        • Connor S.
        • Ghaneh P.
        • Raraty M.
        • et al.
        Minimally invasive retroperitoneal pancreatic necrosectomy.
        Dig Surg. 2003; 20: 270-277
        • Becker V.
        • Huber W.
        • Meining A.
        • et al.
        Infected necrosis in severe pancreatitis: combined nonsurgical multi-drainage with directed transabdominal high volume lavage in critically ill patients.
        Pancreatology. 2009; 9: 280-286
        • Raczynski S.
        • Teich N.
        • Borte G.
        • et al.
        Percutaneous transgastric irrigation drainage in combination with endoscopic necrosectomy in necrotizing pancreatitis (with videos).
        Gastrointest Endosc. 2006; 64: 420-424
        • Gardner T.B.
        • Chahal P.
        • Papachristou G.I.
        • et al.
        A comparison of direct endoscopic necrosectomy with transmural endoscopic drainage for the treatment of walled-off pancreatic necrosis.
        Gastrointest Endosc. 2009; 69: 1085-1094
        • Baron T.H.
        • Thaggard W.G.
        • Morgan D.E.
        • et al.
        Endoscopic therapy for organized pancreatic necrosis.
        Gastroenterology. 1996; 111: 755-764
        • Baron T.H.
        • Morgan D.E.
        Endoscopic transgastric irrigation tube placement via PEG for debridement of organized pancreatic necrosis.
        Gastrointest Endosc. 1999; 50: 574-577
        • Siefert H.
        • Biermer M.
        • Schmitt W.
        • et al.
        Transluminal endoscopic necrosectomy.
        Gut. 2009; 58: 1260-1266
        • Morgan D.E.
        • Ragheb C.M.
        • Lockhart M.E.
        • et al.
        Acute pancreatitis: computed tomography utilization and radiation exposure are related to severity but not patient age.
        Clin Gastroenterol Hepatol. 2010; 8: 303-308
        • Fazel R.
        • Krumholz H.M.
        • Wang Y.
        • et al.
        Exposure to low-dose ionizing radiation from medical imaging procedures.
        N Engl J Med. 2009; 27: 849-857
        • Smith-Bindman R.
        • Lipson J.
        • Marcus R.
        • et al.
        Radiation dose associated with common computed tomography examinations and the associated lifetime attributable risk of cancer.
        Arch Intern Med. 2009; 169: 2078-2086
        • Berrington de Gonzalez A.
        • Mahesh M.
        • Kim K.-P.
        • et al.
        Projected cancer risks from computed tomographic scans performed in the United States in 2007.
        Arch Intern Med. 2009; 169: 2071-2077
        • Amis Jr, E.S.
        • Butler P.F.
        • Applegate K.E.
        • et al.
        American College of Radiology white paper on radiation dose in medicine.
        J Am Coll Radiol. 2007; 4: 272-284