Background Direct endoscopic necrosectomy (DEN) for treatment of walled-off pancreatic necrosis (WOPN) has been performed as an alternative to operative or percutaneous therapy. Objective To report ...the largest combined experience of DEN performed for WOPN. Design Retrospective chart review. Setting Six U.S. tertiary medical centers. Patients A total of 104 patients with a history of acute pancreatitis and symptomatic WOPN since 2003. Interventions DEN for WOPN. Main Outcome Measurements Resolution or near-resolution of WOPN without the need for surgical or percutaneous intervention and procedural complications. Results Successful resolution was achieved in 95 of 104 patients (91%). Of the patients in whom it failed, 5 died during follow-up before resolution, 2 underwent operative drainage for persistent WOPN, 1 required surgery for massive bleeding on fistula tract dilation, and 1 died periprocedurally. The mean time to resolution from the initial DEN was 4.1 months. The first débridement was performed a mean of 63 days after the initial onset of acute pancreatitis. In 73%, the entry was transgastric with median tract dilation diameter of 18 mm. The median number of procedures was 3 with 2 débridements. Complications occurred in approximately 14% and included 5 retrogastric perforations/pneumoperitoneum, which were managed nonoperatively. Univariate analysis identified a body mass index >32 as a risk factor for failed DEN. Limitations Retrospective, highly specialized centers. Conclusions This large, multicenter series demonstrates that transmural, minimally invasive endoscopic débridement of WOPN performed in the United States is an efficacious and reproducible technique with an acceptable safety profile.
Background and Aims Certain pancreatic cysts (mucinous cystic neoplasm and side branch intraductal papillary mucinous neoplasm IPMN) have malignant potential and require surveillance. However, ...whether patients with pancreatic cysts have a higher long-term risk of pancreatic cancer (PaCa) has still not been established. Methods This was a retrospective study of Veterans Administration patients. Patients noted to have pancreatic cysts on CT/magnetic resonance imaging (n = 1050) were identified using International Classification of Diseases, Ninth Revision, Clinical Modification codes. Patients aged <15 years (n = 425), patients with <1 year of follow-up (n = 13,259), and patients diagnosed to have PaCa within 1 year of identification of a pancreatic cyst (n = 102) or within 1 year of follow-up in the remaining patients in the database (n = 200) were excluded. Patients with pancreatic cystic lesions (group A, n = 755) and the remaining patients in the database without cysts (group B, n = 520,215) were followed from 1998 to 2007. Results During the study period, in group A and B PaCa was diagnosed in 17 and 1206 patients, respectively, and the incidence rate of PaCa was 5.08 and .32 per 1000 patient-years, respectively. The hazard ratio of PaCa in all patients with cysts was 19.64 (95% CI, 12.12-31.82; P < .0001) when compared with the rest of the patients without cysts. In the subset of patients with cysts, without a history of acute or chronic pancreatitis (n = 241), the hazard ratio of PaCa (n = 5) was 18.80 (95% CI, 7.80-45.31; P < .0001). Conclusion Patients with pancreatic cysts have a significantly higher overall risk of PaCa. The etiologic distribution of cysts in our study patients is not available. Patients with mucinous cystic neoplasm and side branch IPMN are likely to have a higher risk of PaCa than our estimation of risk based on all etiologies.
Placement of percutaneous endoscopic gastrostomy or jejunostomy is a safe procedure with low periprocedural mortality, but overall mortality rates are high because of underlying disease conditions. ...These procedures are also associated with postprocedure complications. The clinically significant adverse events related to the procedures include infection (at tube site and peritonitis), bleeding, and aspiration. More rare associated events include buried bumpers, injury to adjacent viscera with subsequent fistula formation, and tumor seeding. There is a lack of guidelines about these procedures other than those concerning the use of antibiotics and the management of antithrombotics and anticoagulation before the procedure.
Abstract Chronic pancreatitis (CP) is a progressive inflammatory disease, which leads to loss of pancreatic function and other disease-related morbidities. A group of academic physicians and ...scientists developed comprehensive guidance statements regarding the management of CP that include its epidemiology, diagnosis, medical treatment, surgical treatment, and screening. The statements were developed through literature review, deliberation, and consensus opinion. These statements were ultimately used to develop a conceptual framework for the multidisciplinary management of chronic pancreatitis referred to as an academic pancreas center of excellence (APCOE).
Gastropericardial fistula: an unusual case of “heart burn” Mikolajczyk, Adam E., MD; Chapman, Christopher G., MD; Ferguson, Mark K., MD ...
VideoGIE : an official video journal of the American Society for Gastrointestinal Endoscopy,
09/2016, Letnik:
1, Številka:
1
Journal Article
Background Endoscopic closure of inadvertent or intentional colon perforations might be valuable if comparable to surgical closure. Objective The aim of this study was to compare endoscopic closure ...of a 4-cm colon perforation in a porcine model with surgical closure in a multicenter study. Setting University hospitals in the United States and Europe. Design and Interventions After creating a 4-cm linear colon perforation, the animals were randomized to either endoscopic or surgical closure. The total procedure time from the beginning of perforation to the completion of procedure was measured. The animals were euthanized after 2 weeks to evaluate healing, unless there was a complication. Results Fifty-four animals were randomized to either surgical or endoscopic closure of colon perforation. Eight animals developed complications, and 7 of these were euthanized before 2 weeks. Twenty-three animals in each group survived for 2 weeks. Surgical closure of the perforation was successful in all animals in that group, and endoscopic closure was successful in 25 of the 27 animals. The median procedure time was shorter in the surgery group compared to the endoscopy group (35 vs 44 minutes, P = .016). Peritonitis, local adhesions, and leak test results were comparable in both groups. Distant adhesions were less frequent in the endoscopic closure group (26.1% vs 56.5%, P = .03). Five of the 186 T-tags (2.7%) were noted in the adjacent viscera. Limitation This porcine study does not mimic clean colon perforation in humans; it mimics dirty colon perforation in humans. Conclusions Endoscopic closure of a 4-cm colon perforation was comparable to surgery, and this technique can be potentially used for closure of intentional or inadvertent colon perforations.
Background Covered self-expandable metallic stents (SEMSs) are designed to prevent tumor ingrowth and can be removed if necessary. Only limited comparative data are available on the performance of ...covered SEMSs after primary placement versus reintervention. Objective To assess the effectiveness and safety of covered SEMS placement either as primary treatment or reintervention in patients requiring palliation of malignant biliary obstruction. Design Retrospective clinical cohort study. Setting Tertiary referral center. Patients This study involved 104 patients with unresectable malignant biliary strictures. Intervention Covered biliary SEMS placement. Main Outcome Measurements Stent patency, technical success, and patient survival. Results Covered SEMSs were placed as primary treatment in 48 patients (46%), and reintervention was performed in 56 patients (54%). At 3, 6, and 12 months thereafter, the Kaplan-Meier estimated fractions of all patients with patent stents were 94%, 84%, and 58%, respectively. Covered SEMSs remained patent until the patient's death in 75 of 89 nonsurvivors (84%). Although patency rates 3, 6, and 12 months after primary placement (100%, 93%, and 82%, respectively) were higher than those after reintervention (90%, 78%, and 48%, respectively), the differences were not statistically significant ( P = .057). Overall, the most frequent adverse events were cholangitis (7%) and stent migration (4%). Limitations The distribution of stricture locations differed among the groups, and survival data suggested the presence of more extensive disease in the primary treatment group at baseline. Conclusion The clinical utility and safety of primary covered SEMS placement were confirmed. This study provides the most extensive evidence to date that reintervention with a covered SEMS can provide a useful palliative option.
PDF
