Percutaneous catheter drainage of pancreatic pseudocysts.

Pancreatic pseudocysts represent a complication of severe pancreatic inflammatory disease. Although operative drainage is the cornerstone of therapy for pseudocysts, we have undertaken percutaneous catheter drainage in a selected group of 28 patients over a six-year period (1982-88). This represents 42 per cent of pseudocyst patients managed by the senior author and 1.7 per cent of admissions for pancreatitis at the Medical University Hospitals during that period of time. There were 26 men and two women with an age range of 26-66 years (mean = 42.1). Twenty-six patients had alcohol abuse as the cause of pancreatitis; two were due to surgical trauma. Nondilated pancreatic ducts were demonstrated in 25 patients. Six had pancreatic ascites associated with pseudocysts. Four had previous operative drainage (2 internal and 2 external drainage procedures). Five patients received octreotide acetate, a synthetic peptide which mimics the action of somatostatin, in an attempt to aid closure of external fistulas. The mean length of catheter drainage was 48 days (range 7-210 days). Eight (29%) patients developed procedure-related complications (1 pneumothorax, 1 sheared guidewire, six drain tract infections). There was no mortality. Successful resolution of pseudocysts was achieved in 26 patients (93%). Two patients subsequently had elective caudal pancreaticojejunostomy (CPJ), and one lateral pancreaticojejunostomy (LPJ) to drain obstructed pancreatic ducts. One patient has required repeat external drainage. Percutaneous external drainage is successful in pseudocyst eradication. When underlying pancreatic pathology remains uncorrected, elective surgical decompression of obstructed, dilated ducts may be necessary.     

Changing concepts in the surgical management of pancreatic pseudocysts.

A 27-year experience in the surgical management of 160 patients with pancreatic pseudocysts was reviewed. Sixty-eight patients treated from 1964 to 1981 (Group I) were compared to 92 patients managed from 1982 to 1990 (Group II). During the recent period, computed tomography (CT) scanning, endoscopic retrograde cholangiopancreatography (ERCP), selective visceral angiography, and percutaneous catheter drainage (PCD) techniques were available. The mean age of patients was similar in both groups (45 vs 44 years). Most pseudocysts in both periods represented complications of chronic pancreatitis due to alcohol abuse (82% vs 87%). Pancreatitis-associated complications occurring before management (fistula, obstruction, hemorrhage) were more frequent in Group II (19% vs 40%, P less than .05). There was a significant increase in the number of patients managed with external drainage in Group II (10% vs 52%) attributable to the use of PCD as definitive therapy in 46 per cent of patients in the recent period. Use of internal drainage procedures (cystgastrostomy, cystduodenostomy, cystjejunostomy) decreased in Group II (38% vs 16%, P less than .05). The use of lateral pancreaticojejunostomy (LPJ) combined either with caudal resection or cyst drainage has remained constant in both periods (32% vs 24%, NS). Patient morbidity was similar (26% vs 28%, NS) and mortality improved in Group II (9% vs 1%, P less than .05). Internal or external drainage for pseudocyst is often not definitive because of the underlying ductal disease. The authors' current approach is to manage large symptomatic cysts either with internal drainage or PCD; they employ octreotide acetate in the management of persistent pancreatic fistula following external drainage.(ABSTRACT TRUNCATED AT 250 WORDS)     

Failure of percutaneous catheter drainage of pancreatic pseudocyst

Percutaneous catheter drainage (PCD) of symptomatic pancreatic pseudocysts under CT radiologic guidance is a valuable adjunct or alternative to operative pseudocyst management. PCD failure is characterized by the development of recurrent pseudocysts or external pancreatic fistulas. The purpose of this study is to define the cause and management of PCD failure patients. A retrospective review and analysis of patients with symptomatic pancreatic pseudocysts managed with PCD who required subsequent operative treatment because of PCD failure was undertaken. There were 23 study patients (18 men, 5 women) with a mean age of 44 years identified over a 13-year time period. Pancreatitis etiology was alcohol abuse in 10, gallstones in 7, pancreas divisum in 3, trauma in 2, and sphincter of Oddi dysfunction in 1. Endoscopic retrograde cholangiopancreatography findings were: 13 genu strictures, 4 main pancreatic duct dilations, 2 head strictures, 1 body stricture, 1 stricture in the tail, 1 intact duct, and 1 unknown. Operations used to manage PCD failures were: lateral pancreaticojejunostomy (LPJ) in 9 patients, Roux-en-Y pancreatic fistula jejunostomy in 7, distal pancreatectomy in 3, caudal pancreatectomy in 2, pancreatoduodenectomy in 1, cyst gastrotomy in 1, and caudal pancreatojejunostomy in 1. Follow-up has ranged from 1 to 13 years (mean, 5 years). Five patients who underwent pancreatic fistula jejunostomy developed recurrent pseudocysts or pancreatitis. There have been no recurrent pseudocysts or fistulas in patients managed with LPJ or pancreatic resection. Genu strictures were the cause of PCD failure in the majority of patients. LPJ is the treatment of choice for genu strictures but may not always be possible because of chronic inflammatory changes. Roux-en-Y pancreatic fistula jejunostomy is an acceptable alternative. Recurrent pseudocysts in the head and body are treated with LPJ with cyst incorporation. Pancreatic resection is appropriate for certain strictures of the head, body, and pancreatic tail. Failure of PCD is associated with an underlying ductal disorder that needs to be defined preoperatively with endoscopic retrograde cholangiopancreatography to select the appropriate operation.     

超声引导经皮置管引流治疗重症急性胰腺炎合并感染性坏死

目的：探讨超声引导下经皮置管引流（PCD）治疗重症急性胰腺炎（SAP）合并感染性坏死相关影响因素以及联合胆道镜清创的疗效。 方法：回顾性分析2011年1月—2012年12月以超声引PCD为初始治疗手段的65例SAP合并感染性坏死患者临床资料。 结果：38例（58.5%）仅通过PCD引流治愈,27例（41.5%）需要进一步处理的患者中,4例（6.2%）直接转为开腹手术;23例（35.4%）采取胆道镜引导的腹膜后清创,其中2例因相关并发症转为开腹手术。6例（9.2%）经过PCD或者后续微创/开腹手术治疗后死亡。将单独行PCD治愈的患者与行PCD及后续治疗的患者的资料比较,结果显示,两者的人口学资料、严重度评分、白细胞计数、C反应蛋白及凝血酶原消耗试验等指标差异均无统计学意义（均P>0.05）,首次PCD治疗时间、穿刺引流管管径上差异也均无统计学意义（均P>0.05）,但前者引流管数量多于后者、引流时间长于后者、穿刺相关并发症低于后者,差异具有统计学意义（均P<0.05）。 结论：引流管数量、引流时间、穿刺相关并发症是PCD的影响因素,对于合并感染性坏死的SAP,联合胆道镜清创是安全有效的微创治疗方法。

     

Percutaneous catheter versus open surgical drainage in the treatment of abdominal abscesses

In the past 3 years, percutaneous catheter drainage (PCD) was performed for 24 abdominal and retroperitoneal abscesses while open surgical drainage (OSD) was used for treatment of 24 similar abscesses at the affiliated hospitals of UMDNJ-Rutgers Medical School. Although the method of treatment was arbitrarily selected by the attending physician, the two groups were similar with respect to abscess location, underlying illnesses, and previous operations. In the PCD group, 17 of 24 abscesses developed after operations versus 16 of 24 in the OSD group. Location of abscesses were: PCD group: abdominal (9), renal (5), pelvic (4), subphrenic (3), hepatic (2), pancreatic (1); OSD group: abdominal (10), renal (4), subphrenic (4), pelvic (3), hepatic (2), pancreatic (1). With PCD, the abscesses were localized by ultrasound or computerized tomography scan; a 20- or 22-gauge needle passed into the cavity, followed by progressively larger guide wires, dilators, and catheters; the pus evacuated; and abscess cavity thoroughly irrigated with sterile saline. Percutaneous catheter drainage was successful in 22 of 24 cases. There were two inconsequential complications. The mean post-PCD hospital stay was 11.7 days. With OSD, five patients developed major complications, including three deaths from sepsis. The mean post-OSD stay for surviving patients was 21.2 days. The advantages of PCD versus OSD are: 1) precise noninvasive localization of abscesses, 2) avoidance of general anesthesia, 3) avoidance of major complications, and 4) shorter postdrainage hospital stay. Open surgical drainage should be reserved for cases where PCD fails to control sepsis, close fistulae, or when noninvasive scanning either fails to demonstrate a discrete abscess in the face of intra-abdominal sepsis or identifies an abscess that cannot be percutaneously drained without traversing the bowel.     

Ultrasound-guided percutaneous drainage of infected pancreatic necrosis

Background

The role of percutaneous drainage in the management of infected pancreatic necrosis remains controversial, and ultrasound-guided technique is rarely used for this indication. The purpose of this study was to evaluate the safety and efficacy of sonographically guided percutaneous catheter drainage for infected pancreatic necrosis.

Methods

The patient group consisted of 16 men and 2 women. The mean age of the patients was 47 years. The median computed tomography severity index of acute pancreatitis was 10 points. Percutaneous catheter drainage was performed under sonographic guidance using preferably retroperitoneal approach, and transperitoneal access in selected cases. The medical records and imaging scans were reviewed retrospectively for each patient.

Results

Percutaneous catheter drainage resulted in a complete resolution of infected pancreatic necrosis in 6 of 18 patients (33 %). Twelve of 18 patients who were initially managed with PCD required eventually necrosectomy (67 %). The most common reason for crossover to surgical intervention was persistent sepsis (n = 7). Open necrosectomy was performed in 4 of these patients, and 3 patients underwent successful minimally invasive retroperitoneal necrosectomy. Five patients required conversion to open surgery because of procedure-related complications. In 3 cases, there was leakage of the necrotic material into the peritoneal cavity. Two other patients experienced hemorrhagic complications. Overall mortality rate was 17 %. The size of the largest necrotic collection in patients who were successfully treated with percutaneous drainage decreased by a median of 76 % shortly after the procedure, whereas it decreased only by a median of 16 % in cases of failure of percutaneous drainage.

Conclusions

Ultrasound-guided percutaneous catheter drainage used in infected pancreatic necrosis is a technique with acceptably low morbidity and mortality that may be the definitive treatment or a bridge management to necrosectomy. A negligible decrease in size of the necrotic collection predicts failure of percutaneous drainage.     

Determinants for successful percutaneous image-guided drainage of intra-abdominal abscess

HYPOTHESIS: Characteristics of intra-abdominal abscess can be used to predict successful outcome for percutaneous catheter drainage (PCD). METHODS: We performed a multicenter prospective study of patients who had intra-abdominal infections treated with PCD and intravenous antibiotics. Multivariate regression analysis determined predictors of successful outcome. RESULTS: The study included 96 patients (59% men; mean +/- SD age, 48 +/- 17 years; mean +/- SD Acute Physiology and Chronic Health Evaluation II score, 7.4 +/- 4.9). Postoperative abscess was present in 53% of patients. Isolated microorganisms included Bacteroides species (17%), Escherichia coli (17%), Streptococcus species (14%), Enterococcus species (10%), and fungi (11%). Single abscesses were present in 83% of patients. Computed tomographic guidance was used for drainage in 80% of patients, and ultrasound was used in 20%. The duration of abscess drainage was less than 14 days in 64%. Complete resolution of the infection with a single treatment of PCD was achieved in 67 patients (70%), and with a second attempt in 12 (12%). Thirty-three patients (34%) had PCD for the resolution of intra-abdominal sepsis prior to an elective, definitive procedure. Open drainage as a result of PCD failure was required in 15 (16%) and was more likely in patients with yeast (P<.001) or a pancreatic process (P =.02). Postoperative abscess (P =.04) was an independent predictor of successful outcome. CONCLUSIONS: Percutaneous catheter drainage of intra-abdominal infections was effective with a single treatment in 70% of patients and increased to 82% with a second attempt. A successful outcome is most likely with abscesses that are postoperative, not pancreatic, and not infected with yeast. Percutaneous catheter drainage is now a commonly used staging method for the resolution of intra-abdominal sepsis prior to corrective operation.     

经皮穿刺置管引流在重症急性胰腺炎治疗中应用时机的选择对患者预后影响

目的本研究旨在评估经皮穿刺置管引流(percutaneous catheter drainage,PCD)在重症急性胰腺炎(severe acute pancreatitis,SAP)治疗中应用时机的选择对患者结局和并发症方面的影响。方法回顾性分析2018年1月1日至2018年12月31日德阳市人民医院胰腺中心收治的75例接受PCD治疗的SAP患者的临床资料,研究患者的临床表现、PCD应用时期及其疗效。结果75例SAP患者中液体聚集期(ANC期)51例(68%),包裹坏死形成期(WON期)24例(32%),死亡0例(0%),治愈70例(93.3%),5例(6.7%)行进一步外科治疗。两期的平均PCD放置持续时间、并发症发病率(胰瘘、导管阻塞或脱落、出血)差异无统计学意义(P>0.05)。结论PCD在SAP不同阶段(ANC期和WON期)的应用不影响其安全性和疗效,延迟使用并不能取得较好的疗效。     

Percutaneous catheter drainage of infected pancreatic and peripancreatic fluid collections

Operative drainage is the cornerstone of therapy for pancreatic abscess. Recently it has been suggested that successful percutaneous catheter drainage of infected pancreatic and peripancreatic fluid collections may serve as definitive therapy. We undertook therapeutic, computed tomography-directed percutaneous drainage in a selected group of 29 patients with infected pancreatic and peripancreatic fluid collections. Twenty-three patients (79%) were successfully treated with percutaneous drainage. Of six patients (21%) representing failures of percutaneous drainage, four died and two recovered after operative drainage. The four patients who died had a mean APACHE (acute physiology and chronic health evaluation) II score of 23 and five of Ranson's prognostic signs. Ranson's signs and APACHE II scores were predictive of success and mortality. We conclude that in selected patients, infected pancreatic and peripancreatic fluid collections can be treated definitively with therapeutic percutaneous catheter drainage. Based on this experience, recommendations regarding patient selection are included.     

B 超引导下经皮穿刺置管引流治疗重症急性胰腺炎局部并发症

目的:探讨B超引导下经皮穿刺置管引流(PCD)治疗重症急性胰腺炎(SAP)局部并发症的临床价值。方法:回顾分析2006年1月—2009年10月行B超引导下PCD治疗SAP局部并发症的42例患者的临床资料,其中急性液体积聚14例,无菌性胰腺坏死12例,感染性胰腺坏死9例,包裹性坏死感染1例,胰腺脓肿4例,胰腺假性囊肿2例。并检查穿刺液是否伴感染,观察引流后临床症状、引流效果和影像学的改变。结果:42例中,14例急性液体积聚均治愈(100%),但有2例发生胰周感染,1例出现肠外瘘,无死亡;无菌性胰腺坏死12例中治愈9例(75.0%),3例发生胰腺感染并手术,死亡1例;感染性胰腺坏死9例中治愈2例(22.2%),4例引流效果差而手术,死亡2例,3例放弃治疗;包裹性坏死感染1例PCD后囊内出血急诊手术后死亡;4例胰腺脓肿治愈1例(25.0%),3例中转手术,无死亡。2例胰腺假性囊肿分别于第1,2个月后治愈拔管。结论:B超引导下PCD便捷安全,在治疗SAP不同局部并发症中有着不同的意义。对部分SAP局部并发症,B超引导下PCD可避免传统外科干预。     

Management of peripancreatic fluid collections following partial pancreatectomy: a comparison of percutaneous versus EUS-guided drainage

Background

Peripancreatic fluid collections (PFCs) occur in up to 30 % of patients following partial pancreatic resections. Traditionally, postoperative PFCs are managed via percutaneous drainage (PD). EUS-guided transgastric drainage has been shown to be effective for the management of PFCs secondary to acute pancreatitis. However, there are limited data on the use of EUS-guided drainage (EUSD) for the management of postoperative PFCs.

Objective

To compare the safety and efficacy of PD versus EUSD of PFCs in patients who have undergone partial pancreatic resections.

Design

Retrospective analysis of patients with symptomatic PFCs following pancreatic enucleation or distal pancreatectomy at MSKCC between January 2008 and December 2010. Patients were identified using an electronic medical records query in addition to a prospectively maintained pancreatic surgery complications database.

Setting

Single, academic, tertiary referral center.

Patients

Twenty-three patients with symptomatic PFCs following pancreatic enucleation or distal pancreatectomy were retrospectively identified.

Interventions

CT-guided PD versus endoscopic ultrasound-guided drainage (EUSD)

Main outcome measures

Outcomes included technical success, clinical success, number of interventions, and complications. Technical success was defined as successful localization of the PFC by fine-needle aspiration and placement of a drainage catheter or stent. Clinical success was defined as radiographic resolution of the PFC and removal of the drain or stent, without the need for an alternative drainage procedure or surgery.

Results

PD was initially performed in 14 patients and EUSD initially in 9 patients. Three patients with initial PD had recurrence of PFC after removal of the external drain and underwent subsequent EUSD. The mean size of the fluid collections was 10.0 cm in the PD group and 8.9 cm in the EUSD group. Technical success was achieved in all patients in both groups. Clinical success was achieved in 11 of 14 (79 %) patients in the PD group compared with 11 of 11 (100 %) in the EUSD group, with one patient in the EUSD group lost to follow-up. One patient with initial PD required two additional percutaneous procedures before complete PFC resolution. Five EUSD patients required repeat endoscopy for stent revision or necrosectomy. The median number of interventions was two [range 1–5] in the PD group and two [range 1–5] in the EUSD group. The median number of days the drainage catheters were in place was 44.5 [range 2–87] in the PD group versus 57 [range 32–217] in the EUSD group. There were no procedure-related complications in either group. Adverse events in the PD group included splenic artery stump bleeding, pleural effusion, cysto-colonic and cysto-cutaneous fistulae, and persistent catheter site pain. One patient in the EUSD group developed a small-bowel obstruction and bleeding gastric ulcer.

Limitations

Retrospective, nonrandomized study and small numbers.

Conclusions

EUSD of postoperative PFCs appears to be safe and technically feasible. This technique appears to be as successful as PD for the management of PFCs with the advantage of not requiring an external drainage apparatus and should be considered as a therapeutic option in this group of patients. Further evaluation, with analysis of cost and quality of life, should be considered in a prospective, randomized trial.     

经皮穿刺置管引流治疗急性重症胰腺炎合并胰腺周围组织坏死感染的效果观察

目的:探讨经皮穿刺置管引流术(PCD)治疗急性重症胰腺炎(SAP)胰腺周围组织坏死感染的临床效果。方法:回顾性分析对113例手术治疗的SAP合并胰腺周围组织坏死感染(胰腺坏死范围30%)患者资料,其中采用PCD治疗54例(PCD组),采取直接开腹手术引流治疗的有59例(开腹组),对比两组患者的相关临床指标。结果:两组治疗前白细胞、血淀粉酶、尿淀粉酶、血糖值、血钙值差异均无统计学意义(均P0.05),治疗后两组以上实验室指标均较各自治疗前明显改善(均P0.05)。治疗后比较,PCD组血淀粉酶、尿淀粉酶、血糖值均明显低于开腹组患者(均P0.05);PCD组住院时间、住院费用、死亡或放弃治疗率均明显的低于开腹组(均P0.05);两组治疗有效率(79.6%vs.81.4%)、引流液体细菌培养结果差异均无统计学意义(均P0.05)。结论:PCD治疗SAP合并胰腺周围组织坏死感染(胰腺坏死范围30%)的效果确切,同时具有缩短住院时间、减少住院费用的优势。     

Pancreatic pseudocysts: the role of percutaneous catheter drainage.

The case records of 69 patients who had pancreatic pseudocysts were reviewed retrospectively. All patients had abdominal pain and tenderness, 38 had nausea and vomiting, 9 had chills and fever and 5 had jaundice. Forty-eight patients had elevated body temperatures and 26 had elevated leukocyte counts. A history of alcoholism was obtained in 48 patients. Ultrasonography demonstrated 54 pseudocysts near the body of the pancreas, 8 near the tail and 7 near the head. Thirty-nine patients had internal drainage, 16 had laparotomy and external drainage and 14 had percutaneous catheter drainage. One of these 14 patients died of uncontrollable sepsis. Six of the 39 patients who had internal drainage had clinical evidence of sepsis (4 had septic complications postoperatively, and 2 died); the remaining 33 patients who had noninfected pseudocysts left hospital within 20 days of operation. However, only four of nine patients who had percutaneous drainage for noninfected pseudocysts left hospital within 20 days of the procedure. Thus, the authors recommend that infected pancreatic pseudocysts be managed by percutaneous catheter drainage and noninfected pseudocysts by internal drainage.     

Pancreatic abscess: 10 years experience

Background: Secondary infections of pancreatic and peripancreatic necrosis account for most of the deaths following acute pancreatitis. These infections occur in the form of ‘infected pancreatic necrosis’ and ‘pancreatic abscess’. The latter is a rare complication of acute pancreatitis in comparison with the former. Methods: Twenty‐one patients with pancreatic abscess were managed over a 10‐year period at a tertiary care centre in Northern India. The present report details the clinical profile, investigations performed and management strategy (surgery and intervention radiology) of these patients. The role of surgery and percutaneous catheter drainage (PCD) in the management of pancreatic abscess is discussed, with emphasis on the successful outcome seen in a properly selected group of patients managed by PCD. Results: Of the 21 patients, 12 were managed by percutaneous intervention, nine were managed surgically (of these, two had a prior PCD) and two patients were managed conservatively. The overall mortality was 9.5% (2/21). Thus, percutaneous management was suitable for 57% patients, was successful in 83.3%, with a mortality of 8.3%. Surgical therapy alone was offered to 33% of patients, was successful in 85.7%, with a mortality of 14.2%. Complications were seen in four of the nine patients managed by percutaneous drainage alone and eight of the nine patients managed surgically. Conclusions: Pancreatic abscess is a potentially lethal complication in patients recovering from acute pancreatitis. Early diagnosis and prompt intervention with careful selection of patients based on computed tomography imaging for surgical or percutaneous radio­logical management, is met with a successful outcome in a majority of patients. The roles of surgery and PCD are complementary.     

超声引导下经皮穿刺置管引流在重症急性胰腺炎治疗中的应用

目的 探讨超声引导下经皮穿刺置管引流(PCD)在重症急性胰腺炎(SAP)治疗中的应用价值.方法 1998年1月至2007年5月,对53例SAP病人行超声引导下PCD治疗急性腹腔积液、腹腔感染和胰腺囊肿.所有病人均在行超声引导下PCD的同时常规放置两枚及必要时多枚引流管并行穿刺液常规和涂片染色、淀粉酶含量测定、细菌培养及药敏试验等检查.结果 该组病人除局部穿刺点短期的疼痛外均无明显导管相关并发症.53例中,1例暴发性胰腺炎病人并发腹腔室隔综合征,PCD后死于急性呼吸窘迫综合征;3例胰腺坏死并发腹腔感染病人PCD后症状未见明显缓解,经剖腹探查行坏死组织清除、外引流术,1例死于多器官功能不全综合征,2例治愈;2例胰腺真性囊肿病人行剖腹探查囊肿切除术;5例胰腺假性囊肿病人行PCD后,引流液未见明显减少,MRCP示囊腔与主胰管相通,行囊肿空肠Roux-er-Y吻合术.其余42例行PCD后均治愈.随访3个月至2年未见复发.总治愈率为96.2%(51/53),总死亡率为3.8%(2/53).结论 SAP的治疗应遵循微创化的原则,选择性应用超声引导下PCD治疗急性腹腔积液、腹腔感染和胰腺囊肿是可行、安全和有效的方法.     

A technique for laparoscopic-assisted percutaneous drainage of infected pancreatic necrosis and pancreatic abscess

BACKGROUND: Percutaneous drainage has been shown to be an acceptable method for treating both pancreatic abscesses and infected pancreatic necrosis. However, percutaneous techniques have certain shortcomings, including the time and labor required and failure of the catheters to adequately drain the particulate debris. Growing experience around the world indicates that there is a role for retroperitoneal laparoscopy as a means of facilitating the percutaneous drainage of infected pancreatic fluid collections and avoiding a laparotomy. Our technique is discussed in this paper. METHODS: Once infection is documented in a pancreatic fluid collection by fine-needle aspiration, one or more percutaneous drains are placed into the fluid collection(s). A computed tomography (CT) scan is repeated. If further drainage is indicated, retroperitoneoscopic debridement is performed. Using a combination of the percutaneous drain(s) and the post-drain CT scan, ports are placed and retroperitoneoscopic debridement of the necrosectum is performed under direct visualization. Prior to completion of the operation, a postoperative lavage system is created. RESULTS: Six patients with infected pancreatic necrosis have been treated with this technique. Prior to commencement of our laparoscopic protocol, all six patients would have required open necrosectomy. Four of the six patients were managed with retroperitoneoscopic debridement and catheter drainage alone. Complications included a colocutaneous fistula and a small flank hernia. There were no bleeding complications and no deaths. CONCLUSION: Although open necrosectomy remains the standard of care for the treatment of infected pancreatic necrosis and pancreatic abscess, there is growing evidence that laparoscopic retroperitoneal debridement is feasible.     

Abdominal drainage after hepatic resection is contraindicated in patients with chronic liver diseases

OBJECTIVE: The aim of this study was to determine whether abdominal drainage is beneficial after elective hepatic resection in patients with underlying chronic liver diseases. SUMMARY BACKGROUND DATA: Traditionally, in patients with chronic liver diseases, an abdominal drainage catheter is routinely inserted after hepatic resection to drain ascitic fluid and to detect postoperative hemorrhage and bile leakage. However, the benefits of this surgical practice have not been evaluated prospectively. PATIENTS AND METHODS: Between January 1999 and March 2002, 104 patients who had underlying chronic liver diseases were prospectively randomized to have either closed suction abdominal drainage (drainage group, n = 52) or no drainage (nondrainage group, n = 52) after elective hepatic resection. The operative outcomes of the 2 groups of patients were compared. RESULTS: Fifty-seven (55%) patients had major hepatic resection with resection of 3 Coiunaud's segments or more. Sixty-nine (66%) patients had liver cirrhosis and 35 (34%) had chronic hepatitis. Demographic, surgical, and pathologic details were similar between both groups. The primary indication for hepatic resection was hepatocellular carcinoma (n = 100, 96%). There was no difference in hospital mortality between the 2 groups of patients (drainage group, 6% vs. nondrainage group, 2%; P = 0.618). However, there was a significantly higher overall operative morbidity in the drainage group (73% vs. 38%, P < 0.001). This was related to a significantly higher incidence of wound complications in the drainage group compared with the nondrainage group (62% vs. 21%, P < 0.001). In addition, a trend toward a higher incidence of septic complications in the drainage group was observed (33% vs. 17%, P = 0.07). The mean (+/- standard error of mean) postoperative hospital stay of the drainage group was 19.0 +/- 2.2 days, which was significantly longer than that of the nondrainage group (12.5 +/- 1.1 days, P = 0.005). With a median follow-up of 15 months, none of the 51 patients with hepatocellular carcinoma in the drainage group developed metastasis at the drain sites. On multivariate analysis, abdominal drainage, underlying liver cirrhosis, major hepatic resection, and intraoperative blood loss of >1.5L were independent and significant factors associated with postoperative morbidity. CONCLUSION: Routine abdominal drainage after hepatic resection is contraindicated in patients with chronic liver diseases.     

经皮穿刺置管引流SAP合并胰腺坏死组织感染的临床效果分析

目的探讨经皮穿刺置管引流治疗重症胰腺炎(SAP)合并胰腺周围组织坏死感染患者的临床效果及安全性。方法选取2011年1月至2015年8月98例SAP并胰腺周围组织坏死感染患者进行回顾性分析,其中47例患者采用经皮穿刺置管引流术治疗(引流组),51例患者采用开腹手术治疗(开腹组),对比两种方法的治疗效果差异。统计软件采用SAS9.1,两组间急性生理与慢性健康评分(APACHEⅡ)、CT严重程度指数、WBC、血淀粉酶、尿淀粉酶、血糖、血钙值等采用均数±标准差(x珋±s)进行描述,比较采用t检验;全身炎症反应综合征(SIRS)发生率、入器官衰竭发生率、并发症发生率采用χ~2检验,P值0.05表示差异有统计学意义。结果治疗前和治疗后,引流组和开腹组两组间的WBC、血淀粉酶、尿淀粉酶、血糖、血钙值差异无统计学意义(P0.05);治疗后,两组的WBC、血淀粉酶、尿淀粉酶、血糖值较本组治疗前均显著的降低(P0.05)。引流组的治愈出院率93.62%(44/47)与开腹组的92.16%(47/51)差异无统计学意义(χ~2=0.079,P=0.7790.05);引流组患者的术后腹腔出血率、胰瘘率显著的低于开腹组患者(P0.05)。结论对于胰腺坏死感染范围30%的SAP患者,采用经皮穿刺置管引流同样具有手术效果可靠,并且并发症低的优点。     

The role of percutaneous drainage of pancreatic abscesses

Pancreatic abscess remains the most lethal form of intra-abdominal abscess despite a wide variety of operative approaches that have been advocated for its control. Mortality is frequent, and recurrent abscesses after operative drainage are common. Death often results from ongoing uncontrolled sepsis. The role of percutaneous drainage (PCD) of pancreatic abscesses is controversial. Recent experience with five patients who had pancreatic abscess and in whom a combination of operative drainage and PCD proved instrumental in survival leads the authors to recommend the consideration of both forms of drainage dependent upon the circumstances. Specifically, indications for PCD may include the following: use as a temporizing measure prior to celiotomy in a critically ill patient; use in postoperative patients who have recurrent abscesses and in whom the presence of dense inflammation precludes safe evacuation of pus; and use in the patient who has known portal hypertension and in whom massive bleeding is likely to result from celiotomy and abscess drainage.     

Secondary pancreatic infections: are they distinct clinical entities?

BACKGROUND. Infected pseudocysts, pancreatic abscesses, and infected pancreatic necroses have been proposed as distinct clinical entities in terms of treatment and outcome. To evaluate this classification, we reviewed the clinical course and bacteriologic findings of pancreatic infections. METHODS. Of 1299 patients with pancreatitis or a related complication admitted over a 7-year period, 64 (4.9%) with culture-documented secondary pancreatic infections were reviewed with regard to cause, clinical course, bacteriologic findings, and outcomes. RESULTS. Group I consisted of 23 patients with infected pseudocysts; group II, 20 patients with pancreatic abscesses; and group III, 21 patients with infected pancreatic necrosis. The causes were alcohol in 36%, biliary tract disease in 30%, and postoperative in 16%, with no significant difference between groups. Patients in group I had abdominal pain or a mass without accompanying signs of sepsis, whereas patients in groups II and III had sepsis. In group I, 15 patients were treated with internal drainage, four with percutaneous drainage, and four with external drainage. In group II, three had percutaneous drainage, 15 operative drainage, and two open packing. In group III, 19 patients had operative drainage and two had open packing. Morbidity occurred in 26% of patients in group I, 40% in group II, and 90% in group III (p less than 0.001). Mortality rates were 9% in group I, 25% in group II, and 48% in group III (p less than 0.01). Enteric organisms were present in 66% of isolates, with no difference between groups, suggesting a common mode of infection. CONCLUSIONS. Despite similar bacteriologic findings, infected pseudocysts, pancreatic abscesses, and infected pancreatic necroses have significantly different presentations, clinical courses, and outcomes, confirming that they are distinct entities. This distinction is important when therapeutic outcomes are compared.