Better Outcomes if Percutaneous Drainage Is Used Early and Proactively in the Course of Necrotizing Pancreatitis.

PURPOSE: To compare outcomes after percutaneous catheter drainage (PCD) for acute necrotizing pancreatitis versus those in a randomized controlled trial as a reference standard. MATERIALS AND METHODS: Between September 2010 and August 2014, CT-guided PCD was the primary treatment for 39 consecutive patients with pancreatic necrosis. The indication for PCD was the clinical finding of uncontrolled pancreatic juice leakage rather than infected necrosis. Subsequent to PCD, the drains were proactively studied with fluoroscopic contrast medium every 3 days to ensure patency and position. Drains were ultimately maneuvered to the site of leakage. These 39 patients were compared with 43 patients from the Pancreatitis, Necrosectomy versus Step-up Approach (PANTER) trial. RESULTS: The CT severity index was similar between studies (median of 8 in each). Time from onset of acute pancreatitis to PCD was shorter in the present series (median, 23 d vs 30 d). The total number of procedures (PCD and subsequent fluoroscopic drain studies) per patient was greater in the present series (mean, 14 vs 2). More patients in the PANTER trial had organ failure (62% vs 84%), required open or endoscopic necrosectomy (0% vs 60%), and experienced in-hospital mortality (0% vs 19%; P < .05 for all). CONCLUSIONS: Even though patients in the present series had a similar CT severity index as those in the PANTER trial, the former group showed lower incidences of organ failure, need for necrosectomy, and in-hospital mortality. The use of a proactive PCD protocol early, before the development of severe sepsis, appeared to be effective.

A percutaneous drainage protocol for severe and moderately severe acute pancreatitis.

BACKGROUND: According to the revised Atlanta classification, severe and moderately severe acute pancreatitis (AP) includes patients with pancreatic and peripancreatic collections with or without organ failure. These collections suggest the presence of pancreatic juice leakage. The aim of this study was to evaluate the efficacy of a percutaneous catheter drainage (PCD) protocol designed to control leakage and decrease disease severity. METHODS: Among 663 patients with clinical AP, 122 were classified as moderately severe or severe AP (all had collections). The computed tomography severity index (CTSI) score was calculated. The indication for PCD was based on progressive clinical signs and symptoms. Drain patency, position, and need for additional drainage sites were assessed using CT scans and drain studies initially every 3 days using a proactive protocol. Drain fluid was examined for amylase concentration and microbiological culture. Clinicopathological variables for patients with and without PCD were compared. Since there was no mortality, we used prolonged drainage time to measure the success of PCD. Within the group treated with PCD, variables that resulted in prolonged drainage time were analyzed. RESULTS: PCD was used in 47/122 (39 %) patients of which 33/47 (70 %) had necrosis. PCD cases had a median CTSI of 8 and were classified as moderately severe AP (57 %) and severe AP (43 %). Inhospital mortality was zero. Surgical necrosectomy was not required for patients with necrosis. Independent risk factors for prolonged drainage time were persistent organ failure >48 h (P = 0.001), CTSI 8-10 (P = 0.038), prolonged duration of amylase-rich fluid in drains (P < 0.001), and polymicrobial culture fluid in drains (P = 0.015). CONCLUSIONS: A proactive PCD protocol persistently maintaining drain patency advanced to the site of leak controlled the prolonged amylase in drainage fluid resulting in a mortality rate of zero.

Intraductal papillary mucinous neoplasm of the biliary tract: a real disease?

BACKGROUND: Despite increasing numbers of reports, biliary tract intraductal papillary mucinous neoplasm (BT-IPMN) is not yet recognized as a unique neoplasm. The aim of the present study was to define the presence of BT-IPMN in a large series of resected biliary neoplasms. METHODS: From May 1994 to December 2006, BT-IPMN cases were identified by reviewing pathology specimens of all resected cholangiocarcinomas and other biliary neoplasms when cystic, papillary or mucinous features were cited in pathology reports. RESULTS: BT-IPMN was identified in 23 out of 253 (9%) specimens using the strict histopathological criteria of IPMN. The most common presenting symptom was abdominal discomfort which was present in 15 patients (65%). Only one of the original operative pathology reports used the term IPMN; 16 (70%) used the terms cystic, mucinous and/or papillary. BT-IPMN was isolated to non-hilar extra-hepatic ducts in 12 (52%), intra-hepatic ducts in 6 (26%) and hilar extra-hepatic ducts in 5 patients (22%). Carcinoma was found in association with BT-IPMN in 19 patients (83%); 5-year survival was 38% after resection. CONCLUSION: BT-IPMN occurs throughout the intra- and extra-hepatic biliary system and can be identified readily as a unique neoplasm. Broader acceptance of BT-IPMN as a unique neoplasm may lead to a better understanding of the pathogenesis of biliary malignancies.

Biliary Stenosis and Gastric Outlet Obstruction: Late Complications After Acute Pancreatitis With Pancreatic Duct Disruption.

OBJECTIVES: Pancreatic duct disruption (PDD) after acute pancreatitis can cause pancreatic collections in the early phase and biliary stenosis (BS) or gastric outlet obstruction (GOO) in the late phase. We aimed to document those late complications after moderate or severe acute pancreatitis. METHODS: Between September 2010 and August 2014, 141 patients showed pancreatic collections on computed tomography. Percutaneous drainage was primarily performed for patients with signs or symptoms of uncontrolled pancreatic juice leakage. Pancreatic duct disruption was defined as persistent amylase-rich drain fluid or a pancreatic duct cut-off on imaging. Clinical course of the patients who developed BS or GOO was investigated. RESULTS: Among the 141 patients with collections, 33 patients showed PDD in the pancreatic head/neck area. Among them, 9 patients (27%) developed BS 65 days after onset and required stenting for 150 days, and 5 patients (15%) developed GOO 92 days after onset and required gastric decompression and jejunal tube feeding for 147 days (days shown in median). All 33 patients recovered successfully without requiring surgical intervention. CONCLUSIONS: Anatomic proximity of the bile duct or duodenum to the site of PDD and severe inflammation seemed to contribute to the late onset of BS or GOO. Conservative management successfully reversed these complications.

Enhanced Recovery Pathways in Pancreatic Surgery.

Enhanced recovery after surgery (ERAS) protocols were first introduced to help recovery after colorectal surgery. They have now been applied to multiple surgical specialties, including pancreatic surgery. ERAS protocols in pancreatic surgery have been shown to decrease length of stay and possibly postoperative morbidity.

Epidural anesthesia dysfunction is associated with postoperative complications after pancreatectomy.

BACKGROUND: Epidural anesthesia is an accepted measure of pain control after major abdominal surgery. However, if the epidural anesthesia is unsuccessful, a variety of adverse effects can occur - excessive stress response, poor patient mobilization, increased opioid use, and hypotension due to vasodilation. The aim of this study was to evaluate the influence of epidural dysfunction on outcomes after pan-createctomy. METHODS: Between August 2010 and October 2014, 72 patients underwent open pancreatectomy with epidural anesthesia. Epidural dysfunction was defined as either hypo-function due to inadequate pain control (requirement of epidural replacement, conversion to intravenous continuous opioid infusion, or intravenous bolus opioid use) or hyper-function (hypotension or oliguria). We then analyzed for an association between epidural dysfunction and surgical outcomes. RESULTS: Epidural dysfunction occurred in 49% after pancreatectomy - hypo-function in 35% and hyper-function in 14%. Epidural dysfunction was independently associated with the development of overall (P < 0.001), pancreas-related (P = 0.041), and non-pancreas-related complications (P = 0.001). Hypo-function alone was independently associated with both pancreas-related (P = 0.015) and non-pancreas-related complications (P = 0.004). Hyper-function was independently associated with non-pancreas-related complications (P = 0.002). CONCLUSIONS: Outcomes after pancreatic resection can be improved by increasing the success rate of epidural anesthesia.

Pulmonary autografts in patients with severe left ventricular dysfunction.

BACKGROUND: Performing a Ross operation in patients with severe left ventricular dysfunction is controversial. The objective in this retrospective study was to determine the outcome of 15 patients with aortic valve disease (11 had aortic insufficiency and 4 had aortic insufficiency and aortic stenosis) associated with reduced left ventricular function (ejection fraction < 40%) treated with a pulmonary autograft. METHODS: We identified 15 patients with severe left ventricular dysfunction from 226 consecutive pulmonary autograft procedures done between age 18 and 50 years from 1986 to 2001. Patients had documented preoperative ejection fraction less than 40% and were in New York Heart Association class III or IV. Preoperative ejection fraction ranged from 18% to 37% (mean, 31% +/- 6.5%). Transthoracic echocardiograms obtained preoperatively and at 1-week, 6-month, and 1- and 2-year intervals were reviewed. Records were evaluated for survival, clinical status, left ventricular function, and valve function. RESULTS: There were no operative deaths, late deaths, or reoperations. All patients had follow-up examinations within the past year and are clinically well (67% > 2 years follow-up). Ten of 15 patients (67%) had substantially improved ventricular function (> 20% increase). The average ejection fraction increased from 31% +/- 7% preoperatively to 51% +/- 11% at 2 years, and the increase is significant from 1 week on (p < 0.02). Average left ventricular mass index decreased by 41% at 6 months (n = 10; p = 0.009) and by 44% at 2 years (n = 9; p = 0.02). Mean Z values for left ventricular mass decreased from 7.6 to 3.6 after more than 2 years (p = 0.007). CONCLUSIONS: The Ross operation is an appropriate option in adults age 50 or younger in the presence of decreased left ventricular ejection fraction. Neither operative mortality nor postoperative sequelae were identified in our subset of patients. Excellent survival and ventricular recovery are predicted.

Frequency of subtypes of biliary intraductal papillary mucinous neoplasm and their MUC1, MUC2, and DPC4 expression patterns differ from pancreatic intraductal papillary mucinous neoplasm.

BACKGROUND: Biliary intraductal papillary mucinous neoplasm (B-IPMN) has been proposed as a unique clinicopathologic disease with distinct histopathologic features, although wide acceptance remains controversial. A recent consensus conference classified pancreatic IPMN (P-IPMN) into 4 subtypes (ie, gastric, intestinal, pancreatobiliary, oncocytic) based on morphologic appearance and mucin (MUC) staining properties. The aim of this study was to determine whether B-IPMN has similar histopathologic and immunologic subtypes to P-IPMN. STUDY DESIGN: Specific immunostaining for MUC1, MUC2, and deleted for pancreas cancer, locus 4 were performed on specimens from 19 patients with a histopathologic diagnosis of B-IPMN. Immunostaining patterns of B-IPMN were correlated with histopathology. RESULTS: Based on histopathology, the following subtypes of B-IPMN were identified: pancreatobiliary n = 9 (47%), intestinal n = 8 (42%), oncocytic n = 2 (11%), and gastric n = 0 (0%). Pancreatobiliary and oncocytic subtypes of B-IPMN were positive for MUC1 and negative for MUC2, and intestinal subtypes were positive for MUC2 and negative for MUC1. Thirteen of the 19 B-IPMN were associated with invasive carcinoma; loss of deleted for pancreas cancer, locus 4 was found in 6 of 13 invasive components and in 3 of 19 noninvasive components of B-IPMN. Five-year survival for patients with resected B-IPMN and invasive carcinoma was 38%, which is similar to that for resected P-IPMN with invasive carcinoma. CONCLUSIONS: Histopathologic subtypes and type-specific MUC expression patterns of B-IPMN resemble those of P-IPMN. MUC1 expression and/or absence of MUC2 expression, which correlate with aggressive features of P-IPMN, were found in B-IPMN and correlate with invasive B-IPMN. Loss of deleted for pancreas cancer, locus 4 parallels the findings observed in P-IPMN. These findings provide additional support that B-IPMN is a unique entity with similarities to main duct P-IPMN.

Patterns of pancreatic resection differ between patients with familial and sporadic pancreatic cancer.

BACKGROUND: Although the increased risk of developing pancreatic cancer (PC) in families with a strong history of the disease is well known, characteristics and outcomes of patients with familial PC is not described well. AIMS: This study aims to evaluate outcomes following resection in patients with familial PC. METHODS: We studied 208 patients who underwent resection of PC from 2000 to 2007 and had prospectively completed family history questionnaires for the Biospecimen Resource for Pancreas Research at our institution. We compared clinical characteristics and outcomes of familial and sporadic PC patients. RESULTS: Familial (N = 15) and sporadic PC patients (N = 193) did not have significantly different demographics, pre-operative CA19-9, pre-operative weight loss, R0 status, or T-staging (all p ≥ 0.05). Familial PC patients had lower pre-operative total serum bilirubin concentrations (p = 0.03) and lesions outside of the pancreatic head more frequently (p = 0.02) than sporadic PC patients. There was no difference in survival at 2 years between familial and sporadic PC patients (p = 0.52). CONCLUSIONS: Familial PC patients appear to develop tumors outside of the pancreatic head more frequently than sporadic PC patients. This difference in tumor distribution may be due to a broader area of cancer susceptibility within the pancreas for familial PC patients.

Is there a role for endoscopic therapy as a definitive treatment for post-laparoscopic bile duct injuries?

BACKGROUND: Excellent results of surgical reconstruction of major bile duct injuries (BDIs) have been well-documented. Reports of successful definitive management of central bile duct leakage and stenoses have been reported infrequently. The aim of this study was to assess treatment and outcomes for operative and endoscopic treatment of BDI after laparoscopic cholecystectomy (LC) and define the role of endoscopy in management. STUDY DESIGN: All patients undergoing treatment for post-laparoscopic BDI from 1998 to 2007 at Mayo Clinic, Rochester, Minnesota were reviewed. Outcomes of surgical and endoscopic intervention were analyzed. RESULTS: BDI was identified in 159 patients (mean age 51 years). Injury was recognized intraoperatively in 39 (25%) patients. Primary intervention was surgical in 59 (37%) and endoscopic in 100 (63%) patients. Class A BDIs (n = 77) were successfully treated endoscopically in 76 (99%) patients. Seven had class D BDIs; 4 were managed surgically, and 3 endoscopically. Of 66 patients with E1 to E4 BDI, 44 (67%) were initially managed surgically and 22 (33%) endoscopically. Thirteen of the latter 22 underwent sustained endoscopic therapy (median stent time 7 months), which was successful in 10 (77%). Four patients with E5 were managed surgically. Median follow-up was 45 months. Sixty-three patients underwent Roux-en-Y hepaticojejunostomy reconstruction at Mayo; 3 (5%) failed and required stenting. None required operative revision. CONCLUSIONS: Endoscopic management of class A BDI has excellent outcomes. Although surgical management remains the preferred therapy, short-term endoscopic treatment for class E1 to E4 can optimize the patient and operative field for reconstruction. Prolonged stenting in select patients with E1 to E4 characterized by stenosis is successful in the majority.

Predictive and prognostic value of CA 19-9 in resected pancreatic adenocarcinoma.

BACKGROUND: Preoperative serum values of CA 19-9 have been reported to be associated with survival in patients undergoing resection of pancreatic adenocarcinoma. HYPOTHESIS: Preoperative CA 19-9 levels are associated with margin and/or lymph node status in patients undergoing pancreatoduodenectomy for pancreatic carcinoma. METHODS: We conducted a review of 143 patients undergoing pancreatoduodenectomy for pancreatic adenocarcinoma from July 2001 through April 2006 at our institution. Preoperative serum values of CA 19-9 and total bilirubin, pathologic findings, and survival were analyzed. A cutoff value for CA 19-9 (120 U/ml) was determined using a Cox proportional hazards model for survival. RESULTS: Overall survival at 1, 3, and 5 years for patients with CA 19-9 < or = 120 U/ml was 76%, 41%, and 31%, respectively, versus 64%, 17%, and 10% for patients with CA 19-9 > 120 U/ml (p = 0.002). CA 19-9 > 120 U/ml was not associated, however, with a greater chance of an R1 or R2 resection (p = 0.86), tumor involving the SMA margin (p = 0.88), tumor at the portal vein groove (p = 0.14), or lymph node metastases (p = 0.89). CONCLUSIONS: Our findings do not support a cutoff value for CA 19-9 that is associated with margin or lymph node involvement. Preoperative CA 19-9 < or = 120 U/ml is, however, associated with increased overall and recurrence-free survival.