Consensus ; Humans ; Pancreatitis ; classification ; diagnosis

Both new insights in the pathophysiology of severe acute pancreatitis (SAP) and upspringing related evidence-based supports prompt the staged step-up approach, which stress emphasis on minimal invasiveness and damage control, to be accepted and advocated by the majority of guidelines. For documented or suspected patients with infected pancreatic necrosis, an imaging-guided percutaneous catheter drainage or an endoscopic transluminal drainage should be initially performed followed by, if necessary, a minimal access retroperitoneal necrosectomy, or a video-assisted retroperitoneal debridement, or an endoscopic transluminal necrosectomy, or an even an open access necrosectomy. The outstanding performance of staged step-up approach in patients with SAP has been justified from both a clinical and a health economic point of view, meanwhile, there are some issues remained to be further elucidated and optimized.
Acute Disease ; Debridement ; Drainage ; Endoscopy ; Humans ; Pancreatitis ; surgery ; Retroperitoneal Space ; Treatment Outcome

OBJECTIVETo investigate the feasibility and clinical value of the step-up approach for severe acute pancreatitis (SAP).

METHODSClinical data of 121 SAP patients admitted between January 2002 and December 2011 were retrospectively analyzed. Fifty-eight patients (37 males and 21 females, aged from 20 to 72 years, mean 47.6 years) in the group of direct open necrosectomy from January 2002 to December 2006 were performed laparotomy through removal of all necrotic tissue. Sixty-three patients (42 males and 21 females, aged from 19 to 78 years, mean 46.2 years) of step-up approach from January 2007 to December 2011 underwent percutaneous catheter drainage through retroperitoneum or omental bursa guided by B-type ultrasonography for the first therapy, and then, according to the pathogenetic condition, if necessary, followed by a small incisional necrosectomy along the drainage tube. The two groups were compared for the rates of postoperative complications, death, transfusion and length of stay, medical costs.

RESULTSThe rates of total postoperative complications, organ dysfunction, alimentary tract fistula and incisional hernia in step-up approach group were significantly lower than those of direct open necrosectomy group (31.7% vs. 62.1%, 14.3% vs. 37.5%, 6.3% vs. 19.0%, 9.5% vs. 29.3%; χ(2) = 4.43 to 11.17, P = 0.001 to 0.035). The other complications had no significant differences between the two groups (P > 0.05). Patients in step-up approach group had a lower rates of transfusion (44.4% vs. 70.7%, χ(2) = 8.488, P = 0.004), fewer medical costs of transfusion and hospital stay, compared with those in direct open necrosectomy group ((2525 ± 4573) yuan vs. (4770 ± 6867) yuan, t = 2.131, P = 0.035; (171 213 ± 50 917) yuan vs. (237 874 ± 67 832) yuan, t = 2.496, P = 0.014). There were no significant differences of length of stay and mortality between two groups (P > 0.05).

CONCLUSIONStep-up approach for SAP which can reduce the rates of postoperative complications, transfusion and medical costs has significant feasibility and great clinical value.

Adult ; Aged ; Female ; Humans ; Male ; Middle Aged ; Pancreatitis, Acute Necrotizing ; economics ; surgery ; Paracentesis ; economics ; Peritoneal Cavity ; surgery ; Postoperative Complications ; economics ; epidemiology ; Retrospective Studies ; Treatment Outcome ; Young Adult

OBJECTIVETo investigate the clinical feature, diagnostic and therapeutic experience of autoimmune pancreatitis (AIP).

METHODSTwenty-one patients with AIP treated in the First Affiliated Hospital, Harbin Medical University from January 2006 to July 2014 were analyzed retrospectively. There were 15 men and 6 women among the 21 cases and the age ranged from 36 to 64 years. The characters of diagnosis and treatment of AIP were explored through clinical symptoms, imaging features, serologic test results, diagnostic treatment, and histopathologic characteristics.

RESULTSAll the patients showed obstructive jaundice and upper abdominal pain to different extents as major manifestations and the levels of serum IgG4, CA19-9, CEA were elevated in 16 cases (76.2%), 6 cases (28.5%) and 3 cases (14.2%), respectively. CT showed diffuse enlargement of the pancreas in 9 cases, localized pancreatic head enlargement in 3 cases and focally pancreatic mass in 9 cases. AIP was confirmed by extrapancreatic involvement, radiological and serological results plus biopsy in 11 cases (52.4%), interpretation of response to steroid in 3 cases (14.3%) and open laparotomy in 7 cases (33.3%). Surgery included choledochojejunostomy in 3 cases, cholecystojejunostomy in 1 case, pancreaticoduodenectomy in 2 cases and distal pancreatectomy combined with splenectomy in 1 case. The pathologic results displayed massive lymphocytes and plasma cells infiltration in the pancreatic tissues as well as parenchymal fibrosis. Except for 1 patient who had no symptom, the regular steroid therapy was performed (oral prednisone) and all the patients were cured. The follow-up time range was from 3 to 93 months, 4 cases (19.0%) were recurrent followed by the symptoms alleviated after the steroid was applied again.

CONCLUSIONSAIP is rare and characterized by non-specific clinical manifestations so that the early diagnosis is difficult with a high misdiagnosis rate. The clinicians should strengthen the recognition of AIP and the definite diagnosis depends on the combination of clinical manifestations, radiological, serological and histopathological results so as to avoid the unnecessary operation.

Adult ; Autoimmune Diseases ; diagnosis ; therapy ; Biopsy ; CA-19-9 Antigen ; blood ; Carcinoembryonic Antigen ; blood ; Diagnostic Imaging ; Female ; Humans ; Immunoglobulin G ; blood ; Male ; Middle Aged ; Pancreas ; pathology ; Pancreatectomy ; Pancreatitis ; diagnosis ; therapy ; Retrospective Studies ; Steroids ; therapeutic use

OBJECTIVETo investigate the effect of pancreatic duct stent internal versus external drainage with pancreaticojejunostomy on the early curative effect after pancreaticoduodenectomy (PD).

METHODSThe study was a prospective controlled trial. A total of 219 patients undergoing PD from January 2010 to March 2013 were randomly divided into external drainage group (n = 110) and internal drainage group (n = 109). The pancreatic duct stent was put in the jejunum during the operation in the internal drainage group, while that in the external drainage group was placed outside the body through the jejunum and abdominal wall. The intra-operative blood loss, operative duration, post-operative hospital stay, mortality rate, and the morbidity of pancreatic fistula as well as other complications were compared between the two groups.

RESULTSCompared with internal drainage group, pancreatic duct stent external drainage obviously reduced the morbidity of pancreatic fistula (13.6% vs. 22.6%), delayed gastric emptying (10.0% vs. 27.5%), abdominal infection (6.4% vs. 19.3%), intestinal obstruction (8.2% vs. 20.2%) along with the overall complications (24.5% vs. 41.3%) after PD (χ(2) = 5.735 8 to 11.047 7, P < 0.05), and shortened the healing duration of pancreatic fistula ((11.5 ± 2.9) d vs. (20.1 ± 5.7) d, t = 5.07, P < 0.01), while there was no significant difference in the intra-operative blood loss, operative duration, post-operative hospital stay and mortality rate, etc between the two groups (P > 0.05).

CONCLUSIONSPancreatic duct stent external drainage can effectively reduce the morbidity of pancreatic fistula and the overall complications after PD, which is safe and feasible. The method is worthy of popularization and application clinically.

Adult ; Aged ; Drainage ; methods ; Female ; Humans ; Male ; Middle Aged ; Pancreatic Ducts ; surgery ; Pancreatic Fistula ; etiology ; prevention & control ; Pancreaticoduodenectomy ; Postoperative Complications ; prevention & control ; Prospective Studies ; Treatment Outcome