This document discusses endoscopic management of necrotizing pancreatitis. It begins with an agenda that covers diagnosis and classification of pancreatic fluid collections, indications for intervention in necrotizing pancreatitis, endoscopic techniques for drainage and necrosectomy, risks of EUS-guided drainage, and a literature review. It then provides details on classifying and diagnosing acute pancreatitis, grading severity, classifying pancreatic fluid collections based on the revised Atlanta criteria, and indications for intervening in infected or symptomatic walled-off pancreatic necrosis. Finally, it outlines endoscopic methods for draining or debriding pancreatic necrosis including EUS-guided transmural drainage, the multiple gateway technique, risks and preparations.
Role and types of surgery in chronic pancreatitisShambhavi Sharma
This document discusses the role and types of surgery in chronic pancreatitis. It begins with an introduction and overview of chronic pancreatitis and its causes. It then discusses the various symptoms and complications that can arise. The document outlines the surgical and non-surgical management options, including drainage procedures like Puestow's procedure and resection procedures like pancreaticoduodenectomy. It provides details on the indications, advantages, and disadvantages of different surgical procedures. The key message is that surgery aims to relieve pain and complications while preserving pancreatic function as much as possible.
- Lymphadenectomy plays an important role in staging, local control, and survival for gastric cancer patients.
- The Japanese have standardized lymphadenectomy techniques since the 1960s, removing specific nodal stations (D1, D2 etc.), and achieve much higher 5-year survival rates compared to the West.
- A D2 lymphadenectomy, removing more lymph nodes than just those adjacent to the tumor, significantly increases cure rates according to Japanese studies. However Western studies have difficulty reproducing these results due to lower surgery volumes, lack of standardization, and operating on older patient populations with more advanced cancers.
Bile Duct Injury and Post Cholecystectomy Biliary StrictureArifuzzaman Shehab
Bile duct injuries are a devastating complication of gallbladder surgery that can have tremendous physical and mental effects on both surgeons and patients. Early recognition within 72 hours allows for minimal inflammation and the highest chance of successful repair. Diagnosis involves signs of abdominal pain and jaundice along with imaging and blood tests showing bile leakage and liver dysfunction. Management depends on the severity and location of the injury, ranging from endoscopic stenting to immediate surgical repair.
Laparoscopy and laparoscopic ultrasound are effective tools for staging pancreatic cancer and determining resectability, with a high sensitivity and specificity. They allow avoidance of surgery in some cases and better planning of surgical approach. Laparoscopic techniques can also be used to treat benign pancreatic tumors, pseudocysts, trauma, and perform palliative bypass surgery with benefits of reduced morbidity and shorter hospital stays compared to open surgery.
A 42-year-old male presented with abdominal pain for 20 days. Medical history revealed a past diagnosis of pancreatitis. Physical examination found a vague mass palpable in the epigastric and left hypochondrium region. Imaging studies including ultrasound and CT scan identified a cystic structure along the head and tail of the pancreas, with one cyst extending into the mediastinum. The patient underwent a laparotomy with roux-en-y cystojejunostomy to drain a pseudocyst measuring 15x12 cm communicating with a 10x8 cm cyst. Post-operative recovery was uneventful.
1) Duodenal injuries are uncommon and difficult to diagnose and repair due to the duodenum's retroperitoneal location. The mortality rate for duodenal injuries is high.
2) Diagnosis of duodenal injuries requires a high index of suspicion as there is no single, fully accurate diagnostic test. CT scans, upper GI studies, and exploratory laparotomy can help diagnose duodenal injuries.
3) Treatment depends on the grade of the duodenal injury. Lower grade injuries may be treated with primary closure, tube duodenostomies, or jejunal patching. Higher grade injuries involving complete wall disruption may require duodenal resection or diversion procedures like duodenal divertic
Minimal invasive Surgery in Management of colorectal cancerpiyushpatwa
Laparoscopic Anterior resection. After insertion of ports with patient in steep trendelenburg position Inferior mesenteric artery was identified and high ligation done with division of left colic artery and then medial to lateral dissection was done. Subsequently inferior mesenteric vein was dissected and clipped and divided. Distal dissection proceeded just behind the superior rectal artery and after identification and preservation of the hypogastric nerves, upper rectum was mobilised. Division of bowel was done at upper rectum after giving adequate distal margin and end to end anastomosis was done using circular stapler.
Role and types of surgery in chronic pancreatitisShambhavi Sharma
This document discusses the role and types of surgery in chronic pancreatitis. It begins with an introduction and overview of chronic pancreatitis and its causes. It then discusses the various symptoms and complications that can arise. The document outlines the surgical and non-surgical management options, including drainage procedures like Puestow's procedure and resection procedures like pancreaticoduodenectomy. It provides details on the indications, advantages, and disadvantages of different surgical procedures. The key message is that surgery aims to relieve pain and complications while preserving pancreatic function as much as possible.
- Lymphadenectomy plays an important role in staging, local control, and survival for gastric cancer patients.
- The Japanese have standardized lymphadenectomy techniques since the 1960s, removing specific nodal stations (D1, D2 etc.), and achieve much higher 5-year survival rates compared to the West.
- A D2 lymphadenectomy, removing more lymph nodes than just those adjacent to the tumor, significantly increases cure rates according to Japanese studies. However Western studies have difficulty reproducing these results due to lower surgery volumes, lack of standardization, and operating on older patient populations with more advanced cancers.
Bile Duct Injury and Post Cholecystectomy Biliary StrictureArifuzzaman Shehab
Bile duct injuries are a devastating complication of gallbladder surgery that can have tremendous physical and mental effects on both surgeons and patients. Early recognition within 72 hours allows for minimal inflammation and the highest chance of successful repair. Diagnosis involves signs of abdominal pain and jaundice along with imaging and blood tests showing bile leakage and liver dysfunction. Management depends on the severity and location of the injury, ranging from endoscopic stenting to immediate surgical repair.
Laparoscopy and laparoscopic ultrasound are effective tools for staging pancreatic cancer and determining resectability, with a high sensitivity and specificity. They allow avoidance of surgery in some cases and better planning of surgical approach. Laparoscopic techniques can also be used to treat benign pancreatic tumors, pseudocysts, trauma, and perform palliative bypass surgery with benefits of reduced morbidity and shorter hospital stays compared to open surgery.
A 42-year-old male presented with abdominal pain for 20 days. Medical history revealed a past diagnosis of pancreatitis. Physical examination found a vague mass palpable in the epigastric and left hypochondrium region. Imaging studies including ultrasound and CT scan identified a cystic structure along the head and tail of the pancreas, with one cyst extending into the mediastinum. The patient underwent a laparotomy with roux-en-y cystojejunostomy to drain a pseudocyst measuring 15x12 cm communicating with a 10x8 cm cyst. Post-operative recovery was uneventful.
1) Duodenal injuries are uncommon and difficult to diagnose and repair due to the duodenum's retroperitoneal location. The mortality rate for duodenal injuries is high.
2) Diagnosis of duodenal injuries requires a high index of suspicion as there is no single, fully accurate diagnostic test. CT scans, upper GI studies, and exploratory laparotomy can help diagnose duodenal injuries.
3) Treatment depends on the grade of the duodenal injury. Lower grade injuries may be treated with primary closure, tube duodenostomies, or jejunal patching. Higher grade injuries involving complete wall disruption may require duodenal resection or diversion procedures like duodenal divertic
Minimal invasive Surgery in Management of colorectal cancerpiyushpatwa
Laparoscopic Anterior resection. After insertion of ports with patient in steep trendelenburg position Inferior mesenteric artery was identified and high ligation done with division of left colic artery and then medial to lateral dissection was done. Subsequently inferior mesenteric vein was dissected and clipped and divided. Distal dissection proceeded just behind the superior rectal artery and after identification and preservation of the hypogastric nerves, upper rectum was mobilised. Division of bowel was done at upper rectum after giving adequate distal margin and end to end anastomosis was done using circular stapler.
ACHALASIA CARDIA: ENDOSCOPIC THERAPY (POEM)Dr Amit Dangi
POEM is a highly effective treatment for achalasia, providing long-term symptom relief in over 90% of patients. Studies have shown POEM to have similar efficacy to laparoscopic Heller myotomy with benefits including shorter procedure time, less pain, and shorter hospital stay. POEM allows for a longer myotomy and more complete treatment of achalasia compared to Heller myotomy and has been shown to be particularly effective for type 3 achalasia. While short-term complications are low, concerns remain around POEM's learning curve. Further research is still needed regarding its use in special cases like sigmoid achalasia and treatment failure patients.
The patient presented with a large cystic mass in the pancreas. Imaging showed a 18.8x11cm pseudo cyst in the body and tail of the pancreas. Pseudo cysts are the most common cystic lesions of the pancreas, arising due to pancreatic duct disruption from acute or chronic pancreatitis. The patient underwent a cystogastrostomy to drain the cyst, as the cyst was large and causing symptoms. The procedure went smoothly and the patient recovered well.
Safe Laparoscopic Cholecystectomy Techniques that are discussed here are based on current literature and Evidence Based Medicine guidelines and reviews.
Complications Following Antireflux Surgery: Recognition and ManagementGeorge S. Ferzli
Re-operative antireflux surgery requires extensive pre-operative evaluation to determine the cause of failure and appropriate surgical approach. Common causes of failure include inadequate crus closure, fundoplication disruption, and esophageal shortening. The surgical approach should be tailored to the suspected mechanism of failure but often involves dismantling prior operations andredoing the fundoplication. Re-operation has a higher failure rate than initial surgery due to surgical challenges and patient factors.
The diagnosis and management of common bile duct stones has evolved considerably in recent years. New endoscopic, radiologic and surgical techniques now provide doctors with a range of options. We present an evidence based approach which incorporates the latest technology and techniques to optimize outcomes for patients.
Information about Low Anterior Resection by Dr Dhaval Mangukiya.
Details of GOAL of LAR, Margins, Reconstructions, Anal Anastomosis, End to Side Colorectal Anastomosis, Stapler Vs Hand Sewn, Intersphincteric Resection, Colonic J pouch Anastomosis etc.
https://drdhavalmangukiya.com/
http://www.youtube.com/c/DrDhavalMangukiyaGastrosurgeonSurat
https://gastrosurgerysurat.blogspot.com/
1) Transanal total mesorectal excision (TME) is a novel technique for resection of rectal cancers.
2) TME involves excising the rectum and the surrounding mesorectum in one block through the anus to minimize local recurrence.
3) This "down-to-up" transanal approach aims to improve on open TME by reducing morbidity and impairment of function compared to traditional surgery.
Bile duct injury is a rare but potentially devastating complication of cholecystectomy that can result in biliary peritonitis, sepsis, and cirrhosis. It is most commonly caused by misidentification of structures during laparoscopic cholecystectomy. Management involves controlling infection, delineating biliary anatomy, and reestablishing biliary drainage, usually through surgical hepaticojejunostomy. Prevention relies on identification of anatomical variations, achieving a "critical view of safety" before duct division, and open conversion if needed. Proper management requires a multidisciplinary approach between surgeons, radiologists, and gastroenterologists.
SURGICAL EXPLORATION OF THE COMMON BILE DUCT.pptxmasoom parwez
Surgical exploration of the common bile duct involves removing gallstones discovered during cholecystectomy. Key steps include:
1. Performing intraoperative cholangiography to identify stones
2. Making an incision in the bile duct and extracting stones using forceps, balloons, or baskets
3. Placing a T-tube for drainage and performing a follow up cholangiogram to ensure clearance
Post-operatively, patients are monitored for complications like bleeding or leakage and the T-tube is typically removed after 2 weeks if follow up imaging is normal. Surgical exploration effectively treats gallstones and provides pain relief for most patients.
This document discusses the current evidence for D1 and D2 gastrectomy in treating gastric cancer. It begins by defining the lymph node stations and different levels of lymphadenectomy. It then reviews several key randomized controlled trials that compared D1 and D2 gastrectomy. While initial Western trials found higher morbidity and mortality with D2 without survival benefits, later long-term follow up and recent trials demonstrate lower recurrence rates and improved survival with D2 gastrectomy when performed safely. The consensus is that D2 gastrectomy with preservation of the spleen and pancreas can achieve radical treatment for gastric cancer with excellent outcomes when performed by experienced surgeons.
The document describes the Department of Urology at Government Royapettah Hospital and Kilpauk Medical College in Chennai, India. It provides information on the moderators of the department, a brief history of pyeloplasty techniques, indications for pyeloplasty, goals of the procedure, factors to consider before surgery, principles of pyeloplasty, preoperative preparation and imaging, surgical approaches including open, laparoscopic and robotic techniques, and descriptions of various open pyeloplasty techniques including Anderson-Hynes dismembered pyeloplasty and Foley's V-Y plasty.
Local complications of pancreatitis include pancreatic pseudocysts and pancreatic necrosis. Pancreatic pseudocysts are localized fluid collections that develop 4 weeks after pancreatitis. They are typically treated with endoscopic or surgical drainage if symptomatic. Necrosis involves tissue death and requires drainage and possibly necrosectomy. Complications are managed based on their type, location, and severity with options including endoscopic, percutaneous, or surgical interventions. Close monitoring is needed as complications can include fistulas, vascular issues, or bowel obstructions.
Urinary Diversion after cystectomy [Dr.Edmond Wong]Edmond Wong
1. Various gastrointestinal segments can be used for urinary diversion after cystectomy including stomach, ileum, colon and appendix. Each option has advantages and disadvantages related to metabolic complications and risk of infection.
2. The ileal conduit is the most commonly used form of urinary diversion and involves isolating a segment of ileum to create a low pressure urinary reservoir and conduit. Complications include metabolic abnormalities, stomal issues, and ureteral complications.
3. Continent urinary diversions aim to create a reservoir with a continence mechanism but still face challenges with infection risk, metabolic issues and long term complications like malignancy from chronic bacteriuria. Patient factors also influence diversion outcomes.
Biliary stricture is an abnormal narrowing of the bile duct. The most common cause is injury during cholecystectomy, accounting for 80% of non-malignant strictures. Bile duct injury can cause inflammation, fibrosis, scarring, and cirrhosis. Surgical treatment depends on when the injury is recognized, with immediate repair during surgery or delayed repair weeks later being options. Roux-en-Y hepaticojejunostomy is a common repair method that involves a mucosa-to-mucosa anastomosis of the bile duct to the jejunum. Factors like multiple prior repairs, proximal strictures, and surgeon inexperience can lead to poor outcomes.
Gastric outlet obstruction is caused by benign or malignant diseases that obstruct gastric emptying. Common benign causes include peptic ulcer disease while pancreatic cancer is a frequent malignant cause. Patients experience nausea, vomiting and weight loss. Diagnosis involves distinguishing functional from mechanical causes and identifying the underlying etiology. Treatment focuses on rehydration and correcting metabolic abnormalities as well as addressing the mechanical obstruction through endoscopic or surgical interventions.
Esophagectomy : APPROACHES, CONTROVERSIES AND CURRENT EVIDENCEDr Amit Dangi
This document discusses esophagectomy, the surgical approaches for esophageal cancer resection. It covers the relevant anatomy, blood supply, lymph drainage, and histology of esophageal cancer. It then discusses pre-treatment evaluation including staging assessments and criteria for resection. The key surgical procedures for cervical, thoracic, and esophagogastric junction cancers are described including the transhiatal, Ivor-Lewis, and tri-incisional approaches. Post-operative outcomes from recent studies comparing these approaches are summarized.
Liver failure after major hepatic resection.pptxGian Luca Grazi
Liver failure after hepatic resection has a multifactorial origin. However, the volume of the removed liver, technical problems during the procedure and the development of infections in the post-operative period certainly play a primary role.
The surgeon plays an important role in implementing all those surgical and radiological procedures to prevent the onset of this severe complication.
However, the treatment of liver failure that occurs after a hepatectomy requires multidisciplinary management, including intensive care physicians, neurologists, nephrologists, and others.
In order not to incur in the failure to recognize the complication and to avoid not implementing all the therapeutic measures necessary for the treatment of post-resection liver failure, it is essential that the hospital where the operation is performed is equipped with all professionalism and all the necessary technological tools.
These are the characteristics needed to define where liver surgery can be performed safely.
Information about Gerd surgical management by Dr Dhaval Mangukiya.
Details of both sides of Gerd, Introduction, Surgical Anatomy, Hiatus Hernia, Esophageal dearance, Investigation etc.
http://www.youtube.com/c/DrDhavalMangukiyaGastrosurgeonSurat
https://gastrosurgerysurat.blogspot.com/
https://drdhavalmangukiya.com/
This document provides an overview of pancreatic surgery and management of pancreatic conditions. It discusses the anatomy of the pancreas, classification and management of acute pancreatitis including necrotizing pancreatitis. It covers the indications, timing and approaches for intervention in infected pancreatic necrosis, including radiologic drainage, minimally invasive techniques like VARD and nephroscopic debridement, and open necrosectomy. It also summarizes the principles and techniques of surgical management of pancreatic cancer.
The document discusses the classification and treatment of acute pancreatitis. It classifies pancreatitis based on the absence or presence of local and systemic complications into mild, moderate, or severe. For infected pancreatic collections or necrosis that develop after the initial presentation, the document recommends initially performing simple percutaneous drainage and then considering minimally invasive techniques like endoscopic or laparoscopic necrosectomy if the patient does not improve with drainage alone. It notes that no single technique is clearly superior and treatment should be individualized based on the patient and collection characteristics.
ACHALASIA CARDIA: ENDOSCOPIC THERAPY (POEM)Dr Amit Dangi
POEM is a highly effective treatment for achalasia, providing long-term symptom relief in over 90% of patients. Studies have shown POEM to have similar efficacy to laparoscopic Heller myotomy with benefits including shorter procedure time, less pain, and shorter hospital stay. POEM allows for a longer myotomy and more complete treatment of achalasia compared to Heller myotomy and has been shown to be particularly effective for type 3 achalasia. While short-term complications are low, concerns remain around POEM's learning curve. Further research is still needed regarding its use in special cases like sigmoid achalasia and treatment failure patients.
The patient presented with a large cystic mass in the pancreas. Imaging showed a 18.8x11cm pseudo cyst in the body and tail of the pancreas. Pseudo cysts are the most common cystic lesions of the pancreas, arising due to pancreatic duct disruption from acute or chronic pancreatitis. The patient underwent a cystogastrostomy to drain the cyst, as the cyst was large and causing symptoms. The procedure went smoothly and the patient recovered well.
Safe Laparoscopic Cholecystectomy Techniques that are discussed here are based on current literature and Evidence Based Medicine guidelines and reviews.
Complications Following Antireflux Surgery: Recognition and ManagementGeorge S. Ferzli
Re-operative antireflux surgery requires extensive pre-operative evaluation to determine the cause of failure and appropriate surgical approach. Common causes of failure include inadequate crus closure, fundoplication disruption, and esophageal shortening. The surgical approach should be tailored to the suspected mechanism of failure but often involves dismantling prior operations andredoing the fundoplication. Re-operation has a higher failure rate than initial surgery due to surgical challenges and patient factors.
The diagnosis and management of common bile duct stones has evolved considerably in recent years. New endoscopic, radiologic and surgical techniques now provide doctors with a range of options. We present an evidence based approach which incorporates the latest technology and techniques to optimize outcomes for patients.
Information about Low Anterior Resection by Dr Dhaval Mangukiya.
Details of GOAL of LAR, Margins, Reconstructions, Anal Anastomosis, End to Side Colorectal Anastomosis, Stapler Vs Hand Sewn, Intersphincteric Resection, Colonic J pouch Anastomosis etc.
https://drdhavalmangukiya.com/
http://www.youtube.com/c/DrDhavalMangukiyaGastrosurgeonSurat
https://gastrosurgerysurat.blogspot.com/
1) Transanal total mesorectal excision (TME) is a novel technique for resection of rectal cancers.
2) TME involves excising the rectum and the surrounding mesorectum in one block through the anus to minimize local recurrence.
3) This "down-to-up" transanal approach aims to improve on open TME by reducing morbidity and impairment of function compared to traditional surgery.
Bile duct injury is a rare but potentially devastating complication of cholecystectomy that can result in biliary peritonitis, sepsis, and cirrhosis. It is most commonly caused by misidentification of structures during laparoscopic cholecystectomy. Management involves controlling infection, delineating biliary anatomy, and reestablishing biliary drainage, usually through surgical hepaticojejunostomy. Prevention relies on identification of anatomical variations, achieving a "critical view of safety" before duct division, and open conversion if needed. Proper management requires a multidisciplinary approach between surgeons, radiologists, and gastroenterologists.
SURGICAL EXPLORATION OF THE COMMON BILE DUCT.pptxmasoom parwez
Surgical exploration of the common bile duct involves removing gallstones discovered during cholecystectomy. Key steps include:
1. Performing intraoperative cholangiography to identify stones
2. Making an incision in the bile duct and extracting stones using forceps, balloons, or baskets
3. Placing a T-tube for drainage and performing a follow up cholangiogram to ensure clearance
Post-operatively, patients are monitored for complications like bleeding or leakage and the T-tube is typically removed after 2 weeks if follow up imaging is normal. Surgical exploration effectively treats gallstones and provides pain relief for most patients.
This document discusses the current evidence for D1 and D2 gastrectomy in treating gastric cancer. It begins by defining the lymph node stations and different levels of lymphadenectomy. It then reviews several key randomized controlled trials that compared D1 and D2 gastrectomy. While initial Western trials found higher morbidity and mortality with D2 without survival benefits, later long-term follow up and recent trials demonstrate lower recurrence rates and improved survival with D2 gastrectomy when performed safely. The consensus is that D2 gastrectomy with preservation of the spleen and pancreas can achieve radical treatment for gastric cancer with excellent outcomes when performed by experienced surgeons.
The document describes the Department of Urology at Government Royapettah Hospital and Kilpauk Medical College in Chennai, India. It provides information on the moderators of the department, a brief history of pyeloplasty techniques, indications for pyeloplasty, goals of the procedure, factors to consider before surgery, principles of pyeloplasty, preoperative preparation and imaging, surgical approaches including open, laparoscopic and robotic techniques, and descriptions of various open pyeloplasty techniques including Anderson-Hynes dismembered pyeloplasty and Foley's V-Y plasty.
Local complications of pancreatitis include pancreatic pseudocysts and pancreatic necrosis. Pancreatic pseudocysts are localized fluid collections that develop 4 weeks after pancreatitis. They are typically treated with endoscopic or surgical drainage if symptomatic. Necrosis involves tissue death and requires drainage and possibly necrosectomy. Complications are managed based on their type, location, and severity with options including endoscopic, percutaneous, or surgical interventions. Close monitoring is needed as complications can include fistulas, vascular issues, or bowel obstructions.
Urinary Diversion after cystectomy [Dr.Edmond Wong]Edmond Wong
1. Various gastrointestinal segments can be used for urinary diversion after cystectomy including stomach, ileum, colon and appendix. Each option has advantages and disadvantages related to metabolic complications and risk of infection.
2. The ileal conduit is the most commonly used form of urinary diversion and involves isolating a segment of ileum to create a low pressure urinary reservoir and conduit. Complications include metabolic abnormalities, stomal issues, and ureteral complications.
3. Continent urinary diversions aim to create a reservoir with a continence mechanism but still face challenges with infection risk, metabolic issues and long term complications like malignancy from chronic bacteriuria. Patient factors also influence diversion outcomes.
Biliary stricture is an abnormal narrowing of the bile duct. The most common cause is injury during cholecystectomy, accounting for 80% of non-malignant strictures. Bile duct injury can cause inflammation, fibrosis, scarring, and cirrhosis. Surgical treatment depends on when the injury is recognized, with immediate repair during surgery or delayed repair weeks later being options. Roux-en-Y hepaticojejunostomy is a common repair method that involves a mucosa-to-mucosa anastomosis of the bile duct to the jejunum. Factors like multiple prior repairs, proximal strictures, and surgeon inexperience can lead to poor outcomes.
Gastric outlet obstruction is caused by benign or malignant diseases that obstruct gastric emptying. Common benign causes include peptic ulcer disease while pancreatic cancer is a frequent malignant cause. Patients experience nausea, vomiting and weight loss. Diagnosis involves distinguishing functional from mechanical causes and identifying the underlying etiology. Treatment focuses on rehydration and correcting metabolic abnormalities as well as addressing the mechanical obstruction through endoscopic or surgical interventions.
Esophagectomy : APPROACHES, CONTROVERSIES AND CURRENT EVIDENCEDr Amit Dangi
This document discusses esophagectomy, the surgical approaches for esophageal cancer resection. It covers the relevant anatomy, blood supply, lymph drainage, and histology of esophageal cancer. It then discusses pre-treatment evaluation including staging assessments and criteria for resection. The key surgical procedures for cervical, thoracic, and esophagogastric junction cancers are described including the transhiatal, Ivor-Lewis, and tri-incisional approaches. Post-operative outcomes from recent studies comparing these approaches are summarized.
Liver failure after major hepatic resection.pptxGian Luca Grazi
Liver failure after hepatic resection has a multifactorial origin. However, the volume of the removed liver, technical problems during the procedure and the development of infections in the post-operative period certainly play a primary role.
The surgeon plays an important role in implementing all those surgical and radiological procedures to prevent the onset of this severe complication.
However, the treatment of liver failure that occurs after a hepatectomy requires multidisciplinary management, including intensive care physicians, neurologists, nephrologists, and others.
In order not to incur in the failure to recognize the complication and to avoid not implementing all the therapeutic measures necessary for the treatment of post-resection liver failure, it is essential that the hospital where the operation is performed is equipped with all professionalism and all the necessary technological tools.
These are the characteristics needed to define where liver surgery can be performed safely.
Information about Gerd surgical management by Dr Dhaval Mangukiya.
Details of both sides of Gerd, Introduction, Surgical Anatomy, Hiatus Hernia, Esophageal dearance, Investigation etc.
http://www.youtube.com/c/DrDhavalMangukiyaGastrosurgeonSurat
https://gastrosurgerysurat.blogspot.com/
https://drdhavalmangukiya.com/
This document provides an overview of pancreatic surgery and management of pancreatic conditions. It discusses the anatomy of the pancreas, classification and management of acute pancreatitis including necrotizing pancreatitis. It covers the indications, timing and approaches for intervention in infected pancreatic necrosis, including radiologic drainage, minimally invasive techniques like VARD and nephroscopic debridement, and open necrosectomy. It also summarizes the principles and techniques of surgical management of pancreatic cancer.
The document discusses the classification and treatment of acute pancreatitis. It classifies pancreatitis based on the absence or presence of local and systemic complications into mild, moderate, or severe. For infected pancreatic collections or necrosis that develop after the initial presentation, the document recommends initially performing simple percutaneous drainage and then considering minimally invasive techniques like endoscopic or laparoscopic necrosectomy if the patient does not improve with drainage alone. It notes that no single technique is clearly superior and treatment should be individualized based on the patient and collection characteristics.
Endoscopic drainge of pancreatic absces inchildrenMEDHAT EL-SAYED
This case study describes the minimally invasive management of necrotizing pancreatitis in a 13-year-old pediatric patient. The patient presented with severe abdominal pain, respiratory distress, shock, and other symptoms. Imaging showed necrosis of the pancreatic body and tail with fluid collections. The patient was admitted to the ICU and received antibiotics, fluids, and other supportive care. An endoscopic transmural drainage was performed to drain the fluid collections. The patient's condition improved and follow-up imaging showed resolution of the fluid collections over time with endoscopic management. The case demonstrates the successful treatment of necrotizing pancreatitis in a pediatric patient with minimally invasive endoscopic drainage.
Annular pancreas is an uncommon condition in adults.
The ring formation generally originates from the failure of
normal clockwise rotation of ventral pancreas. First
described by Tiedmann in 1818, its incidence is
1:20,000 population. It has bimodal presentation i.e is seen
either in Infants or in 4th & 5th decade of life.
SEVERE ACUTE PANCREATITIS PRESENTATION 2020karanchhabra75
This document discusses the diagnosis and management of severe acute pancreatitis. It provides details on the case of a 40-year-old male diagnosed with severe acute pancreatitis induced by alcohol. Imaging showed multiple fluid collections surrounding the pancreas. The document then reviews diagnostic criteria, severity assessments, nutritional support, antibiotic use, and approaches to managing complications like necrosis and collections.
This document discusses a case of intestinal obstruction in a patient with a history of colon cancer. It provides background on the patient's symptoms and signs, including abdominal pain and distention, vomiting, and hemoccult-positive stool. The next steps are described as an abdominal series to determine the level and severity of obstruction. The pathophysiology of mechanical bowel obstruction is traced, involving distention, pain, potential ischemia and necrosis. Nursing management focuses on acute pain, risk for deficient fluid volume, risk for imbalanced nutrition, and ineffective tissue perfusion monitoring.
Management of Perforated Duodenal Diverticulum: Case Reportasclepiuspdfs
It has been reported that duodenal diverticula are common but perforated duodenal diverticulum is a rare entity. At this time, there is no standardized management for perforated duodenal diverticulum. In these cases, patients usually complain of vague abdominal pain and computed tomography scan is mostly ordered used as an important diagnostic method. Diagnosis and the severity of the disease need to be assessed before any intervention. Essentially, the perforated small bowel is treated with surgical intervention. However, conservative treatment with broad-spectrum antibiotics and strict nil per os has been offered in the past for stable patients. Below, we report one case of perforated duodenal diverticulum that we managed with conservative treatment.
Laparoscopic Management Of Pseudocyst Pancreas.pptxVarunraju9
The treatment focus of psedo pancreatic cyst is shifting slowly in to minimally invasive procedures and the scientific data is assuring it's long standing future with good results.
This document provides an overview of acute pancreatitis, including its definition, incidence, etiology, clinical presentation, investigations, assessment of severity, management, and complications. Acute pancreatitis is defined as a reversible inflammation of the pancreas that can be mild or severe. It has various etiologies including gallstones, alcohol abuse, and certain drugs. Clinical features include abdominal pain and elevated pancreatic enzymes. Management involves supportive care, treating the underlying cause if possible, and addressing complications which can include pancreatic necrosis, pseudocysts, and abscesses.
This document discusses the complications of acute pancreatitis, including local complications like acute pancreatic fluid collections and acute necrotic collections, as well as chronic complications like pancreatic pseudocysts. It provides details on the diagnosis, management, and treatment options for each complication, which include observation, percutaneous drainage, endoscopic drainage, and surgery. Endoscopic and percutaneous drainage are preferred over surgery when possible due to lower mortality and morbidity. Infected complications generally require invasive drainage to prevent further infection and impacts on patient outcomes.
1. Obstructive ileus is a condition characterized by a blockage in the intestines. 2. Ileus obstructive refers to a situation where there is a hindrance in the normal flow of the intestines. 3. The term obstructive ileus is used to describe a condition where there is an obstruction in the intestines, causing a disruption in the normal movement of food and fluids. Ileus refers to the intolerance of oral intake due to inhibition of the gastrointestinal propulsion without signs of mechanical obstruction. The diagnosis is often associated with surgery, medications, trauma, peritonitis, or severe illness. Mechanical obstruction has to be ruled out, and the diagnosis of ileus is dependent on radiographic evidence, usually on a CT scan or small bowel series. This activity reviews the evaluation and management of an Ileus and highlights the role of the interprofessional team in improving care for patients with this condition.
Objectives:
Identify the etiology of ileus.
Outline the typical presentation of a patient with ileus.
Review the management options available for ileus.
Identify interprofessional team strategies for improving care coordination and outcomes in patients with ileus.
Access free multiple choice questions on this topic.
Go to:
Introduction
Ileus, also known as paralytic ileus or functional ileus, occurs when there is a non-mechanical decrease or stoppage of the flow of intestinal contents.[1][2] Bowel obstruction is a mechanical blockage of intestinal contents by a mass, adhesion, hernia, or some other physical blockage. These two diseases may present similarly, but treatment can be very different depending on the underlying pathology.
Ileus is an often unavoidable consequence of abdominal or retroperitoneal surgery, but can also be found in severely ill patients with septic shock or mechanical ventilation. Due to the delayed refeeding syndrome seen after an ileus, postoperative ileus has a large economic impact in the United States alone.[3] An ileus usually manifests itself from the third to the fifth day after surgery and usually lasts 2 to 3 days with the small bowel being the quickest to return to function (0 to 24 hours), followed by the stomach (24 to 48 hours), and lastly the colon (48 to 72 hours).[2][4][5] A prolonged ileus is diagnosed if the ileus exceeds 2 to 3 days with the continued absence of obstruction signs.[6]
Go to:
Etiology
The cause of ileus has yet to be clearly defined. There are, however, several risk factors that have been shown to increase the likelihood and endurance of an ileus.[7]
Prolonged abdominal/pelvic surgery
Lower gastrointestinal (GI) surgery
Open surgery
Retroperitoneal spinal surgery
Opioid use
Intra-abdominal inflammation (sepsis/peritonitis)
Peritoneal carcinomatosis
Perioperative complications (pneumonia, abscess)
Bleeding (intraoperative or postoperative)
Hypokalemia
Delayed enteral nutrition or nasogastric (NG) tube placement
The risk for an ileus is influenced by a variety of fx
This document summarizes the updated 2013 classification of acute pancreatitis published in the journal Gut. It defines acute pancreatitis diagnosis requiring two of three criteria: abdominal pain, elevated lipase/amylase, characteristic CT findings. CT is indicated if clinical diagnosis is doubtful, severity is high, or complications are suspected and can identify two types: interstitial edematous pancreatitis and necrotizing pancreatitis. Collections are also defined including acute peripancreatic fluid collections in interstitial cases, acute necrotic collections in necrotizing cases, and pseudocysts or walled-off necrosis in later encapsulated collections. Reporting requirements for imaging findings are discussed.
This document summarizes recent advances in the diagnosis and treatment of gastroesophageal reflux disease (GERD). It discusses definitions, pathophysiology, epidemiology, clinical presentation, diagnostic tests including 24-hour pH monitoring and endoscopy, and treatment options including lifestyle modifications, medications like PPIs, and surgical procedures. Key recent advances mentioned include new diagnostic markers, multichannel intraluminal impedance pH monitoring, narrow-band imaging, and endoscopic assessment of mucosal impedance. Surgical treatments discussed are laparoscopic anti-reflux surgery and the Linx device, and recent studies comparing partial versus complete fundoplication and surgical versus medical therapy.
The document summarizes several pancreatic duct anomalies including pancreas divisum, annular pancreas, and ectopic pancreas. It describes the embryological development and classification of each anomaly. For pancreas divisum, it discusses diagnosis using ERCP, MRCP, or EUS and treatment options like endoscopic sphincterotomy or stenting of the dorsal duct. For annular pancreas, it describes the classification and presentations in infants versus adults. Surgical bypass is the preferred treatment. Ectopic pancreas most commonly involves the gastric antrum and is often asymptomatic.
severe acute pancreatitis has high mortality rate and there is always confusions in between physicians. This topic is about management of acute pancreatitis its complications and ongoing controvercies. hope this will help and clear the doubts among physicians, residents and medical students
This document provides information about open esophageal surgical procedures, including cricopharyngeal myotomy and excision of Zenker's diverticulum. It describes the preoperative evaluation and optimization of patients, including imaging, endoscopy, and nutritional support. The surgical technique is explained in 4 steps: 1) incision and dissection of the pharyngeal pouch, 2) myotomy of the cricopharyngeus muscle and esophagus, 3) freeing or excising the diverticulum using a stapler, and 4) drainage/closure. Postoperative care involves monitoring for complications such as recurrent laryngeal nerve injury, fistula, hematoma, and infection.
This study examined 162 patients with cirrhosis who underwent endoscopic variceal band ligation to treat esophageal varices. The study aimed to determine the frequency and risk factors associated with the development of secondary gastric varices after eradicating esophageal varices. The results found that secondary gastric varices developed in 38 patients (23.5%) after eradicating their esophageal varices. Factors associated with an increased risk of developing secondary gastric varices included having more advanced liver disease (based on Child-Pugh class), larger esophageal varices at initial presentation, requiring more sessions of band ligation to eradicate the esophageal varices, and already having gastric varices present at initial presentation.
AbstractIntestinal cystic pneumatosis is a rare condition characterized by the presence of gaseous cysts in the intestinal wall.We report the observation of a 51-year-old patient with dyspepsia syndrome and recurrent episodes of abdominal pain who had a three-day cessation of materials and gas for three days.
A 51-year-old man presented with abdominal pain and cessation of bowel movements for three days. Imaging showed pneumoperitoneum and distension of the small intestine upstream of a large mass. Exploratory laparotomy revealed gas cysts in the small intestine and a volvulus. Resection of the affected small intestine segment showed intestinal cystic pneumatosis. Intestinal cystic pneumatosis is a rare condition characterized by gas-filled cysts in the intestinal wall. It is usually mild but can cause complications like volvulus requiring surgery. Treatment is typically medical but surgery is needed for complicated cases.
Similar to Endoscopic management of walled of pancreatic necrosis (20)
- Video recording of this lecture in English language: https://youtu.be/kqbnxVAZs-0
- Video recording of this lecture in Arabic language: https://youtu.be/SINlygW1Mpc
- Link to download the book free: https://nephrotube.blogspot.com/p/nephrotube-nephrology-books.html
- Link to NephroTube website: www.NephroTube.com
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Promoting Wellbeing - Applied Social Psychology - Psychology SuperNotesPsychoTech Services
A proprietary approach developed by bringing together the best of learning theories from Psychology, design principles from the world of visualization, and pedagogical methods from over a decade of training experience, that enables you to: Learn better, faster!
8 Surprising Reasons To Meditate 40 Minutes A Day That Can Change Your Life.pptxHolistified Wellness
We’re talking about Vedic Meditation, a form of meditation that has been around for at least 5,000 years. Back then, the people who lived in the Indus Valley, now known as India and Pakistan, practised meditation as a fundamental part of daily life. This knowledge that has given us yoga and Ayurveda, was known as Veda, hence the name Vedic. And though there are some written records, the practice has been passed down verbally from generation to generation.
Cell Therapy Expansion and Challenges in Autoimmune DiseaseHealth Advances
There is increasing confidence that cell therapies will soon play a role in the treatment of autoimmune disorders, but the extent of this impact remains to be seen. Early readouts on autologous CAR-Ts in lupus are encouraging, but manufacturing and cost limitations are likely to restrict access to highly refractory patients. Allogeneic CAR-Ts have the potential to broaden access to earlier lines of treatment due to their inherent cost benefits, however they will need to demonstrate comparable or improved efficacy to established modalities.
In addition to infrastructure and capacity constraints, CAR-Ts face a very different risk-benefit dynamic in autoimmune compared to oncology, highlighting the need for tolerable therapies with low adverse event risk. CAR-NK and Treg-based therapies are also being developed in certain autoimmune disorders and may demonstrate favorable safety profiles. Several novel non-cell therapies such as bispecific antibodies, nanobodies, and RNAi drugs, may also offer future alternative competitive solutions with variable value propositions.
Widespread adoption of cell therapies will not only require strong efficacy and safety data, but also adapted pricing and access strategies. At oncology-based price points, CAR-Ts are unlikely to achieve broad market access in autoimmune disorders, with eligible patient populations that are potentially orders of magnitude greater than the number of currently addressable cancer patients. Developers have made strides towards reducing cell therapy COGS while improving manufacturing efficiency, but payors will inevitably restrict access until more sustainable pricing is achieved.
Despite these headwinds, industry leaders and investors remain confident that cell therapies are poised to address significant unmet need in patients suffering from autoimmune disorders. However, the extent of this impact on the treatment landscape remains to be seen, as the industry rapidly approaches an inflection point.
Here is the updated list of Top Best Ayurvedic medicine for Gas and Indigestion and those are Gas-O-Go Syp for Dyspepsia | Lavizyme Syrup for Acidity | Yumzyme Hepatoprotective Capsules etc
TEST BANK For Community Health Nursing A Canadian Perspective, 5th Edition by...Donc Test
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Osteoporosis - Definition , Evaluation and Management .pdfJim Jacob Roy
Osteoporosis is an increasing cause of morbidity among the elderly.
In this document , a brief outline of osteoporosis is given , including the risk factors of osteoporosis fractures , the indications for testing bone mineral density and the management of osteoporosis
These lecture slides, by Dr Sidra Arshad, offer a quick overview of the physiological basis of a normal electrocardiogram.
Learning objectives:
1. Define an electrocardiogram (ECG) and electrocardiography
2. Describe how dipoles generated by the heart produce the waveforms of the ECG
3. Describe the components of a normal electrocardiogram of a typical bipolar lead (limb II)
4. Differentiate between intervals and segments
5. Enlist some common indications for obtaining an ECG
6. Describe the flow of current around the heart during the cardiac cycle
7. Discuss the placement and polarity of the leads of electrocardiograph
8. Describe the normal electrocardiograms recorded from the limb leads and explain the physiological basis of the different records that are obtained
9. Define mean electrical vector (axis) of the heart and give the normal range
10. Define the mean QRS vector
11. Describe the axes of leads (hexagonal reference system)
12. Comprehend the vectorial analysis of the normal ECG
13. Determine the mean electrical axis of the ventricular QRS and appreciate the mean axis deviation
14. Explain the concepts of current of injury, J point, and their significance
Study Resources:
1. Chapter 11, Guyton and Hall Textbook of Medical Physiology, 14th edition
2. Chapter 9, Human Physiology - From Cells to Systems, Lauralee Sherwood, 9th edition
3. Chapter 29, Ganong’s Review of Medical Physiology, 26th edition
4. Electrocardiogram, StatPearls - https://www.ncbi.nlm.nih.gov/books/NBK549803/
5. ECG in Medical Practice by ABM Abdullah, 4th edition
6. Chapter 3, Cardiology Explained, https://www.ncbi.nlm.nih.gov/books/NBK2214/
7. ECG Basics, http://www.nataliescasebook.com/tag/e-c-g-basics
2. AGENDA
S ACUTE PANCREATITIS – DIAGNOSIS AND TYPES
S CLASSIFICATION OF FLUID COLLECTIONS
S WHEN TO INTERVENE IN NECROTISING
PANCREATITIS
S METHODS FOR INTERVENTIONS IN WOPN
S ENDOSCOPIC TECHNIQUES OF
DRAINAGE/NECROSECTOMY
S RISKS AND COMPLICATIONS IN EUS-GUIDED
DRAINAGE
S REVIEW OF LITERATURE
4. DIAGNOSIS (ANY OF THE
TWO)
S Abdominal pain consistent with acute pancreatitis
S Serum lipase activity (or amylase activity) at least three
times greater than the upper limit of normal
S Characteristic findings of acute pancreatitis on contrast-
enhanced computed tomography (CECT) and less
commonly magnetic resonance imaging (MRI) or
transabdominal ultrasonography
S Banks PA et al. Gut 2013;62:102-111.
5. Banks PA et al. Am J Gastroenterol 2006;101:2379; Tsiotos GG et al. Br J Surg 1998;85:1650;
Fagenholz PJ et al. Ann Epidemiol 2007;17:491; Martinez J et al. Pancreatology 2006;6:206;
Chauhan S et al. Am J Gastroenterol 2010;105:443.
Acute Pancreatitis
(AP)
15% Necrotising AP
Mortality 15%
Organ failure 54%
Organ failure with
infected necrosis
(mortality 30%)
85% Interstitial AP
Mortality 3%
Organ failure 10%
Recovery within 5-7 d
6.
7.
8. GRADES OF SEVERITY
S Mild acute pancreatitis
▸ No organ failure
▸ No local or systemic complications
S Moderately severe acute pancreatitis
▸ Organ failure that resolves within 48 h (transient organ
failure) and/or
▸ Local or systemic complications without persistent
organ failure
S Severe acute pancreatitis Persistent organ failure
(>48 h) –Single organ failure
–Multiple organ failure
9. Type of
pancreatitis
Collections < 4 weeks
(Acute collections)
Collections > 4 weeks
Interstitial
(85%)
APFC (acute pancreatic fluid
collection)
- sterile
- infected
Pseudozyste
- sterile
- infected
Necrotising
(15%)
ANC (acute necrotic collection)
- containing solid and fluid material
- intra and/or extrapancreatic
- sterile/infected
WON (walled off pancreatic necrosis)
- sterile
- infected
Banks PA et al. Gut 2013;62:102-111.
Pancreatic fluid collections
According to the revised Atlanta classification
Key points
Acute fluid collections:
Lack a well-defined wall
> 1 week distinction
between APFC vs. ANC
Usually NO treatment
10. Acute peripancreatic fluid
collection
S Occurs in the setting of interstitial oedematous
pancreatitis
S Homogeneous collection with fluid density
S Confined by normal peripancreatic fascial planes
S No definable wall encapsulating the collection
S Adjacent to pancreas (no intrapancreatic extension)
12. ACUTE NECROTIC
COLLECTION
S Occurs only in the setting of acute necrotising
pancreatitis
S Heterogeneous and non-liquid density of varying degrees
in different locations (some appear homogeneous early in
their course)
S No definable wall encapsulating the collection
S Location—intrapancreatic and/or extrapancreatic
13. Acute necrotic collection (ANC)
Banks PA et al. Gut 2012;62:102-111.
Stars: necrosis; arrows: borders of the ANC
14. S Pancreatic and peripancreatic collections should be
described on the basis of…….
S Location (pancreatic, peripancreatic, other)
S Nature of the content (liquid, solid, gas)
S Thickness of any wall (thin, thick).
15. Pancreatic fluid collections
According to the revised Atlanta classification
Type of
pancreatitis
Collections < 4 weeks Collections > 4 weeks
Interstitial
(85%)
APFC (acute pancreatic fluid
collection)
- sterile
- infected
Pseudocyst
- sterile
- infected
- no solid material
Necrotising
(15%)
ANC (acute necrotic collection)
- solid material
- parenchymal and/or
peripancreatic tissue
- sterile/infected
WON (walled-off pancreatic necrosis)
- mature, encapsulated necrotic
collection with well defined wall
- sterile/infected
- parenchymal/peripancreatic/distant
from pancreas
Banks PA et al. Gut 2013;62:102-111.
16. PANCREATIC PSEUDOCYST
S Well circumscribed, usually round or oval
S Homogeneous fluid density
S No non-liquid component
S Well defined wall; that is, completely encapsulated
S Maturation usually requires >4 weeks after onset of acute
pancreatitis
17. PANCREATIC
PSEUDOCYST
Note the round to oval, low-
attenuated, homogeneous
fluid collections with a well
defined enhancing rim, but
absence of areas of greater
attenuation indicative of non-
liquid components.
18. WALLED OF NECROSIS
(WON)
S Heterogeneous with liquid and non-liquid density with
varying degrees of loculations (some may appear
homogeneous)
S Well defined wall, that is, completely encapsulated
S Location—intrapancreatic and/or extrapancreatic
S Maturation usually requires 4 weeks after onset of acute
necrotising pancreatitis
19. WALLED OF NECROSIS
(WON)
Heterogeneous, fully encapsulated collection is noted in the pancreatic and peripancreatic
Non-liquid components of high attenuation (black arrowheads) in the collection are noted
20. Natural history of pancreatic necrosis
is variable
May remain solid or liquefy
May remain sterile or become infected
May persist or disappear over time
Banks PA et al. Gut 2013;62:102-111.
21. Available methods for intervention in pancreatic
necrosis
Freeman ML et al. Pancreas 2012;41:1176-1194.
Endoscopic
Image-guided
percutaneous
Minimally-
invasive
surgery
Open surgical
necrosectomy
22. Available methods for intervention in pancreatic
necrosis
Freeman ML et al. Pancreas 2012;41:1176-1194.
Endoscopic
Image-guided
percutaneous
Minimally-
invasive
surgery
Open surgical
necrosectomy
Last choice!
24. Besselink MG et al. Arch Sur 2007;142:1194-1201.
It’ s all about timing...!
WAIT
at least 3-4 weeks
25. Direct endoscopic necrosectomy for the
treatment of walled-off pancreatic necrosis:
results from a multicenter U.S. series
S The median number of days from acute pancreatitis to
first endoscopic intervention was 46 days.
S Clearly waiting for encapsulation or “walling off” is critical
to the success of primary endoscopic therapy, and the
success of necrosectomy often directly correlates with
the degree to which the collection is encapsulated.
S Gardner TB, Direct endoscopic necrosectomy for the treatment of walled-off
pancreatic necrosis: results from a multicenter U.S. series. Gastrointest Endosc.
2011 Apr;73(4):718-26
26. Freeman ML et al. Pancreas 2012;41:1176-1194;
Baron TH et al. Clin Gastroenterol Hepatol 2012;10:1202-1207.
High suspicion for or known infected WOPN
Early intervention should be avoided whenever possible
(wait >4weeks)
Infected necrosis (WOPN)
Symptomatic sterile necrosis (WOPN)
Intractable pain
Obstructive symptoms (gastric outlet / biliary obstruction)
Inability to eat
When is intervention indicated for necrosis?
27. Freeman ML et al. Pancreas 2012;41:1176-1194.
Peroral flexible
endoscopic
drainage
transpapillary
transmural
Direct
endoscopic
necrosectomy
Nasocystic
catheter
28. FIRST EXPERIENCE
S In 1996, Baron and colleagues reported the first
experience with endoscopic management of WON in 11
patients by performing a standard cystgastrotomy with
nasoscystic tube irrigation.
S Complete resolution occurred in 9 patients.
S Gastroenterology 1996;111:755–64.
30. PREPARATIONS
S Define whether the procedure is being performed for
source control or removal of the collection
S Timing of intervention is appropriate
S Patient does not have any obvious medical
contraindications to the procedure—coagulopathy
S Procedure is within the realm of the endoscopist’s.
S Gastrointest Endoscopy Clin N Am 23 (2013) 787–802
31. PREPARATIONS
S Make sure the collection is an inflammatory collection
and not a premalignant condition, such as a mucinous
cystic neoplasm or intraductal papillary mucinous
neoplasm.
S Anesthesia team- managing the patients with appropriate
airway protection because there is the potential for
extensive reflux and subsequent aspiration of fluid
following initial cavity puncture.
S Be certain to have availability of appropriate endoscopic
expertise following the procedure
S Gastrointest Endoscopy Clin N Am 23 (2013) 787–802
32. PATIENT POSITION
S Prone positioning may allow for better gravitational
drainage from posteriorly located collections and
decrease the incidence of fluid reflux and aspiration.
Gastrointest Endoscopy Clin N Am 23 (2013) 787–802
33. TECHNIQUE
S Initial endoscopy is performed using a therapeutic, side-
viewing video duodenoscope, gastroscope, or
echoendoscope.
S There is evidence that EUS-guided drainage of PFCs is
substantially more effective and less prone to
complications than “conventional” techniques.
S Varadarajulu S et al Gastrointest Endosc 2008;68:1102–11.
34. Prospective randomized trial comparing
EUS and EGD for transmural drainage of
pancreatic pseudocysts
S Technical success was defined as the ability to access
and drain a pseudocyst by placement of transmural
stents.
S Complications were assessed at 24 hours and at day 30.
S Treatment success was defined as the complete
resolution or decrease in size of the pseudocyst to <2 cm
on CT
S GASTROINTESTINAL ENDOSCOPY Volume 68, No. 6 : 2008
35. S 30 patients randomized to undergo pseudocyst drainage
by EGD or the EUS-guided approach.
S All patients who had an EUS underwent successful
drainage.
S EGD was technically successful in only 33%; all who
failed underwent successful drainage on crossover to
EUS.
S Major procedure related bleeding was encountered in 2
patients in whom drainage by EGD was attempted
S GASTROINTESTINAL ENDOSCOPY Volume 68, No. 6 : 2008
36. PREPARATION
S Routine antibiotic use is recommended for those not
already receiving broad- spectrum antibiotics for
presumed or documented infection.
S If possible, CO2 insufflation should be used to help
minimize the risk of air embolism, a rare but potentially
catastrophic complication
37. IDENTIFICATION OF
FISTULA SITE
S With EUS: Endosonography is used to identify the
appropriate site of transmural puncture.
S It is important to ensure that the cyst lumen is well
approximated against the luminal gastroinestinal
tract.
S The most appropriate site of transmural puncture
should ideally be through a combined wall of 10 mm
or less in thickness, although in some circumstances
up to 20 mm may be acceptable.
38. S Without EUS: External compression of the gastric or
duodenal wall is determined endoscopically while
referencing the most recent cross-sectional imaging
S Gastrointest Endoscopy Clin N Am 23 (2013) 787–
802
39. PUNCTURE
S Most endoscopists use a 19-gauge fine-needle aspiration
needle for puncture, and subsequently the needle sheath
for initial dilation.
S Aspiration of cavity contents and/or demonstration of
contrast injection into the cavity under fluoroscopic
guidance confirms cavity access and allows collection of
liquid for microbial culture.
40. Puncture of the
cavity by using the
sheath of an EUS
needle.
Validation of the
guidewire within the
cavity by using
fluoroscopic
guidance.
41. Multiple transluminal gateway
technique for EUS-guided drainage of
symptomatic walled-off pancreatic
necrosis
S Comparison between patients with walled-off pancreatic
necrosis managed endoscopically by a multiple transluminal
gateway technique (MTGT) or a conventional drainage
technique (CDT).
S In MTGT, 2 or 3 transmural tracts were created by using EUS
guidance between the necrotic cavity and the GI lumen.
S One tract was used to flush normal saline solution via a
nasocystic catheter, multiple stents were deployed in others to
facilitate drainage of necrotic contents
S In the CDT, two stents with a nasocystic catheter were
deployed via 1 transmural tract.
S GASTROINTESTINAL ENDOSCOPY Volume 74, No. 1 : 2011
42.
43. S Of 60 patients with symptomatic walled-off pancreatic
necrosis, 12 were managed by MTGT and 48 by CDT.
S Treatment was successful in 11 of 12 (91.7%) patients
managed by MTGT versus 25 of 48 (52.1%) managed by
CDT (P < .01)
S In the CDT cohort, 17 required surgery, 3 underwent
endoscopic necrosectomy, and 3 died of multiple-organ
failure.
S GASTROINTESTINAL ENDOSCOPY Volume 74, No. 1 : 2011
44. EUS versus surgical cystgastrostomy for
management of pancreatic pseudocysts.
S Matched 10 patients who underwent surgical cystgastrostomy with 20
patients who underwent an EUS-guided cystgastrostomy
S No significant differences in rates of treatment success (100% vs
95%), procedural complications (none in either cohort), or
reinterventions (10% vs 0%) was found.
S Mean length of a post procedure hospital stay for an EUS-guided
cystgastrostomy was significantly shorter than for surgical
cystgastrostomy (2.65 vs 6.5 days, P 5 .008).
S Direct cost per case for EUS-guided cystgastrostomy was
significantly less.
S Gastrointest Endosc 2008;68:649–55.
45. FISTULA TRACT CREATION
AND DILATATION
S Standard-sized guidewire (as small as 0.018 inch)
is advanced into the collection under fluoroscopic
guidance.
S Pseudocyst drainage - the tract is dilated to at least
10 mm in size using sequentially larger hydrostatic
balloons.
S Endoscopic debridement - the goal is to dilate the
fistula tract fully to 20 mm at the time of the first
endoscopy.
48. Stent placement for drainage
S Pseudocyst - place stents to maintain the patency of the fistula
tract and not necessarily act as a conduit for drainage.
S Recommend 10-F double-pigtail stents of 2 to 4 cm length,
preferably of soft material to minimize trauma to the back wall of the
cavity or intestinal obstruction if the stents migrate spontaneously.
S Alternatives are placement of a fully covered biliary type metallic
stent, or even various forms of larger enteral or esophageal metallic
stents to create a larger fistula.
S Gastrointest Endoscopy Clin N Am 23 (2013) 787–802
49. Insertion of pigtail & nasocystic catheter
10 F double pigtail
7 F nasocystic catheter
Irrigation with 1500 ml saline/24h
via nasocystic catheter
50. Debridement of WON
S Necrosis will often not resolve with the simple creation of a fistula
tract.
S Drive an endoscope through the dilated fistula tract into the
necrotic cavity.
S Devitalized pancreatic tissue can be removed via a combination of
several accessories including balloons, snares, waterjets,
baskets, and cap-suction techniques.
S Goal is to remove as much of the devitalized necrotic tissue as
possible from the cavity, but without disrupting a major vessel or
the wall of the cavity, potentially leading to perforation, bleeding,
or air embolus.
51. Endoscopic necrosectomy (≠ 1. session)
Dilate up to 18-20 mm
Insert a therapeutic gastroscope, generous lavage,
Instruments:
Dormia basket
Retrieval nets
Soft snares
Nasocystic catheter
Remove debris
53. S At conclusion of each debridement session, stents must
be left in place to allow the fistula tract to remain patent.
S Preferably to use pigtail stents as with the pseudocyst
drainage.
S Fully covered metal stents can be used which may allow
for dissolution of solid necrosis by gastric and bile acids
over several weeks to months ??
S Gastrointest Endoscopy Clin N Am 23 (2013) 787–802
57. TRANSPAPILLARY STENT
PLACEMENT
S Whether to perform direct pancreatography using
ERCP at the time of initial drainage is subject to
variable opinion.
S Transpapillary stenting of the duct is required if the
duct is found to have a persistent leak.
S In ill patients with infected necrosis, ERCP should
generally be avoided at the initial intervention and
postponed until after the infection is controlled.
58. Disconnected pancreatic duct
S Creating a cystenterotomy fistula tract will
usually allow for adequate pancreatic
drainage and general current practice it to
leave the stents across the fistula tract
permanently to allow for adequate pancreatic
drainage proximal to the site of disruption.
S Gastrointest Endoscopy Clin N Am 23 (2013)
787–802
59.
60. Direct endoscopic necrosectomy for the treatment
of walled-off pancreatic necrosis: results from a
multicenter U.S. series
S Largest published multicenter series to date
S Six U.S. tertiary medical centers.
S 104 patients with a history of acute pancreatitis
and symptomatic WOPN since 2003
S Gardner et al.Gastrointest Endosc 2011;73:718–26
61.
62.
63. S 14 % patients had complications
S 19 patients had bleeding requiring endoscopic intervention
S 2 patients had a retrogastric perforation
S 3 patients had pneumoperitoneum
S One death occurred during the initial débridement procedure
64. STEP UP APPROACH
S Minimally invasive technique is initially used
for drainage of WON such as percutaneous
drainage.
S Progress to minimally invasive necrosectomy
(by endoscopic, sinus tract endoscopy,
VARD, or open surgery) as needed.
65. Minimally invasive surgical
necrosectomy
S SINUS TRACT ENDOSCOPY
S VIDEO-ASSISTED RETROPERITONEAL DEBRIDEMENT
(VARD)
S Access to the necrotic pancreas is achieved by following the tract
of a radiologically placed drainage catheter.
66. Sinus tract endoscopy
S A nephroscope is inserted into the infected collection after dilatation
of the drain tract to 30 Fr under fluoroscopic guidance.
S Debridement is carried out using a long forceps, and the necrotic
cavity is flushed using jet irrigation and suction devices.
S Three to five procedures is needed for adequate necrosectomy.
S A large retrospective cohort series indicated that survival rates are
potentially better with sinus tract endoscopy compared with open
necrosectomy (mortality rate: 19 per cent of 137 patients versus 38
per cent of 52 patients)
S Minimal access retroperitoneal pancreatic necrosectomy: improvement in morbidity and mortality with a less invasive approach.
Ann Surg 2010; 251: 787 – 793
67. VIDEO-ASSISTED
RETROPERITONEAL DEBRIDEMENT
(VARD)
S Uses a 5-cm subcostal incision in the left flank near the exit
point of the percutaneous drain
S First solid debris that is encountered can be removed bluntly
using a long grasping forceps.
S Subsequently a laparoscope is introduced into the necrotic
cavity and more central necrotic debris can be removed
68.
69. A Step-up Approach or Open
Necrosectomy for Necrotizing
Pancreatitis (NEJM 2010)
S 88 patients with necrotizing pancreatitis and suspected or
confirmed infected necrotic tissue were randomized to
undergo primary open necrosectomy or a step-up
approach to treatment.
S Step-up approach consisted of percutaneous drainage
followed, if necessary, by minimally invasive
retroperitoneal necrosectomy
70. S Primary end point was a composite of major
complications (new-onset multiple-organ failure or
multiple systemic complications, perforation of a visceral
organ or enterocutaneous fistula, or bleeding) or death
S 31 of 45 patients (69%) assigned to open necrosectomy
and in 17 of 43 patients (40%) assigned to the step-up
approach
S 35% were treated with percutaneous drainage only (step
up group).
71. Endoscopic Transgastric vs Surgical
Necrosectomy
for Infected Necrotizing Pancreatitis
A Randomized Trial
S First and the only trial comparing endoscopic v/s surgical
necrosectomy.
S Objective To compare the proinflammatory response and clinical
outcome of endoscopic transgastric and surgical necrosectomy.
S 3 academic hospitals and 1 regional teaching hospital in the
Netherlands between August 20, 2008, and March 3, 2010.
Bakker OJ et al. JAMA 2012,307:1053-1061.
72.
73. S The primary end point was the postprocedural
proinflammatory response as measured by serum
interleukin 6 (IL-6) levels.
S Secondary clinical end points included a predefined
composite end point of major complications (new- onset
multiple organ failure, intra-abdominal bleeding,
enterocutaneous fistula, or pancreatic fistula) or death.
74.
75. ENDOSCOPIC
NECROSECTOMY
Significant reduction of proinflammatory
response (IL-6)
Significant reduction of major complications
(20% vs. 80%; P=0.03)
Reduction of pancreatic fistula (10% vs.70%;
P=0.02)
76.
77.
78. Comparative evaluation of structural and
functional changes in pancreas after
endoscopic and surgical management
of pancreatic necrosis
S Records of patients who underwent endoscopic transmural
drainage of walled off pancreatic necrosis (WOPN) over the last 3
years and who completed at least 6 months of follow up were
analyzed.
S Structural and functional changes in these patients were
compared with 25 historical surgical controls (operated in 2005-
2006)
S Surinder Singh Ranaa, Deepak Kumar Bhasin Annals of
79.
80.
81. KEY MESSAGES
Define the pancreatic fluid collection (Revised Atlanta classification)
Acute fluid collection: Usually no treatment
Collections > 4 weeks: Distinct between pseudocyst / WOPN
WOPN with solid material
Intervention in WOPN: Timing! Wait >3-4 weeks
Endoscopic interventions in WOPN: effective and safe
Editor's Notes
a heterogeneous, fully encapsulated collection is noted in the pancreatic and peripancreatic area. (A) Non-liquid components of high attenuation (black arrowheads) in the collection are noted. The collection has a thin, well defined, and enhancing wall (thick white arrows). (B, C) A largely liquefied collection in the bed of the pancreas is observed with non-liquid components representing areas of trapped fat (black arrowheads). (D) represents the corresponding T2-weighted MRI to (C), showing the true heterogeneity of the collection. Black arrowheads denote areas of necrotic debris surrounded by fluid (white on T2-weighted image)
Depending on the working channel of the linear echoendo−
scope used
a 10−Fr (working channel 3.7±3.8 mm) or 8.5−Fr
(working channel 3.2 mm) double pigtail stent is inserted
over the guide wire.
A
7−Fr nasoabscess catheter is then in−
serted over the second guide wire.
The abscess cavity is irrigated with 1500 mL saline daily.
The abscess cavity is recannulated and another 0.035−inch
guide wire is inserted. A 7−Fr nasoabscess catheter is then in−
serted over the guide wire and advanced to form at least one
loop inside the cavity to prevent it from being dislodged
when the duodenoscope is withdrawn.
8. The abscess cavity is irrigated with 1500 mL saline daily via
the nasoabscess catheter.
Once sepsis has resolved and there is no more purulent dis−
A, Cross-sectional view depicting an enlarged, partially necrotic pancreas with a peripancreatic collection containing fluid and necrosis. The preferred access route for video-assisted debridement is within the left retroperitoneal space to reach the necrotic collection between the left kidney and descending colon. A laparoscope is inserted, and long grasping forceps are used to debride the necrosis. B, The access route for natural orifice transluminal endoscopic surgery is through the posterior wall of the stomach. The necrotic collection most often bulges into the stomach facilitating endoscopic transgastric necrosectomy. After balloon dilatation of the puncture site in the stomach wall, the endoscope is introduced into the retroperitoneal space and loose necrotic material is removed.