COMPLICATIONS OF PERCUTANEOUS DRAINAGE IN STEP-UP APPROACH FOR MANAGEMENT OF PANCREATIC NECROSIS: EXPERIENCE OF TEN YEARS FROM A TERTIARY CARE CENTRE
Rajesh Gupta*1, Aditya Kulkarni1, Raghavendra Y. Babu2, Sunil D. Shenvi3, Rahul Gupta4, Rohit K. Nimje1, Gopal Sharma1, Prateek Vaswani1, SRIRAM R. DEIVASIGAMANI1, Mandeep Kang5, Surinder S. Rana6
1Surgical Gastroenterology Division, Postgraduate Institute of Medical Education and Research, Chandigarh, India; 2Liver transplantation, Asian Institute of Gastroenterology, Hyderabad, Telangana, India; 3Multiorgan Transplantation and Hepatobiliary Surgery, Ruby Hall Clinic, Pune, Maharashtra, India; 4Gastrointestinal Surgery, Synergy Institute of Medical Sciences, Dehradun, Uttrakhand, India; 5Radiodiagnosis, Postgraduate Institute of Medical Education and Research, Chandigarh, Chandigarh, India; 6Gastroenterology, Postgraduate Institute of Medical Education and REsearch, Chandigarh, Chandigarh, India
Introduction:
Use of percutaneous catheter drainage (PCD) as initial treatment in necrotising pancreatitis has led to improved outcomes and obviated need for surgery in a significant proportion. However, PCD has its own complications including injury to visceral or vascular structures causing enterocutaneous fistulae (ECF) or bleeding. In this study, we reviewed our experience with PCD-related complications.
Methods:
Retrospective analysis of prospectively maintained database of patients with moderately severe and severe acute pancreatitis (revised Atlanta) who were treated by step-up approach in our unit was performed. All patients who underwent percutaneous catheter drainage were included from April 2008 to December 2018. PCD-related complications (ECF and bleeding) were reviewed in detail.
Results:
A total of 707 PCD catheters were utilized in 314 patients (median 2, range 1-8). Total number of interventions (insertion, repositioning, upsizing) was 1194 (median 4, range 1-11). Most commonly used size was 10 Fr and most commonly used imaging modality was ultrasound. Median interval between onset of illness to first PCD was 19 days (range 8-200) and median duration of drainage was 35 days (range 2-235).
PCD-related bleeding complications were seen in 7.3% (23/314) patients. Of those who bled, 34.7% (8/23) were managed conservatively and another 21.7% (5/23) required angiography and embolisation (of pseudo-aneurysms). Surgery was needed in 34.7% (8/23). 2 patients succumbed before initiation of treatment. Patients who bled had significantly increased need for surgery (p=0.02) and need for mechanical ventilator support (p=0.005). However, there was no significant difference in the length of hospital stay, ICU stay and mortality.
Enteric communication was noted in 8.9% (28/314) and 3.9% (28/707) of all PCD's. Fistula was communicating with colon in 71.4% (20/28), duodenum in 17.8% (5/28) and jejunum in 10.7% (3/28) patients. Fistulae were conservatively managed in 78.5% (22/28). Operative management was required in 30% of colonic and 40% of duodenal fistulae. There was no difference in need for surgery (p=0.105), length of hospital stay (p=0.252) or mortality (p=0.29) between those who developed enteric fistula and those who did not.
Conclusion:
Hollow viscus and vascular injuries are infrequent, yet important complications seen with PCD use in step-up approach. Bleeding complications related to PCD carry higher requirement for surgery and mechanical ventilatory support, however mortality remains similar to other patients with necrotizing pancreatitis. Majority (78.5%) of patients with enteric communication of PCD can be managed conservatively with success, with no added morbidity or mortality.
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