CHICAGO – Placement of a U-tube drain provides enhanced percutaneous drainage and minimizes catheter-related complications in patients with complicated or infected necrotizing pancreatitis, new research suggests.
The U-tube method uses a large, 20-French Silastic tube with numerous large holes in the middle. One exit must be anterior through the peritoneal cavity and the other can be posterior in the retroperitoneum, Dr. Daniel E. Abbott said at the annual meeting of the Central Surgical Association.
Patrice Wendling/Frontline Medical News
Dr. Daniel E. Abbott
The novel drainage system allows bidirectional flushing, greater interface with large fluid collections leading to more rapid resolution of retroperitoneal necrosis, and less risk of dislodgement resulting in fewer catheter exchanges or replacements. The system also creates a large-bore fistula tract to fall back on should subsequent fistulojejunostomy be needed, said Dr. Abbott of the University of Cincinnati Medical Center.
He reported on the largest clinical experience with primary U-tube drainage to date, involving 22 patients with necrotizing pancreatitis (NP) treated from 2011 to 2014. In 7 patients, (32%) no surgical procedure was ultimately required.
Of the others, 13 required further surgical intervention for a disrupted duct, and (59%) 2 patients died (9.1% ), Dr. Abbott said. Among eight patients who underwent fistulojejunostomy and five who underwent distal pancreatectomy and/or splenectomy, NP resolved in all but one patient with a recurrent amylase-rich fluid leak.
Courtesy of the University of Cincinnati A typical pattern of pancreatic necrosis, with some degree of viable head and tail with necrotic tissue where the body of the pancreas previously was.
This compares favorably with a 20% mortality rate and 80% NP resolution among five institutional controls treated with open necrosectomy, he said.
Dr. Abbott acknowledged that the study was limited by small numbers and an insufficient control group for direct comparison.
Other studies have shown mortality rates in NP ranging from 39% with open necrosectomy to 4.5% with focused open necrosectomy, but their median length of stays were 54.5 days and 57 days, respectively. LOS was trimmed to just 19 days in one open necrosectomy study (Ann. Surg. 2008;247:294-9), but mortality was 11.4%, Dr. Abbott observed.
Dr. Abbott’s center is currently placing one to two U-tubes per month in patients with symptomatic NP (nausea, vomiting, weight loss, or infection on radiographic imaging) amenable to drainage and plans to update the analysis with prospectively collected data, including costs, in 2-3 years, he said.
Courtesy of the University of Cincinnati When placing the U-tube, one limb must exit anteriorly in the peritoneal cavity.
“The U-tube obviously seems to work very well, but ... our radiologists sometimes have a hard time placing just one single tube. That [U-]tube, in particular, has to come anterior and out posterior and other organs can potentially get in the way,” said Dr. Michael Ujiki, director of minimally invasive surgery at NorthShore University Health System, Evanston, Ill.
The morbidity and mortality rates are certainly better, but the improvements could be the result of improved ICU care or getting away from antibiotics, said Dr. Ujiki, a discussant at the meeting.
Dr. Abbott noted that “we are operating on people when they’re generally well instead of operating when they’re generally sick. When you’re doing an open necrosectomy, not only might there be multisystem organ failure, but [patients’] nutritional status is undoubtedly poor as well.”
Radiologists have yet to be unable to place a U-tube, but have delayed placement in stable, normotensive patients until fluid collections get larger to provide a better target, he said. The U-tube also can be placed at separate interventions. The two things patients complain most about are the size of the large tubes and when enzymatic fluid leaks onto their skin if the tube become clogged.