New opportunities in radiological diagnosis and defining the tactics of acute pancreatitis treatment.

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1 New opportunities in radiological diagnosis and defining the tactics of acute pancreatitis treatment. Poster No.: C-1536 Congress: ECR 2013 Type: Scientific Exhibit Authors: A. Arablinskiy, J. Sidorova, A. Shabunin, V. Bedin, D. Shikov, A. Osipovskaya, S. Lebedev; Moscow/RU Keywords: Abdomen, CT, MR, Computer Applications-Detection, diagnosis, Acute DOI: /ecr2013/C-1536 Any information contained in this pdf file is automatically generated from digital material submitted to EPOS by third parties in the form of scientific presentations. References to any names, marks, products, or services of third parties or hypertext links to thirdparty sites or information are provided solely as a convenience to you and do not in any way constitute or imply ECR's endorsement, sponsorship or recommendation of the third party, information, product or service. ECR is not responsible for the content of these pages and does not make any representations regarding the content or accuracy of material in this file. As per copyright regulations, any unauthorised use of the material or parts thereof as well as commercial reproduction or multiple distribution by any traditional or electronically based reproduction/publication method ist strictly prohibited. You agree to defend, indemnify, and hold ECR harmless from and against any and all claims, damages, costs, and expenses, including attorneys' fees, arising from or related to your use of these pages. Please note: Links to movies, ppt slideshows and any other multimedia files are not available in the pdf version of presentations. Page 1 of 33

2 Purpose Management of acute destructive pancreatitis remains to be one of the most difficult problems in clinical practice. (1) Destruction of pancreatic tissue and pancreatic capsule leads to output of pancreatic ferments into the blood and surrounding tissue outside the pancreas. (2) The severity of destructive and inflammatory process differs among patients and defines the seriousness of their condition and prognosis. (3) Moreover, in the past two decades, several radiologic prognostic scoring systems have been developed. Among them, the CT severity index (CTSI), designed by Balthazar. Its indexes are the most widely adopted for detecting surgical tactic. (4) However the Balthazar index does not allow detecting most favorable surgery method and timing of intervention. High postsurgery mortality rate remains to stand due to sepsis and sepsis complications. (5) The purpose of this work is to study possible variants of evolution of inflammatory destructive processes and to use the received data to create a score of retroperitoneal inflammation changes. we took the localization infiltration and collection in correlation to the position of nephric capsule along which the pancreatic secret is spread as the background of creating a new score. In contrast currently used classifications define the severity of the process depending on the quantity of collectors. (6,7) We aimed to find the most effective management tactic in different levels of destructive processes and to evaluate the clinical effectiveness of the new score. Page 2 of 33

3 Methods and Materials We studied 250 MDSCT and MRI images of patients with acute pancreatitis at Botkinskaya Hospital during the time frame of February 2007 through November 2011 (136 men, 114 women, median age 48,7 years (22-86 y) ( group #). We used the new score in experimental group of 198 patients with acute pancreatitis admitted to Botkinskaya Hospital from February 2011 through April 2012 (group #). Patients from group A were selected as a control group for results comparison. MDCT scanningprotocol slice CT scanner 16-slice CT scanner 18G IV cannula placed in a distal arm vein; crossed arms Scout: diaphraghm to femoral diaphisis. Scan volume from diapraghm to femoral diaphisis. Bolus track (Sure Start, Smart Prep); delay 20 sec after 200 H.U. in abdominal aorta, total delay 30-40sec. Pitch Factor: 0,828 Helical Pitch: 53 mas: fixed ml * 4.5 ml/s di iodinated contrast medium (370 mgi/ml). MDCT reformat / VR protocol Cor, Sag, ax/obl 3mm average images 3D VR images of the pancreas MRI / protocol At 1,5 T Ax T1 fat sat. 5mm Ax T2 fat sat. 5mm FAMA with bolus gadolinium contrast enhancement Post contr T1 fat sat Patient treatment Conservative treatment Percutaneous and endoscopic drainage Surgical necrosectomy Stage surgical method Open drainage Page 3 of 33

4 Results Pancreatic necrosis were discovered in 165 patients. We found out that pancreatic alteration start with enlargement and hipoperfusion of pancreas. Due to that small foci of necrosis under capsule of pancreas appear. (fig1). Larger plots of necrosis are result of merging. (8) Fig. 1: CT with intravenous bolus contrast, pancreatic phase, axial projection. In the tail and body pancreas are sub-capsule foci of necrosis susceptible to merging on the base of low density of contrasted parenchima References: Moscow medical academy named Botkin, City hospital named Botkin Moscow/RU We observed predominance of small sub-capsule foci of necrosis on all parts of gland. (fig. 2) Relation between size and localization of necrosis and volume of pancreas alteration. Page 4 of 33

5 Fig. 2: Relation between size and localization of necrosis and volume of pancreas alteration. References: Moscow medical academy named Botkin, City hospital named Botkin Moscow/RU We detected inflammatory changes in parapancreatic fat tissue of 197 patients. Minor infiltration of parapancreatic fat tissue was detected among 44 patients. (Fig 3) Page 5 of 33

6 Fig. 3: CT with intravenous bolus contrast, pancreatic phase, reconstruction in coronal projection. Minor viscous infiltration parapancreatic fat tissue detected (arrows). References: Moscow medical academy named Botkin, City hospital named Botkin Moscow/RU Intensive infiltration of parapancreatic fat tissue formed in 105 patients (53,2 %) on the average 5th +- 3,8 day. It was accompanied by significant volume increase of retroperitoneum fat. (Fig.4) Page 6 of 33

References: Moscow medical academy named Botkin, City hospital named Botkin Moscow/RU th Fluid collection formations were observed in 48 patients on the 15 +-6.2 days in peripancreatic space (fig.5).

7 Fig. 4: CT with intravenous bolus contrast, pancreatic phase, reconstruction in sagital (a) and coronal (b) projection. We observe infiltration, volume increase, inhomogeneity, small air bubbles in parapancreatic fat tissue (arrows), fluid in the omentum bursa (arrow). References: Moscow medical academy named Botkin, City hospital named Botkin Moscow/RU th Fluid collection formations were observed in 48 patients on the days in peripancreatic space (fig.5). Later collections were confined by the wall. Fig. 5: CT with intravenous bolus contrast pancreatic phase, axial projection and reconstruction in coronal projection. We observed acute perepancreatic fluid collection in the area of body of pancreas. The collection does not have sharp wall and spreads into radix mesocolon. References: Moscow medical academy named Botkin, City hospital named Botkin Moscow/RU Page 7 of 33

8 We observed the spread of parapancreatic changes in adjacent areas of retroperetoneum fat tissue. (table 1) Table 1 Correlation of parapancreatic changes and the range of adjacent areas. Peripancreatic changes Adjacent areas of spread Total Radix mesocolon Under left Radix hemidiaphragmmesenteric Mild infiltration n % 12,5% 62,5% 25,0% 100,0% Intensive infiltration n % 55,2% 41,4% 3,4% 100,0% Peripancreatic n collection % ,0% 18,8% 6,3% 100,0% Total n % 54,7% 37,7% 7,5% 100,0% Further spread of peritoneum inflammatory changes occurs downwards along anterior renal fascia all the way to the pelvis. A linear correlation was discovered between acute pancreatitis severity and grade of retroperitoneal inflammation spread. The correlation is presented in the chart. The horizontal axis presents APACHE II scores and the vertical axis presents the range of localization process contingently divided into 6 levels according to renal fascias and the side of lesion. (fig 6) Correlation between acute pancreatitis severity and grade of retroperitoneal inflammation spread. Page 8 of 33

Fig. 6 References: Moscow medical academy named Botkin, City hospital named Botkin Moscow/RU We discovered that the spread range of destructive process along the retroperitoneal tissue defines the

9 Fig. 6 References: Moscow medical academy named Botkin, City hospital named Botkin Moscow/RU We discovered that the spread range of destructive process along the retroperitoneal tissue defines the acute pancreatitis severity and serves as the base of our classification. 4 grades of retropancreatic spread were outlined. Parapancreatic expansion. Subgroup 1 consists of 81 patients. We detected formation of such changes in the parapancreatic space within this subgroup. These changes spread into the adjacent areas (table 1) but no lower than renal hilus. (Fig 7) Page 9 of 33

10 Fig. 7: CT with intravenous bolus contrast pancreatic phase, reconstruction in coronal projection. We observed intensive inhomogeneous infiltration in the parapancreatic space near the body and tail of the pancreas (arrows). References: Moscow medical academy named Botkin, City hospital named Botkin Moscow/RU Paranephral expansion.subgroup 2 consists of 76 patients. We detected formation of collections and infiltration in the parapancreatic and anterior pararenal space in patients from this subgroup but no longer than lower margin of renal fat capsule. (Fig.8) Page 10 of 33

11 Fig. 8: CT with intravenous bolus contrast pancreatic phase, reconstruction in sagital projection. We observed intensive infiltration of anterior pararenal space spreading along the renal fascia. (arrows) References: Moscow medical academy named Botkin, City hospital named Botkin Moscow/RU Infrarenal expansion.subgroup 3 consists of 57 patients. We observed formation of one or two side collections below the kidneys among the patients within this subgroup. Collections may have possible spreading into the pelvis. (Fig. 9) Page 11 of 33

12 Fig. 9: CT with intravenous bolus contrast, pancreatic phase, reconstruction in coronal projection. We observed infranephral spread of pancreatic secret with formation of collections below the left kidney (arrows). References: Moscow medical academy named Botkin, City hospital named Botkin Moscow/RU Collection within pancreas.subgroup 4 consists of 36 patients. We observed confined collections within pancreas usually combined with extensive pancreatic necrosis. (Fig.10).This subgroup included peripancreatic collection which implied walled-off pancreatic necrosis (WORN) (7,8) (Fig.11) Page 12 of 33

13 Fig. 10: CT with intravenous bolus contrast, pancreatic phase, axial projection. We observed confined collection within the body of the pancreas. References: Moscow medical academy named Botkin, City hospital named Botkin Moscow/RU Page 13 of 33

14 Fig. 11: CT with intravenous bolus contrast, pancreatic phase, reconstruction in coronal projection. We observed the inhomogeneous collection confined with wall (arrows). The collection surrounds necrotizing pancreas. References: Moscow medical academy named Botkin, City hospital named Botkin Moscow/RU All 250 patients diagnosed with acute pancreatitis were treated according to the standards of our clinic. We analyzed the methods and their results in each subgroup. We outlined the most effective and applicable tactics for each subgroup. (Table 2) Table 2 Efficiency of the treatment methods within the subgroups. Most effective n treatment in subgroups complications Non systemic(n) Fatalities (n) Septic (n) Page 14 of 33

15 Subgroup #1 58 (n=81) Conservative treatment Subgroup #2 51 (n=76) Percutaneous drainage Subgroup #3 49 (n=57) Stage surgical method Subgroup #4 28 (n=36) Percutaneous drainage or endoscopic drainage of collection We introduced this classification to the clinical practice within the experimental group of patients (group B). We divided the patients from the experimental group into 4 subgroups according to the classification. The first group consisted of 64 patients who underwent conservative treatment. The second subgroup consisted of 61 patients. 20 of those patients underwent conservative treatment. Percutaneous drainage was used in 36 cases. 4 patients required laparatomic operations. The third subgroup consisted of 45 patients. Stage surgical method was applied to 39 patients. This method consisted of radiological guided drainage at the first stage and open surgical necrosectomy with scheduled revisions at further stages. The fourth subgroup consisted of 28 patients. Percutaneous US guided drainage intrapancreatic fluid collection was applied to 23 patients. 5 patients underwent endoscopic drainage of collection. CT was performed before and after surgical intervention. MRI was performed to define the structure of changes in order to visualize fluid component or necrotic debris detection. (Fig.12, 13) Page 15 of 33

Fig. 12: CT with intravenous bolus contrast, pancreatic phase, axial projection. MRI, T2, axial projection. We observed inflammation in the anterior and posterior pararenal space.

16 Fig. 12: CT with intravenous bolus contrast, pancreatic phase, axial projection. MRI, T2, axial projection. We observed inflammation in the anterior and posterior pararenal space. (arrows) We detect high signal from fluid in these changes. (arrows) References: Moscow medical academy named Botkin, City hospital named Botkin Moscow/RU Fig. 13: MRI, T2, axial projection. On the background of hyperintense fluid content indentified areas of low signal relevant sequestrum. Page 16 of 33

17 References: Moscow medical academy named Botkin, City hospital named Botkin Moscow/RU Fluid collections in the omental bursa were the most often and the most effectively drained ones (47 % of cases) (Fig 14). Additional drainages were installed in case post-surgical CT detected undrained fluid collections. Fig. 14: CT with intravenous bolus contrast, pancreatic phase, axial projection. We observed fluid content in the omental bursa. Drainage proved ineffective. References: Moscow medical academy named Botkin, City hospital named Botkin Moscow/RU In case of infected fluid collection patients underwent maximum-delayed open surgery approach. (Fig.15) We designed surgical technique in advance by CT scan. (Fig. 16) Page 17 of 33

References: Moscow medical academy named Botkin, City hospital named Botkin Moscow/RU Fig. 16: CT with intravenous bolus contrast, pancreatic phase, axial projection before and after surgery.

18 Fig. 15: CT with intravenous bolus contrast, pancreatic phase, reconstruction in sagital (a) and coronal (b) projection. We observed an inhomogeneous confined with wall collection with fluid and gas bubbles content (arrows). The collection surrounds tail and body of the pancreas. References: Moscow medical academy named Botkin, City hospital named Botkin Moscow/RU Fig. 16: CT with intravenous bolus contrast, pancreatic phase, axial projection before and after surgery. We detected fluid collection upper body of pancreas and under left hemidiahpragm. After surgery collection successfully drained References: Moscow medical academy named Botkin, City hospital named Botkin Moscow/RU Results of treatment patients in group B were compared to the results in group A from first part of this study. (Table 3) Page 18 of 33

19 Table 3 Comparative results of patients treatment. Group B (n=198) Group A (n=250) Open surgical 27 (14%) interventions (n) 87 (34%) Local complications (n) 90 (36%) 25 (13%) Cases of infected 41 (21%) pancreatitis (n) 110 (44%) Septic complications (n) 23 (12%) 47 (18%) Fatalities (n) 16 (8%) 28 (11%) Group B (n=198) Group A (n=250) 12±1,1 3±2,3 Timing of surgery Percutaneous drainage Open surgical 28±3,2 interventions 60±7,4 Page 19 of 33

20 Images for this section: Fig. 1: CT with intravenous bolus contrast, pancreatic phase, axial projection. In the tail and body pancreas are sub-capsule foci of necrosis susceptible to merging on the base of low density of contrasted parenchima Moscow medical academy named Botkin, City hospital named Botkin - Moscow/RU Page 20 of 33

21 Fig. 2: Relation between size and localization of necrosis and volume of pancreas alteration. Moscow medical academy named Botkin, City hospital named Botkin - Moscow/RU Page 21 of 33

22 Fig. 3: CT with intravenous bolus contrast, pancreatic phase, reconstruction in coronal projection. Minor viscous infiltration parapancreatic fat tissue detected (arrows). Moscow medical academy named Botkin, City hospital named Botkin - Moscow/RU Page 22 of 33

23 Fig. 17: CT with intravenous bolus contrast, pancreatic phase, reconstruction in sagital projection. We observe infiltration, volume increase, inhomogeneity, small air bubbles in parapancreatic fat tissue (arrows), fluid in the omentum bursa (arrow) Moscow medical academy named Botkin, City hospital named Botkin - Moscow/RU Page 23 of 33

24 Fig. 18: CT with intravenous bolus contrast, pancreatic phase, reconstruction in coronal. We observe infiltration, volume increase, inhomogeneity, small air bubbles in parapancreatic fat tissue (arrows), fluid in the omentum bursa (arrow) Moscow medical academy named Botkin, City hospital named Botkin - Moscow/RU Page 24 of 33

25 Fig. 7: CT with intravenous bolus contrast pancreatic phase, reconstruction in coronal projection. We observed intensive inhomogeneous infiltration in the parapancreatic space near the body and tail of the pancreas (arrows). Moscow medical academy named Botkin, City hospital named Botkin - Moscow/RU Page 25 of 33

26 Fig. 8: CT with intravenous bolus contrast pancreatic phase, reconstruction in sagital projection. We observed intensive infiltration of anterior pararenal space spreading along the renal fascia. (arrows) Moscow medical academy named Botkin, City hospital named Botkin - Moscow/RU Page 26 of 33

27 Fig. 9: CT with intravenous bolus contrast, pancreatic phase, reconstruction in coronal projection. We observed infranephral spread of pancreatic secret with formation of collections below the left kidney (arrows). Moscow medical academy named Botkin, City hospital named Botkin - Moscow/RU Page 27 of 33

28 Fig. 11: CT with intravenous bolus contrast, pancreatic phase, reconstruction in coronal projection. We observed the inhomogeneous collection confined with wall (arrows). The collection surrounds necrotizing pancreas. Moscow medical academy named Botkin, City hospital named Botkin - Moscow/RU Page 28 of 33

29 Fig. 10: CT with intravenous bolus contrast, pancreatic phase, axial projection. We observed confined collection within the body of the pancreas. Moscow medical academy named Botkin, City hospital named Botkin - Moscow/RU Page 29 of 33

30 Fig. 13: MRI, T2, axial projection. On the background of hyperintense fluid content indentified areas of low signal relevant sequestrum. Moscow medical academy named Botkin, City hospital named Botkin - Moscow/RU Page 30 of 33

31 Fig. 14: CT with intravenous bolus contrast, pancreatic phase, axial projection. We observed fluid content in the omental bursa. Drainage proved ineffective. Moscow medical academy named Botkin, City hospital named Botkin - Moscow/RU Page 31 of 33

32 Conclusion The use of this improved four grade classification allowed to define the most effective treatment tactic of patients with acute pancreatitis. The applied approach allowed to reduce the number of laparotomy surgical interventions, postpone the timing of their application, reduce the number of infected cases, septic complications and mortality. (Table 3) Table 3 Comparative results of patients treatment. Group B (n=198) Group A (n=250) Open surgical 27 (14%) interventions (n) 87 (34%) Local complications (n) 90 (36%) 25 (13%) Cases of infected 41 (21%) pancreatitis (n) 110 (44%) Septic complications (n) 23 (12%) 47 (18%) Fatalities (n) 16 (8%) 28 (11%) Group B (n=198) Group A (n=250) 12±1,1 3±2,3 Timing of surgery Percutaneous drainage Open surgical 28±3,2 interventions 60±7,4 Page 32 of 33

33 References Marc G. H. Besselink, HC van Santvoort, TL Bollen, MA Boermeester Management of patients with severe acute #ancreatitis in the new millennium: prophylaxis, nutrition, imaging and intervention; Netherlands journal of critical care : Marja-Leena Kylänpää, Heikki Repo, Pauli Antero Puolakkainen Inflammation and immunosuppression in severe acute pancreatitis World J Gastroenterol 2010 June 21; 16(23): Su Mi Woo, Mying Hwan Noh, Byung Geun Kim at al. Coparison of Serum Procalcitoninum with Ranson, APACHE - II, Glasgow and Bathazar CT Severity Scores in predicting Severity of acute Pancreatitis Korean J Gastroenterol, Vol. 58 No1, July Bollen T.L., Singh V.K., Banks P. A. Comparative Evaluation of the Modified CT Severity Index and CT Severity Index in Assessing Severity of Acute Pancreatitis/ARJ 2011; 197: ####### #.#., ####### #.#., ###### #.#. ############# ####### ###### ########### # ########### ######## ####### ### ###### ############# ########### //########/ ####### ##### ############## ############ 2010 ###11 ###1 # IAP Guidelines for the Surgical Management of Acute Pancreatitis Pancreatology/2002; 2: Marc G. H. Besselink, Hjalmar C. van Santvoort et all Describing Computed Tomography Findings in Acute Necrotizing Pancreatitis With the Atlanta Classification; An Interobserver Agreement Study; Pancreas ;33: Kovalska I., Dronov O., Zemskov S. at al Patterns of Pathomorphological Changes in Acute Necrotizing Pancreatitis/ International Journal of Inflammation Volume 2012, Kiiv, Article ID , 4 pages Stamatacos M., Charikleia C., Kontzoglou K. et al. Walled-off pancreatic necrosis/world J Gastroenterol 2010 Apr 14; 16(14) Ramia J.M., de la Plaza R., Quiñones-Sampedro J.E. Walled-off pancreatic necrosis/the Netherland Jornal of Medicine May 2012 Vo l70 No Page 33 of 33

64-MDCT imaging of the pancreas: Scan protocol optimisation by different scan delay regimes

64-MDCT imaging of the pancreas: Scan protocol optimisation by different scan delay regimes Poster No.: C-051 Congress: ECR 2009 Type: Scientific Exhibit Topic: Abdominal and Gastrointestinal Authors: