Pancreatitis, or inflammation of the pancreas, has many different causes, from alcohol consumption to a migrated and lodged gallstone. Regardless of cause, pancreatitis can be difficult to treat because of its location in the middle of the abdomen surrounded by other vital organs and blood vessels. Pancreatitis is often associated with infected necrotic tissue, abdominal fluid collections, as well as vascular injury which the appropriate treatment is necessary for a successful recovery. Despite great advances in critical care, this disease can become life threatening without complex care coordination.
Zachary T. Berman, MD
In general, an IR can drain fluid collections percutaneously, a gastroenterologist can handle collections near the bowel, and surgeons can operate on an area that won’t interfere with too many arteries or other critical organs. However, the pancreas is in a very difficult to access area: it’s near the skin … but not really. Near the intestines … but not really. And is surrounded by organs and blood vessels deep in the abdomen. Given the complex nature of this disease, no one specialty has the ideal treatment. Necrotizing pancreatitis truly requires multiple teams, numerous procedures and coordination over prolonged period.
Amy E. Liepert, MD, FACS
At our institution, we have a three-person team which mobilizes to treat all pancreatitis patients who enter our system. This team, which was created 2 years ago, consists of an IR, a surgeon and an interventional gastroenterologist. The three of us coordinate patient care so from when a patient presents with pancreatitis, we’re all aware of that patient from day 1, regardless of whether one of us is needed for treatment that day.
Our team works together to determine and achieve the best plan of care. As the patient’s course progresses, if one of our services is needed, we already are all aware of the patient’s needs. We can also discuss advantages and disadvantages of each approach in order to optimize the overall care plan. From an IR perspective, other options of care that may supplement what the GI or surgeon can provide can also be recommended. For example, our surgeon performs a procedure called “video-assisted retroperitoneal debridement” (VARD) which uses a camera to access the pancreas to allow for removal of the dead tissue. This uses the “Step-Up” care process in which IR is needed to place percutaneous retroperitoneal drains for the surgeon to follow to reach the pancreas and remove the necrotic tissue. We place image-guided drains in specific locations for them to follow into the pancreas, so they will not need to dig through the intraperitoneal abdomen. These drains are important since not only do they drain the fluid collection but can create a conduit for surgeons to perform a minimally invasive a surgery to debride any necrotic pancreas, potentially allowing our drains to be removed sooner. Proper drain placement requires discussions between IR and surgery to ensure that it is placed in such a way that is suitable for the surgical approach.
Necrotizing pancreatitis truly requires multiple teams, numerous procedures and coordination over prolonged period.
Another complication from pancreatitis are pseudoaneurysms, or artery injury from the inflammation. Pseudoaneurysms are a potentially life-threatening condition, and if ruptured, they can cause a large hemorrhage. They historically present as a sentinel bleed follows by other progressively worse bleeding that is difficult to impossible to control surgically. This is important to identify, as we can perform rapid embolization to treat the pseudoaneurysm before it ruptures. By having IR, as vascular imaging specialists, review the imaging on every patient, we can detect these injuries early, potentially before they are a problem.
Pancreatitis is also associated with diffuse abdominal pain. IR has a role with celiac nerve blocks which allow for assistance with pain management and decreased dependence on opioid usage. We discuss this procedure with our patients early in their course. This procedure is often performed at the same time as drainage catheter placement, is safe, and can be performed in a short period of time.
We feel that our multidisciplinary team is especially beneficial, because patients with pancreatitis may sometimes be in the system for 6 months or more. During that time, they receive multiple tests and imaging scans, and if a new physician enters the pipeline after months of care, they may order a duplicate test or change the direction of the care plan. In our model, the same core team thinks about and cares for a patient from the first day of treatment to the last. Working at an academic institution, where there are a lot of collaborating physicians, it was occasionally discouraging when we would work on a patient with complex planning needs for 5 months, only for a new team to come in and create a different set of plans since they were the team that was “currently on call”. Other partners usually sub in as needed for procedures depending on the staffing, but the overall treatment trajectory was created as a consensus of our multidisciplinary team.
In addition to providing better coordinated care, this multidisciplinary model has also made our institution a referral center for patients with pancreatitis because we can offer specialized care, ambulatory staff and a clinic dedicated to following these patients through their recovery journey.
We are very proud of this multidisciplinary team. It’s had great success and is a simple model that can be easily duplicated. If any other IR is interested in establishing a similar clinic, all they need is dedicated partners and buy-in from administration. The benefits of coordinated care are unparalleled.
