Fluid Collections and Pseudocysts as a Complication of Acute Pancreatitis

Association between acute peripancreatic fluid collections and early readmission in acute pancreatitis: A propensity-matched analysis

BACKGROUND

Patients with acute pancreatitis (AP) frequently experience hospital readmissions, posing a significant burden to healthcare systems. Acute peripancreatic fluid collection (APFC) may negatively impact the clinical course of AP. It could worsen symptoms and potentially lead to additional complications. However, clinical evidence regarding the specific association between APFC and early readmission in AP remains scarce. Understanding the link between APFC and readmission may help improve clinical care for AP patients and reduce healthcare costs.

AIM

To evaluate the association between APFC and 30-day readmission in patients with AP.

METHODS

This retrospective cohort study is based on the Nationwide Readmission Database for 2016-2019. Patients with a primary diagnosis of AP were identified. Participants were categorized into those with and without APFC. A 1:1 propensity score matching for age, gender, and Elixhauser comorbidities was performed. The primary outcome was early readmission rates. Secondary outcomes included the incidence of inpatient complications and healthcare utilization. Unadjusted analyses used Mann-Whitney U and χ 2 tests, while Cox regression models assessed 30-day readmission risks and reported them as adjusted hazard ratios (aHR). Kaplan-Meier curves and log-rank tests verified readmission risks.

RESULTS

A total of 673059 patients with the principal diagnosis of AP were included. Of these, 5.1% had APFC on initial admission. After propensity score matching, each cohort consisted of 33914 patients. Those with APFC showed a higher incidence of inpatient complications, including septic shock (3.1% vs 1.3%, P < 0.001), portal venous thrombosis (4.4% vs 0.8%, P < 0.001), and mechanical ventilation (1.8% vs 0.9%, P < 0.001). The length of stay (LOS) was longer for APFC patients [4 (3-7) vs 3 (2-5) days, P < 0.001], as were hospital charges ($29451 vs $24418, P < 0.001). For 30-day readmissions, APFC patients had a higher rate (15.7% vs 6.5%, P < 0.001) and a longer median readmission LOS (4 vs 3 days, P < 0.001). The APFC group also had higher readmission charges ($28282 vs $22865, P < 0.001). The presence of APFC increased the risk of readmission twofold (aHR 2.52, 95% confidence interval: 2.40-2.65, P < 0.001). The independent risk factors for 30-day readmission included female gender, Elixhauser Comorbidity Index ≥ 3, chronic pulmonary diseases, chronic renal disease, protein-calorie malnutrition, substance use disorder, depression, portal and splenic venous thrombosis, and certain endoscopic procedures.

CONCLUSION

Developing APFC during index hospitalization for AP is linked to higher readmission rates, more inpatient complications, longer LOS, and increased healthcare costs. Knowing predictors of readmission can help target high-risk patients, reducing healthcare burdens.

Endotherapy in Pancreatic Diseases

Interventional endoscopy is now considered an effective minimally invasive treatment modality for the management of pancreatic diseases. It is important for the clinician to know the indications and contraindications as well as the timing of various endoscopic interventions. This will help in its safe and effective use and consequently decrease morbidity and mortality from various pancreatic diseases. This review will provide a broad overview of the indications, techniques, and outcomes of pancreatic endotherapy.

Intraluminal endoscopy in diagnosis and treatment of fluid collections in acute pancreatitis

OBJECTIVE

To improve treatment outcomes in patients with acute pancreatitis through a differentiated approach to transluminal drainage.

MATERIAL AND METHODS

There were 1074 patients with acute pancreatitis between January 2018 and December 2021 at the Sklifosovsky Research Institute for Emergency Care. EUS was used as a final diagnostic method to determine localization, dimensions, shape and contours of fluid collections. We also assessed content, presence or absence of a capsule and connection with pancreatic ductal system, possibility of intraluminal drainage under EUS control. A plastic stent with rounded ends was installed if homogeneous hypo- and anechoic cavity with clear even contours was detected. The same measure was applied in case of aspiration of serous or serous-hemorrhagic fluid. The indication for installation of covered self-expanding endoprosthesis was inhomogeneous anechoic fluid collection with hyperechoic inclusions (sequesters) and cloudy purulent content. Patients with necrotic forms underwent insertion of a cystonasal drainage tube 7Fr for sanitation of the cavity with 0.05% aqueous chlorhexidine solution. Endoscopic sequestrectomy was performed every 24-48 hours. Stent was removed in 6 (for encapsulated peripancreatic fluid collections) or 1 month (for other types of fluid collections) after discharge.

RESULTS

According to the EUS data, endoscopic TLD was performed in 63 (46%) out of 136 patients with fluid collections. Among 63 patients with TLD, connection with pancreatic ductal system was found in 5 (7.9%) patients. These ones underwent pancreaticoduodenal stenting. Twenty-two patients underwent elective sequestrectomy after stenting of necrotic types of fluid collections with fully covered self-expanding stents. Additional percutaneous drainage was required in 11 (45.8%) of 24 patients. Complicated postoperative period was observed in 4 (6.3%) patients with acute necrotic fluid collections (bleeding from the area of pancreatogenic destruction). Four (6.3%) patients died. Autopsy revealed resolution of purulent-inflammatory process in all patients.

CONCLUSION

Intraluminal surgery is possible not only for homogeneous delimited fluid collections, but also for advanced lesions including infected destructions. This approach allows us to consider endoscopic intraluminal drainage as the final minimally invasive method of surgical treatment of pancreatic necrosis. Its effectiveness is up to 45.8%.

Cardiac depression in severe acute pancreatitis: development mechanisms and possible treatment approaches. Review

Cardiac depression, also known as myocardial depression, is one of the typical complications of severe acute pancreatitis. The review describes modern views on the mechanism of development of this phenomenon; the place of the term «myocardial depression factor» at the current stage of study of the problem was discussed; pathogenetic factors of myocardial depression requiring further study have been identified. An attempt to consider cardiac depression as a phenomenon involving the whole cardiovascular system, rather than the heart along, was made. Each pathophysiological factor is examined in terms of the possibility of clinical use.

A narrative review of acute pancreatitis and its diagnosis, pathogenetic mechanism, and management

Acute pancreatitis (AP) is an inflammatory disease that can progress to severe acute pancreatitis (SAP), which increases the risk of death. AP is characterized by inappropriate activation of trypsinogen, infiltration of inflammatory cells, and destruction of secretory cells. Other contributing factors may include calcium (Ca²⁺) overload, mitochondrial dysfunction, impaired autophagy, and endoplasmic reticulum (ER) stress. In addition, exosomes are also associated with pathophysiological processes of many human diseases and may play a biological role in AP. However, the pathogenic mechanism has not been fully elucidated and needs to be further explored to inform treatment. Recently, the treatment guidelines have changed; minimally invasive therapy is advocated more as the core multidisciplinary participation and "step-up" approach. The surgical procedures have gradually changed from open surgery to minimally invasive surgery that primarily includes percutaneous catheter drainage (PCD), endoscopy, small incision surgery, and video-assisted surgery. The current guidelines for the management of AP have been updated and revised in many aspects. The type of fluid to be used, the timing, volume, and speed of administration for fluid resuscitation has been controversial. In addition, the timing and role of nutritional support and prophylactic antibiotic therapy, as well as the timing of the surgical or endoscopic intervention, and the management of complications still have many uncertainties that could negatively impact the prognosis and patients' quality of life. Consequently, to inform clinicians about optimal treatment, we aimed to review recent advances in the understanding of the pathogenesis of AP and its diagnosis and management.

Duodeno-pancreatic and extrahepatic biliary tree trauma: WSES-AAST guidelines

Duodeno-pancreatic and extrahepatic biliary tree injuries are rare in both adult and pediatric trauma patients, and due to their anatomical location, associated injuries are very common. Mortality is primarily related to associated injuries, but morbidity remains high even in isolated injuries. Optimal management of duodeno-bilio-pancreatic injuries is dictated primarily by hemodynamic stability, clinical presentation, and grade of injury. Endoscopic and percutaneous interventions have increased the ability to non-operatively manage these injuries. Late diagnosis and treatment are both associated to increased morbidity and mortality. Sequelae of late presentations of pancreatic injury and complications of severe pancreatic trauma are also increasingly addressed endoscopically and with interventional radiology procedures. However, for moderate and severe extrahepatic biliary and severe duodeno-pancreatic injuries, immediate operative intervention is preferred as associated injuries are frequent and commonly present with hemodynamic instability or peritonitis. The aim of this paper is to present the World Society of Emergency Surgery (WSES) and American Association for the Surgery of Trauma (AAST) duodenal, pancreatic, and extrahepatic biliary tree trauma management guidelines.

Elevating pancreatic cystic lesion stratification: Current and future pancreatic cancer biomarker(s)

Pancreatic ductal adenocarcinoma (PDAC) is an incredibly deadly disease with a 5-year survival rate of 9%. The presence of pancreatic cystic lesions (PCLs) confers an increased likelihood of future pancreatic cancer in patients placing them in a high-risk category. Discerning concurrent malignancy and risk of future PCL progression to cancer must be carefully and accurately determined to improve survival outcomes and avoid unnecessary morbidity of pancreatic resection. Unfortunately, current image-based guidelines are inadequate to distinguish benign from malignant lesions. There continues to be a need for accurate molecular and imaging biomarker(s) capable of identifying malignant PCLs and predicting the malignant potential of PCLs to enable risk stratification and effective intervention management. This review provides an update on the current status of biomarkers from pancreatic cystic fluid, pancreatic juice, and seromic molecular analyses and discusses the potential of radiomics for differentiating PCLs harboring cancer from those that do not.

Multivariate analysis of the factors affecting the prognosis of walled-off pancreatic necrosis after endoscopic ultrasound-guided drainage

BACKGROUND AND AIMS

Endoscopic ultrasound (EUS)-guided drainage has become the treatment of choice for walled-off pancreatic necrosis (WOPN). However, no consensus exists on the most significant patient- and procedure-related factors that affect prognosis. The aim of the study is to investigate the correlation between patient- and procedure-related factors and post-procedure complications after EUS-guided drainage.

METHODS

A retrospective analysis of the clinical characteristics of patients with WOPN who underwent EUS-guided drainage at our endoscopy center between November 2011 and August 2017 was performed. Chi-square analysis and binary logistic regression statistical methods were used to analyze the correlation between influencing factors and prognosis.

RESULTS

A total of 85 patients (male/female, 50/35) with WOPN were included in the study. The average age was 44.95 years. The cyst diameter was 10.58 ± 4.78 cm. Multivariate analysis showed that WOPN with higher solid content (> 30%) increased the probability of endoscopic necrosectomy (OR 6.798; 95% CI 1.423, 32.470; p = 0.016). The use of a metal stent increased the probability of endoscopic necrosectomy (OR 3.503; 95% CI 1.251, 9.810; p = 0.017) and the length of hospitalization (OR 3.315; 95% CI 1.192, 9.215; p = 0.022). Female patients had a higher probability of requiring endoscopic necrosectomy (OR 2.683; 95% CI 1.027, 7.007; p = 0.044) and prolonged hospitalization (OR 2.675; 95% CI 1.065, 6.721; p = 0.036).

CONCLUSION

The solid content of WOPN, type of stent, and sex of patients were associated with increased probability of endoscopic necrosectomy.

Does Etiology of Pancreatitis Matter? Differences in Outcomes Among Patients With Post-Endoscopic Retrograde Cholangiopancreatography, Acute Biliary, and Alcoholic Pancreatitis

OBJECTIVES

We compared outcomes of acute alcoholic pancreatitis (AAP), acute biliary pancreatitis (ABP), and post-endoscopic retrograde cholangiopancreatography pancreatitis (PEP).

METHODS

This was a retrospective cohort study conducted at a tertiary care center between June 2007 and June 2012.

RESULTS

A total of 300 (68%) patients were diagnosed with AAP, 88 (20%) with ABP, and 55 (12%) with PEP. Longer length of hospital stay (LOHS) was more common in ABP (23%) as compared with AAP (10%) and PEP (7%, P = 0.025). Pseudocyst (P = 0.048), organ failure (OF) (P = 0.01), need for interventions (P ≤ 0.001), and mortality (P = 0.002) occurred more in ABP as compared with other groups. Systemic inflammatory response syndrome was associated with LOHS of more than 10 days (P = 0.01) and multi-OF (P = 0.05). Chronic pancreatitis was associated more with pseudocyst (P < 0.001) and mortality (P = 0.03). Serum urea nitrogen of greater than 25 g/dL predicted LOHS of more than 10 days (P = 0.02), OF (P < 0.001), multi-OF (P < 0.001), and persistent OF (P < 0.001).

CONCLUSIONS

Acute biliary pancreatitis is a more severe disease compared with PEP and AAP. Chronic pancreatitis, systemic inflammatory response syndrome, and high serum urea nitrogen are important predictors of morbidity.

Arterial Pseudoaneurysm within a Pancreatic Pseudocyst

The formation of pancreatic pseudocysts and (pseudo-)aneurysms of intestinal vessels are rare but life-threatening complications in acute and chronic pancreatitis. Here we report the rare case of a patient suffering from chronic pancreatitis with an arterial pseudoaneurysm within a pancreatic pseudocyst and present its successful therapeutic management by angioembolization to prevent critical bleeding. A 67-year-old male with a history of chronic pancreatitis presented with severe acute abdominal pain and vomiting to the emergency department. Seven weeks prior to the present admission, a CT scan had displayed a pancreatic pseudocyst with a maximum diameter of 53 mm. A laboratory examination revealed an elevated white blood cell count (15.40 × 103/μL), as well as elevated serum lipase (191 U/L), bilirubin (1.48 mg/dL), and blood glucose (353 mg/dL) levels. Sonographically, the previously described pancreatic pseudocyst revealed a slightly increased maximum diameter of 65 mm and an inhomogeneous echo of the cystic content. A contrast-enhanced CT scan showed a further increase in maximum diameter to 70 mm of the known pseudocyst. Inside the pseudocyst, a pseudoaneurysm originating from the splenic artery with a maximum diameter of 41 mm was visualized. After interdisciplinary consultation, prophylactic coil embolization of the splenic artery was immediately performed. The pseudoaneurysm was shut off from blood supply by back-door/front-door occlusion employing 27 coils, resulting in complete exclusion of the pseudoaneurysm from the circulation. Pseudoaneurysms are a rare complication of acute and chronic pancreatitis which has been shown to be efficiently treated by coil embolization.