Endoscopic approach to pancreatic pseudocyst, abscess and necrosis: review on recent progress

Medical and surgical management of pancreatic fluid accumulations in dogs: A retrospective study of 15 cases

BACKGROUND

Limited data exist on the diagnosis and successful medical management of suspected pancreatic abscessation, and the appropriate terminology of this condition.

HYPOTHESIS/OBJECTIVES

To describe the diagnosis and management of pancreatic fluid accumulations in dogs where pancreatic fluid cytology results were available, to describe those medically and surgically managed at the same institution, and reconsider the terminology describing acute pancreatitis with pancreatic fluid accumulation.

ANIMALS

Fifteen dogs treated for suspected pancreatic abscessation at a university teaching hospital between January 2010 and March 2020.

METHODS

Retrospective descriptive study.

RESULTS

Ultrasonographic findings described pancreatic fluid accumulations as hypoechoic in 10/15 and anechoic in 2/15 cases, ranging between 1.6 and 7 cm in diameter (median, 3.5 cm). No complications were documented after ultrasound guided fine-needle aspiration. Cytologically, all samples revealed a predominantly neutrophilic inflammation. 11/15 samples yielded a negative culture (9/11 received antimicrobials before sampling) and in 4 cases culture was positive. 7/15 were initially managed surgically including all 4 infected cases. 4/7 surgically managed cases were discharged, including 2 infected cases. The remaining 3/7 surgically managed cases were euthanized due poor quality of life. 8/15 cases were managed medically; 7/8 were discharged, 1 died. 3/7 then represented, and underwent successful surgical intervention after recrudescence of clinical signs, and all were discharged. The remaining 4 medically managed cases did not require further therapeutic intervention, with no clinical deterioration on reassessment.

CONCLUSIONS AND CLINICAL IMPORTANCE

Medical management is a viable treatment option for some dogs with pancreatic fluid accumulation, or as a prequel to surgical management. Subclassifications of pancreatic fluid accumulations using diagnostic findings could enable more tailored management approaches and accurate prognostication.

Analysis of a Step-Up Approach Versus Primary Open Surgical Necrosectomy in the Management of Necrotizing Pancreatitis: Experience in a Cohort of Patients at a US Academic Medical Center

OBJECTIVES

An increasing number of providers have begun to use a minimally invasive step-up approach as opposed to traditional surgical necrosectomy in the management of acute necrotizing pancreatitis. Studies have shown mixed results, thus we hypothesized that the step-up approach is safer and associated with decreased mortality and length of stay (LOS).

METHODS

This is a retrospective cohort study of patients admitted from January 2010 to March 2015 who underwent interventions for walled-off pancreatic necrosis (WOPN). Primary outcomes included LOS after intervention and mortality, in-hospital and 90-day, with secondary outcomes of procedural complications.

RESULTS

Sixty-nine patients developed WOPN requiring intervention during the study period. In-hospital mortality was 5.6% (n = 2) in the step-up cohort compared with 18.2% (n = 6) in the surgical cohort (relative risk, 3.27; 95% confidence interval, 0.71-15.09). Ninety-day mortality was 9.1% (n = 3) in the step-up cohort and 21.9% (n = 7) in the surgical cohort (relative risk, 2.41; 95% confidence interval, 0.68-8.50). Postintervention LOS was 8 days in the step-up cohort and 17 days in the surgical cohort (P = 0.62).

CONCLUSIONS

A step-up approach, as compared with primary surgical necrosectomy in the management of WOPN, results in clinically significant decreases in mortality and LOS.

Diagnosis and treatment of severe acute pancreatitis: Current status and main problems

Acute pancreatitis (AP) is a disease of various causes, characterized by pancreatic enzyme activation and local pancreatic inflammatory response. Serious cases may develop systemic inflammatory response syndrome and even organ dysfunction. Severe AP (SAP) as a category of AP associated with persistent organ failure (>48 h) has an acute onset and high fatality rate. SAP accounts for about 5%-10% of all AP cases, with 30%-50% mortality rate. In this paper, we discuss the current status and main problems on the diagnosis and treatment of SAP based on the literature and our experience.

Endoscopic ultrasonography in interventional diagnosis and treatment of digestive diseases

Since 1980, when endoscopic ultrasonography (EUS) was invented, great progress has been made in the development of EUS devices and technology, and EUS-guided diagnosis and treatment of digestive diseases have been widely adopted. Because of its safety, effectiveness and minimal invasion, EUS-guided interventional diagnosis and treatment of digestive diseases have been widely applied in the clinical work, and more and more new technologies are being developed. In this paper, we review the recent progress of EUS for the interventional diagnosis and treatment of digestive diseases.

Consensus guidelines on severe acute pancreatitis

This Position Paper contains clinically oriented guidelines by the Italian Association for the Study of the Pancreas (AISP) for the diagnosis and treatment of severe acute pancreatitis. The statements were formulated by three working groups of experts who searched and analysed the most recent literature; a consensus process was then performed using a modified Delphi procedure. The statements provide recommendations on the most appropriate definition of the complications of severe acute pancreatitis, the diagnostic approach and the timing of conservative as well as interventional endoscopic, radiological and surgical treatments.

Robotic-assisted cystogastrostomy for a patient with a pancreatic pseudocyst

Pancreatic pseudocysts are generally treated by endoscopic cystogastrostomy. However, difficult cases involving abscess, necrosis, or risk of hemorrhage often require surgical intervention. Here, we report a case of a robotically assisted cystogastrostomy. The patient presented with an infected pseudocyst with adjacent varices. Use of the da Vinci Surgical System allowed us to create a widely patent anastomosis between the pseudocyst and the stomach. The patient tolerated the procedure well without any complications. This report demonstrates the feasibility of robotic cystogastrostomy.