Management of pancreatic ductal leaks and fistulae

Determining the value of endoscopic retrograde cholangiopancreatography in the management of patients with acute pancreatitis and related complications

INTRODUCTION

Endoscopic retrograde cholangiopancreatography (ERCP) has evolved from a diagnostic to a therapeutic tool in acute pancreatitis management, largely due to the availability of less invasive diagnostic modalities such as endoscopic ultrasound (EUS) and magnetic resonance cholangiopancreatography (MRCP).

AREAS COVERED

This review explores the therapeutic applications of ERCP across various acute pancreatitis etiologies and its role in managing complications such as bile duct obstructions, pancreatic duct disruptions, and infected necrosis. The discussion highlights the procedure's expanding indications and its critical role in addressing complex cases.

EXPERT OPINION

ERCP remains central to the management of acute pancreatitis complications. As endoscopic techniques and devices continue to advance, its therapeutic scope is likely to grow. Performing ERCP for appropriate indications and optimizing its use is essential for minimizing risks and improving outcomes.

Efficacy analysis of pancreatic duct stenting in treating severe acute pancreatitis: a retrospective study

BACKGROUND

This study aims to evaluate the clinical efficacy of pancreatic duct stenting in the treatment of SAP, providing reference for clinical diagnosis and treatment.

METHODS

A retrospective analysis was conducted on clinical data from patients with SAP admitted to the General Hospital of Ningxia Medical University from June 1, 2019 to December 31, 2022. A total of 51 patients were included (33 males, 18 females). Patients were divided into two groups based on treatment: the control group (n = 28) receiving conventional treatment and the stent group (n = 23) undergoing pancreatic duct stenting in addition to conventional treatment. Data collected and analyzed include demographic information, rates of late local complications, late surgical interventions, new-onset OF, infected pancreatic necrosis and new-onset systemic complications. Specific outcomes measured were incidences of new-onset respiratory, renal and circulatory failure, single and multiple OF, sepsis, ACS, abdominal hypertension, and pancreatogenic encephalopathy, as well as use of ≥ 3 types of antibiotics, time of antibiotic use, time of analgesic administration, oral refeeding, length of hospital stay, ICU care, and length of ICU stay. These indicators were used to assess the therapeutic efficacy of pancreatic duct stenting.

RESULTS

All 23 patients in the stent group successfully underwent stenting. The incidence of new-onset OF and new-onset systemic complications was significantly lower in the stent group compared to the control group (χ2 = 4.96, 6.65, P < 0.05). However, no significant differences were observed between the groups regarding late local complications, infected pancreatic necrosis, and late surgical intervention (χ2 = 0.22, 0.002, 0.024, P > 0.05). Notably, two patients in the control group required additional procedures due to inadequate drainage, with one undergoing endoscopic debridement and the other, laparotomy. Mortality rates were 3 (10.7%) in the control group and 4 (17.4%) in the stent group, with no statistically significant difference (P > 0.05). Furthermore, significant differences were noted in new-onset respiratory failure, single OF, sepsis, abdominal hypertension, time of analgesic administration, oral refeeding, length of enzyme inhibitor use, and hospitalization expenses (χ2 = 3.94, 4.37, 5.79, 4.79; Z = - 2.008, - 4.176, - 4.165, - 2.309; P < 0.05). No significant differences were found in new-onset renal, circulatory, multiple OF, ACS, pancreatogenic encephalopathy, use of ≥ 3 types of antibiotics, time of antibiotic use, length of hospital stay, ICU care, and length of ICU stay (P > 0.05).

CONCLUSIONS

Pancreatic duct stenting effectively reduces the incidence of new-onset systemic complications and OF in SAP, preventing further deterioration. Pancreatic duct stenting can alleviate symptoms, shorten oral refeeding, and promote patient recovery.

TRIAL REGISTRATION

This study was recorded as a single-center, retrospective case-control study (ChiCTR1900025833).

Colitis-Induced Pancreatic Fistula with Pancreatic Ascites

Introduction

Although cases of severe pancreatitis causing fistula formation into the colon have been documented, the reverse process of colitis causing a pancreatic fistula remains undocumented.

Case Presentation

We present the case of a 79-year-old male with severe colitis resulting in perforation and pericolonic abscess formation adjacent to the pancreas, which resulted in an internal pancreatic fistula and pancreatic ascites. After 2 paracenteses, our patient ultimately underwent endoscopic retrograde cholangiopancreatography (ERCP) with sphincterotomy and pancreatic duct stent placement. The patient clinically improved and was ultimately discharged.

Conclusion

Follow-up ERCP was performed 2 months after discharge and showed no contrast extravasation, illustrating closure of the previous pancreatic fistula. Ultimately, our case demonstrates that cases of severe colitis may contribute to adjacent pancreatic fistula and ascites formation.

Updates in the management of postoperative pancreatic fistula

Postoperative pancreatic fistula (POPF) remains a common and dreaded complication after pancreatic resections and is associated with increased morbidity and mortality. Over the years, several different strategies have been investigated to prevent and mitigate POPF. However, when a POPF occurs, a consensus on the optimal management strategy of grade B and grade C POPF is still lacking, and the current management strategy is often based on local expertise and driven by patient's condition. Nevertheless, whereas the incidence of POPF after pancreatic surgery has remained stable, the overall mortality related to this complication has decreased over the years. This reflects an improvement in the management of this complication, which has become increasingly conservative. The aim of this review is to provide an updated evidence-based overview on the management strategies of POPF for surgeons and physicians in the clinical practice.

Pain in chronic pancreatitis: What can we do today?

The aim of this study is to illustrate the complexity of pain management in chronic pancreatitis (CP). In this context, pain represents the most common and debilitating symptom, and it deeply affects patient's quality of life. Multiple rating scales (unidimensional, bidimensional and multidimensional) have been proposed to quantify CP pain. However, it represents the result of complex mechanisms, involving genetic, neuropathic and neurogenic factors. Considering all these aspects, the treatment should be discussed in a multidisciplinary setting and it should be approached in a stepwise manner. First, a lifestyle change is recommended and nonsteroidal anti-inflammatory drugs represent the gold standard among medical treatments for CP patients. The second step, after medical approach, is endoscopic therapy, especially for complicated CP. In case of failure, tailored surgery represents the third step and decompressive or resection procedures can be chosen. In conclusion, CP pain's management is challenging considering all these complex aspects and the lack of international protocols.

Minimally invasive treatment of an internal pancreaticopleural fistula with massive pleural effusion: a case report

BACKGROUND

A pancreatic duct rupture can lead to various complications such as a fistula, pseudocyst, ascites, or walled-off necrosis. Due to pleural effusion, pancreaticopleural fistula typically causes dyspnea and chest pain. Leaks of enzyme-rich pancreatic fluid forming a pleural effusion can be verified in a thoracocentesis following radiological imaging such as computed tomography or magnetic resonance tomography. While management strategies range from a conservative to endoscopic and surgical approach, we report a case with successful minimally invasive treatment of pancreaticopleural fistula and effusion.

CASE PRESENTATION

We present a case of a patient with pancreaticopleural fistula and successful minimally invasive surgical treatment. A 62-year old Caucasian man presented with acute chest pain and dyspnea. A computed tomography scan identified a left-sided cystoid formation, extending from the abdominal cavity into the left hemithorax with concomitant pleural effusion. Pleural effusion analysis indicated significantly elevated pancreatic enzymes. Magnetic resonance cholangiopancreatography revealed a rupture of the pancreatic duct and nearby fluid accumulation. Endosonography later confirmed proximity to the tail of the pancreas, suggesting a pancreatic pseudocyst with visible tract into the pancreas. We assumed a pancreatic duct rupture with a fistula from the tail of the pancreas transdiaphragmatically into the left hemithorax with a commencing pleural empyema. A visceral and parietal decortication on the left hemithorax and a laparoscopic distal pancreatectomy with splenectomy was performed. The suspected diagnosis of a fistula arising from the pancreatic duct was confirmed histologically.

CONCLUSION

Pancreaticopleural fistulas often have a long course and may remain undiagnosed for a long time. At this point diagnostic management and therapy demand a high level of expertise. In instances of unclear symptomatic pleural effusion, considering an abdominal focus is crucial. If endoscopic treatment is not feasible, minimally invasive surgery should strongly be considered, especially when located in the distal pancreas.

Treatment and Prognosis for Pancreatic Duct Disruption Associated With Pancreatic Cancer: A Case Series of 15 Patients

Background Pancreatic duct (PD) disruption can occasionally be attributed to pancreatic cancer. Therapeutic interventions for PD disruption due to pancreatic cancer and their influence on pancreatic cancer prognosis remain unclear. This study investigated the therapeutic modalities and prognostic implications of PD disruption in pancreatic cancer. Methods This retrospective study included 15 patients with PD disruption concomitant with pancreatic cancer between April 2011 and March 2023. As an endoscopic intervention for PD disruption, endoscopic pancreatic stenting (EPS) or endoscopic ultrasonography-guided pancreatic fluid collection drainage (EUS-PFD) was performed. Technical success was defined as stent placement and clinical success was defined as an improvement in PD disruption. Results Of the 15 cases of PD disruption, two involved only pancreatic juice leakage without symptoms, four involved pancreatic pseudocyst (PPC) without infection, and nine involved PPC with infection. Four patients underwent EPS, nine underwent EUS-PFD, and two underwent lumen-apposing metal stent placement. All patients achieved both technical and clinical success without complications. The clinical stage of pancreatic cancer ranged from carcinoma in situ to the metastatic phase. For the treatment of pancreatic cancer, five patients underwent surgical resection, and eight underwent chemotherapy. There was no obvious recurrence of peritoneal sowing. The median overall survival from the diagnosis of pancreatic cancer in the resected and non-resected cases was 74 and 9.6 months, respectively. Conclusion Endoscopic intervention was effective in all cases of PD disruption due to pancreatic cancer. Furthermore, even in cases of pancreatic cancer after PD disruption, survival rates were similar to those in cases without PD disruption and were achieved through surgical resection or chemotherapy.

Endoscopic Retrograde Cholangiopancreatography for the Management of Pancreatic Duct Leaks and Fistulas

Pancreatic duct (PD) leaks are a common complication of acute and chronic pancreatitis, trauma to the pancreas, and pancreatic surgery. Diagnosis of PD leaks and fistulas is often made with contrast-enhanced pancreatic protocol computed tomography or magnetic resonance imaging with MRCP. Endoscopic retrograde pancreatography with pancreatic duct stenting in appropriately selected patients is often an effective treatment, helps to avoid surgery, and is considered first-line therapy in cases that fail conservative management.

Novel treatment with double scope technique for disconnected pancreatic duct syndrome with external pancreatic fistula

Background and study aims External pancreatic fistula in association with disconnected pancreatic duct syndrome is a common sequelae of the percutaneous step-up approach for infected pancreatic necrosis and is associated with significant morbidity. The present study aimed to report the initial outcome of a novel technique of two-scope guided tractogastrostomy for management of this condition. Patients and methods The present study was a retrospective analysis of data from patients with external pancreatic fistula and disconnected pancreatic duct syndrome, who underwent two-scope-guided tractogastrostomy. All the patients had a 24F or larger drain placed in the left retroperitoneum. Transgastric echo endoscopy and sinus tract endoscopy were performed simultaneously to place a stent between the gastric lumen and the sinus tract. Technical success was defined as placement of the stent between the tract and the stomach. Clinical success was defined as successful removal of the percutaneous drain without the occurrence of pancreatic fluid collection, ascites, external fistula, or another intervention 12 weeks after the procedure. Results Three patients underwent two scope-guided tractogastrostomy. Technical and clinical success were achieved in all the patients. No procedure-related side effects or recurrence occurred in any of the patients. Conclusions Two-scope-guided tractogastrostomy for treatment of external pancreatic fistula due to disconnected pancreatic duct syndrome is a feasible technique and can be further evaluated.

Endoscopic ultrasound-guided tissue sampling induced pancreatic duct leak resolved by the placement of a pancreatic stent: A case report

BACKGROUND

Pancreatic ductal leaks complicated by endoscopic ultrasonography-guided tissue sampling (EUS-TS) can manifest as acute pancreatitis.

CASE SUMMARY

A 63-year-old man presented with persistent abdominal pain and weight loss. Diagnosis: Laboratory findings revealed elevated carbohydrate antigen 19-9 (5920 U/mL) and carcinoembryonic antigen (23.7 ng/mL) levels. Magnetic resonance imaging of the pancreas revealed an approximately 3 cm ill-defined space-occupying lesion in the inferior aspect of the head, with severe encasement of the superior mesenteric artery. Pancreatic ductal adenocarcinoma was confirmed after pathological examination of specimens obtained by EUS-TS using the fanning method. Interventions and outcomes: The following day, the patient experienced severe abdominal pain with high amylase (265 U/L) and lipase (1173 U/L) levels. Computed tomography of the abdomen revealed edematous wall thickening of the second portion of the duodenum with adjacent fluid collections and a suspicious leak from either the distal common bile duct or the main pancreatic duct in the head. Endoscopic retrograde cholangiopancreatography revealed dye leakage in the head of the main pancreatic duct. Therefore, a 5F 7 cm linear plastic stent was deployed into the pancreatic duct to divert the pancreatic juice. The patient's abdominal pain improved immediately after pancreatic stent insertion, and amylase and lipase levels normalized within a week. Neoadjuvant chemotherapy was then initiated.

CONCLUSION

Using the fanning method in EUS-TS can inadvertently cause damage to the pancreatic duct and may lead to clinically significant pancreatitis. Placing a pancreatic stent may immediately resolve acute pancreatitis and shorten the waiting time for curative therapy. When using the fanning method during EUS-TS, ductal structures should be excluded to prevent pancreatic ductal leakage.

Early endoscopic management of an infected acute necrotic collection misdiagnosed as a pancreatic pseudocyst: A case report

BACKGROUND

Infected acute necrotic collection (ANC) is a fatal complication of acute pancreatitis with substantial morbidity and mortality. Drainage plays an exceedingly important role as the first step in invasive intervention for infected necrosis; however, there is great controversy about the optimal drainage time, and better treatment should be explored.

CASE SUMMARY

We report the case of a 43-year-old man who was admitted to the hospital with severe intake reduction due to early satiety 2 wk after treatment for acute pancreatitis; conservative treatment was ineffective, and a pancreatic pseudocyst was suspected on contrast-enhanced computed tomography (CT). Endoscopic ultrasonography (EUS) suggested hyperechoic necrotic tissue within the cyst cavity. The wall was not completely mature, and the culture of the puncture fluid was positive for A-haemolytic Streptococcus. Thus, the final diagnosis of ANC infection was made. The necrotic collection was not walled off and contained many solid components; therefore, the patient underwent EUS-guided aspiration and lavage. Two weeks after the collection was completely encapsulated, pancreatic duct stent drainage via endoscopic retrograde cholangiopancreatography (ERCP) was performed, and the patient was subsequently successfully discharged. On repeat CT, the pancreatic cysts had almost disappeared during the 6-month follow-up period after surgery.

CONCLUSION

Early EUS-guided aspiration and lavage combined with late ERCP catheter drainage may be effective methods for intervention in infected ANCs.

Imaging Diagnosis and Management of Fistulas in Pancreatitis

Pancreatic fistula is a highly morbid complication of pancreatitis. External pancreatic fistulas result when pancreatic secretions leak externally into the percutaneous drains or external wound (following surgery) due to the communication of the peripancreatic collection with the main pancreatic duct (MPD). Internal pancreatic fistulas include communication of the pancreatic duct (directly or via intervening collection) with the pleura, pericardium, mediastinum, peritoneal cavity, or gastrointestinal tract. Cross-sectional imaging plays an essential role in the management of pancreatic fistulas. With the help of multiplanar imaging, fistulous tracts can be delineated clearly. Thin computed tomography sections and magnetic resonance cholangiopancreatography images may demonstrate the communication between MPD and pancreatic fluid collections or body cavities. Endoscopic retrograde cholangiography (ERCP) is diagnostic as well as therapeutic. In this review, we discuss the imaging diagnosis and management of various types of pancreatic fistulas with the aim to sensitize radiologists to timely diagnosis of this critical complication of pancreatitis.

Evolution of Pancreatic Endotherapy

In the last half century, endotherapy for pancreatic diseases has changed considerably. Although endoscopic retrograde cholangiopancreatography (ERCP) and endoscopic ultrasound (EUS) were introduced initially as diagnostic tools, they quickly evolved into therapeutic tools for preventing and managing complications of pancreatitis. More recently, therapeutic endoscopy has shown potential in palliation and cure of pancreatic neoplasms. This article discusses the changing landscape of pancreatic endotherapy as therapeutic ERCP and EUS were introduced and because they have evolved to treat different diseases.

A Step-Up Approach Using Alternative Endoscopic Modalities Is an Effective Strategy for Postoperative and Traumatic Pancreatic Duct Disruption

BACKGROUND AND AIMS

Standard endotherapy for pancreatic duct (PD) disruption is pancreatic stenting and sphincterotomy. In patients refractory to standard treatment, treatment algorithm is currently not standardized. This study aims to report the 10-year experience with the endoscopic treatment of postoperative or traumatic PD disruption and to share our algorithmic approach.

METHODS

This retrospective study was conducted on 30 consecutive patients who underwent endoscopic treatment for postoperative (n = 26) or traumatic (n = 4) PD disruption between 2011 and 2021. Standard treatment was initially applied to all patients. Endoscopic modalities used with a step-up approach in patients unresponsive to standard treatment were stent upsizing and N-butyl-2-cyanoacrilate (NBCA) injection for partial disruption, and the bridging of the disruption with a stent and cystogastrostomy for complete disruption.

RESULTS

PD disruption was partial in 26 and complete in 4 patients. Cannulation and stenting of PD was successful in all patients and sphincterotomy was performed in 22 patients. Standard treatment was successful in 20 patients (66.6%). The resolution of PD disruption in 9 of 10 patients refractory to standard treatment was achieved with stent upsizing in 4, NBCA injection in 2, the bridging of the complete disruption in one, and cystogastrostomy after spontaneously and intentionally developed pseudocyst in one patient each. Overall, therapeutic success rate was 96.6% (100% for partial, 75% for complete disruption). Procedural complications occurred in 7 patients.

CONCLUSIONS

Standart treatment for PD disruption is usually effective. In patients refractory to standard treatment, the outcome may be improved by step-up approach using alternative endoscopic modalities.

Transpapillary Stenting Improves Treatment Outcomes in Patients Undergoing Endoscopic Transmural Drainage of Ductal Disruption-Associated Pancreatic Fluid Collections

INTRODUCTION

Endoscopic transmural drainage (TMD) has been accepted as the preferred therapy for symptomatic pancreatic fluid collections (PFCs). Recurrence of PFCs presents a unique challenge in patients with disrupted pancreatic duct (PD). We aimed to evaluate whether transpapillary drainage (TPD) provides additional benefits to TMD in patients with PD disruption.

METHODS

This was a multicenter retrospective study. Consecutive patients who underwent TMD, TPD, or combined drainage (CD) of PFCs were included. The primary outcome was to compare PFC recurrence among different groups. The secondary outcomes were the technical success rate, length of hospital stay, and procedure-related complications.

RESULTS

A total of 153 patients, which consists of 57 patients with pancreatic pseudocysts and 96 patients with walled-off necrosis, were included. PFC recurrence was more common in patients with PD disruption than those with an intact main duct (19% vs 1.4%, P < 0.001). PD disruption was identified as a major risk factor of PFC recurrence by univariable and multivariable analyses. The recurrence rate of CD was significantly lower than TMD only or TPD only (6.5% vs 15.4% vs 22.7%, P < 0.01). The length of hospital stay of CD was significantly shorter than TMD only or TPD only (5 [3.0-9.0] vs 7.0 [5.0-12.0] vs 9 [7.0-16.0], P < 0.001). Dual-modality drainage did not increase procedure-related complications compared with TMD only (13.0% vs 12.8%, P > 0.05). Partial PD disruption was bridged in 87.3% cases while complete PD disruption was reconnected in 55.2% cases. Although statistically not significant, the clinical success rate in walled-off necrosis cases with actively bridged ducts was much higher than those with passively bridged ducts (76.9% vs 40%).

DISCUSSION

Transpapillary pancreatic duct stenting seems to improve the efficacy of endoscopic TMD of pancreatic duct disruption-associated PFCs by reducing the recurrence rate and shortening the length of hospital stay.

The Pyroptotic and Nonpyroptotic Roles of Gasdermins in Modulating Cancer Progression and Their Perspectives on Cancer Therapeutics

Gasdermins (GSDMs) are a protein family encoded by six paralogous genes in humans, including GSDMA, GSDMB, GSDMC, GSDMD, GSDME (also known as DFNA5), and DFNB59 (also known as pejvakin). Structurally, members of the GSDM family possess a C-terminus (an autoinhibitory domain) and a positively charged N-terminus (a pore-forming domain) linked with divergent peptide linkers. Recently, GSDMs have been identified as key executors of pyroptosis (an immunogenic programmed cell death) due to their pore-forming activities on the plasma membrane when proteolytically cleaved by caspases or serine proteases. Accumulating studies suggest that chemoresistance is attributed to dysregulation of apoptotic machinery and that inducing pyroptosis to bypass aberrant apoptosis can potently resensitize apoptosis-resistant cancer to chemotherapeutics. Pyroptosis is initiated by pore formation and culminates with plasma membrane rupture; these processes enable the release of proinflammatory cytokines (e.g., IL-1β and IL-18) and damage-associated molecular patterns, which further modulate antitumor immunity within the tumor microenvironment. Although pyroptosis is considered a promising strategy to boost antitumor effects, it is also reported to cause unwanted tissue damage (e.g., gut damage and nephrotoxicity). Intriguingly, mounting evidence has uncovered nonpyroptotic roles of GSDMs in tumorigenesis, such as proliferation, invasion, metastasis, and drug resistance. Thus, this provides a rationale for GSDMs as potential therapeutic targets. Taken together, we shed unbiased light on the pyroptosis-dependent roles of GSDMs in cancer progression and highlighted how GSDMs modulate tumorigenesis in a pyroptosis-independent manner. It is evident that targeting GSDMs seems profound in cancer management; however, several problems require further investigation to target GSDMs from bench to bedside, which is elucidated in the discussion section.

Three cases of black pleural effusion

Black pleural effusions (BPE) are rare, exudative pleural effusions that produce a black fluid on thoracentesis. While the name and definition of this pathology is undeniably simple, the etiologies, outcomes, and treatments for BPE are incredibly complex. Currently, BPE is not well-demonstrated in the literature. This case series reports three patients with different etiologies, past medical histories, presenting symptoms, treatments, and outcomes. BPE caused by pancreatic-pleural fistula and opportunistic infections are demonstrated in this case series. This report shows that early identification and treatment of the underlying cause of BPE is critical to the recovery of the patients.

Outcomes after Transgastric Drainage of Pancreatic Duct Leaks

PURPOSE

To determine the outcomes of transgastric drainage (TGD) of pancreatic duct leaks (PDLs), including fluid collections and pancreaticocutaneous fistulae (PCFs).

MATERIALS AND METHODS

Fifty-four patients who underwent attempted TGD of a PDL from 1992 to 2020 were identified. Data regarding patient comorbidities, fluid collection characteristics, technical success, drain exchanges and removals, recurrent collections, and complications were analyzed.

RESULTS

Forty-one patients (41/54, 76%) had a history of pancreatitis. Sixteen patients (16/54, 30%) had a history of recent abdominal surgery. Peripancreatic fluid collections were 11.2 cm ± 4.6 in greatest dimension prior to drainage. Twenty-one collections (21/54, 39%) demonstrated biochemical and/or imaging evidence of an active communication to the pancreatic duct, and 16 (16/54, 30%) of these patients had a PCF due to a direct percutaneous drain prior to TGD. TGD was technically successful in 53 patients (53/54, 98%). During the follow-up period, 46 patients (46/53, 87%) were able to undergo drain removal after resolution of the fluid collection, with a mean catheter indwelling time of 3 months and a median of 1 catheter exchange. There were 2 severe (2/53, 4%) and 4 moderate (4/53, 8%) complications, the most common of which was drain dislodgement requiring repeat transgastric puncture. Recurrent fluid collections were observed in 8 patients (8/53, 15%) after a mean of 5 months following drain removal. There were no recurrent PCFs.

CONCLUSIONS

TGD of PDLs is technically feasible and efficacious in the vast majority of patients with a relatively low complication rate. This technique is effective in preventing or treating the long-term debilitating complication of PCF.

PREDICTION OF EXTERNAL PANCREATIC FISTULA DEVELOPMENT IN PATIENTS WITH ACUTE INFECTED NECROTISING PANCREATITIS

OBJECTIVE

The aim: To search for risk factors for the development of external pancreatic fistula (EPF) in patients with acute infected necrotizing pancreatitis.

PATIENTS AND METHODS

Materials and methods: A prospective single-center observational study was conducted with the participation of 160 adult patients with infected acute necrotizing pancreatitis (ANP) who required intervention at different stages of the disease. Depending on the amylase activity of the drainage secretions, the groups with and without diagnosed EPF were compared according to 15 demographic, clinical, laboratory and instrumental parameters of the disease. To identify predictors of the risk of developing EPF in ANP, a regression logistic analysis was performed and logistic regression models were built for each factor attribute.

RESULTS

Results: We did not find statistically significant differences in the indicators characterising patients on the first day of illness, as well as in the comparison of indicators characterising local complications of AP, the timing of AP infection, the incidence of sepsis and the level of PON in sepsis. When comparing the groups by the frequency of the type of microbial agent of infected APB, no statistically significant differences were found. Comparative pairwise analysis between the groups by morphological characteristics revealed statistical differences in the frequency of focal superficial and transmural PN (p < 0.001). Next, we performed a regression logistic analysis and built logistic regression models for each factor attribute, namely age, gender, BMI, BISAP score and Charlson comorbidity index, morphological characteristics of necrotizing pancreatitis. After univariate regression analysis, a statistically significant association between the depth of PN and the risk of developing PFN was found (OR 2.7 (1.4-5.2), p=0.001).

CONCLUSION

Conclusions: We found that the risk of developing an external pancreatic fistula was associated with the depth of pancreatic necrosis.

Outcomes and predictors of response to endotherapy in pancreatic ductal disruptions with refractory internal and high-output external fistulae

Backgrounds/Aims

Endoscopic retrograde cholangiopancreatography (ERCP) remains the primary treatment for a subset of patients with pancreatic fistulae. The objective of this study was reporting outcomes of ERCP and predictors of resolution in patients with pancreatic fistulae refractory to conservative therapy.

Methods

Retrospective review of patients who underwent ERCP and pancreatic stent placement for pancreatic fistula not responding to medical therapy was performed. Clinical features, laboratory parameters, radiological features and pancreatogram findings were noted. Clinical resolution of fistula was the primary outcome measure.

Results

Sixty-eight patients underwent ERCP for high-output pancreatic fistula (Mean age 34.1 years, 91.1% males, 35/68 chronic pancreatitis, 52.9% alcohol etiology). Internal fistulae (pancreatic ascites, pleural effusion, or pericardial effusion) were seen in 55 (80.9%) patients and external fistula in 13 (19.1%) patients. Technical success for ERCP was 92.6% (63/68). Leak was seen in 98.4% (62/63). The most common leak site was body (69.8%). Multiple leak sites were seen in 23.1%. Pancreatic stricture was found in 36.5%. In 44 (69.4%) patients, stent was placed beyond the site of the leak. Resolution at six weeks was achieved in 76.4% (52/68). On univariate and multivariate analyses, placement of stent beyond site of leak was significantly associated with resolution of high-output fistulae (3/41 [7.3%] vs. 5/19 [26.3%], p = 0.03; odds ratio: 6.5, 95% confidence interval: 1.211-34.94).

Conclusions

In our experience, ERCP was successful in 76% of patients with pancreatic fistulae refractory to conservative therapy. Stent placement beyond the site of leak was associated with higher resolution of fistulae.

Short- and Long-Term Outcomes After Multimodal Treatment of Pancreatic Duct Leakage in Patients With Chronic Pancreatitis

OBJECTIVES

In patients with chronic pancreatitis, pancreatic duct leakage is associated with a prolonged disease course and serious complications. We aimed to assess the efficacy of this multimodal treatment of pancreatic duct leakage.

METHODS

In a retrospective design, patients with chronic pancreatitis, an amylase content greater than 200 U/L in either ascites or pleural fluid and treated between 2011 and 2020, were evaluated. The primary end point was treatment success.

RESULTS

Twenty-seven patients (22 males, median age 60, median American Society of Anesthesiologists score 3) were included.Endoscopic retrograde pancreatography was performed in 23 patients (85%) with transpapillary stenting of the main pancreatic duct in 22 patients (96%). Pancreatic sphincterotomy and dilation of the main pancreatic duct were done in 14 patients (61%) and 17 patients (74%), respectively. Twelve patients (44%) were treated with somatostatin analogs, parenteral nutrition, and were "nil by mouth" for a median of 11 days (range, 4-34 days). Six patients (22%) had extracorporeal shock wave lithotripsy due to pancreatic duct stones. One patient (4%) was referred for surgery. All 23 patients (100%) were treated with success after a median of 21 days (range, 5-80 days).

CONCLUSIONS

Multimodal treatment of pancreatic duct leakage is effective, with minimal need for surgery.

Comprehensive Imaging Review of Pleural Fistulas from Diagnosis to Management

Pleural fistula is an abnormal communication between the pleural cavity and an adjacent structure. The interplay of anatomic and physiologic factors including proximity to various intrathoracic structures, deep pleural recesses, and negative pleural pressures makes the pleura an easy victim of fistulization. Iatrogenic creation followed by necrotizing infections and malignancies are the most common causes. While the overall incidence and size of postsurgical pleural fistulas are decreasing with increased adoption of vascularized flaps for high-risk resections, the smaller fistulas that develop in the setting of post-radiation therapy changes, with necrotizing infections in immunosuppressed patients, and with use of newer antiangiogenic chemotherapies can be challenging to visualize directly. Imaging signs in clinical practice are often subtle and indirect. Multimodality imaging and biochemical pleural fluid analysis can offer important adjunctive information when a diagnosis is only suggested with the first imaging study. Certain pleural fistulas are inconsequential, some spontaneously close with or without diversion of flow or use of positive-pressure ventilation, while others carry a higher risk of complications or recurrence. Estimated fistula size, factors that impair healing, and the possibility of diversion are important considerations when deciding between endoscopic or surgical closure. The authors have tailored this article for a general imager or clinical practitioner and review 10 types of pleural fistulas, ranging from routine to rare, with regard to their etiology, pathophysiology, clinical cues, imaging features, nuances of pleural fluid analysis, and management options available today. ^©RSNA, 2022.

Interventional Radiological Management and Prevention of Complications after Pancreatic Surgery: Drainage, Embolization and Islet Auto-Transplantation

Pancreatic surgery still remains burdened by high levels of morbidity and mortality with a relevant incidence of complications, even in high volume centers. This review highlights the interventional radiological management of complications after pancreatic surgery. The current literature regarding the percutaneous drainage of fluid collections due to pancreatic fistulas, percutaneous transhepatic biliary drainage due to biliary leaks and transcatheter embolization (or stent–graft) due to arterial bleeding is analyzed. Moreover, also, percutaneous intra-portal islet auto-transplantation for the prevention of pancreatogenic diabetes in case of extended pancreatic resection is also examined. Moreover, a topic not usually treated in other similar reviewsas percutaneous intra-portal islet auto-transplantation for the prevention of pancreatogenic diabetes in case of extended pancreatic resection is also one of our areas of focus. In islet auto-transplantation, the patient is simultaneously donor and recipient. Differently from islet allo-transplantation, it does not require immunosuppression, has no risk of rejection and is usually efficient with a small number of transplanted islets.

Endoscopic treatment of pancreaticopleural fistulas

Introduction

Pancreaticopleural fistula (PPF) is a serious complication of acute and chronic pancreatitis.

Objective

To evaluate the effectiveness of various endoscopic techniques for the treatment of patients with PPFs.

Methodology

Prospective analysis of the results of endoscopic treatment of 22 patients with PPF due to pancreatitis was conducted at the Department of General, Gastroenterological, and Oncological Surgery, Ludwik Rydygier Collegium Medicum in Bydgoszcz, Nicolaus Copernicus University in Torun, between 2018 and 2021.

Results

PPF was diagnosed in 22 patients (21 men and 1 woman; mean age 49.52 [30–67] years) with pancreatitis. In 19/22 (86.36%) patients, PPF communicated with the left pleural cavity and in 3/22 (13.64%) patients with the right pleural cavity. Chronic pancreatitis was diagnosed in 14/22 (63.64%) patients. Symptomatic pancreatic fluid collections were found in 15/22 (68.18%) patients with PPF (pancreatic pseudocyst in 11 and walled-off pancreatic necrosis in four patients). Endoscopic retrograde cholangiopancreatography was performed in 21/22 (95.45%) patients, confirming the diagnosis of PPF. All 21 patients underwent endoscopic sphincterotomy with prosthesis implantation in the main pancreatic duct (passive transpapillary drainage). In 1/22 (4.55%) patients, active transmural/transgastric drainage of the PPF was necessary due to inflammatory infiltration of the peripapillary region, precluding endoscopic pancreatography. Endoscopic transmural drainage was performed in all the 15 patients with pancreatic fluid collection. Clinical success was achieved in 21/22 (95.45%) patients. The mean total time of endotherapy was 191 (range 88–712) days. Long-term success of endoscopic treatment of PPFs during one year follow-up period was achieved in 19/22 (86.36%) patients.

Conclusions

Endoscopic treatment is effective for managing post-inflammatory PPFs. The preferred treatment method is passive transpapillary drainage (prosthesis of the main pancreatic duct). If transpapillary drainage is not feasible, transmural drainage of the PPF remains the preferred method. Endoscopic transmural drainage leads to closure of the fistula canal in patients with pancreatic fluid collection complicated by PPF.

Intraoperative endoscopic retrograde cholangiopancreatography for traumatic pancreatic ductal injuries: Two case reports

BACKGROUND

In order to successfully manage traumatic pancreatic duct (PD) leaks, early diagnosis and operative management is paramount in reducing morbidity and mortality. In the acute setting, endoscopic retrograde cholangiopancreatography (ERCP) can be a useful, adjunctive modality during exploratory laparotomy. ERCP with sphincterotomy and stent placement improves preferential drainage in the setting of injury, allowing the pancreatic leak to properly heal. However, data in this acute setting is limited.

CASE SUMMARY

In this case series, a 27-year-old male and 16-year-old female presented with PD leaks secondary to a gunshot wound and blunt abdominal trauma, respectively. Both underwent intraoperative ERCP within an average of 5.9 h from time of presentation. A sphincterotomy and plastic pancreatic stent placement was performed with a 100% technical and clinical success. There were no associated immediate or long-term complications. Following discharge, both patients underwent repeat ERCP for stent removal with resolution of ductal injury.

CONCLUSION

These experiences further demonstrated that widespread adaption and optimal timing of ERCP may improve outcomes in trauma centers.

Rare case of pancreatic lipomatous hamartoma

A middle-aged man had an incidental finding of 10.1 cm lipomatous mass arising from pancreatic body/neck detected on CT scan. He was asymptomatic. He underwent surgical resection of the mass due to concern for malignancy. His postoperative course was complicated by a high-volume pancreatic leak of approximately 900 mL/day. He underwent endoscopic retrograde cholangiopancreatography and insertion of a pancreatic stent, with some improvement in the pancreatic leak. His leak eventually settled after 3 months. The final histopathology showed lobules of mature adipocytes with small islands of disorganised benign pancreatic ducts and acini interspersed within them, suggestive of pancreatic hamartoma of lipomatous variant. Pancreatic lipomatous hamartomas are rare and are often diagnosed on final histopathology when the initial resection was performed due to diagnostic uncertainty or concern for malignancy. It is a benign lesion with an indolent course and must be discriminated from other lipomatous lesions of the pancreas. An awareness of the condition is important to help guide management.

Safety and Efficacy of Early Endotherapy in Management of Pancreatic Ascites: Western Indian Experience

Background Pancreatic ascites is rare but a known complication of pancreatitis. We aimed to study the timings, safety, and efficacy of therapeutic approaches in its management and the outcomes.

Methods We retrospectively studied patients with pancreatic ascites managed in the past 5 years at a single tertiary care center. Therapeutic approaches included conservative therapy, early endoscopic therapy, and surgery. We used descriptive statistics to summarize characteristics of the study population, and performed univariate and binary logistic regression analyses to compare treatment outcomes.

Results Of the 125 patients screened, 70 (male, 81.4%) were included. Disruption in the pancreatic duct (PD) was seen in 51.4% of patients on magnetic resonance cholangiopancreatography (MRCP) and 73.3% of patients on endoscopic retrograde cholangiopancreatography (ERCP). The PD in the body region (46.7%) was the most frequent site of disruption. Early endotherapy included a stent bridging the disruption site in 63.3% of patients and sphincterotomy in 76.7% of patients with a median time to ERCP from symptom onset being 8.5 days. The success rate in early endotherapy was 81.7%, while the recurrence rate was 8%. For conservative therapy only, the success rate was 60% with recurrence in two-thirds. The variables crucial in the success of endotherapy were a partial disruption (p < 0.001), ductal disruption site (p = 0.004), sphincterotomy (p = 0.013), and a bridging stent (p = 0.001). Significant pancreatic necrosis (p < 0.001) and intraductal calculi (p = 0.002) were the factors responsible for failure in endotherapy.

Conclusions Early endotherapy is safe and effective in the treatment of pancreatic ascites. The efficacy of endotherapy is augmented by PD stenting combined with pancreatic sphincterotomy and a bridging stent.

A Case of Pancreatic Duct Leak Presenting as Lower Extremity Pain and Edema

Pancreatic pseudocyst from pancreatic duct leak is one of the common complications of both acute and chronic pancreatitis. The presentation of such leaks can range from patients being completely asymptomatic to septic shock. Extra-abdominal collections of fluid due to pancreatic duct leaks are very rare. We describe a diagnostically challenging patient with acute chronic pancreatitis presenting with lower extremity swelling and pain, who was found to have a pancreatic fluid leak into the right iliopsoas, right gluteal, and thigh muscle compartment. Despite endoscopic stenting of the pancreatic duct and multiple percutaneous drain placement and antibiotic treatment for abscess formation, the patient's condition deteriorated clinically. Surgical options could not be pursued due to poor functional status.

Endoscopic management of pancreaticopleural fistula after recurrent acute pancreatitis

Pancreaticopleural fistula is an extremely rare complication of pancreatitis. We present a case of pancreaticopleural fistula in a patient with recurrent acute pancreatitis who presented with right-sided symptomatic pleural effusion. Pancreatic sphincterotomy and pancreatic duct stenting led to resolution of pleural effusion and withdrawal of the chest tube within 3 weeks.

Endoscopic retrograde cholangiopancreatography: Current practice and future research

Endoscopic retrograde cholangiopancreatography (ERCP) has evolved from a primarily diagnostic to therapeutic procedure in hepatobiliary and pancreatic disease. Most commonly, ERCPs are performed for choledocholithiasis with or without cholangitis, but improvements in technology and technique have allowed for management of pancreatic duct stones, benign and malignant strictures, and bile and pancreatic leaks. As an example of necessity driving innovation, the new disposable duodenoscopes have been introduced into practice. With the advantage of eliminating transmissible infections, they represent a paradigm shift in quality improvement within ERCP. With procedures becoming more complicated, the necessity for anesthesia involvement and safety of propofol use and general anesthesia has become better defined. The improvements in endoscopic ultrasound (EUS) have allowed for direct bile duct access and EUS facilitated bile duct access for ERCP. In patients with surgically altered anatomy, selective cannulation can be performed with overtube-assisted enteroscopy, laparoscopic surgery assistance, or the EUS-directed transgastric ERCP. Cholangioscopy and pancreatoscopy use has become ubiquitous with defined indications for large bile duct stones, indeterminate strictures, and hepatobiliary and pancreatic neoplasia. This review summarizes the recent advances in infection prevention, quality improvement, pancreaticobiliary access, and management of hepatobiliary and pancreatic diseases. Where appropriate, future research directions are included in each section.

Incidence, Risk Factors, and Treatment of Proximally Migrated Pancreatic Stents

AIM

The aim of this study was to investigate the incidence, risk factors, and treatment strategies of proximally migrated pancreatic stents.

MATERIALS AND METHODS

The data of 626 sessions of 421 patients with pancreatic duct stenting were retrospectively analyzed between 2010 and 2018, and patients with proximally migrated stents were included in the study.

RESULTS

Of 626 stents examined, 77 migrated proximally (12%). The migration rate (MR) was 16%, 2%, and 7%, respectively, in patients treated with chronic pancreatitis, malignancy, and pancreatic leakage indication. The MR was 14% in procedures with pancreatic duct stenosis, 21% in procedures with pancreatic sphincterotomy, and 27% in procedures performed from minor papillae. The MR of the 5, 7, and 10 Fr stents was 4%, 17%, and 10%, respectively. Of the 77 migrated stents, 64 were successfully removed (83%). This success rate (SR) was 84% in procedures with chronic pancreatitis indication, 83% in procedures with pancreatic duct stenosis, 79% in procedures with sphincterotomy, and 75% in procedures performed from minor papillae. The SR of the 5, 7, and 10 Fr stents was 100%, 79%, and 92%, respectively. It was also determined that 33 stents were fractured and migrated (43%). The SR of the fractured stents was 76%. Moreover, of the stents that were successfully removed, 35 were removed with forceps (55%) and 15 (23%) were removed with a balloon. Furthermore, in 47 cases, the stent was removed in the first session (73%). Acute pancreatitis occurred in 5 patients (8%) and perforation occurred in 1 patient (2%).

CONCLUSION

In this study, it was shown that proximal migration of pancreatic stents is frequent and most of these stents can be removed successfully.

Acute Pancreatitis with an Ongoing Pancreatic Duct Leak Complicated by Refractory Pleural Effusion: A Case Report

Patient: Female, 52-year-old

Final Diagnosis: Pancreatic duct leak

Symptoms: Epigastric pain

Medication: —

Clinical Procedure: —

Specialty: Gastroenterology and Hepatology

Alcohol use disorder and the gut

Acute and chronic gastrointestinal problems are common in the setting of excessive alcohol use, and excessive alcohol use is associated with injury to all parts of the gastrointestinal tract. There is mounting evidence of gastrointestinal injury and increased cancer risk even from moderate alcohol consumption. The major causes of alcohol-related morbidity and mortality within the gastrointestinal system are liver disease, pancreatitis and gastrointestinal cancer. Other alcohol-related intestinal dysfunction is common but not life-threatening, leading to diarrhoea, malabsorption and nutritional deficiencies. This review describes non-neoplastic and neoplastic alcohol-related disorders of the gastrointestinal tract, omitting the liver, which has been reviewed elsewhere.

Percutaneous direct pancreatic duct intervention in management of pancreatic fistulas: a primary treatment or temporizing therapy to prepare for elective surgery

BACKGROUND

This study evaluates preliminary results of image-guided percutaneous direct pancreatic duct intervention in the management of pancreatic fistula after surgery or pancreatitis when initially ineligible for surgical or endoscopic therapy.

METHODS

Between 2001 and 2018 the medical records of all patients that underwent percutaneous pancreatic duct intervention for radiographically confirmed pancreatic fistula initially ineligible for surgical or endoscopic repair were reviewed for demographics, clinical history, procedure details, adverse events, procedure related imaging and laboratory results, ability to directly catheterized the main pancreatic duct, and whether desired clinical objectives were met.

RESULTS

In 10 of 11patients (6 male and 5 female with mean age 60.5, range 39-89) percutaneous pancreatic duct cannulation was possible. The 10 duct interventions included direct ductal suction drainage in 7, percutaneous duct closure in 3 and stent placement in 1. Pancreatic fistulas closed in 7 of 10, 2 were temporized until elective surgery, and 1 palliated until death from malignancy. The single patient with failed duct cannulation resolved the fistula with prolonged catheter drainage of the peri-pancreatic cavity. There were no major adverse events related to intervention.

CONCLUSION

In patients with pancreatic fistulas initially ineligible for endoscopic therapy or elective surgery, direct percutaneous pancreatic duct interventions are possible, can achieve improvement without major morbidity or mortality, and can improve and maintain the medical condition of patients in preparation for definitive surgery.

Pancreatic Pseudocyst Fistulization: An Unusual Case of Upper GI Bleeding

The pancreas is an unusual source of gastrointestinal (GI) bleeding. GI bleeding from the pancreas is most frequently a result of complications from acute or chronic pancreatitis resulting in vascular damage and bleeding into the pancreatic duct. Rarely, however, a pancreatic pseudocyst can come into contact with the GI tract and form a fistula. However, these fistulas can be difficult to identify during endoscopy due to their lateral position, and computed tomography is often necessary to make a definitive diagnosis. Erosion of the nearby vasculature as a result of the fistula can lead to bleeding. Embolization of the affected vessel is the standard of care, but particular attention should be given to not empirically embolize due to risk of complications. Here, we describe a case of an upper GI bleed due to a pancreatic pseudocyst that fistulized through the duodenal wall.

Endoscopic Management of Pancreatic Fluid Collections

Pancreatic fluid collections (PFCs) are a common sequela of pancreatitis. Most PFCs can be managed conservatively, but symptomatic PFCs require either surgical, percutaneous, or endoscopic intervention. Recent advances in the therapeutics of PFCs, including the step-up approach, endoscopic ultrasound-guided transmural drainage with lumen apposing metal stents, and direct endoscopic necrosectomy, have ushered endoscopy to the forefront of PFCs management and have allowed for improved patient outcomes and decreased morbidity. In this review, we explore the progress and future of endoscopic management of PFCs.

Pancreatic ascites and Pleural Effusion in Children: Clinical Profile, Management and Outcomes

BACKGROUND

Pancreatic ascites (PA) and pleural effusion (PPE) are rarely encountered in children. They develop due to disruption of the pancreatic duct (PD) or leakage from an associated pancreatic fluid collection (PFC). The literature on childhood PA/PPE and its management is scarce.

METHODS

A retrospective review of children with PA/PPE diagnosed and managed at our center over the last 4 years was performed. The clinical, biochemical, radiological and management profiles were analyzed. Conservative management included nil per oral, octreotide and drainage using either percutaneous catheter or repeated paracentesis. Endotherapy included endoscopic retrograde cholangiopancreatography (ERCP) and transpapillary stenting.

RESULTS

Of the 214 children with pancreatitis, 15 (7%) had PA/PPE. Median age was 9 years with a third under 2 years. Median ascitic fluid amylase was 8840 U/L and all had elevated protein (>2.5 g/dl) and low serum ascites-albumin gradient ascites (<1.1). While PA/PPE was the first manifestation of underlying chronic pancreatitis (CP) in 10 children (67%), trauma was seen in 4 (26%) and hypertriglyceridemia in 1 (7%). On imaging, PD disruption could be identified in 10 (67%) children. ERCP and stenting was done in 10 children. Conservative management alone (n = 4) and endotherapy (n = 10) was successful in 93% with only one requiring surgery. The younger children (n = 4), were managed conservatively and only 1 of them required surgery. Resolution of PA/PPE was achieved in all with no recurrences.

CONCLUSIONS

Conservative management and ERCP plus transpapillary stenting results in resolution of majority of pediatric PA/PPE. Children presenting with PA/PPE needs to be evaluated for CP.

Endoscopic Diagnosis and Management of Gastrointestinal Trauma

Trauma affects all sociodemographic profiles and is a major cause of morbidity and mortality particularly in patients less than forty years of age. A variety of endoscopic tools and techniques initially used for iatrogenic etiologies (post-operative bile or pancreatic duct leaks, intra-procedural perforation) have been adopted for use in the gastrointestinal trauma victim. The purpose of this review is to highlight a variety of gastrointestinal traumatic complications where endoscopy can serve a complement and/or definitive management strategy.

Acute Pancreatitis Imaging in MDCT: State of the Art of Usual and Unusual Local Complications. 2012 Atlanta Classification Revisited

Acute pancreatitis is an inflammatory disease in which most common etiologies are biliary lithiasis and alcoholism. Acute pancreatitis can be classified into 2 groups according to its morphologic features: interstitial edematous pancreatitis and necrotizing acute pancreatitis. The prognosis of this group of diseases and its complications varies significantly and contrast-enhanced computed tomography is the imaging study of choice for the diagnosis and detection of complications. . In this review, we aim to summarize the changes introduced in the revised Atlanta classification and describe other usual and unusual local complications of acute pancreatitis that are not analyzed in that classification. We will also describe early detection signs and provide an accurate interpretation of complications on contrast-enhanced computed tomography that will lead to prompt management decisions which can reduce the morbidity and mortality of these patients.

Preoperative endoscopic transpapillary stenting: A solution to preventing and/or treating postsurgical external pancreatic fistula and infection in patients with infected necrotizing pancreatitis

Currently, open surgical necrosectomy is only performed when the step-up approach fails in patients with necrotizing pancreatitis. As a common complication after surgery, external pancreatic fistula often leads to a long hospital stay and increased expenditure. Current therapeutic strategies include conservative management; however, unresponsive patients with pancreatic leaks will frequently require interventions. Existing evidence indicates that endoscopic transpapillary stenting can shorten the duration of external pancreatic fistula; however, the length of conservative treatment in the early stage cannot be avoided. Therefore, endoscopic transpapillary stenting cannot play a decisive role in the treatment and prevention of postsurgical external pancreatic fistula. The authors propose that endoscopic transpapillary stenting before surgery, however, can be used to prevent and treat postsurgical external pancreatic fistula and complications caused by the prolonged maintenance of the drainage tube for abscesses, including retrograde infection, through its physiological drainage effect. This hypothesis has important clinical implications for the accelerated postoperative recovery of patients with necrotizing pancreatitis.

Natural course of low output external pancreatic fistula in patients with disconnected pancreatic duct syndrome following acute necrotising pancreatitis

BACKGROUND

External pancreatic fistulae (EPF) associated with complete pancreatic duct (PD) disruption leading on to disconnected pancreatic duct syndrome (DPDS) is a therapeutic nightmare usually requiring surgery. However, spontaneous closure also has been reported. There is paucity of data on the natural history of EPF associated with DPDS.

OBJECTIVE

To retrospectively study outcome of conservative treatment in patients with low output (<200 ml/day) EPF with DPDS following percutaneous or surgical intervention in acute necrotising pancreatitis (ANP).

METHODS

The data of patients of low output EPF with DPDS treated conservatively in our unit over last 5 years was retrospectively analysed. Their clinical course, complications as well as time taken for fistula closure was retrieved.

RESULTS

33 patients (27 males; mean age: 40.5 ± 9.3 years) of low output EPF and DPDS were studied. 31 patients developed EPF following percutaneous drainage (PCD) and 2 patients developed fistula following surgery. The drain fluid amylase ranged from 1600 to 32,000 IU/l and site of disruption was neck, proximal body and distal body in 4, 16 and 13 patients respectively. EPF closed spontaneously in all patients within 88.2 ± 63.46 days. PCD slipped out in 2 patients and led to formation of pseudocyst in 1 patient that was treated endoscopically. There has been no recurrence in any patient over follow up of 32.5 ± 21.9 months.

CONCLUSION

Low output EPF developing post PCD or surgery in patients with DPDS following ANP closely spontaneously in majority of patients within 3 months with good long term outcome.

Perioperative Management of Pancreaticoduodenectomy: Avoiding Admission to the Intensive Care Unit

Introduction

With the advancement in surgical expertise at high-volume centers and advances in perioperative management, pancreaticoduodenectomy is becoming safer and remains the gold standard for treating periampullary pathologies. We describe our experience in optimizing perioperative management in order to avoid admission to the intensive care unit and improve outcomes.

Method

Retrospective data were collected on 370 surgical patients who underwent a pancreaticoduodenectomy between the years 1994 and 2016.

Results

Of the 370 patients, 200 operated between 2009 and 2016 did not require intensive care admission, blood transfusion, or central line insertion. The results were compared between different time intervals: before the year 1998, between the years 1998 and 2008, and between the years 2009 and 2016. The median blood loss dropped from 800 to 400 to 300 mL, respectively. The median operative time also dropped from 360 to 335 to 215 min, respectively. In addition, the median length of hospital stay decreased from 25 to 16 to 7 days, respectively.

Conclusion

With the centralization of pancreaticoduodenectomy in high-volume centers and with specialized surgeons performing the surgery, there is a significant decrease in the onset of postoperative complications with a lesser need for blood transfusions and, subsequently, better recovery of patients without the need for intensive care unit admission.