Management of pancreatic fluid collections: A comprehensive review of the literature

Pancreaticoduodenectomy after endoscopic ultrasound-guided lumen apposing metal stent (LAMS): A case series evaluating feasibility and short-term outcomes

Introduction

Endoscopic ultrasound (EUS)-guided lumen-apposing metal stents (LAMS) represent a novel tool in therapeutic endoscopy. However, the presence of LAMS may dissuade surgeons from operations with curative-intent. We report three clinical scenarios with deployment of LAMS in patients that subsequently underwent pancreaticoduodenectomy (PD).

Methods

Six patients identified from our IRB-approved pancreas cancer database had EUS-LAMS placement prior to PD. Patient, tumor, treatment-related variables, and outcomes are herein reported.

Results

Two patients underwent a LAMS gastrojejunostomy (GJ) for duodenal obstruction. Another patient underwent LAMS choledochoduodenostomy (CDS) for malignant biliary obstruction. In three patients, a LAMS gastrogastrostomy or jejunogastrostomy was deployed post Roux-en-Y gastric bypass (RYGB) for a EUS-directed transgastric ERCP (EDGE) procedure. The hospital length of stay after LAMS placement was 0-3 days without morbidity. Patients subsequently proceeded to either classic PD (n = 5) or PPPD (n = 1). Interval from LAMS insertion to surgery ranged from 28 to 194 days. Mean PD operative time and EBL were 513 minutes and 560 mL, respectively. Post-PD hospital length of stay was 4-17 days. Clavien-Dindo IIIb morbidity required percutaneous drainage of intra-abdominal collections in two patients. In cases involving LAMS-GJ and CDS, the LAMS directly impacted the surgeon's preference not to perform pylorus preservation.

Conclusions

In this case series, PD following EUS-LAMS was feasible with acceptable morbidity. Additional studies with larger patient populations are needed to evaluate LAMS as a bridge to PD with curative-intent.

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.

Pancreatic Pseudocyst and Obesity: Video Case Report of Management with the One-Stage Procedure

Reports of pancreatic pseudocyst drainage during metabolic bariatric surgery are extremely rare. Our patient is a 38-year-old female suffering from obesity grade IV and presents a persistent symptomatic pancreatic pseudocyst 8 months after an episode of acute biliary pancreatitis. After an extensive evaluation and considering other treatment options, our multidisciplinary team and the patient decided to perform a one-stage procedure consisting of laparoscopic cystogastrostomy, cholecystectomy, and one-anastomosis gastric bypass. After bringing the patient to the operating room, the surgeon performed an anterior gastrostomy to access the stomach's posterior wall, followed by a 6-cm cystogastrostomy on both the stomach's posterior wall and the cyst. Next, a cholecystectomy which involved dissecting the triangle of Calot was performed. Then, an 18-cm gastric pouch using a 36-Fr calibration tube was created. The cystogastrostomy was left in the remaining stomach. Finally, gastrojejunal anastomosis is done. The patient's postoperative course proceeded smoothly, leading to her home discharge on the third postoperative day. At the 1-year follow-up, the patient had lost 56 kg and was symptom-free; a computer tomography scan showed that the pancreatic pseudocyst had resolved. This case shows a video of a successful laparoscopic cystogastrostomy, cholecystectomy, and one-anastomosis gastric bypass (OAGB) used to treat persistent abdominal pain and obesity grade IV. We also conduct a bibliographic review.

Management of Pediatric Solid Organ Injuries

Solid organ injury (SOI) is common in children who experience abdominal trauma, and the management of such injuries has evolved significantly over the past several decades. In 2000, the American Pediatric Surgical Association (APSA) published the first societal guidelines for the management of blunt spleen and/or liver injury (BLSI), advocating for optimized resource utilization while maintaining patient safety. Nonoperative management (NOM) has become the mainstay of treatment for SOI, and since the publication of the APSA guidelines, numerous groups have evaluated how invasive procedures, hospitalization, and activity restrictions may be safely minimized in children with SOI. Here, we review the current evidence-based management guidelines in place for the treatment of injuries to the spleen, liver, kidney, and pancreas in children, including initial evaluation, inpatient management, and long-term care, as well as gaps that exist in the current literature that may be targeted for further optimization of protocols for pediatric SOI.

Single Center Experience of Eus-Guided Cystogastrostomy and Lumen-Apposing Metal Stent (LAMS) Positioning in Children with Pancreatic Fluid Collections: A Case Series

Pancreatic fluid collections (PFCs) are a well-known complication of pancreatitis. PFCs operative management includes percutaneous, endoscopic or surgical drainage. Even if in adult patients, endoscopic drainage is a well-established treatment, few data are available in pediatric setting. We report our single-center experience of EUS-guided cystogastrostomy and lumen-apposing metal stent (LAMS) positioning in children with PFCs; this, at the best of our knowledge, has never been reported before. All consecutive children with PFCs between April 2020 and November 2022 were enrolled in this retrospective study. PFCs were preoperatively evaluated with MRI or CT scan. All the procedures were performed under general anesthesia. A LAMS Hot-AxiosTM 10 × 15 mm was placed in all patients. We evaluated technical feasibility and clinical outcomes, including complications and recurrence rates. Follow-up included clinical observation, blood tests and US. EUS-guided cystogastrostomy was performed in 3 children (2 males; median age 13.2 years). Median maximum cyst diameter was 14.7 cm (range 10-22 cm). Technical and clinical success rates were 100%. No intra or post-operative complications occurred. Our experience suggests that this can be considered a safe and feasible treatment of PCFs even in the pediatric population, as long as the procedure is performed by an expert Endoscopist in a pediatric tertiary-level Center.

Metal stent and percutaneous endoscopic necrosectomy as dual approach for the management of complex walled-off pancreatic necrosis

Pancreatic fluid collections (PFCs) are one of the local complications of acute pancreatitis and include walled-off pancreatic necrosis (WOPN), which are complex entities with challenging management. The infection of pancreatic necrosis leads to a poorer prognosis, with a growth of the mortality rate up to 30%. The primary strategy for managing PFCs is a minimally invasive step-up approach, with endosonography-guided transmural drainage and debridement as the preferred and less invasive method. Percutaneous drainage (PCD) can be the technique of choice when endoscopic drainage is not feasible, for example for early PFCs without a mature wall or for the anatomic location and extension to the paracolic gutter of the collection. As PCD alone may be ineffective, especially when a great amount of necrosis is present, a percutaneous endoscopic necrosectomy (PEN) has been proposed, showing interesting results. The technique consists of the placement of an esophageal fully or partially covered self-expandable metal stent (SEMS) percutaneously into the collection and a direct debridement can be performed using a flexible endoscope through the SEMS. In this review, we will discuss about the role of metal stent and PEN for the management of complex walled-off pancreatic necrosis.

Complications and management of interventional endoscopic ultrasound: A critical review

In the last decades, Endoscopic ultrasound (EUS) has rapidly grown and evolved from being mainly a diagnostic procedure, to being an interventional and therapeutic tool in several pathological clinical scenarios. With the progressive growth in technical expertise and dedicated devices, interventional endoscopic ultrasound procedures (IEUSP) have shown high rates of technical and clinical success, together with a relatively safe profile. However, the description and the standardization of different and specific types of adverse events (AEs) are still scarce in literature, and, consequently, even less the management of AEs. The aim of this study is to critical review and to describe AEs related to each of the main IEUSP, and to provide an overview on the possible management strategies of endoscopic complications. Future studies and guidelines are surely required to reach a better standardization of different AEs and their best management.

Endoscopic Ultrasound-Guided Drainage of Pancreatic Fluid Collections: Not All Queries Are Already Solved

Pancreatic fluid collections (PFCs) are well-known complications of acute pancreatitis. The overinfection of these collections leads to a worsening of the prognosis with an increase in the morbidity and mortality rate. The primary strategy for managing infected pancreatic necrosis (IPN) or symptomatic PFCs is a minimally invasive step-up approach, with endosonography-guided (EUS-guided) transmural drainage and debridement as the preferred and less invasive method. Different stents are available to drain PFCs: self-expandable metal stents (SEMSs), double pigtail stents (DPPSs), or lumen-apposing metal stents (LAMSs). In particular, LAMSs are useful when direct endoscopic necrosectomy is needed, as they allow easy access to the necrotic cavity; however, the rate of adverse events is not negligible, and to date, the superiority over DPPSs is still debated. Moreover, the timing for necrosectomy, the drainage technique, and the concurrent medical management are still debated. In this review, we focus attention on indications, timing, techniques, complications, and particularly on aspects that remain under debate concerning the EUS-guided drainage of PFCs.

Safety and efficacy of early versus late removal of LAMS for pancreatic fluid collections

Background and study aims Optimal timing for removal of lumen-apposing metal stents (LAMS) for effective drainage of pancreatic fluid collections (PFC) while minimizing adverse events (AE) is unknown. Outcomes of early (≤ 4 weeks) or delayed (> 4 weeks) LAMS removal on both clinical efficacy and the incidence of AE were assessed. Patients and methods This was a retrospective analysis of a prospectively maintained registry of PFC drainage between November 2016 and September 2021. Clinical success was defined as a 75% decrease in fluid collection volume with no need for reintervention at 6 months. AE were defined using the American Society for Gastrointestinal Endoscopy lexicon. Multiple logistic regression analysis was performed to determine variables associated with clinical success and AE. Results A total of 108 consecutive PFCs were included. LAMS deployment was technically successful in 103 of 108 cases (95.4%). Failure was associated with collection diameter ≤ 4 cm (odds ratio [OR] 24.0, P = 0.005) and presence of more than 50% necrotic material (OR 20.1, P = 0.01). Stents were left in place for a median of 48 days. Patients with early stent removal (< 4 weeks) had clinical success in 70.0% of cases, which was significantly less than in the group with delayed stent removal (96.4%, P = 0.03). On multiple regression analysis, clinical failure was associated with early stent removal (OR 25.5, P = 0.003). AEs occurred in 8.7% of cases (9/103). There were no predictors of AE. Notably, delayed stent removal did not predict the occurrence of AE. Conclusions Early LAMS removal (< 4 weeks) did not prevent AEs but did lead to increased clinical failure.

Endoscopic ultrasound-guided drainage of pancreatic collections with dedicated metal stents: A nationwide, multicenter, propensity score-matched comparison

BACKGROUND

The new dedicated stents for endoscopic ultrasound (EUS)-guided transluminal drainage of peri‑pancreatic fluid collections (PFCs) demonstrated optimal efficacy and safety profiles.

AIMS

This study aimed to evaluate the safety, technical and clinical success, and recurrence rate of PFCs drained with Lumen Apposing Metal Stent (LAMS) or Bi-Flanged Metal Stent (BFMS).

METHODS

Data from a multicenter series of PFCs treated with LAMS or BFMS at 30 Italian centers during a 5-year period were retrieved. The rate of adverse events (AEs), technical success, clinical success, PFC recurrence were evaluated. To overcome biases, a 1-to-1 match was created using propensity score analysis.

RESULTS

Out of 476 patients, 386 were treated with LAMS and 90 with BFMS, with a median follow-up of 290 days (95% CI 244 to 361). Using propensity score matching, 84 patients were assigned to each group. The incidence of AEs did not differ between the two stents (13.1% versus 15.5%, p = 0.29), mainly bleeding or recurrence rate (4.7% versus 3.5%, p = 1). Technical and clinical success in the BFMS and LAMS groups were 92% versus 95% (p = 0.36) and 91% versus 94% (p = 0.64), respectively.

CONCLUSION

Our study demonstrates that LAMS and BFMS have comparable safety profiles with similar technical and clinical success rates for EUS-guided PFC drainage.

A novel lumen-apposing metal stent for endoscopic drainage of symptomatic pancreatic fluid collections: a retrospective study

Background and Objectives

Previous studies showed that lumen-apposing metal stent (LAMS) provides a feasible route to perform direct endoscopic necrosectomy. However, the high risk of bleeding and migration induced by the placement of LAMS attracted attention. The aim of this study was to evaluate the safety and effectiveness of a novel LAMS.

Methods

In this retrospective study, we enrolled patients with symptomatic pancreatic fluid collections (PFCs) to perform EUS-guided drainage with a LAMS in our hospital. Evaluation variables included technical success rate, clinical success rate, and adverse events.

Results

Thirty-two patients with a mean age of 41.38 ± 10.72 years (53.1% males) were included in our study, and the mean size of PFC was 10.06 ± 3.03 cm. Technical success rate and clinical success rate reached 96.9% and 93.8%, respectively. Stent migration occurred in 1 patient (3.1%), and no stent-induced bleeding occurred. The outcomes of using LAMS in 10 patients with pancreatic pseudocyst and 22 patients with walled-off necrosis were comparable. Compared with pancreatic pseudocyst, walled-off necrosis needed more direct endoscopic necrosectomy times to achieve resolution (P = 0.024).

Conclusions

Our study showed that the novel LAMS is effective and safe for endoscopic drainage of PFCs with a relatively low rate of adverse events. Further large-scale multicenter studies are needed to confirm the present findings.

Increasing trend of endoscopic drainage utilization for the management of pancreatic pseudocyst: insights from a nationwide database

BACKGROUND/AIMS

The pancreatic pseudocyst (PP) is a type of fluid collection that typically develops as a delayed complication of acute pancreatitis. Drainage is indicated for symptomatic patients and/or associated complications, such as infection and bleeding. Drainage modalities include percutaneous, endoscopic, laparoscopic, and open drainage. This study aimed to assess trends in the utilization of different drainage modalities for treating PP from 2016 to 2020. The trends in mortality, mean length of hospital stay, and mean hospitalization costs were also assessed.

METHODS

The National Inpatient Sample database was used to obtain data. The variables were generated using International Classification of Diseases-10 diagnostic and procedural codes.

RESULTS

Endoscopic drainage was the most commonly used drainage modality in 2018-2020, with an increasing trend over time (385 procedures in 2018 to 515 in 2020; p=0.003). This is associated with a decrease in the use of other drainage modalities. A decrease in the hospitalization cost for PP requiring drainage was also noted (29,318 United States dollar [USD] in 2016 to 18,087 USD in 2020, p<0.001).

CONCLUSION

Endoscopic drainage is becoming the most commonly used modality for the treatment of PP in hospitals located in the US. This new trend is associated with decreasing hospitalization costs.

Efficacy and safety of endoscopic drainage versus percutaneous drainage for pancreatic fluid collection; a systematic review and meta-analysis

BACKGROUND/AIMS

Pancreatic fluid collections (PFC) are debris or fluid of the pancreas that needs to be drained out. This may result from surgery or necrotizing pancreatitis. This meta-analysis compared the outcomes of PFC through endoscopic and percutaneous interventions.

METHODS

A medical database was searched up to June 2022, comparing the outcomes of endoscopic drainage (ED) and percutaneous drainage (PD) for the PFC. Eligible studies reporting clinical and technical success and adverse events were selected.

RESULTS

Seventeen studies with 1170 patients were included for meta-analysis, of which 543 patients underwent ED and 627 underwent PD. The odd ratio (OR) of technical success was 0.81 (95% confidence interval (CI) 0.31, 2.1) and clinical success was in the favor of the ED group at OR 2.23 (95% CI 1.45, 3.41). Adverse events OR 0.62 (95% CI 0.27, 1.39) and stent migration OR 0.61 (95% CI 0.10, 3.88) were the same in both groups, but hospital stay pooled mean difference of 15.02 days (95% CI 9.86, 20.18), mortality OR 0.24 (95% CI 0.09, 0.67), and re-interventions OR 0.25 (95% CI 0.16, 0.40) favored ED.

CONCLUSIONS

ED is safe and efficient for PFC with higher clinical success, lower mortality rate, hospital stay, and re-interventions compared with PD.

Novel application of Roux-en-Y for diversion of a cutaneous fistula from an irresectable mesenteric root mature teratoma: a case report

Reconfiguration of the alimentary tract with the Roux-en-Y has been utilized in a wide variety of contexts since its first description by Swiss physician César Roux. We present a novel and unique application of the Roux-en-Y whereby a chronically discharging cutaneous fistula originating at a retroperitoneal mature teratoma within the root of the mesentery was diverted enterically via a cystojejunostomy and the fistula tract excised, providing a resolution of symptoms. The location of the tumour in the root of the mesentery and the involvement of major mesenteric vessels made a radical resection of the tumour technically impossible but due to the distressing symptoms caused by the fistula made diversion of the fistula an excellent treatment option.

Endoscopic ultrasound-guided versus percutaneous drainage for the management of post-operative fluid collections after distal pancreatectomy

BACKGROUND

Post-operative pancreatic fluid collections (POPFCs) can be drained using percutaneous or endoscopic approaches. The primary aim of this study was to compare rates of clinical success between endoscopic ultrasound-guided drainage (EUSD) with percutaneous drainage (PTD) in the management of symptomatic POPFCs after distal pancreatectomy. Secondary outcomes included technical success, total number of interventions, time to resolution, rates of adverse events (AEs), and POPFC recurrence.

METHODS

Adults who underwent distal pancreatectomy from January 2012 to August 2021 and developed symptomatic POPFC in the resection bed were retrospectively identified from a single academic center database. Demographic data, procedural data, and clinical outcomes were abstracted. Clinical success was defined as symptomatic improvement and radiographic resolution without requiring an alternate drainage modality. Quantitative variables were compared using a two-tailed t-test and categorical data were compared using Chi-squared or Fisher's exact tests.

RESULTS

Of 1046 patients that underwent distal pancreatectomy, 217 met study inclusion criteria (median age 60 years, 51.2% female), of whom 106 underwent EUSD and 111 PTD. There were no significant differences in baseline pathology and POPFC size. PTD was generally performed earlier after surgery (10 vs. 27 days; p < 0.001) and more commonly in the inpatient setting (82.9% vs. 49.1%; p < 0.001). EUSD was associated with a significantly higher rate of clinical success (92.5% vs. 76.6%; p = 0.001), fewer median number of interventions (2 vs. 4; p < 0.001), and lower rate of POPFC recurrence (7.6% vs. 20.7%; p = 0.007). AEs were similar between EUSD (10.4%) and PTD (6.3%, p = 0.28), with approximately one-third of EUSD AEs due to stent migration.

CONCLUSION

In patients with POPFCs after distal pancreatectomy, delayed drainage with EUSD was associated with higher rates of clinical success, fewer interventions, and lower rates of recurrence than earlier drainage with PTD.

The perfect biliary plastic stent: the search goes on

The introduction of biliary plastic stents has been a landmark achievement in the field of endoscopic retrograde cholangiopancreatography, ensuring minimally invasive and highly effective relief of the obstructed biliary system. Attempts to improve the patency and avoid complications after biliary plastic stenting have led to several innovations, but complications due to stent occlusion are still frequent. Because these complications are clinically relevant, and may guide stent choice and patient management, efforts have been made to elucidate the causes of and ways to prevent occlusion of indwelling stents. In this narrative review we focus on biliary plastic stents and discuss the mechanisms of stent occlusion, existing evidence on salient outcomes, as well as options to overcome existing limitations and prolong plastic stent patency.

Significance of Postprocedural Contrast Medium Injection after CT-Guided Abscess Drainage

The aim was to evaluate the additive clinical value of an additional post-procedural control-scan after CT-guided percutaneous abscess drainage (PAD) placement with contrast medium (CM) via the newly placed drain. All CT-guided PADs during a 33-month period were retrospectively analyzed. We analyzed two subgroups, containing patients with and without surgery before intervention. Additionally, radiological records were reevaluated, concerning severe inflammatory response syndrome (SIRS) during the intervention. A total of 499 drainages were placed under CT-guidance in 352 patients. A total of 197 drainages were flushed with CM directly after the intervention, and 51 (26%) showed an additional significant finding. An immediate change of therapy was found in 19 cases (9%). The subgroup that underwent surgery (120 CM-drainages; 32 (27%) additional findings; 13 (11%) immediate changes of therapy) showed no statistically significant difference compared to the subgroup without surgery (77 CM-drainages; 19 (25%) additional findings; 5 (6%) immediate changes of therapy). SIRS occurred in 2 of the 197 flushed drainages (1%) after CM application. An additional scan with CM injection via the newly placed drain revealed clinically significant additional information in almost 26% of the drainages reviewed in this study. In 9% of the cases this information led to an immediate change of therapy. Risks for SIRS are low.

Pancreatic pseudocyst mimicking a left kidney abscess: a case report

BACKGROUND

Pancreatic pseudocyst are fluid filled sacs that develop as a result of dissection of pancreatic enzyme tissue. While most commonly found near the pancreas, they can also rarely occur in other areas such as the perirenal region.

CASE PRESENTATION

This study reports a new case of an infected perirenal pancreatic pseudocyst mimicking a left kidney abscess in a 46-year-old North African patient with history of recurrent acute pancreatitis, who presented with left lumbar region pain and fever. Computed tomography revealed a left perirenal collection that turned out to be an infected pancreatic pseudocyst, The diagnostic was first suspected based on the medical history of the patient and confirmed by biochemical examination detecting a high level of pancreatic enzymes in the computed tomography-guided percutaneous drainage fluid. The patient evolved well after early resuscitation, rapid and effective antibiotic therapy, and computed tomography-guided percutaneous drainage of renal collection.

CONCLUSION

Pancreatic pseudocyst is an uncommon disorder, which may present at a complicated stage and that must be considered in patients with a history of pancreatitis.

Current trends in acute pancreatitis: Diagnostic and therapeutic challenges

Acute pancreatitis (AP) is an inflammatory disease of the pancreas, which can progress to severe AP, with a high risk of death. It is one of the most complicated and clinically challenging of all disorders affecting the abdomen. The main causes of AP are gallstone migration and alcohol abuse. Other causes are uncommon, controversial and insufficiently explained. The disease is primarily characterized by inappropriate activation of trypsinogen, infiltration of inflammatory cells, and destruction of secretory cells. According to the revised Atlanta classification, severity of the disease is categorized into three levels: Mild, moderately severe and severe, depending upon organ failure and local as well as systemic complications. Various methods have been used for predicting the severity of AP and its outcome, such as clinical evaluation, imaging evaluation and testing of various biochemical markers. However, AP is a very complex disease and despite the fact that there are of several clinical, biochemical and imaging criteria for assessment of severity of AP, it is not an easy task to predict its subsequent course. Therefore, there are existing controversies regarding diagnostic and therapeutic modalities, their effectiveness and complications in the treatment of AP. The main reason being the fact, that the pathophysiologic mechanisms of AP have not been fully elucidated and need to be studied further. In this editorial article, we discuss the efficacy of the existing diagnostic and therapeutic modalities, complications and treatment failure in the management of AP.

Controversies in the management of acute pancreatitis: An update

This review summarized the current controversies in the management of acute pancreatitis (AP). The controversies in management range from issues involving fluid resuscitation, nutrition, the role of antibiotics and antifungals, which analgesic to use, role of anticoagulation and intervention for complications in AP. The interventions vary from percutaneous drainage, endoscopy or surgery. Active research and emerging data are helping to formulate better guidelines. The available evidence favors crystalloids, although the choice and type of fluid resuscitation is an area of dynamic research. The nutrition aspect does not have controversy as of now as early enteral feeding is preferred most often than not. The empirical use of antibiotics and antifungals are gray zones, and more data is needed for conclusive guidelines. The choice of analgesic is being studied, and the recommendations are still evolving. The position of using anticoagulation is still awaiting consensus. The role of intervention is well established, although the modality is constantly changing and favoring endoscopy or percutaneous drainage rather than surgery. It is evident that more multicenter randomized controlled trials are required for establishing the standard of care in these crucial management issues of AP to improve the morbidity and mortality worldwide.

Delayed endoscopic necrosectomy improves hospital length of stay and reduces endoscopic interventions in patients with symptomatic walled‐off necrosis

Objectives

Advancements in the endoscopic management of walled‐off necrosis using lumen apposing metal stents have improved outcomes over its surgical and percutaneous alternatives. The ideal procedural technique and timing of direct endoscopic necrosectomy (DEN) have yet to be clarified.

Methods

From November 2015 to June 2021, a retrospective comparative cohort analysis was performed comparing clinical outcomes for patients undergoing immediate DEN (iDEN) versus delayed DEN (dDEN). Subgroups were identified based on the quantification of necrosis. Wilcoxon two‐sample tests were used to compare continuous variables and Fisher's exact test was used to compare categorical variables.

Results

A total of 80 patients underwent DEN for management of walled‐off necrosis (iDEN = 43, dDEN = 37). Technical success was achieved in all patients. Clinical success was seen in 39 (91%) patients in the iDEN group and 34 (92%) in the dDEN group. Amongst iDEN patients, the mean number of necrosectomies was 2.5 (standard deviation [SD] 1.4) in comparison to 1.5 (SD 1.0) for dDEN (p‐value = 0.0011). The median index hospital length of stay was longer with iDEN than dDEN (7.5 days vs. 3.0 days respectively, p‐value = 0.010). Subgroup analysis was performed based on the percentage of necrosis (<25% vs. >25% necrosis). iDEN was associated with more necrosectomies than dDEN regardless of the percentage of necrosis (p = 0.017 and 0.0067, respectively).

Conclusion

Patients undergoing dDEN had a shorter index hospital stay and fewer necrosectomies than iDEN. The large diameter of lumen apposing metal stents permits adequate drainage allowing a less aggressive approach thereby improving clinical outcomes and avoiding unnecessary interventions.

Management of Pancreatic Fluid Collections: An Evidence-based Approach

Managing pancreatic fluid collections (PFCs) remains a challenge for many clinicians. Recently, significant progress has been made in the therapy of PFCs, including improvements in technology and devices, as well as in the development of minimally invasive endoscopic techniques, many of which are proven less traumatic when compared with surgical options and more efficacious when compared with percutaneous techniques. This review will explore latest developments in the management of PFCs and how they incorporate into the current treatment algorithm.

Lumen-Apposing Metal Stent With and Without Concurrent Double-Pigtail Plastic Stent for Pancreatic Fluid Collections: A Comparative Systematic Review and Meta-Analysis

Background

Lumen-apposing metal stents (LAMSs) are often used to drain pancreatic fluid collections (PFCs). However, adverse events, such as stent obstruction, infection, or bleeding, have been reported. Concurrent double-pigtail plastic stent (DPPS) deployment has been suggested to prevent these adverse events. This meta-analysis aimed to compare the clinical outcomes of LAMS with DPPS vs. LAMS alone in the drainage of PFCs.

Methods

An extensive search was conducted in the literature to include all the eligible studies that compared LAMS with DPPS vs. LAMS alone for drainage of PFCs. Pooled risk ratios (RRs) with the 95% confidence intervals (CIs) were obtained within a random-effect model. The outcomes were technical and clinical success, and overall adverse events, including stent migration and occlusion, bleeding, infection, and perforation.

Results

Five studies involving 281 patients with PFCs (137 received LAMS plus DPPS vs. 144 received LAMS alone) were included. LAMS plus DPPS group was associated with comparable technical success (RR: 1.01, 95% CI: 0.97 - 1.04, P = 0.70) and clinical success (RR: 1.01, 95% CI: 0.88 - 1.17). Lower trends of overall adverse events (RR: 0.64, 95% CI: 0.32 - 1.29), stent occlusion (RR: 0.63, 95% CI: 0.27 - 1.49), infection (RR: 0.50, 95% CI: 0.15 - 1.64), and perforation (RR: 0.42, 95% CI: 0.06 - 2.78) were observed in LAMS with DPPS group compared to LAMS alone but without a statistical significance. Stent migration (RR: 1.29, 95% CI: 0.50 - 3.34) and bleeding (RR: 0.65, 95% CI: 0.25 - 1.72) were similar between the two groups.

Conclusions

Deployment of DPPS across LAMS for drainage of PFCs has no significant impact on efficacy or safety outcomes. Randomized, controlled trials are necessary to confirm our study results, especially in walled-off pancreatic necrosis.

Spontaneous rupture of an infected pseudocyst of the pancreas: A case report

INTRODUCTION AND IMPORTANCE

A pancreatic pseudocyst is a known complication of acute and chronic pancreatitis. A pseudocyst rupture into the abdomen causes peritonitis, which can be fatal if surgical treatment is delayed. Here in we report the case of a 46-year-old woman presenting with a pancreatic pseudocyst doubly complicated with infection and rupture causing sepsis shock.

CASE PRESENTATION

A 46 year-old-woman, with a history of chronic pancreatitis four years prior complicated with a pancreatic pseudocyst of 3 cm, presented to our emergency department with clinical signs of generalized peritonitis. After a brief resuscitation, we performed a midline laparotomy. It showed purulent peritonitis due to a rupture of an infected pseudocyst of the pancreas. We performed an abundant peritoneal toilet with drainage. The patient was discharged after 25 days. In the one month follow-up, there were no unfavourable outcomes.

CLINICAL DISCUSSION

In presence of ruptured and infected pancreatic pseudocyst, surgical treatment should be performed as soon as possible after brief resuscitation. Laparotomy is the gold standard treatment. The main objective of surgical treatment is to perform abundant peritoneal toilet with large external drainage. In our case, the pancreatic pseudocyst didn't communicate with the Wirsung duct allowing us to withdraw the drainage. Otherwise, the drainage should be retained longer to treat the pancreatic leakage.

CONCLUSION

Rupture and infection of pancreatic pseudocysts is a rare situation. Diagnosis is assessed via computed tomography scan. Emergency laparotomy should be performed timely to make the peritoneal toilet and drain the pancreatic pseudocyst.

Endoscopic management of pancreatic walled-off necrosis

Pancreatic walled-off necrosis (WON) is a complication of severe pancreatitis. Endoscopic transmural drainage has been recognized as the first-line treatment for pancreatic fluid collections. Endoscopy offers a minimally invasive approach when compared to surgical drainage. Today, endoscopists may choose to use self-expanding metal stents, pigtail stents, or lumen-apposing metal stents to facilitate drainage of fluid collections. Current data suggest that all 3 approaches yield similar outcomes. It was previously thought that drainage should be performed 4 weeks from the initial event of pancreatitis, theoretically allowing the capsule to mature. However, current data show that both early (<4 weeks) and standard (≥4 weeks) endoscopic drainage are comparable. Herein, we provide an up-to-date state-of-the-art review of the indications, techniques, innovations, outcomes, and future perspectives following drainage of pancreatic WON.

A case of delayed pancreatic fistula after covered self-expandable metallic stent deployment for pancreatic head cancer

A 69-year-old man was referred to our hospital with obstructive jaundice. A tumor with poor contrast enhancement was found in the pancreatic head, but there was no evidence of pancreatic atrophy, irregular stenosis, or dilation of the main pancreatic duct. He was diagnosed with borderline resectable pancreatic cancer with distal malignant biliary obstruction. After plastic stent placement, serum bilirubin levels improved, and chemotherapy was started. However, he developed cholangitis; thus, the plastic stent was replaced with a covered self-expandable metallic stent. He subsequently developed a delayed pancreatic fistula due to main pancreatic duct disruption. An endoscopic nasopancreatic duct drainage tube was placed to bridge the main pancreatic duct disruption after removing the covered self-expandable metallic stent. In addition, endoscopic ultrasound-guided transmural drainage was performed for the infected fluid collection caused by the pancreatic fistula, and the clinical symptoms quickly improved. This case presents the possibility of a delayed pancreatic fistula due to self-expandable metallic stent deployment. The need for considering such delayed complications when placing self-expanding metallic stents is highlighted.

Successful Treatment of Splenic Vein Thrombosis Secondary to Acute Pancreatitis with Oral Anticoagulants: A Pediatric Case Series

BACKGROUND Two Pediatric Patients with Splanchnic Venous Thrombosis as a Complication of Acute Pancreatitis Successfully Treated with Low-Molecular-Weight Heparin and Rivaroxaban CASE REPORT Case 1: A 13-year-old girl presented with a second attack of acute pancreatitis. She developed a non-occlusive splenic vein thrombosis diagnosed by CT scan on the sixth day of hospitalization. Injectable low-molecular-weight heparin was started during hospitalization and switched to oral rivaroxaban at discharge. Imaging at follow-up showed resolution of thrombosis. Case 2: A 9-year-old girl with history of acute recurrent pancreatitis presented with a third attack of acute pancreatitis. An occlusive splenic vein thrombosis with extension into the portal vein and superior mesenteric vein and necrotizing pancreatitis was seen on CT scan on the third day of hospitalization. Low-molecular-weight heparin was initiated during hospitalization and was switched to oral rivaroxaban at discharge. Imaging at follow-up demonstrated nearly complete resolution of the extensive thrombosis. CONCLUSIONS Splanchnic venous thrombosis remains a rare complication of pediatric pancreatitis. Anticoagulant use in patients with these complications remains controversial. Direct oral anticoagulants are as safe and effective as low-molecular-weight heparin and should be considered for use in children instead of low-molecular-weight heparin due to its advantages, including the availability of enteral forms of administration.

The use of endoscopic ultrasound in the management of post-surgical and pancreatic fluid collections

Fluid collections after abdominal surgeries, particularly pancreatic surgeries, are associated with high morbidity and mortality. Up until recently, percutaneous drainage was the first line therapy, but not without disadvantages, including high maintenance, risk of infection and chronic fistulas, electrolyte losses, and impact on quality of life. Endoscopic ultrasound (EUS)-guided drainage of post-surgical fluid collections (PSFCs) is safe and effective, carrying similar success, adverse event (AE), and recurrence rates as percutaneous drainage. Despite limited data on EUS-guided drainage of PSFCs, especially with regards to direct comparisons to percutaneous drainage, EUS management of these collections is becoming the first-line approach in many expert institutions.

Controversies in EUS-guided treatment of walled-off necrosis

This review gives an overview of different techniques in the treatment of post-acute complications of acute pancreatitis. The endoscopic treatment of those complications is currently standard of care. EUS opened up the broad implementation of internal drainage methods to make them safe and effective. Due to different endoscopic approaches worldwide, controversies have arisen that are pointed out in this paper. The main focus was placed on weighing up evidence to find the optimal approach. However, if no evidence can be provided, the authors, experienced in the field, give their personal advice.

Intravenous fluid therapy in patients with severe acute pancreatitis admitted to the intensive care unit: a narrative review

Patients with acute pancreatitis (AP) often require ICU admission, especially when signs of multiorgan failure are present, a condition that defines AP as severe. This disease is characterized by a massive pancreatic release of pro-inflammatory cytokines that causes a systemic inflammatory response syndrome and a profound intravascular fluid loss. This leads to a mixed hypovolemic and distributive shock and ultimately to multiorgan failure. Aggressive fluid resuscitation is traditionally considered the mainstay treatment of AP. In fact, all available guidelines underline the importance of fluid therapy, particularly in the first 24–48 h after disease onset. However, there is currently no consensus neither about the type, nor about the optimal fluid rate, total volume, or goal of fluid administration. In general, a starting fluid rate of 5–10 ml/kg/h of Ringer’s lactate solution for the first 24 h has been recommended. Fluid administration should be aggressive in the first hours, and continued only for the appropriate time frame, being usually discontinued, or significantly reduced after the first 24–48 h after admission. Close clinical and hemodynamic monitoring along with the definition of clear resuscitation goals are fundamental. Generally accepted targets are urinary output, reversal of tachycardia and hypotension, and improvement of laboratory markers. However, the usefulness of different endpoints to guide fluid therapy is highly debated. The importance of close monitoring of fluid infusion and balance is acknowledged by most available guidelines to avoid the deleterious effect of fluid overload. Fluid therapy should be carefully tailored in patients with severe AP, as for other conditions frequently managed in the ICU requiring large fluid amounts, such as septic shock and burn injury. A combination of both noninvasive clinical and invasive hemodynamic parameters, and laboratory markers should guide clinicians in the early phase of severe AP to meet organ perfusion requirements with the proper administration of fluids while avoiding fluid overload. In this narrative review the most recent evidence about fluid therapy in severe AP is discussed and an operative algorithm for fluid administration based on an individualized approach is proposed.

Interventional radiology followed by endoscopic drainage for pancreatic fluid collections associated with high bleeding risk: Two case reports

BACKGROUND

Endoscopic ultrasound (EUS)-guided transluminal drainage is an advanced technique used to treat pancreatic fluid collections (PFCs). However, gastric varices and intervening vessels may be associated with a high risk of bleeding and are, therefore, listed as relative contraindications. Herein, we report two patients who underwent interventional embolization before EUS-guided drainage.

CASE SUMMARY

Two 32-year-old males developed symptomatic PFCs after acute pancreatitis and came to our hospital for further treatment. One patient suffered from intermittent abdominal pain and vomiting, and computed tomography (CT) imaging showed an encapsulated cyst 7.93 cm × 6.13 cm in size. The other patient complained of a mass inside the abdomen, which gradually became enlarged. Gastric varices around the ideal puncture site were detected by EUS when we evaluated the possibility of endoscopic drainage in both patients. Interventional embolization was recommended as the first procedure to decrease the risk of bleeding. After that, EUS-guided transluminal drainage was successfully conducted, without vascular rupture. No postoperative complications occurred during hospitalization, and no recurrence was detected at the last follow-up CT scan performed at 1 mo.

CONCLUSION

Interventional embolization is a safe, preoperative procedure that is performed before EUS-guided drainage in PFC patients with gastric varices or at high risk of bleeding.

Endoscopic Versus Laparoscopic Drainage of Pancreatic Pseudocysts: a Cost-effectiveness Analysis

BACKGROUND

Both endoscopic and laparoscopic interventions have a high therapeutic success rate in the management of symptomatic pancreatic pseudocysts; however, neither has been established as the gold standard.

METHODS

A decision tree analysis was performed to examine the costs and outcomes of intervening on pancreatic pseudocysts endoscopically versus laparoscopically. Within the model, a theoretical patient cohort was separated into two treatment arms: endoscopic drainage and laparoscopic drainage. Variables within the model were selected from the published literature. Medicare reimbursements rates (US$) were used to represent costs accumulated during a 3-month perioperative period. Effectiveness was characterized by quality-adjusted life-years (QALYs). A willingness-to-pay of $100,000 per 1 year of perfect health (1 QALY) gained was used as the cost-effectiveness threshold. The model was validated using one-way, two-way, and probabilistic sensitivity analysis.

RESULTS

Endoscopic management of symptomatic pancreatic pseudocysts was the dominant strategy, producing 0.22 QALYs more while saving $23,976.37 in comparison to laparoscopic management. This result was further validated by one-way, two-way, and probabilistic sensitivity analysis.

CONCLUSIONS

For patients presenting with symptomatic pancreatic pseudocysts amenable to either endoscopic or laparoscopic management, endoscopic drainage should be considered first-line therapy.

Drainage of pancreatic fluid collections in acute pancreatitis: A comprehensive overview

Moderately severe and severe acute pancreatitis is characterized by local and systemic complications. Systemic complications predominate the early phase of acute pancreatitis while local complications are important in the late phase of the disease. Necrotic fluid collections represent the most important local complication. Drainage of these collections is indicated in the setting of infection, persistent or new onset organ failure, compressive or pressure symptoms, and intraabdominal hypertension. Percutaneous, endoscopic, and minimally invasive surgical drainage represents the various methods of drainage with each having its own advantages and disadvantages. These methods are often complementary. In this minireview, we discuss the indications, timing, and techniques of drainage of pancreatic fluid collections with focus on percutaneous catheter drainage. We also discuss the novel methods and techniques to improve the outcomes of percutaneous catheter drainage.

The endoscopic ultrasound features of pancreatic fluid collections and their impact on therapeutic decisions: an interobserver agreement study

BACKGROUND

A validated classification of endoscopic ultrasound (EUS) morphological characteristics and consequent therapeutic intervention(s) in pancreatic and peripancreatic fluid collections (PFCs) is lacking. We performed an interobserver agreement study among expert endosonographers assessing EUS-related PFC features and the therapeutic approaches used.

METHODS

50 EUS videos of PFCs were independently reviewed by 12 experts and evaluated for PFC type, percentage solid component, presence of infection, recognition of and communication with the main pancreatic duct (MPD), stent choice for drainage, and direct endoscopic necrosectomy (DEN) performance and timing. The Gwet's AC1 coefficient was used to assess interobserver agreement.

RESULTS

A moderate agreement was found for lesion type (AC1, 0.59), presence of infection (AC1, 0.41), and need for DEN (AC1, 0.50), while fair or poor agreements were stated for percentage solid component (AC1, 0.15) and MPD recognition (AC1, 0.31). Substantial agreement was rated for ability to assess PFC-MPD communication (AC1, 0.69), decision between placing a plastic versus lumen-apposing metal stent (AC1, 0.62), and timing of DEN (AC1, 0.75).

CONCLUSIONS

Interobserver agreement between expert endosonographers regarding morphological features of PFCs appeared suboptimal, while decisions on therapeutic approaches seemed more homogeneous. Studies to achieve standardization of the diagnostic endosonographic criteria and therapeutic approaches to PFCs are warranted.

Comparison of modified Glasgow-Imrie, Ranson, and Apache II scoring systems in predicting the severity of acute pancreatitis

&lt;b&gt;Aim:&lt;/b&gt; The course of acute pancreatitis is variable with patients at risk of poor outcomes. The purpose of this study was to compare Modified Glasgow-Imrie, Ranson, and APACHE II scoring systems in predicting the severity of acute pancreatitis. &lt;/br&gt;&lt;/br&gt; &lt;b&gt; Material and Methods: &lt;/b&gt; After a brief history, clinical examination and qualifying inclusion criteria, 70 patients (41 women, 29 men) diagnosed with acute pancreatitis were included in the study. The three scores were calculated for each patient and evaluated for their role in the assessment of specific outcomes. &lt;/br&gt;&lt;/br&gt; &lt;b&gt;Results:&lt;/b&gt; 34.3% patients were diagnosed with severe acute pancreatitis, while 65.7% patients had mild acute pancreatitis. A strong positive correlation was found between all the prognostic scores and the severity of disease. In the prediction of the severity of disease according to AUC, it was found that Glasgow-Imrie score had an AUC of 0.864 (0.7560.973), followed very closely by APACHE II score with an AUC of 0.863 (0.7580.968). APACHE II had the highest sensitivity (79.17%) in predicting severity while Glasgow-Imrie score was the most specific (97.83%) of all the scores. Patients with a Glasgow-Imrie score above the cut-off value of 3 had more complications and a longer hospital stay. &lt;/br&gt;&lt;/br&gt; &lt;b&gt;Conclusion:&lt;/b&gt; The Glasgow-Imrie score was comparable to APACHE II score and better than Ranson score statistically in predicting the severity of acute pancreatitis. Its administration in predicting the severity of acute pancreatitis is recommended.

Retroperitoneal versus transperitoneal percutaneous catheter drainage of necrotic pancreatic collections: a comparative analysis

PURPOSE

To compare the success rate, clinical outcomes, and complications of retroperitoneal (RP) versus transperitoneal (TP) percutaneous catheter drainage (PCD) of the necrotic pancreatic fluid collections.

MATERIALS AND METHODS

This retrospective study comprised consecutive patients with acute pancreatitis who underwent PCD of lesser sac collections amenable to drainage via both TP and RP routes. The patients were divided into two groups based on the route of drainage (group I, RP, and group II, TP). The technical success, clinical success, complications, and clinical outcomes were compared between the groups. Subgroup analysis was performed based on the timing of drainage (acute necrotic collections, ANC vs. walled-off necrosis, WON) and organ failure (OF).

RESULTS

Seventy-nine patients [mean age, 38.7 ± 12.3 years, 54 males] were included in the study. Group I and II comprised 22 (27.8%) and 57 (72.2%) patients, respectively. The procedures were technically successful in all the patients. There was no significant difference in the complication rate between the two groups. The clinical success was higher in group II (75.4%) as compared to group I (54.5%). However, the difference was not statistically significant (p = 0.070). There was no significant difference in the hospital stay (p = 0.298), intensive care unit stay (p = 0.401), need for surgical necrosectomy (p = 0.243), and mortality (p = 0.112) between the two groups. The outcomes in patients with OF and ANC were not affected by the route of PCD. Clinical success rate was significantly higher in WON undergoing TP drainage (p = 0.009).

CONCLUSION

Both RP and TP routes of PCD are safe and effective. Clinical success rate was significantly higher in WON undergoing TP drainage.

Management of pancreatic fluid collections

Pancreatic fluid collections often develop as a complication of acute pancreatitis but can be seen in a variety of conditions including chronic pancreatitis, trauma, malignancy or post-operatively. It is important to classify a pancreatic fluid collection in order to optimize treatment strategies and management. Most interventions are targeted towards the management of delayed complications of pancreatitis, including pancreatic pseudocysts and walled-off necrosis (WON), which often develop days to weeks after the initial episode of pancreatitis. Surgical, percutaneous, and endoscopic interventions are all possible methods for treatment of pancreatic fluid collections, however endoscopic drainage with endoscopic ultrasound has become first-line. Advances within endoscopic drainage strategies have also led to innovative changes in the specific stents used for treatment, with possible options including double pigtail plastic stents, fully covered self-expanding metal stents and lumen-apposing metal stents (LAMS).

Management of severe acute pancreatitis in 2019

Pancreatic fluid collections (PFCs) are frequent complications in severe acute pancreatitis that are the result of damage to the pancreas to include but not limited to trauma, surgery, autoimmune diseases, alcohol abuse, infections, medications, gallstones, metabolic disorders, and premalignant or malignant conditions. The majority of these collections resolve spontaneously; however, if the collection is infected or causes symptoms to include abdominal pain, nausea, vomiting, diarrhea, fevers, and tachycardia, drainage is indicated. Drainage of PFCs can be accomplished surgically, percutaneously, or endoscopically and should be approached in a multidisciplinary fashion for best overall patient care and outcomes. Before the introduction of endoscopic procedures, surgical and percutaneous drainage was the preferred modality. Today a minimally-invasive "step-up" approach is generally accepted depending upon the specific characteristics of the PFC and clinical presentation. Endoscopic ultrasound-guided PFC drainage is favored due to high success rates, shorter hospital stays, and lower cost. Direct debridement of walled-off pancreatitis can now be performed endoscopically with higher success rates with larger caliber fully covered metal stents. At large, the field of endoscopic techniques has evolved, and more specifically, the management of PFCs continues to evolve with increasing experience and with the advent of new stents and accessories, leading to increased efficacy with less adverse events.

Practical Tips for Safe and Successful Endoscopic Ultrasound-Guided Hepaticogastrostomy: A State-of-the-Art Technical Review

Currently, endoscopic ultrasound-guided hepaticogastrostomy (EUS-HGS) is widely performed worldwide for various benign and malignant biliary diseases in cases of difficult or unsuccessful endoscopic transpapillary cholangiopancreatography (ERCP). Furthermore, its applicability as primary drainage has also been reported. Although recent advances in EUS systems and equipment have made EUS-HGS easier and safer, the risk of serious adverse events such as bile leak and stent migration still exists. Physicians and assistants need not only sufficient skills and experience in ERCP-related procedures and basic EUS-related procedures such as fine needle aspiration and pancreatic fluid collection drainage, but also knowledge and techniques specific to EUS-HGS. This technical review mainly focuses on EUS-HGS with self-expandable metal stents for unresectable malignant biliary obstruction and presents the latest and detailed tips for safe and successful performance of the technique.

Multidisciplinary Approach to the Care of Children With Acute Recurrent Pancreatitis and Chronic Pancreatitis

OBJECTIVES

The aim of this article is to provide guidance to centers and organizations on the personnel (both physician and nonphysician) needed to create and sustain an optimal team, along with potential alternatives, to provide care to children with acute recurrent pancreatitis and chronic pancreatitis.

METHODS

This document was developed in collaboration with the North American Society of Pediatric Gastroenterology, Hepatology, and Nutrition (NASPGHAN) Pancreas Committee and the National Pancreas Foundation (NPF) after several meetings.

RESULTS

This document highlights both physician and nonphysician personnel needed to provide multidisciplinary care to children with pancreatitis per the recommendation of the NASPGHAN Pancreas Committee members in year 2021 and added to the currently published NPF criteria. We summarize how the NPF criteria would fit with the recently published pediatric pancreatitis society articles from the NASPGHAN.

CONCLUSIONS

It is important to manage children with acute recurrent pancreatitis and chronic pancreatitis in a multidisciplinary setting. There is need to study the impact of these personnel on the outcomes of children with pancreatitis.

Ruptured Splenic Artery Pseudoaneurysm Causing Hemorrhage Into a Pancreatic Pseudocyst

ABSTRACT

This case report describes fatal exsanguination due to splenic artery hemorrhage into a pancreatic pseudocyst with cystogastrostomy in a 46-year-old woman. The decedent had a complicated medical history including necrotizing pancreatitis, giant pseudocyst formation after cystogastrostomy procedure, and coiling of a hemorrhagic splenic artery. While hospitalized, she underwent embolization of a ruptured splenic artery pseudoaneurysm. Weeks later, she went into hemorrhagic shock and was ultimately pronounced at the hospital. Doctors suspected an upper gastrointestinal (GI) bleed as the cause of death; however, the patient was too unstable to undergo interventional radiology at the time.At autopsy, the pancreas was hemorrhagic and included a 15 × 15 × 15-cm pseudocyst, which contained a metallic stent from a cystogastrostomy. This case describes a unique co-occurrence of numerous common complications of chronic pancreatitis. There are multiple ways by which pancreatitis can cause upper and lower GI bleeds. In this case, the presence of a cystogastrostomy stent allowed for a ruptured pseudoaneurysm to hemorrhage through the pancreatic pseudocyst and into the stomach and duodenum, mimicking the presentation of a more common upper GI bleed. The pseudocyst then ruptured causing abdominal hemorrhage. The passage of hemorrhage through a cystogastrostomy stent is not described in other literature.

Endoscopic drainage versus percutaneous drainage for the management of infected walled-off necrosis: a comparative analysis

BACKGROUND

Comparative data on percutaneous catheter drainage (PCD) vs EUS-guided drainage (EUS-D) for management of symptomatic walled-off-necrosis (WON), specially infected WON with/without organ failure(OF) is limited.

METHODS

Patients with symptomatic WON were divided into two groups of PCD and EUS-D, depending on the modality of drainage. Resolution of OF, adverse events, and other outcome measures were recorded. The two modalities were compared among infected WON sub-cohort and also degree of solid component (SC).

RESULTS

218 patients (175 males; 80.3%) were included who underwent either PCD (n = 102) or EUS-D (n = 116). Clinical success was significantly higher in the EUS-D group (92.1% vs 64.6%; p < 0.0001) and even for infected WON (n = 128) (p = 0.004), with higher (p = 0.007) and faster (p < 0.0001) OF resolution. Other outcome measures including mortality were significantly higher in the PCD group. Among subgroups, PCD with >40% SC had the worst clinical success/OF resolution rates, while EUS-D with <40% SC had the best outcomes.

CONCLUSION

EUS-D should be preferred over PCD in the management of WON, infected or otherwise, for higher clinical success, and higher/faster resolution of OF. PCD should be avoided in WON with>40% SC.

Extrapancreatic Complications in Hospitalized Patients With Mild Acute Pancreatitis Are Associated With Poorer Outcomes: Results From a Single-Center Study

OBJECTIVE

Patients with acute pancreatitis (AP) are at risk for extrapancreatic complications (EPCs) when admitted to the intensive care unit (ICU). We assessed the prevalence of EPCs in non-ICU AP patients and their outcomes.

METHODS

We retrospectively studied EPCs in non-ICU AP patients between 2008 and 2018. Outcomes such as length of stay (LOS), inpatient mortality, and 30-day readmission rates were compared between those with and without EPC.

RESULTS

Of the 830 AP patients, 151 (18.1%) had at least 1 EPC. These included urinary tract infection (15.9%), Clostridium difficile infection (17.2%), pneumonia (7.3%), bacteremia (17.2%), acute kidney injury requiring dialysis (3.3%), gastrointestinal bleeding (12.5%), alcohol withdrawal (24.5%), delirium (14.5%), and falls (1.32%). Patients with EPC had increased mean LOS (6.98 vs 4.42 days; P < 0.001) and 30-day readmissions (32.5% vs 19%; P < 0.001). On multivariate regression, EPCs were independently associated with higher LOS (odds ratio, 1.45 [95% confidence interval, 1.36-1.56]; P < 0.001) and 30-day readmissions (odds ratio, 1.94 [95% confidence interval 1.28-2.95]; P < 0.001).

CONCLUSIONS

The EPCs are common among noncritical AP patients and contribute to poor outcomes like increased LOS and 30-day readmissions.

A preferable modality for the differentiation of peripancreatic fluid collections: Endoscopic ultrasound

Background and Objectives:

Peripancreatic fluid collections (PFCs), including walled-off necrosis (WON) and pancreatic pseudocysts (PPCs), are categorized by imaging modalities, including EUS, computed tomography (CT), and magnetic resonance imaging. Our study aimed to evaluate the effectiveness of EUS in differentiating PFCs compared with that of other modalities.

Subjects and Methods:

Data were collected retrospectively from 99 patients at fourteen centers who were recruited to undergo lumen-apposing metal stent placement to treat PFCs.

Results:

PFCs were detected by CT and EUS in 51 WON and 48 PPC patients. The accuracy in differentiating PFCs by EUS was much higher than that of CT (90.9% vs. 50.5%, P < 0.001). The accuracy in identifying WON on EUS was much higher than that on CT (82.4% vs. 13.7%, P < 0.001), while the accuracy in identifying PPC was comparable in these two modalities (89.6% vs. 100%, P > 0.05). WON patients required more times of debridement than PPC patients (P < 0.001).

Conclusion:

EUS can categorize symptomatic PFCs with higher accuracy than CT and is a preferred imaging modality to detect solid necrotic debris.

Efficacy and safety of endoscopic drainage of peripancreatic fluid collections: a retrospective multicenter European study

BACKGROUND

Endoscopic ultrasound (EUS)-guided transmural drainage allows treatment of symptomatic peripancreatic fluid collections (PFCs), with lumen-apposing metal stents (LAMS) and double pigtail plastic stents (DPPS) being the 2 most frequently used modalities.

METHODS

Consecutive patients undergoing PFC drainage in 10 European centers were retrospectively retrieved. Technical success (successful deployment), clinical success (satisfactory drainage), rate and type of early adverse events, drainage duration and complications on stent removal were evaluated.

RESULTS

A total of 128 patients-92 men (71.9%), age 57.2±11.9 years-underwent drainage, with pancreatic pseudocyst (PC) and walled-off necrosis (WON) in 92 (71.9%) and 36 (28.1%) patients, respectively. LAMS were used in 80 (62.5%) patients and DPPS in 48 (37.5%). Technical success was achieved in 124 (96.9%) of the cases, with no difference regarding either the type of stent (P>0.99) or PFC type (P=0.07). Clinical success was achieved in 119 (93%); PC had a better response than WON (91/92 vs. 28/36, P<0.001), but the type of stent did not affect the clinical success rate (P=0.29). Twenty patients (15.6%) had at least one early complication, with bleeding being the most common (n=7/20, 35%). No difference was detected in complication rate per type of stent (P=0.61) or per PFC type (P=0.1). Drainage duration was significantly longer with DPPS compared to LAMS: 88 (70-112) vs. 35 (29-55.3) days, P<0.001.

CONCLUSIONS

EUS-guided drainage of PFCs achieves high percentages of technical and clinical success. Drainage using LAMS is of shorter duration, but the complication rate is similar between the 2 modalities.

A Clinical Overview of Acute and Chronic Pancreatitis: The Medical and Surgical Management

An inflammatory process involving the pancreas, known as pancreatitis, can be categorized as either acute or chronic and may present in one of many ways. The clinical manifestations of acute pancreatitis are generally limited to epigastric or right upper quadrant pain, while manifestations of chronic pancreatitis are broader and may include abdominal pain in tandem with signs and symptoms of pancreatic endocrine and exocrine insufficiency. An understanding of the initial insult, proper classification, and prognosis are all factors that are of paramount importance as it pertains to managing patients who are afflicted with this disease. Our review delves into the depths of pancreatitis by exploring the embryology and anatomy of the pancreas, the pathophysiology and etiology of acute and chronic pancreatitis, and the medical and surgical management of acute and chronic pancreatitis.

Percutaneous endoscopic necrosectomy in a patient with emphysematous pancreatitis: A case report

RATIONALE

Emphysematous pancreatitis, a rare complication of acute necrotizing pancreatitis with a high mortality rate, is associated with gas-forming bacteria. When using the step-up approach for treating emphysematous pancreatitis, it is preferable to delay drainage interventions for 4 weeks. However, percutaneous drainage may be necessary, even in the early phase of acute pancreatitis, for a patient whose sepsis deteriorates despite optimal medical management. Percutaneous drainage can then be followed by endoscopic necrosectomy through the percutaneous tract.

PATIENT CONCERNS

A 52-year-old man was transferred to our hospital for treatment of sepsis and multiorgan failure associated with emphysematous pancreatitis.

DIAGNOSIS

An abdominal computed tomography scan had shown pancreatic and peripancreatic necrosis, along with extensive gas bubbles.

INTERVENTIONS

Despite optimal medical management, the patient's condition continued to deteriorate, and it became necessary to insert 2 percutaneous catheter drainages (PCDs), even though the patient was still in the early phase of pancreatitis. Each PCD was upsized and irrigated with sterile saline by an interventional radiologist twice a week. The infected necrosis around the tail of the pancreas was completely resolved after PCD. However, PCD through the transperitoneal route did not resolve necrosis around the pancreatic head. Following the PCDs, percutaneous pancreatic necrosectomy using an ultra-slim upper endoscope was performed, after which the patient recovered quickly and was discharged.

OUTCOMES

Follow-up computed tomography was performed 12 weeks after the patient was discharged, and it showed complete resolution of the walled-off necrosis. The patient's condition improved without any fluid collection or complications.

LESSONS

PCD can be used in the early phase of emphysematous pancreatitis for patients who continue to deteriorate due to sepsis. This can easily be followed, if necessary, by percutaneous pancreatic necrosectomy using an ultra-slim endoscope.