• infected necrotizing pancreatitis
• percutaneous catheter drainage
• step-up approach

• distal pancreatectomy
• pancreaticoduodenectomy
• postoperative complications
• postoperative pancreatic fistula

• Humans
• Pancreatic Fistula/etiology
• Pancreatic Fistula/prevention & control
• Postoperative Complications/etiology
• Postoperative Complications/prevention & control
• Pancreatectomy/adverse effects

• Computerized tomography guidance
• Efficacy and safety
• Severe acute pancreatitis
• Somatostatin
• Therapeutic percutaneous puncture catheter drainage

• acute care surgery
• pancreas

• Male
• Humans
• Middle Aged
• Female
• Debridement/methods
• Pancreas/surgery
• Laparoscopy/methods
• Pancreatitis, Acute Necrotizing/surgery
• Retroperitoneal Space/surgery
• Drainage/methods
• Treatment Outcome

• Acute pancreatitis
• Complications of acute pancreatitis
• Complications of percutaneous catheter drainage
• Endovascular management of pseudoaneurysms
• Percutaneous catheter drainage

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.

• Acute pancreatitis
• Fluid resuscitation
• Antibiotics
• Analgesia
• Anti coagulation
• Intervention

• acute necrotic collections
• infected pancreatic necrosis
• minimally invasive interventions
• pancreas
• percutaneous catheter drainage

• Humans
• Pancreatitis, Acute Necrotizing/complications
• Pancreatitis, Acute Necrotizing/diagnosis
• Pancreatitis, Acute Necrotizing/surgery
• Treatment Outcome
• Minimally Invasive Surgical Procedures/adverse effects
• Minimally Invasive Surgical Procedures/methods
• Intraabdominal Infections
• Drainage/adverse effects
• Drainage/methods
• Necrosis/diagnosis
• Necrosis/etiology
• Necrosis/surgery

• infected pancreatic necrosis
• minimally invasive methods of surgical treatment
• open methods of surgical treatment

Introduction

Open necrosectomy in acute infected necrotizing pancreatitis is associated with very high mortality and morbidity. Moreover, if it is performed before four weeks, the benefits are limited. In this study, we evaluated the safety and efficacy of percutaneous catheter drainage (PCD) in patients with acute infected necrotizing pancreatitis.

Methods

It was a single-center, observational study, where all consecutive patients with proven or probable infected acute necrotizing pancreatitis in whom PCD was performed were studied. The patients who failed to respond to PCD underwent open necrosectomy. Baseline characteristics and the outcome of all included patients, including complications of PCD, were studied.

Results

A total of 46 patients (males=36, females=10) underwent PCD over a period of 18 months. Fifteen (32.60%) patients succumbed to their illness. PCD benefitted a total of 31 (67.39%) patients; in 17 (36.95%) patients, it worked as a standalone therapy, while in 14 (30.43%) patients, additional surgery was required where it helped to delay the surgery. Median days at which PCD and surgery were performed were 17.5 days (range: 2-28 days) and 33 days (range: 7-70 days), respectively. Lower mean arterial pressure at presentation, presence of multiorgan failure, more than 50% necrosis, higher baseline creatinine and bilirubin levels, and an early surgery were markers of increased mortality. Three (6.5%) patients had PCD-related complications, out of which only one required active intervention.

Conclusion

PCD in infected acute pancreatic necrosis is safe and effective. In one-third of the patients, it worked as standalone therapy, and in the rest it delayed the surgery beyond four weeks, thereby preventing the complications associated with early aggressive debridement.

• Fistula
• computed tomography-guided drainage
• fluid accumulation
• perisplenic
• splenic

• Acute necrotizing
• Drainage
• Interventional
• Pancreatitis

• Biopsy
• Cross-section interventional radiology
• Drainage
• Pancreas
• Pancreatic cancer
• Pancreatitis

• Image-guided Procedure
• Pancreatic Necrosis
• Pancreatic Pseudocysts
• Pancreatitis, Acute Necrotizing
• Percutaneous Catheter Drainage

• endoscopic drainage
• multidisciplinary team
• pancreatic collection
• pancreatitis
• patient management algorithm
• percutaneous catheter drainage
• surgical drainage

• Acute Disease
• Algorithms
• Biopsy, Fine-Needle
• Debridement
• Drainage
• Endoscopy, Digestive System/methods
• Humans
• Necrosis/surgery
• Pancreatitis/complications
• Pancreatitis/diagnostic imaging
• Pancreatitis/pathology
• Pancreatitis/surgery
• Patient Care Team
• Radiography, Interventional
• Stents
• Vascular Diseases/diagnostic imaging
• Vascular Diseases/etiology

Acute pancreatitis is commonly complicated by the development of pancreatic collections (PCs). Symptomatic PCs warrant drainage, and the available options include percutaneous, endoscopic, and open surgical approaches. The study aimed to assess the therapeutic effectiveness and safety of image guided percutaneous catheter drainage (PCD) in the management of acute pancreatitis related PCs.

This was a single-centre prospective study covering a 4-year study period. Acute pancreatitisrelated PCs complicated by secondary infection or those producing symptoms due to pressure effect on surrounding structures were enrolled and underwent ultrasound or computed tomography (CT)-guided PCD. The patients were followed to assess the success of PCD (defined as clinical, radiological improvement, and the avoidance of surgery) and any PCD-related complications.

The study included 60 patients (60% males) with a mean age of 43.1 ± 21.2 years. PCD recorded a success rate of 80% (16/20) for acute peripancreatic fluid collections (APFC) and pancreatic pseudocysts (PPs), 75% (12/16) for walled-off necrosis (WON), and 50% (12/24) for acute necrotic collections (ANCs). Post-PCD surgery (necrosectomy ± distal pancreatectomy) was needed in 50% of ANC and 25% of WON. Only 20% of APFCs/PPs patients required surgical/endoscopic treatment post-PCD. Minor procedure-related complications were seen in 4 (6.6%) patients.

PCD is an effective, safe, and minimally invasive therapeutic modality with a good success rate in the management of infected/symptomatic PCs.

• acute necrotic collection
• pancreatic collections
• percutaneous catheter drainage
• pseudocyst
• walled-off necrosis

• Arterial bleeding
• Computed tomography
• Drainage
• Necrotizing pancreatitis
• Pseudoaneurysm

Multimodal fusion imaging (MMFI) was usually used to assist percutaneous procedures for difficult lesions, with most applications occurring with hepatic and prostatic interventions. This paper aimed to evaluate the precision and effectiveness of computed tomography-ultrasound (CT-US) fusion imaging (CUFI)-assisted US-guided percutaneous intervention (UGPI) in early local drug therapy for pancreatic contusion and laceration (PCL).

A total of 12 pigs with PCL were randomly divided into a CUFI-assisted UGPI (MU) group (n=6) and a single UGPI (SU) group (n=6). The MU group underwent CUFI-assisted UGPI of locally applied medical protein glue (1 mL) injection while the SU group received the same therapy using two-dimensional UGPI. The duration and accuracy of each procedure were observed in the 2 groups.

In the MU group, the overall time of the procedure for locking the plane was 1.85±0.06 minutes. Less time was spent in the selection of the pathway and puncture site in the MU group compared with the SU group (6.56±0.42 vs. 7.61±0.44 minutes, P<0.01). The duration of puncturing and drug injection was also shorter in the MU group than in the SU group (3.41±0.30 vs. 4.20±0.20 minutes, P<0.01) and the MU group had a higher accuracy of medical protein glue injection than the SU group (100% vs. 50%, P<0.05).

CUFI could increase the precision and effectiveness of early UGPI in the delivery of local drug therapy in PCL.

• Multimodal fusion imaging (MMFI)
• feasibility
• pancreatic contusion and laceration (PCL)
• ultrasound-guided percutaneous intervention

• acute pancreatitis
• computed tomography
• necrotic debris
• necrotizing pancreatitis
• peripancreatic fluid collections

In recent decades, an increasing number of patients have received minimally invasive intervention for infected pancreatic necrosis (IPN) because of the benefits in reducing postoperative multiple organ failure and mortality. However, there are limited published data regarding infection recurrence after treatment of this patient population.

To investigate the incidence and prediction of infection recurrence following successful minimally invasive treatment in IPN patients.

Medical records for 193 IPN patients, who underwent minimally invasive treatment between February 2014 and October 2018, were retrospectively reviewed. Patients, who survived after the treatment, were divided into two groups: one group with infection after drainage catheter removal and another group without infection. The morphological and clinical data were compared between the two groups. Significantly different variables were introduced into the correlation and multivariate logistic analysis to identify independent predictors for infection recurrence. Sensitivity and specificity for diagnostic performance were determined.

Of the 193 IPN patients, 178 were recruited into the study. Of them, 9 (5.06%) patients died and 169 patients survived but infection recurred in 13 of 178 patients (7.30%) at 7 (4-10) d after drainage catheters were removed. White blood cell (WBC) count, serum C-reactive protein (CRP), interleukin-6, and procalcitonin levels measured at the time of catheter removal were significantly higher in patients with infection than in those without (all P < 0.05). In addition, drainage duration and length of the catheter measured by computerized tomography scan were significantly longer in patients with infection (P = 0.025 and P < 0.0001, respectively). Although these parameters all correlated positively with the incidence of infection (all P < 0.05), only WBC, CRP, procalcitonin levels, and catheter length were identified as independent predictors for infection recurrence. The sensitivity and specificity for infection prediction were high in WBC count (≥ 9.95 × 10⁹/L) and serum procalcitonin level (≥ 0.05 ng/mL) but moderate in serum CRP level (cut-off point ≥ 7.37 mg/L). The catheter length (cut-off value ≥ 8.05 cm) had a high sensitivity but low specificity to predict the infection recurrence.

WBC count, serum procalcitonin, and CRP levels may be valuable for predicting infection recurrence following minimally invasive intervention in IPN patients. These biomarkers should be considered before removing the drainage catheters.

• Infectious pancreatic necrosis
• Drainage
• Minimally invasive intervention
• Infection recurrence
• C-reactive protein
• Procalcitonin

• Biomarkers
• C-Reactive Protein
• Calcitonin
• Calcitonin Gene-Related Peptide
• Humans
• Pancreatitis, Acute Necrotizing
• Protein Precursors
• Retrospective Studies

• Bleeding complications
• CT scan guidance
• Infected pancreatic necrosis, Sterile pancreatic necrosis
• Intestinal fistula
• Necrotizing pancreatitis
• Percutaneous catheter drainage
• Pseudoaneurysms
• Ultrasound guidance

• Necrosectomy
• Pancreatitis
• Percutaneous drainage

Percutaneous catheter drainage (PCD) is used as the first step in the management of symptomatic fluid collections in patients with acute pancreatitis (AP). There are limited data on the effect of PCD on inflammatory markers.

To study the effects of PCD on serum levels of C‐reactive protein (CRP), IL‐6, and IL‐10 and its correlation with the outcome.

Consecutive patients of AP with symptomatic fluid collections undergoing PCD were evaluated for serum levels of CRP, IL‐6, and IL‐10 before PCD and at 3 and 7 days after PCD. Resolution of organ failure (OF), sepsis, and pressure symptoms was considered to demonstrate the success of PCD. Changes in levels following PCD were correlated with outcome.

Indications of PCD in 59 patients (age 38.9 ± 13.17 years, 49 male) were suspected/documented infected pancreatic necrosis (n = 45), persistent OF (n = 40), and pressure symptoms (n = 7). A total of 49 (83.1%) patients improved with PCD, five patients required surgery, and six died. A significant difference was noted between baseline levels of CRP (P = 0.026) and IL‐6 (P = 0.013) among patients who improved compared to those who worsened following PCD. Significant decrease (P < 0.01) of all three markers on day 3 of PCD insertion, with further decrease (P < 0.01) on day 7, was noted. The percentage of the decrease of IL‐6 levels on day 3 and of CRP on day 7 correlated with the outcome.

PCD is associated with a significant decrease in CRP, IL‐6, and IL‐10 levels. Percentage decrease in IL‐6 on day 3 and CRP on day 7 correlated with the outcome of patients managed with PCD.

• C‐reactive protein
• acute pancreatitis
• inflammatory markers
• interleukins
• interleukin‐10
• interleukin‐6
• percutaneous catheter drainage

• Infected necrotizing pancreatitis
• percutaneous catheter drainage
• videoscopic assisted retroperitoneal debridement
• prognosis

• Acute Disease
• Humans
• Pancreas
• Pancreatic Pseudocyst

• Acute necrotic collection
• Acute pancreatitis
• Percutaneous catheter drainage
• Walled-off necrosis

• Adult
• Drainage/adverse effects
• Drainage/methods
• Female
• Humans
• Male
• Middle Aged
• Minimally Invasive Surgical Procedures/methods
• Pancreatitis, Acute Necrotizing/surgery
• Retrospective Studies

• Acute necrotizing pancreatitis
• Drainage
• Infection
• Multimodal imaging
• Paracentesis

• infected necrotizing pancreatitis
• pancreatic necrosectomy
• percutaneous catheter drainage
• predictors

• Acute pancreatitis
• Chronic pancreatitis
• Computed tomography (CT)
• Pseudocyst
• Residual fluid collections
• Residual peripancreatic inflammation

• Amylase
• Infected pancreatic necrosis
• Nasopancreatic drainage
• Pancreatic duct disruption
• Pancreatic fistula

• Infected pancreatitis necrosis
• Intervention
• Percutaneous catheter drainage
• Systematic

AIM: To determine the feasibility and safety of transgastric direct endoscopic necrosectomy (DEN) in patients with walled-off necrosis (WON) and gastric varices.

METHODS: A single center retrospective study of consecutive DEN for WON was performed from 2012 to 2015. All DEN cases with gastric fundal varices noted on endoscopy, computed tomography (CT) or magnetic resonance imaging (MRI) during the admission for DEN were collected for analysis. In all cases, external urethral sphincter (EUS) with doppler was used to exclude the presence of intervening gastric varices or other vascular structures prior to 19 gauge fine-needle aspiration (FNA) needle access into the cavity. The tract was serially dilated to 20 mm and was entered with an endoscope for DEN. Pigtail stents were placed to facilitate drainage of the cavity. Procedure details were recorded. Comprehensive chart review was performed to evaluate for complications and WON recurrence.

RESULTS: Fifteen patients who underwent DEN for WON had gastric varices at the time of their procedure. All patients had an INR < 1.5 and platelets > 50. Of these patients, 11 had splenic vein thrombosis and 2 had portal vein thrombosis. Two patients had isolated gastric varices, type 1 and the remaining 13 had > 5 mm gastric submucosal varices on imaging by CT, MRI or EUS. No procedures were terminated without completing the DEN for any reason. One patient had self-limited intraprocedural bleeding related to balloon dilation of the tract. Two patients experienced delayed bleeding at 2 and 5 d post-op respectively. One required no therapy or intervention and the other received 1 unit transfusion and had an EGD which revealed no active bleeding. Resolution rate of WON was 100% (after up to 2 additional DEN in one patient) and no patients required interventional radiology or surgical interventions.

CONCLUSION: In patients with WON and gastric varices, DEN using EUS and doppler guidance may be performed safely. Successful resolution of WON does not appear to be compromised by the presence of gastric varices, with similar rates of resolution and only minor bleeding events. Experienced centers should not consider gastric varices a contraindication to DEN.

• Necrosectomy
• Pancreatic necrosis
• Endoscopy
• Necrotizing pancreatitis
• Gastric varices
• Varices
• Walled off necrosis
• Walled-off necrosis
• Gastrointestinal hemorrhage
• Endoscopic ultrasound

• Anti-Bacterial Agents/administration & dosage
• Biopsy, Fine-Needle
• Consensus
• Drainage/adverse effects
• Drainage/trends
• Drug Administration Schedule
• Health Care Surveys
• Humans
• International Cooperation
• Pancreatectomy/adverse effects
• Pancreatectomy/trends
• Pancreatitis, Acute Necrotizing/diagnosis
• Pancreatitis, Acute Necrotizing/microbiology
• Pancreatitis, Acute Necrotizing/therapy
• Practice Patterns, Physicians'/trends
• Predictive Value of Tests
• Risk Factors
• Surveys and Questionnaires
• Time Factors
• Time-to-Treatment/trends

• 15957 Cancer Research UK
• 8968 Cancer Research UK
• PB-PG-0407-13363 Department of Health

Pancreatic fluid collections (PFCs) are seen in up to 50% of cases of acute pancreatitis. The Revised Atlanta classification categorized these collections on the basis of duration of disease and contents, whether liquid alone or a mixture of fluid and necrotic debris. Management of these different types of collections differs because of the variable quantity of debris; while patients with pseudocysts can be drained by straight-forward stent placement, walled-off necrosis requires multi-disciplinary approach. Differentiating these collections on the basis of clinical severity alone is not reliable, so imaging is primarily performed. Contrast-enhanced computed tomography is the commonly used modality for the diagnosis and assessment of proportion of solid contents in PFCs; however with certain limitations such as use of iodinated contrast material especially in renal failure patients and radiation exposure. Magnetic resonance imaging (MRI) performs better than computed tomography (CT) in characterization of pancreatic/peripancreatic fluid collections especially for quantification of solid debris and fat necrosis (seen as fat density globules), and is an alternative in those situations where CT is contraindicated. Also magnetic resonance cholangiopancreatography is highly sensitive for detecting pancreatic duct disruption and choledocholithiasis. Endoscopic ultrasound is an evolving technique with higher reproducibility for fluid-to-debris component estimation with the added advantage of being a single stage procedure for both diagnosis (solid debris delineation) and management (drainage of collection) in the same sitting. Recently role of diffusion weighted MRI and positron emission tomography/CT with ¹⁸F-FDG labeled autologous leukocytes is also emerging for detection of infection noninvasively. Comparative studies between these imaging modalities are still limited. However we look forward to a time when this gap in literature will be fulfilled.

• Acute pancreatitis
• Contrast-enhanced computed tomography
• Magnetic resonance imaging
• Endoscopic ultrasound
• Positron emission tomography scan
• Pancreatic fluid collections
• Acute necrotic collections
• Acute peripancreatic fluid collections
• Pseudocysts
• Walled-off necrosis

• Acute Disease
• Cholangiopancreatography, Magnetic Resonance
• Diagnostic Imaging/methods
• Drainage/instrumentation
• Endosonography
• Humans
• Multimodal Imaging
• Necrosis
• Pancreas/diagnostic imaging
• Pancreas/pathology
• Pancreatic Cyst/diagnosis
• Pancreatic Cyst/therapy
• Pancreatic Pseudocyst/diagnosis
• Pancreatic Pseudocyst/therapy
• Pancreatitis/diagnosis
• Pancreatitis/therapy
• Positron-Emission Tomography
• Predictive Value of Tests
• Prognosis
• Severity of Illness Index
• Stents
• Tomography, X-Ray Computed

• Acute pancreatitis
• Operative intervention
• Pancreatic necrosis
• Percutaneous catheter drainage

• 15957 Cancer Research UK
• 8968 Cancer Research UK
• PB-PG-0407-13363 Department of Health

Pancreatitis induced by hypertriglyceridemia (HTG) has gained much attention. However, very limited numbers of studies have focused on the clinical significance of TG elevation in non-HTG induced pancreatitis, such as acute biliary pancreatitis (ABP). This study aimed to study the clinical significances of triglyceride (TG) elevation in patients with ABP.

We retrospectively analyzed a total of 426 ABP cases in our research center. According to the highest TG level within 72 h of disease onset, the patients were divided into a normal TG group and an elevated TG group. We analyzed the differences between the two groups of patients in aspects such as general information, disease severity, APACHE II (acute physiology and chronic health evaluation II) and Ranson scores, inflammatory cytokines, complications and prognosis.

Compared with the normal TG group, patients in the elevated TG group showed a significantly higher body mass index and were significantly younger. TG elevation at the early stage of ABP was associated with higher risk of severe pancreatitis and organ failures, especially respiratory failure. For patients with severe pancreatitis, those with elevated TG levels were more likely to have a larger area of necrosis, and higher incidence of pancreatic abscess as well as higher mortality (17.78% versus 9.80%, P < 0.05).

In ABP patients, TG elevation might participate in the aggravation of pancreatitis and the occurrence of systemic or local complications. Thus, the TG level may serve as an important indicator to determine the prognosis of patients with ABP.

Although we previously demonstrated abdominal paracentesis drainage (APD) preceding percutaneous catheter drainage (PCD) as the central step for treating patients with moderately severe (MSAP) or severe acute pancreatitis (SAP), the predictors leading to PCD after APD have not been studied.

Consecutive patients with MSAP or SAP were recruited between June 2011 and June 2013. As a step-up approach, all patients initially received medical management, later underwent ultrasound-guided APD before PCD, if necessary, followed by endoscopic necrosectomy through the path formed by PCD. APD primarily targeted fluid in the abdominal or pelvic cavities, whereas PCD aimed at (peri)pancreatic fluid.

Of the 92 enrolled patients, 40 were managed with APD alone and 52 received PCD after APD (14 required necrosectomy after initial PCD). The overall mortality was 6.5%. Univariate analysis showed that among the 20 selected parameters, 13 factors significantly affected PCD intervention after APD. Multivariate analysis revealed that infected (peri)pancreatic collections (P = -0.001), maximum extent of necrosis of more than 30% of the pancreas (P = -0.024), size of the largest necrotic peri(pancreatic) collection (P = -0.007), and reduction of (peri)pancreatic fluid collections by <50% after APD (P = -0.008) were all independent predictors of PCD.

Infected (peri)pancreatic collections, a largest necrotic peri(pancreatic) collection of more than 100 ml, and reduction of (peri)pancreatic fluid collections by <50% after APD could effectively predict the need for PCD in the early course of the disease.

• Drainage
• Necrosis
• Pancreatic fistula
• Pancreatic juice
• Pancreatitis
• Treatment outcome

• Alcoholism/complications
• Alcoholism/pathology
• Cholangiopancreatography, Endoscopic Retrograde
• Female
• Gallstones/complications
• Gallstones/pathology
• Humans
• Incidence
• Male
• Multiple Organ Failure/mortality
• Multiple Organ Failure/pathology
• Pancreatitis, Acute Necrotizing/etiology
• Pancreatitis, Acute Necrotizing/mortality
• Pancreatitis, Acute Necrotizing/pathology
• Risk Factors
• Severity of Illness Index
• Systemic Inflammatory Response Syndrome/mortality
• Systemic Inflammatory Response Syndrome/pathology
• Therapeutic Irrigation

• Acute necrotizing pancreatitis
• Debridement
• Minimally invasive surgical procedures
• Pancreatic diseases
• Sensitivity and specificity