Drainage Of Collections Research Articles

Endoscopic management of complications in the hepatobiliary and pancreatic system and the tracheobronchial tree

Endoscopic methods are nowadays apriceless tool for the treatment of postoperative complications after hepatobiliary, pancreatic and thoracic surgery. Endoscopic decompression of the biliary tract is the treatment of choice for biliary duct leakage after cholecystectomy, hepatic resection or liver transplantation. Postoperative biliary duct stenosis can also be successfully treated by endoscopic balloon dilatation and implantation of various endoprostheses in most of the patients. In the case of pancreatic fistulas, especially those occurring after central or distal pancreatic resections, endoscopic decompression of the pancreatic duct can significantly contribute to rapid healing. Additionally, interventional endosonography provides avaluable treatment option for transgastric drainage of postoperative fluid collections, which often accompany a pancreatic fistula. Various treatment alternatives have been described for the bronchoscopic treatment of bronchopleural and tracheoesophageal fistulas, which often lead to the rapid alleviation of symptoms and often to the definitive closure of the fistula.

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

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

S1075 Early (<4 Weeks) vs Standard (≥ 4 Weeks) Endoscopic Drainage of Pancreatic Walled-Off Fluid Collections: A Systematic Review and Meta-Analysis

Introduction: Previous studies have demonstrated that the ideal time for drainage of walled off pancreatic fluid collections is 4-6 weeks after its development. However, some pancreatic collections, including pancreatic walled-off necrosis (WON), require earlier drainage. Nevertheless, the optimal timing of the first intervention is unclear, and consensus data are sparse. The aim of this study was to evaluate clinical outcomes and safety of endoscopic ultrasound (EUS) - guided drainage of pancreatic fluid collections < than 4 weeks after its development compared to ≥4 weeks after its development. Methods: Search strategies were developed for PubMed, EMBASE, and Cochrane Library databases from inception through June 2022 in accordance with PRISMA and MOOSE guidelines. Outcomes of interest included technical success defined as successful endoscopic placement of LAMS, clinical success defined as reduction in cystic collection size, and procedure-related adverse events. A random effects model was used for analysis and results were expressed as odds ratio (OR) along with 95% confidence interval (CI). Results: A total of 6 studies (630 patients) were included in our final analysis where 182 patients (28.9%) were enrolled in the early drainage cohort and 448 (71.1%) patients in the standard drainage cohort. Age ranges were similar between groups. Alcohol was the main driver of acute pancreatitis. Infection was the most common indication for pancreatic drainage (42.6%). The mean fluid collection size was 143.4 ± 18.8 mm for the early cohort vs 128 ± 19.7 mm for the standard cohort. Most fluid collections were located in the body of the pancreas (86.7%). Overall, technical success favored standard drainage over early drainage (OR 0.01; 95% CI 0.00 – 0.15; P=0.001). Clinical success also favored standard drainage over early drainage (OR 0.46; 95% CI 0.16 – 1.32; P=0.03). With regards to adverse events, there was no statistically significant difference in overall adverse events (OR 0.76; 95% CI 0.42 – 1.39; P=0.56) or mortality (OR 1.14; 95% CI 0.29 – 4.48; P=0.23). Hospital stay was longer for patients undergoing early drainage compared to standard drainage (23.7 vs 16.0 days, respectively). (Figure) Conclusion: Compared to early drainage (< 4 weeks), endoscopic drainage of pancreatic fluid collections is significantly more efficacious when performed at least 4 weeks after development, with a shorter hospital length of stay. Therefore, pancreatic fluid collections should ideally be drained 4 weeks after development.Figure 1.: Forrest plot showing pooled rates of clinical success.

PROSTHETIC VALVE INFECTIVE ENDOCARDITIS CAUSED BY SERRATIA MARCESCENS IN A PATIENT WITH SURGICAL WOUND INFECTION

PROSTHETIC VALVE INFECTIVE ENDOCARDITIS CAUSED BY SERRATIA MARCESCENS IN A PATIENT WITH SURGICAL WOUND INFECTION

AN UNUSUAL COMPLICATION OF ACUTE APPENDICITIS

AN UNUSUAL COMPLICATION OF ACUTE APPENDICITIS

S1838 Spontaneous Gastro-pancreatic Fistula: A Rare Complication of Acute Pancreatitis

Introduction: Although Gastrointestinal fistula is a well-recognized complication of acute pancreatitis, it has been rarely reported. Here we present a rare case of spontaneous gastro-pancreatic fistula following acute pancreatitis. Case Description/Methods: 42 y/o female with PMH of SLE with a recent prolonged hospitalization for acute drug-induced pancreatitis with pseudocyst came to ED with fever, abdominal pain, nausea, and vomiting. She was tachycardic, had leukocytosis, and was positive for COVID-19. CT Scan A/P showed multiple infected peripancreatic collections with communication of the left upper quadrant collection with the gastric lumen (Figure). The patient was hospitalized, Kept NPO, and started on fluids and antibiotics. IR evaluated and put 2 pigtail catheters for drainage of peripancreatic collections. The tip of the pigtail catheter in the left peripancreatic/retroperitoneal collection was in the gastric lumen. The surgery team recommended continuing with conservative treatment with parenteral nutrition, and IV antibiotics as the patient were nontoxic with no signs of free perforation, and pancreatitis would more likely erode a staple or suture line and would put the patient at further risk of free perforation if repair attempted. IR was successful in pulling the drain out of the gastric lumen on the second attempt to allow gastric perforation to heal. Antibiotics were upgraded as per the culture and sensitivity results of the drain fluid. Repeated multiple bedside leak tests and CT scans with oral contrast continue to be positive for patent gastro-pancreatic fistula. Pigtails catheter continues to drain significant necrotic collection. The patient continues to be hospitalized and is being managed conservatively with Parenteral nutrition, and IV antibiotics. Discussion: Fistula of the GI tract following acute pancreatitis can be caused by multiple reasons. Necrosis of the bowel may occur concomitantly with the pancreatic or peripancreatic tissue. Furthermore, enzyme-rich fluid and necrosis can lead to vascular thrombosis, which compromises the blood supply of the segmental GI tract, eventually leading to bowel necrosis. GI fistulas are more common in patients with necrotizing pancreatitis with infected pancreatic necrosis. Despite pharmacologic suppression of pancreatic exocrine secretion and advances in endoscopic and percutaneous therapeutic techniques, pancreatic fistula continues to be a source of morbidity and mortality following pancreatitis and requires multidisciplinary treatment.Figure 1.: Peripherally enhancing fluid collection in the left upper quadrant/gastric wall. There is a communication between this collection with the gastric lumen.

S1137 Analysis of Off-Label Usage of Lumen Apposing Metal Stents in the GI Tract: A Single Center Experience

Introduction: Lumen apposing metal stents (LAMS) have revolutionized our approach to pancreatic fluid collections (PFCs). In addition to tremendous success in safely and effectively managing PFCs, LAMS have been utilized in other interventions including EUS-guided gallbladder drainage (EUS-GBD), EUS-directed transgastric ERCP (EDGE), EUS-guided transgastric intervention (EDGI), EUS-guided gastrojejunostomy (EUS-GJ), EUS-guided choledochoduodenostomy (EUS-CD), EUS-guided drainage of post-operative collection (EUS-PO) and stricture dilation (SD). There is limited research on the use of LAMS for these off-label indications. We present our experience using LAMS in the management of conditions other than pancreatic fluid collections. Methods: All patients who underwent LAMS placement between March 2015-October 2021 were added to a prospectively maintained database. Collected data including patients’ demographics, procedure details, clinical outcomes, and adverse events was retrospectively reviewed. All patients who underwent LAMS placement for PFCs were excluded from the analysis. Descriptive statistics were used to summarize our findings. Results: A total of 191 patients underwent LAMS placement during the study period. Of these, 65 patients had indications outside of drainage of PFCs. This included EUS-GBD (25), EDGE (6), EDGI (2), EUS-GJ (11), EUS-CD (4), SD (6), EUS-PO (9), and miscellaneous (2) (Table). The average age was 65.7 years (SD 8.6) and 24 were female (36.9%). Technical success was achieved in 63 patients (96.9%). The diameter of LAMS used included 8mm (n=2), 10mm (n=23), 15mm (n=17), and 20mm (n=21). The average procedure time was 39.4 minutes (SD 5.3) and the average duration of LAMS placement was 36.2 days (SD 8.5). Clinical success was achieved in 57/63 patients (90.5%); however, this was much lower for patients who underwent LAMS placement for stricture dilatation (50%). LAMS was left indefinitely in 24 patients (38.1%). Adverse events occurred in six patients (9.2%). Conclusion: LAMS provide an effective and safe modality for securing endoscopic access and allowing interventions outside of PFCs. However, the efficacy of LAMS for managing gastrointestinal strictures remains in question. Table 1. - Summary of usage of LAMS in the GI Tract EUS-GBD (n=25) EDGE (n=6) EDGI (n=2) EUS-GJ (n=11) EUS-CD (n=4) SD (n=6) EUS-PO (n=9) Miscellaneous (n=2) Age, mean, SD 73.64, 12.0 65.8, 8.1 61.0, 9.9 64.5, 13.0 65.3, 17.0 55.2, 11.75 52.0, 18.5 71, 66 Female gender, n, % 6, 24% 5, 83.3% 1, 50% 2, 18% 3, 75% 5, 83% 2, 22.2% 0, 0% Indications, n % Calculous Cholecystitis, 15, 60% Choledocholithiasis (n=4, 66.7%) Pancreatic mass (n=1, 50%) Malignant GOO, 11, 100% Distal malignant biliary obstruction, 4 100% Anastomotic stricture, 4 (67%) Post-operative fluid collections, 9, 100% Liver abscess, 2, 100% Malignant cholecystitis, 5, 20% Acalculous cholecystitis, 2, 8% Benign papillary stenosis (n=2, 33.3%) Pancreatic cyst (n=1, 50%) Pyloric stricture, 2 (33%) Malignant biliary obstruction, 3, 12% Technical success, n, % 23, 92.0% 6, 100% 2, 100% 11, 100% 4, 100% 6, 100% 9, 100% 2, 100% Clinical success, n, % 21/23, 91.3% 6, 100% 2, 100% 11, 100% 4, 100% 3, 50% 8, 88.9% 2, 100% Procedure duration (min), mean, SD 39.5, 21.7 38.7, 20.0 52, 17.0 66, 31.6 24.5, 13.3 18.7, 3.8 27.3, 9.1 28, 7.1 Duration of LAMS placement, mean, SD 47.9, 27.0 30.3, 11.6 28, 0 N/A N/A 68.5, 26.7 47.3, 28.2 39, 5 Adverse events, n, % 4, 18% 0, 0% 1, 50% 0, 0% 0, 0% 1, 16.7% 0, 0% 0, 0% Length of follow-up (days), mean, SD 47.3, 27.9 208.2, 179.1 240, 144.2 46.50, (28.3, 82.8) 143, 119.9 292, 171.2 565.8, 465.1 43.5, 53.0

S2839 Gastrointestinal Bleeding Secondary to Splenic Artery Aneurysm: A Delayed Complication of a Lumen Apposing Metal Stent

Introduction: Lumen apposing metal stents (LAMS) have been widely used for drainage of peri-pancreatic collections. Pseudoaneurysm formation and rupture is an uncommon complication of LAMS. A possible mechanism for bleeding with current LAMS is its bi-flanged design which does not allow mobility of walls or the stent when the size of collection reduces in size post drainage. This can theoretically cause tension over the wall and surrounding vasculature which lead to pseudoaneurysm formation and bleeding. Case Description/Methods: A 71-year-old female with a history of necrotizing pancreatitis complicated by splenic vein thrombosis on warfarin underwent LAMS placement with a significant reduction in the peri-pancreatic collection on follow up imaging. Three months later, she presented with two days of melena and hematochezia. On evaluation, she was hypotensive and tachycardic. Lab work revealed hemoglobin of 6.1 g/dl from a baseline of 12 g/dl. A computerized tomography angiography (CTA) which did not show active GI bleeding. EGD showed a large pulsating non-bleeding vessel within LAMS. Due to the potential of increasing bleeding with the removal of LAMS, a mesenteric angiogram was done demonstrating a splenic artery pseudoaneurysm, and this was successfully embolized with coils. She subsequently underwent repeat EGD following the coiling with successful removal of LAMS. No further bleeding followed stent removal. Discussion: A ruptured pseudoaneurysm can present with abdominal pain, signs of GI bleeding, or hemobilia. CTA is an important (Figure) diagnostic step but can be unremarkable such as in this case. Pseudoaneurysm formation can be prevented with timely removal of LAMS after the successful drainage and reduction in the size of the pancreatic collection Empiric embolization before removal of LAMS can prevent life-threatening bleeding, and therefore discussion with the interventional radiologist should be done before attempting removal of LAMS in such high-risk cases. Although GI bleeding secondary to rupture pseudoaneurysm with LAMS is a rare complication, it should be considered in patients with recent LAMS placement who present with GI bleeding.Figure 1.: Digital subtraction angiogram of the Celiac artery demonstrating luminal irregularity and dilation, consistent with pseudoaneurysm of the main Splenic artery, about the inferior margin of the AXIOS stent.

S3246 Streptococcus Anginosus Causing Simultaneous Infections in an Elderly Male: Empyema and Infrahepatic Abscess: Case Report and Literature Review

Introduction: Streptococcus Anginosus is a gram-positive bacterium of the Streptococcus Viridians group. Usually presents as normal flora in the oral cavity and the gastrointestinal tract, S. Anginosus can cause pyogenic infections in multiple organs in the body especially in the immunocompromised host. We present a case of S. Anginosus multiple sites infection in an immunocompetent host that was successfully treated. Case Description/Methods: A 75-year-old male with history of diabetes, coronary artery disease, and heart failure with reduced ejection fraction presented to ER with worsening lower abdominal pain associated with poor appetite and decreased oral intake over 3 weeks. He had cholecystectomy about a year prior to presentation. He was clinically stable on examination with mild right upper quadrant tenderness without rebound. CT abdomen with intravenous contrast showed 10*7 cm low-density fluid collection with mild rim enhancement inferior to the right hepatic lobe. He underwent CT-guided drainage of the infrahepatic collection with removal of 50 cc of purulent material and placement of an intraabdominal drain. Also, a loculated right pleural effusion was noted on CT, and 350 cc of purulent pleural fluid was drained, with analysis compatible with empyema. Both fluid cultures grew S. anginosus. Empirical antibiotics were changed to ceftriaxone, but patient had recurrence of right pleural effusion and required repeat thoracentesis. He gradually improved and completed 6 weeks of Ceftriaxone. Discussion: S. anginosus is a normal flora that can cause infection in any organ. Most of the patients reported to have S. anginosus infection were immunosuppressed by cancer, long term steroid use, diabetes or splenectomy. It is less common for this organism to cause concurrent multiple organs infections. Published cases of simultaneous S. anginosus infection of multiple organs were limited and usually ended in poor prognosis like death or turned out to be the same infection with an anatomic connection between the organs. Our patient had the infrahepatic collection diagnosed first before the right sided pleural effusion enlarged. When the infrahepatic collection was drained, the pleural effusion size did not go down, suggesting lack of connection between both collections. S. anginosus is commonly sensitive to antibiotics. Thus, it is commonly treated with Ceftriaxone. Penicillin-intermediate or resistant S. anginosus is rare comprising < 2% of infections and does not usually lead to treatment failure.

S1088 Comparison of Safety of Lumen Apposing Metal Stents With or Without Coaxial Plastic Stent Placement for the Management of Pancreatic Fluid Collections

Introduction: Lumen opposing metal stents (LAMS) allow for safe and effective endoscopic drainage of pancreatic fluid collections (PFCs). LAMS, however, have been associated with bleeding within the cavity and pseudoaneurysm formation. Placement of a coaxial double pigtail plastic stent (DPPS) may theoretically reduce this risk and that of symptomatic stent occlusion. The aim of this study is to compare the safety of LAMS alone versus LAMS with coaxial DPPS placement (LAMS/DPPS) for the management of PFCs. Methods: Patients who underwent LAMS placement for management of a PFC between Sep 2019 and Feb 2022 were retrospectively identified from a tertiary care center procedural data base. Cases were categorized as LAMS or LAMS/DPPS. Demographics, clinical characteristics, and outcomes were compared between the two cohorts. The primary outcome was the rate and type of adverse events between the groups. Secondary outcomes included clinical success rates and time to clinical success. Results: 185 unique patients were identified; 83 (44.9%) with LAMS drainage alone and 102 (55.1%) LAMS/DPPS. There were no significant differences in age, sex, PFC etiology, PFC type, size, or paracolic extension (Table). DPPS with 7Fr or 10Fr diameters were utilized with a median length of 4.0 cm (IQR 4.0-7.0). There were no significant differences in rates of clinical success, need for early necrosectomy, number of endoscopies, or number of necrosectomies. However, stent dwell time was significantly longer in the LAMS only group (69 vs. 35 days, p=0.017). Overall, AE rates were the same in the two cohorts (15.7%, vs. 15.7%, p=0.825). Bleeding occurred in 2 (2.4%) and 9 (8.8%) cases in the LAMS and LAMS/DPPS groups, respectively (p=0.067), with 4 confirmed cases of pseudoaneurysm bleeding (1 LAMS and 3 LAMS/DPPS, p=0.220). There were no differences in the rate of clinically significant stent occlusion (2.4% LAMS vs. 2.9% LAMS/DPPS, p=0.825) or migration (3.6% LAMS vs. 1.0% LAMS/DPPS, p=0.220). Incidental DPPS migration was noted in 12 (11.8%) cases, but all patients were asymptomatic. Conclusion: The safety profile of LAMS was similar to LAMS/DPPS in this cohort. The incidence of bleeding and occlusion was low overall and not significantly impacted by the presence of a DPPS. Randomized studies are needed to further elucidate the role of coaxial DPPS in drainage of PFCs. Table 1. - Baseline clinical characteristics and outcomes of patients who underwent placement of either lumen opposing metal stent (LAMS) alone or LAMS with coaxial double pigtail plastic stent (LAMS/DPPS) placement BASELINE CHARACTERISTICS LAMSN = 83 LAMS/DPPSN=102 P Value Age, y, median (IQR) 55.0 (45.5 – 65.0) 56.5 (42.8 – 65.0) 0.760 Female 22 (26.5) 41 (40.2) 0.051 Collection Type Walled-off necrosis Pseudocyst 64 (77.1)21 (25.3) 80 (78.4)22 (21.6) 0.550 Maximum diameter of dominant collection, cm, median (IQR) 12.0 (7.9 – 18.4) 11.0 (7.8 – 15.0) 0.098 Multiple collections 30 (36.6) 51 (50.0) 0.068 Paracolic extension 32 (38.6) 34 (33.3) 0.461 OUTCOMES LAMS dwell time, d, median (IQR) 69.0 (31.0 – 131.0) 35.0 (21.0 – 65.5) 0.017 Clinical success 63 (75.9) 71 (69.6) 0.341 Total therapeutic endoscopies, no., median (IQR) 2 (1 – 3) 3 (2 – 4) 0.216 Total necrosectomies, no., median (IQR) 1 (0 – 2) 1 (0 – 2) 0.976 Unplanned early necrosectomy 12 (14.6) 16 (15.7) 0.843 Incidental stent migration LAMS DPPS 1 (1.2)N/A 1 (0.9)12 (11.8) 0.883 Adverse Events LAMS Occlusion LAMS Migration Bleeding Infection 13 (15.7)2 3 26 16 (15.7)3194 0.9960.8250.2200.0670.322 Data reported as no. (%) unless indicated.

S2845 Inadvertent Treatment of a Vertical Banded Gastroplasty Stricture With a LAMS for Two Years

Introduction: Lumen-apposing metal stents (LAMS) are innovative endoscopic devices representing the next significant advancement in stent technology. LAMS have demonstrated success, most notably with improving drainage of pancreatic fluid collections. Other clinical indications for using LAMS include biliary drainage, gastroenterostomy, or the managment of luminal tract strictures. The stent has a larger lumen diameter than previously created stents as well as a unique “dumbbell” shape to limit migration. Studies have demonstrated advantages such as shorter procedure times and overall reduced repeat endoscopic procedures. As LAMS has gained notoriety, there have been increasing studies demonstrating potential complications of the device. Most common consequences of LAMS include bleeding, biliary stricture, and buried LAMS syndrome. As the anatomical design has decreased migration risk, prompt removal is recommended to prevent buried LAMS syndrome, where the stent is embedded in the wall of the gastric mucosa and can eventually not be visualized endoscopically. In this case, we will present a patient with an endoscopically placed LAMS, which was successfully removed with minimal complications after two years in place. Case Description/Methods: Our patient is a 68 year old female with a Vertical Banded Gastroplasty Stricture. She had required multiple repeat endoscopies for dilation therapy but the stricture was refractory to dilation, as a result, she underwent LAMS placement Due to the onset of the COVID pandemic, patient was lost to follow up. On a repeat EGD two years after placement, the stent remained in its original location. There were signs of mild gastric tissue overgrowth at the right lateral side of the LAMS. The stent was then removed easily with no signs of bleeding. After removal, the stricture remained dilated as the scope could be passed without difficulty. Over course of COVID she ate better than she had in years. (Figure) Discussion: LAMS have demonstrated significant success in a variety of endoscopic interventions. Their potential complications are well documented in various studies. This case is unique in regards to the length of time in which the LAMS remained in position. From a literature review, no study has demonstrated a LAMS in place as long as two years for stricture management. More remarkable is the lack of complications from the stent such as no bleeding with removal and no true buried LAMS syndrome as there was minimal tissue overgrowth.Figure 1.: LAMS on endoscopic evaluation two years after placement.

S75 Safety and Efficacy of Endoscopic Drainage of Pancreatic Fluid Collections Performed by Early Career Advanced Endoscopists: A Multicenter Experience

S75 Safety and Efficacy of Endoscopic Drainage of Pancreatic Fluid Collections Performed by Early Career Advanced Endoscopists: A Multicenter Experience

Entrapped Malecot catheter removal: Our experience.

Some surgeons use a Malecot catheter for drainage of intra-abdominal or mediastinal collections. These tubes are usually removed after 2-3 weeks. If left later, they may become entrapped due to the ingrowing of tissue, and fibrosis within the flower-like tip of the Malecot's catheter. Its removal then needs careful manipulation to prevent organ damage. We present our experience in ensuring the safe removal of such entrapped Malecot's catheters in liver abscess patients.

Computed tomography imaging-based predictors of the need for a step-up approach after initial endoscopic ultrasound-guided transmural drainage for pancreatic fluid collections.

A step-up approach is recommended as a new treatment algorithm for pancreatic fluid collections (PFCs). However, determining which patients with PFCs require a step-up approach after endoscopic ultrasound-guided transmural drainage (EUS-TD) is unclear. If the need for a step-up approach could be predicted, it could be performed early for relevant patients. We aimed to identify PFC-related predictive factors for a step-up approach after EUS-TD. This retrospective cohort study included consecutive patients who had undergone EUS-TD for PFCs from January 2008 to May 2020. Multivariable logistic regression analyses were performed to investigate PFC factors related to requiring a step-up approach. A step-up approach was performed for patients who did not respond clinically to EUS-TD. We enrolled 81 patients, of whom 25 (30.9%) required a step-up approach. In multivariate logistic regression analysis, the pre-EUS-TD number of PFC-occupied regions ≥ 3 (multivariate odds ratio [OR] 16.2, 95% confidence interval [CI] 2.68-97.6, P = 0.002), the post-EUS-TD PFC-remaining percentage ≥ 35% (multivariate OR 19.9, 95% CI 2.91-136.1, P = 0.002), and a positive sponge sign, which is a distinctive computed tomography finding in the early stage after EUS-TD (multivariate OR 6.26, 95% CI 1.33-29.3, P = 0.020), were independent predictive factors associated with requiring a step-up approach for PFCs. Pre-EUS-TD PFC-occupied regions, post-EUS-TD PFC-remaining percentage, and a positive sponge sign were predictors of the need for a step-up approach. Patients with PFC with these findings should be offered a step-up approach whereas conservative treatment is recommended for patients without these findings. UMIN 000030898.

Low-Milliampere CT Fluoroscopy-Guided Percutaneous Drainage Placement after Pancreatic Surgery: Technical and Clinical Outcome in 133 Consecutive Patients during a 14-Year Period.

(1) Purpose: To retrospectively assess the technical and clinical outcome of patients with symptomatic postoperative fluid collections after pancreatic surgery, treated with CT-guided drainage (CTD). (2) Methods: 133 eligible patients between 2004 and 2017 were included. We defined technical success as the sufficient drainage of the fluid collection(s) and the absence of peri-interventional complications (minor or major according to SIR criteria). Per definition, clinical success was characterized by normalization of specific blood parameters within 30 days after the intervention or a decrease by at least 50% without requiring additional surgical revision. C-reactive protein (CRP), Leukocytes, Interleukin-6, and Dose length product (DLP) for parts of the intervention were determined. (3) Results: 97.0% of 167 interventions were technically successful. Clinical success was achieved in 87.5% of CRP, in 78.4% of Leukocytes, and in 87.5% of Interleukin-6 assessments. The median of successful decrease was 6 days for CRP, 5 days for Leukocytes, and 2 days for Interleukin-6. No surgical revision was necessary in 93.2%. DLP was significantly lower in the second half of the observation period (total DLP: median 621.5 mGy*cm between 2011–2017 vs. median 944.5 mGy*cm between 2004–2010). (4) Conclusions: Technical success rate of CTD was very high and the clinical success rate was fair to good. Given an elderly and multimorbid patient cohort, CTD can have a temporizing effect in the postoperative period after pancreatic surgery. Reducing the radiation dose over time might reflect developments in CT technology and increased experience of interventional radiologists.

Renal replacement lipomatosis with granulomatous inflammation – A case report and review of literature

Renal replacement lipomatosis can be defined as the proliferation of fibrofatty tissue which subsequently replace the renal parenchyma. It is usually benign unilateral and occurs as a result of severe atrophy or destruction of the renal parenchyma, due to a calculus with secondary proliferation of renal sinus, renal hilus, and perirenal fatty tissue to a variable extent.A 55yr old female presented to surgeon with history ofpain and swelling in right flank. On CECT abdomen there was seen non functional right kidney with staghorn calculi along with perirenal abscess. Patient was treated with nephrectomy and drainage of collection. Intraoperatively Perirenal Abscess extending to psoas and iliopsoas region along with dense adhesion between kidney and liver was found. The multiple sections studied from the lesion showed extensive fibrofatty tissue with few tubule like structures lined by cuboidal epithelium and containing dense eosinophilic secretions. There is seen mixed inflammatory infiltrates with granulomas. Histological features confirmed that Renal replacement lipomatosis with granulomatous inflammation.The clinical importance of RRL is that it stimulates fat-containing tumors in the kidney or its vicinity such as lipomas, angiomyolipomas and liposarcomas can be misdiagnosed preoperatively. Hence this case report has been presented to create awareness of this condition among the pathologist and practicing urosurgeons.

Current landscape of therapeutic EUS: Changing paradigms in gastroenterology practice.

Therapeutic EUS has witnessed exponential growth in the last decade, but it has been considered investigational until recently. An increasing body of good-quality evidence is now demonstrating clear advantages over established alternatives, adding therapeutic EUS to management algorithms of complex hepato-pancreato-biliary (HPB) and gastrointestinal (GI) conditions. In this review, the available evidence and clinical role of therapeutic EUS in established and evolving applications will be discussed. A Graphical Summary for each scenario will provide (1) technical steps, (2) anatomical sketch, (3) best-supporting evidence, and (4) role in changing current and future GI practice. Therapeutic EUS has accepted well-established applications such as drainage of symptomatic peripancreatic fluid collections, biliary drainage in failed endoscopic retrograde cholangiopancreatography, and treatment of acute cholecystitis in unfit-for-surgery patients. In addition, good-quality evidence on several emerging indications (e.g., treatment of gastric outlet obstruction, local ablation of pancreatic solid lesions, etc.) is promising. Specific emphasis will be given to how these technical innovations have changed management paradigms and algorithms and expanded the possibilities of gastroenterologists to provide therapeutic solutions to old and emerging clinical needs. Therapeutic EUS is cementing its role in everyday practice, radically changing the treatment of different HPB diseases and other conditions (e.g., GI obstruction). The development of dedicated accessories and increased training opportunities will expand the ability of gastroenterologists to deliver highly effective yet minimally invasive therapies, potentially translating into a better quality of life, especially for oncological and fragile patients.

Modified Surgical Drain–Guided Percutaneous Catheter Drainage of Postoperative Fluid Collection in Inaccessible Locations

PurposeTo investigate the feasibility and safety of a modified surgical drain–guided percutaneous catheter drainage technique for postoperative fluid collection in inaccessible locations. Materials and MethodsThe modified technique was used in 24 patients (age, 58.6 years ± 11.3; men, 58.3%) from September 2015 to March 2021. All fluid collections had no safe access route on preprocedural computed tomography (CT) images. Every patient had a long (>20 cm) and tortuous surgical drain, which prevented the use of conventional surgical drain exchange. A favorable midpoint of the surgical drain tract was punctured under either ultrasound or fluoroscopic guidance, and a guide wire was advanced into the fluid collection. Technical success was defined as the successful placement of a drainage catheter, and clinical success was defined as the complete evacuation of fluid collection without recurrence. Follow-up was performed using CT images and a chart review. Adverse events within 30 days of the procedure were evaluated. ResultsTarget fluid collections in the pelvic cavity (n = 9); subphrenic (n = 7), peripancreatic (n = 4), and subhepatic spaces (n = 3); and abdominal cavity (n = 1) were drained using catheters measuring 7–10.2 F in diameter and 25–30 cm in length. The technical success rate was 91.7% (22/24), and the clinical success rate was 90.9% (20/22). No procedure-related or catheter-related adverse events were observed. The median follow-up period was 8.2 months (range, 10–1,721 days). ConclusionsThe modified surgical drain–guided percutaneous catheter drainage technique is a useful alternative when conventional exchange techniques cannot be used because of long and tortuous surgical drain paths.

Identification of early predictors for infected necrosis in acute pancreatitis

BackgroundIn acute pancreatitis, secondary infection of pancreatic necrosis is a complication that mostly necessitates interventional therapy. A reliable prediction of infected necrotizing pancreatitis would enable an early identification of patients at risk, which however, is not possible yet.MethodsThis study aims to identify parameters that are useful for the prediction of infected necrosis and to develop a prediction model for early detection. We conducted a retrospective analysis from the hospital information and reimbursement data system and screened 705 patients hospitalized with diagnosis of acute pancreatitis who underwent contrast-enhanced computed tomography and additional diagnostic puncture or drainage of necrotic collections. Both clinical and laboratory parameters were analyzed for an association with a microbiologically confirmed infected pancreatic necrosis. A prediction model was developed using a logistic regression analysis with stepwise inclusion of significant variables. The model quality was tested by receiver operating characteristics analysis and compared to single parameters and APACHE II score.ResultsWe identified a total of 89 patients with necrotizing pancreatitis, diagnosed by computed tomography, who additionally received biopsy or drainage. Out of these, 59 individuals had an infected necrosis. Eleven parameters showed a significant association with an infection including C-reactive protein, albumin, creatinine, and alcoholic etiology, which were independent variables in a predictive model. This model showed an area under the curve of 0.819, a sensitivity of 0.692 (95%-CI [0.547–0.809]), and a specificity of 0.840 (95%-CI [0.631–0.947]), outperforming single laboratory markers and APACHE II score. Even in cases of missing values predictability was reliable.ConclusionA model consisting of a few single blood parameters and etiology of pancreatitis might help for differentiation between infected and non-infected pancreatic necrosis and assist medical therapy in acute necrotizing pancreatitis.

Empyema after image-guided percutaneous intercostal drainage of subdiaphragmatic collection: a case series.

BackgroundTreatment of subdiaphragmatic collection by intercostal image-guided drain placement is associated with a risk of pleural complications including potentially life-threatening pleural empyema. Descriptions of patient characteristics and clinical course of postinterventional pleural empyema are lacking. We aim to present characteristics, clinical course and outcomes of patients with empyema after intercostal approach of drain placement.MethodsData was collected as a retrospective single center case series and included adult patients with decortication for treatment of pleural empyema after image-guided percutaneous intercostal drainage of a subdiaphragmatic collection between 01.01.2009 and 31.01.2021.ResultsWe identified ten patients, nine male and one female, all suffering from subdiaphragmatic collection treated with intercostal drain. All patients developed pleural empyema after drain placement and received surgical decortication. Similarities between patients were drain placement under computed tomography (CT)-guidance (eight of ten patients), lateral position of the drain (seven of ten patients), drain insertion in the eighth intercostal space (ICS) (six of ten patients) and existing comorbidities as malnutrition (six of ten patients), diabetes (four of ten patients) and cancer (three of ten patients). The majority of patients had a prolonged length of hospital stay (LOS) with an average duration of 40 days. Nearly half of the patients needed intensive care unit (ICU) treatment and one patient died postoperatively from respiratory exhaustion.ConclusionsIn this series, empyema after intercostal drainage was associated with prolonged LOS and was potentially life-threatening. The most commonly shared features in our cohort were the high prevalence of comorbidities, drain insertion above ninth ICS as well as lateral position of the drain. These factors should be addressed in prospective studies to evaluate potential correlation with postinterventional empyema. For optimal management of patients with subdiaphragmatic collection treated by intercostal drainage, awareness of potential associated complications is crucial.