Complication Of Severe Pancreatitis Research Articles

New-onset Diabetes Mellitus after EUS-guided Drainage with LAMS: A Pilot Study.

Walled-off necrosis (WON) is a serious complication of severe pancreatitis, patients with necrotizing pancreatitis having an increased risk of developing diabetes mellitus (DM). The aim of this study was to assess the frequency of new-onset diabetes (NOD) in patients with symptomatic WON after endoscopic ultrasound (EUS)-guided drainage with lumen-apposing metal stents (LAMS). We retrospectively analyzed a prospectively collected database of patients with symptomatic WON treated by EUS-guided drainage with LAMS in a tertiary referral center. The patients were followed-up for at least 12 months after stent removal. These patients were compared with age- and sex-matched asymptomatic WON controls without interventional treatment and healthy controls to assess the one-year occurrence of DM. Diabetes was defined according to the American Diabetes Association criteria. Of the 50 patients with symptomatic WON included in the study (male/female ratio, 33:17; median age, 60 years), 13 patients (26%) had pre-existing DM and were excluded. Ten of the remaining 37 patients (27%) without prior DM developed NOD within one year after stent removal, this frequency being higher than in asymptomatic WON controls (18.9%, p=0.581) and healthy controls (2%, p = 0.002). In the symptomatic WON group, NOD patients compared to non-DM patients were older (63.5 vs. 56 years old, p=0.042), had more frequent necrosis > 50% of the pancreatic parenchyma (p=0.002) and had a body-tail location of WON (p<0.001). On multivariate analysis, the number of direct endoscopic necrosectomy (DEN) sessions was the only significant factor for NOD occurrence (OR=7.05, p=0.010). NOD patients had poor glycemic control and required more DEN sessions to achieve WON resolution than patients with prior DM (p=0.017). In patients with symptomatic WON treated by EUS-guided drainage, DM occurred in 27% of previously non-diabetic patients within one year of follow-up. Patients with extensive pancreatic necrosis were more likely to develop NOD, a high number of DEN sessions being a significant risk factor for NOD occurrence.

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.

S1661 Disseminated Intra Abdominal Pancreatic Pseudocysts as a Complication of Severe Pancreatitis: A Rare Case of Hepatic, Splenic, Gastric Wall and Anterior Abdominal Wall Pancreatic Pseudocysts

S1661 Disseminated Intra Abdominal Pancreatic Pseudocysts as a Complication of Severe Pancreatitis: A Rare Case of Hepatic, Splenic, Gastric Wall and Anterior Abdominal Wall Pancreatic Pseudocysts

Is pancreatic-enteric drainage a definitive operation for pancreatitis associated pancreatic fluid collections?

Presenter: Patrick McLaren MD | Methodist Richardson Medical Center Background: Pancreatic pseudocysts and walled off pancreatic necrosis (WOPN) are complications of severe pancreatitis. Pancreatic-enteric drainage procedures have become standard therapy for symptomatic collections. However, conversion to a pancreatic resection, usually a distal pancreatosplenectomy, is needed in the event of treatment failure of drainage alone. The need for pancreatic resection following cyst-enteric drainage procedure is not well studied. We aimed to quantify the rate of conversion from surgical cystogastrostomy to pancreatic resection and identify predictors of failure. Methods: A single institution retrospective review was conducted to identify all patients undergoing cystogastrostomy between 2012-2020 using CPT procedure codes. Demographic, disease, and treatment characteristics were identified. Failure of surgical drainage was defined as need for subsequent pancreatic resection. Characteristics between failure and non-failure groups were compared using non-parametric statistical tests to identify predictors of treatment failure. Results: A total of 24 cystogastrostomies were performed over the 8-year study period for pancreatic pseudocyst or WOPN. The most common cause of pancreatitis was biliary (n=15, 63%). Cyst diameter ranged from 7.6 - 26.2 cm (mean 14.8 cm). Overall complication rate of cyst-enteric drainage procedure was 25% (3/24). There were no mortalities. All patients initially reported resolution of their symptoms, however, three patients (12.5%) required a subsequent distal pancreatectomy after surgical drainage. Mean time to resection from index operation was 14.7 months. Indication for resection was persistent recurrent abdominal pain in all resection patients. There was no difference between drainage alone and failure of drainage groups with respect to comorbidities: HTN (p=0.277), Diabetes (p=0.371), Tobacco use (p=0.249), and Weight loss at presentation (p=0.69). Mean cyst size at initial drainage was no different between drainage alone and failure groups (15.2cm vs 10.3cm, p=0.51). Estimated blood loss at initial operation was similar between groups (126 mL vs 166 mL, p=0.36). Conclusion: In our series, pancreatic drainage procedure was successful initial management of pancreatic fluid collections, with 12.5% requiring subsequent resection. Our data suggests that upfront drainage without resection offers a largely successful operation that allows for pancreatic tissue preservation with low mortality and morbidity. We did not identify any predictors of failure of initial drainage. Resection with distal pancreatectomy for WOPN and pseudocysts can be reserved for cases of failure of management with drainage alone.

Severe pancreatitis complicated by abdominal compartment syndrome managed with decompressive laparotomy: a case report

BackgroundAbdominal compartment syndrome (ACS) is an uncommon complication of severe pancreatitis. It is defined as a sustained intraabdominal pressure (IAP) > 20 mmHg (with or without an abdominal perfusion pressure (APP) < 60 mmHg), associated with new organ dysfunction/failure. ACS confers a poor prognosis and should be promptly diagnosed and managed. However, it is often missed on clinical examination, leading to a delay of diagnosis.Case presentationA 38-year old Sri Lankan man presented with severe alcohol-induced pancreatitis associated with abdominal compartment syndrome. Diagnosis was delayed due to false reassurance from clinical examination. The patient was managed with a decompressive laparotomy, after which he required treatment with continuous renal replacement therapy (CRRT), total parenteral nutrition (TPN) and broad-spectrum antibiotics for a prolonged period of time. Despite significant post-operative multi-organ failure, the patient survived.ConclusionsEarly trans-bladder measurement of IAP is important for severe pancreatitis. Serial measurements of IAP should be implemented early when any known risk factor for ACS is present in a critically ill patient.

Cerebellar ischaemic infarct: a rare complication of pancreatitis

A 12-year-old female neutered Jack Russell terrier was presented for further investigation of an acute two-day history of lethargy, inappetence and vomiting. Mild increase in urea and amylase and positive...

Streptococcal Hepatic Abscess: A Rare Complication of Severe Necrotizing Pancreatitis

A 60-year-old female was admitted with severe pancreatitis of unknown etiology, with symptoms of epigastric abdominal pain, and nausea with vomiting. Contrast enhanced computed tomography (CT) scan showed large areas of non-enhancement of the pancreatic body, and extensive peripancreatic free fluid and stranding in the regions of the pancreatic head and tail consistent with acute necrotizing pancreatitis. She was also noted to have non-occluding thrombi of the superior mesenteric vein that extended into the portal vein and was started on long-term anticoagulation treatment with oral warfarin. Her clinical course was complicated by the development of a large pancreatic pseudocyst (11 x 13 x 23 cm on CT) that was managed successfully by endoscopic cystogastrostomy [Figure 1]. Unfortunately, after initial good recovery, she was hospitalized 3 months later with ascites and failure to thrive. A repeat contrast enhanced CT scan showed a large multi-loculated 7.4 x 7.8 x 9.2 cm mass in the liver involving caudate lobe, and right lobe of liver concerning for hepatocellular carcinoma [Figure 2]. On endoscopic ultrasound a large hypoechoic, heterogeneous mass was noted in the liver. Fine needle aspiration using a 25G needle was performed and on site evaluation by cytopathology showed extensive necrosis and acute inflammation concerning for hepatic abscess. Additional FNA was performed for culture and sensitivity that revealed gram-positive bacteria in clusters (Group F streptococcus). Patient was treated with longterm intravenous vancomycin. She had near complete resolution of liver abscess at 6-week follow-up. Pancreatic pseudocyst and splenic vein thrombosis are the known complications of severe pancreatitis. However, the development of a liver abscess possibly following pylephlebitis in the background setting of acute necrotizing pancreatitis is a rare entity with only a few cases reported in the literature. Our patient developed severe hepatic abscess and ascites mimicking hepatocellular cancer. Likely etiology of this abscess was superior mesenteric vein and portal vein thrombosis. This case highlights the rare complication of severe necrotizing pancreatitis and role of EUS guided tissue acquisition in diagnosis and management of hepatic abscess.Figure 1Figure 2

Update on Acute Pancreatitis

Acute pancreatitis (AP) is an inflammatory disorder of the pancreas. Majority of cases will recover without complications, but the remainder will have severe disease. It is the most common gastrointestinal disorder that requires hospitalisation. Gallstones and alcohol are the leading culprits. Stratifying severity using the revised Atlanta Classification is of paramount importance. Important aspects of management include fluid resuscitation in the first 24 hours and adequate opiate analgesia. Endoscopic retrograde cholangio pancreatography (ERCP) should be performed within 24 hours in patients with biliary pancreatitis and concurrent cholangitis. Cholecystectomy should be performed in the index admission in cases of mild biliary pancreatitis. Complications of severe pancreatitis should be managed in a multidisciplinary centre with expertise in management of the more complex aspects of the condition including pseudocysts and walled off pancreatic necrosis. This article will explore the aetiology, diagnosis and current advances in the treatment of acute pancreatitis.

Progress in the management of necrotizing pancreatitis

Evaluation of: van Santvoort HC, Besselink MG, Bakker OJ et al. A step-up approach or open necrosectomy for necrotizing pancreatitis. N. Engl. J. Med. 362, 1491–1502 (2010).Pancreatic necrosis, a complication of severe pancreatitis, may become infected, resulting in significant morbidity and potential mortality. Infected necrosis was heretofore considered a surgical condition, and despite aggressive operative management, the mortality remained high. With a better understanding of the natural history of necrosis, established methods to diagnose infection and the increasing use of minimally invasive techniques, less aggressive therapies have been utilized with some success. The present study evaluated a step-up approach for the treatment of infected pancreatic necrosis, utilizing endoscopic and percutaneous techniques, and if ineffective, necrosectomy with a minimally invasive retroperitoneal approach. They compared this step-up approach to the standard open necrosectomy. They demonstrated that when using such an approach compared with open necrosectomy, the frequency of major complications such as organ failure, perforation, fistula or even death was significantly less than in those who received conventional open necrosectomy. Indeed, for those randomized to the step-up approach, roughly a third of the patients were successfully treated with percutaneous drainage alone. In the long-term, development of diabetes was also less frequent in those receiving less aggressive therapy. These findings, in combination with other reports, suggest that the dogma that open necrosectomy is mandatory for all patients with infected necrosis should be re-evaluated, and that less aggressive treatments as part of a multidisciplinary approach can reduce morbidity and mortality.

¿Implica el aislamiento de Candida spp. en muestras intraabdominales de pacientes críticos la necesidad de tratamiento antifúngico?

The diagnostic and therapeutic approaches to IFI have changed significantly in recent years, fostered by the introduction of new diagnostic methods and new antifungal products. The diagnosis of invasive candidiasis (IC) involves both clinical and laboratory parameters, but neither of these are specific and the majority of the yeast isolated showed only colonization but not true infection. This situation occurs in critical care setting especially when surgical drainages are used. A substantial number of patients become colonized with Candida spp. after abdominal surgery, but only a minority subsequently develops invasive candidiasis. The clinical and microbiological diagnosis of Candida peritonitis remains problematic. It is still unclear which patients with may benefit from antifungal treatment. Antifungal therapy can be suggested in critically ill patients with peritonitis where Candida is diagnosed based on perioperatively sampled peritoneal fluid. Since fungal infection is also a relatively common complication of severe pancreatitis it seems reasonable that fungal prophylaxis may be an important component of management although actually there is no evidence to support this approach. However, the high mortality associated with IC is partly correlated to the difficulties of making an early diagnosis, thus, to improve earlier diagnosis and survival of IC, new nonculture-based microbiological tools such as Candida albicans germ tube antibodies (CAGTA) and/or polymerase chain reaction (PCR) techniques for the detection of fungal-specific DNA should be used in conjunction with recent published "Candida score" prediction rule. An algorithm based on this approach has been provided to assess early treatment in surgical patients with yeasts isolated from intra-abdominal samples.

Pancreatitis following percutaneous nephrolithotomy

We report the unusual complication of severe pancreatitis following an uneventful percutaneous nephrolithotomy. We discuss its diagnosis and treatment.

Frequency and time course of pancreatic and extrapancreatic bacterial infection in experimental acute pancreatitis in rats

Background: Infectious complications in severe pancreatitis are the main factors determining clinical course and outcome. The taurocholate model for acute necrotizing pancreatitis was evaluated for frequency and time course of pancreatic and extrapancreatic bacterial infection. Methods: Sixty-five male Wistar rats were divided into 5 groups of 13 animals each. Specimens for bacteriologic examination were taken, and pancreatitis was induced by intraductal infusion of 3% taurocholate under sterile conditions. Animals were killed 8, 16, 24, or 32 hours thereafter, and bacteriologic examination was performed. A control group of animals with intraductal infusion of 0.9% saline solution were killed after 32 hours. Results: There was no significant pancreatic infection in the control group and in the 8-hour group (1 of 13 rats). Sixteen and 24 hours after induction of pancreatitis, infection and inflammation of the pancreas were found in 77% (10 of 13 rats), and after 32 hours pancreatic infection occurred in 69% (9 of 13 rats). Extrapancreatic bacterial infection after 16 hours occurred in the liver (62%), spleen (62%), and mesenteric lymph nodes (46%). Bacteria infecting the pancreas reflected the bacterial spectrum of the large bowel and terminal ileum before induction of pancreatitis (Escherichia coli [77%], Proteus [43%], Enterococcus [37%], and Staphylococcus [23%]). Conclusions: Pancreatic infection is an early and frequent finding in the taurocholate model of acute necrotizing pancreatitis. Infection occurs between 8 and 16 hours after induction of pancreatitis. The source of infecting bacteria seems to be the large bowel or the terminal ileum. We present a useful model of severe pancreatitis in which to study bacterial translocation, the further route of spread, and therapeutic approaches. (Surgery 2000;127:427-32.)