Drainage Of Fluid Collections Research Articles

Combination Dornase and Alteplase for Intra-abdominal Drain, Abscess, and Hematoma Clearance: A Retrospective Case Series

Background: Since the advent of the MIST2 trial, the combined instillation of dornase and alteplase has become an effective nonsurgical treatment option for empyema and pleural fluid collection. Percutaneous drainage of abdominal abscesses and fluid collections, rather than open surgical treatment, also has become commonplace. The are several case reports and studies on the use of fibrinolytics to drain abdominal fluid collections but no literature reporting use of both alteplase and dornase for abdominal administration. Objective: We present a case series from an academic medical center where dornase therapy was added to fibrinolytic therapy to treat intra-abdominal fluid collections, hematoma, and abdominal drainage catheters with low output. Methods: This is an institutional review board-approved retrospective case series of 13 patients who underwent combination use of alteplase and dornase via intra-abdominal route. The primary objective was to assess for increased drain output, reduction in size of the fluid collection, and adverse events. Results: Many patients had improved drain output after dornase-alteplase therapy. One patient had significant bleeding complications. Conclusions: All patients were discharged alive from the hospital. Clinical success was difficult to define due to variable goals of therapy. Further data are needed to establish the safety and efficacy of this practice, especially compared with intra-abdominal alteplase alone. Patients in our series generally received larger doses of alteplase than in prior studies due to use of dosing modeled on the MIST2 trial. Based on the limited experience of our study, we recommend holding therapeutic anticoagulation during the administration of intra-abdominal dornase-alteplase.

Proposal of classification and terminology of interventional endoscopic ultrasonography/endosonography.

Interventional endoscopic ultrasonography/endosongraphy (I-EUS) procedures have rapidly evolved since their introduction three decades ago; however, the classification and terminology for these procedures remain unstandardized. To address this, the Subcommittee for Terminology of I-EUS in the Japan Gastroenterological Endoscopy Society was established to define classifications and a glossary of I-EUS terms. They categorized I-EUS procedures into five types based on purpose and method: (i) EUS-guided sampling; (ii) EUS-guided through-the-needle examination; (iii) EUS-guided drainage/anastomosis (EUS-D/A); (iv) trans-endosonographically/EUS-guided created route (ESCR) procedures; and (v) EUS-guided delivery. EUS-guided sampling includes tissue acquisition and fluid sampling, classified by needle type into fine needle aspiration and fine needle biopsy. Through-the-needle examinations include imaging, measurements, and biopsies. EUS-D/A includes organ drainage/anastomosis, fluid collection drainage, and digestive tract anastomosis. In the EUS-D/A route, "anastomosis" is used for organ-to-organ procedures, whereas "tract" is for fluid drainage. ESCR is a newly proposed term for procedures via anastomosis or tract, such as endoscopic necrosectomy and EUS-guided antegrade stenting. The term "trans-luminal drainage/anastomosis stent" is used for stents that maintain the ESCR rather than treating strictures. EUS-guided delivery involves the delivery of substances, such as fluids, drugs, medical devices, and energy. This proposed categorization and terminology aimed to clarify I-EUS procedures and will require updates as new techniques and concepts emerge.

Outcomes of lumen apposing metal stent placement in patients with surgically altered anatomy: Multicenter international experience.

Background and study aims Although outcomes of lumen-apposing metal stents (LAMS) placement in native anatomy have been reported, data on LAMS placement in surgically altered anatomy (SAA) are sparse. We aimed to assess outcomes of LAMS placement in patients with SAA for different indications. Patients and methods This was an international, multicenter, retrospective, observational study at 25 tertiary care centers through November 2023. Consecutive patients with SAA who underwent LAMS placement were included. The primary outcome was technical success defined as correct placement of LAMS. Secondary outcomes were clinical success and safety. Results Two hundred and seventy patients (125 males; average age 61 ± 15 years) underwent LAMS placement with SAA. Procedures included EUS-directed transgastric ERCP (EDGE) and EUS-directed transenteric ERCP (EDEE) (n = 82), EUS-guided entero-enterostomy (n = 81), EUS-guided biliary drainage (n = 57), EUS-guided drainage of peri-pancreatic fluid collections (n = 48), and EUS-guided pancreaticogastrostomy (n = 2). Most cases utilized AXIOS stents (n = 255) compared with SPAXUS stents (n = 15). Overall, technical success was 98%, clinical success was 97%, and the adverse event (AE) rate was 12%. Using AGREE classification, five events were rated as Grade II, 21 events as Grade IIIa, and six events as IIIb. No difference in AEs were noted among stent types ( P = 0.52). Conclusions This study shows that placement of LAMS is associated with high technical and clinical success rates in patients with SAA. However, the rate of AEs is noteworthy, and thus, these procedures should be performed by expert endoscopists at tertiary centers.

Endoscopic Retrograde Cholangio-Pancreatography and Endoscopic Ultrasound in the Management of Paediatric Acute Recurrent Pancreatitis and Chronic Pancreatitis.

Objectives: To evaluate the role of ERCP (endoscopic retrograde cholangio-pancreatography) and EUS (endoscopic ultrasound) and to describe the efficacy and safety of these procedures in a paediatric cohort with chronic pancreatitis (CP) and acute recurrent pancreatitis (ARP). Methods: All patients (<18 years) undergoing an ERCP or EUS for ARP and CP between January 2008 and December 2022 were included. Data collection included indications for the procedure, technical success, adverse events and outcome data. Results: A total of 222 ERCPs were performed in 98 patients with CP and ARP (60% female, median age 10 years). The commonest indications were a main pancreatic duct stricture (PD) with or without a stone within the main PD. Successful cannulation was achieved in 98% of cases. Improved stricture resolution was demonstrated in 63% of patients. The overall adverse event rate for ERCP was low (n = 8/222, 3.6%). An improvement in abdominal pain was demonstrated in (75/98) 76% of patients. Their Body Mass Index also significantly improved post ERCP (15.5 ± 1.41 vs. 12.9 ± 1.16 kg/m2, p = 0.001). A total of 54 EUS procedures were undertaken in 48 individuals. Moreover, 35 individuals underwent a therapeutic EUS procedure, for which the commonest indication was the drainage of a pancreatic fluid collection. The overall complication rate was low (n = 2.4%) in all EUS cases. Conclusions: ERCP and EUS can be safely and effectively used in a paediatric population with indications analogous to an adult cohort.

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.

Training and quality indicators in interventional endoscopic ultrasound.

Endoscopic ultrasound (EUS) has transformed the landscape of minimally invasive gastrointestinal procedures, necessitating specialized training for proficiency in interventional EUS (iEUS). This study evaluates the effectiveness of iEUS training, focusing on learning curves, success rates, and the associated risks in various procedures, aiming to recommend practices for standardizing training and ensuring competency. Key metrics such as procedure type, learning curve for proficiency, success rates, and risk of adverse events were analyzed to establish benchmarks for training programs. Proficiency in pancreatic fluid collection drainage was achieved after 20-30 procedures, with a 100% success rate and a complication rate ranging from 1.5 to 80%. Gallbladder drainage required 19 cases to reach an 86% success rate, with adverse events reported in 19% of cases. Choledocoduodenostomy mastery was observed after approximately 100 cases, with postintervention pancreatitis affecting 5.3-6.6% of all cases. Hepaticogastrostomy showed a 93% success rate after 33 cases, with a 24.8% adverse event rate. Hepaticoenterostomy reached 100% success beyond the 40th patient, with a 20% rate of postsurgical strictures. Pancreatic duct drainage achieved 89% technical and 87% clinical success after 27 cases, with 12-15% adverse events. Gastro-enteric anastomosis required 25 cases for proficiency and approximately 40 cases for mastery, with 5.5% immediate and 1% late adverse events. iEUS training outcomes vary significantly across different procedures, highlighting the importance of structured, procedure-specific training programs to achieve proficiency. These findings provide a foundation for developing universal competency benchmarks in iEUS, facilitating consistent and effective training worldwide.

Surgical and non-operative treatment of acute complicated diverticulitis in a COVID hospital

Surgical treatment of acute abdomen during the SARS-CoV-2 pandemic was accompanied by an extremely high mortality rate, however, only a few studies have presented the results of acute inflammatory complications of diverticular disease (AICDD).AIM: analysis of treatment of AICDD in a COVID-19 hospital.PATIENTS AND METHODS: the retrospective study included 78 patients with acute diverticulitis (AD) from a COVID hospital, confirmed by CT or intraoperative revision. Assessment of COVID pneumonia, comorbidities, organ dysfunction, CT findings, peritonitis, treatment methods, and in-hospital mortality among patients was performed.RESULTS: organ dysfunction of ≥ 1 point on the qSOFA scale was detected in 59.0% of the patients. According to CT data, abdominal distant gas was detected in 48 (61.5%) patients, and pericolic gas in 14 (17.9%) patients. Segmental colon resection was performed in 60 (76.9%) patients, laparoscopic lavage (LL) of the abdominal cavity — in 3, non-operative treatment (NOT) with drainage of fluid collections — in 6, and only NOT in 10 patients. Most patients with distant or pericolic gas were operated on within an average time of 1 [0; 3.5] hours after admission. Diffuse peritonitis was detected during surgery in 45 (75%) of them. After resection, organ dysfunction of ≥ 2 points on the SOFA scale developed or progressed in 52 (86.7%) patients. The overall mortality rate was 48.7%, and the postoperative mortality was 63.3%. All patients (n = 38) died after segmental colon resection. Successful NOT was achieved in 4 patients with pericolic gas and 3 patients with distant gas.CONCLUSION: surgery for AICDD in patients with COVID-19 is associated with extremely high mortality, therefore, in the absence of obvious signs of diffuse peritonitis, initial non-operative treatment may be life-saving.

Percutaneous computed tomography-guided drainage of presacral fluid collections: a comprehensive analysis of 93 cases in a single-center experience

PurposeTo retrospectively evaluate the safety and efficacy of computed tomography (CT)-guided drainage of presacral fluid collections.MethodsThe records of patients who underwent percutaneous CT-guided drainages of presacral fluid collections at our institution from January 2015 to October 2023 were retrospectively reviewed. Demographics and morphological data, procedural details, complications, and outcomes were analyzed.ResultsIn all, 93 patients with 95 presacral fluid collections received percutaneous CT-guided drainages. A total of 117 procedures were performed with 18 patients who required re-drainages. Technical and radiological success rate of drainage placement procedures was, respectively, 98% and 78%. One of 93 [1%] patients experienced a minor complication from drainage placement. No major complications occurred. The preferred approach was left infrapiriformis transgluteal in prone position. Median drainage size was 10 Fr (range 6–14 Fr).ConclusionsPercutaneous CT-guided drainage is a safe and effective treatment option for presacral fluid collections, which in selected cases can be used as an alternative to surgery or as a preparatory phase for it, with minor complications occurring rarely.

Comprehensive analysis of adverse events associated with transmural use of LAMS in patients with liver cirrhosis: International multicenter study

Abstract Background and study aims Endoscopic ultrasound (EUS)-guided transmural (TM) deployment of lumen-apposing metal stents (LAMS) is considered relatively safe in non-cirrhotic patients and is cautiously offered to cirrhotic patients. Patients and methods This was a retrospective, multicenter, international matched case-control study to study the safety of EUS-guided TM deployment of LAMS in cirrhotic patients. Results Forty-three cirrhotic patients with model for end-stage liver disease score 12.5 ± 5, with 23 having ascites and 16 with varices underwent EUS-guided TM LAMS deployment, including 19 for pancreatic fluid collection (PFC) drainage, 13 gallbladder drainage, six for endoscopic ultrasound-directed transgastric endoscopic retrograde cholangiopancreatography (ERCP), three for EDGI, one for endoscopic ultrasound-directed transenteric ERCP, and one postsurgical collection drainage. Technical failure occurred in one LAMS for PFC drainage. Clinical failure was encountered in another PFC. Nine adverse events (AEs) occurred. The most common AE was LAMS migration (3), followed by non-bleeding mucosal erosion (2), delayed bleeding (2), sepsis (1), and anesthesia-related complication (pulseless electrical activity) (1). Most AEs were graded as mild (6), followed by severe (2), and moderate (1); the majority were managed conservatively. On univariable comparison, risk of AE was higher when using a 20 × 10 mm LAMS and the absence of through-the-LAMS plastic stent(s). Conditional logistic regression of matched case-control patients did not show any association between potential predicting factors and occurrence of AEs. Conclusions Our study demonstrated that mainly in patients with Child-Pugh scores A and B cirrhosis and despite the presence of mild-to-moderate ascites in over half of cases, the majority of AEs were mild and could be managed conservatively. Further studies are warranted to verify the safety of LAMS in cirrhotic patients.

Updated Review of Radiologic Imaging and Intervention for Acute Pancreatitis and Its Complications.

This is a current update on radiologic imaging and intervention of acute pancreatitis and its complications. In this review, we define the various complications of acute pancreatitis, discuss the imaging findings, as well as the timing of when these complications occur. The various classification and scoring systems of acute pancreatitis are summarized. Advantages and disadvantages of the 3 primary radiologic imaging modalities are compared. We then discuss radiologic interventions for acute pancreatitis. These include diagnostic aspiration as well as percutaneous catheter drainage of fluid collections, abscesses, pseudocysts, and necrosis. Recommendations for when these interventions should be considered, as well as situations in which they are contraindicated are discussed. Fortunately, acute pancreatitis usually is mild; however, serious complications occur in 20%, and admission of patients to the intensive care unit (ICU) occurs in over 10%. In this paper, we will focus on the imaging and interventional radiologic aspects for the serious complications and patients admitted to the ICU.

Equivalent efficacy and safety of plastic stents and lumen-apposing metal stents in the treatment of peripancreatic fluid collections: a prospective cohort study.

Endoscopic ultrasound (EUS)-guided transmural drainage using double pigtail plastic stents (DPPS) has been routine for the treatment of peripancreatic fluid collections (PFC). Lumen-apposing metal stents (LAMS) have since their introduction been the preferred choice; however, their superiority has not been proven. The aim of this study was to compare the efficacy and safety of DPPS and LAMS. This was a single-center, prospective study that included consecutive patients undergoing EUS-guided drainage between January 2010 and December 2020. The primary endpoints were technical success, clinical success and adverse event rate, while the secondary endpoints included symptomatic relief, length of hospital stay, and need for adjunct drainage. A subgroup analysis of walled-off necrosis (WON) was performed. A total of 89 patients (median age 56 years) underwent EUS-guided transmural drainage (DPPS: n=53; LAMS: n=36) because of a pseudocyst (n=37) or a WON (n=52). Both DPPS and LAMS had a 100% technical success rate and a comparable adverse event rate (4% vs. 6%, P=0.24). An equivalent efficacy was recorded for the drainage of PFC comparing DPPS and LAMS, and no significant statistical difference was recorded in clinical success (DPPS 60% vs. LAMS 61%, P=0.94) or the need for reintervention (DPPS 11% vs. LAMS 13%, P=0.72). In this large, prospective study of EUS-guided drainage of peripancreatic fluid collections, LAMS and DPPS showed equivalent safety, technical success, clinical success and hospital stay. Both techniques were associated with a comparable need for complementary necrosectomy.

Mishaps with EUS–guided lumen-apposing metal stents in therapeutic pancreatic EUS: Management and prevention

Abstract EUS–guided interventions have become widely accepted therapeutic management options for drainage of peripancreatic fluid collections. Apart from endosonographic skills, EUS interventions require knowledge of the endoscopic stenting techniques and familiarity with the available stents and deployment systems. Although generally safe and effective, technical failure of correct stent positioning or serious adverse events can occur, even in experts' hands. In this article, we address common and rare adverse events in transmural EUS-guided stenting, ways to prevent them, and management options when they occur. Knowing the risks of what can go wrong combined with clinical expertise, high levels of technical skills, and adequate training allows for the safe performance of EUS-guided drainage procedures. Discussing the procedural risks and their likelihood with the patient is a fundamental part of the consenting process.

Intra-abdominal hypertension and abdominal compartment syndrome in acute pancreatitis.

Intra-abdominal hypertension (IAH) and abdominal compartment syndrome (ACS) are underrecognized entities in patients of acute pancreatitis (AP). IAH develops in 30% to60% and ACS in 15% to30% of all AP patients and they are markers of severe disease with high morbidity and mortality. The detrimental effect of increased IAP has been recognized in several organ systems, including the central nervous system, cardiovascular, respiratory, renal and gastrointestinal systems. The pathophysiologyof IAH/ACS developmentin patients with AP is multifactorial. Pathogenetic mechanisms include over-zealous fluid management, visceral edema, ileus, peripancreatic fluid collections, ascites and retroperitoneal edema. Laboratory and imaging markers are neither sensitive nor specific enough to detect IAH/ACS and intra-abdominal pressure (IAP) monitoring is vital for early diagnosis and themanagement of patients of AP with IAH/ACS. The treatment of IAH/ACS requires a multi-modality approach with both medical and surgical attention. Medical management consists of nasogastric/rectal decompression, prokinetics, fluid management and diuretics or hemodialysis. If conservative management is not effective, percutaneous drainage of fluid collection or ascites is necessary. Despite medical management, if IAP worsens, surgical decompression is warranted. The review discusses the relevance of IAH/ACS in patients of AP and its management.

Traumatic Degloving Wounds Treated With Low Continuous Wall Suction Drainage: A Novel and Effective Technique to Prevent Recurrence.

Soft tissue degloving wounds overlying fractures present a technical surgical challenge and have a high rate of recurrence. Despite several current treatment methods, there remains a need for improved therapies to address this complex issue. The purpose of this study was to introduce a novel technique for managing soft tissue degloving wounds in the setting of fractures requiring operative fixation. Eleven consecutive patients with soft tissue degloving wounds overlying operatively managed fractures were treated with our novel technique for "dead space" elimination in the peri-operative period. The technique entails placing Jackson Pratt drain(s) within the degloving wound during operative debridement and placing them to low continuous wall suction postoperatively. This patient series shows that the application of 40 to 60 mm Hg of negative pressure allows for thorough drainage of the hemolymphatic fluid collection and elimination of dead space, allowing the delaminated tissue layers to heal together and preventing recurrence. [Orthopedics. 2023;46(4):e257-e263.].

BACTERIAL TRANSMISSION AND ANTIBIOTIC SENSITIVITY OF CAUSATIVE AGENTS IN PURULENT-SEPTIC COMPLICATIONS IN PATIENTS WITH A SEVERE COURSE OF ACUTE PANCREATITIS

Introduction: Acute pancreatitis has emerged as a leading urgent abdominal condition, with a high mortality rate of up to 70% in cases of purulent-septic complications. The identification of specific causative agents during the infection stage of acute severe pancreatitis is challenging due to the various mechanisms by which pathogens can infiltrate parapancreatic fluid collections. However, early antibiotic prophylaxis is essential in the management of this patient population, considering the potential need for prolonged treatment involving multiple antibiotic rotations. This study aims at analyzing the changes in the microbial species spectrum responsible for purulent-septic complications in acute severe pancreatitis during the course of treatment.&#x0D; Methods: We investigated 174 bacterial cultures obtained from patients diagnosed with acute severe pancreatitis who were treated at the Surgical Department of M.V. Sklifosovsky Poltava Regional Hospital between 2015 and 2018. Among these cultures, 87 were obtained during the initial surgical intervention (39 after initial ultrasound-guided drainage and 38 during the initial open surgical intervention), and 87 were obtained during the course of treatment.&#x0D; Results: Among patients who underwent primary drainage of parapancreatic fluid collections, no aerobic flora was detected in 71.4% of cases, but subsequent bacterial cultures revealed microbial growth in 77.6% of patients. In patients who underwent open surgical intervention, pathological flora was detected in nearly all cases, both during the primary bacterial passage and in subsequent cultures. The species spectrum differed significantly between the primary and repeated bacterial passages. The initial cultures showed a predominance of gram-positive flora (S. epidermidis, Streptococcus spp., Enterococcus spp.), while repeated cultures demonstrated a notable increase in hospital-acquired strains and gram-negative flora (E. coli, Proteus spp., Acinetobacter spp.), along with a nearly three-fold increase in S. aureus. These findings have significant implications for selecting appropriate antibacterial agents throughout the treatment course. Notably, a substantial decrease in the sensitivity of multidrug-resistant strains to reserve antibiotics such as meropenem and trigecycline, by approximately 20%, was observed in subsequent bacterial studies.&#x0D; Conclusion: The microbial spectrum and antibiotic sensitivity of pathogens causing purulent-septic complications in acute severe pancreatitis undergo dynamic changes during the course of treatment. These findings underscore the importance of conducting repeated bacterial cultures and adjusting antibiotic therapy accordingly to optimize treatment outcomes.

Endoscopic Ultrasound-Guided Drainage of a Postoperative Fluid Collection in the Setting of Roux-en-Y Anatomy.

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Perfusion CT in predicting deep pancreatic necrosis and planning early interventions for severe acute pancreatitis

Aim. To explore the potential of perfusion CT for predicting deep pancreatic necrosis and duct injury as well as for determining treatment strategy. Materials and methods. The prospective study included 74 patients hospitalized within 1–2 days of acute pancreatitis. They were exposed to perfusion CT and examination of their arterial blood flow velocity. In 37 observations, a standard CT was also performed on day 3–9 to study the depth and configuration of the necrosis. The severity of acute pancreatitis was assessed according to standard integral scoring systems, organ failure and severity of peripancreatitis. The alfa-amylase activity in fluid collections was examined. Results. Necrosis was detected in 20 patients: deep necrosis – in 11 cases, shallow – in 9. 17 patients did not reveal necrosis. Necrosis configuration of type 1 was detected in 16 patients, type 2 – in 4. Deep necrosis was preceded by a significant decrease in the arterial blood flow velocity: 39–52 ml/min/100 ml. This rate was greater in patients with shallow necrosis and without necrosis: 72–100 and 95–117 ml/min/100 ml (p &lt; 0.001). In cases of deep necrosis, advanced peripancreatitis was formed, organ failure was noted in 9 patients, 3 patients died. Internal pancreatic fistula was detected in 7 out of 9 patients with deep necrosis and in 1 out of 6 patients with shallow necrosis and type 1 configuration. In cases of necrosis type 2 configuration the pancreatic fistula was not noted. Minimally invasive interventions and transformation of the internal fistula into the external one were performed in 12 out of 20 patients: percutaneous drainage of fluid collections – in 9 observations, stenting of the pancreatic duct – in 3. Conclusion. Perfusion CT can be used to predict pancreatic necrosis on day 1–2 of the disease. A decrease in the arterial blood flow velocity in the range of 39–52 ml/min/100 ml is associated with the risk of parenchyma deep necrosis and duct injury. This parameter can be taken into account when determining indications for early minimally invasive interventions.

Ultrasound Guided Drainage and Aspiration of Intra-Abdominal Fluid Collections

Ultrasound Guided Drainage and Aspiration of Intra-Abdominal Fluid Collections

Low-Dose CT Fluoroscopy-Guided Drainage of Deep Pelvic Fluid Collections after Colorectal Cancer Surgery: Technical Success, Clinical Outcome and Safety in 40 Patients

To assess the technical (TS) and clinical success (CS) of CT fluoroscopy-guided drainage (CTD) in patients with symptomatic deep pelvic fluid collections following colorectal surgery. A retrospective analysis (years 2005 to 2020) comprised 43 drain placements in 40 patients undergoing low-dose (10-20 mA tube current) quick-check CTD using a percutaneous transgluteal (n = 39) or transperineal (n = 1) access. TS was defined as sufficient drainage of the fluid collection by ≥50% and the absence of complications according to the Cardiovascular and Interventional Radiological Society of Europe (CIRSE). CS comprised the marked reduction of elevated laboratory inflammation parameters by ≥50% under minimally invasive combination therapy (i.v. broad-spectrum antibiotics, drainage) within 30 days after intervention and no surgical revision related to the intervention required. TS was gained in 93.0%. CS was obtained in 83.3% for C-reactive Protein and in 78.6% for Leukocytes. In five patients (12.5%), a reoperation due to an unfavorable clinical outcome was necessary. Total dose length product (DLP) tended to be lower in the second half of the observation period (median: years 2013 to 2020: 544.0 mGy*cm vs. years 2005 to 2012: 735.5 mGy*cm) and was significantly lower for the CT fluoroscopy part (median: years 2013 to 2020: 47.0 mGy*cm vs. years 2005 to 2012: 85.0 mGy*cm). Given a minor proportion of patients requiring surgical revision due to anastomotic leakage, the CTD of deep pelvic fluid collections is safe and provides an excellent technical and clinical outcome. The reduction of radiation exposition over time can be achieved by both the ongoing development of CT technology and the increased level of interventional radiology (IR) expertise.

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.