Extensive Pancreatic Necrosis Research Articles

Extensive Pancreatic Necrosis, Successful Management with Percutaneous Endoscopic Necrosectomy

Extensive Pancreatic Necrosis, Successful Management with Percutaneous Endoscopic Necrosectomy

Long-term follow-up study of necrotising pancreatitis: interventions, complications and quality of life

ObjectiveTo describe the long-term consequences of necrotising pancreatitis, including complications, the need for interventions and the quality of life.DesignLong-term follow-up of a prospective multicentre cohort of 373 necrotising pancreatitis patients...

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.

THU365 Diabetic Ketoacidosis Unmasking Acute Pancreatitis With A Hidden Surprise

Abstract Disclosure: Y. Arya: None. A. Syal: None. S. Teja Sathi: None. J.V. Mayrin: None. Background: Development of diabetic ketoacidosis (DKA) in acute pancreatitis is rare and requires high clinical suspicion, particularly in cases such as ours where it might lead to presentation and hence, unmasking of pancreatitis. Our case was also complicated by splenic vein thrombosis, making it a therapeutic dilemma. Case Presentation: We describe the case of a female in her mid-40s who presented to the emergency department with complaints of severe epigastric abdominal pain, associated with vomiting, for the past one day. She was hemodynamically stable, and her laboratory analysis revealed a lipase greater than twenty times the upper limits of normal. Patient was also noted to have a random capillary blood glucose of 500 mg/dL with positive urine beta hydroxybutyrate and an anion gap of thirty-five. She was diagnosed with DKA and managed with intravenous (IV) insulin along with IV fluids. Her abdominal pain failed to respond which triggered us to obtain imaging. She underwent a computed tomography (CT) scan of her abdomen and pelvis which showed extensive pancreatic inflammation and necrosis along with peripancreatic fluid collection extending into the mesentery. The patient was managed with a multidisciplinary approach involving endocrinology, gastroenterology, and critical care teams. Her abdominal pain initially improved, followed by worsening around the sixth hospital day. She underwent an MRI of her abdomen which revealed a new splenic vein thrombosis. Given the risk of bleeding from the peri-pancreatic fluid collection and non-occlusive nature of the thrombosis, clinical monitoring was preferred over anticoagulation. Extensive workup did not reveal an etiology of the pancreatitis, and it was deemed idiopathic. The patient became insulin dependent from her pancreatitis. She had a prolonged hospital course and was eventually discharged after three weeks of presentation with appropriate outpatient follow-up. Discussion: The incidence of diabetes mellitus after acute pancreatitis depends on the severity of pancreatic necrosis; the degree of insulin deficiency being directly proportional to the extent of necrosis.[1] The pathophysiology of splenic vein thrombosis revolves around necrosis, venous stasis, and activation of coagulation cascade, all in the background of the inflammatory state.[2] Anticoagulation in splenic vein thrombosis secondary to pancreatitis thus remains controversial, given the increased risk of hemorrhage and formation of pseudoaneurysms. Interestingly, therapeutic anticoagulation might prevent thrombosis progression by reducing portal pressure and thereby decreasing the risk of hemorrhage. Lower rates of hemorrhage have been documented in literature in patients receiving anticoagulation in this subset of patients, versus untreated cases.[3] Thus, an individual risk-benefit analysis is needed before initiating anticoagulation.

Clinical Study of Acute Pancreatitis and its Management at a Tertiary Care Centre

Introduction: Acute pancreatitis includes wide spectrum of disease, from one with mild self-limiting symptoms, to fulminant processes with multiorgan failure and high mortality. Most experience relatively minor episodes of disease characterized by mild parenchymal edema without distant organ dysfunction and uneventful recovery. Severe episodes, however, may involve a progression to extensive pancreatic necrosis, development of the systemic inflammatory response syndrome (SIRS), multiorgan failure, rapid clinical deterioration, and even death. Although the overall mortality rate for acute pancreatitis is 2–10%, this is related primarily to 10–30% of patients with severe disease characterized by pancreatic and peripancreatic necrosis. Aims and Objectives: To study the etiology and clinical profile of acute pancreatitis. Material and Methods: Data collection by meticulous history taking and clinical examination, appropriate laboratory and radiological investigations and follow-up of cases. Results: Study was conducted with 50 patients. The peak incidence of acute Pancreatitis was observed in 2nd to 4th decade. Mean age of the study subjects was 39.78 years with 55% of the cases between 21-40 years of age. The findings shows that pancreatitis occurs in relatively younger adults. Strong male predominance was seen among study subjects as there were 72% males and 28% females with male to female ratio as 2.57:1. Conclusion: Acute Pancreatitis is more common in 2nd to 4th decades. Acute Pancreatitis is more common in males. Pancreatitis was observed to be more common among young adults especially male with alcoholism induced pancreatitis being the commonest etiology followed by biliary etiology. Most of the patients were presented with pain in abdomen with ascites being the commonest complication. Majority of the cases can be managed successfully with conservative approach and the overall mortality is low, however cases with severe pancreatitis and associated organ failure tends to have higher mortality.

Splanchnic Vein Thrombosis in Acute Pancreatitis: Incidence, Risk Factors and Long Term Outcomes

Introduction: There is paucity of data on the incidence, risk factors and role of anticoagulation for splanchnic vein thrombosis (SVT) in acute pancreatitis (AP). Methods: A retrospective review of AP admissions between 2018-2021 across the North East of England was undertaken. Data on demographics, etiology, severity of AP and SVT was collected. In addition, a selective anticoagulation policy for portal vein thrombosis (PVT) and progressive splenic vein thrombosis was explored. Results: 401 patients were included with a mean age of 57.0 and M:F ratio of 1.6:1. 152 patients developed intestinal oedematous pancreatitis and 249 developed necrotising pancreatitis based on Revised Atlanta criteria (RAC). 109 patients (27.2%) developed SVT of which 27 developed a PVT and splenic vein thrombus, 36 PVT only and 46 splenic vein thrombus only. On univariate analysis, alcoholic aetiology, severe pancreatitis, necrotising pancreatitis with >50% necrosis and elevated CRP at 2 weeks were risk factors for developing SVT. On multivariable analysis, alcohol aetiology (OR 2.6, p = 0.002), and >50% pancreatic necrosis (OR 14.6,p = 0.048) increased the risk of developing SVT. 58 patients received anticoagulation for SVT, with a median duration of 90 days of anticoagulation. Recanalization rates were higher for PVT when compared to splenic vein thrombosis. 6 patients developing bleeding complications whilst on anticoagulation therapy. Conclusion: A third of patients with AP develop SVT, particularly those with severe AP secondary to alcohol and with extensive pancreatic necrosis. A selective anticoagulation policy was associated with improved recanalization rates and fewer bleeding complications.

P-P31 Splanchnic vein thrombosis in acute pancreatitis: Incidence, risk factors and long term outcomes

Abstract Background There is paucity of data on the incidence, risk factors and role of anticoagulation for splanchnic vein thrombosis (SVT) in acute pancreatitis (AP). Methods A retrospective review of AP admissions between 2018-2021 across North East England was undertaken. Data on demographics, etiology, severity of AP and SVT was collected. In addition, a selective anticoagulation policy for portal vein thrombosis (PVT) and progressive splenic vein thrombosis was explored. Results 401 patients were included with a mean age of 57.0 and M:F ratio of 1.6:1. 152 patients developed intestinal oedematous pancreatitis and 249 developed necrotising pancreatitis based on Revised Atlanta criteria (RAC). 109 patients (27.2%) developed SVT of which 27 developed a PVT and splenic vein thrombus, 36 PVT only and 46 splenic vein thrombus only. On univariate analysis, alcoholic aetiology, severe pancreatitis, necrotising pancreatitis with &amp;gt;50% necrosis and elevated CRP at 2 weeks were risk factors for developing SVT. On multivariable analysis, alcohol aetiology (OR 2.6, p = 0.002), and &amp;gt;50% pancreatic necrosis (OR 14.6,p = 0.048) increased the risk of developing SVT . 58 patients received anticoagulation for SVT, with a median duration of 90 days of anticoagulation. Recanalization rates were higher for PVT when compared to splenic vein thrombosis. 6 patients developing bleeding complications whilst on anticoagulation therapy. Conclusions A third of patients with AP develop SVT, particularly those with severe AP secondary to alcohol and with extensive pancreatic necrosis. A selective anticoagulation policy was associated with improved recanalization rates and fewer bleeding complications.

The correlation with the patient outcome of modified CT severity index (MCTSI) in evaluation of patients with acute pancreatitis with the currently accepted CT severity index (CTSI)

Acute pancreatitis is an acute inflammatory process of the pancreas that can occur as an isolated event or relapsing episodes. Acute pancreatitis is a heterogeneous disease ranging from minimal pancreatic inflammation seen in mild interstitial pancreatitis to extensive pancreatic necrosis and liquefaction of severe attacks. Study group consists of 47 patient’s selected patients who were admitted, in whom the diagnosis of acute pancreatitis is made through available investigations (clinical investigations, serum amylase & ultrasound) who have got computed tomography done for the confirmation and prognostication. According to CTSI, of these 17 patients, 10 patients had mild, 6 patients had moderate and 1 patient had severe pancreatitis. 29% of patients who had mild pancreatitis had systemic infection, whereas systemic infection was seen in 50% and 100% of patients who had moderate and severe pancreatitis respectively (p=0.180).

Clinical Prediction of outcomes in Acute Pancreatitis with Various Prognostic Indicators and Modified CTSI

Introduction: Acute pancreatitis is the most common cause of patients presenting to the emergency department with pain abdomen. It is an inflammatory process of the pancreas that can range from mild inflammation to severe extensive pancreatic necrosis and multi-organ failure with mortality rates of 20% to 30%. Diagnosis can be difficult, because there is no pathognomic clinical presentation and no diagnostic gold standard. Material and Methods: It was a prospective cross-sectional descriptive study conducted in the Department of Gastroenterology at Sapthagiri Institute of Medical Sciences and Research Center from December 2019 – August 2020 among 100 patients. Results: The total patients studied in this study were 100, which comprises of 93 males and 7 females. Among the male population the maximum age group is 41-50. Next comes the 31-40 which includes 30 patients. Among the female population the maximum age group is 41-50 which includes about 4 patients. In our study distribution of the SAP within and above the cut off value of the different prognostic scores. 11 patients with SAP had RANSONs score &lt; 3 and 10 with SAP had RANSON score ≥ 3. 11 patients with SAP had APACHE II score of ≥8 whereas 10 had APACHE II score &lt; 8. But only 8 patients with SAP had BISAP score &lt; 3 and 13 SAP patients had BISAP score ≥ 3. MCTSI score in 11 SAP was &lt; 4 and 10 patients with MCTSI had ≥ 4. Conclusion: BISAP score is simple and it is the better scoring system in predicting the prognosis when compared to other scores &amp; MCTSI. BISAP score has many advantages when compared to other scoring systems.

Clinical prediction of outcomes in acute pancreatitis with various prognostic indicators and modified CTSI

Introduction: Acute pancreatitis is the most common cause of patients presenting to the emergency department with pain abdomen. It is an inflammatory process of the pancreas that can range from mild inflammation to severe extensive pancreatic necrosis and multi-organ failure with mortality rates of 20% to 30%. Diagnosis can be difficult, because there is no pathognomic clinical presentation and no diagnostic gold standard.Material and Methods: It was a prospective cross-sectional descriptive study conducted in the Department of Gastroenterology at Sapthagiri Institute of Medical Sciences and Research Center from December 2019 – August 2020 among 100 patients.Results: The total patients studied in this study were 100, which comprises of 93 males and 7 females. Among the male population the maximum age group is 41-50. Next comes the 31-40 which includes 30 patients. Among the female population the maximum age group is 41-50 which includes about 4 patients. In our study distribution of the SAP within and above the cut off value of the different prognostic scores. 11 patients with SAP had RANSONs score < 3 and 10 with SAP had RANSON score ≥ 3. 11 patients with SAP had APACHE II score of ≥8 whereas 10 had APACHE II score < 8. But only 8 patients with SAP had BISAP score < 3 and 13 SAP patients had BISAP score ≥ 3. MCTSI score in 11 SAP was < 4 and 10 patients with MCTSI had ≥ 4.Conclusion: BISAP score is simple and it is the better scoring system in predicting the prognosis when compared to other scores & MCTSI. BISAP score has many advantages when compared to other scoring systems.

Panorama of mediators in postpancreatitis diabetes mellitus.

To provide an overview of mediators involved in the pathogenesis of postacute pancreatitis diabetes mellitus. The 'holistic prevention of pancreatitis' framework has brought to the fore the sequelae of not only end-stage chronic pancreatitis and extensive pancreatic necrosis but also mild acute pancreatitis. Insights from the DORADO project have provided a wealth of information on the signalling molecules that do and do not affect glucose metabolism in individuals after mild acute pancreatitis and have challenged conventional views of the pathogenesis of postpancreatitis diabetes mellitus. Growing evidence compels a reconsideration of the dogma that mechanical β-cell destruction (and the resulting insulin deficiency) is the only underlying mechanism of postpancreatitis diabetes mellitus. Chronic low-grade inflammation, β-cell compensation, lipolysis, altered secretion of gut hormones, and changes in iron metabolism characterize postacute pancreatitis diabetes mellitus. Some of these are druggable targets that offer novel opportunities to reduce the burden of pancreatitis through tertiary prevention.

91 Colon Involvement in Necrotizing Pancreatitis—Incidence, Predictors and Outcomes From a Single Tertiary Care Center

INTRODUCTION: Colonic involvement significantly impacts the clinical course of necrotizing pancreatitis (NP) and reported in 6–40%. The spectrum of colonic complications includes fistula, strictures and ischemic colitis. The study aimed to determine the incidence, risk factors and clinical outcomes of colonic involvement of NP managed in our institution. METHODS: A retrospective analysis of all NP patients managed at our institution between 2010–2019 was performed from a prospectively maintained database for the occurrence of colonic complications. Baseline demographic characteristics, clinical presentation, management and outcomes were extracted. RESULTS: Colonic involvement occurred in 20 (3.9%) of the 515 NP patients managed during the study period, with colon fistulation detected in 12 (2.3%), strictures in 6 (1.2%) and ischemic colitis in 2 (0.4%). Males were predominantly involved [16 (80%)]. The median (range) age was 56 (23–84) years and alcohol was the main etiology of pancreatitis [10 (50%)]. All patients had extensive pancreatic and extra-pancreatic necrosis, with average BISAP score of 3 and modified Marshall score of 5. Infected necrosis noted in 18 (90%) patients. Subsequently, all underwent endoscopic and/or percutaneous drainage. Fistulae involved the left colon (mainly splenic flexure) in 9 (69.2%) and the right colon in 4 (30.8%) patients. While spontaneous closure occurred in 7 (53.8%); 4 (30.8%) were managed with over the scope clips and 2 (15.4%) surgically. Clinical outcomes were successful in 11 (92%) and all-cause mortality was 2 (17%). Colonic strictures and ischemia were managed conservatively in 3 (37.5%) subjects; 3 (37.5%) had stent placement, 1 (12.5%) underwent balloon dilation, and 1 (12.5%) underwent right sided hemicolectomy. Outcome was successful in all 8 (100%) patients. CONCLUSION: Male gender, obesity, alcohol etiology, infected necrosis, extensive pancreatic and extra-pancreatic involvement, and need for adjuvant percutaneous drainage may be predictors for development of colon complications in NP. Majority resolved conservatively after complete debridement of necrotic collection, some needed endoscopic management and very few needed surgical interventions.

Percutaneous Endoscopic Step-Up Therapy Is an Effective Minimally Invasive Approach for Infected Necrotizing Pancreatitis.

Infected pancreatic necrosis (IPN) is a major complication of acute pancreatitis (AP), which may require necrosectomy. Minimally invasive surgical step-up therapy is preferred for IPN. To assess the effectiveness of percutaneous endoscopic step-up therapy in patients with IPN and identify predictors of its success. Consecutive patients with AP hospitalized to our tertiary care academic center were studied prospectively. Patients with IPN formed the study group. The treatment protocol for IPN was percutaneous endoscopic step-up approach starting with antibiotics and percutaneous catheter drainage, and if required necrosectomy. Percutaneous endoscopic necrosectomy (PEN) was performed using a flexible endoscope through the percutaneous tract under conscious sedation. Control of sepsis with resolution of collection(s) was the primary outcome measure. A total of 415 patients with AP were included. Of them, 272 patients had necrotizing pancreatitis and 177 (65%) developed IPN. Of these 177 patients, 27 were treated conservatively with antibiotics alone, 56 underwent percutaneous drainage alone, 53 required underwent PEN as a step-up therapy, 1 per-oral endoscopic necrosectomy, and 52 required surgery. Of the 53 patients in the PEN group, 42 (79.2%) were treated successfully-34 after PEN alone and 8 after additional surgery. Eleven of 53 patients died due to organ failure-7 after PEN and 4 after surgery. Independent predictors of mortality were > 50% necrosis and early organ failure. Percutaneous endoscopic step-up therapy is an effective strategy for IPN. Organ failure and extensive pancreatic necrosis predicted a suboptimal outcome in patients with infected necrotizing pancreatitis.

A case with missed pancreatic injury with massive pancreatic ascites and severe traumatic pancreatic necrosis: a case report and literature review

Despite the major advances in the field of trauma management. High grade Blunt pancreatic injury remains a disease with both high mortality and morbidity specially in cases of delayed diagnosis. Herein we will present a case report of 31 years old Saudi male who was involved in motor vehicle accident with a delayed diagnosis of pancreatic injury associated with other multiple injuries. He was diagnosed late on 12th day of admission during laparotomy where a missed high-grade pancreatic fracture at the neck of pancreas, massive pancreatic ascites and extensive pancreatic necrosis was found. Open abdominal closure technique with mesh mediated fascial closure and Vacuum assisted closure was used to improve both respiratory function and abdominal disease through repeated debridement with peritoneal lavage and sequential approximation of fascia. He responded well gradually and offered definitive closure of fascia and feeding jejunostomy. Unfortunately, he had a sudden stroke followed by rapid deterioration then expired 48 hours later.

Acute necrotizing pancreatitis as a fatal complication following DC Bead transcatheter arterial chemoembolization for hepatocellular carcinoma: A case report and review of the literature.

Transcatheter arterial chemoembolization (TACE) is one of the most effective palliative measures for patients with inoperable hepatocellular carcinoma (HCC). Acute pancreatitis is a rare but well-known complication following TACE. We herein present the case of a patient with HCC who developed fatal complications (acute necrotizing pancreatitis and upper gastrointestinal ulcers) after TACE with DC Beads. The patient was diagnosed with HCC in segments 4 and 8, measuring ~70 mm in greatest diameter, and he was treated by TACE. Hepatic arteriography revealed replacement of the origin of the right hepatic artery to the superior mesenteric artery, while the left hepatic artery originated from the celiac artery. After selection of the segmental arterial branches feeding the tumor, 2 ml of 100-300-µm-sized DC Beads loaded with 150 mg epirubicin were injected through the microcatheter. The patient complained of abdominal pain after the TACE procedure. Upper gastrointestinal endoscopy revealed longitudinal ulcers from the esophagus to the duodenum, and contrast-enhanced computed tomography revealed swelling of the pancreas and focal areas of low density in the pancreatic body, suggesting necrosis. The patient developed respiratory insufficiency, renal failure and sepsis, and finally succumbed to the complications 54 days after the procedure, despite general management of the acute pancreatitis. An autopsy revealed that the main cause of the patient's death was extensive pancreatic necrosis due to a gastroduodenal artery embolism after TACE with DC Beads. Therefore, it is crucial for treating physicians to be aware of this complication following TACE with DC Beads, particularly in patients with anatomical variations.

Single transluminal gateway transcystic multiple drainage for extensive walled-off pancreatic necrosis - a single-centre experience.

IntroductionIn last three decades we have observed development in minimally invasive techniques in the treatment of walled-off pancreatic necrosis (WOPN). Endoscopic treatment of the consequences of acute necrotising pancreatitis is a accepted and common minimally invasive method.AimEvaluation of the efficiency and safety of the innovative endoscopic treatment method (single transluminal gateway transcystic multiple drainage – SGTMD) in patients with extensive walled-off pancreatic necrosis.Material and methodsThe retrospective analysis of 114 consecutive patients with symptomatic WOPN, who were treated endoscopically in our medical centre between 2011 and 2016.ResultsSingle transluminal gateway transcystic multiple drainage was performed in 21/114 (18.42%) patients. Endoscopic necrosectomy under fluoroscopic guidance was performed in 12/21 (57.14%) patients. Complications of treatment appeared in 7/21 (33.33%) patients. The most common of complication was upper gastrointestinal bleeding treated conservatively with packed red blood cells transfusions. There were no deaths. Therapeutic success was reached in 20/21 (95.24%) patients. No patient required surgery. The medium time of follow-up was 22 months (16–47). During the observation the recurrence of pancreatic fluid collection was noticed in 1/21 (4.76%) patients. Long-term success of endoscopic treatment was achieved in 19/21 (90.47%) patients.ConclusionsSingle transluminal gateway transcystic multiple drainage is an effective method of endoscopic treatment for extensive walled-off pancreatic necrosis with an acceptable amount of complications. However, the method of interventional treatment of pancreatic necrosis should depend not only on the location of necrosis, but also on the experience of the medical centre.

Same-session placement of multiple lumen-apposing metal stentsto provide effective drainage of extensive walled-off pancreatic necrosis.

Same-session placement of multiple lumen-apposing metal stentsto provide effective drainage of extensive walled-off pancreatic necrosis.

Radiofrequency Ablation of the Pancreas: Protective Effect of Local Cooling Techniques

Pancreatic carcinoma is one of the commonest malignant diseases today and the majority of patients are suitable for palliative treatment only. Radiofrequency ablation (RFA) has been used extensively for the treatment of solid organ tumors but little is known on the efficacy and safety of pancreatic ablation. To further investigate the safety of pancreatic RFA, 18 pigs had RFA of the pancreas, close to superior mesenteric vein and duodenum. Group A (nine animals) was protected with peripancreatic cool perfusion and Group B (nine animals) with portal vein (PV) intravenous injection of cool saline. Biochemical and histological evidence suggested lateral thermal injury of the duodenal wall and superior mesenteric vein and acute pancreatitis in most animals. However, clinically and at autopsy, Group B animals fared much better. PV thrombosis, hepatic abscess, duodenal perforation, ascites, and extensive pancreatic necrosis were observed in Group A but not in Group B. The present study suggests that PV cool saline perfusion can prevent major complications caused by pancreatic RFA and may be used in combination with other protective techniques in the clinical setting to reduce RFA-associated morbidity.

Acute pancreatitis in obese patients

Introduction: Obesity increases severity of acute pancreatitis by unclear mechanisms. Recent clinical studies demonstrate that all major complications are more common and more severe in patients who are obese. Patients with higher body mass index have increased risk of local and systemic complications of acute pancreatitis and patients with android fat distribution and higher waist circumference are at greater risk for developing the severe acute pancreatitis (SAP). Aims:We investigated the relationship between visceral adipose tissue and acute pancreatitis. Patients &methods:We examined 13 patients with acute pancreatitis. In 6 patients BMI was more 30. Computed tomography was performed in all patients. Results: Pancreatitis induces the activation of peritoneal macrophages and a strong inflammatory response in mesenteric sites of adipose tissue. In obese humans, we found that an increase in the volume of intrapancreatic adipocytes was associated with more extensive pancreatic necrosis during acute pancreatitis and that acute pancreatitis was associated with multisystem organ failure in obese individuals. Patients with SAP had higher BMIs and more intrapancreatic fat than those with mild AP. Conclusion: The results confirm the involvement of adipose tissue on the progression of systemic inflammatory response during acute pancreatitis. However, there is a considerable diversity in different adipose tissue sites. These differences need to be taken into account in order to understand the progression from local pancreatic damage to systemic inflammation during acute pancreatitis. Therapeutic approaches that target unsaturated fatty acid-mediated lipotoxicity may reduce adverse outcomes in obese patients with critical illnesses such as severe acute pancreatitis.

Percutaneous direct-endoscopic necrosectomy for walled-off pancreatic necrosis

We report a case where percutaneous direct-endoscopic necrosectomy was successfully used to treat walled-off pancreatic necrosis (WOPN) that could not be accessed via the transluminal approach. A 36-year-old woman with severe alcoholic pancreatitis was referred to our institute. The computed tomography (CT) scan showed extensive WOPN (larger diameter 26cm) spreading from the level of the pancreas to the pelvic floor (● Fig.1). Citrobacter freundiiwas detected from the aspiration fluid obtained from the WOPN. Transluminal observation of theWOPN by endoscopic ultrasonography was not possible, because of the presence of an inflammatory duodenal stricture. The patient initially underwent percutaneous drainage 17 days after the onset of pancreatitis. A stent was placed in the right urinary tract to prevent urinary duct injury during necrosectomy. In total, two percutaneous drainage catheters were placed in the right flank region and right lower abdomen. During the second session, the percutaneous fistula in the right flank was dilated up to 18mm with a balloon dilator (CRETM wire-guided balloon dilator; Boston Scientific, Natik, Massachusetts, USA). Next, a flexible overtube (diameter 20mm), whose length had been shortened by 20cm, was placed to maintain carbon dioxide insufflation of the cavity (● Fig.2). Direct necrosectomy was performed using a gastroscope through the overtube. All the procedures were performed under intravenous anesthesia. The maximum duration of necrosectomy was 2 hours. Abundant solid and purulent necrotic material was removed using a snare, a basket catheter, and alligator forceps. At the end of each necrosectomy session, three drainage catheters (diameter 24Fr) were placed to maintain the fistula, and two irrigation catheters were also placed (● Fig.3). After 11 necrosectomy sessions, the patient was discharged without complications. Endoscopic necrosectomy via the percutaneous approach can be used as a treatment option if the WOPN is located adjacent to the abdominal wall. Fig.1 A contrastenhanced computed tomography (CT) scan showed extensive walled-off pancreatic necrosis (WOPN): a upper abdomen, b pelvic region.