Infected Pseudocyst Research Articles

A minimally invasive multiple percutaneous drainage technique for acute necrotizing pancreatitis.

In approximately 20% of patients, necrotizing pancreatitis is complicated with severe acute pancreatitis, with high morbidity and mortality rates. Minimally invasive step-up approach is both safe and effective, but sometimes requires multiple access sites. A 62-year-old woman was admitted with diabetic ketoacidosis, and initial computed tomography (CT) revealed no evidence of acute pancreatitis. She was clinically improved with insulin therapy, fluid administration, and electrolyte replacement. However, on the 14(th) day of admission, she developed a high-grade fever, and CT demonstrated evidence of acute necrotizing pancreatitis with a large collection of peripancreatic fluid. Percutaneous transgastric drainage was performed and a 14 French gauge (Fr) pigtail catheter was placed 1 week later, which drained copious pus. Because of persistent high-grade fever and poor clinical improvement, multiple 8 and 10 Fr pigtail catheters were placed via the initial drainage route, allowing the safe and effective drainage of the extensive necrotic tissue that was occupying the bilateral anterior pararenal space. After drainage, the patient recovered well and the last catheter was removed on day 123 of admission. Multiple percutaneous drainage requires both careful judgment and specialist skills. The perforation of the colon and small bowel as well as the injury of the kidney and major vessels can occur. The current technique appears to be safe and minimally invasive compared with other drainage methods in patients with extended, infected necrotic pancreatic pseudocysts.

An Intra-Abdominal Pseudocyst around a Ventriculoperitoneal Shunt due to Streptococcus Infection 7 Years after Shunt Surgery.

In 1999, a 50-year-old woman underwent ventriculoperitoneal (VP) shunt surgery for hydrocephalus after subarachnoid hemorrhage. She was hospitalized for fever and recurrent systemic seizures in November 2006. Head computed tomography (CT) showed only old changes. The seizures and fever were controlled by medicinal therapy. However, in December, her consciousness level suddenly decreased, and she showed progressive lower abdominal distension. Head CT showed marked ventriculomegaly, and abdominal CT showed a giant cystic mass at the shunt-tube tip in the lower abdominal cavity. Because thick pus was aspirated from the intra-abdominal mass, we diagnosed the patient with acute obstructive hydrocephalus due to an infected abdominal pseudocyst. Laparotomy and direct cyst drainage were performed, and antibiotic therapy against Streptococcus, the causative pathogen, was administered. The VP shunt tube was replaced. The postoperative course was uneventful, and postoperative CT showed hydrocephalus improvement and no pseudocyst recurrence. Abdominal pseudocysts, which are rare after VP shunt surgeries, usually occur after the subacute postoperative course in younger cerebral hemorrhagic cases. Our case was quite rare because the cyst developed in the chronic phase in an older patient and was caused by streptococcal infection. The cyst components should be examined before cyst drainage when choosing surgical strategies.

Endoscopic ultrasound for treatment of infected pancreatic pseudocysts

Endoscopic ultrasound for treatment of infected pancreatic pseudocysts

To evaluate the role of novel fully covered self-expanding metal stent for endoscopic drainage of infected pancreatic pseudocyst

Endoscopic ultrasonography-guided transgastric drainage of pancreatic pseudocyst (PPC) is the mainstay of treatment. Drainage can be achieved either by plastic stents or fully covered self-expandable metal stent (FCSEMS). Plastic stents have small lumen diameter, which may limit drainage and may necessitate re-intervention. FCSEMS are easier to deploy and preclude the need to place multiple plastic stents. To evaluate the role of novel FCSEMS for endoscopic drainage of infected PPC. 10 patients with single symptomatic pseudocyst in proximity to the stomach or duodenum and fever were treated. Pseudocyst drainage was done per protocol. Repeat computed tomography scan after 72 h. Nasocystic drain removed after 3-5 days. PATIENTS were followed-up at every 2 week interval. Stent was removed after complete disappearance of pseudocyst confirmed on imaging. Early (7 days) and late (>7 days) complications were noted and managed accordingly. Technical success and clinical success achieved in all. Early complication: 1/10 (pneumoperitoneum). No late complications observed. Stent were removed without complication after 6-7 week follow-up period ranges from 6 to 8 months. Use of FCSEMS for pseudocyst drainage is technically feasible and safe.

Extended Cyst Gastrostomy with Hydrogen Peroxide Irrigation Facilitates Endoscopic Pancreatic Necrosectomy

Figure: No Caption available.Purpose: Endoscopic cyst gastrostomy and pancreactic necrosectomy has emerged to be one of the main options for treatment of infected pancreatic pseudocyst or walled off pancreatic necrosis. One of the limitation of successful endoscopic drainage in these situations is the small size of the gastrostomy created (usually around 1 cm) and the large amount of necrotic material within the cyst/ abscess cavity. In this case series we describe our technique of creating large gastrostomy opening (2 cm) with hydrogen peroxide irrigation to facilitate abscess/cyst cavity drainage and hence improve the successfulness of the endoscopic intervention. Methods: This case series demonstrates our modified endoscopic ultrasound (EUS) guided cystgastrostomy technique using the following: 1) Creation of an extended cyst gastrostomy by gastrostomy dilation up to two either with: a) Single-stage dilation if the EUS showed no blood vessels within the puncture site and the CT scan demonstrates a mature cyst wall or b) Dilation of a pre-existing cyst gastrostomy in patients with gastric varices or immature cyst wall; 2) Direct endoscopic examination of the cavity with hydrogen peroxide irrigation to debride adherent nercotic tissue;3) Placement of two 10 French double pig tail stents to keep the gastrostomy tract open. Results: Four cases (2 male, 2 female) were included in this series. Mean age was 54.7 yrs. Three patients had walled-off pancreatic necrosis and one patient had pancreatic abscess after distal pancreatictomy. Resolution of the cyst or abscess cavity was achieved in all patients. No complication were reported. Conclusion: With our technique, patients required a single session or at maximum two-staged sessions of endoscopic pancreatic necrosectomy prior to resolution of the cyst/abscess cavity.

Robotic-assisted cystogastrostomy for a patient with a pancreatic pseudocyst.

Pancreatic pseudocysts are generally treated by endoscopic cystogastrostomy. However, difficult cases involving abscess, necrosis, or risk of hemorrhage often require surgical intervention. Here, we report a case of a robotically assisted cystogastrostomy. The patient presented with an infected pseudocyst with adjacent varices. Use of the da Vinci Surgical System allowed us to create a widely patent anastomosis between the pseudocyst and the stomach. The patient tolerated the procedure well without any complications. This report demonstrates the feasibility of robotic cystogastrostomy.

Mo1540 Intracystic Antibiotic and Crystalloid Lavage Is Safe and Effective in the Management of Persistent Infected Pancreatic Pseudocysts

Mo1540 Intracystic Antibiotic and Crystalloid Lavage Is Safe and Effective in the Management of Persistent Infected Pancreatic Pseudocysts

InShare Direct endoscopic necrosectomy: a minimally invasive endoscopic technique for the treatment of infected walled-off pancreatic necrosis and infected pseudocysts with solid debris

Endoscopic transenteric stenting is the standard treatment for pseudocysts, but it may be inadequate for treating infected collections with solid debris. Surgical necrosectomy results in significant morbidity. Direct endoscopic necrosectomy (DEN), a minimally invasive treatment, may be a viable option. This study examined the efficacy and safety of DEN for the treatment of infected walled-off pancreatic necrosis and infected pseudocysts with solid debris. This study was a retrospective analysis of data collected from a prospective database of patients who underwent DEN in the presence of infected walled-off pancreatic necrosis or infected pseudocysts with solid debris from April 2007 to October 2011. DEN was performed as a staged procedure. Endoscopic ultrasonography-guided transgastric stenting was performed during the first session for initial drainage and to establish endoscopic access to the infected collection. In the second session, the drainage tract was dilated endoscopically to allow transgastric passage of an endoscope for endoscopic necrosectomy. Outcome data included technical success, clinical success and complication rates. Eight patients with infected walled-off pancreatic necrosis or infected pseudocysts with solid debris (mean size 12.5 cm; range 7.8-17.2 cm) underwent DEN. Underlying aetiologies included severe acute pancreatitis (n = 6) and post-pancreatic surgery (n = 2). DEN was technically successful in all patients. Clinical resolution was achieved in seven patients. One patient with recurrent collection opted for surgery instead of repeat endotherapy. No procedural complications were encountered. DEN is a safe and effective minimally invasive treatment for infected walled-off pancreatic necrosis and infected pseudocysts.

Transmural endoscopic necrosectomy of infected pancreatic necroses and drainage of infected pseudocysts: A tailored approach

Objective. Transmural endoscopic drainage and necrosectomy have become favored treatment modes for infected pancreatic pseudocysts and necroses. In this analysis, we summarize the outcome of 40 patients with complicated course of acute pancreatitis after endoscopic treatment. Material and methods. From January 2006 through May 2011, 40 patients of our department with complicated pancreatitis were included in this retrospective analysis. All patients underwent endosonographic transgastric puncture followed by wire-guided insertion of one or more double pigtail stents. Patients with extensive necroses were treated repeatedly with transgastric necrosectomy. Treatment success was determined by clinical, laboratory, and radiological parameters. Results. Nine patients had interstitial pancreatitis (IP) with pancreatic pseudocysts. Thirty-one patients had necrotizing pancreatitis (NP) with acute pancreatic necroses (n = 4) or walled-off pancreatic necrosis (n = 27). All patients with IP and nine patients with NP had pseudocysts without solid material and underwent transgastric drainage only. In this group major complications occurred in 11.1% and no mortality was observed. Twenty-two NP patients were treated with additional repeated necrosectomy. In patients with localized peripancreatic necroses (n = 10) no need of surgery or mortality was observed, major complications occurred in 10%. In patients with extensive necroses reaching the lower abdomen (n = 12), three needed subsequent surgery and three died. Conclusions. Transgastric endoscopy is an effective minimally invasive procedure even in patients with advanced pancreatic necroses. Complication rate is low particularly in patients with sole pseudocysts or localized necroses. The extent of the fluid collections and necroses is a new predictive parameter for the outcome of the patients.

Chromobacterium violaceum—A Rare Cause of Infected Pancreatic Pseudocyst

In Brief Of the 2 species of Chromobacterium, Chromobacterium violaceum has been rarely implicated in human disease. It is a bacterium of low virulence causing occasional localized infection and sepsis. We report a case of C. violaceum infection of pancreatic pseudocyst. The patient was treated by cystojejunostomy with Roux-en-Y jejunal loop and antimicrobial therapy with ciprofloxacin and amikacin. As sepsis due to this organism is associated with high mortality, empiric therapy with fluoroquinolones and aminoglycosides is recommended, along with proper surgical management. C. violaceum is an extremely rare cause of pancreatic pseudocyst infection. Given the fact that sepsis due to this organism is associated with high mortality, initial empiric therapy with drugs such as fluoroquinolones and aminoglycosides is recommended, along with proper surgical management to bring about complete resolution. The prognosis should be guarded even when the infection appears to be localized, because of its propensity to disseminate.

Treatment of infected pancreatic pseudocysts using a novel, dedicated covered self-expandable metal stent (CSEMS) with an effective antimigration system

Treatment of infected pancreatic pseudocysts using a novel, dedicated covered self-expandable metal stent (CSEMS) with an effective antimigration system

Intravénás glutamin és korai nasojejunalis táplálás együttes alkalmazása súlyos acut pancreatitisben – prospektív randomizált kettős vak kontrollált klinikai vizsgálat

Severe acute pancreatitis (SAP) is still one of the great challenges in gastro-intestinal surgery. According to recent studies, intravenously administered glutamine with total parenteral nutrition may be beneficial in the prevention of infectious complications and may reduce mortality rate. However, it has not been investigated yet, whether i.v. glutamine is able to achieve the same effect with early enteral nutrition as well. The objective of our prospective randomized double-blind study was to explore the effects of intravenously administered glutamine with early nasojejunal nutrition in severe acute pancreatitis. Forty-five patients with severe acute pancreatitis (with a Glasgow score at least 3 and/or a CRP level above 150 mg/ml on admission) were randomized into two groups. Group Glutamine (n = 24) was given 0.5 g/kg/die glutamine intravenously, while the control group (n = 21) received normal amino acid solution in the same quantity for 7 days. Nasojejunal nutrition was introduced 48 hours after admission in case of all patients, and their management was the same in every other aspect, too. The primary end-points of the study were the rate of pancreas-specific infectious complications and organ failure, and the secondary end-points were the necessity for radiological and surgical interventions, length of hospital stay and mortality rate. In group Glutamine, infected acute peripancreatic fluid collections (APFC) were detected in 4 patients, 2 patients had post-necrotic pancreatic/peripancreatic fluid collections (PNPFC), 2 patients had infected pseudocysts and 2 patients had walled-off pancreatic necrosis (WOPN). Ten patients were cured by ultrasound assisted puncture or drainage successfully. No surgical intervention was necessary. In the control group, 4 patients had infected APFC, 2 patients had infected PNPFC, infected pseudocysts and infected WOPN were diagnosed in 3 cases. Radiological intervention was effective in 9 cases, but 3 patients needed surgery. Three patients died of multi-organ failure, thus the mortality rate of the control group was 14%, while the mortality rate of the Glutamine group was zero. The mean hospital stay of the Glutamine group was 10.6 days, which is significantly shorter than the mean hospital stay of the control group, which was 15.9 days (p = 0.00104). The results of the Glutamine group are better in every end-points, however, statistically significant difference was detected in one parameter only, the length of hospital stay.

Tu1540 Selective Use of Nasocystic Irrigation Permits Pseudocyst Resolution Rates Comparable to Transmural Stents Alone in Patients With Infected Pseudocysts or Internal Debris: a Report of Over 100 EUS-Guided Drainages At a Single Tertiary Referral Center

Infected PP are more difficult to resolve due to underlying necrosis and septations.Whether nasocystic irrigation(NC)at index endoscopic drainage procedure(IEDP) improves the ability to resolve PP or reduces the need for direct endoscopic necrosectomy(DEN)compared to transmural drainage without NC is mostly unknown.

Outcome and complications of endoscopic ultrasound guided pancreatic pseudocyst drainage using combined endoprosthesis and naso‐cystic drain

Endoscopic ultrasound guided pancreatic pseudocyst drainage (EUS-PPD) is increasingly being used for management of pancreatic pseudocysts. We evaluated the outcome and complications of EUS-PPD with modified combined technique by inserting both endoprosthesis and naso-cystic drain. Forty patients referred between August 2007 and January 2010 for EUS-PPD were prospectively studied. EUS-PPD was attempted for symptomatic pancreatic pseudocysts which were; (i) resistant to conservative treatment, (ii) in contact with the gastric or duodenal wall on EUS and (iii) having no bulge seen on endoscopy. Controlled radial expansion wire guided balloon dilation of the puncture tract was performed followed by insertion of a 10 French double pigtail stent and 7-Fr naso-biliary drain. The early and late outcome and complications of EUS-PPD were analyzed. Thirty-two patients had non-infected and eight had infected pseudocysts. EUS-PPD was technically successful in all. Pseudocysts resolved completely in 39 patients, while one with infected pseudocyst underwent surgical resection for bleeding in the cyst. Naso-cystic drain was removed in 39 patients after median duration of 13 days. Thereafter, the double pigtail stent was removed in all cases after median duration of 10 weeks. Pseudocyst recurred in one patient requiring a second session of EUS-PPD. All 32 patients without cystic infection were successfully treated by EUS-PPD. Seven out of eight patients (87%) with cystic infection were successfully treated by EUS-PPD. Endoscopic ultrasound guided pancreatic pseudocyst drainage with modified combined technique is safe and is associated with high success rate.

Antibiotische Therapie von Enterokokken-Infektionen in der Gastroenterologie mit Daptomycin − erste Erfahrungen aus der Registerstudie EU-CORE (European Cubicin® Outcomes Registry and Experience)

Enterococci are a frequent cause of nosocomial infections in gastroenterology. The increase of Enterococcus faecium infections with development of resistance to gentamicin and vancomycin as well as possible linezolid resistance require alternative antibiotic therapies. Study data show that daptomycin, a highly bactericidal antibiotic is effective in enterococcal infections. However, in Germany daptomycin is so far only approved for the treatment of complicated skin and soft tissue infections, bacteremia and infective endocarditis caused by Staphylococcus aureus. In the Department of Internal Medicine I, University Hospital Halle (Saale) from May 2 009 to April 2 010 all gastroenterological patients with evidence of invasive enterococcal infection received intravenous daptomycin treatment at inclusion in the European Cubicin® Outcomes Registry and Experience (EU-CORE). Gastroenterological diseases treated were necrotising pancreatitis, infected pancreatic pseudocysts, abscesses, obstructive cholangitis and sepsis. The clinical outcome was retrospectively detected by protocol-defined criteria. A total of 13 patients (8 male, 5 female, median age 59 years) with microbiologically assured enterococcal infections (10 × E. faecium, including 1 × VRE, 6 × E. faecalis, including double infections) were treated with intravenous daptomycin (6 mg per kg body weight). In the presence of polymicrobial infections (10 of 13 patients), an additional anti-infective therapy was initiated according to sensitivity testing. Concomitantly a direct focus approach with stenting, puncture or drainage was performed. The clinical cure rate was 92 % (12 of 13 patients). One patient died from a non-surgically uncontrollable malignancy (Klatskin tumour Bismuth IIIb). There were no adverse events. These results allow us to conclude that antibiotic therapy with daptomycin in invasive or bacteraemic enterococcal infections leads to high cure rates (up to 90 % and more) when concomitant and adequate focus relief is performed. Larger clinical studies to obtain an extended drug approval are desirable.

Endoscopic vacuum-assisted therapy of infected pancreatic pseudocyst using a coated sponge

Endoscopic vacuum-assisted therapy (EVAT) is a reliable treatment for endoscopically accessible abscesses and was recently described in the management of infected pancreatic pseudocyst (IPC) [1] [2] [3] [4].

Endoscopic vacuum-assisted therapy of an infected pancreatic pseudocyst

Endoscopic vacuum-assisted therapy of an infected pancreatic pseudocyst

Su1388 Transgastric Endoscopic Treatment of Complicated Pancreatitis: Necrosectomy of Infected Pancreatic Necroses Versus Infected Pancreatic Pseudocysts

Su1388 Transgastric Endoscopic Treatment of Complicated Pancreatitis: Necrosectomy of Infected Pancreatic Necroses Versus Infected Pancreatic Pseudocysts

Survey of trends in minimally invasive intervention for necrotizing pancreatitis

Minimally invasive techniques to manage infected pancreatic necrosis have been recently developed and changes in their pattern of use are unknown. The aims of this survey were to determine the trends in the role of minimally invasive techniques to manage infected complications of necrotizing pancreatitis and the barriers to performing minimally invasive necrosectomy in Australia and New Zealand. Members of the Australian and New Zealand Hepatic Pancreatic and Biliary Association were surveyed. Participant demographics and necrotizing pancreatitis caseload were determined. The perceived role of percutaneous catheter drainage and minimally invasive necrosectomy for pancreatic abscess, infected pseudocyst and infected pancreatic necrosis were scored on Likert scales, comparing 2002 with 2007. Barriers to performing minimally invasive necrosectomy were scored. The response rate was 49% (44/90). Between 2002 and 2007, the role of percutaneous catheter drainage became more important as primary (P= 0.05) and secondary (P= 0.01) treatment for pancreatic abscess, and prior to minimally invasive necrosectomy for abscess, pseudocyst and necrosis (P < 0.01). Minimally invasive necrosectomy became increasingly important as primary treatment for infected necrosis (P < 0.01) and had been used by 47% of respondents. The greatest barriers to performing minimally invasive necrosectomy were lack of training and experience in the techniques, and the anatomical position and complexity of the target lesion. Minimally invasive techniques have an increasingly important perceived role in the management of pancreatic abscess, infected pseudocyst and infected pancreatic necrosis. Further evidence is required to determine the best techniques for treating each form of infection associated with necrotizing pancreatitis.

Mucinous Cystadenocarcinoma Initially Diagnosed as Recurrent Infected Pancreatic Pseudocyst After Acute Pancreatitis ^|^ndash; Report of a Case

Mucinous Cystadenocarcinoma Initially Diagnosed as Recurrent Infected Pancreatic Pseudocyst After Acute Pancreatitis ^|^ndash; Report of a Case