Necrotic Fluid Research Articles

S2068 The Case of a Disrupted Pancreatic Duct with Necrotic Fluid Collection, Treated with Endoscopic Management

S2068 The Case of a Disrupted Pancreatic Duct with Necrotic Fluid Collection, Treated with Endoscopic Management

Timing of minimally invasive Step-up intervention for symptomatic pancreatic necrotic fluid collections: a systematic review and meta-analysis.

Minimally invasive step-up interventions are now the standard treatment recommended by current guidelines for symptomatic pancreatic necrotic fluid collections (PNFC); however, it is controversial whether delayed treatment after four weeks should always be used in patients who have failed conservative treatment and whose condition has not improved or worsened. The aim of this meta-analysis was to evaluate the impacts of the different timing of interventions on the clinical outcomes and prognosis of patients with symptomatic PNEC requiring intervention. We searched Embase, Cochrane Library, PubMed and Web of Science databases to identify comparative studies assessing the safety and efficacy of early and postponed interventions in treating symptomatic PNFC. Mortality. Secondary outcomes included some major complications, need for further minimally invasive necrosectomy and length of hospital stay. This meta-analysis included ten studies (2 RCTs and 8 observational studies) with a total of 1178 symptomatic PNFC patients who required intervention. Pooled results showed that there was no significant difference between early minimally invasive intervention and postponed intervention in mortality(OR 1.41, 95%CI 0.93-2.12;p=0.10) and the incidence of early and late complications, but the early intervention group had a significantly increased need for further minimally invasive necrosectomy compared with postponed intervention (OR 2.04,95%CI 1.04-4.03; p=0.04). There was no increase in length of stay for patients who received early intervention compared to postponed drainage (MD 3.53, 95% CI -4.20, 11.27; p=0.37). Intervention before four weeks should be considered for patients with PNFC complicated by persistent organ failure or infections, who have been treated conservatively to the maximum extent possible.

Transabdominal self-expandable metal stent placement as a rescue therapy for drainage of walled-off necrosis.

Video 1CT scan of a walled-off necrosis in the right pararenal space extended to the iliac area.

Safety and clinical outcomes of early dual modality drainage (< 28days) compared to later drainage of pancreatic necrotic fluid collections: a propensity score-matched study.

Necrotizing pancreatitis can be complicated by Necrotic Fluid Collections (NFC). Guidelines recommend waiting for 4weeks from the onset of acute pancreatitis (AP) before considering endoscopic drainage. We aimed to compare outcomes and safety in patients undergoing early versus late drainage of NFC. We performed a retrospective review of all patients who underwent Dual Modality Drainage (DMD) [combined endoscopic and percutaneous drainage] for NFC from January 2007 to December 2020. Patients were stratified into the "early" group (DMD < 28days from AP onset) and were matched to "late" (DMD ≥ 28days) drainage group using propensity- core-matching. Primary outcomes of interest were technical success and adverse events. Secondary outcomes included clinical success, late complication rates, and mortality. We identified 278 patients who underwent DMD for NFC. Thirty-nine belonged to the early group and were matched to 174 patients from the late group. Technical success was similar in both early and late groups (97.4% vs 99.4%: P = 0.244) as were the procedural and early post-procedural (< 14days) adverse events rates (23.1% vs 27.6%: P = 0.565). Clinical success (92.3% vs 93.1%; P = 0.861) and late complication rates (23.1% vs 31.6%; P = 0.294) were similar. There were 2 deaths (5.7%) in the early vs. 9 (5.2%) in the late group, P = 0.991. When performed in a tertiary care center with expertise in therapeutic endoscopic ultrasound, early drainage of NFC appears to be feasible and safe. Further studies are needed to validate our results.

Drainage of pancreatic fluid collections in acute pancreatitis: A comprehensive overview

Moderately severe and severe acute pancreatitis is characterized by local and systemic complications. Systemic complications predominate the early phase of acute pancreatitis while local complications are important in the late phase of the disease. Necrotic fluid collections represent the most important local complication. Drainage of these collections is indicated in the setting of infection, persistent or new onset organ failure, compressive or pressure symptoms, and intraabdominal hypertension. Percutaneous, endoscopic, and minimally invasive surgical drainage represents the various methods of drainage with each having its own advantages and disadvantages. These methods are often complementary. In this minireview, we discuss the indications, timing, and techniques of drainage of pancreatic fluid collections with focus on percutaneous catheter drainage. We also discuss the novel methods and techniques to improve the outcomes of percutaneous catheter drainage.

Splanchnic Vein Thrombosis: A Harbinger of Infection in Peri/Pancreatic Necrotic Collections.

Infected pancreatic necrosis (IPN) is associated with poor outcomes. The present study looked at incidence of infection and predictors, if any, in these collections. This prospective observational study was done between July 2019 and October 2020. Symptomatic patients of acute necrotic collections and walled-off necrosis of pancreas requiring drainage were included. Necrotic fluid and blood were analyzed for growth of organisms. Sixty-two patients were included. The mean age was 36.8 years (standard deviation, 11.5 years). Male-female ratio was 4:1. Alcohol was the most common etiology. Infection was noted in 44 of the 62 patients (70.9%) and bacteremia noted in 23 of the 62 patients (37%). Escherichia coli was the most common organism in necrotic collections and Staphylococcus was the most common organism isolated from blood culture. The patients with Modified Computed Tomography-Severity Index of 8 of higher ( P < 0.001) had significant association with IPN but not with bacteremia. However, splanchnic vein thrombosis ( P = 0.022) was significantly associated with development of IPN as well as bacteremia on both univariate and multivariate analysis. Escherichia coli and Staphylococcus were the most common organisms grown from necrotic collections and blood respectively. Presence of splanchnic vein thrombosis was a significant factor for development of IPN and bacteremia on univariate as well as multivariate analysis.

Lung Abscess in Adult with Foreign Body (Tooth)

Lung abscess due to foreign body aspiration in adults is relatively rare and is more common in childhood. The number of patients with lung abscess has decreased because of antibiotic therapy; therefore, chest X-rays in cases of abscesses have decreased.1 Chest computed tomography (CT) allows for an improved study of lesions and other associated findings, and when cavitation is present, it allows evaluation of the walls, the content with necrotic fluid, and gas.2 In the presence of a foreign body, in addition to axial scans, multiplanar reconstructions and the virtual bronchoscopy technique have made it possible to identify the trachea and bronchial tree and often delimit the foreign body according to its density, shape, or whether it is surrounded by secretions.

Intraluminal endoscopy in diagnosis and treatment of fluid collections in acute pancreatitis

To improve treatment outcomes in patients with acute pancreatitis through a differentiated approach to transluminal drainage. There were 1074 patients with acute pancreatitis between January 2018 and December 2021 at the Sklifosovsky Research Institute for Emergency Care. EUS was used as a final diagnostic method to determine localization, dimensions, shape and contours of fluid collections. We also assessed content, presence or absence of a capsule and connection with pancreatic ductal system, possibility of intraluminal drainage under EUS control. A plastic stent with rounded ends was installed if homogeneous hypo- and anechoic cavity with clear even contours was detected. The same measure was applied in case of aspiration of serous or serous-hemorrhagic fluid. The indication for installation of covered self-expanding endoprosthesis was inhomogeneous anechoic fluid collection with hyperechoic inclusions (sequesters) and cloudy purulent content. Patients with necrotic forms underwent insertion of a cystonasal drainage tube 7Fr for sanitation of the cavity with 0.05% aqueous chlorhexidine solution. Endoscopic sequestrectomy was performed every 24-48 hours. Stent was removed in 6 (for encapsulated peripancreatic fluid collections) or 1 month (for other types of fluid collections) after discharge. According to the EUS data, endoscopic TLD was performed in 63 (46%) out of 136 patients with fluid collections. Among 63 patients with TLD, connection with pancreatic ductal system was found in 5 (7.9%) patients. These ones underwent pancreaticoduodenal stenting. Twenty-two patients underwent elective sequestrectomy after stenting of necrotic types of fluid collections with fully covered self-expanding stents. Additional percutaneous drainage was required in 11 (45.8%) of 24 patients. Complicated postoperative period was observed in 4 (6.3%) patients with acute necrotic fluid collections (bleeding from the area of pancreatogenic destruction). Four (6.3%) patients died. Autopsy revealed resolution of purulent-inflammatory process in all patients. Intraluminal surgery is possible not only for homogeneous delimited fluid collections, but also for advanced lesions including infected destructions. This approach allows us to consider endoscopic intraluminal drainage as the final minimally invasive method of surgical treatment of pancreatic necrosis. Its effectiveness is up to 45.8%.

ID: 3526710 SAFETY AND OUTCOMES OF PERFORMING EARLY DUAL MODAILITY DRAINAGE (

Acute pancreatitis (AP) can vary in severity and around 5-10% develop necrotizing pancreatitis which can lead to Necrotic Fluid Collections (NFC). In current practice, endoscopic drainage is the primary modality for management of symptomatic NFC. GI society guidelines recommend waiting for 4 weeks from onset of AP before considering endoscopic drainage. There is paucity in information regarding safety and outcomes of endoscopic drainage before 4 weeks. We aimed to compare outcomes and safety in patients undergoing early (< 28 days) versus late drainage of NFC.

Clinical and imaging findings of walled-off pancreatic necrosis misdiagnosed as an intra-abdominal neoplasia in a Schnauzer dog: A case report

A 10-year-old Schnauzer presented with a 1-month history of vomiting, anorexia, and abdominal pain, and a recently detected intra-abdominal mass. The round, soft-tissue opacity masses identified on the radiography in the left mid-abdomen were confirmed as multifocal, cystic masses via ultrasonography. The necrotic masses mimicked an intra-abdominal neoplasia on the initial imaging examinations. The computed tomography (CT) clearly showed encapsulated masses with a necrotic fluid arising from the left limb of the pancreas and extending to the peripancreatic, paracolic, and perigastric regions. Based on the multimodal imaging, surgical exploration, and histopathology, the mass was diagnosed as a walled-off pancreatic necrosis (WOPN). CT is an effective diagnostic modality for diagnosing acute pancreatitis in WOPN.

A Rare Case of Retroperitoneal Isolated Enteric Duplication Cyst with Malignant Transformation

Abstract Introduction/Objective Isolated enteric duplication cysts (IEDC) are rare congenital abnormalities that do not have a communication with the normal intestinal lumen. They are usually recognized before the age of 2 years. They are rarely encountered in adults and very seldom undergo malignant change. These cysts are predominantly located within the abdominal cavity. They histologically demonstrate gastrointestinal mucosal lining and smooth muscle in the wall. Methods We report a case of a 45-year-old African American female who was evaluated for a pain in the left-sided abdomen and pelvis. Magnetic resonance imaging revealed a large multilocular cystic retroperitoneal mass, extending into the left iliac fossa and anteriorly displacing the colon. No other mass lesion was radiologically identified. The main radiologic impression was sarcoma. A biopsy was performed, and a pathologic diagnosis of adenocarcinoma was established with a consideration of primary retroperitoneal mucinous cystadenocarcinoma. An en bloc surgical resection of the retroperitoneal mass with adjacent segment of the descending colon was accomplished. Gross examination revealed an 11 x 5 x 4 cm cystic mass, containing a necrotic fluid and adherent to a 4 cm long segment of descending colon. Microscopically, the mass was lined by neoplastic cells arranged into tubules, villi and glands. Areas of necrosis were present. The wall of the cystic mass showed extensive hyalinized fibrosis and focal invasion. The neoplastic cells had positive immunoreactivity for CK7, CK20 and CDX2, but were negative for PAX8, PR and ER. Desmin immunostain and trichrome special stain highlighted a focus of smooth muscle bundle within the wall of the mass. These findings led to the pathologic diagnosis of adenocarcinoma arising in retroperitoneal IEDC. Conclusion In conclusion, we present this case because of its unusual presentation and location. Recognition of this entity and its rare malignant potential is important as it can pose a diagnostic challenge to pathologists.

S1494 Gastroduodenal Artery Pseudoaneurysm in the Setting of Necrotizing Pancreatitis

INTRODUCTION: Gastroduodenal artery (GDA) pseudoaneurysms are a rare but fatal condition, representing about 1.5% of all visceral artery aneurysms.. If ruptured, mortality rate is high as 75%, particularly from severe upper gastrointestinal bleeding. Fortunately, the availability of imaging studies allows for early detection of these vascular events. Historically, they used to be treated either through surgical ligation or resection. Currently, minimally invasive endovascular procedures can be performed, resulting in a significant reduction in morbimortality. CASE DESCRIPTION/METHODS: 41 year old female with a history of Roux en Y gastric bypass, pancreatic divisum, chronic pancreatitis complicated by necrotic fluid collections was admitted for severe protein calorie malnutrition. She had a G tube place that persistently leaked, requiring a J arm for nutrition. Her hospital course was further complicated by peritonitis and serratia bacteremia, for which she received intravenous antibiotics. Six days after placement of her J arm, she began to have worsening epigastric pain. She became tachycardic up to the 140s. Abdominal exam was soft with epigastric tenderness without rebound or guarding. Labs were notable for new leukocytosis to 23 and a hemoglobin reduction from 8 to 6.6. CT imaging showed gastrostomy tube migration outside the stomach remnant, with spillage of gastric contents in the peritoneum. In addition to the known complicated necrotizing pancreatitis, the scan revealed a new development of a GDA pseudoaneurysm, 2 cm in size. Surgery was consulted to reposition the gastrostomy tube. Interventional radiology was also consulted for urgent GDA pseudoaneurysm coiling. Patient’s hemoglobin stabilized to her baseline the following days. DISCUSSION: Hemorrhagic complications of pancreatitis are rarely seen. Typically, patients with GDA pseudoaneurysms are asymptomatic or have non-specific abdominal pain. If ruptured, mortality rate is high as 75%. Fortunately, the availability of imaging studies allows for early detection of these vascular events. Gold standard diagnostic test is visceral angiography which provides both diagnostic and therapeutic value and has a 100% sensitivity. CT imaging is noninvasive and has a 67% sensitivity. Historically, they used to be treated either through surgical ligation or resection. We now are able to perform minimally invasive endovascular procedures, resulting in a significant reduction in morbimortality.Figure 1.: Gastroduodenal artery pseudoaneurysm (red arrow), 2cm in size, with surrounding complicated necrotizing pancreatitis.Figure 2.: Transcatheter selective embolization via coiling of the gastroduodenal artery pseudoaneurysm.

High levels of reactive oxygen species in pancreatic necrotic fluid of patients with walled-off pancreatic necrosis.

IntroductionWalled-off pancreatic necrosis (WOPN) is a life-threatening, late complication of acute pancreatitis, in which a fluid collection containing necrotic material is formed. Infection of the fluid collection significantly increases the mortality of patients with WOPN.AimTo examine the levels of oxidative stress markers in the pancreatic necrotic fluid (PNF) and serum of patients with sterile and infected WOPN.Material and methodsThirty-three adult patients with sterile WOPN and 14 with infected WOPN, as well as 31 patients with mild AP, were included in this study. Concentrations of oxidative stress markers (8-isoprostane, protein carbonyl groups, and 8-hydroxyguanine) were measured in the PNF and serum of patients with sterile and infected WOPN.ResultsHigh concentrations of all measured oxidative stress markers in PNF, but not in serum, were detected in patients with WOPN. Additionally, oxidative stress markers in PNF were significantly increased in patients with infected as compared to sterile WOPN. The serum high sensitive C-reactive protein (hsCRP) concentrations showed the highest correlation with PNF oxidative stress marker levels. Receiver operating characteristics (ROC) curve analysis confirmed that serum hsCRP could be a good predictor of WOPN infection.ConclusionsOxidative stress is associated with WOPN development; infection of PNF worsens the course of WOPN, possibly via increased production of reactive oxygen species; and serum hsCRP concentrations seem to be a good, noninvasive indicator of PNF infection.

2769 Large Gastric Gastrointestinal Stromal Tumor With Spontaneous Rupture of Necrotic Fluid Collection

INTRODUCTION: Gastrointestinal stromal tumors (GIST) are the most common mesenchymal tumor of the gastrointestinal tract. Fluid collection within GISTs is very rare with only several case reports documented. We present the first case of spontaneous rupture from a large gastric GIST with necrotic fluid collection which has been documented on endoscopic exam. CASE DESCRIPTION/METHODS: A 91 year-old Caucasian female with a 3 month history of weight loss and progressive dysphagia to solids presented for evaluation. She was afebrile and hemodynamically stable with mild tachycardia. Initial labs revealed mild leukocytosis and low protein/albumin. Computer tomography demonstrated large 12 × 11 cm gastric mass with air-fluid level. Follow-up diagnostic esophagogastroduodenoscopy (EGD) showed a large fundic mass with two large cratered ulcerations with bridging mass in the proximal stomach with unremarkable histology on biopsy. Follow-up EGD with endoscopic ultrasound (EUS) demonstrated similar visualization with now small collection of purulent fluid though no fistula was appreciated. On EUS there was a larger heterogeneous hypoechoic mass bridging across all echo layers and a fluid echogenicity without doppler flow contained within the mass. Fine needle aspiration showed spindle cell neoplasm (CD117 +, DOG1 +) compatible with GIST. Given comorbidity and advanced age, she was not considered a surgical candidate. After starting Imatinib, she was offered therapeutic EGD was for possible decompression of the fluid collection within the tumor, to relieve mass effect for palliation. On visual exam there was again evidence of more purulent material that was extruding from a small opening in the center of the mass. The endoscope was advanced into the small opening and revealed a large fluid filled cavity within the mass. After copious irrigation with suction the majority of the cystic fluid was removed and two plastic double pigtail stents were placed to allow full decompression of the cystic cavity. On follow-up exam, she reported improvement of her pain. DISCUSSION: GIST are most often found in the stomach but overall account for 3% of all gastric malignancies. The initial presentation is often asymptomatic but there are many cases of highly variable symptomatic presentations of larger GIST. GIST with cystic changes are considered rare, with only 11 cases reported to date. This case is the first documentation of a cystic GIST that spontaneously ruptured, forming a fistulous tract between the cavity and the stomach.

PERSISTENT PANCREATICOPLEURAL FISTULA COMPLICATED BY PANCREATICOMEDIASTINAL FISTULA WITH EXTENSION TO CERVICAL REGION CAUSING ODYNOPHAGIA TREATED SUCCESSFULLY WITH REPEAT ERCP, AVOIDING OPEN SURGERY

SESSION TITLE: Tuesday Medical Student/Resident Case Report Posters SESSION TYPE: Med Student/Res Case Rep Postr PRESENTED ON: 10/22/2019 01:00 PM - 02:00 PM INTRODUCTION: Pancreaticopleural fistulas (PPF) occur in about 5% of cases of chronic pancreatitis; bilateral pleural effusions or mediastinitis are rare complications. Typical management is octreotide and endoscopic pancreatic duct stenting. Management of pancreaticomediastinal fistulas (PMF) is unclear; recent algorithms suggest open surgery for sepsis, infection, obstruction, rupture, or hemorrhage. CASE PRESENTATION: A 53 year old male with history of chronic alcoholic pancreatitis presented to the pulmonary clinic with three days of progressive odynophagia and anterior neck swelling. Computed tomography (CT) suggested rupture of pancreatic cysts with subphrenic and necrotic fluid collections, suggesting acute on chronic pancreatitis and bilateral pleural effusions. Thoracentesis yielded dark-brown exudative fluid with a pleural fluid amylase 7500mg/mL or greater (left) and 4109mg/mL (right). MRCP showed retroperitoneal fluid extending into the mediastinum and bilateral paramediastinal pleural spaces without obvious fistulous tracts. Outpatient ERCP revealed a culprit pancreatic duct cyst, yet a stent was unable to be placed. The patient was started on octreotide to decrease pancreatic exocrine function. Surveillance MRCP showed little improvement. Following repeat encounters for dyspnea and thoracentesis, diagnostic workup with a repeat CT revealed new retrotracheal fluid collections extending from the pancreatic head with diffuse mediastinal stranding. Given the progressive findings, gastroenterology and surgery were consulted for a potential salvage procedure. Repeat ERCP yielded successful placement of a pancreatic duct stent with resolution of all fluid collections and mediastinitis over the subsequent weeks, allowing the patient to avoid surgical intervention. The patient is currently healthy and working full time in HVAC repair. DISCUSSION: Typical cases of PPF involve middle-aged males with chronic alcoholic pancreatitis and unilateral amylase-rich pleural effusions that resolve with ERCP and octreotide. We present a rare complication of PPF: mediastinitis and bilateral pleural effusions. Based on radiographic evidence and prior proposed mechanisms, we surmise that our case likely involves both retroperitoneal pseudocysts crossing hiatuses and enzymatic destruction of soft-tissue plains. We suggest aggressive treatment with octreotide and ERCP for pancreatic pseudocysts that threaten to cross the diaphragm or in cases where the pleural fluid contains amylase > 1000 mg/mL even if no fistulous tract is found. In the setting of clinical stability, we suggest repeat attempts at ERCP prior to open surgery. CONCLUSIONS: -PPF are a rare complication of alcoholic chronic pancreatitis, rarely they extend to the mediastinum or cause bilateral pleural effusions -In stable but symptomatic patients with a PPF, we suggest repeat ERCP prior to open surgery Reference #1: Scicombinator.com. (2019). SciCombinator - Pancreaticopleural and pancreaticomediastinal fistula extending to the cervical region, with dysphagia as initial symptom: A case report. [online] Available at: http://www.scicombinator.com/articles/4541544 [Accessed 16 Mar. 2019]. DISCLOSURES: No relevant relationships by Patrick Bagley, source=Web Response No relevant relationships by Nikhil Huprikar, source=Web Response No relevant relationships by Jason Unger, source=Web Response

Prognostic factors of critical acute pancreatitis: A prospective cohort study

BackgroundPatients with critical acute pancreatitis (CAP) have the highest risk of mortality. However, there have been no studies specifically designed to evaluate the prognostic factors of CAP. Aims & methodsThis was a prospective observational cohort study involving patients with CAP. Three aspects including organ failure, (peri)pancreatic necrotic fluid cultures and surgical interventions were analyzed specifically to identify prognostic factors. ResultsOf the 102 consecutive patients with CAP, 83 patients (81.4%) received step-up surgical treatment, the mortality of the step-up group was 25.3% (21/83). 19 patients (18.6%) underwent step-down surgical treatment, the mortality of the step-down group was 57.9% (11/19). Overall mortality in the whole cohort was 31.4% (32/102). Multivariate analysis of death predictors indicated that multiple organ failure (MOF) (OR = 5.3; 95% CI, 1.5–18.2; p = 0.008), long duration (≥5 days) of organ failure (OR = 6.4; 95% CI, 1.2–54.3; p = 0.029), multidrug-resistant organisms (MDROs) infection (OR = 4.6; 95% CI, 1.3–15.8; p = 0.013), OPN (OR = 3.7; 95% CI, 1.5–8.8; p = 0.004) and step-down surgical treatment (OR = 3.5; 95% CI, 1.2–10.1; p = 0.019) were significant factors. ConclusionAmong patients with CAP, MOF, long duration (≥5 days) of organ failure, MDROs infection, OPN and step-down surgical treatment were identified as the predictors of mortality.

Transgastric Endoscopic Cystogastrostomy in a Patient With Gastric Sleeve Anatomy

The endoscopic cystogastrostomy has become the standard for management of walled-off pancreatic fluid collections (PFC). However, altered gastric anatomy, such as the gastric sleeve, can present a challenge to endoscopists. As a result, patients with altered gastric anatomy may be referred for surgery, rather than endoscopic intervention. However, surgery is associated with increased costs and length of stay. Here, we report a successful transgastric necrosectomy/ PFC drainage. A 70 year old man with a history of sleeve gastrectomy in 2009 for obesity presented with necrotizing gallstone pancreatitis and subsequent peri- pancreatic fluid collection. After conservative management, the patient was discharged to home, only to present six weeks later with recurrent pancreatitis and poor oral intake. A CT of the abdomen showed an 8 cm pancreatic pseudocyst compressing the gastric sleeve. On upper endoscopy, gastric sleeve anatomy was noted without obstruction. Endoscopic ultrasound (EUS) showed a large 8 cm x 7 cm walled off necrosis adjacent to the stomach with approximately 50% necrosis. Using electrocautery, the hot Axios system (Boston Scientific) was used to access the necrotic collection from the antrum, approximately 3 cm proximal to the pylorus. This site was chosen to avoid intervening vessels seen more proximally and in surrounding areas. Cystogastrostomy was successfully performed with balloon dilation of the stent and placement of pigtail stents. Repeat EGD/EUS one month after Axios placement showed intact gastric anatomy and complete collapse of the prior necrotic fluid collection cavity. To our knowledge, no case reports have been published to date describing a transgastric approach to cystogastrostomy in patients with gastric sleeve anatomy. Endoscopists may shy away from this patient population due to concerns for decreased working space, increased intraluminal pressure and possible disruption of the suture line. One case report notes pseudocyst drainage via the duodenum in a gastric sleeve patient due to the above mentioned concerns. While concerns exist about the feasibility of necrosectomy in post gastric sleeve anatomy, this case shows that transgastric cystogastrostomy can be successfully and safely performed in patients with altered gastric anatomy, such as sleeve gastrectomy. Given the decreased maneuverability, more distal sites, such as the gastric antrum, may be most amenable to the procedure.1408_A.tif Figure 1: Axios stent in the distal gastric wall in post- sleeve gastrectomy anatomy.1408_B.tif Figure 2: 8 cm x 7 cm walled off necrosis adjacent to the stomach.

Pancreatic necrosectomy morbid but life saving

Introduction: Pancreatic necrosectomy has high morbidity and hence is the last resort in necrotizing pancreatitis. Retrospective analysis was done to study its morbidity and sequalae Method: Between 2005 to 2017, 110 patients underwent closed pancreatic necrosectomy. After adequate debridement and washes, multiple tube drains were kept for postoperative irrigation. Need for diversion stoma and feeding jejunostomy was decided on clinical, radiological and intraoperative findings. Results: 93 males & 17 females. Mean age was 36 years (21–77). Pancreatic necrosis was due to alcohol-56, biliary -44 , whereas trauma and idiopathic 3 each ,post ercp and autoimmune pancreatitis -2 each. 53/110 ( 48%) pts had diversion stoma . 68/110 (62 %) patients had feeding jejunostomy. Preoperative percutaneous drainage was done in 35 patients. Average time of intervention was 54th day since onset of pancreatitis. Average amount of necrotic material was 62 gms. Necrotic fluid grew e.coli in 48, klebsiella in 26, pseudomonas in 9. Average post op stay 23 days.(8-70). Post op prolonged ventilation(>48 hrs) required in 28 patients. 11 patients required tracheostomy. 12/ 110(11%) patients had mortality. 49/110 (45%) patients had pancreatic fistula, out of which 30 required postoperative ERCP and pancreatic duct stenting, for the fistula to heal. New onset DM and incisional hernia was seen in 10 and 5 patients respectively. Conclusion: Surgical pancreatic necrosectomy done after 6-7 weeks is less morbid. Diversion stoma and feeding jejunostomy are often required. ERCP and PD stenting are required for prolonged pancreatic fistulae to heal.

Risk Factors for the Need of Surgical Necrosectomy After Percutaneous Catheter Drainage in the Management of Infection Secondary to Necrotizing Pancreatitis.

This study aimed to assess the need of surgical necrosectomy after percutaneous catheter drainage (PCD) for infected necrotizing pancreatitis. The clinical data of documented/suspected patients who were treated with a step-up approach were extracted and analyzed. Of the 329 patients enrolled, the initial PCD was performed at 12 (interquartile range, 9-15) days since onset and 35.3% were cured by PCD alone. In the pre-PCD model, mean computed tomographic (CT) density of necrotic fluid collection (NFC; P < 0.001), and multiple-organ failure (MOF; P < 0.001) within 24 hours before the initial PCD were independent risk factors, and a combination of the previously mentioned 2 factors produced an area under the curve of 0.775. In the post-PCD model, mean CT density of NFC (P = 0.041), MOF (P = 0.002), and serum procalcitonin level (P = 0.035) 3 days after the initial PCD were independent risk factors, and a combination of these previously mentioned factors produced an area under the curve of 0.642. Both mean CT density of NFC and MOF are independent pre- and post-PCD risk factors for the need of necrosectomy after PCD. Post-PCD serum procalcitonin level might be a respondent factor that is correlated with the necessity of necrosectomy.

Granulocyte-colony stimulating factor producing mucinous cystic neoplasm with an associated invasive carcinoma of the pancreas

The present case study documents an autopsy case of granulocyte-colony stimulating factor (G-CSF)-producing mucinous cystic neoplasm (MCN), with an associated invasive carcinoma of the pancreas. A 65-year-old woman presented to Omuta City Hospital (Omuta Japan) with a primary complaint of abdominal pain. Multiple liver nodules and a pancreatic cyst were detected upon abdominal computed tomography. Initially, liver abscess was suspected as the patient exhibited leukocytosis and elevated C-reactive protein level. However, the serum concentration of G-CSF was 98.8 pg/ml (normal, <39.0 pg/ml). At 6 weeks after admission, the patient succumbed to liver failure. At autopsy, a cystic lesion was identified in the pancreatic tail that contained bloody necrotic fluid. Microscopically, the cystic lesion was composed of columnar and mucin-producing epithelium associated with ovarian-type subepithelial stroma. The stroma exhibited positive immunostaining for vimentin, estrogen receptor and progesterone receptor. Calcification on the cystic wall was observed. The tumor invaded the pancreatic parenchyma and metastasized to the liver and lungs. The lesion was diagnosed as invasive adenocarcinoma arising in MCN. By contrast, liver nodules predominantly consisted of pleomorphic cancer cells with small foci of adenocarcinoma. Pancreatic and hepatic cancer cells were confirmed to be positive for G-CSF staining. The present case report indicates that G-CSF-producing MCNs may be associated with an aggressive clinical course, particularly when anaplastic changes are observed.