Pancreatic Duct Leak Research Articles

Endoscopic Management of Pancreaticobiliary Injuries: A Level 1 US Trauma Center Experience.

Background: Traumatic pancreaticobiliary injuries are challenging to diagnose and manage. Endoscopic retrograde cholangiopancreatography (ERCP) has potential diagnostic and therapeutic utility in cases of traumatic pancreaticobiliary injuries. Methods: In this single-center retrospective study, we assessed 25 cases of abdominal trauma in which the patients underwent ERCP for management of suspected pancreaticobiliary injuries. We analyzed basic patient demographics, mechanism of trauma, method of diagnosis, ERCP results, surgical treatments, and outcomes. Results: Of the 25 assessed patients, 12 (48%) had pancreatic injuries, 12 (48%) had biliary injuries, and 1 (4%) patient had both. The median age was 28 years [IQR 25-35], and 84% of patients were males. Fifty-six percent of injuries were from blunt trauma, while 44% were from penetrating trauma. In cases of ERCP-confirmed biliary leaks (n=11), 100% of leaks were resolved in the 8 patients who underwent repeat ERCP after initial ERCP with stenting. In cases of ERCP-confirmed pancreatic duct leaks (n=10), 57% of duct leaks were resolved in the 7 patients who underwent repeat ERCP after initial ERCP with stenting. One patient in the biliary trauma cohort developed post-ERCP pancreatitis and sepsis. Conclusion: ERCP was a useful diagnostic and therapeutic intervention in this population of patients with pancreaticobiliary trauma.

Outcomes after Transgastric Drainage of Pancreatic Duct Leaks

PurposeTo determine the outcomes of transgastric drainage (TGD) of pancreatic duct leaks (PDLs), including fluid collections and pancreaticocutaneous fistulae (PCFs). Materials and MethodsFifty-four patients who underwent attempted TGD of a PDL from 1992 to 2020 were identified. Data regarding patient comorbidities, fluid collection characteristics, technical success, drain exchanges and removals, recurrent collections, and complications were analyzed. ResultsForty-one patients (41/54, 76%) had a history of pancreatitis. Sixteen patients (16/54, 30%) had a history of recent abdominal surgery. Peripancreatic fluid collections were 11.2 cm ± 4.6 in greatest dimension prior to drainage. Twenty-one collections (21/54, 39%) demonstrated biochemical and/or imaging evidence of an active communication to the pancreatic duct, and 16 (16/54, 30%) of these patients had a PCF due to a direct percutaneous drain prior to TGD. TGD was technically successful in 53 patients (53/54, 98%). During the follow-up period, 46 patients (46/53, 87%) were able to undergo drain removal after resolution of the fluid collection, with a mean catheter indwelling time of 3 months and a median of 1 catheter exchange. There were 2 severe (2/53, 4%) and 4 moderate (4/53, 8%) complications, the most common of which was drain dislodgement requiring repeat transgastric puncture. Recurrent fluid collections were observed in 8 patients (8/53, 15%) after a mean of 5 months following drain removal. There were no recurrent PCFs. ConclusionsTGD of PDLs is technically feasible and efficacious in the vast majority of patients with a relatively low complication rate. This technique is effective in preventing or treating the long-term debilitating complication of PCF.

S358 Endoscopic Ultrasound-Directed Transgastric ERCP for Pancreatic Duct Stent Placement to Treat Pancreatic Ascites

Introduction: Endoscopic ultrasound (EUS)-Directed transGastric ERCP (EDGE) is an advanced procedure utilized to enable pancreaticobiliary access in patients with Roux-en-Y gastric bypass anatomy. We hereby present a case of refractory pancreatic ascites from a persistent pancreatic duct (PD) leak treated with EDGE and transpapillary PD stenting. Case Description/Methods: A 62-year-old White female with history of morbid obesity with Roux-en-Y gastric bypass and biliary pancreatitis with prior cholecystectomy was referred for refractory pancreatic ascites causing significant abdominal pain, poor oral intake and weight loss necessitating total parenteral nutrition. MRCP showed a PD leak in the body as cause for ascites (Fig. 1). After multidisciplinary team discussion, a staged EDGE for PD stenting was pursued. The gastric remnant was identified endosonographically through the jejunum, a 19G needle was advanced into it and 500 ml of saline was instilled to dilate the remnant. A 0.025 guidewire was coiled in the remnant and a 15mm by 10 mm cautery enhanced lumen apposing metal stent (LAMS) delivery system was used to create a jejunogastrostomy followed by LAMS deployment. LAMS was post dilated to 15 mm and ERCP was pursued after 10 days. During ERCP, PD leak at the body was confirmed on the pancreaticogram. A 5 Fr by 15 cm single pigtailed stent was deployed to bridge this leak. A large biliary sphincterotomy was also performed for a subjectively stenotic major papilla. Follow up CT scan after 1 month showed resolution of pancreatic ascites and repeat ERCP confirmed resolution of the PD leak. The biliary and pancreatic stents were removed. The jejunogastrostomy stent was removed after three months. She continues to remain asymptomatic and is tolerating a regular diet. Discussion: This case demonstrates the successful use of EDGE procedure for management of refractory pancreatic ascites from a pancreatic duct leak. EDGE for pancreatic endotherapy in Roux-en-Y gastric bypass anatomy is a safe and effective alternative to more invasive laparoscopy or percutaneous gastrostomy access to the gastric remnant and should be considered in cases with ascites. Watch the video at https://tinyurl.com/ACGAbstractS358Figure 1.: MRCP With Pancreatic Duct Leak.

S7 Endoscopic Ultrasound-Guided Pancreatic Duct Drainage: A 10-Year Single-Center Experience

Introduction: EUS-guided pancreatic duct drainage (EUS-PDD) has been recognized as an alternative to surgery for those in whom transpapillary drainage is unfeasible. Previous studies have outlined hurdles that may be encountered with performance of this challenging procedure. These can include lack of stability of the echoendoscope, difficulty with moving a guidewire through the needle for creation of a fistulous tract, or dilation of the fistulous tract. Methods: We performed a retrospective chart review of cases performed in a tertiary academic center of those in whom EUS-PDD was attempted from January 2010 to November 2021. Documentation and imaging were reviewed up to 12 months after the incident event. Figure demonstrates an example of the performance of the procedure. Results: 27 patients were identified for whom baseline characteristics are listed in Table: The pancreatic duct was accessed through the stomach in 26 of 27 cases. Technical success was achieved in 22 of these. Access through the duodenum was attempted in a single case but was unsuccessful due to a discontinuous duct. Clinical success was defined in terms of improvement of upstream dilation of the pancreatic duct on imaging and of symptoms, and was achieved in all 22 patients. However, 5 patients had persistent albeit improved abdominal pain after the procedure. One had bleeding that resulted in a self-limited hematoma, which developed an infection with Escherichia coli that resolved after conservative management with antibiotics. Another patient developed a pancreatic duct leak that was managed with cystgastrostomy with eventual resolution. Stent migration occurred in two of which one was monitored conservatively without laboratory or imaging findings of recurrence of pancreatic duct obstruction. In the second case, the patient had recurrence of pain and was found to have migration of the distal end of the stent on endoscopic evaluation. The stent was nonetheless left in place to allow the fistulous tract to remain patent, with eventual removal 16 months later with resolution of stricture (Figure 1). Conclusion: EUS-PDD is a technically challenging procedure that may nonetheless be the only nonsurgical option in patients in whom endoscopic retrograde pancreatography is infeasible. Technical and clinical success in this cohort is comparable with previous studies. By describing our experience with EUS-PDD, we hope to inform endoscopists of potential hurdles and adverse events that may occur with performance of the procedure (Table 1).Figure 1.: Sample images from one of the cases in this review. 1A shows the fluoroscopic image of the stent placed during EUS-PDD. 1B demonstrates cannulation of the PD through the stomach under ultrasound guidance. Table 1. - Baseline characteristics of patient cohort and post-procedural follow-up Characteristic n (%) Age, mean (SD) 54.6 (12.8) Gender Male Female 12 (44.4)15 (55.6) Indication for EUS-PDD Stricture Stone Mixed (stone + stricture) Pancreas divisum Discontinuous duct 9 (33.3)8 (29.6)2 (7.4)5 (18.5)3 (11.1) Approach Antegrade Retrograde 22 (81.5)5 (18.5) Technical success 22 (81.5) Type of stent Straight Pigtail 12 (54.5)10 (45.5) Adverse events Pancreatitis Stent migration Bleeding Pancreatic duct leak 3 (11.1)2 (7.4)1 (3.7)1 (3.7) Clinical success 22 (100) Number of readmissions, mean (SD) 1.7 (SD 2.2) Re-intervention required 2 (9.1)

Percutaneous transluminal angioplasty balloons for endoscopic ultrasound-guided pancreatic duct interventions.

BACKGROUNDEndoscopic ultrasound (EUS)-guided main pancreatic duct (PD) access may be used when conventional endoscopic retrograde cholangiopancreatography (ERCP) techniques fail. The use of a percutaneous transluminal angioplasty balloon (PTAB), originally developed for vascular interventions, can be used to facilitate transmural (e.g., transgastric) PD access and to dilate high-grade pancreatic strictures.AIMTo describe the technique, efficacy, and safety of PTABs for EUS-guided PD interventions.METHODSPatients who underwent EUS with use of a PTAB from March 2011 to August 2021 were retrospectively identified from a tertiary care medical center supply database. PTABs included 3-4 French angioplasty catheters with 3-4 mm balloons designed to use over a 0.018-inch guidewire. The primary outcome was technical success. Secondary outcomes included incidence of adverse events (AEs) and need for early reintervention. RESULTSA total of 23 patients were identified (48% female, mean age 55.8 years). Chronic pancreatitis was the underlying etiology in 13 (56.5%) patients, surgically altered anatomy (SAA) with stricture in 7 (30.4%), and SAA with post-operative leak in 3 (13.0%). Technical success was achieved in 20 (87%) cases. Overall AE rate was 26% (n = 6). All AEs were mild and included 1 pancreatic duct leak, 2 cases of post-procedure pancreatitis, and 3 admissions for post-procedural pain. No patients required early re-intervention.CONCLUSIONEUS-guided use of PTABs for PD access and/or stricture management is feasible with an acceptable safety profile and can be considered in patients when conventional ERCP cannulation fails.

Abstract No. 378 Outcomes after transgastric drainage of pancreatic duct leaks

Transgastric drainage (TGD) of pancreatic duct leaks (PDLs), which include fluid collections or pancreaticocutaneous fistulae (PCF), offers a unique strategy to prevent the long-term complication of PCF that can be caused by direct percutaneous drainage. TGD can also manage an existing PCF by providing a route for diversion. TGD can be performed by interventional radiology earlier than endoscopic interventions, which require weeks for the development of a mature tract or cyst wall. This study sought to determine the efficacy and safety of TGD of PDLs.

51-Year-Old Man With Ascites and Abdominal Pain

51-Year-Old Man With Ascites and Abdominal Pain

Percutaneous biopsy and drainage of the pancreas.

Percutaneous pancreatic interventions performed by abdominal radiologists play important diagnostic and therapeutic roles in the management of a wide range of pancreatic pathology. While often performed with endoscopy, pancreatic mass biopsy obtained via a percutaneous approach may serve as the only feasible option for diagnosis in patients with post-surgical anatomy, severe cardiopulmonary conditions, or prior non-diagnostic endoscopic attempts. Biopsy of pancreatic transplants are commonly performed percutaneously due to inaccessible location of the allograft by endoscopy, usually in the right lower quadrant or pelvis. Percutaneous drainage of collections in acute pancreatitis is primarily indicated for infection with clinical deterioration and may be performed alone or in combination with endoscopic drainage. Post-surgical pancreatic collections related to pancreatic duct fistula or leak also often warrant therapeutic percutaneous drainage. Knowledge of appropriate indications, strategies of approach, technique, and complications associated with these procedures is critical for a successful clinical practice.

Combined modality therapy including cytoreductive surgery and heated intraperitoneal chemotherapy for synchronous low volume peritoneal carcinomatosis from adenocarcinoma of the tail of pancreas in a BRCA-2 carrier resulting in long-term disease-free survival: A case report.

IntroductionA BRCA-2 mutation carrier with a metachronous pancreatic adenocarcinoma (PC) and established peritoneal metastases is presented. Combined modality therapy including Cytoreductive Surgery (CS) and Hyperthermic Intraperitoneal Chemotherapy (HIPEC) was associated with long-term disease-free survival.Case presentationA 62-yr. old female underwent successful treatment for stage IIIa carcinoma of the right breast at age 48. 11 years later a cystic adenocarcinoma of the tail of the pancreas with peritoneal metastases was diagnosed. Platin based neoadjuvant chemotherapy followed by definitive resection of the pancreatic mass with cytoreductive surgery (CS) and Hyperthermic Intraperitoneal Chemotherapy (HIPEC) with mitomycin C was performed. Postoperatively, a retro-gastric fluid collection developed from a pancreatic duct leak, successfully managed non-operatively. Maintenance poly ADP ribose polymerase (PARP) inhibitor therapy was initiated after recovery from surgery. The patient experienced a 30-month disease free survival and was subsequently found to have oligometastases to the brain.DiscussionCR and HIPEC have not been reported to be efficacious in patients with pancreatic carcinomatosis. However, PC arising in BRCA-2 carriers has a DNA repair defect, which is sensitive to platin based chemotherapy and mitomycin C. HIPEC has more severe postoperative complications following distal pancreatectomy. Isolated brain metastases from PC are rare. BRCA-2 mutation carriers are at significantly increased risk for PC.ConclusionLeveraging the DNA Repair defect in BRCA-2 pancreatic adenocarcinoma, including CS and HIPEC, led to long-term disease-free survival and good locoregional control in this patient. Complications from HIPEC are more severe. BRCA-2 carriers should undergo annual pancreatic cancer screening.

ID: 3523615 PANCREATIC ENDOTHERAPY IMPROVES QUALITY OF LIFE AND PAIN IN PATIENTS WITH CHRONIC PANCREATITIS

Pancreatic Endotherapy (PET) offers potential treatment of chronic pancreatitis (CP) sequelae including pancreatic duct (PD) strictures, stones, leaks and peripancreatic fluid collections. Though widely performed, data regarding the effect of PET on patient-centered outcomes are limited. The aim of this study was to examine the effect of PET on quality of life (QOL) in CP patients.

A RARE CASE OF EMPYEMA SECONDARY TO PANCREATICOPLEURAL FISTULA

SESSION TITLE: Medical Student/Resident Disorders of the Pleura Posters SESSION TYPE: Med Student/Res Case Rep Postr PRESENTED ON: October 18-21, 2020 INTRODUCTION: Pancreaticopleural fistula is a rare complication of pancreatitis resulting from pancreatic duct disruption with leakage of pancreatic secretions into the pleural cavity. CASE PRESENTATION: 50-year-old woman with alcohol use disorder and chronic pancreatitis presented with abdominal pain, vomiting and dyspnea on exertion. Serum chemistries revealed elevated lipase and amylase suggesting acute pancreatitis. Computer Tomography (CT) chest, abdomen and pelvis revealed massive left pleural effusion causing mediastinal shift to the right and multiple rim-enhancing cystic structures around the pancreas, suggestive of pancreatic pseudocysts. Pleural drainage was performed with a chest tube placement, after which patient reported symptom relief. Pleural fluid analysis revealed an exudative pattern with elevated amylase, reflecting likely pancreatic etiology, and raising suspicion of pancreaticopleural fistula (PPF). Following pleural fluid drainage and aeration of the lung, she developed fever with leukocytosis; repeat CT chest revealed multi-loculated pleural effusion. A working diagnosis of empyema secondary to (PPF) was made and patient was started on intravenous (IV) antibiotics. Magnetic resonance cholangiopancreatography (MRCP) revealed walled off necrosis surrounding the pancreatic tail extending into the left subdiaphragmatic and left pleural spaces, confirming the diagnosis of (PPF). She underwent Endoscopic retrograde cholangiopancreatography (ERCP) without successful cannulation of pancreatic duct. Partial distal pancreatectomy was performed with resolution of pleural effusion and symptoms. DISCUSSION: PPF is usually a consequence of leak from an incompletely formed or ruptured pseudocyst or from direct pancreatic duct leak either through the esophageal hiatus or the diaphragm into the pleural space. It typically presents with pulmonary symptoms more than the abdominal symptoms. Left-sided pleural effusion is typical, though right-sided or bilateral effusions are not uncommon. Empyema, a known major complication that can lead to life threatening sepsis, occurs when there is an ascending infection via the fistulous tract. Diagnosis is based on clinical suspicion; elevated amylase in pleural fluid strongly supports the diagnosis. MRCP is a useful diagnostic modality demonstrating the fistula. Initial management consists of pleural drainage and tube thoracotomy placement. Minimally invasive thoracic surgery with pleural debridement can also be considered. Definitive management of fistula is accomplished with stent placement via ERCP, though if that fails, surgical intervention with pancreatectomy is considered, as described in our case. CONCLUSIONS: A high index of clinical suspicion is needed for diagnosis of PPF in patients presenting with dyspnea and history of pancreatitis or its risk factors Reference #1: Schweigert M, Renz M, Dubecz A, Solymosi N, Ofner D, Stein HJ. Pancreaticopleural fistula-induced empyema thoracis: principles and results of surgical management. Thorac Cardiovasc Surg. 2013;61(7):619-625. doi:10.1055/s-0033-1334996 Reference #2: Machado NO. Pancreaticopleural fistula: revisited. Diagn Ther Endosc. 2012;2012:815476. doi:10.1155/2012/815476 DISCLOSURES: No relevant relationships by Ibrahim Asghar Abid, source=Web Response No relevant relationships by Lakshmi Priyanka Mahali, source=Web Response No relevant relationships by Noa Tal, source=Web Response

Mo1981 ENDOSCOPIC MANAGEMENT OF BLUNT PANCREATIC TRAUMA IN CHILDREN: A RETROSPECTIVE SERIES FROM A LARGE HPB CENTRE

Blunt pancreatic trauma leading to disconnected pancreatic duct syndrome is rare sequelae of blunt pancreatic trauma (incidence 0.2%). Conventionally it is treated surgically with associated morbidity and mortality even in high volume centres. Minimally invasive endoscopic approaches are an attractive alternative, but outcome data is limited. In this study we report a case series from a large HPB centre. Data for all paediatric patients (aged ≤18 years) undergoing endoscopic retrograde cholangiopancreatographies (ERCP), at King’s College Hospital, between January 2008 and December 2018 was collected. ERCPs specifically to manage pancreatic duct (PD) trauma were extrapolated and reviewed. Patient demographics, imaging, endoscopy and outcomes were recorded in each case. Of the 374 children undergoing ERCP, 7.5% (28) had it performed following pancreatic trauma. 21 were male, 7 female; median age 10 (range 5-18) years. Injury occurred following bicycle handle bar trauma in 61% (17), horse riding fall 7, road traffic accident in 2 and unknown in 2. Pre-procedure imaging was with ultrasound in 93% (26), computer topography in 57% (16) and MRCP in 46% (13). The pancreatic duct injury occurred in: pancreatic body 43% (12), the head 36% (10) and the tail 21% (6). 18% (5) of patients had a pancreatic stricture associated with their leak. In total, 70 ERCPs were attempted; median of 2 ERCPs (range 1 – 5) per patient. At the primary ERCP the PD was successfully cannulated in 89% (25), a stent placed across the defect in 36% (9) and a stent left in the proximal duct in a further 56 % (14). 68% (19) patients developed a prolonged PD leak. If a stent was successfully placed across the defect at the primary ERCP patients needed statistically significantly fewer additional ERCPs (1 vs 2, p=0.0165). 7% (2) patients ultimately required pancreatic surgery. Adverse events occurred in 1% (n=1, localised perforation, managed conservatively). Patients were followed up for a median of 12 months (range 3 – 84) from the time of their first ERCP with no long-term sequelae. ERCP with PD stenting is a minimally invasive and effective treatment for the management of blunt pancreatic trauma. Successful stenting across the PD defect at primary ERCP reduces the number of subsequent ERCPs needed. There are no long-term pancreatic complications.

1383 Making It Work With the Tools at Hand: Use of a Biliary Stent to Repair a Pancreatic Leak

INTRODUCTION: Pancreatic duct leaks (PDL) are primarily managed by advanced endoscopist, interventional radiologists, and sometimes by pancreatic surgeons. The mainstay of endotherapy for PDL is trans-papillary pancreatic duct stent placement bridging the PDL. Fully covered biliary metal stents are widely accepted in biliary leaks due to its radial force but there is no conventional fully covered metal stent (FCMS) in US for pancreatic duct for refractory PDL. We describe a patient with refractory PDL where biliary SEMS was used to successfully treat PDL. CASE DESCRIPTION/METHODS: Case Presentation A 43-year-old African American male presented to our hospital one month after admission for hemorrhagic pancreatitis attributed to dyslipidemia. Course was complicated by loculated retroperitoneal abscess tracking from pancreas to scrotum. Patient underwent exploratory laparotomy with pancreatic necrosectomy along with broad-spectrum antibiotics resulting in mild improvement in condition. Magnetic resonance cholangiopancreatography revealed PD injury confirmed on abdominal CT with contrast. ERCP confirmed PDL. A 5 F × 8 cm single pigtail plastic pancreatic stent (PPS) was placed. Unfortunately, PPS failed to maintain drainage and prevent leak as observed on contrasted abdominal CT 6 days later. PDL was confirmed again on repeat ERCP and an 8 mm × 6 cm biliary fully covered SEMS was placed in PD. Post stent placement, occlusion pancreatogram (OP) showed no leak. Four days later, repeat CT showed improving fluid collections without leak. After 4 weeks, third ERCP was performed, SEMS was removed with rat tooth forceps without complications, ERCP showed no PDL and a 7 F × 7 cm PPS was placed. Six weeks later, PPS was removed, ERCP showed no PDL and a 7 F × 4 cm PPS was placed. At this time, patient has continued to follow on outpatient basis without further incident. DISCUSSION: Discussion Endoscopic treatments for PDL have replaced surgical interventions in number of situations. Biflanged fully covered metal stents for PDL are only available outside US. In the meantime, cases like this emphasize the importance of considering alternative approaches in the treatment of PDL.

1452 Unusual Complication Following Screening Colonoscopy

INTRODUCTION: Colonoscopy in general can be a challenging procedure as the colon is often quite mobile and tortuous. While abdominal pain is relatively common during and after the procedure, evaluation is always required to rule out serious causes such as colonic perforation and organ injury. CASE DESCRIPTION/METHODS: A 62-year-old female with a history of a left nephrectomy (23 years ago) underwent a screening colonoscopy (performed with good bowel preparation, under conscious sedation, and the whole colon was described as significantly redundant, tortuous and endoscopically normal) at the referring facility. She developed worsening left sided abdominal pain, nausea and vomiting three days after the procedure (managed at several occasions with bowel rest and antibiotics for presumed enteritis/diverticulitis). CT scan, 3 months following colonoscopy showed a complex irregular collection involving pancreatic tail and splenic flexure with adjacent partially rim-enhancing fluid collection abutting the greater curvature of the stomach. A CT guided percutaneous aspiration of fluid collection showed a markedly elevated lipase and amylase. This was concerning for pancreatic duct (PD) leak. She underwent an ERCP and placement of 3 Fr by 13 cm single pigtailed Advantix stent and 5 Fr by 3 cm Geenen stent for a confirmed PD leak. Although no definite fistulous communication to colon was seen on the fluoroscopic images, an immediate post ERCP non-contrast CT scan revealed contrast in the left colon concerning for a colo-pancreatic fistula. Her clinical symptoms resolved immediately following procedure. A follow up ERCP after 4 weeks confirmed no further PD leak. DISCUSSION: This patient's presentation is most consistent with chronic PD leak. The likely explanatory mechanisms include traction on fibrous surgical adhesions between the splenic flexure and distal pancreas, direct blunt trauma by passage of the colonoscope through the splenic flexure, and external abdominal pressure around the left colon. This case illustrates that it is possible for a patient with pre-existing risk factors to develop a significant pancreatic injury following colonoscopy. Careful review of patient's surgical history at time of informed consent is essential to identify those at risk and to take preventive measures including avoiding and reducing endoscope looping, avoiding excessive force and minimizing air insufflation.

1270 Unexpected Microorganism in an Unexpected Place

INTRODUCTION: Candida Parapsilosis (CP) has been implicated in several intra- and extra- vascular infections and rarely been the cause of intraabdominal infections. We describe a case of CP infection complicating acute severe necrotizing pancreatitis. CASE DESCRIPTION/METHODS: A 68-year-old man presented with acute onset epigastric pain associated with nausea and vomiting. Physical examination revealed epigastric tenderness. Lipase was elevated at 7352 mg/dl and initial abdominal CT scan revealed changes consistent with acute edematous pancreatitis with possible early necrosis. His clinical course was complicated by acute respiratory failure, septic shock, and AKI requiring hemodialysis. He was in and out of the intensive care unit despite medical management including nutrition support and broad spectrum antibiotics. A repeat CT scan 4 weeks later showed acute necrotizing pancreatitis with walled-off necrosis (WON). After an episode of acute decompensation, a percutaneous drain was placed prior to necrosectomy. The aspirated fluid grew Candida Parapsilosis and patient was started initially on Micafungin, and then transitioned to oral fluconazole. Soon after starting antifungals the patient stabilized, clinically improved and was able to be discharged home. He subsequently underwent a video assisted retroperitoneal dissection, which revealed a small amount of necrosis and a pancreatic duct leak into the WON. He underwent ERCP with pancreas duct stent bypassing the leak. Upon most recent visit, patient showed considerable improvement. DISCUSSION: The incidence of CP infections has been greatly increased over the last decade. Primarily, CP is implicated in cases of fungemia accounting for 3–27% of all cases of in large studies and to lesser extent in extravascular infections like osteomyelitis. Intraabdominal infections are unusual and mostly associated with peritonitis complicating surgery and peritoneal dialysis. Despite the organism normally colonizes the GI tract, pancreatic infections by CP are rare, and are usually complicating acute pancreatitis. They could be explained by portal extension and be predisposed by use of broad spectrum antibiotics, surgery, and instrumentation. In conclusion, it is important to consider fungal infections in cases of complicated infected pancreatitis especially those not responding to broad spectrum antibiotics as they share similar clinical features with bacterial causes and prompt diagnosis and treatment are key to a better outcome.

2119 Acute Post-Operative Drainage With a Lumen-Apposing Metal Stent (LAMS)

INTRODUCTION: Peripancreatic fluid collections may occur following pancreatic resection and are traditionally managed by percutaneous surgical drains. Endoscopic management of these peripancreatic fluid collections is increasingly utilized and there is growing experience in this realm. CASE DESCRIPTION/METHODS: A 54-year-old woman with a history of resectable adenocarcinoma of the pancreatic tail (T1a) who received FOLFIRINOX neoadjuvant therapy and was transitioned to Gemcitabine/Abraxane, presented for surgical management. She initially underwent laparoscopic, hand-assisted distal pancreatectomy and splenectomy. She tolerated surgery with no immediate complications. On postoperative day #4, she developed moderate abdominal pain. Computed tomography (CT) demonstrated an irregularly-shaped, hypodense fluid collection measuring 7.5 × 6.5 × 8.3 cm about the pancreatic tail, concerning for pancreatic duct leak. The decision was made to perform endoscopic drainage under endoscopic ultrasound guidance. On postoperative day 6, EUS demonstrated a 7 × 4 cm septated collection in the postoperative bed in the region of the distal pancreas (Figure A). The acute collection had not yet become walled off based on CT and EUS. The common wall between the stomach and cyst was interrogated utilizing color Doppler and an ideal puncture sight was determined. An electrocautery enhanced lumen apposing metal stent (LAMS) was advanced into the cyst and a 10 × 10 mm LAMS was placed with flanges in close approximation to the fluid collection and stomach wall through cystgastrostomy (Figure B). An additional 7 Fr by 4 cm soft double pigtail stent was then placed coaxial to the LAMS to maintain patency. At follow-up, two weeks later, her abdominal symptoms had resolved. Her interval scan demonstrated a significantly decreased pancreatic tail collection and transgastric LAMS. At postoperative day 10, cross sectional imaging demonstrated complete resolution of her fluid collection, and endoscopy was performed with uneventful LAMS removal (Figure C). DISCUSSION: This case demonstrates a patient with an acute postoperative peripancreatic fluid collection after distal pancreatectomy which was successfully treated six days postoperatively with transgastric cystgastrostomy using a LAMS. While traditional management in the acute postoperative setting has been percutaneous drain placement, further study is needed to evaluate the safety and efficacy of minimally invasive, endoscopic methods of postoperative drainage.

1276 Acute Pancreatitis Causing Multiple Aortic Thrombi and Multi-Organ Infarcts

INTRODUCTION: There have not been many case reports of acute pancreatitis causing aortic thrombi. In this vignette we illustrate this rare but noteworthy clinical scenario. CASE DESCRIPTION/METHODS: A 44-year-old homeless man with a history of chronic pancreatitis and alcoholism presented with acute, sharp, diffuse abdominal pain. Vital signs were notable for hypotension and tachycardia. Abdominal examination revealed a diffusely tender abdomen with guarding and rigidity. Neurological examination revealed bilateral upper extremity weakness. White blood cell count, lipase, ESR, CRP, and D-dimer were all markedly elevated A CT abdomen revealed acute pancreatitis with diffuse acute multiple thrombi in the aorta with hepatic, splenic, bowel, and bilateral renal infarcts. There was diffuse ascites of the abdomen and pelvis with bilateral pleural effusions. Cervical MRI revealed C4-C6 cord infarct with diffusely abnormal signal. Brain MRI revealed two acute ischemic infarcts in the right occipital lobe. CTA chest revealed multiple large exophytic thrombi in the descending aorta with no evidence of pulmonary embolism. Duplex ultrasound of all extremities and echocardiogram with contrast were non-revealingHypercoagulability studies revealed mildly decreased factor II, antithrombin III, and protein C levels. Anticoagulation was started with IV heparin and later switched to a direct oral anticoagulant. Paracentesis revealed pancreatic ascites. The patient's abdominal pain resolved and he was transferred to a higher tertiary care center where he was found to have a pancreatic duct leak requiring stenting. DISCUSSION: There are only a few reports in the literature of acute pancreatitis causing aortic thrombosis. The pathophysiology remains unclear. However, there are a few hypotheses. First, proteolytic enzymes released in the setting of acute pancreatitis cause direct injury to the aortic wall, resulting in a nidus for mural thrombus formation. Second, trypsin released during acute pancreatitis causes the activation of several thrombogenic factors such as platelets and fibrinogens. Lastly, hypovolemia caused by acute pancreatitis increases the risk of vascular stasis and vasospasm. In conclusion, this is a rare case of acute pancreatitis complicated by multiple aortic thrombi and multi-organ infarcts in the setting of a mild coagulation disorder. The patient responded well to supportive measures for acute pancreatitis and direct oral anticoagulants thereafter.

Endoscopic abdominal exploration in the acute abdomen: No longer a contraindication?

A 41-year-old man with a history of Roux-en-Y gastric bypass, decompensated nonalcoholic steatohepatitis cirrhosis, ascites, and recurrent acute pancreatitis presented to the emergency department with an acute abdomen. Six months prior, he underwent the first stage of an EUS-directed transgastric ERCP (EDGE) procedure, wherein a 15-mm lumen-apposing metal stent (LAMS) was placed between the pouch and the remnant stomach, because of a pancreatic duct leak complicated by a 10-cm peripancreatic fluid collection. Given that his pancreatic duct leak and fluid collection spontaneously resolved on follow-up imaging with normal lipase as shown by follow-up paracentesis, the LAMS was removed 2 months later.

Clip-assisted minor pancreatic duct cannulation to manage pancreatic duct leak.

Clip-assisted minor pancreatic duct cannulation to manage pancreatic duct leak.

Duodeno-Colonic Fistula Associated With an Intestinal Large B-Cell Lymphoma

Enterocolic fistulae are usually caused by conditions such as Crohn's disease and diverticulitis. Less commonly, it can also be seen in the setting of prior surgeries, foreign bodies, pancreatitis, or malignancy. Here we reported a rare case of a spontaneous duodeno-colonic fistula caused by intestinal large B-cell lymphoma. This is a 69 year old male with a history of diabetes mellitus who presented with diarrhea and weight loss of 20 pounds for 5 weeks. He described rapid onset of 5 to 6 daily episodes of non-bloody watery stools associated with nausea, but no vomiting, abdominal pain or fever. There was no recent use of antibiotics, no recent travel or sick contacts. He has no history of Crohn's disease or diverticulitis. He was afebrile and physical exam is unremarkable. Laboratory testing revealed normal complete blood count, electrolytes, serum calcium, thyroid-stimulating hormone, and hepatic panel. A computed tomographic (CT) scan of the abdomen showed mild wall thickening and stranding surrounding the proximal duodenum and the splenic flexure of colon that was measuring up to 15 mm in diameter and multiple enlarged lymph nodes within the mesentery. Additionally, there was suggestion of a duodeno-colonic fistula. An upper endoscopy and colonoscopy were performed. Upper endoscopy revealed a fistulous tract in the transverse duodenum with refluxing of stool, however no duodenal mucosal mass seen. On colonoscopy, a large infiltrative mass with fistula near the splenic flexure was identified, but the mass was not transferable to the proximal colon. Histology was consistent with diffuse large B-cell lymphoma which stained negative for CD3 strongly positive for CD20. The patient was taken to the operating room with colorectal and hepatobiliary surgery with plans for an en bloc left colectomy, partial gastrectomy and small bowel resection and partial pancreatectomy. His post-operative course was complicated by a pancreatic duct leak which is well managed with a percutaneous drain and he will soon be initiated chemotherapy. For sudden onset of diarrhea with associated systemic symptoms suspicious for an underlying organic cause, imaging and endoscopic evaluation should be considered. The initial treatment of enterocolic fistulae is to correct fluid and electrolyte abnormalities, but in our case, oncologic treatment of B cell lymphoma could not be initiated until after surgical resolution of nutrient wasting diarrhea.1610_A Figure 1. CT showed colonic wall thickening with possible duodeno-colonic fistula1610_B Figure 2. Colonoscopy showed a large infiltrative mass with fistula near the splenic flexure.1610_C Figure 3. Pathology showed colonic mass with fistula is identified extending from the colonic mucosa to the duodenal mucosa.