Peripancreatic Abscess Research Articles

EUS-guided methylene blue cholangiopancreatography for benign biliopancreatic diseases after failed ERCP

When ERCP fails, EUS-guided interventional techniques may be an alternative. The aim of this study was to evaluate the general outcomes and safety of EUS-guided methylene blue cholangiopancreatography in patients with failed ERCP in benign biliopancreatic diseases. Patients with benign biliopancreatic diseases and failed ERCP were included. EUS-guided cholangiopancreatography plus injection of methylene blue was performed, and then ERCP using coloring agent flow as an indicator of papilla orifice was performed. Procedures were prospectively collected in this observational, single-center study. Technical success, clinical success, and adverse events were analyzed retrospectively. Eleven patients were included (10 choledocholithiasis, 1 pancreatic stricture). The main reason for failed ERCP was an unidentifiable papilla. EUS-guided ductal access with cholangiopancreatography and papilla orifice identification was obtained in all cases. Technical success and clinical success rates of 91% were achieved, with successful biliopancreatic drainage in 10 patients. Adverse events included 1 peripancreatic abscess attributed to a precut, which was successfully treated. No adverse events were related to the first EUS-guided stage. EUS-guided cholangiopancreatography with methylene blue injection seems to be a feasible and helpful technique for treatment in patients with benign biliopancreatic diseases with previous failed ERCP because of an undetectable papilla.

Value of magnetic resonance imaging in evaluating the pancreatic allograft transplant complications.

To retrospectively investigate the value of magnetic resonance imaging (MRI) in detecting complications following pancreas transplant. Institutional review board approved this retrospective HIPAA-compliant study and waived informed patient consent. We identified all allograft pancreas transplant patients at our institution from 2001 to January 2014 who had all pertinent post-transplant imaging and clinical data available. Transplant type was documented. Patients were divided into two groups according to post-transplant period (group A; <12months, group B; ≥12months). We evaluated the parenchymal enhancement using contrast-enhanced MRI of the allograft and determined the mean percentage of parenchymal enhancement (MPPE) overall and in various abnormalities, the vessel patency, any peripancreatic fluid collection, and the ductal anatomy. We correlated these with clinical results using t test, χ (2), and Fisher's exact test; p<0.05 was considered significant. 51 patients (34 male, mean age 43.7years) were identified, 28 (55%) of whom had abnormal imaging findings; transplant rejection-related necrosis (n=7), fluid collections (n=7), vascular stenosis (n=4), isolated venous thromboses (n=3), acute pancreatitis (n=3), pancreatic and peripancreatic abscesses (n=2), pseudoaneurysm (n=1), and small-bowel obstruction (n=1). Pre vs. post-contrast pancreatic MPPE at 1min was 120% in the normal allografts and 115% in the allografts with pancreatitis and without necrosis (p>0.05). MPPE at 1min was only 9% in the allografts rejections with necrosis/infarction. More complications were found in group A than group B (p<0.05). Contrast-enhanced MRI is useful for the non-invasive assessment of pancreas transplant complications.

Diagnosis and Management of High-Grade Pancreatic Trauma: Report of 14 Cases.

The aim of this study was to review the diagnosis and operative management of cases of high-grade pancreatic trauma. A retrospective analysis was performed on 14 patients treated for high-grade pancreatic trauma at our institution between December 2008 and November 2013. The patients were treated for injuries resulting from blunt abdominal trauma. The main clinical data of the patients was analyzed, including time to diagnosis, initial serum amylase level, ultrasonography and abdominal computed tomography (CT) findings, pancreatic injury severity as scored according to the American Association for the Surgery of Trauma Organ Injury Scale, injury to other organs, operative treatment method, postoperative complications, and patient outcome. All 14 patients were diagnosed with severe (≥ grade III) pancreatic trauma. Diagnosis was confirmed in all seven hemodynamically stable patients that underwent CT and in 9/13 patients receiving ultrasound examination. All patients underwent surgical operations, including emergency pancreaticoduodenectomy (n = 8), splenectomy with distal pancreatectomy (n = 3), spleen-preserving distal pancreatectomy (n = 1), medial pancreatectomy with Roux-en-Y pancreaticojejunostomy (n = 1), and peripancreatic debridement and drainage (n = 1). Diagnosis was delayed beyond 24h in two patients, both of whom underwent reoperative peripancreatic debridement and drainage, with one death. The complications included pancreatic fistula (n = 8), peripancreatic abscess (n = 2), hepatic artery hemorrhage (n = 1), gastrointestinal bleeding (n = 1), and intra-abdominal abscess (n = 1). CT is the most reliable method for diagnosing high-grade pancreatic trauma. Aggressive surgical therapy including pancreaticoduodenectomy is acceptable in hemodynamically stable patients.

A Case of a Peripancreatic Abscess Associated with Untreated Diabetes Mellitus

A Case of a Peripancreatic Abscess Associated with Untreated Diabetes Mellitus

Retroperitoneoscopic Anatomical Necrosectomy: A Modified Single-Stage Video-Assisted Retroperitoneal Approach for Treatment of Infected Necrotizing Pancreatitis.

Video-assisted retroperitoneal necrosectomy is a minimally invasive surgical technique for the treatment of severe acute pancreatitis. This study evaluated the safety and feasibility of a modified single-stage video-assisted retroperitoneal necrosectomy, retroperitoneoscopic anatomical necrosectomy (REAN). Between September 2010 and May 2012, a total of 17 patients with infected necrotizing pancreatitis underwent REAN. The surgical procedures were similar to retroperitoneoscopic pancreatectomy, in which 3 trocars are utilized. Briefly, the perirenal space was entered through the posterior pararenal space. Dissection proceeded from posterior to anterior direction to expose the dorsal side of the perirenal fascia. This was opened to reach the anterior perirenal space, where the peripancreatic abscess was located. Necrotic tissue was then debrided and catheter drainage was performed in a single stage. Operating time ranged from 45 to 100 minutes with minimal blood loss. All patients recovered except for one who died. Major perisurgical complications included peritoneal injury (1 patient), splenic vein injury (1 patient), retroperitoneal infection with paralytic ileus (1 patient), hydrothorax and atelectasis (2 patients), and subcutaneous cellulitis beneath the incision (3 patients). Two patients required additional percutaneous catheter drainage, and 1 patient required a laparotomy to debride the remaining necrotic tissue. Postoperative hospital stay ranged from 21 to 64 days. This study demonstrates that REAN, a modified single-stage video-assisted retroperitoneal approach, was safe and feasible for the treatment of infected necrotizing pancreatitis. The advantages of this procedure include direct access with shorter operating time, complete necrotic tissue debridement, easy hemostasis, simple manipulation, and easy drainage.

Meckel’s Diverticulum Masquerading as an Arterio-Enteric Fistula in an Adult Patient With Simultaneous Pancreas-Kidney Transplantation

Introduction: Simultaneous pancreas-kidney (SPK) transplantation is a treatment for patients with type1 diabetes (DM) and end-stage renal disease (ESRD). Complications of SPK transplantation include peripancreatic abscess, enterocutaneous fistula, and rarely, gastrointestinal bleeding (GIB). We report a case of an adult patient with SPK transplantation who presented with massive GIB caused by Meckel’s diverticulum. Case Report: A 40-year-old male presented 3 years after SPK transplantation to an outside hospital with maroon-colored stool and dizziness. His co-morbidities included DM, ESRD, coronary artery disease, hepatitis C, nonalcoholic steatohepatitis, and cirrhosis. He was hypotensive (94/43), but otherwise, vitals were within reference range. His exam was significant for a soft abdomen with normoactive bowel sounds and mild confusion without any focal deficits or asterixis. Labs were notable for a hemoglobin of 5.9 g/dL, creatinine 1.73 mg/dL (baseline 1.1 mg/dL), BUN 64 mg/dL, and liver function tests within reference range. An esophagogastroduodenoscopy (EGD) revealed presumed Dieulafoy’s lesion, which was cauterized and clipped. Colonoscopy showed mild inflammation, but no obvious source of bleeding. Biopsies were negative for infection or inflammatory bowel disease. The patient was transferred to our center for management of persistent GIB (requiring 26 units of blood total) and worsening renal function. At our center, EGD, colonoscopy, push enteroscopy, tagged RBC scan, and provocative angiography were negative for the source of bleeding. Video capsule endoscopy showed a large amount of red blood in the small bowel without adequate identification of the source lesion. Exploratory laparotomy with intraoperative small bowel endoscopy was performed, which demonstrated a healthy appearing anastomosis with a more distal Meckel’s diverticulum full of clotted blood. The diverticulum was excised without recurrent bleeding. Discussion: The differential for lower GIB is vast, but in adult patients, Meckel’s diverticulum is a rare cause. Patients status-post SPK transplantation have additional considerations for GIB, including anastomotic site ulcer, pseudoaneurysm, arterioenteric fistula, severe graft rejection, and cytomegalovirus infection. This is a rare case of GIB secondary to Meckel’s diverticulum in patients with SPK transplantation. Clinicians should be aware of Meckel’s diverticulum as a cause of massive GIB in SPK transplant patients. A high index of suspicion and timely evaluation can improve morbidity and mortality.

Pancreas and Islet Transplantation

Pancreas and Islet Transplantation

A Case of Duodenal Diverticulum Mimicking a Peripancreatic Abscess

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Laparoscopic Transgastric Drainage of a Pancreatic Abscess with Necrosectomy Through Creation of a Cystgastrostomy in a Morbidly Obese Patient

Infected necrotizing pancreatitis is a challenging and life-threatening clinical scenario, with difficult options for management, specifically in the morbidly obese. We demonstrate a case of a morbidly obese male, with a large peripancreatic abscess secondary to infected necrotizing pancreatitis, where through a minimally invasive approach, a cystgastrostomy was created through which the pancreatic abscess was drained. This lead to complete resolution of the abscess and the patient was discharged from hospital on postoperative day 6. There was no recurrent collection at 6 months follow-up. A minimally invasive approach is feasible in the morbidly obese patient with infected necrotizing pancreatitis requiring surgical intervention. No competing financial interests exist. Runtime of video: 7 mins

Relaparotomies in Pancreatic Transplant

Introduction: Due to the difficulty of pancreatic transplantation technique, relaparotomies remain being the main cause of graft loss over the years. These reoperations increased patient morbidity. The aim of our study is to analyze the pancreatic transplant recipient relaparotomies in our center as well as the subsequent morbidity and mortality in these patients. Patients and methods: 142 patients underwent pancreatic transplant from March 1995 to December 2010, all of them with more than one year of follow up.132 of these patients were simultaneous pancreas-kidney transplants, 2 pancreas after kidney and 8 retransplants. The mean age of our recipients was 38.20 years (± 7.7 years). The average follow up was 35.96 months (± 24.43). Results: 46 of the 142 recipients needed to be reoperated (33.1%). The most important causes of these relaparotomies were due to: thrombosis (13.4%), hemorrhage (12%), drainage conversion from bladder to bowel (10.4%), peripancreatic abscess (9.9%) and bladder leak (8.3%). 24 of these patients (17.3%) required pancreatectomy. The overall patient and graft survival with any relaparotomy at 1, 3 and 5 years was 91.4, 91.4%, 91.4% and 47.8%, 45.7%, 45.7%, respectively. Conclusions: The reoperations rate in our serie is similar to those refered in the literature, which depend on the serie, is nearly 30%. Graft loss rate is really higher in relaparotomies recipients when we compare them with non relaparotomies recipients, concluding that reoperations increased significantly patient morbidity.

Ischemic Injury Following EUS Guided Celiac Plexus Neurolysis

Case Presentation: A 51 yo M with metastatic pancreatic adenocarcinoma with vascular invasion presents with abdominal pain. The patient had an ERCP with CBD stent exchange and EUS with celiac plexus neurolysis (CPN). During the EUS CPN, a total of 10 cc of .25% bupivicaine and 10 cc of dehydrated Etoh were injected. One day following the procedure he had melena and subsequent coffee ground emesis with a 4 gram drop in hemoglobin from admission. An EGD showed extensive ulceration and inflammation along the lesser curvature, which was suggestive of ischemic injury. Discussion: Treatment of pain in pancreatic cancer is an important objective in palliative care. Approximately 80-85% of patients have pain associated with advanced pancreatic cancer. Options for pain control include pharmacotherapy as well as CPN, which can be performed percutaneously, surgically or under the guidance of EUS. EUS CPN has been shown to be effective in achieving pain control. In one meta-analysis of 119 patients, pain was alleviated in 73% of patients. CPN is overall felt to be safe but practitioners should be aware of the possible complications. Side effects include local pain, unopposed parasympathetic activity, which can result in diarrhea (44%) and hypotension (38%). Serious complications include retroperitoneal hemorrhage and peripancreatic abscess. In a series of 189 EUS guided celiac plexus blocks and 31 CPNs, the following 4 complications were reported: hypotension, retroperitoneal abscess, and 2 with post-procedural pain. One case report notes ischemic complications following CPN, including gastric ischemia/necrosis, splenic infarction, and pancreatic necrosis in the distribution of the celiac artery. Similarly, our patient likely developed ischemic injury following CPN. Ethanol can cause vasospasm and severe cases of vasoconstriction can lead to vascular and smooth muscle cell death. Conclusion: CPN is an effective modality for treatment of pain in advanced pancreatic cancer. However, physicians should also be aware of the complications. Patients who develop signs of GI bleeding after CPN should be evaluated for ischemic injury.Figure: No Caption available.

EUS-guided Rendezvous for Pancreatic Endotherapy after Pancreaticoduodenectomy Presidential Poster

Purpose: Define the performance characteristics of EUS-guided rendezvous following classic pancreaticoduodenectomy (PD) or pylorus preserving PD (PPPD). Methods: Single center case series of EUS-guided rendezvous procedures after PD or PPPD between 2005 and 2012. Technique involved transgastric puncture of the pancreatic duct by EUS, wire passage into the jejunum and intraluminal retrieval of the wire (i.e. rendezvous) by another endoscope for attempted endotherapy via the pancreatojejunal (PJ) anastomosis. We abstracted medical records for indications, technical success, complications, and clinical outcomes. Technical success assessed included EUS guided pancreatogram, wire passage into the SB, rendezvous, and pancreatic endotherapy. Results: Twenty-six patients (14F/12M; median 55.5 yrs, range 24-71) underwent 30 EUS procedures at a median of 933 days (range 128-180) following PD (9) or PPPD (17). Procedural indications were: suspected anastomotic stricture (13), stricture with filling defects (3), stricture and stones (6), impacted main pancreatic duct (MPD) stents (2), and acute recurrent pancreatitis (6). Prior to EUS, ERCP had failed once in 16 and twice in 2 and had not been previously attempted in 12. EUS-guided pancreatogram was successful in 30 (100%), with successful wire passage across the PJ anastomosis in 16 (54%; Figure 1). The wire was grasped in nine (9/30, 30%) and successful rendezvous retrograde access to the MPD and pancreatic endotherapy was completed in all nine. Complications occurred in two (7%): needle fracture (1), and peripancreatic abscess (1). Univariate analysis showed no differences between cases with and without successful wire passage into the jejunum (Table 1). Short-term clinical success (pain relief up to 6 months after procedure) was achieved in 9/9 in whom pancreatic endotherapy was successful. For the unsuccessful EUS-guided rendezvous cases (n=21), 2 improved after endoscopic pancreatogastrostomies, 15 were referred for surgery, 2 had celiac plexus block, and 2 were lost to follow-up.Figure: No Caption available.Table 1: No Caption available.Conclusion: EUS-guided rendezvous following PD or PPPD can facilitate pancreatic endotherapy in select cases. Larger cohorts are needed to identify factors that predict technical success.

Transoralgastric Gastroscopic Debridement for Peripancreatic Abscess: A Special Case Report

Transoralgastric debridement for pancreatic abscess is one of the successful applications of NOTES in clinical practice. We present a case report as follows: a 71-year-old female was hospitalized due to acute biliary pancreatitis. Three weeks after onset, the secondary abdominal CT showed a peripancreatic abscess. A passageway between the gastric wall and the abscess was made with a high-frequency puncher under the guidance of an ultrasonic gastroscope and then a gastroscope was directly inserted into the abscess, and a large amount of solid necrotic tissue was taken out with foreign body forceps and snare under the direct vision of a gastroscope. Then a 8.5F double-J stent and a nasobiliary drainage tube were inserted. After three times of intra-abdominal abscess debridement and repeated rinsing with an antibiotic solution, abdominal CT revealed the intra-abdominal abscess nearly disappeared and the patient discharged from hospital.

Spontaneous Fistulization of a Pancreatic Abscess to Colon and Duodenum Treated With Percutaneous Drainage

Pancreatic fistulas are rare clinical entities associated with severe pancreatitis. A 39-year-old man who had been diagnosed and treated for severe pancreatitis 2 months ago presented with abdominal pain, fever, and vomiting. The abdominal computed tomography (CT) demonstrated a peripancreatic abscess and a duodenal fistula communicating the first part of duodenum, which was also verified with fluoroscopy. A size 14-French catheter with pig-tail tip was inserted primarily with a Seldinger 2-step technique through percutaneous route under CT-guidance to avoid intervening bowels or solid organs. The patient's clinic improved and treatment was stopped on the 18th day. On the 26th day of the first intervention, the patient had fever and abdominal pain and his clinic was deteriorated. A second fluoroscopic examination revealed that the duodeno pancreatic fistula was closed while a new 1 has developed into the ascending colon. With aggressive nutrition support, antibiotics and repeated drainage of the abscess pouch a dramatic clinical improvement was observed. Control abdominal CT demonstrated the resolution of pancreatic abscess on the 62nd day.

Ultrasound-guided percutaneous drainage for peripancreatic abscess

Objective To investigate the feasibility of ultrasound-guided percutaneous drainage for the treatment of peripancreatic abscess. Methods The clinical data of 36 patients with peripancreatic abscess who were admitted to the General Hospital of the Chengdu Military Command were retrospectively analyzed. All the puncture sites were designed according to the region, range and shape of the abscess, and then the angle and the direction of the needle penetration were determined according to the spatial relationship between the puncture site and the abscess. Finally, the drainage tubes were placed under the guidance of the ultrasound. Results The technique was successfully performed on all the patients, and 33 patients were cured with the cure rate of 92%.The mean healing time was 37 days. Three patients were converted to laparotomy because of the unsatisfied therapeutic effects. Enterocutaneous fistula was detected in 3 patients after the surgery and they were cured after receiving nonoperative management. All patients were followed up for 3-48 months, and neither residual abscess nor recurrence was detected. Two patients were complicated with type one diabetes, one with dyspepsia, two with gallstone, and they were cured by symptomatic treatment. The body weights of 27 patients were increased compared to those before the operation. Conclusion Ultrasound-guided percutaneous drainage is effective for the treatment of peripancreatic abscess. Key words: Peripancreatic abscess; Ultrasound guidance; Therapy,minimally invasive; Drainage

Sp288: Endoscopic Management of Iatrogenic Peripancreatic Abscess

A 27yo female presented with LUQ abdominal pain. An abdominal CT revealed a pancreatic tail cyst. A distal pancreatectomy with splenectomy was performed revealing a benign MCA. Her post-operative course was complicated by development of a subphrenic abscess. Attempts at percutaneous drainage were ultimately unsuccessful, and we were consulted for endoscopic management.

Therapeutic EUS-assisted endoscopic retrograde pancreatography after failed pancreatic duct cannulation at ERCP

Cannulation of the pancreatic duct (PD) during endoscopic retrograde pancreatography (ERP) can fail even in experienced hands. A technique for therapeutic EUS-assisted rendezvous ERP has been described in a few case reports. To investigate the efficacy and safety of therapeutic EUS-assisted ERP. Retrospective study. Tertiary-care medical center. This study involved 21 patients after failed ERP. EUS-guided transgastric pancreatography by using a mixture of contrast media and methylene blue was attempted. If that was successful, ERP was attempted by using methylene blue flow as an indicator of the PD orifice or by a rendezvous technique using a wire passed into the PD and the small bowel through the EUS needle. Technical success rate and complications. The PD was of a normal diameter in 7 patients and was dilated in 14 patients. EUS-guided pancreatography was successfully done in all patients with a dilated PD but only in 4 of 7 patients (57%) with normal-diameter PDs. In 6 patients, ERP was successfully performed by using methylene blue flow as an indicator of the PD orifice. The rendezvous technique was successful in 4 of 12 cases (33%), and reasons for failure were either a tight stricture (n = 5) or a suboptimal angle of EUS needle insertion (n = 3). Overall, EUS-assisted ERP was successful in 10 of 21 patients (48%). Complications included peripancreatic abscess in 1 patient and mild pancreatitis in 1 patient. Retrospective study, small sample size. EUS-assisted ERP is a complex procedure that can provide access to the PD in selected cases after failed standard ERP.

Magnetic resonance imaging for acute pancreatitis

Acute pancreatitis is characterized by acute chemical injury of the pancreatic parenchyma and peripancreatic tissue. The increased frequency of death in acute pancreatitis is directly correlated with the degree and progress of pancreatic necrosis. Moreover, the occurrence of some local complications in acute pancreatitis, such as pancreatic hemorrhage, peripancreatic abscess or large pseudocyst, and pseudoaneurysm, could influence the choice of treatment for these patients. Magnetic resonance imaging (MRI) can be used to help evaluate the presence and degree of pancreatic necrosis, and is crucial for identifying complications of acute pancreatitis and predicting prognosis. The purpose of this article is to describe MRI techniques for acute pancreatitis, to review the spectrum of pancreatic and peripancreatic patterns, as well as to survey various complications secondary to acute pancreatitis on MRI. The role of MRI in the initial evaluation and staging of acute pancreatitis is emphasized.

Early infection of peripancreatic tissue in mild acute pancreatitis: Report of a case

Mild acute pancreatitis (AP) is rarely complicated by infection, and the value of prophylactic antibiotics is questionable. We report a case of mild AP complicated by infection, which developed within 1 week after the onset. A 66-year-old woman was referred to our hospital where a diagnosis of mild AP was made, based on laboratory data and computed tomography (CT) findings. She was managed conservatively with fluid resuscitation, intravenous antibiotics, and protease inhibitor. Her general condition improved initially, but a high fever redeveloped on hospital day 3. On hospital day 7, a repeat CT scan showed a peripancreatic fluid collection with gas, indicating peripancreatic abscess. A drainage operation was performed, and the organism cultured from the abscess was Escherichia coli. Her postoperative course was uneventful. We report this case to stress that infection may develop even in mild AP, and even in the early phase.

Extension of Nonoperative Management of Blunt Pancreatic Trauma to Include Grade III Injuries: A Safety Analysis

In hemodynamically stable patients after blunt pancreatic trauma, the main pancreatic duct (MPD) disruption (American Association for the Surgery of Trauma [AAST] grade III-IV-V lesions) is usually treated surgically or by endoscopic stent placement, whereas injuries without duct involvement (grade I-II) are liable to medical treatment. To date, no evidence has been reported regarding nonoperative management (NoM) of grade III injuries. We aimed to evaluate the safety of extending medical management to include cases of distal MPD involvement (grade III). Data were collected on patients admitted after blunt pancreatic trauma between January 1999 and December 2007. Patients exhibiting hemodynamic instability or hollow organ perforations were excluded from this study, as they were surgically managed. In all remaining cases NoM was attempted. Antibiotic prophylaxis and early total enteral nutrition were routinely adopted. Grade III patients received octreotide during hospitalization and for 6 months after discharge. Eleven patients (2 with grade I injury, 3 with grade II injury, and 6 with grade III injury, all diagnosed by contrast-enhanced helical CT) were included. Nonsurgical management was carried out in all of these patients. Among grade III patients, one developed a peripancreatic abscess; another, a pancreatic fistula. Both were successfully treated nonoperatively. The average length of hospital stay was similar in grade I-II and grade III patients. After a median follow-up of 57 months no mortality or pancreatic sequelae had occurred. Under the aforementioned conditions, an attempt to extend NoM to include patients with AAST-grade III lesions can be justified. However, such a strategy demands continuous patient monitoring, because should the case worsen, surgery might become necessary.