Peripancreatic Necrosis Research Articles

A deep learning-powered diagnostic model for acute pancreatitis

BackgroundAcute pancreatitis is one of the most common diseases requiring emergency surgery. Rapid and accurate recognition of acute pancreatitis can help improve clinical outcomes. This study aimed to develop a deep learning-powered diagnostic model for acute pancreatitis.Materials and methodsIn this investigation, we enrolled a cohort of 190 patients with acute pancreatitis who were admitted to Sichuan Provincial People’s Hospital between January 2020 and December 2021. Abdominal computed tomography (CT) scans were obtained from both patients with acute pancreatitis and healthy individuals. Our model was constructed using two modules: (1) the acute pancreatitis classifier module; (2) the pancreatitis lesion segmentation module. Each model’s performance was assessed based on precision, recall rate, F1-score, Area Under the Curve (AUC), loss rate, frequency-weighted accuracy (fwavacc), and Mean Intersection over Union (MIOU).ResultsUpon admission, significant variations were observed between patients with mild and severe acute pancreatitis in inflammatory indexes, liver, and kidney function indicators, as well as coagulation parameters. The acute pancreatitis classifier module exhibited commendable diagnostic efficacy, showing an impressive AUC of 0.993 (95%CI: 0.978–0.999) in the test set (comprising healthy examination patients vs. those with acute pancreatitis, P < 0.001) and an AUC of 0.850 (95%CI: 0.790–0.898) in the external validation set (healthy examination patients vs. patients with acute pancreatitis, P < 0.001). Furthermore, the acute pancreatitis lesion segmentation module demonstrated exceptional performance in the validation set. For pancreas segmentation, peripancreatic inflammatory exudation, peripancreatic effusion, and peripancreatic abscess necrosis, the MIOU values were 86.02 (84.52, 87.20), 61.81 (56.25, 64.83), 57.73 (49.90, 68.23), and 66.36 (55.08, 72.12), respectively. These findings underscore the robustness and reliability of the developed models in accurately characterizing and assessing acute pancreatitis.ConclusionThe diagnostic model for acute pancreatitis, driven by deep learning, exhibits excellent efficacy in accurately evaluating the severity of the condition.Trial RegistrationThis is a retrospective study.

Acidic solution irrigation as a novel approach for treating infected walled-off pancreatic necrosis

Walled-off pancreatic necrosis (WOPN) is a severe complication of acute pancreatitis arising from pancreatic or peripancreatic necrosis complicated by infection, leading to elevated mortality rates. Extravasation of pancreatic juice creates a weakly alkaline microenvironment favorable for the survivial of translocated intestinal bacteria and activated pancreatic enzyme-mediated autodigestion of pancreatic and peripancreatic tissues. Conventional treatments for WOPN involve invasive procedures with irrigation to mitigate postoperative infections. However, there remains a lack of a unified standard for lavage fluid. Herein, we raise the hypothesis that the utilization of acidic solution irrigation may serve as a promising strategy for preventing and treating infected WOPN. Acidic solutions create an unfavorable environment for translocated intestinal bacteria in WOPN cases. Additionally, the acidic microenvironment may alleviate self-digestion of pancreatic and peripancreatic tissues by inhibiting pancreatic enzyme activity. This innovative approach holds potential for enhancing the management and outcomes of infected WOPN.

Combined CT and serum CA19-9 for stratifying risk for progression in patients with locally advanced pancreatic cancer receiving intraoperative radiotherapy.

The aim of this study was to evaluate the significance of baseline computed tomography (CT) imaging features and carbohydrate antigen 19-9 (CA19-9) in predicting prognosis of locally advanced pancreatic cancer (LAPC) receiving intraoperative radiotherapy (IORT) and to establish a progression risk nomogram that helps to identify the potential beneficiary of IORT. A total of 88 LAPC patients with IORT as their initial treatment were enrolled retrospectively. Clinical data and CT imaging features were analyzed. Cox regression analyses were performed to identify the independent risk factors for progression-free survival (PFS) and to establish a nomogram. A risk-score was calculated by the coefficients of the regression model to stratify the risk of progression. Multivariate analyses revealed that relative enhanced value in portal-venous phase (REV-PVP), peripancreatic fat infiltration, necrosis, and CA19-9 were significantly associated with PFS (all p < 0.05). The nomogram was constructed according to the above variables and showed a good performance in predicting the risk of progression with a concordance index (C-index) of 0.779. Our nomogram stratified patients with LAPC into low- and high-risk groups with distinct differences in progression after IORT (p < 0.001). The integrated nomogram would help clinicians to identify appropriate patients who might benefit from IORT before treatment and to adapt an individualized treatment strategy.

Presentation of Acute Pancreatitis in Sickle Cell Disease Patients: A Single Hospital Experience.

Sickle cell disease (SCD) is a haemoglobinopathy that leads to the formation of distorted sickle-shaped red blood cells that are prone to vaso-occlusion. This may lead to vaso-occlusive crises that may affect any organ. Acute pancreatitis (AP) in SCD patients may be mimicked by a vaso-occlusive crisis in the abdomen. The objective of this article is to analyse the clinical profiles of SCD patients with AP and understand the differences in the presentation of AP compared to an abdominal vaso-occlusive crisis and the difference between its presentation in SCD patients in comparison to other patients. Twenty-eight SCD patients who were diagnosed with AP during their admission to the paediatric department at a tertiary hospital between January 2012 and December 2020 were retrospectively studied. Patients aged older than 14 years were excluded. The data collected concerned: demographics, the clinical course and the hospital course. The diagnosis and severity protocols followed the revised Atlanta Criteria. The patients were aged with a mean of 9.61 years. There were 15 males and 13 females. Demographics were not significantly correlated to complication rates (P > 0.05). The mean duration of hospitalisation was 6.43 days. The most common clinical presentations were abdominal pain, fever, then vomiting and nausea. Three patients experienced complications and they were all cases of cholangitis (10.71%). There were no cases of pseudocysts, acute necrotic collections, pancreatic or peripancreatic necrosis or walled-off necroses. All of the cases of AP in SCD children were mild according to the revised Atlanta classification. Leucocytosis was present in 29.29% of patients and 17.8% of patients had high C-reactive proteins (CRPs). There was no significant correlation between leucocyte counts, CRP levels, serum or urinary amylase levels and complications (P > 0.05). All patients had haemoglobin (Hb) levels above 7 g/dL. The levels of sickle Hb ranged from 40 to 70 g/dL and reticulocyte counts averaged at 3.57%. Haematologic parameters were not significantly correlated with complication rates (P > 0.05). There were no recurrences. AP in SCD patients presented with classic signs and symptoms. There were no associations between demographics and complications. The levels of leucocytes, CRP counts and serum and urinary amylase were not correlated with complications. The level of Hb and sickle cell Hb was not associated with complication rates. Reticulocytes were slightly elevated in SCD patients with AP. More studies are needed to demarcate factors distinguishing AP in SCD from abdominal vaso-occlusive crises.

Внутрішньочеревна гіпертензія як ускладнення гострого панкреатиту

The aim of our work was to review modern aspects of pathogenesis, diagnosis and treatment of intra-abdominal hypertension as a complication of the severe course of acute pancreatitis. Acute pancreatitis is a systemic disease, the severe course of which is associated with organ dysfunction and increased intra-abdominal pressure. The frequency of intra-abdominal hypertension in patients with severe acute pancreatitis is 60%, while 10-30% of patients in this category hospitalized in the intensive care unit have abdominal compartment syndrome. An increase in intraabdominal pressure has a negative effect on the course of acute pancreatitis. Namely, multiple organ failure occurs more often; pancreatic and peripancreatic necrosis, prolonged systemic inflammatory response syndrome, complications during the use of enteral nutrition, the need for invasive interventions, the length of hospitalization and the percentage of deaths increase. Determination of intra-abdominal pressure through the urinary bladder in patients with severe acute pancreatitis should be considered as a standard for diagnosing intraabdominal hypertension. It has been proven that the use of paracentesis with drainage of the abdominal cavity in the staged treatment of patients with a complicated course of acute pancreatitis (peripancreatic accumulation of fluid in the early period of the disease) reliably reduces intra-abdominal pressure after 72 h since the detection of fluid (17.4 ± 2.6 and 11.4 ± 1.6 mm Hg), serum amylase (774.3 ± 233.9 and 472.7 ± 168.6 Units/l), procalcitonin (1.3 ± 0.7 and 0.6 ± 0.5 ng/ml) and interleukin-6 (531.3 ± 120.9 and 417.1 ± 82.4 pg/ml). Achievements in intensive care, optimization of indications for surgical interventions, early enteral nutrition, rational use of liquid resuscitation and the growing role of minimally invasive interventions have had a positive effect on the prognosis of acute pancreatitis, overall morbidity and led to a decrease in deaths in this category of patients. However, the prevention and treatment of persistent intra-abdominal hypertension and abdominal compartment syndrome require further study and improvement.

Gastroinstestinal Fistula in Acute Necrotising Pancreatitis with Septicaemia: A Case Report

Acute Pancreatitis (AP) is an inflammatory condition with cumbersome side effects. Gastropancreatic (GI) fistula is a rare complication seen in cases with infected pancreatic or peripancreatic necrosis. GI fistulas can result in severe haemorrhage and septicemia. Hereby, the authors present a case of 36-year-old male with a chief complaint of abdominal pain associated with abdominal distension and non bilious vomiting after binge consumption of alcohol for the past 10 days. Computed Tomography (CT) scan showed the presence of free gas in the abdomen. Contrast-Enhanced CT (CECT) imaging revealed diffuse enlargement affecting the head, uncinate process, body, and tail of the pancreas. There were also a few necrotic peripancreatic fluid collections with extensive peripancreatic fat stranding. Based on these findings, the diagnosis of acute necrotising pancreatitis was suggested. Despite treatment with antibiotics and necrosectomy with drainage of the abscess collection, the patient showed no improvement. A repeat CECT examination was performed due to the deterioration of the patient’s clinical condition, which showed a complete non enhancing pancreas. Additionally, a large defect measuring approximately 16 mm was observed in the posteroinferior wall of the stomach at the middle third of the body, with extravasation of contrast material into the pancreatic collection, suggestive of fistula formation. Subsequently, the patient underwent pancreatic necrosectomy with closure of the gastric perforation using feeding jejunostomy. A follow-up CT examination was performed four days later due to the deteriorating status of the patient, as well as new onset haematemesis and bloody discharge from the surgical drain. The CT scan revealed a few peripancreatic soft tissue infiltrates adjacent to the pancreatic head. Persistent collections were noted along the anterolateral surface of the right psoas, extending to the adjoining right anterior pararenal space and the left anterolateral abdominal wall in the left hypochondriac region. Thickening of the bilateral lateroconal fascia and anterior and posterior renal fascia was observed, likely due to inflammation. Following this, the patient underwent another surgery, and percutaneous drainage was performed with antibiotic coverage. The patient showed a significant reduction in the collection and improved clinical condition after 10 days. Imaging plays a crucial role in diagnosing such complications, enabling early detection and reducing mortality in these patients.

Nomenclature of Pancreatic Fluid Collections following Acute Pancreatitis: Need to Further Revise the Atlanta Classification System!

AbstractA better understanding of the disease pathophysiology, improved imaging modalities, and the development of minimally invasive interventions led to the revision of the Atlanta classification and new terminologies for the pancreatic fluid collections (PFCs) occurring in acute pancreatitis. Peripancreatic necrosis (PPN) or extra-pancreatic necrosis (EPN) has been reported as a distinct morphological entity with a better outcome than combined pancreatic and peripancreatic necrosis as well as pancreatic parenchymal necrosis alone and slightly worse than acute interstitial pancreatitis. In this news and views, we discuss a study that compared the morphological features and outcomes of endoscopic drainage of walled off necrotic collections developing after EPN alone with those developing after PN with or without EPN.

S14 Incidence and Risk Factors for Deep Vein Thrombosis and Pulmonary Embolism in Necrotizing Pancreatitis: An Underappreciated Sequalae

Introduction: Inflammatory dysregulation of the coagulation cascade and vascular stasis in hospitalized necrotizing pancreatitis (NP) patients serve as a milieu for venous thromboembolism which is often underrecognized. We aimed to identify the incidence and independent risk factors for deep vein thrombosis (DVT) and pulmonary embolism (PE) in our NP cohort. Methods: All adult NP patients hospitalized at our center between 2009 and 2022 were identified from a prospective database and categorized into two groups based on development of DVT or PE (cases) or not (controls), within 6 months after NP hospitalization. Baseline data included demographics, ASA score, SIRS and organ failure on admission and at 48 hours, interventions (endoscopic, percutaneous or surgical), length of stay, transfer status, need for ICU, clinical and imaging characteristics and anticoagulation during admission. Univariable and multivariable analysis identified independent predictors for DVT and PE. P < 0.05 was considered significant. Results: Among 641 NP patients, 510 patients [males 349 (68%), median age 52 years (IQR 38–64)] were eligible for inclusion. DVT/PE developed in 62 (12%) patients; 26 DVT (5%), 22 PE (4%) and 14 with both (3%) after a median 17 (IQR 7–34) days from NP. Demographics were similar between groups though cases were older with more comorbidities (higher ASA) including a personal history of cancer. Nearly all patients [n = 506, (99%)] including all cases were on DVT prophylaxis (pharmacologic or mechanical) during hospitalization. Significant clinical and imaging predictors for DVT/PE on multivariable analysis were age (>50 years) [OR 2.1 (1.05–4.13)], personal history of cancer [OR 5.02 (1.30–19.35)], peripancreatic extent [OR 7.15 (3.7–13.81)], infected necrosis [OR 2.00 (1.01–3.96)] and increased length of stay (LOS) [OR 1.01 (1.00–1.02)]. Conclusion: Incidence of DVT/PE in our NP cohort was 12% (comparable to incidence rates in cancer and IBD), usually diagnosed within one month of NP hospitalization. Age >50, peripancreatic necrosis extent, personal history of cancer, infected necrosis, and prolonged hospitalization were independent risk factors. This high-risk group of patients may benefit from intensified DVT prophylaxis during hospitalization and closer follow up after discharge (Table 1). Table 1. - Univariable and Multivariable Analysis of Clinical and Imaging Predictors for DVT and PE in NP Characteristic Univariable OR (95% CI) P-Value Multivariable OR (95% CI) P-Value Age ( >50 years) 2.26 (1.26-4.02) 0.006 2.1 (1.05-4.13) 0.035 Personal h/o cancer 3.89 (1.41-10.78) 0.009 5.02 (1.30-19.35) 0.019 ASA score 2.21 (1.46-3.34) 0.0002 1.29 (0.72-2.32) 0.397 Persistent multiorgan failure 3.04 (1.59-5.80) < 0.0001 2.05 (0.81-5.17) 0.128 Peripancreatic involvement 6.94 (3.94-12.21) < 0.0001 7.15 (3.7-13.81) < 0.0001 Infected necrosis 3.07 (1.74-5.44) 0.0001 2.00 (1.01-3.96) 0.046 TLOS 1.03 (1.02-1.03) < 0.0001 1.01 (1.00-1.02) 0.016 Collection Size 1.07 (1.02-1.12) 0.005 1.01 (0.95-1.08) 0.663 ASA- American society of anesthesiologists; TLOS- total length of stay

IMPROVEMENT OF THE METHOD OF MINI-INVASIVE TREATMENT OF PATIENTS WITH ACUTE PANCREATITIS

One of the manifestations of purulent-septic complications in acute pancreatitis is the development of pancreatic and peripancreatic infected necrosis, while the prevalence and location of involved areas of fiber in different patients varies greatly [1]. For a long time in the literature there was an opinion that regardless of the form of acute pancreatitis, the timing of the disease, and the quality of preoperative topical diagnosis of complications, the best is the upper-middle laparotomy, and only after revision of the abdomen, extrahepatic bile ducts, omental sac, pancreas and retroperitoneal cell space can be performed drainage in areas depending on the specific situation [2]. However, with limited abscesses, the use of laparotomy threatens the spread of infection in the abdominal cavity with the development of bacterial-toxic shock and increase the mortality rate [3]. Therefore, in recent years, preference is given to mini-invasive interventions, which are mainly carried out under local anesthesia.

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

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

Assessment of Prophylactic Carbapenem Antibiotics Administration for Severe Acute Pancreatitis: An Updated Systematic Review and Meta-Analysis

Background: The effectiveness of prophylactic antibiotics in severe acute pancreatitis (SAP) remains a debatable issue. This meta-analysis aimed to determine the efficacy of prophylactic carbapenem antibiotics in SAP. Methods: This meta-analysis of prophylactic carbapenem antibiotics for SAP was conducted in PubMed, EMBASE, Web of Science, MEDLINE, and Cochrane Library up to February 2021. The related bibliographies were manually searched. The primary outcomes involved infected pancreatic or peripancreatic necrosis, mortality, complications, infections, and organ failure. Results: Seven articles comprised 5 randomized controlled trials and 2 retrospective observational studies, including 3,864 SAP participants. Prophylactic carbapenem antibiotics in SAP were associated with a statistically significant reduction in the incidence of infections (odds ratio [OR]: 0.27; p = 0.03) and complications (OR: 0.48; p = 0.009). Nevertheless, no statistically significant difference was demonstrated in the incidence of infected pancreatic or peripancreatic necrosis (OR: 0.74; p = 0.24), mortality (OR: 0.69; p = 0.17), extrapancreatic infection (OR: 0.64, p = 0.54), pulmonary infection (OR: 1.23; p = 0.69), blood infection (OR: 0.60; p = 0.35), urinary tract infection (OR: 0.97; p = 0.97), pancreatic pseudocyst (OR: 0.59; p = 0.28), fluid collection (OR: 0.91; p = 0.76), organ failure (OR: 0.63; p = 0.19), acute respiratory distress syndrome (OR: 0.80; p = 0.61), surgical intervention (OR: 0.97; p = 0.93), dialysis (OR: 2.34; p = 0.57), use of respirator or ventilator (OR: 1.90; p = 0.40), intensive care unit treatment (OR: 2.97; p = 0.18), and additional antibiotics (OR: 0.59; p = 0.28) between the experimental and control groups. Conclusions: It is not recommended to administer routine prophylactic carbapenem antibiotics in SAP.

Surgery Management of Pancreatitis with Complication: A Review Article

Introduction: Acute pancreatitis is an inflammatory disease of the pancreas with clinical manifestations that vary from mild to severe manifestations to death. The incidence of pancreatitis varies in various countries in the world and depends on the cause such as alcohol, gallstones, and metabolic factors. The clinical picture and the main symptom in patients with acute pancreatitis is abdominal pain. Abdominal pain varies from mild to severe and excruciating. Abdominal pain that is felt is constant and dull, and is usually felt in the epigastrium and periumbilicus and often spreads to the back, chest, waist, and lower abdomen. Discussion: The onset of acute pancreatitis, the patient should be evaluated for hemodynamic status immediately and receive the necessary resuscitation measures. Patients with acute pancreatitis should receive aggressive intravenous rehydration (250 - 500 ml/hour with isotonic crystalloid fluid) as early as possible with close monitoring, unless contraindicated with cardiovascular and/or renal comorbidities. It is most effective within the first 12-24 hours, but after that the benefits may diminish. Debridement (necrosectomy) is the gold standard in infected acute necrotizing pancreatitis and peripancreatic necrosis. Indications for intervention either through radiological, endoscopic or surgical procedures in necrotizing pancreatitis are suspected or proven infected necrotizing pancreatitis with clinical deterioration, especially after the necrotic tissue has been encapsulated with thick walls (walled-off necrosis). Sterile necrotizing pancreatitis with persistent organ failure several weeks after the onset of acute pancreatitis, particularly after the necrotic tissue has been encapsulated with thick walls (walled-off necrosis). Conclusion: Surgical management is often used in pancreatitis associated with gallstones. Cholecystectomy within 48 hours of the complaint can increase healing time. In addition, cholecystectomy performed early may not increase the risk of complications secondary to surgery. Surgery is not performed in acute necrotizing pancreatitis until the inflammation is reduced and the fluid accumulation no longer increases in size.

Accuracy of a CT density threshold enhancement to identify pancreatic parenchyma necrosis in acute pancreatitis during the first week

PurposeThe purpose of this study was to identify attenuation threshold value on computed tomography (CT) that allowed discriminating between interstitial edematous pancreatitis (IEP) and necrotizing pancreatitis (NP) in patients with acute pancreatitis during the first week of the disease and evaluate interobserver reproducibility for the diagnosis of acute pancreatitis category. Materials and methodsPatients with acute pancreatitis who underwent CT examination of the abdomen between March 2015 and December 2019 were retrospectively included. Actual diagnosis of IEP or NP was based on final clinical report, follow-up evaluation, and complications. Six regions of interest were manually placed in the pancreatic gland and peripancreatic fat, and differences in CT attenuation values before contrast injection and during the portal venous phase of enhancement were computed. Performance in the diagnosis of AP category was evaluated using receiver operating characteristic analysis. Interobserver agreement was estimated by the intraclass correlation coefficient (ICC) and Bland Altman analysis was used to estimate reproducibility between pairs of observers. ResultsSixty-six patients with NP (46 men, 20 women; mean age, 55 ± 17 [SD] years; age range: 20-89 years) and 70 patients with IEP (39 men, 31 women; mean age, 54 ± 18 [SD] years; age range: 21–87 years) were included. An enhancement value less than 30 Hounsfield units (HU) in the pancreatic gland during the portal phase compared to non-contrast phase, yielded 90.9% sensitivity (60/66; 95% CI: 81.3–96.6), 94.3% specificity (66/70; 95% CI: 86.0–98.4) and an area under curve of 0.958 (95% CI: 0.919–0.996) for the diagnosis of NP versus IEP. Interobserver reproducibility for pancreas enhancement was good using Bland Altman plot and ICC was excellent for pancreatic gland analysis (ICC 0.978; 95% CI: 0.961–0.988) but poor or moderate (ICC ≤0.634) regarding peripancreatic fat necrosis. ConclusionBy using a pancreas enhancement threshold value of 30 HU, CT is accurate and reproducible for the diagnosis of NP during the first week of the disease.

Endoscopic transluminal drainage for infected pancreatic necrosis

To evaluate the effectiveness of intraluminal drainage of acute fluid accumulations for infected pancreatic necrosis. There were 848 patients with acute pancreatitis between January 2018 and December 2020 at the Sklifosovsky Research Institute for Emergency Care. Necrotizing pancreatitis was detected in 232 (27.4%) patients. Among necrotic forms, pancreatic parenchymal necrosis was detected in 56 (24.1%) patients, its combination with peripancreatic necrosis - in 176 (75.9%) patients. All patients underwent transabdominal ultrasound, CT of the abdomen and retroperitoneal space, esophagogastroduodenoscopy, endo-ultrasonography of pancreatobiliary zone. Dimensions and localization of acute necrotic accumulations were established using ultrasound and CT data. Endoscopic transluminal drainage was performed in 22 patients with necrotizing pancreatitis and fluid accumulations attached to the stomach or duodenum. There were 12 men (55%) and 10 women (45%) aged 48.5 [39; 56] (35; 88) years. Effectiveness of endoscopic treatment was assessed considering clinical, endoscopic data and reduction of fluid accumulations confirmed by ultrasound and CT data. Among 22 patients, connection with pancreatic ductal system was detected in 3 patients (13.6%) that required pancreaticoduodenal stenting. Early postoperative period was complicated by bleeding from the area of pancreatogenic destruction in 4 patients (18.1%). Therefore, angiography and endovascular embolization of a. gastroduodenalis were required in 2 (9.1%) cases. In 1 (4.5%) case, we performed endoscopic hemostasis using Hemoblock hemostatic solution (4 ml). Combination of both methods was used in 1 (4.5%) patient. In 11 (50%) patients, endoscopic drainage was the final method of surgical treatment of necrotizing pancreatitis. Four patients (18.1%) died. Multiple organ failure caused mortality in 3 patients (13.6%). One (4.5%) patient died from severe nosocomial pneumonia developed in 32 days after drainage. Spurs not drained into the stomach with US-confirmed suspension and sequestration were observed in 11 (50%) out of 22 patients. These accumulations required additional ultrasound-assisted percutaneous drainage. Endoscopic transluminal drainage is a perspective minimally invasive method for necrotizing pancreatitis.

Investigating the correlation between severe acute pancreatitis and pancreatic necrosis with some serum parameters.

Acute pancreatitis (AP) is a disease related to significant morbidity and even mortality. Various factors are involved in the etiology, especially gallstones and excessive alcohol consumption. Although, the course of the disease in most of the cases is generally mild, in some cases, the disease can be severe and lead to pancreatic or peripancreatic necrosis. Radiologically, 'Balthazar computed tomography severity index' (CTSI) is used to assess the severity and presence of necrosis in pancreatitis. In this study, we classified the severity of AP in patients with Balthazar CTSI and investigated whether there is a correlation between some serum parameters and AP severity and which serum parameters can be used as a safe marker to predict the AP severity and the development of pancreatic necrosis (PN). A total of 341 patients diagnosed with AP and hospitalized in our general surgery clinic between the years 2012 and 2018 were included in this study. Hematological and biochemical parameters of the patients were recorded. Abdominal CT's of the patients were evaluated according to the Balthazar CTSI. The correlation between these parameters and AP severity evaluated by Balthazar CTSI was investigated. PN was detected in 19.4% of 341 patients who participated in the study. Patients whose PN detected in their abdominal CT's by Balthazar CTSI; neutrophil counts, neutrophil/lymphocyte ratio (NLR), thrombocyte/lymphocyte ratio, plateletlymphocyte ratio, and neutrophil/monocyte ratio (NMR) were significantly higher and the serum albumin was significantly lower than patients with PN. Neutrophil count, serum albumin levels, NLR, LR, and NMR can be used as predictive markers to determine AP severity.

Surgical Intervention Strategies of Necrotizing Pancreatitis With Abdominal Compartment Syndrome.

ObjectiveAcute pancreatitis can usually recover after conservative treatment. Five to 10 percent of acute pancreatitis may proceed into peripancreatic fluid collection and necrosis development, called necrotizing pancreatitis (NP), which has a high mortality rate. If it is accompanied by the occurrence of abdominal compartment syndrome (ACS) and does not respond to medical therapy, surgical intervention is indicated.MethodsWe analyzed our experience of surgical intervention strategies for NP patients with medically irreversible ACS from January 1, 2004, to December 31, 2018.ResultsOf the 47 NP patients with ACS, mean Ranson score was 6.5, mean Acute Physiology and Chronic Health Evaluation II score was 22.2, and Modified computed tomography severity index score was all 8 or greater. The mean total postoperative hospital length of stay was 80.2 days, of which the mean intensive care unit length of stay was 16.6 days. The overall complication rate was 31.9%. The mortality rate was 8.5%. Among the 47 patients, only fungemia was significantly associated with mortality incidence.ConclusionsThe combination of multiple drainage tube placement, feeding jejunostomy, and ileostomy at the same time were effective surgical intervention strategies for NP patients with ACS, which brought a lower mortality rate.

Dual pigtail intervention in acute necrotising pancreatitis

Acute pancreatitis has multiple aetiologies. Acute pancreatitis is divided into interstitial oedematous pancreatitis or necrotizing pancre­atitis based on morphology. According to the revised Atlanta classification necrotizing pancreatitis is further sub­divided into acute necrotic collec­tion if the disease develops within 4 weeks or walled-off necrosis if the disease develops after 4 weeks.We report a case of 40years male, with acute pancreatitis for 1 month, presenting with decreased appetite, loss of weight, and tremors of extremities. CT featured active necrotizing pancreatitis with peripancreatic necrosis, collections, and superadded infection which was drained by percutaneous pigtail catheter.Percutaneous pigtail insertion controls the symptoms and this procedure is effective in the management of patients with necrotizing pancreatitis. It serves as definitive or intermediate therapy to surgical necrosectomy in patients who are unfit for surgery. Percutaneous pigtail insertion can be done following a peritoneal or retroperitoneal approach, both approaches have different advantages and it is the choice of the radiologist and the location of the residual collections. The disadvantages are duct leak and it needs multiple check CT’s but in well trained and experienced hands the disadvantages are minimized. Percutaneous pigtail insertion is an alternative approach in the management of necrotizing pancreatitis when the patient is seriously ill or unfit for surgery. It can prevent life-threatening complications and it can be considered as a primary modality in treating a patient with walled-off necrosis.Percutaneous pigtail insertion an alternative approach in the management of necrotizing pancreatitis when the patient is seriously ill or unfit for surgery can be considered as the primary modality of choice in treating patients with walled-off necrosis of the pancreas.

The role of intestinal failure in the pathogenesis of severe acute pancreatitis

Severe acute pancreatitis can induce systemic and local complications, with infectious pancreatic necrosis and sepsis leading to the second death peak. Enterogenous infection caused by intestinal failure is considered to be an important mechanism of secondary infection of pancreatic or peripancreatic necrosis. Therefore, the prevention and treatment of intestinal failure is the key point in the treatment of severe acute pancreatitis and has an important influence on the course and prognosis of the disease. Individualized treatment should be selected according to the advantages of treatment centers and the characteristics of patients.

Surgical and Interventional Management and its Outcome in Severe Acute Pancreatitis

Background: Acute pancreatitis is an acute inflammation of the pancreas resulting from an auto-digestion of the gland. Acute pancreatitis represents a spectrum of disease ranging from a mild, self-limited course to a rapidly progressive, severe illness. In 20–25% of acute pancreatitis are severe, characterized by the development of pancreatic or peri-pancreatic necrosis, resulting in general and local complications responsible for a high mortality rate. The most common indication for intervention in acute pancreatitis is for the treatment of complications and most notably the treatment of infected walled off necrosis. Aims: The aim is to study the intervention to surgery and its outcome in managing severe acute pancreatitis and its complications. Methods: A total of 36 patients with severe acute pancreatitis with its complications not responding to conservative treatment were studied. In this prospective observational study, patients were divided based on the mode of treatment received: percutaneous drainage with pigtail catheterisation, endoscopic cystogastrostomy/drainage procedure and necrosectomy (in patient failed to respond by other intervention). Results: In our study, out of 36 patient 22 patient are treated with percutanous drainage with pig tail catheterization,8 patient are treated with endoscopic cystogastrostomy,6 patient underwent necrosectomy (3 patient underwent minimally invasive laparoscopic necrosectomy and 3 underwent open necrosectomy).Higher complication occured in patient underwent surgical intervention.Mortality occurred in 80% of patient who underwent necrosectomy. Most common cause of death is sepsis with multi organ failure. Conclusion: Surgeons have an important contribution to make in the multidisciplinary care of patients with complicated acute pancreatitis .Patients with acute pancreatitis should be managed conservatively in a step up approach. Early surgical intervention is not recommended even for necrotizing pancreatitis. Infected..

Experience in the implementation of a modified step-up approach in the treatment of infected pancreatic necrosis

Aim.Analysis of the results of the application of the modified step-up approach in the treatment of infected pancreatonecrosis in a third-level hospital.Materials and methods.The study included 52 patients over 18 years of age with acute pancreatitis and suspected or proven infection with pancreatic or peripancreatic necrosis .The control group included 27 patients who underwent primary open necrectomy. The comparison group included 25 patients who underwent surgical treatment within the framework of the modified concept of the stepwise surgical approach (Step-up). In the groups compared mortality rates, early postoperative complications (IIIb-IVb grade Clavien-Dindo), late postoperative complications (ventral hernias, pseudocysts, diabetes mellitus), the duration of inpatient treatment, and the duration of treatment in the intensive care unit. The indicator "Full return to primary social activity after treatment" was also proposed.Results.In the Step-up approach group, in comparison with the control group, there was a decrease in the overall incidence of postoperative complications of IIIb-IVb grade Clavien-Dindo (24% and 51.9%, respectively, p &lt;0.05), the frequency of arrosive bleeding (0% and 14 , 8%, respectively, p &lt;0.05), the need for necrsequestrectomy (64 and 100%, respectively, p &lt;0.01), the total average duration of treatment in the intensive care unit (3.2 ± 0.6 and 9.2 ± 1.6 days, respectively, p &lt;0.05), and the average duration of treatment in the intensive care unit after execution of necrosectomy (1,4±0,4 7,2±1,3 days, respectively, p&lt;0.01). A complete return to social activity in the control group was noted only in 10 (37%) patients compared with 19 (76%) in the Step-up group (p &lt;0.01). In the Step-up group, in comparison with the control group, a tendency towards a decrease in mortality was revealed (16% and 34.5%, respectively, p&gt; 0.05).Conclusion.The step-up approach can improve the results of treatment of infected pancreatic necrosis. The most important advantage of this concept is reproducibility - that is, the possibility of using it not only in the leading metropolitan clinics, but also in the regions of the Russian Federation. The step-up approach, however, has not yet acquired a complete form, and there is room for improvement.