Route Of Nutrition Research Articles

Endoscopic enteral accesses: Review article

A benefit of enteral nutritional support over the parenteral for acute and chronic diseases has been observed because it is more physiological and is associated with fewer complications. The most frequently used for this purpose are nasoenterals feeding tubes lasting no more than 30 days and percutaneous accesses involving longterm feeding. Prepiloric feeding is appropriate for most critical patients. However, postpiloric feeding, which is achieved with nasojejunal probes, percutaneous endoscopic gastrostomy with jejunal extension (PEG-J) and jejunostomy is indicated for those with regurgitation, aspiration of gastric foods or presence of leaks in the upper tractodigestive. There are several methods for the placement of enteral accesses, the endoscopic being the first choice in most cases, leaving the one performed by radiointervention and surgical for the technically difficult cases. There are advances with new endoscopic techniques such as endoscopic percutaneous jejunostomy by double balloon enteroscopy (PEJ) and endoscopic ultrasound in pacemakers with modified anatomy (Y-Roux) and excluded stomach, as well as the placement of selfexpanding metal prostheses at the duodenal or gastrojejunostomy by endoscopic ultrasound assisted by fluoroscopy guided by double balloon intestinal occlusion in cases of obstruction to the outflow tract by neoplasia. Due to the above, based on patient characteristics and prognosis, there are already more endoscopic options to preserve the enteral route as the main nutritional route in patients with chronic diseases.

Protein delivery and clinical outcomes in the critically ill: a systematic review and meta-analysis

Objectives: Protein is a fundamental component of critical care nutrition, but there has been uncertainty about the optimal amount. We undertook this systematic review and meta-analysis to examine the relationship between delivered protein and mortality in randomised controlled trials (RCTs) of nutritional interventions involving critically ill adults. Secondary outcomes included the effect of protein dose on lengths of stay, mechanical ventilation and incidence of infections.Methods: We reviewed the relevant English-language literature published between 1966 and 2015 and identified RCTs comparing different strategies of nutritional support lasting at least 48 hours in critically ill adults. Articles were included if mortality was reported and the difference in delivered protein between interventions was significant (P < 0.05). We calculated summary estimates for mortality as odds ratios (ORs) with 95% confidence intervals (CIs) using a random-effects estimator, and we used meta-regression to assess the effect of delivered protein on mortality.Results: From 3016 assessed records, 357 full-text articles were reviewed and 14 studies, investigating various interventions and routes of nutrition and comprising 3238 patients, were included. The mean protein delivered was 42.95 g/day (SD, 20.45 g/day) or 0.67 g//kg/day (SD, 0.38 g/kg/day) in patients receiving less protein, and 67.15 g/day (SD, 28.47 g/day) or 1.02 g/kg/day (SD, 0.42 g/kg/day) in the higher protein group. Provision of less protein did not influence mortality risk (pooled OR, 0.935; 95% CI, 0.716 –1.219; P = 0.618; I2 = 48.2%). Meta-regression analysis did not show a relationship between mean daily protein delivered and mortality (P = 0.433; I2 = 50.18%). There were no differences between groups in any secondary outcomes.Conclusions: Delivery of varying amounts of nutritional protein was not associated with any effect on mortality.

Starting up Korea's First Intestinal Rehabilitation Program

Intestinal failure (IF) is a state in which the insufficiency of bowel mass or function mandates alternative routes of nutrition support other than the oral route. These patients harbor a multitude of presentations and potential complications that require the attention of medical and non-medical experts and the multidisciplinary team approach has proven to be beneficial in the course of their treatment. The concept of IF was not well known in South Korea and these patients have been managed sporadically by medical personnel who were not familiar to the concept of intestinal rehabilitation. We have set up a multidisciplinary intestinal rehabilitation program (IRP) at Samsung Medical Center (Seoul), which is the first of its kind in Korea. The team consisted of surgeons, pharmacists, nutritionists, ward nurses and home-care nurses. Weekly meetings were held among team members to discuss inpatient care and develop standardized protocols for complication monitoring (intestinal failure associated liver disease) and management of enteral and parenteral nutrition supplement, central line associated blood stream infection and at-home care. A multidisciplinary intestinal rehabilitation clinic was also set up for care of patients after discharge and a computerized flowsheet was developed for easier monitoring of patient flow. As of June 2016, 17 patients (11 children and 6 adults) were managed in the IRP. The causes of IF in pediatric patients were short bowel (64%), disorders of motility (27%) and radiation enteritis (9%). In adults malignant obstruction (67%) and short bowel (33%) were the main causes. Full enteral autonomy was achieved in 3 adults and 2 children. Length of initial hospital stay was shortened by more than 12 months before and after the initiation of IRP. In conclusion, we have successfully began Korea's first multidisciplinary IRP. We hope to continue our efforts in adopting more advanced treatment strategies to better care for Korea's IF patients.

32-Year-Old-Woman With Abdominal Pain

32-Year-Old-Woman With Abdominal Pain

Traumatic brain injury and palliative care: a retrospective analysis of 49 patients receiving palliative care during 2013-2016 in Turkey.

Traumatic brain injury (TBI), which is seen more in young adults, affects both patients and their families. The need for palliative care in TBI and the limits of the care requirement are not clear. The aim of this study was to investigate the length of stay in the palliative care center (PCC), Turkey, the status of patients at discharge, and the need for palliative care in patients with TBI. The medical records of 49 patients with TBI receiving palliative care in PCC during 2013–2016 were retrospectively collected, including age and gender of patients, the length of stay in PCC, the cause of TBI, diagnosis, Glasgow Coma Scale score, Glasgow Outcome Scale score, Karnofsky Performance Status score, mobilization status, nutrition route (oral, percutaneous endoscopic gastrostomy), pressure ulcers, and discharge status. These patients were aged 45.4 ± 20.2 years. The median length of stay in the PCC was 34.0 days. These included TBI patients had a Glasgow Coma Scale score ≤ 8, were not mobilized, received tracheostomy and percutaneous endoscopic gastrostomy nutrition, and had pressure ulcers. No difference was found between those who were discharged to their home or other places (rehabilitation centre, intensive care unit and death) in respect of mobilization, percutaneous endoscopic gastrostomy, tracheostomy and pressure ulcers. TBI patients who were followed up in PCC were determined to be relatively young patients (45.4 ± 20.2 years) with mobilization and nutrition problems and pressure ulcer formation. As TBI patients have complex health conditions that require palliative care from the time of admittance to intensive care unit, provision of palliative care services should be integrated with clinical applications.

Usefulness of a peripherally inserted central catheter for total parenteral nutrition in patients with inflammatory bowel disease.

Peripherally inserted central catheters (PICC) have been widely used as a blood access route for total parenteral nutrition (TPN) in recent years. However, there have been few reports that evaluated the usefulness of PICC for patients with inflammatory bowel disease (IBD). In this study, we compared the clinical courses in patients with IBD who received TPN during their hospitalization by conventional central venous catheters (CVC) and PICC. A total of 137 IBD patients were enrolled. The CVC group and the PICC group included 56 and 81 patients, respectively. The clinical courses in both groups were compared retrospectively. As a complication of the puncture, pneumothorax occurred in two patients (3.6%) in the CVC group, but in none (0%) in the PICC group. The PICC group had significantly higher rates of achieving the scheduled TPN without removing the catheter, lower rates of catheter-related blood stream infection (CRBSI) and longer periods without CRBSI than the CVC group. PICC might be more useful than CVC in terms of safety and the ability to deliver scheduled TPN for IBD patients.

嚥下訓練開始時の状態と訓練の効果の関連について

In this study, we investigated for a period of 8 years, 884 patients who underwent swallowing rehabilitation in our hospital, and evaluated the factors affecting resumption of oral intake of food. We found that the number of patients undergoing swallowing rehabilitation in our hospital increased over time. Of the included patients, 82.8% were ≥70 years of age and men were more frequent than women (p=0.004). At the end of the rehabilitation, 56.3% patients' main nutrition route was oral. Most (60.5%) patients required <30 days of rehabilitation. We evaluated correlation between the states of patients at starting point of swallowing rehabilitation and the result of the rehabilitation. The patients having a desire for eating were significantly more successful in regaining oral intake of food than those without the desire (p<0.001) and those with desire unknown (p<0.001). We classified the patients as per the Japan Coma Scale into four groups: alert, 1 digit, 2 digits, and 3 digits; the 3-digit group was significantly less successful in resumption of oral ingestion compared to all other groups (p<0.001). Based on the activities of daily living (ADL), we classified the patients into four groups: supine position, possible to semi-sitting group (get-up more than 30°), possible to sit-up group, and possible more than transferring by oneself group. It was proved that the supine position group was significantly less successful in regaining oral intake of food compared to all other groups (p<0.001). Multivariate analysis showed that the strongest correlation for regaining oral ingestion was desire for eating (p<0.001), followed by ADL and level of consciousness. In conclusion, we found that the number of patients undertaking swallowing rehabilitation in our hospital is increasing, and that factors such as desire for eating, ADL, and level of consciousness significantly influence the resumption of oral intake of food.

Timing and route of early enteral nutrition in acute pancreatitis

Timing and route of early enteral nutrition in acute pancreatitis

Nutrition: A Primary Therapy in Pediatric Acute Respiratory Distress Syndrome

Appropriate nutrition is an essential component of intensive care management of children with acute respiratory distress syndrome (ARDS) and is linked to patient outcomes. One out of every two children in the pediatric intensive care unit (PICU) will develop malnutrition or have worsening of baseline malnutrition and present with specific micronutrient deficiencies. Early and adequate enteral nutrition (EN) is associated with improved 60-day survival after pediatric critical illness, and, yet, despite early EN guidelines, critically ill children receive on average only 55% of goal calories by PICU day 10. Inadequate delivery of EN is due to perceived feeding intolerance, reluctance to enterally feed children with hemodynamic instability, and fluid restriction. Underlying each of these factors is large practice variation between providers and across institutions for initiation, advancement, and maintenance of EN. Strategies to improve early initiation and advancement and to maintain delivery of EN are needed to improve morbidity and mortality from pediatric ARDS. Both, over and underfeeding, prolong duration of mechanical ventilation in children and worsen other organ function such that precise calorie goals are needed. The gut is thought to act as a “motor” of organ dysfunction, and emerging data regarding the role of intestinal barrier functions and the intestinal microbiome on organ dysfunction and outcomes of critical illness present exciting opportunities to improve patient outcomes. Nutrition should be considered a primary rather than supportive therapy for pediatric ARDS. Precise nutritional therapies, which are titrated and targeted to preservation of intestinal barrier function, prevention of intestinal dysbiosis, preservation of lean body mass, and blunting of the systemic inflammatory response, offer great potential for improving outcomes of pediatric ARDS. In this review, we examine the current evidence regarding dose, route, and timing of nutrition, current recommendations for provision of nutrition to children with ARDS, and the current literature for immune-modulating diets for pediatric ARDS. We will examine emerging data regarding the role of the intestinal microbiome in modulating the response to critical illness.

MON-P059: Influences of Nutritional Route on Kupffer Cell Phagocytic Function

MON-P059: Influences of Nutritional Route on Kupffer Cell Phagocytic Function

Comparison of nasojejunal tube insertion and percutaneous endoscopic gastrostomy for enteral nutrition in elderly patients

Objective To evaluate the clinical application of enteral nutrition by nasojejunal tube insertion and by percutaneous endoscopic gastrostomy (PEG) in elderly patients. Methods A total of 65 elderly patients with dysphagia recruited at our department from January 2010 to November 2014 were divided into the nasojejunal tube feeding group (35 cases) and the PEG feeding group (30 cases). Differences between these two groups in nutritional indexes, immunological indexes, complications and mortality were analyzed retrospectively. Results Serum total protein, albumin and prealbumin and upper arm circumferences all increased after treatment with nasojejunal tube feeding or percutaneous endoscopic gastrostomy (P>0.05). There was overall improvement in nutritional status, as assessed by Nutritional Risk Screening 2002 (NRS2002). Specifically, the before/one month-after-treatment ratio of scores was 3.72±0.91/1.90±0.61 (t=7.24, P 0.05). Although improvement in CD3+ , CD4+ , CD8+ , CD4+ /CD8+ , IgA, IgG, and IgM was seen in both groups after operation, the differences did not reach statistical significance (P>0.05). The incidence of aspiration pneumonia was notably lower (P<0.05) while the incidence of diarrhea was much higher (P<0.05) in the nasojejunal tube feeding group than in the PEG feeding group at one month and three months. The two groups had similar causes of death and mortality rates. Conclusion Both nasojejunal tube and PEG feeding can improve the nutritional status of elderly patients with dysphagia. However, the choice for the route of nutrition should be individualized. Key words: Jejunostomy; Gastroscopes

Changes in physical function after hospitalization in patients with nursing and healthcare-associated pneumonia

To clarify the functional changes after hospitalization due to pneumonia in elderly Japanese patients, we investigated the changes in physical functioning, nutritional routes, and diet that occurred after hospitalization in patients with nursing and healthcare-associated pneumonia (NHCAP). We analyzed 405 patients with NHCAP and compared findings with 448 patients with community-acquired pneumonia (CAP). Among the NHCAP patients, 140 (34%) patients showed a decline in activities of daily living function between baseline and discharge. After hospital discharge, 149 (37%) NHCAP patients did not return to the same residence location compared with where they were living prior to hospital admission. The frequency of this outcome was significantly higher in NHCAP patients than in CAP patients (p<0.0001). After 6 months' follow-up, of the patients who transferred to different hospitals, 41 (73%) patients with CAP had returned to their own home, but only 16 (20%) patients with NHCAP could return home (p<0.0001). Rates of alteration of nutritional route and type of diet from oral nutrition were significantly higher in NHCAP patients compared with CAP patients (22% vs 4%, p<0.0001). Our results demonstrated that approximately one-third of hospitalized patients with NHCAP showed a decline in physical function. In addition, approximately one-fifth of NHCAP patients had changed their route of nutrition and type of diet. Our results indicated that physicians should attach greater importance to preventative measures against NHCAP rather than relying on antibiotic therapy post-infection in the management of pneumonia in elderly patients in order to extend their healthy life expectancy.

Nutritional route in oesophageal resection trial II (NUTRIENT II): study protocol for a multicentre open-label randomised controlled trial

IntroductionEarly start of an oral diet is safe and beneficial in most types of gastrointestinal surgery and is a crucial part of fast track or enhanced recovery protocols. However, the...

The science and art of pediatric critical care nutrition.

Nutritional status and nutrient delivery during critical illness impact clinical outcomes. We have reviewed recent studies that may guide best practices regarding nutrition therapy in critically ill children. Malnutrition is prevalent in the pediatric ICU population, and is associated with worse outcomes. Nutrition support teams, dedicated dietitians, and educational programs facilitate surveillance for existing malnutrition and nutrition risk, but specific tools for the pediatric ICU population are lacking. Estimation of macronutrient requirements is often inaccurate; novel strategies to accurately determine energy expenditure are being explored. Indirect calorimetry remains the reference method for measuring energy expenditure. Enteral nutrition is the preferred route for nutrition in patients with a functioning gut. Early enteral nutrition and delivery of adequate macronutrients, particularly protein, have been associated with improved clinical outcomes. Delivery of enteral nutrition is often interrupted because of fasting around procedures and perceived intolerance. Objective measures for detection and management of intolerance to nutrient intake are required. In low-risk patients who are able to tolerate enteral nutrition, supplemental parenteral nutrition may be delayed during the first week of critical illness. Systematic research and consensus-based practices are expected to promote optimal nutritional practices in critically ill children with the potential to improve clinical outcomes.

Routes of early enteral nutrition following oesophagectomy.

Introduction Oesophagectomy for cancer is a challenging procedure with a five-year overall survival rate of 15-20%. Early enteral nutrition following oesophagectomy is a crucial component of the postoperative recovery and carries a significant impact on the outcome. Different methods of enteral feeding were conducted in our unit. The aim of this study was to examine the efficacy and safety of nasojejunal tube (NJT), jejunostomy tube (JT) and pharyngostomy tube (PT) feeding after oesophagectomy. Methods A retrospective review was carried out of prospectively collected data on patients with oesophageal cancer who underwent an oesophagectomy between 2011 and 2014. The primary outcome was feeding tube related complications such as occlusion, dislocation and leak. The secondary outcomes were length of stay and 30-day morbidity. Results A total of 90 oesophagectomies were included in the study. A NJT was inserted in 41 patients (45.6%), a JT was used in 14 patients (15.5%) and a PT was the route for enteral nutrition in 35 patients (38.9%). In total, five patients (5.5%) developed tube related complications. There were no tube related complications in the NJT group but one JT patient (7.1%) developed tube related cellulitis (p=0.189) and four PT patients (11.4%) developed tube related haemorrhage (p=0.544), tube dislocation (p=0.544) or cellulitis (p=0.189). The median length of stay and 30-day postoperative morbidity were similar between the groups. Conclusions NJT feeding is a less invasive, feasible route for early enteral nutrition following oesophagectomy. A randomised controlled trial is recommended to verify these findings.

Immediate Postoperative Oral Nutrition Following Esophagectomy: A Multicenter Clinical Trial

Immediate start of oral intake is beneficial following colorectal surgery. However, following esophagectomy the safety and feasibility of immediate oral intake is unclear, thus these patients are still kept nil by mouth. This study therefore aimed to determine the feasibility and safety of oral nutrition immediately after esophagectomy. A multicenter, prospective trial was conducted in 3 referral centers between August 2013 and May 2014, including 50 patients undergoing a minimally invasive esophagectomy. Oral nutrition was started postoperatively immediately (clear liquids on postoperative day [POD] 0, liquid nutrition on POD 1 to 6, solid food from POD 7). Nonoral enteral nutrition was started when <50% of caloric need was met on postoperative day POD 5 or when oral intake was impossible. A comparison was made with a retrospective cohort (n= 50) with a per-protocol delayed start of oral intake until POD 4 to7. The median caloric intake at POD 5 was 58% of required. In 38% of the patients nonoral nutrition was started, mainly due to complications (36%). The pneumonia rate was 28% following immediate oral intake and 40% following delayed oral intake (p= 0.202). The aspiration pneumonia rate was 4% in both groups. The anastomotic leakage rate was 14% after immediate oral intake versus 24% following delayed oral intake (p= 0.202). The 90-day mortality rate was 2% in both groups. Hospital stay and intensive care unit stay were significantly shorter following immediate oral intake. Immediate start of oral nutrition following esophagectomy seems to be feasible and does not increase complications compared to a retrospective cohort and literature. However, if complications arise an alternative nutritional route is required. This explorative study shows that a randomized controlled trial is needed.

Enteral versus parenteral nutrition in critically ill patients: an updated systematic review and meta-analysis of randomized controlled trials.

BackgroundEnteral nutrition (EN) is recommended as the preferred route for early nutrition therapy in critically ill adults over parenteral nutrition (PN). A recent large randomized controlled trial (RCT) showed no outcome differences between the two routes. The objective of this systematic review was to evaluate the effect of the route of nutrition (EN versus PN) on clinical outcomes of critically ill patients.MethodsAn electronic search from 1980 to 2016 was performed identifying relevant RCTs. Individual trial data were abstracted and methodological quality of included trials scored independently by two reviewers. The primary outcome was overall mortality and secondary outcomes included infectious complications, length of stay (LOS) and mechanical ventilation. Subgroup analyses were performed to examine the treatment effect by dissimilar caloric intakes, year of publication and trial methodology. We performed a test of asymmetry to assess for the presence of publication bias.ResultsA total of 18 RCTs studying 3347 patients met inclusion criteria. Median methodological score was 7 (range, 2–12). No effect on overall mortality was found (1.04, 95 % CI 0.82, 1.33, P = 0.75, heterogeneity I2 = 11 %). EN compared to PN was associated with a significant reduction in infectious complications (RR 0.64, 95 % CI 0.48, 0.87, P = 0.004, I2 = 47 %). This was more pronounced in the subgroup of RCTs where the PN group received significantly more calories (RR 0.55, 95 % CI 0.37, 0.82, P = 0.003, I2 = 0 %), while no effect was seen in trials where EN and PN groups had a similar caloric intake (RR 0.94, 95 % CI 0.80, 1.10, P = 0.44, I2 = 0 %; test for subgroup differences, P = 0.003). Year of publication and methodological quality did not influence these findings; however, a publication bias may be present as the test of asymmetry was significant (P = 0.003). EN was associated with significant reduction in ICU LOS (weighted mean difference [WMD] -0.80, 95 % CI −1.23, −0.37, P = 0.0003, I2 = 0 %) while no significant differences in hospital LOS and mechanical ventilation were observed.ConclusionsIn critically ill patients, the use of EN as compared to PN has no effect on overall mortality but decreases infectious complications and ICU LOS. This may be explained by the benefit of reduced macronutrient intake rather than the enteral route itself.Electronic supplementary materialThe online version of this article (doi:10.1186/s13054-016-1298-1) contains supplementary material, which is available to authorized users.

Jejunostomy or nasoenteric tube: Which is the best route for nutrition after Whipple procedure

Jejunostomy or nasoenteric tube: Which is the best route for nutrition after Whipple procedure

Route of nutrition and risk of blood stream infections in critically ill patients; a comparative study

The association of nutritional support practices with intensive care unit (ICU) - acquired infections is a current field of interest. The objective of this study was to determine whether different routes of delivery of nutritional support are associated with a different risk of bloodstream infection (BSI) in critically ill patients. An observational study in a multidisciplinary ICU. Adult ICU patients, with ICU stay ≥96h who were fed artificially were included. Patients were grouped into three categories of nutrition support routes: those on enteral nutrition alone (EN group), on parenteral nutrition alone (PN group) or on both EN and PN (EN+PN group). Illness severity, co-morbidities and routine laboratory values were recorded on ICU admission. Route of feeding, caloric, protein and immunonutrient intake was recorded daily for each patient. Nosocomial BSIs were identified by infection control surveillance methods. The incidence of BSI among the three groups was compared with Kaplan-Meier plots and Cox proportional-hazards models. A total of 249 patients were included in the analysis. There were no significant differences between groups in illness severity scores and in the time to nutritional support initiation (median time 48 [24-48] hours). The median daily caloric intake was significantly lower for the EN group than for patients of PN and EN+PN group (415 [157-687] kcal vs. 1077 [297-2087] kcal and 1292 [890-1819] kcal respectively, p<0.001). BSI occurred in 69 (27.7%) patients. Bivariate Cox analysis revealed that APACHE II score and admission category were significantly associated to BSI development [hazard ratio (HR), 1.05; 95% confidence interval (CI), 1.01-1.09 and HR 0.45; 95% CI 0.18-1.15, respectively]. Presence of co-morbidities, SOFA score, hospital length of stay (LOS) before ICU admission, late initial feeding, serum albumin at admission, average daily maximum concentration of serum glucose, caloric, protein and immunonutrient intake did not affect the hazard of BSI development. After adjustment for the confounding variables, in a multivariate analysis, patients of the EN+PN group had lower incidence of BSI than the other two groups (HR 0.30; 95% CI 0.17-0.53), irrespective of the number of days of PN intake and the percentage of calories received from PN. There was no difference in the hazard for BSI development between the EN and PN group. Patients with EN+PN had a significantly longer ICU-LOS whereas mortality was not different among the three groups. In this retrospective analysis of 249 consecutively enrolled ICU patients, we found that in critically ill patients EN+PN feeding strategy was associated with a significantly reduced hazard of BSI development, compared to EN or PN route of nutritional support.

Management of pancreatic fluid collections: A comprehensive review of the literature.

Pancreatic fluid collections (PFCs) are a frequent complication of pancreatitis. It is important to classify PFCs to guide management. The revised Atlanta criteria classifies PFCs as acute or chronic, with chronic fluid collections subdivided into pseudocysts and walled-off pancreatic necrosis (WOPN). Establishing adequate nutritional support is an essential step in the management of PFCs. Early attempts at oral feeding can be trialed in patients with mild pancreatitis. Enteral feeding should be implemented in patients with moderate to severe pancreatitis. Jejunal feeding remains the preferred route of enteral nutrition. Symptomatic PFCs require drainage; options include surgical, percutaneous, or endoscopic approaches. With the advent of newer and more advanced endoscopic tools and expertise, and an associated reduction in health care costs, minimally invasive endoscopic drainage has become the preferable approach. An endoscopic ultrasonography-guided approach using a seldinger technique is the preferred endoscopic approach. Both plastic stents and metal stents are efficacious and safe; however, metal stents may offer an advantage, especially in infected pseudocysts and in WOPN. Direct endoscopic necrosectomy is often required in WOPN. Lumen apposing metal stents that allow for direct endoscopic necrosectomy and debridement through the stent lumen are preferred in these patients. Endoscopic retrograde cholangio pancreatography with pancreatic duct (PD) exploration should be performed concurrent to PFC drainage. PD disruption is associated with an increased severity of pancreatitis, an increased risk of recurrent attacks of pancreatitis and long-term complications, and a decreased rate of PFC resolution after drainage. Any pancreatic ductal disruption should be bridged with endoscopic stenting.