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Background Endoscopic ultrasound (EUS)-guided drainage of pancreatic fluid collections (PFCs) by cautery-enhanced lumen-apposing metal stents (LAMS) has largely been limited to collections located Methods This international, multicenter study analyzed all adults with PFCs located ≥ 10 mm from the luminal wall who were treated by EUS-guided drainage using the 15-mm-long cautery-enhanced LAMS. The primary outcome was technical success. Secondary outcomes included clinical success (decrease in PFC size by ≥ 50 % at 30 days and resolution of clinical symptoms without surgical intervention), complications, and recurrence. Results 35 patients (median age 57 years; interquartile range [IQR] 47–64 years; 49 % male) underwent novel LAMS placement for drainage of PFCs (26 walled-off necrosis, 9 pseudocysts), measuring 85 mm (IQR 64–117) maximal diameter and located 11.8 mm (IQR 10–12.3; range 10–14) from the gastric/duodenal wall. Technical and clinical success were high (both 97 %), with recurrence in one patient (3 %) at a median follow-up of 123 days (58–236). Three complications occurred (9 %; one mild, two moderate). Conclusions The 15-mm-long cautery-enhanced LAMS was feasible and safe for drainage of PFCs located 10–14 mm from the luminal wall.

Cystic pancreatic lesions are a frequent incidental finding on ultrasound or cross sectional imaging. The incidence of pancreatic lesions experience a steady climb in recent years due to an increased number of cross sectional imaging and an increasing life expectancy. The clinical challenge is to identify individuals bearing lesions with potentially malignant or pre-malignant features. Indeed, by far most cystic pancreatic lesions are not associated with an increased risk for the development of cancer. Taking into account the increasing incidence rates of cystic pancreatic lesions a rational and economic use of diagnostics is warranted. This review provides an overview on the different types of cystic lesions, the appropriate use of diagnostics and a clinical management algorithm balancing intervention and surveillance.

A mass lesion of the gastric cardia or fundus causing an alteration in the normal regular, translucent gastric fundal air shadow on a frontal erect chest radiograph is referred to as “the Kirklin sign.” Here we present “Pseudo-Kirklin sign” observed on the frontal radiograph of a 46-year-old male patient due to a soft tissue shadow/contour deformity of the fundal gas shadow caused by pseudocyst of the pancreas. We evaluated the patient using plain radiography, contrast enhanced computed tomography, magnetic resonance imaging, and endoscopic ultrasound (EUS) with the cyst drained under EUS guidance. So far only two cases of mediastinal pseudocysts have been drained successfully by EUS-guided aspiration.

Background Larger caliber lumen-apposing stents (LAMSs) have been increasingly used in the management of pancreatic fluid collections, specifically when solid debris is present; however, their advantages over smaller caliber plastic stents in the management of pancreatic pseudocysts are unclear. The aim of this study was to investigate the safety and efficacy of LAMS specifically in the management of pancreatic pseudocysts compared with double-pigtail plastic stents (DPPSs). Methods We performed a multicenter, international, retrospective study between January 2012 and August 2016. A total of 205 patients with a diagnosis of pancreatic pseudocysts were included, 80 patients received LAMSs and 125 received DPPSs. Measured outcomes included clinical success, technical success, adverse events, stent dysfunction, pancreatic pseudocyst recurrence, and need for surgery. Results Technical success was similar between the LAMS and the DPPS groups (97.5 % vs. 99.2 %; P = 0.32). Clinical success was higher for LAMSs than for DPPSs (96.3 % vs. 87.2 %; P = 0.03). While the need for surgery was similar between the two groups (1.3 % vs. 4.9 %, respectively; P = 0.17), the use of percutaneous drainage was significantly lower in the LAMS group (1.3 % vs. 8.8 %; P = 0.03). At 6-month follow-up, the recurrence rate was similar between the groups (6.7 % vs 18.8 %, respectively; P = 0.12). The rate of adverse events was significantly higher in the DPPS group (7.5 % vs. 17.6 %; P = 0.04). There was no difference in post-procedure mean length of hospital stay (6.3 days [standard deviation 27.9] vs. 3.7 days [5.7]; P = 0.31). Conclusion When compared to DPPSs, LAMSs are a safe, feasible, and effective modality for the treatment of pancreatic pseudocysts and are associated with a higher rate of clinical success, shorter procedure time, less need for percutaneous interventions, and a lower overall rate of adverse events.

Background and study aims Acute obstructive suppurative pancreatic ductitis (AOSPD) is a suppurative pancreatic duct infection with main pancreatic duct (MPD) or accessory pancreatic duct obstruction in the absence of a pancreatic pseudocyst or necrosis, which is experienced usually in chronic pancreatitis. The diagnosis is confirmed by the finding of pancreatic duct obstruction on endoscopic retrograde cholangiopancreatography (ERCP) with evidence of infection, such as a positive pancreatic juice culture or drainage of purulent pancreatic juice. Patients and methods We studied five patients with pancreatic ductal adenocarcinoma (PDAC) and one with chronic myelogenous leukemia (CML), who suffered from AOSPD. Results Of the 281 PDAC and 39 CML patients who we treated in the past 2 years in our hospital, five with PDAC (1.8 %) and one with CML (2.6 %) experienced AOSPD. Each patient had fever, abdominal pain, and increased blood C-reactive protein. Pancreatography found that each patient had a MPD stricture and an upstream dilatation. Four had a disruption of the MPD in the upper stream of the stricture. Nasopancreatic drainage was successfully performed in all patients. Pancreatic juice culture was positive for Klebsiella pneumonia, Enterobacter agerogenes, or Enterococcus cloacae in four patients. Conclusion AOSPD should be considered in pancreatic malignancy with fever and abdominal pain. Prompt diagnosis of AOSPD could avoid shortening of survival of patients with an already poor prognosis by infection.

Pancreatic fluid collection (PFC) is a common complication of acute pancreatitis. Endoscopic ultrasound (EUS)-guided drainage, which is often followed by direct endoscopic necrosectomy (DEN), has become the primary approach to treat PFC, including pancreatic pseudocysts (PP) and walled-off necrosis (WON). We aimed to determine retrospectively the short- and long-term results of patients treated in our endoscopy unit and to identify parameters that are associated with treatment efficacy and outcome.The data of 41 consecutive patients with post-pancreatitic PFC, who underwent endoscopic transmural intervention between 2014 and 2016, were analyzed retrospectively. After an initial EUS-guided puncture, one or more plastic stents were placed and DEN was performed if necrotic tissue remained.The mean diameter of the PFC was 74.0 ± 4.8 mm. Of the PFCs, 29.3% were classified as PP and 70.7% as WON. Altogether, 196 transmural endoscopic procedures were performed, including 73 endoscopic necrosectomies in a subgroup of 21 patients (20 WON, 1 PP). Initial technical success was achieved in 97.6% of patients and the short-term clinical success rate was 90.2%. The long-term clinical success rate was 82.9%, since four patients died from septic shock and/or multiple organ failure and three patients developed recurrent PFC some months after the initial discharge from endoscopic treatment. Procedural complications were registered in 9 patients during 10 of 196 endoscopic procedures (5.1%): bleeding (6), cardiorespiratory insufficiency (2), perforation with pneumoperitoneum (1), aspiration with respiratory insufficiency (1), and non-perforating superficial damage of the gastric wall (1). Neither the size of the PFC nor the initial value of C-reactive protein (CRP) or other biochemical markers were correlated with efficacy or outcome of treatment. Only the cumulative number of days with CRP 50 mg/L significantly correlated with the number of follow-up endoscopic sessions and DEN. Fungal colonization of PFC correlated significantly (p 0.05) with the risk of mortality (44% vs. 0%), need for intensive care treatment (66.7% vs. 25%), and sepsis (55.6% vs. 12.5%).We confirm that EUS-guided drainage followed by DEN in patients with solid necrotic material is an effective and relatively safe therapeutic approach. Prolonged elevation of CRP and fungal colonisation of the PFC are associated with a worse course of the disease.Peripankreatische Flüssigkeitsansammlungen (PFC) sind eine häufige Komplikation der akuten Pankreatitis. Die endosonografisch (EUS) gesteuerte Drainage, oft gefolgt von der direkten endoskopischen Nekrosektomie (DEN), stellt mittlerweile den primären Therapieansatz von PFC einschließlich Pankreaspseudozysten (PP) und ummauerten Nekrosen (WON) dar. Ziel war es, retrospektiv die Kurz- und Langzeitergebnisse der in unserer Endoskopie behandelten Patienten zu ermitteln und Parameter zur Verlaufseinschätzung zu identifizieren.Daten von 41 konsekutiven Patienten mit postpankreatitischer PFC, die zwischen 2014 und 2016 eine endoskopische transmurale Intervention erhielten, wurden retrospektiv analysiert. Zunächst wurden nach einer EUS-gesteuerten Punktion ein oder mehrere Kunststoff-Stents platziert und im Falle verbleibenden nekrotischen Materials erfolgte eine DEN.Der mittlere Durchmesser der PFC betrug 74,0 ± 4,8 mm. 29,3% wurden als PP und 70,7% als WON eingestuft. Insgesamt erfolgten 196 transmurale Endoskopien, darunter 73 DEN in einer Subgruppe von 21 Patienten (20 WON, 1 PP). Die initiale technische Erfolgsrate betrug 97,6% und die kurzfristige klinische Erfolgsrate 90,2%. Die langfristige klinische Erfolgsrate betrug 82,9%, da 4 Patienten an septischem Schock/multiplem Organversagen starben und 3 Patienten einige Monate nach Beendigung der endoskopischen Therapie rezidivierende PFC entwickelten. Prozedurale Komplikationen wurden bei 10 von 196 endoskopischen Eingriffen (5,1%) bei 9 Patienten registriert: Blutung (6), kardiorespiratorische Insuffizienz (2), Perforation mit Pneumoperitoneum (1), Aspiration (1) und nichtperforierender oberflächlicher Magenwandriss (1). Weder die Größe der PFC noch der Anfangswert des C-reaktiven Proteins (CRP) oder andere biochemische Marker korrelierten mit Effizienz oder Behandlungsergebnis. Nur die kumulative Anzahl an Tagen mit einem CRP 50 mg/l korrelierte signifikant mit der Anzahl der Verlaufsendoskopien und der DEN. Eine Pilzbesiedelung der PFC korrelierte signifikant (p 0,05) mit dem Mortalitätsrisiko (44% vs. 0%), mit Intensivpflichtigkeit (66,7% vs. 25%) und Sepsis (55,6% vs. 12,5%).Unsere Daten bestätigen, dass die EUS-gesteuerte Drainage gefolgt von DEN bei Vorhandensein festen nekrotischen Materials ein effektiver und relativ sicherer Therapieansatz ist. Anhaltende CRP-Erhöhung und Pilzbesiedlung der PFC sind mit einem schlechteren Erkrankungsverlauf assoziiert.

Background Pancreatic cystic lesions represent a diagnostic dilemma as some may harbor malignancy or have potential for malignant transformation. The aim of this study was to present our experience with a novel endoscopic ultrasound (EUS)-guided microbiopsy procedure enabling procurement of tissue from the wall of the cystic lesion. Methods We collected data from 31 consecutive patients with pancreatic cystic lesions who underwent an EUS-guided microbiopsy procedure at our institution. Records were retrospectively reviewed from a prospectively maintained database. Results The technical success was 87.1 %. Diagnostic yield of microbiopsies was 71.0 %. Microbiopsies offered sufficient tissue for morphological and immunohistochemical characterization of the lesions, as well as determination of grade of dysplasia. Furthermore, evaluation of microbiopsies changed the clinical management in six patients (19.4 %). Three nonsevere adverse events were observed (9.7 %): two cases of mild infection and one case of mild pancreatitis. All three patients recovered completely. Conclusions EUS-guided microbiopsy procedure was technically feasible, with a high diagnostic yield. Further prospective studies are needed to confirm these promising results.

Background and study aims Endoscopic ultrasound-guided drainage is an effective and accepted primary modality for management of pancreatic pseudocyst (PP). A lumen-apposing metal stent (LAMS) has recently been developed specifically for drainage of pancreatic fluid collections which may be superior to using traditional plastic stents (PS) but is more expensive. Because use of a stent involves a risk of unplanned endoscopy, percutaneous drainage (PCD) and surgery, their costs should also be included in the comparison and a cost-effectiveness analysis of LAMS and PS should therefore be performed Patients and methods A decision tree was developed assessing both endoscopic drainage strategies for patients with PP: LAMS and PS over a 6-month time horizon. For each strategy, inpatients received a stent and were followed for subsequent need for direct further interventions or adverse events leading to unplanned endoscopy, PCD, surgery, or successful endoscopic drainage using probabilities obtained from the literature. The unit of effectiveness was successful endoscopic drainage without need for PCD or surgery. Sensitivity analyses were performed. Results Success rates were 93.9 % for LAMS and 96.96 % for PS. Respective costs per successful drainage were US $ 18,129 (LAMS) and US $ 10,403 (PS). The LAMS strategy was thus characterized as dominated by the PS approach because it was costlier and less effective than PS. Both deterministic and probabilistic sensitivity analyses confirmed the robustness of these findings. Conclusion Use of LAMS is not less effective and more costly than PS in management of patients with PP. As such, PS should be preferred over LAMS as initial management of these patients.

The aim of this study was to evaluate whether the placement of a coaxial double-pigtail plastic stent (DPS) within a lumen-apposing metal stent (LAMS) may improve the safety of endoscopic ultrasound (EUS)-guided drainage of pancreatic fluid collections (PFCs).This was a retrospective cohort study including patients with PFCs and an indication for transmural drainage. Two strategies (LAMS alone or LAMS plus DPS) were used at the endoscopist's discretion.A total of 41 patients were treated (21 LAMS alone; 20 LAMS plus DPS). The characteristics of the PFCs, and the technical and clinical success rates did not differ between groups. The LAMS alone group had a significantly higher rate of adverse events than the LAMS plus DPS group (42.9 % vs. 10.0 %;The addition of a coaxial DPS to LAMS was associated with a lower rate of adverse events in EUS-guided drainage of PFCs.The aim of this study was to evaluate whether the placement of a coaxial double-pigtail plastic stent (DPS) within a lumen-apposing metal stent (LAMS) may improve the safety of endoscopic ultrasound (EUS)-guided drainage of pancreatic fluid collections (PFCs).This was a retrospective cohort study including patients with PFCs and an indication for transmural drainage. Two strategies (LAMS alone or LAMS plus DPS) were used at the endoscopist’s discretion.A total of 41 patients were treated (21 LAMS alone; 20 LAMS plus DPS). The characteristics of the PFCs, and the technical and clinical success rates did not differ between groups. The LAMS alone group had a significantly higher rate of adverse events than the LAMS plus DPS group (42.9 % vs. 10.0 %;The addition of a coaxial DPS to LAMS was associated with a lower rate of adverse events in EUS-guided drainage of PFCs.

Introduction EUS-guided cystoenterostomy (EUCE), a technique used for the drainage of pancreatic pseudocysts and peri-enteric collections, requires specific skills for which dedicated models are needed. Based on a compact EASIE model (Erlangen Active Simulator for Interventional Endoscopy), we developed two ex vivo porcine models of retrogastric cysts and evaluated learning performance within the frame of a structured training program. Material and methods The first model was made of porcine colon (i. e. “natural cyst”), the second one with an ostomy bag (i. e. “artificial cyst”). All procedures were achieved with an EUS scope under fluoroscopy. Both models were evaluated prospectively over a 2-day session involving 14 students and five experts. The primary end point was overall satisfaction with each model. Results The “natural cyst” and “artificial cyst” were prepared within 10 and 16.5 minutes (P = 0.78), respectively. Model grading showed a non-significant trend for overall satisfaction in favor of the artificial model (P = 0.06). As secondary end points, difference was not significant for impression of realism (P = 0.75) whereas the “artificial cyst” was graded significantly better by experts and students in terms of ability to teach procedural steps (P = 0.01) and ease of puncture (P = 0.03). Moreover, experts considered the ability to improve students’ proficiency to be superior with the “artificial cyst” (P = 0.008). Conclusion Both “artificial” and “natural cysts” are efficient for EUCE training in terms of overall satisfaction. However, the “artificial cyst” model appears to make the procedure easier with a higher ability to teach procedural steps and improve the students’ proficiency. Larger applications of this model are needed to validate as a standard of training.

Blunt pancreatic injuries are rare as they only comprise 1–5% of abdominal trauma, and half of the cases are seen in combination with multiple injuries. More than 60% of pancreatic injuries are located in the body and tail of the gland (Krige JE et al. Pancreatology. 2017;17(4):592–598). Pancreatic trauma often entails severe lesions with a high morbidity and mortality if treatment is delayed or inadequate (Mohseni S et al. Injury. 2018;49(1):27–32). Treatment is controversial and depends on whether the main pancreatic duct has been injured. Grade I and II trauma is usually managed conservatively, while grade III to V trauma is generally managed operatively either with drainage or resection of major parts of the gland (Ho VP et al. J Trauma Acute Care Surg . 2017;82(1):185–99). However, an increasing number of studies suggest that non-operative management with drainage alone rather than resection may provide acceptable outcomes (Menahem B et al. Hepato Biliary Surg Nutr. 2016;5(6):470–77). We present an acute case with a grade III lesion of the pancreatic neck in an adult treated with surgical drainage and subsequent drainage of a pseudocyst with a lumen-apposing metal stent (LAMS) with conservation of the gland. Case presentation A 27-year-old healthy female suffered a grade III lesion of her pancreas after she fell from a bicycle and landed on the handlebar. At a local hospital a pancreatic contusion was found on a trauma CT scan, and the patient was referred to a level 1 trauma center with specialized HPB function. A reassessment of the CT scan revealed complete rupture of the pancreatic neck with a retroperitoneal hematoma without signs of other abdominal injuries. An MRCP confirmed rupture of the main duct with a diastasis measuring 2 cm ( Fig. 1 ). A conservative approach was chosen, and the patient was treated with a nasogastric tube with continuous suction, intravenous proton pump inhibitor (pantoprazole 40 mg b.i.d.), subcutaneous octreotide 100 microgram t.i.d., intravenous cefuroxime 1500 mg t.i.d., metronidazole 1500 mg q.d. and parenteral nutrition. On the third day of admission an endoscopic retrograde cholangiopancreatography (ERCP) with papillotomy of the pancreatic duct was performed to ease the flow to the duodenum and diminish the leakage from the severed duct. Due to the considerable diastasis of the duct ends and the large hematoma with displacement of the fractured parts, an attempt to insert a bridge prosthesis over the contused area was not attempted. On the fourth day the patient’s condition deteriorated with increasing abdominal pain, inflammatory parameters and on free intraperitoneal fluid seen on ultrasonography. A laparotomy was performed with removal of 2000 ml ascites, but the surgeon refrained from resection of the distal part of the gland due to a large retroperitoneal hematoma in the retroperitoneal space. Instead two external 18 Fr tubes were placed along the superior and inferior pancreatic border, respectively, and the abdomen was closed. The patient’s general condition quickly improved with no need for pain killers, the systemic inflammatory response decreased, she started eating regular food and one abdominal tube was discontinued because of the decreasing amount of fluid. In the remaining tube the level of liquid was stable around 200 ml/day with amylase of 10,000 U/l. The patient was discharged on day 16 and followed up once a week at the outpatient clinic with intermittent retraction of the drain until a fistula to the skin had formed and the drain was removed 8 weeks later. Two weeks after removal of the drain, the discharge had ceased from the fistula and the patient complained of increasing discomfort and abdominal pain. A CT scan revealed a pseudocyst of 4.6×3.1×2.6 cm ( Fig. 1 ) and an MRCP and MR angiography showed the severed pancreatic duct with a diameter of 6 mm and both halves of the gland with arterial perfusion ( Fig. 2 ). Endoscopic ultrasonography was performed and a 10×10 mm HOT AXIOS TM stent (Boston scientific, Marlborough, MA) was inserted between the stomach and the cyst ( Fig. 3 and ​and4 ).4 ). A therapeutic Pentax echoendoscope (EG-3870UTK; Pentax, Tokyo, Japan) and Hitachi ultrasound workstation (EUB 7500, HI Vison Preirus; Hitachi Medical Corp., Tokyo, Japan) were used. The collection was punctured under EUS control using the electrocautery wire at the tip of the Hot AXIOS stent. Once the device was satisfactorily positioned within the cyst, the distal flange of the stent was deployed under EUS control. The device was then pulled back until the distal flange deformed against the cavity wall. The proximal flange was then deployed on the luminal side under direct endoscopic control. The same evening the patient could eat normally, the abdominal pain had ceased, and she was discharged the following day. Five weeks later a CT scan revealed a collapsed cyst and nine weeks from insertion the stent was removed by regular gastroscopy. Two weeks after removal of the stent, a CT scan showed no recurrence of the cyst, the pancreatic duct still measured 6 mm and both halves of the pancreas had blood supply. The patient was doing well without signs of malabsorption or diabetes and the follow-ups were terminated but with open contact to our department. Open in a separate window Fig. 1 The CT scan shows trauma to the neck of the pancreas with a 2 cm diastasis between the head and body with retroperitoneal extravasation.

Mediastinal pseudopancreatic cyst (MPP) is the extension of a pancreatic pseudocyst through esophageal or aortic hiatus into the posterior mediastinum. It can produce a range of manifestations caused by compression by the cyst, for instance, odynophagia, dysphagia, pericardial, or pleural effusion. Here we report a case of MPP in a 7-year-old child who was presented with repeated chest infections and left pleural effusion. It was successfully drained by cystogastrostomy.

A 7-year-old male patient with a history of recurrent abdominal pain over 1 year presented with cardiac tamponade due to massive pericardial effusion, which was percutaneously drained. Contrast-enhanced computed tomography revealed a large posterior mediastinal cyst and calcified, heterogeneous pancreatic parenchyma. Elevated amylase and lipase levels of the cyst fluid confirmed the diagnosis of pancreatic pseudocyst, which was treated with an octreotide infusion and Roux-en-Y cystojejunostomy. The child was discharged on pancreatic enzyme supplement and was asymptomatic on follow-up.

Background and Aims: Therapeutic interventions for complicated pancreatitis, especially in pseudocysts and walled-off necroses as a sequel of necrotizing pancreatitis, have a long history. Originally a stronghold of classical surgery and radiology, in the last two decades this was increasingly supplemented by endoscopy, often with adjuvant percutaneous drainage, mostly reducing open surgery to a salvage intervention in case of failure and complication. This study aims to evaluate and compare the current therapeutic options for pancreatic fluid collections, especially pseudocysts. Methods: Systematic literature search via MedLine and Pubmed was performed with comprehensive tabulations of original publications of the endoscopic, surgical and percutaneous therapeutic interventions in pancreatic pseudocysts and WON in the last 27 years. Only studies including more than 10 cases were further analysed. The results with regard to complications, outcome, recurrence and mortality were analysed for each approach, the risk of bias was assessed and a conclusive statement was made. Results: The initial literature search identified 46 studies. 12 studies had to be excluded because the number of individuals included was too low. 34 endoscopic, 8 surgical and 8 percutaneous studies were further analysed, leading to a number of 2485 patients in this review. The short-term clinical success was 85 % for the endoscopic approach, 83 % for surgery and 67 % for the percutaneous intervention. The complication rates were 16 %, 45 % and 34 % for endoscopic, surgical and percutaneous therapy, respectively. Typical complications were hemorrhage, infection, perforation and, especially in the percutaneous approach, pancreatocutaneous fistulisation. Conclusion: According to the high success and low complication rates the endoscopic intervention appears as the most efficient method. But each method has its own indications, restrictions and therefore patient groups. Therefore it is reasonable to consider all the available methods in a productive interdisciplinary manner for the ultimate benefit of the patient in the future.

Chronic pancreatitis shows an increasing prevalence and incidence mainly in the Western Hemisphere. Early diagnosis and therapy are frequently delayed because of non-specific symptoms as well as non-specific blood values. The German Society of Digestive and Metabolic Diseases (DGVS) organized the preparation and publication of an interdisciplinary S3 level guideline with the support of the German Radiological Society (DRG) as 1 of 11 contributing societies. In this article we present and discuss the main topics of the guideline regarding the diagnosis, differential diagnosis and therapy of complications of this complex chronic disease with a focus on clinical and scientific radiologists. Key Points: • Ultarsound represents the perfect first line imaging modality • For further diagnostic werk up MRI with MRCP are recommended for the differential diagnosis of pancreatic cancer • For clinical studies the modified (CT, MRI) Cambridge classification is recommended Citation Format: • Schreyer AG, Jung M, Riemann JF et al. S3 Guideline for Chronic Pancreatitis – Diagnosis, Classification and Therapy for the Radiologist. Fortschr Rontgenstr 2014; 186: 1002 – 1008

Introduction Blunt trauma of the pancreas represents a significant part of abdomen trauma in children with an incidence estimated at around 10%. If the conservative management is widely accepted concerning the stages I and II, it remains controversial concerning stages III and IV. The aim of our study was to perform a descriptive analysis of the nonoperative management, with a focus on the occurrence of pseudocysts. Materials and Methods The charts of the patients treated in our center for pancreatic trauma from 1990 to 2010 have been reviewed. It was defined by an initial lipase greater than three times the norm and an abnormal computed tomography scan. Results A total of 36 patients were included, with 26 boys (72%) and 10 girls (28%) with an average age of 8.7 years. The trauma was isolated in 13 cases (36.1%) and in 23 cases, there were other associated lesions (mainly liver [ n = 9] and spleen [ n = 5]). Pancreatic injuries were graded as follows: I ( n = 21), II ( n = 2), III ( n = 7), and IV ( n = 6). Pseudocysts occurred in 11 patients (30.5%) mainly in grades III ( n = 3) and IV ( n = 7), with an average delay of 17 days. Initial management of pseudocysts was conservative in six patients (54.6%), whereas five patients required mimi-invasive procedures. Conclusion Nonoperative management remains a safe way to treat pancreatic injuries despite an average 30% rate of pseudocyst (PC) appearance. It allows a reduction in the number of children who required procedures to less than half of the patients where PC occurred. Furthermore, these procedures were exclusively mini-invasive.

Transenteric drainage of a pancreatic fluid collection (PFC) with poor adherence to the bowel wall risks leakage and perforation. Elimination of tract dilation and the use of a fully covered self-expanding metal stent (FCSEMS) may improve safety. We evaluated endoscopic ultrasound (EUS)-guided drainage of PFCs using a one-step access device followed by placement of a FCSEMS. Eighteen patients (12 males; median age 50) with PFCs (median size 135 mm) meeting the criteria for indeterminate adherence were enrolled. After 7 - 10 days, the FCSEMSs were removed and exchanged for double-pigtail stents. When indicated, tract dilation and endoscopy-guided cyst debridement was performed. FCSEMS placement was technically successful in all patients without complications. Median procedure time was 37.5 minutes. Cystgastrostomy dilation resulted in dehiscence in one patient and was treated with repeat FCSEMS placement. Cyst resolution was achieved in 78 % of patients. FCSEMS placement without tract dilation enables safe initial drainage of PFCs with indeterminate adherence.

Background and study aim A prototype forward-viewing instrument has been developed for therapeutic endoscopic ultrasound (EUS)-guided fine needle aspiration (FNA). We had the opportunity to use this forward-viewing echo endoscope and to study its clinical usefulness, mainly for diagnostic EUS-FNA. Patients and methods The prototype forward-viewing echo endoscope was used for 15 months between November 2006 and March 2010, in a study group comprising 47 consecutive patients. Diagnostic EUS-FNA was done in 38 patients and the diagnostic accuracy of the forward-viewing device was compared with that from an oblique-viewing echo endoscope in reference patients who were matched by disease and puncture route. Therapeutic EUS was done in nine patients (pseudocyst drainage in six; celiac ganglia neurolysis, biliary drainage, and pancreatic duct drainage in one each). Results Diagnostic EUS-FNA provided a correct diagnosis in 97.4 % (37/38 patients), which was not significantly different from the 94.7 % (36/38) in the reference patients. Lesions considered difficult to access with an oblique-viewing scope, such as those located at the fornix, or the head of the pancreas, or associated with strictures, were easily punctured, as were those located at the body or tail of the pancreas or at the porta hepatis. Treatment was successful in all nine patients who underwent therapeutic EUS procedures. None of the 47 patients had any complications. Conclusions A forward-viewing echo endoscope that allows target sites to be punctured more perpendicularly with minimal effort, can be used for diagnostic EUS-FNA and this may be advantageous, depending on the site of target lesions.

Endosonography (EUS)-guided drainage of paragastric fluid collections using fully covered self-expanding metal stents (FCSEMS) is now a well-established procedure. Recently, new and specially designed lumen-apposing, fully-covered metal cystgastrostomy stents have been employed for this indication. In this case series, the use of these new stents for the drainage of malignant fluid collections in three symptomatic patients is described. Cases included a large pancreatic pseudocyst, secondary to underlying acute lymphoblastic leukemia, and two large collections of loculated ascites due to metastatic ovarian and cervical cancer, respectively. Technical success in inserting the new stents was achieved in all three patients, and resulted in symptomatic relief. There were no clinically significant complications directly attributed to the stents. These new lumen-apposing cystgastrostomy stents may provide a viable, minimally invasive, and effective alternative for drainage of malignant fluid collections, either for definitive treatment or for palliation of symptoms.

Cystic pancreatic lesions are often discovered incidentally as an asymptomatic finding, at a rate which is increasing considerably. In recent years the understanding of such tumors has become clearly differentiated. The spectrum of relevant lesions includes in particular the intraductal papillary mucinous neoplasm (IPMN), serous cystic neoplasm (SCN) and mucinous cystic neoplasm (MCN). With certain knowledge of their histological and radiomorphological structure as well as their distribution in terms of location, age and sex, such tumors are easy to differentiate and demarcate from common pancreatic pseudocysts. This also implies the fundamental understanding of complementary endoscopic procedures such as endosonography, which enables aspiration of the content of the cyst. A number of cystic pancreatic lesions have the potential to undergo malignant transformation along the adenoma-carcinoma sequence and therefore necessitate a differentiated approach to their radiological management. This review aims to develop a broad understanding of the pathological and radiomorphological characteristics of cystic pancreatic lesions and provides advice regarding procedures, particularly with respect to incidentally detected lesions.

BACKGROUND AND STUDY AIMS: Although endoscopic ultrasound (EUS)-guided transmural drainage (EUD) is preferred over conventional transmural drainage (CTD) of pancreatic pseudocysts by endoscopy in many centers, its superiority with -respect to technical success and clinical outcome has not yet been demonstrated in a prospective randomized trial. We conducted this prospective randomized trial to compare the technical success and clinical outcomes of EUD and CTD in treating pancreatic pseudocysts. Patients and methods: A total of 60 consecutive patients with pancreatic pseudocysts were randomly divided into two groups to undergo either EUD (n = 31) or CTD (n = 29) of pancreatic pseudocysts. The technical success rate, complications, and short-term and long-term results were prospectively evaluated. RESULTS: The rate of technical success of the -drain-age was higher for EUD (94 %, 29 / 31) than for CTD (72 %, 21 / 29; P = 0.039) in intention-to-treat analy-sis. In cases where CTD failed (n = 8), because the pseudocysts were non-bulging, a crossover was made to EUD, which was successfully performed in all these patients. Complica-tions occurred in 7 % of the EUD and 10 % of the CTD group (P = 0.67). During short-term follow-up, pseudocyst resolution was achieved in 97 % (28 / 29) in the EUD group and in 91 % (19 / 21) in the CTD group (P = 0.565). Long-term results analyzed on a per-protocol basis showed no significant difference in clinical outcomes be-tween EUD (89 %, 33 / 37) and CTD (86 %, 18 / 21, P = 0.696). CONCLUSIONS: We found that EUD and CTD can both be considered first-line methods of endo-scop-ic transmural drainage of bulging pseudocysts, whereas EUD should be preferred for non-bulging pseudocysts.

Background and study aims Although endoscopic ultrasound (EUS)-guided transmural drainage (EUD) is preferred over conventional transmural drainage (CTD) of pancreatic pseudocysts by endoscopy in many centers, its superiority with respect to technical success and clinical outcome has not yet been demonstrated in a prospective randomized trial. We conducted this prospective randomized trial to compare the technical success and clinical outcomes of EUD and CTD in treating pancreatic pseudocysts. Patients and methods A total of 60 consecutive patients with pancreatic pseudocysts were randomly divided into two groups to undergo either EUD (n = 31) or CTD (n = 29) of pancreatic pseudocysts. The technical success rate, complications, and short-term and long-term results were prospectively evaluated. Results The rate of technical success of the drainage was higher for EUD (94 %, 29/31) than for CTD (72 %, 21/29; P = 0.039) in intention-to-treat analysis. In cases where CTD failed (n = 8), because the pseudocysts were nonbulging, a crossover was made to EUD, which was successfully performed in all these patients. Complications occurred in 7 % of the EUD and 10 % of the CTD group ( P = 0.67). During short-term follow-up, pseudocyst resolution was achieved in 97 % (28/29) in the EUD group and in 91 % (19/21) in the CTD group ( P = 0.565). Long-term results analyzed on a per-protocol basis showed no significant difference in clinical outcomes between EUD (89 %, 33/37) and CTD (86 %, 18/21, P = 0.696). Conclusions We found that EUD and CTD can both be considered first-line methods of endoscopic transmural drainage of bulging pseudocysts, whereas EUD should be preferred for nonbulging pseudocysts.

Hemorrhage into pancreatic pseudocysts is a known complication of chronic pancreatitis. -Direct hemorrhage into the pancreatic duct is a rare entity, described first by Lower and Farrell , and only a few cases have been reported so far. The term “hemosuccus pancreaticus” was first used by Sandblom . Hemosuccus pancreaticus is often accompanied by epigastric pain, attacks of gastrointestinal hemorrhage with consecutive anemia, shock and sometimes with symptoms of hemobilia. Patients with splenic artery aneurysm and hemosuccus pancraticus present most often with the symptoms of the underlying disease, e. g., (chronic) pancreatitis. We report on two -cases with different diagnostic and therapeutic man-agement which reflect changes over time.

BACKGROUND: We describe the case of a patient aged 25 years showing the rare finding of a me-di-astinal tumour containing ectopic pancreatic -tissue (maximum diameter of 15 cm). At admis-sion, the patient presented with symptoms comparable to those of pneumonia. A computed tomographic scan of the thorax confirmed an -extensive mediastinal mass. A transthoracic puncture aspiration followed by a cytological examination failed to provide information of diagnostical relevance. OPERATION: To resect the mass and its adjacent tissue completely, a posterolateral thoracotomy on the left side was performed. The histopathological examination revealed exo- and endocrinic pan-creatic tissue and a pancreatic pseudocyst with-out a thoracopancreatic fistula. DISCUSSION: The incidence of mediastinal cysts containing pancreatic tissue seems to be extremely low. Above all, our case is the only one presenting clinical symptoms of a lobar pneumonia. In consideration of the current literature, we give a description of histological pattern, the possible pathogenesis and classification. CONCLUSION: Surgical therapy provides the chance for tumour removal. It provides an excellent outcome when performed completely.

OBJECTIVE Peripancreatic fluid collections are common complications of acute pancreatitis or acute exacerbations of chronic pancreatitis. Surgery is required when these fluid collections become infected or cause obstruction or pain. However, morbidity and mortality after surgery in these cases are still too high, therefore minimally invasive approaches have been encouraged. The aim of this study was to evaluate the feasibility of endoscopic ultrasound-guided transmural drainage with intracystic endoscopy and necrosectomy. MATERIAL AND METHODS From 2000 to 2006 30 patients (age: 57 +/- 10 years, range: 34 - 74 years) with an infected pancreatic pseudocyst or infected pancreatic necrosis were included in the study. The diagnosis of infection in patients who had fever despite an adequate antibiotic regime was confirmed by endoscopic fine needle aspiration with a positive bacterial or mycological result. The mean C-reactive protein value before treatment was 202 +/- 58 mg/L and the mean leukocyte count was 13.25 +/- 4.75 GPt/L. Transgastric cyst drainage was performed using a therapeutic endoscopic ultrasound probe (Pentax 38 UX or Olympus GF UCT 140) with insertion of an 8-Fr double pigtail prosthesis. After balloon dilatation (12 mm) a normal gastroscope was inserted into the cavity and all the fluid and easy removable necrosis were removed. The prosthesis was removed 4 weeks after the end of the endoscopic treatment. Clinical and ultrasound follow-up were carried out 3 and 6 months after removal of the prosthesis. The mean follow-up was 60 weeks. RESULTS The technical success of the procedure was 96.7 %, the long-term success was 83.4 %. On average 2.7 (range: 1 - 16) procedures were necessary for complete removal of necrosis and the remaining fluid. Major complications (bleeding, perforation, fistulation) occurred in 10 %. In 10 % a secondary operation was necessary. The overall mortality rate was 6.6 %. DISCUSSION Endoscopic treatment of infected pseudocysts and infected postacute pancreatic necrosis using transgastral retroperitoneal endoscopy with fluid and necrosis removal is a minimally invasive and effective procedure in patients with acute pancreatitis or acute exacerbation of chronic pancreatitis. However, the mortality rate of 6.6 % has to be taken into account.

BACKGROUND AND STUDY AIMS: Magnetic resonance cholangiopancreatography (MRCP) is a less-invasive alternative to endoscopic retrograde cholangiopancreatography (ERCP) for the diagnosis of primary sclerosing cholangitis (PSC). This study evaluated the diagnostic accuracy of MRCP in PSC compared with ERCP, and assessed the diagnostic accuracy of different T2w sequences. PATIENTS AND METHODS: 95 patients (69 PSC, 26 controls) were evaluated using both ERCP and MRCP. Exclusion criteria included secondary sclerosing cholangitis and contraindications to MRCP. The diagnosis of PSC was confirmed in 69 patients based on ERCP as the reference gold standard. MRCP was performed using a 1.5 Tesla MR unit, using breath hold, coronal and transverse half-Fourier acquisition single-shot turbo spin-echo (HASTE), coronal-oblique, fat-suppressed half-Fourier rapid acquisition with relaxation enhancement (RARE), and coronal-oblique, fat-suppressed, multisection, thin-section HASTE (TS-HASTE) sequences. The MRCP morphological criteria of PSC were evaluated and compared with ERCP. RESULTS: The sensitivity, specificity, and diagnostic accuracy were 86 %, 77 %, and 83 %, respectively, using the MRCP-RARE sequence, and increased further to 93 %, 77 %, and 88 %, respectively, by the inclusion of follow-up MRCP in 52 patients, performed at 6 - 12-month intervals. HASTE and TS-HASTE sequences showed significantly lower diagnostic accuracy but provided additional morphologic information. CONCLUSIONS: MRCP can diagnose PSC but has difficulties in early PSC and in cirrhosis, and in the differentiation of cholangiocarcinoma, Caroli’s disease, and secondary sclerosing cholangitis. A positive MRCP would negate some diagnostic ERCP studies but a negative MRCP would not obviate the need for ERCP.

Endoscopic ultrasonography (EUS)-guided interventions are an essential tool for complex (such as combined or subsequent) therapeutic measures and are, in current as well as future endoscopy, an indispensable part of modern gastroenterology. Longitudinal EUS scanners allow one to puncture transluminally both mediastinal and abdominal lesions which cannot be approached with other techniques. Using the EUS-guided puncture of such pathological lesions, it becomes possible to perform further, more advanced endoscopic interventions which thus become safer as well as more efficient and are associated with a lower complication rate compared with conventional endoscopic or even surgical interventions. A crucial aspect in interventional EUS is the adequate, less traumatic treatment of pancreatic pseudocysts. The transluminal route for interventions spanning from the approach to the placement of a drainage for abscesses and/or necroses is considerably easier under EUS-guidance, including better outcomes. Novel approaches and interventions are the internal EUS-guided insertion of a transluminal (from the upper GI tract) I) cholangiodrainage in patients with malignant obstruction of the bile duct but no option to achieve sufficient conventional cholangiodrainage with ERC or PTC, II) pancreaticodrainage in symptomatic patients with enlarged pancreatic duct -/+ pancreatic fistula postoperatively or in patients with chronic pancreatitis, which may be considered new therapeutic strategies with non-operative intentions and/or low invasiveness.

AIM Differential diagnosis of cystic lesions in the abdomen may be very difficult. We present the clinical manifestation and the diagnostic steps of a rare case of an aneurysm of the gastroduodenal artery mimicking a cystic lesion. We also discuss the imaging methods we used to verify the diagnosis such as colour Doppler sonography and 3D-sonography. METHOD AND PATIENT A 42-year old woman with chronic pancreatitis was admitted to our hospital after an extended diagnostic program (sonography, computed tomography and laparoscopy) with the diagnosis of a pancreatic pseudocyst with vascular erosion. Using conventional sonography we found a cystic lesion of 5 x 5 cm diameter with parietal deposits between pancreas and coeliac trunk. After colour Doppler sonography we found an arterial jet in the cystic tumor; initially the source of the jet seemed to be the hepatic artery. We referred the patient to our department of radiology with the diagnosis of hepatic artery aneurysm. The aneurysm was confirmed by the angiography and was embolised with coils in the same session. However, the source of the aneurysm was not the hepatic, but the gastroduodenal artery. By postangiographical 3D-sonography we could clearly reconstruct the relation of the aneurysm to the gastroduodenal artery. CONCLUSION Colour Doppler sonography should be the first imaging tool for clarifying cystic lesions in the abdomen. 3D-sonography is a reliable and useful method to identify visceral vessels of the abdomen. Nowadays the "gold standard" angiography should preferably be used as a therapeutic procedure.

BACKGROUND AND OBJECTIVE Endoscopic drainage of a pancreatic pseudocyst is an alternative to surgical intervention. But transmural drainage carries the risk of bleeding or perforation. Effectiveness and complication rate of endoscopic ultrasound-guided drainage, to avoid these risks, was investigated. PATIENTS AND METHODS Eleven patients (eight men, three women; mean age 55 years) with a pancreatic pseudocyst (nine with alcoholic and two with biliary pancreatitis) were studied prospectively between 1996 and 1998. In all of them transpapillary drainage of the cyst had not been technically possible. After an endoscopic ultrasound (EUS) examination, the gastric wall was incised with a fistulotome under EUS guidance. A guide-wire was then advanced through the fistulotome into the pseudocyst. A double pigtail catheter was implanted for drainage. The size of the pseudocyst was monitored sonographically at two-week intervals. RESULTS A cystogastrostomy was successfully established in ten of the twelve patients without serious complication. The pseudocyst was no longer demonstrated after a mean of 4.2 months (2 weeks to 6 months), while a small pseudocyst (1.6 cm [0.9-2.4 cm) remained in three patients. In two of the latter the size of the pseudocyst increased again after removal of the drainage catheter. Complete drainage by repeat cystogastrostomy succeeded in one of them, while a cystojejunostomy was established in the other. CONCLUSION Endoscopic ultrasound-guided transgastric drainage of a pancreatic pseudocyst is an effective treatment with few complications.

Between 1966 and 1985, 994 patients with chronic pancreatitis were treated at a University Surgical Department, 346 by drainage or diversion procedure, 339 by resection and 309 conservatively. The most frequent non-resecting procedures were: pancreatic pseudocyst drainage in 146, biliary-digestive tract anastomosis in 80, gastro-enterostomy in 15, biliary-tract revision in 58 and pancreatic duct drainage in 7 patients. More than half the patients had previously been operated on at least once. Overall postoperative death rate was 6.6%. Of those operated on up to 1983, whose subsequent course was analysed retrospectively, 16% had died (mean observation period 4.6 years). As many as 29% of patients had further bouts of pancreatitis. Weight remained steady or increased in 82%, the number of those with diabetes increased by 6%. All but 12% remained free of pain postoperatively or had only minor and occasional symptoms. Alcohol abuse decreased markedly. If alcohol consumption remained moderate (less than 50 g daily), late mortality rate was definitely decreased. Drainage or diversion procedures and pancreas resection are not competitive but complementary methods in chronic pancreatitis. Imaging techniques have helped the trend towards more conservative management.

AIM OF STUDY To compare retrospectively the endoscopic treatment of pancreatic pseudocysts by retrograde pancreatic drainage (ERPD), cystogastrostomy (ECG) or cystoduodenostomy (ECD). PATIENTS AND METHODS Between 1987 and 1995 pancreatic pseudocysts were successfully treated endoscopically in 30 patients (13 women, 17 men; mean age 49 [18-89] years): ERPD was accomplished through papillary insertion of 5-7 F prostheses into the cysts or pancreatic duct in 9 patients; ECG achieved drainage of cysts in the body or tail of the pancreas in 15 patients, and ECD for cysts in the head of the pancreas in three. Combined ERPD and ECG was necessary in three patients. RESULTS Significant pain relief was achieved in all patients, accompanied by increased appetite and weight. Occlusion or dislocation of the prosthesis required renewed endoscopic drainage in three patients. The prostheses were removed, 2-12 months after implantation, when pain relief had occurred and clinical as well as radiological findings had become normal. Recurrence 10-22 months after removal of the drain was observed in four patients, of whom two had a successful second drainage procedure. Surgical intervention became necessary in three patients because of inadequate drainage or (one case) bleeding. CONCLUSION These data indicate that endoscopic drainage of pancreatic pseudocysts gives good results with a low complication rate and no deaths. The procedure is thus an alternative to the at present prevailing operative treatment.

AIM Assessment of differential diagnostic criteria of cystic adenomas of the pancreas. METHOD We rechecked on all diagnostic criteria of patients with pancreatic pseudocysts retrospectively who had been treated in our department between 1981 and 1993. RESULTS 12 patients with cystic adenomas of the pancreas had been treated in our department i.a. 7.8% of all cystic pancreatic tumours. Histopathologically 1 microcystic and 4 macrocystic adenomas as well as 7 cystic adenocarcinomas were seen. CONCLUSION Diagnostic ultrasound criteria are discussed. Ultrasound-guided fine--needle-biopsy (FNB) is necessary to diagnose the content as well as the status of the pancreatic cysts. The ultrasound and the fine-needle-biopsy findings are important for differentiating between cystic adenomas and pseudocysts of the pancreas.

Background and study aims Portal hypertension often coexists with pancreatic pseudocysts and is potentially dangerous if a collateral vessel is in the vicinity of the needle puncture pathway. Hitherto, there have been no reports of pseudocyst drainage in this setting. Patients and methods Patients who underwent endoscopic ultrasound (EUS)-guided pancreatic pseudocyst drainage complicated by intervening vessels were assessed for success and outcomes. An Olympus mechanical linear-array video echo endoscope GF-UM 140D was used for the drainage procedure in all patients. Either a "hot" diathermy technique was employed or a "cold" technique using direct aspiration with a 19-G needle, followed by deployment of a nasocystic catheter. Results Eight patients with a symptomatic pseudocyst and intervening vessels underwent drainage that was guided (n = 6) or assisted (n = 2) by EUS. All were found to have successful resolution of the cyst at follow-up 6 weeks later, while segmental portal hypertension had disappeared in one patient. There were no major complications. One patient had transient hemorrhagic drainage that resolved by itself. Conclusions Pseudocysts complicated by portal hypertension or by intervening vessels can be safely drained under EUS guidance, even in the absence of color Doppler imaging.

In hydrocephalic children, ventriculo-peritoneal shunting is the preferred treatment with few complications. However, an obviously non-infectious peritoneal reaction to the cerebrospinal fluid (CSF) may occasionally lead to shunt malfunction. In eight hydrocephalic children, shunt malfunction with distal catheter complication was found with abdominal pseudocyst formation in seven cases and accumulation of the CSF in one. All children had a normal CSF cell count and glucose concentration, and white cell count, and C-reactive protein in peripheral blood were normal. No CSF infection could be detected despite prolonged aerobic and anaerobic cultures. After initial externalisation of the shunt and subsequent routine administration of antibiotics because infection initially was suspected, ventriculo-peritoneal shunting was attempted one to three times with identical failure before successful conversion to a ventriculo-atrial system. At laparotomy the peritoneum and intestinal serosa were hyperaemic and oedematous in all patients, five of whom also had pseudocysts and two of whom also had intra-abdominal adhesions. Four children had a revision 6-24 years after the ventriculo-atrial conversion due to short atrial catheter with distal obstruction. In three of them, the distal catheter was successfully replaced into the peritoneal cavity. The fourth child, however, developed an infectious abdominal pseudocyst with adhesions due to a then undetected Propionibacterium acnes infection. After externalisation and antibiotics, a new ventriculo-atrial shunt was inserted. At follow-up between 5 months to nearly 6 years later, the three children with peritoneal catheters did not show any signs of shunt malfunction or abdominal problems. Thus hydrocephalic children may develop shunt malfunction with distal catheter obstruction due to a still unexplained, transient, non-infectious peritoneal reaction leading to abdominal pseudocyst formation or accumulation of CSF. In some children, however, it may later be possible to replace the distal catheter into the peritoneal cavity, if no infection is involved.