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Pancreatic fluid collections (PFC) are primarily seen in acute pancreatitis (AP), chronic pancreatitis, or after trauma. PFC are considered late, four weeks after AP, and correspond to liquid pseudocysts (PC) and walled-off necrosis (WON). Most PFC are asymptomatic and regress spontaneously. When AP goes unnoticed, diagnosing PC can be challenging. Common complications of PFC include infection, organ compression, and haemorrhages. Abdominal CT scan is the imaging modality of choice for managing PFC and should include an arterial phase for evaluating vascular lesions. MRI may be useful to characterize a disconnected duct syndrome. Only symptomatic PFC require specific treatment, which is initially EUS drainage. In case of WON infection, empirical antibiotic therapy, sometimes sufficient, should be initiated upon suspicion. The step-up approach is preferred. Luminal apposition metal stent placement reduces procedure time. Percutaneous radiological drainage is performed for PFC distant from the digestive tract and carries a high risk of pancreaticocutaneous fistula. Surgical necrosectomy is reserved for cases of failure. Common adverse event of PFC drainage are haemorrhagic events, favoured by arterial injuries during AP, mainly occurring after four weeks. An emergency abdominal angio-CTscan should be performed in case of bleeding suspicion. In the presence of a pseudoaneurysm, preventive embolization should be carried out. In cases of pancreatic disconnection, medical-endoscopic treatment is often effective. [ABSTRACT FROM AUTHOR]

Background and Aims: Replacing lumen apposing metal stents (LAMS) with permanent indwelling plastic stents after the resolution of pancreatic fluid collections (PFC) in patients with disconnected pancreatic duct (DPD) is a debatable issue. We retrospectively evaluated the safety and efficacy of replacing LAMS with long-term indwelling transmural plastic stents in patients with DPD at head/neck of pancreas. Methods: The database of patients with PFC who underwent endoscopic transmural drainage with LAMS over the last three years was retrospectively analyzed to identify patients with DPD at the level of the head/neck of the pancreas. The patients were divided into two groups: Group A where LAMS could be replaced with plastic stents and Group B, where LAMS could not be replaced with plastic stents. The two groups were compared for recurrence of symptoms/PFC and complications. Results: Out of 53 patients studied, 39 patients (34 males; mean age: 35.7 ± 6.6 years) were included in Group A and 14 patients in Group B (11 males; mean age: 33.4 ± 5.9 years). The demographic profile as well as indwelling time of LAMS was comparable between two groups. PFC recurrence was observed in 2/39 (5.1%) patients in group A and 6/14 (42.8%) patients in group B (p = 0.0001) with one patient in group A and 5 patients in group B requiring repeat intervention for recurrent PFC. Conclusions: Long-term transmural plastic stent placement after removal of LAMS in pancreatic duct disconnection at head/neck of the pancreas is safe and effective strategy to prevent the recurrence of PFC. [ABSTRACT FROM AUTHOR]

Background & Aims: Previous studies have shown that patients with extra-pancreatic necrosis (EPN) alone are associated with better outcomes than patients with pancreatic necrosis (PN) in acute pancreatitis (AP). The natural history and drainage outcome of pancreatic collections resulting from PN vs. EPN has not been studied. Methods: Clinical records of a prospectively maintained cohort of AP patients who underwent endoscopic drainage of walled of necrosis (WON) were reviewed. Computed tomography (CT) done on day 4 to 7 of illness was reviewed to identify EPN alone (Group 1) or PN with or without EPN (Group 2). Group 1 and 2 were compared for WON characteristics, as well as outcome and adverse effects of endoscopic drainage. Results: Seventy-one patients in Group 2 (57 males; mean age 38.6±11.5 years) were compared with sixteen patients in Group 1 (12 males; mean age 34.5±10.8 years). WON developing in Group 2 were significantly larger (11.7±2.8 cm vs. 9.5±2.03 cm) with higher solid necrotic debris (30.4±9.8% vs. 13.7±7.2%). Endoscopic transmural drainage of WON associated with PN required a greater number of direct endoscopic necrosectomy (DEN) sessions along with a longer time for resolution. The time taken for resolution correlated with size (r=0.629, p <0.01) and solid debris content (r=0.647, p<0.01), which were significantly higher in the PN group. Conclusions: This new entity of walled of extra pancreatic necrosis alone has lesser solid necrotic debris and its endoscopic drainage is associated with better outcomes as compared to patients with walled off pancreatic necrosis. [ABSTRACT FROM AUTHOR]

Résumé: L'infection de nécrose organisée pancréatique est une complication majeure des pancréatites aiguës graves, associée à une mortalité pouvant s'élever jusqu'à 20 à 30 %. Sa prise en charge est multidisciplinaire et repose sur un traitement anti-infectieux et un drainage de la nécrose préférentiellement « mini-invasif ». De nombreuses études se sont intéressées à l'écologie bactérienne des infections de nécrose pour guider le choix de l'antibiothérapie. Les séries récentes montrent une diminution des infections à bacilles Gram négatif d'origine digestive au profit de germes à Gram positif, une émergence des infections à bactéries multirésistantes et une augmentation des surinfections fongiques à Candida. Le recours trop précoce à une antibiothérapie dans le traitement de la nécrose organisée pancréatique stérile pourrait être en cause dans ce changement de spectre bactérien, et n'est actuellement pas recommandé. L'antibiothérapie doit idéalement être adaptée aux prélèvements microbiologiques réalisés lors du drainage des collections. La survenue d'une infection de coulée de nécrose pancréatique est une indication formelle au drainage. L'écho-endoscopie thérapeutique occupe une place centrale dans l'approche dite « step-up », qui privilégie en premier lieu le recours aux techniques les moins invasives. En effet, la nécrosectomie endoscopique est associée à une morbidité inférieure à celle des techniques chirurgicales. L'apparition récente des prothèses d'apposition luminale représente une évolution importante, dans la mesure où elles facilitent la procédure de drainage et sont associées à des taux élevés de succès techniques et cliniques. La prise en charge multidisciplinaire de l'infection de coulée de nécrose est donc la pierre angulaire de la gestion de cette affection grave parfois mortelle. L'antibiothérapie doit être débutée devant des arguments forts d'infection de coulée de nécrose afin d'éviter de sélectionner des bactéries avec un haut niveau de résistance ou des surinfections fongiques. Infected walled off necrosis (WON) is a major complication of acute pancreatitis. It is associated with a mortality that can rise up to 20 to 30%. Its treatment is based on a multidisciplinary approach and requires antibiotics associated with drainage, which has to be as less invasive as possible. Studies have been carried out to identify the main bacterias responsible for those infections and guide the antibiotherapy. The most recent series have shown less infections due do gram-negative bacilli. It has also shown an increased prevalence of gram-positive infections, the emergence of multidrug resistant bacteria, and an increase in fungal infections (Candida spp.). The overuse of antibiotics for non-infected WON might be in cause in these changes. Antibiotics should be adapted to microbiological samples taken from collections as much as possible. The occurrence of WON infection is a formal indication for drainage. Therapeutic echo-endoscopy occupies a central place in the "step-up" approach, which favours the use of the least invasive techniques first. Indeed, endoscopic necrosectomy is associated with lower morbidity than surgery. The recently development luminal apposition metal stent can ease the drainage procedure, with a higher rate of technical and clinical success. Multidisciplinary management of WON infection is therefore the cornerstone of the management of this serious and sometimes fatal condition. Antibiotic therapy should be initiated when there is strong evidence of necrotic flow infection to avoid selecting bacteria with a high level of resistance and fungal superinfections. [ABSTRACT FROM AUTHOR]

Introduction: Internal drainage of walled of necrosis of pancreas has been considered as the standard of care. For symptomatic walled off necrosis (WON) of pancreas with the advent of laparoscopy and refinement of techniques and instrumentation, laparoscopic internal drainage is becoming the standard surgical drainage procedure for these patients. However, there is a dearth of literature regarding outcomes following laparoscopic drainage. Most of the studies have small number of patients with limited follow-up. We in this study describe our experience of laparoscopic internal drainage of walled off necrosis over the last 13 years.Materials and Methods: This is a retrospective analysis of a prospectively maintained database. All patients with WON undergoing laparoscopic internal drainage between January 2005 and December 2018 were included. Primary outcome measure was successful drainage. Secondary outcome measures included morbidity, hospital stay, re-intervention rate and mortality. Patients were followed up post-operatively at 1 week, 4 weeks, 3 months and then annually thereafter. Ultrasonography was done periodically for the assessment of cyst resolution.Results: Between 2005 and 2018, 154 surgical drainage procedures were performed for symptomatic pseudocyst/walled off necrosis. Out of these, 134 underwent laparoscopic drainage; 129 patients (96.3%) underwent laparoscopic cystogastrostomy and 5 (3.7%) underwent laparoscopic cystojejunostomy. Majority of the patients were male (male:female = 6:1) with a mean age of 36 ± 12.9 years (range 15-58 years). The mean operative time was 94 min (range 64-144 min). There were three conversions because of intra-operative bleeding. The overall post-operative morbidity was 8.9%. The average hospital stay was 4.4 days (2-19 days). The mean duration of follow-up was 5.5 years (range 6 months-13 years). Complete cyst resolution was achieved in 95.5% (n = 128) patients. There has been no mortality till date.Conclusion: In conclusion, laparoscopic internal drainage is a very effective technique for drainage of WON with an excellent success rate. [ABSTRACT FROM AUTHOR]

Acute Pancreatitis (AP) tends to have a benign course in children. However there is a paucity of information with respect to severity of AP in children, the categorization of collections viz., walled off necrosis (WON)& pseudocyst and their natural history & outcomes. A retrospective medical record review of 187 children with pancreatitis diagnosed and managed at our centre was performed. 101 children (59% boys, Median age 9yrs) had AP of which 37.6%, 60.4% and 2% had mild, moderately severe and severe AP. 61.4%(62) had PFC at diagnosis; 34%(21) acute pancreatic fluid collections (APFC) and 66%(41) acute necrotic collections (ANC). 52.3%(11of21) of APFC evolved into pseudocysts & 68.2%(28of41) of ANC into WON's. Drainage was required in 31%(12of39) of persisting collections, more frequently in children with traumatic AP. Percutaneous catheter drainage (PCD) was done in 6 children and endoscopic ultrasound (EUS) guided cystogastrostomy with placement of plastic or self expanding metal stents (SEMS) in 6 children. Moderately severe AP is common in hospitalized children with AP with PFC developing in 61.4%, majority being APFC. 48% of APFC and 32% of ANC will resolve and the rest evolve into pseudocyst or WON. Spontaneous resolution is more likely in children with non -traumatic AP having pseudocysts rather than WON's. [ABSTRACT FROM AUTHOR]

Computed tomography (CT) is the most commonly performed imaging test for acute pancreatitis. Nevertheless, magnetic resonance (MRI) imaging is useful in many specific situations. These include evaluating patients with acute pancreatitis who cannot receive iodinated CT contrast, elucidating the underlying cause of acute pancreatitis, assessing ductal disconnection and for guiding intervention of necrotic collections. Non-contrast MRI is superior to non-contrast CT and MRI for the diagnosis of acute pancreatitis. We discuss these specific uses of MRI in acute pancreatitis. We highlight the future advances in MRI including faster, free-breathing scans that allow MRI to be completed within 10 min. [ABSTRACT FROM AUTHOR]

Résumé: La nécrose pancréatique organisée (NOP) compliquant un épisode de pancréatite aiguë sévère grève le pronostic. De nombreuses études se sont intéressées à la prise en charge de ces patients, faisant passer d'une prise en charge chirurgicale à une approche progressive « step-up » intégrant les drainages par voie radiologique puis endoscopique. Le drainage endoscopique a été initialement réalisé avec des prothèses plastiques puis des prothèses métalliques couvertes. Cette technique a permis d'accéder via le tube digestif à la nécrose pancréatique et de développer la nécrosectomie endoscopique. De nouvelles prothèses dites d'apposition luminale sont apparues récemment. Il a été montré un important succès technique et clinique avec un taux de résolution de la nécrose pancréatique de l'ordre de 95 % et un faible taux de récidive. Un nouveau système « tout-en-un » a révolutionné la mise en œuvre de ces prothèses diminuant le nombre d'instruments et de manipulations nécessaires rendant la pose plus facile et rapide. Cependant, il a été décrit des complications sévères notamment à distance de la pose par lésion d'un vaisseau adjacent justifiant une surveillance rapprochée et un retrait précoce de la prothèse. Par ailleurs, il existe un surcoût à mettre en balance avec les succès technique et clinique. Les prothèses d'apposition luminale redéfinissent la prise en charge de la NOP. Les taux de succès technique et clinique importants mis en évidence dans les études en témoignent. Il faut cependant réserver cette technique aux centres experts afin de proposer une approche « step-up » en coordination avec les équipes de radiologie et de chirurgie mais aussi en raison de complications parfois graves lors de la pose ou au décours, et du surcoût qu'engendrent ces prothèses. Il semble intéressant que de nouvelles études soient réalisées afin de préciser la gestion de ces prothèses et de leurs complications. Walled off necrosis (WON) is a major complication of acute necrotizing pancreatitis (ANP) and strikes patients' prognosis. Many studies have been studying ANP management which has progressively evolved from exclusive surgery towards to a step-up approach including radiological and endoscopic drainages. As far as endoscopy is concerned, initial management consisted on stenting pancreatic collection with double pigtail plastic stent. Then full covered self-expandable metallic stent was developed to allow a direct access to WON passing through a standard gastroscope. It was the emergence of Direct Endoscopic Necrosectomy. More recently, a lumen apposing metal stent (LAMS) was designed to anastomose digestive tract to adjacent structure. It represents an important technical and clinical success since WON resolution was observed nine times out of ten with lower recurrence. Finally, new LAMS integrating electrocautery enhanced delivery system emerged reducing procedure steps. However, severe complications have been described, including acute hemorrhage by erosion of an adjacent vessel. These adverse events advocate close monitoring by compute tomodensitometry and early stent's removal. Unfortunately, there are no recommendations for the withdrawal of the stent. This new device has an additional cost compared to DPPS. However, it is important to keep in mind the global cost of management of WON not only endoscopic procedure to compare it with other devices. In conclusion, LAMS redefine the management of symptomatic WON and appear to provide a benefit in terms of technical and clinical success. But now, this technique should be reserved only for expert centers in order to propose a step-up approach in coordination with the radiology and surgery teams. Moreover, serious complications can occur and should be manage by expert teams. New studies should be carried out to determine the management of this stent and their complications and include them in new recommendation in management of WON. [ABSTRACT FROM AUTHOR]

Background and objective: Acute pancreatitis (AP) is an inflammatory process of the pancreas, with variable involvement of peri-pancreatic tissues and remote organ systems. In this study we discuss surgical and conservative management of acute pancreatitis and its local complication. Methods: This retrospective study was carried out on 128 patients, who were admitted to Gastrointestinal Surgery Unit, Main Alexandria University Hospital, Alexandria University, and who were complaining of acute pancreatitis with fluid collections and sequels (PP, ANC and walled-off pancreatic necrosis (WOPN). Medical information was retrieved retrospectively from patient's files recorded in Main Alexandria University Hospital and from computerized data system in Gastrointestinal Surgery Department, between October 2013 - October 2018. Results: Forty-five patients with acute edematous pancreatitis with free collection were managed conservatively successfully. Thirty-two patients with PP underwent drainage, endoscopic (n=17), or open (n=15) approach. Twentythree patients with WON underwent drainage and debridement whether by open (n=11), endoscopic (n=9), or PCD (n=3) approaches. Twenty-eight patients with necrotizing pancreatitis, 16 patients were managed conservatively, 12 patients needed intervention either, PCD (n=9) or open surgical necrosectomy (n=3). Conclusions: The operative management of acute pancreatitis is focused on managing the acute complications, and the long-term sequelae. However, the evolution of videoscopic and endoscopic techniques have greatly expanded the tools available. [ABSTRACT FROM AUTHOR]

Background: Pancreatic fluid collections (PFC) may develop following acute pancreatitis (AP). Endoscopic and laparoscopic internal drainage are accepted modalities for drainage of PFCs but have not been compared in a randomized trial. Our objective was to compare endoscopic and laparoscopic internal drainage of pseudocyst/walled-off necrosis following AP.Patients and Methods: Patients with symptomatic pseudocysts or walled-off necrosis suitable for laparoscopic and endoscopic transmural internal drainage were randomized to either modality in a randomized controlled trial. Endoscopic drainage comprised of per-oral transluminal cystogastrostomy. Additionally, endoscopic lavage and necrosectomy were done following a step-up approach for infected collections. Surgical laparoscopic cystogastrostomy was done for drainage, lavage, and necrosectomy. Primary outcome was resolution of PFCs by the intended modality and secondary outcome was complications.Results: Sixty patients were randomized, 30 each to laparoscopic and endoscopic drainage. Both groups were comparable for baseline characteristics. The initial success rate was 83.3% in the laparoscopic and 76.6% in the endoscopic group (p = 0.7) after the index intervention. The overall success rate of 93.3% (28/30) and 90% (27/30) in the laparoscopic and endoscopic groups respectively was also similar (p = 1.0). Two patients in the laparoscopic group required endoscopic cystogastrostomy for persistent collections. Similarly, two patients in the endoscopic group required laparoscopic drainage. Postoperative complications were comparable between the groups except for higher post-procedure infection in the endoscopic group (19 vs. 9; p = 0.01) requiring endoscopic re-intervention.Conclusions: Endoscopic and laparoscopic techniques have similar efficacy for internal drainage of suitable pancreatic fluid collections with < 30% debris. The choice of procedure should depend on available expertise and patient preference. [ABSTRACT FROM AUTHOR]

Background: EUS-guided drainage of pancreatic fluid collections (PFCs; pancreatic pseudocyst (PPC) or walled-off necrosis (WON)) using lumen apposing metal stents (LAMSs) is now standard of care. We adopted a protocol of early LAMS removal and prospectively followed patients to determine if this protocol avoids bleeding complications. Methods: Prospective, consecutive case series of all patients with PPC and WON who underwent drainage with LAMS at a tertiary care referral center from July 2016 to November 2018. LAMS was removed within 4 weeks for PPC and within 6 weeks for WON. Patients with residual necrosis after 6 weeks underwent removal of initial LAMS and replacement with new LAMS every 6 weeks until resolution. Patients were followed within protocol while monitoring for bleeding complications and clinical success. We also performed a literature review to determine rates of LAMS related bleeding at various timepoints. Results: Forty patients (PPC n = 19, WON n = 21) underwent drainage with LAMS. Median time for LAMS removal was 21.0 days for PPC and 33.5 days for WON. Technical success and clinical success were achieved in 40/40 patients with zero cases of delayed bleeding. A literature review of 21 studies and 1378 patients showed 52/1378 (3.8%) bleeding events with 24/52 (46.2%) events occurring within 1 week of LAMS placement. Conclusions: An early removal LAMS protocol for PFC is highly efficacious and prevents delayed bleeding. Based on analysis of published cases, half of LAMS related bleeding occurs within the first week suggesting procedural factors rather than stent dwell time impact risk of bleeding. [ABSTRACT FROM AUTHOR]

Objectives The minimally invasive step-up approach for treatment of walled off necrosis (WON) involves drainage followed by later necrosectomy as needed, and is superior to primary surgical necrosectomy. Reported series of endoscopic transluminal necrosectomy include highly selected patients. We report outcomes of a large series of patients with WON managed by an algorithm based on an endoscopically centered step-up approach. Methods Consecutive patients with necrotizing pancreatitis from 2009 to 2014, with intervention only for infected or persistently symptomatic WON. The primary approach involved endoscopic transluminal drainage plus minus necrosectomy whenever feasible, with percutaneous catheter drainage (PCD) plus minus sinus tract endoscopy if not feasible or sufficient. Surgery was reserved for failures of the step up approach. Results Of 109 consecutive patients with necrotizing pancreatitis, intervention was required in 83, including endoscopic transluminal drainage in 73 (88%) (alone in 49 and combined with PCD in 24), and PCD alone in 10 (12%). 64 (77%) of the 83 patients required endoscopic transluminal and/or sinus tract necrosectomy. Adverse events occurred in 11 (13%). Three patients (4%) failed step up approach and required open surgical necrosectomy. All-cause mortality occurred in 6 (7%) of 83 patients after intervention, including 2 of 3 requiring surgery. Conclusions An algorithm based step-up approach for interventions in necrotizing pancreatitis using primarily endoscopic techniques with adjunctive percutaneous approaches as needed resulted in favorable outcomes with small numbers proceeding to open surgery, and with acceptable rates of major complications and mortality. A purely endoscopic transluminal approach was feasible in approximately 60% of patients requiring intervention in this series. [ABSTRACT FROM AUTHOR]

Background Walled off necrosis (WON) can be treated endoscopically using multiple transmural plastic stents or fully covered self-expandable metallic stent (FCSEMS) and direct endoscopic necrosectomy (DEN). We evaluated the efficacy of “step-up” endoscopic transmural approach for treatment of WON. Methods Retrospective analysis of data of 86 patients with WON who were treated with attempted endoscopic ultrasound (EUS) guided “step up” transmural drainage during last 5 years was done. Initially multiple plastic stents were placed and patients not responding underwent FCSEMS placement and/or DEN. Results Patients presented 10.8 ± 2.8 weeks after an acute attack of acute pancreatitis and mean size of WON was 10.7 ± 2.9 cm. EUS guided transmural drainage was technically successful in 85/86 (98.8%) patients and 70 (82.4%) were drained with multiple 7/10Fr plastic stents alone while DEN was needed in 9 (10.6%) and FCSEMS was inserted in 6 (7%) patients. All patients had successful outcome with none requiring surgery. The patients who needed DEN/FCSEMS presented earlier and had large size collection with more solid necrotic debris as compared to patients treated with multiple plastic stents alone. The complications were pneumoperitoneum (n = 1), bile leak following cholecystecomy (n = 1), development of external pancreatic fistula following percutaneous drainage (n = 1) and gastrointestinal bleed (n = 1). Conclusions “Step up” endoscopic transmural drainage using multiple plastic stents as an initial therapy is safe and effective treatment of WON and avoids more aggressive DEN in majority of patients. Large size WON with more necrotic debris may require DEN. [ABSTRACT FROM AUTHOR]

Background and Aim Endoscopic transmural drainage ( ETMD) of peripancreatic fluid collections ( PFC) is an effective alternative to surgical drainage. Conventional drainage using plastic stents has its limitations. A wide-bore short-length wide flange fully covered self-expandable metallic stent ( FCSEMS) has recently been developed. The present study evaluates the efficacy of this new FCSEMS for ETMD of PFC. Methods This was a retrospective, multicenter study. Patients with PFC undergoing endoscopic ultrasound ( EUS)-guided drainage of PFC using specially designed FCSEMS were included. Parameters evaluated were technical success of stent placement, clinical success as defined by resolution of PFC without any further surgical intervention, ability to carry out endoscopic necrosectomy, complications and feasibility of endoscopic stent removal. Results Twenty-one PFC in 19 patients were drained using FCSEMS. Technical and clinical success for drainage was seen in all patients (100%). Endoscopic necrosectomy was carried out in seven (33%) PFC. Complications occurred in two patients (10.5%). Stents could be endoscopically removed in all patients (100%). Conclusions The new specially designed FCSEMS is safe and effective for drainage of PFC. Necrosectomy can be carried out through the stent. Stent can be removed endoscopically at the end of the treatment period. [ABSTRACT FROM AUTHOR]

Pancreatic necrosis may result as a complication of acute pancreatitis, often causing significant morbidity and mortality. There are many recommendations concerning the management of pancreatic necrosis, including non-operative management with supportive care and antibiotics, computed tomography (CT)-guided percutaneous drainage, endoscopic transluminal drainage, and operative necrosectomy. Historically, pancreatic necrosis has been treated surgically. However, surgical management of pancreatic necrosis is associated with high mortality (6-28 %) and morbidity (19-62 %). Thus, endoscopic therapy has emerged as a relatively new minimally invasive technique for treating infected and/or symptomatic pancreatic necrosis in the last decade. Although there have been two randomized trials comparing endoscopic transluminal drainage versus operative necrosectomy, there is little data regarding timing, indication, and outcomes of these procedures. [ABSTRACT FROM AUTHOR]