Pancreaticopleural fistula causing pleural effusion: a case report and review of the literature.

BACKGROUND: Pancreaticopleural fistula is a rare complication of pancreatitis and poses diagnostic and therapeutic challenges. This case report sheds light on the unique challenges posed by pancreaticopleural fistula as a rare complication of pancreatitis. The aim is to contribute valuable insights to the scientific literature by presenting a case involving a middle-aged man with acute necrotizing pancreatitis and associated pleural effusion. CASE PRESENTATION: A 41-year-old Asian male with a history of pancreatitis and chronic alcohol use presented with severe dyspnea, chest pain, and left-sided pleural effusion. Elevated serum amylase lipase levels and imaging confirmed acute necrotizing pancreatitis with a computed tomography severity index of 8/10. Magnetic resonance cholangiopancreatography revealed pancreatic necrosis and pseudocyst formation and findings suggestive of pancreaticopleural fistula. The patient was then treated with octreotide therapy. CONCLUSION: The management of pancreaticopleural fistula demands a comprehensive and individualized approach. Recognition guided by high clinical suspicion coupled with appropriate investigations and a careful balance between medical, endoscopic, and surgical interventions is crucial for achieving favorable outcomes. This case report adds to the scientific literature by providing insights into the complexities of pancreaticopleural fistula and emphasizing the importance of personalized strategies in its management.

Epidemiology, treatment and outcomes of infected pancreatic necrosis in France: a bicenter study.

INTRODUCTION: Acute necrotizing pancreatitis (ANP) mortality increases when pancreatic necrosis is infected (IPN). Current treatment of IPN relies on prolonged antibiotic therapies associated with a step-up strategy of drainage. The objective of this study was to analyze IPN treatment outcomes in two referral centers in France. METHODS: Data of consecutive patients with documented IPN hospitalized in two expert centers in France between 2014 and 2019 were retrospectively reviewed. The composite primary outcome was the proportion of unsuccessful management outcome, defined as new emergency drainage to treat sepsis with organ failure, an unplanned new antibiotic course, an unplanned prolongation of antibiotic course and/or death by septic shock, within three months following the diagnosis of ANP. RESULTS: All in all, 187 patients (138 males; 74.0%), with documented IPN were included. The most frequently identified microorganism was Escherichia coli (26.2%). Ninety-eight patients (52.4%) were admitted to an intensive care unit or resuscitation ward within the first two days of ANP care. Overall, 126 patients (67.4%) endured an unsuccessful outcome: new emergency drainage to treat acute sepsis (62.0%), unplanned new antibiotic course (47.1%), unplanned prolongation of antibiotic course (44.9%) and/or death by septic shock complicating IPN (8.0%). CONCLUSION: The unfavorable evolution in two thirds of patients shows that determination of optimal drainage timing and choice of antibiotic therapy remain major challenges in 2024.

Neutrophil CD64 index as a new early predictive biomarker for infected pancreatic necrosis in acute pancreatitis.

OBJECTIVE: Infectious pancreatic necrosis (IPN) is a serious complication of acute pancreatitis, and early recognition and timely intervention are the keys to improving clinical outcomes. The purpose of this study was to investigate the predictive capacity of the neutrophil CD64 index (nCD64 index) on IPN in patients with acute pancreatitis METHODS: This study comprises two independent cohorts: the training cohort consisted of 202 patients from Hunan Provincial People's Hospital, and the validation cohort consisted of 100 patients from Changsha Central Hospital. Peripheral blood samples were collected on the day of admission and on the 3rd, 5th, 7th, and 10th days of hospitalization, and the nCD64 index was detected by flow cytometry. Additionally, relevant clinical characteristics and laboratory biomarkers were collected and analyzed. RESULTS: We observed that nCD64 index on admission was significantly higher in the IPN group than Non-IPN group (p < 0.001). In the training cohort, a higher occurrence rate of IPN was observed in the high nCD64 index group compared to the moderate and low nCD64 index group (p < 0.001). Further analysis showed that nCD64 index was significant positive correlated with the incidence rate of IPN (p < 0.001, correlation coefficient = 0.972). Furthermore, logistic regression analysis showed that high expression of the nCD64 index on admission was a risk factor for the occurrence of IPN (OR = 2.971, p = 0.038). We further found that the nCD64 index of IPN patients was significantly higher than the Non-IPN patients on the days 1, 3, and 5 after admission, and the nCD64 index of IPN patients before and after the onset (p < 0.05). At the same time, this study revealed that the nCD64 index on admission showed good predictive efficacy for IPN (AUC = 0.859, sensitivity = 80.8%, specificity = 87.5%), which was comparable to APACHE II score. And this finding was further validated in an independent cohort of 100 participants (AUC = 0.919, Sensitivity = 100.0%, Specificity = 76.6%). CONCLUSION: This study demonstrated the clinical value of nCD64 index in patients with IPN patients for the first time through two independent cohort studies. The nCD64 index can be used as an early prediction and risk assessment tool for the occurrence of IPN, contributing to the improvement of patient outcomes and efficiency of medical resource allocation.

Long-term follow-up study of necrotising pancreatitis: interventions, complications and quality of life.

OBJECTIVE: To describe the long-term consequences of necrotising pancreatitis, including complications, the need for interventions and the quality of life. DESIGN: Long-term follow-up of a prospective multicentre cohort of 373 necrotising pancreatitis patients (2005-2008) was performed. Patients were prospectively evaluated and received questionnaires. Readmissions (ie, for recurrent or chronic pancreatitis), interventions, pancreatic insufficiency and quality of life were compared between initial treatment groups: conservative, endoscopic/percutaneous drainage alone and necrosectomy. Associations of patient and disease characteristics during index admission with outcomes during follow-up were assessed. RESULTS: During a median follow-up of 13.5 years (range 12-15.5 years), 97/373 patients (26%) were readmitted for recurrent pancreatitis. Endoscopic or percutaneous drainage was performed in 47/373 patients (13%), of whom 21/47 patients (45%) were initially treated conservatively. Pancreatic necrosectomy or pancreatic surgery was performed in 31/373 patients (8%), without differences between treatment groups. Endocrine insufficiency (126/373 patients; 34%) and exocrine insufficiency (90/373 patients; 38%), developed less often following conservative treatment (p<0.001 and p=0.016, respectively). Quality of life scores did not differ between groups. Pancreatic gland necrosis >50% during initial admission was associated with percutaneous/endoscopic drainage (OR 4.3 (95% CI 1.5 to 12.2)), pancreatic surgery (OR 3.2 (95% CI 1.1 to 9.5) and development of endocrine insufficiency (OR13.1 (95% CI 5.3 to 32.0) and exocrine insufficiency (OR6.1 (95% CI 2.4 to 15.5) during follow-up. CONCLUSION: Acute necrotising pancreatitis carries a substantial disease burden during long-term follow-up in terms of recurrent disease, the necessity for interventions and development of pancreatic insufficiency, even when treated conservatively during the index admission. Extensive (>50%) pancreatic parenchymal necrosis seems to be an important predictor of interventions and complications during follow-up.

The First Successful Living Donor Liver Transplantation for Acute-on-Chronic Liver Failure Caused by Severe Acute Necrotizing Pancreatitis: A Case Report.

Liver transplantation (LT) is the only life-saving option when acute-on-chronic liver failure (ACLF) does not improve with conservative therapy. Acute pancreatitis (AP) can cause chronic liver disease progression to ACLF. However, deceased donor LT for patients with AP has had mixed results, and no consensus has been established regarding the indication for LT. We report the first successful living donor LT (LDLT) for ACLF caused by severe AP. The 38-year-old patient with alcoholic liver disease was transferred to our institute with worsening refractory ascites. During the pretransplant workup, she developed severe acute necrotizing pancreatitis, resulting in grade 3 ACLF. The patient's clinical course was further complicated by high levels of donor-specific antibodies and immune thrombocytopenia. The AP gradually improved after intensive care combined with artificial liver support. The patient successfully underwent urgent LDLT with upfront splenectomy and desensitization therapy, including plasm exchange, high-dose intravenous immunoglobulin, and anti-thymocyte globulin. No infection or recurrence of AP was observed postoperatively. We conclude that LDLT is a feasible option for ACLF patients caused by severe AP if a deceased donor is not readily available.

Dynamic nomogram for predicting infected pancreatic necrosis in female patients of childbearing age with hypertriglyceridemia-induced acute pancreatitis.

BACKGROUND: Hypertriglyceridemia is a common cause of acute pancreatitis. Pregnant women are at risk of developing hypertriglyceridemia-induced acute pancreatitis (HTG-AP); however, whether pregnancy increases the risk of infected pancreatic necrosis (IPN) is unknown. AIM: We aimed to assess the association between pregnancy and IPN. METHODS: This 10-year retrospective cohort study was conducted at Jinling Hospital. Adult female patients of childbearing age with HTG-AP between January 2013 and September 2022 were screened. Logistic regression analyses were performed to assess the risk factors for IPN. Patients admitted within 7 days were assigned to the training and validation sets to develop a dynamic nomogram for IPN prediction. RESULTS: 489 patients were included, and 144 developed IPN. Logistic regression analyses revealed pregnancy (OR: 2.578 95% CI: 1.474-4.510) as an independent risk factor for IPN. Gestation weeks, ARDS, albumin level, and serum creatinine level were selected as the predictors of the dynamic nomogram for IPN prediction, with good discrimination in the training set (AUC 0.867 95% CI: 0.794-0.940) and validation set (AUC 0.957 95% CI: 0.885-1.000). CONCLUSION: Pregnancy increases the risk of IPN in adult patients of childbearing age with HTG-AP, and the dynamic nomogram may help risk stratification for IPN.

Prognostic significance of organ failure and infected pancreatic necrosis in acute pancreatitis: An updated systematic review and meta-analysis.

OBJECTIVES: In patients with acute pancreatitis (AP), minimally invasive treatment and the step-up approach have been widely used to deal with infected pancreatic necrosis (IPN) in the last decade. It is unclear whether IPN has become a less important determinant of mortality relative to organ failure (OF). We aimed to statistically aggregate recent evidence from published studies to determine the relative importance of IPN and OF as determinants of mortality in patients with AP (PROSPERO: CRD42020176989). METHODS: Relevant studies were sourced from MEDLINE and EMBASE databases. Relative risk (RR) or weighted mean difference (WMD) was analyzed as outcomes. A two-sided P value of less than 0.05 was regarded as statistical significance. RESULTS: Forty-three studies comprising 11 601 patients with AP were included. The mortality was 28% for OF patients and 24% for those with IPN. Patients with OF without IPN had a significantly higher risk of mortality compared to those with IPN but without OF (RR 3.72, P < 0.0001). However, patients with both OF and IPN faced the highest risk of mortality. Additionally, IPN increased length of stay in hospital for OF patients (WMD 28.75, P = 0.032). CONCLUSION: Though IPN remains a significant concern, which leads to increased morbidity and longer hospital stay, it is a less critical mortality determinant compared to OF in AP.

PREDICTION OF EXTERNAL PANCREATIC FISTULA DEVELOPMENT IN PATIENTS WITH ACUTE INFECTED NECROTISING PANCREATITIS.

OBJECTIVE: The aim: To search for risk factors for the development of external pancreatic fistula (EPF) in patients with acute infected necrotizing pancreatitis. PATIENTS AND METHODS: Materials and methods: A prospective single-center observational study was conducted with the participation of 160 adult patients with infected acute necrotizing pancreatitis (ANP) who required intervention at different stages of the disease. Depending on the amylase activity of the drainage secretions, the groups with and without diagnosed EPF were compared according to 15 demographic, clinical, laboratory and instrumental parameters of the disease. To identify predictors of the risk of developing EPF in ANP, a regression logistic analysis was performed and logistic regression models were built for each factor attribute. RESULTS: Results: We did not find statistically significant differences in the indicators characterising patients on the first day of illness, as well as in the comparison of indicators characterising local complications of AP, the timing of AP infection, the incidence of sepsis and the level of PON in sepsis. When comparing the groups by the frequency of the type of microbial agent of infected APB, no statistically significant differences were found. Comparative pairwise analysis between the groups by morphological characteristics revealed statistical differences in the frequency of focal superficial and transmural PN (p < 0.001). Next, we performed a regression logistic analysis and built logistic regression models for each factor attribute, namely age, gender, BMI, BISAP score and Charlson comorbidity index, morphological characteristics of necrotizing pancreatitis. After univariate regression analysis, a statistically significant association between the depth of PN and the risk of developing PFN was found (OR 2.7 (1.4-5.2), p=0.001). CONCLUSION: Conclusions: We found that the risk of developing an external pancreatic fistula was associated with the depth of pancreatic necrosis.

[A modified method for percutaneous drainage of acute necrotic collections in patients with infected pancreatic necrosis]. / Modifitsirovannyi metod chreskozhnogo drenirovaniya ostrykh nekroticheskikh skoplenii u patsientov s infitsirovannym pankreonekrozom.

OBJECTIVE: To develop a modified method for percutaneous drainage of acute necrotic collections in patients with infected pancreatic necrosis. MATERIALS AND METHODS: Minimally invasive surgical technologies were used in 74 patients with infected acute necrotic collections at the Krasnodar Regional Clinical Hospital No. 2 between 2017 and 2019. Of these, 59 (79.7%) people underwent percutaneous drainage as a final treatment. In 11 (14.9%) patients, video sequestrectomy through the fistula was additionally used to increase efficiency of percutaneous drainage. RESULTS: PCD in our modification implies delivery of double-lumen drains 26-32 Fr in the same plane to zones of necrosis, their programmed replacement for prevention of obstruction and flexible endoscopy for control of pathological process. Local purulent-necrotic parapancreatitis occurred in 31 (41.9%) patients, widespread parapancreatitis - in 43 (58.1%) patients. There were 339 minimally invasive interventions. Laparotomy was required in 4 (5.4%) patients. Incidence of perioperative complications was 10.6%, mortality - 16.2%. CONCLUSION: A modified percutaneous drainage method may be used as final surgical treatment in 79.7% of patients with infected pancreatic necrosis.

Impact of contrast-enhanced versus non-contrast computed tomography on acute kidney injury in acute necrotizing pancreatitis: A randomized controlled trial.

BACKGROUND: The data evaluating contrast-induced-acute kidney injury (AKI) in patients with acute pancreatitis is scarce. This study aimed to compare the frequency of AKI in patients with acute necrotizing pancreatitis undergoing non-contrast computed tomography (NCCT) with those undergoing contrast-enhanced computed tomography (CECT) during hospitalization. METHODS: This prospective randomized controlled trial (CTRI/2019/12/022206) screened consecutive patients with acute pancreatitis for eligibility and randomly allocated patients with acute necrotizing pancreatitis (based on CECT in the first week of illness) and normal renal functions to receive either NCCT or CECT during hospitalization. The incidence of development of new AKI and clinical outcomes was compared between the two groups. Post-hoc analysis was done to adjust for disease severity. RESULTS: As many as 105 patients completed the study as per protocol (NCCT = 45 and CECT = 60). AKI occurred in 36 (34.3%) patients, nine (20%) in the NCCT and 27 (45%) in the CECT group. Contrast induced-AKI occurred in 11 (18.3%) patients, while 25 had AKI secondary to acute pancreatitis. The relative risk (RR) of AKI in the CECT group was 2.25 (95% CI 1.17-4.30, p = .0142). The frequency of intensive care unit (ICU) admission (RR = 2.1, 95% CI 1.34-3.27, p = .0001) and need for drainage of collections (RR = 1.39, 95% CI 1.1-1.7, p = .005) was significantly higher and the length of hospitalization (p = .001) and ICU admission (p = 0.001) were significantly longer in the CECT group. However, when adjusted for the severity of acute pancreatitis, there was no difference in AKI and clinical outcomes between the NCCT and CECT groups. The duration of AKI was significantly longer and the need for dialysis was significantly higher in patients who had AKI secondary to acute pancreatitis compared to those with contrast induced-AKI (p = .003). CONCLUSION: CECT is not significantly associated with AKI in acute necrotizing pancreatitis.

A Risk Score for Predicting the Necessity of Surgical Necrosectomy in the Treatment of Infected Necrotizing Pancreatitis.

BACKGROUND: For infected necrotizing pancreatitis (INP), percutaneous catheter drainage (PCD) is now widely acknowledged as the initial intervention in a step-up approach, followed, if necessary, by minimally invasive necrosectomy or even open pancreatic necrosectomy. However, an overemphasis on PCD may cause a patient's condition to deteriorate, leading to missed surgical opportunities or even death. This study aimed to develop a simple and convenient scoring tool for assessing the need for surgery in INP patients who received PCD procedures. METHODS: In an observational study conducted between April 2015 and December 2020, PCD was utilized as the initial step to treat 143 consecutive INP patients. A surgical necrosectomy was performed when the patient failed to respond. Risk factors of PCD failure (i.e., need for surgical necrosectomy) were identified by multivariate logistic regression models. An integer-based risk scoring tool was developed using the ß coefficients derived from the logistic regression model. RESULTS: In 62 (43.4%) patients, PCD was successful, while the remaining 81 (56.6%) individuals required subsequent surgical necrosectomy. In the multivariate model, organ failure, percentage of pancreatic necrosis, extrapancreatic necrosis volume, and mean CT density of extrapancreatic necrosis volume were associated with a need for surgical necrosectomy. A predictive scoring tool based on these four factors demonstrated an area under the receiver operating characteristic curve (AUC) of 0.893. Under the scoring tool, a total score of 4 or more indicates a high possibility of surgical necrosectomy being required (at least 80%). Using the coordinates of the receiver operating characteristic curve (ROC), the sensitivity and specificity at this threshold are 0.802 and 0.903, respectively. CONCLUSIONS: A risk score model integrating organ failure, percentage of pancreatic necrosis, extrapancreatic necrosis volume, and mean CT density of extrapancreatic necrosis volume can identify INP patients at high risk for necrosectomy. The straightforward risk assessment tool assists clinicians in stratifying INP patients and making more judicious medical decisions.

Clinical characteristics and outcomes of pancreatic fungal infection in patients with necrotizing pancreatitis.

Pancreatic fungal infection (PFI) in patients with necrotizing pancreatitis can lead to significant morbidity and mortality. The incidence of PFI has increased during the past decade. Our study aimed to provide contemporary observations on the clinical characteristics and outcomes of PFI in comparison to pancreatic bacterial infection and necrotizing pancreatitis without infection. We conducted a retrospective study of patients with necrotizing pancreatitis (acute necrotic collection or walled-off necrosis), who underwent pancreatic intervention (necrosectomy and/or drainage) and had tissue/fluid culture between 2005 and 2021. We excluded patients with pancreatic procedures prior to hospitalization. Multivariable logistic and Cox regression models were fitted for in-hospital and 1-year survival outcomes. A total of 225 patients with necrotizing pancreatitis were included. Pancreatic fluid and/or tissue was obtained from endoscopic necrosectomy and/or drainage (76.0%), CT-guided percutaneous aspiration (20.9%), or surgical necrosectomy (3.1%). Nearly half of the patients had PFI with or without concomitant bacterial infection (48.0%), while the remaining patients had either bacterial infection alone (31.1%) or no infection (20.9%). In multivariable analysis to assess the risk of PFI or bacterial infection alone, only previous pancreatitis was associated with an increased odds of PFI vs. no infection (OR 4.07, 95% CI 1.13-14.69, p = .032). Multivariable regression analyses revealed no significant differences in in-hospital outcomes or one-year survival between the 3 groups. Pancreatic fungal infection occurred in nearly half of necrotizing pancreatitis. Contrary to many of the previous reports, there was no significant difference in important clinical outcomes between the PFI group and each of the other two groups.

We examined 225 patients with necrotizing pancreatitis who had tissue/fluid culture available and found that nearly half of the patients had pancreatic fungal infection. Interestingly, there was no difference in clinical outcomes between the fungal infection group and non-fungal infection groups.

Increased incidence and reduced mortality after first attack of acute pancreatitis over an 18-year period.

AIMS: To determine time trends in the incidence and etiology of acute pancreatitis and identify predictors for in-hospital mortality. PATIENTS AND METHODS: Retrospective study of 1722 patients with acute pancreatitis admitted to Akershus University Hospital between January 2000 and December 2017. Data were obtained from electronic patient files and computed tomography scans. We estimated a logistic regression model to assess differences in associations between patient characteristics and in-hospital mortality in two time periods, 2000-2009 (first period) and 2010-2018 (second period). RESULTS: First attack of acute pancreatitis (FAAP) was identified in 1579 patients (91.7%). The incidence of FAAP increased from 20.1/100,000 during the first period to 27.7/100,000 in the second period (p = .011). Etiology showed no differences between the two time periods. Gallstone was the most frequent etiology (47.2%). In total, 187 patients (11.8%) had necrotizing pancreatitis; more in the second period compared to the first (14.2 vs. 7.7%; p < .001). The overall mortality rate was 3.9%. Mortality rates decreased for both inflammatory and necrotizing pancreatitis during the study period. Age and comorbidity according to Charlson Comorbidity Index (CCI) were predictors of in-hospital mortality (OR 1.07, 95% CI 0.07; 0.40 and 13.58, 95% CI 3.88; 47.52), as were alcohol and organ failure (OR 7.20, 95% CI 2.02; 25.67 and OR 34.15, 95% CI 8.94; 130.53, respectively). CONCLUSIONS: The incidence of FAAP is increasing in southeast Norway. The etiology has remained unchanged over an 18-year period, with gallstones being the most frequent cause. The outcomes for both inflammatory and necrotic pancreatitis are improving.

[Technological features of open and minimally invasive surgical treatment of local complications of purulent-necrotic pancreatitis]. / Sravnenie tekhnologicheskikh osobennostei primeneniya otkrytykh i minimal'no invazivnykh sposobov khirurgicheskogo lecheniya mestnykh oslozhnenii gnoino-nekroticheskogo pankreatita.

There are various options for surgical treatment of purulent-necrotic pancreatitis with significant technological differences. Combining surgical methods other than traditional ones into a group of minimally invasive ones based on the principle of the absence of standard laparotomy is not entirely correct. The review presents modern methods of surgical treatment of acute pancreatitis, comparison of their technology regarding classical stages of surgical intervention and their classification.

Nomogram development and validation for predicting minimally invasive step-up approach failure in infected necrotizing pancreatitis patients: a retrospective cohort study.

BACKGROUND: Previous studies have shown that minimally invasive treatment for infected necrotizing pancreatitis (INP) may be safer and more effective than open necrosectomy (ON), but ON is still irreplaceable in a portion of INP patients. Furthermore, there is a lack of tools to identify INP patients at risk of minimally invasive step-up approach failure (eventually received ON or died), which may enable appropriate treatment for them. Our study aims to identify risk factors that can predict minimally invasive step-up approach failure in INP patients and to develop a nomogram for early prediction. METHODS: Multivariate logistic regression was performed to evaluate the association between minimally invasive step-up approach failure and factors regarding demographics, disease severity, laboratory index, and the location of extrapancreatic necrotic collections. A novel nomogram was developed, and its performance was validated both internally and externally by its discrimination, calibration, and clinical usefulness. RESULTS: There were 267, 89, and 107 patients in the training, internal, and external validation cohorts, respectively. Multivariate logistic regression demonstrated that the computed tomography severity index (CTSI) greater than 8 points, Acute Physiology and Chronic Health Evaluation II (APACHE II) score of 16 points or more, early spontaneous bleeding, fungi infection, granulocyte and platelet decrease within 30 days of acute pancreatitis onset, and extrapancreatic necrosis collection located in small bowel mesentery were independent risk factors for minimally invasive step-up approach failure. The area under the curve and coefficient of determination ( R2 ) of the nomogram constructed from the above factors were 0.920 and 0.644, respectively. The Hosmer-Lemeshow test showed that the model had good fitness ( P =0.206). In addition, the nomogram performed well in both the internal and external validation cohorts. CONCLUSIONS: The nomogram had a good performance in predicting minimally invasive step-up approach failure, which may help clinicians distinguish INP patients at risk of minimally invasive step-up approach failure early.

Time to think prime times for treatment of necrotizing pancreatitis: Pendulum conundrum.

Pancreatic fluid collections (PFCs) typically develop as local complications of acute pancreatitis and complicate the clinical course of patients with acute pancreatitis and potentially fatal clinical outcomes. Interventions are required in cases of symptomatic walled-off necrosis (WON) (matured PFCs with necrosis) and pancreatic pseudocysts (matured PFCs without necrosis). In the management of necrotizing pancreatitis and WON, endoscopic ultrasound-guided transluminal drainage combined with on-demand endoscopic necrosectomy (i.e. the step-up approach) is increasingly used as a less invasive treatment modality compared with a surgical or percutaneous approach. Through the substantial research efforts and development of specific devices and stents (e.g. lumen-apposing metal stents), endoscopic techniques of PFC management have been standardized to some extent. However, there has been no consensus about timing of carrying out each treatment step; for instance, it is uncertain when direct endoscopic necrosectomy should be initiated and finished and when a plastic or metal stent should be removed following clinical treatment success. Despite emerging evidence for the effectiveness of noninterventional supportive treatment (e.g. antibiotics, nutritional support, irrigation of the cavity), there has been only limited data on the timing of starting and stopping the treatment. Large studies are required to optimize the timing of those treatment options and improve clinical outcomes of patients with PFCs. In this review, we summarize the current available evidence on the indications and timing of interventional and supportive treatment modalities for this patient population and discussed clinical unmet needs that should be addressed in future research.

Endoscopic Ultrasound-guided Trans-esophageal Transmural Drainage of Mediastinal Pseudocysts: A Case Series.

BACKGROUND AND AIMS: Mediastinal pseudocysts (MP) are rare, and surgery is the conventional treatment modality. However, in the last decade, excellent outcomes have been reported with endoscopic transpapillary drainage. Endoscopic ultrasound (EUS) guided trans-esophageal transmural drainage of MP is a minimally invasive and effective non-surgical treatment modality, but the experience is limited. We aimed to report our experience of EUS-guided transmural drainage in 10 patients with MP's. METHODS: A retrospective analysis of patients with pancreatic fluid collections treated with EUS-guided transmural drainage over the last ten years was completed to to identify patients with MP's. RESULTS: Ten patients (8 males, with a mean age of 34.9±9.17 years) with MP treated with EUS-guided transesophageal transmural drainage were identified. Nine patients with MP had concurrent chronic pancreatitis, and only one had MP following acute necrotizing pancreatitis. The mean size of MP was 5.70±1.64 cm, and nine patients (90%) had concurrent abdominal pseudocyst. EUS-guided transesophageal transmural drainage was technically successful in all ten patients. Transmural plastic stents were placed in 9 patients, whereas one patient underwent single-time complete aspiration of the MP. There were no immediate or delayed procedure-related complications. All ten patients had a successful outcome, with the mean resolution time being 2.80±0.79 weeks. There has been no recurrence of PFC or symptoms in nine (90%) successfully treated patients over a mean follow-up period of 43.3 months. CONCLUSIONS: EUS-guided trans-esophageal drainage of MP is safe with a high technical and clinical success rate.

Acute Pancreatitis: Presenting in Different Clinical Settings.

INTRODUCTION: Acute pancreatitis (AP) is one of the most important gastrointestinal emergencies with significant morbidity, mortality, and financial burden. It is potentially a life-threatening condition unless attended to earliest. MATERIALS: Acute Pancreatitis can present in various clinical scenarios with or without the involvement of multiple organ systems. This is a case series on Acute pancreatitis presented in various clinical settings and its tailor-made approach. RESULT: Case-1: A 23-year-old pregnant female, 34 weeks of gestation, and a known case of connective tissue disorder on steroid therapy with acute edematous pancreatitis, treated with conservative management. Case-2: A 56-year-old male with acute interstitial edematous pancreatitis associated with hypertriglyceridemia was treated with plasmapheresis twice and recovered completely. Case-3: A 28-year-old male with Acute necrotizing pancreatitis with Intra & extra pancreatic collections and walled-off necrosis treated with Necrosectomy. Case-4: A 35-year-old male with Acute necrotizing pancreatitis who developed Hyperglycemia, AKI, Metabolic acidosis, Jaundice, Ascites Hyperkalemia, Pleural effusion, High-grade fever & MODS. Case-5: A 26-year-old male, known alcoholic with severe acute pancreatitis and bilateral pleural effusion, with insertion of Naso jejunal tube to start early enteral nutrition. Case-6: A 34-year-old male with acute necrotizing pancreatitis with a stone in the gall bladder was treated conservatively followed by cholecystectomy. CONCLUSION: Given its rising prevalence, acute pancreatitis should be dealt with appropriately to prevent mortality or morbidity of the patients thereby increasing their disease-free life years.

Escherichia coli infection indicates favorable outcomes in patients with infected pancreatic necrosis.

Introduction: Infected pancreatic necrosis (IPN) is a severe complication of acute necrotizing pancreatitis with increasing morbidity. Escherichia coli is the most frequently cultured microorganism in IPN. However, the implications of Escherichia coli infection on the outcomes of patients with IPN remain unclear. Therefore, this study aimed to evaluate the clinical impacts of Escherichia coli infection on IPN. Methods: A prospective database with consecutive patients with IPN between January 2010 and April 2022 at a tertiary hospital was post-hoc analyzed. The clinical and microbiological characteristics, surgical management, and follow-up data of patients with and without Escherichia coli infection were compared. Results: A total of 294 IPN patients were enrolled in this cohort. Compared with non-Escherichia coli infection cases (n=80, 27.2%), patients with Escherichia coli infection (n=214, 72.8%) were characterized by more frequent polymicrobial infections (77.5% vs. 65.0%, P=0.04) but a lower occurrence of severe acute pancreatitis (SAP) (42.5% vs. 61.7%, P=0.003). In addition, significantly lower mortality (12.5% vs. 30.4%, p=0.002), fewer step-up surgical interventions (73.8% vs. 85.1%, P=0.025), and a lower rate of multiple organ failure (MOF) (25.0% vs. 40.2%, P=0.016) were also observed in patients with Escherichia coli infection. Multivariate analysis of mortality predictors indicated that MOF (odds ratio [OR], 6.197; 95% confidence interval [CI], 2.373-16.187; P<0.001) and hemorrhage (OR, 3.485; 95% CI, 1.623-7.487; P=0.001) were independent predictors associated with higher mortality in patients with IPN. Escherichia coli infection was significantly associated with a lower mortality (OR, 0.302; 95% CI, 0.121-0.751; P= 0.01). Conclusion: Escherichia coli infection indicates a favorable prognosis in patients with IPN, although the mechanism needs further investigation.