Development of pancreatic diseases during long-term follow-up after acute pancreatitis: a post-hoc analysis of a prospective multicenter cohort.

BACKGROUND AND AIM: More insight into the incidence of and factors associated with progression following a first episode of acute pancreatitis (AP) would offer opportunities for improvements in disease management and patient counseling. METHODS: A long-term post hoc analysis of a prospective cohort of patients with AP (2008-2015) was performed. Primary endpoints were recurrent acute pancreatitis (RAP), chronic pancreatitis (CP), and pancreatic cancer. Cumulative incidence calculations and risk analyses were performed. RESULTS: Overall, 1184 patients with a median follow-up of 9 years (IQR: 7-11) were included. RAP and CP occurred in 301 patients (25%) and 72 patients (6%), with the highest incidences observed for alcoholic pancreatitis (40% and 22%). Pancreatic cancer was diagnosed in 14 patients (1%). Predictive factors for RAP were alcoholic and idiopathic pancreatitis (OR 2.70, 95% CI 1.51-4.82 and OR 2.06, 95% CI 1.40-3.02), and no pancreatic interventions (OR 1.82, 95% CI 1.10-3.01). Non-biliary etiology (alcohol: OR 5.24, 95% CI 1.94-14.16, idiopathic: OR 4.57, 95% CI 2.05-10.16, and other: OR 2.97, 95% CI 1.11-7.94), RAP (OR 4.93, 95% CI 2.84-8.58), prior pancreatic interventions (OR 3.10, 95% CI 1.20-8.02), smoking (OR 2.33, 95% CI 1.14-4.78), and male sex (OR 2.06, 95% CI 1.05-4.05) were independently associated with CP. CONCLUSION: Disease progression was observed in a quarter of pancreatitis patients. We identified several risk factors that may be helpful to devise personalized strategies with the intention to reduce the impact of disease progression in patients with AP.

Yield of Adding chest CT to Abdominal CT to Detect COVID-19 in Patients Presenting With Acute Gastrointestinal Symptoms (SCOUT-3): Multicenter Study.

OBJECTIVE: To determine the incremental yield of standardized addition of chest CT to abdominal CT to detect COVID-19 in patients presenting with primarily acute gastrointestinal symptoms requiring abdominal imaging. Summary Background Data: Around 20% of patients with COVID-19 present with gastrointestinal symptoms. COVID-19 might be neglected in these patients, as the focus could be on finding abdominal pathology. During the COVID-19 pandemic, several centers have routinely added chest CT to abdominal CT to detect possible COVID-19 in patients presenting with gastrointestinal symptoms. However, the incremental yield of this strategy is unknown. METHODS: This multicenter study in 6 Dutch centers included consecutive adult patients presenting with acute nontraumatic gastrointestinal symptoms, who underwent standardized combined abdominal and chest CT between March 15, 2020 and April 30, 2020. All CT scans were read for signs of COVID-19 related pulmonary sequelae using the СО-RADS score. The primary outcome was the yield of high COVID-19 suspicion (СО-RADS 4-5) based on chest CT. RESULTS: A total of 392 patients were included. Radiologic suspicion for COVID-19 (СО-RADS 4-5) was present in 17 (4.3%) patients, eleven of which were diagnosed with COVID-19. Only 5 patients with СО-RADS 4-5 presented without any respiratory symptoms and were diagnosed with COVID-19. No relation with community prevalence could be detected. CONCLUSION: The yield of adding chest CT to abdominal CT to detect COVID-19 in patients presenting with acute gastrointestinal symptoms is extremely low with an additional detection rate of around 1%.

Recurrence of idiopathic acute pancreatitis after cholecystectomy: systematic review and meta-analysis.

BACKGROUND: Occult biliary disease has been suggested as a frequent underlying cause of idiopathic acute pancreatitis (IAP). Cholecystectomy has been proposed as a strategy to prevent recurrent IAP. The aim of this systematic review was to determine the efficacy of cholecystectomy in reducing the risk of recurrent IAP. METHODS: PubMed, Embase and Cochrane Library databases were searched systematically for studies including patients with IAP treated by cholecystectomy, with data on recurrence of pancreatitis. Studies published before 1980 or including chronic pancreatitis and case reports were excluded. The primary outcome was recurrence rate. Quality was assessed using the Newcastle-Ottawa Scale. Meta-analyses were undertaken to calculate risk ratios using a random-effects model with the inverse-variance method. RESULTS: Overall, ten studies were included, of which nine were used in pooled analyses. The study population consisted of 524 patients with 126 cholecystectomies. Of these 524 patients, 154 (29·4 (95 per cent c.i. 25·5 to 33·3) per cent) had recurrent disease. The recurrence rate was significantly lower after cholecystectomy than after conservative management (14 of 126 (11·1 per cent) versus 140 of 398 (35·2 per cent); risk ratio 0·44, 95 per cent c.i. 0·27 to 0·71). Even in patients in whom IAP was diagnosed after more extensive diagnostic testing, including endoscopic ultrasonography or magnetic resonance cholangiopancreatography, the recurrence rate appeared to be lower after cholecystectomy (4 of 36 (11 per cent) versus 42 of 108 (38·9 per cent); risk ratio 0·41, 0·16 to 1·07). CONCLUSION: Cholecystectomy after an episode of IAP reduces the risk of recurrent pancreatitis. This implies that current diagnostics are insufficient to exclude a biliary cause.

ANTECEDENTES: Se ha sugerido que la enfermedad biliar oculta es una causa subyacente frecuente de pancreatitis aguda idiopática (idiopathic acute pancreatitis, IAP). La colecistectomía se ha propuesto como una estrategia para prevenir la IAP recidivante. El objetivo de esta revisión sistemática era determinar la eficacia de la colecistectomía para reducir el riesgo de la IAP recidivante. MÉTODOS: Se realizó una búsqueda sistemática en PubMed, Embase y Cochrane de estudios que incluían pacientes con IAP tratados con colecistectomía, y con datos sobre la recidiva de la pancreatitis. Se excluyeron los estudios anteriores a 1980, los que incluían pancreatitis crónica y los casos clínicos. El resultado principal fue la tasa de recidiva. La calidad se evaluó utilizando la escala de Newcastle-Ottawa. Se realizaron metaanálisis para calcular la tasa de riesgo utilizando un modelo de efectos aleatorios con el método de varianza inversa. RESULTADOS: En total, se incluyeron 10 estudios, de los cuales 9 se utilizaron para realizar análisis agrupados. La población de estudio incluyó 524 pacientes en los que se habían efectuado 126 colecistectomías. De estos 524 pacientes, 154 (29% (i.c. del 95% 25,5-33,3)) presentaron recidiva de la enfermedad. La tasa de recidiva fue significativamente menor después de la colecistectomía que después del tratamiento conservador (14/126 (11%) versus 140/398 (35)); tasa de riesgo 0,44 (i.c. del 95% 0,27-0,71)). Incluso en pacientes en los que se diagnosticó IAP tras haber efectuado pruebas diagnósticas más extensas, incluyendo ultrasonografía endoscópica o colangiopancreatografía por resonancia magnética, la tasa de recidiva después de la colecistectomía era menor (4/36 (11%) versus 42/108 (39%); tasa de riesgo 0,41 (i.c. del 95% 0,16-1,07)). CONCLUSIÓN: La práctica de una colecistectomía después de un episodio de IAP disminuye el riesgo de pancreatitis recidivante. Esto implica que los diagnósticos actuales son insuficientes para excluir una causa biliar (PROSPERO CRD42017055275).

Comparison of endoscopic closure modalities for standardized colonic perforations in a porcine colon model.

BACKGROUND AND STUDY AIM: Colonic perforation is a serious complication of colonoscopy, with surgical repair usually indicated. The aim was to compare acute strength of various endoscopic colonic closure techniques by assessing air leak pressures in a previously described ex vivo experimental apparatus. METHODS: Standardized colonic perforations were created using fresh porcine colon and subsequently closed on a bench. Six techniques included surgical suture (gold standard), QuickClips, T-tags, over-the-scope-clip (OTSC) system, and two types of flexible stapler (Covidien). After closure, each specimen was fixed in the apparatus and pressure was gradually increased until air bubbles were seen. Leak pressure was the primary outcome parameter. Closure using the gold standard (first 15 experiments) resulted in a mean leak pressure of 86.9 mmHg (SD 7). Using a noninferiority design a sample size of 12 specimens for each closure technique was determined. RESULTS: Mean colotomy leak pressures in millimeters of mercury (mmHg) and difference (with 95% confidence intervals [CI]) between each technique and the gold standard were: QuickClips 85.1 (difference -1.8; 95% CI -7.0 to 3.9); T-tags 53.9 (difference -33.0; -39.0 to -27.0); OTSC 90.3 mmHg (difference 3.4; -6.1 to 12.9); 15-mm shaft stapler 98.5 mmHg (difference 9.7; 0.8 to 18.5) and 8-mm shaft stapler 96.6 mmHg (difference 11.6; 1.5 to 21.7). CONCLUSIONS: OTSCs, QuickClips, and both flexible staplers produced results comparable to hand-sewn colotomy closure in this ex vivo porcine colonic model. These devices seem to be prime candidates for further evaluation in survival animal studies.

Laparoscopic resection with transcolonic specimen extraction for ileocaecal Crohn's disease.

BACKGROUND: Ileocolic resection for Crohn's disease can be performed entirely laparoscopically. However, an incision is needed for specimen extraction. This prospective observational study assessed the feasibility of endoscopic transcolonic specimen removal. METHODS: Endoscopic specimen removal was attempted in a consecutive series of ten patients scheduled for laparoscopic ileocolic resection. Primary outcomes were feasibility, operating time, reoperation rate, pain scores, morphine requirement and hospital stay. To assess applicability, outcomes were compared with previous data from patients who had laparoscopically assisted operations. RESULTS: Transcolonic removal was successful in eight of ten patients; it was considered not feasible in two patients because the inflammatory mass was too large (7-8 cm). Median operating time was 208 min and median postoperative hospital stay was 5 days. After surgery two patients developed an intra-abdominal abscess, drained laparoscopically or percutaneously, and one patient had another site-specific infection. The operation took longer than conventional laparoscopy, with no benefits perceived by patients in terms of cosmesis or body image. CONCLUSION: Transcolonic removal of the specimen in ileocolic Crohn's disease is feasible in the absence of a large inflammatory mass but infection may be a problem. It is unclear whether the technique offers benefit compared with conventional laparoscopic surgery.

Comparison of transcolonic NOTES and laparoscopic peritoneoscopy for the detection of peritoneal metastases.

BACKGROUND AND AIMS: Peritoneoscopy by natural orifice transluminal endoscopic surgery (NOTES) could replace laparoscopic staging peritoneoscopy (LAP) if the yield were comparable to that from LAP. In previously performed porcine experiments, transgastric peritoneoscopy seemed inferior to LAP due to limited visualization of the liver. The aim of the present study was to improve liver visualization by using a colonic approach and to compare transcolonic peritoneoscopy (TCP) with the previously set LAP standard. METHODS: Small beads were stapled into porcine peritoneal cavities to simulate metastases. Previously in the same model LAP had detected 95% of beads (95% CI 87% -98%). Using a non inferiority design, a sample size of 33 beads was determined; these were distributed among six animals with randomization for numbers and location. TCP was performed using either standard endoscopic accessories (TCP-s) or a specially designed toolkit (TCP-t) in randomized order by one of two blinded endoscopists. Primary outcome was number of beads found and touched during peritoneoscopy. RESULTS: Locations of beads included abdominal peritoneum (6 beads), diaphragm (8), liver (18), and miscellaneous sites (1). TCP-s found 25 beads (yield 76%, 95% CI 59% -87%). TCP-t found 19 beads (yield 58%, 95% CI 41%-71%). The majority of missed beads were located at the inferior liver surface: TCP-s detected 8/15 (53%) and TCP-t 5/15 (33%) of these simulated metastases. CONCLUSIONS: In this prospective, experimental trial, transcolonic NOTES peritoneoscopy was inferior in comparison with the diagnostic laparoscopy done previously in the same model.

Novel over-the-scope-clip system for gastrotomy closure in natural orifice transluminal endoscopic surgery (NOTES): an ex vivo comparison study.

BACKGROUND AND STUDY AIMS: Secure transluminal closure remains a fundamental barrier to clinical introduction of natural orifice transluminal endoscopic surgery (NOTES). Current NOTES closure modalities either do not provide secure closure or are too challenging to apply in vivo. The aims of this study were to evaluate gastric closure using the over-the-scope clip (OTSC) system in a previously described experimental setup, comparing the acute strength with a gold standard (hand surgical suturing). METHODS: Comparison was done using an ex vivo porcine stomach experimental setup. The gastric opening was created by a needle knife puncture followed by dilation with 18-mm balloon. Control gastrotomies (n = 15; surgical suturing) showed a mean leak pressure of 206 mmHg (SD 59). A noninferiority design required a sample size of 11 specimens for the OTSC group. Closure comprised: (i) approximation of muscular layers using a flexible twin grasper; (ii) pulling the tissue into the OTSC cap at the tip of the scope; (iii) releasing the clip. Main outcome measures were leak pressure of closed gastrotomies, leak location, and time needed for adequate closure. RESULTS: Closure was successful in all specimens in a median of 3 minutes. Closed gastrotomies showed air leakage at mean pressure of 233 mmHg (SD 47), which was non-inferior compared with the predetermined gold standard (P = 0.003). CONCLUSIONS: Closure of gastric incisions to meet a predetermined leak pressure criterion was attainable and easy with the OTSC system. In vivo survival animal experiments are needed to further evaluate this promising closure modality.

In vitro comparison and evaluation of seven gastric closure modalities for natural orifice transluminal endoscopic surgery (NOTES).

BACKGROUND AND STUDY AIMS: Secure transluminal closure is the most fundamental prerequisite for the safe introduction of natural orifice transluminal endoscopic surgery (NOTES). The aim was to compare acute strength of various gastrotomy closure techniques in an in vitro porcine stomach model by assessing leak pressures. METHODS: Standardized gastrotomies were closed manually, without the use of an endoscope, by one of seven NOTES closure devices: (i) T tags, (ii) purse string modified T tags, (iii) Eagle Claw VIII, (iv) Resolution clips, (v) flexible stapler; (vi) purse string suturing device, and (vii) flexible Endostitch. After closure, each specimen was fixed on the experimental apparatus and the pressure was gradually increased. By linking the pressure gauge and two cameras, the leak location and pressure could be determined in detail. We began by collecting gold standard reference values, by testing 15 gastrotomies closed with interrupted surgical sutures; these were associated with a mean leak pressure of 206 mmHg (SD 59). Using a noninferiority design, a sample size of 11 specimens for each NOTES closure technique was determined. RESULTS: The Resolution clips ( P = 0.0285), Eagle Claw VIII ( P = 0.0325), flexible stapler ( P < 0.001) and flexible Endostitch ( P = 0.002) produced noninferior closures in comparison with the predetermined gold standard; T tags ( P > 0.6775), purse string modified T tags ( P > 0.999), and the purse string suturing device ( P = 0.9875) resulted in inferior closures. CONCLUSIONS: The Eagle Claw VIII, Resolution clips, flexible stapler and flexible Endostitch produced noninferior closures in comparison with surgical closure in this model. These techniques seem to be the prime candidates for further testing in animal experiments before human trials can be initiated.

[Natural orifice translumenal endoscopic surgery]. / Endoscopische abdominale chirurgie via natuurlijke lichaamsopeningen.

Over the past few decades gastrointestinal endoscopy has developed from a purely diagnostic technique to one having numerous therapeutic gastrointestinal applications. Simultaneously, minimal invasive surgery is increasingly replacing traditional open abdominal procedures. These trends have led to a new and innovative way of accessing the peritoneal cavity through the orifices of the body (mouth, anus and vagina) by means ofendoscopic surgery: natural orifice translumenal endoscopic surgery (NOTES). Thanks to excellentcollaboration between surgeons and gastroenterologists and experimental animal research, NOTES has developed extremely rapidly over the past few years. Although many limitations need to be surmounted before NOTES can reach the human clinical trial stage, the prospect of safe, minimal invasive and scar-less surgery appears very promising. The near future will tell whether current barriers will be broken down and NOTES will acquire a fixed place in the diagnostic and therapeutic work-up of certain gastrointestinal afflictions.

Review article: Translumenal endoscopic debridement of organized pancreatic necrosis--the first step towards natural orifice translumenal endoscopic surgery.

BACKGROUND: Over the last decades, gastrointestinal endoscopy has transformed from serving purely diagnostic purposes to therapeutic applications. One recent major progress is taking the endoscope beyond the gastrointestinal lumen into the peritoneal cavity for diagnostic and therapeutic procedures. The first step towards Natural Orifice Translumenal Endoscopic Surgery (NOTES) was translumenal endoscopic debridement of pancreatic necrosis. AIM: To overview current status of endoscopic debridement of organized pancreatic necrosis. Finally, we take a short look into the potential future of translumenal endoscopic procedures. METHODS: Medical databases were searched for relevant publications, dealing with endoscopic debridement of pancreatic necrosis and NOTES. RESULTS: All current published studies concerning endoscopic debridement of organized pancreatic necrosis were retrospectively performed and relatively small (largest n = 25). Success rates varies from 80-93% and complication rates from 7-20%. There was no procedure related mortality reported. Published NOTES experiments showed feasibility of a variety of transgastric, transcolonic and transvaginal procedures in the porcine model. CONCLUSION: Endoscopic debridement seems to be an effective and relatively safe minimally invasive therapy in patients with symptomatic organized pancreatic necrosis and is the first step towards NOTES. Further comparative studies need to define its definitive role in the management of these patients.