Management of acute pancreatitis in Japan: Analysis of nationwide epidemiological survey.

Acute pancreatitis (AP) is an acute inflammatory disease of the exocrine pancreas. In Japan, nationwide epidemiological surveys have been conducted every 4 to 5 years by the Research Committee of Intractable Pancreatic Diseases, under the support of the Ministry of Health, Labour, and Welfare of Japan. We reviewed the results of the nationwide surveys focusing on the severity assessment and changes in the therapeutic strategy for walled-off necrosis. The severity assessment system currently used in Japan consists of 9 prognostic factors and the imaging grade on contrast-enhanced computed tomography. By univariate analysis, all of the 9 prognostic factors were associated with AP-related death. A multivariate analysis identified 4 out of the 9 prognostic factors (base excess or shock, renal failure, systemic inflammatory response syndrome criteria, and age) that were associated with AP-related death. Receiver-operating characteristics curve analysis showed that the area under the curve was 0.82 for these 4 prognostic factors and 0.84 for the 9 prognostic factors, suggesting the comparable utility of these 4 factors in the severity assessment. We also examined the temporal changes in treatment strategy for walled-off necrosis in Japan according to the 2003, 2007, and 2011 surveys. Step-up approaches and less-invasive endoscopic therapies were uncommon in 2003 and 2007, but became popular in 2011. Mortality has been decreasing in patients who require intervention for walled-off necrosis. In conclusion, the nationwide survey revealed the comparable utility of 4 prognostic factors in the severity assessment and the increased use of less-invasive, step-up approaches with improved clinical outcomes in the management of walled-off necrosis.

EUS-guided drainage of pancreatic pseudocysts offers similar success and complications compared to surgical treatment but with a lower cost.

BACKGROUND AND AIM: Pancreatic pseudocysts (PPC) are a complication that occurs in acute and chronic pancreatitis. They comprise 75% of cystic lesions of the pancreas. There are scarce data about surgical versus endoscopic treatment on PPC. The aim of this study was to compare both treatment modalities regarding clinical success, complication rate, recurrence, hospital stay and cost. METHODS: Retrospectively, data obtained prospectively from 2000 to 2012 were analyzed. A PPC was defined as a fluid collection in the pancreatic or peripancreatic area that had a well-defined wall and contained no solid debris or recognizable parenchymal necrosis. Clinical success was defined as complete resolution or a decrease in size of the PPC to 2 cm or smaller. RESULTS: Overall, 64 procedures in 61 patients were included: 21 (33%) cases were drained endoscopically guided by EUS and 43 (67%) cases were drained surgically. The clinical success of the endoscopic group was 90.5 versus 90.7% for the surgical group (P = 0.7), with a complication rate of 23.8 and 25.6%, respectively (P = 0.8), and a mortality rate of 0 and 2.3% for each group, respectively (P = 0.4). The hospital stay was lower for the endoscopic group: 0 (0-10) days compared with 7 (2-42) days in the surgical group (P < 0.0001). Likewise, the cost was lower in the endoscopic group (P < 0.001). The recurrence rate was similar in both groups: 9.5 and 4.5% respectively (P = 0.59). The two recurrences found in the endoscopic group were associated with stent migration, and the recurrence in the surgical group was due to the type of surgery performed (open drainage). CONCLUSION: Endoscopic treatment of PPC offers the same clinical success, recurrence, complication and mortality rate as surgical treatment but with a shorter hospital stay and lower costs.

Single-step, natural orifice transluminal endoscopic incision drainage of a pancreatic pseudocyst: can it be simpler, safer and more cost effective?

Conventional endotherapy for pancreatic pseudocyst involves placement of stents in the cyst cavity. We have successfully treated bulging pseudocyst in a 50 year old male by endoscopic incision drainage (EID), without insertion of endoprostheses. The presenting complaints in our patient were epigastric mass and postprandial vomiting. He had recently undergone open cholecystectomy following recovery from gallstone pancreatitis. EID was performed under general anaesthesia. Needle knife was advanced through the accessory channel of a flexible gastroscope. Cyst contents were evacuated by making 5 cm horizontal incision on the gastric indentation with dramatic relief in symptoms There is no cyst recurrence during follow up for over 3 years.

Radiologic assessment of acute and chronic pancreatitis.

The capabilities of various imaging modalities, including CT, MRI, and ultrasound, have markedly increased over recent years. This has translated into improved detection and improved characterization of various pathologic processes. This article discusses the current role of imaging in the evaluation of acute and chronic pancreatitis. CT remains a major focal point in issues related to acute pancreatitis, whereas MRI (and magnetic resonance cholangiopancreatography) plays a larger role in chronic pancreatitis.

[Ultrasonographic assessment of chronic pancreatitis severity. Pancreatic index].

AIM: To introduce the pancreatic index assessing severity of chronic pancreatitis (CP). MATERIAL AND METHODS: Ultrasonography was made in 28 patients with clinically documented diagnosis of CP. A total of 6 groups of ultrasonographic signs served the basis for calculation of scores for a complex formalized semiquantitative criterion--the pancreatic index (PI). Ultrasonographic signs--the size of the head, calcinates, structure, maximal size of the ductus pancreaticus, pseudocysts, etc. were assessed in scores from 1 to 3. Severity of the disease was classified according to total PI. RESULTS: The following correlation was found between severity of CP and the PI: in mild CP--57%, in moderate CP--71%, in severe CP--66%. CONCLUSION: Ultrasonographic PI objectively evaluates severity of CP course.

Pancreatic pseudoaneurysm converted from pseudocyst: transcatheter embolization and serial CT assessment.

We present a case of pancreatic pseudoaneurysm converted from a pseudocyst. Contrast-enhanced CT disclosed a round enhancing lesion at the previously identified pseudocyst, and angiography confirmed the diagnosis of a pseudoaneurysm. The pseudoaneurysm was successfully treated by arterial embolization. We believe arterial embolization to be the treatment of choice for pseudoaneurysm as a complication of pancreatitis.

Intraoperative ultrasound assessment in management of complex pancreatic pseudocysts.

Preoperative imaging studies and operative inspection may provide insufficient information to appropriately manage certain complex pancreatic pseudocysts. Intraoperative ultrasound accurately identifies and localizes peripancreatic fluid collections, cyst wall thickness, parenchymal and ductal anatomy, and relationships to adjacent visceral and vascular structures. Adjunctive use of intraoperative ultrasonography altered the surgical management in the clinical case described herein and is advocated for assessment of problematic pancreatic pseudocysts.

Endoscopic ultrasonography of the pancreas.

The pancreas is the most technically demanding area to image with EUS. This technique, however, has found a clinical niche in evaluating patients with pancreatic cancer to determine resectability and likely will play a prominent role in the future in diagnosis through ultrasonographically directed FNA. Its role in localization of neuroendocrine tumors is established as long as preoperative localization is important in management. It is unlikely that a competing technology will develop in the near future with resolution the same or better than EUS. The role of EUS in the evaluation of early chronic pancreatitis is still under investigation, but it is likely that it can play a role adjunctive to ERCP. If FNA can be demonstrated to be safe and the interpretation of the cytology is accurate, then EUS could play an important role in this area. In the future, EUS may be used to acutely aspirate pancreatic pseudocysts and potentially could be useful in differentiating pseudocysts amenable to endoscopic drainage versus those that would be managed best by percutaneous or surgical drainage. With some design modifications, it may be feasible in the future to use ultrasonographic guidance to puncture pseudocysts and then place nasocystic drains or internal stents. These areas will need further investigation and further technological development.

Assessment of antimicrobial penetrance into the pancreatic juice in humans.

The penetrance of mezlocillin, metronidazole and trimethoprim-sulfamethoxazole into the pancreatic juice of humans was measured in ten patients convalescing from acute pancreatitis at the time of endoscopic retrograde cholangiopancreatography. Therapeutic levels were obtained in the serum for all three antimicrobial agents; simultaneously aspirated nonbile stained pancreatic juice contained therapeutic levels of metronidazole and trimethoprim-sulfamethoxazole. Mezlocillin was not present in a therapeutic level in any patient with nonbile stained pancreatic fluid.