A Case Series of Late Gastrointestinal Fistulization in 16 Patients with Walled-Off Necrosis.

BACKGROUND: Gastrointestinal fistulization (GIF) is a rare and potentially fatal complication of acute necrotizing pancreatitis (ANP). There is paucity of data on clinical course and outcome of GIF in walled of necrosis (WON). OBJECTIVE: To evaluate frequency, clinical as well as imaging findings and outcome of spontaneous symptomatic GIF in patients with WON. METHODS: Retrospective analysis of database of patients with asymptomatic WON on regular follow-up over last six years to identify patients with symptomatic GIF. RESULTS: Out of 138 patients with asymptomatic WON seen during the study period, 16 (11.5%) patients (all males; mean age 41.7 ± 9.9 years) developed symptomatic GIF. The mean size of WON in patients who developed GIF was 9.5 ± 2.4 cm, and fistulization occurred after 65.1 ± 17.8 days of the onset of ANP. The site of fistulization was stomach, duodenum, jejunum, colon, and esophagus in seven (43.7%), five (31.2%), one (6.2%), two (12.5%), and one (6.2%) patients, respectively. GIF resulted in spontaneous resolution in two patients (stomach 1 and esophagus 1). The remaining patients with gastric (six patients) and duodenal (five patients) fistulization were successfully treated endoscopically by placing multiple plastic stents in the necrotic cavity after balloon dilatation of the fistulous tract. Patients with colonic fistulization required surgery. None of the patients succumbed to the illness. CONCLUSION: Symptomatic GIF of WON usually occurs within the first three months of onset of ANP. It commonly occurs in either stomach or duodenum and can be successfully managed endoscopically.

Assessing the Efficacy and Outcomes Following Irrigation with Streptokinase Versus Hydrogen Peroxide in Necrotizing Pancreatitis: A Randomized Pilot Study.

BACKGROUND: Percutaneous catheter drainage (PCD's) are prone to blockage because of necrosum. To improve the efficacy of PCD, necrolytic agents have been used. The present study compared the use of Streptokinase with H2O2 in saline irrigation. MATERIALS AND METHODS: This is a single-center randomized pilot study (from July 2018 to Dec 2019). Patients with infected pancreatic necrosis not showing response to PCD and saline irrigation were included in the study. Patients received either Streptokinase (Streptokinase group 50,000 IU in 100 ml normal saline) or 3% H2O2 (3% H2O2 in 100 ml normal saline in 1:10 dilution). Primary endpoints were the need for surgery and mortality while secondary endpoints were hospital stay and complications attributable to necrolytic agents. RESULTS: There were 30 patients in the study, 15 in each arm. Organ failure was seen in 23 (76.6%), single organ failure was present in 11 (47%), and multi-organ failure in 12 (53%). Bleeding complications (20% in H2O2 vs 6.6% in Streptokinase), need for surgery (73% in H2O2 vs 33.3% in Streptokinase) and mortality (60% in H2O2 vs 33% in Streptokinase) were higher in H2O2 group but the difference was not significant statistically. Post-irrigation hospital stay was lesser in the Streptokinase group compared to H2O2 group but the difference did not reach statistical significance (14.1 ± 7.7 vs 19.2 ± 11.7, p = 0.09) CONCLUSIONS: Streptokinase irrigation led to a trend for reduced need for necrosectomy and mortality. H2O2 group had more bleeding complications. Post-irrigation hospital stay was lesser in Streptokinase group.

Utility of percutaneous thrombin injection for treating visceral pseudoaneurysms.

PURPOSE: To assess the efficacy and outcome of percutaneous thrombin injection in treatment of visceral arterial pseudoaneurysms (PAs) in a selective group of patients. MATERIAL AND METHODS: Retrospective review of the institutional database showed 19 cases of visceral arterial pseudoaneurysms that were treated with percutaneous ultrasound-guided thrombin injection between January 2014 and December 2019 (13 men and 6 women). Of the pseudoaneurysms, 36% were due to pancreatitis, 35% were iatrogenic, 21% were infective and 8% traumatic. Most of the pseudoaneurysms arose from the hepatic artery (27%) followed by the splenic artery (26%) and renal artery (21%). Mean sac size of the pseudoaneurysms was 23 mm (range, 8 -40 mm). Technical success was defined as absence of flow within the PAs on follow-up ultrasonography (USG) 24 h and 3 days after thrombin injection. RESULTS: Overall technical success was seen in 10/19 patients. Technical success of thrombin injection was higher in cases of distal branch PAs as compared to main vessel PAs (9/13 vs. 1/6). Success rates were higher with smaller (<23mm) pseudoaneurysms (7/12) as compared to larger ones (3/7). There were no procedure-related complications. CONCLUSION: Ultrasound-guided percutaneous thrombin injection is a novel method of treating visceral pseudoaneurysms as a painless, cheap and radiation-free procedure. However, further large-scale studies are needed to prove the efficacy in treating visceral pseudoaneurysms.

Natural course of low output external pancreatic fistula in patients with disconnected pancreatic duct syndrome following acute necrotising pancreatitis.

BACKGROUND: External pancreatic fistulae (EPF) associated with complete pancreatic duct (PD) disruption leading on to disconnected pancreatic duct syndrome (DPDS) is a therapeutic nightmare usually requiring surgery. However, spontaneous closure also has been reported. There is paucity of data on the natural history of EPF associated with DPDS. OBJECTIVE: To retrospectively study outcome of conservative treatment in patients with low output (<200 ml/day) EPF with DPDS following percutaneous or surgical intervention in acute necrotising pancreatitis (ANP). METHODS: The data of patients of low output EPF with DPDS treated conservatively in our unit over last 5 years was retrospectively analysed. Their clinical course, complications as well as time taken for fistula closure was retrieved. RESULTS: 33 patients (27 males; mean age: 40.5 ± 9.3 years) of low output EPF and DPDS were studied. 31 patients developed EPF following percutaneous drainage (PCD) and 2 patients developed fistula following surgery. The drain fluid amylase ranged from 1600 to 32,000 IU/l and site of disruption was neck, proximal body and distal body in 4, 16 and 13 patients respectively. EPF closed spontaneously in all patients within 88.2 ± 63.46 days. PCD slipped out in 2 patients and led to formation of pseudocyst in 1 patient that was treated endoscopically. There has been no recurrence in any patient over follow up of 32.5 ± 21.9 months. CONCLUSION: Low output EPF developing post PCD or surgery in patients with DPDS following ANP closely spontaneously in majority of patients within 3 months with good long term outcome.

Renal doppler changes in patients with acute pancreatitis: A prospective study.

BACKGROUND: Renal Doppler to assess renal resistive index (RRI) is an attractive option to prognosticate acute kidney injury (AKI) in acute pancreatitis (AP) as it is feasible within scope of point-of-care ultrasound. However, RRI has been infrequently evaluated in AP. OBJECTIVE: Prospectively study diagnostic and prognostic performance of RRI in patients with AP. METHODOLOGY: 75 patients with AP were prospectively enrolled and followed till recovery/death. All patients were subjected to renal Doppler and RRI was compared between patients with and without AKI. RESULTS: Thirty six patients developed AKI and 39 patients did not develop AKI. AKI network stage 1, 2 and 3 AKI was seen in 7(19.4%), 12(33.3%) and 17 (47.2%) patients respectively. Prognostic scoring done at admission by SIRS, modified marshal score, and BISAP scores, as well as duration of hospitalization and mortality rates were significantly higher in patients with AKI. Mean peak systolic velocity and RRI at upper, middle and lower poles of bilateral kidneys were comparable between patients with and without AKI. The RRI was abnormal in 46 (66.6%) patients and it was <0.6 in 35/46 (76%) and >0.7 in 11/46 (24%) patients respectively. RRI <0.6 was observed in 16 (53.3%) and 19 (48.7%) patients with and without AKI respectively (p = 0.80). RRI >0.7 was observed in 4 (53.3%) and 7 (48.7%) patients with and without AKI respectively (p = 0.74). CONCLUSIONS: AKI is associated with poor prognosis in AP. RRI on renal Doppler at admission seems to have poor diagnostic as well as prognostic performance for AKI in patients with AP.

Retino-choroidal changes in patients with acute pancreatitis: A prospective analysis of a novel biomarker.

BACKGROUND: There is paucity of data on ocular changes in acute Pancreatitis (AP). Moreover, subclinical alterations in retina & choroid have not been studied in AP. OBJECTIVE: To prospectively study retino-choroidal changes in AP. METHODS: Sixty patients (mean age 39.07 years; 41 males) with AP were followed up till recovery/death. Baseline slit-lamp examination, choroidal thickness (CT), retinal thickness (RT), choroidal vascularity index (CVI), retinal capillary density index (CDI) and arteriovenous ratio (AVR) were recorded. The patients were divided into two groups - mild (Group A; 5 patients) and moderately severe/severe (Group B; 55 patients) as per revised Atlanta classification. RESULTS: Fundus examination showed mild optic disc edema with retinal hemorrhages in 6 (10%) patients in group B as compared to none in group A (p = 1.00). None of the patients had Purtscher retinopathy. Mean CT (317 ± 56.29 µm) was increased as compared to normal subjects (278.90 ± 57.84 µm, p = 0.003). The mean CVI (0.62 ± 0.04) was decreased as compared to normal (0.66 ± 0.01, p < 0.0001) as was the mean AVR (0.67 ± 0.03 vs. 0.7 ± 0.02, p < 0.0001). However, the mean RT of subjects with AP (239.68 ± 33.76 µm) was not significantly different compared to the normal subjects 253.17 ± 33.67 µm (p=NS). The mean CDI of superficial and deep plexus were comparable between normal and patients with AP. CT, RT, CVI, AVR and CDI were comparable between group A and group B as well as survivors and non-survivors. CONCLUSIONS: Clinically significant ocular changes are seen infrequently in AP. However, subclinical changes in CT, CVI and AVR are observed in patients with AP compared to normal individuals.

Gastrointestinal Failure Is a Predictor of Poor Outcome in Patients with Acute Pancreatitis.

OBJECTIVE: Although gastrointestinal dysfunction is common in patients with acute pancreatitis, its impact on the outcome of disease has not been adequately studied. The present study was conducted to study the frequency of gastrointestinal failure (GIF) as well as its effect on outcome in patients with acute pancreatitis. METHODS: Patients with acute pancreatitis admitted in our unit were prospectively studied. Gastrointestinal dysfunction and intra-abdominal pressures were measured daily till their resolution, and gastrointestinal failure score was calculated. Baseline parameters including various severity scores were noted. The patients were followed till clinical recovery or death. RESULTS: Sixty-four patients (mean age 41.52 ± 16.28 years; 45 (70.3%) males) were prospectively studied. Forty-five (70.3%) patients had severe disease, and 18 (28.1%) patients succumbed to illness. GIF was present in 31 (48.4%) patients. The median duration of GIF was 5 (range 1-20) days. The presence of GIF was significantly associated with mortality (p value < 0.05). On multivariate analysis, the presence of GIF [OR 10.6 (95% CI 1.97-57.04)] and duration of ICU stay [OR 1.08 (95% CI 1.015-1.15)] were found to be independent predictors of mortality. CONCLUSION: Gastrointestinal failure is an important organ failure in patients with acute pancreatitis and is an independent predictor of mortality. Incorporation of gastrointestinal failure scores in dynamic assessment of patients with acute pancreatitis could help us in better stratifying severity of patients and predicting outcome.

Percutaneous glue embolization as a primary treatment for visceral pseudoaneurysms.

Aim: To evaluate the feasibility and outcome of percutaneous glue embolisation as primary treatment for pseudoaneurysms in selective patients.Material and methods: A review of the pseudoaneurysm cases managed with percutaneous glue at our institute was analyzed in this study. A total of 21 patients over a period of last one year who were treated for pseudoaneurysm at varied sites primarily with percutaneous n-butyl cynoacrylate were retrospectively evaluated. Site of pseudoaneurysm was Pulmonary (seven cases), renal (four cases), pelvic (4four cases) and miscellaneous abdomen (six cases). Combined ultrasound and fluoroscopy approach was used in 17 cases, CT guidance in three cases and combined ultrasound and CT guidance in one case. Patients were evaluated for therapeutic response (radiological and clinical) and procedure related complications.Results: Complete occlusion of the pseudoaneurysm was seen in all patients. Two patients showed mild pneumothorax and one patient showed reflux into the intercostal artery. All the patients showed symptomatic improvement and discharged in stable condition.Conclusions: Percutaneous glue embolisation of the pseudoaneurysms as a primary treatment is feasible and can be safely carried out in select group of patients with good therapeutic response and minimal complications.

Development of an Orthogonal Tie2 Ligand Resistant to Inhibition by Ang2.

Angiopoietin-1 (Ang1) is a vascular protective ligand that acts through the receptor tyrosine kinase Tie2 to enhance endothelial survival and quiescence. In sepsis, diabetic retinopathy, and a range of other diseases, Ang2, an antagonist of Tie2, increases markedly. This antagonist suppresses Ang1 protective effects leading to vascular destabilization, inflammation, and endothelial death. Administration of recombinant Ang1 can counter Ang2 antagonism and restore vascular function. However, recombinant Ang1 is needed at sufficiently high concentrations to block Ang2, and the protein is difficult to produce, requires mammalian expression systems, and is prone to aggregation. Here we present an engineered synthetic Tie2 ligand that is not antagonized by Ang2 but is easy to produce and more robust than Ang1. Using a peptide phage display, we isolated a heptameric sequence that binds Tie2-ectodomain and fused this to the coiled:coil domain of cartilage oligomeric matrix protein. This pentameric protein is 60 kDa in size, expressed in E. coli, and facile to purify. The protein, designated TSL1, binds to Tie2-ectodomain in vitro and on the cell surface. TSL1 inhibits endothelial apoptosis. Crucially, TSL1 binds at a site on Tie2 distinct from the angiopoietin-binding site and is resistant to antagonism by Ang2. This engineered ligand has several advantages over recombinant Ang1 for potential therapeutic applications. The study also highlights the value of orthogonal ligands for regulating cellular receptors without being subject to antagonism or modulation by endogenous ligands.

Safety and efficacy of angioembolisation followed by endoscopic ultrasound guided transmural drainage for pancreatic fluid collections associated with arterial pseudoaneurysm.

BACKGROUND AND AIMS: Arterial pseudoaneurysms associated with pancreatic fluid collections (PFC's) are serious complication of pancreatitis. There is insufficient data on safety of endoscopic ultrasound (EUS) guided drainage in these patients. AIM: To retrospectively analyze results of combination of angioembolisation followed by EUS guided transmural drainage of PFC's associated with pseudoaneurysms. METHODS: Retrospective analysis of data base of eight patients (all males; mean age: 36.9 + 9.2 years; age range: 26-51 years) who underwent angioembolisation of pseudoaneurysm followed by EUS guided transmural drainage of the PFC's. RESULTS: The median size of PFC was 6.5 cm (range 5-14 cm) with 7 patients having acute pancreatitis and one patient having idiopathic chronic pancreatitis. The etiology for acute pancreatitis was alcohol in 5 patients, trauma and gall stones in one patient each. Six patients had walled off pancreatic necrosis (WOPN) and 2 had pseudocysts. The pseudoaneurysm was located in splenic artery (5 patients), gastro-duodenal artery (2) and short gastric artery (1). All patients underwent successful digital subtraction angiography followed by angioembolisation. EUS guided transmural drainage was successfully done through stomach in 7 patients and via duodenum in one patient. The PFC's resolved in 3.9 + 2.5 weeks with no recurrence of either PFC or bleed over a follow up period of up to 24 months. No significant complications were observed in any patient. CONCLUSIONS: Arterial pseudoaneurysms associated with PFC's can be successfully and safely treated with combination of initial radiological obliteration of the pseudoaneurysm followed by EUS guided transmural drainage.

Comparison of radiofrequency ablation alone & in combination with percutaneous ethanol injection for management of hepatocellular carcinoma.

Background & objective: It has been shown that the combined use of alcohol before radiofrequency ablation (RFA) helps to augment the therapeutic advantage of RFA. The present study was conducted to compare the outcome of treatment with RFA alone and RFA with alcohol as ablative technique in patients with small hepatocellular carcinomas (HCCs), who were not candidates for surgery. Methods: Fifty patients with chronic liver disease and concurrent HCC were enrolled in this prospective study. The patients were treated with either RFA alone (n=25) or RFA combined with alcohol (n=25). Patient outcome was evaluated, and the tumour recurrence and survival of the patients were assessed in the two groups. Results: The survival rates at six months in patients who completed at least six months of follow up were 84 and 80 per cent in patients treated with RFA alone and combination therapy, respectively. During the follow up period, 11 and four patients treated with RFA alone showed local and distant intrahepatic tumour recurrence, respectively. All local recurrences were at one to 18 months of the follow up period. The distant recurrences occurred at 6-36 months of the follow up period. During the follow up period, eight and six patients treated with combination therapy showed local and distant intrahepatic tumour recurrence, respectively. All local recurrences were at 1.5-15 months during the follow up period. The distant intrahepatic recurrences occurred at 6-72 months during the follow up period. Interpretation & conclusions: No significant difference was seen between the survival time of the patients treated with RFA alone and RFA with alcohol as well as in the local recurrences and distant intrahepatic recurrences in RFA compared to RFA and alcohol group patients. Combined use of RFA and alcohol did not improve the local tumour control and survival in patients with HCC compared to RFA alone.

Timing of surgical intervention in patients of infected necrotizing pancreatitis not responding to percutaneous catheter drainage.

BACKGROUND: The timing of surgery in patients not responding to percutaneous catheter drainage (PCD) in infected pancreatic necrosis remains challenging. MATERIALS AND METHODS: A randomized controlled trial was designed to establish the optimal timings of surgery following PCD in patients with infected pancreatic necrosis (IPN). Patients who did not improve by day 10 after PCD insertion were included in the present study and were randomized to group A (step-up approach as a bridge to surgery) or group B (step-up approach with intention to avoid surgery). Weekly inflammatory and nutritional markers were monitored in both groups (clinical trials. gov identifier NCT-01527084). RESULTS: From July 2011 to December 2012, 40 patients underwent treatment with PCD. The first 8 patients were randomized into two groups. The trial was stopped prematurely because of difficulty in accrual and poor progress. All subsequent patients were managed with step-up approach with the intention to avoid surgery. Of 35 patients, 24 patients were managed by PCD alone while 11 patients required surgery. In patients who did not require surgery; levels of serum high sensitivity C-reactive protein (hsCRP), interleukin-6(IL6) and prealbumin showed a falling trend. This group also had higher baseline albumin and higher albumin at 4 weeks. CONCLUSION: During the present study, randomization into surgery at a predetermined time in step-up approach was discontinued due to poor progress. Step-up approach with the intention to avoid surgery led to a success rate of 68.5%. The present study failed to predict the optimal timing of surgery after PCD. Patients who needed surgery were sicker at the time of admission, had higher incidence of organ failure, and spent more time in the ICU compared to patients who did not need surgery. In future, inflammatory and nutritional markers may be useful to identify patients who are unlikely to respond to PCD and may help determine the timing of surgery.

Prospective comparison of long term outcomes in patients with severe acute pancreatitis managed by operative and non operative measures.

AIM: Present study reports the long term functional and morphological changes following severe acute pancreatitis and compares patients managed by operative and non-operative methods. Association between morphological changes and functional parameters were studied. MATERIALS AND METHODS: 35 patients with one year of follow up after recovery from attack of acute pancreatitis were evaluated. RESULTS: Etiology was alcohol in 19, gallstones in 11 and idiopathic in 5. Fourteen patients were managed non-operatively and 21 operatively. Patients in non-operative group had a mean follow-up of 18.4 ± 8.2 months while patients in necrosectomy group had 31.4 ± 20.6 months. 40% patients had exocrine insufficiency (abnormal fecal fat) while 48.5% patients (17/35) had new onset diabetes. 90% patients had morphological changes in pancreas. Exocrine abnormality was significantly higher in necrosectomy group compared to non-operative group (57.2% vs 14.1%, p = 0.01). Patients undergoing necrosectomy had higher incidence of endocrine dysfunction {61.9% in surgery and 28.5% in non-operative group (p = 0.053)}. Operative group had more number of patients with completely non-visualized main pancreatic duct (MPD) (p = 0.028) and non-operative group had significantly higher irregular MPD (p = 0.021). Exocrine dysfunction was more in patients with complete non-visualization of MPD and/or incompletely visualized MPD (p = 0.013). CONCLUSION: Patients managed non-operatively had significantly less exocrine and endocrine dysfunction compared to operated patients. Exocrine dysfunction was significantly associated with complete non-visualization of MPD and/or incompletely visualized MPD.

Diagnostic accuracy of F-18 FDG PET/CECT vs. CECT for detecting recurrence of periampullary carcinoma and its prognostic significance.

PURPOSE: To evaluate the additive value of whole-body F-18 fluoro-deoxyglucose positron emission tomography (FDG PET) as an adjunct to contrast-enhanced computed tomography (CECT) for detecting recurrence following Whipple's resection for periampullary carcinoma and to analyze the prognostic significance of FDG PET-/CECT-based detection of recurrence. METHODS: Fifty patients (34 males, 16 females; mean age: 55 ± 11 years) who underwent PET/CECT following resection of periampullary carcinoma were included. The study was duly approved by the institutional ethical committee for retrospective analysis of the data. The sensitivity, specificity, positive predictive value (PPV), negative predictive value (NPV) and accuracy of FDG PET/CECT and CECT alone for detection of recurrence were calculated, and the accuracy was compared with ROC analysis. The prognostic factors for survival following recurrence were analyzed by univariate and multivariate methods. RESULTS: PET/CECT indicated recurrence of disease in 26 (52%) patients. The overall mean survival time was 46 months with an overall survival rate of 42%. The sensitivity, specificity, PPV, NPV and accuracy of PET/CECT and CECT for detection of recurrence were 96.1%, 91.6%, 92.6%, 95.6%, 94% and 76.9%, 75%, 76.9%, 75%, 76%, respectively (p = 0.037). Also change in management could have been achieved in 18% of patients based on the PET/CECT results. In univariate analyses, SUVmax >7.3 was the only predictor of poor survival (p < 0.05). CONCLUSION: PET/CECT could be used as a one-stop imaging tool for staging and prognostication of recurrent periampullary carcinoma that could result in better patient management.

Gastrointestinal bleeding in acute pancreatitis: etiology, clinical features, risk factors and outcome.

BACKGROUND: There is paucity of data on the effect of interventions on risk of gastrointestinal bleeding (GIB) in acute pancreatitis (AP). METHODS: Retrospective study of records of patients with AP and GIB. RESULTS: 16 (3.7%) patients (14 males; mean age 39.3 ± 12.8 years) had gastrointestinal bleeding. Two patients had peptic ulcer disease related GIB. The cause of GIB in remaining patients was: pseudoaneurysms in 5, gastrointestinal fistulization in 4, and no identifiable lesion in 5. Two patients with pseudoaneurysms were treated with angioembolisation whereas 3 needed surgery. The patients with gastrointestinal fistula had complicated course and 3 of these 4 patients died due to sepsis and multi organ failure. Rest 5 patients with no identifiable lesion were managed conservatively and there was no recurrence of GIB. Of the 14 patients with AP related GIB, a previous intervention had been done in 11(79%) patients. Fifty-three patients (12.7%) without GIB died whereas 5 (31.2%) patients with GIB succumbed to the illness (p = 0.04). CONCLUSIONS: The majority of our patients of AP with GIB had antecedent history of interventions. The mortality was higher in patients with GIB, which was not due to hemorrhage but to sepsis and related complications.

Multidetector computed tomography evaluation of post cholecystectomy complications: A tertiary care center experience.

OBJECTIVE: To evaluate the role of multidetector computed tomography (CT) and CT angiography (CTA) in post cholecystectomy complications. METHODS: A retrospective analysis of data from December 2012 to August 2014 was performed. Eight hundred sixty consecutive patients with history of cholecystectomy (laparoscopic or open) were evaluated. After exclusion of 645 patients with normal imaging, analysis for post cholecystectomy complications was performed in 215 patients. A contrast enhanced CT/CTA was performed. Mean interval to imaging was 10 months (range 3 days to 15 months). RESULTS: A complication rate of 25% was noted in patients undergoing imaging following cholecystectomy. Gallbladder bed or perihepatic collections were seen in 11.9% cases (n = 103). Intrahepatic biliary radicle dilatation (IHBRD) was seen in 7% patients (n = 60). Isolated right or left ductal dilatation was seen in 9 patients; rest of the patients had bilateral IHBRD. Cholangitic abscesses and mild acute pancreatitis were seen in 11 (1.2%) and 12 (1.3%) patients respectively. These comprised biliary complications. Venous thrombosis involving the portal vein was the most frequently encountered vascular complication (n = 12). Right hepatic artery pseudoaneurysm was seen in two patients. Less common complications were abdominal wall hematoma (n = 2), incisional hernia (n = 6), port site hernia (n = 2), large bowel injury (n = 1), biliocutaneous fistula (n = 1) and enterocutaneous fistula (n = 1). CONCLUSION: CT allows classification of post cholecystectomy complications and guides further management. CTA provides an efficient road map for management of vascular complications.

Streptokinase may play role in expanding non-operative management of infected walled off pancreatic necrosis: preliminary results.

GOALS AND BACKGROUND: We evaluated ex and in vivo effect of streptokinase on pancreatic necrosum to improve the success rate of pigtail catheter drainage and irrigation in infected walled off pancreatic necrosis using step up approach and also looked at potential risk of bleeding. EXPERIMENT AND CLINICAL CASES: 1000 IU/ml of streptokinase was added to 10 g. of intra-operatively obtained fresh tissue of peripancreatic necrosis and results compared to treatment with saline. Mixture was incubated for 12 h in thermostat at 37.5 °C and subjected to histopathology. Subsequently streptokinase (50,000 units thrice a day for 5 days through PCD) was used in two patients with walled off pancreatic necrosis (WOPN) not responding to step up approach and who were being considered for surgery. Grossly there was fragmentation of necrosum in streptokinase treated tissue. Microscopically complete loss of supportive collagenous framework was noted in streptokinase treated necrosum with clumping of necrotic tissue into structure-less mass. No such changes were discernible in saline treated tissue. In two patients with WOPN there was clearance of debris after streptokinase instillation. None of the patients was on thromboprophylaxis and bleeding was not noticed in any of the patients. CONCLUSION: Based on ex vivo effect of streptokinase in dissolution of necrosum at periphery, we believe that in patients with walled off pancreatic necrosis (WOPN) not responding to pigtail catheter drainage and saline irrigation; streptokinase may prove to be useful adjunct.

Minimally invasive image-guided interventional management of hepatic artery pseudoaneurysms.

BACKGROUND: Hepatic artery pseudoaneurysms (HAPs) are uncommon entities. With the development of interventional techniques, their management has evolved from conventional (surgical) to non-surgical minimally invasive image-guided interventional techniques. METHODS: Fifteen cases of HAPs who had undergone non-surgical interventional management in our department were reviewed. All patients were comprehensively evaluated for demographic information, morphology of pseudoaneurysm, indication for intervention and means of intervention, approach (endovascular or percutaneous), follow up and complications. RESULTS: Trauma and iatrogenic injury were most common causes of HAPs. Most of the HAPs (9 out of 10 in whom long follow up was available) managed with image-guided interventional techniques had favorable outcome. CONCLUSION: Minimally invasive image-guided interventional management is the preferred modality for HAPs.

Safety and Efficacy of Genicular Artery Embolization for the Treatment of Knee Pain Secondary to Osteoarthritis-Initial Indian Experience.

Background Osteoarthritis (OA) is the commonest form of arthritis with pain and disability as hallmark symptoms. Despite various nonpharmacologic, pharmacologic, and surgical approaches, pain control may be hard to achieve. Over the last few years, few studies have been conducted on managing knee OA using novel endovascular genicular artery embolization (GAE) with varied outcomes. No such study has been reported in India yet to the best of our knowledge. Purpose The main aim of this article was to evaluate the efficacy and safety of transcatheter GAE in relieving knee pain in patients with mild-to-moderate OA. Materials and Methods Ten patients with radiographic knee OA and moderate-to-severe pain refractory to conservative therapy were enrolled in a prospective observational study. GAE was performed with 100 to 300-µm spherical particles. Patients were assessed with magnetic resonance imaging at the baseline. Visual analog scale (VAS) and Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC) were used to assess pain and disability respectively at the baseline, 1 month, and 3 months. Clinical success was asserted by the downstaging of VAS and WOMAC scores. Adverse events were recorded at all-time points. Descriptive and inferential statistics have been performed using SPSS. A p -Value less than 0.05 was considered statistically significant. Results Embolization of at least 1 genicular artery was achieved in all the patients (100%). Clinical success was demonstrated in 08 (80%) of the patients. Median VAS reduced from 07 at baseline to 3.5 at 3-month follow-up ( p < 0.001). Median WOMAC score improved from 53 to 23.50 at 3-month follow-up ( p < 0.001). Minor complications were seen in two patients in the form of puncture site hematoma and mild petechial spots over the knee. Conclusion Our pilot study demonstrates GAE as a safe and efficacious procedure to treat knee pain secondary to OA. Further randomized comparative studies with a larger sample size are needed to determine the true treatment effect versus the placebo effect.

Mucormycosis: Cytomorphological Spectrum in Fine-Needle Aspiration Cytology.

Background: Mucormycosis is a fungal infection that can affect multiple organs. The role of fine-needle aspiration cytology (FNAC) in its diagnosis is not well documented. Aim: The objective of this study was to describe the detailed cytomorphologic features of mucormycosis on FNAC samples. Materials and Methods: A retrospective analysis of all cases diagnosed as mucormycosis on FNAC between January 2014 and July 2021 was performed for detailed cytomorphological evaluation and correlation to clinical data and microbiological studies wherever available. FNA was computed tomography-guided (n = 38), ultrasonography-guided (n = 31) or palpation-guided (n = 12), and slides were reviewed in two cases. Results: A total of 83 cases of mucormycosis were evaluated. An immunocompromised setting was observed in 48 cases. The most common site of FNA was the lung (n = 57) followed by liver, soft tissue, palate, mediastinum, orbital/ocular region, and lymph node. Isolated renal involvement, a unique feature, was seen in seven cases. The aspirates were necrotic to pus-like or blood-mixed particulate. Broad, nonseptate, foldable, ribbon-like fungal hyphae showing right-angled branching were seen. The tissue reaction was predominantly necro-inflammatory (n = 36), bland necrotic (n = 22), mixed inflammatory (n = 16), suppurative (n = 5), necrotizing granulomatous (n = 3), and granulomatous (n = 1). Immunocompromised patients showed mixed inflammatory responses more frequently. Fungal culture was positive for Rhizopus species in 2/13 cases and molecular testing in two additional cases corresponding to Rhizopus and Syncephalastrum spp. Conclusion: FNA provides quick and conclusive diagnosis of mucormycosis from varied anatomic sites enabling prompt institution of therapy. The tissue response is variable and to some extent dependent on the immune status of the patient.