Hemosuccus pancreaticus - Multidisciplinary therapy for a splenic artery aneurysm, ruptured into the pancreatic duct.

BACKGROUND: Numerous conditions may lead to gastrointestinal bleeding (GIB). Compared with common causes, hemosuccus pancreaticus (HP) is a scarce and potentially life-threatening condition. CASE PRESENTATION: We report the case of a 45-year-old female patient who suffered from hematemesis and subsequent hemorrhagic shock. In repeat esophagogastroduodenoscopies, bleeding from the major duodenal papilla was detected. To stop the acute bleeding, an ERCP was performed, and a plastic stent was inserted into the pancreatic duct (PD). Subsequently, MR and CT scans demonstrated a pseudoaneurysm of the splenic artery (SA) with a fistula to the PD. An interventional therapy approach failed due to a highly twisted course of the SA. Thus, the patient underwent surgery with ligation of the SA. The stent from the PD was removed postoperatively, and the patient recovered well. A histological examination of the SA revealed fibromuscular dysplasia. A lifelong ASA therapy was prescribed, and the patient was discharged on the 14th postoperative day in good condition. CONCLUSION: The diagnosis and treatment of HP might be impeded due to its multiple causes, ambiguous symptoms, and challenging diagnostic verification. Being a potentially life-threatening condition, the knowledge of this rare entity and the provision of multidisciplinary and multimodal therapy are mandatory for the successful treatment of patients with obscure GIB and proven HP.

Risk factor analysis of postoperative pancreatic fistula after distal pancreatectomy with a focus on the peritoneum to portal vein distance on computed tomography.

BACKGROUND: Postoperative pancreatic fistula (POPF) is a major complication of distal pancreatectomy (DP). Although the visceral fat area (VFA) is a risk factor for POPF in DP, its measurement is complicated. This study aimed to identify a simple marker as a predictive indicator of POPF. METHODS: We included 210 patients who underwent resection at our institution between 2020 and 2023. The patients' characteristics, preoperative laboratory data, and radiographic findings (e.g., portal vein distance and VFA) and their association with pancreatic fistula after DP were analyzed. POPF was defined as Grade B or C pancreatic fistula on the basis of the International Study Group of Pancreatic Surgery 2016 consensus. RESULTS: POPF developed in 82 (39.0%) patients. Univariate analysis showed that female sex, pancreatic thickness of the cutting line, operative time, blood loss, C-reactive protein (CRP) level on postoperative day (POD) 3, drain amylase level on POD 3, VFA, and the peritoneum to portal vein distance (PPD) were associated with POPF. Receiver operating characteristic curve analysis of PPD showed a higher area under the curve than VFA (cutoff for PPD: 68 mm). Multivariate analysis showed that CRP (odds ratio [OR]: 2.214), drain amylase (OR: 2.875), and PPD (OR: 15.538) were independent risk factors. When we compared the DP fistula risk score and PPD, receiver operating characteristic analysis showed areas under the curve of 0.650 and 0.803, respectively. CONCLUSIONS: A PPD of ≥68 mm is a useful risk predictor of POPF. Determining this distance is simple and easily applicable in the clinical setting.

Spontaneous Twin Internal Fistulae: A Rare Complication of Acute Pancreatitis.

Spontaneous internal fistulae (cystocolonic, cystogastric and cystoenteric) have been described as potential complications of severe acute pancreatitis with pseudocyst or walled off necrosis (WON). Ours is possibly the first ever report of double internal fistulae (pancreatico-gastric and pancreatico-colonic) occurring as a spontaneous complication of acute pancreatitis.

Evaluation of postoperative pancreatic fistula prediction scales following pancreatoduodenectomies based on magnetic resonance imaging: A diagnostic test study.

BACKGROUND: Postoperative pancreatic fistula (POPF) is one of the most feared and common complications following pancreatoduodenectomies. This study aims to evaluate the performance of different scales in predicting POPF using magnetic resonance imaging (MRI), including estimation of the pancreatic duct diameter, pancreatic texture, main duct index, relation to the portal vein, and intra-abdominal fat thickness. MATERIALS AND METHODS: A retrospective diagnostic test study was designed. Between January 2017 and December 2021, 133 pancreatoduodenectomies were performed at our institution. The performance for predicting overall POPF and clinically relevant POPF (CR-POPF) was evaluated using a receiver operating characteristic (ROC) curve. RESULTS: A total of 96 patients were included in the study, of whom 26 patients experienced overall POPF, and 8 patients had CR-POPF. When analyzing the predictive value of each of the different scores applied, the Birmingham score showed the highest performance for predicting overall POPF and CR-POPF with an AUC (area under the curve) of 0.815 (95 % CI 0.725-0.906) and 0.813 (0.679-0.947), respectively. CONCLUSION: The Birmingham scale demonstrated the highest predictive performance for POPF. It is a simple scale with only two variables that can be obtained preoperatively using MRI. Based on these results, we recommend its use in patients undergoing pancreatoduodenectomy.

Association of preoperative CT-scan features and clinically relevant postoperative pancreatic fistula after pancreaticoduodenectomy: a meta-analysis.

BACKGROUND: Clinically relevant postoperative pancreatic fistula (CR-POPF) is a significant complication after pancreaticoduodenectomy. CR-POPF is associated with various adverse outcomes, including high mortality rates. Identifying complication predictors for CR-POPF, such as preoperative CT scan features, including pancreatic attenuation index (PAI) and pancreatic duct diameter (PDD), is critical. This systematic review and meta-analysis consolidate existing literature to assess the impact of these variables on CR-POPF risk. METHODS: Our comprehensive search, conducted in May 2023, covered PubMed, Scopus, Embase, and Web of Science databases. Inclusion criteria encompassed peer-reviewed cohort studies on pancreaticoduodenectomy, focusing on preoperative CT scan data. Case reports, case series, and studies reporting distal pancreatectomy were excluded. The quality assessment of included articles was done using New-Castle Ottawa Scale for cohort studies. Statistical analysis was carried out using Review Manager 5. This study was registered at the International Prospective Register of Systematic Reviews database (PROSPERO) on 12 May 2023 (registration number: CRD42023414139). RESULTS: We conducted a detailed analysis of 38 studies with 7393 participants. The overall incidence of CR-POPF was 24%. Multiple linear regression analyses revealed that PDD and pancreatic parenchymal thickness were significantly associated with CR-POPF. CONCLUSION: Our systematic review and meta-analysis shed light on CT scan findings for predicting CR-POPF after Whipple surgery. Age, PDD, and pancreatic parenchymal thickness significantly correlate with CR-POPF.

Endoscopic Retrograde Cholangiopancreatography for the Management of Pancreatic Duct Leaks and Fistulas.

Pancreatic duct (PD) leaks are a common complication of acute and chronic pancreatitis, trauma to the pancreas, and pancreatic surgery. Diagnosis of PD leaks and fistulas is often made with contrast-enhanced pancreatic protocol computed tomography or magnetic resonance imaging with MRCP. Endoscopic retrograde pancreatography with pancreatic duct stenting in appropriately selected patients is often an effective treatment, helps to avoid surgery, and is considered first-line therapy in cases that fail conservative management.

Refractory postoperative pancreatic fistula following laparoscopic distal pancreatectomy for pancreatic cancer caused by incomplete pancreas divisum: a case report.

Pancreas divisum (PD) represents a prevalent congenital pancreatic variant, typically arising from the failure of fusion between the ventral and dorsal pancreatic ducts. This condition is frequently associated with recurrent pancreatitis. We herein present a case involving an incomplete PD diagnosis following the identification of a refractory postoperative pancreatic fistula (POPF) after laparoscopic distal pancreatectomy (DP) for pancreatic cancer. A 74-year-old female patient, who had undergone laparoscopic DP for pancreatic cancer, developed a POPF accompanied by intraabdominal bleeding, necessitating urgent intervention radiology to avert life-threatening complications. Following this, intraabdominal drainage was performed through an intraoperative drainage root. Subsequent fistulography and endoscopic retrograde pancreatography unveiled the presence of an incomplete PD for the first time. Consequently, a stent was placed in the Santorini duct. However, the volume of pancreatic juice from the intraabdominal drainage tube exhibited no reduction. Despite repeated attempts to access the pancreatic duct via a guidewire through the drainage tube, these endeavors proved futile. Paradoxically, the removal of the external drainage tube led to a recurrence of intraabdominal abscess formation. Consequently, reinsertion of the drainage tube became imperative. Consideration was given to draining the abscess under endoscopic ultrasonography and performing pancreatic duct drainage. However, due to the diminution of the abscess cavity through the external fistula drainage procedure, coupled with the absence of pancreatic duct dilation and its tortuous course, it was deemed a formidable challenge. the patient necessitated a lifestyle adaptation with a permanently placed percutaneous drainage tube.

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.

Radiomics for the prediction of a postoperative pancreatic fistula following a pancreatoduodenectomy: A systematic review and radiomic score quality assessment.

BACKGROUND: Postoperative pancreatic fistula (POPF) is a severe complication following a pancreatoduodenectomy. An accurate prediction of POPF could assist the surgeon in offering tailor-made treatment decisions. The use of radiomic features has been introduced to predict POPF. A systematic review was conducted to evaluate the performance of models predicting POPF using radiomic features and to systematically evaluate the methodological quality. METHODS: Studies with patients undergoing a pancreatoduodenectomy and radiomics analysis on computed tomography or magnetic resonance imaging were included. Methodological quality was assessed using the Radiomics Quality Score (RQS) and Transparent Reporting of a Multivariable Prediction Model for Individual Prognosis or Diagnosis (TRIPOD) statement. RESULTS: Seven studies were included in this systematic review, comprising 1300 patients, of whom 364 patients (28 %) developed POPF. The area under the curve (AUC) of the included studies ranged from 0.76 to 0.95. Only one study externally validated the model, showing an AUC of 0.89 on this dataset. Overall adherence to the RQS (31 %) and TRIPOD guidelines (54 %) was poor. CONCLUSION: This systematic review showed that high predictive power was reported of studies using radiomic features to predict POPF. However, the quality of most studies was poor. Future studies need to standardize the methodology. REGISTRATION: not registered.

Endoscopic Nasopancreatic Drainage Contributes to Early Resolution of Postgastrectomy Gastropancreatic Fistula.

A 76-year-old man experienced abdominal pain 43 days after gastric cancer resection. Computed tomography revealed a gastric wall defect extending to the pancreas, and endoscopic retrograde pancreatography revealed a gastropancreatic fistula. Afterward, a nasopancreatic duct drainage tube was inserted. Seven days later, no leakage of the contrast medium from the duct was observed, and the patient was discharged 22 days after endoscopic nasopancreatic duct drainage. Endoscopic nasopancreatic duct drainage prevents pancreatic juice leakage and promotes gastric ulcer healing.

Preoperative ultrasound elastography for postoperative pancreatic fistula prediction after pancreatoduodenectomy: A prospective study.

BACKGROUND: Postoperative pancreatic fistulas are the most frequent major complications after pancreatoduodenectomy. The soft pancreatic texture is a critical, independent risk factor for postoperative pancreatic fistulas after pancreatoduodenectomy. The current gold standard for postoperative pancreatic fistula risk evaluation consists of the surgeon's intraoperative palpation of the pancreatic texture and, thus, lacks objectivity. In this prospective study, we used ultrasound-based shear-wave elastography, image data analysis, and a fistula risk score calculator to correlate the stiffness of pancreatic tissue with the occurrence of clinically relevant postoperative pancreatic fistulas. METHODS: We included 100 patients with pancreatic pathologies (71% pancreatic ductal adenocarcinoma) and 100 healthy individuals who were preoperatively assessed via real-time tissue ultrasound-based shear-wave elastography on a Philips EPIQ 7 ultrasound device and had pancreatic parenchyma histologically evaluated with manually stained images. RESULTS: We found a significant difference in the mean elasticity between the soft (1.22 m/s) and the hard pancreas group (2.10 m/s; P < .0001). The mean elasticity significantly correlated with the pancreatic fibrosis rate and the appearance of a postoperative pancreatic fistula after pancreatoduodenectomy. Low elasticity (≤1.2 m/s, mean) correlated with soft and high elasticity (>2.0 m/s, mean) with hard pancreatic parenchyma, as assessed by pathologic evaluation. Multivariate analysis revealed a mean elasticity of <1.3 m/s as a significant cut-off predictor for clinically relevant postoperative pancreatic fistulas (P = .003; Youden-Index = 0.6945). CONCLUSION: Preoperative ultrasound-based shear-wave elastography is a feasible and objective clinical diagnostic modality in evaluating pancreatic tissue stiffness. A mean pancreatic elasticity of <1.3 m/s was a significant independent risk predictor of clinically relevant postoperative pancreatic fistulas after pancreatoduodenectomy.

Imaging Diagnosis and Management of Fistulas in Pancreatitis.

Pancreatic fistula is a highly morbid complication of pancreatitis. External pancreatic fistulas result when pancreatic secretions leak externally into the percutaneous drains or external wound (following surgery) due to the communication of the peripancreatic collection with the main pancreatic duct (MPD). Internal pancreatic fistulas include communication of the pancreatic duct (directly or via intervening collection) with the pleura, pericardium, mediastinum, peritoneal cavity, or gastrointestinal tract. Cross-sectional imaging plays an essential role in the management of pancreatic fistulas. With the help of multiplanar imaging, fistulous tracts can be delineated clearly. Thin computed tomography sections and magnetic resonance cholangiopancreatography images may demonstrate the communication between MPD and pancreatic fluid collections or body cavities. Endoscopic retrograde cholangiography (ERCP) is diagnostic as well as therapeutic. In this review, we discuss the imaging diagnosis and management of various types of pancreatic fistulas with the aim to sensitize radiologists to timely diagnosis of this critical complication of pancreatitis.

Postoperative computed tomography findings predict re-drainage cases after early drain removal in pancreaticoduodenectomy.

PURPOSE: This study aimed to investigate the risk factors for re-drainage in patients with early drain removal after pancreaticoduodenectomy (PD). METHODS: This study retrospectively analyzed 114 patients who underwent PD and prophylactic drain removal on postoperative day (POD) 4 between January 2012 and March 2021. We analyzed the risk factors for re-drainage according to various factors. Peri-pancreaticojejunostomic fluid collection (PFC) index and pancreatic cross-sectional area (CSA) were evaluated using computed tomography on POD 4. The PFC index was calculated by multiplying the length, width, and height at the maximum aspect. RESULTS: Among the 114 patients, 15 (13%) underwent re-drainage due to postoperative pancreatic fistula. Multivariate analysis identified a PFC index ≥ 8.16 cm3 on POD 4 (odds ratio [OR], 20.40, 95%CI 2.38-174.00; p = 0.006) and pancreatic CSA on POD 4 ≥ 3.65 cm2 (OR, 16.40, 95%CI 1.57-171.00; p = 0.020) as independent risk factors for re-drainage. CONCLUSION: A careful decision might be necessary for early drain removal in patients with a PFC index ≥ 8.16 cm3 and pancreatic CSA ≥ 3.65 cm2.

Case Series of MRI and CT Assessment of Acquired Hepato-Biliary and Pancreatic Transdiaphragmatic Fistulae.

Transdiaphragmatic fistulae are rare conditions characterized by pathological communication between two epithelium-lined surfaces. Hepato-thoracic fistula consists of abnormal communication between the liver and/or the biliary system and the thorax; while the pancreaticopleural fistula consists of abnormal communication between the pancreas and the thorax, the pleuro-biliary fistula represents the more common type. Clinical symptoms and laboratory findings are generally non-specific (e.g., thoracic and abdominal pain, dyspnea, cough, neutrophilia, elevated CPR, and bilirubin values) and initially, first-level investigations, such as chest RX and abdominal ultrasound, are generally inconclusive for the diagnosis. Contrast-enhanced CT represents the first two-level radiological imaging technique, usually performed to identify and evaluate the underlying pathology sustained by transdiaphragmatic fistulae, their complications, and the evaluation of the fistulous tract. When the CT remains inconclusive, other techniques such as MRI and MRCP can be performed. A prompt and accurate diagnosis is crucial because the recognition of fistulae and the precise definition of the fistulous tract have a major impact on the management acquisition process.

Prediction of clinically relevant postoperative pancreatic fistula using radiomic features and preoperative data.

Clinically relevant postoperative pancreatic fistula (CR-POPF) can significantly affect the treatment course and outcome in pancreatic cancer patients. Preoperative prediction of CR-POPF can aid the surgical decision-making process and lead to better perioperative management of patients. In this retrospective study of 108 pancreatic head resection patients, we present risk models for the prediction of CR-POPF that use combinations of preoperative computed tomography (CT)-based radiomic features, mesh-based volumes of annotated intra- and peripancreatic structures and preoperative clinical data. The risk signatures were evaluated and analysed in detail by visualising feature expression maps and by comparing significant features to the established CR-POPF risk measures. Out of the risk models that were developed in this study, the combined radiomic and clinical signature performed best with an average area under receiver operating characteristic curve (AUC) of 0.86 and a balanced accuracy score of 0.76 on validation data. The following pre-operative features showed significant correlation with outcome in this signature ([Formula: see text]) - texture and morphology of the healthy pancreatic segment, intensity volume histogram-based feature of the pancreatic duct segment, morphology of the combined segment, and BMI. The predictions of this pre-operative signature showed strong correlation (Spearman correlation co-efficient, [Formula: see text]) with the intraoperative updated alternative fistula risk score (ua-FRS), which is the clinical gold standard for intraoperative CR-POPF risk stratification. These results indicate that the proposed combined radiomic and clinical signature developed solely based on preoperatively available clinical and routine imaging data can perform on par with the current state-of-the-art intraoperative models for CR-POPF risk stratification.