Management of Rectal Wall Abscess: A Rare Case Report.

A 34-year-old male presented with spontaneous rectal pain. He was diagnosed with a posterior rectal wall abscess 7 cm proximal to the anal verge that was confirmed on an MRI (magnetic resonance imaging) pelvis. This abscess was drained through a transrectal route. Rectal wall abscess is an exceedingly rare pathology compared to perianal abscess; therefore, this case highlights the key aspects of its management.

Endoscopic Ultrasound Guided Walled-off Necrosis Drainage.

Walled-off necrosis is a well-recognized complication of necrotizing pancreatitis that can cause sepsis, luminal or ductal obstruction, or persistent unwellness requiring multidisciplinary care. Recent data suggest that minimally invasive endoscopic treatment strategies are preferred over more invasive surgical approaches. Although endoscopic transmural drainage with or without necrosectomy is the primary approach for patients requiring an intervention, for collections not amenable to endoscopic approach, percutaneous drain placement followed by video-assisted retroperitoneal debridement or laparoscopic cystogastrostomy with internal debridement are other alternatives. More studies are required to optimize post-procedure care to shorten the length of stay and minimize resource utilization.

Efficacy and safety of endoscopic drainage versus percutaneous drainage for pancreatic fluid collection; a systematic review and meta-analysis.

BACKGROUND/AIMS: Pancreatic fluid collections (PFC) are debris or fluid of the pancreas that needs to be drained out. This may result from surgery or necrotizing pancreatitis. This meta-analysis compared the outcomes of PFC through endoscopic and percutaneous interventions. METHODS: A medical database was searched up to June 2022, comparing the outcomes of endoscopic drainage (ED) and percutaneous drainage (PD) for the PFC. Eligible studies reporting clinical and technical success and adverse events were selected. RESULTS: Seventeen studies with 1170 patients were included for meta-analysis, of which 543 patients underwent ED and 627 underwent PD. The odd ratio (OR) of technical success was 0.81 (95% confidence interval (CI) 0.31, 2.1) and clinical success was in the favor of the ED group at OR 2.23 (95% CI 1.45, 3.41). Adverse events OR 0.62 (95% CI 0.27, 1.39) and stent migration OR 0.61 (95% CI 0.10, 3.88) were the same in both groups, but hospital stay pooled mean difference of 15.02 days (95% CI 9.86, 20.18), mortality OR 0.24 (95% CI 0.09, 0.67), and re-interventions OR 0.25 (95% CI 0.16, 0.40) favored ED. CONCLUSIONS: ED is safe and efficient for PFC with higher clinical success, lower mortality rate, hospital stay, and re-interventions compared with PD.

Feasibility of Biliary Drainage Using a Novel Integrated Biliary Stent and Nasobiliary Drainage Catheter System for Acute Cholangitis.

Background Acute cholangitis is caused by cholestasis and bacterial infection, and if exacerbated, sepsis may occur and be fatal. Biliary drainage is recommended for acute cholangitis regardless of severity, except in some cases of mild acute cholangitis, in which antibiotics are effective. A novel integrated device comprising a biliary drainage stent and a nasobiliary drainage tube, called the UMIDAS NB stent (UMIDAS Inc., Kanagawa, Japan), was developed. In this study, we evaluated the efficacy and safety of biliary drainage using the UMIDAS NB stent outside type for acute cholangitis in clinical practice. Methods Patients with acute cholangitis with common bile duct stones or distal biliary strictures who underwent biliary drainage with the UMIDAS NB stent outside type at our institution between January 2022 and December 2022 were examined retrospectively. The UMIDAS NB stent outside type was placed transpapillary using endoscopic retrograde cholangiopancreatography (ERCP). Patients with biliary drainage stent placement other than the UMIDAS NB stent outside type on the same ERCP session and patients with acute cholecystitis were excluded. Results A total of 13 patients were included in this study. The severity of cholangitis was mild in four cases, moderate in five, and severe in four. There were eight cases of common bile duct stones and five cases of pancreatic cancer. The stent diameter was 7 French scale (Fr) in five cases and 8.5 Fr in eight cases. The median procedure time was 20 minutes. Clinical success was achieved in all 13 patients (100%). No treatment-related adverse events were observed. Unintended removal of the nasobiliary drainage tube was not observed. There were no cases of biliary drainage stent dislocation with nasobiliary drainage tube removal. Conclusions Although the sample size was small, our study demonstrated that biliary drainage with the UMIDAS NB stent outside type was effective and safe for patients with acute cholangitis who had common bile duct stones or distal biliary strictures, regardless of the severity of cholangitis.

Endoscopic ultrasound-guided transrectal drainage of a pelvic abscess after Hinchey II sigmoid colon diverticulitis: A case report.

BACKGROUND: Acute diverticulitis is one of the most prevalent complications of diverticular disease and may result in abscess formation, perforation, fistula formation, obstruction, or bleeding. Diverticular abscesses may be initially treated with antibiotics and/or percutaneous drainage and/or surgery. Endoscopic ultrasound (EUS)-guided drainage techniques are increasingly used as a minimally invasive alternative to percutaneous or surgical approaches, as they are associated with better treatment outcomes, shorter recovery time and duration of hospitalization. CASE SUMMARY: A 57-year-old female presented to the emergency department on account of abdominal pain and fever. Clinical examination revealed tenderness in the left lower abdominal quadrant, with elevated inflammatory markers in laboratory tests. Abdominal computed tomography (CT) revealed an 8 cm × 8 cm × 5 cm well-encapsulated abscess of the sigmoid colon, surrounded by numerous diverticula. A diagnosis of Hinchey II diverticular abscess was made, and the patient was admitted and commenced on appropriate antibiotic treatment. A transrectal EUS showed a fluid collection in direct contact with the sigmoid colon. Transluminal drainage was performed, and a lumen-apposing metal stent was inserted into the abscess collection. A follow-up CT scan showed a regression of the collection. The patient's general condition improved, and the stent was removed during a follow-up transrectal EUS that revealed no visible collection. CONCLUSION: We report the first successful management of a pelvic abscess in patient with Hinchey II acute diverticulitis using EUS-guided transluminal drainage in Slovenia. The technique appears effective for well-encapsulated intra-abdominal abscesses larger than 4 cm in direct contact with the intestinal wall of left colon.

Analysis of pancreatic pseudocyst drainage procedural outcomes: a population based study.

BACKGROUND: A pancreatic pseudocyst is a collection of fluid surrounded by a well-defined wall that contains no solid material. Studies on outcomes of pancreatic pseudocyst drainage have largely been limited to small cohorts. This study aims to take a population based approach to evaluate differences in inpatient outcomes among laparoscopic, percutaneous, and endoscopic drainage for pancreatic pseudocysts. METHODS: The National Inpatient Sample database was used to identify inpatient stays for pancreatic pseudocysts in which a single drainage approach was conducted. Baseline characteristic differences were compared with Rao-Scott chi squared and Mann-Whitney U tests. Propensity score matching controlling for clinical and demographic covariates followed by multivariable regression was used to pairwise compare drainage outcomes. Primary outcomes were length of stay, total charge, mortality, and disposition. Secondary outcomes were procedure related complication rates. RESULTS: Among a total of 35,640 weighted pancreatic pseudocyst cases, 3235 underwent drainage via a single procedure. Percutaneous was the most frequent drainage method performed (44.5%) and was more likely to be performed at nonteaching hospitals than laparoscopic (17% vs 9%, p = 0.04). Percutaneous drainage was associated with longer LOS (aIRR 1.42, 95% CI 1.07-1.86, p = 0.01) versus endoscopic and lower rates of routine disposition (aOR 0.45, 95% CI 0.23-0.89, p = 0.02) relative to endoscopic and laparoscopic (aOR 0.41, 95% CI 0.27-0.61, p < 0.01) drainage. There were no differences in primary outcomes in laparoscopic versus endoscopic drainage. Percutaneous drainage was associated with higher rates of septic shock than laparoscopic drainage (aOR 2.59, 95% CI 1.15-5.82, p = 0.02). CONCLUSIONS: Endoscopic and laparoscopic pancreatic pseudocyst drainage are associated with the least short term procedure related complications and more favorable in-hospital outcomes compared to percutaneous approaches. However, percutaneous drainage was the most commonly performed method in the 2017 NIS database.

Management of clinically relevant postoperative pancreatic fistula-related fluid collections after distal pancreatectomy.

BACKGROUND: Distal pancreatectomy is burdened by a high rate of clinically relevant postoperative pancreatic fistula (CR-POPF). The presence of a fistula-related abdominal collection often requires additional treatment such as antibiotics, percutaneous drainage, and endoscopic drainage thus prolonging patient recovery. Aim of this study was to describe the management of abdominal collections related to CR-POPF and identify variables associated with the need for invasive procedures. METHODS: A retrospective review of clinical data for patients who underwent distal pancreatectomy between 2015 and 2020 was conducted. All postoperative CT-scan imaging performed for clinical signs related to POPF was reviewed. The main outcome of the study was the need for procedural management (percutaneous or endoscopic) of CR-POPF-related fluid collections at 90 days after surgery. A multivariate regression analysis was adopted to analyze factors influencing procedural management of the collection. RESULTS: Five hundred sixteen patients were included in the study. Laparoscopic resection was performed in 290 patients (56%). At 90 days after surgery, CR-POPF occurred in 207 (40.1%) patients. A symptomatic collection related to fistula was observed in 130 patients (25.2%). Factors associated with fluid collections were increased body mass index (BMI) (25.5 versus 24, p = 0.001) and intraoperative blood loss (median of 250 versus 200 ml, p < 0.001). Procedural management was required in 70 patients (13.6%); 52 patients required interventional radiology and 18 endoscopic drainage. At multivariate analysis, risk factors for invasive procedures were the following CT-scan parameters: fluid collection diameter greater than 5 cm (OR 6.366, 95%CI 2.29-17.66, p = 0.001), presence of blood in the fluid collection (OR 10.618, 95%CI 1.94-58.09, p = 0.006), and enhancement of its walls (OR 4.073, 95%CI 1.22-13.57, p = 0.022). CONCLUSION: CR-POPF-related fluid collections affect about a quarter of patients undergoing distal pancreatectomy. CT-scan provides important information which can guide the management of the collection in a "step-up" fashion.

Acute cholecystitis in high-risk patients. surgical, radiological, or endoscopic treatment? brazilian college of digestive surgery position paper / Colecistite aguda em pacientes de alto risco. tratamento cirúrgico, radiológico ou endoscópico? posicionamento do colégio brasileiro de cirurgia digestiva

ABSTRACT Acute cholecystitis (AC) is an acute inflammatory process of the gallbladder that may be associated with potentially severe complications, such as empyema, gangrene, perforation of the gallbladder, and sepsis. The gold standard treatment for AC is laparoscopic cholecystectomy. However, for a small group of AC patients, the risk of laparoscopic cholecystectomy can be very high, mainly in the elderly with associated severe diseases. In these critically ill patients, percutaneous cholecystostomy or endoscopic ultrasound gallbladder drainage may be a temporary therapeutic option, a bridge to cholecystectomy. The objective of this Brazilian College of Digestive Surgery Position Paper is to present new advances in AC treatment in high-risk surgical patients to help surgeons, endoscopists, and physicians select the best treatment for their patients. The effectiveness, safety, advantages, disadvantages, and outcomes of each procedure are discussed. The main conclusions are: a) AC patients with elevated surgical risk must be preferably treated in tertiary hospitals where surgical, radiological, and endoscopic expertise and resources are available; b) The optimal treatment modality for high-surgical-risk patients should be individualized based on clinical conditions and available expertise; c) Laparoscopic cholecystectomy remains an excellent option of treatment, mainly in hospitals in which percutaneous or endoscopic gallbladder drainage is not available; d) Percutaneous cholecystostomy and endoscopic gallbladder drainage should be performed only in well-equipped hospitals with experienced interventional radiologist and/or endoscopist; e) Cholecystostomy catheter should be removed after resolution of AC. However, in patients who have no clinical condition to undergo cholecystectomy, the catheter may be maintained for a prolonged period or even definitively; f) If the cholecystostomy catheter is maintained for a long period of time several complications may occur, such as bleeding, bile leakage, obstruction, pain at the insertion site, accidental removal of the catheter, and recurrent AC; g) The ideal waiting time between cholecystostomy and cholecystectomy has not yet been established and ranges from immediately after clinical improvement to months. h) Long waiting periods between cholecystostomy and cholecystectomy may be associated with new episodes of acute cholecystitis, multiple hospital readmissions, and increased costs. Finally, when selecting the best treatment option other aspects should also be considered, such as costs, procedures available at the medical center, and the patient's desire. The patient and his family should be fully informed about all treatment options, so they can help making the final decision.

RESUMO A colecistite aguda (CA) é um processo inflamatório agudo da vesícula biliar que pode estar associado a complicações potencialmente graves, como empiema, gangrena, perfuração da vesícula biliar e sepse. O tratamento padrão para a CA é a colecistectomia laparoscópica. No entanto, para um pequeno grupo de pacientes com CA, o risco de colecistectomia laparoscópica pode ser muito alto, principalmente em idosos com doenças graves associadas. Nestes pacientes críticos, a colecistectomia percutânea ou a drenagem endoscópica da vesícula biliar guiada por ultrassom podem ser uma opção terapêutica temporária, como ponte para a colecistectomia. O objetivo deste artigo de posicionamento do Colégio Brasileiro de Cirurgia Digestiva é apresentar novos avanços no tratamento da CA em pacientes cirúrgicos de alto risco, para auxiliar cirurgiões, endoscopistas e clínicos a selecionar o melhor tratamento para os seus pacientes. A eficácia, segurança, vantagens, desvantagens e resultados de cada procedimento são discutidos. As principais conclusões são: a) Pacientes com CA e risco cirúrgico elevado devem ser tratados preferencialmente em hospitais terciários onde a experiência e os recursos cirúrgicos, radiológicos e endoscópicos estão disponíveis. b) A modalidade de tratamento ideal para pacientes com elevado risco cirúrgico, deve ser individualizada, com base nas condições clínicas e na experiência disponível. c) A colecistectomia laparoscópica continua sendo uma excelente opção de tratamento, principalmente em hospitais em que a drenagem da vesícula biliar percutânea ou endoscópica não está disponível. d) A colecistostomia percutânea e a drenagem endoscópica da vesícula biliar devem ser realizadas apenas em hospitais bem equipados e com radiologista intervencionista e/ou endoscopista experientes. e) O cateter de colecistostomia deve ser removido após a resolução da CA. No entanto, em pacientes que não têm condição clínica para realizar colecistectomia, o cateter pode ser mantido por um período prolongado ou mesmo definitivamente. f) Se o cateter de colecistostomia for mantido por longo período de tempo podem ocorrer várias complicações, como sangramento, fístula biliar, obstrução, dor no local de inserção, remoção acidental do cateter e CA recorrente. g) O tempo de espera ideal entre a colecistostomia e a colecistectomia ainda não foi estabelecido, e vai desde imediatamente após a melhoria clínica, até meses após. h) Longos períodos de espera entre colecistostomia e colecistectomia podem estar associados a novos episódios de CA, múltiplas readmissões hospitalares e aumento dos custos. Finalmente, ao selecionar a melhor opção de tratamento, outros aspectos também devem ser considerados, como custos, disponibilidade dos procedimentos no centro médico e o desejo do paciente. O paciente e sua família devem ser completamente informados sobre todas as opções de tratamento, para que possam ajudar a tomar a decisão final.

Duodenal diverticula perforation caused by an impacted bezoar successfully treated by endoscopic drainage and lithotripsy: A case report and literature review.

Duodenal diverticula perforation due to an impacted bezoar is a rare disease. Surgical treatment is associated with high rates of complications and mortality; therefore, treatment strategies must be carefully decided. Endoscopic treatment offers significant benefits to patients over surgery.

Percutaneous endoscopic drainage for acute long segment epidural abscess following endoscopic lumbar discectomy: A case report.

Introduction: Acute epidural abscess after percutaneous endoscopic lumbar discectomy is a rare but grievous complication. When faced with a long-segment epidural abscess, open surgery has traditionally been performed which can lead to huge surgical trauma and unpredictable complications. For this reason, surgeons around the world are constantly looking for more minimally invasive and effective surgical methods. Patient Concerns: Our patient was a 32-year-old woman who had been receiving percutaneous endoscopic interlaminar discectomy for L5/S1 lumbar disc herniation one week ago. She returned to our institution with a fever and lower back pain. Diagnoses: Magnetic resonance imaging revealed a long segment epidural abscess accompanied by a paravertebral abscess, and staphylococcus aureus was detected in a bacterial culture of pyogenic fluids extracted from the paravertebral abscess. Treatments: We performed percutaneous endoscopic drainage (PED) for the epidural abscess. Long-term sensitive antibiotic treatment after surgery. Outcomes: Immediate pain relief was achieved and the inflammatory reaction subsided after 4 weeks of antibiotic therapy. Re-examination of the lumbar spine MRI after 1 month showed that the epidural abscess disappeared completely. Conclusion: Percutaneous endoscopy allowed us to approach the epidural abscess directly, enabling the immediate drainage of the abscess with minimal trauma to the patient. The good results obtained show that percutaneous endoscopic drainage is a reliable way to treat a long-segment epidural abscess.

Interventional radiology followed by endoscopic drainage for pancreatic fluid collections associated with high bleeding risk: Two case reports.

BACKGROUND: Endoscopic ultrasound (EUS)-guided transluminal drainage is an advanced technique used to treat pancreatic fluid collections (PFCs). However, gastric varices and intervening vessels may be associated with a high risk of bleeding and are, therefore, listed as relative contraindications. Herein, we report two patients who underwent interventional embolization before EUS-guided drainage. CASE SUMMARY: Two 32-year-old males developed symptomatic PFCs after acute pancreatitis and came to our hospital for further treatment. One patient suffered from intermittent abdominal pain and vomiting, and computed tomography (CT) imaging showed an encapsulated cyst 7.93 cm × 6.13 cm in size. The other patient complained of a mass inside the abdomen, which gradually became enlarged. Gastric varices around the ideal puncture site were detected by EUS when we evaluated the possibility of endoscopic drainage in both patients. Interventional embolization was recommended as the first procedure to decrease the risk of bleeding. After that, EUS-guided transluminal drainage was successfully conducted, without vascular rupture. No postoperative complications occurred during hospitalization, and no recurrence was detected at the last follow-up CT scan performed at 1 mo. CONCLUSION: Interventional embolization is a safe, preoperative procedure that is performed before EUS-guided drainage in PFC patients with gastric varices or at high risk of bleeding.

Invasive intervention timing for infected necrotizing pancreatitis: Late invasive intervention is not late for collection.

With the advance of invasive interventions, the treatment model for infected necrotizing pancreatitis (INP) has shifted from open surgery to the step-up minimally invasive treatment. Late intervention, originating from the open surgery era, has been questioned in the minimally invasive period. With the emergence of new high-quality evidence about the timing for intervention, it seems to be increasingly apparent that, even in the age of minimal invasiveness, "late intervention" waiting for the necrotic collections to be encapsulated is still necessary. This opinion review mainly discusses the intervention timing for INP.

[Disconnected pancreatic duct syndrome in acute pancreatitis]. / Sindrom raz"edinennogo glavnogo protoka podzheludochnoi zhelezy pri ostrom pankreatite.

The review is devoted to diagnosis and treatment of disconnected pancreatic duct syndrome (DPDS) in patients with acute pancreatitis. Data on terminology, indications and options for endoscopic transluminal interventions are presented in detail. The results of numerous studies evaluating clinical efficacy of various endoscopic and open surgical procedures are analyzed. Available data confirm advisability of staged treatment of DPDS with primary endoscopic drainage of pancreatic fluid accumulations in specialized centers.

The Role of Antibiotics in Endoscopic Transmural Drainage of Post-Inflammatory Pancreatic and Peripancreatic Fluid Collections.

Background: Although endoscopic treatment of symptomatic post-inflammatory pancreatic and peripancreatic fluid collections (PPPFCs) is an established treatment method, some aspects of endotherapy and periprocedural management remain controversial. The role of antibiotics is one of the most controversial issues in interventional endoscopic management of local complications of pancreatitis. Methods: This study was a randomized, non-inferiority, placebo-controlled, and double-blinded clinical trial to investigate the role of antibiotic prophylaxis in endoscopic transmural drainage in patients with symptomatic non-infected PPPFCs and assess the influence of antibiotic treatment on the results of endotherapy in patients with symptomatic infected PPPFCs.This trial included 62 patients treated endoscopically for PPPFCs in 2020 at our medical center. Patients were divided into two groups; group 1 comprised patients who had received empirical intravenous antibiotic therapy during endotherapy and group 2 comprised patients who did not receive antibiotic therapy during endoscopic drainage of PPPFCs. The end points were clinical success and long-term success of endoscopic treatment. Results: Thirty-one patients were included in group 1 (walled-off pancreatic necrosis [WOPN, 51.6%; pseudocyst, 48.4%) and 31 patients in group 2 (WOPN, 58.1%; pseudocyst, 41.9%) (p=0.6098/nonsignificant statistical [NS]). Infection with PPPFCs was observed in 15/31 (48.39%) patients in group 1 and in 15/31 (48.39%) patients in group 2 (p=1.0/NS). The average time of active (with flushing through nasocystic drainage) drainage in group 1 was 13.0 (6 - 21) days and was 14.0 (7 - 25) days in group 2 (p=0.405/NS). The average total number endoscopic procedures on one patient was 3.3 (2 - 5) in group 1 and 3.4 (2 - 7) in group 2 (p=0.899/NS). Clinical success of PPPFCs was observed in 29/31 (93.5%) patients from group 1 and in 30/31 (96.8%) patients from group 2 (p=0.5540/NS). Complications of endotherapy were noted in 8/31 (25.8%) patients in group 1 and in 10/31 (32.3%) patients in group 2 (p=0.576/NS). Long-term success in group 1 and 2 was reported in 26/31 (83.9%) and 24/31 (77.4%) patients, respectively (p=0.520/NS). Conclusions: The effective endoscopic drainage of sterile PPPFCs requires no preventive or prophylactic use of antibiotics. In infected PPPFCs, antibiotic therapy is not required for effective endoscopic transmural drainage.

Management of severe acute pancreatitis in 2019.

Pancreatic fluid collections (PFCs) are frequent complications in severe acute pancreatitis that are the result of damage to the pancreas to include but not limited to trauma, surgery, autoimmune diseases, alcohol abuse, infections, medications, gallstones, metabolic disorders, and premalignant or malignant conditions. The majority of these collections resolve spontaneously; however, if the collection is infected or causes symptoms to include abdominal pain, nausea, vomiting, diarrhea, fevers, and tachycardia, drainage is indicated. Drainage of PFCs can be accomplished surgically, percutaneously, or endoscopically and should be approached in a multidisciplinary fashion for best overall patient care and outcomes. Before the introduction of endoscopic procedures, surgical and percutaneous drainage was the preferred modality. Today a minimally-invasive "step-up" approach is generally accepted depending upon the specific characteristics of the PFC and clinical presentation. Endoscopic ultrasound-guided PFC drainage is favored due to high success rates, shorter hospital stays, and lower cost. Direct debridement of walled-off pancreatitis can now be performed endoscopically with higher success rates with larger caliber fully covered metal stents. At large, the field of endoscopic techniques has evolved, and more specifically, the management of PFCs continues to evolve with increasing experience and with the advent of new stents and accessories, leading to increased efficacy with less adverse events.

Acute Pancreatitis: The Increasing Role of Medical Management of a Traditionally Surgically Managed Disease.

Management of acute pancreatitis and its complications has rapidly evolved in recent years. The earlier pillars of management that included prolonged bowel rest, empiric intravenous antibiotics, and early surgical intervention for complications such as pancreatic necrosis have become much less common. The latest evidence-based approaches to acute pancreatitis are taking almost a diametrically different path to previous management. The current strategy focuses on early feeding, judicious use of antibiotics, and delayed use of invasive interventions. Even in complex cases, when surgical interventions may be indicated, there is an expressed preference for minimally invasive techniques. We review the changes that have evolved rapidly over the past decade in this common clinical problem.

Efficacy of transgastric combined with percutaneous endoscopy for infected pancreatic necrosis / 中华消化内镜杂志

Objective:To evaluate the efficacy of transgastric combined with percutaneous endoscopic treatment for infected pancreatic necrosis (IPN).Methods:Clinical data of 19 IPN patients who received transgastric combined with percutaneous endoscopy at the Gastroenterology Intensive Care Unit of Nanjing Drum Tower Hospital from August 2015 to August 2020 were retrospectively studied. The clinical efficacy and the procedure-related complications were analyzed.Results:The mean procedure of endoscopic transmural drainage (ETD) was 1.1±0.3 times. During ETD procedure, lumen-apposing metal stents (LAMS) were placed in 9 patients, metal coated stents in 2 patients, double pigtail plastic stents in 7 patients, and only a nasal cyst drainage tube in 1 patient. All 19 patients received 12-14 F drainage catheters for drainage during the first percutaneous catheter drainage (PCD) treatment with the mean number of catheters of 1.8±1.2. Double cannulas was subsequently replaced in 3 of them for continuous drainage, and a percutaneous metal coated stent was replaced in 1 patient. The culture results of drainage fluid were 11 cases of gram-negative bacilli and gram-positive cocci, 4 cases of gram-positive cocci, 1 case of gram-positive bacilli, 3 cases of gram-negative bacilli. Among 19 patients, 4 cases had concurrent fungal infections. The mean number of debridement was 3.1±1.8 times, 2 cases of which were treated with endoscopic transluminal necrosectomy combined with percutaneous endoscopic necrosectomy. The mean procedure per patient was 6.1±2.4 times. Bleeding occurred in 1 case (5.3%) after the operation. But the bleeding was successfully stopped after endoscopic hemostasis. No serious complications such as gastrointestinal fistula, perforation or pancreatic fistula occurred. One patient died due to sepsis, and 18 other patients showed significant absorption of IPN after the treatment. None of the 19 patients were transferred to laparotomy.Conclusion:Transgastric combined with percutaneous endoscopic approach is safe and effective for IPN.

Splenic injury following endoscopic drainage of a large pancreatic pseudocyst: a case report.

BACKGROUND: Many pancreatic pseudocysts spontaneously resolve, but larger or symptomatic pseudocysts may require procedural management. Though endoscopic ultrasound guided approaches are standard of care and have high success rates, complications can include bleeding, infection, and splenic perforation. This patient case report details an unusual series of complications of endoscopic cystogastrostomy that should encourage clinicians to evaluate for anatomic disruptions caused by mass effects of pancreatic pseudocysts prior to endoscopic pseudocyst drainage. CASE PRESENTATION: A 53-year-old African American male with a past medical history notable for alcohol use disorder, chronic pancreatitis, and insulin dependent diabetes presented with a 4-day history of left upper quadrant abdominal pain. Computed tomography imaging with contrast revealed enlargement of a known pancreatic pseudocyst to 15.9 × 10.4 cm. Due to pseudocyst size and the patient's symptoms, endoscopic cystogastrostomy stent placement was performed. However, postprocedurally, he developed leukocytosis to 19,800 cells/m3 (from 14,100 cells/m3 preoperatively) as well as acute hypoxemic respiratory failure with a large left pleural effusion. Postprocedural computed tomography with contrast demonstrated a new large subcapsular splenic hematoma in communication with a new subdiaphragmatic fluid collection. Due to suspicion of endoscopic procedural complication, he underwent open laparotomy which revealed grade 4 splenic laceration, septic splenic hematoma, and a subdiaphragmatic abscess. CONCLUSIONS: While endoscopic drainage of pancreatic pseudocyst was technically successful, this case demonstrates complications from mass effect of a large pancreatic pseudocyst which putatively tore the splenorenal ligament, leading to excessive separation of the left kidney and spleen. If anatomic disruptions caused by mass effect from a pancreatic pseudocyst are recognized through preprocedural abdominal imaging, such cases may be considered for early open repair versus cystogastrostomy.

Extrahepatic cholangiocarcinoma: Current status of endoscopic approach and additional therapies.

The prognosis of patients with advanced or unresectable extrahepatic cholangiocarcinoma is poor. More than 50% of patients with jaundice are inoperable at the time of first diagnosis. Endoscopic treatment in patients with obstructive jaundice ensures bile duct drainage in preoperative or palliative settings. Relief of symptoms (pain, pruritus, jaundice) and improvement in quality of life are the aims of palliative therapy. Stent implantation by endoscopic retrograde cholangiopancreatography is generally preferred for long-term palliation. There is a vast variety of plastic and metal stents, covered or uncovered. The stent choice depends on the expected length of survival, quality of life, costs and physician expertise. This review will provide the framework for the endoscopic minimally invasive therapy in extrahepatic cholangiocarcinoma. Moreover, additional therapies, such as brachytherapy, photodynamic therapy, radiofrequency ablation, chemotherapy, molecular-targeted therapy and/or immunotherapy by the endoscopic approach, are the nonsurgical methods associated with survival improvement rate and/or local symptom palliation.

Multidisciplinary Management of Complicated Pancreatitis: What Every Interventional Radiologist Should Know.

Management of acute pancreatitis is challenging in the presence of local complications that include pancreatic and peripancreatic collections and vascular complications. This review, targeted for interventional radiologists, describes minimally invasive endoscopic, image-guided percutaneous, and surgical procedures for management of complicated pancreatitis and provides insight into the procedures' algorithmic application. Local complications are optimally managed in a multidisciplinary team setting that includes advanced endoscopists; pancreatic surgeons; diagnostic and interventional radiologists; and specialists in infectious disease, nutrition, and critical care medicine. Large symptomatic or complicated sterile collections and secondary infected collections warrant drainage or débridement. The drainage is usually delayed for 4-6 weeks unless clinical deterioration warrants early intervention. If collections are accessible by endoscopy, endoscopic procedures are preferred to avoid pancreaticocutaneous fistulas. Image-guided percutaneous drainage is indicated for symptomatic collections that are not accessible for endoscopic drainage or that present in the acute setting before developing a mature wall. Peripancreatic arterial pseudoaneurysms should be embolized before necrosectomy procedures to prevent potentially life-threatening hemorrhage. Surgical procedures are reserved for symptomatic collections that persist despite endoscopic or interventional drainage attempts. Understanding these procedures facilitates their integration by interventional radiologists into the complex longitudinal care of patients with complicated pancreatitis.