Different timing for abdominal paracentesis catheter placement and drainage in severe acute pancreatitis complicated by intraabdominal fluid accumulation

BACKGROUND Non-surgical methods such as percutaneous drainage are crucial for the treatment of patients with severe acute pancreatitis(SAP).However,there is still an ongoing debate regarding the optimal timing for abdominal paracentesis catheter place-ment and drainage.AIM To explore the influence of different timing for abdominal paracentesis catheter placement and drainage in SAP complicated by intra-abdominal fluid accumu-lation.METHODS Using a retrospective approach,184 cases of SAP complicated by intra-abdominal fluid accumulation were enrolled and categorized into three groups based on the timing of catheter placement:group A(catheter placement within 2 d of symptom onset,n=89),group B(catheter placement between days 3 and 5 after symptom onset,n=55),and group C(catheter placement between days 6 and 7 after symptom onset,n=40).The differences in progression rate,mortality rate,and the number of cases with organ dysfunction were compared among the three groups.RESULTS The progression rate of group A was significantly lower than those in groups B and groups C(2.25%vs 21.82%and 32.50%,P<0.05).Further,the proportion of patients with at least one organ dysfunction in group A was significantly lower than those in groups B and groups C(41.57%vs 70.91%and 75.00%,P<0.05).The mortality rates in group A,group B,and group C were similar(P>0.05).At postoperative day 3,the levels of C-reactive protein(55.41±19.32 mg/L vs 82.25±20.41 mg/L and 88.65±19.14 mg/L,P<0.05),procalcitonin(1.36±0.51 ng/mL vs 3.20±0.97 ng/mL and 3.41±0.98 ng/mL,P<0.05),tumor necrosis factor-alpha(15.12±6.63 pg/L vs 22.26±9.96 pg/L and 23.39±9.12 pg/L,P<0.05),interleukin-6(332.14±90.16 ng/L vs 412.20±88.50 ng/L and 420.08±87.65ng/L,P<0.05),interleukin-8(415.54±68.43 ng/L vs 505.80±66.90 ng/L and 510.43±68.23ng/L,P<0.05)and serum amyloid A(270.06±78.49 mg/L vs 344.41±81.96 mg/L and 350.60±80.42 mg/L,P<0.05)were significantly lower in group A compared to those in groups B and group C.The length of hospital stay in group A was significantly lower than those in groups B and group C(24.50±4.16 d vs 35.54±6.62 d and 38.89±7.10 d,P<0.05).The hospitalization expenses in group A were also significantly lower than those in groups B and groups C[2.70(1.20,3.55)ten-thousand-yuan vs 5.50(2.98,7.12)ten-thousand-yuan and 6.00(3.10,8.05)ten-thousand-yuan,P<0.05).The incidence of complications in group A was markedly lower than that in group C(5.62%vs 25.00%,P<0.05),and similar to group B(P>0.05).CONCLUSION Percutaneous catheter drainage for the treatment of SAP complicated by intra-abdominal fluid accumulation is most effective when performed within 2 d of onset.

Severe acute pancreatitis complicated with intra-abdominal infection secondary to trauma:A case report

BACKGROUND Pancreatic trauma(PT)is rare among traumatic injuries and has a low incidence,but it can still lead to severe infectious complications,resulting in a high mortality rate.Acute pancreatitis(AP)is a common complication after PT,and when combined with organ dysfunction and sepsis,it will result in a poorer prognosis.CASE SUMMARY We report a 25-year-old patient with multiple organ injuries,including the pancreas,due to abdominal trauma,who developed necrotising pancreatitis secondary to emergency caesarean section,combined with intra-abdominal infection(IAI).The patient underwent performed percutaneous drainage,pancreatic necrotic tissue debridement,and abdominal infection foci debridement on the patient.CONCLUSION We report a case of severe AP and IAI secondary to trauma.This patient was managed by a combination of conservative treatment such as antibiotic therapy and fluid support with surgery,and a better outcome was obtained.

Rescue from complications after pancreaticoduodenectomies at a low-volume Caribbean center:Value of tailored peri-pancreatectomy protocols

BACKGROUND Pancreaticoduodenectomy(PD)is a technically complex operation,with a re-latively high risk for complications.The ability to rescue patients from post-PD complications is as a recognized quality measure.Tailored protocols were instituted at our low volume facility in the year 2013.AIM To document the rate of rescue from post-PD complications with tailored protocols in place as a measure of quality.METHODS A retrospective audit was performed to collect data from patients who experienced major post-PD complications at a low volume pancreatic surgery unit in Trinidad and Tobago between January 1,2013 and June 30,2023.Stan-dardized definitions from the International Study Group of Pancreatic Surgery were used to define post-PD complications,and the modified Clavien-Dindo classification was used to classify post-PD complications.RESULTS Over the study period,113 patients at a mean age of 57.5 years(standard deviation[SD]±9.23;range:30-90;median:56)underwent PDs at this facility.Major complications were recorded in 33(29.2%)patients at a mean age of 53.8 years(SD:±7.9).Twenty-nine(87.9%)patients who experienced major morbidity were salvaged after aggre-ssive treatment of their complication.Four(3.5%)died from bleeding pseudoaneurysm(1),septic shock secondary to a bile leak(1),anastomotic leak(1),and myocardial infarction(1).There was a significantly greater salvage rate in patients with American Society of Anesthesiologists scores≤2(93.3%vs 25%;P=0.0024).CONCLUSION This paper adds to the growing body of evidence that volume alone should not be used as a marker of quality for patients requiring PD.Despite low volumes at our facility,we demonstrated that 87.9%of patients were rescued from major complications.We attributed this to several factors including development of rescue protocols,the competence of the pancreatic surgery teams and continuous,and adaptive learning by the entire institution,cul-minating in the development of tailored peri-pancreatectomy protocols.

Pathogenic aspects of pulmonary complications in acute pancreatitis patients

BACKGROUND:Experimental and clinical observations show that proinflammatory cytokines and oxidative stress are involved in the development of local and particularly systemic complications in acute pancreatitis (AP) patients. There are often pulmonary complications in such patients. The mechanisms through which lung injury is induced in AP are not fully clear. METHODS:In order to assess the role of activated neutrophils, pro- and anti-inflammatory cytokines and adhesion molecules at the onset and development of respiratory complications and respiratory failure, we measured the serum levels of pro-inflammatory (IL-1β, IL-6, IL-8, IL-18, TNF-α) and anti-inflammatory (IL-1ra, IL-10) cytokines in 51 AP patients who had been diagnosed with pancreatitis-associated lung injury with and without the development of organ dysfunction. RESULTS:When admitted to the hospital, severe AP patients had increased concentrations of IL-1β, IL-6, IL-8, IL-18, and TNF-α. The concentration of IL-18 alone was considerably increased in the patients who later developed respiratory failure. The onset of acute respiratory distress syndrome in the AP patients was accompanied by an increase in the level of anti-inflammatory cytokines, especially IL-10. It was noted that in severe lung injury, myeloperoxidase activity in the blood increased significantly, but still reflected the processes taking place in the lung parenchyma. Increase in the concentrations of adhesion molecules preceded the development of pulmonary infiltration with respiratory failure symptoms, which provoked endothelial dysfunction and determined the capillary surface permeability for neutrophils and monocytes.CONCLUSIONS:In the pathogenesis of respiratory complications in AP cytokines, chemokines and adhesion molecules, in particular IL-1β, IL-6, IL-8, IL-18, TNF-α, ICAM-1, and E-selectin play major roles. At IL-18 concentrations >650 pg/ml, AP patients are likely to develop pulmonary dysfunction (sensitivity 58%, specificity 100%, LR-positive >58) which allows us to use it as a screening test.

Surgical and interventional management of complications caused by acute pancreatitis

Acute pancreatitis is one of the most common gastrointestinal disorders worldwide. It requires acute hospitalization, with a reported annual incidence of 13 to 45 cases per 100000 persons. In severe cases there is persistent organ failure and a mortality rate of 15% to 30%, whereas mortality of mild pancreatitis is only 0% to 1%. Treatment principles of necrotizing pancreatitis and the role of surgery are still controversial. Despite surgery being effective for infected pancreatic necrosis, it carries the risk of long-term endocrine and exocrine deficiency and a morbidity and mortality rate of between 10% to 40%. Considering high morbidity and mortality rates of operative necrosectomy, minimally invasive strategies are being explored by gastrointestinal surgeons, radiologists, and gastroenterologists. Since 1999, several other minimally invasive surgical, endoscopic, and radiologic approaches to drain and debride pancreatic necrosis have been described. In patients who do not improve after technically adequate drainage, necrosectomy should be performed. When minimal invasive management is unsuccessful or necrosis has spread to locations not accessible by endoscopy, open abdominal surgery is recommended. Additionally, surgery is recognized as a major determinant ofoutcomes for acute pancreatitis, and there is general agreement that patients should undergo surgery in the late phase of the disease. It is important to consider multidisciplinary management, considering the clinical situation and the comorbidity of the patient, as well as the surgeons experience.

Magnetic resonance imaging for local complications of acute pancreatitis: A pictorial review

Acute pancreatitis is a common disease characterized by sudden upper abdominal pain and vomiting. Alcoholism and choledocholithiasis are the most common factors for this disease. The choice of treatment for acute pancreatitis might be affected by local complications, such as local hemorrhage in or around the pancreas, and peripancreatic infection or pseudoaneurysm. Diagnostic imaging modalities for acute pancreatitis have a significant role in confirming the diagnosis of the disease, helping detect the extent of pancreatic necrosis, and for diagnosing local complications. Magnetic resonance imaging (MRI) might be indicated in acute pancreatitis for detecting and characterizing local complications of acute pancreatitis that involve necrotic, hemorrhagic, infectious, vascular, and pseudocyst disorders. The general MRI sequences for pancreatitis require the combined use of T1-weighted, T2-weighted sequences, and magnetic resonance chol-angiopancreatography. For imaging of pancreatic necrosis, the combination of T1-weighted and T2-weighted findings with dynamic contrast-enhanced imaging gives a comprehensive evaluation of the extent of necrosis and full range of inflammatory extension. For imaging of infectious complications, dynamic contrast-enhanced examinations might help differentiate pancreatic cellulitis or abscesses, from pancreatic fluid collection or simple pseudocysts. For vascular abnormalities, the combination of cross-sectional pancreatic parenchyma imaging with MRA represents a single diagnostic modality for the full evaluation of peripancreatic artery and vein involvement, such as arterial pseudoaneurysms and venous thromboses. The purpose of this pictorial review is to examine the MRI appearances of various local complications of acute pancreatitis and to discuss the practical setup of MRI in local complications of acute pancreatitis.

Pathophysiology of pulmonary complications of acute pancreatitis

Acute pancreatitis in its severe form is complicated by multiple organ system dysfunction, most importantly by pulmonary complications which include hypoxia, acute respiratory distress syndrome, atelectasis, and pleural effusion. The pathogenesis of some of the above complications is attributed to the production of noxious cytokines. Clinically significant is the early onset of pleural effusion, which heralds a poor outcome of acute pancreatitis. The role of circulating trypsin, phospholipase A2, platelet activating factor, release of free fatty acids, chemoattractants such as tumor necrsosis factor （TNF）- alpha, interleukin （IL）-1, IL-6, IL-8, fMet-leu-phe （a bacterial wall product）, nitric oxide, substance P, and macrophage inhlbitor factor is currently studied. The hope is that future management of acute pancreatitis with a better understanding of the pathogenesis of lung injury will be directed against the production of noxious cytokines.

Acute pancreatitis as a complication of acute COVID-19 in kidney transplant recipients

BACKGROUND Acute pancreatitis is a rare extrapulmonary manifestation of coronavirus disease 2019(COVID-19)but its full correlation with COVID-19 infection remains unknown.AIM To identify acute pancreatitis’occurrence,clinical presentation and outcomes in a cohort of kidney transplant recipients with acute COVID-19.METHODS A retrospective observational single-centre cohort study from a transplant centre in Croatia for all adult renal transplant recipients with a functioning kidney allograft between March 2020 and August 2022 to record cases of acute pancreatitis during acute COVID-19.Data were obtained from hospital electronic medical records.Severe acute respiratory syndrome coronavirus 2(SARS-CoV-2)infection was proven by a positive SARS-CoV-2 real-time reverse transcriptase-polymerase chain reaction on the nasopharyngeal swab.RESULTS Four hundred and eight out of 1432(28.49%)patients who received a renal allograft developed COVID-19 disease.The analyzed cohort included 321 patients(57%males).One hundred and fifty patients(46.7%)received at least one dose of the anti-SARS-CoV-2 vaccine before the infection.One hundred twenty-five(39.1%)patients required hospitalization,141(44.1%)developed pneumonia and four patients(1.3%)required mechanical ventilation.Treatment included immunosuppression modification in 233 patients(77.1%)and remdesivir in 53 patients(16.6%),besides the other supportive measures.In the study cohort,only one transplant recipient(0.3%)developed acute pancreatitis during acute COVID-19,presenting with abdominal pain and significantly elevated pancreatic enzymes.She survived without complications with a stable kidney allograft function.CONCLUSION Although rare,acute pancreatitis may complicate the course of acute COVID-19 in kidney transplant recipients.The mechanism of injury to the pancreas and its correlation with the severity of the COVID-19 infection in kidney transplant recipients warrants further research.

Early complications after interventions in patients with acute pancreatitis

AIM: To identify the possible predictors of early complications after the initial intervention in acute necrotizing pancreatitis.METHODS: We collected the medical records of 334 patients with acute necrotizing pancreatitis who received initial intervention in our center. Complications associated with predictors were analyzed.RESULTS: The postoperative mortality rate was 16% (53/334). Up to 31% of patients were successfully treated with percutaneous catheter drainage alone. The rates of intra-abdominal bleeding, colonic fistula, and progressive infection were 15% (50/334), 20% (68/334), and 26% (87/334), respectively. Multivariate analysis indicated that Marshall score upon admission, multiple organ failure, preoperative respiratory infection, and sepsis were the predictors of postoperative progressive infection (P &#x0003c; 0.05). Single organ failure, systemic inflammatory response syndrome upon admission, and C-reactive protein level upon admission were the risk factors of postoperative colonic fistula (P &#x0003c; 0.05). Moreover, preoperative Marshall score, organ failure, sepsis, and preoperative systemic inflammatory response syndrome were the risk factors of postoperative intra-abdominal bleeding (P &#x0003c; 0.05).CONCLUSION: Marshall score, organ failures, preoperative respiratory infection, sepsis, preoperative systemic inflammatory response syndrome, and C-reactive protein level upon admission are associated with postoperative complications.

Treatment of severe acute pancreatitis and its complications

Severe acute pancreatitis(SAP),which is the most serious type of this disorder,is associated with high morbidity and mortality. SAP runs a biphasic course. During the first 1-2 wk,a pro-inflammatory response results in systemic inflammatory response syndrome(SIRS). If the SIRS is severe,it can lead to early multisystem organ failure(MOF). After the first 1-2 wk,a transition from a pro-inflammatory response to an anti-inflammatory response occurs;during this transition,the patient is at risk for intestinal flora translocation and the development of secondary infection of the necrotic tissue,which can result in sepsis and late MOF. Many recommendations have been made regarding SAP management and its complications. However,despite the reduction in overall mortality in the last decade,SAP is still associated with high mortality. In the majority of cases,sterile necrosis should be managed conservatively,whereas in infected necrotizing pancreatitis,the infected non-vital solid tissue should be removed to control the sepsis. Intervention should be delayed for as long as possible to allow better demarcation and liquefaction of the necrosis. Currently,the step-up approach(delay,drain,and debride) may be considered as the reference standard intervention for this disorder.

Diagnostic value of contrast enhanced ultrasound for splenic artery complications following acute pancreatitis

AIM: To assess the value of contrast-enhanced ultrasound (CEUS) in diagnosing splenic artery complications (SACs) after acute pancreatitis (AP). METHODS: One hundred and eighteen patients with AP were enrolled in the study. All patients were examined by CEUS and contrast-enhanced computed tomography (CECT). CECT was accepted as a gold standard for the diagnosis of SACs in AP. The diagnostic accuracy of splenic CEUS and pancreatic CEUS was compared with that of CECT. Splenic infarction was the diagnostic criterion for splenic artery embolism and local dysperfusion of the splenic parenchyma was the diagnostic criterion for splenic arterial stenosis. The incidence of splenic sub-capsular hemorrhage, splenic artery aneurysms, and splenic rupture was all lower than that of SACs. RESULTS: Nine patients were diagnosed as having SACs after AP by CECT among the 118 patients. The patients with SACs were diagnosed with severe acute pancreatitis (SAP). Among them, 6 lesions were diagnosed as splenic artery embolism, 5 as splenic artery aneurysms, and 1 as splenic arterial stenosis. No lesion was diagnosed by pancreatic CEUS and 5 lesions were diagnosed by splenic CEUS. By splenic CEUS, 4 cases were diagnosed as splenic artery embolism and 1 as splenic arterial stenosis. The accuracy of splenic CEUS in diagnosis of SACs in SAP was 41.7% (5/12), which was higher than that of pancreatic CEUS (0%). CONCLUSION: Splenic CEUS is a supplementary method for pancreatic CEUS in AP patients, which can decrease missed diagnosis of SACs. (C) 2014 Baishideng Publishing Group Co., Limited. All rights reserved.

Splenic Vein Thrombosis as a Complication of Hypertriglyceridemia-Induced Acute Pancreatitis

Background: Acute pancreatitis (AP) is an extensive inflammation condition that may lead to local and systemic complications, ranging from mild edematous peripancreatic fluid collection to multiorgan failure and death. Aim: To report the case of the patient with the complications that happened and the presented management. Case presentation: A 37-year-old female patient presented with acute necrotizing pancreatitis secondary to hypertriglyceridemia. During hospitalization, the patient developed severe ileus with splenic vein thrombosis. She was treated conservatively with Intravenous (IV) fluids, insulin infusion, anticoagulant, pain relief medication and antibiotics. Discussion: This case of pancreatitis induced splenic vein thrombosis (PIVST) was treated supportively with outstanding improvement of the patient’s symptoms. Conclusion: Acute pancreatitis can be complicated by splenic vein thrombosis that can be self-limited and treated with conservative measures.

Timing, distribution, and microbiology of infectious complications after necrotizing pancreatitis

BACKGROUND Acute pancreatitis(AP)is a common acute abdominal disease worldwide,and its incidence rate has increased annually.Approximately 20%of AP patients develop into necrotizing pancreatitis(NP),and 40%to 70%of NP patients have infectious complications,which usually indicate a worse prognosis.Infection is an important sign of complications in NP patients.AIM To investigate the difference in infection time,infection site,and infectious strain in NP patients with infectious complications.METHODS The clinical data of AP patients visiting the Department of General Surgery of Xuanwu Hospital of Capital Medical University from January 1,2014 to December 31,2018 were collected retrospectively.Enhanced computerized tomography or magnetic resonance imaging findings in patients with NP were included in the study.Statistical analysis of infectious bacteria,infection site,and infection time in NP patients with infectious complications was performed,because knowledge about pathogens and their antibiotic susceptibility patterns is essential for selecting an appropriate antibiotic.In addition,the factors that might influence the prognosis of patients were analyzed.RESULTS In this study,539 strains of pathogenic bacteria were isolated from 162 patients with NP infection,including 212 strains from pancreatic infections and 327 strains from extrapancreatic infections.Gram-negative bacteria were the main infectious species,the most common of which were Escherichia coli and Pseudomonas aeruginosa.The extrapancreatic infection time(9.1±8.8 d)was earlier than the pancreatic infection time(13.9±12.3 d).Among NP patients with early extrapancreatic infection(<14 d),bacteremia(25.12%)and respiratory tract infection(21.26%)were predominant.Among NP patients with late extrapancreatic infection(>14 d),bacteremia(15.94%),respiratory tract infection(7.74%),and urinary tract infection(7.71%)were predominant.Drug sensitivity analysis showed that P.aeruginosa was sensitive to enzymatic penicillins,thirdand fourth-generation cephalosporins,and carbapenems.Acinetobacter baumannii and Klebsiella pneumoniae were sensitive only to tigecycline;Staphylococcus epidermidis and Enterococcus faecium were highly sensitive to linezolid,tigecycline,and vancomycin.CONCLUSION In this study,we identified the timing,the common species,and site of infection in patients with NP.

Endoscopic management of complications of chronic pancreatitis

Pseudocysts and biliary obstructions will affect approximately one third of patients with chronic pancreatitis(CP).For CP-related,uncomplicated,pancreatic pseudocysts(PPC),endoscopy is the first-choice therapeutic option.Recent advances have focused on endosonography-guided PPC transmural drainage,which tends to replace the conventional,duodenoscope-based coma immediately approach.Ancillary material is being tested to facilitate the endosonography-guided procedure.In this review,the most adequate techniques depending on PPC characteristics are presented along with supporting evidence.For CP-related biliary obstructions,endoscopy and surgery are valid therapeutic options.Patient co-morbidities(e.g.,portal cavernoma)and expected patient compliance to repeat endoscopic procedures are important factors when selecting the most adapted option.Malignancy should be reasonably ruled out before embarking on the endoscopic treatment of presumed CP-related biliary strictures.In endoscopy,the gold standard technique consists of placing simultaneous,multiple,side-by-side,plastic stents for a oneyear period.Fully covered self-expandable metal stents are challenging this method and have provided 50%mid-term success.

The impacts of infectious complications on outcomes in acute pancreatitis: a retrospective study

Background: The occurrence of infectious complications characterizes the more severe forms of acute pancreatitis(AP) and is associated with high mortality. We investigated the effects of infection at different sites in patients with AP, including those with necrotizing pancreatitis(NP).Methods: We conducted a retrospective analysis of 285 patients who met the inclusion criteria for AP and were admitted to Tianjin Nankai Hospital between January 2016 and September 2019. According to the source of the culture positivity during hospitalization, patients were divided into four groups: sterile group(n=148), pancreatic infection group(n=65), extrapancreatic infection group(n=22) and combined infection group(n=50). The source of infection, microbiology, biochemical parameters and prognostic indicators were analyzed.Results: In terms of baseline characteristics, the four groups were similar in age, sex, aetiology, previous pancreatitis and diabetes. Compared with the severity of the disease in the other groups, the APACHE II scores(9.91±4.65, 9.46±5.05, respectively) and organ failure rate(40.9% and 50%, respectively)were higher in the extrapancreatic infection group and the combined infection group(P<0.05). The frequency of surgical intervention and hospitalization time in patients with NP complicated with extrapancreatic infection was greatly increased(P<0.05). Regarding the primary outcome, patients in the combined infection group had longer hospital stays(68.28±51.80 vs. 55.58±36.24, P<0.05) and higher mortality(24.0% vs. 9.2%, P<0.05) than patients in the pancreatic infection group. In addition, patients in the extrapancreatic infection group also showed high intensive care utilization(59.1%) and mortality rates(18.2%). Among the 137 AP patients with infection complications, 89 patients exhibited multidrug-resistant(MDR) microorganisms, and the mortality rate of patients with MDR bacterial infection was higher than that of patients with non-MDR bacterial infection(24.7% vs. 3.6%, P=0.001).Conclusions: Clinicians should be aware that extrapancreatic infection(EPI) significantly aggravates the main outcome in pancreatic infection patients. Infection with MDR bacteria is also associated with AP mortality.

Onset time of complications in patients with severe acute pancreatitis receiving nonoperative therapy

Objective: To retrospectively analyze 85 hospitalizednonoperative patients with severe acute pancreatitis(SAP) and to find out the stages of the disease.Methods: We statistically calculated the time of onsetof complications in these patients from 1987 to 1999.Results: The 95% confidence interval of total averagefor the complications of acute respiratory distress syn-drome (ARDS), shock and kidney failure was between2 to 4 days, and for encephalopathy, hemorrhage ofthe digestive tract, bacterial infection, fungous infec-tion and abscess between 3 to 6 days, 3 to 5 days, 13to 16 days, 13 to 16 days, and 14 to 23 days respec-tively. The 95% confidence interval of total averagein 18 deaths (21%) was between 5 to 6 days. ARDS,kidney failure, and shock occurred within 4 days, en-cephalopathy within 6 days (average 4.8±0.9 days),abscesses after 14 days, systemic bacterial infectionand fungous infection within half a month (average14.6±1.1days, 14.8±0.9days respectively), and deathwithin 6 days.Conclusion: According to the time of the occurrence ofcomplications, we divide the courses of the disease intothree stages: early phase(first 4 days) with ARDS,kidney failure, shock, encephalopathy and hemorrhageof the digestive tract; middle phase (5-15 days) withbacterial infection and fungous infection; late phase(15 days after the onset) with abscess.

Vascular complications of pancreatitis

More than 200000 hospital admissions happen per year for acute pancreatitis and more than 50000 for chronic pancreatitis in the United States of America.Necrotizing pancreatitis accounts for 20%-30%of the cases.One-quarter of the patients with pancreatitis develop vascular complications,which carries a high mortality.This mini-review will address these complications that can help primary care physicians and hospitalists in managing their patients effectively.

Experience in Diagnosis and Treatment of Bleeding Complications in Severe Acute Pancreatitis by TAE

Summary: The experience in diagnosis and treatment of bleeding complications in severe acute pancreatitis (SAP) by transcatheter arterial embolization was summarized. The clinical data of 19 SAP patients complicated with intra-abdominal bleeding in our hospital from Jan. 2000 to Jan. 2003 were analyzed retrospectively and the therapeutic outcome of TAE was evaluated statistically. The results showed that the short-term successful rate of hemostasis by TAE was 89.5 % (17/19), the incidence of re-bleeding after TAE was 36.8 % (7/19) and the successful rate of hemostatis by second TAE was 71.4 % (5/7). It was concluded that the intra-abdominal bleeding in SAP was mainly caused by the rupture of erosive/infected pseudoaneurysm. Mostly, the broken vessels were splenic artery and gastroduodenal artery. In terms of emergence hemostatis, TAE is the most effective method. Surgical hemostasis is necessary if hemostasis by TAE is failed or re-bleeding occurs after TAE.

Complications of chronic pancreatitis prior to and following surgical treatment:A proposal for classification

BACKGROUND Chronic pancreatitis(CP)is a long-lasting disease frequently associated with complications for which there is no comprehensive pathophysiological classification.AIM The aims of this study were to:Propose a pathophysiological classification of the complications of CP;evaluate their prevalence in a surgical cohort prior to,and following surgical management;and assess the impact of the surgical treatment on the occurrence of new complications of CP during follow-up.We hypothesized that optimal surgical treatment can resolve existing complications and reduce the risk of new complications,with the exclusion of pancreatic insufficiency.The primary outcomes were prevalence of complications of CP at baseline(prior to surgical treatment)and occurrence of new complications during follow-up.METHODS After institutional review board approval,a prospective observational cohort study with long-term follow-up(up to 20.4 years)was conducted.All consecutive single-center adult patients(≥18 years of age)with CP according to the criteria of the American Pancreas Association subjected to surgical management between 1997 and 2021,were included.The prevalence of CP complications evaluated,according to the proposed classification,in a surgical cohort of 166 patients.Development of the pathophysiological classification was based on a literature review on the clinical presentation,course,and complications of CP,as well a review of previous classification systems of CP.RESULTS We distinguished four groups of complications:Pancreatic duct complications peripancreatic complications,pancreatic hemorrhages,and pancreatic insufficiency(exocrine and endocrine).Their baseline prevalence was 20.5%,23.5%,10.2%,31.3%,and 27.1%,respectively.Surgical treatment was highly effective in avoiding new complications in the first and third groups.In the group of peripancreatic complications,the 15-year Kaplan-Meier prevalence of new complications was 12.1%.The prevalence of pancreatic exocrine and endocrine insufficiency increased during follow-up,being 66.4%and 47.1%,respectively,at 15 years following surgery.Pancreatoduodenal resection resulted optimal results in avoiding new peripancreatic complications,but was associated with the highest rate of pancreatic exocrine insufficiency.CONCLUSION The proposed complication classification improves the understanding of CP.It could be beneficial for clinical decision making,as it provides an opportunity for more comprehensive judgement on patient’s needs on the one hand,and on the pros and cons of the treatment under consideration,on the other.The presence of complications of CP and the risk of development of new ones should be among the main determinants of surgical choice.

Vascular complications of chronic pancreatitis and its management

Chronic pancreatitis is a chronic fibro-inflammatory disorder of the pancreas,resulting in recurrent abdominal pain,diabetes mellitus,and malnutrition.It may lead to various other complications such as pseudocyst formation,benign biliary stricture,gastric outlet obstruction;and vascular complications like venous thrombosis,variceal and pseudoaneurysmal bleed.Development of varices is usually due to chronic venous thrombosis with collateral formation and variceal bleeding can easily be tackled by endoscopic therapy.Pseudoaneurysmal bleed can be catastrophic and requires radiological interventions including digital subtraction angiography followed by endovascular obliteration,or sometimes with a percutaneous or an endoscopic ultrasound-guided approach in technically difficult situations.Procedure-related bleed is usually venous and mostly managed conservatively.Procedure-related arterial bleed,however,may require radiological interventions.