Fistulization in the GI tract in acute pancreatitis

Comprehensive management of gastrointestinal fistulas in necrotizing pancreatitis: a review of diagnostic and therapeutic approaches

INTRODUCTION

Gastrointestinal fistula (GIF) is a rare but severe complication in patients with necrotizing pancreatitis (NP), significantly prolonging disease course and increasing morbidity and mortality. Its subtle and nonspecific early symptoms often delay diagnosis and intervention. Despite its clinical significance, the low incidence of GIF in NP has resulted in limited research and a lack of consensus on optimal diagnostic and therapeutic strategies.

AREAS COVERED

This review focuses on the epidemiology, pathophysiology, diagnostic approaches, and therapeutic management of GIF in NP patients. Imaging techniques, such as contrast-enhanced computed tomography and endoscopy, have been integral to early diagnosis. Advances in interventional and surgical techniques provide new avenues for treatment, but variability in clinical practice highlights the need for standardized protocols.

EXPERT OPINION

Recent advances in diagnostic imaging have improved the detection of GIF, while innovations in interventional and surgical treatments show promise. Current research is still insufficient and varied. Future research should focus on developing diagnostic methods and treatment measures for such complications. By improving early diagnosis and offering insights into effective management strategies, it is hoped that patient outcomes can be improved.

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.

Acute pancreatitis in Turkey: Results of a nationwide multicenter study

BACKGROUND

Acute pancreatitis (AP) is the most common gastrointestinal disease requiring hospitalization, with significant mortality and morbidity. We aimed to evaluate the clinical characteristics of AP and physicians' compliance with international guidelines during its management.

METHODS

All patients with AP who were hospitalized at 17 tertiary centers in Turkey between April and October 2022 were evaluated in a prospective cohort study. Patients with insufficient data, COVID-19 and those aged below 18 years were excluded. The definitions were based on the 2012 revised Atlanta criteria.

RESULTS

The study included 2144 patients (median age:58, 52 % female). The most common etiologies were biliary (n = 1438, 67.1 %), idiopathic (n = 259, 12 %), hypertriglyceridemia (n = 128, 6 %) and alcohol (n = 90, 4.2 %). Disease severity was mild in 1567 (73.1 %), moderate in 521 (24.3 %), and severe in 58 (2.6 %) patients. Morphology was necrotizing in 4.7 % of the patients. The overall mortality rate was 1.6 %. PASS and BISAP had the highest accuracy in predicting severe pancreatitis on admission (AUC:0.85 and 0.81, respectively). CT was performed in 61 % of the patients, with the majority (90 %) being within 72 h after admission. Prophylactic NSAIDs were not administered in 44 % of the patients with post-ERCP pancreatitis (n = 86). Antibiotics were administered to 53.7 % of the patients, and 38 % of those received them prophylactically.

CONCLUSIONS

This prospective study provides an extensive report on clinical characteristics, management and outcomes of AP in real-world practice. Mortality remains high in severe cases and physicians' adherence to guidelines during management of the disease needs improvement in some aspects.

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.

Gastrointestinal Fistulas in Necrotizing Pancreatitis Receiving a Step-Up Approach Incidence, Risk Factors, Outcomes and Treatment

Purpose

Necrotizing pancreatitis (NP) complicated by gastrointestinal fistula is challenging and understudied. As the treatment of necrotizing pancreatitis changed to a step-up strategy, we attempted to evaluate the incidence, risk factors, clinical outcomes and treatment of gastrointestinal fistulas in patients receiving a step-up approach.

Methods

Clinical data from 1274 patients with NP from 2014-2022 were retrospectively analyzed. Multivariable logistic regression analysis was conducted to identify risk factors and propensity score matching (PSM) to explore clinical outcomes in patients with gastrointestinal fistulas.

Results

Gastrointestinal fistulas occurred in 8.01% (102/1274) of patients. Of these, 10 were gastric fistulas, 52 were duodenal fistulas, 14 were jejunal or ileal fistulas and 41 were colonic fistulas. Low albumin on admission (OR, 0.936), higher CTSI (OR, 1.143) and invasive intervention prior to diagnosis of gastrointestinal fistula (OR, 5.84) were independent risk factors for the occurrence of gastrointestinal fistula, and early enteral nutrition (OR, 0.191) was a protective factor. Patients who developed a gastrointestinal fistula were in a worse condition on admission and had a poorer clinical outcome (p<0.05). After PSM, both groups of patients had similar baseline information and clinical characteristics at admission. The development of gastrointestinal fistulas resulted in new-onset persistent organ failure, increased open surgery, prolonged parenteral nutrition and hospitalization, but not increased mortality. The majority of patients received only conservative treatment and minimally invasive interventions, with 7 patients (11.3%) receiving surgery for upper gastrointestinal fistulas and 11 patients (26.9%) for colonic fistulas.

Conclusion

Gastrointestinal fistulas occurred in 8.01% of NP patients. Independent risk factors were low albumin, high CTSI and early intervention, while early enteral nutrition was a protective factor. After PSM, gastrointestinal fistulas resulted in an increased proportion of NP patients receiving open surgery and prolonged hospitalization. The majority of patients with gastrointestinal fistulas treated with step-up therapy could avoid surgery.

Validation of the Revised Atlanta Criteria in determining the severity of acute pancreatitis

BACKGROUND/AIM

Determining the severity of acute pancreatitis (AP) is crucial for patient management. The aim of our study was to assess the accuracy and limitations of the Revised Atlanta Criteria (RAC) in determining the severity of AP.

MATERIALS AND METHODS

The study was retrospectively conducted on AP patients admitted to the Gastroenterology Department of Sakarya University Faculty of Medicine. The severity, morphology and local complications of AP were evaluated according to the RAC. Laboratory parameters, clinical scores predicting disease severity and Computer Tomography Severity Index scores were assessed.

RESULTS

The study group included 113 patients. Ninety-eight (86.7%) had interstitial edematous, and 15 (13.3%) had necrotizing pancreatitis. AP pancreatitis was mild in 69 (61.1%), moderate in 33 (29.2%), and severe in 11 (9.7%). Compared to the moderate group, patients in the severe group had a higher hematocrit, creatinine, SIRS and BISAP scores at admission and more length of hospital stay, more ICU requirements, and higher mortality rates ( P  < 0.05). Eleven patients had single or multiple persistent organ failure (POF). The mortality rate of patients who developed early POF (n = 6) was higher compared to the group of patients who developed late POF (n = 2) (83.3% and 40%, respectively).

CONCLUSION

Severity assessment using the RAC in patients with AP is consistent with laboratory parameters and scoring systems predicting severity. Severe pancreatitis cases who develop early POF may be classified separately.

Perforation and Fistula of the Gastrointestinal Tract in Patients With Necrotizing Pancreatitis: A Nationwide Prospective Cohort

OBJECTIVE

The aim of this study was to explore the incidence, risk factors, clinical course and treatment of perforation and fistula of the gastrointestinal (GI) tract in a large unselected cohort of patients with necrotizing pancreatitis.

BACKGROUND

Perforation and fistula of the GI tract may occur in necrotizing pancreatitis. Data from large unselected patient populations on the incidence, risk factors, clinical outcomes, and treatment are lacking.

METHODS

We performed a post hoc analysis of a nationwide prospective database of 896 patients with necrotizing pancreatitis. GI tract perforation and fistula were defined as spontaneous or iatrogenic discontinuation of the GI wall. Multivariable logistic regression was used to explore risk factors and to adjust for confounders to explore associations of the GI tract perforation and fistula on the clinical course.

RESULTS

A perforation or fistula of the GI tract was identified in 139 (16%) patients, located in the stomach in 23 (14%), duodenum in 56 (35%), jejunum or ileum in 18 (11%), and colon in 64 (40%). Risk factors were high C-reactive protein within 48 hours after admission [odds ratio (OR): 1.19; 95% confidence interval (CI): 1.01-1.39] and early organ failure (OR: 2.76; 95% CI: 1.78-4.29). Prior invasive intervention was a risk factor for developing a perforation or fistula of the lower GI tract (OR: 2.60; 95% CI: 1.04-6.60). While perforation or fistula of the upper GI tract appeared to be protective for persistent intensive care unit-admission (OR: 0.11, 95% CI: 0.02-0.44) and persistent organ failure (OR: 0.15; 95% CI: 0.02-0.58), perforation or fistula of the lower GI tract was associated with a higher rate of new onset organ failure (OR: 2.47; 95% CI: 1.23-4.84). When the stomach or duodenum was affected, treatment was mostly conservative (n=54, 68%). Treatment was mostly surgical when the colon was affected (n=38, 59%).

CONCLUSIONS

Perforation and fistula of the GI tract occurred in one out of six patients with necrotizing pancreatitis. Risk factors were high C-reactive protein within 48 hours and early organ failure. Prior intervention was identified as a risk factor for perforation or fistula of the lower GI tract. The clinical course was mostly affected by involvement of the lower GI tract.

Massive Haematochezia due to Splenic Artery Bleeding into the Colon: Unusual Manifestation of Advanced Pancreatic Cancer

We describe a case of an uncommon early pancreatic cancer presentation in a patient in his 60s who had haemorrhagic shock from extensive haematochezia and required blood transfusions as well as surveillance in an intensive care unit. A splenic artery pseudoaneurysm that had been effectively embolized by angiography was seen to be actively bleeding into the colon lumen on a computerized tomography (CT) scan along with a necrotic mass of the pancreatic tail. A pancreatic mucinous adenocarcinoma was diagnosed by a transgastric biopsy. A pancreatico-colic fistula was discovered by CT scan after a colic contrast enema. A transabdominal drainage of the necrotic collection and targeted antibiotic treatment had been performed with a satisfying patient outcome. In order to assess a potential secondary surgical resection, systemic chemotherapy was planned. In conclusion, haematochezia with hemodynamic instability originated from a splenic artery pseudoaneurysm fistulising into the colon (arterio-colic fistula) and sepsis originating from a tumoral pancreatic abscess fistulising into the colon (tumoral pancreatico-colic fistula).

Characteristics and Incidence of Colon Complication in Necrotizing pancreatitis: A Propensity Score-Matched Study

Objective

To clarify the incidence of colonic complications in patients with NP and their impact on prognosis.

Methods

The clinical data of NP patients admitted to the Department of General Surgery of Xuanwu Hospital, Capital Medical University from January 2014 to December 2020 were retrospectively analyzed. Patients were grouped according to the presence or absence of colonic complications, and the clinical prognosis of the two groups was analyzed after matching using a 1:1 propensity score, The primary study endpoint was patient mortality during hospitalization. Data are reported as median (range) or percentage of patients (%).

Results

A total of 306 patients with NP were included in this study, and the incidence of colonic complications was 12.4%, including 15 cases of colonic obstruction, 17 cases of colonic fistula, and 9 cases of colonic hemorrhage. Before matching, patients in the colonic group had severe admissions and poor clinical outcomes (P<0.05). After matching, the baseline data and clinical characteristics at admission were comparable between the two groups of patients. In terms of clinical outcomes, although the mortality was similar in the two groups (P>0.05), but patients in the colonic group were more likely to have multiorgan failure, length of nutrition support, number of minimally invasive interventions, number of extra-pancreatic infections, length of ICU stay and total length of stay were significantly higher than those of patients in the group without colonic complications (P<0.05). During long-term follow-up, patients in the colonic group were more likely to develop recurrent pancreatitis.

Conclusion

About 12.4% of NP patients developed colonic complications, and after PSM it was found that colonic complications only led to a longer hospital stay and an increased number of clinical interventions in NP patients and did not increase the mortality.

Use of a novel endoscopic tack and suture system for the management of pancreatocolonic fistula

Video 1Use of a novel endoscopic tack and suture system for the management of pancreatocolonic fistula.

Indian College of Radiology and Imaging Consensus Guidelines on Interventions in Pancreatitis

Acute pancreatitis (AP) is one of the common gastrointestinal conditions presenting as medical emergency. Clinically, the severity of AP ranges from mild to severe. Mild AP has a favorable outcome. Patients with moderately severe and severe AP, on the other hand, require hospitalization and considerable utilization of health care resources. These patients require a multidisciplinary management. Pancreatic fluid collections (PFCs) and arterial bleeding are the most important local complications of pancreatitis. PFCs may require drainage when infected or symptomatic. PFCs are drained endoscopically or percutaneously, based on the timing and the location of collection. Both the techniques are complementary, and many patients may undergo dual modality treatment. Percutaneous catheter drainage (PCD) remains the most extensively utilized method for drainage in patients with AP and necrotic PFCs. Besides being effective as a standalone treatment in a significant proportion of these patients, PCD also provides an access for percutaneous endoscopic necrosectomy and minimally invasive necrosectomy. Endovascular embolization is the mainstay of management of arterial complications in patients with AP and chronic pancreatitis. The purpose of the present guideline is to provide evidence-based recommendations for the percutaneous management of complications of pancreatitis.

Occurrence of spontaneous fistulas detected by contrast filling during computed tomography-guided percutaneous drainage placement of splenic and perisplenic fluid collections

BACKGROUND

Fistulas are serious complications of splenic and perisplenic fluid accumulations, which are often difficult to detect by routine imaging methods.

PURPOSE

To evaluate the occurrence of spontaneous fistulas detectable during computed tomography-guided percutaneous drainage placement (CTGDP) with contrast filling of splenic or perisplenic fluid collections and to assess characteristics in comparison with perihepatic or peripancreatic fluid accumulations, also being treated with CTGDP.

MATERIAL AND METHODS

In 127 CTGDP-procedures, pre-interventional CTs conducted with intravenous contrast agent were compared to post-interventional CTs including contrast filling of the drain to identify spontaneous fistulas. Patient and case characteristics were evaluated, and therapeutic consequences of fistula identification were analyzed.

RESULTS

A total of 43 perisplenic, 40 peripancreatic, and 44 perihepatic drains were evaluated; 13 (30.2%) perisplenic, 7 (17.5%) peripancreatic, and 10 (22.7%) perihepatic fistulas were observed. Concerning the frequency of fistulas, no significant difference was found between the patient groups (P = 0.39). All fistulas were solely proven in CT scans including contrast filling of the drain. Seven fistulas (23.3%) required additional interventions. Perihepatic drains were significantly more often associated with recent surgery (P < 0.001). The mean size of peripancreatic drains was significantly greater (11.8 ± 3.9 F; P < 0.001) than in perihepatic or perisplenic fluid collections.

CONCLUSION

Spontaneous fistulas detected during CTGDP of splenic or perisplenic fluid collections are common. Post-interventional contrast filling of the drain drastically improves the detection rate of perisplenic, peripancreatic and perihepatic fistulas simultaneously initiating appropriate follow-up interventions.

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.

Progress in research of minimally invasive therapy of local complications of acute pancreatitis

Acute pancreatitis is an inflammatory disease of the pancreas that can be life-threatening. Patients with severe acute pancreatitis require further rescue treatment in the intensive care unit. In recent years, treatment of local complications of acute pancreatitis has undergone considerable changes, including multidisciplinary team mode and individualized treatment scheme, and traditional open surgery has been gradually replaced by minimally invasive treatment. This article summarizes the progress in research on minimally invasive therapy of the local complications of acute pancreatitis in recent years.

Spontaneous Internal Pancreatic Fistulae Complicating Acute Pancreatitis

Spontaneous pancreatic fistula (PF) is a rare but challenging complication of acute pancreatitis (AP). The fistulae could be internal (draining into another viscera or cavity, e.g., pancreaticocolonic, gastric, duodenal, jejunal, ileal, pleural, or bronchial) or external (draining to skin, i.e., pancreaticocutaneous). Internal fistulae constitute the majority of PF and will be discussed in this review. Male sex, alcohol abuse, severe AP, and infected necrosis are the major risk factors for development of internal PF. A high index of suspicion is required to diagnose PF. Broad availability of computed tomography makes it the initial test of choice. Magnetic resonance cholangiopancreatography and endoscopic retrograde cholangiopancreatography have higher sensitivity compared with computed tomography scan and also allow for assessment of pancreatic duct for leak or disconnection, which affects treatment approaches. Certain complications of PF including hemorrhage and sepsis could be life-threatening and require urgent intervention. In nonurgent/chronic cases, management of internal PF involves control of sepsis, which requires effective drainage of any residual pancreatic collection/necrosis, sometimes by enlarging the fistula. Decreasing fistula output with somatostatin analogs (in pancreaticopleural fistula) and decreasing intraductal pressure with endoscopic retrograde cholangiopancreatography or endoscopic ultrasound/interventional radiology-guided interventions or surgery are commonly used strategies for management of PF. More than 60% of the internal PF close with medical and nonsurgical interventions. Colonic fistula, medical refractory-PF, or PF associated with disconnected pancreatic duct can require surgical intervention including bowel resection or distal pancreatectomy. In conclusion, AP-induced spontaneous internal PF is a complex complication requiring multidisciplinary care for successful management.

Management of colonic fistulas in patients with infected pancreatic necrosis being treated with a step-up approach

BACKGROUND

Colonic fistula is a potentially fatal complication in acute necrotizing pancreatitis (ANP), especially in patients with infected pancreatic necrosis (IPN). The aim of this study was to evaluate the feasibility of a step-up approach including percutaneous catheter drainage (PCD) and continuous negative pressure irrigation (CNPI) in a group of patients with colonic fistula.

METHODS

A retrospective review of a prospectively collected data was performed. Data were extracted for patients complicated by colonic fistula from January 2010 to January 2017.

RESULTS

A total of 1750 patients were admitted with ANP during the study period. Of these patients, 711 (41%) developed IPN and colonic fistula was present in 132 (19%). A step-up approach was adopted for all patients, with 47% avoiding surgery. The mortality in patients requiring surgery (37%) was higher than that in patients managed non-surgically (19%) constituting an overall mortality rate of 29%. In patients managed conservatively, 92% had spontaneous closure of the fistula.

CONCLUSION

Colonic fistula is not a rare complication in ANP occurring in 19% of patients with IPN in the current study. A step-up approach was effective and safe in managing colonic fistula and surgery could be obviated in nearly half of the patients.

Spontaneous fistulization of walled-off pancreatic necrosis into the colon

Spontaneous fistulization of the pancreatic necrosis into the colon is rare. It should be kept as differentials in the presence of massive air in the WOPN. Sometimes, simple bedside X-ray abdomen may clinch the diagnosis in the presence of large radiolucent air-fluid level with a peripheral displaced bowel loops.

Necrotizing pancreatitis: A review for the acute care surgeon

BACKGROUND

Necrotizing pancreatitis is a common condition with high mortality; the acute care surgeon is frequently consulted for management recommendations. Furthermore, there has been substantial change in the timing, approach, and frequency of surgical intervention for this group of patients.

METHODS

In this article we summarize key clinical and research developments regarding necrotizing pancreatitis, including current recommendations for treatment of patients requiring intensive care and those with common complications. Articles from all years were considered to provide proper historical context, and most recent management recommendations are identified.

RESULTS

Epidemiology, diagnosis, treatment in the acute phase, and complications (both short-term and long-term) are discussed. Images of surgical interventions are included from our institutional experience.

CONCLUSION

Necrotizing pancreatitis management remains heavily based on clinical judgement, although technological advances and clinical trials have made decision making more straightforward.

Abdominal rebleeding after transcatheter arterial embolization for ruptured pseudoaneurysms associated with severe acute pancreatitis: a retrospective study

Introduction

Patients are at risk of abdominal rebleeding after transcatheter arterial embolization (TAE) for pancreatitis-related pseudoaneurysm, which increases the mortality rate.

Aim

This study was performed to evaluate the effects of an intestinal fistula (IF) and the anatomical location of the pseudoaneurysm on abdominal rebleeding after TAE of a ruptured pseudoaneurysm associated with severe acute pancreatitis (SAP).

Material and methods

From February 2013 to November 2019, 24 patients with SAP-related pseudoaneurysm rupture and hemorrhage in our hospital underwent TAE. All patients’ epidemiological data and related medical histories were collected and statistically analyzed. We classified the pseudoaneurysms as type I, II, and III according to their anatomical locations and as type A (without an IF) and type B (with an IF).

Results

The interventions for abdominal infection in patients with type I pseudoaneurysms were percutaneous drainage in 6 patients, endoscopic necrotic tissue removal in 5, and surgical necrotic tissue removal or enterostomy in none, with a rebleeding rate of 33.3% (3/9 patients). The interventions for abdominal infection in patients with type II pseudoaneurysms were percutaneous drainage in 7 patients, endoscopy in three, and surgery in one, with a rebleeding rate of 20.0% (2/10 patients). The interventions for abdominal infection in patients with type III pseudoaneurysms were percutaneous drainage in 3 patients, endoscopy in 1, and surgery in 2, with a rebleeding rate of 80.0% (4/5 patients). There was no statistically significant difference in the types of interventions for abdominal infection among patients with type I, II, and III pseudoaneurysms (p = 0.355) or in the rate of abdominal rebleeding after TAE for type III pseudoaneurysms (p = 0.111). The interventions for abdominal infection in patients with type A pseudoaneurysms were percutaneous drainage in 13 patients, endoscopy in 6, and surgery in 1, with a rebleeding rate of 22.2% (4/18 patients) and mortality rate of 11.1% (2/18 patients). The interventions for abdominal infection in patients with type B pseudoaneurysms were percutaneous drainage in 3 patients, endoscopy in 3, and surgery in 2, with a rebleeding rate of 83.3% (5/6 patients) and mortality rate of 66.7% (4/6 patients). There was no significant difference in the types of interventions for abdominal infection in patients with and without IF (p = 0.215); however, the rebleeding rate and mortality rate were significantly higher in patients with IF (p = 0.015 and 0.018, respectively).

Conclusions

IF may increase the rate of abdominal rebleeding after TAE for ruptured SAP-related pseudoaneurysms, while the anatomical location of the pseudoaneurysm may not affect the rate of rebleeding after TAE.

Complications of Percutaneous Drainage in Step-Up Approach for Management of Pancreatic Necrosis: Experience of 10 Years from a Tertiary Care Center

INTRODUCTION

Percutaneous catheter drainage (PCD) as initial intervention in necrotizing pancreatitis has led to improved outcomes and obviated need for surgery in a significant proportion. However, there can be difficulty in accessing deep-seated necrotic collections by percutaneous catheter and complications are likely.

METHODS

The present study involves a retrospective analysis of a prospectively maintained database of patients with necrotizing pancreatitis managed by a step-up approach. All patients who underwent PCD were studied for catheter-related complications.

RESULTS

A total of 707 PCD catheters were used in 314 patients (median 2, interquartile range IQR 1-3). The total number of interventions were 1194 (median 3, IQR 2-5). Enteric communication was seen in 8.9%, of which colonic fistula occurred in 71.4%, duodenal in 17.8%, and jejunal in 10.7% of patients. Majority (78.5%) of the fistulae were managed conservatively by withdrawal of the drain. Operative management was required in 30% of colonic and 40% of duodenal fistulae. Need for surgery, length of hospital stay, and mortality were not significantly different between patients with and without fistulae. Bleeding complications were seen in 7.3% of patients, out of which 34.7% were managed conservatively, 21.7% required angioembolization of pseudo-aneurysms, and 34.7% needed surgery. Patients with bleeding had significantly higher requirement for surgery and mechanical ventilation compared to those with no bleeding. There was no significant increase in hospital stay, ICU stay, and mortality.

CONCLUSION

Hollow viscus and vascular injuries are important complications seen with catheter drainage of necrotic collections. Majority of patients with enteric communication were managed conservatively, with no added morbidity or mortality. Bleeding complications related to PCD had higher requirement for surgical intervention, but mortality rates remained similar to those of patients with no bleeding complications.

Gastrointestinal complications in acute and chronic pancreatitis

Pancreatitis is one of the important medical conditions. Gastrointestinal (GI) complications of pancreatitis are important and lead to significant morbidity and mortality. Diagnosis of these complications is difficult and may require a strong clinical suspicion coupled with various imaging features. This review provides an extensive update of the whole spectrum of GI complication of pancreatitis, both acute and chronic, from inflammation, ischemia, and necrosis to obstruction, perforation, and GI fistulae. The focus is on the clinical and imaging features of this less commonly described aspect of pancreatitis.

Over-the-Scope Clip Closure of Pancreatico-Colonic Fistula Secondary to Acute or Chronic Pancreatitis: A Case Series

Introduction: Pancreatico-colonic fistula (PCF) is a rare adverse effect secondary to severe acute or chronic pancreatitis and potentially life-threatening because of abdominal sepsis. Over-the-scope clip (OTSC^®) system is a recently developed endoscopic device and has been successfully used for bleeding and perforations of the gastrointestinal tract. We hereby report a series of patients with PCFs in whom OTSC was used. Materials and Methods: From January 2011 to December 2018, we retrospectively collected data on cases of PCFs with endoscopic treatment using the OTSC system. After conservative management, the endoscopic intervention was carried out on patients in deep sedation by single skilled operators. Results: A total of 9 patients were enrolled and patients were treated with 14/6 t-type OTSC. PCF occurred secondary to chronic (n = 5) and acute pancreatitis (n = 4). There were no adverse effects related to the endoscopic procedure itself. Further endoscopic evaluation was performed 8 weeks later and revealed a successful fistula closure in 4 patients with chronic pancreatitis (80%) and in 2 patients with acute pancreatitis (50%). An insufficient fistula closure was observed in 3 cases because of dislocation of the OTSC and an additional surgical procedure was required. Conclusion: The OTSC system seems to be safe and effective in short-term management of PCFs because of acute or chronic pancreatitis in addition to the already established nonsurgical therapy. However, the OTSC closure of PCFs in patients with acute pancreatitis seems to be associated with a higher failure rate. To sum up, more evidence and long-term studies are needed to determine the criteria for the use of OTSC in closure of PCFs owing to acute or chronic pancreatitis.

Colopancreatic Fistula: An Uncommon Complication of Recurrent Acute Pancreatitis

Colonic complications, including colopancreatic fistulas (CPFs), are uncommon after acute and chronic pancreatitis. However, they have been reported and are serious. CPFs are less likely to close spontaneously and are associated with a higher risk of complications. Therefore, more definitive treatment is required that includes surgical and endoscopic options. We present a case of a 62-year-old male patient with a history of heavy alcohol intake and recurrent acute pancreatitis who presented with a 6-month history of watery diarrhea and abdominal pain. His abdominal imaging showed a possible connection between the colon and the pancreas. A further multidisciplinary workup by the gastroenterology and surgery teams, including endoscopic ultrasound, endoscopic retrograde cholangiopancreatography, and colonoscopy, resulted in a diagnosis of CPF. A distal pancreatectomy and left hemicolectomy were performed, and the diagnosis of CPF was confirmed intraoperatively. The patient showed improvement afterward.

Endoscopic treatment of walled-off pancreatic necrosis complicated with pancreaticocolonic fistula

BACKGROUND

Pancreaticocolonic fistulas (PCFs) are serious complication of acute pancreatitis related with high mortality. The aim of this study was to evaluate the efficiency and safety of endoscopic treatment in patients with walled-off pancreatic necrosis (WOPN) complicated with PCF.

METHODS

This is a retrospective analysis of results and complications in the group of 226 patients, who underwent endoscopic treatment of symptomatic WOPN between years 2001 and 2016 in the Department of Gastroenterology and Hepatology of Medical University of Gdańsk.

RESULTS

PCF was recognized in 21/226 (9.29%) patients. Transmural drainage was performed in 20/21 (95.24%) patients. Transpapillary drainage was used in 2/21 (9.52) patients. The mean time since the start of endotherapy to the diagnosis of a fistulas was 9 (3-21) days. Fluoroscopic nasocystic tube-check imaging of an existing drain was the initial imaging diagnosis of a PCF in 19/21 (90.48%) patients. The mean duration of endoscopic drainage of WOPN was 39.29 (15-87) days. Procedure-related adverse events occurred in 10/21 (47.62%) patients and most of them were treated conservatively. Three patients required surgical treatment. One patient died during endotherapy. The closure of PCF was confirmed via imaging in 17/21 (80.95%) patients. The average time since the recognition till the closure of PCF was 21 (14-48) days. Complete therapeutic success of WOPN complicated with PCF was reached in 16/21 (76.19%) patients. Long-term success of endoscopic treatment was achieved in 15/21 (71.43%) patients.

CONCLUSIONS

Endoscopic treatment of patients with WOPN complicated with PCF is an effective method with an acceptable number of complications. The complete regression of the WOPN may lead to spontaneous closure of pancreaticocolonic fistulas.

Pancreatocolonic fistulization secondary to pancreatic adenocarcinoma presenting as unexplained halitosis

Pancreatic cancer is often detected in late stages, which contributes to its grim prognosis. Although the manifestations of pancreatic cancer most often include nonspecific gastrointestinal complaints, we report a case with the sole initial complaint of halitosis and subsequent diagnostic workup demonstrating a pancreatic mass with secondary pancreatocolonic fistulization. The etiologies of and the radiological findings pertaining to halitosis, the presenting symptoms and imaging studies relevant to the diagnosis of pancreatic cancer, and the imaging and clinical findings of pancreatic fistulization are discussed.

Role of enteral nutrition in pancreaticocolonic fistulas secondary to severe acute pancreatitis: A case report

RATIONALE

Pancreaticocolonic fistula (PCF) is an exceedingly rare complication of severe acute pancreatitis (SAP) and has primarily been treated surgically, but a few reported cases are successfully treated with nonsurgical methods.

PATIENT CONCERNS

A 32-year-old male presented to our hospital with chief complaints of sharp and persistent left upper quadrant abdominal pain radiating to the back.

DIAGNOSES

Computed tomography showed a pancreatic pseudocyst replacing a majority of the pancreatic parenchyma and PCF that formed between the pancreas and the colon. However, the final diagnosis of PCF was confirmed by drainage tube radiograph, which revealed extravasation of contrast from the tail of the pancreas into the colon.

INTERVENTIONS

A therapeutic strategy of enteral nutrition (EN) was applied.

OUTCOMES

The patient responded well to the treatment. No complication and recurrence were reported during 2-year follow-up.

LESSONS

This case highlights the role of EN in the treatment of PCF secondary to SAP. To the best of our knowledge, this is the first case of PCF that treated successfully with EN, rather than surgical or endoscopic intervention.

Gastroduodenal Artery Psuedoaneurysm Bleed through a Spontaneous Pancreaticoduodenal Fistula as a Result of Acute Necrotizing Pancreatitis

Spontaneous pancreaticoduodenal fistulization and arterial psuedoaneurysm formation are both complications of acute pancreatitis. We present a 27-year-old man with hematemesis who was found to be bleeding from a gastroduodenal artery psuedoaneurysm through a spontaneous pancreaticoduodenal fistula as a result of severe alcohol-related necrotizing pancreatitis. This is the first reported case in the literature to describe this occurrence.

Ileostomy site approach for adhesiolysis and laparoscopic cholecystectomy in a hostile abdomen: A novel technique

Introduction:

Gallstones are an etiological factor in 23%–54% of patients with acute pancreatitis. A small proportion of these patients will also have intestinal complications requiring necrosectomy with diverting loop ileostomy. Later, these patients require cholecystectomy and ileostomy reversal. Laparoscopic cholecystectomy is fraught with difficulty in these patients due to dense intra-abdominal adhesions, and many surgeons resort to an open approach. We describe a technique which takes advantage of the ileostomy site for initial access.

Materials and Surgical Technique:

Ileostomy reversal is done and a SILS™ (Covidien, Mansfield, Massachusetts, USA) port is inserted under direct vision, through the ileostomy site. Adhesiolysis is done through the SILS™ port. Additional ports are inserted and standard steps are followed for cholecystectomy.

Conclusion:

The use of ileostomy incision as the first port facilitates adhesiolysis and subsequent port placement in the hostile abdomen encountered in these patients. We describe a novel technique of ileostomy reversal and laparoscopic cholecystectomy using SILS™ port.

Revised Atlanta Classification for Acute Pancreatitis: A Pictorial Essay

The 2012 revised Atlanta classification is an update of the original 1992 Atlanta classification, a standardized clinical and radiologic nomenclature for acute pancreatitis and associated complications based on research advances made over the past 2 decades. Acute pancreatitis is now divided into two distinct subtypes, necrotizing pancreatitis and interstitial edematous pancreatitis (IEP), based on the presence or absence of necrosis, respectively. The revised classification system also updates confusing and sometimes inaccurate terminology that was previously used to describe pancreatic and peripancreatic collections. As such, use of the terms acute pseudocyst and pancreatic abscess is now discouraged. Instead, four distinct collection subtypes are identified on the basis of the presence of pancreatic necrosis and time elapsed since the onset of pancreatitis. Acute peripancreatic fluid collections (APFCs) and pseudocysts occur in IEP and contain fluid only. Acute necrotic collections (ANCs) and walled-off necrosis (WON) occur only in patients with necrotizing pancreatitis and contain variable amounts of fluid and necrotic debris. APFCs and ANCs occur within 4 weeks of disease onset. After this time, APFCs or ANCs may either resolve or persist, developing a mature wall to become a pseudocyst or a WON, respectively. Any collection subtype may become infected and manifest as internal gas, though this occurs most commonly in necrotic collections. In this review, the authors present a practical image-rich guide to the revised Atlanta classification system, with the goal of fostering implementation of the revised system into radiology practice, thereby facilitating accurate communication among clinicians and reinforcing the radiologist's role as a key member of a multidisciplinary team in treating patients with acute pancreatitis. (©)RSNA, 2016.

Analysis of risk factors related to gastrointestinal fistula in patients with severe acute pancreatitis: a retrospective study of 344 cases in a single Chinese center

BACKGROUND

Gastrointestinal fistula (GIF) in severe acute pancreatitis (SAP) is considered as a sparse episode and studied sporadically in the literature. There is paucity of data on the prediction of the effect on risk of GIF in patient with SAP. This study was aimed to investigate risk factors related to GIF in the development of SAP.

METHODS

The clinical data of 344 patients with SAP from 2011 to 2016 were reviewed retrospectively. All patients were divided into the GIF group and the non-GIF group, and their data analyzed with respect to 15 parameters were applied to explore potential risk factors for GIF in patients with SAP.

RESULTS

Of the 344 eligible patients, 52 (15.12%) progressed to GIF. Only occurrence of infected pancreatic and extra-pancreatic necrosis (IPN) (P = 0.004, OR = 3.012) and modified CT severity index (MCTSI) (P = 0.033, OR = 1.183) were proved to be independent risk factors for GIF in patients with SAP, and blood type B (P = 0.048, OR = 2.096, 95% CI: 0.748-3.562) indicated weaker association of risk factor for GIF. The early (48-72 h after admission) enteral nutrition (EEN) (P = 0.016, OR = 0.267) acted as a protective factor.

CONCLUSIONS

Occurrence of IPN and high MCTSI are independent risk factors for the development of GIF in patients with SAP, blood type B reveals a potential correlation with GIF in patients with SAP. EEN is helpful to prevent the progression of GIF secondary to SAP.

Gastrointestinal Fistulas in Acute Pancreatitis With Infected Pancreatic or Peripancreatic Necrosis: A 4-Year Single-Center Experience

Gastrointestinal (GI) fistula is a well-recognized complication of acute pancreatitis (AP). However, it has been reported in limited literature. This study aimed to evaluate the incidence and outcome of GI fistulas in AP patients complicated with infected pancreatic or peripancreatic necrosis (IPN).Between 2010 and 2013 AP patients with IPN who diagnosed with GI fistula in our center were analyzed in this retrospective study. And we also conducted a comparison between patients with and without GI fistula regarding the baseline characteristics and outcomes.Over 4 years, a total of 928 AP patients were admitted into our center, of whom 119 patients with IPN were diagnosed with GI fistula and they developed 160 GI fistulas in total. Colonic fistula found in 72 patients was the most common form of GI fistula followed with duodenal fistula. All duodenal fistulas were managed by nonsurgical management. Ileostomy or colostomy was performed for 44 (61.1%) of 72 colonic fistulas. Twenty-one (29.2%) colonic fistulas were successfully treated by percutaneous drainage or continuous negative pressure irrigation. Mortality of patients with GI fistula did not differ significantly from those without GI fistula (28.6% vs 21.9%, P = 0.22). However, a significantly higher mortality (34.7%) was observed in those with colonic fistula.GI fistula is a common finding in patients of AP with IPN. Most of these fistulas can be successfully managed with different procedures depending on their sites of origin. Colonic fistula is related with higher mortality than those without GI fistula.

Consensus guidelines on severe acute pancreatitis

This Position Paper contains clinically oriented guidelines by the Italian Association for the Study of the Pancreas (AISP) for the diagnosis and treatment of severe acute pancreatitis. The statements were formulated by three working groups of experts who searched and analysed the most recent literature; a consensus process was then performed using a modified Delphi procedure. The statements provide recommendations on the most appropriate definition of the complications of severe acute pancreatitis, the diagnostic approach and the timing of conservative as well as interventional endoscopic, radiological and surgical treatments.

Acute on Chronic Pancreatitis Causing a Highway to the Colon with Subsequent Road Closure: Pancreatic Colonic Fistula Presenting as a Large Bowel Obstruction Treated with Pancreatic Duct Stenting

Context. Colonic complications associated with acute pancreatitis have a low incidence but carry an increased risk of mortality with delayed diagnosis and treatment. Pancreatic colonic fistula is most commonly associated with walled off pancreatic necrosis or abscess formation and rarely forms spontaneously. Classic clinical manifestations for pancreatic colonic fistula include diarrhea, hematochezia, and fever. Uncommonly pancreatic colonic fistula presents as large bowel obstruction. Case. We report a case of a woman with a history of recurrent episodes of acute pancreatitis who presented with large bowel obstruction secondary to pancreatic colonic fistula. Resolution of large bowel obstruction and pancreatic colonic fistula was achieved with pancreatic duct stenting. Conclusion. Pancreatic colonic fistula can present as large bowel obstruction. Patients with resolved acute pancreatitis who have radiographic evidence of splenic flexure obstruction, but without evidence of mechanical obstruction on colonoscopy, should be considered for ERCP to evaluate for PCF. PCF not associated with walled off pancreatic necrosis or peritoneal abscess can be treated conservatively with pancreatic duct stenting.

Pancreaticocolonic fistulas secondary to severe acute pancreatitis treated by percutaneous drainage: successful nonsurgical outcomes in a single-center case series

PURPOSE

Pancreaticocolonic fistulas (PCFs) are uncommon complications of acute necrotizing pancreatitis (ANP). Studies advocating primary surgical treatment showed severe morbidity and mortality with nonsurgical treatment, with survival rates of approximately 50%. However, a nonsurgical treatment scheme with primary percutaneous drainage and other interventions may show improved outcomes. This retrospective single-center study describes the presentation, diagnosis, course, treatment strategy, and outcome of successfully treated PCFs, with an emphasis on nonsurgical interventions.

MATERIALS AND METHODS

Twenty patients with PCFs caused by ANP were treated with percutaneous drainage and medical therapy. Additional interventions included endoscopic transenteric drainage and pancreatic duct (PD) stent placement. Surgery was reserved for patients in whom this nonsurgical management failed.

RESULTS

All PCFs closed during a median follow-up of 56 days (mean, 106 d; range, 13-827 d). Treatment included percutaneous drainage of the PCF-related collection in all patients, PD stents in 60%, transenteric drainage in 15%, and definitive surgery in 15%. Indications for surgery included severe PCF-related symptoms, large feculent peritoneal collection, and colonic stricture. Two patients (10%) died, one of complications of ANP and one of esophageal carcinoma. Additional enteric fistulas were identified in 50% of patients. Median time from the most recent diagnosis of pancreatitis to PCF diagnosis was 89 days (mean, 113 d; range, 13-394 d).

CONCLUSIONS

A nonsurgical approach to PCFs caused by ANP, including percutaneous drainage and other techniques, yields good survival, with surgery reserved for cases in which this approach fails.

Attempted endoscopic closure of a pancreaticocolonic fistula with an over-the-scope clip

CONTEXT

Spontaneous development of fistulae is an uncommon complication of acute pancreatitis. Until recently, surgical management has been the standard of care. Endoscopic treatment has been described with hemoclips and glue.

CASE REPORT

We report a case of a gentleman with a history of recurrent episodes of acute pancreatitis who presented with symptoms correlating with the development of a pancreatic-colonic fistula. Closure of the fistula was attempted with an over-the-scope clip.

CONCLUSION

More evidence is needed to determine criteria for use of over-the-scope clip in closure of GI and pancreatic fistulae.