Infected pancreatic pseudocysts with colonic fistula formation successfully managed by endoscopic drainage alone: report of two cases

Acute pancreatitis after total aortic arch replacement leading to walled-off necrosis: A case report and review of literature

BACKGROUND

Although acute pancreatitis and walled-off necrosis (WON) are rare complications following aortic surgery, they are serious risk factors for postoperative mortality. Considering the poor general condition of the postoperative patient, more effective and less invasive treatments are favorable.

CASE SUMMARY

A 67-year-old man was referred to our hospital for the treatment of WON after acute pancreatitis. He had undergone total aortic arch replacement due to aortic arch aneurysm and coronary artery bypass grafting due to angina pectoris 6 weeks prior in another hospital. On the second postoperative day, laboratory data and computed tomography showed that the patient had developed acute pancreatitis. Although conservative management (antibiotics, hydration, etc.) had helped in relieving the symptoms of acute pancreatitis, peripancreatic fluid collection (PFC) persisted, accompanied by duodenal obstruction and vomiting. Contrast-enhanced computed tomography showed that the heterogeneous enhancement and fluid collection in the pancreatic body and tail had increased, consistent with walled-off WON. We therefore performed endoscopic ultrasound-guided transluminal drainage for the PFC. As a result, the WON resolved gradually, resulting in improved oral intake.

CONCLUSION

Acute pancreatitis is a rare gastrointestinal complication following thoracic and thoracoabdominal aortic aneurysm surgery. To the best of our knowledge, this is the first case of WON after aortic arch surgery treated with endoscopic ultrasound-guided transluminal drainage for PFC.

Ischemic pancreatitis with infected walled-off necrosis with a colonic fistula after cardiopulmonary bypass successfully treated by endoscopic ultrasound-guided drainage

A 72-year-old man who had been on continuous ambulatory peritoneal dialysis treatment for 10 years underwent cardiopulmonary bypass for aortic valve replacement due to aortic valve stenosis. After surgery, he experienced pancreatitis, and rupture of a splenic artery aneurysm. He went into cardiopulmonary arrest but was successfully treated by transcatheter arterial embolization (TAE) with cardiopulmonary resuscitation. At three weeks after TAE, CT showed heterogeneous enhancement and the accumulation of pancreatic fluid in the pancreatic tail. At 4 months after TAE, he had sepsis and CT showed greater fluid collection with emphysema in comparison to 3 months previously. We diagnosed infected walled-off necrosis (WON). Conservative therapy with antibiotics was not sufficiently effective; thus, we performed endoscopic ultrasound-guided drainage (EUS-D). Contrast imaging revealed WON with colonic fistula. The WON remarkably decreased in size on CT after EUS-D. We experienced a rare case of ischemic acute pancreatitis (AP) caused by cardiopulmonary bypass complicated with infected WON with a colonic fistula. Ischemic AP more frequently shows a severe course with a fatal outcome in comparison to AP of other causes. However, in our case, ischemic AP with infected WON was successfully treated by EUS-D despite the presence of a WON with a colonic fistula.

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.

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.

Pancreatic pseudocystocolonic fistula treated without surgical or endoscopic intervention

We report here a case of pancreatic pseudocystocolic fistula that was treated without surgical or endoscopic intervention. A 76-year-old woman, presenting with a fever and epigastric pain, was referred to our institution. Three months prior to this admission, the patient had been admitted to the hospital for acute pancreatitis. Abdominal computerized tomography (CT) revealed a 9 cm pseudocyst containing air, and a fistular opening was observed via colonoscopy. After colonoscopy, the abdominal pain was slightly improved, the fever subsided and laboratory results showed decreased C-reactive protein levels. The observed improvement was likely due to the cleansing of the bowel, which induced spontaneous drainage from the pseudocyst into the colon. Antibiotic therapy was administered and daily bowel cleansing was performed using a polyethylene glycol solution. After three weeks, a follow-up CT revealed that the size of the pseudocyst had decreased significantly from 9 to 5.3 cm. In addition, laboratory tests were improved. The patient was able to resume a normal diet and was discharged in good overall health from the hospital, without aggravation of the symptoms. A colonoscopy performed 3 mo later and a follow-up CT performed 6 mo later confirmed that both the fistula and pseudocyst had completely disappeared.

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.

Severe Colonic Complications requiring Sub-Total Colectomy in Acute Necrotizing Pancreatitis-A Retrospective Study of 8 Patients

Colonic involvement in acute pancreatitis is associated with high mortality. Diagnosis of colonic pathology complicating acute pancreatitis is difficult. The treatment of choice is resection of the affected segment. The aim of this study is to evaluate the feasibility of aggressive surgical approach when colonic complication is suspected. Retrospectively, 8 patients with acute necrotizing pancreatitis and colonic complications (2006-2010) were reviewed. Eight patients with acute necrotizing pancreatitis requiring colonic resection were evaluated. Presentation was varied, including rectal bleeding (2), clinical deterioration during severe pancreatitis (4), colonic contrast leak on CT scan (1) and large bowel obstruction (1). Typically, patients with severe acute pancreatitis had colonic pathology obscured and unrecognized initially because of the ongoing, fulminant inflammatory process. All eight patients underwent Sub-total colectomy & ileostomy for suspected imminent or overt ischemia/perforation, based on the outer aspect of the colon. There was one mortality due to severe sepsis and multiorgan dysfunction syndrome. All other patients recovered well and later underwent closure of the stoma. Recognition of large bowel involvement may be difficult because of nonspecific symptoms or be masked by the systemic features of a critical illness. Clinicians should be aware that acute pancreatitis may erode or inflame the large bowel, resulting in lifethreatening colonic necrosis, bleeding or perforation. In our series of eight patients, we observed that mortality can be reduced by this aggressive surgical approach. We recommend a low threshold for colonic resection due to unreliable detection of ischemia or imminent perforation by outside inspection during surgery for acute necrotizing pancreatitis.

Uncommon acquired fistulae involving the digestive system: summary of data

PURPOSE

Most gastrointestinal fistulae commonly occur following surgery. A minority is caused by a myriad of other etiologies and is termed by some as "uncommon fistulae". The aim of this study was to review these fistulae and their treatment.

METHODS

A literature review was carried out. Searches were conducted in Pubmed and related references reviewed.

RESULTS

Except for Crohn's disease and diverticulitis, "uncommon fistulae" are described in case reports or very small case series. Most of the patients were treated by surgery.

CONCLUSIONS

The anatomic features of the fistula and the etiology usually dictate the approach. Most patients will eventually need surgery to resolve this pathology.

Understanding the colonic complications of pancreatitis

BACKGROUND

Colonic necrosis, fistula and stricture are infrequent but potentially lethal complications of pancreatitis. As any individual unit will have only limited experience, this study aims to provide a structured, systematic appraisal of published experience to identify any consistent trends and disease patterns that may help in practical management.

METHODS

A computerized search of the MEDLINE databases for the period January 1950 through January 2006 yielded 43 articles. Pooled extracted data were examined for type of pancreatitis and colonic complications, method and time of diagnosis, treatment and outcome.

RESULTS

43 reports provided pooled data on 97 patients. Colonic complications were more frequent in severe disease, occurring in 15%. The principal presentations were necrosis, fistula and stricture. All episodes of colonic necrosis complicated severe acute pancreatitis, were diagnosed operatively, presented at a median of 25 (1-55) days into the episode and were associated with a mortality of 54%. In contrast, stricture presented at a median of 50 (10-270) days. Surgical resection without anastomosis is the mainstay of management of necrosis. Trial of conservative management in a stable patient with a fistula may facilitate spontaneous closure.

CONCLUSIONS

This study highlights several consistent trends: preoperative diagnosis is difficult, colonic necrosis and fistula are rare complications principally of severe acute pancreatitis and they present either as ongoing abdominal sepsis or rectal bleeding. Surgical resection remains the mainstay of management. A high index of suspicion should be maintained in patients with severe acute pancreatitis, with ongoing sepsis and evidence of gastrointestinal blood loss.

Colonic fistula associated with severe acute pancreatitis: report of two cases

Colonic fistula is a rare and potentially critical sequela of severe acute pancreatitis, which requires surgical treatment. We report two cases that were successfully treated by a colectomy for colonic fistula associated with severe acute pancreatitis. Case 1 is a 71-year-old man infected with pseudocysts owing to severe acute pancreatitis that developed into a colonic fistula as an early complication with a resulting pancreatic abscess. This patient underwent a left hemicolectomy, a transverse colostomy, and drainage of the pancreatic abscess. He has done well without recurrent disease for 35 months following surgery. Case 2 is a 58-year-old woman who had a past history of drainage during a laparotomy for a pancreatic abscess induced by endoscopic retrograde cholangiopancreatography 10 years earlier. She was admitted to our hospital with left lateral abdominal pain and low-grade fever. Abdominal magnetic resonance imaging showed a retroperitoneal abscess and fistula to the descending colon. She underwent a left hemicolectomy and drainage of the retroperitoneal abscess. She has remained symptom-free for 20 months following surgery. The colonic fistula should therefore be recognized as a late complication during long-term follow-up as well as an early sequela associated with severe acute pancreatitis.

Toward an update of the atlanta classification on acute pancreatitis: review of new and abandoned terms

OBJECTIVES

The 1992 Atlanta classification is a clinically based classification system that defines the severity and complications of acute pancreatitis. The purpose of this review was to assess whether the terms abandoned by the Atlanta classification are really discarded in the literature. The second objective was to review what new terms have appeared in the literature since the Atlanta symposium.

METHODS

We followed a Medline search strategy in review and guideline articles after the publication of the Atlanta classification. This search included the abandoned terms: "phlegmon," "infected pseudocyst," "hemorrhagic pancreatitis," and "persistent pancreatitis."

RESULTS

A total of 239 publications were reviewed, including 10 guideline articles and 42 reviews. The abandoned terms "hemorrhagic pancreatitis" and "persistent pancreatitis" are hardly encountered, in contrast, both "infected pseudocyst" and "phlegmon" are frequently used, and several authors question their abandonment. New terminology in acute pancreatitis consists of "organized pancreatic necrosis," "necroma," "extrapancreatic necrosis," and "central gland necrosis."

CONCLUSIONS

This review demonstrates that the Atlanta classification is still not universally accepted. Several abandoned terms are frequently used, and new terms have emerged that describe manifestations in acute pancreatitis that were not specifically addressed during the Atlanta symposium.

Differential treatment and early outcome in the interventional endoscopic management of pancreatic pseudocysts in 27 patients

AIM: Pancreatic pseudocysts (PPC) as a complication of pancreatitis are approached only in the case of abdominal pain, infection, bleeding, and compression onto the gastrointestinal tract or biliary tree.

METHODS: From 02/01/2002 to 05/31/2004, all consecutive patients with symptomatic PPC who underwent an interventional endoscopic approach were evaluated in this pilot case-series study: Group (Gr.) I-Primary percutaneous (external), ultrasound-guided drainage. Gr. II-Primary EUS-guided cystogastrostomy. Gr. III-EUS-guided cystogastrostomy including intracystic necrosectomy.

RESULTS: (=“follow up”: n = 27): Gr. I (n = 9; 33.3%): No complaints (n = 3); change of an external into an internal drainage (n = 4); complications: (a) bleeding (n = 1) followed by 3 d at ICU, discharge after 40 d; (b) septic shock (n = 1) followed by ICU and several laparotomies for programmed lavage and necrosectomy, death after 74 d. Gr. II (n = 13; 48.1%): No complaints (n = 11); external drainage (n = 2); complications/problems out of the 13 cases: 2nd separate pseudocyst (n = 1) with external drainage (since no communication with primary internal drainage); infection of the residual cyst (n = 1) + following external drainage; spontaneous PPC perforation (n = 1) + following closure of the opening of the cystogastrostomy using clips and subsequently ICU for 2 d. Gr. III (n = 5; 18.5%): No complaints in all patients, in average two endoscopic procedures required (range, 2-6).

CONCLUSION: Interventional endoscopic management of pancreatic pseudocysts is a reasonable alternative treatment option with low invasiveness compared to surgery and an acceptable outcome with regard to the complication rate (11.1%) and mortality (3.7%), as shown by these initial study results.

Severe colonic complications of pancreatic disease

INTRODUCTION

Colonic involvement in pancreatic disorders is rare but potentially fatal. Extension of contiguous inflammation or neoplasm, autodigestive effects of enzymes, or dissection of a pseudocyst or abscess may involve the colon producing obstruction, perforation, hemorrhage, or abdominal pain.

RESULTS

Nine patients with pancreatic disease requiring colonic resection were identified. Cases included pancreatic abscess producing colonic necrosis (2). pancreatic carcinoma invading the colon (3). extension of pancreatitis producing a colonic stricture (3). and pseudocyst eroding into the splenic flexure (1). Presentation was varied, including rectal bleeding (2). clinical deterioration during severe pancreatitis (4). and large bowel obstruction (3). The 3 cases due to malignancy, 1 of which was recurrent, presented with primary large bowel symptoms suggesting intestinal obstruction rather than pancreatic disease. Typically, patients with severe acute pancreatitis had colonic pathology obscured and unrecognized initially because of the ongoing, fulminant inflammatory process.

CONCLUSIONS

Recognition of large bowel involvement may be difficult because of nonspecific symptoms or be masked by the systemic features of a critical illness. Colonoscopy, contrast x-rays, or CT scan may be vital in selected cases to detect underlying pathology. Clinicians should be aware that acute or chronic pancreatitis or pancreatic carcinoma may compress, erode, or inflame the large bowel, resulting in life-threatening colonic necrosis, bleeding, obstruction, or perforation.

Pancreatic Fistula

External and internal pancreatic fistulas have a different etiology and natural history. Approximately 50% of internal and 70% to 90% of external pancreatic fistulas can be expected to heal with nonoperative management. Nonclosure is predicted by anatomic factors, which may be defined at endoscopic retrograde cholangiopancreatography or by CT if disconnected pancreatic segments are seen. Enteral nutrition beyond the ligament of Treitz is probably as effective as total parenteral nutrition in reducing fistula output. Octreotide reduces output and, possibly, time to closure. It does not increase the incidence of closure, and there is no convincing evidence that it prevents significant postoperative leaks. Endoscopic stenting has been reported to be effective treatment for side leaks, particularly when associated with stenoses or calculi. However, it is not widely available and has a significant complication rate related to pancreatic sphincterotomy and stent blockage. Surgical treatment is indicated for end leaks with a disconnected pancreatic segment. The choice of appropriate procedure is important. Percutaneous interventional therapies are emerging as options for treatment of end leaks but are still investigational.

Therapeutic pancreatic endoscopy

Therapeutic endoscopy in pancreatitis has included biliary or pancreatic sphincterotomy, or both, for microlithiasis and sphincter dysfunction. Alternatively, endoscopic treatment has been used to treat ductal disruption, including external or internal fistulas (high amylase effusions, pancreatic ascites, pancreaticoenteric communications, or pseudocysts). Finally, endoscopy has been used to treat obstructive disease, including both stones and strictures. This article reviews the state of the art in this field over the past year. Unfortunately, this is an area in which the appropriate approaches are still poorly defined, and prospective studies randomly assigning patients to endoscopic treatment in comparison with medical or surgical therapy remain few and far between.