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

The i-EUS consensus on the management of pancreatic fluid collections - Part 1

Pancreatic fluid collections (PFCs), including pancreatic pseudocysts (PPs) and walled-off pancreatic necrosis (WON), are common complications of pancreatitis and pancreatic surgery. Historically, the treatment of these conditions has relied on surgical and radiological approaches; however, it has later shifted toward an endoscopy-based approach. With the development of dedicated lumen-apposing metal stents (LAMS), interventional Endoscopic Ultrasound (EUS)-guided procedures have become the standard approach for PFC drainage. However, there is still limited consensus on several aspects of the multidisciplinary management of PFCs. The interventional endoscopy and ultrasound (i-EUS) group is an Italian network of clinicians and scientists with special interest in biliopancreatic interventional endoscopy, especially interventional EUS. This manuscript describes the first part of the results of a consensus conference organized by i-EUS with the aim of providing evidence-based guidance on aspects such as indications for treating PFCs, the timing of intervention, and different technical strategies for managing patients with PFCs.

Comprehensive Review of Surgical and Radiological Management of Hemorrhagic Pancreatitis: Current Strategies and Outcomes

Hemorrhagic pancreatitis, a severe complication of acute and chronic pancreatitis, involves bleeding due to vascular disruptions. This condition presents significant clinical challenges and is associated with high morbidity and mortality. The bleeding can result from arterial or venous complications, often exacerbated by inflammatory and enzymatic damage to blood vessels within the pancreas. Patients with hemorrhagic pancreatitis may experience symptoms such as abdominal pain, nausea, vomiting, and gastrointestinal bleeding. Diagnostic imaging, including CT and MRI, is crucial in identifying the source of bleeding and guiding treatment decisions. Management strategies have evolved over the past two decades, shifting from purely surgical approaches to including interventional radiology techniques. Surgical intervention is often reserved for hemodynamically unstable patients or those with large pseudoaneurysms, offering definitive treatment but carrying higher risks of complications. Endovascular techniques, such as transcatheter embolization, provide a less invasive alternative with high success rates and shorter recovery times, though rebleeding may occur. Treatment choice depends on various factors, including the patient's stability, the size and location of the bleeding, and the availability of specialized expertise. Overall, the management of hemorrhagic pancreatitis requires a multidisciplinary approach, combining surgical and radiological techniques to optimize patient outcomes and reduce the risk of mortality. Long-term follow-up is essential to monitor for recurrent disease and manage the metabolic consequences of pancreatic insufficiency.

International Consensus Recommendations for Safe Use of LAMS for On- and Off-Label Indications Using a Modified Delphi Process

INTRODUCTION

The study aimed to develop international consensus recommendations on the safe use of lumen-apposing metal stents (LAMSs) for on- and off-label indications.

METHODS

Based on the available literature, statements were formulated and grouped into the following categories: general safety measures, peripancreatic fluid collections, endoscopic ultrasound (EUS)-biliary drainage, EUS-gallbladder drainage, EUS-gastroenterostomy, and gastric access temporary for endoscopy. The evidence level of each statement was determined using the Grading of Recommendations Assessment, Development, and Evaluation methodology.International LAMS experts were invited to participate in a modified Delphi process. When no 80% consensus was reached, the statement was modified based on expert feedback. Statements were rejected if no consensus was reached after the third Delphi round.

RESULTS

Fifty-six (93.3%) of 60 formulated statements were accepted, of which 35 (58.3%) in the first round. Consensus was reached on the optimal learning path, preprocedural imaging, the need for airway protection and essential safety measures during the procedure, such as the use of Doppler, and measurement of the distance between the gastrointestinal lumen and the target structure. Specific consensus recommendations were generated for the different LAMS indications, covering, among others, careful patient selection, the preferred size of the LAMS, the need for antibiotics, the preferred anatomic location of the LAMS, the need for coaxial pigtail placement, and the appropriate management of LAMS-related adverse events.

DISCUSSION

Through a modified international Delphi process, we developed general and indication-specific experience- and evidence-based recommendations on the safe use of LAMS.

Updated Review of Radiologic Imaging and Intervention for Acute Pancreatitis and Its Complications

This is a current update on radiologic imaging and intervention of acute pancreatitis and its complications. In this review, we define the various complications of acute pancreatitis, discuss the imaging findings, as well as the timing of when these complications occur. The various classification and scoring systems of acute pancreatitis are summarized. Advantages and disadvantages of the 3 primary radiologic imaging modalities are compared. We then discuss radiologic interventions for acute pancreatitis. These include diagnostic aspiration as well as percutaneous catheter drainage of fluid collections, abscesses, pseudocysts, and necrosis. Recommendations for when these interventions should be considered, as well as situations in which they are contraindicated are discussed. Fortunately, acute pancreatitis usually is mild; however, serious complications occur in 20%, and admission of patients to the intensive care unit (ICU) occurs in over 10%. In this paper, we will focus on the imaging and interventional radiologic aspects for the serious complications and patients admitted to the ICU.

An Analysis of Outcomes and Management Strategies for Patients With Cholecystostomy Tubes

BACKGROUND

Percutaneous cholecystostomy tube (PCT) drainage is an effective management strategy for acute cholecystitis in patients medically unfit for surgery. However, little is known about the fate of patients managed by PCT. We conducted this study to determine tube management outcomes for patients with acute cholecystitis managed by PCT.

METHODS

The electronic record was queried to identify patients with acute cholecystitis managed by PCT from 2012-2020. Patients were divided into three groups for analysis: 1) ultimately managed by cholecystectomy, 2) eventual confirmation of distal flow of bile from the gallbladder and tube removal, and 3) tubes left in place without further management.

RESULTS

A total of 179 patients with acute cholecystitis treated by PCT were included. Sixty-six patients never fully recovered from the medical insult associated with their diagnosis of acute cholecystitis and had their tubes left in situ. Sixty-four of these 66 patients (97%) died during follow-up. The remaining 113 patients recovered from their illness and presented to clinic for evaluation for tube removal and/or cholecystectomy. When distal biliary flow was confirmed, tube removal was favored (n = 70). When cystic duct outflow occlusion persisted, cholecystectomy was planned for patients who became acceptable surgical candidates (n = 43). For patients managed by cholecystectomy, 8 were approached open and 35 laparoscopically, with 12 of 35 (34.3%) converted to open and 23 (65.7%) completed laparoscopically.

CONCLUSION

Our study favors PCT removal for patients who recover from their acute illness when distal bile flow from the gallbladder is confirmed. We reserve cholecystectomy for patients who recover from their illness and demonstrate persistent cystic duct outflow obstruction.

Gastrointestinal Bleeding Due to the Rupture of Splenic Artery Caused by Pancreatic Carcinoma: A Case Requiring Repeated Transcatheter Arterial Embolization in a Short Period of Time

In this report, we present a case of gastrointestinal bleeding due to splenic artery rupture, which required repeated transcatheter arterial embolization (TAE) within a short period of time. A 75-year-old man with pancreatic carcinoma was transported to our hospital with active hematemesis and vital signs consistent with shock. Contrast-enhanced computed tomography images showed a pancreatic tumor that had caused a pseudoaneurysm of the splenic artery to rupture. The pseudoaneurysm was embolized using only an N-butyl-2-cyanoacrylate (NBCA) and lipiodol mixture. However, hematemesis with signs of shock recurred 13 h later, and angiography showed rebleeding from the origin of the splenic artery. The splenic artery was subsequently embolized using an NBCA and lipiodol mixture. Repeated TAE finally controlled the hemorrhage; however, asymptomatic splenic infarction and hepatic infarction occurred due to nontarget embolization.

Percutaneous Chemical and Mechanical Necrosectomy for Walled-Off Pancreatic Necrosis

PURPOSE

To test the hypothesis that percutaneous combined chemical and mechanical necrosectomy using a Malecot anchor drain and an Arrow-Trerotola percutaneous thrombolytic device (PTD) in patients with walled-off pancreatic necrosis (WOPN) is feasible, safe, and effective compared with a control group undergoing mechanical necrosectomy alone.

MATERIALS AND METHODS

In a retrospective analysis, patients with WOPN not amenable to endoscopic-guided cystogastrostomy placement were studied as case and control groups. The patients in the case group underwent percutaneous combined chemical (hydrogen peroxide 3%) and mechanical necrosectomy using a Malecot anchor drain and/or Arrow-Trerotola PTD from December 2020 to April 2022. The controls underwent mechanical necrosectomy alone without chemical necrosectomy. Clinical success was defined as complete resolution of the cavity on follow-up noncontrast computed tomography scans with subsequent drain removal.

RESULTS

Thirteen patients in the case group and 11 patients in the control group underwent percutaneous drain placement followed by percutaneous combined chemical and mechanical necrosectomy (case group) or mechanical necrosectomy only (control group) for WOPN. Drain placement and necrosectomy were technically successful in all patients studied. One patient in the case group developed postprocedural sepsis because of communication between the cavity and the splenic vein. Another patient in the case group developed bleeding from a branch of the pancreaticoduodenal artery on postnecrosectomy day 9, which was successfully embolized by interventional radiology. No pancreaticocutaneous fistula was reported at the 3-month follow-up. The clinical success rates in the case and control groups were 100% and 38.4%, respectively (P = .003).

CONCLUSIONS

Percutaneous combined chemical and mechanical necrosectomy is a feasible, safe, and effective treatment of WOPN.

Interventional management and diagnostic follow-up of a large pancreatic pseudocyst: A case report

We present a case of a large pancreatic pseudocyst in a 69-year-old man following post biopsy pancreatitis. Radiological findings revealed a thick-walled, fluid filled mass in proximity to the pancreas. Although pancreatic pseudocysts generally self-resolve, extensive or complicated cysts may require surgical or interventional management. Pseudocyst size >6 cm, compression of the inferior vena cava or biliary duct, and severe symptoms often prognosticate the need for intervention.

Percutaneous biopsy and drainage of the pancreas

Percutaneous pancreatic interventions performed by abdominal radiologists play important diagnostic and therapeutic roles in the management of a wide range of pancreatic pathology. While often performed with endoscopy, pancreatic mass biopsy obtained via a percutaneous approach may serve as the only feasible option for diagnosis in patients with post-surgical anatomy, severe cardiopulmonary conditions, or prior non-diagnostic endoscopic attempts. Biopsy of pancreatic transplants are commonly performed percutaneously due to inaccessible location of the allograft by endoscopy, usually in the right lower quadrant or pelvis. Percutaneous drainage of collections in acute pancreatitis is primarily indicated for infection with clinical deterioration and may be performed alone or in combination with endoscopic drainage. Post-surgical pancreatic collections related to pancreatic duct fistula or leak also often warrant therapeutic percutaneous drainage. Knowledge of appropriate indications, strategies of approach, technique, and complications associated with these procedures is critical for a successful clinical practice.