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Endoscopic management of infected walled-off pancreatic necrosis is increasingly being performed. Although the role of the interventional endoscopist in treating necrotizing pancreatitis is growing, a multidisciplinary team includ...
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Endoscopic management of infected walled-off pancreatic necrosis is increasingly being performed. Although the role of the interventional endoscopist in treating necrotizing pancreatitis is growing, a multidisciplinary team including dedicated surgeons and interventional radiologists is a condition sine qua non for optimal patient management. Optimal management starts with a correct diagnosis with accurate description of the extent and nature of the inflammatory changes according to the recently updated criteria. This is important to consequently select the correct patients for the correct intervention at the correct interval after onset. When a decision is made to endoscopically intervene in a patient with (infected) pancreatic necrosis, the actual endoscopic technique does not differ much from the first retrospective series published a decade ago. Although endoscopic intervention for pancreatic necrosis is increasingly performed, evidence for superiority of endoscopic treatment over other techniques is still lacking. Dedicated endoscopic accessories for optimal drainage and necrosectomy are still lacking as well. This review provides an overview of current status, technique and recent innovations of endoscopic treatment of walled-off pancreatic necrosis.
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The recognition and definition of severe pancreatitis have made the treatment of pancreatitis more standardized. This has been aided by the use of better imaging techniques, particularly contrast-enhanced dynamic CT. Most of the t...
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The recognition and definition of severe pancreatitis have made the treatment of pancreatitis more standardized. This has been aided by the use of better imaging techniques, particularly contrast-enhanced dynamic CT. Most of the time, severe pancreatitis defined by clinically explicit criteria related to organ system failure is identified with necro-tizing pancreatitis on CT imaging. The ability to recognize patients with more severe disease and the ability to pursue more aggressive diagnostic methods, including aspiration of fluid collections to find infection, have resulted in improved survival for the 20% of patients who develop severe disease. Infection, the most frequent cause of death in severe pancreatitis, is now easier to diagnose and to determine appropriate therapy. In fact, there is now strong evidence that infection can be prevented by antibiotics given to this group of patients with severe disease. As technology expands, so do the options for dealing with severe pancreatitis. For patients with gallstone-induced severe pancreatitis, endoscopic retrograde cholangiopancreatography with stone removal is now the standard recommendation for therapy. For patients with complications of fluid collections and infections, increasing efforts are being made to offer nonsurgical, radiologic, or endoscopic therapies. The status of these newer methods is still unclear. The role of surgery for severe disease is becoming better defined, with infected necrosis being a clear indication, and for most surgeons, sterile necrosis not necessitating surgery. The diagnosis of pancreatitis, the delineation of severity of disease, and newer treatments have brought significant changes to the treatment of severe pancreatitis in the last 10 years. This article summarizes where we stand to start the next millennium in the treatment of pancreatic disease.
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Acute pancreatitis can be complicated with necrosis of the pancreatic or peripancreatic tissue. This necrosis can become liquified and form a well-defined wall (walled-off necrosis or WON) and can become infected and form abscesse...
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Acute pancreatitis can be complicated with necrosis of the pancreatic or peripancreatic tissue. This necrosis can become liquified and form a well-defined wall (walled-off necrosis or WON) and can become infected and form abscesses. Necrotizing soft tissue infections are rare infections of the deep tissue and subcutaneous fat and are mostly caused by trauma or perforated visceral organs. They can, however, rarely be caused by infected retroperitoneal collections. To date only 3 case reports have been published of a necrotizing soft tissue infection complicating a necrotizing pancreatitis. Both acute, complicated pancreatitis and necrotizing soft tissue infections carry a high mortality and morbidity rate with surgery being the mainstay therapy for the latter, often leaving the patient disfigured. We report the case of a 62-year-old man presenting to the emergency department with a painful and erythematous rash of the upper leg as complication of an acute necrotizing pancreatitis. (Acta gastroenterol. belg., 2022, 85, 518-521).
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Since the Atlanta Symposium several guidelines and consensus conferences have been published to improve the management and understanding of patients with acute pancreatitis. Herein, a review of the most recent guidelines on acute ...
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Since the Atlanta Symposium several guidelines and consensus conferences have been published to improve the management and understanding of patients with acute pancreatitis. Herein, a review of the most recent guidelines on acute pancreatitis is carried out, trying to find differences and similarities.
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In the last two decades, the incidence of a cute pancreatitis (AP) in children has increased. Knowing different aspects of this condition like incidence, etiology, and severity is essential for the prevention and management of AP....
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In the last two decades, the incidence of a cute pancreatitis (AP) in children has increased. Knowing different aspects of this condition like incidence, etiology, and severity is essential for the prevention and management of AP. There is a paucity of well-defined research in India on this topic. Hence, this review was done to evaluate the incidence, etiology, complications, and outcome of a cute pancreatitis. The key findings can aid the pediatrician to be aware of the epidemiology and etiology, which would help in the early diagnosis and treatment to decrease the morbidity and mortality. We have conducted an independent search in PubMed and Google Scholar and analyzed articles by Indian authors on this issue from 1990 onwards. The range of incidence of acute pancreatitis is12–20 cases per year and idiopathic is the most common cause ranging from 21 to 82.25%. Necrotizing pancreatitis (2.5–22.5%) is the most common complication which is high compared to Western countries and the mortality rate is in the range of 1.6% to 3.6%. This highlights the findings of researches in India regarding the epidemiology, etiology, complication, and mortality rate of pediatric acute pancreatitis; the incidence of which has increased considerably over the past few decades.
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Background: Retroperitoneal abscesses are rare complications of intraabdominal infectious processes and can progress to necrotizing infections. Necrotizing pancreatitis occurs in 10-25% of patients that require hospital admission ...
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Background: Retroperitoneal abscesses are rare complications of intraabdominal infectious processes and can progress to necrotizing infections. Necrotizing pancreatitis occurs in 10-25% of patients that require hospital admission for pancreatitis, is associated also with a 25% mortality rate, and may lead to formation of a retroperitoneal abscess. Case Report: We report a case of a 63-year-old woman with a recently resolved case of pancreatitis who presented to the Emergency Department (ED) with a painful nodule on her left flank for 3 weeks, rapidly progressing over the last 12 h. In the ED, examination revealed an expanding area of erythema over the left flank with sepsis. Computed tomography scan revealed necrotizing pancreatitis with retroperitoneal abscess tracking to the abdominal wall, resulting in necrotizing fasciitis. She was taken emergently to the operating room with a good outcome. Why Should An Emergency Physician Be Aware of This?: Acute pancreatitis is common, with a minority of cases resulting in parenchymal necrosis, which can lead to retroperitoneal infections. Rarely, necrotizing fasciitis can present on the abdominal wall as a complication of intraabdominal or retroperitoneal infections. The emergency provider should be aware of these complications that may lead to necrotizing infections and a potentially indolent course. (C) 2014 Elsevier Inc.
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The incidence of acute pancreatitis continues to rise, inducing substantial medical and social burden, with annual costs exceeding $2 billion in the United States alone. Although most patients develop mild pancreatitis, 20% develo...
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The incidence of acute pancreatitis continues to rise, inducing substantial medical and social burden, with annual costs exceeding $2 billion in the United States alone. Although most patients develop mild pancreatitis, 20% develop severe and/or necrotizing pancreatitis, requiring advanced medical and interventional care. Morbidity resulting from local and systemic complications as well as invasive interventions result in mortality rates historically as high as 30%. There has been substantial evolution of strategies for interventions in recent years, from open surgery to minimally invasive surgical and endoscopic step-up approaches. In contrast to the advances in invasive procedures for complications, early management still lacks curative options and consists of adequate fluid resuscitation, analgesics, and monitoring. Many challenges remain, including comprehensive management of the entire spectrum of the disease, which requires close involvement of multiple disciplines at specialized centers.
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Acute pancreatitis (AP) is the most common indication for hospital admission and its incidence is rising. It has a variable prognosis, which is mainly dependent upon the development of persistent organ failure and infected necroti...
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Acute pancreatitis (AP) is the most common indication for hospital admission and its incidence is rising. It has a variable prognosis, which is mainly dependent upon the development of persistent organ failure and infected necrotizing pancreatitis. In the past few years, based on large-scale multicenter randomized trials, some novel insights regarding clinical management have emerged. In patients with infected pancreatic necrosis, a step-up approach of percutaneous catheter drainage followed by necrosectomy only when the patient does not improve, reduces new-onset organ failure and prevents the need for necrosectomy in about a third of patients. A randomized pilot study comparing surgical to endoscopic necrosectomy in patients with infected necrotizing pancreatitis showed a striking reduction of the pro-inflammatory response following endoscopic necrosectomy. These promising results have recently been tested in a large multicenter randomized trial whose results are eagerly awaited. Contrary to earlier data from uncontrolled studies, a large multicenter randomized trial comparing early (within 24 h) nasoenteric tube feeding compared with an oral diet after 72 h, did not show that early nasoenteric tube feeding was superior in reducing the rate of infection or death in patients with AP at high risk for complications. Although early ERCP does not have a role in the treatment of predicted mild pancreatitis, except in the case of concomitant cholangitis, it may ameliorate the disease course in patients with predicted severe pancreatitis. Currently, a large-scale randomized study is underway and results are expected in 2017. (C) 2016 S. Karger AG, Basel
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History and clinical findings: A 55-year-old man suffered from severe acute abdominal pain. 10 years previously he had been diagnosed with acute pancreatitis. On palpation, there was pronounced abdominal tenderness and guarding. I...
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History and clinical findings: A 55-year-old man suffered from severe acute abdominal pain. 10 years previously he had been diagnosed with acute pancreatitis. On palpation, there was pronounced abdominal tenderness and guarding. Investigations: Emergency CT revealed signs of intra- and extrahepatic cholestasis and biliar sludge; serum-lipase was increased. Treatment and course: Acute biliary pancreatitis was diagnosed. After admission the patient's condition deteriorated; acute renal failure and respiratory insufficiency developed. After 4 weeks of intensive care he was discharged to a rehabilitation facility via normal ward. At that time pancreatic sonography showed a walled-off necrosis. 7 weeks later colicky abdominal pain occurred again. Altough there were no signs of infection, suction-irrigation drainage was administered. This led to a secondary infection of the necrotic cavity, and 20 sessions of endoscopic necrosectomy were performed for 3 month. Then the patient was discharged to follow-up treatment in a stable condition. Conclusion: Even in supposedly usual" acute pancreatitis complications can lead to a prolonged course. Sterile necroses should be managed very cautiously.
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Background: Percutaneous drainage as the initial procedure for severe pancreatitis (SP) may not always be optimal. Our aim was to identify the characteristics of patients who failed percutaneous drainage and compare their outcomes...
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Background: Percutaneous drainage as the initial procedure for severe pancreatitis (SP) may not always be optimal. Our aim was to identify the characteristics of patients who failed percutaneous drainage and compare their outcomes with patients who underwent surgical intervention as the initial approach.Methods: A retrospective review of a prospectively collected emergency general surgery registry of patients admitted to a tertiary-care, academic center with the diagnosis of SP who underwent an intervention was performed (2010-2018). Patients were divided into successful drainage (SD), drainage failure (DF), and surgery first (SF) groups. DF was defined as the need for surgical intervention.Results: The study included 129 patients. Fifty (38.8%) patients underwent SF as their initial management modality. Among 79 patients who underwent drainage, 34 (43.0%) were in the DF group and progressed to surgical intervention. Within that group, 19 (55.9%) underwent open necrosectomy. The DF group was more likely to have lower rates of peripancreatic fluid collections, a higher rate of necrotizing pancreatitis, and a higher Acute Physiology and Chronic Health Evaluation (APACHE) II score when compared with the DS group. Mortality was higher in the DF and SF groups, and total length of stay and ICU length of stay were highest in the DF group.Discussion: Patients who experience failure of drainage for SP have high morbidity and mortality rates and fare worse overall than patients who undergo surgery as the primary intervention. Patients with necrotizing pancreatitis and a higher APACHE II score might warrant surgical intervention over a drainage-first approach.
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