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Aim.Analysis of the results of the application of the modified step-up approach in the treatment of infected pancreatonecrosis in a third-level hospital.Materials and methods.The study included 52 patients over 18 years of age with acute pancreatitis and suspected or proven infection with pancreatic or peripancreatic necrosis .The control group included 27 patients who underwent primary open necrectomy. The comparison group included 25 patients who underwent surgical treatment within the framework of the modified concept of the stepwise surgical approach (Step-up). In the groups compared mortality rates, early postoperative complications (IIIb-IVb grade Clavien-Dindo), late postoperative complications (ventral hernias, pseudocysts, diabetes mellitus), the duration of inpatient treatment, and the duration of treatment in the intensive care unit. The indicator "Full return to primary social activity after treatment" was also proposed.Results.In the Step-up approach group, in comparison with the control group, there was a decrease in the overall incidence of postoperative complications of IIIb-IVb grade Clavien-Dindo (24% and 51.9%, respectively, p 0.05).Conclusion.The step-up approach can improve the results of treatment of infected pancreatic necrosis. The most important advantage of this concept is reproducibility - that is, the possibility of using it not only in the leading metropolitan clinics, but also in the regions of the Russian Federation. The step-up approach, however, has not yet acquired a complete form, and there is room for improvement.

Sinus tract endoscopy (STE) is a minimally invasive technique for debridement of dead or infected tissue. STE is usually used for treatment of infected pancreatic or peripancreatic necrosis, though other applications have been described. STE involves placement of a percutaneous drain followed by fluoroscopically guided dilation of the drain tract to allow placement of a working sheath. An endoscope is then introduced through the sheath and used to debride necrotic tissue. A drain is then replaced through the same tract at the conclusion of the procedure. In this case we use STE to debride infected peripancreatic necrosis caused by a traumatic pancreatic injury and complicated by an enteric fistula.

Acute pancreatitis is a frequent entity encountered by radiologists. In 2012, the Atlanta criteria were revised to help radiologists use a common nomenclature when describing acute pancreatitis and its complications. One delayed complication of acute necrotizing pancreatitis in walled-off necrosis, a collection seen at least 4 weeks after an episode of acute pancreatic necrosis and/or acute peripancreatic necrosis. Multiple treatments have been adapted in the setting of walled-off necrosis, including endoscopic cystogastrostomy. The focus of this article is to familiarize the radiologist with the imaging appearance of this procedure as well as, review the outcomes and potential complications of endoscopic cystogastrostomy.

Aim. To study the nature of peripancreatic lesions and its course in patients with AP without CT-signs of pancreatic necrosis. Material and Methods. We had analyzed the treatment of 38 patients with AP in whom contrast-enhanced CT did not reveal disorders of contrast accumulation by pancreatic tissue. Peripancreatic changes were assessed by presence of inhomogeneous acute necrotic collections and homogeneous acute peripancreatic fluid collections. Balthazar (2002) and K. Ishikawa et al. (2006) classification was used to estimate prevalence of parapancreatitis. Results. Acute necrotic collections were revealed in 15 patients. Balthazar index was 3.7 ± 0.1, K. Ishikawa index — 2.46 ± 0.45 on the left side and 0.86 ± 0.4 on the right side (p 0.05). Patients were discharged after 34 ± 5 days. Acute peripancreatic fluid collections were in 23 patients. Balthazar index was 2.5 ± 0.2, the gradation by Japanese classification — 1.3 ± 0.2 on the left side and 0.8 ± 0.2 on the right side. Conservative treatment was applied in 22 (96%) patients, 1 patient was exposed to percutaneous puncture. All patients were discharged after 16 ± 1 day. Conclusion. Our data evidence the importance to identify acute necrotic collections in the absence of pancreatic necrosis as a marker of peripancreatic necrosis. 33% of these patients required surgery due to infection. Classification of parapancreatitis by Kazuo Ishikawa reflects parapancreatitis development and its localization more precisely than Balthazar index.

Background and aims Peripancreatic necrosis (PPN) is considered as a distinct entity with a better outcome when compared with combined pancreatic and peripancreatic necrosis (CPN), but there is no systematic review to summarize the evidence. Our study aimed to perform a meta-analysis of existing observational studies comparing the outcomes of PPN with CPN. Methods Studies in adult patients comparing the outcomes of PPN and CPN from PubMed, Medline, and Scopus databases from inception to November 2018 were systematically searched. The primary outcome was mortality, and secondary outcomes included multi-organ failure, persistent organ failure, infected necrosis, need for interventions including open necrosectomy. Pooled adjusted odds ratios, and 95% confidence intervals (CI) were obtained by the random-effects model. Forrest plots were constructed to show the summary pooled estimate. Heterogeneity was assessed by using I2 measure of inconsistency. Results A total of 6 studies involving 1851 patients (1295 (70%) with CPN and 556 (30%) with PPN) were included. Patients with CPN had a significantly higher mortality (OR 2.49, 95% CI: 1.61–3.87), risk for multi-organ failure (OR 3.24, 95% CI: 2.38–4.43), persistent organ failure (OR 2.79, 95% CI: 1.53–5.08), and infected necrosis (OR 6.21, 95% CI: 3.85–10.03). They underwent more interventions (OR 5.86, 95% CI: 3.69–9.32), including open necrosectomy (OR 5.04, 95% CI: 3.33–7.63). Heterogeneity was low (I2 = 18.1, p = 0.296), and there was no publication bias. Conclusion Isolated peripancreatic necrosis portends an overall better prognosis when compared to necrosis involves pancreatic parenchyma. Clinicians should recognize this distinction for management decisions.

Background & Aims Two new classification systems for the severity of acute pancreatitis (AP) have been proposed, the determinant-based classification (DBC) and a revision of the Atlanta classification (RAC). Our aim was to validate and compare these classification systems. Methods We analyzed data from adult patients with AP (543 episodes of AP in 459 patients) who were admitted to Hospital General Universitario de Alicante from December 2007 to February 2013. Imaging results were reviewed, and the classification systems were validated and compared in terms of outcomes. Results Pancreatic necrosis was present in 66 of the patients (12%), peripancreatic necrosis in 109 (20%), walled-off necrosis in 61 (11%), acute peripancreatic fluid collections in 98 (18%), and pseudocysts in 19 (4%). Transient and persistent organ failures were present in 31 patients (6%) and 21 patients (4%), respectively. Sixteen patients (3%) died. On the basis of the DBC, 386 (71%), 131 (24%), 23 (4%), and 3 (0.6%) patients were determined to have mild, moderate, severe, or critical AP, respectively. On the basis of the RAC, 363 patients (67%), 160 patients (30%), and 20 patients (4%) were determined to have mild, moderately severe, or severe AP, respectively. The different categories of severity for each classification system were associated with statistically significant and clinically relevant differences in length of hospital stay, need for admission to the intensive care unit, nutritional support, invasive treatment, and in-hospital mortality. In comparing similar categories between the classification systems, no significant differences were found. Conclusion The DBC and the RAC accurately classify the severity of AP in subgroups of patients.

Acute pancreatitis still represents a challenge for physicians; it ranges from mild self-limiting forms Walled-off necrosis (WON), previously called by other names, such as organized pancreatic necrosis, necroma, pancreatic sequestration, pseudocyst associated with necrosis and subacute pancreatic necrosis is a new entity of complications of acute pancreatitis. It is defined as a mature, encapsulated collection of pancreatic and/or peripancreatic necrosis which has developed a well-defined inflammatory wall. WON usually occurs >4 weeks after the onset of necrotizing pancreatitis. However, it derives from the necrotic pancreatic parenchyma and/or necrotic peripancreatic tissues, and may be sterile or infected, single or multiple, and present at sites distant from the pancreas. In this paper, the current data regarding WON as to its definition, diagnosis and treatment will be narratively reviewed.

Objective: The aim of this study was to develop a new international classification of acute pancreatitis severity on the basis of a sound conceptual framework, comprehensive review of published evidence, and worldwide consultation. Background: The Atlanta definitions of acute pancreatitis severity are ingrained in the lexicon of pancreatologists but suboptimal because these definitions are based on empiric descriptions of occurrences that are merely associated with severity. Methods: A personal invitation to contribute to the development of a new international classification of acute pancreatitis severity was sent to all surgeons, gastroenterologists, internists, intensive medicine specialists, and radiologists who are currently active in clinical research on acute pancreatitis. The invitation was not limited to members of certain associations or residents of certain countries. A global Web-based survey was conducted and a dedicated international symposium was organised to bring contributors from different disciplines together and discuss the concept and definitions. Result: The new international classification is based on the actual local and systemic determinants of severity, rather than descriptions of events that are correlated with severity. The local determinant relates to whether there is (peri)-pancreatic necrosis or not, and if present, whether it is sterile or infected. The systemic determinant relates to whether there is organ failure or not, and if present, whether it is transient or persistent. The presence of one determinant can modify the effect of another such that the presence of both infected (peri) pancreatic necrosis and persistent organ failure have a greater effect on severity than either determinant alone. The derivation of a classification based on the above principles results in 4 categories of severity - mild, moderate, severe, and critical. Conclusions: This classification is the result of a consultative process amongst pancreatologists from 49 countries spanning North America, South America, Europe, Asia, Oceania, and Africa. It provides a set of concise up-to-date definitions of all the main entities pertinent to classifying the severity of acute pancreatitis in clinical practice and research. This ensures that the determinant-based classification can be used in a uniform manner throughout the world.

Adipocytes of peripancreatic and intrapancreatic adipose tissue secret adipocytokines such as leptin, adiponectin, and resistin. For resistin, a role as an early predictor of peripancreatic necrosis and clinical severity in acute pancreatitis has been reported. It was the aim of this study to investigate whether the adipocytokine visfatin is able to serve as an early marker predicting peripancreatic necrosis and clinical severity.A total of 50 patients (20 females and 30 males) with acute pancreatitis were included in this noninterventional, prospective, and monocentric cohort study on diagnostic accuracy. Clinical severity was classified by the Ranson score and APACHE-II (Acute Physiology and Chronic Health Evaluation II) score. Pancreatic and peripancreatic necrosis were quantified by the computed tomography-based Balthazar score, the Schroeder score, and the pancreatic necrosis score. Visfatin was measured at admission and daily for 10 days by enzyme-linked immunosorbent assay (ELISA).Visfatin values were significantly and positively correlated with clinical severity (APACHE-II score and Ranson score) and with clinical end points such as death and need for interventions. Admission visfatin levels were significantly elevated in patients with higher pancreatic and extrapancreatic necrosis scores. It was shown by receiver operator characteristics that admission visfatin concentration provides a positive predictive value of 93.3% in predicting the extent of peripancreatic necrosis (area under the curve (AUC): 0.89, P0.001, sensitivity: 93.3%, specificity: 81.8%, likelihood ratio: 5.1, post-test probability: 93%) by using a cutoff value of 1.8 ng/ml.Admission visfatin concentration serves as an early predictive marker of peripancreatic necrosis and clinical severity in acute pancreatitis. Visfatin may have potential for clinical use as a new and diagnostic serum marker.

Introduction Surgical debridement is the mainstay in the management of infected pancreatic necrosis. Minimally invasive techniques have been shown to minimize surgical insult. We aim to review our recent experience with minimally invasive retroperitoneal pancreatic necrosectomy (MIRP). Methods The medical records of consecutive patients between October 2007 and April 2008 who underwent MIRP at our hospital were reviewed. All the patients had a preoperative computed tomography-guided aspiration and positive bacteriologic culture of the peripancreatic collection. Results Five patients underwent MIRP during the 8-month period. Fourteen procedures were carried out, with a median of 3 (range, 1 to 5) procedures per patient. Only 1 patient required postoperative intensive care monitoring. One patient had a left renal contusion that resolved, and 2 patients developed pancreatic fistula owing to pancreatic duct disruption requiring stenting of the pancreatic duct. There were no mortalities. Conclusion MIRP is a good alternative technique in the management of selected patients with infected peripancreatic necrosis.

Key points. 1. CT is used to confirm the diagnosis of acute pancreatitis when the diagnosis is in doubt and to differentiate acute interstitial pancreatitis from necrotizing pancreatitis, which is a key element of the updated Atlanta nomenclature. The acute interstitial variety accounts for 90-95% of cases, with acute necrotizing pancreatitis accounting for the remaining cases. 2. Necrosis due to acute pancreatitis is best assessed on IV contrast-enhanced CT performed 40 seconds after injection. Peripancreatic necrosis is a subtype of necrotizing pancreatitis in which tissue death occurs in peripancreatic tissues. This is seen in isolation in 20% of patients with necrotizing pancreatitis. 3. Simple fluid collections associated with acute interstitial pancreatitis are subdivided chronologically. A collection observed within approximately 4 weeks of acute pancreatitis onset is termed an "acute peripancreatic fluid collection (APFC)." A collection older than 4 weeks should have a thin wall and is termed a "pseudocyst." Both APFCs and pseudocysts can be infected or sterile. 4. Fluid collections associated with necrotizing pancreatitis are labeled on the basis of age and the presence of a capsule. Within 4 weeks of acute pancreatitis onset, a fluid collection associated with necrotizing pancreatitis is termed an "acute necrotic collection (ANC)" whereas an older collection is termed an area of "walled-off necrosis (WON)" if it has a perceptible wall on CT. The term "pseudocyst" is not used in the setting of necrotizing pancreatitis collections. Although an ANC and a (WON can be infected or sterile, infection is far more likely compared with acute interstitial pancreatitis collections. 5. The severity of acute pancreatitis is graded on the basis of the presence of acute complications or organ failure. Mild acute pancreatitis has neither acute complications nor organ failure. Moderate-severity acute pancreatitis is associated with acute complications or organ failure lasting fewer than 48 hours. Severe acute pancreatitis is characterized by single- or multiorgan failure persisting for greater than 48 hours.

In acute pancreatitis, infection of pancreatic or peripancreatic necrosis is the most important risk factor determining the patient’s outcome. Pancreatic necrosis develops within the first 4 days afte

Item does not contain fulltext OBJECTIVE: In the revised Atlanta classification of acute pancreatitis, the term necrotising pancreatitis also refers to patients with only extrapancreatic fat necrosis without pancreatic parenchymal necrosis (EXPN), as determined on contrast-enhanced CT (CECT). Patients with EXPN are thought to have a better clinical outcome, although robust data are lacking. METHODS: A post hoc analysis was performed of a prospective multicentre database including 639 patients with necrotising pancreatitis on contrast-enhanced CT. All CECT scans were reviewed by a single radiologist blinded to the clinical outcome. Patients with EXPN were compared with patients with pancreatic parenchymal necrosis (with or without extrapancreatic necrosis). Outcomes were persistent organ failure, need for intervention and mortality. A predefined subgroup analysis was performed on patients who developed infected necrosis. RESULTS: 315 patients with EXPN were compared with 324 patients with pancreatic parenchymal necrosis. Patients with EXPN less often suffered from complications: persistent organ failure (21% vs 45%, p

Item does not contain fulltext OBJECTIVE:: To develop a new international classification of acute pancreatitis severity on the basis of a sound conceptual framework, comprehensive review of published evidence, and worldwide consultation. BACKGROUND:: The Atlanta definitions of acute pancreatitis severity are ingrained in the lexicon of pancreatologists but suboptimal because these definitions are based on empiric description of occurrences that are merely associated with severity. METHODS:: A personal invitation to contribute to the development of a new international classification of acute pancreatitis severity was sent to all surgeons, gastroenterologists, internists, intensivists, and radiologists who are currently active in clinical research on acute pancreatitis. The invitation was not limited to members of certain associations or residents of certain countries. A global Web-based survey was conducted and a dedicated international symposium was organized to bring contributors from different disciplines together and discuss the concept and definitions. RESULT:: The new international classification is based on the actual local and systemic determinants of severity, rather than description of events that are correlated with severity. The local determinant relates to whether there is (peri)pancreatic necrosis or not, and if present, whether it is sterile or infected. The systemic determinant relates to whether there is organ failure or not, and if present, whether it is transient or persistent. The presence of one determinant can modify the effect of another such that the presence of both infected (peri)pancreatic necrosis and persistent organ failure have a greater effect on severity than either determinant alone. The derivation of a classification based on the above principles results in 4 categories of severity-mild, moderate, severe, and critical. CONCLUSIONS:: This classification is the result of a consultative process amongst pancreatologists from 49 countries spanning North America, South America, Europe, Asia, Oceania, and Africa. It provides a set of concise up-to-date definitions of all the main entities pertinent to classifying the severity of acute pancreatitis in clinical practice and research. This ensures that the determinant-based classification can be used in a uniform manner throughout the world.

About 10% to 20% of patients with acute pancreatitis develop severe disease, which is characterized by intrapancreatic or peripancreatic necrosis [1-6]. Necrotizing pancreatitis is the most severe form of acute pancreatitis associated with high morbidity and mortality due to the development of infected pancreatic necrosis, and multisystem organ failure. In severe necrotizing pancreatitis, the mortality rate ranges from 10% to 40%, and it is especially high (up to 50%) when the necrosis is infected and progressing to sepsis and multiorgan failure [1-3,7]. The appropriate treatment of infected pancreatic necrosis remains the subject of much debate. It is generally accepted that in infected necrotizing pancreatitis the infected non-vital solid tissue has to be removed in order to control the sepsis. For decades, open surgery and immediate surgical necrosectomy was the gold standard treatment for patients with infected pancreatic necrosis [1,3,7,8]. However, several reports have shown that early surgical intervention for pancreatic necrosis could result in a worse prognosis compared to cases where surgery is delayed or avoided [9-13]. It has been suggested that the invasiveness of open surgery in an already critically ill patient may be the cause of high morbidity rates. Therefore, several groups worldwide have developed new minimal invasive approaches using conservative treatment, endoscopic necrosectomy or drainage therapy in the management of infected necrotizing pancreatitis [14-19].

The progression of acute pancreatitis to necrotizing pancreatitis which often results in high morbidity and mortality is difficult to predict. Here we report that serum concentrations of sCD137 are increased in patients with acute pancreatitis. Admission levels and 10-day median sCD137 levels positively correlate with markers of biliary pancreatitis and the 10-day sCD137 median is significantly higher in metabolic than in alcoholic pancreatitis. Serum concentrations of sCD137 at time of admission and the 10-day median of sCD137 correlate with the Ranson and APACHE II disease scores but not with the radiological Balthazar and Schroeder scores that reflect pancreatic and peripancreatic necrosis. Further, sCD137 levels correlate with the probability of complications and lethality. The association of sCD137, a product of activated T cells, with the severity of acute pancreatitis suggests that T cells contribute to the pathogenesis of acute pancreatitis.

Introduction Wide flange fully covered self-expandable metallic stents (FCSEMS) have recently been developed for EUS-guided transmural drainage of pancreatic fluid collections. We used these wide calibre stents for transgastric access for endoscopic necrosectomy in patients requiring necrotic debridement. Method Patients referred with large, symptomatic walled off-necrosis for endoscopic therapy were included. Under EUS guidance, the necrotic cavity was accessed using the needle knife of a cystotome. After securing the access with a guidewire the new tract was enlarged to 10 F using the ring diathermy of the cystotome. This allowed a 2 or 3 cm long 14 mm diameter FCSEMS to be placed transmurally. If clinically required, endoscopic necrosectomy sessions were performed through the FCSEMS in weekly intervals. Results Six patients (5 men, median age 50 years) had a walled off-necrosis with a median size of 16 cm (range 12–17 cm) causing gastric outlet obstruction (5) or biliary compression (1). One patient with an endosonographically visible artery transversing the necrotic cavity was declined due to bleeding risk. In the other five patients, the insertion of a transgastric FCSEMS under EUS guidance was successful without immediate complications. In all five patients, the cavity reduced to Conclusion EUS-guided insertion of FCSEMS into walled-off necrosis appears safe and results in effective drainage. Endoscopic necrosectomy can be performed through the transmural FCSEMS which provides endoscopic access for repeated debridement and flushing of the necrotic cavity. Disclosure of interest None Declared. References Seifert H, Wehrmann T, Schmitt T, Zeuzem S, Caspary WF. Retroperitoneal endoscopic debridement for infected peripancreatic necrosis. Lancet 2000;356(9230):653–5 Braden B, Dietrich CF. Endoscopic ultrasonography-guided endoscopic treatment of pancreatic pseudocysts and walled-off necrosis: new technical developments. World J Gastroenterol. 2014;20(43):16191–6. doi: 10.3748/wjg.v20.i43.16191

Infection complicating pancreatic or peripancreatic necrosis is the single most accepted criterion for surgical intervention in severe acute pancreatitis. A failure to improve after 72 h of high-quali

Despite extensive clinical trials, acute necrotizing pancreatitis remains a poorly understood clinical entity, partly because of the difficulty of diagnosing its presence and assessing its severity, and also to marked variability in its natural history. Studies published to date have shown significant improvement in the clinical and morphological staging of necrotizing pancreatitis [1, 3, 4, 6], but indication for surgery according to either clinical or morphological staging alone remains a controversial issue [7].

We recently experienced a case of spontaneous perforation of infected necrosis into the colon and duodenum during the course of acute pancreatitis in a 63 year-old male patient. Enteric perforations or fistulas in the setting of acute pancreatitis implicate severe underlying pathology and have substantial morbidity and mortality. In the meantime it has generally been accepted that infected pancreatic or peripancreatic necrosis should be managed surgically as soon as possible. Enteric perforations in the present case contributed to transient improvement of the patient's infection sign and condition, and thus an early operation was able to be avoided. Delayed surgical management resulted in complete recovery of the patient without postoperative morbidity. Herein we report an unusual complication of acute pancreatitis.

Clinical management of acute pancreatitis remains controversial. None of the nonsurgical measures that have undergone controlled clinical trials has demonstrated any significant therapeutic benefit. No subgroup of patients who benefit from early intra-abdominal surgery has been identified. Percutaneous peritoneal lavage appears to be an extremely effective adjunct to the management of early cardiovascular and respiratory complications of severe acute pancreatitis and has prevented virtually all early deaths from these causes. Lavage has not prevented the late septic sequelae of peripancreatic necrosis, and better measures are still needed to prevent and treat these complications.

Morphological changes in necrotizing pancreatitis may be confined to the pancreas itself; they may then possibly lead to the formation of a distinctly outlined pancreatic sequestrum. In most cases, however, inflammation spreads to extrapancreatic regions. Distant necroses and those adjacent to the organ can be differentiated; the latter spread locally into the surroundings.