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The incidence of acute pancreatitis (AP) is increasing and it is associated with a major healthcare concern. New insights in the pathophysiology, better imaging techniques, and novel treatment options for complicated AP prompted the update of the 1992 Atlanta Classification. Updated nomenclature for pancreatic collections based on imaging criteria is proposed. Adoption of the newly Revised Classification of Acute Pancreatitis 2012 by radiologists should help standardise reports and facilitate accurate conveyance of relevant findings to referring physicians involved in the care of patients with AP. This review will clarify the nomenclature of pancreatic collections in the setting of AP.

Background: We evaluated national compliance to selected quality indicators from the Dutch multidisciplinary evidence-based guideline on pancreatic and periampullary carcinoma and identified areas for improvement. Methods: Compliance to 3 selected quality indicators from the guideline was evaluated before and after implementation of the guideline in 2011: 1) adjuvant chemotherapy after tumor resection for pancreatic carcinoma, 2) discussion of the patient within a multidisciplinary team (MDT) meeting and 3) a maximum 3-week interval between final MDT meeting and start of treatment. Results: In total 5086 patients with pancreatic or periampullary carcinoma were included. In 2010, 2522 patients were included and in 2012, 2564 patients. 1) Use of adjuvant chemotherapy following resection for pancreatic carcinoma increased significantly from 45% (120 out of 268) in 2010 to 54% (182 out of 336) in 2012 which was mainly caused by an increase in patients aged

We report a case of a 60-year-old female with severe and progressive pain of her right knee. Physical therapy, pain medication, and arthroscopic debridement were unsuccessful. Finally, pathological examination revealed an intra-articular epithelioid sarcoma, a rare tumor in an atypical location. Patient died within 5 months after initial admission. Despite this unusual clinical course and presentation, we would like to share the valuable clinical lessons we learned from this case. Introduction of a coordinating physician in combination with a multidisciplinary treatment regarding optimal pain management should optimize treatment results in future patients.

Our aim was to prospectively evaluate the ability of the bedside index for severity in acute pancreatitis (BISAP) score to predict mortality as well as intermediate markers of severity in a tertiary center.The BISAP score was evaluated among 397 consecutive cases of acute pancreatitis admitted to our institution between June 2005 and December 2007. BISAP scores were calculated on all cases using data within 24 h of presentation. The ability of the BISAP score to predict mortality was evaluated using trend and discrimination analysis. The optimal cutoff score for mortality from the receiver operating curve was used to evaluate the development of organ failure, persistent organ failure, and pancreatic necrosis.Among 397 cases, there were 14 (3.5%) deaths. There was a statistically significant trend for increasing mortality (P0.0001) with increasing BISAP score. The area under the receiver operating curve for mortality by BISAP score in the prospective cohort was 0.82 (95% confidence interval: 0.70, 0.95), which was similar to that of the previously published validation cohort. A BISAP scoreor=3 was associated with an increased risk of developing organ failure (odds ratio=7.4, 95% confidence interval: 2.8, 19.5), persistent organ failure (odds ratio=12.7, 95% confidence interval: 4.7, 33.9), and pancreatic necrosis (odds ratio=3.8, 95% confidence interval: 1.8, 8.5).The BISAP score represents a simple way to identify patients at risk of increased mortality and the development of intermediate markers of severity within 24 h of presentation. This risk stratification capability can be utilized to improve clinical care and facilitate enrollment in clinical trials.

Background: The percutaneous transgluteal approach is a well-accepted method for drainage of deep pelvic abscesses. Recently, in 3 patients, transgluteal drainage was complicated by the development of large gluteal abscesses requiring multiple surgical interventions. Methods: This report describes these cases as well as a search of the literature. Results: Three patients with a complicated clinical course after colon resection are described. After CT-guided percutaneous transgluteal drainage of the pelvic abscess, large gluteal abscesses were diagnosed after 2–6 weeks. Subsequent surgical interventions were needed to adequately drain these abscesses. In the literature, transgluteal drainage of pelvic abscesses is well described as a safe and efficient method. However, until now the development of gluteal abscesses has not been mentioned as a complication in the literature. Conclusion: In our own experience, a transrectally (radiologically or surgically performed) drainage route is recommended in patients who develop a deep pelvic abscess after bowel resection and suspicion of an anastomotic leak.

Toourknowledge, wepresent the first case in the English literature of kidneyrupture accompanied by massive PVT. Discussion on thetreatment of this patient focused on the question whetherthemassiveportalveinthrombosiswasofacuteonsetormayhave been pre-existent. Anticoagulant therapy would beindicated in case of acute PVT, but the concomitant kidneyrupture is a contra-indication for rigorous anticoagulativetreatment.

BackgroundIn a complex disease such as acute pancreatitis, correct terminology and clear definitions are important. The clinically based Atlanta Classification was formulated in 1992, but in recent years it has been increasingly criticized. No formal evaluation of the use of the Atlanta definitions in the literature has ever been performed.MethodsA Medline literature search sought studies published after 1993. Guidelines, review articles and their cross-references were reviewed to assess whether the Atlanta or alternative definitions were used.ResultsA total of 447 articles was assessed, including 12 guidelines and 82 reviews. Alternative definitions of predicted severity of acute pancreatitis, actual severity and organ failure were used in more than half of the studies. There was a large variation in the interpretation of the Atlanta definitions of local complications, especially relating to the content of peripancreatic collections.ConclusionThe Atlanta definitions for acute pancreatitis are often used inappropriately, and alternative definitions are frequently applied. Such lack of consensus illustrates the need for a revision of the Atlanta Classification.

Intense adrenal enhancement has previously been reported in patients with hypovolemic and septic shock. The purpose of this study was to assess whether this computed tomography (CT) finding is also observed in patients presenting with severe acute pancreatitis and early organ failure. A retrospective analysis of a prospectively collected database was performed. Out of 38 consecutive patients with predicted severe acute pancreatitis, 3 patients showed intense bilateral adrenal enhancement on early CT. All patients had early multiple organ failure and subsequently died. In two cases, pathologic correlation was obtained. Intense adrenal enhancement may be a new prognostic indicator in patients with acute pancreatitis, particularly when organ failure is present at the time of CT examination. Further studies are necessary to confirm this observation.

Surgical intervention in patients with infected necrotizing pancreatitis generally consists of laparotomy and necrosectomy. This is an invasive procedure that is associated with high morbidity and mortality rates. In this report, we present an alternative minimally invasive technique: videoscopic assisted retroperitoneal debridement (VARD). This technique can be considered a hybrid between endoscopic and open retroperitoneal necrosectomy. A detailed technical description is provided and the advantages over various other minimally invasive retroperitoneal techniques are discussed.

Background Despite improvements in diagnostic imaging and staging, unresectable pancreatic cancer is still encountered during surgical exploration with curative intent. This nationwide study investigated outcomes in patients with unresectable pancreatic cancer found during surgical exploration. Methods All patients diagnosed with primary pancreatic (adeno)carcinoma (2009–2013) in the Netherlands Cancer Registry were included. Predictors of unresectability, 30-day mortality and poor survival were evaluated using logistic and Cox proportional hazards regression analysis. Results There were 10 595 patients with pancreatic cancer during the study interval. The proportion of patients undergoing surgical exploration increased from 19·9 to 27·0 per cent (P < 0·001). Among 2356 patients who underwent surgical exploration, the proportion of patients with tumour resection increased from 61·6 per cent in 2009 to 71·3 per cent in 2013 (P < 0·001), whereas the contribution of M1 disease (18·5 per cent overall) remained stable. Patients who had exploration only had an increased 30-day mortality rate compared with those who underwent tumour resection (7·8 versus 3·8 per cent; P < 0·001). In the non-resected group, among those with M0 (383 patients) and M1 (435) disease at surgical exploration, the 30-day mortality rate was 4·7 and 10·6 per cent (P = 0·002), median survival was 7·2 and 4·4 months (P < 0·001), and 1-year survival rates were 28·0 and 12·9 per cent, respectively. Among other factors, low hospital volume (0–20 resections per year) was an independent predictor for not undergoing tumour resection, but also for 30-day mortality and poor survival among patients without tumour resection. Conclusion Exploration and resection rates increased, but one-third of patients who had surgical exploration for pancreatic cancer did not undergo resection. Non-resectional surgery doubled the 30-day mortality rate compared with that in patients undergoing tumour resection.

Background The role of percutaneous catheter drainage (PCD) in patients with (infected) necrotizing pancreatitis was evaluated. Methods A systematic literature search was performed. Inclusion criteria were: consecutive cohort of patients with necrotizing pancreatitis undergoing PCD as primary treatment for peripancreatic collections; indication for PCD either (suspected) infected necrosis or symptomatic sterile pancreatic necrosis; and outcomes reported to include percentage of infected peripancreatic collections, need for additional surgical necrosectomy, complications and deaths. Exclusion criteria were: cohort of fewer than five patients; cohort included patients with chronic pancreatitis; selected subgroup of patients with acute pancreatitis studied, such as those with pseudocysts, pancreatic abscesses and/or exclusively sterile pancreatic necrosis; and cohort in which PCD was combined with another minimally invasive strategy and results for PCD alone not reported separately. Results Eleven studies, including 384 patients, fulfilled the inclusion criteria. Only one study was a randomized controlled trial; most others were retrospective case series. Four studies reported on the presence of organ failure before PCD; this occurred in 67·2 per cent of 116 patients. Infected necrosis was proven in 271 (70·6 per cent) of 384 patients. No additional surgical necrosectomy was required after PCD in 214 (55·7 per cent) of 384 patients. Complications consisted mostly of internal and external pancreatic fistulas. The overall mortality rate was 17·4 per cent (67 of 384 patients). Nine of 11 studies reported mortality separately for patients with infected necrosis undergoing PCD; the mortality rate in this group was 15·4 per cent (27 of 175). Conclusion A considerable number of patients can be treated with PCD without the need for surgical necrosectomy.

s / Pancreatology 12 (2012) 502–597 575 showed that endoscopic necrosectomy significantly reduced the proinflammatory response as well as complications and death compared to surgical necrosectomy. These preliminary outcomes require confirmation in a larger trial. We describe the design and rationale of a nationwide study called TENSION: “Endoscopic transluminal step-up approach versus surgical step-up approach in patients with infected necrotizing pancreatitis” (Trial registration: ISRCTN09186711). Methods: The TENSION trial is a randomized controlled parallel-group, superiority multicenter trial. Patients with infected necrotizing pancreatitis will be randomized to an endoscopic or surgical step-up approach. The endoscopic step-up approach consists of endoscopic transluminal drainage followed, if necessary, by endoscopic transluminal necrosectomy. The surgical step-up approach consists of percutaneous catheter drainage, if necessary, followed by video-assisted retroperitoneal debridement (VARD). The primary endpoint is a composite of major complications (i.e., new onset organ failure, bleeding requiring intervention, perforation of a visceral organ requiring intervention, enterocutaneous fistula requiring intervention and incisional hernia) or death within 6 months following randomization. Secondary endpoints include other complications such as pancreatic fistula, pancreatic insufficiency, length of intensive careand hospital stay, quality of life, and costs. 98 patients will be enrolled in 25 hospitals of the Dutch Pancreatitis Study Group in a 3-year period. Conclusion: The TENSION trial is designed to evaluate if an endoscopic step-up approach is superior to a surgical step-up approach in terms of clinical outcomes and cost-effectiveness in patients with infected necrotizing pancreatitis.

Departments of Surgery, 1University Medical Centre Utrecht, Utrecht, 2Leiden University Medical Centre, Leiden, 3St Antonius Hospital, Nieuwegein and 4Radboud University Nijmegen Medical Centre, Nijmegen, The Netherlands Correspondence to: Professor H. G. Gooszen, Department of Surgery, University Medical Centre Utrecht, HP G04.228, PO Box 85500, 3508 GA Utrecht, The Netherlands (e-mail: h.gooszen@umcutrecht.nl)

Introduction: Infection of pancreatic necrosis in necrotizing pancreatitis increases the lethality. Aims/objectives: To examine the mechanisms underlying this clinical circumstance we used a model of primary infected pancreatic necrosis in taurocholate induced pancreatitis in mice. Materials and methods: Acute necrotizing pancreatitis with sterile necrosis (SN) was induced by retrograde injection of 4% taurocholate in the common bile duct of Balb/c mice, infected pancreatic necrosis (IN) was induced by co-injecting 108 CFU E. coli. For antibiotic therapy 10 mg/kg bodyweight moxifloxacin were administered intravenously (AIN). After 6, 12, 24, 48 and 120 hours animals were sacrificed and serum as well as SIRS related organs were examined. Results: Prolonged bacteremia occurred when infected acinar cell necrosis was induced (24h CFU E. coli in blood; bacteria only not detected, IN 121 63). Infection of pancreatic necrosis with E. coli further increased the pancreatic damage (histology score 24h: SN 17.8 2.6 vs. IN 23.7 2.2; p