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Pancreatic pathologies are varied and wide-ranging, and a multidisciplinary approach is essential for effective diagnosis and management. We describe image-guided percutaneous (nonendoscopic) interventions in the management of pancreatic disease, with emphasis on inflammatory and neoplastic pancreatic pathologies and on the transplanted pancreas. Image-guided treatments for the complications of pancreatitis include percutaneous interventions on simple and complex peripancreatic collections, pseudocysts, and fistulas. Vascular interventions predominantly focus on the treatment of pseudoaneurysms, hemorrhagic pseudocysts, and arteriovenous malformations. Emerging ablative techniques for pancreatic cancer are promising and include percutaneous radiofrequency ablation, microwave ablation, irreversible electroporation, and electrochemotherapy. Image-guided interventions on the transplanted pancreas commonly include percutaneous biopsy and drainage in addition to endovascular treatments of vascular complications.

Pancreatic duct disruption may follow acute pancreatitis, chronic pancreatitis, pancreatic surgery, and trauma. Diagnosis in these patients is usually made by endoscopic retrograde cholangiopancreaticogram or secretin-stimulated magnetic resonance cholangiopancreaticogram. We report five cases where pancreatic duct disruption was diagnosed by contrast-enhanced computed tomography (CECT). Five patients with acute pancreatitis were studied; three were secondary to alcohol and two were posttraumatic. Three patients developed pancreatic ascites, one developed pancreatico-pleural effusion, and the other had pancreatic pseudocyst. CECT of the abdomen revealed pancreatic ductal injury in all the patients. In one patient with pancreatic ascites, multiple peripancreatic collections and dilated and disrupted pancreatic duct communicating with the peritoneal cavity were noted. The patient of traumatic pancreatitis had a fracture of the head of the pancreas, with peripancreatic collection communicating with the main pancreatic duct (MPD). In the other traumatic pancreatitis, there was a pseudocyst near the head of pancreas communicating with the MPD. CECT can provide a comprehensive assessment in acute pancreatitis including duct integrity, type and location of pancreatic ductal injury and can be an effective noninvasive alternative imaging modality in diagnosing pancreatic duct disruption.

Background: Peripancreatic collections occur frequently after distal pancreatectomy. However, the sequelae of peripancreatic collections vary from case to case, and their clinical impact is uncertain. In this study, the correlations between CT findings of peripancreatic collections and complications after distal pancreatectomy were investigated.Methods: Ninety-six consecutive patients who had undergone distal pancreatectomy between 2010 and 2015 were retrospectively investigated. The extent and heterogeneity of peripancreatic collections and background clinicopathological characteristics were analyzed. The extent of peripancreatic collections was calculated based on three-dimensional computed tomography images, and the degree of heterogeneity of peripancreatic collections was assessed based on the standard deviation of their density on computed tomography.Results: Of 85 patients who underwent postoperative computed tomography imaging, a peripancreatic collection was detected in 77 (91%). Patients with either a large extent or a high degree of heterogeneity of peripancreatic collection had a significantly higher rate of clinically relevant pancreatic fistula than those without (odds ratio 5.95, 95% confidence interval 2.12-19.72, p = 0.001; odds ratio 8.0, 95% confidence interval 2.87-24.19, p = 0.0001, respectively).Conclusions: A large and heterogeneous peripancreatic collection was significantly associated with postoperative complications, especially clinically relevant postoperative pancreatic fistula. A small and homogenous peripancreatic collection could be safely observed. [ABSTRACT FROM AUTHOR]

Linear echoendoscopes with large instrument channels enable EUS-guided interventions in organs and anatomical spaces in proximity to the gastrointestinal tract. Novel devices and tools designed for EUS-guided transluminal interventions allow various new applications and improve the efficacy and safety of these procedures. New-generation biopsy needles provide higher histology rates and require less passes. Specially designed stents and stent insertion devices enable intra- and extra-hepatic bile and pancreatic duct stenting as well as gallbladder drainage. Currently, EUS-guided biliary drainage in obstructive jaundice due to malignant distal bile duct obstruction is feasible and safe when ERCP has failed. It might replace ERCP as first choice intervention in future. EUS-guided transmural stenting is regarded as the preferred intervention in the management of symptomatic peripancreatic fluid collections. Creating a new anastomosis between different organs such as gastrojejunostomy has also become possible with lumen-apposing stents. EUS-guided creation of a gastrogastrostomy is a promising novel technique to access the excluded stomach to facilitate conventional ERCP in patients with Roux-en-Y gastric bypass anatomy. The role of EUS in tumor ablation and targeted angiotherapy is also constantly expanding. In this review, we report on the newest developments of therapeutic EUS within the past 4 years., Competing Interests: None

Abstract: Peripancreatic collections related to acute pancreatitis can range from simple serous fluid to infected phlegmon. The latter can be associated with significant morbidity and mortality. A patient with striking abdominal computed tomography images of an infected phlegmonous peripancreatic collection was seen at our institution. The clinical picture was much different from what the images predicted. Endoscopic retrograde cholangiopancreatography revealed a fistulous connection between the collection and the stomach, also seen on retrospective abdominal computed tomography scan review, indicating spontaneous decompression, which cured the patient. [Copyright &y& Elsevier]