review of literature on clinical pancreatology - The Pancreapedia

drainage. It was concluded that intrahepatic fluid collection in the course <strong>of</strong> acute biliarypancreatitis is a rare occurrence. The therapeutic approach is the same as that for pancreaticand peripancreatic fluid collections. In case <strong>of</strong> infection, the patient undergoes percutaneousUS/CT guided drainage [236].Endoscopic treatmentNecrosectomy is the gold standard treatment for infected pancreatic necrosis (IPN). Apercutaneous and endoscopic approach has been accepted in selected cases. Endoscopicdrainage (ED) <strong>of</strong> IPN can be performed by using transpapillary or transmural procedures, ora combination <strong>of</strong> both with or without endoscopic ultrasound. The aim <strong>of</strong> one study was todetermine the indications, complications, success rate, and the importance <strong>of</strong> assessment <strong>of</strong>main pancreatic duct integrity by endoscopic retrograde pancreatography (ERP) in patientswith IPN. Records <strong>of</strong> all patients who underwent endoscopic necrosectomy from 2002 toDecmber 2007 were <strong>review</strong>ed. A total <strong>of</strong> 56 patients were included. ED was performed usingdaily transmural and transpapillary drainage. A diagnostic pancreatogram (ERP) to searchfor communications between the pancreatic duct and the collection were performed in allcases and in cases where communication existed. A pre-cut needle knife was used topuncture the cyst wall, aspirate the content and then enter at the cyst cavity (contrast wasinjected to ensure opacification <strong>of</strong> the cyst and subsequent drainage). Sphincterotomycatheter or balloons were used to enlarge and ensure a wide cystoenterostomy. All patientswere followed with computerized tomography scans or ultrasound to ensure clinicalresolution. Mean follow-up was 21 months.49/56 patients could be successfully treated. EDwas successful in 49 patients (87 %) and in 3 (13 %) it failed. Mean follow-up was 21months. During this period, there were 2 (11 %) pseudocyst recurrences and only 1 (5 %)recurrence <strong>of</strong> new episodes <strong>of</strong> pancreatic necrosis, and all were managed clinically and/orendoscopically. No mortality was related to the procedure [237].It was described a case <strong>of</strong> successful endoscopic management <strong>of</strong> two pancreatic abscessesin a critically ill patient. CT scan showed two large abscesses. The first was bulging to theposterior wall <strong>of</strong> the stomach and another at the tail <strong>of</strong> the pancreas. An endoscopicretrograde cholangiopancreatography was performed. The pancreatic duct communicatedwith the abscess at the tail <strong>of</strong> the pancreas. The drainage <strong>of</strong> this abscess was donetranspapillarily. Endoscopic cystogastrostomy was performed to treat the pancreatic abscessthat bulged to the posterior gastric wall. A double nasocystic tube was placed for continuouslavage <strong>of</strong> the abscess. Pseudomonas aeruginosa was cultured and antibiotics wereadministered according to sensitivity tests. The clinical status returned gradually to normal. Afollow-up CT scan 4 months later showed complete resolution <strong>of</strong> abscesses. It wasconcluded that endoscopic drainge <strong>of</strong> pancreatic abscesses may be the therapy <strong>of</strong> choice insuch patients mainly because it does not prevent the chance <strong>of</strong> subsequent surgicalintervention if needed [238].Radiologic interventionsIt has previously been reported that organ failure and mortality in necrotizing pancreatitis(NP) are not different between patients with infected and sterile necrosis. However,management <strong>of</strong> this disease has evolved to include image-guided percutaneous catheterdrainage (PCD) to improve morbidity and mortality. A total <strong>of</strong> 689 consecutive patientstreated for acute pancreatitis between 2001 and 2005, <strong>of</strong> whom 64 (9 %) had pancreaticnecrosis documented on contrast-enhanced computed tomography was studied. In the 64patients with documented necrotizing pancreatitis, overall mortality was 16 percent. Thirty-sixpatients (56 %) had organ failure according to the Atlanta classification. Compared withpatients with sterile necrosis, those with infected necrosis did not have an increasedprevalence <strong>of</strong> organ failure or increased need for intubation, pressors, or dialysis but had an