Todd H. Baron

Acute Necrotizing Pancreatitis

Acute pancreatitis may be clinically mild or severe. Severe acute pancreatitis is usually a result of pancreatic glandular necrosis. The morbidity and mortality associated with acute pancreatitis are substantially higher when necrosis is present, especially when the area of necrosis is also infected.1 It is important to identify patients with pancreatic necrosis so that appropriate management can be undertaken. In recent years, the treatment of these patients has shifted away from early surgical debridement (“necrosectomy”) to aggressive intensive medical care, with specific criteria for operative and nonoperative intervention.2,3 Advances in radiologic imaging and aggressive medical management with emphasis on .xa0.xa0.

Interventions for Necrotizing Pancreatitis Summary of a Multidisciplinary Consensus Conference

Abstract Pancreatic and peripancreatic necrosis may result in significant morbidity and mortality in patients with acute pancreatitis. Many recommendations have been made for management of necrotizing pancreatitis, but no published guidelines have incorporated the many recent developments in minimally invasive techniques for necrosectomy. Hence, a multidisciplinary conference was convened to develop a consensus on interventions for necrotizing pancreatitis. Participants included most international experts from multiple disciplines. The evidence for efficacy of interventions was reviewed, presentations were given by experts, and a consensus was reached on each topic. In summary, intervention is primarily indicated for infected necrosis, less often for symptomatic sterile necrosis, and should ideally be delayed as long as possible, preferably 4 weeks or longer after the onset of disease, for better demarcation and liquefaction of the necrosis. Both the step-up approach using percutaneous drainage followed by minimally invasive video-assisted retroperitoneal debridement and per-oral endoscopic necrosectomy have been shown to have superior outcomes to traditional open necrosectomy with respect to short-term and long-term morbidity and are emerging as treatments of choice. Applicability of these techniques depends on the availability of specialized expertise and a multidisciplinary team dedicated to the management of severe acute pancreatitis and its complications.

Transmural drainage of pancreatic fluid collections without electrocautery using the Seldinger technique

BACKGROUNDnComplications of endoscopic transmural drainage of pancreatic fluid collections arise from entry through the gastrointestinal wall. We describe transmural drainage of these collections using the Seldinger technique without electrocautery.nnnMETHODSnFrom January 1995 to September 1997, we attempted endoscopic transmural drainage of 94 consecutive pancreatic fluid collections without EUS guidance (needle-knife entry in 51, Seldinger entry technique in 43). Success of entry and complications were compared.nnnRESULTSnSuccessful entry was achieved in 95.3% using the Seldinger technique and 92.1% using the needle-knife entry technique (p = NS). Complications of bleeding and perforation were seen in 4.6% of patients in the Seldinger group and 15.7% in the needle-knife entry group.nnnCONCLUSIONSnThe Seldinger technique of endoscopic transmural drainage of pancreatic fluid collections appears effective and safer than entry using the needle-knife. Collections as small as 3 cm in diameter can be entered using the Seldinger technique without EUS guidance.

Low-dose oral methotrexate in refractory inflammatory bowel disease

The purpose of this study was to evaluate the efficacy and safety of low-dose weekly, oral methotrexate in patients with steroid-dependent or steroid-refractory inflammatory bowel disease (IBD). Oral methotrexate was given weekly at 15 mg/week. The primary criterion of response was based on steroid withdrawal. Of the 10 patients with Crohns disease, daily prednisone dosage dropped from a mean of 37±9.6 mg to 8.3±2.1 mg/day (P<0.02); two had a complete withdrawal and four a partial response (<7.5 mg/day). In the eight patients with ulcerative colitis, daily prednisone dose dropped from a mean of 26.3±3.2 mg/day to 12.7±2.0 mg/day (P<0.001); three had a partial response. Adverse effects due to methotrexate were mild in both groups. We conclude that oral methotrexate may be useful and reasonably safe as a steroid-sparing agent in patients with refractory IBD.

Surgical gastrostomy placement as access for diagnostic and therapeutic ERCP

Therapeutic endoscopic retrograde cholangiopancreatography (ERCP) through a gastrostomy has been described only twice.1-2 In both of these case reports, ERCP was performed through gastrostomy tracks placed for enteral nutrition because of esophageal obstruction before development of biliary obstruction. We describe the case of a patient who underwent surgical gastrostomy exclusively for allowing endoscopic access to the papilla for evaluation of recurrent acute pancreatitis in the setting of a remote gastric bypass operation.

Minimally invasive techniques in pancreatic necrosis.

Traditional open surgical necrosectomy for treatment of infected pancreatic necrosis is associated with high morbidity and mortality, leading to a shift toward minimally invasive endoscopic, radiologic, and laparoscopic approaches. Percutaneous drainage is useful as a temporizing method to control sepsis and as an adjunctive treatment to surgical intervention. It is limited because of the requirement for frequent catheter care and the need for repeated procedures. Endoscopic transgastric or transduodenal therapies with endoscopic debridement/necrosectomy have recently been described and are highly successful in carefully selected patients. It avoids the need for open necrosectomy and can be used in poor operative candidates. Laparoscopic necrosectomy is also promising for treatment of pancreatic necrosis. However, the need for inducing a pneumoperitoneum and the potential risk of infection limit its usefulness in patients with critical illness. Retroperitoneal access with a nephroscope is used to directly approach the necrosis with complete removal of a sequestrum. Retroperitoneal drainage using the delay-until-liquefaction strategy also appears to be successful to treat pancreatic necrosis. The anatomic location of the necrosis, clinical comorbidities, and operator experience determine the best approach for a particular patient. Tertiary care centers with sufficient expertise are increasingly using minimally invasive procedures to manage pancreatic necrosis.Abbreviations: CT - computed tomography, EUS - endoscopic ultrasound, PANTER - pancreatitis necrosectomy versus step-up approach, PCD - percutaneous drainage, PEG - percutaneous endoscopic gastrostomy, RCT - randomized controlled trials, SAP - severe acute pancreatitis, WOPN - walled-off pancreatic necrosis

Mast cell cholangiopathy: Another cause of sclerosing cholangitis

A 75-year-old woman with known systemic mastocytosis presented with abdominal pain, ascites, and bile duct thickening on computed tomography and ultrasonography. A liver biopsy specimen showed infiltration with mast cells. Endoscopic retrograde cholangiography showed ductal changes compatible with those found in primary sclerosing cholangitis. Brush cytology of the intrahepatic bile ducts confirmed mast cell infiltration. Systemic mastocytosis can infiltrate the biliary system, producing a cholangiopathy radiographically similar to primary sclerosing cholangitis.

Proximal migration of a pancreatic duct stent: Endoscopic retrieval using interventional cardiology accessories

Removal of endoscopically placed biliary stents that have migrated proximal to the duodenal papilla is possible with a wide variety of techniques.1,2 Although similar techniques may be used to retrieve proximally migrated pancreatic duct stents3,4, the smaller diameters of the pancreatic duct and the associated stents used in this ductal system limit the possibilities for endoscopic removal. Endoscopically irretrievable pancreatic duct stents may have to be removed surgically, and resection of a portion of the pancreatic parenchyma may be necessary.4,5 We describe endoscopic retrieval of a proximally migrated 5F pancreatic duct stent in which we used interventional cardiology accessories when other endoscopic methods of stent extraction failed.

Role of ERCP in asymptomatic orthotopic liver transplant patients with abnormal liver enzymes.

Role of ERCP in asymptomatic orthotopic liver transplant patients with abnormal liver enzymes

LEAKING GALLBLADDER REMNANT WITH CHOLELITHIASIS COMPLICATING LAPAROSCOPIC CHOLECYSTECTOMY

Since its introduction in 1989, laparoscopic cholecystectomy has rapidly become the preferred alternative to open cholecystectomy for symptomatic cholelithiasis. Although possible complications of laparoscopic cholecystectomy are essentially the same as for open cholecystectomy, we report a case of an inadvertent subtotal cholecystectomy, a complication that we believe has not been previously reported.