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Pseudocysts andWalled- Off Necrosis After Acute Pancreatitis: Surgical Approach

Naohiro Sata, Masaru Koizumi, and Alan Kawarai Lefor

Department of Surgery, Division of Gastroenterological, General and Transplant Surgery, Jichi Medical University, School of Medicine, Shimotsuke, Tochigi, Japan

Introduction

The strategy for surgical intervention in patients with pancreatic pseudocysts (PPC) and walled- off necrosis (WON) has dramatically changed in recent decades. In the early 1980s, open drainage and closed lavage were the most common surgical procedures performed for “pancreatic abscess.” A more aggressive approach resulting in earlier surgical intervention, with more extensive drainage and debridement of associated necrotic tissue has been recommended[1]. However, early intervention including open necrosectomy is associated with poor outcomes and the latest guidelines suggest that surgical intervention should be delayed as long as possible, until at least 4weeks after the onset of the illness[2,3].

Peripancreatic fluid collections are frequently seen in the management of patients with acute pancreatitis. Acute pancreatitis is divided into interstitial edematous pancreatitis and necrotizing pancreatitis[4]. In interstitial edematous pancreatitis, fluid collections are usually resorbed spontaneously and clinical symptoms are improved after a week. However, remnant localized fluid collections sometimes require intervention in patients with necrotizing pancreatitis. The terminology for these remnant localized fluid collections was changed completely in 2012, by the revised Atlanta classification [4]. This chapter will focus on surgical strategies for the treatment of patients with PPC and WON after episodes of acute pancreatitis.

Definition ofPancreatic Pseudocyst andWalled- Off Necrosis

In the Atlanta classification, advocated at the International Symposium on Acute Pancreatitis in Atlanta in 1992, acute fluid collections and pancreatic

necrosis/infected necrosis were defined as local complications in the early stage of acute pancreatitis [5]. Additionally, PPC and pancreatic abscess are also defined as local complications in the late stage. The term “pancreatic pseudocyst” had been used to describe a wide spectrum of fluid collections derived from necrotizing pancreatitis, interstitial edematous pancreatitis, and acute exacerbations of chronic pancreatitis. Capsulized liquefied necrotic pancreatic and/or peripancreatic tissue after necrotizing pancreatitis should be considered to be different from a capsulized collection of pure pancreatic exocrine secretions. If the same treatment had been performed, the outcome would be different [6,7]. In fact, pancreatic abscess was seldom encountered in either Western countries or East Asia. Based on this background, the concept of “walled- off pancreatic necrosis” was proposed for an encapsulated fluid collection derived from necrotic pancreatic and/or peripancreatic tissue in patients with necrotizing pancreatitis [8]. The term was changed to “walled- off necrosis” (WON), and the concept of this condition was then established by the revised Atlanta classification in 2012 [4] (Fig. 34.1). WON is defined as a mature, encapsulated collection of pancreatic and/or peripancreatic necrosis that has developed a well- defined inflammatory wall and usually occurs more than 4weeks after the onset of necrotizing pancreatitis[4]. Fluid collections originating from necrosis less than 4weeks after the onset of necrotizing pancreatitis is referred to as an acute necrotic collection (ANC). The concept of a pancreatic pseudocyst (PPC) was proposed to be limited to an encapsulated collection of fluid with a well- defined inflammatory wall, usually outside the pancreas, with minimal or no necrosis that occurs more than fourweeks after the onset of interstitial edematous pancreatitis[4,9]. As the concept of PPC changed and the new concept of WON was developed in

The Pancreas: An Integrated Textbook of Basic Science, Medicine, and Surgery, Fourth Edition. Edited by Hans G. Beger, Markus W. Büchler, RalphH. Hruban, Julia Mayerle, John P. Neoptolemos, Tooru Shimosegawa, Andrew L. Warshaw, David C. Whitcomb, and Yupei Zhao. © 2023 John Wiley & Sons Ltd. Published 2023 by John Wiley & Sons Ltd. Companion website: www.wiley.com/go/beger/thepancreas4e

>4 weeks after onset of pancreatitis

4 weeks

Necrosis(–)

Necrosis(+)

Figure34.1 Eight categories of local

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complications of acute pancreatitis defined by the revised Atlanta classification of 2012. APFC: acute peri-

pancreatic fluid collection; ANC: acute necrotic collection; PPC: pancreatic pseudocyst; WON: walled- off necrosis.

Timing of Interventions and Optimal Interventional Strategy for WON 289

<4 weeks after onset of pancreatitis

APFC(sterile)

PPC(sterile)

2012, care must be taken to avoid confusion regarding the terms PPC and WON, especially when reviewing clinical studies reported before 2012.

The International Association of Pancreatology and the American Pancreatic Association (IAP/APA) guidelines were revised according to the revised Atlanta classification of 2012, and the IAP/APA evidence- based guidelines for the management of acute pancreatitis were published in 2013 (IAP/APA guideline 2013)[2]. At the same time, Japanese guidelines for the management of acute pancreatitis were revised and the fourth and the fifth editions were published in 2015, 2021 (JPN guidelines 2015, 2021)[3]. The diagnosis and treatment of acute pancreatitis should be based on these guidelines.

Indications forSurgical Intervention

Previously, surgical intervention with drainage and necrosectomy, was the gold standard for treatment of the infectious complications of acute pancreatitis. In the early 2000s, minimally invasive interventions were developed and have been replacing highly invasive surgical procedures such as open drainage. Minimally invasive interventions include procedures such as endoscopic and laparoscopic drainage and necrosectomy. Both the IAP/APA guideline 2013 and the JPN guidelines 2015, 2021 recommend that interventions should be performed in patients with infections or other persistent symptoms, such as ongoing gastric outlet, intestinal, or biliary obstruction, pain, or complications due to a mass effect secondary to WON or PPC. Most patients with infected localized fluid collections that cannot be managed by the administration of widesome therapeutic intervention.

The terminology for drainage and necrosectomy should be appropriately used. Drainage is a procedure to drain fluid by percutaneous, transgastric, enteral, or

spectrum antibiotics will require

APFC(infected)

ANC(sterile)

ANC(infected)

PPC(infected)

WON(sterile)

WON(infected)

transpapillary routes, or by open surgery. Necrosectomy is a procedure to remove necrotic tissue aggressively, using percutaneous, transgastric, or enteral approaches, or by open surgery. Confusion regarding the terminology for drainage and necrosectomy procedures must be considered when evaluating clinical studies reported before

2012.

Timing of Interventions and Optimal Interventional Strategy for WON

In the past, outcomes following early invasive surgical interventions were very poor [10–12]. In a prospective study of 629 patients, late intervention significantly decreased mortality and morbidity[13]. Both the IAP/ APA guideline 2013 and the JPN guidelines 2015, 2021 refute the beneficial therapeutic effect of early intervention and recommend that intervention should be delayed as long as possible, until at least 4weeks after the onset of pancreatitis[2,3]. Interventions should be performed when fluid collections are encapsulated, and the capsule wall is thickened.

The optimal interventional strategy is still controversial. Open surgery was the only choice for intervention before 2000. Minimally invasive interventions, including endoscopic drainage and necrosectomy, and laparoscopic necrosectomy, were introduced in the late 1990s and early 2000s. Though the use of these novel interventions has been increasing, they require advanced technical skills and should be done only in high- volume centers. Some centers reported good results, although there is a large variation in expertise in performing these novel interventions among centers. Further assessment is necessary for these interventions to become standard approaches.

The Dutch Pancreatitis Study Group proposed a step up approach for the treatment of patients with suspected

Pseudocysts andWalled- Off Necrosis After Acute Pancreatitis: Surgical Approach

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290

or confirmed infected necrotizing pancreatitis[14]. The step- up approach is composed of two parts, including initial image- guided percutaneous (retroperitoneal) catheter drainage or endoscopic transluminal drainage followed by endoscopic or surgical necrosectomy. Percutaneous catheter drainage alone is reported to reduce the necessity for necrosectomy in 23–50% of patients with infected necrotizing pancreatitis[2,14–19]. Additionally, the step- up approach is reported to decrease major short- term and long- term complications and reduce overall costs compared to conventional surgical necrosectomy [14]. At present, the step- up approach is thought to be the most effective approach and both the IAP/APA guideline 2013 and the JPN guidelines 2015, 2021 clearly recommend it as the optimal interventional strategy [2,3]. The IAP/APA guideline 2013 also states that no subgroup of patients requiring a different strategy can be defined, and the optimal method of necrosectomy (i.e., surgical or endoscopic necrosectomy) is unclear if catheter drainage fails[2].

Catheter drainage is always the first step for intervention in patients with local infectious complications of necrotizing pancreatitis. Less-

invasive procedures, such as percutaneous drainage guided by ultrasonography or computed tomography, and endoscopic transluminal drainage are the initial recommendations [13–16] (Fig.34.2). Surgical drainage with a small incision is indicated in patients for whom percutaneous or endoscopic approaches are contraindicated or fail. Multi- loculated cysts, multiple cysts, presence of significant necrotic debris, cysts in the pancreatic tail and uncontrolled hemorrhage are also indications for surgical drainage. If catheter drainage fails to control infection, minimally invasive

or open surgery or endoscopic transluminal necrosectomy are the next steps[20,21].

Laparoscopic and video-

assisted retroperitoneal debridement (VARD) have become new choices for a second- step intervention[14]. The results from 14 recent series of percutaneous drainage for necrotizing pancreatitis indicate a 19.4–26.4% conversion rate from percutaneous drainage to surgical drainage, with a 15.2–21% mortality rate [14,22–34]. The results from 18 recent series of surgical necrosectomy indicate the need for additional necrosectomy in 10–16.5%, additional drainage in 13–13.8%, and an overall 1.7–25.8% mortality rate[35–52]. However, the step- up approach has better outcomes. The results from 10 recent series report a

17.4% conversion rate to the surgical approach with a

9.1–14.9% mortality rate[14,36,43–59]. Recently, robotassisted transgastric cyst- gastrostomy, robot- assisted transgastric drainage and debridement of WON were reported as new minimally invasive surgical treatment[60–62]. Bleeding, pancreatic fistula and gastrointestinal fistula are frequent complications of these interventions.

Surgical Intervention for PPC

Since acute exacerbations of chronic pancreatitis are a leading cause of PPC, the strategy for the treatment of PPC should be different from that used for WON. Most small PPC spontaneously regress without specific interventions. Evidence of infection or persistent symptoms are a common indication for intervention in patients with PPC (Fig.34.3). External or internal drainage is thefirst choice for infected PPC, and other novel interventions have been developed

Figure34.2 Computed tomography scan findings of infected

walled off necrosis on the 170th day after the onset of necrotizing pancreatitis. Air bubbles were observed in the area of walled- off necrosis located in the lesser omentum, which strongly suggests the presence of infection.

Figure34.3 Computed tomography scan findings of a pancreatic

pseudocyst. The pancreatic pseudocyst resulted from an acute exacerbation of chronic pancreatitis and is located in the left subphrenic space.

References 291

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and evaluated clinically. Open cyst- enterostomy (i.e., cystgastrostomy or cyst- jejunostomy) is often used with a reported 15.9–25.4% morbidity and 0.2–0.4% of mortality in six recent retrospective series [63–68]. Laparoscopic cystenterostomy, a minimally invasive approach, is becoming more common and performed by various methods, including a Roux- en- Y anastomosis and intra- gastric procedures [69–76]. The laparoscopic procedure has good outcomes, with 9.5–26.9% morbidity, 3.6%PPC recurrence, and 0% mortality in eight recent series [69–77]. Percutaneous cyst- gastrostomy, draining the PPC via both percutaneous

References

1 Warshaw AL, Jin GL. Improved survival in 45 patients

with pancreatic abscess. Ann Surg 1985;202: 408–417.

2 Working Group IAP/APA Acute Pancreatitis Guidelines.

IAP/APA evidenceof acute pancreatitis. Pancreatology 2013;13(4 Suppl

2):e1–15.

3 Yokoe M, Takada T, Mayumi T etal. Japanese guidelines

for the management of acute pancreatitis: Japanese Guidelines 2015. J Hepatobiliary Pancreat Sci 2015;22:405–432.

4 Banks PA, Bollen TL, Dervenis C etal. Acute Pancreatitis

Classification Working Group. Classification of acute pancreatitis- - 2012: revision of the Atlanta classification and definitions by international consensus. Gut 2013;62:102–111.

5 Bradley EL, 3rd. A clinically based classification system

for acute pancreatitis. Summary of the International Symposium on Acute Pancreatitis, Atlanta, Ga, September 11 through 13, 1992. Arch Surg 1993;128: 586–590.

6 Baron TH, Thaggard WG, Morgan DE etal. Endoscopic

therapy for organized pancreatic necrosis. Gastroenterology 1996;111:755–764.

7 Baron TH, Morgan DE. Acute necrotizing pancreatitis.

NEngl J Med 1999;340:1412–1417.

8 Papachristou GI, Takahashi N, Chahal P etal. Peroral

endoscopic drainage/debridement of walled- off pancreatic necrosis. Ann Surg 2007;245:943–951.

9 Sarr MG, Banks PA, Bollen TL etal. The new revised

classification of acute pancreatitis 2012. Surg Clin North Am 2013;93:549–562.

10 Mier J, León EL, Castillo A etal. Early versus late

necrosectomy in severe necrotizing pancreatitis. Am J Surg 1997;173:71–75.

11 Besselink MG, Verwer TJ, Schoenmaeckers EJ etal.

Timing of surgical intervention in necrotizing pancreatitis. Arch Surg 2007;142:1194–1201.

12 De Rai P, Zerbi A, Castoldi L etal. ProInf- AISP (Progetto

Informatizzato Pancreatite Acuta, Associazione Italiana

based guidelines for the management

and transgastric routes with a gastroscopic procedure, is feasible with 11.3% morbidity and 9.4% requiring an additional surgical cyst- gastrostomy [14,78–80]. Robot- assisted cystenterostomy for PPC has not been reported. Bleeding, abdominal abscess including cyst infection, pancreatic fistulae, and surgical site infections are common complications of surgical procedures for PPC [63–77]. Pancreatectomy, distal pancreatectomy, pancreaticoduodenectomy, or duodenum- preserving pancreas head resection, are indicated in some patients with a PPC and persistent chronic pain[67].

per lo Studio del Pancreas [Computerized Project on Acute Pancreatitis, Italian Association for the Study of the Pancreas]) Study Group. Surgical management of acute pancreatitis in Italy: lessons from a prospective multicentre study. HPB (Oxford) 2010;12:597–604.

13 van Santvoort HC, Bakker OJ, Bollen TL etal. Dutch

Pancreatitis Study Group. A conservative and minimally invasive approach to necrotizing pancreatitis improves outcome. Gastroenterology 2011;141:1254–1263.

14 van Santvoort HC, Besselink MG, Bakker OJ etal. Dutch

Pancreatitis Study Group. A stepnecrosectomy for necrotizing pancreatitis. N Engl J Med 2010;362:1491–1502.

15 Horvath K, Freeny P, Escallon J etal. Safety and efficacy

of videoinfected pancreatic collections: a multicenter, prospective, single- arm phase 2 study. Arch Surg 2010;145:817–825.

16 Bello B, Matthews JB. Minimally invasive treatment of

pancreatic necrosis. World J Gastroenterol 2012;18:6829–6835.

17 Babu RY, Gupta R, Kang M etal. Predictors of surgery in

patients with severe acute pancreatitis managed by the step- up approach. Ann Surg 2013;257:737e50.

18 Van Baal MC, Van Santvoort HC, Bollen TL etal.

Systematic review of percutaneous catheter drainage as primary treatment for necrotizing pancreatitis. Br J Surg 2011;98:18e27.

19 Mouli VP, Sreenivas V, Garg PK. Efficacy of conservative

treatment, without necrosectomy, for infected pancreatic necrosis: a systematic review and metaanalysis. Gastroenterology 2013;144:333–340.

20 Baron TH, DiMaio CJ, Wang AY etal. American

Gastroenterological Association Clinical Practice Update: Management of Pancreatic Necrosis. Gastroenterology 2020;158:67–75.

21 Gomes CA, Di Saverio S, Sartelli M etal. Severe acute

pancreatitis: eight fundamental steps revised according to the ‘PANCREAS’ acronym. Ann R Coll Surg Engl 2020;102:555–559.

assisted retroperitoneal debridement for

up approach or open

Pseudocysts andWalled- Off Necrosis After Acute Pancreatitis: Surgical Approach

https://t.me/medicina_free

292

22 Baril NB, Ralls PW, Wren SM etal. Does an infected

peripancreatic fluid collection or abscess mandate operation? Ann Surg 2000;231:361–367.

23 Zerem E, Imamovic G, Omerović S etal. Randomized

controlled trial on sterile fluid collections management in acute pancreatitis: should they be removed? Surg Endosc 2009;23:2770–2777.

24 Zerem E, Imamović G, Sušić A etal. Step- up approach to

infected necrotising pancreatitis: a 20-

year experience of percutaneous drainage in a single centre. Dig Liver Dis 2011;43:478–483.

25 Tong Z, Li W, Yu W etal. Percutaneous catheter drainage

for infective pancreatic necrosis: is it always the first choice for all patients? Pancreas 2012;41:302–305.

26 Navalho M, Pires F, Duarte A etal. Percutaneous drainage

of infected pancreatic fluid collections in critically ill patients: correlation with C-

reactive protein values.

ClinImaging 2006;30:114–119.

27 Mortelé KJ, Girshman J, Szejnfeld D etal. CT- guided

percutaneous catheter drainage of acute necrotizing pancreatitis: clinical experience and observations in patients with sterile and infected necrosis. Am J Roentgenol 2009;192:110–116.

28 Wig JD, Gupta V, Kochhar R etal. The role of non-

operative strategies in the management of severe acute pancreatitis. JOP 2010;11:553–559.

29 Gluck M, Ross A, Irani S etal. Endoscopic and

percutaneous drainage of symptomatic walled-

off pancreatic necrosis reduces hospital stay and radiographic resources. Clin Gastroenterol Hepatol 2010;8:1083–1088.

30 Sleeman D, Levi DM, Cheung MC etal. Percutaneous

lavage as primary treatment for infected pancreatic necrosis. J Am Coll Surg 2011;212:748–752.

31 Baudin G, Chassang M, Gelsi E etal. CT- guided

percutaneous catheter drainage of acute infectious necrotizing pancreatitis: assessment of effectiveness and safety. Am J Roentgenol 2012;199:192–199.

32 Gluck M, Ross A, Irani S etal. Dual modality drainage

for symptomatic walled-

off pancreatic necrosis reduces length of hospitalization, radiological procedures, and number of endoscopies compared to standard percutaneous drainage. JGastrointest Surg 2012;16: 248–256; discussion 256–7.

33 Bruennler T, Langgartner J, Lang S etal. Outcome of

patients with acute, necrotizing pancreatitis requiring drainage- does drainage size matter? World JGastroenterol 2008;14(5):725–730.

34 Shenvi S, Gupta R, Kang M etal. Timing of surgical

intervention in patients of infected necrotizing pancreatitis not responding to percutaneous catheter drainage. Pancreatology 2016;16:778–787.

35 Tan J, Tan H, Hu B etal. Short- term outcomes from a

multicenter retrospective study in China comparing laparoscopic and open surgery for the treatment of infected pancreatic necrosis. J Laparoendosc Adv Surg Tech A 2012;22:27–33.

36 Besselink MG, de Bruijn MT, Rutten JP etal. Dutch Acute

Pancreatitis Study Group. Surgical intervention in patients with necrotizing pancreatitis. Br J Surg 2006;93:593–599.

37 Raraty MG, Halloran CM, Dodd S etal. Minimal access

retroperitoneal pancreatic necrosectomy: improvement in morbidity and mortality with a less invasive approach. Ann Surg 2010;251:787–793.

38 Beattie GC, Mason J, Swan D etal. Outcome of necrosectomy

in acute pancreatitis: the case for continued vigilance. Scand J Gastroenterol 2002;37:1449–1453.

39 Bhansali SK, Shah SC, Desai SB etal. Infected necrosis

complicating acute pancreatitis: experience with 131 cases. Indian J Gastroenterol 2003;22:7–10.

40 Nieuwenhuijs VB, Besselink MG, van Minnen LP etal.

Surgical management of acute necrotizing pancreatitis: a 13-

year experience and a systematic review. Scand

JGastroenterol Suppl 2003;239:111–116.

41 Wig JD, Mettu SR, Jindal R etal. Closed lesser sac lavage in

the management of pancreatic necrosis. J Gastroenterol Hepatol 2004;19:1010–1015.

42 Rau B, Bothe A, Beger HG. Surgical treatment of

necrotizing pancreatitis by necrosectomy and closed lavage: changing patient characteristics and outcome in a

year, single- center series. Surgery 2005;138:28–39.

19-

43 Farkas G, Márton J, Mándi Y etal. Surgical management

and complex treatment of infected pancreatic necrosis: 18- year experience at a single center. J Gastrointest Surg 2006;10:278–285.

44 Funariu G, Binţinţan V, Seicean R etal. Surgical treatment of

severe acute pancreatitis. Chirurgia (Bucur) 2006;101:599–607.

45 Oláh A, Belágyi T, Bartek P etal. Alternative treatment

modalities of infected pancreatic necrosis. Hepatogastroenterology 2006;53:603–607.

46 Reddy M, Jindal R, Gupta R etal. Outcome after

pancreatic necrosectomy: trends over 12 years at an Indian centre. ANZ J Surg 2006;76:704–709.

47 Besselink MG, Verwer TJ, Schoenmaeckers EJ etal.

Timing of surgical intervention in necrotizing pancreatitis. Arch Surg 2007;142:1194–1201.

48 Olejnik J, Vokurka J, Vician M. Acute necrotizing

pancreatitis: intra- abdominal vacuum sealing after necrosectomy. Hepatogastroenterology 2008;55:315–318.

49 Rodriguez JR, Razo AO, Targarona J etal. Debridement

and closed packing for sterile or infected necrotizing pancreatitis: insights into indications and outcomes in 167 patients. Ann Surg 2008;247:294–299.

50 Parikh PY, Pitt HA, Kilbane M etal. Pancreatic

necrosectomy: North American mortality is much lower than expected. J Am Coll Surg 2009;209:712–719.

51 Wittau M, Scheele J, Gölz I etal. Changing role of surgery in

necrotizing pancreatitis: a single- center experience. Hepatogastroenterology 2010;57:1300–1304.

52 Driedger M, Zyromski NJ, Visser BC etal. Surgical

transgastric necrosectomy for necrotizing pancreatitis: a single- stage procedure for walled- off pancreatic necrosis. Ann Surg 2020;271:163–168.

References 293

https://t.me/medicina_free

53 Horvath KD, Kao LS, Ali A etal. Sinanan MN.

Laparoscopic assisted percutaneous drainage of infected pancreatic necrosis. Surg Endosc 2001;15:677–682.

54 Risse O, Auguste T, Delannoy P etal. Percutaneous

assisted necrosectomy for infected pancreatic

videonecrosis. Gastroenterol Clin Biol 2004;28:868–871.

55 van Santvoort HC, Besselink MG, Bollen TL etal. Dutch

Acute Pancreatitis Study Group. Case-

matched comparison of the retroperitoneal approach with laparotomy for necrotizing pancreatitis. World J Surg 2007;31:1635–1642.

56 Connor S, Alexakis N, Raraty MG etal. Early and late

complications after pancreatic necrosectomy. Surgery 2005;137:499–505.

57 Bausch D, Wellner U, Kahl S etal. Minimally invasive

operations for acute necrotizing pancreatitis: comparison of minimally invasive retroperitoneal necrosectomy with endoscopic transgastric necrosectomy. Surgery 2012;152 (3 Suppl 1):S128–134.

58 Tang LJ, Wang T, Cui JF etal. Percutaneous catheter

drainage in combination with choledochoscope-

guided debridement in treatment of peripancreatic infection. World J Gastroenterol 2010;16:513–517.

59 Jones JD, Clark CJ, Dyer R etal. Analysis of a step- up

approach versus primary open surgical necrosectomy in the management of necrotizing pancreatitis: experience in a cohort of patients at a US academic medical center. Pancreas 2018;47:1317–1321.

60 Nassour I, Ramzan Z, Kukreja S. Robotic cystogastrostomy

and debridement of walled-

off pancreatic necrosis. Case

Reports J Robot Surg 2016;10:279–282.

61 Morelli L, Furbetta N, Gianardi D etal. Robot- assisted

trans-

gastric drainage and debridement of walled- off pancreatic necrosis using the EndoWrist stapler for the da Vinci Xi: a case report. World J Clin Cases 2019;7:1461–1466.

62 Kirks RC, Jr, Sola R, Jr, Iannitti DA etal. Robotic

transgastric cystgastrostomy and pancreatic debridement in the management of pancreatic fluid collections following acute pancreatitis. J Vis Surg 2016;2:127.

63 Usatoff V, Brancatisano R, Williamson RC. Operative

treatment of pseudocysts in patients with chronic pancreatitis. Br J Surg 2000;87:1494–1499.

64 Nealon WH, Walser E. Main pancreatic ductal anatomy

can direct choice of modality for treating pancreatic pseudocysts (surgery versus percutaneous drainage). Ann Surg 2002;235:751–758.

65 Boutros C, Somasundar P, Espat NJ. Open

cystogastrostomy, retroperitoneal drainage, and G-

J enteral tube for complex pancreatitis- associated pseudocyst: 19 patients with no recurrence. J Gastrointest Surg 2010;14:1298–1303.

66 Schlosser W, Siech M, Beger HG. Pseudocyst treatment in

chronic pancreatitis— surgical treatment of the underlying

disease increases the long- term success. Dig Surg 2005;22:340–345.

67 Grzebieniak Z, Woytoń M, Kielan W. Surgical and

endoscopic treatment of pancreatic pseudocysts. Przegl Lek 2000;57(Suppl 5):50–52.

68 Ye J, Wang L, Lu S etal. Clinical study on cystogastrostomy

and Rouxpancreatic pseudocyst: a single-

en- Y- type cystojejunostomy in the treatment of

center experience.

Medicine(Baltimore) 2021;100:e25029.

69 Chowbey PK, Soni V, Sharma A etal. Laparoscopic

intragastric stapled cystogastrostomy for pancreatic pseudocyst. J Laparoendosc Adv Surg Tech A 2001;11:201–205.

70 Teixeira J, Gibbs KE, Vaimakis S etal. Laparoscopic

en- Y pancreatic cyst- jejunostomy. Surg Endosc

Roux2003;17:1910–1913.

70 Obermeyer RJ, Fisher WE, Salameh JR etal. Laparoscopic

pancreatic cystogastrostomy. Surg Laparosc Endosc Percutan Tech 2003;13:250–253.

72 Hauters P, Weerts J, Navez B etal. Laparoscopic treatment

of pancreatic pseudocysts. Surg Endosc 2004;18:1645–1648.

73 Dávila- Cervantes A, Gómez F, Chan C etal. Laparoscopic

drainage of pancreatic pseudocysts Surg Endosc 2004;18:1420–1426.

74 Barragan B, Love L, Wachtel M etal. A comparison of

anterior and posterior approaches for the surgical treatment of pancreatic pseudocyst using laparoscopic cystogastrostomy. J Laparoendosc Adv Surg Tech A 2005;15:596–600.

75 Wu TM, Jin ZK etal. Treatment of retrogastric

pancreaticpseudocysts by laparoscopic transgastric cystogastrostomy. J Huazhong Univ Sci Technolog Med Sci 2017;37:726–731.

76 Naik P, Sahoo MR, Nayak J. Comparison of surgical

outcome between conventional laparoscopic cystogastrostomy method and plication of the edge of anterior gastrotomy in patients with pancreatic pseudocyst: a retrospective study at two tertiary care centres. J Minim Access Surg 2022;18(2):181–185.

77 Hamza N, Ammori BJ. Laparoscopic drainage of

pancreatic pseudocysts: a methodological approach. JGastrointest Surg 2010;14:148–155.

78 White SA, Sutton CD, Berry DP etal. Experience of

combined endoscopic percutaneous stenting with ultrasound guidance for drainage of pancreatic pseudocycts. Ann R Coll Surg Engl 2000;82:11–15.

79 Andersson R, Cwikiel W. Percutaneous cystogastrostomy

in patients with pancreatic pseudocysts. Eur J Surg 2002;168:345–348.

80 Thomasset SC, Berry DP, Garcea G etal. A simple, safe

technique for the drainage of pancreatic pseudocysts. ANZ J Surg 2010;80:609–614.

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Management ofFluid Collection inAcute Pancreatitis

Georg Beyer1, Simon Sirtl1, Christoph Ammer- Herrmenau2, and Albrecht Neesse

Department of Medicine II, LMU University Hospital, Ludwig- Maximilians- University, Munich, Germany

Department of Gastroenterology, Gastrointestinal Oncology and Endocrinology, University Medical Center Göttingen, Gottingen, Germany

Introduction

Acute pancreatitis is the most common cause for hospitalization in gastroenterology and has an incidence of 13–45/100,000with regional variations[1,2]. Alcohol and gallstones are the main risk factors (30–50%) with alcohol as an etiology being more common in men[3].

Considering the variety of different courses of pancreatitis, ranging from mild abdominal pain to death, it is important to predict the likely severity of the disease early in the clinical course.

The current definition of acute pancreatitis, the grades of severity (mild, moderately severe, and severe), and the detailed description of the systemic and local complications based on the revised Atlanta classification from 2012[4] are discussed in Chapter20.

Definitions

The way acute fluid collections are classified depends on the time frame of their development as well as some morphological imaging features. The acute (pericreatic fluid collection (APFC) is a typical complication of the interstitial and edematous subtype and often develops during the first 7days of pancreatitis. It has no wall and a homogenous internal structure. The spread of an APFC is orientated along the fascial anatomy. Occasionally, APFC are found in multiple locations and they tend to regress spontaneously. If an APFC persists for longer than 4weeks there is a high probability that a pseudocyst or walled- off pancreatic necrosis (WOPN) will develop.

A pseudocyst is defined as a fluid- filled space, similar to a neoplastic cyst, with a fibrotic wall. In contrast to

)pan-

neoplastic cysts, pseudocysts have no internal epithelial cell lining. Pseudocysts are considered merely complications of chronic pancreatitis and occasionally of acute pancreatitis. Following the latter they evolve from APFC usually later than 4weeks after the onset of symptoms. The treatment strategies of pancreatic pseudocysts are described in Chapter3.23.

Regions of nonvital tissue damaged by hemorrhage extravasated pancreatic juice or immune cells are defined as necrosis. It represents a form of tissue injury resulting in premature nonapoptotic cell death. The morphological characteristics of necrosis caused by acute pancreatitis are highly variable. The necrotic tissue may appear as a (semi)solid or fluid structure on imaging, although the sensitivity for detecting the solid component varies greatly between computed tomography (CT), magnetic resonance imaging (MRI), and endoscopic ultrasound (EUS)[5].

An acute necrotic collection (ANC) arises within the first 4weeks of the disease in the pancreatic parenchyma as well as the extrapancreatic tissue. It contains varying amounts of fluid or solid material. The solid parts are the crucial feature to distinguish an ANC from an APFC or a pseudocyst[4] as illustrated in Fig.35.1.

If a necrotic area is enclosed by a radiologically distinguishable capsule it is called walled- off pancreatic necrosis (WOPN). The difference between WOPN and a pseudocyst is the presence of variable amounts of solid content in the cystic cavity. Usually it arises from an ANC later than 4weeks from the onset of pancreatitis. Contrast- enhanced MRI and EUS are best suited to distinguish solid from liquid contents, but in most cases contrast- enhanced multiphase CT or even contrastenhanced ultrasound will enable the diagnosis to be made[3,5].

(a) (b)

(c)

(d)

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Imaging ofAcute Fluid Collections 295

Figure35.1 Examples for the occurrence of acute pancreatic fluid collections (APFC), post- acute pancreatic pseudocysts (PP), acute necrotic

collection (ANC), and walled- off pancreatic necrosis (WOPN) on imaging. The upper panels depict an APFC on EUS (a), which later developed into a large, but oligo- symptomatic pseudocyst (b), demonstrated on a CT scan. The reader will appreciate the absence of solid debris within the collection. In contrast, the lower panel shows an ANC on EUS (c), which matured to a WOPN. On both images, the solid content is clearly visible. The CT scan (d) was obtained prior to percutaneous drainage of the collection, which was necessary due to infection.

An originally sterile necrosis can maintain its status or become infected over the course of the disease. The diagnosis of infected necrosis is based on the patient’s clinical presentation and the presence of gas in the necrotic cavity on radiological imaging. It is of note that an asymptomatic fistula from the necrotic cavern to the gastrointestinal tract also leads to the presence of gas within the necrosis but can be without any signs of infection. Fine- needle aspiration followed by microbiological analysis of the content can confirm the presence of infected necrosis but is not needed in most cases and has a high false negative rate. Moreover, microorganisms isolated from the blood of patients with the clinical presentation of an infection or signs of an infected necrosis on imaging are of greater relevance for choosing appropriate antibiosis than those

isolated from cultured content of the necrotic cavity. Other than the extent, there are currently no features by which to predict whether necrosis will persist or regress over weeks and months.

Imaging ofAcute Fluid Collections

Transabdominal Ultrasound

Transabdominal ultrasound is an inexpensive, immediately available technique to allow a first imaging impression of a patient with an acute abdomen. The imaging of the pancreatic gland is often impaired by abdominal pain and an atonic gut. Edematous pancreas is characterized

Management ofFluid Collection inAcute Pancreatitis

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296

by an inhomogeneous, hypoechoic structure with poorly defined boundaries[6]. The pancreatic main duct is often not visualized inside the edema. Necrotic and hemorrhagic tissue appears more hypoechoic than the inflamed parenchyma. The echo contrast gain or use of ultrasound contrast agent permits a somewhat better distinction between vital or nonperfused tissue. For the detection of small amounts of free fluids in the abdominal or pleural cavity ultrasound remains the undisputed gold standard. The presence of ascites or the mostly left- sided pleural effusions are predictors for a more severe course of acute pancreatitis. Another domain of sonography is the fast and reliable imaging of the gallbladder and, if present, gallstones, which can confirm or rule out a biliary pathogenesis and detection of pleural effusions, which indicate poor prognosis [7]. In expert hands, transabdominal ultrasound with optional contrast enhancement is equally accurate as CT in detecting necrosis, vascular involvement, and severity grading[8–12].

Computed Tomography Endoscopic Ultrasound, andMagnetic Resonance Imaging

Contrast- enhanced CT scan is the fastest and most accurate method for the differential diagnosis of an acute abdomen. At hospital admission CT scan is not recommended for patients with clinical confirmed acute pancreatitis unless other differential diagnosis cannot be ruled out. Imaging via CT should not be performed to assess the severity of pancreatitis on admission [13], because the extent of necrosis can still evolve until up to 72 hours after the disease onset. Therefore, a CT scan should be delayed, if required at all, for 4days after symptom onset[3,14].

Contrast- enhanced CT can confirm the size, shape, and volume of fluid collections or necrosis and is a valuable tool to identify extrapancreatic complications including hemorrhage or pseudoaneurysms.

Two alternative methods are EUS and MRI. Despite having cost and procedural disadvantages, both methods are more sensitive in detecting solid content within a fluid collection and thus in distinguishing between plain fluid collections and pseudocysts on the one hand and areas of necrosis and WOPN on the other[5]. For more details Chapters25 and 3.23 are recommended.

Conservative Treatment ofPancreatitis andPancreatic Fluid Collections

Basic Support

All patients with acute pancreatitis should be monitored regularly within the first 48 hours after admission[3,15]. Important parameters include:

● heart frequency, 6- lead ECG, blood pressure, respira-

tory rate and oxygen saturation (to detect circulatory respiratory failure and shock);

● blood gas analysis (in case of oxygenation <90%) (to

detect respiratory failure) and lactic acidosis;

● hourly urinary excretion measurements for the man-

agement of fluid resuscitation (for fluid management and to detect renal failure);

● abdominal pressure measurement via bladder pressure

measurement (to detect compartment syndrome) if clinically suspected;

● blood electrolytes;

● blood glucose levels (to detect endocrine failure).

Fluid andElectrolyte Management

Due to retroperitoneal edema and increased vessel permeability a massive fluid shift is typical for acute pancreatitis leading to APFC. Fluid resuscitation is currently the most important intervention for reducing incidence of necrosis and patient mortality[16]. Mortality can increase to 61% if less than 3.5 L of fluid are transfused in the first day. An increase of blood urea nitrogen (BUN) of 5 mg/dL within 48 hours is a sign of prerenal kidney failure and increases mortality by a factor of 2.2[17,18]. The recommended amount of fluid is 5–10 mL/kg body weight/h or 200–250 ml/h for the first day of treatment[16], or even less, as shown by a recent randomized trial comparing aggressive to moderate fluid resuscitation, which was stopped due to increased rate of fluid overload in the aggressive treatment arm (20.5% vs. 6.3%, p=.004) [33]. Greater therapeutic fluid volumes lead to a mortality increase partially due to abdominal compartment syndrome (intra- abdominal pressure >20 mmHg), sepsis, or a prolonged stay in the intensive care unit[19]. The monitoring of fluid resuscitation should use either invasive thermodilution techniques or, if unavailable, the following parameters:

● heart frequency <120 bpm;

● mean arterial pressure between 65 and 85 mmHg;

● urinary excretion >0.5–1 mL/kg per hour;

● hematocrit between 35 and 45%.

Another important point is the composition of administered fluid. Crystalline solutions are superior to colloids. Colloidal infusions are suspected of being associated with a higher incidence of renal insufficiency and should be avoided. The advantage of Ringer’s solution is its similar composition to blood as well as the nonimpairment of electroneutrality by compensating the anion gap with lactate or acetate. Moreover, the incidence of systemic inflammatory response syndrome (SIRS) is reduced within the first 24 hours if Ringer’s solution is used rather than saline[20].

Conservative Treatment ofPancreatitis andPancreatic Fluid Collections 297

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Nutrition

Complete fasting has no positive influence on the outcome and course of pancreatitis [21]. In fact, fasting leads to atrophy of gut villi resulting in a more rapid translocation of intraluminal bacteria, facilitating the infection of necrotic areas. Starting enteral nutrition early is recommended[22]. If the patients are not able to take oral food, feeding by tube is the most effective method. Nasogastric and nasojejunal tubes have been shown to be equally effective and safe [23], although nasojejunal feeding tubes tend to dislocate more often. The best and most natural form of nutrition remains eating by mouth. Once patients are pain- free (with pain medication if required) and can tolerate food they should take oral food. If not enteral nutrition is less expensive and more physiologic than parenteral nutrition. Starting enteral nutrition immediately after admission was not found to lead to better outcomes than withholding food for 72 hours[24]. The current approach to nutrition has become much more pragmatic than in the past when all patients were put on nil-

by- mouth for long periods.

There is no role for a specific pancreatitis diet.

Antibiotics

Prophylactic application of antibiotics is not necessary for patients with acute pancreatitis, regardless of its predicted severity, and could contribute to the rise of multiresistant bacteria. Neither the mortality nor the rate of infected necrosis is positively influenced by prophylactic antibiotics [17]. Conversely, if infected necrosis is suspected, antibiotic therapy must be initialized immediately. Antibiotics with appropriate pancreatic tissue levels are carbapenems, fluorochinolones, or metronidazole. If the response to the administered antibiotics is insufficient, fine- needle aspiration followed by microbiological testing allows switching to antibiotics based on resistograms. In patients with sepsis other infectious foci must be considered, such as peritonitis, cholangitis, or pneumonia. In general, microbes sampled from blood cultures of pancreatitis are often more informative than those from necrotic fluid collection because of the high rate of false negatives among the latter.

Management ofEdematous Fluid Collections

An APFC tends to regress spontaneously. If it persists longer than 4weeks under conservative treatment it may develop into a pseudocyst or WOPN. Simple intra- or extrapancreatic fluid collections, the focus of this chapter, generally do not require interventional treatment unless they give rise to compartment syndrome as characterized by fluid overload and elevated urinary bladder pressure. An abdominal compartment syndrome is defined as an

increased abdominal pressure (>20 mmHg) for longer than 12 hours and simultaneous organ failure[25].

Minimally Invasive Treatment ofAcute Fluid Collections inAcute Pancreatitis

When conservative management is unsuccessful, minimally invasive treatment is recommended. The following sections give an overview about the different modalities.

Imaging- Guided Percutaneous Drainage

This is a technically easy and well- established method to treat pseudocysts or fluid collections. Ultrasound, CT, or MRI can be used for imaging. Although single- step needle aspiration is associated with a high relapse rate, continuous catheter- drainage systems are recommended based on their high success rate (70–100%) and a low recurrence rate[26,27]. The risk of fistula formation must be considered.

Endoscopic Drainage

This method provides a minimally invasive access for draining a pseudocyst. Transpapillary and transmural approaches from the stomach or duodenum are available. The aim is to create an artificial connection between the cyst cavity and the gastrointestinal tract. For pseudocysts communicating with the pancreatic main or branch duct transpapillary techniques are to be considered[28]. However, the superiority of transpapillary vs. transmural drainage in these cases has not been established. A larger retrospective study including 375 patients from the USA with different types of PFC compared the treatment success after transmural treatment alone with combined transmural and transpapillary access with no difference in long- term resolution (69% vs. 62%; P = 0.61). The presence of duct disruption was not routinely investigated [29]. Therefore, a step-

wise diagnostic approach with duct assessment via MRI for cases with suspected duct disruption might be more promising[30].

In the authors’ view endoscopic transmural drainage is recommended for cysts that do not communicate with the pancreatic ductal system. Based on a better visualization of vessels EUS- guided drainage is associated with a lower complication rate than the endoscopic technique without EUS visualization and the latter should be abandoned[3,14,31].

For the treatment of pseudocysts with a location distant to gastric lumen and with a thick fibrotic capsule a laparoscopic approach should be favored. In Chapter3.23 the strategies for surgical and endoscopic interventions for pancreatic pseudocysts, infected necrosis, and WOPN are outlined and discussed in detail.

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