Pancreatic fluids collections are local complications related to acute or chronic pancreatitis and may require intervention when symptomatic and/or complicated. Within the last decade, endoscopic management of these collections via endoscopic ultrasound-guided transmural drainage has become the gold standard treatment for encapsulated pancreatic collections with high clinical success and lower morbidity compared to traditional surgery and percutaneous drainage. Proper understanding of anatomic landmarks, including assessment of the main pancreatic duct and any associated lesions - such as disruptions and strictures - are key to achieving clinical success, reducing the need for reintervention or recurrence, especially in cases with suspected disconnected pancreatic duct syndrome. Additionally, proper review of imaging and anatomic landmarks, including collection location, are pivotal to determine type and size of pancreatic stenting as well as approach using long-term transmural indwelling plastic stents. Pancreatography to adequately assess the main pancreatic duct may be performed by two methods: Either non-invasively using magnetic resonance cholangiopancreatography or endoscopically via retrograde cholangiopan-creatography. Despite the critical need to understand anatomy via pancrea-tography and assess the main pancreatic duct, a standardized approach or uniform assessment strategy has not been described in the literature. Therefore, the aim of this review was to clarify the role of pancreatography in the endoscopic management of encapsulated pancreatic collections and to propose a new classification system to aid in proper assessment and endoscopic treatment.

Acute pancreatitis complicated by walled-off necrosis (WON) is associated with high morbidity and mortality, and if infected, typically necessitates intervention. Clinical outcomes of infected WON have been described as poorer than those of symptomatic sterile WON. With the evolution of minimally invasive therapy, we sought to compare outcomes of infected to symptomatic sterile WON.

We performed a retrospective cohort study examining patients who were undergoing dual-modality drainage as minimally invasive therapy for WON at a high-volume tertiary pancreatic center. The main outcome measures included mortality with a drain in place, length of hospital stay, admission to intensive care unit, and development of pancreatic fistulae.

Of the 211 patients in our analysis, 98 had infected WON. The overall mortality rate was 2.4%. Patients with infected WON trended toward higher mortality although not statistically significant (4.1% vs 0.9%, p=0.19). Patients with infected WON had longer length of hospitalization (29.8 days vs 17.3 days, p<0.01), and developed more spontaneous pancreatic fistulae (23.5% vs 7.8%, p<0.01). Multivariate analysis showed that infected WON was associated with higher odds of spontaneous pancreatic fistula formation (odds ratio, 2.65; 95% confidence interval, 1.20 to 5.85).

This study confirms that infected WON has worse outcomes than sterile WON but also demonstrates that WON, once considered a significant cause of death, can be treated with good outcomes using minimally invasive therapy.

It is rare to encounter massive hemothorax as a complication of pancreatic pseudocyst. In addition, as no obvious hypotension and abdominal discomfort were noted, it was difficult to consider gastrointestinal lesion a possibility.

A 54-year-old Taiwanese man had tightness on the left side of his chest and shortness of breath for 3 days. He had a history of acute pancreatitis 3 months ago. After history taking and a series of examinations including thoracocentesis and computed tomography of his abdomen and chest, the diagnosis was finally confirmed based on the high amylase levels in his pleural fluid.

Treatment with distal pancreatectomy and splenectomy was subsequently successfully performed. Based on our experience, we briefly discuss the currently available treatment options for pancreatic pseudocyst.

Pancreaticocolonic fistulas (PCFs) are uncommon complications of acute necrotizing pancreatitis (ANP). Studies advocating primary surgical treatment showed severe morbidity and mortality with nonsurgical treatment, with survival rates of approximately 50%. However, a nonsurgical treatment scheme with primary percutaneous drainage and other interventions may show improved outcomes. This retrospective single-center study describes the presentation, diagnosis, course, treatment strategy, and outcome of successfully treated PCFs, with an emphasis on nonsurgical interventions.

Twenty patients with PCFs caused by ANP were treated with percutaneous drainage and medical therapy. Additional interventions included endoscopic transenteric drainage and pancreatic duct (PD) stent placement. Surgery was reserved for patients in whom this nonsurgical management failed.

All PCFs closed during a median follow-up of 56 days (mean, 106 d; range, 13-827 d). Treatment included percutaneous drainage of the PCF-related collection in all patients, PD stents in 60%, transenteric drainage in 15%, and definitive surgery in 15%. Indications for surgery included severe PCF-related symptoms, large feculent peritoneal collection, and colonic stricture. Two patients (10%) died, one of complications of ANP and one of esophageal carcinoma. Additional enteric fistulas were identified in 50% of patients. Median time from the most recent diagnosis of pancreatitis to PCF diagnosis was 89 days (mean, 113 d; range, 13-394 d).

A nonsurgical approach to PCFs caused by ANP, including percutaneous drainage and other techniques, yields good survival, with surgery reserved for cases in which this approach fails.

The advent of computed tomographic scan with its wide use in the evaluation of acute pancreatitis has opened up a new topic in pancreatology i.e. fluid collections. Fluid collections in and around the pancreas occur often in acute pancreatitis and were defined by the Atlanta Symposium on Acute Pancreatitis in 1992. Two decades since the Atlanta Conference additional experience has brought to light the inadequacy and poor understanding of the terms used by different specialists involved in the care of patients with acute pancreatitis when interpreting imaging modalities and the need for a uniformly used classification system. The deficiencies of the Atlanta definitions and advances in medicine have led to a proposed revision of the Atlanta classification promulgated by the Acute Pancreatitis Classification Working Group. The newly used terms "acute peripancreatic fluid collections," "pancreatic pseudocyst," "postnecrotic pancreatic/peripancreatic fluid collections," and "walled-off pancreatic necrosis" are to be clearly understood in the interpretation of imaging studies. The current treatment methods for fluid collections are diverse and depend on accurate interpretations of radiologic tests. Management options include conservative treatment, percutaneous catheter drainage, open and laparoscopic surgery, and endoscopic drainage. The choice of treatment depends on a correct diagnosis of the type of fluid collection. In this study we have attempted to clarify the management and clinical features of different types of fluid collections as they have been initially defined under the 1992 Atlanta Classification and revised by the Working Group's proposed categorization.

This prospective study aimed at evaluating dynamic computed tomography (CT) as a prognostic indicator of local complications in patients with pancreatic necrosis.

We analyze the relationship between the anatomic pattern of pancreatic necrosis at dynamic CT (pancreatic necrosis, peripancreatic necrosis, and transparenchymal necrosis) and the development of local complications (infected pancreatic necrosis and pseudocyst).

One hundred thirty-eight patients were included in the study. Nine patients were excluded, and 86 required surgery. Average time from the onset of symptoms to dynamic CT was 8.3 days. Multivariate analysis identified the following prognostic factors for local complications: (1) extent of pancreatic necrosis (odds ratio [OR], 7.32; 95% confidence interval [CI], 1.32-23.76; P = 0.015) and presence of peripancreatic necrosis (OR, 37.32; 95% CI, 3.77-369.38; P = 0.002) were useful to predict the development of infected pancreatic necrosis; and (2) transparenchymal necrosis with upstream viable (enhancing) pancreas (OR, 36.22; 95% CI, 3.18-412.36; P = 0.004) and no peripancreatic necrosis (OR, 0.016; 95% CI, 0.004-0.62; P < 0.001) were associated with pseudocyst development.

Dynamic CT prognostic factors useful to predict local complications in patients with pancreatic necrosis were the extent of pancreatic necrosis, presence of peripancreatic necrosis, and the finding of transparenchymal necrosis with upstream viable (enhancing) pancreas.

The treatment of severe pancreatitis and its complications is rapidly evolving because of increasing clinical application of effective, minimally invasive techniques. With ongoing innovations in therapeutic endoscopy, image-guided percutaneous techniques, and minimally invasive surgery, the long-standing traditional management algorithms have recently changed. A multidisciplinary approach is necessary for the treatment of complicated inflammatory diseases of the pancreas and benign periampullary tumors. Surgeons, gastroenterologists, and therapeutic radiologists combine expertise as members of a team to offer their patients improved outcomes and faster recovery.

In 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.

A 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.

A 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.

The 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.

In patients with severe acute pancreatitis, the percentage of necrosis of pancreatic glandular parenchyma is an important predictor of prognosis. However, little attention has been paid to necrosis of ductal epithelium, which may result in disconnection of the main pancreatic duct. In pancreatic duct disconnection, a viable segment of the pancreatic body or tail is isolated from the gastrointestinal tract; the result is a persistent end fistula, that is, an uncontrolled leak of pancreatic secretions into peripancreatic spaces without communication to the gastrointestinal tract. The authors present their experience with clinical and radiologic follow-up of 85 patients with necrotic pancreatitis who either did (n = 46) or did not (n = 39) have pancreatic duct disconnection at surgery. Confident preoperative diagnosis of a disconnected duct requires both imaging tests (computed tomography or magnetic resonance imaging) and pancreatography. However, not all peripancreatic collections signify ductal disconnection, and imaging has poor accuracy in differentiation between pancreatic and peripancreatic necrosis. Early recognition of disconnected pancreatic duct obviates unnecessary and potentially harmful drainage procedures.

Severe acute pancreatitis (SAP) develops in about 25% of patients with acute pancreatitis (AP). Severity of AP is linked to the presence of systemic organ dysfunctions and/or necrotizing pancreatitis pathomorphologically. Risk factors determining independently the outcome of SAP are early multi-organ failure, infection of necrosis and extended necrosis (>50%). Up to one third of patients with necrotizing pancreatitis develop in the late course infection of necroses. Morbidity of SAP is biphasic, in the first week strongly related to early and persistence of organ or multi-organ dysfunction. Clinical sepsis caused by infected necrosis leading to multi-organ failure syndrome (MOFS) occurs in the later course after the first week. To predict sepsis, MOFS or deaths in the first 48-72 h, the highest predictive accuracy has been objectified for procalcitonin and IL-8; the Sepsis-Related Organ Failure Assessment (SOFA)-score predicts the outcome in the first 48 h, and provides a daily assessment of treatment response with a high positive predictive value. Contrast-enhanced CT provides the highest diagnostic accuracy for necrotizing pancreatitis when performed after the first week of disease. Patients who suffer early organ dysfunctions or at risk of developing a severe disease require early intensive care treatment. Early vigorous intravenous fluid replacement is of foremost importance. The goal is to decrease the hematocrit or restore normal cardiocirculatory functions. Antibiotic prophylaxis has not been shown as an effective preventive treatment. Early enteral feeding is based on a high level of evidence, resulting in a reduction of local and systemic infection. Patients suffering infected necrosis causing clinical sepsis, pancreatic abscess or surgical acute abdomen are candidates for early intervention. Hospital mortality of SAP after interventional or surgical debridement has decreased in high volume centers to below 20%.

Pseudocysts complicate acute pancreatitis in less than 5% of cases and chronic pancreatitis in 20% to 40% of cases. A pseudocyst is a localized collection of pancreatic fluid surrounded by a wall of granulation tissue and collagen. It takes 4 to 6 weeks for a fluid collection to mature and become a true pseudocyst. Unlike other cystic lesions of the pancreas from which they should be differentiated, pseudocysts lack an epithelial layer. Patients with pseudocysts present with a range of symptoms and signs. Pseudocysts are imaged using transabdominal ultrasound, CT, endoscopic ultrasound (EUS), and MRI. EUS confers an advantage over other imaging modalities in that certain EUS features are suggestive of pseudocysts over other cystic lesions. The diagnostic accuracy of EUS has improved further with the use of EUS-guided fine-needle aspiration. Therapeutic options include watchful observation or intervention. In our opinion, if acute pseudocysts are uncomplicated, asymptomatic, and do not appear to be enlarging on serial imaging, it is preferable to withhold intervention because many of these cysts resolve spontaneously. However, one needs to beware of the possibility of complications such as infection in unresolved pseudocysts. Pseudocysts associated with chronic pancreatitis are less likely to resolve spontaneously and are drained by intervention more frequently. Of the three interventional options, namely endoscopic, percutaneous, and surgical drainage, endoscopic drainage should be the treatment of choice if certain criteria are met. Preinterventional endoscopic retrograde cholangiopancreatography is mandatory to define ductal anatomy. If there is communication between the pseudocyst and the pancreatic duct, a transpapillary approach is preferred. Use of EUS should increase the number of cases in which pseudocysts can be drained endoscopically. Surgery should be reserved for cases in which there is a concern about malignancy or when there is glandular disruption.

The end result of leakage of pancreatic juice into the peripancreatic space can be sterile necrosis, infected necrosis, or rupture into an adjacent hollow viscus or blood vessel (eg, colon, small bowel, or pseudoaneurysm). If a pancreatic duct (PD) leak is present, should treatment be aimed at minimizing the sequela of the leakage of pancreatic juice and not just supportive observation until a necrosectomy is required?

In 144 patients with severe pancreatitis we investigated whether the presence of a PD leak was associated with necrosis and also asked if PD leak might predict other outcomes such as a length of stay (LOS), mortality, and need for surgery. Furthermore, we questioned whether the use of endoscopic retrograde cholangiopancreatography (ERCP) to search for a PD leak might worsen the clinical outcome because of the potential for introducing microorganisms into an undrained space or exacerbating pancreatitis.

The presence of a demonstrable pancreatic duct leak was observed in 37% of patients and was significantly associated with both a higher incidence of necrosis and prolonged LOS (> or = 20 days). These patients were 3.4 times more likely to have necrosis and 2.6 times more likely to have a prolonged LOS. When treated with a combination of percutaneous drains, pancreatic duct stents, and surgery as necessary, a PD leak (even with its higher necrosis rate) was not significantly correlated with either mortality or the need for necrosectomy. The use of ERCP was not associated with LOS, mortality, or the need for necrosectomy, provided discovered PD leaks were immediately drained.

A PD leak is common in patients with pancreatic necrosis but it is also important to locate and decompress in order to impede progression of the disease and keep mortality low.

To evaluate the prevalence of pancreatic pseudocyst after persistent fistula closure with somatostatin or octreotide. To compare the patient characteristics according to the subsequent presence or absence of pseudocyst.

This retrospective study from January 1994 to August 1999 included 15 patients with an external pancreatic fistula. Fistula closure was observed for all patients with somatostatin or octreotide. CT scan was performed 66 +/- 34 days after the end of this treatment.

CT scan was normal in 9 patients (favorable group) and showed pancreatic pseudocyst (failure group) in 6 patients. Pancreatic fistula etiologies were different between the two groups. The 5 patients presenting pancreatic fistula after duodenopancreatectomy belonged to the favorable group. Six of the 10 patients presenting pancreatic fistula after pseudocyst drainage belonged to the failure group. There were no other differences between the two groups.

Persistent pancreatic fistula can be cured with somatostatin or octreotide. However, fistulas occurring after duodenopancreatectomy are more easily cured with somatostatin or octreotide than fistulas occurring after external pseudocyst drainage. Somatostatin or octreotide cannot be considered to be an effective treatment for pancreatic fistula occurring after pseudocyst drainage, despite the fact that 40% of them were permanently cured.

Endoscopic retrograde cholangiopancreatography (ERCP) has been used for diagnosis and treatment of pancreatic diseases for over 20 years. ERCP has been most intensely investigated for acute biliary pancreatitis. Randomized trials have proven that its use will decrease morbidity and have suggested a decrease in mortality for patients with severe gallstone pancreatitis. ERCP is also valuable in detecting and treating main pancreatic duct leaks with transpapillary stenting. Symptomatic pseudocysts, which may be seen in either acute or chronic pancreatitis, can be drained via the papilla or through creation of a cystogastrostomy or cystoduodenostomy with a needle-knife sphincterotome. Endoscopic treatment of patients with recurrent acute pancreatitis presumed due to pancreas divisum and sphincter of Oddi dysfunction remains controversial. Dominant pancreatic strictures or calculi in the setting of chronic pancreatitis may be treated with stenting and removal of calculi to improve abdominal pain. Finally, diagnosis of pancreatic cancer by brush cytology and palliative management of biliary obstruction with various plastic and expandable metal sents have simplified management of this difficult problem.