Clinical Case Summary

We present the case of a 51-year-old gentleman with von Hippel-Lindau disease and a complex surgical history involving bilateral adrenalectomy in childhood and a Whipple’s procedure for neuroendocrine tumor (NET) at 36 years of age. Surveillance imaging demonstrated recurrent paraganglioma adjacent to the left aspect of the coeliac axis and a 2 cm NET in the pancreatic tail. The paraganglioma was resected, but attempted resection of the tail was complicated by haemorrhage and had to be abandoned. He was readmitted two weeks later with abdominal pain. CT demonstrated a post operative pancreatic fluid collection which was initially managed by percutaneous drainage. This reduced the collection volume, but resulted in a chronic pancreatic fistula with daily output of 100-150 ml.
Initial attempt to drain this cavity by EUS cyst-gastrostomy proved unsuccessful due to an incomplete cavity wall precluding expansion of the cavity with saline injection. CT with contrast injection through the external drain delineated communication with the dilated main pancreatic duct (PD) and extension of the collection between the liver and gastro-jejunal anastomosis.
Previous Whipple’s procedure made ERCP challenging therefore EUS directed pancreaticogastrostomy was planned.. EUS demonstrated a dilated PD containing significant debris and calculi, particularly centrally towards the pancreatico-jejunal anastomosis. Due to the PD calculi burden it was not possible to insert sufficient wire to facilitate plastic stent insertion. Therefore an 8 mm X 8 mm lumen apposing metal stent (LAMS) was deployed from the stomach into the PD. Injection of contrast through the LAMS opacified the pancreatic duct confirming successful procedure.
The percutaneous drain output reduced to zero within two days and the patient clinically improved. The drain was removed at 4 weeks. Subsequent imaging demonstrated resolution of the collection.

References

1. Preprocedural CT demonstrating communication between the collection and the pancreatic duct.
2. EUS demonstrated dilated PD containing debris and calculi.
3. Fluoroscopic image confirming technically successful pancreaticogastrostomy
4. Follow up CT confirming resolution of percutaneous fistula and associated collection

Clinical Case Summary

Patient of 71 years old with CP was admitted for painless jaundice with benign common bile duct (CBD) stricture. ERCP failed at her center due to duodenal edema that prevented seeing the papilla so the patient was transferred to our center for assisted EUS drainage.

After after a first attempt with an unsuccessful rendezvous ERCP due to guidewire loss in the exchange of devices, cholecystoduodenostomy was performed with a coaxial double pigtail after confirmation of cystic duct permeability in the cholangiogram (previously performed under EUS guidance with puncture of the CBD to perform de rendezvous). In a second attempt to treat the stricture, a rendezvous through the gallbladder was performed. After papilloplasty and dilating the stricture, a 10 x 60 mm FCMS was placed. The patient improved and the lumen apposing metal stent of the cholecystoduodenostomy was removed. In followup, proximal migration of the stent was observed, impossible to remove by ERCP at her center due to impossibility of accessing the papilla.

In our center, a new endoscopy was performed. CBD was punctured by EUS with a 22 G needle through the biliary stent to perform a rendezvous and a novagold guidewire was advanced to the duodenum. The CBD was accessed with a monorail sphincterotome over the guidewire and rigid guidewire was advanced to the biliary tract. Papilloplasty was performed againd and the migrated stent was removed with rat tooth forceps. A new FCMS was placed successfully.

To conclude, endoscopic management of patients with CP can be very complex and several advanced combined bile duct access techniques are sometimes required. So, these patients should ideally be managed in referral centers.

Clinical Case Summary

A 90-year-old woman was referred to our endoscopy unit from another hospital for urgent rescue therapy because of impacted Dormia basket during ERCP performed for symptomatic recurrent choledochal lithiasis. In attempt to perform extracanalar lithotripsy Dormia basket was broken near the handle. Another ERCP was performed, and the contrast cholangiography showed dilated common bile duct (up to 13mm) with a constriction in the middle part and impacted Dormia basket with multiple gallstones, confirmed by Spyglass single-operator per-oral cholangioscopy with direct visualization. Electrohydraulics lithotripsy with Autolith EHL system (2437 pulses, medium-high power) was performed with stones fragmentation but Dormia basket entrapped stone fragments. Dormia basket distal margin was caught with a biopsy forceps and passed in duodenoscope working channel. Then biliary clearance was completed with ballon catheter and the following cholangiography confirmed successful biliary drainage and optimal bile outflow without contrast biliary or duodenal spreading. Postprocedural course was regular, and the patient was discharged after three days of hospitalization.

Clinical Case Summary

Introduction: Superior mesenteric artery pseudoaneurysms (SMA) are rare vascular entities, but can potentially result in significant morbidity and mortality (up to 60%) if rupture occurs. Traditionally, SMA pseudoaneurysms are associated with arterial dissection, pancreatitis, infection, trauma, tumor invasion, or arise as post-operative and iatrogenic complication.^1-8
Case report: A 51-year-old man with a medical history of chronic alcohol consumption and chronic pancreatitis presented with multiple episodes of hematemesis and hematochezia, jaundice and severe abdominal pain with a supraumbilical pulsatile mass. The patient was haemodynamically unstable (BP: 79/45 mmHg, HR: 123/min) with inadequate resuscitation despite transfusions of blood products and intravenous fluids. Laboratory tests showed significant reduction in hematocrit (Hct: 23,9%, Hb: 7,7 g/dL) and abnormal liver function tests (TBL: 7,21 mg/dL, DBL: 4,88 mg/dL, SGOT: 156 U/l, SGPT: 92 U/l, γGT: 1822 U/l, ALP: 1577 U/l). An abdominal vascular lesion was suspected and an urgent CT angiography was performed. The CT scan confirmed the presence of a ruptured superior mesenteric artery pseudoaneurysm, 11.5cm in diameter, localized inside a giant pancreatic pseudocyst (Figure A). Ultimately, as the patient was a poor surgical candidate we decided to treat him using endovascular therapy. Arterial catheterization and angiographic evaluation of the superior mesenteric artery pseudoaneurysm was performed, showing active contrast agent extravasation treated by a fully covered stent placement (Figure B). The final angiogram confirmed the the success of the intervention. The postoperative course was uneventful and the patient was discharged on the 8^th postoperative day.
Conclusions: In conclusion, physicians should keep alert to this rare etiology of haemobilia. It is of utmost importance to urgently manage SMA pseudoaneurysms because of the high risk of rupture and potential life-threatening haemorrhage.

References

1. Guirgis M, Xu JH, Kaard A, Mwipatayi BP. Spontaneous Superior Mesenteric Artery Branch Pseudoaneurysm: A Rare Case Report. EJVES Short Rep. 2017 Oct 12;37:1-4.
2. Patelis N, Doukas P, Dodos I, Karampelas T, Kanellopoulos I, Kyriakopoulou K, Bisdas T. Endovascular Repair of a Complex Isolated Dissecting Aneurysm of the Superior Mesenteric Artery. EJVES Short Rep. 2019 Jun 17;44:5-8.
3. Kochar S, Sharparis Y, Banerjee B, Karasek M, Brennan S. Endovascular Coil Embolization of Superior Mesenteric Artery Branch Pseudoaneurysm. Cureus. 2021 Sep 16;13(9):e18014.
4. Camarasa Pérez Á, Soto Sánchez A, Pérez Sánchez E, Hernández Barroso M, Hernández Hernández G, Barrera Gómez M. Obstructive jaundice secondary to a pseudoaneurysm of the superior mesenteric artery. Rev Esp Enferm Dig. 2022 Dec;114(12):756.
5. Kimbara Y, Sato Y, Hasegawa T, Morinaga H, Murata S, Imai Y, Hara K, Okuno N, Inaba Y. Covered stent placement for emergency repair of a ruptured superior mesenteric artery pseudoaneurysm in advanced pancreatic head cancer. Radiol Case Rep. 2018 Oct 29;14(1):133-135.
6. Dávila Arias C, Ruiz-Rodríguez AJ, Cabrera Peña Á. Hematochezia secondary to hemosuccus pancreaticus due to a pseudoaneurysm associated with a pancreatic pseudocyst. Rev Esp Enferm Dig. 2021 Aug;113(8):618.

Clinical Case Summary

Introduction: Pancreaticopleural fistula (PPF) is an abnormal communication between the pancreas and the pleural cavity that represents a rare complication of pancreatitis.¹ Pleural effusions can result that tend to be massive and recurrent, in the context of enduring pancreatic fluid production. As presenting symptoms and investigation are pulmonary-focused, diagnosis is often delayed, ranging from 12 to 49 days with there being no consensus on optimal management.²
Case details: A 62-year-old male presented with worsening abdominal pain, cough, dyspnea and absent breath sounds over the right lung field on examination following a recent episode of acute-on-chronic pancreatitis due to excessive alcohol consumption. Initial work-up showed neutrophilia, transaminitis, and an elevated serum lipase level of 1,720 U/L. Initial chest X-ray and computed tomography (CT) showed a massive right pleural effusion with underlying lung collapse and mediastinal shift. Diagnosis of PPF was confirmed after intercostal catheter drainage for symptomatic relief, with pleural fluid analysis showing an exudative process with elevated amylase and lipase content along with magnetic resonance imaging visualising a fistulous connection between the pleura and pancreas. Endoscopic intervention was considered but not undertaken in the absence of pancreatic ductal obstruction and consideration of procedural/case-specific risks. A solely conservatively approach of intercostal catheter drainage of reaccumulating pleural fluid was successful with serial follow-up confirming complete resolution of the pleural effusion and fistulous tract.
Conclusion: This case exemplifies the success of conservative management of PPF where an advanced endoscopic or surgical intervention is not always required, as well as the importance of tailoring management to the individual in conjunction with a multidisciplinary team.

References

1. Rockey DC, Cello JP. Pancreaticopleural fistula report of 7 patients and review of the literature. Medicine; 69: 332–344.
2. Dhebri AR, Ferran N. Nonsurgical management of pancreaticopleural fistula. Journal of the pancreas; 6(2):152-61.

Images to be included:
Figure 1: Chest radiography showing a massive right pleural effusion.
Figure 2: Magnetic resonance imaging (coronal view) showing a retroperitoneal collection.
Figure 3: Magnetic resonance imaging (axial view) showing a communication between the peripancreatic retroperitoneal fluid collection and the right pleural cavity.

Clinical Case Summary

Introduction: Acute pancreatitis may cause massive intraabdominal bleeding as vascular complications caused by the erosion of a major pancreatic or peripancreatic vessel. Although infrequent, vascular complications are the main cause of death in >50% of fatal cases of pancreatitis.^1-4
Case report: A 71-year-old male patient presented to the emergency department with abdominal pain and epigastric tenderness. Laboratory tests revealed amylasemia and a subsequent abdominal CT scan was suggestive of acute pancreatitis. The patient was treated with intravenous fluids and bowel rest and on day 7 during hospitalization he became hemodynamically unstable (BP: 80/50 mmHg, HR: 113/min) with abdominal flatulence and significant reduction in hematocrit (Hct: 35.6% à Hct: 23.0%,). Urgent CT angiography revealed acute necrotizing pancreatitis, with peri-pancreatic fluid collections accompanied by extensive hematoma collaterally to the greater and lesser curvatures of the stomach (Figure A, B), and extravasation of the contrast agent (red arrows) from bleeding branches of the left hepatic artery and left gastric artery, with massive hemoperitoneum (Figure C, D, yellow arrows). The patient underwent angiographic embolization with coils (Figure E, F) of the bleeding vessels and transferred to the intensive care unit. The patient had a short-term clinical improvement, but 6 days after embolization the patient developed acute abdomen, CT scan revealed air bubbles within the hematoma (Figure G, H, yellow arrows) and focal resolution of the continuity of the stomach wall in the lesser curvature (Figure G, H, red arrow), due to ischemia caused by the embolization. The patient underwent surgery and fortunately after several days of postoperative hospitalization he was discharged.
Conclusion: Massive bleeding from peripancreatic vessels is a rare complication of acute pancreatitis, however, it is associated with increased morbidity and mortality.

References

1. Luckhurst CM, El Hechi M, Maurer LR, Yamada K, Krishnan K, Castillo CF, Lillemoe KD, Fagenholz PJ. Treatment and Prevention of Intraabdominal Bleeding in Necrotizing Pancreatitis Patients Treated With a Step-Up Approach. Pancreas. 2022 May 1;51(5):516-522.
2. Lee SH, Yun SJ, Ryu S, Choi SW, Kim HJ, Kang TK, Oh SC, Cho SJ. Massive Bleeding From Inferior Mesenteric Vein With Hypovolemic Shock: A Rare Complication of Acute Pancreatitis. J Emerg Med. 2018 Jul;55(1):e5-e8.
3. Kreso A, Yamada K, Irani Z, Kalva S, Fagenholz P. Novel techniques for management of portal system hemorrhage in acute pancreatitis. Pancreatology. 2020 Dec;20(8):1576-1581.
4. Gupta V, Krishna P, Kochhar R, Yadav TD, Bargav V, Bhalla A, Kalra N, Wig JD. Hemorrhage complicating the course of severe acute pancreatitis. Ann Hepatobiliary Pancreat Surg. 2020 Aug 31;24(3):292-300.

Introduction

Pancreatic walled-off necrosis (WON) presents a significant challenge in acute pancreatitis management, often necessitating endoscopic intervention for drainage and necrosectomy. However, the optimal selection of stent type for endoscopic drainage remains debatable. This study aimed to evaluate the utility of the QNI classification in guiding stent selection for WON drainage.

Aims & Methods

We conducted a retrospective analysis of patients who underwent endoscopic drainage and necrosectomy for symptomatic pancreatic WON at a tertiary referral center between January 2022 and September 2023. Patients were divided into two groups based on the QNI classification: Group 1 consisted of patients who had WON affecting 1 quadrant or 2 quadrants with a necrosis of less than 30%. Group 2 consisted of patients whose WON had affected 3 quadrants, 2 quadrants with 30% necrosis, or 1 quadrant with more than 60% necrosis at the time of the index procedure. A WON-based decision was made by the endoscopist regarding the use of LAMS or plastic stents. Necrosectomy was performed in cases of infection following WON drainage. Resolution was considered in clinically asymptomatic patients with WON < 30 mm at the 3-month imaging follow-up.

Results

Forty-eight patients were included in the study, with a mean age of 55.7 (±12.28) and a male-to-female ratio of 2.4:1, 20 patients in Group 1 and 28 patients in Group 2. Except for infection, which occurred more frequently in Group 2, the indications for drainage (pain, weight loss) were similar between the two groups (28% vs 5%, p=0.03). LAMS were used more frequently in group 2 than in group 1 (64% vs 40%, p=0.001). The mean number of endoscopic procedures in Group 1 was 1.7 and in Group 2 it was 3. The interval between endoscopic procedures in Group 1 and Group 2 was 20.3 days and 12.4 days, respectively (p=0.05). Clinical resolution at 3 months showed no significant difference between groups, with rates of 90% vs 85% (p=0.87), and the complication rates was 10% vs 14.2% (p=NS). Percutaneous drainage was done in 0% vs 7.14% cases, and surgery was required in 0% vs 7.1% of cases.

Conclusion

As a result of the newly proposed QNI classification system, patients can be guided in the selection of LAMS placement as well as for multidisciplinary management. Severe QNI scores may need more aggressive interventions, yet outcomes are comparable to those with milder disease.

References

Baroud, S., Chandrasekhara, V., Storm, A. C., Law, R. J., Vargas, E. J., Levy, M. J., Mahmoud, T., Bazerbachi, F., Bofill-Garcia, A., Ghazi, R., Maselli, D. B., Martin, J. A., Vege, S. S., Takahashi, N., Petersen, B. T., Topazian, M. D., & Abu Dayyeh, B. K. (2023). Novel classification system for walled-off necrosis: a step toward standardized nomenclature and risk-stratification framework. Gastrointestinal endoscopy, 97(2), 300–308.