Pancreatic pseudocysts (PPs) present a challenging problem for physicians dealing with pancreatic disorders. Their management demands the co-operation of surgeons, radiologists and gastroenterologists. Historically, they have been treated either conservatively or surgically, with acceptable rates of complications and recurrence. However, recent advances in radiology and endoscopy, have leaded physicians to implement percutaneous and endoscopic drainage (ED) into their treatment algorithms. Moreover, laparoscopic surgery, with its advantages, has become an attractive alternative choice when surgical drainage (SD) is required. The aim of this review is to summarize the main diagnostic and therapeutic tools in the management of pseudocysts and to present the main studies that compare the three different types of pseudocyst drainage.

Objective:The ISGPS aimed to develop a universally accepted definition for PPAP for standardized reporting and outcome comparison.Background: :PPAP is an increasingly recognized complication after partial pancreatic resections, but its incidence and clinical impact, and even its existence are variable because an internationally accepted consensus definition and grading system are lacking.Methods:The ISGPS developed a consensus definition and grading of PPAP with its members after an evidence review and after a series of discussions and multiple revisions from April 2020 to May 2021.Results:We defined PPAP as an acute inflammatory condition of the pancreatic remnant beginning within the first 3 postoperative days after a partial pancreatic resection. The diagnosis requires (1) a sustained postoperative serum hyperamylasemia (POH) greater than the institutional upper limit of normal for at least the first 48 hours postoperatively, (2) associated with clinically relevant features, and (3) radiologic alterations consistent with PPAP. Three different PPAP grades were defined based on the clinical impact: (1) grade postoperative hyperamylasemia, biochemical changes only; (2) grade B, mild or moderate complications; and (3) grade C, severe life-threatening complications.Discussions:The present definition and grading scale of PPAP, based on biochemical, radiologic, and clinical criteria, are instrumental for a better understanding of PPAP and the spectrum of postoperative complications related to this emerging entity. The current terminology will serve as a reference point for standard assessment and lend itself to developing specific treatments and prevention strategies.

Seed bezoars are a subcategory of phytobezoars, caused by consumption of indigestible vegetable or fruit seeds. We present the case of a 64-year-old male patient, who presented at the Emergency Department, complaining of constipation, tenesmus and rectal pain. History and digital examination revealed a rectal seed bezoar due to sunflower seeds, impacted in the lower rectum. The patient underwent manual disimpaction under general anaesthesia, after conservative measures failed. Seed bezoars represent a different pathophysiological process compared to fibre bezoars. They are usually found in the rectum of patients without predisposing factors, causing constipation and anorectal pain. History taking and digital rectal examination are the cornerstones of diagnosis, with manual disimpaction under general anaesthesia being the procedure of choice.

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Background: Previous studies among populations at high risk of venous thromboembolism (VTE) development have demonstrated that current recommended doses for enoxaparin thromboprophylaxis are associated with high incidence of subprophylactic anti-Factor Xa (anti-Xa) levels. This study examines the efficacy and safety of dose adjusted enoxaparin guided by anti-Xa levels in pancreas surgery patients. Methods: Patients undergoing abdominal cancer surgery at single university affiliated cancer center who received at least three postoperative doses of prophylactic enoxaparin 40mg once daily and had dose adjustments based on peak anti-Xa levels to attain a target of >0.20 IU/ml were prospectively enrolled and compared to a historic cohort of patients receiving recommended enoxaparin thromboprophylaxis without anti-Xa monitoring or enoxaparin adjustment. Incidence of in-hospital VTE and major bleeding following changes in enoxaparin dosing were monitored. Results: The study population comprised 114 patients e 36 patients in the prospective intervention group and 78 patients in the historical control group. Baseline characteristic were similar between the intervention and control groups with the exception of Caprini score (8.33 vs 7.31, P=0.007). In the intervention group, 27 of 36 patients (75.0%) initially had subprophylactic peak anti-Xa levels. VTE rates were not significantly different between the intervention and control (0 [0%] vs 6 [7.69%], P=0.174), although did trend toward fewer VTE in the intervention group. There were no differences in major bleeding events (5.56% vs 2.56%; P=0.590), rate of postoperative packed red blood cell transfusion (19.4% vs 25.6%; P=0.627), or mean hemoglobin on discharge (9.74 vs 9.44g/dL, P=0.385). Within the intervention group, prophylactic anti-Xa levels positively correlated with age (68.2 vs 60.8 years, P=0.045) and negatively correlated with operating room time (233 vs 336 minutes, P=0.028) and BMI (25.2 vs 31.6, P=0.010). Conclusion: Thromboprophylactic enoxaparin 40mg daily is often associated with subprophylactic peak anti-Xa levels in pancreatic surgery patients undergoing pancreatic resection. Dose adjustment based on anti-Xa level did alter the incidence of in-hospital VTE and did not increase risk of bleeding.

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