The present study failed to provide evidence that early endoscopic intervention reduces systemic and local inflammation in patients with acute gallstone pancreatitis and biliopancreatic obstruction. If acute cholangitis can be safely excluded, early endoscopic intervention is not mandatory and should not be considered a standard indication.

A prospective study of choledocholithiasis was performed using 110 patients with presumptive diagnoses of acute gallstone pancreatitis. The incidence of migrating and persistent bile duct stones was determined using stool screening and intraoperative cholangiography, and the clinical significance of continued stone obstruction of the papilla was investigated using ultrasound assessment of migration time and a second evaluation of prognostic signs. Pancreatic inflammation was confirmed at surgery in 51 patients, of whom only 27 had stones in the stools (n = 22) or the bile duct (n = 5), suggesting that choledocholithiasis may not be the sole triggering factor of acute gallstone pancreatitis. Neither delayed migration nor persistent stone obstruction of the papilla promoted pancreatic inflammation.

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Background: Internal drainage of giant pancreatic pseudocysts secondary to acute pancreatitis is frequently complicated with postoperative retroperitoneal infection and hemorrhage. Recent data suggest that the risk factor is unrecognized pancreatic necrosis; presumably, pancreatic necrosis becomes infected with bacteria introduced by the cystoenteric anastomosis. Hypothesis: Video-assisted pancreatic necrosectomy, performed at the time of internal drainage, may prevent postoperative retroperitoneal complications in patients with giant acute pseudocysts. Design: A consecutive case-series. Setting: An urban, university-affiliated, tertiary referral center. Patients: Ten consecutive patients with acute pseudocysts measuring 10 cm or more in major diameter. The mean extent of pancreatic necrosis, as shown by contrast-enhanced computed tomography, was 50%. All patients were operated on electively, at an average time of 7.7 weeks from onset of the attack to surgical treatment. Intervention: Through a midline incision, a 4-cm opening is made at the base of the pseudocyst. Standard laparoscopic instruments are introduced into the pseudocyst and video-assisted pancreatic necrosectomy is performed. The opening is then anastomosed to a Rouxen-Y limb of the jejunum. Main Outcome Measures: Feasibility and safety of video-assisted pancreatic necrosectomy, postoperative morbidity and mortality, hospital stay, and resolution of pseudocysts. Results: Complete necrosectomy was safely performed throughout. There were neither postoperative retroperitoneal complications nor mortality. Mean hospital stay was 8.2 days and all pseudocysts resolved at a mean follow-up of 6.9 months. Conclusions: Video-assisted pancreatic necrosectomy at the time of internal drainage seems to prevent postoperativeretroperitonealcomplicationsinpatientswithgiantacute pseudocysts. Depending on appropriate surgical timing, video-assisted necrosectomy is a feasible and safe procedure.

Objectives Because infected pancreatic necrosis (IPN) has multiple presentations, not all patients are likely to benefit from the same first-line treatment. Our objective was to evaluate morbidity and mortality in a series of patients treated with a multimodal therapeutic approach. Methods Between May 2012 and May 2019, 51 patients diagnosed with IPN were treated. The 5 initial treatment alternatives were as follows: percutaneous drainage, minimally invasive necrosectomy, antibiotics alone, transgastric necrosectomy, and temporizing percutaneous/endoscopic drainage. Initial treatment selection depended on evolution, clinical condition, and extension of pancreatic necrosis. Success, morbidity, and mortality rates were determined. Results In terms of determinant-based classification, 37 were classified as severe, and 14 as critical. Percutaneous, temporizing drainage, minimally invasive necrosectomy, antibiotics alone and transgastric necrosectomy approaches were used in 21, 10, 11, 4, and 5 patients, respectively. Necrosectomy was not required in 18 patients (35%). There were no significant differences in mortality among the different treatment approaches (P < 0.45). Overall success, morbidity, and mortality rates were 68.6%, 52.9%, and 7.8%, respectively. Conclusions The multimodal approach seems to be a rational and efficient strategy for the initial treatment of IPN.