INTRODUCTION:Irreversible electroporation (IRE) is a form of non-thermal ablation that delivers pulses of high-voltage electric current between electrodes. Although IRE has been demonstrated to achieve tumor necrosis, its role in the treatment of colorectal hepatic metastases is unestablished. This study is an international questionnaire survey on the use of IRE for patients with colorectal hepatic metastases. METHODS:A questionnaire addressing views on the use of IRE for colorectal liver metastases was circulated to clinicians with an interest and/or expertise in this technique. The questionnaire addressed indications for the use of IRE in a range of scenarios: methods of use, assessment of treatment response, and outcome. RESULTS:64 clinicians from 17 different countries replied to the questionnaire. The preferred mode of delivery of IRE was percutaneous treatment under computed tomographic guidance. Thirty-three (70% of 47 respondents) used IRE exclusively for lesions in proximity to inflow or outflow structures. Twenty (43% respondents) used IRE as their sole ablative treatment, while 19 (40% of 47 respondents) used IRE in combination with thermal ablation. The maximum number of lesions that could be treated by IRE was two and the preferred size of lesion was <3 cm. CONCLUSION:Respondents to this international questionnaire survey indicate that IRE is an acceptable ablative option for small colorectal liver metastases (<3 m in diameter) close to inflow/outflow structures.

Abstract Background Symptomatic pancreatic pseudocysts or walled off necrosis following pancreatitis can be drained via a stoma from the collection to the GI tract, this is typically facilitated by endoscopic stents. These stents are left in-situ until the area has drained, this can take several months. The stent is then ideally removed endoscopically. Little is known about the consequences of failed endoscopic stent removal or factors contributing to this failure. Methods Retrospective analysis of prospective data at LUHFT between 1st January 2018 and 31st December 2019 of patients receiving at least one Hot Axios stent for management of pancreatic collection. Normally distributed data were compared using Student’s two tailed T test, with non-parametric data compared using Mann-Witney U test, categorical data were analysed using Chi2 test Results 131 patients were included in analysis, of which 74 were male with a median age of 56 years (IQR 46-66.5). Failure of endoscopic removal (14 patients) was associated with a longer time to removal; 101 days (IQR 78-121) to first attempt vs. 49 days (IQR 19-104) to first endoscopic attempt where the stent was successfully retrieved endoscopically (p < 0.01). Surgical removal was undertaken in 6 patients, with significant morbidity in 2 of 6 patients. Overall 90-day mortality in patients undergoing Hot Axios stent placement was 8 of 131 (6%). Conclusions Endoscopic stent removal fails more frequently in patients where the stent has remained in situ for a long time before removal is attempted. Surgical removal of Hot Axios Stents is associated with significant morbidity, and this should be balanced against the as yet unknown consequences of leaving Hot Axios stent in-situ permanently.

Objectives:. To assess both individual patient and institutional costs as well as outcomes in patients with pancreatic necrosis who underwent either endoscopic, minimal access or open pancreatic necrosectomy. These data can be used to evaluate clinical effectiveness with a view to informing local healthcare providers. Background:. Intervention for infected pancreatic necrosis is associated with a high morbidity, mortality, and long hospital stays. Minimal access surgical step-up approaches have been the gold standard of care; however, endoscopic approaches are now offered preferentially. Methods:. All patients undergoing endoscopic (EN), minimal access retroperitoneal (MARPN), and open (OPN) necrosectomy at a single institution from April 2015 to March 2017 were included. Patients were selected for intervention based on morphology and position of the necrosis and on clinical factors. Patient-level costing systems were used to determine inpatient and outpatient costs. Results:. Eighty-six patients were included: 38 underwent EN, 35 MARPN, and 13 OPN. Preoperative APACHEII was 6 versus 9 versus 9 (P = 0.017) and CRP 107 versus 204 versus 278 (P = 0.012), respectively. Postoperative stay was 19 days for EN versus 41 for MARPN versus 42 for OPN (P = 0.007). Complications occurred in 68.4%, 68.6%, and 46.2% (P = 0.298), whereas mortality was 10.5%, 22.9%, and 15.4% (P = 0.379), respectively. Mean total cost was £31,364 for EN, £52,770 for MARPN (P = 0.008), and £60,346 for OPN. Ward and critical care costs for EN were lower than for MARPN (ward: £9430 vs £14,033, P = 0.024; critical care: £5317 vs £16,648, P = 0.056). Conclusions:. EN was at least as safe and effective as MARPN and OPN and was associated with markedly reduced hospital stay and cost, although some markers of disease severity were higher in patients undergoing MARPN and OPN. These results support EN as the preferred approach to necrosectomy, but hybrid utilization of all available techniques remains integral to optimal outcomes.

Idiopathic granulomatous mastitis (GM) is an uncommon chronic benign disease of the breast that is challenging to clinically distinguish from malignancy. However, it is unusual to diagnose GM concurrently with carcinoma in the same breast and rarer still to encounter GM and malignancy in contralateral breasts. We describe the case of a 39-year-old female who presented with right multifocal breast cancer and left granulomatous mastitis, discuss complexities in her management plan and review the literature on this unusual concurrent condition.

4505 Background: Patients with borderline resectable pancreatic cancer have poor survival and low resection rates. Neoadjuvant therapy may improve the outcome for these patients. The aim of this trial was to determine the feasibility and efficacy of a comparison of immediate surgery versus neoadjuvant GEMCAP or FOLFIRINOX or CRT. Methods: Eligible patients with NCCN defined borderline resectable (following central review of the baseline CT scan) and biopsy proven pancreatic cancer were randomised (stratified by centre) to receive immediate surgery, or neoadjuvant therapy of either 2 cycles of GEMCAP, or 4 cycles of FOLFIRINOX or 50.4Gy capecitabine-based CRT in 28 daily fractions over 5 ½ weeks. Patients were restaged at 4-6 weeks and underwent surgical exploration if still borderline resectable. Resected patients received adjuvant therapy. Follow up was 12 months. There was quality assurance of surgery and CRT. Primary endpoints were recruitment rate and resection rate (R1/R0). Secondary endpoints included overall survival and toxicity. A target of 90 patients was set to determine feasibility and resection rates. Rates will be presented as point estimates and survival compared across treatment arms using a log-rank test. Analyses will be on an ITT basis. Results: Between August 2014 and December 2018, 90 patients were randomised with 88 included in the full analysis set (32 immediate surgery, 20 GEMCAP, 20 FOLFIRINOX, 16 CRT). Median age was 63 years, 44% were men. WHO performance status was 0 and 1 in 45% and 55% respectively. Median CA19-9 was 603 kU/L at baseline. 44 (79%) patients completed neoadjuvant therapy. Recruitment rate was 21 patients per year. Resection rate was 62% for immediate surgery and 55% for neoadjuvant therapy (p=0.668). R0 resection rate on resected patients was 15% and 23% respectively (p=0.721). One year survival rate was 40% [95% CI, 26% – 62%] for immediate surgery and 77% [95%CI, 66% - 89%] for neoadjuvant therapy. Log-rank analysis showed an HR=0.27 [95% CI, 0.13 – 0.55]; χ2 (1) = 14.91, P<0.001. 9 out of the 51 neoadjuvant patients included in the safety set reported 12 serious adverse events of grade 3 or above. Conclusions: There was no difference in resection rate between arms, however neoadjuvant therapy had a significant survival benefit compared with immediate surgery. Clinical trial information: 89500674 .

Introduction The use of fully covered metal stents (FCSEMS) and specifically designed lumen apposing metal stents (LAMS) for transmural drainage of peri-pancreatic fluid collections has become widespread. A systematic review published in 20151 did not support the routine use of metal stents for drainage of pancreatic fluid collections. However, recent studies have shown conflicting data; therefore a systematic review and meta-analysis was performed. Method We conducted a Pubmed search for English language original comparative studies between plastic and metal stents from January 2014 to January 2017. The random effects model was used to calculate pooled risk ratios (RR) with 95% confidence intervals (CI). Outcomes analysed were clinical success, defined as near complete or complete resolution of the pseudocyst on imaging, adverse events and requirement of further intervention. Results The search identified 183 studies, 6 studies2-7 with 592 (284 metal, 308 plastic) patients met inclusion criteria and were included in the meta-analysis. Clinical success was achieved in 96.1% vs 87.5%, in the metal and plastic groups respectively, RR 1.08 [95% CI 1.01–1.15], I2=38.1%. The rate of adverse events was 10.7% for metal stents vs 26.6% for plastic, RR 0.43 [95% CI 0.21–0.88], I2=53.5%. Further intervention was required in 18.2% of patients in the metal stent group vs 27.3% RR 0.61 [95% CI 0.22–1.71], I2= 73.6%. Conclusion Metal stent usage for drainage of peripancreatic fluid collections improves clinical outcomes and reduces adverse events. References . Bang J, et al. Dig Endosc2015;27(4):486–98. . Lee B, et al. Endoscopy2014;46(12):1078–84. . Mukai S, et al. Endoscopy2015;47(1):47–55. . Bang J, et al. Dig Endosc2017;29(1):83–90. . Bapaye A, et al. Dig Endosc2017;29(1):104–110. . Ang T, et al. Endosc Ultrasound2016;(5): 320–7. . Sharaiha R, et al. Gastrointest Endosc2015;82(5):822–7. Disclosure of Interest None Declared

To retrospectively review outcomes in patients treated for colorectal liver metastases with DEBIRI.

Insulinomas are predominantly benign (~90%), pancreatic neuroendocrine tumours characterized by hyperinsulinaemic hypoglycaemia. They usually present as a small (<2 cm), well-demarcated, solitary nodule that can arise in any part of the organ. Treatment for sporadic insulinomas is generally aimed at curative surgical resection with special consideration in genetic syndromes. Patients with significant hypoglycaemia can pose a difficult management challenge. In isolated cases where the patient is not medically fit for surgery or with metastatic spread, other treatment options are employed. Medical therapy with diazoxide or somatostatin analogues is commonly used first line for symptom control, albeit with variable efficacy. Other medical options are emerging, including newer targeted biological therapies, including everolimus (an mTOR inhibitor), sunitinib (a tyrosine kinase inhibitor) and pasireotide, a multisomatostatin receptor ligand. Pasireotide and everolimus both cause hyperglycaemia by physiological mechanisms synergistic with its antitumour/antiproliferative effects. Minimally invasive treatment modalities such as ethanol ablation are available in selected cases (particularly in patients unfit for surgery), peptide receptor radionuclide therapy (PRRT) can effectively control tumour growth or provide symptomatic benefit in metastatic disease, while cytotoxic chemotherapy can be used in patients with higher-grade tumours. This review considers the developments in the medical and other nonsurgical management options for cases refractory to standard medical management. Early referral to a dedicated neuroendocrine multidisciplinary team is critical considering the array of medical, oncological, interventional radiological and nuclear medical options. We discuss the evolving armamentarium for insulinomas when standard medical therapy fails.

BACKGROUND:Pancreatic cancer diagnosis and staging can be difficult in 10-20% of patients. Positron emission tomography (PET)/computed tomography (CT) adds precise anatomical localisation to functional data. The use of PET/CT may add further value to the diagnosis and staging of pancreatic cancer. OBJECTIVE:To determine the incremental diagnostic accuracy and impact of PET/CT in addition to standard diagnostic work-up in patients with suspected pancreatic cancer. DESIGN:A multicentre prospective diagnostic accuracy and clinical value study of PET/CT in suspected pancreatic malignancy. PARTICIPANTS:Patients with suspected pancreatic malignancy. INTERVENTIONS:All patients to undergo PET/CT following standard diagnostic work-up. MAIN OUTCOME MEASURES:The primary outcome was the incremental diagnostic value of PET/CT in addition to standard diagnostic work-up with multidetector computed tomography (MDCT). Secondary outcomes were (1) changes in patients' diagnosis, staging and management as a result of PET/CT; (2) changes in the costs and effectiveness of patient management as a result of PET/CT; (3) the incremental diagnostic value of PET/CT in chronic pancreatitis; (4) the identification of groups of patients who would benefit most from PET/CT; and (5) the incremental diagnostic value of PET/CT in other pancreatic tumours. RESULTS:Between 2011 and 2013, 589 patients with suspected pancreatic cancer underwent MDCT and PET/CT, with 550 patients having complete data and in-range PET/CT. Sensitivity and specificity for the diagnosis of pancreatic cancer were 88.5% and 70.6%, respectively, for MDCT and 92.7% and 75.8%, respectively, for PET/CT. The maximum standardised uptake value (SUVmax.) for a pancreatic cancer diagnosis was 7.5. PET/CT demonstrated a significant improvement in relative sensitivity (p = 0.01) and specificity (p = 0.023) compared with MDCT. Incremental likelihood ratios demonstrated that PET/CT significantly improved diagnostic accuracy in all scenarios (p < 0.0002). PET/CT correctly changed the staging of pancreatic cancer in 56 patients (p = 0.001). PET/CT influenced management in 250 (45%) patients. PET/CT stopped resection in 58 (20%) patients who were due to have surgery. The benefit of PET/CT was limited in patients with chronic pancreatitis or other pancreatic tumours. PET/CT was associated with a gain in quality-adjusted life-years of 0.0157 (95% confidence interval -0.0101 to 0.0430). In the base-case model PET/CT was seen to dominate MDCT alone and is thus highly likely to be cost-effective for the UK NHS. PET/CT was seen to be most cost-effective for the subgroup of patients with suspected pancreatic cancer who were thought to be resectable. CONCLUSION:PET/CT provided a significant incremental diagnostic benefit in the diagnosis of pancreatic cancer and significantly influenced the staging and management of patients. PET/CT had limited utility in chronic pancreatitis and other pancreatic tumours. PET/CT is likely to be cost-effective at current reimbursement rates for PET/CT to the UK NHS. This was not a randomised controlled trial and therefore we do not have any information from patients who would have undergone MDCT only for comparison. In addition, there were issues in estimating costs for PET/CT. Future work should evaluate the role of PET/CT in intraductal papillary mucinous neoplasm and prognosis and response to therapy in patients with pancreatic cancer. STUDY REGISTRATION:Current Controlled Trials ISRCTN73852054 and UKCRN 8166. FUNDING:The National Institute for Health Research Health Technology Assessment programme.

Background: The optimal management approach to pancreatic serous cystic neoplasms (SCNs) is still evolving. Methods: Consecutive patients with SCN managed at the Liverpool Pancreas Cancer Centre between 2000 and 2013 were retrospectively reviewed. Results: There were 64 patients consisting of 39 women (60.9%) and 25 men (39.1%). Forty-seven patients (73.4%) had surgical removal and 17 (26.6%) were observed. The possibility of a non-SCN malignancy was the predominant indication for resection in 27 (57.4%) patients. Postoperative morbidity occurred in 26 (55.3%) patients with 2 (4.3%) deaths. An increased risk of resection was associated with patient's age (p = 0.011), diagnosis before 2009 (p < 0.001), pain (p = 0.043), possibility of cancer (p = 0.009) and a solid SCN component on imaging (p = 0.002). Independent factors associated with resection were a diagnosis before 2009 (p = 0.005) and a solid SCN component (p < 0.001). Independent factors associated with shorter time to surgical resection were persistent pain (p = 0.003) and a solid SCN component (p = 0.007). Conclusion: There was a reduction in the proportion of resections with the application of an observe-only policy for asymptomatic patients with more definite features of SCN. Improved criteria are still required in the remainder of patients with uncertain features of SCN in deciding for intervention or surveillance.

OBJECTIVES:Individuals from hereditary pancreatitis (HP) and familial pancreatic cancer (FPC) kindreds are at increased risk of developing pancreatic cancer. Premalignant molecular changes may be detected in pancreatic juice collected by endoscopic retrograde cholangiopancreatography (ERCP). The objective was to determine the risk of post-ERCP pancreatitis (PEP). METHODS:A prospective study (1999-2013) was undertaken of 80 ERCPs (24 in HP and 56 in FPC) from 60 individuals and the impact of PEP prophylaxis using a self-expelling pancreatic stent and 50 mg diclofenac per rectum from 2008. RESULTS:There was no PEP in the HP cohort and 13 (23.2%) PEP from 56 procedures in the FPC cohort (P = 0.0077). Up to 2008 PEP had occurred in 7 (43.8%) of 16 procedures in FPC individuals versus none of 18 procedures in HP individuals (P = 0.0021). After the introduction of prophylaxis, the incidence of PEP fell to 6 (15.0%) of 40 procedures in FPC individuals (P = 0.0347).The odds ratio (95% confidence interval) was 0.23 (0.06-0.84) in favor of prophylaxis (0.035). CONCLUSIONS:Individuals with HP are at minimal risk for PEP. Although the risk of PEP in individuals with FPC can be reduced by using prophylactic self-expelling stents and diclofenac, it remains too high for routine screening.

Objective:To examine the outcomes from minimal access retroperitoneal pancreatic necrosectomy (MARPN) and open pancreatic necrosectomy (OPN) for severe necrotizing pancreatitis in a single center.Background:The optimal management of severe pancreatic necrosis is evolving with a few large center single series.Methods:Between 1997 and 2013, patients with necrotizing pancreatitis at the Liverpool Pancreas Center were reviewed. Outcome measures were retrospectively analyzed by intention to treat.Results:There were 394 patients who had either MARPN (274, 69.5%) or OPN (120, 30.5%). Complications occurred in 174 MARPN patients (63.5%) and 98 (81.7%) OPN patients (P<0.001). OPN was associated with increased postoperative multiorgan failure [42 (35%) vs 56 (20.4%), P=0.001] and median (inter-quartile range) Acute Physiology and Chronic Health Evaluation II score 9 (6-11.5) vs 8 (5-11), P<0.001] with intensive care required less frequently in MARPN patients [40.9% (112) vs 75% (90), P<0.001]. The mortality rate was 42 (15.3%) in MARPNs and 28 (23.3%) in OPNs (P=0.064). Both the mortality and the overall complication rates decreased between 1997-2008 and 2008-2013 [49 (23.8%) vs 21 (11.2%) P=0.001, respectively; and 151 (73.3%) vs 121 (64.4%), P=0.080, respectively). Increased mortality was independently associated with age (P<0.001), preoperative intensive care stay (P=0.014), and multiple organ failure (P<0.001); operation before 2008 (P<0.001) and conversion to OPN (P=0.035). MARPN independently reduced mortality odds risk (odds ratio=0.27; 95% confidence interval=0.12-0.57; P<0.001).Conclusions:Increasing experience and advances in perioperative care have led to improvement in outcomes. The role of MARPN in reducing complications and deaths within a multimodality approach remains substantial and should be used initially if feasible.

Endoscopic ultrasonography (EUS)-guided choledochoduodenostomy (CDS) is an alternative to percutaneous transhepatic cholangiography (PTC) drainage in patients with an obstructed biliary system where conventional endoscopic retrograde biliary drainage (ERBD) has been unsuccessful.Five EUS-CDS procedures were reviewed to assess whether successful decompression was achieved and maintained.There was technical success in each instance with no immediate complications. There was a significant fall in the median bilirubin of 164 mmol/l. The median follow-up was 44 days. In one patient the stent migrated with no adverse outcome.EUS-CDS is a viable alternative to PTC with fewer complications and comparable success rates. EUS-CDS may offer a future route for novel therapeutic advances.

Question: A 74-year-old man with cirrhosis (Child–Pugh class A, score 5) was admitted for treatment of a 4.5-cm hepatocellular carcinoma with combined radiofrequency ablation and drug-eluting beads transcatheter arterial chemoembolization (DEB-TACE). During the procedure, a 7-cm ablation was performed under ultrasound guidance followed by TACE using a total of 75 mg doxorubicin beads administered selectively into branches of the right and middle hepatic arteries. The next day, the patient complained of severe abdominal pain. Physical examination revealed tachycardia and generalized abdominal tenderness without rebound or guarding. Laboratory tests were as follows: Serum amylase, 1223 U/L (normal, 0–50); C-reactive protein, 120 mg/L (normal, 0–5); and lactate, 3 mmol/L (normal, 0.5–2.2). Contrast-enhanced abdominal computed tomography (CT) was performed (Figure A). He was managed conservatively. Two weeks after the procedure he deteriorated with evidence of sepsis and Enterococcus foecalis grown on blood cultures. Abdominal CT was repeated (Figure B). Despite initial clinical improvement with treatment, 5 weeks after the DEB-TACE he developed further pyrexia with increasing severe abdominal pain. A repeat abdominal CT was performed (Figure C). What is the diagnosis? Look on page 2277 for the answer and see the Gastroenterology web site (www.gastrojournal.org) for more information on submitting your favorite image to Clinical Challenges and Images in GI. Figure A shows acute pancreatitis (black arrow) and duodenitis (white arrow) owing to reflux of DEB into the gastroduodenal artery. Figure B shows pancreatic necrosis (black arrow) with a subhepatic and peripancreatic collection (white arrowhead), and evidence of duodenal perforation (air is seen tracking into the fluid collections; white arrow). Figure C shows an inflamed gallbladder with a thickened, necrosed wall and localized perforation (white arrows). The patient was initially treated with systemic antibiotics, total parenteral nutrition, and CT-guided drainage of abdominal collections with clinical improvement. After the development of gallbladder perforation and further sepsis, he rapidly deteriorated and died. The final diagnosis was acute necrotizing pancreatitis, sepsis, and gallbladder perforation complicating DEB-TACE. Radiofrequency ablation and DEB-TACE is a bimodal treatment approach for hepatocellular carcinoma. Acute pancreatitis is a recognized complication of TACE (incidence of 1.7%–4%) with a mortality of 1%–2%, which can rise to as high as 30%–50% when sepsis and multiorgan failure develop.1Komekado H. Kokuryu H. Kimura T. et al.Two cases of acute necrotizing pancreatitis complicating after transcatheter arterial embolization for hepatocellular carcinoma.J Gastroenterol. 2005; 40: 107-108Crossref PubMed Scopus (14) Google Scholar Gastroduodenal ulceration occurs in 3% of patients after TACE, but duodenal perforation is rare (incidence 0.05%).2Xia J. Ren Z. Ye S. Sharma D. et al.Study of severe and rare complications of transarterial chemoembolization (TACE) for liver cancer.Eur J Radiol. 2006; 59: 407-412Abstract Full Text Full Text PDF PubMed Scopus (131) Google Scholar Similarly, although cholecystitis and gallbladder necrosis are common (owing to nontarget embolization of the cystic artery), gallbladder perforation is rare.3Wagnetz U. Jaskolka J. Yang P. et al.Acute ischemic cholecystitis after transarterial chemoembolization of hepatocellular carcinoma: incidence and clinical outcome.J Comput Assist Tomogr. 2010; 34: 348-353Crossref PubMed Scopus (42) Google Scholar Ischemic complications of TACE arise from inadvertent embolization through collateral vessels or regurgitation of embolic materials or chemotherapeutic agents to nontargeted arteries. Strategies used to minimize risk include selective embolization with the catheter tip placed as close to the distal branches of the hepatic artery as possible, careful injection of embolic materials to avoid regurgitation and prophylactic embolization of nontargeted arteries. The treatment of necrotizing pancreatitis from TACE is conservative. Serious complications such as gangrenous cholecystitis, gallbladder perforation, and emphysematous cholecystitis may necessitate urgent open or percutaneous cholecystectomy.

Objective: Comparison of minimal access retroperitoneal pancreatic necrosectomy (MARPN) versus open necrosectomy in the treatment of infected or nonresolving pancreatic necrosis.Summary of Background Data: Infected pancreatic necrosis may lead to progressive organ failure and death. Minimal access techniques have been developed in an attempt to reduce the high mortality of open necrosectomy.Methods: This was a retrospective analysis on a prospective data base comprising 189 consecutive patients undergoing MARPN or open necrosectomy (August 1997 to September 2008). Outcome measures included total and postoperative ICU and hospital stays, organ dysfunction, complications and mortality using an intention to treat analysis.Results: Overall 137 patients underwent MARPN versus open necrosectomy in 52. Median (range) age of the patients was 57.5 (18-85) years; 118 (62%) were male. A total of 131 (69%) patients were tertiary referrals, with a median time to transfer from index hospital of 19 (2-76) days. Etiology was gallstones or alcohol in 129 cases (68%); 98 of 168 (58%) patients had a positive culture at the first procedure. Of the 137 patients, 34 (31%) had postoperative organ failure in the MARPN group, and 39 of 52 (56%) in the open group (P < 0.0001); 59/137 (43%) versus 40/52 (77%), respectively, required postoperative ICU support (P < 0.0001). Of the 137 patients 75 (55%) had complications in the MARPN group and 42 of 52 (81%) in the open group (P = 0.001). There were 26 (19%) deaths in the MARPN group and 20 (38%) following open procedure (P = 0.009). Age (P < 0.0001), preoperative multiorgan failure (P < 0.0001), and surgical procedure (MARPN, P = 0.016) were independent predictors of mortality.Conclusion: This study has shown significant benefits for a minimal access approach including fewer complications and deaths compared with open necrosectomy.

Background/Aims: The current terminology for describing peripancreatic collections in acute pancreatitis (AP) derived from the Atlanta Symposium (e.g. pseudocyst, pancreatic abscess) has shown a very poor interobserver agreement, creating the potential for patient mismanagement. A study was undertaken to determine the interobserver agreement for a new set of morphologic terms to describe peripancreatic collections in AP. Methods: An international, interobserver agreement study was performed: 7 gastrointestinal surgeons, 2 gastroenterologists and 8 radiologists in 3 US and 5 European tertiary referral hospitals independently evaluated 55 computed tomography (CT) scans of patients with predicted severe AP. The percentage agreement [median, interquartile range (IQR)] for 9 clinically relevant morphologicterms was calculated among all reviewers, and separately among radiologists and clinicians. The percentage agreement was defined as poor (<0.50), moderate (0.51–0.70), good (0.71–0.90), and excellent (0.91–1.00). Results: Overall agreement was good to excellent for the terms collection (percentage agreement =1; IQR 0.68-1), relation with pancreas (1; 0.68–1), content (0.88; 0.87–1), shape (1; 0.78–1), mass effect (0.78; 0.62–1), loculated gas bubbles (1; 1-1), and air-fluid levels (1; 1-1). Overall agreement was moderate for extent of pancreatic nonenhancement (0.60; 0.46–0.88) and encapsulation (0.56; 0.48–0.69). The percentage agreement was greater among radiologists than clinicians for extent of pancreatic nonenhancement (0.75 vs. 0.57, p = 0.008), encapsulation (0.67 vs. 0.46, p = 0.001), and content (1 vs. 0.78, p = 0.008). Conclusion: Interobserver agreement for the new set of morphologic terms to describe peripancreatic collections in AP is good to excellent. Therefore, we recommend that current clinically based definitions for CT findings in AP (e.g. pancreatic abscess) should no longer be used.