Consensus advocating a principle of early organ support, nutritional optimisation, followed ideally by delayed minimally invasive intervention within a “step-up” framework where possible has radically changed the surgical approach to complications of acute pancreatitis in the last 20 years. The 2012 revision of the Atlanta Classification incorporates these changes, and provides a background which underpins the complexities of individual patient management decisions. This paper discusses the place for delayed minimally invasive surgical intervention (percutaneous necrosectomy, video-assisted retroperitoneal debridement (VARD)), and the rationale for opting to adopt a percutaneous approach over endoscopic or laparoscopic approaches in different clinical situations.

Pseudoaneurysms after visceral transplantation represent a significant risk to patients. We report the successful treatment of three transplant (pancreas, liver and kidney) artery anastomotic pseudoaneurysms using physician-modified fenestrated endovascular stent grafts. In all cases, surgical repair was considered high risk and would have compromised the arterial supply to the graft. The endovascular approach in all cases obviated the need for surgical intervention and maintained graft arterial supply.

Background We present the short‐term outcomes of robotic fenestration of symptomatic liver cysts using the EndoWrist One Vessel Sealer. Methods Data from patients who underwent robotic deroofing were collected and analysed retrospectively. Results A total of 17 patients were treated. Mean cyst size was 14 cm (median 15 cm, range 6.3‐24). Seven cysts were in posterosuperior or central segments. There were no mortalities or conversions. Blood loss was minimal in all but one case of 200 ml. Mean operating time was 174 minutes (median 170 min, range 97‐335). Mean hospital stay was 2.5 days (median 2 days, range 1‐10). One patient developed a bile leak requiring ERCP. There are no recurrences with a median follow‐up of 19 months. Conclusion Robotic fenestration can be safely performed and offers distinct advantages over the laparoscopic approach in the treatment of posterosuperior and perihilar cysts at the expense of longer operating times and increased cost.

Background: The laparoscopic approach in distal pancreatectomy is associated with higher rates of splenic preservation compared to open surgery. Although favorable postoperative short-term outcomes have been reported in open spleen-preserving distal pancreatectomy compared with distal pancreatectomy with splenectomy, it is unclear whether this observation applies to the laparoscopic approach. The aim of this study is to compare laparoscopic spleen preserving distal pancreatectomy (LSPDP) with laparoscopic distal pancreatectomy with splenectomy (LDPS), using propensity score matching. Methods: This is a UK wide, propensity score matched study, including all patients who underwent LSPDP or LDPS between 2006 and 2016. Patients were categorized according to intention to treat. Subsequently, propensity score matching was applied and short-term outcomes were compared between LSPDP and LDPS. Additionally, risk factors for unplanned splenectomy were explored. Results: 456 patients were included from eleven centers (229 LSPDP and 227 LDPS). The mean age of the cohort was 56AE16 years and 293 (64%) were female. The most common histopathologic diagnoses were neuroendocrine tumor (NET), Mucinous Cystic Neoplasm (MCN) and Intraductal Papillary Mucinous Neoplasm (IPMN). Splenic preservation was achieved in 184 (80%) of the attempted LSPDP. We were able to match 173 LSPDP cases to 173 LDPS cases. After matching, the groups were well balanced in terms of tumor size, age and sex. No differences were seen in postoperative morbidity between the groups. The only identified risk factor for unplanned splenectomy was tumor size !30mm. Conclusions: A high splenic preservation rate was achieved with tumor size as a risk factor for unplanned splenectomy. Preserving the spleen during laparoscopic distal pancreatectomy is not associated with reduced postoperative morbidity compared with sacrifising the spleen. However, taking in consideration the long-term risks of post-splenectomy patients, we believe splenic preservation should be attempted in laparoscopic distal pancreatectomy for benign or low-grade malignant lesions.

ObjectiveSevere acute pancreatitis (SAP) is associated with high mortality (15%–30%). Current guidelines recommend these patients are best managed in a multidisciplinary team setting. This study reports experience in the management of SAP within the UK’s first reported hub-and-spoke pancreatitis network.DesignAll patients with SAP referred to the remote care pancreatitis network between 2015 and 2017 were prospectively entered onto a database by a dedicated pancreatitis specialist nurse. Baseline characteristics, aetiology, intensive care unit (ICU) stay, interventions, complications, mortality and follow-up were analysed.Results285 patients admitted with SAP to secondary care hospitals during the study period were discussed with the dedicated pancreatitis specialist nurse and referred to the regional service. 83/285 patients (29%; 37 male) were transferred to the specialist centre mainly for drainage of infected pancreatic fluid collections (PFC) in 95% (n=79) of patients. Among the patients transferred; 29 (35%) patients developed multiorgan failure with an inpatient mortality of 14% (n=12/83). The median follow-up was 18.2 months (IQR=11.25–35.51). Multivariate analysis showed that transferred patients had statistically significant longer overall hospital stay (p<0.001) but less ICU stay (p<0.012).ConclusionThis hub-and-spoke model facilitates the management of the majority of patients with SAP in secondary care setting. 29% warranted transfer to our tertiary centre, predominantly for endoscopic drainage of PFCs. An evidence-based approach with a low threshold for transfer to tertiary care centre can result in lower mortality for SAP and fewer days in ICU.