In severe acute pancreatitis, accompanied by local complications such as acute peripancreatic fluid collection, pancreatic pseudocyst, acute necrotic collection and walled-off necrosis, the mortality rate is as high as 12-25%. In many cases, interventional procedure or surgical treatment are required at an appropriate time. Conservative treatment is considered for acute peripancreatic fluid collection. Endoscopic drainage could be considered preferentially for the treatment of pancreatic pseudocysts with clinical symptoms or complications. In the case of necrotizing pancreatitis, conservative treatment is preferred, but therapeutic intervention should be considered if infectious pancreatic necrosis with clinical deterioration is suspected. For therapeutic intervention, it is recommended to proceed with a step-up approach in which drainage is first performed and, if necessary, necrosectomy is performed. The optimal timing of intervention is considered 4 weeks after the onset of pancreatitis when necrosis become walled-off, but early drainage within 4 weeks can be considered depending on the patient's condition. This guideline provides an overview of current treatment strategies for local complications of acute pancreatitis.

배경/목적: 간내결석으로 간절제술 시행 후 재발한 경우, 주로 피부간경유쓸개관조영술(PTCS)로 치료하는데 이런 PTCS의 효과 및 경과에 대한 연구는 거의 없다. 이에 간절제술 후 간내결석 관련 합병증이 발생한 환자에서 PTCS의 효과 및 경과에 대해서 보고한다. 방법: 1998년 1월부터 2014년 12월까지 삼성서울병원에서 간내결석으로 수술 후 PTCS를 시행한 19명의 환자를 대상으로 후향적 연구를 시행하였다. PTCS 시행 전 환자 특성, 시술 후 결석의 제거 여부 및 합병증, 경과 관찰 중에 재발 여부 등에 대해서 조사하였으며, 시술 후 간내결석의 재발과 관련된 요인에 대한 분석을 하였다. 결과: PTCS의 적응증은 담관염(12/19, 63.2%), 복통(3/19, 15.7%), 간농양(2/19, 10.5%), 담관 확장(2/19, 10.5%) 등의 급성 합병증이었으며 이러한 급성 합병증은 치료 후 모두 호전되었다. PTCS 시행 후 63.2% (12/19)에서 간내결석이 완전히 제거되었고, 평균 4.9년(범위, 1.8-7.8)의 추적관찰 기간 동안에 간내담석 관련 합병증이 52.6% (10/19)에서 발생하였다. 합병증은 담관염 5명(50%), 담관염 및 간농양 3명(30%), 간 농양 1명(10%), 복통을 동반한 결석 1명(10%)이었다. 재발과 관련된 요인으로 결석의 다발성, 완전 제거 여부, 담관 협착 등을 분석하였으나 합병증 재발과 통계적으로 유의한 관련성이 없었다. 결론: PTCS는 간내결석으로 간절제술을 받은 환자에서 재발된 간내결석의 급성 합병증에 효과적인 치료 방법이다. 그러나 PTCS로 결석 치료 후에도 간내결석의 재발 및 급성 합병증이 흔하게 발생하므로 추적관찰이 필요하다.

Endoscopic snare papillectomy (ESP) for ampulla of Vater tumor (AVT) has been performed successfully instead of surgical ampullectomy (SA) because ESP is a less invasive procedure than SA. Hemorrhage, perforation and pancreatitis are relatively common complications of ESP and other rare complications such as cholangitis, liver abscess has been reported. Recently we encountered a case of acute acalculous cholecystitis after ESP for AVT, which was treated successfully with percutaneous cholecystostomy with intravenous antibiotics. We therefore report this case with a brief review of the literature.

Hartmann’s procedure is most often used if immediate anastomosis is not feasible and considered very high risk of anastomotic leakage. The reversal of Hartmann operation has a significant benefit in patient's quality of life, but there are disadvantages because it is procedure of a high degree of complexity. For reversal of Hartmann operation to be truly beneficial, morbidity rate should be reasonable. The aim of this study is therefore to review clinical outcomes of the conversion of Hartmann procedure and define the complication rate of reversal of Hartmann operation in a contemporary practice. Patients undergoing an elective reversal of Hartmann’s procedure at Chosun University Hospital between January 2011 and December 2016 were included in our analysis, and the medical records were retrospectively reviewed. Total 70 patients underwent Hartmann reversal during this period. There were 33 men (47.1%) and the mean age was 67.7±14.5. The most frequent indications for Hartmann’s procedure were complicated diverticulitis in 37 patients (52.9%). Major morbidity rate was 14.3 % (10 patients), anastomotic leakage rate of 4.3% and mortality rate was 2.9% (2 patients). The most common complication was wound infection (25.7%). Univariate analysis demonstrated that there were no statistically significant variables. This study demonstrates that patients who underwent reversal of their Hartmann’s operation did not have increased postoperative morbidity based on advanced age, higher ASA score, presence of multiple comorbidities, type of operation, and longer operation time.

Spontaneous perirenal hematoma is an unusual but serious complication of tumors, vascular disease, ruptured cyst, or infection. The authors report the case of a diabetic patient who presented with spontaneous perirenal hematoma and who was subsequently diagnosed to have emphysematous pyelonephritis.