Association of extent and infection of pancreatic necrosis with organ failure and death in acute necrotizing pancreatitis

Infected Pancreatic Necrosis due to Multidrug-Resistant Organisms and Persistent Organ failure Predict Mortality in Acute Pancreatitis

Background

Organ failure determines outcome in acute pancreatitis (AP). It is controversial if infected pancreatic necrosis (IPN) is also an independent determinant of mortality. We hypothesized that the predictors of mortality in AP might have changed with advances in management and consequent decline in mortality over the past decades. Our objective was to study the predictors of mortality in patients with AP.

Methods

Consecutive patients with a first episode of AP hospitalized from January 2015 to December 2016 were included in an observational study. Patients with IPN were treated with a conservative first approach followed by intervention. Necrosectomy, if required, was delayed beyond 4 weeks and done primarily employing minimally invasive techniques. The primary outcome measure was independent predictors of in-hospital mortality.

Results

Of 209 patients with AP, 81 (39%) had persistent organ failure (OF) and 108 (52%) developed IPN. Overall, 46/209 (22%) patients died. Independent predictors of mortality were OF (odds ratio [OR]19; 95% CI: 6.1–58.8), and IPN due to infection with multidrug resistant (MDR) organisms (OR: 8.4; 95% CI:3.1–22.5). Infected pancreatic necrosis by itself was not found to be a significant predictor of mortality (OR 2; 95% CI: 0.4–9.5).

Conclusion

Persistent OF and complicated IPN due to MDR infection were independent predictors of mortality in patients with AP. Renewed efforts to prevent MDR infection with antibiotic stewardship and strategies for early control of sepsis are urgently required.

Early (<4 Weeks) Versus Standard (≥ 4 Weeks) Endoscopically Centered Step-Up Interventions for Necrotizing Pancreatitis

OBJECTIVES

Current guidelines for necrotizing pancreatitis (NP) recommend delay in drainage ± necrosectomy until 4 or more weeks after initial presentation to allow collections to wall off. However, evidence of infection with clinical deterioration despite maximum support may mandate earlier (<4 weeks) intervention. There are concerns, but scant data regarding risk of complications and outcomes with early endoscopic intervention. Our aim was to compare the results of an endoscopic centered step-up approach to NP when initiated before versus 4 or more weeks.

METHODS

All patients undergoing intervention for NP were managed using an endoscopically centered step-up approach, with transluminal drainage whenever feasible, ±necrosectomy, and/or percutaneous catheter drainage as needed, with surgery only for failures. Interventions were categorized as early or standard based on timing of intervention (<4 weeks or ≥ 4 weeks from onset of pancreatitis). Demographic data, indications and timing for interventions, number and type of intervention, mortality and morbidity (length of stay in hospital and ICU) and complications were compared.

RESULTS

Of 305 patients with collections associated with NP, 193 (63%) (median age-52 years) required intervention, performed by a step-up approach. Of the 193 patients, 76 patients underwent early and 117 patients standard intervention. 144 (75%) interventions included endoscopic drainage ± necrosectomy. As compared with standard intervention, early intervention was more often performed for infection (91% vs. 39%, p < 0.05), more associated with acute kidney injury (43% vs. 32%, p = 0.09), respiratory failure (41% vs. 22%, p = 0.005), and shock (13% vs. 4%, p < 0.05). Organ failure improved significantly after intervention in both groups. There was a significant difference in mortality (13% vs. 4%, p = 0.02) and need for rescue open necrosectomy (7% vs. 1%, p = 0.03) between groups. Patients undergoing early intervention had increased median hospital (37 days vs. 26 days, p = 0.01) and ICU stay (median 2.5 days vs. 0 days, p = 0.001). There was no difference in complications.

CONCLUSIONS

When using an endoscopically centered step-up strategy in necrotizing pancreatitis, early (<4 weeks) interventions were more often performed for infection and organ failure, with no increase in complications, similar improvement in organ failure, slightly increased need for surgery, and relatively low mortality. Early endoscopic drainage ± necrosectomy should be considered when there is a strong indication for intervention.

Interleukin-6 significantly improves predictive value of systemic inflammatory response syndrome for predicting severe acute pancreatitis

BACKGROUND

Predicting severe acute pancreatitis (AP) is important for triage, prognosis, and designing therapeutic trials. Persistent systemic inflammatory response syndrome (SIRS) predicts severe AP but its diagnostic accuracy is suboptimal. Our objective was to study if cytokine levels could improve the predictive value of clinical variables for the development of severe AP.

METHODS

Consecutive patients with AP were included in a prospective cohort study at a tertiary care center. Serum levels of IL-6, TNF-α, IL-10, MCP-1, GM-CSF and IL-1β were measured at day 3 of onset of AP. Variables such as age, co-morbidity, etiology, SIRS, and cytokines were modeled to predict severe AP by multivariable regression analysis. Genotyping was done to correlate IL-6, TNF-α and MCP-1 gene polymorphisms with cytokine levels.

RESULTS

Of 236 patients with AP, 115 patients admitted within 7 days of onset formed the study group. 37 of the 115 (32%) patients developed organ failure. Independent predictors of organ failure were persistent SIRS (OR 34; 95% CI: 7.2-159) and day 3 serum IL-6 of >160 pg/ml (OR 16.1; 95% CI:1.8-142). IL-6 gene (-174 G/C) GG genotype was associated with significantly higher levels of IL-6 compared to CC/CG genotype. Serum IL-6 >160 pg/ml increased the positive predictive value of persistent SIRS from 56% to 85% and specificity from 64% to 95% for predicting OF without compromising its sensitivity and negative predictive value.

CONCLUSION

Serum IL-6 of >160 ng/ml added significantly to the predictive value of SIRS for severe AP.

Pancreatic Necrosectomy through Sinus Tract Endoscopy

BACKGROUND/AIMS

Direct endoscopic pancreatic necrosectomy is increasingly being utilized to treat infected or symptomatic walled-off necrosis (WON) located close to the stomach or duodenum. Laterally-placed WON has traditionally been treated surgically. We evaluated a less utilized technique of sinus tract endoscopy (STE) for symptomatic laterally-placed WON.

METHODS

Two hundred seventy-six patients with acute pancreatitis admitted in our hospital, 32 had symptomatic or infected WON requiring intervention. Of the 12 patients with laterally placed WON, 10 were treated by STE. STE was performed with a standard adult gastroscope passed through a percutaneous tract created by the placement of a 32-Fr drain.

RESULTS

Ten patients (7 males; mean age, 43.8 years) underwent STE. Mean number of sessions was 2.3 (range, 1-4), with mean time of 70 minutes for each session (range, 15-70 minutes). While 9 patients had complete success, 1 patient had fever and chose to undergo surgery. Two patients developed pneumoperitoneum, which was treated conservatively. There was no mortality, cutaneous fistula, or recurrence during follow-up.

CONCLUSIONS

Laterally placed WON can be successfully managed by STE performed through a percutaneously placed drain. Details of the technique and end-points of STE require further evaluation.

Impact of Antibiotic-Resistant Bacterial and Fungal Infections in Outcome of Acute Pancreatitis

OBJECTIVES

The knowledge about pathogens and their antibiotic susceptibility patterns is essential to select an appropriate antibiotic.

METHODS

We investigated the microbiological profile in pancreatic and extrapancreatic infections, and antibiotic sensitivity pattern in patients with acute pancreatitis.

RESULTS

Of 556 patients with acute pancreatitis, only 189 developed bacterial infection; however, bacteremia was present in 42 patients (7.6%). Culture-proven infected pancreatic necrotic collection was present in 161 patients (29%). Escherichia coli and Klebsiella pneumoniae were the most common organisms. Among the bacterial infection cohort, 164 patients developed multidrug-resistant bacterial infection. Infection with multidrug-resistant bacteria, especially at multiple sites, increased mortality. Nearly 50% of patients (n = 94) acquired extremely drug-resistant bacterial infection at some time and emerged as key reason for prolonged hospital and intensive care unit stay. Colistin resistance and tigecycline resistance were documented in 2.1% and 17.2% of the specimens at admission and in 4.6% and 21% of specimens during the hospital stay. Of 556 patients, 102 patients developed fungal infection and 28 patients had only fungal infection without bacterial infection.

CONCLUSIONS

Colistin and tigecycline are best reserved as last-resort antibiotics. Fungal infection was found to be associated with increased mortality, median hospital stay, and intensive care unit stay.

Development and validation of a multivariate prediction model for patients with acute pancreatitis in Intensive Care Medicine

BACKGROUND/OBJECTIVES

Development and validation of a multivariate prediction model for patients with acute pancreatitis (AP) admitted in Intensive Care Units (ICU).

METHODS

A prospective multicenter observational study, in 1 year period, in 46 international ICUs (EPAMI study).

PATIENTS

adults admitted to an ICU with AP and at least one organ failure.

INTERVENTIONS

Development of a multivariate prediction model, using the worst data of the stay in ICU, based in multivariate analysis, simple imputation in a development cohort. The model was validated in another cohort.

RESULTS

374 patients were included (mortality of 28.9%). Variables with statistical significance in multivariate analysis were age, no alcoholic and no biliary etiology, development of shock, development of respiratory failure, need of continuous renal replacement therapy, and intra-abdominal pressure. The model created with these variables presented an AUC of ROC curve of 0.90 (CI 95% 0.81-0.94) in the validation cohort. We developed a multivariable prediction model, and AP cases could be classified as low mortality risk (between 2 and 9.5 points, mortality of 1.35%), moderate mortality risk (between 10 and 12.5 points, 28.92% of mortality), and high mortality risk (13 points of more, mortality of 88.37%). Our model presented better AUC of ROC curve than APACHE II (0.91 vs 0.80) and SOFA in the first 24 h (0.91 vs 0.79).

CONCLUSIONS

We developed and validated a multivariate prediction model, which can be applied in any moment of the stay in ICU, with better discriminatory power than APACHE II and SOFA in the first 24 h.

Primary and Secondary Organ Failures Cause Mortality Differentially in Acute Pancreatitis and Should be Distinguished

OBJECTIVE

The aim of this study was to study the development of early and late organ failure (OF) and their differential impact on mortality in patients with acute pancreatitis (AP).

METHODS

Consecutive patients (N = 805) with acute pancreatitis were included in an observational study. Organ failure was categorized as primary if it occurred early due to pancreatitis per se and secondary if it occurred late due to infected pancreatic necrosis (IPN). Primary outcome was a relative contribution of primary OF, secondary OF, and IPN to mortality.

RESULTS

Of the 614 patients (mean age, 38.8; standard deviation, 14.6 years; 430 males) in a derivation cohort, 274 (44.6%) developed OF, with 177 having primary OF and 97 secondary OF due to sepsis. Primary OF caused early mortality in 15.8% and was a risk factor for IPN in 76% of patients. Mortality in patients with primary OF and IPN was 49.5% versus 36% in those with IPN and secondary OF (P = 0.06) and 4% in those with IPN but without OF (P < 0.001). The results of the 191 patients in the validation cohort confirmed the relative contribution of primary and secondary OF to mortality.

CONCLUSION

Primary and secondary OF contributed to mortality independently and are distinct in their timing, window of opportunity for intervention, and prognosis.

Identification and Characterization of Blood and Neutrophil-Associated Microbiomes in Patients with Severe Acute Pancreatitis Using Next-Generation Sequencing

Infectious complications are a leading cause of death for patients with severe acute pancreatitis (SAP). Yet, our knowledge about details of the blood microbial landscape in SAP patients remains limited. Recently, some studies have reported that the peripheral circulation harbors a diverse bacterial community in healthy and septic subjects. The objective of this study was to examine the presence of the blood bacterial microbiome in SAP patients and its potential role in the development of infectious complications. Here we conducted a prospective observational study on a cohort of 50 SAP patients and 12 healthy subjects to profile the bacterial composition in the blood. The patients were subgrouped into uninfected (n = 17), infected (n = 16), and septic (n = 17) cases. Applying 16S rDNA-based next-generation sequencing technique, we investigated blood and neutrophil-associated microbiomes in SAP patients, and assessed their connections with immunological alterations. Based on the sequencing data, a diverse bacterial microbiota was found in peripheral blood and neutrophils from the healthy and SAP subjects. As compared to healthy controls, the blood and neutrophil-associated microbiomes in the patients were significantly altered, with an expansion in Bacteroidetes and Firmicutes as well as a decrease in Actinobacteria. Variations in the microbiome composition in patients were associated with immunological disorders, including altered lymphocyte subgroups, elevated levels of serum cytokines and altered proteomic profiles of neutrophils. However, no significant compositional difference was observed between the patient subgroups, implying that the microbiota alterations might not be linked to presence/absence of infectious complications in SAP. Together, we present an initial description of the blood and neutrophil-associated bacterial profiles in SAP patients, offering novel evidence for the existence of the blood microbiome. Identification of the blood microbiome provides novel insights into characteristics and diagnostics of bacteremia in the patients. Further study is required to assess the possible implications of the blood microbiome in health and diseases.

Comparison of Various Scoring Systems and Biochemical Markers in Predicting the Outcome in Acute Pancreatitis

OBJECTIVE

Early risk assessment is important in acute pancreatitis (AP). The primary objective of this study was to compare various scores and biochemical markers done on the day of admission in predicting the outcome.

METHODS

Demographic, clinical, and laboratory data of patients presenting within 2 weeks of onset were collected. Various scores were calculated and biochemical markers were measured on the day of admission. Optimum cutoffs were identified through receiver operating curve analysis. Multivariate analysis was used to identify predictors of outcome.

RESULTS

Of 343 patients included, 202 (59%) were male; mean (SD) age was 38.7 (15.5) years. Acute pancreatitis was severe in 170 (49.6%) patients. Twenty-eight percent of the patients developed infected pancreatic necrosis and 18% died. An Acute Physiology and Chronic Health Evaluation (APACHE II) score of at least 7, bedside index for severity of AP (BISAP) of at least 2, systemic inflammatory response syndrome score of at least 3, and C-reactive protein of at least 82 ng/mL predicted severity. Predictors of infected pancreatic necrosis were as follows: PANC 3 score of at least 1, BISAP score of at least 2, and Marshall score of at least 2, whereas C-reactive protein of greater than 98, BISAP score of at least 2, APACHE score of at least 10, and a blood urea nitrogen of at least 17 predicted mortality.

CONCLUSIONS

Both BISAP and APACHE II are comparable in predicting outcome, but BISAP predicted all 3 outcomes with the same cutoff and hence is a robust scoring system.

Analysis of Factors Associated with the Severity of Acute Pancreatitis according to Etiology

Background

The objective of this study was to determine the factors associated with severity of acute pancreatitis (AP) according to two major etiologies: alcohol and gallstones.

Methods

We reviewed the medical records of consecutive patients who were admitted with AP between January 2003 and January 2013. A total of 905 patients with AP (660 alcohol-induced, 245 gallstone-induced) were enrolled. Among them, severe AP (SAP) occurred in 72 patients (53 alcohol-induced, 19 gallstone-induced). Contributing factors between patients with and without SAP were analyzed according to the etiology.

Results

Multivariate analysis demonstrated that current smoking, pancreatic necrosis, and bacteremia were associated with AP severity in both alcohol- and gallstone-induced AP. Pancreatic fluid collection was significantly associated with alcohol-induced SAP (p = 0.04), whereas dyslipidemia was significantly associated with gallstone-induced SAP (p = 0.01). Body mass index was significantly correlated with the Bedside Index of Severity in Acute Pancreatitis score in both alcohol- and gallstone-induced AP (p = 0.03 and 0.01, resp.).

Conclusions

Current smoking, pancreatic necrosis, and bacteremia can aggravate the clinical course of AP. Pancreatic fluid collection and dyslipidemia were associated with AP severity according to the different etiologies. Obesity may also be associated with AP severity in both etiologies.

Systemic histone release disrupts plasmalemma and contributes to necrosis in acute pancreatitis

BACKGROUND

Clinical and experimental acute pancreatitis feature histone release within the pancreas from innate immune cells and acinar cell necrosis. In this study, we aimed to detail the source of circulating histones and assess their role in the pathogenesis of acute pancreatitis.

METHODS

Circulating nucleosomes were measured in patient plasma, taken within 24 and 48 h of onset of acute pancreatitis and correlated with clinical outcomes. Using caerulein hyperstimulation, circulating histones were measured in portal, systemic venous and systemic arterial circulation in mice, and the effects of systemic administration of histones in this model were assessed. The sites of actions of circulating histones were assessed by administration of FITC-labelled histones. The effects of histones on isolated pancreatic acinar cells were further assessed by measuring acinar cell death and calcium permeability in vitro.

RESULTS

Cell-free histones were confirmed to be abundant in human acute pancreatitis and found to derive from pancreatitis-associated liver injury in a rodent model of the disease. Fluorescein isothianate-labelled histones administered systemically targeted the pancreas and exacerbated injury in experimental acute pancreatitis. Histones induce charge- and concentration-dependent plasmalemma leakage and necrosis in isolated pancreatic acinar cells, independent of extracellular calcium.

CONCLUSION

We conclude that histones released systemically in acute pancreatitis concentrate within the inflamed pancreas and exacerbate injury. Circulating histones may provide meaningful biomarkers and targets for therapy in clinical acute pancreatitis.

Deletion Of XIAP reduces the severity of acute pancreatitis via regulation of cell death and nuclear factor-κB activity

Severe acute pancreatitis (SAP) still remains a clinical challenge, not only for its high mortality but the uncontrolled inflammatory progression from acute pancreatitis (AP) to SAP. Cell death, including apoptosis and necrosis are critical pathology of AP, since the severity of pancreatitis correlates directly with necrosis and inversely with apoptosis Therefore, regulation of cell death from necrosis to apoptosis may have practicably therapeutic value. X-linked inhibitor of apoptosis protein (XIAP) is the best characterized member of the inhibitor of apoptosis proteins (IAP) family, but its function in AP remains unclear. In the present study, we investigated the potential role of XIAP in regulation of cell death and inflammation during acute pancreatitis. The in vivo pancreatitis model was induced by the administration of cerulein with or without lipopolysaccharide (LPS) or by the administration of l-arginine in wild-type or XIAP-deficient mice, and ex vivo model was induced by the administration of cerulein+LPS in AR42J cell line following XIAP inhibition. The severity of acute pancreatitis was determined by serum amylase activity and histological grading. XIAP deletion on cell apoptosis, necrosis and inflammatory response were examined. Caspases activities, nuclear factor-κB (NF-κB) activation and receptor-interacting protein kinase1 (RIP1) degradation were assessed by western blot. Deletion of XIAP resulted in the reduction of amylase activity, decrease of NF-κB activation and less release of TNF-α and IL-6, together with increased caspases activities and RIP1 degradation, leading to enhanced apoptosis and reduced necrosis in pancreatic acinar cells and ameliorated the severity of acute pancreatitis. Our results indicate that deletion of XIAP switches cell death away from necrosis to apoptosis and decreases the inflammatory response, effectively attenuating the severity of AP/SAP. The critical role of XIAP in cell death and inflammation suggests that inhibition of XIAP represents a potential therapeutic strategy for the treatment of acute pancreatitis.

Endothelial markers are associated with pancreatic necrosis and overall prognosis in acute pancreatitis: A preliminary cohort study

BACKGROUND

Endothelial injury is believed to play an important role in the evolution of pancreatic microcirculatory dysfunction and pancreatic necrosis (PN) in patients with acute pancreatitis (AP). The aim of this study was to investigate the role of three endothelial markers (von Willebrand factor, vWF; E-selectin; endothelial protein C receptor, EPCR) in the early phase of AP, especially the relationship between endothelial markers and PN.

METHODS

From March 2015 to March 2016, 57 AP patients admitted within 72 h of symptom onset in our hospital were included for this study. Blood samples were taken on admission and the clinical characteristics and outcomes of these patients were recorded. The levels of vWF, E-selectin and EPCR were measured using ELISA for analysis and compared with other severity markers of AP.

RESULTS

All the three markers were significantly different in healthy control, mild, moderate and severe AP patients. Moreover, the endothelial markers, especially vWF, also showed significant difference in patients with different extent of PN, as well as those with or without MODS. Additionally, the levels of endothelial markers correlated well with other commonly used markers of AP severity.

CONCLUSION

Elevated endothelium-related mediators (vWF, E-selectin and EPCR) appear to participate in the development of PN and may be a potential indicator of overall prognosis. Our results may help clinicians better understand the pathophysiological process of the development of PN.

Prognostic significance of differentiating necrosis from fluid collection on endoscopic ultrasound in patients with presumed isolated extrapancreatic necrosis

BACKGROUND

Extrapancreatic necrosis is diagnosed on computed tomography (CT) as extrapancreatic changes that are more than fat stranding; both fluid collections and necrosis would have a similar appearance. The aim of this study was to determine the prognostic significance of differentiating peripancreatic necrosis from fluid collection on endoscopic ultrasound (EUS) in patients with presumed isolated extrapancreatic necrosis.

METHODS

We carried out a retrospective analysis of prospectively collected data from 36 patients (25 males; age range 19-65 years) with acute pancreatitis (AP) and isolated extrapancreatic necrosis. On EUS, peripancreatic anechoic areas were labeled as peripancreatic fluid collections and peripancreatic heterogeneously echotextured areas as peripancreatic necrosis.

RESULTS

The etiology of AP was alcohol in 16 (44.4%) patients, gallstone disease in 13 (36.1%), and other in 7 (19.4%). On EUS, 25 (69.4%) patients had peripancreatic necrosis and 11 (30.6%) patients had peripancreatic fluid collections. Compared with patients who had peripancreatic fluid collections, patients with peripancreatic necrosis had a significantly higher frequency of pleural effusion (88% vs. 55%; P=0.04), organ failure (OF) (68% vs. 27%; P=0.03), and persistent OF (48% vs. 9%; P=0.03). The patients with peripancreatic necrosis also had a higher frequency of ascites (20% vs. 9%), need for intervention (20% vs. nil), surgery (8% vs. nil) and mortality (8% vs. nil), but these differences were not statistically significant.

CONCLUSION

Isolated extrapancreatic necrosis on contrast-enhanced CT comprises a heterogeneous group, with patients who show peripancreatic fluid collections on EUS having a less severe disease course compared to patients with peripancreatic necrosis.

Ileus is a predictor of local infection in patients with acute necrotizing pancreatitis

BACKGROUND & OBJECTIVES

Infected pancreatic necrosis (IPN) is associated with increased morbidity and mortality. Gut barrier dysfunction has been shown to increase the risk of bacterial translocation from the gut into the pancreatic bed. The primary aim of the study is to evaluate if ileus, a clinical marker of gut barrier dysfunction, can predict the development of IPN.

METHODS

A retrospective cohort study of patients with necrotizing pancreatitis (NP) was conducted from 2000 to 2014. Ileus was defined as ≥2 of the following criteria: nausea/vomiting; inability to tolerate a diet, absence of flatus, abdominal distension and features of ileus on imaging. Extensive necrosis was defined as >30% nonenhancing pancreatic parenchyma on contrast-enhanced CT. Multivariable cox proportional hazard analysis was used to evaluate known and potential predictors of IPN.

RESULTS

142 patients were identified with NP, 61 with IPN and 81 with sterile necrosis. In comparison to a diagnosis of ileus documented in the medical chart, the ileus criteria had a sensitivity, specificity and positive and negative predictive value of 100%, 93%, 78% and 100%, respectively. On multivariate cox proportional hazard analysis, ileus [HR:2.6; 95%CI:1.4-4.9] and extensive necrosis [HR:2.8; 95%CI:1.3-5.8] were independently associated with the development of IPN while there was no association with bacteremia [HR:1.09; 95%CI:0.6-2.1].

CONCLUSION

Ileus in NP can be accurately defined using surgical criteria. Ileus is independently associated with the future development of IPN. Further studies will be needed to determine if ileus can serve as a clinical marker to direct therapeutic interventions aimed at reducing the incidence of IPN.

Antibiotic use in acute pancreatitis: An audit of current practice in a tertiary centre

INTRODUCTION

Intravenous antibiotic prophylaxis is not recommended in acute pancreatitis. According to current international guidelines antibiotics together with further intervention should be considered in the setting of infected necrosis. Appropriate antibiotic therapy particularly avoiding over-prescription is important. This study examines antibiotic use in acute pancreatitis in a tertiary centre using the current IAP/APA guidelines for reference.

METHODS

Data were collected on a consecutive series of patients admitted with acute pancreatitis over a 12 month period. Data were dichotomized by patients admitted directly to the centre and tertiary transfers. Information was collected on clinical course with specific reference to antibiotic use, episode severity, intervention and outcome.

RESULTS

111 consecutive episodes of acute pancreatitis constitute the reported population. 31 (28%) were tertiary transfers. Overall 65 (58.5%) patients received antibiotics. Significantly more tertiary transfer patients received antibiotics. Mean person-days of antibiotic use was 23.9 (sd 29.7) days in the overall study group but there was significantly more use in the tertiary transfer group as compared to patients having their index admission to the centre (40.9 sd 37.1 vs 10.2 sd 8.9; P < 0.005). Thirty four (44%) of patients with clinically mild acute pancreatitis received antibiotics.

CONCLUSIONS

There is substantial use of antibiotics in acute pancreatitis, in particular in patients with severe disease. Over-use is seen in mild acute pancreatitis. Better consideration must be given to identification of prophylaxis or therapy as indication. In relation to repeated courses of antibiotics in severe disease there must be clear indications for use.

Evaluation of the AXIOS stent for the treatment of pancreatic fluid collections

INTRODUCTION

Endoscopic ultrasound guided translumenal drainage of pancreatic fluid collections (PFCs) has been widely practiced for over a decade, using conventional plastic and self-expandable metal stents. The use of such stents for transmural drainage is off-label and limited by the lack of lumen-to-lumen anchorage, which can lead to leakage, migration and tissue trauma.

AREAS COVERED

Novel stent designs dedicated to applications of translumenal drainage have recently emerged and promise to make transmural drainage quicker, safer, and more effective. Achieving faster resolution of the fluid collection, decreasing adverse events, decreasing recurrence rates, and lowering costs are critical to advancing the endoscopic management of PFCs. Expert commentary: Our paper suggests that the AXIOS stent is an innovative therapeutic approach for PFC drainage with excellent efficacy, safety, and relatively few adverse outcomes. Preliminary reports appear promising and large multicenter prospective studies are needed in the future to further determine its safety and efficacy.

Patients With Sentinel Acute Pancreatitis of Alcoholic Etiology Are at Risk for Organ Failure and Pancreatic Necrosis: A Dual-Center Experience

OBJECTIVES

To assess the relationship between alcoholic etiology, tobacco use, and severe acute pancreatitis (AP).

METHODS

Smoking and alcohol exposure were recorded upon admission in a cohort of patients with AP within the United States. Patients with first, "sentinel" attack of AP were identified for analysis.Associations between alcohol, smoking, and severe AP were validated in an independent cohort of patients from Spain.

RESULTS

US cohort (n = 222): Thirty-five percent developed organ failure (OF), 35% pancreatic necrosis (PNec), and 7% died. OF (54% vs 33%, P = 0.03), PNec (62% vs 31%, P = 0.006), intensive care unit admission (58% vs 36%, P = 0.03), and length of stay (LOS) (20 vs 8 days, P = 0.007) were greater in alcoholic when compared to other etiologies.Spanish cohort (n = 366): Similar differences in outcomes were also found with between alcoholic and nonalcoholic etiologies: OF (24% vs 8%, P = 0.001), PNec (38% vs 14%, P < 0.001), intensive care unit admission (20% vs 3%, P < 0.001), and LOS (17 vs 11 days, P = 0.04).Multivariable analysis confirmed alcoholic etiology to be independently associated with OF and PNec in both cohorts.

CONCLUSIONS

Alcoholic etiology is independently associated with OF and PNec in patients with sentinel AP and is important when evaluating risk for severe disease in AP.

Severe acute hemorrhagic pancreatitis secondary to cholelithiasis as a rare cause of sudden unexpected death in medico-legal case: A case report

INTRODUCTION

Acute pancreatitis (AP) is an uncommon disease with a wide clinical course varying from mild and self-limiting to severe with eventual death. However, death caused by AP is rare. Most cases of AP reported in the English-language literature are based on clinical data; few are medico-legal studies.

CASE PRESENTATION

The author recently experienced a case of sudden unexpected death in a young man caused by extensive severe hemorrhagic AP secondary to cholelithiasis, not chronic alcoholism, which is a much more prominent etiology of AP in medico-legal perspectives. The deceased had complained of dizziness, nausea, and fatigue without significant abdominal pain for about 1 week and received some home medications for symptomatic treatment including an antibiotic drug from a clinic just 2 days prior to his death. He had complained of lower extremity weakness, intense thirst, and subsequently collapsed and was brought to a nearby hospital where he was pronounced dead shortly after his admission following unsuccessful advanced cardiopulmonary resuscitation attempts.

CONCLUSION

This case is herein reported with an extensive review of the pertinent literature to highlight the findings of the case and raise awareness within the medico-legal profession and also the medical profession.

Reduction in mortality in severe acute pancreatitis: A time trend analysis over 16 years

BACKGROUND

The trend in the outcome of patients with acute pancreatitis (AP) as a result of evolving management practices is not known.

OBJECTIVE

To study and compare the outcomes of patients with AP at a tertiary care academic center over a period of 16 years.

METHODS

In a retrospective study on a prospectively acquired database of patients with AP, we analyzed time trends of severity and mortality of AP. The influence of determinants of severity [APACHE II score, organ failure (OF), infected pancreatic necrosis (IPN)], and management strategy on the actual and predicted mortality was assessed. The actual mortality was adjusted for severity to analyze the severity-adjusted mortality at different times as a reflection of management practices over time.

RESULTS

A total of 1333 patients were studied. The number of patients hospitalized with AP has been increasing over time. The proportion of patients with severe AP also increased from 1997 to 2013 as shown by increasing incidence of organ failure and IPN (Spearman's rank correlation coefficient (ρ): OF ρ(17) = 0.797, p < 0.01; IPN ρ(17) = 0.739, p < 0.001), indicating an increasing referral of sicker patients. Consequently, the overall mortality has been increasing (ρ(17) = 0.584; p = 0.014). However, despite increasing severity of AP, the mortality adjusted for OF has decreased significantly (ρ(17) = -0.55, p = 0.02).

CONCLUSION

Even with increasing proportion of patients with severe AP, there has been a significant decrease in organ failure adjusted mortality due to AP suggesting improved management over years.

Better Outcomes if Percutaneous Drainage Is Used Early and Proactively in the Course of Necrotizing Pancreatitis

PURPOSE

To compare outcomes after percutaneous catheter drainage (PCD) for acute necrotizing pancreatitis versus those in a randomized controlled trial as a reference standard.

MATERIALS AND METHODS

Between September 2010 and August 2014, CT-guided PCD was the primary treatment for 39 consecutive patients with pancreatic necrosis. The indication for PCD was the clinical finding of uncontrolled pancreatic juice leakage rather than infected necrosis. Subsequent to PCD, the drains were proactively studied with fluoroscopic contrast medium every 3 days to ensure patency and position. Drains were ultimately maneuvered to the site of leakage. These 39 patients were compared with 43 patients from the Pancreatitis, Necrosectomy versus Step-up Approach (PANTER) trial.

RESULTS

The CT severity index was similar between studies (median of 8 in each). Time from onset of acute pancreatitis to PCD was shorter in the present series (median, 23 d vs 30 d). The total number of procedures (PCD and subsequent fluoroscopic drain studies) per patient was greater in the present series (mean, 14 vs 2). More patients in the PANTER trial had organ failure (62% vs 84%), required open or endoscopic necrosectomy (0% vs 60%), and experienced in-hospital mortality (0% vs 19%; P < .05 for all).

CONCLUSIONS

Even though patients in the present series had a similar CT severity index as those in the PANTER trial, the former group showed lower incidences of organ failure, need for necrosectomy, and in-hospital mortality. The use of a proactive PCD protocol early, before the development of severe sepsis, appeared to be effective.

Perfusion-CT--Can We Predict Acute Pancreatitis Outcome within the First 24 Hours from the Onset of Symptoms?

PURPOSE

Severe acute pancreatitis (AP) is still a significant clinical problem which is associated with a highly mortality. The aim of this study was the evaluation of prognostic value of CT regional perfusion measurement performed on the first day of onset of symptoms of AP, in assessing the risk of developing severe form of acute pancreatitis.

MATERIAL AND METHODS

79 patients with clinical symptoms and biochemical criteria indicative of acute pancreatitis (acute upper abdominal pain, elevated levels of serum amylase and lipase) underwent perfusion CT within 24 hours after onset of symptoms. The follow-up examinations were performed after 4-6 days to detect progression of the disease. Perfusion parameters were compared in 41 people who developed severe form of AP (pancreatic and/or peripancreatic tissue necrosis) with parameters in 38 consecutive patients in whom course of AP was mild. Blood flow, blood volume, mean transit time and permeability surface area product were calculated in the three anatomic pancreatic subdivisions (head, body and tail). At the same time the patient's clinical status was assessed by APACHE II score and laboratory parameters such as CRP, serum lipase and amylase, AST, ALT, GGT, ALP and bilirubin were compared.

RESULTS

Statistical differences in the perfusion parameters between the group of patients with mild and severe AP were shown. Blood flow, blood volume and mean transit time were significantly lower and permeability surface area product was significantly higher in patients who develop severe acute pancreatitis and presence of pancreatic and/or peripancreatic necrosis due to pancreatic ischemia. There were no statistically significant differences between the two groups in terms of evaluated on admission severity of pancreatitis assessed using APACHE II score and laboratory tests.

CONCLUSIONS

CT perfusion is a very useful indicator for prediction and selection patients in early stages of acute pancreatitis who are at risk of developing pancreatic and/or peripancreatic necrosis already on the first day of the onset of symptoms and can be used for treatment planning and monitoring of therapy of acute pancreatitis. Early suspicion of possible pancreatic necrosis both on the basis of scores based on clinical status and laboratory tests have low predictive value.

Antibiotic use in acute pancreatitis: Global overview of compliance with international guidelines

INTRODUCTION

Practice guidelines for the management of acute pancreatitis make recommendations in relation to antibiotic prophylaxis and treatment in acute pancreatitis. However, it is difficult to ascertain whether this information translates into clinical practice. The aim of this study is to obtain a global overview assessing reports from across the world of the use of antibiotic use in acute pancreatitis.

METHODS

A computerised literature search was performed from January 1992 to September 2015. Studies were either national physician surveys or national database reports on antibiotic prophylaxis in acute pancreatitis. Using these criteria, 10 studies were identified which comprise the final study population.

RESULTS

Eight studies report on the questionnaire responses of 2397 physicians. The range of response rate was 38-96%. A separate study reported on outcome of a national insurance database outcomes in 7193 patients. The lowest incidence of use of antibiotic prophylaxis was 41% and the highest 88%.

CONCLUSION

This study provides a unique global perspective on antibiotic use in acute pancreatitis and indicates that the use of antibiotics, both as prophylaxis and as treatment in this disease is widespread.

Current concepts in the management of acute pancreatitis

Guidelines for the management of acute pancreatitis (AP) are based on the Western experience, which may be difficult to extrapolate in India due to socioeconomic constraints. Hence, modifications based on the available resources and referral patterns should be introduced so as to ensure appropriate care. We reviewed the current literature on the management of AP available in English on Medline and proposed guidelines locally applicable. Patients of AP presenting with systemic inflammatory response syndrome are at risk of moderate-severe pancreatitis and hence, should be referred to a tertiary center early. The vast majority of patients with AP have mild disease and can be managed at smaller centers. Early aggressive fluid resuscitation with controlled fluid expansion, early enteral nutrition, and culture-directed antibiotics improve outcomes in AP. Infected pancreatic necrosis should be managed in a tertiary care hospital within a multidisciplinary setup. The "step up" approach involving antibiotics, percutaneous drainage, and minimally invasive necrosectomy instituted sequentially based on clinical response has improved the outcomes in this subgroup of patients.

Clinical outcomes of combined necrotizing pancreatitis versus extrapancreatic necrosis alone

INTRODUCTION

Extrapancreatic necrosis (EPN) alone, i.e., in the absence of pancreatic parenchyma necrosis has gradually come to be regarded as a separate entity of acute necrotizing pancreatitis (ANP). However, data regarding the prognostic significance of EPN are quite limited, and the outcomes of interventions for patients with EPN alone are not well elucidated. The aim of this study was to explore the differences in the outcomes of patients with EPN alone and patients with both the pancreatic parenchyma and extrapancreatic necrosis (combined necrosis).

METHODS

From January 2009 to December 2013, a total of 334 patients with ANP who had received interventions in the West China Hospital in China were included. Based on the extent of necrosis as assessed with contrast-enhanced CT, the patients were divided into Group 1 (n = 285) in which the necrosis involved both the pancreatic parenchyma and extrapancreatic tissues (combined necrosis) and Group 2 (n = 49) in which the necrosis involved only the extrapancreatic tissues. Additionally, Group 3 included 443 patients with interstitial pancreatitis who were also included in the analyses. The demographic characteristics, support treatment information, organ failure information, infection necrosis, persistent systemic inflammatory response syndrome (SIRS) in the first week of onset, CT severity index, and intervention types, as well as the postoperative stay lengths, ICU utility, and complications were collected and compared.

RESULTS

Compared with the patients in Group 1, the patients in Group 2 suffered less persistent SIRS in the first week of onset (12/24.5% vs. 145/50.9%; P < 0.05), less persistent organ failure (6/12.2% vs. 95/33.3%; P < 0.05), less persistent multiple organ failure (3/6.1% vs. 67/23.5%; P < 0.05), and less bacteremia (5/10.2% vs. 107/37.5%; P < 0.001). The intervention types were significantly different between the two groups (P < 0.001); initial open necrosectomy was performed in 174/61.6% and 8/16.3% of the patients in Groups 1 and 2, respectively, and initial percutaneous catheter drainage (PCD) was performed in 73/25.6% and 29/59.2% of the patients in the two respective groups. Second open necrosectomies following PCD were required in 61/83.5% and 9/31.0% of the patients in Groups 1 and 2, respectively (P < 0.001). A greater number of patients in Group 1 were diagnosed with infected necrosis (204/71.6% vs. 10/20.4%; P < 0.001) and had to be sent to the ICU for further postoperative care (221/77.5% vs. 23/46.9%; P < 0.001). The postoperative stay was longer for Group 1 (median: 43.0 vs. 26.5 days; P < 0.001). Residual necrotic tissue or abscess was the most common postoperative complication in both groups. The mortality was higher in Group 1 (52/18.2% vs. 1/2.1%; P < 0.05). Compared with the patients in Group 2, the patients with interstitial pancreatitis exhibited milder courses and better outcomes. Subgroup comparisons with Group 1 indicated that early multiple organ failure was significantly associated with higher mortality.

CONCLUSION

The patients with EPN alone exhibited significantly better prognoses than those with combined necrosis, and EPN alone should be regarded as a separate group of acute necrotizing pancreatitis. Open necrosectomy can be avoided in the majority of patients with EPN alone, who receive PCD as the initial first intervention.

Clinical significance of presence and extent of extrapancreatic necrosis in acute pancreatitis

BACKGROUND AND AIM

Extrapancreatic necrosis (EPN) alone represents a subgroup of pancreatitis with better outcome than patients with pancreatic parenchymal necrosis (PN). However, data on clinical significance of EPN is limited, and significance of the extent of EPN is not known.

METHODS

Two hundred thirteen patients (136 [63.8%] males; mean age: 39.8 ± 13.2 years) with acute pancreatitis were prospectively enrolled and followed up till recovery or death. Contrast-enhanced computed tomography of each patient was retrospectively evaluated for presence of PN and EPN, pleural effusion and ascites. EPN was termed extensive if it extended to paracolic gutters or pelvis.

RESULTS

Twenty-one (9.9%) patients had interstitial pancreatitis, seven (3.3%) patients had PN alone, 48 (22.5%) patients had EPN alone, and 137 (64.3%) patients had combined PN and EPN. Patients with EPN alone had significantly higher frequency of organ failure than patients with interstitial pancreatitis. Compared with patients with EPN alone, the patients with combined necrosis had significantly higher frequency of pleural effusion (88.2% vs. 75%), ascites (41% vs. 20.8%), and need for intervention (32.6% vs. 14.6%). Patients with extensive EPN (n = 57) had significantly higher frequency of pleural effusion, ascites, and multi-organ failure than those with limited EPN.

CONCLUSION

EPN alone should be considered as a separate category of acute pancreatitis as it has less severe course than PN but has more severe course than interstitial pancreatitis. Patients with extensive EPN in spite of having increased frequency of ascites, pleural effusion, and multi-organ failure had similar outcome as compared to patients with limited EPN.

Perfusion CT: can it predict the development of pancreatic necrosis in early stage of severe acute pancreatitis?

PURPOSE

Pancreatic necrosis is an important determinant of patient outcome in severe acute pancreatitis (SAP). This prospective study was conducted to evaluate if perfusion CT (PCT) can predict the development of necrosis at an early stage in SAP.

METHODS

PCT was performed within 72 h of abdominal pain in 57 consecutive admitted patients of acute pancreatitis, out of which four patients were excluded. Thirty-two patients were classified as SAP and 21 as mild acute pancreatitis (MAP) on the basis of APACHE II or SIRS criteria or presence of organ failure. All patients underwent a follow-up CECT at 3 weeks to look for pancreatic necrosis.

RESULTS

Out of 32 patients of SAP, 14 patients showed perfusion defects. The mean blood flow (BF) in these areas was 11.47 ± 5.56 mL/100 mL/min and median blood volume (BV) was 3.92 mL/100 mL (0.5-8.49 mL/100 mL). All these patients developed necrosis on follow-up scan. Two patients who did not show perfusion defects also developed necrosis. Remaining 37 patients (16 SAP and 21 MAP) did not show perfusion defect and did not develop necrosis on follow-up. All regions showing BF less than ≤23.45 mL/100 mL/min and BV ≤8.49 mL/100 mL developed pancreatic necrosis. The values of perfusion parameters may vary with the scanner, mathematical model and protocol used. The sensitivity and specificity of PCT for predicting pancreatic necrosis were 87.5% and 100%, respectively. The cut off values of BF and BV for predicting the development of pancreatic necrosis were 27.29 mL/100 mL/min and 8.96 mL/100 mL, respectively, based on ROC curve. PCT is a reliable tool for early prediction of pancreatic necrosis, which may open new avenues to prevent this ominous complication.

Role of antibiotic prophylaxis in necrotizing pancreatitis: a meta-analysis

Several studies have yielded conflicting results on the role of antibiotic prophylaxis in improving outcomes in acute necrotizing pancreatitis. A meta-analysis was carried out to investigate the impact of antibiotic prophylaxis in the incidence of infected pancreatic necrosis and mortality.

METHODOLOGY

Randomized controlled trials and cohort studies investigating impact of prophylactic systemic antibiotic used in acute necrotizing pancreatitis were retrieved from online databases. An overall analysis was done with all studies (Group 1), followed by subgroup analyses with randomized controlled trials (Group 2) and cohort studies (Group 3). Risk ratios (RR) were calculated for the impact of antibiotic prophylaxis in the incidence of infected pancreatic necrosis and mortality in each group using random effects model.

RESULTS

Eleven studies involving 864 patients were included. No significant differences in the incidence of infected pancreatic necrosis were observed with prophylactic antibiotic use in all groups. Prophylactic antibiotic use was not associated with significant differences in all-cause mortality in Group 2 (RR = 0.75; p = 0.24) but was associated with a reduction in Groups 1 (RR = 0.66, p = 0.02) and 3 (RR = 0.55, p = 0.04). There was no statistical difference in the incidence of fungal infections and surgical interventions.

CONCLUSION

Antibiotic prophylaxis does not significantly reduce the incidence of infected pancreatic necrosis but may affect all-cause mortality in acute necrotizing pancreatitis.

Single or multiport percutaneous endoscopic necrosectomy performed with the patient under conscious sedation is a safe and effective treatment for infected pancreatic necrosis (with video)

BACKGROUND

Infected pancreatic necrosis (IPN) is a dreaded adverse event of acute pancreatitis (AP). Most patients with IPN require drainage and necrosectomy, preferably by a minimally invasive method.

OBJECTIVE

To study the success and safety of an alternative form of minimally invasive necrosectomy for IPN.

DESIGN

Observational study.

SETTING

Tertiary care academic center.

PATIENTS

Consecutive patients with IPN formed the study group.

INTERVENTION

Patients with IPN were initially treated conservatively including percutaneous drainage. Those who failed to improve underwent percutaneous endoscopic necrosectomy (PEN). Single- or multiport PEN was performed by using a flexible endoscope through the percutaneous tract. PEN involved vigorous lavage and suction followed by necrosectomy. Multiple sessions were undertaken depending on the size and number of collections and the amount of necrotic debris.

MAIN OUTCOME MEASUREMENTS

Control of sepsis and resolution of collection(s) without the need for surgical necrosectomy.

RESULTS

During the period from October 2012 to July 2013, 165 patients (mean age, 38.82 ± 14.99 years; 119 male patients) were studied. Of them, 103 patients had necrotizing pancreatitis and IPN had developed in 74. Of these 74 patients with IPN, 15 underwent PEN after a mean interval of 39.2 days. Fourteen of the 15 patients improved after a mean of 5 sessions of PEN. Two of 15 patients had minor adverse events: self-limiting bleeding and pancreatic fistula in 1 patient each. One patient required surgery but died of organ failure.

LIMITATIONS

Lack of a control arm.

CONCLUSION

PEN is a safe and effective minimally invasive technique for necrosectomy for IPN.

Hypotension in the first week of acute pancreatitis and APACHE II score predict development of infected pancreatic necrosis

BACKGROUND

Hypotension and intestinal mucosal ischemia lead to bacterial translocation from the gut lumen into systemic circulation.

AIM

The purpose of this study was to determine the strength of association between different types of organ failure (OF): hypotension (cardiovascular system failure), renal failure, respiratory failure, CNS failure and coagulopathy in the first week of acute pancreatitis (AP) and the subsequent development of infected pancreatic necrosis (IN).

METHODS

Consecutive patients with AP were evaluated for OF and its severity in the first week of hospital admission. Modified multiple organ failure score (MOFS) was used to identify and grade severity of OF. MOFS of ≥2, lasting for more than 48 h was defined as OF. Occurrence of IN (isolation of bacteria in necrosectomy specimen or image guided fine needle aspiration of pancreatic necrosis) was compared between groups with and without OF.

RESULTS

Of the 81 patients, mean age was 40.1 ± 14.4 years and 55 were males; 60 (74 %) patients had OF and 13 (16 %) patients had IN. Occurrence of IN was not significantly different between patients with OF (18.3 %) and without OF (14.3 %), p = 0.48. However IN occurred in 10 % of patients without and 33.7 % patients with hypotension, p = 0.01. The rest of the organ systems analyzed did not show any significant difference in occurrence of infected necrosis. On multivariate analysis independent predictors of occurrence of IN were hypotension (odds ratio, OR 2.5, p < 0.001) and APACHE II score at 24 h of hospital admission (OR 4.77, p < 0.001).

CONCLUSION

Hypotension in the first week of AP and APACHE II score predict development of IN.

A percutaneous drainage protocol for severe and moderately severe acute pancreatitis

BACKGROUND

According to the revised Atlanta classification, severe and moderately severe acute pancreatitis (AP) includes patients with pancreatic and peripancreatic collections with or without organ failure. These collections suggest the presence of pancreatic juice leakage. The aim of this study was to evaluate the efficacy of a percutaneous catheter drainage (PCD) protocol designed to control leakage and decrease disease severity.

METHODS

Among 663 patients with clinical AP, 122 were classified as moderately severe or severe AP (all had collections). The computed tomography severity index (CTSI) score was calculated. The indication for PCD was based on progressive clinical signs and symptoms. Drain patency, position, and need for additional drainage sites were assessed using CT scans and drain studies initially every 3 days using a proactive protocol. Drain fluid was examined for amylase concentration and microbiological culture. Clinicopathological variables for patients with and without PCD were compared. Since there was no mortality, we used prolonged drainage time to measure the success of PCD. Within the group treated with PCD, variables that resulted in prolonged drainage time were analyzed.

RESULTS

PCD was used in 47/122 (39 %) patients of which 33/47 (70 %) had necrosis. PCD cases had a median CTSI of 8 and were classified as moderately severe AP (57 %) and severe AP (43 %). Inhospital mortality was zero. Surgical necrosectomy was not required for patients with necrosis. Independent risk factors for prolonged drainage time were persistent organ failure >48 h (P = 0.001), CTSI 8-10 (P = 0.038), prolonged duration of amylase-rich fluid in drains (P < 0.001), and polymicrobial culture fluid in drains (P = 0.015).

CONCLUSIONS

A proactive PCD protocol persistently maintaining drain patency advanced to the site of leak controlled the prolonged amylase in drainage fluid resulting in a mortality rate of zero.

Spectrum of microorganisms in infected walled-off pancreatic necrosis - impact on organ failure and mortality

OBJECTIVE

Data on the microbial spectrum in infected pancreatic necrosis are scarce. Only few studies have addressed this issue in a larger, consecutive group of patients treated by a standardized algorithm. Since 2005 endoscopic, transmural drainage and necrosectomy (ETDN) has been the treatment of choice for walled-off necrosis in our centre. The present study evaluated the microbial spectrum of infected pancreatic necrosis and the possible relationship between infected necrosis, organ failure, and mortality. Furthermore, we investigated whether the aetiology of pancreatitis, use of external drainage, and antibiotic treatment influenced the microbial findings.

METHODS

Retrospective review of medical charts on 78 patients who underwent ETDN in our tertiary referral centre between November 2005 and November 2011.

RESULTS

Twenty-four patients (31%) developed one or more organ failures, 23 (29%) needed treatment in the intensive care unit (ICU), and 9 (11%) died during hospital admission. The prevailing microbial findings at the index endoscopy were enterococci (45%), enterobacteriaceae (42%), and fungi (22%). There was a significant association between the development of organ failure (p < 0.001), need of treatment in ICU (p < 0.002), in-hospital mortality (p = 0.039) and infected necrosis at the time of index endoscopy. Enterococci (p < 0.0001) and fungi (p = 0.01) were found more frequently in patients who died during admission as compared to survivors.

CONCLUSION

Different microbes in pancreatic necrosis may influence the prognosis. We believe that a detailed knowledge on the microbial spectrum in necrotizing pancreatitis may be utilized in the treatment to improve the outcome.

Electron-microscopic evidence of mitochondriae containing macroautophagy in experimental acute pancreatitis: implications for cell death

BACKGROUND

Dysfunctional autophagy and necrosis are characteristic features of severe acute pancreatitis.

OBJECTIVE

To unravel the cellular mechanisms underlying the pathogenesis of acute pancreatitis.

METHODS

We studied the ultrastructural pancreatic morphology using electron microscopy in experimental acute pancreatitis. The control group of animals received intraperitoneal injections of normal saline. Different severity of acute pancreatitis was induced by low and high doses of caerulein in Swiss albino mice. In the low dose group, pancreatitis was induced by 4 injections of caerulein given hourly [50 μg/kg/dose - total of 200 μg/kg] and in the high dose group by 8 injections given hourly (total of 400 μg/kg). The experiments were repeated in Na-taurocholate model of acute pancreatitis in rats. The pancreatic tissue was processed and studied by transmission electron microscopy for ultrastructural changes.

RESULTS

The acinar cells of the pancreatitis animals revealed autophagosomes that contained cellular organelles, including mitochondria. The animals that received a higher dose of caerulein had numerous cells showing a necrotic morphology, whereas the animals in the low dose group showed a predominantly apoptotic cell morphology. The Na-taurocholate model in rats also showed similar features of severe pancreatitis with cellular necrosis and macroautophagy.

CONCLUSIONS

Dysfunctional mitochondria in the injured pancreatic acinar cells are degraded by macroautophagy. These observations are not model specific. Mitochondrial dysfunction and consequent energy deficit in the cells might be causally related to cellular necrosis.

Systemic Review for The Effectiveness of Current Conservative Treatment in Necrotizing Pancreatitis

The standard treatment of pancreatic necrosis has been surgical necrosectomy. There has been debate on whether early surgical intervention can reduced by infected pancreatic necrosis (IPN). Early emergency laparotomy and multiple organ failure remain associated with high mortality. However, reports have presented during the last 10 years of survival of severe acute pancreatitis with medical management. Large and multicenter study showed that about two thirds of patients with necrotizing pancreatitis can be treated conservatively with relatively low mortality. Patients with IPN benefit from postponding intervention and minimal invasive treatment. We reviewed 4 literatures including 2 Korean institute reseached reports concerning non-surgical, conservative treatments of necrotizing pancreatitis including IPN. Large and multicenter study showed that about two thirds of patients with necrotizing pancreatitis can be treated conservatively with relatively low mortality.

[International multidisciplinary classification of acute pancreatitis severity: the 2013 Spanish edition]

OBJECTIVE

To develop a new classification of acute pancreatitis severity on the basis of a sound conceptual framework, comprehensive review of the published evidence, and worldwide consultation.

BACKGROUNDS

The Atlanta definitions of acute pancreatitis severity are ingrained in the lexicon of specialist in pancreatic diseases, but are suboptimal because these definitions are based on the empiric description of events not associated with severity.

METHODS

A personal invitation to contribute to the development of a new classification of acute pancreatitis severity was sent to all surgeons, gastroenterologists, internists, intensivists and radiologists currently active in the field of clinical acute pancreatitis. The invitation was not limited to members of certain associations or residents of certain countries. A global web-based survey was conducted, and a dedicated international symposium was organized to bring contributors from different disciplines together and discuss the concept and definitions.

RESULTS

The new classification of severity is based on the actual local and systemic determinants of severity, rather than on the description of events that are non-causally associated with severity. The local determinant relates to whether there is (peri) pancreatic necrosis or not, and if present, whether it is sterile or infected. The systemic determinant relates to whether there is organ failure or not, and if present, whether it is transient or persistent. The presence of one determinant can modify the effect of another, whereby the presence of both infected (peri) pancreatic necrosis and persistent organ failure has a greater impact upon severity than either determinant alone. The derivation of a classification based on the above principles results in four categories of severity: mild, moderate, severe, and critical.

CONCLUSIONS

This classification is the result of a consultative process among specialists in pancreatic diseases from 49 countries spanning North America, South America, Europe, Asia, Oceania and Africa. It provides a set of concise up to date definitions of all the main entities pertinent to classifying the severity of acute pancreatitis in clinical practice and research. This ensures that the determinant-based classification can be used in a uniform manner throughout the world.

Duration of injury correlates with necrosis in caerulein-induced experimental acute pancreatitis: implications for pathophysiology

Pancreatic acinar cell necrosis is indicative of severe pancreatitis and the degree of necrosis is an index of its outcome. We studied whether the dose and duration of injury correlates with severity, particularly in terms of necrosis, in caerulein-induced acute pancreatitis (AP) in Swiss albino mice. In addition to control group 1 (G1), groups 2 and 3 received four injections of caerulein every hour but were sacrificed at five hours (G2) and nine hours (G3) respectively, and group 4 received eight injections and was sacrificed at nine hours (G4). The severity of pancreatitis was assessed histopathologically and biochemically. The histopathological scores of pancreatitis in groups 3 and 4 were significantly higher than in groups 1 and 2 (4 vs. 1, 4 vs. 2, 3 vs. 1, 3 vs. 2; P < 0.05). TUNEL-positive apoptotic cells were significantly higher in groups 2 and 3 compared with groups 1 and 4 (P < 0.05). Necrosis was significantly more in group 4 than other groups (37.49% (4.68) vs. 19.97% (1.60) in G2; 20.36% (1.56) in G3; P = 0.006 for G 2 vs. 4 and P = 0.019 for G 3 vs. 4). Electron microscopy revealed numerous autophagosomes in groups 2 and 3 and mitochondrial damage and necrosis in group 4. The pancreatic and pulmonary myeloperoxidase activity in group 4 was significantly higher than that in the other groups (P < 0.01). Hence, severity of pancreatitis is a function of the dose of injurious agent, while inflammation is both dose and duration dependent, which may also explain the wide spectrum of severity of AP seen in clinical practice.

Nutrition, inflammation, and acute pancreatitis

Acute pancreatitis is acute inflammatory disease of the pancreas. Nutrition has a number of anti-inflammatory effects that could affect outcomes of patients with pancreatitis. Further, it is the most promising nonspecific treatment modality in acute pancreatitis to date. This paper summarizes the best available evidence regarding the use of nutrition with a view of optimising clinical management of patients with acute pancreatitis.

Bedside index for severity in acute pancreatitis: comparison with other scoring systems in predicting severity and organ failure

BACKGROUND

The early identification of severe acute pancreatitis is important for the management and for improving outcomes. The bedside index for severity in acute pancreatitis (BISAP) has been considered as an accurate method for risk stratification in patients with acute pancreatitis. This study aimed to evaluate the comparative usefulness of the BISAP.

METHODS

We retrospectively analyzed 303 patients with acute pancreatitis diagnosed at our hospital from March 2007 to December 2010. BISAP, APACHE-II, Ranson criteria, and CT severity index (CTSI) of all patients were calculated. We stratified the number of patiants with severe pancreatitis, pancreatic necrosis, and organ failure as well as the number of deaths by BISAP score. We used the area under the receiver-operating curve (AUC) to compare BISAP with other scoring systems, C-reactive protein (CRP), hematocrit, and body mass index (BMI) with regard to prediction of severe acute pancreatitis, necrosis, organ failure, and death.

RESULTS

Of the 303 patiants, 31 (10.2%) were classified as having severe acute pancreatitis. Organ failure occurred in 23 (7.6%) patients, pancreatic necrosis in 40 (13.2%), and death in 6 (2.0%). A BISAP score of 2 was a statistically significant cutoff value for the diagnosis of severe acute pancreatitis, organ failure, and mortality. AUCs for BISAP predicting severe pancreatitis and death were 0.80 and 0.86, respectively, which were similar to those for APACHE-II (0.80, 0.87) and Ranson criteria (0.74, 0.74) and greater than AUCs for CTSI (0.67, 0.42). The AUC for organ failure predicted by BISAP, APACHE-II, Ranson criteria, and CTSI was 0.93, 0.95, 0.84 and 0.57, respectively. AUCs for BISAP predicting severity, organ failure, and death were greater than those for CRP (0.69, 0.80, 0.72), hematocrit (0.45, 0.35, 0.14), and BMI (0.41, 0.47, 0.17).

CONCLUSION

The BISAP predicts severity, death, and especially organ failure in acute pancreatitis as well as APACHE-II does and better than Ranson criteria, CTSI, CRP, hematocrit, and BMI.

The revised Atlanta classification for acute pancreatitis: updates in imaging terminology and guidelines

Imaging of acute pancreatitis requires not only an understanding of the disease subtypes and the myriad of associated complications but also familiarity with the appropriate radiologic nomenclature as defined by the Atlanta symposium in 1992 and, more recently, by the Acute Pancreatitis Classification Working Group in 2008. The accurate description of the radiological findings plays a critical role in the evaluation and management of patients with acute pancreatitis, particularly those with severe disease. There have been increasing efforts to develop uniformity in the use of terminology used to define the radiologic findings in acute pancreatitis, in particular, the terminology for fluid collections, a common area of inconsistency and confusion. Terms such as "acute peripancreatic fluid collections," "acute post- necrotic fluid collections," "pseudocyst," and "walled-off pancreatic necrosis" are now recommended as they describe the evolution of fluid collections in patients with both interstitial and necrotizing pancreatitis and nonspecific terms such as "pancreatic abscess" and "phlegmon" are being abandoned. In this review we illustrate, with case examples, the standardized terminology used in the radiological and clinical description of acute pancreatitis, its severity, and complications with an emphasis on the role of ultrasound, computed tomography and magnetic resonance imaging. Different management options of the associated complications are also discussed. The use of standardized terminology will hopefully improve the communication between radiologists, gastroenterologists, and surgeons to facilitate treatment planning and will lead to enhanced outcomes for patients with acute pancreatitis as well as create uniformity for enrollment into research studies.

Efficacy of conservative treatment, without necrosectomy, for infected pancreatic necrosis: a systematic review and meta-analysis

BACKGROUND & AIMS

Conservative treatment (intensive care, a combination of antimicrobial agents, and nutritional support, with or without drainage of the infected fluid) has recently been shown to be effective for patients with infected pancreatic necrosis (IPN), but the data from individual studies are not robust enough to recommend it as the standard of care. We performed a systematic review and meta-analysis of studies related to primary conservative management for IPN.

METHODS

We performed a literature search of MEDLINE/PubMed from January 1990 to March 2012 for studies of a priori protocols for primary conservative treatment, without necrosectomy, for consecutive patients with IPN. We analyzed data from 8 studies, comprising 324 patients with IPN who received primary conservative management. We then analyzed an additional 4 studies (comprising 157 patients) that reported the efficacy of percutaneous drainage in nonconsecutive patients with IPN. Outcome measures were the success of conservative management strategy, need for necrosectomy, and mortality.

RESULTS

There was significant heterogeneity in results among the studies. Based on a random effects model, conservative management was successful for 64% of patients (95% confidence interval [CI], 51%-78%); mortality was 12% (95% CI, 6%-18%), and 26% of patients required necrosectomy or additional surgery for complications (95% CI, 15%-37%). A separate analysis of 4 studies that reported outcomes of nonconsecutive patients with IPN following percutaneous drainage had comparable results; 50% had successful outcomes (95% CI, 43%-58%), mortality was 18% (95% CI, 6%-30%), and 38% of patients required surgery (95% CI, 20%-56%).

CONCLUSIONS

Conservative management without necrosectomy is a successful approach for 64% of patients with IPN. This approach has low mortality and prevents surgical necrosectomy.

Determinant-based classification of acute pancreatitis severity: an international multidisciplinary consultation

OBJECTIVE

To develop a new international classification of acute pancreatitis severity on the basis of a sound conceptual framework, comprehensive review of published evidence, and worldwide consultation.

BACKGROUND

The Atlanta definitions of acute pancreatitis severity are ingrained in the lexicon of pancreatologists but suboptimal because these definitions are based on empiric description of occurrences that are merely associated with severity.

METHODS

A personal invitation to contribute to the development of a new international classification of acute pancreatitis severity was sent to all surgeons, gastroenterologists, internists, intensivists, and radiologists who are currently active in clinical research on acute pancreatitis. The invitation was not limited to members of certain associations or residents of certain countries. A global Web-based survey was conducted and a dedicated international symposium was organized to bring contributors from different disciplines together and discuss the concept and definitions.

RESULT

The new international classification is based on the actual local and systemic determinants of severity, rather than description of events that are correlated with severity. The local determinant relates to whether there is (peri)pancreatic necrosis or not, and if present, whether it is sterile or infected. The systemic determinant relates to whether there is organ failure or not, and if present, whether it is transient or persistent. The presence of one determinant can modify the effect of another such that the presence of both infected (peri)pancreatic necrosis and persistent organ failure have a greater effect on severity than either determinant alone. The derivation of a classification based on the above principles results in 4 categories of severity-mild, moderate, severe, and critical.

CONCLUSIONS

This classification is the result of a consultative process amongst pancreatologists from 49 countries spanning North America, South America, Europe, Asia, Oceania, and Africa. It provides a set of concise up-to-date definitions of all the main entities pertinent to classifying the severity of acute pancreatitis in clinical practice and research. This ensures that the determinant-based classification can be used in a uniform manner throughout the world.

Early detection of low enhanced pancreatic parenchyma by contrast-enhanced computed tomography predicts poor prognosis of patients with acute pancreatitis

OBJECTIVES

The usefulness of early severity assessment of acute pancreatitis (AP) by contrast-enhanced computed tomography (CECT) was investigated.

METHODS

Data were obtained from a 2007 nationwide survey in Japan. Clinical data of 983 patients with AP were analyzed. All were examined by CECT on the day of admission.

RESULTS

Early findings of CECT demonstrated that low enhanced pancreatic parenchyma (LEPP) was associated with the incidence of organ failure (OF), multiple OF, and infectious complications as well as mortality (P < 0.0001). Next, patients were further divided into 4 groups according to the CECT findings, which focused on the LEPP and peripancreatic collections (PPCs). The LEPP/PPC (+/+) group was characterized as high morbidity and high mortality. The incidence of OF (28.2%), multiple OF (15.5%), and mortality (11.4%) in patients assigned to the (+/+) group was significantly higher than in those assigned to the other groups. The incidence of infectious complications was significantly higher in patients assigned to the (+/+) group (16.7%), the (+/-) group (9.0%), and the (-/+) group (7.0%) than those assigned to the (-/-) group (1.8%).

CONCLUSIONS

The detection of LEPP and PPC was a useful CECT finding for the early assessment of the severity of AP.

Minimally invasive operations for acute necrotizing pancreatitis: comparison of minimally invasive retroperitoneal necrosectomy with endoscopic transgastric necrosectomy

BACKGROUND

A "step-up" approach is currently the treatment of choice for acute necrotizing pancreatitis. Our aim was to evaluate the outcome of minimally invasive retroperitoneal necrosectomy (MINE) and endoscopic transgastric necrosectomy (ETG) and to compare it to open necrosectomy (ONE).

METHODS

Patients with acute pancreatitis admitted to our institution from 1998 to 2010 (n = 334) were identified. From these, patients who underwent either ONE, MINE, or ETG were selected for further analysis. Statistical analysis employed 2-sided Fisher's exact test and Mann-Whitney U-test.

RESULTS

From 2002 to 2010, 32 patients with acute necrotizing pancreatitis were treated by minimally invasive procedures including MINE (n = 14) and ETG (n = 18) or with the classic technique of ONE (n = 30). Time from onset of symptoms to intervention was less for ONE than for MINE or ETG (median, 11 vs 39 vs 54 days; P < .05). The rate of critically ill patients with sepsis or septic shock was greatest in ONE (93%) and MINE (71%) compared with ETG (17%; P < .05). Problems after ONE and MINE were ongoing sepsis (ONE 73% vs MINE 29% vs ETG 11%) and bleeding requiring intervention (ONE 26% vs MINE 21% vs ETG 17%). A specific complication of ETG was gastric perforation into the peritoneal cavity during the procedure (28%), requiring immediate open pseudocystogastrostomy. Laparotomy was necessary in 21% after MINE and 28% after ETG owing to specific complications or persistent infected necrosis. Overall mortality was greatest after ONE (ONE 63% vs MINE 21% vs ETG 6%; P < .05).

CONCLUSION

Morbidity and mortality remains high in acute necrotizing pancreatitis. Operative procedures should be delayed as long as possible to decrease morbidity and mortality. Minimally invasive procedures can avoid laparotomy, but also introduce specific complications requiring immediate or secondary open operative treatment. Minimally invasive procedures require unique expertise and therefore should only be performed at specialized centers.

Correlation between procalcitonin and intra-abdominal pressure and their role in prediction of the severity of acute pancreatitis

BACKGROUND/AIMS

Early assessment of disease severity and vigilant patient monitoring are key factors for adequate treatment of acute pancreatitis (AP). The aim of this study was to determine the correlation of procalcitonin (PCT) serum concentrations and intra-abdominal pressure (IAP) as prognostic markers in early stages of AP.

METHODS

This prospective observational study included 51 patients, of which 29 had severe AP (SAP). Patients were evaluated with the Acute Physiology And Chronic Health Evaluation (APACHE II) score, C-reactive protein (CRP) and PCT serum concentrations and IAP at 24 h from admission. PCT was measured three times in the 1st week of disease and three times afterward, while IAP was measured daily. PCT and IAP values correlated with each other, and also compared with APACHE II score and CRP values.

RESULTS

PCT, IAP, CRP values and APACHE II score at 24 h after hospital admission were significantly elevated in patients with SAP. There was significant correlation between PCT and IAP values measured at 24 h of admission, and between maximal PCT and IAP values. Sensitivity/specificity for predicting AP severity at 24 h after admission was 89%/69% for APACHE II score, 75%/86% for CRP, 86%/63% for PCT and 75%/77% for IAP.

CONCLUSIONS

Increased IAP was accompanied by increased PCT serum concentration in patients with AP. PCT and IAP can both be used as early markers of AP severity.

Fluid collections in and around the pancreas in acute pancreatitis

The advent of computed tomographic scan with its wide use in the evaluation of acute pancreatitis has opened up a new topic in pancreatology i.e. fluid collections. Fluid collections in and around the pancreas occur often in acute pancreatitis and were defined by the Atlanta Symposium on Acute Pancreatitis in 1992. Two decades since the Atlanta Conference additional experience has brought to light the inadequacy and poor understanding of the terms used by different specialists involved in the care of patients with acute pancreatitis when interpreting imaging modalities and the need for a uniformly used classification system. The deficiencies of the Atlanta definitions and advances in medicine have led to a proposed revision of the Atlanta classification promulgated by the Acute Pancreatitis Classification Working Group. The newly used terms "acute peripancreatic fluid collections," "pancreatic pseudocyst," "postnecrotic pancreatic/peripancreatic fluid collections," and "walled-off pancreatic necrosis" are to be clearly understood in the interpretation of imaging studies. The current treatment methods for fluid collections are diverse and depend on accurate interpretations of radiologic tests. Management options include conservative treatment, percutaneous catheter drainage, open and laparoscopic surgery, and endoscopic drainage. The choice of treatment depends on a correct diagnosis of the type of fluid collection. In this study we have attempted to clarify the management and clinical features of different types of fluid collections as they have been initially defined under the 1992 Atlanta Classification and revised by the Working Group's proposed categorization.