Classification of acute pancreatitis--2012: revision of the Atlanta classification and definitions by international consensus

Fluid Resuscitation in the Treatment of Acute Pancreatitis: Rate and Volume Controversies

The aim of the Research to Practice column is to enhance the research critique abilities of both advanced practice registered nurses and emergency nurses, while also aiding in the translation of research findings into clinical practice. Each column focuses on a specific topic and research study. In this article, we used a scenario of left upper quadrant pain to explore the study by de-Madaria et al., titled "Aggressive or moderate fluid resuscitation in acute pancreatitis".

Evaluation of retinal structural and microvascular changes in patients with acute pancreatitis

BACKGROUND

This study aimed to show the changes in retinal vascular densities and thicknesses in the peripapillary and macular regions in the acute period in patients with acute pancreatitis (AP).

METHODS

This prospective cross-sectional study included 57 eyes of 30 patients with AP and 58 eyes of 30 healthy people. Optical coherence tomography angiography (OCTA) was taken within 24-72 h of AP patients' hospitalization. OCTA was used to evaluate the retinal microvascular structure and retinal thickness.

RESULTS

Peripapillary retinal nerve fiber layer (pp-RNFL) and perifoveolar ganglion cell complex (pef-GCC) thickness in patients with AP were significantly higher than in the healthy control group (p = 0.020 and p = 0.039, respectively). While whole image vessel density (wiVD) and perifoveal vessel density (pefVD) were significantly lower in the deep capillary plexus (DCP), choriocapillaris flow area (CCFA) in the macula were significantly lower in each of the 1 mm and 3 mm radius areas in patients with AP (p = 0.014, p = 0.011; p = 0.011, and p = 0.035 respectively). In the univariable and multivariable linear regression analysis, it was observed that serum lipase and procalcitonin levels affected the thickness of pp-RNFL and pef-GCC (for pp-RNFL, β= 0.001, p = 0.002, β=24.992, p < 0.001, and for pef-GCC, β= 0.001 p = 0.014, β=17.107 p < 0.001 respectively).

CONCLUSIONS

There are significant microvascular and structural changes in the optic nerve and macula in patients with AP. The relationship between these changes and serum lipase and procalcitonin levels was shown. Clinicians should consider ocular involvement in AP patients with high serum lipase and procalcitonin levels.

Comorbidity burden and outcomes of endoscopic ultrasound-guided treatment of pancreatic fluid collections: Multicenter study with nationwide data-based validation

OBJECTIVES

The appropriate holistic management is mandatory for successful endoscopic ultrasound (EUS)-guided treatment of pancreatic fluid collections (PFCs). However, comorbidity status has not been fully examined in relation to clinical outcomes of this treatment.

METHODS

Using a multi-institutional cohort of 406 patients receiving EUS-guided treatment of PFCs in 2010-2020, we examined the associations of Charlson Comorbidity Index (CCI) with in-hospital mortality and other clinical outcomes. Multivariable logistic regression analysis was conducted with adjustment for potential confounders. The findings were validated using a Japanese nationwide inpatient database including 4053 patients treated at 486 hospitals in 2010-2020.

RESULTS

In the clinical multi-institutional cohort, CCI was positively associated with the risk of in-hospital mortality (Ptrend < 0.001). Compared to patients with CCI = 0, patients with CCI of 1-2, 3-5, and ≥6 had adjusted odds ratios (95% confidence intervals) of 0.76 (0.22-2.54), 5.39 (1.74-16.7), and 8.77 (2.36-32.6), respectively. In the nationwide validation cohort, a similar positive association was observed; the corresponding odds ratios (95% confidence interval) were 1.21 (0.90-1.64), 1.52 (0.92-2.49), and 4.84 (2.63-8.88), respectively (Ptrend < 0.001). The association of higher CCI with longer length of stay was observed in the nationwide cohort (Ptrend < 0.001), but not in the clinical cohort (Ptrend = 0.18). CCI was not associated with the risk of procedure-related adverse events.

CONCLUSIONS

Higher levels of CCI were associated with a higher risk of in-hospital mortality among patients receiving EUS-guided treatment of PFCs, suggesting the potential of CCI in stratifying the periprocedural mortality risk.

TRIAL REGISTRATION

The research based on the clinical data from the WONDERFUL cohort was registered with UMIN-CTR (registration number UMIN000044130).

Contemporary Approach to Acute Pancreatitis in Emergency Medicine

Acute pancreatitis is a commonly encountered pathology in the emergency department. We presented a clinical review summarizing the contemporary emergency medicine approach to managing acute pancreatitis. Although the diagnostic criteria for acute pancreatitis are straightforward, it has many possible causes, several treatment options, and both short- and long-term sequelae. We discussed diagnostic, intervention, and disposition considerations relevant to emergency clinicians and considered risk assessment using available clinical decision tools. We also discussed changes to traditional treatments and ongoing investigational therapies, including steroids, monoclonal antibodies, and calcium release-activated calcium channel inhibitors.

Predictive value of postoperative serum lipase level for postoperative pancreatic fistula after pancreaticoduodenectomy

BACKGROUND

The prediction of postoperative pancreatic fistula (POPF) is important. This study aimed to investigate the role of postoperative serum lipase level in predicting POPF.

METHODS

Data from 234 consecutive patients who underwent pancreaticoduodenectomy (PD) were collected. The predictive values of serum amylase and serum lipase during postoperative days (PODs) 1 to 3 for POPF were compared. Subgroup analyses were performed to determine the prognostic value of different levels and durations of elevated serum lipase.

RESULTS

Fifty-six patients developed POPF. The POPF group exhibited increased levels of serum amylase and lipase from PODs 1 to 3 (all P < 0.001). Compared with serum amylase, serum lipase has greater predictive value for POPF. Specifically, serum lipase had the highest area under the receiver operating characteristic curve (AUC) at POD 1 (0.791). Body mass index > 24 kg/m2 [odds ratio (OR) = 2.431, 95% confidence interval (CI): 1.094-5.404, P = 0.029], soft pancreatic texture (OR = 3.189, 95% CI: 1.263-8.056, P = 0.014), serum lipase > 60 U/L at POD 1 (OR = 5.135, 95% CI: 1.257-20.982, P = 0.023), and C-reactive protein > 167 mg/dL at POD 3 (OR = 3.607, 95% CI: 1.431-9.090, P = 0.007) were identified as independent risk factors for POPF. Patients with serum lipase ≤ 60 U/L at POD 1 (n = 104) exhibited lower rates of POPF (3.8% vs. 40.0%, P < 0.001) and severe complications (Clavien-Dindo ≥ IIIa) (4.8% vs. 25.4%, P < 0.001) than those with serum lipase > 60 U/L at POD 1. Moreover, no additional elevation or duration of serum lipase offered any further prognostic value.

CONCLUSIONS

Postoperative serum lipase outperformed serum amylase in the prediction of POPF, and patients with normal serum lipase level at POD 1 had favorable outcomes. A sustained increase in the serum lipase level offers no additional prognostic value.

Systematic review of peritoneal lavage and dialysis for patients with severe acute pancreatitis

AIMS

Severe acute pancreatitis (SAP) remains a lethal condition with a rising incidence worldwide. Recent randomised trials suggest that peritoneal lavage and/or dialysis (PLD), when administered early in SAP, may be beneficial to improve patient outcomes. This study aimed to review this data systematically.

METHODS

Studies featuring PLD for the treatment of SAP were searched systematically (2012 Atlanta classification to 2023). A traditional approach to reporting data was augmented by a narrative synthesis.

RESULTS

210 articles were reviewed, of which six studies featuring 499 patients were included. The technical approach, duration and type of lavage varied in each study and no safety concerns were reported. In patients undergoing PLD, improvements in inflammatory markers and length of stay were seen in all studies. Where reported, fewer invasive procedures for peri-pancreatic fluid collections were required after PLD. Lower mortality was seen in cohorts receiving laparoscopic lavage alone and combined lavage and dialysis when compared with standard treatment. All studies were rated at moderate or high risk of bias.

CONCLUSIONS

PLD demonstrates potential as an early therapy to improve outcomes for patients with SAP. Further research is required to define intervention delivery, explore acceptability and investigate efficacy through a powered randomised controlled trial.

Effect of periampullary diverticulum morphology on ERCP cannulation and clinical results

AIM

Periampullary diverticulum (PAD) is a common anatomical variant that can potentially impact the technical difficulty and outcomes of endoscopic retrograde cholangiopancreatography (ERCP), necessitating a comprehensive understanding of its effects on the procedure. To evaluate the effect of PAD subtypes and diameter on ERCP cannulation success and clinical outcomes.

MATERIALS AND METHODS

The study included patients with PAD and papilla-naïve patients undergoing ERCP for suspected common bile duct stones or distal benign strictures (due to PAD compression). PAD subtyping was based on Lobo and Li-Tanaka classifications. Diverticulum size was categorized as small (<1 cm), medium (1-2 cm), and giant (≥2 cm).

RESULTS

Of the 907 patients analyzed, 164 (18%) had PAD with a median age of 63 years. PAD patients were significantly older than non-PAD patients and had more comorbidities. The most frequent PAD type was 2B (34.1%) based on the Li-Tanaka classification. Subgroup analysis of PAD types 1, 2, 3, and 4 showed no statistically significant differences in cannulation time, success, total procedure time, or adverse events (AEs). Overall cannulation success rates were similar between PAD and non-PAD groups (99.4% vs 99.6%). Analysis based on diverticulum size revealed higher probabilities of giant stones and procedure-related AEs in giant diverticula. The risk of post-ERCP pancreatitis was notably low at 1.8% in the PAD group.

CONCLUSION

Diverticulum size, rather than PAD subtype, may be more closely associated with cannulation success and procedure-related AEs in ERCP. Individualized management considering diverticulum size may improve outcomes in PAD patients undergoing ERCP.

Standardized approach to removal of lumen apposing metal stents following endoscopic necrosectomy: one size does not fit all

Background

Walled-off necrosis (WON) is a sequela of acute necrotizing pancreatitis preferentially managed with lumen apposing metal stents (LAMS). Adverse events including buried stent syndrome and bleeding have been associated with a longer duration of LAMS placement.

Objectives

We attempt to examine our outcomes of a standardized approach to LAMS dwell time and hypothesize that LAMS removal based on imaging characteristics and patient symptoms improves outcomes.

Design

From November 2015 to May 2022, a prospectively maintained database on patients with symptomatic WON undergoing endoscopic drainage with LAMS was retrospectively reviewed and analyzed.

Methods

Patient characteristics, procedure details, and outcomes were recorded. Imaging was performed at 1, 3, and 6 weeks after LAMS placement and 1 week after each necrosectomy. Imaging findings and patient symptoms were used to determine the need for repeat necrosectomy. The timing of LAMS removal was guided by adequate endoscopic necrosectomy and resolution of the patient's symptoms. Subgroups were identified based on the duration of LAMS placement (less than 4 weeks and more than 4 weeks). Independent t-tests (continuous variables) and Fisher's exact tests (categorical outcomes) were used to analyze the two groups.

Results

In all, 104 patients underwent endoscopic necrosectomy during the study period. Of the two subgroups identified based on LAMS dwell time, 70 patients had a LAMS duration greater than 4 weeks and 34 patients had a LAMS duration less than 4 weeks. Collections with >50% necrosis were more commonly seen in patients with longer LAMS dwell time (<4 weeks (12%) vs >4 weeks (33%), p = 0.031). The median number of necrosectomies was fewer in the early LAMS removal group compared to the late LAMS removal cohort (p = 0.03). Clinical outcomes including technical success, clinical success, delayed adverse events, and 6-month mortality were similar in both groups.

Conclusion

A patient-specific customized approach to endoscopic drainage of WON improves outcomes. Patients with extensive necrosis may require a longer LAMS dwell time to achieve adequate debridement and clinical resolution. An increased risk of bleeding or adverse events related to prolonged duration of LAMS placement was not observed in our study. Future larger prospective studies are needed to confirm these conclusions.

Association Between Glycemic Variability and All-Cause Mortality in Patients with Acute Pancreatitis in the Intensive Care Unit: A Retrospective Analysis

BACKGROUND

Identifying high-risk acute pancreatitis (AP) patients in the ICU is vital for improving prognosis. Thus, this study aims to explore the relationship between the coefficient of variation (CV) of blood glucose and the all-cause mortality of patients with AP in the ICU.

METHODS

A retrospective analysis was conducted on AP patients in the MIMIC-IV database. The CV was used to describe the glycemic variability (GV) and the optimal cut-off value was determined using the ROC curve. Subsequently, analyze the correlation between CV and all-cause mortality.

RESULTS

A total of 907 patients with AP in the ICU were included in this study. The ROC curve determined the optimal CV cut-off value as 0.25. The KM survival curves and univariate and multivariate logistics regression analyses all showed that CV was associated with the 30-day, 60-day, and 90-day all-cause mortality (P < 0.05). The RCS curves showed a nonlinear correlation (P < 0.05). When CV is less than 0.421, 0.449, and 0.428, respectively, the risk of death at 30-day, 60-day, and 90-day increases as the CV value rises. Subgroup analysis showed an interaction between congestive heart failure and CV in 30-day and 60-day all-cause mortality, between age and CV in 60-day and 90-day all-cause mortality, and between chronic pulmonary disease and CV in 30-day all-cause mortality (P all < 0.05).

CONCLUSION

The CV is associated with the all-cause mortality of AP patients in the ICU, especially when the CV value is between 0.25 and 0.45. When using CV, the effects of age, congestive heart failure, and chronic pulmonary disease should be considered.

VMP1 Constitutive Expression in Mice Dampens Pancreatic and Systemic Histopathological Damage in an Experimental Model of Severe Acute Pancreatitis

Acute pancreatitis (AP) an inflammatory condition caused by the premature activation of pancreatic proteases, leads to organ damage, systemic inflammation, and multi-organ failure. Severe acute pancreatitis (SAP) has high morbidity and mortality, affecting the liver, kidneys, and lungs. Autophagy maintains pancreatic homeostasis, with VMP1-mediated selective autophagy (zymophagy) preventing intracellular zymogen activation and acinar cell death. This study examines the protective role of VMP1 (Vacuole Membrane Protein 1)-induced autophagy using ElaI-VMP1 transgenic mice in a necrohemorrhagic SAP model (Hartwig's model). ElaI-VMP1 mice show significantly reduced pancreatic injury, including lower necrosis, edema, and inflammation, compared to wild-type (WT) mice. Biochemical markers (lactate dehydrogenase-LDH-, amylase, and lipase) and histopathology confirm that VMP1 expression mitigates pancreatic damage. Increased zymophagy negatively correlates with acinar necrosis, reinforcing its protective role. Beyond the pancreas, ElaI-VMP1 mice exhibit preserved liver, kidney, and lung histology, indicating reduced systemic organ damage. The liver maintains normal architecture, kidneys show minimal tubular necrosis, and lung inflammation features are reduced compared to WT mice. Our results confirm that zymophagy functions as a protective pathophysiological mechanism against pancreatic and extrapancreatic tissue injury in SAP. Further studies on the mechanism of VMP1-mediated selective autophagy in AP are necessary to determine its relevance and possible modulation to prevent the severity of AP.

AI and Machine Learning for Precision Medicine in Acute Pancreatitis: A Narrative Review

Acute pancreatitis (AP) presents a significant clinical challenge due to its wide range of severity, from mild cases to life-threatening complications such as severe acute pancreatitis (SAP), necrosis, and multi-organ failure. Traditional scoring systems, such as Ranson and BISAP, offer foundational tools for risk stratification but often lack early precision. This review aims to explore the transformative role of artificial intelligence (AI) and machine learning (ML) in AP management, focusing on their applications in diagnosis, severity prediction, complication management, and treatment optimization. A comprehensive analysis of recent studies was conducted, highlighting ML models such as XGBoost, neural networks, and multimodal approaches. These models integrate clinical, laboratory, and imaging data, including radiomics features, and are useful in diagnostic and prognostic accuracy in AP. Special attention was given to models addressing SAP, complications like acute kidney injury and acute respiratory distress syndrome, mortality, and recurrence. AI-based models achieved higher AUC values than traditional models in predicting acute pancreatitis outcomes. XGBoost reached an AUC of 0.93 for early SAP prediction, higher than BISAP (AUC 0.74) and APACHE II (AUC 0.81). PrismSAP, integrating multimodal data, achieved the highest AUC of 0.916. AI models also demonstrated superior accuracy in mortality prediction (AUC 0.975) and ARDS detection (AUC 0.891) AI and ML represent a transformative advance in AP management, facilitating personalized treatment, early risk stratification, and allowing resource utilization to be optimized. By addressing challenges such as model generalizability, ethical considerations, and clinical adoption, AI has the potential to significantly improve patient outcomes and redefine AP care standards globally.

Comparative Analysis of Laboratory Markers, Severity Scores, and Outcomes in 179 Patients with Severe Acute Pancreatitis

Background and Objectives: Severe acute pancreatitis carries a substantial risk of complications and death. Prompt identification of prognostic factors is crucial to optimize management and reduce mortality. This study aims to compare inflammatory scores, laboratory markers, and clinical outcomes between survivors and non-survivors with severe acute pancreatitis, drawing on data from 179 patients admitted between 2017 and 2024. Methods: We conducted a retrospective cohort study of 179 patients diagnosed with severe acute pancreatitis. Of these, 55 patient records were extracted from an existing database, and an additional 124 were included from hospital archives (2017-2024). We divided participants into survivors (n = 121) and non-survivors (n = 58). Clinical data were obtained from medical records, including demographic information, comorbidities, laboratory markers (neutrophil-to-lymphocyte ratio (NLR) and platelet-to-lymphocyte ratio (PLR)), and severity scores (Acute Physiology and Chronic Health Evaluation (APACHE), Computed Tomography Severity Index (CTSI), and Ranson). Results: Non-survivors had significantly higher ages (mean of 66.4 vs. 52.7 years, p = 0.002), elevated inflammatory markers (median NLR of 14.2 vs. 10.3, p = 0.031), and more frequent multiorgan failure (75.9% vs. 31.4%, p < 0.001). The timing of intervention before 28 days was associated with higher mortality (p = 0.004). Chronic kidney disease and advanced cardiovascular comorbidities independently predicted worse survival (p = 0.009). The mortality rate in this cohort was 32.4%. Logistic regression identified age >60 years with an odds ratio (OR = 2.9), multiple organ failure (OR = 4.1), and high severity scores as primary contributors to mortality. Conclusions: Advanced age, comorbidities, elevated inflammatory markers, and multiple organ failure significantly impact mortality in severe acute pancreatitis. Delaying major interventions when feasible, optimizing perioperative care, and early recognition of high-risk patients may improve outcomes. Further research should explore targeted management strategies for high-risk groups and refine the role of delayed or minimally invasive approaches in severe acute pancreatitis management.

Atherogenic index of plasma as a novel predictor for acute kidney injury and disease severity in acute pancreatitis: a retrospective cohort study

BACKGROUND

The atherogenic index of plasma (AIP) can be used to reveal atherosclerosis. This study evaluated the AIP's efficacy in predicting the prognosis of acute kidney injury (AKI) and severity of acute pancreatitis (AP).

METHODS

This retrospective cohort study recruited AP cases from the First College of Clinical Medical Science of China Three Gorges University between January 2019 and October 2023, including 1470 patients. AIP was computed using the formula: log10 [serum triglyceride (mmol/L)/serum high-density lipoprotein cholesterol (mmol/L)]. The AIP relationships with AKI occurrence and AP severity were validated using multivariable logistic regression models, subgroup and sensitivity analyses, and curve fitting.

RESULTS

Among the 1470 patients with AP, 250 (17%) developed AKI and 166 (11.3%) with severe AP. AIP was positively correlated with AKI and the severity of AP. Potential confounders were adjusted, consequently, AIP was positively linearly related to AKI (P for non-linearity: 0.731, OR 2.5, 95% CI 1.31-4.77,) and the severity of AP (P for non-linearity: 0.145, OR 3.1, 95% CI 1.53-6.27), respectively. The strength of the association between AIP and AKI, along with the severity of AP, was demonstrated through stratified analyses. Significant interactions were not observed in sex, age, hypertension, BMI, diabetes mellitus, SOFA score, BISAP score, and etiology of AP (all P for interaction > 0.05). The areas under the curves for AIP in predicting the incidence of AKI and severity of AP were 0.64 and 0.65, respectively.

CONCLUSIONS

This is the first study to suggest that the AIP is critical for the assessment of AKI risk, recommending early screening of severity among AP cases. Due to the observational nature of the study, the potential for residual confounding, and the need for external validation in larger, independent cohorts.

Effect of selective COX-2 inhibitors and non-selective non-steroidal anti-inflammatory drugs on severity of acute pancreatitis: A systematic review and meta-analysis

BACKGROUND

It's been suggested that non-steroidal anti-inflammatory drugs (NSAIDs) may reduce the inflammatory response and severity of acute pancreatitis (AP). In this systematic review and meta-analysis, we aimed to explore the impact of selective COX-2 and non-selective NSAIDs compared to non-NSAID options on the severity of AP.

METHODS

We searched MEDLINE, EMBASE, and Cochrane Central, from database inception through September 2023. We included RCTs and observational studies comparing NSAIDs with non-NSAID controls. The primary outcome was the development of severe acute pancreatitis (SAP) characterized by persistent organ failure lasting >48 h. Secondary outcomes included mortality, pancreatic necrosis, length of stay (LOS), pain relief, and requirement for rescue analgesia. Meta-analysis was conducted separately for selective COX-2 inhibitors and non-selective NSAIDs.

RESULTS

Eleven studies met eligibility criteria including 1830 patients with AP. Of 3 studies that used selective NSAIDs (1 RCT and 2 observational), COX-2 inhibitors significantly reduced SAP (OR = 0.38; 95 %CI 0.27-0.52; p < 0.001; I2 = 0 %), pancreatic necrosis (OR = 0.48; 95 %CI 0.29-0.78; p = 0.003; I2 = 0 %), LOS by 5.51 days (95 %CI -10.80 to -0.22; p = 0.04; I2 = 97 %), and rescue opioids (OR = 0.32; 95 %CI 0.24-0.45; p < 0.001; I2 = 0 %). However, the certainty of the evidence was graded as low to very low using GRADE methodology. There was no significant effect of COX-2 inhibitors on mortality. Of 8 studies (all RCTs) that compared non-selective NSAIDs and non-NSAIDs, there was no difference in clinical outcomes, pain relief, and need for rescue analgesia.

CONCLUSIONS

Selective COX-2 inhibitors potentially mitigate disease severity and shorten hospitalization in patients with AP, while non-selective NSAIDs lack this benefit. Confirmatory large-scale RCTs are warranted to validate these findings.

LESS IS MORE: classified management of hypertriglyceridemia-induced acute pancreatitis on the basis of a propensity score matching cohort study

BACKGROUND

Effective management of hypertriglyceridemia is crucial in the treatment of hypertriglyceridemia-induced acute pancreatitis (HTG-AP). The prognosis of HTG-AP may vary with different serum triglyceride levels, suggesting the need for stratified treatment approaches. In this study, we investigated hypertriglyceridemia management in HTG-AP patients and the optimal strategy.

METHODS

Patients with HTG-AP from October 2020 to October 2022 were included in the study. Propensity score matching was used to balance the bias and confounding variables. A mixed-effects model was used to analyse the decreasing tendency of triglycerides.

RESULTS

A total of 171 patients who were diagnosed with HTG-AP were enrolled in this cohort. Patients with very severe serum triglycerides (> 22.6mmol/L) had a higher proportion of severe acute pancreatitis (p < 0.05) than patients with severe hypertriglyceridemia (11.3-22.6 mmol/L). For the very severe hypertriglyceridemia group, no significant differences in prognosis were noted between the insulin and heparin group and the plasma exchange group. The cost of the insulin and heparin group was significantly lower than that of the plasma exchange group (p < 0.01). In patients with severe hypertriglyceridemia, no significant differences in prognosis were noted between the nothing-by-mouth (NPO) group and the insulin and heparin group. Compared with the insulin and heparin group, the NPO group had lower hospital costs (p < 0.05).

CONCLUSION

HTG-AP patients with very severe hypertriglyceridemia may be treated safely and effectively with insulin and heparin, potentially offering a more cost-effective treatment approach. Similarly, patients with severe hypertriglyceridemia might benefit from treatment involving NPO, which may be associated with lower costs. Further studies are needed to validate these findings in diverse populations and through long-term follow-up.

Establishment and validation of a prediction model for acute kidney injury in moderate severe and severe acute pancreatitis patients

PURPOSE

This study aimed to develop a nomogram for predicting acute kidney injury (AKI) in patients with moderate severe acute pancreatitis (MSAP) and severe acute pancreatitis (SAP).

METHODS

This study enrolled a total of 1,077 patients with MSAP and SAP, categorizing them into three groups: training (n = 646), internal validation (n = 278), and external validation (n = 153). In the training cohort, logistic regression analysis identified independent predictors of AKI in patients with MSAP and SAP. A nomogram was developed based on these independent predictors. The model's performance was assessed using the receiver operating characteristics (ROC) curve, precision-recall (PR) curve, calibration curve, and decision curve analysis (DCA).

RESULTS

The incidence rates of AKI in the training set, internal validation set, and external validation set were 32.82%, 32.01%, and 27.45%, respectively. Independent predictors of AKI in patients with MSAP and SAP included: shock index (odds ratio [OR] = 7.42, 95% confidence interval [CI] 2.18-25.19), blood urea nitrogen (OR = 1.32, 95% CI 1.22-1.43), uric acid (OR = 1.002, 95% CI 1.000-1.003), serum calcium (OR = 0.38, 95% CI 0.18-0.79), triglycerides (OR = 1.02, 95% CI 1.004-1.041), hematocrit > 0.5 (OR = 3.24, 95% CI 1.10-9.59), serum sodium < 135 mmol/L (OR = 2.01, 95% CI 1.15-3.49), creatine kinase isoenzyme > 4 ng/mL (OR = 2.61, 95% CI 1.48-4.61), and thrombin time < 14 s (OR = 2.83, 95% CI 1.28-6.27). In the training, internal validation, and external validation sets, the areas under the ROC curves for the nomogram were 0.841, 0.789, and 0.853, respectively. Similarly, the areas under the PR curves were 0.807, 0.733, and 0.770. The calibration curves demonstrated that the predicted outcomes were well-aligned with the actual results. The decision curve analysis (DCA) indicated that the model had satisfactory clinical applicability.

CONCLUSIONS

Nine indicators have been identified as independent predictors of AKI in patients with MSAP and SAP. The developed nomogram exhibits robust predictive capability and shows promise for clinical application.

Frequency and predictors of delayed clearance of prophylactic pancreatic stents after ERCP

BACKGROUND AND AIMS

Timely evaluation and removal of prophylactic pancreatic stents (PSs) placed during ERCP are recommended. The aim of the study was to examine the proportion of patients whose prophylactic PSs passed or were removed within 4 weeks of ERCP.

METHODS

Consecutive patients who received ERCP with prophylactic PS placement (May 2014 to October 2022) at a tertiary center were identified. The primary endpoint was clearance of the PS ≤4 weeks from ERCP confirmed by radiologic studies or endoscopy. Multivariate analysis was used to identify endoscopist-, patient-, and procedure-related factors associated with the primary endpoint.

RESULTS

Of 4724 patients undergoing ERCP, 262 (5.5%) received a prophylactic PS (mean age, 56.6 ± 18.5 years; 168 [64%] women). After ERCP, PSs were evaluated in ≤2 weeks in 177 patients (68%; 95% CI, 62-73). Furthermore, PSs were cleared at ≤4 weeks in 135 patients (52%; 95% CI, 46-58) by radiologic studies in 86 (33%) or endoscopic removal in 49 (19%). On multivariate analysis, biliary stent placement (adjusted odds ratio [aOR], 0.5; 95% CI, 0.3-0.8) reduced the odds of timely PS clearance after adjusting for endoscopist-specific clearance rates: top (aOR, 11.1; 95% CI, 4.0-30.5), second (aOR, 5.4; 95% CI, 2.5-11.9), and third (aOR, 4.1; 95% CI, 1.9-9.0) compared with the bottom quartile. During follow-up of 20.1 ± 23.5 months, 47 of 127 patients (37%) with delayed PS clearance demonstrated a median stent dwelling time of 55 days (range, 29-929).

CONCLUSIONS

Prophylactic PSs were cleared within 4 weeks in only half of the patients after ERCP. In addition to primarily endoscopist-driven factors, biliary stent placement was associated with delayed clearance of prophylactic PSs.

Complications of Endoscopic Retrograde Cholangiopancreatography

Up to 1 in 6 patients will experience an unplanned hospitalization after endoscopic retrograde cholangiopancreatography (ERCP), largely for the evaluation and management of adverse events. Therefore, a commitment to the prevention, early recognition, and effective rescue of complications related to ERCP is critical toward improving outcomes. ERCP is most often complicated by acute pancreatitis, bleeding, infection, or perforation, although myriad other adverse events may occur. The prevention of post-ERCP pancreatitis has been the area of greatest interest and progress in the last decade, but the application of evidence-based prophylactic measures remains inconsistent. Innovations in stent, hemostasis, and perforation closure technology now allow effective and efficient endoscopic management of several important nonpancreatitis complications. Overall, our ability to prevent and treat ERCP-related adverse events has improved substantially, amplifying the importance of a high level of suspicion for and a thorough understanding of these events.

Association between the triglyceride glucose index and the risk of acute respiratory failure in patients with acute pancreatitis

BACKGROUND

The triglyceride glucose (TyG) index serves as a dependable marker for insulin resistance and has shown a significant correlation with the severity of acute pancreatitis (AP). However, no research exists regarding the association between the TyG index and the development of acute respiratory failure (ARF) in AP. This study assesses the association between TyG index and ARF in patients with AP.

METHODS

Retrospective cohort analysis was conducted with the MIMIC-IV 2.2 critical care data. The endpoint focused on ARF during hospitalization. Statistical analysis encompassed univariate and multivariate logistic regressions, alongside restricted cubic spline (RCS) analysis to explore potential nonlinear associations. Receiver operating characteristic (ROC) curve analysis was employed to identify the optimal TyG index cutoff, leading to the classification of patients into Low TyG and High TyG groups. Propensity score matching (PSM) and inverse probability of treatment weighting (IPTW) were subsequently applied to minimize the influence of confounding factors, thereby further clarifying the relationship between the TyG index and ARF in patients with AP.

RESULTS

A total of 758 patients were involved in this study, the incidence of ARF was 21.64%. Logistic regression analyses demonstrated a significant association between the TyG index and the incidence of ARF in patients with AP. The RCS model illustrated a nonlinear relationship between a higher TyG index and an increased risk of ARF. The cutoff value of TyG index was 9.099 for ARF in patients with AP based on the ROC curve analysis. Furthermore, following PSM and IPTW, multivariate logistic regression analysis indicated that the High TyG group exhibited a significantly higher risk of ARF compared to the Low TyG group (P < 0.05).

CONCLUSIONS

The TyG index is associated with ARF risk in AP patients and may aid in early risk assessment.

High-dose intravenous vitamin C reduce C-reactive protein levels, fluid retention, and APACHE II scores in patients with moderately severe acute pancreatitis: a prospective, randomized, double-blinded, placebo-controlled study

BACKGROUND

The aim of this study was to investigate whether high-dose intravenous vitamin C (HDIVC) could decrease the mortality rate within 28 days among patients moderately severe acute pancreatitis (MSAP) and severe acute pancreatitis (SAP).

METHODS

In this randomized, placebo-controlled trial, patients diagnosed with predicted MSAP or SAP within 72 h of symptom onset were enrolled to receive either a vitamin C infusion (200 mg/kg/24 h) or a matched placebo for 7 days. The primary outcome was 28-day mortality.

RESULTS

212 adults including 155 MSAP and 57 SAP were enrolled from September 2019 to June 2023. The trial was terminated prematurely due to a lower than expected 28-day mortality rate which showed no difference between the HDIVC and Control group (3/109 vs. 4/103, unadjusted OR: 0.70, 95% CI, 0.15-3.21, p = 0.647). Among patients with MSAP, the HDIVC group exhibited a more pronounced reduction in C-reactive protein levels compared to the Control group (Day0 to Day3, median 72 mg/L vs. 46 mg/L, p = 0.003; Day0 to Day7, median 168 mg/L vs. 121 mg/L, p = 0.013); The volume of fluid retention was lower in the HDIVC group compared to the Control group (Day0-Day1, median 676.5 ml vs. 1130 ml, P = 0.04; Day0-Day2, median 511 ml vs. 1290 ml, P = 0.02; Day0-Day3, median 692 ml vs. 1534 ml, P = 0.04). The APACHE II scores reduction from Day0 to Day7 was significantly greater in the HDIVC group in APACHE II scores (median change of 3 vs. 2, P = 0.01). No significant difference was observed among patients with SAP.

CONCLUSION

HDIVC did not significantly reduce 28-day mortality in MSAP and SAP patients. While it showed potential benefits in reducing CRP, fluid retention, and APACHE II scores in MSAP patients, these effects may not be directly related to the study drug, and no similar changes were observed in SAP patients.

TRIAL REGISTRATION

ChiCTR.org.cn, ChiCTR1900022022. Registered March 21 2019, https//www.chictr.org.cn/showproj.html?proj=37,106 .

Incidence, Risk Factors, and Prevention Strategies for Post-ERCP Pancreatitis in Patients with Biliopancreatic Disorders and Acute Cholangitis: A Study from a Romanian Tertiary Hospital

Background/Objectives: Pancreatitis is the most frequent and serious complication of endoscopic retrograde cholangiopancreatography (ERCP), with an incidence between 2 and 10% and a mortality rate of 1 in 500 patients. Etiopathogenesis remains poorly understood. The aim of this study was to analyze the incidence of post-ERCP pancreatitis (PEP) and to identify potential patient- and procedure-related risk factors (RF) in a cohort of patients from a tertiary referral center in Romania. Methods: We conducted a retrospective, observational, single-center study in which we analyzed ERCP procedures performed in the Gastroenterology Department of Colentina Clinical Hospital, Bucharest, Romania, between January 2019 and September 2024. All patients received intrarectal diclofenac before the ERCP and were hydrated with at least 1500 mL of Ringer's solution after the procedure in the absence of contraindications, according to the latest international recommendations. Results: In total, 2743 ERCPs were performed in the given time period, while 2350 procedures were analyzed in the study. PEP occurred in 350 cases (14.9%). Of these, 191 (54.6%) occurred in males with a mean age of 66.5 years. Procedural RF with adjusted odds ratios (OR) were as follows: difficult cannulation of the common bile duct, OR = 3.734, p < 0.001, main pancreatic duct catheterization, OR = 1.454, p = 0.022, and endoscopic papillary balloon dilatation, with an OR of 3.258, p < 0.001. Pancreatic duct stent placement was shown to prevent PEP in this study group (p < 0.001). Conclusions: PEP remains a serious complication of ERCP, associated with significant morbidity and occasional mortality. While some proven risk factors, such as age, gender, or comorbidities, are unmodifiable, avoiding Wirsung duct cannulation and pancreatography, or prophylactic pancreatic duct stent placement, could play a significant role in PEP prevention.

Endocrine-exocrine miR-503-322 drives aging-associated pancreatitis via targeting MKNK1 in acinar cells

Aging is the risk factor for chronic pancreatitis and severity determinant for its acute attack, yet the underlying cause is unclear. Here, we demonstrate that senescent β-cells of endocrine pancreas decide the onset and severity of chronic and acute pancreatitis. During physiological aging, senescent β-cells increase the expression of miR-503-322 which is secreted as small extracellular vesicles to enter exocrine acinar cells, driving a causal and reversible role on aging-associated pancreatitis. Mechanistically, miR-503-322 targets MKNK1 to inhibit acinar-cell secretion leading to autodigestion and repress proliferation causing repair damage of exocrine pancreas. In the elderly population, serum miR-503 concentration is negatively correlated with amylase, prone to chronic pancreatitis due to increased miR-503 and decreased MKNK1 in the elderly pancreas. Our findings highlight the miR-503-322-MKNK1 axis mediating the endocrine-exocrine regulatory pathway specifically in aged mice and humans. Modulating this axis may provide potential preventive and therapeutic strategies for aging-associated pancreatitis.

Inhibition of CD53 Reduces the Formation of ROS-Induced Neutrophil Extracellular Traps and Protects Against Inflammatory Injury in Acute Pancreatitis

Background

The tetraspanin CD53 transmembrane protein is vital in immune cells like B cells and T cells, playing a crucial role in various inflammatory conditions. However, its involvement in neutrophils regarding inflammation remains uncertain. This study aims to examine the impact of CD53 on neutrophil extracellular traps (NETs) formation.

Methods

Phorbol 12-myristate 13-acetate (PMA) was utilized to establish an in vitro classical NETs model to investigate the influence of CD53 on NETs formation and its regulatory mechanisms. Subsequently, the link between CD53 and acute pancreatitis (AP), a model of aseptic inflammatory responses connected to NETs, was verified. Peripheral blood neutrophils from clinical AP patients were collected to explore the role of CD53 in AP, while an AP mouse model induced by caerulein was employed to confirm the impact of CD53 inhibition on AP mice pancreatic tissue.

Results

Our study has shown that CD53 is significantly elevated in in vitro NETs models and neutrophils from AP patients. The expression of CD53 is closely related to the clinical prognosis of AP patients. At the same time, CD53 neutralizing antibody (Anti-CD53) can significantly inhibit the formation of NETs in vitro, inflammatory injury in AP mice and the formation of NETs in damaged tissues. Mechanistically, CD53 can modulate the PI3K/AKT pathway and promote the formation of NETs. Finally, targeted regulation of CD53 can effectively reduce inflammatory injury and NETs formation in damaged tissues of AP mice.

Conclusion

The results of this study mark the first confirmation that CD53 plays a crucial role in NETs formation. Targeting CD53 inhibition could potentially serve as a novel therapeutic approach for the treatment of AP.

Tephrosia purpurea, with (-)-Pseudosemiglabrin as the Major Constituent, Alleviates Severe Acute Pancreatitis-Mediated Acute Lung Injury by Modulating HMGB1 and IL-22

Ischemia-reperfusion (IR) injury is a major cause of multiple organ failure. The purpose of this study was to look into the role of Tephrosia purpurea (TEP) and its active constituent pseudosemiglabrin (PS) in alleviating severe acute pancreatitis and its associated acute lung injury. We established a rat pancreatic IR model, and the rats were treated with TEP (200 mg/kg and 400 mg/kg) and PS (20 and 40 mg/kg), in addition to the IR control and sham groups. The results showed that the respiratory parameters, including inspiratory time (Ti), expiratory time (Te), duration (Dr), and respiratory rate (RR), were comparable among all groups, while peak inspiratory flow (PIF), forced vital capacity (FVC), and forced expiratory volume at 0.1 s (FEV0.1) were significantly impaired. Notably, PS at 40 mg/kg showed normal PIF, FVC, and FEV0.1/FVC compared to the IR group, indicating an improved lung function. Additionally, TEP and PS showed protective effects on pancreatic and lung tissues compared to the IR control group, with the following effects: alleviating pathological damage; reducing serum levels of trypsinogen activation peptide (TAP), lipase, and amylase; decreasing oxidative stress markers such as MDA and MPO; restoring antioxidant enzyme activity (GPx); suppressing inflammatory markers TNF-α, IL-6, and NF-κB; downregulating HMGB1 gene in pancreatic tissue; and upregulating the IL-22 gene in lung tissues. In conclusion, the obtained findings demonstrate that oral supplementation of TEP and PS to rats with pancreatic IR alleviates pancreatic and lung injuries by reducing oxidative stress and modulating inflammatory processes, which offers an attractive therapeutic option for severe acute pancreatitis and its associated acute lung injury.

Readmission of patients with hypertriglyceridemia-induced acute pancreatitis: a prospective cohort study

BACKGROUND

Acute pancreatitis (AP) is a common cause of acute hospital admissions in digestive system diseases. In East Asia, hypertriglyceridemia is gradually emerged as the second most common cause of pancreatitis. Vigilance for recurrence and unplanned readmissions due to other causes is still necessary after discharge. studies on hypertriglyceridemia-induced acute pancreatitis (HTG-AP) are scarce and mainly consists of retrospective studies.

METHODS

This was a prospective cohort study of adult patients with first episode of HTG-AP from December 2019 to February 2021 who were followed up for two years. Unscheduled readmission after the index discharge was the primary outcome. The Cox proportional-hazards model, and the Fine and Gray's competing-risk model were applied to the analyses.

RESULTS

Totally, 293 survival patients were followed-up after discharge. The overall unplanned readmission rate was 30.0% in two years. Among them, 60 (20.5%) patients were readmitted to hospital once, 16 (5.5%) were readmitted twice, and 13 (4.4%) were readmitted three times or more. In summary, a total of 143 cases of readmission information were collected during the follow-up period. The recurrence accounts for a significant 77.3% proportion and stands as the primary cause for readmission. Cox regression model favors infection (Hazard ratio [HR], 3.066; 95% confidence interval [CI], 1.192-7.888; P = 0.02) and age lower than 41.5 years old (HR, 3.157; 95% CI 1.883-5.292; P < 0.01) as independent risk factors for patient readmission by multivariate analysis. The competing-risk model support the similar results compared with the former.

CONCLUSION

Unplanned readmission of patients with hypertriglyceridemia-induced acute pancreatitis is common, especially for young patients with occurrence of any infection during hospitalization, and warrant further investigation.

Decreased Life Expectancy in Patients with Acute and Chronic Pancreatitis

BACKGROUND AND AIMS

Population-based data on the life expectancy and mortality for acute (AP) and chronic pancreatitis (CP) in the United States are limited. This study evaluates the life expectancy, mortality rates and the cause of death in AP and CP patients.

METHODS

Using the nationwide Veterans Administration database from 1999 to 2015, we identified AP and CP patients (using ICD-9 codes) and non-pancreatitis patients (controls). Age at the time of death was used as a surrogate indicator of life expectancy. Life expectancy in AP and CP patients was compared with the controls, using Cox-proportional hazards model. The mortality rates and cause of death for AP, CP, and controls were also assessed.

RESULTS

Overall, we selected 35,550 AP and 12,545 CP patients and 100,000 controls. The life expectancy was significantly lower for both AP (69 years) and CP (71 years) patients compared to the controls (81 years, p < 0.001). The risk of mortality was higher for AP (adjusted hazard ratio (aHR) 1.61, 95% CI 1.58-1.65, p < 0.001) and CP (aHR 1.64, 95% CI 1.59-1.68, p < 0.001) than in controls. Approximately forty-two percent of all patients died during the follow-up (AP-44.3%, CP-52.1% and controls-39.7%). Circulatory disorders, neoplasms, and respiratory disorders were the leading causes of death in AP and CP patients.

CONCLUSIONS

Acute and chronic pancreatitis are associated with decreased life span and higher mortality emphasizing their clinical importance. Although the deaths due to gastrointestinal/digestive system disorders were significantly higher, most of the deaths in AP and CP patients were primarily due to non-gastrointestinal causes.

Early Readmissions of Necrotizing Pancreatitis in the US: Where Do We Stand?

BACKGROUND

Necrotizing pancreatitis (NP), a severe form of pancreatitis characterized by necrosis of pancreatic tissue, is associated with a significant health care burden worldwide. In this study, we assess early readmissions of NP in the US.

METHODS

The National Readmission Database from 2016 to 2020 was utilized to identify all index and 30-day readmissions of NP in the US. Hospitalization characteristics, readmission rates, clinical outcomes, predictors of readmissions, and health care burden were assessed. P-values <0.05 were statistically significant.

RESULTS

From 2016 to 2020, 43,968 index admissions for NP were identified. Of which, 18.6% were readmitted within 30 days. There was a higher proportion of males on index and 30-day readmission. On readmission, NP was identified as the admitting diagnosis in only 27.64% of the patients, followed by pancreatitis without necrosis (17.7%), sepsis (8.8%), pancreatic pseudocyst (6.85%), and chronic pancreatitis (2.5%). Biliary pancreatitis (aHR 1.46, 95% CI 1.30-1.65, P<0.001), idiopathic pancreatitis (aHR 1.45, 95% CI 1.33-1.57, P<0.001), and other etiologies of pancreatitis (aHR 1.74, 95% CI 1.46-2.06, P<0.001) had a higher risk of 30-day readmission compared with alcohol-induced pancreatitis. We noted lower inpatient mortality (2.11 vs. 2.97%, aOR:0.65, 95% CI 0.50-0.83, P=0.001), mean length of stay (7.36 vs. 10.97 days, mean difference 3.86, 95% CI 4.25-3.48, P<0.001), and total hospitalization charges ($75,282 vs. $125,480, mean difference $53,979, 95% CI $59,417-$48,541, P<0.001) for 30-day readmissions compared with index NP hospitalizations.

CONCLUSION

About one-fifth of NP patients were readmitted within 30 days. However, these patients had lower mortality and health care burden compared with index hospitalization.

Radiomics-based prediction of recurrent acute pancreatitis in individuals with metabolic syndrome using T2WI magnetic resonance imaging data

Objective

This study sought to clarify the utility of T2-weighted imaging (T2WI)-based radiomics to predict the recurrence of acute pancreatitis (AP) in subjects with metabolic syndrome (MetS).

Methods

Data from 196 patients with both AP and MetS from our hospital were retrospectively analyzed. These patients were separated into two groups according to their clinical follow-up outcomes, including those with first-onset AP (n = 114) and those with recurrent AP (RAP) (n = 82). The 196 cases were randomly divided into a training set (n = 137) and a test set (n = 59) at a 7:3 ratio. The clinical characteristics of these patients were systematically compiled for further analysis. For each case, the pancreatic parenchyma was manually delineated slice by slice using 3D Slicer software, and the appropriate radiomics characteristics were retrieved. The K-best approach, the least absolute shrinkage and selection operator (LASSO) algorithm, and variance thresholding were all used in the feature selection process. The establishment of clinical, radiomics, and combined models for forecasting AP recurrence in patients with MetS was then done using a random forest classifier. Model performance was measured using the area under the receiver operating characteristic curve (AUC), and model comparison was done using the DeLong test. The clinical utility of these models was evaluated using decision curve analysis (DCA), and the optimal model was determined via a calibration curve.

Results

In the training set, the clinical, radiomics, and combined models yielded respective AUCs of 0.651, 0.825, and 0.883, with corresponding test sets of AUCs of 0.606, 0.776, and 0.878. Both the radiomics and combined models exhibited superior predictive effectiveness compared to the clinical model in both the training (p = 0.001, p < 0.001) and test sets (p = 0.04, p < 0.001). The combined model outperformed the radiomics model (training set: p = 0.025, test set: p = 0.019). The DCA demonstrated that the radiomics and combined models had greater clinical efficacy than the clinical model. The calibration curve for the combined model demonstrated good agreement between the predicted probability of AP recurrence and the observed outcomes.

Conclusion

These findings highlight the superior predictive power of a T2WI-based radiomics model for predicting AP recurrence in patients with MetS, potentially supporting early interventions that can mitigate or alleviate RAP.

Machine learning for the rElapse risk eValuation in acute biliary pancreatitis: The deep learning MINERVA study protocol

BACKGROUND

Mild acute biliary pancreatitis (MABP) presents significant clinical and economic challenges due to its potential for relapse. Current guidelines advocate for early cholecystectomy (EC) during the same hospital admission to prevent recurrent acute pancreatitis (RAP). Despite these recommendations, implementation in clinical practice varies, highlighting the need for reliable and accessible predictive tools. The MINERVA study aims to develop and validate a machine learning (ML) model to predict the risk of RAP (at 30, 60, 90 days, and at 1-year) in MABP patients, enhancing decision-making processes.

METHODS

The MINERVA study will be conducted across multiple academic and community hospitals in Italy. Adult patients with a clinical diagnosis of MABP, in accordance with the revised Atlanta Criteria, who have not undergone EC during index admission will be included. Exclusion criteria encompass non-biliary aetiology, severe pancreatitis, and the inability to provide informed consent. The study involves both retrospective data from the MANCTRA-1 study and prospective data collection. Data will be captured using REDCap. The ML model will utilise convolutional neural networks (CNN) for feature extraction and risk prediction. The model includes the following steps: the spatial transformation of variables using kernel Principal Component Analysis (kPCA), the creation of 2D images from transformed data, the application of convolutional filters, max-pooling, flattening, and final risk prediction via a fully connected layer. Performance metrics such as accuracy, precision, recall, and area under the ROC curve (AUC) will be used to evaluate the model.

DISCUSSION

The MINERVA study aims to address the specific gap in predicting RAP risk in MABP patients by leveraging advanced ML techniques. By incorporating a wide range of clinical and demographic variables, the MINERVA score aims to provide a reliable, cost-effective, and accessible tool for healthcare professionals. The project emphasises the practical application of AI in clinical settings, potentially reducing the incidence of RAP and associated healthcare costs.

TRIAL REGISTRATION

ClinicalTrials.gov ID: NCT06124989.

Explainable machine learning model for predicting acute pancreatitis mortality in the intensive care unit

BACKGROUND

Current prediction models are suboptimal for determining mortality risk in patients with acute pancreatitis (AP); this might be improved by using a machine learning (ML) model. In this study, we aimed to construct an explainable ML model to calculate the risk of mortality in patients with AP admitted in intensive care unit (ICU) and compared it with existing scoring systems.

METHODS

A gradient-boosting ML (XGBoost) model was developed and externally validated based on two public databases: Medical Information Mart for Intensive Care (MIMIC, training cohort) and the eICU Collaborative Research Database (eICU-CRD, validation cohort). We compared the performance of the XGBoost model with validated clinical risk scoring systems (the APACHE IV, SOFA, and Bedside Index for Severity in Acute Pancreatitis [BISAP]) by area under receiver operating characteristic curve (AUC) analysis. SHAP (SHapley Additive exPlanations) method was applied to provide the explanation behind the prediction outcome.

RESULTS

The XGBoost model performed better than the clinical scoring systems in correctly predicting mortality risk of AP patients, achieving an AUC of 0.89 (95% CI: 0.84-0.94). When set the sensitivity at 100% for death prediction, the model had a specificity of 38%, much higher than the APACHE IV, SOFA and BISAP score, which had a specificity of 1%, 16% and 1% respectively.

CONCLUSIONS

This model might increase identification of very low-risk patients who can be safely monitored in a general ward for management. By making the model explainable, physicians would be able to better understand the reasoning behind the prediction.

Non-infectious complications of peritoneal dialysis in children

Peritoneal dialysis (PD) remains a cornerstone treatment for children with stage 5 chronic kidney disease, offering significant benefits in terms of quality of life and patient autonomy compared to hemodialysis. Recent advances in care protocols, particularly in infection prevention, have led to a substantial reduction in peritonitis and other infectious complications in pediatric patients on PD. Despite these improvements, non-infectious complications continue to pose significant challenges to the long-term efficacy of PD. Mechanical issues, such as catheter malposition and dysfunction, are common and can lead to discomfort and diminished dialysis efficiency. A more serious concern is peritoneal membrane failure, which results from prolonged PD, particularly with glucose-based solutions, and recurrent peritonitis, leading to structural changes in the membrane. Encapsulating peritoneal sclerosis (EPS), although rare, is a severe and often devastating complication that significantly impacts patient morbidity and mortality. Despite its low incidence, EPS underscores the importance of careful monitoring and management of long-term PD patients. Additional complications, including metabolic disturbances, pancreatitis, and hemoperitoneum, further complicate care. Looking ahead, improving catheter management, preserving peritoneal membrane function, and exploring new dialysis solutions are essential to reducing these complications and optimizing outcomes for pediatric patients on PD.

Current status and future perspectives for endoscopic treatment of local complications in chronic pancreatitis

Chronic pancreatitis is a progressive disease characterized by irregular fibrosis, cellular infiltration, and parenchymal loss within the pancreas. Chronic pancreatitis treatment includes lifestyle modifications based on disease etiology, dietary adjustments appropriate for each stage and condition, drug therapy, endoscopic treatments, and surgical treatments. Although surgical treatments of symptomatic chronic pancreatitis provide good pain relief, endoscopic therapies are recommended as the first-line treatment because they are minimally invasive. In recent years, endoscopic therapy has emerged as an alternative treatment method to surgery for managing local complications in patients with chronic pancreatitis. For pancreatic stone removal, a combination of extracorporeal shock wave lithotripsy and endoscopic extraction is used. For refractory pancreatic duct stones, intracorporeal fragmentation techniques, such as pancreatoscopy-guided electrohydraulic lithotripsy and laser lithotripsy, offer additional options. Interventional endoscopic ultrasound has become the primary treatment modality for pancreatic pseudocysts, except in the absence of disconnected pancreatic duct syndrome. This review focuses on the current status of endoscopic therapies for common local complications of chronic pancreatitis, including updated information in the past few years.

Practical management of severe acute pancreatitis

Acute pancreatitis (AP) represents one of the most common reasons for hospital admission and intensive care treatment in internal medicine. The incidence of AP is increasing, posing significant financial burden on healthcare systems due to the necessity for frequent medical interventions. Severe acute pancreatitis (SAP) is a potentially life-threatening condition with substantial morbidity and mortality. The management of SAP requires prolonged hospitalization and the expertise of a multidisciplinary team, comprising emergency physicians, intensivists, internists, gastroenterologists, visceral surgeons, and experts in nutrition, infectious disease, endoscopy, as well as diagnostic and interventional radiology. Effective management and beneficial patient outcomes depend on continuous interdisciplinary collaboration. This review synthesizes recent evidence guiding the practical management of SAP, with a particular focus on emergency and intensive care settings. Both established as well as new diagnostic and therapeutic paradigms are highlighted, including workup, risk stratification, fluid management, analgesia, nutrition, organ support, imaging modalities and their timing, along with anti-infective strategies. Furthermore, the review explores interventions for local and vascular complications of SAP, with particular attention to the indications, timing and selection between endoscopic (both endoscopic retrograde cholangiopancreatography (ERCP) and endoscopic ultrasound (EUS)), percutaneous and surgical approaches. Similarly, the management of biliary AP due to obstructive gallstones, including the imaging, timing of ERCP and cholecystectomy, are discussed. By integrating new evidence with relevant guidance for everyday clinical practice, this review aims to enhance the interdisciplinary approach essential for improving outcomes in SAP management.

Spontaneous Splenic Rupture in Severe Acute Pancreatitis: A Rare Life-Threatening Complication and Its Successful Management

The severity of acute pancreatitis ranges from mild discomfort to severe illness with significant complications. While most cases resolve with supportive care, severe acute pancreatitis may lead to rare but serious issues such as spontaneous splenic rupture. A 46-year-old female with a history of alcohol use, hypertension, depression, and anxiety presented with persistent abdominal pain, nausea, and vomiting. Initial imaging revealed acute pancreatitis with peripancreatic fluid collections. Despite conservative management, her symptoms persisted. She experienced sudden worsening of abdominal pain and a significant drop in hemoglobin levels. Imaging confirmed a spontaneous splenic rupture with a large subcapsular hematoma and hemoperitoneum. She underwent splenic artery embolization to control the bleeding and received blood transfusions for anemia. Her condition improved with supportive care, and she was discharged with plans for outpatient follow-up. Spontaneous splenic rupture is a rare complication of acute pancreatitis resulting from the close anatomical relationship between the pancreas and spleen. Mechanisms behind it include direct enzymatic damage, pseudocyst extension, vascular injury, and increased pressure from splenic vein thrombosis. Early recognition is crucial for timely intervention. Clinicians should consider splenic complications when patients with pancreatitis exhibit sudden clinical deterioration or unexplained anemia. Prompt imaging and appropriate management can improve outcomes. Understanding the potential complications of severe pancreatitis is essential for effective patient care.

Endoscopic ultrasound-guided gastroenterostomy for the treatment of gastric outlet obstruction secondary to acute pancreatitis

BACKGROUND

Endoscopic ultrasound-guided gastroenterostomy (EUS-GE) is a minimally invasive technique for treating gastric outlet obstruction (GOO). The aim of this study was to assess the outcomes of EUS-GE in managing benign GOO caused by duodenal stenosis in patients with acute pancreatitis.

METHODS

This international retrospective study analyzed patients treated with EUS-GE for GOO caused by acute pancreatitis until December 2023, evaluating technical and clinical success, adverse events, and reintervention.

RESULTS

39 patients (median age 55 years, 15 women) were included. There was a 92.3% technical success rate, with only three patients unable to undergo EUS-GE owing to a long distance between the stomach and small bowel or an inadequate window for puncture. Clinical success was observed in 34 patients (87.2%). The median Gastric Outlet Obstruction Scoring System (GOOSS) improved from 0 before EUS-GE to 2 afterward (P <0.001). Follow-up (≥3 months) was available in 25 patients. During a median follow-up of 23 months, four patients required reintervention. It was possible to remove the lumen-apposing metal stent in 18 patients. The only adverse event was a gastrocolic fistula detected incidentally after 3 months.

CONCLUSION

EUS-GE is an effective and safe method for managing benign GOO in the setting of acute pancreatitis.

Evolving trends in interventions and outcomes for acute biliary pancreatitis during pregnancy: A two-decade analysis

BACKGROUND/OBJECTIVES

Cholelithiasis is the most common cause of acute pancreatitis in pregnancy. We analyzed trends in acute biliary pancreatitis (ABP) among pregnant women over the past two decades to evaluate changes in outcomes, including the incidence of severe acute pancreatitis, mortality rates, and hospital length of stay.

METHODS

Using the National Inpatient Sample, we identified adult women of childbearing age (age 18-50 years) with hospitalization for ABP from 2002 to 2020. Trends were analyzed using Cochran-Armitage and F-tests. Multivariable binary logistic regression was used to evaluate the outcome of severe acute pancreatitis (SAP).

RESULTS

45,064 pregnant and 212,009 non-pregnant women were hospitalized for ABP (2002-2020), with a significant increase in ABP during pregnancy (14.1 %→17.8 %; p < 0.001). Trend analyses in the pregnant cohort revealed increasing age (mean 27  →  28.1 years; p < 0.001), Class-III obesity (0.7 %→7.8 %; p < 0.001), comorbidities (Elixhauser index ≥3) (2.9 %→11.2 %; p < 0.001), and SAP (2.2 %→5.0 %; p < 0.001). Mortality remained very low (<0.01 %). Performance of ERCP (22.2 %→26.5 %; p < 0.001) and cholecystectomy (41.0 %→54.1 %; p < 0.001) increased while duration of hospitalization decreased (Mean 4.9  →  3.6 days; p < 0.001). Multivariable analysis revealed that the development of SAP was associated with Black race (OR 1.70, 95 % CI: 1.10-2.63) and comorbidities (OR 5.10, 95 % CI 3.64-7.14).

CONCLUSIONS

Pregnant women represent a significant portion of hospitalized ABP cases, paralleling increases in age, comorbidities, and obesity rates. Racial disparities are linked to higher odds of SAP, though comorbidities have a dominant effect. There has been an increase in guideline-recommended procedures (ERCP and cholecystectomy); however, further research is needed to address the implementation gap, considering the increased complexity of pregnant women with ABP.

Construction and validation of a nomogram for predicting survival in diabetic patients with severe acute pancreatitis: A retrospective study from a tertiary center

BACKGROUND

There is currently a lack of nomograms specifically designed for predicting the risk of death in diabetic patients with severe acute pancreatitis (SAP). The objective of this study was to develop a nomogram tailored to diabetic patients with SAP to predict overall survival.

METHODS

Diabetic patients diagnosed with SAP between January 1, 2018 and December 31, 2023 were included in the study. Risk factors were identified through least absolute shrinkage and selection operator regression analysis. Subsequently, a novel nomogram model was developed through multivariable logistic regression analysis. The predictive performance of the nomogram was evaluated using metrics such as the receiver operating characteristic curve, calibration curve, and decision curve analysis (DCA).

RESULTS

A total of 206 patients were included in the analysis, with 171 in the survival group and 35 in the deceased group. Multivariate logistic regression indicated that age, platelet, total bilirubin, and potassium were independent prognostic factors for the survival of diabetic patients with SAP. The nomogram demonstrated a performance comparable to sequential organ failure assessment ( P = 0.570). Additionally, the calibration curve showed satisfactory predictive accuracy, and the DCA highlighted the clinical application value of the nomogram.

CONCLUSION

We have identified key demographic and laboratory parameters that are associated with the survival of diabetic patients with SAP. These parameters have been utilized to create a precise and user-friendly nomogram, which could be an effective and valuable clinical tool for clinicians.

The role of MRCP for preventing pancreatic fluid collection recurrence after EUS-guided drainage of walled-off necrosis

BACKGROUND AND AIMS

Pancreatic fluid collections (PFCs) may recur after initial successful endoscopic drainage of walled-off necrosis (WON), most commonly due to disconnected pancreatic duct syndrome (DPDS). The primary aim of this study was to assess the role of MRCP for identifying DPDS to guide appropriate management and prevent PFC recurrence.

METHODS

Patients with WON undergoing lumen-apposing metal stent drainage of a PFC were retrospectively identified and categorized as those with MRCP versus those without MRCP before removal of transmural stents. Data on patient demographic characteristics, procedural details, cross-sectional imaging, and recurrence rates were collected through chart review.

RESULTS

A total of 121 patients with WON were identified, of whom 44 (36.4%) had an MRCP before transmural stent removal. In patients without MRCP, 13 (16.8%) of 77 had PFC recurrence versus 0 of 44 (0%; P = .003) in those with MRCP. MRCP identified DPDS in 12 (27.2%) patients, all of whom were managed with indefinite drainage with double-pigtail plastic stents without recurrence. In the group without MRCP, PFCs recurred at a median interval of 284 days (interquartile range, 182-618 days) after transmural stent removal. Among the 13 patients with PFC recurrence, 11 (85%) had undiagnosed DPDS detected on subsequent imaging, of whom 9 were subsequently managed with indefinite double-pigtail plastic stents, with no further PFC recurrence.

CONCLUSIONS

Patients with WON who underwent MRCP before transmural stent removal had a lower rate of PFC recurrence largely due to the identification of DPDS with appropriate endoscopic management.

A Case Report on Protease Serine 1 (PRSS1)-Related Acute Pancreatitis

Acute pancreatitis (AP) is a multifactorial disease. Genetic predisposition as the etiology of AP is rare. We report the case of a 29-year-old male patient who presented with symptoms suggestive of AP. A complete workup, including genetic analysis, revealed the presence of both protease serine 1 (PRSS1) and UDP Glucuronosyltransferase family 1 member A1 (UGT1A1) mutations. Both PRSS1 and UGT1A1 mutations can cause AP by different mechanisms. This case has been reported because of the novelty of the two different genetic mutations in the same individual that could independently increase pancreatitis risk. The possible synergistic effect has not been reported previously. Understanding this interaction emphasizes the importance of genetic testing in AP.

Organ Failure and Prediction of Severity in Acute Pancreatitis

Organ failure (OF) is a sinister development in the clinical course of acute pancreatitis, and its prediction is crucial for triaging the patient. Persistent systemic inflammatory response syndrome and raised interleukin-6 levels have a good predictive accuracy. Pathophysiology involves the release of damage-associated molecular patterns as a consequence of pancreatic injury, recruitment of inflammatory cells, and the release of proinflammatory cytokines and chemokines causing cytokine storm. Respiratory system is the most common and earliest to fail. Although a few therapeutic options are in the pipeline, renewed efforts are required to develop targeted therapies to mitigate systemic inflammation and OF.

Bodyweight-Adjusted Nonsteroidal Anti-inflammatory Drugs Dose in the Prevention of Post-endoscopic Retrograde Cholangiopancreatography Pancreatitis

OBJECTIVES

Although rectal nonsteroidal anti-inflammatory drugs (NSAIDs) reduce the incidence of postendoscopic retrograde cholangiopancreatography pancreatitis (PEP), their optimal dosage is unknown. Given possible interindividual variability in the pharmacodynamics of NSAIDs, we hypothesized that the dose required to achieve adequate PEP prophylaxis varies with body weight.

MATERIALS AND METHODS

We conducted an analysis using single-center, prospective, observational cohort study data. The primary outcome was PEP incidence by NSAID dosage per body weight (mg/kg). Patients meeting the inclusion criteria were classified into 3 groups.

RESULTS

We included 891 patients, with 400, 454, and 37 patients in the control group with no NSAID therapy, the NSAID <1.0 mg/kg group, and the NSAID ≥1.0 mg/kg group, respectively. In the adjusted cohort, the odds ratio of PEP was 0.18 (95% confidence interval: 0.041-0.79; P = 0.023) for NSAID ≥1.0 mg/kg and 1.3 (95% confidence interval: 0.76-2.3; P = 0.31) for NSAID <1.0 mg/kg compared to the control group without NSAID.

CONCLUSIONS

PEP was not prevented by NSAID dosages below 1.0 mg/kg body weight whereas a dosage above 1.0 mg/kg body weight had a significant prophylactic effect. An NSAID dosage adjusted to body weight may be necessary to achieve an adequate prophylactic effect against PEP.

Endoscopic Step-Up Approach in Management of Necrotizing Pancreatitis

The endoscopic step-up approach in the management of necrotizing pancreatitis involves sequential steps of intervention at different time points in the clinical course of the disease. EUS -guided drainage of walled-off necrosis is the first step of the endoscopic step-up approach. Lumen-apposing metal stents are preferred over plastic stents for safe and effective drainage because of their wide caliber. Successive steps in the endoscopic step-up approach include direct endoscopic necrosectomy and/or irrigation using naso-cystic tube in symptomatic patients, primarily based on necrotic debris characteristics. Minimally invasive percutaneous radiological and/or surgical drainage are considered when endoscopic drainage is not feasible or successful.

Pancreatic necrosis: a scoping review

Acute pancreatitis (AP) is a commonly encountered GI diagnosis, accounting for 275,000 hospital admissions annually in the United States alone. Pancreatic necrosis (PN) is the most common complication of AP, and the development of PN is associated with significant morbidity and increased mortality. This expert review evaluates the evidence-based management of symptomatic PN from the era of maximal open pancreatic necrosectomy in the late 1990s though the modern paradigm of minimally invasive and endoscopic interventions. The authors present the retrospective and controlled data behind the "step-up approach" to PN treatment and discuss the application of current society guidance. Evidence based management of PN is characterized by early supportive care, and treatment by minimally invasive intervention when a patient is critically ill or persistently symptomatic. Appropriate choices when intervention is required include percutaneous drainage, minimally invasive surgery, and/or endoscopic treatment. The transition from open maximal necrosectomy to minimally invasive intervention has resulted in improved outcomes for patients, including gains in mortality, significant morbidity, and cost. The ideal precision management strategy for an individual patient remains an area of increasing understanding.

Surgical Step-Up Approach in Management of Necrotizing Pancreatitis

Necrotizing pancreatitis often demands intervention; contemporary management is directed by the step-up approach. Timing of intervention and specific approach is best directed by a multi-disciplinary team including advanced endosocpists, interventional radiologists, and surgeons with interest and experience managing this complex problem. The intervention is often a combination of percutaneous drainage, transluminal endoscopic approaches, and surgical debridement (minimally invasive or open). Goals of treatment are to evacuate solid infected necrosis, gain enteral access when needed, and to prevent recurrence-cholecystectomy in the setting of biliary pancreatitis. Experienced clinical judgment leads to optimal patient outcomes.

Pancreatitis in children: practical management from the BSPGHAN Pancreatitis Working Group

Pancreatitis, a condition characterised by inflammation of the pancreas, has multiple aetiologies. Improving clinical proficiency in prompt diagnosis and effective management leads to better outcomes for children with acute pancreatitis, acute recurrent pancreatitis and chronic pancreatitis. Establishing consensus guidance via the British Society of Paediatric Gastroenterology Hepatology and Nutrition Pancreatitis Working Group has ensured further focus on these patients who are often cared for in a multidisciplinary framework and may prompt future research in this area. Initial assessment includes serum amylase/lipase, triglyceride levels, full blood count, C reactive protein, renal and liver function profile, glucose, calcium and capillary blood gas. Fasted transabdominal ultrasound for all children and young people with suspected pancreatitis is recommended to identify pancreatic parenchyma and pancreatobiliary ductal changes, and complications. For fluid resuscitation, use crystalloids or Ringer’s lactate: initial bolus of 10 to 20 mL/kg, 1.5–2 times maintenance volume, with hourly monitoring of urine output over the initial 24–48 hours. Initiate oral intake within the first 24 hours after fluid resuscitation; fat restriction is not recommended. For suspected autoimmune pancreatitis, workup includes immunoglobulin levels (IgG, IgM, IgA, IgG subclasses), complement components and autoantibody profile to confirm diagnosis. Significant interventional management for pancreatitis and related complications is performed via endoscopic retrograde cholangiopancreatography or endoscopic ultrasound; referral to a specialised paediatric hepatobiliary surgical team is highly recommended. Close collaboration with a specialist centre can improve diagnostic and management pathways and outcomes for children.

Diffusion weighted MRI and neutrophil lymphocyte ratio non-invasively predict infection in pancreatic necrosis: a pilot study

BACKGROUND

Infected pancreatic necrosis (IPN) is a major determinant of mortality in acute pancreatitis (AP). Non-invasive diagnosis of IPN could guide the intervention in AP. We aimed to investigate the role of non-invasive methods like diffusion weighted magnetic resonance imaging (DW-MRI) and clinico-laboratory parameters as predictors of IPN.

METHODS

Prospective evaluation for predictors of IPN by diffusion restriction (DR) on DW-MRI and clinico-laboratory parameters was performed.

RESULTS

Out of 39 patients included, 31 were analysed after exclusion. Twenty-six (83.8%) patients had moderately severe AP, and the rest had severe disease. They were categorized into Group A: patients with documented infection after intervention (n = 17) and Group B: successfully managed without intervention or negative culture after intervention (n = 14). On univariate analysis, Group A had significantly more incidence of fever (P = 0.020), persistent unwellness (P = 0.003), elevated neutrophil count (P = 0.007), lymphocyte count (P = 0.007), neutrophil lymphocyte ratio (NLR) (P = 0.028), DR on DW-MRI (P = 0.001) and low apparent diffusion coefficient (ADC) (P = 0.086). Multivariate analysis revealed DR on DW-MRI (P = 0.004) and NLR (P = 0.035) as significant predictors of IPN, among other factors. The sensitivity, specificity, positive predictive value (PPV), and negative predictive value (NPV) of DW-MRI were 94.1%, 78.6%, 91.66%, and 84.21%, respectively. The area under curve of NLR on the ROC plot was 0.85 and the best cutoff was >3.5, with sensitivity, specificity, PPV, and NPV of 70.6%, 78.6%, 80%, and 68.7% respectively.

CONCLUSION

DW-MRI and NLR are promising non-invasive tools for accurate prediction of IPN and hence can guide the need for intervention in acute pancreatitis.

Safety and efficacy of lumen-apposing metal stents for endoscopic ultrasound-guided drainage of pancreatic fluid collections: a systematic review and meta-analysis

Endoscopic ultrasound (EUS)-guided drainage of pancreatic fluid collections (PFCs) has variable outcomes according to the type of lumen-apposing metal stent (LAMS) used. We aimed to perform a systematic review and meta-analysis of the available data.Online databases, including EMBASE, PubMed, and SCOPUS, were searched from inception to 30 January 2024. The outcomes of interest were technical success, clinical success, adverse events (AEs), and the need for endoscopic necrosectomy. Pooled estimates stratified by the type of stent (Axios, Nagi, or Spaxus), severity of bleeding, and type of PFC were calculated using a random-effects model. Heterogeneity was assessed by I 2 values.37 studies were included in the final analysis. The pooled outcomes (95%CIs) for PFC drainage using the Axios, Nagi, and Spaxus stents, respectively, were: technical success 97.7% (96.4%-98.8%), 96.9% (94.6%-98.5%), 98.2% (94.4%-99.9%); clinical success 90.9% (88.7%-92.8%), 88.5% (79.9%-95.0%), 93.5% (91.0%-95.6%); total AEs 20.4% (16.6%-24.6%), 17.1% (8.3%-28.3%), 7.6% (3.6%-13.0); migration 4.2% (2.9%-5.7%), 7.8% (4.1%-12.4%), 0.9% (0.1%-2.8%); overall bleeding 7.0% (4.9%-9.5%), 4.4% (2.2%-7.4%), 1.8% (0.8%-3.3%); and endoscopic necrosectomy 54.5% (38.9%-69.7%), 16.0% (11.4%-21.3%), 19.9% (6.6%-38.1%). In terms of severity, moderate-severe bleeding was most common with all three stents. AEs were higher in patients with walled-off necrosis compared with pseudocysts. Substantial-to-considerable heterogeneity (I 2 >60%) was present for total AEs for all of the stents.Our study shows good technical and clinical success rates with all three LAMSs for EUS-guided PFC drainage. Total AEs and bleeding were highest with the Axios stent and lowest with the Spaxus. Stent migration was highest with the Nagi stent and lowest with the Spaxus.

Percutaneous cystogastrostomy for treatment of pancreatic collections

OBJECTIVE

Acute pancreatitis (AP) is an inflammatory condition associated with a potential torpid evolution comprising multiple organ failure, pancreatic necrosis, infected collections and high mortality. Current management tends use the step-up approach, with endoscopic collection drainage, followed by percutaneous drainage by an interventional radiologist and video-assisted necrosectomy. We present our experience with a new percutaneous technique of establishing an anastomosis of the pancreatic collection with the closest loop, stomach, duodenum or jejunum that uses balloon dilation and drainage in cases of infection.

MATERIAL AND METHODS

Between 2009 and 2023 we have applied this technique in 30 patients, aged between 32 and 82 years (mean=67 years), 14 with pseudocysts (infected in six cases) and 16 with encapsulated necrosis (all infected). We use dilation balloons of different calibre, to establish the anastomosis between the digestive loop and the collection, as well as different drainages.

RESULTS

The intervention had a primary technical success of 93%. In two patients the cystogastrostomy had to be repeated due to initial technical failure; in both cases a good result was achieved. One patient had a severe postintervention haemorrhage (3%) that required embolisation. Length of follow-up has ranged from between three months and 10 years (mean=4 years), with no recurrence of the anastomosed collection or cutaneous fistula observed in any case.

CONCLUSION

Percutaneous cystogastrostomy is a technique that allows infected collections to be resolved and pancreatic fistulas to be avoided, with few complications, which can be resolved by interventional vascular radiologists.

Metal stents versus plastic stents for drainage of pancreatic fluid collections: a systematic review and meta-analysis of randomized trials with trial sequential analysis

BACKGROUND AND AIMS

Pancreatic fluid collections (PFCs), including walled-off necrosis (WON), are significant complications of acute pancreatitis, and their management often involves drainage, although the optimal type of stent for this purpose remains uncertain. This meta-analysis aimed to compare metal versus plastic stents for endoscopic ultrasound (EUS)-guided drainage of PFCs.

METHODS

We searched PubMed, Embase, and Cochrane Library for randomized controlled trials (RCTs) comparing metal with plastic stents for drainage of PFCs. The odds ratio (OR) was used for binary outcomes and the mean difference (MD) for continuous outcomes with their respective 95% confidence interval (CI).

RESULTS

This study included eight RCTs and over 500 patients. Procedure duration was shorter in the metal stent arm compared with the plastic stent arm (MD - 10.63; 95% CI - 16.12 to - 5.15, p < 0.001). However, there was no statistically significant difference between metal and plastic stents in clinical success (OR 1.10; 95% CI 0.56 to 2.14), technical success (OR 1.53; 95% CI 0.23 to 10.0), overall mortality (OR 0.75; 95% CI 0.34 to 1.67), recurrence (OR 1.76; 95%CI 0.70 to 4.44), total number of interventions (MD 0.06; 95% CI - 0.52 to 0.64), need of necrosectomy (OR 1.27; 95% CI 0.77 to 2.11), length of hospitalization (MD - 0.41; 95% CI - 5.10 to 4.27), exocrine insufficiency (OR 1.37; 95% CI 0.50 to 3.71), endocrine insufficiency (OR 1.11; 95% CI 0.57 to 2.16), and adverse events (OR 0.74; 95% CI 0.39 to 1.41).

CONCLUSION

Metal stents for EUS-guided drainage of WON are associated with a shorter procedure duration. Besides that, it may not improve other clinically relevant outcomes in comparison with plastic stents.

Adjuvant non-opioid analgesics decrease in-hospital mortality in targeted patients with acute pancreatitis receiving opioids

OBJECTIVES

Opioid administration in acute pancreatitis (AP) exacerbates its severity, prompting concerns regarding the increased requirement for intensive care and its potential impact on patient survival. We aimed to elucidate the influence of analgesic patterns on mortality among patients with AP hospitalized in the ICU.

METHODS

We included 784 patients (198 receiving opioid monotherapy and 586 receiving opioid polytherapy) from the Medical Information Mart for Intensive Care database. The primary outcome was in-hospital mortality. Propensity score matching was used to account for baseline differences. We used Kaplan-Meier survival curves and multivariate regression models to indicate survival discrepancies and potential associations.

RESULTS

Polytherapy group exhibited prolonged hospital survival (79.8 vs. 57.3 days, P < 0.001); polytherapy was associated with decreasing in-hospital mortality adjusted for confounders (HR = 0.49, 95% CI: 0.26-0.92; P = 0.027). Stratification analysis indicated that patients receiving adjunctive acetaminophen had prolonged hospital survival (opioid vs. opioid + acetaminophen, P < 0.001; opioid vs. opioid + NSAIDs + acetaminophen, P = 0.026). Opioid polytherapy benefited patients with APACHE III scores >83 and those with mean oral morphine equivalent >60 mg/day (HR = 0.17, 95% CI: 0.1-0.3, P < 0.001 and HR = 0.32, 95% CI: 0.2-0.52, P < 0.001, respectively).

CONCLUSION

Our findings suggest that an opioid-based analgesic regimen offers a survival advantage for patients with AP, particularly those in critical condition or with concerns about opioid use. This approach provides a viable clinical strategy for pain management. Further randomized clinical trials are warranted to validate these results.