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Abstract
The term "source control" encompasses all those physical measures used to control a focus of invasive infection and to restore the optimal function of the affected area. Source-control measures can be categorized into 3 broad modalities: drainage controls the liquid component of an infection by converting a closed space infection to a controlled sinus or fistula; debridement is the physical removal of solid necrotic tissue (removal of an infected device can be considered a form of debridement); definitive measures seek to restore optimal function to the involved area. This article discusses specific approaches to source control in the abdomen, chest, and skin and soft tissues.
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Affiliation(s)
- John C Marshall
- Department of Surgery, Li Ka Shing Knowledge Institute, St Michael's Hospital, University of Toronto, Toronto, Ontario, Canada.
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152
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Abstract
OBJECTIVES Our aims were to evaluate the efficacy of ozone therapy (OT) in an experimental rat model of acute necrotizing pancreatitis (ANP) and to compare its effects with hyperbaric oxygen (HBO) therapy in this entity. METHODS Forty Sprague-Dawley rats were divided into sham-operated, ANP, ANP + HBO, and ANP + OT groups. Acute necrotizing pancreatitis was induced by infusing 1-mL/kg 3% sodium taurocholate into the common biliopancreatic duct. Hyperbaric oxygen was administered twice daily at a 2.8-atm pressure for 90 minutes. Ozone therapy was set as daily intraperitoneal injections of 0.7-mg/kg ozone/oxygen gas mixture. Hyperbaric oxygen and OT were continued for 3 days after the induction of ANP. The surviving animals were killed at the fourth day, and their pancreases were harvested for biochemical, microbiological, and histopathologic analyses. RESULTS Serum amylase/lipase and neopterin levels and tissue oxidative stress parameters were similar to sham's values in both the ANP + HBO and the ANP + OT groups. Histopathologic injury scores were significantly lower in the treatments groups than in the ANP group. When compared with the ANP group, the number of infected rats was significantly lesser in the ANP + HBO and the ANP + OT groups. CONCLUSIONS Hyperbaric oxygen and OT reduce the severity and the mortality in the experimental rat model of ANP, and a greater benefit was received for OT comparing with HBO.
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Treatment strategy for acute pancreatitis. JOURNAL OF HEPATO-BILIARY-PANCREATIC SCIENCES 2009; 17:79-86. [PMID: 20012325 DOI: 10.1007/s00534-009-0218-z] [Citation(s) in RCA: 27] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/01/2009] [Accepted: 09/01/2009] [Indexed: 12/16/2022]
Abstract
When a diagnosis of acute pancreatitis (AP) is made, fundamental medical treatment consisting of fasting, intravenous (IV) fluid replacement, and analgesics with a close monitoring of vital signs should be immediately started. In parallel with fundamental medical treatment, assessment of severity based on clinical signs, blood test, urinalysis and imaging tests should be performed to determine the way of treatment for each patient. A repeat evaluation of severity is important since the condition is unstable especially in the early stage of AP. At the time of initial diagnosis, the etiology should be investigated by means of blood test, urinalysis and diagnostic imaging. If a biliary pancreatitis accompanied with acute cholangitis or biliary stasis is diagnosed or suspected, an early endoscopic retrograde cholangiopancreatography with or without endoscopic sphincterotomy (ERCP/ES) is recommended in addition to the fundamental medical treatment. In mild cases, the fundamental medical treatment should be continued until clinical symptom is subsided with normal laboratory data. In cases with severe acute pancreatitis (SAP) referral should be considered to medical centers experienced in the treatment of SAP, and intensive care is recommended for preventing both organ failures and infectious complications. Hemodynamic stabilization with vigorous fluid resuscitation, respiratory support and antibiotics are the major parts of intensive care in the early period of SAP. Continuous hemodiafiltration (CHDF) and continuous regional arterial infusion (CRAI) of protease inhibitor and/or antibiotics may be effective to improve pathophysiology of AP especially in the early stage of the disease. In the late stage of AP, infectious complications are critical. If an infectious complication is suspected based on clinical signs, blood test and imaging, a fine needle aspiration (FNA) is recommended to establish a diagnosis. The accuracy of FNA is reported to be 89 ~ 100%. For patients with sterile pancreatitis, non-surgical treatment should be indicated. For patients with infected pancreatic necrosis, therapeutic intervention either by percutaneous, endoscopic, laparoscopic or surgical approach are indicated. The most preferred surgical intervention is necrosectomy, however, non-surgical treatment with antibiotics is still the treatment of choice if the general condition is stable. Necrosectomy should be performed as late as possible. For patients with pancreatic abscess, drainage is recommended.
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Kamei K, Takeyama Y, Yasuda T, Kawasaki M, Ueda T, Ohyanagi H, Shiozaki H. Early infection of peripancreatic tissue in mild acute pancreatitis: report of a case. Surg Today 2009; 39:1083-5. [PMID: 19997807 DOI: 10.1007/s00595-008-4105-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/17/2008] [Accepted: 06/26/2008] [Indexed: 10/20/2022]
Abstract
Mild acute pancreatitis (AP) is rarely complicated by infection, and the value of prophylactic antibiotics is questionable. We report a case of mild AP complicated by infection, which developed within 1 week after the onset. A 66-year-old woman was referred to our hospital where a diagnosis of mild AP was made, based on laboratory data and computed tomography (CT) findings. She was managed conservatively with fluid resuscitation, intravenous antibiotics, and protease inhibitor. Her general condition improved initially, but a high fever redeveloped on hospital day 3. On hospital day 7, a repeat CT scan showed a peripancreatic fluid collection with gas, indicating peripancreatic abscess. A drainage operation was performed, and the organism cultured from the abscess was Escherichia coli. Her postoperative course was uneventful. We report this case to stress that infection may develop even in mild AP, and even in the early phase.
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Affiliation(s)
- Keiko Kamei
- Department of Surgery, Kinki University School of Medicine, 377-2 Ohno-higashi, Osaka-sayama, 589-8511, Japan
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Liu ZH, Peng JS, Li CJ, Yang ZL, Xiang J, Song H, Wu XB, Chen JR, Diao DC. A simple taurocholate-induced model of severe acute pancreatitis in rats. World J Gastroenterol 2009; 15:5732-9. [PMID: 19960573 PMCID: PMC2789229 DOI: 10.3748/wjg.15.5732] [Citation(s) in RCA: 14] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023] Open
Abstract
AIM: To investigate gut barrier damage and intestinal bacteria translocation in severe acute pancreatitis (SAP), a simple rat model of SAP was induced and studied.
METHODS: Pancreatitis was induced by uniformly distributed injection of 3.8% Na taurocholate (1 mL/kg) beneath the pancreatic capsule. Rats in the control group were injected with normal saline in the identical location.
RESULTS: Serum amylase, plasma endotoxin, intestinal permeability, and pancreatitis pathology scores were all markedly higher in the pancreatitis group than in the control group (P < 0.01). The bacterial infection rate was significantly higher in the SAP group than in the control group (P < 0.01), observed in parallel by both bacterial culture and real-time polymerase chain reaction. Acute damage of the pancreas was observed histologically in SAP rats, showing interstitial edema, leukocyte infiltration, acinar cell necrosis and hemorrhage. The microstructure of the intestinal mucosa of SAP rats appeared to be destroyed with loose, shortened microvilli and rupture of the intercellular junction, as shown by electron microscopy.
CONCLUSION: Significant gut barrier damage and intestinal bacterial translocation were definitely observed with few potential study confounders in this SAP rat model, suggesting that it may be an appropriate animal model for study of gut barrier damage and bacterial translocation in SAP.
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157
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Abstract
Traditional open surgical necrosectomy for treatment of infected pancreatic necrosis is associated with high morbidity and mortality, leading to a shift toward minimally invasive endoscopic, radiologic, and laparoscopic approaches. Percutaneous drainage is useful as a temporizing method to control sepsis and as an adjunctive treatment to surgical intervention. It is limited because of the requirement for frequent catheter care and the need for repeated procedures. Endoscopic transgastric or transduodenal therapies with endoscopic debridement/necrosectomy have recently been described and are highly successful in carefully selected patients. It avoids the need for open necrosectomy and can be used in poor operative candidates. Laparoscopic necrosectomy is also promising for treatment of pancreatic necrosis. However, the need for inducing a pneumoperitoneum and the potential risk of infection limit its usefulness in patients with critical illness. Retroperitoneal access with a nephroscope is used to directly approach the necrosis with complete removal of a sequestrum. Retroperitoneal drainage using the delay-until-liquefaction strategy also appears to be successful to treat pancreatic necrosis. The anatomic location of the necrosis, clinical comorbidities, and operator experience determine the best approach for a particular patient. Tertiary care centers with sufficient expertise are increasingly using minimally invasive procedures to manage pancreatic necrosis.
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158
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Abstract
PURPOSE OF REVIEW Patients with acute pancreatitis have traditionally been treated with 'bowel rest'. Recent data, however, suggest that this approach may be associated with increased morbidity and mortality. This paper reviews evolving concepts in the nutritional management of patients with acute pancreatitis. RECENT FINDINGS Both experimental and clinical data strongly support the concept that enteral nutrition started within 24 h of admission to hospital reduces complications, length of hospital stay and mortality in patients with acute pancreatitis. Clinical trials suggest that both gastric and jejunal tube feeding is well tolerated in patients with severe pancreatitis. Although there is limited data for the optimal type of enteral feed, a semielemental formula with omega-3 fatty acids is recommended. On the basis of current evidence, immune modulating formulas with added arginine and probiotics are not recommended. SUMMARY Nutritional support should be viewed as an active therapeutic intervention that improves the outcome of patients with acute pancreatitis. Enteral nutrition should begin within 24 h after admission and following the initial period of volume resuscitation and control of nausea and pain. Patients with mild acute pancreatitis should be started on a low-fat oral diet. In patients with severe acute pancreatitis, enteral nutrition may be provided by the gastric or jejunal route.
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159
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Deng LH, Xiang DK, Xue P, Zhang HY, Huang L, Xia Q. Effects of Chai-Qin-Cheng-Qi Decoction on cefotaxime in rats with acute necrotizing pancreatitis. World J Gastroenterol 2009; 15:4439-43. [PMID: 19764097 PMCID: PMC2747066 DOI: 10.3748/wjg.15.4439] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023] Open
Abstract
AIM: To investigate the effect of Chai-Qin-Cheng-Qi Decoction (CQCQD) on cefotaxime (CTX) concentration in pancreas of rats with acute necrotizing pancreatitis (ANP).
METHODS: Sixty healthy male Sprague-Dawley rats were divided randomly into an ANP group (ANP model + CTX, n = 20), treatment group (ANP model + CTX + CQCQD, n = 20) and control group (normal rats + CTX, n = 20). ANP models were induced by retrograde intraductal injection of 3.5% sodium taurocholate (1 mL/kg), and the control group was injected intraductally with normal saline. All rats were injected introperitoneally with 0.42 g/kg CTX (at 12-h intervals for a continuous 72 h) at 6 h after intraductal injection. Meanwhile, the treatment group received CQCQD (20 mL/kg) intragastrically at 8-h intervals, and the ANP and control group were treated intragastrically with normal saline. At 15 min after the last CTX injection, blood and pancreas samples were collected for the determination of CTX concentration using validated high-performance liquid chromatography. Pathological changes and wet-to-dry-weight (W/D) ratio of pancreatic tissue were examined.
RESULTS: Serum CTX concentrations in three groups were not significantly different. Pancreatic CTX concentration and penetration ratio were lower in ANP group vs control group (4.4 ± 0.6 μg/mL vs 18.6 ± 1.7 μg/mL, P = 0.000; 5% vs 19%, P = 0.000), but significantly higher in treatment group vs ANP group (6.4 ± 1.7 μg/mL vs 4.4 ± 0.6 μg/mL, P = 0.020; 7% vs 5%, P = 0.048). The histological scores and W/D ratio were significantly decreased in treatment group vs ANP and control group.
CONCLUSION: CQCQD might have a promotive effect on CTX concentration in pancreatic tissues of rats with ANP.
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160
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Tonsi AF, Bacchion M, Crippa S, Malleo G, Bassi C. Acute pancreatitis at the beginning of the 21st century: the state of the art. World J Gastroenterol 2009. [PMID: 19554647 DOI: 10.3748/wjg.v15.i24.2945] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023] Open
Abstract
Acute pancreatitis is an acute inflammatory disease of the pancreas which can lead to a systemic inflammatory response syndrome with significant morbidity and mortality in 20% of patients. Gallstones and alcohol consumption are the most frequent causes of pancreatitis in adults. The treatment of mild acute pancreatitis is conservative and supportive; however severe episodes characterized by necrosis of the pancreatic tissue may require surgical intervention. Advanced understanding of the pathology, and increased interest in assessment of disease severity are the cornerstones of future management strategies of this complex and heterogeneous disease in the 21st century.
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161
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Stapleton JR, McClave SA. Controversial results with use of probiotics in critical illness: early single-center positive results. Curr Gastroenterol Rep 2009; 11:255-256. [PMID: 19615298 DOI: 10.1007/s11894-009-0050-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/28/2023]
Affiliation(s)
- Jeremy R Stapleton
- University of Louisville School of Medicine, Division of Gastroenterology/Hepatology, Louisville, KY, USA
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162
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Abstract
OBJECTIVES Studies on the clinical value of parameters of hemostasis in predicting pancreatitis-associated complications are still scarce. The aim of this prospective study was to identify the useful hemostatic markers for accurate determination of the subsequent development of organ failure (OF) during the very early course of acute pancreatitis (AP). METHODS In 91 consecutive primarily admitted patients with AP, prothrombin time, activated partial thromboplastin time, fibrinogen, antithrombin III, protein C, plasminogen activator inhibitor 1, D-dimer, and plasminogen were measured in plasma within the first 24 hours of admission and 24 hours thereafter. Two study groups comprising 24 patients with OF and 67 patients without OF were compared. RESULTS Levels of prothrombin time, fibrinogen, and D-dimer on admission were significantly different between the OF and non-OF groups, and all these parameters plus antithrombin III were significantly different 24 hours later. A D-dimer value of 414.00 microg/L on admission was the best cutoff value in predicting the development of OF with sensitivity, specificity, and positive and negative predictive values of 90%, 89%, 75%, and 96%, respectively. CONCLUSIONS Measurement of plasma levels of D-dimer on the admission is an accurate method for the identification of patients who will develop OF in the further course of AP.
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163
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Andersson R, Axelsson J, Norrman G, Wang X. Gut barrier failure in critical illness: Lessons learned from acute pancreatitis. ACTA ACUST UNITED AC 2009. [DOI: 10.1080/17471060500233034] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
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164
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Andersson R, Swärd A, Tingstedt B, Akerberg D. Treatment of acute pancreatitis: focus on medical care. Drugs 2009; 69:505-14. [PMID: 19368414 DOI: 10.2165/00003495-200969050-00001] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Abstract
Acute pancreatitis has an incidence of about 300 per 1 million individuals per year, of which 10-15% of patients develop the severe form of the disease. Novel management options, which have the potential to improve outcome, include initial proper fluid resuscitation, which maintains microcirculation and thereby potentially decreases ischaemia and reperfusion injury. The traditional treatment concept in acute pancreatitis, fasting and parenteral nutrition, has been challenged and early initiation of enteral feeding in severe pancreatitis and oral intake in mild acute pancreatitis is both feasible and provides some benefits. There are at present no data supporting immunonutritional supplements and probiotics should be avoided in patients with acute pancreatitis. There is also no evidence of any benefits provided by prophylactic antibacterials in patients with predicted severe acute pancreatitis. A variety of specific medical interventions have been investigated (e.g. intense blood glucose monitoring by insulin) but none has become clinically useful. Lessons can probably be learned from critical care in general, but studies are needed to verify these interventions in acute pancreatitis.
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Affiliation(s)
- Roland Andersson
- Department of Surgery, Clinical Sciences Lund, Lund University Hospital, Lund, Sweden.
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165
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Abstract
OBJECTIVES The aim of our study was to evaluate the bacteriologic findings in secondary infection of severe acute pancreatitis (SAP) and the potential correlation with infection. METHODS Three hundred thirty-six patients with acute pancreatitis admitted to our department between January 1, 2000, and April 30, 2008, were recruited. All patients were treated with Chinese standard treatment. Of these 336 patients, 65 with infected necrosis were studied according to the clinical data. RESULTS Sixty-five (19.35%) of 336 patients had SAP with secondary infection; the time for secondary infection was diagnosed after a mean of 14 to 20 days. One hundred thirty-three strains were found in 65 patients with SAP with infection; culture-revealed organism infection included 85 gram-negative germs, 44 gram-positive germs, and 4 fungi. In the group without infection, 271 patients were managed conservatively, of which 16 patients (5.90%) died; in the other group, 61 (93.85%) of 65 patients were treated by operation and 15 patients (23.08%) died. CONCLUSIONS The predominant infections were gram-negative bacterium, gram-positive bacterium, and fungi concomitantly or consecutively. Most of the infected patients had polyinfection. There were many patients with hospital-acquired infection and opportunistic infection. Multiple factors affected the outcome.
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Tonsi AF, Bacchion M, Crippa S, Malleo G, Bassi C. Acute pancreatitis at the beginning of the 21st century: The state of the art. World J Gastroenterol 2009; 15:2945-59. [PMID: 19554647 PMCID: PMC2702102 DOI: 10.3748/wjg.15.2945] [Citation(s) in RCA: 60] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023] Open
Abstract
Acute pancreatitis is an acute inflammatory disease of the pancreas which can lead to a systemic inflammatory response syndrome with significant morbidity and mortality in 20% of patients. Gallstones and alcohol consumption are the most frequent causes of pancreatitis in adults. The treatment of mild acute pancreatitis is conservative and supportive; however severe episodes characterized by necrosis of the pancreatic tissue may require surgical intervention. Advanced understanding of the pathology, and increased interest in assessment of disease severity are the cornerstones of future management strategies of this complex and heterogeneous disease in the 21st century.
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167
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Acute pancreatitis: radiologic scores in predicting severity and outcome. ACTA ACUST UNITED AC 2009; 35:349-61. [PMID: 19437067 DOI: 10.1007/s00261-009-9522-y] [Citation(s) in RCA: 22] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/04/2009] [Accepted: 04/19/2009] [Indexed: 02/06/2023]
Abstract
Acute pancreatitis (AP) is a common inflammatory disease which can be mild and self-limiting without complications or severe with prolonged hospitalization, high morbidity, and high mortality. Different radiological scoring systems to predict severity and outcome in AP have been developed since the early 1990s. In the meantime, new insights in the pathophysiology of AP and consequently, therapeutic management of these patients have been introduced. The purpose of this review is therefore (1) to describe the current terminology and new concepts in the pathophysiology, (2) to outline the long existing and newly developed radiological scoring systems in prediction of severity and outcome with their respective advantages and limitations, and (3) to define the role of radiological prognostic scoring systems in the new environment of perception of the last decade. Risk stratification in AP requires scoring systems that can be calculated early in the course of disease which allows time for intervention. For that reason, scoring systems based on necrosis are not useful in severity prediction. The recent developed radiological scoring systems based on signs of systemic inflammatory response syndrome and organ dysfunction are promising in prediction of severity early after onset of AP.
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168
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Xue P, Deng LH, Zhang ZD, Yang XN, Wan MH, Song B, Xia Q. Effect of antibiotic prophylaxis on acute necrotizing pancreatitis: results of a randomized controlled trial. J Gastroenterol Hepatol 2009; 24:736-42. [PMID: 19220676 DOI: 10.1111/j.1440-1746.2008.05758.x] [Citation(s) in RCA: 40] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/05/2023]
Abstract
BACKGROUND AND AIMS This study addresses whether antibiotic prophylaxis is beneficial for acute necrotizing pancreatitis. METHODS This randomized, controlled trial enrolled 276 patients with severe acute pancreatitis. There were 56 patients with 30% or more necrosis proved by contrast-enhanced computerized tomography who were eligible for randomization: 29 in the study group and 27 in the control group, who received i.v. imipenem-cilastatin (3 x 500 mg/day) within 72 h of the onset of symptoms for 7-14 days, and no antibiotic prophylaxis, respectively. The primary end-point was the incidence of infectious complication. The secondary end-points were mortality, the incidence of necrosectomy for infected necrosis, the incidence of organ complication and hospital courses. RESULTS Characteristics of baseline data were similar in the two groups. No significant differences were found in the incidence of infected pancreatic necrosis (37% vs 27.6%), mortality (10.3% vs 14.8%) and the incidence of operative necrosectomy (29.6% vs 34.6%) between the study group and the control group (P > 0.05). The incidence of extrapancreatic infections, organ complications and hospital courses between the groups were also not significantly different. However, a significantly increased incidence of fungal infection was observed in the study group versus the control group (36.1% vs 14.2%, P < 0.05). CONCLUSION There was no benefit in the outcomes when antibiotic prophylaxis was routinely used in patients with acute necrotizing pancreatitis.
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Affiliation(s)
- Ping Xue
- Department of Integrated Traditional Chinese and Western Medicine, West China Hospital, Sichuan University, Chengdu, Sichuan Province, China
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169
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Kochhar R, Ahammed SKM, Chakrabarti A, Ray P, Sinha SK, Dutta U, Wig JD, Singh K. Prevalence and outcome of fungal infection in patients with severe acute pancreatitis. J Gastroenterol Hepatol 2009; 24:743-7. [PMID: 19220667 DOI: 10.1111/j.1440-1746.2008.05712.x] [Citation(s) in RCA: 32] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
BACKGROUND AND AIM To study the prevalence of risk factors and outcome of fungal infections in patients with severe acute pancreatitis. METHODS Fifty consecutive patients with severe acute pancreatitis were investigated for evidence of fungal infection by weekly culture of body fluids and aspirate from pancreatic/peripancreatic tissue and samples collected at necrosectomy. All patients were managed as per a standard protocol. Patients with documented fungal infection were treated with intravenous amphotericin or fluconazole. Data were analyzed using SPSS software (version 13), and risk factors for fungal infection and mortality were determined. RESULTS Fungal infection was documented in 18 (36%) of 50 patients with Candida albicans (the commonest species). The incidence of fungal infection steadily increased with increasing duration of hospital stay. Those with fungal infection more often had evidence of respiratory failure (P = 0.031) and hypotension (P = 0.031) at admission, prolonged hospital stay > 4 weeks (P = 0.034), longer duration of antibiotics (P = 0.003), received total parenteral nutrition (P = 0.005), and required mechanical ventilation (P = 0.001) in contrast to those without fungal infection. The logistic regression analysis found the independent risk factors for fungal infection to be antibiotic therapy for > 4 weeks and hypotension at hospitalization. Of the 18 patients with fungal infection, 13 were administered intravenous antifungals; eight of these patients survived, while the five who did not receive antifungals died. CONCLUSION Fungal infection was detected in 36% of our patients. The independent risk factors associated with it were hypotension at hospitalization and prolonged antibiotic therapy. Antifungal therapy improved their chances of survival.
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Affiliation(s)
- Rakesh Kochhar
- Department of Gastroenterology, Postgraduate Institute of Medical Education and Research, Chandigarh, India.
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170
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Rau B, Steinbach G, Baumgart K, Gansauge F, Grünert A, Beger HG. The clinical value of procalcitonin in the prediction of infected necrosis in acute pancreatitis. Intensive Care Med 2009; 26 Suppl 2:S159-64. [PMID: 18470712 DOI: 10.1007/bf02900730] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/01/2022]
Abstract
OBJECTIVE Infection of pancreatic necrosis (IN) has a major impact on management and outcome in acute pancreatitis (AP). Currently, guided fine-needle aspiration (FNA) is the only means for an accurate diagnosis of IN. Procalcitonin (PCT), a 116 amino acid pro-peptide of calcitonin has been found in high concentrations in patients with sepsis. In the present study we analyzed the clinical value of serum PCT for predicting IN in AP and compared the results to guided FNA. DESIGN Clinical study. SETTING A collaborative study between the Departments of General Surgery and Clinical Chemistry/ Pathobiochemistry of the University of Ulm, Germany. PATIENTS 61 patients with AP entered this study and were stratified into three groups according to morphological and bacteriological data: I. 22 patients with edematous pancreatitis (AIP), II. 18 patients with sterile necrosis (SN), III. 21 patients with IN. MEASUREMENTS AND RESULTS During an observation period of 14 days PCT was measured by immunoluminometry, CRP was determined by lasernephelometry on a routine base. In patients with IN overall PCT concentrations were significantly higher than in those with SN, whereas CRP levels did not differ in both groups. In contrast, only low concentrations of both parameters were found in patients with AIP. By ROC analysis the best PCT cut-off level for predicting IN or persisting pancreatic sepsis was obtained at > or =1.8 ng/ml. If this cut-off was reached on at least two consecutive days, IN could be predicted with a sensitivity of 95%, a specificity, of 88%, and an accuracy of 90%. Guided FNA achieved a sensitivity, specificity, and accuracy of 91%. 79%, and 84% in differentiating IN from SN, respectively. After surgical treatment of IN median PCT values continued to be significantly higher in patients with persisting pancreatic sepsis (n=12) compared to those with an uneventful postoperative course (n=7). Our results demonstrate that monitoring of serum PCT could serve as a noninvasive and accurate method to predict IN in AP as well as to select patients with persisting septic complications after surgical debridement.
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Affiliation(s)
- B Rau
- Department of General Surgery, University of Ulm, D-89075 Ulm, Germany
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Gülben K, Ozdemir H, Berberoğlu U, Mersin H, Yrkin F, Cakýr E, Aksaray S. Melatonin modulates the severity of taurocholate-induced acute pancreatitis in the rat. Dig Dis Sci 2009. [PMID: 19399617 DOI: 10.1009/s10620-009-0808-2] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 03/06/2023]
Abstract
The aim of this study was to investigate the effects of melatonin on serum amylase, tumor necrosis factor-alpha (TNF-alpha) and histological changes in rats with taurocholate-induced acute pancreatitis. Thirty male Wistar rats were randomly divided into three groups; group 1, group 2 and group 3 were enrolled as melatonin, control and sham groups, respectively (n = 10 per group). Acute pancreatitis was induced by 1 ml/kg body weight using 5% taurocholate injection into the biliopancreatic duct in groups 1 and 2 after clamping the hepatic duct. Those in group 1 received 50 mg/kg body weight melatonin by intraperitoneal (i.p.) injection. Group 2 received physiological saline i.p. at the same dose. Group 3 solely underwent laparotomy with cannulation of the biliopancreatic duct. Twenty-four hours after the intervention, the rats were killed, and serum samples were collected to measure amylase and TNF-alpha levels. Simultaneously, pancreatic tissues were removed, stained with hematoxylin-eosin and examined under a light microscope. Serum amylase and TNF-alpha levels were significantly lower in the melatonin group compared to the controls (P < 0.001). The total histological score, including edema, inflammation, perivascular infiltrate, acinar necrosis, fat necrosis and hemorrhage, was also significantly lower in the melatonin group as compared to the control (P < 0.0001). In conclusion, melatonin is potentially capable of reducing pancreatic damage by decreasing serum TNF-alpha levels in taurocholate-induced acute pancreatitis in rats. This result supports the idea that melatonin might be beneficial in ameliorating the severity of acute pancreatitis.
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Affiliation(s)
- Kaptan Gülben
- Department of Surgery, Ankara Oncology Training and Research Hospital, Urankent sitesi, C-9 blok, No. 33, 06200, Demetevler, Ankara, Turkey.
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García-Barrasa A, Borobia FG, Pallares R, Jorba R, Poves I, Busquets J, Fabregat J. A double-blind, placebo-controlled trial of ciprofloxacin prophylaxis in patients with acute necrotizing pancreatitis. J Gastrointest Surg 2009; 13:768-74. [PMID: 19082671 DOI: 10.1007/s11605-008-0773-7] [Citation(s) in RCA: 66] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/25/2008] [Accepted: 11/24/2008] [Indexed: 02/07/2023]
Abstract
BACKGROUND The use of prophylactic antibiotics in acute severe necrotizing pancreatitis is controversial. METHODS Prospective, randomized, placebo-controlled, double-blind study was carried out at Bellvitge Hospital, in Barcelona, Spain. Among 229 diagnosed with severe acute pancreatitis, 80 had evidence of necrotizing pancreatitis (34/80 patients were excluded of the protocol). Forty-six patients without previous antibiotic treatment with pancreatic necrosis in a contrast-enhanced CT scan were randomly assigned to receive either intravenous ciprofloxacin or placebo. Five patients were secondarily excluded, and the remaining 41 patients were finally included in the study (22 patients received intravenous ciprofloxacin and 19 patients placebo). RESULTS Comparing the 22 with intravenous ciprofloxacin and 19 with placebo, infected pancreatic necrosis was detected in 36% and 42% respectively (p = 0.7). The mortality rate was 18% and 11%, respectively (p = 0.6). No significant differences between both treatment groups were observed with respect to variables such as: non-pancreatic infections, surgical treatment, timing and the re-operation rate, organ failure, length of hospital and ICU stays. CONCLUSION The prophylactic use of ciprofloxacin in patients with severe necrotizing pancreatitis did not significantly reduce the risk of developing pancreatic infection or decrease the mortality rate. The small number of patients included in this study should be considered.
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Affiliation(s)
- A García-Barrasa
- Department of General Surgery and Digestive Tract, Bellvitge Hospital, Idibell, University of Barcelona, Barcelona, Spain
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173
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Besselink MG, van Santvoort HC, Boermeester MA, Nieuwenhuijs VB, van Goor H, Dejong CHC, Schaapherder AF, Gooszen HG. Timing and impact of infections in acute pancreatitis. Br J Surg 2009; 96:267-73. [PMID: 19125434 DOI: 10.1002/bjs.6447] [Citation(s) in RCA: 209] [Impact Index Per Article: 13.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Abstract
BACKGROUND Although infected necrosis is an established cause of death in acute pancreatitis, the impact of bacteraemia and pneumonia is less certain. METHODS This was a cohort study of 731 patients with a primary episode of acute pancreatitis in 2004-2007, including 296 patients involved in a randomized controlled trial to investigate the value of probiotic treatment in severe pancreatitis. Time of onset of bacteraemia, pneumonia, infected pancreatic necrosis, persistent organ failure and death were recorded. RESULTS The initial infection in 173 patients was diagnosed a median of 8 (interquartile range 3-20) days after admission (infected necrosis, median day 26; bacteraemia/pneumonia, median day 7). Eighty per cent of 61 patients who died had an infection. In 154 patients with pancreatic parenchymal necrosis, bacteraemia was associated with increased risk of infected necrosis (65 versus 37.9 per cent; P = 0.002). In 98 patients with infected necrosis, bacteraemia was associated with higher mortality (40 versus 16 per cent; P = 0.014). In multivariable analysis, persistent organ failure (odds ratio (OR) 18.0), bacteraemia (OR 3.4) and age (OR 1.1) were associated with death. CONCLUSION Infections occur early in acute pancreatitis, and have a significant impact on mortality, especially bacteraemia. Prophylactic strategies should focus on early intervention.
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Affiliation(s)
- M G Besselink
- Department of Surgery, University Medical Centre Utrecht, Utrecht, The Netherlands
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174
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Hasibeder WR, Torgersen C, Rieger M, Dünser M. Critical Care of the Patient with Acute Pancreatitis. Anaesth Intensive Care 2009; 37:190-206. [DOI: 10.1177/0310057x0903700206] [Citation(s) in RCA: 29] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Abstract
Acute pancreatitis is an inflammatory process of the pancreas with variable involvement of regional tissues and remote organs. This review gives a comprehensive overview of the aetiology, pathophysiology, diagnosis and therapy of acute pancreatitis relevant to the intensivist. Recent international guidelines on the management of acute pancreatitis are summarised. Eighty percent of acute pancreatitis episodes are related either to gallstones or to alcohol abuse. Independent of its aetiology, the pathophysiologic hallmark of acute pancreatitis is the premature activation of trypsin, which leads to massive pancreas inflammation, systemic overproduction of pro-inflammatory mediators and ultimately remote organ dysfunction. All guidelines agree that the diagnosis of acute pancreatitis should include clinical symptoms, increased serum amylase or lipase levels and/or characteristic findings on computed tomography. Endoscopic retrograde cholangiopancreatography is recommended as a causative therapy in patients with acute cholangitis or a strong suspicion of gallstones. All guidelines underline the importance of vigorous fluid resuscitation and supplemental oxygen therapy and prefer enteral over parenteral nutrition, with the majority favouring the nasojejunal route. In view of lacking scientific evidence, antibiotic prophylaxis to prevent infection of pancreatic necroses is discouraged by most guidelines. Computed tomography-guided fine needle aspiration is the technique of choice to differentiate between sterile and infected pancreas necrosis. While sterile pancreatic necrosis should be managed conservatively, infected pancreatic necrosis requires debridement and drainage supplemented by antibiotic therapy. Surgical necrosectomy is the traditional approach, but less invasive techniques (retroperitoneal or laparoscopic necrosectomy, computed tomography-guided percutaneous catheter drainage) may be equally effective.
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Affiliation(s)
- W. R. Hasibeder
- Department of Anaesthesiology and Critical Care Medicine, Innsbruck Medical University, Innsbruck, Austria
- Department of Anaesthesiology and Critical Care Medicine, Krankenhaus der Barmherzigen Schwestern, Ried im Innkreis
| | - C. Torgersen
- Department of Anaesthesiology and Critical Care Medicine, Innsbruck Medical University, Innsbruck, Austria
- Anaesthetist
| | - M. Rieger
- Department of Anaesthesiology and Critical Care Medicine, Innsbruck Medical University, Innsbruck, Austria
- Department of Radiology
| | - M. Dünser
- Department of Anaesthesiology and Critical Care Medicine, Innsbruck Medical University, Innsbruck, Austria
- Anaesthetist
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175
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Zheng YJ, Wang YL, Mao EQ, Liu W, Li L, Wu J, Zhang RY, Tang YQ. Gut-derived endotoxin translocation is the main aggravating mechanism of acute severe pancreatitis. BIOSCIENCE HYPOTHESES 2009; 2:286-289. [DOI: 10.1016/j.bihy.2009.03.013] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 10/13/2023]
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176
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Affiliation(s)
- Emmanuel Charbonney
- Department of Critical Care Medicine, St. Michael's Hospital, Toronto, Ontario, Canada
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177
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Fritz S, Hartwig W, Lehmann R, Will-Schweiger K, Kommerell M, Hackert T, Schneider L, Büchler MW, Werner J. Prophylactic antibiotic treatment is superior to therapy on-demand in experimental necrotising pancreatitis. CRITICAL CARE : THE OFFICIAL JOURNAL OF THE CRITICAL CARE FORUM 2008; 12:R141. [PMID: 19014609 PMCID: PMC2646352 DOI: 10.1186/cc7118] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 05/13/2008] [Revised: 10/09/2008] [Accepted: 11/16/2008] [Indexed: 01/12/2023]
Abstract
Introduction High morbidity and mortality rates in patients with severe acute pancreatitis are mainly caused by bacterial superinfection of pancreatic necrosis and subsequent sepsis. The benefit of early prophylactic antibiotics remains controversial because clinical studies performed to date were statistically underpowered. Thus, the aim of this study was to evaluate on-demand versus prophylactic antibiotic treatment in a standardised experimental model. Methods Treatment groups received meropenem either therapeutically 24 hours after induction of necrotising pancreatitis or prophylactically before development of pancreatic superinfection. At 24 and 72 hours, pancreatic injury was investigated by histology and translocation by bacterial cultures of pancreatic tissue and mesenteric lymph nodes. Septic complications were evaluated by blood cultures and survival. Results Without antibiotic treatment, pancreatic superinfection was observed in almost all cases after induction of necrotising pancreatitis. The 72-hour-mortality rate was 42.9% and bacterial infection of mesenteric lymph nodes and bacteraemia was found in 87.5% of the surviving animals. Therapeutic administration of meropenem on-demand reduced bacteraemia to 50% and mortality to 27.3%. However, prophylactic antibiotic treatment significantly reduced bacteraemia to 25.0% (p = 0.04) and pancreatic superinfection as well as mortality to 0% (p < 0.001 and p = 0.05, respectively) compared with controls. Conclusions In the present study both prophylactic and delayed antibiotic treatment on-demand reduced septic complications in a standardised setting of experimental necrotising pancreatitis. However, pancreatic superinfection, bacteraemia and mortality rates were reduced significantly by early treatment. Thus, in the absence of statistically relevant and well-designed clinical trials, the study demonstrates that prophylactic antibiotic treatment is superior to antibiotic treatment on-demand.
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Affiliation(s)
- Stefan Fritz
- Department of General and Visceral Surgery, University of Heidelberg, Im Neuenheimer Feld 110, 69120 Heidelberg, Germany.
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178
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Navarro S, Amador J, Argüello L, Ayuso C, Boadas J, de Las Heras G, Farré A, Fernández-Cruz L, Ginés A, Guarner L, López Serrano A, Llach J, Lluis F, de Madaria E, Martínez J, Mato R, Molero X, Oms L, Pérez-Mateo M, Vaquero E. [Recommendations of the Spanish Biliopancreatic Club for the Treatment of Acute Pancreatitis. Consensus development conference]. GASTROENTEROLOGIA Y HEPATOLOGIA 2008; 31:366-87. [PMID: 18570814 DOI: 10.1157/13123605] [Citation(s) in RCA: 23] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Affiliation(s)
- Salvador Navarro
- Servicio de Gastroenterología, Institut de Malalties Digestives i Metabóliques, Hospital Clínic, Barcelona, Spain.
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179
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Pupelis G, Zeiza K, Plaudis H, Suhova A. Conservative approach in the management of severe acute pancreatitis: eight-year experience in a single institution. HPB (Oxford) 2008; 10:347-55. [PMID: 18982151 PMCID: PMC2575676 DOI: 10.1080/13651820802140737] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/24/2008] [Indexed: 02/06/2023]
Abstract
INTRODUCTION Recognition of severe acute pancreatitis (SAP), intensive care, shifting away from early surgical treatment, and monitoring of the intra-abdominal pressure (IAP) is important in the management of SAP. The aim of our study was retrospective evaluation and critical assessment of the experience with SAP management protocol involving new strategy in the university hospital. METHODS Protocols of 274 SAP patients treated in our institution during the last eight years were reassessed. APACHE II, CRP and SOFA score, IAP, pulmonary complications, ventilatory support and infection rate were evaluated. The success of the conservative treatment, surgical interventions and mortality was analysed comparing period 1 from 1999 to 2002 and period 2 from 2003 to 2006. RESULTS More patients with necrotising SAP were treated in period 2. The average CRP and SOFA score was higher in period 2, p=0.018; p=0.011. A total of 139 patients underwent continuous veno-venous haemofiltration (CVVH) as a component of fluid resuscitation and IAP control. Application of CVVH increased in period 2, p<0.005. Only 5-8% of patients were managed with ventilatory support. The overall infection rate decreased in period 2 comprising 21%, p<0.005. Success rate of the conservative therapy reached 69% in period 2, p<0.01. Surgical treatment was performed in 41% of patients in period 1 vs. 19% in period 2, p<0.001. Overall mortality was 19%, with a reduction to 12% in year 2006. CONCLUSION The conservative protocol-based approach is a rational treatment strategy for the management of SAP and can be successfully implemented in the setting of the university hospital.
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Affiliation(s)
- G. Pupelis
- Department of Surgery, Clinical University Hospital “Gailezers”RigaLatvia
| | - K. Zeiza
- Department of Surgery, Clinical University Hospital “Gailezers”RigaLatvia
| | - H. Plaudis
- Department of Surgery, Clinical University Hospital “Gailezers”RigaLatvia
| | - A. Suhova
- Department of Surgery, Clinical University Hospital “Gailezers”RigaLatvia
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180
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Wu BU, Johannes RS, Kurtz S, Banks PA. The impact of hospital-acquired infection on outcome in acute pancreatitis. Gastroenterology 2008; 135:816-20. [PMID: 18616944 PMCID: PMC2570951 DOI: 10.1053/j.gastro.2008.05.053] [Citation(s) in RCA: 52] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/14/2008] [Revised: 05/14/2008] [Accepted: 05/21/2008] [Indexed: 12/15/2022]
Abstract
BACKGROUND & AIMS Little is known regarding the impact of hospital-acquired infection (HAI) in acute pancreatitis (AP). We conducted a population-based assessment of the impact of HAI on outcome in AP. METHODS Patient data were obtained from the Cardinal Health Clinical Outcomes Research Database, a large population-based data set. Cases with principal diagnosis by International Classification of Diseases, ninth revision, clinical modification 577.0 (AP) between January 2004 and January 2005 were identified. These cases were linked with recently reported HAI data collected by the Pennsylvania Health Care Cost Containment Council. Identification of HAI was based on definitions set forth by the National Nosocomial Infection Surveillance System. We conducted a 5:1 multivariate propensity-matched cohort study to determine the independent contribution of HAI to in-hospital mortality, length of stay (LOS), and hospital charges. RESULTS From 177 participating hospitals, there were 11,046 AP cases identified. Eighty-two (0.7%) patients developed an HAI. Mortality in the overall AP population was 1.2% vs 11.4% among 405 matched non-HAI controls vs 28.4% among patients who developed HAI (chi(2) test, P < .0001). Fifteen percent of all deaths was associated with an HAI. Both average LOS and hospital charges were significantly increased among patients with HAI compared with matched non-HAI controls. CONCLUSIONS We determined that HAI had a major impact on mortality in AP. Patients who developed HAI also had significantly increased LOS and hospital charges. These differences were not explained by increased disease severity alone. Reducing HAI is an important step to improving outcome in AP.
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Affiliation(s)
- Bechien U Wu
- Division of Gastroenterology, Brigham and Women's Hospital, Center for Pancreatic Disease, Harvard Medical School, Boston, Massachusetts 02115, USA.
| | - Richard S. Johannes
- Brigham and Women’s Hospital, Division of Gastroenterology, Center for Pancreatic Disease, Harvard Medical School, Boston MA,Cardinal Health, Marlborough MA
| | | | - Peter A. Banks
- Brigham and Women’s Hospital, Division of Gastroenterology, Center for Pancreatic Disease, Harvard Medical School, Boston MA
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181
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Pérez-Mateo M. [Pancreas and biliary tract. When is antibiotic therapy indicated in acute pancreatitis and which drug(s) should be used?]. GASTROENTEROLOGIA Y HEPATOLOGIA 2008; 31:394-395. [PMID: 18570818 DOI: 10.1157/13123609] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/26/2023]
Affiliation(s)
- Miguel Pérez-Mateo
- Hospital General Universitario de Alicante, Pintor Baeza 12, Alicante, Spain.
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182
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Abstract
The aim of the present review is to summarize the current knowledge regarding pharmacological prevention and treatment of acute pancreatitis (AP) based on experimental animal models and clinical trials. Somatostatin (SS) and octreotide inhibit the exocrine production of pancreatic enzymes and may be useful as prophylaxis against Post Endoscopic retrograde cholangiopancreatography Pancreatitis (PEP). The protease inhibitor Gabexate mesilate (GM) is used routinely as treatment to AP in some countries, but randomized clinical trials and a meta-analysis do not support this practice. Nitroglycerin (NGL) is a nitrogen oxide (NO) donor, which relaxes the sphincter of Oddi. Studies show conflicting results when applied prior to ERCP and a large multicenter randomized study is warranted. Steroids administered as prophylaxis against PEP has been validated without effect in several randomized trials. The non-steroidal anti-inflammatory drugs (NSAID) indomethacin and diclofenac have in randomized studies showed potential as prophylaxis against PEP. Interleukin 10 (IL-10) is a cytokine with anti-inflammatory properties but two trials testing IL-10 as prophylaxis to PEP have returned conflicting results. Antibodies against tumor necrosis factor-alpha (TNF-α) have a potential as rescue therapy but no clinical trials are currently being conducted. The antibiotics beta-lactams and quinolones reduce mortality when necrosis is present in pancreas and may also reduce incidence of infected necrosis. Evidence based pharmacological treatment of AP is limited and studies on the effect of potent anti-inflammatory drugs are warranted.
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183
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Shinzeki M, Ueda T, Takeyama Y, Yasuda T, Matsumura N, Sawa H, Nakajima T, Matsumoto I, Fujita T, Ajiki T, Fujino Y, Kuroda Y. Prediction of early death in severe acute pancreatitis. J Gastroenterol 2008; 43:152-8. [PMID: 18306989 DOI: 10.1007/s00535-007-2131-z] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/29/2007] [Accepted: 10/13/2007] [Indexed: 02/04/2023]
Abstract
BACKGROUND In severe acute pancreatitis (SAP), it is clinically important at the time of admission to predict the likelihood of early death. This investigation aimed to clarify the factors predicting early death in SAP. METHODS Early death was defined as death within 10 days after disease onset. Prediction factors for early death were evaluated from data obtained on admission from 93 patients with SAP, and the characteristics of patients who died early were analyzed. RESULTS Between the early-death and early-survival groups, significant factors were base excess (BE), serum creatinine (Cr), blood sugar, serum glutamate oxaloacetic transaminase, and serum calcium. Multivariate analysis revealed that BE was an independent prediction factor for early death. The early-death rate in patients with BE < -5.5 mEq/l and Cr >or= 3.0 mg/dl was 31% and 36%, respectively. The combination of BE and Cr raised the positive predictive value to 50%, and was equally able to predict early death as the Japanese Severity Score (JSS), which was the most useful of the three conventional scoring systems used. All early-death patients had pancreatic necrosis, and their JSS was >or= 15 (stage 4). Characteristically, early-death patients had lactate dehydrogenase (LDH)>1300 IU/l, or they had serious preexisting comorbidities. CONCLUSIONS As a single parameter, BE was most useful for predicting early death. The combination of BE and Cr could predict early death as well as the JSS. An extreme rise of LDH and serious preexisting comorbidity may also be risk factors for early death.
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Affiliation(s)
- Makoto Shinzeki
- Department of Gastroenterological Surgery, Kobe University Graduate School of Medical Sciences, 7-5-2 Kusunoki, Chuo-ku, Kobe, 650-0017 Japan
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184
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Abstract
OBJECTIVES The aim of our study was to evaluate the clinical significance of prolonged organ failure during the first week of severe acute pancreatitis and the potential correlation with final outcome. METHODS Of 234 patients with acute pancreatitis admitted to our department between January 2002 and December 2006, 64 patients with predicted severe acute pancreatitis were studied according to the presence and also the duration of organ failure early in the course of the disease. RESULTS Transient (<48 h duration) or persistent (>48 h duration) early organ failure (EOF) was present in 33 of 64 patients (51.5%). All 9 deaths (9/55 patients; 16.5% mortality) were recorded among patients who developed pancreatic necrosis, and the combination ofEOF and necrosis was present in most (8/9) patients with fatal outcome (P = 0.009). Persistent EOF was significantly associated with development of infected necrosis (P = 0.037) and worse outcome (P=0.028) as well. Multivariate analysis with backward elimination identified the duration of EOF as an independent factor affecting outcome. CONCLUSIONS Persistent organ failure early in the course of acute pancreatitis is a major determinant of outcome. In combination with pancreatic necrosis, survival rate is strongly compromised.
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185
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Percutaneous necrosectomy in patients with acute, necrotizing pancreatitis. Eur Radiol 2008; 18:1604-10. [PMID: 18357453 DOI: 10.1007/s00330-008-0928-7] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/28/2007] [Revised: 01/10/2008] [Accepted: 02/03/2008] [Indexed: 12/15/2022]
Abstract
The objective of this retrospective study was to evaluate the outcome of patients with acute necrotizing pancreatitis treated by active percutaneous necrosectomy. By searching the radiological, surgical and internal medicine databases, all patients with acute necrotizing pancreatitis treated by active percutaneous necrosectomy between 1992 and 2004 were identified. Demographic, laboratory, and clinical data, and details about invasive procedures were collected by reviewing patient charts, radiological and surgical reports. The computed tomography severity index (CTSI) scores were determined by reviewing CT images. Eighteen patients were identified. Median Ranson score on admission was 2. The Acute Physiology and Chronic Health Evaluation (APACHE) II score was median 22. Median CTSI score was 7. Initially all patients were treated with CT-guided drainage placement. Because passive drainage proved not to be effective, subsequent minimally invasive, percutaneous necrosectomy was performed. Eight out of 18 patients recovered fully without the need for surgery. Ten of 18 patients required additional surgical necrosectomy. For one of ten patients, percutaneous necrosectomy allowed postponing surgery by 39 days. Four of ten surgically treated patients died: three from septic multiorgan failure, one from pulmonary embolism. Percutaneous minimally invasive necrosectomy can be regarded as a safe and effective complementary treatment modality in patients with necrotizing pancreatitis. It is suitable for a subset of patients to avoid or delay surgery.
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186
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Pharmacokinetic and pharmacodynamic properties of biapenem, a carbapenem antibiotic, in rat experimental model of severe acute pancreatitis. Pancreas 2008; 36:125-32. [PMID: 18376302 DOI: 10.1097/mpa.0b013e3181568ed7] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/30/2022]
Abstract
OBJECTIVES It is known that prophylaxis with imipenem reduces the risk of infection accompanying severe acute pancreatitis. In this study,we modified a rat experimental model of severe acute pancreatitis for antibiotic evaluation, and the effect of biapenem was compared with that of imipenem to determine the usefulness of biapenem. METHODS Severe acute pancreatitis was induced by 5% sodium taurocholate. Antibiotics were subcutaneously administered at 3 and 6 hours and evaluated at 12 hours after the pancreatitis induction. For pharmacokinetic evaluation, antibiotics were subcutaneously administered at 3 hours after the pancreatitis induction. RESULTS From 3 hours after the induction, bacteria were detected from the pancreas. The total bacterial count increased in a time-dependent manner for 12 hours. Biapenem administration reduced the total bacterial count in the pancreas, as observed in imipenem administration. The plasma concentration of biapenem was almost equivalent to that of imipenem; however, the pancreatic penetration of biapenem was approximately twice that of imipenem in this model. CONCLUSIONS Biapenem was suggested to be effective in prophylactic treatment of infectious complications as much as imipenem because of its superior penetration to the pancreas in severe acute pancreatitis.
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187
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Abstract
OBJECTIVES A clinical study was made to test the hypothesis that gut mucosal damage happens and correlates with endotoxemia, systemic inflammation, severity of disease, septic complication, and outcome in acute pancreatitis (AP) patients. METHODS Patients were divided into 3 groups according to severity: grade 1 (n = 26, mild), grade 2 (n = 18, severe AP [SAP] without organ dysfunction), and grade 3 (n = 18, SAP with organ dysfunction). Twenty healthy volunteers were enrolled as control group. The intestinal lactulose and mannitol absorption ratio, d-xylose absorption, endotoxin, and tumor necrosis factor alpha were detected in parallel to clinical data collection. RESULTS Lactulose and mannitol absorption ratio increased in patients with AP, and the increase was more pronounced in SAP (grade 1: 0.044 +/- 0.017, grade 2: 0.39 +/- 0.16, grade 3: 0.48 +/- 0.22, control: 0.024 +/- 0.009; P < 0.01 between control and AP, P < 0.01 between mild and severe group). d-Xylose absorption decreased in pancreatitis groups (P < 0.01) especially in severe groups (P < 0.01 between mild and SAP). We also observed a significant positive correlation of mucosal permeability with endotoxin (r = 0.902, P < 0.001) and tumor necrosis factor alpha changes (r = 0.862, P < 0.001). The severity and septic complication in AP patients were different accompanied with severity of gut mucosal damage. CONCLUSIONS Intestinal mucosal function is injured in early phase of AP especially in patients with organ dysfunction, which may be a stimulus for development of multiple organ dysfunction and correlate with bad outcome in AP patients.
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188
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Abstract
Approximately 20% of patients with acute pancreatitis develop a severe disease associated with complications and high risk of mortality. The purpose of this study is to review pathogenesis and prognostic factors of severe acute pancreatitis (SAP). An extensive medline search was undertaken with focusing on pathogenesis, complications and prognostic evaluation of SAP. Cytokines and other inflammatory markers play a major role in the pathogenesis and course of SAP and can be used as prognostic markers in its early phase. Other markers such as simple prognostic scores have been found to be as effective as multifactorial scoring systems (MFSS) at 48 h with the advantage of simplicity, efficacy, low cost, accuracy and early prediction of SAP. Recently, several laboratory markers including hematocrit, blood urea nitrogen (BUN), creatinine, matrix metalloproteinase-9 (MMP-9) and serum amyloid A (SAA) have been used as early predictors of severity within the first 24 h. The last few years have witnessed a tremendous progress in understanding the pathogenesis and predicting the outcome of SAP. In this review we classified the prognostic markers into predictors of severity, pancreatic necrosis (PN), infected PN (IPN) and mortality.
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189
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Bruennler T, Langgartner J, Lang S, Wrede CE, Klebl F, Zierhut S, Siebig S, Mandraka F, Rockmann F, Salzberger B, Feuerbach S, Schoelmerich J, Hamer OW. Outcome of patients with acute, necrotizing pancreatitis requiring drainage-does drainage size matter? World J Gastroenterol 2008; 14:725-30. [PMID: 18205262 PMCID: PMC2683999 DOI: 10.3748/wjg.14.725] [Citation(s) in RCA: 59] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023] Open
Abstract
AIM: To assess the outcome of patients with acute necrotizing pancreatitis treated by percutaneous drainage with special focus on the influence of drainage size and number.
METHODS: We performed a retrospective analysis of 80 patients with acute pancreatitis requiring percutaneous drainage therapy for infected necroses. Endpoints were mortality and length of hospital stay. The influence of drainage characteristics such as the median drainage size, the largest drainage size per patient and the total drainage plane per patient on patient outcome was evaluated.
RESULTS: Total hospital survival was 66%. Thirty-four patients out of all 80 patients (43%) survived acute necrotizing pancreatitis with percutaneous drainage therapy only. Eighteen patients out of all 80 patients needed additional percutaneous necrosectomy (23%). Ten out of these patients required surgical necrosectomy in addition, 6 patients received open necrosectomy without prior percutaneous necrosectomy. Elective surgery was performed in 3 patients receiving cholecystectomy and one patient receiving resection of the parathyroid gland. The number of drainages ranged from one to fourteen per patient. The drainage diameter ranged from 8 French catheters to 24 French catheters. The median drainage size as well as the largest drainage size used per patient and the total drainage area used per patient did not show statistically significant influence on mortality.
CONCLUSION: Percutaneous drainage therapy is an effective tool for treatment of necrotizing pancreatitis. Large bore drainages did not prove to be more effective in controlling the septic focus.
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190
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Bollen TL, van Santvoort HC, Besselink MG, van Leeuwen MS, Horvath KD, Freeny PC, Gooszen HG. The Atlanta Classification of acute pancreatitis revisited. Br J Surg 2008; 95:6-21. [PMID: 17985333 DOI: 10.1002/bjs.6010] [Citation(s) in RCA: 190] [Impact Index Per Article: 11.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
BACKGROUND In a complex disease such as acute pancreatitis, correct terminology and clear definitions are important. The clinically based Atlanta Classification was formulated in 1992, but in recent years it has been increasingly criticized. No formal evaluation of the use of the Atlanta definitions in the literature has ever been performed. METHODS A Medline literature search sought studies published after 1993. Guidelines, review articles and their cross-references were reviewed to assess whether the Atlanta or alternative definitions were used. RESULTS A total of 447 articles was assessed, including 12 guidelines and 82 reviews. Alternative definitions of predicted severity of acute pancreatitis, actual severity and organ failure were used in more than half of the studies. There was a large variation in the interpretation of the Atlanta definitions of local complications, especially relating to the content of peripancreatic collections. CONCLUSION The Atlanta definitions for acute pancreatitis are often used inappropriately, and alternative definitions are frequently applied. Such lack of consensus illustrates the need for a revision of the Atlanta Classification.
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Affiliation(s)
- T L Bollen
- Department of Radiology, St Antonius Hospital Nieuwegein, The Netherlands
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191
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Bollen TL, van Santvoort HC, Besselink MGH, van Es WH, Gooszen HG, van Leeuwen MS. Update on acute pancreatitis: ultrasound, computed tomography, and magnetic resonance imaging features. Semin Ultrasound CT MR 2008; 28:371-83. [PMID: 17970553 DOI: 10.1053/j.sult.2007.06.002] [Citation(s) in RCA: 46] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
Imaging of patients with acute pancreatitis requires an understanding of the subtypes and complications that were defined at the Atlanta symposium in 1992. In the last decade, several new entities have been recognized with important clinical implications. In this article, the radiological aspects of the terminology and classification of acute pancreatitis are reviewed and new entities are clarified. The roles of ultrasound, computed tomography, and magnetic resonance imaging in the diagnosis and evaluation of acute pancreatitis and its complications are discussed and the limitations of each imaging technique, when interpreting pancreatic and peripancreatic inflammatory disease, are addressed.
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Affiliation(s)
- Thomas L Bollen
- Department of Radiology, St. Antonius Hospital, Nieuwegein, The Netherlands.
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192
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Pancreas. Surgery 2008. [DOI: 10.1007/978-0-387-68113-9_47] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
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193
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Marshall JC. Acute Pancreatitis. Crit Care Med 2008. [DOI: 10.1016/b978-032304841-5.50080-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/01/2022]
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194
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Bai Y, Gao J, Zou DW, Li ZS. Prophylactic antibiotics cannot reduce infected pancreatic necrosis and mortality in acute necrotizing pancreatitis: evidence from a meta-analysis of randomized controlled trials. Am J Gastroenterol 2008; 103:104-10. [PMID: 17925000 DOI: 10.1111/j.1572-0241.2007.01575.x] [Citation(s) in RCA: 94] [Impact Index Per Article: 5.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
BACKGROUND There is no agreement whether intravenous prophylactic antibiotics can reduce infected pancreatic necrosis and mortality in acute necrotizing pancreatitis (ANP). We performed a meta-analysis comparing intravenous antibiotics with placebo or no treatment in randomized controlled trials (RCTs). METHODS Databases including MEDLINE, EMBASE, the Cochrane controlled trials register, the Cochrane Library, and Science Citation Index were searched to find relevant trials. Outcome measures were infected necrosis and mortality. RESULTS Seven trials involving 467 patients were included. Analysis suggested infected pancreatic necrosis rates were not significantly different (antibiotics 17.8%, controls 22.9%), RR 0.81 (95% CI 0.54-1.22). There was nonsignificantly decreased mortality with antibiotics (9.3%) versus controls (15.2%), RR 0.70 (95% CI 0.42-1.17). Subsequent subgroup analysis confirmed antibiotics were not statistically superior to controls in reduction of infected necrosis and mortality. CONCLUSIONS Prophylactic antibiotics cannot reduce infected pancreatic necrosis and mortality in patients with ANP.
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Affiliation(s)
- Yu Bai
- Department of Gastroenterology, Changhai Hospital, Second Military Medical University, Shanghai, China
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195
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Flint RS, Phillips ARJ, Power SE, Dunbar PR, Brown C, Delahunt B, Cooper GJS, Windsor JA. Acute pancreatitis severity is exacerbated by intestinal ischemia-reperfusion conditioned mesenteric lymph. Surgery 2007; 143:404-13. [PMID: 18291262 DOI: 10.1016/j.surg.2007.10.005] [Citation(s) in RCA: 22] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/21/2006] [Revised: 09/12/2007] [Accepted: 10/11/2007] [Indexed: 12/16/2022]
Abstract
OBJECTIVE To determine the effect of intestinal ischemia-reperfusion (IIR) on acute pancreatitis (AP) and the role of mesenteric lymph. SUMMARY BACKGROUND DATA Intestinal ischemia is an early feature of AP and is related to the severity of disease. It is not known whether this contributes to the severity of AP or is a consequence. METHODS Two experiments are reported here using intravital microscopy and a rodent model of mild acute pancreatitis (intraductal 2.5% sodium taurocholate). In the first, rats had an episode of IIR during AP that was produced by temporary occlusion of the superior mesenteric artery (30 min or 3 x 10 min) followed by 2h reperfusion. In a second study rats with AP had an intravenous infusion of mesenteric lymph collected from donor rats that had been subjected to IIR. In both experiments the pancreatic erythrocyte velocity (EV), functional capillary density (FCD), leukocyte adherence (LA), histology and edema index were measured. RESULTS The addition of IIR to AP caused a decline in the pancreatic microcirculation greater than that of AP alone (EV 42% of baseline vs. 73% of baseline AP alone, FCD 43% vs 72%, LA 7 fold increase vs 4 fold increase). This caused an increased severity of AP as evidenced by 1.4-1.8 fold increase of pancreatic edema index and histologic injury respectively. A very similar exacerbation of microvascular failure and increased pancreatitis severity was then demonstrated by the intravenous infusion of IIR conditioned mesenteric lymph from donor animals. CONCLUSIONS Unidentified factors released into the mesenteric lymph following IIR injury are capable of exacerbating AP. This highlights an important role for the intestine in the pathophysiology of AP pathogenesis and identifies mesenteric lymph as a potential therapeutic target.
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Affiliation(s)
- Richard S Flint
- Department of Surgery, Faculty of Medicine and Health Sciences, University of Auckland, Auckland, New Zealand
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196
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Mofidi R, Lee AC, Madhavan KK, Garden OJ, Parks RW. Prognostic factors in patients undergoing surgery for severe necrotizing pancreatitis. World J Surg 2007; 31:2002-7. [PMID: 17687599 DOI: 10.1007/s00268-007-9164-6] [Citation(s) in RCA: 22] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
Pancreatic necrosectomy remains an important treatment modality for the management of infected pancreatic necrosis but is associated with significant mortality. The aim of this study was to identify factors associated with mortality following pancreatic necrosectomy. Patients who underwent pancreatic necrosectomy from January 1995 to December 2004 were reviewed. The association between admission, preoperative and postoperative variables, and mortality was assessed using logistic regression analysis. A total of 1248 patients presented with acute pancreatitis, of whom 94 (7.5%) underwent pancreatic necrosectomy (51 men, 43 women). The preoperative median Acute Physiology, Age, and Chronic Health Evaluation (APACHE II) score was 9 (range 2-19). The median cumulative organ dysfunction score was 2 (0-9) preoperatively and 4 (1-11) postoperatively. In all, 23 patients (24.5%) died. Those who died were older than the survivors; the ages (median and range) were 69 years (40-80 years) versus 52 years (19-79 years) (p < 0.05). They also had higher admission APACHE II scores (median and range): 14 (12-19) versus 9 (2-22) (p < 0.001). There were significant associations between preoperative (p < 0.01) and postoperative (p < 0.01) Marshall scores and mortality following pancreatic necrosectomy. The presence of the systemic inflammatory response syndrome (SIRS) during the first 48 hours (p < 0.01) and the time between presentation and necrosectomy (p < 0.01) were independent predictors of survival. Pancreatic necrosectomy is associated with higher mortality in patients with increased APACHE II scores, early persistent SIRS, and unresolved multiorgan dysfunction. Necrosectomy is associated with poorer outcome when performed within 2 weeks of presentation.
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Affiliation(s)
- R Mofidi
- Department of Clinical and Surgical Sciences, University of Edinburgh, Royal Infirmary of Edinburgh, Old Dalkeith Road, Edinburgh, UK
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197
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Abstract
OBJECTIVE To test the hypothesis that disruption of acinar cell membranes is the earliest event that takes place after the onset of acute pancreatitis. METHODS Cerulein and taurocholate pancreatitis were induced in rats. Furthermore, stimulation with different doses of bombesin, pilocarpine, and cerulein was performed. Five to 180 minutes after initiation of treatment, animals were killed. Disruption of cell membranes was detected by the penetration of the experimental animal's own albumin or immunoglobulin G (IgG) into acinar cells by immunocytological localization. Tissue was further analyzed by electron microscopy and electron microscopic immunostaining. RESULTS Animals with pancreatitis displayed significantly greater antialbumin and anti-IgG immunostaining in the cytoplasm of acinar cells and in vacuoles in comparison with controls, confirming membrane disruption. This was not detectable after stimulation with bombesin, pilocarpine, and nonsupramaximal doses of cerulein. The first changes were seen after 5 minutes of induction of pancreatitis. Results were verified by electron microscopy and electron microscopic immunohistochemistry. CONCLUSIONS The penetration of albumin and IgG into acinar cells indicates that wounding of their plasma membrane occurs at the onset of acute pancreatitis. Disruption of the membranes could be expected to allow the influx of calcium ions, causing massive intracellular alterations, and exit of molecules, such as enzymes from acinar cells.
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198
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Christophi C, Millar I, Nikfarjam M, Muralidharan V, Malcontenti-Wilson C. Hyperbaric oxygen therapy for severe acute pancreatitis. J Gastroenterol Hepatol 2007; 22:2042-6. [PMID: 17914992 DOI: 10.1111/j.1440-1746.2006.03380.x] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Abstract
Despite improvements in the supportive management of severe acute pancreatitis over the last decade, the morbidity and mortality rate remains high. The main feature of this condition is pancreatic necrosis leading to sepsis, with both localized and systemic inflammatory response syndromes. Early pathophysiological changes of the pancreas include alterations in microcirculation, ischemia reperfusion injury, and leukocyte and cytokine activation. The efficacy of hyperbaric oxygen (HBO) therapy in improving these pathophysiological disturbances is documented for various conditions. However, its effect in the treatment of severe acute pancreatitis is undetermined. This report documents the case of a 56-year-old woman presenting with severe acute pancreatitis treated by HBO therapy. The severity of disease was based on an Acute Physiology and Chronic Health Evaluation (APACHE II) illness grading score of 11 and a Baltazar based computed tomography severity index (CTSI) score of 9. Administration of 100% oxygen was commenced within 72 h of presentation at a pressure of 2.5 atmospheres for 90 min and given twice daily for a total of 5 days. Therapy was well tolerated with improvements in APACHE II and CTSI grading scores. HBO therapy for severe acute pancreatitis appeared to be safe and may have a role in improving treatment outcomes. Further study is required.
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Affiliation(s)
- Christopher Christophi
- Department of Surgery, University of Melbourne, Austin Hospital, Melbourne, Victoria, Australia.
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199
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Muller CA, Belyaev O, Vogeser M, Weyhe D, Gloor B, Strobel O, Werner J, Borgstrom A, Buchler MW, Uhl W. Corticosteroid-binding globulin: a possible early predictor of infection in acute necrotizing pancreatitis. Scand J Gastroenterol 2007; 42:1354-61. [PMID: 17852861 DOI: 10.1080/00365520701416691] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
OBJECTIVE Infected pancreatic necrosis is the main cause of death in patients with acute pancreatitis, and therefore its early prediction is of utmost importance. Endogenous cortisol metabolism plays a basic role both in the course of acute pancreatitis and in the process of infection. The purpose of this study was to analyze corticosteroid-binding globulin (CBG), total cortisol, calculated free cortisol and adrenocorticotropic hormone as potential early predictors in order to differentiate between infected pancreatic necrosis and sterile pancreatic necrosis in patients with acute pancreatitis. MATERIAL AND METHODS Serum levels of CBG, total cortisol, calculated free cortisol, and plasma levels of adrenocorticotropic hormone were determined in 109 consecutive patients with acute pancreatitis. C-reactive protein was measured as the control parameter. Thirty-five patients developed necrotizing pancreatitis and 10 developed infection of the necrosis. Blood was monitored for 6 days after the onset of pain; 30 healthy individuals served as controls. RESULTS Of all parameters only CBG showed a significant difference (p = 0.0318) in its peak levels measured in the first 48 h in patients with sterile (26.5 microg/ml, range 21.3-34.7) and infected (16.0 microg/ml, range 15.2-25.0) necrosis at a cut-off level of 16.8 microg/ml. That difference was further preserved for the first 6 days after onset of pain. CONCLUSIONS In our group of patients, a decreased CBG level below 16.8 g/ml within the initial 48 h of acute pancreatitis was an early predictor of later infected pancreatic necrosis, with a positive predictive value of 100% and a negative predictive value of 87.5%.
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Affiliation(s)
- Christophe A Muller
- Department of General Surgery, St. Josef Hospital, Ruhr University Bochum, Germany.
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200
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Turkyilmaz S, Alhan E, Ercin C, Kural Vanizor B, Kaklikkaya N, Ates B, Erdogan S, Topaloglu S. Effects of caffeic acid phenethyl ester on pancreatitis in rats. J Surg Res 2007; 145:19-24. [PMID: 18028950 DOI: 10.1016/j.jss.2007.04.019] [Citation(s) in RCA: 14] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/01/2006] [Revised: 01/31/2007] [Accepted: 04/08/2007] [Indexed: 01/01/2023]
Abstract
BACKGROUND This study investigated the effect of caffeic acid phenethyl ester (CAPE) on acute necrotizing pancreatitis (ANP) induced by glycodeoxycholic acid in rats. CAPE, an active component of honeybee propolis, has previously been determined to have antioxidant, anti-inflammatory, antiviral, and anticancer activities. MATERIALS AND METHODS Forty-eight rats were divided into four groups of 12. Group 1 animals received intraductal saline and intravenous saline infusion treatment. Group 2 was given intraductal saline and intraperitoneal CAPE infusion treatment. ANP was induced in the animals in group 3 (ANP with saline infusion), and group 4 had induced ANP plus CAPE infusion treatment (ANP with CAPE infusion). Sampling was performed 48 h after treatment. RESULTS ANP induction significantly increased mortality rate, pancreatic necrosis, and bacterial infection in pancreatic and extrapancreatic organs. ANP also increased levels of amylase and alanine aminotransferase (ALT) in serum, increased levels of urea and lactate dehydrogenase in bronchoalveolar lavage fluid (BAL LDH), increased the activities of myeloperoxidase (MPO) and malondialdehyde (MDA) in pancreas and lung tissue, and decreased the serum calcium levels. The use of CAPE did not significantly reduce the mortality rate but significantly reduced the ALT and BAL LDH levels, the activities of MPO and MDA in the pancreas, the activity of MDA in the lungs, and pancreatic damage. The administration of CAPE did not reduce the bacterial infection. CONCLUSIONS These results indicate that CAPE had beneficial effects on the course of ANP in rats and suggest that CAPE shows promise as a treatment for ANP.
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Affiliation(s)
- Serdar Turkyilmaz
- Department of Surgery, Karadeniz Technical University, School of Medicine, Trabzon, Turkey.
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