Early routine endoscopic retrograde cholangiopancreatography strategy versus early conservative management strategy in acute gallstone pancreatitis

Management of Gallstone Pancreatitis: A Review

Importance

Gallstone pancreatitis (GSP) is the leading cause of acute pancreatitis, accounting for approximately 50% of cases. Without appropriate and timely treatment, patients are at increased risk of disease progression and recurrence. While there is increasing consensus among guidelines for the management of mild GSP, adherence to these guidelines remains poor. In addition, there is minimal evidence to guide clinicians in the treatment of moderately severe and severe pancreatitis.

Observations

The management of GSP continues to evolve and is dependent on severity of acute pancreatitis and concomitant biliary diagnoses. Across the spectrum of severity, there is evidence that goal-directed, moderate fluid resuscitation decreases the risk of fluid overload and mortality compared with aggressive resuscitation. Patients with isolated, mild GSP should undergo same-admission cholecystectomy; early cholecystectomy within 48 hours of admission has been supported by several randomized clinical trials. Cholecystectomy should be delayed for patients with severe disease; for severe and moderately severe disease, the optimal timing remains unclear. Preoperative endoscopic retrograde cholangiopancreatography (ERCP) is only useful for patients with suspected cholangitis or biliary obstruction, although the concomitance of these conditions in patients with GSP is rare. Modality of evaluation of the common bile duct to rule out concomitant choledocholithiasis varies and should be tailored to level of concern based on objective measures, such as laboratory results and imaging findings. Among these modalities, intraoperative cholangiography is associated with reduced length of stay and decreased use of ERCP. However, the benefit of routine intraoperative cholangiography remains in question.

Conclusions and Relevance

Treatment of GSP is dependent on disease severity, which can be difficult to assess. A comprehensive review of clinically relevant evidence and recommendations on GSP severity grading, fluid resuscitation, timing of cholecystectomy, need for ERCP, and evaluation and management of persistent choledocholithiasis can help guide clinicians in diagnosis and management.

Surgical management of acute pancreatitis: Historical perspectives, challenges, and current management approaches

Acute pancreatitis (AP) is a serious condition presenting catastrophic consequences. In severe AP, the mortality rate is high, and some patients initially diagnosed with mild-to-moderate AP can progress to a life-threatening severe state. Treatment of AP has evolved over the years. Drainage was the first surgical procedure performed for AP; however, later, surgical approaches were replaced by more conservative approaches due to the availability of advanced medical care and improved understanding of the course of AP. Currently, surgery is used to manage several complications of AP, such as pseudocysts, pancreatic fistulas, and biliary tract obstruction. Patients who are unresponsive to conservative treatment or have complications are typically considered for surgical intervention. This review focuses on the surgical approaches (endoscopic, percutaneous, and open) that have been established in recent studies to treat this acute condition and summarizes the common management guidelines for AP, discussing the relevant indications, significance, and complications. It is evident that despite their reduced involvement, surgeons lead the multidisciplinary care of patients with AP; however, given the gaps in existing knowledge, more research is required to standardize surgical protocols for AP.

Diagnosis, severity stratification and management of adult acute pancreatitis–current evidence and controversies

Acute pancreatitis (AP) is a disease spectrum ranging from mild to severe with an unpredictable natural course. Majority of cases (80%) are mild and self-limiting. However, severe AP (SAP) has a mortality risk of up to 30%. Establishing aetiology and risk stratification are essential pillars of clinical care. Idiopathic AP is a diagnosis of exclusion which should only be used after extended investigations fail to identify a cause. Tenets of management of mild AP include pain control and management of aetiology to prevent recurrence. In SAP, patients should be resuscitated with goal-directed fluid therapy using crystalloids and admitted to critical care unit. Routine prophylactic antibiotics have limited clinical benefit and should not be given in SAP. Patients able to tolerate oral intake should be given early enteral nutrition rather than nil by mouth or parenteral nutrition. If unable to tolerate per-orally, nasogastric feeding may be attempted and routine post-pyloric feeding has limited evidence of clinical benefit. Endoscopic retrograde cholangiopancreatogram should be selectively performed in patients with biliary obstruction or suspicion of acute cholangitis. Delayed step-up strategy including percutaneous retroperitoneal drainage, endoscopic debridement, or minimal-access necrosectomy are sufficient in most SAP patients. Patients should be monitored for diabetes mellitus and pseudocyst.

[Evidence-based medicine of gallstone disease regarding development of national clinical guidelines]

OBJECTIVE

To study the Cochrane evidence base of systematic reviews and meta-analyses regarding development of national guidelines for surgical treatment of gallstone disease and its complications.

MATERIAL AND METHODS

We analyzed the original database involving 35 systematic reviews and meta-analyses of Cochrane Library devoted to gallstone disease and its complications. Methodology of electronic and manual searching of trials was used for identification and screening of information for the period until October 2021.

RESULTS

There were 430 randomized controlled trials from different countries estimated in 35 systematic reviews of Cochrane Library. At the same time, Russian-language researches are not included in the world's evidence database of biliary tract surgery. Expert groups couldn't perform meta-analysis and limited to systematic-review in 6 (17%) publications because of insufficient statistical power or primary researches. Need for further research of this issue was determined after assessment of 26 (74%) meta-analyses.

CONCLUSION

We have to convey foreign experience as subbase of national clinical guidelines taking into account deficiency of scientific trials with high level of evidence in our country. Need for further evidence trials, considering the peculiarities of surgical care in the Russian Federation, is determined by unsolved issues of treatment of gallstone disease and its complications.

Acute Pancreatitis During COVID-19 Pandemic: An Overview of Patient Demographics, Disease Severity, Management and Outcomes in an Acute District Hospital in Northern Ireland

Background Acute pancreatitis (AP) is a common disease requiring admissions under surgical and critical care units. The two most common causes are alcohol and gallstones. Coronavirus disease 2019 (COVID-19) pandemic had a significant impact on service delivery and patient management throughout all surgical specialties. In this study, the primary aim was to ascertain the incidence of COVID-19 in acute pancreatitis patients. Secondary objectives were to study aetiology, demographics, severity, 30-day mortality, outcomes and management of acute pancreatitis patients from 1st March, 2020 till 31st August, 2020. Methods A retrospective observational review of all patients admitted under the General Surgical team was performed. Information regarding demographics, severity of AP (using Glasgow score, Atlanta classification and CT severity index score), ICU admission and organ support, treatment modalities and follow-up data for outcomes was collected based on data collection tool used by COVID-PAN study and results were compared to outcomes results of COVID-PAN study. Results Forty-three (43) patients were admitted with AP. Only one patient (2.3%) was diagnosed with COVID-19 at the time of pancreatitis. Gallstones were noted to be the most common cause of AP in our population. Mortality was 7% (3 patients). Five patients (11%) needed ITU admission due to organ dysfunction. Three patients (7%) developed ARDS. Conclusion The overall incidence of COVID-19 in pancreatitis in our population of the study was low. The incidence of COVID-19 during the first wave in Derry/Londonderry area was low and this may explain why the incidence was low in our study as well. Patients with AP in our target population were mostly elderly, one in five had moderate to severe or severe pancreatitis and in 16.3% the aetiology could not be identified. As observed in other centres globally, urgent cholecystectomy for gallstone pancreatitis faced significant delays with no patients being offered index cholecystectomy and only 4 out of 19 patients having undergone interval cholecystectomy within six months of index admission for gallstone pancreatitis in our centre.

[Interventional endoscopic treatment in acute pancreatitis]

BACKGROUND

Acute pancreatitis (AP) represents a frequent gastrointestinal diseases. Approximately 80% of patients have a mild course of the disease and conservative treatment is sufficient; however, 20% of patients develop a severe AP with local and systemic complications. This article focuses on the currently recommended endoscopic management of severe AP.

OBJECTIVE

Classification of AP by the revised Atlanta classification and the occurrence of local or systemic complications. Summary of current evidence with respect to endoscopic management.

MATERIAL AND METHODS

Inspection of the current literature from specialist journals and current guidelines.

RESULTS

The AP is classified as mild, moderate or severe based on systemic (hypotension, renal failure, lung failure) and/or local complications, such as acute peripancreatic fluid collections (APFC), peripancreatic pseudocysts (PPC), acute necrotic collections (ANC) and walled-off necrosis (WON). In recent years the staged endoscopic treatment of infected ANC, WON and PPC has become established. The initial step is the endoscopic ultrasound-guided puncture and drainage with plastic or lumen-apposing metal stents. For solid components or insufficient drainage, a transgastric endoscopic necrosectomy is recommended. The treatment of severe AP requires an interdisciplinary management in specialized centers and regular re-evaluation of the therapeutic efficacy.

CONCLUSION

Interventional endoscopy has become established as the standard for treatment of severe AP.

ERCP improves mortality in acute biliary pancreatitis without cholangitis

Background and study aims  Acute pancreatitis (AP) is an increasingly common indication for hospitalization in the United States. The necessity for endoscopic retrograde cholangiopancreatography (ERCP) and the timing of ERCP in acute gallstone-related pancreatitis without cholangitis (AGPNC) is controversial. The aim of this study was to evaluate the association of ERCP and its performance during admission with mortality and length of stay (LOS) in patients with AGPNC. Patients and methods  We queried the Nationwide Inpatient Sample (NIS) from 2004 to 2014 to identify all patients with admissions for gallstone AP. We excluded patients with chronic pancreatitis or concurrent cholangitis, and those who were transferred from elsewhere for treatment. Our primary outcome measure was inpatient mortality. Our secondary outcome measure was hospital length of stay (LOS). Results  We identified 491,011 records eligible for analysis. Of the patients, 30.6 % (150,101) had AGPNC. There were 1.34 deaths per 100 admissions in patients with AGPNC. The average LOS was 5.88 (± 6.38) days with a median stay of 4 days (range, 3-7). When adjusted for age, Elixhauser Comorbidity Index, and severe pancreatitis, patients with ERCP during admission were 43 % less likely to die. ERCP performed between Days 3 and 9 of hospitalization resulted in a significant mortality benefit. Among those who had ERCP, a shorter wait time for ERCP was associated with a shorter LOS after adjustment for demographics and severity of illness. Conclusion  ERCP performed during inpatient admission for AGPNC was associated with decreased mortality. These data support early ERCP in patients with acute gallstone pancreatitis without cholangitis.

Timing of endoscopic retrograde cholangiopancreatography in acute biliary pancreatitis without cholangitis: a nationwide inpatient cohort study

Background

The timing of endoscopic retrograde cholangiopancreatography (ERCP) in patients with acute biliary pancreatitis without cholangitis is unclear. We accessed a national database to analyze the outcomes of urgent (<24 h) and early (24-72 h) ERCP in this cohort.

Methods

The cohort was extracted from the Nationwide Inpatient Sample database. Hospital ERCP volumes were generated using unique hospital identifiers. Multivariate regression modeling was used to analyze the predictors of urgent vs. early ERCP use, and to determine various outcome variables between the 2 cohorts.

Results

Overall, 105,433 admissions were evaluated. There was a significant rise in urgent ERCP performed over the study period. Older patients, males, patients with comorbidities, African American and Hispanic patient populations were less likely to receive urgent ERCP. High ERCP volume hospitals, teaching hospitals, and hospitals in the Midwest and West were more likely to perform urgent ERCP. There were no differences in mortality rates or complication rates between the 2 cohorts. However, there were significant differences in length of stay and healthcare cost analysis.

Conclusions

The increasing use of urgent ERCP did not result in a clinically significant benefit in terms of mortality, length of stay, or healthcare cost analysis. The use of urgent ERCP is also not uniform across various demographic and hospital cohorts. Urgent ERCP may be over-utilized, and it may be reasonable to perform ERCP in this patient population based on the physician’s suspicion about the severity of disease.

Timing of endoscopic therapy for acute bilio-pancreatic diseases: a practical overview

Diseases of the pancreas and hepatobiliary tree often require a therapeutic approach with endoscopic retrograde cholangiopancreatography (ERCP), generally following noninvasive imaging techniques. Appropriate indications and the correct timing for urgent ERCP would benefit both patients and clinicians and allow optimal utilization of health resources. Indications for urgent (<24 h) ERCP include severe acute cholangitis, acute biliary pancreatitis with cholangitis, biliary or pancreatic leaks, in the absence of percutaneous drainage, and severe acute cholecystitis in patients who are unfit for surgery and do not respond to conservative management. In patients who have severe acute biliary pancreatitis with ongoing biliary obstruction but without cholangitis, early (<48-72 h) ERCP is indicated. This overview aims to provide decisional flowcharts that can be easily used for managing patients with acute bilio-pancreatic disorders when they are referred to the Emergency Department.

Gallstone pancreatitis: general clinical approach and the role of endoscopic retrograde cholangiopancreatography

Gallstones account for majority of acute pancreatitis in the Western world. Increase in number and smaller size of the stones increases the risk for biliary pancreatitis. In addition to features of acute pancreatitis, these patients also have cholestatic clinical picture. Fluid therapy and enteral nutrition are vital components in management of any case of acute pancreatitis. During initial evaluation, a right upper quadrant ultrasonogram is particularly important. On a case-bycase basis, further advanced imaging studies such as magnetic resonance cholangiopancreatography or endoscopic ultrasound may be warranted. Acute management also involves monitoring for local and systemic complications. Patients are triaged based on predictors of ongoing biliary obstruction in order to identify who would need endoscopic retrograde cholangiopancreatography. Index cholecystectomy is safe and recommended, with exception of cases with significant local and systemic complications where delayed cholecystectomy may be safer.

Consensus and controversy among severe pancreatitis surgery guidelines: a guideline evaluation based on the Appraisal of Guidelines for Research and Evaluation II (AGREE II) tool

The purpose of this study was to systematically evaluate guidelines for surgery in patients with severe pancreatitis and to identify gaps limiting evidence-based medicine practice. A systematic search of databases and related websites was conducted to identify surgical guidelines for patients with severe pancreatitis. The quality of the included guidelines was assessed using the Appraisal of Guidelines for Research and Evaluation II (AGREE II) tool. The similarities among key recommendations were compared, and the evidence supporting them was extracted and analysed. Seven surgical guidelines for patients with severe pancreatitis were included. Only two guidelines, those of the World Society of Emergency Surgery (WSES) and the European Society of Gastrointestinal Endoscopy (ESGE), scored more than 60% for overall quality and were worthy of clinical recommendation. We found that the quality of the severe acute pancreatitis surgical guidelines have much room for improvement, especially in the field of application, the participation of stakeholders and editorial independence. The heterogeneity and causes of surgical recommendations were further analysed, and the latest evidence was retrieved. It was found that the surgical guidelines for severe pancreatitis lacked high-quality evidence, some of the recommendations were controversial, and evidence citation was unreasonable. The quality of surgical guidelines for patients with severe pancreatitis varies widely. In the past 5 years, the key recommendations of the surgical guidelines for severe pancreatitis have been somewhat consistent and controversial, and improvement in these existing problems and controversies will be an effective way for developers to upgrade the surgical guidelines for severe pancreatitis.

Imaging guidelines for acute pancreatitis: when and when not to image

In patients with acute pancreatitis (AP), diagnostic imaging is performed for various reasons, including the detection of the etiology (e.g., biliary obstruction caused by gallstones), diagnosis of pancreatitis in an unclear clinical setting, assessment of the severity of the process, and evaluation of its complications. In spite of the potential benefits of these imaging studies in the setting of AP, especially economic consequences but also medical risks are associated with diagnostic imaging, including increase of the effective radiation dose received by patients with AP and rising health care costs, frequently without impact on management. The rising incidence of acute pancreatitis in the Western world is escalating its financial burden with national health care expenses of over 2.5 billion dollars annually. Despite evidence-based national recommendations on utilization of diagnostic imaging in patients with AP, unnecessary imaging studies are still frequently performed, especially in the early hospital course. The purpose of this article is, therefore, to review the imaging guidelines for acute pancreatitis with regards to when and when not to image, with the aim to minimize inappropriate utilization.

Continuous veno-venous hemofiltration for severe acute pancreatitis

BACKGROUND

Severe acute pancreatitis is associated with high rates of mortality and life-threatening complications. Continuous veno-venous hemofiltration (CVVH) has been used in some centers to reduce mortality and avoid local or systemic complications, however its efficiency and safety is uncertain.

OBJECTIVES

To assess the benefits and harms of CVVH in patients suffering from severe acute pancreatitis; to compare the effects of different CVVH techniques; and to evaluate the optimal time for delivery of CVVH.

SEARCH METHODS

We searched the Cochrane Library (2019, Issue 8), MEDLINE (1946 to 13 September 2019), Embase (1974 to 13 September 2019), and Science Citation Index Expanded (1982 to 13 September 2019).

SELECTION CRITERIA

We included all randomized controlled trials (RCTs) that compared CVVH versus no CVVH in participants with severe acute pancreatitis. We also included RCTs that compared different types of CVVH and different schedules for CVVH in participants with severe acute pancreatitis.

DATA COLLECTION AND ANALYSIS

Two review authors independently identified the trials for inclusion, collected the data, and assessed the risk of bias. We performed the meta-analyses using Review Manager 5. We calculated the risk ratio (RR) for dichotomous outcomes, and the mean difference (MD) for continuous outcomes, with 95% confidence intervals (CIs).

MAIN RESULTS

We included two studies, involving a total of 94 participants, in the review.Continuous veno-venous hemofiltration versus no interventionWe included one study in which 64 participants with severe acute pancreatitis were randomized to undergo CVVH (32 participants) or no intervention (32 participants). There were no deaths in either group (very low-quality evidence). Adverse events, length of stay in the intensive care unit (ICU), length of hospital stay, total hospital cost, and quality of life were not reported in the study.One type of continuous veno-venous hemofiltration versus a different type of continuous veno-venous hemofiltrationWe included one study in which 30 participants with severe acute pancreatitis were randomized to undergo high-volume CVVH (15 participants) or standard CVVH (15 participants). High-volume CVVH may lead to little or no difference in in-hospital mortality rates (20.0% in the high-volume CVVH group versus 33.3% in the standard CVVH group; risk ratio (RR) 0.60, 95% confidence interval (CI) 0.17 to 2.07; 30 participants; 1 study; low-quality evidence). We are uncertain whether high-volume hemofiltration reduces rates of adverse events (13.3% in both groups; RR 1.00, 95% CI 0.16 to 6.20; 30 participants; 1 study; very low-quality evidence). Length of ICU stay, length of hospital stay, total hospital cost, and quality of life were not reported in the study.

AUTHORS' CONCLUSIONS

The quality of the current evidence is very low or low. For both comparisons addressed in this review, data are sparse. It is unclear whether CVVH has any effect on mortality or complications in patients with severe acute pancreatitis. It is also unclear whether high-volume CVVH is superior, equivalent or inferior to standard CVVH in patients with severe acute pancreatitis.

Practical guide to the management of acute pancreatitis

Acute pancreatitis (AP) is characterised by inflammation of the exocrine pancreas and is associated with acinar cell injury and both a local and systemic inflammatory response. AP may range in severity from self-limiting, characterised by mild pancreatic oedema, to severe systemic inflammation with pancreatic necrosis, organ failure and death. Several international guidelines have been developed including those from the joint International Association of Pancreatology and American Pancreatic Association, American College of Gastroenterology and British Society of Gastroenterology. Here we discuss current diagnostic and management challenges and address the common dilemmas in AP.

2019 WSES guidelines for the management of severe acute pancreatitis

Although most patients with acute pancreatitis have the mild form of the disease, about 20-30% develops a severe form, often associated with single or multiple organ dysfunction requiring intensive care. Identifying the severe form early is one of the major challenges in managing severe acute pancreatitis. Infection of the pancreatic and peripancreatic necrosis occurs in about 20-40% of patients with severe acute pancreatitis, and is associated with worsening organ dysfunctions. While most patients with sterile necrosis can be managed nonoperatively, patients with infected necrosis usually require an intervention that can be percutaneous, endoscopic, or open surgical. These guidelines present evidence-based international consensus statements on the management of severe acute pancreatitis from collaboration of a panel of experts meeting during the World Congress of Emergency Surgery in June 27-30, 2018 in Bertinoro, Italy. The main topics of these guidelines fall under the following topics: Diagnosis, Antibiotic treatment, Management in the Intensive Care Unit, Surgical and operative management, and Open abdomen.

Detection of Common Bile Duct Stones in Mild Acute Biliary Pancreatitis Using Magnetic Resonance Cholangiopancreatography

Background

All patients with mild acute biliary pancreatitis should undergo early cholecystectomy. Whether routine common bile duct (CBD) imaging should be employed before the surgical procedure in these patients is a matter of current controversy. The aim of this study was to investigate the rate of detection of CBD stones using magnetic resonance cholangiopancreatography (MRCP) at different time intervals from admission.

Methods

From January 1, 2011, through December 31, 2016, 72 patients with acute biliary pancreatitis underwent MRCP. Fifty-six (n=56) of them with mild biliary pancreatitis met the study criteria. The patients were divided into two groups. Group A did not have stones in the CBD (n=45), and Group B had stones in the CBD (n=11). The time from admission to MRCP was divided into several periods (day 1 through day 180), and the presence of the CBD stones on MRCP was weighted against remoteness from admission. Liver chemistry profiles were compared between the groups on admission and before the MRCP.

Results

The cumulative rate of choledocholithiasis was 19.7% (Group B, n=11). Forty-five patients (Group A, n=45, 80.3%) did not have gallstones in the CBD. Eight patients with choledocholithiasis (8/56, 14.2%) were detected during the first 10 days from admission out of 27 patients. In patients who underwent MRCP between days 11 and 20, choledocholithiasis was found in two patients (2/56, 3.5%) and in one patient between days 21 and 30 (1/56, 1.8%). No stones were found in patients who underwent MRCP beyond 30 days from admission. Liver chemistry profiles did not show a significant difference in both groups. CBD dilatation was observed at presentation in 11 patients (n=11/56), 6 in Group A (6/45, 13.3%) and 5 in Group B (5/11, 45.5%) (p=0.016).

Conclusions

Routine CBD evaluation should be encouraged after mild acute biliary pancreatitis. Early performance of MRCP gives high yield in selecting the patients for endoscopic retrograde cholangiopancreatography (ERCP) before cholecystectomy. A liver chemistry profile either on admission or before MRCP cannot predict the presence of CBD stones.

Ursodeoxycholic acid combined with percutaneous transhepatic balloon dilation for management of gallstones after elimination of common bile duct stones

AIM

To evaluate the effectiveness and safety of combined ursodeoxycholic acid and percutaneous transhepatic balloon dilation for management of gallstones after expulsion of common bile duct (CBD) stones.

METHODS

From April 2014 to May 2016, 15 consecutive patients (6 men and 9 women) aged 45-86 (mean, 69.07 ± 9.91) years suffering from CBD stones associated with gallstones were evaluated. Good gallbladder contraction function was confirmed by type B ultrasonography. Dilation of the CBD and cystic duct was detected. Percutaneous transhepatic balloon dilation of the papilla was performed, ursodeoxycholic acid was administered, and all patients had a high-fat diet. All subjects underwent repeated cholangiography, and percutaneous transhepatic removal was carried out in patients with secondary CBD stones originating from the gallbladder.

RESULTS

All patients underwent percutaneous transhepatic balloon dilation with a primary success rate of 100%. The combined therapy was successful in 86.7% of patients with concomitant CBD stones and gallstones. No remaining stones were detected in the gallbladder. Transient adverse events include abdominal pain (n = 1), abdominal distension (n = 1), and fever (n = 1). Complications were treated successfully via nonsurgical management without long-term complications. No procedure-related mortality occurred.

CONCLUSION

For patients with concomitant CBD stones and gallstones, after percutaneous transhepatic removal of primary CBD stones, oral ursodeoxycholic acid and a high-fat diet followed by percutaneous transhepatic removal of secondary CBD stones appear to be a feasible and effective option for management of gallstones.

Recent advances in understanding and managing acute pancreatitis

This review highlights advances made in recent years in the diagnosis and management of acute pancreatitis (AP). We focus on epidemiological, clinical, and management aspects of AP. Additionally, we discuss the role of using risk stratification tools to guide clinical decision making. The majority of patients suffer from mild AP, and only a subset develop moderately severe AP, defined as a pancreatic local complication, or severe AP, defined as persistent organ failure. In mild AP, management typically involves diagnostic evaluation and supportive care resulting usually in a short hospital length of stay (LOS). In severe AP, a multidisciplinary approach is warranted to minimize morbidity and mortality over the course of a protracted hospital LOS. Based on evidence from guideline recommendations, we discuss five treatment interventions, including intravenous fluid resuscitation, feeding, prophylactic antibiotics, probiotics, and timing of endoscopic retrograde cholangiopancreatography (ERCP) in acute biliary pancreatitis. This review also highlights the importance of preventive interventions to reduce hospital readmission or prevent pancreatitis, including alcohol and smoking cessation, same-admission cholecystectomy for acute biliary pancreatitis, and chemoprevention and fluid administration for post-ERCP pancreatitis. Our review aims to consolidate guideline recommendations and high-quality studies published in recent years to guide the management of AP and highlight areas in need of research.

Recent advances in understanding and managing acute pancreatitis

This review highlights advances made in recent years in the diagnosis and management of acute pancreatitis (AP). We focus on epidemiological, clinical, and management aspects of AP. Additionally, we discuss the role of using risk stratification tools to guide clinical decision making. The majority of patients suffer from mild AP, and only a subset develop moderately severe AP, defined as a pancreatic local complication, or severe AP, defined as persistent organ failure. In mild AP, management typically involves diagnostic evaluation and supportive care resulting usually in a short hospital length of stay (LOS). In severe AP, a multidisciplinary approach is warranted to minimize morbidity and mortality over the course of a protracted hospital LOS. Based on evidence from guideline recommendations, we discuss five treatment interventions, including intravenous fluid resuscitation, feeding, prophylactic antibiotics, probiotics, and timing of endoscopic retrograde cholangiopancreatography (ERCP) in acute biliary pancreatitis. This review also highlights the importance of preventive interventions to reduce hospital readmission or prevent pancreatitis, including alcohol and smoking cessation, same-admission cholecystectomy for acute biliary pancreatitis, and chemoprevention and fluid administration for post-ERCP pancreatitis. Our review aims to consolidate guideline recommendations and high-quality studies published in recent years to guide the management of AP and highlight areas in need of research.

Acute pancreatitis: current perspectives on diagnosis and management

The last two decades have seen the emergence of significant evidence that has altered certain aspects of the management of acute pancreatitis. While most cases of acute pancreatitis are mild, the challenge remains in managing the severe cases and the complications associated with acute pancreatitis. Gallstones are still the most common cause with epidemiological trends indicating a rising incidence. The surgical management of acute gallstone pancreatitis has evolved. In this article, we revisit and review the methods in diagnosing acute pancreatitis. We present the evidence for the supportive management of the condition, and then discuss the management of acute gallstone pancreatitis. Based on the evidence, our local institutional pathways, and clinical experience, we have produced an outline to guide clinicians in the management of acute gallstone pancreatitis.

Continuous veno‐venous hemofiltration for severe acute pancreatitis

This is a protocol for a Cochrane Review (Intervention). The objectives are as follows:

To assess the benefits and harms of CVVH in people suffering from severe acute pancreatitis, compare the effects of different CVVH techniques, and evaluate the optimal time for delivery of CVVH.

Urgent endoscopic retrograde cholangiopancreatography is not superior to early ERCP in acute biliary pancreatitis with biliary obstruction without cholangitis

Acute pancreatitis is a common diagnosis worldwide, with gallstone disease being the most prevalent cause (50%). The American College of Gastroenterology recommends urgent endoscopic retrograde cholangiopancreatography (ERCP) (within 24 h) for patients with biliary pancreatitis accompanied by cholangitis. Most international guidelines recommend that ERCP be performed within 72 h in patients with biliary pancreatitis and a bile duct obstruction without cholangitis, but the optimal timing for endoscopy is controversial. We investigated the optimal timing for ERCP in patients with biliary pancreatitis and a bile duct obstruction without cholangitis, and whether performing endoscopy within 24 h is superior to performing it after 24 h. We analyzed the clinical data of 505 patients with newly diagnosed acute pancreatitis, from January 1, 2005 to December 31, 2014. We divided the patients into two groups according to the timing of ERCP: < 24 h (urgent) and 24–72 h (early).Among the 505 patients, 73 were diagnosed with biliary pancreatitis and a bile duct obstruction without cholangitis. The mean age of the patients was 55 years (range: 26–90 years). Bile duct stones and biliary sludge were identified on endoscopy in 45 (61.6%) and 11 (15.0%) patients, respectively. The timing of ERCP within 72 h was not associated with ERCP-related complications (P = 0.113), and the total length of hospital stay was not different between urgent and early ERCP (5.9 vs. 5.7 days, P = 0.174). No significant differences were found in total length of hospitalization or procedural-related complications, in patients with biliary pancreatitis and a bile duct obstruction without cholangitis, according to the timing of ERCP (< 24 h vs. 24–72 h).

A comparison of endoscopic and non-endoscopic biliary intervention outcomes in patients with prior bariatric surgery

BACKGROUND AND STUDY AIMS

Endoscopic biliary intervention (BI) is often difficult to perform in patients with prior bariatric surgery (BRS). We sought to analyze outcomes of patients with prior BRS undergoing endoscopic and non-endoscopic BI.

PATIENTS AND METHODS

 The Nationwide Inpatient Sample (2007 - 2011) was reviewed to identify all adult inpatients (≥ 18 years) with a history of BRS undergoing BI. The clinical outcomes of interest were in-patient mortality, length of stay (LOS), and total hospital charges.

RESULTS

 There were 7,343 patients with prior BRS who underwent BIs where a majority were endoscopic (4,482 vs. 2,861, P  < 0.01). The mean age was 50±30.8 years and the majority were females (80.5 %). Gallstone-related disease was the most common indication for BI and managed more often with primary endoscopic management (2,146 vs. 1,132, P  < 0.01). Inpatient mortality was not significantly different between patients undergoing primary endoscopic versus non-endoscopic BI (0.2 % vs. 0.7 %, P  = 0.2). Patients with sepsis were significantly more likely to incur failed primary endoscopic BI (OR 2.74, 95 % CI 1.15, 6.53) and were more likely to be managed with non-endoscopic BI (OR 2.13, 95 % CI 1.3, 3.5). Primary non-endoscopic BI and failed endoscopic BI were both associated with longer LOS (by 1.77 days, P  < 0.01 and by 2.17 days, P  < 0.01, respectively) and higher hospitals charges (by $11,400, P  < 0.01 and by $ 14,200, P  < 0.01, respectively).

CONCLUSION

 Primary endoscopic management may be a safe and cost-effective approach for patients with prior BRS who need BI. While primary endoscopic biliary intervention is more common, primary non-endoscopic intervention may be used more often for sepsis.

Methodological overview of systematic reviews to establish the evidence base for emergency general surgery

BACKGROUND

The evidence for treatment decision-making in emergency general surgery has not been summarized previously. The aim of this overview was to review the quantity and quality of systematic review evidence for the most common emergency surgical conditions.

METHODS

Systematic reviews of the most common conditions requiring unplanned admission and treatment managed by general surgeons were eligible for inclusion. The Centre for Reviews and Dissemination databases were searched to April 2014. The number and type (randomized or non-randomized) of included studies and patients were extracted and summarized. The total number of unique studies was recorded for each condition. The nature of the interventions (surgical, non-surgical invasive or non-invasive) was documented. The quality of reviews was assessed using the AMSTAR checklist.

RESULTS

The 106 included reviews focused mainly on bowel conditions (42), appendicitis (40) and gallstone disease (17). Fifty-one (48·1 per cent) included RCTs alone, 79 (74·5 per cent) included at least one RCT and 25 (23·6 per cent) summarized non-randomized evidence alone. Reviews included 727 unique studies, of which 30·3 per cent were RCTs. Sixty-five reviews compared different types of surgical intervention and 27 summarized trials of surgical versus non-surgical interventions. Fifty-seven reviews (53·8 per cent) were rated as low risk of bias.

CONCLUSION

This overview of reviews highlights the need for more and better research in this field.

Evidence-based clinical practice guidelines for cholelithiasis 2016

Cholelithiasis is one of the commonest diseases in gastroenterology. Remarkable improvements in therapeutic modalities for cholelithiasis and its complications are evident. The Japanese Society of Gastroenterology has revised the evidence-based clinical practice guidelines for cholelithiasis. Forty-three clinical questions, for four categories-epidemiology and pathogenesis, diagnosis, treatments, and prognosis and complications-were selected, and a literature search was performed for the clinical questions with use of the MEDLINE, Cochrane, and Igaku Chuo Zasshi databases for the period between 1983 and June 2012. The guidelines were developed with use of the Grading of Recommendations Assessment, Development, and Evaluation (GRADE) system. This article preferentially describes the clinical management of cholelithiasis and its complications. Following description of the diagnosis performed stepwise through imaging modalities, treatments of cholecystolithiasis, choledocholithiasis, and hepatolithiasis are introduced along with a flowchart. Since there have been remarkable improvements in endoscopic treatments and surgical techniques, the guidelines ensure flexibility in choices according to the actual clinical environment. The revised clinical practice guidelines are appropriate for use by clinicians in their daily practice.

Management of patients after recovering from acute severe biliary pancreatitis

Cholelithiasis is the most common cause of acute pancreatitis, accounting 35%-60% of cases. Around 15%-20% of patients suffer a severe attack with high morbidity and mortality rates. As far as treatment is concerned, the optimum method of late management of patients with severe acute biliary pancreatitis is still contentious and the main question is over the correct timing of every intervention. Patients after recovering from an acute episode of severe biliary pancreatitis can be offered alternative options in their management, including cholecystectomy, endoscopic retrograde cholangiopancreatography (ERCP) and sphincterotomy, or no definitive treatment. Delaying cholecystectomy until after resolution of the inflammatory process, usually not earlier than 6 wk after onset of acute pancreatitis, seems to be a safe policy. ERCP and sphincterotomy on index admission prevent recurrent episodes of pancreatitis until cholecystectomy is performed, but if used for definitive treatment, they can be a valuable tool for patients unfit for surgery. Some patients who survive severe biliary pancreatitis may develop pseudocysts or walled-off necrosis. Management of pseudocysts with minimally invasive techniques, if not therapeutic, can be used as a bridge to definitive operative treatment, which includes delayed cholecystectomy and concurrent pseudocyst drainage in some patients. A management algorithm has been developed for patients surviving severe biliary pancreatitis according to the currently published data in the literature.

Clinical practice guideline: management of acute pancreatitis

ABSTRACT

There has been an increase in the incidence of acute pancreatitis reported worldwide. Despite improvements in access to care, imaging and interventional techniques, acute pancreatitis continues to be associated with significant morbidity and mortality. Despite the availability of clinical practice guidelines for the management of acute pancreatitis, recent studies auditing the clinical management of the condition have shown important areas of noncompliance with evidence-based recommendations. This underscores the importance of creating understandable and implementable recommendations for the diagnosis and management of acute pancreatitis. The purpose of the present guideline is to provide evidence-based recommendations for the management of both mild and severe acute pancreatitis as well as the management of complications of acute pancreatitis and of gall stone-induced pancreatitis.

Decision Making in Necrotizing Pancreatitis

The management of acute necrotizing pancreatitis (ANP) has undergone a change of paradigms during the last 2 decades with a decreasing impact of surgical interventions. Modern ANP management is done conservatively as long as possible and therapeutic approaches aim at volume resuscitation, pain management and early enteral nutrition. The diagnostic gold standard of contrast-enhanced CT scan helps to evaluate the extent of necrosis of the pancreas, which correlates with the risk of tissue infection. The crucial point for decision making is the proven existence of infected pancreatic necrosis. This can be achieved by diagnostic needle aspiration of the necrotic material and staining to prove bacterial and/or fungal infection. In case of infected necrosis - besides calculated antimicrobial treatment - an interventional or surgical approach is required to prevent systemic septic progression of the disease. As the first step, percutaneous interventional drainage and spilling of the necrosis are preferable. In case of insufficient clearing of the infectious focus, a step-up approach must be considered, which implies a retroperitoneoscopic or transabdominal minimally invasive necrosectomy and drain placement. Postoperatively, a continuous lavage should be performed using these drains. In case of further deterioration of the patient or development of associated intra-abdominal complications (e.g. bowel perforation or uncontrolled bleeding), an open surgical intervention must always be regarded as a salvage therapy and this offers the possibility to control complications and perform a further necrosectomy and extensive lavage for focus control. However, associated morbidity (e.g. pancreatic fistula, fluid collections, pseudocysts) is about 50-60% and mortality up to 20%. In summary, ANP is managed primarily by a conservative therapy. In case of infected necrosis, interventional and minimally invasive approaches are the therapy of choice. Open surgery should be considered for patients deteriorating despite other measures and should be postponed as long as possible.

Improving the Outcome of Acute Pancreatitis

Acute pancreatitis (AP) is the most common indication for hospital admission and its incidence is rising. It has a variable prognosis, which is mainly dependent upon the development of persistent organ failure and infected necrotizing pancreatitis. In the past few years, based on large-scale multicenter randomized trials, some novel insights regarding clinical management have emerged. In patients with infected pancreatic necrosis, a step-up approach of percutaneous catheter drainage followed by necrosectomy only when the patient does not improve, reduces new-onset organ failure and prevents the need for necrosectomy in about a third of patients. A randomized pilot study comparing surgical to endoscopic necrosectomy in patients with infected necrotizing pancreatitis showed a striking reduction of the pro-inflammatory response following endoscopic necrosectomy. These promising results have recently been tested in a large multicenter randomized trial whose results are eagerly awaited. Contrary to earlier data from uncontrolled studies, a large multicenter randomized trial comparing early (within 24 h) nasoenteric tube feeding compared with an oral diet after 72 h, did not show that early nasoenteric tube feeding was superior in reducing the rate of infection or death in patients with AP at high risk for complications. Although early ERCP does not have a role in the treatment of predicted mild pancreatitis, except in the case of concomitant cholangitis, it may ameliorate the disease course in patients with predicted severe pancreatitis. Currently, a large-scale randomized study is underway and results are expected in 2017.

Temporal trends in the use of diagnostic imaging for inpatients with pancreatic conditions: How much ionizing radiation are we using?

BACKGROUND

Low-dose ionizing radiation from medical imaging has been indirectly linked with subsequent cancer and increased costs. Computed tomography (CT) is the gold standard for defining pancreatic anatomy and complications. Our primary goal was to identify the temporal trends associated with diagnostic imaging for inpatients with pancreatic diseases.

METHODS

Data were extracted from the Healthcare Cost and Utilization Project Nationwide Inpatient Sample (NIS) database from 2000 to 2008. Pancreas-related ICD-9 diagnostic codes were matched to all relevant imaging modalities.

RESULTS

Between 2000 and 2008, a significant increase in admissions (p < 0.001), but decrease in overall imaging procedures (p = 0.032), for all pancreatic disorders was observed. This was primarily a result of a reduction in the number of CT and endoscopic retrograde cholangiopancreatography examinations (i.e., reduced radiation exposure, p = 0.008). A concurrent increase in the number of inpatient magnetic resonance cholangiopancreatography/magnetic resonance imaging performed was observed (p = 0.040). Intraoperative cholangiography and CT remained the dominant imaging modality of choice overall (p = 0.027).

CONCLUSION

Inpatients with pancreatic diseases often require diagnostic imaging during their stay. This results in substantial exposure to ionizing radiation. The observed decrease in the use of CT may reflect an improved awareness of potential stochastic risks.

Early biliary decompression versus conservative treatment in acute biliary pancreatitis (APEC trial): study protocol for a randomized controlled trial

Background

Acute pancreatitis is mostly caused by gallstones or sludge. Early decompression of the biliary tree by endoscopic retrograde cholangiography (ERC) with sphincterotomy may improve outcome in these patients. Whereas current guidelines recommend early ERC in patients with concomitant cholangitis, early ERC is not recommended in patients with mild biliary pancreatitis. Evidence on the role of routine early ERC with endoscopic sphincterotomy in patients without cholangitis but with biliary pancreatitis at high risk for complications is lacking. We hypothesize that early ERC with sphincterotomy improves outcome in these patients.

Methods/Design

The APEC trial is a randomized controlled, parallel group, superiority multicenter trial. Within 24 hours after presentation to the emergency department, patients with biliary pancreatitis without cholangitis and at high risk for complications, based on an Acute Physiology and Chronic Health Evaluation (APACHE-II) score of 8 or greater, Modified Glasgow score of 3 or greater, or serum C-reactive protein above 150 mg/L, will be randomized. In 27 hospitals of the Dutch Pancreatitis Study Group, 232 patients will be allocated to early ERC with sphincterotomy or to conservative treatment. The primary endpoint is a composite of major complications (that is, organ failure, pancreatic necrosis, pneumonia, bacteremia, cholangitis, pancreatic endocrine, or exocrine insufficiency) or death within 180 days after randomization. Secondary endpoints include ERC-related complications, infected necrotizing pancreatitis, length of hospital stay and an economical evaluation.

Discussion

The APEC trial investigates whether an early ERC with sphincterotomy reduces the composite endpoint of major complications or death compared with conservative treatment in patients with biliary pancreatitis at high risk of complications.

Trial registration

Current Controlled Trials ISRCTN97372133 (date registration: 17-12-2012)

Electronic supplementary material

The online version of this article (doi:10.1186/s13063-015-1132-0) contains supplementary material, which is available to authorized users.

Surgery for Acute Pancreatitis

Surgery for acute pancreatitis has undergone significant changes over the last 3 decades. A better understanding of the pathophysiology has contributed to this, but the greatest driver for change has been the rise of less invasive interventions in the fields of laparoscopy, endoscopy and radiology. Surgery has a very limited role in the diagnosis of acute pancreatitis. The most common indication for intervention in acute pancreatitis is for the treatment of complications and most notably the treatment of infected walled off necrosis. Here, the step-up approach has become established, with prior drainage (either endoscopic or percutaneous) followed by delay for maturing of the wall and then debridement by endoscopic or minimally invasive surgical methods. Open surgery is only indicated when this approach fails. Other indications for surgery in acute pancreatitis are for the treatment of acute compartment syndrome, non-occlusive intestinal ischaemia and necrosis, enterocutaneous fistulae, vascular complications and pseudocyst. Surgery also has a role in the prevention of recurrent acute pancreatitis by cholecystectomy. Despite the more restricted role, surgeons have an important contribution to make in the multidisciplinary care of patients with complicated acute pancreatitis.

Comparison of clinical course and outcome of acute pancreatitis according to the two main etiologies: alcohol and gallstone

Background

Studies concerning clinical course and outcome of acute pancreatitis (AP) according to etiologies were rare, especially after year 2000. This study was designed to investigate the difference between the clinical course of alcoholic and biliary AP.

Methods

Of the 153 patients diagnosed as AP with a first attack between January 2011 and January 2013, extensive clinical data of 50 patients with AP caused by alcohol and 76 patients with AP caused by gallstone were analyzed retrospectively. We compared the severity of AP defined by revised Atlanta classification in 2012, local complications, severity scores, and computed tomography severity index (CTSI) between alcoholic and biliary AP. We also evaluated the length of hospital stay, duration of NPO, and in-hospital mortality in each group.

Results

Hemoglobin, hematocrit, and serum C-reactive protein level measured after admission for 24 h were significantly higher in the alcohol group than in the biliary group. Incidence of pseudocyst formation was significantly higher in the alcohol group than in the biliary group (20.0 % vs. 6.6 %, P = 0.023). Among prognostic scoring systems, only CTSI showed significant difference (P < 0.001) with a mean score of 3.0 ± 0.9 in the alcohol group and 1.7 ± 1.2 in the biliary group. Severe AP with organ failure persisting beyond 48 h was observed in 12 patients (24.0 %) in the alcohol group and one patient (1.3 %) in the biliary group (P < 0.001). There were 4 mortalities in the alcohol group only (P = 0.012).

Conclusion

More severe forms of AP and local complication, such as pseudocyst formation, are associated with alcoholic AP compared with biliary AP.

[Acute pancreatitis: guideline-based diagnosis and treatment]

Acute pancreatitis is most frequently of biliary or alcoholic origin and less frequently due to iatrogenic (ERCP, medication) or metabolic causes. Diagnosis is usually based on abdominal pain and elevation of serum lipase to more than three-times the normal limit. Acute pancreatitis can either resolve quickly following an oedematous swelling or present as a severe necrotizing form. A major risk is the systemic inflammatory response syndrome (SIRS), which can cause multi-organ failure. Prediction of disease course is initially difficult, thus necessitating immediate therapy and regular re-evaluation. In order to prove or exclude biliary genesis, abdominal ultrasonography should first be performed and endoscopic ultrasound may also be required. Primary therapy includes rapid and correctly dosed fluid substitution. Biliary pancreatitis requires causal treatment. In the case of cholangitis, stone extraction must be performed immediately; in the absence of cholangitis, it might be advisable to wait for spontaneous stone clearance. Timely cholecystectomy is necessary in all cases of biliary pancreatitis.

The efficacy of endoscopic papillary balloon dilation for patients with acute biliary pancreatitis

Background. No study investigated the efficacy and safety of endoscopic papillary balloon dilation (EPBD) for the treatment of acute biliary pancreatitis (ABP). Method. We retrospectively reviewed the effects of EPBD on patients with ABP from February 2003 to December 2012. The general data, findings of image studies, details of the procedure, and outcomes after EPBD were analyzed. Result. Total 183 patients (male/female: 110/73) were enrolled. The mean age was 65.9 years. Among them, 155 patients had mild pancreatitis. The meantime from admission to EPBD was 3.3 days. Cholangiogram revealed filling defects inside the common bile duct (CBD) in 149 patients. The mean dilating balloon size was 10.5 mm and mean duration of the dilating procedure was 4.3 minutes. Overall, 124 patients had gross stones retrieved from CBD. Four (2.2%) adverse events and 2 (1.1%) intraprocedure bleeding incidents but no procedure-related mortality were noted. Bilirubin and amylase levels significantly decreased after EPBD. On average, patients resumed oral intake within 1.4 days. The clinical parameters and outcomes were similar in patients with different severity of pancreatitis. Conclusion. EPBD can be effective and safe for the treatment of ABP, even in patients presenting with severe disease.

Laparoscopic cholecystectomy: consensus conference-based guidelines

INTRODUCTION

Laparoscopic cholecystectomy (LC) is the gold standard technique for gallbladder diseases in both acute and elective surgery. Nevertheless, reports from national surveys still seem to represent some doubts regarding its diffusion. There is neither a wide consensus on its indications nor on its possible related morbidity. On the other hand, more than 25 years have passed since the introduction of LC, and we have all witnessed the exponential growth of knowledge, skill and technology that has followed it. In 1995, the EAES published its consensus statement on laparoscopic cholecystectomy in which seven main questions were answered, according to the available evidence. During the following 20 years, there have been several additional guidelines on LC, mainly focused on some particular aspect, such as emergency or concomitant biliary tract surgery.

METHODS

In 2012, several Italian surgical societies decided to revisit the clinical recommendations for the role of laparoscopy in the treatment of gallbladder diseases in adults, to update and supplement the existing guidelines with recommendations that reflect what is known and what constitutes good practice concerning LC.

Enteral nutrition formulations for acute pancreatitis

BACKGROUND

Acute pancreatitis is a common and potentially lethal disease with increasing incidence. Severe cases are characterised by high mortality, and despite improvements in intensive care management, no specific treatment relevantly improves clinical outcomes of the disease. Meta-analyses suggest that enteral nutrition is more effective than conventional treatment consisting of discontinuation of oral intake with use of total parenteral nutrition. However, no systematic review has compared different enteral nutrition formulations for the treatment of patients with acute pancreatitis.

OBJECTIVES

To assess the beneficial and harmful effects of different enteral nutrition formulations in patients with acute pancreatitis.

SEARCH METHODS

We searched the Cochrane Upper Gastrointestinal and Pancreatic Diseases Group Specialised Register of Clinical Trials, the Cochrane Central Register of Controlled Trials (CENTRAL) (2013, Issue 7), MEDLINE (from inception to 20 August 2013), EMBASE (from inception to 2013, week 33) and Science Citation Index-Expanded (from 1990 to August 2013); we conducted full-text searches and applied no restrictions by language or publication status.

SELECTION CRITERIA

We considered randomised clinical trials assessing enteral nutrition in patients with acute pancreatitis. We allowed concomitant interventions if they were received equally by all treatment groups within a trial.

DATA COLLECTION AND ANALYSIS

Two review authors independently assessed trials for inclusion and extracted data. We performed the analysis using Review Manager 5 (Review Manager 2013) and both fixed-effect and random-effects models. We expressed results as risk ratios (RRs) for dichotomous data, and as mean differences (MDs) for continuous data, both with 95% confidence intervals (CIs). Analysis was based on an intention-to-treat principle.

MAIN RESULTS

We included 15 trials (1376 participants) in this review. We downgraded the quality of evidence for many of our outcomes on the basis of high risk of bias. Low-quality evidence suggests that immunonutrition decreases all-cause mortality (RR 0.49, 95% CI 0.29 to 0.80). The effect of immunonutrition on other outcomes from a subset of the included trials was uncertain. Subgrouping trials by type of enteral nutrition did not explain any variation in effect. We found mainly very low-quality evidence for the effects of probiotics on the main outcomes. One eligible trial in this comparison reported a higher rate of serious adverse events leading to increased organ failure and mortality due to low numbers of events and low risk of bias. When we excluded this study as a post hoc sensitivity analysis, risks of mortality (RR 0.30, 95% CI 0.10 to 0.84), organ failure (RR 0.74, 95% CI 0.59 to 0.92) and local septic complications (RR 0.40, 95% CI 0.22 to 0.72) were lower with probiotics. In one trial assessing immunonutrition with probiotics and fibres, no deaths occurred, but hospital stay was shorter with immunonutrition (MD -5.20 days, 95% CI -8.73 to -1.67). No deaths were reported following semi-elemental enteral nutrition (EN), and the effect on length of hospital stay was small (MD 0.30 days, 95% CI -0.82 to 1.42). Fibre-enriched formulations reduced the number of other local complications (RR 0.52, 95% CI 0.32 to 0.87) and length of hospital stay (MD -9.28 days, 95% CI -13.21 to -5.35) but did not significantly affect all-cause mortality (RR 0.23, 95% CI 0.03 to 1.84) and other outcomes. Very low-quality evidence from the subgroup of trials comparing EN versus no intervention showed a decrease in all-cause mortality with EN (RR 0.50, 95% CI 0.29 to 0.86).

AUTHORS' CONCLUSIONS

We found evidence of low or very low quality for the effects of immunonutrition on efficacy and safety outcomes. The role of supplementation of enteral nutrition with potential immunomodulatory agents remains in question, and further research is required in this area. Studies assessing probiotics yielded inconsistent and almost contrary results, especially regarding safety and adverse events, and their findings do not support the routine use of EN enriched with probiotics in routine clinical practice. However, further research should be carried out to try to determine the potential efficacy or harms of probiotics. Lack of trials reporting on other types of EN assessed and lack of firm evidence regarding their effects suggest that additional randomised clinical trials are needed. The quality of evidence for the effects of any kind of EN on mortality was low, and further studies are likely to have an impact on the finding of improved survival with EN versus no nutritional support. Evidence remains insufficient to support the use of a specific EN formulation.

Acute necrotizing pancreatitis: Surgical indications and technical procedures

Necrosis of pancreatic parenchyma or extrapancreatic tissues is present in 10%-20% of patients with acute pancreatitis, defining the necrotizing presentation frequently associated with high morbidity and mortality rates. During the initial phase of acute necrotizing pancreatitis the most important pillars of medical treatment are fluid resuscitation, early enteral nutrition, endoscopic retrograde colangiopancreatography if associated cholangitis and intensive care unit support. When infection of pancreatic or extrapancreatic necrosis occurs, surgical approach constitutes the most accepted therapeutic option. In this context, we have recently assited to changes in time for surgery (delaying the indication if possible to around 4 wk to deal with “walled-off” necrosis) and type of access for necrosectomy: from a classical open approach (with closure over large-bore drains for continued postoperative lavage or semiopen techniques with scheduled relaparotomies), trends have changed to a “step-up” philosophy with initial percutaneous drainage and posterior minimally invasive or endoscopic access to the retroperitoneal cavity for necrosectomy if no improvement has been previously achieved. These approaches are progressively gaining popularity and morbidity and mortality rates have decreased significantly. Therefore, a staged, multidisciplinary, step-up approach with minimally invasive or endoscopic access for necrosectomy is widely accepted nowadays for management of pancreatic necrosis.

Early phase of acute pancreatitis: Assessment and management

Acute pancreatitis (AP) is a potentially life-threatening disease with a wide spectrum of severity. The overall mortality of AP is approximately 5%. According to the revised Atlanta classification system, AP can be classified as mild, moderate, or severe. Severe AP often takes a clinical course with two phases, an early and a late phase, which should both be considered separately. In this review article, we first discuss general aspects of AP, including incidence, pathophysiology, etiology, and grading of severity, then focus on the assessment of patients with suspected AP, including diagnosis and risk stratification, followed by the management of AP during the early phase, with special emphasis on fluid therapy, pain management, nutrition, and antibiotic prophylaxis.

Treatment options for acute pancreatitis

This Review covers the latest developments in the treatment of acute pancreatitis. The Atlanta Classification of acute pancreatitis has been revised, proposing several new terms and abandoning some of the old and confusing terminology. The 2012 Revised Atlanta Classification and the determinant-based classification aim to universally define the different local and systemic complications and predict outcome. The most important differences between these classifications are discussed. Several promising treatment options for the early management of acute pancreatitis have been tested, including the use of enteral nutrition and antibiotics as well as novel therapies such as haemofiltration and protease inhibitors. The results are summarized and the quality of evidence is discussed. Finally, new developments in the management of patients with infected pancreatic necrosis are addressed, including the use of the 'step-up approach' and results of minimally invasive necrosectomy.