Pancreatic infection complicating acute pancreatitis

Guidelines for Antibiotics Prescription in Critically Ill Patients

How to cite this article: Khilnani GC, Tiwari P, Mittal S, Kulkarni AP, Chaudhry D, Zirpe KG, et al. Guidelines for Antibiotics Prescription in Critically Ill Patients. Indian J Crit Care Med 2024;28(S2):S104-S216.

Laparoscopic necrosectomy for acute necrotising pancreatitis: Retrospective analysis of a decade-long experience from a tertiary centre

INTRODUCTION

The objective of this study is to evaluate the role of minimally invasive surgery for the management of necrotising pancreatitis in acute settings and to propose tailor-made approaches to deal with various locations of pancreatic necrosis.

PATIENTS AND METHODS

Three hundred and thirteen patients underwent laparoscopic management of necrotising pancreatitis in this study period from January 2010 to June 2021, out of which 122 patients underwent minimally invasive necrosectomy for acute necrotising pancreatitis. The remaining 191 patients underwent laparoscopic internal drainage in the form of cystogastrostomy/cystojejunostomy for walled-off pancreatic necrosis.

RESULTS

Mean body mass index was 26.45 ± 3.78 kg/sqm. Mean operating time was 56.40 ± 20.48 min and mean blood loss was 120 ± 31.45 mL. Ten patients required reoperation (6 underwent open procedure and 4 underwent laparoscopic redo necrosectomy). Six patients died of multi-organ failure. The mean duration of return of bowel function was 5 ± 1.8 days. The mean length of hospital stay after surgery was 10.19 ± 7.09 days. There were no major wound-related complications.

CONCLUSION

A minimally invasive approach to pancreatic necrosectomy is safe and feasible with good outcomes in centres with advanced laparoscopic expertise. It requires not only careful case selection but also proper timing and the ideal route of access to achieve optimal outcomes.

Butyrate ameliorated the intestinal barrier dysfunction and attenuated acute pancreatitis in mice fed with ketogenic diet

Butyrate, a short-chain fatty acid (SCFA), has demonstrated significant efficacy in preventing colitis-associated inflammation. Acute pancreatitis is an acute gastrointestinal disorder characterized by increased systemic inflammation, bacterial translocation, and disrupted intestinal barrier. However, the effects and mechanisms of butyrate in attenuating acute pancreatitis remain unclear. In this study, we established two mouse models of acute pancreatitis induced by cerulein (Cer) and taurocholate (TA), which were further exacerbated by a ketogenic diet (KD). The results suggested that butyrate supplementation effectively reduced mortality rates, systemic inflammation, and intestinal barrier disruption caused by Cer- and TA-induced acute pancreatitis in mice fed a KD. Furthermore, we observed a significant reduction in gut microbiota diversity as well as overgrowth of Lachnospirales and Erysipelotrichales along with depletion of SCFAs in mice fed a KD, and these alterations were reversed by butyrate supplement. To evaluate the role of microbiota and butyrate supplement, we conducted germ-depletion trials by antibiotics. The results showed that while systemic inflammation was attenuated in mice with TA-induced pancreatitis following antibiotic treatment, the reduction in mortality remained inconclusive (p = 0.055). Importantly, the key differential change between antibiotic treatment and butyrate supplementation was found to be related to intestinal barrier dysfunction and repairment. These results suggest that butyrate plays a central role in mitigating acute pancreatitis through amelioration of intestinal barrier dysfunction.

Fibrinogen-like Protein 1 as a Predictive Marker for the Incidence of Severe Acute Pancreatitis and Infectious Pancreatic Necrosis

Background and Objectives: Acute pancreatitis (AP) is defined as an acute inflammatory disorder of the pancreas and is a common gastrointestinal disease. Since currently used indicators lack specifics and cannot accurately reflect the phase of disease, better diagnostic approaches need to be explored. Fibrinogen-like protein 1 (FGL-1) is a reactant in acute inflammatory diseases and is increased in the plasma of AP patients. In the current study, we aim to investigate the clinical benefits of FGL-1 in predicting the severity of AP and infected pancreatic necrosis (IPN), which can improve the diagnostic efficiency of AP. Materials and Methods: In this study, 63 patients diagnosed with AP from December 2018 to September 2019 were enrolled. Regarding the severity of AP, patients were separated into severe acute pancreatitis (SAP, n = 12) and No-SAP groups (n = 51). On the basis of infective conditions, patients were divided into IPN (n = 9) and No-IPN (n = 54) groups. The demographic data (sex and age) and blood parameters (WBC, HCT, glucose, calcium, FIB, APTT, PCT, CRP, and FGL-1) were retrospectively analyzed. Results: The plasma FGL-1 levels were increased in both SAP (p < 0.01) and IPN (p < 0.05) subgroups compared to the healthy control group. Multivariate analysis showed that elevated plasma FGL-1 (p < 0.01) and PCT levels (p < 0.05) within 72 h after the onset of AP were positively correlated with the severity of AP, while increased plasma FGL-1 (p < 0.01) and CRP (p < 0.05) levels were positively correlated with the occurrence of IPN. The combination of FGL-1 and PCT showed superiority to both individual markers in SAP prediction. However, the combination of FGL-1 and CRP showed no diagnostic advantage over CRP in IPN prediction. Conclusions: Plasma FGL-1 within 72 h after the onset could be used for the stratification of AP and its infectious complications. The combination of PCT and FGL-1 presents an enormous advantage for the early identification of SAP.

MiR155 Disrupts the Intestinal Barrier by Inducing Intestinal Inflammation and Altering the Intestinal Microecology in Severe Acute Pancreatitis

BACKGROUND

Intestinal dysfunction is a common complication of acute pancreatitis. MiR155 may be involved in the occurrence and development of intestinal dysfunction mediated by acute pancreatitis, but the specific mechanism is not clear.

AIMS

To investigate the effect of miR155 on severe acute pancreatitis (SAP)-associated intestinal dysfunction and its possible mechanism in a mice model.

METHODS

In this study, SAP mice model was induced by intraperitoneal injection of caerulein and LPS in combination. Adeno-associated virus (AAV) was given by tail vein injection before the SAP model. The pancreatic and intestinal histopathology changes were analyzed. Cecal tissue was collected for 16S rRNA Gene Sequencing. Intestinal barrier proteins ZO-1 and E-cad were measured by Immunohistochemistry Staining and Western Blot, respectively. Intestinal tissue miR155 and inflammatory factors TNF-α, IL-1β, and IL-6 were detected by Q-PCR. The expression levels of protein associated with TNF-α and TLR4/MYD88 pathway in the intestinal were detected.

RESULTS

In miR155 overexpression SAP group, the levels of tissue inflammatory factor were significantly increased, intestinal barrier proteins were significantly decreased, and the injury of intestinal was aggravated. Bacterial 16S rRNA sequencing was performed, showing miR155 promotes gut microbiota dysbiosis. The levels of TNF-α, TLR4, and MYD88 in the intestinal were detected, suggesting that miR155 may regulate gut microbiota and activate the TLR4/MYD88 pathway, thereby affecting the release of inflammatory mediators and regulating SAP-related intestinal injury. After application of miR155-sponge, imbalance of intestinal flora and destruction of intestinal barrier-related proteins have been alleviated. The release of inflammatory mediators decreased, and the histopathology injury of intestinal was improved obviously.

CONCLUSION

MiR155 may play an important role in SAP-associated intestinal dysfunction. MiR155 can significantly alter the intestinal microecology, aggravated intestinal inflammation through TLR4/MYD88 pathway, and disrupts the intestinal barrier in SAP mice.

Spatioregional assessment of the gut microbiota in experimental necrotizing pancreatitis

BACKGROUND

Infectious complications following experimental pancreatitis involve major disruptions in the gut microbiota. The aim of this study was to characterize this disruption by examining the spatioregional distribution in microbial community structure and function following experimental pancreatitis associated with pancreatic infection.

METHODS

Mice were subjected to infusion of the pancreatic duct with either taurocholate to induce necrotizing pancreatitis or normal saline (control group). The spatial (lumen versus mucosa) and regional composition and function of the microbiota from the duodenum, ileum, caecum, colon, pancreas and blood were evaluated using 16S rRNA gene amplicon sequencing.

RESULTS

Mice that developed necrotizing pancreatitis demonstrated a decrease in microbial richness and significantly altered microbiota in distal parts of the gastrointestinal tract, compared with controls. Among the most differentially increased taxa were the mucus-degrading Akkermansia muciniphila, and there was a decrease of butyrate-producing bacteria following pancreatitis. Application of the SourceTracker tool to the generated metadata indicated that the duodenum was the most probable source of bacteria that subsequently infected pancreatic tissue in this model. The functional prediction annotation using pathway analyses indicated a diminished capacity of the caecal microbiota to metabolize carbohydrate, and fatty and amino acids.

DISCUSSION

The distal gut microbiota was significantly impacted in this model of experimental necrotizing pancreatitis. Data suggest that the duodenal microbiota might also play a role in bacterial translation and secondary infections.

Western-type diet influences mortality from necrotising pancreatitis and demonstrates a central role for butyrate

OBJECTIVE

The gut microbiota are the main source of infections in necrotising pancreatitis. We investigated the effect of disruption of the intestinal microbiota by a Western-type diet on mortality and bacterial dissemination in necrotising pancreatitis and its reversal by butyrate supplementation.

DESIGN

C57BL/6 mice were fed either standard chow or a Western-type diet for 4 weeks and were then subjected to taurocholate-induced necrotising pancreatitis. Blood and pancreas were collected for bacteriology and immune analysis. The cecum microbiota composition of mice was analysed using 16S rRNA gene amplicon sequencing and cecal content metabolites were analysed by targeted (ie, butyrate) and untargeted metabolomics. Prevention of necrotising pancreatitis in this model was compared between faecal microbiota transplantation (FMT) from healthy mice, antibiotic decontamination against Gram-negative bacteria and oral or systemic butyrate administration. Additionally, the faecal microbiota of patients with pancreatitis and healthy subjects were analysed.

RESULTS

Mortality, systemic inflammation and bacterial dissemination were increased in mice fed Western diet and their gut microbiota were characterised by a loss of diversity, a bloom of Escherichia coli and an altered metabolic profile with butyrate depletion. While antibiotic decontamination decreased mortality, Gram-positive dissemination was increased. Both oral and systemic butyrate supplementation decreased mortality, bacterial dissemination, and reversed the microbiota alterations. Paradoxically, mortality and bacterial dissemination were increased with FMT administration. Finally, patients with acute pancreatitis demonstrated an increase in Proteobacteria and a decrease of butyrate producers compared with healthy subjects.

CONCLUSION

Butyrate depletion and its repletion appear to play a central role in disease progression towards necrotising pancreatitis.

Early intra-abdominal hypertension: A reliable bedside prognostic marker for severe acute pancreatitis

BACKGROUND AND AIM

Severe acute pancreatitis (SAP) is commonly associated with intra-abdominal hypertension (IAH). This acute increase of intra-abdominal pressure (IAP) may be attributed to early organ dysfunction, leading to an increased morbidity and mortality. To assess the incidence of raised IAH and its correlation with other prognostic indicators and various outcomes in SAP.

METHODS AND RESULTS

This was a prospective observational study in patients of SAP between July 2009 and December 2010. All patients of SAP who were admitted to the hospital within 2 weeks of onset of pain were included in the study. A total of 35 patients with SAP were included in the study. Among these, 25 (71.4%) were males. All our patients had raised IAP; however, IAH was present in 51.4% (18/35). Patients with IAH were found to have a higher APACHE II score (88.9 vs 5.9%; P < 0.001), infectious complications (72.2 vs 5.9%; P < 0.001), circulatory failure (88.9 vs 0%; P < 0.001), and respiratory failure (100 vs 41.2%; P < 0.001). All the eight (22.8%) patients who succumbed to sepsis had IAH. Patients with IAH were found to have a significantly longer intensive care unit (ICU) stay (17.72 vs 12.29 days) and in-hospital stay (24.89 vs 12.29 days).

CONCLUSION

IAH is a good negative prognostic marker in SAP, seen in up to 51.4%. IAH was found to have a significant negative impact on the outcome in terms of increased mortality, morbidity, in-hospital stay, and ICU stay among the patients of SAP.

Can infected pancreatic necrosis really be managed conservatively?

OBJECTIVES

Guidelines advocate minimally invasive drainage rather than open surgery for infected pancreatic necrosis (IPN) after acute pancreatitis. We hypothesized that the conservative approach could be extended even further by treating patients using an antibiotics-only protocol.

PATIENTS AND METHODS

Between June 2009 and July 2017, patients with IPN were selectively managed with carbapenem antibiotics for a minimum of 6 weeks. We compared these patients with patients who underwent minimal access retroperitoneal pancreatic necrosectomy (MARPN) for IPN to identify characteristics of this patient group.

RESULTS

Of 33 patients with radiologically proven IPN, 13 patients received antibiotics without any surgical or radiological intervention and resulted in no disease-specific mortality and one case of pancreatic insufficiency. In comparison, 44 patients underwent MARPN with a mortality of 20%, and 81.8% developed pancreatic insufficiency. The modified Glasgow score and computed tomography severity score was less in the antibiotic-only group (P<0.001 and P=0.014, respectively). Patients who underwent MARPN had lower serum haemoglobin and albumin levels (P=0.030 and 0.001, respectively), and a higher C-reactive protein (P=0.027).

CONCLUSION

Conservative treatment of IPN with antibiotics is a valid management option for haemodynamically stable patients experiencing less severe disease, requiring careful selection by experienced clinicians.

Successful treatment for severe pancreatitis with colonic perforation using video-assisted retroperitoneal debridement: A case report

•

Severe acute pancreatitis with necrotizing colonic perforation is refractory and the mortality is high.

•

Step-up approach for severe acute pancreatitis with infectious walled-off necrosis has been increasingly used.

•

We performed percutaneous drainage, ileostomy, and video-assisted retroperitoneal debridement (VARD) as a step-up approach.

•

VARD enable sufficient washing of the abscess and radical debridement of the necrotic tissues under direct view.

Introduction

Colorectal complications including penetration and perforation in acute pancreatitis often become severe and fatal. Effective drainage is pivotal for successful treatment. We present a case of large retroperitoneal abscess with colonic necrotizing perforation due to severe acute pancreatitis treated with video-assisted retroperitoneal debridement (VARD) in a step-up approach.

Presentation of case

A 31-year-old man was admitted to a general hospital with a diagnosis of severe acute pancreatitis. Ten days after onset, he was referred to our hospital for more intensive treatment. On day 16, he experienced melena and shock, and embolization of the three straight arteries of the descending colon was performed. On day 30, percutaneous drainage was performed for large retroperitoneal abscess. On day 36, ileostomy was performed because the drained pus from the retroperitoneal abscess became feces-like. On day 58, VARD was performed to treat the refractory retroperitoneal abscesses causing high systemic inflammation due to insufficient drainage. On day 85, fluoroscopic examination showed disappearance of the abscess cavity. He was transferred to the previous hospital on day 89.

Discussion

Colonic perforation due to severe acute pancreatitis often causes sepsis and fatal condition of patients, and drainage of the retroperitoneal abscesses via laparotomy is thought to be highly invasive and risky. VARD enables radical necrosectomy and drainage less invasively.

Conclusions

VARD enabled less invasive treatment for patients with large retroperitoneal abscess due to colonic necrotizing perforation in severe pancreatitis.

Outcome of Acute Pancreatic and Peripancreatic Collections Occurring in Patients With Acute Pancreatitis

OBJECTIVE

To study the outcome of acute collections occurring in patients with acute pancreatitis BACKGROUND:: There are limited data on natural history of acute collections arising after acute pancreatitis (AP).

METHODS

Consecutive patients of AP admitted between July 2011 and December 2012 were evaluated by imaging for development of acute collections as defined by revised Atlanta classification. Imaging was repeated at 1 and 3 months. Spontaneous resolution, evolution, and need for intervention were assessed.

RESULTS

Of the 189 patients, 151 patients (79.9%) had acute collections with severe disease and delayed hospitalization being predictors of acute collections. Thirty-six patients had acute interstitial edematous pancreatitis, 8 of whom developed acute peripancreatic fluid collections, of which 1 evolved into pseudocyst. Among the 153 patients with acute necrotizing pancreatitis, 143 (93.4%) developed acute necrotic collection (ANC). Twenty-three of 143 ANC patients died, 21 had resolved collections, whereas 84 developed walled-off necrosis (WON), with necrosis >30% (P = 0.010) and Computed Tomographic Severity Index score ≥7 (P = 0.048) predicting development of WON. Of the 84 patients with WON, 8 expired, 53 patients required an intervention, and 23 were managed conservatively. Independent predictors of any intervention among all patients were Computed Tomographic Severity Index score ≥7 (P < 0.001) and interval between onset of pain to hospitalization >7 days (P = 0.04).

CONCLUSIONS

Patients with severe AP and delayed hospitalization more often develop acute collections. Pancreatic pseudocysts are a rarity in acute interstitial pancreatitis. A majority of patients with necrotising pancreatitis will develop ANC, more than half of whom will develop WON. Delay in hospitalization and higher baseline necrosis score predict need for intervention.

Fungal Infections in Patients With Walled-off Pancreatic Necrosis

OBJECTIVES

This study aimed to evaluate the influence of fungal infection and antifungal treatment on outcome in patients with walled-off pancreatic necrosis (WON).

METHODS

A retrospective description of fungal infections in a cohort of consecutive patients undergoing endoscopic, transmural drainage and necrosectomy for WON, treated in a tertiary referral center was reviewed.

RESULTS

Between 2005 and 2013, fungal infection in WON was documented in 57 (46%) of 123 patients. The most common isolates at first positive culture were Candida albicans (55%) and Candida glabrata (20%). Thirty-nine (70%) patients were treated with antifungals after the first fungal finding. There was no significant difference in mortality (21% vs 13%, P = 0.517) or organ failure (34% vs 33%, P = 0.903) between the group treated with adequate antifungals after the first fungal finding compared to the group not treated or treated inadequately.The in-hospital mortality was 18% (10 patients). Concomitant fungemia was found in 6 patients, of which 3 died, as opposed to 7 with fungi in the necrosis only (50% vs 14%, P = 0.027).

CONCLUSIONS

This study demonstrates a high incidence and associated high in-hospital mortality of fungal infection in WON, thus emphasizing the importance of fungal infections in WON.

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.

Necrotizing pancreatitis: A review of the interventions

Acute pancreatitis may have a wide range of severity, from a clinically self-limiting to a quickly fatal course. Necrotizing pancreatitis (NP) is the most dreadful evolution associated to a poor prognosis: mortality is approximately 15% and up to 30-39% in case of infected necrosis, which is the major cause of death. Intervention is generally required for infected pancreatic necrosis and less commonly in patients with sterile necrosis who are symptomatic (gastric or duodenal outlet or biliary obstruction). Traditionally the most widely used approach to infected necrosis has been open surgical necrosectomy, but it is burdened by high morbidity (34-95%) and mortality (11-39%) rates. In the last two decades the treatment of NP has significantly evolved from open surgery towards minimally invasive techniques (percutaneous catheter drainage, per-oral endoscopic, laparoscopy and rigid retroperitoneal videoscopy). The objective of this review is to summarize the current state of the art of the management of NP and to clarify some aspects about its diagnosis and treatment.

Role of Biomarkers in Diagnosis and Prognostic Evaluation of Acute Pancreatitis

Acute pancreatitis is a potentially life threatening disease. The spectrum of severity of the illness ranges from mild self-limiting disease to a highly fatal severe necrotizing pancreatitis. Despite intensive research and improved patient care, overall mortality still remains high, reaching up to 30–40% in cases with infected pancreatic necrosis. Although little is known about the exact pathogenesis, it has been widely accepted that premature activation of digestive enzymes within the pancreatic acinar cell is the trigger that leads to autodigestion of pancreatic tissue which is followed by infiltration and activation of leukocytes. Extensive research has been done over the past few decades regarding their role in diagnosis and prognostic evaluation of severe acute pancreatitis. Although many standalone biochemical markers have been studied for early assessment of severity, C-reactive protein still remains the most frequently used along with Interleukin-6. In this review we have discussed briefly the pathogenesis and the role of different biochemical markers in the diagnosis and severity evaluation in acute pancreatitis.

Is necrosectomy obsolete for infected necrotizing pancreatitis? Is a paradigm shift needed?

In 1886, Senn stated that removing necrotic pancreatic and peripancreatic tissue would benefit patients with severe acute pancreatitis. Since then, necrosectomy has been a mainstay of surgical procedures for infected necrotizing pancreatitis (NP). No published report has successfully questioned the role of necrosectomy. Recently, however, increasing evidence shows good outcomes when treating walled-off necrotizing pancreatitis without a necrosectomy. The literature concerning NP published primarily after 2000 was reviewed; it demonstrates the feasibility of a paradigm shift. The majority (75%) of minimally invasive necrosectomies show higher completion rates: between 80% and 100%. Transluminal endoscopic necrosectomy has shown remarkable results when combined with percutaneous drainage or a metallic stent. Related morbidities range from 40% to 92%. Single-digit mortality rates have been achieved with transluminal endoscopic necrosectomy, but not with video-assisted retroperitoneal necrosectomy series. Drainage procedures without necrosectomy have evolved from percutaneous drainage to transluminal endoscopic drainage with or without percutaneous endoscopic gastrostomy access for laparoscopic instruments. Most series have reached higher success rates of 79%-93%, and even 100%, using transcystic multiple drainage methods. It is becoming evident that transluminal endoscopic drainage treatment of walled-off NP without a necrosectomy is feasible. With further refinement of the drainage procedures, a paradigm shift from necrosectomy to drainage is inevitable.

Contemporary review of drug-induced pancreatitis: A different perspective

Although gallstone and alcohol use have been considered the most common causes of acute pancreatitis, hundreds of frequently prescribed medications are associated with this disease state. The true incidence is unknown since there are few population based studies available. The knowledge of drug induced acute pancreatitis is limited by the availability and the quality of the evidence as the majority of data is extrapolated from case reports. Establishing a definitive causal relationship between a drug and acute pancreatitis poses a challenge to clinicians. Several causative agent classification systems are often used to identify the suspected agents. They require regular updates since new drug induced acute pancreatitis cases are reported continuously. In addition, infrequently prescribed medications and herbal medications are often omitted. Furthermore, identification of drug induced acute pancreatitis with new medications often requires accumulation of post market case reports. The unrealistic expectation for a comprehensive list of medications and the multifactorial nature of acute pancreatitis call for a different approach. In this article, we review the potential mechanisms of drug induced acute pancreatitis and provide the perspective of deductive reasoning in order to allow clinicians to identify potential drug induced acute pancreatitis with limited data.

Risk factors for pancreatic infection in patients with severe acute pancreatitis: an analysis of 163 cases

OBJECTIVE

We aimed to identify the risk factors for predicting pancreatic infection in patients with severe acute pancreatitis (SAP).

METHODS

In all, 163 patients with SAP were included and divided into two groups based on the presence or absence of pancreatic infection. Their demographic and clinical characteristics, laboratory examination results, complications and treatment modalities were collected from their medical records. Variables were initially screened by univariate analysis and those with statistical significance were then filtered by multivariate analysis to determine the independent risk factors for pancreatic infection in SAP.

RESULTS

Patients having SAP with pancreatic infection had a lower partial pressure of arterial carbon dioxide (PaCO2 ), peripheral white blood cell count and alkaline phosphatase levels, together with a higher computed tomography severity index (CTSI) than those without pancreatic infection, while their lactate dehydrogenase (LDH) levels and blood urea nitrogen were much higher. Pancreatic infection was also more common in patients receiving late fluid resuscitation than in those receiving early fluid resuscitation. Multivariate analyses revealed that increased LDH level, high CTSI, delayed fluid resuscitation and hypoxemia were independent risk factors for pancreatic infection in SAP. The sensitivity, specificity, positive and negative predictive values for a model combining the parameters in predicting pancreatic infection were 84%, 97%, 88% and 96%, respectively, with a cut-off value of 0.393, and the area under the receiver operating characteristic curve was 0.923.

CONCLUSION

Increased LDH, high CTSI, delayed fluid resuscitation and hypoxemia are independent risk factors for predicting pancreatic infection in patients with SAP.

Clinical pharmacokinetics of meropenem in pancreatic juice and site-specific pharmacodynamic target attainment against Gram-negative bacteria: dosing considerations

BACKGROUND AND OBJECTIVE

Very few studies have revealed the dynamics of meropenem penetration into the pancreas or pancreatic juice in humans. This study of the clinical pharmacokinetics and pharmacodynamics of meropenem in human pancreatic juice was performed to establish a basis for the validation of dosing regimens for pancreatic infections.

METHODS

Ten patients with endoscopic naso-pancreatic drainage received 500 mg meropenem over 0.5 h via intravenous infusion. Venous blood and pancreatic juice samples were collected post-infusion for up to 5.0 h and used to obtain measures of meropenem concentration. The probability of attaining the pharmacodynamic target (40% of the time above the minimum inhibitory concentration [MIC]) in pancreatic juice against MIC distributions for clinical isolates of Gram-negative bacteria was determined using a Monte Carlo simulation.

RESULTS

The mean maximum concentration of meropenem in pancreatic juice was 2.08 ± 0.94 μg/mL at 1.025 ± 0.18 h. The pancreatic juice/plasma ratio was 0.055 ± 0.028. A 0.5-h infusion of 500 mg meropenem every 8 h achieved a 99.4% probability of target attainment against Escherichia coli, 96.4% against Klebsiella species, 94.3% against Enterobacter species and 96.2% against Proteus species, but only 41.3% against Pseudomonas aeruginosa isolates.

CONCLUSION

Intravenous meropenem exhibits low penetrance into pancreatic juice. However, a dosing regimen of 500 mg meropenem (0.5-h infusion) every 8 h provides sufficient drug-exposure time in pancreatic juice against the four common Gram-negative bacteria populations.

The role of open necrosectomy in the current management of acute necrotizing pancreatitis: a review article

The optimal management of necrotizing pancreatitis continues to evolve. Currently, conservative intensive care treatment represents the primary therapy of acute severe necrotizing pancreatitis, aiming at prevention of organ failure. Following this mode of treatment most patients with sterile necroses can be managed successfully. Surgery might be considered as an option in the late phase of the disease for patients with proven infected pancreatic necroses and organ failure. For these patients surgical debridement is still considered the treatment of choice. However, even for this subgroup of patients, the concept of operative strategy has been recently challenged. Nowadays, it is generally accepted that necrotizing pancreatitis with proven infected necroses as well as septic complications directly caused by pancreatic infection are strong indications for surgical management. However, the question of the most appropriate surgical technique for the treatment of pancreatic necroses remains unsettled. At the same time, recent advances in radiological imaging, new developments in interventional radiology, and other minimal access interventions have revolutionised the management of necrotizing pancreatitis. In light of these controversies, the present paper will focus on the current role of surgery in terms of open necrosectomy in the management of severe acute necrotizing pancreatitis.

The role of sphingosine kinase 1 in patients with severe acute pancreatitis

OBJECTIVE

To investigate the role of sphingosine kinase 1 (SphK1)/sphingosine 1-phosphate (S1P) signaling in inflammatory response in severe acute pancreatitis (SAP).

BACKGROUND

SAP is an acute inflammatory process of the pancreas, which may lead to systemic inflammatory response syndrome and multiorgan dysfunction syndrome. SphK1 and its product S1P have been implicated in inflammatory response and various immune cell functions. However, the potential role for SphK1/S1P in inflammatory response in SAP is still unclear.

METHODS

Twenty-two patients with SAP were enrolled in this study. SphK1 expression on peripheral neutrophils, monocytes, and lymphocytes was evaluated by flow cytometry. SphK enzymatic activity in neutrophils and lymphocytes was measured using a radiometric assay. The expression of S1P1 and S1P3 mRNA was determined by reverse transcriptase-polymerase chain reaction (RT-PCR). The serum levels of tumor necrosis factor-α (TNF-α), interleukin-1 (IL-1β), and IL-6 were measured by ELISA.

RESULTS

The expression of SphK1 and SphK activity were markedly increased in peripheral immune cells in the early stage of SAP and then reduced in the restoration stage in the patients. Moreover, we found that the level of S1P3 mRNA in peripheral neutrophils and lymphocytes of SAP patients was significantly elevated in the early stage as compared with the healthy volunteers, and it reduced in the restoration period. SphK1 expression on human peripheral neutrophils, monocytes, and CD4(+) T lymphocytes were positively correlated with the APACHE (Acute Physiological and Chronic Health Evaluation) II scores in patients with SAP. The levels of serum proinflammatory cytokines including TNF-α, IL-1β, and IL-6 showed similar shifts with intracellular SphK1 expression in SAP patients.

CONCLUSIONS

The authors identified a link between the SphK1 expression on peripheral immune cells and the severity of SAP. Observations showed a possible immunomodulating role for SphK1/S1P signaling in inflammatory response in SAP, suggesting that regulation of SphK1/S1P pathway may represent novel targets in the treatment of SAP.

Effects of prophylactic antibiotics in acute pancreatitis

OBJECTIVES

The use of prophylactic antibiotics in severe acute pancreatitis (SAP) is controversial. The aim of this study was to compare the effects of antibiotics administered as prophylaxis and as treatment on demand, respectively, in two prospective, non-randomized cohorts of patients.

METHODS

The study population consisted of 210 patients treated for SAP. In Group 1 (n= 103), patients received prophylactic antibiotics (ciprofloxacin, metronidazole). In Group 2 (n= 107), patients were treated on demand. Ultrasound-guided drainage and/or surgical debridement of infected necrosis were performed when the presence of infected pancreatic necrosis was demonstrated. The primary endpoints were infectious complication rate, need for and timing of surgical interventions, incidence of nosocomial infections and mortality rate.

RESULTS

Ultrasound-guided fine needle aspiration [in 18 (16.8%) vs. 13 (12.6%) patients; P= 0.714], ultrasound-guided drainage [in 15 (14.0%) vs. six (5.8%) patients; P= 0.065] and open surgical necrosectomy [in 10 (9.3%) vs. five (4.9%) patients; P= 0.206] were performed more frequently and earlier [at 16.6 ± 7.8 days vs. 17.2 ± 6.7 days (P= 0.723); at 19.5 ± 9.4 days vs. 24.5 ± 14.2 days (P= 0.498), and at 22.6 ± 13.5 days vs. 26.7 ± 18.1 days (P= 0.826), respectively] in Group 2 compared with Group 1. There were no significant differences between groups in mortality and duration of stay in the surgical ward or intensive care unit.

CONCLUSIONS

The results of this study support the suggestion that the use of prophylactic antibiotics does not affect mortality rate, but may decrease the need for interventional and surgical management, and lower the number of reoperations.

Primary conservative treatment results in mortality comparable to surgery in patients with infected pancreatic necrosis

BACKGROUND & AIMS

The standard treatment for patients with infected pancreatic necrosis (IPN) is surgical necrosectomy. We compared the outcomes of surgical treatment versus primary conservative treatment (patients kept in intensive care unit and treated with antibiotics, organ support, intensive nutritional support, and, if required, percutaneous drainage) among patients with IPN.

METHODS

We performed retrospective comparative (with prospectively acquired database) and prospective observational studies; data were collected from all consecutive patients with acute pancreatitis (n = 804), and those with IPN formed the study group. Patients with IPN were divided into 2 groups on the basis of diagnosis of IPN during 1997-2002 (group 1, n = 30) or 2003-2006 (group 2, n = 50). Eighteen patients in group 1 were treated by surgical necrosectomy, and 40 patients in group 2 were given primary conservative treatment; surgery was performed on patients if conservative treatment failed (n = 10). The primary outcome measure was mortality.

RESULTS

The mortality was comparable in group 1 versus group 2 (43% vs 28%; P = .22). During a period of 10 years, the patients who received primary conservative treatment had significantly higher survival rates than those who received surgery (76.9% vs 46.4%; P = .005). In the prospective study during 2007-2008, the mortality from infected necrosis was 29.6% after primary conservative treatment, confirming the results of the comparative study.

CONCLUSIONS

In treating patients with IPN, a primary conservative strategy resulted in mortality that was comparable with that after surgery, and 76% of the patients were able to avoid surgery; 54.5% of IPN patients were successfully managed with the primary conservative strategy.

Melatonin modulates the severity of taurocholate-induced acute pancreatitis in the rat

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.

Surgical management of pancreatic necrosis: towards lesser and later

BACKGROUND/PURPOSE

Our aim was to determine the overall success rate and survival rate with respect to the timing of intervention in the management of pancreatic necrosis. The use of minimally invasive pancreatic necrosectomy was also examined.

METHODS

This was a retrospective study carried out in a tertiary referral hospital. The subjects were all patients who suffered from acute pancreatic necrosis with emergency interventions from January 2001 to December 2007. For outcome measures, special emphasis was placed on the overall success rate and survival rate with respect to the timing of intervention. The success rate of percutaneous pancreatic necrosectomy (PCPN) was examined.

RESULTS

A total of 26 patients with pancreatic necrosis were studied. The overall mortality rate was 26.9% and the rate was significantly higher in those patients who had earlier intervention (before 6 weeks). Eleven patients had PCPN. There were 2 failures due to PCPN in the early phase; 2 had partial success, while the procedure was completely successful to remove all the necrotic tissues in the other 7 patients.

CONCLUSIONS

With a multidisciplinary approach, particularly with sophisticated intensive care, most patients with pancreatic necrosis can survive the initial phase. Open surgery should be limited to simple drainage and laparostomy to relieve the abdominal tension. Active intervention preferably should be delayed until the necrosis has become walled off, when a variety of minimally invasive maneuvers, notably percutaneous necrosectomy, can be offered to remove the debris. The surgical management of pancreatic necrosis should change towards a strategy of "lesser and later".

Characteristics and outcomes of patients undergoing debridement of pancreatic necrosis

BACKGROUND

Pancreatic necrosis is associated with high morbidity and mortality. The Atlanta Classification underwent proposed revisions in 2007 to better categorize acute pancreatitis.

METHODS

From 1999 to 2008, patients with pancreatic necrosis treated with surgical debridement were analyzed. Computed tomography (CT) images were independently reviewed to classify of pancreatic collections according to the revised Atlanta classification.

RESULTS

Seventy-three patients were categorized as infected extrapancreatic necrosis (40%), sterile extrapancreatic necrosis (29%), infected pancreatic necrosis (15%), sterile pancreatic necrosis (11%), or post-necrotic collection (5%). Mortality was 14%, and morbidity was 55%. Debridement with external drainage or open packing was associated with higher mortality than cystgastrostomy (p = 0.03). Atlanta Classification was not associated with operative procedure or mortality. Degree of chronic disease, demonstrated by albumin level, and infection were associated with longer stay (p < 0.05).

CONCLUSION

Type of necrosis by the revised Atlanta Classification was not associated with outcomes or type of operation. Debridement by cystgastrostomy was associated with lower mortality rates than external drainage or open packing. Length of stay was increased in patients with evidence of chronic disease, infection, and postoperative complications. Necrotizing pancreatitis continues to be associated with significant morbidity and mortality and should undergo aggressive treatment at tertiary care centers.

Therapeutic intervention and surgery of acute pancreatitis

The clinical course of acute pancreatitis varies from mild to severe. Assessment of severity and etiology of acute pancreatitis is important to determine the strategy of management for acute pancreatitis. Acute pancreatitis is classified according to its morphology into edematous pancreatitis and necrotizing pancreatitis. Edematous pancreatitis accounts for 80-90% of acute pancreatitis and remission can be achieved in most of the patients without receiving any special treatment. Necrotizing pancreatitis occupies 10-20% of acute pancreatitis and the mortality rate is reported to be 14-25%. The mortality rate is particularly high (34-40%) for infected pancreatic necrosis that is accompanied by bacterial infection in the necrotic tissue of the pancreas (Widdison and Karanjia in Br J Surg 80:148-154, 1993; Ogawa et al. in Research of the actual situations of acute pancreatitis. Research Group for Specific Retractable Diseases, Specific Disease Measure Research Work Sponsored by Ministry of Health, Labour, and Welfare. Heisei 12 Research Report, pp 17-33, 2001). On the other hand, the mortality rate is reported to be 0-11% for sterile pancreatic necrosis which is not accompanied by bacterial infection (Ogawa et al. 2001; Bradely and Allen in Am J Surg 161:19-24, 1991; Rattner et al. in Am J Surg 163:105-109, 1992). The Japanese (JPN) Guidelines were designed to provide recommendations regarding the management of acute pancreatitis in patients having a variety of clinical characteristics. This article describes the guidelines for the surgical management and interventional therapy of acute pancreatitis by incorporating the latest evidence for the management of acute pancreatitis in the Japanese-language version of JPN guidelines 2010. Eleven clinical questions (CQ) are proposed: (1) worsening clinical manifestations and hematological data, positive blood bacteria culture test, positive blood endotoxin test, and the presence of gas bubbles in and around the pancreas on CT scan are indirect findings of infected pancreatic necrosis; (2) bacteriological examination by fine needle aspiration is useful for making a definitive diagnosis of infected pancreatic necrosis; (3) conservative treatment should be performed in sterile pancreatic necrosis; (4) infected pancreatic necrosis is an indication for interventional therapy. However, conservative treatment by antibiotic administration is also available in patients who are in stable general condition; (5) early surgery for necrotizing pancreatitis is not recommended, and it should be delayed as long as possible; (6) necrosectomy is recommended as a surgical procedure for infected necrosis; (7) after necrosectomy, a long-term follow-up paying attention to pancreatic function and complications including the stricture of the bile duct and the pancreatic duct is necessary; (8) drainage including percutaneous, endoscopic and surgical procedure should be performed for pancreatic abscess; (9) if the clinical findings of pancreatic abscess are not improved by percutaneous or endoscopic drainage, surgical drainage should be performed; (10) interventional treatment should be performed for pancreatic pseudocysts that give rise to symptoms, accompany complications or increase the diameter of cysts and (11) percutaneous drainage, endoscopic drainage or surgical procedures are selected in accordance with the conditions of individual cases.

The clinical value of procalcitonin in the prediction of infected necrosis in acute pancreatitis

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.

Melatonin modulates the severity of taurocholate-induced acute pancreatitis in the rat

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.

Critical Care of the Patient with Acute Pancreatitis

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.

Pretreatment but not treatment with probiotics abolishes mouse intestinal barrier dysfunction in acute pancreatitis

BACKGROUND

Intestinal barrier failure during acute pancreatitis (AP) is associated with translocation of luminal bacteria, resulting in infectious complications. We examined the effects of multispecies probiotics on the intestinal barrier impairment in a murine model of AP.

METHODS

Mice were injected with cerulein to induce AP and were sacrificed 11 (early AP) or 72 hours (late AP) after start of induction. AP and associated systemic effects were confirmed by histology of pancreas and lung. Animals received daily probiotics starting 2 days prior to AP induction (pretreatment) or at the moment of AP induction (treatment). Mucosal barrier function of the distal ileum was assessed in Ussing chambers by measurement of the epithelial electrical resistance and the permeability to Na-fluorescein.

RESULTS

Histological analysis revealed pancreatic injury in both phases of AP, and lung damage in the early phase. Epithelial resistance of the ileum was reduced and permeability increased in both phases of AP, indicating impairment of the intestinal barrier. Pretreatment had no effect on resistance or permeability in the early phase of AP. In the late phase of AP, pretreatment but not treatment abolished the AP induced resistance decrease and permeability increase. Administration of probiotics as such (ie, without induction of AP) had no effect on intestinal barrier function.

CONCLUSION

Pretreatment with multispecies probiotics for 2 days abolishes intestinal barrier dysfunction in the late phase of AP, while treatment does not. The effectiveness of probiotics in this model depends on the timing of administration. Clinical trials with probiotics should seek conditions where treatment can be started prior to onset of disease or elective surgical intervention.

Severe acute pancreatitis: Pathogenetic aspects and prognostic factors

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.

Infectious complications, prognostic factors and assessment of anti-infectious management of 212 consecutive patients with acute pancreatitis

AIM

Acute pancreatitis is an important cause of morbidity and mortality, mainly due to sepsis. The aim of this study was to determine the incidence of infectious complications and their impact on mortality in patients hospitalized for acute pancreatitis.

PATIENTS AND METHODS

Patients admitted for acute pancreatitis were retrospectively included within a period between 1995 and 2000. Incidence of abdominal and extra-abdominal sepsis and specific care were specifically analyzed. Risk factors for death were evaluated by uni- and multivariated analysis.

RESULTS

Two hundreds and twelve consecutive patients (128 males, median age 54 years) were included. Mortality was 10.8%. At least one infectious episode was collected in 25% of the patients with an abdominal sepsis (26.8%), bacteriemia (24.4%), respiratory (24.4%) and urinary tracts (19.5%) infections. Infection was polymicrobial in 37.5%. An antibiotic prophylaxis was administered in 10.8%, more often in patients with severe pancreatitis. It did not alter mortality or incidence of infections but significantly delayed occurrence of sepsis. Mortality of patients treated with more than one line of antibiotics was higher. However in this study infectious complications were not an independent factor for mortality.

CONCLUSION

Infections are frequent and polymicrobial but are not an independent prognostic factor during acute pancreatitis.

Modification of intestinal flora with multispecies probiotics reduces bacterial translocation and improves clinical course in a rat model of acute pancreatitis

BACKGROUND

Infection of pancreatic necrosis by gut bacteria is a major cause of morbidity and mortality in patients with severe acute pancreatitis. Use of prophylactic antibiotics remains controversial. The aim of this experiment was assess if modification of intestinal flora with specifically designed multispecies probiotics reduces bacterial translocation or improves outcome in a rat model of acute pancreatitis.

METHODS

Male Sprague-Dawley rats were allocated into 3 groups: (1) controls (sham-operated, no treatment), (2) pancreatitis and placebo, and (3) pancreatitis and probiotics. Acute pancreatitis was induced by intraductal glycodeoxycholate and intravenous cerulein infusion. Daily probiotics or placebo was administered intragastrically from 5 days prior until 7 days after induction of pancreatitis. Tissue and fluid samples were collected for microbiologic and quantitative real-time PCR analysis of bacterial translocation.

RESULTS

Probiotics reduced duodenal bacterial overgrowth of potential pathogens (Log(10) colony-forming units [CFU]/g 5.0 +/- 0.7 [placebo] vs 3.5 +/- 0.3 CFU/g [probiotics], P < .05), resulting in reduced bacterial translocation to extraintestinal sites, including the pancreas (5.38 +/- 1.0 CFU/g [placebo] vs 3.1 +/- 0.5 CFU/g [probiotics], P < .05). Accordingly, health scores were better and late phase mortality was reduced: 27% (4/15, placebo) versus 0% (0/13, probiotics), respectively, P < .05.

CONCLUSIONS

This experiment supports the hypothesis that modification of intestinal flora with multispecies probiotics results in reduced bacterial translocation, morbidity, and mortality in the course of experimental acute pancreatitis.

Prevention of infectious complications in severe acute pancreatitis with systemic antibiotics: where are we now?

Infectious complications are the leading cause of death in patients with severe acute pancreatitis. Currently, there is controversy concerning the therapeutic possibilities to reduce the incidence of bacterial infection in this disease. Numerous studies are available which apparently support the prophylactic use of antibiotics in patients with necrotizing pancreatitis. The results, however, are contradicting and interpretation is difficult as these studies have used various antibiotic drugs with different application schemes and heterogeneous study end points. This article gives a critical overview of the background of antibiotic treatment in severe acute pancreatitis, the published data on antibiotic treatment and an outlook on the topics that need to be addressed by future research.

Infected Pancreatic Necrosis

BACKGROUND

Infected pancreatic necrosis is a late infective complication of acute necrotizing pancreatitis in which infection tends to spread from the pancreas to the peripancreatic tissues, retroperitoneum, and, more rarely, the peritoneal cavity. Severe and rapid deterioration of the clinical condition may lead to septic shock and multiple organ dysfunction syndrome. CAUSATIVE ORGANISMS: The microorganisms most frequently isolated in cases of acute bacterial pancreatitis have been historically gram-negative bacteria of enteric origin. However, gram-positive cocci are isolated with increasing frequency. Enterococci are the single most commonly isolated species.

TREATMENT

Aggressive multimodal therapy in the early stage of severe necrotizing pancreatitis improves survival; patients with infective complications tend to die later from multiple organ dysfunction syndrome. Initially, the treatment consists of fluids, analgesics, and oxygen supplementation. Surgical debridement should be limited to proved infections and delayed as long as possible to allow necrotic tissue to become demarcated. When surgery is necessary, blunt debridement of necrotic tissues is the procedure largely utilized and usually is not accompanied by excessive bleeding. Pancreatic resection should be reserved for massive necrosis of the gland substance. In many situations, the abdominal incision can be closed primarily. Treatment by the "open abdomen" technique should be reserved for those patients in whom further laparotomies are planned, mainly because of incomplete unsatisfactory debridement or uncontrolled bleeding that necessitates packing of the lesser sac.

CONCLUSION

Modern management techniques have reduced the mortality of infected pancreatic necrosis to 15-20% from historical rates that were twice as high. Aggressive resuscitation and surveillance of infection are crucial for successful outcomes, although fewer patients are undergoing surgical debridement.

JPN Guidelines for the management of acute pancreatitis: surgical management

Acute pancreatitis represents a spectrum of disease ranging from a mild, self-limited course to a rapidly progressive, severe illness. The mortality rate of severe acute pancreatitis exceeds 20%, and some patients diagnosed as mild to moderate acute pancreatitis at the onset of the disease may progress to a severe, life-threatening illness within 2–3 days. The Japanese (JPN) guidelines were designed to provide recommendations regarding the management of acute pancreatitis in patients having a diversity of clinical characteristics. This article sets forth the JPN guidelines for the surgical management of acute pancreatitis, excluding gallstone pancreatitis, by incorporating the latest evidence for the surgical management of severe pancreatitis in the Japanese-language version of the evidence-based Guidelines for the Management of Acute Pancreatitis published in 2003. Ten guidelines are proposed: (1) computed tomography-guided or ultrasound-guided fine-needle aspiration for bacteriology should be performed in patients suspected of having infected pancreatic necrosis; (2) infected pancreatic necrosis accompanied by signs of sepsis is an indication for surgical intervention; (3) patients with sterile pancreatic necrosis should be managed conservatively, and surgical intervention should be performed only in selected cases, such as those with persistent organ complications or severe clinical deterioration despite maximum intensive care; (4) early surgical intervention is not recommended for necrotizing pancreatitis; (5) necrosectomy is recommended as the surgical procedure for infected pancreatic necrosis; (6) simple drainage should be avoided after necrosectomy, and either continuous closed lavage or open drainage should be performed; (7) surgical or percutaneous drainage should be performed for pancreatic abscess; (8) pancreatic abscesses for which clinical findings are not improved by percutaneous drainage should be subjected to surgical drainage immediately; (9) pancreatic pseudocysts that produce symptoms and complications or the diameter of which increases should be drained percutaneously or endoscopically; and (10) pancreatic pseudocysts that do not tend to improve in response to percutaneous drainage or endoscopic drainage should be managed surgically.

Antibiotic prophylaxis of pancreatic infection in patients with necrotizing pancreatitis: rationale, evidence, and recommendations

Infectious complications are the most common cause of morbidity and mortality in patients suffering from severe acute pancreatitis. Approximately 25% of patients develop pancreatic necrosis. In these patients with severe disease complicated by necrosis, there is evidence that preventing infection of the pancreatic necrosis decreases morbidity and mortality. Whereas sterile necrosis is often treated conservatively, surgical debridement is required when the necrosis becomes infected. Although surgery is necessary in patients with infected necrosis, for a variety of reasons surgical intervention increases the morbidity and mortality of the disease. Preventing infectious complications, such as infected necrosis, through the use of prophylactic antibiotics is controversial. Despite reviewing the same evidence, different authors and organizations have formed different conclusions. In this review, we perform a critical analysis of the studies. Overall, the use of antibiotics in patients with necrotizing pancreatitis appears to decrease infectious complications and mortality.

Factors influencing mortality in acute pancreatitis: can we alter them?

Severe acture pancreatitis (SAP), a multisystem disease, is characterized by multiple organ system failure and additionally by local pancreatic complications such as necrosis, abscess, or pseudocyst. The rate of mortality in SAP, which is about 20% of all cases of acute pancreatitis (AP), may be as high as 25%, as in infected pancreatic necrosis. The factors that influence mortality in different degrees are various. Etiology for the episode, age, sex, race, ethnicity, genetic makeup, severity on admission, and the extent and nature of pancreatic necrosis (sterile vs. infected) influence the mortality. Other factors include treatment modalities such as administration of prophylactic antibiotics, the mode of feeding (TPN vs. enteral), ERCP with sphincterotomy, and surgery in selected cases. Epidemiological studies indicate that the incidence of AP is increasing along with an increase in obesity, a bad prognostic factor. Many studies have indicated a worse prognosis in idiopathic AP compared to pancreatitis induced by alcoholism or biliary stone. The risk for SAP after ERCP is the subject of extensive study. AP after trauma, organ transplant, or coronary artery bypass surgery is rare but may be serious. Since Ranson reported early prognostic criteria, a number of attempts have been made to simplify or add new clinical or laboratory studies in the early assessment of severity. Obesity, hemoconcentration on admission, presence of pleural effusion, increased fasting blood sugar, as well as creatinine, elevated CRP in serum, and urinary trypsinogen levels are some of the well-documented factors in the literature. The role of appropriate prophylactic antibiotic therapy although still is highly controversial, in properly chosen cases appears to be beneficial and well accepted in clinical practice. Early enteral nutrition has gained much support and jejunal feeding bypassing the pancreatic stimulatory effect of it in the duodenum is desirable in selected cases. The limited role for endoscopic sphincterotomy in patients with demonstrated dilated CBD with impacted stone and evidence of impending cholangitis is well documented. Surgery in AP other than for removal of the gallbladder is often limited to infected pancreatic necrosis, pseudocysts, and pancreatic abscess and in some cases of traumatic pancreatitis with a ruptured duct system. The progress in the understanding of the role of cytokines will over us opportunities to use immunomodulatory therapies to improve the outcome in SAP.

Surgical treatment of necrotizing pancreatitis by necrosectomy and closed lavage: changing patient characteristics and outcome in a 19-year, single-center series

BACKGROUND

Surgical treatment of necrotizing pancreatitis (NP) has undergone considerable changes during the past 2 decades. In this study, we report our experience of necrosectomy and continuous closed lavage over the past 19 years in an attempt to define changes in patient characteristics and outcome at an academic referral center.

METHODS

Among 1520 patients admitted with acute pancreatitis, 392 had NP, 285 of whom underwent operative treatment. The total series was evaluated separately for treatment period A (May 1982 until April 1993) and treatment period B (May 1993 until May 2001).

RESULTS

Intraoperative bacteriology revealed sterile necrosis in 145 and infected necrosis in 140 patients. Preoperative disease severity did not differ between the groups; however, the extent of pancreatic parenchymal necrosis was less in patients with sterile necrosis (P < .003). Postoperative complications were more frequent in infected necrosis (78%) than in sterile necrosis (61%) (P < .004), with mortality rates of 27% and 23%, respectively. The analysis of the 2 treatment periods revealed that during period B, there was a decrease in operatively treated patients with sterile necrosis (P < .0005). The preoperative systemic disease severity was significantly higher in these patients than in patients with infected necrosis.

CONCLUSIONS

Surgical treatment of NP by necrosectomy and closed lavage carries an overall mortality of 25%. Patients with sterile necrosis and early onset high disease severity may represent a distinct clinical entity in whom the optimal treatment strategy remains to be defined.

Severe acute pancreatitis: nonsurgical treatment of infected necroses

OBJECTIVES

In acute pancreatitis, infection of necrosis is associated with a substantial mortality of 15% to >50% even if immediate necrosectomy, the recommended standard treatment, is performed, mainly because of the patients' critical systemic and unstable local conditions at the time of manifestation of infection. We investigated whether this dreaded complication can be managed conservatively.

METHODS

We evaluated 88 consecutive patients with severe (APACHE II score, > or =11; Ranson score, > or =4) acute necrotizing pancreatitis who received ICU treatment including early antibiotic prophylaxis. Twenty-eight patients were included who developed infection of necroses, verified by fine needle aspiration, 19 +/- 6 days after admission. No patient received urgent surgery; rather, in all patients, nonsurgical therapy was continued after adapting the antibiotic regimen to bacteriology. In the further course, 12 patients were excluded due to refractory local complications eventually requiring surgical treatment 36 +/- 14 days after diagnosis of infection.

RESULTS

Sixteen patients (APACHE II score: 18.1 [11-33]; Ranson score, 5.9 [4-10]) were managed with medical treatment alone. Six patients recovered without further complications; 10 patients (62%) developed single or multiple organ failure, and 2 died (mortality, 12%).

CONCLUSION

These data suggest that in patients with acute necrotizing pancreatitis and infected necroses, surgery can be avoided without compromising prognosis and outcome.