JPN clinical practice guidelines 2021 with easy-to-understand explanations for the management of acute pancreatitis

Usefulness of simplified comprehensive geriatric assessment as a pre-ERCP screening for the elderly

BACKGROUND

Endoscopic retrograde cholangiopancreatography (ERCP) is often performed in elderly patients for stone removal and biliary drainage following common bile duct stones or malignant biliary obstruction. Safety in ERCP should be considered in elderly patients due to complications and decreased activities of daily living (ADL), but there are no adequate pretest evaluation criteria. In recent years, the usefulness of the comprehensive geriatric assessment (CGA) for planning treatment and predicting prognosis has been reported.

METHODS

We retrospectively analyzed consecutive patients who underwent ERCP at our institution between October 2021 and June 2023. The relationship between CGA and ERCP outcomes was examined by dividing CGA scores into three groups (Group A; score 0, Group B; score 1-4, Group C; score 5-7) among patients 65 years of age and older. Risk factors for prolonged hospitalization were identified using univariate and multivariate analysis.

RESULTS

Of the 388 patients, 290 were 65 or older with a CGA score. The median length of hospital stay was significantly longer in the higher CGA7 scores group (5 vs. 8 vs. 15 days, p < .01). There was no significant difference in the rate of adverse events (p = .54) and median total procedure time (p = .35). In univariate and multivariate analysis, higher CGA score groups were significant risk factors for a prolonged hospital stay.

CONCLUSIONS

CGA appears to be a valuable tool for preadmission screening in elderly patients undergoing ERCP.

Current status and issues for prediction and prevention of postendoscopic retrograde cholangiopancreatography pancreatitis

Acute pancreatitis, which sometimes results in mortality, is a significant complication of endoscopic retrograde cholangiopancreatography (ERCP). Many studies have been conducted to predict and prevent post-ERCP pancreatitis (PEP), and meta-analyses have been reported that summarized these studies. However, many issues remain unresolved. Many risk factors for PEP have been reported, and it is rare for patients undergoing ERCP to have only one risk factor. The use of artificial intelligence may be important for analyzing complex and diverse risk factors. It is desirable to develop an alternative test for pancreatic enzymes that can predict the onset of PEP within 1 h after ERCP. The effectiveness of low-dose nonsteroidal anti-inflammatory drugs (NSAIDs) are controversial. Nitrate and tacrolimus are considered medications that have additional effects on NSAIDs and may be used for the prevention of PEP. Pancreatic stent placement with deliberate placement of the guidewire into the pancreatic duct may be more effective in preventing PEP. A comparison between transpancreatic sphincterotomy with deliberate guidewire placement into the pancreatic duct and needle-knife precut sphincterotomy is necessary. Early precutting is thought to be effective for the prevention of PEP, and the effectiveness of primary precut has been reported. However, the optimal timing of precut for the prevention of PEP has not been sufficiently discussed. Further research on prediction and prevention must be conducted to eliminate the mortality caused by PEP.

Practical management of severe acute pancreatitis

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

Feasibility of endoscopic submucosal dissection including papilla (with video)

OBJECTIVES

Endoscopic papillectomy (EP) is a low-invasive treatment for duodenal tumors including papilla. The limit of lesion size and local recurrence have been issues in EP. We developed endoscopic submucosal dissection (ESD) for the duodenal tumors including papilla (ESDIP: ESD including papilla) to overcome the problems. The aim of this study was to evaluate the feasibility of ESDIP.

METHODS

We included the patients who underwent ESDIP from August 2010 to January 2024 in this study. We evaluated the retrospective characteristics of patients and lesions, clinical results of ESDIP and of endoscopic retrograde cholangiopancreatography (ERCP) as prevention for delayed adverse events, and pathological findings. We also calculated the cumulative recurrence rate and overall survival rate at 12 months after ESDIP.

RESULTS

Fifty-four patients were included in this study. The mean lesion size was 39 mm. The third-quarter cases revealed a less than half-circumferential lesion, and the one case with a full-circumferential lesion. Resection was accomplished in 96% (n = 52), and also the en-bloc resection rate was 96%. Of the cases in accomplished resection, 98% of patients were intubated with a pancreaticobiliary drainage tube by ERCP. Intraprocedural perforation occurred in eight cases. Delayed bleeding occurred in 10 cases. Delayed perforation was seen only in one case. The incidence of post-ERCP pancreatitis was 25%. Cumulative local recurrence rate and the overall survival rate were 15% and 96%, respectively.

CONCLUSION

ESDIP may be feasible for duodenal tumors including papilla, and is a potential alternative option to avoid pancreaticoduodenectomy.

Oral high-carbohydrate solution as an alternative dietary modality in patients with acute pancreatitis

BACKGROUND/OBJECTIVES

Early enteral feeding is crucial in acute pancreatitis (AP) to preserve the intestinal mucosa, prevent bacterial overgrowth, and prevent progression to pancreatic necrosis, multi-organ failure, and death. However, the optimal early diet remains unclear. This study compared an oral carbohydrate solution (OCS) diet versus a conventional diet (CD) in patients with AP.

METHODS

We retrospectively enrolled 538 patients diagnosed with AP in 2018-2022: 346 received a CD and 192 received an OCS diet. Because of differences in AP severity between groups, we performed 1:1 propensity score matching to obtain comparable groups (n = 182 in each). The CD group progressed from a liquid diet to soft foods and finally solid foods. The OCS group followed the same progression but received OCS instead of a liquid diet. Primary outcomes were the rate of recurrent postprandial pain after initiating the dietary intervention and hospital length of stay (LOS). Secondary outcomes included intensive care unit admission, mortality, 28-day hospital readmission, and AP-related complications.

RESULTS

After propensity score matching, baseline characteristics of the OCS and CD groups were comparable. The rate of recurrent pain was significantly higher in the CD group than in the OCS group (13.2 % vs. 3.8 %, p < 0.001), but hospital LOS was similar between groups (CD vs. OCS: 9.2 days vs. 8.7 days, p = 0.533). There were no significant differences in secondary outcomes between groups.

CONCLUSIONS

In patients with AP, OCS diet was associated with a lower rate of recurrent postprandial pain compared to a CD. Thus, OCS appears to be a beneficial dietary alternative for initial management of AP.

Percutaneous Biopsy and Drainage of the Pancreas

Percutaneous biopsy and drainage of pancreatic lesions, though less frequent due to advancements in endoscopic techniques, remain vital skills for interventional radiologists. This review details the indications, options, approaches, and technical considerations for pancreatic biopsy and (peri)pancreatic fluid drainage by examining a comprehensive range of literature. The importance of a multidisciplinary approach is emphasized to ensure optimal patient care and outcomes, highlighting current best practices and recent advancements.

Impact of glucose-containing fluid on acute pancreatitis outcomes: A multicenter retrospective analysis

INTRODUCTION

Fluid resuscitation reduces mortality and morbidity in acute pancreatitis (AP); however, whether glucose-containing fluids negatively impact AP remains uncertain. We aimed to examine the association between glucose-containing fluids and AP outcomes.

METHODS

This multicenter retrospective cohort study included patients diagnosed with AP between January 2015 and December 2018. Glucose density was defined as total glucose content divided by total fluid volume (g/dl) on day 1, and was considered high if the level exceeded the median. Endpoints were early organ failure (OF), including cardiovascular, renal, or respiratory system failure within 7 days; 30-day OF; ICU admission; and AP-related 90-day mortality. Logistic regression models, restricted cubic spline curves, and Cox proportional hazards models were used for statistical analysis.

RESULTS

From the database, 1,146 patients with AP were included. Early OF occurred in 8.8% of patients within 7 days. The high glucose-density group (>5 g/dl) had increased risk of early OF (9.7% vs. 8.2%; adjusted odds ratio [aOR], 1.69; 95% confidence interval [CI], 1.03-2.80; P = 0.039), respiratory failure (8.0% vs. 6.2%; aOR, 1.88; 95% CI, 1.09-3.24; P = 0.024), cardiovascular failure (3.4% vs. 2.4%; aOR, 3.59; 95% CI, 1.28-10.0; P = 0.015), and ICU admission (6.8% vs. 5.8%; aOR, 2.06; 95% CI, 1.08-3.94; P = 0.029), with a dose-response effect observed for cardiovascular failure and ICU admission. A significant increase 30-day OF risk (adjusted hazard ratio [aHR], 1.70; 95% CI, 1.19-2.45) was also noted.

CONCLUSION

Excess glucose-containing fluid was associated with increased risks of overall, respiratory, and cardiovascular OF and ICU admission in AP.

Risk factors for postoperative acute pancreatitis after thoracic aortic surgery

BACKGROUND

We aimed to investigate the incidence and risk factors of postoperative acute pancreatitis (PAP) following thoracic aortic surgery with circulatory arrest.

METHODS

One hundred fifty-two patients who underwent thoracic aortic surgery with circulatory arrest between February 2015 and March 2023 were retrospectively reviewed. Postoperative acute pancreatitis was defined as the presence of two or more of the following criteria: (1) abdominal pain, (2) postoperative amylase or lipase levels greater than three times the upper limit of normal, and (3) evidence of pancreatitis on postoperative computed tomography (CT) scan. Univariate and multivariate analyses were performed to find risk factors for PAP.

RESULTS

Nine patients (5.9%) developed PAP without mortality. All of the nine patients had elevated pancreatic enzymes and evidence of pancreatitis on CT. They improved with conservative therapy. In multivariate analysis, only cross-clamp time was found to be a significant risk factor for PAP (adjusted odds ratio, 1.04; 95% confidence interval, 1-1.08; p = 0.042).

CONCLUSION

The incidence of PAP after thoracic aortic surgery with circulatory arrest was 5.9%, and cross-clamp time is an independent risk factor for PAP.

Prediction model establishment and validation for enteral nutrition aspiration during hospitalization in patients with acute pancreatitis

BACKGROUND

Acute pancreatitis (AP) is a disease caused by abnormal activation of pancreatic enzymes and can lead to self-digestion of pancreatic tissues and dysfunction of other organs. Enteral nutrition plays a vital role in the treatment of AP because it can meet the nutritional needs of patients, promote the recovery of intestinal function, and maintain the barrier and immune functions of the intestine. However, the risk of aspiration during enteral nutrition is high; once aspiration occurs, it may cause serious complications, such as aspiration pneumonia, and suffocation, posing a threat to the patient's life. This study aims to establish and validate a prediction model for enteral nutrition aspiration during hospitalization in patients with AP.

AIM

To establish and validate a predictive model for enteral nutrition aspiration during hospitalization in patients with AP.

METHODS

A retrospective review was conducted on 200 patients with AP admitted to Chengdu Shangjin Nanfu Hospital, West China Hospital of Sichuan University from January 2020 to February 2024. Clinical data were collected from the electronic medical record system. Patients were randomly divided into a validation group (n = 40) and a modeling group (n = 160) in a 1:4 ratio, matched with 200 patients from the same time period. The modeling group was further categorized into an aspiration group (n = 25) and a non-aspiration group (n = 175) based on the occurrence of enteral nutrition aspiration during hospitalization. Univariate and multivariate logistic regression analyses were performed to identify factors influencing enteral nutrition aspiration in patients with AP during hospitalization. A prediction model for enteral nutrition aspiration during hospitalization was constructed, and calibration curves were used for validation. Receiver operating characteristic curve analysis was conducted to evaluate the predictive value of the model.

RESULTS

There was no statistically significant difference in general data between the validation and modeling groups (P > 0.05). The comparison of age, gender, body mass index, smoking history, hypertension history, and diabetes history showed no statistically significant difference between the two groups (P > 0.05). However, patient position, consciousness status, nutritional risk, Acute Physiology and Chronic Health Evaluation (APACHE-II) score, and length of nasogastric tube placement showed statistically significant differences (P < 0.05) between the two groups. Multivariate logistic regression analysis showed that patient position, consciousness status, nutritional risk, APACHE-II score, and length of nasogastric tube placement were independent factors influencing enteral nutrition aspiration in patients with AP during hospitalization (P < 0.05). These factors were incorporated into the prediction model, which showed good consistency between the predicted and actual risks, as indicated by calibration curves with slopes close to 1 in the training and validation sets. Receiver operating characteristic analysis revealed an area under the curve (AUC) of 0.926 (95%CI: 0.8889-0.9675) in the training set. The optimal cutoff value is 0.73, with a sensitivity of 88.4 and specificity of 85.2. In the validation set, the AUC of the model for predicting enteral nutrition aspiration in patients with AP patients during hospitalization was 0.902, with a standard error of 0.040 (95%CI: 0.8284-0.9858), and the best cutoff value was 0.73, with a sensitivity of 91.9 and specificity of 81.8.

CONCLUSION

A prediction model for enteral nutrition aspiration during hospitalization in patients with AP was established and demonstrated high predictive value. Further clinical application of the model is warranted.

WONDER-02: plastic stent vs. lumen-apposing metal stent for endoscopic ultrasound-guided drainage of pancreatic pseudocysts-study protocol for a multicentre randomised non-inferiority trial

BACKGROUND

Endoscopic ultrasound (EUS)-guided transluminal drainage has become a first-line treatment modality for symptomatic pancreatic pseudocysts. Despite the increasing popularity of lumen-apposing metal stents (LAMSs), plastic stents may resolve non-necrotic fluid collections effectively with lower costs and no LAMS-specific adverse events. To date, there has been a paucity of data on the appropriate stent type in this setting. This trial aims to assess the non-inferiority of plastic stents to a LAMS for the initial EUS-guided drainage of pseudocysts.

METHODS

The WONDER-02 trial is a multicentre, open-label, non-inferiority, randomised controlled trial, which will enrol pancreatic pseudocyst patients requiring EUS-guided treatment in 26 centres in Japan. This trial plans to enrol 80 patients who will be randomised at a 1:1 ratio to receive either plastic stents or a LAMS (40 patients per arm). In the plastic stent group, EUS-guided drainage will be performed using two 7-Fr double pigtail stents. In the LAMS group, the treatment will be performed in the same way except for LAMS use. The step-up treatment will be performed via endoscopic and/or percutaneous procedures at the trial investigator's discretion. The primary endpoint is clinical success, which is defined as a decrease in a pseudocyst size to ≤ 2 cm and an improvement in inflammatory indicators (i.e. body temperature, white blood cell count, and serum C-reactive protein). Secondary endpoints include technical success, adverse events including mortality, pseudocyst recurrence, and medical costs.

DISCUSSION

The WONDER-02 trial will investigate the efficacy and safety of plastic stents compared to a LAMS in EUS-guided treatment of symptomatic pancreatic pseudocysts with a particular focus on the non-inferior efficacy of plastic stents. The findings will help establish a new treatment algorithm for this population.

TRIAL REGISTRATION

ClinicalTrials.gov NCT06133023 registered on 9 November 2023. UMIN000052647 registered on 30 October 2023. jRCT1032230444 registered on 7 November 2023.

A Retrospective Study on the Start and End of Continuous Hemodialysis Using a Polymethylmethacrylate Hemofilter for Severe Acute Pancreatitis

Objective We previously reported the successful outcomes in severe acute pancreatitis (SAP) after continuous hemodialysis using a polymethylmethacrylate hemofilter (PMMA-CHD). The present study makes informative suggestions regarding the initiation and termination of PMMA-CHD. Methods We retrospectively studied 63 patients with SAP admitted to the intensive care unit between January 1, 2011, and December 31, 2022, including 30 who received PMMA-CHD therapy for renal dysfunction. Statistical significance was evaluated using a multiple logistic regression analysis for severity scores, prognostic factor scores in the Japanese severity criteria, the Kidney Disease: Improving Global Outcomes (KDIGO) stage, and the lung injury score (LIS). Results At the onset of blood purification therapy using PMMA-CHD, a significant increase in the KDIGO stage was shown, with a cutoff value of 2.0. The prognostic factor score and LIS at the start of blood purification therapy were significantly high, with a cutoff value of 3.0. Analyses of severity scores, the KDIGO stage, and the LIS before the start of PMMA-CHD were also increased significantly, with cutoff values of +2.0, +1.0, and +3.0, respectively. Furthermore, on analyses of improvements in values after starting PMMA-CHD, the value of KDIGO staging significantly decreased, and the cutoff value was -2.0. The prognostic factor score was also significantly decreased, with a cutoff value of -2.0. Conclusion Prognostic factor scores of the Japanese severity criteria and LIS, as well as the KDIGO stage, are valuable indicators for determining the start and end of PMMA-CHD therapy.

Long-term follow-up study of necrotising pancreatitis: interventions, complications and quality of life

OBJECTIVE

To describe the long-term consequences of necrotising pancreatitis, including complications, the need for interventions and the quality of life.

DESIGN

Long-term follow-up of a prospective multicentre cohort of 373 necrotising pancreatitis patients (2005-2008) was performed. Patients were prospectively evaluated and received questionnaires. Readmissions (ie, for recurrent or chronic pancreatitis), interventions, pancreatic insufficiency and quality of life were compared between initial treatment groups: conservative, endoscopic/percutaneous drainage alone and necrosectomy. Associations of patient and disease characteristics during index admission with outcomes during follow-up were assessed.

RESULTS

During a median follow-up of 13.5 years (range 12-15.5 years), 97/373 patients (26%) were readmitted for recurrent pancreatitis. Endoscopic or percutaneous drainage was performed in 47/373 patients (13%), of whom 21/47 patients (45%) were initially treated conservatively. Pancreatic necrosectomy or pancreatic surgery was performed in 31/373 patients (8%), without differences between treatment groups. Endocrine insufficiency (126/373 patients; 34%) and exocrine insufficiency (90/373 patients; 38%), developed less often following conservative treatment (p<0.001 and p=0.016, respectively). Quality of life scores did not differ between groups. Pancreatic gland necrosis >50% during initial admission was associated with percutaneous/endoscopic drainage (OR 4.3 (95% CI 1.5 to 12.2)), pancreatic surgery (OR 3.2 (95% CI 1.1 to 9.5) and development of endocrine insufficiency (OR13.1 (95% CI 5.3 to 32.0) and exocrine insufficiency (OR6.1 (95% CI 2.4 to 15.5) during follow-up.

CONCLUSION

Acute necrotising pancreatitis carries a substantial disease burden during long-term follow-up in terms of recurrent disease, the necessity for interventions and development of pancreatic insufficiency, even when treated conservatively during the index admission. Extensive (>50%) pancreatic parenchymal necrosis seems to be an important predictor of interventions and complications during follow-up.

A location-based anatomic classification system for acute pancreatic fluid collections: Roadmap for optimal intervention in the step-up era

Walled-off pancreatic necrosis (WOPN) is a local complication of acute necrotizing pancreatitis frequently requiring intervention. Treatment is typically through the coordinated efforts of a multidisciplinary team. Current management guidelines recommend a step-up approach beginning with minimally invasive techniques (percutaneous or transmural endoscopic drainage) followed by escalation to more invasive procedures if needed. Although the step-up approach is an evidence-based treatment paradigm for management of pancreatic fluid collections, it lacks guidance regarding optimal invasive technique selection based on the anatomic characteristics of pancreatic fluid collections. Similarly, existing cross-sectional imaging-based classification systems of pancreatic fluid collections have been used to predict disease severity and prognosis; however, none of these systems are designed to guide intervention. We propose a novel classification system which incorporates anatomic characteristics of pancreatic fluid collections (location and presence of disconnected pancreatic duct) to guide intervention selection and clinical decision making. We believe adoption of this simple classification system will help streamline treatment algorithms and facilitate cross-study comparisons for pancreatic fluid collections.

The 2023 MANCTRA Acute Biliary Pancreatitis Care Bundle: A Joint Effort Between Human Knowledge and Artificial Intelligence (ChatGPT) to Optimize the Care of Patients With Acute Biliary Pancreatitis in Western Countries

OBJECTIVE

To generate an up-to-date bundle to manage acute biliary pancreatitis using an evidence-based, artificial intelligence (AI)-assisted GRADE method.

BACKGROUND

A care bundle is a set of core elements of care that are distilled from the most solid evidence-based practice guidelines and recommendations.

METHODS

The research questions were addressed in this bundle following the PICO criteria. The working group summarized the effects of interventions with the strength of recommendation and quality of evidence applying the GRADE methodology. ChatGPT AI system was used to independently assess the quality of evidence of each element in the bundle, together with the strength of the recommendations.

RESULTS

The 7 elements of the bundle discourage antibiotic prophylaxis in patients with acute biliary pancreatitis, support the use of a full-solid diet in patients with mild to moderately severe acute biliary pancreatitis, and recommend early enteral nutrition in patients unable to feed by mouth. The bundle states that endoscopic retrograde cholangiopancreatography should be performed within the first 48 to 72 hours of hospital admission in patients with cholangitis. Early laparoscopic cholecystectomy should be performed in patients with mild acute biliary pancreatitis. When operative intervention is needed for necrotizing pancreatitis, this should start with the endoscopic step-up approach.

CONCLUSIONS

We have developed a new care bundle with 7 key elements for managing patients with acute biliary pancreatitis. This new bundle, whose scientific strength has been increased thanks to the alliance between human knowledge and AI from the new ChatGPT software, should be introduced to emergency departments, wards, and intensive care units.

Evaluation of the therapeutic efficiency and efficacy of blood purification in the treatment of severe acute pancreatitis

This study aimed to evaluate the therapeutic efficacy and effect of blood purification (BP) therapy on severe acute pancreatitis (SAP). Information on 305 patients (BP group 68, control group 237) diagnosed with SAP was retrieved from the Medical Information Mart for Intensive Care IV (MIMIC IV) database. Firstly, the influence of BP treatment was preliminarily evaluated by comparing the outcome indicators of the two groups. Secondly, multiple regression analysis was used to screen the mortality risk factors to verify the impact of BP on the survival outcome of patients. Then, the effect of BP treatment was re-validated with baseline data. Finally, cox regression was used to make the survival curve after matching to confirm whether BP could affect the death outcome. The results indicated that the BP group had a lower incidence of shock (p = 0.012), but a higher incidence of acute kidney injury (AKI) (p < 0.001), with no differences observed in other outcome indicators when compared to the control group. It was also found that the 28-day survival curve of patients between the two groups was significantly overlapped (p = 0.133), indicating that BP treatment had no significant effect on the survival outcome of patients with SAP. Although BP is beneficial in stabilizing hemodynamics, it has no effect on short- and long-term mortality of patients. The application of this technology in the treatment of SAP should be done with caution until appropriate BP treatment methods are developed, particularly for patients who are not able to adapt to renal replacement therapy.

Efficacy of nafamostat mesylate in the prevention of pancreatitis after endoscopic retrograde cholangiopancreatography: a systematic review and meta-analysis of randomized controlled trials

We conducted a systematic review and meta-analysis to evaluate the effect of nafamostat on the prevention of post-endoscopic retrograde cholangiopancreatography (ERCP) pancreatitis (PEP). PubMed, Web of Science, and Ichushi Web were searched for randomized controlled trials (RCTs) using nafamostat to prevent PEP. In subgroup analyses, we studied the preventive effects of nafamostat according to the severity of PEP, risk category, and dose. A random-effects model was adopted; heterogeneity between studies was examined using the chi-squared test and I2 statistics. This analysis uses the PRISMA statement as general guidance. 9 RCTs involving 3321 patients were included. The risk of PEP was lower in the nafamostat group than in the control group [4.4% vs. 8.3%, risk ratio (RR): 0.50, 95% confidence interval (CI): 0.36-0.68]. In subgroup analyses, the protective effects were evident in low-risk patients for PEP before ERCP (RR: 0.34, 95% CI: 0.21-0.55). The association between PEP and nafamostat was significant only in patients who developed mild PEP (RR: 0.49; 95% CI: 0.36-0.69). The benefits were independent of the dose. The prophylactic use of nafamostat resulted in a lower risk of PEP. The subgroup analyses suggested uncertain benefits for severe PEP or high-risk patients for PEP. This warrants further investigation through additional RCTs.

Trends and clinical characteristics of pediatric acute pancreatitis patients in Japan: A comparison with adult cases based on a national administrative inpatient database

BACKGROUND

/Objectives: Pediatric acute pancreatitis (AP) is not as rare as previously thought, and an increased incidence thereof has been reported. We aimed to clarify the trends and clinical characteristics of pediatric AP in Japan.

METHODS

We utilized the Japanese Diagnosis Procedure Combination inpatient database for patients admitted between April 2012 and March 2021, and extracted the data of patients whose principal diagnosis was AP (ICD-10 code K85) or in whom AP accounted for most of the medical expenses. Patients were classified into pediatric (≤18 years) and adult (age >18 years) groups.

RESULTS

We included 3941 AP cases in pediatrics and 212,776 in adults. AP cases accounted for 0.08 % of all admissions in pediatrics and 0.33 % in adults, with upward trends during the study period. The proportion of AP patients among all admissions was increased with advancing age in pediatrics. Compared to adults, pediatric AP patients had a smaller proportion of severe cases (22.9 % vs. 28.7 %; P < 0.001), fewer interventions for late complications (0.2 % vs. 1.3 %; P < 0.001), shorter hospital stays (mean 16.6 days vs. 18.0 days; P = 0.001), lower overall mortality (0.7 % vs. 2.9 %; P < 0.001), and lower mortality in severe cases (1.3 % vs. 5.6 %; P < 0.001). Pediatric cases were more frequently transferred from other institutions and treated at academic hospitals than adults (both P < 0.001).

CONCLUSIONS

There was an upward trend in the proportion of AP among all admissions in pediatrics, with a lower risk of complications and mortality than adult cases.

Investigating COVID-19 Pandemic Effects on Acute Pancreatitis Development-From the Perspective of Alcohol Sales (Consumption) in a Japanese Regional Hospital

[Aim and Background] People's lifestyles changed considerably due to the coronavirus disease 2019 (COVID-19) pandemic. The number of patients with acute pancreatitis (AP) can be expected to decrease as alcohol consumption decreases. This study was conducted to assess COVID-19 pandemic effects on AP patients in a Japanese regional hospital. [Methods] Based on the first and second states of emergency declarations in Tochigi Prefecture, the survey periods were set as follows: period A, 16 April-14 May; period B, 15 May-13 January; period C, 14 January-7 February; and period D, 8 February-15 April. Using data acquired in 2017, 2018, 2019, and 2020, we retrospectively reviewed the number of patients admitted to our hospital with a diagnosis of AP, and their clinical characteristics. [Results] According to a National Tax Agency survey, the average alcohol sales per adult in Tochigi Prefecture were 71.3 L in 2017 before the pandemic, and 64.0 L in 2021 under the pandemic. The number of AP patients in 2020 was 38% lower than in 2017. Comparing 2017 with 2020, the number of alcoholic AP patients was lower in 2020 (p = 0.007). [Conclusions] The findings suggest that COVID-19-pandemic-related lifestyle changes contributed to the decrease in AP patients.

Inverse association of hospital volume with in-hospital mortality rate of patients receiving EUS-guided interventions for pancreatic fluid collections

BACKGROUND AND AIMS

EUS-guided interventions currently serve as first-line treatment for symptomatic pancreatic fluid collections (PFCs) but require high-level expertise and multidisciplinary care. Hospital caseload has not been fully examined in relation to clinical outcomes of patients with endoscopically managed PFCs.

METHODS

Using the Diagnosis Procedure Combination database (a Japanese nationwide inpatient database), we identified 4053 patients receiving EUS-guided treatment of PFCs at 486 hospitals between 2010 and 2020 and examined an association of hospital volume (average annual number of cases at a hospital) with in-hospital mortality. Associations with bleeding, length of stay, and total costs were examined as secondary analyses. Multivariable logistic regression analysis was conducted with adjustment for potential confounders.

RESULTS

The hospital volume was inversely associated with the risk of in-hospital mortality (Ptrend < .001). The adjusted odds ratio for in-hospital mortality comparing the extreme quintiles of hospital volume was .17 (95% confidence interval, .09-.33). A restricted cubic spline analysis yielded no statistically significant evidence on the nonlinear relationship (Pnonlinearity = .19). The types of stents (plastic vs lumen-apposing metal stent) seemed to have no effect modification on the volume-mortality relationship (Pinteraction = .58). Higher hospital volume was also associated with lower risk of bleeding, shorter length of stay, and lower medical costs of inpatient care.

CONCLUSIONS

Higher hospital volume was associated with a lower risk of in-hospital mortality of patients receiving EUS-guided treatment of PFCs. A further investigation is warranted to justify the volume-based selective referral of the patients.

Update on the strategy for intravenous fluid treatment in acute pancreatitis

Fluid therapy/resuscitation is mandatory in acute pancreatitis due to the pathophysiology of fluid loss as a consequence of the inflammatory process. For many years, without clear evidence, early and aggressive fluid resuscitation with crystalloid solutions (normal saline solution or Ringer lactate solution) was recommended. Recently, many randomized control trials and meta-analyses on fluid therapy have revealed that high fluid rate infusion is associated with increased mortality and severe adverse events compared to those resulting from moderate fluid rates, and this has triggered a paradigm shift in fluid management strategies. Meanwhile, there is evidence to show that Ringer lactate solution is superior to normal saline solutions in this context. The purpose of this review is to provide an update on the strategies for intravenous fluid treatment in acute pancreatitis, including the type, optimal amount, rate of infusion, and monitoring guides. Recommendations from recent guidelines are critically evaluated for this review in order to reach the authors' recommendations based on the available evidence.

Controversies in the management of acute pancreatitis: An update

This review summarized the current controversies in the management of acute pancreatitis (AP). The controversies in management range from issues involving fluid resuscitation, nutrition, the role of antibiotics and antifungals, which analgesic to use, role of anticoagulation and intervention for complications in AP. The interventions vary from percutaneous drainage, endoscopy or surgery. Active research and emerging data are helping to formulate better guidelines. The available evidence favors crystalloids, although the choice and type of fluid resuscitation is an area of dynamic research. The nutrition aspect does not have controversy as of now as early enteral feeding is preferred most often than not. The empirical use of antibiotics and antifungals are gray zones, and more data is needed for conclusive guidelines. The choice of analgesic is being studied, and the recommendations are still evolving. The position of using anticoagulation is still awaiting consensus. The role of intervention is well established, although the modality is constantly changing and favoring endoscopy or percutaneous drainage rather than surgery. It is evident that more multicenter randomized controlled trials are required for establishing the standard of care in these crucial management issues of AP to improve the morbidity and mortality worldwide.

Computed tomography imaging-based predictors of the need for a step-up approach after initial endoscopic ultrasound-guided transmural drainage for pancreatic fluid collections

BACKGROUND

A step-up approach is recommended as a new treatment algorithm for pancreatic fluid collections (PFCs). However, determining which patients with PFCs require a step-up approach after endoscopic ultrasound-guided transmural drainage (EUS-TD) is unclear. If the need for a step-up approach could be predicted, it could be performed early for relevant patients. We aimed to identify PFC-related predictive factors for a step-up approach after EUS-TD.

METHODS

This retrospective cohort study included consecutive patients who had undergone EUS-TD for PFCs from January 2008 to May 2020. Multivariable logistic regression analyses were performed to investigate PFC factors related to requiring a step-up approach. A step-up approach was performed for patients who did not respond clinically to EUS-TD.

RESULTS

We enrolled 81 patients, of whom 25 (30.9%) required a step-up approach. In multivariate logistic regression analysis, the pre-EUS-TD number of PFC-occupied regions ≥ 3 (multivariate odds ratio [OR] 16.2, 95% confidence interval [CI] 2.68-97.6, P = 0.002), the post-EUS-TD PFC-remaining percentage ≥ 35% (multivariate OR 19.9, 95% CI 2.91-136.1, P = 0.002), and a positive sponge sign, which is a distinctive computed tomography finding in the early stage after EUS-TD (multivariate OR 6.26, 95% CI 1.33-29.3, P = 0.020), were independent predictive factors associated with requiring a step-up approach for PFCs.

CONCLUSION

Pre-EUS-TD PFC-occupied regions, post-EUS-TD PFC-remaining percentage, and a positive sponge sign were predictors of the need for a step-up approach. Patients with PFC with these findings should be offered a step-up approach whereas conservative treatment is recommended for patients without these findings.

CLINICAL REGISTRATION NUMBER

UMIN 000030898.

Supportive treatment during the periprocedural period of endoscopic treatment for pancreatic fluid collections: a critical review of current knowledge and future perspectives

Pancreatic fluid collections (PFCs) commonly develop as complications of acute pancreatitis and ductal disruption due to chronic pancreatitis. In the revised Atlanta classification, PFCs were classified based on the presence of necrosis and duration following the onset of acute pancreatitis. Interventions are required in cases of symptomatic pancreatic pseudocysts or walled-off necrosis (WON). In the management of these PFCs, endoscopic ultrasound-guided transluminal drainage and subsequent direct endoscopic necrosectomy for WON are increasingly utilized as less invasive treatment modalities compared to surgical debridement. To date, researchers have focused predominantly on the technical aspects of endoscopic therapy for symptomatic PFCs. Given the poor physical condition of patients receiving endoscopic treatment for PFCs, systemic support may have a substantial impact on the short- and long-term outcomes of these patients. A multidisciplinary approach is required to improve the clinical outcomes of patients with infected PFCs and their associated comorbidities. However, non-interventional support during the periprocedural period of endoscopic treatment of PFCs has not been fully discussed, and there have been considerable variations in the selection of treatment options between endoscopists and centers. To address these unmet needs in the clinical management of PFCs and promote future research to improve the clinical outcomes, we conducted a review of the literature within a multicenter consortium of expert endoscopists with specific expertise in the endoscopic treatment of PFCs. In this review, we summarize the current evidence on non-interventional supportive care (e.g., continuous lavage, medications, nutritional support, and antimicrobials) and propose potential topics for future research.

Pheochromocytoma Multisystem Crisis Complicated by Severe Acute Pancreatitis

A 43-year-old man developed headache, dizziness, abdominal pain, and vomiting. His blood pressure was 203/121 mmHg, heart rate 122 beats/min, body temperature 39.1 °C, and respiratory rate 24/min. He had elevated levels of creatinine at 2.95 mg/dL and lipase at 1,364 U/L as well as an extremely low calcium level at 5.2 mg/dL. Hypertriglyceridemia and hyperglycemia were seen. Chest and abdominal computed tomography showed interstitial pneumonia, severe pancreatitis, and a right adrenal tumor. The patient also developed vertebral artery dissection and medullary infarction. After right adrenalectomy, the patient was diagnosed with pheochromocytoma multisystem crisis (PMC). Acute pancreatitis might augment numerous life-threatening manifestations of PMC.

Development of individual fitness score for conformity of prescriptions to the "Guidelines For Pharmacological Therapy of Schizophrenia"

AIMS

The Guidelines for the Pharmacotherapy of Schizophrenia were established to improve the quality of medical care, and the EGUIDE project was conducted to train clinicians on guideline usage. A quality indicator (QI) was established to measure the prevalence of the guidelines, and a survey was conducted, which revealed a gap between the guidelines and actual clinical practice (evidence-practice-gap). The purpose of this study was to develop an individual fitness score (IFS) formula that expresses the degree to which prescribers adhere to the Guidelines for Pharmacological Therapy of Schizophrenia in a simple manner, and to determine the validity of this formula from a survey of the prescriptions of the EGUIDE project participants'.

METHODS

To establish appropriate scores, members discussed the proposed formula and then voted on them. The IFS formula developed was set up so that antipsychotic monotherapy would be given 100 points, with points deducted if concomitant or adjunctive antipsychotic medications were used, and a minimum score of 0. To validate this formula, prescriptions of hospitalized schizophrenic patients at admission and at discharge were scored and compared.

RESULT

IFS points vary and ranged from 0 to100. The average pre-admission score for all subjects was 45.6, and the average score at discharge was 54, those were significantly higher during discharge.

CONCLUSIONS

We developed an IFS formula, a tool to easily visualize the degree to which current prescriptions conform to the guidelines for the pharmacological treatment of schizophrenia.

Pancreatic colonization of fungi in the development of severe acute pancreatitis

Acute pancreatitis is a common emergent disorder, a significant population of which develops the life-threatening condition, called severe acute pancreatitis (SAP). It is generally accepted that bacterial infection is associated with the development and persistence of SAP. In addition to bacterial infection, recent clinical studies disclosed a high incidence of fungal infection in patients with SAP. Moreover, SAP patients with fungal infection exhibit a higher mortality rate than those without infection. Although these clinical studies support pathogenic roles played by fungal infection in SAP, beneficial effects of prophylactic anti-fungal therapy on SAP have not been proved. Here we summarize recent clinical findings as to the relationship between fungal infection and the development of SAP. In addition, we discuss molecular mechanisms accounting for the development of SAP in the presence of fungal infection.