Severe acute pancreatitis: surgical indications and treatment

Predicting the severity of acute pancreatitis: Current approaches and future directions

Acute pancreatitis (AP) is a sudden-onset inflammatory disease of the pancreas. The severity of AP is classified into mild, moderate, and severe categories based on the presence and persistence of organ failure. Severe acute pancreatitis (SAP) can be associated with significant morbidity and mortality. It requires early recognition for appropriate timely management. Prognostic scores for predicting SAP incorporating many clinical, laboratory, and radiological parameters have been developed in the past. However, all of these prognostic scores have low positive predictive value for SAP and some of these scores require >24 h for assessment. There is a need to develop biomarkers that can accurately identify patients at risk for SAP early in the course of the presentation. In this review, we aim to provide a summary of the most commonly utilized prognostic scores for AP and discuss future directions.

Elimination of intracellular Ca2+ overload by BAPTA‑AM liposome nanoparticles: A promising treatment for acute pancreatitis

Calcium overload, a notable instigator of acute pancreatitis (AP), induces oxidative stress and an inflammatory cascade, subsequently activating both endogenous and exogenous apoptotic pathways. However, there is currently lack of available pharmaceutical interventions to alleviate AP by addressing calcium overload. In the present study, the potential clinical application of liposome nanoparticles (LNs) loaded with 1,2‑bis(2‑aminophenoxy)ethane‑N,N,N',N'‑tetraacetic acid tetrakis (acetoxymethyl ester) (BAPTA‑AM), a cell‑permeant calcium chelator, was investigated as a therapeutic approach for the management of AP. To establish the experimental models in vitro, AR42J cells were exposed to high glucose/sodium oleate (HGO) to induce necrosis, and in vivo, intra‑ductal taurocholate (TC) infusion was used to induce AP. The findings of the present study indicated that the use of BAPTA‑AM‑loaded LN (BLN) effectively and rapidly eliminated excessive Ca2+ and reactive oxygen species, suppressed mononuclear macrophage activation and the release of inflammatory cytokines, and mitigated pancreatic acinar cell apoptosis and necrosis induced by HGO. Furthermore, the systemic administration of BLN demonstrated promising therapeutic potential in the rat model of AP. Notably, BLN significantly enhanced the survival rates of rats subjected to the TC challenge, increasing from 37.5 to 75%. This improvement was attributed to the restoration of pancreatic function, as indicated by improved blood biochemistry indices and alleviation of pancreatic lesions. The potential therapeutic efficacy of BLN in rescuing patients with AP is likely attributed to its capacity to inhibit oxidative stress, prevent premature activation of zymogens and downregulate the expression of TNF‑α, IL‑6 and cathepsin B. Thus, BLN demonstrated promising value as a novel therapeutic approach for promptly alleviating the burden of intracellular Ca2+ overload in patients with AP.

Evaluating the efficacy of different volume resuscitation strategies in acute pancreatitis patients: a systematic review and meta-analysis

INTRODUCTION

Acute pancreatitis poses a significant health risk due to the potential for pancreatic necrosis and multi-organ failure. Fluid resuscitation has demonstrated positive effects; however, consensus on the ideal intravenous fluid type and infusion rate for optimal patient outcomes remains elusive.

METHODS

A comprehensive literature search was conducted using PubMed, Embase, the Cochrane Library, Scopus, and Google Scholar for studies published between 2005 and January 2023. Reference lists of potential studies were manually searched to identify additional relevant articles. Randomized controlled trials and retrospective studies comparing high (≥ 20 ml/kg/h), moderate (≥ 10 to < 20 ml/kg/h), and low (5 to < 10 ml/kg/h) fluid therapy in acute pancreatitis were considered.

RESULTS

Twelve studies met our inclusion criteria. Results indicated improved clinical outcomes with low versus moderate fluid therapy (OR = 0.73; 95% CI [0.13, 4.03]; p = 0.71) but higher mortality rates with low compared to moderate (OR = 0.80; 95% CI [0.37, 1.70]; p = 0.55), moderate compared to high (OR = 0.58; 95% CI [0.41, 0.81], p = 0.001), and low compared to high fluids (OR = 0.42; 95% CI [0.16, 1.10]; P = 0.08). Systematic complications improved with moderate versus low fluid therapy (OR = 1.22; 95% CI [0.84, 1.78]; p = 0.29), but no difference was found between moderate and high fluid therapy (OR = 0.59; 95% CI [0.41, 0.86]; p = 0.006).

DISCUSSION

This meta-analysis revealed differences in the clinical outcomes of patients with AP receiving low, moderate, and high fluid resuscitation. Low fluid infusion demonstrated better clinical outcomes but higher mortality, systemic complications, and SIRS persistence than moderate or high fluid therapy. Early fluid administration yielded better results than rapid fluid resuscitation.

Different timing for abdominal paracentesis catheter placement and drainage in severe acute pancreatitis complicated by intra-abdominal fluid accumulation

BACKGROUND

Non-surgical methods such as percutaneous drainage are crucial for the treatment of patients with severe acute pancreatitis (SAP). However, there is still an ongoing debate regarding the optimal timing for abdominal paracentesis catheter placement and drainage.

AIM

To explore the influence of different timing for abdominal paracentesis catheter placement and drainage in SAP complicated by intra-abdominal fluid accumulation.

METHODS

Using a retrospective approach, 184 cases of SAP complicated by intra-abdominal fluid accumulation were enrolled and categorized into three groups based on the timing of catheter placement: group A (catheter placement within 2 d of symptom onset, n = 89), group B (catheter placement between days 3 and 5 after symptom onset, n = 55), and group C (catheter placement between days 6 and 7 after symptom onset, n = 40). The differences in progression rate, mortality rate, and the number of cases with organ dysfunction were compared among the three groups.

RESULTS

The progression rate of group A was significantly lower than those in groups B and groups C (2.25% vs 21.82% and 32.50%, P < 0.05). Further, the proportion of patients with at least one organ dysfunction in group A was significantly lower than those in groups B and groups C (41.57% vs 70.91% and 75.00%, P < 0.05). The mortality rates in group A, group B, and group C were similar (P > 0.05). At postoperative day 3, the levels of C-reactive protein (55.41 ± 19.32 mg/L vs 82.25 ± 20.41 mg/L and 88.65 ± 19.14 mg/L, P < 0.05), procalcitonin (1.36 ± 0.51 ng/mL vs 3.20 ± 0.97 ng/mL and 3.41 ± 0.98 ng/mL, P < 0.05), tumor necrosis factor-alpha (15.12 ± 6.63 pg/L vs 22.26 ± 9.96 pg/L and 23.39 ± 9.12 pg/L, P < 0.05), interleukin-6 (332.14 ± 90.16 ng/L vs 412.20 ± 88.50 ng/L and 420.08 ± 87.65ng/L, P < 0.05), interleukin-8 (415.54 ± 68.43 ng/L vs 505.80 ± 66.90 ng/L and 510.43 ± 68.23ng/L, P < 0.05) and serum amyloid A (270.06 ± 78.49 mg/L vs 344.41 ± 81.96 mg/L and 350.60 ± 80.42 mg/L, P < 0.05) were significantly lower in group A compared to those in groups B and group C. The length of hospital stay in group A was significantly lower than those in groups B and group C (24.50 ± 4.16 d vs 35.54 ± 6.62 d and 38.89 ± 7.10 d, P < 0.05). The hospitalization expenses in group A were also significantly lower than those in groups B and groups C [2.70 (1.20, 3.55) ten-thousand-yuan vs 5.50 (2.98, 7.12) ten-thousand-yuan and 6.00 (3.10, 8.05) ten-thousand-yuan, P < 0.05). The incidence of complications in group A was markedly lower than that in group C (5.62% vs 25.00%, P < 0.05), and similar to group B (P > 0.05).

CONCLUSION

Percutaneous catheter drainage for the treatment of SAP complicated by intra-abdominal fluid accumulation is most effective when performed within 2 d of onset.

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.

Indication and Timing of Cholecystectomy in Acute Biliary Pancreatitis - Systematic Review

Acute biliary pancreatitis (ABP) poses significant challenges in determining the optimal timing and approach for cholecystectomy, particularly in mild, moderately severe, and severe forms. This article reviews the existing literature on cholecystectomy timing and its impact on outcomes in ABP. A systematic literature search yielded 41 relevant articles from PubMed and Scopus databases. In mild ABP, early cholecystectomy within 72 hours of onset is increasingly favoured due to reduced technical difficulty and lower risk of recurrent pancreatitis. Conversely, delayed cholecystectomy, although traditionally practiced, may lead to higher recurrence rates and prolonged hospital stays. For moderate severe ABP, evidence remains limited, but early cholecystectomy appears to decrease hospital stay without increasing perioperative complications. In severe ABP, consensus suggests delaying cholecystectomy until peripancreatic collections resolve, typically 6 to 10 weeks post-onset, to minimize surgical morbidity. The role of endoscopic retrograde cholangiopancreatography (ERCP) alongside cholecystectomy remains contentious, with guidelines recommending its use in specific scenarios such as cholangitis or biliary obstruction. However, routine ERCP in mild ABP lacks robust evidence and may increase complications. Challenges persist regarding the management of residual choledocholithiasis post-ABP, highlighting the need for improved diagnostic criteria and management protocols. Overall, this review underscores the evolving landscape of cholecystectomy timing in ABP and provides insights into current best practices and areas for future research.

Infected Walled-Off Necrosis Following COVID-19-Associated Acute Pancreatitis

A 54-year-old man was admitted for fever and dyspnea. He presented with severe COVID-19 pneumonia and elevated amylase and lipase levels. He received treatment for COVID-19 and possible acute pancreatitis (AP). Although pneumonia and amylase levels improved, a high-grade fever persisted. On day 39, abdominal CT revealed heterogenous liquid and non-liquid components with a well-defined wall around the pancreas, and he was diagnosed with infected walled-off necrosis (WON) after AP. It was concluded to be associated with COVID-19 because there were no identifiable causes, such as alcohol consumption, gallstones, or other viral infections. The necrotic collection and fever improved after endoscopic transgastric drainage and necrosectomy. SARS-CoV-2 is becoming recognized as a new etiological infectious factor for AP, and COVID-19-associated AP shows higher severity and mortality. Clinicians should evaluate COVID-19 patients for concomitant AP, and if it is present, they should carefully monitor the development of local complications, including WON.

Imaging after Pancreatic Surgery: Expected Findings and Postoperative Complications

Pancreatic surgery is considered one of the most technically challenging surgical procedures, despite the evolution of modern techniques. Neoplasms remain the most common indication for pancreatic surgery, although inflammatory conditions may also prompt surgical evaluation. The choice of surgical procedure depends on the type and location of the pathologic finding because different parts of the pancreas have separate vascular supplies that may be shared by adjacent organs. The surgical approach could be conventional or minimally invasive (laparoscopic, endoscopic, or robotic assisted). Because of the anatomic complexity of the pancreatic bed, perioperative complications may be frequently encountered and commonly involve the pancreatic-biliary, vascular, lymphatic, or bowel systems, irrespective of the surgical technique used. Imaging plays an important role in the assessment of suspected postoperative complications, with CT considered the primary imaging modality, while MRI, digital subtraction angiography, and molecular imaging are considered ancillary diagnostic tools. Accurate diagnosis of postoperative complications requires a solid understanding of pancreatic anatomy, surgical indications, normal postoperative appearance, and expected postsurgical changes. The practicing radiologist should be familiar with the most common perioperative complications, such as anastomotic leak, abscess, and hemorrhage, and be able to differentiate these entities from normal anticipated postoperative changes such as seroma, edema and fat stranding at the surgical site, and perivascular soft-tissue thickening. In addition to evaluation of the primary operative fossa, imaging plays a fundamental role in assessment of the adjacent organ systems secondarily affected after pancreatic surgery, such as vascular, biliary, and enteric complications. Published under a CC BY 4.0 license. Test Your Knowledge questions are available in the supplemental material. See the invited commentary by Winslow in this issue.

Ulinastatin combined with somatostatin enhances disease control and modulates serum inflammatory factors in patients with severe pancreatitis

OBJECTIVE

This study was designed to explore the effects of ulinastatin combined with somatostatin on disease control and serum inflammatory factors in patients with severe pancreatitis.

METHODS

The data of 80 patients with severe pancreatitis treated in the First Affiliated Hospital of Jiangxi Medical College from May 2020 to April 2022 were analyzed retrospectively. Among them, 36 patients treated with somatostatin alone (3 mg somatostatin added in 50 mL normal saline) on the basis of standard treatment were assigned to a control group, and the other 44 patients treated with both ulinastatin (100,000 U of ulinastatin injection added in 250 mL 5% glucose solution) and somatostatin (3 mg somatostatin added in 50 mL normal saline) were enrolled into a study group. The levels of serum inflammatory factors (interleukin-1β (IL-1β), interleukin-6 (IL-6), and soluble intercellular adhesion molecule-1 (sICAM-1)), biochemical indexes (C-reactive protein, white blood cell count, and serum amylase) and gastrointestinal function indexes (motilin and gastrin) in the two groups were analyzed and compared before and after treatment. Additionally, the alleviation of clinical symptoms, treatment response and occurrence of adverse reactions were compared between the two groups. The mortality rate of patients within 1 month after the treatment was evaluated, and the risk factors affecting the prognosis were analyzed through logistics regression.

RESULTS

Before treatment, there was no significant difference between the two groups in the levels of IL-1β, IL-6 and sICAM-1 (P>0.05), while after treatment, the levels of all three factors decreased significantly in both groups (P<0.0001), with more notable decreases in the study group than those in the control group (P<0.0001). Before treatment, the two groups were not significantly different in the levels of C-reactive protein, white blood cell count, and serum amylase (P>0.05), while after treatment, all the three levels decreased notably in both groups (P<0.0001), with notably lower levels in the study group than those in the control group (P<0.0001). Before treatment, the levels of motilin and gastrin in the two groups were not significantly different (P>0.05), while after treatment, motilin increased significantly and gastrin decreased significantly in both groups (P<0.0001), and the study group showed a notably higher motilin level and a notably lower gastrin level than the control group (P<0.0001). The study group experienced a significantly earlier disappearance time of abdominal distension and abdominal pain and a significantly shorter hospitalization time than the control group (P<0.0001). Moreover, the study group showed a notably higher overall response rate than the control group (P=0.029), and presented a notably lower incidence of adverse reactions than the control group (P=0.036). According to univariate analysis, age, onset time, Acute Physiology and Chronic Health Evaluation II score and therapeutic regimen were the factors impacting the patients' prognosis. According to logistics regression analysis, therapeutic regimen was an independent risk factor affecting the prognosis.

CONCLUSION

Compared with somatostatin alone, ulinastatin combined with somatostatin is more effective in the treatment of severe pancreatitis. The combination can substantially alleviate the inflammatory response and improve the gastrointestinal function and clinical symptoms of patients, without increasing adverse reactions. Therefore, ulinastatin combined with somatostatin is worthy of clinical promotion.

The Asociación Mexicana de Gastroenterología consensus on the diagnosis and treatment of acute pancreatitis in children and adolescents

Acute pancreatitis (AP) and recurrent acute pancreatitis (RAP) are conditions, whose incidence is apparently on the rise. Despite the ever-increasing evidence regarding the management of AP in children and adults, therapeutic actions that could potentially affect having a poor prognosis in those patients, especially in the pediatric population, continue to be carried out. Therefore, the Asociación Mexicana de Gastroenterología convened a group of 24 expert pediatric gastroenterologists from different institutions and areas of Mexico, as well as 2 pediatric nutritionists and 2 specialists in pediatric surgery, to discuss different aspects of the epidemiology, diagnosis, and treatment of AP and RAP in the pediatric population. The aim of this document is to present the consensus results. Different AP topics were addressed by 6 working groups, each of which reviewed the information and formulated statements considered pertinent for each module, on themes involving recommendations and points of debate, concerning diagnostic or therapeutic approaches. All the statements were presented and discussed. They were then evaluated through a Delphi process, with electronic and anonymous voting, to determine the level of agreement on the statements. A total of 29 statements were formulated, all of which reached above 75% agreement in the first round of voting.

Cutoff Value of Psoas Muscle Area as Reduced Muscle Mass and Its Association with Acute Pancreatitis in China

Objective

The Global Leadership Initiative on Malnutrition (GLIM) has proposed criteria for the diagnosis of malnutrition, one of which is reduced muscle mass. Computed tomography (CT) assessment of psoas muscle area (PMA) has been used to estimate muscle mass in patients, including those with acute pancreatitis (AP). The present study aimed to define the cutoff value of PMA indicative of reduced muscle mass in patients with AP and to assess the impact of reduced muscle mass on the severity and early complications of AP.

Methods

Clinical data of 269 patients with AP were analyzed retrospectively. The severity of AP was determined according to the revised Atlanta classification. PMA was evaluated by CT and used to calculate the psoas muscle index (PMI). Cutoff values for reduced muscle mass were calculated and validated. Logistic regression analysis was performed to assess the relationship between PMA and the severity of AP.

Results

PMA was a better indicator of reduced muscle mass than PMI, with cutoff values of 11.50 cm² for men and 8.22 cm² for women. Rates of local complications, splenic vein thrombosis, and organ failure were significantly higher in AP patients with low than high PMA (all p < 0.05). PMA showed good ability to predict splenic vein thrombosis in women, with an area under the receiver operating characteristic curve of 0.848 (95% confidence interval 0.768-0.909, sensitivity 100%, specificity 83.64%). Multivariate logistic regression revealed that PMA was an independent risk factor for moderately severe plus severe AP (odds ratio 5.639, p = 0.001) and severe AP (odds ratio 3.995, p = 0.038).

Conclusion

PMA is a good predictor of the severity and complications of AP. The PMA cutoff value is a good indicator of reduced muscle mass.

Acute pancreatitis: Structured report template of magnetic resonance imaging

Acute pancreatitis (AP) is a common acute abdomen disease of the digestive system. It has a potentially fatal risk because of its variable severity and various complications. With the widespread application of the Revised Atlanta Classification, new requirements for AP imaging reports are introduced. Experts in abdominal radiology and pancreatology in the United States published the first structured computed tomography reporting template for AP in 2020. However, there is no corresponding structured magnetic resonance imaging (MRI) reporting template globally. Therefore, this article focuses on the structured MRI report of AP images from our pancreatitis imaging center, which is intended to improve the systematic understanding of this disease and standardize the writing of MRI structured reports. In the meantime, we aim to promote the clinical diagnosis and assessment of MRI efficacy for AP and its multiple complications. It is further intended to facilitate academic exchanges and scientific research between different medical centers.

Severe Acute Pancreatitis Treated with Negative Pressure Wound Therapy System: Influence of Laboratory Markers

(1) Background: An open abdomen is a serious medical condition that requires prompt and effective treatment to prevent complications and improve patient outcomes. Negative pressure therapy (NPT) has emerged as a viable therapeutic option for temporary closure of the abdomen, offering several benefits over traditional methods. (2) Methods: We included 15 patients with pancreatitis who were hospitalized in the I-II Surgery Clinic of the Emergency County Hospital "St. Spiridon" from Iasi, Romania, between 2011-2018 and received NPT. (3) Results: Preoperatively, the mean IAP level was 28.62 mmHg, decreasing significantly postoperatively to 21.31 mmHg. The mean level of the highest IAP value recorded in pancreatitis patients treated with VAC did not differ significantly by lethality (30.31 vs. 28.50; p = 0.810). In vacuum-treated pancreatitis patients with a IAP level > 12, the probability of survival dropped below 50% during the first 7 days of stay in the ICU, so that after 20 days the probability of survival was approximately 20%. IAP enters the determinism of surgery with a sensitivity of 92.3% and a specificity of 99%, the cut-off value of IAP being 15 mmHg. (4) Conclusions: The timing of surgical decompression in abdominal compartment syndrome is very important. Consequently, it is vital to identify a parameter, easy to measure, within the reach of any clinician, so that the indication for surgical intervention can be made judiciously and without delay.

Institute-based nurse-led care versus home-based resistance training for patients with acute pancreatitis: Clinical outcomes analysis

Surgeries may have worse clinical outcomes in pancreatitis. In our institute surgical procedure is barely used surgery to treat pancreatitis nowadays. Chinese guidelines recommended regular exercise for severe pancreatitis. The objectives of the current study were to compare nurse-led resistance training at the institute against usual care provided to patients with acute pancreatitis for favorable clinical outcome measures. For acute pancreatitis, patients (≥18 years, of age) received 6 months of resistance training in the garden of the institute under the supervision of registered nurses (NR cohort, n = 102), or received 6 months of resistance training at their home by themselves according to a training manual (HR cohort, n = 120) or received 6 months of usual care only (UC cohort, n = 120). Fewer numbers patients died in the follow-up period in the NR cohort than those of the HR (8 vs 21, P = .0447) and the UC (8 vs 32, P = .0046) cohorts. The frequency of rehospitalization of patients due to any of the reasons in the follow-up period was fewer for patients of the NR cohort than those of the HR and the UC cohorts (P < .05 for both). Hospitalization of patients due to any of the reasons in the follow-up period was fewer for patients of the HR cohort than those of the UC cohort (P < .05). A 52 median score was the quality of life of patients before the start of the non-treatment intervention(s). After 6 months of non-treatment intervention(s), patients of the NR cohort improved their quality of life as compared to their initial quality of life (P < .001), those of HR cohort (P < .05), and those of UC cohort (P < .001). The quality of life of patients with severe pancreatitis after the surgical procedure was worse. Six months of nurse-assisted resistant training at the institute has significant improvement on the quality of life of patients in the follow-up periods of acute pancreatitis. Resistant training at the institute would improve the quality of life of patients with acute pancreatitis (Level of Evidence: IV; Technical Efficacy Stage: 5).

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

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

Decrease of Membrane B7-H5 on CD14+ Cells in Severe Acute Pancreatitis Is Related to RANSON Scores and APACHE II Scores

BACKGROUND

B7-H5 is an important ligand which is deeply involved in the immune response in various diseases. However, its clinical usefulness as an early indicator in acute pancreatitis (AP) remains unclear.

AIMS

To determine the role of B7-H5 in severe acute pancreatitis (SAP).

METHODS

Whole blood samples from patients with SAP (n = 20) and healthy donors (n = 20) were collected. Expression of soluble B7-H5 (sB7-H5) in plasma was determined by ELISA and membrane B7-H5 (mB7-H5) on the peripheral CD14+ cells was determined by flow cytometry. Peripheral blood mononuclear cells (PBMCs) were isolated from healthy donors and stimulated with serum from SAP patients, lipopolysaccharide (LPS), TNF-α, or IFN-γ, then, sB7-H5 and mB7-H5 were measured. The relationship between expression levels of mB7-H5 and clinical features of SAP patients were analyzed.

RESULTS

The expression levels of sB7-H5 in plasma were increased and the expression levels of mB7-H5 on the peripheral CD14+ cells were decreased in SAP patients. These changes of B7-H5 expression pattern in cultured PBMCs could be induced by stimulation with serum from SAP patients, LPS, TNF-α, or IFN-γ. Expression levels of mB7-H5 were negatively related to levels of hematocrit, urea nitrogen, creatinine, lactic acid, RANSON scores, and APACHE II scores.

CONCLUSION

Changes of B7-H5 expression pattern were involved in immune response of SAP. Innate immunity activation-induced decrease of mB7-H5 might be related to poor prognosis of SAP patients.

[Technological features of open and minimally invasive surgical treatment of local complications of purulent-necrotic pancreatitis]

There are various options for surgical treatment of purulent-necrotic pancreatitis with significant technological differences. Combining surgical methods other than traditional ones into a group of minimally invasive ones based on the principle of the absence of standard laparotomy is not entirely correct. The review presents modern methods of surgical treatment of acute pancreatitis, comparison of their technology regarding classical stages of surgical intervention and their classification.

Hemorheological and Microcirculatory Relations of Acute Pancreatitis

Acute pancreatitis still means a serious challenge in clinical practice. Its pathomechanism is complex and has yet to be fully elucidated. Rheological properties of blood play an important role in tissue perfusion and show non-specific changes in acute pancreatitis. An increase in blood and plasma viscosity, impairment of red blood cell deformability, and enhanced red blood cell aggregation caused by metabolic, inflammatory, free radical-related changes and mechanical stress contribute to the deterioration of the blood flow in the large vessels and also in the microcirculation. Revealing the significance of these changes in acute pancreatitis may better explain the pathogenesis and optimize the therapy. In this review, we give an overview of the role of impaired microcirculation by changes in hemorheological properties in acute pancreatitis.

Long non-coding RNA plasmacytoma variant translocation 1 correlates with higher inflammation, multiple organ injury and mortality risk in acute pancreatitis, especially in severe acute pancreatitis

BACKGROUND

Long non-coding RNA plasmacytoma variant translocation 1 (lnc-PVT1) possesses a good ability to regulate inflammation as well as multiple organ injury via multiple pathways, and clinically exacerbates severe acute pancreatitis (SAP) via autophagy. This study aimed to further assess the correlation of lnc-PVT1 with inflammation, multiple disease assessment scales, and prognostication in acute pancreatitis (AP) patients.

METHODS

Peripheral blood mononuclear cell (PBMC) samples were collected from 98 AP patients (within 24 h after admission) and 50 healthy controls (HCs). lnc-PVT1 in PBMC samples was examined by reverse transcription-quantitive polymerase chain reaction. Multiple AP assessments, C-reactive protein (CRP) level, and in-hospital deaths were evaluated or recorded.

RESULTS

lnc-PVT1 was overexpressed in AP patients compared with HCs; it was also positively correlated with Ranson's score, acute pathologic and chronic health evaluation II (APACHE II) score, sequential organ failure assessment (SOFA) score, and CRP level in AP patients. Besides, lnc-PVT1 disclosed a good predictive value for higher in-hospital mortality in AP patients (the area under the curve: 0.838, 95% confidence interval: 0.708-0.968). Lastly, lnc-PVT1 was generally correlated with CRP level as well as SOFA score among mild AP, moderate-severe AP, and SAP subgroups, especially in SAP subgroup; it was also correlated with higher mortality risk in SAP subgroup, but not in mild AP or moderate-severe AP subgroup.

CONCLUSION

lnc-PVT1 is associated with CRP level, SOFA score, and higher mortality risk in AP patients, especially in SAP patients, indicating its potential as a biomarker for AP.

Salidroside alleviates severe acute pancreatitis-triggered pancreatic injury and inflammation by regulating miR-217-5p/YAF2 axis

BACKGROUND

Our previous studies have shown that salidroside (Sal) exerted a protective effect in severe acute pancreatitis (SAP) via inhibiting the inflammatory response. However, the molecular mechanism has not been fully elucidated.

METHODS

Using SAP rat model and miRNA microarray, the effect of Sal on miRNA expression profiling was determined and then validated their changes by quantitative Real-time PCR (qRT-PCR). Then, SAP cell model, enzyme-linked immunosorbent assay (ELISA) and Cell Counting Kit-8 (CCK-8) assay were used to explore the biological function of miR-217-5p in vitro. Bioinformatics analysis, luciferase reporter assay and miRNA pulldown assay were performed to investigate the underlying mechanism of miR-217-5p in the protection of Sal against SAP.

RESULTS

Compared with SAP group, 21 differentially expressed miRNAs were identified in SAP + Sal group. The target genes of these miRNAs were strongly associated with regulation of transcription, Axon guidance, Pathways in cancer and MAPK signaling pathway. Among these miRNAs, miR-217-5p was the most downregulated miRNA. Sal treatment alleviated cell injury and reduced the production of pro-inflammatory cytokines. Whereas overexpression of miR-217-5p reversed the effects of Sal. We identified YY1 associated factor 2 (YAF2) as a direct target gene of miR-217-5p and Sal treatment could upregulate YAF2 expression via targeting miR-217-5p. Furthermore, knockdown of YAF2 counteracted Sal-induced alleviation of cell injury and inflammation. Moreover, Sal could suppress the activation of p38 MAPK pathway by regulating miR-217-5p/YAF2 axis.

CONCLUSIONS

Our findings for the first time highlighted that Sal alleviated pancreatic injury and inhibited inflammation by regulating miR-217-5p/YAF2 axis, which might provide new therapeutic strategies for SAP treatment.

Plasma metagenomic next-generation sequencing of microbial cell-free DNA detects pathogens in patients with suspected infected pancreatic necrosis

Background

Infected pancreatic necrosis (IPN) is a life-threatening complication of acute pancreatitis (AP). Timely diagnosis of IPN could facilitate appropriate treatment, but there is a lack of reliable non-invasive screening tests. In this study, we aimed to evaluate the diagnostic value of plasma metagenomic next-generation sequencing (mNGS) based on circulating microbial cell-free DNA in patients with suspected IPN.

Methods

From October 2020 to October 2021, 44 suspected IPN patients who underwent plasma mNGS were reviewed. Confirmatory diagnosis of IPN within two weeks after the index blood sampling was considered the reference standard. The confirmation of IPN relied on the microbiological results of drains obtained from the necrotic collections. The distribution of the pathogens identified by plasma mNGS was analyzed. Positive percent agreement (PPA) and negative percent agreement (NPA) were evaluated based on the conformity between the overall mNGS results and culture results of IPN drains. In addition, the clinical outcomes were compared between mNGS positive and negative patients.

Results

Across all the study samples, thirteen species of bacteria and five species of fungi were detected by mNGS. The positivity rate of plasma mNGS was 54.55% (24/44). Of the 24 mNGS positive cases, twenty (83.33%, 95% CI, 68.42–98.24%) were consistent with the culture results of IPN drains. The PPA and NPA of plasma mNGS for IPN were 80.0% (20/25; 95% CI, 64.32–95.68%) and 89.47% (17/19; 95% CI, 75.67–100%), respectively. Compared with the mNGS negative group, patients in the positive group had more new-onset septic shock [12 (50.0%) vs. 4 (20.0%), p = 0.039].

Conclusion

IPN relevant pathogens can be identified by plasma mNGS, potentially facilitating appropriate treatment. The clinical application of mNGS in this cohort appears feasible.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12879-022-07662-2.

Interventional strategies in infected necrotizing pancreatitis: Indications, timing, and outcomes

Acute pancreatitis (AP) is one of the most common gastrointestinal diseases and remains a life-threatening condition. Although AP resolves to restitutio ad integrum in approximately 80% of patients, it can progress to necrotizing pancreatitis (NP). NP is associated with superinfection in a third of patients, leading to an increase in mortality rate of up to 40%. Accurate and early diagnosis of NP and associated complications, as well as state-of-the-art therapy are essential to improve patient prognoses. The emerging role of endoscopy and recent trials on multidisciplinary management of NP established the “step-up approach”. This approach starts with endoscopic interventions and can be escalated to other interventional and ultimately surgical procedures if required. Studies showed that this approach decreases the incidence of new multiple-organ failure as well as the risk of interventional complications. However, the optimal interventional sequence and timing of interventional procedures remain controversial. This review aims to summarize the indications, timing, and treatment outcomes for infected NP and to provide guidance on multidisciplinary decision-making.

Efficacy of Glutamine in Treating Severe Acute Pancreatitis: A Systematic Review and Meta-Analysis

Objectives

The prognosis of severe acute pancreatitis (SAP) patients is closely related to early nutritional support. It is well-established that changes in glutamine (Gln), an important amino acid and nutritional supplement, can reflect disease severity. However, no consensus has been reached on the role of Gln nutrition therapy for SAP patients. We conducted this systematic review and meta-analysis to summarize and evaluate the advantages of Gln supplementation in SAP.

Methods

PubMed, Web of Science, the Embase, Cochrane Library, and Chinese databases (CNKI, SinoMed, Wanfang, and VIP) were systematically searched for eligible studies that included glutamine supplementation in SAP patients from inception to October 31 2021, excluding non-SAP studies. Primary outcome measures included mortality, APACHE II score, complications, and length of hospital stay. The meta-analysis was registered with PROSPERO (CRD42021288371) and was conducted using Review Manager and Stata softwares.

Results

This meta-analysis included 30 randomized controlled trials (RCTs) with a total of 1,201 patients. Six primary outcomes and six secondary outcomes were analyzed. For the primary outcomes, Gln supplementation was associated with lower mortality (OR = 0.38, 95% CI: 0.21-0.69, P = 0.001), total hospital stay (MD = -3.41, 95% CI: -4.93 to -1.88, P < 0.0001) and complications (OR = 0.45, 95% CI: 0.31-0.66, P < 0.0001) compared with conventional nutrition. Further subgroup analysis found that parenteral glutamine was more effective in reducing mortality. In terms of secondary outcomes, Gln supplementation helped restore liver, kidney and immune function, with significantly increased serum albumin (SMD = 1.02, 95% CI: 0.74-1.31, P < 0.00001) and IgG levels (MD = 1.24, 95% CI: 0.82-1.67, P < 0.00001), and decreased serum creatinine (Scr) (MD = -12.60, 95% CI: -21.97 to -3.24, P = 0.008), and inflammatory indicators such as C-reaction protein (CRP) (SMD = -1.67, 95% CI: -2.43 to -0.90, P < 0.0001).

Conclusion

Although Gln supplementation is not routinely recommended, it is beneficial for SAP patients. Indeed, glutamine nutrition has little effect on some indicator outcomes but contributes to improving the prognosis of this patient population.Systematic Review Registration: PROSPERO (york.ac.uk). Unique Identifier: CRD42021288371.

Construction of simple and sensitive pancreatitis related microRNA detection strategy via self-priming triggered cascade signal amplification

Pancreatic diseases, such as pancreatitis and pancreatic cancer, remain the most threatening gastrointestinal diseases with a high mortality due to atypical symptoms. MicroRNA plays crucial roles in regulating metastasis and cell proliferation of pancreatic cancer, constituting important biomarkers for the early diagnosis of pancreatic cancers. Herein, we develop a sensitive and simple exosomal miRNA detection method with only a dual-hairpin-probe. In detail, the dual-hairpin-probe is constructed through combination of two functional sections for both target miRNA identification and signal amplification. With only one probe, the method possesses the capability to avoid interferences from concentration changes of other probes, and exhibits a higher stability which is demonstrated through the obtained low coefficients of variation (CV) of 6.73%. With let-7a as detection target, the LOD of the established method is determined to be 243 aM, while maintaining a high discriminating capability towards let-7a homogenous miRNAs.

New challenges for microRNAs in acute pancreatitis: progress and treatment

Acute pancreatitis (AP) is a common clinical abdominal emergency, with a high and increasing incidence each year. Severe AP can easily cause systemic inflammatory response syndrome, multiple organ dysfunction and other complications, leading to higher hospitalization rates and mortality. Currently, there is no specific treatment for AP. Thus, we still need to understand the exact AP pathogenesis to effectively cure AP. With the rise of transcriptomics, RNA molecules, such as microRNAs (miRNAs) transcribed from nonprotein-coding regions of biological genomes, have been found to be of great significance in the regulation of gene expression and to be involved in the occurrence and development of many diseases. Increasing evidence has shown that miRNAs, as regulatory RNAs, can regulate pancreatic acinar necrosis and apoptosis and local and systemic inflammation and play an important role in the development and thus potentially the diagnosis and treatment of AP. Therefore, here, the current research on the relationship between miRNAs and AP is reviewed.

Effects of imipenem combined with glutamine in the treatment of severe acute pancreatitis with abdominal infection in mainland China: a meta-analysis

OBJECTIVE

The aim of this study was to explore the efficacy of imipenem combined with glutamine in the treatment of severe acute pancreatitis with abdominal infection in mainland China using meta-analysis.

METHODS

We searched China National Knowledge Network, Wanfang Medical Network, Chinese Science Citation Database, PubMed, and Embase Databases for publications of imipenem combined with glutamine in the treatment of severe acute pancreatitis abdominal infection. The search time limit was from the establishment of the database to April 10, 2021. Stata software version 12.0 was used for statistical analysis; the combined effect size odds ratio and standardized mean difference values were calculated for the count data and measurement data, respectively; and the heterogeneity test was performed in this study.

RESULTS

A total of five randomized controlled trials were included. A total of 499 cases were included, with 251 in the observation group and 248 in the control group. Meta-analysis results showed that the efficacy of imipenem combined with glutamine in the treatment of severe acute pancreatitis with abdominal infection was significantly better than that of imipenem alone (odds ratio=0.78, 95%CI 0.71-0.86, p=0.040).

CONCLUSION

Imipenem combined with glutamine can significantly improve the efficacy in the treatment of severe acute pancreatitis with abdominal cavity infection.

Management of pancreatic walled-off necrosis using an ultrasonic pneumatic lithotripsy system and double-catheter aspirated lavage performed through drainage tract: a case report

Patients with pancreatic walled-off necrosis (WON) treated by minimally invasive approaches often require repeated necrosectomy instead of conventional open necrosectomy. A 55-year-old woman with lateral infected pancreatic WON was successfully treated by an infrequently used technique involving an ultrasonic pneumatic lithotripsy system (UPLS) and double-catheter aspirated lavage through a percutaneous drainage tract. No perioperative complications occurred. The mean operating time of the repeated procedures was 35 minutes (range, 25–48 minutes). The total hospitalization stay was 46 days, and no recurrence of the fluid collection was observed during the 15-month follow-up period. UPLS-assisted necrosectomy and double-catheter aspirated lavage is an alternative technique for lateral WON that fails to improve by percutaneous drainage. It efficiently combines disintegration and aspiration procedures and can be safely repeated under total intravenous anesthesia through sinus tracts.

Acute Responses to Infectious and Inflammatory Disorders of the Gastrointestinal System

Infectious and inflammatory disorders of the gastrointestinal system are life-threatening and occur frequently in hospitalized adults. Inflammatory and inflammation-related diseases of the gastrointestinal tract seen in the acutely and critically ill have numerous causes. In acute pancreatitis and toxic infections caused by the bacterium Clostridium difficile, where severe infections can develop, inflammation plays a causative and crucial role. Severe acute pancreatitis puts a patient at risk for infected necrosis, which can result in septicemia and shock. Similarly, patients treated with antibiotics are at risk for C difficile colitis, which can progress to toxic megacolon. These conditions require volume resuscitation and interventions supported by current evidence. Percutaneous or surgical interventions are often undertaken at a critical point in these illnesses. Patients who require surgery for these diagnoses present challenges for the interprofessional team. Inflammatory and infectious disorders often can lead to complications of systemic inflammatory response syndrome, sepsis, and multiorgan failure. New strategies are on the horizon to prevent the onset of and improve care for patients with severe acute pancreatitis, fulminant C difficile infection, and megacolon.

Effects of Indwelling Pleural Catheter on Severe Acute Pancreatitis: A Retrospective Study

Background. Pleural effusion (PE) is an important predictor for severity and prognosis of severe acute pancreatitis (SAP). However, there are few studies focused on the effects and timing of indwelling pleural catheter (IPC) on SAP. Considering this, we designed a retrospective study to verify the relationship between PE and severity of SAP and observe the effects and timing of IPC in SAP. Methods. A total of 309 SAP patients were enrolled. Based on the presence or absence of PE and IPC and IPC time, the enrolled patients were divided into 6 groups. Then, baseline parameters, disease severity, critical complications, ventilator supporting time (VST), length of stay (LOS), and 60-day mortality were compared between each two groups. Results. PE was a risk factor for death of SAP, but not an independent risk factor. SAP patients with PE rather without PE had higher critical complication rates ( $p<0.001$ ), along with longer VST ( $p<0.001$ ) and LOS ( $p<0.001$ ). And the critical complication rates were lower in group 1 (IPC within 1 week of onset) than group 2 (IPC after 1 week of onset). Further, patients in group 1 also had shorter LOS ( $p=0.042$ ) and VST ( $p=0.001$ ) than those in group 2. In addition, the survival analysis showed the risk of death in the PE group was higher than the non-PE group (HR 6.6, 95% CI, 3.67–11.86, and $p<0.001$ ). And the risk of death in group 1 was lower than group 2 (HR 0.26, 95% CI, 0.08–0.84, and $p=0.025$ ). Conclusions. PE is a risk factor for death of SAP, but not an independent risk factor. IPC, especially IPC within 1 week of onset, has clinical practical value in SAP.

Transfistulous endoscopic sequestrectomy in the treatment of infected pancreatic necrosis

OBJECTIVE

To develop an effective minimally invasive method for the treatment of infected pancreatic necrosis.

MATERIAL AND METHODS

There were 168 patients with infected pancreatic necrosis who were treated at the Regional Clinical Hospital No. 2 between 2011 and 2018. Eighty-seven (51.8%) patients underwent primary drainage with large-diameter double-lumen drains 28-32 Fr, and original technique of transfistulous endoscopic sequestrectomy was used. Puncture-drainage interventions with transfistulous endoscopic sequestrectomy were used in 23 (26.4%) patients with local and 64 (73.6%) patients with widespread purulent-necrotic parapancreatitis.

RESULTS

Percutaneous channels are accesses to purulent-necrotic cavity and used for transfistulous endoscopic sequestrectomy. This procedure was performed 98 times. Time of primary sanitation in patients with 3 accesses in omental bursa was significantly less compared to 2 accesses (62±4.3 vs. 89±8.2 min, p<0.05). In case of repeated sanitation, time of intervention did not depend on the number of accesses. Incidence of local complications was 9.1%, extra-abdominal complications - 19.4%. Mortality rate was 12.6%.

CONCLUSION

Original technique of transfistulous endoscopic sequestrectomy increases efficiency of sanitation of infected parapancreatitis, improves treatment outcomes and reduces mortality to 12.3%.

Percutaneous catheter drainage of pancreatic associated pathologies: A systematic review and meta-analysis

PURPOSE

The main goal of this systematic review was to assess the technical and clinical success, adverse events (AEs), surgery, and overall mortality proportion after percutaneous catheter drainage (PCD) of two pancreatic lesions.

METHODS

An extant search in online databases including Scopus, PubMed (Medline), Embase (Elsevier), Web of Science, Cochrane library, and Google Scholar, was conducted to recognize all studies that used PCD intervention in the management of pancreatic necrosis (PN) and pancreatic pseudocysts (PP). Random effects meta-analysis was performed, and Cochrane's Q test and I²statistic were utilized to determine heterogeneity. In addition, meta-regression was used to explore the influence of categorical variables on heterogeneity.

RESULTS

Thirty-two studies (1398 patients) including PN in 26 (1256 cases, 89.8%) studies and PP in 6 (142 cases, 10.2%) studies were identified. Technical success proportion was 100% (95% confidence interval [CI] 100%-100%, I²: 0.0%), clinical success 63% (95% CI 55%-71%, I²: 92.9%), AEs 26% (95% CI 21%-31%, I²: 78%), surgery after PCD intervention 33% (95% CI 25%-40%, I²: 92.4%), and overall mortality was 13% (95% CI 9%-17%, I²: 82.8%). The most common ADs after PCD intervention were development of fistula (106, 42.6%), hemorrhage (44, 17.7%), sepsis (40, 16.1%).

CONCLUSION

A significant clinical success proportion with low AEs, surgery, and overall mortality proportion after PCD intervention was found, although the results should be interpreted with caution due to the high heterogeneity.

Astaxanthin Inhibits Interleukin-6 Expression in Cerulein/Resistin-Stimulated Pancreatic Acinar Cells

Acute pancreatitis is a common clinical condition with increasing the proinflammatory mediators, including interleukin-6 (IL-6). Obesity is a negative prognostic factor in acute pancreatitis. Obese patients with acute pancreatitis have a higher systemic inflammatory response rate. Levels of serum resistin, an adipocytokine secreted by fat tissues, increase with obesity. Cerulein, a cholecystokinin analog, induces calcium (Ca²⁺) overload, oxidative stress, and IL-6 expression in pancreatic acinar cells, which are hallmarks of acute pancreatitis. A recent study showed that resistin aggravates the expression of inflammatory cytokines in cerulein-stimulated pancreatic acinar cells. We aimed to investigate whether resistin amplifies cerulein-induced IL-6 expression and whether astaxanthin (ASX), an antioxidant carotenoid with anti-inflammatory properties, inhibits ceruelin/resistin-induced IL-6 expression in pancreatic acinar AR42J cells. We found that resistin enhanced intracellular Ca²⁺ levels, NADPH oxidase activity, intracellular reactive oxygen species (ROS) production, NF-κB activity, and IL-6 expression in cerulein-stimulated AR42J cells, which were inhibited by ASX in a dose-dependent manner. The calcium chelator BAPTA-AM inhibited cerulein/resistin-induced NADPH oxidase activation and ROS production. Antioxidant N-acetyl cysteine (NAC) and ML171, a specific NADPH oxidase 1 inhibitor, suppressed cerulein/resistin-induced ROS production, NF-κB activation, and IL-6 expression. In conclusion, ASX inhibits IL-6 expression, by reducing Ca²⁺ overload, NADPH oxidase-mediated ROS production, and NF-κB activity in cerulein/resistin-stimulated pancreatic acinar cells. Consumption of ASX-rich foods could be beneficial for preventing or delaying the incidence of obesity-associated acute pancreatitis.