Therapeutic intervention and surgery of acute pancreatitis

Comparative safety assessment of nasogastric versus nasojejunal feeding initiated within 48 hours post-admission versus unrestricted timing in moderate or severe acute pancreatitis: a systematic review and meta-analysis

BACKGROUND

The primary objective of this study is to comparatively assess the safety of nasogastric (NG) feeding versus nasojejunal (NJ) feeding in patients with acute pancreatitis (AP), with a special focus on the initiation of these feeding methods within the first 48 h of hospital admission.

METHODS

Studies were identified through a systematic search in PubMed, EMbase, Cochrane Central Register of Controlled Trials, and Web of Science. Four studies involving 217 patients were included. This systematic review assesses the safety and efficacy of nasogastric versus nasojejunal feeding initiated within 48 h post-admission in moderate/severe acute pancreatitis, with a specific focus on the timing of initiation and patient age as influential factors.

RESULTS

The results showed that the mortality rates were similar between NG and NJ feeding groups (RR 0.86, 95% CI 0.42 to 1.77, P = 0.68). Significant differences were observed in the incidence of diarrhea (RR 2.75, 95% CI 1.21 to 6.25, P = 0.02) and pain (RR 2.91, 95% CI 1.50 to 5.64, P = 0.002) in the NG group. The NG group also showed a higher probability of infection (6.67% vs. 3.33%, P = 0.027) and a higher frequency of multiple organ failures. Subgroup analysis for early intervention (within 48 h) showed a higher risk of diarrhea in the NG group (RR 2.80, P = 0.02). No significant differences were found in the need for surgical intervention, parenteral nutrition, or success rates of feeding procedures.

CONCLUSION

This meta-analysis highlights the importance of considering the method and timing of nutritional support in acute pancreatitis. While NG feeding within 48 h of admission increases the risk of certain complications such as diarrhea and infection, it does not significantly impact mortality or the need for surgical intervention.

Not All Fluid Collections Are Created Equal: Clinical Course and Outcomes of Pancreatic Pseudocysts and Acute Peripancreatic Fluid Collections Requiring Intervention

Background

Knowledge on pancreatic pseudocyst (PP) management has mostly involved large database analysis, which limits understanding of a complex and heterogeneous disease. We aimed to review the clinical course and outcomes of PP and acute peripancreatic fluid collections (APFC) that require intervention at 1 high-volume center.

Methods

Retrospective review of patients with APFC and PP undergoing drainage (2011-2018) was performed. Patients were divided into groups based on initial intervention: surgical (SR), percutaneous (PC), or endoscopic (EN) drainage. Primary outcome was mortality by initial intervention type. Secondary outcomes included subsequent interventions required, length of stay (LOS), readmission rates, and discharge disposition.

Results

Of 88 patients, 40 (46.1%) underwent SR, 40 (44.9%) PC, and 8 (9.0%) EN. No patients in EN group had APACHE II scores>20. Pancreatic necrosis was higher in SR (80.5%) and PC (62.5%) groups ( P = .006). There were no differences in mortality, LOS, or readmission rates. Ten patients in the PC group underwent subsequent surgical intervention, of which 9 were due to bowel ischemia. The PC group was 3.4 times more likely to be discharged to rehabilitation over home when compared to the other 2 groups ( P = .04).

Conclusion

Patients undergoing surgical or percutaneous drainage of APFC and PP have a greater burden of illness and more local complications requiring intervention compared to endoscopic drainage. The heterogeneity in presentation of peripancreatic fluid collections in acute pancreatitis must be considered when evaluating the benefits of each intervention.

The role of endoscopic therapy in the minimally invasive management of pancreatic necrosis

Pancreatic necrosis is among the most frequently encountered local complications of acute pancreatitis and associates with severe disease. Infected pancreatic necrosis further enhances the risk for morbidity and mortality. Pancreatic fluid collections that result from pancreatic necrosis evolve from acute necrotic collections to walled off necrosis and are defined by their distinct characteristics on cross sectional imaging. A variety of interventions spanning multiple disciplines are available for the drainage and debridement of pancreatic necrosis. Prospective, randomized trials have identified management strategies that incorporate minimally invasive interventions as having the best outcomes for patients with symptomatic pancreatic necrosis. The scientific literature has confidently positioned endoscopic drainage and necrosectomy among the most effective interventions for patients with symptomatic walled off necrosis. Innovations such as the use of metallic stents, chemical debridement and multiple modalities for drainage of pancreatic necrosis show promise in improving outcomes for patients managed with endoscopic interventions.

Analysis of a Step-Up Approach Versus Primary Open Surgical Necrosectomy in the Management of Necrotizing Pancreatitis: Experience in a Cohort of Patients at a US Academic Medical Center

OBJECTIVES

An increasing number of providers have begun to use a minimally invasive step-up approach as opposed to traditional surgical necrosectomy in the management of acute necrotizing pancreatitis. Studies have shown mixed results, thus we hypothesized that the step-up approach is safer and associated with decreased mortality and length of stay (LOS).

METHODS

This is a retrospective cohort study of patients admitted from January 2010 to March 2015 who underwent interventions for walled-off pancreatic necrosis (WOPN). Primary outcomes included LOS after intervention and mortality, in-hospital and 90-day, with secondary outcomes of procedural complications.

RESULTS

Sixty-nine patients developed WOPN requiring intervention during the study period. In-hospital mortality was 5.6% (n = 2) in the step-up cohort compared with 18.2% (n = 6) in the surgical cohort (relative risk, 3.27; 95% confidence interval, 0.71-15.09). Ninety-day mortality was 9.1% (n = 3) in the step-up cohort and 21.9% (n = 7) in the surgical cohort (relative risk, 2.41; 95% confidence interval, 0.68-8.50). Postintervention LOS was 8 days in the step-up cohort and 17 days in the surgical cohort (P = 0.62).

CONCLUSIONS

A step-up approach, as compared with primary surgical necrosectomy in the management of WOPN, results in clinically significant decreases in mortality and LOS.

Weekend Effect in Acute Pancreatitis-Related Hospital Admissions in the United States: An Analysis of the Nationwide Inpatient Sample

OBJECTIVE

This study aimed to assess the difference in overall outcomes between weekend admissions for acute pancreatitis (AP) and weekday admissions.

METHODS

Between 2005 and 2012, data were extracted from the Nationwide Inpatient Sample on adult patients with AP. Exclusion criteria were applied for chronic pancreatitis and other pancreatic and biliary malignancies. In-hospital mortality, length of stay, hospitalization costs, comorbidities, complications, and intervention rates were compared between the weekend and weekday admissions.

RESULTS

During the study period, there were a total of 432,303 weekday admissions and 147,435 weekend admissions for AP in the United States hospitals. Weekend AP admissions were more likely to develop alcohol withdrawal (5.9% vs 5.7%, P = 0.001) and ileus (4.1% vs 3.1%, P = 0.04). They were also more likely to develop acute respiratory distress syndrome (4.7% vs 4.4%, P < 0.001) and required more endotracheal intubation (3.9% vs 3.6%, P < 0.001). There was no significant in-hospital mortality difference between the weekend and weekday admissions on both univariate and multivariate analysis.

CONCLUSIONS

Weekend AP admissions develop more severe complications requiring intensive care. Despite this, there was no weekend effect for in-hospital mortality for AP-related admissions.

Update: Role of surgery in acute necrotizing pancreatitis

Acute necrotizing pancreatitis is a prevalent disease with high morbidity and mortality. The development of radiologic and endoscopic techniques to manage pancreatic necrosis commands a multidisciplinary approach, which has considerably decreased the need for laparotomy. The objective of this update is to define the role of surgery in the multidisciplinary approach to management of necrotizing acute pancreatitis.

Mortality and morbidity in necrotizing pancreatitis managed on principles of step-up approach: 7 years experience from a single surgical unit

AIM

To determine percentage of patients of necrotizing pancreatitis (NP) requiring intervention and the types of interventions performed. Outcomes of patients of step up necrosectomy to those of direct necrosectomy were compared. Operative mortality, overall mortality, morbidity and overall length of stay were determined.

METHODS

After institutional ethics committee clearance and waiver of consent, records of patients of pancreatitis were reviewed. After excluding patients as per criteria, epidemiologic and clinical data of patients of NP was noted. Treatment protocol was reviewed. Data of patients in whom step-up approach was used was compared to those in whom it was not used.

RESULTS

A total of 41 interventions were required in 39% patients. About 60% interventions targeted the pancreatic necrosis while the rest were required to deal with the complications of the necrosis. Image guided percutaneous catheter drainage was done in 9 patients for infected necrosis all of whom required further necrosectomy and in 3 patients with sterile necrosis. Direct retroperitoneal or anterior necrosectomy was performed in 15 patients. The average time to first intervention was 19.6 d in the non step-up group (range 11-36) vs 18.22 d in the Step-up group (range 13-25). The average hospital stay in non step-up group was 33.3 d vs 38 d in step up group. The mortality in the step-up group was 0% (0/9) vs 13% (2/15) in the non step up group. Overall mortality was 10.3% while post-operative mortality was 8.3%. Average hospital stay was 22.25 d.

CONCLUSION

Early conservative management plays an important role in management of NP. In patients who require intervention, the approach used and the timing of intervention should be based upon the clinical condition and local expertise available. Delaying intervention and use of minimal invasive means when intervention is necessary is desirable. The step-up approach should be used whenever possible. Even when the classical retroperitoneal catheter drainage is not feasible, there should be an attempt to follow principles of step-up technique to buy time. The outcome of patients in the step-up group compared to the non step-up group is comparable in our series. Interventions for bowel diversion, bypass and hemorrhage control should be done at the appropriate times.

Specialized Imaging and Procedures in Pediatric Pancreatology: A North American Society for Pediatric Gastroenterology, Hepatology, and Nutrition Clinical Report

OBJECTIVES

An increasing number of children are being diagnosed with pancreatitis and other pancreatic abnormalities. Dissemination of the information regarding existing imaging techniques and endoscopic modalities to diagnose and manage pancreatic disorders in children is sorely needed.

METHODS

We conducted a review of the medical literature on the use of the following imaging and procedural modalities in pediatric pancreatology: transabdominal ultrasonography (TUS), computed tomography (CT), magnetic resonance imaging (MRI)/magnetic resonance cholangiopancreatography (MRCP), endoscopic ultrasonography (EUS), and endoscopic retrograde cholangiopancreatography (ERCP). Recommendations for current use and future research were identified.

RESULTS

TUS offers noninvasive images of the pancreas but has limitations to details of parenchyma and ductal structures. CT offers improved detail of pancreatic parenchyma, solid masses, and traumatic injuries, but requires relatively high levels of ionizing radiation and does not adequately assess ductal anatomy. MRI/MRCP offers detailed intrinsic tissue assessment and pancreatic ductal characterization, but requires longer image acquisition time and is relatively poor at imaging calcifications. EUS provides excellent evaluation of pancreatic parenchyma and ductal anatomy, but can be subjective and operator dependent and requires sedation or anesthesia. EUS offers the capacity to obtain tissue samples and drain fluid collections and ERCP offers the ability to improve drainage by performing sphincterotomy or placing pancreatic stents across duct injuries and strictures.

CONCLUSIONS

Various imaging modalities may be used in pediatric pancreatology, but TUS and MRI/MRCP are favored. Interventional therapeutic maneuvers primarily involve use of ERCP and EUS. Future research is necessary to optimize equipment, expertise, and appropriate indications.

Asian consensus statements on endoscopic management of walled-off necrosis Part 1: Epidemiology, diagnosis, and treatment

Walled-off necrosis (WON) is a relatively new term for encapsulated necrotic tissue after severe acute pancreatitis. Various terminologies such as pseudocyst, necroma, pancreatic abscess, and infected necrosis were previously used in the literature, resulting in confusion. The current and past terminologies must be reconciled to meaningfully interpret past data. Recently, endoscopic necrosectomy was introduced as a treatment option and is now preferred over surgical necrosectomy when the expertise is available. However, high-quality evidence is still lacking, and there is no standard management strategy for WON. The consensus meeting aimed to clarify the diagnostic criteria for WON and the role of endoscopic interventions in its management. In the Consensus Conference, 27 experts from eight Asian countries took an active role and examined key clinical aspects of WON diagnosis and endoscopic management. Statements were crafted based on literature review and expert opinion, employing the modified Delphi method. All statements were substantiated by the level of evidence and the strength of the recommendation. We created 27 consensus statements for WON diagnosis and management, including details of endoscopic procedures. When there was not enough solid evidence to support the statements, this was clearly acknowledged to facilitate future research. Proposed management strategies were formulated and are illustrated using flow charts. These recommendations, which are based on the best current scientific evidence and expert opinion, will be useful for guiding endoscopic management of WON. Part 1 of this statement focused on the epidemiology, diagnosis, and timing of intervention.

[Optimization of antisecretory component of severe acute pancreatitis intensive management]

AIM

Improvement of complex intensive care of severe acute pancreatitis with use of continued intravenous infusion of octreotid.

METHODS

85 patients with severe acute pancreatitis were involved into the investigation, were divided into 2 groups. Patients of the control group (44 patients) got an intensive care according to severe acute pancreatitis treatment. Complex intensive treatment of the group of comparison (41 patients) included injections of octreotid (300 mcg 3 times a day).

RESULTS

The change of octreotid usege scheme allowed to improve treatment resultes, wchis is the decrease of endotoxemia level and minimization of time spent at emergency department.

[Surgical Site Infections after Open Appendectomy and Effectiveness of Complex Approach to Their Prevention]

AIM

To assess an incidence rate of surgical site infections (SSI) after open appendectomy and effectiveness of combined preventive measures (CPM).

MATERIAL AND METHODS

This study was performed at three surgical departments of Smolensk hospitals. A total of 150 consecutive patients (50 at each department) hospitalized since January 2012 were included into the retrospective observation (period I). In order to perform prospective evaluation of CPM, a total of 66 consecutive patients (randomized 1:1) hospitalized since December 2012 (period II) were followed up at each of the departments. Antibiotic prophylaxis (AP) with IV amoxicillin/clavulanate (1.2 g) was planned for all patients from period II. The study group (group 1) included patients with surgical wound closure with triclosan-coated polyglactin 910 and additionally with a skin 2-octylcyanoacrylate-based adhesive. The control group (group 2) included patients with surgical wound closure with non-triclosan-coated polyglactin 910. Each patient from the period II was assigned to an "Individual SSI Prevention Package" (IPP), which included an antibiotic, sutures, skin adhesive (only in a package for CPM) and label "AP" for patients' medical records. Patients' medical records were reviewed by one expert. Exclusion criteria were: age <14 years; transition to midline laparotomy; drainage of the abdominal cavity through the surgical wound; simultaneous interventions; secondary appendicitis; refusal to use of sutures from the IPP. In order to determine signs of SSI presence/absence within 30 days after surgery, attempts to contact with patients by phone were made. The data obtained was recorded into case report forms and then entered into the study database.

RESULTS

A total of 322 patients were included into the final analysis (mean age: 34.8±17.1 years). The mean length of hospital stay was 8.2±2.5 days. The mean duration of hospital stay with or without SSI was 7.9±1.8 and 14.2±4.0 days, respectively (p<0.001). The AP during the periods I and II was performed in 56.1% (83/148) and 97.7% (170/174) of patients, respectively (p<0.00001). Cephalosporins I-IV were the most frequently used antibiotics during the period I (85.6%). During the period II, amoxicillin/clavulanate from IPP was used in 98.2% of patients. Percentage of IV antibiotic administration in different time periods was 57.3% and 98.2%, respectively (p<0.0001); frequency of the first administration before skin incision was 53.6% and 97.1%, respectively (p<0.0001). The telephone contact with patient was successful in 74.8% (both periods), 56.8% (period I) and 90.2% (period II) of cases, respectively. SSI was recorded only once per patient with the following priority: SSI was documented in the patient's medical record; patient developed SSI that was not documented (in the expert's opinion) in the patient's medical record; SSI signs were determined during the telephone contact or reported by the patient. The incidence of SSI in both study periods, period I and period II was 14.9%, 15.5% and 14.4%, respectively (p>0.05 for all comparisons). In the patient subgroup with successful telephone contact, the incidence of SSI in both study periods, period I and period II was 17.4%, 21.4% and 15.3%, respectively; the incidence of SSI in group 1 and group 2 of the period II was 12.0% and 18.9%, respectively (p>0.05 for all comparisons).

CONCLUSION

SSI after an open appendectomy remains an important problem. In order to determine a true incidence of SSI, it is necessary to improve the national nosocomial infection surveillance system. The CMP used in the study have showed a trend to significant SSI risk reduction and may be recommended to maximize patient protection. Further large studies are needed to confirm effectiveness of the proposed CMP.

Time Trend of Outcomes for Severe Acute Pancreatitis After Publication of Japanese Guidelines Based on a National Administrative Database

OBJECTIVES

This study aimed to investigate the recent time trend of outcomes for severe acute pancreatitis after publication of Japanese guidelines based on a national administrative database.

METHODS

A total of 10,400 patients with severe acute pancreatitis were referred to 1021 hospitals between 2010 and 2012 in Japan. We collected patients' data from the administrative database to compare in-hospital mortality (within 28 days and overall), length of stay (LOS), and medical costs during hospitalization. The study periods were categorized into 3 groups according to fiscal year: 2010 (n = 2698), 2011 (n = 3842), and 2012 (n = 3860).

RESULTS

In-hospital mortality within 28 days and overall in-hospital mortality were significantly decreased according to fiscal year (6.3% [2010] vs 5.7% [2011] vs 4.5% [2012], P = 0.005; 7.6% vs 7.1% vs 5.6%, P = 0.002, respectively). However, mean LOS and medical costs were not different between fiscal years (27.0 vs 27.1 vs 26.9 days, P = 0.218; 13,998.0 vs 14,156.4 vs 14,319.2 USD, P = 0.232, respectively).

CONCLUSIONS

This study shows that mortality of severe acute pancreatitis was reduced according to the time course, whereas LOS or medical costs were stable after publication of the Japanese guidelines.

Revised Japanese guidelines for the management of acute pancreatitis 2015: revised concepts and updated points

BACKGROUND

Taking together the recent dramatic changes of the revised Atlanta classification and evidence newly obtained such as the role of step-up approach for necrotizing pancreatitis, the revision committee of the Japanese (JPN) Guidelines 2015 was prompted to perform an extensive revision of the guidelines.

METHODS

The JPN Guidelines 2015 was compared to the former edition 2010, and revision concepts and major revision points were reviewed. We compared the JPN 2015 with the other two guidelines, International Association of Pancreatology (IAP)/American Pancreas Association (APA) 2013 and American College of Gastroenterology (ACG) 2013, in order to clarify the distinct points.

RESULTS

The meta-analysis team conducted a new meta-analysis of four subjects that have been associated with conflicting results. It is apparent that the revised guidelines have been created more systematically and more objectively. As of antibiotics prophylaxis, its use in early phase (within 72 h of onset) for severe acute pancreatitis is recommended in JPN 2015 according to the results of original meta-analysis, whereas the other two guidelines do not recommend its routine use. An approach and management of local complications in necrotizing pancreatitis including infected necrosis are almost similar in the three guidelines. JPN 2015 alone emphasizes the implementation of the pancreatitis bundles that specify the management and treatment within the first 48 h after the onset of severe acute pancreatitis.

CONCLUSION

The JPN Guidelines 2015 prove to be the highest quality in terms of systematic literature review conducting original analyses by the meta-analysis team, determining the grading of recommendations and providing pancreatitis bundles.

Acute pancreatitis as a complication of childhood cancer treatment

Acute pancreatitis (AP) is now well recognized as a possible complication of childhood cancer treatment, interrupting the chemotherapy regimen, and requiring prolonged hospitalization, possibly with intensive care and surgical intervention, thereby compromising the effect of chemotherapy and the remission of the underlying malignant disease. This review summarizes the current literature and presents the various etiological factors for AP during chemotherapy as well as modern trends in the diagnosis and therapy of AP in children.

Acute Pancreatitis Classifications: Basis and Key Goals

To explore the efficacy of the revised Atlanta classification (RACAP) and the determinant-based classification of acute pancreatitis severity (DBCAPS) on the basis of clinical data and feedback from patients with acute pancreatitis (AP). The authors retrospectively investigated a total of 573 patients with AP admitted to our hospital between December 2011 and December 2014. The definitions of severity and local complications in AP using RACAP and DBCAPS are presented and common points and mutual differences between the 2 groups are analyzed and discussed. Classification according to RACAP and DBCAPS found 86 (15%) and 178 (31.1%) mild cases (P < 0.01), 269 (46.9%) and 176 (30.7%) moderate cases (P < 0.01), and 218 (38.0%) and 219 (38.2%) severe cases (P = 0.95), respectively. A major contribution of DBCAPS is the introduction of a new type of severe AP, critical AP, identified in 4 patients (0.7%). Complications were observed in 313 RACAP-defined cases and 153 DBCAPS-defined cases (P < 0.01). Among the 313 RACAP-defined cases, acute peripancreatic fluid collection (236 patients, 75.40%), pancreatic pseudocysts (20 patients, 6.4%), acute necrotic collection (42 patients, 13.4%), and walled-off necrosis (15 patients, 4.8%) were observed. Among the 153 DBCAPS-defined cases, sterile peripancreatic necrosis (105 patients, 68.6%), sterile pancreatic necrosis (44 patients, 28.8%), infected peripancreatic necrosis (2 patients, 1.3%), and infected pancreatic necrosis (2/153 patients, 1.3%) were observed. Both classifications adopted organ failure and complications as determinants of severity. Revised Atlanta classification refined local complications and DBCAPS modified severity to include critical AP. In accordance with the demands of precision medicine, a combination of the 2 could be important for further clinical practice and scientific research.

Effects of proton pump inhibitor on outcomes of patients with severe acute pancreatitis based on a national administrative database

OBJECTIVE

This study aimed to investigate whether proton pump inhibitors (PPIs) affect the outcomes of patients with severe acute pancreatitis based on a national administrative database.

METHODS

A total of 10,400 patients with severe acute pancreatitis were referred to 1021 hospitals between 2010 and 2012 in Japan. Patients were divided into two groups: patients who used PPIs (n = 3879) and those without PPIs (n = 6521). We collected patients' data from the administrative database to compare in-hospital mortality within 7, 14, and 28 days, and overall in-hospital mortality between groups, using propensity score analysis to adjust for treatment selection bias.

RESULTS

Multiple logistic regression showed that use of PPIs did not affect in-hospital mortality within 7 and 14 days. The odds ratio (OR) for mortality within 7 days was 1.14 (95% confidence interval [CI]: 0.91-1.42, p = 0.236) while that within 14 days was 1.10 (95% CI: 0.89-1.35, p = 0.349). No significant association was observed for in-hospital mortality within 28 days and overall in-hospital mortality (OR for within 28 days: 1.12, 95% CI: 0.92-1.37, p = 0.224; OR for overall in-hospital mortality: 1.42, 95% CI: 0.97-1.87, p = 0.065).

CONCLUSIONS

This study shows that use of PPIs does not affect clinical outcomes of patients with severe acute pancreatitis. Prospective or randomized studies are needed to confirm the efficacy of PPIs on outcomes of patients with severe acute pancreatitis in the future.

Influence of comorbidity on outcomes of older patients with acute pancreatitis based on a national administrative database

BACKGROUND

Little information is available on the influence of comorbidities on outcomes of older patients with acute pancreatitis. This study aimed to investigate the influence of comorbidities on outcomes of older patients with acute pancreatitis using data from a national Japanese administrative database.

METHODS

A total of 14 322 older patients (≥70 years) with acute pancreatitis were referred to 1090 hospitals between 2010 and 2012 in Japan. We collected patients' data from the administrative database to compare the in-hospital mortality and length of stay of older patients with acute pancreatitis. The patients were categorized into four groups according to comorbidity level using the Charlson Comorbidity Index (CCI): none (CCI score=0; n=6890); mild (1; n=3874); moderate (2; n=2192) and severe (≥3; n=1366).

RESULTS

Multiple logistic and linear regression analyses revealed that severe comorbidity was significantly associated with higher in-hospital mortality and longer length of stay [odds ratio (OR)=2.26; 95% confidence interval (CI): 1.75-2.92, P<0.001 and coefficient 4.37 days; 95% CI: 2.89-5.85, P<0.001, respectively]. In addition, cardiovascular and renal diseases were the most significant comorbidities affecting outcomes of the older patients. ORs of cardiovascular and renal diseases for mortality were 1.44 (95% CI: 1.13-1.85, P=0.003) and 2.69 (95% CI: 1.88-3.85, P<0.001), respectively, and coefficients for length of stay were 3.01 days (95% CI: 1.34-4.67, P<0.001) and 3.72 days (95% CI: 1.01-6.42, P=0.007), respectively.

CONCLUSION

This study demonstrated that comorbidities significantly influenced outcomes of older patients with acute pancreatitis and cardiovascular and renal comorbidities were significant factors affecting outcomes.

Japanese guidelines for the management of acute pancreatitis: Japanese Guidelines 2015

BACKGROUND

Japanese (JPN) guidelines for the management of acute pancreatitis were published in 2006. The severity assessment criteria for acute pancreatitis were later revised by the Japanese Ministry of Health, Labour and Welfare (MHLW) in 2008, leading to their publication as the JPN Guidelines 2010. Following the 2012 revision of the Atlanta Classifications of Acute Pancreatitis, in which the classifications of regional complications of pancreatitis were revised, the development of a minimally invasive method for local complications of pancreatitis spread, and emerging evidence was gathered and revised into the JPN Guidelines.

METHODS

A comprehensive evaluation was carried out on the evidence for epidemiology, diagnosis, severity, treatment, post-endoscopic retrograde cholangiopancreatography (ERCP) pancreatitis and clinical indicators, based on the concepts of the GRADE system (Grading of Recommendations Assessment, Development and Evaluation). With the graded recommendations, where the evidence was unclear, Meta-Analysis team for JPN Guidelines 2015 conducted an additional new meta-analysis, the results of which were included in the guidelines.

RESULTS

Thirty-nine questions were prepared in 17 subject areas, for which 43 recommendations were made. The 17 subject areas were: Diagnosis, Diagnostic imaging, Etiology, Severity assessment, Transfer indication, Fluid therapy, Nasogastric tube, Pain control, Antibiotics prophylaxis, Protease inhibitor, Nutritional support, Intensive care, management of Biliary Pancreatitis, management of Abdominal Compartment Syndrome, Interventions for the local complications, Post-ERCP pancreatitis and Clinical Indicator (Pancreatitis Bundles 2015). Meta-analysis was conducted in the following four subject areas based on randomized controlled trials: (1) prophylactic antibiotics use; (2) prophylactic pancreatic stent placement for the prevention of post-ERCP pancreatitis; (3) prophylactic non-steroidal anti-inflammatory drugs (NSAIDs) for the prevention of post-ERCP pancreatitis; and (4) peritoneal lavage. Using the results of the meta-analysis, recommendations were graded to create useful information. In addition, a mobile application was developed, which made it possible to diagnose, assess severity and check pancreatitis bundles.

CONCLUSIONS

The JPN Guidelines 2015 were prepared using the most up-to-date methods, and including the latest recommended medical treatments, and we are confident that this will make them easy for many clinicians to use, and will provide a useful tool in the decision-making process for the treatment of patients, and optimal medical support. The free mobile application and calculator for the JPN Guidelines 2015 is available via http://www.jshbps.jp/en/guideline/jpn-guideline2015.html.

Pancreatic Abscess in a Cat with Diabetes Mellitus

An 11 yr old spayed female Maine coon cat was referred with uncontrolled diabetes mellitus. The cat had a 2 mo history of weight loss and intermittent vomiting. An abdominal ultrasound identified the presence of a large cavity measuring a maximum of 4.6 cm in the pancreas that was filled with a homogeneous echogenic fluid. Cytological analysis and culture of the fluid obtained from the pancreatic mass indicated the presence of a bacterial abscess. The application of nonsurgical drainage and the administration of glargine insulin and antibiotics resolved the clinical signs. The size of the pancreatic abscess was reduced after 5 mo, and the cat achieved diabetic remission and remained healthy at the time this report was prepared. This case report describes the successful treatment of a pancreatic bacterial abscess concurrent with diabetes mellitus in a Maine coon cat.

Unexpected fetal demise despite the reactive nonstress test during the conservative management of acute pancreatitis in pregnancy

•

Dealing with acute pancreatitis in pregnancy is a challenging problem.

•

Even in the presence of reassuring NST and biophysical profile assessment, an unpredictable fetal loss can occur during the medical management of the pregnancies complicated with mild acute pancreatitis.

•

Acute pancreatitis (AP) is a potentially life threatening inflammatory condition of the pancreas with a high mortality and morbidity rates.

•

We report a complicated case of mild acute pancreatitis induced by gallbladder sludge in a pregnant woman whose pregnancy ended up with unexpected fetal demise at 34 weeks of her gestation.

INTRODUCTION

Dealing with acute pancreatitis in pregnancy is a challenging problem due to unexpected nature of the disease.

PRESENTATION OF CASE

We report a complicated case of a 29-year-old pregnant woman with a mild acute pancreatitis whose pregnancy ended up with an unexpected fetal demise at her 34th gestational week. This unfortunate outcome led us reconsider our obstetrical approach to acute pancreatitis during pregnancy.

CONCLUSION

Based on this unfortunate event, we now think that obstetricians should keep in mind that even in the presence of reassuring NST and biophysical profile assessment, an unpredictable fetal loss can occur during the medical management of the pregnancies complicated with mild acute pancreatitis.

DISCUSSION

The subject patient of this case report was diagnosed with mild AP and underwent conservative medical management. Since the patient was stable and fetal well-being was confirmed with BPP and NST, the termination of pregnancy was out of question at that time. The occurrence of unexpected fetal death despite assuring parameters led us reconsider the approach to the pregnant women with mild AP.

Surgical and interventional management of complications caused by acute pancreatitis

Acute pancreatitis is one of the most common gastrointestinal disorders worldwide. It requires acute hospitalization, with a reported annual incidence of 13 to 45 cases per 100000 persons. In severe cases there is persistent organ failure and a mortality rate of 15% to 30%, whereas mortality of mild pancreatitis is only 0% to 1%. Treatment principles of necrotizing pancreatitis and the role of surgery are still controversial. Despite surgery being effective for infected pancreatic necrosis, it carries the risk of long-term endocrine and exocrine deficiency and a morbidity and mortality rate of between 10% to 40%. Considering high morbidity and mortality rates of operative necrosectomy, minimally invasive strategies are being explored by gastrointestinal surgeons, radiologists, and gastroenterologists. Since 1999, several other minimally invasive surgical, endoscopic, and radiologic approaches to drain and debride pancreatic necrosis have been described. In patients who do not improve after technically adequate drainage, necrosectomy should be performed. When minimal invasive management is unsuccessful or necrosis has spread to locations not accessible by endoscopy, open abdominal surgery is recommended. Additionally, surgery is recognized as a major determinant of outcomes for acute pancreatitis, and there is general agreement that patients should undergo surgery in the late phase of the disease. It is important to consider multidisciplinary management, considering the clinical situation and the comorbidity of the patient, as well as the surgeons experience.

Laparoscopic transgastric endolumenal cystogastrostomy and pancreatic debridement

BACKGROUND

Cystogastrostomy is commonly performed for internal drainage of pancreatic pseudocysts (PP) and concomitant debridement of walled-off pancreatic necrosis (WOPN). While an open approach to cystogastrostomy is well established, an optimal minimally invasive technique continues to evolve. This laparoscopic transgastric endolumenal cystogastrostomy presented here allows for a large cystogastrostomy with complete debridement of necrosis and internal drainage through a minimally invasive approach.

METHODS

We performed a retrospective review of 22 patients with symptomatic PP/WOPN treated with attempted laparoscopic transgastric endolumenal cystogastrostomy (Lap-TEC) and pancreatic debridement. Short- and long-term outcomes were assessed.

RESULTS

From November 2006 to March 2013, a total of 22 Lap-TEC/pancreatic debridement procedures were attempted; 15 were completed laparoscopically. The median age of the cohort was 49.5 ± 12 years (range = 18-71), average body mass index = 29.1 kg/m(2), 77 % had an ASA score ≥ 3, and 10 were female. Gallstones were the most common etiology (50 %), and median time between initial presentation and surgery was 86 days (range = 0-360). Median operative time and estimated blood loss were 213 min and 100 cc, respectively. Forty-one percent of the patients were admitted to the ICU postoperatively and the average length of stay was 14 days (range = 4-50). Median follow-up was 2 months (range = 0-62.5), with one patient having a procedure-related complication. No other reoperations, late complications, or mortalities occurred. All patients had resolution of their symptoms and fluid collections.

CONCLUSION

This technique of internal drainage via Lap-TEC and pancreatic debridement has been successful in achieving primary drainage and relieving symptoms of PP/WOPN with no mortality and minimal morbidity.

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

BACKGROUND AND OBJECTIVE

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

METHODS

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

RESULTS

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

CONCLUSION

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

Laparoscopic pancreatic surgery: An overview of the literature and experiences of a single center

Pancreatic surgery was reported as early as 1898. Since then significant developments have been made in the field of pancreatic resections. In addition, advances in laparoscopic surgery in general have seen the description of this approach in pancreatic surgery with increasing frequency. Although there are no randomized controlled trials, several large series and comparative studies have reported on the short and long term outcome of laparoscopic pancreatic surgery. Furthermore, in the last decade published systematic reviews and meta-analyses have reported on cost effectiveness and outcomes of these procedures.

A review of animal models of nonneoplastic pancreatic diseases

The nonneoplastic diseases of the human pancreas generally comprise the inflammatory and degenerative conditions that include acute and chronic pancreatitis, with cystic fibrosis being arguably one of the most important diseases that induce the condition. Both acute and chronic conditions vary in severity, but both can be life threatening; and because of this fact, the study of their progression, and their responsiveness to therapy, is largely conducted by indirect means using serum markers of damage and repair such as amylase and lipase activities that normally occur at very low levels in the circulation but can be significantly increased during inflammatory episodes. Progress in the understanding the pathogenesis of both conditions has therefore been largely due to time course studies in animal models of pancreatitis, and it is in this context that animal model development has been so significant. In general terms, the animal models can be divided into the invasive, surgical procedures, and those induced by the administration of chemical secretagogues that induce hypersecretion of the pancreatic enzymes. The former include ligation and/or cannulation of the biliopancreatic ducts with infusion of solutions of various kinds, or the formation of closed duodenal loops. Secretagogue administration includes administration of caerulein or l-arginine in various protocols. An additional model involves administration of dibutyltin dichloride, which induces a partial blockage of the pancreatic ducts to induce pancreatic disease through enzymic reflux into the gland. The models have been invaluable in generating testable hypotheses for the human diseases. These hypotheses for the production of cellular damage as the initiating events in the disease include (1) intracellular chemical activation, (2) pancreatic secretion reflux, (3) intracellular production of reactive oxygen species, and (4) intracellular production of free radicals.

Infective severe acute pancreatitis: A comparison of 99mTc-ciprofloxacin scintigraphy and computed tomography

AIM: To evaluate ^99mTc-ciprofloxacin scintigraphy compared with computed tomography (CT) for detecting secondary infections associated with severe acute pancreatitis (SAP) in swine.

METHODS: Six healthy swine were assigned to a normal control group (group A, n = 6). SAP was induced in group B (n = 9) and C (n = 18), followed by inoculation of the resulting pancreatic necroses with inactive Escherichia coli (E. coli) (group B) and active E. coli (group C), respectively. At 7 d after inoculation, a CT scan and a series of analyses using infecton imaging (at 0.5, 1, 2, 3, 4 and 6 h after the administration of 370 MBq of intravenous infecton) were performed. The scintigrams were visually evaluated and semi-quantitatively analyzed using region of interest assignments. The differences in infecton uptake and changes in the lesion-background radioactive count ratios (L/B) in the 3 groups were recorded and compared. After imaging detection, histopathology and bacterial examinations were performed, and infected SAP was regarded as positive. The imaging findings were compared with histopathological and bacteriological results.

RESULTS: In group A, 6 animals survived without infection in the pancreas. In group B, 7/9 swine survived and one suffered from infection. In group C, 15/18 animals survived with infection. Hence, the number of normal, non-infected and infected SAP swine was 6, 6 and 16, respectively. The sensitivity, specificity, accuracy, positive predictive value and negative predictive value of the infecton method were 93.8% (15/16), 91.7% (11/12), 92.9% (26/28), 93.8% (15/16) and 91.7% (11/12), whereas these values for CT were 12.5% (2/16), 100.0% (12/12), 50.0% (14/28), 100.0% (2/2) and 46.2% (12/26), respectively. The changes in L/B for the infected SAP were significantly different from those of the non-infected and normal swine (P < 0.001). The mean L/B of the infectious foci at 0.5, 1, 2, 3, 4 and 6 h was 1.17 ± 0.10, 1.71 ± 0.30, 2.46 ± 0.45, 3.36 ± 0.33, 2.04 ± 0.37 and 1.1988 ± 0.09, respectively. At 3 h, the radioactive counts (2350.25 ± 602.35 k) and the mean L/B of the infectious foci were significantly higher than that at 0.5 h (P = 0.000), 1 h (P = 0.000), 2 h (P = 0.04), 4 h (P = 0.000) and 6 h (P = 0.000).

CONCLUSION: ^99mTc-ciprofloxacin scintigraphy may be an effective procedure for detecting SAP secondary infections with higher sensitivity and accuracy than CT.

Laparotomy versus retroperitoneal laparoscopy in debridement and drainage of retroperitoneal infected necrosis in severe acute pancreatitis

BACKGROUND

The aim of this study was to compare laparotomy and retroperitoneal laparoscopy in debridement and drainage of retroperitoneal infected necrosis of severe acute pancreatitis (SAP), and to evaluate the curative efficacy and the timing of retroperitoneal laparoscopic debridement drainage (RLDD) for SAP patients.

METHODS

We performed a retrospective analysis of 50 SAP cases, including 18 patients in the RLDD group and 32 patients in the laparotomy group. Observed indices included gender, age, CT severity index, Ranson score, APACHE II score, preoperative course, length of stay, operation time, mortality, postoperative complications, drainage tube indwelling time, and change of body temperature and peripheral white blood cell (PWBC) count between the time before the operation and at 48 h after surgery.

RESULTS

Between the RLDD group and the laparotomy group, there was a significant difference in operation time (130 ± 15 vs. 148 ± 25 h; P = 0.007), length of stay [40.8 (6-121) vs. 55.9 (28-133) days; P = 0.053], and preoperative course [14.7 (5-31) vs. 18.3 (6-31) days; P = 0.05], but no significant difference in average drainage tube indwelling time [44.4 (2-182) vs. 49.8 (2-175) days; P = 0.663]. More improvement in body temperature and PWBC count was observed in the patients of the RLDD group. There was one death (1/18) in the RLDD group and four (4/32) in the laparotomy group. Fourteen cases (14/32) in the laparotomy group had postoperative complications, including pancreatic fistula (n = 11), intestinal fistula (n = 2), retroperitoneal hemorrhage (n = 2), infection of incision (n = 9), and 5 cases (5/18) in the RLDD group, including pancreatic fistula (n = 4) and retroperitoneal hemorrhage (n = 1).

CONCLUSIONS

RLDD, as minimally invasive surgery, is technically feasible, safe, and effective in the treatment of retroperitoneal infected necrosis in SAP patients, in contrast to the laparotomy technique, and can be performed in the early phase of SAP to prevent the deterioration of the disease.

An update on minimally invasive therapies for pancreatic necrosis

Pancreatic necrosis is a local complication of severe acute pancreatitis associated with multiple organ dysfunction, infection and increased mortality. While surgery is the mainstay for invasive management, studies have demonstrated that delaying necrosectomy translates to improved patient outcomes. Minimally invasive therapies have been described both for early and late management of necrotic pancreatic collections and fall into three broad categories: endoscopic, radiology assisted percutaneous drainage and laparoscopic or retroperitoneal surgical techniques. Such interventions may serve as temporizing measures delaying necrosectomy, but more importantly, as best demonstrated in recent randomized controlled trials, can serve as alternative approaches resulting in improved patient outcomes. Access to these techniques is based on their availability at expert centers. Minimally invasive therapies have increased in popularity, with a general consensus among experts being that reduced complications and mortality rates are realized by approaches other than open necrosectomy. However, additional well-designed, randomized trials are needed.

Multivariate analysis of factors influencing medical costs of acute pancreatitis hospitalizations based on a national administrative database

BACKGROUND

Little information is available on the analysis of medical costs of acute pancreatitis hospitalizations.

AIM

This study aimed to determine the factors affecting medical costs of patients with acute pancreatitis during hospitalization using a Japanese administrative database.

METHODS

A total of 7193 patients with acute pancreatitis were referred to 776 hospitals. We defined "patients with high medical costs" as patients whose medical costs exceeded the 90th percentile in medical costs during hospitalization and identified the independent factors for patients with high medical costs with and without controlling for length of stay.

RESULTS

Multiple logistic regression analysis demonstrated that necrosectomy was the most significant factor for medical costs of acute pancreatitis during hospitalization. The odds ratio of necrosectomy was 33.64 (95% confidence interval, 14.14-80.03; p<0.001). Use of an intensive care unit was the most significant factor for medical costs after controlling for LOS. The OR of an ICU was 6.44 (95% CI, 4.72-8.81; p<0.001).

CONCLUSION

This study demonstrated that necrosectomy and use of an ICU significantly affected the medical costs of acute pancreatitis hospitalization. These results highlight the need for health care implementations to reduce medical costs whilst maintaining the quality of patient care, and targeting patients with severe acute pancreatitis.

Effect of hospital volume on clinical outcome in patients with acute pancreatitis, based on a national administrative database

OBJECTIVE

This study aimed to investigate the relationship between hospital volume and clinical outcome in patients with acute pancreatitis, using a Japanese national administrative database.

METHODS

A total of 7007 patients with acute pancreatitis were referred to776 hospitals in Japan. Patient data were corrected according to the severity of acute pancreatitis to allow the comparison of risk-adjusted in-hospital mortality and length of stay in relation to hospital volume. Hospital volume was categorized based on the number of cases during the study period into low-volume (<10 cases), medium-volume (10-16 cases), and high-volume hospitals (HVHs, >16 cases).

RESULTS

Increased hospital volume was significantly associated with decreased relative risk of in-hospital mortality in both patients with mild and those with severe acute pancreatitis. The odds ratios for HVHs were 0.424 (95% confidence interval [CI], 0.228-0.787; P = 0.007) and 0.338 (95% CI, 0.138-0.826; P = 0.017), respectively. Hospital volume was also significantly associated with shorter length of stay in patients with mild acute pancreatitis. The unstandardized coefficient for HVHs was -0.978 days (95% CI, -1.909 to -0.048; P = 0.039).

CONCLUSIONS

This study demonstrated that hospital volume influences the clinical outcome in both patients with mild and those with severe acute pancreatitis.

Two cases of monomicrobial intraabdominal abscesses due to KPC--3 Klebsiella pneumoniae ST258 clone

BACKGROUND

Knowledge of the etiology of pyogenic liver and pancreatic abscesses is an important factor in determining the success of combined surgical and antibiotic treatment. Literature shows geographical variations in the prevalence and distribution of causative organisms, and the spread of Klebsiella pneumoniae carbapenemase-producing bacteria is an emerging cause of abdominal infections.

CASE PRESENTATION

We herein describe two cases of intra-abdominal abscesses due to monomicrobial infection by Klebsiella pneumoniae Sequence Type 258 producing K. pneumoniae carbapenemase 3 (KPC-Kp). In case 1, a 50-year-old HIV-negative Italian woman with chronic pancreatitis showed infection of a pancreatic pseudocystic lesion caused by KPC-Kp. In case 2, a 64-year-old HIV-negative Italian woman with pancreatic neoplasm and liver metastases developed a liver abscess due to KPC after surgery. Both women were admitted to our hospital but to different surgical units. The clonal relationship between the two isolates was investigated by pulsed-field gel electrophoresis (PFGE). In case 2, the patient was already colonized at admission and inter-hospital transmission of the pathogen was presumed. A long-term combination regimen of colistin with tigecycline and percutaneous drainage resulted in full recovery and clearance of the multidrug-resistant (MDR) pathogen.

CONCLUSIONS

Timely microbiological diagnosis, the combined use of new and old antibiotics and radiological intervention appeared to be valuable in managing these serious conditions. The emergence and dissemination of MDR organisms is posing an increasing challenge for physicians to develop new therapeutic strategies and control and prevention frameworks.

Pancreatite necro-hemorrágica: atualização e momento de operar

INTRODUÇÃO: A pancreatite necro-hemorrágica representa a variante mais grave do espectro de apresentações clínicas que podem compor o quadro da pancreatite aguda. Embora já conhecida há muitos séculos, inúmeras questões permanecem em aberto acerca dessa entidade e o número de trabalhos sobre o assunto publicados nos últimos anos tem sido muito expressivo. MÉTODO: Foi realizada ampla pesquisa na literatura, com especial atenção aos artigos publicados nos últimos três anos e indexados ao PubMed. Foram utilizados os seguintes descritores de forma cruzada: pancreatitis, surgical procedures; necrosis. A pesquisa inicial evidenciou cerca de 13.000 artigos, sendo avaliados os mais relevantes dos últimos três anos além de artigos mais antigos, considerados "clássicos" sobre o assunto e que, portanto, não poderiam deixar de ser citados. CONCLUSÃO: O tratamento da pancreatite aguda envolve um grande número de questões, dentre as quais as mais importantes estão relacionadas ao manejo da antibioticoterapia, tipo de dieta empregada e as questões relacionadas ao manejo da necrose infectada. Em especial, mudanças radicais foram implementadas nos últimos anos sobre todos esses tópicos, e uma atualização constante deve ser obrigatoriamente buscada pelos profissionais envolvidos no tratamento dessa doença.