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Deng G, Wen B, Jia L, Liu J, Yan Q. Clostridium butyricum upregulates GPR109A/AMPK/PGC-1α and ameliorates acute pancreatitis-associated intestinal barrier injury in mice. Arch Microbiol 2024; 206:265. [PMID: 38761195 DOI: 10.1007/s00203-024-04001-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/08/2024] [Revised: 05/07/2024] [Accepted: 05/11/2024] [Indexed: 05/20/2024]
Abstract
Acute pancreatitis frequently causes intestinal barrier damage, which aggravates pancreatitis. Although Clostridium butyricum exerts anti-inflammatory and protective effects on the intestinal barrier during acute pancreatitis, the underlying mechanism is unclear. The G protein-coupled receptors 109 A (GPR109A) and adenosine monophosphate-activated protein kinase (AMPK)/ peroxisome proliferator-activated receptor-gamma coactivator 1 alpha (PGC-1α) signaling pathways can potentially influence the integrity of the intestinal barrier. Our study generated acute pancreatitis mouse models via intraperitoneal injection of cerulein and lipopolysaccharides. After intervention with Clostridium butyricum, the model mice showed reduced small intestinal and colonic intestinal barrier damage, dysbiosis amelioration, and increased GPR109A/AMPK/PGC-1α expression. In conclusion, Clostridium butyricum could improve pancreatic and intestinal inflammation and pancreatic injury, and relieve acute pancreatitis-induced intestinal barrier damage in the small intestine and colon, which may be associated with GPR109A/AMPK/PGC-1α.
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Affiliation(s)
- Guiqing Deng
- Department of Gastroenterology, The Second Affiliated Hospital, School of Medicine, South China University of Technology, Guangzhou, 510180, China
| | - Biyan Wen
- Department of Gastroenterology, The Second Affiliated Hospital, School of Medicine, South China University of Technology, Guangzhou, 510180, China
| | - Lin Jia
- Department of Gastroenterology, The Second Affiliated Hospital, School of Medicine, South China University of Technology, Guangzhou, 510180, China.
| | - Jiaxin Liu
- Department of Gastroenterology, The Second Affiliated Hospital, School of Medicine, South China University of Technology, Guangzhou, 510180, China
| | - Qingqing Yan
- Department of Gastroenterology, The Second Affiliated Hospital, School of Medicine, South China University of Technology, Guangzhou, 510180, China
- Department of Gastroenterology, Guangzhou First People's Hospital, South China University of Technology, Guangzhou, 510180, China
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2
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Köksal AŞ, Tozlu M, Sezgin O, Oğuz D, Kalkan İH, Altıntaş E, Yaraş S, Bilgiç Y, Yıldırım AE, Barutçu S, Hakim GD, Soytürk M, Bengi G, Özşeker B, Yurci A, Koç DÖ, İrak K, Kasap E, Cindoruk M, Oruç N, Ünal NG, Şen İ, Gökden Y, Saruç M, Ünal H, Eminler AT, Toka B, Basır H, Sağlam O, Ergül B, Gül Ö, Büyüktorun İ, Özel M, Şair Ü, Kösem G, Nedirli F, Tahtacı M, Parlak E. Acute pancreatitis in Turkey: Results of a nationwide multicenter study. Pancreatology 2024; 24:327-334. [PMID: 37880021 DOI: 10.1016/j.pan.2023.10.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/01/2023] [Revised: 08/12/2023] [Accepted: 10/05/2023] [Indexed: 10/27/2023]
Abstract
BACKGROUND Acute pancreatitis (AP) is the most common gastrointestinal disease requiring hospitalization, with significant mortality and morbidity. We aimed to evaluate the clinical characteristics of AP and physicians' compliance with international guidelines during its management. METHODS All patients with AP who were hospitalized at 17 tertiary centers in Turkey between April and October 2022 were evaluated in a prospective cohort study. Patients with insufficient data, COVID-19 and those aged below 18 years were excluded. The definitions were based on the 2012 revised Atlanta criteria. RESULTS The study included 2144 patients (median age:58, 52 % female). The most common etiologies were biliary (n = 1438, 67.1 %), idiopathic (n = 259, 12 %), hypertriglyceridemia (n = 128, 6 %) and alcohol (n = 90, 4.2 %). Disease severity was mild in 1567 (73.1 %), moderate in 521 (24.3 %), and severe in 58 (2.6 %) patients. Morphology was necrotizing in 4.7 % of the patients. The overall mortality rate was 1.6 %. PASS and BISAP had the highest accuracy in predicting severe pancreatitis on admission (AUC:0.85 and 0.81, respectively). CT was performed in 61 % of the patients, with the majority (90 %) being within 72 h after admission. Prophylactic NSAIDs were not administered in 44 % of the patients with post-ERCP pancreatitis (n = 86). Antibiotics were administered to 53.7 % of the patients, and 38 % of those received them prophylactically. CONCLUSIONS This prospective study provides an extensive report on clinical characteristics, management and outcomes of AP in real-world practice. Mortality remains high in severe cases and physicians' adherence to guidelines during management of the disease needs improvement in some aspects.
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Affiliation(s)
- Aydın Şeref Köksal
- Sakarya University, School of Medicine, Department of Gastroenterology, Turkey.
| | - Mukaddes Tozlu
- Sakarya University, School of Medicine, Department of Gastroenterology, Turkey
| | - Orhan Sezgin
- Mersin University, School of Medicine, Department of Gastroenterology, Turkey
| | - Dilek Oğuz
- Kırıkkale University, School of Medicine, Department of Gastroenterology, Turkey
| | - İsmail Hakkı Kalkan
- TOBB Economy and Technology University, Department of Gastroenterology, Turkey
| | - Engin Altıntaş
- Mersin University, School of Medicine, Department of Gastroenterology, Turkey
| | - Serkan Yaraş
- Mersin University, School of Medicine, Department of Gastroenterology, Turkey
| | - Yılmaz Bilgiç
- İnönü University, School of Medicine, Department of Gastroenterology, Turkey
| | | | - Sezgin Barutçu
- Gaziantep University, School of Medicine, Department of Gastroenterology, Turkey
| | - Gözde Derviş Hakim
- Sağlık Bilimleri University, Izmir School of Medicine, Department of Gastroenterology, Turkey
| | - Müjde Soytürk
- Dokuz Eylül University, School of Medicine, Department of Gastroenterology, Turkey
| | - Göksel Bengi
- Dokuz Eylül University, School of Medicine, Department of Gastroenterology, Turkey
| | - Burak Özşeker
- Muğla Sıtkı Koçman University, School of Medicine, Department of Gastroenterology, Turkey
| | - Alper Yurci
- Erciyes University, School of Medicine, Department of Gastroenterology, Turkey
| | - Deniz Öğütmen Koç
- Sağlık Bilimleri University, Gaziosmanpaşa Education and Research Hospital, Department of Gastroenterology, Turkey
| | - Kader İrak
- Sağlık Bilimleri University, Başakşehir Çam and Sakura City Hospital, Department of Gastroenterology, Turkey
| | - Elmas Kasap
- Manisa Celal Bayar University, School of Medicine, Department of Gastroenterology, Turkey
| | - Mehmet Cindoruk
- Ankara Gazi University, School of Medicine, Department of Gastroenterology, Turkey
| | - Nevin Oruç
- Ege University, School of Medicine, Department of Gastroenterology, Turkey
| | - Nalan Gülşen Ünal
- Ege University, School of Medicine, Department of Gastroenterology, Turkey
| | - İlker Şen
- Sağlık Bilimleri University, Şişli Hamidiye Etfal Education and Research Hospital, Department of Gastroenterology, Turkey
| | - Yasemin Gökden
- Sağlık Bilimleri University, Prof. Dr. Cemil Taşçıoğlu City Hosoital, Department of Gastroenterology, Turkey
| | - Murat Saruç
- Acıbadem Mehmet Ali Aydınlar University, School of Medicine, Department of Gastroenterology, Turkey
| | - Hakan Ünal
- Acıbadem Mehmet Ali Aydınlar University, School of Medicine, Department of Gastroenterology, Turkey
| | - Ahmet Tarık Eminler
- Sakarya University, School of Medicine, Department of Gastroenterology, Turkey
| | - Bilal Toka
- Sakarya University, School of Medicine, Department of Gastroenterology, Turkey
| | - Hakan Basır
- Mersin University, School of Medicine, Department of Gastroenterology, Turkey
| | - Osman Sağlam
- İnönü University, School of Medicine, Department of Gastroenterology, Turkey
| | - Bilal Ergül
- Kırıkkale University, School of Medicine, Department of Gastroenterology, Turkey
| | - Özlem Gül
- Kırıkkale University, School of Medicine, Department of Gastroenterology, Turkey
| | - İlker Büyüktorun
- Dokuz Eylül University, School of Medicine, Department of Gastroenterology, Turkey
| | - Mustafa Özel
- Erciyes University, School of Medicine, Department of Gastroenterology, Turkey
| | - Ümit Şair
- Sağlık Bilimleri University, Gaziosmanpaşa Education and Research Hospital, Department of Internal Medicine, Turkey
| | - Gizem Kösem
- Manisa Celal Bayar University, School of Medicine, Department of Internal Medicine, Turkey
| | - Ferda Nedirli
- Gazi University, School of Medicine, Department of Internal Medicine, Turkey
| | - Mustafa Tahtacı
- Ankara Yıldırım Beyazıt University, Department of Gastroenterology, Turkey
| | - Erkan Parlak
- Hacettepe University, School of Medicine, Department of Gastroenterology, Turkey
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Lv C, Zhang ZX, Ke L. Early prediction and prevention of infected pancreatic necrosis. World J Gastroenterol 2024; 30:1005-1010. [PMID: 38577189 PMCID: PMC10989483 DOI: 10.3748/wjg.v30.i9.1005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/18/2023] [Revised: 01/02/2024] [Accepted: 02/06/2024] [Indexed: 03/06/2024] Open
Abstract
Approximately 20%-30% of patients with acute necrotizing pancreatitis develop infected pancreatic necrosis (IPN), a highly morbid and potentially lethal complication. Early identification of patients at high risk of IPN may facilitate appropriate preventive measures to improve clinical outcomes. In the past two decades, several markers and predictive tools have been proposed and evaluated for this purpose. Conventional biomarkers like C-reactive protein, procalcitonin, lymphocyte count, interleukin-6, and interleukin-8, and newly developed biomarkers like angiopoietin-2 all showed significant association with IPN. On the other hand, scoring systems like the Acute Physiology and Chronic Health Evaluation II and Pancreatitis Activity Scoring System have also been tested, and the results showed that they may provide better accuracy. For early prevention of IPN, several new therapies were tested, including early enteral nutrition, antibiotics, probiotics, immune enhancement, etc., but the results varied. Taken together, several evidence-supported predictive markers and scoring systems are readily available for predicting IPN. However, effective treatments to reduce the incidence of IPN are still lacking apart from early enteral nutrition. In this editorial, we summarize evidence concerning early prediction and prevention of IPN, providing insights into future practice and study design. A more homogeneous patient population with reliable risk-stratification tools may help find effective treatments to reduce the risk of IPN, thereby achieving individualized treatment.
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Affiliation(s)
- Cheng Lv
- Department of Critical Care Medicine, Jinling Hospital, Affiliated Hospital of Medical School, Nanjing University, Nanjing 210000, Jiangsu Province, China
| | - Zi-Xiong Zhang
- Department of Critical Care Medicine, Jinling Hospital, Affiliated Hospital of Medical School, Nanjing University, Nanjing 210000, Jiangsu Province, China
| | - Lu Ke
- Department of Critical Care Medicine, Jinling Hospital, Affiliated Hospital of Medical School, Nanjing University, Nanjing 210000, Jiangsu Province, China
- Research Institute of Critical Care Medicine and Emergency Rescue, Nanjing University, Nanjing 210000, Jiangsu Province, China
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4
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Tenner S, Vege SS, Sheth SG, Sauer B, Yang A, Conwell DL, Yadlapati RH, Gardner TB. American College of Gastroenterology Guidelines: Management of Acute Pancreatitis. Am J Gastroenterol 2024; 119:419-437. [PMID: 38857482 DOI: 10.14309/ajg.0000000000002645] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/08/2023] [Accepted: 12/08/2023] [Indexed: 06/12/2024]
Abstract
Acute pancreatitis (AP), defined as acute inflammation of the pancreas, is one of the most common diseases of the gastrointestinal tract leading to hospital admission in the United States. It is important for clinicians to appreciate that AP is heterogenous, progressing differently among patients and is often unpredictable. While most patients experience symptoms lasting a few days, almost one-fifth of patients will go on to experience complications, including pancreatic necrosis and/or organ failure, at times requiring prolonged hospitalization, intensive care, and radiologic, surgical, and/or endoscopic intervention. Early management is essential to identify and treat patients with AP to prevent complications. Patients with biliary pancreatitis typically will require surgery to prevent recurrent disease and may need early endoscopic retrograde cholangiopancreatography if the disease is complicated by cholangitis. Nutrition plays an important role in treating patients with AP. The safety of early refeeding and importance in preventing complications from AP are addressed. This guideline will provide an evidence-based practical approach to the management of patients with AP.
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Affiliation(s)
- Scott Tenner
- State University of New York, Health Sciences Center, Brooklyn, New York, USA
| | | | - Sunil G Sheth
- Beth Israel Deaconess Medical Center, Boston, Massachusetts, USA
| | - Bryan Sauer
- University of Virginia, Charlottesville, Virginia, USA
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5
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Otsuka Y, Hara A, Minaga K, Sekai I, Kurimoto M, Masuta Y, Takada R, Yoshikawa T, Kamata K, Kudo M, Watanabe T. Leucine-rich repeat kinase 2 promotes the development of experimental severe acute pancreatitis. Clin Exp Immunol 2023; 214:182-196. [PMID: 37847786 PMCID: PMC10714192 DOI: 10.1093/cei/uxad106] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/03/2023] [Revised: 08/10/2023] [Accepted: 09/08/2023] [Indexed: 10/19/2023] Open
Abstract
Translocation of gut bacteria into the pancreas promotes the development of severe acute pancreatitis (SAP). Recent clinical studies have also highlighted the association between fungal infections and SAP. The sensing of gut bacteria by pattern recognition receptors promotes the development of SAP via the production of proinflammatory cytokines; however, the mechanism by which gut fungi mediate SAP remains largely unknown. Leucine-rich repeat kinase 2 (LRRK2) is a multifunctional protein that regulates innate immunity against fungi via Dectin-1 activation. Here, we investigated the role of LRRK2 in SAP development and observed that administration of LRRK2 inhibitors attenuated SAP development. The degree of SAP was greater in Lrrk2 transgenic (Tg) mice than in control mice and was accompanied by an increased production of nuclear factor-kappaB-dependent proinflammatory cytokines. Ablation of the fungal mycobiome by anti-fungal drugs inhibited SAP development in Lrrk2 Tg mice, whereas the degree of SAP was comparable in Lrrk2 Tg mice with or without gut sterilization by a broad range of antibiotics. Pancreatic mononuclear cells from Lrrk2 Tg mice produced large amounts of IL-6 and TNF-α upon stimulation with Dectin-1 ligands, and inhibition of the Dectin-1 pathway by a spleen tyrosine kinase inhibitor protected Lrrk2 Tg mice from SAP. These data indicate that LRRK2 activation is involved in the development of SAP through proinflammatory cytokine responses upon fungal exposure.
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Affiliation(s)
- Yasuo Otsuka
- Department of Gastroenterology and Hepatology, Kindai University Faculty of Medicine, Osaka-Sayama, Osaka, Japan
| | - Akane Hara
- Department of Gastroenterology and Hepatology, Kindai University Faculty of Medicine, Osaka-Sayama, Osaka, Japan
| | - Kosuke Minaga
- Department of Gastroenterology and Hepatology, Kindai University Faculty of Medicine, Osaka-Sayama, Osaka, Japan
| | - Ikue Sekai
- Department of Gastroenterology and Hepatology, Kindai University Faculty of Medicine, Osaka-Sayama, Osaka, Japan
| | - Masayuki Kurimoto
- Department of Gastroenterology and Hepatology, Kindai University Faculty of Medicine, Osaka-Sayama, Osaka, Japan
| | - Yasuhiro Masuta
- Department of Gastroenterology and Hepatology, Kindai University Faculty of Medicine, Osaka-Sayama, Osaka, Japan
| | - Ryutaro Takada
- Department of Gastroenterology and Hepatology, Kindai University Faculty of Medicine, Osaka-Sayama, Osaka, Japan
| | - Tomoe Yoshikawa
- Department of Gastroenterology and Hepatology, Kindai University Faculty of Medicine, Osaka-Sayama, Osaka, Japan
| | - Ken Kamata
- Department of Gastroenterology and Hepatology, Kindai University Faculty of Medicine, Osaka-Sayama, Osaka, Japan
| | - Masatoshi Kudo
- Department of Gastroenterology and Hepatology, Kindai University Faculty of Medicine, Osaka-Sayama, Osaka, Japan
| | - Tomohiro Watanabe
- Department of Gastroenterology and Hepatology, Kindai University Faculty of Medicine, Osaka-Sayama, Osaka, Japan
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Wang K, Qin X, Ran T, Pan Y, Hong Y, Wang J, Zhang X, Shen X, Liu C, Lu X, Chen Y, Bai Y, Zhang Y, Zhou C, Zou D. Causal link between gut microbiota and four types of pancreatitis: a genetic association and bidirectional Mendelian randomization study. Front Microbiol 2023; 14:1290202. [PMID: 38075894 PMCID: PMC10702359 DOI: 10.3389/fmicb.2023.1290202] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/07/2023] [Accepted: 10/13/2023] [Indexed: 04/12/2024] Open
Abstract
BACKGROUND A number of recent observational studies have indicated a correlation between the constitution of gut microbiota and the incidence of pancreatitis. Notwithstanding, observational studies are unreliable for inferring causality because of their susceptibility to confounding, bias, and reverse causality, the causal relationship between specific gut microbiota and pancreatitis is still unclear. Therefore, our study aimed to investigate the causal relationship between gut microbiota and four types of pancreatitis. METHODS An investigative undertaking encompassing a genome-wide association study (GWAS) comprising 18,340 participants was undertaken with the aim of discerning genetic instrumental variables that exhibit associations with gut microbiota, The aggregated statistical data pertaining to acute pancreatitis (AP), alcohol-induced AP (AAP), chronic pancreatitis (CP), and alcohol-induced CP (ACP) were acquired from the FinnGen Consortium. The two-sample bidirectional Mendelian randomization (MR) approach was utilized. Utilizing the Inverse-Variance Weighted (IVW) technique as the cornerstone of our primary analysis. The Bonferroni analysis was used to correct for multiple testing, In addition, a number of sensitivity analysis methodologies, comprising the MR-Egger intercept test, the Cochran's Q test, MR polymorphism residual and outlier (MR-PRESSO) test, and the leave-one-out test, were performed to evaluate the robustness of our findings. RESULTS A total of 28 intestinal microflora were ascertained to exhibit significant associations with diverse outcomes of pancreatitis. Among them, Class Melainabacteria (OR = 1.801, 95% CI: 1.288-2.519, p = 0.008) has a strong causality with ACP after the Bonferroni-corrected test, in order to assess potential reverse causation effects, we used four types of pancreatitis as the exposure variable and scrutinized its impact on gut microbiota as the outcome variable, this analysis revealed associations between pancreatitis and 30 distinct types of gut microflora. The implementation of Cochran's Q test revealed a lack of substantial heterogeneity among the various single nucleotide polymorphisms (SNP). CONCLUSION Our first systematic Mendelian randomization analysis provides evidence that multiple gut microbiota taxa may be causally associated with four types of pancreatitis disease. This discovery may contribute significant biomarkers conducive to the preliminary, non-invasive identification of Pancreatitis. Additionally, it could present viable targets for potential therapeutic interventions in the disease's treatment.
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Affiliation(s)
- Kui Wang
- Department of Gastroenterology, Ruijin Hospital, School of Medicine, Shanghai Jiao Tong University, Shanghai, China
- Department of Gastroenterology, The Affiliated Hospital of Kunming University of Science and Technology, The First People’s Hospital of Yunnan Province, Kunming, China
| | - Xianzheng Qin
- Department of Gastroenterology, Ruijin Hospital, School of Medicine, Shanghai Jiao Tong University, Shanghai, China
| | - Taojing Ran
- Department of Gastroenterology, Ruijin Hospital, School of Medicine, Shanghai Jiao Tong University, Shanghai, China
| | - Yundi Pan
- Department of Gastroenterology, Ruijin Hospital, School of Medicine, Shanghai Jiao Tong University, Shanghai, China
| | - Yu Hong
- Department of Gastroenterology, Ruijin Hospital, School of Medicine, Shanghai Jiao Tong University, Shanghai, China
| | - Jiawei Wang
- Department of Gastroenterology, Ruijin Hospital, School of Medicine, Shanghai Jiao Tong University, Shanghai, China
| | - Xianda Zhang
- Department of Gastroenterology, Ruijin Hospital, School of Medicine, Shanghai Jiao Tong University, Shanghai, China
| | - XiaoNan Shen
- Department of Gastroenterology, Ruijin Hospital, School of Medicine, Shanghai Jiao Tong University, Shanghai, China
| | - Chenxiao Liu
- Department of Gastroenterology, Ruijin Hospital, School of Medicine, Shanghai Jiao Tong University, Shanghai, China
| | - Xinchen Lu
- Department of Gastroenterology, Ruijin Hospital, School of Medicine, Shanghai Jiao Tong University, Shanghai, China
| | - Yifei Chen
- Department of Gastroenterology, Ruijin Hospital, School of Medicine, Shanghai Jiao Tong University, Shanghai, China
| | - Yaya Bai
- Department of Gastroenterology, Ruijin Hospital, School of Medicine, Shanghai Jiao Tong University, Shanghai, China
| | - Yao Zhang
- Department of Gastroenterology, Ruijin Hospital, School of Medicine, Shanghai Jiao Tong University, Shanghai, China
| | - Chunhua Zhou
- Department of Gastroenterology, Ruijin Hospital, School of Medicine, Shanghai Jiao Tong University, Shanghai, China
| | - Duowu Zou
- Department of Gastroenterology, Ruijin Hospital, School of Medicine, Shanghai Jiao Tong University, Shanghai, China
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7
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Liu Y, Liu H, Rong Y, Shi Q, Yang Q, Li H, Zhang Z, Tao J. Alterations of oral microbiota are associated with the development and severity of acute pancreatitis. J Oral Microbiol 2023; 15:2264619. [PMID: 37808891 PMCID: PMC10557549 DOI: 10.1080/20002297.2023.2264619] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/11/2023] [Accepted: 09/24/2023] [Indexed: 10/10/2023] Open
Abstract
Acute pancreatitis (AP) is a common abdomen clinical emergency. Most APs have mild clinical symptoms and a good prognosis. However, about 20% of patients develop severe acute pancreatitis (SAP), increasing morbidity and mortality. The microbiome's impact on AP pathophysiology has received increasing attention. Hence, to explore changes in oral microbial composition in acute pancreatitis, we collected clinical information and oral saliva samples from 136 adult participants: 47 healthy controls, 43 acute mild AP (MAP), 29 moderate AP (MSAP), and 17 severe AP (SAP). Using 16S rRNA gene sequencing, 663,175 high-quality sequences were identified. The relative abundance and diversity of oral microorganisms in AP patients increased, with decreased beneficial bacteria such as Streptococcus, Neisseria, and Gemella, and increased Prevotella, Veillonella, Granulicatella, Actinomyces, and Peptostreptococcus in the AP group. Further changes in microbial composition occurred with increasing disease severity, including a decreased abundance of beneficial bacteria such as Neisseria, Haemophilus, and Gemella in MSAP and SAP compared to MAP. Moreover, the Lefse analysis showed that Prevotella, Peptostreptococcus, Actinomyces, and Porphyromonas were better microbial markers for AP. Therefore, oral microbiome changes could distinguish AP from healthy individuals and serve as an early novel predictor of disease severity in AP patients.
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Affiliation(s)
- Yiting Liu
- Department of Pancreatic Surgery, Renmin Hospital of Wuhan University, Wuhan, China
| | - Hang Liu
- Department of Clinical Laboratory, Institute of Translational Medicine, Renmin Hospital of Wuhan University, Wuhan, China
| | - Yuping Rong
- Department of Pancreatic Surgery, Renmin Hospital of Wuhan University, Wuhan, China
| | - Qiao Shi
- Department of Pancreatic Surgery, Renmin Hospital of Wuhan University, Wuhan, China
| | - Qiang Yang
- Department of Pancreatic Surgery, Renmin Hospital of Wuhan University, Wuhan, China
| | - Hanjun Li
- Department of Pancreatic Surgery, Renmin Hospital of Wuhan University, Wuhan, China
| | - Zhengle Zhang
- Department of Pancreatic Surgery, Renmin Hospital of Wuhan University, Wuhan, China
| | - Jing Tao
- Department of Pancreatic Surgery, Renmin Hospital of Wuhan University, Wuhan, China
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8
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Wang Z, Guo M, Li J, Jiang C, Yang S, Zheng S, Li M, Ai X, Xu X, Zhang W, He X, Wang Y, Chen Y. Composition and functional profiles of gut microbiota reflect the treatment stage, severity, and etiology of acute pancreatitis. Microbiol Spectr 2023; 11:e0082923. [PMID: 37698429 PMCID: PMC10580821 DOI: 10.1128/spectrum.00829-23] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/26/2023] [Accepted: 07/13/2023] [Indexed: 09/13/2023] Open
Abstract
Acute pancreatitis (AP) is a type of digestive system disease with high mortality. Previous studies have shown that gut microbiota can participate in developing and treating acute pancreatitis by affecting the host's metabolism. In this study, we followed 20 AP patients to generate longitudinal gut microbiota profiles and activity during disease (before treatment, on the third day of treatment, and 1 month after discharge). We analyzed species composition and metabolic pathways' changes across the treatment phase, severity, and etiology. The diversity of the gut microbiome of patients with AP did not show much variation with treatment. In contrast, the metabolic functions of the gut microbiota, such as the essential chemical reactions that produce energy and maintain life, were partially reinstated after treatment. The severe AP (SAP) patients contained less beneficial bacteria (i.e., Bacteroides xylanisolvens, Clostridium lavalense, and Roseburia inulinivorans) and weaker sugar degradation function than mild AP patients before treatment. Moreover, etiology was one of the drivers of gut microbiome composition and explained the 3.54% variation in species' relative abundance. The relative abundance of pathways related to lipid synthesis was higher in the gut of hyperlipidemia AP patients than in biliary AP patients. The composition and functional profiles of the gut microbiota reflect the severity and etiology of AP. Otherwise, we also identified bacterial species associated with SAP, i.e., Oscillibacter sp. 57_20, Parabacteroides johnsonii, Bacteroides stercoris, Methanobrevibacter smithii, Ruminococcus lactaris, Coprococcus comes, and Dorea formicigenerans, which have the potential to identify the SAP at an early stage. IMPORTANCE Acute pancreatitis (AP) is a type of digestive system disease with high mortality. Previous studies have shown that gut microbiota can participate in the development and treatment of acute pancreatitis by affecting the host's metabolism. However, fewer studies acquired metagenomic sequencing data to associate species to functions intuitively and performed longitudinal analysis to explore how gut microbiota influences the development of AP. We followed 20 AP patients to generate longitudinal gut microbiota profiles and activity during disease and studied the differences in intestinal flora under different severities and etiologies. We have two findings. First, the gut microbiota profile has the potential to identify the severity and etiology of AP at an early stage. Second, gut microbiota likely acts synergistically in the development of AP. This study provides a reference for characterizing the driver flora of severe AP to identify the severity of acute pancreatitis at an early stage.
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Affiliation(s)
- Zhenjiang Wang
- Department of Gastroenterology, Zhuhai Hospital Affiliated with Jinan University (Zhuhai People’s Hospital), Zhuhai, China
| | - Mingyi Guo
- Department of Gastroenterology, Zhuhai Hospital Affiliated with Jinan University (Zhuhai People’s Hospital), Zhuhai, China
| | - Jing Li
- School of Management, University of Science and Technology of China, Hefei, Anhui, China
- Department of Research and Development, Shenzhen Byoryn Technology Co., Ltd., Shenzhen, China
| | - Chuangming Jiang
- Department of Gastroenterology, Gaolangang Branch of Zhuhai People’s Hospital (Hospital of Gaolangang), Zhuhai, China
| | - Sen Yang
- Department of Gastroenterology, Zhuhai Hospital Affiliated with Jinan University (Zhuhai People’s Hospital), Zhuhai, China
| | - Shizhuo Zheng
- Department of Gastroenterology, Zhuhai Hospital Affiliated with Jinan University (Zhuhai People’s Hospital), Zhuhai, China
| | - Mingzhe Li
- College of Medicine and Biological Information Engineering, Northeastern University, Shenyang, China
| | - Xinbo Ai
- Department of Gastroenterology, Zhuhai Hospital Affiliated with Jinan University (Zhuhai People’s Hospital), Zhuhai, China
| | - Xiaohong Xu
- Department of Gastroenterology, Zhuhai Hospital Affiliated with Jinan University (Zhuhai People’s Hospital), Zhuhai, China
| | - Wenbo Zhang
- College of Medicine and Biological Information Engineering, Northeastern University, Shenyang, China
| | - Xingxiang He
- Department of Gastroenterology, The First Affiliated Hospital of Jinan University, Guangzhou, China
| | - Yinan Wang
- Department of Obstetrics and Gynecology, Peking University Shenzhen Hospital, Shenzhen, China
| | - Yuping Chen
- Department of Gastroenterology, Zhuhai Hospital Affiliated with Jinan University (Zhuhai People’s Hospital), Zhuhai, China
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Nakai Y, Hamada T, Saito T, Shiomi H, Maruta A, Iwashita T, Iwata K, Takenaka M, Masuda A, Matsubara S, Sato T, Mukai T, Yasuda I, Isayama H. Time to think prime times for treatment of necrotizing pancreatitis: Pendulum conundrum. Dig Endosc 2023; 35:700-710. [PMID: 37209365 DOI: 10.1111/den.14598] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/10/2023] [Accepted: 05/16/2023] [Indexed: 05/22/2023]
Abstract
Pancreatic fluid collections (PFCs) typically develop as local complications of acute pancreatitis and complicate the clinical course of patients with acute pancreatitis and potentially fatal clinical outcomes. Interventions are required in cases of symptomatic walled-off necrosis (WON) (matured PFCs with necrosis) and pancreatic pseudocysts (matured PFCs without necrosis). In the management of necrotizing pancreatitis and WON, endoscopic ultrasound-guided transluminal drainage combined with on-demand endoscopic necrosectomy (i.e. the step-up approach) is increasingly used as a less invasive treatment modality compared with a surgical or percutaneous approach. Through the substantial research efforts and development of specific devices and stents (e.g. lumen-apposing metal stents), endoscopic techniques of PFC management have been standardized to some extent. However, there has been no consensus about timing of carrying out each treatment step; for instance, it is uncertain when direct endoscopic necrosectomy should be initiated and finished and when a plastic or metal stent should be removed following clinical treatment success. Despite emerging evidence for the effectiveness of noninterventional supportive treatment (e.g. antibiotics, nutritional support, irrigation of the cavity), there has been only limited data on the timing of starting and stopping the treatment. Large studies are required to optimize the timing of those treatment options and improve clinical outcomes of patients with PFCs. In this review, we summarize the current available evidence on the indications and timing of interventional and supportive treatment modalities for this patient population and discussed clinical unmet needs that should be addressed in future research.
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Affiliation(s)
- Yousuke Nakai
- Department of Gastroenterology, Graduate School of Medicine, The University of Tokyo, Tokyo, Japan
- Department of Endoscopy and Endoscopic Surgery, The University of Tokyo Hospital, Tokyo, Japan
| | - Tsuyoshi Hamada
- Department of Gastroenterology, Graduate School of Medicine, The University of Tokyo, Tokyo, Japan
- Department of Hepato-Biliary-Pancreatic Medicine, Cancer Institute Hospital of Japanese Foundation for Cancer Research, Tokyo, Japan
| | - Tomotaka Saito
- Department of Gastroenterology, Graduate School of Medicine, The University of Tokyo, Tokyo, Japan
| | - Hideyuki Shiomi
- Division of Gastroenterology and Hepatobiliary and Pancreatic Diseases, Department of Internal Medicine, Hyogo Medical University, Hyogo, Japan
| | - Akinori Maruta
- Department of Gastroenterology, Gifu Prefectural General Medical Center, Gifu, Japan
| | - Takuji Iwashita
- First Department of Internal Medicine, Gifu University Hospital, Gifu, Japan
| | - Keisuke Iwata
- Department of Gastroenterology, Gifu Municipal Hospital, Gifu, Japan
| | - Mamoru Takenaka
- Department of Gastroenterology and Hepatology, Faculty of Medicine, Kindai University, Osaka, Japan
| | - Atsuhiro Masuda
- Division of Gastroenterology, Department of Internal Medicine, Kobe University Graduate School of Medicine, Hyogo, Japan
| | - Saburo Matsubara
- Department of Gastroenterology and Hepatology, Saitama Medical Center, Saitama Medical University, Saitama, Japan
| | - Tatsuya Sato
- Department of Gastroenterology, Graduate School of Medicine, The University of Tokyo, Tokyo, Japan
| | - Tsuyoshi Mukai
- Department of Gastroenterological Endoscopy, Kanazawa Medical University, Ishikawa, Japan
| | - Ichiro Yasuda
- Third Department of Internal Medicine, University of Toyama, Toyama, Japan
| | - Hiroyuki Isayama
- Department of Gastroenterology, Graduate School of Medicine, Juntendo University, Tokyo, Japan
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10
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Yan X, Li J, Wu D. The Role of Short-Chain Fatty Acids in Acute Pancreatitis. Molecules 2023; 28:4985. [PMID: 37446647 DOI: 10.3390/molecules28134985] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/28/2023] [Revised: 06/17/2023] [Accepted: 06/21/2023] [Indexed: 07/15/2023] Open
Abstract
Acute pancreatitis (AP) is a digestive emergency and can develop into a systematic illness. The role of the gut in the progression and deterioration of AP has drawn much attention from researchers, and areas of interest include dysbiosis of the intestinal flora, weakened intestinal barrier function, and bacterial and endotoxin translocation. Short-chain fatty acids (SCFAs), as one of the metabolites of gut microbiota, have been proven to be depleted in AP patients. SCFAs help restore gut homeostasis by rebuilding gut flora, stabilizing the intestinal epithelial barrier, and regulating inflammation. SCFAs can also suppress systematic inflammatory responses, improve the injured pancreas, and prevent and protect other organ dysfunctions. Based on multiple beneficial effects, increasing SCFAs is an essential idea of gut protective treatment in AP. Specific strategies include the direct use of butyrate or indirect supplementation through fiber, pre/pro/synbiotics, or fecal microbiota transplantation as a promising adjective therapy to enteral nutrition.
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Affiliation(s)
- Xiaxiao Yan
- Department of Gastroenterology, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing 100730, China
- Eight-Year Medical Doctor Program, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing 100730, China
| | - Jianing Li
- Department of Gastroenterology, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing 100730, China
| | - Dong Wu
- Department of Gastroenterology, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing 100730, China
- Clinical Epidemiology Unit, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing 100730, China
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11
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Chiba N, Sugita A, Mizuochi M, Sato J, Saito T, Sakurai A, Kinoshita K. Clinical significance of reactive thrombocytosis in the course of acute pancreatitis. BMC Gastroenterol 2023; 23:206. [PMID: 37312072 DOI: 10.1186/s12876-023-02837-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/13/2022] [Accepted: 05/26/2023] [Indexed: 06/15/2023] Open
Abstract
BACKGROUND Reactive thrombocytosis occurs secondary to systemic infections, inflammatory, and other conditions. The relationship between thrombocytosis and acute pancreatitis (AP) in inflammatory diseases is uncertain. This study aimed to evaluate the clinical significance of thrombocytosis in AP patients during hospitalization. METHODS Subjects within 48 h of AP onset were consecutively enrolled over 6 years. Platelet counts of ≥ 450,000/µL were defined as thrombocytosis, < 100,000/µL as thrombocytopenia, and other counts as normal. We compared clinical characteristics, including the rate of severe AP (SAP) assessed by the Japanese Severity Score; blood markers, including hematologic and inflammatory factors and pancreatic enzymes during hospitalization; and pancreatic complications and outcomes in the three groups. RESULTS A total of 108 patients were enrolled. Although, SAP was more common in patients with thrombocytosis and thrombocytopenia (87.9% and 100%, respectively), the differences in lymphocytes and C-reactive protein, lactase dehydrogenase, and antithrombin levels, which are factors of the systemic inflammatory response, and the mean platelet volume, an indicator of platelet activation, were observed among patients with thrombocytosis and thrombocytopenia during hospitalization. Regarding pancreatic complications and outcomes, patients with thrombocytosis and thrombocytopenia had higher acute necrotic collection (ANC), pancreatic necrosis, intestinal paralysis, respiratory dysfunction, and pancreatic-related infection levels than patients with normal platelet levels. The relationship between pancreatic complications and thrombocytosis was assessed by multivariate logistic regression; the odds ratios for development of ANC, pancreatic necrosis and pancreatic-related infections were 7.360, 3.735 and 9.815, respectively. CONCLUSIONS Thrombocytosis during hospitalization for AP suggests development of local pancreatic complications and pancreatic-related infections.
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Affiliation(s)
- Nobutaka Chiba
- Division of Emergency and Critical Care Medicine, Department of Acute Medicine, Nihon University School of Medicine, 30-1 Oyaguchi-kamimachi, Itabashi-Ku, Tokyo, 173-8610, Japan
| | - Atsunori Sugita
- Division of Emergency and Critical Care Medicine, Department of Acute Medicine, Nihon University School of Medicine, 30-1 Oyaguchi-kamimachi, Itabashi-Ku, Tokyo, 173-8610, Japan
| | - Minori Mizuochi
- Division of Emergency and Critical Care Medicine, Department of Acute Medicine, Nihon University School of Medicine, 30-1 Oyaguchi-kamimachi, Itabashi-Ku, Tokyo, 173-8610, Japan
| | - Jun Sato
- Division of Emergency and Critical Care Medicine, Department of Acute Medicine, Nihon University School of Medicine, 30-1 Oyaguchi-kamimachi, Itabashi-Ku, Tokyo, 173-8610, Japan
| | - Takeshi Saito
- Division of Emergency and Critical Care Medicine, Department of Acute Medicine, Nihon University School of Medicine, 30-1 Oyaguchi-kamimachi, Itabashi-Ku, Tokyo, 173-8610, Japan
| | - Atsushi Sakurai
- Division of Emergency and Critical Care Medicine, Department of Acute Medicine, Nihon University School of Medicine, 30-1 Oyaguchi-kamimachi, Itabashi-Ku, Tokyo, 173-8610, Japan
| | - Kosaku Kinoshita
- Division of Emergency and Critical Care Medicine, Department of Acute Medicine, Nihon University School of Medicine, 30-1 Oyaguchi-kamimachi, Itabashi-Ku, Tokyo, 173-8610, Japan.
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12
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Kryvoruchko IA, Boyko VV, Sartelli M, Ivanova YV, Yevtushenko DO, Honcharov AS. Pancreatic Necrosis Infection as a Determinant of Multiple Organ Failure and Mortality in Acute Pancreatitis. Pathogens 2023; 12:pathogens12030428. [PMID: 36986350 PMCID: PMC10054645 DOI: 10.3390/pathogens12030428] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/30/2022] [Revised: 03/06/2023] [Accepted: 03/07/2023] [Indexed: 03/30/2023] Open
Abstract
Several recommendations and data on the treatment of acute necrotizing pancreatitis (ANP) are conflicting and different surgical approaches continue to exist. We conducted a study on 148 patients with ANP, who were divided into two groups: the main group (n = 95) when the tactics of the step-up approach were applied with the principles of the concept of Enhanced Recovery After Surgery (ERAS) in order to determine this approach on effectiveness in reducing complications and 30-day mortality (2017-2022); the comparison group (n = 53) when the same tactic of the treatment was used without ERAS principles (2015-2016). Treatment time for the main group in the intensive care unit was minimized (p ≤ 0.004); it has been shown to reduce the frequency of complications in these patients (p < 0.001) requiring conservative or surgical treatment without general anaesthesia (Clavien-Dindo I-IIIa); no statistically significant differences were observed for the total incidence of Clavien-Dindo IIIb-IVb complications (p > 0.05); the median duration of treatment for patients in the primary group was 23 days, and in the reference group-34 days (p ≤ 0.003). Pancreatic infections have been observed in 92 (62.2%) patients and gram-negative bacteria predominated in the overall pathogen structure with 222 (70.7%) strains. The only evidence of multiple organ failure before (AUC = 0.814) and after surgery (AUC = 0.931) was found to be predictive of mortality. Antibiotic sensitivity of all isolated bacteria better understood local epidemiology and identified the most effective antibiotics when treating patients.
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Affiliation(s)
- Igor A Kryvoruchko
- Department of Surgery No.2, Kharkiv National Medical University, Nezalezhnosti Avenue, 61022 Kharkiv, Ukraine
| | - Valeriy V Boyko
- Institute General and Emergency Surgery Named after V.T. Zaitcev of the National Academy of Medical Sciences of Ukraine, Balakireva Entry, 61103 Kharkiv, Ukraine
- Department of Surgery No.1, Kharkiv National Medical University, Balakireva Entry, 61103 Kharkiv, Ukraine
| | - Massimo Sartelli
- Department of Surgery, Macerata Hospital, Santa Lucia Street, 62100 Macerata, Italy
| | - Yulia V Ivanova
- Department of Surgery No.1, Kharkiv National Medical University, Balakireva Entry, 61103 Kharkiv, Ukraine
| | - Denys O Yevtushenko
- Department of Surgery No.1, Kharkiv National Medical University, Balakireva Entry, 61103 Kharkiv, Ukraine
| | - Andrij S Honcharov
- Department of Surgery No.2, Kharkiv National Medical University, Nezalezhnosti Avenue, 61022 Kharkiv, Ukraine
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13
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Muacevic A, Adler JR. Predicting the Success of Catheter Drainage in Infected Necrotising Pancreatitis: A Cross-Sectional Observational Study. Cureus 2022; 14:e32289. [PMID: 36505951 PMCID: PMC9728500 DOI: 10.7759/cureus.32289] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 12/07/2022] [Indexed: 12/12/2022] Open
Abstract
Background Management of acute necrotising pancreatitis is often challenging for clinicians. Secondary infection of the necrotic collections leads to sepsis and warrants intervention. Minimally invasive techniques like catheter drainage have recently been proposed over more risky and morbid traditional open procedures. Factors that can predict successful catheter drainage of the necrotic pancreatic collection are still unclear and not well established. Materials and methods This study is designed as a retrospective cross-sectional observational study to investigate the association of 21 factors in predicting successful catheter drainage. Data from 30 patients admitted with acute necrotising pancreatitis treated with catheter drainage were collected and analysed. Twenty-one factors, including demographic variables, disease severity factors, drainage criteria, and morphological criteria on imaging, were studied for their predictive association with successful outcomes. Univariate analysis was done for each variable against the outcome. The study was conducted between December 2012 to March 2017. P-value <0.05 was considered statistically significant. Results Patients with no organ involvement responded better to primary catheter drainage. Patients with BMI>25 and multi-organ failure were poor candidates for primary catheter drainage. Clinically unwell patients with a Bedside Index for Severity in Acute Pancreatitis (BISAP) score of ≥4 had a negative outcome on catheter drainage and usually ended up in a surgical procedure or eventually succumbed to the disease. Other variables included in our study did not statistically associate with the success or failure of percutaneous catheter drainage. Conclusion BMI >25, multiple organ failure, and BISAP score ≥ 4 are independent negative predictors for the success of catheter drainage in infected necrotising pancreatitis. No organ failure showed a positive predictor for successful catheter drainage. Further studies are required to explore these predictive factors in a larger sample size to predict the success of catheter drainage in infected pancreatic necrosis.
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14
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The microbiota and aging microenvironment in pancreatic cancer: Cell origin and fate. Biochim Biophys Acta Rev Cancer 2022; 1877:188826. [DOI: 10.1016/j.bbcan.2022.188826] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/19/2022] [Revised: 10/14/2022] [Accepted: 10/15/2022] [Indexed: 11/30/2022]
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15
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Nakai Y, Shiomi H, Hamada T, Ota S, Takenaka M, Iwashita T, Sato T, Saito T, Masuda A, Matsubara S, Iwata K, Mukai T, Isayama H, Yasuda I. Early versus delayed interventions for necrotizing pancreatitis: A systematic review and meta-analysis. DEN OPEN 2022; 3:e171. [PMID: 36247314 PMCID: PMC9549879 DOI: 10.1002/deo2.171] [Citation(s) in RCA: 19] [Impact Index Per Article: 9.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 08/08/2022] [Revised: 09/07/2022] [Accepted: 09/18/2022] [Indexed: 11/05/2022]
Abstract
Objectives Interventions for necrotizing pancreatitis are generally postponed until 4 weeks after the onset of acute pancreatitis, but there remains controversy about whether we should always wait >4 weeks or can intervene early when necessary. This meta‐analysis was conducted to evaluate treatment outcomes of necrotizing pancreatitis according to the cut‐off defined in the revised Atlanta classification (≤4 vs. >4 weeks). Methods Using PubMed, Web of Science, and the Cochrane database, we identified clinical studies published until March 2022 with data comparing outcomes of early and delayed interventions of necrotizing pancreatitis. We pooled data on adverse events, mortality, technical and clinical success rates, and needs for necrosectomy and open surgery, using the random‐effects model. Results We identified 11 retrospective studies, including 775 patients with early interventions and 725 patients with delayed interventions. Patients with early interventions tended to be complicated by organ failure. The rate of adverse events was comparable (OR 1.41, 95% CI 0.66–3.01; p = 0.38) but the rate of mortality was significantly higher (OR 1.70, 95% CI 1.21–2.40; p < 0.01) in early interventions. Technical success rates were similarly high but clinical success rates tended to be low (OR 0.39, 95% CI 0.15–1.00; p = 0.05) in early interventions, though not statistically significant. Pooled ORs for necrosectomy and open surgery were 2.14 and 1.23, respectively. Conclusions Early interventions for necrotizing pancreatitis were associated with higher mortality rates and did not reduce adverse events or improve clinical success. However, our results should be confirmed in prospective studies.
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Affiliation(s)
- Yousuke Nakai
- Department of GastroenterologyGraduate School of MedicineThe University of TokyoTokyoJapan,Department of Endoscopy and Endoscopic SurgeryThe University of Tokyo HospitalTokyoJapan
| | - Hideyuki Shiomi
- Division of Gastroenterology and Hepatobiliary and Pancreatic DiseasesDepartment of Internal MedicineHyogo Medical UniversityHyogoJapan
| | - Tsuyoshi Hamada
- Department of GastroenterologyGraduate School of MedicineThe University of TokyoTokyoJapan,Department of Hepato‐Biliary‐Pancreatic MedicineThe Cancer Institute Hospital of Japanese Foundation for Cancer ResearchTokyoJapan
| | - Shogo Ota
- Division of Gastroenterology and Hepatobiliary and Pancreatic DiseasesDepartment of Internal MedicineHyogo Medical UniversityHyogoJapan
| | - Mamoru Takenaka
- Department of Gastroenterology and HepatologyKindai University Faculty of MedicineOsakaJapan
| | - Takuji Iwashita
- First Department of Internal MedicineGifu University HospitalGifuJapan
| | - Tatsuya Sato
- Department of GastroenterologyGraduate School of MedicineThe University of TokyoTokyoJapan
| | - Tomotaka Saito
- Department of GastroenterologyGraduate School of MedicineThe University of TokyoTokyoJapan
| | - Atsuhiro Masuda
- Division of GastroenterologyDepartment of Internal MedicineKobe University Graduate School of MedicineHyogoJapan
| | - Saburo Matsubara
- Department of Gastroenterology and Hepatology, Saitama Medical CenterSaitama Medical UniversitySaitamaJapan
| | - Keisuke Iwata
- Department of GastroenterologyGifu Municipal HospitalGifuJapan
| | - Tsuyoshi Mukai
- Department of Gastroenterological EndoscopyKanazawa Medical UniversityIshikawaJapan
| | - Hiroyuki Isayama
- Department of GastroenterologyGraduate School of MedicineJuntendo UniversityTokyoJapan
| | - Ichiro Yasuda
- Third Department of Internal MedicineUniversity of ToyamaToyamaJapan
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16
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Chida K, Ishido K, Sakamoto Y, Kimura N, Morohashi H, Miura T, Wakiya T, Yokoyama H, Nagase H, Ichinohe D, Suto A, Kuwata D, Ichisawa A, Nakamura A, Kasai D, Hakamada K. Necrotizing pancreatitis complicated by retroperitoneal emphysema: two case reports. Surg Case Rep 2022; 8:183. [PMID: 36163599 PMCID: PMC9512950 DOI: 10.1186/s40792-022-01542-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/30/2022] [Accepted: 09/22/2022] [Indexed: 12/02/2022] Open
Abstract
Background Emphysematous pancreatitis is acute pancreatitis associated with emphysema based on imaging studies and has been considered a subtype of necrotizing pancreatitis. Although some recent studies have reported the successful use of conservative treatment, it is still considered a serious condition. Computed tomography (CT) scan is useful in identifying emphysema associated with acute pancreatitis; however, whether the presence of emphysema correlates with the severity of pancreatitis remains controversial. In this study, we managed two cases of severe acute pancreatitis complicated with retroperitoneal emphysema successfully by treatment with lavage and drainage. Case presentation Case 1: A 76-year-old man was referred to our hospital after being diagnosed with acute pancreatitis. At post-admission, his abdominal symptoms worsened, and a repeat CT scan revealed increased retroperitoneal gas. Due to the high risk for gastrointestinal tract perforation, emergent laparotomy was performed. Fat necrosis was observed on the anterior surface of the pancreas, and a diagnosis of acute necrotizing pancreatitis with retroperitoneal emphysema was made. Thus, retroperitoneal drainage was performed. Case 2: A 50-year-old woman developed anaphylactic shock during the induction of general anesthesia for lumbar spine surgery, and peritoneal irritation symptoms and hypotension occurred on the same day. Contrast-enhanced CT scan showed necrotic changes in the pancreatic body and emphysema surrounding the pancreas. Therefore, she was diagnosed with acute necrotizing pancreatitis with retroperitoneal emphysema, and retroperitoneal cavity lavage and drainage were performed. In the second case, the intraperitoneal abscess occurred postoperatively, requiring time for drainage treatment. Both patients showed no significant postoperative course problems and were discharged on postoperative days 18 and 108, respectively. Conclusion Acute pancreatitis with emphysema from the acute phase highly indicates severe necrotizing pancreatitis. Surgical drainage should be chosen without hesitation in necrotizing pancreatitis with emphysema from early onset.
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Xiao HL, Wang GX, Wang Y, Tan ZM, Zhou J, Yu H, Xie MR, Li CS. Dynamic blood presepsin levels are associated with severity and outcome of acute pancreatitis: A prospective cohort study. World J Gastroenterol 2022; 28:5203-5216. [PMID: 36188715 PMCID: PMC9516673 DOI: 10.3748/wjg.v28.i35.5203] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/06/2022] [Revised: 07/10/2022] [Accepted: 09/01/2022] [Indexed: 02/06/2023] Open
Abstract
BACKGROUND Acute pancreatitis (AP) is an inflammatory disorder of the pancreas with an unpredictable course of illness. A major challenge of AP is the early identification of patients at high-risk for organ failure and death. However, scoring systems are complicated and time consuming, and the predictive values for the clinical course are vague.
AIM To determine whether the dynamic changes in presepsin levels can be used to evaluate the severity of disease and outcome of AP.
METHODS In this multicentric cohort study, 133 patients with AP were included. Clinical severity was dynamically evaluated using the 2012 revised Atlanta Classification. Blood presepsin levels were measured at days 1, 3, 5 and 7 after admission by chemiluminescent enzyme immunoassay.
RESULTS The median concentration of presepsin increased and the clearance rate of presepsin decreased with disease severity and organ failure in AP patients. The presepsin levels on days 3, 5 and 7 were independent predictors of moderately severe and severe AP with time-specific area under the curve (AUC) values of 0.827, 0.848 and 0.867, respectively. The presepsin levels positively correlated with bedside index of severity in AP, Ranson, acute physiology and chronic health evaluation II, computed tomography severity index and Marshall scores. Presepsin levels on days 3, 5 and 7 were independent predictors of 28-d mortality of AP patients with AUC values of 0.781, 0.846 and 0.843, respectively.
CONCLUSION Blood presepsin levels within 7 d of admission were associated with and may be useful to dynamically predict the severity of disease course and 28-d mortality in AP patients.
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Affiliation(s)
- Hong-Li Xiao
- Department of Emergency Medicine, Beijing Friendship Hospital, Capital Medical University, Beijing 100050, China
| | - Guo-Xing Wang
- Department of Emergency Medicine, Beijing Friendship Hospital, Capital Medical University, Beijing 100050, China
| | - Yan Wang
- Department of Emergency Medicine, Beijing Friendship Hospital, Capital Medical University, Beijing 100050, China
| | - Zhi-Min Tan
- Department of Emergency Medicine, Beijing Friendship Hospital, Capital Medical University, Beijing 100050, China
| | - Jie Zhou
- Department of Emergency Medicine, Beijing Friendship Hospital, Capital Medical University, Beijing 100050, China
| | - Han Yu
- Department of Emergency Medicine, Beijing Chao-Yang Hospital, Capital Medical University, Beijing 100020, China
| | - Miao-Rong Xie
- Department of Emergency Medicine, Beijing Friendship Hospital, Capital Medical University, Beijing 100050, China
| | - Chun-Sheng Li
- Department of Emergency Medicine, Beijing Friendship Hospital, Capital Medical University, Beijing 100050, China
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18
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Emerging Trends in Intestinal Knowledge Structure Associated With Acute Pancreatitis From 1981 to 2021: A Bibliometric Analysis. Pancreas 2022; 51:957-965. [PMID: 36607940 DOI: 10.1097/mpa.0000000000002140] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/07/2023]
Abstract
OBJECTIVES Bibliometric analysis has not comprehensively summarized studies of acute pancreatitis (AP)-associated intestinal diseases. This work aimed to evaluate cooperative networks of authors, countries, and institutions and explore the field's developing trends and hot topics. METHODS Original articles and reviews of AP-associated intestinal diseases were obtained from the Web of Science Core Collection on October 11, 2021. VOSviewer and CiteSpace software were used to perform co-occurrence analyses for authors, countries, and institutions and detect the highest citation burst. RESULTS A total of 1634 articles on the intestine associated with AP were identified. The United States, the University of Auckland, and Roland Andersson are the most influential country, research institute, and scholar, respectively. The World Journal of Gastroenterology (73 articles) has the highest number of publications, and Gastroenterology was the most co-cited journal. The top 5 key words are "acute pancreatitis," "bacterial translocation," "management," "gut," and "inflammatory bowel disease." We find that several emergent key words like "gut microbiota," "pathway," "gut barrier," "risk," and "oxidative stress" experienced a continuous and rapid development as new research directions. CONCLUSIONS This bibliometric study summarizes current important perspectives and offers comprehensive guidance on the AP-associated intestinal diseases, which may help researchers choose the most appropriate research directions.
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Diagnosis and Treatment of Acute Pancreatitis. Diagnostics (Basel) 2022; 12:diagnostics12081974. [PMID: 36010324 PMCID: PMC9406704 DOI: 10.3390/diagnostics12081974] [Citation(s) in RCA: 11] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/08/2022] [Revised: 08/02/2022] [Accepted: 08/08/2022] [Indexed: 11/25/2022] Open
Abstract
The pancreas is a glandular organ that is responsible for the proper functioning of the digestive and endocrine systems, and therefore, it affects the condition of the entire body. Consequently, it is important to effectively diagnose and treat diseases of this organ. According to clinicians, pancreatitis—a common disease affecting the pancreas—is one of the most complicated and demanding diseases of the abdomen. The classification of pancreatitis is based on clinical, morphologic, and histologic criteria. Medical doctors distinguish, inter alia, acute pancreatitis (AP), the most common causes of which are gallstone migration and alcohol abuse. Effective diagnostic methods and the correct assessment of the severity of acute pancreatitis determine the selection of an appropriate treatment strategy and the prediction of the clinical course of the disease, thus preventing life-threatening complications and organ dysfunction or failure. This review collects and organizes recommendations and guidelines for the management of patients suffering from acute pancreatitis.
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Singh S, Prakash S, Kaushal D, Chahal H, Sood A. Percutaneous Catheter Drainage in Acute Infected Necrotizing Pancreatitis: A Real-World Experience at a Tertiary Care Hospital in North India. Cureus 2022; 14:e27994. [PMID: 36120245 PMCID: PMC9469754 DOI: 10.7759/cureus.27994] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 08/14/2022] [Indexed: 12/02/2022] Open
Abstract
Introduction Open necrosectomy in acute infected necrotizing pancreatitis is associated with very high mortality and morbidity. Moreover, if it is performed before four weeks, the benefits are limited. In this study, we evaluated the safety and efficacy of percutaneous catheter drainage (PCD) in patients with acute infected necrotizing pancreatitis. Methods It was a single-center, observational study, where all consecutive patients with proven or probable infected acute necrotizing pancreatitis in whom PCD was performed were studied. The patients who failed to respond to PCD underwent open necrosectomy. Baseline characteristics and the outcome of all included patients, including complications of PCD, were studied. Results A total of 46 patients (males=36, females=10) underwent PCD over a period of 18 months. Fifteen (32.60%) patients succumbed to their illness. PCD benefitted a total of 31 (67.39%) patients; in 17 (36.95%) patients, it worked as a standalone therapy, while in 14 (30.43%) patients, additional surgery was required where it helped to delay the surgery. Median days at which PCD and surgery were performed were 17.5 days (range: 2-28 days) and 33 days (range: 7-70 days), respectively. Lower mean arterial pressure at presentation, presence of multiorgan failure, more than 50% necrosis, higher baseline creatinine and bilirubin levels, and an early surgery were markers of increased mortality. Three (6.5%) patients had PCD-related complications, out of which only one required active intervention. Conclusion PCD in infected acute pancreatic necrosis is safe and effective. In one-third of the patients, it worked as standalone therapy, and in the rest it delayed the surgery beyond four weeks, thereby preventing the complications associated with early aggressive debridement.
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Tran A, Fernando SM, Rochwerg B, Inaba K, Bertens KA, Engels PT, Balaa FK, Kubelik D, Matar M, Lenet TI, Martel G. Prognostic factors associated with development of infected necrosis in patients with acute necrotizing or severe pancreatitis-A systematic review and meta-analysis. J Trauma Acute Care Surg 2022; 92:940-948. [PMID: 34936587 DOI: 10.1097/ta.0000000000003502] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/08/2022]
Abstract
PURPOSE Acute pancreatitis is a potentially life-threatening condition with a wide spectrum of clinical presentation and illness severity. An infection of pancreatic necrosis (IPN) results in a more than twofold increase in mortality risk as compared with patients with sterile necrosis. We sought to identify prognostic factors for the development of IPN among adult patients with severe or necrotizing pancreatitis. METHODS We conducted this prognostic review in accordance with systematic review methodology guidelines. We searched six databases from inception through March 21, 2021. We included English language studies describing prognostic factors associated with the development of IPN. We pooled unadjusted odds ratio (uOR) and adjusted odds ratios (aOR) for prognostic factors using a random-effects model. We assessed risk of bias using the Quality in Prognosis Studies tool and certainty of evidence using the GRADE approach. RESULTS We included 31 observational studies involving 5,210 patients. Factors with moderate or higher certainty of association with increased IPN risk include older age (uOR, 2.19; 95% confidence interval [CI], 1.39-3.45, moderate certainty), gallstone etiology (aOR, 2.35; 95% CI, 1.36-4.04, high certainty), greater than 50% necrosis of the pancreas (aOR, 3.61; 95% CI, 2.15-6.04, high certainty), delayed enteral nutrition (aOR, 2.09; 95% CI, 1.26-3.47, moderate certainty), multiple or persistent organ failure (aOR, 11.71; 95% CI, 4.97-27.56, high certainty), and invasive mechanical ventilation (uOR, 12.24; 95% CI, 2.28-65.67, high certainty). CONCLUSION This meta-analysis confirms the association between several clinical early prognostic factors and the risk of IPN development among patients with severe or necrotizing pancreatitis. These findings provide the foundation for the development of an IPN risk stratification tool to guide more targeted clinical trials for prevention or early intervention strategies. LEVEL OF EVIDENCE Systematic review and meta-analysis, Level IV.
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Affiliation(s)
- Alexandre Tran
- From the Department of Surgery (A.T., K.A.B., F.K.B., D.K., M.M., T.I.L., G.M.), School of Epidemiology and Public Health (A.T., T.I.L., G.M.), Division of Critical Care, Department of Medicine (A.T., S.M.F., D.K.), Department of Emergency Medicine (S.M.F.), University of Ottawa, Ottawa; Department of Medicine (B.R.), Department of Health Research Methods, Evidence, and Impact (B.R.), McMaster University, Hamilton, ON, Canada; Division of Acute Care Surgery, Department of Surgery (K.I.), University of Southern California, Los Angeles, California; Division of General Surgery, Department of Surgery (P.T.E.), and Division of Critical Care, Department of Medicine (P.T.E.), McMaster University, Hamilton, Canada
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Mohamadnejad M, Anushiravani A, Kasaeian A, Sorouri M, Djalalinia S, Kazemzadeh Houjaghan A, Gaidhane M, Kahaleh M. Endoscopic or surgical treatment for necrotizing pancreatitis: Comprehensive systematic review and meta-analysis. Endosc Int Open 2022; 10:E420-E428. [PMID: 35433210 PMCID: PMC9010078 DOI: 10.1055/a-1783-9229] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/09/2021] [Accepted: 11/10/2021] [Indexed: 11/18/2022] Open
Abstract
Background and study aims Treatment of necrotizing pancreatitis is changed over the past two decades with the availability of endoscopic, and minimally invasive surgical approaches. The aim of this systematic review was to assess outcomes of endoscopic drainage, and different types of surgical drainage approaches in necrotizing pancreatitis. Methods Medline, Embase, Scopus, and Web of Science were searched from 1998 to 2020 to assess outcomes in endoscopic drainage and various surgical drainage procedures. The assessed variables consisted of mortality, development of pancreatic or enteric fistula, new onset diabetes mellitus, and exocrine pancreatic insufficiency. Results One hundred seventy studies comprising 11,807 patients were included in the final analysis. The pooled mortality rate was 22 % (95 % confidence interval [CI]: 19%-26 %) in the open surgery (OS), 8 % (95 %CI:5 %-11 %) in minimally invasive surgery (MIS), 13 % (95 %CI: 9 %-18 %) in step-up approach, and 3 % (95 %CI:2 %-4 %) in the endoscopic drainage (ED). The pooled rate of fistula formation was 35 % (95 %CI:28 %-41 %) in the OS, 17 % (95 %CI: 12%-23 %) in MIS, 17 % (95 %CI: 9 %-27 %) in step-up approach, and 2 % (95 %CI: 0 %-4 %) in ED. There were 17 comparative studies comparing various surgical drainage methods with ED. The mortality rate was significantly lower in ED compared to OS (risk ratio [RR]: 30; 95 %CI: 0.20-0.45), and compared to MIS (RR: 0.40; 95 %CI: 0.26-0.6). Also, the rate of fistula formation was lower in ED compared to all other surgical drainage approaches. Conclusions This systematic review demonstrated lower rate of fistula formation with ED compared to various surgical drainage methods. A lower rate of mortality with ED was also observed in observational studies. PROSPERO Identifier: CRD42020139354.
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Affiliation(s)
- Mehdi Mohamadnejad
- Liver and Pancreaticobiliary Research Center, Digestive Disease Research Institute, Tehran University of Medical Sciences, Tehran, Iran
| | - Amir Anushiravani
- Liver and Pancreaticobiliary Research Center, Digestive Disease Research Institute, Tehran University of Medical Sciences, Tehran, Iran
| | - Amir Kasaeian
- Liver and Pancreaticobiliary Research Center, Digestive Disease Research Institute, Tehran University of Medical Sciences, Tehran, Iran,Hematology, Oncology and Stem Cell Transplantation Research Center, Research Institute for Oncology, Hematology and Cell Therapy, Tehran University of Medical Sciences, Tehran, Iran,Inflammation Research Center, Tehran University of Medical Sciences, Tehran, Iran.
| | - Majid Sorouri
- Liver and Pancreaticobiliary Research Center, Digestive Disease Research Institute, Tehran University of Medical Sciences, Tehran, Iran
| | - Shirin Djalalinia
- Deputy of Research and Technology, Ministry of Health and Medical Education, Tehran, Iran
| | - Amirmasoud Kazemzadeh Houjaghan
- Liver and Pancreaticobiliary Research Center, Digestive Disease Research Institute, Tehran University of Medical Sciences, Tehran, Iran
| | - Monica Gaidhane
- Division of Gastroenterology, Rutgers-Robert Wood Johnson Medical School, New Brunswick, New Jersey, United States
| | - Michel Kahaleh
- Division of Gastroenterology, Rutgers-Robert Wood Johnson Medical School, New Brunswick, New Jersey, United States
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Hentschel V, Walter B, Harder N, Arnold F, Seufferlein T, Wagner M, Müller M, Kleger A. Microbial Spectra and Clinical Outcomes from Endoscopically Drained Pancreatic Fluid Collections: A Descriptive Cohort Study. Antibiotics (Basel) 2022; 11:antibiotics11030420. [PMID: 35326883 PMCID: PMC8944472 DOI: 10.3390/antibiotics11030420] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/14/2022] [Revised: 03/04/2022] [Accepted: 03/12/2022] [Indexed: 12/10/2022] Open
Abstract
Pancreatic pseudocyst (PC) and walled-off necrosis (WON) are dreaded complications of acute pancreatitis. Standard therapy consists of endoscopic ultrasound-guided transmural placement of stents to expedite resolution through internal drainage of fluids or necrotic material. Either double pigtail plastic stents (DPPS) or lumen-apposing metal stents (LAMS), or a combination of both, are available for this purpose. The objective of this study was to examine the impact of different stent types on infection rates in addition to clinical outcome measures such as periprocedural adverse events. We conducted a retrospective study comprising 77 patients who had undergone endoscopic drainage for PC or WON in a pancreatitis tertiary referral center. Analysis revealed that both bacterial and fungal infections occurred more frequently in patients treated with LAMS with or without DPPS compared to DPPS only. The use of antibiotics and antimycotics followed the same pattern. Furthermore, a prolonged length of hospital stay and a higher likelihood of transfer to an intermediate care unit were observed in patients with LAMS with or without DPPS. These differences were eliminated if only WON patients were analyzed. Our data imply that the clinical course is primarily influenced by the complexity of the pancreatic fluid collection (PFC) itself rather than the stent type. Prospective large-scale cohort studies are mandatory to underpin these findings.
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Affiliation(s)
- Viktoria Hentschel
- Department of Gastroenterology, Clinic of Internal Medicine 1, University Hospital of Ulm, 89081 Ulm, Germany; (V.H.); (B.W.); (N.H.); (F.A.); (T.S.); (M.W.); (M.M.)
- Interdisciplinary Endoscopy Unit, University Hospital of Ulm, 89081 Ulm, Germany
| | - Benjamin Walter
- Department of Gastroenterology, Clinic of Internal Medicine 1, University Hospital of Ulm, 89081 Ulm, Germany; (V.H.); (B.W.); (N.H.); (F.A.); (T.S.); (M.W.); (M.M.)
- Interdisciplinary Endoscopy Unit, University Hospital of Ulm, 89081 Ulm, Germany
| | - Noemi Harder
- Department of Gastroenterology, Clinic of Internal Medicine 1, University Hospital of Ulm, 89081 Ulm, Germany; (V.H.); (B.W.); (N.H.); (F.A.); (T.S.); (M.W.); (M.M.)
| | - Frank Arnold
- Department of Gastroenterology, Clinic of Internal Medicine 1, University Hospital of Ulm, 89081 Ulm, Germany; (V.H.); (B.W.); (N.H.); (F.A.); (T.S.); (M.W.); (M.M.)
| | - Thomas Seufferlein
- Department of Gastroenterology, Clinic of Internal Medicine 1, University Hospital of Ulm, 89081 Ulm, Germany; (V.H.); (B.W.); (N.H.); (F.A.); (T.S.); (M.W.); (M.M.)
- Interdisciplinary Endoscopy Unit, University Hospital of Ulm, 89081 Ulm, Germany
| | - Martin Wagner
- Department of Gastroenterology, Clinic of Internal Medicine 1, University Hospital of Ulm, 89081 Ulm, Germany; (V.H.); (B.W.); (N.H.); (F.A.); (T.S.); (M.W.); (M.M.)
- Interdisciplinary Endoscopy Unit, University Hospital of Ulm, 89081 Ulm, Germany
| | - Martin Müller
- Department of Gastroenterology, Clinic of Internal Medicine 1, University Hospital of Ulm, 89081 Ulm, Germany; (V.H.); (B.W.); (N.H.); (F.A.); (T.S.); (M.W.); (M.M.)
- Interdisciplinary Endoscopy Unit, University Hospital of Ulm, 89081 Ulm, Germany
| | - Alexander Kleger
- Department of Gastroenterology, Clinic of Internal Medicine 1, University Hospital of Ulm, 89081 Ulm, Germany; (V.H.); (B.W.); (N.H.); (F.A.); (T.S.); (M.W.); (M.M.)
- Interdisciplinary Endoscopy Unit, University Hospital of Ulm, 89081 Ulm, Germany
- Correspondence: ; Tel.: +49-731-5000
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Stassen PMC, de Jonge PJF, Bruno MJ, Koch AD, Trindade AJ, Benias PC, Sejpal DV, Siddiqui UD, Chapman CG, Villa E, Tharian B, Inamdar S, Hwang JH, Barakat MT, Andalib I, Gaidhane M, Sarkar A, Shahid H, Tyberg A, Binmoeller K, Watson RR, Nett A, Schlag C, Abdelhafez M, Friedrich-Rust M, Schlachterman A, Chiang AL, Loren D, Kowalski T, Kahaleh M. Safety and efficacy of a novel resection system for direct endoscopic necrosectomy of walled-off pancreas necrosis: a prospective, international, multicenter trial. Gastrointest Endosc 2022; 95:471-479. [PMID: 34562471 DOI: 10.1016/j.gie.2021.09.025] [Citation(s) in RCA: 18] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/09/2021] [Accepted: 09/10/2021] [Indexed: 02/08/2023]
Abstract
BACKGROUND AND AIMS Direct endoscopic necrosectomy (DEN) of walled-off pancreatic necrosis (WOPN) lacks dedicated instruments and requires repetitive and cumbersome procedures. This study evaluated the safety and efficacy of a new powered endoscopic debridement (PED) system designed to simultaneously resect and remove solid debris within WOPN. METHODS This was a single-arm, prospective, multicenter, international device trial conducted from November 2018 to August 2019 at 10 sites. Patients with WOPN ≥6 cm and ≤22 cm and with >30% solid debris were enrolled. The primary endpoint was safety through 21 days after the last DEN procedure. Efficacy outcomes included clearance of necrosis, procedural time, adequacy of debridement, number of procedures until resolution, hospital stay duration, and quality of life. RESULTS Thirty patients (mean age, 55 years; 60% men) underwent DEN with no device-related adverse events. Of 30 patients, 15 (50%) achieved complete debridement in 1 session and 20 (67%) achieved complete debridement within 2 or fewer sessions. A median of 1.5 interventions (range, 1-7) were required. Median hospital stay was 10 days (interquartile range, 22). There was an overall reduction of 91% in percent necrosis within WOPN from baseline to follow-up and 85% in collection volume. Baseline WOPN volume was positively correlated with the total number of interventions (ρ = .363, P = .049). CONCLUSIONS The new PED system seems to be a safe and effective treatment tool for WOPN, resulting in fewer interventions and lower hospital duration when compared with published data on using conventional instruments. Randomized controlled trials comparing the PED system with conventional DEN are needed. (Clinical trial registration number: NCT03694210.).
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Affiliation(s)
- Pauline M C Stassen
- Department of Gastroenterology and Hepatology, Erasmus MC University Medical Center Rotterdam, Rotterdam, The Netherlands
| | - Pieter Jan F de Jonge
- Department of Gastroenterology and Hepatology, Erasmus MC University Medical Center Rotterdam, Rotterdam, The Netherlands
| | - Marco J Bruno
- Department of Gastroenterology and Hepatology, Erasmus MC University Medical Center Rotterdam, Rotterdam, The Netherlands
| | - Arjun D Koch
- Department of Gastroenterology and Hepatology, Erasmus MC University Medical Center Rotterdam, Rotterdam, The Netherlands
| | - Arvind J Trindade
- Zucker School of Medicine at Hofstra/Northwell, Northwell Health System, Long Island Jewish Medical Center, New Hyde Park, New York, USA
| | - Petros C Benias
- Zucker School of Medicine at Hofstra/Northwell, Northwell Health System, Long Island Jewish Medical Center, New Hyde Park, New York, USA
| | - Divyesh V Sejpal
- Zucker School of Medicine at Hofstra/Northwell, Northwell Health System, Long Island Jewish Medical Center, New Hyde Park, New York, USA
| | - Uzma D Siddiqui
- The Center for Endoscopic Research and Therapeutics (CERT), University of Chicago Medicine, Chicago, Illinois, USA
| | - Christopher G Chapman
- The Center for Endoscopic Research and Therapeutics (CERT), University of Chicago Medicine, Chicago, Illinois, USA
| | - Edward Villa
- Division of Gastroenterology and Hepatology, University of Illinois at Chicago Medical Center, Chicago, Illinois, USA
| | - Benjamin Tharian
- Department of Internal Medicine, Division of Gastroenterology and Hepatology, University of Arkansas for Medical Sciences, Little Rock, Arkansas, USA
| | - Sumant Inamdar
- Department of Internal Medicine, Division of Gastroenterology and Hepatology, University of Arkansas for Medical Sciences, Little Rock, Arkansas, USA
| | - Joo Ha Hwang
- Division of Gastroenterology and Hepatology, Stanford University Medical Center, Stanford University, Stanford, California, USA
| | - Monique T Barakat
- Division of Gastroenterology and Hepatology, Stanford University Medical Center, Stanford University, Stanford, California, USA
| | - Iman Andalib
- Division of Gastroenterology, Rutgers Robert Wood Johnson Medical School, New Brunswick, New Jersey, USA
| | - Monica Gaidhane
- Division of Gastroenterology, Rutgers Robert Wood Johnson Medical School, New Brunswick, New Jersey, USA
| | - Avik Sarkar
- Division of Gastroenterology, Rutgers Robert Wood Johnson Medical School, New Brunswick, New Jersey, USA
| | - Haroon Shahid
- Division of Gastroenterology, Rutgers Robert Wood Johnson Medical School, New Brunswick, New Jersey, USA
| | - Amy Tyberg
- Division of Gastroenterology, Rutgers Robert Wood Johnson Medical School, New Brunswick, New Jersey, USA
| | - Kenneth Binmoeller
- Interventional Endoscopy Services, California Pacific Medical Center, San Francisco, California, USA
| | - Rabindra R Watson
- Interventional Endoscopy Services, California Pacific Medical Center, San Francisco, California, USA
| | - Andrew Nett
- Interventional Endoscopy Services, California Pacific Medical Center, San Francisco, California, USA
| | - Christoph Schlag
- Medical Department, Klinikum rechts der Isar, Technical University of Munich, Munich, Germany
| | - Mohamed Abdelhafez
- Medical Department, Klinikum rechts der Isar, Technical University of Munich, Munich, Germany
| | - Mireen Friedrich-Rust
- Department of Internal Medicine 1, Hospital of the Goethe University Frankfurt, Frankfurt am Main, Germany
| | - Alexander Schlachterman
- Department of Gastroenterology and Hepatology, Thomas Jefferson University, Philadelphia, Pennsylvania, USA
| | - Austin L Chiang
- Department of Gastroenterology and Hepatology, Thomas Jefferson University, Philadelphia, Pennsylvania, USA
| | - David Loren
- Department of Gastroenterology and Hepatology, Thomas Jefferson University, Philadelphia, Pennsylvania, USA
| | - Thomas Kowalski
- Department of Gastroenterology and Hepatology, Thomas Jefferson University, Philadelphia, Pennsylvania, USA
| | - Michel Kahaleh
- Division of Gastroenterology, Rutgers Robert Wood Johnson Medical School, New Brunswick, New Jersey, USA
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Sureka B, Rai B, Varshney VK, Nag VL, Garg MK, Garg P, Yadav T, Khera PS. Diffusion-Weighted Magnetic Resonance Imaging Is an Ideal Imaging Method to Detect Infection in Pancreatic Collections: A Brief Primer for the Gastroenterologists. Cureus 2022; 14:e21530. [PMID: 35223305 PMCID: PMC8863503 DOI: 10.7759/cureus.21530] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 01/23/2022] [Indexed: 11/30/2022] Open
Abstract
Background: The development of infection in pancreatitis significantly increases the mortality rate up to 100% in the absence of any intervention. Therefore, it is extremely important to diagnose these cases at an early stage. The objectives of this study were to assess the diagnostic performance of computed tomography (CT) and diffusion-weighted MR imaging (DW-MRI) in the diagnosis of infection in pancreatic collections. Materials and methods: Prospective observational study of abdominal collections due to pancreatitis that underwent both CT and DW-MRI from August 2018 to July 2020 were enrolled in the study. The collections were analysed for infections - air foci in CT and diffusion restriction on DW-MRI. Results: Of the 39 patients recruited in the study, infected collections were present in 17, and 22 cases had sterile collections. On CT, air foci within the collection were present only in seven of the cases in our study (sensitivity 35%, specificity 95.4%, PPV 85.7%, NPV 65.6%). DW-MRI detected infection in all 17 cases (sensitivity 100%, specificity 72.7%, PPV 74%, NPV 100%). Discussion: Thirteen out of 17 collections suspicious for infection on DW-MR showed microbiological growth on culture examination. We believe that this is likely due to the patient's prior antibiotic use, which might have altered the micro-environment or inflammatory cell and bacterial content of the collection. Conclusion: DW-MRI is complementary and superior to CT in detecting infection in pancreatic collections. CT may be used to detect disease burden, extent and vascular complication.
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Daniluk J, Daniluk U, Rogalski P, Dabrowski A, Swidnicka-Siergiejko A. Microbiome-Friend or Foe of Pancreatic Cancer? J Clin Med 2021; 10:jcm10235624. [PMID: 34884327 PMCID: PMC8658245 DOI: 10.3390/jcm10235624] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/10/2021] [Revised: 11/15/2021] [Accepted: 11/27/2021] [Indexed: 12/12/2022] Open
Abstract
Pancreatic ductal adenocarcinoma is one of the deadliest human neoplasms. Despite the development of new surgical and adjuvant therapies, the prognosis remains very poor, with the overall survival rate not exceeding 9%. There is now increasing evidence that the human microbiome, which is involved in many physiological functions, including the regulation of metabolic processes and the modulation of the immune system, is possibly linked to pancreatic oncogenesis. However, the exact mechanisms of action are poorly understood. Our review summarizes the current understanding of how the microbiome affects pancreatic cancer development and progression. We discuss potential pathways of microbe translocation to the pancreas, as well as the mechanism of their action. We describe the role of the microbiome as a potential marker of pancreatic cancer diagnosis, progression, and survival. Finally, we discuss the possibilities of modifying the microbiome to improve treatment effectiveness for this deadly disease.
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Affiliation(s)
- Jaroslaw Daniluk
- Department of Gastroenterology and Internal Medicine, Medical University of Bialystok, 15-276 Bialystok, Poland; (P.R.); (A.D.); (A.S.-S.)
- Correspondence: ; Tel.: +48-(85)-746-82-34; Fax: +48-(85)-746-85-06
| | - Urszula Daniluk
- Department of Pediatrics, Gastroenterology, Hepatology, Nutrition and Allergology, Medical University of Bialystok, 15-274 Bialystok, Poland;
| | - Pawel Rogalski
- Department of Gastroenterology and Internal Medicine, Medical University of Bialystok, 15-276 Bialystok, Poland; (P.R.); (A.D.); (A.S.-S.)
| | - Andrzej Dabrowski
- Department of Gastroenterology and Internal Medicine, Medical University of Bialystok, 15-276 Bialystok, Poland; (P.R.); (A.D.); (A.S.-S.)
| | - Agnieszka Swidnicka-Siergiejko
- Department of Gastroenterology and Internal Medicine, Medical University of Bialystok, 15-276 Bialystok, Poland; (P.R.); (A.D.); (A.S.-S.)
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Gut microbiota in pancreatic diseases: possible new therapeutic strategies. Acta Pharmacol Sin 2021; 42:1027-1039. [PMID: 33093569 DOI: 10.1038/s41401-020-00532-0] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/06/2020] [Accepted: 09/08/2020] [Indexed: 12/13/2022] Open
Abstract
Pancreatic diseases such as pancreatitis, type 1 diabetes and pancreatic cancer impose substantial health-care costs and contribute to marked morbidity and mortality. Recent studies have suggested a link between gut microbiota dysbiosis and pancreatic diseases; however, the potential roles and mechanisms of action of gut microbiota in pancreatic diseases remain to be fully elucidated. In this review, we summarize the evidence that supports relationship between alterations of gut microbiota and development of pancreatic diseases, and discuss the potential molecular mechanisms of gut microbiota dysbiosis in the pathogenesis of pancreatic diseases. We also propose current strategies toward gut microbiota to advance a developing research field that has clinical potential to reduce the cost of pancreatic diseases.
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Pancreatic Disorders of Pregnancy. Clin Obstet Gynecol 2021; 63:226-242. [PMID: 31789887 DOI: 10.1097/grf.0000000000000503] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
Abstract
The pancreas is an organ with both exocrine and endocrine functions that has a vital role in both digestion as well as glucose metabolism. Although pancreatic dysfunction and disorders are rare in pregnancy, they are becoming increasingly more common. Recognition of these disorders and understanding how they can affect pregnancy is imperative to allow for proper management. We provide an overview of the most common pancreatic disorders that are seen in pregnancy.
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Saunders R, Hughes FE, Evans JC, Smart HL, Ghaneh P, Ramesh J, Sutton R, Halloran CM. Cost analysis and outcomes of endoscopic, minimal access and open pancreatic necrosectomy. ANNALS OF SURGERY OPEN 2021; 2:e068. [PMID: 34079959 PMCID: PMC7610877 DOI: 10.1097/as9.0000000000000068] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/02/2021] [Accepted: 04/08/2021] [Indexed: 12/30/2022] Open
Abstract
OBJECTIVES To assess both individual patient and institutional costs as well as outcomes in patients with pancreatic necrosis who underwent either endoscopic, minimal access or open pancreatic necrosectomy. These data can be used to evaluate clinical effectiveness with a view to informing local health care providers. SUMMARY BACKGROUND DATA Intervention for infected pancreatic necrosis is associated with a high morbidity, mortality and long hospital stays. Minimal access surgical step-up approaches have been the gold standard of care, however endoscopic approaches are now offered preferentially. METHODS All patients undergoing endoscopic (EN), minimal access retroperitoneal (MARPN) and open (OPN) necrosectomy at a single institution from April 2015-March 2017 were included. Patients were selected for intervention based on morphology and position of the necrosis and on clinical factors. Patient level costing systems were used to determine inpatient and outpatient costs. RESULTS 86 patients were included: 38 underwent EN, 35 MARPN and 13 OPN. Pre-operative APACHEII was 6 vs 9 vs 9 (p=0.017) and CRP 107 vs 204 vs 278, (p=0.012), respectively. Post-operative stay was 19 days for EN vs. 41 for MARPN vs. 42 for OPN (p=0.007). Complications occurred in 68.4%, 68.6% and 46.2% (p=0.298) while mortality was 10.5%, 22.9% and 15.4% (p=0.379) respectively. Mean total cost was £31,364 for EN, £52,770 for MARPN (p=0.008) and £60,346 for OPN. Ward and critical care costs for EN were lower than for MARPN (ward: £9,430 vs. £14,033, p=0.024; critical care: £5,317 vs. £16,648, p=0.056).
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Affiliation(s)
- Rebecca Saunders
- From the Department of Molecular & Clinical Cancer Medicine, University of Liverpool, UK
| | - Faye E. Hughes
- Department of General & Pancreatic Surgery, Liverpool University Hospitals NHS Foundation Trust, UK
| | - Jonathan C. Evans
- Department of Radiology, Liverpool University Hospitals NHS Foundation Trust, UK
| | - Howard L. Smart
- Department of Gastroenterology, Liverpool University Hospitals NHS Foundation Trust, UK
| | - Paula Ghaneh
- From the Department of Molecular & Clinical Cancer Medicine, University of Liverpool, UK
- Department of General & Pancreatic Surgery, Liverpool University Hospitals NHS Foundation Trust, UK
| | - Jayapal Ramesh
- Department of Gastroenterology, Liverpool University Hospitals NHS Foundation Trust, UK
| | - Robert Sutton
- From the Department of Molecular & Clinical Cancer Medicine, University of Liverpool, UK
- Department of General & Pancreatic Surgery, Liverpool University Hospitals NHS Foundation Trust, UK
| | - Christopher M. Halloran
- From the Department of Molecular & Clinical Cancer Medicine, University of Liverpool, UK
- Department of General & Pancreatic Surgery, Liverpool University Hospitals NHS Foundation Trust, UK
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Spontaneous Free Peritoneal Perforation of an Infected Pancreatic Fluid Collection Managed with Laparoscopic Drainage and Necrosectomy. Case Rep Surg 2021; 2021:5532096. [PMID: 33815860 PMCID: PMC7990526 DOI: 10.1155/2021/5532096] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/02/2021] [Revised: 03/05/2021] [Accepted: 03/10/2021] [Indexed: 11/17/2022] Open
Abstract
Introduction Free peritoneal perforation of pancreatic fluid collections is extremely rare and only few case reports exist in the literature. Many of these patients undergo emergency exploratory laparotomy due to sepsis and haemodynamic instability requiring sepsis control. The use of laparoscopic techniques in this circumstance is limited by the haemodynamic stability of the patient and the technical challenges. But effective laparoscopic management is associated with less morbidity to the patient. Case Presentation. A 28-year-old patient presented with worsening generalized abdominal pain with increased inflammatory markers. She required persistent inotropic support despite adequate fluid resuscitation. She had transient acute renal impairment and acute respiratory distress, which improved with noninvasive support. CECT (contrast-enhanced computed tomography) showed an infected pancreatic fluid collection with peritoneal free fluid. Aspiration of pelvic collection showed purulent fluid. Based on these clinical and imaging findings, she was diagnosed with a free peritoneal perforation of an infected pancreatic fluid collection. She underwent a laparoscopic drainage and necrosectomy of the infected pancreatic collection and peritoneal washout. She had a gradual recovery. All inotropes were omitted on the second day following surgery. She was sent to the ward from the ICU (intensive care unit) on the 4th postoperative day. Conclusion The laparoscopic approach is a viable option in managing ruptured pancreatic fluid collections when patient and technical factors are supportive. It reduces surgical morbidity, thereby reducing the overall strain on physiological reserves. When opted for laparoscopic drainage, the procedure must be guided by imaging findings. Multidisciplinary participation is critical in the overall management.
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Cho SY, Cho E, Park CH, Kim HJ, Koo JY. Septic shock due to Granulicatella adiacens after endoscopic ultrasound-guided biopsy of a splenic mass: A case report. World J Gastroenterol 2021; 27:751-759. [PMID: 33716452 PMCID: PMC7934004 DOI: 10.3748/wjg.v27.i8.751] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/24/2020] [Revised: 01/18/2021] [Accepted: 02/11/2021] [Indexed: 02/06/2023] Open
Abstract
BACKGROUND Endoscopic ultrasound-guided fine needle aspiration or biopsy (EUS-FNA or FNB) has become a popular method for diagnosing various lesions of the gastrointestinal tract and surrounding tissue due to the accuracy and safety. To the best of our knowledge, no case report of severe infection after EUS-FNB of a solid lesion in the spleen has been described. Herein, we report a rare case of septic shock after EUS-FNB of a splenic mass.
CASE SUMMARY A 45-year-old male patient presented to the outpatient clinic due to an incidentally detected splenic mass. A definitive diagnosis could not be established based on the abdominal magnetic resonance imaging. EUS of the spleen showed a 6 cm-sized, relatively well-demarcated, heterogeneous mass, and EUS-FNB with a 22G needle was performed. Ten days after the procedure patient developed septic shock and a splenic abscess was identified. Blood culture revealed growth of Granulicatella adiacens. After the treatment with antibiotics the patient underwent surgical resection, and the pathological examination showed diffuse large B-cell lymphoma. The patient received chemotherapy and he is in complete remission.
CONCLUSION Infection of a splenic mass after EUS-FNB is a rare complication and prophylactic antibiotics might be considered.
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Affiliation(s)
- Seo-Yeon Cho
- Division of Gastroenterology, Department of Internal Medicine, Chonnam National University Hospital, Gwangju 61469, South Korea
| | - Eunae Cho
- Division of Gastroenterology, Department of Internal Medicine, Chonnam National University Hospital, Gwangju 61469, South Korea
| | - Chang-Hwan Park
- Division of Gastroenterology, Department of Internal Medicine, Chonnam National University Hospital, Gwangju 61469, South Korea
| | - Hee-Joon Kim
- Department of Surgery, Chonnam National University Hospital, Gwangju 61469, South Korea
| | - Joo-Yeon Koo
- Department of Pathology, Chonnam National University Hospital, Gwangju 61469, South Korea
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Waele JJD, Hesse UJ, Pattyn P, Decruyenaere J, Hemptinne BD. Postoperative Lavage and On Demand Surgical Intervention in the Treatment of Acute Necrotizing Pancreatitis. Acta Chir Belg 2020. [DOI: 10.1080/00015458.2000.12098509] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
Affiliation(s)
- J. J. De Waele
- Department of Surgery, University Hospital Ghent, Gent, Belgium
| | - U. J. Hesse
- Department of Surgery, University Hospital Ghent, Gent, Belgium
| | - P. Pattyn
- Department of Surgery, University Hospital Ghent, Gent, Belgium
| | - J. Decruyenaere
- Department of Intensive Care, University Hospital Ghent, Gent, Belgium
| | - B. de Hemptinne
- Department of Surgery, University Hospital Ghent, Gent, Belgium
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Identification of Dysfunctional Gut Microbiota Through Rectal Swab in Patients with Different Severity of Acute Pancreatitis. Dig Dis Sci 2020; 65:3223-3237. [PMID: 32076933 DOI: 10.1007/s10620-020-06061-4] [Citation(s) in RCA: 33] [Impact Index Per Article: 8.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/28/2019] [Accepted: 01/09/2020] [Indexed: 02/07/2023]
Abstract
BACKGROUND Acute pancreatitis (AP) has a wide spectrum of severity and can be associated with considerable morbidity and mortality. Whether gut microbiota dysbiosis is associated with AP severity remains obscure. AIMS We aim to investigate the differences in the alterations of gut microbiota in different grades of AP severity. METHODS We collected clinical information and rectal swab samples from 80 individuals. The gut microbiota was tested by 16S rRNA gene sequencing, gut microbiota species composition analysis, difference analysis, random forest model prediction analysis, and gut microbiota species correlation network analysis. RESULTS There was a different microbiota profile in different severity grades. Bacteroides, Escherichis-Shigella, and Enterococcus were dominant species in mild, moderately severe, and severe AP, respectively. Finegoldia was the most significantly increased and Blautia the most decreased species in mild AP. Anaerococcus was the most significantly increased and Eubacterium hallii the most decreased species in moderately severe AP. Enterococcus was the most significantly increased and Eubacterium hallii the most decreased species in severe AP. Finegoldia, Eubacterium_hallii, and Lachnospiraceae were potential diagnostic biomarkers for mild AP and Eubacterium_hallii and Anaerococcus for moderately severe AP. There was a positive interaction between Firmicutes and Bacteroidetes in mild AP. CONCLUSIONS The disturbed gut microbiota is different among grades of AP, suggesting their potential role in the progression of disease severity. There was a different microbiota profile in different severity grades. Bacteroides, Escherichis-Shigella, and Enterococcus were dominant gut microbiota species in MAP, MSAP, and SAP, respectively. Finegoldia was the most significantly increased and Blautia the most decreased gut microbiota species in MAP. Anaerococcus was the most significantly increased and Eubacterium hallii the most decreased species in MSAP. Enterococcus was the most significantly increased and Eubacterium hallii the most decreased species in SAP. Finegoldia, Eubacterium_hallii, and Lachnospiraceae were potential diagnostic biomarkers for MAP and Eubacterium_hallii and Anaerococcus for MSAP. There was a positive interaction between Firmicutes and Bacteroidetes in MAP.
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Heckler M, Hackert T, Hu K, Halloran CM, Büchler MW, Neoptolemos JP. Severe acute pancreatitis: surgical indications and treatment. Langenbecks Arch Surg 2020; 406:521-535. [PMID: 32910276 PMCID: PMC8106572 DOI: 10.1007/s00423-020-01944-6] [Citation(s) in RCA: 35] [Impact Index Per Article: 8.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/11/2020] [Accepted: 07/21/2020] [Indexed: 12/14/2022]
Abstract
Background Acute pancreatitis (AP) is defined as an acute inflammatory attack of the pancreas of sudden onset. Around 25% of patients have either moderately severe or severe disease with a mortality rate of 15–20%. Purpose The aim of this article was to summarize the advances being made in the understanding of this disease and the important role of surgery. Results and conclusions An accurate diagnosis should be made a soon as possible, initiating resuscitation with large volume intravenous fluids and oxygen by mask. Predicted severe disease will require intensive monitoring. Most deaths within the first week are due to multi-organ failure; thus, these patients will require intensive therapy unit management. During the second phase of the disease, death is due to local complications arising from the pancreatic inflammation, requiring accurate identification to determine the correct form of treatment. Acute peripancreatic fluid collections arise < 4 weeks after onset of interstitial edematous pancreatitis, not requiring any treatment. Most pancreatic pseudocysts arise > 4 weeks and largely resolve on conservative management. Necrotizing pancreatitis causing acute necrotic collections and later walled-off necrosis will require treatment if symptomatic or infected. Initial endoscopic transgastric or percutaneous drainage will resolve less serious collections but necrosectomy using minimally invasive approaches will be needed for more serious collections. To prevent recurrent attacks of AP, causative factors need to be removed where possible such as cholecystectomy and cessation of alcohol. Future progress requires improved management of multi-organ failure and more effective minimally invasive techniques for the removal of necrosis.
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Affiliation(s)
- Max Heckler
- Department of General, Visceral and Transplantation Surgery, University of Heidelberg, Im Neuenheimer Feld 110, 69120, Heidelberg, Baden-Württemberg, Germany
| | - Thilo Hackert
- Department of General, Visceral and Transplantation Surgery, University of Heidelberg, Im Neuenheimer Feld 110, 69120, Heidelberg, Baden-Württemberg, Germany
| | - Kai Hu
- Department of General, Visceral and Transplantation Surgery, University of Heidelberg, Im Neuenheimer Feld 110, 69120, Heidelberg, Baden-Württemberg, Germany
| | - Cristopher M Halloran
- Department of Molecular and Clinical Cancer Medicine, University of Liverpool, Liverpool, UK
| | - Markus W Büchler
- Department of General, Visceral and Transplantation Surgery, University of Heidelberg, Im Neuenheimer Feld 110, 69120, Heidelberg, Baden-Württemberg, Germany
| | - John P Neoptolemos
- Department of General, Visceral and Transplantation Surgery, University of Heidelberg, Im Neuenheimer Feld 110, 69120, Heidelberg, Baden-Württemberg, Germany.
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Wolbrink DR, Grundsell JR, Witteman B, Poll MVD, Santvoort HC, Issa E, Dennison A, Goor HV, Besselink MG, Bouwense SA. Are omega-3 fatty acids safe and effective in acute pancreatitis or sepsis? A systematic review and meta-analysis. Clin Nutr 2020; 39:2686-2694. [DOI: 10.1016/j.clnu.2019.12.006] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/24/2019] [Revised: 09/10/2019] [Accepted: 12/02/2019] [Indexed: 12/13/2022]
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Leonard-Murali S, Lezotte J, Kalu R, Blyden DJ, Patton JH, Johnson JL, Gupta AH. Necrotizing pancreatitis: A review for the acute care surgeon. Am J Surg 2020; 221:927-934. [PMID: 32878690 DOI: 10.1016/j.amjsurg.2020.08.027] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/27/2020] [Revised: 07/30/2020] [Accepted: 08/22/2020] [Indexed: 02/07/2023]
Abstract
BACKGROUND Necrotizing pancreatitis is a common condition with high mortality; the acute care surgeon is frequently consulted for management recommendations. Furthermore, there has been substantial change in the timing, approach, and frequency of surgical intervention for this group of patients. METHODS In this article we summarize key clinical and research developments regarding necrotizing pancreatitis, including current recommendations for treatment of patients requiring intensive care and those with common complications. Articles from all years were considered to provide proper historical context, and most recent management recommendations are identified. RESULTS Epidemiology, diagnosis, treatment in the acute phase, and complications (both short-term and long-term) are discussed. Images of surgical interventions are included from our institutional experience. CONCLUSION Necrotizing pancreatitis management remains heavily based on clinical judgement, although technological advances and clinical trials have made decision making more straightforward.
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Affiliation(s)
- Shravan Leonard-Murali
- Department of Surgery, Henry Ford Hospital, 2799 West Grand Blvd, Detroit, MI, 48202, USA.
| | - Jonathan Lezotte
- Department of Surgery, Henry Ford Hospital, 2799 West Grand Blvd, Detroit, MI, 48202, USA.
| | - Richard Kalu
- Department of Surgery, Henry Ford Hospital, 2799 West Grand Blvd, Detroit, MI, 48202, USA.
| | - Dionne J Blyden
- Department of Surgery, Division of Acute Care Surgery, Henry Ford Hospital, 2799 West Grand Blvd, Detroit, MI, 48202, USA.
| | - Joe H Patton
- Department of Surgery, Division of Acute Care Surgery, Henry Ford Hospital, 2799 West Grand Blvd, Detroit, MI, 48202, USA.
| | - Jeffrey L Johnson
- Department of Surgery, Division of Acute Care Surgery, Henry Ford Hospital, 2799 West Grand Blvd, Detroit, MI, 48202, USA.
| | - Arielle H Gupta
- Department of Surgery, Division of Acute Care Surgery, Henry Ford Hospital, 2799 West Grand Blvd, Detroit, MI, 48202, USA.
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Alcohol and Smoking Mediated Modulations in Adaptive Immunity in Pancreatitis. Cells 2020; 9:cells9081880. [PMID: 32796685 PMCID: PMC7463831 DOI: 10.3390/cells9081880] [Citation(s) in RCA: 18] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/07/2020] [Revised: 08/05/2020] [Accepted: 08/06/2020] [Indexed: 12/12/2022] Open
Abstract
Pancreatitis is a condition of pancreatic inflammation driven by injury to the pancreatic parenchyma. The extent of acinar insult, intensity, and type of immune response determines the severity of the disease. Smoking, alcohol and autoimmune pancreatitis are some of the predominant risk factors that increase the risk of pancreatitis by differentially influencing the adaptive immune system. The overall decrease in peripheral lymphocyte (T-, B- and (natural killer T-) NKT-cell) count and increased infiltration into the damaged pancreatic tissue highlight the contribution of adaptive immunity in the disease pathology. Smoking and alcohol modulate the responsiveness and apoptosis of T- and B-cells during pancreatic insult. Acute pancreatitis worsens with smoking and alcohol, leading to the development of systemic inflammatory response syndrome and compensatory anti-inflammatory response syndrome, suggesting the critical role of adaptive immunity in fatal outcomes such as multiple organ dysfunction. The presence of CD4+ and CD8+ T-lymphocytes and perforin-expressing cells in the fibrotic tissue in chronic pancreatitis modulate the severity of the disease. Due to their important role in altering the severity of the disease, attempts to target adaptive immune mediators will be critical for the development of novel therapeutic interventions.
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38
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Gao CC, Li J, Cao F, Wang XH, Li A, Wang Z, Li F. Infection recurrence following minimally invasive treatment in patients with infectious pancreatic necrosis. World J Gastroenterol 2020; 26:3087-3097. [PMID: 32587450 PMCID: PMC7304114 DOI: 10.3748/wjg.v26.i22.3087] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/02/2020] [Revised: 03/27/2020] [Accepted: 05/12/2020] [Indexed: 02/06/2023] Open
Abstract
BACKGROUND In recent decades, an increasing number of patients have received minimally invasive intervention for infected pancreatic necrosis (IPN) because of the benefits in reducing postoperative multiple organ failure and mortality. However, there are limited published data regarding infection recurrence after treatment of this patient population.
AIM To investigate the incidence and prediction of infection recurrence following successful minimally invasive treatment in IPN patients.
METHODS Medical records for 193 IPN patients, who underwent minimally invasive treatment between February 2014 and October 2018, were retrospectively reviewed. Patients, who survived after the treatment, were divided into two groups: one group with infection after drainage catheter removal and another group without infection. The morphological and clinical data were compared between the two groups. Significantly different variables were introduced into the correlation and multivariate logistic analysis to identify independent predictors for infection recurrence. Sensitivity and specificity for diagnostic performance were determined.
RESULTS Of the 193 IPN patients, 178 were recruited into the study. Of them, 9 (5.06%) patients died and 169 patients survived but infection recurred in 13 of 178 patients (7.30%) at 7 (4-10) d after drainage catheters were removed. White blood cell (WBC) count, serum C-reactive protein (CRP), interleukin-6, and procalcitonin levels measured at the time of catheter removal were significantly higher in patients with infection than in those without (all P < 0.05). In addition, drainage duration and length of the catheter measured by computerized tomography scan were significantly longer in patients with infection (P = 0.025 and P < 0.0001, respectively). Although these parameters all correlated positively with the incidence of infection (all P < 0.05), only WBC, CRP, procalcitonin levels, and catheter length were identified as independent predictors for infection recurrence. The sensitivity and specificity for infection prediction were high in WBC count (≥ 9.95 × 109/L) and serum procalcitonin level (≥ 0.05 ng/mL) but moderate in serum CRP level (cut-off point ≥ 7.37 mg/L). The catheter length (cut-off value ≥ 8.05 cm) had a high sensitivity but low specificity to predict the infection recurrence.
CONCLUSION WBC count, serum procalcitonin, and CRP levels may be valuable for predicting infection recurrence following minimally invasive intervention in IPN patients. These biomarkers should be considered before removing the drainage catheters.
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Affiliation(s)
- Chong-Chong Gao
- Department of General Surgery, Xuanwu Hospital, Capital Medical University, Beijing 100053, China
| | - Jia Li
- Department of General Surgery, Xuanwu Hospital, Capital Medical University, Beijing 100053, China
| | - Feng Cao
- Department of General Surgery, Xuanwu Hospital, Capital Medical University, Beijing 100053, China
| | - Xiao-Hui Wang
- Department of General Surgery, Xuanwu Hospital, Capital Medical University, Beijing 100053, China
| | - Ang Li
- Department of General Surgery, Xuanwu Hospital, Capital Medical University, Beijing 100053, China
| | - Zhe Wang
- Department of General Surgery, Xuanwu Hospital, Capital Medical University, Beijing 100053, China
| | - Fei Li
- Department of General Surgery, Xuanwu Hospital, Capital Medical University, Beijing 100053, China
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Ausania F, Senra Del Río P, Borin A, Guzmán Suárez S, Rivera Irigoin R, Fort Martorell E, Concepción-Martín M, Del Val Antoñana A, Ferrández A, Grau García FJ, Ruiz Rebollo ML, Andreu EB, de-Madaria E. Factors associated with mortality in patients with infected pancreatic necrosis: the "surgery effect". Updates Surg 2020; 72:1097-1103. [PMID: 32306274 DOI: 10.1007/s13304-020-00764-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/27/2020] [Accepted: 04/10/2020] [Indexed: 11/26/2022]
Abstract
Severe acute pancreatitis complicated by infection is associated with high mortality. Invasive treatment is indicated in the presence of infected (suspected) pancreatic and/or peripancreatic necrosis (IPN) in the absence of response to intensive medical support. Step-up approach (SUA) has been demonstrated to lower complication rate compared to upfront open surgery. However, this approach has not been associated with lower mortality, and no factors have been studied that could help to identify the high risk patients. In this study, we aimed to analyse those factors associated with mortality following the invasive treatment of IPN, focusing on the role of surgical necrosectomy. A retrospective and observational study based on a multicentre prospective database was conducted. The database was coordinated by the Hospital General Universitario de Alicante, Spain and the Spanish Association of Pancreatology. Demographics, clinical data, and laboratory and imaging findings were collected. Atlanta 2012 criteria were considered to classify acute necrotizing pancreatitis and for the definition of IPN. Step-up approach was used in all centres with the intention of avoiding surgery whenever possible. Surgical necrosectomy was performed by open approach. From January 2013 to October 2014, a total of 1655 patients with the diagnosis of acute pancreatitis were included in our database. 1081 were recruited for the final analysis. Out of them, 205 (19%) were classified into acute necrotizing pancreatitis. 77 (8.3%) patients underwent invasive treatment of INP and were included in our study. Overall mortality was 29.9%. Upfront endoscopic or percutaneous drainage was performed in 60 (77.9%) patients and mortality was 26.6%. Out of 60, 22 (36.6%) patients subsequently received rescue surgery; mortality in rescue surgery group was 18.3%. Upfront surgery was carried out in 17 (22.1%) patients; mortality in this group was 41%. At univariate analysis, surgical necrosectomy, extrapancreatic infection, immunosuppression and de-novo haemodialysis were associated with mortality. At multivariate analysis, only surgical necrosectomy was significantly associated with mortality (p = 0.002 OR 3.89). Surgical approach for IPN is associated with high mortality rate. However, these data should be interpreted with caution, since we are not able to assess whether this occurs due to the need of surgery as the only resort when the other approaches are not feasible or fail.
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Affiliation(s)
| | | | - Alex Borin
- Department of General and Pancreatic Surgery, Pancreas Institute, University and Hospital Trust of Verona, Verona, Italy.
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Abstract
Pancreatic fluid collections (PFC), including pancreatic pseudocysts and walled-off pancreatic necrosis, are a known complication of severe acute pancreatitis. A majority of the PFCs remain asymptomatic and resolve spontaneously. However, some PFCs persist and can become symptomatic. Persistent PFCs can also cause further complications such as the gastric outlet, intestinal, or biliary obstruction and infection. Surgical interventions are indicated for the drainage of symptomatic sterile and infected PFCs. Management of PFCs has evolved from a primarily surgical or percutaneous approach to a less invasive endoscopic approach. Endoscopic interventions are associated with improved outcomes with lesser chances of complications, faster recovery time, and lower healthcare utilization. Endoscopic ultrasound-guided drainage of PFCs using lumen-apposing metal stents has become the preferred approach for the management of symptomatic and complicated PFCs.
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Abstract
GOALS The aim of this study was to determine a potential strategy to prevent acute pancreatitis (AP) from deteriorating in obese patients. BACKGROUND Nutritional support plays a critical role in the treatment of AP. Early enteral nutrition (EEN) is considered to be able to protect mucosa of AP patients and alleviate inflammatory reactions. Obesity worsen AP prognosis. However, little is known about the effects of EEN in obese patients. STUDY Prospective randomized control trial. Subjects with moderately severe AP or severe AP were divided into the visceral fat obesity (VFO) group and the non-VFO group by obesity index VFO. The patients received "delayed" enteral nutrition (started enteral nutrition feeding after the first 48 hours after admission to the hospital: group A: patients of non-VFO, n=108; group B: VFO patients, n=88) or EEN (in the VFO subgroup, group C: n=91).Occurrence of complication, clinical outcomes, plasma levels of cytokines, and intestine gut barrier index were measured at different timepoints after admission. RESULTS VFO was a risk factor for aggravating of AP. EEN prevented the VFO patients from developing pancreatic necrotic infection, the mechanism of which might be related with inhibiting excessive inflammatory reactions, adjusting the imbalance of inflammatory response, and alleviating ischemia of intestine mucosa. CONCLUSIONS The potential strategy, EEN, was able to prevent AP from deteriorating in obese patients.
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Thomas RM, Jobin C. Microbiota in pancreatic health and disease: the next frontier in microbiome research. Nat Rev Gastroenterol Hepatol 2020; 17:53-64. [PMID: 31811279 DOI: 10.1038/s41575-019-0242-7] [Citation(s) in RCA: 151] [Impact Index Per Article: 37.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 11/11/2019] [Indexed: 12/12/2022]
Abstract
Diseases intrinsic to the pancreas such as pancreatitis, pancreatic cancer and type 1 diabetes mellitus impart substantial health and financial burdens on society but identification of novel mechanisms contributing to these pathologies are slow to emerge. A novel area of research suggests that pancreatic-specific disorders might be modulated by the gut microbiota, either through a local (direct pancreatic influence) or in a remote (nonpancreatic) fashion. In this Perspectives, we examine literature implicating microorganisms in diseases of the pancreas, specifically pancreatitis, type 1 diabetes mellitus and pancreatic ductal adenocarcinoma. We also discuss evidence of an inherent pancreatic microbiota and the influence of the intestinal microbiota as it relates to disease association and development. In doing so, we address pitfalls in the current literature and areas of investigation that are needed to advance a developing field of research that has clinical potential to reduce the societal burden of pancreatic diseases.
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Affiliation(s)
- Ryan M Thomas
- Department of Surgery, University of Florida College of Medicine, Gainesville, FL, USA.,Department of Molecular Genetics and Microbiology, University of Florida, Gainesville, FL, USA
| | - Christian Jobin
- Department of Medicine, Division of Gastroenterology, University of Florida College of Medicine, Gainesville, FL, USA.
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Wang B, Li J, Wang S, Hao Y, Zhao X, Chen J. Lactobacillus plantarum ameliorates tumour necrosis factor-induced bacterial translocation in Caco-2 cells by regulation of TLR4 expression. J Med Microbiol 2019; 67:982-991. [PMID: 29877788 DOI: 10.1099/jmm.0.000762] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/08/2023] Open
Abstract
Purpose. Translocation of bacteria across the intestinal barrier is important in the pathogenesis of systemic sepsis. In inflammatory conditions, commensal bacteria exploit transcytotic pathways to cross the intestinal epithelium in a TLR4-dependent manner. The aim of this study was to test the hypothesis that Lactobacillus plantarum ameliorates tumour necrosis factor-induced bacterial translocation by regulation of Toll-like receptor-4 expression.Methodology. L. plantarum strains were investigated to determine their capacity to inhibit the initial adhesion of Escherichia coli B5 to Caco-2 cells. The inhibitory effects of L. plantarum on TNF-α-induced E. coli B5 translocation across Caco-2 cells were studied. Barrier function and integrity were simultaneously assessed by transepithelial electrical resistance, HRP permeability, LDH release and distribution of tight junctional proteins. Expression of TLR4 was assessed by RT-PCR.Results/Key findings. Pretreatment of monolayers with L. plantarum L2 led to a significant decrease in E. coli B5 adhesion and cell internalization (P<0.01). Exposure to TNF-α for six hours caused a significant increase in E. coli B5 translocation across Caco-2 cells, which was uncoupled from increases in paracellular permeability and disruption of tight junction proteins. Manipulations that induced bacterial translocation were associated with a marked increase in TLR4 mRNA expression and IL-8 secretion. L. plantarum L2 significantly abrogated TNF-α-induced bacterial translocation of E. coli B5, and also downregulated expression of TLR4 and IL-8 in intestinal epithelial cells.Conclusion. Live L. plantarum L2 can inhibit TNF-α-induced transcellular bacterial translocation via regulation of TLR4 expression.
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Affiliation(s)
- Bin Wang
- Jiangsu Academy of Science and Technology for Inspection and Quarantine, Nanjing, Jiangsu 210001, PR China.,Department of Travel Health, Nanjing Entry-Exit Inspection and Quarantine Bureau, Nanjing, Jiangsu 211106, PR China
| | - Jingjing Li
- Department of Ultrasound, Nanjing Hospital of Armed Police Force Corps, Nanjing, Jiangsu 210028, PR China
| | - Shuiming Wang
- Department of Travel Health, Nanjing Entry-Exit Inspection and Quarantine Bureau, Nanjing, Jiangsu 211106, PR China
| | - Yu Hao
- Department of Travel Health, Nanjing Entry-Exit Inspection and Quarantine Bureau, Nanjing, Jiangsu 211106, PR China
| | - Xiaoyan Zhao
- Department of Travel Health, Nanjing Entry-Exit Inspection and Quarantine Bureau, Nanjing, Jiangsu 211106, PR China
| | - Jun Chen
- Research Institute of General Surgery, Jinling Hospital, Nanjing, Jiangsu 210002, PR China
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Abstract
Bacterial translocation is a phenomenon in which live bacteria or their products cross the intestinal barrier to other organs or the circulatory system. Gut translocation of bacteria has been reported in both animal models, and clinical trials often accompany acute pancreatitis and are believed to be linked to patient outcome, especially in severe acute pancreatitis. Therefore, the mechanisms of intestinal bacterial translocation in acute pancreatitis have become a topic of interest in recent years. This review discusses Bacterial translocation in acute pancreatitis, identifies possible mechanisms of action, and provides an overview of the methods used to detect Bacterial translocation in acute pancreatitis. This review also highlights areas that require further research.
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Affiliation(s)
- Jinbo Liu
- Department of Hepatobiliary Surgery, The Affiliated Hospital of Southwest Medical University, Luzhou, Sichuan, P.R. China.,Academician (Expert) Workstation of Sichuan Province, The Affiliated Hospital of Southwest Medical University, Luzhou,Sichuan, P.R. China
| | - Lin Huang
- Department of Paediatrics, The Affiliated Hospital of Southwest Medical University, Luzhou, Sichuan, P.R. China
| | - Ming Luo
- Department of Hepatobiliary Surgery, The Affiliated Hospital of Southwest Medical University, Luzhou, Sichuan, P.R. China
| | - Xianming Xia
- Department of Hepatobiliary Surgery, The Affiliated Hospital of Southwest Medical University, Luzhou, Sichuan, P.R. China.,Academician (Expert) Workstation of Sichuan Province, The Affiliated Hospital of Southwest Medical University, Luzhou,Sichuan, P.R. China
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Li H, Yang Z, Tian F. Risk factors associated with intolerance to enteral nutrition in moderately severe acute pancreatitis: A retrospective study of 568 patients. Saudi J Gastroenterol 2019; 25:362-368. [PMID: 30900608 PMCID: PMC6941459 DOI: 10.4103/sjg.sjg_550_18] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/16/2022] Open
Abstract
BACKGROUND/AIMS To assess the frequency of and risk factors for intolerance to enteral nutrition through nasogastric (NG) or nasojejunal (NJ) tube feeding in patients with moderately severe acute pancreatitis. PATIENTS AND METHODS Patients who underwent enteral nutrition via the nasojejunal tube or nasogastric tube, from January 2012 to December 2017, were enrolled. Demographic and etiological data, admission variables, enteral nutrition related variables, and radiological variables were evaluated using univariate and multivariate analysis. RESULTS A total of 568 patients were included, with 235 (41.4%) receiving nasojejunal tube feeding and 333 (56.8%) receiving nasogastric tube feeding. Tube-feeding intolerance was observed in 184 patients (32.4%), occurring at a median of 3 days (range, 1-5 days) after the start of enteral nutrition. The variables independently associated with risk of intolerance to tube feeding were hypertriglyceridemia (odds ratio, 8.13;95% CI, 5.21-10.07; P = 0.002), the presence of systemic inflammatory response syndrome (odds ratio, 6.58;95% CI, 3.03-8.34; P = 0.002), acute gastrointestinal injury-III status (odds ratio, 5.51;95% CI, 2.30-7.33; P = 0.02), the time from admission to commencement of enteral nutrition (odds ratio, 7.21;95% CI, 2.16-9.77; P = 0.001), and pancreatic infection (odds ratio, 6.15;95% CI, 4.94-8.75; P = 0.002) Patients with tube-feeding intolerance required prolonged enteral nutrition (P < 0.001) and had longer hospitalizations (P < 0.001). CONCLUSIONS Tube-feeding intolerance accounts for a considerable proportion in patients with moderately severe acute pancreatitis. The presence of hypertriglyceridemia, systemic inflammatory response syndrome and acute gastrointestinal injury grade III or pancreatic infection and the time from admission to commencing enteral nutrition increase the risk for tube-feeding intolerance.
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Affiliation(s)
- Hui Li
- Department of Gastroenterology, Shengjing Hospital Affiliated to China Medical University, Shenyang, Liaoning, China
| | - Zhenyu Yang
- Intensive Care Unit, Shengjing Hospital Affiliated to China Medical University, Shenyang, Liaoning, China
| | - Feng Tian
- Department of Gastroenterology, Shengjing Hospital Affiliated to China Medical University, Shenyang, Liaoning, China,Address for correspondence: Dr. Feng Tian, Department of gastroenterology, Shengjing Hospital Affiliated to China Medical University, No. 36 Sanhao Street, Shenyang, Liaoning - 110004, China. E-mail:
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Kumar M, Kandhasamy SC, Sahoo AK, Amaranathan A, Goneppanavar M, Nelamangala Ramakrishnaiah VP. Pigtail catheter drainage and surgery in severe acute pancreatitis. JGH OPEN 2019; 3:429-434. [PMID: 31633050 PMCID: PMC6788367 DOI: 10.1002/jgh3.12182] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 11/07/2018] [Revised: 03/04/2019] [Accepted: 03/20/2019] [Indexed: 12/12/2022]
Abstract
Background and Aim Severe acute pancreatitis is initially managed with conservative treatment. Patients who failed conservative management were effectively treated with pigtail drainage. Factors predicting surgery remain uncertain. Methods A total of 58 patients with severe acute pancreatitis presenting to JIPMER Hospital were studied and managed with a step‐up approach. In this prospective observational study, patients were divided into three groups based on the final mode of treatment received: conservative, pigtail alone, and surgery groups. Results Of 58 patients, 30 patients were managed with conservative treatment, 20 patients with pigtail alone, and 8 patients underwent surgical treatment after pigtail failure. Overall sepsis reversal was achieved in 22 of 28 (78.5%) patients: 18 were in the pigtail alone group, and 4 were in surgery group, which was statistically significant (P = 0.03). Respiratory failure was the most common organ failure, 68.9%, and overall mortality was 8.62 in this study. On univariate analysis, absence of sepsis reversal within 2 weeks of pigtail insertion is a predictor of need of surgery. Other significant findings were higher catheter‐related complications in the surgery group (P = 0.01) and a 100% unimicrobial infection in the surgery group (P = 0.02). Overall mortality was 8.6%, which did not differ significantly between the groups. Conclusion The step‐up approach avoided unnecessary intervention, and 52% patients recovered by conservative treatment alone. Sepsis reversal within 2 weeks of pigtail insertion can be used as a predictor of surgery in the early course of severe acute pancreatitis managed by the step‐up approach.
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Affiliation(s)
- Manish Kumar
- Department of Surgery Jawaharlal Institute of Postgraduate Medical Education and Research (JIPMER) Puducherry India
| | | | - Ashok Kumar Sahoo
- Department of Surgery Jawaharlal Institute of Postgraduate Medical Education and Research (JIPMER) Puducherry India
| | - Anandhi Amaranathan
- Department of Surgery Jawaharlal Institute of Postgraduate Medical Education and Research (JIPMER) Puducherry India
| | - Mangala Goneppanavar
- Department of Pathology Mahatma Gandhi Medical College and Research Institute Puducherry India
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Predrainage and Postdrainage Prognostic Nomograms to Predict Outcome of Percutaneous Drainage for Infected Pancreatic and Peripancreatic Necrotic Collections. Pancreas 2019; 48:1212-1219. [PMID: 31593016 DOI: 10.1097/mpa.0000000000001395] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/12/2023]
Abstract
OBJECTIVES This study aimed to identify factors affecting outcome of percutaneous catheter drainage (PCD) in management of infected pancreatic necrosis treated with step-up approach. METHODS This was a single-center retrospective cohort study that included patients with infected necrosis undergoing PCD as initial intervention. Patients who did not respond underwent necrosectomy. Predictors of PCD failure (ie, mortality or need for necrosectomy) were analyzed. Models were constructed for predrainage and postdrainage use and were internally validated. RESULTS Of 304 patients included, catheter drainage was successful in 59.8%, with overall mortality of 22%. Predrainage model consisted of Acute Physiologic and Chronic Health Evaluation II score at admission, early organ failure, and pancreatic necrosis of greater than 50%. Postdrainage model consisted of Acute Physiologic and Chronic Health Evaluation II at first PCD, early organ failure, pancreatic necrosis of greater than 50%, sepsis reversal within 1 week of PCD and Escherichia coli in PCD culture. Both models were internally validated with area under receiver operating characteristics curve of 71.2% for pre-PCD and 81.2% for post-PCD model. Prognostic nomograms were constructed using the models. CONCLUSIONS Percutaneous catheter drainage alone was successful in 59.8% with mortality of 22%. The nomograms can help in guiding treatment strategy and referral of high-risk cases.
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Hyun JJ, Sahar N, Singla A, Ross AS, Irani SS, Gan SI, Larsen MC, Kozarek RA, Gluck M. Outcomes of Infected versus Symptomatic Sterile Walled-Off Pancreatic Necrosis Treated with a Minimally Invasive Therapy. Gut Liver 2019; 13:215-222. [PMID: 30602076 PMCID: PMC6430426 DOI: 10.5009/gnl18234] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/25/2018] [Revised: 08/23/2018] [Accepted: 08/24/2018] [Indexed: 12/11/2022] Open
Abstract
Background/Aims Acute pancreatitis complicated by walled-off necrosis (WON) is associated with high morbidity and mortality, and if infected, typically necessitates intervention. Clinical outcomes of infected WON have been described as poorer than those of symptomatic sterile WON. With the evolution of minimally invasive therapy, we sought to compare outcomes of infected to symptomatic sterile WON. Methods We performed a retrospective cohort study examining patients who were undergoing dual-modality drainage as minimally invasive therapy for WON at a high-volume tertiary pancreatic center. The main outcome measures included mortality with a drain in place, length of hospital stay, admission to intensive care unit, and development of pancreatic fistulae. Results Of the 211 patients in our analysis, 98 had infected WON. The overall mortality rate was 2.4%. Patients with infected WON trended toward higher mortality although not statistically significant (4.1% vs 0.9%, p=0.19). Patients with infected WON had longer length of hospitalization (29.8 days vs 17.3 days, p<0.01), and developed more spontaneous pancreatic fistulae (23.5% vs 7.8%, p<0.01). Multivariate analysis showed that infected WON was associated with higher odds of spontaneous pancreatic fistula formation (odds ratio, 2.65; 95% confidence interval, 1.20 to 5.85). Conclusions This study confirms that infected WON has worse outcomes than sterile WON but also demonstrates that WON, once considered a significant cause of death, can be treated with good outcomes using minimally invasive therapy.
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Affiliation(s)
- Jong Jin Hyun
- Digestive Disease Institute, Virginia Mason Medical Center, Seattle, WA, USA.,Division of Gastroenterology and Hepatology, Korea University College of Medicine, Seoul, Korea
| | - Nadav Sahar
- Digestive Disease Institute, Virginia Mason Medical Center, Seattle, WA, USA
| | - Anand Singla
- Division of Gastroenterology, Northwestern University, Chicago, IL, USA
| | - Andrew S Ross
- Digestive Disease Institute, Virginia Mason Medical Center, Seattle, WA, USA
| | - Shayan S Irani
- Digestive Disease Institute, Virginia Mason Medical Center, Seattle, WA, USA
| | - S Ian Gan
- Digestive Disease Institute, Virginia Mason Medical Center, Seattle, WA, USA
| | - Michael C Larsen
- Digestive Disease Institute, Virginia Mason Medical Center, Seattle, WA, USA
| | - Richard A Kozarek
- Digestive Disease Institute, Virginia Mason Medical Center, Seattle, WA, USA
| | - Michael Gluck
- Digestive Disease Institute, Virginia Mason Medical Center, Seattle, WA, USA
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Rashid MU, Hussain I, Jehanzeb S, Ullah W, Ali S, Jain AG, Khetpal N, Ahmad S. Pancreatic necrosis: Complications and changing trend of treatment. World J Gastrointest Surg 2019; 11:198-217. [PMID: 31123558 PMCID: PMC6513789 DOI: 10.4240/wjgs.v11.i4.198] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/12/2019] [Revised: 04/19/2019] [Accepted: 04/23/2019] [Indexed: 02/06/2023] Open
Abstract
Incidence of acute pancreatitis seems to be increasing in the Western countries and has been associated with significantly increased morbidity. Nearly 80% of the patients with acute pancreatitis undergo resolution; some develop complications including pancreatic necrosis. Infection of pancreatic necrosis is the leading cause of death in these patients. A significant portion of these patients needs surgical interventions. Traditionally, the “gold standard” procedure has been the open surgical necrosectomy, which is now being completed by the relatively lesser invasive interventions. Minimally invasive surgical (MIS) procedures include endoscopic drainage, percutaneous image-guided catheter drainage, and retroperitoneal drainage. This review article discusses the open and MIS interventions for pancreatic necrosis with each having its own respective benefits and disadvantages are covered.
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Affiliation(s)
- Mamoon Ur Rashid
- Department of Internal Medicine, Advent Health Graduate Medical Education, Orlando, FL 32804, United States
| | - Ishtiaq Hussain
- Department of Gastroenterology, Cleveland Clinic, Weston, FL 33326, United States
| | - Sundas Jehanzeb
- Department of Gastroenterology, Cleveland Clinic, Weston, FL 33326, United States
| | - Waqas Ullah
- Internal Medicine, Abington Hospital, Abington, PA 19001, United States
| | - Saeed Ali
- Department of Internal Medicine, Advent Health Graduate Medical Education, Orlando, FL 32804, United States
| | - Akriti Gupta Jain
- Department of Internal Medicine, Advent Health Graduate Medical Education, Orlando, FL 32804, United States
| | - Neelam Khetpal
- Department of Internal Medicine, Advent Health Graduate Medical Education, Orlando, FL 32804, United States
| | - Sarfraz Ahmad
- Department of Gynecologic Oncology, Advent Health Cancer Institute, Orlando, FL 32804, United States
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Impact of timing of presentation of acute pancreatitis to a tertiary care centre on the outcome. Pancreatology 2019; 19:143-148. [PMID: 30366676 DOI: 10.1016/j.pan.2018.10.005] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/29/2018] [Revised: 10/14/2018] [Accepted: 10/16/2018] [Indexed: 02/06/2023]
Abstract
BACKGROUND AND OBJECTIVES Despite improvement in outcomes of acute pancreatitis (AP), some subgroups remain at increased risk. We studied the impact of onset-to-admission interval to a tertiary care centre on outcomes in AP. METHODS Retrospective analysis of consecutive patients with first episode of AP admitted between 2009 and 2017 on the basis of onset-to-admission interval: ≤7 days, 8-21 days and >21 days was done. Patients were assessed for severity and managed using a step-up approach. Primary outcome measures were surgical necrosectomy and mortality. RESULTS Of 745 patients (age 39.26 ± 13.18 yrs, 69% male), 380 (51%) had presented ≤7 days, 229 (30.7%) between 8 and 21 days and 136 (18.3%) >21 days after pain onset. Severe pancreatitis was highest in 8-21 days group (129; 56.3%) followed by ≤ 7 days (166; 43.7%) and >21 days of illness (52; 38.2%).Surgical intervention rates were highest in the 8-21 days group(14%) followed by > 21 days (12.5%) and ≤7 days (6.6%) respectively (p = 0.007). Also, mortality was highest in patients with onset to admission interval of 8-21 days (24%) followed by > 21 days (15.4%) and ≤7 days (14.2%) (P = 0.007). On the multivariate analysis, age, late presentation, and the presence of organ failure were found to predict the mortality. CONCLUSION Patients presenting between 8 and 21 days after onset perform poorly than those presenting earlier or later than them in terms of severity, organ failure, need for surgery and mortality although organ failure remains the most important determinant of outcome. This data can help in devising guidelines for referral of such patients.
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