Association of extent and infection of pancreatic necrosis with organ failure and death in acute necrotizing pancreatitis

Approach to the Diagnosis and Management of Infected Pancreatic Necrosis: A Narrative Review

Infected pancreatic necrosis (IPN) is a dreaded complication of acute necrotizing pancreatitis and is linked to persistent organ failure, sepsis, and increased morbidity and mortality. Clinical indicators of IPN include fever, clinical deterioration, and worsening inflammatory markers. The diagnosis of IPN is based on clinical signs, microbiological confirmation, and radiological evidence, with contrast-enhanced CT being the preferred imaging modality. In the absence of tests with high sensitivity, a high clinical suspicion is required for early recognition and treatment. Although there is no way to prevent IPN, a systematic management approach with parenteral antibiotics, nutritional management, and minimally invasive procedures has become the cornerstone of the treatment. The step-up approach includes minimally invasive procedures that minimize procedure-related complications and are associated with improved outcomes. The percutaneous route remains the most common route for drainage, while endoscopic interventions are preferred for perigastric or periduodenal encapsulated collections. The use of lumen-apposing metal stents is associated with excellent outcomes in cases of infected walled-off necrosis. Patients with significant quantities of infected necrosis may benefit from direct or percutaneous endoscopic necrosectomy. Minimally invasive surgical techniques followed by open surgeries are reserved for patients who do not improve with percutaneous or endoscopic necrosectomies. The outcome can be maximized through a multidisciplinary approach by a team of interventional radiologists, advanced therapeutic endoscopists, and surgeons.

Organ Failure and Prediction of Severity in Acute Pancreatitis

Organ failure (OF) is a sinister development in the clinical course of acute pancreatitis, and its prediction is crucial for triaging the patient. Persistent systemic inflammatory response syndrome and raised interleukin-6 levels have a good predictive accuracy. Pathophysiology involves the release of damage-associated molecular patterns as a consequence of pancreatic injury, recruitment of inflammatory cells, and the release of proinflammatory cytokines and chemokines causing cytokine storm. Respiratory system is the most common and earliest to fail. Although a few therapeutic options are in the pipeline, renewed efforts are required to develop targeted therapies to mitigate systemic inflammation and OF.

Intra-abdominal Hypertension Is a Strong Predictor of Mortality and Poor Clinical Outcome in Severe Acute Pancreatitis

BACKGROUND

Acute pancreatitis is one of the leading causes of mortality and morbidity. Most acute pancreatitis scoring systems have no pathophysiologic basis when evaluating severity. Such a limitation led to an interest in measuring intra-abdominal pressure (IAP) as a method to predict outcomes in patients with acute pancreatitis.

AIMS

Investigate the predictive impact of intra-abdominal hypertension (IAH) on mortality and clinical outcomes in a patient hospitalized with severe acute pancreatitis.

METHODS

We conducted a systematic search of the PubMed, Embase, and Cochrane databases from inception through November 2021 for studies evaluating the effect of IAH on acute pancreatitis. Relevant data were extracted and analyzed using STATA 17 software. A random-effects model was used for all variables. Publication bias was assessed using Egger's test.

RESULTS

Fourteen studies investigating 1197 patients were included. Mortality, multiorgan dysfunction syndrome, pancreatic necrosis, renal, respiratory, and cardiovascular failure were more likely in the IAH group. However, infected necrosis and surgical intervention were not statistically significant between the two groups. After excluding abdominal compartment syndrome patients, mortality and respiratory failure were the only outcomes, which remained statistically significant.

CONCLUSIONS

Patients admitted to the hospital with severe acute pancreatitis have higher odds for mortality, multiorgan dysfunction syndrome, renal, respiratory, and cardiovascular failure if they developed IAH. IAH remained a strong predictor of mortality and respiratory failure even in the absence of abdominal compartment syndrome. Therefore, the development of IAH is a strong predictor of mortality and poor clinical outcome in such a population.

Characterization of Pancreatic Infections in Patients with Severe Acute Pancreatitis: A Retrospective Study from 2019 to 2023

Objective

This study investigated the distribution and changes in pancreatic infections among patients with acute pancreatitis (AP) from 2019 to 2023, while exploring the impact of multidrug-resistant bacterial infections on the prognosis of patients with poor outcomes.

Methods

This study included patients diagnosed with SAP between 2019 and 2023 and collected the demographic and clinical characteristics of all participants. Based on routine clinical microbiological culture results, the distribution and drug resistance of pathogens associated with pancreatic infections were analyzed. Multivariable logistic regression was used to evaluate the association between multidrug-resistant organism (MDRO) infection and poor prognosis.

Results

A total of 1586 pancreatic fluid specimens were analyzed and collected from 843 patients diagnosed with AP. The positive rate of the culture results was 81% (1280/1586), with the predominant pathogens identified as Klebsiella pneumoniae, Pseudomonas aeruginosa, Enterococcus faecium, and Acinetobacter baumannii complex. Of the 843 patients, 756 met the criteria, and the proportion of MDROs in pancreatic infections was 87.57% (662/756). Multivariate logistic regression analysis revealed that septic shock, acute kidney injury, and tracheostomy were associated with a poor prognosis, whereas ICU length of stay, infected pancreatic necrosis, and tracheostomy were associated with multidrug-resistant bacterial infections in patients with severe or critical AP.

Conclusion

The proportion of MDRO infections in patients with severe or critical AP was notably high, primarily involving multidrug-resistant Klebsiella pneumoniae, Pseudomonas aeruginosa, and Acinetobacter baumannii. Septic shock, acute kidney injury, and tracheostomy have been identified as independent risk factors of poor prognosis in patients with severe or critical AP.

Epidemiology of chronic and acute pancreatitis in India (EPICAP-India): protocol for a multicentre study

INTRODUCTION

Acute and chronic pancreatitis (CP) are inflammatory conditions of the pancreas that cause local and systemic complications. The epidemiology of these conditions are not well-known in India.

METHODS AND ANALYSIS

We describe the protocol and procedures of a multicentre study for delineating the epidemiology of pancreatitis in India. We plan to cover 110 000 people across 10 geographically distributed sites in 10 states of India to estimate the burden and risk factors of CP. Trained investigators will make house visits and screen for abdominal pain requiring hospitalisation or pre-diagnosed CP. The screened positive participants will be reviewed by a gastroenterologist to confirm the diagnosis of CP based on radiological imaging. For each case, four controls will be selected and data on risk factors for CP (tobacco, alcohol, family history, metabolic causes) and blood for genetic markers will be collected. Information on the cost of treatment and quality of life will be collected from patients with CP. For estimating incidence of acute pancreatitis (AP), hospital-based sentinel surveillance will be conducted in 10 districts across these 10 states. All hospitals in the district will be contacted to provide a line list of admissions due to acute abdomen including AP for 2 years. The spread of acute abdomen cases will be used to define the catchment area and estimate the denominator population. The line-listed cases with AP living in the catchment area will form the numerator to calculate the incidence. The study will provide critical information for planning pancreatitis-related services in the country.

ETHICS AND DISSEMINATION

The institutional ethics committee (IECs) at all the participating sites have given their approval for the study. All the participants whose data will be collected will be included after written informed consent. The results may be presented at national or international conferences and will be reported in peer-reviewed publications.

Clinical course for pancreatic necrosis and pancreatic pseudocysts due to severe acute or chronic pancreatitis

BACKGROUND

The acute and chronic pancreatitis (CP) can lead to severe complications like walled-off necrosis, large symptomatic pseudocyst or multiorgan failure. The treatment of these complications is multivariate and can differ from conservative, symptomatic treatment or minimal-invasive, endoscopic transgastral stenting to transgastral necrosectomy.

OBJECTIVES

This study aims to analyse the clinical course for patients that develop local complications of severe pancreatitis.

DESIGN

This is a retrospective observational single-centre study on 46 patients with severe pancreatitis.

METHODS

In this retrospective single-centre study, 46 out of 474 inpatients from January 2014 to December 2020, who were treated because of an acute or CP, developed acute pancreatitis complications and could be included. We analysed and compared the clinical course of different treatments (lumen apposing metal stents, transgastral double pigtail stent, endoscopic retrograde cholangiopancreatography, operation, conservative treatment) and different complications (walled-off necrosis (WON), pancreatic pseudocyst (PPC)).

RESULTS

Forty-six patients developed an acute complication due to severe pancreatitis. Twenty-seven patients developed a WON, while 19 patients suffered from PPC. 48% of the whole cohort had an alcoholic aetiology of pancreatitis. 78% were treated with antibiotics, 48% suffered from infected pancreatitis and 22% needed intensive care treatment. WON patients more often had a longer hospitalization of more than 21 days. PPC patients were correlated with an alcoholic aetiology, whereas WON patients were inversely correlated with an alcoholic aetiology. Increased lactate dehydrogenase, lipase, and C-reactive protein levels as well as leucocyte count could be associated with a higher probability to exhibit a WON instead of another local complication. The mortality rate was low with 7% in our study.

CONCLUSION

WON and PPC differ in certain patients and laboratory characteristics such as aetiology, elevated laboratory values, antibiotic treatment or the duration of hospitalization. Invasive treatment is not required in all severe pancreatitis cases.

Natural History and Microbiological Profiles of Patients With Acute Pancreatitis With Suspected Infected Pancreatic Necrosis

INTRODUCTION

Acute pancreatitis (AP) is a prevalent emergency. The clinical spectrum of the condition is varied, ranging from a mild to a malignant course with higher mortality rates. Infection of pancreatic/peri necrosis, extrapancreatic infections, and organ failure are significant complications in AP. In the recent era, microbiological composition has shifted more towards multi-drug-resistant organisms due to irrational antibiotic use.

OBJECTIVE

This study aims to understand the natural history of patients with suspected infected pancreatic necrosis (IPN), the prevalence of multi-drug-resistant organisms (MDROs), and their antibiotic susceptibility patterns.

METHODS

This prospective, observational study was performed on 130 cases of acute necrotizing pancreatitis (ANP) with suspected IPN that were evaluated during their period of admission in the department of gastroenterology, emergency medicine, or surgery ward of the Postgraduate Institute of Medical Education and Research, Chandigarh, India, a tertiary hospital. The details of outcomes were recorded. The organisms in cases with IPN and antibiotic resistance patterns of various organisms were studied.

RESULTS

The most prevalent site of necrosis was combined pancreatic and peripancreatic tissues in 111 (85.4%) patients. The computed tomography severity index (CTSI) had a mean of 8.72±1.43. Of all participants, 36 (27.7%) patients had <30% necrosis, 47 (36.2%) had 30%-50% necrosis, and 47 (36.2%) had >50% necrosis. Overall, 80 (61.5%) patients had organ failure, with acute lung injury (ALI) being the most common. Rates of complications were markedly greater in cases with higher pancreatic necrosis and with infected necrosis (p<0.05). The most common organism isolated from necrotic tissue was Escherichia coli (E. coli) in 17 (32.07%) cases, followed by Acinetobacter baumannii (A. baumannii) in 12 (22.64%) cases. The most common extrapancreatic infection site was respiratory tract infections. Pseudomonas aeruginosa (P. aeruginosa) and A. baumannii revealed maximum resistance to most of the drugs.  Conclusion: Infected pancreatic necrosis is linked to high rates of morbidity and mortality. Our study suggests that irrational usage of antibiotics increases the incidence of combined infection, especially with higher rates of multi-drug-resistant infections.

When to Intervene in Acute Necrotizing Pancreatitis: A Narrative Review of the Optimal Timing for Intervention Strategies

Introduction: Acute necrotizing pancreatitis (ANP) is the acute inflammation of pancreatic parenchyma, most commonly due to alcohol abuse or cholelithiasis. The treatment can be either conservative or invasive, including a variety of techniques; however, it has not yet been established if the intervention should be early or if it should be delayed. The aim of this review is to investigate the optimal time for intervention in ANP. Methods: A literature search was conducted in PubMed and Scopus from inception until September 2024 for studies reporting the comparison between early and late intervention. Results: Early intervention, within 4 weeks of symptom onset, often involves drainage via percutaneous, endoscopic, or combined methods. Delayed intervention occurs after 4 weeks of symptom onset. This can be conducted either surgically or via minimally invasive means. The results of this review reveal that the time of intervention for ANP plays an important role in the prognosis and the course of the disease. In particular, early intervention is associated with higher mortality, which is also the primary clinical outcome. Delayed intervention is also superior regarding secondary clinical outcomes, specifically the complications associated with the intervention. Thus, it is accompanied by fewer episodes of new-onset organ failure, bleeding, gastrointestinal fistula, pancreatic fistula, wound infection, endocrine pancreatic insufficiency, and other complications. Finally, delayed intervention results in shorter stays, both in hospitals and the ICU. Conclusions: Delayed intervention is clearly more effective than early intervention and should be preferred. However, early intervention appears to be both safe and effective, and it is feasible.

When to Intervene in Acute Necrotizing Pancreatitis: A Narrative Review of the Optimal Timing for Intervention Strategies

Introduction: Acute necrotizing pancreatitis (ANP) is the acute inflammation of pancreatic parenchyma, most commonly due to alcohol abuse or cholelithiasis. The treatment can be either conservative or invasive, including a variety of techniques; however, it has not yet been established if the intervention should be early or if it should be delayed. The aim of this review is to investigate the optimal time for intervention in ANP. Methods: A literature search was conducted in PubMed and Scopus from inception until September 2024 for studies reporting the comparison between early and late intervention. Results: Early intervention, within 4 weeks of symptom onset, often involves drainage via percutaneous, endoscopic, or combined methods. Delayed intervention occurs after 4 weeks of symptom onset. This can be conducted either surgically or via minimally invasive means. The results of this review reveal that the time of intervention for ANP plays an important role in the prognosis and the course of the disease. In particular, early intervention is associated with higher mortality, which is also the primary clinical outcome. Delayed intervention is also superior regarding secondary clinical outcomes, specifically the complications associated with the intervention. Thus, it is accompanied by fewer episodes of new-onset organ failure, bleeding, gastrointestinal fistula, pancreatic fistula, wound infection, endocrine pancreatic insufficiency, and other complications. Finally, delayed intervention results in shorter stays, both in hospitals and the ICU. Conclusions: Delayed intervention is clearly more effective than early intervention and should be preferred. However, early intervention appears to be both safe and effective, and it is feasible.

Development of a Nomogram to Predict the Risk for Acute Necrotizing Pancreatitis

Background/Aims

Necrotizing pancreatitis (NP) presents a more severe clinical trajectory and increased mortality compared to edematous pancreatitis. Prompt identification of NP is vital for patient prognosis. A risk prediction model for NP among Chinese patients has been developed and validated to aid in early detection.

Methods

A retrospective analysis was performed on 218 patients with acute pancreatitis (AP) to examine the association of various clinical variables with NP. The least absolute shrinkage and selection operator (LASSO) regression was utilized to refine variables and select predictors. Subsequently, a multivariate logistic regression was employed to construct a predictive nomogram. The model's accuracy was validated using bootstrap resampling (n=500) and its calibration assessed via a calibration curve. The model's clinical utility was evaluated through decision curve analysis.

Results

Of the 28 potential predictors analyzed in 218 AP patients, the incidence of NP was 25.2%. LASSO regression identified 14 variables, with procalcitonin, triglyceride, white blood cell count at 48 hours post-admission, calcium at 48 hours post-admission, and hematocrit at 48 hours post-admission emerging as independent risk factors for NP. The resulting nomogram accurately predicted NP risk with an area under the curve of 0.822, sensitivity of 82.8%, and specificity of 76.4%. The bootstrap-validated area under the curve remained at 0.822 (95% confidence interval, 0.737 to 0.892). This model exhibited excellent calibration and demonstrated greater predictive efficacy and clinical utility for NP than APACHE II, Ranson, and BISAP.

Conclusions

We have developed a prediction nomogram of NP that is of great value in guiding clinical decision.

Overexpression of Plakophilin2 Mitigates Capillary Leak Syndrome in Severe Acute Pancreatitis by Activating the p38/MAPK Signaling Pathway

Purpose

Capillary leak syndrome (CLS) is an intermediary phase between severe acute pancreatitis (SAP) and multiple organ failure. As a result, CLS is of clinical importance for enhancing the prognosis of SAP. Plakophilin2 (PKP2), an essential constituent of desmosomes, plays a critical role in promoting connections between epithelial cells. However, the function and mechanism of PKP2 in CLS in SAP are not clear at present.

Methods

We detected the expression of PKP2 in mice pancreatic tissue by transcriptome sequencing and bioinformatics analysis. PKP2 was overexpressed and knocked down to assess its influence on cell permeability, the cytoskeleton, tight junction molecules, cell adhesion junction molecules, and associated pathways.

Results

PKP2 expression was increased in the pancreatic tissues of SAP mice and human umbilical vein endothelial cells (HUVECs) after lipopolysaccharide (LPS) stimulation. PKP2 overexpression not only reduced endothelial cell permeability but also improved cytoskeleton relaxation in response to acute inflammatory stimulation. PKP2 overexpression increased levels of ZO-1, occludin, claudin1, β-catenin, and connexin43. The overexpression of PKP2 in LPS-induced HUVECs counteracted the inhibitory effect of SB203580 (a p38/MAPK signaling pathway inhibitor) on the p38/MAPK signaling pathway, thereby restoring the levels of ZO-1, β-catenin, and claudin1. Additionally, PKP2 suppression eliminated the enhanced levels of ZO-1, β-catenin, occludin, and claudin1 induced by dehydrocorydaline. We predicted that the upstream transcription factor PPARγregulates PKP2 expression, and our findings demonstrate that the PPARγactivator rosiglitazone significantly upregulates PKP2, whereas its antagonist GW9662 down-regulates PKP2. Administration of rosiglitazone significantly reduced the increase in HUVECs permeability stimulated by LPS. Conversely, PKP2 overexpression counteracted the GW9662-induced reduction in ZO-1, phosphorylated p38/p38, and claudin1.

Conclusion

The activation of the p38/MAPK signaling pathway by PKP2 mitigates CLS in SAP. PPARγactivator rosiglitazone can up-regulate PKP2. Overall, directing efforts toward PKP2 could prove to be a feasible treatment approach for effectively managing CLS in SAP.

Prediction of Admission to Intensive Care Unit and 1-Year Mortality After Acute Pancreatitis With Walled-Off Pancreatic Necrosis: A Retrospective, Single-Center Cohort Study

BACKGROUND AND AIMS

Pancreatic walled-off necrosis (WON) carries significant mortality and morbidity risks, often necessitating intensive care unit (ICU) admission. This retrospective study aimed to evaluate whether routine biochemical parameters at the time of the index endoscopic procedure could predict ICU admission and 1-year mortality following endoscopic treatment of WON.

MATERIALS AND METHODS

We retrospectively identified 201 consecutive patients who underwent endoscopic drainage for WON between January 1, 2010, and December 31, 2020. Associations between routine biochemical blood tests and outcomes were assessed using logistic regression models.

RESULTS

Within 1 year of the index endoscopy, 31 patients (15.4%) died, and 40 (19.9%) were admitted to the ICU due to sepsis. Preoperative electrolyte disturbances were more prevalent among ICU-admitted patients and nonsurvivors. Hyperkalemia, hypoalbuminemia, and elevated urea were significant predictors of 1-year mortality, while hypernatremia, elevated serum creatinine, and hypoalbuminemia predicted ICU admission. Predictive models exhibited good discriminative ability, with an AUC of 0.84 (95% CI,0,75-0.93) for 1-year mortality and 0.86 (95%CI, 0.79-0.92) for ICU admission.

CONCLUSIONS

Preoperative imbalances in routine blood tests effectively predict adverse outcomes in endoscopically treated WON patients.

Epidemiology and risk factors for mortality in critically ill patients with pancreatic infection

Background

The AbSeS-classification defines specific phenotypes of patients with intra-abdominal infection based on the (1) setting of infection onset (community-acquired, early onset, or late-onset hospital-acquired), (2) presence or absence of either localized or diffuse peritonitis, and (3) severity of disease expression (infection, sepsis, or septic shock). This classification system demonstrated reliable risk stratification in intensive care unit (ICU) patients with intra-abdominal infection. This study aimed to describe the epidemiology of ICU patients with pancreatic infection and assess the relationship between the components of the AbSeS-classification and mortality.

Methods

This was a secondary analysis of an international observational study ("AbSeS") investigating ICU patients with intra-abdominal infection. Only patients with pancreatic infection were included in this analysis (n=165). Mortality was defined as ICU mortality within 28 days of observation for patients discharged earlier from the ICU. Relationships with mortality were assessed using logistic regression analysis and reported as odds ratio (OR) and 95% confidence interval (CI).

Results

The overall mortality was 35.2% (n=58). The independent risk factors for mortality included older age (OR=1.03, 95% CI: 1.0 to 1.1 P=0.023), localized peritonitis (OR=4.4, 95% CI: 1.4 to 13.9 P=0.011), and persistent signs of inflammation at day 7 (OR=9.5, 95% CI: 3.8 to 23.9, P<0.001) or after the implementation of additional source control interventions within the first week (OR=4.0, 95% CI: 1.3 to 12.2, P=0.013). Gram-negative bacteria were most frequently isolated (n=58, 49.2%) without clinically relevant differences in microbial etiology between survivors and non-survivors.

Conclusions

In pancreatic infection, a challenging source/damage control and ongoing pancreatic inflammation appear to be the strongest contributors to an unfavorable short-term outcome. In this limited series, essentials of the AbSeS-classification, such as the setting of infection onset, diffuse peritonitis, and severity of disease expression, were not associated with an increased mortality risk.ClinicalTrials.gov number: NCT03270345.

Severe Acute Pancreatitis Prediction: A Model Derived From a Prospective Registry Cohort

Background Severe acute pancreatitis (SAP) has a mortality rate as high as 40%. Early identification of SAP is required to appropriately triage and direct initial therapies. The purpose of this study was to develop a prognostic model that identifies patients at risk for developing SAP of patients managed according to a guideline-based standardized early medical management (EMM) protocol. Methods This single-center study included all patients diagnosed with acute pancreatitis (AP) and managed with the EMM protocol Methodist Acute Pancreatitis Protocol (MAPP) between April 2017 and September 2022. Classification and regression tree (CART®; Professional Extended Edition, version 8.0; Salford Systems, San Diego, CA), univariate, and logistic regression analyses were performed to develop a scoring system for AP severity prediction. The accuracy of the scoring system was measured by the area under the receiver operating characteristic curve. Results A total of 516 patients with mild (n=436) or moderately severe and severe (n=80) AP were analyzed. CART analysis identified the cutoff values: creatinine (CR) (1.15 mg/dL), white blood cells (WBC) (10.5 × 109/L), procalcitonin (PCT) (0.155 ng/mL), and systemic inflammatory response system (SIRS). The prediction model was built with a multivariable logistic regression analysis, which identified CR, WBC, PCT, and SIRS as the main predictors of severity. When CR and only one other predictor value (WBC, PCT, or SIRS) met thresholds, then the probability of predicting SAP was >30%. The probability of predicting SAP was 72% (95%CI: 0.59-0.82) if all four of the main predictors were greater than the cutoff values. Conclusions Baseline laboratory cutoff values were identified and a logistic regression-based prognostic model was developed to identify patients treated with a standardized EMM who were at risk for SAP.

A Risk Score for Predicting the Necessity of Surgical Necrosectomy in the Treatment of Infected Necrotizing Pancreatitis

BACKGROUND

For infected necrotizing pancreatitis (INP), percutaneous catheter drainage (PCD) is now widely acknowledged as the initial intervention in a step-up approach, followed, if necessary, by minimally invasive necrosectomy or even open pancreatic necrosectomy. However, an overemphasis on PCD may cause a patient's condition to deteriorate, leading to missed surgical opportunities or even death. This study aimed to develop a simple and convenient scoring tool for assessing the need for surgery in INP patients who received PCD procedures.

METHODS

In an observational study conducted between April 2015 and December 2020, PCD was utilized as the initial step to treat 143 consecutive INP patients. A surgical necrosectomy was performed when the patient failed to respond. Risk factors of PCD failure (i.e., need for surgical necrosectomy) were identified by multivariate logistic regression models. An integer-based risk scoring tool was developed using the β coefficients derived from the logistic regression model.

RESULTS

In 62 (43.4%) patients, PCD was successful, while the remaining 81 (56.6%) individuals required subsequent surgical necrosectomy. In the multivariate model, organ failure, percentage of pancreatic necrosis, extrapancreatic necrosis volume, and mean CT density of extrapancreatic necrosis volume were associated with a need for surgical necrosectomy. A predictive scoring tool based on these four factors demonstrated an area under the receiver operating characteristic curve (AUC) of 0.893. Under the scoring tool, a total score of 4 or more indicates a high possibility of surgical necrosectomy being required (at least 80%). Using the coordinates of the receiver operating characteristic curve (ROC), the sensitivity and specificity at this threshold are 0.802 and 0.903, respectively.

CONCLUSIONS

A risk score model integrating organ failure, percentage of pancreatic necrosis, extrapancreatic necrosis volume, and mean CT density of extrapancreatic necrosis volume can identify INP patients at high risk for necrosectomy. The straightforward risk assessment tool assists clinicians in stratifying INP patients and making more judicious medical decisions.

Predictive Value of Antithrombin III and d -Dimer in the Development of Moderate-To-Severe Acute Pancreatitis : A Prospective, Observational Study (AT-PROPANC)

OBJECTIVES

To analyze if antithrombin III (AT-III) and d -dimer levels at admission and at 24 hours can predict acute pancreatitis (AP) progression to moderately severe AP (MSAP) to severe AP (SAP) and to determine their predictive value on the development of necrosis, infected necrosis, organ failure, and mortality.

METHODS

Prospective observational study conducted in patients with mild AP in 2 tertiary hospitals (2015-2017).

RESULTS

Three hundred forty-six patients with mild AP were included. Forty-four patients (12.7%) evolved to MSAP/SAP. Necrosis was detected in 36 patients (10.4%); in 10 (2.9%), infection was confirmed. Organ failure was recorded in 9 patients (2.6%), all of whom died. Those who progressed to MSAP/SAP showed lower AT-III levels; d -dimer and C-reactive protein (CRP) levels increased. The best individual marker for MSAP/SAP at 24 hours is CRP (area under the curve [AUC], 0.839). Antithrombin III (AUC, 0.641), d -dimer (AUC, 0.783), and creatinine added no benefit compared with CRP alone. Similar results were observed for patients who progressed to necrosis, infected necrosis, and organ failure/death.

CONCLUSION

Low AT-III and high d -dimer plasma levels at 24 hours after admission were significantly associated with MSAP/SAP, although their predictive ability was low. C-reactive protein was the best marker tested.

CLINICAL STUDY IDENTIFIER

ClinicalTrials.gov NCT02373293.

Novel classification system for walled-off necrosis: a step toward standardized nomenclature and risk-stratification framework

BACKGROUND AND AIMS

The optimal therapeutic approach for walled-off necrosis (WON) is not fully understood, given the lack of a validated classification system. We propose a novel and robust classification system based on radiologic and clinical factors to standardize the nomenclature, provide a framework to guide comparative effectiveness trials, and inform the optimal WON interventional approach.

METHODS

This was a retrospective analysis of patients who underwent endoscopic management of WON by lumen-apposing metal stent placement at a tertiary referral center. Patients were classified according to the proposed QNI classification system: quadrant ("Q"), represented an abdominal quadrant distribution; necrosis ("N"), denoted by the percentage of necrosis of WON; and infection ("I"), denoted as positive blood culture and/or systemic inflammatory response syndrome reaction with a positive WON culture. Two blinded reviewers classified all patients according to the QNI system. Patients were then divided into 2 groups: those with a lower QNI stratification (≤2 quadrants and ≤30% necrosis; group 1) and those with a higher stratification (≥3 quadrants, 2 quadrants with ≥30% necrosis, or 1 quadrant with >60% necrosis and infection; group 2). The primary outcome was mean time to WON resolution. Secondary procedural and clinical outcomes between the groups were compared.

RESULTS

Seventy-one patients (75% men) were included and stratified by the QNI classification; group 1 comprised 17 patients and group 2, 54 patients. Patients in group 2 had a higher number of necrosectomies, longer hospital stays, and more readmissions. The mean time to resolution was longer in group 2 than in group 1 (79.6 ± 7.76 days vs 48.4 ± 9.22 days, P = .02). The mortality rate was higher in group 2 (15% vs 0%, P = .18).

CONCLUSIONS

Despite the heterogeneous nature of WON in severe acute pancreatitis, a proposed QNI system may provide a standardized framework for WON classification to inform clinical trials, risk-stratify the disease course, and potentially inform an optimal management approach.

Clinical characteristics and risk factors of organ failure and death in necrotizing pancreatitis

BACKGROUND

Organ failure (OF) and death are considered the most significant adverse outcomes in necrotizing pancreatitis (NP). However, there are few NP-related studies describing the clinical traits of OF and aggravated outcomes.

PURPOSE

An improved insight into the details of OF and death will be helpful to the management of NP. Thus, in our research, we addressed the risk factors of OF and death in NP patients.

METHODS

We performed a study of 432 NP patients from May 2017 to December 2021. All patients with NP were followed up for 36 months. The primary end-points were risk factors of OF and death in NP patients. The risk factors were evaluated by logistic regression analysis.

RESULTS

NP patients with OF or death patients were generally older, had a higher APACHE II score, longer hospital stay, longer ICU stay, as well as a higher incidence of severe acute pancreatitis (SAP), shock and pancreatic necrosis. Independent risk factors related to OF included BMI, APACHE II score and SAP (P < 0.05). Age, shock and APACHE II score (P < 0.05) were the most significant factors correlated with the risk of death in NP patients. Notably, increased mortality was linked to the number of failed organs.

CONCLUSIONS

NP is a potentially fatal disease with a long hospital or ICU stay. Our study indicated that the incidence of OF and death in NP patients was 69.9% and 10.2%, respectively. BMI, SAP, APACHE II score, age and shock are potential risk factors of OF and death in NP patients. Clinicians should focus on these factors for early diagnosis and appropriate therapy.

Altered gut microbiota in the early stage of acute pancreatitis were related to the occurrence of acute respiratory distress syndrome

Background

Acute respiratory distress syndrome (ARDS) is the most common cause of organ failure in acute pancreatitis (AP) patients, which associated with high mortality. Specific changes in the gut microbiota have been shown to influence progression of acute pancreatitis. We aimed to determine whether early alterations in the gut microbiota is related to and could predict ARDS occurrence in AP patients.

Methods

In this study, we performed 16S rRNA sequencing analysis in 65 AP patients and 20 healthy volunteers. The AP patients were further divided into two groups: 26 AP-ARDS patients and 39 AP-nonARDS patients based on ARDS occurrence during hospitalization.

Results

Our results showed that the AP-ARDS patients exhibited specific changes in gut microbiota composition and function as compared to subjects of AP-nonARDS group. Higher abundances of Proteobacteria phylum, Enterobacteriaceae family, Escherichia-Shigella genus, and Klebsiella pneumoniae, but lower abundances of Bifidobacterium genus were found in AP-ARDS group compared with AP-nonARDS groups. Random forest modelling analysis revealed that the Escherichia-shigella genus was effective to distinguish AP-ARDS from AP-nonARDS, which could predict ARDS occurrence in AP patients.

Conclusions

Our study revealed that alterations of gut microbiota in AP patients on admission were associated with ARDS occurrence after hospitalization, indicating a potential predictive and pathogenic role of gut microbiota in the development of ARDS in AP patients.

Differential expression of plasma exosomal microRNA in severe acute pancreatitis

The incidence rate of acute pancreatitis is increasing, and severe acute pancreatitis (SAP) is associated with a high mortality rate, which may be reduced by a deeper understanding of its pathogenesis. In addition, an early determination of the severity of acute pancreatitis remains challenging. The aim of this study was to match potential biomarkers for early identification and monitoring of acute pancreatitis and to shed light on the underlying pathogenic mechanisms of SAP. The expression levels of plasma exosomal microRNA (miRNA) in patients with pancreatitis have been associated with the disease. Thus, this study compared the expression levels of exosomal miRNA in plasma collected from four patients with SAP and from four healthy participants. Analyses of the miRNA expression profiles indicated that three previously unreported miRNAs were differentially expressed in the patient group: Novel1, which was downregulated, and Novel2 and Novel3, which were upregulated. The miRNA target genes for those novel miRNAs were predicted using Metascape. Of these miRNA target genes, those that were also differentially expressed at different time points after disease induction in a mouse model of acute pancreatitis were determined. The gene for complement component 3 (C3), a target gene of Novel3, was the only gene matched in both the patient group and the mouse model. C3 appeared at most of the time points assessed after induction of acute pancreatitis in mice. These findings are foundational evidence that C3 warrants further study as an early biomarker of SAP, for investigating underlying pathogenic mechanisms of SAP, and as a therapeutic target for ameliorating the occurrence or development of SAP.

Predicting success of direct endoscopic necrosectomy with lumen-apposing metal stents for pancreatic walled-off necrosis

BACKGROUND AND AIMS

Direct endoscopic necrosectomy (DEN) with lumen-apposing metal stents (LAMSs) is increasingly used in the management of pancreatic walled-off necrosis (WON). However, it still remains unknown which patients will fail to respond to DEN with LAMSs and require additional surgical intervention. Therefore, the aim of our study was to explore predictors of successful DEN with LAMSs for pancreatic WON.

METHODS

This is a retrospective analysis of a prospectively collected database. All consecutive patients who underwent DEN with LAMSs for pancreatic WON were included. Collected data were demographics, disease severity, morphologic features, and procedure characteristics. Potential factors affecting DEN outcome were predefined and analyzed.

RESULTS

One hundred one consecutive patients undergoing DEN with LAMSs for WON were identified, among whom 4 patients were excluded for technical failure (n = 1) and previous debridement without LAMSs (n = 3). In the 97 included patients, clinical success was achieved in 79 patients (81.4%). In logistic multivariable regression, 3 independent factors were negatively associated with success of DEN with LAMSs: increasing Acute Physiology and Chronic Health Evaluation II score (odds ratio [OR], .70; 95% confidence interval [CI], .55-.90; P = .005), >50% pancreatic necrosis (OR, .16; 95% CI, .03-.77; P = .022), and paracolic gutter extension (OR, .08; 95% CI, .02-.42; P = .003). A receiver-operating characteristic curve of the prediction model with these 3 factors demonstrated an area under the curve of .926.

CONCLUSIONS

Paracolic gutter extension, increasing Acute Physiology and Chronic Health Evaluation II score, and >50% gland necrosis are negative predictors for success of DEN with LAMSs in WON. This prediction model with nomogram may be helpful in clinical decision-making and prognostication.

Immune enhancement in patients with predicted severe acute necrotising pancreatitis: a multicentre double-blind randomised controlled trial

PURPOSE

Infected pancreatic necrosis (IPN) is a highly morbid complication of acute necrotising pancreatitis (ANP). Since there is evidence of early-onset immunosuppression in acute pancreatitis, immune enhancement may be a therapeutic option. This trial aimed to evaluate whether early immune-enhancing Thymosin alpha 1 (Tα1) treatment reduces the incidence of IPN in patients with predicted severe ANP.

METHODS

We conducted a multicentre, double-blind, randomised, placebo-controlled trial involving ANP patients with an Acute Physiology and Chronic Health Evaluation II (APACHE II) score ≥ 8 and a computed tomography (CT) severity score ≥ 5 admitted within 7 days of the advent of symptoms. Enrolled patients were assigned to receive a subcutaneous injection of Tα1 1.6 mg every 12 h for the first 7 days and 1.6 mg once a day for the subsequent 7 days or matching placebos (normal saline). The primary outcome was the development of IPN during the index admission.

RESULTS

A total of 508 patients were randomised, of whom 254 were assigned to receive Tα1 and 254 placebo. The vast majority of the participants required admission to the intensive care unit (ICU) (479/508, 94.3%). During the index admission, 40/254(15.7%) patients in the Tα1 group developed IPN compared with 46/254 patients (18.1%) in the placebo group (difference -2.4% [95% CI - 7.4 to 5.1%]; p = 0.48). The results were similar across four predefined subgroups. There was no difference in other major complications, including new-onset organ failure (10.6% vs. 15%), bleeding (6.3% vs. 3.5%), and gastrointestinal fistula (2% vs. 2.4%).

CONCLUSION

The immune-enhancing Tα1 treatment of patients with predicted severe ANP did not reduce the incidence of IPN during the index admission.

Prognostic factors associated with development of infected necrosis in patients with acute necrotizing or severe pancreatitis-A systematic review and meta-analysis

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.

Pancreatic hemorrhage contributes to late mortality in patients with acute necrotizing pancreatitis

OBJECTIVES

The frequency, risk factors, and impact on survival of hemorrhage into (peri)pancreatic collections in patients with acute pancreatitis (AP) has not been well studied. The study was designed to evaluate the risk factors for hemorrhage, successful hemostasis and its effect on in-hospital mortality.

METHODS

In a prospective cohort study for prediction of severity of AP, the incidence, risk factors, and outcomes of pancreatic hemorrhage were analyzed. Patients with significant hemorrhage were managed according to a predefined protocol including endovascular intervention.

RESULTS

Out of 363 patients hospitalized during the study-period, 33(9%) patients developed hemorrhage. Median time from onset of AP to hemorrhage was 59(45-68) days. The cause of hemorrhage was arterial in 19(57.5%) patients and unlocalized in 14(42.5%) patients. Hemorrhage was managed by conservative approach in 7 (21.2%), radiographic angioembolisation in 16 (48.5%), radiographic angioembolisation followed by surgery in 3 (9.1%), and surgery in 7 (21.2%) patients. Persistent organ failure [aHR 2.3 (1.1-5.1), p = 0.03], use of large bore (>20 Fr) catheter for initial drainage [aHR 3.9 (1.7-9.1), p = 0.001] and extensive (>50%) necrosis [aHR 3.1 (1.4-6.9), p = 0.005] were significant risk factors for hemorrhage. Hemorrhage was an independent predictor of mortality [aHR 2.0 (1.2-3.4), p = 0.008] in addition to persistent organ failure (aHR 12.1 (5.7-25.8), p < 0.001). In-hospital mortality in patients with hemorrhage was 22/33 (66.7%) vs. 81/330 (25%) in no hemorrhage group [p <0.001].

CONCLUSION

Pancreatic hemorrhage occurs later in the course of acute pancreatitis in relatively sicker group of patients with organ failure and extensive necrosis, and is independently associated with a higher risk of in-hospital mortality.

Pleuropulmonary pathologies in the early phase of acute pancreatitis correlate with disease severity

Background

Respiratory failure worsens the outcome of acute pancreatitis (AP) and underlying factors might be early detectable.

Aims

To evaluate the prevalence and prognostic relevance of early pleuropulmonary pathologies and pre-existing chronic lung diseases (CLD) in AP patients.

Methods

Multicentre retrospective cohort study. Caudal sections of the thorax derived from abdominal contrast enhanced computed tomography (CECT) performed in the early phase of AP were assessed. Independent predictors of severe AP were identified by binary logistic regression analysis. A one-year survival analysis using Kaplan-Meier curves and log rank test was performed.

Results

358 patients were analysed, finding pleuropulmonary pathologies in 81%. CECTs were performed with a median of 2 days (IQR 1–3) after admission. Multivariable analysis identified moderate to severe or bilateral pleural effusions (PEs) (OR = 4.16, 95%CI 2.05–8.45, p<0.001) and pre-existing CLD (OR = 2.93, 95%CI 1.17–7.32, p = 0.022) as independent predictors of severe AP. Log rank test showed a significantly worse one-year survival in patients with bilateral compared to unilateral PEs in a subgroup.

Conclusions

Increasing awareness of the prognostic impact of large and bilateral PEs and pre-existing CLD could facilitate the identification of patients at high risk for severe AP in the early phase and thus improve their prognosis.

Outcomes of Endoscopic Management of Sterile Walled-Off Pancreatic Necrosis: A Systematic Review

OBJECTIVES

The aim of this study is to systematically review outcomes related to treatment success, mortality, and adverse events of endoscopic management in patients with sterile walled-off pancreatic necrosis.

METHODS

We reviewed studies published from 2008 to 2018 from Medline and Embase that evaluated the endoscopic treatment of necrotizing pancreatitis. The primary outcome was success of treatment in resolving the collection. Secondary outcomes included length of hospitalization, mortality rate, and adverse events.

RESULTS

Five studies were included, which entailed a total of 280 patients with a mean age of 51.8 years. The primary indication for endoscopic treatment was symptomatic walled-off pancreatic necrosis. Four studies used endoscopic transmural drainage, one of them combining percutaneous drainage and 1 study performed transpapillary drainage. The pooled treatment success was 94.3% with a mean time to resolution of 77.8 days. The mean length of stay was 16.3 days, and mortality rate was 1.3%. The overall adverse event rate was 24.6%, with bleeding the most common adverse event (11%), followed by pancreatic fistula formation (3.4%) and perforation (2.7%).

CONCLUSIONS

Although endoscopic management of sterile pancreatic necrosis has a high rate of treatment success, there is a relatively high rate of adverse events, bleeding being the most common.

Acute necrotising pancreatitis: measurements of necrosis volume and mean CT attenuation help early prediction of organ failure and need for intervention

OBJECTIVES

This study explored the early predictive value of volume and mean CT density of necrosis for adverse outcomes in patients with acute necrotising pancreatitis (ANP).

METHODS

A total of 155 patients with ANP who underwent CECT within 7 days of symptom onset were included. The necrosis volume, mean CT density, and modified CT severity index (mCTSI) were calculated. C-reactive protein (CRP) and blood urea nitrogen (BUN) levels both 48 h after symptom onset were reviewed. Adverse outcomes were recorded. The predictive value of each indicator was assessed using ROC curve analysis.

RESULTS

There were significant associations between necrosis volume and mean CT density and organ failure (OF), persistent OF (POF), and need for intervention (p < 0.001 for all). For predicting OF, the area under the curve (AUC) was significantly higher for necrosis volume than for mCTSI and BUN (AUC: 0.84 vs 0.67, p = 0.0011; 0.84 vs 0.71, p = 0.0193, respectively). For predicting POF and need for intervention, the AUCs for necrosis volume were significantly higher than those for mCTSI (AUC: 0.79 vs 0.66, p = 0.0045; 0.77 vs 0.61, p = 0.0019, respectively), but did not significantly differ from those for CRP and BUN. For predicting OF, a significantly better predictive value was achieved with mean CT density than with mCTSI (AUC: 0.79 vs 0.67, p = 0.0163). There were no significant differences in predictive value between mean CT density, CRP, and BUN.

CONCLUSIONS

The volume and mean CT density of necrosis based on CECT can provide early prediction of OF, POF, and need for intervention.

KEY POINTS

• Compared to mCTSI, necrosis volume might be used to more accurately diagnose organ failure and persistent organ failure and might be better associated with the need for intervention. • Necrosis volume and mean CT density based on CECT are reliable quantitative predictors for organ failure, persistent organ failure, and intervention in acute pancreatitis.

Activin A Modulates Inflammation in Acute Pancreatitis and Strongly Predicts Severe Disease Independent of Body Mass Index

Acute pancreatitis (AP) is a healthcare challenge with considerable mortality. Treatment is limited to supportive care, highlighting the need to investigate disease drivers and prognostic markers. Activin A is an established mediator of inflammatory responses, and its serum levels correlate with AP severity. We hypothesized that activin A is independent of body mass index (BMI) and is a targetable promoter of the AP inflammatory response.

Mesenchymal stromal cell therapy for pancreatitis: Progress and challenges

Pancreatitis is a common gastrointestinal disease with no effective therapeutic options, particularly for cases of severe acute and chronic pancreatitis (CP). Mesenchymal stromal cells (MSCs) are multipotent cells with diverse biological properties, including directional migration, paracrine, immunosuppressive, and antiinflammatory effects, which are considered an ideal candidate cell type for repairing tissue damage caused by various pathogenies. Several researchers have reported significant therapeutic efficacy of MSCs in animal models of acute and CP. However, the specific underlying mechanisms are yet to be clarified and clinical application of MSCs as pancreatitis therapy has rarely been reported. This review mainly focuses on the potential and challenges in clinical application of MSCs for treatment of acute and CP, along with discussion of the underlying molecular mechanisms.

Undernutrition and Obesity Are Associated with Adverse Clinical Outcomes in Hospitalized Children and Adolescents with Acute Pancreatitis

Background: Adult studies demonstrated that extremes of nutritional status adversely impact clinical outcomes in acute pancreatitis (AP). With rising prevalence of undernutrition/obesity in children, we analyzed the effect of nutritional status on the clinical outcomes in children and adolescents with acute pancreatitis. Methodology: We analyzed the Kids' Inpatient Database (KID) between 2003 and 2016 to include all patients with a primary diagnosis of AP using specific International Classification of Diseases (ICD) codes. We classified into (1) undernutrition, (2) obesity and (3) control groups, based on ICD codes, and we compared severe acute pancreatitis and healthcare utilization (length of stay and hospitalization costs). Results: Total number of AP admissions was 39,805. The prevalence of severe AP was higher in the undernutrition and obesity groups than the control group (15.7% vs. 5.8% vs. 3.5% respectively, p < 0.001). Multivariate analyses demonstrated that undernutrition and obesity were associated with 2.5 and 1.6 times increased risk of severe AP, p < 0.001. Undernutrition was associated with an additional six days of hospitalization and almost $16,000 in hospitalization costs. Obesity was associated with an additional 0.5 day and almost $2000 in hospitalization costs, p < 0.001. Conclusion: Undernutrition and obesity were associated with greater severity of AP, as well as prolonged hospitalization stay and costs. It is imperative for treating clinicians to be aware of these high-risk groups to tailor management and strive for improved outcomes.

N-(3',4'-dimethoxycinnamonyl) anthranilic acid alleviates severe acute pancreatitis by inhibiting intestinal barrier dysfunction and NF-κB activation

Severe acute pancreatitis (SAP) can affect intestinal barrier with a high mortality. To date, effective therapies for SAP are still in urgently need. The purpose of this study was to investigate the role of anthranilic acid active synthetic derivative, N-(3',4'-dimethoxycinnamonyl) anthranilic acid (3,4-DAA), in intestinal barrier dysfunction of SAP. In this study, SAP mice model was induced by caerulein combined with lipopolysaccharide (LPS). SAP mice were pretreated with 3,4-DAA orally. Histological structures of pancreatic and intestinal tissues were observed via hematoxylin-eosin (H&E) staining. Pancreas myeloperoxidase (MPO), serum lipase, and amylase were detected using corresponding kits. Western blot analysis and reverse transcription and quantitative PCR (RT-qPCR) were employed to determine the levels of inflammatory factors in both pancreatic and intestinal tissues. Moreover, the levels of intestinal barrier-related proteins, NLRP3 inflammasome and NF-κB pathway were examined by western blot analysis. Result revealed that 3,4-DAA significantly attenuated pancreas and intestine damage, inhibited the release of inflammatory factors and intestinal barrier dysfunction. Moreover, the expression of NLRP3 and phospho-NF-κB p65 in pancreatic and intestinal tissues was notably suppressed by 3,4-DAA. To sum up, these results demonstrated that 3,4-DAA could ameliorate SAP, partly attributing to the inhibition of intestinal barrier dysfunction and the release of inflammatory factors. These findings may provide a new mechanism support for 3,4-DAA application in the clinical treatment of SAP.

Rethinking Carbapenems: A Pharmacokinetic Approach for Antimicrobial Selection in Infected Necrotizing Pancreatitis

OBJECTIVE

To provide an overview of pathophysiological changes to the pancreas during infected necrotizing pancreatitis (INP), optimal drug properties needed to penetrate the pancreas, human and animal studies supporting the use of antimicrobials, and carbapenem-sparing strategies in INP.

DATA SOURCES

A literature analysis of PubMed/MEDLINE was performed (from 1960 to September 2020) using the following key terms: infected necrotizing pancreatitis, necrotizing acute pancreatitis, and infected pancreatitis antimicrobial concentration. Individual antimicrobials were investigated with these search terms.

STUDY SELECTION AND DATA EXTRACTION

All relevant studies describing the management of INP, and human and animal pharmacokinetic (PK) data supporting antimicrobial use in the pancreas were reviewed for possible inclusion regardless of sample size or study design.

DATA SYNTHESIS

Piperacillin/tazobactam and cefepime achieve adequate pancreatic tissue concentrations in INP studies. A majority of the literature supporting carbapenem use in INP involves imipenem, and meropenem Monte Carlo simulations suggest that standard dosing regimens of meropenem may not achieve PK targets to eradicate Pseudomonas aeruginosa.

RELEVANCE TO PATIENT CARE AND CLINICAL PRACTICE

Carbapenems are often utilized for INP treatment based on guideline recommendations. This review discusses PK data, the history of carbapenem use in INP, and the pathophysiology of pancreatitis to suggest carbapenem-sparing strategies and provides stewardship tactics such as when to start antimicrobials, which empirical antimicrobial to use, and when to discontinue antimicrobials in the INP setting.

CONCLUSIONS

Noncarbapenem antipseudomonals, such as piperacillin/tazobactam and cefepime, are appropriate carbapenem-sparing options in INP, based on PK data, spectrum of activity, and risk of collateral damage.

Necrotizing pancreatitis: A review for the acute care surgeon

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.

Continuous regional arterial infusion versus intravenous administration of the protease inhibitor nafamostat mesilate for predicted severe acute pancreatitis: a multicenter, randomized, open-label, phase 2 trial

BACKGROUND

Continuous regional arterial infusion (CRAI) of protease inhibitor nafamostat mesilate (NM) is used in the context of predicted severe acute pancreatitis (SAP) to prevent the development of pancreatic necrosis. Although this therapy is well known in Japan, its efficacy and safety remain unclear.

METHODS

This investigator-initiated and -driven, multicenter, open-label, randomized, controlled trial (UMIN000020868) enrolled 39 patients with predicted SAP and low enhancement of the pancreatic parenchyma on computed tomography (CT). Twenty patients were assigned to the CRAI group, while 19 served as controls and were administered NM at the same dose intravenously (IV group). The primary endpoint was the development of pancreatic necrosis as determined by CT on Day 14, judged by blinded central review.

RESULTS

There was no difference between the CRAI and IV groups regarding the percentages of participants who developed pancreatic necrosis (more than 1/3 of the pancreas: 25.0%, range 8.7-49.1% vs. 15.8%, range 3.4-39.6%, respectively, P = 0.694; more than 2/3 of the pancreas: 20%, range 5.7-43.7% vs. 5.3%, range 0.1-26.0%, respectively, P = 0.341). The early analgesic effect was evaluated based on 24-h cumulative fentanyl consumption and additional administration by intravenous patient-controlled analgesia. The results showed that the CRAI group used significantly less analgesic. There were two adverse events related to CRAI, namely bleeding and splenic infarction.

CONCLUSIONS

CRAI with NM did not inhibit the development of pancreatic necrosis although early analgesic effect of CRAI was superior to that of IV. Less-invasive IV therapy can be considered a viable alternative to CRAI therapy.

Pulmonary complications of acute pancreatitis

Introduction: Acute pancreatitis is an inflammatory condition of the pancreas, which runs a severe course in 20% of patients, wherein it is associated with high mortality. It is associated with several pleuro-pulmonary complications with variable severity that may occur either in isolation but are frequently present in combination. Clinicians need to be aware of these complications for early and appropriate management.Areas covered: We performed a systematic search of the PUBMED database (1970-2019) to identify relevant articles focusing on pleuro-pulmonary complications that may occur in patients with acute pancreatitis. We also retrieved articles describing the pathophysiological mechanisms and treatment approach of the various complications.Expert opinion: Acute pancreatitis is usually a self-limiting disease, but the development of organ failure during the course worsens the clinical outcome. Pulmonary complications usually occur early in the course of acute pancreatitis. Clinicians need to recognize the various pulmonary complications of acute pancreatitis, early during the disease, and manage them appropriately and aggressively to improve outcomes.

Ultrasonic Pressure Ballistic System-Assisted Minimally Invasive Pancreatic Necrosectomy for Necrotizing Pancreatitis

Background: Although minimally invasive pancreatic necrosectomy (MIPN) is a new invasive technique for necrotizing pancreatitis, it has some disadvantages. This study aimed to improve the debridement technique with an ultrasonic pressure ballistic system. We hypothesized that this system would facilitate debridement and improve the safety of the procedure. Materials and Methods: Between October 2016 and January 2019, 5 patients diagnosed with necrotizing pancreatitis were enrolled in the clinical cohort. All patients underwent debridement due to infective necrosis. Access for debridement was typically established with percutaneous puncture. Then MIPN was performed. During the procedure, ultrasonic pressure was applied to liquefy the necrotic material and make it absorbable. The effect of debridement was assessed by analyzing the average bleeding volume, operation time, and complications. Postoperative clinical parameters were evaluated. Results: Debridement was performed successfully for all patients. Semisolid necrotic tissue was dissolved with ultrasonic pressure. Viscous pus was rapidly aspirated with the suction applied with negative pressure, which greatly enhanced efficiency. This approach enhanced the visibility of blood vessels, which improved safety. No major complications were encountered. Two patients (40%) developed puncture site infections. The average blood loss during the operation was 13 ± 6 mL. The average operation time was 78 ± 31 minutes. Postoperative APACHE II scores were significantly lower than preoperative scores (P < .05). White blood cells, C-reactive protein, and procalcitonin levels declined postoperatively. Conclusions: The ultrasonic pressure ballistic system could potentially enhance MIPN and make it safer.

Predrainage and Postdrainage Prognostic Nomograms to Predict Outcome of Percutaneous Drainage for Infected Pancreatic and Peripancreatic Necrotic Collections

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.

Can Disturbed Liver Perfusion Revealed in p-CT on the First Day of Acute Pancreatitis Provide Information about the Expected Severity of the Disease?

Background

The aim of the study was to evaluate the prognostic properties of perfusion parameters of liver parenchyma based on computed tomography (CT) of patients with acute pancreatitis (AP) made on the first day of onset of symptoms, to assess their usefulness in identifying patients with increased risk of the development of severe AP.

Methods

79 patients with clinical symptoms and biochemical criteria indicative of AP underwent perfusion computed tomography (p-CT) within 24 hours after onset of the symptoms. Perfusion parameters in 41 people who developed a severe form of AP were compared with parameters in 38 patients in whom the course of AP was mild.

Results

Statistical differences in the liver perfusion parameters between the group of patients with mild and severe AP were shown. The permeability-surface area product was significantly lower, and the hepatic arterial fraction was significantly higher in the group of patients with progression of AP.

Conclusions

Based on the results, it seems that p-CT performed on the first day from the onset of AP is a method that, by revealing disturbances in hepatic perfusion, can help in identifying patients with increased risk of the development of severe AP.

Artificial neural networks accurately predict intra-abdominal infection in moderately severe and severe acute pancreatitis

OBJECTIVE

The aim of this study was to evaluate the efficacy of artificial neural networks (ANN) in predicting intra-abdominal infection in moderately severe (MASP) and severe acute pancreatitis (SAP) compared with that of a logistic regression model (LRM).

METHODS

Patients suffering from MSAP or SAP from July 2014 to June 2017 in three affiliated hospitals of the Army Medical University in Chongqing, China, were enrolled in this study. A univariate analysis was used to determine the different parameters between patients with and without intra-abdominal infection. Subsequently, these parameters were used to build LRM and ANN.

RESULTS

Altogether 263 patients with MSAP or SAP were enrolled in this retrospective study. A total of 16 parameters that differed between patients with and without intra-abdominal infection were used to construct both models. The sensitivity of ANN and LRM was 80.99% (95% confidence interval [CI] 72.63-87.33) and 70.25% (95% CI 61.15-78.04), respectively (P > 0.05), whereas the specificity was 89.44% (95% CI 82.89-93.77) and 77.46% (95% CI 69.54-83.87), respectively (P < 0.05). ANN predicted the risk of intra-abdominal infection better than LRM (area under the receiver operating characteristic curve: 0.923 [0.883-0.952] vs 0.802 [0.749-0.849], P < 0.001).

CONCLUSIONS

ANN accurately predicted intra-abdominal infection in MSAP and SAP and is an ideal tool for predicting intra-abdominal infection in such patients. Coagulation parameters played an important role in such prediction.

Quality of Care Indicators in Patients with Acute Pancreatitis

BACKGROUND

Acute pancreatitis (AP) is a common and expensive condition. Improving quality of care in AP is vital to minimizing cost and improving patient outcomes. However, there has been little work accomplished toward developing and validating explicit quality indicators (QIs) in AP.

AIMS

To define quality of care in patients with AP by developing explicit QIs using standardized techniques.

METHODS

We used the UCLA/RAND Delphi panel approach to combine a comprehensive literature review with the collective judgment of experts to identify a defined set of process measures for AP.

RESULTS

We produced 164 candidate QIs after a comprehensive literature review. After Delphi review, 75 had a median rating ≥ 7. We excluded 11 QIs where the disagreement index exceeded 1.0 and combined indicators overlapping in content to produce a final list of 22 QIs. Overall, 8 QIs related to diagnosis, prevention, or determination of etiology, 2 QIs focused on determination of severity, 3 QIs captured fluid resuscitation, 2 QIs measured nutrition, 1 QI use of antibiotics, and 6 QIs captured endoscopic or surgical management.

CONCLUSIONS

We have developed 22 QIs spanning the spectrum of AP management including diagnosis, risk stratification, and pharmacological and endoscopic therapy. These QIs will facilitate future quality improvement by practitioners and organizations who treat patients with AP and further identify areas that are amenable to improvement to enhance patient care. We anticipate that this QI set will represent the first step in determining a framework for demonstrating value in the care of patients with AP.

Ischemic pancreatitis with infected walled-off necrosis with a colonic fistula after cardiopulmonary bypass successfully treated by endoscopic ultrasound-guided drainage

A 72-year-old man who had been on continuous ambulatory peritoneal dialysis treatment for 10 years underwent cardiopulmonary bypass for aortic valve replacement due to aortic valve stenosis. After surgery, he experienced pancreatitis, and rupture of a splenic artery aneurysm. He went into cardiopulmonary arrest but was successfully treated by transcatheter arterial embolization (TAE) with cardiopulmonary resuscitation. At three weeks after TAE, CT showed heterogeneous enhancement and the accumulation of pancreatic fluid in the pancreatic tail. At 4 months after TAE, he had sepsis and CT showed greater fluid collection with emphysema in comparison to 3 months previously. We diagnosed infected walled-off necrosis (WON). Conservative therapy with antibiotics was not sufficiently effective; thus, we performed endoscopic ultrasound-guided drainage (EUS-D). Contrast imaging revealed WON with colonic fistula. The WON remarkably decreased in size on CT after EUS-D. We experienced a rare case of ischemic acute pancreatitis (AP) caused by cardiopulmonary bypass complicated with infected WON with a colonic fistula. Ischemic AP more frequently shows a severe course with a fatal outcome in comparison to AP of other causes. However, in our case, ischemic AP with infected WON was successfully treated by EUS-D despite the presence of a WON with a colonic fistula.

Organ Failure Due to Systemic Injury in Acute Pancreatitis

Acute pancreatitis may be associated with both local and systemic complications. Systemic injury manifests in the form of organ failure, which is seen in approximately 20% of all cases of acute pancreatitis and defines "severe acute pancreatitis." Organ failure typically develops early in the course of acute pancreatitis, but also may develop later due to infected pancreatic necrosis-induced sepsis. Organ failure is the most important determinant of outcome in acute pancreatitis. We review here the current understanding of the risk factors, pathophysiology, timing, impact on outcome, and therapy of organ failure in acute pancreatitis. As we discuss the pathophysiology of severe systemic injury, the distinctions between markers and mediators of severity are highlighted based on evidence supporting their causality in organ failure. Emphasis is placed on clinically relevant end points of organ failure and the mechanisms underlying the pathophysiological perturbations, which offer insight into potential therapeutic targets to treat.

Comparison of early and delayed EUS-guided drainage of pancreatic fluid collection

Background and study aims  While endoscopic ultrasound (EUS)-guided drainage of pancreatic fluid collection (PFC) is recommended to be performed ≥ 4 weeks after onset of acute pancreatitis (AP), early (< 4 weeks) interventions are needed in some symptomatic cases. Despite feasibility of early percutaneous drainage, there have been few studies about early EUS-guided drainage of PFC. Patients and methods  Consecutive patients who received EUS-guided drainage (EUS-PCD) of infected or symptomatic PFC at the University of Tokyo were retrospectively studied. Contraindications for EUS-PCD are lack of encapsulation or adhesion to the gastrointestinal tract. Safety and effectiveness of early vs delayed (≥ 4 weeks) EUS-PCD were compared. Results  A total of 35 patients underwent EUS-PCD (12 early and 23 delayed) using 19 large-bore fully-covered metallic stent and 16 plastic stents. The median diameter of PFC was 110 mm (40 - 180) and 122 mm (17 - 250) in the early and delayed drainage groups, respectively. Median time from onset of AP to drainage was 23 and 85 days for early and delayed drainage, respectively. The technical success rate of EUS-guided drainage was 100 %. Endoscopic necrosectomy was performed in six early and 16 cases of delayed drainage. The adverse event rate was 25 % (3 bleeding) and 13 % (2 perforations and 1 CO ₂ retention) in the early and delayed drainage groups, respectively. Two patients died (1 early and 1 delayed) due to multiorgan failure. Conclusion  Endoscopic drainage and subsequent necrosectomy of symptomatic PFC within 4 weeks after onset of acute pancreatitis was feasible, given that the collection was encapsulated and attached to the gastrointestinal tract.