Evidence-based treatment of acute pancreatitis: a look at established paradigms

Circulating Protectin D1 and Neutrophils Extracellular Traps in the Diagnosis and Progression of Acute Pancreatitis

Purpose

Protectin D1 (PD1), a biologically active molecule derived from docosahexaenoic acid (DHA), plays a major role in the body's endogenous lipid-mediated inflammatory response. The study aims to explore the relationship between PD1, inflammatory response and the severity of acute pancreatitis (AP).

Patients and Methods

Sixty consecutive AP patients within 72h of disease onset were enrolled as the study group, a further thirty healthy people were enrolled as the control group. General demographics collected at the time of enrollment. Serum PD1, Citrullinated Histone 3 (CitH3), myeloperoxidase-Deoxyribonucleic acid (MPO-DNA), tumor necrosis factor-α (TNF-α), interleukin-6 (IL-6) level were measured in AP patients on enrollment day 0, day 1, day 3 and day 7. Meanwhile, the Acute Physiology and Chronic Health evaluation II (APACHE II) scores, Sequential Organ Failure Assessment (SOFA) scores were also evaluated on day 0, day 1, day 3 and day 7.

Results

AP was severe in 29 patients (48.3%), moderately severe acute pancreatitis (MSAP) was found in 9 patients (15%), and mild acute pancreatitis (MAP) was found in 22 patients (36.7%). The level of PD1, CitH3 and MPO-DNA were statistically significantly higher in AP patients than in the healthy population. Serum PD1, CitH3 and MPO-DNA concentration increased with AP severity. In AP patients, PD1 has a strong linear association with TNF-α, CitH3 and MPO-DNA. The AUC for SAP predicted by PD1 was 0.938. The calculated cut-off point for prognosis SAP is 7.94 pg/mL. The AUC for infected pancreatic necrosis (IPN) predicted by PD1 was 0.836 and the cut-off point was 8.65 pg/mL. The AUC for organ failure (OF) predicted by PD1 was 0.719 and the cut-off point was 7.94 pg/mL.

Conclusion

PD1 is associated with both the presence of AP and the severity of pancreatitis.

Latest Progress in Risk-Adapted Surgery for Medullary Thyroid Cancer

(1) Background: The wider adoption of a preoperative ultrasound and calcitonin screening complemented by an intraoperative frozen section has increased the number of patients with occult sporadic medullary thyroid cancer (MTC). These advances offer new opportunities to reduce the extent of the initial operations, minimizing operative morbidity and the risk of postoperative thyroxin supplementation without compromising the cure. (2) Methods: This systematic review of the international literature published in the English language provides a comprehensive update on the latest progress made in the risk-adapted surgery for sporadic and hereditary MTC guided by an intraoperative frozen section. (3) Results: The current evidence confirms the viability of a hemithyroidectomy for desmoplasia-negative sporadic MTC. To add an extra safety margin, the hemithyroidectomy may be complemented by a diagnostic ipsilateral central node dissection. Despite the limited extent of the surgery, all the patients with desmoplasia-negative sporadic tumors achieved a biochemical cure with excellent clinical outcomes. A hemithyroidectomy decreases the need for postoperative thyroxine substitution, but a total thyroidectomy may be required for bilateral nodular thyroid disease. Hereditary MTC is a different issue. Because each residual thyroid C cell carries its own risk of malignant progression, a total thyroidectomy remains mandatory for hereditary MTC. (4) Conclusion: In experienced hands, a hemithyroidectomy, which minimizes morbidity without compromising the cure, is an adequate therapy for desmoplasia-negative sporadic MTC.

No role for protease inhibitors as a mitigation strategy for postpancreatectomy acute pancreatitis (PPAP): Propensity score matching analysis

BACKGROUND

While the use of protease inhibitor gabexate mesylate (GM) is still controversial in acute pancreatitis, it has never been tested for postpancreatectomy acute pancreatitis (PPAP). This study aims to assess the impact of GM on postoperative serum hyperamylasaemia (POH) or PPAP after pancreatoduodenectomy (PD).

METHODS

Consecutive patients developing POH after PD between 2016 and 2021 were included. According to GM administration, patients were divided into GM-treated and control (CTR) groups. GM was administered from postoperative day 1-3 in POH patients who underwent surgery before 2017. A 2:1 propensity matching was used to minimize the risk of bias.

RESULTS

Overall, 264 patients with POH were stratified in the GM (59 patients) and CTR (104 patients) cohorts, which showed balanced baseline characteristics after matching. No difference in postoperative complications was observed between the groups (all p > 0.05), except for PPAP occurrence, which was significantly higher in the GM group (37% vs. 22%, p = 0.037). A total of 45 patients (28%) evolved to PPAP. Comparing PPAP patients in the GM and CTR groups, no significant differences in POPF, relaparotomy, and mortality (all p > 0.09) were found. No difference in intravenous crystalloid administration was found in patients with PPAP, whether or not they developed major complications or pancreatic fistula (p > 0.05) CONCLUSION: Protease inhibitor seems ineffective in preventing a PPAP after PD once a POH has occurred. Further studies are needed to achieve benchmarks for treating PPAP and identify mitigation strategies to prevent the evolution of POH into additional morbidity.

Endoscopic versus minimally invasive surgical approach for infected necrotizing pancreatitis: a systematic review and meta-analysis of randomized controlled trials

BACKGROUND/AIMS

Acute pancreatitis is a common condition of the digestive system, but sometimes it develops into severe cases. In about 10-20% of patients, necrosis of the pancreas or its periphery occurs. Although most have aseptic necrosis, 30% of cases will develop infectious necrotizing pancreatitis. Infected necrotizing pancreatitis (INP) requires a critical treatment approach. Minimally invasive surgical approach (MIS) and endoscopy are the management methods. This meta-analysis compares the outcomes of MIS and endoscopic treatments.

METHODS

We searched a medical database until December 2022 to compare the results of endoscopic and MIS procedures for INP. We selected eligible randomized controlled trials (RCTs) that reported treatment complications for the meta-analysis.

RESULTS

Five RCTs comparing a total of 284 patients were included in the meta-analysis. Among them, 139 patients underwent MIS, while 145 underwent endoscopic procedures. The results showed significant differences (p < 0.05) in the risk ratios (RRs) for major complications (RR: 0.69, 95% confidence interval (CI): 0.49-0.97), new onset of organ failure (RR: 0.29, 95% CI: 0.11-0.82), surgical site infection (RR: 0.26, 95% CI: 0.07-0.92), fistula or perforation (RR: 0.27, 95% CI: 0.12-0.64), and pancreatic fistula (RR: 0.14, 95% CI: 0.05-0.45). The hospital stay was significantly shorter for the endoscopic group compared to the MIS group, with a mean difference of 6.74 days (95% CI: -12.94 to -0.54). There were no significant differences (p > 0.05) in the RR for death, bleeding, incisional hernia, percutaneous drainage, pancreatic endocrine deficiency, pancreatic exocrine deficiency, or the need for enzyme use.

CONCLUSIONS

Endoscopic management of INP performs better compared to surgical treatment due to its lower complication rate and higher patient life quality.

Nil per os or Enteral Nutrition in Mild and Moderately Severe Acute Pancreatitis: A Case Series

BACKGROUND: There are controversies regarding the treatment of mild-to-moderate pancreatitis, especially when comparing the efficacy of nil per os regime versus the nasogastric feeding. While some sources suggest the benefits of the nasogastric feeding, there are meager data available toward the impact of the selected treatment vis-à-vis the length of hospital stay, and as of the final outcome. AIM: Authors collected data from two subgroups (treated with nil per os regime or nasogastric feeding, respectively) with the aim to define a safe and more efficacious regime. METHODS: This case series collection was carried out in the University Hospital Center in Tirana (UHC) at the Service of Gastroenterology. The period of the study was January 1, 2018–December 31, 2019. The patients were divided into two subgroups (the control group had a nil per os regime and patients in the intervention group received a nasogastric feeding) according to approved inclusion and exclusion criteria. RESULTS: Twenty subjects were allocated to the control group and 21 subjects were allocated to the intervention group. The length of hospital stay in the control group was 10.2 days compared with 8.4 days in the intervention group (p < 0.05). The days’ average spent with pain was 4.5 in the control group and 3.14 in the intervention group (p < 0.05). Oral feeding begun approximately 5.45 days since the admission in the control group and 3.14 days in the intervention group (p < 0.05). Oral food intolerance occurred in 6 patients (30%) in the control group and in one patient in the intervention group (4.8%) (p < 0.05). CONCLUSIONS: Nasogastric feeding seems to have significant benefits in the treatment of mild to moderate acute pancreatitis, when compared with the nil per os regime. Nasogastric feeding reduces length of stay in hospital and improves early the clinical outcomes.

C-reactive protein accurately predicts severity of acute pancreatitis in children

INTRODUCTION

Predicting severity of acute pancreatitis enables optimization of care, reducing morbidity and length of stay. Modified adult scoring systems have not been able to adequately predict severity in children.

METHODS

This was a retrospective study of children presenting with a first episode of acute pancreatitis from 2002 to 2020 in a single tertiary paediatric surgical centre. Serum markers including CRP at 48 h of admission were analysed. Promising biomarkers underwent ROC (Receiver Operating Curve) analysis, and these were compared to the modified Glasgow Pancreas Score. An AUC (Area Under Curve) > 0.90 was taken as an excellent predictor of severity.

RESULTS

Data of 59 children were analysed, median age 13 years. 22 patients (37%) had a severe episode. ROC analysis demonstrated CRP as the best predictor of severity giving an AUC of 0.92. Optimum cut off value for CRP was 107.5 mg/L (p < 0.0001) producing sensitivity of 91%, specificity of 84%. This was superior to the modified Glasgow Pancreas score, which produced a sensitivity of 36% and specificity of 100%.

CONCLUSION

We have shown that a CRP value of > 108 mg/L within 48 h of admission can be used to predict severity of acute pancreatitis in children with greater accuracy than current scoring systems.

TYPE OF STUDY

Diagnostic test.

LEVEL OF EVIDENCE

Level I.

Early endoscopic transpapillary drainage through the minor papilla in the treatment of acute pancreatitis

Background

To explore the feasibility, safety, and efficacy of endoscopic transpapillary drainage through the minor papilla in the treatment of acute pancreatitis (AP).

Methods

We retrospectively evaluated the safety and efficacy of endoscopic transpapillary drainage via the minor papilla among AP patients who were treated in our hospital from September 2018 to March 2020.

Results

The present study included 18 patients (12 males and 6 females). All patients successfully received endoscopic transpapillary drainage via the minor papilla and were discharged upon recovery. No patient died, received ICU treatment, or had endoscopic operation-related complications. Two patients (11.11%) received additional abdominal paracentesis due to local complications. Fifteen patients (83.33%) resumed oral feeding within 3 days. The postoperative 24-hour leukocyte level, APACHE II score, serum amylase level, and lipase level significantly decreased compared with those at admission. The median hospitalization stay was 5 (3.75-9) days. The median hospitalization cost was 25,123.82 (22,942.50-43,874.68) RMB. The patients were followed up at 6-24 months, during which 4 patients (22.22%) had recurrence. Two patients had recurrence after pancreatic duct removal and other 2 patients in the period of carrying ducts.

Conclusions

Early endoscopic transpapillary drainage via the minor papilla in cases of difficult cannulation or stenting via the major papilla is safe and effective in the treatment of AP, and is worthy of further popularization.

Prevalence of imaging findings of acute pancreatitis in emergency department patients with elevated serum lipase

PURPOSE

To assess the association of imaging features of acute pancreatitis (AP) with the magnitude of lipase elevation in Emergency Department (ED) patients.

METHODS

This Institutional Review Board-approved retrospective study included 509 consecutive patients presenting from 9/1/13-8/31/15 to a large academic ED with serum lipase levels ≥3× the upper limit of normal (ULN) (≥180 U/L). Patients were excluded if they did not have imaging (n = 131) or had a history of trauma, abdominal metastases, altered mental status, or transfer from an outside hospital (n = 190); the final study population was 188 patients. Imaging exams were retrospectively evaluated, and a consensus opinion of two subspecialty-trained abdominal radiologists was used to diagnose AP. Primary outcome was presence of imaging features of AP stratified by lipase level (≥3×-10× ULN and > 10× ULN). Secondary outcome was rate of discordant consensus evaluation compared to original radiologist's report.

RESULTS

25.0% of patients (47/188) had imaging features of AP. When lipase was >10× ULN (n = 94), patients were more likely to have imaging features of AP (34%) vs. those with mild elevation (16%) (p = 0.0042). There was moderately strong correlation between lipase level and presence of imaging features of AP (r = 0.48, p < 0.0001). Consensus review of CT and MRI images was discordant with the original report in 14.9% (28/188) of cases.

CONCLUSION

Prevalence of imaging signs of AP in an ED population with lipase ≥3× ULN undergoing imaging is low. However, the probability of imaging features of AP increases as lipase value increases.

Knowledge acquired from Clinical Guidelines on the Diagnosis and Treatment of Acute Pancreatitis by attending physicians and residents in hospitals in Veracruz

INTRODUCTION

Clinical practice guidelines on the diagnosis and treatment of acute pancreatitis (CPGDTAP) have been designed in an effort to reduce the morbidity and mortality of that severe disease.

AIM

To identify the knowledge acquired from CPGDTAP in hospitals in Veracruz.

MATERIALS AND METHODS

A descriptive, observational, multicenter study was conducted at four hospitals in Veracruz, through the application of a survey to evaluate the knowledge of attending physicians and residents that treat patients with acute pancreatitis. Descriptive statistics were employed to analyze the results.

RESULTS

A total of 74 physicians were surveyed: 55.41% of whom were attending physicians and 44.59% of whom were resident physicians. The majority of physicians (67.57%) were familiar with CPGDTAP from the Asociación Mexicana de Gastroenterología (AMG), followed by those of the General Health Council of the Mexican Department of Health (CENETEC, the Spanish acronym) (54.05%) and the American College of Gastroenterology (ACG) (48.65%). A total of 97.30% of the physicians routinely use a nasogastric tube, 79.73% considered early enteral nutrition to be very important, as did 98.65% regarding generous fluid replacement, 85.14% did not routinely use antimicrobials, 63.51% ordered a CAT scan at 72h or later, and 87.84% answered that infected necrosis was the indication for surgery, preferably after the third week.

DISCUSSION AND CONCLUSIONS

In our hospital environment, the CPGDTAP issued by the AMG and CENETEC were the most well-known, but their recommended measures were given importance by under 85% of the physicians surveyed. Therefore, the diffusion of the knowledge they contain is advisable to guarantee optimal results in acute pancreatitis management.

The Effects of Rhein and Honokiol on Metabolic Profiles in a Mouse Model of Acute Pancreatitis

BACKGROUND Acute pancreatitis (AP) is generally a self-limiting inflammatory disease, but is associated with a high mortality rate when severe. The present study aimed to investigate the effects of rhein and honokiol on AP. MATERIAL AND METHODS Thirty mice were randomly divided into 5 groups (n=6 per group): blank control, AP model, AP+rhein, AP+honokiol, and AP+rhein+honokiol. The AP model was prepared by intraperitoneal injection of cerulein and lipopolysaccharide (LPS). We observed the pathological changes of the pancreas by hematoxylin and eosin (H&E) staining. A mouse amylase kit was utilized to detect the level of amylase content in serum. Gas chromatography mass spectrometer analysis was performed to detect the differences in metabolites among the blank control, AP model, and AP+rhein+honokiol groups. RESULTS The serum amylase level was significantly higher in the AP model, which suggested that the AP model was constructed successfully. The AP+rhein+honokiol group had significantly reduced interstitial edema, inflammatory cell infiltration, hemorrhage, and necrosis. In addition, the rhein and honokiol treatment influenced some of the metabolic pathways in AP, including riboflavin metabolism, glycerophospholipid metabolism, linoleic acid metabolism, and the pentose and glucuronate interconversions pathway. CONCLUSIONS This study showed that the combination of rhein and honokiol ameliorated pathological changes in the pancreas of mice with AP.

Comparison of early and delayed cholecystectomy for biliary pancreatitis: A meta-analysis

BACKGROUND

Biliary stones are the most common etiology of acute pancreatitis Cholecystectomy has been accepted as a popular treatment for acute biliary pancreatitis (ABP) to reduce the risk of recurrent complications. However, the precise time of intervention still remains controversial.

OBJECTIVE

The aim of this meta-analysis was to compare early and delayed cholecystectomy and determine the most precise timing of cholecystectomy following gallstone pancreatitis.

METHOD

Search the publications on comparison the efficacy of early cholecystectomy comparison with delayed cholecystectomy in treatment outcomes of ABP to October, 2018. After rigorous reviewing on quality, the data was extracted from eligible trials. All trials analyzed the summary hazard ratios (HRs) of the endpoints of interest, including survival data and individual postoperative complications.

RESULTS

A total of 9 trials were met our inclusion criteria. The pooled results indicate that postoperative complications、readmission rate、conversion to an open procedure and cholecystectomy-related morbidity/mortality did not have statistical significance (P > 0.05) between the early and delayed cholecystectomy. While, the length of hospital stay was shorter for the early cholecystectomy group than the delayed group in all included studies.

CONCLUSIONS

Although the efficacy of delayed intervention in terms of inflammation reduction is definite, their adverse events are often major limitations. In the present study, an early cholecystectomy may result in a significantly shortened hospital stays without increased complications or mortality.

Endoscopic versus surgical treatment for infected necrotizing pancreatitis: a systematic review and meta-analysis of randomized controlled trials

OBJECTIVE

To compare outcomes of endoscopic and surgical treatment for infected necrotizing pancreatitis (INP) based on results of randomized controlled trials (RCT).

BACKGROUND

Treatment of INP has changed in the last two decades with adoption of interventional, endoscopic and minimally invasive surgical procedures for drainage and necrosectomy. However, this relies mostly on observational studies.

METHODS

We performed a systematic review following Cochrane and PRISMA guidelines and AMSTAR-2 criteria and searched CENTRAL, Medline and Web of Science. Randomized controlled trails that compared an endoscopic treatment to a surgical treatment for patients with infected walled-off necrosis and included one of the main outcomes were eligible for inclusion. The main outcomes were mortality and new onset multiple organ failure. Prospero registration ID: CRD42019126033 RESULTS: Three RCTs with 190 patients were included. Intention to treat analysis showed no difference in mortality. However, patients in the endoscopic group had statistically significant lower odds of experiencing new onset multiple organ failure (odds ratio (OR) confidence interval [CI] 0.31 [0.10, 0.98]) and were statistically less likely to suffer from perforations of visceral organs or enterocutaneous fistulae (OR [CI] 0.31 [0.10, 0.93]), and pancreatic fistulae (OR [CI] 0.09 [0.03, 0.28]). Patients with endoscopic treatment had a statistically significant lower mean hospital stay (Mean difference [CI] - 7.86 days [- 14.49, - 1.22]). No differences in bleeding requiring intervention, incisional hernia, exocrine or endocrine insufficiency or ICU stay were apparent. Overall certainty of evidence was moderate.

CONCLUSION

There seem to be possible benefits of endoscopic treatment procedure. Given the heterogenous procedures in the surgical group as well as the low amount of randomized evidence, further studies are needed to evaluate the combination of different approaches and appropriate timepoints for interventions.

Surgical Transgastric Necrosectomy for Necrotizing Pancreatitis: A Single-stage Procedure for Walled-off Pancreatic Necrosis

OBJECTIVE

The aim of this study was to evaluate the role of surgical transgastric necrosectomy (TGN) for walled-off pancreatic necrosis (WON) in selected patients.

BACKGROUND

WON is a common consequence of severe pancreatitis and typically occurs 3 to 5 weeks after the onset of acute pancreatitis. When symptomatic, it can require intervention.

METHODS

A retrospective review of patients with WON undergoing surgical management at 3 high-volume pancreatic institutions was performed. Surgical indications, intervention timing, technical methodology, and patient outcomes were evaluated. Patients undergoing intervention <30 days were excluded. Differences across centers were evaluated using a P value of <0.05 as significant.

RESULTS

One hundred seventy-eight total patients were analyzed (mean WON diameter = 14 cm, 64% male, mean age = 51 years) across 3 centers. The majority required inpatient admission with a median preoperative length of hospital stay of 29 days (25% required preoperative critical care support). Most (96%) patients underwent a TGN. The median duration of time between the onset of pancreatitis symptoms and operative intervention was 60 days. Thirty-nine percent of the necrosum was infected. Postoperative morbidity and mortality were 38% and 2%, respectively. The median postoperative length of hospital length of stay was 8 days, with the majority of patients discharged home. The median length of follow-up was 21 months, with 91% of patients having complete clinical resolution of symptoms at a median of 6 weeks. Readmission to hospital and/or a repeat intervention was also not infrequent (20%).

CONCLUSION

Surgical TGN is an excellent 1-stage surgical option for symptomatic WON in a highly selected group of patients. Precise surgical technique and long-term outpatient follow-up are mandatory for optimal patient outcomes.

Docosahexaenoic acid inhibits zymogen activation by suppressing vacuolar ATPase activation in cerulein-stimulated pancreatic acinar cells

BACKGROUND

The premature activation of digestive enzyme zymogens within pancreatic acinar cells is an important early feature of acute pancreatitis. Supraphysiological concentrations of cholecystokinin (CCK) cause intrapancreatic zymogen activation and acute pancreatitis. Stimulation of vacuolar ATPase (vATPase) activity is required for zymogen activation in pancreatic acinar cells. Parkin, a multiprotein E3 ubiquitin ligase complex, promotes vATPase ubiquitination and degradation, which inhibits vATPase activity. Docosahexaenoic acid (DHA), an omega-3 fatty acid, exerts anti-inflammatory effects. It is reported to bind to G-protein coupled receptor 120 (GPR120) and GPR40. DHA induces the degradation of certain proteins by activating ubiquitin-proteasome system in various cells. This study aimed to investigate whether DHA induces Parkin and inhibits vATPase activity, resulting in zymogen inactivation in pancreatic acinar AR42J cells stimulated with cerulein, a CCK analog.

RESULTS

Cerulein induced the translocation of the cytosolic V1 domain (E subunit) of vATPase to the membrane, which indicated vATPase activation, and zymogen activation in AR42J cells. DHA suppressed the association of the vATPase with membranes, and zymogen activation (increased trypsin activity and amylase release) induced by cerulein. Pretreatment with a GPR120 antagonist AH-7614, a GPR40 antagonist DC260126, or an ubiquitination inhibitor PYR-41 reduced the effect of DHA on cerulein-induced zymogen activation. Treatment with PYR-41 reversed the DHA-induced decrease in vATPase activation in cerulein-treated cells. Furthermore, DHA increased the level of Parkin in membranes of cerulein-treated cells.

CONCLUSIONS

DHA upregulates Parkin which inhibits vATPase-mediated zymogen activation, via GPR120 and GPR40, in cerulein-stimulated pancreatic acinar cells.

A patient with severe acute pancreatitis who was successfully rescued by multiple disciplinary teams: a case report

Severe acute pancreatitis (SAP) is a type of acute abdominal disease. SAP has a high incidence, rapid progression, many complications, high mortality rate (as high as 30%–50%), and is difficult to treat, accounting for approximately 5% to 10% cases of acute pancreatitis. We report diagnosis and treatment of a case of SAP, including a combination of the relevant guidelines and our experience. The patient, who was a 42-year-old woman, was admitted to our hospital after suffering from abdominal pain in the upper abdomen for 1 day. The results of a computed tomography scan in the upper abdomen showed changes in the pancreas accompanied by acute fluid accumulation. The blood amylase level was 1150 U/L. The patient was treated at our Gastroenterology Department for 5.5 months, and received 22 blood transfusions (including red blood cell suspension, plasma, cryoprecipitate, and platelets), four surgical operations, three angiographic interventions, and two times of embolization for hemostasis. We successfully rescued this patient with SAP using minimally invasive, staged, multidisciplinary, and diversified treatment modalities.

An endoscopic or minimally invasive surgical approach for infected necrotizing pancreatitis: a systematic review and meta-analysis

BACKGROUND AND AIM

the incidence of acute pancreatitis is rising across the world, thus further increasing the burden on healthcare services. Approximately 10% of patients with acute pancreatitis will develop infected necrotizing pancreatitis (INP), which is the leading cause of high mortality in the late phase. There is currently no consensus with regard to the use of endoscopic or minimally invasive surgery as the first-line therapy of choice for INP. However, more clinical research with regard to the superiority of an endoscopic approach has been recently published. Therefore, we conducted a systematic review and meta-analysis to determine which of the two treatments leads to a better prognosis.

METHODS

four databases (Medline, SINOMED, EMBASE and Cochrane Library) were searched for eligible studies from 1980 to 2018, comparing endoscopic and minimally invasive surgery for INP.

RESULTS

two randomized controlled trials (RCTs) and seven clinical cohort studies were included. After the analysis of data amenable to polling, significant advantages were found in favor of the endoscopic approach in terms of pancreatic fistulas (OR = 0.10, 95% CI 0.04-0.30, p < 0.001) and the length of hospital stay (weighted mean difference [WMD] = -24.72, 95% CI = -33.87 to -15.57, p < 0.001). No marked differences were found in terms of mortality, multiple organ failure, intra-abdominal bleeding, enterocutaneous fistula, recurrence of pseudocysts, and length of stay (LOS) in the Intensive Care Unit (ICU), endocrine insufficiency and exocrine insufficiency.

CONCLUSION

compared with minimally invasive surgery, an endoscopic approach evidently improved short-term outcomes for infected necrotizing pancreatitis, including pancreatic fistula and the length of hospital stay. Furthermore, relevant multicenter RCTs are eager to validate these findings.

[Treatment of acute necrotizing pancreatitis]

Acute pancreatitis (AP) has an annual incidence of 30-45 per 100,000 inhabitants. In Germany approximately one third of the cases are of biliary or alcoholic origin. The diagnosis is based on the typical epigastric pain with radiation and a threefold increase of lipase or amylase in serum. Imaging procedures only rarely need to be included for the primary diagnostics. An early risk assessment is important to be able to allocate patients with severe AP to surveillance in an intensive care unit (ICU). Elevation of blood urea nitrogen, hematocrit and blood glucose are early predictors of poor outcome.The removal of impacted gall-stones by endoscopic retrograde cholangiography (ERC) is the only causal treatment of biliary AP, which must be carried out when there are signs of cholangitis and in severe biliary AP. Pain management and early fluid substitution are the most important symptomatic approaches. In the early phase of AP 150-250 ml/h of crystalloid solution should be administered to compensate for the extravasal loss of fluid. In certain cases, the initial fluid requirement might be even higher. In the ICU setting echocardiography and advanced hemodynamic monitoring are available for guidance. Prophylactic antibiotic treatment is not recommended in mild AP and it is a matter of debate even in severe AP. Early enteral nutrition has been shown to improve the outcome. Even in cases of fluid collection and necrosis a primary surgery approach should be avoided in favor of a "step-up" procedure with radiologically guided drainage as well as endoscopic and if necessary video-assisted percutaneous retroperitoneal débridement. Surgery remains an option for complications and for infected necrosis which cannot be reached by any other means.

How does neural monitoring help during thyroid sugery for Graves' disease?

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Risk of RLN palsy during thyroidectomy for Graves’ disease is high.

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I-IONM and C-IONM are feasible and useful during thyroidectomy for Graves’ disease.

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Proportion of complete thyroidectomy was significantly higher using IONM technology.

We evaluate the role of intraoperative neuromonitoring (IONM) in thyroidectomy performed for Graves’ disease (GD) with an emphasis on recurrent laryngeal nerve (RLN) management and completeness of resection. The study is a retrospective series comprising 55 thyroidectomy (control group) versus 82 procedures with intermittent IONM (I-IONM) and 72 by means of continuous IONM (C-IONM). In the control group the laryngeal nerves have been identified by visualization solely. In the I-IONM group both vagal nerve (VN) and RLN have been localized and monitored during thyroid resection. C-IONM was achieved with a vagal stimulation probe. I-IONM group had shorter operating times (P = 0.032). RLN morbidity, meaning palsy rate, was 2.7% in the C-IONM group, 3.6% in I-IONM and 5.4% in the control group (P = 0.058). The proportion of complete procedures (total or near total resections) were significantly higher using monitoring technology (P = 0.049). Persistent positive serum TBII values were found in 25 (45%), 25 (30%) and 20 (27%) patients at 12 months in the control, I-IONM and C-IONM groups respectively (P = 0,04). IONM is an effective technology in GD patients.

Feasibility of Temporary Pancreatic Stenting after Early Endoscopic Retrograde Cholangiopancreatography in Patients with Acute Biliary Pancreatitis

Background/Aims

To assess the safety and effectiveness of temporary pancreatic stenting after early endoscopic retrograde cholangiopancreatography (ERCP) in patients with acute biliary pancreatitis regardless of the severity or concomitant cholangitis.

Methods

Temporary pancreatic stenting was performed in 79 patients with visualized pancreatic duct during ERCP. The outcomes of 64 patients with adequate pancreatic stenting (PS) and 15 patients with inadequate pancreatic stenting (no PS) were compared in this prospective, observational trial.

Results

The baseline characteristics were similar. Development of systemic inflammatory response syndrome (7.8% for PS vs. 13.3% for no PS; p=0.50) and mortality (none for both groups; p=0.99) did not differ. However, fewer local complications occurred in PS than in no PS (4.7% for PS vs. 20.0% for no PS; p=0.04) and the difference was most outstanding in necrosis (1.6% for PS vs. 13.3% for no PS; p=0.03).

Conclusions

Temporary pancreatic stenting after early ERCP should be considered safe, as complications did not increase even in cases of inadequate stenting. However, if successful, there appears to be a reduction in local complications.

Fungal Infections in Patients With Infected Pancreatic Necrosis and Pseudocysts: Risk Factors and Outcome

OBJECTIVES

Fungal infections in patients with acute pancreatitis are common and potentially life threatening. Data on fungal pancreatic infections are inconsistent. Therefore, the aim of this study was to identify risk factors for fungal infection and to determine their impact on survival.

METHODS

This was a retrospective analysis of pathogen spectrum and outcome of infected pancreatic necrosis or pseudocysts from 3 German hospitals from 2002 to 2016.

RESULTS

A total of 187 fine-needle aspirations were performed in 113 patients. Fungal pancreatic infections, predominantly caused by Candida species, were identified in 52 patients (46%). Antibiotic treatment before fine-needle aspiration (84.6% vs 49.2%, P = 0.003) and the duration of therapy (9 vs 2 days, P = 0.024) identified patients at an increased risk of fungal infection. Patients with fungal pancreatic infections had a longer hospital stay (34 vs 14 days, P < 0.001), received intensive care treatment more often (55.8% vs 27.9%, P = 0.002), and had a lower 365-day survival (78.4 [SE, 6.6%] vs 95.0 [SE, 2.0%], P = 0.035) than patients with bacterial pancreatic infections only.

CONCLUSIONS

Fungal infections are common in patients with infected pancreatic necrosis and pseudocysts and indicate patients with a higher risk of mortality in the long term.

Serial lipase for pancreatitis: not enough evidence

BACKGROUND

Lipase is both a sensitive and specific marker for diagnosing pancreatitis. However, the benefit of serial lipase in both monitoring and defining prognosis remains undetermined. This systematic review was conducted to further evaluate this potential application. In addition, this review also looked into the benefits of serial lipase in the subgroup of traumatic pancreatitis.

METHODS

PubMed, Cochrane Library and Google Scholar were systematically searched for related articles, between January 1995 and December 2015, according to Preferred Reporting Items for Systematic Reviews and Meta-analyses standards. Data was extracted and analysed by two authors.

RESULTS

Seven studies were included in the final analysis: six retrospective and one prospective studies were identified. Five studies (all retrospective) concluded no benefits in serial lipase for prognostication, while two studies identified serial lipase as a beneficial prognostic factor for acute pancreatitis. Of the included studies, only two involved traumatic pancreatitis (both dedicated to the paediatric population).

CONCLUSION

The evidence supporting or opposing serial lipase as a prognostic factor for pancreatitis is weak and consists mainly of retrospective analyses. The only prospective data identified suggested benefits to serial lipase in prognosis. Further prospective studies evaluating the prognostic value of serial lipase in the adult population with both traumatic and non-traumatic pancreatitis are required given the paucity of available evidence.

A Mini-Review on the Effect of Docosahexaenoic Acid (DHA) on Cerulein-Induced and Hypertriglyceridemic Acute Pancreatitis

Acute pancreatitis refers to the sudden inflammation of the pancreas. It is associated with premature activation and release of digestive enzymes into the pancreatic interstitium and systemic circulation, resulting in pancreatic tissue autodigestion and multiple organ dysfunction, as well as with increased cytokine production, ultimately leading to deleterious local and systemic effects. Although mechanisms involved in pathogenesis of acute pancreatitis have not been completely elucidated, oxidative stress is regarded as a major risk factor. In human acute pancreatitis, lipid peroxide levels in pancreatic tissues increase. Docosahexaenoic acid (DHA), an omega-3 polyunsaturated fatty acid (C22:6n-3), exerts anti-inflammatory and antioxidant effects on various cells. Previous studies have shown that DHA activates peroxisome proliferator-activated receptor-γ and induces catalase, which inhibits oxidative stress-mediated inflammatory signaling required for cytokine expression in experimental acute pancreatitis using cerulein. Cerulein, a cholecystokinin analog, induces intra-acinar activation of trypsinogen in the pancreas, which results in human acute pancreatitis-like symptoms. Therefore, DHA supplementation may be beneficial for preventing or inhibiting acute pancreatitis development. Since DHA reduces serum triglyceride levels, addition of DHA to lipid-lowering drugs like statins has been investigated to reduce hypertriglyceridemic acute pancreatitis. However, high DHA concentrations increase cytosolic Ca²⁺, which activates protein kinase C and may induce hyperlipidemic acute pancreatitis. In this review, effect of DHA on cerulein-induced and hypertriglyceridemic acute pancreatitis has been discussed. The relation of high concentration of DHA to hyperlipidemic acute pancreatitis has been included.

Dai-Huang-Fu-Zi-Tang alleviates pulmonary and intestinal injury with severe acute pancreatitis via regulating aquaporins in rats

BACKGROUND

Dai-Huang-Fu-Zi-Tang (DHFZT) is a famous traditional Chinese prescription with intestinal obstruction, acute pancreatitis and cholecystalgia for thousands of years. Our previous work found that DHFZT could act against pulmonary and intestinal pathological injury in rats with severe acute pancreatitis (SAP). But the underlying mechanism has not been fully elucidated. The aim of present study was to investigate whether DHFZT could relieve pulmonary and intestinal injury by regulating aquaporins after SAP induced by sodium taurocholate in rats.

METHODS

Forty of SD rats were used for dose dependant experiments of DHFZT.Accurate-mass Time-of-flight liquid chromatography-mass spectrometry was used for qualitative screening of chemical compositions of DHFZT. Twenty-four rats were randomly divided into 3 groups: sham group (n = 8), model group (SAP, n = 8), DHFZT group (SAP with DHFZT treatment, n = 8). SAP models were established by retrograde injections of 5% sodium taurocholate solutions into rat pancreaticobiliary ducts. Blood samples were taken at 0, 12, 24, 48 h post-operation for detecting serum amylase, lipase, endotoxin, TNF-α, IL-6 and IL-10. Protein expression and location of aquaporin (AQP)1, 5, 8 and 9 were assessed by immunohistochemistry, western blot and immunofluorescence respectively.

RESULTS

The study showed that 27 kinds of chemical composition were identified, including 10 kinds in positive ion mode and 17 kinds in negative ion mode. The results showed that AQP1, AQP5 of lung, and AQP1, AQP5, AQP8 of intestine in model group were significantly lower than that of sham group (P < 0.05), and which were obviously reversed by treatment with DHFZT. In addition, protein levels of pro-inflammatory cytokines such as TNF-α, IL-6 and endotoxin in peripheral blood were significantly suppressed by DHFZT, and that anti-inflammatory cytokine like IL-10 was just opposite. Finally, we also noted that DHFZT reduced serum levels of amylase, lipase and endotoxin, and also improved edema and pathological scores of lung and intestine after SAP.

CONCLUSIONS

DHFZT ameliorated the pulmonary and intestinal edema and injury induced by SAP via the upregulation of different AQPs in lung and intestine, and suppressed TNF-α, IL-6 expression and enhanced IL-10 expression.

Docosahexaenoic acid inhibits IL-6 expression via PPARγ-mediated expression of catalase in cerulein-stimulated pancreatic acinar cells

Cerulein pancreatitis mirrors human acute pancreatitis. In pancreatic acinar cells exposed to cerulein, reactive oxygen species (ROS) mediate inflammatory signaling by Janus kinase (JAK) 2/signal transducer and activator of transcription (STAT) 3, and cytokine induction. Docosahexaenoic acid (DHA) acts as an agonist of peroxisome proliferator activated receptor γ (PPARγ), which mediates the expression of some antioxidant enzymes. We hypothesized that DHA may induce PPARγ-target catalase expression and reduce ROS levels, leading to the inhibition of JAK2/STAT3 activation and IL-6 expression in cerulein-stimulated acinar cells. Pancreatic acinar AR42J cells were treated with DHA in the presence or absence of the PPARγ antagonist GW9662, or treated with the PPARγ agonist troglitazone, and then stimulated with cerulein. Expression of IL-6 and catalase, ROS levels, JAK2/STAT3 activation, and nuclear translocation of PPARγ were assessed. DHA suppressed the increase in ROS, JAK2/STAT3 activation, and IL-6 expression induced nuclear translocation of PPARγ and catalase expression in cerulein-stimulated AR42J cells. Troglitazone inhibited the cerulein-induced increase in ROS and IL-6 expression, but induced catalase expression similar to DHA in AR42J cells. GW9662 abolished the inhibitory effect of DHA on cerulein-induced increase in ROS and IL-6 expression in AR42J cells. DHA-induced expression of catalase was suppressed by GW9662 in cerulein-stimulated AR42J cells. Thus, DHA induces PPARγ activation and catalase expression, which inhibits ROS-mediated activation of JAK2/STAT3 and IL-6 expression in cerulein-stimulated pancreatic acinar cells.

Continuous Regional Arterial Infusion of Protease Inhibitors Has No Efficacy in the Treatment of Severe Acute Pancreatitis: A Retrospective Multicenter Cohort Study

OBJECTIVE

The aim of this study is to assess the effectiveness of continuous regional arterial infusion (CRAI) of protease inhibitors in patients with severe acute pancreatitis (SAP) including acute necrotizing pancreatitis.

METHODS

This retrospective study was conducted among 44 institutions in Japan from 2009 to 2013. Patients 18 years or older diagnosed with SAP according to the criteria of the Japanese Ministry of Health, Labour and Welfare study group (2008) were consecutively enrolled. We evaluated the association between CRAI of protease inhibitors and mortality, incidence of infection, and the need for surgical intervention using multivariable logistic regression analysis.

RESULTS

Of 1159 patients admitted, 1097 patients with all required data were included for analysis. Three hundred and seventy-four (34.1%) patients underwent CRAI of protease inhibitors and 723 (65.9%) did not. In multivariable analysis, CRAI of protease inhibitors was not associated with a reduction in mortality, infection rate, or need for surgical intervention (odds ratio [OR] 0.79, 95% confidence interval [CI] 0.47-1.32, P = 0.36; OR 0.97, 95% CI 0.61-1.54, P = 0.89; OR 0.76, 95% CI 0.50-1.15, P = 0.19; respectively).

CONCLUSIONS

Continuous regional arterial infusion of protease inhibitors was not efficacious in the treatment of patients with SAP.

Prophylactic antibiotics in acute pancreatitis: endless debate

INTRODUCTION The development of pancreatic infection is associated with the development of a deteriorating disease with subsequent high morbidity and mortality. There is agreement that in mild pancreatitis there is no need to use antibiotics; in severe pancreatitis it would appear to be a logical choice to use antibiotics to prevent secondary pancreatic infection and decrease associated mortality. MATERIALS AND METHODS A non-systematic review of current evidence, meta-analyses and randomized controlled trials was conducted to assess the role of prophylactic antibiotics in acute pancreatitis and whether it might improve morbidity and mortality in pancreatitis. RESULTS Mixed evidence was found to support and refute the role of prophylactic antibiotics in acute pancreatitis. Most studies have failed to demonstrate much benefit from its routine use. Data from our unit suggested little benefit of their routine use, and showed that the mortality of those treated with antibiotics was significantly higher compared with those not treated with antibiotics (9% vs 0%, respectively, P = 0.043). In addition, the antibiotic group had significantly higher morbidity (36% vs 5%, respectively, P = 0.002). CONCLUSIONS Antibiotics should be used in patients who develop sepsis, infected necrosis-related systemic inflammatory response syndrome, multiple organ dysfunction syndrome or pancreatic and extra-pancreatic infection. Despite the many other factors that should be considered, prompt antibiotic therapy is recommended once inflammatory markers are raised, to prevent secondary pancreatic infection. Unfortunately, there remain many unanswered questions regarding the indications for antibiotic administration and the patients who benefit from antibiotic treatment in acute pancreatitis.

Prophylactic antibiotics in acute pancreatitis: endless debate

INTRODUCTION The development of pancreatic infection is associated with the development of a deteriorating disease with subsequent high morbidity and mortality. There is agreement that in mild pancreatitis there is no need to use antibiotics; in severe pancreatitis it would appear to be a logical choice to use antibiotics to prevent secondary pancreatic infection and decrease associated mortality. MATERIALS AND METHODS A non-systematic review of current evidence, meta-analyses and randomized controlled trials was conducted to assess the role of prophylactic antibiotics in acute pancreatitis and whether it might improve morbidity and mortality in pancreatitis. RESULTS Mixed evidence was found to support and refute the role of prophylactic antibiotics in acute pancreatitis. Most studies have failed to demonstrate much benefit from its routine use. Data from our unit suggested little benefit of their routine use, and showed that the mortality of those treated with antibiotics was significantly higher compared with those not treated with antibiotics (9% vs 0%, respectively, P = 0.043). In addition, the antibiotic group had significantly higher morbidity (36% vs 5%, respectively, P = 0.002). CONCLUSIONS Antibiotics should be used in patients who develop sepsis, infected necrosis-related systemic inflammatory response syndrome, multiple organ dysfunction syndrome or pancreatic and extra-pancreatic infection. Despite the many other factors that should be considered, prompt antibiotic therapy is recommended once inflammatory markers are raised, to prevent secondary pancreatic infection. Unfortunately, there remain many unanswered questions regarding the indications for antibiotic administration and the patients who benefit from antibiotic treatment in acute pancreatitis.

Intraoperative neuromonitoring for thyroid malignancy surgery: technical notes and results from a retrospective series

This study evaluates the role of intraoperative neuromonitoring (IONM) for thyroidectomy performed in cancer patients with emphasis on postoperative recurrent laryngeal nerve paralysis (RLNP). The study is a retrospective series comprising 76 thyroidectomy alone (control group) versus 76 thyroidectomy with IONM. In the control group the laryngeal nerves have been identified by visualization solely. In the IONM group both vagal nerve and RLN have been localized and monitored during thyroid resection. The main surgical outcome was RLN morbidity. All patients undergo pre- and postoperative laryngeal examination. Overall RLN morbidity was 3.9% in the IONM group and 9.2% in the control group (P < 0.05). There have been two cases of permanent RLNP (2.6%) in the control group and one in the IONM group (1.3%), one case of bilateral RLN injury in the control group. The incidences of temporary RLNP in the IONM group have been 2.6 versus 6.5% in the control group. IONM is an effective procedure in thyroid cancer patients.

Advances in Management of Acute Pancreatitis

This article reviews advances in the management of acute pancreatitis. Medical treatment has been primarily supportive for this diagnosis, and despite extensive research efforts, there are no pharmacologic therapies that improve prognosis. The current mainstay of management, notwithstanding the ongoing debate regarding the volume, fluid type, and rate of administration, is aggressive intravenous fluid resuscitation. Although antibiotics were used consistently for prophylaxis in severe acute pancreatitis to prevent infection, they are no longer used unless infection is documented. Enteral nutrition, especially in patients with severe acute pancreatitis, is considered a cornerstone in management of this disease.

Acute pancreatitis as a complication of childhood cancer treatment

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

Minimally invasive percutaneous catheter drainage versus open laparotomy with temporary closure for treatment of abdominal compartment syndrome in patients with early-stage severe acute pancreatitis

This study aimed to examine the clinical efficacy of minimally invasive percutaneous catheter drainage (PCD) versus open laparotomy with temporary closure in the treatment of abdominal compartment syndrome (ACS) in patients with early-stage severe acute pancreatitis (SAP). Clinical data of 212 patients who underwent PCD and 61 patients who were given open laparotomy with temporary closure in our hospital over the last 10-year period were retrospectively analyzed, and outcomes were compared, including total and post-decompression intensive care unit (ICU) and hospital stays, physiological data, organ dysfunction, complications, and mortality. The results showed that the organ dysfunction scores were similar between the PCD and open laparotomy groups 72 h after decompression. In the PCD group, 134 of 212 (63.2%) patients required postoperative ICU support versus 60 of 61 (98.4%) in the open laparotomy group (P<0.001). Additionally, 87 (41.0%) PCD patients experienced complications as compared to 49 of 61 (80.3%) in the open laparotomy group (P<0.001). There were 40 (18.9%) and 32 (52.5%) deaths, respectively, in the PCD and open laparotomy groups (P<0.001). In conclusion, minimally invasive PCD is superior to open laparotomy with temporary closure, with fewer complications and deaths occurring in PCD group.

Assessment of nutritional knowledge of patients with pancreatitis

Introduction

Proper nourishment is one of the basic elements in the treatment of patients with both acute and chronic pancreatitis. Following acute pancreatitis, the essential element of nutritional treatment is dietary education. The dietary approach is used not only for treatment, but also for prevention of reoccurrence of the condition.

Aim

To evaluate nutritional knowledge of patients with acute and chronic pancreatitis.

Material and methods

The selected group consisted of 36 patients, 19 females and 17 males, suffering from acute or chronic pancreatitis. Participation in our survey was anonymous and voluntary. The study population was divided into two groups: 12 patients with acute pancreatitis (5 males and 7 females) and 24 patients with chronic pancreatitis (12 males and 12 females). The median age of patients was 42.4 ±14 years (range: 20–76 years). The duration of illness among the study population was varied. The biggest group of 16 (44.4%) patients suffered from pancreatitis for more than 5 years, 8 (22.2%) patients had pancreatitis diagnosed 1–2 years previously, only 3 (8.3%) subjects suffered from pancreatitis for shorter than half a year. To analyse patients’ nutritional knowledge an authorial questionnaire was used that contained 17 closed questions and open-type questions were used three times.

Results

Most (97%) subjects with acute and chronic pancreatitis adhered to the diet to various degrees, but almost 50% of people up to 35 years of age declared that they didn't respect the diet, or that they followed only a few recommendations. Despite each interviewer admitted to follow dietary recommendations for pancreatitis, 11.1% of patients could not indicate any of them. Most patients knew that their diet should contain a low amount of fat (61% of patients). Awareness of alcohol abstinence was confirmed in 44.4% of subjects. One third (33.3%) of patients knew that fried food should be avoided. Only a few patients were aware that smoking, spicy food, and strong coffee should be excluded from their diet. About 80% of the surveyed patients evaluated their level of nutritional knowledge as good or very good. Only 20% of the study population admitted their dietary knowledge was unsatisfactory, and most of these were woman (86%).

Conclusions

The results of the present study demonstrate that dietary knowledge among patients suffering from acute and chronic pancreatitis is insufficient. Although patients have theoretical knowledge about nutritional management, they have problems implementing the diet on a daily basis. It is necessary to pay more attention to nutritional education for patients suffering from pancreatitis.

Recent Advances in Managing Acute Pancreatitis

This article will review the recent advances in managing acute pancreatitis. Supportive care has long been the standard of treatment for this disease despite extensive, but ultimately unsuccessful, efforts to develop disease-specific pharmacologic therapies. The primary interventions center on aggressive fluid resuscitation, initiation of early enteral nutrition, targeted antibiotic therapy, and the management of complications. In this article, we will detail treatment of acute pancreatitis with a focus on intravenous fluid resuscitation, enteral feeding, and the current evidence behind the use of antibiotics and other pharmacologic therapies.

Necrotizing pancreatitis: new definitions and a new era in surgical management

BACKGROUND

Necrotizing pancreatitis is a challenging condition that requires surgical treatment commonly and is associated with substantial morbidity and mortality. Over the past decade, new definitions have been developed for standardization of severity of acute and necrotizing pancreatitis, and new management techniques have emerged based on prospective, randomized clinical trials.

METHODS

Review of English-language literature.

RESULTS

A new international classification of acute pancreatitis has been developed by PANCREA (Pancreatitis Across Nations Clinical Research and Education Alliance) to replace the Atlanta Classification. It is based on the actual local (whether pancreatic necrosis is present or not, whether it is sterile or infected) and systemic determinants (whether organ failure is present or not, whether it is transient or persistent) of severity. Early management requires goal-directed fluid resuscitation (with avoidance of over-resuscitation and abdominal compartment syndrome), assessment of severity of pancreatitis, diagnostic computed tomography (CT) imaging to assess for necrotizing pancreatitis, consideration of endoscopic retrograde cholangiopancreatography (ERCP) for biliary pancreatitis and early enteral nutrition support. Antibiotic prophylaxis is not recommended. Therapeutic antibiotics are required for treatment of documented infected pancreatic necrosis. The initial treatment of infected pancreatic necrosis is percutaneous catheter or endoscopic (transgastric/transduodenal) drainage with a second drain placement as required. Lack of clinical improvement after these initial procedures warrants consideration of minimally invasive techniques for pancreatic necrosectomy including video-assisted retroperitoneal debridement (VARD), minimally invasive retroperitoneal pancreatectomy (MIRP), or transluminal direct endoscopic necrosectomy (DEN). Open necrosectomy is associated with substantial morbidity, but to date no randomized trial has documented superiority of either minimally invasive or open surgical technique. Additional trials are underway to address this.

CONCLUSIONS

Severe acute and necrotizing pancreatitis requires a multi-disciplinary treatment strategy that must be individualized for each patient. Optimal treatment of necrotizing pancreatitis now requires a staged, multi-disciplinary, minimally invasive "step-up" approach that includes a team of interventional radiologists, therapeutic endoscopists, and surgeons.

Sporadic multiple parathyroid gland disease--a consensus report of the European Society of Endocrine Surgeons (ESES)

BACKGROUND

Sporadic multiglandular disease (MGD) has been reported in literature in 8-33 % of patients with primary hyperparathyroidism (pHPT). This paper aimed to review controversies in the pathogenesis and management of sporadic MGD.

METHODS

A literature search and review was made to evaluate the level of evidence concerning diagnosis and management of sporadic MGD according to criteria proposed by Sackett, with recommendation grading by Heinrich et al. and Grading of Recommendations, Assessment, Development and Evaluation (GRADE) system. Results were discussed at the 6th Workshop of the European Society of Endocrine Surgeons entitled 'Hyperparathyroidism due to multiple gland disease: An evidence-based perspective'.

RESULTS

Literature reports no prospective randomised studies; thus, a relatively low level of evidence was achieved. Appropriate surgical therapy of sporadic MGD should consist of a bilateral approach in most patients. Unilateral neck exploration guided by preoperative imaging should be reserved for selected patients, performed by an experienced endocrine surgeon and monitored by intraoperative parathormone assay (levels of evidence III-V, grade C recommendation). There is conflicting or equally weighted levels IV-V evidence supporting that cure rates can be similar or worse for sporadic MGD than for single adenomas (no recommendation). Best outcomes can be expected if surgery is performed by an experienced parathyroid surgeon working in a high-volume centre (grade C recommendation). Levels IV-V evidence supports that recurrent/persistence pHPT occurs more frequently in patients with double adenomas hence in situations where a double adenoma has been identified, the surgeon should have a high index of suspicion during surgery and postoperatively for the possibility of a four-gland disease (grade C recommendation).

CONCLUSIONS

Identifying preoperatively patients at risk for MGD remains challenging, intraoperative decisions are important for achieving acceptable cure rates and long-term follow-up is mandatory in such patients.

Hereditary hyperparathyroidism--a consensus report of the European Society of Endocrine Surgeons (ESES)

BACKGROUND

Hereditary hyperparathyroidism has been reported to occur in 5-10 % of cases of primary hyperparathyroidism in the context of multiple endocrine neoplasia (MEN) types 1, 2A and 4; hyperparathyroidism-jaw tumour (HPT-JT); familial isolated hyperparathyroidism (FIHPT); familial hypocalciuric hypercalcaemia (FHH); neonatal severe hyperparathyroidism (NSHPT) and autosomal dominant moderate hyperparathyroidism (ADMH). This paper aims to review the controversies in the main genetic, clinical and pathological features and surgical management of hereditary hyperparathyroidism.

METHODS

A peer review literature analysis on hereditary hyperparathyroidism was carried out and analyzed in an evidence-based perspective. Results were discussed at the 2015 Workshop of the European Society of Endocrine Surgeons devoted to hyperparathyroidism due to multiple gland disease.

RESULTS

Literature reports scarcity of prospective randomized studies; thus, a low level of evidence may be achieved.

CONCLUSIONS

Hereditary hyperparathyroidism typically presents at an earlier age than the sporadic variants. Gene penetrance and expressivity varies. Parathyroid multiple gland involvement is common, but in some variants, it may occur metachronously often with long disease-free intervals, simulating a single-gland involvement. Bilateral neck exploration with subtotal parathyroidectomy or total parathyroidectomy + autotransplantation should be performed, especially in MEN 1, in order to decrease the persistent and recurrent hyperparathyroidism rates; in some variants (MEN 2A, HPT-JT), limited parathyroidectomy can achieve long-term normocalcemia. In FHH, surgery is contraindicated; in NSHPT, urgent total parathyroidectomy is required. In FIHPT, MEN 4 and ADMH, a tailored case-specific approach is recommended.

Surgical management of secondary hyperparathyroidism in chronic kidney disease--a consensus report of the European Society of Endocrine Surgeons

BACKGROUND

Despite advances in the medical management of secondary hyperparathyroidism due to chronic renal failure and dialysis (renal hyperparathyroidism), parathyroid surgery remains an important treatment option in the spectrum of the disease. Patients with severe and complicated renal hyperparathyroidism (HPT), refractory or intolerant to medical therapy and patients with specific requirements in prospect of or excluded from renal transplantation may require parathyroidectomy for renal hyperparathyroidism.

METHODS

Present standard and actual controversial issues regarding surgical treatment of patients with hyperparathyroidism due to chronic renal failure were identified, and pertinent literature was searched and reviewed. Whenever applicable, evaluation of the level of evidence concerning diagnosis and management of renal hyperparathyroidism according to standard criteria and recommendation grading were employed. Results were discussed at the 6th Workshop of the European Society of Endocrine Surgeons entitled Hyperparathyroidism due to multiple gland disease: An evidence-based perspective.

RESULTS

Presently, literature reveals scant data, especially, no prospective randomized studies to provide sufficient levels of evidence to substantiate recommendations for surgery in renal hyperparathyroidism. Appropriate surgical management of renal hyperparathyroidism involves standard bilateral exploration with bilateral cervical thymectomy and a spectrum of four standardized types of parathyroid resection that reveal comparable outcome results with regard to levels of evidence and recommendation. Specific patient requirements may favour one over the other procedure according to individualized demands.

CONCLUSIONS

Surgery for patients with renal hyperparathyroidism in the era of calcimimetics continues to play an important role in selected patients and achieves efficient control of hyperparathyroidism. The overall success rate and long-term control of renal hyperparathyroidism and optimal handling of postoperative metabolic effects also depend on the timely indication, individually suitable type of parathyroid resection and specialized endocrine surgery.

Continuous Regional Arterial Infusion of Protease Inhibitors for Treatment of Severe Acute Pancreatitis: Systematic Review and Meta-Analysis

OBJECTIVE

We performed a systematic review and meta-analysis of observational studies and randomized controlled trials (RCTs) to assess the benefit and risk of continuous regional arterial infusion (CRAI) of protease inhibitors (CRAIpis) in patients with severe acute pancreatitis (SAP) or acute necrotizing pancreatitis (ANP).

METHODS

The search was performed using the key words "pancreatitis" and "regional arterial infusion." All language studies involving adult cases of SAP or ANP, which assessed the impact of the CRAIpis, were included.

RESULTS

Our analysis included 8 observational studies and 2 RCTs from 376 potentially relevant articles. With regard to the observational studies, the CRAIpi was significantly associated with decreased both mortality (odds ratio, 0.40; 95% confidential interval [CI], 0.25-0.64; P = 0.0001) and the need for urgent surgical intervention (odds ratio, 0.22; 95% CI, 0.12-0.3; P < 0.0001). In the RCTs, the application of CRAIpi tends to decrease the mortality but does not reach the significance (risk reduction, -0.12; 95% CI, -0.36-0.12; P = 0.33).

CONCLUSIONS

The CRAIpi has the potential to reduce the mortality or the need for urgent surgical intervention in cases of SAP or ANP. Further, large multicenter trials are needed to refute or confirm our findings.

Management of acute pancreatitis in dogs: a critical appraisal with focus on feeding and analgesia

Knowledge about acute pancreatitis has increased recently in both the medical and veterinary fields. Despite this expansion of knowledge, there are very few studies on treatment interventions in naturally occurring disease in dogs. As a result, treatment recommendations are largely extrapolated from experimental rodent models or general critical care principles. General treatment principles involve replacing fluid losses, maintaining hydrostatic pressure, controlling nausea and providing pain relief. Specific interventions recently advocated in human medicine include the use of neurokinin-1 antagonists for analgesia and early interventional feeding. The premise for early feeding is to improve the health of the intestinal tract, as unhealthy enterocytes are thought to perpetuate systemic inflammation. The evidence for early interventional feeding is not supported by robust clinical trials to date, but in humans there is evidence that it reduces hospitalisation time and in dogs it is well tolerated. This article summarises the major areas of management of acute pancreatitis in dogs and examines the level of evidence for each recommendation.

[Estimation of the role of octreotide in treatment of severe pancreatic necrosis]

It was analyzed the results of treatment of 204 patients with severe course of destructive pancreatitis (severity of organs' dysfunction was 9 and more scores according to APACHE-II scale upon admission to the hospital). Logistic regression and Cox regression were used along with univariant statistical analysis, what permitted to estimate overall effect of octreotide and other potential predictors including severity of condition and medical factors on the mortality rate and extension of necrosis in patients with pancreatic necrosis. It was established that the use of octreotide in case of severe pancreatic necrosis significantly decreases mortality and extension of necrosis.

Timing of Cholecystectomy for Biliary Pancreatitis in Chinese Patients

BACKGROUND

The aim of this study was to determine the most feasible and cost-effective time of cholecystectomy following gallstone pancreatitis in Chinese patients.

MATERIALS AND METHODS

A total of 233 patients who underwent cholecystectomy for biliary pancreatitis (January 2004 to July 2012) were categorized into one of 2 groups: group A patients underwent cholecystectomy during admission (n=123), and group B patients delayed cholecystectomy after discharge from admission (n=110).

RESULTS

The groups were comparable in demographics, comorbidities, and disease severity. In total, 100% of patients in group A had a cholecystectomy within 3 weeks after admission, and 60.9% of patients in group B experienced precholecystectomy gallstone-related events (including 15 cases of recurrent pancreatitis) after discharge. The median total length of hospital stay was greater for group B than for group A [12 d (range, 4 to 24 d) vs. 17 d (range, 9 to 39 d), respectively, P=0.000]. The average cost of management was greater in group B than group A [23,036.11 Yuan (range, 9073.53 to 85,132.33 Yuan) vs. 36,643.27 Yuan (range, 14,096.36 to 69,642.02 Yuan), respectively, P=0.000].

CONCLUSION

In Chinese patients, cholecystectomy should be performed within 3 weeks after admission without delay, and is feasible and cost-effective.

PGC-1α expression is increased in leukocytes in experimental acute pancreatitis

Severe acute pancreatitis (AP) induces a systemic inflammatory disease that is responsible for high mortality rates, particularly when it is complicated by infection. Therefore, differentiating sepsis from the systemic inflammation caused by AP is a serious clinical challenge. Considering the high metabolic rates of leukocytes in response to stress induced by infection, we hypothesized that the transcription coactivator peroxisome proliferator-activated receptor gamma coactivator 1 (PGC-1α), a master regulator of mitochondrial biogenesis and function, would be distinctly expressed during inflammation or infection and, therefore, could constitute a useful marker to differentiate between these two conditions. Rats were subjected to injection of taurocholate into the main pancreatic duct, which caused a severe AP with high amylase levels and white blood cell counts. In these animals, a marked increase in PGC-1α mRNA levels in circulating leukocytes was observed 48 h after the surgical procedure, a time when bacteremia is present. Antibiotic treatment abolished PGC-1α up-regulation. Moreover, PGC-1α expression was higher in peritoneal macrophages from animals subjected to a bacterial insult (cecal ligation and puncture) than in animals with AP. In isolated macrophages, we also observed that PGC-1α expression is more prominent in the presence of a phagocytic stimulus (zymosan) when compared to lipopolysaccharide-induced aseptic inflammation. Moreover, abolishing PGC-1α expression with antisense oligos impaired zymosan phagocytosis. Together, these findings suggest that PGC-1α is differentially expressed during aseptic inflammation and infection and that it is necessary for adequate phagocytosis. These results could be useful in developing new tests for differentiating infection from inflammation for clinical purposes in patients with AP.

[Correction of endotoxemia in patients with pancreatic necrosis]

AIM

To study the results of deferoxamine (Deferal) administration in intensive therapy program of 63 patients with severe acute pancreatitis to decrease effect of oxidative stress and endotoxemia.

MATERIAL AND METHODS

In deferoxamine group (31 patients) there were decrease of serum iron's level and inhibition of free radical oxidation that led to early relief of endotoxemia, reducing periods of organs' dysfunction. It was not observed in comparison group (32 patients).

RESULTS

Deferoxamine decrease risk of pancreatic necrosis and pancreatogenic sepsis. It allows reducing ICU- and hospital-stay and number of extended surgical procedures.

Pharmacologic therapy for acute pancreatitis

While conservative management such as fluid, bowel rest, and antibiotics is the mainstay of current acute pancreatitis management, there is a lot of promise in pharmacologic therapies that target various aspects of the pathogenesis of pancreatitis. Extensive review of preclinical studies, which include assessment of therapies such as anti-secretory agents, protease inhibitors, anti-inflammatory agents, and anti-oxidants are discussed. Many of these studies have shown therapeutic benefit and improved survival in experimental models. Based on available preclinical studies, we discuss potential novel targeted pharmacologic approaches that may offer promise in the treatment of acute pancreatitis. To date a variety of clinical studies have assessed the translational potential of animal model effective experimental therapies and have shown either failure or mixed results in human studies. Despite these discouraging clinical studies, there is a great clinical need and there exist several preclinical effective therapies that await investigation in patients. Better understanding of acute pancreatitis pathophysiology and lessons learned from past clinical studies are likely to offer a great foundation upon which to expand future therapies in acute pancreatitis.