New advances in acute pancreatitis

High versus low energy administration in the early phase of acute pancreatitis (GOULASH trial): protocol of a multicentre randomised double-blind clinical trial

INTRODUCTION

Acute pancreatitis (AP) is an inflammatory disease with no specific treatment. Mitochondrial injury followed by ATP depletion in both acinar and ductal cells is a recently discovered early event in its pathogenesis. Importantly, preclinical research has shown that intracellular ATP delivery restores the physiological function of the cells and protects from cell injury, suggesting that restoration of energy levels in the pancreas is therapeutically beneficial. Despite several high quality experimental observations in this area, no randomised trials have been conducted to date to address the requirements for energy intake in the early phase of AP.

METHODS/DESIGN

This is a randomised controlled two-arm double-blind multicentre trial. Patients with AP will be randomly assigned to groups A (30 kcal/kg/day energy administration starting within 24 hours of hospital admission) or B (low energy administration during the first 72 hours of hospital admission). Energy will be delivered by nasoenteric tube feeding with additional intravenous glucose supplementation or total parenteral nutrition if necessary. A combination of multiorgan failure for more than 48 hours and mortality is defined as the primary endpoint, whereas several secondary endpoints such as length of hospitalisation or pain will be determined to elucidate more detailed differences between the groups. The general feasibility, safety and quality checks required for high quality evidence will be adhered to.

ETHICS AND DISSEMINATION

The study has been approved by the relevant organisation, the Scientific and Research Ethics Committee of the Hungarian Medical Research Council (55961-2/2016/EKU). This study will provide evidence as to whether early high energy nutritional support is beneficial in the clinical management of AP. The results of this trial will be published in an open access way and disseminated among medical doctors.

TRIAL REGISTRATION

The trial has been registered at the ISRCTN (ISRTCN 63827758).

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

AIM

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

METHODS

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

RESULTS

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

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

AIM

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

MATERIAL AND METHODS

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

RESULTS

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

CONCLUSION

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

Cathelicidin-related antimicrobial peptide modulates the severity of acute pancreatitis in mice

The present study aimed to investigate the immunomodulatory effects of mouse cathelicidin-related antimicrobial peptide (CRAMP) on experimental acute pancreatitis (AP). AP is a common clinical condition characterized by acute abdominal inflammation. Innate immune cells and mediators are intrinsically linked to the pathogenesis of AP. Cathelicidins are innate immunity-derived antimicrobial peptides that exert immunomodulatory effects on various host cells. However, how cathelicidins are involved and modulate the severity and inflammatory responses of AP remains unclear. In the present study, the mouse CRAMP gene-deficient cnlp^−/− mice and their wild-type C57BL/6J littermates were induced with AP by multiple hourly injections of supramaximal doses of caerulein. Serum amylase levels, pancreatic myeloperoxidase activity and histological examination were performed in order to determine the disease severity and the levels of inflammatory cytokines. Disease severity and inflammatory markers were subsequently evaluated in the control mice, cnlp^−/− C57BL/6J mice with AP, and wild-type C57BL/6J mice with AP. The results demonstrated that cnlp^−/− mice exhibited a more severe phenotype and inflammatory response following AP induction compared with the wild-type mice, as evidenced by increased serum amylase levels, pancreatic myeloperoxidase release, and early inflammatory mediator tumor necrosis factor-α production. Histological examination confirmed that CRAMP deficiency worsened the pancreatic inflammatory condition. These results indicate that CRAMP may be considered a novel modulatory mediator in mouse experimental AP.

Early phase of acute pancreatitis: Assessment and management

Acute pancreatitis (AP) is a potentially life-threatening disease with a wide spectrum of severity. The overall mortality of AP is approximately 5%. According to the revised Atlanta classification system, AP can be classified as mild, moderate, or severe. Severe AP often takes a clinical course with two phases, an early and a late phase, which should both be considered separately. In this review article, we first discuss general aspects of AP, including incidence, pathophysiology, etiology, and grading of severity, then focus on the assessment of patients with suspected AP, including diagnosis and risk stratification, followed by the management of AP during the early phase, with special emphasis on fluid therapy, pain management, nutrition, and antibiotic prophylaxis.

A combined paging alert and web-based instrument alters clinician behavior and shortens hospital length of stay in acute pancreatitis

OBJECTIVES

There are many published clinical guidelines for acute pancreatitis (AP). Implementation of these recommendations is variable. We hypothesized that a clinical decision support (CDS) tool would change clinician behavior and shorten hospital length of stay (LOS).

DESIGN/SETTING

Observational study, entitled, The AP Early Response (TAPER) Project. Tertiary center emergency department (ED) and hospital.

PARTICIPANTS

Two consecutive samplings of patients having ICD-9 code (577.0) for AP were generated from the emergency department (ED) or hospital admissions. Diagnosis of AP was based on conventional Atlanta criteria. The Pre-TAPER-CDS-Tool group (5/30/06-6/22/07) had 110 patients presenting to the ED with AP per 976 ICD-9 (577.0) codes and the Post-TAPER-CDS-Tool group (5/30/06-6/22/07) had 113 per 907 ICD-9 codes (7/14/10-5/5/11).

INTERVENTION

The TAPER-CDS-Tool, developed 12/2008-7/14/2010, is a combined early, automated paging-alert system, which text pages ED clinicians about a patient with AP and an intuitive web-based point-of-care instrument, consisting of seven early management recommendations.

RESULTS

The pre- vs. post-TAPER-CDS-Tool groups had similar baseline characteristics. The post-TAPER-CDS-Tool group met two management goals more frequently than the pre-TAPER-CDS-Tool group: risk stratification (P<0.0001) and intravenous fluids >6L/1st 0-24 h (P=0.0003). Mean (s.d.) hospital LOS was significantly shorter in the post-TAPER-CDS-Tool group (4.6 (3.1) vs. 6.7 (7.0) days, P=0.0126). Multivariate analysis identified four independent variables for hospital LOS: the TAPER-CDS-Tool associated with shorter LOS (P=0.0049) and three variables associated with longer LOS: Japanese severity score (P=0.0361), persistent organ failure (P=0.0088), and local pancreatic complications (<0.0001).

CONCLUSIONS

The TAPER-CDS-Tool is associated with changed clinician behavior and shortened hospital LOS, which has significant financial implications.

Clinical observation of immunity for severe acute pancreatitis

The aim of our study was to observe the dynamic changes of immunity for patients with severe acute pancreatitis (SAP) and intervention by traditional Chinese medicine. Twenty-three patients who met the inclusion criteria were randomized to combined treatment of traditional Chinese medicine and Western medicine (TCM) or conventional western medicine treatment (WM) groups. The clinical data for all patients were collected. Peripheral venous blood samples were obtained from patients on days 1, 7, 14, and 28 after admission. Biochemical data including the percentage of CD4+/CD8+/natural killer (NK) cells/B lymphocytes/HLA-DR and CD4+/CD8+ ratio in serum were determined by flow cytometer. Patients' characteristics and immunity at admission were similar between the two groups. The secondary infection was different. The levels of T-lymphocyte subsets in the TCM group were quite different from the WM group, with much more the percentage of CD4+ and the CD4+/CD8+ ratio on days 7, 14, and 28 and much less the percentage of CD8+ on days 4 and 28. On days 14 and 28, the levels of NK cells and B lymphocytes were significantly higher in the TCM group compared with the controls. Compared with the TCM group, the levels of HLA-DR were significantly decreased in the WM group on days 7, 14, and 28. The immune dysregulation exists in the development and progression of SAP. The combined treatment of traditional Chinese medicine and western medicine can upregulate the patient's immune and maintain the immune balance.

Inhibition of acinar apoptosis occurs during acute pancreatitis in the human homologue DeltaF508 cystic fibrosis mouse

Previously, we found that the University of North Carolina cystic fibrosis (UNC-CF) mouse had more severe experimental acute pancreatitis (AP) than wild-type (WT) mice characterized by exuberant pancreatic inflammation and impaired acinar apoptosis. Because exon 10 CFTR gene mutations exhibit different phenotypes in tissues such as the mouse lung, we tested the hypothesis that DeltaF508-CF mice also develop severe AP associated with an antiapoptotic acinar phenotype, which requires indirect effects of the extracellular milieu. We used cerulein hyperstimulation models of AP. More severe pancreatitis occurred in cerulein-injected DeltaF508-CF vs. WT mice based on histological severity (P < 0.01) and greater neutrophil sequestration [P < 0.0001; confirmed by myeloperoxidase activity (P < 0.005)]. In dispersed acini cerulein-evoked necrosis was greater in DeltaF508-CF acini compared with WT (P < 0.05) and in WT acini pretreated with CFTR(inh)-172 compared with vehicle (P < 0.05). Cerulein-injected DeltaF508-CF vs. WT mice had less apoptosis based on poly(ADP-ribose) polymerase (PARP) cleavage (P < 0.005), absent DNA laddering, and reduced terminal deoxynucleotidyltransferase biotin-dUTP nick end labeling (TUNEL) staining (P < 0.005). Unexpectedly, caspase-3 activation was greater in DeltaF508-CF vs. WT acini at baseline (P < 0.05) and during AP (P < 0.0001). Downstream, DeltaF508-CF pancreas overexpressed the X-linked inhibitor of apoptosis compared with WT (P < 0.005). In summary, the DeltaF508-CF mutation, similar to the UNC-CF "null" mutation, causes severe AP characterized by an exuberant inflammatory response and impaired acinar apoptosis. Enhanced acinar necrosis in DeltaF508-CF occurs independently of extracellular milieu and correlates with loss of CFTR-Cl conductance. Although both exon 10 models of CF inhibit acinar apoptosis execution, the DeltaF508-CF mouse differs by increasing apoptosis signaling. Impaired transduction of increased apoptosis signaling in DeltaF508-CF acini may be biologically relevant to the pathogenesis of AP associated with CFTR mutations.

Effect of salvia miltiorrhizae on pulmonary apoptosis of rats with severe acute pancreatitis or obstructive jaundice

To investigate the effect of apoptosis about Salvia miltiorrhizae injection on the lungs of SAP and OJ rats. Total 288 rats were used for SAP-associated experiments and OJ-associated experiments, respectively. The rats were randomly divided into sham-operated, model control and treated group. According to the difference of time points after operation, the SAP rats in each group were subdivided into 3, 6 and 12 h groups while the OJ rats were divided into 7, 14, 21 and 28 days groups. The pathological changes, expression levels of Bax protein and apoptotic indexes in the lungs of SAP or OJ rats were observed, and the mortality rates of SAP or OJ rats were recorded, respectively. The numbers of dead SAP and OJ rats in treated groups declined. The pathological changes in the lungs of SAP or OJ rats in treated groups were relieved to varying degrees. There was no marked difference in pathological severity scores and the positive staining intensity of Bax protein between treated groups and model control groups (all P > 0.05). Salvia miltiorrhizae has some protective effect on the lungs of rats with SAP or OJ which may be related apoptosis although our results can not find significant difference between treated groups and model control groups.

Advances in managing acute pancreatitis

This review highlights advances in acute pancreatitis (AP) made in the past year. We focus on clinical aspects of AP - severe disease especially - and risk stratification tools to guide the clinical care of patients. Most patients with AP have mild disease that requires a diagnostic evaluation, self-limited supportive care, and a short hospital stay. In patients with potentially severe AP, it is important for clinicians to use available risk-stratifying tools to identify high-risk patients and initiate timely interventions such as aggressive fluid resuscitation, close monitoring, early initiation of enteral nutrition, and appropriate use of endoscopic retrograde cholangio-pancreatography. This approach decreases morbidity and possibly mortality and is supported by evidence drawn from recent clinical guidelines, historical literature, and the highest quality studies published in the last year.

Advances in researches on the immune dysregulation and therapy of severe acute pancreatitis

During the development and progression of severe acute pancreatitis (SAP), conspicuous immune dysregulation develops, which is mainly manifested as excessive immune response in the early stage and immunosuppression in the late stage. This process involves complex changes in a variety of immune molecules and cells, such as cytokines, complements, lymphocytes, and leukocytes. With the gradual deepening of studies on the development and progression of SAP, the role of immune dysregulation in the pathogenesis of SAP has attracted more and more attention. In this article, we review the advances in research on the immune dysregulation in SAP and the immunotherapy of this disease through exploring the formation of excessive immune response and immune suppression as well as their mutual transformation.

The changing character of acute pancreatitis: epidemiology, etiology, and prognosis

Acute pancreatitis continues to be a diagnostic and therapeutic challenge for physicians and surgeons. It ranks third in the list of hospital discharges for gastro-intestinal diseases. In most patients the cause is either gallstones or alcoholism. The overall mortality is less than 5%, but severe acute pancreatitis leads to prolonged hospitalization and much higher mortality. There are important differences in disease susceptibility and case fatality rates: the incidence is higher in blacks than in whites, and mortality is higher in older patients than in younger patients. Reports from various countries reveal that the frequency of acute pancreatitis is increasing, perhaps in relation to rising obesity rates, which would increase the likelihood of gallstone pancreatitis. Conversely, mortality rates for acute pancreatitis are declining in many, but not all, reports.

Effects of Baicalin and Octreotide on the serum TNF-alpha level and apoptosis in multiple organs of rats with severe acute pancreatitis

We investigated the effects of Baicalin and Octreotide on the levels of endotoxin and TNF-alpha in blood and the effects of apoptotic changes in multiple organs of SAP rats, and explored the underlying therapeutic mechanisms of Baicalin and Octreotide. In this study, 135 SAP rats were randomly divided into model control, Baicalin treated and Octreotide treated group (n = 45), respectively, the same number of normal rats were included in sham-operated group (n = 45). The above-mentioned groups were further subdivided into 3, 6 and 12 h subgroups, respectively (15 rats in each subgroup). At 3, 6 and 12 h after operation, the mortality rate of rats, endotoxin and TNF-alpha levels in blood as well as the pathological severity scores, expression levels of Bax protein and apoptosis indexes in multiple organs were determined. Compared to model control group (1),both drugs can relieve the pathological injuries of multiple organs and decrease significantly the levels of endotoxin and TNF-alpha in blood and the mortality rate of rats in treated groups (P < 0.05 or P < 0.01); (2) the expression of Bax protein was upregulated in pancreas, lung, intestinal mucosa (P < 0.05 or P < 0.01) but downregulated in spleen and lymph nodes (P < 0.001 and P < 0.05, respectively) in Baicalin treated group; The apoptosis indexes significantly increased in pancreas, intestinal mucosa, lymph nodes and spleen (P < 0.05 or P < 0.01). (3) the expression of Bax protein was upregulated in pancreas and lung but downregulated in spleen and lymph nodes (P < 0.05 or P < 0.01) in Octreotide treated group; The apoptosis indexes significantly increased in lymph nodes and spleen in Octreotide treated group (P < 0.05 or P < 0.01). Baicalin and Octreotide share a similar therapeutic efficacy in the treatment of SAP via a mechanism that is associated with inhibiting the levels of TNF-alpha in blood and induce apoptosis in multiple organs.

Alcohol use and cigarette smoking as risk factors for post-endoscopic retrograde cholangiopancreatography pancreatitis

BACKGROUND & AIMS

Alcohol use and cigarette smoking are associated with various pancreatic diseases, but it is not known whether they associate with post-endoscopic retrograde cholangiopancreatography (ERCP) pancreatitis (PEP). We performed a retrospective case-control study to determine if these activities increase the risk of PEP.

METHODS

We identified 7638 patients who had undergone ERCP in the University of Michigan Health System and applied exclusion criteria to identify 123 with PEP. We randomly selected 308 age- and sex-stratified controls (2.5-fold case sample); after applying exclusion criteria 248 remained. In a masked fashion, we collected data for alcohol use, cigarette smoking, and 5 internal control variables: suspected sphincter of Oddi dysfunction (SOD), pancreatic sphincterotomy, moderate/difficult cannulation, 2 or more pancreatic injections, and pancreatic stent placement.

RESULTS

The univariate model showed an increased frequency of PEP in current drinkers (P < .001), former drinkers (P < .001), and former smokers (P < .001), as well as patients who were suspected of having SOD (P < .001), had undergone pancreatic sphincterotomy (P < .001), had a moderate/difficult cannulation (P = .001), and/or had 2 or more pancreatic injections (P = .007). The frequency of PEP was reduced in current smokers (P < .001). The multivariate model showed that the only independent significant predictors of PEP were current drinking (odds ratio [OR], 4.70; 95% confidence interval [CI], 2.60-8.50; P < .0001), former cigarette smoking (OR, 3.29; 95% CI, 1.28-8.44; P < .013), suspected SOD (OR, 3.69; 95% CI, 1.94-7.02; P < .001), and pancreatic sphincterotomy (OR, 5.91; 95% CI, 2.04-17.14; P = .001).

CONCLUSIONS

Current alcohol use and potentially former cigarette smoking are new risk factors for PEP. It is important to consider these variables in designing PEP prevention trials.

Advances in research of severe acute pancreatitis complicated by lung injury

Lung injury is one of the most common complications of severe acute pancreatitis (SAP). At present, the pathogenesis of SAP complicated by lung injury still remains unclear. However, great attention has been paid to it at home and abroad. Many factors such as pancreatic enzyme, polymorphonuclear neutrophil, oxygen free radical, cytokine, microcirculatory disturbance, complement, kinin, NO and ET play an important role in the pathogenesis of SAP by interacting with each other. This paper reviews the advances in the pathogenesis of SAP complicated by lung injury and related studies in order to provide the theoretical basis for its effective prevention and treatment.