1
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Evans D, Hajibandeh S, Hajibandeh S, Athwal TS, Satyadas T. Meta-analysis and trial sequential analysis of randomized controlled trials comparing aggressive versus non-aggressive intravenous fluid therapy in acute pancreatitis: an insight into the existence of type 2 error. J Gastroenterol Hepatol 2024; 39:2018-2030. [PMID: 38872377 DOI: 10.1111/jgh.16648] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/02/2024] [Revised: 04/26/2024] [Accepted: 05/24/2024] [Indexed: 06/15/2024]
Abstract
BACKGROUND AND AIM We aimed to evaluate comparative outcomes of aggressive versus non-aggressive intravenous fluid (IVF) therapy in patients with acute pancreatitis. METHODS A systematic search of electronic data sources and bibliographic reference lists were conducted. All randomized controlled trials (RCTs) reporting outcomes of aggressive versus non-aggressive IVF therapy in acute pancreatitis were included and their risk of bias were assessed. Effect sizes were determined for overall mortality, systemic inflammatory response syndrome (SIRS), sepsis, respiratory failure, pancreatic necrosis, severe pancreatitis, clinical improvement, AKI, and length of stay using random-effects modeling. Trial sequential analysis was conducted to determine risk of types 1 or 2 errors. RESULTS We included 10 RCTs reporting 993 patients with acute pancreatitis who received aggressive (n = 475) or non-aggressive (n = 518) IVF therapy. Aggressive IVF therapy was associated with significantly higher rate of sepsis (OR: 2.68, P = 0.0005) and longer length of stay (MD: 0.94, P < 0.00001) compared with the non-aggressive approach. There was no statistically significant difference in mortality (RD: 0.02, P = 0.31), SIRS (OR: 0.93, P = 0.89), respiratory failure (OR: 2.81, P = 0.07), pancreatic necrosis (OR: 1.98, P = 0.06), severe pancreatitis (OR: 1.31, P = 0.38), clinical improvement (OR: 1.12, P = 0.83) or AKI (OR: 1.06, P = 0.91) between the two groups. Sub-group analysis demonstrated higher morbidity and mortality associated with the aggressive approach in more severe disease. Trial sequential analysis detected risk of type 2 error. CONCLUSIONS Aggressive IVF therapy may be associated with higher morbidity in patients with acute pancreatitis compared with the non-aggressive approach, particularly in patients with more severe disease. It may also prolong length of hospital stay. The available evidence is subject to type 2 error indicating the need for adequately powered RCTs.
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Affiliation(s)
- Daisy Evans
- Department of Hepatobiliary and Pancreatic Surgery, Royal Stoke University Hospital, University Hospitals of North Midlands NHS Trust, Stoke-on-Trent, UK
| | - Shahin Hajibandeh
- Department of Hepatobiliary and Pancreatic Surgery, Royal Stoke University Hospital, University Hospitals of North Midlands NHS Trust, Stoke-on-Trent, UK
| | - Shahab Hajibandeh
- Department of Hepatobiliary and Pancreatic Surgery, Morriston Hospital, Swansea, UK
| | - Tejinderjit S Athwal
- Department of Hepatobiliary and Pancreatic Surgery, Royal Stoke University Hospital, University Hospitals of North Midlands NHS Trust, Stoke-on-Trent, UK
| | - Thomas Satyadas
- Department of Hepatobiliary and Pancreatic Surgery, Manchester Royal Infirmary Hospital, Manchester, UK
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Kumari R, Sadarat F, Luhana S, Parkash O, Lohana AC, Rahaman Z, Wang HY, Mohammed YN, Kumar SK, Chander S. Evaluating the efficacy of different volume resuscitation strategies in acute pancreatitis patients: a systematic review and meta-analysis. BMC Gastroenterol 2024; 24:119. [PMID: 38528470 PMCID: PMC10962108 DOI: 10.1186/s12876-024-03205-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/31/2023] [Accepted: 03/12/2024] [Indexed: 03/27/2024] Open
Abstract
INTRODUCTION Acute pancreatitis poses a significant health risk due to the potential for pancreatic necrosis and multi-organ failure. Fluid resuscitation has demonstrated positive effects; however, consensus on the ideal intravenous fluid type and infusion rate for optimal patient outcomes remains elusive. METHODS A comprehensive literature search was conducted using PubMed, Embase, the Cochrane Library, Scopus, and Google Scholar for studies published between 2005 and January 2023. Reference lists of potential studies were manually searched to identify additional relevant articles. Randomized controlled trials and retrospective studies comparing high (≥ 20 ml/kg/h), moderate (≥ 10 to < 20 ml/kg/h), and low (5 to < 10 ml/kg/h) fluid therapy in acute pancreatitis were considered. RESULTS Twelve studies met our inclusion criteria. Results indicated improved clinical outcomes with low versus moderate fluid therapy (OR = 0.73; 95% CI [0.13, 4.03]; p = 0.71) but higher mortality rates with low compared to moderate (OR = 0.80; 95% CI [0.37, 1.70]; p = 0.55), moderate compared to high (OR = 0.58; 95% CI [0.41, 0.81], p = 0.001), and low compared to high fluids (OR = 0.42; 95% CI [0.16, 1.10]; P = 0.08). Systematic complications improved with moderate versus low fluid therapy (OR = 1.22; 95% CI [0.84, 1.78]; p = 0.29), but no difference was found between moderate and high fluid therapy (OR = 0.59; 95% CI [0.41, 0.86]; p = 0.006). DISCUSSION This meta-analysis revealed differences in the clinical outcomes of patients with AP receiving low, moderate, and high fluid resuscitation. Low fluid infusion demonstrated better clinical outcomes but higher mortality, systemic complications, and SIRS persistence than moderate or high fluid therapy. Early fluid administration yielded better results than rapid fluid resuscitation.
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Affiliation(s)
- Roopa Kumari
- Department of Medicine, Icahn School of Medicine at Mount Sinai, 1 Gustave L. Levy PI, New York, NY, USA
| | - Fnu Sadarat
- Department of Medicine, University of Buffalo, New York, USA
| | - Sindhu Luhana
- Department of Medicine, Icahn School of Medicine at Mount Sinai, 1 Gustave L. Levy PI, New York, NY, USA
| | - Om Parkash
- Department of Medicine, Montefiore Medical Center, Weikfield, NY, USA
| | - Abhi Chand Lohana
- Department of Medicine, WVU Camden Clark Medical Center, West, VA, USA
| | - Zubair Rahaman
- Department of Medicine, University of Buffalo, New York, USA
| | - Hong Yu Wang
- Department of Medicine, Icahn School of Medicine at Mount Sinai, 1 Gustave L. Levy PI, New York, NY, USA
| | - Yaqub N Mohammed
- Department of Medicine, Western Michigan University, Pontiac, USA
| | - Sanjay Kirshan Kumar
- Department of Medicine, Bahria University Health Sciences Karachi, Karachi, Pakistan
| | - Subhash Chander
- Department of Medicine, Icahn School of Medicine at Mount Sinai, 1 Gustave L. Levy PI, New York, NY, USA.
- Department of Medicine, University of Buffalo, New York, USA.
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Tenner S, Vege SS, Sheth SG, Sauer B, Yang A, Conwell DL, Yadlapati RH, Gardner TB. American College of Gastroenterology Guidelines: Management of Acute Pancreatitis. Am J Gastroenterol 2024; 119:419-437. [PMID: 38857482 DOI: 10.14309/ajg.0000000000002645] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/08/2023] [Accepted: 12/08/2023] [Indexed: 06/12/2024]
Abstract
Acute pancreatitis (AP), defined as acute inflammation of the pancreas, is one of the most common diseases of the gastrointestinal tract leading to hospital admission in the United States. It is important for clinicians to appreciate that AP is heterogenous, progressing differently among patients and is often unpredictable. While most patients experience symptoms lasting a few days, almost one-fifth of patients will go on to experience complications, including pancreatic necrosis and/or organ failure, at times requiring prolonged hospitalization, intensive care, and radiologic, surgical, and/or endoscopic intervention. Early management is essential to identify and treat patients with AP to prevent complications. Patients with biliary pancreatitis typically will require surgery to prevent recurrent disease and may need early endoscopic retrograde cholangiopancreatography if the disease is complicated by cholangitis. Nutrition plays an important role in treating patients with AP. The safety of early refeeding and importance in preventing complications from AP are addressed. This guideline will provide an evidence-based practical approach to the management of patients with AP.
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Affiliation(s)
- Scott Tenner
- State University of New York, Health Sciences Center, Brooklyn, New York, USA
| | | | - Sunil G Sheth
- Beth Israel Deaconess Medical Center, Boston, Massachusetts, USA
| | - Bryan Sauer
- University of Virginia, Charlottesville, Virginia, USA
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Song Y, Lee SH. Recent Treatment Strategies for Acute Pancreatitis. J Clin Med 2024; 13:978. [PMID: 38398290 PMCID: PMC10889262 DOI: 10.3390/jcm13040978] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/18/2023] [Revised: 01/26/2024] [Accepted: 02/06/2024] [Indexed: 02/25/2024] Open
Abstract
Acute pancreatitis (AP) is a leading gastrointestinal disease that causes hospitalization. Initial management in the first 72 h after the diagnosis of AP is pivotal, which can influence the clinical outcomes of the disease. Initial management, including assessment of disease severity, fluid resuscitation, pain control, nutritional support, antibiotic use, and endoscopic retrograde cholangiopancreatography (ERCP) in gallstone pancreatitis, plays a fundamental role in AP treatment. Recent updates for fluid resuscitation, including treatment goals, the type, rate, volume, and duration, have triggered a paradigm shift from aggressive hydration with normal saline to goal-directed and non-aggressive hydration with lactated Ringer's solution. Evidence of the clinical benefit of early enteral feeding is becoming definitive. The routine use of prophylactic antibiotics is generally limited, and the procalcitonin-based algorithm of antibiotic use has recently been investigated to distinguish between inflammation and infection in patients with AP. Although urgent ERCP (within 24 h) should be performed for patients with gallstone pancreatitis and cholangitis, urgent ERCP is not indicated in patients without cholangitis. The management approach for patients with local complications of AP, particularly those with infected necrotizing pancreatitis, is discussed in detail, including indications, timing, anatomical considerations, and selection of intervention methods. Furthermore, convalescent treatment, including cholecystectomy in gallstone pancreatitis, lipid-lowering medications in hypertriglyceridemia-induced AP, and alcohol intervention in alcoholic pancreatitis, is also important for improving the prognosis and preventing recurrence in patients with AP. This review focuses on recent updates on the initial and convalescent management strategies for AP.
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Affiliation(s)
| | - Sang-Hoon Lee
- Department of Internal Medicine, Konkuk University School of Medicine, Seoul 05030, Republic of Korea;
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Dawson A, Karunakaran M, Sharma ZD, Ullah S, Barreto SG. Fluid resuscitation in the early management of acute pancreatitis - evidence from a systematic review and meta-analysis. HPB (Oxford) 2023; 25:1451-1465. [PMID: 37689561 DOI: 10.1016/j.hpb.2023.08.013] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/21/2023] [Revised: 05/07/2023] [Accepted: 08/23/2023] [Indexed: 09/11/2023]
Abstract
BACKGROUND Third space fluid loss is one of the hallmarks of the pathophysiology of acute pancreatitis (AP) contributing to complications, including organ failure and death. We conducted a systematic review of literature to determine the ideal fluid resuscitation in the early management of AP, primarily comparing aggressive versus moderate intravenous fluid resuscitation (AIR vs MIR). METHODS A systematic review of major reference databases was undertaken. Meta-analysis was performed using random-effects model. Bias was assessed using Cochrane risk of bias and ROBINS-I tools for randomized and non-randomised studies, respectively. RESULTS Twenty studies were included in the analysis. Though there was no significant difference in mortality between AIR and MIR groups (8.3% versus 6.0%; p = 0.3), AIR cohort had significantly higher rates of organ failure (p = 0.009), including pulmonary (p = 0.02) and renal (p = 0.01) complications. Similarly, there was no difference in mortality between normal saline (NS) and Ringer's lactate (RL) (3.17% versus 3.01%; p = 0.23), though patients treated with NS had a significantly longer length of hospital stay (LOS) (p = 0.009). CONCLUSIONS Current evidence appears to support moderate intravenous resuscitation (level of evidence, low) with RL (level of evidence, moderate) in the early management of AP.
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Affiliation(s)
- Abby Dawson
- College of Medicine and Public Health, Flinders University, South Australia, Australia
| | - Monish Karunakaran
- College of Medicine and Public Health, Flinders University, South Australia, Australia; Department of Surgical Gastroenterology, Asian Institute of Gastroenterology, Hyderabad, India
| | - Zubin D Sharma
- Department of Gastroenterology, Medanta Institute of Digestive and Hepatobiliary Sciences, Medanta, The Medicity, Gurgaon, India
| | - Shahid Ullah
- College of Medicine and Public Health, Flinders University, South Australia, Australia
| | - Savio G Barreto
- College of Medicine and Public Health, Flinders University, South Australia, Australia; Division of Surgery and Perioperative Medicine, Flinders Medical Center, Bedford Park, Adelaide, South Australia, Australia.
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Guo J, Hong J, He Y, Li Q, Huang T, Lou D, Zhang J. Comparison of early aggressive versus nonaggressive fluid resuscitation in acute pancreatitis: a meta-analysis. Therap Adv Gastroenterol 2023; 16:17562848231192144. [PMID: 37655061 PMCID: PMC10467253 DOI: 10.1177/17562848231192144] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/15/2023] [Accepted: 07/19/2023] [Indexed: 09/02/2023] Open
Abstract
Background Early fluid resuscitation is one of the main therapeutic strategies for acute pancreatitis (AP). This study investigated the effects of early aggressive and nonaggressive hydration on AP. Objectives The aim of this meta-analysis is to investigate the differences between aggressive and nonaggressive intravenous fluid resuscitation in AP. Design This study was based on publicly available data, all of which have been extracted from previous ethically approved studies. Data sources and methods Two authors systematically searched PubMed, Embase (via OVID), Web of Science, and Cochrane Library to find all published research before February 2023. In-hospital mortality were set as primary endpoints. Results This meta-analysis included seven randomized controlled trials (RCTs) and eight cohort studies with 4072 individuals in nonaggressive (n = 2419) and aggressive (n = 1653) hydration groups. The results showed that patients in the nonaggressive group had a lower mortality rate than those in the aggressive hydration group [relative risks (RR), 0.66; p = 0.02]. Subgroup analysis results showed that patients in the nonaggressive hydration group had lower mortality rates in RCTs (RR, 0.39; p = 0.001), studies conducted in Eastern countries (RR, 0.63; p = 0.002), and studies with severe pancreatitis (RR, 0.65; p = 0.02). In addition, the nonaggressive hydration group had lower rates of infection (RR, 0.62; p < 0.001), organ failure (RR, 0.65; p = 0.02), and shock (RR, 0.21; p = 0.02), as well as a shorter hospital stay (weighted mean difference, -1.63; p = 0.001) than the aggressive hydration group. Conclusions Early nonaggressive fluid resuscitation is associated with lower mortality, lower risk of organ failure and infection, and shorter hospital stays than aggressive fluid resuscitation. Registration prospero registration number CRD42023396388.
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Affiliation(s)
- Jian Guo
- Intensive Care Unit, The Affiliated Hospital of Ningbo University, LiHuiLi Hospital, Ningbo, Zhejiang, China
| | - Jiaze Hong
- Department of Gastroenterology, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, Hubei, China
- The Second Clinical Medical College, Zhejiang Chinese Medical University, Hangzhou, Zhejiang, China
| | - Yujing He
- The Second Clinical Medical College, Zhejiang Chinese Medical University, Hangzhou, Zhejiang, China
| | - Qingyuan Li
- The Second Clinical Medical College, Zhejiang Chinese Medical University, Hangzhou, Zhejiang, China
| | - Tongmin Huang
- The Second Clinical Medical College, Zhejiang Chinese Medical University, Hangzhou, Zhejiang, China
| | - Dandi Lou
- The First Clinical Medical College, Zhejiang Chinese Medical University, Hangzhou, Zhejiang, China
| | - Jie Zhang
- Emergency Department, Zhuji People’s Hospital, No.9, Jianmin Road, Taozhu Street, Shaoxing, Zhejiang 311899, China
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Alves JAM, Magalhães MR, Zampieri FG, Veiga VC, Maia IS, Cavalcanti AB. Physiological and linical ffects of ifferent nfusion ates of ntravenous luids for olume xpansion: A coping eview. J Crit Care 2023; 76:154295. [DOI: 10.1016/j.jcrc.2023.154295] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/24/2022] [Revised: 01/16/2023] [Accepted: 03/16/2023] [Indexed: 03/31/2023]
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8
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He K, Gao L, Yang Z, Zhang Y, Hua T, Hu W, Wu D, Ke L. Aggressive versus controlled fluid resuscitation in acute pancreatitis: A systematic review and meta-analysis of randomized controlled trials. Chin Med J (Engl) 2023; 136:1166-1173. [PMID: 37185290 PMCID: PMC10278702 DOI: 10.1097/cm9.0000000000002684] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/16/2022] [Indexed: 05/17/2023] Open
Abstract
BACKGROUND Early fluid resuscitation is one of the fundamental treatments for acute pancreatitis (AP), but there is no consensus on the optimal fluid rate. This systematic review and meta-analysis aimed to compare the efficacy and safety of aggressive vs. controlled fluid resuscitation (CFR) in AP. METHODS The Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE, Embase, and Web of Science databases were searched up to September 30, 2022, for randomized controlled trials (RCTs) comparing aggressive with controlled rates of early fluid resuscitation in AP patients without organ failure on admission. The following keywords were used in the search strategy: "pancreatitis," "fluid therapy,""fluid resuscitation,"and "randomized controlled trial." There was no language restriction. The Grading of Recommendations Assessment, Development and Evaluation (GRADE) framework was used to assess the certainty of evidence. Trial sequential analysis (TSA) was used to control the risk of random errors and assess the conclusions. RESULTS A total of five RCTs, involving 481 participants, were included in this study. For primary outcomes, there was no significant difference in the development of severe AP (relative risk [RR]: 1.87, 95% confidence interval [CI] 0.95-3.68; P = 0.07; n = 437; moderate quality of evidence) or hypovolemia (RR: 0.98, 95% CI: 0.32-2.97; P = 0.97; n = 437; moderate quality of evidence) between the aggressive and CFR groups. A significantly higher risk of fluid overload (RR: 3.25, 95% CI: 1.53-6.93; P <0.01; n = 249; low quality of evidence) was observed in the aggressive fluid resuscitation (AFR) group than the controlled group. Additionally, the risk of intensive care unit admission ( P = 0.02) and the length of hospital stay ( P <0.01) as partial secondary outcomes were higher in the AFR group. TSA suggested that more studies were required to draw precise conclusions. CONCLUSION For AP patients without organ failure on admission, CFR may be superior to AFR with respect to both efficacy and safety outcomes. REGISTRATION PROSPERO; https://www.crd.york.ac.uk/PROSPERO/ ; CRD 42022363945.
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Affiliation(s)
- Kun He
- Department of Gastroenterology, State Key Laboratory of Complex Severe and Rare Diseases, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing 100730, China
| | - Lin Gao
- Department of Critical Care Medicine, Center of Severe Acute Pancreatitis (CSAP), Jinling Hospital, Medical School of Nanjing University, Nanjing, Jiangsu 210010, China
| | - Zihan Yang
- Department of Internal Medicine, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing 100730, China
| | - Yuelun Zhang
- Medical Research Center, State Key Laboratory of Complex Severe and Rare Diseases, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing 100730, China
| | - Tianrui Hua
- Department of Internal Medicine, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing 100730, China
| | - Wenmo Hu
- Department of Gastroenterology, State Key Laboratory of Complex Severe and Rare Diseases, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing 100730, China
| | - Dong Wu
- Department of Gastroenterology, State Key Laboratory of Complex Severe and Rare Diseases, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing 100730, China
| | - Lu Ke
- Department of Critical Care Medicine, Center of Severe Acute Pancreatitis (CSAP), Jinling Hospital, Medical School of Nanjing University, Nanjing, Jiangsu 210010, China
- National Institute of Healthcare Data Science, Nanjing University, Nanjing, Jiangsu 210010, China
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Zerem E, Kurtcehajic A, Kunosić S, Zerem Malkočević D, Zerem O. Current trends in acute pancreatitis: Diagnostic and therapeutic challenges. World J Gastroenterol 2023; 29:2747-2763. [PMID: 37274068 PMCID: PMC10237108 DOI: 10.3748/wjg.v29.i18.2747] [Citation(s) in RCA: 20] [Impact Index Per Article: 20.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/09/2023] [Revised: 02/07/2023] [Accepted: 04/18/2023] [Indexed: 05/11/2023] Open
Abstract
Acute pancreatitis (AP) is an inflammatory disease of the pancreas, which can progress to severe AP, with a high risk of death. It is one of the most complicated and clinically challenging of all disorders affecting the abdomen. The main causes of AP are gallstone migration and alcohol abuse. Other causes are uncommon, controversial and insufficiently explained. The disease is primarily characterized by inappropriate activation of trypsinogen, infiltration of inflammatory cells, and destruction of secretory cells. According to the revised Atlanta classification, severity of the disease is categorized into three levels: Mild, moderately severe and severe, depending upon organ failure and local as well as systemic complications. Various methods have been used for predicting the severity of AP and its outcome, such as clinical evaluation, imaging evaluation and testing of various biochemical markers. However, AP is a very complex disease and despite the fact that there are of several clinical, biochemical and imaging criteria for assessment of severity of AP, it is not an easy task to predict its subsequent course. Therefore, there are existing controversies regarding diagnostic and therapeutic modalities, their effectiveness and complications in the treatment of AP. The main reason being the fact, that the pathophysiologic mechanisms of AP have not been fully elucidated and need to be studied further. In this editorial article, we discuss the efficacy of the existing diagnostic and therapeutic modalities, complications and treatment failure in the management of AP.
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Affiliation(s)
- Enver Zerem
- Department of Medical Sciences, The Academy of Sciences and Arts of Bosnia and Herzegovina, Sarajevo 71000, Bosnia and Herzegovina
| | - Admir Kurtcehajic
- Department of Gastroenterology and Hepatology, Plava Medical Group, Tuzla 75000, Bosnia and Herzegovina
| | - Suad Kunosić
- Department of Physics, Faculty of Natural Sciences and Mathematics, University of Tuzla, Tuzla 75000, Bosnia and Herzegovina
| | - Dina Zerem Malkočević
- Department of Internal Medicine, Cantonal Hospital “Safet Mujić“ Mostar, Mostar 88000, Bosnia and Herzegovina
| | - Omar Zerem
- Department of Internal Medicine, Cantonal Hospital “Safet Mujić“ Mostar, Mostar 88000, Bosnia and Herzegovina
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Yaowmaneerat T, Sirinawasatien A. Update on the strategy for intravenous fluid treatment in acute pancreatitis. World J Gastrointest Pharmacol Ther 2023; 14:22-32. [PMID: 37179816 PMCID: PMC10167805 DOI: 10.4292/wjgpt.v14.i3.22] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/12/2023] [Revised: 03/21/2023] [Accepted: 04/18/2023] [Indexed: 04/27/2023] Open
Abstract
Fluid therapy/resuscitation is mandatory in acute pancreatitis due to the pathophysiology of fluid loss as a consequence of the inflammatory process. For many years, without clear evidence, early and aggressive fluid resuscitation with crystalloid solutions (normal saline solution or Ringer lactate solution) was recommended. Recently, many randomized control trials and meta-analyses on fluid therapy have revealed that high fluid rate infusion is associated with increased mortality and severe adverse events compared to those resulting from moderate fluid rates, and this has triggered a paradigm shift in fluid management strategies. Meanwhile, there is evidence to show that Ringer lactate solution is superior to normal saline solutions in this context. The purpose of this review is to provide an update on the strategies for intravenous fluid treatment in acute pancreatitis, including the type, optimal amount, rate of infusion, and monitoring guides. Recommendations from recent guidelines are critically evaluated for this review in order to reach the authors' recommendations based on the available evidence.
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Affiliation(s)
- Thanapon Yaowmaneerat
- Nanthana-Kriangkrai Chotiwattanaphan Institute of Gastroenterology and Hepatology, Faculty of Medicine, Prince of Songkla University, Hat Yai , Songkhla 90110, Thailand
| | - Apichet Sirinawasatien
- Department of Medicine, Division of Gastroenterology, Rajavithi Hospital, College of Medicine, Rangsit University, Bangkok 10400, Thailand
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Manrai M, Dawra S, Singh AK, Jha DK, Kochhar R. Controversies in the management of acute pancreatitis: An update. World J Clin Cases 2023; 11:2582-2603. [PMID: 37214572 PMCID: PMC10198120 DOI: 10.12998/wjcc.v11.i12.2582] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/27/2022] [Revised: 01/22/2023] [Accepted: 03/29/2023] [Indexed: 04/25/2023] Open
Abstract
This review summarized the current controversies in the management of acute pancreatitis (AP). The controversies in management range from issues involving fluid resuscitation, nutrition, the role of antibiotics and antifungals, which analgesic to use, role of anticoagulation and intervention for complications in AP. The interventions vary from percutaneous drainage, endoscopy or surgery. Active research and emerging data are helping to formulate better guidelines. The available evidence favors crystalloids, although the choice and type of fluid resuscitation is an area of dynamic research. The nutrition aspect does not have controversy as of now as early enteral feeding is preferred most often than not. The empirical use of antibiotics and antifungals are gray zones, and more data is needed for conclusive guidelines. The choice of analgesic is being studied, and the recommendations are still evolving. The position of using anticoagulation is still awaiting consensus. The role of intervention is well established, although the modality is constantly changing and favoring endoscopy or percutaneous drainage rather than surgery. It is evident that more multicenter randomized controlled trials are required for establishing the standard of care in these crucial management issues of AP to improve the morbidity and mortality worldwide.
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Affiliation(s)
- Manish Manrai
- Department of Internal Medicine, Armed Forces Medical College, Pune 411040, India
| | - Saurabh Dawra
- Department of Medicine and Gastroenterology, Command Hospital, Pune 411040, India
| | - Anupam K Singh
- Department of Gastroenterology, Post Graduate Institute of Medical Education and Research, Chandigarh 160012, India
| | - Daya Krishna Jha
- Department of Gastroenterology, Army Hospital (Research and Referral), New Delhi 11010, India
| | - Rakesh Kochhar
- Department of Gastroenterology, Post Graduate Institute of Medical Education and Research, Chandigarh 160012, India
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12
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Li XW, Wang CH, Dai JW, Tsao SH, Wang PH, Tai CC, Chien RN, Shao SC, Lai ECC. Comparison of clinical outcomes between aggressive and non-aggressive intravenous hydration for acute pancreatitis: a systematic review and meta-analysis. Crit Care 2023; 27:122. [PMID: 36949459 PMCID: PMC10035244 DOI: 10.1186/s13054-023-04401-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/10/2023] [Accepted: 03/12/2023] [Indexed: 03/24/2023] Open
Abstract
BACKGROUND Current practice guidelines for optimal infusion rates during early intravenous hydration in patients with acute pancreatitis (AP) remain inconsistent. This systematic review and meta-analysis aimed to compare treatment outcomes between aggressive and non-aggressive intravenous hydration in severe and non-severe AP. METHODS This study followed the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. We systematically searched PubMed, Embase and Cochrane Library for randomized controlled trials (RCTs) on November 23, 2022, and hand-searched the reference lists of included RCTs, relevant review articles and clinical guidelines. We included RCTs that compared clinical outcomes from aggressive and non-aggressive intravenous hydration in AP. Meta-analysis was performed using a random-effects model for participants with severe AP and non-severe AP. Our primary outcome was all-cause mortality, and several secondary outcomes included fluid-related complications, clinical improvement and APACHE II scores within 48 h. RESULTS We included a total of 9 RCTs with 953 participants. The meta-analysis indicated that, compared to non-aggressive intravenous hydration, aggressive intravenous hydration significantly increased mortality risk in severe AP (pooled RR: 2.45, 95% CI: 1.37, 4.40), while the result in non-severe AP was inconclusive (pooled RR: 2.26, 95% CI: 0.54, 9.44). However, aggressive intravenous hydration significantly increased fluid-related complication risk in both severe (pooled RR: 2.22, 95% CI 1.36, 3.63) and non-severe AP (pooled RR: 3.25, 95% CI: 1.53, 6.93). The meta-analysis indicated worse APACHE II scores (pooled mean difference: 3.31, 95% CI: 1.79, 4.84) in severe AP, and no increased likelihood of clinical improvement (pooled RR:1.20, 95% CI: 0.63, 2.29) in non-severe AP. Sensitivity analyses including only RCTs with goal-directed fluid therapy after initial fluid resuscitation therapy yielded consistent results. CONCLUSIONS Aggressive intravenous hydration increased the mortality risk in severe AP, and fluid-related complication risk in both severe and non-severe AP. More conservative intravenous fluid resuscitation protocols for AP are suggested.
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Affiliation(s)
- Xiu-Wei Li
- Division of Hepatogastroenterology, Department of Internal Medicine, Keelung Chang Gung Memorial Hospital, Keelung, Taiwan
- College of Medicine, Chang Gung University, Taoyuan, Taiwan
| | - Chien-Ho Wang
- College of Medicine, Chang Gung University, Taoyuan, Taiwan
- Department of Emergency Medicine, Keelung Chang Gung Memorial Hospital, Keelung, Taiwan
| | - Jhih-Wei Dai
- College of Medicine, Chang Gung University, Taoyuan, Taiwan
- Department of Cardiology, Keelung Chang Gung Memorial Hospital, Keelung, Taiwan
| | - Shu-Han Tsao
- College of Medicine, Chang Gung University, Taoyuan, Taiwan
- Department of Urology, Linkou Chang Gung Memorial Hospital, Taoyuan, Taiwan
| | - Po-Hsi Wang
- Department of Nephrology, Keelung Chang Gung Memorial Hospital, Keelung, Taiwan
| | - Cheng-Chen Tai
- Medical Library, Department of Medical Education, Linkou Chang Gung Memorial Hospital, Taoyuan, Taiwan
| | - Rong-Nan Chien
- Division of Hepatogastroenterology, Department of Internal Medicine, Keelung Chang Gung Memorial Hospital, Keelung, Taiwan
- College of Medicine, Chang Gung University, Taoyuan, Taiwan
- Division of Hepatogastroenterology, Department of Internal Medicine, Linkou Chang Gung Memorial Hospital, Taoyuan, Taiwan
| | - Shih-Chieh Shao
- Department of Pharmacy, Keelung Chang Gung Memorial Hospital, Keelung, Taiwan.
- Center for Evidence-Based Medicine, Keelung Chang Gung Memorial Hospital, Keelung, Taiwan.
- School of Pharmacy, Institute of Clinical Pharmacy and Pharmaceutical Sciences, College of Medicine, National Cheng Kung University, Tainan, Taiwan.
| | - Edward Chia-Cheng Lai
- School of Pharmacy, Institute of Clinical Pharmacy and Pharmaceutical Sciences, College of Medicine, National Cheng Kung University, Tainan, Taiwan
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13
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Ding X, Chen B. Effect of Aggressive Intravenous Fluid Resuscitation Versus Nonaggressive Fluid Resuscitation in the Treatment of Acute Pancreatitis: A Systematic Review and Meta-Analysis. Pancreas 2023; 52:e89-e100. [PMID: 37523599 DOI: 10.1097/mpa.0000000000002230] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 08/02/2023]
Abstract
OBJECTIVES Despite the need for active fluid therapy, fluid management of most acute pancreatitis (AP) cases is still supportive. The aim of this review is to compare the effect of aggressive versus nonaggressive intravenous (IV) fluid resuscitation in the treatment of acute pancreatitis. METHODS A systematic search of medical databases, such as Medline, Google Scholar, Science Direct, Cochrane Central, was conducted for publication until April 2022. We included randomized controlled trials or cohort (prospective and retrospective) studies reporting the outcomes of AP in patients that were managed with aggressive and nonaggressive IV fluid resuscitation. The primary outcome of interest was in-hospital mortality. RESULTS Fourteen trials involving 3423 acute pancreatitis patients were included in the review. We did not observe any differences in the risk of mortality, persistent organ failure, and systemic inflammatory response syndrome in both study groups. However, there was an increased risk of development of pancreatic necrosis, renal failure, and respiratory failure in the aggressive fluid therapy group compared with nonaggressive therapy. The funnel plot showed no publication bias. CONCLUSIONS Aggressive fluid therapy did not improve mortality rates in acute AP patients and was associated with an increased risk of acute renal failure, and respiratory failure.
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Affiliation(s)
| | - Bo Chen
- Department of Gastroenterology, QiLu Hospital (Qingdao), Cheeloo College of Medicine, Shandong University, Qingdao, China
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14
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Crosignani A, Spina S, Marrazzo F, Cimbanassi S, Malbrain MLNG, Van Regenemortel N, Fumagalli R, Langer T. Intravenous fluid therapy in patients with severe acute pancreatitis admitted to the intensive care unit: a narrative review. Ann Intensive Care 2022; 12:98. [PMID: 36251136 PMCID: PMC9576837 DOI: 10.1186/s13613-022-01072-y] [Citation(s) in RCA: 15] [Impact Index Per Article: 7.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/25/2022] [Accepted: 10/11/2022] [Indexed: 11/26/2022] Open
Abstract
Patients with acute pancreatitis (AP) often require ICU admission, especially when signs of multiorgan failure are present, a condition that defines AP as severe. This disease is characterized by a massive pancreatic release of pro-inflammatory cytokines that causes a systemic inflammatory response syndrome and a profound intravascular fluid loss. This leads to a mixed hypovolemic and distributive shock and ultimately to multiorgan failure. Aggressive fluid resuscitation is traditionally considered the mainstay treatment of AP. In fact, all available guidelines underline the importance of fluid therapy, particularly in the first 24–48 h after disease onset. However, there is currently no consensus neither about the type, nor about the optimal fluid rate, total volume, or goal of fluid administration. In general, a starting fluid rate of 5–10 ml/kg/h of Ringer’s lactate solution for the first 24 h has been recommended. Fluid administration should be aggressive in the first hours, and continued only for the appropriate time frame, being usually discontinued, or significantly reduced after the first 24–48 h after admission. Close clinical and hemodynamic monitoring along with the definition of clear resuscitation goals are fundamental. Generally accepted targets are urinary output, reversal of tachycardia and hypotension, and improvement of laboratory markers. However, the usefulness of different endpoints to guide fluid therapy is highly debated. The importance of close monitoring of fluid infusion and balance is acknowledged by most available guidelines to avoid the deleterious effect of fluid overload. Fluid therapy should be carefully tailored in patients with severe AP, as for other conditions frequently managed in the ICU requiring large fluid amounts, such as septic shock and burn injury. A combination of both noninvasive clinical and invasive hemodynamic parameters, and laboratory markers should guide clinicians in the early phase of severe AP to meet organ perfusion requirements with the proper administration of fluids while avoiding fluid overload. In this narrative review the most recent evidence about fluid therapy in severe AP is discussed and an operative algorithm for fluid administration based on an individualized approach is proposed.
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Affiliation(s)
- Andrea Crosignani
- School of Medicine and Surgery, University of Milan-Bicocca, Milan, Italy.,Department of Anaesthesia and Critical Care, ASST Grande Ospedale Metropolitano Niguarda, Milan, Italy
| | - Stefano Spina
- School of Medicine and Surgery, University of Milan-Bicocca, Milan, Italy.,Department of Anaesthesia and Critical Care, ASST Grande Ospedale Metropolitano Niguarda, Milan, Italy
| | - Francesco Marrazzo
- School of Medicine and Surgery, University of Milan-Bicocca, Milan, Italy.,Department of Anaesthesia and Critical Care, ASST Grande Ospedale Metropolitano Niguarda, Milan, Italy
| | - Stefania Cimbanassi
- General Surgery and Trauma Team, ASST Grande Ospedale Metropolitano Niguarda, Milan, Italy.,Department of Pathophysiology and Transplantation, University of Milan, Milan, Italy
| | - Manu L N G Malbrain
- First Department of Anaesthesia and Intensive Therapy, Medical University of Lublin, Lublin, Poland.,International Fluid Academy, Lovenjoel, Belgium
| | - Niels Van Regenemortel
- Department of Intensive Care Medicine, Antwerp University Hospital, Antwerp, Belgium.,Department of Intensive Care Medicine, Ziekenhuis Netwerk Antwerpen Campus Stuivenberg, Antwerp, Belgium
| | - Roberto Fumagalli
- School of Medicine and Surgery, University of Milan-Bicocca, Milan, Italy.,Department of Anaesthesia and Critical Care, ASST Grande Ospedale Metropolitano Niguarda, Milan, Italy
| | - Thomas Langer
- School of Medicine and Surgery, University of Milan-Bicocca, Milan, Italy. .,Department of Anaesthesia and Critical Care, ASST Grande Ospedale Metropolitano Niguarda, Milan, Italy.
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15
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Takada T, Isaji S, Mayumi T, Yoshida M, Takeyama Y, Itoi T, Sano K, Iizawa Y, Masamune A, Hirota M, Okamoto K, Inoue D, Kitamura N, Mori Y, Mukai S, Kiriyama S, Shirai K, Tsuchiya A, Higuchi R, Hirashita T. JPN clinical practice guidelines 2021 with easy-to-understand explanations for the management of acute pancreatitis. JOURNAL OF HEPATO-BILIARY-PANCREATIC SCIENCES 2022; 29:1057-1083. [PMID: 35388634 DOI: 10.1002/jhbp.1146] [Citation(s) in RCA: 19] [Impact Index Per Article: 9.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/23/2021] [Revised: 02/02/2022] [Accepted: 02/08/2022] [Indexed: 11/09/2022]
Abstract
BACKGROUND In preparing the Japanese (JPN) guidelines for the management of acute pancreatitis 2021, the committee focused the issues raised by the results of nationwide epidemiological survey in 2016 in Japan METHOD: In addition to a systematic search using the previous JPN guidelines, papers published from January 2014 to September 2019 were searched for the contents to be covered by the guidelines based on the concept of GRADE system. RESULTS Thirty-six clinical questions (CQ) were prepared in 15 subject areas. Base on the facts that patients diagnosed with severe disease by both Japanese prognostic factor score and contrast-enhanced CT grade had a high fatality rate and that little prognosis improvement after 2 weeks of disease onset was not obtained, we emphasized the importance of Pancreatitis Bundles, which was shown to be effective in improving prognosis, and the CQ sections for local pancreatic complications had been expanded to ensure adoption of a step-up approach. Furthermore, on the facts that enteral nutrition for severe acute pancreatitis was not started early within 48 hours of admission and that unnecessary prophylactic antibiotics was used in almost all cases, we emphasized early enteral nutrition in small amounts even if gastric feeding is used and no prophylactic antibiotics in mild pancreatitis. CONCLUSION All the members of the committee have put a lot of effort into preparing the extensively revised guidelines in the hope that more people will have a common understanding and that better medical care will be spread.
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Affiliation(s)
- Tadahiro Takada
- Department of Surgery, Teikyo University School of Medicine, Tokyo, Japan
| | - Shuji Isaji
- Department of Hepato-Biliary-Pancreatic and Transplant Surgery, Mie University Graduate School of Medicine, Mie, Japan
| | - Toshihiko Mayumi
- Department of Emergency Medicine, School of Medicine, University of Occupational and Environmental Health, Fukuoka, Japan
| | - Masahiro Yoshida
- Department of Hepato-Biliary-Pancreatic and Gastrointestinal Surgery, School of Medicine, International University of Health & Welfare, Chiba, Japan
| | - Yoshifumi Takeyama
- Department of Surgery, Kindai University Faculty of Medicine, Osaka, Japan
| | - Takao Itoi
- Department. of Gastroenterology and Hepatology, Tokyo Medical University, Tokyo, Japan
| | - Keiji Sano
- Department of Surgery, Teikyo University School of Medicine, Tokyo, Japan
| | - Yusuke Iizawa
- Department of Hepato-Biliary-Pancreatic and Transplant Surgery, Mie University Graduate School of Medicine, Mie, Japan
| | - Atsushi Masamune
- Division of Gastroenterology, Tohoku University Graduate School of Medicine, Sendai, Japan
| | - Morihisa Hirota
- Division of Gastroenterology, Tohoku Medical and Pharmaceutical University, Sendai, Japan
| | - Kohji Okamoto
- Department of Surgery, Center for Gastroenterology and Liver Disease, Kitakyushu City Yahata Hospital, Fukuoka, Japan
| | - Dai Inoue
- Department of Radiology, Kanazawa University Hospital, Ishikawa, Japan
| | - Nobuya Kitamura
- Department of Emergency and Critical Care Medicine, Kimitsu Chuo Hospital, Chiba, Japan
| | - Yasuhisa Mori
- Department of Surgery I, School of Medicine, University of Occupational and Environmental Health, Fukuoka, Japan
| | - Shuntaro Mukai
- Department. of Gastroenterology and Hepatology, Tokyo Medical University, Tokyo, Japan
| | - Seiki Kiriyama
- Department of Gastroenterology, Ogaki Municipal Hospital, Gifu, Japan
| | - Kunihiro Shirai
- Department of Emergency, Disaster and Critical Care Medicine, Hyogo College of Medicine, Hyogo, Japan
| | - Asuka Tsuchiya
- Department of Emergency and Critical Care Medicine, Tokai University School of Medicine, Kanagawa, Japan
| | - Ryota Higuchi
- Department of Surgery, Institute of Gastroenterology, Tokyo Women's Medical University, Tokyo, Japan
| | - Teijiro Hirashita
- Department of Gastroenterological and Pediatric Surgery, Oita University Faculty of Medicine, Oita, Japan
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16
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Liao J, Zhan Y, Wu H, Yao Z, Peng X, Lai J. Effect of aggressive versus conservative hydration for early phase of acute pancreatitis in adult patients: A meta-analysis of 3,127 cases. Pancreatology 2022; 22:226-234. [PMID: 35031209 DOI: 10.1016/j.pan.2022.01.001] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/10/2021] [Revised: 12/30/2021] [Accepted: 01/02/2022] [Indexed: 12/11/2022]
Abstract
BACKGROUND The advantages of aggressive hydration compared to conservative hydration within 24 h for acute pancreatitis (AP) remain controversial in adult patients. A meta-analysis was undertaken to investigate whether aggressive strategies are more beneficial. METHODS We searched (on February 1, 2021) PubMed, Embase, and the Cochrane Library for eligible trials that assessed the two therapies and performed a meta-analysis. The primary endpoint was in-hospital mortality. Secondary outcomes were adverse events (e.g., renal failure and pancreatic necrosis) within 24 h of treatment. RESULTS Five randomized controlled trials and 8 observational trials involving 3127 patients were identified. Patients with severe pancreatitis showed significant difference of in-hospital mortality (OR 1.75; 95% CI 1.32-2.33) in aggressive hydration group, which were less susceptible to study type and age. Patients with severe pancreatitis were likely to develop respiratory failure (OR 5.08; 95% CI 2.31-11.15), persistent SIRS (OR 2.83; 95% CI 1.58-5.04), renal failure (OR 2.58; 95% CI 1.90-3.50) with significant difference. A longer hospital stay was observed in patients with severe pancreatitis (WMD 7.61; 95% CI 5.51-9.71; P < 0.05) in the aggressive hydration group. Higher incidence of pancreatic necrosis (OR 2.34; 95% CI 1.60-3.42; P < 0.05) was major susceptible to observational studies, old patients and mild pancreatitis. CONCLUSIONS Compared to conservative hydration, aggressive hydration increases in-hospital mortality and the incidence of renal failure, pancreatic necrosis with relatively strong evidence. Further investigation should be designed with a definitive follow-up period and therapeutic goals to address reverse causation bias.
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Affiliation(s)
- Jiyang Liao
- Department of Intensive Care Unit, Shenzhen Hospital of Integrated Traditional Chinese and Western Medicine, No. 3 Shajing Street, Baoan District, Shenzhen, 518000, Guangdong Province, China
| | - Yang Zhan
- The Acupuncture Rehabilitation Clinical College of Guangzhou University of Chinese Medicine, No. 12 Airport Road, Baiyun District, Guangzhou, 510000, Guangdong Province, China
| | - Huachu Wu
- Department of Intensive Care Unit, Shenzhen Hospital of Integrated Traditional Chinese and Western Medicine, No. 3 Shajing Street, Baoan District, Shenzhen, 518000, Guangdong Province, China
| | - Zhijun Yao
- Department of Intensive Care Unit, Shenzhen Hospital of Integrated Traditional Chinese and Western Medicine, No. 3 Shajing Street, Baoan District, Shenzhen, 518000, Guangdong Province, China
| | - Xian Peng
- Department of Intensive Care Unit, Shenzhen Hospital of Integrated Traditional Chinese and Western Medicine, No. 3 Shajing Street, Baoan District, Shenzhen, 518000, Guangdong Province, China
| | - Jianbo Lai
- Department of Intensive Care Unit, Shenzhen Hospital of Integrated Traditional Chinese and Western Medicine, No. 3 Shajing Street, Baoan District, Shenzhen, 518000, Guangdong Province, China.
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17
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Schorn S, Demir IE, Friess H. [Treatment of acute pancreatitis from the viewpoint of surgery]. Chirurg 2021; 93:913-922. [PMID: 34783867 DOI: 10.1007/s00104-021-01532-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 10/11/2021] [Indexed: 10/19/2022]
Abstract
The role of surgery in the treatment of acute pancreatitis has clearly changed over the years. In the 1990s a clear reduction in hospital mortality was achieved through surgery, whereas the value of surgery (open, in general) has slipped into the background due to the improvement in intensive care medicine in general and the development of minimally invasive treatment options. Nowadays, patients with acute pancreatitis are only operated on after exhaustion of intensive medical care treatment and minimally invasive interventions or when complications occur that cannot be treated in any other way (e.g. hollow organ perforation). This article provides an overview of the currently used treatment measures.
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Affiliation(s)
| | | | - Helmut Friess
- Klinik und Poliklinik für Chirurgie, Medizinische Fakultät, Technische Universität München, Klinikum rechts der Isar, Ismaninger Straße 22, 81675, München, Deutschland.
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18
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Di Martino M, Van Laarhoven S, Ielpo B, Ramia JM, Manuel-Vázquez A, Martínez-Pérez A, Pavel M, Beltran Miranda P, Orti-Rodríguez R, de la Serna S, Ortega Rabbione GJ, Sanz-Garcia A, Martín-Pérez E. Systematic review and meta-analysis of fluid therapy protocols in acute pancreatitis: type, rate and route. HPB (Oxford) 2021; 23:1629-1638. [PMID: 34325967 DOI: 10.1016/j.hpb.2021.06.426] [Citation(s) in RCA: 17] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/19/2021] [Revised: 06/21/2021] [Accepted: 06/25/2021] [Indexed: 02/07/2023]
Abstract
BACKGROUND Adequate fluid resuscitation is paramount in the management of acute pancreatitis (AP). The aim of this study is to assess benefits and harms of fluid therapy protocols in patients with AP. METHODS MEDLINE, Embase, Science Citation Index and clinical trial registries were searched for randomised clinical trials published before May 2020, assessing types of fluids, routes and rates of administration. RESULTS A total 15 trials (1073 participants) were included. Age ranged from 38 to 73 years; follow-up period ranged from 0.5 to 6 months. Ringer lactate (RL) showed a reduced number of severe adverse events (SAE) when compared to normal saline (NS) (OR 0.48; 95%CI 0.29-0.81, p = 0.006); additionally, NS showed reduced SAE (RR 0.38; 95%IC 0.27-0.54, p < 0.001) and organ failure (RR 0.30; 95%CI 0.21-0.44, p < 0.001) in comparison with hydroxyethyl starch (HES). High fluid rate fluid infusion showed increased mortality (OR 2.88; 95%CI 1.41-5.88, p = 0.004), increased number of SAE (RR 1.42; 95%CI 1.04-1.93, p = 0.030) and higher incidence of sepsis (RR 2.80; 95%CI 1.51-5.19, p = 0.001) compared to moderate fluid rate infusion. CONCLUSIONS In patients with AP, RL should be preferred over NS and HES should not be recommended. Based on low-certainty evidence, moderate-rate fluid infusion should be preferred over high-rate infusion.
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Affiliation(s)
- Marcello Di Martino
- HPB Unit, Department of General and Digestive Surgery, Hospital Universitario La Princesa, Instituto de Investigación Sanitaria Princesa (IIS-IP), Universidad Autónoma de Madrid (UAM), Madrid, Spain.
| | - Stijn Van Laarhoven
- Department of HPB Surgery University Hospitals Bristol and Weston NHS Foundation Trust, Bristol, UK
| | - Benedetto Ielpo
- HPB Unit, University Mar Hospital, Parc Salut, Barcelona, Spain
| | - Jose M Ramia
- Faculty of Health Sciences, Valencian International University (VIU), 46002, Valencia, Spain; Department of Surgery, Hospital General Universitario de Alicante, ISABIALAlicante (Spain)
| | - Alba Manuel-Vázquez
- Department of General and Digestive Surgery, Hospital Universitario de Getafe, Madrid, Spain
| | - Aleix Martínez-Pérez
- Faculty of Health Sciences, Valencian International University (VIU), 46002, Valencia, Spain
| | - Mihai Pavel
- HPB Unit, Department of General Surgery, Hospital Universitari de Tarragona Joan XXIII, Tarragona, Spain, Universitat Rovira i Virgili, Departament de Medicina i Cirugia, Reus, Spain, Universitat Rovira i Virgili, Departament de Medicina i Cirugia, Reus, Spain
| | - Pablo Beltran Miranda
- Unidad de Cirugía Hepato-Bilio-Pancreática, Hospital Universitario Juan Ramón Jiménez, Huelva, Spain
| | - Rafael Orti-Rodríguez
- Department of General and Digestive Surgery, Hospital Universitario Nuestra Señora de Candelaria, Santa Cruz de Tenerife, Spain
| | - Sofía de la Serna
- HPB Surgery Unit, Department of General and Digestive Surgery, Hospital Universitario Clínico San Carlos, Instituto de Investigación Sanitaria Hospital Clínico San Carlos (IdISSC), Universidad Complutense de Madrid, Spain
| | - Guillermo J Ortega Rabbione
- Data Analysis Unit, Hospital Universitario La Princesa, Instituto de Investigación Sanitaria Princesa (IIS-IP), Madrid, Spain
| | - Ancor Sanz-Garcia
- Data Analysis Unit, Hospital Universitario La Princesa, Instituto de Investigación Sanitaria Princesa (IIS-IP), Madrid, Spain
| | - Elena Martín-Pérez
- HPB Unit, Department of General and Digestive Surgery, Hospital Universitario La Princesa, Instituto de Investigación Sanitaria Princesa (IIS-IP), Universidad Autónoma de Madrid (UAM), Madrid, Spain
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19
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Affiliation(s)
- Pramod K Garg
- Department of Gastroenterology All India Institute of Medical Sciences, New Delhi, India.
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