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Sissingh NJ, Timmerhuis HC, Groen JV, de Jong MJP, Besselink MG, Boekestijn B, Bollen TL, Bonsing BA, Bouwense SAW, Hazen WL, Klok FA, van Santvoort HC, van Eijck CHJ, Verdonk RC, Mieog JSD, van Hooft JE. Splanchnic vein thrombosis in necrotizing pancreatitis: a post-hoc analysis of a nationwide prospective cohort. HPB (Oxford) 2024; 26:548-557. [PMID: 38336603 DOI: 10.1016/j.hpb.2024.01.011] [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: 10/23/2023] [Revised: 01/02/2024] [Accepted: 01/22/2024] [Indexed: 02/12/2024]
Abstract
BACKGROUND Treatment guidelines for splanchnic vein thrombosis in necrotizing pancreatitis are lacking due to insufficient data on the full clinical spectrum. METHODS We performed a post-hoc analysis of a nationwide prospective necrotizing pancreatitis cohort. Multivariable analyses were used to identify risk factors and compare the clinical course of patients with and without SVT. RESULTS SVT was detected in 97 of the 432 included patients (22%) (median onset: 4 days). Risk factors were left, central, or subtotal necrosis (OR 28.52; 95% CI 20.11-40.45), right or diffuse necrosis (OR 5.76; 95% CI 3.89-8.51), and younger age (OR 0.94; 95% CI 0.90-0.97). Patients with SVT had higher rates of bleeding (n = 10,11%) and bowel ischemia (n = 4,4%) compared to patients without SVT (n = 14,4% and n = 2,0.6%; OR 3.24; 95% CI 1.27-8.23 and OR 7.29; 95% CI 1.31-40.4, respectively), and were independently associated with ICU admission (adjusted OR 2.53; 95% CI 1.37-4.68). Spontaneous recanalization occurred in 62% of patients (n = 40/71). Radiological and clinical outcomes did not differ between patients treated with and without anticoagulants. DISCUSSION SVT is a common and early complication of necrotizing pancreatitis, associated with parenchymal necrosis and younger age. SVT is associated with increased complications and a worse clinical course, whereas anticoagulant use does not appear to affect outcomes.
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Affiliation(s)
- Noor J Sissingh
- Department of Gastroenterology and Hepatology, Leiden University Medical Center, Leiden, the Netherlands; Department of Research and Development, St Antonius Hospital, Nieuwegein, the Netherlands.
| | - Hester C Timmerhuis
- Department of Research and Development, St Antonius Hospital, Nieuwegein, the Netherlands; Department of Surgery, St. Antonius Hospital, Nieuwegein, the Netherlands
| | - Jesse V Groen
- Department of Surgery, Leiden University Medical Center, Leiden, the Netherlands
| | - Mike J P de Jong
- Department of Research and Development, St Antonius Hospital, Nieuwegein, the Netherlands; Department of Gastroenterology and Hepatology, Radboud University Medical Center, Nijmegen, the Netherlands
| | - Marc G Besselink
- Amsterdam UMC, Location University of Amsterdam, Department of Surgery, Amsterdam, the Netherlands; Amsterdam Gastroenterology Endocrinology Metabolism, the Netherlands
| | - Bas Boekestijn
- Department of Radiology, Leiden University Medical Center, Leiden, the Netherlands
| | - Thomas L Bollen
- Department of Radiology, St. Antonius Hospital, Nieuwegein, the Netherlands
| | - Bert A Bonsing
- Department of Surgery, Leiden University Medical Center, Leiden, the Netherlands
| | - Stefan A W Bouwense
- Department of Surgery, Maastricht University Medical Center, Maastricht, the Netherlands; NUTRIM, School of Nutrition and Translational Research in Metabolism, Maastricht University, Maastricht, the Netherlands
| | - Wouter L Hazen
- Department of Gastroenterology and Hepatology, Elisabeth TweeSteden Hospital, Tilburg, the Netherlands
| | - Frederikus A Klok
- Department of Medicine - Thrombosis and Hemostasis, Leiden University Medical Center, Leiden, the Netherlands
| | - Hjalmar C van Santvoort
- Department of Surgery, St. Antonius Hospital, Nieuwegein, the Netherlands; Department of Surgery, University Medical Center Utrecht, Utrecht, the Netherlands
| | | | - Robert C Verdonk
- Department of Gastroenterology and Hepatology, St. Antonius Hospital, Nieuwegein, the Netherlands
| | - J Sven D Mieog
- Department of Surgery, Leiden University Medical Center, Leiden, the Netherlands
| | - Jeanin E van Hooft
- Department of Gastroenterology and Hepatology, Leiden University Medical Center, Leiden, the Netherlands.
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2
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Borbély RZ, Szalai EÁ, Philip BM, Dobszai D, Teutsch B, Zolcsák Á, Veres DS, Erőss B, Gellért B, Hegyi PJ, Hegyi P, Faluhelyi N. The risk of developing splanchnic vein thrombosis in acute pancreatitis increases 3 days after symptom onset: A systematic review and meta-analysis. United European Gastroenterol J 2024. [PMID: 38400822 DOI: 10.1002/ueg2.12550] [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: 10/16/2023] [Accepted: 01/12/2024] [Indexed: 02/26/2024] Open
Abstract
BACKGROUND Splanchnic vein thrombosis is a complication of acute pancreatitis (AP) and is likely often underdiagnosed. OBJECTIVES We aimed to understand the time course and risk factors of splanchnic vein thrombosis in the early phase of AP. METHODS A systematic search was conducted using the PRISMA guidelines (PROSPERO registration CRD42022367578). Inclusion criteria were appropriate imaging techniques in adult AP patients, studies that reported splanchnic vein thrombosis data from the early phase, and reliable information on the timing of imaging in relation to the onset of pancreatitis symptoms or hospital admission. The proportion of patients with thrombosis with 95% confidence intervals (CI) was calculated using random-effects meta-analyses, and multiple subgroup analyses were performed. RESULTS Data from 1951 patients from 14 studies were analyzed. The proportion of patients with splanchnic vein thrombosis within 12 days after symptom onset was 0.13 (CI 0.07-0.23). The occurrence was lowest at 0.06 (CI 0.03-0.1) between 0 and 3 days after symptom onset, and increased fourfold to 0.23 (CI 0.16-0.31) between 3 and 11 days. On hospital admission, the proportion of patients affected was 0.12 (CI 0.02-0.49); it was 0.17 (CI 0.03-0.58) 1-5 days after admission. The prevalence in mild, moderate, and severe AP was 0.15 (CI 0.05-0.36), 0.26 (CI 0.15-0.43), and 0.27 (CI 0.17-0.4), respectively. Alcoholic etiology (0.31, CI 0.13-0.58) and pancreatic necrosis (0.55, CI 0.29-0.78, necrosis above 30%) correlated with increased SVT prevalence. CONCLUSION The risk of developing splanchnic vein thrombosis is significant in the early stages of AP and may affect up to a quarter of patients. Alcoholic etiology, pancreatic necrosis, and severity may increase the prevalence of splanchnic vein thrombosis.
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Affiliation(s)
- Ruben Zsolt Borbély
- Centre for Translational Medicine, Semmelweis University, Budapest, Hungary
- Department of Medical Imaging, Bajcsy-Zsilinszky Hospital and Clinic, Budapest, Hungary
| | - Eszter Ágnes Szalai
- Centre for Translational Medicine, Semmelweis University, Budapest, Hungary
- Department of Restorative Dentistry and Endodontics, Semmelweis University, Budapest, Hungary
| | | | - Dalma Dobszai
- Institute for Translational Medicine, Medical School, University of Pécs, Pécs, Hungary
| | - Brigitta Teutsch
- Centre for Translational Medicine, Semmelweis University, Budapest, Hungary
- Institute for Translational Medicine, Medical School, University of Pécs, Pécs, Hungary
| | - Ádám Zolcsák
- Centre for Translational Medicine, Semmelweis University, Budapest, Hungary
- Department of Biophysics and Radiation Biology, Semmelweis University, Budapest, Hungary
| | - Dániel Sándor Veres
- Centre for Translational Medicine, Semmelweis University, Budapest, Hungary
- Department of Biophysics and Radiation Biology, Semmelweis University, Budapest, Hungary
| | - Bálint Erőss
- Centre for Translational Medicine, Semmelweis University, Budapest, Hungary
- Institute for Translational Medicine, Medical School, University of Pécs, Pécs, Hungary
- Institute of Pancreatic Diseases, Semmelweis University, Budapest, Hungary
| | - Bálint Gellért
- Centre for Translational Medicine, Semmelweis University, Budapest, Hungary
- Department of Surgery, Transplantation and Gastroenterology, Semmelweis University, Budapest, Hungary
| | - Péter Jenő Hegyi
- Centre for Translational Medicine, Semmelweis University, Budapest, Hungary
- Institute of Pancreatic Diseases, Semmelweis University, Budapest, Hungary
| | - Péter Hegyi
- Centre for Translational Medicine, Semmelweis University, Budapest, Hungary
- Institute for Translational Medicine, Medical School, University of Pécs, Pécs, Hungary
- Institute of Pancreatic Diseases, Semmelweis University, Budapest, Hungary
- Translational Pancreatology Research Group, Interdisciplinary Centre of Excellence for Research Development and Innovation, University of Szeged, Szeged, Hungary
| | - Nándor Faluhelyi
- Centre for Translational Medicine, Semmelweis University, Budapest, Hungary
- Department of Medical Imaging, Medical School, University of Pécs, Pécs, Hungary
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3
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Mao WJ, Zhou J, Zhang GF, Chen FX, Zhang JZ, Li BQ, Ke L, Li WQ. Early systemic anticoagulation reduces hospital readmission in acute necrotizing pancreatitis patients: A retrospective cohort study. Hepatobiliary Pancreat Dis Int 2024; 23:77-82. [PMID: 37087368 DOI: 10.1016/j.hbpd.2023.04.003] [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: 09/03/2022] [Accepted: 04/07/2023] [Indexed: 04/24/2023]
Abstract
BACKGROUND Early systemic anticoagulation (SAC) is a common practice in acute necrotizing pancreatitis (ANP), and its impact on in-hospital clinical outcomes had been assessed. However, whether it affects long-term outcomes is unknown. This study aimed to evaluate the effect of SAC on 90-day readmission and other long-term outcomes in ANP patients. METHODS During January 2013 and December 2018, ANP patients admitted within 7 days from the onset of abdominal pain were screened. The primary outcome was 90-day readmission after discharge. Cox proportional-hazards regression model and mediation analysis were used to define the relationship between early SAC and 90-day readmission. RESULTS A total of 241 ANP patients were enrolled, of whom 143 received early SAC during their hospitalization and 98 did not. Patients who received early SAC experienced a lower incidence of splanchnic venous thrombosis (SVT) [risk ratio (RR) = 0.40, 95% CI: 0.26-0.60, P < 0.01] and lower 90-day readmission with an RR of 0.61 (95% CI: 0.41-0.91, P = 0.02) than those who did not. For the quality of life, patients who received early SAC had a significantly higher score in the subscale of vitality (P = 0.03) while the other subscales were all comparable between the two groups. Multivariable Cox regression model showed that early SAC was an independent protective factor for 90-day readmission after adjusting for potential confounders with a hazard ratio of 0.57 (95% CI: 0.34-0.96, P = 0.04). Mediation analysis showed that SVT mediated 37.0% of the early SAC-90-day readmission causality. CONCLUSIONS The application of early SAC may reduce the risk of 90-day readmission in the survivors of ANP patients, and reduced SVT incidence might be the primary contributor.
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Affiliation(s)
- Wen-Jian Mao
- Department of Critical Care Medicine, Jinling Hospital, Nanjing Medical University, Nanjing 210002, China; Department of Critical Care Medicine, Jinling Hospital, Medical School of Nanjing University, Nanjing 210002, China
| | - Jing Zhou
- Department of Critical Care Medicine, Jinling Hospital, Nanjing Medical University, Nanjing 210002, China; Department of Critical Care Medicine, Jinling Hospital, Medical School of Nanjing University, Nanjing 210002, China
| | - Guo-Fu Zhang
- Department of Critical Care Medicine, Jinling Hospital, Nanjing Medical University, Nanjing 210002, China; Department of Critical Care Medicine, Jinling Hospital, Medical School of Nanjing University, Nanjing 210002, China
| | - Fa-Xi Chen
- Department of Critical Care Medicine, Jinling Hospital, Nanjing Medical University, Nanjing 210002, China; Department of Critical Care Medicine, Jinling Hospital, Medical School of Nanjing University, Nanjing 210002, China
| | - Jing-Zhu Zhang
- Department of Critical Care Medicine, Jinling Hospital, Nanjing Medical University, Nanjing 210002, China
| | - Bai-Qiang Li
- Department of Critical Care Medicine, Jinling Hospital, Nanjing Medical University, Nanjing 210002, China; Department of Critical Care Medicine, Jinling Hospital, Medical School of Nanjing University, Nanjing 210002, China
| | - Lu Ke
- Department of Critical Care Medicine, Jinling Hospital, Nanjing Medical University, Nanjing 210002, China; Department of Critical Care Medicine, Jinling Hospital, Medical School of Nanjing University, Nanjing 210002, China; National Institute of Healthcare Data Science, Nanjing University, Nanjing 210010, China
| | - Wei-Qin Li
- Department of Critical Care Medicine, Jinling Hospital, Nanjing Medical University, Nanjing 210002, China; Department of Critical Care Medicine, Jinling Hospital, Medical School of Nanjing University, Nanjing 210002, China; National Institute of Healthcare Data Science, Nanjing University, Nanjing 210010, China.
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4
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Liu J, Gong H, Chen X, Tang C, Huang L. A narrative review of acute pancreatitis-induced splanchnic vein thrombosis: from pathogenesis to clinical management. Scand J Gastroenterol 2024; 59:204-212. [PMID: 37933195 DOI: 10.1080/00365521.2023.2271111] [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: 09/16/2023] [Accepted: 10/11/2023] [Indexed: 11/08/2023]
Abstract
Acute pancreatitis-induced splanchnic vein thrombosis (APISVT) is an important sequela complication of acute pancreatitis, which may cause poor prognosis, such as severe gastrointestinal hemorrhage, bowel ischemic necrosis and liver failure. However, its mechanism remains uncertain, and there is not a general consensus on the management. In this study, we reviewed the latest academic publications in APISVT, and discussed its pathogenesis, clinical presentation, adverse outcome and treatment, especially focused on the role of anticoagulant therapy. It was indicated that anticoagulation therapy can significantly elevate thrombus recanalization and reduce the incidence of complications and mortality with no increase of bleeding. Actually, as most of these studies were retrospective analyses and prospective studies included small samples, the conclusion remains controversial. Thus, well-designed randomized controlled trials are urged to verify the effectiveness and safety of anticoagulation therapy for APISVT.
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Affiliation(s)
- Jiaping Liu
- Department of Gastroenterology, West China Hospital, Sichuan University, Chengdu, China
- Laboratory of Gastroenterology and Hepatology, State Key Laboratory of Biotherapy, West China Hospital, Sichuan University, Chengdu, China
| | - Hui Gong
- Department of Gastroenterology, West China Hospital, Sichuan University, Chengdu, China
| | - Xiaohua Chen
- Central Department of Transportation, West China Hospital, Sichuan University, Chengdu, China
| | - Chengwei Tang
- Department of Gastroenterology, West China Hospital, Sichuan University, Chengdu, China
- Laboratory of Gastroenterology and Hepatology, State Key Laboratory of Biotherapy, West China Hospital, Sichuan University, Chengdu, China
| | - Libin Huang
- Department of Gastroenterology, West China Hospital, Sichuan University, Chengdu, China
- Laboratory of Gastroenterology and Hepatology, State Key Laboratory of Biotherapy, West China Hospital, Sichuan University, Chengdu, China
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5
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Wilson TM, Daneshmand A, Parys S, Watanabe Y. Splanchnic vein thrombosis in acute pancreatitis: a review of treatment indications, methods, and outcomes in a single institution. ANZ J Surg 2023; 93:2487-2491. [PMID: 36994906 DOI: 10.1111/ans.18442] [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: 09/05/2022] [Revised: 02/28/2023] [Accepted: 03/17/2023] [Indexed: 03/31/2023]
Abstract
BACKGROUND Splanchnic vein thrombosis (SVT) is a well-recognized complication of acute pancreatitis. The question of whether or not to treat SVT with systemic therapeutic anticoagulation (STA) remains to be seen. The universal use of anticoagulation may lead to an increased risk of bleeding complications associated with acute pancreatitis. Literature on this subject is sparse and there is no clear guideline on how to treat SVT. Our research demonstrates local practice where therapeutic anticoagulation in SVT varies. METHODS A retrospective review of patients presenting with acute pancreatitis admitted over a five-year period to a single tertiary hospital with splanchnic vein thrombosis was performed. RESULTS Of the 1408 patients admitted with acute pancreatitis, 42 were diagnosed with splanchnic vein thrombosis, with a male dominance of 34 (81%). A total of 25 patients received anticoagulation. The use of anticoagulation was dependent on the location of the thrombus, P < 0.01. Anticoagulation use was most common in cases of combination mesenteric, splenic, and portal vein thrombus (100%), isolated mesenteric vein (100%), isolated portal vein (89%), combination portal and splenic vein (87%), and combination mesenteric and splenic vein (75%). The rate of anticoagulation use was lowest in isolated splenic vein thrombus (23%). CONCLUSION The early commencement of STA in patients with acute pancreatitis and triple-vessel SVT or with portal vein involvement is supported by our data. Isolated splenic vein thrombus does not require systemic therapy. Further research is needed to establish a clear clinical guideline.
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Affiliation(s)
- Tamalee M Wilson
- General Surgery Unit, Royal Perth Hospital WA, Perth, Western Australia, Australia
| | - Ali Daneshmand
- General Surgery Unit, Royal Perth Hospital WA, Perth, Western Australia, Australia
| | - Simon Parys
- General Surgery Unit, Armadale Health Service WA, Perth, Western Australia, Australia
| | - Yuki Watanabe
- General Surgery Unit, Royal Perth Hospital WA, Perth, Western Australia, Australia
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6
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Zhang Z, Gao L, Liu Z, Li G, Ye B, Zhou J, Ke L, Tong Z, Li W. Catheter-directed thrombolysis versus systemic anticoagulation in the treatment of symptomatic splanchnic venous thrombosis secondary to acute pancreatitis: a retrospective cohort study. BMC Surg 2023; 23:199. [PMID: 37438694 DOI: 10.1186/s12893-023-02046-y] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/15/2022] [Accepted: 05/13/2023] [Indexed: 07/14/2023] Open
Abstract
BACKGROUND Catheter-directed thrombolysis (CDT) has been an important therapy and seems effective in patients with splanchnic venous thrombosis (SVT) secondary to some diseases, but this intervention hasn't been formally evaluated in the setting of acute pancreatitis (AP). METHODS This was a retrospective study enrolled patients between January 2013 and December 2018. AP patients who developed SVT-induced symptoms, including intractable ascites and/or enteral nutrition intolerance, were included. Demographics, SVT associated parameters, clinical features and outcomes, long-term quality of life evaluated by using SF-36 questionnaire were compared between CDT group and systemic anticoagulation (SAC) group. RESULTS 6 patients underwent CDT and 17 received SAC. Patients in CDT group had a higher recanalization rate (100% versus 35.3%; p = 0.014) and shorter time to symptoms resolution (median 8 days versus. 31.5 days, p = 0.004). Mortality and length of hospital stay were comparable between two groups. The association analysis indicated that CDT use exerted a significantly beneficial effect on recanalization rate (risk ratio, 2.833; 95% CI, 1.489 to 5.393; p = 0.002) and time to symptoms resolution (mean difference, -33.333; 95% CI, -64.612 to -2.055; p = 0.038). No SVT-related symptoms recurrence was recorded in survivors at six-month follow-up. There was no statistical difference in either item of SF-36 questionnaire between two groups. CONCLUSIONS Compared with SAC, CDT may facilitate vascular recanalization and shorten symptom resolution for symptomatic SVT.
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Affiliation(s)
- Zongwen Zhang
- Center of Severe Acute Pancreatitis (CSAP), Department of Critical Care Medicine, Jinling Hospital, Affiliated Hospital of Medical School, Nanjing University, Nanjing, Jiangsu, China
| | - Lin Gao
- Center of Severe Acute Pancreatitis (CSAP), Department of Critical Care Medicine, Jinling Hospital, Affiliated Hospital of Medical School, Nanjing University, Nanjing, Jiangsu, China
| | - Zirui Liu
- Center of Severe Acute Pancreatitis (CSAP), Department of Critical Care Medicine, Jinling Hospital, Affiliated Hospital of Medical School, Nanjing University, Nanjing, Jiangsu, China
| | - Gang Li
- Center of Severe Acute Pancreatitis (CSAP), Department of Critical Care Medicine, Jinling Hospital, Affiliated Hospital of Medical School, Nanjing University, Nanjing, Jiangsu, China
| | - Bo Ye
- Center of Severe Acute Pancreatitis (CSAP), Department of Critical Care Medicine, Jinling Hospital, Affiliated Hospital of Medical School, Nanjing University, Nanjing, Jiangsu, China
| | - Jing Zhou
- Center of Severe Acute Pancreatitis (CSAP), Department of Critical Care Medicine, Jinling Hospital, Affiliated Hospital of Medical School, Nanjing University, Nanjing, Jiangsu, China.
- Center of Severe Acute Pancreatitis (CSAP), Department of Critical Care Medicine, Jinling Hospital, Nanjing Medical University, Nanjing, Jiangsu, China.
| | - Lu Ke
- Center of Severe Acute Pancreatitis (CSAP), Department of Critical Care Medicine, Jinling Hospital, Affiliated Hospital of Medical School, Nanjing University, Nanjing, Jiangsu, China
- National Institute of Healthcare Data Science, Nanjing University, Nanjing, Jiangsu, China
| | - Zhihui Tong
- Center of Severe Acute Pancreatitis (CSAP), Department of Critical Care Medicine, Jinling Hospital, Affiliated Hospital of Medical School, Nanjing University, Nanjing, Jiangsu, China.
| | - Weiqin Li
- Center of Severe Acute Pancreatitis (CSAP), Department of Critical Care Medicine, Jinling Hospital, Affiliated Hospital of Medical School, Nanjing University, Nanjing, Jiangsu, China
- National Institute of Healthcare Data Science, Nanjing University, Nanjing, Jiangsu, China
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7
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Füssel LM, Müller-Wille R, Dinkhauser P, Schauer W, Hofer H. Treatment of colonic varices and gastrointestinal bleeding by recanalization and stenting of splenic-vein-thrombosis: A case report and literature review. World J Gastroenterol 2023; 29:3922-3931. [PMID: 37426315 PMCID: PMC10324528 DOI: 10.3748/wjg.v29.i24.3922] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/01/2023] [Revised: 04/27/2023] [Accepted: 05/30/2023] [Indexed: 06/28/2023] Open
Abstract
BACKGROUND Splenic vein thrombosis is a known complication of pancreatitis. It can lead to increased blood flow through mesenteric collaterals. This segmental hypertension may result in the development of colonic varices (CV) with a high risk of severe gastrointestinal bleeding. While clear guidelines for treatment are lacking, splenectomy or splenic artery embolization are often used to treat bleeding. Splenic vein stenting has been shown to be a safe option.
CASE SUMMARY A 45-year-old female patient was admitted due to recurrent gastrointestinal bleeding. She was anemic with a hemoglobin of 8.0 g/dL. As a source of bleeding, CV were identified. Computed tomography scans revealed thrombotic occlusion of the splenic vein, presumably as a result of a severe acute pancreatitis 8 years prior. In a selective angiography, a dilated mesenterial collateral leading from the spleen to enlarged vessels in the right colonic flexure and draining into the superior mesenteric vein could be confirmed. The hepatic venous pressure gradient was within normal range. In an interdisciplinary board, transhepatic recanalization of the splenic vein via balloon dilatation and consecutive stenting, as well as coiling of the aberrant veins was discussed and successfully performed. Consecutive evaluation revealed complete regression of CV and splenomegaly as well as normalization of the red blood cell count during follow-up.
CONCLUSION Recanalization and stenting of splenic vein thrombosis might be considered in patients with gastrointestinal bleeding due to CV. However, a multidisciplinary approach with a thorough workup and discussion of individualized therapeutic strategies is crucial in these difficult to treat patients.
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Affiliation(s)
- Lisa-Michaela Füssel
- Department of Internal Medicine I, Gastroenterology and Hepatology, Klinikum Wels-Grieskirchen, Wels 4600, Austria
| | - Rene Müller-Wille
- Department of Radiology, Klinikum Wels-Grieskirchen, Wels 4600, Austria
| | - Patrick Dinkhauser
- Department of Internal Medicine I, Gastroenterology and Hepatology, Klinikum Wels-Grieskirchen, Wels 4600, Austria
| | - Walter Schauer
- Department of Abdominal Surgery, Klinikum Wels-Grieskirchen, Wels 4600, Austria
| | - Harald Hofer
- Department of Internal Medicine I, Gastroenterology and Hepatology, Klinikum Wels-Grieskirchen, Wels 4600, Austria
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8
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Yin Y, Wang L, Gao F, Liu L, Qi X. Anticoagulation Therapy for Splanchnic Vein Thrombosis Associated With Acute Pancreatitis: A Systematic Review and Meta-Analysis. Clin Appl Thromb Hemost 2023; 29:10760296231188718. [PMID: 37461391 DOI: 10.1177/10760296231188718] [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] [Indexed: 07/20/2023] Open
Abstract
Splanchnic vein thrombosis (SVT) is not rare in patients with acute pancreatitis. It remains unclear about whether anticoagulation should be given for acute pancreatitis-associated SVT. The PubMed, EMBASE, and Cochrane Library databases were searched. Rates of SVT recanalization, any bleeding, death, intestinal ischemia, portal cavernoma, and gastroesophageal varices were pooled and compared between patients with acute pancreatitis-associated SVT who received and did not receive therapeutic anticoagulation. Pooled rates and risk ratios (RRs) with 95% confidence intervals (CIs) were calculated. Heterogeneity among studies was evaluated. Overall, 16 studies including 698 patients with acute pancreatitis-associated SVT were eligible. After therapeutic anticoagulation, the pooled rates of SVT recanalization, any bleeding, death, intestinal ischemia, portal cavernoma, and gastroesophageal varices were 44.3% (95%CI = 32.3%-56.6%), 10.7% (95%CI = 4.9%-18.5%), 13.3% (95%CI = 6.9%-21.4%), 16.8% (95%CI = 6.9%-29.9%), 21.2% (95%CI = 7.5%-39.5%), and 29.1% (95%CI = 16.1%-44.1%), respectively. Anticoagulation therapy significantly increased the rate of SVT recanalization (RR = 1.69; 95%CI = 1.29-2.19; P < .01), and marginally increased the risk of bleeding (RR = 1.98; 95%CI = 0.93-4.22; P = .07). The rates of death (RR = 1.42; 95%CI = 0.62-3.25; P = .40), intestinal ischemia (RR = 2.55; 95%CI = 0.23-28.16; P = .45), portal cavernoma (RR = 0.51; 95%CI = 0.21-1.22; P = .13), and gastroesophageal varices (RR = 0.71; 95%CI = 0.38-1.32; P = .28) were not significantly different between patients who received and did not receive anticoagulation therapy. Heterogeneity was statistically significant in the meta-analysis of intestinal ischemia, but not in those of SVT recanalization, any bleeding, death, portal cavernoma, or gastroesophageal varices. Anticoagulation may be effective for recanalization of acute pancreatitis-associated SVT, but cannot improve the survival. Randomized controlled trials are warranted to further investigate the clinical significance of anticoagulation therapy in such patients.
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Affiliation(s)
- Yuhang Yin
- Meta-Analysis Interest Group & Department of Gastroenterology, General Hospital of Northern Theater Command, Shenyang, China
- Postgraduate College, China Medical University, Shenyang, China
| | - Le Wang
- Meta-Analysis Interest Group & Department of Gastroenterology, General Hospital of Northern Theater Command, Shenyang, China
- Postgraduate College, China Medical University, Shenyang, China
| | - Fangbo Gao
- Meta-Analysis Interest Group & Department of Gastroenterology, General Hospital of Northern Theater Command, Shenyang, China
- Department of Life Sciences and Biopharmaceutics, Shenyang Pharmaceutical University, Shenyang, China
| | - Lei Liu
- Department of Digestive Diseases, Daping Hospital, Army Medical University, Chongqing, China
| | - Xingshun Qi
- Meta-Analysis Interest Group & Department of Gastroenterology, General Hospital of Northern Theater Command, Shenyang, China
- Postgraduate College, China Medical University, Shenyang, China
- Department of Life Sciences and Biopharmaceutics, Shenyang Pharmaceutical University, Shenyang, China
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9
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Abstract
Importance For decades, infected or symptomatic pancreatic necrosis was managed by open surgical necrosectomy, an approach that has now been largely supplanted by an array of techniques referred to as the step-up approach. Observations This review describes the evidence base behind the step-up approach, when to use the different techniques, and their technical basics. The most common treatment strategies are included: percutaneous drainage, video-assisted retroperitoneal debridement, sinus tract endoscopy, endoscopic transgastric necrosectomy, and surgical transgastric necrosectomy. Also included is the evidence base around management of common complications that can occur during step-up management, such as hemorrhage, intestinal fistula, and thrombosis, in addition to associated issues that can arise during step-up management, such as the need for cholecystectomy and disconnected pancreatic duct syndrome. Conclusions and Relevance The treatment strategies highlighted in this review are those most commonly used during step-up management, and this review is designed as a guide to the evidence base underlying these strategies, as surgeons tailor their therapeutic approach to individual patients.
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Affiliation(s)
- Lydia R Maurer
- Department of Surgery, Massachusetts General Hospital, Boston
| | - Peter J Fagenholz
- Division of Trauma, Emergency Surgery, and Surgical Critical Care, Massachusetts General Hospital, Boston
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10
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Jaber S, Garnier M, Asehnoune K, Bounes F, Buscail L, Chevaux JB, Dahyot-Fizelier C, Darrivere L, Jabaudon M, Joannes-Boyau O, Launey Y, Levesque E, Levy P, Montravers P, Muller L, Rimmelé T, Roger C, Savoye-Collet C, Seguin P, Tasu JP, Thibault R, Vanbiervliet G, Weiss E, Jong AD. Pancréatite aiguë grave du patient adulte en soins critiques 2021. ANESTHÉSIE & RÉANIMATION 2022. [DOI: 10.1016/j.anrea.2022.10.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
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11
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Kalas MA, Leon M, Chavez LO, Canalizo E, Surani S. Vascular complications of pancreatitis. World J Clin Cases 2022; 10:7665-7673. [PMID: 36158481 PMCID: PMC9372863 DOI: 10.12998/wjcc.v10.i22.7665] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/26/2022] [Revised: 05/01/2022] [Accepted: 06/30/2022] [Indexed: 02/06/2023] Open
Abstract
More than 200000 hospital admissions happen per year for acute pancreatitis and more than 50000 for chronic pancreatitis in the United States of America. Necrotizing pancreatitis accounts for 20%-30% of the cases. One-quarter of the patients with pancreatitis develop vascular complications, which carries a high mortality. This mini-review will address these complications that can help primary care physicians and hospitalists in managing their patients effectively.
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Affiliation(s)
- M Ammar Kalas
- Department of Medicine, Texas Tech University Health Center, El Paso, TX 79905, United States
| | - Monica Leon
- Department of General Surgery, Centro Medico ABC, Ciudad de Mexico 01120, Mexico
| | - Luis Omar Chavez
- Department of Medicine, Texas Tech University Health Center, El Paso, TX 79905, United States
| | - Eduardo Canalizo
- Department of General Surgery, Centro Medico ABC, Ciudad de Mexico 01120, Mexico
| | - Salim Surani
- Department of Medicine, Texas A&M University, Bryan, TX 77807, United States
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12
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Yang J, Tang X, Wu Q, Ren P, Yan Y, Liu W, Pan C. Heparin Protects Severe Acute Pancreatitis by Inhibiting HMGB-1 Active Secretion from Macrophages. Polymers (Basel) 2022; 14:polym14122470. [PMID: 35746047 PMCID: PMC9227308 DOI: 10.3390/polym14122470] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/19/2022] [Revised: 06/10/2022] [Accepted: 06/15/2022] [Indexed: 12/01/2022] Open
Abstract
Heparin has shown benefits in severe acute pancreatitis (SAP) therapy, but the underlying mechanisms were unknown. Extracellular high-mobility group protein-1 (HMGB-1) has been regarded as a central mediator contributing to inflammation exacerbation and disease aggravation. We hypothesized heparin attenuated the disease by targeting HMGB-1-related pathways. In the present study, the possible therapeutic roles of heparin and its non-anticoagulant derivatives, 6-O-desulfulted heparin and N-acylated-heparin, were determined on mouse models induced by “Two-Hit” of L-arginine. The compounds exhibited potent efficiency by substantially decreasing the pancreatic necrosis, macrophage infiltration, and serum inflammatory cytokine (IL-6 and TNF-α) concentration. Moreover, they greatly reduced the rapidly increasing extracellular HMGB-1 levels in the L-arginine injured pancreases. As a result, multiple organ failure and mortality of the mice were inhibited. Furthermore, the drugs were incubated with the RAW264.7 cells activated with damaged pancreatic tissue of SAP mice in vitro. They were found to inhibit HMGB-1 transfer from the nucleus to the plasma, a critical step during HMGB-1 active secretion from macrophages. The results were carefully re-examined with a caerulein and LPS induced mouse model, and similar results were found. The paper demonstrated heparin alleviated SAP independent of the anti-coagulant functions. Therefore, non-anticoagulant heparin derivatives might become promising approaches to treat patients suffering from SAP.
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Affiliation(s)
- Jing Yang
- School of Life Sciences and Health Engineering, Jiangnan University, Wuxi 214122, China; (J.Y.); (X.T.); (Q.W.); (P.R.)
| | - Xujiao Tang
- School of Life Sciences and Health Engineering, Jiangnan University, Wuxi 214122, China; (J.Y.); (X.T.); (Q.W.); (P.R.)
| | - Qingqing Wu
- School of Life Sciences and Health Engineering, Jiangnan University, Wuxi 214122, China; (J.Y.); (X.T.); (Q.W.); (P.R.)
| | - Panpan Ren
- School of Life Sciences and Health Engineering, Jiangnan University, Wuxi 214122, China; (J.Y.); (X.T.); (Q.W.); (P.R.)
| | - Yishu Yan
- School of Life Sciences and Health Engineering, Jiangnan University, Wuxi 214122, China; (J.Y.); (X.T.); (Q.W.); (P.R.)
- Correspondence:
| | - Wei Liu
- Jiangsu Key Laboratory of Druggability of Biopharmaceuticals, State Key Laboratory of Natural Medicines, School of Life Science and Technology, China Pharmaceutical University, Nanjing 210009, China;
| | - Chun Pan
- Department of Critical Care Medicine, Zhongda Hospital, Southeast University, Nanjing 210009, China;
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13
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Jaber S, Garnier M, Asehnoune K, Bounes F, Buscail L, Chevaux JB, Dahyot-Fizelier C, Darrivere L, Jabaudon M, Joannes-Boyau O, Launey Y, Levesque E, Levy P, Montravers P, Muller L, Rimmelé T, Roger C, Savoye-Collet C, Seguin P, Tasu JP, Thibault R, Vanbiervliet G, Weiss E, De Jong A. Guidelines for the management of patients with severe acute pancreatitis, 2021. Anaesth Crit Care Pain Med 2022; 41:101060. [PMID: 35636304 DOI: 10.1016/j.accpm.2022.101060] [Citation(s) in RCA: 34] [Impact Index Per Article: 17.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/27/2023]
Abstract
OBJECTIVE To provide guidelines for the management of the intensive care patient with severe acute pancreatitis. DESIGN A consensus committee of 22 experts was convened. A formal conflict-of-interest (COI) policy was developed at the beginning of the process and enforced throughout. The entire guideline construction process was conducted independently of any industrial funding (i.e. pharmaceutical, medical devices). The authors were required to follow the rules of the Grading of Recommendations Assessment, Development and Evaluation (GRADE®) system to guide assessment of quality of evidence. The potential drawbacks of making strong recommendations in the presence of low-quality evidence were emphasised. METHODS The most recent SFAR and SNFGE guidelines on the management of the patient with severe pancreatitis were published in 2001. The literature now is sufficient for an update. The committee studied 14 questions within 3 fields. Each question was formulated in a PICO (Patients Intervention Comparison Outcome) format and the relevant evidence profiles were produced. The literature review and recommendations were made according to the GRADE® methodology. RESULTS The experts' synthesis work and their application of the GRADE® method resulted in 24 recommendations. Among the formalised recommendations, 8 have high levels of evidence (GRADE 1+/-) and 12 have moderate levels of evidence (GRADE 2+/-). For 4 recommendations, the GRADE method could not be applied, resulting in expert opinions. Four questions did not find any response in the literature. After one round of scoring, strong agreement was reached for all the recommendations. CONCLUSIONS There was strong agreement among experts for 24 recommendations to improve practices for the management of intensive care patients with severe acute pancreatitis.
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Affiliation(s)
- Samir Jaber
- Department of Anaesthesiology and Intensive Care (DAR B), University Hospital Center Saint Eloi Hospital, Montpellier, France; PhyMedExp, Montpellier University, INSERM, CNRS, CHU de Montpellier, Montpellier, France.
| | - Marc Garnier
- Sorbonne Université, GRC 29, DMU DREAM, Service d'Anesthésie-Réanimation et Médecine Périopératoire Rive Droite, Paris, France
| | - Karim Asehnoune
- Service d'Anesthésie, Réanimation chirurgicale, Hôtel Dieu/HME, CHU Nantes, Nantes cedex 1, France; Inserm, UMR 1064 CR2TI, team 6, France
| | - Fanny Bounes
- Toulouse University Hospital, Anaesthesia Critical Care and Perioperative Medicine Department, Toulouse, France; Équipe INSERM Pr Payrastre, I2MC, Université Paul Sabatier Toulouse III, Toulouse, France
| | - Louis Buscail
- Department of Gastroenterology & Pancreatology, University of Toulouse, Rangueil Hospital, Toulouse, France
| | | | - Claire Dahyot-Fizelier
- Anaesthesiology and Intensive Care Department, University hospital of Poitiers, Poitiers, France; INSERM U1070, University of Poitiers, Poitiers, France
| | - Lucie Darrivere
- Department of Anaesthesia and Critical Care Medicine, AP-HP, Hôpital Lariboisière, F-75010, Paris, France
| | - Matthieu Jabaudon
- Department of Perioperative Medicine, CHU Clermont-Ferrand, Clermont-Ferrand, France; iGReD, Université Clermont Auvergne, CNRS, INSERM, Clermont-Ferrand, France
| | - Olivier Joannes-Boyau
- Service d'Anesthésie-Réanimation SUD, CHU de Bordeaux, Hôpital Magellan, Bordeaux, France
| | - Yoann Launey
- Critical Care Unit, Department of Anaesthesia, Critical Care and Perioperative Medicine, University Hospital of Rennes, Rennes, France
| | - Eric Levesque
- Department of Anaesthesia and Surgical Intensive Care, AP-HP, Henri Mondor Hospital, Créteil, France; Université Paris-Est Creteil, EnvA, DYNAMiC, Faculté de Santé de Créteil, Creteil, France
| | - Philippe Levy
- Service de Pancréatologie et d'Oncologie Digestive, DMU DIGEST, Université de Paris, Hôpital Beaujon, APHP, Clichy, France
| | - Philippe Montravers
- Université de Paris Cité, INSERM UMR 1152 - PHERE, Paris, France; Département d'Anesthésie-Réanimation, APHP, CHU Bichat-Claude Bernard, DMU PARABOL, APHP, Paris, France
| | - Laurent Muller
- Réanimations et surveillance continue, Pôle Anesthésie Réanimation Douleur Urgences, CHU Nîmes Caremeau, Montpellier, France
| | - Thomas Rimmelé
- Département d'anesthésie-réanimation, Hôpital Édouard Herriot, Hospices Civils de Lyon, Lyon, France; EA 7426: Pathophysiology of Injury-induced Immunosuppression, Pi3, Hospices Civils de Lyon-Biomérieux-Université Claude Bernard Lyon 1, Lyon, France
| | - Claire Roger
- Réanimations et surveillance continue, Pôle Anesthésie Réanimation Douleur Urgences, CHU Nîmes Caremeau, Montpellier, France; Department of Intensive care medicine, Division of Anaesthesiology, Intensive Care, Pain and Emergency Medicine, Nîmes University Hospital, Nîmes, France
| | - Céline Savoye-Collet
- Department of Radiology, Normandie University, UNIROUEN, Quantif-LITIS EA 4108, Rouen University Hospital-Charles Nicolle, Rouen, France
| | - Philippe Seguin
- Service d'Anesthésie Réanimation 1, Réanimation chirurgicale, CHU de Rennes, Rennes, France
| | - Jean-Pierre Tasu
- Service de radiologie diagnostique et interventionnelle, CHU de Poitiers, Poitiers, France; LaTim, UBO and INSERM 1101, University of Brest, Brest, France
| | - Ronan Thibault
- Service Endocrinologie-Diabétologie-Nutrition, CHU Rennes, INRAE, INSERM, Univ Rennes, NuMeCan, Nutrition Metabolisms Cancer, Rennes, France
| | - Geoffroy Vanbiervliet
- Department of Digestive Endoscopy, Centre Hospitalier Universitaire de Nice, Nice, France
| | - Emmanuel Weiss
- Department of Anaesthesiology and Critical Care, Beaujon Hospital, DMU Parabol, AP-HP.Nord, Clichy, France; University of Paris, Paris, France; Inserm UMR_S1149, Centre for Research on Inflammation, Paris, France
| | - Audrey De Jong
- Department of Anaesthesiology and Intensive Care (DAR B), University Hospital Center Saint Eloi Hospital, Montpellier, France; PhyMedExp, Montpellier University, INSERM, CNRS, CHU de Montpellier, Montpellier, France
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14
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Abi-Saleh SP, Miller EA, Magge A, Perez M. Necrotizing Pancreatitis: To Anticoagulate or Not to Anticoagulate? Cureus 2022; 14:e23267. [PMID: 35449612 PMCID: PMC9012552 DOI: 10.7759/cureus.23267] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/16/2022] [Indexed: 11/25/2022] Open
Abstract
Necrotizing pancreatitis is an inflammatory process that poses a strong risk of systemic venous thromboembolism. However, it is often challenging to opt for systemic anticoagulation since the disease is also associated with an increased risk of hemorrhage. Given these opposing complications, a risk versus benefit analysis has to be employed in the management of necrotizing pancreatitis on a case-by-case basis. We discuss a case where the team was faced with a dilemma regarding anticoagulation in a patient with newly developed atrial fibrillation in the setting of necrotizing pancreatitis. We found that there is a lack of guidelines that address the time of initiation and the type of systemic anticoagulation that should be administered in such patients.
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15
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Anis FS, Adiamah A, Lobo DN, Sanyal S. Incidence and treatment of splanchnic vein thrombosis in patients with acute pancreatitis: A systematic review and meta-analysis. J Gastroenterol Hepatol 2022; 37:446-454. [PMID: 34657310 DOI: 10.1111/jgh.15711] [Citation(s) in RCA: 13] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/26/2021] [Revised: 08/17/2021] [Accepted: 10/02/2021] [Indexed: 12/20/2022]
Abstract
BACKGROUND AND AIM This meta-analysis aimed to estimate the incidence of splanchnic vein thrombosis (SVT) in patients with acute pancreatitis and assess the effects of therapeutic anticoagulation. METHODS Systematic searches of the Medline, Embase, and Cochrane databases were undertaken to identify studies reporting the incidence and outcomes associated with SVT in patients with acute pancreatitis. The pooled incidence, odds ratios (ORs) and 95% confidence intervals (CIs) were calculated using a random effects model. PROSPERO database registration no. CRD 42021230912. RESULTS Only 18 of the 238 studies identified met the inclusion criteria. Of the 943 patients who had SVT, 264 (28.0%) received anticoagulation. The pooled incidence of SVT at first presentation of acute pancreatitis was 15% (95% CI 5 to 26%), but was 17% (95% CI 14 to 20%) in all studies. Recanalization was more likely to occur in the anticoagulation-treated than in the untreated group (OR 0.51, 95% CI 0.31 to 0.83, P = 0.007). There were no differences in hemorrhagic complications (OR 2.27, 95% CI 0.81 to 6.37, P = 0.12) or overall mortality (OR 2.37, 95% CI 0.86 to 6.52, P = 0.10) in relation to the use of anticoagulation. The overall incidence of portal hypertension in patients was 60% (95% CI 55 to 65%). However, it was not possible to determine the incidence in each group. CONCLUSIONS The incidence of SVT in patients with acute pancreatitis is significant. Treatment with anticoagulants improved the odds of recanalization but did not increase the risk of hemorrhagic complications or overall mortality.
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Affiliation(s)
- Fady S Anis
- Gastrointestinal Surgery, Nottingham Digestive Diseases Centre and National Institute for Health Research Nottingham Biomedical Research Centre, Nottingham University Hospitals NHS Trust and University of Nottingham, Queen's Medical Centre, Nottingham, UK
| | - Alfred Adiamah
- Gastrointestinal Surgery, Nottingham Digestive Diseases Centre and National Institute for Health Research Nottingham Biomedical Research Centre, Nottingham University Hospitals NHS Trust and University of Nottingham, Queen's Medical Centre, Nottingham, UK
| | - Dileep N Lobo
- Gastrointestinal Surgery, Nottingham Digestive Diseases Centre and National Institute for Health Research Nottingham Biomedical Research Centre, Nottingham University Hospitals NHS Trust and University of Nottingham, Queen's Medical Centre, Nottingham, UK
- MRC Versus Arthritis Centre for Musculoskeletal Ageing Research, School of Life Sciences, University of Nottingham, Queen's Medical Centre, Nottingham, UK
| | - Sudip Sanyal
- Gastrointestinal Surgery, Nottingham Digestive Diseases Centre and National Institute for Health Research Nottingham Biomedical Research Centre, Nottingham University Hospitals NHS Trust and University of Nottingham, Queen's Medical Centre, Nottingham, UK
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16
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Chandan S, Buddam A, Khan SR, Mohan BP, Ramai D, Bilal M, Dhindsa B, Bhogal N, Kassab LL, Goyal H, Perisetti A, Facciorusso A, Adler DG. Use of therapeutic anticoagulation in splanchnic vein thrombosis associated with acute pancreatitis: a systematic review and meta-analysis. Ann Gastroenterol 2021; 34:862-871. [PMID: 34815653 PMCID: PMC8596205 DOI: 10.20524/aog.2021.0661] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/22/2021] [Accepted: 04/26/2021] [Indexed: 12/11/2022] Open
Abstract
Background Splanchnic vein thrombosis is a well-recognized local vascular complication of acute pancreatitis (AP), estimated to occur in approximately 15% of patients. While splanchnic vein recanalization occurs spontaneously in approximately one third of patients, severe complications such as bowel ischemia and liver failure have also been reported. At present, there is no consensus on whether patients presenting with AP-associated splanchnic vein thrombosis should receive therapeutic anticoagulation. Methods We searched multiple databases from inception through December 2020 to collect studies that compared the clinical outcomes of patients with AP and splanchnic vein thrombosis who received therapeutic anticoagulation (AC group) with those who did not (N-AC group). A meta-analysis was performed to calculate the relative risk (RR) of vessel recanalization, bleeding complications, collateral formation and death in the 2 groups. Results Seven studies with 8353 patients, 339 of whom had splanchnic vein thrombosis, were included in the final analysis. A total of 154 patients (45.4%) had acute severe pancreatitis. A significantly higher proportion of patients had vessel recanalization in the AC group: RR 1.6, 95% confidence interval 1.17-2.27; I2=0%; P=0.004. There was no difference between the 2 groups in the RR of bleeding complications, collateral formation and death. Conclusions Our analysis demonstrated that, among patients with AP-associated splanchnic vein thrombosis, therapeutic anticoagulation resulted in recanalization of the involved vessels without significantly increasing the risk of bleeding complications. There was no difference in the RR of death or the rates of collateral vessel formation during the follow up.
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Affiliation(s)
- Saurabh Chandan
- Division of Gastroenterology & Hepatology, CHI Creighton University Medical Center, Omaha, Nebraska, USA (Saurabh Chandan, Avanija Buddam)
| | - Avanija Buddam
- Division of Gastroenterology & Hepatology, CHI Creighton University Medical Center, Omaha, Nebraska, USA (Saurabh Chandan, Avanija Buddam)
| | - Shahab R Khan
- Department of Medicine, Brigham & Women's Hospital, Harvard Medical School, Boston, Massachusetts, USA (Shahab R. Khan)
| | - Babu P Mohan
- Division of Gastroenterology and Hepatology, University of Utah School of Medicine, Salt Lake City, Utah, USA (Babu P. Mohan, Douglas G. Adler)
| | - Daryl Ramai
- Internal Medicine, Brooklyn Hospital Center, Brooklyn, New York, USA (Daryl Ramai)
| | - Mohammad Bilal
- Division of Gastroenterology, University of Minnesota & Minneapolis VA Health Care System, Minneapolis, Minnesota, USA (Mohammad Bilal)
| | - Banreet Dhindsa
- Gastroenterology & Hepatology, University of Nebraska Medical Center, Omaha, Nebraska, USA (Banreet Dhindsa, Neil Bhogal)
| | - Neil Bhogal
- Gastroenterology & Hepatology, University of Nebraska Medical Center, Omaha, Nebraska, USA (Banreet Dhindsa, Neil Bhogal)
| | - Lena L Kassab
- Internal Medicine, Mayo Clinic, Rochester, Minnesota, USA (Lena L. Kassab)
| | - Hemant Goyal
- Gastroenterology, The Wright Center For Graduate Medical Education, Scranton, Philadelphia, USA (Hemant Goyal)
| | - Abhilash Perisetti
- Gastroenterology & Hepatology, University of Arkansas for Medical Sciences, Little Rock, Arkansas, USA (Abhilash Perisetti)
| | - Antonio Facciorusso
- Gastroenterology Unit, Department of Surgical and Medical Sciences, University of Foggia, Foggia, Italy (Antonio Facciorusso)
| | - Douglas G Adler
- Division of Gastroenterology and Hepatology, University of Utah School of Medicine, Salt Lake City, Utah, USA (Babu P. Mohan, Douglas G. Adler)
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