Biliary versus alcohol-related infected pancreatic necrosis: similarities and differences in the follow-up

Quality of life instruments in acute and chronic pancreatitis: a consensus-based standards for the selection of health measurement instruments (COSMIN) approach

BACKGROUND

Pancreatitis is a common surgical emergency, associated with pain and poor quality of life for patients. However, assessment of patient-reported outcome measures in these patients is unclear. This study aimed to identify and evaluate the methodological quality of the health-related quality of life instruments used for patients with acute or chronic pancreatitis.

METHODS

Prospective studies that evaluated health-related quality of life in acute or chronic pancreatitis were identified from systematic review of MEDLINE, EMBASE, and Web of Science until 28th June 2023 (PROSPERO: CRD42021274743). Instrument characteristics were extracted, and methodological quality assessed using COSMIN (COnsensus-based Standards for the selection of health status Measurement Instruments) guidelines and GRADE approach. Narrative synthesis was conducted, with recommendations for use based on COSMIN criteria, evaluated according to World Health Organisation (WHO) quality of life domains.

RESULTS

From 3850 records screened, 41 quality of life instruments were identified across 138 studies included. The majority (69.8%, n = 26) were designed to assess general health-related quality of life, whereas the remainder were abdominal-specific (n = 5) or pancreas-specific (n = 10). Only ten instruments (24.3%) demonstrated sufficient content validity, incorporating items in ≥5 WHO quality of life domains. However, only nine instruments (21.9%) incorporated public and patient involvement. Only the Gastrointestinal Quality of Life Index and PAN-PROMISE met the criteria to be recommended for use based on COSMIN methodological assessment.

CONCLUSION

There is significant heterogeneity in instruments used to assess quality of life after pancreatitis, with almost all instruments considered insufficient. Robust, validated, and relevant instruments are needed to better understand and determine appropriate interventions to improve quality of life for these patients.

Quality of life after severe acute pancreatitis: systematic review

BACKGROUND

Severe acute pancreatitis, the most severe form of acute pancreatitis, can alter pancreatic morphology, physiology, and function resulting in long-term morbidity, even after a single episode. This review assesses long-term outcomes and quality of life of severe acute pancreatitis.

METHODS

A comprehensive literature review was conducted across MEDLINE, Embase, Scopus, and PubMed electronic databases on 18 January 2021 and updated on 26 April 2022 to ensure no new literature had been omitted. All studies were prospective or retrospective, included adult patients (>18 years) presenting with acute pancreatitis for whom data on long-term outcomes specifically after severe acute pancreatitis were reported. Quantitative and qualitative data extraction and synthesis were carried out and no meta-analysis was performed. Outcome measures included aetiology and mortality of severe acute pancreatitis, length of stay, endocrine and exocrine pancreatic insufficiency, chronic symptoms, and quality of life compared with healthy controls as assessed by validated questionnaires.

RESULTS

Fourteen retrospective cohort studies were included, for a total of 779 patients, using quality of life questionnaires. The most common aetiology of severe acute pancreatitis was biliary (36 per cent) followed by alcoholic (29 per cent). Mortality rate ranged from 5 to 35 per cent and length of stay ranged from 2 to 367 days. Quality of life was somewhat lower in patients with exocrine insufficiency, but unaffected by endocrine insufficiency or chronic symptoms. Quality of life was more likely to be reduced in the first 4 years but normalize thereafter and was more likely to be negatively affected where alcohol was the aetiology. In four studies, the relationship between disease severity and lower quality of life was investigated, and a significant correlation was found.

CONCLUSION

The review shows how a single episode of severe acute pancreatitis can have a variable effect on long-term quality of life, which is different to previous studies showing a strong reduction in quality of life. This could indicate that in current times treatment modalities are more effective.

Quality of life after surgical and endoscopic management of severe acute pancreatitis: A systematic review

BACKGROUND

Treatment for severe acute severe pancreatitis (SAP) can significantly affect Health-related quality of life (HR-QoL). The effects of different treatment strategies such as endoscopic and surgical necrosectomy on HR-QoL in patients with SAP remain poorly investigated.

AIM

To critically appraise the available evidence on HR-QoL following surgical or endoscopic necrosectomy in patient with SAP.

METHODS

A literature search was performed on PubMed, Google™ Scholar, the Cochrane Library, MEDLINE and Reference Citation Analysis databases for studies that investigated HR-QoL following surgical or endoscopic necrosectomy in patients with SAP. Data collected included patient characteristics, outcomes of interventions and HR-QoL-related details.

RESULTS

Eleven studies were found to have evaluated HR-QoL following treatment for severe acute pancreatitis including 756 patients. Three studies were randomized trials, four were prospective cohort studies and four were retrospective cohort studies with prospective follow-up. Four studies compared HR-QoL following surgical and endoscopic necrosectomy. Several metrics of HR-QoL were used including Short Form (SF)-36 and EuroQol. One randomized trial and one cohort study demonstrated significantly improved physical scores at three months in patients who underwent endoscopic necrosectomy compared to surgical necrosectomy. One prospective study that examined HR-QoL following surgical necrosectomy reported some deterioration in the functional status of the patients. On the other hand, a cohort study that assessed the long-term HR-QoL following sequential surgical necrosectomy stated that all patients had SF-36 > 60%. In the only study that examined patients following endoscopic necrosectomy, the HR-QoL was also very good. Three studies investigated the quality adjusted life years suggesting that endoscopic and surgical approaches to management of pancreatic necrosis were comparable in cost effectiveness. Finally, regarding HR-QoL between open necrosectomy and minimally invasive approaches, patients who underwent the later had a significantly better overall quality of life, vitality and mental health.

CONCLUSION

This review would suggest that the endoscopic approach might offer better HR-QoL compared to surgical necrosectomy. However, the available comparative literature was very limited. More randomized trials powered to detect differences in HR-QoL are required.

Exocrine Pancreatic Insufficiency Following Acute Pancreatitis: Systematic Review and Meta-Analysis

BACKGROUND/OBJECTIVES

The epidemiology of exocrine pancreatic insufficiency (EPI) after acute pancreatitis (AP) is uncertain. We sought to determine the prevalence, progression, etiology and pancreatic enzyme replacement therapy (PERT) requirements for EPI during follow-up of AP by systematic review and meta-analysis.

METHODS

Scopus, Medline and Embase were searched for prospective observational studies or randomized clinical trials (RCTs) of PERT reporting EPI during the first admission (between the start of oral refeeding and before discharge) or follow-up (≥ 1 month of discharge) for AP in adults. EPI was diagnosed by direct and/or indirect laboratory exocrine pancreatic function tests.

RESULTS

Quantitative data were analyzed from 370 patients studied during admission (10 studies) and 1795 patients during follow-up (39 studies). The pooled prevalence of EPI during admission was 62% (95% confidence interval: 39-82%), decreasing significantly during follow-up to 35% (27-43%; risk difference: - 0.34, - 0.53 to - 0.14). There was a two-fold increase in the prevalence of EPI with severe compared with mild AP, and it was higher in patients with pancreatic necrosis and those with an alcohol etiology. The prevalence decreased during recovery, but persisted in a third of patients. There was no statistically significant difference between EPI and new-onset pre-diabetes/diabetes (risk difference: 0.8, 0.7-1.1, P = 0.33) in studies reporting both. Sensitivity analysis showed fecal elastase-1 assay detected significantly fewer patients with EPI than other tests.

CONCLUSIONS

The prevalence of EPI during admission and follow-up is substantial in patients with a first attack of AP. Unanswered questions remain about the way this is managed, and further RCTs are indicated.

Pancreatic exocrine insufficiency following acute pancreatitis: Systematic review and study level meta-analysis

OBJECTIVES

This study systematically explores the prevalence of pancreatic exocrine insufficiency (PEI) after acute pancreatitis in different subgroups of etiology (biliary/alcoholic/other), disease severity and follow-up time (<12, 12-36 and > 36 months after index admission).

METHODS

PubMed and EMBASE databases were searched, 32 studies were included in this study level meta-analysis.

RESULTS

In a total of 1495 patients with acute pancreatitis, tested at a mean of 36 months after index admission, the pooled prevalence of PEI was 27.1% (95%-confidence interval [CI]: 20.3%-35.1%). Patients from seven studies (n = 194) underwent direct tests with pooled prevalence of 41.7% [18.5%-69.2%]. Patients from 26 studies (n = 1305) underwent indirect tests with pooled prevalence of 24.4% [18.3%-31.8%]. In subgroup analyses on patients that underwent fecal elastase-1 tests, PEI occurred more often in alcoholic pancreatitis (22.7% [16.6%-30.1%]) than in biliary pancreatitis (10.2% [6.2%-16.4%]) or other etiology (13.4% [7.7%-22.4%]; P = 0.02). Pooled prevalence of PEI after mild and severe pancreatitis was 19.4% [8.6%-38.2%] and 33.4% [22.6%-46.3%] respectively in studies using fecal elaste-1 tests (P = 0.049). Similar results were seen in patients without (18.9% [9.3%-34.6%]) and with necrotizing pancreatitis (32.0% [18.2%-49.8%]; P = 0.053). Over time, the prevalence of PEI decreased in patients who underwent the fecal elastase-1 test and increased in patients who underwent the fecal fat analysis.

CONCLUSIONS

After acute pancreatitis, a quarter of all patients develop PEI during follow-up. Alcoholic etiology and severe and necrotizing pancreatitis are associated with higher risk of PEI. The prevalence of PEI may change as time of follow-up increases.

Evidence-based Guidelines for the Management of Exocrine Pancreatic Insufficiency After Pancreatic Surgery

OBJECTIVE

To provide evidence-based recommendations for the management of exocrine pancreatic insufficiency (EPI) after pancreatic surgery.

BACKGROUND

EPI is a common complication after pancreatic surgery but there is certain confusion about its frequency, optimal methods of diagnosis, and when and how to treat these patients.

METHODS

Eighteen multidisciplinary reviewers performed a systematic review on 10 predefined questions following the GRADE methodology. Six external expert referees reviewed the retrieved information. Members from Spanish Association of Pancreatology were invited to suggest modifications and voted for the quantification of agreement.

RESULTS

These guidelines analyze the definition of EPI after pancreatic surgery, (one question), its frequency after specific techniques and underlying disease (four questions), its clinical consequences (one question), diagnosis (one question), when and how to treat postsurgical EPI (two questions) and its impact on the quality of life (one question). Eleven statements answering those 10 questions were provided: one (9.1%) was rated as a strong recommendation according to GRADE, three (27.3%) as moderate and seven (63.6%) as weak. All statements had strong agreement.

CONCLUSIONS

EPI is a frequent but under-recognized complication of pancreatic surgery. These guidelines provide evidence-based recommendations for the definition, diagnosis, and management of EPI after pancreatic surgery.

Quality of life after acute pancreatitis: a systematic review and meta-analysis

Patient-centered outcomes, including quality of life (QoL), after acute pancreatitis (AP) remain largely unknown. Our aim was to systematically review the best available evidence on QoL after AP. English-language articles on the effect of AP on QoL were identified in MEDLINE, EMBASE, and Scopus. Results were statistically aggregated to obtain a pooled mean difference (MD) and corresponding 95% confidence interval (CI) for individual QoL domains and component summaries, where appropriate. A total of 16 prospective observational studies encompassing 687 AP patients were included. Four studies comprising 267 AP patients, as measured by SF-36 and SF-12 questionnaires, were suitable for meta-analysis. The general health and vitality domains were significantly worse in the patients compared with healthy controls (MD, -10.90; 95% CI, -15.63 to -6.17; P < 0.00001 and MD, -4.64; 95% CI, -7.32 to -1.95; P = 0.0007, respectively). The remaining individual domains and physical and mental component summary scores did not differ between patients and controls. The QoL seems to be significantly impaired in patients after AP with a need to standardize reporting on QoL. Future studies should investigate the effect of different interventions on patients' QoL.

Necro-inflammatory response of pancreatic acinar cells in the pathogenesis of acute alcoholic pancreatitis

The role of pancreatic acinar cells in initiating necro-inflammatory responses during the early onset of alcoholic acute pancreatitis (AP) has not been fully evaluated. We investigated the ability of acinar cells to generate pro- and anti-inflammatory mediators, including inflammasome-associated IL-18/caspase-1, and evaluated acinar cell necrosis in an animal model of AP and human samples. Rats were fed either an ethanol-containing or control diet for 14 weeks and killed 3 or 24 h after a single lipopolysaccharide (LPS) injection. Inflammasome components and necro-inflammation were evaluated in acinar cells by immunofluorescence (IF), histology, and biochemical approaches. Alcohol exposure enhanced acinar cell-specific production of TNFα, IL-6, MCP-1 and IL-10, as early as 3 h after LPS, whereas IL-18 and caspase-1 were evident 24 h later. Alcohol enhanced LPS-induced TNFα expression, whereas blockade of LPS signaling diminished TNFα production in vitro, indicating that the response of pancreatic acinar cells to LPS is similar to that of immune cells. Similar results were observed from acinar cells in samples from patients with acute/recurrent pancreatitis. Although morphologic examination of sub-clinical AP showed no visible signs of necrosis, early loss of pancreatic HMGB1 and increased systemic levels of HMGB1 and LDH were observed, indicating that this strong systemic inflammatory response is associated with little pancreatic necrosis. These results suggest that TLR-4-positive acinar cells respond to LPS by activating the inflammasome and producing pro- and anti-inflammatory mediators during the development of mild, sub-clinical AP, and that these effects are exacerbated by alcohol injury.

Alcohol exacerbates LPS-induced fibrosis in subclinical acute pancreatitis

The role of pancreatic acinar cells in initiating fibrogenic responses during the early stages of alcoholic acute pancreatitis has not been evaluated. We investigated the ability of injured acinar cells to generate pancreatic fibrosis in acute pancreatitis. Rats were fed either an ethanol-containing or control diet over 14 weeks and euthanized 3 or 24 hours after a single lipopolysaccharide injection. Profibrotic transforming growth factor-β of acinar cells and pancreatic fibrosis were assessed by immunofluorescence, histological characteristics, and electron microscopy. Human pancreatic tissues were also evaluated. Periacinar cell fibrosis and collagen were exacerbated 24 hours after endotoxemia in alcohol-fed rats. Alcohol exposure exacerbated acinar cell-specific production of transforming growth factor β in response to lipopolysaccharide in vivo and in acinar cell-like AR42J cells in vitro. Although a morphological examination showed no visible signs of necrosis, early pancreatic fibrosis can be initiated by little or no pancreatic necrosis. Transforming growth factor β was also significantly increased in human acinar cells from patients with acute/recurrent pancreatitis compared with chronic pancreatitis tissue. Alcohol exacerbates lipopolysaccharide-induced pancreatic fibrosis during the early onset of mild, subclinical, acute pancreatitis. We suggest that multiple, subclinical, acute pancreatitis episodes can accumulate in fibrosis during the development of chronic pancreatitis, even if there is no history of acute pancreatitis.

Alcoholic acute pancreatitis: pathogenesis and clinical characteristics

Animal and clinical studies have shown that alcohol and its metabolic products, endotoxin, viral infection, drinking pattern, smoking, obesity, genetic variability, and gene polymorphisms were very important in the pathogenesis of alcoholic acute pancreatitis (AAP). The morbidity of AAP has been increased in the past decade, and male gender is strongly associated with increased risk of AAP. The mortality of AAP is high, while the quality of life of survivors of severe AAP is low. In this paper, we review the pathogenesis and clinical characteristics of AAP.

Management of pancreatic exocrine insufficiency: Australasian Pancreatic Club recommendations

Pancreatic exocrine insufficiency (PEI) occurs when the amounts of enzymes secreted into the duodenum in response to a meal are insufficient to maintain normal digestive processes. The main clinical consequence of PEI is fat maldigestion and malabsorption, resulting in steatorrhoea. Pancreatic exocrine function is commonly assessed by conducting a 3-day faecal fat test and by measuring levels of faecal elastase-1 and serum trypsinogen. Pancreatic enzyme replacement therapy is the mainstay of treatment for PEI. In adults, the initial recommended dose of pancreatic enzymes is 25,000 units of lipase per meal, titrating up to a maximum of 80,000 units of lipase per meal. In infants and children, the initial recommended dose of pancreatic enzymes is 500 units of lipase per gram of dietary fat; the maximum daily dose should not exceed 10,000 units of lipase per kilogram of bodyweight. Oral pancreatic enzymes should be taken with meals to ensure adequate mixing with the chyme. Adjunct therapy with acid-suppressing agents may be useful in patients who continue to experience symptoms of PEI despite high-dose enzyme therapy. A dietitian experienced in treating PEI should be involved in patient management. Dietary fat restriction is not recommended for patients with PEI. Patients with PEI should be encouraged to consume small, frequent meals and to abstain from alcohol. Medium-chain triglycerides do not provide any clear nutritional advantage over long-chain triglycerides, but can be trialled in patients who fail to gain or to maintain adequate bodyweight in order to increase energy intake.

Acute pancreatitis: risk of recurrence and late consequences of the disease

Research into the clinical management of acute pancreatitis has primarily focused on the immediate complications of the disease, whereas its late consequences have received less attention. These late sequelae of acute pancreatitis refer to complications that arise after the convalescence period, which lasts for 3-6 months after the initial episode. In patients who do not undergo necrosectomy that involves removal of the exocrine gland, pancreatic exocrine function usually improves rather than deteriorates during follow-up. By contrast, glucose intolerance is likely to worsen over time in all patients with acute pancreatitis. Despite the risk of late complications for patients with acute pancreatitis, their long-term quality of life is usually good. The number of pancreatitis episodes a patient has experienced is an important factor that determines the severity of late complications of acute pancreatitis. Risk factors for the recurrence of acute pancreatitis episodes have now been identified. This Review focuses on data from studies that investigated the risk factors for recurrent attacks of acute pancreatitis, and discusses the late consequences of this disease.

Impaired autolysosome formation correlates with Lamp-2 depletion: role of apoptosis, autophagy, and necrosis in pancreatitis

BACKGROUND & AIMS

Acute pancreatitis constitutes a life-threatening condition in which pancreatic acinar cells undergo massive cell death. We investigated the incidence of apoptosis, autophagy, and necrosis affecting acinar cells in the early onset of acute pancreatitis induced by chronic alcohol feeding and acute endotoxemia.

METHODS

Rats were fed either an ethanol-containing or a control diet over 14 weeks and killed 3 or 24 hours after a single lipopolysaccharide injection. Apoptosis, necrosis, and autophagy of pancreatic acinar cells were assessed by histology, electron microscopy, immunofluorescence, and biochemical methods.

RESULTS

The combination of alcohol exposure and endotoxemia resulted in the depletion of several lysosomal proteins including lysosomal-associated membrane protein-2 (Lamp-2), a protein that is required for the proper fusion of autophagosomes with lysosomes. Accordingly, Lamp-2 depletion correlated with the accumulation of autophagosomes and a relative paucity of autolysosomes, reduced adenosine-5'-triphosphate levels, and a switch from apoptotic to necrotic cell death. This switch to necrosis was accompanied by reduced caspase activation and the nuclear release of the proinflammatory factor high mobility group box 1. Importantly, human patients with alcoholic pancreatitis also exhibited local Lamp-2 depletion, which points to a crucial role for Lamp-2 and autophagy in pancreatic acinar cell death.

CONCLUSIONS

Our data suggest that acinar cell vacuolization in pancreatitis is mediated by an endotoxemia-induced inhibition of the late stage of autophagy. The combination of alcohol and endotoxemia attenuated apoptosis response yet enhanced acinar cell necrosis. The depletion of lysosomal proteins plays a critical role in the early onset of acute pancreatitis.

Progress in evidence-based medicine for treatment of severe acute pancreatitis

Severe acute pancreatitis (SAP) is an abdominal catastrophe with a high morbidity and mortality. Up to now, no special drugs or therapeutic methods are available for SAP. Since evidence-based medicine came into being, much more clinical evidence has provided better choice of treatment for SAP. However, such evidence does not fit for all ASP patients based on its critical inclusion and exclusion criteria. It is, therefore, important to treat ASP patients by combining such evidence with clinical experiences.