Determinant-based classification of acute pancreatitis severity: an international multidisciplinary consultation. Ann Surg. 2012;256:875-880. [PMID: 22735715 DOI: 10.1097/sla.0b013e318256f778]

Diagnosis and Management of Acute Pancreatitis

Acute pancreatitis (AP) is increasing in incidence across the world, and in all age groups. Major changes in management have occurred in the last decade. Avoiding total parenteral nutrition and prophylactic antibiotics, avoiding overly aggressive fluid resuscitation, initiating early feeding, avoiding endoscopic retrograde cholangiopancreatography in the absence of concomitant cholangitis, same-admission cholecystectomy, and minimally invasive approaches to infected necrosis should now be standard of care. Increasing recognition of the risk of recurrence of AP, and progression to chronic pancreatitis, along with the unexpectedly high risk of diabetes and exocrine insufficiency after AP is the subject of large ongoing studies. In this review, we provide an update on important changes in management for this increasingly common disease.

Early discharge of patients with mild acute pancreatitis - A scoping review

BACKGROUND

Acute pancreatitis is a common disease that is usually mild and self-limiting. Early discharge of patients with mild acute pancreatitis, with the use of supporting outpatient services including remote monitoring or smartphone applications, might be safe and could reduce the healthcare demand. The objective of this review was to provide a comprehensive overview of existing strategies aimed at facilitating early discharge of patients diagnosed with mild acute pancreatitis and to assess clinical outcomes, feasibility and costs associated with these strategies.

METHODS

PubMed, Cochrane, Embase, and Web of Science were systematically searched, to identify studies that evaluated strategies to reduce the length of hospital stay in patients with mild acute pancreatitis.

RESULTS

Five studies, including 84 to 419 patients each, were identified and described three different early discharge protocols. The early discharge strategies resulted in a median length of hospital stay of a minimum of 6 to a maximum of 23 h in these studies. Early discharge compared to usual care did not result in increased 30-day readmissions. Additionally, no occurrences of complications or mortality were observed in either group. A significant reduction in overall costs was reported ranging from 43.1 % to 85.4 %.

CONCLUSIONS

Early discharge of patients with mild acute pancreatitis seems both feasible and safe. Further studies are warranted, since focus on safe early discharge could significantly reduce inpatient healthcare utilization and associated costs.

Endoscopic management of pancreatic collections. Endoscopic Ultrasound Group, Spanish Society of Digestive Endoscopy (GSEED-USE) Clinical Guidelines

Acute pancreatitis is associated with significant morbidity and mortality. It can develop complications such as fluid collections and necrosis. Infection of necrosis occurs in about 20-40 % of patients with severe acute pancreatitis, and is associated with organ failure and worse prognosis. In the past few years the treatment of pancreatic collections has shifted from open surgery to minimally invasive techniques such as endoscopic ultrasound-guided drainage. These guidelines from a selection of experts among the Endoscopic Ultrasound Group, Spanish Society of Gastrointestinal Endoscopy (GSEED-USE) are intended to provide advice on the management of pancreatic collections based on a thorough review of the available scientific evidence. It also reflects the experience and clinical practice of the authors, who are advanced endoscopists or clinical pancreatologists with extensive experience in managing patients with acute pancreatitis.

Pancreas units within gastroenterology departments. Organizational and operational standards for a patient-centered service

The Asociación Española de Pancreatología (AESPANC), Asociación Española de Gastroenterología (AEG), and Sociedad Española de Patología Digestiva (SEPD) have developed a consensus document on the standards and recommendations they consider essential for the organization of pancreas units (PUs) within gastroenterology services (GSs) in order to conduct their activities in an efficient, high-quality manner. The consensus document defines PUs and lays down standards relating to their organization, structure, service portfolio, processes, and teaching and research activities. Standards have been categorized as mandatory (requirements to be met to qualify for certification by the scientific societies responsible for the standards) or recommendations. Standards should be updated at most within five years based on the experience gained in Spanish PUs and the advance of knowledge regarding pancreas disease. Development of health outcome indicators, including patient-reported outcome measures (PROMs), is considered a relevant challenge, as is evidence on the association of PU structure and activity standards with health outcomes.

[Management of acute pancreatitis in the emergency department and the intensive care unit]

Acute pancreatitis is a gastrointestinal emergency where diagnosis is based on typical symptoms, increased serum lipase concentration, and abdominal imaging. Local complications and organ failure in severe acute pancreatitis regularly necessitate treatment in the intensive care unit and are associated with increased mortality rates. Only optimal interdisciplinary treatment can improve the prognosis of patients with severe acute pancreatitis. This article gives guidance on the initial diagnostic and etiological examinations as well as on the evaluation of organ failure and the severity assessment according to common classification systems. Furthermore, the endoscopic management of biliary pancreatitis and infected necrosis is discussed and the basics of targeted volume therapy, nutrition, and indications for antibiotic treatment are reviewed.

Pancreas units within gastroenterology departments. Organizational and operational standards for a patient-centered service

The Asociación Española de Pancreatología (AESPANC), Asociación Española de Gastroenterología (AEG), and Sociedad Española de Patología Digestiva (SEPD) have developed a consensus document on the standards and recommendations they consider essential for the organization of pancreas units (PUs) within gastroenterology services (GSs) in order to conduct their activities in an efficient, high-quality manner. The consensus document defines PUs and lays down standards relating to their organization, structure, service portfolio, processes, and teaching and research activities. Standards have been categorized as mandatory (requirements to be met to qualify for certification by the scientific societies responsible for the standards) or recommendations. Standards should be updated at most within five years based on the experience gained in Spanish PUs and the advance of knowledge regarding pancreas disease. Development of health outcome indicators, including patient-reported outcome measures (PROMs), is considered a relevant challenge, as is evidence on the association of PU structure and activity standards with health outcomes.

Predicting the severity of acute pancreatitis: Current approaches and future directions

Acute pancreatitis (AP) is a sudden-onset inflammatory disease of the pancreas. The severity of AP is classified into mild, moderate, and severe categories based on the presence and persistence of organ failure. Severe acute pancreatitis (SAP) can be associated with significant morbidity and mortality. It requires early recognition for appropriate timely management. Prognostic scores for predicting SAP incorporating many clinical, laboratory, and radiological parameters have been developed in the past. However, all of these prognostic scores have low positive predictive value for SAP and some of these scores require >24 h for assessment. There is a need to develop biomarkers that can accurately identify patients at risk for SAP early in the course of the presentation. In this review, we aim to provide a summary of the most commonly utilized prognostic scores for AP and discuss future directions.

Is Contemporary Open Pancreatic Necrosectomy Still Useful In The Minimally Invasive Era?

BACKGROUND

Previous studies have shown that open pancreatic necrosectomy for infected pancreatic necrosis was associated with high morbidity and mortality. However, these results were mostly concluded from historical cohorts with traditional early necrosectomy in the absence of a minimally invasive step-up approach.

OBJECTIVE

To explore the value of contemporary open pancreatic necrosectomy for infected pancreatic necrosis in the minimally invasive era.

METHODS

A post hoc analysis was performed in a prospective maintained database of 320 patients with infected pancreatic necrosis from January 2011 to December 2022 at a large Chinese tertiary hospital.

RESULTS

A total of 320 patients with infected pancreatic necrosis received either a minimally invasive step-up approach (245, 76.6%) or open pancreatic necrosectomy (75, 23.4%), which included upfront open pancreatic necrosectomy (32, 10.0%) and salvage open pancreatic necrosectomy (43, 13.4%). Upfront open pancreatic necrosectomy was associated with similar morbidity and mortality rates but fewer surgical interventions compared with a minimally invasive step-up approach. However, salvage open pancreatic necrosectomy was associated with significantly higher mortality (48.8% vs 18.8%, P = .007), gastrointestinal fistula (44.2% vs 18.8%, P = .021), hemorrhage (48.8% vs 15.6%, P = .003), and intensive care unit stay (25 vs 7 days, P = .040) compared with upfront open pancreatic necrosectomy. Multivariate analysis suggested that multiple organ failure (hazard ratio = 5.1; 95% confidence interval, 1.4-18.2, P = .013) and synchronous critical acute pancreatitis (hazard ratio = 3.0; 95% confidence interval, 1.1-8.6, P = .040) were 2 independent risk factors of death for patients who received open pancreatic necrosectomy.

CONCLUSION

Patients undergoing upfront open pancreatic necrosectomy received fewer surgical interventions with comparable efficacy compared to the minimally invasive step-up approach. Salvage open pancreatic necrosectomy was potentially lifesaving, though it carried high morbidity and mortality. Multiple organ failure and synchronous critical acute pancreatitis were 2 independent risk factors of death for patients who received open pancreatic necrosectomy.

The Ongoing Debate on the Use of Prophylactic Antibiotics in Acute Pancreatitis-Is There a Conclusion? A Comprehensive Narrative Review

Acute pancreatitis (AP) is a common but often self-limiting disease in the majority of patients. However, in the minority, who may progress to moderately severe or severe AP, high mortality risk has been reported. Infected pancreatitis necrosis (IPN) in necrotising pancreatitis has been shown to result in more than twice the mortality rate compared with in sterile pancreatic necrosis. This raises the question on whether prophylactic antibiotics (PABs) should be given in subgroups of AP to prevent superimposed infection to improve survival outcomes. Despite numerous randomised controlled trials (RCTs), meta-analyses, and guidelines on the management of AP, there is a lack of strong evidence to suggest the use of PABs in AP. Additionally, use of PABs is associated with antimicrobial resistance. Considerable heterogeneity exists and limits the interpretation of results-subgroup of AP benefitting from PAB use, choice/class of PAB, and timing of administration from symptom onset and duration of PAB use. Only a minority of existing meta-analyses suggest mortality benefits and reduction in IPN. The majority of existing guidelines do not recommend the use of PABs in AP. More research is required to make more definitive conclusions. Currently, PAB should only be administered after multidisciplinary discussions led by pancreatology experts.

Long-term follow-up study of necrotising pancreatitis: interventions, complications and quality of life

OBJECTIVE

To describe the long-term consequences of necrotising pancreatitis, including complications, the need for interventions and the quality of life.

DESIGN

Long-term follow-up of a prospective multicentre cohort of 373 necrotising pancreatitis patients (2005-2008) was performed. Patients were prospectively evaluated and received questionnaires. Readmissions (ie, for recurrent or chronic pancreatitis), interventions, pancreatic insufficiency and quality of life were compared between initial treatment groups: conservative, endoscopic/percutaneous drainage alone and necrosectomy. Associations of patient and disease characteristics during index admission with outcomes during follow-up were assessed.

RESULTS

During a median follow-up of 13.5 years (range 12-15.5 years), 97/373 patients (26%) were readmitted for recurrent pancreatitis. Endoscopic or percutaneous drainage was performed in 47/373 patients (13%), of whom 21/47 patients (45%) were initially treated conservatively. Pancreatic necrosectomy or pancreatic surgery was performed in 31/373 patients (8%), without differences between treatment groups. Endocrine insufficiency (126/373 patients; 34%) and exocrine insufficiency (90/373 patients; 38%), developed less often following conservative treatment (p<0.001 and p=0.016, respectively). Quality of life scores did not differ between groups. Pancreatic gland necrosis >50% during initial admission was associated with percutaneous/endoscopic drainage (OR 4.3 (95% CI 1.5 to 12.2)), pancreatic surgery (OR 3.2 (95% CI 1.1 to 9.5) and development of endocrine insufficiency (OR13.1 (95% CI 5.3 to 32.0) and exocrine insufficiency (OR6.1 (95% CI 2.4 to 15.5) during follow-up.

CONCLUSION

Acute necrotising pancreatitis carries a substantial disease burden during long-term follow-up in terms of recurrent disease, the necessity for interventions and development of pancreatic insufficiency, even when treated conservatively during the index admission. Extensive (>50%) pancreatic parenchymal necrosis seems to be an important predictor of interventions and complications during follow-up.

Lumen apposing metal stents vs. double pigtail plastic stents for the drainage of pancreatic walled-off necrosis

BACKGROUND

Few studies compared lumen-apposing metal stents (LAMS) and standard double pigtail plastic stents (PS) for the endoscopic drainage of pancreatic walled-off necrosis (WON). Albeit sometimes large, previously described cohorts display considerable heterogeneity and often pooled together data from several centers, involving multiple operators and techniques. Moreover, they often lack a control group for the comparison of outcomes. The aim of this study was to compare clinical efficacy and safety of PS versus LAMS for the endoscopic drainage of infected WON.

METHODS

Thirty patients were enrolled between 2011 and 2017. The present study is a single-center, 1:1 case-control study. We compared patients undergoing endoscopic drainages of infected WON through LAMS (cases) or PS (controls). The primary endpoint was the clinical efficacy (resolution of the WON/sepsis), the secondary endpoint was safety (procedure-related complications).

RESULTS

Cases and controls were homogeneous in terms of etiology and clinical characteristics: 93% of cases and 86.7% of controls were clinically successfully treated, with no significant differences in rates of postoperative infections, bleedings, and stent migrations (respectively 13.3% vs. 21.4%; P=0.65; 13.3% vs. 0%; P=0.48; 13.3% vs. 7.1%; P=1.00). No difference was shown regarding the need for additional percutaneous or surgical treatments (33.3% vs. 13.3%; P=0.39). Cases, however, displayed a significantly prolonged mean hospital stay (90.2 days vs. 18.5 days; P<0.01) and a higher mean number of endoscopic procedures per patient (4.8 vs. 1.5; P<0.01).

CONCLUSIONS

PS might be not inferior to LAMS for the treatment WONs. Further prospective RCT is needed to compare clinical efficacy and safety in the two groups.

A location-based anatomic classification system for acute pancreatic fluid collections: Roadmap for optimal intervention in the step-up era

Walled-off pancreatic necrosis (WOPN) is a local complication of acute necrotizing pancreatitis frequently requiring intervention. Treatment is typically through the coordinated efforts of a multidisciplinary team. Current management guidelines recommend a step-up approach beginning with minimally invasive techniques (percutaneous or transmural endoscopic drainage) followed by escalation to more invasive procedures if needed. Although the step-up approach is an evidence-based treatment paradigm for management of pancreatic fluid collections, it lacks guidance regarding optimal invasive technique selection based on the anatomic characteristics of pancreatic fluid collections. Similarly, existing cross-sectional imaging-based classification systems of pancreatic fluid collections have been used to predict disease severity and prognosis; however, none of these systems are designed to guide intervention. We propose a novel classification system which incorporates anatomic characteristics of pancreatic fluid collections (location and presence of disconnected pancreatic duct) to guide intervention selection and clinical decision making. We believe adoption of this simple classification system will help streamline treatment algorithms and facilitate cross-study comparisons for pancreatic fluid collections.

[Management of acute pancreatitis in the emergency department and the intensive care unit]

Acute pancreatitis is a gastrointestinal emergency where diagnosis is based on typical symptoms, increased serum lipase concentration, and abdominal imaging. Local complications and organ failure in severe acute pancreatitis regularly necessitate treatment in the intensive care unit and are associated with increased mortality rates. Only optimal interdisciplinary treatment can improve the prognosis of patients with severe acute pancreatitis. This article gives guidance on the initial diagnostic and etiological examinations as well as on the evaluation of organ failure and the severity assessment according to common classification systems. Furthermore, the endoscopic management of biliary pancreatitis and infected necrosis is discussed and the basics of targeted volume therapy, nutrition, and indications for antibiotic treatment are reviewed.

circ_UTRN inhibits ferroptosis of ARJ21 cells to attenuate acute pancreatitis progression by regulating the miR-760-3p/FOXO1/GPX4 axis

Aim

To explore the function of circ_UTRN in acute pancreatitis (AP).

Methods

After exposing AR42J cells to caerulein, the levels of circ_UTRN, miR-760-3p, and glutathione peroxidase 4 (GPX4) were determined by quantitative polymerase chain reaction. Additionally, GPX4 and forkhead box O1 (FOXO1) protein levels were assessed by western blot. The levels of oxidative stress and ferroptosis in the supernatant of the treated AR42J cells were also assessed using commercial kits.

Results

circ_UTRN inhibited caerulein-induced oxidative stress and ferroptosis by binding with miR-760-3p. Additionally, miR-760-3p directly targeted FOXO1, thereby regulating GPX4 levels. Furthermore, GPX4 knockdown abolished the effect of miR-760-3p downregulation in AP.

Conclusion

circ_UTRN inhibited oxidative stress and ferroptosis by regulating the miR-760-3p/FOXO1/GPX4 axis. This is a potential new treatment strategy for AP.

Updated Review of Radiologic Imaging and Intervention for Acute Pancreatitis and Its Complications

This is a current update on radiologic imaging and intervention of acute pancreatitis and its complications. In this review, we define the various complications of acute pancreatitis, discuss the imaging findings, as well as the timing of when these complications occur. The various classification and scoring systems of acute pancreatitis are summarized. Advantages and disadvantages of the 3 primary radiologic imaging modalities are compared. We then discuss radiologic interventions for acute pancreatitis. These include diagnostic aspiration as well as percutaneous catheter drainage of fluid collections, abscesses, pseudocysts, and necrosis. Recommendations for when these interventions should be considered, as well as situations in which they are contraindicated are discussed. Fortunately, acute pancreatitis usually is mild; however, serious complications occur in 20%, and admission of patients to the intensive care unit (ICU) occurs in over 10%. In this paper, we will focus on the imaging and interventional radiologic aspects for the serious complications and patients admitted to the ICU.

Nicotinamide adenine dinucleotide phosphate oxidase in pancreatic diseases: Mechanisms and future perspectives

Pancreatitis and pancreatic cancer (PC) stand as the most worrisome ailments affecting the pancreas. Researchers have dedicated efforts to unraveling the mechanisms underlying these diseases, yet their true nature continues to elude their grasp. Within this realm, oxidative stress is often believed to play a causal and contributory role in the development of pancreatitis and PC. Excessive accumulation of reactive oxygen species (ROS) can cause oxidative stress, and the key enzyme responsible for inducing ROS production in cells is nicotinamide adenine dinucleotide phosphate hydrogen oxides (NOX). NOX contribute to pancreatic fibrosis and inflammation by generating ROS that injure acinar cells, activate pancreatic stellate cells, and mediate macrophage polarization. Excessive ROS production occurs during malignant transformation and pancreatic carcinogenesis, creating an oxidative microenvironment that can cause abnormal apoptosis, epithelial to mesenchymal transition and genomic instability. Therefore, understanding the role of NOX in pancreatic diseases contributes to a more in-depth exploration of the exact pathogenesis of these diseases. In this review, we aim to summarize the potential roles of NOX and its mechanism in pancreatic disorders, aiming to provide novel insights into understanding the mechanisms underlying these diseases.

Quantitative CT features on admission combined with laboratory biomarkers for predicting severe acute pancreatitis

AIM

To assess the association of quantitative computed tomography (CT) features on admission with acute pancreatitis (AP) severity, and to explore the performance of combined CT and laboratory markers for predicting severe AP (SAP).

MATERIALS AND METHODS

Data from 208 AP patients were reviewed retrospectively. Pancreas volume, the area of extrapancreatic inflammation, extrapancreatic fluid collection volume, and number were calculated based on CT images on admission. Laboratory biomarkers within 24 h of admission were collected. Interobserver agreement for CT measurements was measured by calculating interclass correlation coefficient (ICC). The associations of quantitative CT features with AP severity were evaluated. Predictive models for SAP were constructed based on CT and laboratory markers. Performances of single marker and the models were evaluated using receiver operating characteristic (ROC) curve and area under the ROC curve (AUC).

RESULTS

Pancreas volume, area of extrapancreatic inflammation, extrapancreatic fluid collection volume, and number were significantly different between severe and non-severe AP groups. In predicting SAP, the AUCs of quantitative CT indicators ranged from 0.72 to 0.79; the AUCs of laboratory biomarkers were between 0.53 and 0.66. The combined model of area of extrapancreatic inflammation, serum calcium, and haematocrit yielded an AUC of 0.84, significantly higher than that of the laboratory model, single CT, or laboratory marker. Interobserver agreements for quantitative CT indicators were excellent, with ICC ranging from 0.91 to 0.98.

CONCLUSION

Quantitative CT features on admission were significantly associated with AP severity; the combination of extrapancreatic inflammation area, serum calcium, and haematocrit could be taken as a new method for predicting SAP.

Prognostic significance of organ failure and infected pancreatic necrosis in acute pancreatitis: An updated systematic review and meta-analysis

OBJECTIVES

In patients with acute pancreatitis (AP), minimally invasive treatment and the step-up approach have been widely used to deal with infected pancreatic necrosis (IPN) in the last decade. It is unclear whether IPN has become a less important determinant of mortality relative to organ failure (OF). We aimed to statistically aggregate recent evidence from published studies to determine the relative importance of IPN and OF as determinants of mortality in patients with AP (PROSPERO: CRD42020176989).

METHODS

Relevant studies were sourced from MEDLINE and EMBASE databases. Relative risk (RR) or weighted mean difference (WMD) was analyzed as outcomes. A two-sided P value of less than 0.05 was regarded as statistical significance.

RESULTS

Forty-three studies comprising 11 601 patients with AP were included. The mortality was 28% for OF patients and 24% for those with IPN. Patients with OF without IPN had a significantly higher risk of mortality compared to those with IPN but without OF (RR 3.72, P < 0.0001). However, patients with both OF and IPN faced the highest risk of mortality. Additionally, IPN increased length of stay in hospital for OF patients (WMD 28.75, P = 0.032).

CONCLUSION

Though IPN remains a significant concern, which leads to increased morbidity and longer hospital stay, it is a less critical mortality determinant compared to OF in AP.

Clinical usefulness of scoring systems to predict severe acute pancreatitis: A systematic review and meta-analysis with pre and post-test probability assessment

BACKGROUND

Scoring systems for severe acute pancreatitis (SAP) prediction should be used in conjunction with pre-test probability to establish post-test probability of SAP, but data of this kind are lacking.

OBJECTIVE

To investigate the predictive value of commonly employed scoring systems and their usefulness in modifying the pre-test probability of SAP.

METHODS

Following PRISMA statement and MOOSE checklists after PROSPERO registration, PubMed was searched from inception until September 2022. Retrospective, prospective, cross-sectional studies or clinical trials on patients with acute pancreatitis defined as Revised Atlanta Criteria, reporting rate of SAP and using at least one score among Bedside Index for Severity in Acute Pancreatitis (BISAP), Acute Physiology and Chronic Health Examination (APACHE)-II, RANSON, and Systemic Inflammatory Response Syndrome (SIRS) with their sensitivity and specificity were included. Random effects model meta-analyses were performed. Pre-test probability and likelihood ratio (LR) were combined to estimate post-test probability on Fagan nomograms. Pooled severity rate was used as pre-test probability of SAP and pooled sensitivity and specificity to calculate LR and generate post-test probability. A priori hypotheses for heterogeneity were developed and sensitivity analyses planned.

RESULTS

43 studies yielding 14,116 acute pancreatitis patients were included: 42 with BISAP, 30 with APACHE-II, 27 with Ranson, 8 with SIRS. Pooled pre-test probability of SAP ranged 16.6%-25.3%. The post-test probability of SAP with positive/negative score was 47%/6% for BISAP, 43%/5% for APACHE-II, 48%/5% for Ranson, 40%/12% for SIRS. In 18 studies comparing BISAP, APACHE-II, and Ranson in 6740 patients with pooled pre-test probability of SAP of 18.7%, post-test probability when scores were positive was 48% for BISAP, 46% for APACHE-II, 50% for Ranson. When scores were negative, post-test probability dropped to 7% for BISAP, 6% for Ranson, 5% for APACHE-II. Quality, design, and country of origin of the studies did not explain the observed high heterogeneity.

CONCLUSIONS

The most commonly used scoring systems to predict SAP perform poorly and do not aid in decision-making.

Diagnosis and Contemporary Management of Necrotizing Pancreatitis

BACKGROUND

Acute pancreatitis is a common diagnosis which requires a prompt diagnosis and management by a multidisciplinary team with often general surgeons as the initial provider. Morbidity and mortality from an acute pancreatitis can be very high, especially in patients with a progressive worsening acute pancreatitis developing into pancreatic necrosis in the setting of multiple underlying medical comorbidities.

PURPOSE

In this review paper, we discuss all aspects of acute pancreatitis and its potential complications, as well providing updates in the modern management of necrotizing pancreatitis. Practicing general surgeons need to be aware of the evolution in the diagnosis and treatment of this disease.

RESEARCH DESIGN

We conducted a review of literature of evidence and management options for acute pancreatitis, including all published manuscripts from 2012 to 2022.

RESULTS

Diagnosis and management of this disease can vary among specialiaties. The decision to utilize a percutaneous or endoscopic techniques are relevant points of discussion within general surgery and gastroenterology societies. In the past decade, the use of advanced endoscopic interventions has slowly replaced conventional open surgery in managing complications of acute severe pancreatitis.

CONCLUSION

Acute pancreatitis is a disease which requires multidisciplinary approach with evolving treatment options to less invasive nonsurgical methods.

Validation of the Revised Atlanta Criteria in determining the severity of acute pancreatitis

BACKGROUND/AIM

Determining the severity of acute pancreatitis (AP) is crucial for patient management. The aim of our study was to assess the accuracy and limitations of the Revised Atlanta Criteria (RAC) in determining the severity of AP.

MATERIALS AND METHODS

The study was retrospectively conducted on AP patients admitted to the Gastroenterology Department of Sakarya University Faculty of Medicine. The severity, morphology and local complications of AP were evaluated according to the RAC. Laboratory parameters, clinical scores predicting disease severity and Computer Tomography Severity Index scores were assessed.

RESULTS

The study group included 113 patients. Ninety-eight (86.7%) had interstitial edematous, and 15 (13.3%) had necrotizing pancreatitis. AP pancreatitis was mild in 69 (61.1%), moderate in 33 (29.2%), and severe in 11 (9.7%). Compared to the moderate group, patients in the severe group had a higher hematocrit, creatinine, SIRS and BISAP scores at admission and more length of hospital stay, more ICU requirements, and higher mortality rates ( P  < 0.05). Eleven patients had single or multiple persistent organ failure (POF). The mortality rate of patients who developed early POF (n = 6) was higher compared to the group of patients who developed late POF (n = 2) (83.3% and 40%, respectively).

CONCLUSION

Severity assessment using the RAC in patients with AP is consistent with laboratory parameters and scoring systems predicting severity. Severe pancreatitis cases who develop early POF may be classified separately.

The East Asian-specific LPL p.Ala288Thr (c.862G > A) missense variant exerts a mild effect on protein function

BACKGROUND

Lipoprotein lipase (LPL) is the key enzyme responsible for the hydrolysis of triglycerides. Loss-of-function variants in the LPL gene are associated with hypertriglyceridemia (HTG) and HTG-related diseases. Unlike nonsense, frameshift and canonical GT-AG splice site variants, a pathogenic role for clinically identified LPL missense variants should generally be confirmed by functional analysis. Herein, we describe the clinical and functional analysis of a rare LPL missense variant.

METHODS

Chinese patients with HTG-associated acute pancreatitis (HTG-AP) were screened for rare nonsense, frameshift, missense or canonical GT-AG splice site variants in LPL and four other lipid metabolism-related genes (APOC2, APOA5, GPIHBP1 and LMF1) by Sanger sequencing. The functional consequences of the LPL missense variant of interest were characterized by in vitro expression in HEK-293T and COS-7 cells followed by Western blot and LPL activity assays.

RESULTS

Five unrelated HTG-AP patients were found to be heterozygous for a rare East Asian-specific LPL missense variant, c.862G > A (p.Ala288Thr). All five patients were adult males, and all were overweight and had a long history of alcohol consumption. Transfection of LPL wild-type and c.862G > A expression vectors into two cell lines followed by Western blot analysis served to exclude the possibility that the p.Ala288Thr missense variant either impaired protein synthesis or increased protein degradation. Contrary to a previous functional study that claimed that p.Ala288Thr had a severe impact on LPL function (reportedly having 36% normal activity), our experiments consistently demonstrated that the variant had a comparatively mild effect on LPL functional activity, which was mediated through its impact upon LPL protein secretion (~ 20% reduced secretion compared to wild-type).

CONCLUSIONS

In this study, we identified the East Asian-specific LPL c.862G > A (p.Ala288Thr) missense variant in five unrelated HTG-AP patients. We demonstrated that this variant exerted only a relatively mild effect on LPL function in two cell lines. Heterozygosity for this LPL variant may have combined with alcohol consumption to trigger HTG-AP in these patients.

Establishment and Validation of a Nomogram Prediction Model for the Severe Acute Pancreatitis

Background

Severe acute pancreatitis (SAP) can progress to lung and kidney dysfunction, and blood clotting within 48 hours of its onset, and is associated with a high mortality rate. The aim of this study was to establish a reliable diagnostic prediction model for the early stage of severe pancreatitis.

Methods

The clinical data of patients diagnosed with acute pancreatitis from October 2017 to June 2022 at the Shangluo Central Hospital were collected. The risk factors were screened by least absolute shrinkage and selection operator (LASSO) regression analysis. A novel nomogram model was then established by multivariable logistic regression analysis.

Results

The data of 436 patients with acute pancreatitis, 45 (10.3%) patients had progressed to SAP. Through univariate and LASSO regression analyses, the neutrophils (P <0.001), albumin (P < 0.001), blood glucose (P < 0.001), serum calcium (P < 0.001), serum creatinine (P < 0.001), blood urea nitrogen (P < 0.001) and procalcitonin (P = 0.005) were identified as independent predictive factors for SAP. The nomogram built on the basis of these factors predicted SAP with sensitivity of 0.733, specificity of 0.9, positive predictive value of 0.458 and negative predictive value of 0.967. Furthermore, the concordance index of the nomogram reached 0.889 (95% CI, 0.837-0.941), and the area under the curve (AUC) in receiver operating characteristic curve (ROC) analysis was significantly higher than that of the APACHEII and ABISAP scoring systems. The established model was validated by plotting the clinical decision curve analysis (DCA) and clinical impact curve (CIC).

Conclusion

We established a nomogram to predict the progression of early acute pancreatitis to SAP with high discrimination and accuracy.

Acute Pancreatitis: Current Clinical Approaches, Molecular Pathophysiology, and Potential Therapeutics

OBJECTIVE

Severe acute pancreatitis (SAP), pancreatic inflammation leading to multiorgan failure, is associated with high morbidity and mortality. There is a critical need to identify novel therapeutic strategies to improve clinical outcomes for SAP patients.

MATERIALS AND METHODS

A comprehensive literature review was performed to identify current clinical strategies, known molecular pathophysiology, and potential therapeutic targets for SAP.

RESULTS

Current clinical approaches focus on determining which patients will likely develop SAP. However, therapeutic options are limited to supportive care and fluid resuscitation. The application of a novel 5-cytokine panel accurately predicting disease outcomes in SAP suggests that molecular approaches will improve impact of future clinical trials in AP.

CONCLUSIONS

Inflammatory outcomes in acute pancreatitis are driven by several unique molecular signals, which compound to promote both local and systemic inflammation. The identification of master cytokine regulators is critical to developing therapeutics, which reduce inflammation through several mechanisms.

Identification and characterization of pancreatic infections in severe and critical acute pancreatitis patients using 16S rRNA gene next generation sequencing

Objectives

This study aimed to identify the bacterial composition in the pancreatic fluid of severe and critical acute pancreatitis (SAP and CAP) patients.

Methods

A total of 78 pancreatic fluid samples were collected from 56 SAP and CAP patients and analyze using aerobic culture and 16S rRNA gene next-generation sequencing. The clinical data of the patients were obtained from the electronic medical records.

Results

Among the total 78 samples, 16S rRNA gene NGS identified a total of 660 bacterial taxa, belonging to 216 species in 123 genera. The dominant aerobic bacteria included Klebsiella pneumoniae, Acinetobacter baumannii, and Enterococcus faecium, while the dominant anaerobic bacteria included Bacteroides, Dialister invisus, and Olsenella uli. As compared to aerobic culturing, 95.96% (95/99) of the aerobic cultured bacteria were detected using the 16S rRNA gene NGS.

Conclusion

The pancreatic infections in SAP and CAP patients might originate not only from the gut but also from the oral cavity and airways as well as related environments. Dynamic analysis of bacterial profile and abundance showed that some bacteria with low abundance might become the main pathogenic bacteria. There were no significant differences in the bacterial diversity between SAP and CAP.

Clinical significance of reactive thrombocytosis in the course of acute pancreatitis

BACKGROUND

Reactive thrombocytosis occurs secondary to systemic infections, inflammatory, and other conditions. The relationship between thrombocytosis and acute pancreatitis (AP) in inflammatory diseases is uncertain. This study aimed to evaluate the clinical significance of thrombocytosis in AP patients during hospitalization.

METHODS

Subjects within 48 h of AP onset were consecutively enrolled over 6 years. Platelet counts of ≥ 450,000/µL were defined as thrombocytosis, < 100,000/µL as thrombocytopenia, and other counts as normal. We compared clinical characteristics, including the rate of severe AP (SAP) assessed by the Japanese Severity Score; blood markers, including hematologic and inflammatory factors and pancreatic enzymes during hospitalization; and pancreatic complications and outcomes in the three groups.

RESULTS

A total of 108 patients were enrolled. Although, SAP was more common in patients with thrombocytosis and thrombocytopenia (87.9% and 100%, respectively), the differences in lymphocytes and C-reactive protein, lactase dehydrogenase, and antithrombin levels, which are factors of the systemic inflammatory response, and the mean platelet volume, an indicator of platelet activation, were observed among patients with thrombocytosis and thrombocytopenia during hospitalization. Regarding pancreatic complications and outcomes, patients with thrombocytosis and thrombocytopenia had higher acute necrotic collection (ANC), pancreatic necrosis, intestinal paralysis, respiratory dysfunction, and pancreatic-related infection levels than patients with normal platelet levels. The relationship between pancreatic complications and thrombocytosis was assessed by multivariate logistic regression; the odds ratios for development of ANC, pancreatic necrosis and pancreatic-related infections were 7.360, 3.735 and 9.815, respectively.

CONCLUSIONS

Thrombocytosis during hospitalization for AP suggests development of local pancreatic complications and pancreatic-related infections.

Controversies in the management of acute pancreatitis: An update

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.

Mortality and costs related to severe acute pancreatitis in the intensive care units of Australia and New Zealand (ANZ), 2003-2020

BACKGROUND AND OBJECTIVE

Comprehensive data on the burden of severe acute pancreatitis (SAP) in global intensive care units (ICUs) and trends over time are lacking. Our objective was to compare trends in hospital and ICU mortality, in-hospital and ICU length of stay, and costs related to ICU admission in Australia and New Zealand (ANZ) for SAP.

METHODS

We performed a retrospective, observational, cohort study of ICU admissions reported to the ANZ Intensive Care Society Adult Patient Database over three consecutive six-year time periods from 2003 to 2020.

RESULTS

12,635 patients with SAP from 189 ICUs in ANZ were analysed. No difference in adjusted hospital mortality (11.4% vs 11.5% vs 11.0%, p = 0.85) and ICU mortality rates (7.5% vs 8.0% vs 8.1%, p = 0.73) were noted over the study period. Median length of hospital admission reduced over time (13.9 days in 2003-08, 13.1 days in 2009-14 and 12.5 days in 2015-20; p < 0.01). No difference in length of ICU stay was noted over the study period (p = 0.13). The cost of managing SAP in ANZ ICUs remained constant over the three time periods.

CONCLUSIONS

In critically-ill SAP patients in ANZ, no change in mortality has been noted over nearly two decades. There was a slight reduction in hospital stay (1 day), while the length of ICU stay remained unchanged. Given the significant costs related to care of patients with SAP in ICU, these findings highlight the need to prioritise resource allocation for healthcare delivery and targeted clinical research to identify treatments aimed at reducing mortality.

Minimally Invasive Surgery for the Treatment of Moderate to Critical Acute Pancreatitis: A Case-matched Comparison With the Traditional Open Approach Over 10 years

PURPOSE

The purpose of this study is to compare short-term and midterm outcomes between patients with acute pancreatitis (AP) treated with minimally invasive surgery (MIS) and patients treated with open necrosectomy (ON).

MATERIALS AND METHODS

We compared data of all patients who had undergone MIS for AP with a similar group of patients with ON patients between January 2012 and June 2021 using a case-matched methodology based on AP severity and patient characteristics. Inhospital and midterm follow-up variables, including quality-of-life assessment, were evaluated.

RESULTS

Starting from a whole series of 79 patients with moderate to critical AP admitted to our referral center, the final study sample consisted of 24 patients (12 MIS and 12 ON). Postoperative (18.7±10.9 vs. 30.3±21.7 d; P =0.05) and overall hospitalization (56.3±17.4 vs. 76.9±39.4 d; P =0.05) were lower in the MIS group. Moreover, the Short-Form 36 scores in the ON group were statistically significantly lower in role limitations because of emotional problems ( P =0.002) and health changes ( P =0.03) at 3 and 6 months and because of emotional problems ( P =0.05), emotional well-being ( P =0.02), and general health ( P =0.007) at 1 year.

CONCLUSIONS

MIS for the surgical management of moderate to critical AP seems to be a good option, as it could provide more chances for a better midterm quality of life compared with ON. Further studies are needed to confirm our findings.

Surgical management of acute pancreatitis: Historical perspectives, challenges, and current management approaches

Acute pancreatitis (AP) is a serious condition presenting catastrophic consequences. In severe AP, the mortality rate is high, and some patients initially diagnosed with mild-to-moderate AP can progress to a life-threatening severe state. Treatment of AP has evolved over the years. Drainage was the first surgical procedure performed for AP; however, later, surgical approaches were replaced by more conservative approaches due to the availability of advanced medical care and improved understanding of the course of AP. Currently, surgery is used to manage several complications of AP, such as pseudocysts, pancreatic fistulas, and biliary tract obstruction. Patients who are unresponsive to conservative treatment or have complications are typically considered for surgical intervention. This review focuses on the surgical approaches (endoscopic, percutaneous, and open) that have been established in recent studies to treat this acute condition and summarizes the common management guidelines for AP, discussing the relevant indications, significance, and complications. It is evident that despite their reduced involvement, surgeons lead the multidisciplinary care of patients with AP; however, given the gaps in existing knowledge, more research is required to standardize surgical protocols for AP.

A novel mini-invasive step-up approach for the treatment of severe acute pancreatitis with extensive infected necrosis: A single center case series study

RATIONALE

Complete removal of necrosis is critical for treating patients with severe acute pancreatitis (SAP) presenting infection of pancreatic necrosis (IPN). Frequently used mini-invasive methods include the surgical step-up approach suitable for necrosis extending laterally, whereas the endoscopic step-up approach is suitable for medial necrosis. However, in patients with extensive IPN, either approach alone usually has limited treatment effects.

PATIENT CONCERNS

We describe a case series of combined mini-invasive step-up approach for treating extensive IPN.

DIAGNOSES

Patients were diagnosed with SAP and had extensive IPN.

INTERVENTIONS

Seven patients with SAP and extensive IPN were enrolled. All patients underwent a combined step-up approach comprising 4 steps: percutaneous catheter drainage, continuous negative pressure irrigation (CNPI), percutaneous endoscopic necrosectomy (PEN), and transgastric necrosectomy (TN).

OUTCOMES

The median interval from symptom onset to percutaneous catheter drainage and CNPI was 11 days (range, 6-14) and 18 days (range, 14-26), and the median CNPI duration was 84 days (range, 54-116). The median interval from the onset of symptoms to PEN and TN was 36 days (range, 23-42) and 41 days (range, 34-48), respectively, and the median number of procedures was 2 (range, 1-2) for PEN and 3 (range, 2-4) for TN. Only a minor case of abdominal bleeding and a pancreatic-cutaneous fistula were reported, both resolved after conservative treatment. The median length of stay in the intensive care unit was 111 days (range, 73-133); all patients survived.

LESSONS

This mini-invasive step-up approach shows promising clinical effects and is relatively safe in critically ill patients with extensive IPN and high-risk surgical intervention.

Predicting Persistent Acute Respiratory Failure in Acute Pancreatitis: The Accuracy of Two Lung Injury Indices

BACKGROUND/AIMS

Early and accurate identification of patients with acute pancreatitis (AP) at high risk of persistent acute respiratory failure (PARF) is crucial. We sought to determine the accuracy of simplified Lung Injury Prediction Score (sLIPS) and simplified Early Acute Lung Injury (sEALI) for predicting PARF in ward AP patients.

METHODS

Consecutive AP patients in a training cohort from West China Hospital of Sichuan University (n = 912) and a validation cohort from The First Affiliated Hospital of Nanchang University (n = 1033) were analyzed. PARF was defined as oxygen in arterial blood/fraction of inspired oxygen < 300 mmHg that lasts for > 48 h. The sLIPS was composed by shock (predisposing condition), alcohol abuse, obesity, high respiratory rate, low oxygen saturation, high oxygen requirement, hypoalbuminemia, and acidosis (risk modifiers). The sEALI was calculated from oxygen 2 to 6 L/min, oxygen > 6 L/min, and high respiratory rate. Both indices were calculated on admission.

RESULTS

PARF developed in 16% (145/912) and 22% (228/1033) (22%) of the training and validation cohorts, respectively. In these patients, sLIPS and sEALI were significantly increased. sLIPS ≥ 2 predicted PARF in the training (AUROC 0.87, 95% CI 0.84-0.89) and validation (AUROC 0.81, 95% CI 0.78-0.83) cohorts. sLIPS was significantly more accurate than sEALI and current clinical scoring systems in both cohorts (all P < 0.05).

CONCLUSIONS

Using routinely available clinical data, the sLIPS can accurately predict PARF in ward AP patients and outperforms the sEALI and current existing clinical scoring systems.

Impact of sarcopenic obesity on predicting the severity of acute pancreatitis

BACKGROUND AND AIMS

This work aimed to evaluate the impact of sarcopenia and sarcopenic obesity on the occurrence of severe pancreatitis and to study the performance of anthropometric indices to predict severe forms.

METHODS

We conducted a single-center retrospective study at Caen University Hospital between 2014 and 2017. Sarcopenia was assessed by measuring the psoas area on an abdominal scan. The psoas area /body mass index ratio reflected sarcopenic obesity. By normalizing the value to the body surface, we obtained an index called sarcopancreatic index, avoiding sex differences in measurements.

RESULTS

Among 467 included patients, 65 (13.9%) developed severe pancreatitis. The sarcopancreatic index was independently associated with the occurrence of severe pancreatitis (1.455 95% CI [1.028-2.061]; p = 0.035), as was the Visual Analog Scale, creatinine or albumin. The complication rate was not different depending on sarcopancreatic index value. Based on variables independently associated with the occurrence of severe pancreatitis, we constructed a score called Sarcopenia Severity Index. This score presented an area under the receiver operating characteristics curve of 0.84, comparable to the Ranson score (0.87) and superior to body mass index or the sarcopancreatic index to predict a severe form of acute pancreatitis.

CONCLUSIONS

Sarcopenic obesity seems to be associated with severe acute pancreatitis.

Clinical characteristics and risk factors of organ failure and death in necrotizing pancreatitis

BACKGROUND

Organ failure (OF) and death are considered the most significant adverse outcomes in necrotizing pancreatitis (NP). However, there are few NP-related studies describing the clinical traits of OF and aggravated outcomes.

PURPOSE

An improved insight into the details of OF and death will be helpful to the management of NP. Thus, in our research, we addressed the risk factors of OF and death in NP patients.

METHODS

We performed a study of 432 NP patients from May 2017 to December 2021. All patients with NP were followed up for 36 months. The primary end-points were risk factors of OF and death in NP patients. The risk factors were evaluated by logistic regression analysis.

RESULTS

NP patients with OF or death patients were generally older, had a higher APACHE II score, longer hospital stay, longer ICU stay, as well as a higher incidence of severe acute pancreatitis (SAP), shock and pancreatic necrosis. Independent risk factors related to OF included BMI, APACHE II score and SAP (P < 0.05). Age, shock and APACHE II score (P < 0.05) were the most significant factors correlated with the risk of death in NP patients. Notably, increased mortality was linked to the number of failed organs.

CONCLUSIONS

NP is a potentially fatal disease with a long hospital or ICU stay. Our study indicated that the incidence of OF and death in NP patients was 69.9% and 10.2%, respectively. BMI, SAP, APACHE II score, age and shock are potential risk factors of OF and death in NP patients. Clinicians should focus on these factors for early diagnosis and appropriate therapy.

Acute pancreatitis is characterized by generalized intestinal barrier dysfunction in early stage

BACKGROUND AND AIMS

The role of intestinal-barrier in acute pancreatitis(AP) is poorly understood. We aimed to assess structural and functional changes in the intestinal-barrier in patients with early AP (time from onset<2 weeks) and the effect of enteral nutrition on them.

METHODS

In this prospective observational study, patients with early AP not on enteral nutrition were compared with controls for baseline intestinal-permeability(lactulose: mannitol ratio(L:M)), endotoxinemia(serum IgM/IgG anti-endotoxin antibodies), bacterial-translocation(serum bacterial 16S rRNA) and duodenal epithelial tight-junction structure by immunohistochemistry(IHC) for tight-junction proteins(claudin-2,-3,-4, zonula occludens-1(ZO1), junctional adhesion molecule(JAM) and occludin) and electron microscopy. These parameters were reassessed after 2 weeks enteral feeding in a AP patients subset.

RESULTS

96 patients with AP(age: 38.0 ± 14.5 years; etiology: biliary[46.8%]/alcohol[39.6%]; severe:53.2%, mortality:11.4%) and 40 matched controls were recruited. Patients with AP had higher baseline intestinal permeability(median L:M 0.176(IQR 0.073-0.376) vs 0.049(0.024-0.075) in controls; p < 0.001) and more frequent bacteraemia(positive bacterial 16S rRNA in 24/48 AP vs 0/21 controls; p < 0.001) with trend towards higher serum endotoxinemia(median IgG anti-endotoxin 78(51.2-171.6) GMU/ml vs 51.2(26.16-79.2) in controls; p = 0.061). Claudin-2, claudin-3, ZO1 were downregulated in both duodenal crypts and villi while claudin-4 and JAM were downregulated in duodenal villi and crypts respectively. 22 AP patients reassessed after initiation of enteral nutrition showed trend towards improving intestinal permeability, serum endotoxinemia and bacteraemia, with significant improvement in claudin-2,-3 in duodenal villi.

CONCLUSION

Patients with AP have significant disturbances in intestinal barrier structure and function in first 2 weeks from onset that persist despite institution of enteral nutrition.

Abdominal Compartment Syndrome in Acute Pancreatitis: A Narrative Review

Abdominal compartment syndrome (ACS) represents a severe complication of acute pancreatitis (AP), resulting from an acute and sustained increase in abdominal pressure >20 mmHg, in association with new organ dysfunction. The harmful effect of high intra-abdominal pressure on regional and global perfusion results in significant multiple organ failure and is associated with increased morbidity and mortality. There are several deleterious consequences of elevated intra-abdominal pressure on end-organ function, including respiratory, cardiovascular, gastrointestinal, neurologic, and renal effects. It is estimated that about 15% of patients with severe AP develop intra-abdominal hypertension or ACS, with a mortality rate around 50%. The treatment of abdominal compartment syndrome in acute pancreatitis begins with medical intervention and percutaneous drainage, where possible. Abdominal compartment syndrome unresponsive to conservatory treatment requires immediate surgical decompression, along with vacuum-assisted closure therapy techniques, followed by early abdominal fascia closure.

The clinical significance of body mass index in the early evaluation of acute biliary pancreatitis

Objective

Obesity has increased across the globe in recent years and is considered an established risk factor for many diseases. The main objective was to investigate the early assessment value of Body Mass Index (BMI) in the prediction of severity in acute biliary pancreatitis (ABP) and by using BMI to evaluate the severity of ABP.

Methods

The retrospective analysis was designed to assess the relationship between Body Mass Index and the severity of acute pancreatitis in Beijing Jishuitan Hospital from January 2019 to December 2021. The SPSS 24.0 software was used for statistical analysis, Logistic Regression, and ROC curve for the factors affecting the severity of acute biliary pancreatitis.

Results

A total of 259 ABP patients were analyzed in our study. The BMI was significantly correlated with the Ranson scoring and MCTSI scoring (p = 0.000, 0.000). The difference in BMI in different severity of ABP patients was statistically significant (p = 0.000). The Logistic Regression analyses confirmed that BMI was an independent risk factor for the severity of ABP (p = 0.035). Combined detection of BMI, WBC, serum calcium, and SAMY in prognosis of the severity of acute pancreatitis positive rate is higher than single positive rate.

Conclusion

The BMI gradually increased with the severity of acute pancreatitis and was an independent risk factor for the condition. Combined detection of BMI and medical tests can effectively improve acute pancreatitis patients' clinical diagnostic accuracy and early treatment, and help to reduce complications.

Diagnosis, severity stratification and management of adult acute pancreatitis-current evidence and controversies

Acute pancreatitis (AP) is a disease spectrum ranging from mild to severe with an unpredictable natural course. Majority of cases (80%) are mild and self-limiting. However, severe AP (SAP) has a mortality risk of up to 30%. Establishing aetiology and risk stratification are essential pillars of clinical care. Idiopathic AP is a diagnosis of exclusion which should only be used after extended investigations fail to identify a cause. Tenets of management of mild AP include pain control and management of aetiology to prevent recurrence. In SAP, patients should be resuscitated with goal-directed fluid therapy using crystalloids and admitted to critical care unit. Routine prophylactic antibiotics have limited clinical benefit and should not be given in SAP. Patients able to tolerate oral intake should be given early enteral nutrition rather than nil by mouth or parenteral nutrition. If unable to tolerate per-orally, nasogastric feeding may be attempted and routine post-pyloric feeding has limited evidence of clinical benefit. Endoscopic retrograde cholangiopancreatogram should be selectively performed in patients with biliary obstruction or suspicion of acute cholangitis. Delayed step-up strategy including percutaneous retroperitoneal drainage, endoscopic debridement, or minimal-access necrosectomy are sufficient in most SAP patients. Patients should be monitored for diabetes mellitus and pseudocyst.

Predicting persistent organ failure on admission in patients with acute pancreatitis: development and validation of a mobile nomogram

BACKGROUND

Early prediction of persistent organ failure (POF) is important for triage and timely treatment of patients with acute pancreatitis (AP).

METHODS

All AP patients were consecutively admitted within 48 h of symptom onset. A nomogram was developed to predict POF on admission using data from a retrospective training cohort, validated by two prospective cohorts. The clinical utility of the nomogram was defined by concordance index (C-index), decision curve analysis (DCA), and clinical impact curve (CIC), while the performance by post-test probability.

RESULTS

There were 816, 398, and 880 patients in the training, internal and external validation cohorts, respectively. Six independent predictors determined by logistic regression analysis were age, respiratory rate, albumin, lactate dehydrogenase, oxygen support, and pleural effusion and were included in the nomogram (web-based calculator: https://shina.shinyapps.io/DynNomapp/). This nomogram had reasonable predictive ability (C-indexes 0.88/0.91/0.81 for each cohort) and promising clinical utility (DCA and CIC). The nomogram had a positive likelihood ratio and post-test probability of developing POF in the training, internal and external validation cohorts of 4.26/31.7%, 7.89/39.1%, and 2.75/41%, respectively, superior or equal to other prognostic scores.

CONCLUSIONS

This nomogram can predict POF of AP patients and should be considered for clinical practice and trial allocation.

Acute Pancreatitis: Diagnosis and Treatment

Acute pancreatitis is a common indication for hospital admission, increasing in incidence, including in children, pregnancy and the elderly. Moderately severe acute pancreatitis with fluid and/or necrotic collections causes substantial morbidity, and severe disease with persistent organ failure causes significant mortality. The diagnosis requires two of upper abdominal pain, amylase/lipase ≥ 3 ×upper limit of normal, and/or cross-sectional imaging findings. Gallstones and ethanol predominate while hypertriglyceridaemia and drugs are notable among many causes. Serum triglycerides, full blood count, renal and liver function tests, glucose, calcium, transabdominal ultrasound, and chest imaging are indicated, with abdominal cross-sectional imaging if there is diagnostic uncertainty. Subsequent imaging is undertaken to detect complications, for example, if C-reactive protein exceeds 150 mg/L, or rarer aetiologies. Pancreatic intracellular calcium overload, mitochondrial impairment, and inflammatory responses are critical in pathogenesis, targeted in current treatment trials, which are crucially important as there is no internationally licenced drug to treat acute pancreatitis and prevent complications. Initial priorities are intravenous fluid resuscitation, analgesia, and enteral nutrition, and when necessary, critical care and organ support, parenteral nutrition, antibiotics, pancreatic exocrine and endocrine replacement therapy; all may have adverse effects. Patients with local complications should be referred to specialist tertiary centres to guide further management, which may include drainage and/or necrosectomy. The impact of acute pancreatitis can be devastating, so prevention or reduction of the risk of recurrence and progression to chronic pancreatitis with an increased risk of pancreas cancer requires proactive management that should be long term for some patients.

α‑lipoic acid inhibits cerulein/resistin‑induced expression of interleukin‑6 by activating peroxisome proliferator‑activated receptor‑γ in pancreatic acinar cells

Cerulein‑induced pancreatitis resembles human acute pancreatitis in terms of pathological events, such as enzymatic activation and inflammatory cell infiltration in the pancreas. Cerulein is a cholecystokinin analog that increases levels of reactive oxygen species (ROS) and interleukin‑6 (IL‑6) expression level in pancreatic acinar cells. Serum levels of resistin, which is secreted from adipocytes, are reportedly higher in patients with acute pancreatitis than in healthy individuals. Previously, it was shown that the adipokine resistin can aggravate the cerulein‑induced increase in ROS levels and IL‑6 expression level in pancreatic acinar cells. Peroxisome proliferator‑activated receptor‑gamma (PPAR‑γ) is a key regulator of the transcription and expression of antioxidant enzymes, including heme oxygenase 1 (HO‑1) and catalase. α‑lipoic acid, a naturally occurring dithiol antioxidant, can prevent cerulein‑induced pancreatic damage in rats. In the present study, it was aimed to investigate whether α‑lipoic acid can attenuate the cerulein/resistin‑induced increase in IL‑6 expression and ROS levels via PPAR‑γ activation in pancreatic acinar AR42J cells. The anti‑inflammatory mechanism of α‑lipoic acid was determined using reverse transcription‑quantitative PCR, western blot analysis, enzyme‑linked immunosorbent assay, immunofluorescence staining and fluorometry. Treatment with cerulein and resistin increased ROS levels and IL‑6 expression level, which were inhibited by α‑lipoic acid in pancreatic acinar cells. α‑lipoic acid increased the nuclear translocation and expression level of PPAR‑γ and the expression levels of its target genes: HO‑1 and catalase. The PPAR‑γ antagonist GW9662 and HO‑1 inhibitor zinc protoporphyrin reversed the inhibitory effect of α‑lipoic acid on cerulein/resistin‑induced increase in ROS and IL‑6 levels. In conclusion, α‑lipoic acid inhibits the cerulein/resistin‑induced increase in ROS production and IL‑6 expression levels by activating PPAR‑γ and inducing the expression of HO‑1 and catalase in pancreatic acinar cells.

Dao-Chi Powder Ameliorates Pancreatitis-Induced Intestinal and Cardiac Injuries via Regulating the Nrf2-HO-1-HMGB1 Signaling Pathway in Rats

Dao-Chi powder (DCP) has been widely used in the treatment of inflammatory diseases in the clinical practice of traditional Chinese medicine, but has not been used in acute pancreatitis (AP). This study aimed to evaluate the effect of DCP on severe AP (SAP) and SAP-associated intestinal and cardiac injuries. To this end, an SAP animal model was established by retrograde injection of 3.5% taurocholic acid sodium salt into the biliopancreatic ducts of rats. Intragastric DCP (9.6 g/kg.BW) was administered 12 h after modeling. The pancreas, duodenum, colon, heart and blood samples were collected 36 h after the operation for histological and biochemical detection. The tissue distributions of the DCP components were determined and compared between the sham and the SAP groups. Moreover, molecular docking analysis was employed to investigate the interactions between the potential active components of DCP and its targets (Nrf2, HO-1, and HMGB1). Consequently, DCP treatment decreased the serum levels of amylase and the markers of gastrointestinal and cardiac injury, further alleviating the pathological damage in the pancreas, duodenum, colon, and heart of rats with SAP. Mechanistically, DCP rebalanced the pro-/anti-inflammatory cytokines and inhibited MPO activity and MDA levels in these tissues. Furthermore, Western blot and RT-PCR results showed that DCP intervention enhanced the expression of Nrf2 and HO-1 in the duodenum and colon of rats with SAP, while inhibiting the expression of HMGB1 in the duodenum and heart. HPLC-MS/MS analysis revealed that SAP promoted the distribution of ajugol and oleanolic acid to the duodenum, whereas it inhibited the distribution of liquiritigenin to the heart and ajugol to the colon. Molecular docking analysis confirmed that the six screened components of DCP had relatively good binding affinity with Nrf2, HO-1, and HMGB1. Among these, oleanolic acid had the highest affinity for HO-1. Altogether, DCP could alleviated SAP-induced intestinal and cardiac injuries via inhibiting the inflammatory responses and oxidative stress partially through regulating the Nrf2/HO-1/HMGB1 signaling pathway, thereby providing additional supportive evidence for the clinical treatment of SAP.

Role of Pancreatic Stone Protein as an Early Biomarker for Risk Stratification of Acute Pancreatitis

BACKGROUND

Early risk stratification of acute pancreatitis is crucial to improve clinical outcomes. The objective of this study was to evaluate the ability of pancreatic stone protein (PSP) to predict acute pancreatitis severity and to compare it with the biomarkers and severity scores currently used for that purpose.

PATIENTS AND METHODS

Prospective single-center observational study enrolling 268 adult patients with acute pancreatitis. Biomarkers including PSP were measured upon admission to the Emergency Department and severity scores as SOFA, PANC-3, and BISAP were computed. Patients were classified into mild-moderate (non-severe) and severe acute pancreatitis according to the Determinant-Based Classification Criteria. Area under the curve (AUC) and regression analysis were used to analyze the discrimination abilities and the association of biomarkers and scores with severity.

RESULTS

Two hundred and thirty-five patients (87.7%) were classified as non-severe and 33 (12.3%) as severe acute pancreatitis. Median [IQR] PSP was increased in patients with severe acute pancreatitis (890 μg/L [559-1142] vs. 279 μg/L [141-496]; p < 0.001) and it was the best predictor (ROC AUC: 0.827). In multivariate analysis, PSP and urea were the only independent predictors for severe acute pancreatitis and a model combining them both ("biomarker model") showed an AUC of 0.841 for prediction of severe acute pancreatitis, higher than the other severity scores.

CONCLUSIONS

PSP is a promising biomarker for predicting the severity of acute pancreatitis upon admission. A model combining PSP and urea might further constitute a potential tool for early risk stratification of this disease.

Soluble mannose receptor CD206 and von Willebrand factor are early biomarkers to identify patients at risk for severe or necrotizing acute pancreatitis

Background

In acute pancreatitis (AP), microcirculatory dysfunction and leukocyte activation contribute to organ damage, inflammation, and mortality. Given the role of macrophage activation, monocyte recruitment, and microthrombus formation in the early pathogenesis of AP, we examined the macrophage activation marker soluble mannose receptor (sCD206) and the endothelial function marker von Willebrand factor (vWF) in patients admitted for AP.

Methods

In an exploratory analysis, serum sCD206 and plasma vWF were prospectively analyzed on day 1 and day 3 in 81 patients with AP admitted to the hospital. In addition, blood samples from 59 patients with early AP admitted to the intensive care unit and symptom onset < 24 h were retrospectively analyzed. Patients were dichotomized as per study protocol into two groups: (i) “non-severe edematous AP” including patients with mild AP without organ failure and patients with transient organ failure that resolves within 48 h and (ii) “severe/necrotizing AP” including patients with severe AP and persistent organ failure > 48 h and/or patients with local complications.

Results

In the prospective cohort, 17% developed severe/necrotizing pancreatitis compared with 56% in the ICU cohort. Serum concentrations of sCD206 on admission were higher in patients with severe/necrotizing AP than in patients with non-severe edematous AP (prospective: 1.57 vs. 0.66 mg/l, P = 0.005; ICU: 1.76 vs. 1.25 mg/l, P = 0.006), whereas other inflammatory markers (leukocytes, C-reactive protein, procalcitonin) and disease severity (SOFA, SAPS II, APACHE II) did not show significant differences. Patients with severe/necrotizing AP had a greater increase in sCD206 than patients with non-severe edematous AP at day 3 in the prospective cohort. In contrast to routine coagulation parameters, vWF antigen levels were elevated on admission (prospective cohort: 375 vs. 257%, P = 0.02; ICU cohort: 240 vs. 184%, P = 0.03). When used as continuous variables, sCD206 and VWF antigen remained predictors of severe/necrotizing AP after adjustment for etiology and age in both cohorts.

Conclusions

sCD206 identifies patients at risk of severe AP at earlier timepoints than routine markers of inflammation and coagulation. Prospective studies are needed to investigate whether incorporating early or repeated measurements into the existing scoring system will better identify patients at increased risk for complications of AP.

Supplementary Information

The online version contains supplementary material available at 10.1186/s40560-022-00619-2.

Guidelines for the management of patients with severe acute pancreatitis, 2021

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.

A "tailored" interventional and surgical management for moderate to critical acute pancreatitis in late phase: a cohort study

PURPOSE

Several interventional procedures are available to treat moderate-to-critical acute pancreatitis (AP) in its late phase. The ongoing debate on these options, together with the scarcity of reported quality of life (QoL) information in the Literature, prompted us to conduct a review of our experience.

METHODS

All the patients treated at our referral Center for moderate-to-critical AP according to Determinant-Based Classification (DBC) were retrospectively reviewed. Patients treated conservatively or operated within 4 weeks were excluded. The included patients were managed following a "tailored" interventional-surgical approach, which did not exclude the possibility to skip one or more steps of the classic "step-up" approach, based on the patient's clinical course, and divided into four groups, according to the first procedure performed: percutaneous drainage (PD), endoscopic approach (END), internal derivation (INT), and necrosectomy (NE). In-hospital and mid-term follow-up variables were analyzed.

RESULTS

The study sample consisted in 47 patients: 11 patients were treated by PD, 11 by END, 13 by INT, and 12 by NE. A significant distribution of the DBC severity (p = 0.029) was registered among the four groups. Moreover, the NE group had statistically significant reduced SF-36 scores in the domain of social functioning at 3 months (p = 0.011), at 1 year (p = 0.002), and at 2 years (p = 0.001); role limitations due to physical health at 6 months (p = 0.027); and role limitations due to emotional problems at 1 year (p = 0.020).

CONCLUSIONS

In the "late phase" of moderate to critical AP requiring an invasive management, PD, END, INT, and NE are all effective options, depending on patents' status and necrosis location. A "tailored" interventional-surgical management could be pursued, but up-front more invasive approaches are at higher risk of worse QoL.

TRIAL REGISTRATION

The manuscript was registered at clinicaltrials.gov in 04/2021 and identified with NCT04870268.

How to Identify the Indications for Early Intervention in Acute Necrotizing Pancreatitis Patients: A Long-Term Follow-Up Study

Aim

To explore the indications for early intervention in patients with acute necrotizing pancreatitis (ANP) and evaluate the effect of early intervention on the prognosis of ANP patients.

Methods

The clinical data of patients with ANP who underwent general surgery at Xuanwu Hospital of Capital Medical University from January 1, 2014, to December 31, 2020, were collected retrospectively. The patients were followed-up every 6 months after discharge, and the last follow-up date was June 30, 2021.

Results

A total of 98 patients with ANP were included in the study. They were divided into an early group (n= 43) and a delayed group (n = 55) according to the first percutaneous drainage (PCD) intervention time (≤ 4 weeks or &gt; 4 weeks). Body temperature, inflammatory factor levels, and the number of patients with persistent organ failure (POF) were higher in the early group than in the delayed group. After the minimally invasive intervention, the body temperature and inflammatory factors of the two groups decreased significantly, most patients with POF improved, and the number of patients with reversal of POF in the early group was higher than that in the delayed group. Although the patients in the early group required more surgical intervention than those in the delayed group, there was no significant difference in mortality, incidence of postoperative complications, total length of hospital stay, or operation cost between the two groups. During long-term follow-up, there was no significant difference in the incidence of short-term and long-term complications and overall survival between the two groups.

Conclusions

Compared to patients in the delayed group, early intervention did not affect the prognosis of patients with ANP. It may be more suitable for patients with ANP with deterioration [such as POF or infected pancreatic necrosis (IPN)].

Risk Factors for Mortality Among Critical Acute Pancreatitis Patients with Carbapenem-Resistant Organism Infections and Drug Resistance of Causative Pathogens

Introduction

Carbapenem-resistant organisms (CRO) have emerged as a major global public health threat, but their role in critical acute pancreatitis (CAP) is still not defined. Our study aims to investigate risk factors associated with mortality and drug resistance among CAP patients with CRO infection.

Methods

The clinical characteristics of CAP patients with CRO infection and drug resistance of causative pathogens from January 1, 2016, to October 1, 2021, were reviewed retrospectively. Independent risk factors for mortality were determined via univariate and multivariate analyses.

Result

Eighty-two CAP patients suffered from CRO infection, with mortality of 60.0%. The independent risk factors for mortality were procalcitonin > 5 ng/L (hazard ratio = 2.300, 95% confidence interval = 1.180–4.484, P = 0.014) and lactic acid > 2 mmol/L (hazard ratio = 2.101, 95% confidence interval = 1.151–3.836, P = 0.016). The pancreas was the main site of infection, followed by lung, bloodstream and urinary tract. Klebsiella pneumoniae and Acinetobacter baumannii were the main pathogenic bacteria of CRO strains with extensive antibiotic resistance (> 60%) to 6 of 8 common antibiotics, except sulfamethoxazole (56.3%) and tigecycline (33.2%).

Conclusion

CRO infection has become a serious threat for CAP patients, with high rates of mortality. Procalcitonin and lactic acid represent two independent risk factors for mortality in CAP patients with CRO infection. Klebsiella pneumoniae and Acinetobacter baumannii are the primary categories of CRO pathogens. Greater efforts are needed for early prevention and prompt treatment of CRO infections in CAP patients.

Supplementary Information

The online version contains supplementary material available at 10.1007/s40121-022-00624-w.