Review article: the relative effectiveness of somatostatin and octreotide therapy in pancreatic disease

Somatostatin-analog effect on pancreatic fistula after radical gastrectomy: a pilot randomized controlled trial

PURPOSE

Radical gastrectomy with D2 lymphadenectomy can trigger a high incidence of postoperative pancreatic fistula (POPF), which produces a poor clinical prognosis. We sought to evaluate the effect of somatostatin analogs (SSA) on POPF and clinical prognosis after radical gastrectomy.

METHODS

A total of 123 patients with a high risk of POPF after radical gastrectomy (drainage fluid amylase concentration on a postoperative day [POD] 1 > 3 times the upper limit of normal serum amylase value) were randomly divided into the SSA group (n = 61) and the control group (n = 62). The former received continuous intravenous SSA (0.3 mg/8 h) for 3 days from POD1, and the latter normal saline. The primary outcome was the incidence of POPF.

RESULTS

The incidence of POPFs in the SSA group was significantly lower than that in the control group (3.3% vs. 14.5%, P = 0.029). The incidence of short-term postoperative complications was significantly lower in the SSA group than in the control group (9.8% vs. 24.2%, P = 0.034). The median white blood cell counts, neutrophil counts, and the percentage of neutrophils on POD4 were significantly lower in the SSA group than in the control group (all P < 0.05). The SSA group had a shorter mean time to the first liquid diet (87.33 ± 17.92 h vs. 93.97 ± 17.29 h, P = 0.039). And the SSA group had less median daily drainage volume (96.33 mL vs. 119.67 mL, P = 0.025) and shorter drainage duration (7.0 days vs. 10.0 days, P = 0.013).

CONCLUSION

Postoperative treatment with a somatostatin analog reduced the incidence of POPF and short-term complications after radical gastrectomy. (TRN: ChiCTR2200056201, Reg. Date: 2022/2/1).

Somatostatin analogues and the risk of post-operative pancreatic fistulas after pancreatic resection - A systematic review & meta-analysis

BACKGROUND

Post-operative pancreatic fistula (POPF) is a common complication of pancreatic resection. Somatostatin analogues (SA) have been used as prophylaxis to reduce its incidence. The aim of this study is to appraise the current literature on the effects of SA prophylaxis on the prevention of POPF following pancreatic resection.

METHODS

The review of the literature was conducted using the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. Data from studies that reported the effects of SA prophylaxis on POPF following pancreatic resection were extracted, to determine the effect of SA on POPF morbidity and mortality.

RESULTS

A total of 15 studies, involving 2221 patients, were included. Meta-analysis revealed significant reductions in overall POPF (Odds ratio: 0.65 (95% CI 0.53-0.81, p < 0.01)), clinically significant POPF (Odds ratio: 0.53 (95% CI 0.34-0.83, p < 0.01)) and overall morbidity (OR: 0.69 (95% CI: 0.50-0.95, p = 0.02)) following SA prophylaxis. There is no evidence that SA prophylaxis reduces mortality (OR: 1.10 (95%CI: 0.68-1.79, p = 0.68)).

CONCLUSION

SA prophylaxis following pancreatic resection reduces the incidence of POPF. However, mortality is unaffected.

Add-on effect of crude rhubarb to somatostatin for acute pancreatitis: A meta-analysis of randomized controlled trials

ETHNOPHARMACOLOGICAL RELEVANCE

Rhubarb is one of the common herbs used in traditional Chinese complex prescriptions for the treatment of various inflammatory diseases. We sought to determine the add-on effect of crude rhubarb to somatostatin in patients with acute pancreatitis by conducting a meta-analysis.

MATERIALS AND METHODS

We searched the Pubmed, EMBASE, Cochrane Library, CNKI, Wanfang, VIP databases up to November 2015. Randomized controlled trials (RCTs) comparing crude rhubarb plus somatostatin to somatostatin alone for acute pancreatitis were included. Risk ratio (RR) or weighted mean difference (WMD) with their 95% confidence interval (CI) was calculated between with and without crude rhubarb therapy.

RESULTS

A total of 19 RCTs involving 1161 patients were identified. Compared with somatostatin alone, crude rhubarb plus somatostatin significantly reduced the total complications (RR 0.55; 95% CI 0.41-0.73) and APACHE Ⅱ scores (WMD -1.16; 95% CI -1.91 to -0.41) as well as shortened the duration of elevated serum amylase (WMD -2.01 days; 95% CI -2.57 to -1.44), duration of abdominal pain (WMD -1.33 days; 95% CI -1.61 to -1.05), the first defecation time (WMD -2.27 days; 95% CI -3.06 to -1.47), and duration of hospital stay (WMD -6.70 days; 95% CI -8.81 to -4.60). However, there were no significant differences in total mortality rates (RR 0.61; 95% CI 0.34 to 1.12) between two groups.

CONCLUSIONS

Crude rhubarb as adjuvant therapy to somatostatin appears to have additional benefits in patients with acute pancreatitis. However, interpretation of these results should be cautioned due to the methodological flaws.

Is there a relationship between beginning time and efficiency of octreotide in the treatment of experimental acute pancreatitis?

Purpose

The efficacy of octreotide in the treatment of acute pancreatitis is controversial. Octreotide treatment for acute pancreatitis often shows poor correlation between results obtained in experimental studies and results of clinical trials. In a clinical setting, there is always a delay between the onset of the disease and initiation of the octreotide treatment. The aim of this study is to investigate the relationship between the beginning of treatment and alteration in effectiveness of octreotide.

Methods

Acute pancreatitis was induced by pancreatic duct ligation in 50 rats. The rats were randomly divided into five groups. Octreotide was not used in group 1 (control group). Only single dose (4 µg/kg) octreotide was administered subcutaneously to rats in group 2, having induced pancreatitis. Octreotide treatment was begun at different times (8th, 24th, 48th hour) in three other groups and continued treatment at a dosage of 4 µg/kg t.i.d. The animals were sacrificed at the end of the 72nd hour and blood and tissue samples were collected.

Results

Leukocyte count and plasma amylase values were less in groups 2 and 3. Hemorrhagic focuses were encountered less at pancreas tissues in group 3. Pancreatic necrosis and alveolar capillary basal membrane damage were lower in groups 3 and 4. No difference was found in fasting blood glucose, calcium and hematocrit.

Conclusion

Octreotide had benefical effects in acute pancreatitis when octreotide treatment was begun in the first 24 hours.

Octreotide ameliorates intestinal dysmotility by interstitial cells of Cajal protection in a rat acute necrotizing pancreatitis model

OBJECTIVES

Intestinal motility is impaired in acute necrotizing pancreatitis (ANP). The aim of present study was to investigate the effects of octreotide on the small intestinal motor function during experimentally induced ANP.

METHODS

L-Ornithine was intraperitoneally injected to induce ANP. Octreotide was administrated subcutaneously every 8 hours. The small intestine migrating myoelectrical complexes and slow waves in vivo were recorded before and after (24, 48, and 72 hours) ANP induction. The morphological alterations of interstitial cells of Cajal (ICCs) in deep muscular plexus were evaluated by immunohistochemistry and Western blots.

RESULTS

Disturbed migrating myoelectrical complex cycle length and decreased dominant frequency of slow waves exacerbated gradually with time. The bolus applications of octreotide per 8 hours attenuated these functional abnormalities. The result of morphological study suggested that octreotide might ameliorate the damage of ICCs at 48 and 72 hours after ANP induction. Decreased expression of c-Kit protein at 72 hours was also attenuated by octreotide.

CONCLUSIONS

The pathogenesis of the ileus in ANP may be related to the sustained deficiencies in ICCs. Octreotide may ameliorate the severity of ileus by minimizing the injury of ICCs.

Mechanisms of Chinese herb emodin and somatostatin analogs on pancreatic regeneration in acute pancreatitis in rats

INTRODUCTION

Studies have revealed that emodin is a potent agent in the management of clinical and experimental acute pancreatitis, but the molecular mechanisms by which emodin produces its biologic effects, especially on pancreatic regeneration after acute pancreatitis, remain unknown. Numerous experimental and clinical studies have shown that somatostatin analogs have favorable effects on acute pancreatitis, but their role in the management of acute pancreatitis remains controversial.

AIM

To investigate mechanisms of the Chinese herb emodin and somatostatin analogs (SSa; Sandostatin) in acute pancreatitis of rats by analyzing the changes in pancreatic tissue cytokine transforming growth factor beta1 (TGFbeta1) and epidermal growth factor (EGF) gene expression, DNA synthesis, total protein content, and the relations between them.

METHODOLOGY

Acute pancreatitis was induced by intraperitoneal infusion of cerulein in rats. Emodin was administered intravenously and Sandostatin was administered subcutaneously at the time of induction of pancreatitis and 24, 48, and 72 hours afterward. Rats were killed at 6, 24, 48, 72, and 96 hours after the operation. The mRNA expression of TGFbeta1 and EGF were evaluated by reverse transcription polymerase chain reaction, and pancreatic tissue DNA synthesis was measured by the 3H-thymidine incorporation method in vitro. Total protein content was detected by Lowry's method.

RESULTS

The serum amylase level was decreased significantly in the emodin-treated and Sandostatin-treated groups in comparison with the nontreated group. Pancreatic tissue DNA synthesis was significantly decreased at 72 hours after the induction of pancreatitis, and a marked increase was observed at 96 hours after treatment with emodin and Sandostatin. Within 48 hours of the induction of pancreatitis, the total protein content in pancreatic tissue declined, but there was a remarkable increase in the emodin-treated group at 96 hours and Sandostatin-treated group at 48 hours. Expression of TGFbeta1 mRNA and EGF mRNA were undetectable in normal pancreas and the nontreated group at 6 hours but was observed from 24 hours to 96 hours after the induction of pancreatitis and reached its maximum at 72 hours. TGFbeta1 mRNA could be detected 6 hours after treatment with emodin and Sandostatin, and its expression was significantly higher in the emodin-treated and Sandostatin-treated groups than in the nontreated group at 24 and 48 hours. The expression of EGF mRNA was significantly higher in the emodin-treated and Sandostatin-treated group than in the nontreated group at 48 hours.

CONCLUSION

It was concluded that mechanisms of the Chinese herb emodin and somatostatin analogs in the management of acute pancreatitis in rats might be ascribed to the upregulation of TGFbeta1 and EGF gene expression, which subsequently increases DNA synthesis and protein content and thus accelerates pancreatic repair and regeneration.

Octreotide versus hydrocortisone versus placebo in the prevention of post-ERCP pancreatitis: a multicenter randomized controlled trial

BACKGROUND

Octreotide is a potent inhibitor of pancreatic secretion, and corticosteroids suppress humoral and cellular activity. Both agents may reduce the frequency of post-ERCP pancreatitis. The aim of this study was to determine the effectiveness of octreotide and hydrocortisone in preventing post-ERCP pancreatitis.

METHODS

Three hundred fifty-four patients were entered in to a multicenter randomized controlled trial of 100 microg subcutaneous octreotide (Group 1) versus 100 mg intravenous hydrocortisone (Group 2) versus normal saline solution as placebo (Group 3). All medications were administered approximately 30 minutes before the procedure. Patients were assessed clinically and serum amylase was also measured before the procedure and 3, 12, and 24 hours after the procedure.

RESULTS

Three hundred forty patients were included in the analysis. Pancreatitis was observed in 11 of 112 patients (9.8%) in Group 1, 8 of 113 (7.1%) patients in Group 2, and in 15 of 115 (13.0%) patients in Group 3 (p = 0.32). The mean length of hospitalization in days was similar in all 3 groups: mean (SD) for Groups 1, 2, and 3 were, respectively, 3.6 (1.6) versus 2.9 (0.6) versus 4.3 (1.8) (p = 0.13). Multivariate logistic regression analysis showed that number of pancreatic injections, suspicion of sphincter dysfunction, therapeutic procedure, and age were risk factors for pancreatitis.

CONCLUSIONS

The results of this trial indicate that octreotide and hydrocortisone do not prevent ERCP-induced pancreatitis.

Effects and mechanisms of somatostatin analogs on apoptosis of pancreatic acinar cells in acute pancreatitis in mice

AIM

To investigate the effects of somatostatin analogs (SSa) on apoptosis of pancreatic acinar cells and apoptosis-regulated gene bax, and p53 in treating acute pancreatitis in mice.

METHODS

In cerulein-induced pancreatitis, with or without treatment of somatostatin, analogs (Octreotide) in CD-1 (BALB/c x DBetaAlpha/1) mice, apoptosis of pancreatic acinar cells was detected by using the TdT-mediated dUTP nick-end labeling (TUNEL) method, and the expression of apoptosis-regulated gene bax and p53 was determined by using the streptavidin-peroxidase immunohistochemical technique and the RT-PCR method, respectively.

RESULTS

On HE staining, acinar cells in the pancreas showed pyknotic nuclei and the formation of apoptotic bodies, which are the typical morphological features of apoptosis. Regarding TUNEL use, the apoptotic index of pancreatic acinar cells in the non-treated group at 5 and 14 h after induction of acute pancreatitis was significantly lower than those of the SSa-treated group, respectively (P < 0.01). On immunohistochemistry and RT-PCR, there was an expression of neither bax nor p53 in normal pancreatic tissues. The expression of bax in the SSa-treated group at 5 and 14 h after treatment of SSa was markedly higher than those of the non-treated group, respectively (P < 0.01), but there was no significant difference in the expression of p53 between the SSa-treated group and the non-treated group.

CONCLUSIONS

The induction of apoptosis in pancreatic acinar cells injury to reduce inflammatory reaction might be one of the mechanisms of SSa in treating acute pancreatitis in mice, and the mechanisms of apoptosis probably correlated with the expression of apoptosis-regulated gene bax, but have no relationship with the expression of p53.

Complicated Acute Pancreatitis

The treatment of severe, complicated pancreatitis requires: Rapid assessment and recognition of severity, determined by using APACHE or equivalent scoring systems. Aggressive resuscitation with crystalloid and colloid solutions using central venous monitoring for guidance, and to help identify and treat early organ failure. Nutritional support including total parenteral feeding, which can assist in maintaining nutrition during the prolonged period that may ensue. Nasojejunal feedings, bypassing the duodenum, supply nutrition and may decrease infectious complications. Judicious use of imaging studies, mainly dynamic-bolus contrast computed tomography (CT) of the abdomen. These studies will identify necrosis and other local complications of pancreatitis that are treatable by endoscopic, radiological or surgical means. Antibiotics, whose role has evolved to that of prophylaxis to prevent infection of necrotizing pancreatitis. Other medications such as octreotide have a limited role in the management of certain specific complications such as fistulas and post-pancreatic surgery. A multidisciplinary approach, including the use of endoscopic techniques and surgery to treat complicated pancreatitis. This approach provides optimal care of this challenging group of patients.

Economic evaluation of the use of octreotide for prevention of complications following pancreatic resection

Recent studies have concluded that octreotide can prevent complications in patients undergoing pancreatic resections. Given the acquisition cost of octreotide, a cost-effectiveness analysis was performed to establish whether if the additional cost associated with its use was justified by a decrease in the consumption of other resources. To evaluate success rates and complication rates, a meta-analysis of double-blind, randomized, controlled clinical trials was conducted. The rates for pancreatic fistula and fluid collection were 10.7% (95% confidence interval [CI] 7.9 to 13.4) and 3.6% (95% CI 1.9 to 5.2) for octreotide vs. 23.4% (95% CI 19.7 to 27. 1) and 8.8% (95% CI 6.2 to 11.3) for placebo. In a second phase we evaluated the treatment cost for patients with and without complications using two different models of cost savings. In the first model the cost to treat a pancreatic fistula was calculated as the per diem rate (as determined by Statistics Canada) multiplied by the incremental length of stay associated with the complication. In the second model we used data from institutions participating in the Ontario Case Costing Project. In model 1 the estimated incremental length of hospital stay attributed to a pancreatic fistula was 7 days, based on a review of the literature, and the per diem was $552. In model 2 the average cost of care for patients with or without complication was $32,347 (n = 17; 95% CI $20,882 to $43,812) and $11, 169 (n = 18; 95% CI $7558 to $14,779), respectively. The data suggest that when compared to placebo, octreotide is a dominant treatment strategy. In model 1, in a cohort of 100 patients, octreotide saved an average of $853 per patient while allowing 16 incremental patients to avoid complications. In model 2 use of octreotide resulted in an average savings of $1642 per patient while still allowing 16 patients to avoid complications. Detailed one-way and two-way sensitivity analyses suggest that both models were robust. The use of octreotide is a cost-effective strategy in patients undergoing elective pancreatic resection. Consideration should be given to extending its use to patients who are at high risk for development of complications following pancreatic surgery and who do not have any contraindications to the use of this drug.

Prophylactic effect of somatostatin on post-ERCP pancreatitis: a randomized controlled trial

BACKGROUND

Somatostatin is a potent inhibitor of pancreatic secretion and has been studied for its prophylactic effect on post-ERCP pancreatitis. However, results of previous trials have been inconclusive.

METHODS

A prospective double-blind controlled study was performed to evaluate the effectiveness of somatostatin in preventing post-ERCP pancreatitis. Post-ERCP enzyme elevation, abdominal pain and pancreatitis were evaluated and compared between 109 patients randomized to receive somatostatin infusion and 111 patients randomized to receive normal saline infusion (placebo); both started 30 minutes before ERCP and continued for 12 hours.

RESULTS

Post-ERCP elevation of serum amylase and lipase levels at 6 and 24 hours after ERCP was less frequent in the group given somatostatin but not statistically significant. There was a tendency toward lower mean serum amylase and lipase levels at 24 hours in patients given somatostatin, although the difference was not statistically significant either. Eight patients given somatostatin (7%) and 18 patients given placebo (16%) had significant abdominal pain after ERCP requiring analgesia (p = 0.04). The frequency of clinical pancreatitis was significantly lower in patients given somatostatin (3%) than in those given placebo (10%) (p = 0.03).

CONCLUSIONS

Prophylactic treatment with somatostatin reduced the frequency of post-ERCP pancreatitis.

Somatostatin and the gastrointestinal tract

Somatostatin has various significant effects on the gastrointestinal tract: it inhibits the release of several gastrointestinal hormones, blocks the exocrine function of the stomach and the pancreas, and decreases the motility of both the stomach and the gut. Its physiological effects make it potentially useful in the therapy of various gastrointestinal diseases and disorders. Somatostatin is effective in the management of active variceal bleeding and increases the effectiveness of sclerotherapy. Previous studies show controversial data about the efficacy of somatostatin in preventing complications following endoscopic retrograde cholangiopancreatography. The use of this compound may be indicated only in high-risk patients in whom endoscopic sphincterotomy may also become necessary. The perioperative use of somatostatin decreases the risk of pancreatic surgery and its application is effective in promoting the closure of pancreatic fistulae. The somatostatin analogue octreotide has a definitive role in the medical management of hormone-secreting neuroendocrine tumours of the gut.